December 19, 2014

Unnecessary Chest X-Rays for Kids

X-rays should never be given unless there’s a good reason, but researchers at the Mayo Clinic have found that too many children are being given chest X-rays when there’s no benefit to them.

In a news release issued by the Radiological Society of North America, Dr. Ann Packard said, "Chest X-rays can be a valuable exam when ordered for the correct indications. However, there are several indications where pediatric chest X-rays offer no benefit and likely should not be performed to decrease radiation dose and cost." Packard is a radiologist at the Mayo Clinic.

The dangers of radiation are cumulative. That is, exposure to radiation builds up in the body, and problems might not present for decades. So being exposed to the radiation in an X-ray should be carefully considered, especially in young people because the effects of the experience stay with them forever.

Packard and Dr. Kristen B. Thomas, co-author of the study and head of the pediatric division at the Mayo Clinic, reviewed 719 pediatric chest X-ray exams given over a six-year period in inpatient, outpatient and emergency room settings. The patients ranged in age from newborn to 17 years old.

Of the 719 X-rays:

  • 377 exams were ordered for chest pain

  • 98 for syncope (fainting) or presyncope

  • 21 for a general feeling of being unwell or under distress (spells)

  • 37 for postural orthostatic hypotension (POTS), a condition in which blood pressure drops suddenly when the individual stands up from sitting or lying down

  • 185 for dizziness

  • 1 for cyclical vomiting

Eighty-two of the 719 exams were excluded because of congenital or other known heart disease, and other causes.

A key finding was that in nearly 9 in 10 of the nonexcluded patients, the exam did not alter clinical treatment. None of the patients who underwent X-rays for syncope, spells, POTS, dizziness or cyclical vomiting had any finding that affected treatment.

Only about 12 in 100 of the chest X-rays for chest pain were positive, and included respiratory symptoms such as cough, fever or trauma.

Clearly, too many kids are getting too many chest X-rays. "I would like this research to help guide clinicians and deter them from ordering unnecessary exams which offer no clinical benefit to the patient," Packard said in the statement.

If your practitioner wants to give your child a chest X-ray, ask why he or she believes this is the best, or only approach, especially if the patient has no respiratory symptoms. Ask the doctor what he or she expects to learn from the test.

For more information, see our safety tips for radiation exposure, and read our patient safety blog on new guidelines for imaging tests.

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August 29, 2014

Worrisome Trend: Sunscreen Use Declines Among Teens

Although the rate of some cancers has declined in recent years, melanoma — the most serious form of skin cancer — is not among them. The situation is more troubling with the news of a new study that fewer teenagers are using sunscreen than they used to.

Because sun damage is cumulative — that is, like X-rays and other forms of radiation, the more exposure you have and the longer you have it, the greater the risk of developing cancer — the news is particularly unsettling. The earlier in life you develop the habit of reducing sun exposure, and of using sunscreen when you are outside, the greater your chances of minimizing the risk.

The study about teens was part of the Youth Risk Behavior Surveillance System, an initiative of the Centers for Disease Control and Prevention (CDC). It reviewed use of sunscreen and indoor tanning devices among high-school students across the U.S. between 2001 and 2011. Even though teens generally practice fewer skin-protection habits than adults, this study, as reported on, showed a decline sunscreen use and an increase in indoor tanning use even from previous reviews.

The number of teens who use sunscreen dropped by more than 1 in 10 from 2009 to 2011. The lowest rate of sunscreen use was in 2005, when only 5 in 100 teens applied it. The rate teens used indoor tanning devices varied less in that period, from 15 in 100 in 2009 to 13 in 100 in 2011, but it still declined.

Although as adults, more women than men wear sunscreen, the CDC study showed that girls used indoor tanning devices more than boys. In 2009, 1 in 4 girls tanned indoor regularly compared with 6 in 100 boys. And their use of tanning beds increased as they got older. Sunscreen use was fairly consistent across all grade levels.

A few years ago, we blogged about the dangers of kids and tanning beds, “Youth and Tanning Beds: Do Not Mix,” but it appears American youth — and their parents — aren’t getting the message.

According to the American Cancer Society, melanoma is diagnosed in about 69,000 Americans each year, and about 8,650 die from it. The CDC says that rates of melanoma rose 1.6% among men and 1.4% among women every year from 2001 to 2010.

Other forms of skin cancer are less lethal than melanoma, but are still problematic and require treatment. AboutLawsuits refers to a study from a few months ago that showed that teenagers who use tanning beds are more likely to develop basal cell carcinoma, one of those forms, and that they were more likely to be diagnosed at a much earlier age.

However you get harmful radiation, and wherever it shows up on your body, it’s not good. And, often, it’s preventable. Adults should make sure they minimize exposure to the sun, and should spurn the use of tanning beds, and they should make sure their kids do, too. It’s an investment in future health.

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July 18, 2014

Kids and CT Scans: Not So Fast, Parents

Responsible doctors are worried that children can get way too much radiation exposure when they are tested for common problems in the emergency room. X-rays can have great benefit in diagnosing what's wrong, but they can also pose serious long-term risks of cancer from accumulated unnecessary testing.

The main culprit is the CT scanner. Parents need to know that CT scans send out X-ray beams. The typical CT study doses a patient with the equivalent of many dozen chest X-rays.

Ultrasound, by contrast, uses sound waves, so there's no exposure to potentially harmful radiation.

Smart parents sometimes mistakenly push for a CT scan because it's the fanciest and therefore "best" technology. But that's not always true. Ultrasound has now replaced CT as the first-line choice for imaging the abdomen to see if a kid with severe pain might have an inflamed appendix.

A group of doctors just published an article they titled An Appeal for Safe and Appropriate Imaging of Children, in the Journal of Patient Safety. They used as a case study a true story of an 11-year-old girl with abdominal pain who wound up getting two CT scans and scaring her parents to death, all because of a benign nodule found as an "incidental finding" in the lung. She should have received an ultrasound and no CT.

They wrote:

This child has already received an estimated ~20 mSv, which carries with it an increased cancer risk of approximately 1 in 500. Stories like this likely occur every day in the United States.

This unfortunate sequence of patient harm, waste, and needless anxiety could have been completely avoided with the Ultrasound First policy being used at many centers.

We've written before about how doctors are worried about overuse and misuse of radiation imaging. Parents need to know about the issue and work with medical professionals to get their sick and injured children the right imaging test and not necessarily the most high-tech one.

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December 20, 2013

Ultrasound Versus CT Scan for Diagnosing Appendicitis in Kids

CT scans often are used to detect appendicitis, but a new study at the Children's Hospital at Montefiore Medical Center in New York suggests that ultrasound is equally adept at diagnosing this emergency condition. That’s important, because a CT image is an X-ray, which emits radiation; an ultrasound image, which involves sound waves, does not.

The research was published in the American Journal of Roentgenology, and concluded that not only is ultrasound safer than a CT scan and provides a comparable result, it does not increase the length of a hospital stay, another important consideration in medical treatment.

As reported on, appendicitis is one of the most commonly experienced conditions among children in the U.S., and it’s becoming more frequent. Usually, a CT scan is the imaging technique used to evaluate patients with symptoms of appendicitis.

That’s inflammation of the appendix, a small pouch attached to the beginning of the large intestine. Appendicitis is the result of a blockage by a foreign object (food morsel, fingernail, etc.) feces or, rarely, a tumor, and the site becomes infected.

The study was a collaboration between radiologists and clinicians in pediatric surgery and emergency medicine. They increased the use of ultrasound as the first imaging option from 1 in 3 at the beginning of the study to almost 9 in 10 at the study's completion. Use of a CT scan as the first and only diagnostic test decreased from about 4 in 10 to fewer than 1 in 10 by the end of the study.

In a news release from Montefiore, co-author Jessica Kurian, M.D., said, "As more people become aware of the risks of medical radiation, there are increasing efforts to utilize nonradiation emitting imaging techniques as a first approach to diagnosis. Our research shows that using ultrasound first in the evaluation of appendicitis commonly produces actionable results and should be considered more frequently as clinicians try to limit medical radiation exposure in children."

As we explained in “More Evidence to Let Caution Be Your Guide in CT Scans,” radiation is cumulative, and the more you receive over the course of your life, the likelier you are to develop cancer. (See our backgrounder on radiation overdose injuries.) Sometimes, diagnosis via X-ray is necessary, but if there are options, such as ultrasound or MRI, they should be exercised. If your doctor suspects appendicitis is the cause of your child’s problem, and plans to perform a CT scan, ask instead for an ultrasound.

Symptoms of appendicitis can vary, and it can be difficult to diagnose in young children. Usually, the first symptom is pain that might be mild at first, but becomes sharper and more severe. Appetite falls off, and often there is nausea, vomiting and a low fever.

If the appendix ruptures, the pain might diminish briefly, but once the lining of the abdominal cavity becomes swollen and infected (a condition known as peritonitis), the pain escalates. Serious, later symptoms include:

  • chills

  • constipation

  • diarrhea

  • fever

  • nausea

  • shaking

  • vomiting.

Treatment is surgical removal of the appendix. If it’s removed before it ruptures, recovery is generally quick. If the appendix has ruptured, recovery is slower are more likely to involve complications such as infection.

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June 15, 2012

CT Scans Pose Increased Radiation Risk for Children

X-rays are a wonderful diagnostic tool, but like many other tests, they come with risks. In this case, radiation, an excess of which can lead to cancer. CT scans, which create detailed images of the interior of the body, are superior for diagnosing several medical problems—more than 80 million are performed every year in the U.S.

But they use significantly more radiation than standard X-rays, and a breakthrough study in Britain confirms that the risk is higher for children.

Concern about the effects of radiation are especially appropriate for children, who are at greater risk because their cells turn over more rapidly and because they have a longer life span in which to be exposed to all forms of radiation. We’ve addressed this concern before, and have described the general risk in “Radiation Overdose Injuries.”

As reported by NPR in conjunction with Kaiser Health News, children who get CT scans have a slightly higher risk for brain cancer and leukemia, according to the study published in the Lancet.

The study is considered significant because it’s the first to follow youngsters who had CT scans for their subsequent cancer risk. Nearly 180,000 patients who got CT scans between 1985 and 2002 before their 22nd birthdays were followed.

Researchers calculated that the amount of radiation from two or three scans of the head before age 15 would increase the risk of brain cancer threefold. It would take five to 10 head scans to triple the risk of leukemia.

Researchers emphasized that the overall risk for brain cancer and leukemia is very low, so although a threefold increase sounds ominous, the risk remains quite low even among people who got scans.

In the 10 years following the scans, researchers estimated that about one excess brain tumor and one case of leukemia occurred per 10,000 head CT scans performed in young children.

But scans of other parts of the body also look risky, they concluded, and it's probably not just a matter of multiple CTs and leukemia and brain tumors among kids; there's a good chance even one CT scan poses some risk to children and possibly for various cancers.

Experts say it's important to remember that CT scans save a lot of lives, and that they are certainly appropriate in some situations, including:

  • major motor vehicle accidents where there's multiple potential organ injuries;

  • abdominal pain for which surgery might be required—for example a bowel obstruction or sometimes appendicitis;

  • for some symptoms of head injuries, but not all.

The bottom line is that many CT scans are unnecessary, and doctors must be much more selective about how are used.

If your doctor suggests that you or your child has a CT scan, ask why. Ask if there are other options, such as ultrasound, which doesn’t offer as much detail as a CT scan, but in some cases is a sufficient diagnostic approach.

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May 4, 2012

Less Radiation Is Good Medicine for Diagnosing Appendicitis

Appendicitis often presents as an emergency, and whether you’re old or young, the belly pain can be extreme. Typically, it’s diagnosed using a CT scan, and a new study indicates that this evaluation should be performed differently for adults and for children.

As published in the New England Journal of Medicine, the research shows that exposure to the radiation in a CT scan is of concern particularly for children and young adults. Such scans can employ different levels of radiation, and it appears that low-dose CT scans are just as effective in diagnosing appendicitis in teens and young adults as standard doses.

Because the effects of radiation exposure can be dire—an increased risk of cancer, primarily—the lower the dose the better. (See our article, “Radiation Overdose Injuries”.) But these lower levels haven’t been accepted widely, according to analysis of the NEJM study by MedPage Today, because of the quality of the images rendered was suspect.

So the researchers conducted a randomized trial of 879 patients ages 15 to 44 suspected of having appendicitis. About half received a low-dose CT scan and half received the standard-dose scan.

About 4 in 10 patients in each group had an appendectomy after the scan. Afterward, it was determined that six patients in each group did not have inflammation, and had undergone the operation unnecessarily.

The difference between the two groups was so negligible that using the low-dose CT instead of the standard dose would have resulted in only one additional unnecessary operation in 330 patients. That risk, researchers noted, is favorably weighed against the potentially higher cancer risk with the standard dose.

"However, it is highly debatable whether the radiation levels used in our two groups can actually induce cancer and whether use of the low dose instead of the standard dose can actually reduce the carcinogenic risk," they added.

The rate of perforated appendix, which indicates that the diagnosis was delayed, also was similar between the two dosage groups.

The welcome performance of the lower dose scan was attributed to superior imaging capability of modern equipment and the fact that it’s fairly simple to interpret CT images of an appendix.

Cells that divide rapidly are more susceptible to cancer. Because the active growth of children signifies rapid cell turnover; because gastrointestinal tract cells continually turn over; and because children have a longer life span and are therefore more vulnerable to all forms of radiation exposure for a longer period, it just makes sense to limit their radiation exposure when you can.

If your child’s doctor prescribes a CT scan to diagnose possible appendicitis, request a low-dose procedure. And if it’s prescribed for other diagnostic reasons, discuss the options. Sometimes, care providers embrace the more-is-more solution out of habit, and that’s not always the best medicine.

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March 9, 2011

Preemies exposed to excessive radiation at Brooklyn hospital

Technicians at a Brooklyn, N.Y. hospital exposed premature babies to dangerous levels of radiation, according to a recently published report in the New York Times.

Technologists with the radiology department at the State University of New York (SUNY) Downstate Medical Center routinely gave premature infants whole-body X-rays when physicians ordered only a chest X-ray. They also failed to shield the infants’ reproductive organs as required by New York state health codes.

(The photo at the top of this blog entry shows a whole-body X-ray of a baby from a textbook, intended to show how to use X-rays to detect child abuse. This practice is now out of favor with up-to-date doctors due to the radiation risks, but as the article shows, medical practice is sometimes slow to catch up with knowledge.)

The errors were first discovered by the chairman of the SUNY Downstate Department of Radiology, Dr. Salvatore Sclafani. In a letter to colleagues, Sclafani wrote that he was “mortified” after finding the “full, unabashed total irradiation of a neonate” when examining the chart of a premature baby in his care. A pediatric radiologist Sclafani brought in to evaluate the hospital’s procedures found other “alarming” practices: In addition to frequently performing whole body X-rays, known as babygrams, technicians were performing CT scans on infants using the wrong settings, resulting in excessive radiation.

Although new, tighter procedures for radiological imaging of infants were instituted and babygrams were halted altogether, the hospital never reported the errors to N.Y. state officials as required by law. State officials now are investigating the claims in the New York Times article.

With technologists in many states either lightly regulated or unregulated, their own professional group is calling for greater oversight and standards. The American Society of Radiologic Technologists has been lobbying Congress for 12 years to pass a bill that would establish minimum educational and certification requirements for technologists, medical physicists and 10 other occupations in medical imaging and radiation therapy. However, Congress has yet to pass such a bill, leaving regulation up to individuals states. And in many states, radiation therapists (15 states), imaging technologists (11 states) and medical physicists (18 states) remain unregulated.

“It’s amazing to us, knowing the complexity of medical imaging, that there are states that require massage therapists and hairdressers to be licensed, but they have no standards in place for exposing patients to ionizing radiation,” said Christine Lung, the technologist association’s vice president of government relations.

Source: The New York Times

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November 23, 2010

3-D Imaging for Orthodontics Exposes Teens to High Dose Radiation

A new technology sweeping through dentistry -- especially orthodontics -- is called cone-beam CT scanning. It creates gorgeous 3-D images of the teeth and facial bones, but at a price of potentially high doses of X-rays, that carry a low risk (but still a risk) of cancer.

The risk accumulates with the more X-ray exposure there is, and sometimes dentists can run a child through the cone-beam CT scanner four times in the course of fitting braces.

The problem is worse because many dentists don't understand the X-ray exposure risk, and therefore minimize it when counseling parents and teens. Also, some dentists who are flacking for the CT scanner manufacturers are spreading mis-information, according to a big investigative report in the New York Times.

One dentist who is a paid spokesman claims in online lectures that the X-ray exposure of a cone-beam CT scan is no more than an airport whole body scanner. In fact, the dose can be more than one hundred times higher with the CT scan.

Sometimes the scans aren't needed at all but are done for convenience. A regular digital camera can produce images of the location of teeth that are adequate to make custom braces, but they take longer than with the CT scan.

Here is a good list of questions prepared by the Times reporters for parents to ask when the dentist wants to put their child through one of these CT scan machines.

Read the whole report in the Times here.

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