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RADIOLOGIC Journal of the American Society of Radiologic Technologists T E C H N Volume 87, Number 2 November/December 2015 O L O G Y 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 Safety 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 Implement the best patient care strategies for all patient populations. Module 1 – Introduction to Health Care Safety Module 2 – Workplace Safety Module 3 – Risk Management 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 www.asrt.org/safetyessentials essentialeducation essentialeducation www.asrt.org/safetyessentials www.asrt.org/patientcare 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. • Earn 11.5 CE credits. 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 High Performance in Health Care • Learn strategies for success. • Develop the leader in you. • 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. www.asrt.org/leadership 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 www.asrt.org/featuredce 800-444-2778 Raise the Profile of Radiologic Technologists Patients don’t always know that you’re a licensed and credentialed medical imaging or radiation therapy professional. To help you educate patients about your background, follow the ACE campaign’s three easy steps: • Announce your name • Communicate your credentials • Explain what you’re going to do Show your support – Click To Commit at www.asrt.org/ACE. Click To Commit! www.asrt.org/ACE ©2014 ASRT. All rights reserved. My Membership My Peace of Mind “ I love the CE track and transfer service. I attend the OSRT conference each year in order to keep up with my CE credits. The ASRT does a great job of tracking them, accounting for them and sending them to ARRT for my registration. The turnaround time is great as I typically get them back much quicker than promised. “ — Connie Pabst, R.T.(R), of Cincinnati, Ohio DID YOU KNOW ASRT tracks 88,865 continuing education credits each month for members. When you’re within two months of the end of your biennium, we begin sending your CE record to the ARRT. Learn more about the track and transfer service at www.asrt.org/trackandtransfer. Thank you for being an ASRT member! Need assistance? Call us at 800-444-2778 or e-mail [email protected]. Cutting-edge, Cost-effective CE... ...Designed to Meet Your Goals! • • • • • Choose from more than 150 titles—and 400 credits! MR and CT cross-training. MR and CT registry preparation. Best Money Back Guarantee in the industry! MQSA compliance in Digital Mammography and Digital Breast Tomosynthesis. Technologists and their managers agree: “MIC’s courses really work!” The CT Registry Review Program • Free UPS GroUnd ShiPPinG (for orders over $99) • Free PoSt-teSt retakeS • Free CertiFiCate rePlaCement • Free PoStaGe For PoSt-teStS • Fax or mail YoUr anSwerS • toll-Free CUStomer ServiCe • major Credit CardS aCCePted • diSCoUntS For Former StUdentS, GroUPS and earlY reGiStration • BoldeSt moneY BaCk GUarantee in the indUStrY! The MRI Registry Review Program ™ ™ • Covers every topic on the ARRT & NMTCB post-primary exams in CT. NEW • It’s guaranteed: Pass the ARRT 5th Ed! exam in CT or your money back! • 22 Credits & 8 StudyModules. • Covers every topic on the ARRT & NMTCB post-primary exams in MRI. NEW • It’s guaranteed: Pass the ARRT exam in MRI or your money back! 5th Ed! • 30 Credits & 12 StudyModules. The CT CrossTrainer The MR CrossTrainer ™ ™ • Covers all the essentials of MR. • Requires no prior training in MR. • Explains MR so you’ll understand it! • 18 Credits & 6 StudyModules. • Covers all the essentials of CT. • Requires no prior training in CT. • Explains CT so you’ll understand it! • 17 Credits & 6 StudyModules. Digital Mammography Essentials Digital Breast Tomosynthesis Essentials ™ • Meets MQSA requirements for modality-specific training. • Covers all the essentials of digital mammography & requires no prior training. • 11 Credits & 4 StudyModules. • Meets MQSA requirements for modality-specific training. • Covers all the essentials of digital breast tomosynthesis. • 8 Credits & 3 StudyModules. Sectional Anatomy & Imaging Strategies ™ • Learn all the essential concepts of sectional imaging...in a convenient self-study format! • Explains sectional anatomy and tomographic imaging so you’ll really understand it! • 18 Credits & 6 StudyModules. New! Radiology Trends for Technologists ™ • Choose from 75 hot topic review articles. • StudyBuddy helps you focus on relevant info. • CT, MR, Mammo, PET, SPECT, etc. • 1.5 to 4 Cat A credits for each “Trends” title! Every MIC course is accredited for Category A CE credits which are fully recognized by the ARRT & NMTCB. Call today for your Free Info Kit ...since 2000 RT11/12-15 800-589-5685 or visit www.MICinfo.com …f or y our pe r f e c t i ma ge ™ . ™ See how our delivery systems are designed to work the way you work. With select injectors including features such as: Controls at the powerhead, for programming and control of injections and patency checks at the patient bedside Patency CheckTM feature, for verification of proper stick and vascular patency at the patient bedside Battery-free operation, to eliminate time and cost of battery charging and replacement Easy operation, with the ability to use prefilled syringes Schedule your free virtual demo today. For more information, or to schedule a free virtual demonstration of a contrast delivery system, please contact Mallinckrodt at 866.223.4434 or via email at [email protected]. Mallinckrodt contrast delivery systems are all part of the OptiSuite™ Imaging System — a platform of products intelligently and purposefully integrated to help streamline your workflow and give you more time to optimize confidence in patient care. Mallinckrodt contrast media products are now available through Liebel-Flarsheim, a Mallinckrodt company. Mallinckrodt, the “M” brand mark, the Mallinckrodt Pharmaceuticals logo and other brands are trademarks of a Mallinckrodt company. © 2015 Mallinckrodt. RADIOLOGIC T E C H N O L O G Y An Official Journal Subscriptions Radiologic Technology (ISSN 0033-8397) is the official scholarly/ professional journal of the American Society of Radiologic Technologists. It is published bimonthly at 15000 Central Ave SE, Albuquerque, NM 87123-3909. 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The initials “R.T.” following proper names in this journal refer to individuals certified by the American Registry of Radiologic Technologists. 124 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 RADIOLOGIC T E C H N O L O G Y 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 ASRT Office 15000 Central Ave SE Albuquerque, NM 87123-3909 Phone: 800-444-2778; Fax: 505-298-5063 www.asrt.org For questions regarding subscriptions or missing issues, call Member Services at 800-444-2778 or e-mail [email protected]. For advertising information, contact Robin Treaster at 800-444-2778 or e-mail [email protected]. For questions concerning editorial content, e-mail [email protected]. Submissions Submissions from radiologic science professionals and researchers are encouraged. Visit asrt.msubmit.net to upload a manuscript. Author guidelines are available at www.asrt.org/authorguide. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 125 The New ASRT Communities An Online Social Network for the Profession Top Features Member Directory. Search for members and send them messages directly. Personal Profile. Share your educational background, job history, awards and more. Recognition Ribbons. Discussions. E-mail Notifications. Earn virtual ribbons for membership duration, discussions, donations and volunteering. Start or contribute to discussions and view posted resources. Receive convenient e-mails summarizing activity in your Communities. Shared Files. Mobile Friendly. Share videos, images and documents to build a profession-wide knowledge base. View and reply to discussions directly from your phone, tablet or e-mail. THE COMMUNITIES www.asrt.org/myasrt QUICK START GUIDE www.asrt.org/communitiesguide win prizes! ENTER TO WIN Monthly Prizes Include: $10 gift cards redeemable at online retail outlets and Sharing Is Good pens, totes, tumblers, lanyards, portfolios and more! Grand Prize One winner will receive airfare and a five-night hotel stay to attend the 2016 ASRT Educational Symposium and Annual Governance and House of Delegates Meeting in Las Vegas! RADIOLOGIC T E C H N O L O G Y 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. 129 Peer Review 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 Peer Review 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 131 Peer Review 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 Peer Review 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). 133 Peer Review 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). RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 Peer Review 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 135 Peer Review 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 Peer Review 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 References 1. Sabih DE, Sabih A, Sabih Q , Khan AN. Image perception and interpretation of abnormalities; can we believe our eyes? Can we do something about it? Insights Imaging. 2011;2(1):4755. doi:10.1007/s13244-010-0048-1. 2. Thompson JD, Manning DJ, Hogg P. Analysing data from observer studies in medical imaging research: an introductory guide to free-response techniques. Radiography. 2014;20(4):295-299. doi:10.1016/j.radi.2014.04.005. 3. Birkelo C, Chamberlain W, Phelps P, Schools P, Zacks D, Yerushalmy J. Tuberculosis case finding: comparison of effectiveness of various roentgenographic and photofluorographic methods. JAMA. 1947;133(6):359-366. 4. Lee C, Nagy PG, Weaver SJ, Newman-Toker DE. Cognitive and system factors contributing to diagnostic errors in radiology. AJR Am J Roentgenol. 2013;201(3):611-617. doi:10.2214 /AJR.12.10375. 5. Forrest J V, Friedman PJ. Radiologic errors in patients with lung cancer. West J Med. 1981;134(6):485-490. 6. Bass J, Chiles C. Visual skill. Correlation with detection of solitary pulmonary nodules. Invest Radiol. 1990;25(9):994-998. 7. Manning D, Ethell S, Donovan T, Crawford T. How do radiologists do it? The influence of experience and training on searching for chest nodules. Radiography. 2006;12(2):134142. doi:10.1016/j.radi.2005.02.003. 8. Krupinski EA. Influence of experience on scanning strategies in mammography. In: Kundel HL, ed. Proc SPIE 2712, Medical Imaging 1996: Image Perception, 95. 1996:95-101. doi:10.1117/12.236845. 9. Nodine CF, Mello-thoms C, Kundel HL, Weinstein SP. Time course of perception and decision making during mammographic interpretation. AJR Am J Roentgenol. 2002;179(4):917-923. 10. Kang I, Reem RE, Kaczmarowski AL, Malpeli JG. Contrast sensitivity of cats and humans in scotopic and mesopic conditions. J Neurophysiol. 2009;102(2):831-840. doi:10.1152 /jn.90641.2008. 11. Kohnen T, Bühren J, Kasper T, Terzi E. Quality of vision after refractive surgery. In: Kohnen T, Koch DD, ed. Cataract and Refractive Surgery. Berlin, Germany: Springer; 2005:303-314. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 12. Safdar NM, Siddiqui KM, Qureshi F, et al. Vision and quality in the digital imaging environment: how much does the visual acuity of radiologists vary at an intermediate distance? AJR Am J Roentgenol. 2009;192(6):W335-W340. doi:10.2214 /AJR.07.3515. 13. Straub WH, Gur D, Good BC. Visual acuity of radiologists-is it time? AJR Am J Roentgenol. 1991;156(5):1107-1108. 14. Sia DIT, Martin S, Wittert G, Casson RJ. Age-related change in contrast sensitivity among Australian male adults: Florey Adult Male Ageing Study. Acta Ophthalmol. 2013;91(4): 312-317. doi:10.1111/j.1755-3768.2011.02379.x. 15. Quaghebeur G, Bhattacharya JJ, Murfitt J. Radiologists and visual acuity. Eur Radiol. 1997;7(1):41-43. 16. Colenbrander A. Measuring vision and vision loss. In: Duane TD, Tasman W EA, eds. Duane’s Clinical Ophthalmology. Vol 5. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1-42. 17. Kaiser PK. Prospective evaluation of visual acuity assessment: a comparison of snellen versus ETDRS charts in clinical practice (an AOS thesis). Trans Am Ophthalmol Soc. 2009;107:311-24. 18. Holladay JT. Visual acuity measurements. J Cataract Refract Surg. 2004;30(2):287-290. 19. Arden GB. The importance of measuring contrast sensitivity in cases of visual disturbance. Br J Ophthalmol. 1978;62(4):198-209. 20. Apelt D, Peitgen H. Contrast sensitivity in mammographic softcopy reading – determination with psychophysical procedures. In: Krupinski E, ed. Digital Mammography. Heidelberg, Germany: Springer-Verlag; 2008:756-763. 21. Apelt D, Strasburger H, Klein J, Preim B. Impact of adaptation time on contrast sensitivity. In: Manning DJ, Abbey C, eds. Proc SPIE 7627, Medical Imaging 2010: Image Perception, Observer Performance, and Technology Assessment. 2010. doi:10.1117/12.845241. 22. Drum B, Calogero D, Rorer E. Assessment of visual performance in the evaluation of new medical products. Drug Discov Today Technol. 2007;4(2):55-61. doi:10.1016/j.ddtec .2007.10.009. 23. Bourne R. The spatial and frequency domains. In: Fundamentals of Digital Imaging in Medicine. London, England: Springer-Verlag; 2010:55-86. doi:10.1007/978-1 -84882-087-6. 24. Lança L, Silva A. Image quality in diagnostic radiology. In: Digital Imaging Systems for Plain Radiography. New York, NY: Springer; 2013:63-77. doi:10.1007/978-1-4614-5067-2. 25. Lee SY, Koo NK. Change of stereoacuity with aging in normal eyes. Korean J Ophthalmol. 2005;19(2):136-139. 26. Krupinski E. Current perspectives in medical image perception. Atten, Percept, Psychophys. 2010;72(5):1205-1217. doi:10.3758/APP.72.5.1205. 137 Peer Review Visual Function Assessment in Medical Imaging Research 27. Fielder A, Moseley MJ. Does stereopsis matter in humans? Eye(Lond). 1996;10(part 2):233-238. doi:10.1038/eye .1996.51. 28. Ohlsson J, Villarreal G. Normal visual acuity in 17-18 year olds. Acta Ophthalmol Scand. 2005;83(4):487-491. doi:10.1111/j.1600-0420.2005.00516.x. 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 mPas at 20°C and 10 mPas 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 63 maceutical. 30 To simulate a typical clinical set5 45° 63 ting, studies were performed with an automated power injector, Dual 30 Shot Alpha, and the contrast mediContrast medium 45° 5 63 um was injected via the antecubital 30 64 venous access. The manyfill line 5 45° 63 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. 149 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 Peer Review 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 Peer Review 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 Peer Review 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 153 Peer Review Evaluation of Stress and a Stress-Reduction Program Among Radiologic Technologists 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. 154 9 10 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 Peer Review Reingold 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. 155 Peer Review Evaluation of Stress and a Stress-Reduction Program Among Radiologic Technologists 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). 156 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). RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 Peer Review Reingold 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. 157 Peer Review Evaluation of Stress and a Stress-Reduction Program Among Radiologic Technologists 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 158 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. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 Peer Review Reingold 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 159 Peer Review 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 160 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 Peer Review Reingold 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 161 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 CE Directed Reading 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 163 CE Directed Reading Medical Ethics and Law in Radiologic Technology 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 164 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Matthews, Matthews 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 165 CE Directed Reading Medical Ethics and Law in Radiologic Technology 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Matthews, Matthews 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 167 CE Directed Reading Medical Ethics and Law in Radiologic Technology 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 168 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Matthews, Matthews 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. 169 CE Directed Reading Medical Ethics and Law in Radiologic Technology 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 170 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, RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Matthews, Matthews 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: RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 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, 171 CE Directed Reading Medical Ethics and Law in Radiologic Technology 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 172 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Matthews, Matthews 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 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 173 CE Directed Reading Medical Ethics and Law in Radiologic Technology 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 174 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Matthews, Matthews 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 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. 175 CE Directed Reading Medical Ethics and Law in Radiologic Technology 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 CE Directed Reading 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 CE 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 References 1. Slowther A. Introduction. In: Singer P, Viens A, eds. Cambridge Textbook of Bioethics. Cambridge, UK: Cambridge University Press; 2008:1-9. 178 2. Andre J. Bioethics as Practice. Chapel Hill, NC: University of North Carolina Press; 2002:1-26, 62-69. 3. Pozgar G. Legal and Ethical Issues for Health Professionals. 4th ed. Burlington, MA: Jones & Bartlett Learning; 2016:1-49, 69-74, 121-234, 245-249, 264, 360-361, 437-465. 4. Aiken T. Legal and Ethical Issues in Health Occupations. St Louis, MO: Saunders; 2002:3-38, 99-130, 160-163. 5. Riesleman D. What are values? UC Magazine. http://maga zine.uc.edu/issues/0805/whatarevalues.html. Accessed August 21, 2015. 6. Morrison E. Ethics in Health Administration: A Practical Approach for Decision Makers. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2016:1-29. 7. Shields C. Aristotle. The Stanford Encyclopedia of Philosophy Archive. Spring 2014 ed. http://plato.stanford.edu/archives /spr2014/entries/aristotle/. Published September 25, 2008. Accessed April 8, 2015. 8. Kücükuysal B, Beyhan E. Virtue ethics in Aristotle’s Nichomachean ethics. Int J Human Sci [serial online]. 2011;8(2):43-51. http://www.j-humanscienc es.com/ojs /index.php/IJHS/article/view/1737. Accessed August 31, 2015. 9. Moss J. Virtue makes the goal right: virtue and phronesis in Aristotle’s ethics. Phronesis. 2011;56(3):204-261. doi:10.1163/156852811X575907. 10. Vaughn R. The Life and Labours of Saint Thomas Aquin: Vol I. London, UK: Longmans and Co; 1871. 11. Conway P. Saint Thomas Aquinas. London, UK: Longmans, Green and Co; 1911. https://archive.org/details/saintthomasaquin00conwuoft. Accessed August 28, 2015. 12. Hampden R. The Life of Thomas Aquinas: A Dissertation of the Scholastic Philosophy of the Middle Ages. Glasgow, UK: John J Griffin and Co; 1848. https://archive.org/details/lifethoma saquin01hampgoog. Accessed August 28, 2015. 13. Murphy M. The natural law tradition in ethics. The Stanford Encyclopedia of Philosophy Archive. Winter 2011 ed. http:// plato.stanford.edu/archives/win2011/entries/natural-law -ethics/. Revised September 27, 2011. Accessed April 6, 2015. 14. Gregg S. Health, health care, and rights: a new natural law theory perspective. Notre Dame J Law, Ethics & Public Policy. 2014;25(2):463-479. 15. Rohlf M. Immanuel Kant. The Stanford Encyclopedia of Philosophy Archive. http://plato.stanford.edu/archives /sum2014/entries/kant/. Summer 2014 ed. Accessed April 7, 2015. 16. Pozgar G. Legal Aspects of Health Care Administration. 12th ed. Burlington, MA: Jones & Bartlett Learning; 2016:39,100181. 17. Wilson F. John Stuart Mill. The Stanford Encyclopedia of Philosophy Archive. Spring 2014 ed. http://plato.stanford.edu RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Matthews, Matthews /archives/spr2014/entries/mill/. Revised July 10, 2007. Accessed April 7, 2015. 18. Summers J. Theory of healthcare ethics. In: Morrison E, Furlong B, eds. Health Care Ethics: Critical Issues for the 21st Century. Burlington, MA: Jones & Bartlett Learning; 2014: 3-46. 19. Zank M, Braiterman Z. Martin Buber. The Stanford Encyclopedia of Philosophy Archive. Winter 2014 ed. http:// plato.stanford.edu/archives/win2014/entries/buber/. Revised December 4, 2014. Accessed April 12, 2015. 20. Esping A. Autoethnography and existentialism: the conceptual contributions of Viktor Frankl. J Phenomenological Psychol. 2010;41(2):201-215. doi:10.1163/156916210X532126. 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 1948:385-399. 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 Patient Care. 5th ed. St Louis, MO: Elsevier Saunders; 2012:127-140, 307-336. 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: legal issues in medical intervention. J Altern Complement Med. 2008;14(6):785-792. doi:10.1089/acm.2007.0803. 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 Learning; 2011:70-90. 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. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 36. Facts about pregnancy discrimination 2015. United States Equal Employment Opportunity Commission Web site. http://www.eeoc.gov/facts/fs-preg.html. Updated September 8, 2008. Accessed April 27, 2015. 37. The Age Discrimination in Employment Act of 1967, (Pub L No. 90-202). (1967). 38. Cook JC. Prepare to avoid trouble under the Civil Rights Act of 1991. Labor Manage Decisions. 1992;2(2). http://are.berke ley.edu/~howardrr/pubs/lmd/html/summer_92/prepare 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 Web site. http://www.northwestregisteredagent.com/law 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. 179 CE Directed Reading Medical Ethics and Law in Radiologic Technology 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 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. 189 CE Directed Reading Medical Imaging of Oral and Oropharyngeal Cancer 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. 190 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, RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 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. 191 CE Directed Reading Medical Imaging of Oral and Oropharyngeal Cancer 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. 192 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: RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 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 193 CE Directed Reading Medical Imaging of Oral and Oropharyngeal Cancer 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. 194 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 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 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 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. 195 CE Directed Reading Medical Imaging of Oral and Oropharyngeal Cancer 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. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 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. 197 CE Directed Reading Medical Imaging of Oral and Oropharyngeal Cancer 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. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 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 199 CE Directed Reading Medical Imaging of Oral and Oropharyngeal Cancer 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. 200 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. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 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 201 CE Directed Reading Medical Imaging of Oral and Oropharyngeal Cancer 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 202 RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 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 203 CE Directed Reading Medical Imaging of Oral and Oropharyngeal Cancer 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. References 1. Oral cancer facts. The Oral Cancer Foundation Web site. http://oralcancerfoundation.org/facts. Accessed October 10, 2014. 2. General information about lip and oral cavity cancer. National Cancer Institute Web site. http://www.cancer.gov /types/head-and-neck/patient/lip-mouth-treatment -pdq#link/stoc_h2_0. Updated July 23, 2015. Accessed September 10, 2015. 204 3. American Cancer Society. Oral cavity and oropharyngeal cancer. http://www.cancer.org/acs/groups/cid/documents /webcontent/003128-pdf.pdf. Updated March 3, 2015. Accessed September 10, 2015. 4. General information about oropharyngeal cancer. National Cancer Institute Web site. http://www.cancer.gov/types /head-and-neck/patient/oropharyngeal-treatment-pdq #section/_1. Updated July 23, 2015. Accessed September 10, 2015. 5. World Health Organization. Global data on incidence of oral cancer. http://www.who.int/oral_health/publications/oral _cancer_brochure.pdf?ua=1. Published 2005. Accessed October 10, 2014. 6. Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol. 2009;45(4-5):309-316. doi:10.1016/j.oraloncology.2008.06.002. 7. Cancer facts and figures 2013. American Cancer Society Web site. http://www.cancer.org/research/cancerfactsfigures /cancerfactsfigures/cancer-facts-figures-2013. Published 2013. Accessed October 10, 2014. 8. SEER stat fact sheets: oral cavity and pharynx cancer. National Cancer Institute Web site. http://seer.cancer.gov /statfacts/html/oralcav.html. Accessed October 10, 2014. 9. Cancer of lip, oral cavity and pharynx. EUCAN Web site. http://eco.iarc.fr/EUCAN/Cancer.aspx?Cancer=1. Published 2013. Accessed September 10, 2015. 10. Country: European Union (27). EUCAN Web site. http:// eco.iarc.fr/EUCAN/Country.aspx?ISOCountryCd=930. Published 2013. Accessed September 10, 2015. 11. Country: Hungary. EUCAN Web site. http://eco.iarc.fr /EUCAN/Country.aspx? ISOCountryCd=348. Published 2013. Accessed September 10, 2015. 12. Country: France. EUCAN Web site. http://eco.iarc.fr /EUCAN/Country.aspx?ISOCountryCd=250. Published 2013. Accessed September 10, 2015. 13. Why screening works. Oral Cancer Foundation Web site. http://www.oralcancerfoundation.org/dental/why_screening _works.php. Accessed October 10, 2014. 14. Risk factors. Oral Cancer Foundation Web site. http:// oralcancerfoundation.org/understanding/risk-factors.php. Accessed October 10, 2014. 15. Oral cancer risk factors. Cancer Research UK Web site. http://www.cancerresearchuk.org/health-professional /cancer-statistics/statistics-by-cancer-type/oral-cancer/risk -factors#undefined. Accessed October 15, 2014. 16. Oropharyngeal cancer treatment- for health professionals (PDQ). National Cancer Institute Web site. http://www.can cer.gov/types/head-and-neck/hp/oropharyngeal-treatment -pdq#section/all. Updated July 10, 2015. Accessed September 10, 2015. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 CE Directed Reading Anderson 17. Travasso C. Betel quid chewing is responsible for half of oral cancer cases in India, finds study. BMJ. 2013;347:f7536. doi:10.1136/bmj.f7536. 18. HPV/oral cancer facts. Oral Cancer Foundation Web site. http://oralcancerfoundation.org/hpv/hpv-oral-cancer-facts. php. Accessed October 16, 2014. 19. Premalignant lesions. Oral Cancer Foundation Web site. http://oralcancerfoundation.org/cdc/cdc_chapter4.php. Accessed October 16, 2014. 20. Meyers AD. Premalignant conditions of the oral cavity. Medscape Web site. http://emedicine. medscape.com /article/1491418-overview. Updated July 24, 2015. Accessed September 10, 2015. 21. Dental health and leukoplakia. WebMD Web site. http:// www.webmd.com/oral-health/guide/dental-health-leukopla kia. Accessed October 16, 2014. 22. Diagnosis. Oral Cancer Foundation Web site. http://oralcancerfoundation.org/discovery-diagnosis/diagnosis.php. Accessed October 16, 2014. 23. The role of dental and medical professionals. Oral Cancer Foundation Web site. http://oralcancerfoundation .org/dental/role_of_dentists.php. Accessed October 20, 2014. 24. Six steps to a thorough oral cancer screening. Six Step Screening.org Web site. http://www.sixstepscreening.org /oral-cancer/. Accessed October 20, 2014. 25. Uthman EO. The biopsy report: a patient’s guide. Oral Cancer Foundation Web site. http://oralcancerfoundation .org/discovery-diagnosis/detailed-biopsy.php. Accessed October 20, 2014. 26. MacCarthy D, Mills L. Word of Mouth: Coping with and Surviving, Mouth, Head and Neck Cancers. Dublin, Ireland: 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- 221 In the Clinic Computed Tomography for Assessment of Coronary Artery Bypass Grafts 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 1. Mehrabian A. Silent Messages. Belmont, CA: Wadsworth Publishing; 1971. 2. Shen X, Wu Q , Fu X. Effects of the duration of expressions on the recognition of microexpressions. J Zhejiang Univ Sci B. 2012;13(3):221-230. doi:10.1631/jzus.B1100063. 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 development of newly qualified nurses using focus groups. Int J Nurs Stud. 2007;44(7):1210-1220. 3. Castillo J, Caruana CJ, Wainwright D. The changing concept of competence and categorisation of learning outcomes in Europe: implications for the design of higher education radiography curricula at the European level. Radiography. 2011;17(3)230-234. doi:10.1016/j.radi.2010.12.008. 4. Norman IJ, Watson R, Murrells T, Calman L, Redfern S. The validity and reliability of methods to assess the competence to practise of pre-registration nursing and midwifery students. Int J Nurs Stud. 2002;39(2):133-145. 5. Baramee J, Blegen MA. New graduate perception of clinical competence: testing a causal model. Int J Nurs Stud. 2003;40(4):389-399. RADIOLOGIC TECHNOLOGY, November/December 2015, Volume 87, Number 2 Teaching Techniques Rose, McIntosh 6. Edwards H, Smith S, Courtney M, Finlayson K, Chapman H. The impact of clinical placement location on nursing students’ competence and preparedness for practice. Nurse Educ Today. 2004;24(4):248-255. 7. Meechan R, Jones H, Valler-Jones T. Students’ perspectives on their skills acquisition and confidence. Br J Nurs. 2011;20(7):445-450. 8. Pointer JE. Experience and mentoring requirements for competence in new/inexperienced paramedics. Prehosp Emerg Care. 2001;5(4):379-383. 9. Tilley DS, Allen P, Collins C, Bridges RA, Francis P, Green A. Promoting clinical competence using scaffolded instruction for practice-based learning. J Prof Nurs. 2007;23(5):285-289. 10. Wimmers PF, Schmidt HG, Splinter TA. Influence of clerkship experiences on clinical competence. Med Educ. 2006;40(5):450-458. StatementOwnshp2015.pdf 1 10/22/15 12:40 PM 11. Daelmans HE, Hoogenboom RJ, Donker AJ, Scherpbier AJ, Stehuower CD, van der Vleuten CP. Effectiveness of clinical rotations as a learning environment for achieving competences. Med Teach. 2004;26(4):305-312. 12. Shin K-R, Jung D, Kim MW, Lee YJ, Eom JY. Clinical supervisors’ satisfaction with the clinical competence of newly employed nurses in Korea. Nurs Outlook. 2010;58(3):129-134. RADIOLOGIC T E C H N O L O G Y doi:10.1016/j.outlook.2010.01.002. 13. Calman L. Patients’ views of nurses’ competence. Nurse Educ Today. 2008;26(8):719-725. 14. Flinton D, Simpson R. A study into the expectations of managers regarding newly qualified radiographers within the department. Radiography. 1996;2(2):161-162. doi:10.1016 /S1078-8174(96)90008-5. 15. Sloan DA, Donnelly MB, Drake DB, Schwartz RW. Faculty sensitivity in detecting medical students’ clinical competence. Med Teach. 1995;17(3):335-342. doi:10.3109/01421599509008325. 16. Wright CA, Jolly B, Schneider-Kolsky ME, Baird MA. Defining fitness to practise in Australian radiation therapy: a focus group study. Radiography. 2011;17(1):6-13. doi:10.1016/j.radi.2010.10.001. 17. Das J, Hammer J. Which doctor? Combining vignettes and item response to measure clinical competence. J Dev Econ. 2005;78(2):348-383. doi:10.1016/j.jdeveco.2004.11.004. 18. Hair J, Black W, Babin B, Anderson R. Multivariate Data Analysis. 7th ed. Upper Saddle River, NJ: Prentice Hall; 2010:117. Circulation A. Total No. of Copies B. Paid and/or Requested 1. Outside-County Mail Subscriptions 2. In-County Subscriptions and Vendors Statement of Ownership, Management and Circulation as of 8-21-15 Radiologic Technology Publication No. 0033-8397 6 issues annually; bimonthly Price $8.15 per year, included in member dues. Publisher: American Society of Radiologic Technologists, 15000 Central Ave SE, Albuquerque, NM 87123-3909. Owner: American Society of Radiologic Technologists, 15000 Central Ave SE, Albuquerque, NM 87123-3909. No other known bondholders, mortgages or other security holders. the USPS C. Total Paid and/or Requested Circulation D. Nonrequested Distribution 1. Outside County 2. In-County E. F. G. H. I. Other Classes of Mail 4. Distributed Outside the Mail Total Nonrequested Distribution Total Distribution Copies Not Distributed Total Percent Paid and/or Requested Circulation Actual 152,226 Average 145,782 149,869 0 0 143,181 0 0 660 590 150,529 143,771 110 0 0 110 0 0 0 110 150,639 1,587 152,226 0 110 143,881 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 essentialeducation Use our Online Testing System for Instant Certificates We now have e-books! We have a new website! We are continually striving to make your CE ordering experience easier. 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