Tables for effective dose assessment from diagnostic radiology (period 1946-1995) in epidemiologic studies.

Diagnostic radiology is a leading cause of man-made radiation exposure to the population. It is an important factor in many epidemiological studies as variable of interest or as potential confounder. The effective dose as a risk related quantity is the most often stated patient dose. Nevertheless, there exists no comprehensive quantification model for retrospective analysis for this quantity. This paper gives a catalog of effective dose values for common and rare examinations and demonstrates how to modify the dose values to adapt them to different calendar years using a quantification concept already used for retrospective analysis of the red bone marrow dose. It covers the time period of 1946 to 1995 and allows considering technical development and different practical standards over time. For an individual dose assessment, if the dose area product is known, factors are given for most examinations to convert the dose area product into the effective dose. Additionally factors are stated for converting the effective dose into the red bone marrow dose or vice versa.

Assessment of the safety climate in outpatient diagnostic services: Development and psychometric evaluation of a questionnaire.

INTRODUCTION: Safe practice and safety culture are important issues in outpatient diagnostic imaging services. As questionnaires assessing safety culture through the measurement of safety climate in this setting are not yet available, the present study aimed to develop and validate such an instrument. MATERIALS AND METHODS: After adaptation of an existing questionnaire and qualitative pretesting, the instrument was tested by collaborators from three outpatient imaging services in Switzerland. Results were first assessed using descriptive statistics. Scores of individual services were compared using a Wilcoxon test assessing differences between rank distributions. The final instrument was tested for validity using inter-rater agreement measures, such as reliability within groups (rWG), and an intraclass correlation coefficient measure (ICC(1)). These measures allowed the assessment of validity of aggregation into a total score (rWG(j)) and validated the instrument for its capacity to distinguish various safety climates of different groups by comparing inter-rater agreement in the overall sample to inter-rater agreement of individual services (rWG) and by measuring group effects (ICC(1)). Furthermore, the final instrument was tested for internal consistency and reliability using Cronbach's Alpha. RESULTS: Safety climate scores vary significantly between services. Inter-rater agreement measures show that item aggregation is justified and that the instrument distinguishes various patterns of safety climate. The final instrument proves to be valid, consistent and reliable. CONCLUSIONS: The final instrument presents a valid, consistent and reliable option to measure safety climate in outpatient diagnostic imaging services. Results can be used as a basis for quality improvement. KEY POINTS: • An adapted questionnaire that assesses safety climate in outpatient diagnostic imaging services was developed and tested in Switzerland. • Psychometric evaluation showed the questionnaire to be a valid, consistent and reliable instrument. • Results are of interest for imaging services as well as for stakeholders interested more globally in monitoring and quality improvement.

Surveillance Scans in Lymphoma: Friend or Foe?

OPINION STATEMENT: Advancements in the treatment of lymphoma over the last few decades have allowed more patients to achieve a remission after the completion of therapy. Due to the improvement in response rates, methods to detect recurrence early and accurately during follow-up, especially in patients with potential curable aggressive lymphomas, are a key. Observation has always involved close clinical follow-up with the use of physical exams and routine labs, but rapid changes in technology have allowed CT scans, PET scans, and MRIs to become an integral part of managing patients with lymphoma. While the utility of scans in initial staging and immediately after completion of therapy is well established, the use of these imaging modalities for monitoring recurrence in lymphoma patients is still controversial. Patient advocacy groups and other regulatory committees have questioned the frequency and in some cases even the need for these tests in patients without evidence of active disease given the concern for radiation-associated health risks. Additionally, the extent to which this form of testing impacts the psyche of our patients is not completely known. Given the numerous questions raised about the benefits, safety, and cost-effectiveness of CT imaging, firm guidelines are needed at this time in standard practice and within our clinical trials to limit the use of surveillance imaging. Such efforts are expected to improve the utility of these scans in asymptomatic patients, reduce healthcare costs, and reduce patient exposure to radiation.

Diagnostic radiology dosimetry: Status and trends.

Since 1970s the expression of protection standards shifted from a dose -to a risk-based approach, with dose limits established to yield risks to medical radiation workers. Worldwide interest in patient dose measurement was stimulated by the publication of Patient Dose Reduction in Diagnostic Radiology by the UK National Radiological Protection Board (NRPB). This has resulted in the development of new dosimetric measuring instruments, techniques and terminologies which present challenges to those working in the clinic al environment and those supporting them in calibration facilities. In this sense, thermoluminescent dosimetry (TLD) has been actively developed in the past last 3 decades thanks to their successful applications in diagnostic radiology. The present work analyzes current status and future trends of diagnostic radiology dosimetry using thermoluminescence phenomena.

Evaluation of diagnostic medical exposure in Republic of Korea.

National statistical data for diagnostic radiation exposure in Republic of Korea were collected from four public institutes and government agencies during the period 2006-2013. The data were pooled, reclassified and analysed. A total of 1574 million exposures occurred during the study period. To evaluate the effective diagnostic radiation exposure dose, the dose conversion factors developed by the Korea Food and Drug Administration were applied. The number of diagnostic radiation exposures was 197 million per year. The collective effective dose averaged 64 043 man Sv y(-1), and the annual per caput effective dose averaged 1.27 mSv. The annual per caput effective dose in 2013 was 1.54 mSv compared with 0.89 mSv in 2006, a marked increase of 73.9 % over the study period. These research data, compiled from reliable sources within the public health system of Republic of Korea, demonstrate a trend of increasing diagnostic radiation exposure and provide valuable information for further research.

Retrospective assessment of self-reported exposure to medical ionizing radiation: results of a feasibility study conducted in Germany.

BACKGROUND: Exposure to medical ionizing radiation has been increasing over the past decades and constitutes the largest contributor to overall radiation exposure in the general population. While occupational exposures are generally monitored by national radiation protection agencies, individual data on medical radiation exposure for the general public are not regularly collected. The aim of this study was to determine the feasibility of assessing lifetime medical ionizing radiation exposure from diagnostic and therapeutic procedures retrospectively and prospectively within the framework of the German National Cohort study. METHODS: Retrospective assessment of individual medical radiation exposure was done using an interviewer-based questionnaire among 199 participants (87 men and 112 women) aged 20-69 randomly drawn from the general population at two recruitment locations in Germany. X-ray cards were distributed to 97 participants at one recruitment center to prospectively collect medical radiation exposure over a 6-month period. The Wilcoxon-Mann-Whitney test was used to test differences in self-reported median examination frequencies for the variables age, sex, and recruitment center. To evaluate the self-reported information on radiological procedures, agreement was assessed using health insurance data as gold standard for the time period 2005 to 2010 from 8 participants. RESULTS: Participants reported a median of 7 lifetime X-ray examinations (interquartile range 4-13), and 42% (n = 83) reported having had a CT scan (2, IQR = 1-3). Women reported statistically significant more X-ray examinations than men. Individual frequencies above the 75th percentile (≥15 X-ray examinations) were predominantly observed among women and in individuals >50 years of age. The prospective exposure assessment yielded a 60% return-rate of X-ray cards (n = 58). 16 (28%) of the returned cards reported radiological examinations conducted during the 6-month period but generally lacked more detailed exposure information. X-ray examinations reported for the period for which health insurance data were available provided a moderately valid measure of individual medical radiation exposure. CONCLUSIONS: The assessment of more recent medical examinations seems in the German National Cohort study feasible, whereas lifetime medical radiation exposure appears difficult to assess via self-reports. Health insurance data may be a potentially useful tool for the assessment of individual data on medical radiation exposure both retrospectively and prospectively.

Protection of patients in diagnostic and interventional medical imaging: collaboration is the key.

The radiology community (medical physicists, radiologic technologists, radiologists, and interventional proceduralists) has led the educational and awareness efforts in the medical arena to reduce radiation dose to patients through effective collaborations that bridge traditional medical specialty silos to reach health worker stakeholders. These successful collaborations have also included both vendors and regulators, with the overarching goal of radiation protection of patients (justification, optimization, and use of dose reference levels). This focus on patients often raises overall safety awareness and lowers occupational radiation doses as well. It is critical that the entire radiology community continue to act as leaders in these radiation safety efforts for both employees and patients. In order to be successful, it is important to understand safety culture and the growing, worldwide, multimedia resources that are available. There is little time or budget to recreate or duplicate training materials or risk communication information that may already exist. Together with the increasingly fast-paced and demanding healthcare environment and sharp focus on quality, it has never been more important to understand how to achieve better quality care for radiology departments. It is also important to measure and report quality for many customers, including patients, referring providers, and many other stakeholders. This short report will briefly define safety culture and describe methods for using collective learning tools that document radiation protection of patients in diagnostic and interventional imaging. These tools include the use of imaging modality registries, such as the Computed Tomography Does Index Registry, peer review of imaging reports, the use of clinical decision support, and guidelines. Finally, the Image Gently and Image Wisely campaigns provide examples of cross-disciplinary collaboration to improve radiation protection of patients.

Surveillance imaging for lymphoma: pros and cons.

There is no international consensus on the optimal frequency or duration of computed tomography or positron emission tomography scanning for surveillance in patients who achieve complete remission after initial therapy for lymphoma. Although some clinical practice guidelines suggest periodic imaging is reasonable, others suggest little or no benefit to this practice. From a theoretical perspective, the frequency and duration of surveillance imaging is largely dependent upon the lymphoma subtype. Aggressive lymphomas with a fast growth rate will require surveillance more frequently and for a shorter duration compared to the indolent lymphomas. Historically, relapse has been detected in a majority of patients based upon clinically evident signs and symptoms. Currently, no study has demonstrated an overall survival difference for patients with relapse detected by imaging as opposed to clinical evaluation, although one study did demonstrate a lower second-line International Prognostic Index in patients with relapse detected by surveillance imaging. Enthusiasm for this finding has been tempered by recent studies highlighting the potential long-term risk of secondary malignancies because of ionizing radiation exposure from diagnostic imaging. These factors along with the significant costs associated with diagnostic imaging have contributed to an ongoing debate regarding the relative costs, risks, and benefits of radiographic surveillance. Herein we present perspectives for and against routine surveillance imaging in an effort to facilitate a better understanding of the issues relevant to what is ultimately a clinical decision made by an oncologist and his or her patient.

Patient requests for office-based imaging.

The rising cost of health care affects our economy and can impact the health of our citizens. Costs can be divided into direct costs, which are incurred in the provision of services and procedures, and ancillary costs, such as labs and imaging. While ancillary services greatly assist providers in diagnosing and treating medical conditions, they can be overused or inappropriately used and can lead to adverse events. All providers should work to order the most appropriate imaging and tests and to protect patients at all times.

Pain and stress assessment after retinopathy of prematurity screening examination: indirect ophthalmoscopy versus digital retinal imaging.

BACKGROUND: Increasingly, neonatal clinics seek to minimize painful experiences and stress for premature infants. Fundoscopy performed with a binocular indirect ophthalmoscope is the reference examination technique for screening of retinopathy of prematurity (ROP), and it is associated with pain and stress. Wide-field digital retinal imaging is a recent technique that should be evaluated for minimizing infant pain and stress. METHODS: The purpose of the study was to assess and compare the impact of using a binocular indirect ophthalmoscope (BIO), or wide-field digital retinal imaging (WFDRI) on pain and stress in infants undergoing ROP screening examination. This was a comparative evaluation study of two screening procedures. Ophthalmologic examinations (N = 70) were performed on 24 infants with both BIO and WFDRI. Pain assessments were performed with two specific neonatal scales (Crying, requires oxygen, increased vital signs, expression and sleeplessness, CRIES and, Premature infant pain profile, PIPP) just prior to the examination, and 30 seconds, 1 hour, and 24 hours later after ending the examination. RESULTS: Changes over time were significantly different between BIO and WFDRI with both scales (PIPP score, p = .007, and CRIES score, p = .001). Median PIPP score (interquartile interval) at baseline was 4 (3-5). At 30 seconds the score was 8 (6-9) for BIO and 6 (5-7) for WFDRI, respectively. The increase in PIPP score between baseline and 30 seconds was significantly lower with WFDRI (p = .006). The median increase in CRIES score from baseline to 30 seconds was 1 point lower for WFDRI than for BIO (p < .001). No significant difference in response remained at 1 hour or 24 hour assessments. CONCLUSIONS: A transient short-term pain and stress response occurs with both BIO and WFDRI. Infants examined for screening of ROP with digital retinal imaging present less pain and stress at 30 seconds following completion of the exam when compared with binocular indirect ophthalmoscopy.

What do radiology incident reports reveal about in-hospital communication processes and the use of health information technology?

BACKGROUND: There has been recent rapid growth in the use of medical imaging leading to concerns about an increase in unnecessary investigations, patient exposure to radiation, and incorrect diagnoses. Incident reporting systems provide a portal for staff to catalogue adverse events which occur within a hospital or department. Analysing incident reports can reveal trends and provide guidance for quality improvement efforts. METHODS: Classification of medical imaging related-incidents from a major teaching hospital in Sydney, Australia using WHO International Classification for Patient Safety (ICPS) taxonomy. All incidents with radiology identified as incident location (n=219) were extracted. Incidents were from January 2005 to October 2011. Two researchers independently cleaned the data set. One researcher then applied the ICPS to free text incident reports. RESULTS: 216 unique incidents were extracted. 15 incidents were unable to be classified using the ICPS. 8 incidents were classified twice, resulting in 209 coded incidents. Communication breakdown was a contributing factor in 49% (103/209) of incidents reported. 147 of the 209 incidents were associated with activities associated with data collection, storage or retrieval of electronic information. Health information technology (HIT) systems were mentioned explicitly in 10% of incidents, indicating some contribution to the error. CONCLUSIONS: Communication breakdown and HIT systems are contributors to error, and should be addressed. HIT systems need to be monitored and flaws addressed to ensure quality care.

Environmental causes of breast cancer and radiation from medical imaging: findings from the Institute of Medicine report.

Susan G. Komen for the Cure asked the Institute of Medicine (IOM) to perform a comprehensive review of environmental causes and risk factors for breast cancer. Interestingly, none of the consumer products (ie, bisphenol A, phthalates), industrial chemicals (ie, benzene, ethylene oxide), or pesticides (ie, DDT/DDE) considered could be conclusively linked to an increased risk of breast cancer, although the IOM acknowledged that the available evidence was insufficient to draw firm conclusions for many of these exposures, calling for more research in these areas. The IOM found sufficient evidence to conclude that the 2 environmental factors most strongly associated with breast cancer were exposure to ionizing radiation and to combined postmenopausal hormone therapy. The IOM's conclusion of a causal relation between radiation exposure and cancer is consistent with a large and varied literature showing that exposure to radiation in the same range as used for computed tomography will increase the risk of cancer. It is the responsibility of individual health care providers who order medical imaging to understand and weigh the risk of any medical procedures against the expected benefit.

The impact of socioeconomic status and comorbid medical conditions on ionizing radiation exposure from diagnostic medical imaging in adults.

PURPOSE: The aim of this study was to characterize cumulative exposure to ionizing radiation from diagnostic imaging (CEDI) in adult patients and investigate its relationship to a patient's socioeconomic status and comorbid medical conditions. METHODS: A retrospective cohort study was conducted of 54,015 patients seen within the outpatient clinic system of an academic, tertiary care, urban medical center during the month of January 2006, estimating the CEDI from all procedures performed within 3 years of the index visit (until January 2009). Socioeconomic status was estimated from census tract geocoding. Comorbid medical conditions were identified from the electronic medical record. RESULTS: A total of 9,537 adult patients were seen within the index month and underwent imaging tests. Eighty percent were living in areas with >10% poverty. Thirty-six percent of men and 43% of women had diagnoses from the Elixhauser list. Mean CEDI values were 10 ± 19.09 mSv for those from areas with >10% poverty and 8.9 ± 22.42 mSv for those living in areas with <10% poverty. Poverty and comorbidities covaried. Estimated CEDI within groups of patients with the same comorbidity was not associated with socioeconomic status. CONCLUSION: At this institution, there is a high prevalence of patients living in poverty. Those living in poverty are at higher risk for comorbid conditions that are associated with increased CEDI. However, controlling for comorbidity, socioeconomic status was no longer predictive of CEDI.

Assessment of patient doses in CR examinations throughout a large health region.

Optimization and standardization of radiographic procedures in a health region minimizes patient exposure while producing diagnostic images. This report highlights the dose variation in common computed radiography (CR) examinations throughout a large health region. The RadChex cassette was used to measure the radiation exposure at the table or wall bucky in 20 CR rooms, in seven hospitals, using CR technology from two vendors. Exposures were made to simulate patient exposure (21 cm polymethyl methacrylate) under standard conditions for each bucky: 81 kVp at 100 cm for anteroposterior abdomen table bucky exposures (180 cm for posteroanterior chest wall bucky exposures), using the left, the right, or the center automatic exposure control (AEC) cells. Protocol settings were recorded. An average of 37% variation was found between AEC chambers, with a range between 4% and 137%. A 60% difference in dose was discovered between manufacturers, which was the result of the manufacture's image processing algorithm and subsequently corrected via software updates. Finally, standardizing AEC cell selection during common chest examinations could reduce patient dose by up to 30%. In a large health region, variation in exam protocols can occur, leading to unnecessary patient dose from the same type of examination. Quality control programs must monitor exam protocols and AEC chamber calibration in CR to ensure consistent, minimal, patient dose, regardless of hospital or CR vendor. Furthermore, this report highlights the need for communication between radiologists, technologists, medical physicist, service engineers, and manufacturers required to optimize CR protocols.

Percepción de la población respecto a los riesgos asociados a los estudios de imágenes / Public perception of radiation-related risks of imaging studies

Introduction: In recent years, diagnostic procedures using ionizing radiation have achieved a great boom, although patients are often unaware of the risks they involve. Objectives: To know how is ionizing radiation perceived by the population attending Clínica Dávila, Department of Radiology (DRCD).Methods: A voluntary and anonymous survey was conducted on patients and / or companions. Results: A total of 330 adults were surveyed. An 57 percent had completed higher education, whereas 7.9 percent had only finished elementary schooling; 78.8 percent had undergone three or more imaging tests. CT examination was considered to pose the highest levels of risk (42.4 percent), followed by Ultrasonography (30.6 percent). Discussion: The survey group was made up of young adults, mostly college graduates, and predominantly female. Surprinsingly enough, considering that obstetric sonography is commonly used during pregnancy, US was ranked second in terms of associated health risks. There is an evident interest in the subject, since 90 percent of responders would like to receive further information.

Introducción: Los procedimientos diagnósticos que usan radiación ionizante están en auge, aunque conllevan riesgos muchas veces desconocidos por los pacientes. Objetivos: Conocer la percepción de la población que acude al Departamento de Radiología de Clínica Dávila (DRCD) sobre la radiación. Material y métodos: Se aplicó una encuesta voluntaria y anónima a pacientes y/o acompañantes. Resultados: Se encuestó a 330 adultos. El 57 por ciento poseía estudios superiores y 7,9 por ciento sólo estudios básicos. El 78,8 por ciento se había efectuado 3 o más estudios radiológicos. La TC fue el examen considerado con mayor riesgo (42,4 por ciento), luego la US (30,6 por ciento). Discusión: El grupo encuestado fueron adultos jóvenes, con estudios superiores en su mayoría y con predominio femenino. Sorprendió que la US se considerara como el segundo examen de mayor riesgo, ya que las mujeres poseen mayor contacto con este estudio durante el embarazo. Hay interés en el tema, porque el 90 por ciento desea recibir información.