Download Radiologic Technology, November/December 2015, Volume 87

RADIOLOGIC
Journal of the American Society of Radiologic Technologists
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Volume 87, Number 2  November/December 2015
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DIRECTED READING ARTICLES
Medical Ethics and Law in
Radiologic Technology
PAGE 163
Medical Imaging of Oral and
Oropharyngeal Cancer
PAGE 187
PEER-REVIEWED ARTICLES
Visual Function Assessment in
Medical Imaging Research
PAGE 129
Microbial Safety Assessment of a
Double Check-Valve Patient Line in a
Multiuse Contrast Delivery System
PAGE 139
Evaluation of Stress and a
Stress-Reduction Program
Among Radiologic Technologists
PAGE 150
Continuing Education
Easy online access.
Patient-centered Care for
DIVERSE POPULATIONS
Diverse Patients.
Consistent Care.
NEW! Patient-centered Care
For Diverse Populations
SAFETY ESSENTIALS
Create a
Culture of
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Credits: 14
Credits: 12
• Deliver quality care for all patients.
• Explore concepts of cultural
awareness and equitable care.
• Earn 12 CE credits.
Patient-centered Care for Diverse Populations
Module 1 – Fundamentals
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Implement the best patient care
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Module 1 – Introduction to Health Care Safety
Module 2 – Workplace Safety
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Module 4 – Patient Transfer and Transport
Module 5 – Patient Fall Prevention
Module 7 – Health Literacy
Module 3 – Pediatric Patients
Module 8 – Diverse Body Habitus
Module 4 – Patients With Physical Disabilities
Module 9 – Chronically Ill Patients
Module 5 – Patients With Intellectual Disabilities
Module 10 – Equitable Patient Care
Module 6 – Infection Control Practices
Module 7 – Medication Safety
Module 8 – Wrong Site, Wrong Procedure, and Wrong Person
Module 9 – Sentinel Event Policy and Prevention
Module 10 – Radiation Protection
Focuses on quality patient care and prevention of medical errors as outlined in The Joint Commission
patient safety performance requirements.
www.asrt.org/patientcare
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essentialeducation
essentialeducation
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SECTIONAL ANATOMY
Essentials
Improve Your
Clinical
Competence
• Identify anatomical structures
in MR and CT images.
• Explore anatomy through
animation sequences.
• View images from a
radiologist’s perspective.
Sectional Anatomy
Essentials
Improve Your Clinical
Competence
Credits: 11.5
• Study anytime, anywhere.
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Study anatomical structures with
high quality MR and CT images.
Sectional Anatomy Essentials  Online Education
Module 6 – The Thorax
Module 7 – The Abdomen
Module 8 – The Pelvis
Module 9 – The Extremities
Earn 11.5 CE credits and receive a document recognizing your achievement once you successfully complete all nine
modules. We also offer individual credit modules and an institutional/educator series for classroom use or training.
www.asrt.org/sectionalanatomy
LEADERSHIP
Essentials
Inspire
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• Supervise with skill.
• Earn 11 CE credits.
Essentials of
DIGITAL IMAGING
Digital
Imaging
Leadership Essentials  Online Education
Module 1 – Introduction to Supervision
Module 2 – Competent Communication
Module 3 – Employment Law
Module 4 – Performance Coaching
Module 5 – Quality Standards
Module 6 – Accreditation and Regulations
Module 7 – Budgeting and Finance
Module 8 – Project Management
Module 9 – Leadership Skills
Module 10 – Health Economics
Earn 11 CE credits and receive a document recognizing your achievement once you successfully complete all ten modules.
We also offer individual credit modules and an institutional/educator series for classroom use or training.
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essentialeducation
Essentials of
Digital Imaging
Stay Current
Essentials of Digital Imaging  Online Education
Module 5 – PACS
Module 6 – Dose Reduction and Patient Safety
Module 7 – Quality
Earn 7 CE credits and receive a document recognizing your achievement once you successfully complete all seven modules.
We also offer individual credit modules and an institutional/educator series for classroom use or training.
www.asrt.org/digitalimaging
essentialeducation
Find out how digital
technology has advanced
medical imaging.
www.asrt.org/digitalimaging
MR BASICS
A Solid
Foundation
in MR
• Gain expertise in the science of MR.
• Explore the properties of magnetic fields.
• Learn the physics of MR through
animation sequences.
• Demonstrate the essentials of
safe MR practices.
• Earn 16 CE credits.
Professional
Skill Set
• Keep up with the expanding use of
computed tomography.
• Learn the basics of CT in an easy-to-follow format.
• Earn 16 CE credits.
Module 7 – Safety Essentials
Module 8 – Image Quality
Module 9 – Neuroimaging
Module 10 – Body and Joint Imaging
New! Module 11: Pathology Part 1
New! Module 12: Pathology Part 2
Module 1 – Fundamentals
Module 2 – Equipment and Instrumentation
Module 3 – Data Acquisition
Module 4 – Image Processing and Reconstruction
Module 5 – Patient Safety
Module 6 – Image Quality
Module 7 – Procedures
Module 8 – Cross-sectional Anatomy of the Head and Neck
Module 9 – Cross-sectional Anatomy of the Chest,
Abdomen and Pelvis
Module 10 – Additional Applications
Module 11 – Pathology Part 1
Module 12 – Pathology Part 2
Earn 16 CE credits and receive a document recognizing your achievement once you successfully complete
all 12 modules. We also offer individual credit modules and an institutional series for classroom use or training.
essentialeducation
www.asrt.org/ctbasics
Evaluate complex MR topics with
easy-to-understand animations
and illustrations.
www.asrt.org/mrbasics
essentialeducation
www.asrt.org/mrbasics
essentialeducation
Identify the basics of CT in an
easy-to-follow format.
www.asrt.org/ctbasics
MR Basics
A Solid Foundation in MR
Earn 16 CE credits and receive a document recognizing your achievement once you successfully complete all 12 modules.
We also offer individual credit modules and an institutional/educator series for classroom use or training.
CT Basics
Update Your Professional
Skill Set
Credits: 16
CT Basics  Online Education
FLUOROSCOPY
Protect Your
Patients.
Protect Yourself.
Credits: 16
MR Basics  Online Education
Module 1 – Fundamentals
Module 2 – Equipment and Instrumentation
Module 3 – Radiofrequency and Gradients
Module 4 – Image Production Parameters
Module 5 – Contrast Media
Module 6 – Pulse Sequences
CT BASICS
Update Your
Credits: 7
• Review the fundamental aspects of
digital imaging.
• Stay current in your career.
• Learn how technology has advanced
medical imaging.
• Refresh your safety skills and focus on quality.
• Earn 7 CE credits.
Apply strategies for success in any
health care leadership role.
www.asrt.org/leadership
www.asrt.org/sectionalanatomy
A Solid Foundation in
Leadership Essentials
Inspire High Performance
Credits: 11
Discover the leadership skills needed
to take your career to the next level.
essentialeducation
Module 1 – Fundamentals
Module 2 – Processing
Module 3 – Display
Module 4 – Image Analysis
Provide a secure environment
for your patients.
Earn up to 14 CE credits and receive a document recognizing your achievement once you successfully complete all 10 modules.
We also offer individual credit modules and an institutional/educator series for classroom use or training.
Earn 12 CE credits and receive a document recognizing your achievement once you successfully complete all 10 modules.
We also offer individual credit modules and an institutional/educator series for classroom use or training.
Module 1 – Introduction to Sectional Anatomy
Module 2 – Cranium and Facial Bones
Module 3 – The Brain
Module 4 – The Spine
Module 5 – The Neck
• Improve the quality and safety
of the care you provide.
• Implement strategies for safe
patient care.
• Earn 14 CE credits.
Safety Essentials  Online Education
Online Education
Module 6 – Cultural Competence
Module 2 – Elderly Patients
Safety Essentials
Create a Culture of Safety
• Expand your technical skills
and accuracy.
• Limit radiation risks.
• Understand legal responsibilities
and regulations.
• Study anywhere, anytime.
• Earn 12.75 CE credits.
Fluoroscopy  Online Education
Module 1 – Radiation Protection and Safety
Module 2 – Operation and Safety of Fixed
Fluoroscopy Units
Module 3 – Regulation and Radiation Protection
Module 4 – Mobile Unit Operation and Safety
Module 5 – Radiation Protection of the Eye
Module 6 – Image Quality and Analysis
Earn 12.75 A+ CE credits and receive a document recognizing your achievement once you successfully complete all six modules.
We also offer individual credit modules and an institutional/educator series for classroom use or training.
www.asrt.org/fluoroscopy
essentialeducation
Fluoroscopy
Protect Your Patients
Protect Yourself
Credits: 12.75
Expand your technical skills,
limit radiation risks and improve
your knowledge.
www.asrt.org/fluoroscopy
Find these courses and more at
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Radiologic Technology (ISSN 0033-8397) is the official scholarly/
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RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
RADIOLOGIC
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Radiologic Technology Editorial Review Board
Chairman
James Johnston, PhD, R.T.(R)(CV), FASRT
Richard J Merschen, EdS, R.T.(R)(CV), RCIS
Vice Chairman
Quentin Moore, MPH, R.T.(R)(T)(QM)
[email protected]
Midwestern State University, Wichita Falls, Texas
Tricia Leggett, DHEd, R.T.(R)(QM)
[email protected]
Zane State College, Zanesville, Ohio
Members
Jessica Curtis, BSRS, R.T.(R)(CT)
[email protected]
Raleigh, North Carolina
Cheryl DuBose, EdD,R.T.(R)(CT)(MR)(QM)
[email protected]
Arkansas State University, Jonesboro, Arkansas
Daniel DeMaio, MEd, R.T.(R)(CT)
[email protected]
University of Hartford, West Hartford, Connecticut
Kelli Haynes, MSRS, R.T.(R)
[email protected]
Northwestern State University, Shreveport, Louisiana
[email protected]
Jefferson School of Health Professions, Philadelphia, Pennsylvania
[email protected]
Mercy College of Ohio, Toledo, Ohio
Christina A Truluck, PhD, R.T.(N), CNMT
[email protected]
Thomas Jefferson University, Philadelphia, Pennsylvania
Beth Vealé, PhD, R.T.(R)(QM)
[email protected]
Midwestern State University, Wichita Falls, Texas
Ben D Wood, MSRS, R.T.(R)
[email protected]
Northwestern State University, Shreveport, Louisiana
Jennifer Yates, EdD, R.T.(R)(M)(BD)
[email protected]
Merritt College, Oakland, California
Rebecca L Ludwig, PhD, R.T.(R)(QM),
FASRT, FAEIRS
[email protected]
St Petersburg College, St Petersburg, Florida
Radiologic Technology Journal Staff
Lisa Ragsdale, scientific journal editor
Julie Hinds, associate editor
Sherri Mostaghni, associate editor
Connor Lemp, academic editor
Lisa Kisner, scientific publications manager
Kathi Schroeder, director of communications
Katherine Ott, senior professional development editor
Ellen Lipman, director of professional development
Taylor Henry, graphic designer
Myron King, graphic designer
Marge Montreuil, graphic designer
Laura Reed, graphic design manager
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Author guidelines are available at www.asrt.org/authorguide.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
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The New
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Contents
Volume 87, Number 2  November/December 2015
PEER-REVIEWED ARTICLES
Visual Function Assessment in Medical Imaging Research
Carla Lança, John D Thompson, Luis Lança, Peter Hogg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Microbial Safety Assessment of a Double Check-Valve Patient Line in a Multiuse Contrast Delivery System
Catherine Vermeulen, Barbara Noury, Frédéric Dolle, Habib Rebergue, Raphaël Boisgard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Evaluation of Stress and a Stress-Reduction Program Among Radiologic Technologists
Lynn Reingold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
DIRECTED READING ARTICLES
Medical Ethics and Law in Radiologic Technology
Eric P Matthews, Tracy M Matthews. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Medical Imaging of Oral and Oropharyngeal Cancer
Susan M Anderson. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
COLUMNS
JRCERT Update
Leslie Winter on Her Role and the Challenges Facing Our Profession. . . . . . . . . . 213
In the Clinic
Computed Tomography for Assessment of Coronary Artery Bypass Grafts. . . . 216
Patient Care
Microexpressions: Do They Have Value in Radiology?. . . . . . . . . . . . . . . . . . . . . . . . . 223
Advances in Technology
E-Portfolios for Radiologic Technology Students. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Teaching Techniques
Developing Clinical Competence in Diagnostic Imaging Students . . . . . . . . . . . . 230
Writing & Research
Writing Research Proposals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Backscatter
Image Fusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
ON THE COVER
Michael G Rooney, R.T.(R), of Gloversville,
New York, was inspired to draw “The
Dichotomous Hand” while studying how to
obtain the posteroanterior projection of the
hand using art as a tool. The drawing displays what the eye sees and what the radiograph reveals in a harmonious marriage of
bone and flesh.
This symbol indicates expanded content.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
127
Daniel Jackson, R.T.(R)(MR)(ARRT),
ARRT certified and registered since 1985.
Striving to provide gold standard professionalism.
I became an R.T. to make a difference. And I do.
®
Dan’s role as a Registered Technologist® is essential in his organization. His expertise
and care enhance patient safety and ultimately drive better patient outcomes.
By maintaining his certification and registration he can have confidence that he
is doing his best professionally for his patients, colleagues and organization.
Be the gold standard. ARRT.org
© 2015 The American Registry of Radiologic Technologists. All Rights Reserved.
Peer Review
Visual Function Assessment in
Medical Imaging Research
Carla Lança, PhD
John D Thompson, PhD
Luis Lança, PhD
Peter Hogg, BSc(Hons), MPhil, PgCert
Background Medical image perception research relies on visual data to study the diagnostic relationship between
observers and medical images. A consistent method to assess visual function for participants in medical imaging
research has not been developed and represents a significant gap in existing research.
Methods Three visual assessment factors appropriate to observer studies were identified: visual acuity, contrast sensitivity,
and stereopsis. A test was designed for each, and 30 radiography observers (mean age 31.6 years) participated in each
test.
Results Mean binocular visual acuity for distance was 20/14 for all observers. The difference between observers who did
and did not use corrective lenses was not statistically significant (P  .12). All subjects had a normal value for near visual
acuity and stereoacuity. Contrast sensitivity was better than population norms.
Conclusion All observers had normal visual function and could participate in medical imaging visual analysis studies.
Protocols of evaluation and populations norms are provided. Further studies are necessary to understand fully the relationship between visual performance on tests and diagnostic accuracy in practice.
M
edical image quality needs to be assessed in
both clinical and research settings, and
image quality testing in the clinical setting
must comply with regulations and best
practices. Interpretation of radiographs depends on the
clarity of visual patterns within the image in addition to
the neurological and psychological factors that affect
the observer’s analysis.1 Traditional approaches to
assessing image quality involve only physical measures
such as noise reduction or resolution and contrast
improvement. These measures are useful but cannot
predict the combined diagnostic performance of system
and observer.
Observer performance assessment is useful to quantify
combined system and observer performance. This typically has been done using receiver operating characteristic
(ROC) analysis, but the location sensitive free-response
ROC (FROC) method offers improved statistical power.
ROC analysis measures observer accuracy on identifying
the presence or absence of signs of disease in a presented
image along with self-assessment of confidence. In this
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
type of study, an observer is asked to decide whether an
image shows signs of disease, and to state his or her confidence in this decision using a rating scale. The observer is
not required to indicate the anatomical location of disease
using this method. ROC analysis has been an important
tool in medical imaging, but the development of FROC
analysis has improved researchers’ ability to measure
results closer to the clinical reality.2 FROC analysis provides greater certainty than ROC methods by including
location data. In FROC analysis the observer must locate
specific suspicious areas within the image. ROC methods
are limited to a single rating per image, whereas FROC
methods allow multiple true (lesion) and false (nonlesion)
localizations in each image.
A robust approach to assessing image quality should
include physical measures (eg, noise, resolution, contrast) and observer performance measures (eg, ROC,
FROC). Approaches that optimize visual elements such
as contrast are easy to perform and highly reproducible;
however, observer-based approaches can be harder to
control and analyze.
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Visual Function Assessment in Medical Imaging Research
This study examined measures to identify and characterize observers’ visual function in the context of
medical image evaluation. The intention was to reveal
how visual function data should be analyzed and how
conclusions about visual function can be drawn.
Errors in Medical Imaging
Diagnostic errors in medical imaging have been
reported since 1947.3 In 2013, Lee et al reported an
error rate for radiologic examinations of approximately
30%, with some techniques particularly prone to
errors. 4 For example, 20% to 50% of chest radiographs
are misdiagnosed.5 Most missed tumors occurred in the
apices, paramediastinal, and hilar areas. Difficulty in
separating healthy structures from signs of early stage
lung cancer was the apparent cause of these errors. 5
Factors contributing to errors in interpretation are complex and hard to isolate. One potential source of error
could be changes in visual function that decrease an
observer’s ability to identify small, solitary pulmonary
nodules. This seems to hold true for medical students. 6
However, among radiology residents and boardcertified radiologists, no correlation was found between
visual performance and the ability to locate pulmonary
nodules correctly. 6 These findings suggest that factors
other than visual perception determine a radiologist’s
ability to identify solitary pulmonary nodules. In addition, some have argued that experience brings an economy of effort and greater efficiency, which can improve
visual performance.8-10
Increased workload, equipment and technique problems, and cognitive biases (eg, referring physician failing
to communicate adequately the reason for performing
the examination) contribute to diagnostic errors in radiology.5 Perception research in medical imaging relies on
data to quantify the relationship between visual stimuli
and observer recognition. Contrast sensitivity and visual
acuity are fundamental quality measures for visual systems.10,11 These factors play a primary role in perception
and affect the ability of an observer to detect pathophysiology on a medical image.
Visual Function
An observer’s ability to process visual information is a fundamental link in the diagnostic imaging
130
chain.12 Visual function is the primary tool through
which imaging information is gathered for processing into concrete data. Decreased visual acuity could
significantly increase the threshold contrast required
to identify high-frequency diagnostic information.13
Contrast sensitivity is an indicator of visual pattern
detection for stimuli of various sizes. Low-contrast
objects are difficult to evaluate and are one of the
greatest challenges for observers reviewing images.1
Contrast sensitivity across all spatial frequencies
declines with age. This decline typically starts at age
45, and higher spatial frequencies are more affected
than are lower frequencies.14 However, this topic
has been subject to little scrutiny in medical imaging. Quaghebeur et al found that 71% of radiologists
believed that regular monitoring of visual acuity
should be required for practice, and 82% agreed to
undergo such testing.15
Measurement of Visual Function
The Snellen Visual Acuity test is a common standard
in the measurement of vision. Results from this test
take the format 20/x. In this system, the numerator (20)
is the distance at which the subject recognizes an optotype (letters or symbols on the chart), and the denominator (x) is the distance at which a person with standard
visual acuity would recognize the optotype.16 In this
system, 20/10 vision is excellent, because the observer
could see at 20 feet what a person with standard vision
could see at 10 feet. 20/100 vision is poor, because the
observer could see at 20 feet what a person with standard vision could see at 100 feet.
Numerous charts are used for visual acuity testing,
but the Early Treatment Diabetic Retinopathy Study
(ETDRS) chart is preferred for vision testing in clinical trials.17 This study used a Vector Vision ETDRS
Chart – CSV-1000 (see Figure 1). Logarithm of the
Minimum Angle of Resolution (LogMAR) is a precise
method of calculating visual acuity. In LogMAR notation, lower scores correspond to better vision, and as
acuity worsens, the value of the LogMAR increases.
When converting LogMAR to a Snellen visual acuity
measurement, the following equation can be used18:
Decimal acuity  antilog (LogMAR)  10-LogMAR
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
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Lança, Thompson, Lança, Hogg
Figure 1. CSV 1000 Vector Vision Chart – The Early Treatment
Diabetic Retinopathy Study (ETDRS). Image courtesy of Carla
Lança.
This example assumes a LogMAR result of 0.15,
which corresponds to a Snellen visual acuity measurement of approximately 20/14 using the previous equation:
Decimal visual acuity  10-LogMAR  10 0.15  1.41
Snellen visual acuity denominator  20/decimal acuity
 20/1.41  14
Snellen visual acuity  20/14
Grating contrast sensitivity is an important measure
of visual function. It measures the ability of an observer
to perceive slight changes in luminance between
regions not separated by definite borders.19,20 This is a
significant function in imaging analysis of low-contrast
targets such as isoechoic lesions on ultrasonography or
isodense lesions on computed tomography (CT). These
lesions can be recognized only indirectly through contour irregularities or displacement of identifiable adjacent structures.1 The perception of complex patterns in
mammograms also is linked to the observer’s contrast
sensitivity.21 Pattern-detection is determined by eye
contrast sensitivity for stimuli of various sizes. If an
observer has abnormal contrast sensitivity, low-contrast
targets might be difficult to identify and can be missed
(see Figure 2).
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Figure 2. A simulated 5-mm pulmonary nodule (A) that is only
distinguishable from simulated pulmonary vessels (B) by the
shape of the object. Image courtesy of John D Thompson.
Grating contrast sensitivity is measured by detection
of sinusoidal gratings, which are patterns of parallel
light and dark bars. Contrast sensitivity testing measures the eye’s sensitivity over a range of spatial frequencies represented by bar widths.22 The spatial frequency,
measured in cycles per degree (cpd), is a measure of
how often sinusoidal components of the structure
repeat per unit of distance. Normal contrast sensitivity maximizes at a spatial frequency of about 6 cpd and
declines at both higher and lower spatial frequencies
(see Figure 3).
Digital images could be represented both in spatial
and frequency domains.23 The spatial domain refers to
a matrix of gray level intensities in a 2-D spatial plane.
The frequency domain refers to the rate of change of
intensity in an image in terms of sinusoidal intensity
profile.24
Stereopsis is a measure of an observer’s ability to perceive 3-D features (ie, the ability to perceive the depth
of an object) and thus obtain binocular single vision.25
Binocular single vision is the coordination of both eyes,
fusing 2 slightly differing images into a whole image
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Visual Function Assessment in Medical Imaging Research
Figure 3. Contrast sensitivity and spatial frequency. Going
upward the contrast decreases, while going from left to right
the cycles per degree decrease. Public domain image courtesy of
Aleksey463 via Wikimedia Commons.
with 3-D perception. Although the radiographic image is
a 2-D depiction, it represents 3-D anatomy. Radiographs
are created from the shadows of the x-ray absorption pattern as they pass through the body, including information from multiple planes in 3-D space.26 The observer
must translate the image into a 3-D representation to
analyze and localize structures properly.
Recent investigations indicate that stereopsis is an
advantage27 and probably affects the comprehension
of complex radiographs with many visible structures.
Stereopsis is an important function that helps the
observer when reviewing spatial information from medical imaging. Figure 4 shows a 3-D reconstruction of a
chest CT scan in which the anatomic structures are represented volumetrically. Stereopsis allows the observers
to determine the depth of objects in the central visual
area, enhancing vision quality.
Stereopsis is measured using minutes/seconds of
arc, which is a measure of angular distance. A minute
of arc is equal to 1/60th of 1°; a second of arc is equal
1/3600th of 1°. These small measurements are useful when calculating the slight changes in perception
between each eye when observing small or distant
objects. A standard stereopsis test measures from 3500
to 20 seconds of arc, which provides an idea of the kind
of tiny angles the human eye is capable of recognizing.
132
Figure 4. A 3-D reconstruction of a chest computed tomography
acquisition. Image courtesy of John D Thompson.
Methods
Thirty observers with a mean age of 31.6 years
(17-57 years) agreed to be visually assessed before evaluating plain radiographs and CT scans. The observer
group included radiographers, student radiographers,
and medical physicists. Ethical standards for the study
complied with Lisbon School of Health Technology
requirements, and observers received feedback on the
results of their visual function tests.
The observers received a visual assessment that
included visual acuity, contrast sensitivity, and stereopsis tests. These visual function tests measured
abilities necessary for assessing medical image quality
(see Table 1). The most commonly measured aspect
of visual function is visual acuity.16,17 Visual acuity
describes the ability of the eye to resolve the size of an
object. In radiology, this function is key to an observer’s
ability to identify small, solitary pulmonary nodules, for
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
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Lança, Thompson, Lança, Hogg
example. 6 A nodule could be missed because the visual
acuity of the observer is not sufficient to resolve the size
of the nodule (see Figure 5).
Eye charts are used to measure visual acuity. These
charts consist of uppercase letters arranged in rows,
with the largest letters at the top and progressively
smaller letters toward the bottom. The observers’ visual
acuity for distance was assessed in low-light conditions
at a distance of 8 feet with an illuminated ETDRS chart
in a backlit stand.
The CSV chart incorporates LED light source
technology and autocalibrates the test luminance to
85 candela per square meter (cd/m2). The CSV-1000
– ETDRS chart has the advantage of having 5 letters
on every row, equal spacing of the rows on a log scale
(separated by 0.1 log unit), equal spacing of the letters
on a log scale, and letter difficulty balanced for each
row. Vision testing begins with the left-most letter on
the top row of the chart. Visual acuity is worse than
average above 0.0 LogMAR or when the denominator
of the Snellen visual acuity measurement is greater than
20 (eg, 20/100).28
Near visual acuity was assessed in well-lit conditions with both eyes at a distance of 40 cm using a
LogMAR chart (Good-Lite; see Figure 6). Visual acuity was recorded at the last line on which the observer
correctly identified at least 3 of the 5 letters. Visual
Table 1
Visual Functions Necessary for Assessing Medical
Image Quality
Visual Function
Basis for Testing
Visual acuity
Makes possible the accurate detection of the size of radiologic
16,17
anatomic structures.
Contrast sensitivity
Makes possible the discrimination
of low-contrast and high-contrast
19,20
frequency information.
Stereoacuity
Reduces the amount of visual scanning necessary to extract spatial
information, which sustains comprehension of complex visual experi25,27
ences. Provides visual memory
with a 3-D interpretation.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Figure 5. The 3 arrows in the magnified box indicate a 5-mm
simulated solitary pulmonary nodule in a chest phantom model.
Image courtesy of John D Thompson.
acuity was considered abnormal when greater than 1M
(the M-unit is the unit of letter size).16
In this study, contrast sensitivity was assessed in lowlight conditions with the CSV-1000E contrast chart.
The chart consists of a matrix of sinusoidal gratings:
circles filled with dark and light bars. Spatial frequency
increased from top to bottom, and contrast decreased
from left to right (see Figure 7). For the purpose of the
study, spatial frequency was divided into low (3 cpd),
medium (6 cpd), and high (12 and 18 cpd) categories.
The contrast level of the last circle the observer correctly identified on each row was recorded as the contrast
sensitivity score for that row. The procedure was repeated for each row in descending order. Visual contrast was
considered abnormal when less than 1.61 for 3 cpd, less
than 1.66 for 6 cpd, less than 1.08 for 12 cpd, and less
than 0.56 for 18 cpd.29
Stereoacuity was assessed with a Stereo Butterfly test
(Stereo Optical Company) at 40 cm. For this test, a card
with superimposed images of circles was shown to the
observer to measure the ability to detect the elevation
of the circles above the plane of the card (see Figure 8).
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Visual Function Assessment in Medical Imaging Research
Figure 8. The Stereo Butterfly test (Stereo Optical Inc). Image
Figure 6. LogMAR Good-Lite chart. Image courtesy of Carla
Lança.
courtesy of Carla Lança.
that might affect the testing. These conditions require
correction with glasses or contact lenses to achieve
the best possible corrected visual acuity.30 Because the
observers typically would use both eyes to perform
image evaluation, the 3 visual functions were measured
with both eyes open.
Results
Figure 7. CSV-1000E Vector Vision contrast chart. Image cour-
tesy of Carla Lança.
The circles indicate a stereopsis level ranging from
800 to 40 seconds of arc. The standard stereopsis test
has been applied, with results equal to or shorter than
50 seconds of arc considered normal stereoacuity.25
Subjects who usually wear corrective lenses were
asked to wear them during vision testing to ensure that
refractive errors were corrected. Refractive error refers
to the amount of myopia, hyperopia, or astigmatism
134
Of the 30 observers, 3 (10%) could not recall ever
having their vision examined, and 5 (16.7%) were examined approximately 5 years before the study began.
Eleven observers (36.7%) reported having a vision
examination within the previous 2 years.
Visual acuity, contrast sensitivity, and stereoacuity
distributions were recorded. The mean visual acuity
for distance was 20/14, with a minimum of 20/10 and
a maximum of 20/20. All subjects had maximal visual
acuities of 20/20 (LogMAR, 0.0) or better for distance
(see Table 2). The mean visual acuity of female observers (n  15) was 20/14 (LogMAR, 0.15) and for male
observers (n  15) it was 20/14 (LogMAR, 0.16).
Subgroup analyses by sex revealed no significant differences (P  .46).
The 7 subjects who wore corrective lenses had a mean
visual acuity of 20/16 (LogMAR, 0.11). Participants
who did not wear corrective lenses had a mean visual acuity of 20/14 (LogMAR, 0.17). The difference between
observers who used corrective lenses and those who did
not was not statistically significant (P  .12).
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Lança, Thompson, Lança, Hogg
Table 2
Descriptive Statistics Data From the 3 Visual Function Tests
Descriptive Acuity
Distance acuity (LogMAR)
Near acuity (M)
Stereoacuity (seconds of arc)
Minimum
-0.3
0.32
40
Maximum
Mean  SD
0.0
-0.15  0.07
0.40
0.39  0.02
50
40.67  2.54
(1.34  0.15) than those who did
not (1.52  0.08). Subgroup analyses by sex revealed no significant
differences (P  .05) for all spatial
frequencies.
Discussion
For this group of observers, the
minimum
criteria for participation
Contrast sensitivity (6 cpd)
1.70
2.29
2.16  0.15
in medical imaging studies were met.
Contrast sensitivity (12 cpd)
1.25
1.99
1.89  0.16
All observers’ visual abilities were
Contrast sensitivity (18 cpd)
1.25
1.55
1.47  0.12
adequate for the study, although
Abbreviations: cpd, cycles per degree; SD, standard deviation.
one observer required a new optical
prescription. All subjects achieved
Table 3
the normative range and had acceptable results for
Normative Data for Analyzing Visual Function
the 3 visual functions. These 3 abilities are necessary
Tests Results
for medical image evaluation in 2 codependent tasks:
Visual Functions
Population Norms
detection (visual acuity and contrast sensitivity) and
28
localization (stereopsis). For these preliminary results,
Distance acuity
 0.0 LogMAR
16
the researchers used population norms as a measure of
Near acuity
 1M
adequacy and supposed that these norms would apply
25
Stereopsis
 50 seconds
to medical imaging. This assumption needs to be supContrast Sensitivity
ported with more research.
29
3 cpd
 1.61  0.21
The mean binocular visual acuity of participants for
29
distance
was 20/14. The findings are comparable with
6 cpd
 1.66  0.23
29
one
previous
study, which reported the mean acuity of
12 cpd
 1.08  0.32
radiologists
as
20/15.12 In the present study, visual acuity
29
18 cpd
 0.56  0.35
was not significantly different when comparing observAbbreviation: cpd, cycles per degree.
ers by sex, and all subjects had maximal visual acuities
measuring LogMAR 0.0 (20/20) or better for distance.
All subjects had normal near visual acuity
Visual acuity influences the ability to detect nodules,
(0.39  0.02M) and near normal stereoacuity
which makes the assessment of this function an impor(40.67  2.54 seconds of arc). The log average values
tant measure for medical imaging.6 All subjects had norof contrast sensitivity for each spatial frequency were
mal values for contrast sensitivity. Only one observer had
better than population norms (see Table 3). Of the
low contrast sensitivity for spatial frequencies of 6 cpd
30 observers, one had low contrast sensitivity for spaand 12 cpd. The observer’s glasses were updated to a new
tial frequencies of 6 cpd (1.55) and of 12 cpd (0.31).
prescription, which resolved this problem.
However, this observer’s contrast sensitivity was
The authors detected a statistically significant differimproved, after receiving a new optical prescription, to
ence (P  .012) between observers who used corrective
6 cpd (2.14) and 12 cpd (1.25).
lenses and those who did not in the log average values
The difference between observers who used correcfor higher spatial frequencies (18 cpd). This difference
tive lenses and those who did not was significant for
favored the participants who did not use corrective
the higher spatial frequencies (18 cpd spatial frequency,
lenses. One cannot conclude, however, that there would
P = .012). Observers who used corrective lenses of any
be any resultant clinical effect on medical image observkind had a lower log average value of contrast sensitivity
er studies. Only 7 observers used corrective lenses,
Contrast sensitivity (3 cpd)
1.63
2.08
1.85  0.09
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Visual Function Assessment in Medical Imaging Research
and although a statistically significant difference was
detected, both values were within the normal range. It is
unlikely that this difference would adversely influence
clinical performance.
In the present study, visual function was measured
with different charts for each function. However, in
future studies these tests could be standardized and displayed on the same monitor used for medical image display. This will provide more accurate information about
visual function for the observers’ actual practice and
could be applied to the set of visual tests in this study.
Three observers could not recall ever having their
vision examined, and 5 were examined approximately
5 years ago. The elapsed time since the last reported
eye examination raises the question of whether regular
examinations are important to medical imaging. No
strict international recommendations in medical imaging exist, although it is recommended that even those
with no signs or risk factors for eye disease receive a
comprehensive eye evaluation at 40 years of age. 31 More
research is necessary to identify norms and guidelines
for visual performance evaluation in medical imaging.
Observers without prescribed corrective lenses should
be tested, and when visual anomalies are detected, those
observers must be excluded from studies that involve
image interpretation unless the corrective lenses are used.
Observers with corrective lenses should have routine eye
examinations and, if necessary, an updated prescription
to ensure they maintain maximal visual performance.
The authors plan to continue evaluating the role of
visual function in image interpretation to determine the
level of decreased eye function that could lead to errors
in image interpretation. Future challenges are related
to the visual function tests, which could be correlated
with the screen viewing distance used by observers to
provide more relevant information about diagnostic
accuracy.
Visual function assessments of medical image observers is absent in the literature. Although quality control
programs have been implemented for the performance
of digital displays, similar attention has not been devoted
to quality control for radiologists and other health care
professionals who examine the results of medical imaging
systems.12 This study proposes a range of visual tests suitable for assessing observers before participation in studies
136
on medical imaging. The authors propose that visual
function tests be conducted on potential observers before
their participation in medical imaging research using perceptual methodologies.
Conclusion
Quality standards for visual assessment should be
implemented to determine whether an observer has
adequate eye function to participate in medical imaging observer studies. A method has been provided for
visual function assessment of observers before medical
imaging perceptual research studies. Normal visual
function should be confirmed before performing visionbased tasks in medical imaging. Protocols of evaluation
and population norms have been provided with the
assessment of 3 functions (visual acuity, contrast sensitivity, and stereopsis). Observers with visual function
anomalies should be excluded from observer studies
that involve image evaluation and interpretation, unless
corrective lenses are used. Further studies are necessary
to clarify the relationship between visual function and
diagnostic performance.
Carla Lança, PhD, is lecturer in orthoptics at the
Orthoptic Department for the Lisbon School of Health
Technology in Lisbon, Portugal. Her research interest is
in visual function and its assessment in medical imaging
research. She can be reached at [email protected].
John D Thompson, PhD, is associate lecturer for the
University of Salford in Manchester, England.
Luis Lança, PhD, is senior lecturer in radiography for
the Lisbon School of Health Technology and lead for the
radiography program. He also is affiliated senior research
specialist in radiography for the Department of Clinical
Science Intervention and Technology for Karolinska
Institutet in Stockholm, Sweden.
Peter Hogg, BSc (Hons), MPhil, PgCert, is professor for
the University of Salford and the lead for the Diagnostic
Imaging Research Program. He is research dean and director
of the Health Sciences Research Centre for the University of
Salford. He also is affiliated senior research specialist in radiography at the Department of Clinical Science Intervention
and Technology for Karolinska Institutet.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
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Lança, Thompson, Lança, Hogg
Received November 12, 2014; accepted after revision
March 11, 2015.
Reprint requests may be mailed to the American Society
of Radiologic Technologists, Communications Department,
at 15000 Central Ave SE, Albuquerque, NM 87123-3909,
or e-mailed to [email protected].
© 2015 American Society of Radiologic Technologists
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29. CSV norms: contrast sensitivity values andnorms for the
CSV-1000E. Vector Vision Web site. http://www.vectorvision
.com/html/educationCSV1000Norms.html. Published
2004. Accessed August 28, 2015.
30. Refractive Error. Royal College of Opthalmologists Web site.
https://www.rcophth.ac.uk/professional-resources/revali
dation/clinical-sub-spe cialties/cataract/refractive-error/.
Accessed August 28, 2015.
31. Frequency of ocular examinations-2015. American Academy
of Opthalmology Web site. http://www.aao.org/clinical
-statement/frequency-of-ocular-examinations--november
-2009. Published March 2015. Accessed August 28, 2015.
138
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Peer Review
Microbial Safety Assessment of a Double
Check-Valve Patient Line in a Multiuse
Contrast Delivery System
Catherine Vermeulen, PhD
Barbara Noury, MSc
Frédéric Dolle, PhD
Habib Rebergue, MSc
Raphaël Boisgard, PhD
Purpose To demonstrate the microbial safety of a secure filling and injection kit designed to allow for multiple injections
of contrast media from a single large-volume container in computed tomography (CT) and magnetic resonance (MR)
imaging examinations.
Methods Two male Papio anubis baboons were injected with technetium-99 labeled albumin to mimic a contaminated
patient. Researchers injected iodinated contrast medium into the animals using an automated power injector via an
antecubital vein, with an injection line fitted with a double check-valve positioned at a 45° angle toward the vein (worstcase condition). Two contact times (before and after injection) were assessed in 3 experiments and repeated 3 times for
a total of 9 tested lines. Radioactivity levels were measured in the animals’ plasma and in the injection system.
Results Crude values were corrected for background signal and technetium Tc 99m radioactive decay. Results showed
an absence of contamination in the line above the check-valve. Negative results were because the mean value of
background noise was similar to the crude values measured.
Discussion Injecting contrast media from a large-volume container decreases the cost of CT and MR examinations.
However, this practice, which involves the use of the same injection system for multiple patients, is associated with a risk
of cross-contamination and requires manufacturers to demonstrate the safety of reusable injection kits.
Conclusion Based on appropriate demonstration of worst-case conditions and the use of a radiolabeled molecule
mimicking a pathogen particle (ie, as small as viral particles), this study highlights the safety and performance of the
tested injection system to perform repeated injections from a multidose container to more than one patient, regardless
of the conditions and duration of the examination.
A
utomated contrast media injections are
required in approximately 40% to 60% of
computed tomography (CT) scans and 30%
of magnetic resonance (MR) imaging proce1
dures. Because of the risks of nosocomial infection
associated with gravity infusion and power injection,
single-use bottles of contrast media, tubing, and other
supplies are recommended.2 However, as a result of
increased use and the high cost of contrast media, disposable material constitutes a chief financial burden for
medical imaging centers. 3-5 To decrease costs, as well as
improve CT room workflow and minimize radiographer handling error, contrast media sometimes are
injected into several patients from the same container. 6
Large-volume contrast media containers (vials or
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
prefilled soft bags) permit multiple administrations.
Almost all iodinated contrast media manufacturers
offer containers with a larger volume ( 500 mL) than
one required for a single patient (usually  100 mL).
The growing use of this practice is supported by
improved handling conditions, especially injection
materials and aseptic procedures. However, the cost
savings related to multiuse practices must be considered
in conjunction with the risk of cross-contamination
between patients.
Literature Review
According to the literature, the risk of bacterial,
parasitic, or viral infection associated with radiologic
examinations is low; nevertheless, the risk exists and
139
Peer Review
Microbial Safety Assessment of a Double Check-Valve Patient Line
must be taken into account.7-11 One study reported
malaria infection in 6 cases attributed to a power failure
that shut down injection, possibly causing reflux into an
injection line not equipped with an antireflux valve.12
Other case reports highlight failure to comply with
aseptic procedures as the reason for these incidents.13-16
In May 2008, 5 cases of hepatitis C virus infection
were reported after cardiac imaging. It was suspected
that these were caused by the inappropriate use of a bottle of physiological saline solution, although this could
not be proved. The study highlighted the importance of
using syringes and needles only once to avoid the risk of
cross-contamination when using one bottle.13
From August through November 2004, 6 cases of
hepatitis C were identified following CT scan in 3 centers in Spain. Blood contamination was possible in all
3 centers via the personnel who, in order to change the
extension tubes, disconnected the tube from the patient
first and then from the equipment without changing
gloves between these manipulations.14 An October
2004 investigation identified an acute hepatitis C virus
infection outbreak identified among patients who
underwent myocardial perfusion studies. The investigation concluded that the practices at the pharmacy could
have facilitated breaks in aseptic technique.15
On February 19, 2003, 4 cases of contamination with
Klebsiella oxytoca were reported following injections
made during intracranial nuclear MR examinations. It
was reported that the physiological saline solution used
to flush tubing before the injection of contrast media
was from one insufficiently sterilized bottle.16
Cases of infection related to the use of multiuse contrast delivery systems reported in the literature have led
the studies’ authors to implicate the absence of antireflux valves, inappropriate disconnecting procedures,
and noncompliance with required aseptic procedures as
potential causes of infection.12-16
Recommendations to reduce contamination risk
related to multidose containers include strict compliance with aseptic techniques, use of all materials within
8 hours, and adherence to multi-injection protocols.
These protocols include following the correct disconnection sequence and using patient lines fitted with 2
antireflux valves that must be changed between each
patient. 4 Injection tubing manufacturers are required
140
to demonstrate the effectiveness of the antireflux valves
and the bacterial safety of multiuse injection systems.
However, few studies have been done, and clinical relevance is sometimes doubtful in the existing studies
because they do not reflect clinical reality or worst-case
scenarios. For example, Cona et al evaluated the performance and safety of a multiuse injection system in relation to the risk of back-contamination17; this study was
conducted on rabbits, did not simulate clinical human
conditions, and did not include worst-case conditions.
Moreover, radioactivity counts were not evaluated with
respect to a potential viral load, and the bias related to
possible absorption of radioactive elements into the plastic tubing was not taken into account.
Purpose
The aim of this study was to investigate the biological safety, under clinical worst-case conditions, of a
patient delivery system designed to allow for multiple
safe injections from a single-use multidose container.
The tested system comprised a combination of 2 commercially available devices, manyfill (Medex) and secufill (Medex). The manyfill is a filling and injection system connected to the injector. The secufill is a patient
line with a double check-valve connected between the
manyfill and the patient. The secufill patient line is
changed between each patient, while the manyfill system can be used for up to 8 hours when complying with
device instructions.
The secufill check-valve is equipped with 2 silicone
mechanical components that permit fluid to flow in
one direction. It is characterized by its opening pressure
being lower than the valve opening pressure, thereby
preventing injection and backflow of blood into the
injector line.18 Silicone diaphragms of check-valves
typically are closed, and their opening and closing are
directly related to a positive cut-off upstream/downstream differential pressure. Valve safety is directly
related to a short closure time.
This nonclinical study was conducted in 3 steps.
The first step involved investigating the reproducibility of the performances of the double check-valve by
in vitro characterization of valve parameters (opening
pressure parameters and closure time) and assessing
the influence of the viscosity of the injected solution
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Peer Review
Vermeulen, Noury, Dolle, Rebergue, Boisgard
(contrast medium or saline). In the second step, an in
vitro backflow test using blue dye defined the clinical
worst-case conditions that would expose patients to a
risk of back-contamination due to blood backflow. Last,
in an in vivo study performed in baboons, the risk of
back-contamination of the delivery system was assessed
under the previously defined clinical worst-case conditions.
a risk of back-contamination due to blood backflow in
the line. The test consisted of identifying parameters
that influence backflow of Patent Blue V (Guerbet)
through the secufill: the nature of the product in contact with blood according to its viscosity (contrast
medium or saline), the position of the connection of the
patient line to the venous access, and the contact time
(see Figure 2). Backflow was defined as diffusion of
the blue dye from the distal end of the secufill (patient
side) to the other side of the valve (injector side), thus
mimicking back-contamination from a patient to fluid
containers (syringes, in most cases).
First, 2 solutions, a saline solution and a contrast
medium solution (iobitridol 350 mgI/mL; viscosity
21 mPas at 20°C and 10 mPas at 37°C) were tested.
Each solution was tested in combination with 2 secufill
positions (45° or 45°) in relation to the connection
point (6 for each solution and position for a total of 12
for each solution). Each test was repeated 3 times (18
samples for each solution). Then 2 solution contact
times (5 min or 30 min) were tested for only the contrast medium solution in only one position (45°), and
Materials and Methods
Test 1
This experiment was conducted to assess secufill
valve parameters following automated injections of
either iodinated contrast medium or standard saline
solution for CT (see Figure 1). The aim of this test was
to qualify the secufill line and valve and determine the
impact of the injected product on valve function. Four
batches of silicone and 2 manufacturing processes were
compared. Statistical tests were performed by Medex
in Excel (Microsoft); significance was determined by a
t-test and coefficients of variation. Two separate automated power injectors, ADDIX (Medex) and Dual Shot
Alpha (Nemoto Kyorindo
Co Ltd), were used to eliminate biases linked to injecIn Vitro Characterization of Secufill Valve Parameters
tor parameters. The parameters studied were the time
Flow direction
to complete closure of the
Contrast media
diaphragm and the pressure
or saline
differential between the
2 sides of the system. The
Pressure
column
effect of repeated injections
on the valve and the impact
of the fluid on time-toclosure and pressure differh 20-G
Double level
3-way
3-way
ential also were examined.
safety valve
catheter
stopcock
stopcock
A total of 100 valves were
5-cm tubing
10-cm tubing
10-cm tubing
tested in various configuraFlowmeter
EM
flowmeter
tions (see Table 1).
Pressure sensor
UPSTREAM
1 - 25 bar
Figure 1. The set-up was prepared to measure pressure and flow upstream and downstream to the
5000
secufill valve under conditionsTest
mimicking
clinical
conditions. The upstream line was connected to the
1
Test 2
Test 3
injector, and a back pressure of 10 mmHg was applied to the downstream line with an appropriately
prefilled column. This back pressure was applied to mimic human intravascular pressure.
4000
cpm/g
Test 2
The objective of this
second test was to identify the worst-case clinical
conditions associated with
Pressure sensor
DOWNSTREAM
0 - 2 bar
Injector
3000
2000
In Vivo Preclinical Study
1000
RADIOLOGIC TECHNOLOGY, November/December
2015, Volume 87, Number 2
Luer
Seg 1
Seg 2
Seg 3
Patient line
Seg 4
Seg 5
Junction Seg 1
Seg 2
Seg 3
Seg 4
Filling & injection kit
Contrast media
Injector
141
Peer Review
Microbial Safety Assessment of a Double Check-Valve Patient Line
Table 1
approval by the
CEA institutional
In Vitro Characterization of Secufill Valve Parmeters: Configurations Tested
ethics commitInjector and Tested Solution
tee (see Figure 3).
Dual Shot Alpha Injector
ADDIX Injector
All experimental
(Nemoto Kyorindo Co Ltd)
(Medex)
procedures were
Standard Saline Iodinated Contrast Standard Saline Iodinated Contrast
performed in accorBatch
Solution
Medium
Solution
Medium
dance with French
A (silicone lot)
x
x
regulations and in
compliance with the
B (silicone lot)
x
x
x
x
European Economic
C (silicone lot)
x
x
Community Directive
D (manufacturing
x
x
(2010/63/EU) on aniprocess)
mal welfare. Statistical
means and standard deviations were calculated
using Excel. Two male Papio anubis primates
weighing 21.5 kg and 25 kg were included.
One of the animals was included in both the
pilot study and the complementary study,
while the other animal was included only in
the complementary study. In both studies, the
animals were anesthetized by intramuscular
administration of 1 mg/kg of ketamine hydrochloride and 5 mg/kg of 2% xylazine hydrochloride. Each animal was sedated for a maxiFigure 2. The set-up was prepared to compare 6 secufill devices connected in
mum of 3 hours with the use of 10 mg/mL of
series to 6 stopcocks on an infusion manifold. Before connecting and filling the
propofol
at 3.5 mg/kg/h, injected through a
secufill lines, a back pressure of 10 mmHg was applied throughout the system
dedicated
3-way stopcock connected to a cathwith the use of an appropriately prefilled column connected upstream to the
eter
introduced
into an antecubital vein. Each
manifold. This back pressure was applied to mimic normotensive patient
intravascular pressure.
animal was intubated and ventilated throughout the experiments. Thermoregulation was
the test was repeated 4 times (24 samples). Patent Blue
maintained with a warming air pad system to
V solution was chosen as it has similar osmolarity as
limit the decrease in body temperature caused by anesblood, and it can be measured easily by spectrophothesia. Blood pressure was monitored with blood prestometry at a wavelength of 640 nm because of staining
sure cuffs, and physiological parameters (respiratory
caused by diffusion of the solution. The Beer-Lambert
frequency, oxygen saturation pCO2 , body temperature,
law was applied to determine Patent Blue V concentraand arm blood pressure) of the anesthetized primates
tions. A total of 96 secufill valves were tested in various
were controlled throughout the study. On completion
configurations (see Table 2).
of the experiment, animals woke under supervision
before being transferred to their facilities.
In Vivo Preclinical Study
A single dose of 220 MBq of technetium Tc 99m
A pilot study and a complementary study were
albumin was prepared extemporaneously according
performed at the French Alternative Energies and
to the manufacturer’s recommendations. Quality conAtomic Energy Commission (Commissariat à l’Energie
trol tests were performed for each synthesized batch
Atomique et aux Energies Alternatives [CEA]) after
proving the absence of free pertechnetate in the final
142
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Peer Review
Vermeulen, Noury, Dolle, Rebergue, Boisgard
Table 2
a 1 mL sample of arterial blood was
drawn to monitor plasma radioIn Vitro Diffusion Tests of a Patent Blue V Solution in Saline or
tracer concentrations over time on
Iodinated Contrast Medium Solutions at 21°C
200 L of plasma to assess natural
Solution
Angle
Time (min)
No. Lines  No. tests
blood clearance of the radiopharSaline
45°
5
63
maceutical.
30
To simulate a typical clinical set5
45°
63
ting, studies were performed with
an automated power injector, Dual
30
Shot Alpha, and the contrast mediContrast medium
45°
5
63
um was injected via the antecubital
30
64
venous access. The manyfill line
5
45°
63
was connected to the injector. One
30
of the 2 syringes was filled with
iobitridol using the manyfill filling
and injection line.
Researchers chose the iodinated contrast medium
instead of saline on the basis of conclusions from the
previous in vitro diffusion tests of a Patent Blue V solution in saline or iodinated contrast medium solution
that identified that the worst-case clinical conditions
associated with a risk of blood backflow is higher
when blood comes in contact with contrast medium as
opposed to contact with saline. For each animal, the
secufill line was then connected to the manyfill injection line and the entire injection system was purged of
contrast medium. The patency of the animals’ venous
access was checked by a preliminary saline flush before
connecting the secufill through a short 22-gauge
radiopaque IV catheter (Jelco, reference 4030, length
25 mm, diameter 0.9 mm). This catheter was closed
between injections with a 22-gauge obturator (Jelco,
reference 4022, length 25 mm). The secufill line was
configured according to the conclusion of the previous
Figure 3. The primates were injected with contrast media, and
worst-case studies that showed that the risk of blood
the secufill was connected to the primate arm at a 45° angle from
backflow was higher when the secufill line was posithe venous access. These conditions have the highest risk of blood
backflow. Two experiments, a pilot study and its complementary
tioned at a 45° angle from the venous access. This constudy, were performed to assess 2 criteria: the contact time after
dition was applied to all in vivo experiments.
the connection of the secufill line and animal vein before the
In the pilot study, contrast medium was injected
injection, and the lapse time before disconnecting the secufill line
2 minutes after connecting the secufill line to the vein.
from the animal after the injection.
Iobitridol (10 mL) was injected at a rate of 2 mL/s. A
30-minute contact time was observed before disconnecting the secufill line from the animal’s vein. The
ready-to-inject preparations. Technetium Tc 99m albucomplementary studies consisted of applying the same
min (5 mL, 48 MBq/mL) was administered to the aniprotocol in 2 animals under 2 different conditions,
mals through the calf venous access. Every 15 minutes,
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
143
Peer Review
Microbial Safety Assessment of a Double Check-Valve Patient Line
complementary study A and complementary study B
(see Table 3). Contact times before injection were 15
minutes for A and 2 minutes for B; contact times after
injection were 30 minutes for the CT scan in A and 60
minutes for the MR scan in B. Each experiment was
performed in triplicate for each animal, resulting in a
total of 3 results for the pilot study and 6 results for the
complementary studies. Nine secufill lines were used
for these 3 experiments.
The lines were disconnected from the catheter
after the predefined contact times, and the radioactivity associated with the lines was determined. To limit
biases in radiometer counts due to radiopharmaceutical absorption onto the plastics, the entire secufill
line and only the distal segment of the manyfill line
containing contrast medium were immediately frozen
in dry ice before being cut into fragments for analysis.
The distal part of the manyfill line was cut into four
3-cm segments (m1-m4). The secufill line was cut into
five 2.7-cm segments: 4 segments in the distal line
(s1-s4) and 1 segment above the check-valve (s5). The
luer locks between the secufill and the animal’s vein
and between the secufill and the manyfill also were
sampled. These 11 samples were weighed to express
radioactivity counts per unit weight (see Table 4).
Radioactivity of plasma samples and frozen samples
was determined with a Cobra II system (Hewlett
Packard) using gamma ray detection between 15 kiloelectron volts (keV) and 2000 keV for 60 seconds, and
values in cut samples were expressed in counts per
minute per gram of blood (cpm/g).
Table 3
In Vivo Preclinical Study: Configurations Tested
Study
Pilot study
Contact Time
After Connection
of Secufill Line to
Vein in Min (before
injection)
Contact
Time Before
Disconnecting
Secufill Line From
Animal Vein in Min
2
30
Complementary
study A
15
30
Complementary
study B
2
60
144
Radioactivity levels in primate plasma were measured every 15 minutes to assess radiopharmaceutical
blood clearance. The background noise of the device
also was assessed 3 times with the use of empty hemolysis tubes, or tubes containing a segment of line not
previously exposed to radioactivity, and a small volume
of iobitridol. Both the background noise and the technetium Tc 99m radioisotope half-life (6 hours) were taken
into account to normalize the values.
Background noise was subtracted from the count values of the various samples to determine the true radioactivity in the sample. The values obtained then were
corrected from technetium Tc 99m decay over time to
allow for direct comparison of the final values regardless of the sampling time.
Results
Test 1
The results of in vitro characterization of the secufill
valve opening pressure and parameters are as follows:
 The batches of silicone used for manufacture of
the valve had a limited impact on the pressure differential required for valve closure and no impact
on time-to-closure.
 As expected, time-to-closure of the valve was longer following contrast medium injection than following saline injection because of the different viscosities of the 2 solutions, indicating that contrast
medium constituted the worst-case condition.
 Repeated injection had no impact on these
parameters.
 No significant variation of the results was
observed according to the power injectors used.
 Valves obtained by different manufacturing
processes gave similar results.
Test 2
The results of in vitro backflow tests of Patent Blue
V in saline or iodinated contrast medium solutions were
used to define the worst-case conditions to mimic blood
backflow:
 The longer the valve made contact with the blue
solution, the more the blue solution diffused
throughout the line (see Figure 4).
 Backflow was more marked with iodinated
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Peer Review
Vermeulen, Noury, Dolle, Rebergue, Boisgard
Table 4
Measurement of Radioactivity in the Baboon Blood and in the Device in cpm/ga
Double Check-Valve Patient Line
(proximal to double check-valve)
b
Pilot Study
Complementary
c
Study A
Complementary
d
Study B
Mean
SD
Mean
SD
Mean
SD
Luer
8262
8681
18180
9518
10153
6929
s1
2201
1630
4297
3137
3141
3546
s2
1945
1132
5307
4130
3296
2965
s3
1994
1095
4997
3825
3671
3120
s4
1699
1050
4041
3114
3420
3570
s5
21
50
28
19
53
13
Junction
21
34
4
2
8
25
m1
7
49
37
47
86
121
m2
20
39
25
42
52
42
m3
20
10
23
34
44
39
m4
28
41
32
57
12
40
Double Check-Valve Patient Line
(distal to double check-valve)
Injection Line
(distal to double check-valve)
a
Values are corrected for background noise and decay of the radioisotope.
b
Contact time after connecting patient line to animal vein before injection: 2 min. Contact time before disconnecting patient line from animal vein after
injection: 30 min.
c
Contact time after connecting patient line to animal vein before injection: 15 min. Contact time before disconnecting patient line from animal vein after
injection: 30 min.
d
Contact time after connecting patient line to animal vein before injection: 2 min. Contact time before disconnecting patient line from animal vein after
injection: 60 min.
Abbreviations: cpm/g, counts per minute per gram of blood; m, manyfill; s, secufill; SD, standard deviation.
Visit asrt.org/as.rt?xvEytY to see full results of analysis.
contrast medium injection than with saline.
 An angle of 45° with the secufill resulted in more
marked backflow (see Figure 5).
In Vivo Experiments
Laboratory parameters analyzed during the in
vivo studies demonstrated that the 2 baboons tolerated all experimental procedures, including sedation,
anesthesia, catheterizations, radiopharmaceutical
injection, iodinated contrast medium injection, and
multiple blood samples for 3 hours in each protocol, and
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
recovered a normal status following the experiments
(see Table 5).
The mean radioactivity in the baboons’ plasma at
the end of the contact time for the 3 experiments was
7 340 937  2 374 843 cpm/g of plasma (n  3). Mean
radioactivity measured on the patient side of the patient
line just before the double check-valve was 3054  2644
cpm/g (n  9). In comparison, mean radioactivity measured in the patient line beyond the double check-valve
was 20  43 cpm/g (n  9), and in the injection line
it was 38  80 cpm/g (n  9). The radioactivity measured during the pilot study demonstrated the absence
of contamination of the secufill segment above the
valve (mean corrected radioactivity in segment 5 of the
145
Table 5
Blue V concentration
- µmol/L
Patent Blue VPatent
concentration
- µmol/L
Backflow of Patent Blue V According to Contact Time
Baboon Plasma Radioactivity Values at Start and
End of Experimental Time in cpm/ga
600
30min
5min
500
Pilot Study
Complementary Complementary
Study A
Study B
Start time
8 435 593
9 427 908
11 562 924
End time
7 458 922
4 909 300
9 654 589
Backflow of Patent Blue V According to Contact Time
400
600
30min
5min
300
500
a
Values are corrected for background noise and decay of the
radioisotope.
Abbreviation: cpm/g, counts per minute per gram of blood.
200
400
300
100
2000
100
Line 1
Line 2
Line 3
Line 4
Line 5
Line 6
Figure 4. For each line of 6 samples tested, the colored solution
NaCl-45
Xenetix+45
Xenetix-45
NaCl+45
2,5000 Backflow of Patent Blue V According to the
Solution and the Position of the Line
NaCl-45
Xenetix+45
Xenetix-45
NaCl+45
2,0000
2,5000
450,0000
400,0000
350,0000
450,0000
300,0000
1,5000
400,0000
2,0000
350,0000
1,0000
300,0000
250,0000
200,0000
150,0000
1,5000
250,0000
100,0000
0,5000
200,0000
1,0000
0,0000
0,5000
0,0000
50,0000
150,0000
Line 1
Line 1
Line 2
Line 2
Line 3
Line 3
Line 4
Line 4
Line 5
Line 5
0,0000
Line 6100,0000
50,0000
Line 6
0,0000
Figure 5. For each line of 6 samples tested, backflow was more
marked when the iodinated contrast medium (compared with
saline) was injected at an angle of 45° to the secufill.
secufill: 21  50 cpm/g; n  3) and in the manyfill line
(mean corrected radioactivity in segment 1 of the manyfill: 7  49 cpm/g; n  3) (see Figure 6). The complementary studies confirmed these observations (n  6)
and demonstrated that contact times between lines before
(2 and 15 mins) and after (30 and 60 mins) contrast
medium injection did not modify the range of radioactivity values measured proximal and distal to the valve, as
illustrated in Figure 7. Standard deviations reported for
each sample were calculated from triplicate experiments.
146
Patent Blue V concentration - µmol/L
Xenetix +45°
Backflow
Patenttime
Blue
to the with
diffused0 more
when theofcontact
is V10According
minutes (compared
Line 2 and
Line
3 Position
Line 4 ofLine
Line 6
the
the5 Line
5 minutes).Line 1Solution
Patent Blue V concentration - µmol/L
Xenetix +45°
35 37 39
Microbial Safety Assessment of a Double Check-Valve Patient Line
Patent
Blue V concentration
Patent Blue
V concentration
- µmol/L - µmol/L
5 37 39
Peer Review
Radioactivity expressed in cpm/g in the distal part of
the secufill was sometimes negative (see Table 4). The
crude values measured by the gamma counting system after correction for natural decay and background
noise were similar, and the mean background noise was
sometimes higher than the sample values, resulting in a
negative result. This observation confirms the absence
of radioactivity in the distal part of the secufill beyond
the valve.
Discussion
Reducing contamination risks of multidose containers to an acceptable level requires compliance with
aseptic technique, the use of all materials within
8 hours, an appropriate disconnection sequence, use
of the devices according to their intended use, and safe
injection protocols using a single-use double checkvalve injection system for each patient.2,4,19,20 The safety
of the multiuse procedure depends on the technique
of the health care professionals who perform the injections, as well as on the safety of the multiuse delivery
system. Because demonstration of the safety of these
delivery systems is not defined by any standards, it is
the manufacturer’s responsibility to demonstrate safety.
Such safety testing must be conducted under conditions reproducing clinical conditions as closely as possible and under worst-case conditions associated with
maximum contamination risks. The conditions associated with maximum contamination risks must first
be identified, particularly the conditions resulting in
the longest valve-closing time. The clinical conditions
associated with the highest contamination risks, such
as a maximum risk of backflow of the patient’s blood
into the injection line, also must be taken into account.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Pressure
column
h
20-G
catheter
Double level
safety valve
3-way
stopcock
5-cm tubing
3-way
stopcock
10-cm tubing
h
EM
flowmeter
Double level
3-way
Vermeulen,
Noury, Dolle, Rebergue, Boisgard
safety valve
stopcock
Pressure
sensor
Pressure sensor
UPSTREAM
DOWNSTREAM
1 - 25 bar 10-cm tubing
10-cm tubing 0 - 2 bar
20-G
catheter
3-way
stopcock
5-cm tubing
Flowmeter
EM
flowmeter
5000
Pressure sensor
Test 2
Test 3
DOWNSTREAM
0 - 2 bar
Test 1
cpm/g
4000
3000
5000
2000
Test 1
Test 2
Test 3
cpm/g
4000
1000
3000
Luer
Seg 1
Seg 2
Seg 3
Seg 4
Seg 5
Patient line
2000
Seg 2
Seg 3
Seg 2
Seg 3
Seg 4
Junction between patient
line and filling & injection kit
and animal vein
Seg 1
Junction Seg 1
Filling & injection kit
1000 Luer between patient line
Luer
Seg 4
Seg 5
Junction Seg 1
Seg 2
Seg 3
Figure 6. Radioactivity measurements (cpm/g) of 11 distinct
Seg 4
pieces of the
(secufill and
14000
manyfill line): triplicate results (test 1, test 2, and
test 3) in one
Complementary
study A
Luer betweenvalue
patientfor
line“luer security”Junction
between
patient
study B
animal. Truncated
test Complementary
1
14485
cpm/g.
cpm/g
Patient
line
injection
system
9000
Filling
distal
part& injection
of the kit
and animal vein
line and filling & injection kit
thatPressure
contrast
medium had a higher risk of backflow than
sensor
salineUPSTREAM
because the valve-closing rate was significantly
- 25 bar
longer1 with
contrast medium. A second in vitro diffusion study with a blue dye (test 2, allowing for diffusion
determination by visual inspection or spectrophotometry measurement) permitted the definition of worst-case
clinical conditions.
physicalStudy
position of the secufill
In VivoThe
Preclinical
in relation to the venous access (45° angle) was shown to
be a critical parameter
the in vivo experiments. The
Contrast in
media
45° angle between the secufill and the venous access was
associated with
increased
riskStudy
ofInjector
viral contamination
Inan
Vivo
Preclinical
because of the viscosity difference between blood and
the contrast medium.
Contrast media
This study alsoJunction
confirmed
that contact time must
between
injection
kit theInjector
be taken into account
and that
highest risk of conand patient line
tamination of the system occurred with
the contrast
Patient line with
double valve
medium
rather
than with saline as a result
of more
Filling injection
kit
marked diffusion of the Patent Blue V solution, which
Junction between
has similar osmolarity
to that
limitation
Luer between
injection
kit of blood. The
Segments to be tested
patient line
and patient line
of (radioactivity
these inassessment):
vitro observations
is that Patient
extrapolation
of
and
animal vein
line with
• 5 patient line segments: s1 → s5
doublesecufill
valve
• 4 injection
kit segments: m1 → m4 proximal to the
blue
dye
concentrations
valve
Filling
injection patient
kit
• luer
between
line and animal vein
[ Tc] albumin
• junction
kit and patient
line
is not
clinically
relevant
becauseRadiolabelled
the
molecular
weight
Technetium
NB: patient line valve was not tested
of Patent Blue V is not comparable to that
ofbetween
blood
Luer
Segments to be tested
patient
cells,
the viscosity
of line
the tested
(radioactivity
assessment): and diffusion properties
and animal vein
• 5 patient line segments: s1 → s5
fluids
arekitdifferent
• 4 injection
segments: m1 from
→ m4 those of blood, and the limit
• luer between patient line and animal vein
-7
[ Tc]
albumin M) does not
junction kit and patient
line
of •NB:
detection
of spectrophotometry
(8.10
Radiolabelled Technetium
patient line valve was not tested
allow for accurate and sensitive measurements proximal
to the secufill valve.
In this context, experiments were performed using
nonhuman primates and a radiopharmaceutical to
reproduce clinical conditions and obtain higher sensitivities. Animals were placed in a supine position,
and contrast medium was injected into an antecubital
vein to simulate clinical conditions. To mimic worstcase clinical conditions for the in vivo study, contrast
medium, rather than saline, was injected at a 45° angle
between the secufill and the venous access, after contamination by technetium Tc 99m albumin. The use
of this radiopharmaceutical was justified by the nature
and, more importantly, the size of this molecule: It
is a highly soluble protein with a diameter of 3.6 nm,
which is smaller than the viral contaminants typically
tested, such as minute mice virus (18-26 nm) and
poliovirus (20 nm), and is therefore a worst-case diffusible molecule.
Double valve
s4
s2
s1
m2
m4
9000
Complementary study A
Complementary study B
s3
s5
m1
14000
4000
cpm/g
Peer Review
10-cm tubing
Flowmeter
m3
Double valve
s4
s3
s5
s2
Luer
Seg 1
Seg 2
Seg 3
Seg 4
Seg 5
Junction Seg 1
Seg 2
Seg 3
Seg 4
m1
m2
Patient line
Filling & injection kit
4000
Luer between patient line
and animal vein
Luer
Seg 1
Seg 2
Seg 3
Junction between patient
line and filling & injection kit
Seg 4
Seg 5
Junction Seg 1
Seg 2
Seg 3
Seg 4
m4
99m
s1
m3
99m
Patient line
Luer between patient line
and animal vein
Filling & injection kit
Junction between patient
line and filling & injection kit
Figure 7. Radioactivity measurements (cpm/g) of 11 distinct
weighed pieces of the injection system (mean results of triplicate
tests for complementary studies A and B).
Safety testing should use the worst-case contaminant,
or an element representing this contaminant, to simulate contamination by a number of small diffusible
molecules such as viruses comparable to that of viruscontaminated blood. Simulation of contamination
is a difficult exercise; apart from studies of bacterial
contamination, only a few preclinical and clinical studies have evaluated the risk of contamination with viral
particles or small diffusible molecules.13
In this study, worst-case conditions were defined in
2 stages. A first in vitro study (test 1) evaluated valve
function according to certain criteria and demonstrated
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
147
Peer Review
Microbial Safety Assessment of a Double Check-Valve Patient Line
In the in vivo study, primates were injected intravenously with a mean dose of 9.9  0.8 MBq/kg of
body weight using freshly prepared technetium Tc 99m
albumin solution. The quantity of radiolabeled albumin
injected is equivalent in terms of number of molecules
to a viral load of approximately 1.10 9 particles per mL
of blood. This dose was defined to be representative of
a viral infection. Visual observations during the pilot
study showed blood flowed into the proximal part
of the secufill when it was connected to the patient’s
catheter. The presence of blood close to the valve was
identified as the main risk for backflow contamination;
therefore, 2 contact times before injection were tested
in the complementary studies. In addition to these 2
contact times, 2 more contact times after injection were
tested to mimic real examination times: a 30-minute
contact time for CT and a 60-minute contact time for
MR imaging examinations.
To ensure more reliable radioactivity measurements, all crude radioactivity counts were corrected
for background noise and decay of the radioisotope.
The biological plasma half-life of labeled albumin,
measured by counting plasma radioactivity every 15
minutes, was estimated to be 3 hours. This time period is long enough to permit a slight variation of the
plasma concentration of technetium Tc 99m albumin
during the experiment, thereby allowing for extrapolation of the quantity of radiolabeled albumin to a stable
viral load. Clearance of the radiopharmaceutical was
calculated for the 2 primates and ranged from 3 hours
to 12 hours. To limit biases possibly due to radiopharmaceutical absorption onto the plastic lines, the whole
secufill line and the distal part of the manyfill line
containing contrast medium were immediately frozen
in dry ice before being cut into fragments for analysis.
The design of the in vivo study, taking all of these
parameters into account, ensured the reliability of the
method and results as well as the performance of the
device in worst-case clinical conditions despite the
small number of animal experiments.
A study previously published by Cona et al also evaluated the performance and safety of a multiuse injection system in relation to the risk of back-contamination.17 They found their tested delivery system allowed
the contrast injection system to be used multiple times
without risk of cross-contamination. However, their
148
study did not take into account worst-case conditions
and did not simulate clinical human conditions, among
other limitations.
Conclusion
This study, based on in vitro characterization of the
secufill check valve and appropriate demonstration
of clinical worst-case conditions of power injections
in medical imaging, provides a reliable demonstration of the performance and safety of the secufill valve
in terms of the risk of contamination due to blood
backflow. The results of the in vivo preclinical study
performed in baboons with the use of a radiolabeled
molecule mimicking a pathogen particle demonstrate
the impermeability of the double check-valve even in
worst-case conditions. The combination of the secufill single-use patient line and appropriate tubing for
automated power contrast medium injection allows for
multiple injections with no risk of cross-contamination
between patients provided the manufacturer’s recommendations, handling procedures, and aseptic conditions are observed.
In the future, this type of study might lead to official
guidelines for the use of multiuse materials, such as bottles of contrast medium and tubing, by helping medical
imaging centers improve the workflow in a CT room,
minimize handling errors for radiographers, and reduce
operating costs.
Catherine Vermeulen, PhD, is regulatory affairs and
quality manager for Medex in Saint-Priest, France.
Barbara Noury, PhD, works for Pharmacie de la Cité in
Bron, France.
Frédéric Dolle, PhD , is head of the molecular probes
group at the CEA Life Science department and is in charge
of novel imaging probes and labeling processes for Service
Hospitalier Frédéric Joliot, Orsay, France.
Habib Rebergue, MSc, is research and development
manager for Medex in Saint-Priest, France.
Raphaël Boisgard, PhD, is head of the experimental
imaging group at the CEA Life Science department and
is in charge of the preclinical imaging platform for Service
Hospitalier Frédéric Joliot, Orsay, France.
Received November 13, 2014; accepted February 2,
2015.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Peer Review
Vermeulen, Noury, Dolle, Rebergue, Boisgard
Reprint requests may be mailed to the American Society
of Radiologic Technologists, Communications Department,
at 15000 Central Ave SE, Albuquerque, NM 87123-3909,
or e-mailed to [email protected].
© 2015 American Society of Radiologic Technologists
References
1. Ma X, Singh A, Fay J, Boland G, Sahani DV. Comparison of
dual-syringe and syringeless power injectors in outpatient
MDCT practice: impact on the operator’s performance, CT
workflow, and operation cost. J Am Coll Radiol. 2012;9:578582. doi:10.1016/j.jacr.2012.04.007.
2. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health
Infection Control Practices Advisory Committee. 2007
guideline for isolation precautions: preventing transmission
of infectious agents in health care settings. Am J Infect Control.
2007;35(10)(suppl 2):S65-S164. doi:10.1016/j.ajic.2007.10.007.
3. Beussink DR, Godat JF, Seaton T. Antimicrobial properties of
magnetic resonance imaging contrast media. Am J Health Syst
Pharm. 2000;57(1):48-50.
4. Cantin V, Labadie R, Rhainds M, Simard C; for L’ Unité
d’évaluation des technologies et des modes d’intervention
en santé du Centre Hospitalier Universitaire de Québec.
L’administration intraveineuse des substances de contraste en
imagerie médicale au CHUQ. http://www.chuq.qc.ca/NR
/rdonlyres/30F16456-0DF4-474B-B657-1176948AAA94/0
/rapport_substance_contraste.pdf. Published May 14, 2007.
Accessed September 9, 2015,
5. Buerke B, Puesken M, Mellmann A, Seifarth H, Heindel W,
Wessling J. Microbiologic contamination and time efficiency
of use of automatic MDCT injectors with prefilled syringes:
results of a clinical investigation. AJR Am J Roentgenol.
2010;194(2):299-303. doi:10.2214/AJR.09.3189.
6. Routhier J, Piazzo K, Sodickson A. Contrast and cost savings
by implementation of a multidose bulk IV contrast delivery
system. J Am Coll Radiol. 2011;8(4):265-270. doi:10.1016/j
.jacr.2010.08.031.
7. Longfield R, Longfield J, Smith LP, Hyams KC, Strohmer
ME. Multidose medication vial sterility: an in-use study and
a review of the literature. Infect Control. 1984;5(4):165-169.
8. Mattner F, Gastmeier P. Bacterial contamination of
multiple-dose vials: a prevalence study. Am J Infect Control.
2004;32(1):12-16.
9. Green KA, Mustachi B, Schoer K, Moro D, Blend R, McGeer
A. Gadolinium-based MR contrast media: potential for growth
of microbial contaminants when single vials are used for multiple patients. AJR Am J Roentgenol. 1995;165(3):669-671.
10. Dominik RH, Segebade IE, Taenzer V. Risk of microbial contamination of iodinated contrast media on multiple use
of large-volume bottles. Eur J Radiol. 1995;19(3):198-205.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
11. Paparella S. The risks associated with the use of multidose
vials. J Emerg Nurs. 2006;32(5):428-430.
12. Chen KT, Chen CJ, Chang PY, Morse DL. A nosocomial outbreak of malaria associated with contaminated catheters and
contrast medium of a computed tomographic scanner. Infect
Control Hosp Epidemiol. 1999;20(1):22-25.
13. Moore ZS, Schaefer MK, Hoffmann KK, et al. Transmission
of hepatitis C virus during myocardial perfusion imaging
in an outpatient clinic. Am J Cardiol. 2011;108(1):126-132.
doi:10.1016/j.amjcard.2011.03.010.
14. Pañella H, Rius C, Caylà JA, Barcelona Hepatitis C
Nosocomial Research Working Group. Transmission of hepatitis C virus during computed tomography scanning with
contrast. Emerg Infect Dis. 2008;14(2):333-336. doi:10.3201
/eid1402.060763.
15. Patel PR, Larson AK, Castel AD, et al. Hepatitis C virus
infections from a contaminated radiopharmaceutical used in
myocardial perfusion studies. JAMA. 2006;296(16):20052011.
16. Sardan YC, Zarakolu P, Altun B, et al. A cluster of nosocomial
Klebsiella oxytoca bloodstream infections in a university hospital. Infect Control Hosp Epidemiol. 2004;25(10):878-882.
17. Cona MM, Bauwens M, Zheng Y, et al. Study on the microbial safety of an infusion set for contrast-enhanced imaging.
Invest Radiol. 2012;47(4):247-251. doi:10.1097/RLI.0b013
e31823c0f87.
18. Gretzinger DT, Cafazzo JA, Ratner J, Conly JM, Easty AC.
Validating the integrity of one-way check valves for the
delivery of contrast solution to multiple patients. J Clin Eng.
1996;21(5):375-382.
19. Tress BM, Hellyar AG, Pennington J, et al. Multiple doses
of contrast medium from a single container: bacteriological
studies. Australas Radiol. 1994;38(2):115-118.
20. Blake MP, Halasz SJ. The effects of x-ray contrast media on
bacterial growth. Australas Radiol. 1995;39(1):10-13.
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Peer Review
Evaluation of Stress and a Stress-Reduction
Program Among Radiologic Technologists
Lynn Reingold, MS, R.T.(R)(CT)
Purpose To investigate stress levels and causes of stress among radiologic technologists and determine whether an
intervention could reduce stress in a selected radiologic technologist population.
Methods Demographic characteristics and data on preintervention stress sources and levels were collected through
Internet-based questionnaires. A 6-week, self-administered, mindfulness-based stress-reduction program was conducted
as a pilot intervention with 42 radiologic technologists from the Veterans Administration Medical Center. Data also were
collected postintervention. Identified sources of stress were compared with findings from previous studies.
Results Some radiologic technologists experienced improvement in their perceptions of stress after the intervention.
Sources of stress for radiologic technologists were similar to those shown in earlier research, including inconsistent
management, poor management communication, conflicting demands, long work hours, excessive workloads, lack of
work breaks, and time pressures.
Conclusion The mindfulness-based stress-reduction program is an example of an inexpensive method that could improve
personal well-being, reduce work errors, improve relationships in the workplace, and increase job satisfaction. More research
is needed to determine the best type of intervention for stress reduction in a larger radiologic technologist population.
S
tress is an inevitable physiological and psychological force that disturbs equilibrium.
Equilibrium refers to the body’s ability to maintain a level of balance. When a stressor is sensed,
the body prepares for “fight or flight,” which can be
beneficial in situations in which an immediate threat
exists. Ongoing stress, however, is detrimental to physical and mental health. Balancing the demands of daily
life at home and at work requires individuals to think
about factors that create stress and consider actions that
can be taken to restore equilibrium.
Stress in the workplace, or occupational stress, is
well-described in health care. According to the National
Institute for Occupational Safety and Health, occupational stress is “harmful physical and emotional
responses which occur when job requirements do not
match the capabilities, resources, or needs of the worker.”1 Occupational stressors, including long hours, work
150
overload, time pressure, difficult or complex tasks, lack
of breaks or variety, and poor work conditions can lead
to health problems.1
Stress affects radiologic technologists who must
interact with physicians, nurses, department supervisors, emergency department personnel, housekeeping
personnel, maintenance staff, patients, and patients'
families. Radiologic technologists often must work
rotating shifts, handle trauma situations, and inject
iodinated contrast agents that might cause an allergic
reaction in the patient. Physical stressors include positioning patients, moving equipment, and the risk of
exposure to ionizing radiation, which can cause physical
harm, including cataracts, skin erythema, and thyroid
issues. The current unpredictability in the health care
industry also can increase stress.
Occupational stress is costly to employers and
employees. Outcomes of work-related stress include
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
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Reingold
measurable increases in work-quality errors, downtime
related to sick leave, accidents, worker’s compensation
claims, and burnout. Identifying sources of occupational
stress in radiologic technologists and encouraging their
participation in a self-administered stress-reduction program might benefit employers and employees.
This study examined occupational stress among
radiologic technologists certified by the American
Registry of Radiologic Technologists within Veterans
Integrated Service Network (VISN) 19 of the Veterans
Health Administration (VHA). VISN 19 comprises
the VHA Rocky Mountain Network, which includes
Denver, Colorado; Fort Harrison, Montana; Salt Lake
City, Utah; Cheyenne, Wyoming; Grand Junction,
Colorado; and Sheridan, Wyoming. The study’s hypothesis was that occupational stress has a negative effect
on radiologic technologists and that participation in a
stress-reduction program would reduce the stress levels
of radiologic technologists.
The program explored the potential to be used
by radiologic technologists throughout the Veterans
Administration Medical Center (VAMC) system and
by those in other health care systems.
Literature Review
The National Institute for Occupational Safety and
Health reported the early warning signs of occupational
stress include cardiovascular disease, musculoskeletal
disease, psychological disorders, and risk of workplace
injuries. Although more research is needed to correlate
recent findings, it is believed that occupational stress
leads to suicide, cancer, ulcers, and impaired immune
function. A survey conducted by the Princeton Review
Research Associates showed 75% of employees believe
the average worker has more on-the-job stress than a
generation ago.1 A survey by Northwestern National Life
indicated that 40% of workers rated their job as being
either very or extremely stressful, whereas 25% viewed
their job as the most significant stressor in their lives.1
According to the Mayo Clinic, physical effects of
stress on the body include headache, muscle tension
and pain, chest pain, fatigue, changes in sex drive,
upset stomach, and sleep problems.2 Emotional effects
include anxiety, restlessness, lack of motivation or focus,
irritability and anger, and sadness and depression.
Sadock and Sadock linked stress to high blood pressure,
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
arrhythmia, blood clots, atherosclerosis, coronary
artery disease, heart attack, and heart failure.3
When stress is not relieved, burnout is inevitable.
According to Hobfoll and Shirom, one of the principal
consequences of work-related stress is burnout. Burnout
phenomena include emotional exhaustion, depersonalization, reduced personal accomplishment, decreased
enthusiasm about work, hopelessness, and feelings of
entrapment. 4 Stress differs from burnout in numerous
ways (see Table 1). Generally, stress tends to disappear
once the stressor is removed, whereas burnout remains.
A career change is the optimal solution to burnout.
If that is not an option, it is important to address issues
actively, clarify one’s job description, consider asking
for new duties, and, most importantly, take time off.5
Relieving stress before reaching burnout is crucial to
maintaining physical and mental health.
Recognizing the factors that create stress in radiologic technologists might help to prevent burnout.
However, extensive research on the topic has not been
performed, with even less research done on interventional methods used to lower occupational stress.
According to Raj, stress is common among radiologic technologists but they, like other health professionals, often do not actively seek professional help
Table 1
Stress vs Burnout
Stress
Burnout
Characterized by
overengagement
Characterized by
disengagement
Emotions are over-reactive Emotions are blunted
Produces urgency and
hyperactivity
Produces helplessness and
hopelessness
Loss of energy
Loss of motivation, ideals, and
hope
Leads to anxiety disorders
Leads to detachment and
depression
Primary damage is
physical
Primary damage is emotional
May kill prematurely
May make life seem not
worth living
©Helpguide.org. All rights reserved. Helpguide.org is a trusted nonprofit guide to mental health and well-being.
151
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Evaluation of Stress and a Stress-Reduction Program Among Radiologic Technologists
(see Table 2). 6 These individuals are hesitant to reach
out for emotional support because of the perception of
themselves as providers rather than receivers of health
care. Professional help is sought only when intervention
is necessary to maintain working status. 6
A study by Rutter and Lovegrove in the United
Kingdom focused on radiologic technologists in the UK
National Health Service Breast Screening Programme.7
A postal questionnaire was designed to determine
how radiologic technologists felt at work, how satisfied
they were with the job, and what the principal causes
of stress and dissatisfaction were. A total of 103 of 134
returned surveys showed that 30% of the sample had
high levels of stress; 17% of radiologic technologists
described being very satisfied with their jobs. The most
important predictors of stress were communication
problems, such as not knowing what to tell the client
and conflicts between home and work. The study
reported that the most important predictor of dissatisfaction was role ambiguity.7 This reinforces the findings
of Smith et al and Raj regarding the need for clarification of job descriptions, uncertainty about job responsibilities, and unclear reporting channels.5,6
A study by Verhovsek et al showed that a lack of
effective interprofessional communication leads to job
dissatisfaction and occupational stress.8 Of the radiologic technologists surveyed, 92% agreed or strongly agreed
that poor communication among colleagues, especially
nurses, was a source of stress. Verhovsek et al noted that
of the stress-inducing factors identified by Raj in Table 2,
many are related to communication failures.8
Akroyd et al and Crosby focused on burnout among
radiologic technologists in their studies.9,10 They found
that recognition, praise, and acknowledgement of worth
from supervisors can inhibit the development of burnout.
Crosby suggested improvements in working conditions to
minimize environmental stressors for radiologic technologists.10 Akroyd et al recommended that individuals adopt
healthy lifestyles and use relaxation techniques but also
favored interventions sponsored by the worksite such as
workshops in time management, interpersonal communication, and career planning.9
Many instruments have been used to measure the
markers of stress such as sleeplessness, depression, daily
aggravations, and health issues. One validated tool is
the Perceived Stress Scale (PSS), designed by Cohen et
al in 1983.11 The PSS has been used to assess the stressfulness of situations, the effectiveness of stress-reducing
interventions, and the extent to which associations
between psychological stress and psychiatric and physical disorders exist.
Another tool is the American Institute of Stress
(AIS) Workplace Stress Survey, developed in 1998 to
serve as a screening measure to determine the need for
Table 2
Work Conditions That Might Increase Stress Levels
6
Physical Conditions
Job Design
Work Relationships
Work Organization
Noise
Inconsistent time management
Inconsistent management
Changes in work organization and structure
Vibration
Conflicting demands
Poor management
communication
New technology
Poor lighting
Repetitive work
Lack of support or assistance
Lack of participation or promotional prospects
Poor ventilation
Underuse of skills
Social isolation
Excessive workloads
Poor workstation
Time pressures
Bullying
Long work hours
Uncertainty about
responsibilities
Harassment
Unclear reporting channels
Responsibility for others
Threats of violence
Lack of work breaks
Lack of appropriate training
Reprinted from Raj VV. Occupational stress and radiography. Radiol Technol. 2006;78(2):114.
152
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Reingold
further investigation with more comprehensive assessments.12 The AIS is a nonprofit organization that serves
as a resource for information on stress reduction, stress
in the workplace, stress related to military service, and
the health consequences of chronic, unmanaged stress.
Organization-based programs have been designed
to reduce occupational stress levels. Richardson
and Rothstein described programs employers can
implement that use meditation, relaxation, and deepbreathing practices.13 Other options include exercise
programs, journaling courses, time-management programs, and goal-setting classes. Although debate exists
over which techniques are the most effective, cognitive
behavioral interventions—in which the employee is
encouraged to take charge of negative thoughts, behaviors, and feelings by changing emotions and practicing
behavior-modifying techniques—seem to be the most
successful; these interventions generally are taught
by trained professionals in a group setting. Studies
indicate, however, that relaxation and meditation techniques remain the most popular choice. This is likely
because such techniques are less expensive, simpler, and
easier to implement than other interventional methods.
Mindfulness-based stress-reduction (MBSR)
intervention programs have become a popular option.
MBSR programs combine meditation, body awareness,
and yoga to help individuals cope with stress, anxiety,
and the personal challenges of everyday life. These
programs vary in length from several days to several
years; short versions of mindfulness training have
not been shown to be less effective in studied populations.14 Kabat-Zinn originally developed MBSR at the
University of Massachusetts Medical Center in 1979
as an 8-week program that included a full-day retreat.
Since that time, variations of MBSR have been devised,
and programs have been delivered face-to-face, via the
Web, and via teleconference calls.15
Goodman and Schorling conducted a study of MBSR
associated with significant improvements in burnout
scores and mental well-being for a broad range of health
care providers.16 Investigators found that over the 8-week
program, mindfulness significantly increased by the
second week, although the levels of perceived stress did
not change until the fourth week. The extent to which
mindfulness skills changed during the first 3 weeks of the
program appear to predict the change in perceived stress
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
levels over the course of the program.17
An advantage of MBSR programs is that they can
be conducted over the Internet. Benefits of conducting
a program online include low cost, the ability to participate at any hour from any location (especially from
home or another comfortable setting), and the possibility of offering the program to large populations in
diverse geographical locations.
Although radiologic technologists are similar in
some ways to nurses, the MBSR programs that have
been conducted for nurses might not be appropriate for
technologists. Radiologic technologists often have less
time to build relationships with patients. In addition,
machines intervene between radiologic technologists
and the patient, creating a barrier and possibly increasing stress for both.
Methods
The study included the collection of demographic
data, preintervention and postintervention survey questions, and a 6-week self-administered stress-reduction
program. An MBSR program was chosen because it was
inexpensive to conduct, it was offered via the Internet so
participants could choose their own best time to conduct
the intervention, and the participants could reuse the program after data collection ended.
Radiologic technologists included in the study were
certified in radiography, magnetic resonance imaging,
computed tomography, nuclear medicine, or interventional radiology. There was no planned control group
or randomization in this study. Randomization using
a control group could have led to bias; if the radiologic
technologists in one department had discussed the
study, some technologists could have identified that
they were excluded from the intervention group, which
might have led to a higher incidence of withdrawal from
the study, or obtaining the study link from colleagues to
become out-of-group participants. To avoid this, participation was offered to all radiologic technologists across
VISN 19 hospitals.
Individuals were asked to complete an online
informed consent document. Those who agreed to participate completed a set of demographic questions; a
set of survey questions18; and 2 self-administered
online pretests, the PSS19 and the AIS test (see Box 1),
via Survey Gizmo (an online survey tool). These tests
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Box 2
were freely available on the Internet. Participants
also answered qualitative questions (see Box 2).
The survey questions used were from a survey
(SurveyMonkey.com LLC) found online. The source
for the survey was not identifiable after extensive
searching. The questions appeared to be useful and
were included as part of the study, although the survey
is not a validated instrument.
Open-ended Questions
1.
List the top 3 stressors in your home life.
2.
List the top 3 stressors at work.
3.
How do you typically relax or reduce your stress levels?
 Week 1 – an introduction to mindfulness.
 Week 2 – a reminder to maintain a healthy and
Visit asrt.org/as.rt?66K6A8 to see the preintervention
surveys and tests for this study.
respectful relationship with food.
 Week 3 – steps to take when feeling nervous or
anxious.
After completing the preintervention survey and
tests, participants were asked to listen to a 20-minute
mindfulness/stress-reduction audio program twice a
week for 6 weeks and review a weekly lesson online. The
weekly lessons outlined basic tenets of mindfulness,
included imagery and stress self-awareness exercises, and
touched on basic mindfulness principles.
 Week 4 – the value of physical activity while
mentally focusing inward.
 Week 5 – the cathartic value of journaling.
 Week 6 – the value of ongoing mindfulness
practice, the importance of understanding
potential obstacles, and the benefit of developing
a plan to move forward.
Box 1
12
American Institute of Stress Workplace Stress Survey
Enter a number from the sliding scale below that best describes you.
Strongly disagree
1
2
3
Agree somewhat
4
5
6
Strongly agree
7
8
_______
I can’t honestly say what I really think or get things off my chest at work.
_______
My job has a lot of responsibility, but I don’t have very much authority.
_______
I could usually do a much better job if I were given more time.
_______
I seldom receive adequate acknowledgement or appreciation when my work is really good.
_______
In general, I am not particularly proud of or satisfied with my job.
_______
I have the impression that I am repeatedly picked on or discriminated against at work.
_______
My workplace environment is not very pleasant or safe.
_______
My job often interferes with my family and social obligations or personal needs.
_______
I tend to have frequent arguments with superiors, coworkers, or customers.
_______
Most of the time, I feel I have very little control over my life at work.
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9
10
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Visit asrt.org/as.rt?6n6wKa to access the program.
In addition to weekly lessons, a blog in which study
participants could contribute thoughts, feelings, and
ideas was available. Participants also were entered into a
drawing to win 1 of 4 $50 American Express gift cards
in appreciation for their time and to encourage participation in the study. At the end of the 6-week intervention
period, participants again self-administered the PSS, AIS
test, and follow-up qualitative questions online.
A sequential, coded ID number was assigned to each
participant. No identifying information was collected.
The demographic data collected included age, ethnicity, marital status, whether they had children living at
home, VAMC location, role within radiologic technology, level of education, and religion; answers to openended questions about general happiness and outside
stressors also were obtained.
Participants’ preintervention and postintervention
test scores were compared. Means of each of the groups
of radiologic technologists by role were compared with
one another to see whether differences in the levels
of stress among the groups existed preintervention
and postintervention. Qualitative analysis was conducted on the open-ended questions. The Wilcoxon
signed rank test and the Mann-Whitney U test were
used for pretesting and post-testing statistical analysis.
The Wilcoxon signed rank test was used to examine
whether paired differences between responses at time
1 (preintervention) and time 2 (postintervention) were
significantly different (P  .05) from 0. Stress survey
questions were rated on a Likert scale, ranging from
1 (disagree) to 4 (strongly agree). Institutional review
board approval was granted through Weber State
University and the University of Utah, which serves the
Salt Lake City VA Medical Center, where the investigator is based.
Participants
All participants were radiologic technologists. The
VISN 19 radiologic technologists were chosen because
the investigator works within this division. This
population was demographically diverse yet homogeneous in that all individuals worked within the same
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
organizational structure, thus reducing variability
among radiologic technologist workplaces. This group
of radiologic technologists represented a sample of the
larger VAMC radiologic technologist population and
also represented a sample of the radiologic technologist
population in the United States.
The study population of radiologic technologists in
VISN 19 (6 hospitals, approximately 150 technologists)
were asked to take part by their departmental supervisors, who were provided with the study description.
The VISN 19 radiology department directors received
a letter describing this project and asking for support in
encouraging staff participation. An information sheet
was included with the letter sent to supervisors for
placement in staff lounges or other locations. Forty-two
radiologic technologists participated in the study.
Instruments
The data collection tool captured demographic data
and responses to open-ended questions about issues that
might cause stress, a 15-question survey about stress,18
the PSS,19 and the AIS workplace stress survey. Data were
compiled in an Excel (Microsoft) spreadsheet.
The PSS predicts both objective biological markers of stress and increased risk of disease among persons with higher perceived stress levels. Cohen et al’s
research found that:
individuals with higher scores (suggestive of chronic
stress) on the PSS trend worse on biological markers
of aging, cortisol levels, immune markers, depression,
infectious disease, wound healing, and prostate-specific
antigen levels in men.20
Although the AIS survey was developed and is
endorsed by AIS, the organization notes that the survey is
not validated. AIS states on its Web site that the organization is developing it into a validated survey.12
Data analysis compared participants’ stress survey scores preintervention and postintervention.
Means were compared to analyze differences in the
levels of preintervention and postintervention stress.
Qualitative analysis was conducted by sorting the
responses to open-ended questions into themes; the
themes were compared with the findings of the studies
cited previously.
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Results
The average age of participants was 37.6 years, with
31.0% aged 25 to 34 years, 40.5% aged 35 to 54 years,
and 28.6% aged 55 years or older. Men made up 40.5%
of the participants. Regarding relationship status,
47.6% were married, 16.7% were living with a partner,
16.7% were divorced, and 19.0% were single. Full-time
employment in the VAMC system was noted by 95.2%
of participants. Education levels varied, with the majority possessing either an associate degree (40.5%) or
bachelor’s degree (33.3%).
By race and ethnicity, 92.9% were Caucasian, 2.4%
were African American, 2.4% were Hispanic/Latino,
and 2.4% chose not to answer. More than half of
respondents (53.9%) had worked in radiology for more
than 10 years. Of the remaining individuals, 3.9% had
worked 8 to 10 years, 30.8% worked 4 to 7 years, 3.9%
worked 1 to 3 years, and 7.7% worked less than 1 year.
Supervisory staff made up 15.4% of the respondents.
The majority of radiologic technologists (88.1%) were
based at the Salt Lake City VAMC.
Job responsibilities within radiology included diagnostic radiography (40.5%), computed tomography
(38.1%), magnetic resonance imaging (14.3%), angiography (38.1%), and other areas such as dual energy x-ray
absorptiometry and nuclear medicine (33.3%; the total
is  100%, indicating multiple job responsibilities).
Of the 15 survey questions, 7 items represented statistically significant improvements within individuals
from preintervention to postintervention (see Table 3).
The PSS instrument used a Likert scale of 1 (never)
to 4 (very often). Only 1 of 10 questions in the PSS was
statistically significant for change in individuals’ preintervention and postintervention scores:
 In the last month, how often have you felt difficulties
were piling up so high that you could not overcome
them? (mean difference  –0.667, P  .02).
The AIS instrument used a 1 (strongly disagree) to
10 (strongly agree) Likert scale. In the set of AIS questions, 2 of 10 statements demonstrated statistically
significant improvement from preintervention to postintervention for individuals:
 I could usually do a much better job if I were given
more time (mean difference  –2.267, P  .001).
 My workplace environment is not very pleasant or
safe (mean difference  –2.200, P  .001).
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Table 3
Seven Areas of Improvement Postintervention
Question
Mean
Difference
P
Value
During the course of my normal workweek as a radiologic technologist, I
often feel a general lack of respect from
my patients.
0.47
.04
I often find that current management
rules and/or protocols work against me
in my daily routine.
0.67
.01
I often find that current management
rules and/or protocols work against the
best interests of my patients.
0.60
.047
I often find the radiologists that I work
with daily tend to be easy to work with.
0.73
.03
In the last month, how often have you
felt difficulties were piling up so high
that you could not overcome them?
0.67
.02
I could usually do a much better job if I
were given more time.
2.27
 .001
My workplace environment is not very
pleasant or safe.
2.20
 .001
The Mann-Whitney U test reflects the findings of all
subjects at time 1 vs all subjects at time 2, significant at
P  .05. Of the 15 survey questions, 4 were significantly different before and after the program (see Table 4).
One PSS question out of 10 was statistically significantly different from preintervention to postintervention:
 In the last month, how often have you felt difficulties
were piling up so high that you could not overcome
them? (2  sometimes, 3  fairly often; mean of
time 1  2.667, mean of time 2  2.000, P  .05).
No statistically significant changes were seen in the
AIS survey results for all subjects’ preintervention to
postintervention scores. Additional Mann-Whitney U
tests were conducted on specific variables to determine
any statistically significant differences among respondents. For example, sex as a factor was statistically
significant before the intervention. The same analysis
(women vs men) was completed postintervention. Only
the questions that demonstrated statistical significance
are reported (see Table 5).
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Table 4
Significant Time 1 and Time 2 Findings From the
Mann-Whitney U Test
Mean for
Time 1/Time 2
P
Value
During the course of my normal
workweek as a radiologic technologist, I often feel a general lack of
respect from my patients
(1  disagree, 2  somewhat agree)
1.60/1.13
.02
During the course of my normal
workweek as a radiologic technologist, I often feel a general lack of
support from physicians other than
radiologists.
0.40/0.07
.04
I often find that current management rules and/or protocols work
against me in my daily routine (1 
disagree, 2  somewhat agree).
2.33/1.67
.03
I often find the radiologists that I
work with daily tend to be neither
easy nor difficult to work with  3,
easy to work with  4.
3.07/3.80
.04
Question
When age was analyzed as a factor, no statistically
significant differences among age groups existed preintervention. The significant findings were all postintervention:
 During the course of my normal workweek as a
radiologic technologist, I often feel a general lack of
support (mean for ages 25-34  0.000, mean for
ages 35-54  0.833, mean for ages 55  0.750,
P  .0302; the mean response for ages 35-54 was
significantly greater than that for ages 25-34, and
the mean response for ages 55 was significantly
greater than that for ages 25-34).
 In the last month, how often have you been angered
because of things that were outside of your control?
(mean for ages 25-34  3.200, mean for ages 35-54
 2.333, mean for ages 55  2.000, P  .04; the
mean response for ages 25-34 was significantly greater than that for ages 35-54, and the mean response
for ages 25-34 was significantly greater than that for
ages 55).
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Marital status was not a statistically significant factor
preintervention. Only the statistically significant findings postintervention are presented:
 I can’t get things off my chest at work (mean married  7.57, mean not married  8.000, mean
divorced  1.667, mean single  3.500, P  .03;
the mean response for married was significantly
greater than that for divorced, the mean response
for married was significantly greater than that for
single, and the mean response for not married was
significantly greater than divorced).
 I have the impression that I am repeatedly picked on
or discriminated against at work (mean married 
1.857, mean not married  6.667, mean divorced
 1.000, mean single  4.000, P  .04; the mean
response for not married was significantly greater
than that for married, and the mean response for
not married was significantly greater than that for
divorced).
Whether radiologic technologists had children living at home was examined as a factor that might influence stress levels preintervention and postintervention.
Table 6 shows the questions found to be statistically significant preintervention and postintervention.
Thirty-three percent of participants also provided
qualitative comments about the top stressors and stress
relievers at work and at home, both preintervention
and postintervention. The results were categorized,
and trends and commonalities were noted. Money was
a common stressor (64% of radiologic technologists)
as was a lack of time to complete tasks (64%), both at
home and at work. Family issues including aging parents, young children, and maintaining relationships
with significant others were recurring themes. Several
radiologic technologists noted feeling rushed and
crowded at work and too busy, with no time for breaks
or lunch. The Salt Lake City VAMC is a teaching hospital with student technologists, which created frustration for some radiologic technologists. Other stressors
noted by participants included a lack of consistency
from management, feeling underappreciated at work,
and a negative work environment, including “unnecessary drama” and complaints about management in general. Although an online blog was provided for anyone
who wanted to contribute to it, no participants chose
to do so.
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Table 5
Sex as a Factor
Mean:
Women/Men
P Value
During the course of my normal workweek as a radiologic technologist,
I often feel a general lack of respect from my immediate supervisor.
2.56/1.00
 .001
During the course of my normal workweek as a radiologic technologist,
I often feel a general lack of respect from my patients.
1.33/2.00
.03
During the course of my normal workweek as a radiologic technologist,
I often feel a general lack of support from my supervisor.
0.78/ 0.00
.01
During the course of my normal workweek as a radiologic technologist,
I often feel a general lack of support from radiologists.
0.11/0.67
.02
(1 = very difficult, 4 = easy to work with).
3.67/2.17
.01
In the last month, how often have you been upset because of something that happened unexpectedly?
3.33/2.17
.02
In the last month, how often have you felt nervous and stressed?
3.56/2.83
.02
In the last month, how often have you felt that you were on top of things?
2.67/4.00
 .001
My workplace environment is not very pleasant or safe.
5.78/2.50
.02
Most of the time I feel I have very little control over my life at work.
6.89/2.33
.01
During the course of my normal workweek as a radiologic technologist,
I often feel a general lack of support from my immediate coworkers.
0.44/0.00
.04
In the last month, how often have you been upset because of something that happened unexpectedly?
2.78/2.17
.04
In the last month, how often have you felt nervous and stressed?
3.33/2.33
 .001
In the last month, how often have you felt that you were on top of things?
3.13/4.00
.02
Question
Preintervention
I often find the radiologists that I work with daily tend to be . . .
Postintervention
Discussion
Seven of the 15 survey questions indicated individual improvement postintervention, with participants’
attitudes toward stressors becoming more positive.
Based on these survey questions, some radiologic
technologists experienced significant improvement
in their perceptions of stress from preintervention to
postintervention.
Only 1 of 10 questions in the PSS showed significantly different responses from individuals postintervention. Two of the 10 statements in the AIS instrument demonstrated statistically significant change in
individuals from preintervention to postintervention.
Participants’ attitudes about having enough time to
complete tasks at work improved. This might have
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been the result of a slow period in the department, or it
might have been that the radiologic technologists felt
calmer and more in control after practicing mindfulness. Attitudes also shifted positively regarding the
workplace environment. After the 6-week intervention,
participants felt better about the safety and overall
pleasantness of the workplace. This finding could be
related to an increased sense of self-control.
Responses to the majority of the PSS and AIS questions did not show statistically significant change. This
could be because technologists in VISN 19 are generally satisfied with working conditions and are not experiencing high levels of stress. It could be that radiologic
technologists are stressed, but that this program did
not affect work stress levels enough to elicit a change.
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Table 6
Children Living at Home as a Factor
Mean:
No/Yes
P Value
During the course of my normal workweek as a radiologic technologist,
I often feel a general lack of support.
0.88/0.43
.045
I often find that current management rules and/or protocols work against
the best interests of my patients.
1.50/2.43
.03
I feel that I am inadequately compensated at my workplace for my education and training.
1.25/2.43
.03
I have the impression that I am repeatedly picked on or discriminated against at work.
2.88/4.57
.04
My job often interferes with my family and social obligations or my personal needs.
2.88/6.00
.04
Question
Mean: Never/Very Often P Value
In the last month, how often have you found that you could not cope with all the things that
you had to do?
2.13/ 2.86
.049
Question
Mean: No/Yes
P Value
During the course of my normal workweek as a radiologic technologist,
I often feel a general lack of respect from my immediate supervisor.
1.13/1.86
.04
I feel that I am inadequately compensated at my workplace for my education and training.
1.50/2.71
.04
I feel that I am inadequately compensated at my workplace for my level of performance.
1.38/2.57
.03
I seldom receive adequate acknowledgement or appreciation when my work is really good.
3.38/7.43
.01
My workplace environment is not very pleasant or safe.
1.75/2.86
.04
My job often interferes with my family and social obligations or my personal needs.
2.38/6.71
.01
Most of the time I feel I have very little control over my life at work.
2.75/5.86
.03
Question
Mean: Never/Very Often P Value
In the last month, how often have you felt confident about your ability
to handle your personal problems?
4.25/3.14
.02
In the last month, how often have you found that you could not cope with
all the things that you had to do?
1.88/2.86
.01
In the last month, how often have you been able to control irritations in your life?
4.00/3.43
.01
In the last month, how often have you felt that you were on top of things?
3.86/3.14
.048
In the last month, how often have you felt difficulties were piling up so high
that you could not overcome them?
1.63/2.43
.04
Question
Preintervention
Postintervention
A program longer than 6 weeks might have proven to be
more beneficial.
For all subjects, 4 of the 15 survey questions were
significantly different before and after the program.
Postintervention, radiologic technologists perceived an
increase in respect from patients and felt more supported
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
by other (nonradiologist) doctors. No significant change
in the perception of respect received from radiologists,
coworkers, or supervisors occurred. As a group, participants did not agree that management’s rules were
working against them in their daily routine. Study participants generally felt neutral about interactions with
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Evaluation of Stress and a Stress-Reduction Program Among Radiologic Technologists
radiologists before the intervention, but that improved to
a statistically significant difference after the intervention.
Participants felt less burdened by difficulties after the
6-week course but, in general, were not feeling significantly burdened before or after the program.
Sex as a factor was statistically significant before the
intervention for several statements. Women appeared
to feel a lack of respect from supervisors more than men
did; men reported feeling less respected by patients.
Women tended to feel more nervous, more stressed, and
more upset by unexpected events than did their male
counterparts. Women also felt less on top of things than
men did and perceived significantly less control over
their lives at work. In contrast, women felt safer and had
the sense of a more pleasant work environment than
male radiologic technologists.
The same analysis (women vs men) was completed
postintervention. A lack of coworker support was significantly greater for female radiologic technologists
postintervention, which was not statistically significant
preintervention. Events occurring during the intervention period might have led to this change and reflected a
short-term response, not indicative of a permanent state.
Although being upset over an unexpected event did not
occur often (as an absolute number) either preintervention or postintervention, this issue was more statistically
significant for women than for men at both time points.
The mean response for feeling nervous and stressed was
more statistically significant for women than for men,
both preintervention and postintervention, although
the scores improved slightly for both groups after the
intervention. The feeling of being on top of things was
significantly different between men and women before
and after the intervention, and decreased slightly for
women postintervention. No change in mean score was
found in men from preintervention to postintervention. Interestingly, only 2 questions appeared in both
preintervention and postintervention findings, and both
questions dealt with self-management of issues. The
men’s mean value (the absolute value) did not change
from preintervention to postintervention, but the women’s mean value did change.
When age was analyzed as a factor, no statistically
significant differences among age groups preintervention existed. Postintervention, radiologic technologists
older than age 34 appeared to feel more support than did
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those younger than age 34. Older radiologic technologists might have worked longer in the technologist role
and established more connections and social networks
among peers than younger workers who were still developing work relationships. Radiologic technologists aged
25 to 34 were more easily angered by what could not
be controlled than were older technologists. This again
might reflect a lack of social relationships at work; older
radiologic technologists might have been able to more
easily vent their emotions.
Divorced and single individuals might discuss concerns with work colleagues more than with family or
friends outside the workplace. The social networks for
these individuals might be stronger at work than the
interpersonal work relationships of those who are married. Married individuals might share concerns with
spouses and do not need to discuss stressors with work
colleagues to the extent that divorced and single individuals do. Radiologic technologists who were not married
felt significantly more discriminated against than did
those who were married or divorced. This finding might
be culturally related to the VISN 19 study population or
could be related to internalization of personal issues if,
as a single individual, a radiologic technologist has fewer
intimate connections with peers at work.
Those participants with children living at home
agreed with the statement that work can interfere with
personal or external needs. The requirement to be
on call and work night shifts, holidays, and weekends
affects this finding. Having children at home might
increase stress levels. More statistically significant
results were found postintervention relative to children
at home than at preintervention. Of note, individuals
without children living at home felt more confident
about handling personal problems. One can hypothesize that these individuals have more time and energy
to spend on themselves, and this stress-reduction
intervention might have helped with dealing with
these issues. Controlling irritations was easier for those
without children living at home. Radiologic technologists with children living at home felt less appreciated
or acknowledged at work; this might be a spillover
from the same feeling at home. As in the preintervention survey, individuals with children living at home
perceived work as interfering with family and social
obligations more than did those without children living
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at home, although the change from preintervention to
postintervention was minimal.
It was encouraging to find no statistical significance
to the response regarding participants changing careers
or leaving the health care field. In addition, few radiologic technologists felt that unnecessary examinations
were conducted or that patients were abusive.
Based on the responses to the postintervention
qualitative questions, it appears that VISN 19 radiologic
technologists are using healthy approaches to managing
stress, including working out, hiking, yoga, gardening,
and reading. A few participants reported choosing less
healthy remedies, including alcohol consumption, watching television, or simply “shutting down.”
Similarities between this study and Raj’s 2006 study
confirm that stress-causing issues have not changed.
Both studies showed that radiologic technologists
reported the following stressors: inconsistent management, poor management communication, conflicting demands, inconsistent time management, long
work hours, excessive workloads, lack of work breaks,
and time pressures. In the current study, participants
reported these comments in response to the qualitative
questions, although many of these stressors were not
reflected in statistically significant findings.
Studies by Verhovsek et al, Akroyd et al, and Crosby
noted that staff receiving acknowledgement and reassurance of their worth from their supervisors makes a significant difference in reducing occupational stress.8-10
This study appeared to show a trend toward a positive effect of the MBSR program. Raising awareness
of stress might have caused individual technologists to
reflect on stressful issues and how best to handle them.
More research is needed on a larger scale.
Study Limitations
This study had several limitations. The participants
were all VHA employees who might not be representative of all radiologic technologists nationwide. The
6-week study length might have been too long for
participants to remain engaged. Conversely, it might
have been too short to demonstrate significant change,
although other programs have demonstrated change
after only a few weeks. It is likely that the longer individuals practice mindfulness, the better the results
will be. In addition, there is no way to know whether
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
participants performed the mindfulness activities twice
weekly or used the weekly lessons at all.
This study included a small number of participants.
In hindsight, the study could have been opened to more
hospitals in the VHA system to gain a larger study sample. The participation level might reflect the fact that
radiologic technologists are too stressed to participate
in an after-work program, are apathetic, or that busy
home and work lives make it difficult to participate in
an MBSR program. The hope was that offering a drawing to win an American Express gift card would boost
participation; however, this tactic did not seem to affect
the participation level.
A question remains as to what role department
managers and supervisors played in affecting participation. Contact was made with supervisors at VAMC
radiology departments within VISN 19. Supervisors
received program information in advance and were
sent weekly e-mail reminders. Although read-receipts
were obtained, it is not known whether supervisors
ignored the information, shared it with employees,
or actively discouraged participation by downplaying the value of participation. Supervisors might not
have wanted to know what the results would be if the
findings showed high levels of stress among radiologic
technologists because it might have created the perception that supervisors were responsible for stressful
work environments.
The statistically significant change from preintervention to postintervention was less than expected.
Participants might have experienced “survey fatigue.”
Fewer questions to answer preintervention and postintervention might have shown different results. This
program was relatively easy to develop and conduct, but
it leaves the question open as to which type of intervention program is the most successful: instructor-led or
self-directed.
Conclusion
This was a pilot study designed to evaluate whether
a short-term mindfulness-based program reduced stress
levels in radiologic technologists. A need for further
investigation was demonstrated. This study should be
repeated on a larger scale. Ideally, a randomized controlled trial that compares this MBSR program (or a
similar one) with an instructor-led program of similar
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Peer Review
Evaluation of Stress and a Stress-Reduction Program Among Radiologic Technologists
content and duration could demonstrate an optimal
future direction for an MBSR stress-reduction program.
Another study could explore a comparison of this
MBSR program with a non-MBSR program to investigate the type of stress-reduction program that best
suits radiologic technologists. The American Society
of Radiologic Technologists, the VAMS, or both might
consider conducting research among their entire radiologic technologist populations to provide a rich source
of information about stress levels in radiologic technologists and useful methods for occupational stress
reduction.
Lynn Reingold, MS, R.T.(R)(CT), is a radiologic
technologist for the U.S. Department of Veterans Affairs in
Salt Lake City, Utah.
Received August 1, 2014; accepted after revision March
11, 2015.
Reprint requests may be mailed to the American Society
of Radiologic Technologists, Communications Department,
at 15000 Central Ave SE, Albuquerque, NM 87123-3909,
or e-mailed to [email protected].
© 2015 American Society of Radiologic Technologists
References
1. Sauter S, Murphy L, Colligan M, et al. Stress...at work.
Centers for Disease Control and Prevention Web site. http://
www.cdc.gov/niosh/docs/99-101/. Published 1999. Accessed
March 6, 2014.
2. Stress symptoms: effects on your body and behavior. Mayo
Clinic Web site. http://www.mayoclinic.org/healthy-life
style/stress-management/in-depth/stress-symptoms/art
-20050987. Published July 19, 2013. Accessed March 6, 2014.
3. Sadock B, Sadock V. Psychological factors affecting physical
conditions. In: Kaplan and Sadock’s Synopsis of Psychiatry.
10th ed. Philadelphia, PA: Lippincott, Williams & Wilkins;
2007:813-828.
4. Hobfoll SE, Shirom A. Conservation of resources theory:
applications to stress and management in the workplace. In:
Golembiewski RT, ed. Handbook of Organizational Behavior.
2nd ed. New York, NY: Marcel Dekker; 2001;57-80. http://
psycnet.apa.org/psycinfo/2001-14053-003. Accessed
March 7, 2014.
5. Smith M, Segal J, Segal R. Preventing burnout: signs, symptoms, and coping strategies. HelpGuide.org Web site. http://
www.helpguide.org/mental/burnout_signs_symptoms.htm.
Published 2012. Accessed March 6, 2014.
162
6. Raj V. Occupational stress and radiography. Radiol Technol.
2006;78(2):113-122.
7. Rutter D, Lovegrove M. Stress and job satisfaction in mammography radiographers. Work Stress. 1995;9(4):544-547.
8. Verhovsek E, Byington R, Deshkulkarni S. Perceptions of
interprofessional communication: impact on patient care,
occupational stress, and job satisfaction. Internet J Radiol.
2009;12(2).
9. Akroyd D, Caison A, Adams R. Patterns of burnout among
U.S. radiographers. Radiol Technol. 2002;73(3):215-223.
10. Crosby CS. Occupational stress and burnout in radiologic
technologists. Radiol Manage. 1987;9(2):52-54.
11. Cohen S, Kamarck T, Mermelstein R. A global measure of
perceived stress. J Health Soc Behav. 1983;24(4):385-396.
12. American Institute of Stress. Workplace Stress Survey. http://
www.stress.org/wp-content/uploads/2011/08/Workplace
-Stress-Survey.pdf. Accessed March 6, 2014.
13. Richardson K, Rothstein H. Effects of occupational stress
management intervention programs: a meta-analysis. J Occup
Health Psychol. 2008;13(1):69-93.
14. Carmody J, Baer R. How long does a mindfulness-based
stress reduction program need to be? A review of class contact
hours and effect sizes for psychological distress. J Clin Psychol.
2009;65(6):627-638.
15. History of MBSR. Center for Mindfulness Web site. http://
www.umassmed.edu/cfm/stress-reduction/history-of-mbsr/.
Published 2014. Accessed March 9, 2014.
16. Goodman M, Schorling J. A mindfulness course decreases
burnout and improves well-being among healthcare providers. Int J Psychiatry Med. 2012;43(2):119-128.
17. Baer R, Carmody J, Hunsinger M. Weekly change in mindfulness and perceived stress in a mindfulness-based stress reduction program. J Clin Psychol. 2012;68(7):755-765.
18. Survey: occupational stress – radiologic technologists. http://
www.surveymonkey.com/s/WBGLBSF. Accessed March 6,
2014.
19. Cohen Perceived Stress. http://podcast.uctv.tv/webdocu
ments/COHEN-PERCEIVED-STRESS-Scale.pdf. Accessed
March 6, 2014.
20. Reddy V, Naveenm N, Prabu, Manipal S, Preethi A,
Ahmed A. The evaluation of perceived stress and depression in dental undergraduates. Int Dent J Student’s Res.
2013;1(4):37-41.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
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Medical Ethics and Law in
Radiologic Technology
Eric P Matthews, PhD, R.T.(R)(CV)(MR), EMT
Tracy M Matthews, PhD
At every stage of their careers,
radiologic technologists
and student technologists
must adhere to high ethical
standards, obey the law, and
consistently conduct themselves
with professionalism. This
article explains how modern
health care ethics evolved,
focusing on 8 important
theorists. It also describes
the ethical responsibilities
of health care providers
and the rights of patients.
Important civil rights laws
are discussed, focusing on the
rights of health care workers as
employees. A brief overview of
the U.S. legal system follows,
including the causes of action
that most commonly involve
health care professionals.
Finally, this article discusses
professionalism and its
implications for radiologic
technologists.
This article is a Directed
Reading. Your access to
Directed Reading quizzes
for continuing education
credit is determined by
your membership status
and CE preference.
After completing this article, the reader should be able to:

Identify the ethical theorists whose work is the foundation for modern health care ethics
and explain their models.

Outline health care providers’ ethical responsibilities and patients’ rights.

Discuss civil rights laws and how they protect health care workers.

Explain in broad terms how the U.S. legal system works and describe common causes of
action against health care professionals.

Summarize what radiologic technologists must know about professionalism, including
guidelines for appropriate use of social media.
M
edical ethics is, in its simplest form, a set of principles
that guides practitioners in
making informed choices
about the delivery of medical care.
Often, the term medical ethics is used
interchangeably with bioethics; however,
these terms are not synonymous.
Bioethics is the study of ethical issues
emerging in new situations, or possibilities brought about by scientific discoveries in biology or medicine.1,2 Medical
ethics is a system of moral principles
that apply individual, professional, and
societal values and judgment to the
practice of medicine.3,4 The fundamental principle that guides the practice of
medical ethics, our personal and professional sense of right and wrong, is the
foundation on which we base each decision in our daily interactions.
Ethical Foundations
The foundation of a radiologic technologist’s professional identity is the
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
ability to make appropriate decisions
regarding the health care he or she
provides patients. These decisions are
ethical choices that are an informed judgment about the “right” way to accomplish
something. With each ethical decision,
the technologist lays the foundation for
consistent moral and ethical professional
behaviors. This is the fundamental concept of ethical maturity, which is based
on personal values and morals.
Personal values are the basic principles an individual uses to determine
what he or she believes to be right. They
help people determine the difference
between right and wrong, or good vs
bad when evaluating actions, ideas, or
relationships. Values include honesty,
integrity, compassion, courage, honor,
responsibility, respect, and fairness.5
Morals are manners, customs, or
generally accepted standards of good or
right conduct that reflect our personal
values framed within a larger, external
system of beliefs. The external system
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can be religious, societal, or both. Regardless of the
external system that defines our morality, morals are
not internal. Morals are more accepted by a society than
an individual’s personal values, but they are informed
by personal values.
Ethics, like morals, are defined externally.
Sometimes, ethics are professionally defined, as in the
ethics statement of the American Registry of Radiologic
Technologists (ARRT), but they are personally applied.
When acting ethically, the radiologic technologist
behaves in ways consistent with the beliefs and values of
the professional association.
For the purposes of this article, values are an individual’s belief system that governs the way he or she acts.
Morals are a belief system influenced by societal norms,
which guide the evaluation of actions. Ethics are professional expectations of the way an individual will behave
in a given circumstance (eg, patient care). The terms
will not be used interchangeably.
Ethical Theorists
There are innumerable ethical theorists, and each
created or espoused a unique ethical model or theory;
however, 8 have had the greatest applications to health
care6:
Aristotle.
 Saint Thomas Aquinas.
 Immanuel Kant.
 John Stuart Mill.
 Martin Buber.
 Viktor Frankl.
 John Rawls.
 Lawrence Kohlberg.
Together, these men laid the foundation for all modern health care ethics models.
Aristotle
Aristotle was a Greek philosopher born in
Macedonia in 384 bce.7 He studied under Plato, attending Plato’s lectures for more than 20 years. Aristotle’s
work in ethics, although nearly 2000 years old, makes
him relevant to the current health care environment.8
Aristotle focused his ethical works on defining how
people can achieve the greatest level of virtue or good.
He defined virtue as an actionable item, not something merely to be discussed; therefore, virtue requires
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making choices that are predicated on action. As a
result of the idea that virtue—and being virtuous—
requires action and choice, Aristotle advanced the concept of practical wisdom, or phronesis. 6,9
Phronesis is founded on the premise that individuals should be stronger than their impulses. When
faced with decisions, people should apply reasoning
and explore choices. They should use their ability to
think rationally, assess choices as good or bad, and
choose the best option for each situation. In health
care and medicine, this is particularly important.
Radiologic technologists must continually ask themselves, “What would someone with similar training
in a comparable situation be expected to do?” This
question is the fundamental basis for professional
standards of care. 3,8-9
Saint Thomas Aquinas
Thomas of Aquin, or Thomas Aquinas, was born to
a wealthy Sicilian family in 1225. He became a member of the Dominican Order of the Catholic Church
in 1243 to continue his education with the major
scholars of his day. Later, he became a philosopher,
theologian, and teacher who wrote many books.10,11 He
was canonized into sainthood in 1323, 50 years after
his death.12 As an author, Aquinas’ most renowned
work was the Summa Theologica. Although he died
before finishing the text, Part Two of the work (Prima
Secundae Summa Theologica) was dedicated entirely to
ethics. This work laid the groundwork for the theory
of natural law. 6
The theory of natural law has 2 key features. The first
is that natural law is one component of divine providence.
The second focuses on a human’s role as the recipient of
natural law, which comprises the principles of practical
rationality. These principles allow human action to be
judged as either reasonable or unreasonable.6,13
Practical rationality can be interpreted to mean that
people will make decisions that are good for themselves
and the people around them. For example, if people
perform actions that have detrimental effects on themselves or others around them, they would be acting in
contradiction to practical rationality. The principles
of practical rationality are based on Aquinas’ idea of
basic good. The concept of basic good simply means
to respect others’ dignity and help them live within
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community. 6,13,14 This concept is the fundamental basis
of beneficence and nonmaleficence, which are terms
used to describe the duty of care entrusted to health
care workers.
Immanuel Kant
Immanuel Kant was born in Königsberg, Prussia, in
1724. He was a prolific scholar, studying mathematics,
physics, logic, metaphysics, and natural law. On completion of his academic credentialing, he taught philosophy
for more than 40 years.15 Kant believed that a person’s
attributes are not good in and of themselves and that
an individual could use any of the assets he or she possessed for good or evil. He also believed that individuals
would typically act with goodwill; that is, they would
use their gifts for good, even if the action provided no
direct benefit to the actor, but because it was the right
thing to do. According to Kant, doing the right thing is
the moral duty of an individual as a productive member of society. The concept of duty-based ethic, first
advanced by Kant, is known as deontological ethics.3,6,16
Deontological ethics focuses on the duty of an individual to others and the rights of those recipient individuals. Typically, deontology involves ethical analyses
based on a moral code and that hinge on obligation to
a recipient (eg, a patient). Individuals who follow the
deontological paradigm believe that the “highest virtue
comes from doing what you are supposed to do—either
because you have to (eg, following the law), or because
you agreed to.”16
A major challenge to deontological ethics is the concept of categorical imperative. Kant advanced the idea
that universalization, or the ability to apply a decision
equally to everyone, was fundamental to duty-based
ethics. This means moral duty hinges on reasoning to
determine one’s actions, and not personal feelings or
needs. Simply, moral duty transcends a single person
and his or her motives; rather, the categorical imperative mandates that unless a person could agree that an
act should become universal law, he or she should not
perform that act. Kant also said that people are to be
treated only as ends, not as means. 6
In health care, the categorical imperative holds that
there is value in all human beings, and they all deserve
respect. This means every person in a similar circumstance deserves the same respect and treatment. In
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
theory, this sounds fair, but goodwill and Kantian theory
can be problematic for a health care administrator. To
strictly follow Kant, each decision made by an administrator should be based on goodwill and not account for
things such as profit or legal mandate; however, this is
not possible. For example, when a researcher uses human
subjects (perhaps to find a cure for cancer), the subjects
are a means to an end, which negates their equal worth
and fails to meet the categorical imperative. There is
potential benefit to a much larger group from the knowledge gained in using human subjects for research, but
it might not be the right course of action according to
Kant’s theory.3,6,16
John Stuart Mill
Many consider John Stuart Mill to be the most influential English-speaking philosopher of the 19th century. Mill disagreed with some moral theorists, including
Kant, and wrote his own moral theory that focused on
the idea of telos, or ends. Mill’s concept of utilitarianism,
or consequentialism, is the ethical justification for many
health care policies in the United States today.3,17
Utilitarianism is the idea that a decision or action is
ethically and morally sound if it provides the greatest
benefit to the most people. Using this ethical framework
makes difficult decisions easier in health care, where
resources are typically scarce. Employing the utilitarian theory, decision making is simply a triage process,
whereby the greatest good is sought even if it marginalizes certain individuals. Unfortunately, marginalization
is the greatest concern with utilitarianism; because the
individual is not the focus, it becomes possible to violate
the rights or needs of individuals in the minority.3,6,17
Situations like these have been referred to as the “tyranny of the majority.”18
Martin Buber
Martin Buber was born in Vienna in 1878. Breaking
from his traditional Jewish family, he began to study secular philosophy. Escaping from Nazi Germany in 1938, he
ultimately assumed a professorship in anthropology and
sociology at Hebrew University in Jerusalem.19
Buber is most well known for his studies on how
people relate to one another; specifically, he was interested in how people behaved with one another in either
moral or immoral ways. Buber described a hierarchical
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system that defined the relationships people had and
how they moved from the lowest to the highest ethical
levels. People begin at the “I-I” level, where they are an
extension of someone else (eg, a child who wants to
emulate his or her parents). Individuals then progress to
the “I-IT” relationship level. “I-IT” individuals are morally corrupt, because they remove individuality from
the other person’s identity. For example, if a health care
worker refers to a patient as “the 0900 barium enema,”
instead of Mr Jones, he or she dehumanizes the patient
and makes the patient an “it.”6,19
Buber’s next level is the “I-YOU” relationship. In
this type of relationship, each person is seen to possess
individual talents that are equal to everyone else’s gifts.
A fundamental premise of this relationship is that each
person must be accepted and respected. The greatest
moral relationship an individual can engage in is the
“I-THOU” relationship. Buber thought that people in
this type of relationship were capable of recognizing
the differences in individuals and embracing those differences as having value. A person then makes a conscientious choice to consider an individual as special.
Individuals categorized as special by someone entering
an “I-THOU” relationship are treated as equals by putting their needs at a comparable level with one’s own. 6,19
Viktor Frankl
Born in Vienna in 1905, Viktor Frankl was a student of classical psychology from an early age. In 1944,
Frankl and his family were sent to concentration camps.
His family died while in the camps, but Frankl survived. While he was imprisoned, he tested his personal
theories of human motivation and conscience. Frankl
observed that, even though individuals were in a concentration camp and undergoing immense suffering, if
they could maintain a sense of meaning and purpose,
they retained their humanity. This observation gave rise
to his lifelong work: the meaning of life.20,21
Frankl focused his definition of a meaningful life
on the sense of purpose he first observed during his
imprisonment. According to Frankl, a sense of purpose
led to an individual’s conscience, which allowed an
individual to find meaning in situations; in turn, this
meaning enabled an individual to make ethical choices
not centered on selfish needs. 6,20 Therefore, “a conscientious person is one who has moral integrity and a strict
166
regard for doing what is considered the right thing to
do.”3 It is important to remember that an individual’s
conscience is finite because it does not possess absolute
knowledge. Rather, a conscience attempts to determine
the best action to take in a situation based on the moral
and ethical foundations of the individual’s belief system. In theory, the conscience allows the individual to
make decisions that are valued and avoid decisions that
bring harm. 6
The concept of choosing is different from making
a decision. Choosing is making an informed selection
from a number of alternative choices. The term implies
having a right or opportunity to choose. A decision
implies having alternative possibilities or choices, and
choosing a specific course of action after analyzing the
choices. By defining decisions an individual makes as
a choice, Frankl implies that each person is responsible
for his or her choices. In the litigious world of health
care, this has profound implications. Practitioners of all
levels should not choose expediency when making decisions; rather, they should obtain as much data as possible and make decisions based on practical wisdom.9
John Rawls
John Rawls was born in 1921 in Baltimore,
Maryland, and studied moral philosophy. Rawls
focused his theories on social justice and included the
concepts of self-interest and fairness. He defined his
theory through 2 principles: the liberty principle and
the maximin principle.22
For Rawls, the liberty principle indicated that all individuals should have the same basic rights in society. For
example, if someone has a right to basic education, then
everyone should have that right. Rawls proposed the idea
that every person has a claim to the basic liberties of society; however, to be just, individuals also should address
inequalities in society. Actions an individual might take to
address societal inequality were addressed in his maximin
principle. Rawls believed that everyone should address the
inequalities in society because everyone has the potential,
at some point, to be in a lesser position. That is not to
say that Rawls felt everyone should have equal access to
everything at the same time, merely that the opportunity
for equal access would exist. For example, in an emergency department, individuals with less severe injuries wait
so that patients with life-threatening injuries can be cared
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for first. It is in the self-interest of less severely injured
individuals to wait while people with greater needs are
served first, because it is assumed that if they were in a
life-threatening position, they would be first to receive
treatment.22
Lawrence Kohlberg
Lawrence Kohlberg was born in Bronxville, New
York, in 1927. After World War II, he helped smuggle
Jewish people through the British blockade and into
the Mandate of Palestine. He was arrested and served
time in an internment camp in Cyprus, where he
reflected on how individuals develop moral reasoning and ethical thinking. Later, as a doctoral student,
Kohlberg defined an entirely new hierarchy of moral
development founded on the observations he made
while a prisoner. 6,23,24
Kohlberg and his theories are especially important
to health care administrators. The fundamental premise of his work was that all people do not have the same
capacity for ethical reasoning. Kohlberg’s work allows
administrators to analyze their own decisions and those
of their employees. A secondary premise was the concept of societal authority. Society imbues health care
administrators with a large degree of authority. This
authority is paired with trust in the system. This trust
implies that the administrator is acting with a high level
of moral reasoning when making decisions; high-level
moral reasoning, according to Kohlberg, would mean
that administrators make decisions based on the needs
of the patient as their primary responsibility. The needs
of the organization, including profit, should be secondary to those of the patient.6 Successfully balancing profit
vs patient well-being might be difficult for an administrator to accomplish. However, the administrator must
recognize that profit and positive patient outcomes
can be related. The profit could be direct (increased
patient census as a result of good outcomes) or indirect
(decrease in litigation as a result of good patient outcomes), but it will manifest itself in time.
Health Care Providers’ Ethical
Responsibilities
Beneficence and Nonmaleficence
Radiologic technologists, along with all health care
professionals, are guided by a moral responsibility to
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
deliver quality patient care. Regardless of whether the
care is diagnostic or therapeutic, providers are guided
by 2 overarching ethical principles that can be exhibited
personally or institutionally: beneficence and nonmaleficence.25 These concepts are important considerations in patient care and are complementary to one
another. Beneficence is the active process of helping
someone, and nonmaleficence is the passive process of
not harming a person while providing aid.26
Beneficence means helping patients to make their situation better. The desire to help people by doing healing
work or being kind is common in health care workers.
Compassion also is a strong motivator behind the actions
of health care providers.4
The primary characteristic of a nonmaleficent action
is that it does not make a patient’s condition worse.
Often, the interaction of beneficence and nonmaleficence
is interpreted to mean that an action must have a greater
benefit than risk.4,25 Imaging professionals, for example,
weigh benefits and risks to determine whether their
actions are nonmaleficent. Towsley-Cook and Young discussed the example of balloon angioplasty, asking whether the benefit of opening an occluded vessel outweighs
the risk of dislodging plaque and producing a myocardial
infarction, stroke, or death. In an otherwise healthy
patient, the answer is simple and usually yes; however, if
a patient already is physiologically compromised (eg, suffering from respiratory or renal impairment), the decision
is more difficult.26
The concepts of beneficence and nonmaleficence
guide the moral responsibilities of health care providers
and are closely aligned; however, they possess varying
degrees of force. Nonmaleficence is more important.
Radiologic technologists are interested in helping people,
but they also must be cognizant of not harming them.26
Veracity and Confidentiality
Veracity and confidentiality are important to patients’
rights and the radiologic technologist’s obligations.
Veracity is the alignment of one’s statements with fact or
reality, and confidentiality is the ability to keep obligatory
secrets such as patient information and health records.26
Veracity
Veracity is the principle of truth telling. In health
care, the concept of veracity is at the core of establishing
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trust with patients and their families. Often veracity needs to be tempered by a patient’s need to know
certain information. The technologist must provide
adequate information about an examination so the
patient can make an informed decision. However, the
technologist does not need to be exhaustive in discussing every possible adverse effect or alternative diagnostic procedure with patients unless they request the
information. For example, technologists do not need to
discuss the ramifications of latex allergies with a patient
just because they are wearing latex-based examination
gloves; a simple inquiry into whether the patient is allergic to latex generally is sufficient.3,26,27
Telling a patient the truth before or during an examination allows the patient to make an informed decision
about whether to proceed; however, patients might ask
radiologic technologists to provide information that can
come only from a physician. In this case, the technologist is not obligated to answer the question. For example,
although a patient might ask about the outcome of his or
her procedure, the radiologic technologist cannot ethically or legally provide that information. The technologist’s
professional obligation to uphold a standard of practice
outweighs the patient’s right to the truth. However, the
technologist should direct the patient to his or her physician to receive the results of the study.26
Confidentiality
Confidentiality is an ethical concern with legal
ramifications that requires the radiologic technologist
to keep obligatory secrets. Obligatory secrets arise from
the fact that some intrinsic or extrinsic harm will come
if the information is revealed. Obligatory secrets come
in 3 types: natural secrets, promised secrets, and professional secrets. Natural secrets are information that
would be harmful if shared. Promised secrets are those
that an individual has sworn not to share. Professional
secrets are those that, if revealed, are harmful to the
patient and the professional. Professional secrets are the
most binding type and often carry legal ramifications if
confidentiality is breached.26
According to George Pozgar, “[h]ealth care professionals who have access to medical records have a legal,
ethical, and moral obligation to protect the confidentiality of the information in the records.”3 Pozgar’s explanation could be expanded to include any health care
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information a professional has access to, not only information contained within the medical record. Both confidentiality and invasion of privacy involve revelation of a
patient’s private medical information. The difference is in
who accesses the information and how. Breach of confidentiality occurs when an individual who has a legitimate
need to know private information and is involved in
the care of a patient shares privileged information with
someone who has no need to know it. Invasion of privacy
occurs when someone who does not need access to a
patient’s medical record reviews it anyway.
A major provision of the Health Information
Portability and Accountability Act of 1996 (HIPAA)
is the protection of private patient information, particularly information that might lead to discrimination.
All patient information must be safeguarded under the
auspices of HIPAA; however, information that forms or
could form the basis for discrimination is protected at a
heightened level. Such information includes references
to substance abuse, mental illness, sexually transmitted
disease, and genetic information. 3,4,26-28
As with any ethical or legal issue in medicine,
there are exceptions to patient confidentiality laws.
Exceptions include cases where patients consent to
the release of their information, cases of statutory disclosure (such as that brought on by court order), and
when a duty to warn third parties exists, such as in the
case of mandatory reporting or impending harm to a
third party. In AIDS reporting a conflict exists between
patient confidentiality and the duty to warn others of
possible harm. The issue has become so pronounced
that some states have passed legislation specifically dealing with patient privacy issues and AIDS. Radiologic
technologists should check with their employers and
their state legal code to determine what their specific
responsibilities are regarding patients with AIDS and
confidentiality issues.3,26, 27
Patients’ Rights
Autonomy
Autonomy is the right of individuals to make their
own decisions. 3 The concepts of beneficence and
nonmaleficence extend to the care of every patient a
radiologic technologist cares for, perhaps none more so
than those whose ability to make their own decisions is
questionable: elderly patients, patients with declining
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cognitive ability, and patients with an advanced level of
dependency. When working with patients who fall into
these categories and are incapable of making sound decisions, a medical professional might be tempted to make
decisions that he or she believes are in a patient’s best
interest. This form of beneficence is known as paternalism. When a health care worker chooses to make decisions on a patient’s behalf or falsely informs patients who
are capable of making their own choices, it is known as
medical paternalism. Medical paternalism often is undertaken unintentionally. For example, a medical professional might choose to withhold information or provide
only selected information based on his or her own beliefs.
Paternalism directly violates a patient’s autonomy.3,29, 30
The concept of autonomy has been repeatedly
upheld in the court system beginning with the U.S.
Supreme Court decision in Union Pacific Railway
Company v Botsford (141 U.S. 250) in 1891. In this case,
the court’s decision noted that:
no right is held more sacred or is more carefully
guarded by the common law than the right of every
individual to the possession and control of his own
person, free from all restraint or interference of others
unless by clear and unquestionable authority of law.31
The concept of autonomy is not absolute; however,
legal authority may waive it when an individual’s autonomy infringes on the right of another person.
Nevertheless, people have an inviolable right to make
decisions about their health care, even if it means the loss
of the patient’s life. The right to autonomy also is inviolable in the face of disagreement by family members, so long
as the individual is capable of making sound legal decisions. The Patient Self-Determination Act of 1990 made
it the legal right of patients to make autonomous decisions relative to their health care. The act allows patients
to accept or refuse medical treatment and to make their
wishes known via advanced health care directives, which
govern their care after they are no longer mentally or
physically capable of making decisions on their own.3,27
Informed Consent
Radiologic technologists often must gain informed
consent from patients. Therefore, the technologist
must know the facts and statistics pertaining to the
procedure and provide patients with knowledge that
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
will make them truly informed.26 For consent to
qualify as informed, the patient must understand the
procedure completely and have all the information he
or she needs to make an autonomous decision. The
patient should sign an informed consent form that
contains a list of the information the patient was given
and the components in Box 1.26 The witness who signs
the informed consent clause should be a third party
not involved in the procedure.27
Privacy
Health care providers have a legal and ethical
responsibility to maintain patient privacy. Patients
have a right to expect that their privacy will be maintained. Most patient bills of rights include privacy
clauses, and hospitals are required to provide their privacy policies to patients, which often are included with
HIPAA policy information. To safeguard a patient’s
privacy, health care workers must avoid discussing
patient information with anyone not associated with
the patient’s care or obtain written permission from
the patient or his or her advocate before doing so. 3
Respect for Diverse Populations
Diversity is the difference in individuals that arises
from variance in ethnicity, age, sex, sexual orientation,
marital status, or other characteristics that make an
individual unique. Discrimination occurs when the way
an individual is treated is altered based on a characteristic of diversity. Caring for diverse patient populations
introduces many ethical challenges. Nevertheless,
health care workers must provide equal quality of care
for every patient.
Box 1
Components of an Informed Consent Form
29
1. Authorization clause that permits the examination or
procedure to be conducted.
2. Disclosure clause explaining the procedure, risks, benefits,
and possible alternatives.
3. Anesthesia clause, if anesthesia will be necessary.
4. No-guarantee clause for therapeutic procedures.
5. Tissue-disposal clause, if tissue will be removed.
6. Patient understanding clause.
7. Signature clause for the patient and a witness.
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One challenge arises when caring for patients who
are very young, elderly, or who have decreased mental
capacity. These patients often require advocates, who
might not have the same value system as their charge.26
When dealing with an advocate, the technologist must
act in the patient’s best interest and not in the interest of
the advocate.
Diversity in health care workers also must be
respected, but to a degree. For example, they have an
innate right, upheld by the law, to defer their participation in patient care. Refusal to participate in patient
care typically centers on the provider’s cultural or
religious beliefs and commonly is invoked during
elective abortions or end-of-life decisions. A patient’s
health must not be compromised because of a staff
member’s right to refuse to treat him or her. However,
if a patient’s health might be compromised by a health
professional’s refusal to treat, the provider has a duty
to treat the patient regardless of his or her personal
beliefs. This duty has been upheld by the courts in the
case of nurses who refused to participate in an emergency abortion on the grounds of religious beliefs.
Because the procedure was emergent, the nurses had
a duty to participate. When they did not, they were
found to be negligent. This suggests that radiologic
technologists are allowed to refuse care to patients, but
there must be a demonstrable point of election on the
part of the patient for the procedure. If the procedure
is emergent, a health care worker’s personal beliefs are
subjugated to the needs of the patient. 3
Advanced Directives and Living Wills
Death and dying are constant reminders to health professionals that not every patient situation has a positive
outcome; however, it is the legal and ethical responsibility of health care professionals to act, within the law, in
the patient’s best interest and in accordance with his or
her wishes, even if those interests and wishes counter the
health care worker’s ethical or moral standards.
Death generally is defined as the “cessation of respiration, heartbeat, and certain indications of central
nervous system activity, such as respiration and pulsation.”3 Seldom, even in trauma, is death instantaneous;
rather, death is a process that a patient, his or her family,
and the health care team experiences together. When a
patient is dying, the health care team must continue to
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act in the patient’s best interest, and in accordance with
the wishes of the patient or his or her advocate.3,26
In chronically ill patients, 2 forms of death usually
occur: active or passive euthanasia. Active and passive
euthanasia can be voluntary or involuntary. In most of
the United States, active euthanasia, the act of administering medication or some manner of force to physically
end an individual’s life, generally is illegal; however, passive euthanasia, the act of withholding life-saving measures (such as a ventilator or nutrition), is legal and a universally accepted practice. A patient or his or her advocate
can make decisions about passive euthanasia.3, 26, 27
A patient’s wishes often are made known through
an advanced directive or living will. Living wills and
advanced directives are legal and must be offered to
every patient in the United States as a result of the
Patient Self-Determination Act of 1990. The fundamental point of the act is that a person’s autonomy,
including the right to refuse medical treatment, is not
forfeited when physical or mental changes occur. 3,27
Living wills help patients understand the definition
of death and reveal their perception of what constitutes
quality of life. The oldest and most commonly used definition of death is heart-lung death, which is the absence
of heartbeat and respiration. A patient’s wish to not be
placed on a ventilator, even in the presence of neurologic function, would be in accordance with the heartlung definition of death. Quality of life is determined
by the patient, and living wills allow patients to state
unequivocally what should be done when that quality is
no longer maintainable. 3,26,27
In 1968, the Harvard Medical School defined brain
death as an unreceptive, unresponsive individual who is
incapable of movement or independent breathing, has
no reflexes, and a flat electroencephalograph. Although
heart-lung function can be maintained after most of
these criteria are met, an individual who wishes not to
be supported artificially by mechanical means after
complete loss of brain function is acting in accordance
with the definition of brain death.3,26,28
The most nebulous definition of death, but one commonly addressed in advanced directives, is the persistent vegetative state. Often called an irreversible coma,
this state occurs only when higher brain function is lost.
A patient still might be capable of self-sustained circulation and respiration as a result of a patent brainstem,
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but higher-order cognitive function is absent. Patients
in a persistent vegetative state might even be conscious,
but they have no awareness of self or environment.
Individuals who wish to have nutrition withheld when
in this state are acting in accordance with the laws of
passive euthanasia.3,26
Do Not Resuscitate Orders
Do not resuscitate (DNR), or no-code, orders are
treated differently from any other form of life-sustaining
treatment and must be addressed separately from
advanced directives and living wills. While a patient’s
wish not to have resuscitation performed is addressed in a
living will, this facet of the advanced directive has no legal
standing. DNR orders are, in their strictest sense, a physician order that is written in accordance with a patient’s
wishes provided orally or in writing to the physician.
DNR orders must be in accordance with state law,
which is fluid and changes occasionally. As such, these
orders must be reviewed and updated. DNR orders simply state that, in the presence of a loss of spontaneous
circulation, respiration, or both, a patient does not wish
to have cardiopulmonary resuscitation performed on
him or her. A technologist should always verify the presence or absence of a DNR order prior to performing any
study, particularly those that have a higher risk of death,
such as contrast-enhanced or interventional studies.3,26
Health Care Providers’ Rights as
Employees
The Civil Rights Act of 1964 was only the latest in
several attempts to ensure civil rights that date back
to the Civil Rights Act of 1866 and the 14th amendment of the Constitution. 32 The Civil Rights Act of
1964 contains 10 sections or titles; title VII is the most
relevant to health care workers, employers, and health
care facilities. 33, 34
Although Title VII applies only to employers who have
more than 15 employees each business day for 20 contiguous weeks, it often is broadly applied to employment
law in the United States. According to the United States
Department of Justice Civil Rights Division, Title VII
of the Civil Rights Act of 1964, as amended (42 U.S.C.
§2000e, et seq), prohibits discrimination in employment
on the basis of race, sex, national origin, and religion.35
The act states that it is illegal for an employer to:
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fail or refuse to hire or to discharge any individual,
or otherwise to discriminate against any individual
with respect to his compensation, terms, conditions or
privileges or employment, because of such individual’s
race, color, religion, sex, or national origin.35
Title VII essentially prohibits workplace harassment
and discrimination.33-35
However, it is still possible for an employer to refuse
to hire an individual if the employer can demonstrate
that the reasons are related to a bona fide occupational
trait. That is, there must be some qualification that is
absolutely necessary for the job to be completed successfully that the individual cannot meet. To meet
the bona fide occupational qualification defense, an
employer must demonstrate that all 3 of the following
parameters are met35:
 There must be a direct relationship between the
trait and the ability to perform the job.
 The qualification must directly relate to the central mission of the employer’s business.
 There must be no alternative that is less restrictive
or more reasonable.
Religion and customer (or patient) preferences are
not reasons to allow an exception under the occupational qualification discrimination clause; however, exceptions are allowed to Native American groups, religious
groups working in accordance with their religion, and
nonprofit private member organizations. 35
Several supporting pieces of legislation and amendments to the Civil Rights Act of 1964 have been
enacted since its original passage to prohibit employer
discrimination against certain groups (see Table).
The U.S. Legal System
In the United States, law is divided into 2 broad
categories: criminal law and civil law. The fundamental difference in the 2 types is the involvement of the
government in litigation.
Criminal Law
In criminal law, the government brings a case
against one or more defendants. Criminal law necessarily involves a breach of regulations or law that
can be enforced by government action. The state or
federal government can be the prosecuting authority,
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depending on whether the infraction was against a state
or federal law. Generally, only 2 criminal suits can be
brought against health care workers: distribution of a
controlled substance for profit and without a medically
necessitated physician’s order and the commission of
a crime on federal property, in the case of health care
workers in federal facilities. 41
Civil Law
Civil law involves a suit brought by an individual
against another individual or concerned party (eg, a
hospital) to recover compensation for loss or damages. 41 Typically, civil lawsuits are handled by the state
in which the loss occurred; however, if the dispute
involved a question of federal law or parties who are
residents of different states, then the case would be
remanded to the federal courts. Questions of federal
law might include civil rights violations or discrimination, for example. In the United States, civil lawsuits can
arise from any loss or damage; if the loss or damage in a
civil lawsuit arises from personal injury, then the action
is called a tort. 41
Torts are common in health care. Compensation for
an injury serves sound social policy; if someone suffers
a loss, that person should be remunerated for the loss. In
addition, legal issues involving truthfulness and confidentiality are known as quasi-intentional torts. Quasiintentional torts resemble other torts but are not always
unintentional. Quasi-intentional torts are based on
issues that arise from something an individual said vs
something they did. For example, defamation (libel or
slander) is a common tort. One item that is not covered
under tort law is a HIPAA violation, regardless of how
the breach of privacy occurs.
Tort law is typically a matter of state common law.
Unlike statutory law, which is derived from bills being
passed into law, common law evolves as courts and
judges are confronted with42:
 New issues legally distinct from existing law.
 Cultural changes (eg, those created by emerging
technologies).
 Changing social policy considerations.
Common law is a unique tradition within the United
Kingdom and its former colonies, including the United
States, in that there is no system of rules that can be
applied to every potential situation. As a result, when
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faced with a new or unique tort case, a judge will evaluate the facts and write an opinion that compares and
contrasts the current case to similar previous cases. A
judge then decides which law is most applicable to the
case, and a decision is added to the common law of the
specific jurisdiction. Reported judicial decisions are law
in every state; however, the law is unique to individual
states and some variance between state common laws
should be expected. 42
The Process of Lawsuits
In the United States, lawsuits follow a standard and
prescribed progression. Most cases involving radiologic
technologists are civil law proceedings, usually tort
cases. The first action in a civil case is the filing of a
complaint. During this phase, the plaintiff contacts a
lawyer, who files a complaint and summons with the
local court. The matter then becomes a lawsuit and litigation begins. The complaint and summons is served to
the defendant by mail or in person.3,16,26,43
The defendant, having been served a complaint and
summons, has a specific time frame in which to file
an answer to the court. Defendants typically retain
a defense attorney, although they may choose to represent themselves. When individuals represent their
own interests, they engage in a pro se or self defense.
Regardless of whether a defendant is represented by an
attorney, he or she must file an answer to the complaint
and summons. The answer is a formal written response
to the allegations set forth by the plaintiff in the original
complaint. The answer is the second phase of litigation
and is filed with the same court where the original complaint was registered.3,16,26,43,44
The third phase in litigation is the discovery phase.
During discovery, the parties in the suit request information of one another and establish the facts of the
case. The requests for information can be3,16,26,43:
 Admissions − questions are asked and the opposing party either denies or admits facts.
 Interrogatories − parties provide detailed answers
to questions concerning facts about the case.
 Production − one side asks the opposing party to
provide relevant documents or exhibits.
The fourth phase involves filing supplemental
motions. Motions are written requests asking the
court to do something on behalf of one of the parties
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Table
Year
Amendment or Act
Purpose
1967
Age Discrimination in
Employment Act
Prohibits discrimination in employment against people aged 40 years or older and allows for
bona fide occupational qualifications. The act does not exclude favoring older employees
33
over younger ones (ie, reverse age discrimination).
1972
Equal Employment
Opportunity Act
Allows the Equal Employment Opportunity Commission to bring suit on behalf of plaintiffs
in discrimination cases. The act also made it illegal for employers to intentionally or unintentionally exclude, recruit, or select their workforce with an intention that might eliminate a
protected class. The broad interpretation of this has been that word-of-mouth advertising is
35
illegal because it might maintain a workforce that lacks diversity. Employers must publicly
post all job openings.
1978
Pregnancy Discrimination
Act
Forbids employers from mandating or requiring maternity and/or paternity leave and from
discriminating against pregnant women or individuals with new children, regardless of
whether the children were adopted by or born to the employee. The only exemption to the
law is if a company does not allow time off from the point of hire for a given length of time
when similar exclusions exist for other medical issues. For example, an employer might not
allow pregnancy or childbirth-related time off for one year after initial hire. The act mandates
that an employer allow an employee who has taken time off under the protections of the
act to return to his or her original job as soon as the employee is willing and able to fulfill the
36
requirements.
1990
Americans With Disabilities
Act
Prohibits discrimination against individuals with disabilities in employment, transportation,
public accommodation, communications, and governmental activities. The act also mandated
that communication relay services be available for individuals with hearing disability and that
37
access to buildings and other facilities is provided for individuals of all capabilities.
1991
Civil Rights Act of 1991
Allows jury trials in discrimination cases, emotional distress as a cause for damages, and
caps the amount of monetary awards a jury could levy for a plaintiff in discrimination cases.
The act also established a commission to study barriers to the advancement of women and
minorities in the workplace, extended civil rights coverage to certain federal employees,
including American and American-controlled companies operated abroad, extended protections to employees suffering from unintentional discrimination, and included a fail-safe
general provisions and severability clause that stated if any one part of the act was deemed
38-40
unlawful or ineffective, the remaining portions would remain in effect.
involved. Typically, a judge decides a motion and provides his or her ruling in writing without a hearing;
however, a formal hearing might be required to bring
the parties together in court for the judge to render a
decision. One common motion is a motion to compel,
which usually is filed when a deadline is missed, such as
a defendant’s failure to respond to discovery in a timely
or factual manner. Another common motion is an entry
default judgment, which occurs when a defendant fails
to answer the complaint. In this case, a judge will review
the complaint and, if approved, mandate a default judgment requiring the defendant to pay damages.3,16,26, 43
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The final phase of a lawsuit is the conclusion. During
conclusion, the parties enter mediation, and a mediator
determines an equitable means and method of payment.
If the losing party fails to render compensation, the
winning party can seek court interference to get payment. This interference can include garnishment of
wages or other income.3,16,26,43
The Legal System and Health Care Professionals
The range of legal issues facing health care professionals daily is virtually unlimited. The most common include negligence, malpractice, and breach of
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confidentiality. All of these challenge radiologic technologists to act ethically and responsibly.
Negligence
Negligence is the most common tort in the United
States.35 Negligence generally is unintentional and
occurs through the commission or omission of an
act that an individual who is considered reasonably
prudent would or would not have done in a similar
circumstance. Radiologic technologists have a duty to
provide patients with reasonable care. When that duty
is breached, medical negligence has occurred. When a
case of medical negligence is brought against a health
care professional, the plaintiff must unequivocally demonstrate that3,26:
 There was a duty on the part of the radiologic
technologist.
 The duty was breached.
 An injury occurred.
 The breach caused the injury.
The existence of a medical injury does not prove
negligence, and although negligence and malpractice
often are used interchangeably, the terms vary in that
malpractice is carelessness practiced on the part of a
health professional. 3,26
A medical professional might be found indirectly
negligent through the legal doctrines of respondeat superior and res ipsa loquitur. These are indirect negligence
challenges that arise from communally negligent acts.
Respondeat superior, Latin for “let the master answer,”
means an employer is legally liable for its employees’
actions. In certain instances, this doctrine has been
referred to as vicarious liability. Vicarious liability makes
the employer responsible for torts committed by its
employees. For an employer to be found liable under
the premise of respondeat superior, a master-servant
relationship must exist; typically, although not always,
the master-servant relationship is defined as that of an
employer-employee. Further, the negligent act must
have been committed by the servant or employee within the scope of his or her employment.3,27 Res ipsa loquitur, a Latin expression meaning “let the thing speak for
itself,” often is used as the basis for lawsuits that involve
a team-centered patient care activity, such as surgery
or interventional procedures. When res ipsa loquitur is
invoked by a plaintiff, each individual involved in the
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procedure becomes a defendant because one of them
was negligent.3,26,27
Defamation
Defamation of character damages a person’s good
standing and can be either written or spoken. Written
defamation is libel, and spoken defamation is slander.
Defaming communication must be false, published
(including words spoken in public), and damaging to
an individual’s reputation, business, or profession. In
the strictest legal sense, statements that are true are not
defamation; however, there are instances of defamation
per se, which can be either libel per se or slander per se.
These cases arise when the communication involves
criminal activity (eg, sexual misconduct) or allegations
that the individual might have a contagious or infectious disease. In the case of defamation per se, no specific
damage to the individual need take place. For example,
simply claiming that a physician is HIV positive or
sexually molests their patients would be defamation
per se; the physician does not need to demonstrate that
any specific damage resulted from the claims, merely
that they were made in order to find the accuser guilty.
This is because the mere suggestion that someone has a
specific disease or has committed certain acts damages
their reputation.3,26,42
While the truth is considered a qualified defense
against charges of defamation, it has been shown to
be a defense in most, but not all, cases. In the case of
qualified privilege, the truth will always protect the
individual. Qualified privilege protects those who have
a legal responsibility to report elder or child abuse, or a
concern about probable abuse. This defense shields the
reporter from claims of defamation by the defendant so
long as the report is made in good faith.
Although many employers suggest refraining from
providing anything other than dates of employment
when references are requested, they usually are protected if they provide more detailed information. State reference immunity laws vary widely, but in general, protection is extended when reporting truthfully about an
individual in the case of prospective future employers
contacting a current or former employer for a job reference. As long as employers are acting in good faith, they
cannot be held liable for providing job-related information such as performance or the reason for termination
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if it is truthful. 45 Even so, an unsolicited opinion about
an employee should never be given. 4
Fraud
In general, fraud is a form of dishonesty that involves
willful misrepresentation of a fact that causes harm or
loss to an individual. Health care fraud typically takes
several forms; for example, submitting a false insurance
claim, charging varying rates depending on whether an
individual is insured or not, claiming to have a degree or
some other credential that one does not actually possess,
or altering medical records in an attempt to cover up some
wrongdoing. Regardless of the type of fraud an individual
has perpetrated, penalties can be severe, ranging from the
loss of right to bill insurance to imprisonment.3,26,27 To win
a fraud claim, the plaintiff must show that27:
 The defendant made an untrue statement, knew it
to be untrue, and made it to mislead others.
 The injured party relied on the statement.
 Damages were incurred as a result of relying on
the statement.
Typically the injured party is the plaintiff, except in
cases involving guardians, powers of attorney, or estates.
The injured party is always the individual who suffered
the loss, while the plaintiff may bring suit on the injured
party’s behalf.
Professionalism
Professionalism refers to a person’s behavior in the
workplace. It is common to hear someone say a provider
is “professional” or “acted professionally”; however, it is
difficult to define professionalism concisely. Mitchell
and Haroun describe professionalism as caring competence.28 Towsley-Cook and Young define professionalism as the actions of a person who possesses the ability
to care for other humans and apply “the knowledge of
a discipline, including its science, theory, practice, and
art.”26 Adler and Carlton state that professionals make
difficult choices while acting on the concepts of beneficence and nonmaleficence, and apply the virtues of caring and compassion.27 Perhaps the most concise definition was offered by Jonsen et al, who noted that professionalism in health care “demands placing the interest
of patients above those of the [caregiver], setting and
maintaining standards of competence and integrity,
and providing expert advice to society on matters of
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health.”46 In short, “professionalism encourages placing
care for the patient ahead of the business of medicine.”46
If someone behaves in an unprofessional manner,
depending on the action, the behavior could be in violation of professional standards of ethics. The violations
could result in ethical or legal censure dependent upon
the circumstances. Furthermore, he or she could be
found in violation of civil or criminal law.27,28
Professional Etiquette
While not always directly related to ethics, a health
care worker’s professional etiquette can directly affect
patient care and change patient outcomes. Creating
a polite and welcoming atmosphere is important so
patients feel they are in a caring environment. Although
a health care worker might have differing values and
morals, he or she must maintain a professional demeanor. Professional etiquette can be compromised if the
health care worker lacks cultural and emotional intelligence. Rash judgments about a patient’s or coworker’s
character based on outward appearance, language, or
other personal characteristics are not professional behaviors. Failing to maintain professional etiquette when
involved in patient care leads to a poor impression of
the caregiver by the patient and might make the patient
more inclined to notice other failures.6 Radiologic technologists should maintain their professionalism and
practice professional etiquette (see Box 2).
Professional Ethics
In general, the public expects professionals to act
in a self-disciplined manner according to guidelines
Box 2
Professional Etiquette
47
Use ICARE as a reminder of the principles of professional
etiquette:
I – Introduce yourself to your patient.
C – Communicate effectively and frequently so your
patient knows you care.
A – Address the needs of the patient in a prompt and
caring manner.
R – Respect, show dignity and compassion to your patient.
E – Explain your role on the team.
Adapted with permission from the Department of Medicine, King Fahd
Medical City.
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provided by a professional organization. These guidelines are particularly important because of health care’s
role in human life and well-being. A professional ethic is
“the publicly displayed ethical conduct of a profession,
usually embedded in a code of ethics.”27 Professional
codes of ethics affirm an individual member of a given
profession to be independent, autonomous, and a
responsible decision maker.27 Ethical codes that govern
health care in general, and radiography in particular,
arise from specific ethical models and theories.
Standards of Ethics
As health care professionals, radiologic technologists
are guided by occupation-specific principles of conduct
contained within the ARRT Standards of Ethics, which
comprises the Code of Ethics and the Rules of Ethics.
The ARRT established these standards to support its
mission statement and aid in promoting its goals. The
Code of Ethics is intended to “serve as a guide by which
Certificate Holders and Candidates may evaluate their
professional conduct as it relates to patients, healthcare
consumers, employers, colleagues, and other members
of the healthcare team.”48 The Code of Ethics helps
radiologic technologists maintain a high level of ethical
conduct (see Box 3).48
The primary purpose of the ARRT Rules of Ethics
is to “promote the protection, safety, and comfort of
patients.”49 They are “mandatory and enforceable standards” that describe minimally acceptable conduct for
any individual certified, or eligible for certification, by the
ARRT.48,49 A violation of the Rules of Ethics can result
in sanctions on the individual. In addition, the rules of
Box 3
The ARRT Code of Ethics
48
The Code of Ethics forms the first part of the Standards of Ethics. The Code of Ethics shall serve as a guide by which Certificate Holders
and Candidates may evaluate their professional conduct as it relates to patients, healthcare consumers, employers, colleagues, and
other members of the healthcare team. The Code of Ethics is intended to assist Certificate Holders and Candidates in maintaining a
high level of ethical conduct and in providing for the protection, safety, and comfort of patients. The Code of Ethics is aspirational.
1. The radiologic technologist acts in a professional manner, responds to patient needs, and supports colleagues and associates in
providing quality patient care.
2. The radiologic technologist acts to advance the principal objective of the profession to provide services to humanity with full
respect for the dignity of mankind.
3. The radiologic technologist delivers patient care and service unrestricted by the concerns of personal attributes or the nature of
the disease or illness, and without discrimination on the basis of sex, race, creed, religion, or socio-economic status.
4. The radiologic technologist practices technology founded upon theoretical knowledge and concepts, uses equipment and
accessories consistent with the purposes for which they were designed, and employs procedures and techniques appropriately.
5. The radiologic technologist assesses situations; exercises care, discretion, and judgment; assumes responsibility for professional
decisions; and acts in the best interest of the patient.
6. The radiologic technologist acts as an agent through observation and communication to obtain pertinent information for the
physician to aid in the diagnosis and treatment of the patient and recognizes that interpretation and diagnosis are outside the
scope of practice for the profession.
7. The radiologic technologist uses equipment and accessories, employs techniques and procedures, performs services in accordance with an accepted standard of practice, and demonstrates expertise in minimizing radiation exposure to the patient, self,
and other members of the healthcare team.
8. The radiologic technologist practices ethical conduct appropriate to the profession and protects the patient’s right to quality
radiologic technology care.
9. The radiologic technologist respects confidences entrusted in the course of professional practice, respects the patient’s right to
privacy, and reveals confidential information only as required by law or to protect the welfare of the individual or the community.
10. The radiologic technologist continually strives to improve knowledge and skills by participating in continuing education and
professional activities, sharing knowledge with colleagues, and investigating new aspects of professional practice.
The ARRT Code of Ethics are reprinted with permission of the American Registry of Radiologic Technologists (ARRT). The ARRT Code of Ethics are copyrighted by the ARRT.
176
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
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Matthews, Matthews
evidence are not as stringently upheld by the ARRT as
they are by state or federal lawyers. For example, rule 10
states that a registered radiologic technologist is in violation of the Rules of Ethics if he or she engages in:
any unethical conduct, including, but not limited to,
conduct likely to deceive, defraud, or harm the public;
or demonstrating a willful or careless disregard for
the health, welfare, or safety of a patient. Actual
injury need not be established under this clause.49
In contradiction to civil or criminal law, where there
generally must be admissible proof of fraud or harm
(injury), the ARRT does not require the technologist
to have defrauded or caused injury; he or she just has
to engage in conduct that might be likely to defraud or
cause harm. 48, 49
Social Media
The use of social media sites increases the potential for ethical compromise. Social media sites include
Facebook, LinkedIn, Twitter, YouTube, wikis, blogs, or
any social network or bookmarking site. In the United
States, approximately 75% of adults with Internet access
use social media and social networking sites.50 The most
popular is Facebook, with nearly 1.5 billion active users
worldwide. About 80% of those users reside outside of
the United States and Canada.50,51 The inappropriate
use of social media can create severe ethical problems
coupled with legal consequences. Broad ethical and
legal issues can arise from social media use such as52,53:
 Breach of privacy or confidentiality.
 Failure to report privacy or confidentiality
violations.
 Boundary violations.
 Lateral violence against employers.
 Communication against employers.
 The use of social media against employees or
students by employers or faculty members.
Radiologic technologists must understand the
ethical implications that can arise from inappropriate
use of social media sites. Health care workers have
an ethical responsibility to report breaches of patient
privacy or confidentiality. Confidential information
is protected by law and may only be shared with
the patient’s consent. Privacy is the expectation the
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
patient has to be treated with dignity and respect. It is
important to remember that posting any information
that might be linked to a specific patient is a direct
violation of federal law and can result in disciplinary
action. Similarly, health care providers must maintain
appropriate boundaries with patients and their families;
social or personal contact between professionals and
patients should be limited, if not avoided completely.
In addition, it is important to ensure boundaries are
established between faculty and students, including
clinical faculty members or employees at clinical
sites.54 Although communication against an employer
generally is protected on social media, so long as it is
not unlawful (eg, discriminatory statements based on
protected class such as race, ethnicity, religion, sex,
disability, or age), caution should be exercised when
posting negative information about named individuals.
Negative posts might be interpreted as bullying or
cyberbullying, which is against most employment
policies and illegal in many states.52,53
In addition, radiologic science educators and
students should follow a set of guidelines on social
media use to meet their ethical and professional
responsibilities. Because social media use can affect a
student’s professional standing, educators must stress
that students maintain a positive image when they
post online. Students should be cognizant of professionalism in electronic communications because
faculty members and prospective employers might
check social media sites. At a time when health care
and medicine is still new to them, students might be
tempted to post photos or commentary on “cool” or
unique cases. However, educators should inform students about the effect unprofessional behaviors can
have on their careers and counsel students against
having a double standard for their online presence and
professional image. For example, students should be
cautioned against posting their photo in a professional
setting doing something decidedly unprofessional.
This includes acting in an unprofessional manner
while attired as a health care professional (eg, wearing scrubs). 52 To avoid legal ramifications from social
media activities50,52:
 Be responsible.
 Be authentic.
177
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Directed Reading
Medical Ethics and Law in Radiologic Technology
 Use privacy settings to restrict public access.
 Follow professional ethical standards, even in
your personal capacity.
Conclusion
For health care professionals, most litigation arises
from breaching the standard of care or breaking applicable state or federal laws. Health care professionals
must understand the threat of lawsuits and public or
professional censure arising from unethical or illegal
acts. They must stay abreast of changing laws and act
in accordance with professional standards of conduct,
including the duty to treat patients in their best interest
while doing minimal harm. Radiologic technologists
always should keep ethical principles in mind when
dealing with patients, coworkers, and employers; this
includes being truthful, respectful, and maintaining
confidentiality and trust.
Eric Matthews, PhD, R.T.(R)(CV)(MR), EMT, is
associate professor in the master of health science program
for Washburn University in Topeka, Kansas. Matthews
completed his doctorate in education at Southern Illinois
University with an emphasis in adult and vocational/
technical education (workforce education and development).
He also holds graduate degrees in education (administration
and supervision) and museum studies.
Tracy Matthews, PhD, is lecturer in the bachelor of
health science program for Washburn University in Topeka,
Kansas. She completed her doctorate in education at
Southern Illinois University with an emphasis in adult and
vocational/technical education (workforce education and
development). She also holds a master’s degree in history
and has conducted extensive research on gender, diversity,
and discrimination issues in health care and allied health
education.
Reprint requests may be mailed to the American Society
of Radiologic Technologists, Communications Department,
at 15000 Central Ave SE, Albuquerque, NM 87123-3909,
or e-mailed to [email protected].
© 2015 American Society of Radiologic Technologists
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/archives/spr2014/entries/mill/. Revised July 10, 2007.
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21. Frankl V. Recollections: An Autobiography. New York, NY:
Basic Books; 2000:19-104.
22. Wenar L. John Rawls. The Stanford Encyclopedia of Philosophy.
Winter 2013 ed. http://plato.stanford.edu/archives
/win2013/entries/rawls/. Accessed April 8, 2015. 23. Walsh C. The life and legacy of Lawrence Kohlberg. Society.
2000;37(2):36-41.
24. Kohlberg, L. Beds for bananas. Menorah J. 1948; Autumn
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25. Shi L, Singh D. Essentials of the U.S. Health Care System. 3rd ed.
Burlington, MA: Jones & Bartlett Learning; 2013:205-207.
26. Towsley-Cook D, Young T. Ethical and Legal Issues for Imaging
Professionals. St Louis, MO: Mosby;1999:1-122, 176-179.
27. Adler A, Carlton R. Introduction to Radiologic Sciences and
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28. Mitchell D, Haroun L. Introduction to Health Care. 3rd ed.
Clifton Park, NY: Delmar; 2012:61-82, 297-304.
29. Sjostrand M, Erikkson S, Juth N, Helgesson G. Paternalism
in the name of autonomy. J Med Philos. 2013;38:710-724.
doi:10.1093/jmp/jht049.
30. McCoy M. Autonomy, consent, and medical paternalism:
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31. Union Pacific Railroad Co. v Botsford, 141 US 250 (1891).
32. 1866 Civil Rights Act, 14 USC § 31 (1866).
33. Matthews E. The Civil Rights Act of 1964: changing the
face of employment. In: McConnell C, ed. The Health Care
Manager’s Legal Guide. Sudbury, MA: Jones & Bartlett
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34. Civil Rights Act of 1964, 78 Stat § 241 (1964).
35. National Archives of the United States. Teaching with
documents: the Civil Rights Act of 1964 and the Equal
Employment Opportunity Commission. http://www
.archives.gov/education/lessons/civil-rights-act/. Accessed
August 21, 2015.
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36. Facts about pregnancy discrimination 2015. United States
Equal Employment Opportunity Commission Web site.
http://www.eeoc.gov/facts/fs-preg.html. Updated September
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37. The Age Discrimination in Employment Act of 1967, (Pub L
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38. Cook JC. Prepare to avoid trouble under the Civil Rights Act
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toav.html.
39. Rosenbaum S, Markus A, Darnell J. U.S. civil rights
policy and access to health care by minority Americans:
implications for a changing health care system. Medical
Care Research and Review. 2000;57(4 supp):236-259.
doi:10.1177/1077558700574011.
40.Civil Rights Act of 1991, Pub L No. 102-166. (1991).
41. Storm L. Criminal Law. Irvington, NY: Flatworld Publishing
Inc; 2015. http://catalog.flatworldknowledge.com/bookhub
/reader/4373?e=storm_1.0-ch01#storm_1.0-ch01. Accessed
August 28, 2015.
42. Stader D. Law and Ethics in Educational Leadership. Upper
Saddle River, NJ: Pearson; 2007:208-234, 289-290.
43. How to file a lawsuit 2015. Northwest Registered Agent LLC
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suit.html. Accessed April 21, 2015.
44.Pro se. Cornell University Law School. Legal Information
Institute: Wex Legal Dictionary. https://www.law.cornell.edu
/wex/pro_se. Accessed April 22, 2015.
45. Society for Human Resource Management. Job-references
/blacklisting. http://www.shrm.org/legalissues/stateand
localresources/stateandlocalstatutesandregulations
/documents/job%20reference%20immunity.pdf. Published
September 2012. Accessed August 19, 2015.
46.Jonsen A, Siegler M, Winslade W. Clinical Ethics: A Practical
Approach to Ethical Decisions in Clinical Medicine. 7th ed. New
York, NY: McGraw Medical; 2010:12,165-168.
47. ICARE. Etiquette-based medicine project at KFMC. In:
Qushmaq KA, ed. Etiquette Based Medicine: Achieving
Excellence in Patient Care. 9-10. https://www.acponline.org
/ethics/. Accessed August 31, 2015.
48. American Registry of Radiologic Technologists. Ethics.
https://www.arrt.org/ethics/. Accessed April 17, 2015.
49. American Registry of Radiologic Technologists. Standards of
Ethics. https://www.arrt.org/pdfs/governing-documents
/standards-of-ethics.pdf. Revised September 1, 2014.
Accessed April 17, 2015.
50. Bagley JE, DiGiacinto DD, Hargraves K. Imaging professionals’ views of social media and its implications. Radiol Technol.
2014;85(4):377-389.
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51. Company info: stats. Facebook Web site. http://newsroom
.fb.com/company-info/. Accessed April 11, 2015.
52. Lachman V. Social media: managing the ethical issues.
Medsurg Nurs. 2013;22(5):326-329.
53. Basevi R, Reid D, Godbold R. Ethical guidelines and the use
of social media and text messaging in health care: a review of
literature. New Zealand J Physiother. 2014;42(2):68-80.
54. Yap KYL, Tiang YL. Recommendations for health care educators on e-professionalism and student behavior on social
networking sites. Medicolegal and Bioethics. 2014;(4):25-36.
doi:10.2147/mb.s60563.
180
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Directed Reading Quiz
15806-01
1.5 Category A credits
2.5 MDCB Credits
Expires Dec. 31, 2017*
Medical Ethics and Law in
Radiologic Technology
To earn continuing education credit:
 Take this Directed Reading quiz online at www.asrt.org/drquiz.
 Or, transfer your responses to the answer sheet on Page 186
410M
and
and
mail
mail
toto
ASRT,
ASRT,
POPO
Box
Box
51870,
51870,
Albuquerque, NM 87181-1870.
New and rejoining members are ineligible to take DRs from journal issues published prior to their most recent join date unless
they have purchased access to the quiz from the ASRT. To purchase access to other quizzes, go to www.asrt.org/store.
*Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date.
Read the preceding Directed Reading and choose the answer that is most correct based on the article.
1. Medical ethics is a:
a. study of ethical issues emerging in new
situations, or possibilities brought about by
scientific discoveries in biology or medicine.
b. set of biological principles that guide the practice
of medicine.
c. system of moral principles that apply individual,
professional, and societal values and judgment to
the practice of medicine.
d. framework of the medical ethics system and the
legal basis by which that system is governed.
2. Morals are manners, customs, or generally accepted
standards of good or right conduct that reflect our
personal values framed within a larger, external
system of beliefs.
a.true
b.false
3. The work of ______ laid the groundwork for the
theory of natural law.
a.Aristotle
b. Saint Thomas Aquinas
c. Immanuel Kant
d. John Stuart Mill
4. Which of the following applies to the theory of
deontological ethics?
1. It focuses on the duty of an individual to
others and the rights of those recipient
individuals.
2. Decisions are ethically and morally sound
if they provide the greatest benefit to the
most people.
3. The highest virtue comes from doing what
you are supposed to do.
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
continued on next page
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
181
Directed Reading Quiz
5. Lawrence Kohlberg’s theories are especially
important to administrators because they allow:
a. administrators to analyze their own decisions
and those of their employees.
b. everyone to have equal access to everything at
the same time.
c. employees to find a sense of purpose.
d. individuals to progress to the “I-YOU”
relationship.
6. According to the article, which of the following
overarching ethical principles guide health care
providers?
a. ethical and moral responsibility
b. beneficence and nonmaleficence
c. humanity and compassion
d. trust and respect
10. When a medical professional makes a decision for a
patient that he or she believes is in the patient’s best
interest, the medical professional is engaging in:
a.paternalism.
b. patient advocacy.
c.self-determination.
d.veracity.
11. An informed consent form should contain all of the
following except a(n):
a. authorization clause allowing performance of
the examination or procedure.
b. disclosure clause explaining the procedure.
c. signature clause for the patient and a witness.
d. guarantee clause for therapeutic procedures.
7. ______ is the principle of truth telling.
a.Confidentiality
b. Obligatory honesty
c. Qualified privilege
d.Veracity
12. Health care providers have a right to defer their
participation in patient care except when:
a. cultural or religious beliefs are involved.
b. it might be inconvenient to find another
provider.
c. a patient’s health might be compromised.
d. the care involves an elective procedure.
8. The Health Information Portability and
Accountability Act (HIPAA) protects which of the
following types of private patient information at a
heightened level?
1. substance abuse
2. mental illness
3. sexually transmitted diseases
13. Do not resuscitate (DNR) written orders are put
in effect by ______ to prevent cardiopulmonary
resuscitation from being performed.
a. advanced directives
b. living wills
c.patients
d.physicians
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
9. Which of the following refers to an individual’s
right to make his or her own decisions?
a.autonomy
b.paternalism
c.self-determination
d.veracity
182
14. According to the article, Title VII of the Civil
Rights Act of 1964:
a. prohibits discrimination against people older
than 40 years.
b. requires accommodations for people with
disabilities.
c. prohibits discrimination in employment on the
basis of race, sex, national origin, and religion.
d. mandates that all job openings be posted
publicly.
continued on next page
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Directed Reading Quiz
15.Employers always are required to allow individuals
time off work, without consequence, for pregnancyrelated health care.
a.true
b.false
16. In the United States, law is divided into which 2
broad categories?
a. civil and health
b. criminal and personal injury
c. tort and malpractice
d. criminal and civil
17. Criminal lawsuits are brought against one or more
defendants by the:
a.plaintiff.
b. Department of Health.
c. government.
d.patient.
18. Which action is first in a civil case?
a. the filing of a complaint
b.discovery
c. the filing of a motion
d. answering a summons
19.The most common tort in the United States is:
a.malpractice.
b.negligence.
c.assault.
d.battery.
20. When each individual involved in the procedure
becomes a defendant in a negligence case, ______
has been invoked.
a. defendants et moritoria
b. negligence per se
c. res ipsa loquitur
d. respondeat superior
21. If someone submits a false insurance claim, he or
she has committed:
a. breach of trust.
b.defamation.
c.fraud.
d.libel.
22. According to one concise definition,
professionalism includes:
1. placing the interest of patients above those
of the caregiver.
2. setting and maintaining standards of
competence and integrity.
3. providing expert advice to society on
matters of health.
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
23. The American Registry of Radiologic Technologists
(ARRT) ______ is (are) mandatory and
enforceable.
a. Code of Ethics
b. Rules of Ethics
c. review process
d. policies and procedures
24. Ethical and legal issues that can arise from using
social media include:
1. breach of privacy or confidentiality.
2. communication against employers.
3. boundary violations.
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
continued on next page
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
183
Directed Reading Quiz
25. To avoid legal ramifications from social media
activities, do all of the following except:
a. use privacy settings to restrict public access.
b. follow professional ethical standards, even in
your personal capacity.
c. use patient identification numbers instead of
names.
d. be authentic.
184
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
✁
Carefully cut or tear here.
CE
Directed Reading
Medical Imaging of Oral and
Oropharyngeal Cancer
Susan M Anderson, MAED, R.T.(R)
Oral cancer is associated
with documented risk
factors, yet no comprehensive
screening program is in
place in the United States
for early detection of the
disease. Oral cancer often is
diagnosed in more advanced
stages, resulting in a poor
prognosis. Dental practitioners
and radiographers play
an important role in the
management of the disease
and in helping to improve the
quality of life for people who
have oral cancer. This article
discusses types of oral and
oropharyngeal cancer, their
diagnosis, treatment options,
and the role of dental imaging
in patients with these cancers.
This article is a Directed
Reading. Your access to
Directed Reading quizzes
for continuing education
credit is determined by
your membership status
and CE preference.
After completing this article, the reader should be able to:

Describe oral cancer and typical sites of presentation.

Explain risk factors associated with oral cancer.

Discuss how oral cancer is diagnosed.

List treatment options available for oral cancer and typical complications of treatment.

Recognize the role of dental practitioners in oral cancer treatment.

Define the role of dental imaging in management of patients with oral cancer.

Identify oral cancer indications and challenges to imaging these patients.
R
adiographers provide medical
imaging services for patients
who have many types of cancer,
but they might be less familiar
with oral cancer. Oral cancers are part
of a diverse group of head and neck cancers that often are not diagnosed until
the cancer has metastasized.1
Oral cancer refers to cancer of the
oral cavity, and oropharyngeal cancer
refers to cancer of the oropharynx,
which includes the middle throat, back
of the tongue, soft palate, tonsils, and
the side and back walls of the throat.
In the literature, oral and oropharyngeal cancer often are included under
the umbrella term oral cancers, and the
National Cancer Institute defines oral
cancers as any cancer that “forms in the
oral cavity (the mouth) or the oropharynx (the part of the throat at the back of
the mouth).”2
Both oral and oropharyngeal cancers are types of head and neck cancer.1,3 Head and neck cancers typically
originate in the squamous cells that
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
line the mucosal surfaces of the mouth,
nose, sinuses, and throat.2,3 Oral and
oropharyngeal cancers make up 85%
of all head and neck cancer incidence.1
Typical sites for oral and oropharyngeal
cancers are shown in Box 1.
Epidemiology
According to World Health
Organization statistics, oropharyngeal
cancer was the 11th most common cancer in 2005.5 More than 450 000 new
cases are diagnosed worldwide each
year, and the average U.S. 5-year survival rate is currently near 57% according to the Oral Cancer Foundation.1
This represents an increase in survival
of only about 3% in the past 10 years.1
A particularly noteworthy trend is the
increased incidence of the disease in
developing countries. 6 The 5-year survival rates vary from country to country, but for most it stands at 50%.1
Oral and oropharyngeal cancers are
more common in men than in women,
and they tend to be diagnosed in older
187
CE
Directed Reading
Medical Imaging of Oral and Oropharyngeal Cancer
Box 1
Typical Sites of Presentation for Oral and
Oropharyngeal Cancers2,4
Oral Cancer
Oral cancer develops in the oral cavity. Typical sites include
the:








Anterior two-thirds of the tongue.
Buccal mucosa and lips.
Floor of the mouth beneath the tongue.
Gingivae.
Hard palate.
Lips.
Retromolar trigone (area located behind the molars).
Salivary glands.
Oropharyngeal Cancer
Oropharyngeal cancer develops in the regions
of the throat located behind the mouth including the:




Base of the tongue (posterior third).
Sides and back of the throat.
Soft palate.
Tonsils.
rather than younger individuals. Oral cancers usually
are diagnosed in people aged 50 years and older.1,3,6
United States Prevalence
According to American Cancer Society 2013 statistics,
oral and oropharyngeal cancers are the eighth leading
cancer site for new cases in men. Estimates for 2015 predicted approximately 39 500 new cases of oral and oropharyngeal cancer in the United States, and 7500 deaths;
the disease is estimated to contribute to the death of one
person every hour.3,7 In the United States, the median
age at diagnosis is 62 years and the median age at death is
67 years.8 Fifty-seven percent to 62% of individuals who
receive an oral or oropharyngeal cancer diagnosis survive
more than 5 years.1,8 In the United States, the mortality
rate for oral cancer is higher than the mortality rate for
Hodgkin lymphoma, malignant melanoma, or cervical,
thyroid, testicular, or laryngeal cancers.1,3,7
Global Prevalence
Incidence for oral and oropharyngeal cancers differs by geographic location. Globally, areas with high
188
incidence rates of oral and oropharyngeal cancers
include South and Southeast Asia such as Sri Lanka,
India, Pakistan, Bangladesh, and Taiwan. 6,9 In these
areas, oral cancer is the most common cancer among
men.
Hungary, Slovakia, Romania, and France have the
highest rates of oral, lip, and oropharyngeal cancer in
the world. Oral and oropharyngeal cancers were listed
as the fifth-most common cancer among men in the
European Union in 2012.10 In Hungary, incidence and
mortality rates for oral and oropharyngeal cancers have
doubled in recent decades. Oral cancers are the most
common cancer among men in Hungary, with the
third highest cancer-related mortality rate.11 In France,
Romania, and Slovakia, oral and oropharyngeal cancers
are the fourth most common cancer among men. They
also are fourth highest in cancer-caused mortality rates
for men in Romania and Slovakia and the seventh highest for cancer-related mortality in France.12
In South America and the Caribbean, the countries
of Brazil, Uruguay, and Puerto Rico have the highest
incidence rates. In this geographic region, oral and oropharyngeal cancers rank fifth in cancers among men
and sixth among women in occurrence. 6,9
Anatomic Site
Anatomic sites of oral cancer at diagnosis vary by
patients’ geographic region. In Spain and in white populations of Australia and Canada, the lip is the most common
reported site for oral cancer. In the United States and
European Union other than Spain, the tongue is the most
common site.6,10 In Asia, the buccal mucosa is the most
common site for oral cancers. Other common sites include
the palate, the floor of the mouth, and the gingivae.3,6,10
Risk Factors
Several risk factors are associated with the development of oral and oropharyngeal cancers. It is estimated
that between 75% and 90% of these cancers are directly
related to lifestyle choices and could be prevented.1,13-16
The most important risk factors associated with oral
cancer are the use of tobacco (including smokeless
tobacco, chewing tobacco, and snuff) and alcohol. 3,13-16
Smoking marijuana is not associated with increased risk
for developing oral and oropharyngeal cancers.15
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Tobacco Use
Use of any form of tobacco causes most oral and
oropharyngeal cancers. 3 The risk increases with the
amount smoked per day and the length of smoking history.15 After quitting, the risk of oral cancer from smoking decreases each smoke-free year. Generally, the risk
from smoking a pipe or cigar is similar to the risk associated with smoking cigarettes.14,15 Pipe smoking increases
the risk for lip cancer more so than cigarette or cigar
smoking.14,15 Exposure to secondhand smoke in the
home increases the risk of oral and oropharyngeal cancers in nonsmokers.14,15 The risk of oral and oropharyngeal cancer is twice as high for nonsmokers if they are
exposed to secondhand smoke for 15 years or more.14,15
The use of chewing tobacco increases the risk of
cancer to the cheeks, gingivae, and inner lip mucosa.14,15
The risk of cancer increases as years of use increase. For
long-term users, the risk can be 50 times that of a person who has never used chewing tobacco.15
Alcohol
Drinking alcohol is linked to increased risk of developing oral and oropharyngeal cancer.14,15 It is estimated that
7 out of 10 people who have oral cancer have a history of
heavy drinking.15 However, many patients with oral cancer use both tobacco and alcohol, which makes it difficult
to determine how alcohol use contributes to increased risk
for oral cancers.14,15 According to some studies, individuals who both smoke and drink alcohol could be 100 times
more likely to develop oral and oropharyngeal cancers
than individuals who abstain from both.15
Paan and Gutka
Paan is a popular chewable stimulant, made of areca
nut and slaked lime wrapped in a betel leaf.3,17 Gutka is
a similar preparation, but with tobacco included. Paan
and gutka are commercially available products in India
and Asia; paan is most popular in Southeast Asia.3,15,16
Chewing paan increases risk of oral cavity cancer by 3.5
times the rate of the general population. Chewing gutka
increases risk of oral and oropharyngeal cancer 7 times
more than for people who do not use these products. A
person who chews gutka, smokes cigarettes, and drinks
alcohol has a risk of oral and oropharyngeal cancer that
is 30 times that of the general population.15 Studies
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
show that paan and gutka could be responsible for 50%
of all oral cancer cases in India.17
Radiation
Ultraviolet radiation is a probable cause of lip cancer
in people with outdoor jobs that expose them to sunlight for long periods. Lip cancer is more common in
people who have fair skin; the risk increases further in
those who smoke tobacco. 6,15
According to Cancer Research UK, ionizing forms
of radiation such as x-rays and gamma rays are known
causes of salivary gland cancer. Salivary gland cancer
is relatively rare, but incidence is higher in survivors of
childhood cancers, thyroid cancer, and Hodgkin lymphoma. This is primarily because of treatment using
radioactive iodine or radiation therapy.15
Human Papillomavirus
Human papillomavirus (HPV) is a group of more
than 150 specific viruses. Infection with certain types
of these viruses can cause plantar and genital warts,
while infection with other types of HPV can cause cancer.18 The HPV viruses are assigned numbers to identify
each type. HPV-16 has been linked to oropharyngeal
and cervical cancer.16,18 There is no current U.S. Food
and Drug Administration–approved test for HPV infections of the mouth and throat.18
According to the Oral Cancer Foundation, the incidence of oral and oropharyngeal cancers is rising among
people aged 25 to 50 years. Typically, these individuals
are otherwise healthy and do not smoke, implicating the
HPV virus in the development of oral cancers. Signs of
HPV infection are present in 2 of every 3 oropharyngeal
cancers and some oral cancers. In the United States,
nonsmoking white men aged 35 to 55 years are most at
risk for HPV-related oral cancers.18 In the United States,
the prevalence of HPV-related oropharyngeal cancers
has increased 225% between 1988 and 2004.16
Precancerous Conditions
Several diseases or conditions that occur in the
mouth are considered precancerous; these are leukoplakia and erythroplakia. Both conditions can be precancerous, but each also can be attributed to specific causes
other than cancer.
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Leukoplakia is an abnormal patch of white tissue or
plaque that forms in the mouth (see Figure 1).19,20 In
many cases, leukoplakia is simply the response of an
individual’s body to an irritant and can be attributed to
problems such as ill-fitting dentures, chronic cheek biting, or malocclusion.21 Heavy alcohol use, smoking, and
the use of smokeless tobacco also can cause leukoplakia.
In approximately 20% of cases, leukoplakia shows evidence of dysplasia or carcinoma; sites such as the floor
of the mouth and the ventral surface of the tongue have
demonstrated a 45% rate of dysplasia or carcinoma.19,20
Erythroplakia is described as an abnormal red
patch of tissue that forms on the mucosal surfaces in
the mouth (see Figure 2).19,20 Causes of erythroplakia
include exposure to harsh chemicals or UV radiation,
and tobacco and alcohol use.15 Erythroplakia is cause
for concern, as it has been reported to have up to 91%
dysplasia, or precancerous findings, at diagnosis.19
Other Risk Factors
Several other factors are associated with an
increased risk of having oral or oropharyngeal cancers,
including1,14,15:
 Age – people older than 55 are at greater risk.
 Sex – men are twice as likely to have oral and
oropharyngeal cancer, despite a substantial
increase in women with oral and oropharyngeal
cancers in recent decades. Before the increase,
the cancer ratio was 6 to 1 for men vs women.
Figure 1. Leukoplakia, appears as an abnormal area of white
tissue or plaque in the mouth. Image courtesy of Dublin Dental
University Hospital, Dublin, Ireland.
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Figure 2. Erythroplakia on the roof of the mouth with some
patches of leukoplakia also visible. Image courtesy of Dublin
Dental University Hospital, Dublin, Ireland.
 Diet – several studies show that a diet low in fruits
and vegetables can increase the risk of oral and
oropharyngeal cancer.
 Previous cancer – individuals with a history of
head and neck cancers are at a 12% to 16% greater
risk for developing a second cancer in the region.
Screening and Diagnosis
The initial signs and symptoms of oral or oropharyngeal cancer can be confused with other conditions
(see Box 2 and Figures 3-4). In addition, many patients
are asymptomatic or take little notice of initial symptoms.
Diagnosis of oral and oropharyngeal cancer begins
with detection. This is important because the low global rate of 5-year survival (50%) for people who receive
a diagnosis can be largely attributed to late detection of
the disease, after metastasis. Metastatic spread typically
occurs through the lymph nodes.13 Diagnosis at later
stages is not a result of oral and oropharyngeal cancers
being hard to detect, but rather because of a lack of public information and screening programs in many countries, including the United States.13,23
Screening is ideal for oral cancers because they often
are preceded by premalignant lesions and the progression to malignancy is slow; it can take from 2.5 to 8
years for the average premalignant oral lesion to become
cancerous.13 Individuals can be screened for the disease by a physician or by request during regular dental
check-ups. According to the Oral Cancer Foundation,
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Box 2
Signs and Symptoms of Oral and Oropharyngeal
Cancer1,3,17,22
 Constant bad breath.
 Difficulty chewing or swallowing (dysphagia).
 Loosening of the teeth or pain around the teeth.
 Mass or thickening in the cheek or neck.
 A mouth sore that does not heal or is present longer than
2 weeks.
 Numbness of the tongue or other area in the mouth.
 Persistent mouth pain.
 Persistent sore throat or feeling that something is caught in
the throat.
 Swelling of the jaw, resulting in poorly fitting dentures.
 Trouble moving the jaw or tongue.
 Voice changes.
 Weight loss.
 White or red patches on the tongue, gingivae, cheeks, or
tonsils present more than 2 weeks.
Figure 3. Ulceration on the lower lip. Biopsy was positive for
squamous cell carcinoma. Image courtesy of Dublin Dental
University Hospital, Dublin, Ireland.
60% of Americans see a dentist yearly and professional
studies show that fewer than 25% of them report having
oral cancer screenings during these visits. The foundation has set a goal of increasing awareness in the dental
profession.23
Screening for oral and oropharyngeal cancer is a relatively simple process that takes less than 10 minutes to
complete and is minimally invasive. Individuals can perform self-screening at home; this might be recommended
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Figure 4. Swelling on alveolar area of the maxilla. Biopsy was
negative for cancer. Image courtesy of Dublin Dental University
Hospital, Dublin, Ireland.
for those who have risk factors for oral cancers. Selfscreening should never replace a dental examination or
screening by a medical professional (see Box 3).
There are no recommendations with respect to frequency or effectiveness of self-screening. The general
public should be aware of the signs and symptoms of
oral cancers and how to look for changes in the mouth.
In addition, everyone should regularly visit his or her
dentist, especially young adults. The fastest growing
group of people diagnosed with oral cancer has become
young nonsmokers who have developed the disease as a
result of contracting HPV-16.
Dental professionals perform a screening examination similar to the self-screening that patients can
perform at home. Patients who are uncertain whether
they have received an oral cancer screening when visiting their dentist should ask the dentist to perform one.
Dentists also can teach patients the steps for home
screening and provide guidance on healthy appearance
of oral tissues and structures so that patients can better
identify early changes in the mouth if they occur.
Changes observed in the mouth that persist for 2
weeks typically indicate the need for medical attention.
After a suspicious area is identified during a medical
screening appointment, tests are required to determine
whether malignant cells are present. Both dentists and
doctors can order or perform these tests. A biopsy confirms the oral or oropharyngeal cancer diagnosis.
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Box 3
Self-screening for Oral Cancer
24
Find a comfortable area with good lighting and a large mirror.
Have a small dental mirror handy along with gauze or a small
washcloth for drying the mouth and tongue. Signs to note
include color differences, texture changes, lesions, and lumps.
Most oral cancers are found in the floor of the mouth and
on the tongue, but individuals should examine 6 areas of the
mouth during self-screening:
Tongue.
 Buccal mucosa and gingivae.
Lips.
 Floor of the mouth.
 Roof of the mouth.
 Back of the throat.
To perform the examination, follow these steps:
1. Dry the inside of the mouth with gauze or a washcloth.
2. Gently grasp the tip of the tongue with the cloth or gauze and
extend the tongue out as far as possible. With the mirror, look
closely at the sides, top, and underside of the tongue for any
white, red, or dark areas. Feel for lumps or erosions.
3. Using an index finger, feel the lip, gum, and cheek areas for
lumps and erosions. Visually inspect the same areas using
the dental mirror. Look for areas of discoloration such as
patches of white, red, or dark coloration.
4. Assess the floor of the mouth and the area under the
tongue. With the mouth open and the tongue curled back
in the mouth, examine the floor of the mouth in the dental
mirror and look for areas of discoloration.
5. Place one index finger in the mouth behind the lower front
teeth and the other index finger under the jaw at the chin
to assist in feeling for lumps and swelling by moving both
fingers toward the back of the mouth. Repeat this action
on both sides of the mouth and then directly under the
tongue.
6. Assess the palate by looking at it using the dental mirror for
areas of white, red, or dark discolorations. With an index finger,
feel the roof of the mouth for lumps or areas of softness.
7. Use 2 or 3 fingers to palpate the outside of both sides of the
mouth and the front of the neck to check for swelling or
lumps.
8. Open the mouth as fully as possible and depress the
tongue or extend it out of the mouth as far as possible
and look at the back of the throat. With the dental mirror,
look for areas of discoloration and assess the tonsils for
asymmetry, swelling, or visible lumps.
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The least invasive type of biopsy for diagnosing oral
cancers is exfoliative cytology.3,22 Using this technique,
the doctor or dentist scrapes the suspected area vigorously with a small brush to collect cells for microscopic
examination. This procedure is easy to perform, is noninvasive, and can extract samples from small areas that
are only slightly abnormal in appearance. Exfoliative
biopsy cannot be used alone, however. This method
might not detect all cancers and sometimes fails to distinguish between malignant and abnormal, but benign,
cells. A traditional biopsy should follow this approach if
abnormalities are found. 3,22
The more traditional approach is the incisional
biopsy. The biopsy can be performed in the office or in
an operating room. A doctor or dentist removes part or
all of the lesion, mass, or abnormal tissue.3,25 A punch
biopsy, in which a small circular blade is pressed into
an area of abnormal tissue and a small core of tissue is
removed is a common type of incisional biopsy used for
oral cancer diagnosis. 3,25 This technique can be effective
for small areas of abnormal coloration in the mouth.
There is little bleeding with this type of biopsy and the
area often heals with no need for stitches.
A third type of biopsy used for masses, especially
those located on the neck, is a fine-needle aspiration
biopsy. The doctor or dentist uses a small-gauge needle
and a syringe to extract cells from a mass. This type of
biopsy also is used in patients with known oral or oropharyngeal cancer to determine whether the cancer has
metastasized to the lymph nodes.3,25
Patients with suspected oropharyngeal cancers might
undergo an endoscopic procedure called a panendoscopy
to look at the oral cavity, nose, pharynx, larynx, trachea,
and esophagus.26,27 This examination also can be used
to obtain tissue samples for biopsy.26,27 The scope’s light
and lens provide the physician with an improved view for
visual evaluation and tissue sample removal.
If biopsy results are positive, a patient might
undergo additional tests to determine the extent of
the cancer and to establish a formal treatment plan
best suited to the patient’s needs. In addition to blood
tests to assess the overall health of the patient before
surgery, diagnostic imaging might be used. Imaging
examinations for preoperative assessment and staging
can include:
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 Chest radiography – assists in evaluating metastases to the lungs or lung conditions that might
affect a surgical procedure’s safety or outcome.
 Computed tomography (CT) – helps determine
the size and location of any tumors and possible
metastases, particularly to bone. CT scans also can
help the physician determine whether a tumor can
be surgically excised.
 Magnetic resonance (MR) imaging – used to
evaluate soft tissues such as the tongue or tonsils
and to display the soft tissues of the neck, primarily to look for metastasis.
 Positron emission tomography (PET) scans –
helpful in the cancer staging process and in identifying distant metastases.
Staging
After initial diagnosis and staging, patients receive
treatment from physicians, dentists, and health care
professionals who provide support for pain and symptom management, wound management following surgery, adverse effects of radiation therapy, nutritional
support, speech therapy, and social work or case management.28
Staging helps determine the extent of the cancer,
whether and how far the cancer has metastasized,
patient prognosis, and optimal treatment options. Oral
and oropharyngeal cancers are staged using the TNM
(tumor-node-metastases) staging system, which provides information on the3,29:
 Size (in centimeters) of the primary tumor.
 Presence of metastasis, including number of sites,
size, and local lymph node involvement.
 Presence or absence of distant metastases.
Combining the TNM classifications provides the
information needed to assign a stage grouping for the
cancer.3,29 Stage 0 is associated with the best prognosis
for the patient, and stage IV with the worst. General
staging information for oral and oropharyngeal cancers
is listed in Box 4.
Survival rate is part of the prognosis and is based on
5 years of surveillance following treatment for people
with the same cancer type and stage. According to the
Surveillance, Epidemiology, and End Results program,
5-year survival rates in the United States from 2005
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
through 2011 were 63.2% for people diagnosed with
oral and oropharyngeal cancers.8 The Table shows survival data for lip, tongue, and mouth floor cancer. 3
Treatment
Once the cancer has been staged, a team of physicians
determines optimal treatment based on the type, location, staging, and molecular information gathered. The
team assists the patient in making the best possible treatment choice to meet individual patient needs and goals.
Treatment Team
The treatment team for oral and oropharyngeal cancers might include several physicians and other health
care professionals. A medical oncologist or radiation
oncologist typically oversees treatment. In the United
States, some community hospitals use a tumor board,
a multidisciplinary group of health care professionals
who meet regularly to review cancer cases and discuss
the best treatment options for patients.32 In addition
to the radiation oncology team, the treatment team
for patients with oral and oropharyngeal cancer might
include these health professionals26,32:
Otolaryngologist.
 Oral and maxillofacial surgeon.
 Dental oncologist.
Psychologist.
 Prosthodontist (a dentist who restores the mouth
following surgery).
 Plastic surgeon.
Dietician.
 Speech therapist.
Treatment plans and teams are specific to each
patient’s needs. Treatment plans typically consider the
patient’s age, overall heath, patient input, and treatment
preference, along with the type of cancer, stage, and the
expert opinions of the treatment team.32
Treatment Options
Treatment options for patients with oral and oropharyngeal cancers generally include surgery, radiation
therapy, chemotherapy, targeted therapy, and palliative
therapy.3,26,32 One or more of these options can be used
depending on the cancer’s stage and site. Surgery is the
most common treatment for patients with oral cancer
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Table
Box 4
Stages for Oral and Oropharygeal Cancers
30,31,a
Stage 0
Considered in situ cancer, abnormal cells are found in
otherwise healthy tissue, such as the oropharyngeal lining,
that could become malignant.
Stage I
Cancer is still confined to the local tissue (such as the lip
only),  2 cm, and has not spread to any lymph nodes.
Stage II
The cancer has not spread to any lymph nodes and the
tumor is 2-4 cm.
Stage III
The tumor might still be  4 cm, but cells have spread
from the tumor to a nearby lymph node (such as a node on
the ipsilateral side of the neck), or the tumor  4 cm; the
tumor also might be larger and have spread to local organ
or tissue.
Stage IV
By stage IV, staging becomes more specific for each subtype
of oral and oropharyngeal cancer. Stage IV usually includes
substages (A, B, and C) to delineate TNM involvement.
Typically, stage IVA involves local or regional spread, limited
tumor size, and involvement of a single ipsilateral lymph
node or involvement of one or more nearby lymph nodes
(on the same or opposite side of the neck), growth of the
tumor, and local-regional spread. Stage IVB usually indicates
larger tumor size, more advanced local-regional tissue or
organ involvement, and lymph node involvement. Stage IVC
indicates metastatic involvement, regardless of tumor size.
a
This is general information that summarizes findings from tumor
size, lymph node involvement, and distant metastases for oral lip and
cavity and oropharyngeal cancers.
Visit asrt.org/as.rt?YC3YZx to see specific staging
information on oral cancers.
and early-stage oropharyngeal cancer; chemotherapy and
radiation therapy often are administered after surgery,
and often in combination for more advanced oropharyngeal cancers.16,32 Surgery can be curative for patients who
have early-stage oral cancers. Patients and designated family members should be informed of the risks and adverse
effects of all potential treatments before they begin.
The goal of palliative therapy is to maintain the quality
of life of the patient by relieving symptoms such as pain.
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5-Year Survival Rates for Select Oral and
Oropharyngeal Cancers3,8
Localized
a
Stage (%)
Regional
b
Stage (%)
Distant
c
Stage (%)
Overall oral cavity
and pharynx
31
47
18
Lip
93
48
52
Tongue
78
63
36
Floor of mouth
75
38
20
Site
a
Stages I, II, III with no lymph node involvement.
Stage III with regional node involvement or stage IV with no metastasis.
c
Stage IV with metastatic involvement.
b
Palliative therapy often is used for patients with advanced
cancer. Patients with less advanced stages of oral cancer
also might receive therapy for pain management.
Surgery is performed to remove the tumor or cancerous tissue. Surgical approach is determined by tumor size
and site. If a tumor is located near the front of the mouth,
the tumor can be removed through the mouth. Often, the
surgeon has to reach the tumor through an incision in the
neck that requires mandibulotomy, or surgically splitting
the mandible to facilitate tumor removal.3,33 The most
common types of surgical procedures for oral and oropharyngeal cancers are listed in Box 5.
Radiation therapy has been used to destroy cancer cells
or slow tumor growth for oral and oropharyngeal cancers as a primary treatment. Typically, radiation therapy
is the primary treatment for small, early-stage cancers.
Radiation therapy also is used in conjunction with surgery
for larger or more advanced cancers.3,26,32 For most oral
and oropharyngeal cancers, radiation therapy is administered 5 days a week for 5 to 7 weeks, and treatments last
10 to 15 minutes per session.26 The dental oncologist and
dental team play an important role in assisting with radiation therapy planning and treatment.
Chemotherapy for oropharyngeal or oral cancers
typically uses intravenous injection of oral medications; chemotherapy usually is used in conjunction with
radiation therapy. The combination of chemotherapy
and radiation therapy can be used instead of surgery to
treat some oral cancers or to treat cancers that are too
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Box 5
Common Surgeries for Oral Cancers
30,31
 Resection of the primary tumor. The entire tumor and
surrounding area of normal appearing tissue are removed.
Resection is used often for cancer of the lip, floor of mouth,
tongue, alveolar ridge, retromolar trigone, hard palate, and
buccal mucosa.
 Glossectomy, which is removal of all or part of the tongue.
 Mandibulectomy, or removal of part or all of the mandible.
 Maxillectomy, removal of part or all of the maxilla.
 Laryngectomy, which is complete or partial removal of the
larynx.
 Neck dissection, which is performed to remove affected
lymph nodes. The amount of tissue removed from the
neck depends on the primary lesion size and local-regional
spread of the cancer.
 Partial neck dissection involves removal of only selective
lymph nodes.
 Modified radical neck dissection involves removal of most
lymph nodes on the ipsilateral side of the neck between
the mandible and clavicle, along with some surrounding
muscle and nerve tissue.
 Radical neck dissection involves removal of all ipsilateral
lymph nodes in the neck and extensive muscle tissue,
nerves, and veins.
advanced or widespread for successful surgical resection.27
Chemotherapy combined with radiation therapy might
produce better results than radiation therapy alone, but
the adverse effects can be severe and difficult to tolerate
for some patients, especially those in poor health.27
Chemotherapy can be used alone or with radiation
to decrease the size of large tumors before surgery.3,26,32
Chemotherapy alone or with radiation therapy also can
be used following surgery to destroy any remaining
cancerous cells. 3
Targeted therapy medications target the genes or
proteins in cells that affect the cancer’s ability to grow
and survive. 3 The use of targeted therapy is designed
to limit damage to healthy surrounding tissues while
destroying the cancer cells. Targeted therapy drugs
often have different or less severe adverse effects than
standard chemotherapy drugs. Targeted therapy also
can be used in conjunction with radiation therapy or
standard chemotherapy. 3
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Adverse Effects
Patients with oral and oropharyngeal cancer face
many possible adverse effects from their cancer treatments; many of the effects are long lasting and can be
life altering. For example, various treatments can affect
a survivor’s appearance, as well as the ability to eat,
chew, swallow, speak, and hear.3,26,27
Surgical resection can cause the most disfigurement for patients because healthy skin, muscle, and
bone might be removed along with the cancer. In some
instances, all or part of the patient’s tongue, cheek,
lip, mandible, maxilla, gingivae, teeth, hard palate, or
zygoma (the bony arch below the eye orbit) might be
removed. 3,26,27 These patients require further reconstructive surgery after the cancer is removed. They also
can experience problems with the ability to eat, chew,
and speak if the zygoma is removed.
Patients who undergo a partial glossectomy will still
be able to speak, although not as clearly as before surgery
and the surgery might affect their ability to swallow normally.34 A total glossectomy results in the patient losing
both the ability to speak and swallow. Reconstructive
surgery and speech therapy might help the patient regain
some speaking and swallowing function.34 A laryngectomy also affects speaking and swallowing.26,34
Some patients with oral cancer might need a tracheostomy following surgery if swelling and bruising make
breathing difficult. The tracheostomy tube could be
temporary or might be needed permanently in patients
with a total laryngectomy.3,26 The patient might need
temporary assistance from a feeding tube to help meet
nutritional needs during recovery from surgery or at
various points during the treatment process.26
Radiation therapy and chemotherapy also might be
associated with adverse effects. Many are temporary,
but some can be permanent. Common adverse effects
from radiation therapy for oral and oropharyngeal cancers include3,26,35:
 Skin erythema, causing irritation.
Fatigue.
 Temporary or permanent alopecia (hair loss) in
the irradiated area.
 Mucositis from ulcerations and inflammation of
the mucous membranes in the mouth.
 Pain and difficulty eating and swallowing.
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Xerostomia (dry mouth).
Trismus (jaw spasm).
Dysgeusia (lost or distorted sense of taste).
Loss of appetite.
Change in voice or hoarseness.
Infections of the mouth, such as Candida infection (see Figure 5).
Adverse effects of radiation therapy can be damage to the salivary glands, mandible, pituitary gland,
or thyroid gland. As a result of this damage, patients
might experience permanent xerostomia, which can
lead to extensive tooth decay and difficulty swallowing
foods.26,27,35 Extensive caries (cavities) can occur following radiation therapy because of poor saliva production
(see Figure 6).26,27
Osteonecrosis of the mandible can be a serious adverse
effect of radiation treatment. Osteonecrosis occurs when
the bone begins to weaken and die because of decreased
blood flow.3,26,27,35 Osteoradionecrosis describes osteonecrosis from compromised blood flow to the bone following radiation treatments.3,27,35 The risk of osteoradionecrosis lasts for the duration of the patient’s life3 and is higher
following tooth infections, dental irritation, periodontal
disease, tooth extractions, or trauma to the mouth.35
Complications of osteoradionecrosis include pain, drug
dependency, fistulas, pathologic fractures, and loss of
bone and soft tissues (see Figures 7-8).35
Adverse effects from chemotherapy often are specific
to the medication used. Some general adverse effects of
chemotherapy include3,26,27,35:
 Neutropenia, or reduction in circulating white
blood cells, which increases the patient’s risk of
infection.
 Bruising and bleeding because of reduced platelet
count.
 Anemia and fatigue.






A
B
Figure 6. A. Orthopantomogram (OPG) acquired as part
of preradiation therapy dental evaluation. B. OPG of the
same patient 7 months after completion of radiation therapy.
Radiolucent areas (arrows) show extensive radiation-induced
caries and broken teeth. Images courtesy of Dublin Dental
University Hospital, Dublin, Ireland.
Figure 7. Extensive bone loss in the anterior mandible from necroFigure 5. White areas represent Candida fungal infection. Image
courtesy of Dublin Dental University Hospital, Dublin, Ireland.
196
sis. Image acquired 1 year following completion of radiation therapy for oral cancer. Image courtesy of Dublin Dental University
Hospital, Dublin, Ireland.
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Figure 9. Exposed bone in the area of the alveolar ridge of the
mandible in patient with osteochemonecrosis. Image courtesy of
Dublin Dental University Hospital, Dublin, Ireland.
Right
Figure 8. Pathologic fracture in the right anterior side of the
mandible. Patient is edentulous following radiation therapy for
oral cancer. Image courtesy of Dublin Dental University Hospital,
Dublin, Ireland.
 Nausea and vomiting.
Diarrhea.
Alopecia.
Mucositis.
 Hearing changes such as tinnitus or hearing loss.
 Osteochemonecrosis, which can occur following
chemotherapy treatments that include bisphosphonates.
Most adverse effects of chemotherapy cease after
treatment. The use of chemotherapy in conjunction with
radiation therapy can worsen adverse effects, making
it difficult for some patients to tolerate treatments.26,27,35
Osteochemonecrosis causes bone complications.35 It typically presents as pain, soft tissue swelling, loose teeth,
infection, and exposed areas of bone (see Figure 9).36
Many aspects of oral cancer and its treatment affect
a patient’s quality of life, in particular psychological and
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
emotional changes; physical appearance; and activities
such as eating, speech, and hearing. Because of this,
the patient’s treatment team includes support professionals. Dietitians help patients receive proper nutrition
and manage difficulty or pain with chewing or swallowing. 3,26 Speech therapists can assist patients with
speech problems caused by the cancer or treatment. An
otolaryngologist might be needed to assist with changes
to hearing, and a psychologist or cancer counselor can
help patients with their emotional and psychological
needs relating to cancer and the changes they face.3,26,27
Patients who have surgical resections might require
additional surgery to replace bone and teeth, or to
reconstruct facial features. Reconstruction can help
repair damage following cancer treatments and restore
the function and appearance of the affected area.
Specialists in reconstruction or maxillofacial surgeons
typically perform these procedures. If a portion of the
maxilla or the mandible is removed, the patient also is
cared for by a maxillofacial prosthodontist.26
Reconstruction
Because oral and oropharyngeal cancer can cause
both functional and cosmetic impairments that can
affect a patient’s quality of life, reconstruction or restoration procedures might be recommended. Cancer
site and extent of tissue removal contribute to decisions
regarding the procedure used.
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A radical or partial maxillectomy might be performed
in patients with cancers affecting the maxilla, particularly
the hard or soft palate.34 A total, or radical, maxillectomy
involves resection of the entire maxilla to the midline.
The bone is removed through incisions in the patient’s
upper lip and cheek. In a partial maxillectomy, the physician removes the diseased area through the mouth.16,34
Eating can be difficult for patients who have had a
partial or radical maxillectomy, which can affect both
chewing and swallowing. 34 Food and liquids can be
forced up through the surgical opening, into the nasal
cavity and out the nose when swallowing. The patient
also might have facial disfigurement, problems with
nasal cavity secretions collecting in the surgical area,
and drying of nasal cavity mucous membranes.34
Restoration for maxillary defects can begin during the
maxillectomy. During surgery, a preconstructed surgical
obturator, which is a temporary prosthesis, is placed into
the surgical opening, closing the defect.34 The surgeon can
place a permanent prosthesis after the tissues have healed.
Glossectomy and mandibular resection often present
the greatest challenges of all surgeries for oral cancer.34
Patients can experience difficulty with speech, swallowing, mandibular movement, and salivary control; facial
disfigurements are common and often result in diminished function compared with presurgical abilities.34,37
Advanced tumors involving the floor of the mouth and
the anterior portion of the tongue often result in a large
amount of tissue being resected. The tongue can be
reconstructed using tissue from the patient’s thigh or
forearm.37,38 Figure 10 shows a postmandibular resection for cancer involving the left mandible before beginning the restoration processes.
Restoration processes for the mandible can be initiated during the cancer resection. Bone sections from
the patient’s fibula are commonly used to replace
bone lost from surgical removal and initiate the restorative process, which might involve dental implants to
improve chewing and preserve cosmetic appearance
(see Figures 11-12).38 The entire restoration process
can take several years to complete.
of patients with oral and oropharyngeal cancers.
Often, the dentist is the health care professional who
first discovers a suspicious abnormality in the mouth
and initiates investigation, or in some cases, performs
the biopsy.
Role of the Dental Team
Figure 12. Patient with healed fibular restoration with dental
Dental professionals including hygienists, nurses,
radiographers, and dentists all have a role in the care
198
Figure 10. An OPG demonstrating removal of the left body of the
mandible and ramus. No initial restorative steps had been taken
at the time the image was acquired. Image courtesy of Dublin
Dental University Hospital, Dublin, Ireland.
Figure 11. Patient with fibular restoration. Dentition on the
right has not yet been replaced. Image courtesy of Dublin Dental
University Hospital, Dublin, Ireland.
implants to restore dentition on the right. The image is slightly
distorted with the patient rotated to the right. Image courtesy of
Dublin Dental University Hospital, Dublin, Ireland.
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Pretreatment Evaluation
Once a patient has received an oral or oropharyngeal
cancer diagnosis, and if the treatment plan includes
radiation therapy or chemotherapy, the patient requires
a thorough pretreatment dental evaluation by a dental
oncologist. Assessment should take place at least one
month before treatment initiation and can involve several visits. Pretreatment assessments are used to39,40:
 Reduce risk or severity of oral complications from
treatment.
 Identify and treat current oral problems (such
as infections or caries) and minimize the risk of
developing complications during treatment.
 Provide a baseline for future examinations.
 Prevent, eliminate, or reduce oral pain.
 Prevent or minimize complications that could
affect nutrition.
 Prevent or reduce chances of osteonecrosis.
 Preserve and improve oral health.
 Provide patient education about oral hygiene during and after treatment.
 Help improve the patient’s quality of life.
 Decrease the cost of care.
During the first visit, a thorough dental evaluation,
including dental radiography, is conducted. The evaluation assesses teeth, gums, and surrounding soft tissues.
The dental evaluation for a patient with oral cancer usually begins the process of 39,40:
 Identifying and initializing treatment for mouth
infections, caries, broken teeth, and any tissue
injuries or disease.
 Identifying and extracting any teeth in the radiation field that cannot be restored to minimize
the chances of osteonecrosis from post-treatment
extractions. Required oral surgery should take
place at least 2 weeks before treatment begins.
 Evaluate current prostheses such as dentures in
the patient’s mouth to ensure cleanliness and
proper fit.
 Measure saliva flow.
From the pretreatment evaluation, a dental plan is created and discussed with the patient. Patient education is
essential for reducing complications and ensuring treatment success. Patients are advised about oral care, nutrition, and smoking and alcohol cessation as necessary.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Patients also are advised regarding an oral care routine to
follow during treatment.39 Oral care education includes
the type and use of toothbrushes and dental floss,
instructions for using fluoride gel if applicable, jaw exercises to maintain flexibility and prevent stiffness and trismus, the use and care of dental appliances, and strategies
for relieving xerostomia and mucositis.39,40
Visit asrt.org/as.rt?89lg3B to read examples of patient
education information.
During pretreatment dental visits, patients also might
have impressions taken for fitting medication trays and
radiation stents.40 Medication trays are used for application of a medicated or fluoride gel to help prevent tooth
decay. Radiation stents serve as positioning aids during
radiation treatment and help minimize effects from radiation to the surrounding healthy tissues.40
Patients also will have a thorough cleaning of their
teeth by a dental hygienist before treatment.39,40 Scaling
to remove tartar and teeth polishing also will be performed. Patients are instructed how to perform daily
mouth checks and record changes in their oral and dental condition during and after treatment. 40
During Treatment
During cancer treatment, a dental nurse plays a primary role in helping patients maintain oral care. The
dental nurse can assist the patient by39:
 Answering questions about daily mouth checks.
 Monitoring adherence to daily oral care by giving
guidance and support to caregivers and patients.
 Providing topical or systemic analgesia as directed and allowed by scope of practice for pain management.
 Administering medications for mouth infections
such as thrush as directed by dentist or other physician.
 Helping the patient manage xerostomia.
A patient with oral cancer might see the dental
oncologist for up to 2 years following radiation therapy
or chemotherapy. 39,40 During these visits, the dentist
checks teeth and soft tissues for disease, treats the
mouth as needed, and monitors saliva flow. The patient
continues to receive education and advice regarding
diet and oral hygiene during this time.39,40 Patients also
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should continue to keep regular appointments with
their own dentist.
Some hospitals employ dental radiographers who are
specifically trained to acquire images for dental patients.
Dental radiographers are fully qualified radiologic technologists who undertake extra training to become competent in dental imaging for special needs, pediatric, and
oncology patients. Although dental hygienists and nurses
who complete a specified training course are allowed to
perform dental radiography, a dental radiographer has a
more in-depth understanding of radiography and might
be preferred to image patients with oral cancer.
Role of Radiography
Radiography is not used in the initial diagnosis of
oral or oropharyngeal cancer, although radiographs
can assist in displaying alveolar bone and tissues in
the region of suspected cancer to assess for localized
involvement.22 Cancers of the mouth and oropharyngeal
region are routinely diagnosed through tissue biopsy
with histological examination of the tissue samples.22
CT scans, PET scans, or a chest radiograph might be
used to assist with evaluation of metastases and staging
in some cases.22 Oral radiographs are an integral part of
the patient’s evaluation and follow-up.
Obtaining dental images of the patient with oral or
oropharyngeal cancer following treatment can be difficult for the dental radiographer. Positioning can complicate imaging because of the patient’s limited motion
and anatomic changes associated with the cancer or
treatment. To obtain the best images possible, the dental radiographer should have knowledge of the type of
cancer, the treatment options used, adverse effects or
complications from treatment, and the specific indication for the examination.
Radiographs that are part of the patient’s evaluation before and after treatment include intraoral and
extraoral imaging. Intraoral images are taken with the
film, image plate, or digital detector placed inside the
patient’s mouth. Extraoral imaging places the film,
image plate, or detector outside the patient’s mouth.
Most commonly, orthopantomograms (OPGs), periapical images, or bitewing images are taken. Each type of
image plays a specific role in demonstrating anatomy
and pathophysiology in the mouth.
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Orthopantomogram
OPG images are based on tomography principles
and are considered an extraoral examination. The OPG
equipment uses tube and receptor motion to create a
2-D slice image of the patient’s entire lower face from
the temporomandibular joints to the mandibular symphysis. OPG imaging uses long exposure times of 16
to 20 seconds while the machine moves in a circular
motion around the patient’s head to form a single-slice
image that demonstrates dentition and bones of the
entire mandible and maxilla. A long object-to-image
receptor distance results in a magnified image that is
diagnostically useful. 42
OPG images routinely are acquired as part of the
pretreatment and post-treatment assessment of patients
with oral and oropharyngeal cancer. Indications for
OPG imaging before radiation or chemotherapy treatment include assessment for bone loss; lesions; general
status of tooth health, such as evidence of broken teeth
or caries; and retained roots from prior extractions. 42
Following treatment, an OPG might be used to assess
restorations and dental implants. 42 A periapical radiograph or bitewing images might be ordered to provide
better detail of an area the dentist observes on the
OPG.
Root
7
Root canal
Periapical region
Area of infection
Figure 13. Periapical image of lower right premolars and first 2
molars. Tooth 7, the second molar, has a large cavity in the crown;
tooth 6, the first molar, is broken and has an associated infection below the apex, or root tip. Image courtesy of Dublin Dental
University Hospital, Dublin, Ireland.
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Periapical Radiographs
Periapical images are intraoral images that show
individual or small sections of teeth and their surrounding tissues (see Figure 13). Their usefulness in imaging
the patient with oral cancer is to further explore an area
of concern noted by an OPG, physical examination,
or patient complaint. Periapical images are used for
detection of periapical disease or infection that occurs
at the root of the tooth and its surrounding tissues,
evaluation of lesions in the alveolar bone, assessment
of areas around loose or sensitive teeth, evaluation of
roots before tooth extraction, to evaluate caries, and to
evaluate single implants in patients who can tolerate the
image receptor placement in their mouth. 42
Bitewing Images
A common type of intraoral image taken for caries
assessment between the crowns of the teeth is the bitewing image. Bitewing images also can be used to monitor caries’ progression and assess restorations to crowns
(see Figure 14).42 Bitewing images display the crowns
of the molar and premolar teeth used most for chewing.
Assessment of the alveolar ridge also is possible from
these images.
Bitewing images might be used to assess patients
before and after radiation and chemotherapy treatments
begin. If multiple areas of caries are noted on the OPG
image or by dental examination, bitewing images might
Figure 14. Bitewing image demonstrating caries (arrows). Image
courtesy of Dublin Dental University Hospital, Dublin, Ireland.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
be taken to provide a closer assessment of the caries.
Bitewing images also are used to detect smaller, less
obvious caries between the teeth.
Positioning
Positioning of patients for dental radiography following surgery or radiation therapy can pose special
challenges for the dental radiographer because of complications from treatment such as trismus and mucositis. In addition, positioning can be made more difficult
because of anatomic changes in the patient’s mouth
and facial area from surgical removal of tissue, teeth,
and bone. The extraoral OPG often is the simplest
radiography examination to perform for patients with
oral cancer immediately following surgical resection or
radiation therapy; the OPG provides information for a
good general assessment of the entire mouth. Because
the OPG detector is located outside the patient’s mouth,
limitations from mucositis, trismus, or internal anatomic changes are of less concern for imaging.
When positioning for an OPG, 3 positioning planes
are used. The patient rests the chin on the unit’s chin
rest and the unit is moved vertically to ensure the
Frankfort plane (infraorbital meatal line) is parallel to
the floor. 42 The midsagittal plane is aligned to the central positioning light. The positioning light, called the
canine light, is placed between the patient’s upper cuspid and lateral incisor on either side (the upper second
and third teeth according to the Federation Dentaire
International system). 42 Use of the patient’s left or right
upper teeth during positioning is based solely on location of the positioning light on the panoramic unit and
is of no clinical significance. Patients who are edentulous might have the canine positioning light placed at
the outer junction of the lips. The patient then bites
gently on the bite stick with the front teeth or gums.
The patient must be able to stand or sit erect for the
15-second exposure without moving while the C-arm
detector and x-ray tube rotate around the patient’s head
(see Figure 15).
Positioning must be precise for an OPG. Because
orthopantomography is based on tomographic principles, the image is a slice or section of the area of
interest. The section, which is referred to as the focal
trough, is the part of the image that is in focus and well
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defined. 42 Any changes to patient positioning alter the
area that is in focus.
The main positioning challenge when acquiring
OPGs on patients with oral cancer is with patients who
have had a recent mandibulectomy. These patients can
have swelling and pain in the lower anterior jaw region
or in the neck. The dental radiographer might need to
adjust positioning for patients following mandibulectomy to minimize discomfort from the surgical site
resting on the chin rest.
Intraoral images such as periapicals and bitewings
can pose problems for dental radiographers when imaging patients following radiation therapy, chemotherapy,
and surgical resection. Intraoral images require that an
image plate and holder be placed inside the patient’s
mouth parallel to the area of interest (see Figure 16).
The beam alignment ring remains outside the patient’s
mouth. The typical size of an image plate used
for intraoral imaging is 1.2 inches  1.6 inches
(31 mm  41 mm), which is a particular problem for
patients with trismus.
Restricted mouth opening can affect a patient’s ability to eat, speak, and perform oral hygiene. Trismus
can develop secondary to surgical scarring and edema
or be induced by radiation treatments. The ability of
Figure 15. OPG C-arm setup showing proper positioning. Image
the patient to open his or her mouth can be measured
courtesy of Dublin Dental University Hospital, Dublin, Ireland.
using 3 fingers. If a health care practitioner can insert
3 fingers stacked between the
upper and lower front teeth
(incisors), then the opening is considered functional.
Anything less is considered an
indication for treatment and
possibly for alteration of the
examination or positioning. 36
The dental radiographer
must adjust positioning for
patients who have trismus and
need intraoral images. Most
often, this means that the
image plate holder and beam
alignment cannot be used. The
dental radiographer might have
Figure 16. Rinn image plate holder and positioning ring with image plate. Image courtesy of Dublin
to place the image plate in posiDental University Hospital, Dublin, Ireland.
tion using one finger or hand
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and slide it into position in the patient’s mouth without
bending the image plate or causing the patient discomfort. The radiographer should then instruct the patient
how to use a finger to hold the plate in position during
the radiographic exposure. Because dental intraoral units
have no collimator or central ray lights, the radiographer
must line up the tube and image plate visually to ensure
the image is captured.
Mucositis is another adverse effect of radiation therapy or chemotherapy that can hinder the acquisition of
intraoral radiographs following treatment. Although
mucositis usually resolves by the time a patient arrives
for a 6-month or 1-year follow-up examination, some
patients need radiographs before 6 months, or have
more serious or long-lasting mucositis. 36 Mucositis can
cause sores or ulcers in the mouth, tongue, or gums
and pain, swelling, and bleeding. Patients who have
ulcers or pain in the area of interest might not be able
to tolerate intraoral images. The radiographer who
attempts to acquire intraoral images in these cases
should take extra care to avoid causing further pain or
tissue damage in the area. This includes positioning
the imaging plate slowly and gently. As with patients
with trismus, the radiographer might need to have the
patient hold the plate.
Scarring or surgical removal of bone or tissue also
can complicate intraoral radiography. Scars, edema,
or changes to the patient’s anatomy can prevent the
radiographer from placing the image plate in the mouth
properly. Swelling or changes to patient anatomy can
prevent the image plate from being positioned well
enough to include the roots of the teeth and the apex
region in the field of view; these areas often are required
on periapical images.
It is the radiographer’s responsibility to recognize
when it is not possible to take diagnostic quality dental
images of patients with oral cancer. It also is the radiographer’s responsibility to suggest other options for imaging the area of interest (eg, extraoral imaging or oblique
images). No exposure should be made unnecessarily.
Communication and Radiation Safety
The dental radiographer should demonstrate compassion, empathy, and patience when working with
patients. Often, a patient has an altered appearance
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
from scarring or removal of bone, teeth, or tissue following treatment and might feel embarrassed and
concerned about the changes. Pain from treatment
and anger at the diagnosis also can affect patients.
Radiographers should understand that some patients
with oral and oropharyngeal cancer might have speech
difficulties or be unable to speak while recovering
from glossectomy or laryngectomy. The radiographer
can alter assessments to include simple “yes” or “no”
questions, or ask the patient to nod if speaking is too
difficult.
The radiographer should thoroughly explain the
examination to the patient. This includes explaining
steps the radiographer is taking and what the patient
needs to do to assist with the examination. The more
time spent with the patient and the more the patient
understands what is required, the better cooperation
radiographers are likely to receive, even if the procedure
causes some discomfort for the patient.
Because of the low dose of radiation used in dental
imaging, there is no need to shield a patient’s gonadal
regions, breast, or thyroid in most circumstances. 43,44
Doses from dental images do not affect tissues or
organs below the diaphragm, and if the proper rectangular collimators are used, the dose will not affect the
thyroid unless the beam is directed toward the thyroid
or the thyroid is located in the primary beam. 43,44 Dental
departments using circular collimators should shield
the patient’s thyroid area. 43,44
Patients who have received radiation therapy usually are concerned about the amount of radiation they
receive from follow-up radiographs and might ask that
shielding be used. The shields should be used to reduce
these fears if possible. Radiographers also can explain
radiation protection trends in radiography and dentistry
so that patients are aware of standards; radiographers
should never refuse to provide shielding if it is requested
and available. Shielding cannot be used for the external
OPG unit because the shield will affect the image quality. The radiographer might need to explain this thoroughly to ensure the patient understands the limitation
and consents to the examination.
Survivors of oral cancer might need several radiographs during the 2 to 3 years following treatment. Some
patients return because of cancer recurrence, but others
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might need additional radiographs to evaluate complications from osteonecrosis, xerostomia, and increased caries
formation. Radiographs also might be needed to evaluate for extractions because of tooth disease or infection
or to assess the mouth for restoration and placement of
dental implants. The dental radiographer is integral to the
patient’s care and health care experience.
Conclusion
Oral cancers affect many aspects of life for patients
and their families. Patients can suffer severe physical
and emotional changes from the cancer, its treatment,
and potential lifelong changes to appearance, speech,
and function.26,32
Simple screenings for oral and oropharyngeal cancers can aid early diagnosis, which leads to a higher
survival rate.13 No comprehensive screening programs
are in place in the United States, and public awareness
is still lacking. As a result, most cancers are found in the
later stages and are associated with a poor 5-year survival rate.1,8 Because these cancers are on the rise in young
nonsmokers, often as a result of HPV infection, dental
and radiography professionals should be advocates for
implementing screening protocols and increasing public
awareness.1,3
Susan M Anderson, MAED, R.T.(R), is senior
radiographer, clinical instructor, and radiation safety officer
for the Dublin Dental University Hospital at Trinity College
in Dublin, Ireland.
Reprint requests may be mailed to the American Society
of Radiologic Technologists, Communications Department,
at 15000 Central Ave SE, Albuquerque, NM 87123-3909,
or e-mailed to [email protected].
© 2015 American Society of Radiologic Technologists.
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Word of Mouth Publishing; 2013.
27. Irish Cancer Society. Understanding Cancers of the Head,
Neck, and Mouth. Dublin, Ireland: Irish Cancer Society; 2012.
28. National Comprehensive Cancer Network. NCCN clinical
practice guidelines in oncology:head and neck cancers.
Version 1.2015. http://oralcancerfoundation.org/treatment
/pdf/head-and-neck.pdf. Updated May 12, 2015. Accessed
July 23, 2015.
29. Stages of cancer. Oral Cancer Foundation Web site. http://
www.oralcancerfoundation.org/discovery-diagnosis
/stages-of-cancer.php. Accessed October 20, 2014.
30. Stages of oropharygeal cancer. National Cancer Institute Web
site. http://www.cancer.gov/types/head-and-neck/patient
/oropharyngeal-treatment-pdq#section/_22. Updated July
23, 2015. Accessed September 10, 2015.
31. Stages of lip and oral cavity cancer. National Cancer Institute
Web site. http://www.cancer.gov/types/head-and-neck
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
/patient/lip-mouth-treatment-pdq#section/_22. Updated
July 23, 2015. Accessed September 10, 2015.
32. Descriptive epidemiology. Oral Cancer Foundation Web site.
http://www.oralcancerfoundation.org/cdc/cdc_chapter6
.php. Accessed October 20, 2014.
33. Types of mouth cancer operation. Cancer Research UK Web
site. http://www.cancerresearchuk.org/about-cancer/type
/mouth-cancer/treatment/surgery/types-of-mouth-cancer
-operations. Updated October 14, 2014. Accessed October
15, 2014.
34. Restoration/rehabilitation. Oral Cancer Foundation Web
site. http://oralcancerfoundation.org/restoration/. Accessed
October 21, 2014.
35. Sequelae of treatment. Oral Cancer Foundation Web site.
http://oralcancerfoundation.org/cdc/cdc_chapter7.php.
Accessed October 21, 2014.
36. Complications of treatment. Oral Cancer Foundation
Web site. http://oralcancerfoundation.org/complications/.
Accessed October 22, 2014.
37. Song M, Li QL, Li FJ, et al. Mandibular lingual release
approach: an appropriate approach for total or subtotal
glossectomy. Head Neck Oncol. 2013;5(2):11.
38. George RK, Krishnamurthy A. Microsurgical free flaps:
controversies in maxillofacial reconstruction. Ann Maxillofac
Surg. 2013;3(1):72-79. doi:10.4103/2231-0746.110059.
39. Oral complications of cancer treatment: what the dental
team can do. National Institute of Dental and Craniofacial
Research Web site. http://www.nidcr.nih.gov/OralHealth
/Topics/CancerTreatment/OralComplicationsCancerOral
.htm. Updated July 14, 2015. Accessed September 10, 2015.
40.MacCarthy D; Dublin Dental School and Hospital.
Important information for patients who receive radiation
therapy to the head & neck region. http://www.dental
hospital.ie/wp-content/uploads/2012/11/Revised-Dec-07
-IImportant-Information-for-Patients-who-receive-Radiation
-Theraphy-to-the-Head-Neck-Region.pdf. Published January
2013. Accessed March 3, 2014.
41. Royal College of Surgeons. Clinical guidelines for the oral
management of oncology patients requiring radiotherapy,
chemotherapy and/or bone marrow transplantation. https://
www.rcseng.ac.uk/fds/publications-clinical-guidelines/clin
cal_guidelines/documents/clinical-guidelines-for-the-oral
-management-of-oncology-patients-requiring-radiotherapy
-chemotherapy-and-or-bone-marrow-transplantation/view.
Updated October 2012. Accessed November 1, 2014.
42. Whaites E, Drage N. Radiography and Radiology for Dental
Care Professionals. 3rd ed. Beijing, China: Elsevier Ltd;
2013:79-163.
205
CE
Directed Reading
Medical Imaging of Oral and Oropharyngeal Cancer
43. Dental Council of Ireland. Protocols for standard radiological
practice. http://www.dentalcouncil.ie/files/ionisingradiation
/Protocols%20for%20Standard%20Radiological%20
Practice%20%28amended%29%20-%20SI%20478%20of%20
2002%20-%2020120919.pdf. Updated September 2012.
Accessed November 1, 2014.
44.European Commission. Radiation protection: European
guidelines on radiation protection in dental radiology.
https://ec.europa.eu/energy/sites/ener/files/documents/136
.pdf. Published 2004. Accessed November 1, 2014.
206
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Directed Reading Quiz
15806-02
1.5 Category A+ credits
2.5 MDCB credits
Expires Dec. 31, 2017*
Medical Imaging of Oral
and Oropharyngeal Cancer
To earn continuing education credit:
 Take this Directed Reading quiz online at www.asrt.org/drquiz.
 Or, transfer your responses to the answer sheet on Page 212
410M
and
and
mail
mail
toto
ASRT,
ASRT,
POPO
Box
Box
51870,
51870,
Albuquerque, NM 87181-1870.
New and rejoining members are ineligible to take DRs from journal issues published prior to their most recent join date unless
they have purchased access to the quiz from the ASRT. To purchase access to other quizzes, go to www.asrt.org/store.
*Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date.
Read the preceding Directed Reading and choose the answer that is most correct based on the article.
1. Head and neck cancers typically originate in the
______ cells that line mucosal surfaces.
a.epithelial
b.squamous
c.epidermal
d.sarcoma
3.The most commonly reported oral cancer site in the
United States is the:
a.tongue.
b.gums.
c.lips.
d. inner surface of the cheeks.
2. Which of the following are sites for oropharyngeal
cancer?
1. soft palate
2.tonsils
3.gingivae
4. Which of the following is not a known risk factor
for the development of oral cancer?
a. cigarette smoking
b. chewing paan
c. drinking alcohol
d. smoking marijuana
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
5. ______ is a risk factor that is implicated in
increased oral cancer among adults aged
25 to 50 years.
a. Cigarette smoking
b. Alcohol use
c. Human papillomavirus
d.AIDS
continued on next page
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
207
Directed Reading Quiz
6. ______ is an abnormal red patch that forms in the
mucosal lining of the mouth that is a concern for
dysplasia and cancer.
a.Erythroplakia
b.Leukoplakia
c. Erythema nodosum
d.Xerostomia
7. Which of the following statements regarding oral
cancer screening is false?
a. Oral cancers are easy to identify early through
screening.
b. Screening can be done by patients at home and
takes less than 10 minutes.
c. The United States has a comprehensive oral
cancer screening program.
d. Screening looks for color differences, texture
changes, lesions, and lumps.
8. On average, changes that persist in the mouth for
______ indicate a need for medical attention.
a. 4 days
b. 2 weeks
c. 2 months
d. 4 months
9. A(n) ______ biopsy uses a small circular blade
pressed into an abnormal area to remove a small
core of tissue.
a. exfoliative cytology
b.punch
c.fine-needle
d.conventional
10. According to the article, computed tomography is
used in oral cancer for:
1.screening.
2. determining the size and location of a
tumor.
3. detecting possible metastases.
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
11. Cancer at which location is associated with a 5-year
relative survival rate of 38%?
a. distant tongue
b. regional tongue
c. regional floor of the mouth
d. localized floor of the mouth
12. Radiation therapy is the most common treatment
for patients with oral cancer and early stages of
oropharyngeal cancer.
a.true
b.false
13. Glossectomy is surgical removal of:
a. a tumor of the gums.
b. all or part of the tongue.
c. all or part of the buccal mucosa.
d. lip tissues.
14. Radiation therapy for oral cancer can cause which
of the following adverse effects?
1. skin erythema
2.trismus
3.dysgeusia
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
continued on next page
208
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Directed Reading Quiz
15. Which of the following statements is false regarding
osteoradionecrosis?
a. It is an adverse effect of radiation therapy for oral
cancer.
b. The risk of osteoradionecrosis is present only
during treatment.
c. The complication causes bone to weaken and die
from loss of blood.
d. Tooth extractions or trauma to the mouth
increase risk for osteoradionecrosis.
16. Chemotherapy for oral cancer can cause:
1.alopecia.
2.mucositis.
3. skin erythema.
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
17. Restoration processes for the mandible can be
initiated during cancer resection.
a.true
b.false
18. A dental evaluation for a patient with oral cancer
usually begins the process of:
1. initializing treatment for possible
infections, caries, or broken teeth.
2. evaluating current oral prostheses to
ensure cleanliness and fit.
3. measuring saliva flow.
a.
b.
c.
d.
1 and 2
1 and 3
2 and 3
1, 2, and 3
19. Radiation ______ serve as positioning aids during
treatment and can minimize effects from
radiation to the surrounding healthy tissues.
a.stents
b.prostheses
c.obturators
d.trays
20. Which of the following is an extraoral dental
radiographic examination?
a.bitewing
b. orthopantomogram (OPG)
c.periapical
d.occlusal
21. Assessing which of the following would not be an
indication for taking a periapical image?
a.caries
b. the apex of the tooth
c. lesions in the alveolar bone
d. the entire mandibular dentition
22. Which of the following examinations would be best
for patients with trismus?
a.OPG
b.periapical
c. left bitewing
d. magnetic resonance imaging
23. Which of the following statements is true regarding imaging of a patient who has mucositis as an
adverse effect of treatment?
a. Muscositis has no effect on intraoral or extraoral
radiography.
b. Patients will not be required to hold the plate
during imaging.
c. The primary problem with mucositis is sores
and ulcers that cause pain in the mouth during
intraoral positioning.
d. The radiographer must adjust positioning to
avoid artifacts that interfere with image quality.
continued on next page
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
209
Directed Reading Quiz
24. According to the article, which of the following
is false regarding radiation protection in dental
imaging?
a. Thyroid shielding always must be used.
b. Patients do not need shielding for the gonadal
region.
c. Circular collimators require thyroid shielding.
d. When using rectangular collimators, patients do
not need any shielding.
25. If a patient is concerned about radiation from a
dental imaging examination, the radiographer
should:
1. explain current radiation protection
trends.
2. provide shielding if available and
requested.
3. refuse shielding when it is not clinically
necessary.
a.
b.
c.
d.
210
1 and 2
1 and 3
2 and 3
1, 2, and 3
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
✁
Carefully cut or tear here.
JRCERT Update
Leslie Winter on Her Role and the
Challenges Facing Our Profession
L
eslie Winter, MS, R.T.(R),
is chief executive officer
(CEO) for the Joint Review
Committee on Education
in Radiologic Technology
(JRCERT). She recently was
invited by the JRCERT Board of
Directors to respond to questions
about the responsibilities of a
CEO, and offer her comments on
the role of the JRCERT and the challenges facing radiologic technology.
would need to develop the policy, review it with independent legal counsel, and then gain final approval from our
Board of Directors before implementing the policy.
The JRCERT does a tremendous amount of consulting throughout the day via telephone and e-mail. I am also
responsible for investigating complaints lodged against
our programs. Internal issues are challenging, but I also
have to pay close attention to external factors such as the
activities of the U.S. Department of Education and the
Council for Higher Education Accreditation; these organizations have a significant impact on the JRCERT’s daily
operations.
What is a typical day like at the JRCERT
office?
Q
What are your primary responsibilities as
CEO of the JRCERT?
That’s an interesting question because I do not
believe there is a “typical day” at the JRCERT. I
always tell new employees that if they have a “to do” list
for the day, chances are that list will not get completed.
Many people find that type of work atmosphere very
frustrating. I enjoy it because there are no 2 days that are
exactly alike in the JRCERT office. A small office poses
many challenges for a CEO because you have limited
resources to depend on such as human resources, marketing, or a finance department. For example, if the JRCERT
needed to modify a personnel policy, there would be no
opportunity to walk down the hallway to the human
resources department to ask for assistance. As CEO, I
A
My primary responsibilities include:
 Overseeing staff to ensure they have the tools
to perform the responsibilities of their respective positions, and that they perform in a manner consistent with the spirit of our mission.
 Ensuring that the JRCERT is compliant with
federal and other regulatory requirements.
 Ensuring that the Board of Directors takes
accreditation actions consistent with all regulatory requirements, and that its actions are consistent with our mission.
 Fulfilling my fiduciary responsibilities to ensure
the organization remains financially stable.
Q
A
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
213
JRCERT Update
Leslie Winter on Her Role and the Challenges Facing Our Profession
 Ensuring close collaboration with other professional organizations to advance the profession.
 Facilitating strategic planning to ensure we
meet our goals and the organization continues
to move forward.
Q
Who were your mentors when you began your
JRCERT career?
When I first began my career at the JRCERT in
1995, there was a lack of agreement among
the professional organizations in several areas. The
American Registry of Radiologic Technologists decided
to accept regional accreditation as an acceptable mechanism to be eligible for the credentialing examination.
JRCERT directors were appointed by the various professional organizations (American Society of Radiologic
Technologists, American College of Radiology,
Association for Medical Imaging Management), rather
than the Board electing to fill those positions from a
slate of candidates provided by the professional organizations. The JRCERT Board was “finding its way” during this transitional period and having some difficulties
determining what was best for the organization, which
led to tension between management and the Board.
With all of the external and internal pressures present at
that time, finding a positive mentor was difficult.
However, 2 individuals provided me with tools to
grow: Janis Stiewing, MS, R.T.(R)(CV)(M), director
1997-2000 and chair 2001-2003; and Sara Baker, EdD,
R.T.(R), FASRT, director 1996-2002. These women
provided the guidance I needed to be successful at the
JRCERT. As I worked through the ranks of the organization and became CEO in 2007, the relationship I
developed with the directors became more important
to my development and the success of the organization. Many of the past and present directors have been
incredible mentors to me.
A
214
Q
What, in your opinion, are the challenges we
face in our profession?
The JRCERT’s key challenge is addressing the
lack of understanding of the importance and
value of accreditation; especially when it comes to individual state regulations that accept both regional and
programmatic accreditation. With regional accreditation, there is no assurance that the clinical component
of the program is evaluated during the accreditation
process, therefore jeopardizing patient care and safety.
With all of the emphasis on radiation protection and
regulatory efforts, programmatic accreditation plays
a vital role in ensuring the clinical component is educationally valid and provides a safe environment for
patients and students.
A
Q
How is the JRCERT addressing this key
challenge?
We continue to be proactive and educate all
communities of interest so they understand the
importance and value of programmatic accreditation,
especially those that are instrumental in developing state legislation affecting our profession. We also
continue to keep the public informed on the value of
programmatic accreditation to ensure that dollars spent
for higher education are based on sound and informed
decision making.
A
Q
What would you say to a new graduate and an
individual 5 years postgraduation?
New graduates need to embrace continual learning and stay active in the professional societies.
Your work and attitude must reflect professionalism and
pride. You must always demonstrate the values and ethics that reflect the highest standards of our profession.
For the radiologic technologist employed longer than
5 years in the profession, it is time to give back to the
profession and become more actively involved. Be a
mentor to someone. Demonstrate strong leadership
skills and continue to be an advocate for the profession.
A
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
JRCERT Update
If I were a program director, what recommendations would you give for my program to
achieve the maximum accreditation award?
Q
The JRCERT offers numerous resources to
ensure program directors are successful during
the continuing accreditation process and that they have
the tools needed to maintain academic excellence. The
JRCERT Web site is an excellent tool and has an abundance of resources. On the Program & Faculty tab, you
can find learning modules that range from developing
an assessment plan to submitting an acceptable interim
report. We are developing an Assessment Corner on
the Web site that will contain additional assessment
resources. The JRCERT’s e-newsletter, Pulse, is another
excellent resource for programs. Pulse is published after
our Board of Directors’ meetings in April and October.
Attending a JRCERT Accreditation Seminar or an
Outcomes Assessment Workshop is tremendously helpful for program directors if their program is preparing
for a self-study report or an interim report.
A
Many government regulations apply to patient
safety in radiology. What role does programmatic accreditation play with regard to patient
safety?
Q
Many government regulations affect patient
safety. The JRCERT is not only concerned about
the optimal use of radiation, we also are committed to
ensuring that the overall health and safety of patients
and students is protected. It is critical that the JRCERT
stay abreast of the ever-changing health care industry
safety guidelines so that patient and student safety can
be reflected appropriately throughout the JRCERT
Standards.
A
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
215
In the Clinic
Computed Tomography for Assessment of
Coronary Artery Bypass Grafts
Sagar Prabhu, BS, R.T.(R)
C
omputed tomography (CT) allows visualization of internal structures without the need for
invasive surgeries and is a valuable preoperative
and postoperative tool for surgeons. One procedure that benefits from CT use is coronary artery
bypass graft (CABG) surgery. Preoperative use of CT
can help surgeons decide whether CABG is the best
treatment for revascularization.1-5 CT scans also allow
surgeons to evaluate a vessel’s potential for use as a graft
before the surgery begins. Preoperative CT scans can
be used to predict postoperative complications based on
morphometric findings.2,6,7 Preoperative scan data can
be coupled with data from other sources such as ultrasonography or robotic fixtures to provide a roadmap for
surgeons, reducing the chance of error during the operation.8,9 Postoperatively, CT can be used to assess graft
patency and examine potential complications.2,7,10-12
These findings are useful in treating patients in
a timely manner, as the resolution and speed of CT
allows for visualization of several sequelae at once. CT
data also is important to surgeons planning and executing revision surgeries by allowing them to avoid damaging previous alterations to the heart’s vasculature or surrounding tissue.7,12 The use of CT for CABG procedures
ensures greater quality of care for patients.
History
The use of CT for CABG procedures has benefited
surgeons and their patients since at least 1980, when
it was first discussed in the literature.13 Early uses of
216
conventional CT proved effective in assessing the
patency of grafts after successful operations. In a study
by Guthaner et al, dynamic CT successfully visualized
more than 75% of grafts to the left anterior descending and right coronary arteries. These early successes
proved that CT was at the very least equal to invasive
cardiac catheterization procedures.14
Ultrafast CT allowed for cardiac imaging to be
achieved within a few milliseconds. The increased
speed of imaging facilitated the tracking of a contrast
bolus after injection. These advanced scanners allowed
for evaluation of cardiac function, structural anomalies,
and vessel studies for diagnostic information and preoperative assessment. Ultrafast CT also allowed physicians to assess adjacent structures to the heart, such as
the lungs or aorta, and determine the perioperative risk
posed by any structural abnormalities discovered.15
There were some limitations during the early days
of CT use, however. In Guthaner et al’s study, only 40%
of grafts to the obtuse marginal and circumflex arteries
were visualized.14 Imaging of smaller vessels with early
CT technology was limited and hampered by cardiac
motion, especially if the vessel of interest was close to a
ventricle. The study also demonstrated interference in
the image when overlapping or adjacent structures were
filled with contrast.14
The advent of spiral CT overcame the limitations of
ultrafast CT regarding patient positioning. The development of spiral CT enabled rapid imaging of the heart
in the axial plane and improved volumetric imaging.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
In the Clinic
Prabhu
The increased speed of the scanner, improved resolution of images, and relatively low need for contrast
proved that spiral CT was equal to, if not superior to,
conventional angiography. Three-dimensional reconstructions, albeit rough compared to contemporary CT
images, made this modality even more appealing.13
Literature on the use of CT for assessing postoperative complications is limited and suggests that CT was
adequately able to identify only large sequelae such as
significant atelectasis or aortic dissection.16,17 Because
of these limitations, CT has not been used for assessing
postoperative complications until more recently.
Computed Tomography for
Coronary Artery Disease
Contemporary CT systems using multidetector
CT (MDCT) can vary in design. MDCT systems are
available with a range of 16 to 320 detectors. A majority
of modern studies are performed using systems with
either 16 or 64 detectors.4
The first step in deciding whether a patient should
undergo a CABG procedure is determining the degree
of disease in the coronary arteries. Miller et al reported
that 64-slice MDCT is effective in evaluating the
degree of stenosis within a diseased vessel.18 This multicenter study compared the findings of 64-slice MDCT
to conventional angiography. The primary measure
for the study was the presence of at least 50% stenosis
of the coronary arteries, which the authors deemed
obstructive. The study showed that of the 291 symptomatic patients scanned, 56% percent suffered from
obstructive disease of the coronary arteries. Compared
to the findings of conventional angiography, 64-slice
MDCT displayed the same diagnostic findings in
approximately 93% of the cases, with a sensitivity and
specificity of 85% and 90%, respectively. Furthermore,
84% of the MDCT cases matched with conventional
angiographic predictions for revascularization, meaning
that MDCT helped to predict correctly which patients
would undergo either CABG or percutaneous coronary
intervention.18
MDCT also allows physicians to determine the type
of plaque present in the affected artery by measuring
the density of the lesion.3 Comparative studies of intravascular imaging modalities have shown that findings
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
from MDCT are comparable to that of intravascular
ultrasonography. MDCT allows surgeons to gather
valuable volumetric data without having to perform an
invasive procedure. 4
Mlynarska et al demonstrated that 64-slice MDCT
also can be used to assess accurately the degree of
coronary artery disease, specifically calcification of
the arteries, in asymptomatic patients.19 The coronary
artery calcium score system compares calcium densities to the highest density material within a vessel. The
coronary artery calcium score, when combined with
64-slice MDCT, allowed for accurate assessment of 180
subjects with risk factors such as hypertension, hypercholesterolemia, diabetes mellitus, history of smoking,
and family history of disease. The study showed that
coronary artery calcium scores are predictive of
coronary artery stenosis and subsequent intervention.
Follow-up 6 months later showed that 13 of the 60
patients with a high coronary artery calcium score
underwent a CABG procedure as predicted. These
findings support the use of MDCT to assess accurately
the degree of disease in asymptomatic patients and even
predict subsequent revascularization.19 One drawback
to MDCT is that a blooming artifact can cause overestimation of plaque volumetric data in patients with
severe calcific lesions. This effect also might occur in
vessels with coronary stents, specifically those with
thick struts. 4
Not all patients who suffer from high risk of coronary artery disease need to undergo CABG; for some, a
percutaneous coronary intervention is a better approach
for revascularization. Some patients might not need
revascularization at all. Moscariello et al analyzed the
predictive value of CT angiography for revascularization and compared it to the predictive value of conventional angiography. 5 Of the 185 patients studied, 96%
did not require revascularization. This suggests that
CT angiography might help surgeons make decisions
about whether surgery is the best option for a patient.
The remaining 4% who did require revascularization
underwent either percutaneous coronary intervention
or CABG. When the decision was made as to which
procedure to perform, the procedure indicated by CT
angiography matched the procedure indicated by conventional angiography 92% of the time.5 Similar studies
217
In the Clinic
Computed Tomography for Assessment of Coronary Artery Bypass Grafts
also have validated the prognostic value of CT angiography in predicting future cardiac events and the need
for a CABG procedure.1
Preoperative Use
CT can provide the cardiac surgeon with a plethora
of information during the planning stages of the CABG
operation. This information is useful for mapping
anatomy and planning graft harvesting and incision
sites.2,6,8,9,20 The ability to map anatomy is the most obvious benefit of using CT preoperatively. MDCT allows
visualization of the course of the coronary arteries so
that vessels can be examined before exposing the heart.8
Graft harvesting is the first step of the CABG procedure, and MDCT can be used to locate a vessel free of
disease and other problems before the surgery begins.
For example, great saphenous veins in the legs, although
commonly used as grafts, can be unsuitable because
of anatomical abnormalities approximately 30% of the
time. 6 MDCT of the site from which the graft will be
harvested allows surgeons to assess adequately viable
vessels before harvesting them. Some options include
the saphenous vein, the internal mammary artery, and
the radial artery. 6,10,20 Saphenous veins are most commonly used and typically connect the proximal aorta
to a distal segment of the obstructed coronary artery.
Internal mammary artery grafts typically stay connected to their respective subclavian artery and are
anastomosed with the closest coronary artery. The
right internal mammary artery is used as a free or composite graft more often than the left.7,10 The sensitivity
and specificity of MDCT allows surgeons to assess the
viability of even relatively small vessels which might not
be commonly used, such as the gastroepiploic artery.20
Three-dimensional mapping of potential vessels allows
surgeons to harvest them efficiently because they have a
complete image of the vessel’s course before an incision
is made. 6
MDCT also can be coupled with robotic devices and
other imaging modalities to facilitate a minimally invasive approach to the harvesting and bypass procedures.
Intraoperative ultrasonography, when coupled with preoperative CT data, can prevent complications caused by
perioperative heart migration after lung deflation and
thoracic insufflation.
218
A study by Cho et al showed that the migration of
the heart is typically within 5 mm.9 To keep track of this
movement, the authors obtained coupled sonography
images and CT data acquired at 3 stages of the procedure to locate the target vessel. Using this data also
reduces the chance that surgeons will have to perform
a sternotomy. Moreover, the use of coupled scan data
proved to be successful in tests using 2 different registration systems on phantoms and in tests with one registration system on live patients.9 CT also has proven to be
helpful in facilitating robot-assisted CABG procedures.
Although robot-assisted CABG is being used more frequently, the procedure involves a high learning curve for
surgeons because the equipment allows a great degree of
freedom. Integrating limits based on CT data can help
reduce the degree of freedom in the robotic system and
the complexity of the procedure. Studies by Park et al
showed that these limits prevented surgeons from making incisions beyond the region of interest and enabled
them to complete tasks at a faster rate.8
Preoperative findings also can be used to predict the
course of recovery for patients undergoing a CABG procedure. This information is useful for surgeons as well
as the physicians who care for patients after the procedure. The most recent studies analyzing preoperative
volumetric data showed associations between certain
volumetric parameters and postoperative complications. Independent studies by Drossos et al and Opolski
et al demonstrated how CT volumetric and structural
findings are warning flags for potential atrial fibrillation
episodes after the procedure.21,22 Drossos and colleagues
found that almost 34% of their 84 surgical candidates
experienced new onset of atrial fibrillation. They found
that those with the new electrical abnormality had
significantly more pericardial fat volume than those
without.21 This suggests that a high volume of pericardial fat might be a risk factor for new onset of atrial
fibrillation postoperatively. In the study by Opolski et
al, 24% of the 102 surgical candidates experienced atrial
fibrillation postoperatively.22 Those who experienced
atrial fibrillation showed a number of differences in
heart morphometrics when compared with those who
experienced normal cardiac rhythm postoperatively.
Multivariate analysis showed that left atrium epicardial
adipose tissue volume and right superior pulmonary
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
In the Clinic
Prabhu
vein ostium area were the only factors that showed a
significant difference.22 This data suggests that preoperative measurements could facilitate care for postoperative complications.
Postoperative Use
Evaluation of Graft Patency and Revascularization
The main objective of postoperative CT scans is to
assess the patency of a newly anastomosed graft.2,7,10
The sensitivity and specificity of MDCT ranges from
91% to 100% when assessing graft patency, occlusion,
and stenosis.7,10,23 The resolution of 16-slice MDCT
has been demonstrated to visualize adequately the
proximal anastomosis of a sutureless vein graft with
the aorta.24 Studies have shown that internal mammary
artery grafts tend to display a higher patency rate in
all postoperative stages when compared to other types
of grafts.10,25 Similar patency trends also are exhibited
after minimally invasive CABG procedures.26 Bassri et
al demonstrated that “the patency rates of the coronary
grafts was comparable irrespective of the surgical technique…need for packed cell transfusion, and postoperative cardiac arrest.” 25 Early loss of graft patency typically
is due to thrombosis. Other sequelae that can compromise graft patency include graft malposition, kinking,
and vasospasm, all of which can be visualized via CT
angiography.7,12
Although MDCT provides a lot of information pertaining to graft success, it has several limitations. It is
difficult to obtain crisp images of the distal coronary
arteries even with 64-slice MDCT. This is especially
true in those with elevated heart rates and increased
cardiac motion.2,23 Assessment of distal segments might
be hampered by excessive noise if the patient is morbidly obese.23 This lack of data makes it difficult for
surgeons to determine whether revascularization was
a success. MDCT also is unable to visualize composite arterial grafts accurately. Lim et al, when assessing
patency of Y-composite grafts derived from bilateral
internal mammary arteries, found that noninvasive
imaging modalities resulted in underestimation of the
anatomical patency in nearly 17% of patients during
follow-up.27 The study compared the findings of early
postoperative MDCT scans to later conventional angiography or MDCT images. Lim et al believe that this
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
underestimation occurs because MDCT uses nonselective injection of contrast to the graft when compared
with conventional angiography. Functional patency
showed no discrepancies.27
Differences in patency rates between the same types
of graft might occur based upon the contrast media
selected. In Wang et al’s comparative study of iodinated
contrast media iodixanol 270 and iohexol 350, use of
the former provided significantly higher quality images
of arterial grafts.28 This was because the metal clips of
the arterial grafts facilitated beam hardening with use
of iodixanol 270.28 Careful attention should be paid to
the selection of contrast media when visualizing graft
patency.
Recent studies have suggested that graft occlusion
might be exacerbated by adjacent postoperative complications. Risnes et al showed that the presentation of
mediastinitis can be predictive of graft patency loss via
CT follow-up studies.29 The studies showed a significantly
greater rate of internal mammary artery graft occlusion in
those who suffered from mediastinitis vs those who did
not. In fact, the findings showed that those with mediastinitis were 5 times as likely to have reduced patency of
an internal mammary artery graft 3 years after surgery.
Risnes suggested that this is caused by proximity between
the graft and mediastinum and the inflammatory pathway of atherosclerotic disease.29 This research suggests
that postoperative complications such as mediastinitis can
indicate future loss of graft patency.
Evaluation of Nongraft Complications
MDCT can be used to evaluate a number of
nongraft-related postoperative complications, such as
mediastinitis. Up to 20% of CABG recipients develop
an infection of the sternum, particularly mediastinitis.12
On a CT scan, fluid correction via contrast enhancement is indicative of a sternal infection, as are collections of gas.7 A study by Mueller et al described incidental findings on MDCT scans for a postoperative population of 259 patients.11 According to their data, 19.7%
of this sample experienced an unsuspected significant
clinical finding in the immediate postoperative period.
Cardiac findings were found in 24 patients, whereas
34 patients experienced noncardiac findings. All unsuspected findings pertained to the lungs.11
219
In the Clinic
Computed Tomography for Assessment of Coronary Artery Bypass Grafts
The most common complications after a CABG procedure are pericardial and pleural effusions. Pericardial
effusion has a reported prevalence of up to 85% and can
easily result in cardiac tamponade. Pleural effusions
have a prevalence of 90% and typically occur within the
first postoperative week. Pleural effusions appear on
CT scans and are usually small and located on the left
side.7,12
Another postoperative concern, albeit less common, is trapped lung. This condition is “characterized by the presence of a restrictive visceral pleural
peel.”30 Diagnosis of the condition requires the use of
air-contrast CT scans, as the fluid is not likely to be
visualized without an air outline. Air-contrast CT also
enables providers to visualize the abnormal thickness of
the visceral pleural peel that is characteristic of the condition. 30 Pulmonary embolism can be difficult to diagnose without CT because the clinical manifestations
mimic those of other pathologies and postoperative
norms (eg, difficulty breathing and chest pain). Deep
vein thrombosis can be similarly difficult to diagnose
because pain and swelling of the legs is common after
a saphenous vein is harvested. These complications
require diagnosis via contrast-enhanced CT.7 The resolution of MDCT could be useful in detecting the source
of these complications.
Considerations for Revision Surgery
It is common for patients to undergo revision of a
CABG procedure because of inadequate perfusion.
However, revision surgery is associated with increased
mortality and morbidity. 31 The most important purpose
of CT scans for revision operations is to understand the
position of the anastomosed graft in relation to adjacent
structures. It is critical that the existing graft be preserved unharmed even if it fails to revascularize the
heart. Damage to existing grafts could result in complications that increase patient morbidity and mortality.
Graft relations to the sternum and ribs can be visualized via the use of multiplanar reconstruction and 3-D
volume-rendered images to help the surgeon avoid nicking the graft upon re-entry.7
Certain postoperative complications also can complicate re-entry. Frazier et al describe a scenario in
which an aortic aneurysm had the potential to press
220
a saphenous vein against the sternum, which could
impede a surgeon’s access.12 Adhesions from the first
CABG procedure also could cause complications for
surgeons during the revision operation.31 CT scans
performed before the revision surgery allow surgeons
to tailor their approach to the patient’s unique anatomy.
3-D mapping of a remaining vessel after a graft has been
excised would be beneficial to determine whether the
same vessel can be used again. 6
Conclusion
CT is useful for improving the preoperative assessment and postoperative care of patients who undergo
CABG procedures. Preoperative use of CT angiography
allows physicians to diagnose accurately the degree
and course of disease in coronary arteries. The procedure allows surgeons to make an informed decision
as to whether a CABG is the most effective choice for
revascularization of the heart. MDCT allows surgeons
to understand the anatomy of the heart, blood vessels,
and potential replacement vessels before incisions are
made. Coupling CT data with ultrasonography and
robotic surgical devices facilitates minimally invasive
surgeries with faster completion and fewer complications.8,12,22,25,28-30 Postoperative CT scans are mainly
used to assess graft patency, occlusion, and stenosis.8,13,14,20,21,27,29-31
CT also is useful for diagnosing postoperative complications as they arise. Complications can be cardiac
or noncardiac in nature and usually are limited to the
thoracic cavity. Some complications, such as deep vein
thrombosis, might be found incidentally.13,15,30 Limited
literature is available on the prevalence of stroke after
CABG procedures. Likosky et al report that this complication, while reported in up to 4.3% of cases, is one
of the most devastating potential sequelae of the procedure. 32 CT scans have the capacity to rule out hemorrhaging in patients with neurological symptoms and
can show whether symptoms correlate with delirium
or anesthesia. 32 This suggests that CT should be used
to assess extremities and the head after CABG procedures as a predictive measure for vascular sequelae.
Imaging of these body parts could become standard
after CABG procedures to predict these postoperative
risks.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
In the Clinic
Prabhu
CT plays a significant role in the planning stages of
revision surgeries. Although CT greatly aids surgeons,
some limitations include inadequate resolution of distal
arterial branches and limited visualization of blood vessels because of cardiac motion.8,27 Patients who suffer
from heart arrhythmias might not obtain the full diagnostic benefit of CT scans for this reason. The evaluation of certain grafts, particularly composite grafts,
is limited because of CT’s nonselective injection of
contrast.7 Development of a CT scan that uses uniform
contrast injection could greatly improve graft patency
data obtained from scans. As technology advances,
these limitations will be overcome.
Sagar Prabhu, BS, R.T.(R), is a cardiac catheterization
lab technologist for Mose H Cone Memorial Hospital in
Greensboro, North Carolina.
References
1. Kim SY, Lee HJ, Kim YJ, et al. Coronary computed tomography angiography for selecting coronary artery bypass graft
surgery candidates. Ann Thorac Surg. 2013;95(4):1340-1346.
doi:10.1016/j.athoracsur.2013.01.004.
2. Herzog C, Wimmer-Greinecker G, Schwarz W, et al. Progress
in CT imaging for the cardiac surgeon. Semin Thorac
Cardiovasc Surg. 2004;16(3):242-248.
3. Treede H, Becker C, Reichenspurner H, et al. Multidetector
computed tomography (MDCT) in coronary surgery:
first experiences with a new tool for diagnosis of coronary
artery disease. Ann Thorac Surg. 2002;74(4):1398-1402.
doi:10.1016/S0003-4975(02)04010-9.
4. Munnur RK, Cameron JD, Ko BS, Meredith IT, Wong DT.
Cardiac CT: atherosclerosis to acute coronary syndrome.
Cardiovasc Diagn Ther. 2014;4(6):430-448. doi:10.3978/j
.issn.2223-3652.2014.11.03.
5. Moscariello A, Vliegenthart R, Schoepf UJ, et al. Coronary
CT angiography versus conventional cardiac angiography for
therapeutic decision making in patients with high likelihood
of coronary artery disease. Radiology. 2012;265(2):385-392.
doi:10.1148/radiol.12112426.
6. Maruyama Y, Imura H, Shirakawa M, Ochi M. Preoperative
evaluation of the saphenous vein by 3-D contrastless
computed tomography. Interact Cardiovasc Thorac Surg.
2013;16(4):550-552. doi:10.1093/icvts/ivs576.
7. Nakazono T, Suzuki M, White CS. Computed tomography
angiography of coronary artery bypass graft grafts. Semin
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Roentgenol. 2012;47(3):240-252. http://dx.doi.org/10.1053/j
.ro.2011.11.010.
8. Park S, Howe RD, Torchiana DF. Virtual fixtures for robotic
cardiac surgery. Proceedings of the 4th International Conference
on Medical Image Computing and Computer-Assisted
Intervention. Utrecht, The Netherlands:Springer-Verlag;
2001:1419-1420.
9. Cho DS, Linte C, Chen EC, et al. Predicting target vessel
location on robot-assisted coronary artery bypass graft using
CT to ultrasound registration. Med Phys. 2012;39(3):15791587. doi:10.1118/1.3684958.
10. Laspas F, Roussakis A, Kritikos N, Mourmouris C,
Efthimiadou R, Andreou J. Imaging of coronary artery
bypass grafts by computed tomography coronary angiography. Curr Probl Diagn Radiol. 2013;42(6):241-248.
doi:10.1067/j.cpradiol.2013.05.004.
11. Mueller J, Jeudy J, Poston R, White CS. Cardiac CT angiography after coronary bypass surgery: prevalence of incidental findings. AJR Am J Roentgenol. 2007;189(2):414-419.
doi:189/2/414.
12. Frazier AA, Qureshi F, Read KM, Gilkeson RC, Poston RS,
White CS. Coronary artery bypass grafts: assessment with
multidetector CT in the early and late postoperative settings.
Radiographics. 2005;25(4):881-896. doi:10.1148/rg.254045151.
13. Tello R, Costello P, Hartnell G. Spiral CT evaluation of
coronary artery bypass graft patency. J Comput Assist Tomogr.
1993;17(2):253-259.
14. Guthaner DF, Brody WR, Ricci M, Oyer PE, Wexler L. The
use of computed tomography in the diagnosis of coronary
artery bypass graft patency. Cardiovasc Intervent Radiol.
1980;3(1):3-8.
15. Flicker S, Naidech HJ, Altin RS, Eldredge WJ, Carr KF.
Ultrafast computed tomography techniques in cardiac disease. J Thorac Imaging. 1989;4(3):42-49.
16. Archer AG, Choyke PL, Zeman RK, Green CE, Zuckerman
M. Aortic dissection following coronary artery bypass
surgery: diagnosis by CT. Cardiovasc Intervent Radiol.
1986;9(3):142-145.
17. Tenling A, Hachenberg T, Tydén H, Wegenius G,
Hedenstierna G. Atelectasis and gas exchange after cardiac
surgery. Anesthesiology. 1998;89(2):371-378.
18. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med.
2008;359(22):2324-2336. doi:10.1056/NEJMoa0806576.
19. Mlynarska A, Mlynarski R, Sosnowski M. Effect of coronary
artery calcium score on the reduction of global cardiovascular
risk. Pol Arch Med Wewn. 2014;124(3):88-96.
20. Lee DH, Lee W, Kim KB, et al. Availability of the right gastroepiploic artery for coronary artery bypass grafting: preop-
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erative multidetector CT evaluation. Int J Cardiovasc Imaging.
2010;26(Suppl 2):303-310. doi:10.1007/s10554-010-9713-1.
21. Drossos G, Koutsogiannidis CP, Ananiadou O, et al.
Pericardial fat is strongly associated with atrial fibrillation
after coronary artery bypass graft surgerydagger. Eur J
Cardiothorac Surg. 2014;46(6):1014-1020. doi:10.1093/ejcts
/ezu043.
22. Opolski MP, Staruch AD, Kusmierczyk M, et al. Computed
tomography angiography for prediction of atrial fibrillation
after coronary artery bypass grafting: proof of concept. J
Cardiol. 2015;65(4):285-292. doi:S0914-5087(14)00359-1.
23. Schachner T, Feuchtner GM, Bonatti J, et al. Evaluation of
robotic coronary surgery with intraoperative graft angiography and postoperative multislice computed tomography. Ann
Thorac Surg. 2007;83(4):1361-1367.
24. Strecker T, Ropers D, Weyand M, Feyrer R. Non-invasive
imaging of sutureless vein graft anastomosis with 16-slice
multi-detector row spiral computed tomography. Heart Surg
Forum. 2005;8(5):E370-372.
25. Bassri H, Salari F, Noohi F, et al. Evaluation of early coronary graft patency after coronary artery bypass graft surgery
using multislice computed tomography angiography. BMC
Cardiovasc Disord. 2009;9:53. doi:10.1186/1471-2261-9-53.
26. Ruel M, Shariff MA, Lapierre H, et al. Results of the minimally invasive coronary artery bypass grafting angiographic
patency study. J Thorac Cardiovasc Surg. 2014;147(1):203208. doi:10.1016/j.jtcvs.2013.09.016.
27. Lim C, Park KH, Kim TH, et al. Computerized tomography
may underestimate the patency of internal thoracic artery
composite grafts. Heart Surg Forum. 2012;15(2):E73-78.
doi:10.1532/HSF98.20111125.
28. Wang H, Xu L, Zhang N, Fan Z, Zhang Z, Sun Z. Coronary
computed tomographic angiography in coronary artery
bypass grafts: comparison between low-concentration
iodixanol 270 and iohexol 350. J Comput Assist Tomogr.
2015;39(1):112-118. doi:10.1097/RCT.0000000000000162.
29. Risnes I, Abdelnoor M, Ulimoen G, et al. Mediastinitis after
coronary artery bypass grafting increases the incidence
of left internal mammary artery obstruction. Int Wound J.
2014;11(6):594-600. doi:10.1111/iwj.12007.
30. Huggins JT, Sahn SA, Heidecker J, Ravenal J, Doelken
P. Characteristics of trapped lung: pleural fluid analysis, manometry, and air-contrast chest CT. Chest.
2007;131(1):206-213.
31. Khan NU, Yonan N. Does preoperative computed tomography reduce the risks associated with re-do cardiac surgery? Interact Cardiovasc Thorac Surg. 2009;9(1):119-123.
doi:10.1510/icvts.2008.189506.
32. Likosky DS, Marrin CA, Caplan LR, et al. Determination
of etiologic mechanisms of strokes secondary to coronary
222
artery bypass graft surgery. Stroke. 2003;34(12):2830-2834.
doi:10.1161/01.STR.0000098650.12386.B3.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Patient Care
Microexpressions:
Do They Have Value in Radiology?
Danielle Parent, BS, R.T.(R)
A
lbert Mehrabian conducted several studies
investigating the communication of feelings
and attitudes and found that 93% was nonverbal.1 He claimed that 55% of attitudes and feelings are communicated through nonverbal elements,
and 38% are communicated through vocal, nonword
means.1 Many radiologic technologists rely on the spoken word when dealing with patients and might pay little
attention to their subtle nonverbal cues. Recently, there
has been a push to better understand nonverbal communication. However, even with this shift, our perception
of nonverbal cues is incomplete. One aspect of nonverbal
communication that would benefit technologists and
their patients is the observation of microexpressions. A
microexpression is a “brief and subtle facial movement”
usually lasting from 0.04 to 0.2 seconds that reveals “an
emotion a person is trying to conceal.” 2 Radiologic technologists should consider training in the perception of
microexpressions so they can provide better patient care
such as assessing pain or cooperativeness.
of the situation, such as knowing how much pain the
patient is actually feeling. 4
One study in an assisted living facility showed that
certified nursing assistants used facial expressions to
gauge pain in patients who were cognitively impaired. 4
In addition, when physicians were able to perceive
patient emotions accurately, many patient psychosocial
characteristics improved, such as the quality of the
physician-patient relationship, social adjustment, and
mental health. 3 Moreover, these patients were more
satisfied, adherent to treatment plans, and engaged.3
Another advantage of physicians perceiving their
patients’ expressions accurately is the potential to
reduce ambiguity. If a physician does not completely
understand a verbal message, observing the patient’s
expressions might give the physician a better understanding of the patient’s needs. 4 Overall, health care
workers have much to gain by perceiving their patients’
expressions accurately.
Advantages
In one study, Ekman et al examined video recordings
from the National Institutes of Neurological Diseases
and Blindness. 5 These recordings spanned the course
of 10 years and featured 2 populations in New Guinea:
the South Fore and the Kukukuku. These groups had
little contact with people from Western cultures and
none with each other.5 The authors’ goal was to determine whether facial expressions are universal or socially
constructed. They examined the videos for 2 things:
The ability of physicians to identify patient emotions accurately has been shown to be valuable.
Blanch-Hartigan and Ruben explained that patients’
“emotional states are often revealed to the clinician
not as blatant, explicit, or perfectly labeled moments,
but instead as subtle verbal and nonverbal hints of
their underlying state.”3 Accurately perceiving patient
expressions could aid in understanding the gravity
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Microexpressions Are Universal
223
Patient Care
Microexpressions: Do They Have Value in Radiology?
identical expressions in both groups that symbolized
the same emotion and different expressions in both
groups that symbolized the same emotion.5 To determine the meaning behind an expression, the authors
had to understand the context of the situation.5 To
compensate for this, if information about the situation
in which the microexpression occurred was not evident
on the film, Gajdusek and Sorenson provided an explanation.5 From this study, Ekman et al concluded that
microexpressions can be both universal and socially
constructed.5 They concluded that some expressions
had the same meaning in both cultures and that some
similar expressions had different meanings in each culture.5
Other studies by Ekman and Friesen identified 6
universal expressions: anger, fear, disgust, happiness,
surprise, and contempt. 6 However, “each universal
expression has a family of related expressions” that are
socially constructed.7 Ekman stated that:
the anger family differs in intensity from annoyance
to rage, and also contains such variations as
indignation, vengefulness, and sulking, [and] are
reflected in variations in the anger expressions, all
revolving around one prototypical expression.7
Thus, while expressions might vary based on intensity,
most expressions can be classified under one of the universal prototypical expressions.
Detecting Microexpressions
Incorporating microexpressions into radiology practice is not useful unless the ability to detect them can be
learned. Several studies directly related to health care
have been conducted on the acquisition of this skill.
The Ekman Micro Expression Training Tool teaches
people how to recognize concealed emotions.8 Trainees
watch slow motion video of actors portraying facial
expressions to compare and contrast emotions commonly confused with each other such as anger and disgust, fear and surprise, and fear and sadness.8 Second,
the program teaches how to recognize microexpressions
by showing a subject with a neutral expression who
then changes expressions briefly and quickly returns to
the neutral expression.8 The trainee is then asked which
of emotions was displayed.8
224
Another tool is the patient emotion cue test, which
consists of 47 video clips covering anger, sadness, happiness, anxiety, and confusion. Neutral video clips also are
included, which are devoid of emotional content.9 These
clips show a series of emotional statements derived from
real patient interactions depicted by a female actor.9 The
actor is instructed to vary her nonverbal behavior while
depicting the emotional statements.9 Emotional expression in these clips varies in nonverbal and verbal intensity
from high, low, or neutral.9
Since 1979, at least 5 studies have been completed
that evaluate person perception training developed for,
or implemented with, clinicians.3 Robbins et al performed a study using 51 internal medicine residents.
Twenty-six residents made up the experimental group,
and 25 residents made up the control group.10 The
experimental group received person perception training, while “the control group simultaneously participated in a traditional didactic program that included
content on pertinent psychosocial issues appropriate for
an outpatient setting.”10 Residents were tested using the
Affective Sensitivity Scale, a test of sensitivity to emotions displayed in prerecorded videos taken in health
care settings.3,10 Results showed a significant increase
in the experimental group’s scores on the Affective
Sensitivity Scale and a nonsignificant increase in the
scores of the control group. 3,10 These results suggest that
person perception using microexpressions is a trainable
skill.
In 2009, Endres and Laidlaw performed a pilot study
with 24 first-year medical students who varied from low
to high in communication skills based on the Objective
Structured Clinical Examination.4 These students were
first tested on their abilities to detect microexpressions,
and then were trained using the Micro Expression
Training Tool and tested once more. 4 No difference was
seen between the highest and lowest percentile medical
students in differentiating microexpressions on pretest
scores. However, after training, the highest percentile
group had a significant increase in ability to spot microexpressions. No difference was seen after training in
the lowest percentile group. 4 This study suggests that
success in training individuals to spot microexpressions
might vary based on their level of communication skills,
learning difficulties, and motivation to learn. 4
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Patient Care
Parent
In 2011, Riess et al performed a study using 11 otolaryngology residents.11 The residents participated in
three 90-minute sessions using videos that included
difficult patient-physician interactions to train their
empathy and relational skills.3,11 Results showed a nonsignificant increase in the residents’ ability to identify
emotions by observing subtle facial expressions.3,11
Although results showed an increase in the residents’
ability to perceive patient emotions related to facial
expressions, it was not significant enough to warrant the
effort to provide training to residents in the future.
In 2012, Riess et al performed a similar study using
99 residents from various departments.3,12 The residents
received either three 60-minute video training sessions
over a 4-week period, or they received standard postgraduate medical education.3,12 The video training sessions included the physiology of the physician-patient
interaction, including skin conductance tracings, with
emphasis on empathy and facial expressions.12 Physicians
were rated on the Consultation and Relational Empathy
(CARE) Measure 1 month before training and between
1 and 2 months after training.12 The CARE Measure is a
10-item questionnaire used to assess physician empathy
and relational skills.12 Items are rated on a 5-point scale
and added to yield a total score.12 Physicians were rated
by different patients before and after the physicians’
training, but because the CARE Measure is subjective,
more than one patient rated each physician each time to
provide more accurate data.12 Patients were instructed to
rate each interaction they had with the physician, but not
the overall relationship.12 Scoring showed that physicians
who underwent the training sessions showed the most
improvement in decoding facial expressions and received
higher patient ratings on physician empathy than did the
control group.3,12
Finally, a study by Blanch-Hartigan et al in 2012
involved 203 undergraduate students to assess improvement of person perception after training.3,13 The training
included increasing participants’ awareness about the
importance of emotional cues in clinical interactions,
increasing emotion cue recognition accuracy, and practicing emotion recognition while receiving feedback.
The training session lasted 32 minutes, and the patient
emotion cue test was used to assess participants’ skills.3,13
Results showed that participants who underwent the
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
training showed significant improvement, whereas the
control group did not.3,13 These results suggest that person perception training is effective.
The studies included here are related to health
care. Four of the 5 studies concluded that accurate
person perception is a trainable skill, while Riess et al
concluded in their 2011 study that while there was an
improvement in physician’s ability to identify patient
emotions accurately, there was not a significant enough
improvement to warrant future training. 4,10-13 Endres
and Laidlaw determined that the ability to improve
one’s perception might be influenced by one’s communication skills. 4 The author would argue, based on the
aggregate data, that training would be useful for health
care professionals.
Benefits
No studies have been conducted evaluating the use
of microexpressions in radiology settings; however, the
ability is likely as beneficial in the radiology department
setting as it is in the physician-patient setting, and studies should be performed to test this theory. Furthermore,
training for microexpression recognition should be done
while technologists are still in school. Benefits of this
training could include an increased ability to meet patient
needs, especially those that are not expressed verbally.
The ability to perceive patient emotions by evaluating expressions could improve the technologist-patient
relationship. Building a good rapport between technologists and patients could open channels for better communication, as well as improve the reputation of the
health care facility.
Conclusion
Mehrabian concluded that there is more to communication than the spoken word.1 Ekman et al further
determined that nonverbal expressions are both universal and socially constructed.5 As a result of those
findings, researchers began to wonder whether accurate
person perception is a trainable skill, and studies suggest that it is.4,10,12,13 Future studies should be conducted
to evaluate the advantages of observing microexpressions in the radiology department. Training radiologic
technologists to perceive patient emotions accurately
could improve patient care.
225
Patient Care
Microexpressions: Do They Have Value in Radiology?
Danielle Parent, BS, R.T.(R), is a radiologic technologist
for Canton-Potsdam Hospital in Potsdam, New York.
References
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3. Blanch-Hartigan D, Ruben MA. Training clinicians to accurately perceive their patients: current state and future directions. Patient Educ Couns. 2013;92(3):328-336. doi:10.1016/j
.pec.2013.02.010.
4. Endres J, Laidlaw A. Micro-expression recognition training
in medical students: a pilot study. BMC Med Educ. 2009;9:47.
doi:10.1186/1472-6920-9-47.
5. Ekman P, Friesen WV, O’Sullivan, et al. Universals and cultural differences in facial expressions of emotion. J Pers Soc
Psychol. 1987;53(4):712:717.
6. Ekman P, Friesen WV. Which emotions does the face show?
In: Unmasking the Face: A Guide to Recognizing Emotions From
Facial Expressions. Los Altos, CA: Malor Books; 2003:22.
7. Ekman P. Become versed in reading faces. Entrepreneur
Web site. http://www.entrepreneur.com/article/200934.
Published March 25, 2009. Accessed September 25, 2014.
8. Ekman P. Paul Ekman Group Web site. https://www
.paulekman.com/product-category/face-training/.
Accessed February 14, 2015.
9. Blanch-Hartigan D. Measuring providers’ verbal and nonverbal emotion recognition ability: reliability and validity
of the patient emotion cue test (PECT). Patient Educ Couns.
2011;82(3):370-376. doi:10.1016/j.pec.2010.11.017.
10. Robbins AS, Kauss DR, Heinrich R, Abrass I, Dreyer J,
Clyman B. Interpersonal skills training: evaluation in an internal medicine residency. J Med Educ. 1979;54(11):885-894.
11. Riess H, Kelley JM, Bailey R, Konowitz PM, Gray ST.
Improving empathy and relational skills in otolaryngology residents: a pilot study. Otolaryngol Head Neck Surg.
2011;144(1):120-122. doi:10.1177/0194599810390897.
12. Riess H, Kelley JM, Bailey RW, Dunn EJ, Phillips M.
Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum. J Gen
Intern Med. 2012;27(10):1280-1286.
13. Blanch-Hartigan D, Andrzejewski SA, Hill KM. The effectiveness of training to improve person perception accuracy:
a meta-analysis. Basic Appl Soc Psychol. 2012;34(6):483-498.
doi:10.1080/01973533.2012.728122.
226
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Advances in Technology
E-Portfolios for Radiologic
Technology Students
Annette Ortiz, MA, R.T.(R)(CT)
Geraldine Burghart, MA, R.T.(R)(MR)(M)
A
key challenge when constructing a transformative curriculum is designing a learning
community that reflects students’ individual
learning styles. A primary concern in radiologic technology is helping students develop the communication skills that will enable them to grow professionally. Over the past several years, the radiologic technology program at the Bronx Community College
implemented ways to improve students’ interaction
with patients, including improved language skills, confidence building, and increased competence through
continual assessment. Another way faculty improved
student competence was by designing an e-portfolio to
provide students with interactive experience before
clinical placement. This tool was used to improve students’ confidence and competence during the 2-year
continuum of professional development for clinical
instruction.
E-portfolios are common in higher education to prepare students for lifelong learning and to teach critical
thinking and problem-solving skills.1 E-portfolios have
been used in undergraduate and postgraduate health
programs, as well as for continuing professional development. They support reflection, assessment, and accurate
feedback. E-portfolios within these contexts are important tools in facilitating the transition toward competencybased medical education from residency to retirement.2
E-portfolios can be classified as developmental,
assessment, or showcase portfolios. A developmental
e-portfolio provides evidence of the advancement of
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
skills over time. This type of e-portfolio primarily is
used for communication between student and faculty
and is a collection of work that demonstrates a student’s journey of learning over time. Developmental
e-portfolios can include writing samples, photos, videos,
audio recordings, research projects, observations by
mentors and peers, and evidence of reflective thinking.
An assessment e-portfolio can demonstrate proficiency
in a particular task or realm of knowledge. A showcase
e-portfolio is a collection of work in a particular field
and often is used as a means to gain employment. To
help meet student learning outcomes, faculty for the
radiologic technology program at Bronx Community
College developed a hybrid e-portfolio specifically for
radiologic technology. This e-portfolio improved students’ long-term professional development and included
materials from faculty.
Researchers have found that e-portfolios motivate
students and help them to gain proficiency with technology, self-reflection, and content-specific skills. 3,4
The Bronx Community College program’s e-portfolio
used free software (Audacity 2.1.1) to record audio
simulations of patient and technologist interactions.
The recordings introduced students to medical terminology and its accurate pronunciation, and the professional interactions necessary to meet clinical criteria.
They focused on maintaining the accuracy of patient
data including name, date of birth, and clinical history. Students could listen to the recordings at their
convenience, and during the first semester, quizzes
227
Advances in Technology
E-Portfolios for Radiologic Technology Students
E-portfolio Feedback
90
% of Students Answering Affirmatively
were administered to assess students’ use of the recordings via the e-portfolio. A noticeable improvement was
seen in student communication and listening skills
during competency testing. In addition to the audio
recordings, videos from YouTube were posted that
demonstrated table top, table Bucky, and wall Bucky
procedures. These videos were intended as visual references to introduce students to the process of obtaining
radiographs.
The initial phase of the radiologic technology
e-portfolio was well received by the 23 first-year students surveyed (see Figure). The audio collection was
expanded to include conversational Spanish appropriate
for the clinical setting. Later, more complicated conversations with patients were added for studies requiring
contrast, such as esophogram, upper gastrointestinal
series, barium enema, and voiding cystourethrogram
studies. The videos provided an easily accessible
resource for students in an environment where contrast
studies have diminished because the use of advanced
imaging modalities such as computed tomography are
preferred. The addition of PowerPoint (Microsoft)
presentations diversified instruction, allowing students
to complete the slide presentations before a rotation in
special imaging areas such as computed tomography,
mammography, magnetic resonance imaging, and interventional radiography.
80
70
60
50
40
30
20
10
0
Question 1
Question 2
Question 3
Question 4
Question 1: Did the audio recordings provide an accurate
expectation for dialogue with patients?
Question 2: Did the audio recordings help you focus on the
communication details with patients?
Questions 3: Did you use e-portfolio as a resource for further
study of positioning skills via the Internet/technology?
Question 4: Did the videos improve your confidence when
dealing with patients as you transitioned from the classroom
to the hospital setting?
Figure. E-portfolio feedback from first-year students.
Conclusion
Gatyan and McEwan found that online students
enjoyed using e-portfolios because they diversified
instruction and increased student motivation.5 Research
suggests that collaborative activities augment student
performance. However, the extent to which the integration and peer evaluation of e-portfolios foster connections and improve quality communication is unknown.6
Students who used the hybrid e-portfolio indicated the
audio recordings gave them an accurate expectation for
dialogue and communication with patients. Watching
the videos moderately improved students’ confidence as
they transitioned to the clinical setting because it gave
them a chance to explore the Internet to find additional
resources. Nevertheless, using e-portfolios can motivate
21st century learners and demonstrate the relationship
between clinical objectives and professional competencies that they need to achieve.
228
Both authors work for the Bronx Community College
Radiology Technology Program. Annette Ortiz, MA,
R.T.(R)(CT), is assistant professor, and Geraldine
Burghart, MA, R.T.(R)(MR)(M), is associate professor.
Access the e-portfolio at asrt.org/as.rt?xNiCsB.
References
1. Gordan JA, Campbell CM. The role of ePortfolios in supporting continuing professional development in practice.
Med Teach. 2013;35(4):287-294. doi:10.3109/014215
9X.2013.773395.
2. Barbera E. Mutual feedback in e-portfolio assessment:
an approach to the netfolio system. Brit J Edu Technol.
2009;40(2):342-357.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Advances in Technology
Ortiz, Burghart
3. Chen C, Chen M. Mobile formative assessment tool based
on data mining techniques for supporting web-based learning. Comput Educ. 2009;52(1):256-273. doi:10.1016/j.compe
du.2008.08.005.
4. Zubizarreta J. The Learning Portfolio: Reflective Practice for
Improving Student Learning. 2nd ed. San Francisco, CA:
Jossey-Bass; 2009.
5. Gaytan J, McEwan BC. Effective online instructional and
assessment strategies. Am J Distance Educ. 2007;21(3):117132. doi:10.1080/08923640701341653.
6. Bolliger DU, Shepherd CE. Student perceptions of ePortfolio
integration in online courses. Distance Educ. 2010;31(3):295314. doi:10.1080/01587919.2010.513955.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
229
Teaching Techniques
Developing Clinical Competence in
Diagnostic Imaging Students
Carol Rose, MBA, BSc, DCR(R), Dip Ed
Jannet McIntosh, MSc, BSc, CDDR
D
iagnostic imaging training programs have
come under increased pressure to improve the
clinical competence of their graduates.
However, professional competence has no
accepted definition, and statements of competence are
not easily quantifiable,1 are nebulous and open to interpretation,2 and ambiguous. 3 In addition, no single method has been deemed most appropriate for assessing
clinical competence. 4 The variables believed to influence the development of clinical competence include
input variables such as personal background and school
characteristics, and process variables such as student
effort, clinical learning environment, and facultystudent relationships. These variables together can produce outcome variables such as program grade point
average and clinical competence.5 Other models
attempting to establish convergence of stakeholder perspectives (to include professional bodies, academics,
students, and radiography clinicians representing
employers) have regarded competence as fitness for
purpose, fitness for award, and fitness for practice. 3
Competence development has been studied for its
relationship with:
 Clinical placement location of nursing students. 6
Curriculum.7
Mentorship.8
 Scaffolded instruction – the student is supported
and guided by coaching in the construction of
knowledge.9
230
 Clerkship experience – the student is assigned
supervised workplace experience.10
 Effectiveness of clinical rotation.11
However, few studies have produced definitive answers
to the considerations in the development of clinical competence. This might be because of the lack of consensus
on a definition of clinical competence, the context-specific
considerations of clinical competence,12 and the concomitant subjective nature of competence evaluation.13-17 The
absence of empirical investigation into the development
of competence in diagnostic imaging students at the local
level inspired this exploration into the complex interplay
of stakeholders in the process.
Methods
A mixed-methods approach was employed for the
study. An initial qualitative survey was conducted
among radiographers in 3 public clinic sites (2 urban
and 1 rural) and 3 private urban sites involved in the
clinical placement of students and among final-year
diagnostic imaging students as well as lecturers in the
School of Medical Radiation Technology in Mona,
Jamaica. Twenty-nine (63%) of the 46 people invited to
participate responded. The survey yielded 111 openended responses, which were qualitatively coded into
3 categories:
Site-related.
Program-related.
Student-related.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Teaching Techniques
Program-related Variables
10
Rose, McIntosh
Eigenvalue
8
6
Eigenvalue
In a second survey, a 5-point Likert scale was developed4 to rate the 111 responses. Ninety survey instruments were distributed to 3 rural and 3 urban public
clinic sites, 5 urban private clinic sites, and to lectur2
ers and final-year diagnostic imaging students in the
School of Medical Radiation Technology. Seventy-four
0
responses
were returned, representing an 82% return
rate. The1 responses
in13the
3 categories
were
3 5 7 9 11
15 17
19 21 23 25 27
29 31analyzed
33 35 37 39 41
using SPSS software (IBM).
The Kaiser-Meyer-Olkin
Component
Number
measure of sample adequacy above 0.5 was obtained for
all 3 datasets. Bartlett’s test of sphericity at 0.000 significance was obtained for each dataset as a measure of
Variables
suitability of eachStudent-related
dataset for factor
analysis.
14
Having satisfied assumptions of suitability, principal
component
extraction was used to reduce each dataset
12
by defining sets of common underlying dimensions
10 the rated variables in each of the 3 categories iniamong
tially8 identified. Scree plot and latent root criteria were
used to determine the number of variables to be extracted per
6 dataset. However, as an exploratory survey of
opinions, all variables in each dataset were retained for
4
determination
of structure. The datasets were further
explored
for structure using quartimax, varimax, and
2
equamax (orthogonal) rotation methods. Equamax
0
rotation,
as a compromise between quartimax and
varimax1 methods,
the
3 5 7 9produced
11 13 15 17
19 most
21 23 distinct
25 27 29 structure
31 33 35 37
2 variables.
4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
among the
Component Number
Results
Eigenvalue
Qualitative coding of the 111 variables yielded
3 categories for initial consideration in establishing structure among the variables.
These variables were coded as
Site-related Variables
33 site-related
variables, 41 program-related variables, and
6
37 student-related variables (see Figure 1). Kaiser-MeyerOlkin5measures of sample adequacy of 0.590, 0.603, and
0.783 were obtained for site-related, program-related,
4
and student-related
datasets, respectively. Bartlett’s test
of sphericity at 0.000 significance was obtained for each
3
dataset,
indicating correlation between the variables and
suitability of each dataset for factor analysis.
2
Principal
component extraction of variables using
the latent root criterion (eigenvalues  1) indicated that
1
of the 33 site-related variables, 12 (explaining 72.3% of
variance)
best describe the concept of site-related vari0
ables and are to be retained for rotation. Similarly, of the
1
2
3
4
5
6
7
37
33
41
Site-related variables
Program-related variables
Student-related variables
Figure 1. Qualitative coding of variables considered important in
developing clinical competence in students.
41 program-related variables, 11 (explaining 70.8% of
variance) best describe this concept, and of the 37 student-related variables, 10 (explaining 77.6% of variance)
best describe this concept.
Visit asrt.org/as.rt?i8Xrk1 to see latent root criterion
extraction data for the 3 categories of variables.
Scree plot test criterion for site-related, programrelated, and student-related variables indicated 2, 4, and
2 variables, respectively, as explaining the bulk of the
variance between the variables, as indicated by nodes
located at and above the inflection point of each scree
plot (see Figure 2). However, as an exploratory survey
of opinions, all variables in each dataset were retained
for further determination of structure. Equamax rotation of site-related, program-related, and student-related
variables resulted in loading of variables on 4 components for each dataset.
Visit asr.t.org/as.rt?nHyrlj to see equamax rotation data
for the 3 categories of variables.
9 11 13 15 17 19 21 23 25 27 29 31 33
8 10 12 14 16 18 20 22 24 26 28 30 32
Component Number
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
231
4
2
0
1 3 5 7 Techniques
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37
Teaching
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Number
Developing ClinicalComponent
Competence
in Diagnostic Imaging Students
Program-related Variables
A
10
Site-related Variables
6
B
8
5
Eigenvalue
Eigenvalue
Program-related Variables
10
8
6
4
Eigenvalue
4
3
22
0
4
37
2
1
0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
1
2
3
4
5
C
6
7
9 11 13 15 17 19 21 23 25 27 29 31 33
8 10 12 14 16 18 20 22 24 26 28 30 32
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
Component Number
41
Component Number
Student-related Variables
2
The data indicates how the variables are weighted
under each component and the correlation between the
Student-related Variables
variables.
Distinct clusters of variables emerged from
14
each dataset, indicating
a pattern
or structure among
Site-related
variables
12 Variables that loaded simultaneously on
them.
Program-related variables
2 components were assigned to the component on
10
Student-related
variables Components
which their higher loading
was obtained.
were
8 ascribed labels as indicated in Table 1. Variables
that loaded below  0.3 were suppressed.18 Loadings
of 6 0.5 are considered practically significant and are
shown
under their respective ascribed labels in Table 2.
4
0
2
Conclusion
12
10
Eigenvalue
8
6
4
1
2
3
The results of the study indicate wide variations in
0
opinions among respondents on the factors considered
1 3 in
5 developing
7 9 11 13 15
17 19 21
23 25 27 29 31
35 37
important
clinical
competence
in 33
stu2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
dents. These findingsComponent
support expressions
Number of the nebulous nature of the concept of competence and the need
to establish consensus among stakeholders about what
5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37
4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Component Number
Figure 2. Scree test criterion extraction of site-related variables (A),
program-related variables (B), and student-related variables (C).
Site-related Variables
6 1
Table
Ascribed
Labels for Distinct Components Following Rotation of
6 Variables
5
Site-related Variables
Site-related Variables
Program-related Variables
5
1. Administration
1. Interest and motivation
2. Competence
evaluation methods
4
2. Work-related skills
3. Quality of supervision
3. Laboratory preparation
3. Depth of knowledge
3
4. Depth
of student orientation and integration into clinic sites
2
1
4.
Eigenvalue
4
Mentorship
Student-related Variables
2. Quality of clinical rotation
Eigenvalue
1.
33
0
Component Number
14
Eigenvalue
6
3 preparation
Didactic
4. Self-awareness
2
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
232
1
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33
Teaching Techniques
Rose, McIntosh
Table 2
Loadingsa
Site-related Variables
Program-related Variables
Mentorship
Administration
Positive mentorship from radiographers
0.64
Wider geographic rotation to include Caribbean sites
0.75
Encouragement from radiographers
0.63
Commendations for excellent performance
0.72
More vacation, rest, and recreation
0.72
0.66
Involvement of senior radiographers in mentoring
students
0.61
Reducing cost of program to reduce worry
Radiographers’ attitudes toward students
0.60
Putting a reward/merit system in place
0.61
Financial assistance to students to meet the cost of
clinical rotation
0.61
Students being allowed a measure of independence
in carrying out procedures
0.56
Radiographers’ awareness of school standards and
training criteria
0.56
Quality of Clinical Rotation
Competence Evaluation Methods
Broader assessment/evaluation other than clinical
competency
0.85
Regularity of competence evaluation
0.78
Rotation to both public and private clinic sites
0.61
Multiple evaluations of a single examination
0.75
Range of diagnostic studies to which the
student is exposed
0.58
Proper introduction, preparation, and orientation to
clinic evaluation in the classroom
0.63
Opportunities for students to critique their own
radiographs
0.56
Use of multiple methods of student evaluation in
clinics
0.56
Equipment in good working condition
0.56
Equal clinical rotation for all students
0.53
Number of students assigned per radiographic
room or clinic site
0.53
Extension of competency evaluation to include room
management rather than single cases
0.52
Exposure to multiple imaging modalities
0.51
Quality of Supervision
Level of feedback received from supervisor
0.76
Guidance received in conducting examinations
0.64
Supervisor’s competence
0.62
Being taught the correct way to carry out
examinations
0.53
Depth of student orientation and integration into clinic sites
Level of supervision received by students in clinic
0.72
Students’ knowledge of department vision
0.63
Exposure to all functional areas of the clinic sites
(office, reporting, and darkroom)
0.53
Students’ knowledge of department guidelines
0.52
Laboratory Preparation
Simulations prior to clinic assignment
0.75
Training in intravenous drug administration and
reactions to contrast medium
0.70
Laboratory simulation of difficult situations that could
occur in clinic sites
0.66
Continuous simulations and laboratory
demonstrations throughout the program
0.62
How the scheduling of classes and clinics is timed
0.61
Didactic Preparation
Strong anatomy and physiology base
0.72
Good academic knowledge base
0.68
Level of interactive teaching in the classroom
0.62
Clear-cut clinical guidelines provided by the school
0.51
Quality of lecture material delivered in the classroom
0.50
a
Numbers were rounded to 2 decimal places. Some variables that have identical loadings are fractionally different.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
233
Teaching Techniques
Developing Clinical Competence in Diagnostic Imaging Students
Table 2 continued
Loadings
a
Student-related Variables
Interest and Motivation
Interest in radiography
0.86
Interest in the job at hand
0.75
Ability to see each case as an opportunity to practice
0.73
Willingness to work
0.72
Level of self-motivation
0.71
Commitment to learning
0.61
Approach to work
0.61
Ability to reflect on feedback about their
performance and achievement
0.59
Listening skills
0.58
Regular attendance at clinic
0.54
Work-related Skills
Use of initiative
0.78
Use of teamwork
0.75
Ability to prioritize
0.63
Decision making ability
0.60
Observation skills
0.59
Ability to empathize
0.50
Depth of Knowledge
Knowledge of special procedures
0.77
Development of personal confidence before
competency evaluation
0.61
Participation in radiographic procedures
0.60
Willingness to accept constructive criticism
0.57
Use of judgment
0.56
Asking questions and seeking clarification
0.56
Knowledge of equipment
0.53
Self-awareness
Recognition of the limits of their competence
0.76
Working within the limits of their competence
0.74
Keeping written record of important clinical
information
0.69
Contribution to the education of fellow students
0.59
Level of confidentiality
0.54
Interpersonal communication
0.54
a
Numbers were rounded to 2 decimal places. Some variables that have
identical loadings are fractionally different.
234
constitutes clinical competence. In keeping with the literature, the findings generally conform to consideration
of the interplay of the clinical experiences of students,
the nature of their preparation from the training program, and the personal characteristics of the student.
The findings of the survey must be taken in the context
of the local field.
Although several of the ascribed labels for the distinct components from the rotation conform to findings
in the literature, many of the loaded variables under
each component are expressions of the reality of the
local landscape and might not be generalizable to diagnostic imaging students universally. The scope of the
survey also was limited by the selection of the major
sites involved in the training of students. Extension
to additional sites would provide a wider database for
analysis. Although exploratory in nature, and lacking
generalizability, the findings can provide insight for
further research into designing programs for developing
clinical competence in diagnostic imaging students.
Carol Rose, MBA, BSc, DCR(R), Dip Ed, and Jannet
McIntosh, MSc, BSc, CDDR, are assistant lecturers for
the School of Medical Radiation Technology in the Faculty
of Medical Sciences, University of the West Indies, Mona,
Jamaica, West Indies.
References
1. Williams PL, Berry JS. What is competence? A new model for
diagnostic radiographers: part 1. Radiography. 1999;5(4):221235. doi:10.1016/S1078-8174(99)90055-X.
2. Clarke T, Holmes S. Fit for practice? An exploration of the
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3. Castillo J, Caruana CJ, Wainwright D. The changing concept of competence and categorisation of learning outcomes
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4. Norman IJ, Watson R, Murrells T, Calman L, Redfern S. The
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practise of pre-registration nursing and midwifery students.
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5. Baramee J, Blegen MA. New graduate perception of
clinical competence: testing a causal model. Int J Nurs Stud.
2003;40(4):389-399.
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H. The impact of clinical placement location on nursing students’ competence and preparedness for practice. Nurse Educ
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1,900
145,781
99.926%
99.923%
I certify that the statements made by me above are correct and complete.
Stephanie Barela,
Communications Administrative Assistant
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
235
Writing & Research
Writing Research Proposals
Melissa B Jackowski, EdD, R.T.(R)(M)
Tricia Leggett, DHEd, R.T.(R)(QM)
I
ntellectual curiosity often motivates people to conduct research; however, performing research frequently requires funding. Securing funding often
begins with writing a research proposal, which
involves clearly and concisely stating the facts and
developing a sound argument to convince others to
fund the project.1 Each funding body has specific
requirements for research proposals. As an example,
this column describes the requirements for an ASRT
Foundation research grant.
Research Proposal Components
For the ASRT Foundation, a full research proposal
has 8 components (see Box).2 However, before the full
proposal is written, a letter of intent must be submitted.
This preliminary step ensures that projects align with
the Foundation’s mission and have a strong research
agenda. Letters of intent also provide an opportunity
for the primary investigator to refine the proposal in
collaboration with Foundation staff and the Research
and Grants Advisory Panel before creating the full version. The letter of intent is due no later than 5 weeks
before the proposal deadline.2 After the letter of intent
is accepted, the full proposal must be written, beginning with the application form.
Application Form
The application form must be completed fully for the
proposal to be considered. Primary investigators must
be a member of the American Society of Radiologic
236
Box
ASRT Foundation Research Proposal Components
2
Application form
Table of contents
Statement in support of the ASRT Foundation mission
Abstract
Itemized budget
Supporting budget statement
Narrative
Appendices
Download additional information, including the
application form and component examples, at
asrt.org/as.rt?ug9gla.
Technologists with current American Registry of
Radiologic Technologists registration or equivalent, or
an unrestricted state license to be eligible.2
Table of Contents
The table of contents should reflect each of the 8
research proposal components and provide page numbers. Proposals cannot exceed 10 pages.2 The project
title should be included at the top of the table of contents page.
Statement in Support of the Mission
This statement should justify how the research will
further the ASRT Foundation’s mission: “to support
and empower medical imaging and radiation therapy
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Writing & Research
Jackowski, Leggett
professionals and students as they pursue opportunities to enhance the quality and safety of patient care.”2
For any grant proposal, researchers should learn about
the funding organization to determine whether their
research goals correspond with the granting agency’s priorities. Even a well-written research proposal is unlikely
to receive funding if sent to the wrong institution.3
Abstract
The purpose of the abstract is to describe briefly
the main components of the project proposal. For the
ASRT Foundation grant proposal, this includes2:
 A brief background.
 Significance of the project.
Objectives.
 Research questions or hypotheses.
 Methods to be employed.
Writing an abstract can be difficult because of
its limited length. The ASRT Foundation limits the
abstract to one page of double-spaced text, which is
approximately 250 words. It might seem as though that
is not enough space to say everything, and fitting in the
crucial information is the biggest challenge the abstract
presents. The abstract allows you to see your project
from the outside in rather than the inside out. When
drafting the abstract, the researcher must ask himself
or herself4:
 What are your project’s most important elements?
 What must someone absolutely know in order to
understand the project?
 What elements of the research project must someone know to grasp why it should be funded?
Although it is tempting to write the abstract first,
writing it after the full proposal is complete will help
researchers identify the most important points that
should be included in the shorter abstract format. 4
Itemized Budget
The itemized budget provides the awarding agency
a clear estimate of the expenses associated with the
research. The best way to write a budget is to follow a
template. For ASRT Foundation grants, funding requests
must not exceed $10 000 and are limited to direct costs
only.2 Examples of items that can be includ-ed in the
itemized budget are expendable supplies, sala-ries and
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
wages based on the sponsoring institution, and travel
costs related to presenting the research findings.2 If more
than $10 000 is needed, researchers should contact the
ASRT Foundation before submitting.
Supporting Budget Statement
The supporting budget statement justifies budget
items that are not self-explanatory.2 For example, if
the research requires the purchase of equipment, the
rationale should be explained in this section along with
a plan for the disposition of the equipment after the
project has ended. If the itemized budget represents
only part of the cost of the project, the proposal author
should indicate this, provide the estimated total cost
of the project, and identify other funding resources. If
other financial support is not already committed, the
ASRT Foundation requires the approximate date when
other funding decisions will be made.2
Narrative
The narrative portion of a research proposal submitted to the ASRT Foundation should not exceed 3 pages
and must include the following elements2:
 Statement of problem – describes the problem
addressed by the research proposal, the rationale
for the research, its significance, and how it is relevant to the radiologic sciences.
 Specific aims – states the specific objectives of the
project, including the hypotheses that will be tested and research questions it will attempt to answer.
 Literature review – describes other work leading
to the proposed project and relevant research with
similar or relevant conceptual or experimental
approaches. It also might demonstrate a gap in the
existing literature and support the need for the
proposed research. For ASRT Foundation grants,
references must be provided in American Medical
Association style.
 Proposed methodology – describes the activities
for completing the research and states why the
planned methods or strategies are appropriate.
This section also includes a logical explanation of
how the data will be collected and analyzed.
 Calendar – outlines the expected timetable
for stages of the project (ie, data collection and
237
Writing & Research
Writing Research Proposals
analysis) for each year of the proposed research.
 Personnel – describes the role of each person
expected to be involved in the project. This
includes researchers, radiologic sciences personnel, health care personnel, students, consultants,
and any oth-ers who will play a significant role on
the project.
 Facilities and equipment – describes facilities
such as laboratories or clinical areas and equipment required to conduct the proposed research.
 Agreement – states intent to submit a peerreviewed manuscript to Radiologic Technology
or Radiation Therapist to publish the results of
research funded by an ASRT Foundation grant.
Appendices
Appendices should include curricula vitae or résumés for the primary investigator and any coinvestigators, documentation of necessary institutional approvals by appropriate boards or committees, commonly
known as an institutional review board, and cooperating institution documentation if applicable.2
Write a Proposal That Gets Funded
The purpose of writing a project proposal is to
gain funding to pursue research interests. The ASRT
Foundation has the following suggestions for successfully funding your project5:
 Ensure your research question is significant and relevant to the purpose of the funding organization.
 Demonstrate a strong alignment to the mission
and vision of the funding organization.
 Show evidence that the researcher and his or her
team are qualified to investigate the proposed
research question thoroughly.
 Demonstrate a strong understanding and use of
current study protocols, assurances, and agreements. Assurance means assuring compliance with
policy such as institutional review board approval
to protect human subjects. An example of an agreement would be a collaboration agreement between
2 institutions conducting research together.
 Show evidence of awareness and understanding of
similar research in the field and seek to build on
the profession’s body of knowledge.
238
 Present and adhere to a reasonable and adequate
budget.
 Provide sound methodology appropriate for the
proposed research.
The ASRT Foundation funds research in the professions of medical imaging and radiation therapy because
innovation is critical for improving best practices and
ensuring quality patient care. The opportunity to apply
for and receive a research grant enables researchers to
continually advance our profession.
Melissa B Jackowski, EdD, R.T.(R)(M), is competency
management development specialist for CX USA Education
Services at Siemens Medical Solutions USA Inc in Cary,
North Carolina. She is secretary-treasurer for the ASRT
Board of Directors.
Tricia Leggett, DHEd, R.T.(R)(QM), is vice president
for student success for Zane State College in Zanesville,
Ohio. She is also vice chairman of the Radiologic
Technology Editorial Review Board. She can be reached
at [email protected].
Visit asrt.org/as.rt?iKjDU7 for information about ASRT’s
“How to Write a Winning Research Grant” educational
module.
References
1. Van Ekelenburg H. The art of writing good research proposals. Sci Prog. 2010:93(4):429-442. doi:10.3184/003685010X
12798150447676.
2. ASRT Foundation. Research grant award program. http://
www.asrt.org/docs/librariesprovider3/pdfs/fdn15_grant
_brochure.pdf?sfvrsn=2. Updated December 2014. Accessed
September 3, 2015.
3. Grant proposals (or give me the money!). University of North
Carolina at Chapel Hill Writing Center Web site. http://writ
ingcenter.unc.edu/handouts/grant-proposals-or-give-me-the
-money/. Accessed August 20, 2015.
4. The elements of a good proposal abstract. Grant Central
Station Web site. http://grant-central-station.com/articles
/the-elements-of-a-good-proposal-abstract/. Accessed
August 22, 2015.
5. Which research proposals get funded? ASRT Foundation
Web site. http://foundation.asrt.org/what-we-do/research
-grants. Accessed September 17, 2015.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Backscatter
Image Fusion
A
B
Archive
C
You Might Have Missed…
“Training radiologic
technologists to perceive
patient emotions
accurately could impove
patient care.”
Turn to Page 223 for the full story.
240
Image fusion, commonly used in proton
therapy, merges data sets from different
types of scans of the same patient. One
data set usually is the simulation computed tomography (CT) scan, which is
fused with a positron emission tomography (PET) or magnetic resonance scan.
The CT scan (A) and PET scan (B) are
fused in C to demonstrate good soft tissue
and bony anatomical alignment between
the 2 data sets. A multimodality approach
provides the greatest detail and the precision required for proton therapy. These
detailed images help the physician and
treatment planner better define the target
volume and critical structures.
This image appears in Proton Therapy
Module 1: Physics and Equipment. Visit
www.asrt.org/protontherapy to learn more.
The Multi-wonder Ray.
The X-Ray Technician,
May 1960.
Art, too, has turned to
x-ray. It is a means to
determine the authenticity of old masters’ works.
The pigments used in
their times had a metallic content; the mediums
used at a later date do not.
Old paintings can be found. Reconstruction of
overlaid masterpieces is made possible, too.
Read the full story at www.asrt.org/archive.
RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2
Patient-centered Care for
DIVERSE POPULATIONS
Diverse Patients.
Consistent Care.
• Deliver quality care for all patients.
• Explore concepts of cultural
awareness and equitable care.
• Earn 12 CE credits.
Patient-centered Care for Diverse Populations

Online Education
Module 1 – Fundamentals
Module 6 – Cultural Competence
Module 2 – Elderly Patients
Module 7 – Health Literacy
Module 3 – Pediatric Patients
Module 8 – Diverse Body Habitus
Module 4 – Patients With Physical Disabilities
Module 9 – Chronically Ill Patients
Module 5 – Patients With Intellectual Disabilities
Module 10 – Equitable Patient Care
Earn 12 CE credits and receive a document recognizing your achievement once you successfully complete all 10 modules.
We also offer individual credit modules and an institutional/educator series for classroom use or training.
www.asrt.org/patientcare
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