Recurrent medical imaging exposures for the care of patients: one way forward.

Medical imaging is both valuable and essential in the care of patients. Much of this imaging depends on ionizing radiation with attendant responsibilities for judicious use when performing an examination. This responsibility applies in settings of both individual as well as multiple (recurrent) imaging with associated repeated radiation exposures. In addressing the roles and responsibilities of the medical communities in the paradigm of recurrent imaging, both the International Atomic Energy Agency (IAEA) and the American Association of Physicists in Medicine (AAPM) have issued position statements, each affirmed by other organizations. The apparent difference in focus and approach has resulted in a lack of clarity and continued debate. Aiming towards a coherent approach in dealing with radiation exposure in recurrent imaging, the IAEA convened a panel of experts, the purpose of which was to identify common ground and reconcile divergent perspectives. The effort has led to clarifying recommendations for radiation exposure aspects of recurrent imaging, including the relevance of patient agency and the provider-patient covenant in clinical decision-making. CLINICAL RELEVANCE STATEMENT: An increasing awareness, generating some lack of clarity and divergence in perspectives, with patients receiving relatively high radiation doses (e.g., ≥ 100 mSv) from recurrent imaging warrants a multi-stakeholder accord for the benefit of patients, providers, and the imaging community. KEY POINTS: • Recurrent medical imaging can result in an accumulation of exposures which exceeds 100 milli Sieverts. • Professional organizations have different perspectives on roles and responsibilities for recurrent imaging. • An expert panel reconciles differing perspectives for addressing radiation exposure from recurrent medical imaging.

Proposed Priorities for Low-Dose Radiation Research and Their Relevance to the Practice of Radiology.

Because ionizing radiation is widely used in medical imaging and in military, industry, and commercial applications, programmatic management and advancement in knowledge is needed, especially related to the health effects of low-dose radiation. The U.S. Congress in partnership with the U.S. Department of Energy called on the National Academies of Sciences, Engineering, and Medicine (NASEM) to develop a long-term strategic and prioritized agenda for low-dose radiation research. Low doses were defined as dose amounts less than 100 mGy or low-dose rates less than 5 mGy per hour. The 2022 NASEM report was divided into sections detailing the low-dose radiation exposure and health effects, scientific basis for radiation protection, status of low-dose radiation research, a prioritized radiation research agenda, and essential components of a low-dose radiation research program, including resources needed and recommendations for financial recourse. The purpose of this review is to summarize this report and examine the recommendations to assess how these pertain to the practice of radiology and medicine.

An FDA Guide on Indications for Use and Device Reporting of Artificial Intelligence-Enabled Devices: Significance for Pediatric Use.

Radiology has been a pioneer in adopting artificial intelligence (AI)-enabled devices into the clinic. However, initial clinical experience has identified concerns of inconsistent device performance across different patient populations. Medical devices, including those using AI, are cleared by the FDA for their specific indications for use (IFUs). IFU describes the disease or condition the device will diagnose or treat, including a description of the intended patient population. Performance data evaluated during the premarket submission support the IFU and include the intended patient population. Understanding the IFUs of a given device is thus critical to ensuring that the device is used properly and performs as expected. When devices do not perform as expected or malfunction, medical device reporting is an important way to provide feedback about the device to the manufacturer, the FDA, and other users. This article describes the ways to retrieve the IFU and performance data information as well as the FDA medical device reporting systems for unexpected performance discrepancy. It is crucial that imaging professionals, including radiologists, know how to access and use these tools to improve the informed use of medical devices for patients of all ages.

Making CT Dose Monitoring Meaningful: Augmenting Dose with Imaging Quality.

Due to the concerns about radiation dose associated with medical imaging, radiation dose monitoring systems (RDMSs) are now utilized by many radiology providers to collect, process, analyze, and manage radiation dose-related information. Currently, most commercially available RDMSs focus only on radiation dose information and do not track any metrics related to image quality. However, to enable comprehensive patient-based imaging optimization, it is equally important to monitor image quality as well. This article describes how RDMS design can be extended beyond radiation dose to simultaneously monitor image quality. A newly designed interface was evaluated by different groups of radiology professionals (radiologists, technologists, and physicists) on a Likert scale. The results show that the new design is effective in assessing both image quality and safety in clinical practices, with an overall average score of 7.8 out of 10.0 and scores ranging from 5.5 to 10.0. Radiologists rated the interface highest at 8.4 out of 10.0, followed by technologists at 7.6 out of 10.0, and medical physicists at 7.5 out of 10.0. This work demonstrates how the assessment of the radiation dose can be performed in conjunction with the image quality using customizable user interfaces based on the clinical needs associated with different radiology professions.

Comparison of the different imaging modalities used to image pediatric oncology patients: A COG diagnostic imaging committee/SPR oncology committee white paper.

Diagnostic imaging is essential in the diagnosis and management, including surveillance, of known or suspected cancer in children. The independent and combined roles of the various modalities, consisting of radiography, fluoroscopy, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine (NM), are both prescribed through protocols but also function in caring for complications that may occur during or subsequent to treatment such as infection, bleeding, or organ compromise. Use of a specific imaging modality may be based on situational circumstances such as a brain CT or MR for a new onset seizure, chest CT for respiratory signs or symptoms, or US for gross hematuria. However, in many situations, there are competing choices that do not easily lend themselves to a formulaic approach as options; these situations depend on the contributions of a variety of factors based on a combination of the clinical scenario and the strengths and limitations of the imaging modalities. Therefore, an improved understanding of the potential influence of the imaging decision pathways in pediatric cancer care can come from comparison among the individual diagnostic imaging modalities. The purpose of the following material to is to provide such a comparison. To do this, pediatric imaging content experts for the individual modalities of radiography and fluoroscopy, US, CT, MRI, and NM will discuss the individual modality strengths and limitations.

Pediatric Applications of Photon-Counting Detector CT.

Photon-counting detector (PCD) CT represents the most recent generational advance in CT technology. PCD CT has the potential to reduce image noise, improve spatial resolution and contrast resolution, and provide multispectral capability, all of which may be achieved with an overall decrease in the radiation dose. These effects may be used to reduce the iodinated contrast media dose and potentially obtain multiphase images through a single-acquisition technique. The benefits of PCD CT have previously been shown primarily in phantoms and adult patients. This article describes the application of PCD CT in children, as illustrated by clinical examples from a commercially available PCD CT system.

Imaging of Right Lower Quadrant Pain in Children and Adolescents: AJR Expert Panel Narrative Review.

Right lower quadrant (RLQ) pain is a common clinical presentation in children, and accurate clinical diagnosis remains challenging given that this nonspecific presentation is associated with numerous surgical and nonsurgical conditions. The broad differential diagnosis varies by patient age and sex. Important considerations in the selection of a diagnostic imaging strategy include the sequencing, performance, and cost of tests. This article provides a comprehensive narrative review of the diagnostic imaging of RLQ pain in children and adolescents, including a discussion of the complementary roles of ultrasound, CT, and MRI; description of key imaging findings based on available evidence; and presentation of salient differential diagnoses. Subspecialized pediatric emergency medicine and surgical perspectives are also provided as further clinical insight into this common, but often challenging, scenario. Finally, the current status of imaging of RLQ pain in children and adolescents is summarized on the basis of expert consensus.

Thyroid Nodules on Ultrasound in Children and Young Adults: Comparison of Diagnostic Performance of Radiologists' Impressions, ACR TI-RADS, and a Deep Learning Algorithm.

BACKGROUND. In current clinical practice, thyroid nodules in children are generally evaluated on the basis of radiologists' overall impressions of ultrasound images. OBJECTIVE. The purpose of this article is to compare the diagnostic performance of radiologists' overall impression, the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS), and a deep learning algorithm in differentiating benign and malignant thyroid nodules on ultrasound in children and young adults. METHODS. This retrospective study included 139 patients (median age 17.5 years; 119 female patients, 20 male patients) evaluated from January 1, 2004, to September 18, 2020, who were 21 years old and younger with a thyroid nodule on ultrasound with definitive pathologic results from fine-needle aspiration and/or surgical excision to serve as the reference standard. A single nodule per patient was selected, and one transverse and one longitudinal image each of the nodules were extracted for further evaluation. Three radiologists independently characterized nodules on the basis of their overall impression (benign vs malignant) and ACR TI-RADS. A previously developed deep learning algorithm determined for each nodule a likelihood of malignancy, which was used to derive a risk level. Sensitivities and specificities for malignancy were calculated. Agreement was assessed using Cohen kappa coefficients. RESULTS. For radiologists' overall impression, sensitivity ranged from 32.1% to 75.0% (mean, 58.3%; 95% CI, 49.2-67.3%), and specificity ranged from 63.8% to 93.9% (mean, 79.9%; 95% CI, 73.8-85.7%). For ACR TI-RADS, sensitivity ranged from 82.1% to 87.5% (mean, 85.1%; 95% CI, 77.3-92.1%), and specificity ranged from 47.0% to 54.2% (mean, 50.6%; 95% CI, 41.4-59.8%). The deep learning algorithm had a sensitivity of 87.5% (95% CI, 78.3-95.5%) and specificity of 36.1% (95% CI, 25.6-46.8%). Interobserver agreement among pairwise combinations of readers, expressed as kappa, for overall impression was 0.227-0.472 and for ACR TI-RADS was 0.597-0.643. CONCLUSION. Both ACR TI-RADS and the deep learning algorithm had higher sensitivity albeit lower specificity compared with overall impressions. The deep learning algorithm had similar sensitivity but lower specificity than ACR TI-RADS. Interobserver agreement was higher for ACR TI-RADS than for overall impressions. CLINICAL IMPACT. ACR TI-RADS and the deep learning algorithm may serve as potential alternative strategies for guiding decisions to perform fine-needle aspiration of thyroid nodules in children.

Medical workforce in the United States.

This section focuses on the professional workforce comprised of the primary medical specialties that utilize ionizing radiation in their practices. Those discussed include the specialties of radiology and radiation oncology, as well as the subspecialties of radiology, namely diagnostic radiology, interventional radiology, nuclear radiology, and nuclear medicine. These professionals provide essential health care services, for example, the interpretation of imaging studies, the provision of interventional procedures, radionuclide therapeutic treatments, and radiation therapy. In addition, they may be called on to function as part of a radiologic emergency response team to care for potentially exposed persons following radiation events, for example, detonation of a nuclear weapon, nuclear power plant accidents, and transportation incidents. For these reasons, maintenance of an adequate workforce in each of these professions is essential to meeting the nation's future needs. Currently, there is a shortage for all physicians in the medical radiology workforce.

Cardiovascular computed tomography in pediatric congenital heart disease: A state of the art review.

Cardiac computed tomography (CCT) has increasingly been used in the assessment of both children and adults with congenital heart disease (CHD), in part due to advances in CCT technology and an increased prevalence of adults with palliated CHD. It serves as a complimentary modality to echocardiography, cardiac magnetic resonance imaging and cardiac catheterization. CCT can provide unique diagnostic information, is less invasive and less likely to require sedation compared to other modalities. Detailed knowledge of individual patient cardiac anatomy, physiology, surgical repair and possible residual lesions are paramount to optimal CCT imaging. This comprehensive review details the use of CCT both pre- and postoperatively for the most common CHD diagnoses. We also aim to highlight some new and innovative technologies that have become available and can further optimize CCT imaging for CHD patients.

Intrapersonal and Institutional Influences On Overall Perception of Radiation Safety Among Radiologic Technologists.

PURPOSE: The purpose of the study was to examine mean differences between intrapersonal and institutional variables and the overall perception of radiation safety (OPRS) among U.S. radiologic technologists. The study also sought to demonstrate the applicability of the socioecological model for radiation safety decision-making. METHODS: A quantitative, cross-sectional design with the Radiation Actions and Dimensions of Radiation Safety survey instrument was used to collect data and guide hypotheses testing. The 425 research participants included radiologic technologists working in radiography, mammography, computed tomography, and radiology management. Categorical and descriptive data were calculated, and 1-way analysis of variance tests were used to analyze hypotheses. RESULTS: Seven main effects demonstrated mean differences between groups for the OPRS, including age (F5,419 = 2.55, P = .03), years of experience (F5,419 = 4.27, P = .001), primary employed imaging modality (F2,422 = 9.04, P < .001), primary role (F2,422 = 4.58, P = .01), shift length (F3,421 = 10.33, P < .001), primary practice facility (F4,404 = 5.00, P = .001), and work shift (F3,405 = 4.14, P = .007), with shift length having the largest effect. Level of education, employment status, number of imaging credentials, gender, patient population, and practice location were not significant at the level of P ≤ .05. DISCUSSION: Radiation safety culture is a multidimensional topic that requires consideration of several intervening influences, making the socioecological model well aligned when considering radiation safety culture and radiation safety perception in medical imaging. Previous research on radiation safety perception among radiologic technologists demonstrated that leadership actions, teamwork across imaging stakeholders, organizational learning, and questioning behavior are drivers of OPRS. However, this study's findings demonstrate that radiologic technologist scheduling practices and primary employed imaging modalities also should be considered when seeking to improve OPRS. CONCLUSION: This study presents an extensive examination of intrapersonal and institutional variables on OPRS among U.S.-based radiologic technologists and provides findings to support radiation safety culture decision-making in medical imaging, particularly for shift length considerations.