JACC VOL. 66, NO. 6, 2015

Letters

AUGUST 11, 2015:754–60

on the patient’s vulnerability—which is often neglec-

As the authors noted, it has already been indi-

ted in our considerations of patients’ risk of adverse

cated that the incidence of musculoskeletal pain is

events. The “protecting” effect of dense calcium

associated with higher case volumes and more years

found by Criqui et al. (4) indeed may be interpreted as

in practice for interventional cardiologists. In other

a marker for individuals who are resistant to vascular

words, the total time exposed to a radiation-bearing

thrombosis in response to plaque ruptures and thus

lead apron might lead to increased risk of musculo-

exhibit more features of plaque healing/organization

skeletal pain. Therefore, it is essential to investigate

in the absence of events. The PESA (Progression of

the association between the total radiation exposure

Early Subclinical Atherosclerosis) study found sub-

time (self-reported exposure time per week  years in

clinical atherosclerotic disease in 63% of participants

the current profession) and the proportion of work-

within a middle-aged cohort (5). The discussion on

related pain. Similarly, the association between the

risk assessment in patients warrants a broader,

total time of wearing a lead apron (time per week 

comprehensive view rather than focusing on indi-

years in the current profession) and the proportion of

vidual plaque components.

work-related pain also should be analyzed. Unfortunately, years in current profession was not integrated

*Armin Arbab-Zadeh, MD, PhD, MPH Valentin Fuster, MD, PhD

into the analysis when the authors investigated the

*Division of Cardiology

As a result, this led to some cumbersome and feeble

Johns Hopkins University

explanations, such as constant and different physical

600 North Wolfe Street, Halsted 559

stress to argue why nonphysician employees in the

Baltimore, Maryland 21287

interventional lab reported a higher prevalence of

E-mail: [email protected]

work-related musculoskeletal pain, even if they were

http://dx.doi.org/10.1016/j.jacc.2015.06.011

younger with fewer working years. If the authors

Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Peter Libby, MD, served as Guest Editor for this paper.

investigated the association between musculoskeletal

factors associated with increase of work-related pain.

pain and the total time the catheterization lab operators and staff wore a radiation-bearing lead apron,

REFERENCES 1. Baber U, Mehran R, Sartori S, et al. Prevalence, impact, and predictive value of detecting subclinical coronary and carotid atherosclerosis in asymptomatic adults: the BioImage study. J Am Coll Cardiol 2015;65:1065–74. 2. Puchner SB, Liu T, Mayrhofer T, et al. High-risk plaque detected on coronary CT angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: results from the ROMICAT-II trial. J Am Coll Cardiol 2014;64:684–92. 3. Stone GW, Maehara A, Lansky AJ, et al. A prospective natural-history study of coronary atherosclerosis. N Engl J Med 2011;364:226–35. 4. Criqui MH, Denenberg JO, Ix JH, et al. Calcium density of coronary artery plaque and risk of incident cardiovascular events. JAMA 2014;311:271–8. 5. Fernandez-Friera L, Penalvo JL, Fernandez-Ortiz A, et al. Prevalence, vascular distribution, and multi-territorial extent of subclinical atherosclerosis in a middle-aged cohort: the PESA (Progression of Early Subclinical Atherosclerosis) study. Circulation 2015;131:2104–13.

they might have been to obtain evidence to clarify the issue. Moreover, it might have been more interesting to investigate whether there is any correlation between the pain score and the total time of wearing a lead apron in participants exposed to radiation without taking a pain medication. In this cross-sectional case-control study, the authors identified no difference in cancer prevalence between groups (9% vs. 9%; p ¼ 0.96). We suspect a significant bias within this analysis because many staff involved in procedures with radiation exposure had fewer working years and less cancer risk, exhibiting a linear/linear-quadratic, no-threshold radiation relationship with stochastic effects (2). Thus, the comparison of cancer prevalence between groups should be stratified by the working years.

Musculoskeletal Pain and Cancer Risk of Staff Working With Fluoroscopically Guided Procedures

Guoxin Fan, MD *Shisheng He, MD Zhengqi Chen, MD *Orthopedic Department Shanghai Tenth People’s Hospital Tongji University School of Medicine 301 Yanchang Road Shanghai 200072

We took great interest in the paper by Orme et al. (1)

China

recently published in the Journal; however, we have

E-mail: [email protected]

some concerns regarding the statistical analysis.

http://dx.doi.org/10.1016/j.jacc.2015.04.080

759

760

JACC VOL. 66, NO. 6, 2015

Letters

AUGUST 11, 2015:754–60

Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Jonathan Tobis, MD, served as Guest Editor for this paper.

apron less (572 h vs. 2,652 h; p < 0.001). We believe that these additional data confirm our previous assertions that time per week involved in interventional

REFERENCES 1. Orme NM, Rihal CS, Gulati R, et al. Occupational health hazards of working in the interventional laboratory: a multisite case control study of physicians and allied staff. J Am Coll Cardiol 2015;65:820–6.

procedures and use of the lead apron are associated with increased musculoskeletal pain in the catheterization lab. However, given the difference in lead apron use among physicians and technicians, additional

2. Fan G, Fu Q, Zhang H, He S. Direct-beam radiation exposure to surgeons during pinning of supracondylar humerus fractures. J Pediatr Orthop 2015; 35:e37.

factors may be involved as we described in the dis-

REPLY: Musculoskeletal Pain and Cancer Risk

parison of cancer prevalence among interventional

of Staff Working With Fluoroscopically

laboratory employees compared with noninterven-

cussion of our paper (patient transfers, sheath pull, less rotation out of the catheterization lab, and so on). Fan and colleagues also suggested that our com-

Guided Procedures

tional lab employees be stratified by working years. Our original paper reported no difference in years

We greatly appreciate the interest of Dr. Fan and

in current profession among the study or control

colleagues in our recent study published in the

group (p ¼ 0.81), which is why we did not assess as-

Journal (1). We reported that hours per week involved

sociations with cancer history stratified by working

in radiation-utilizing procedures and time per week

years. The stratified analyses suggested by Fan and

wearing the lead apron were associated with in-

colleagues also did not detect any difference in cancer

creased musculoskeletal pain. It was suggested by

prevalence between the 2 groups among employees

Dr. Fan and colleagues that we analyze these factors

working 0 to 5 years (p ¼ 0.7), 6 to 10 years (p ¼ 0.5),

using cumulative lifetime values (time per week 

11 to 15 years (p ¼ 0.3), 16 to 20 years (p ¼ 0.4), or

years in profession). We did not perform the analyses

>20 years (p ¼ 0.8). The overall Cochran-Mantel-

in the original paper because of concerns on varia-

Haenszel p value was 0.78. We continue to acknowl-

tions in the weekly time spent by the operators over

edge the limitations of our cross-sectional design and

the course of their careers. However, we have per-

the need for large, longitudinal studies of employees

formed the requested analysis.

exposed to radiation.

As expected, employees participating in radiation-

vs. 2,002 h; p < 0.001) and hours wearing the lead

Nicholas M. Orme, MD Ryan J. Lennon, MS *Mandeep Singh, MD

apron (1,950 h vs. 559 h; p < 0.001). There was a

*Division of Cardiovascular Diseases

small, significant correlation between total time

Mayo Clinic

wearing the lead apron and the objective pain rating

200 First Street SW

index pain score in patients not taking pain medica-

Rochester, Minnesota 55905

tion (Spearman r ¼ 0.178; p ¼ 0.002). Nurses reported

E-mail: [email protected]

more musculoskeletal pain than physicians and

http://dx.doi.org/10.1016/j.jacc.2015.04.081

correspondingly had more lifetime hours of proce-

Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Jonathan Tobis, MD, served as Guest Editor for this paper.

utilizing procedures who reported musculoskeletal pain had more hours of lifetime participation (6,240 h

dural participation (6,578 h vs. 2,704 h; p < 0.001) and more hours wearing the lead apron (4,940 h vs. 2,652 h; p < 0.001). Technicians also reported more pain than physicians and had higher lifetime hours of participation in radiation-intensive procedures (4,680 h vs. 2,704 h; p < 0.001) but wore the lead

REFERENCE 1. Orme NM, Rihal CS, Gulati R, et al. Occupational health hazards of working in the interventional laboratory: a multisite case control study of physicians and allied staff. J Am Coll Cardiol 2015;65:820–6.

Musculoskeletal Pain and Cancer Risk of Staff Working With Fluoroscopically Guided Procedures.

Musculoskeletal Pain and Cancer Risk of Staff Working With Fluoroscopically Guided Procedures. - PDF Download Free
1KB Sizes 0 Downloads 11 Views