CT scans increase the risk of cancer in children

Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians

 

Objective To assess the cancer risk in children and adolescents following exposure to low dose ionising radiation from diagnostic computed tomography (CT) scans.

Design Population based, cohort, data linkage study in Australia.

Cohort members 10.9 million people identified from Australian Medicare records, aged 0-19 years on 1 January 1985 or born between 1 January 1985 and 31 December 2005; all exposures to CT scans funded by Medicare during 1985-2005 were identified for this cohort. Cancers diagnosed in cohort members up to 31 December 2007 were obtained through linkage to national cancer records.

Main outcome Cancer incidence rates in individuals exposed to a CT scan more than one year before any cancer diagnosis, compared with cancer incidence rates in unexposed individuals.

Results 60 674 cancers were recorded, including 3150 in 680 211 people exposed to a CT scan at least one year before any cancer diagnosis. The mean duration of follow-up after exposure was 9.5 years. Overall cancer incidence was 24% greater for exposed than for unexposed people, after accounting for age, sex, and year of birth (incidence rate ratio (IRR) 1.24 (95% confidence interval 1.20 to 1.29); P<0.001). We saw a dose-response relation, and the IRR increased by 0.16 (0.13 to 0.19) for each additional CT scan. The IRR was greater after exposure at younger ages (P<0.001 for trend). At 1-4, 5-9, 10-14, and 15 or more years since first exposure, IRRs were 1.35 (1.25 to 1.45), 1.25 (1.17 to 1.34), 1.14 (1.06 to 1.22), and 1.24 (1.14 to 1.34), respectively. The IRR increased significantly for many types of solid cancer (digestive organs, melanoma, soft tissue, female genital, urinary tract, brain, and thyroid); leukaemia, myelodysplasia, and some other lymphoid cancers. There was an excess of 608 cancers in people exposed to CT scans (147 brain, 356 other solid, 48 leukaemia or myelodysplasia, and 57 other lymphoid). The absolute excess incidence rate for all cancers combined was 9.38 per 100 000 person years at risk, as of 31 December 2007. The average effective radiation dose per scan was estimated as 4.5 mSv.

Conclusions The increased incidence of cancer after CT scan exposure in this cohort was mostly due to irradiation. Because the cancer excess was still continuing at the end of follow-up, the eventual lifetime risk from CT scans cannot yet be determined. Radiation doses from contemporary CT scans are likely to be lower than those in 1985-2005, but some increase in cancer risk is still likely from current scans. Future CT scans should be limited to situations where there is a definite clinical indication, with every scan optimised to provide a diagnostic CT image at the lowest possible radiation dose.

 Mathews. J. D. et al. Cancer risk in 680.000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013 online 22. Mai; doi: 10.1136/bmj.f2360

Opinions regarding the managment of hand and wrist injuries in athletes

Abstract

Injuries to the hand and wrist are commonly encountered in athletes. Decisions regarding the most appropriate treatment, the timing of treatment, and return to play are made while balancing desires to resume athletic activities and sound orthopedic principles. Little recognition in the literature exists regarding the need for a different approach when treating these injuries in elite athletes and the timing to return to play.

This study explored the complexities of treating hand and wrist injuries in the elite athlete. Thirty-seven consultant hand surgeons for teams in the National Football League, National Basketball Association, and Major League Baseball completed a brief electronic survey about the management of 10 common hand injuries. Notable variability existed in responses for initial management, return to protected play, and return to unprotected play for all injuries, aside from near consensus agreement (94%) that elite athletes with stable proximal interphalangeal dislocations could immediately return to protected play. Basketball surgeons were less likely to recommend early return to protected play than non-basketball surgeons. Baseball surgeons were more likely to recommend early unprotected play after scaphoid fixation. Football surgeons were more likely to recommend earlier return to protected play after thumb ulnar collateral ligament injuries, whereas basketball surgeons were less likely to recommend earlier return to protected play.

This study demonstrated wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries. The findings emphasize the need to individually tailor treatment decisions to the patient’s desires and demands, particularly in high-performance athletes.

The authors are from the Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York.
The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Michelle Gerwin Carlson, MD, Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 E 72nd St, 4th Floor, New York, NY 10021 (carlsonm@hss.edu).

Injuries to the hand and wrist are commonly encountered in athletes.^1–3  After arriving at a diagnosis, the treating physician must address the many considerations that make treating an athlete different than caring for other patients. Decisions regarding the most appropriate treatment, the timing of treatment, and circumstances surrounding return to play are made while balancing desires to resume athletic activities and sound orthopedic principles.⁴  The same complexities that differentiate the treatment of athletes from nonathletes are what distinguish the management of injuries in elite athletes.⁵  High-performance athletes are likely to have a different perspective than casual athletes, placing greater importance on return to play given the implications on their livelihood. Given these differences, expectations for treatment outcomes in elite athletes are likely to be higher than those of casual athletes. Although the literature is replete with case series and expert opinions regarding the management of hand and wrist injuries in athletes, little recognition exists regarding the need for a different approach when treating injuries in elite athletes and timing to return to play.

To further explore the complexities of treating hand and wrist injuries in elite athletes, the authors conducted a survey of consultant hand surgeons for professional football, basketball, and baseball teams in the United States. Physicians were asked about their practice of timing of surgery and return to play (both protected and unprotected) for 10 common hand injuries. The authors hypothesized opinions would vary widely regarding the treatment of hand and wrist injuries in elite athletes, with notable differences based on experience with athletes from different sports.

Materials and Methods

To generate the study cohort, team physicians for every team in the National Football League, National Basketball Association, and Major League Baseball were contacted and asked for the contact information for their consultant hand surgeon. Those 78 hand surgeons were requested to complete a brief electronic survey with questions about the management of metacarpal shaft fractures, scaphoid fractures, pisiform fractures, hamate hook fractures, thumb ulnar collateral ligament injuries, and dislocations of the proximal interphalangeal joint. This survey included questions about indications for surgery, return to protected play, and return for unprotected play (Table  ). The survey items were derived from the senior author’s (M.G.C.) experience in treating professional athletes, including primary coverage of a National Basketball Association team. Invitations to complete the anonymous survey were distributed via e-mail using third-party software (SurveyMonkey, Palo Alto, California). One reminder to complete the survey was sent after the initial invitation. The research protocol was approved by the authors’ institutional review board prior to survey administration.
 

Table: Return to Play and Treatment Recommendations According to Hand and Wrist Injury

Crosstab calculations and chi-square analysis were performed using SPSS version 19.0 software (IBM, Armonk, New York). Responses were compared by sport treated by the surgeon (baseball vs no baseball; football vs no football; basketball vs no basketball), by the number of sports treated (1 sport or more than 1 sport), and number of professional athletes treated (more or less than 12 per year). An a priori sample size calculation was not performed because a convenience sample of a limited cohort was planned.

Results

Thirty-seven consultant hand surgeons completed the survey, all of whom were affiliated with at least 1 professional sports team. Respondents were asked which sport they were currently affiliated with and were allowed to list more than 1 sport. Fifteen respondents reported that they treated elite athletes in only 1 sport and 22 reported that they treated elite athletes from more than 1 sport. The most commonly treated sports were baseball (n=22) and football (n=22), followed by basketball (n=19) and hockey (n=12). Eighteen of the respondents treated more than 12 elite athletes in 1 year, whereas 19 treated less than 12 elite athletes in 1 year.

Metacarpal Fractures

Protected Play. Slightly more than half (n=21; 56.8%) of the 37 respondents allow elite athletes with nondisplaced metacarpal fractures to return to protected play at 3 to 4 weeks after injury, whereas 14 (37.8%) allow immediate return to protected play. Surgeons who treated basketball players were less likely to recommend early return to protected play than non-basketball surgeons (P=.047).
Unprotected Play. Most respondents (n=27; 73%) waited until 4 to 8 weeks after injury for unprotected play to resume.

Scaphoid Fractures

Protected Play. Slightly more than half of the 37 respondents (n=19; 51.4%) allow elite athletes to return to protected play 4 to 6 weeks after treatment of a nondisplaced a scaphoid fracture. Twelve surgeons (32.4%) allow elite athletes to return to protected play immediately.
Unprotected Play. Opinions regarding return to unprotected play were more variable: 9 (24.3%) allow return to unprotected play after 4 to 6 weeks, 18 (48.6%) after 6 to 12 weeks, and 10 (27%) wait more than 12 weeks. Surgeons who treated baseball players were more likely than non-baseball surgeons to recommend their patients to unprotected play earlier after treatment of a nondisplaced a scaphoid fracture (P=.005). Surgeons who treated athletes from more than 1 sport were also more aggressive in recommending earlier unprotected play after treatment of a non-displaced a scaphoid fracture (P=.042).

Pisiform Fractures

Treatment Decision. For elite athletes with pisiform fractures, 11 (29.7%) surgeons allow immediate return to play, 7 (18.9%) recommend immediate excision, 8 (21.6%) recommend splinting for 4 weeks followed by return to sport, 3 (8.1%) recommend excision after 4 weeks if not healed, and 8 (21.6%) recommend excision after 8 weeks if not healed.
Surgeons who treat more than 12 elite athletes in 1 year are more likely to recommend immediate treatment (either immediate return to play or immediate excision), whereas surgeons who treat less than 12 elite athletes in 1 year are more likely to explore delayed treatment options (P=.043).

Hamate Hook Fractures

Protected Play. Following excision of hamate hook fractures, 11 (30.6%) of 36 surgeons allow immediate return to protected play, 19 (52.8%) allow return to protected play after 2 weeks, and 6 (16.7%) of surgeons allow return to protected play in 6 weeks.
Unprotected Play. More than half of the 37 surgeons (n=20; 54.1%) allow return to unprotected play at 6 weeks, 15 (40.5%) allow return to unprotected play at 2 weeks, and 1 (2.7%) allows immediate return to unprotected play.

Thumb Ulnar Collateral Ligament Tears

Treatment Decision. For an elite athlete with a complete thumb ulnar collateral ligament tear, 14 (37.8%) of the 37 surgeons recommended immediate repair, 12 (32.4%) recommended repair at the end of the season (if within 6 weeks), 3 (8.1%) recommended repair at the end of the season (if within 3 months), 7 (18.9%) recommended repair at the end of the season (even if beyond 6 months from injury), and 1 (2.7%) surgeon recommended nonoperative treatment.
Protected Play. For return to protected play after thumb ulnar collateral ligament injury, 5 (13.9%) of 36 surgeons recommended immediate return, 20 (55.6%)recommended waiting 2 weeks, 10 (27.8%) recommended waiting 6 weeks, and 1 (2.8%) recommended waiting 3 months. Surgeons who treat football players are more likely to recommend earlier return to protected play than non-football surgeons (P=.023), whereas surgeons who treat basketball players are less likely to recommend earlier return to protected play than non-basketball surgeons (P=.021).
Unprotected Play. For return to unprotected play, most of the 36 surgeons (n=23; 63.9%) recommended waiting 3 months.

Stable Proximal Interphalangeal Joint Dislocation

Protected Play. Almost all 36 (n=34; 94.4%) surgeons recommended immediate return to protected play for elite athletes with stable proximal interphalangeal dislocations, whereas 2 (5.6%) surgeons recommended waiting 4 weeks.
Unprotected Play. More than one-quarter (n=11; 29.7%) of the 37 surgeons recommended returning to unprotected play after 4 weeks, 14 (37.8%) recommended waiting 4 to 8 weeks, and 3 (8.1%) surgeons recommended a period of more than 3 months before return to unprotected play.

Discussion

Increasing awareness of the influence of patient expectations on treatment outcomes⁶  indicates that surgeons need to be more cognizant of what patients desire and expect from treatment. This is particularly true when treating athletes who not only participate in sports for recreational or fitness pursuits but also rely on their athletic abilities for their livelihood. Recognition of elite athletes as a distinct patient population is important in allowing surgeons and patients to participate in shared decision making that balances the desires of immediate return to play with long-term sequelae.⁴  In the current study, the authors demonstrated wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries. The individual experiences of the respondents have shaped their approaches to management, as the current results indicate that those who care for athletes of different sports occasionally have significantly different thresholds for return to protected and unprotected play. Treatment is tailored to the demands of the individual athletes and their sports, as evidenced by instances of more conservative management among surgeons who treat basketball players, whose sport requires distinct dexterity with a short interval between games.
Although this survey provides a glimpse into the decision making of consultant hand surgeons, it is beyond the scope of this investigation to indicate whether these treatment recommendations predict outcomes, and this research needs to be done. Surgeons must carefully counsel patients about the risks and benefits of each nuanced aspect of treatment and, in situations where athletic performance has deep-seated career or financial implications, informed and shared decision making is critical to ensure satisfactory outcomes.
As the authors demonstrated, a major challenge in treating elite athletes is determining the appropriate time frame for return to play. The benefits of early return must be weighed against the consequences of potential complications. Although all patients with fractures who return to play too early may experience delayed healing or nonunion, the difficulty in treating these sequelae vary depending on the type of fracture. Metacarpal shaft nonunions or malunions can be readily treated with internal fixation and bone grafting (if needed), whereas pisiform nonunions can be treated with excision. However, premature return to play after scaphoid fracture can create unnecessarily challenging treatment scenarios because an acute fracture that is easily treatable may develop into a difficult-to-treat nonunion. Because the latter may have substantial negative short- and long-term effects, return to play after scaphoid fractures should be approached with more caution. For example, the authors prefer to confirm at least 50% healing with computed tomography before allowing return to play. Conversely, for proximal interphalangeal dislocations, the risk of a redislocation is small, especially with buddy taping, and the likelihood of being able to reduce a redislocated joint is high. Surgeons have a low threshold to allow immediate return to play for this injury.
The main limitations of the current study are centered on the survey tool. The injuries included in the survey are those that were felt to be commonly encountered, but with at least mild to moderate controversy regarding treatment. The survey was not designed to assess actual treatment decisions, but rather to demonstrate variability in decision making among consultant hand surgeons. A formalized validation process was not undertaken, but the survey was internally piloted among the hand surgery faculty of the authors’ academic institution. The response rate of the study cohort was 47% (37 of 78 consultant hand surgeons), which is less than desired but acceptable when compared with other surveys of professional surgeon groups.^7–11  It is possible that the results may have been different if a larger proportion of the study cohort had completed the survey. Despite these limitations, the authors believe that the study has demonstrated the amount of variability in the decision making of consultant hand surgeons.

Conclusion

The findings emphasize the need to individually tailor treatment decisions to patients’ desires and demands, particularly in high-performance athletes. This survey has spurred the formation of a group of consultant hand surgeons who are now collaborating for multicenter prospective studies of hand and wrist injuries in elite athletes.

CJ Dy; E Khmelnitskaya; KA Hearns; MG Carlson: Opinions Regarding the Management of Hand and Wrist Injuries in Elite Athletes.Orthopedics; June 2013 - Volume 36 · Issue 6: 815-819

Major Medical Outcomes With Spinal Augmentation vs Conservative Therapy

Importance  The symptomatic benefits of spinal augmentation (vertebroplasty or kyphoplasty) for the treatment of osteoporotic vertebral compression fractures are controversial. Recent population-based studies using medical billing claims have reported significant reductions in mortality with spinal augmentation compared with conservative therapy, but in nonrandomized settings such as these, there is the potential for selection bias to influence results.
Objective  To compare major medical outcomes following treatment of osteoporotic vertebral fractures with spinal augmentation or conservative therapy. Additionally, we evaluate the role of selection bias using preprocedure outcomes and propensity score analysis.
Design, Setting, and Participants  Retrospective cohort analysis of Medicare claims for the 2002-2006 period. We compared 30-day and 1-year outcomes in patients with newly diagnosed vertebral fractures treated with spinal augmentation (n = 10 541) or conservative therapy (control group, n = 115 851). Outcomes were compared using traditional multivariate analyses adjusted for patient demographics and comorbid conditions. We also used propensity score matching to select 9017 pairs from the initial groups to compare the same outcomes.
Exposures  Spinal augmentation (vertebroplasty or kyphoplasty) or conservative therapy.
Main Outcomes and Measures  Mortality, major complications, and health care utilization.
Results  Using traditional covariate adjustments, mortality was significantly lower in the augmented group than among controls (5.2% vs 6.7% at 1 year; hazard ratio, 0.83; 95% CI, 0.75-0.92). However, patients in the augmented group who had not yet undergone augmentation (preprocedure subgroup) had lower rates of medical complications 30 days post fracture than did controls (6.5% vs 9.5%; odds ratio, 0.66; 95% CI, 0.57-0.78), suggesting that the augmented group was less medically ill. After propensity score matching to better account for selection bias, 1-year mortality was not significantly different between the groups. Furthermore, 1-year major medical complications were also similar between the groups, and the augmented group had higher rates of health care utilization, including hospital and intensive care unit admissions and discharges to skilled nursing facilities.
Conclusions and Relevance  After accounting for selection bias, spinal augmentation did not improve mortality or major medical outcomes and was associated with greater health care utilization than conservative therapy. Our results also highlight how analyses of claims-based data that do not adequately account for unrecognized confounding can arrive at misleading conclusions.

Brendan J. McCullough, Bryan A. Comstock, Richard A. Deyo, William Kreuter, Jeffrey G. Jarvi^: Medical Outcomes With Spinal Augmentation vs Conservative Therapy, JAMA, ONLINE FIRST

Claimant solicitors attack insurer’s ‘biased’ whiplash proposals

Wednesday 17 July 2013 by John Hyde

Claimant solicitors have dismissed a report into whiplash by insurer Axa as ‘highly biased’ and based on inaccurate or outdated statistics.

The insurance giant yesterday put pressure on the government to impose new medical and time limits for making low-value RTA claims.

The report pointed to countries such as Sweden and France as proof that the number of exaggerated or fraudulent claims will fall if the threshold is set higher.

But the Motor Accident Solicitors Society today rejected Axa’s report and said it ‘promised enlightenment but delivers only a blinkered view’.

In a statement, MASS said: ‘There are real dangers in trying to draw direct comparisons across different legal systems which have alternative structures, classifications of injuries and systems of award. 

‘Other countries may have a smaller proportion of whiplash claims, but this is likely to mean that genuine accident victims are not compensated and cannot access the support and rehabilitation services that they need.’

Axa had claimed that whiplash accounts for just 3% of all bodily injury claims in France, but MASS argued this figure was back-dated to 2004. The claimant organisation said the insurance industry’s own research, published this year, found there had been a 1,000% increase in whiplash claims, which now account for 30% of all PI claims.

Axa had lobbied for whiplash claims to be rejected without an x-ray or MRI scan, but MASS said it was ‘disingenuous’ to impose such rules for a soft-tissue injury.

The group added that by excluding injured people from receiving damages, more pressure would be placed on the NHS and the benefits system because it would have to support claimants unable to work.

The Law Society, which is running an advertising campaign urging accident victims to go to a solicitor, also dismissed the Axa recommendations. 

A Society spokesman said: ‘Whiplash can cause real, painful and debilitating injuries, not always revealed by x-rays or MRI scans. There is evidence that some insurers have offered paltry, insulting sums in compensation for nasty injuries. 

‘We are not interested in defending the small minority of accident claims which are fraudulent, but anyone who has suffered a genuine injury should get advice from a solicitor.’

 http://www.lawgazette.co.uk/news/claimant-solicitors-attack-insurer-s-biased-whiplash-proposals