Development of CT Scans for Cancer Studies

Development of CT Scans for Cancer Studies According to the statistics presented by the World Health Organization (WHO), with around 7.4 million deaths (around 13% of the total death) in 2004, cancer is the leading cause of death throughout the world (WHO, 2009). These levels are expected to rise further in future, with an estimated 12 million death in 2030 (WHO, 2009). There are more than 100 different types of cancer (Crosta, n.d.), among them the Lung cancer, stomach cancer, colorectal cancer, liver cancer and the breast cancer are the most common types. Tobacco is the most important risk factor for cancer, with nearly 1.3 million deaths per year just due to lung cancer alone (WHO, 2009). Cancer At the primary level, human body consists of large number building blocks, called the cells. Under normal circumstances, new cells are formed by the body depending on the body requirement, in order to replace the dead cells. But sometimes, under abnormal conditions, there is an exponential (uncontrolled) increase in the formation and growth of new cells. The accumulation of these extra cells forms mass or lumps of tissues, called the tumor (National Cancer Institute, 2010). Most of the cancers, in general form tumors, but there are certain exceptions, like leukemia, that do not form tumors (in leukemia or blood cancer, the cancer cells hinder the normal blood functions due to abnormal cell disintegration in the blood stream (Crosta, n.d.)). The tumors can be of two types; benign tumor and malignant tumor. The benign tumors do not propagate to other sections of the body and have restrained growth (Crosta, n.d.), whereas the malignant tumor cells have the ability to invade into the sur rounding tissues. Also the malignant tumor cells can escape from their initial location and spread to other sections of the body through blood or lymph. Only the malignant tumors are cancerous in nature. Therefore, the cancer has three distinctive properties that distinguish malignant tumors from benign tumors: Uncontrolled growth Invasive nature Metastasis (ability to spread to other sections of the body) These disorders in cells are the result of the interaction between the genetic factors and external agents (which are called carcinogens) (WHO, 2009). The carcinogens can be categorized as (WHO, 2009): Biological carcinogens, like certain bacteria, viruses or parasites. Physical carcinogens, which includes the high energy radiations (ionizing radiations). Chemical carcinogens, these include substances like tobacco smoke, arsenic (water contaminant), aflatoxin (food contaminant), asbestos etc. Another factor essential in the development of cancer is the age. According to the studies conducted by the Cancer Research UK, the risk increase predominantly with increasing age, with nearly 74% of the cases of cancer diagnosed in people aged 60 and above (Cancer Research UK, 2009). Cancer Treatment Principle In case of normal cells there is specific pattern of growth, division and death (orderly destruction of cells is called apoptosis) (Crosta, n.d.). It is known that the cancer is the result of the uncontrolled growth of cells which do not die (Crosta, n.d.), that is, the apoptosis process fails in the cancer cells. The cancer cells thus do not die and rather continue to grow, resulting in the formation of tumors. As the problem in the cancer cells lies in the DNA, therefore a possible treatment of cancer is the destruction of the DNA in cancer cells, leading to a self initiated destruction of the cells. There are various methods used for the treatment of cancer depending upon the type of cancer. The most common types of treatment are (Fayed, 2009): Surgery Chemotherapy Radiation therapy or Radiotherapy Biologic or Targeted Therapy Radiotherapy Radiotherapy, also referred to as radiation therapy, is one of the most common types of treatments used for cancer. It is the utilization of higher energy radiations like x-rays, gamma rays in order to kill cancer cells, treatment of thyroid disorder and even some blood disorders, in a particular section (effected part) of the body (Nordqvist, 2009). The high energy ionizing radiations can be produced using a number of radioactive substrates like Cobalt (60Co), Radium (228Ra), Iodine (131I), Radon (221Rn), Cesium (137Cs), Phosphorus (32P), Gold (198Au), Iridium (192Ir), and Yttrium (90Y) (Howington, 2006). The cancer cells have the ability to multiply faster than other body cells. The high energy ionizing radiations are more destructive towards the faster growing cells, and thus they damage the cancer cell more than the other body cells (Mason, 2008). These high energy radiations like gamma rays and x-rays; especially damage the DNA inside these cancer cells (or tumor cells) thereby annihilating the ability of the cells to reproduce or grow. Apart from treatment of cancer, radiation therapy is also used to shrink a tumor before being surgically removed (Mason, 2008). Depending upon the method of irradiation, the process of radiation therapy is categorized into two forms (Mason, 2008): External Radiotherapy In this method (more common), the infected part of the body (tumor) is irradiated by high energy x-rays from outside the body. Internal Radiotherapy For this method, a radioactive substance are injected (or taken orally) into the body (close to the tumor) in the form of fluids. These substances, taken up by the cancer cells, radiate the tumor through internal beam radiation (or interstitial radiation) (Mason, 2008). Radiotherapy Planning A careful planning is essentially required for radiation therapy, as over exposure can be critically dangerous to healthy tissues in the body. The ionizing radiations have side effects, therefore once the full dose of radiations is decided; the patient is given these radiations in the form of small doses in a series of therapy sessions (Cancer Research UK, 2009). Each small dose of radiation is called a fraction. The gap between sessions provides the recovery time for the body, which may depend on the type of cancer and patients health condition. The area of the body that is radiated during the treatment is called the radiotherapy field and the section inside the body that experiences the maximum exposure dose is called the target volume (Cancer Research UK, 2009). The doctors decide the marginal area around the tumor that should be radiated to encapsulate any movement of the cancer cells. In order to accurately determine the position of tumor (or target volume), body scans are done. Computed Tomography (CT) scans are done as a planning procedure, this provides vital information regarding the location of the tumor as well as the kind of treatment required by the patient (Cancer Research UK, 2009). The radiotherapy treatment planning process can be divided into 6 major steps . Computer Tomography (CT) Scan The invention of Computer Tomography (CT) scanned is credited to Sir Godfrey Hounsfield in early 1970s, for which he along with Allen Cormack, was awarded the Nobel Prize in 1979 (Smith, n.d.). A CT scanner, also known as the Computed Axial Tomography (CAT) scanner uses X-rays to produce cross sectional images (or slices) of the body like a slice in a loaf of bread (FDA, 2010). The word tomography suggests the process of generating a two-dimensional image of a slice or section through a 3-dimensional object (a tomogram) (Nordqvist, 2009). These cross-sectional slides render an accurate picture of the size and location of the tumor along with the position of major organs in the body (Cancer Research UK, 2009). This would be essentially useful during the radiotherapy process, where these can be used to lower the dose of radiations on the organs. It is known that in case of radiation therapy treatment, the doses are given in fractions over a certain period of time (to prevent major side effects), which may vary from few weeks to months. Thus, before each fraction of radiation dose, computed tomography (CT) scan of the patients is done to determine the exact location of the tumor or cancer cells. So in case the full dose has been divided into 30 fractions, then the patient has to undergo 30 CT scans, each before a fractional therapy. The machine used for the radiation therapy planning is known as the simulator (Cancer Research UK, 2009). The simulator identifies the position of the tumor and marks the position of radiation on the body with the help of light rays. The radiographer uses ink markers on the body before the actual radiotherapy is begun. These linear ink marks are used by the radiographer for positioning the machine for radiotherapy (Cancer Research UK, 2009). Simulators take the pictures (CT scans) in the form of X-rays, which locates the accurate tumor position for the radiographer to carry out the treatment. During a CT scan, it is essential that the person remains completely still so that the measurements are accurate. In order to insure the correct position supports like neck rest, chest board or arm pole are used (Cancer Research UK, 2009). In case of children it is ensured by giving proper sedatives. Sometimes, under critical condition, extra measures are taken in order to prevent essential organs from being radiated during the therapy. These measures include injecting fluids or dyes which mark the position of vital human organs in the CT scan (Cancer Research UK, 2009). These markers may be given orally, through injections or rectally depending upon the requirement. Using this vital information from the CT scans, a treatment plan for radiation therapy is prepared. This plan indicates the position and direction of the radiations during the therapy, so as to minimize the exposure of healthy cells and organs. The scans generated by a CT scanner are in the form of 2 dimensional (2-D) slides, but by the used of digital geometry processing they can be used to generate a 3 dimensional (3-D) images of the body (Nordqvist, 2009). This can be achieved by integrating all the slides (along the same axis) together using a computer system. The CT scan can be understood as a technically advanced format of X-rays machines. The x-rays images are produced by the projection of a broad beam of x-rays on a film after passing through the body (Medindia, 2010). It provides a 2-dimentional projection of the body, where much of the information is lost. In case of CT scan, a thin beam of x-rays is absorbed by the detector after passing though the patients body (Medindia, 2010). Like the x-ray process, the CT scanning is a painless process for the patients but has been known to be accompanied with some side effects. These side effects may vary from the patient to patient depending upon the amount of radiation dose and health of the patient. The detailed discussion on the health effects of CT scanning has been discussed in the later sections of the project. Theory In order to understand the working of a computed tomography (CT) scanner it is essential to understand the properties of ionizing radiations (X-rays) used in the scanning process. The electromagnetic radiations are the arrangement of electric-field and magnetic-field vectors perpendicular to each other and also perpendicular to the propagation direction of the wave (Resnick et al., 2009). These Electromagnetic radiations have penetrating powers, which are directly dependent on the energy (or frequency) of these radiations. So that radiations with higher frequency have higher penetration powers. Therefore, on the basic the energy, the electromagnetic radiations are categorized as Non-ionizing radiations and Ionizing radiations. Non-Ionizing radiations refer to the electromagnetic radiations which have energy lower than that required for an atomic ionization (MIT, 2001). The non-ionizing radiations include radio waves, micro waves, visible light etc. These radiations have lower penetration powers. Alternatively the Ionizing radiations are the high frequency radiations which have enough energy to knockout an electron from an atom and thus causing ionization (MIT, 2001). The Gamma rays and X-rays are the common type of ionizing radiations. Even the alpha particles and beta particles emitted in a nuclear reaction are ionizing radiations (MIT, 2001). Due to the higher energy they have higher penetration power than the non-ionizing radiations. Principle of CT Scanning The most important section of a Computed Tomography (CT) scanning is the interaction of the ionizing X-ray radiations with the living tissues in the body. When the ionizing radiations (X-rays) interact with the living tissues in the body, they break up atoms and molecules from the living tissues and disrupt chemical reactions within the body (Zamanian Hardiman, 2005). The intensity of absorption of the x-ray radiations by the body varies depending upon the tissue coming in interaction. Different body tissues have different absorption power, where some are permeable to x-rays others are impermeable (Medindia, 2010). It is due to this difference in the absorption ability of different sections of the body, which results in the generation of a graded pattern in the scans. High density tissues like the bones appear white in the scan while the soft tissues (like brain and kidneys) appear dark. The cavities (like the lungs) are seen as black sections in the scan (Medindia, 2010). Therefore, this gradation in the pattern can be used as method to distinguish different body organs depending upon their absorption capacity. This forms the basic principle behind the working of an X-ray scanning. Radon (1917) was the first to develop the principles of computed tomography (CT) mathematically (Bushberg et al., 2002). According to Radon, with the help of infinite number of projections through an object, it could be possible to produce an image of an unknown object. In case of film imaging (as in conventional X-rays), a two-dimensional (2-D) projection of the body is generated on the film. Due to this, details in the dimension of the body along the direction parallel to the x-ray beam are lost. In order to overcome this drawback (only up to a certain level) projections can be taken along two directions; posteroanterior (PA) projection and lateral projection (Bushberg et al., 2002) (as shown in Figure 4). Increasing the number of scans improves the amount of information but in critical and complex cases where much more details are required. For these critical cases, CT scan is done. The CT scan provides the tomographical image, which is the picture of patients body in the sections or slabs. The thickness of these uniform slabs may vary from 1 millimeter to 10 millimeter (Bushberg et al., 2002), according to the program, depending upon the requirement. Each CT image consists of an array of large number of pixels forming a two dimensional (2-D) image, which corresponds to the same number of three dimensional thin rectangular slabs called the voxel. The voxels are the volume element whereas the pixels are the picture element (Bushberg et al., 2002). Every ray from the X-ray source passes (transmits) through the patient before the transmission measurement is done by the detector. Intensity of the un-attenuated x-ray radiation emitted by the source is Io whereas the intensity of the attenuated radiation after transmitting through the patient is given as It. The intensities Io and It are related by the equation (Bushberg et al., 2002):   Ã‚  Ã‚  Ã‚  Ã‚  It=Ioe-ÃŽ ¼t   Ã‚  Where;   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚ µ is the total linear attenuation coefficient of the tissue (Smith, n.d.).   Ã‚  Ã‚  Ã‚  Ã‚  t is the distance travelled by the radiation in the tissue i.e. the tissue thickness. The coefficient  µ is dependent on the atomic number and electron density of the tissues (Smith, n.d.). Higher the atomic number and electron density of the tissues, higher would be the attenuation coefficient (Smith, n.d.). This form the basic principle of CT scanning, that different tissues have different level of attenuation properties depending upon their atomic number and electron density. For every measurement, the overall attenuation coefficient is calculated using the above equation. During a complete 360o ­ scan, various transmission measurements for the intensity of X-ray photon are done. Using these intensity measurements specific attenuation values are allotted to every voxel (volume element). These attenuation numbers are directly proportional to the linear attenuation coefficient. The average of these attenuation values is called the CT number (Smith, n.d.). These values can be arranged on a linear scale, the units of which are called the Hounsfield units (HU). The scale for modern CT scanners varies from approximately -1,000 to 3,000 HU. The attenuation scale is based on binary system and therefore the exact values range from -1,024 to +3,071, with a total of 4,096 (or 212) attenuation numbers. Here, the lower represent the black section while the higher values represent the white section of the CT image. On this scale the attenuation value of water is zero HU and that of air is -1,000 HU (Smith, n.d.). Both of these values act as the reference points. Construction of a CT scanner CT scanner is a complex machine, but the basic structure is simple. A common CT scanner has been shown in Figure 2. Two most important parts of a CT scanner are the X-ray source and detector. The source and detector are placed in a circular structure, which has a shape similar to a doughnut. This doughnut shaped circular opening is called the gantry (RadiologyInfo, 2009), with an inner (opening) diameter varying from 60 cms to 70 cms. The X-ray source and detector are placed exactly (diagonally) opposite each other, so that the radiations emitted by the source pass through the body and the transmitted radiations are measured by the detector. The x-ray source and detector system in the gantry is motorized to rotate around the patient for measurements in different projection angles. The rational speed of the system is adjusted according to the detectors ability to measure and convert the x-ray beam into electronic signal. Cobalt (60Co) is generally used as the source of x-rays in the CT scanners. The detector used in CT scanner consists of an array of detectors in a slightly curved shape (like a banana). This curved shape is especially useful in fan-shaped beam projects. Two types of detectors are generally utilized in the CT scans; solid state or scintillation detector and Xenon gas detector (Reddinger, 1997). But the solid state detectors with scintillators like Cadmium Tungstate (CdWO4), yttrium, gadolinium ceramics etc are commonly used (Bushberg et al., 2002). The principle of the scintillation detector is that, when it is struck by a x-ray photon, it produces light. This light signal is then transformed to electrical signal with the help of photodiode. The Depending upon their structure, the detectors are categorized into two categories; single detector array and multiple detector array. Another essential part of a CT scanner is the motorized examination table. The table is controlled to move in and out of the gantry during the scanning process. As the position of the x-ray source and detector is fixed therefore the section being scanned is controlled by the movement of the examination table. For a better scan it is necessary that the patient remains completely still. To insure this table is equipped with neck rest, chest board and arm pole (Cancer Research UK, 2009). The detector measures the intensity of the radiation and converts them into electrical signals. These raw signals are analyzed and manipulated by the computer to convert them into images which can be understood by the radiologists and the technicians. Multiple computers are required in a CT scanner. The main computer that controls the operation of the entire system is called the host computer (Imaginis, n.d.). The computers and controls are located in a room adjoining the scanning room. This prevents the technicians and the radiographer from exposure to x-rays. Scanning Procedure in a CT scanner Initially the patient is positioned on the examination (or scanning) table in a flat upright posture (face towards the roof). In order to insure the correct and stationary position, straps and pillows may be used along the body. Once the patient is correctly positioned on the scanning table, the motorized table moves the patient into the circular opening of the CT scanner (FDA, 2010), which the x-ray radiations are projected on the patient from the scanning. For a particular position of the x-ray source and detector, the rays from the source pass through a region called the projection or view. There are two different types of projection geometries that are used in CT scanning; parallel beam geometry and fan beam geometry. In the parallel beam geometry, the rays projected on the patient are parallel to each other whereas in fan beam geometry, the rays diverge from the source in the shape of a fan (Bushberg et al., 2002) as shown in Figure 7. The fan beam projections are the most commonly in used x-ray projections in the CT scanners. The X-ray tube is attached with a collimator which controls the thickness of the fan beam. This thickness (of the fan beam projection) determines the width of the tissue slide in the scanning process. It is through the collimator that the slice thickness is varied between 1mm to 10mm (Smith, n.d.). The x-ray source and detector rotate around the patient (for imaging) in a circular motion such that they always remain exactly (diametrically) opposite to each other (as shown in Figure 7). During the rotation the source keeps emitting x-rays which are attenuated after passing through the patient. For a single projection (or slice), the x-ray source and detector make a complete 360o rotation around the patient. During the rotation the detector takes a large number of snapshots of the absorbed X-ray beam at different projection angles. A single image may involve approximately 800 rays and there can be up to 1,000 different projection angles (Bushberg et al., 2002). Therefore for a single projection (one slice), the detector does nearly 800,000 transmission measurements (Bushberg et al., 2002). The scanning of a single projection generally takes around 1 sec (for axial CT scanners) (FDA, 2010). Once all the transmission measurements (complete 360o) for a projection (or slice) are completed, the motorized table moves along the axis of the gantry so that the next slice of tissues forms the projection view. The process is continued till the complete required section of the body has been scanned. In the traditional CT scanners, the table moved on to the next projection (slice) only when the scanning of the previous was completed. Such conventional type of scanning is called the axial scanning. But in modern CT scanners, called the helical or spiral CT scanners, the rotation of the x-ray source and detector is accompanied with the uniform movement of the examination table, thus producing a helical projection. The helical CT scanning has been shown in Figure 9. These modern helical CT scanners are much faster than the traditional scanners due to continuous scanning process. They have been reported to take nearly half the time for scanning as compared to the traditional CT scanner s. In order to analyze and study the cardiac structure which is under constant motion, even helical CT is ineffective. For such applications a special CT scanner with an exposure time of 50ms and a maximum exposure rate of 17 images per second are used (Smith, n.d.). These scanners, called the cine CT, freeze the cardiac motion due to extremely low exposure time resulting in a sharp image (Smith, n.d.). These scanners use electron beam to generate x-rays, thus are also known as Electron Beam Computed Tomography (EBCT). In the CT scanning process large volume of data and operations are required to be processed, which is achieved with the help of multiple computers. The detector converts the intensity measurements of the attenuated x-rays in to electrical signals. The main computer, called the hub computer processes these signals and converts them into an image. These images can then be analyzed for radiotherapy planning. Result Computed Tomography (CT) has become an invaluable medical tool. It provides detailed 3-D images of various sections of the body like pelvis, soft tissues, lungs brain, blood vessels and bones (Nordqvist, 2009). Generally, CT scanning is the preferred method of diagnosing different types of cancers like liver, lungs and pancreatic cancers (Nordqvist, 2009). The tomographic images produced by the CT scan provide specific location and size of the tumor along with the details of affected tissues in the proximity of the tumor. This is especially advantageous in planning, guiding, and monitoring therapies like radiotherapy (FDA, 2010). CT scanning has various benefits over other traditional diagnostic techniques; some of the benefits are (RadiologyInfo, 2009): It is non-invasive, painless and extremely accurate. A major advantage is the ability to identify and distinguish bones, soft tissues and blood vessels in the same image. It also provides real time images which cannot be done in conventional X-rays. This technique is fast and simple; and is extensively used to locate internal injuries after accidents. It is less sensitive towards patient movement as compared to MRI. CT scanning can be used on patients with medical implants unlike the MRI. For an effective radiation therapy treatment, it is necessary that only the tumor is irradiated while minimum damage occurs to the surrounding health (normal) body tissues (Badcock, 1982). This is achieved with the help of CT imaging technique. In a study by Badcock (1982), 186 patients with various malignancies were studied and it was found that in nearly 39% of the treatment cases CT scanning was valuable in the assessment of the radiationdose calculation (Badcock, 1982). According to his study, CT scanner resulted in an alternation in target dose by more than 5%, (as compared to the traditional methods) in 27% of the patients (Badcock, 1982). The result has been shown in the table below. The mean alternation was 6.5% of the target dose and usually resulted in reduction of dose per fraction by factors upto 35% (Badcock, 1982). Even with these advantages, the adverse affect of the ionizing x-ray radiations cannot be neglected. Various experiments and researches have consolidated the fact that ionizing radiations like x-rays, gamma rays etc have adverse effect on living tissues. Zamanian Hardiman (2005) have explained that when high energy ionizing radiations interact with living tissues they strip-off atoms and molecules from them. This disrupts the chemical reaction within the body and failure in organ functioning (Zamanian Hardiman, 2005). The adverse effects of ionizing radiations were seen shortly after its discovery in 1890s, with a scientist involved in the study of radioactivity were reported with skin cancer in 1902. But is was not until 1944, that the role of radiations in causing leukemia in human was first documented, mainly in radiologists and physicists (Zamanian Hardiman, 2005). In recent years the use of x-rays has extensviely increased in medical field for diagonostic and treatment application. According to the U.S. Environmental Protection Agency, X-ray deveices are the largest source of man-made radiation exposure (US_EPA, 2007). According to NCRP Report No. 160 (2006), the average annual effective dose per individual in the US population, from all sources has increase from 1.7mSv in 1980s to 6.2mSv in 2006. This increase is mainly attributed to the striking growth of high dose medical imaging procedures that utilize x-rays and radionuclides (NCRP, 2008). Such man-made devices include X-ray machines, CT scans etc. CT scans, especially result in high dose x-ray exposure, with nealy 100 times the exposure dose as compared to standard x-ray equipments (Coach, 2008). Some of the major risks associated with CT scanning are: It is well documented that ionizing radiaitons like x-rays have the ability to cause cancer on exposure. Therefore, the CT dose in radiotherapy increase the probabilty of cancer in the future. Even though only 4% of the total x-ray examinations are CT scans, they account for more than 20% of the radiation dose to the population by medical x-rays (King Saud University, 2004). In general, the effective dose in a CT scan procedure ranges from 2 mSv to 10mSv, which is nearly equivalent to the amount of radiation that a person receive from the background exposures in three to five years (RadiologyInfo, 2009). A CT scan during preganacy make cause serious illness or even birth defects in the unborn baby (FDA, 2010). Children are more sensitive and vulnerable to x-ray exposures than the adults, therefore their CT scanning should be done only under extremely essential and necessary conditions. Women have higher risk of developing cancer in the lifetime, as compared to men under same levels of exposure (FDA, 2009). In some rare situation of high-dose prolonged radiation exposure, the x-rays can cause adverse effects like skin reddening (erythema), skin tissue injury, hair loss, cataracts etc (FDA, 2010). In a study, Sawyer et al (2009) estimated the effective dose resulting from a cone beam CT scanning for planning of radiation therapy using thermoluminescent dosemeters (TLDs) for organ dose and using International Commission on Radiological Protection (ICRP) 60 tissue weighing factor (Sawyer et al., 2009). The results obtained for effective dose from TLD measurements and ICRP 60 weighting factor, for breast, pelvis and head simulation have been shown in the table below. The scanning process results in the exposure of the normal tissues outside the treatment volume (Waddington McKenzie, 2004). It is thus important to analyze the effect that the irradiation caused by the CT scanning process has on the patients body. In a study, Waddington McKenzie (2004) analyzed the propability of developing cancer from the irradiations caused by the extended field portal imaging techniques, the results of which are given in the table below (Waddington McKenzie, 2004). In order to illustrate a real life situation, the calulations in the study were done for an average man with a height of 170 cms and weight of 70 kgs (Waddington McKenzie, 2004). Therefore, these values may change depending upon the height, weight and tumor size of the patient. Discussion Various studies have been done to statistically evaluate the effect of the ionizing radiations on the human health. These risks have severely amplified due to the rapid increase in the number of CT scans for diagnostic applications. CT scans form nearly 5% of all procedures used in diagnostic radiology in the developed countries (Wrixon et al., 2004). In U.S., nearly 70 million CT scans were done in 2007 as compared to just 3 million done in 1980 (Steenhuysen, 2009), this includes more than 4 million children in 2006 (Brenner Hall, 2007). Thus, according to the NCRP Report no. 160, the average radiation dose per person has increased from 3.6 mSv in early 1980s to 6.2 mSv in 2006 (NCRP, 2008). Steenhuysen (2009) has reported that the radiations from CT scans done in 2007 will cause 29,000 cancers and kill nearly 15,000 people in America (Steenhuysen, 2009). These stats explain the level of exposure caused by the CT scans. According to estimates by Amy Berrington de Gonzalez of the National Cancer Institute, Development of CT Scans for Cancer Studies Development of CT Scans for Cancer Studies According to the statistics presented by the World Health Organization (WHO), with around 7.4 million deaths (around 13% of the total death) in 2004, cancer is the leading cause of death throughout the world (WHO, 2009). These levels are expected to rise further in future, with an estimated 12 million death in 2030 (WHO, 2009). There are more than 100 different types of cancer (Crosta, n.d.), among them the Lung cancer, stomach cancer, colorectal cancer, liver cancer and the breast cancer are the most common types. Tobacco is the most important risk factor for cancer, with nearly 1.3 million deaths per year just due to lung cancer alone (WHO, 2009). Cancer At the primary level, human body consists of large number building blocks, called the cells. Under normal circumstances, new cells are formed by the body depending on the body requirement, in order to replace the dead cells. But sometimes, under abnormal conditions, there is an exponential (uncontrolled) increase in the formation and growth of new cells. The accumulation of these extra cells forms mass or lumps of tissues, called the tumor (National Cancer Institute, 2010). Most of the cancers, in general form tumors, but there are certain exceptions, like leukemia, that do not form tumors (in leukemia or blood cancer, the cancer cells hinder the normal blood functions due to abnormal cell disintegration in the blood stream (Crosta, n.d.)). The tumors can be of two types; benign tumor and malignant tumor. The benign tumors do not propagate to other sections of the body and have restrained growth (Crosta, n.d.), whereas the malignant tumor cells have the ability to invade into the sur rounding tissues. Also the malignant tumor cells can escape from their initial location and spread to other sections of the body through blood or lymph. Only the malignant tumors are cancerous in nature. Therefore, the cancer has three distinctive properties that distinguish malignant tumors from benign tumors: Uncontrolled growth Invasive nature Metastasis (ability to spread to other sections of the body) These disorders in cells are the result of the interaction between the genetic factors and external agents (which are called carcinogens) (WHO, 2009). The carcinogens can be categorized as (WHO, 2009): Biological carcinogens, like certain bacteria, viruses or parasites. Physical carcinogens, which includes the high energy radiations (ionizing radiations). Chemical carcinogens, these include substances like tobacco smoke, arsenic (water contaminant), aflatoxin (food contaminant), asbestos etc. Another factor essential in the development of cancer is the age. According to the studies conducted by the Cancer Research UK, the risk increase predominantly with increasing age, with nearly 74% of the cases of cancer diagnosed in people aged 60 and above (Cancer Research UK, 2009). Cancer Treatment Principle In case of normal cells there is specific pattern of growth, division and death (orderly destruction of cells is called apoptosis) (Crosta, n.d.). It is known that the cancer is the result of the uncontrolled growth of cells which do not die (Crosta, n.d.), that is, the apoptosis process fails in the cancer cells. The cancer cells thus do not die and rather continue to grow, resulting in the formation of tumors. As the problem in the cancer cells lies in the DNA, therefore a possible treatment of cancer is the destruction of the DNA in cancer cells, leading to a self initiated destruction of the cells. There are various methods used for the treatment of cancer depending upon the type of cancer. The most common types of treatment are (Fayed, 2009): Surgery Chemotherapy Radiation therapy or Radiotherapy Biologic or Targeted Therapy Radiotherapy Radiotherapy, also referred to as radiation therapy, is one of the most common types of treatments used for cancer. It is the utilization of higher energy radiations like x-rays, gamma rays in order to kill cancer cells, treatment of thyroid disorder and even some blood disorders, in a particular section (effected part) of the body (Nordqvist, 2009). The high energy ionizing radiations can be produced using a number of radioactive substrates like Cobalt (60Co), Radium (228Ra), Iodine (131I), Radon (221Rn), Cesium (137Cs), Phosphorus (32P), Gold (198Au), Iridium (192Ir), and Yttrium (90Y) (Howington, 2006). The cancer cells have the ability to multiply faster than other body cells. The high energy ionizing radiations are more destructive towards the faster growing cells, and thus they damage the cancer cell more than the other body cells (Mason, 2008). These high energy radiations like gamma rays and x-rays; especially damage the DNA inside these cancer cells (or tumor cells) thereby annihilating the ability of the cells to reproduce or grow. Apart from treatment of cancer, radiation therapy is also used to shrink a tumor before being surgically removed (Mason, 2008). Depending upon the method of irradiation, the process of radiation therapy is categorized into two forms (Mason, 2008): External Radiotherapy In this method (more common), the infected part of the body (tumor) is irradiated by high energy x-rays from outside the body. Internal Radiotherapy For this method, a radioactive substance are injected (or taken orally) into the body (close to the tumor) in the form of fluids. These substances, taken up by the cancer cells, radiate the tumor through internal beam radiation (or interstitial radiation) (Mason, 2008). Radiotherapy Planning A careful planning is essentially required for radiation therapy, as over exposure can be critically dangerous to healthy tissues in the body. The ionizing radiations have side effects, therefore once the full dose of radiations is decided; the patient is given these radiations in the form of small doses in a series of therapy sessions (Cancer Research UK, 2009). Each small dose of radiation is called a fraction. The gap between sessions provides the recovery time for the body, which may depend on the type of cancer and patients health condition. The area of the body that is radiated during the treatment is called the radiotherapy field and the section inside the body that experiences the maximum exposure dose is called the target volume (Cancer Research UK, 2009). The doctors decide the marginal area around the tumor that should be radiated to encapsulate any movement of the cancer cells. In order to accurately determine the position of tumor (or target volume), body scans are done. Computed Tomography (CT) scans are done as a planning procedure, this provides vital information regarding the location of the tumor as well as the kind of treatment required by the patient (Cancer Research UK, 2009). The radiotherapy treatment planning process can be divided into 6 major steps . Computer Tomography (CT) Scan The invention of Computer Tomography (CT) scanned is credited to Sir Godfrey Hounsfield in early 1970s, for which he along with Allen Cormack, was awarded the Nobel Prize in 1979 (Smith, n.d.). A CT scanner, also known as the Computed Axial Tomography (CAT) scanner uses X-rays to produce cross sectional images (or slices) of the body like a slice in a loaf of bread (FDA, 2010). The word tomography suggests the process of generating a two-dimensional image of a slice or section through a 3-dimensional object (a tomogram) (Nordqvist, 2009). These cross-sectional slides render an accurate picture of the size and location of the tumor along with the position of major organs in the body (Cancer Research UK, 2009). This would be essentially useful during the radiotherapy process, where these can be used to lower the dose of radiations on the organs. It is known that in case of radiation therapy treatment, the doses are given in fractions over a certain period of time (to prevent major side effects), which may vary from few weeks to months. Thus, before each fraction of radiation dose, computed tomography (CT) scan of the patients is done to determine the exact location of the tumor or cancer cells. So in case the full dose has been divided into 30 fractions, then the patient has to undergo 30 CT scans, each before a fractional therapy. The machine used for the radiation therapy planning is known as the simulator (Cancer Research UK, 2009). The simulator identifies the position of the tumor and marks the position of radiation on the body with the help of light rays. The radiographer uses ink markers on the body before the actual radiotherapy is begun. These linear ink marks are used by the radiographer for positioning the machine for radiotherapy (Cancer Research UK, 2009). Simulators take the pictures (CT scans) in the form of X-rays, which locates the accurate tumor position for the radiographer to carry out the treatment. During a CT scan, it is essential that the person remains completely still so that the measurements are accurate. In order to insure the correct position supports like neck rest, chest board or arm pole are used (Cancer Research UK, 2009). In case of children it is ensured by giving proper sedatives. Sometimes, under critical condition, extra measures are taken in order to prevent essential organs from being radiated during the therapy. These measures include injecting fluids or dyes which mark the position of vital human organs in the CT scan (Cancer Research UK, 2009). These markers may be given orally, through injections or rectally depending upon the requirement. Using this vital information from the CT scans, a treatment plan for radiation therapy is prepared. This plan indicates the position and direction of the radiations during the therapy, so as to minimize the exposure of healthy cells and organs. The scans generated by a CT scanner are in the form of 2 dimensional (2-D) slides, but by the used of digital geometry processing they can be used to generate a 3 dimensional (3-D) images of the body (Nordqvist, 2009). This can be achieved by integrating all the slides (along the same axis) together using a computer system. The CT scan can be understood as a technically advanced format of X-rays machines. The x-rays images are produced by the projection of a broad beam of x-rays on a film after passing through the body (Medindia, 2010). It provides a 2-dimentional projection of the body, where much of the information is lost. In case of CT scan, a thin beam of x-rays is absorbed by the detector after passing though the patients body (Medindia, 2010). Like the x-ray process, the CT scanning is a painless process for the patients but has been known to be accompanied with some side effects. These side effects may vary from the patient to patient depending upon the amount of radiation dose and health of the patient. The detailed discussion on the health effects of CT scanning has been discussed in the later sections of the project. Theory In order to understand the working of a computed tomography (CT) scanner it is essential to understand the properties of ionizing radiations (X-rays) used in the scanning process. The electromagnetic radiations are the arrangement of electric-field and magnetic-field vectors perpendicular to each other and also perpendicular to the propagation direction of the wave (Resnick et al., 2009). These Electromagnetic radiations have penetrating powers, which are directly dependent on the energy (or frequency) of these radiations. So that radiations with higher frequency have higher penetration powers. Therefore, on the basic the energy, the electromagnetic radiations are categorized as Non-ionizing radiations and Ionizing radiations. Non-Ionizing radiations refer to the electromagnetic radiations which have energy lower than that required for an atomic ionization (MIT, 2001). The non-ionizing radiations include radio waves, micro waves, visible light etc. These radiations have lower penetration powers. Alternatively the Ionizing radiations are the high frequency radiations which have enough energy to knockout an electron from an atom and thus causing ionization (MIT, 2001). The Gamma rays and X-rays are the common type of ionizing radiations. Even the alpha particles and beta particles emitted in a nuclear reaction are ionizing radiations (MIT, 2001). Due to the higher energy they have higher penetration power than the non-ionizing radiations. Principle of CT Scanning The most important section of a Computed Tomography (CT) scanning is the interaction of the ionizing X-ray radiations with the living tissues in the body. When the ionizing radiations (X-rays) interact with the living tissues in the body, they break up atoms and molecules from the living tissues and disrupt chemical reactions within the body (Zamanian Hardiman, 2005). The intensity of absorption of the x-ray radiations by the body varies depending upon the tissue coming in interaction. Different body tissues have different absorption power, where some are permeable to x-rays others are impermeable (Medindia, 2010). It is due to this difference in the absorption ability of different sections of the body, which results in the generation of a graded pattern in the scans. High density tissues like the bones appear white in the scan while the soft tissues (like brain and kidneys) appear dark. The cavities (like the lungs) are seen as black sections in the scan (Medindia, 2010). Therefore, this gradation in the pattern can be used as method to distinguish different body organs depending upon their absorption capacity. This forms the basic principle behind the working of an X-ray scanning. Radon (1917) was the first to develop the principles of computed tomography (CT) mathematically (Bushberg et al., 2002). According to Radon, with the help of infinite number of projections through an object, it could be possible to produce an image of an unknown object. In case of film imaging (as in conventional X-rays), a two-dimensional (2-D) projection of the body is generated on the film. Due to this, details in the dimension of the body along the direction parallel to the x-ray beam are lost. In order to overcome this drawback (only up to a certain level) projections can be taken along two directions; posteroanterior (PA) projection and lateral projection (Bushberg et al., 2002) (as shown in Figure 4). Increasing the number of scans improves the amount of information but in critical and complex cases where much more details are required. For these critical cases, CT scan is done. The CT scan provides the tomographical image, which is the picture of patients body in the sections or slabs. The thickness of these uniform slabs may vary from 1 millimeter to 10 millimeter (Bushberg et al., 2002), according to the program, depending upon the requirement. Each CT image consists of an array of large number of pixels forming a two dimensional (2-D) image, which corresponds to the same number of three dimensional thin rectangular slabs called the voxel. The voxels are the volume element whereas the pixels are the picture element (Bushberg et al., 2002). Every ray from the X-ray source passes (transmits) through the patient before the transmission measurement is done by the detector. Intensity of the un-attenuated x-ray radiation emitted by the source is Io whereas the intensity of the attenuated radiation after transmitting through the patient is given as It. The intensities Io and It are related by the equation (Bushberg et al., 2002):   Ã‚  Ã‚  Ã‚  Ã‚  It=Ioe-ÃŽ ¼t   Ã‚  Where;   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚ µ is the total linear attenuation coefficient of the tissue (Smith, n.d.).   Ã‚  Ã‚  Ã‚  Ã‚  t is the distance travelled by the radiation in the tissue i.e. the tissue thickness. The coefficient  µ is dependent on the atomic number and electron density of the tissues (Smith, n.d.). Higher the atomic number and electron density of the tissues, higher would be the attenuation coefficient (Smith, n.d.). This form the basic principle of CT scanning, that different tissues have different level of attenuation properties depending upon their atomic number and electron density. For every measurement, the overall attenuation coefficient is calculated using the above equation. During a complete 360o ­ scan, various transmission measurements for the intensity of X-ray photon are done. Using these intensity measurements specific attenuation values are allotted to every voxel (volume element). These attenuation numbers are directly proportional to the linear attenuation coefficient. The average of these attenuation values is called the CT number (Smith, n.d.). These values can be arranged on a linear scale, the units of which are called the Hounsfield units (HU). The scale for modern CT scanners varies from approximately -1,000 to 3,000 HU. The attenuation scale is based on binary system and therefore the exact values range from -1,024 to +3,071, with a total of 4,096 (or 212) attenuation numbers. Here, the lower represent the black section while the higher values represent the white section of the CT image. On this scale the attenuation value of water is zero HU and that of air is -1,000 HU (Smith, n.d.). Both of these values act as the reference points. Construction of a CT scanner CT scanner is a complex machine, but the basic structure is simple. A common CT scanner has been shown in Figure 2. Two most important parts of a CT scanner are the X-ray source and detector. The source and detector are placed in a circular structure, which has a shape similar to a doughnut. This doughnut shaped circular opening is called the gantry (RadiologyInfo, 2009), with an inner (opening) diameter varying from 60 cms to 70 cms. The X-ray source and detector are placed exactly (diagonally) opposite each other, so that the radiations emitted by the source pass through the body and the transmitted radiations are measured by the detector. The x-ray source and detector system in the gantry is motorized to rotate around the patient for measurements in different projection angles. The rational speed of the system is adjusted according to the detectors ability to measure and convert the x-ray beam into electronic signal. Cobalt (60Co) is generally used as the source of x-rays in the CT scanners. The detector used in CT scanner consists of an array of detectors in a slightly curved shape (like a banana). This curved shape is especially useful in fan-shaped beam projects. Two types of detectors are generally utilized in the CT scans; solid state or scintillation detector and Xenon gas detector (Reddinger, 1997). But the solid state detectors with scintillators like Cadmium Tungstate (CdWO4), yttrium, gadolinium ceramics etc are commonly used (Bushberg et al., 2002). The principle of the scintillation detector is that, when it is struck by a x-ray photon, it produces light. This light signal is then transformed to electrical signal with the help of photodiode. The Depending upon their structure, the detectors are categorized into two categories; single detector array and multiple detector array. Another essential part of a CT scanner is the motorized examination table. The table is controlled to move in and out of the gantry during the scanning process. As the position of the x-ray source and detector is fixed therefore the section being scanned is controlled by the movement of the examination table. For a better scan it is necessary that the patient remains completely still. To insure this table is equipped with neck rest, chest board and arm pole (Cancer Research UK, 2009). The detector measures the intensity of the radiation and converts them into electrical signals. These raw signals are analyzed and manipulated by the computer to convert them into images which can be understood by the radiologists and the technicians. Multiple computers are required in a CT scanner. The main computer that controls the operation of the entire system is called the host computer (Imaginis, n.d.). The computers and controls are located in a room adjoining the scanning room. This prevents the technicians and the radiographer from exposure to x-rays. Scanning Procedure in a CT scanner Initially the patient is positioned on the examination (or scanning) table in a flat upright posture (face towards the roof). In order to insure the correct and stationary position, straps and pillows may be used along the body. Once the patient is correctly positioned on the scanning table, the motorized table moves the patient into the circular opening of the CT scanner (FDA, 2010), which the x-ray radiations are projected on the patient from the scanning. For a particular position of the x-ray source and detector, the rays from the source pass through a region called the projection or view. There are two different types of projection geometries that are used in CT scanning; parallel beam geometry and fan beam geometry. In the parallel beam geometry, the rays projected on the patient are parallel to each other whereas in fan beam geometry, the rays diverge from the source in the shape of a fan (Bushberg et al., 2002) as shown in Figure 7. The fan beam projections are the most commonly in used x-ray projections in the CT scanners. The X-ray tube is attached with a collimator which controls the thickness of the fan beam. This thickness (of the fan beam projection) determines the width of the tissue slide in the scanning process. It is through the collimator that the slice thickness is varied between 1mm to 10mm (Smith, n.d.). The x-ray source and detector rotate around the patient (for imaging) in a circular motion such that they always remain exactly (diametrically) opposite to each other (as shown in Figure 7). During the rotation the source keeps emitting x-rays which are attenuated after passing through the patient. For a single projection (or slice), the x-ray source and detector make a complete 360o rotation around the patient. During the rotation the detector takes a large number of snapshots of the absorbed X-ray beam at different projection angles. A single image may involve approximately 800 rays and there can be up to 1,000 different projection angles (Bushberg et al., 2002). Therefore for a single projection (one slice), the detector does nearly 800,000 transmission measurements (Bushberg et al., 2002). The scanning of a single projection generally takes around 1 sec (for axial CT scanners) (FDA, 2010). Once all the transmission measurements (complete 360o) for a projection (or slice) are completed, the motorized table moves along the axis of the gantry so that the next slice of tissues forms the projection view. The process is continued till the complete required section of the body has been scanned. In the traditional CT scanners, the table moved on to the next projection (slice) only when the scanning of the previous was completed. Such conventional type of scanning is called the axial scanning. But in modern CT scanners, called the helical or spiral CT scanners, the rotation of the x-ray source and detector is accompanied with the uniform movement of the examination table, thus producing a helical projection. The helical CT scanning has been shown in Figure 9. These modern helical CT scanners are much faster than the traditional scanners due to continuous scanning process. They have been reported to take nearly half the time for scanning as compared to the traditional CT scanner s. In order to analyze and study the cardiac structure which is under constant motion, even helical CT is ineffective. For such applications a special CT scanner with an exposure time of 50ms and a maximum exposure rate of 17 images per second are used (Smith, n.d.). These scanners, called the cine CT, freeze the cardiac motion due to extremely low exposure time resulting in a sharp image (Smith, n.d.). These scanners use electron beam to generate x-rays, thus are also known as Electron Beam Computed Tomography (EBCT). In the CT scanning process large volume of data and operations are required to be processed, which is achieved with the help of multiple computers. The detector converts the intensity measurements of the attenuated x-rays in to electrical signals. The main computer, called the hub computer processes these signals and converts them into an image. These images can then be analyzed for radiotherapy planning. Result Computed Tomography (CT) has become an invaluable medical tool. It provides detailed 3-D images of various sections of the body like pelvis, soft tissues, lungs brain, blood vessels and bones (Nordqvist, 2009). Generally, CT scanning is the preferred method of diagnosing different types of cancers like liver, lungs and pancreatic cancers (Nordqvist, 2009). The tomographic images produced by the CT scan provide specific location and size of the tumor along with the details of affected tissues in the proximity of the tumor. This is especially advantageous in planning, guiding, and monitoring therapies like radiotherapy (FDA, 2010). CT scanning has various benefits over other traditional diagnostic techniques; some of the benefits are (RadiologyInfo, 2009): It is non-invasive, painless and extremely accurate. A major advantage is the ability to identify and distinguish bones, soft tissues and blood vessels in the same image. It also provides real time images which cannot be done in conventional X-rays. This technique is fast and simple; and is extensively used to locate internal injuries after accidents. It is less sensitive towards patient movement as compared to MRI. CT scanning can be used on patients with medical implants unlike the MRI. For an effective radiation therapy treatment, it is necessary that only the tumor is irradiated while minimum damage occurs to the surrounding health (normal) body tissues (Badcock, 1982). This is achieved with the help of CT imaging technique. In a study by Badcock (1982), 186 patients with various malignancies were studied and it was found that in nearly 39% of the treatment cases CT scanning was valuable in the assessment of the radiationdose calculation (Badcock, 1982). According to his study, CT scanner resulted in an alternation in target dose by more than 5%, (as compared to the traditional methods) in 27% of the patients (Badcock, 1982). The result has been shown in the table below. The mean alternation was 6.5% of the target dose and usually resulted in reduction of dose per fraction by factors upto 35% (Badcock, 1982). Even with these advantages, the adverse affect of the ionizing x-ray radiations cannot be neglected. Various experiments and researches have consolidated the fact that ionizing radiations like x-rays, gamma rays etc have adverse effect on living tissues. Zamanian Hardiman (2005) have explained that when high energy ionizing radiations interact with living tissues they strip-off atoms and molecules from them. This disrupts the chemical reaction within the body and failure in organ functioning (Zamanian Hardiman, 2005). The adverse effects of ionizing radiations were seen shortly after its discovery in 1890s, with a scientist involved in the study of radioactivity were reported with skin cancer in 1902. But is was not until 1944, that the role of radiations in causing leukemia in human was first documented, mainly in radiologists and physicists (Zamanian Hardiman, 2005). In recent years the use of x-rays has extensviely increased in medical field for diagonostic and treatment application. According to the U.S. Environmental Protection Agency, X-ray deveices are the largest source of man-made radiation exposure (US_EPA, 2007). According to NCRP Report No. 160 (2006), the average annual effective dose per individual in the US population, from all sources has increase from 1.7mSv in 1980s to 6.2mSv in 2006. This increase is mainly attributed to the striking growth of high dose medical imaging procedures that utilize x-rays and radionuclides (NCRP, 2008). Such man-made devices include X-ray machines, CT scans etc. CT scans, especially result in high dose x-ray exposure, with nealy 100 times the exposure dose as compared to standard x-ray equipments (Coach, 2008). Some of the major risks associated with CT scanning are: It is well documented that ionizing radiaitons like x-rays have the ability to cause cancer on exposure. Therefore, the CT dose in radiotherapy increase the probabilty of cancer in the future. Even though only 4% of the total x-ray examinations are CT scans, they account for more than 20% of the radiation dose to the population by medical x-rays (King Saud University, 2004). In general, the effective dose in a CT scan procedure ranges from 2 mSv to 10mSv, which is nearly equivalent to the amount of radiation that a person receive from the background exposures in three to five years (RadiologyInfo, 2009). A CT scan during preganacy make cause serious illness or even birth defects in the unborn baby (FDA, 2010). Children are more sensitive and vulnerable to x-ray exposures than the adults, therefore their CT scanning should be done only under extremely essential and necessary conditions. Women have higher risk of developing cancer in the lifetime, as compared to men under same levels of exposure (FDA, 2009). In some rare situation of high-dose prolonged radiation exposure, the x-rays can cause adverse effects like skin reddening (erythema), skin tissue injury, hair loss, cataracts etc (FDA, 2010). In a study, Sawyer et al (2009) estimated the effective dose resulting from a cone beam CT scanning for planning of radiation therapy using thermoluminescent dosemeters (TLDs) for organ dose and using International Commission on Radiological Protection (ICRP) 60 tissue weighing factor (Sawyer et al., 2009). The results obtained for effective dose from TLD measurements and ICRP 60 weighting factor, for breast, pelvis and head simulation have been shown in the table below. The scanning process results in the exposure of the normal tissues outside the treatment volume (Waddington McKenzie, 2004). It is thus important to analyze the effect that the irradiation caused by the CT scanning process has on the patients body. In a study, Waddington McKenzie (2004) analyzed the propability of developing cancer from the irradiations caused by the extended field portal imaging techniques, the results of which are given in the table below (Waddington McKenzie, 2004). In order to illustrate a real life situation, the calulations in the study were done for an average man with a height of 170 cms and weight of 70 kgs (Waddington McKenzie, 2004). Therefore, these values may change depending upon the height, weight and tumor size of the patient. Discussion Various studies have been done to statistically evaluate the effect of the ionizing radiations on the human health. These risks have severely amplified due to the rapid increase in the number of CT scans for diagnostic applications. CT scans form nearly 5% of all procedures used in diagnostic radiology in the developed countries (Wrixon et al., 2004). In U.S., nearly 70 million CT scans were done in 2007 as compared to just 3 million done in 1980 (Steenhuysen, 2009), this includes more than 4 million children in 2006 (Brenner Hall, 2007). Thus, according to the NCRP Report no. 160, the average radiation dose per person has increased from 3.6 mSv in early 1980s to 6.2 mSv in 2006 (NCRP, 2008). Steenhuysen (2009) has reported that the radiations from CT scans done in 2007 will cause 29,000 cancers and kill nearly 15,000 people in America (Steenhuysen, 2009). These stats explain the level of exposure caused by the CT scans. According to estimates by Amy Berrington de Gonzalez of the National Cancer Institute,

A New Look at Flagstaff :: Personal Narratives College Essays

A New Look at Flagstaff Flagstaff has always been an exciting and interesting town to me. When I decided to go to college here, I wanted to go someplace with a fun outdoorsy atmosphere where there would always be new stuff to do. I think I have found the excitement and adventure I was looking for in the somewhat small and comfortable city of Flagstaff. Through my new experience and my time in Flagstaff, I have found myself to be a stronger and well rounded person. When I found out the assignment of doing something new in Flagstaff, I was excited because it gave me a chance to make myself get out of my comfort zone and try something different. I first decided that I wanted to go hiking, but then decided it was too cold. By Sunday night, the weekend was almost over and I still hadn’t done anything totally different. So I decided to be bold and ask a new friend, Jim, from class if he wanted to go out and do something. At least I would be doing something with someone I don’t usually hang out with, so that would give me something to write about. Jim and I decided we would go bowling, which I actually hadn’t done since I’ve been in Flagstaff. We got to the bowling alley and found that many people had the same idea of what to do on a Sunday night. The bowling lanes in Flagstaff are much different than the lanes in my home town. The lanes here are small and there are about 15 of them. There is also only one bowling alley in all of Flagstaff, which is weird because in my home town, we always have to choose between ten different places to go when we decide to go bowling. Since there were so many people at the lanes, the man told us it would be a two hour wait for a lane. So we decided not to wait, and to simply find something else to do. Jim and I ended up going to the pool hall in town, which I didn’t even know existed.

Steroids and Sports Essay -- Sports Argumentative Drugs Essays

Steroids and Sports Steroids, ever since their introduction into the sports world five decades ago, they have been a controversial issue (WebMD medical news). Anabolic performance dates as far back as the original Olympic Games. Today walking into any gym you will find some one who is using steroids or some kind of enhancement supplement. Anabolic steroids are so popular with athletes from high School level all the way up to the top. For the past fifty years, athletes around the world use steroids to gain muscle mass, and along with regular work-outs try to achieve the results they desire. Kids today using these drugs are getting younger and younger every day. But is it worth the cost? I believe the ban on steroids should be strictly enforced because besides the health risks it provides, it also compromises the integrity of the game in sports. The history of anabolic steroids can be traced back to the 1930's when a team of scientists first produced synthetic testosterone. The purpose of this synthetic steroid was to improve malnutrition and muscle loss in patients. In to the sports arena they were first introduced by the German athletes in preparation for the 1936 Olympic Games (Measles 2). The Russian Weight-lifting team won several metals in 1952 Olympic Games due to the use of "synthetic testosterone (Measles 54). After this American sport's physicians determined the US athletes should have the same completive advantage, and so the Americans started to use steroids. By the 1968 Olympic Games in Mexico City, the debate was not over the ethical or moral use of the drugs, but whether which drug was more effective. By 1969 all was in the open; the talk among users was all praise of the effect steroids had on performance (M... ...ung athletes should be encouraged to rely on their natural talents and strengths for the sake of fair play and medical safety. Anabolic steroids improve strength but that doesn't necessarily make you a better player. Work Cited Anabolic steroids in Sport and Exercise. Second edition. Charles E. Yesalis, MPH, ScD the Pennsylvania State University Editor. Explains the history of Steroids and also talks about how it is used in today's sports, and how steroids can be prevented. www.9NEWS.com/acm_news.aspx?OSGNAME=KUSA&IKOBJECTID=b401471f-0abe-42 In this article they talk about the growing use of steroid in sports. INFOFACTS; Steroids : www.drugabuse.gov In this website they talk about the health hazards of using Anabolic steroids. AMETRICAN COLLEGE of SPORTS MEDICINE Steroid survey reveals dangerous trends among users: June 1, 2005. www.acsm.org

Social Conditioning of Boys Essay -- Papers Stereotypes Role Essays

Social Conditioning of Boys As everyone knows, within the human race there are males and there are females. We all figure out what our gender identity is at a young age. For boys, male toys like building blocks and trucks and sports like baseball and soccer help a boy form into what society considers to be a man. Society believes that boys should grow up to be strong, dependant and bread winning in order to be a real man. These social standards that are expected from boys, can also be explained by social roles. We are cast into social roles at the moment we are born. These social roles construct boys to be a certain way and follow the set boy code. Boy’s are taught to stay clear from emotional openness, vulnerability, and dependance. We are also taught to not let others know when we feel scared , depressed or when we are happy and in love. The most important rule altogether for boys, is to stay away from anything that people think of as being feminine. Society has made it clear that in order to be a ‘real man’, you must be a leader, successful, in control, confident, d...

A Study on Workplace Stress Among Women Working

A STUDY ON WORKPLACE STRESS AMONG WOMEN WORKING IN BANKING INDUSTRY By ASSISTANT PROFESSOR: CHARU MODI ABSTRACT Women in India have served a lot after independence. From just a experienced homemaker, women today have gained skills and potential of not just being a homemaker but being at parity with their male counterpart. Moreover, varying roles of working women, they have preserved the conventional work culture of household. Now a day the companies are thriving towards high rate that the women have to work for longer hours to sustain the standard of living and accomplish their basic needs.In spite of having the recent technologies and services, women feel to be work loaded and stressed. The abstract literature on stress recommends that working women are lying on to the same face stressors practiced by working men. So far, women are also confronting with possibly exceptional stressors such as inequality, social disconnection, and work/home classes. Stress arises because of many cause s which are emphasized in the research paper. The research paper also contains reasons of stress and how to ease the stress and rise above such problems by the working women at their workplace.KEYWORDS: Workplace, Stress, Working Women. INTRODUCTION Know About Stress Stress is a mood that is formed when we respond to particular events. It is the body's manner of growing to a challenge and getting ready to meet a strong situation with focal point, power, energy, and sensitive alertness. [9] Stress is a normal physical reaction to actions that make you feel endanger and disturb your balance in some way. Fortunately, research shows that lifestyles vary and stress-reduction techniques can facilitate people learn to cope up with stress. 1] Stress refers to the tension from the argument between external environment and internal environment, guiding towards emotional and bodily pressure. [9] In this fast moving world, it is not viable to live without stress, whether it is a student or work ing women. There is both constructive and destructive stress, depending on each individual’s exclusive observation of the force between the two factors. Not all stress is terrible. For instance, constructive stress, also known as eustress, [17] can assist a person to perform a task at best efficacy and effectiveness.Therefore, it is clear that some form of constructive stress can adjoin more shades and enthusiasm to lives. The presence of a target, for example, can drive to make the most of the moment pleasurable and generate enhanced value. It is considerable to keep this in mind, as stress management signify to use stress to our benefit, and not on eliminating the occurrence of stress in our lives. [8] I. 4. Present Status Psychological Well Being The present status of women in the current working environment can be demonstrated using some current data on the working women culture. [11] FIG 1. PSYCHOLOGICAL WELL BEINGSource [11] DIFFERENT TYPES OF STRESS: External and Inter nal Stressors [1] People can get known with stress from outer or inner causes. * Outer stressors include adverse physical state or distressing psychological atmosphere (such as poor working conditions or unpleasant relationships). [9] * Inner stressors can also be physical (viruses and other diseases, irritation) or psychosomatic (such as deep worry about a destructive event that may or may not occur). [9] * Severe or Unrelieved Stress Stressors can also be defined as temporary (severe) or lasting (unrelieved). Severe Stress.Severe stress is the reaction to an instantaneous threat, usually known as the fight response. The threat can be any circumstances that are supposed, even subconsciously or incorrectly, as a threat. Common severe stressors include: * Noise (which can cause a stress answer even during sleep) * Crowding * Isolation * Starvation * Danger * Illness * Hi-tech equipment effects (playing videotape ,playoffs, regularly buzzing mobile phones) * Visualizing the threat or detection of a precarious incident Under most conditions, once the severe threat has agreed, stages of stress hormones come back to normal.This is known as the repose reaction. Unrelieved Stress. Often, up to date life poses ongoing stressful conditions that are not short-lived. The recommendation to take action (to fight or flee) must thus be cautiously handled. Stress, after that, turns into unrelieved. Common unrelieved stressors contain: * Ongoing extremely pressured work * Long-term relationship problems * Lonesomeness * Constant financial worries WORK PLACE STRESS: Stress at work is quite a new perceptible fact of contemporary lifestyles. Occupational stress adds a load to physical health.Work related stress in the life of controlled workers, thus, have an effect on the wellbeing of organizations. Stress, either fast or steady, can bring risky body-mind disorders. Instant disorders such as nervousness attacks, worry, sleeplessness, tenseness and muscle pain can all result in u nrelieved health problems. It has an effect on immune system, cardiovascular and nervous systems and direct individuals to regular addictions. Like â€Å"stress reactions†, â€Å"relaxation responses† and stress management techniques are some of the important built-in response systems.Unfortunately, at present, don't get peaceful and calming situations without asking. For relaxation one has to struggle to create such circumstances. [19] This study is carried out to investigate that how much the women workforce of the banks are strained and how do the pressure of work influence their occupation life, societal life, productivity etc. In order to do so a sample of 10 women employees are selected from each of the three banks for the research of workplace stress among them. Symptoms of Work StressIt is no surreptitious that stress and associated disarray is being considered as generally regular cause of employee disability. Managing of workplace stress is leadership account ability. Good leaders who are familiar with the symptoms of stress can manage situations to create more pleasing workplaces and to improve both efficiency and the bottom line. Corporate women who have served in all conditions distinguish stress when they monitor symptoms such as: [7] * Nervousness * Indecisiveness * Petulance * Complaining * Forgetfulness Loss of self confidence * Sleeplessness * Physical tiredness WORKING WOMEN: This is the fresh generation of women, who needs to chase their dream career. But this life is not a couch of roses for everyone. Waken up at sharp 6 in the morning after retiring to bed late at night, crackling up an delicious breakfast for each one while getting the children all dress up for school, taking care of the sundry house needs that require her consideration that's the average working woman's home schedule for all. Things are not easy for her on the work frontage either.The collective-roles that women are have to play these days, bring about ener gy leak both at the bodily as well as mental level. [16] II. OBJECTIVES OF THE STUDY The study on the workplace stress among women is conducted with the following objectives: * To determine the major causes of workplace stress. * To find the steps to reduce work place stress among women. * To find the measures to reduce workplace stress. LIMITATIONS OF THE STUDY The questionnaires were filled by 30 women those who are working in three major Banks of Bhopal i. e. Axis Bank, HDFC Bank and ICICI Bank, so the reach of sample findings was less. 0 women employees of different designations filled the questionnaires. Due to this the opinion of employees differs as they are from different levels/designation. Data are collected from various sources, current articles like from online services, the Internet, and public libraries. The research describes the factors causing stress in the workplace and its impact on women. An effective method of coping with stress is given, but limited to ones exa mined in the primary and secondary resources. LITERATURE REVIEW Women and Workplace Stress: WOMEN ACCOUNTABILITYStress at work, the stress of lifting up children, the stresses that come with growing old parents, some of these circumstances could offer a fairly high sum of stress [12]. When women are faced with collective roles, all of which carry serious demands, they face stages of stress that are high enough to add to fitness problem, neglected work, and a reduced ability to obtain on additional. ACCOUNTABILITY AT OFFICE ACCOUNTABILITY AT HOME Source: [5] An environment with little flexibility or option would be a bigger risk of agony than an atmosphere of no-voice for a working woman.Interestingly, women’s stress matters do not deviate considerably. Women are all-rounder by character and include responsibilities inside responsibilities. [3] Job, relations and dwelling are not detached and the subjects around balance surmount in spite of working for yourself or someone else . The new study from University of Melbourne has publicized that almost 1 in every 5 Victorians working women undergo depression[23] that can be attributed to job stress and more than one in eight or 13 per cent of the working men with depression have trouble due to job stress. 3] The literature on work-related stress has made known many different courses of job related stressors and linked them to such matters as job pleasure and worker yield (Beehr & Bhaget, 1985) [6]. One of the major causes of workplace stress is whether the person is satisfied with the job or not. Many researchers found that job related stress issues are related to role ambiguity, role conflict, employee performance and satisfaction, over work load, need for achievement and organizational effectiveness.In 1976 Research [6] conducted in the financial services sector recognized that stress can also increase the probability of errors and arguments as workers cut corners to achieve targets – 81% believe irri tation in the workplace has pessimistic effect on spirits, 74% are less dynamic when in a bad frame of mind, and 15% work slower (in fear of making a mistake) when their boss is angry. Fear of aggression is often on the minds of individuals who handle cash on a regular basis, and can be a major cause of mental and physical distress (Violence and stress in financial services, 2003).A survey of 1,299 employees from 37 organizations [6] recognized ten causes as the more important providers to employee stress. These were Employees not being free to converse with one another, individual disagreements on the job, Employees not being given charge over their work, insufficient employment or budget, Management and workers not talking frankly, Management supposed as being uncooperative, below average unwell and holiday benefit, lessening in employees profit, Lack of gratitude or return for doing a good job.In one more research â€Å"Managing Stress at Work† by Kate Jenkins conducted in 2001 [6] drew number of factors which add to stress in work places, which are people are working longer hours, taking shorter or no breaks, with increase growth in IT and globalization, decrease in spare time and less sleep and there are more time and travel pressures. (Jenkins, 2001) [6] . Work stress sometimes affects organization by: * Increased rate of absenteeism. * Decreasing rate of dedication to work. * Increasing rate of employees return. * Increasing rate of grievances from clients and customers. Increasing rate of insecure working exercise. * Negatively affecting staff recruitment. [6] With the rapid progression of technology, the rate of work load has increased and thus the stress among working women. To some extent there is the fright from being economized in awful times, leading to better job uncertainty on the part of those who stay [21]. Unquestionably, work-related stress is one of the most frequently quoted stressors faced by persons all over the world. The remark s reported by Lundberg offer some descriptions for why Luecken et l originate that women working in clerical and customer service place who had children at home reported greater than before strain at home, but no increase in strain on the job. [2] While some stress is good for inspiration and growing competence, stress after a limit can result in depressing crash such as reduced efficiency and effectiveness. Most of the people are feeling secluded and upset at work, and this has resulted to better work-related stress. Consulting experts and professionals are being consulted on ways to raise link and inspiration of their employees.Few companies arrange parties and make their workforce feel appreciated at work. These are method to encourage employees and assist them to sense protected at their jobs, interpret into greater yield. On the other hand, not all companies have such method in place. Figure 2 : Model Of Causes And Consequences Of Work-Related Stress * Source: [14] RESEARCH MET HODOLOGY III. Research Design: This study includes exploratory research on the concerned areas relating to working women and the stress levels that are constantly being felt by them at their workplace.I have tried to highlight the situation in context of such problem and tried to suggest some of them for correcting the situation. IV. Data Collection: primary Data was collected with the help of self-administered questionnaire which includes 15 items. Secondary data was gathered from newspapers, magazines and online sources such as websites. Some analytical graphs were also collected to support the research objectives. VI. Sample Size: I have taken the sample of 30 women employees from three different private banks of Bhopal named ICICI Bank, HDFC Bank, AXIS Bank.DISCUSSION & FINDINGS: The Major Causes of Work Place Stress among women are: In the Modern times stresses can take the form of financial needs, or emotional disturbance. Contest at work and an increased workload are also the root cause of greater levels of stress. The stress can be identified by the symptoms as mental symptoms usually experienced include sleeplessness, headaches and an incapability to focus. Physical symptoms like heart palpitations, breathlessness, excessive sweating and stomach-aches.Reasons for stress are? There are many different reasons of stress which are also known as stressors, like Common lifestyle stressors include performance, intimidation, and demise stressors. Performance stressors are generated when a person is placed in a state where she feels a need to shine. This could be during performance evaluation, lunch with the boss, or delivering a speech. Threat stressors occur usually when the present situation poses a risky threat, such as a monetary recession, or from a misfortune.Last but not least, demise stressors take place when there is a feeling of loss such as the fear of losing a loved one, or any other loss. Therefore, there are a variety of stressors, and even more diverse methods and ways of handling with pressure and turning it to our own advantages. The causes which are faced mostly by working women at their workplace in my study at Bank are: * Extended working hours * Harder to balance work and home demands * Under utilization of skills * Unreasonable demands for performance[17] * Underpaid job * Multiple tasks at work Deficient of maintaining interpersonal communication between the employer and the women employees. [15] * Deficient of maintaining interpersonal relationship among the women employees * The fright of losing one's work * Minimum time left to spend with the family [15] * Treated substandard to your male contemporaries. [1] * Experiencing sexually nagging funny story from your superior and male contemporaries. [4] * Very few of the women employees feel that they are suffering from depression while most of the employees experience that that they are liberated from the despair.Most of the women employees worry about their contem poraries view about them whereas hardly any of the women employees are not concerned with the view about their colleague. Most of the women workforce of the bank talk about their difficulty and share their opinion with their other half or associates or others while very few of the women employees are not worried with it. Major part of the women employees job above 8 hours which is the starting point of the stress while few of the women employees don’t work for more than 8 hours.Nearly 50% of the female employee spent regular time on leisure activities which assists them to stay stress free while 3/4th of the women employees don’t do that. Nearly half of the women employees find their social life to be even-handed whereas 2/5th of the women employees don’t have their social life balanced. Very few of the women employees remain silent. Most of the women employees fright the value of performance being offered by them whereas 15 % of the women employees don’t fear the quality of their work. Major part of the sample i. e. round 70 % women workforce try to find the key of their stress while 30% of them do not find any solution. 45% of the women employees try traditional exercises like meditation, naturopathy, yoga and other ancient medicinal methods to decrease their stress whereas 55 % of the women employees use other techniques to reduce stress like resorting to pastime, holiday. After analyzing the data of all the three banks, it is seen that the women employees working in AXIS bank are less stressed out when compared to other banks. It can be for the reason that it’s a brand name and believe in teamwork as their core values.Steps To ease from Work Place Stress among Women: Management of Stress is the requirement of the hour. Though hard we try to go ahead of a stress situation, life appears to discover new behaviour of stressing us out and resulting with nervousness attacks. [18] Furthermore, be it our nervousness, mind-body ti redness or our erring outlooks, we tend to ignore causes of stress and the circumstances generated by those. In such disconcerting instants we often do not recall that stressors, if not avoidable, are reasonably manageable and treatable. [10] Unfortunately, today, they do not get peaceful and soothing situations without requesting.To be stress-free one has to struggle to make such situations. The suggestions range from individually focused actions to broad based organizational policy changes. These include the following: * â€Å"Just smile away and forget everything† An employee of HDFC Bank * â€Å"Talking to family members ,loved ones, Watching TV or listening good music, Going for a walk or long drive† An employee of HDFC Bank * â€Å"Working in environment benefits, lot of optimistic approach. Optimistic approach is only that reduces stress and achieves triumph. † AXIS Bank employee. â€Å"Adjust with others, Find and spend time to go to temple, pray and ta lk to GOD, Study novels, All are the child of the supreme GOD† An employee of AXIS Bank * â€Å"We should do such actions from which we get pleasure and also make people happy. Share your moments of life with your close friends and relatives. † An employee of ICICI Bank. * Provide day care and substitute work preparation as resources for preventing stress. * Provide more job elasticity for women to better manage work home clashes. [22] * Deal with Finances and Treat physically in spa, massage centres in weekends. Get Help by a mate or servant so that time could be spent with family. [22] * Cook if you like it and serve by your hand to family members. [22] * Dropping / Picking up Kids from School in your leave days and then go for a little walk. [22] * When stressed at work for deadlines or otherwise, give priority to your â€Å"me† time first and maintaining home comes second. [13,20] CONCLUSION: In recent years majority of the women discovered that their stress was essentially due to their idleness and also they were happy with fewer responsibilities.Lack of loving behavior from their colleagues, scolding from boss, more working hours, under utilization of skill sets was reported as cause of stress always by maximum percentage of the women. Higher percentage of the respondent experienced stress always because of lack of their involvement in decision making in their organization that reduced their responsibilities on their shoulder and the participatory model followed in their organizational set up enhanced their responsibilities to the point of exhaustion. As women, they need to acknowledge what they have and can do for them to reduce stress.All must remember that old saying, if you don’t look after yourself, no one else will look after you. Honour yourself! SCOPE FOR FUTURE WORK I know that the current level of research may not reveal the exact parameters of stress regarding the causes and suggestions. Therefore, exhaustive researc h shall be carried out in future research work in this particular field. REFERENCES: 1. Brief, A. P. , ; Aldage, R. J. (1998). The self in work organizations: A conceptual Review. Academic of Management Review, 6, 75-88. 2. C. Light Kathleen , â€Å"Psychosomatic Medicine 59:360-361 (1997) 0033-31, Editorial Comment 3.NALAG Centre for Loss ; Grief  © 2008 PRM 003. 1 The Bereavement Buddy Version 1. 1 Last Updated 1 February 2009, pp 1 4. Long C. Bonita,† ERIC Digest† EDO-CG-95-53 5. Pathak Sonal, 2. Dr. Sarin Anil, â€Å"IJMBS Vol. 1, Issue 3, September 2011†,pp 66 6. Rehman Hina, â€Å" Literature Review†, International Review Of Business Research Papers Vol 4 No. 4 Aug – Sept 2008, Pp. 164-166 7. Richardson, A. M. , Burke, R. J. , ; Leiter, M. P. (1992). Occupational demands, psychological burnout and anxiety among hospital personnel in Norway. Anxiety, stress and coping. An international Journal, 5, 55-68. 8. Organizational Behaviour by V.G. Go ndalkar, pp 177-179 9. Stephen P. Robbins ,Timothy A. Judge, Seema Sanghi, Organizational Behavior, 13th Edition, pp 700-703 10. Stein, Franklin, â€Å"Occupational Stress, Relaxation Therapies, Exercise, and Biofeedback†, Psychological Therapy:    A Holistic Approach, Second Edition, 2001, pp. 235-245. 11. Tripathi Parul , Bhattacharjee Sandeep â€Å"Present Status†, Zenith International Journal Of Multidisciplinary Research Vol. 2 Issue 2, February 2012, Pp. 3 12. University of Pennsylvania School of Medicine (November, 2007) . â€Å"Brain Imaging Shows How Men And Women Cope Differently Under Stress: Science Daily†. Online] Available: http://www. sciencedaily. com 13. â€Å"Women suffer more stress at work â€Å"TNN Jul 22, 2010, 14. European foundation for the improvement of living and working conditions 2007(Adapted from Kompier and Marcelissen, 1990) 15. Irene Houtman, Karin Jettingh off, Raising Awareness of Stress at Work in Developing Countries, A m odern hazard in a traditional working environment, Advice to employers and worker representatives, Protecting Workers' Health Series No. 6, pp 17-18 16. http://mm. bharatmatrimony. com/featured-story/288-stress-and-the-working-women

Juvenile Justice: Incarceration vs. Intervention Essay

Abstract The national trend towards getting tough on juvenile crime by altering the juvenile justice system to more closely mirror the adult system was examined in order to determine whether secure confinement of juvenile offenders is as effective as community-based rehabilitative and treatment programs for these youth. Politicians and public perceptions have allowed the juvenile justice system to evolve from one of reform based thinking to one of punishment based thinking, placing more young offenders in secure facilities than ever before. The social repercussions of secure confinement of juveniles, without the use of proper rehabilitative tools, including education and life-building skills, are evident as youth are being ‘set aside’ rather than being encouraged to become productive members of their communities.  Not a day goes by where our national media doesn’t report on stories involving heinous and criminal acts committed by juveniles in the United States. Juvenile delinquency is a fact of life – ranging from minor status offenses to unimaginable acts of violence. When dealing with young offenders, there are always difficult decisions to make concerning appropriate punishments that take both public safety and the needs of the juvenile into account. In response to a recognizable increase in youth crime, getting tough on juvenile delinquency and holding young offenders more accountable has been the national trend in the past two decades  (Brinks, 2004). Many argue that removing juveniles from the environment in which their crimes were committed is the most successful deterrent of future negative behavior. But what does secure confinement provide these troubled juveniles aside from isolation from the negative influences they may be subjected to on the outside? Should young offenders be incarcerated for their crimes as they would be as adults, or is it possible to ‘rehabilitate’ a juvenile delinquent without the use of detent ion or incarceration? Of course, juvenile offenders must be held accountable for their offenses – it is an essential element in the natural process of learning and maturation. However, the immaturity that is seen in children and adolescents is an indicator that these behaviors will not be well deterred by harsh punitive action, but rather be better served by rehabilitative attempts. The fact that young offenders tend to outgrow their nonconformity is even more of a reason to believe that a castigatory approach to these juveniles will not be successful in reaching deterrent or rehabilitative goals (Young & Gainsborough, 2000). Because of these matters, community programs and intense intervention are more effective than secure confinement when it comes to juvenile delinquency rehabilitation. In order to explore the effectiveness of treatment and intervention versus incarceration of juveniles, it is helpful to look at the original intentions of the juvenile justice system and how the system has since evolved. The question of rehabilitation versus incarceration of juvenile delinquents came to a head in the late 1800s, resulting in the creation of the first juv enile court system in the United States. Prior to this time, institutionalized children were held along with adults, and no efforts were being made to teach them the necessary skills they required to make positive contributions to society. After centuries of treating very young children as property, and those over the age of five or six as simply little adults when it came to criminal misconduct, it was finally recognized, and widely accepted, that the developmental differences between juveniles and adults provided an increased opportunity for the successful rehabilitation of juveniles outside of secure confinement. The early years of the juvenile justice system focused on recovering the lives of the juvenile offenders before they were completely immersed in a life of criminal activity. The states took on the role of ‘parents’ or â€Å"parens patriae† (state as guardian) and undertook the  parenting responsibility until the juveniles showed improved behaviors, or became adults. Juveniles were no longer tried as adult offenders, and reform houses, rather than prisons, were used to emphasize behavior reform rather than punishment (Brinks, 2004). The juvenile justice system’s focus on reform continued throughout much of the 20th century. Changes began emerging in the juvenile court system in the mid 1900s. During this time, the main objective of juvenile justice remained focused on reformation rather than criminal punishment, however, principles which were not previously in place, were being established by the Supreme Court, requiring juvenile courts to guarantee specific constitutional protections to young offenders. These protections included the right to be represented by an attorney, the right against self-incrimination and the right to hear the testimony against them (Ramsey & Abrams, 2004, p. 42). Although these rights are in line with constitutional rights afforded adults, many within the juvenile justice system were concerned that the court’s reformative techniques would be lessened if the same constitutional rights were applied to children as to adults. Justice Potter Stewart expressed concern that the court’s decision would â€Å"convert a juvenile proceeding into a criminal prosecution† (â€Å"History of America’s,† 2008). While constitutional rights must now be afforded to everyone, this was the first of many changes which began to alter the historical intent of the juvenile justice system. Until 1980, other changes in the juvenile justice system seemed to consistently refer back to the main objective of its creation. The Juvenile Delinquency Prevention and Control Act of 1968 encouraged states to establish programs geared towards the prevention and rehabilitation of juvenile delinquency at the community level. These programs, once approved, were eligible to receive federal funding. The Juvenile Justice and Delinquency Prevention Act of 1974 built upon the 1968 act and increased nationwide rehabilitative efforts for juvenile offenders. If states wished to receive funding under this act, they were required to remove all juveniles within their jurisdictions from secure confinement facilities and separate them from convicted adults, building on the be lief of writer Morrison Swift who commented on jailing young offenders with adults, â€Å"young and impressionable offenders were being carried off to Rutland with more hardened men, there to receive an education in lawlessness from their experienced associates†Ã‚  (Swift, 1911). Despite these steps towards delinquency prevention, or perhaps because of them, public perception towards an increase in juvenile crime in the 1980s caused radically different changes to begin to take place within the juvenile justice system. In the past two decades, the U.S. has gravitated towards a â€Å"get tough† approach with juvenile delinquents. In the mid 1980s and early 1990s, the U.S. saw a steep rise in violent juvenile crime, a predictable increase in the juvenile population, and many high profile occurrences of youth crime such as public school shootings in Paducah, KY and Columbine High School in Littleton, CO. In 1996, Janet Reno, U.S. Attorney General stated, â€Å"no corner of America is safe from increasing levels of criminal violence, including violence committed by and against juveniles† (Zavlek, 2005). American’s feared that they were under assault by a generation of adolescent time-bombs and that â€Å"only the abandonment of soft education al and rehabilitative approaches, in favor of strict and unrelenting discipline – a zero tolerance approach† could effectively address the issues (Browne, 2003, p. 10). In reaction to these public fears, legislatures resolved to crack-down on juvenile crime, even though by the mid 1990s, juvenile arrest rates for violent offenses were as low as they had been 20 years earlier. State and local laws imposing harsher punishments on juvenile offenders were enacted, and in turn, more youth were brought into the court system for longer amounts of time (McCord, Widom & Crowell, 2001). This led to an extremely large population of young offenders being held, to this day, in secure confinement facilities. Secure juvenile detention facilities have become the most accepted form of punishment for youthful offenders. Although there was a 66% increase in the juvenile arrest rate during the late 1980s and early 1990s, from 139 arrests per 100,000 youth in 1986 to 231 arrests per 100,000 in 1993, there was an even larger, 74% increase in the number of youth confined in secure facilities during that same period. Furthermore, in 2001, when juvenile crime rates were comparable to the rates in 1980, the number of youth confined in secure juvenile or adult detention centers was more than double the number in 1980 – 51,000 on any given day in 1980, compared to 104,000 on an average day in 2001. Additionally, despite the dramatic decline in juvenile arrest rates since 1994, more than 44%, there has not been a parallel decline in youth confinement, which has stayed relatively constant  since 1995 (Sickmund, 2002). This increased reliance on secure detention accommodations brings with it several concerns regarding the present juvenile justice model of confinement. After looking at the apparent trends in the United States in regards to juvenile crime rates and a propensity towards harsher punishments despite a seeming decrease in juvenile delinquency, there are concerns which arise out of the adult adjudication and incarceration of our youth. Melissa Sickmund claims that one of the largest c oncerns about secure detention and confinement of juveniles is overcrowding of facilities. She estimates that 39% of juvenile detention facilities are housing more residents than they are meant to accommodate, creating dangerous situations for management, and hindering opportunities for treatment and rehabilitation (Sickmund, 2002). Overcrowding of facilities presents many challenges for administrators, potential rehabilitators, and the confined youth. Opportunities for educational development, such as obtaining a GED, for youth detained for extended periods of time, are extremely limited. Furthermore, mental health needs cannot be appropriately addressed. It is estimated that between 50 – 70% of juveniles who are incarcerated have diagnosable mental health issues and up to a quarter of those may be suicidal, but access to proper treatment is difficult in crowded facilities (Wasserman, Ko & McReynolds, 2004). In addition to the physical, educational and mental health needs of confined youth not being successfully met, unproven effectiveness of detention and confinement is another major concern. Recidivism rates are extremely high for youth confined in correctional units, such as training schools, where up to 70% of released youth are rearrested within one or two years after their release (Wiebush et al., 2005). Not only are there substantial concerns for the well-being of juveniles in secure facilities, the cost of operating and continuing to construct these facilities is extraordinary. In the year 2000 alone, at least $10-$15 billion was expended in the United States for juvenile justice, most of which went towards paying confinement expenses (Mendel, 2000). Rather than focus on treatment and teaching skills which will help these juveniles become productive members of society, these facilities create a considerable separation from family and community, succeeding only in isolating these youth and making community re-entry difficult (Wiebush et al., 2005). Because of these, and other, issues,  positive alternatives to incarceration for young offenders must be made availab le and used to the fullest extent possible. As is illustrated by the many concerns surrounding the secure confinement of juvenile offenders, its ineffectiveness is apparent, and there are much more advantageous and beneficial alternatives available to these youth. According to Rolf Loeber and David Farrington, secure confinement should be reserved only for those juveniles who are a likely threat to themselves or public safety, and even then, small, community based facilities are preferable. They contend that â€Å"The most effective strategy for treating and rehabilitating juvenile offenders and preventing recidivism is a comprehensive, community-based model that integrates prevention programming; a continuum of pretrial and sentencing placement options, services and sanctions; and aftercare programs† (Loeber & Farrington, 1998, p 333). Community-based curricula are affordable alternatives available to a large number of juvenile offenders, which are intended to decrease crowding, cut costs of maintaining juvenile detention centers, protect offenders from the negative attention of institutionalization, and help sustain positive relationships between the youth and their families and communities while discouraging association with youth who have similar, or more serious criminal histories. One community-based program which has proven to be very effective as an alternative to secure confinement for juveniles is home detention. Home detention requires the offender to remain at home either at all times, at all times when not in school or working, or at night. During home detention, supervisors, normally paraprofessional outreach workers, have much more frequent contact with the youth than traditional probation officers, but the juveniles are allowed to remain with family in their communities (Ball, Huff & Lilly, 1998, p. 158). High levels of success are reported with home detention programs. Studies conducted in California, Ohio and Alabama have reported an 89-97% success rate with their home detention programs, success being measured by recidivism rates, which were generally under 8%, compared to up to 70% for those youth being held in secure detention (Austin, Johnson & Weitzer, 2005). In addition to keeping children within their communities, community-based treatment and therapy has been pegged as one of the most effective treatments for juvenile delinquency. A goal of community-based treatment is to increase parental  authority and supervision as well as focus on any school, family or interpersonal needs or potential problems (Cullen & Gendreau, 2000). There are many successful intensive supervision programs (ISPs) of this type across the country. One such program is the San Francisco based Detention Diversion Advocacy Program (DDAP). Juveniles are referred to DDAP by parents, courts, probation officers or other community agencies. Upon referral to the program, DDAP identifies potential problems, and presents a rehabilitative plan to the court. Offenders live at home, and they and their families are provided with needed services by DDAP case workers. A 2007 study of DDAP found that the recidivism rate of juveniles in this program was less than half that of juve niles who were held in detention facilities for at least 3 days (24 percent versus 60 percent) (Sheldon, 2009). Many reasons were cited for DDAP’s success, including: smaller caseloads, freedom of the caseworkers from administrative limitations of the juvenile justice system, and the program’s emphasis on treatment and educational services along with precise goals to follow the youth’s progress (Sheldon, 2009). Similar programs are also in place for those youth who are unable to return to their homes or families for any reason. Treatment foster care programs are suitable alternative locations in the community for those children who may not be able to live at home. Treatment foster care programs are unlike traditional group homes or foster homes in that the foster care families are actively recruited and specially trained to care for only one youth at a time in their home. The training provided to the foster parents stresses behavior management methods in order to provide the youth in their care with structure and a corrective living environment. Even after training, daily support is provided by case managers through telephone calls and visits. Biological families are also provided family therapy services. Random evaluations of these programs have shown that recidivism rates are lower among these participants than in those in traditional group homes and secure facilities (Greenwood, 2008). Treatment foster care programs are another example of successful alternatives to juvenile detention. As has been shown in the above examples, the research that exists in regards to juvenile justice suggests that community-based alternatives to detention and s ecure confinement of juveniles are at least, and most times more, effective in reducing recidivism rates among young  offenders, while being significantly lower in cost to operate. Despite noticeable decreases in juvenile crime, many jurisdictions are still faced with the problems of overcrowding in their juvenile detention facilities. In addition to the many negative consequences surrounding overcrowding, such as the facility’s inability to maintain safety and security, most youth will simply not benefit from confinement without the use of evidence based programs (Greenwood, 2008). Effectively dealing with juvenile delinquency involves a myriad of issues ranging from the immaturity of young offenders to the changing trends of juvenile crime. When looking at the many possible outcomes of both incarceration and alternate forms of punishment, we should be able to draw a better conclusion about what types of punishments or treatments are most effective for this group of offend ers. As a community, we must focus on opportunities to mentor and grow the youth of today into productive contributors of tomorrow’s society. To achieve this, youthful offenders must be embraced, not forgotten. References Austin, J., Johnson, K. D., & Weitzer, R. U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention. 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