Radiographers' role in justification of medical imaging examinations.

INTRODUCTION: Justification is one of the fundamental principles in radiation protection and according to the ICRP, justification means that any decision that alters the radiation exposure situation should do more good than harm. The purpose of this study was to explore diagnostic radiographers' attitude towards their role in justification, and to assess the perceived need for justification discussions with peers and the ability to reject unjustified referrals during day, evening, and night shifts. METHODS: This study was conducted in Norway and Denmark. A questionnaire was developed in Norwegian and translated into Danish, and two experienced radiographers assessed content validity. A secure online data capture solution was used, and the questionnaire was distributed to radiographers working in clinical settings in March and April 2022 (n = 1215). RESULTS: A total of 202 radiographers were included in the study, 93 from Norway and 109 from Denmark, respectively. Seventy-nine per cent of the radiographers reported that they had a duty to assess justification and 86 % did so daily. Their role in justification assessment was reported as relatively important, where CT and MRI had significantly different results than the total respondents. Radiologists were designated as being most responsible in the assessment, closely followed by referring doctors and radiographers. The most important criterion for justification assessment was the referring doctor's clinical assessment. The need to confer was highest during daytime when there were also more opportunities to confer. CONCLUSION: The need to discuss justification of examinations is greater during daytime when access to radiologists is also high, while both access and need are low during night shifts. Further research is needed to explain the latter finding. Radiographers who engage in daily justification assessments, and perceive it as a duty, find justification important and report having sufficient knowledge to carry out these assessments.

Halved contrast medium dose in lower limb dual-energy computed tomography angiography-a randomized controlled trial.

OBJECTIVES: To compare vascular attenuation (VA) of an experimental half iodine-load dual-layer spectral detector CT (SDCT) lower limb computed tomography angiography (CTA) with control (standard iodine-load conventional 120-kilovolt peak (kVp) CTA). METHODS: Ethical approval and consent were obtained. In this parallel RCT, CTA examinations were randomized into experimental or control. Patients received 0.7 vs 1.4 mL/kg of iohexol 350 mgI/mL in the experimental- vs the control group. Two experimental virtual monoenergetic image (VMI) series at 40 and 50 kiloelectron volts (keV) were reconstructed. PRIMARY OUTCOME: VA. SECONDARY OUTCOMES: image noise (noise), contrast- and signal-to-noise ratio (CNR and SNR), and subjective examination quality (SEQ). RESULTS: A total of 106 vs 109 were randomized and 103 vs 108 were analyzed in the experimental vs, control groups, respectively. VA was higher on experimental 40 keV VMI than on control (p < 0.0001), but lower on 50 keV VMI (p < 0.022). Noise was higher on experimental 40 keV VMI than on control (p = 0.00022), but lower on 50 keV VMI (p = 0.0033). CNR and SNR were higher than the control on experimental 40 keV VMI (both p < 0.0001) and 50 keV (p = 0.0058 and p = 0.0023, respectively). SEQ was better on both VMIs in the experimental group than in the control (both p < 0.0001). CONCLUSIONS: Half iodine-load SDCT lower limb CTA at 40 keV achieved higher VA than the control. CNR, SNR, noise, and SEQ were higher at 40 keV, while 50 keV showed lower noise. CLINICAL RELEVANCE STATEMENT: Spectral detector CT with low-energy virtual monoenergetic imaging performed halved iodine contrast medium (CM) lower limb CT-angiography with sustained objective and subjective quality. This facilitates CM reduction, improvement of low CM-dosage examinations, and examination of patients with more severe kidney impairment. TRIAL REGISTRATION: Retrospectively registered 5 August 2022 at clinicaltrials.gov NCT05488899. KEY POINTS: • Contrast medium dosage may be halved in lower limb dual-energy CT angiography with virtual monoenergetic images at 40 keV, which may reduce contrast medium consumption in the face of a global shortage. • Experimental half-iodine-load dual-energy CT angiography at 40 keV showed higher vascular attenuation, contrast-to-noise ratio, signal-to-noise ratio, and subjective examination quality than standard iodine-load conventional. • Half-iodine dual-energy CT angiography protocols may allow us to reduce the risk of PC-AKI, examine patients with more severe kidney impairment, and provide higher quality examinations or salvage poor examinations when impaired kidney function limits the CM dose.

What information did pregnant women want related to risks and benefits attending X-ray examinations?

BACKGROUND: In connection with X-ray examinations of pregnant patients, good communication of benefit and risk is important to provide adequate patient care. Pregnant women often become concerned about the foetus and are unsure of the risk of malformations and the development of cancer. Health professionals who are involved in imaging pregnant women require specif knowledge about risks and benefits so they can convey information without creating unnecessary fear. PURPOSE: This study identifies the information needs of pregnant women in connection with X-ray examinations and how they prefer to have the information communicated. METHOD: A qualitative study using semi-structured interviews of seven pregnant women aged 28-36 in weeks 16-33 of their pregnancy. The interviews were analysed using interpretive phenomenological analysis. RESULTS: The participants had expectations regarding the information provided about X-ray examinations during pregnancy. They needed concrete information on radiation doses, risks and any effects on the foetus. The risk was thought to be low, but several of the participants would still have been concerned when undergoing an X-ray examination. CONCLUSION: To provide adequate care of pregnant women in connection with X-ray examinations, healthcare professionals must have knowledge of pregnancy and radiation and have expertise in risk communication. This will prevent unnecessary concern in the pregnant woman, ensure that justified necessary examinations are carried out, and avoid adverse decisions such as termination of pregnancy based on erroneous grounds.

Communicating Radiation Risk to Patients: Experiences Among Radiographers in Norway.

INTRODUCTION: Risk communication related to radiation has become more important during the last decade. Informing patients of benefits, risks, and alternative imaging methods is necessary to make informed decisions. The purpose of this study was to investigate radiographers' knowledge of radiation dose and risk, and their experiences with radiation risk communication. METHODS: This study used a qualitative approach using semi-structured interviews with clinical radiographers. The participants were presented with three authentic cases describing situations where risk communication is necessary. The interviews were audio-recorded, transcribed, and analyzed in four steps before the transcript interviews were coded and collected in meaningful themes. Participation was voluntary and participants signed an informed consent form. RESULTS: Six radiographers from two hospitals took part in the study. The mean age was 34 years, their work experiences as radiographers varied from 3.5 to 30 years and with an equal number of women and men. The participants provided reflections on the cases, how they managed the patients' need for information, and how they dealt with concerned patients. They also reflected on the knowledge and skills needed to be confident with risk communication. DISCUSSION: The participants were insecure of their knowledge of radiation dose and risk. They expressed difficulties with informing patients of radiation risk, without raising unnecessary concerns among the patients. When informing patients of the amount of radiation dose, they compared the dose in the examination to flights, background radiation, and the number of chest x-rays. The participants expressed challenges around radiation risk communication. All participants used the principle of justification in radiation risk communication. CONCLUSION: This study shows that risk communication among radiographers is challenging, and the key challenge is the lack of knowledge of radiation doses and lack of experience in risk communication. There is a need for increased focus to and knowledge of radiation dose and risk, and radiation risk communication among radiographers working in clinical practice. This should be amplified in the education of radiographers, focusing on theoretical knowledge and skills such as reflection and critical thinking. This could cause radiographers to be confident and able to offer adequate information of doses and risks to the patients, so the patients can make an informed decision.

Are Antimony-Bismuth Aprons as Efficient as Lead Rubber Aprons in Providing Shielding against Scattered Radiation?

AIM: The aim of this study is to compare the absorption ability of two lead-free aprons with a lead apron. METHOD: The absorption ability of three aprons was measured and compared; Opaque Fusion 0.35 mm (OpaqFu) bilayer apron containing bismuth and antimony, No Lead 0.35 mm (NoLead) one-layer apron containing antimony, and a lead apron. The measurements were repeated with and without each of the aprons present in both primary and scattered beams. The selected tube voltages were between 60 and 113 kVp with constant mAs, a fixed field size, and fixed source-to-object distance. RESULTS: No significant difference in absorption ability of the two lead-free aprons compared with that of the lead apron was observed when the dose was measured in the primary beam. When measurements were performed in the scatter radiation field, the absorption ability of the OpaqFu apron was 1.3 times higher than that of NoLead apron and nearly equal to the absorption ability of the lead apron. An increase in the difference between the OpaqFu and NoLead aprons was observed for the tube energies higher than 100 kVp in favour of OpaqFu apron. CONCLUSION: It is safe to use the lead-free aprons that were tested in this study in a clinical environment for the tube energy range of 60 kVp-113 kVp.

Compression force and radiation dose in the Norwegian Breast Cancer Screening Program.

PURPOSE: Compression force is used in mammography to reduce breast thickness and by that decrease radiation dose and improve image quality. There are no evidence-based recommendations regarding the optimal compression force. We analyzed compression force and radiation dose between screening centers in the Norwegian Breast Cancer Screening Program (NBCSP), as a first step towards establishing evidence-based recommendations for compression force. MATERIALS AND METHODS: The study included information from 17 951 randomly selected screening examinations among women screened with equipment from four different venors at fourteen breast centers in the NBCSP, January-March 2014. We analyzed the applied compression force and radiation dose used on craniocaudal (CC) and mediolateral-oblique (MLO) view on left breast, by breast centers and vendors. RESULTS: Mean compression force used in the screening program was 116N (CC: 108N, MLO: 125N). The maximum difference in mean compression force between the centers was 63N for CC and 57N for MLO. Mean radiation dose for each image was 1.09mGy (CC: 1.04mGy, MLO: 1.14mGy), varying from 0.55mGy to 1.31mGy between the centers. Compression force alone had a negligible impact on radiation dose (r2=0.8%, p=<0.001). CONCLUSION: We observed substantial variations in mean compression forces between the breast centers. Breast characteristics and differences in automated exposure control between vendors might explain the low association between compression force and radiation dose. Further knowledge about different automated exposure controls and the impact of compression force on dose and image quality is needed to establish individualised and evidence-based recommendations for compression force.

Lithium Formate for EPR Dosimetry (2): Secondary Radicals in X-Irradiated Crystals.

The secondary radiation-induced radicals in lithium formate monohydrate were studied using electron paramagnetic resonance (EPR), electron nuclear double resonance (ENDOR) and ENDOR-induced EPR (EIE) techniques complemented with periodic density functional theory (DFT) calculations. Single crystals of lithium formate monohydrate were X irradiated at 77 K and at room temperature. The main radicals present after irradiation at 77 K are the CO(2)(•-) radical (R1), the recently identified protonated electron-gain product, HCOOH(•-) (R2) (Krivokapic et al., Radiat Res 2014: 181:503-11), and a different geometrical conformation of this latter radical, a species that, up until now, has remained unidentified (R3). The successful quantum chemical modeling of R3 confirmed its structure and also provided a possible mechanism for its formation. After irradiation at 295 K, the crystals were investigated both shortly after irradiation and after storage for eight months at room temperature in ambient environments. After long-term storage the CO(2)(•-) radical had significantly decayed and the EPR spectra were dominated by two minority radicals. Both of these radicals are most likely formate-centered π-radicals, and based on the observed EPR parameters (g- and hyperfine coupling tensors) tentative candidates are the CO(•-) radical and the dimer formed by the CO(2)(•-) radical and a neighboring formate molecule yielding the radical (-)O(2)C·O·(•)CH·O(-).

Lesion detection performance: comparative analysis of low-dose CT data of the chest on two hybrid imaging systems.

UNLABELLED: Incidental findings on low-dose CT images obtained during hybrid imaging are an increasing phenomenon as CT technology advances. Understanding the diagnostic value of incidental findings along with the technical limitations is important when reporting image results and recommending follow-up, which may result in an additional radiation dose from further diagnostic imaging and an increase in patient anxiety. This study assessed lesions incidentally detected on CT images acquired for attenuation correction on two SPECT/CT systems. METHODS: An anthropomorphic chest phantom containing simulated lesions of varying size and density was imaged on an Infinia Hawkeye 4 and a Symbia T6 using the low-dose CT settings applied for attenuation correction acquisitions in myocardial perfusion imaging. Twenty-two interpreters assessed 46 images from each SPECT/CT system (15 normal images and 31 abnormal images; 41 lesions). Data were evaluated using a jackknife alternative free-response receiver-operating-characteristic analysis (JAFROC). RESULTS: JAFROC analysis showed a significant difference (P < 0.0001) in lesion detection, with the figures of merit being 0.599 (95% confidence interval, 0.568, 0.631) and 0.810 (95% confidence interval, 0.781, 0.839) for the Infinia Hawkeye 4 and Symbia T6, respectively. Lesion detection on the Infinia Hawkeye 4 was generally limited to larger, higher-density lesions. The Symbia T6 allowed improved detection rates for midsized lesions and some lower-density lesions. However, interpreters struggled to detect small (5 mm) lesions on both image sets, irrespective of density. CONCLUSION: Lesion detection is more reliable on low-dose CT images from the Symbia T6 than from the Infinia Hawkeye 4. This phantom-based study gives an indication of potential lesion detection in the clinical context as shown by two commonly used SPECT/CT systems, which may assist the clinician in determining whether further diagnostic imaging is justified.

Relaxation-time determination from continuous-microwave saturation of EPR spectra.

Based on the theories of Portis and of Castner 50 years ago, different continuous-wave measurement procedures for analyzing the microwave saturation power dependence of inhomogeneously broadened EPR lines were developed. Although these procedures have been refined, they still use only a few selected points on the saturation curve. A non-linear least-squares procedure for analyzing the microwave-power dependence of inhomogeneously broadened lines using all data points on a saturation curve has been developed. This procedure provides a simple alternative method to obtain magnetic relaxation data when the more direct pulse-saturation techniques are not available or are less suitable. The latter includes applications of quantitative EPR such as dosimetry. Then microwave saturation data should be obtained under conditions similar to those used in the quantitative measurements, which are usually made on first derivative spectra recorded using continuous-wave spectrometers. Selected applications to benchmark literature data and within the field of EPR dosimetry are discussed. The results obtained illustrate that relaxation times comparable to those yielded by various pulse-saturation EPR techniques can be obtained. It appears as a systematic feature that, whenever the pulse EPR data are fitted using bi-exponential functions, the shortest relaxation times obtained are those that correspond best to those measured using the current continuous-wave saturation method.

Single crystals of L-O-serine phosphate X-irradiated at low temperatures: EPR, ENDOR, EIE, and DFT studies.

Single crystals of the phosphorylated amino acid L-O-serine phosphate were X-irradiated and studied at 10 K and at 77 K using EPR, ENDOR, and EIE techniques. Two radicals, R1(10 K) and R1(77 K), were detected and characterized as two different geometrical conformations of the protonated reduction product >CH-C(OH)(2). R1(10 K) is only observed after irradiation at 10 K, and upon heating to 40 K, R1(10 K) transforms rapidly and irreversibly into R1(77 K). The transition from R1(10 K) to R1(77 K) strongly increases the isotropic hyperfine coupling of the C-CH(beta) coupling (Delta = 32 MHz) and the major C-OH(beta) coupling (Delta = 47 MHz), in sharp contrast to the their much reduced anisotropic hyperfine couplings after the transition. An umbrella-like inversion of the carboxylic acid center, accompanied by minor geometrical adjustments, explains the changes of these observed isotropic and anisotropic couplings. DFT calculations were done on the reduced and protonated L-O-serine phosphate radical at the B3LYP/6-311+G(2df,p)//B3LYP/6-31+G(d) level of theory in order to support the experimental observations. Two different conformations of the anion radical, related by an inversion at the carboxylic center, could be found within the single molecule partial energy-optimization scheme. These two conformations reproduce the experimental hyperfine couplings from radicals R1(10 K) and R1(77 K). A third radical, radical R2, was observed experimentally at both 10 and 77 K and was shown to be due to the decarboxylated L-O-serine phosphate oxidation product, a conclusion fully supported from the DFT calculations. Upon thermal annealing from 77 to 295 K, radicals R1(77 K) and R2 disappeared and all three previously observed room-temperature radicals could be observed. No phosphate-centered radicals could be observed at any temperatures, indicating that the phosphate-ester bond break for one of the room-temperature radicals does not occur by dissociative electron capture at the phosphate group.

The solid-state radiation chemistry of simple amino acids, revisited.

The solid-state radiation-induced free radical formation in simple amino acids like alpha-glycine (gly) and L-alpha-alanine (ala) has been the subject of investigations by EPR spectroscopy since the late 1950s. The EPR spectra from crystals of gly and ala generally are very complex due to the simultaneous trapping of several free radicals regardless of irradiation and observation temperatures. Untangling these complex spectra is necessary for understanding the mechanisms for the solid-state radiation chemistry of amino acids. Recently, radical formation in gly and ala after room-temperature irradiation has been reinvestigated in our laboratories using X-, K- and Q-band EPR and ENDOR spectroscopy, combined with the ENDOR-induced EPR (EIE) techniques as well as single-crystal and powder EPR and ENDOR spectrum simulations. Several new radical products have been detected and characterized, most prominently the gly species H2N - C x H - COOH and the ala species H3+N - C x (CH3) - COO and H2N - C x (CH3) - COOH. A short description of these radicals is given, and an overview of the solid-state radiation chemistry of the simple amino acids is presented, based on a review of the literature combined with these recent experimental results.