Mammography Guide PDF

**Week 10- Mammography** [Breast anatomy ] [Introduction to breast imaging ] Mammography - Screening vs Diagnostic Mammography - "Having a Mammogram" - Psycho-social Elements & Patient Preparation - Routine Projections - Breast Tissue Density - Implants -...

**Week 10- Mammography** [Breast anatomy ] [Introduction to breast imaging ] Mammography - Screening vs Diagnostic Mammography - "Having a Mammogram" - Psycho-social Elements & Patient Preparation - Routine Projections - Breast Tissue Density - Implants - 3D Tomosynthesis [Screening vs diagnostic mammography ] **Screening** - Individuals who were born, present, or identify as women aged 50-74 years in Queensland (QLD) are eligible for a free screening mammogram and will receive reminder letters every two years. - Individuals aged 40-49 or those above 75 in QLD, who were born, present, or identify as women, are also eligible for a free screening mammogram but do not receive reminder letters. - The program aims to detect breast cancer at an early stage, before symptoms appear, to facilitate earlier treatment. **Diagnostic** - A mammogram offered to anyone (regardless of gender) who has symptoms or has had a previous diagnosis of breast cancer and requires follow-up. [Clinical indications for diagnostic mammograms ] - Palpable lumps - Breast pain - Change in size/ shape - Recent change to nipple (e.g. inversion) - Change in appearance of skin (rash/ dimpling) [Having a mammogram] - Individuals aged 40 and above can have a mammogram, but those aged 50-74 will receive reminder letters encouraging them to undergo regular mammograms. - An ultrasound alone is not sufficient. A mammogram can detect early-stage changes, such as microcalcifications, that may not be visible on an ultrasound. These microcalcifications can be pre-cancerous. - In most imaging facilities in Australia, men typically do not perform mammograms for the comfort and respect of women. [Psycho-social elements of mammograms ] Approximately 70% of women in the target group participate in Breast Screen, leaving 30% who do not attend. - There are lower participation rates in minority and low socio-economic groups, which may be due to factors such as unfamiliarity with the Australian healthcare system, poor health literacy, and financial concerns that deter people from seeking healthcare due to fear of costs. 1. **Fear of Radiation**\ *How can we address this concern?* - If screening is performed regularly and early, the risk of developing cancer is reduced, as cancers can be detected in pre-cancerous stages. - Without the minimal dose of radiation from screening, a cancer could progress to more serious stages, requiring treatments like chemotherapy and additional examinations, which involve more radiation and could lead to worse outcomes, including death. 2. **Fear of Results**\ *How can we reduce the anxiety of receiving a 'bad result'?* - Radiographers can help by being empathetic and communicating clearly. Instead of delivering the news bluntly, they can emphasize the importance of early detection and highlight that undergoing the screening now is a proactive step toward a healthier future. 3. **Fear of Painful Compression**\ *How can radiographers reduce the discomfort of the examination?* - Radiographers should explain the reasons for compression. Proper compression ensures a more accurate image and helps avoid the need for repeat examinations, which can reduce overall discomfort and improve the chances of detecting any potential threats early. [Patient preparation ] **Avoid wearing talc or deodorant** - Talc is a crushed mineral that contains calcium silicate, and most deodorants contain aluminum. - These products can show up on X-ray images as small white spots or calcifications, which are artifacts that can mimic the signs of breast cancer or abnormalities, potentially leading to a false-positive result. **Wear a two-piece outfit** - This ensures patient comfort, as only the top half of the body will need to be uncovered during the procedure. **For women -- attend around day 10 of your menstrual cycle** - This is when breasts are typically less tender, making the examination more comfortable. [Reason for compression of the breast ] **Effective immobilization** - Ensures the breast remains still during the imaging, leading to clearer images. **Decreased geometric unsharpness** - More breast tissue is brought closer to the image receptor (IR), resulting in sharper images. **Increased contrast** - Compression reduces tissue thickness, which in turn decreases scatter radiation and improves image contrast. **Effective separation of superimposed structures** - Compression helps separate overlapping tissues, making it easier to see any abnormalities. **Reduced radiation dose** - By reducing tissue thickness, less radiation is required to capture clear images with less scatter radiation. **Improved uniformity of image density** - Compression ensures that the breast tissue is of uniform thickness across the image, resulting in more consistent image density. **Research findings** - \"Research has shown that under-compression decreases specificity, while over-compression decreases sensitivity\" in lesion visibility (Serwan et al., 2021). [Projections ] - Cranio-Caudad (CC)- - Medio-Lateral Oblique (MLO) Other views are performed but will not be covered here -- - Lateral - Extended CC - Magnification views - Spot compression views - And more... [Cranio-caudal (CC)] - Unit in vertical position - Patient faces the mammography unit - Arms by side, shoulders relaxed - Lift breast to extend inframammary fold - Adjust mammography unit such that the IR is level with the inferior border of the breast - Lift and pull breast tissue forward onto the IR - Keep breast still and extended while applying compression - Compression of between 10-15 N - Select AEC chamber, kV, target and filter [Medio-lateral oblique (MLO)]  - Angle of unit altered to match the angle of the upper part of the pectoral muscle (45-60 degrees) - Height of unit is altered such that the superior border of the IR is level with the axilla - Patient leans over IR such that the corner of IR is tucked into axilla - Breast is extended forwards to separate the tissue - Compression applied - Upper abdominal skin pulled down to reveal the infra-mammary fold - Compression of between 10-15 N - Select AEC chamber, kV, target and filter [Breast tissue density ] 0%= fatty breast that doesn't have much glandular tissue so easiest to see lesions 50% plus= dense breast tissue that has low levels of contrast so lesions will look very similar to the natural dense breast tissue [AEC chambers ]  [The operator typically has two or three options for AEC settings: ] **Fully automatic AEC mode:**\ This mode automatically selects the optimal kV, filtration, and in some systems, the target material, based on a short test exposure (approximately 100 ms) to assess the penetrability of the breast. This is the most commonly used setting for patient imaging. **Automatic kV selection with user-selected target and filter values:**\ The system performs a short test exposure to determine the appropriate kV, while the operator manually selects the target and filter settings. **Automatic exposure time with manually set target, filter, and kV values:**\ In this mode, the operator sets the target, filter, and kV values manually, while the system automatically adjusts the exposure time. **Modern AEC systems with "auto" selection:**\ The \"auto\" mode evaluates the entire exposed area of the detector and measures the signal in the most attenuating region of the breast to ensure adequate exposure before terminating the exposure. However, in cases such as imaging breast implants, the \"auto\" setting should be avoided, except for implant-displaced views. [Routine projections ] A close-up of a breast scan Description automatically generated [Breast implants and mammography] - Breast implants make the image kind of look under-exposed  [Breast implants "pushed back" (displaced)] - This is an image of the breast, excluding the patients implants from the view - Getting a little bit of implant still in the image/ on the detector, might effect the exposure given when using AEC 3D mammography (tomosynthesis) - The tube moves around the patient to get a more 3D image of this 3D object. - Shows a degree of separation between structures- good differentiation between what is normal tissue and what is not - Longer scan - Gold standard is still 2D at this stage in research  **Mammography- Image evaluation and pathologies** - Image evaluation - Pathologies [Image evaluation ] - Symmetry is important when evaluating the quality of mammography images. - The PGMI method is used in Queensland. There may be other similar methods used in other states and territories - P -- Perfect - G -- Good - M -- Moderate - I -- Inadequate  [Check the amount of tissue imaged] - PNL= posterior nipple line (line drawn from nipple anteriorly to pectoral muscle posteriorly) - Length of PNL must be within 1cm difference in CC and MLO projections to ensure full coverage of breast tissue - Want to see roughly 6cm in the CC and MLO view, if there's 5cm (off by 1cm from length of PNL in MLO) in CC for example, that is still acceptable - Demonstrate pectoral muscle posteriorly [Cranio-caudad (CC)- evaluation criteria ] - Nipple in profile and in midline - PNL length (measure the length and compare it to the MLO, should be the same or within 1cm of the MLO PNL to be diagnostically sufficient) - Visualisation for retro-mammary fat (the fat this is behind the mammary- different from the glandular tissue) - Slight medial skin reflection demonstrating the inclusion of poster-medial tissue (very far back tissue on the medial side) - Pectoral muscle seen on some CC projections (can be difficult to demonstrate) - No skin folds (causing artefacts) [Mediolateral oblique (MLO)- evaluation criteria ] - Nipple in profile - PNL length (within 1cm of the same length as the CC view to know we have enough tissue) - Inferior aspect of pectoral muscle extends at least to and preferably beyond the PNL - Open infra-mammary fold (IMF) (below the breast fold) - Well-separated glandular tissue - Visualisation of retro-mammary fat - No skin folds  [Skin fold ] - Large skin fold from the axilla and involving the breast tissue - We want really smooth skin around the breast so that these folds aren't creating artefacts [Pathologies ] Check for when looking at a mammogram- - Masses/ densities - Calcifications - Skin thickening - Architectural distortion Common pathologies of the breast are- - Breast cysts - Fibroadenomas - Malignancies NB- approximately 10% of palpable carcinomas in pre-menopausal women are not diagnosable on mammography [Masses/ densities- benign or malignant ] +-----------------------------------+-----------------------------------+ | Probably benign | Probably malignant | +===================================+===================================+ | - Smooth borders | - Spiculated (little arms | | | coming out of it" | | - Capsule around mass | | | | - "comet tail" | | - "halo" sign | | | | - Greater density than | | | surrounding tissue | | | (radio-opaque) | | | | | | - But- can also be smooth and | | | be iso-dense with the | | | surrounding tissue | +-----------------------------------+-----------------------------------+  [Calcifications ] +-----------------------------------+-----------------------------------+ | Probably benign | Probably malignant | +===================================+===================================+ | - Arterial calcifications | - Micro-calcifications | | within the vascular walls -- | | | tramline and tortuous | - Mixture of size and shape | | | | | - "Popcorn" appearance | - Associated soft tissue | | | opacity | | - Linear, thick, rod-like | | | | - Deterioration on serial | | - Fat necrosis: "eggshell" or | mammography (deterioration of | | oil cyst | the calcifications on | | | previous mammographs) | | - Large individual | | | calcification (one large | | | calcification in one area for | | | example) | | | | | | - Symmetrical distribution | | +-----------------------------------+-----------------------------------+ Benign popcorn calcification  [Skin thickening ] - Symmetric thickening of the breast tissue- this is not always abnormal and can sometimes suggest a benign process. - BUT always be suspicious of malignancy- When skin thickening is asymmetric or associated with other findings like a mass or distortion, it raises significant concern for malignancy, particularly for conditions like inflammatory breast cancer. - Be aware that the perception of skin thickening can be misleading, and may simply be normal anatomy- such as scarring, post-surgical changes, or lymphedema. Careful assessment and comparison with prior images are crucial to avoid over-diagnosis.  [Nipple retraction ] - Always suspicious of malignancy- New-onset nipple inversion if it wasn't previously present, is concerning and could indicate a tumour present as they can pull on the ducts and surrounding tissues. - Some peoples nipples are naturally inverted and therefore this can be a normal anatomical appearance- if it was always inverted. [Architectural distortion ] - The ductal structures, while not individually evident on mammography, present a pattern of subtle radial line that converge towards the nipple. - Architectural distortion is the interruption or disruption of this normal tissue pattern. They could be pulled, twisted or altered in some way. - A strong indicator of malignancy as it could be an underlying tumour pulling on surrounding tissue. Although can be present in benign processes such as surgical changes and resolving haematoma  [Simple cyst] - Typically benign, appear round/oval in shape, well-defined margins and thin walls containing clear fluid. - Most common breast lesions. - May come and go with hormonal fluctuations or changes during the menstrual cycle. - May be associated with fibrocystic disease or hormonal factors. - Can also be complex cysts that might require further evaluation due to internal debris etc. - Don't typically require treatment but can be drained if too large and painful, to relieve discomfort. [Fibroadenoma ] - Typically have thin walls and are well-defined, smooth borders- similar to cysts. - They are wider then they are tall in structure and come in varying sizes - They are benign lesions composed of both fibrous and glandular tissue- common in younger women - Over time they may calcify, particularly as they age- leading to characteristic appearances on mammograms [Ductal carcinoma in situ (DCIS) ] - DCIS involves the presence of abnormal cells confined within the milk ducts of the breast. - Considered the earliest and non-invasive form of breast cancer- hasn't spread beyond the milk ducks as of yet. - If left untreated, has the potential to become invasive breast cancer - Treatment involves lumpectomy most commonly or sometimes mastectomy. Chemotherapy not usually required at early stages. Exam style questions on Breast Pathologies: **Skin Thickening** 1. **False**: Symmetric skin thickening is not always abnormal. It can sometimes suggest a benign process, such as scarring or lymphedema. 2. **Benign processes** that can cause skin thickening include: - Post-surgical changes or scarring - Lymphedema 3. Asymmetric skin thickening is concerning because it raises suspicion for **malignancy**, particularly for conditions like **inflammatory breast cancer**. **Nipple Retraction** 4. **C) Malignancy**: New-onset nipple retraction is commonly associated with malignancy, especially due to tumors pulling on surrounding ducts and tissues. 5. To differentiate between malignant nipple retraction and a naturally inverted nipple, check the patient's history. If the nipple was previously normal and suddenly became retracted, it suggests **malignancy**. However, if the nipple has always been inverted, it is likely a **normal anatomical variant**. **Architectural Distortion** 6. Architectural distortion indicates an **interruption of the normal tissue pattern**, where the tissue appears pulled or twisted. It is a strong sign of malignancy because an underlying **tumor** can pull on the surrounding tissue. 7. Architectural distortion could also be a benign finding and may be present due to **surgical changes** or **resolving hematoma**. **Simple Cyst** 8. A simple cyst typically appears **round or oval**, with **well-defined margins** and **thin walls** containing clear fluid. It is considered benign because it usually fluctuates with hormonal changes and does not exhibit malignant characteristics. 9. A simple cyst may require further evaluation if it has **complex features** (e.g., internal debris), or treatment (e.g., drainage) if it becomes **too large or painful**. **Fibroadenoma** 10. A fibroadenoma typically appears with **thin walls**, **well-defined, smooth borders**, and is usually **wider than it is tall**. It is classified as benign because it is composed of **fibrous and glandular tissue** and is common in younger women. 11. Over time, fibroadenomas may **calcify**, which can alter their appearance on mammograms and lead to **characteristic calcified patterns**. **Ductal Carcinoma in Situ (DCIS)** 12. **False**: DCIS is considered a **non-invasive** form of breast cancer because it remains confined within the milk ducts and has not yet spread to surrounding tissue. 13. The most common treatment for DCIS is a **lumpectomy**, sometimes combined with radiation therapy. **Chemotherapy is usually not required** because DCIS has not spread beyond the milk ducts, making it an early-stage, non-invasive cancer **An introduction to AI in mammography quality assurance** History of mammography QA - Each year mammographers need to be achieving 50% P (perfect) and G (good) images, within 50 random sets of images. - This is a subjective assessment- compression was evaluated by visual assessment of an examination Modern AI tech assessment/ analysis - It provides objective positioning and compression evaluation and analysis for CC and MLO mammograms Volpara Health- Creator of this AI software - Used to evaluate quality control measures in mammography - Two criteria of which is: - **Positioning evaluation**- using a slight variation of the Australian PGMI criteria - **Compression evaluation** - These two quality factors are evaluated to ensure the best quality image is obtained in mammography imaging (particularly breast screening) - Its critical to maintain a high standard of imaging in screening mammography to identify small changes in the breast, not detected by the touch, healthy women that want to find anything potentially threatening at very early stages of its development  Positioning Evaluation - Australia uses the "PGMI" criteria (standing for perfect, good, moderate and inaccurate), adapted from the PGMI standard UK criteria - The Volpara software uses a slight variation of the Australia PGMI criteria, using all the PGMI with the addition of the "Pectoral Muscle Shape". Compression Evaluation - Compression evaluation was always difficult to assess prior to AI -- was too subjective using qualitative data - The recommended amount of pressure compression for mammography imaging is 10kPa, with Volpara accepting a range of 7-15kPa - Research has shown that under-compression [decreases specificity] while over-compression [decreases sensitivity.] PGMI Criteria (Australia)  AI positioning and Compression data - The AI software evaluates mammography images based on the adapted PGMI (Perfect, Good, Moderate, Inadequate) criteria. The criteria above \^ giving a score of "perfect, good, moderate or inadequate, based on if the criteria has been met or not. - AI evaluates compression by calculating the pressure using the formula P=F/A - P=Pressure (Pa) - F=Force (N) - A=Area (m2) - This calculation ensures that the compression falls within the acceptable range of 7-15 kPa. - The AI then analyzes positioning metrics (such as nipple in profile, PNL met and no cut off or skin fold etc) and compression data (within range of 7-15kPa), providing feedback on how well the mammographer meets specific metrics. Role of the radiographer: - Radiographers may not need to **manually** complete the PGMI criteria themselves if the AI is fully responsible for image evaluation. - Instead, they can review the AI\'s feedback and ensure the **compression**, **positioning**, and **image quality** meet the standards. If the AI flags any issues, radiographers can make adjustments or corrections during future image acquisition. Enables: - This data can be tracked over time, showing trends such as improvements in positioning or more appropriate use of compression after training. - The information can also be compared with data from mammography centres worldwide, demonstrating adherence to evidence-based practices and maintaining high standards. Benefits: - Objective evaluation - Time efficient - Timely feedback to the mammographer and chief mammographer - Benefits to the patient (i.e. improve patient positioning with ongoing training and using appropriate compression pressure, improving the patient experience) Limitations: - The algorithm does not have the ability to evaluate implants - MLO pectoral shape not recognised as a criterion in Australia - Reject/ repeat analysis could be further explored using this software - Some radiographers may not agree with evaluations (e.g. appears to have skin fold but volpara recognises the image as perfect) How this AI technology could be used to meet accreditation standards - Assessing training needs within a team - Performance reviews - The software can create a selection of 50 images, evaluate, analyse and create a report, ready for accreditation in a timely manner - Provide user and department global benchmarking, evidence of demonstrating best practice - Provide population insights such as breast density distribution by age **Week 11- Introduction to mobile and theatre radiography** **Introduction to mobile imaging** - Mobile Equipment - Why do mobile imaging? - Infection control - Standard precautions - Preparation - Limitations & considerations - Radiation safety - Imaging/Techniques Mobile equipment - Digital vs. - Cassette to process the image in the department after Why do mobile imaging - Patient too unwell to leave ward and require constant observation/ care - Intensive Care Unit (ICU) Common examinations -- CXR, AXR - Neonatal Intensive Care Unit (NICU) - High Dependency Unit (HDU) - Cardiac Care Unit (CCU) - Emergency Department (ED) Common examinations -- C-spine, CXR, Pelvis Infection control - Standard precautions - Airborne precautions -- e.g. Meningitis, Tuberculosis (TB), Severe Acute Respiratory Syndrome (SARS) - Droplet precautions -- e.g. Influenza, whooping cough - Contact precautions -- e.g. Methicillin-resistant Staphylococcus Aureus (MRSA), Vancomycin- resistant Enterococci (VRE), Clostridium difficile (C diff) - Neutropenia -- depressed immune systems e.g. chemotherapy Standard precautions - For every patient and every examination always follow standard precautions - Hand hygiene -- perform before and after every patient contact - PPE -- use when at risk of body fluid exposure i.e. patients with special precautions - Cleaning/disinfection -- routine cleaning of mobile equipment & IRs (cover with plastic cover or pillow slip) Mobile imaging preparation - Ensure you have adequate information from the phone call- ask at what time you're required, what body part you're imaging/if you need a grid and remember to bring the key from the department to use the mobile unit - Take appropriate IRs/Grids/ Mobile unit - Don't forget the key! - Move in a timely fashion - On arrival at dept, introduce yourself and ask for the referral- from there you can talk to the patient etc. Mobile imaging limitations/ challenges - Basic inconvenience of leaving the dept and using a heavy mobile unit and (CR cassettes)- can be inconvenient but best for the patient - No secure, definite, protected radiation zone- just make sure everyone's behind you at which you should be at 2m - Working around patients that cannot necessarily assist you in positioning themselves - Poorer quality of imaging without the use of buckys- but great in getting an idea of the patients current condition - In some instances, delays in processing image (with no DR) by taking CR cassettes back to dept for processing Mobile imaging considerations - Are there any infection control issues?- need to ensure you have PPE on if precautions are stated - Cleanliness of the equipment & hand hygiene - Communication with staff and patient and visitors- even before we see the patient, ask what is going on and any background about the patient you should know of. - Can the patient position be modified?- eg. Supine in a neck brace= cannot be modified or moved much. - Are you going to require any assistance? - Consider respirators, oxygen tubing, monitors, drips etc.- always ask nurse first before moving ANYTHING, to ensure you aren't pulling out or moving anything that might effect the patient negatively - Position of mobile unit and angle of tube required - Position the IR- to include all relevant anatomy - Radiation safety- Two meters from the tube - Leaving the area Radiation safety - Different environment compared to the Medical Imaging Department - Communication &/or signage- let everyone know that an Xray is going to be taken - Shielding- lead, behind a wall, 2m distance etc. - Self- lead protection - Staff- lead protection or to vacate - Patient- position where you can see the patient and they can hear you, any necessary lead over other anatomy - Carers- if you can vacate they should, in cases of children they should wear lead to stay with them Adult mobile CXR technique - Erect, semi-erect or supine? - How are you positioning the IR beneath the patient? - Where should the mobile unit be positioned? - How can you get the correct SID? - What angle should we put on the tube- caudal to the sternum, angles going to change depending on how erect or supine they are - Arm position- arms by side so no overlap over relevant anatomy - Leads, infusion lines etc. -- ask nurse to remove lines (don't do it yourself without asking because you might not be able to) - Grid use- depends on the unit type and body part - Exposure- optimise to patient condition - Communication with patient and staff- everyone should be aware of what's occurring and being vocal when exposure is occurring When a grid should be used - If you already know for example that the patent has fluid-filled lungs or opacities that will require extra penetration and therefore scatter to be cleaned up- a grid should be used Better to use a grid and increase the kV for this image **Introduction to theatre imaging** - Theatre preparation - Theatre imaging considerations - Radiographer's role - Asepsis - Sterile technique - Image Intensifier (also called the II) - Radiation safety - Surgical procedures In theatre preparation allow enough time to- - Walk to theatres -- it may be quite a distance - Change into theatre scrubs - Theatre shoe covers - Cap to cover all of hair - Remove wrist watches etc (bare below elbow) - Ensure II is clean & ready prior to being brought into the theatre room - Wear lead apron (thyroid cover and long apron to knees) - Hand hygiene - Mask - Get II & monitors positioned in theatre and switched on - Enter patient details prior to image Theatre imaging considerations - Patient identification + no pregnancy + correct side (patient generally under anaesthetic) -\> confirm with theatre staff - Get referral (or use a patient sticker from patient notes)- write some clinical history - Enter patient details into II system - Position of the II and monitor- ask surgeon what they prefer - Sterile field! and other obstacles- anything draped is sterile so don't touch - Theatre staff -- surgeons, anaesthetist, scrub nurse, scout nurse - Radiation safety- rooms aren't lead lined but large rooms that wont allow radiation through to outside area. Also radiation illuminated sign on when xray machines in use. - Log the dose in the II log book & send images, before switching off II - On leaving the theatre, don't forget to take the signed request form Radiographers role - [Asepsis] - just assume it's sterile unless told otherwise to be safe- don't want the unsterile II to touch the sterile equipment - Make sure you know where every part of the II is positioned- don't want to run into the table or knock anything over - Equipment -- - Capabilities/manoeuvrability - Image Quality - Radiation safety - for all persons present - Technique/anatomy - know it, and know the correct terminology [Asepsis ] - Clean technique (medical asepsis) - Reduce the probability of an infectious agent being transmitted to a susceptible host - Standard precautions - hand washing, proper cleaning - Sterile technique [(surgical asepsis)] - Equipment is treated with gas, heat or chemicals to remove pathogens at CSSD/TSSD -- (Central/Theatre Sterile Supplies Department) - Complete removal of all micro- organisms - Sterile fields - Eg. When the patient is covered in a surgical iodine ready for operation and everything else is covered in blue covers etc. [Surgical Asepsis/ sterile technique ] - Don't touch anything! - Green/blue draped areas - Surgical scrub personnel - Sterile field -- sheets, trollies & C-arm cover - Do not turn your back to the sterile field when walking close to sterile drapes - Be aware of the type of procedure and where you will need to bring in the equipment. Ask if you're not sure. Image intensifier (II) C-arm capabilities The movements that a C-arm can make Radiation safety - Shielding - Lead protection - TLD badges - Distance - Type of fluoroscopy (quality vs dose) - Single shot - Screening - Pulsed screening - Low dose - Minimise radiation - Collimation - Watch for surgeons hands in FOV - Watch the surgeons eyes - Save images - Orientation of the C-arm- to minimise dose and increase image quality, you want intensifier on top as much as possible and tube underneath. This is because the top of the patient has lots of covering vs no protection coming from underneath Radiation safety- C-arm orientation  Endoscopic procedures - Ureteroscopy - Endoscopic Retrograde, Cholangio Pancreatogram (ERCP) - Endoscopy/colonoscopy - Medical or surgical aseptic technique - Medical aseptic technique- II isn't covered and not too many blue sheets and doctor just has lead on Manipulation under anaesthetic (mUA) - MUA -- dislocated joints, displaced \#s - Medical or surgical aseptic technique? - Surgical aseptic Surgical aseptic (sterile) procedures - Open reduction internal fixation (ORIF) - Tibial nail - Dynamic hip screw (DHS) - Operative cholangiogram (Op Chole) - Laparoscopic cholecystectomy (Lap Chole= keyhole) - Spinal fusion **Week 12- Introduction to Dental radiography and Bone densitometry** **Dental anatomy** [Surfaces of the teeth ] [Dental notation]  [Orthopantomogram radiographic anatomy ] [Lateral cephalometry ]  Lateral cephalometry radiographic anatomy TMJ (OPJ) radiographic anatomy  Lateral oblique TMJ (closed vs open) radiographic anatomy Closed Open  **Dental Imaging** - Clinical Presentations - Occlusal Imaging - Intra-oral Imaging - Frankfort Plane - Lateral Cephalogram - Temporomandibular Joints - Laser Lights - Orthopantomogram (OPG) - Pathologies [Clinical presentations ] - Caries - Impacted teeth - Un-erupted teeth - Supernumerary teeth - Alignment - Trauma - Treatment planning and evaluation - Forensic identification and ageing [Patient preparation ] Ask for your patient to remove: - All jewellery from head/ neck area, including tongue rings - Dentures/ plates - Hair away from the neck, including hair accessories - Clothing from neck area, check for buttons - Offer assistance - Ensure your patient takes their belongings [Occlusal images -- special dental xray machine for these] [Intra-oral imaging ]  [Frankfort Plane] - The line from the infra-orbital (IOML) margin to superior border of the EAM [Lateral cephalogram- clinical presentations ] - Evaluation of facial growth and development - Trauma - Developmental abnormalities - Often used for planning and evaluation of orthodontic treatment [Lateral cephalogram- positioning ] - Performed on an OPG machine - Patient stands with shoulder close to IR, feet shoulder-width apart - Mid-sagittal plane parallel to IR - Frankfort plane parallel to floor (IOML straight) - Clean positioning guides placed within EAMs, and against nasion at front - Patient clenches top and bottom molar teeth together irrespective of where this places the anterior teeth, with lips lightly closed - Filter may be placed to ensure soft tissue detail of face and provides some shielding (look at xray above \^ the front of the face is shielded to show facial soft tissue) [Temporomandibular joints ] - TMJ imaging will likely be done if the patient is struggling to open and close the jaw - Achieved through OPG as well, but might use a different bite block/method depending on the manufacturer - On first rotation the patient should be instructed to keep their jaw closed and bite down on back molars - On the second rotation the patient should be instructed to open their mouth as wide as they can which brings the joints forward and away from the fossa  [Three laser lights ] 1. Mid sagittal light - A vertical light that should pass through the midline of the face. Used to ensure the patient is centred correctly and that there is no tilt of the head. 2. Frankfort plane light - A horizontal light that should pass through the Frankfort plane. Used to ensure correct the axial orientation of the head. 3. Focal trough light - A vertical light that should pass through the canine teeth of the patient. Used to ensure that the patient's teeth fall within the focal trough.  [Orthopantomogram (OPG) positioning ] - Assist patient with placing lead gown on (no thyroid collar) - Wipe over machine, apply bite block cover - Explanation required! - Patient stands facing into the unit - Raise/lower chin rest to \~level of patient's chin - Both hands holding the handles - Walk feet forward so that patient leans back slightly - Neck as upright as possible, but with shoulders relaxed - With chin on chin rest, gently bite on the grooves in the bite-block (demonstrate the bite-block earlier) - Upper and lower incisors must both be in groove, where possible - Adjust the height of the unit so that the Frankfort plane is parallel to the floor - Ensure that the mid-sagittal plane is perpendicular to the floor - Ensure focal-trough laser light centres over canine teeth - Move head-supports into place to maintain position - Ask patient to push their tongue to the roof of their mouth and hold it there for the duration of the exposure - Watch position of lead gown... [OPG evaluation criteria ] Need to demonstrate -- - Symmetry of mandible without rotation or tilt (mandibular rami and body equal on both sides, joints at equal height and no distortion of the anatomy) - Slight downward tilt of the occlusal plane (slight smile) (appropriate positioning of Frankfurt plane to achieve this) - Upper and lower teeth positioned slightly apart (bite block allows this) - Spine and ghost images minimal - Tongue held to roof of mouth to minimise air gap across top teeth (helps to visualise roots of maxillary teeth better) [Pathology] Mandibular cyst  Impaction (wisdom teeth coming through in the wrong direction, impacting other teeth) Over-retained deciduous teeth  **OPG image creation and image appearances and causes** Objectives - How an OPG is created - Common appearances and causes [OPG image formation ] - Slight cephalic angle of tube up towards the IR at a set SID- rotating at same time - Chin rest and temple supports - Assuming centre of rotation is at patients MSP and centre of the mouth - IR moves in an arch around the front of the teeth, tube moves posteriorly to match this - Uses tomography to blur out everything else outside of the focal trough - Once a full rotation across the mouth has been completed, each little image is pieced together to get the final image  [Focal trough ] - Determines the region of anatomy that will be in focus - In the focal trough -- in focus - The further from the focal trough -- progressively more out of focus - Radiographer selects the shape and size from the control panel- these shapes are typically what patients anatomy will match to - Radiographer ensures the anatomy is in the focal trough by correctly aligning the patient to the focal trough laser light [Common appearances and causes ] - Blurry front teeth - Overlapping teeth - Lucency through the roots of the maxillary teeth - Teeth length errors - Smile/ frown shape - Missing TMJs - Lack of symmetry - Ghosting [Focal trough positioning error ] Caused by: - Teeth outside the focal trough - Teeth anterior or posterior to the focal trough Appearance: - Blurry front teeth with poor visualisation of the root canals in the front teeth - Incisor size distortion - Teeth anterior to the focal trough (bite down over the top of the trough)- decreased OID- narrower - Teeth posterior to the focal trough (bite not far enough over the focal trough)- increased OID- wider Appearance when focal trough too anterior:  Appearance when focal trough too posterior: [Teeth overlap ] Caused by: - Missing bit block - Missing central incisors Appearance: - No separation between the upper and lower teeth (overlap makes it hard to visualise pathology) Appearance of teeth overlap  [Tongue too low ] Caused by: - Tongue not applied to roof of the mouth Appearance: - Horizontal radiolucent band through the roots of the maxillary teeth Appearance of tongue too low  [Frankfort plane errors ] Caused by: - Chin being tilted too high (first image) - Chin being depressed too low (second image) Appearance: - Shape distortion - Chin too high- foreshortening of the upper incisors, jaw frowning and TMJs too lateral (can disappear off image) - Chin too low- foreshortening of the lower incisors, jaw too smiley and TMJs too superior (can be cut off image) Chin down= smiley Chin up= frown red= size if chins down  Blue= size if chins up Appearance of chin up too high  Missing parts of TMJ laterally Appearance of chin down too low Missing TMJs superiorly [Rotation ] Caused by: - Patient looking to their right - Patient looking to their left Appearance: - Destruction in symmetry - Size and shape distortion - Looking to the right: - Right side of mandible further from IR- magnification - Right side of mandible more OID difference- elongated - Left side of mandible less OID difference- foreshortened - Looking to the left: - Left side of manible further from IR- magnification - Left side of mandible more oID difference- elongated - Right side of manible more oID difference- foreshortened Appearance of rotation (patient rotated to their right)  [Ghosting ] Could be: - Anatomy - Jewellery or other objects Caused by: - Object between the source and centre of rotation Relative to the "real" structure appear: - Higher on the image - Magnified - On the opposite side of the image - Out of focus/ blurry Appearance of ghosting  The left earring has appeared as a ghost image on the right side of the image and vice versa. The sides of the angle of the mandible have become ghost images on the opposite sides of the image. Theres also been ghosting of the patients spine through the midline Combination  - The incisors are not in the focal trough- sitting anteriorly in the focal trough- appear narrow - There's more of a smiley face appearance and TMJs are very superior- which means the patient's head is tilted downwards - The patient is slightly rotated to their left because there's magnification of the left bottom teeth and mandible size on the left **Bone mineral densitometry (BMD)** Content: - What is BMD? - What is Osteoporosis? - Risk factors for Osteoporosis - Clinical Indications for BMD - Dual Energy X-Ray Absorptiometry (DEXA) - Patient Preparation for DEXA - DEXA Examination - DEXA Analysis - DEXA Interpretation [What is BMD ] - BMD is a technique used to measure the density of the bone in a given area of the body - BMD measures the presence and severity of osteoporosis - The fracture risk assessment tool (FRAX), predicts the risk of sustaining a fracture [Osteoporosis ] - Osteoporosis is a disease in which the bones become extremely brittle which makes them more susceptible to fractures - The World Health Organisation (WHO) defines osteoporosis based on bone mass measurement: - Normal- BMD (T-score) of less than 1 standard deviation of the young adult reference mean (YARM) - Low bone mass (osteopenia): BMD (T-score) between 1.0 and -2.5 standard deviations below the YARM - Osteoporosis: BMD (T-score) more than -2.5 standard deviations below the YARM [Risk factors for osteoporosis ] - Family history of osteoporosis - Fractures caused by minimal trauma - Increasing age - Women - Caucasian or Asian - Small body frame (BMI \