Do the Risks of Gonadal Shielding during Pelvic X-Ray Exams Outweight the Benefits - Research Paper Example

DO THE RISKS OF GONADAL SHIELDING DURING PELVIC X-RAY EXAMS OUTWEIGHT THE BENEFITS Research Project HP Introduction Gonad Shielding has been gaining significance and becoming a common practice over the years. During pelvic x-rays, gonads are shielded to protect them from radiation. The placement of the gonad shield needs to be very specific, at the same time it appears to be quite hard to place the shield immaculately. Inaccurate placement of the shield leads to detrimental effects; for such placement leads to repeated x-ray exams and unnecessary exposure to radiation. Due to the shield being inaccurately placed significant amount of valuable data is also lost. The research will investigate the problem statement: ‘Do the risks of gonadal shielding during pelvic exam out weight the benefits?’ The problem will be investigated by employing the empirical approach. The research will use the survey questionnaire developed by the researchers and approved by IRB (Institutional Review Board). The research will aim to investigate the tendency of increased exposure to radiation due to the inadequate placement of gonad shields in patients. Inadequate placement of gonad shields leads to repeated radiographs, resulting in repeated exposure. This exposure is unnecessary and can be easily avoided by eliminating the practice of using gonad shields altogether. In most hospitals the first pelvic x-ray does not make it even obligatory to use the gonad shield. Literature Review Pelvic x-rays, like any other are carried out for diagnostic purposes. They aid in detection of tumors, urinary tract stones and cysts. Gonads are shielded during these radiographs to protect them from radiation and harm, as the gonads tend to show specific sensitivity to radiation (Gul, Zafar, & Mafulli, 2005). Mostly, x-rays pelvic exams are conducted in Young children, and Gonads tend to display particularly heightened sensitivity to radiation at about or below reproductive age (Kenny &Hill, 1992; Gul, et. al 2005). In the 1950’s the concept of Gonadal protection against x-rays during these radiographs started to gain significance and popularity; leading to the shielding of Gonads becoming commonly practiced (Frantzen, Robben, Postma, Zoetelief, Wildberger, & Kemerink, 2011), in both males and females (Fawcett & Barter, 2009). The Gonads are protected using specific lead shields that require to be placed immaculately. Gonad shielding is a recommended national and international practice for conducting radiographs. The shielding of gonads is specially a recommended practice during and before reproductive years of the patient; as damage to these organs can lead to affecting the reproductive capabilities of the patients. Guidelines are provided for the use of gonadal shielding in the radiology departments of hospitals. Gonads show high susceptibility to radiation as the location of the gonadal organs places them in direct path of radiation, during pelvic x-ray exam (Sikand, Stinchcombe & Livesley, 2003). Exposure to radiation is detrimental and should be avoided; especially in terms of the reproductive areas. The method employed to reduce the gonads exposure to radiation dosage is that of covering the gonads is with a shield, which can significantly reduce the radiation dosage; that is from 500 to 2000 mr or less (Ardran, 1957). But due to the extreme difficulty involved in its placement, if the radiologist fails to place the gonadal shield accurately and immaculately, the same protection method can result in the gonads being directly damaged by the radiation or be mutated (Gul, et. al, 2005). The effects that result from exposure to radiation to reproductive organs do not become apparent for some while, at times also exhibiting detrimental effects in the next generation; thus allowing practitioners and patients to lax in using proper guidelines for using the gonad shield (Wainwright, 2008). Radiographs conducted at King’s Mill Hospital, revealed that out of the 355 radiographs that were conducted at the hospital radiology department, only 23% demonstrated the correct use of Gonad shields; in the remaining 67% radiographs, no shield was used, hinting that all shields used were inaccurately placed; thus the incorrect placement exposing 45% of the patients to an unnecessary amount of radiation that could have been avoided (Sikand et. al, 2003). More than often the shield is placed inaccurately; either due to difficulty in its placement or not following the guidelines properly, and thus leads to ineffectively protecting the gonadal region, leading to complications (Fawcett, Gomez, Barter, Ditchfield & Set, 2012). Such placing increases the radiation exposure of ovaries or testes and culminates in harmfully affecting the organs (Hill & Kenny, 1992). 26% of the times shields result in being accurately placed in patients, which leaves the room for placing inaccurate shields very high (Fawcett & Barter, 2009). In a study conducted by Kenny and Hill (1992) on 32 children, out of the 346 radiographs, the gonadal shield in 109 radiographs failed to protect the gonadal region of the patients, thus exposing the patient’s gonads to high levels of radiation that could have been avoided during the treatment. In children accurate placement of shield is even more significant that the shield be placed accurately, for the detrimental effects of exposure to radiation in children are more significant due to heightened sensitivity. Research has been ongoing to investigate the positioning of gonad shields. Audits were published in the UK, on Gonad shields being used in children, identifying that only 25% of the times the shields were accurately used and positioned (Fawcett & Barter, 2008). Such a low ratio of shields being accurately used show heightened exposure of children to radiation thus exposing them to the lifelong risk of mutation. Although due to scientific progress the technological advances have enabled to reduce the radiation to be used in utmost minimal levels, but even at such ratios, recurring exposure can be hazardous. Radiation effects are cumulative and pose greatest risk to children; exposure can later on lead to higher incidences of developing cancer, and occurrence of hereditary diseases can also result in the children of the person exposed to radiation (Gul et. al, 2005). Genetic effects of ionizing radiations can lend to risk entire generations of the person exposed (Sikand et. al, 2003). When the primary radiation beam has been reduced to its significant minimum, the gonadal shield for pelvic X-ray patients should purportedly reduce exposure to radiation up to 25% (Ardran & Kemp, 1957). Due to the inadequate placement of shields, gonads are unnecessarily exposed to radiation, thus reducing and sometimes altogether eliminating the benefits of the gonadal shield. In a study 50.8% of the gonad area was exposed to radiation from radiographs due to either absence or inappropriate placement of the shield in 70% of cases (Gul et. al, 2006). The gonadal tissues are the most sensitive tissues in human body and repeated exposure to radiation can damage the tissues of reproductive organs. Mutations of the cells in reproductive organs can also result from repeated exposure. The rate of Fatality of cancer, resulting from exposure to radiation is very low, but the radiation dosage or extent of exposure can lead to its variability; 15 persons per million is the estimated risk of developing a fatal cancer through one radiographic examination (Gul et. al, 2006). The accuracy and placement of the Gonad shield is seen as more of a problem in girls as compared to boys; 26% rate of accurate placement of gonad shields is attributed to girls, where as 54% of gonad shields are purportedly accurately placed in boys (Fawcett & Barter, 2008). Providing protection to Ovaries during radiography, presents with a more complicated problem, due to the varying position of the ovaries, within the pelvis of the children (Abram, Wilkinson & Hodson, 1958). One other reason for the inaccurate placement of gonad shield in girls can be attributed to the fact that the gonad shield are always placed in the midline region of the pelvis so that the ovaries are not exposed to radiation, whereas the position of the ovaries is positioned laterally in the pelvis; thus rendering the current methods of shielding in female patients ineffective (Bardo, Black & Schenk, 2009). In male patients, the Testes are covered by the lead shield to reduce the radiation exposure to a significant measure (Ardran & Kemp, 1957), scattered radiation occurs nonetheless in females but the ovaries can be shielded somewhat from direct exposure, while allowing the rest of the surrounding structures to be accessible to the x-rays (Abram et. al, 1958). Fawcett and Barter (2009), demonstrated that accurate placing of gonad shields in girls can be somewhat difficult, and thus a statistically significant difference can be observed in the accuracy rate with which the Gonad shield is used with boys and girls. The difference in positioning of shield can be attributed to the changed position of gonads in females. Female ovaries can be more adequately protected by changing the current technique of shielding, and by positioning the shield more laterally than in the midline (Bardo et. al, 2009). Technically the advantages of conducting a radiograph should outnumber the hazards that are associated with exposure to radiation, but the incorrect placement and repeated x-ray exams result in detrimental somatic or genetic effects (Sikand et. al, 2003). Kenny and Hill (1992), concluded that gonad shields fail to protect the gonads in 71% of radiographs, either resulting from their omission or inadequate placement; such avoidable exposure resulting from a greater number of radiographs being conducted, increases the probability of disease development in the future generation of the patient. Methodology The methodology employed to gather data on the hypothesis was empirical. A survey questionnaire was prepared for the purpose. After careful research the questionnaire for ‘Practice of shielding during Pelvic Radiography’ was created. The questionnaire was submitted and thus approved by IRB (Institutional Review Board). Any questionnaire that requires the evaluation of human subjects requires that it be verified by the IRB. The sample that was chosen for the research was (number) radiologists. The radiologists are currently practicing and thus aware of the current practices of gonad shield and radiation exposure. The sample had no restriction of age or other demographics. The number of male radiologists and female radiologists was also not preordained. The Questionnaire consists of three parts, a cover letter and a consent form. The surveys were given to ‘Radiologic Technologists’, who are practicing radiologists at the (name of hospital). The radiologic technologists were not informed of the identities of the researchers, and thus remained anonymous. The survey questionnaires were handed over to the department supervisors in each department of the hospital, who further distributed them to the ‘Radio Technologists’. The survey questionnaire started with the cover letter, which introduced the radiologists to the survey and what was required of them. The cover letter elaborated on how they were required to fill out the survey. The cover letter related directions on completing the survey and how much time the survey was likely to consume; which was about 5 minutes. The cover letter also encouraged the radiologist to complete and return the survey as soon as it was completed, as each radiologist’s opinion counts. The radiologists were asked to sign a consent form before filling in the information regarding the practice of shielding during pelvic radiography. The consent form conveyed the purpose of the study to the radiologists and why their opinion mattered in the subject. The consent form clearly states that the radiologists’ participation in this study is voluntary. The identities of the radiologists will be kept confidential and no responses will be related to them in any way. Also, the consent form ensures the survey takers that the research was being conducted by students and was for strictly academic purposes. The consent form also informs the radiologists that they are not forced to answer the questions that they do not want to and at any time can quit answering the questionnaire if they are not willing to carry on further. The consent form also ascertains that the minimum age limit for taking the survey is 18 years and that by taking the survey the radiologist is consenting to this. The consent form elaborates on the role of IRB and informs the survey taker that the research has been exempted by IRB. Finally, the consent form provides the contact number for contacting IRB administrator, in case if the survey taker has any doubts about his rights as a research participant and can contact them for further information. The survey consists of three parts. The first part of the survey concentrates on the practice of shielding during pelvic radiography and has five questions. The questions are based on the practice of gonadal shields during pelvic x-ray or exam. Every question offers 3 or 4 point answering scale to the radiologist. They were required to answer the question as yes, no or other. The survey questions are aptly designed and structured to measure the radiologist’s opinions regarding the practice of gonad shielding. The questions 1 and 5 focus on the purported necessity of using a gonad shield. Question number 2 deals with the difficulty of gonad shielding for radiologists. Questions 3 and 4 focus on the loss of data due to use of gonad shield and the resulting repeated x-rays due to ill placement of the shield, respectively. The second part of the survey questionnaire focused on the demographics of the radiologist completing the survey. Obtaining demographic information allows for multi-dimensional analysis of the data gathered. This section consisted of three questions. The demographic section gathered information on the gender, educational level, and years of experience in practice of the radio technologist. The third part of the survey dealt with the comments of the radiologist. The comments area was added to gather additional data in the form of suggestions, recommendations or comments. Such open ended responses allow for detecting gaps in research and opens avenues for further research. The questionnaires were distributed among the sampled radiologists. Most of the questionnaires were returned within two days. The responses from the questionnaires were gathered and sorted into appropriate categories. The responses were yes, no and other. The responses for each question were recorded. References Abram, E., Wilkinson, D. M. & Hodson, C. J. (1958). Gonadal Protection from X Radiation for the Female [Electronic Version]. British Journal of Radiology, 31, 335-336. (http://bjr.birjournals.org/content/31/366/335.extract?ijkey=28045104fa8844e3aea31809956ee7dcc53bc017&keytype2=tf_ipsecsha) Ardran, G. M. & Kemp, F. H. (1957). Protection of the Male Gonads in Diagnostic Measures [Electronic Version]. British Journal of Radiology, 30, 280. (http://bjr.birjournals.org/content/30/353/280.extract?ijkey=7d0d2affc4aca74073fe0602bcef1f1bb0afa3cb&keytype2=tf_ipsecsha) Bardo, D. M. E., Black, M. Schenk, K. & Zaritzky, M F. (2009). Location of the ovaries in girls from newborn to 18 years of age: reconsidering ovarian shielding [Electronic Version]. Pediatric Radiology, 39/3, 253-259. (http://www.ncbi.nlm.nih.gov/pubmed/19130048) Fawcett, S. L., Gomez, A. C., Barter, S. J., Ditchfield, M. & Set, P. (2012). More harm than good? The anatomy of misguided shielding of the ovaries [Electronic Version]. The British Journal of Radiology, 85, 442-447. (http://bjr.birjournals.org/content/85/1016/e442.long) Fawcett, S. L. & Barter, S. J. (2009). The use of gonad shielding in paediatric hip and pelvis radio-graphs [Electronic Version]. The British Journal of Radiology, 82, 363-370. (http://bjr.birjournals.org/content/82/977/363.long) Frantzen, M. J., Robben, S., Postma, A, A., Zoetelief, J., Wildberger, J. E. & Kemerink. (2011). Gonad Shielding in Paediatric pelvic radiography: disadvantages prevail over benefit [Electronic Version]. Insights into Imaging, 3/1, 23-32. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503612/) Gul, A., Zafar, M. & Mafulli, N. (2005). Gonadal Shields in Pelvic Radiographs in Pediatric Patients [Electronic Version]. Bulletin of the Hospital for Joint Diseases, 63/1 & 2, 13-14. (http://www.ncbi.nlm.nih.gov/pubmed/16536211) Kenny, N. & Hill, J. (1992). Gonad Protection in Young Orthopedic Children [Electronic Version]. British Medical Journal, 304, 1411-1413. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1882157/) Sikand, M., Stinchcombe, S. & Livesley, P. J. (2003). Study on the use of Gonadal protection shields during paediatric pelvic X-rays [Electronic Version]. Annals of the Royal College of Surgeons of England, 85, 422-425. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964410/pdf/14629889.pdf) Wainwright, A. M. (2000). Shielding reproductive organs of orthopaedic patients during pelvic radiography [Electronic Version]. The Royal College of Surgeons of England, 82, 318-321. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503612/) Read More