Notwithstanding that 100 mSv is not a threshold for radiation effects, cumulative effective dose (CED) for patients of ≥100 mSv derived from recurrent imaging procedures with ionising radiation has ...been recently the topic of several publications. The International Commission on Radiological Protection has alerted on the problems to use effective dose for risk estimation in individual patients but has accepted to use this quantity for comparison the relative radiation risks between different imaging modalities. A new International Commission on Radiological Protection document on the use of effective dose (including medicine), is in preparation. Recently published data on the number of patients with CED ≥100 mSv ranged from 0.6 to 3.4% in CT and around 4% in interventional radiology. The challenges to manage the existing situation are summarised. The main aspects identified are: 1) New technology with dose reduction techniques. 2) Refinements in the application of the justification and optimisation for these groups of patients. 3) Patient dose management systems with alerts on the cumulative high doses. 4) Education on the proper use of cumulative effective dose for referrers and practitioners including information for patients. 5) Future research programmes in radiation biology and epidemiology may profit the patient dose data from the groups with high cumulative dose values.
In recent years, the issue of cumulative effective dose received from recurrent computed tomography examinations has become a subject of increasing concern internationally. Evidence, predominantly ...from the USA, has shown that a significant number of patients receive a cumulative effective dose of 100 mSv or greater. To obtain a European perspective, EuroSafe Imaging carried out a survey to collect European data on cumulative radiation exposure of patients from recurrent computed tomography examinations. The survey found that a relatively low percentage of patients (0.5%) received a cumulative effective dose equal to or higher than 100 mSv from computed tomography, most of them having an oncological disease. However, there is considerable variation between institutions as these values ranged from 0 to 2.72%, highlighting that local practice or, depending on the institution and its medical focus, local patient conditions are likely to be a significant factor in the levels of cumulative effective dose received, rather than this simply being a global phenomenon. This paper also provides some practical actions to support the management of cumulative effective dose and to refine or improve practice where recurrent examinations are required. These actions are focused around increasing awareness of referring physicians through encouraging local dialogue, actions focused on optimisation where a team approach is critical, better use of modern equipment and the use of Dose Management and Clinical Decision Support Systems together with focused clinical audits. The proper use of cumulative effective dose should be part of training programmes for referrers and practitioners, including what information to give to patients.
Patient summary
Radiation is used to the benefit of patients in diagnostic procedures such as CT examinations, and in therapeutic procedures like the external radiation treatment for cancer. However, radiation is also known to increase the risk of cancer. To oversee this risk, the cumulative effective dose (CED) received by a patient from imaging procedures over his or her life is important. In this paper, the authors, on behalf of EuroSafe Imaging, report on a survey carried out in Europe that aims to estimate the proportion of patients that undergo CT examinations and are exposed to a CED of more than 100 mSv. At the same time, the survey enquires about and underlines radiologists’ measures and radiology departments’ strategies to limit such exposure. Over the period of 2015–2018, respondents reported that 0.5% (0–2.72%) of patients were exposed to a CED of ≥ 100 mSv from imaging procedures. The background radiation dose in Europe depends on the location, but it is around 2.5 mSv per year. It is obvious that patients with cancer, chronic diseases and trauma run the highest risk of having a high CED. However, even if the number of patients exposed to ≥ 100 mSv is relatively low, it is important to lower this number even further. Measures could consist in using procedures that do not necessitate radiation, using very low dose procedures, being very critical in requiring imaging procedures and increasing awareness about the issue.
Key Points
• A relatively low percentage of patients (0.5%) received a cumulative effective dose from CT computed tomography equal to or greater than 100 mSv, in Europe, most of them having an oncological disease.
• There is a wide range in the number of patients who receive cumulative effective dose equal to or greater than 100 mSv (0–2.72%) and optimisation should be improved.
• Increasing the awareness of referring physicians through encouraging local dialogue, concrete actions focused on optimisation and development of dose management systems is suggested.
Get Protected! Recommendations for Staff in IR Bartal, Gabriel; Vano, Eliseo; Paulo, Graciano
CardioVascular and Interventional Radiology,
06/2021, Letnik:
44, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Purpose
Evaluation and registration of patient and staff doses are mandatory under the current European legislation, and the occupational dose limits recommended by the ICRP have been adopted by most ...of the countries in the world.
Methods
Relevant documents and guidelines published by international organisations and interventional radiology societies are referred. Any potential reduction of patient and staff doses should be compatible with the clinical outcomes of the procedures.
Results
The review summarises the most common protective measures and the needed quality control for them, the criteria to select the appropriate protection devices, and how to avoid unnecessary occupational radiation exposures. Moreover, the current and future advancements in personnel radiation protection using medical simulation with virtual and augmented reality, robotics, and artificial intelligence (AI) are commented. A section on the personnel radiation protection in the era of COVID-19 is introduced, showing the expanding role of the interventional radiology during the pandemic.
Conclusion
The review is completed with a summary of the main factors to be considered in the selection of the appropriate radiation protection tools and practical advices to improve the protection of the staff.
The benefits of fluoroscopically guided interventional procedures are significant and have established new standards in the clinical management of many diseases. Despite the benefits, it is known ...that they come with known risks, such as the exposure to ionizing radiation. To minimize such risks, it is crucial that the health professionals involved in the procedures have a common understanding of the concepts related to radiation protection, such as dose descriptors, diagnostic reference levels and typical dose values. An update about these concepts will be presented with the objective to raise awareness amongst health professionals and contribute to the increase in knowledge, skills and competences in radiation protection in fluoroscopically guided interventional procedures.
To estimate ocular radiation doses and prevalence of lens opacities in a group of interventional catheterization professionals and offer practical recommendations based on these findings to avoid ...future lens damage.
Subjects included 58 physicians and 69 nurses and technicians attending an interventional cardiology congress and appropriate unexposed age-matched controls. Lens dose estimates were derived from combining experimental measurements in catheterization laboratories with questionnaire responses regarding workload, types of procedures, and use of eye protection. Lens opacities were observed by dilated slit lamp examination using indirect illumination and retroillumination. The frequency and severity of posterior lens changes were compared between the exposed and unexposed groups. The severity of posterior lens changes was correlated with cumulative eye dose.
Posterior subcapsular lens changes characteristic of ionizing radiation exposure were found in 50% of interventional cardiologists and 41% of nurses and technicians compared with findings of similar lens changes in<10% of controls. Estimated cumulative eye doses ranged from 0.1-18.9 Sv. Most lens injuries result after several years of work without eye protection.
A high prevalence of lens changes likely induced by radiation exposure in the study population suggests an urgent need for improved radiation safety and training, use of eye protection during catheterization procedures, and improved occupational dosimetry.
The "radiation issue" is the need to consider possible deterministic effects (e.g., skin injuries) and long-term cancer risks due to ionizing radiation in the risk-benefit assessment of diagnostic or ...therapeutic testing. Although there are currently no data showing that high-dose medical studies have actually increased the incidence of cancer, the "linear-no threshold" model in radioprotection assumes that no safe dose exists; all doses add up in determining cancer risks; and the risk increases linearly with increasing radiation dose. The possibility of deterministic effects should also be considered when skin or lens doses may be over the threshold. Cardiologists have a special mission to avoid unjustified or non-optimized use of radiation, since they are responsible for 45% of the entire cumulative effective dose of 3.0 mSv (similar to the radiological risk of 150 chest x-rays) per head per year to the US population from all medical sources except radiotherapy. In addition, interventional cardiologists have an exposure per head per year two to three times higher than that of radiologists. The most active and experienced interventional cardiologists in high volume cath labs have an annual exposure equivalent to around 5 mSv per head and a professional lifetime attributable to excess cancer risk on the order of magnitude of 1 in 100. Cardiologists are the contemporary radiologists but sometimes imperfectly aware of the radiological dose of the examination they prescribe or practice, which can range from the equivalent of 1-60 mSv around a reference dose average of 10-15 mSv for a percutaneous coronary intervention, a cardiac radiofrequency ablation, a multi-detector coronary angiography, or a myocardial perfusion imaging scintigraphy. A good cardiologist cannot be afraid of life-saving radiation, but must be afraid of radiation unawareness and negligence.
Over recent years, an increasing number of fluoroscopically guided interventions (FGIs) have been performed by radiologists and non-radiologists. Also, the number of complex interventional procedures ...has increased. In the late nineties, first reports of skin injuries appeared in the literature. The medical community responded through increased awareness for radiation protection and public authorities by recommendations and legislation, for example, the European Basic Safety Standards (EU-BSS) which were published in 2014, or the international Basic Safety Standards (BSS). Implementation of the EU-BSS requires concerted action from interventionalists, radiographers, medical physics experts and competent national authorities. Interventionalists should play an important role in this project since implementation of the EU-BSS will affect their daily practice. This paper discusses some important issues of the EU-BSS such as unintended and accidental radiation exposures of patients, the meaning of significant dose events and how to deal with patients who were exposed to a substantial radiation dose with the risk of tissue injuries. In addition, this paper provides practical advice on how to implement alert and trigger levels in daily practice of FGIs in order to increase patient safety.
The benefits of cardiac imaging are immense, and modern medicine requires the extensive and versatile use of a variety of cardiac imaging techniques. Cardiologists are responsible for a large part of ...the radiation exposures every person gets per year from all medical sources. Therefore, they have a particular responsibility to avoid unjustified and non-optimized use of radiation, but sometimes are imperfectly aware of the radiological dose of the examination they prescribe or practice. This position paper aims to summarize the current knowledge on radiation effective doses (and risks) related to cardiac imaging procedures. We have reviewed the literature on radiation doses, which can range from the equivalent of 1-60 milliSievert (mSv) around a reference dose average of 15 mSv (corresponding to 750 chest X-rays) for a percutaneous coronary intervention, a cardiac radiofrequency ablation, a multidetector coronary angiography, or a myocardial perfusion imaging scintigraphy. We provide a European perspective on the best way to play an active role in implementing into clinical practice the key principle of radiation protection that: 'each patient should get the right imaging exam, at the right time, with the right radiation dose'.
This review aims to furnish an updated assessment of the societal healthcare load, including cancer and cardiovascular disease resulting from diagnostic radiologic operations. The previously ...projected additional cancer risk of 0.9% in a United States 2004 study referred to radiological conditions in 1996 with an X-ray exposure of 0.50 millisievert (mSv) per capita annually. Radiological exposure (radiology + nuclear medicine) has escalated to 2.29 mSv (2016) per capita per year. Low-dose exposures were previously assumed to have a lower biological impact, since they allow the DNA repair system to mitigate molecular damage. However, epidemiological data matured and disproved this assumption, as shown by updated cancer risk assessments derived from the World Health Organization 2013 and the German Institute of Radioprotection 2014 data. The risk of cardiovascular disease aligns within the same order of magnitude as cancer risk and compounds it, as shown by a comprehensive meta-analysis of 93 studies. The collective societal burden arising from the augmented risks of cancer and cardiovascular disease attributable to diagnostic radiology and nuclear medicine is higher than previously thought.
According to a fundamental law of radiobiology ("Law of Bergonié and Tribondeau", 1906), the brain is a paradigm of a highly differentiated organ with low mitotic activity, and is thus ...radio-resistant. This assumption has been challenged by recent evidence discussed in the present review.
Ionizing radiation is an established environmental cause of brain cancer. Although direct evidence is lacking in contemporary fluoroscopy due to obvious sample size limitation, limited follow-up time and lack of focused research, anecdotal reports of clusters have appeared in the literature, raising the suspicion that brain cancer may be a professional disease of interventional cardiologists. In addition, although terminally differentiated neurons have reduced or mild proliferative capacity, and are therefore not regarded as critical radiation targets, adult neurogenesis occurs in the dentate gyrus of the hippocampus and the olfactory bulb, and is important for mood, learning/memory and normal olfactory function, whose impairment is a recognized early biomarker of neurodegenerative diseases. The head doses involved in radiotherapy are high, usually above 2 Sv, whereas the low-dose range of professional exposure typically involves lifetime cumulative whole-body exposure in the low-dose range of < 200 mSv, but with head exposure which may (in absence of protection) arrive at a head equivalent dose of 1 to 3 Sv after a professional lifetime (corresponding to a brain equivalent dose around 500 mSv).
At this point, a systematic assessment of brain (cancer and non-cancer) effects of chronic low-dose radiation exposure in interventional cardiologists and staff is needed.
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