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Granata C, Sofia C, Francavilla M, Kardos M, Kasznia-Brown J, Nievelstein RA, Olteanu BS, Owens C, Salerno S, Sorantin E, Apine I. Let's talk about radiation dose and radiation protection in children. Pediatr Radiol 2024:10.1007/s00247-024-06009-0. [PMID: 39095613 DOI: 10.1007/s00247-024-06009-0] [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: 05/07/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 08/04/2024]
Abstract
Children are more sensitive to ionizing radiation than adults. Even though the risk is very low, exposure from radiological examinations can possibly cause them long-term side effects. Recent large epidemiological studies involving children and young adults have added evidence suggesting that even small doses of radiation, such as those from computed tomography scans, might slightly increase the risk of developing cancer later in life. Therefore, even though radiologic studies are essential for an accurate diagnosis and management of various conditions, it is crucial to minimize radiation exposure. This article addresses radiation protection for children in the medical use of ionizing radiation and it is set in the context of the European legislative framework regarding radiation protection. It advocates for a holistic approach to paediatric radiological tests. This approach includes the key principles of radiation protection, such as the justification of imaging procedures supported by referral guidelines, as well as the optimization of techniques (according to the ALARA principle) and effective communication with parents about the benefits and the risks of radiologic procedures. Protecting children from unnecessary radiation is not only a technical challenge, but also a moral obligation and a legal requirement.
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Affiliation(s)
- Claudio Granata
- Department of Radiology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Via Dell'Istria, 65, 34137, Trieste, TS, Italy.
| | - Carmelo Sofia
- Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Policlinico "G. Martino", Messina, Italy
| | | | - Marek Kardos
- Department of Functional Diagnostics, Children's Cardiac Center, Bratislava, Slovakia
| | - Joanna Kasznia-Brown
- Department of Radiology, Musgrove Park Hospital, University of Bristol, Bristol, UK
| | - Rutger Aj Nievelstein
- Department of Radiology & Nuclear Medicine, University Medical Center Utrecht & Princess Máxima Center for Paediatric Oncology, Utrecht, Netherlands
| | - Bogdan Stefan Olteanu
- Department of Radiology, Emergency Hospital for Children "Grigore Alexandrescu", Bucharest, Romania
| | | | - Sergio Salerno
- UOC di Radiologia Pediatrica, ARNAS Civico, Palermo, Italy
- Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | | | - Ilze Apine
- Department of Radiology, Riga Stradin's University, Riga, Latvia
- Department of Radiology, Children Clinical University Hospital, Riga, Latvia
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Chawla T, Gopee-Ramanan P, Green CR, Hartery A, Kassam Z, Murray N, Vu KN, Kirkpatrick IDC. CAR/CETARS/CSAR Practice Guideline on Imaging the Adult Patient With Right Lower Quadrant Pain. Can Assoc Radiol J 2024:8465371241266568. [PMID: 39066632 DOI: 10.1177/08465371241266568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
In 2023, the Canadian Society of Abdominal Radiology (CSAR) and Canadian Emergency, Trauma, and Acute Care Radiology Society (CETARS) received Canadian Association of Radiologists (CAR) member feedback that there was an unmet educational need for guidance in the imaging investigation of right lower quadrant (RLQ) pain. Members requested specific guidance on how to handle controversial scenarios including which test to order when, specifics of imaging protocols, and managing pregnant patients who have RLQ pain-all from a Canadian perspective. After conducting an exhaustive literature review, the working group agreed that a Canadian-specific set of guidelines was warranted. The management recommendations presented in this guideline were discussed as a group to achieve expert consensus. As the workup for RLQ pain can vary considerably in the paediatric population, the scope of this paper was restricted to adults (18 years of age or older). Whenever possible, the best evidence was used to inform the clinical guidance, and where gaps existed, the guidelines reflect consensus among experts in the field. The result is a framework to aid in this process of managing patients with RLQ pain across various clinical scenarios while addressing current questions and controversies, particularly those most relevant to the Canadian healthcare system.
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Affiliation(s)
- Tanya Chawla
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Prasaanthan Gopee-Ramanan
- Department of Radiology, McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Angus Hartery
- Discipline of Radiology, Faculty of Medicine, Memorial University of Newfoundland, Health Sciences Centre, St John's, NL, Canada
| | - Zahra Kassam
- Department of Medical Imaging, Western University, London, ON, Canada
- St. Joseph's Health Care London, London, ON, Canada
| | - Nicolas Murray
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Kim-Nhien Vu
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Université de Montréal, Montréal, QC, Canada
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
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Suuronen M, Lehtonen L, Autti T. Radiation safety of dentomaxillofacial radiology in Finland: Reported abnormal irradiation-related incidents during 2012-2022. Radiography (Lond) 2024; 30:1265-1271. [PMID: 38996492 DOI: 10.1016/j.radi.2024.06.017] [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: 02/09/2024] [Revised: 06/16/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION This study evaluates adverse events (AEs) in dentomaxillofacial radiology (DMFR) in Finland, including their quantity, nature, and outcomes. It also compares reporting activity between public and private healthcare organizations, as they share same legal obligations to report AEs. Two-thirds of dental images are taken in public, the rest in private healthcare. METHODS In Finland, radiation-related AEs are reported to the Radiation and Nuclear Safety Authority (STUK). We categorized DMFR-related AEs by nature, outcome, and imaging modality. We also submitted a questionnaire to STUK to gather information on their observations and remarks made during inspections of establishments providing dental imaging services. RESULTS During 2012-2022, STUK received reports of 1343 DMFR-related AEs, mostly causing patient harm (92.9%) leading almost always to excessive radiation doses (99.7%). Private healthcare reported most AEs (65.2%), with municipal institutions reporting the remainder (34.8%). Intraoral-related AEs (20.0%) slightly outnumbered panoramic-related ones (18.7%), but the majority (56.7%) didn't specify the imaging modality. CBCT-related incidents were least reported (4.5%). During STUK's inspections, remarks mostly concerned deficiencies in practical quality assurance (31.3%) or technical quality assurance (32.9%). CONCLUSION DMFR-related AEs may be underreported despite legal obligations, with most stemming from human error, highlighting the need to enhance patient safety culture. There's a notable reporting gap between private and public healthcare providers relative to the number of dental radiographs conducted. Organizational deficiencies in practical and technical quality assurance underscore the importance of ongoing education, as well as monitoring by STUK. IMPLICATIONS FOR PRACTICE Enhancing patient safety culture in dentistry, including dentomaxillofacial radiology, demands customized multiprofessional development, as unaltered patient safety procedures from medicine and secondary care may not align with dentistry's requirements.
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Affiliation(s)
- M Suuronen
- Helsinki University Hospital, University of Helsinki, Finland.
| | - L Lehtonen
- Helsinki University Hospital, University of Helsinki, Finland
| | - T Autti
- Helsinki University Hospital, University of Helsinki, Finland
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Qamar SR, Green CR, Ghandehari H, Holmes S, Hurley S, Khumalo Z, Mohammed MF, Ziesmann M, Jain V, Thavanathan R, Berger FH. CETARS/CAR Practice Guideline on Imaging the Pregnant Trauma Patient. Can Assoc Radiol J 2024:8465371241254966. [PMID: 38813997 DOI: 10.1177/08465371241254966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Imaging of pregnant patients who sustained trauma often causes fear and confusion among patients, their families, and health care professionals regarding the potential for detrimental effects from radiation exposure to the fetus. Unnecessary delays or potentially harmful avoidance of the justified imaging studies may result from this understandable anxiety. This guideline was developed by the Canadian Emergency, Trauma and Acute Care Radiology Society (CETARS) and the Canadian Association of Radiologists (CAR) Working Group on Imaging the Pregnant Trauma Patient, informed by a literature review as well as multidisciplinary expert panel opinions and discussions. The working group included academic subspecialty radiologists, a trauma team leader, an emergency physician, and an obstetriciangynaecologist/maternal fetal medicine specialist, who were brought together to provide updated, evidence-based recommendations for the imaging of pregnant trauma patients, including patient safety aspects (eg, radiation and contrast concerns) and counselling, initial imaging in maternal trauma, specific considerations for the use of fluoroscopy, angiography, and magnetic resonance imaging. The guideline strives to achieve clarity and prevent added anxiety in an already stressful situation of injury to a pregnant patient, who should not be imaged differently.
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Affiliation(s)
- Sadia R Qamar
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Hournaz Ghandehari
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Signy Holmes
- Department of Radiology, University of Manitoba, Max Rady College of Medicine, Winnipeg, MB, Canada
| | - Sean Hurley
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Zonah Khumalo
- Department of Medical Imaging, McGill University Health Centre, Montreal Children's Hospital, Montreal, QC, Canada
| | - Mohammed F Mohammed
- Department of Radiology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Markus Ziesmann
- Department of Surgery, University of Manitoba, Max Rady College of Medicine, Winnipeg, MB, Canada
| | - Venu Jain
- Department of Obstetrics & Gynaecology, University of Alberta, Edmonton, AB, Canada
| | - Rajiv Thavanathan
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ferco H Berger
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Bazzi M, Afram SS, Ndipen IM, Kåreholt I, Bjällmark A. Factors affecting radiographers' use of dose-reduction measures. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2024; 44:011506. [PMID: 38232402 DOI: 10.1088/1361-6498/ad1fde] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/17/2024] [Indexed: 01/19/2024]
Abstract
This study investigates radiographers' views on implementing dose-reduction measures, with a focus on verifying patient identity and pregnancy status, practising gonad shielding in men and using compression. An electronic questionnaire was distributed to radiographers working in general radiography and/or computed tomography. The questionnaire was based on factors from a framework for analysing risk and safety in clinical medicine. Ordered logistic regressions were used to analyse associations among factors and use of dose-reduction measures. In total, 466 questionnaires were distributed and 170 radiographers (36%) completed them. Clear instructions and routines, support from colleagues, knowledge and experience, a strong safety culture, managerial support and access to proper equipment influence the likelihood of using dose-reduction measures. The strongest associations were found between support from colleagues and verifying pregnancy status (OR = 5.65,P= 0.026), safety culture and use of gonad shielding (OR = 2.36,P= 0.042), and having enough time and use of compression (OR = 2.11,P= 0.003). A strong safety culture and a supportive work environment appears to be essential for the use of dose-reduction measures, and education, training and stress management can improve utilisation of dose-reduction measures.
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Affiliation(s)
- May Bazzi
- Department of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Ingemar Kåreholt
- Institute of Gerontology, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Anna Bjällmark
- Department of Clinical Diagnostics, School of Health and Welfare, Jönköping University, Gjuterigatan 5, Jönköping SE-553 18, Sweden
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Caruana K, Hayre C, Makanjee C. Radiographers' perceptions on the quality of managing general radiographic paediatric examinations through the use of a reflective tool. PLoS One 2023; 18:e0295603. [PMID: 38060598 PMCID: PMC10703265 DOI: 10.1371/journal.pone.0295603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Paediatric patients are a vulnerable population that require additional care by healthcare professionals. Quality managing these examinations ensures that effective and quality care is provided to individual patients, whilst encouraging consistency within the medical imaging department. This study explored radiographers' perspectives on quality management strategies of general radiographic paediatric examinations using a paediatric imaging reflective checklist. METHODS A quantitative descriptive research design with qualitative questions was used through a purposive sampling method from both public and private Australian diagnostic imaging qualified radiographers who had experience in paediatric imaging examinations. The paediatric imaging service reflective tool consisted of 65 items in total. Data analysis entailed Microsoft Excel version 16.16.6 and Jamovi version 2.3.21 for the closed-ended questions and for the open-ended responses a thematic analysis. RESULTS The participation rate was 13.2% and the most significant findings were: lead shielding was still being used at their organisation, despite recent recommendations to suspend its use; access to paediatric patient related information resources is limited; there was no involvement of families and communities regarding policy development or quality improvement measures as advocated in literature; and there was a need for enhanced specialised paediatric education, training and protocols. CONCLUSION Using the paediatric patient-centred imaging reflective checklist, radiographers had an opportunity to identify quality improvement indicators as well as issues that could further enhance best practice principles. Further studies could inform on the validity of this reflective tool.
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Affiliation(s)
- Kate Caruana
- Department of Medical Imaging, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Chris Hayre
- Department of Health and Care Professions, University of Exeter, Exeter, Devon, United Kingdom
| | - Chandra Makanjee
- Department of Medical Radiation Science, University of Canberra, Bruce, Australian Capital Territory, Australia
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Long M, Albeshan S, Alashban Y, England A, Moore N, Young R, Bezzina P, McEntee MF. The effect of contact radiation shielding on breast dose during CT abdomen-pelvis: a phantom study. RADIATION PROTECTION DOSIMETRY 2023; 199:2104-2111. [PMID: 37551012 DOI: 10.1093/rpd/ncad218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 07/05/2023] [Accepted: 07/09/2023] [Indexed: 08/09/2023]
Abstract
This study aims to investigate if contact shielding reduces breast radiation dose during computed tomography (CT) abdomen-pelvis examinations using automatic tube current modulation to protect one of the four most radiosensitive organs during CT examinations. Dose measurements were taken with and without contact shielding across the anterior and lateral aspects of the breasts and with and without organ dose modulation (ODM) to quantify achievable dose reductions. Although there are no statistically significant findings, when comparing with and without shielding, the mean breast surface dose was reduced by 0.01 μSv without ODM (1.92-1.91 μSv, p = 0.49) and increased by 0.03 μSv with ODM (1.53-1.56 μSv, p = 0.44). Comparing with and without ODM, the mean breast surface dose was reduced by 0.35 μSv with shielding (1.91-1.56 μSv, p = 0.24) and by 0.39 μSv without shielding (1.92-1.53 μSv, p = 0.17). The addition of contact shielding does not provide significant breast surface radiation dose reduction during CT abdomen-pelvis.
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Affiliation(s)
- Maria Long
- Medical Imaging and Radiation Therapy Department, School of Medicine, UG Assert, Brookfield Health Sciences, University College Cork, Cork T12 AK54, Ireland
| | - Salman Albeshan
- Radiological Sciences Department, College of Applied Medical Sciences, King Saud University, PO Box 145111, Riyadh 4545, Saudi Arabia
| | - Yazeed Alashban
- Radiological Sciences Department, College of Applied Medical Sciences, King Saud University, PO Box 145111, Riyadh 4545, Saudi Arabia
| | - Andrew England
- Medical Imaging and Radiation Therapy Department, School of Medicine, UG Assert, Brookfield Health Sciences, University College Cork, Cork T12 AK54, Ireland
| | - Niamh Moore
- Medical Imaging and Radiation Therapy Department, School of Medicine, UG Assert, Brookfield Health Sciences, University College Cork, Cork T12 AK54, Ireland
| | - Rena Young
- Medical Imaging and Radiation Therapy Department, School of Medicine, UG Assert, Brookfield Health Sciences, University College Cork, Cork T12 AK54, Ireland
| | - Paul Bezzina
- Department of Radiography, Faculty of Health Sciences, University of Malta, Msida MSD 2080, Malta
| | - Mark F McEntee
- Medical Imaging and Radiation Therapy Department, School of Medicine, UG Assert, Brookfield Health Sciences, University College Cork, Cork T12 AK54, Ireland
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Kim DJ, Dermott JA, Howard AW, Lebel DE. How useful is pre-referral pediatric spine imaging? Spine Deform 2023; 11:1065-1070. [PMID: 37060518 PMCID: PMC10425477 DOI: 10.1007/s43390-023-00687-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] [Received: 02/08/2023] [Accepted: 04/01/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE Primary care physicians rely on radiology reports to confirm a scoliosis diagnosis and inform the need for spine specialist referral. In turn, spine specialists use these reports for triage decisions and planning of care. The objectives were to determine (1) the adequacy of index images to inform treatment decisions at the initial consultation and (2) the utility of index radiology reports for appropriate triage decisions. METHODS A retrospective chart review was conducted including all idiopathic scoliosis patients seen for initial consultation, aged three to 18 years, between January 1 and April 30, 2021. A score out of five was generated based on the adequacy of index images to provide accurate Cobb angle measurements and determine skeletal maturity. Index images were considered inadequate if repeat imaging was necessary. Index radiology reports, associated imaging, and new imaging, if obtained at the initial consultation, were compared. RESULTS Of the 94 patients reviewed, 79% (n = 74) required repeat imaging at the initial consultation, of which 74% (n = 55) were due to insufficient quality and/or limited field of view. Of index images available for review at the initial consult (n = 80), 41.2% scored five out of five, and 32.5% scored two or below. Comparing index radiology reports to initial visit evaluation with ≤ 60 days between imaging (n = 49), discrepancies in Cobb angle were found in 24.5% (95% CI 14.6, 38.1) of patients. The Risser stage was reported in 14% of index radiology reports. CONCLUSION Although pre-referral pediatric spine radiographs serve a diagnostic purpose, most are inadequate for comprehensive idiopathic scoliosis evaluation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dorothy J Kim
- Hospital for Sick Children, 555 University Avenue, Room S229, Toronto, ON, M5G 1X8, Canada.
| | - Jennifer A Dermott
- Hospital for Sick Children, 555 University Avenue, Room S229, Toronto, ON, M5G 1X8, Canada
| | - Andrew W Howard
- Hospital for Sick Children, 555 University Avenue, Room S229, Toronto, ON, M5G 1X8, Canada
| | - David E Lebel
- Hospital for Sick Children, 555 University Avenue, Room S229, Toronto, ON, M5G 1X8, Canada
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Ahern M, McEntee MF, Moore N. Radiographers' attitudes toward the use of lead contact shielding. J Med Imaging Radiat Sci 2023; 54:415-420. [PMID: 37517982 DOI: 10.1016/j.jmir.2023.07.006] [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: 12/08/2022] [Revised: 05/26/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Lead contact shielding has been a crucial component of patient radiation protection since it was first introduced in the early 1900s. Concerns surrounding the hereditary effects of ionising radiation were a driver for using lead shielding. Recently the American Association of Physics in Medicine (AAPM) and the British Institute of Radiology (BIR) have published position papers that suggest that lead contact shielding is no longer needed due to reduced radiation doses for x-ray examinations. This work examines radiographers' opinions on these position papers. METHODS An online survey with quantitative and qualitative elements was designed to explore knowledge and attitudes toward the BIR and AAPM position papers. The population for this survey was all qualified radiographers. RESULTS The majority (59%) of participants are aware of the AAPM guidance, and 76% are aware of the BIR guidance. Given the changes in the gonad tissue weighting factor, 66% believed additional emphasis should be placed on protecting organs and tissues with higher tissue weighting factors. The vast majority (87%) believed lead shielding is not the primary dose reduction strategy, with 82% agreeing that lead shielding may interfere with the AEC. CONCLUSION This study identifies a perception that lead protection may still play a role in patient protection, particularly for children and pregnant patients. However, it is not considered the primary mechanism of protection. More specific guidance and information are needed to incorporate the guidance for radiographers into working practice, improving patient care. IMPLICATIONS FOR PRACTICE Lead shielding remains a tool for radiation protection in particular examinations, however, its role has diminished in clinical practice. RECOMMENDATIONS Additional research is required into the number of repeat x-rays associated with the use of lead shielding and the actual dose saving for shielding outside the field of view. Additional education and specific clarification on when to use and not use lead contact shielding is required.
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Affiliation(s)
- Maebh Ahern
- Medical Imaging and Radiation Therapy, School of Medicine, University College Cork, T12 AK54, Ireland
| | - Mark F McEntee
- Medical Imaging and Radiation Therapy, School of Medicine, University College Cork, T12 AK54, Ireland
| | - Niamh Moore
- Medical Imaging and Radiation Therapy, School of Medicine, University College Cork, T12 AK54, Ireland.
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Stogiannos N, Psimitis A, Bougias H, Georgiadou E, Leandrou S, Papavasileiou P, Polycarpou I, Malamateniou C, McEntee MF. Exploring radiographers' perceptions and knowledge about patient lead shielding: a cross-sectional study in Greece and Cyprus. RADIATION PROTECTION DOSIMETRY 2023; 199:1401-1409. [PMID: 37415570 DOI: 10.1093/rpd/ncad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/02/2023] [Accepted: 06/19/2023] [Indexed: 07/08/2023]
Abstract
The present study aimed to explore radiographers' knowledge, clinical practice and perceptions regarding the use of patient lead shielding in Greece and Cyprus. Qualitative data were analyzed using conceptual content analysis and through the classification of findings into themes and categories. A total of 216 valid responses were received. Most respondents reported not being aware of the patient shielding recommendations issued by the American Association of Physicists in Medicine (67%) or the guidance issued by the British Institute of Radiology (69%). Shielding-related training was generally not provided by radiography departments (74%). Most of them (85%) reported that they need specific guidance on lead shielding practices. Also, 82% of the respondents said that lead shielding should continue to be used outside the pelvic area when imaging pregnant patients. Pediatric patients are the most common patient category to which lead shielding was applied. Significant gaps in relevant training have been identified among radiographers in Greece and Cyprus, highlighting the need for new protocols and provision of adequate training on lead shielding practices. Radiography departments should invest in appropriate shielding equipment and adequately train their staff.
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Affiliation(s)
- Nikolaos Stogiannos
- Discipline of Medical Imaging and Radiation Therapy, University College Cork, Cork, T12 R229, Ireland
- Division of Midwifery and Radiography, City University of London, London, EC1V OHB, United Kingdom
- Medical Imaging Department, Corfu General Hospital, Corfu 49100, Greece
| | | | - Haralabos Bougias
- Department of Clinical Radiology, Ioannina University Hospital, Ioannina 45110, Greece
| | | | - Stephanos Leandrou
- School of Science, European University Cyprus, Nicosia 1516, Cyprus
- School of Mathematical Sciences, Computer Science and Engineering, City University of London, London, EC1V 0HB, United Kingdom
| | - Periklis Papavasileiou
- Section of Radiography and Radiotherapy, Department of Biomedical Sciences, School of Health Sciences, University of West Attica, Athens 12243, Greece
| | - Irene Polycarpou
- Department of Health Sciences, European University Cyprus, Nicosia 1516, Cyprus
| | - Christina Malamateniou
- Division of Midwifery and Radiography, City University of London, London, EC1V OHB, United Kingdom
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne 1007, Switzerland
| | - Mark F McEntee
- Discipline of Medical Imaging and Radiation Therapy, University College Cork, Cork, T12 R229, Ireland
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Alkhateeb SM, Bamusa A, Almutairi N, Barayan B, Alamodi H, Alnadawi F, Alnowaimi M. Effectiveness of protective thyroid shield in chest X-ray imaging. Radiat Phys Chem Oxf Engl 1993 2023; 209:110965. [PMID: 37065502 PMCID: PMC10089664 DOI: 10.1016/j.radphyschem.2023.110965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 04/18/2023]
Abstract
Chest X-ray imaging is the most common X-ray imaging method for diagnosing coronavirus disease. The thyroid gland is one of the most radiation-sensitive organs of the body, particularly in infants and children. Therefore, it must be protected during chest X-ray imaging. Yet, because it has benefits and drawbacks, using a thyroid shield as protection during chest X-ray imaging is still up for debate.Therefore, this study aims to clarify the need for using a protective thyroid shield during chest X-ray imaging. This study was performed using different dosimeters (silica beads as a thermoluminescent dosimeter and an optically stimulated luminance dosimeter) embedded in an adult male ATOM dosimetric phantom. The phantom was irradiated using a portable X-ray machine with and without thyroid shielding. The dosimeter readings indicated that a thyroid shield reduced the radiation dose to the thyroid gland by 69% ± 18% without degrading the obtained radiograph. The use of a protective thyroid shield during chest X-ray imaging is recommended because its benefits outweigh the risks.
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Affiliation(s)
- Shyma M Alkhateeb
- Radiologic Sciences Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdulkreem Bamusa
- Radiologic Sciences Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nawaf Almutairi
- Radiologic Sciences Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Badr Barayan
- Radiologic Sciences Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hasan Alamodi
- Radiologic Sciences Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fouad Alnadawi
- Nuclear Engineering Department, Faculty of Engineering, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Majdi Alnowaimi
- Nuclear Engineering Department, Faculty of Engineering, King Abdulaziz University, Jeddah, Saudi Arabia
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Granata C, Briers E, Candela-Juan C, Damilakis J, De Bondt T, Faj D, Foley S, Frija G, de Las Heras Gala H, Hiles P, Pauwels R, Sans Merce M, Simantirakis G, Vano E, Gilligan P. European survey on the use of patient contact shielding during radiological examinations. Insights Imaging 2023; 14:108. [PMID: 37336849 DOI: 10.1186/s13244-023-01452-3] [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: 01/09/2023] [Accepted: 05/09/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVES Contact shielding (CS) of patients during X-ray studies has been used for decades to protect radiosensitive organs. This practice has not changed much despite increasing evidence that CS is not useful in many cases. The Gonad And Patient Shielding (GAPS) group-founded by representatives of the main European bodies involved in radiology-promoted this survey to assess the current practice of CS among European radiology departments and the attitude towards a non-shielding policy. METHODS Over a four-month period (15 May-15th September 2021) European Society of Radiology and European Society of Paediatric Radiology radiologist members were invited to respond to a web-based questionnaire consisting of 59 questions. RESULTS 225 centres from 35 countries responded to this survey. CS was routinely applied in at least one radiological modality in 49.2% of centres performing studies in adults, 57.5% of centres performing studies in children, and 47.8% of centres performing studies on pregnant women. CS was most frequently used in conventional radiography, where the most frequently shielded organs were the gonads, followed by thyroid, female breasts, and eye lens. 83.6% respondents would follow European recommendations on the use of CS when provided by the main European bodies involved in radiology. CONCLUSIONS This review shows that CS is still largely used across Europe. However, a non-shielding policy could be adopted in most departments if European professional societies provided recommendations. In this regard, a strong commitment by European and national professional societies to educate and inform practitioners, patients and carers is paramount. CLINICAL RELEVANCE STATEMENT According to this survey expectations of patients and carers, and skepticism among professionals about the limited benefits of CS are the most important obstacles to the application of a no-shielding policy. A strong commitment from European and national professional societies to inform practitioners, patients and carers is fundamental.
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Affiliation(s)
- Claudio Granata
- Department of Paediatric Radiology, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.
| | - Erik Briers
- Member ESR‑Patient Advisory Group, Patient Advocate, Hasselt, Belgium
| | - Cristian Candela-Juan
- European Federation of Organizations for Medical Physics, Utrecht, The Netherlands
- Centro Nacional de Dosimetría (CND), Instituto Nacional de Gestión Sanitaria, Valencia, Spain
| | - John Damilakis
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria
- University of Crete, Iraklion, Crete, Greece
| | - Timo De Bondt
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria
- VITAZ, Department of medical physics, Moerlandstraat 1, 9100, Sint-Niklaas, Belgium
- AZ Sint-Blasius, Department of medical physics, Kroonveldlaan 50, 9200, Dendermonde, Belgium
| | - Dario Faj
- European Radiation Dosimetry Group, Neuherberg, Germany
- Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Shane Foley
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria
- European Federation of Radiographer Societies, Utrecht, Belgium
- Radiography and Diagnostic Imaging, University College Dublin, Dublin, Ireland
| | - Guy Frija
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria
- Université de Paris, Paris, France
| | | | - Peter Hiles
- Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK
| | - Ruben Pauwels
- Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
- Department of Radiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Marta Sans Merce
- European Radiation Dosimetry Group, Neuherberg, Germany
- Geneva University Hospitals, Geneva, Switzerland
| | - Georgios Simantirakis
- European Radiation Dosimetry Group, Neuherberg, Germany
- Greek Atomic Energy Commission, Agia Paraskevi, Athens, Greece
| | - Eliseo Vano
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria
- Radiology Department, Complutense University, Madrid, Spain
| | - Patrick Gilligan
- European Federation of Organizations for Medical Physics, Utrecht, The Netherlands
- Mater Misericordiae University Hospital, Eccles St., Dublin, Ireland
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13
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Hurley L, Alashban Y, Albeshan S, England A, McEntee MF. The effect of breast shielding outside the field of view on breast entrance surface dose in axial X-ray examinations: a phantom study. Diagn Interv Radiol 2023; 29:555-560. [PMID: 37129301 PMCID: PMC10679606 DOI: 10.4274/dir.2023.232126] [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: 01/20/2023] [Accepted: 04/03/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the effect of outside-field-of-view (FOV) lead shielding on the entrance surface dose (ESD) of the breast on an anthropomorphic X-ray phantom for a variety of axial skeleton X-ray examinations. METHODS Using an anthropomorphic phantom and radiation dosimeter, the ESD of the breast was measured with and without outside-FOV shielding in anterior-posterior (AP) abdomen, AP cervical spine, occipitomental 30° (OM30) facial bones, AP lumbar spine, and lateral lumbar spine radiography. The effect of several exposure parameters, including a low milliampere-seconds technique, grid use, automatic exposure control use, wraparound lead (WAL) use, trolley use, and X-ray table use, on the ESD of the breast with and without outside-FOV shielding was investigated. The mean ESD (μSv) and standard deviation for each radiographic protocol were calculated. A one-tailed Student's t-test was carried out to evaluate whether ESD to the breast was reduced with the use of outside-FOV shielding. RESULTS A total of 920 breast ESD measurements were recorded across the different protocol parameters. The largest decrease in mean ESD of the breast with outside-FOV shielding was 0.002 μSv (P = 0.084), recorded in the AP abdomen on the table with a grid, OM30 on the table with a grid, OM30 standard protocol on the trolley, and OM30 on the trolley with WAL protocols. This decrease was found to be statistically non-significant. CONCLUSION This study found no significant decrease in the ESD of the breast with the use of outside-FOV shielding for the AP abdomen, AP cervical spine, OM30 facial bones, AP lumbar spine, or lateral lumbar spine radiography across a range of protocols.
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Affiliation(s)
- Lauren Hurley
- Department of Medical Imaging and Radiation Therapy, University College Cork, School of Medicine, Brookfield Health Sciences, Munster, Ireland
| | - Yazeed Alashban
- Department of Radiological Sciences, King Saud University, College of Applied Medical Sciences, Riyadh, Saudi Arabia
| | - Salman Albeshan
- Department of Radiological Sciences, King Saud University, College of Applied Medical Sciences, Riyadh, Saudi Arabia
| | - Andrew England
- Department of Medical Imaging and Radiation Therapy, University College Cork, School of Medicine, Brookfield Health Sciences, Munster, Ireland
| | - Mark F. McEntee
- Department of Medical Imaging and Radiation Therapy, University College Cork, School of Medicine, Brookfield Health Sciences, Munster, Ireland
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14
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Downing J, Sjeklocha L. Trauma in Pregnancy. Emerg Med Clin North Am 2023; 41:223-245. [PMID: 37024160 DOI: 10.1016/j.emc.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Trauma is the leading cause of nonobstetric maternal death. Pregnant patients have a similar spectrum of traumatic injuries with a noted increase in interpersonal violence. A structured approach to trauma evaluation and management is recommended with several guidelines expanding on ATLS principles; however, evidence is limited. Optimal management requires understanding of physiologic changes in pregnancy, a team-based approach, and preparation for interventions that may including neonatal resuscitation. The principles of trauma management are the same in pregnancy with a systematic approach and initial maternal focused resuscitation..
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Affiliation(s)
- Jessica Downing
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Lucas Sjeklocha
- Department of Emergency Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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15
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Lestari YM, Anam C, Sutanto H, Arifin Z, Alkian I, Suyudi I, Dougherty G. Evaluation of silicone rubber-lead shield's effectiveness in protecting the breast during thoracic CT. Biomed Phys Eng Express 2023; 9. [PMID: 36689768 DOI: 10.1088/2057-1976/acb551] [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: 11/15/2022] [Accepted: 01/23/2023] [Indexed: 01/24/2023]
Abstract
Radiation of thoracic computed tomography (CT) involves the breast although it is not considered an organ of interest. According to the International Commission on Radiological Protection (ICRP) No. 103, the breast is an organ with a high level of sensitivity when interacting with x-rays, increasing the potential risk of breast cancer. Therefore, the radiation dose must be optimized while maintaining image quality. The dose optimization can be accomplished using a radiation shield. This study aims to determine the effect of silicone rubber (SR)-lead (Pb) in various thicknesses as an alternative protective material limiting dose and preserving the image quality of the breast in thoracic CT. SR-Pb was made from SR and Pb by a simple method. The SR-Pb had thicknesses of 3, 6, 9, and 12 mm. The breast dose was measured using a CT dose profiler on the surface of the breast phantom. The CT number and the noise level of the resulting image were determined quantitatively. The dose without the radiation shield was 5.4 mGy. The doses measured using shielding with thicknesses of 3, 6, 9, and 12 mm were 5.2, 4.5, 4.3, and 3.3 mGy, respectively. Radiation shielding with a thickness of 12 mm reduced breast surface dose by up to 38%. The CT numbers and noise levels for the left and right breast phantom images were almost the same as those without radiation shields indicating there were only slight artifacts in the image. Therefore, SR-Pb is considered a good shielding material which can be pplied in a clinical setting by placing it directly on the breast surface for dose optimization.
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Affiliation(s)
| | - Choirul Anam
- Department of Physics, Diponegoro University, Semarang, Indonesia
| | - Heri Sutanto
- Department of Physics, Diponegoro University, Semarang, Indonesia.,Smart Material Research Center, Diponegoro University, Semarang, Indonesia
| | - Zaenal Arifin
- Department of Physics, Diponegoro University, Semarang, Indonesia
| | - Ilham Alkian
- Smart Material Research Center, Diponegoro University, Semarang, Indonesia
| | - Imam Suyudi
- Radiology Installation, Kardinah Hospital, Tegal, Indonesia
| | - Geoff Dougherty
- Department of Applied Physics and Medical Imaging, California State University Channel Islands, Camarillo, CA 93012, United States of America
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16
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Kelaranta A, Mäkelä T, Hyppänen T, Toroi P, Kortesniemi M. EFFECT OF PELVIC LEAD SHIELD ON ORGAN DOSES IN POSTERO-ANTERIOR CHEST RADIOGRAPHY. RADIATION PROTECTION DOSIMETRY 2023; 199:29-34. [PMID: 36347420 DOI: 10.1093/rpd/ncac216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 09/12/2022] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
Lead shields are commonly used in X-ray imaging to protect radiosensitive organs and to minimise patient's radiation dose. However, they might also complicate or interfere with the examination, and even decrease the diagnostic value if they are positioned incorrectly. In this study, the radiation dose effect of waist half-apron lead shield was examined via Monte Carlo simulations of postero-anterior (PA) chest radiography examinations using a female anthropomorphic phantom. Relevant organs for dose determination were lungs, breasts, liver, kidneys and uterus. The organ dose reductions varied depending on shield position and organ but were negligible for properly positioned shields. The shield that had the largest effective dose reduction (9%) was partly positioned inside the field of view, which should not be done in practice. Dose reduction was practically 0% for properly positioned shields. Therefore, the use of lead shield in the pelvic region during chest PA examinations should be discontinued.
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Affiliation(s)
- Anna Kelaranta
- HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, FI-00290 Helsinki, Finland
- Department of Physics, University of Helsinki, FI-00014 Helsinki, Finland
- Suomen Terveystalo Ltd, Jaakonkatu 3A, FI-00100 Helsinki, Finland
| | - Teemu Mäkelä
- HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, FI-00290 Helsinki, Finland
- Department of Physics, University of Helsinki, FI-00014 Helsinki, Finland
| | - Teemu Hyppänen
- HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, FI-00290 Helsinki, Finland
| | - Paula Toroi
- STUK-Radiation and Nuclear Safety Authority, Jokiniemenkuja 1, FI-01370 Vantaa, Finland
| | - Mika Kortesniemi
- HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, FI-00290 Helsinki, Finland
- Department of Physics, University of Helsinki, FI-00014 Helsinki, Finland
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17
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Gillespie CD, Yates A, Murphy MC, Hughes M, Ewins K, NíAinle F, Bolster F, Rowan M, Foley S, MacMahon PJ. Breast Shielding Combined With an Optimized Computed Tomography Pulmonary Angiography Pregnancy Protocol: A Special Use-Case for Shielding? J Thorac Imaging 2023; 38:36-43. [PMID: 36162076 DOI: 10.1097/rti.0000000000000677] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine the impact of breast shields on breast dose and image quality when combined with a low-dose computed tomography pulmonary angiography (CTPA) protocol for pregnancy. METHODS A low-dose CTPA protocol, with and without breast shields, was evaluated by anthropomorphic phantom and 20 prospectively recruited pregnant participants from January to October 2019. Thermoluminescent dosimeters measured surface and absorbed breast dose in the phantom and surface breast dose in participants. The Monte-Carlo method estimated the absorbed breast dose in participants. Image quality was assessed quantitatively by regions of interest analysis and subjectively by the Likert scale. Doses and image quality for CTPA alone were compared with CTPA with breast shields. RESULTS Mean surface and absorbed breast dose for CTPA alone were 1.3±0.4 and 2.8±1.5 mGy in participants, and 1.5±0.7 and 1.6±0.6 mGy in the phantom. Shielding reduced surface breast dose to 0.5±0.3 and 0.7±0.2 mGy in the phantom (66%) and study participants (48%), respectively. Absorbed breast dose reduced to 0.9±0.5 mGy (46%) in the phantom.Noise increased with breast shields at lower kV settings (80 to 100 kV) in the phantom; however, in study participants there was no significant difference between shield and no-shield groups for main pulmonary artery noise (no-shield: 34±9.8, shield: 36.3±7.2, P =0.56), SNR (no-shield: 11.2±3.7, shield: 10.8±2.6, P =0.74) or contrast-to-noise ratio (no-shield: 10.0±3.3, shield: 9.3±2.4, P =0.6). Median subjective image quality scores were comparable (no-shield: 4.0, interquartile range: 3.5 to 4.4, shield: 4.3, interquartile range: 4.0 to 4.5). CONCLUSION Combining low-dose CTPA with breast shields confers additional breast-dose savings without impacting image quality and yields breast doses approaching those of low-dose scintigraphy, suggesting breast shields play a role in protocol optimization for select groups.
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Affiliation(s)
| | | | | | | | - Karl Ewins
- Haematology, Mater Misericordiae University Hospital
| | | | - Ferdia Bolster
- Departments of Radiology
- School of Medicine, University College Dublin
| | - Michael Rowan
- Department of Medical Physics, St James Hospital, Dublin, Ireland
| | - Shane Foley
- Radiography & Diagnostic Imaging, School of Medicine, University College Dublin
| | - Peter J MacMahon
- Departments of Radiology
- School of Medicine, University College Dublin
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18
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Dias Cardoso CEM, Bezzina P, Portelli JL. Gonad contact shielding in digital radiography: A questionnaire survey. Eur J Radiol 2023; 158:110620. [PMID: 36521379 DOI: 10.1016/j.ejrad.2022.110620] [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: 08/08/2022] [Revised: 10/16/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The use of gonad contact shielding (GCS) in radiology departments has varied across countries, possibly because, until recently, there was no agreed consensus with mixed evidence supporting its use. This study aims to explore radiographers' use and opinion on GCS in digital radiography (DR) and to evaluate whether radiographers' use of GCS is associated with their gender, highest educational qualification, and/or years of experience. METHOD An online survey was sent via email to potential participants through the Society of Medical Radiographers Malta (SRM) as well as social media posts on local radiography pages. Descriptive and inferential statistics were used to analyse the collected data. RESULTS Almost half of the registered radiographers working in radiology departments in Malta (n = 101/203) completed the survey (49.7 % response rate). 61.4 % of participating radiographers indicated they 'often' use GCS in some patients, with 56.4 % stating they perceive GCS as an effective tool to protect the gonads from radiation exposure in DR. Equally, 56.4 % claimed that GCS use is guided by local rules and/or departmental protocols. While 58.4 % indicated that patients' gender does not impact their use of GCS, patients' age does influence their use. No statistically significant association was noted between radiographers' likeliness of using GCS and their gender, highest educational qualification, and/or years of experience. CONCLUSIONS Some misconceptions and uncertainties among radiographers concerning the benefits and risks of using GCS were noted. Local radiology departments should look into their protocols and assess the need for an update aligned with the latest recommendations.
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Affiliation(s)
| | - Paul Bezzina
- Radiography Department, Faculty of Health Sciences, University of Malta, Msida MSD2090, Malta.
| | - Jonathan L Portelli
- Radiography Department, Faculty of Health Sciences, University of Malta, Msida MSD2090, Malta.
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Zaleski KL, Blazey MH, Carabuena JM, Economy KE, Valente AM, Nasr VG. Perioperative Anesthetic Management of the Pregnant Patient With Congenital Heart Disease Undergoing Cardiac Intervention: A Systematic Review. J Cardiothorac Vasc Anesth 2022; 36:4483-4495. [PMID: 36195521 DOI: 10.1053/j.jvca.2022.09.001] [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: 06/13/2022] [Revised: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 11/11/2022]
Abstract
Maternal congenital heart disease is increasingly prevalent, and has been associated with a significantly increased risk of maternal, obstetric, and neonatal complications. For patients with CHD who require cardiac interventions during pregnancy, there is little evidence-based guidance with regard to optimal perioperative management. The periprocedural management of pregnant patients with congenital heart disease requires extensive planning and a multidisciplinary teams-based approach. Anesthesia providers must not only be facile in the management of adult congenital heart disease, but cognizant of the normal, but significant, physiologic changes of pregnancy.
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Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Critical Care, and Pain Medicine-Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Jean M Carabuena
- Department of Anesthesiology, Perioperative and Pain Medicine-Brigham and Women's Hospital, Harvard Medical School, Boston MA
| | - Katherine E Economy
- Division of Maternal-Fetal Medicine, Brigham, and Women's Hospital, Harvard Medical School, Boston, MA
| | - Anne M Valente
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care, and Pain Medicine-Boston Children's Hospital, Harvard Medical School, Boston, MA.
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20
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Hamzian N, Asadian S, Zarghani H. A Study of Radiation Protection Standards Compliance in Hospital Radiographic Departments in Iran. J Biomed Phys Eng 2022; 12:513-520. [PMID: 36313405 PMCID: PMC9589086 DOI: 10.31661/jbpe.v0i0.2108-1375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 03/10/2022] [Indexed: 11/16/2022]
Abstract
Background The X-ray is a critical diagnostic and therapeutic tool with harmful effects. The International Commission on Radiological Protection (ICRP) has some recommendations regarding applying radiation protection principles. Objective This study aimed to determine the standards of the typical radiation protection in radiographic departments of hospitals in Iran. Material and Methods In this cross-sectional descriptive study, the usual radiation protection standards in places, such as the physical environment of the control and waiting rooms, radiographic devices, the physical space of the darkroom, and shielding facilities, were investigated using a checklist in Iran. A total of 84 hospitals in 51 cities throughout Iran were randomly selected, and the checklists were distributed to the radiation protection officers. In hospitals with multiple radiography rooms, the radiation protection officers were asked to complete the checklist about the room with the highest workload as a baseline to evaluate their facilities. Finally, the authors reviewed all checklists. Results In radiology departments in control and waiting rooms, the mean of radiation protection was 71.9%. Pregnancy and radiation warning signs and labels were present in 96.1% of the parameters, while gonad shielding protocols were not presented. Conclusion The principles of observed radiation protection were unsatisfactory, and it is recommended that surveillance be conducted at frequent intervals.
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Affiliation(s)
- Nima Hamzian
- PhD, Department of Medical Physics, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Saeed Asadian
- BSc, Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
| | - Hassan Zarghani
- PhD, Cardiovascular Diseases Research Center, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
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21
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Oglat AA, Hasan H. Jordanian women’s (studying or working in medical fields) awareness in terms of the use of dental imaging during pregnancy. BMC Oral Health 2022; 22:427. [PMID: 36153531 PMCID: PMC9508717 DOI: 10.1186/s12903-022-02459-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/13/2022] [Indexed: 11/20/2022] Open
Abstract
Background The anxiety among pregnant women about the imaging of teeth during pregnancy may have an adverse effect on the oral health of both the mother and the fetus too. This research study was conducted to evaluate women’s knowledge of the utilization of dental imaging during pregnancy. Methods In this research, structured questionnaires were distributed electronically through social media. The questionnaires contained questions focused on the women’s (studying or working in medical fields) awareness regarding the ionizing radiation protection that takes place during dental imaging, the safest period for dental imaging, the sort of radiographs that can be required, and the chance of radiation-induced malignant tumor and malformation of the fetal as a result of dental imaging. Results Overall, 984 participants completed questionnaires that were analyzed after being received. Most of the participants (n = 637; 64.7%) were < 30 years of age. The greater number of the participants (66.8%) had fair knowledge of dental imaging. 25.4% mentioned that pregnant women are able to do dental imaging during the first trimester. And approximately half of the participants thought that cone-beam computed tomography and panoramic images must not be carried out during pregnancy. Moreover, nearly the same percentage of them also believed that the risk of inborn malformation is high due to dental imaging. Conclusions The results refer to a low awareness among people who have medical knowledge regarding dental radiograph protection during pregnancy. This needs to be paid attention to among students, graduates, and workers in medical fields by focusing on the courses and lectures related to dental imaging protection during pregnancy. Supplementary Information The online version contains supplementary material available at 10.1186/s12903-022-02459-w.
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22
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Freeman A. Paediatric gonad shielding in pelvic radiography: A systematic review and meta-analysis. Radiography (Lond) 2022; 28:964-972. [PMID: 35849887 DOI: 10.1016/j.radi.2022.06.009] [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: 12/09/2021] [Revised: 06/05/2022] [Accepted: 06/17/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION The British Institute of Radiology (BIR) and American Association of Physicists in Medicine (AAPM) have recommended that gonad shielding is no longer used during pelvic X-ray examinations. The BIR guidance states that shielding may still be considered for use on males, but should not be used on females. This paper aimed to evaluate if this decision was supported by evidence from practice, by comparing the accuracy of gonad shield placement in paediatric males and females. METHODS A systematic review of databases including EMBASE, MEDLINE and PubMed was performed in February 2021. Studies were considered eligible if they provided data on the use of gonad shielding during pelvic X-ray examinations on male and female patients under the age of 18. Nine studies met the inclusion criteria and data extraction was performed. Quality appraisal was undertaken, and a meta-analysis of shielding accuracy was performed on seven studies. RESULTS The results from the meta-analysis (2187 total radiographs) demonstrated that female patients were significantly more likely (OR 1.38, 95% CI 0.88-1.87) than males to have gonad shields placed inaccurately (p value < 0.001). CONCLUSION Gonad shield placement on paediatric female patients is significantly less accurate than on males, and so the results support the AAPM and BIR guidance to stop the practice for females. Shield application may also be frequently inaccurate for males, but the review does not provide clear evidence for or against continuing the practice for males. IMPLICATIONS FOR PRACTICE Discontinuing the use of gonad shields in paediatric pelvic radiography on female patients is supported. Any continued use on male patients, or for reasons such as psychological reassurance, should be subject to enhanced training and audit to ensure benefits outweigh any risks.
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Affiliation(s)
- A Freeman
- University of Leeds School of Medicine, Worsley Building, Woodhouse, Leeds, LS2 9JT, UK
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23
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Rautiainen J, Juntunen MAK, Kotiaho AO. THE EFFECT OF OUT-OF-PLANE PATIENT SHIELDING ON CT RADIATION EXPOSURE AND TUBE CURRENT MODULATIONS: A PHANTOM STUDY ACROSS THREE VENDORS. RADIATION PROTECTION DOSIMETRY 2022; 198:229-237. [PMID: 35313335 DOI: 10.1093/rpd/ncac032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/10/2022] [Accepted: 02/21/2022] [Indexed: 06/14/2023]
Abstract
The aim of this study was to evaluate how out-of-plane patient shielding affects radiation exposure parameters and tube current modulation on different vendors' computed tomography (CT) scanners. Helical CT scans were performed using two homogenous phantoms to mimic patient attenuation. Four CT scanners from three vendors were investigated by varying the distance of the patient shield from the border of the imaging volume. Scans were performed with a shield placed before and after the localizer. Changes in volume computed tomography dose index (CTDIvol), dose-length product (DLP) and tube current-time products were studied. Out-of-field lead shield increased the CTDIvol and DLP values for each scanner at least for one scan setting when the shield was present in the localizer. The most notable changes were recorded with >1.3 pitch values when the shield was closest to the scanned volume (2.5 cm), and the scan direction was towards the shield. The usage of patient shields in the localizer CT scans can disturb TCM even when placed 7.5 cm away from the edge of the scan.
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Affiliation(s)
- Jari Rautiainen
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu 90220, Finland
- Department of Radiology, Lapland Central Hospital, Rovaniemi 96101, Finland
| | - Mikael A K Juntunen
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu 90220, Finland
- Research Unit of Medical Imaging, Physics and Technology, Medical Research Center, University of Oulu and Oulu University Hospital, Oulu 90220 Finland
| | - Antti O Kotiaho
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu 90220, Finland
- Terveystalo Healthcare, Helsinki 00100, Finland
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Hughes J, Harris M, Snaith B, Benn H. Comparison of scattered entrance skin dose burden in MSCT, CBCT, and X-ray for suspected scaphoid injury: Regional dose measurements in a phantom model. Radiography (Lond) 2022; 28:811-816. [PMID: 35183441 DOI: 10.1016/j.radi.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/18/2022] [Accepted: 01/28/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Scaphoid radiography has poor sensitivity for acute fracture detection and often requires repeat delayed imaging. Although magnetic resonance (MR) imaging is considered the gold standard, computed tomography (CT) is often used as an alternative due to ease of access. Cone-Beam CT (CBCT) offers equivalent diagnostic efficacy to Multi Slice CT (MSCT) at reduced dose. We aimed to establish the difference in scattered dose between modalities for scaphoid imaging. METHODS Anatomical regional entrance surface dose measurements were taken at 3 regions on an anthropomorphic torso phantom positioned as a patient to a wrist phantom undergoing scaphoid imaging for three modalities (CBCT, MSCT, four-view projection radiography). Exposure factors were based on audit of clinical exposures. Each dose measurement was repeated three times per anatomical region, modality, exposure setting and projection. RESULTS Under unpaired T-test CBCT gave significantly lower mean dose at the neck (1.64 vs 18 mGy), chest (2.78 vs 8.01) and abdomen (1.288 vs 2.93) than MSCT (p < .0001). However CBCT had significantly higher mean dose than four-view radiography at the neck, chest and abdomen (0.031, 0.035, and 0.021 mGy) (p < .0001). CONCLUSION CBCT of the wrist carries a significantly higher scattered radiation dose to the neck, chest and abdomen than four view scaphoid radiography, but significantly lower scattered dose than MSCT of the wrist of equivalent diagnostic value. IMPLICATIONS FOR PRACTICE The use of CBCT for scaphoid injury carries significantly lower scattered dose to radio-sensitive structures investigated here than equivalent MSCT, and may be of greater use as an early cross-sectional investigation for suspected scaphoid fracture.
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Affiliation(s)
- J Hughes
- Mid Yorkshire Hospitals NHS Trust, Pinderfields Hospital, Aberford Road, Wakefield, WF1 4DG, United Kingdom.
| | - M Harris
- Mid Yorkshire Hospitals NHS Trust, Pinderfields Hospital, Aberford Road, Wakefield, WF1 4DG, United Kingdom
| | - B Snaith
- University of Bradford, Richmond Road, Bradford, BD7 1DP, United Kingdom
| | - H Benn
- Mid Yorkshire Hospitals NHS Trust, Pinderfields Hospital, Aberford Road, Wakefield, WF1 4DG, United Kingdom
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25
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Samara ET, Saltybaeva N, Sans Merce M, Gianolini S, Ith M. Systematic literature review on the benefit of patient protection shielding during medical X-ray imaging: Towards a discontinuation of the current practice. Phys Med 2022; 94:102-109. [PMID: 35030383 DOI: 10.1016/j.ejmp.2021.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/15/2021] [Accepted: 12/28/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Patient shielding during medical X-ray imaging has been increasingly criticized in the last years due to growing evidence that it often provides minimal benefit and may even compromise image quality. In Europe, and as also shown in a short assessment in Switzerland, the use of patient shielding is inhomogeneous. The aim of this study was to systematically review recent literature in order to assess benefits and appraise disadvantages related to the routine use of patient shielding. METHODS To evaluate benefits and disadvantages related to the application of patient shielding in radiological procedures, a systematic literature review was performed for CT, radiography, mammography and fluoroscopy-guided medical X-ray imaging. In addition, reports from medical physics societies and authorities of different countries were considered in the evaluation. RESULTS The literature review revealed 479 papers and reports on the topic, from which 87 qualified for closer analysis. The review considered in- and out-of-plane patient shielding as well as shielding for pregnant and pediatric patients. Dose savings and other dose and non-dose related effects of patient shielding were considered in the evaluation. CONCLUSIONS Although patient shielding has been used in radiological practice for many years, its use is no longer undisputed. The evaluation of the systematic literature review of recent studies and reports shows that dose savings are rather minimal while significant dose- and non-dose-related detrimental effects are present. Consequently, the routine usage of patient protection shielding in medical X-ray imaging can be safely discontinued for all modalities and patient groups.
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Affiliation(s)
- Eleni Theano Samara
- Radiation Protection Unit, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Natalia Saltybaeva
- Radiation Protection Unit, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marta Sans Merce
- Department of Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
| | | | - Michael Ith
- Department of Diagnostic, Interventional and Pediatric Radiology (DIPR), Inselspital, Bern University Hospital, University of Bern, Switzerland
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26
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Frush DP, Strauss KJ. Changing the practice of routine gonadal shielding during radiography: 'Y'? Pediatr Radiol 2022; 52:7-9. [PMID: 34741179 DOI: 10.1007/s00247-021-05230-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 09/23/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Donald P Frush
- Department of Radiology, Duke University Medical Center, Room #2568, 40 Duke Medicine Circle, Red Zone, Duke South, Box 3808, Durham, NC, 27710, USA.
| | - Keith J Strauss
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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27
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Hiles P, Gilligan P, Damilakis J, Briers E, Candela-Juan C, Faj D, Foley S, Frija G, Granata C, de Las Heras Gala H, Pauwels R, Sans Merce M, Simantirakis G, Vano E. European consensus on patient contact shielding. Insights Imaging 2021; 12:194. [PMID: 34939154 PMCID: PMC8695402 DOI: 10.1186/s13244-021-01085-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/19/2021] [Indexed: 12/25/2022] Open
Abstract
Patient contact shielding has been in use for many years in radiology departments in order to reduce the effects and risks of ionising radiation on certain organs. New technologies in projection imaging and CT scanning such as digital receptors and automatic exposure control systems have reduced doses and improved image consistency. These changes and a greater understanding of both the benefits and the risks from the use of shielding have led to a review of shielding use in radiology. A number of professional bodies have already issued guidance in this regard. This paper represents the current consensus view of the main bodies involved in radiation safety and imaging in Europe: European Federation of Organisations for Medical Physics, European Federation of Radiographer Societies, European Society of Radiology, European Society of Paediatric Radiology, EuroSafe Imaging, European Radiation Dosimetry Group (EURADOS), and European Academy of DentoMaxilloFacial Radiology (EADMFR). It is based on the expert recommendations of the Gonad and Patient Shielding (GAPS) Group formed with the purpose of developing consensus in this area. The recommendations are intended to be clear and easy to use. They are intended as guidance, and they are developed using a multidisciplinary team approach. It is recognised that regulations, custom and practice vary widely on the use of patient shielding in Europe and it is hoped that these recommendations will inform a change management program that will benefit patients and staff.
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Affiliation(s)
- Peter Hiles
- Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK.
| | - Patrick Gilligan
- European Federation of Organizations for Medical Physics, Utrecht, The Netherlands.,Mater Private Hospital, Eccles St., Dublin, Ireland
| | - John Damilakis
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria.,University of Crete, Iraklion, Crete, Greece
| | - Eric Briers
- Member ESR-Patient Advisory Group, Patient Advocate, Hasselt, Belgium
| | - Cristian Candela-Juan
- European Federation of Organizations for Medical Physics, Utrecht, The Netherlands.,Centro Nacional de Dosimetría (CND), Instituto Nacional de Gestión Sanitaria, Valencia, Spain
| | - Dario Faj
- European Radiation Dosimetry Group, Neuherberg, Germany.,Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Shane Foley
- European Federation of Radiographer Societies, Utrecht, Belgium.,Radiography and Diagnostic Imaging, University College Dublin, Dublin, Ireland
| | - Guy Frija
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria.,Université de Paris, Paris, France
| | - Claudio Granata
- European Society of Paediatric Radiology, Le Kremlin-Bicêtre, France.,Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - Hugo de Las Heras Gala
- European Federation of Organizations for Medical Physics, Utrecht, The Netherlands.,Federal Office for Radiation Protection, Oberschleißheim, Germany
| | - Ruben Pauwels
- Aarhus Institute of Advanced Studies, Aarhus University, Aarhus, Denmark
| | - Marta Sans Merce
- European Radiation Dosimetry Group, Neuherberg, Germany.,Geneva University Hospitals, Geneva, Switzerland
| | - Georgios Simantirakis
- European Radiation Dosimetry Group, Neuherberg, Germany.,Greek Atomic Energy Commission, Agia Paraskevi, Athens, Greece
| | - Eliseo Vano
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria.,Radiology Department, Complutense University, Madrid, Spain
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28
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Hiles P, Gilligan P, Damilakis J, Briers E, Candela-Juan C, Faj D, Foley S, Frija G, Granata C, de Las Heras Gala H, Pauwels R, Sans Merce M, Simantirakis G, Vano E. European consensus on patient contact shielding. Radiography (Lond) 2021; 28:353-359. [PMID: 34953726 DOI: 10.1016/j.radi.2021.12.003] [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] [Indexed: 12/16/2022]
Abstract
Patient contact shielding has been in use for many years in radiology departments in order to reduce the effects and risks of ionising radiation on certain organs. New technologies in projection imaging and CT scanning such as digital receptors and automatic exposure control (AEC) systems have reduced doses and improved image consistency. These changes and a greater understanding of both the benefits and the risks from the use of shielding have led to a review of shielding use in radiology. A number of professional bodies have already issued guidance in this regard. This paper represents the current consensus view of the main bodies involved in radiation safety and imaging in Europe: European Federation of Organisations for Medical Physics, European Federation of Radiographer Societies, European Society of Radiology, European Society of Paediatric Radiology, EuroSafe Imaging, European Radiation Dosimetry Group (EURADOS), and European Academy of DentoMaxilloFacial Radiology (EADMFR). It is based on the expert recommendations of the Gonad and Patient Shielding (GAPS) Group formed with the purpose of developing consensus in this area. The recommendations are intended to be clear and easy to use. They are intended as guidance, and they are developed using a multidisciplinary team approach. It is recognised that regulations, custom and practice vary widely on the use of patient shielding in Europe and it is hoped that these recommendations will inform a change management program that will benefit patients and staff.
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Affiliation(s)
- P Hiles
- Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK.
| | - P Gilligan
- European Federation of Organizations for Medical Physics, Utrecht, the Netherlands; Mater Private Hospital, Eccles St., Dublin 7, Ireland
| | - J Damilakis
- European Society of Radiology, EuroSafe Imaging, Vienna, Austria; University of Crete, Iraklion, Crete, Greece
| | - E Briers
- Member ESR-Patient Advisory Group, Patient Advocate, Hasselt, Belgium
| | - C Candela-Juan
- European Federation of Organizations for Medical Physics, Utrecht, the Netherlands; Centro Nacional de Dosimetría (CND), Instituto Nacional de Gestión Sanitaria, Valencia, Spain
| | - D Faj
- European Radiation Dosimetry Group, Neuherberg, Germany; Faculty of Dental Medicine and Health, Osijek, Croatia
| | - S Foley
- European Federation of Radiographer Societies, Utrecht, the Netherlands; Radiography & Diagnostic Imaging, University College Dublin, Ireland
| | - G Frija
- European Society of Radiology, EuroSafe Imaging, Vienna, Austria; Université de Paris, France
| | - C Granata
- European Society of Paediatric Radiology, Le Kremlin-Bicêtre, France; Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - H de Las Heras Gala
- European Federation of Organizations for Medical Physics, Utrecht, the Netherlands; Federal Office for Radiation Protection, Oberschleißheim, Germany
| | - R Pauwels
- Aarhus Institute of Advanced Studies, Aarhus University, Denmark
| | - M Sans Merce
- European Radiation Dosimetry Group, Neuherberg, Germany; Geneva University Hospitals, Geneva, Switzerland
| | - G Simantirakis
- European Radiation Dosimetry Group, Neuherberg, Germany; Greek Atomic Energy Commission, Agia Paraskevi, Athens, Greece
| | - E Vano
- European Society of Radiology, EuroSafe Imaging, Vienna, Austria; Radiology Department, Complutense University, Spain
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29
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Hiles P, Gilligan P, Damilakis J, Briers E, Candela-Juan C, Faj D, Foley S, Frija G, Granata C, de Las Heras Gala H, Pauwels R, Sans Merce M, Simantirakis G, Vano E. European consensus on patient contact shielding. Phys Med 2021; 96:198-203. [PMID: 34955383 DOI: 10.1016/j.ejmp.2021.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patient contact shielding has been in use for many years in radiology departments in order to reduce the effects and risks of ionising radiation on certain organs. New technologies in projection imaging and CT scanning such as digital receptors and automatic exposure control (AEC) systems have reduced doses and improved image consistency. These changes and a greater understanding of both the benefits and the risks from the use of shielding have led to a review of shielding use in radiology. A number of professional bodies have already issued guidance in this regard. This paper represents the current consensus view of the main bodies involved in radiation safety and imaging in Europe: European Federation of Organisations for Medical Physics, European Federation of Radiographer Societies, European Society of Radiology, European Society of Paediatric Radiology, EuroSafe Imaging, European Radiation Dosimetry Group (EURADOS), and European Academy of DentoMaxilloFacial Radiology (EADMFR). It is based on the expert recommendations of the Gonad and Patient Shielding (GAPS) Group formed with the purpose of developing consensus in this area. The recommendations are intended to be clear and easy to use. They are intended as guidance, and they are developed using a multidisciplinary team approach. It is recognised that regulations, custom and practice vary widely on the use of patient shielding in Europe and it is hoped that these recommendations will inform a change management program that will benefit patients and staff.
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Affiliation(s)
- Peter Hiles
- Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK.
| | - Patrick Gilligan
- European Federation of Organizations for Medical Physics, Utrecht, The Netherlands; Mater Private Hospital, Eccles St., Dublin 7, Ireland
| | - John Damilakis
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria; University of Crete, Iraklion, Crete, Greece
| | - Eric Briers
- Member ESR-Patient Advisory Group, Patient Advocate, Hasselt, Belgium
| | - Cristian Candela-Juan
- European Federation of Organizations for Medical Physics, Utrecht, The Netherlands; Centro Nacional de Dosimetría (CND), Instituto Nacional de Gestión Sanitaria, Valencia, Spain
| | - Dario Faj
- European Radiation Dosimetry Group, Neuherberg, Germany; Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Shane Foley
- European Federation of Radiographer Societies, Utrecht, The Netherlands; Radiography & Diagnostic Imaging, University College Dublin, Ireland
| | - Guy Frija
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria; Université de Paris, France
| | - Claudio Granata
- European Society of Paediatric Radiology, Le Kremlin-Bicêtre, France; Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - Hugo de Las Heras Gala
- European Federation of Organizations for Medical Physics, Utrecht, The Netherlands; Federal Office for Radiation Protection, Oberschleißheim, Germany
| | - Ruben Pauwels
- Aarhus Institute of Advanced Studies, Aarhus University, Denmark
| | - Marta Sans Merce
- European Radiation Dosimetry Group, Neuherberg, Germany; Geneva University Hospitals, Geneva, Switzerland
| | - Georgios Simantirakis
- European Radiation Dosimetry Group, Neuherberg, Germany; Greek Atomic Energy Commission, Agia Paraskevi, Athens, Greece
| | - Eliseo Vano
- European Society of Radiology - EuroSafe Imaging, Vienna, Austria; Radiology Department, Complutense University, Spain
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30
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Elshami W, Tekin HO, Issa SAM, Abuzaid MM, Zakaly HMH, Issa B, Ene A. Impact of Eye and Breast Shielding on Organ Doses During Cervical Spine Radiography: Design and Validation of MIRD Computational Phantom. Front Public Health 2021; 9:751577. [PMID: 34746086 PMCID: PMC8569301 DOI: 10.3389/fpubh.2021.751577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose: The study aimed to design and validate computational phantoms (MIRD) using the MCNPX code to assess the impact of shielding on organ doses. Method: To validate the optimized phantom, the obtained results were compared with experimental results. The validation of the optimized MIRD phantom was provided by using the results of a previous anthropomorphic phantom study. MIRD phantom was designed by considering the parameters used in the anthropomorphic phantom study. A test simulation was performed to compare the dose reduction percentages (%) between the experimental anthropomorphic phantom study and the MCNPX-MIRD phantom. The simulation was performed twice, with and without shielding materials, using the same number and locations of the detector. Results: The absorbed dose amounts were directly extracted from the required organ and tissue cell parts of output files. Dose reduction percentages between the simulation with shielding and simulation without shielding were compared. The highest dose reduction was noted in the thymus (95%) and breasts (88%). The obtained dose reduction percentages between the anthropomorphic phantom study and the MCNPX-MIRD phantom were highly consistent and correlated values with experimental anthropomorphic data. Both methods showed Relative Difference (%) ranges between 0.88 and 2.22. Moreover, the MCNPX-MIRD optimized phantom provides detailed dose analysis for target and non-target organs and can be used to assess the efficiency of shielding in radiological examination. Conclusion: Shielding breasts and eyes during cervical radiography reduced the radiation dose to many organs. The decision to not shield patients should be based on research evidence as this approach does not apply to all cases.
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Affiliation(s)
- Wiam Elshami
- Department of Medical Diagnostic Imaging, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Huseyin Ozan Tekin
- Department of Medical Diagnostic Imaging, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Shams A. M. Issa
- Physics Department, Faculty of Science, University of Tabuk, Tabuk, Saudi Arabia
- Physics Department, Faculty of Science, Al-Azhar University, Cairo, Egypt
| | - Mohamed M. Abuzaid
- Department of Medical Diagnostic Imaging, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Hesham M. H. Zakaly
- Physics Department, Faculty of Science, Al-Azhar University, Cairo, Egypt
- Department of Experimental Physics, Institute of Physics and Technology, Ural Federal University, Yekaterinburg, Russia
| | - Bashar Issa
- Department of Medical Diagnostic Imaging, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Antoaneta Ene
- Department of Chemistry, Physics and Environment, Faculty of Sciences and Environment, INPOLDE Research Center, Dunarea de Jos University of Galati, Galati, Romania
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31
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Keegan S, Gravell R, Belfield J, Wiles R. Urological imaging in the pregnant patient. BJU Int 2021; 128:519-522. [PMID: 34581481 DOI: 10.1111/bju.15580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S Keegan
- Liverpool University Hospitals NHS Foundation Trust
| | - R Gravell
- Liverpool University Hospitals NHS Foundation Trust
| | - J Belfield
- Liverpool University Hospitals NHS Foundation Trust
| | - R Wiles
- Liverpool University Hospitals NHS Foundation Trust
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32
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Bocian S, Granato A, Cain M, Friis CM, Loyola M, Robertson L. RADIATION SAFETY IN THE GASTROENTEROLOGY SETTING. Gastroenterol Nurs 2021; 44:368-371. [PMID: 34417405 DOI: 10.1097/sga.0000000000000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Susan Bocian
- Society of Gastroenterology Nurses and Associates, Inc, 330 N Wabash Ave., Suite 2000, Chicago, IL 60611, Tel: 312-321-5165, Fax: 312-673-6694, Online:
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33
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Hiles P. Using patient shielding - What is the risk? THE BRITISH JOURNAL OF RADIOLOGY 2021; 94:20210701. [PMID: 34347543 DOI: 10.1259/bjr.20210701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The practice of placing radiation protective shielding on patients ('in contact') in order to reduce the dose to certain radiosensitive organs for diagnostic X-ray examination, has been employed for decades. However, there has been a growing body of evidence that this practice is often ineffective or even counterproductive and the use of such shielding can also overemphasise the hazards of ionising radiation in the public mind. This has led to a growing disparity in the application of patient contact shielding and culminated in several professional bodies issuing guidance and statements to provide a consistent approach to patient contact shielding. This, in turn, has led to a healthy discussion and re-evaluation of when and why patient contact shielding should be used, where the main issue centres around the criteria used to arrive at the recommendations. The decision process involves considering, among others, the reported effectiveness of the shielding and a subjective assessment of the subsequent risks from their use. In order to improve the transparency of these recommendations, it is therefore suggested that a threshold for dose and/or risk should be clearly stated, below which no protection is required. A suggested starting point for defining this threshold is discussed. This would enhance uniformity of application and provide clarity for staff, patients and the public. It would also ensure that any future research in this area could be easily incorporated into the general guidance.
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Affiliation(s)
- Peter Hiles
- Glan Clwyd Hospital, Bodelwyddan, United Kingdom
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34
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Women's awareness regarding the use of dental imaging during pregnancy. BMC Oral Health 2021; 21:357. [PMID: 34284764 PMCID: PMC8290609 DOI: 10.1186/s12903-021-01726-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/15/2021] [Indexed: 11/14/2022] Open
Abstract
Background There is often anxiety among pregnant women about dental imaging during pregnancy. This may hinder some women from seeking dental treatment during pregnancy and consequently, may negatively affect the oral health of the mother and fetus. This study was conducted to assess women’s awareness regarding the use of dental imaging during pregnancy. Methods In this cross-sectional study, the electronic distribution of structured questionnaires was done via social media. The self-administered questionnaires contained questions related to women’s knowledge regarding the radiation protection measures during dental imaging, the safest period for dental imaging, the type of radiographs that can be acquired during pregnancy, and the possibility of radiation-induced malignancy and fetal malformation as a result of dental imaging. Results In total, 410 completed questionnaires were received and analyzed. More than half of the participants were 30–49 years of age. The majority of the participants (91%) demonstrated poor knowledge concerning dental imaging. Only 4% reported that pregnant women can have dental imaging during any trimester. The majority believed that panoramic images and cone-beam computed tomography should not be acquired during pregnancy. The majority also believed there is a high risk of congenital malformation due to dental imaging and were unsure about the oncogenic risks. Conclusions Our study suggests that there is insufficient knowledge about dental imaging safety during pregnancy. This misconception may have a direct impact on the attitude toward seeking dental care. Therefore, community awareness initiatives aimed at informing our society about radiation exposure, safety, and required protection measures are critical. Supplementary Information The online version contains supplementary material available at 10.1186/s12903-021-01726-6.
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35
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Kaasalainen T, Ekholm M, Siiskonen T, Kortesniemi M. Dental cone beam CT: An updated review. Phys Med 2021; 88:193-217. [PMID: 34284332 DOI: 10.1016/j.ejmp.2021.07.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/16/2021] [Accepted: 07/09/2021] [Indexed: 12/12/2022] Open
Abstract
Cone beam computed tomography (CBCT) is a diverse 3D x-ray imaging technique that has gained significant popularity in dental radiology in the last two decades. CBCT overcomes the limitations of traditional two-dimensional dental imaging and enables accurate depiction of multiplanar details of maxillofacial bony structures and surrounding soft tissues. In this review article, we provide an updated status on dental CBCT imaging and summarise the technical features of currently used CBCT scanner models, extending to recent developments in scanner technology, clinical aspects, and regulatory perspectives on dose optimisation, dosimetry, and diagnostic reference levels. We also consider the outlook of potential techniques along with issues that should be resolved in providing clinically more effective CBCT examinations that are optimised for the benefit of the patient.
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Affiliation(s)
- Touko Kaasalainen
- HUS Diagnostic Center, Radiology, Helsinki University and Helsinki University Hospital, P.O. Box 340, Haartmaninkatu 4, 00290 Helsinki, Finland.
| | - Marja Ekholm
- Institute of Dentistry, University of Turku, Lemminkäisenkatu 2, 20520 Turku, Finland; South West Finland Imaging Center, Turku University Hospital, Lemminkäisenkatu 2, 20520 Turku, Finland
| | - Teemu Siiskonen
- Radiation Practices Regulation, Radiation and Nuclear Safety Authority - STUK, P.O. Box 14, FI-00881 Helsinki, Finland
| | - Mika Kortesniemi
- HUS Diagnostic Center, Radiology, Helsinki University and Helsinki University Hospital, P.O. Box 340, Haartmaninkatu 4, 00290 Helsinki, Finland
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36
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Kosik RO, Quek ST, Kan E, Aoki S, Yang CH, Pongnapang N, Setioko M, Chan WP. APQS consensus regarding patient shielding during routine radiographic imaging. Br J Radiol 2021; 94:20210252. [PMID: 34142869 DOI: 10.1259/bjr.20210252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Shielding, particularly of the gonads, has been a routine part of diagnostic radiographic imaging for many years. However, recent thinking suggests that such shielding may offer little benefit, and in some cases may actually cause harm, e.g. by obscuring anatomy or paradoxically increasing patient radiation dose secondary to the need for repeat imaging. This thinking has led many institutions in the West to abandon routine shielding. However, in Asia, shielding is still commonplace. It was felt that the Asia-Pacific Forum on Quality and Safety in Medical Imaging (APQS) was an ideal place to discuss the merits of shielding and deliver a pan-Asian consensus. The APQS is an annual meeting that convenes radiation safety and imaging quality experts from all of the major Asian regions. During the 2020 APQS meeting, radiation safety experts from each region discussed their opinions of shielding during a dedicated session. These experts' views were mostly in line with the views of Western radiologists. However, important country specific and cultural factors were noted by each of the experts. A pan-Asian consensus was issued by the forum. It is hoped that this consensus will guide the development of future shielding policies throughout Asia.
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Affiliation(s)
- Russell Oliver Kosik
- Departmentof Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Swee-Tian Quek
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Elaine Kan
- Department of Diagnostic Radiology, Hong Kong Children's Hospital, Hong Kong, Hong Kong
| | - Shigeki Aoki
- Department of Radiology, Juntendo University, Tokyo, Japan
| | - Chin Hua Yang
- Department of Radiology, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan.,Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Napapong Pongnapang
- Department of Radiological Technology, Faculty of Medical Technology, Mahidol University, Bangkok, Thailand
| | - Maryastuti Setioko
- Department of Radiology, Persahabatan General Hospital, Jakarta, Indonesia
| | - Wing P Chan
- Departmentof Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Malaiyandi D, James E, Peglar L, Karim N, Henkel N, Guilliams K. Neurocritical Care of the Pregnant Patient. Curr Treat Options Neurol 2021; 23:22. [PMID: 34177249 PMCID: PMC8214980 DOI: 10.1007/s11940-021-00676-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
Purpose of review To summarize recent changes in management and emerging therapies for pregnant neurocritical care patients. Recent findings Diagnostic and treatment options for managing neurologic emergencies in pregnant patients have expanded with both greater understanding of the effects of imaging modalities and medications on pregnancy and application of standard treatments for non-pregnant patients to pregnant populations. Specifically, this includes cerebrovascular diseases (pregnancy-associated ischemic stroke, pregnancy-associated intracerebral hemorrhage, cerebral venous sinus thrombosis), post-maternal cardiac arrest care, seizures and status epilepticus, myasthenia gravis, and fetal somatic support in maternal death by neurologic criteria. Summary With the exception of direct abdominal computed tomography (CT), most imaging studies are reasonably safe in pregnancy. When emergent imaging is needed to prevent maternal morbidity or mortality, any CT sequence with or without contrast is appropriate to pursue. Though new safety data on antiplatelets, antihypertensives, thrombolytics, and antiepileptic drugs have increased options for disease management in pregnancy, unfractionated and low-molecular weight heparin remain the safest options for anticoagulation. Early studies on hypothermia, ketamine, and immunomodulating therapies in pregnancy are promising. In myasthenia gravis, new data on adjunct devices may allow more patients to undergo safe vaginal delivery, avoiding cesarean section and the associated risk of crisis. When difficult decisions regarding preterm delivery arise, recent outcome studies can help inform discussion. Lastly, when the feared complication of maternal death by neurologic criteria occurs, fetal somatic support may help to save at least one life.
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Affiliation(s)
- Deepa Malaiyandi
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,University of Toledo/ProMedica Neurosciences Center, 2130 W Central Ave, Ste. 201, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Elysia James
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Lindsay Peglar
- Department of Neurology, Washington University, St. Louis, MO USA
| | - Nurose Karim
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Nicholas Henkel
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Kristin Guilliams
- Department of Neurology, Washington University, St. Louis, MO USA.,Department of Pediatrics, Washington University, St. Louis, MO USA
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Strax R, Molina E. Discussing X-Ray Shielding With Patients: First Do No Harm. J Am Coll Radiol 2021; 18:1365-1366. [PMID: 34089667 DOI: 10.1016/j.jacr.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/13/2021] [Indexed: 12/01/2022]
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Candela-Juan C, Ciraj-Bjelac O, Sans Merce M, Dabin J, Faj D, Gallagher A, de Las Heras Gala H, Knežević Ž, Malchair F, De Monte F, Simantirakis G, Theodorakou C. Use of out-of-field contact shielding on patients in medical imaging: A review of current guidelines, recommendations and legislative documents. Phys Med 2021; 86:44-56. [PMID: 34052671 DOI: 10.1016/j.ejmp.2021.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/09/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Abstract
The use of patient contact-shielding has become a topic of intensive scientific debate. While it has been common practice during the last decades, some studies have questioned the efficiency of using such shielding while others have highlighted the inconsistencies in its application. The objective of this work is to review current recommendations and legislative documents on the use of out-of-field shielding in X-ray imaging, including those from national authorities and from international and national organisations and professional bodies. The review, performed within the framework of the activities of EURADOS Working Group 12, covers available recommendations on use of contact shielding in adult, pregnant and paediatric patients in general radiography, fluoroscopy, computed tomography, mammography and dental radiology. It includes a comprehensive search of 83 documents from 32 countries and 6 international organisations over the last 39 years. In general, using shielding is recommended only under two conditions: if it does not compromise the diagnostic task and the performance of the procedure and/or if it reassures the patient and comforters that they are appropriately protected against potentially harmful effects of radiation. There are very few specific regulatory requirements to use shielding in a particular imaging modality, although they may consider use of shielding either as part of good radiological practice or as requirements for availability of protective or ancillary tools, without further specification of their use. There is a wide variety of positions among documents that recommend out-of-field shielding, those that do not recommend it and those that are not specific. Therefore, evidence-based consensus is still needed to ensure best and consistent practice.
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Affiliation(s)
- Cristian Candela-Juan
- Centro Nacional de Dosimetría (CND), Instituto Nacional de Gestión Sanitaria, Valencia, Spain.
| | | | - Marta Sans Merce
- University Hospital of Geneva, Geneva, Switzerland; University Hospital of Lausanne, Lausanne, Switzerland
| | - Jérémie Dabin
- Belgian Nuclear Research Centre (SCK CEN), Mol, Belgium
| | - Dario Faj
- Medical Faculty of Osijek, University of Osijek, Croatia; Faculty of Dental Medicine and Health, University of Osijek, Croatia
| | - Aoife Gallagher
- Medical Physics Department, University Hospital Limerick, Ireland
| | | | - Željka Knežević
- Radiation Chemistry and Dosimetry Laboratory, Ruđer Bošković Institute, Zagreb, Croatia
| | | | - Francesca De Monte
- Medical Physics Department, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - George Simantirakis
- Licensing and Inspections Department, Greek Atomic Energy Commission, Ag. Paraskevi, Greece
| | - Chrysoula Theodorakou
- Christie Medical Physics and Engineering, The Christie NHS Foundation, Manchester, UK
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Frush DP, Sorantin E. Radiation use in diagnostic imaging in children: approaching the value of the pediatric radiology community. Pediatr Radiol 2021; 51:532-543. [PMID: 33743037 DOI: 10.1007/s00247-020-04924-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 08/19/2020] [Accepted: 11/30/2020] [Indexed: 01/15/2023]
Abstract
Medical imaging is foundational in the care of children, and much of the medical imaging province depends on ionizing radiation: radiography, fluoroscopy, CT and nuclear imaging. Many considerations for this imaging in children are distinct in the domains of appropriate radiation use, other factors that determine examination quality, the opportunities to engage and educate through networking, and the translation of research efforts. Given these needs, it is worth approaching the contributions and their impact by the pediatric radiology community, especially to the enhancement of this value in the care of children.
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Affiliation(s)
- Donald P Frush
- Pediatric Radiology, Duke University Medical Center, Room #2568, 40 Duke Medicine Circle, Red Zone, Duke South Box 3808, Durham, NC, 27710, USA.
| | - Erich Sorantin
- Division of Pediatric Radiology, Department of Radiology, Medical University Graz, Graz, Austria
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41
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Nguyen ET, Hague C, Manos D, Memauri B, Souza C, Taylor J, Dennie C. Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 1: Acquisition and Safety Considerations. Can Assoc Radiol J 2021; 73:203-213. [PMID: 33781098 DOI: 10.1177/08465371211000737] [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] [Indexed: 11/15/2022] Open
Abstract
Acute pulmonary embolism (APE) is a well-recognized cause of circulatory system compromise and even demise which can frequently present a diagnostic challenge for the physician. The diagnostic challenge is primarily due to the frequency of indeterminate presentations as well as several other conditions which can have a similar clinical presentation. This often obliges the physician to establish a firm diagnosis due to the potentially serious outcomes related to this disease. Computed tomography pulmonary angiography (CTPA) has increasingly cemented its role as the primary investigation tool in this clinical context and is widely accepted as the standard of care due to several desired attributes which include great accuracy, accessibility, rapid turn-around time and the ability to suggest an alternate diagnosis when APE is not the culprit. In Part 1 of this guidance document, a series of up-to-date recommendations are provided to the reader pertaining to CTPA protocol optimization (including scan range, radiation and intravenous contrast dose), safety measures including the departure from breast and gonadal shielding, population-specific scenarios (pregnancy and early post-partum) and consideration of alternate diagnostic techniques when clinically deemed appropriate.
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Affiliation(s)
- Elsie T Nguyen
- Department of Radiology, Joint Department of Medical Imaging, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Cameron Hague
- Department of Radiology, University of British Columbia, Ontario, Canada
| | - Daria Manos
- Department of Diagnostic Radiology, Dalhousie University, Ontario, Canada
| | - Brett Memauri
- Department of Radiology, University of Manitoba, Cardiothoracic Sciences Division, St. Boniface General Hospital, Ontario, Canada
| | - Carolina Souza
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Jana Taylor
- Department of Radiology, McGill University Health Centre, Ontario, Canada
| | - Carole Dennie
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ontario, Canada.,Department of Radiology, University of Ottawa, Ottawa Hospital Research Institute, Ontario, Canada
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McEvoy-May JH, Bihari S, Hooker AM, Dixon DL. A retrospective audit of cumulative ionising radiation levels in hospitalised pregnant patients. Aust N Z J Obstet Gynaecol 2021; 61:700-707. [PMID: 33772762 DOI: 10.1111/ajo.13336] [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: 08/20/2020] [Accepted: 02/05/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Among hospitalised patients, diagnostic radiation is possibly used least on pregnant patients due to the fear of ionising radiation on the fetus; however, what levels are currently being prescribed? AIMS To assess the cumulative levels of ionising radiation received by pregnant patients during a single admission to a tertiary hospital. MATERIALS AND METHODS A retrospective audit of pregnant patients admitted to Flinders Medical Centre, South Australia, Australia, between 2013 and 2017 inclusive was performed. All procedures utilising ionising radiation were collected including conventional radiology, computed tomography, fluoroscopy and nuclear medicine. Individual and cumulative effective doses for mother and fetus were calculated using patient dose reports and published conversion factors. RESULTS From 547 patients, the median cumulative effective dose was 0.02 mSv and only five patients received more than 10 mSv, with 19.07 mSv the highest dose received. The median fetal cumulative effective dose was 0.01 mSv but only three fetuses received more than 10 mSv, likely due to fetal exclusion in some procedural fields of view. Stays longer than ten days were associated with significantly higher cumulative effective dose, as did those with maternal cardiovascular related admission, for both maternal and fetal exposures. CONCLUSION These results suggest that pregnant patients are exposed to low doses of ionising radiation, in both individual procedures and cumulative doses. The detrimental risks associated with these levels of ionising radiation are not overt and so clinicians should question which risk is higher, the ionising radiation from the radiological procedures received or the lack of diagnostic information if avoided?
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Affiliation(s)
- James H McEvoy-May
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Department of Biology, McMaster University, Hamilton, Ontario, Canada.,Centre for Radiation Research, Education and Innovation, University of Adelaide, Adelaide, South Australia, Australia
| | - Shailesh Bihari
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Antony M Hooker
- Centre for Radiation Research, Education and Innovation, University of Adelaide, Adelaide, South Australia, Australia
| | - Dani-Louise Dixon
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
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43
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Vandecaveye V, Amant F, Lecouvet F, Van Calsteren K, Dresen RC. Imaging modalities in pregnant cancer patients. Int J Gynecol Cancer 2021; 31:423-431. [PMID: 33649009 PMCID: PMC7925814 DOI: 10.1136/ijgc-2020-001779] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022] Open
Abstract
Cancer during pregnancy is increasingly diagnosed due to the trend of delaying pregnancy to a later age and probably also because of increased use of non-invasive prenatal testing for fetal aneuploidy screening with incidental finding of maternal cancer. Pregnant women pose higher challenges in imaging, diagnosis, and staging of cancer. Physiological tissue changes related to pregnancy makes image interpretation more difficult. Moreover, uncertainty about the safety of imaging modalities, fear of (unnecessary) fetal radiation, and lack of standardized imaging protocols may result in underutilization of the necessary imaging tests resulting in suboptimal staging. Due to the absence of radiation exposure, ultrasound and MRI are obvious first-line imaging modalities for detailed locoregional disease assessment. MRI has the added advantage of a more reproducible comprehensive organ or body region assessment, the ability of distant staging through whole-body evaluation, and the combination of anatomical and functional information by diffusion-weighted imaging which obviates the need for a gadolinium-based contrast-agent. Imaging modalities with inherent radiation exposure such as CT and nuclear imaging should only be performed when the maternal benefit outweighs fetal risk. The cumulative radiation exposure should not exceed the fetal radiation threshold of 100 mGy. Imaging should only be performed when necessary for diagnosis and likely to guide or change management. Radiologists play an important role in the multidisciplinary team in order to select the most optimal imaging strategies that balance maternal benefit with fetal risk and that are most likely to guide treatment decisions. Our aim is to provide an overview of possibilities and concerns in current clinical applications and developments in the imaging of patients with cancer during pregnancy.
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Affiliation(s)
- Vincent Vandecaveye
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium .,Department of Imaging & Pathology, KU Leuven, Leuven, Belgium
| | - Frédéric Amant
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium.,Center for Gynecological Oncology, Academic Medical Centre Amsterdam-University of Amsterdam and The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Frédéric Lecouvet
- Department of Radiology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Kristel Van Calsteren
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Raphaëla Carmen Dresen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium.,Department of Imaging & Pathology, KU Leuven, Leuven, Belgium
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Perceptions of radiographers regarding establishing a self-regulatory body for radiation safety in Eswatini. Radiography (Lond) 2020; 27:627-632. [PMID: 33349548 DOI: 10.1016/j.radi.2020.12.001] [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: 06/21/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Eswatini remains one of the countries in Southern Africa without a regulating authority for radiation safety in the radiography departments. Quality control (QC) tests and radiation protection practices are unmonitored. This study sought to explore radiographers' perceptions regarding establishing a self-regulatory body that will formulate, implement and monitor compliance of standardised guidelines for radiation safety. METHODS A qualitative, exploratory and descriptive research approach was undertaken. Radiographers currently registered and practicing in Eswatini were purposively selected and invited to participate. Data was collected using semi-structured interviews. Audiotapes and field notes were used. Audio taped interviews were transcribed verbatim and then analyzed using qualitative content analysis. RESULTS Six themes emerged from the analysis of data, namely; a) awareness of the need for QC tests, b) radiation protection and safety in the radiography departments, c) radiographers' responsibility towards radiation protection, d) education and training in radiation safety for radiographers and other stakeholders, e) support from governmental and management structures and f) the need for the self-regulatory body in the radiography departments. CONCLUSION The study demonstrated that there is awareness among radiographers in Eswatini that radiation safety practices are necessary in the radiography departments. Continuous education and training were deemed as imperative to improve radiation safety in the radiography departments. There is also support for the idea of establishing the self-regulatory body. IMPLICATIONS FOR PRACTICE The need for monitoring structures in order to ensure radiation safety in the radiography departments is highlighted in this study. Government officials and hospital management are crucial in ensuring radiation safety in radiography departments.
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Lawson M, Kuganesan A, Parry G, Badawy MK. THE EFFICACY OF RADPAD AS A RADIATION PROTECTION TOOL IN CT FLUOROSCOPY GUIDED LUNG BIOPSIES. RADIATION PROTECTION DOSIMETRY 2020; 191:328-334. [PMID: 33120428 DOI: 10.1093/rpd/ncaa169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 08/04/2020] [Accepted: 09/29/2020] [Indexed: 06/11/2023]
Abstract
Computed tomography fluoroscopy is now the preferred technique for percutaneous lung biopsies. However, concern regarding operator and patient radiation dose remains, which warrants further exploration into dose optimisation tools. This phantom-study aims to assess the dose reduction capabilities of RADPAD, a single-use patient drape designed to decrease staff exposure to scattered radiation. Dosemeters at the waist and eye levels were used to determine the whole-body and lens exposure during simulated lung biopsy procedures while using RADPAD and other combinations of personal protective equipment. RADPAD resulted in a 36% and 38% dose reduction for whole-body and eye exposure, respectively. However, when used in combination with radioprotective eyewear and aprons, RADPAD did not reduce the radiation dose further. Consequently, the use of standard personal protective equipment is a more cost-effective option for staff dose reduction. RADPAD is useful in the reduction of radiation dose to unprotected regions.
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Affiliation(s)
- Michael Lawson
- Monash Imaging, Monash Health, Clayton, VIC 3168, Australia
| | | | - Georgia Parry
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
| | - Mohamed Khaldoun Badawy
- Monash Imaging, Monash Health, Clayton, VIC 3168, Australia
- Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3800, Australia
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F Z, C A, H S, Y I, Z A, Y K. Effect of Silicone Rubber-Lead (SR-Pb) Thickness on Dose Reduction and Image Quality as Gonad Shield. J Biomed Phys Eng 2020; 10:699-706. [PMID: 33364207 PMCID: PMC7753262 DOI: 10.31661/jbpe.v0i0.1912-1007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Some organs in the body are sensitive to radiation such as eyes, breast, and gonads. Protection of sensitive organs against radiation is necessary. Recently, many sensitive organ shields have been developed from different materials. OBJECTIVE The aim of this study is to evaluate the dose reduction and image quality from implementation of Silicone Rubber-Lead (SR-Pb) as an alternative gonad shield in digital radiography (DR). MATERIAL AND METHODS In this experimental study, the SR-Pb gonad shields with various thicknesses of 2, 4, 6, 8, and 10 mm were synthesized. This study used the Pb percentage of 5 wt%. An anthropomorphic phantom was used in abdomen plain examinations. The results obtained from the use of the SR-Pb was compared with standard gonad shield, i.e. lead apron. To measure the dose reduction, the Piranha detector was used. The image quality assessment was evaluated with the signal-to-noise ratio (SNR) and the contrast-to-noise ratio (CNR). RESULTS This study showed the dose reduction was significant for all SR-Pb thicknesses, and incrementally increased with the increase of the SR-Pb thickness. The minimum and maximum of dose reduction were 22.8% for 2 mm and 66.9% for 10 mm SR-Pb, respectively. CONCLUSION Compared to the reference image without gonad shield, the SNR and CNR do not significantly change. Hence, the SR-Pb is probably to be used as an alternative gonad shield.
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Affiliation(s)
- Zahroh F
- MSc, Department of Physics, Faculty of Sciences and Mathematics, Diponegoro University, Semarang, Indonesia
- MSc, Smart Material Research Center (SMARC), Diponegoro University, Semarang, Indonesia
| | - Anam C
- PhD, Department of Physics, Faculty of Sciences and Mathematics, Diponegoro University, Semarang, Indonesia
| | - Sutanto H
- PhD, Department of Physics, Faculty of Sciences and Mathematics, Diponegoro University, Semarang, Indonesia
- PhD, Smart Material Research Center (SMARC), Diponegoro University, Semarang, Indonesia
| | - Irdawati Y
- MSc, Department of Physics, Faculty of Sciences and Mathematics, Diponegoro University, Semarang, Indonesia
- MSc, Smart Material Research Center (SMARC), Diponegoro University, Semarang, Indonesia
| | - Arifin Z
- MSc, Department of Physics, Faculty of Sciences and Mathematics, Diponegoro University, Semarang, Indonesia
| | - Kartikasari Y
- MSc, Health Polytechnic of Semarang, Ministry of Health, Indonesia
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Vogel E, Leaver T, Wall F, Johnson B, Uglow M, Aarvold A. Repeated Pelvic Radiographs in Infants, After Harness Treatment for Developmental Dysplasia of the Hip, Carry Very Low Radiation Risk. Indian J Orthop 2020; 55:1543-1548. [PMID: 34987727 PMCID: PMC8688633 DOI: 10.1007/s43465-021-00438-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/02/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE There are no data on the effect of X-Ray irradiation to the vulnerable pelvic organs of babies during DDH follow-up. This study aims to calculate, for the first time, the radiation exposure to infants during follow-up for DDH harness treatment, and thus quantify the lifetime risk of malignancy. METHODS Patients who had completed 5 years' follow-up following successful Pavlik harness treatment were identified from the hospital DDH database. The radiation dose was extracted from the Computerised Radiology Information System database for every radiograph of every patient. The effective dose (ED) was calculated using conversion coefficients for age, sex and body region irradiated. Cumulative ED was compared to Health Protection Agency standards to calculate lifetime risk of malignancy from the radiographs. RESULTS All radiographs of 40 infants, successfully treated in Pavlik harness for DDH, were assessed. The mean number of AP pelvis radiographs was 7.00 (range: 6-9, mode: 7). The mean cumulative ED was 0.25 mSv (Range: 0.11-0.46, SD: 0.07). This is far lower than the annual 'safe' limit for healthcare workers of 20 mSv and is categorised as "Very Low Risk". CONCLUSION Clinicians involved in the treatment DDH can be re-assured that the cumulative radiation exposure from pelvic radiographs following Pavlik harness treatment is "Very Low Risk". Whilst being mindful of any radiation exposure in children, this study provides a scientific answer that help addresses parental concerns.
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Affiliation(s)
- Elizabeth Vogel
- Southampton Medical School, Southampton University, Southampton, UK
| | - Thomas Leaver
- Southampton Medical School, Southampton University, Southampton, UK
| | - Fiona Wall
- Medical Physics Department, University Hospital Southampton, Southampton, UK
| | - Ben Johnson
- Medical Physics Department, University Hospital Southampton, Southampton, UK
| | - Michael Uglow
- Paediatric Orthopaedics, Southampton Children’s Hospital, Southampton, UK
| | - Alexander Aarvold
- Southampton Medical School, Southampton University, Southampton, UK
- Paediatric Orthopaedics, Southampton Children’s Hospital, Southampton, UK
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48
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Contemporary radiation protection in dentistry: Recommendations of National Council on Radiation Protection and Measurements Report No. 177. J Am Dent Assoc 2020; 151:716-719.e3. [PMID: 32979944 DOI: 10.1016/j.adaj.2020.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/06/2020] [Accepted: 05/06/2020] [Indexed: 01/01/2023]
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49
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Somasundaram E, Brady SL, Strauss KJ. Achievable dose reductions with gonadal shielding for children and adults during abdominal/pelvic radiographic examinations: A Monte Carlo simulation. Med Phys 2020; 47:5514-5522. [PMID: 32978986 DOI: 10.1002/mp.14495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 09/04/2020] [Accepted: 09/06/2020] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Recently, medical professionals have reconsidered the practice of routine gonadal shielding for radiographic examinations. The objective of this study was to evaluate the gonadal dose reduction achievable with gonadal shields in the primary beam during abdominal/pelvic radiographic examinations under ideal and non-ideal shielding placement. METHODS CT scans of CIRS anthropomorphic phantoms were used to perform voxelized Monte Carlo simulations of the photon transport during abdominal/pelvic radiographic examinations with standard filtration and 0.1 mm Cu + 1 mm Al added filtration to estimate gonadal doses for an adult, 5 yr old, and newborn phantom with and without gonadal shields. The reduction in dose when the shields were not placed at the ideal locations was also evaluated. The ratio of the number of scattered-to-primary photons (SPR) across the anteroposterior (AP) dimension of the phantoms was also reported. RESULTS The simulated dose reduction with ideal shielding placement for the testes and ovaries ranged from 80% to 90% and 55% to 70% respectively. For children, a misalignment of the shield to the gonad of 4 cm reduced the measured dose reduction to the gonads to <10%. For adults, this effect did not occur until the misalignment increased to ~6 cm. Effects of dose reduction with and without the gonadal shields properly placed were similar for standard filtration and added filtration. SPR at the level of the testes was consistently <1 for all phantoms. SPR for ovaries was ~1.5 for the adult and 5-yr old, and ~1 for the newborn phantom. CONCLUSION Dose reduction with ideal alignment of the simulated gonadal shield to the gonads in this study was greater for the testes than the ovaries; both reductions were substantial. However, the dose reductions were greatly reduced (to <10%) for both sexes with misalignment of the gonads to the shields by 4 cm for children and 6 cm for adults.
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Affiliation(s)
- Elanchezhian Somasundaram
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Samuel L Brady
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Keith J Strauss
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Trožić Š, Mekiš N, Zalokar N. The efficiency of lead and non-lead shielding on breast dose in head CT. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2020; 40:816-826. [PMID: 32460255 DOI: 10.1088/1361-6498/ab96d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The aim of the study was to assess the effect of the shielding material and its thickness on the measured skin dose to the breasts during the CT examination of the head. The helical and axial head CT was performed on an anthropomorphic phantom (PBU 60). Two types of shielding were tested-lead and non-lead (antimony-bismuth) shielding. Measurements with different thicknesses were performed and the shielding efficiency of the materials was compared. Skin dose to the breasts was measured with an educational direct dosimeter (EDD-30). The shielding efficiency during both scanning protocols indicated an increased dose reduction with the thicker equivalent thickness in both shielding materials. Dose reduction was the highest at 0.5 mm equivalent thickness for both materials; lead shielding reduced the dose by 91% and 83%, the antimony-bismuth shielding by 90% and 86%, during the axial and helical head CT protocols, respectively. Statistically significant differences were found between the materials of the same equivalent thickness (0.175, 0.25 and 0.5 mm) during the helical protocol in favor of the antimony-bismuth shielding. During the axial protocol there were no statistically significant differences. Shielding of radiosensitive organs can prevent unnecessary exposure of radiosensitive organs outside the primary beam. Due to the significant decrease in radiation dose to the breasts, and many other positive attributes, use of the antimony-bismuth shielding instead of the lead shielding should be considered, especially during the helical CT scan of the head.
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Affiliation(s)
- Šejla Trožić
- Faculty of Health Sciences, Medical Imaging and Radiotherapy Department, University of Ljubljana, Zdravstvena pot 5, Ljubljana 1000, Slovenia
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