Internal Audit to Monitor the Injected Activity in PET/CT Using Control Charts

BACKGROUND AND OBJECTIVE

In an effort to limit the risks associated with medical radiation exposure, the last century witnessed the development of dose control mechanisms, recommended by the International Commission on Radiological Protection. This organization recommends the optimization of radiation protection to provide the highest level of safety that may reasonably be achievable. Adhering to the "as low as reasonably achievable" principle, the purpose of this study was to monitor the 18 F-FDG injected activity in PET and optimize the radiation protection through an internal audit process. This monitoring allows the identification of opportunities for improvement in patient care and safety, as well as to establish a periodic review of the medical unit reference levels.

METHODS

The methodology is based on short run Quesenberry (Q) statistics and normalized nonconstant sample size (Z-chart) control charts. Anonymized data from 512 patients were selected from a set of 18 F-FDG PET/CT (Siemens, Biograph 6) examinations performed during 10 months. The analyzed variable was the ratio between the 18 F-FDG injected activity (MBq) and patient weight (kg).

RESULTS

Mean injected 18 F-FDG activity was 347.811 ± 64.967 MBq corresponding to a mean effective dose of 6.608 ± 1.234 mSv. The ratio between the 18 F-FDG injected activity and the body mass of patients was reduced from 5.243 ± 0.716 to 5.171 ± 0.672 MBq/kg during the statistical data analysis. The study demonstrates that control charts can be a useful tool to signal situations where patients receive an activity significantly different from the standard practice in a medical unit.

CONCLUSION

The use of joint control charts is a suitable tool for detecting nonoptimized radiopharmaceutical administration. This analysis provides opportunities to evaluate and improve the quality of practice in nuclear medicine. This methodology constitutes an internal audit that may help health care professionals to make appropriate decisions to ensure all patients receive the safest and most appropriate care.

Artificial Intelligence Chatbots' Understanding of the Risks and Benefits of Computed Tomography and Magnetic Resonance Imaging Scenarios

PURPOSE

Patients may seek online information to better understand medical imaging procedures. The purpose of this study was to assess the accuracy of information provided by 2 popular artificial intelligence (AI) chatbots pertaining to common imaging scenarios' risks, benefits, and alternatives.

METHODS

Fourteen imaging-related scenarios pertaining to computed tomography (CT) or magnetic resonance imaging (MRI) were used. Factors including the use of intravenous contrast, the presence of renal disease, and whether the patient was pregnant were included in the analysis. For each scenario, 3 prompts for outlining the (1) risks, (2) benefits, and (3) alternative imaging choices or potential implications of not using contrast were inputted into ChatGPT and Bard. A grading rubric and a 5-point Likert scale was used by 2 independent reviewers to grade responses. Prompt variability and chatbot context dependency were also assessed.

RESULTS

ChatGPT's performance was superior to Bard's in accurately responding to prompts per Likert grading (4.36 ± 0.63 vs 3.25 ± 1.03 seconds, P < .0001). There was substantial agreement between independent reviewer grading for ChatGPT (κ = 0.621) and Bard (κ = 0.684). Response text length was not statistically different between ChatGPT and Bard (2087 ± 256 characters vs 2162 ± 369 characters, P = .24). Response time was longer for ChatGPT (34 ± 2 vs 8 ± 1 seconds, P < .0001).

CONCLUSIONS

ChatGPT performed superior to Bard at outlining risks, benefits, and alternatives to common imaging scenarios. Generally, context dependency and prompt variability did not change chatbot response content. Due to the lack of detailed scientific reasoning and inability to provide patient-specific information, both AI chatbots have limitations as a patient information resource.

ETHICS IN RADIOLOGICAL PROTECTION FOR MEDICAL DIAGNOSIS AND TREATMENT

Publication 138 defines the ethical foundations of the ICRP System of Radiological Protection based on core values (beneficence and non-maleficence, dignity, justice, and prudence) and procedural values (accountability, transparency, and inclusiveness). The purpose of the present publication is to propose a practical application of values for medical radiological protection professions. As medicine has a long history and strong culture of ethics, this publication starts by identifying the shared values, and defines a common language between biomedical ethics and radiological protection. The core values are very similar, with the autonomy of biomedical ethics, which can be seen as a corollary of dignity, and the precautionary principle, which can be understood as the implementation of prudence. In recent years, medical education and training has emphasised the values of solidarity, honesty, and, above all, empathy. All these values are defined and interpreted in the specific context of the use of ionising radiation in medicine. For those more familiar with radiological protection, the ethical implications of their actions are described. Conversely, for those who already have a good background in ethics, this publication highlights the specificities of ionising radiation that also deserve consideration.In order to emphasise the coherence between the values involved in biomedical ethics and those involved in radiological protection, this publication proposes to combine them: dignity and autonomy; beneficence and non-maleficence; prudence and precaution; justice and solidarity; transparency, accountability, and honesty; and inclusiveness and empathy. This allows a structured review of practical situations from an ethical perspective. For the sake of both example and education, this publication proposes 21 realistic scenarios (11 in imaging procedures and 10 in radiation therapies). Sensitising questions are provided to stimulate reflection and discussion. The ultimate goal is to be able to use ethical values in clinical imaging and therapy situations. Required education and training in ethics is essential for medical radiological workers throughout their career span. An example of a framework of knowledge, skills, and competencies is proposed. In order to assist the reader in a theoretically complex subject, key messages are distributed throughout the text as fixed points that can be easily understood. Although primarily aimed at medical radiological protection professionals, this publication is also intended for authorities, patients, and the public.© 2024 ICRP. Published by SAGE.

[Explaining radiation dose exposure : The role of the banana equivalent dose compared to the effective dose in patient communication]

BACKGROUND AND OBJECTIVES

Communicating the amount and effects of ionizing radiation to patients prior to an examination using x‑rays is associated with challenges: first, calculating the expected dose prior to the examination and, second, quantifying and illustrating cancer risks. Analogies, such as comparing radiation exposure to accident risks, have limitations and may evoke unease. This study explores and compares two new approaches to discuss radiation exposure from common clinical examinations with patients: effective dose and exposure based on radioactive potassium-40 intake from the ingestion of bananas, the banana equivalent dose (BED).

MATERIALS AND METHODS

The effective doses of the diagnostic reference levels (DRL) for computed tomography (CT) and X-ray examinations in adults were calculated using mean conversion factors for specific anatomic body regions. For the BED calculation of the diagnostic reference levels, the radiation dose from a conventional banana ingested over 50 years per becquerel was calculated. The outcomes were juxtaposed against an equivalent number of bananas and its respective radiation doses.

RESULTS

The calculated doses, namely effective dose and BED, of the German DRL can serve as a reliable metric to discuss radiation exposure from medical imaging with patients prior to an examination.

CONCLUSION

This is the first study to calculate the effective doses of the current DRL and to compare these with the pseudoscientific unit BED. While the BED serves as an interesting illustration to metaphorize radiation exposure, it is recommended to use the calculated effective dose of the DRL as the basis for educational consultations with patients.

The why, who, how, and what of communicating CT radiation risks to patients and healthcare providers

Computed tomography (CT) has witnessed tremendous growth in utilization. Despite its immense benefits, there is a growing concern from the general public and the medical community about the detrimental consequences of ionizing radiation from CT. Anxiety from the perceived risks associated with CT can deter referring physicians from ordering clinically indicated CT scans and patients from undergoing medically necessary exams. This article discusses various strategies for educating patients and healthcare providers on the benefits and risks of CT scanning and salient techniques for effective communication.

Checklist-based Training Improves Consenting Skills Among Radiology Residents

PURPOSE

This study aimed to demonstrate whether a curriculum based on an informed consent conversation checklist led to improvement in a resident's ability to obtain patient centered and legally sound consent.

MATERIAL/METHODS

In this prospective, IRB approved study, Radiology residents from a single institution were asked to obtain informed consent for an imaging study or image-guided procedure from a standardized patient (SP). Encounters were scored by an attending radiologist on a 20-point checklist as well as by the SPs on four consent related questions. Residents were then provided reading material, a lecture, and a consent checklist pocket card. Residents participated in a post-intervention SP encounter. Wilcoxon Signed-Ranks Test was performed to determine if there was a significant improvement in scores after intervention.

RESULTS

Twenty-one residents completed all aspects of the program. There was statistically significant improvement in consenting skills as measured by the attending scores and the SP scores after receiving formal education. Pre-intervention scores had a mean of 9.29 of 20 (SD 1.39), while post-intervention scores had a mean of 16.95 of 20 (SD 1.83). 95.2% (20/21) of residents found the training useful and stated they would recommend it to future trainees.

CONCLUSION

Checklist-based consent training improved radiology residents' ability to obtain informed consent.

Informed Consent in Dentomaxillofacial Radiology: A Cross- Sectional Study

Objective: This study assessed the opinions and attitudes of dentomaxillofacial (DMF) radiology physicians worldwide about informed consent in terms of oral radiology applications. Methods: DMF radiology physicians in various countries were invited to this study via e-mail. The participants answered their demographic information (gender, age, years of experience, title, institution, and country), and questions about informed consent. The Pearson chi-square and Fisher’s exact tests were used for statistical analysis Results: From 22 countries, 46 male (51.7%) and 43 female (48.3%) DMR radiology physicians completed the questionnaire. More than half of the participants (53.9%) were working in the university hospital, and the highest number of participants (32.6%) was from the European region. Most of the surveyors (70.8%) stated that consent is required in dental radiology. No statistically significant difference was found in the radiographic methods (intraoral, panoramic/extraoral, and cone-beam CT) applied in terms of obtaining consent (p > 0.05). While middle-aged physicians (30 –45 age) thought that patients should not be informed about the risk of radiation causing cancer, experienced participants (45 age and above) stated that information should be given about the cancer risk (p < 0.05). Conclusion: The results of this study showed that most of the DMF radiology physicians stated that they have responsibility for getting informed consent and only one-third of the participants inform patients about the risks of radiation.

Patient radiation dose during angiography and embolization for abdominal hemorrhage: the influence of CT angiography, fluoroscopy system, patient and procedural variables

Background

Angiography and embolization (AE) is a lifesaving, high radiation dose procedure for treatment of abdominal arterial hemorrhage (AAH). Interventional radiologists have utilized pre-procedure CT angiography (CTA) and newer fluoroscopic systems in an attempt to reduce radiation dose and procedure time.

Purpose

To study the factors contributing to the radiation dose of AE for AAH and to compare to the reference standard.

Materials and methods

This retrospective single-centre observational cohort study identified 154 consecutive AE procedures in 138 patients (median age 65 years; interquartile range 54–77; 103 men) performed with a C-arm fluoroscopic system (Axiom Artis DTA or Axiom Artis Q (Siemens Healthineers)), between January 2010 and December 2017. Parameters analysed included: demographics, fluoroscopy system, bleeding location, body mass index (BMI), preprocedural CT, air kerma-area product (PKA), reference air kerma (K_a,r), fluoroscopy time (FT) and the number of digital subtraction angiography (DSA) runs. Factors affecting dose were assessed using Mann–Whitney U, Kruskal–Wallis one-way ANOVA and linear regression.

Results

Patients treated with the new angiographic system (NS) had a median PKA, median K_a,r, Q3 PKA and Q3 K_a,r that were 74% (p < 0.0005), 66%(p < 0.0005), 55% and 52% lower respectively than those treated with the old system (OS). This dose reduction was consistent for each bleeding location (upper GI, Lower GI and extraluminal). There was no difference in PKA (p = 0.452), K_a,r (p = 0.974) or FT (p = 0.179), between those who did (n = 137) or did not (n = 17) undergo pre-procedure CTA. Other factors significantly influencing radiation dose were: patient BMI and number of DSA runs. A multivariate model containing these variables accounts for 15.2% of the variance in K_a,r (p < 0.005) and 45.9% of the variance of PKA (p < 0.005).

Conclusion

Radiation dose for AE in AAH is significantly reduced by new fluoroscopic technology. Higher patient body mass index is an independent key parameter affecting patient dose. Radiation dose was not influenced by haemorrhage site or performance of pre-procedure CTA.

Patient understanding of diagnostic ultrasound examinations in an Australian private radiology clinic

Purpose

To determine patient understanding and expectations of ultrasound imaging and its safety, sources of examination information and levels of examination anxiety.

Methods

1070 consecutive patients presenting to a private, regional radiology practice in New South Wales, Australia between 16^th May and 14^th June 2019, were invited to complete a survey while waiting for their non-interventional ultrasound examination. The survey included questions on demographic characteristics, knowledge such as examination risks and safety, ultrasound expectations such as dissemination of results, sources of examination information and levels of participant anxiety. Data were analysed using Kruskal-Wallis tests (SPSS v. 25) to determine statistical associations between participant demographic factors, knowledge, anxiety level and the main source of examination information.

Results

A total of 215/1070 (20%) patients voluntarily participated in the study. Most were female (74%, 159/215), with a median (range) age of 55 (18-92) years. Participant's median (range) score of ultrasound imaging knowledge was 3 (0-5) scored out of six and indicated uncertainty regarding the ultrasound procedure, result dissemination and ultrasound safety. Participants with previous personal experience had significantly higher levels of ultrasound imaging knowledge than those whose primary information source was their referring doctor (P = 0.0005) or the internet (P = 0.026). Significantly higher levels of ultrasound examination knowledge were also associated with lower self-reported levels of anxiety (P = 0.002).

Conclusion

Participants had incomplete ultrasound examination knowledge, including misconceptions regarding safety and result dissemination, some of which could be clarified by the sonographer at the beginning of the ultrasound examination.

Radiation safety education and diagnostic imaging in pediatric patients with surgically treated hydrocephalus: the patient and family perspective

PURPOSE

Surgically treated hydrocephalus patients are frequently imaged with head computed tomography (CT), and risk/benefit communication with families is inconsistent and unknown. We aimed to educate patients and caregivers about radiation safety in CT and explore their communication preferences.

METHODS

We conducted a pediatric CT radiation safety and diagnostic imaging educational workshop for patients and caregivers at a national conference on hydrocephalus to characterize current practice and desired communication about CT imaging. Our workshop consisted of an interactive educational intervention with pre-/post-session surveys followed by feedback from participants.

RESULTS

Our session included 34 participants (100% response rate for surveys) with 28 being parents of individuals with hydrocephalus. A total of 76% (n = 26) participants showed an increase in knowledge after the session (p < 0.01). All participants (N = 34) uniformly desired risk/benefit discussions before CT scans. However, 71% stated that they were not informed of risks/benefits of CT scans by a medical professional. Following the session, the number of participants indicating that informed consent should be obtained before CT scans increased from 30 to 33. Respondents also revealed that 14% of children and young adults had received > 100 CT scans for shunt evaluation with the median being 25 scans (IQR 20).

CONCLUSIONS

Caregivers desire and deserve to be empowered through education and social support, and continuously engaged through sharing decisions and co-designing care plans. The neurosurgical community is in an ideal position to collaborate with radiologists, primary care providers, and parents in the development and testing of credible, high-quality online and social media resources.

Radiation dose reference card for interventional radiology procedures: Experience in a tertiary referral centre

Background:

Fluoroscopy-guided interventions can potentially increase radiation risk to patients, if awareness on angiographic imaging technique and radiation dose is neglected.

Aim:

To develop patient radiation dose reference card from standardized imaging techniques for various radiology interventions performed using flat detector based angiography system.

Materials and Methods:

Real-time monitoring of angiographic exposure parameters and radiation dose were performed for 16 types of radiological interventions. Effective dose (ED) was estimated from dose area product (DAP) using PCXMC Monte Carlo simulation software. Radiation risk levels were estimated based on Biological Effects of Ionising radiation (BEIR) report VII predictive models for an Asian population.

Results:

Pulse rates of 7.5 pps and 0.6 mm Copper filtration during fluoroscopy and 4 frames per second (fps) and 0.1-0.3 mm Cu filtration during image acquisitions were found to reduce radiation dose. Owing to increased number of image acquisitions, DAP was highest during diagnostic spinal angiography 186.7 Gycm² (44.0–377.5). This resulted in highest ED of 59.4 mSv with moderate risk levels (1 in 1000 to 1 in 500). Most of the radiological interventions had low radiation risk levels (1 in 10,000 to 1 in 1000).

Conclusion:

The patient radiation dose reference card is valuable to the medical community and can aid in patient counselling on radiation induced risk from radiological interventions.

Ionising radiation exposure from medical imaging - A review of Patient's (un) awareness

INTRODUCTION

Medical imaging is the main source of artificial radiation exposure. Evidence, however, suggests that patients are poorly informed about radiation exposure when attending diagnostic scans. This review provides an overview of published literature with a focus on nuclear medicine patients on the level of awareness of radiation exposure from diagnostic imaging.

METHODS

A review of available literature on awareness, knowledge and perception of ionising radiation in medical imaging was conducted. Articles that met the inclusion criteria were subjected to critical appraisal using the Mixed Methods Appraisal Tool.

RESULTS

140 articles identified and screened for eligibility, 24 critically assessed and 4 studies included in synthesis. All studies demonstrated that patients were generally lacking awareness about radiation exposure and highlighted a lack of communication between healthcare professionals and patients with respect to radiation exposure.

CONCLUSION

Studies demonstrate a need to better inform patients about their radiation exposure, and further studies focusing on nuclear medicine patients are particularly warranted.

IMPLICATIONS FOR PRACTICE

Adequate and accurate information is crucial to ensure the principle of informed consent is present.

SURVEY OF KEY RADIATION SAFETY PRACTICES IN INTERVENTIONAL RADIOLOGY: AN IRISH AND ENGLISH STUDY

Interventional radiology is a rapidly evolving speciality with potential to deliver high patient radiation doses, as a result high standards of radiation safety practice are imperative. IR radiation safety practice must be considered before during and after procedures through appropriate patient consent, dose monitoring and patient follow-up. This questionnaire-based study surveyed fixed IR departments across Ireland and England to establish clinical practice in relation to radiation safety. Pre-procedure IR patient consent includes all radiation effects in 11% of cases. The patient skin dose surrogate parameter of Kerma to air at a reference point (Kar) is under-reported. Only 39% of respondents use a substantial radiation dose level and inform patients after these have been reached. Poor compliance with unambiguous, readily available best practice guidance was observed throughout highlighting patient communication, patient dose quantification and subsequent patient dose management concerns.

Barriers and pathways to informed consent for ionising radiation imaging examinations: A qualitative study

INTRODUCTION

Informed consent for ionising radiation medical imaging examinations represents a recent change to medical imaging practice. This practice has not had a definitive and authoritative integration into clinical practice, and lack of direction has caused many health care professionals to be unsure of an appropriate consent methodology. Consent practices have been undertaken inconsistently and sometimes poorly. This research sought to investigate what barriers exist to meaningful informed consent, and what pathways are suggested to overcome these barriers. These views are then discussed in the context of practical health care consent practices.

METHODS

A semi-structured interview explored the views of radiographers and radiologists on the practice of disclosing the ionising radiation risk of a clinical medical imaging examination. Qualitative data was analysed using a nominal method of quantitative transformation. Responses were reviewed, and a set of definitive themes constructed. Participants considered the influences, logistics and barriers to the informed consent process. Participants were then asked what pathways might be developed that would improve the process.

RESULTS

Twenty-one (21) radiographer participants and nine (9) radiologists were interviewed. The barriers to consent identified issues of time constraints, lack of a unified message, and patient presentations. Pathways suggested included limiting the scope of the consent practice, sharing the consent responsibility, and formulation of definitive consent guidelines.

CONCLUSION

A unified, definitive series of guidelines for informed consent for ionising radiation examinations would alleviate many of the identified barriers. Having the consent process consistently begin with the referring doctor would facilitate more meaningful consent.

Optimizing Communication With Parents on Benefits and Radiation Risks in Pediatric Imaging

Effective radiation risk communication is a core competency for radiology care providers and can prevent and resolve potential conflicts while helping achieve effective public health safeguards. The authors present a synopsis of the challenges to holding such dialogue and review published methods for strengthening and maintaining this discourse. Twelve strategies are discussed in this article that can help alleviate concerns about the iatrogenic risk associated with medical imaging using radiation exposure.

Informed Consent for Radiation in Interventional Radiology Procedures

Purpose

To explore the patient perception on radiation-related cancer risk from interventional radiology (IR) procedures and whether informed radiation consent is warranted.

Methods

A multiple-choice survey was prospectively administered to 68 adults undergoing a body or neuro-IR procedure with ionizing radiation exposure. Subgroup analysis with chi-square or Fisher exact test was performed based on patient past IR history ( P < .05).

Results

A total of 81% of patients wanted to be informed if there was a radiation-related 3% increased cancer risk over 5 years. Although 55% considered 3% a small risk, 28% wanted to further discuss the risks and alternate options, and 15% would have only proceeded if it were a life-saving procedure: 89%, 80%, and 67% of patients wanted to be informed with exposure risks of 1 in 100, 1 in 1000, and 1 in 10,000, respectively. Only 53% were aware they were going to be exposed to radiation, irrespective of past IR history ( P = .15). Most patients believed radiation consent should include radiation-related cancer risks (85%). No past IR history was significantly associated with wanting consent to include cancer-related risk (100% vs 76%; P = .01) and deterministic risks (70% vs 41%; P = .04). A majority (69%) believed both the referring physician and the interventional radiologist were responsible for obtaining radiation consent, and 65% of patients wanted verbal consent followed by signed written consent, regardless of past IR history.

Conclusions

Many patients want to discuss cancer-related radiation risks with both radiologists and physicians. Informed radiation consent should be considered for procedures with high anticipated radiation doses.

Autonomy, consent and responsibility. Part II. Informed consent in medical care and in the law

Legal recognition of patient's rights aspired to change clinical relationship and medical lex artis. However, its implementation has been hampered by the scarcity of resources and the abundance of regulations. For several years, autonomy, consent, and responsibility have formed one of the backbones of the medical profession. However, they have sparked controversy and professional discomfort. In the first part of this article, we examine the conceptual and regulatory limitations of the principle of autonomy as the basis of informed consent. We approach the subject from philosophical, historical, legal, bioethical, deontological, and professional standpoints. In the second part, we cover the viability of informed consent in health care and its relationship with legal responsibility.

The radiology informed consent form: recommendations from the European Society of Cardiology position paper

Every radiological and nuclear medicine examination confers a definite long-term risk of cancer, but most patients undergoing such examinations receive no or inaccurate information about radiation dose and corresponding risk related to the dose received. Informed consent is a procedure to support (not substitute) the physician/patient dialogue and relationship, facilitating a free, informed and aware expression of the patient's will in the principle of patient autonomy. Physicians are responsible for providing patients with all the information on risks, benefits and alternatives useful to the patient to make the decision. In current radiological practice the information on the radiation dose and long-term cancer risks is difficult to find and not easy to understand. The form using plain language should spell-out the type of examination, the effective dose (mSv), the effective dose expressed in number of chest radiographs and the risk of cancer. The current practice clashes against the guidelines and the law.

Prevalence and Correlates of Worry About the Health Harms of Medical Imaging Radiation in the General Population

BACKGROUND

In recent years, there have been dramatic increases in medical imaging use and increasing media attention to increased exposure to ionizing radiation in the United States. Patient perspectives on medical imaging radiation (MIR) use is understudied, but could guide primary care discussions. This study examines prevalence of worry about the health harms from MIR in the US general population.

METHODS

This cross-sectional study used the 2012-2013 Health Information National Trends Survey conducted by the National Cancer Institute. A nationally representative sample (N = 3532) was drawn from the US general population to observe prevalence of worry about MIR as well as potential covariates, including demographic, medical, and psychological factors, health information-seeking, physician trust in providing cancer information, and cancer fatalism.

RESULTS

About 65% of the sample population reported experiencing at least some worry about MIR. Univariable and multivariable logistic regressions indicate higher rates of MIR worry among women, racial/ethnic minorities, those with lower educational attainment, foreign-born Americans, those who self-report poorer health, and those with a personal history of cancer. Lower trust in cancer information from physicians and greater attention to cancer information from popular media were each associated with higher rates of worry about health harms of MIR.

CONCLUSIONS

An accurate assessment of public worry about MIR will aid primary care providers' efforts to understand patient responses to medical imaging and identify addressable knowledge gaps regarding benefits and risks of medical imaging. These data may improve risk communication regarding medical imaging among referring primary care physicians, radiologists, and patients.

Pragmatic ethical basis for radiation protection in diagnostic radiology

OBJECTIVE

Medical ethics has a tried and tested literature and a global active research community. Even among health professionals, literate and fluent in medical ethics, there is low recognition of radiation protection principles such as justification and optimization. On the other hand, many in healthcare environments misunderstand dose limitation obligations and incorrectly believe patients are protected by norms including a dose limit. Implementation problems for radiation protection in medicine possibly flow from apparent inadequacies of the International Commission on Radiological Protection (ICRP) principles taken on their own, coupled with their failure to transfer successfully to the medical world. Medical ethics, on the other hand, is essentially global, is acceptable in most cultures, is intuitively understood in hospitals, and its expectations are monitored, even by managements. This article presents an approach to ethics in diagnostic imaging rooted in the medical tradition, and alert to contemporary social expectations. ICRP and the International Radiation Protection Association (IRPA), both alert to growing ethical concerns, organized a series of consultations on ethics for general radiation protection in the last few years.

METHODS

The literature on medical ethics and implicit ICRP ethical values were reviewed qualitatively, with a view to identifying a system that will help guide contemporary behaviour in radiation protection of patients. Application of the system is illustrated in six clinical scenarios. The proposed system is designed, as far as is possible, so as not to be in conflict with the conclusions emerging from the ICRP/IRPA consultations.

RESULTS AND CONCLUSION

A widely recognized and well-respected system of medical ethics was identified that has global reach and claims acceptance in all cultures. Three values based on this system are grouped with two additional values to provide an ethical framework for application in diagnostic imaging. This system has the potential to be robust and to reach conclusions that are in accord with contemporary medical, social and ethical thinking. The system is not intended to replace the ICRP principles. Rather, it is intended as a well-informed interim approach that will help judge and analyse situations that arouse ethical concerns in radiology. Six scenarios illustrate the practicality of the value system in alerting one to possible deficits in practice.

ADVANCES IN KNOWLEDGE

Five widely recognized values and the basis for them are identified to support the contemporary practice of diagnostic radiology. These are essential to complement the widely used ICRP principles pending further development in the area.

Clinical imaging guidelines part 2: Risks, benefits, barriers, and solutions

A recent international meeting was convened by two United Nations bodies to focus on international collaboration on clinical appropriateness/referral guidelines for use in medical imaging. This paper, the second of 4 from this technical meeting, addresses barriers to the successful development/deployment of clinical imaging guidelines and means of overcoming them. It reflects the discussions of the attendees, and the issues identified are treated under 7 headings: ■ Practical Strategy for Development and Deployment of Guidelines; ■ Governance Arrangements and Concerns with Deployment of Guidelines; ■ Finance, Sustainability, Reimbursement, and Related Issues; ■ Identifying Benefits and Radiation Risks from Radiological Examinations; ■ Information Given to Patients and the Public, and Consent Issues; ■ Special Concerns Related to Pregnancy; and ■ The Research Agenda. Examples of topics identified include the observation that guideline development is a global task and there is no case for continuing it as the project of the few professional organizations that have been brave enough to make the long-term commitment required. Advocacy for guidelines should include the expectations that they will facilitate: (1) better health care delivery; (2) lower cost of that delivery; with (3) reduced radiation dose and associated health risks. Radiation protection issues should not be isolated; rather, they should be integrated with the overall health care picture. The type of dose/radiation risk information to be provided with guidelines should include the uncertainty involved and advice on application of the precautionary principle with patients. This principle may be taken as an extension of the well-established medical principle of "first do no harm."

Improving the Informed Consent Conversation: A Standardized Checklist that Is Patient Centered, Quality Driven, and Legally Sound

The informed consent conversation is a key component of patient-centered medicine, a concept that emphasizes the importance of patients actively participating in their care. Studies reveal that many informed consent conversations throughout medical practice lack essential elements and leave patients' needs unmet. This review addresses these deficiencies, discusses solutions, and introduces a standardized checklist that values the patient's role in shared decision making during the informed consent conversation. The checklist could be particularly helpful to interventional radiologists and other consulting physicians who usually obtain informed consent early in their encounters with patients.

Patient perspectives and preferences for communication of medical imaging risks in a cancer care setting

PURPOSE

To identify opportunities for improving patient-centered communication about diagnostic imaging tests that involve the use of radiation in a cancer care setting.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained for this HIPAA-compliant study. Patient knowledge, information sources, and communication preferences were assessed in six focus groups during 2012. The groups consisted of patients undergoing treatment for metastatic colorectal carcinoma, women treated within the past 6 months for early-stage breast carcinoma, men undergoing surveillance after testicular cancer treatment, parents of patients treated for stage I-III neuroblastoma, patients in a thoracic oncology survivorship program, and participants in a lung cancer screening program. A multidisciplinary research team performed thematic content analysis of focus group transcripts. High-level findings were summarized during consensus conferences.

RESULTS

Although they were aware of the long-term risk of cancer from exposure to ionizing radiation, most participants reported that their health care provider did not initiate discussion about benefits and risks of radiation from imaging tests. Most patients obtained information by means of self-directed internet searches. Participants expressed gratitude for tests ("That CT saved my daughter's life," "I'd rather have the radiation dosage than being opened up"), yet they expressed concern about having to initiate discussions ("If you don't ask, nobody is going to tell you anything") and the desire to be offered information concerning the rationale for ordering specific imaging examinations, intervals for follow-up imaging, and testing alternatives. Participants believed that such information should be available routinely and that conversation with their personal physician or endorsed, readily available reference materials were ideal methods for information exchange. Understanding imaging radiation risks and active participation in decision making about imaging were especially important to cancer survivors.

CONCLUSION

A substantial gap exists between patient expectations and current practices for providing information about medical imaging tests that involve the use of radiation.

A novel ultrasound methodology for estimating spine mineral density

We investigated the possible clinical feasibility and accuracy of an innovative ultrasound (US) method for diagnosis of osteoporosis of the spine. A total of 342 female patients (aged 51-60 y) underwent spinal dual X-ray absorptiometry and abdominal echographic scanning of the lumbar spine. Recruited patients were subdivided into a reference database used for US spectral model construction and a study population for repeatability and accuracy evaluation. US images and radiofrequency signals were analyzed via a new fully automatic algorithm that performed a series of spectral and statistical analyses, providing a novel diagnostic parameter called the osteoporosis score (O.S.). If dual X-ray absorptiometry is assumed to be the gold standard reference, the accuracy of O.S.-based diagnoses was 91.1%, with k = 0.859 (p < 0.0001). Significant correlations were also found between O.S.-estimated bone mineral densities and corresponding dual X-ray absorptiometry values, with r(2) values up to 0.73 and a root mean square error of 6.3%-9.3%. The results obtained suggest that the proposed method has the potential for future routine application in US-based diagnosis of osteoporosis.

The communication of the radiation risk from CT in relation to its clinical benefit in the era of personalized medicine: part 2: benefits versus risk of CT

In order to personalize the communication of the CT risk, we need to describe the risk in the context of the clinical benefit of CT, which will generally be much higher, provided a CT scan has a well-established clinical indication. However as pediatric radiologists we should be careful not to overstate the benefit of CT, being aware that medico-legal pressures and the realities of health care economics have led to overutilization of the technology. And even though we should not use previously accumulated radiation dose to a child as an argument against conducting a clinically indicated scan (the "sunk-cost" bias), we should consider patients' radiation history in the diagnostic decision process. As a contribution to future public health, it makes more sense to look for non-radiating alternatives to CT in the much larger group of basically healthy children who are receiving occasional scans for widely prevalent conditions such as appendicitis and trauma than to attempt lowering CT use in the smaller group of patients with chronic conditions with a limited life expectancy. When communicating the CT risk with individual patients and their parents, we should acknowledge and address their concerns within the framework of informed decision-making. When appropriate, we may express the individual radiation risk, based on estimates of summated absorbed organ dose, as an order of magnitude rather than as an absolute number, and compare this with the much larger natural cancer incidence over a child's lifetime, and with other risks in medicine and daily life. We should anticipate that many patients cannot make informed decisions on their own in this complex matter, and we should offer our guidance while maintaining respect for patient autonomy. Proper documentation of the informed decision process is important for future reference. In concert with our referring physicians, pediatric radiologists are well-equipped to tackle the complexities associated with the communication of CT risk, a task that often falls upon us, and by becoming more involved in the diagnostic decision process we can add value to the health care system.

Approaches to enhancing radiation safety in cardiovascular imaging: a scientific statement from the American Heart Association

Education, justification, and optimization are the cornerstones to enhancing the radiation safety of medical imaging. Education regarding the benefits and risks of imaging and the principles of radiation safety is required for all clinicians in order for them to be able to use imaging optimally. Empowering patients with knowledge of the benefits and risks of imaging will facilitate their meaningful participation in decisions related to their health care, which is necessary to achieve patient-centered care. Limiting the use of imaging to appropriate clinical indications can ensure that the benefits of imaging outweigh any potential risks. Finally, the continually expanding repertoire of techniques that allow high-quality imaging with lower radiation exposure should be used when available to achieve safer imaging. The implementation of these strategies in practice is necessary to achieve high-quality, patient-centered imaging and will require a shared effort and investment by all stakeholders, including physicians, patients, national scientific and educational organizations, politicians, and industry.

Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures

Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. More and more complex procedures have the risk to increase the radiation exposure, both for the patients and the operators. The professional lifetime attributable excess cancer risk may be around 1 in 100 for the operators, the same as for a patient undergoing repetitive complex procedures. Moreover, recent reports have also hinted at an excess risk of brain tumours among interventional cardiologists. Apart from evaluating the need for and justifying the use of radiation to assist their procedures, physicians have to continuously explore ways to reduce the radiation exposure. After an introduction on how to quantify the radiation exposure and defining its current magnitude in electrophysiology compared with the other sources of radiation, this position paper wants to offer some very practical advice on how to reduce exposure to patients and staff. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. Finally, we suggest further improvements that can be implemented by both the physicians and the industry in the future. We are confident that these suggestions are able to reduce patient and operator exposure by more than an order of magnitude, and therefore think that these recommendations are worth reading and implementing by any electrophysiological operator in the field.

Age estimation for forensic purposes in Italy: ethical issues

Age assessment in children and young adults is a relevant medicolegal issue due to the gradual increase of persons devoid of proper identification documents in European countries. Because of the illegal immigration and growing crime rates among children and adolescents, age estimation for forensic purposes is often required. The scientific research and the extensive experience of forensic experts in the last decades focused on the use of radiographic methods addressed to evaluate the degree of skeletal or dental development as the most accurate parameters to estimate the chronological age of children and adolescents. This paper analyzes the ethical issues related to age estimation procedures based on radiographic methods, showing how the ethical principles of beneficence, nonmalevolence, justice, and autonomy may be guaranteed during the execution of the age assessment in forensic practice. The procedure might be conducted in accordance with international guidelines and protocols, though they need a higher homogenization and standardization. A strong collaboration between various scientific societies of professionals (forensic odontologists, forensic pathologists, forensic anthropologist, radiologists, pediatricians, and psychologists), who have been involved in age estimation for years, is needed to reach this goal.

Patient-centered imaging: shared decision making for cardiac imaging procedures with exposure to ionizing radiation

The current paper details the recommendations arising from an NIH-NHLBI/NCI-sponsored symposium held in November 2012, aiming to identify key components of a radiation accountability framework fostering patient-centered imaging and shared decision-making in cardiac imaging. Symposium participants, working in 3 tracks, identified key components of a framework to target critical radiation safety issues for the patient, the laboratory, and the larger population of patients with known or suspected cardiovascular disease. The use of ionizing radiation during an imaging procedure should be disclosed to all patients by the ordering provider at the time of ordering, and reinforced by the performing provider team. An imaging protocol with effective dose ≤3 mSv is considered very low risk, not warranting extensive discussion or written informed consent. However, a protocol effective dose >20 mSv was proposed as a level requiring particular attention in terms of shared decision-making and either formal discussion or written informed consent. Laboratory reporting of radiation dosimetry is a critical component of creating a quality laboratory fostering a patient-centered environment with transparent procedural methodology. Efforts should be directed to avoiding testing involving radiation, in patients with inappropriate indications. Standardized reporting and diagnostic reference levels for computed tomography and nuclear cardiology are important for the goal of public reporting of laboratory radiation dose levels in conjunction with diagnostic performance. The development of cardiac imaging technologies revolutionized cardiology practice by allowing routine, noninvasive assessment of myocardial perfusion and anatomy. It is now incumbent upon the imaging community to create an accountability framework to safely drive appropriate imaging utilization.

Event-based versus process-based informed consent to address scientific evidence and uncertainties in ionising medical imaging

Background

Inappropriate ionising medical imaging has been escalating in the last decades. This trend leads to potential damage to health and has been associated to bioethical and legal issues of patient autonomy.

Methods

While the doctrine underlines the importance of using informed consent to improve patient autonomy and physician-patient communication, some researchers have argued that it often falls short of this aim. There are basically two different informed consent practices. The first — the so-called “event-based model” — regards informed consent as a passive signature of a standard unreadable template, performed only once in each medical pathway. The second — the so-called “process-based model” — integrates information into the continuing dialogue between physician and patient, vital for diagnosis and treatment.

Results

Current medical behaviour often embraces the event-based model, which is considered ineffective and contributes to inappropriateness. We sought, in this review, to analyse from juridical and communication standpoints whether process-based informed consent can deal with scientific uncertainties in radiological decision-making. The informed consent is still a distinctive process in defence of both patients’ and physicians’ health and dignity in rule-of-law states and consequently in curtailing the abuse of ionising medical radiation.

Main Messages

• Inappropriate ionising medical imaging is widespread and increasing worldwide.

• This trend leads to noteworthy damage to health and is linked to the issue of patient autonomy.

• Some authors have argued that informed consent often falls short of improving patient autonomy.

• Process-based informed consent can deal with scientific uncertainties to contrast inappropriateness.

• Informed consent is still a distinctive process in defence of both patients and physicians.

Patients with testicular cancer undergoing CT surveillance demonstrate a pitfall of radiation-induced cancer risk estimates: the timing paradox

PURPOSE

To demonstrate a limitation of lifetime radiation-induced cancer risk metrics in the setting of testicular cancer surveillance-in particular, their failure to capture the delayed timing of radiation-induced cancers over the course of a patient's lifetime.

MATERIALS AND METHODS

Institutional review board approval was obtained for the use of computed tomographic (CT) dosimetry data in this study. Informed consent was waived. This study was HIPAA compliant. A Markov model was developed to project outcomes in patients with testicular cancer who were undergoing CT surveillance in the decade after orchiectomy. To quantify effects of early versus delayed risks, life expectancy losses and lifetime mortality risks due to testicular cancer were compared with life expectancy losses and lifetime mortality risks due to radiation-induced cancers from CT. Projections of life expectancy loss, unlike lifetime risk estimates, account for the timing of risks over the course of a lifetime, which enabled evaluation of the described limitation of lifetime risk estimates. Markov chain Monte Carlo methods were used to estimate the uncertainty of the results.

RESULTS

As an example of evidence yielded, 33-year-old men with stage I seminoma who were undergoing CT surveillance were projected to incur a slightly higher lifetime mortality risk from testicular cancer (598 per 100 000; 95% uncertainty interval [UI]: 302, 894) than from radiation-induced cancers (505 per 100 000; 95% UI: 280, 730). However, life expectancy loss attributable to testicular cancer (83 days; 95% UI: 42, 124) was more than three times greater than life expectancy loss attributable to radiation-induced cancers (24 days; 95% UI: 13, 35). Trends were consistent across modeled scenarios.

CONCLUSION

Lifetime radiation risk estimates, when used for decision making, may overemphasize radiation-induced cancer risks relative to short-term health risks.

Environmental causes of breast cancer and radiation from medical imaging: findings from the Institute of Medicine report

Susan G. Komen for the Cure asked the Institute of Medicine (IOM) to perform a comprehensive review of environmental causes and risk factors for breast cancer. Interestingly, none of the consumer products (ie, bisphenol A, phthalates), industrial chemicals (ie, benzene, ethylene oxide), or pesticides (ie, DDT/DDE) considered could be conclusively linked to an increased risk of breast cancer, although the IOM acknowledged that the available evidence was insufficient to draw firm conclusions for many of these exposures, calling for more research in these areas. The IOM found sufficient evidence to conclude that the 2 environmental factors most strongly associated with breast cancer were exposure to ionizing radiation and to combined postmenopausal hormone therapy. The IOM's conclusion of a causal relation between radiation exposure and cancer is consistent with a large and varied literature showing that exposure to radiation in the same range as used for computed tomography will increase the risk of cancer. It is the responsibility of individual health care providers who order medical imaging to understand and weigh the risk of any medical procedures against the expected benefit.