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Goyal SK, Wang JJ, McCandlish JA, Cronin PP, Barish M, Sanelli PC, Cohen SL. Ten-Year Trend in Advanced Imaging Utilization for Suspected Pulmonary Embolism in Pregnancy. J Am Coll Radiol 2024; 21:549-557. [PMID: 37775066 DOI: 10.1016/j.jacr.2023.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE Advanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy. METHODS The authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P < .05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE. RESULTS A total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P < .001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P < .001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P < .001). Finally, there was a decrease of 0.004 (P = .009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016. CONCLUSIONS Advanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations.
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Affiliation(s)
- Sameer K Goyal
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Jason J Wang
- The Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Paul P Cronin
- Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, Georgia
| | - Matthew Barish
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Pina C Sanelli
- Vice Chairman of Research and Executive Director, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York
| | - Stuart L Cohen
- Department of Radiology, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York.
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2
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Grison S, Braga-Tanaka II, Baatout S, Klokov D. In utero exposure to ionizing radiation and metabolic regulation: perspectives for future multi- and trans-generation effects studies. Int J Radiat Biol 2024; 100:1283-1296. [PMID: 38180060 DOI: 10.1080/09553002.2023.2295293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/03/2023] [Accepted: 11/22/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE The radiation protection community has been particularly attentive to the risks of delayed effects on offspring from low dose or low dose-rate exposures to ionizing radiation. Despite this, the current epidemiologic studies and scientific data are still insufficient to provide the necessary evidence for improving risk assessment guidelines. This literature review aims to inform future studies on multigenerational and transgenerational effects. It primarily focuses on animal studies involving in utero exposure and discusses crucial elements for interpreting the results. These elements include in utero exposure scenarios relative to the developmental stages of the embryo/fetus, and the primary biological mechanisms responsible for transmitting heritable or hereditary effects to future generations. The review addresses several issues within the contexts of both multigenerational and transgenerational effects, with a focus on hereditary perspectives. CONCLUSIONS Knowledge consolidation in the field of Developmental Origins of Health and Disease (DOHaD) has led us to propose a new study strategy. This strategy aims to address the transgenerational effects of in utero exposure to low dose and low dose-rate radiation. Within this concept, there is a possibility that disruption of epigenetic programming in embryonic and fetal cells may occur. This disruption could lead to metabolic dysfunction, which in turn may cause abnormal responses to future environmental challenges, consequently increasing disease risk. Lastly, we discuss methodological limitations in our studies. These limitations are related to cohort size, follow-up time, model radiosensitivity, and analytical techniques. We propose scientific and analytical strategies for future research in this field.
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Affiliation(s)
- Stéphane Grison
- PSE-SANTE, Institut de Radioprotection et de Sûreté Nucléaire, Fontenay-aux-Roses, France
| | - Ignacia Iii Braga-Tanaka
- Department of Radiobiology, Institute for Environmental Sciences (IES), Rokkasho Kamikita, Aomori, Japan
| | - Sarah Baatout
- Belgian Nuclear Research Centre, SCK CEN, Institute of Nuclear Medical Applications, Mol, Belgium
- Department of Molecular Biotechnology (BW25) and Department of Human Structure and Repair (GE38), Ghent University, Ghent, Belgium
| | - Dmitry Klokov
- PSE-SANTE, Institut de Radioprotection et de Sûreté Nucléaire, Fontenay-aux-Roses, France
- Department of Microbiology, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
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Akhlaghi P, Mohammadi N, Karimi-Shahri K, Ebrahimi-Khankook A, Rezaei-Moghaddam Y. Efficiency of tungsten-polymer composite shields on fetal dose reduction in chest CT scans. Med Eng Phys 2023; 118:104008. [PMID: 37536843 DOI: 10.1016/j.medengphy.2023.104008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/21/2023] [Accepted: 06/15/2023] [Indexed: 08/05/2023]
Abstract
Given their desirable shielding properties, 5 polymer composite shields reinforced with tungsten were selected and their effects as gamma shields on fetal dose reduction were investigated. According to the results, the selected shields reduce the fetus brain, the fetus lungs, the fetus kidneys, and the total fetus dose almost 34.17%-41.19%, 20.47%-25.08%, 9.27%-12.13%, and 15.39%-18.69%, respectively, at tube voltage of 80 kVp. At the higher tube potentials, the values of dose reduction were smaller. Moreover, it was observed that polymers named PHEMA-WO3 and RS-U-30 had an excellent shielding ability among the other studied composites.
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Affiliation(s)
- Parisa Akhlaghi
- Department of Medical Physics, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Najmeh Mohammadi
- Physics Department, Faculty of Sciences, Sahand University of Technology, Tabriz, Iran
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Mainprize JG, Yaffe MJ, Chawla T, Glanc P. Effects of ionizing radiation exposure during pregnancy. Abdom Radiol (NY) 2023; 48:1564-1578. [PMID: 36933026 PMCID: PMC10024285 DOI: 10.1007/s00261-023-03861-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE To review the effects of ionizing radiation to the conceptus and the relationship to the timing of the exposure during pregnancy. To consider strategies that would mitigate potential harms associated with exposure to ionizing radiation during pregnancy. METHODS Data reported in the peer-reviewed literature on entrance KERMA received from specific radiological examinations were combined with published results from experiment or Monte Carlo modeling of tissue and organ doses per entrance KERMA to estimate total doses that could be received from specific procedures. Data reported in the peer-reviewed literature on dose mitigation strategies, best practices for shielding, consent, counseling and emerging technologies were reviewed. RESULTS For procedures utilizing ionizing radiation for which the conceptus is not included in the primary radiation beam, typical doses are well below the threshold for causing tissue reactions and the risk of induction of childhood cancer is low. For procedures that include the conceptus in the primary radiation field, longer fluoroscopic interventional procedures or multiphase/multiple exposures potentially could approach or exceed thresholds for tissue reactions and the risk of cancer induction must be weighed against the expected risk/benefit of performing (or not) the imaging examination. Gonadal shielding is no longer considered best practice. Emerging technologies such as whole-body DWI/MRI, dual-energy CT and ultralow dose studies are gaining importance for overall dose reduction strategies. CONCLUSION The ALARA principle, considering potential benefits and risks should be followed with respect to the use of ionizing radiation. Nevertheless, as Wieseler et al. (2010) state, "no examination should be withheld when an important clinical diagnosis is under consideration." Best practices require updates on current available technologies and guidelines.
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Affiliation(s)
- James G. Mainprize
- Physical Sciences Platform, Sunnybrook Research Institute, 2075 Bayview Ave., Rm S632/S657, Toronto, ON M4N 3M5 Canada
| | - Martin J. Yaffe
- Physical Sciences Platform, Sunnybrook Research Institute, 2075 Bayview Ave., Rm S632/S657, Toronto, ON M4N 3M5 Canada
- Departments of Medical Biophysics and Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave., Rm S657, Toronto, ON M4N 3M5 Canada
| | - Tanya Chawla
- Joint Department of Medical Imaging, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Phyllis Glanc
- Departments Medical Imaging, Obstetrics & Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Rm MG 160, Toronto, ON M4N 3M5 Canada
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Patient and Fetal Radiation-Induced Malignancy Risk From Imaging For Evaluation of Pulmonary Embolism in Pregnancy. J Emerg Med 2023; 64:295-303. [PMID: 36932003 DOI: 10.1016/j.jemermed.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 08/22/2022] [Accepted: 10/21/2022] [Indexed: 03/17/2023]
Abstract
BACKGROUND Imaging for diagnosis of suspected pulmonary embolism in pregnancy presents radiation concerns for patient and fetus. OBJECTIVES Estimate the risks of radiation-induced breast cancer and childhood leukemia from common imaging techniques for the evaluation of suspected pulmonary embolism in pregnancy. METHODS Breast and uterine absorbed doses for various imaging techniques were input into the National Cancer Institute Radiation Risk Assessment Tool to calculate risk of breast cancer for the patient and childhood leukemia for the fetus. Absorbed doses were obtained by synthesizing data from a recent systematic review and the International Commission on Radiological Protection. Primary outcomes were the estimated excess incidences of breast cancer and childhood leukemia per 100,000 exposures. RESULTS Baseline incidences of breast cancer for a 30-year-old woman and childhood leukemia for a male fetus were 13,341 and 939, respectively. Excess incidences of breast cancer were 0.003 and 0.275 for a single and two-view chest radiograph, respectively, 9.53 and 20.6 for low- and full-dose computed tomography pulmonary angiography (CTPA), respectively, 0.616 and 2.54 for low- and full-dose perfusion scan, respectively, and 0.732 and 2.66 for low- and full-dose ventilation perfusion scan, respectively. Excess incidences of childhood leukemia were 0.004 and 0.007 for a single and two-view chest radiograph, respectively, 0.069 and 0.490 for low- and full-dose CTPA, respectively, 0.359 and 1.47 for low- and full-dose perfusion scan, respectively, and 0.856 and 1.97 for low- and full-dose ventilation perfusion scan, respectively. CONCLUSION Excess cancer risks for all techniques were small relative to baseline cancer risks, with CTPA techniques carrying slightly higher risk of breast cancer for the patient and ventilation perfusion techniques a higher risk of childhood leukemia.
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6
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Kane SV, Reau N. Clinical advances: pregnancy in gastroenterologic and hepatic conditions. Gut 2023; 72:1007-1015. [PMID: 36759153 DOI: 10.1136/gutjnl-2022-328893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023]
Abstract
The fields of gastroenterology and hepatology, along with endoscopic practice, have seen significant changes and innovations to practice in just the past few years. These practice changes are not limited to gastroenterology, but maternal fetal medicine and the care of the pregnant person have become increasingly more sophisticated as well. Gastroenterologists are frequently called on to provide consultative input and/or perform endoscopy during pregnancy. To be able to provide the best possible care to these patients, gastroenterologists need to be aware of (and familiar with) the various nuances and caveats related to the care of pregnant patients who either have underlying gastrointestinal (GI) conditions or present with GI and liver disorders. Here, we offer a clinical update with references more recent than 2018, along with a few words about SARS-CoV-2 infection and its relevance to pregnancy.
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Affiliation(s)
- Sunanda V Kane
- Medicine, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Nancy Reau
- Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Roseland ME, Zhang M, Caoili EM. Imaging of pregnant and lactating patients with suspected adrenal disorders. Rev Endocr Metab Disord 2023; 24:97-106. [PMID: 35624403 DOI: 10.1007/s11154-022-09733-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 02/01/2023]
Abstract
A high level of clinical suspicion is essential in the diagnosis and management of a suspected adrenal mass during pregnancy and the peripartum period. Timely recognition is important in order to improve fetal and maternal outcomes. Imaging is often performed to confirm a suspected adrenal lesion; however, increasing usage of diagnostic imaging during pregnancy and lactation has also increased awareness, concerns and confusion regarding the safety risks regarding fetal and maternal exposure to radiation and imaging intravenous contrast agents. This may lead to anxiety and avoidance of imaging examinations which can delay diagnosis and appropriate treatment. This article briefly reviews evidence-based recommended imaging modalities during pregnancy and the lactation period for the assessment of a suspected adrenal mass while recognizing that no examination should be withheld when the exam is necessary to confirm an important clinical suspicion. The imaging characteristics of the more common adrenal pathologies that may affect pregnant women are also discussed.
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Affiliation(s)
- Molly E Roseland
- Department of Radiology, Michigan Medicine, 1500. E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Man Zhang
- Department of Radiology, Michigan Medicine, 1500. E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Elaine M Caoili
- Department of Radiology, Michigan Medicine, 1500. E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Burton CS, Frey K, Fahey F, Kaminski MS, Brown RKJ, Pohlen JM, Shulkin BL. Fetal Dose from PET and CT in Pregnant Patients. J Nucl Med 2023; 64:312-319. [PMID: 36215573 DOI: 10.2967/jnumed.122.263959] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 02/04/2023] Open
Abstract
When pregnancy is discovered during or after a diagnostic examination, the physician or the patient may request an estimate of the radiation dose received by the fetus as per guidelines and standard operating procedures. This study provided the imaging community with dose estimates to the fetus from PET/CT with protocols that are adapted to University of Michigan low-dose protocols for patients known to be pregnant. Methods: There were 9 patients analyzed with data for the first, second, and third trimesters, the availability of which is quite rare. These images were used to calculate the size-specific dose estimate (SSDE) from the CT scan portion and the SUV and 18F-FDG uptake dose from the PET scan portion using the MIRD formulation. The fetal dose estimates were tested for correlation with each of the following independent measures: gestational age, fetal volume, average water-equivalent diameter of the patient along the length of the fetus, SSDE, SUV, and percentage of dose from 18F-FDG. Stepwise multiple linear regression analysis was performed to assess the partial correlation of each variable. To our knowledge, this was the first study to determine fetal doses from CT and PET images. Results: Fetal self-doses from 18F for the first, second, and third trimesters were 2.18 mGy (single data point), 0.74-1.82 mGy, and 0.017-0.0017 mGy, respectively. The combined SSDE and fetal self-dose ranged from 1.2 to 8.2 mGy. These types of images from pregnant patients are rare. Conclusion: Our data indicate that the fetal radiation exposure from 18F-FDG PET and CT performed, when medically necessary, on pregnant women with cancer is low. All efforts should be made to minimize fetal radiation exposure by modifying the protocol.
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Affiliation(s)
| | - Kirk Frey
- Michigan Medicine, Ann Arbor, Michigan
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Ece B, Aydın S, Kantarci M. Antenatal imaging: A pictorial review. World J Clin Cases 2022; 10:12854-12874. [PMID: 36569012 PMCID: PMC9782949 DOI: 10.12998/wjcc.v10.i35.12854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/17/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Today, in parallel with the use of imaging modalities increases in all fields, the use of imaging methods in pregnant women is increasing. Imaging has become an integral component of routine pregnancy follow-up. Imaging provides parents with an early opportunity to learn about the current situation, including prenatal detection of anomalies or diseases, etiology, prognosis, and the availability of prenatal or postnatal treatments. Various imaging modalities, especially ultrasonography, are frequently used for imaging both maternal and fetal imaging. The goal of this review was to address imaging modalities in terms of usefulness and safety, as well as to provide demonstrative examples for disorders. And this review provides current information on selecting a safe imaging modality to evaluate the pregnant and the fetus, the safety of contrast medium use, and summarizes major pathological situations with demonstrative sonographic images to assist radiologists and obstetricians in everyday practice.
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Affiliation(s)
- Bunyamin Ece
- Department of Radiology, Kastamonu University, Kastamonu 37150, Turkey
| | - Sonay Aydın
- Department of Radiology, Erzincan University, Erzincan 24142, Turkey
| | - Mecit Kantarci
- Department of Radiology, Erzincan University, Erzincan 24142, Turkey
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Zhang X. Magnetic resonance imaging of the monkey fetal brain in utero. INVESTIGATIVE MAGNETIC RESONANCE IMAGING 2022; 26:177-190. [PMID: 36937817 PMCID: PMC10019598 DOI: 10.13104/imri.2022.26.4.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Non-human primates (NHPs) are the closest living relatives of the human and play a critical role in investigating the effects of maternal viral infection and consumption of medicines, drugs, and alcohol on fetal development. With the advance of contemporary fast MRI techniques with parallel imaging, fetal MRI is becoming a robust tool increasingly used in clinical practice and preclinical studies to examine congenital abnormalities including placental dysfunction, congenital heart disease (CHD), and brain abnormalities non-invasively. Because NHPs are usually scanned under anesthesia, the motion artifact is reduced substantially, allowing multi-parameter MRI techniques to be used intensively to examine the fetal development in a single scanning session or longitudinal studies. In this paper, the MRI techniques for scanning monkey fetal brains in utero in biomedical research are summarized. Also, a fast imaging protocol including T2-weighted imaging, diffusion MRI, resting-state functional MRI (rsfMRI) to examine rhesus monkey fetal brains in utero on a clinical 3T scanner is introduced.
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Affiliation(s)
- Xiaodong Zhang
- EPC Imaging Center and Division of Neuropharmacology and Neurologic Diseases, Emory National Primate Research Center, Emory University, Atlanta, Georgia, 30329, USA
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Motavaselian M, Bayati F, Amani-Beni R, Khalaji A, Haghverdi S, Abdollahi Z, Sarrafzadeh A, Rafie Manzelat AM, Rigi A, Arabzadeh Bahri R, Nakhaee Z, Fadaei M, Ghasemi Falaverjani H, Malekpour-Dehkordi S, Hoseinpour M, Bidares M, Zandkarimi S, Ahmadi R, Beheshtiparvar D, Ahadiat SA, Farshi M, Farrokhi M. Diagnostic Performance of Magnetic Resonance Imaging for Detection of Acute Appendicitis in Pregnant Women; a Systematic Review and Meta-Analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e81. [PMID: 36426165 PMCID: PMC9676701 DOI: 10.22037/aaem.v10i1.1727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION The diagnosis of acute appendicitis (AA) in pregnant women is commonly challenging owing to the normal results of laboratory tests, organ displacement, and normal physiological inflammatory alterations. This meta-analysis aimed to investigate the accuracy of magnetic resonance imaging (MRI) in diagnosis of AA in pregnant women. METHODS Two investigators independently performed a comprehensive systematic literature search of electronic databases including MEDLINE, Cochrane Central, EMBASE, Web of Science, Scopus, and Google Scholar to identify studies that reported accuracy of MRI for diagnosis of AA in pregnant women from inception to April 1, 2022. RESULTS Our systematic search identified a total of 525 published papers. Finally, a total of 26 papers were included in the meta-analysis. The pooled sensitivity and specificity of MRI in diagnosis of AA in pregnant women were 0.92 (95% CI: 0.88-0.95) and 0.98 (95% CI 0.97-0.98), respectively. The pooled positive likelihood ratio and negative likelihood ratio were 29.52 (95% CI: 21.90-39.81) and 0.10 (95% CI: 0.04-0.25), respectively. The area under hierarchical summary receiver operating characteristic (HSROC) curve indicated that the accuracy of MRI for diagnosis of AA in pregnant women is 99%. CONCLUSION This meta-analysis showed that MRI has high sensitivity, specificity, and accuracy for diagnosis of AA in pregnant women and can be used as a first-line imaging modality for suspected cases of AA during pregnancy. Furthermore, it should be noted that when the result of ultrasonography is inconclusive, the use of MRI can reduce unnecessary appendectomy in pregnant patients.
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Affiliation(s)
- Mohsen Motavaselian
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fateme Bayati
- USERN Office, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Amani-Beni
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirreza Khalaji
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sara Haghverdi
- Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Arash Sarrafzadeh
- School of Dentistry, Arak University of Medical Sciences, Arak, Iran
| | | | - Amir Rigi
- Islamic Azad University, Zahedan Branch, Zahedan, Iran
| | | | | | - Mahta Fadaei
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hajar Ghasemi Falaverjani
- Department of Internal Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Matin Bidares
- Islamic Azad University of Najafabad, Najafabad, Iran
| | - Sarvenaz Zandkarimi
- Faculty of Pharmacy, Islamic Azad University of Tehran Medical Sciences, Tehran, Iran
| | - Rasha Ahmadi
- Shariati Hospital, Tehran University of Medical Science, Tehran, Iran
| | | | - Seyed-Amirabbas Ahadiat
- Research Center of Biochemistry and Nutrition in Metabolic Disorder, Kashan University of Medical science. Kashan, Iran
| | - Mohsen Farshi
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Farrokhi
- Men’s Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding author: Mehrdad Farrokhi; Men’s Health and Reproductive Health Research Center, Shohadaye Tajrish Hospital, Tehran, Iran. , Phone number: +989384226664
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13
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Cancer in pregnancy: overview and epidemiology. Abdom Radiol (NY) 2022; 48:1559-1563. [PMID: 35960309 DOI: 10.1007/s00261-022-03633-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/01/2022]
Abstract
Cancer in pregnancy, one of the most distressing and demanding conditions in all of women's health care, occurs about 1:1000 pregnancies with an increasing incidence due to delayed childbearing. Diagnosis of pregnancy associated cancer is especially challenging because tumor symptoms may be masked by normal physiologic changes of pregnancy. The burden of care for both mother and child goes well beyond factual medical information. Balancing the potential risks and benefits to the mother and fetus necessitates a superior level of knowledge and expertise that includes epidemiology, pathophysiology, ionizing radiation and teratogenesis, risks and benefits of various imaging modalities, oncology, and radiotherapy, and other areas. Radiologists are an integral part of a multidisciplinary team that shares responsibility for selection of safe and effective diagnosis and management. Throughout the course of treatment, counseling and support are of paramount importance to the patient and her family. A compassionate culture of care bolsters the effectiveness of the care team to inform, counsel, and engage with the patient to achieve optimal outcomes. This special section of Abdominal Radiology is meant to offer insights for diagnostic imaging and its role in personalized management of this most serious and challenging condition. This article will provide an overview of imaging cancer in pregnancy and detail the relevant epidemiology.
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Little MP, Brenner AV, Grant EJ, Sugiyama H, Preston DL, Sakata R, Cologne J, Velazquez-Kronen R, Utada M, Mabuchi K, Ozasa K, Olson JD, Dugan GO, Pazzaglia S, Cline JM, Applegate KE. Age effects on radiation response: summary of a recent symposium and future perspectives. Int J Radiat Biol 2022; 98:1-11. [PMID: 35394411 PMCID: PMC9626395 DOI: 10.1080/09553002.2022.2063962] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
One of the principal uncertainties when estimating population risk of late effects from epidemiological data is that few radiation-exposed cohorts have been followed up to extinction. Therefore, the relative risk model has often been used to estimate radiation-associated risk and to extrapolate risk to the end of life. Epidemiological studies provide evidence that children are generally at higher risk of cancer induction than adults for a given radiation dose. However, the strength of evidence varies by cancer site and questions remain about site-specific age at exposure patterns. For solid cancers, there is a large body of evidence that excess relative risk (ERR) diminishes with increasing age at exposure. This pattern of risk is observed in the Life Span Study (LSS) as well as in other radiation-exposed populations for overall solid cancer incidence and mortality and for most site-specific solid cancers. However, there are some disparities by endpoint in the degree of variation of ERR with exposure age, with some sites (e.g., colon, lung) in the LSS incidence data showing no variation, or even increasing ERR with increasing age at exposure. The pattern of variation of excess absolute risk (EAR) with age at exposure is often similar, with EAR for solid cancers or solid cancer mortality decreasing with increasing age at exposure in the LSS. We shall review the human data from the Japanese LSS cohort, and a variety of other epidemiological data sets, including a review of types of medical diagnostic exposures, also some radiobiological animal data, all bearing on the issue of variations of radiation late-effects risk with age at exposure and with attained age. The paper includes a summary of several oral presentations given in a Symposium on "Age effects on radiation response" as part of the 67th Annual Meeting of the Radiation Research Society, held virtually on 3-6 October 2021.
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Affiliation(s)
- Mark P. Little
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | | | - Eric J. Grant
- Radiation Effects Research Foundation, Hiroshima, Japan
| | | | | | - Ritsu Sakata
- Radiation Effects Research Foundation, Hiroshima, Japan
| | - John Cologne
- Radiation Effects Research Foundation, Hiroshima, Japan
| | - Raquel Velazquez-Kronen
- Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), Cincinnati, OH, USA
| | - Mai Utada
- Radiation Effects Research Foundation, Hiroshima, Japan
| | - Kiyohiko Mabuchi
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Kotaro Ozasa
- Radiation Effects Research Foundation, Hiroshima, Japan
| | - John D. Olson
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Gregory O. Dugan
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Simonetta Pazzaglia
- Laboratory of Biomedical Technologies, Agenzia Nazionale per le Nuove Tecnologie, l’Energia e lo Sviluppo Economico Sostenibile (ENEA), Rome, Italy
| | - J. Mark Cline
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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15
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Affiliation(s)
- Rebecca Wiles
- Department of radiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Beth Hankinson
- Department of radiology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Emily Benbow
- Liverpool Babies Patient and Public Involvement and Engagement Group, Department of women's and children's health, University of Liverpool, Liverpool, UK
| | - Andrew Sharp
- Department of women's and children's health, University of Liverpool, Liverpool, UK
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16
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Role of Ultrasound in the Assessment and Differential Diagnosis of Pelvic Pain in Pregnancy. Diagnostics (Basel) 2022; 12:diagnostics12030640. [PMID: 35328194 PMCID: PMC8947205 DOI: 10.3390/diagnostics12030640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 02/04/2023] Open
Abstract
Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.
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17
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Kwan ML, Miglioretti DL, Bowles EJA, Weinmann S, Greenlee RT, Stout NK, Rahm AK, Alber SA, Pequeno P, Moy LM, Stewart C, Fong C, Jenkins CL, Kohnhorst D, Luce C, Mor JM, Munneke JR, Prado Y, Buth G, Cheng SY, Deosaransingh KA, Francisco M, Lakoma M, Martinez YT, Theis MK, Marlow EC, Kushi LH, Duncan JR, Bolch WE, Pole JD, Smith-Bindman R. Quantifying cancer risk from exposures to medical imaging in the Risk of Pediatric and Adolescent Cancer Associated with Medical Imaging (RIC) Study: research methods and cohort profile. Cancer Causes Control 2022; 33:711-726. [PMID: 35107724 DOI: 10.1007/s10552-022-01556-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/18/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The Risk of Pediatric and Adolescent Cancer Associated with Medical Imaging (RIC) Study is quantifying the association between cumulative radiation exposure from fetal and/or childhood medical imaging and subsequent cancer risk. This manuscript describes the study cohorts and research methods. METHODS The RIC Study is a longitudinal study of children in two retrospective cohorts from 6 U.S. healthcare systems and from Ontario, Canada over the period 1995-2017. The fetal-exposure cohort includes children whose mothers were enrolled in the healthcare system during their entire pregnancy and followed to age 20. The childhood-exposure cohort includes children born into the system and followed while continuously enrolled. Imaging utilization was determined using administrative data. Computed tomography (CT) parameters were collected to estimate individualized patient organ dosimetry. Organ dose libraries for average exposures were constructed for radiography, fluoroscopy, and angiography, while diagnostic radiopharmaceutical biokinetic models were applied to estimate organ doses received in nuclear medicine procedures. Cancers were ascertained from local and state/provincial cancer registry linkages. RESULTS The fetal-exposure cohort includes 3,474,000 children among whom 6,606 cancers (2394 leukemias) were diagnosed over 37,659,582 person-years; 0.5% had in utero exposure to CT, 4.0% radiography, 0.5% fluoroscopy, 0.04% angiography, 0.2% nuclear medicine. The childhood-exposure cohort includes 3,724,632 children in whom 6,358 cancers (2,372 leukemias) were diagnosed over 36,190,027 person-years; 5.9% were exposed to CT, 61.1% radiography, 6.0% fluoroscopy, 0.4% angiography, 1.5% nuclear medicine. CONCLUSION The RIC Study is poised to be the largest study addressing risk of childhood and adolescent cancer associated with ionizing radiation from medical imaging, estimated with individualized patient organ dosimetry.
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Affiliation(s)
- Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Diana L Miglioretti
- Department of Public Health Sciences, University of California, Davis, CA, USA.,Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Erin J A Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA.,Center for Integrated Health Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Robert T Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Alanna Kulchak Rahm
- Center for Health Research, Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Susan A Alber
- Department of Public Health Sciences, University of California, Davis, CA, USA
| | | | - Lisa M Moy
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Carly Stewart
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | | | - Charisma L Jenkins
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Diane Kohnhorst
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Casey Luce
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Joanne M Mor
- Center for Integrated Health Research, Kaiser Permanente Hawaii, Honolulu, HI, USA
| | - Julie R Munneke
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Yolanda Prado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Glen Buth
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, USA
| | | | - Kamala A Deosaransingh
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Melanie Francisco
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Matthew Lakoma
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | - Mary Kay Theis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Emily C Marlow
- Department of Public Health Sciences, University of California, Davis, CA, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - James R Duncan
- Interventional Radiology Section, Washington University in St. Louis, St. Louis, MI, USA
| | - Wesley E Bolch
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Jason D Pole
- ICES, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Rebecca Smith-Bindman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.,Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
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18
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Weinmann S, Francisco MC, Kwan ML, Bowles EJA, Rahm AK, Greenlee RT, Stout NK, Pole JD, Kushi LH, Smith-Bindman R, Miglioretti DL. Positive predictive value and sensitivity of ICD-9-CM codes for identifying pediatric leukemia. Pediatr Blood Cancer 2022; 69:e29383. [PMID: 34773439 PMCID: PMC9933870 DOI: 10.1002/pbc.29383] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/17/2021] [Accepted: 09/08/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND To facilitate community-based epidemiologic studies of pediatric leukemia, we validated use of ICD-9-CM diagnosis codes to identify pediatric leukemia cases in electronic medical records of six U.S. integrated health plans from 1996-2015 and evaluated the additional contributions of procedure codes for diagnosis/treatment. PROCEDURES Subjects (N = 408) were children and adolescents born in the health systems and enrolled for at least 120 days after the date of the first leukemia ICD-9-CM code or tumor registry diagnosis. The gold standard was the health system tumor registry and/or medical record review. We calculated positive predictive value (PPV) and sensitivity by number of ICD-9-CM codes received in the 120-day period following and including the first code. We evaluated whether adding chemotherapy and/or bone marrow biopsy/aspiration procedure codes improved PPV and/or sensitivity. RESULTS Requiring receipt of one or more codes resulted in 99% sensitivity (95% confidence interval [CI]: 98-100%) but poor PPV (70%; 95% CI: 66-75%). Receipt of two or more codes improved PPV to 90% (95% CI: 86-93%) with 96% sensitivity (95% CI: 93-98%). Requiring at least four codes maximized PPV (95%; 95% CI: 92-98%) without sacrificing sensitivity (93%; 95% CI: 89-95%). Across health plans, PPV for four codes ranged from 84-100% and sensitivity ranged from 83-95%. Including at least one code for a bone marrow procedure or chemotherapy treatment had minimal impact on PPV or sensitivity. CONCLUSIONS The use of diagnosis codes from the electronic health record has high PPV and sensitivity for identifying leukemia in children and adolescents if more than one code is required.
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Affiliation(s)
- Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest Portland, OR,Center for Integrated Health Research, Kaiser Permanente Hawaii Honolulu, Hawaii
| | | | - Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California Oakland, CA
| | - Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington Seattle WA
| | - Alanna Kulchak Rahm
- Center for Health Research, Genomic Medicine Institute, Geisinger Health System Danville, PA 17822
| | - Robert T. Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System Marshfield, WI
| | - Natasha K. Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute Boston, MA
| | - Jason D. Pole
- The Hospital for Sick Children, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada,Centre for Health Services Research, The University of Queensland Brisbane, Australia
| | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California Oakland, CA
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, Epidemiology and Biostatistics, University of California San Francisco,The Philip R. Lee Institute for Health Policy, University of California San Francisco
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19
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Applegate KE, Findlay Ú, Fraser L, Kinsella Y, Ainsbury L, Bouffler S. Radiation exposures in pregnancy, health effects and risks to the embryo/foetus-information to inform the medical management of the pregnant patient. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:S522-S539. [PMID: 34380129 DOI: 10.1088/1361-6498/ac1c95] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/11/2021] [Indexed: 06/13/2023]
Abstract
Generally, intentional exposure of pregnant women is avoided as far as possible in both medical and occupational situations. This paper aims to summarise available information on sources of radiation exposure of the embryo/foetus primarily in medical settings. Accidental and unintended exposure is also considered. Knowledge on the effects of radiation exposure on the developing embryo/foetus remains incomplete-drawn largely from animal studies and two human cohorts but a summary is provided in relation to the key health endpoints of concern, severe foetal malformations/death, future cancer risk, and future impact on cognitive function. Both the specific education and training and also the literature regarding medical management of pregnant females is in general sparse, and consequently the justification and optimisation approaches may need to be considered on a case by case basis. In collating and reviewing this information, several suggestions for future basic science research, education and training, and radiation protection practice are identified.
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Affiliation(s)
- Kimberly E Applegate
- Department of Radiology (retired), University of Kentucky College of Medicine, 800 Rose St, Lexington, KY 40536, United States of America
| | - Úna Findlay
- Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Harwell Campus, Chilton, Didcot, Oxon OX11 0RQ, United Kingdom
| | - Louise Fraser
- Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Harwell Campus, Chilton, Didcot, Oxon OX11 0RQ, United Kingdom
| | - Yvonne Kinsella
- Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Harwell Campus, Chilton, Didcot, Oxon OX11 0RQ, United Kingdom
| | - Liz Ainsbury
- Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Harwell Campus, Chilton, Didcot, Oxon OX11 0RQ, United Kingdom
| | - Simon Bouffler
- Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Harwell Campus, Chilton, Didcot, Oxon OX11 0RQ, United Kingdom
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20
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Berrington de Gonzalez A, Pasqual E, Veiga L. Epidemiological studies of CT scans and cancer risk: the state of the science. Br J Radiol 2021; 94:20210471. [PMID: 34545766 DOI: 10.1259/bjr.20210471] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
20 years ago, 3 manuscripts describing doses and potential cancer risks from CT scans in children raised awareness of a growing public health problem. We reviewed the epidemiological studies that were initiated in response to these concerns that assessed cancer risks from CT scans using medical record linkage. We evaluated the study methodology and findings and provide recommendations for optimal study design for new efforts. We identified 17 eligible studies; 13 with published risk estimates, and 4 in progress. There was wide variability in the study methodology, however, which made comparison of findings challenging. Key differences included whether the study focused on childhood or adulthood exposure, radiosensitive outcomes (e.g. leukemia, brain tumors) or all cancers, the exposure metrics (e.g. organ doses, effective dose or number of CTs) and control for biases (e.g. latency and exclusion periods and confounding by indication). We were able to compare results for the subset of studies that evaluated leukemia or brain tumors. There were eight studies of leukemia risk in relation to red bone marrow (RBM) dose, effective dose or number of CTs; seven reported a positive dose-response, which was statistically significant (p < 0.05) in four studies. Six of the seven studies of brain tumors also found a positive dose-response and in five, this was statistically significant. Mean RBM dose ranged from 6 to 12 mGy and mean brain dose from 18 to 43 mGy. In a meta-analysis of the studies of childhood exposure the summary ERR/100 mGy was 1.78 (95%CI: 0.01-3.53) for leukemia/myelodisplastic syndrome (n = 5 studies) and 0.80 (95%CI: 0.48-1.12) for brain tumors (n = 4 studies) (p-heterogeneity >0.4). Confounding by cancer pre-disposing conditions was unlikely in these five studies of leukemia. The summary risk estimate for brain tumors could be over estimated, however, due to reverse causation. In conclusion, there is growing evidence from epidemiological data that CT scans can cause cancer. The absolute risks to individual patients are, however, likely to be small. Ongoing large multicenter cohorts and future pooling efforts will provide more precise risk quantification.
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Affiliation(s)
- Amy Berrington de Gonzalez
- Radiation Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Elisa Pasqual
- Radiation Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Lene Veiga
- Radiation Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, MD, USA
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21
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Marlow EC, Ducore J, Kwan ML, Cheng SY, Bowles EJA, Greenlee RT, Pole JD, Rahm AK, Stout NK, Weinmann S, Smith-Bindman R, Miglioretti DL. Leukemia Risk in a Cohort of 3.9 Million Children with and without Down Syndrome. J Pediatr 2021; 234:172-180.e3. [PMID: 33684394 PMCID: PMC8238875 DOI: 10.1016/j.jpeds.2021.03.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/18/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess leukemia risks among children with Down syndrome in a large, contemporary cohort. STUDY DESIGN Retrospective cohort study including 3 905 399 children born 1996-2016 in 7 US healthcare systems or Ontario, Canada, and followed from birth to cancer diagnosis, death, age 15 years, disenrollment, or December 30, 2016. Down syndrome was identified using International Classification of Diseases, Ninth and Tenth Revisions, diagnosis codes. Cancer diagnoses were identified through linkages to tumor registries. Incidence and hazard ratios (HRs) of leukemia were estimated for children with Down syndrome and other children adjusting for health system, child's age at diagnosis, birth year, and sex. RESULTS Leukemia was diagnosed in 124 of 4401 children with Down syndrome and 1941 of 3 900 998 other children. In children with Down syndrome, the cumulative incidence of acute myeloid leukemia (AML) was 1405/100 000 (95% CI 1076-1806) at age 4 years and unchanged at age 14 years. The cumulative incidence of acute lymphoid leukemia in children with Down syndrome was 1059/100 000 (95% CI 755-1451) at age 4 and 1714/100 000 (95% CI 1264-2276) at age 14 years. Children with Down syndrome had a greater risk of AML before age 5 years than other children (HR 399, 95% CI 281-566). Largest HRs were for megakaryoblastic leukemia before age 5 years (HR 1500, 95% CI 555-4070). Children with Down syndrome had a greater risk of acute lymphoid leukemia than other children regardless of age (<5 years: HR 28, 95% CI 20-40, ≥5 years HR 21, 95% CI 12-38). CONCLUSIONS Down syndrome remains a strong risk factor for childhood leukemia, and associations with AML are stronger than previously reported.
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Affiliation(s)
- Emily C Marlow
- Graduate Group in Epidemiology, University of California, Davis, Davis, CA; Department of Public Health Sciences, University of California, Davis, Davis, CA
| | - Jonathan Ducore
- Department of Pediatrics, University of California, Davis, Davis, CA
| | - Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Erin J A Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Salt Lake City, UT
| | - Robert T Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI
| | - Jason D Pole
- ICES, Toronto, Ontario, Canada; Centre for Health Service Research, University of Queensland, Brisbane, Australia; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR; Center for Integrated Health Care Research, Kaiser Permanente Hawaii, Honolulu, HI
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA; Department of Obstetrics, Gynecology and Reproductive Medicine, University of California, San Francisco, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA
| | - Diana L Miglioretti
- Department of Public Health Sciences, University of California, Davis, Davis, CA; Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Salt Lake City, UT.
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22
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Bourgioti C, Konidari M, Gourtsoyianni S, Moulopoulos LA. Imaging during pregnancy: What the radiologist needs to know. Diagn Interv Imaging 2021; 102:593-603. [PMID: 34059484 DOI: 10.1016/j.diii.2021.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 12/14/2022]
Abstract
During the last decades, there has been a growing demand for medical imaging in gravid women. Imaging of the pregnant woman is challenging as it involves both the mother and the fetus and, consequently, several medical, ethical, or legal considerations are likely to be raised. Theoretically, all currently available imaging modalities may be used for the evaluation of the pregnant woman; however, in practice, confusion regarding the safety of the fetus often results in unnecessary avoidance of useful diagnostic tests, especially those involving ionizing radiation. This review article is focused on the current safety guidelines and considerations regarding the use of different imaging modalities in the pregnant population; also presented is an imaging work-up for the most common medical conditions of pregnant women, with emphasis on fetal and maternal safety.
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Affiliation(s)
- Charis Bourgioti
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 76, Vassilisis Sofias Avenue, Athens 11528, Greece.
| | - Marianna Konidari
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 76, Vassilisis Sofias Avenue, Athens 11528, Greece
| | - Sofia Gourtsoyianni
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 76, Vassilisis Sofias Avenue, Athens 11528, Greece
| | - Lia Angela Moulopoulos
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 76, Vassilisis Sofias Avenue, Athens 11528, Greece
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23
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Fetal dose evaluation for body CT examinations of pregnant patients during all stages of pregnancy. Eur J Radiol 2021; 141:109780. [PMID: 34049058 DOI: 10.1016/j.ejrad.2021.109780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/23/2021] [Accepted: 05/13/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE CTDIvol-to-fetal-dose coefficients from Monte Carlo simulations are useful for fetal dose evaluations, but the available data is limited to the fetus being completely inside the abdominopelvic scan range. Whereas in a chest examination, the fetus is completely outside the scan range. In an abdominal examination, the fetus after 16 gestational weeks is partly in the scan region, and an earlier fetus is completely outside of it. This work proposes a practical approach to evaluate fetal dose for pregnant patients undergoing body CT examinations, without using Monte Carlo simulation. METHODS The proposed method was based on the z-axis dose profile computed for a CT examination, considering CTDIvol, scan range, mA, and maternal WED (water equivalent diameter) at the fetus centroid. Fetal average dose was calculated over the fetus z-axis coverage. For validation, we considered a reference dataset of 24 pregnant patients, each underwent two abdominopelvic examinations (fixed mA, tube current modulation). WED was 30.1 ± 3.3 (25.3-35.6) cm [mean(range)]. Gestational age was <5 weeks for one patient, and 20.3 ± 9.1 (5-35.9) weeks for the others. Fetal depth (from the anterior skin surface to the most anterior part of fetus) was 6.1 ± 2.1 (2.5-10.9) cm. We further considered three whole-body models of a pregnant patient (gestational age, 3, 6, 9 months; weight, 62-73 kg) undergoing chest, abdominal, and abdominopelvic examinations (fixed mA). For the patients and models, profile-based fetal dose calculations were compared with the results of Monte Carlo simulations. Statistical software (R, version 3.5.1) was used to determine the mean and 95th percentile. RESULTS The fetal dose difference between profile-based evaluations and Monte Carlo simulations was (5.9 ± 3.8)% for 24 fixed-mA examinations, (5.8 ± 4.6)% for 24 tube current modulated examinations, and (8.8 ± 5.9)% for the whole-body models in three scan ranges. CONCLUSIONS Profile-based fetal dose calculations can be performed for patients in body CT, considering maternal size, fetus size and location, and whether fetus is completely inside, partly inside, or outside scan ranges.
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24
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Radiation Dose to the Fetus From Computed Tomography of Pregnant Patients-Development and Validation of a Web-Based Tool. Invest Radiol 2021; 55:762-768. [PMID: 32604386 DOI: 10.1097/rli.0000000000000701] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Estimations of radiation dose absorbed by the fetus from computed tomography (CT) in pregnant patients is mandatory, but currently available methods are not feasible in clinical routine. The aims of this study were to develop and validate a tool for assessment of fetal dose from CT of pregnant patients and to develop a user-friendly web interface for fast fetal dose calculations. METHODS In the first study part, 750 Monte Carlo (MC) simulations were performed on phantoms representing pregnant patients at various gestational stages. The MC code simulating vendor-independent dose distributions was validated against CT dose index (CTDI) measurements performed on CT scanners of 2 vendors. The volume CTDI-normalized fetal dose values from MC simulations were used for developing the computational algorithm enabling fetal dose assessments from CT of various body regions at different exposure settings. In the institutional review board-approved second part, the algorithm was validated against patient-specific MC simulations performed on CT data of 29 pregnant patients (gestational ages 8-35 weeks) who underwent CT. Furthermore, the tool was compared with a commercially available software. A user-friendly web-based interface for fetal dose calculations was created. RESULTS Weighted CTDI values obtained from MC simulations were in excellent agreement with measurements performed on the 2 CT systems (average error, 4%). The median fetal dose from abdominal CT in pregnant patients was 2.7 mGy, showing moderate correlation with maternal perimeter (r = 0.69). The algorithm provided accurate estimates of fetal doses (average error, 11%), being more accurate than the commercially available tool. The web-based interface (www.fetaldose.org) enabling vendor-independent calculations of fetal doses from CT requires the input of gestational age, volume CTDI, tube voltage, and scan region. CONCLUSIONS A tool for fetal dose assessments from CT of pregnant patients was developed and validated being freely available on a user-friendly web interface.
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25
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Bowles EJA, Miglioretti DL, Kwan ML, Bartels U, Furst A, Cheng SY, Lau C, Greenlee RT, Weinmann S, Marlow EC, Rahm AK, Stout NK, Bolch WE, Theis MK, Smith-Bindman R, Pole JD. Long-term medical imaging use in children with central nervous system tumors. PLoS One 2021; 16:e0248643. [PMID: 33882069 PMCID: PMC8059842 DOI: 10.1371/journal.pone.0248643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/15/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Children with central nervous system (CNS) tumors undergo frequent imaging for diagnosis and follow-up, but few studies have characterized longitudinal imaging patterns. We described medical imaging in children before and after malignant CNS tumor diagnosis. PROCEDURE We conducted a retrospective cohort study of children aged 0-20 years diagnosed with CNS tumors between 1996-2016 at six U.S. integrated healthcare systems and Ontario, Canada. We collected computed topography (CT), magnetic resonance imaging (MRI), radiography, ultrasound, nuclear medicine examinations from 12 months before through 10 years after CNS diagnosis censoring six months before death or a subsequent cancer diagnosis, disenrollment from the health system, age 21 years, or December 31, 2016. We calculated imaging rates per child per month stratified by modality, country, diagnosis age, calendar year, time since diagnosis, and tumor grade. RESULTS We observed 1,879 children with median four years follow-up post-diagnosis in the U.S. and seven years in Ontario, Canada. During the diagnosis period (±15 days of diagnosis), children averaged 1.10 CTs (95% confidence interval [CI] 1.09-1.13) and 2.14 MRIs (95%CI 2.12-2.16) in the U.S., and 1.67 CTs (95%CI 1.65-1.68) and 1.86 MRIs (95%CI 1.85-1.88) in Ontario. Within one year after diagnosis, 19% of children had ≥5 CTs and 45% had ≥5 MRIs. By nine years after diagnosis, children averaged one MRI and one radiograph per year with little use of other imaging modalities. CONCLUSIONS MRI and CT are commonly used for CNS tumor diagnosis, whereas MRI is the primary modality used during surveillance of children with CNS tumors.
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Affiliation(s)
- Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, United States of America
- Department of Public Health Sciences, University of California, Davis, Davis, California, United States of America
- University of California Davis Comprehensive Cancer Center, Davis, California, United States of America
| | - Marilyn L. Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Ute Bartels
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Adam Furst
- Department of Public Health Sciences, University of California, Davis, Davis, California, United States of America
| | | | | | - Robert T. Greenlee
- Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin, United States of America
| | - Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
- Center for Integrated Health Research, Kaiser Permanente Hawaii, Honolulu, Hawaii, United States of America
| | - Emily C. Marlow
- Department of Public Health Sciences, University of California, Davis, Davis, California, United States of America
| | - Alanna K. Rahm
- Center for Health Research, Genomic Medicine Institute, Geisinger, Danville, Pennsylvania, United States of America
| | - Natasha K. Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Wes E. Bolch
- Department of Biomedical Engineering, University of Florida, Gainesville, Florida, United States of America
| | - Mary Kay Theis
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, United States of America
| | - Rebecca Smith-Bindman
- Department of Radiology and Biomedical Imaging, Epidemiology and Biostatistics and The Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, California, United States of America
| | - Jason D. Pole
- The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
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Affiliation(s)
- Jayson Potts
- Department of Medicine, University of British Columbia, Canada
| | - Sandra A Lowe
- Royal Hospital for Women and School of Women's and Children's Health, University of New South Wales, Sydney, Australia
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Dymbe B, Mæland EV, Styve JR, Rusandu A. Individualization of computed tomography protocols for suspected pulmonary embolism: a national investigation of routines. J Int Med Res 2020; 48:300060520918427. [PMID: 32290743 PMCID: PMC7157970 DOI: 10.1177/0300060520918427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective Given the extensive use of computed tomography (CT) in radiation-sensitive patients such as pregnant and pediatric patients, and considering the importance of tailoring CT protocols to patient characteristics for both the radiation dose and image quality, this study was performed to investigate the extent to which individualization of CT protocols is practiced across Norway. Methods This cross-sectional study involved collection of CT protocols and administration of a mini-questionnaire to obtain additional information about how CT examinations are individualized. All public hospitals performing CT to detect pulmonary embolism were invited, and 41% participated. Results Tailoring a standard protocol to different patient groups was more common than using dedicated protocols. Most of the available radiation dose-reduction approaches were used. However, implementation of these strategies was not systematic. Children and pregnant patients were examined without using dedicated CT protocols or by using protocol adjustments focusing on radiation dose reduction in 30% and 39% of the hospitals, respectively. Conclusion Practice optimization is needed, especially the development of dedicated CT protocols or guidelines that tailor the existing protocol to pediatric and pregnant patients. Practice might benefit from a more systematic approach to individualization of CT examinations, such as inserting tailoring instructions into CT protocols.
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Affiliation(s)
- Berit Dymbe
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Elisabeth Vespestad Mæland
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Jorunn Rønhovde Styve
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Albertina Rusandu
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Lum M, Tsiouris AJ. MRI safety considerations during pregnancy. Clin Imaging 2020; 62:69-75. [PMID: 32109683 DOI: 10.1016/j.clinimag.2020.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 12/12/2022]
Abstract
The use of magnetic resonance imaging (MRI) during pregnancy is on the rise due its ability to provide detailed cross-sectional anatomy without ionizing radiation. Despite the favorable radiation profile, theoretically concerns regarding the safety of MRI and gadolinium-based contrast agent (GBCA) administration have been raised. Currently there are no studies that have shown any attributable harms of MRI during any trimester of pregnancy although prospective and longitudinal studies are lacking. GBCA administration may be associated with a slightly higher rate of neonatal death, although this is based on a single, large cohort study. Understanding the available evidence regarding MRI safety during pregnancy in the context of current society guidelines will help the radiologist serve as a valuable resource to patients and referring providers.
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Affiliation(s)
- Mark Lum
- Department of Radiology, New York Presbyterian Hospital, Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065, United States of America.
| | - A John Tsiouris
- Department of Radiology, New York Presbyterian Hospital, Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065, United States of America
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