IMAGE GENTLY HOW CAN YOU HELP?
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1 IMAGE GENTLY HOW CAN YOU HELP? Keith J. Strauss, MSc, FAAPM, FACR Director, Radiology Physics & Engineering Children s s Hospital Boston Harvard Medical School
2 Acknowledgment Marilyn J. Goske,, MD Robert Pizzutiello
3 INTRODUCTION A. Introduction to Image Gently B. Image Gently Focus C. Pediatric Considerations D. Your Involvement 1. Training 2. CT Patient Dose Index? 3. Pediatric CT Scan Parameters
4 The Alliance. A. Coalition of health care organizations dedicated to providing safe, high quality pediatric imaging worldwide. B. Primary objective is to raise awareness of the need to adjust pediatric radiation dose. C. The ultimate goal of the Alliance is to accelerate the change of local practice. 1. Scientific observation to local practice change ~ 17 years! 1 1 Greenberg SB. Trans Clin Climatol Assoc 119: , 2008
5 What is Image Gently? A Campaign Of education and awareness To improve radiation protection for children
6 How much do we really understand? Under estimation by 75% of MDs! Lee et al. Radiology. 2004; 231:
7 PARTNERSHIPS A. 42 Affiliates; 13 International; > 700,000 individuals Academy of Radiology Research American Academy of Pediatrics American Institute of Ultrasound in Medicine American Osteopathic College of Radiology American Registry of Radiologic Technologists American Roentgen Ray Society American Society of Emergency Radiology American Society of Head and Neck Radiology American Society of Pediatric Neuroradiology Asian-Oceanic Society for Paediatric Radiology Association of University Radiologists Australian & New Zealand Society for Paediatric Radiology Canadian Association of Medical Radiation Technologists Canadian Association of Radiologists Canadian Interventional Radiology Association Canadian Organization of Medical Physicists Coalition for Imaging and Bioengineering Research College of Radiology, Academy of Medicine of Malaysia Conference of Radiation Control Program Directors European Society of Paediatric Radiology National Council on Radiation Protection and Measurements North American Society for Cardiovascular Imaging Radiological Society of North America The Royal Australian and New Zealand College of Radiologists Society of Interventional Radiology Sociedad Latino Americana de Radiología Pediátrica Society for Pediatric Interventional Radiology Society of Computed Body Tomography and Magnetic Resonance Society of Gastrointestinal Radiologists The Society of Nuclear Medicine The Society of Nuclear Medicine - Technologist Section Sociedad Mexicana De Radiologia E Imagen Society of Radiologists in Ultrasound Society of Uroradiology
8 IMAGE GENTLY S S FOCUS A. Positive, unified message 1. Vetted through Alliance member committees 2. Adds depth, clarity, and credibility. B. Consistent tone 1. Respectful to all a. Medical professionals and b. Families 2. Seeking information about patient radiation doses.
9 IMAGE GENTLY S S FOCUS Managing Patient Dose in CT Holistically Configuration of CT Scanner Radiation Dose / Image Radiation Output Calibration Operation of CT Tissue Volume Irradiated Should CT be Performed? Image Quality Verification Automatic Exposure Control Exam Specific Acquisitions Scan Length? Contrast Media Management Total Patient Dose from CT
10 IMAGE GENTLY S S FOCUS C. Advocacy issues include: 1. Improved education regarding radiation risk 2. Promotion of standardized a. Nomenclature of technique parameters b. Radiation dose utilization (technique factors) c. Radiation dose display 3. Improving medical literacy for parents and patients. a. Medical Image Record Card b. Educational brochures for parents - Multiple translations
11 IMAGE GENTLY S S FOCUS Working together to change practice Medical Physicist Radiologists Radiologic Technologist Imager vendor
12 GROWTH OF MEDICALRADIATION DOSE A. Early 1980s Snapshot 1. 15% of Annual Radiation Dose due to medical imaging msv per year a. X-rays: X 0.39 b. Nuc Med: 0.14 Nuclear Medicine 4% Medical X-rays 11% Internal 11% Consumer Products 3% Other 1% Radon 54% Terrestiral 8% Cosmic 8% Adapted from Mahesh
13 Procedures vs Effective dose contributions Interventiona 2% CT 12% Nuclear Medicin e Radiography & Fluoroscopy* 19% Interventiona l CT 46% Radiography & Fluoroscopy* 83% Percent Procedures Nuclear Medicin e Effective Dose Contributions Adapted from Mahesh 17% of All Exams Deliver 81% of Total Effective dose 91% of Pediatric Dose in the ED comes from CT
14 Preliminary estimate of changes in Medical radiation exposure to US population US 1980* US 2006 Medical 0.54 Other 0.06 Radiography 0.6 msv Interventional 0.4 msv Nuclear Medicine Natural?? (3.0 msv) Natural 3.0 msv CT 1.5 msv Medical 0.54 msv per capita Total 3.6 msv per capita Medical 3.2 msv per capita Total?? msv per capita * NCRP 93 Adapted from Mahesh
15 IMAGE GENTLY S S FOCUS E. Newest Development 1. Image Gently in Pediatric Interventional Radiology F. Currently Under Development 1. Pediatric Nuclear Medicine 2. Pediatric CR/DR 3. Pediatric Fluoroscopy
16 PEDIATRIC CONSIDERATIONS A. Radiation Induced Cancer Lifetime Risk From 1 Sv Dose 1. Average a. 5% Males b. 6% Females 2. First Decade 15% 3. Middle Age 2-3 % 4. Children 3 5 times more sensitive Adapted from Hall
17 PEDIATRIC CONSIDERATIONS Radiation Risk based on Effective Dose? A. Almen and S. Mattsson, J. Radiol. Prot. 16 (2), (1996). Somatic risk %/Sv Hereditary risk %/Sv Total risk %/Sv Children Aged Children Aged Whole population 5 1 6
18 PEDIATRIC CONSIDERATIONS B. Pediatric Patient Size Variation is Large Abdomen 1. 5 yr old: cm yr old: cm
19 RADIATION PROTECTION FOR CHILDREN ONE SIZE DOES NOT FIT ALL
20 PEDIATRIC CONSIDERATIONS
21 PEDIATRIC ANATOMICAL CONSIDERATIONS Large Adult Adult 5 year 1 year 5 cm Neonate KVP 1 70 KVP
22 ASSUME 5 CM TISSUE HVL Abdominal Girth (kg) Mass PA (cm) # HVL LAT (cm) # HVL Neonate Newborn yr yr yr Adult Adult
23 PEDIATRIC CONSIDERATIONS Clinical dynamic range of mas per image to maintain a fixed kvp PA projection 6 HVL Range of 64 LAT projection 9 HVL Range of 512
24 PEDIATRIC CONSIDERATIONS CTDI vol Tube Tube Current Changed by Weight or Mass
25 PEDIATRIC CONSIDERATIONS CLINICAL EDUCATIONAL MATERIALS Table II: mas Reduction Factors for the Pediatric Head Room #: CT Unit: Date: kvp ma Time (sec) Pitch Filter Head Baseline: fill in fill in fill in fill in fill in PA Thickness Head (cm) Approx Age mas Reduction Factor (RF) Estimated mas = BL x RF 12 newborn 0.74 #VALUE! 16 2 yr 0.86 #VALUE! 17 6 yr 0.93 #VALUE! 19 med adult 1 fill in 1. Type in baseline head techniques and mas in yellow cells 2. Spreadsheet will calculate mas estimated for pediatric patients of varying sizes IMAGE GENTLY HEAD Table II: mas Reduction Factors for the Pediatric Head Room #: CT Unit: Date: kvp ma Time (sec) Pitch Filter Head Baseline: fill in PA Thickness Head (cm) Approx Age mas Reduction Factor (RF) Estimated mas = BL x RF 12 newborn yr yr med adult Type in baseline head techniques and mas in yellow cells 2. Spreadsheet will calculate mas estimated for pediatric patients of varying sizes
26 PEDIATRIC CONSIDERATIONS CLINICAL EDUCATIONAL MATERIALS Abdomen kvp ma Time (sec) Pitch Abdomen Pitch Thorax Baseline: fill in fill in fill in fill in fill in Abdomen Thorax PA Thickness (cm) Approx Age mas Reduction Factor (RF) Estimated mas = BL x RF mas Reduction Factor (RF) Estimated mas = BL x RF 9 newborn 0.43 #VALUE! 0.42 #VALUE! 12 1 yr 0.51 #VALUE! 0.49 #VALUE! 14 5 yr 0.59 #VALUE! 0.57 #VALUE! yr 0.66 #VALUE! 0.64 #VALUE! yr 0.76 #VALUE! 0.73 #VALUE! 22 small adult 0.90 #VALUE! 0.82 #VALUE! 25 med adult 1.0 fill in 0.91 #VALUE! 31 large adult 1.27 #VALUE! 1.16 #VALUE! IMAGE GENTLY BODY Abdomen kvp ma Time (sec) Pitch Abdomen Pitch Thorax Baseline: Abdomen Thorax PA Thickness (cm) Approx Age mas Reduction Factor (RF) Estimated mas = BL x RF mas Reduction Factor (RF) Estimated mas = BL x RF 9 newborn yr yr yr yr small adult med adult large adult
27 IMAGE GENTLY NEEDS YOU TRAINING Complete training fosters Full use of equipment design Improved image quality Reduced radiation dose
28 IMAGE GENTLY NEEDS YOU TRAINING Training is only as effective as the trainer s understanding of their trainees Each trainee may have a bit different perspective! YOUR HOUSE as seen by... Yourself
29 Your Lender Your Buyer Your Appraiser Your Tax Assessor
30 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? A. Limitations of CTDI 1. CTDI 100 measured with 100 mm pencil chamber a. Two Standard Phantoms b. Scanner Dose Index c. Allows compari- son of radiation output of different CT scanner models & manufaturers
31 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? A. Limitations of CTDI 2. CTDI vol (mgy) responds to changes in: a. Scanner Design i. Bow Tie Filter Composition & Shape ii. Focal Spot to Detector Distance b. Scan Parameters i. kvp ii. Pitch iii. mas c. Patient Size? NO
32 CT RADIATION DOSE BODY, 32 cm. HEAD, 16 cm Adapted from Frey 100 CTDI vol = CTDI vol = 84
33 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? A. Limitations of CTDI 3. CTDI vol (mgy) does not respond to changes in Patient Size!! a. IG recommendations deliver similar patient dose independent of patient size IMAGE GENTLY BODY Abdomen kvp ma Time (sec) Pitch Abdomen Pitch Thorax Baseline: Abdomen Thorax PA Thickness (cm) Approx Age mas Reduction Factor (RF) Estimated mas = BL x RF mas Reduction Factor (RF) Estimated mas = BL x RF 9 newborn yr yr yr yr small adult med adult large adult
34 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? A. Limitations of CTDI 4. CTDI doses UNDERESTIMATE pediatric doses: creates false sense of security a. New Born vs Adult dose display error i. Head: ~ 35% ii. Thorax: ~ 175% iii. Abdomen:~200%
35 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? A. Limitations of CTDI 4. CTDI doses UNDERESTIMATE pediatric doses: b. Solution: Pediatric CT Physics Work Group i. Group within Medical Imaging & Technology Alliance (MITA) Developing Correction Factors to estimate a Patient Dose Index from CTDI vol as a function of patient size ii. AAPM Task Group Developing standardized recommendation that can be universally adapted.
36 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? A. Limitations of CTDI 5. No uniformity of display currently exists among CT Scanner manufacturers a. Incomplete information b. Confusion among Users
37 IMAGE GENTLY NEEDS YOU 6. Actual Displays a. CTDI vol in mgy CT Patient Dose Index?
38 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? 6. Actual Displays c. CTDI: Which one? d. DLP with units
39 CURRENT DOSE DISPLAYS 6. Actual Displays e. CTDI vol Units? f. How does Eff. DLP differ from DLP?
40 CURRENT DOSE DISPLAYS 6. Actual Displays g. CTDI vol & DLP with units h. Phantom size identified! i. Is only DLP additive for multiple series? 4. Does the vendor bother to to teach this information?
41 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? A. Limitations of CTDI 7. Dixon s s challenge to 100 mm pencil chamber a. A New Look at CT Dose Measurement: Beyond CTDI Med Phys 30(6) b. Restructuring CT Dosimetry A A Realistic Strategy for the Future Requiem for the Pencil Chamber Med Phys 33(10) 2006.
42 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? A. Limitations of CTDI 8. Boone s s response to 100 mm chamber dilemma The Trouble with CTDI 100 Med Phys 34(4) a. 100 mm chamber underestimates the dose for all scans, 40 mm vs a 10 mm fan beam.
43 IMAGE GENTLY NEEDS YOU CT Patient Dose Index? B. Solutions to Limitations of CTDI 1. Point Chamber Measurement of Dose 2. Develop agreed upon correction factors to estimate and display Patient Dose Index 3. Simplify and standardize dose displays on CT Scanners
44 IMAGE GENTLY NEEDS YOU CT Pediatric Scan Parameters A. AAPM CT Dose Summit 1. Atlanta at end of April 2. All 11 hours of presentations will be in AAPM Virtual Library 3. Clinical Users Need Help Setting Up Scan Parameters a. Not a simple endeavor. b. ACR CT Accreditation
45 A. Conclusions IMAGE GENTLY NEEDS YOU 1. Image Gently is an Awareness Campaign 2. Vast majority of Pediatric Imaging Occurs in Adult facilities 3. Children are not small Adults CT Patient Dose Index Function of Size 5. Help Clinicians with CT Scan Techniques Now 6. Children are not small Adults, but Most Adults are BIG Babies!
46 Working together to improve radiation protection for children worldwide! Don t forget to Image Gently and Step Lightly.
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