Health effects related to exposure of static magnetic fields and acoustic noise-comparison between MR and CT radiographers.

OBJECTIVES: We explored the prevalence of health complaints subjectively associated with static magnetic field (SMF) and acoustic noise exposure among MR radiographers in Sweden, using CT radiographers as a control group. Additionally, we explored radiographers' use of strategies to mitigate adverse health effects. METHODS: A cross-sectional survey was sent to all hospitals with MR units in Sweden. MR and/or CT personnel reported prevalence and attribution of symptoms (vertigo/dizziness, nausea, metallic taste, illusion of movement, ringing sensations/tinnitus, headache, unusual drowsiness/tiredness, forgetfulness, difficulties concentrating, and difficulties sleeping) within the last year. We used logistic regression to test associations between sex, age, stress, SMF strength, working hours, and symptom prevalence. Data regarding hearing function, work-environmental noise, and strategies to mitigate adverse symptoms were also analysed. RESULTS: In total, 529 out of 546 respondents from 86 hospitals were eligible for participation. A ≥ 20 working hours/week/modality cut-off rendered 342 participants grouped into CT (n = 75), MR (n = 121), or mixed personnel (n = 146). No significant differences in symptom prevalence were seen between groups. Working at ≥ 3T increased SMF-associated symptoms as compared with working at ≤ 1.5T (OR: 2.03, CI95: 1.05-3.93). Stress was a significant confounder. Work-related noise was rated as more troublesome by CT than MR personnel (p < 0.01). MR personnel tended to use more strategies to mitigate adverse symptoms. CONCLUSION: No significant differences in symptom prevalence were seen between MR and CT radiographers. However, working at 3T increased the risk of SMF symptoms, and stress increased adverse health effects. Noise nuisance was considered more problematic by CT than MR personnel. KEY POINTS: • No significant differences in symptom prevalence were seen between MR and CT radiographers. • Working at ≥ 3 T doubled the odds of experiencing SMF symptoms (vertigo/dizziness, nausea, metallic taste, and/or illusion of movement) as compared to working exclusively at ≤ 1.5 T. • Work-related acoustic noise was less well mitigated and was rated as more troublesome by CT personnel than by MR personnel.

Maintaining Image Quality While Reducing Acoustic Noise and Switched Gradient Field Exposure During Lumbar MRI.

BACKGROUND: MR-generated acoustic noise can contribute to patient discomfort and potentially be harmful. One way to reduce this noise is by altering the gradient output and/or waveform using software optimization. Such modifications might influence image quality and switched gradient field exposure, and different techniques appear to affect sound pressure levels (SPLs) to various degrees. PURPOSE: To evaluate SPLs, image quality, switched gradient field exposure, and participants' perceived noise levels during two different acoustic noise reduction (ANR) techniques, Quiet Suite (QS) and Whisper Mode (WM), and to compare them with conventional T2-weighted turbo spin echo (T2W TSE) of the lumbar spine. DESIGN: Prospective. SUBJECTS: Forty adults referred for lumbar MRI. FIELD STRENGTH/SEQUENCE: Conventional T2W TSE, T2W TSE with QS, and T2W TSE with WM were acquired at 1.5 T. ASSESSMENT: Peak SPL (A-weighted decibels, dBA), perceived noise levels (Borg CR10®-scale), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), three radiologists' qualitative assessments in image quality on an ordinal scale 1-4, switched gradient field exposure (% general public), and gradient currents were measured. Interobserver reliability was reported as percentage agreement. STATISTICAL TESTS: Repeated measures ANOVA, Friedman's ANOVA, and Wilcoxon's Signed-Rank Test for acoustic noise measurements and image quality assessments. RESULTS: Mean peak SPLs were 89.9 dBA, 74.3 dBA, and 78.8 dBA for conventional, QS, and WM, respectively (P < 0.05). Participants perceived QS as the quietest and conventional as the loudest sequence (P < 0.05). No qualitative differences in image quality were seen (P > 0.05), although QS showed significantly improved SNR and CNR (P < 0.05). Switched gradient field exposure was reduced by 66% and 48% for QS and WM, respectively. DATA CONCLUSION: Without degrading image quality, both QS and WM are viable ANR techniques in lumbar T2W TSE. QS provided the lowest SPL, the lowest gradient field exposure and was perceived as the most silent among the three sequences. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 5.

Swedish national survey on MR safety compared with CT: a false sense of security?

OBJECTIVES: The objectives were to survey MR safety incidents in Sweden during a 12-month period, to assess severity scores, and to evaluate the confidence of MR personnel in incident-reporting mechanisms. METHOD: Data were collected within a web-based questionnaire on safety in clinical MR environments with CT for comparison. Data reported MR and CT safety incidents (human injury, material damage, and close calls), incident severity, and confidence of participants in incident-reporting systems. RESULTS: The study population consisted of 529 eligible participants. Participants reported 200 MR and 156 CT safety incidents. Among MR incidents, 16% were given the highest potential severity score. More MR workers (73%) than CT workers (50%) were confident in being aware of any incident occurring at their workplace. However, 69% MR workers (83% for CT) were not aware of reported incidents at their hospitals. CONCLUSION: Safety incidents resulting in human injury, material damage, and close calls in clinical MR environments do occur. According to national risk assessment recommendations, risk level is high. Results indicated that MR personnel tend to a false sense of security, as a high proportion of staff members were sure that they would have been aware of any incident occurring in their own department, while in reality, incidents did occur without their knowledge. We conclude that false sense of security exists for MR. KEY POINTS: • Safety incidents in clinical MR environments still result in human injury and material damage. • Severity level of MR incidents-assessed using Swedish national risk assessment recommendations-is high. • Confidence of MR personnel in incident-reporting mechanisms is high, but reflects a false sense of security, as a high proportion of staff is unaware of reported incidents in the same workplace.

Valid Exposure Protocols Needed in Magnetic Resonance Imaging Genotoxic Research.

Several in vitro and in vivo studies have investigated if a magnetic resonance imaging (MRI) examination can cause DNA damage in human blood cells. However, the electromagnetic field (EMF) exposure that the cells received in the MR scanner was not sufficiently described. The first studies looking into this could be regarded as hypothesis-generating studies. However, for further exploration into the role of MRI exposure on DNA integrity, the exposure itself cannot be ignored. The lack of sufficient method descriptions makes the early experiments difficult, if not impossible, to repeat. The golden rule in all experimental work is that a study should be repeatable by someone with the right knowledge and equipment, and this is simply not the case with many of the recent studies on MRI and genotoxicity. Here we discuss what is lacking in previous studies, and how we think the next generation of in vitro and in vivo studies on MRI and genotoxicity should be performed. Bioelectromagnetics. © 2020 Bioelectromagnetics Society.

EMF exposure variation among MRI sequences from pediatric examination protocols.

The magnetic resonance imaging (MRI) exposure environment is unique due to the mixture and intensity of magnetic fields involved. Current safety regulations are based on well-known acute effects of heating and neuroexcitation while the scientific grounds for possible long-term effects from MRI exposure are lacking. Epidemiological research requires careful exposure characterization, and as a first step toward improved exposure assessment we set out to characterize the MRI-patient exposure environment. Seven MRI sequences were run on a 3-Tesla scanner while the radiofrequency and gradient magnetic fields were measured inside the scanner bore. The sequences were compared in terms of 14 different exposure parameters. To study within-sequence variability, we varied sequence settings such as flip angle and slice thickness one at a time, to determine if they had any impact on exposure endpoints. There were significant differences between two or more sequences for all fourteen exposure parameters. Within-sequence differences were up to 60% of the corresponding between-sequence differences, and a 5-8 fold exposure increase was caused by variations in flip angle, slice spacing, and field of view. MRI exposure is therefore not only sequence-specific but also patient- and examination occurrence-specific, a complexity that requires careful consideration for an MRI exposure assessment in epidemiological studies to be meaningful. Bioelectromagnetics. 40:3-15, 2019. © 2018 The Authors. Bioelectromagnetics Published by Wiley Periodicals, Inc.

Short-term effects experienced during examinations in an actively shielded 7 T MR.

The objective of this study was to evaluate occurrence and strength of short-term effects experienced by study participants in an actively shielded (AS) 7 tesla (7 T) magnetic resonance (MR) scanner, to compare results with earlier reports on passively shielded (PS) 7 T MR scanners, and to outline possible healthcare strategies to improve patient compliance. Study participants (n = 124) completed a web-based questionnaire directly after being examined in an AS 7 T MR (n = 154 examinations). Most frequently experienced short-term effects were dizziness (84%) and inconsistent movement (70%), especially while moving into or out of the magnet. Peripheral nerve stimulation (PNS)-twitching-was experienced in 67% of research examinations and showed a dependence between strength of twitches and recorded predicted PNS values. Of the participants, 74% experienced noise levels as acceptable and the majority experienced body and room temperature as comfortable. Of the study participants, 95% felt well-informed and felt they had had good contact with the staff before the examination. Willingness to undergo a future 7 T examination was high (>90%). Our study concludes short-term effects are often experienced during examinations in an AS 7 T MR, leaving room for improvement in nursing care strategies to increase patient compliance. Bioelectromagnetics. 2019;9999:XX-XX. © 2019 The Authors. Bioelectromagnetics Published by Wiley Periodicals, Inc.

Measurements of the ripple effect and geometric distribution of switched gradient fields inside a magnetic resonance scanner.

Knowledge of patient exposure during magnetic resonance imaging (MRI) procedures is limited, and the need for such knowledge has been demonstrated in recent in vitro and in vivo studies of the genotoxic effects of MRI. This study focuses on the dB/dt of the switched gradient field (SGF) and its geometric distribution. These values were characterized by measuring the peak dB/dt generated by a programmed gradient current of alternating triangles inside a 1.5T MR scanner. The maximum dB/dt exposure to the gradient field was 6-14 T/s, and this occurred at the edges of the field of view (FOV) 20-25 cm from the isocenter in the longitudinal direction. The dB/dt exposure dropped off to roughly half the maximum (3-7 T/s) at the edge of the bore. It was found that the dB/dt of the SGF was distorted by a 200 kHz ripple arising from the amplifier. The ripple is small in terms of B-field, but the high frequency content contributes to a peak dB/dt up to 18 times larger than that predicted by the slew rate (4 T/s m) and the distance from the isocenter. Measurements on a 3 T MRI scanner, however, revealed a much smaller filtered ripple of 100 kHz in dB/dt. These findings suggest that the gradient current to each coil together with information on the geometrical distribution of the gradient field and ripple effects could be used to assess the SGF exposure within an MRI bore.

Exposure classification of MRI workers in epidemiological studies.

We estimate that there are about 100,000 workers from different disciplines, such as radiographers, nurses, anesthetists, technicians, engineers, etc., who can be exposed to substantial electromagnetic fields (compared to normal background levels) around magnetic resonance imaging (MRI) scanners. There is a need for well-designed epidemiological studies of MRI workers but since the exposure from MRI equipment is a very complex mixture of static magnetic fields, switched gradient magnetic fields, and radiofrequency electromagnetic fields (RF EMF), it is necessary to discuss how to assess the exposure in epidemiological studies. As an alternative to the use of job title as a proxy of exposure, we propose an exposure categorization for the different professions working with MRI equipment. Specifically, we propose defining exposure in three categories, depending on whether people are exposed to only the static field, to the static plus switched gradient fields or to the static plus switched gradient plus RF fields, as a basis for exposure assessment in epidemiological studies.

Protection of Workers Exposed to Radiofrequency Electromagnetic Fields: A Perspective on Open Questions in the Context of the New ICNIRP 2020 Guidelines.

Workers in occupational settings are usually exposed to numerous sources of electromagnetic fields (EMF) and to different physical agents. Risk assessment for industrial workplaces concerning EMF is not only relevant to operators of devices or machinery emitting EMF, but also to support-workers, bystanders, service and maintenance personnel, and even visitors. Radiofrequency EMF guidelines published in 2020 by the International Commission on Non-Ionizing Radiation Protection (ICNIRP) may also be indirectly applied to assess risks emerging from EMF sources at workplaces by technical standards or legislation. To review the applicability and adequacy to assess exposure to EMF in occupational settings in the European Union, the most current ICNIRP guidelines on radiofrequency EMF are reviewed. Relevant ICNIRP fundamentals and principles are introduced, followed by practical aspects of exposure assessment. To conclude, open questions are formulated pointing out gaps between the guidelines' principles and occupational practice, such as the impact of hot and humid environments and physical activity or controversies around ICNIRPS's reduction factors in view of assessment uncertainty in general. Thus, the article aims to provide scientific policy advisors, labor inspectors, or experts developing standards with a profound understanding about ICNIRP guidelines' applicability to assess hazards related to radiofrequency EMF in occupational settings.

Exposure assessment of electromagnetic fields near electrosurgical units.

Electrosurgical units (ESU) are widely used in medical health services. By applying sinusoidal or pulsed voltage in the frequency range of 0.3-5 MHz to the electrode tip, the desired mixture of coagulation and cutting are achieved. Due to the high voltage and current in the cable, strong electromagnetic fields appear near the ESU. The surgeon and others inside the operating room such as nurses, anesthesiologists, etc., will be highly exposed to these fields. The stray fields surrounding the ESU have previously been measured, but now a deeper analysis has been made of the curve shape of the field and the implication of this when assessing exposure from a commonly used ESU in accordance with the International Commission on Non-Ionizing Radiation Protection (ICNIRP) guidelines. The result showed that for some of the modes, especially those using high-pulsed voltage with only a few sinusoidal periods, the E-field close to the cable could reach linear spatially averaged values of 20 kV/m compared to the 2.1 kV/m stated in ICNIRP guidelines. Assessing the E- and B-field from ESU is not straightforward since in this frequency range, both induced current density and specific absorption rate are restricted by the ICNIRP guidelines. Nevertheless, work needs to be done to reduce the stray fields from ESU.

Modification of pulse sequences reduces occupational exposure from MRI switched gradient fields: Preliminary results.

The gradient fields in magnetic resonance imaging (MRI) will in some circumstances exceed the ICNIRP guidelines of occupational electromagnetic field exposure when personnel are near the scanner during MRI scanning. In this work we have shown that using commercially available modified sequences for noise reduction purposes, exposure will decrease by a factor of 1.5 with preserved image quality. This is a first step toward optimizing occupational exposure within the scanner room without affecting image quality.

Background ELF magnetic fields in incubators: a factor of importance in cell culture work.

Extremely low frequency (ELF) magnetic fields in cell culture incubators have been measured. Values of the order of tens of muT were found which is in sharp contrast to the values found in our normal environment (0.05-0.1microT). There are numerous examples of biological effects found after exposure to MF at these levels, such as changes in gene expression, blocked cell differentiation, inhibition of the effect of tamoxifen, effects on chick embryo development, etc. We therefore recommend that people working with cell culture incubators check for the background magnetic field and take this into account in performing their experiments, since this could be an unrecognised factor of importance contributing to the variability in the results from work with cell cultures.

Non-Ionizing Radiation in Swedish Health Care-Exposure and Safety Aspects.

The main aim of the study was to identify and describe methods using non-ionizing radiation (NIR) such as electromagnetic fields (EMF) and optical radiation in Swedish health care. By examining anticipated exposure levels and by identifying possible health hazards we also aimed to recognize knowledge gaps in the field. NIR is mainly used in health care for diagnosis and therapy. Three applications were identified where acute effects cannot be ruled out: magnetic resonance imaging (MRI), transcranial magnetic stimulation (TMS) and electrosurgery. When using optical radiation, such as class 3 and 4 lasers for therapy or surgical procedures and ultra-violet light for therapy, acute effects such as unintentional burns, photo reactions, erythema and effects on the eyes need to be avoided. There is a need for more knowledge regarding long-term effects of MRI as well as on the combination of different NIR exposures. Based on literature and after consulting staff we conclude that the health care professionals' knowledge about the risks and safety measures should be improved and that there is a need for clear, evidence-based information from reliable sources, and it should be obvious to the user which source to address.

No effect of mobile phone-like RF exposure on patients with atopic dermatitis.

This study investigates the effect of exposure to a mobile phone-like radiofrequency (RF) electromagnetic field on people with atopic dermatitis (AD). Fifteen subjects with AD were recruited and matched with 15 controls without AD. The subjects were exposed for 30 min to an RF field at 1 W/kg via an indoor base station antenna attached to a 900 MHz GSM mobile phone. Blood samples for ELISA analysis of the concentration of substance P (SP), tumor necrosis factor receptor 1 (TNF R1), and brain derived neurotrophic factor (BDNF) in serum were drawn before and after the provocation (exposure/sham). Baseline heart rate and heart rate variability, local blood flow, and electrodermal activity were also recorded. No significant differences between the subject groups were found for baseline neurophysiological data. The cases displayed a serum concentration of TNF R1 significantly higher than the control subjects and a significantly lower serum concentration of BDNF in the baseline condition. For SP there was no difference between groups. However, no effects related to RF exposure condition were encountered for any of the measured substances. As to symptoms, a possible correlation with exposure could not be evaluated, due to too few symptom reports. The result of the study does not support the hypothesis of an effect of mobile phone-like RF exposure on serum levels of SP, TNF R1, and BDNF in persons with AD.

Assessing Exposures to Magnetic Resonance Imaging's Complex Mixture of Magnetic Fields for In Vivo, In Vitro, and Epidemiologic Studies of Health Effects for Staff and Patients.

A complex mixture of electromagnetic fields is used in magnetic resonance imaging (MRI): static, low-frequency, and radio frequency magnetic fields. Commonly, the static magnetic field ranges from one to three Tesla. The low-frequency field can reach several millitesla and with a time derivative of the order of some Tesla per second. The radiofrequency (RF) field has a magnitude in the microtesla range giving rise to specific absorption rate values of a few Watts per kilogram. Very little attention has been paid to the case where there is a combined exposure to several different fields at the same time. Some studies have shown genotoxic effects in cells after exposure to an MRI scan while others have not demonstrated any effects. A typical MRI exam includes muliple imaging sequences of varying length and intensity, to produce different types of images. Each sequence is designed with a particular purpose in mind, so one sequence can, for example, be optimized for clearly showing fat water contrast, while another is optimized for high-resolution detail. It is of the utmost importance that future experimental studies give a thorough description of the exposure they are using, and not just a statement such as "An ordinary MRI sequence was used." Even if the sequence is specified, it can differ substantially between manufacturers on, e.g., RF pulse height, width, and duty cycle. In the latest SCENIHR opinion, it is stated that there is very little information regarding the health effects of occupational exposure to MRI fields, and long-term prospective or retrospective cohort studies on workers are recommended as a high priority. They also state that MRI is increasingly used in pediatric diagnostic imaging, and a cohort study into the effects of MRI exposure on children is recommended as a high priority. For the exposure assessment in epidemiological studies, there is a clear difference between patients and staff and further work is needed on this. Studies that explore the possible differences between MRI scan sequences and compare them in terms of exposure level are warranted.

Frequency spectra from current vs. magnetic flux density measurements for mobile phones and other electrical appliances.

The frequency spectra of electromagnetic fields have to be determined to evaluate human exposure in accordance to ICNIRP guidelines. In the literature, comparisons with magnetic field guidelines have been performed by using the frequency distribution of the current drawn from the battery. In the present study we compared the frequency spectrum in the range 217 Hz to 2.4 kHz of the magnetic flux density measured near the surface of a mobile phone with the frequency spectrum of the supply current. By using the multiple frequency rule, recommended in the ICNIRP guidelines, we estimated the magnetic field exposure in the two cases. Similar measurements and estimations were done for an electric drill, a hair dryer, and a fluorescent desk lamp. All the devices have a basic frequency of 50 Hz, and the frequency spectra were evaluated up to 550 Hz. We also mapped the magnetic field in 3D around three mobile phones. The frequency distributions obtained from the two measurement methods are not equal. The frequency content of the current leads to an overestimation of the magnetic field exposure by a factor up to 2.2 for the mobile phone. For the drill, the hair dryer, and the fluorescent lamp, the supply current signal underestimated the exposure by a factor up to 2.3. In conclusion, an accurate exposure evaluation requires the magnetic flux density spectrum of the device to be measured directly. There was no indication that the devices studied would exceed the reference levels at the working distances normally used.

Exposure to the magnetic field from an induction loop pad for a hearing aid system.

As a case study we have measured the magnetic field from an induction loop pad designed for hearing aid assistance. The magnitude of the field was high, although well below international guidelines. We recorded values up to 70% of the recommended standard in some instances. However, in view of the many reports indicating health effects of low-level exposure, we recommend that the precautionary principle is applied when such pads are given to people who might be especially vulnerable, such as children, pregnant women and women on breast cancer medication.

Health complaints among nurses working near MRI scanners--a descriptive pilot study.

A questionnaire-based descriptive pilot study was conducted among all nurses routinely working with MRI in the Northern part of Sweden to provide an indication of the self-reported prevalence of health complaints related to working with MRI systems. Fifty-nine nurses (88% response rate), with on average 8 (±6) years experience with MRI scanning procedures, returned the questionnaire. In total, 9 nurses (15%) reported regularly experiencing at least one of the health complaints (1-5% for specific health complaints) attributed to arise or be aggravated by their presence in the MRI scanning room. Stratification of the results indicated that reporting of adverse symptoms was not related to the level of occupational workload/stress. However, reporting of health complaints was related to the strength of the magnet(s) the nurses worked with, with 57% of symptoms reported by those nurses working with the strongest systems (both 1.5 and 3T scanners in this population). Although this descriptive study did not include a control population and was based on self-reporting of health complaints, these data indicate that the prevalence of reported health complaints is not related to perceived work load or occupational stress, but does confirm data from other occupational sectors and indicates that the prevalence of adverse health complaints increases with the strength of the MRI system for nurses as well.

Changes in heart rate variability among RF plastic sealer operators.

In a previous study, we showed that operators of radiofrequency (RF) plastic sealers, RF operators (n = 35) had a lower heart rate during nighttime compared to a control group (n = 37). We have analyzed the heart rate variability (HRV) on the same group of people to better understand the possible underlying rhythm disturbances. We found a significantly increased total HRV and very low frequency (VLF) power during nighttime among the RF operators compared to a control group. Together with our previous finding of a significantly lower heart rate during nighttime among the RF operators compared to the controls, this finding indicates a relative increase in parasympathetic cardiac modulation in RF operators. This could in turn be due to an adaptation of the thermoregulatory system and the cardiac autonomic modulation to a long-term low-level thermal exposure in the RF operators.