Session Schedule for Webinar Session 1 History of Bone Densitometry Osteoporosis and Bone Health 6:30pm Eastern 5:30pm Central 4:30pm Mountain 3:30pm Pacific What's my timezone? Definition and types of osteoporosis Bone physiology Risk factor BMMA (Bone Mass Measurement Act) Diagnosis and evaluation Session 2 6:30pm Eastern 5:30pm Central 4:30pm Mountain 3:30pm Pacific What's my timezone? Equipment Operations Basic computer concepts Quality Control Equipment QC Pencil beam Fan beam Components of DXA Patient Preparation and Safety Basic principles of radiation safety Radiation doses in densitometry Preparation for patients Session 3 DXA Scanning of the Lumbar Spine, Proximal Femur and Forearm 6:30pm Eastern 5:30pm Central 4:30pm Mountain 3:30pm Pacific What's my timezone? Anatomy Scan acquisition Scan analysis Dilemmas related to positioning ROI placement and analysis Session 4 Mock Registry 6:30pm Eastern 5:30pm Central 4:30pm Mountain 3:30pm Pacific What's my timezone? Exam content Preparation resources Mock exam 1
Educational Objectives Session 1 - Objectives At the completion of this webinar, participants will: Have begun their preparation to take the ARRT Bone Densitometry Certification Exam or the ISCD examination. Be able to define and identify types of osteoporosis Understand the Bone Mass Measurement Act Be able to discuss prevention and treatment of osteoporosis Session 2 - Objectives At the completion of this webinar, participants will: Have begun their preparation to take the ARRT Bone Densitometry Certification Exam or the ISCD examination. Address patient preparation for densitometry imaging and its radiation safety. Obtain knowledge of the operation and QC of DXA equipment. Comprehend the importance of proper positioning. Explain the differences between pencil and fan beam techniques. Maintain accurate and consistent analysis of images and ROI placement. Session 3 - Objectives At the completion of this webinar, participants will: Have begun their preparation to take the ARRT Bone Densitometry Certification Exam or the ISCD examination. Understand key concepts in densitometry scanning. Identify related anatomy of areas scanned. Understand DXA Scanning of lumbar spine, proximal femur, and forearm, Session 4 - Objectives At the completion of this webinar, participants will: Have begun their preparation to take the ARRT Bone Densitometry Certification Exam or the ISCD examination. Identify conditions, complications and causes of osteoporosis and bone health. Obtain knowledge to help prepare for the ARRT Mammography exam 2
Michelle Heater, RT(R)(M)(BD), CBDT Michelle Heater, RT(R)(M)(BD), CDT is certified in Bone Densitometry by both the ISCD and the ARRT and has worked in BD for the past 15 years. She was an item writer for the ARRT Bone Densitometry Certification Exam and a member of the expert panel that reviewed the exam. Michelle has extensive clinical experience in bone densitometry having worked with both GE Lunar and Hologic units. She has participated in several community outreach programs aimed at educating the public and healthcare professionals about bone health. Michelle is also the Northeast Regional Representative for Technologists for the ISCD. Her friendly teaching style and extensive knowledge of bone densitometry will make this a very enjoyable educational experience. 4
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Michelle Heater RT(R)(M)(BD), CBDT My opinion NOF.org ISCD.org / 2015 Position Statement Bone Densitometry for Technologists Osteoporosis: Prevention, Diagnosis and Management Read the operators manual! DXA dual x ray absorptiometry SXA single x ray absorptiometry DPA dual photon absorptiometry SPA single photon absorptiometry QCT quantitative computed tomography QUS quantitative ultrasound BMD bone mineral density BMC bone mineral content VFA vertebral fracture assessment BMMA Bone Mass Measurement Act QC quality control PE precision error LSC least significant change ALARA as low as reasonably achievable SD standard deviation CV coefficient of variation WHO world Health Organization HAL hip axis length ROI region of interest BUA Broadband ultrasound attenuation SOS speed of sound FN femoral neck TBS trabecular bone score There are three content categories on the Bone Densitometry Examination for the ARRT: Patient care Image production Procedures 75 scored 30 unscored questions 8
Patient Care (16) Patient Bone Health, Care, and Radiation Principles Image Production (21) Equipment Operation and Quality Control DXA Scanning of Lumbar spine (15) DXA Scanning of Proximal Femur (15) DXA Scanning of Forearm (8) Definition and Types Bone Physiology Risk Factors Bone Mass Measurement Act Prevention and Treatment 9
11.9 Million people have osteoporosis 40.4 Million people to have low bone mass One in 2 women and one in 4 men are at risk of suffering an osteoporosis related fx in their lifetime Each year there will be more osteoporotic fxs in women than strokes, heart attacks and breast cancer combined 800,000 Vertebral 700,000 Fractures 600,000 Hip 500,000 Fractures 400,000 300,000 Wrist 200,000 Fractures 100,000 0 Fractures at Other Sites Fractured bone Death Disabilty 10
Osteoporosis fractures $19 billion/year in US 2.5 million MD visits 432,000 annual hospital visits 180,000 nursing home admissions Hip fractures related costs $40,000 Definitions of osteoporosis WHO Types of osteoporosis The 1991 and 1993 Consensus Development Conference A systemic skeletal disease, characterized by low bone mass and microarchitectural deterioration of tissue with a consequent increase in bone fragility and susceptibility to fracture 11
Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength primarily reflects the integration of bone density and bone quality. Bone density is expressed as grams of mineral per area or volume, and in any given individual is determined by peak bone mass and amount of bone loss. Bone quality refers to architecture, turnover, damage accumulation (e.g. Microfractures), and mineralization. A fracture occurs when a failure-inducing force such as a trauma is applied to osteoporotic bone. Thus, osteoporosis is a significant risk factor for fracture, and a distinction between risk factors that affect bone metabolism and risk factors for fracture must be made Clinical Definition of Osteoporosis WHO T Score In 1994, the WHO selected a BMD cut point for defining the prevalence of osteoporosis in the Caucasian postmenopausal female population. T score < 2.5 SD 12 Normal Osteopenia Osteoporosis Severe Osteoporosis 1 or better SD Between 1 and 2.5 SD 2.5 SD or lower 2.5 SD & lower with a fragility fracture
Pro: Provides a simple objective diagnostic number for practitioners to use. Recognizes that osteoporosis should be diagnosed prior to the first fragility fracture Con: Limited data relating WHO criteria to fracture risk in other races or genders. Dependent on peak adult bone mass reference databases. Fracture risk is a gradient, not a threshold and 2.5 SD may be used as a threshold cutoff. Application to healthy premenopausal, estrogen-replete women and young men is inappropriate In 1994, members of the World Health Organization defined osteoporosis based on bone density. Using standardized bone density measurements of the total hip, "normal" bone is greater than.833 g /cm 2. "Osteopenia" is between.833 and.648g/cm 2. Osteoporosis is lower than.648g/cm 2, and "Severe osteoporosis" is when there has been a fragility fracture. Should be used for an estimate of the risk of future fractures Risk as the possibility of an untoward event (the fracture) not as absolute prediction Primary or Idiopathic Osteoporosis Type l Type ll Secondary Osteoporosis 13
Type l Ovarian failure Type ll Aging Process Fractures may be secondary to: Medical conditions Medications Neurologic diseases spinal cord injury, stroke, Parkinson's disease, history of polio Hereditary skeletal/connective tissue diseases osteogenesis imperfecta, rickets, hypophosphatasia, Marfan's syndrome, pseudoglioma. Psychiatric diseases Pulmonary diseases Other alcoholism, depression, anorexia nervosa chronic obstructive pulmonary disease AIDS, transient regional osteoporosis, any disease that causes serious weight loss or prolonged bedrest Endocrine and metabolic Gastro intestinal HYPOGONADISM, prolactinoma, hypopituitarism, hyperparathyroidism, hyperthyroidism, Cushing syndrome, acidosis, diabetes type I and type II, androgen insensitivity, Gaucher's disease, hemochromatosis Celiac sprue, malabsorption, malnutrition, inflammatory bowel disease, chronic hepatic disease Fractures not caused by osteoporosis severe trauma, cancer metastasis to the bone, Paget's disease, tuberculosis (Pott's disease), avascular necrosis, fibrous dysplasia, osteomalacia, repetitive injury 14 Rheumatologic diseases Marrow diseases systemic lupus, ankylosing spondylitis, rheumatoid arthritis myeloma, mastocytosis, thalassemia, leukemia
Medications: corticosteroids, dilantin and other anticonvulsants,, loop diuretics, methotrexate, excess thyroid, heparin, depomedroxyprogesterone acetate, antineoplastic agents, cyclosporin, proton pump inhibitors, aromatase inhibitors Women Men Other causes Hyperthyroi dism Oral steroids Primary Other causes Alcoholism Oral steroids Primary Neoplasia Hypoganadism Functions of bone Structural anatomy Types of bone: Cortical Trabecular Cellular structure: Osteoclasts Osteoblasts Bone remodeling 15
Protection of vital internal organs Scaffolding for the musculoskeletal system 3. Manufactures red blood cells Axial or appendicular sites Weight bearing or non weight bearing sites Cortical or trabecular sites Central or peripheral sites Axial - Primarily trabecular bone Appendicular- Primarily cortical bone Weight Bearing Lower extremities, spine, calcaneus and portions of the pelvis Non Weight Bearing The remainder of the skeleton 16
Cortical Site Trabecular Site Forearm Total Body Femoral Neck Fingers Proximal Forearm Distal Forearm Spine Ward s Calcaneus Ultra Distal Forearm Thoracic Spine Lumbar Spine Proximal Femur Fingers Metacarpals Tibia Calcaneus Trabecular and Cortical Bone Trabecular (cancellous) Cortical (compact) Trabecular Bone 20% of skeletal body mass Spongy/honeycomb, cancellous Supports compressive loads Axial skeleton Most responsive to therapy Higher metabolic rate Cortical Bone 80% of skeletal body mass Compact, strong, dense, haversian bone Resists twisting and bending motion Appendicular skeleton Shaft of long bones 17 End of long bones
Site % Cortical % Trabecular Femoral Neck 75 25 PA Spine 34 66 Total Body 80 20 Trochanter 50 50 Site % Cortical % Trabecular Calcaneus 5 95 Distal Radius 80 20 Mid Radius 99 1 Phalanges 60 40 Ultra Distal 34 66 PA spine with Quantitative Computed Tomography (QCT) is a volumetric measurement of 100% trabecular bone gr/cm 3 18
Bone is made up of both organic and inorganic materials Bone modeling Bone remodeling They have their own blood vessels & are made of living cells which help them grow and repair themselves. Proteins, minerals and vitamins also make up bone Bone forming cells(osteoblasts and octeocytes) Bone resorbing cells(osteoclasts) Nonmineral matrix of collagen and noncollagenous protein(osteoid) Inorganic mineral salts deposited within the matrix 19
Four classes of cells that are involved: Osteoclasts Osteoblasts Osteocytes Lining cells Osteoclasts: live in the central portion of the bone responsible for resorption dissolve bone mineral and digest bone matrix Osteoblasts: responsible for bone formation main function is to synthesize bone matrix Mature osteoblasts (maintain exiting bone) 20
Lining cells: former osteoblasts, which become flat line the entire surface of the bone The amount of bone resorbed by a bone remodeling unit depends on 3 factors: The number of osteoclasts recruited as the site of resorption The rate at which each osteoclast works The lifespan of the osteoclasts The bone remodeling cycle is more active in trabecular bone. This explains why osteoporotic fxs tend to occur in: The vertebra The FN End of long bones Bone Balance Bone mass is maintained when the resorption and formation phases are balanced or coupled. Negative bone balance (uncoupling) results from: Overactive osteoclasts Impaired osteoblasts 21
22 Modeling is when bone resorption and bone formation occur on separate surfaces (i.e. formation and resorption are not coupled). An example of this process is during long bone increases in length and diameter. Bone modeling occurs during birth to adulthood and is responsible for gain in skeletal mass and changes in skeletal form
Remodeling is the replacement of old tissue by new bone tissue. This mainly occurs in the adult skeleton to maintain bone mass. This process involves the coupling of bone formation and bone resorption Osteoclasts Osteoblasts Genetic Endocrine Nutritional Lifestyle Medications Ethnicity Family History Vitamin D genetic defect 23
Turner s syndrome (hypoestrogenism) Primary Hyperparathyroidism (excess PTH is secreted by a solitary parathyroid adenoma or by four gland parathyroid hyperplasia) Secondary hyperparathyroidism Calcium Vitamin D Recommended Daily Intake(mg/day) Birth- 6 mo. 400 6 mo.- 1 yr. 600 1-10 yrs. 800-1200 11-24 yrs. 1200-1500 25-50 yrs.(women and men) 1000 51-64 yrs.(women ERT and men) 1000 51 + (women not on ERT) 1500 65 or older 1500 Pregnant or lactating 1200-1500 Absorbed primarily in the small intestines Absorption is complete within 4 hours of it s intake 500 mg 24
Provide 40 % elemental calcium Best absorbed if taken with food Oscal Caltrate Tums Viactiv Provides 24 % elemental calcium Citracal Calcium Phosphate Provides 30 % elemental calcium Posture 800 iu- 1200 iu/d Sunlight, fortified milk, butter, margarine, egg yolks, fatty fish, and liver U.S. multivitamin- 800 iu/d Inactivity Excessive use of alcohol Smoking Caffeine ingestion 25
26
Glucocorticoids Anticonvulsants Antacids (that contain AL) Federal Laws Standardize Medicare Reimbursement for BMD Testing (Patients need to understand their Medicare part B carrier s Local Medicare Review policy regarding BMD testing) A woman to be estrogen deficient at clinical risk for osteoporosis An individual with vertebral abnormalities An individual receiving long term steroid therapy An individual with primary hyperparathyroidism An individual being monitored to assess the response to an FDA approved osteoporosis drug therapy 27 Two exceptions: Patients on glucocorticoid therapy for more than 3 months If BD technique would not be used for monitoring
ICD 10 codes M80 85 (osteoporosis) CPT code DXA 77080 Lifestyle factors Fall prevention Drug therapies Nutrition Exercise Smoking C D E Calcium Vitamin D Exercise 28
Decreased risk of falling Improved bone strength and bone mass Improve balance and flexibility Improve mood Recommend: weight bearing strengthening Need to reduce prevalence of falls Identify high risk fall patients Let s take a look at the pharmaceuticals that are on the market for the prevention and treatment of osteoporosis US FDA approved meds for the prevention and or treatment for osteoporosis: Antiresorptives: Bisphosphonates Calcitonin SERM Estrogen/Hormone therapy Anabolic: Teriparatide Abaloparatide Human monoclonal antibody to RANK ligand (Prolia) 29
PREVENTION AND TREATMENT Alendronate (Fosamax) Risedronate (Actonel) Raloxifene (Evista) Ibandronate (Boniva) TREATMENT ONLY Calcitonin (Miacalcin) FORTEO & Zoledronic acid (reclast) Prolia Tymlos Classified as antiresorptive medications Bind to hydroxyapatite crystals in bone and osteoclast bone interface Inhibit resorption of bone and may increase BD Reduce fracture risk PREVENTION ONLY HT Oral Alendronate Ibandronate Risedronate IV Ibandronate Zoledronic acid Take first thing in AM with 8 oz of plain water Take nothing by mouth for at least 60 minutes Pt remains upright for at least 60 minutes Ibandronate is taken once monthly 30
May include: Hypocalcemia Abdominal pain Bone, joint, or muscle pain Rash Osteonecrosis of the jaw(unclear) May include: difficult or painful swallowing Nausea Heart burn Irritation or burning of the esophagus May include short term post dose symptoms: Flu like symptoms, fever, myalgia, and arthragia, and headache Calcium, creatine, 25 OH D levels should be checked before administering these meds Because bisphosphonates are excreted through the kidneys, they are not recommended for pts with renal failure or severe renal dysfuntion Not recommended for pts with low blood calcium 31
Rare type of fracture More common in pts taking bisphosphonates for more than 5 years Pain in thigh precedes fracture pain needs to be investigated More research is needed to understand relationship(currently under review) The use of alendronate increased or maintained bone density and reduced the incidence of fractures at the hip, spine, and wrist FDA approved for: Prevention of osteoporosis in PM women Treatment of osteoporosis in PMO women, men and glucocorticoid induced osteoporosisin women and men Reduces the incidence of spine fxs by about 50% over a 3 year period Data does not yet confirm it can reduce risk of hip and other nonspine fractures It increases BD throughout the skeleton FDA approved for prevention and treatment PM women(oral) treatment in PM women as IV In contolled clinical trials, increased or maintained BD and reduced the risk of spine and nonspine fractures Approved by the FDA for: Prevention in PM women Treatment in PM women and men Prevention and treatment of glucocorticoid induced osteoporosis in men and women 32
Once yearly for treatment and every other year for prevention Increase BD and reduces fractures in the hip, spine, and non spine sites FDA approved for the treatment of osteoporosis in PM women and in men For prevention & treatment glucocorticoid induced osteoporosis in men and women Weak effects on BMD and bone turnover Antiresorptive Reduced the risk of vertebral fxs in trials FDA approved treatment of osteoporosis Nasal spray Injection Nasal irritation Allergic response Runny nose Headache Raloxifene is a nonhormonal agent that acts as an estrogen agonist on bone but acts as an estrogen antagonist on both the breast and uterus Formerly classified as a SERM FDA approved for the prevention and treatment of PMO Approved to reduce the risk of invasive breast cancer in patients with osteoporosis and pts at increased risk of breast cancer Once daily tablet Side effects:deep vein thrombosis, hot flashes, leg cramps, and fluid retention 33
FDA approved to prevent osteoporosis Available in a variety of oral dosing Prescribe ET/HT products only when bebefits are believed to out weigh risks for a specific patient Classified as an anabolic agent that builds new bone Daily subcutaneous injection Decreases risk of vertebral fracture & nonvertebral fracture after an average of 18 months Indications:men/women with previous 733 fx men/women with multiple risk factors Extremely low BMD pts unresponsive to other meds Contraindications: Hypercalcemia or hyperparathyroidism Pagets disease Growing children and young adults Pregnant or nursing women History of bone cancer History of CA metastasized to bone Radiation to the skeleton Side effects: just to name a few leg cramps, dizziness, increase serum uric acid & urine Ca Because long term effects of treatment are unknown & because an increase incidence of osteosarcoma was seen in earlier animal studies, FDA currently limits use to 2 years No excess osteosarcoma reported in human population 34
Fully human monoclonal antibody that inhibits receptor activator of nuclear factor kappa B ligand(rankl) Reduces development, activity and longevity of osteoclasts, decreasing bone resorption and increasing bone densiy Reduces the incidence of vertebral, nonvertebral, and hip fractures in PM women with osteoporosis Indicated for the treatment of PM women with osteoporosis at high risk for fracture Administered by a health professional, 60mg every six months asa subcutaneous injection Contraindications:hypocalemia Warnings: hypocalcemia, serious infections(skin), osteonecrosis of the jaw, suppression of bone turnover Treatment of osteoporosis for women at risk of fx, hx of osteoporotic fxs, multiple risk factors for fx, and who failed to other therapy Increase bone density Increase marker of bone formation Black box warning Not recommended for pts with Paget s, bone mets, high alk phos Patient Preparation Radiation Safety 35
Specials needs * Patient instructions* Patient history relevant to scan Scan preparation Documentation of unusual positioning, acquisition, or analysis Patient history: Medical History Recent contrast agents Recent radiopharmaceuticals Scan preparation: Entry of pt. data Removal of artifact Documentation of unusual positioning Pinch points Laser safety Radiation safety Measurement modes Mechanical safety Basic principles: ALARA Work station/scanner distance Levels of radiation in DXA: Entrance dose Effective dose Relationship to other studies 36
As Low As Reasonably Achievable Time refers to the length of exposure Distance refers to the distance away from radiation source 56FR 23396 May 21, 1991 Congress incorporated in 10CFR20. 1101B May 1993 Shielding Radiation survey Film badges/tld 37
reontgen ( R) Basic unit of radiation exposure (only for Air) gray (gy) Measurement of absorbed dose rad reontgen absorbed dose Sivert (Sv) effective dose rem reontgen equivalent men. ALARA the basic goal of radiation protection 1/10 of a chest x ray DXA : 1 5 μsv /scan Natural background : 5 8 μsv/day Source usv SXA 1 DXA 1 5 QCT 60 Lateral Lumbar spine film 700 Natural Background (d) 5 8 Boston to Chicago (rt) 30 Markers of Bone Formation Markers of Bone Resorption 38
Serum Alkaline Phosphatase Serum Osteocalcim (BGP) Serum type I collagen propeptides C Terminal Propeptide )PICP) N Terminal Propeptide (PINP) Urine hydroxyproline Pyridinoline cross links Free pyridinoline (Pyr) and Deoxypyridinoline (D Pyr) Urine N terminal to helix links (NTX) Urine C terminal to helix cross links (CTX) Serum C terminal to helix cross links (ICIP) Patient Preparation Radiation Safety Specials needs * Patient instructions* Patient history relevant to scan Scan preparation Documentation of unusual positioning, acquisition, or analysis 39
Patient history: Medical History Recent contrast agents Recent radiopharmaceuticals Scan preparation: Entry of pt. data Removal of artifact Documentation of unusual positioning Pinch points Laser safety Radiation safety Measurement modes Mechanical safety Basic principles: ALARA Work station/scanner distance Levels of radiation in DXA: Entrance dose Effective dose Relationship to other studies As Low As Reasonably Achievable 56FR 23396 May 21, 1991 Congress incorporated in 10CFR20. 1101B May 1993 40
Time refers to the length of exposure Distance refers to the distance away from radiation source Radiation survey Film badges/tld Shielding reontgen ( R) Basic unit of radiation exposure (only for Air) gray (gy) Measurement of absorbed dose rad reontgen absorbed dose Sivert (Sv) effective dose rem reontgen equivalent men. ALARA the basic goal of radiation protection 41
1/10 of a chest x ray DXA : 1 5 μsv /scan Natural background : 5 8 μsv/day Source usv SXA 1 DXA 1 5 QCT 60 Lateral Lumbar spine film 700 Natural Background (d) 5 8 Boston to Chicago (rt) 30 42 Osteoporosis is common : About 54 million Americans have osteoporosis and low bone mass, placing them at increased risk for osteoporosis. Studies suggest that approximately one in two women and up to one in four men age 50 and older will break a bone due to osteoporosis. Osteoporosis is serious : Breaking a bone is a serious complication Osteoporosis is costly and responsible for two million fractured bones and $19 billion in related costs every year. By 2025, experts predict that osteoporosis will be responsible for approximately three million fractures and $25.3 billion in costs each year of osteoporosis
A woman s risk of breaking a hip due to osteoporosis is equal to her risk of breast, ovarian and uterine cancer combined. And a man age 50 or older is more likely to break a bone due to osteoporosis than he is to get prostate cancer. WHO Normal Osteopenia Osteoporosis Severe Osteoporosis T Score 1 or better SD Between 1 and 2.5 SD 2.5 SD or lower 2.5 SD & lower with a fragility fracture Trabecular and Cortical Bone Primary or Idiopathic Osteoporosis Type l Type ll Secondary Osteoporosis Trabecular Bone 20% of skeletal body mass Spongy/honeycomb, cancellous Supports compressive loads Axial skeleton Most responsive to therapy Higher metabolic rate Cortical Bone 80% of skeletal body mass Compact, strong, dense, haversian bone Resists twisting and bending motion Appendicular skeleton Shaft of long bones 43 End of long bones
Four classes of cells that are involved: Osteoclasts Osteoblasts Osteocytes Lining cells Uncontrollable Risk Factors Being over age 50. Being female. Menopause. Family history of osteoporosis. Low body weight/being small and thin. Broken bones or height loss Controllable Risk Factors Not getting enough calcium & vitamin D Inactive lifestyle Drinking too much alcohol Smoking Advance age Female White/Caucasi an Small body size Diet low in calcium Inactive lifestyle Low sex hormones History of fracture Certain medications and medical conditions 44 Currently smoking Impaired vision Dementia Poor health Early menopause Frequent falls
Rheumatoid Arthritis Endocrine disorders Gastrointestinal disease celiac disease & bariatric surgery Liver diseases Dietary disorders Neurologic disorders Organ transplantation Glucocorticoids oral and high dose inhaled Lupron Anticonvulsants Lithium Long term heparin use Depo Provera Long term PPI therapy A woman to be estrogen deficient at clinical risk for osteoporosis An individual with vertebral abnormalities An individual receiving long term steroid therapy An individual with primary hyperparathyroidism An individual being monitored to assess the response to an FDA approved osteoporosis drug therapy 45 Remember C,D, and E Fall prevention Pharmaceutical therapies
Remember Patient prep Special needs Patient instructions Patient hx Scan prep Documentation of anything unusual Remember Basic principles Levels of radiation in DXA 46