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Be Your Own Advocate: Understanding Ionizing Radiation and Exposure from Medical Imaging

Joy Yvette Payne, PhD Student Walden University PUBH 8165-1 Dr. Robert Marino Fall, 2011. Be Your Own Advocate: Understanding Ionizing Radiation and Exposure from Medical Imaging. Objectives. At the end of this presentation you will be able to: . Introduction.

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Be Your Own Advocate: Understanding Ionizing Radiation and Exposure from Medical Imaging

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  1. Joy Yvette Payne, PhD Student Walden UniversityPUBH 8165-1 Dr. Robert Marino Fall, 2011 Be Your Own Advocate:Understanding Ionizing Radiation and Exposure from Medical Imaging

  2. Objectives At the end of this presentation you will be able to:

  3. Introduction Natural News. (2010). Use of high-radiation CT scans in emergency rooms triples over nine years. Retrieved October 20, 2011 from http://www.naturalnews.com/030776_CT_scans_radiation.html New York Timers. (2010). Radiation, Risks Are Focus of Breast Screening Study. Retrieved October 21, 2011 from http://www.nytimes.com/2010/08/24/science/24breast.html USA Today. (2010). Cancer risks prompt doctors to try to lower imaging scan radiation. Retrieved October 21, 2011 from http://www.usatoday.com/news/health/2010-05-05-radiation05_st_N.htm

  4. Paper Energy Concrete Foil Alpha Low Beta Medium Gamma High Radiation Waves Penetration Power U.S. Environmental Protection Agency (EPA). (2011e) . Why are some atoms Radioactive. Retrieved October 13, 2011 from http://www.epa.gov/rpdweb00/understand/radiation.html

  5. Common Radiation Units and Symbol • Sievert (Sv)1 – unit of equivalent dose (international) • 1 Sv = 100 rem (0.001 Sv = 1mSv) • Rem1 - US unit of measurement • Millirem (mrem) = 1/1000 of a rem • Gray (Gy) 1 – unit of absorbed dose (international) • Used to describe radiation treatment dose • Rad1 – US unit of absorbed dose • 1 Gy = 100 rad Tri-foil2 1. U.S. Environmental Protection Agency (EPA). (2011a). Radiation Protection Basics. Retrieved October 7, 2011 from http://www.epa.gov/radiation/understand/protection_basics.html 2..U. S. Environmental Protection Agency (EPA). (2011d). Radiation Protection. Radiation Symbols. Retrieved October 7, 2011 from http://www.epa.gov/rpdweb00/understand/symbols.html

  6. Exposure Limits and Averages U.S. Environmental Protection Agency (EPA) U.S. Nuclear Regulatory Commission (NRC) Average Annual Dose Natural Sources 310 mrem Average Annual Dose All Sources 620 mrem U.S. Environmental Protection Agency (EPA). (2007). Radiation Risks and Realities. Retrieved October 7, 2011 from http://epa.gov/radiation/docs/402-k-07-006.pdf U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 14, 2011 from http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/bio-effects-radiation.html

  7. Biological Effects of Radiation Outcomes of living cells: • Cells die and replace themselves (normal process) • Cells repair themselves - no left-over damage • Cells incorrectly repair themselves – biophysical changes Doses around 1 Sievert (Sv) may lead to heart disease, stroke, digestive disorders and respiratory disease. The exact effects of the cumulative health effects of exposure to ionizing radiation are difficult to determine. U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/bio-effects-radiation.html

  8. Health Effects Based on Acute Exposure U.S. Environmental Protection Agency (EPA). (2011c). Radiation Protection. Health Effects. Retrieved October 1, 2011 from http://epa.gov/radiation/understand/health_effects.html

  9. Estimated Health Effects of Radiationin Pregnancy • Increased Cancer Risk • Depends on amount of radiation and amount of time exposed • If acute exposure = to 500 Chest X rays, increased risk about 2% • Other health effects are unlikely when the dose to the fetus is very low • During 1st two weeks of pregnancy – greatest concern is death • Weeks 2-18 – birth defects, especially mental retardation • If 1000 fetuses exposed to 1 rem radiation 1 to 4 would be born with mental retardation • Week 18 to birth – unlikely effects, unless dose is very high • Genetic mutations – both parents exposed to 1 rem of radiation • In 1 million births, 50 severe hereditary effects expected • Compared to 100,000 other cases of genetic defects Centers for Disease Control and Protection (CDC). (2011). Emergency Preparedness and Response. Radiation and Pregnancy: A Fact Sheet. Retrieved October 3, 2011 from http://www.bt.cdc.gov/radiation/prenatal.asp U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/bio-effects-radiation.html

  10. Estimated Health Effects of Exposure toIonizing Radiation – Lifetime Exposure Cancer – increased risk of developing cancer with increasing doses of radiation • 10,000 people exposed to 1 rem in small doses over their lifetime • 2000 non-radiation deaths expected (baseline) • 5 or 6 radiation deaths would occur • Indistinguishable from cancer from other causes • Normal exposure to background radiation per year is 3/10 of a rem (300mrem) • Cancers do not appear until many years after the radiation has been received U. S. Environmental Protection Agency (EPA). (2007). Radiation Risks and Realities. Retrieved October 7, 2011 from http://epa.gov/radiation/docs/402-k-07-006.pdf U.S. Nuclear Regulatory Commission. (2011b). Radiation Exposure and Cancer. Retrieved October 3, 2011 from http://www.nrc.gov/about-nrc/radiation/health-effects/rad-exposure-cancer.html

  11. Benefits / Uses of Radiation • Some televisions and computers • Smoke detectors • Power (illumination) • Steel and paper factories • Inspection • Security - Airport • Welds – airplanes/boats • Sterilization of hospital supplies • Diagnostic imaging • Therapeutic • Medicine • Treatment (XRT) American Nuclear Association. (2008). Societal Benefits of Radiation Position Statement. Retrieved Oct 7, 2011 from http://www.ans.org/pi/ps/docs/ps73.pdf

  12. U.S. Population Exposed to Increased Radiation In March, 2009, the National Council on Radiation Protection and Measurement released a critical report that indicated that radiation dose to the United States population had risen dramatically since the early 1980’s. Schauer, D. A. & Linton, O. W. (2009). National Council on Radiation Protection and Measurements Report shows substantial medical exposure increase. Radiology, 253 (2), 293-296.

  13. Sources of U.S. Radiation Exposure U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/bio-effects-radiation.html

  14. Medical Imaging Procedures / Examples • Standard projection x-rays • Chest, hip, dental x-rays, • Mammogram • CT scan (CAT Scan) • Head, chest, abdomen • Nuclear medicine procedures • Angiogram • Fluoroscopy • Used in cardiac catherazation U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf

  15. Radiation Doses of Medical Imaging Procedures Medscape Reference. (2011). Ionizing Radiation Exposure with Medical Imaging . Abbreviated from Table 4. Retrieved October 12, 2011 from http://emedicine.medscape.com/article/1464228-overview

  16. Public Health Concern Millions of exams performed each year Estimates that 1 in 270 Women & 1 in 600 Men who undergo CT coronary angiography at age 40 will develop cancer from that CT scan1 1. Smith-Bindman, R., Lipson, J., Marcus, R., Kim, K. P., Mahesh, M., & Gould, R. (2009). Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine, 169(22), 2078-2086. 2. U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf

  17. Balance Risk and Benefits • Some level of exposure is necessary • Determine extent of injury • Determine extent of disease • Support diagnosis or treatment • Exposure from medical procedures should not be feared – but must be respected • ALARA Principle – as low as reasonably achievable • Risks reduction by decreasing unnecessary exposure Medscape Reference. (2011). Ionizing Radiation Exposure with Medical Imaging . Retrieved October 12, 2011 from http://emedicine.medscape.com/article/1464228-overview

  18. Radiation Protection Principle SHIELDING TIME DISTANCE U.S. Environmental Protection Agency (EPA). (2011a). Radiation Protection Basics. Retrieved October 7, 2011 from http://www.epa.gov/radiation/understand/protection_basics.html

  19. Safe Use of Medical Imaging Devices U. S. Food and Drug Administration. (2010)b. White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf

  20. FDA and Partners Initiative Reduce Unnecessary Radiation Exposure from Medical Imaging: • Promote safe use of medical imaging devices • Support informed clinical decision making • Increase patient awareness U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf

  21. Image Gently Campaign • Primary Objective: raise awareness of the opportunities to lower radiation dose in the imaging of children • Ultimate Goal: change practice • Strategy: straightforward information provided to every member of the care team www.imagegently.org http://www.imagewisely.org/ The Alliance for Radiation Safety in Pediatric Imaging. (2011). Image Gently. Retrieved October 12, 2011 from http://www.pedrad.org/associations/5364/ig/ Image Wisely. (2010b). Radiation Safety in Adult Medical Imaging. Retrieved October 15, 2011 from http://www.imagewisely.org/2.

  22. Informed Clinical Decision Making FDA Actions / Recommendations • Establish requirements for manufacturers of imaging equipment to record radiation dose information for use in patient charts or in a dose registry • Recommend continued development of criteria for appropriate medical imaging use U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf

  23. American College of Radiology Appropriateness Criteria http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx • Diagnostic Imaging Topics • Breast • Cardiac • Gastrointestinal • Musculoskeletal • Neurologic • Pediatric • Thoracic • Vascular • Women’s • Interventional Radiology Topics • Radiation Oncology Topics • Bone Metastases • Brain Metastases • Breast • Gynecology • Head & Neck • Hodgkin’s Lymphoma • Lung • Prostate • Rectal/Anal American College of Radiology. (2011). ACR Appropriateness Criteria®. Retrieved October 7, 2011 from http://www.acr.org/ac.

  24. Ask your doctor… • Why do I need this exam? • How will information from this exam improve my health? • Are there others tests , as good, that do not use radiation? Image Wisely. (2010a). Patients. Retrieved October 15, 2011 from http://www.imagewisely.org/Patients.aspx?CSRT=11519610464130392779

  25. Increase Patient Awareness • FDA collaboration with American College of Radiology and Radiological Society of North America to develop medical imaging card tool for tracking medical procedures • Paper tracking • Electronic tracking • Radiation dose calculators U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf

  26. My Medical Imaging History U.S. Food and Drug Administration. (2010a). My Medical Imaging History. Retrieved October 11, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf

  27. Calculate Your Radiation Dose Open this hyperlink to the EPA website http://epa.gov/radiation/understand/calculate.html U.S. Environmental Protection Agency. (2011b). Radiation Protection. Calculate Your Radiation Dose. Retrieved Oct 1, 2011 from http://epa.gov/radiation/understand/calculate.html

  28. Know Your Risks and Advocate! • 48% of radiation exposure in the U.S. is from medical procedures • Cumulative exposure may lead to long term health problems, especially cancer • Document and share your medical imaging history with your doctor • Calculate and know your estimated annual radiation exposure • Discuss, with your doctor, the need for imaging or alternatives that may be available • Have a healthy respect for radiation; it provides great benefit to our society

  29. References American College of Radiology. (2011). ACR Appropriateness Criteria®. Retrieved October 7, 2011 from http://www.acr.org/ac. American Nuclear Association. (2008). Societal Benefits of Radiation Position Statement. Retrieved October 7, 2011 from http://www.ans.org/pi/ps/docs/ps73.pdf Berrington de González, A. & Darby, S. (2004). Risk of cancer from diagnostic X-rays: Estimates for the UK and 14 other countries. Lancet, 363, 345-51. Centers for Disease Control and Protection (CDC). (2011). Emergency Preparedness and Response. Radiation and Pregnancy: A Fact Sheet. Retrieved October 3, 2011 from http://www.bt.cdc.gov/radiation/prenatal.asp Health Physics Society. (2011). Radiation Basics. Retrieved October 9, 2011 from http://www.hps.org/publicinformation/ate/faqs/radiation.htmlI Image Wisely. (2010a). Patients. Retrieved October 15, 2011 from http://www.imagewisely.org/Patients.aspx?CSRT=11519610464130392779

  30. References Image Wisely. (2010b). Radiation Safety in Adult Medical Imaging. Retrieved October 15, 2011 from http://www.imagewisely.org/ McCollough, C. H., Schuler, B. A., Atwell, T. D., Braun, N. N., Regner, D. M., Brown, D. L., & LeRoy, A. J. (2007). Radiation Exposure and Pregnancy: When Should We Be Concerned? Radiographics, 27, 909-917. doi: 10.1148/rg.274065149 Medscape Reference. (2011). Ionizing Radiation Exposure with Medical Imaging. Retrieved October 12, 2011 from http://emedicine.medscape.com/article/1464228-overview Natural News. (2010). Use of high-radiation CT scans in emergency rooms triples over nine years. Retrieved October 20, 2011 from http://www.naturalnews.com/030776_CT_scans_radiation.html New York Timers. (2010). Radiation, Risks Are Focus of Breast Screening Study. Retrieved October 21, 2011 from http://www.nytimes.com/2010/08/24/science/24breast.html Schauer, D. A. & Linton, O. W. (2009). National Council on Radiation Protection and Measurements Report shows substantial medical exposure increase. Radiology, 253 (2), 293-296.

  31. References Smith-Bindman, R., Lipson, J., Marcus, R., Kim, K. P., Mahesh, M., & Gould, R. (2009). Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine, 169(22), 2078-2086. The Alliance for Radiation Safety in Pediatric Imaging. (2011). Image Gently. Retrieved October 12, 2011 from http://www.pedrad.org/associations/5364/ig/ USA Today. (2010). Cancer risks prompt doctors to try to lower imaging scan radiation. Retrieved October 21, 2011 from http://www.usatoday.com/news/health/2010-05-05-radiation05_st_N.htm U. S. Environmental Protection Agency (EPA). (2007). Radiation Risks and Realities. Retrieved October 7, 2011 from http://epa.gov/radiation/docs/402-k-07-006.pdf U. S. Environmental Protection Agency (EPA). (2011a). Radiation Protection Basics. Retrieved October 7, 2011 from http://www.epa.gov/radiation/understand/protection_basics.html U.S. Environmental Protection Agency (EPA). (2011b). Radiation Protection. Calculate Your Radiation Dose. Retrieved Oct 1, 2011 from http://epa.gov/radiation/understand/calculate.html

  32. References U.S. Environmental Protection Agency (EPA). (2011c). Radiation Protection. Health Effects. Retrieved October 1, 2011 from http://epa.gov/radiation/understand/health_effects.html U. S. Environmental Protection Agency (EPA). (2011d). Radiation Protection. Radiation Symbols. Retrieved October 7, 2011 from http://www.epa.gov/rpdweb00/understand/symbols.html U. S. Environmental Protection Agency (EPA). (2011e) Why are some atoms Radioactive. Retrieved October 13, 2011 from http://www.epa.gov/rpdweb00/understand/radiation.html U.S. Food and Drug Administration. (2010a). My Medical Imaging History. Retrieved October 11, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM235128.pdf U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/bio-effects-radiation.htmlh U.S. Nuclear Regulatory Commission. (2011b). Radiation Exposure and Cancer. Retrieved October 3, 2011 from http://www.nrc.gov/about-nrc/radiation/health-effects/rad-exposure-cancer.html

  33. Additional Resources American Academy of Pediatrics. (2009). Imaging and Medical Radiation Safety: Important Information for Parents. Retrieved October 21, 2011 from http://www.aap.org/sections/radiology/RadiologyParentPage.pdf Furry Elephant. (n.d.). Lesson 5: How radiation harms. Retrieved October 21, 2011 from http://www.furryelephant.com/content/radioactivity/nuclear-radiation-health-effects/ RadiologInfo.org. (2011). Patient Safety: Radiation Exposure in X-ray and CT Examinations. Retrieved October 21, 2011 from http://www.radiologyinfo.org/en/safety/index.cfm?pg=sfty_xray U.S. Food and Drug Administration. (2009). FDA Makes Interim Recommendations to Address Concern of Excess Radiation Exposure during CT Perfusion Imaging. Retrieved October 21, 2011 from http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm193190.htm U.S. Food and Drug Administration. (2010). Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010. Retrieved October 21, 2010 from http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm185898.htm World Health Organization. (2011). Ionizing Radiation. Retrieved October 21, 2011 from http://www.who.int/ionizing_radiation/about/what_is_ir/en/index.html

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