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What you should tell your patients about radiation

What you should tell your patients about radiation. Lisa Lowe MD, FAAP Professor, Univ of MO-Kansas City Pediatric Radiologist, Children’s Mercy Hospitals & Clinics. Learning Objectives. After this talk, learner should be able to: Explain general radiation risk to patients and parents

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What you should tell your patients about radiation

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  1. What you should tell your patients about radiation Lisa Lowe MD, FAAP Professor, Univ of MO-Kansas City Pediatric Radiologist, Children’s Mercy Hospitals & Clinics

  2. Learning Objectives After this talk, learner should be able to: • Explain general radiation risk to patients and parents • State ways to lower radiation exposure in children • Be able to list helpful resources to determine the best radiology test

  3. Outline • History and Background • Radiation Risk • Increased use of CT • Image Gently • Helpful resources • What can you say? • What can we do?

  4. History: Roentgen discovers the X-ray! • Dec 1895 – Publication • 1 week later - radiograph of wife’s hand

  5. History: Radiology - fastest translational research • Mid 1896, in practice, including fluoroscopy • < 9 months from publication

  6. History: X rays became a public spectacle • Patented shoe fitting fluoroscope • Bloomingdales • FASCINATION!

  7. History: Side effects appeared later • Vision impaired • Skin injury • Hair loss

  8. History: Risk of radiation “exposed” • 1956 Alice Stewart, MD, reports X-Ray risks to fetuses • Argued no radiation was safe • Radiation effects grossly underestimated • 1945 US drops atomic bomb • Life Span Study cohort of atomic bomb survivors • > 50 years • Hiroshima Nagasaki • Increased risk of solid cancers • Children highest cancer mortality rates

  9. Radiation risk: Biological effects of radiation Damage to DNA • Damage to DNA is rapid • Damage to DNA may lead to genomic instability • Induction of cancer takes many years

  10. Radiation Risks in Children:No Debate • Children are more radiosensitive • Longer lifetime to manifest radiation-induced injury (cancer, cataracts) • Children 2-10x more sensitive than adults

  11. Increased use X-rays: Invention of CT 1979 Nobel Prize in Physics Allan Cormack Godfrey Hounsfield

  12. Increased use: Helical CT • Significant increase in the use of CT from 2001 to 2006 • Increase of 10% per year • 62 million CTs done per year • 6-11% of all CT’s done in children • Initially multidetector and 3D CT increased radiation doses by 3 to 10X • 50% of all medical radiation • ?? Dose quantification Arch, Michael and Donald P. Frush. “Pediatric Body MDCT: A 5-year follow up survey of scanning parameters used by Pediatric Radiologists.” AJR 2008; 191: 611-617.

  13. Increased use of CT: AJR Feb 2001 1 in 500 - 1,000 < 20% cases

  14. Increased use & radiation risk • Each exam (therefore dose) is cumulative Brenner et al: AJR 2001

  15. Increased use & radiation risk • AGE at exposure is most important risk factor • Females 2X males • Breast • Thyroid Hall. Pediatric Radiology. Apr 2002

  16. Image Gently Campaign • Society for Pediatrics Radiology (SPR) & American Academy of Pediatrics (AAP) plus 33 other medical organizations formed the Alliance for Radiation Safety in Pediatric Imaging - 2008 • Represents over 400,000 healthcare professionals promoting appropriate and high quality CT for children

  17. Image Gently Campaign • ALARA principle • As Low As Reasonably Achievable • 4 Image Gently guidelines: • Scan only when necessary • Scan only indicated region • Reduce or “child-size” the radiation dose • Scan once • www.imagegently.com

  18. Helpful resources: ACR website • Imaging guidelines and appropriateness criteria on the Amer College of Radiology (ACR) website: • http://www.acr.org/s_acr/bin.asp?TrackID=&SID=1&DID=14800&CID=1848&VID=2&DOC=File.PDF

  19. Helpful resources: AAP website • Radiology section of the AAP • Imaging guidelines: http://www.aap.org/sections/radiology/default.cfmRadiation safety information for parents & pediatricians

  20. Radiation report card

  21. Helpful resources: CMH Radiology website • Children’s Mercy Hospital Radiology website

  22. Sample newsletters: • Image gently campaign

  23. How do we respond? One size does NOT fit all We all must ask? • Appropriate to do exam? • Appropriate timing of exam? • Appropriate modality?

  24. How Do We Respond? • Radiologists’ responsibility • Understand radiation doses • Review requests for higher dose studies • Discuss with clinicians and parents/patients PRN • Child size technical factors

  25. Examples • Sinus CT • Old: 150 mAs • New: 30 mAs • Scoliosis CT • Craniosynostosis CT } 5x lower dose!

  26. How Do We Respond? • Pediatricians’ responsibility: • Understand radiation doses of modalities • Know which facilities are “kid friendly! • Don’t ass-u-me? • ASK, even demand! • Order on medical indications not parental/legal pressure • Discuss options with radiologist PRN • Consider information for parents PRN

  27. Talking to parents • Discuss risk vs. benefit • Use websites for more detailed explanations • Compare to other every day risks

  28. Typical radiation doses compared to background (3.5 mSv/yr) Procedure Effective dose Comparable background dose* Chest x-ray 0.02mSv 1 month VCUG 0.3mSv 3 months Dental X-rays 0.9 mSv 6 months Lumbar spine 1.3 mSv 7 months CT head 2mSv 8 months Upper GI 3mSv 1 year Barium enema 7mSv 2.3 years CT abdomen 10mSv 3 years 1 Airline flight 0.3mSv 2-3 months *Average background dose is 3.5 mSv/year

  29. Risk of death from various activities Activity Risk of death per million/year Having a chest X-ray 1 Visiting Denver for 2 months 1 Traveling 5,000 by air 5 Fishing (drowning) 10 Traveling 1,500 miles by car 40 Motorcycling for 1,000 200 Smoking 1 pack/day 3,500 Being > 55 years age 10,000

  30. What is CMH doing to lower doses? Pediatric radiologist is actively involved • Using US and MRI when possible • Appendicitis and screening • Pulsed fluoroscopy • UGI/VCUG – Up to 10X less dose

  31. What is CMH doing to lower doses? Pediatric radiologist is actively involved • Child size all CT doses • New protocols: 5x less dose • Av CT dose: 2009 • CMH: 1025 mSv • Other providers: 1818 mSv 44% less radiation!!

  32. What is CMH doing to lower doses? We make sure your patient gets the: • Right test (best test with least radiation) • ? US or MRI • Right time • ? Does something else need to be done first? • Right way (individualize protocols) • ? Contrast or not • Lowest radiation dose possible • 44% less for CT on average

  33. Thanks for your attention Questions?

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