2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 2: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection.

The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure to clinical personnel. While the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. ACC leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. "Optimal Use of Ionizing Radiation in Cardiovascular Imaging - Best Practices for Safety and Effectiveness" is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. "Part I: Radiation Physics and Radiation Biology" addresses radiation physics, dosimetry and detrimental biologic effects. "Part II: Radiologic Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection" covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy). For each modality, it includes the determinants of radiation exposure and techniques to minimize exposure to both patients and to medical personnel.

2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways Developed in Collaboration With Mended Hearts.

The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure for clinical personnel. Although the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. The American College of Cardiology leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. Part I: Radiation Physics and Radiation Biology addresses the issue of medical radiation exposure, the basics of radiation physics and dosimetry, and the basics of radiation biology and radiation-induced adverse effects. Part II: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy) and will be published in the next issue of the Journal.

Comparison of skin dose measurement using nanoDot® dosimeter and machine readings of radiation dose during cardiac catheterization in children.

OBJECTIVES: Direct measurement of skin dose of radiation for children using optically stimulated luminescence (OSL) technology using nanoDot® (Landauer, Glenwood, IL, USA). BACKGROUND: Radiation dose is estimated as cumulative air kerma (AK) and dosearea product based on standards established for adult size patients. Body size of pediatric patients who undergo cardiac catheterization for congenital heart disease vary widely from newborn to adolescence. Direct, skindose measurement applying OSL technology may eliminate errors in the estimate. MATERIALS AND METHODS: The nanoDot® (1 cm × 1 cm × flat plastic cassette) is applied to patient's skin using adhesive tape during cardiac catheterization and radiation skin doses were read within 24 hrs. nanoDot® values were compared to the currently available cumulative AK values estimated and displayed on fluoroscopy monitor. RESULTS: A total of 12 children were studied, aged 4 months to 18 years (median 1.1 years) and weight range 5.3-86 kg (median 8.4 kg). nanoDot® readings ranged from 2.58 mGy to 424.8 mGy (median 84.1 mGy). Cumulative AK ranged from 16.2 mGy to 571.2 mGy (median 171.1 mGy). Linear correlation was noted between nanoDot® values and AK values (R2 = 0.88, R = 0.94). nanoDot® readings were approximately 65% of the estimated cumulative AK estimated using the International Electrotechnical Commission standards. CONCLUSIONS: Application of OSL technology using nanoDot® provides an alternative to directly measure fluoroscopic skin dose in children during cardiac catheterization. Our data show that the actual skin dose for children is approximately one-third lower than the AK estimated using international standards for adult size patients.

Impact of using scatter-mimicking beams instead of standard beams to measure penetration when assessing the protective value of radiation-protective garments.

PURPOSE: Use standardized methods to determine how assessment of protective value of radiation-protective garments changes under conditions employing standard beam qualities, scatter-mimicking primary beams, and a modified Hp (10) measurement. METHODS: The shielding properties of radiation-protective garments depend on the spectrum of beam energies striking the garment and the attenuation properties of materials used to construct the garment, including x-ray fluorescence produced by these materials. In this study the primary beam spectra employed during clinical interventional radiology and cardiology procedures (clinical primary beams, CPB) were identified using radiation dose structured reports (RDSR) and fluoroscope log data. Monte Carlo simulation was used to determine the scattered radiation spectra produced by these CPB during typical clinical application. For these scattered spectra, scatter-mimicking primary beams (SMPB) were determined using numerical optimization-based spectral reconstruction that adjusted kV and filtration to produce the SMPB that optimally matched the scattered spectrum for each CPB. The penetration of a subset of SMPB through four radiation-protective garments of varying compositions and nominal thicknesses was measured using a geometry specified by the International Electrotechnical Commission (IEC). The diagnostic radiological index of protection (DRIP), which increases with increasing penetration through a garment, was calculated using these measurements. Penetration through the same garments was measured for standard beams specified by the American Society of Testing and Materials (ASTM). Finally, 10 mm of PMMA was affixed to the inside of each garment and the DRIP remeasured in this configuration to simulate Hp (10). RESULTS: The SMPB based on actual CPB were in general characterized by lower kV (range 60-76) and higher half-value layer (HVL, range 3.44-4.89 mm Al) than standard beam qualities specified by ASTM (kV range 70-85; HVL range 3.4-4.0 mm Al). A lead garment of nominal thickness 0.5 mm (D) had a DRIP of 0.8%, two lead-free garments of 0.5 mm nominal thickness had DRIPs of 1.2% (A) and 2.2% (B), and a lead-free bilayer (C) had a DRIP of 1.4%. When standard beam qualities specified by the ASTM were used, the DRIP for D was 2.2%, 175% higher than the DRIP measured using SMPB, and for A, B, and C was 2.8%, 3.2%, and 2.9%, respectively. This was 133%, 45%, and 107% higher than the DRIP measured using SMPB. Differences between the DRIP of lead-alternative garments and the lead garment were reduced when measured with 10 mm of PMMA. Using this method, the measured DRIPs were 2.2% (A), 3.1% (B), 2.5% (C), and 2.3% (D). CONCLUSIONS: Penetration of radiation through radiation-protective garments depended strongly on the methods and X-ray spectra used for evaluation. The DRIP was higher (i.e., protective value was lower) for lead-alternative garments than for lead garments in this evaluation. The DRIP was lower for all garments when SMPB based on actual clinical beam quality data were used to measure penetration compared to ASTM standard beams. Differences in penetration between lead-alternative and lead garments were less when the DRIP was measured with 10 mm of PMMA between the garment and the chamber.

Sensitivity of the diagnostic radiological index of protection to procedural factors in fluoroscopy.

PURPOSE: To evaluate the sensitivity of the diagnostic radiological index of protection (DRIP), used to quantify the protective value of radioprotective garments, to procedural factors in fluoroscopy in an effort to determine an appropriate set of scatter-mimicking primary beams to be used in measuring the DRIP. METHODS: Monte Carlo simulations were performed to determine the shape of the scattered x-ray spectra incident on the operator in different clinical fluoroscopy scenarios, including interventional radiology and interventional cardiology (IC). Two clinical simulations studied the sensitivity of the scattered spectrum to gantry angle and patient size, while technical factors were varied according to measured automatic dose rate control (ADRC) data. Factorial simulations studied the sensitivity of the scattered spectrum to gantry angle, field of view, patient size, and beam quality for constant technical factors. Average energy (Eavg) was the figure of merit used to condense fluence in each energy bin to a single numerical index. RESULTS: Beam quality had the strongest influence on the scattered spectrum in fluoroscopy. Many procedural factors affect the scattered spectrum indirectly through their effect on primary beam quality through ADRC, e.g., gantry angle and patient size. Lateral C-arm rotation, common in IC, increased the energy of the scattered spectrum, regardless of the direction of rotation. The effect of patient size on scattered radiation depended on ADRC characteristics, patient size, and procedure type. CONCLUSIONS: The scattered spectrum striking the operator in fluoroscopy is most strongly influenced by primary beam quality, particularly kV. Use cases for protective garments should be classified by typical procedural primary beam qualities, which are governed by the ADRC according to the impacts of patient size, anatomical location, and gantry angle.

Application of the diagnostic radiological index of protection to protective garments.

PURPOSE: Previously, the diagnostic radiological index of protection (DRIP) was proposed as a metric for quantifying the protective value of radioprotective garments. The DRIP is a weighted sum of the percent transmissions of different radiation beams through a garment. Ideally, the beams would represent the anticipated stray radiation encountered during clinical use. However, it is impractical to expect a medical physicist to possess the equipment necessary to accurately measure transmission of scatteredradiation. Therefore, as a proof of concept, the authors tested a method that applied the DRIP to clinical practice. METHODS: Primary beam qualities used in interventional cardiology and radiology were observed and catalogued. Based on the observed range of beam qualities, five representative clinical primary beam qualities, specified by kV and added filtration, were selected for this evaluation. Monte Carlo simulations were performed using these primary beams as source definitions to generate scatteredspectra from the clinical primary beams. Using numerical optimization, ideal scatter mimicking primary beams, specified by kV and added aluminum filtration, were matched to the scatteredspectra according to half- and quarter-value layers and spectral shape. To within reasonable approximation, these theoretical scatter-mimicking primary beams were reproduced experimentally in laboratory x ray beams and used to measure transmission through pure lead and protective garments. For this proof of concept, the DRIP for pure lead and the garments was calculated by assigning equal weighting to percent transmission measurements for each of the five beams. Finally, the areal density of lead and garments was measured for consideration alongside the DRIP to assess the protective value of each material for a given weight. RESULTS: The authors identified ideal scatter mimicking primary beams that matched scatteredspectra to within 0.01 mm for half- and quarter-value layers in copper and within 5% for the shape function. The corresponding experimental scatter-mimicking primary beams matched the Monte Carlo generated scatteredspectra with maximum deviations of 6.8% and 6.6% for half- and quarter-value layers. The measured DRIP for 0.50 mm lead sheet was 2.0, indicating that it transmitted, on average, 2% of incident radiation. The measured DRIP for a lead garment and one lead-alternative garment closely matched that for pure lead of 0.50 mm thickness. The DRIP for other garments was substantially higher than 0.50 mm lead (3.9­5.4), indicating they transmitted about twice as much radiation. When the DRIP was plotted versus areal density, it was clear that, of the garments tested, none were better than lead on a weight-by-weight basis. CONCLUSIONS: A method for measuring the DRIP for protective garments using scatter-mimicking primary beams was developed. There was little discernable advantage in protective value per unit weight for lead-alternative versus lead-only garments. Careful consideration must be given to the balance of protection and weight when choosing a lead-alternative protective garment with a lower specified "lead equivalence," e.g., 0.35 mm. The DRIP has the potential to resolve this dilemma. Reporting the DRIP relative to areal density is an ideal metric for objective comparisons of protective garment performance, considering both protective value in terms of transmission of radiation and garment weight.

Application of the diagnostic radiological index of protection to protective garments.

PURPOSE: Previously, the diagnostic radiological index of protection (DRIP) was proposed as a metric for quantifying the protective value of radioprotective garments. The DRIP is a weighted sum of the percent transmissions of different radiation beams through a garment. Ideally, the beams would represent the anticipated stray radiation encountered during clinical use. However, it is impractical to expect a medical physicist to possess the equipment necessary to accurately measure transmission of scattered radiation. Therefore, as a proof of concept, the authors tested a method that applied the DRIP to clinical practice. METHODS: Primary beam qualities used in interventional cardiology and radiology were observed and catalogued. Based on the observed range of beam qualities, five representative clinical primary beam qualities, specified by kV and added filtration, were selected for this evaluation. Monte Carlo simulations were performed using these primary beams as source definitions to generate scattered spectra from the clinical primary beams. Using numerical optimization, ideal scatter mimicking primary beams, specified by kV and added aluminum filtration, were matched to the scattered spectra according to half- and quarter-value layers and spectral shape. To within reasonable approximation, these theoretical scatter-mimicking primary beams were reproduced experimentally in laboratory x ray beams and used to measure transmission through pure lead and protective garments. For this proof of concept, the DRIP for pure lead and the garments was calculated by assigning equal weighting to percent transmission measurements for each of the five beams. Finally, the areal density of lead and garments was measured for consideration alongside the DRIP to assess the protective value of each material for a given weight. RESULTS: The authors identified ideal scatter mimicking primary beams that matched scattered spectra to within 0.01 mm for half- and quarter-value layers in copper and within 5% for the shape function. The corresponding experimental scatter-mimicking primary beams matched the Monte Carlo generated scattered spectra with maximum deviations of 6.8% and 6.6% for half- and quarter-value layers. The measured DRIP for 0.50 mm lead sheet was 2.0, indicating that it transmitted, on average, 2% of incident radiation. The measured DRIP for a lead garment and one lead-alternative garment closely matched that for pure lead of 0.50 mm thickness. The DRIP for other garments was substantially higher than 0.50 mm lead (3.9-5.4), indicating they transmitted about twice as much radiation. When the DRIP was plotted versus areal density, it was clear that, of the garments tested, none were better than lead on a weight-by-weight basis. CONCLUSIONS: A method for measuring the DRIP for protective garments using scatter-mimicking primary beams was developed. There was little discernable advantage in protective value per unit weight for lead-alternative versus lead-only garments. Careful consideration must be given to the balance of protection and weight when choosing a lead-alternative protective garment with a lower specified "lead equivalence," e.g., 0.35 mm. The DRIP has the potential to resolve this dilemma. Reporting the DRIP relative to areal density is an ideal metric for objective comparisons of protective garment performance, considering both protective value in terms of transmission of radiation and garment weight.

Characterization of scatter in digital mammography from use of Monte Carlo simulations and comparison to physical measurements.

PURPOSE: Monte Carlo simulations were performed with the goal of verifying previously published physical measurements characterizing scatter as a function of apparent thickness. A secondary goal was to provide a way of determining what effect tissue glandularity might have on the scatter characteristics of breast tissue. The overall reason for characterizing mammography scatter in this research is the application of these data to an image processing-based scatter-correction program. METHODS: mcnpx was used to simulate scatter from an infinitesimal pencil beam using typical mammography geometries and techniques. The spreading of the pencil beam was characterized by two parameters: mean radial extent (MRE) and scatter fraction (SF). The SF and MRE were found as functions of target, filter, tube potential, phantom thickness, and the presence or absence of a grid. The SF was determined by separating scatter and primary by the angle of incidence on the detector, then finding the ratio of the measured scatter to the total number of detected events. The accuracy of the MRE was determined by placing ring-shaped tallies around the impulse and fitting those data to the point-spread function (PSF) equation using the value for MRE derived from the physical measurements. The goodness-of-fit was determined for each data set as a means of assessing the accuracy of the physical MRE data. The effect of breast glandularity on the SF, MRE, and apparent tissue thickness was also considered for a limited number of techniques. RESULTS: The agreement between the physical measurements and the results of the Monte Carlo simulations was assessed. With a grid, the SFs ranged from 0.065 to 0.089, with absolute differences between the measured and simulated SFs averaging 0.02. Without a grid, the range was 0.28-0.51, with absolute differences averaging -0.01. The goodness-of-fit values comparing the Monte Carlo data to the PSF from the physical measurements ranged from 0.96 to 1.00 with a grid and 0.65 to 0.86 without a grid. Analysis of the data suggested that the nongrid data could be better described by a biexponential function than the single exponential used here. The simulations assessing the effect of breast composition on SF and MRE showed only a slight impact on these quantities. When compared to a mix of 50% glandular/50% adipose tissue, the impact of substituting adipose or glandular breast compositions on the apparent thickness of the tissue was about 5%. CONCLUSIONS: The findings show agreement between the physical measurements published previously and the Monte Carlo simulations presented here; the resulting data can therefore be used more confidently for an application such as image processing-based scatter correction. The findings also suggest that breast composition does not have a major impact on the scatter characteristics of breast tissue. Application of the scatter data to the development of a scatter-correction software program can be simplified by ignoring the variations in density among breast tissues.

Should risk from medical imaging be assessed in the absence of benefit and vice versa?

Diagnostic radiology has an image problem. In its effort to develop a better understanding of benefit-risk in medical radiology, data on potential risks associated with medical imaging have been welcomed into the medical community. As such, risk perspectives and mantras from the occupational health profession have been adopted and applied to patients. These perspectives often focus on risk with only casual, incidental, or no reference to the benefits experienced by patients. These occupational health viewpoints have accumulated over decades, have overshadowed a very limited perspective about the benefits of medical X-rays, and have become an integrated part of our profession. This review argues that the medical profession should abandon perspectives on risk that are adopted from occupational health professions and focus on perspectives that realistically focus on the medical benefit-risk for patients.

If it is published in the peer-reviewed literature, it must be true?

Epidemiological research correlating cancer rates in a population of patients with radiation doses from medical X-rays is fraught with confounding factors that obfuscate the likelihood that any positive relationship is causal. This is a review of four studies involving some of those confounding factors. Comparisons of findings with other studies not encumbered by similar confounding factors can enhance assertions of causation between medical X-rays and cancer rates. Even so, such assertions rest significantly on opinions of researchers regarding the degree of consistency between findings among various studies. The question as to what degree any findings truly represent cause and effect will likely still meet with controversy. The importance of these findings to medicine should therefore not lie in any controversy regarding causation, but in what the findings potentially mean with regard to benefit and risk for patients and the professional practice of medicine.

Characterization of scatter in digital mammography from physical measurements.

PURPOSE: That scattered radiation negatively impacts the quality of medical radiographic imaging is well known. In mammography, even slight amounts of scatter reduce the high contrast required for subtle soft-tissue imaging. In current clinical mammography, image contrast is partially improved by use of an antiscatter grid. This form of scatter rejection comes with a sizeable dose penalty related to the concomitant elimination of valuable primary radiation. Digital mammography allows the use of image processing as a method of scatter correction that might avoid effects that negatively impact primary radiation, while potentially providing more contrast improvement than is currently possible with a grid. For this approach to be feasible, a detailed characterization of the scatter is needed. Previous research has modeled scatter as a constant background that serves as a DC bias across the imaging surface. The goal of this study was to provide a more substantive data set for characterizing the spatially-variant features of scatter radiation at the image detector of modern mammography units. METHODS: This data set was acquired from a model of the radiation beam as a matrix of very narrow rays or pencil beams. As each pencil beam penetrates tissue, the pencil widens in a predictable manner due to the production of scatter. The resultant spreading of the pencil beam at the detector surface can be characterized by two parameters: mean radial extent (MRE) and scatter fraction (SF). The SF and MRE were calculated from measurements obtained using the beam stop method. Two digital mammography units were utilized, and the SF and MRE were found as functions of target, filter, tube potential, phantom thickness, and presence or absence of a grid. These values were then used to generate general equations allowing the SF and MRE to be calculated for any combination of the above parameters. RESULTS: With a grid, the SF ranged from a minimum of about 0.05 to a maximum of about 0.16, and the MRE ranged from about 3 to 13 mm. Without a grid, the SF ranged from a minimum of 0.25 to a maximum of 0.52, and the MRE ranged from about 20 to 45 mm. The SF with a grid demonstrated a mild dependence on target/filter combination and kV, whereas the SF without a grid was independent of these factors. The MRE demonstrated a complex relationship as a function of kV, with notable difference among target/filter combinations. The primary source of change in both the SF and MRE was phantom thickness. CONCLUSIONS: Because breast tissue varies spatially in physical density and elemental content, the effective thickness of breast tissue varies spatially across the imaging field, resulting in a spatially-variant scatter distribution in the imaging field. The data generated in this study can be used to characterize the scatter contribution on a point-by-point basis, for a variety of different techniques.

Medical imaging using ionizing radiation: optimization of dose and image quality in fluoroscopy.

The 2012 Summer School of the American Association of Physicists in Medicine (AAPM) focused on optimization of the use of ionizing radiation in medical imaging. Day 2 of the Summer School was devoted to fluoroscopy and interventional radiology and featured seven lectures. These lectures have been distilled into a single review paper covering equipment specification and siting, equipment acceptance testing and quality control, fluoroscope configuration, radiation effects, dose estimation and measurement, and principles of flat panel computed tomography. This review focuses on modern fluoroscopic equipment and is comprised in large part of information not found in textbooks on the subject. While this review does discuss technical aspects of modern fluoroscopic equipment, it focuses mainly on the clinical use and support of such equipment, from initial installation through estimation of patient dose and management of radiation effects. This review will be of interest to those learning about fluoroscopy, to those wishing to update their knowledge of modern fluoroscopic equipment, to those wishing to deepen their knowledge of particular topics, such as flat panel computed tomography, and to those who support fluoroscopic equipment in the clinic.

On the (f)utility of measuring the lead equivalence of protective garments.

PURPOSE: Protective garments incorporating lead (Pb) or other moderate to high atomic number elements are a necessary radiation protection tool. However, as lead has been replaced by other elements, verifying manufacturers' claims regarding the lead equivalence of such garments has become nearly impossible, and current standards only require measurement of attenuation or lead equivalence at a single beam quality. A garment may provide a high degree of protection at the specified beam quality, but underperform at others. The authors sought to measure the lead equivalence of several protective garments and propose a better method for quantifying the protective value of garments. METHODS: The authors measured the penetration of primary and scattered radiation through lead sheets and three protective garments of nominal 0.5 mm Pb equivalence, one lead and two lead-free. Penetration was measured using beams of nominal 60, 80, 100, and 120 kVp. Primary penetration through protective garments at 70 kVp was also measured. A lead-lined enclosure was constructed for measuring scatter penetration, as instruments must be protected from stray radiation when measuring low-level penetration of scattered radiation. Using polynomial least-squares fits to the measured data of penetration through lead sheets, the authors determined the lead equivalence of the protective garments across a range of beam qualities. RESULTS: The lead garment was 0.5 mm Pb equivalent across all beam qualities evaluated. While the maximum lead equivalence of the lead-free garments did occur at the manufacturer-specified beam quality, neither garment was 0.5 mm Pb equivalent at the specified beam quality. The lead equivalence of the lead-free garments was a strong function of beam quality and nature of the radiation, i.e., primary or scattered. The lead equivalence of the lead-free garments in primary beams ranged from 0.40 to 0.47 mm Pb equivalent and in scattered beams ranged from 0.37 to 0.46 mm Pb equivalent. The penetration through one lead-free garment at 60 kVp was 478% higher than the penetration through the lead garment. The authors have also provided linear fits of radiation penetration through lead as a function of half-value layer. It is likely that assessment of protective value can be performed using primary beams matched to the spectra of scattered beams. The authors propose the diagnostic radiation index of protection (DRIP), a weighted sum of the percentage of radiation penetration across a range of beam qualities, as a more robust method for specifying the protective value of garments. CONCLUSIONS: The protective value of garments from both primary and scattered radiation is a strong function of beam quality. Assessment of the protective value should be performed across a range of beam qualities. Methods for performing such assessment must be developed and must specify beam qualities, measurement geometry, and the appropriate weighting across the beam quality range for different applications.

Toward a holistic approach in the presentation of benefits and risks of medical radiation.

Frequently messages are conveyed about benefit and risk in medical imaging or in imaging-guided medical intervention that are quite different from the intended communication. This is because communication is not merely the words used to express an idea. The message involves many personal factors on the part of the communicator and on the part of the audience. The intent of this article is to disclose some of the underlying factors that disproportionately bias communication of benefit and risk. Suggestions on how to develop a holistic communication of benefits and risks are presented. It is recommended that communication about the application of radiation to patients be disassociated from standard radiation protection concepts. The medical profession should develop unique communication tools to deliver a message that focuses on benefit/risk as a holistic entity, not benefit or risk as separate entities.