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One of the principal uncertainties when estimating population risk of late effects from epidemiological data is that few radiation-exposed cohorts have been followed up to extinction. Therefore, the relative risk model has often been used to estimate radiation-associated risk and to extrapolate risk to the end of life. Epidemiological studies provide evidence that children are generally at higher risk of cancer induction than adults for a given radiation dose. However, the strength of evidence varies by cancer site and questions remain about site-specific age at exposure patterns. For solid cancers, there is a large body of evidence that excess relative risk (ERR) diminishes with increasing age at exposure. This pattern of risk is observed in the Life Span Study (LSS) as well as in other radiation-exposed populations for overall solid cancer incidence and mortality and for most site-specific solid cancers. However, there are some disparities by endpoint in the degree of variation of ERR with exposure age, with some sites (e.g., colon, lung) in the LSS incidence data showing no variation, or even increasing ERR with increasing age at exposure. The pattern of variation of excess absolute risk (EAR) with age at exposure is often similar, with EAR for solid cancers or solid cancer mortality decreasing with increasing age at exposure in the LSS. We shall review the human data from the Japanese LSS cohort, and a variety of other epidemiological data sets, including a review of types of medical diagnostic exposures, also some radiobiological animal data, all bearing on the issue of variations of radiation late-effects risk with age at exposure and with attained age. The paper includes a summary of several oral presentations given in a Symposium on "Age effects on radiation response" as part of the 67th Annual Meeting of the Radiation Research Society, held virtually on 3-6 October 2021.

US physicians in multiple specialties who order or conduct radiological procedures lack formal radiation science education and thus sometimes order procedures of limited benefit or fail to order what is necessary. To this end, a multidisciplinary expert group proposed an introductory broad-based radiation science educational program for U.S. medical schools. Suggested preclinical elements of the curriculum include foundational education on ionizing and nonionizing radiation (eg, definitions, dose metrics, and risk measures) and short- and long-term radiation-related health effects as well as introduction to radiology, radiation therapy, and radiation protection concepts. Recommended clinical elements of the curriculum would impart knowledge and practical experience in radiology, fluoroscopically guided procedures, nuclear medicine, radiation oncology, and identification of patient subgroups requiring special considerations when selecting specific ionizing or nonionizing diagnostic or therapeutic radiation procedures. Critical components of the clinical program would also include educational material and direct experience with patient-centered communication on benefits of, risks of, and shared decision making about ionizing and nonionizing radiation procedures and on health effects and safety requirements for environmental and occupational exposure to ionizing and nonionizing radiation. Overarching is the introduction to evidence-based guidelines for procedures that maximize clinical benefit while limiting unnecessary risk. The content would be further developed, directed, and integrated within the curriculum by local faculties and would address multiple standard elements of the Liaison Committee on Medical Education and Core Entrustable Professional Activities for Entering Residency of the Association of American Medical Colleges.

Generally, intentional exposure of pregnant women is avoided as far as possible in both medical and occupational situations. This paper aims to summarise available information on sources of radiation exposure of the embryo/foetus primarily in medical settings. Accidental and unintended exposure is also considered. Knowledge on the effects of radiation exposure on the developing embryo/foetus remains incomplete—drawn largely from animal studies and two human cohorts but a summary is provided in relation to the key health endpoints of concern, severe foetal malformations/death, future cancer risk, and future impact on cognitive function. Both the specific education and training and also the literature regarding medical management of pregnant females is in general sparse, and consequently the justification and optimisation approaches may need to be considered on a case by case basis. In collating and reviewing this information, several suggestions for future basic science research, education and training, and radiation protection practice are identified.

The International Commission on Radiological Protection (ICRP) has embarked on a review and revision of the system of Radiological Protection that will update the 2007 general recommendations in ICRP Publication 103. This is the beginning of a process that will take several years, involving open and transparent engagement with organisations and individuals around the world. While the system is robust and has performed well, it must adapt to address changes in science and society to remain fit for purpose. The aim of this paper is to encourage discussions on which areas of the system might gain the greatest benefit from review, and to initiate collaborative efforts. Increased clarity and consistency are high priorities. The better the system is understood, the more effectively it can be applied, resulting in improved protection and increased harmonisation. Many areas are identified for potential review including: classification of effects, with particular focus on tissue reactions; reformulation of detriment, potentially including non-cancer diseases; re-evaluation of the relationship between detriment and effective dose, and the possibility of defining detriments for males and females of different ages; individual variation in the response to radiation exposure; heritable effects; and effects and risks in non-human biota and ecosystems. Some of the basic concepts are also being considered, including the framework for bringing together protection of people and the environment, incremental improvements to the fundamental principles of justification and optimisation, a broader approach to protection of individuals, and clarification of the exposure situations introduced in 2007. In addition, ICRP is considering identifying where explicit incorporation of the ethical basis of the system would be beneficial, how to better reflect the importance of communications and stakeholder involvement, and further advice on education and training. ICRP invites responses on these and other areas relating to the review of the System of Radiological Protection.

Whereas scientific evidence is the basis for recommendations and guidance on radiological protection, professional ethics is critically important and should always guide professional behaviour. The International Commission on Radiological Protection (ICRP) established Task Group 109 to advise medical professionals, patients, families, carers, the public, and authorities about the ethical aspects of radiological protection of patients in the diagnostic and therapeutic use of radiation in medicine. Occupational exposures and research-related exposures are not within the scope of this task group. Task Group 109 will produce a report that will be available to the different interested parties for consultation before publication. Presently, the report is at the stage of a working document that has benefitted from an international workshop organised on the topic by the World Health Organization. It presents the history of ethics in medicine in ICRP, and explains why this subject is important, and the benefits it can bring to the standard biomedical ethics. As risk is an essential part in decision-making and communication, a summary is included on what is known about the dose–effect relationship, with emphasis on the associated uncertainties. Once this theoretical framework has been presented, the report becomes resolutely more practical. First, it proposes an evaluation method to analyse specific situations from an ethical point of view. This method allows stakeholders to review a set of six ethical values and provides hints on how they could be balanced. Next, various situations (e.g. pregnancy, elderly, paediatric, end of life) are considered in two steps: first within a realistic, ethically challenging scenario on which the evaluation method is applied; and second within a more general context. Scenarios are presented and discussed with attention to specific patient circumstances, and on how and which reflections on ethical values can be of help in the decision-making process. Finally, two important related aspects are considered: how should we communicate with patients, family, and other stakeholders; and how should we incorporate ethics into the education and training of medical professionals?

Tissue reactions and stochastic effects after exposure to ionising radiation are variable between individuals but the factors and mechanisms governing individual responses are not well understood. Individual responses can be measured at different levels of biological organization and using different endpoints following varying doses of radiation, including: cancers, non-cancer diseases and mortality in the whole organism; normal tissue reactions after exposures; and, cellular endpoints such as chromosomal damage and molecular alterations. There is no doubt that many factors influence the responses of people to radiation to different degrees. In addition to the obvious general factors of radiation quality, dose, dose rate and the tissue (sub)volume irradiated, recognized and potential determining factors include age, sex, life style (e.g., smoking, diet, possibly body mass index), environmental factors, genetics and epigenetics, stochastic distribution of cellular events, and systemic comorbidities such as diabetes or viral infections. Genetic factors are commonly thought to be a substantial contributor to individual response to radiation. Apart from a small number of rare monogenic diseases such as ataxia telangiectasia, the inheritance of an abnormally responsive phenotype among a population of healthy individuals does not follow a classical Mendelian inheritance pattern. Rather it is considered to be a multi-factorial, complex trait.

BACKGROUND: Screening tests are generally not recommended in patients with advanced cancer and limited life expectancy. Nonetheless, screening mammography still occurs and may lead to follow-up testing. OBJECTIVE: We assessed the frequency of downstream breast imaging following screening mammography in patients with advanced colorectal or lung cancer. DESIGN: Population-based study. PARTICIPANTS: The study included continuously enrolled female fee-for-service Medicare beneficiaries ≥65 years of age with advanced colorectal (stage IV) or lung (stage IIIB-IV) cancer reported to a Surveillance, Epidemiology, and End Results (SEER) registry between 2000 and 2011. MAIN MEASURES: We assessed the utilization of diagnostic mammography, breast ultrasound, and breast MRI following screening mammography. Logistic regression models were used to explore independent predictors of utilization of downstream tests while controlling for cancer type and patient sociodemographic and regional characteristics. KEY RESULTS: Among 34,127 women with advanced cancer (23% colorectal; 77% lung cancer; mean age at diagnosis 75 years), 9% (n = 3159) underwent a total of 5750 screening mammograms. Of these, 11% (n = 639) resulted in at least one subsequent diagnostic breast imaging examination within 9 months. Diagnostic mammography was most common (9%; n = 532), followed by ultrasound (6%; n = 334) and MRI (0.2%; n = 14). Diagnostic mammography rates were higher in whites than African Americans (OR, 1.6; p

Purpose To assess breast cancer screening utilization in Medicare beneficiaries with colorectal and lung cancer versus cancer-free controls. Methods Female fee-for-service Medicare beneficiaries who were ≥67 years old and diagnosed with lung or colorectal cancer between 2000 and 2011 and who reported to a Surveillance, Epidemiology, and End Results (SEER) registry (case group) were followed for 2 years after their diagnoses, unless death, a diagnosis of breast cancer, or the end of 2013 came first. A similar number of cancer-free controls were individually matched to cases by age, race, registry region, and follow-up time. Screening utilization was defined as the percentage of women with ≥1 screening mammogram during follow-up. Results Overall, 104,164 cases (48% colorectal, 52% lung; 30% advanced cancer) and 104,164 controls were included. Among women with lung or colorectal cancer, 22% underwent ≥1 screening mammogram versus 26% of controls (odds ratio [OR] 0.80; 95% confidence interval [CI] 0.78-0.82). Stratified by cancer type, 28% of colorectal cancer cases versus 29% of controls (OR 0.98; 95% CI 0.95-1.01) and 17% of lung cancer cases versus 23% of controls (OR 0.63; 95% CI 0.60-0.65) received ≥1 mammogram. When stratified by stage, 8% with advanced cancer versus 18% of controls (OR 0.33; 95% CI 0.31-0.35) and 30% with early-stage cancer versus 30% of controls (OR 1; 95% CI 0.97-1.02) underwent ≥1 mammogram. Conclusion Screening mammography utilization rates are similar between Medicare beneficiaries with early-stage cancer versus controls. Although the majority of patients with advanced-stage cancer appropriately do not pursue screening mammography, a small number (8%) continue with screening.

To determine the prevalence of unanticipated events (UE) associated with MRI examinations in a multicenter academic radiology department.UE reported by MRI technologists for examinations performed between June 2013 and November 2014 on 17 scanners in a university- and community-affiliated single health system were retrospectively reviewed. Events were categorized into the following categories: (1) problems with orders and scheduling; (2) scan delays; (3) unanticipated foreign bodies; (4) non-contrast-related patient events (eg, patient motion, discomfort, claustrophobia, need for sedation); (5) contrast-related patient events; and (6) technical acquisition issues. Logistic regression analysis of UE was performed after adjusting based on scanner site (university- vs community-affiliated hospital), hospital setting (outpatient [OP] vs mixed outpatient and inpatient [OP/IP]), and timing of the scan (business days vs weekends/holidays).A total of 34,587 MRI examinations were assessed (87% university-affiliated; 58% OP) with 5775 (16.7%) UE (1.9% of patients had more than one category event). Rates of UE for each category were as follows: 1.9% orders and scheduling, 3.3% delays in scan, 0.5% foreign bodies, 10.4% non-contrast-related patient events, 1.3% contrast-related patient events, and 1.5% technical issues. After adjustment for location of scanner, clinical setting, and timing of the scan, the rate of overall UE was significantly higher in university-affiliated sites (coefficient, 0.09 [95% confidence interval (CI), 0.07-0.10]; P.001), in scans performed in the mixed OP/IP setting (coefficient, 0.09 [95% CI, 0.08-0.09]; P.001), and in scans performed during weekends/holidays (coefficient, 0.02 [95% CI, 0.01-0.04]; P.001).UE associated with MRI examinations are common (16.7%), with the majority being patient-related issues unrelated to contrast administration.

To assess the trends of women in voluntary leadership roles in the ACR from 2001 to 2015.Retrospective leadership records from 2001 to 2015 were collected from the ACR Membership Database based on member demographics, gender, and participation in leadership roles at the national and state level. Data were sorted by gender and year to assess the proportion of women in each leadership position relative to total member/representation counts.Overall, there were increasing numbers of women represented in ACR leadership. From 2001 to 2015, there were increasing rates of women achieving fellowship in the College (7%-11%), now at parity with male member rates. Representation by women has risen from 7% to 21% for state chapter presidents and from 14% to 18% for state councilors. Comparing rolling 5-year averages from 2001-2005 and 2011-2015 showed statistically significant increases (P.05) in these leadership roles. Women members of the council steering committee rose from 13% in 2001 to 19% in 2015, peaking at 24% in 2014. The Board of Chancellors (BOC) showed the largest increase in women, from 9% to 33%, with a peak at 37% in 2014. However, no BOC chairs were women, one council speaker was a woman, two women were ACR presidents, and two women were vice presidents.Women's participation in ACR leadership has increased significantly at the state level and in fellowship recognition. Although there are increasing numbers of women on the BOC, top positions remain male-dominated at the national level.

Purpose The study sought to assess the gastrointestinal (GI) distribution of oral contrast (OC) among emergency department (ED) patients and determine if contrast reaches the terminal ileum or site of pathology to assist in diagnosis. Methods Retrospectively, adults undergoing abdominal-pelvic computed tomography (APCT) in the ED at 2 hospitals were identified over a 3-month period. APCTs were reviewed for location of OC. Presence, site, type of bowel pathology, and prior gastrointestinal surgery were documented. When applicable, the site of bowel pathology was evaluated for the presence or absence of OC. Results There were 1349 exams with mean age 50.5 years (range 18–97 years), 41% male, with 530 (39%) receiving OC. In 271 of 530 (51%), OC reached the terminal ileum (TI). Bowel pathology was present in 31% of cases (165 of 530). When bowel pathology was present, 47% (77 of 165) had OC present at the pathology site. The GI tract was divided into 4 anatomic segments: OC most frequently reached pathology in stomach and duodenum (84%), but was present less frequently at sites of pathology from jejunum to TI (35%), proximal colon (57%), and distal colon (28%). In only 84 of 530 OC cases (16%) did contrast extend from the stomach to distal colon. OC administration contributed to longer mean APCT order to final report of 0.5 hours and longer mean ED length of stay of 0.8 hours compared with all patients who received APCT. Conclusions Optimal OC distribution is not achieved in more than half of ED patients, raising questions about the continued use of OC in the ED.

The purpose of the article is to determine if miscentering affected dose with use of automated tube voltage selection software. An anthropomorphic phantom was imaged at different table heights (centered in the computed tomography [CT] gantry, and -6, -3, +3, and +5.7cm relative to the centered position). Topogram magnification, tube voltage selection, and dose were assessed. Effect of table height on dose also was assessed retrospectively in human subjects (n = 50). When the CT table was positioned closer to the x-ray source, subjects appeared up to 33% magnified in topogram images. When subjects appeared magnified in topogram images, automated software selected higher tube potentials and tube currents that were based on the magnified size of the subject rather than the subject׳s true size. Table height strongly correlated with CT dose index (r = 0.98, P < 0.05) and dose length product (r = 0.98, P < 0.05) in the phantom study. Transverse dimension in the topogram highly correlated with dose in human subjects (r = 0.75-0.87, P

Aim: To investigate outcomes in unresectable hepatocellular carcinoma (HCC) patients stratified by sociodemographic and clinical factors in a population study. Materials & methods: Surveillance, Epidemiology and End Results (SEER) database was used to identify patients diagnosed in 2000–2011. Overall survival (OS) was stratified using patient sociodemographic characteristics and American Joint Commission on Cancer (AJCC) staging. Log-rank test and Cox proportional hazard models were used to identify prognostic factors of OS. Results: In patients with AJCC stage I and II unresectable HCC, prolonged OS was correlated with being married, younger age, ethnicity, geographic location, living in large urban areas, being insured and higher income and education levels. Conclusion: In AJCC stage I and II unresectable HCC patients with favorable sociodemographic factors, prolonged OS maybe in part related to better access to cancer-directed therapy.

Purpose The purpose of this article is to demonstrate the role of the ACR Dose Index Registry ® (DIR) in a dose reduction program at a large academic health care system. Methods Using the ACR DIR, radiation doses were collected for four common CT examination types (head without contrast, chest with contrast, chest without contrast, and abdomen and pelvis with contrast). Baseline analysis of 7,255 CT examinations from seven scanners across the institution was performed for the period from December 1, 2011, to March 15, 2012. A comprehensive dose reduction initiative was guided by the identification of targets for dose improvement from the baseline analysis. Data for 14,938 examinations from the same seven scanners were analyzed for the postimplementation period of January 1, 2013, to July 1, 2013. Results The program included protocol changes, iterative reconstruction, optimization of scan acquisition, technologist education, and continuous monitoring with feedback tools. Average decrease in median dose-length product (DLP) across scanners was 30% for chest CT without contrast, 29% for noncontrast head CT, 26% for abdominal and pelvic CT with contrast, and 10% for chest CT with contrast. Compared with average median DLP in the ACR DIR, the median institution-wide CT DLPs after implementation were lower by 33% for chest CT without contrast, 32% for chest CT with contrast, 26% for abdominal and pelvic CT with contrast, and 6% for head CT without contrast. Conclusions A comprehensive CT dose reduction program using the ACR DIR can lead to substantial dose reduction within a large health care system.

Rationale and Objectives To identify and reduce reasons for delays in procedure start times, particularly the first cases of the day, within the interventional radiology (IR) divisions of the Department of Radiology using principles of continuous quality improvement. Materials and Methods An interdisciplinary team representative of the IR and preprocedure/postprocedure care area (PPCA) health care personnel, managers, and data analysts was formed. A standardized form was used to document both inpatient and outpatient progress through the PPCA and IR workflow in six rooms and to document reasons for delays. Data generated were used to identify key problems areas, implement improvement interventions, and monitor their effects. Project duration was 6 months. Results The average number of on-time starts for the first case of the day increased from 23% to 56% ( P value P value P value Conclusions Many complex factors contribute to procedure start time delays within an IR practice. A data-driven and patient-centered, interdisciplinary team approach was effective in reducing delays in IR.

BACKGROUND AND PURPOSE: Radiologists should manage the radiation dose for pediatric patients to maintain reasonable diagnostic confidence. We assessed the variation in estimated radiation dose indices for pediatric noncontrast head CT in the United States. MATERIALS AND METHODS: Radiation dose indices for single-phase noncontrast head CT examinations in patients 18 years of age and younger were retrospectively reviewed between July 2011 and June 2016 using the American College of Radiology CT Dose Index Registry. We used the reported volume CT dose index stratified by patient demographics and imaging facility characteristics. RESULTS: The registry included 295,296 single-phase pediatric noncontrast head CT studies from 1571 facilities (56% in male patients and 53% in children older than 10 years of age). The median volume CT dose index was 33 mGy (interquartile range = 22–47 mGy). The volume CT dose index increased as age increased. The volume CT dose index was lower in children9s hospitals (median, 26 mGy) versus academic hospitals (median, 32 mGy) and community hospitals (median, 40 mGy). There was a lower volume CT dose index in level I and II trauma centers (median, 27 and 32 mGy, respectively) versus nontrauma centers (median, 40 mGy) and facilities in metropolitan locations (median, 30 mGy) versus those in suburban and rural locations (median, 41 mGy). CONCLUSIONS: Considerable variation in the radiation dose index for pediatric head CT exists. Median dose indices and practice variations at pediatric facilities were both lower compared with other practice settings. Decreasing dose variability through proper management of CT parameters in pediatric populations using benchmarks generated by data from registries can potentially decrease population exposure to ionizing radiation.

When children present with head trauma, as with any imaging examination, it is necessary to consider the risks, costs, and benefits of testing. In many instances of pediatric head trauma, imaging studies are used for “confirming” or “excluding” certain diagnoses.[1][1] However, imaging tests

Many patients at our pediatric hospital have had a contrast-enhanced CT of the abdomen and pelvis performed by an outside imaging facility before admission. We have noticed that many of these exams are multiphase, which may contribute to unnecessary radiation dose. To determine the frequency of multiphase acquisitions and radiation dose indices in contrast-enhanced CTs of the abdomen and pelvis performed by outside imaging facilities in patients who were subsequently transferred to our pediatric hospital for care, and compare these metrics to contrast-enhanced CTs of the abdomen and pelvis performed internally. A retrospective analysis was performed of contrast-enhanced CTs of the abdomen and pelvis from outside imaging facilities uploaded to our picture archiving and communication system (PACS) between January 1, 2012, and December 31, 2015. CT images and dose pages were reviewed to determine the number of phases and dose indices (CT dose index–volume [CTDIvol], dose-length product, size-specific dose estimate). Exams for abdominal or pelvic mass, trauma or urinary leak indications were excluded. Data were compared to internally acquired contrast-enhanced CTs of the abdomen and pelvis by querying the American College of Radiology (ACR) Dose Index Registry. This review was institutional review board and HIPAA compliant. There were 754 contrast-enhanced CTs of the abdomen and pelvis from 104 outside imaging facilities. Fifty-three percent (399/754) had 2 phases, and 2% (14/754) had 3 or more phases. Of the 939 contrast-enhanced CTs of the abdomen and pelvis performed internally, 12% (115) were multiphase exams. Of 88% (664) contrast-enhanced CTs of the abdomen and pelvis from outside imaging facilities with dose data, CTDIvol was 2.7 times higher than our institution contrast-enhanced CTs of the abdomen and pelvis (939) for all age categories as defined by the ACR Dose Index Registry (mean: 9.4 vs. 3.5 mGy, P

OBJECTIVE Imaging registries afford opportunities to study large, heterogeneous populations. The purpose of this study was to examine the American College of Radiology CT Dose Index Registry (DIR) for dose-related demographics and metrics of common pediatric body CT examinations. MATERIALS AND METHODS Single-phase CT examinations of the abdomen and pelvis and chest submitted to the DIR over a 5-year period (July 2011-June 2016) were evaluated (head CT frequency was also collected). CT examinations were stratified into five age groups, and examination frequency was determined across age and sex. Standard dose indexes (volume CT dose index, dose-length product, and size-specific dose estimate) were categorized by body part and age. Contributions to the DIR were also categorized by region and practice type. RESULTS Over the study period 411,655 single-phase pediatric examinations of the abdomen and pelvis, chest, and head, constituting 5.7% of the total (adult and pediatric) examinations, were submitted to the DIR. Head CT was the most common examination across all age groups. The majority of all scan types were performed for patients in the second decade of life. Dose increased for all scan types as age increased; the dose for abdominopelvic CT was the highest in each age group. Even though the DIR was queried for single-phase examinations only, as many as 32.4% of studies contained multiple irradiation events. When these additional scans were included, the volume CT dose index for each scan type increased. Among the studies in the DIR, 99.8% came from institutions within the United States. Community practices and those that specialize in pediatrics were nearly equally represented. CONCLUSION The DIR provides valuable information about practice patterns and dose trends for pediatric CT and may assist in establishing diagnostic reference levels in the pediatric population.

Urinary tract infection (UTI) is the most common infection in children. Prompt diagnosis and treatment of UTI are recommended. In the absence of vesicoureteral reflux (VUR), grade I to IV antibiotic prophylaxis is not warranted following UTI. Voiding cystourethrography (VCUG) is not required after the first UTI unless ultrasound (US) reveals abnormalities that are suggestive of high-grade VUR.

The standard medical education in Western medicine has emphasized skills and knowledge learned from experts, particularly those encountered in the course of postgraduate medical education and through national publications and meetings. This reliance on experts, referred to by Dr. Paul Gerber of Dartmouth Medical School as “eminence-based medicine,” is based on the construct that the individual practitioner, particularly a specialist devoting extensive time to a given discipline, can arrive at the best approach to a problem through his or her experience. The practitioner builds up an experience base over years and digests information from national experts who have a greater base of experience due to their focus in a particular area. The evidence-based imaging (EBI) paradigm, in contradistinction, is based on the precept that a single practitioner cannot through experience alone arrive at the best course of action. Assessment of appropriate medical care should instead be derived through an evidence-based process. The role of the practitioner, then, is not simply to accept information from an expert but rather to assimilate and critically assess the research evidence that exists in the literature to guide a clinical decision. This chapter will discuss what evidence-based imaging is and what the evidence-based process is and how to apply this process.

Acute lower abdominal and pelvic pain in premenopausal women has a wide range of etiologies including gastrointestinal, urological, obstetrical, and gynecological causes. Specifically, in younger patients, it is difficult to localize the pain during both history and physical examination, making it a diagnostic challenge. Life- and/or fertility-threatening conditions are the first to be considered until they can be confidentially excluded. History, physical examination, and laboratory testing narrow the differential diagnosis and guide the physician to choose the proper imaging test. Ultrasound is the recommended initial imaging tool for pregnant and nonpregnant women and girls presenting with acute pelvic pain and in which a gynecological etiology is suspected.

Intussusception is an acquired invagination of the bowel into itself, usually involving both small and large bowel. Ileocolic intussusception is the most common cause of small bowel obstruction in children and occurs in at least 56 children per 100,000 per year in the USA. Intussusception is an emergent condition where delay in diagnosis is not rare and may result in bowel obstruction, venous congestion, subsequent bowel necrosis, and perforation. Ultrasound plays a key role in both diagnosis and management of this entity. This chapter provides the evidence summary and tools in these situations.

Evidence-based imaging (EBI) requires the critical assessment and application of the best available evidence to patient imaging. Unfortunately, the published studies that comprise the available evidence are often limited by bias, small sample size, and methodological inadequacy. Further, the information provided in published reports may be insufficient to allow estimation of the quality of the research. Initiatives by journal editors to improve the reporting of research studies, including the CONSORT (1), STARD (2), SQUIRE (3), and others, provide useful guides but are incompletely implemented. The objective of this chapter is to summarize the common sources of error and bias in the imaging literature to guide the critical assessment required for EBI.

Malrotation of the small bowel and abnormal mesenteric fixation can lead to potentially life-threatening midgut volvulus. Evaluation for malrotation is part of every pediatric upper GI exam, particularly in the neonate and infant. While the diagnosis of malrotation is often straight forward, perhaps 15% of upper gastrointestinal (UGI) studies result in findings that are equivocal, leading to both false-positive and false-negative results. Additionally, much less is known about the less common situation of abnormalities limited to colonic malrotation and mesocolon malfixation. This chapter summarizes the evidence and provides common pitfalls for imaging.

Patient-centered emergency diagnostic imaging relies on efficient communication and multispecialty care coordination to ensure optimal imaging utilization. The construct of the emergency diagnostic imaging care coordination cycle with three main phases (pretest, test, and posttest) provides a useful framework to evaluate care coordination in patient-centered emergency diagnostic imaging. This article summarizes findings reached during the patient-centered outcomes session of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The primary objective was to develop a research agenda focused on 1) defining component parts of the emergency diagnostic imaging care coordination process, 2) identifying gaps in communication that affect emergency diagnostic imaging, and 3) defining optimal methods of communication and multidisciplinary care coordination that ensure patient-centered emergency diagnostic imaging. Prioritized research questions provided the framework to define a research agenda for multidisciplinary care coordination in emergency diagnostic imaging.

Objectives The objective was to evaluate variation in the current estimated radiation dose index for pediatric cervical spine (c-spine) computed tomography (CT) examinations. Methods This was a retrospective analysis of pediatric (age younger than 19 years) c-spine CT examinations from the American College of Radiology Dose Index Registry, July 2011 through December 2014. We used the volume CT dose index (CTDIvol) as the radiation dose estimate and used summary statistics to describe patient and hospital characteristics. Results There were 12,218 pediatric CT c-spine examinations performed across 296 participating hospitals. Fifty-six percent were in male patients, and 79% were in children older than 10 years. Most hospitals (55%) were community hospitals without trauma designations, and the largest proportion of examinations (41%) were performed at these hospitals. The median CTDIvol was 15 mGy (interquartile range = 9 to 23 mGy) representing a more than 2.5-fold difference between the 25th and 75th percentiles. Pediatric hospitals (both trauma and nontrauma centers) delivered the lowest CTDIvol across all age groups and showed the least amount of variability in dose. Conclusions There is significant variation in the radiation dose index for pediatric c-spine CT examinations. Pediatric hospitals practice at lower CT dose estimates than other hospitals. Individual hospitals should examine their practices in an effort to ensure standardization and optimization of CT parameters to minimize radiation exposures to pediatric patients.

The purpose of this study was to assess the effectiveness and safety of air versus liquid enema reduction in the treatment of intussusception in children.Literature searches of the PubMed, Embase, and Cochrane Library databases were conducted from January 1, 1966, through May 31, 2013. Articles on the use of air or liquid enema in children with a confirmed diagnosis of intussusception and reporting either a success rate for enema reduction of intussusception or a perforation rate were selected. Enema reduction success rate, perforation rate, and recurrence rate were the main outcomes and were calculated by random effects modeling.One hundred two articles (101 reporting success rate, 71 reporting perforation rate) were included that presented results for 32,451 children (age range, 1 day-22 years; boys, 66%; girls, 34%). In 44 studies (16,187 children), the combined estimate for success rate of air enema was 82.7% (95% CI, 79.9-85.6%; inconsistency index [I(2)] = 97%), and in 52 studies (13,081 children) of liquid enema, it was 69.6% (95% CI, 65.0-74.1%; I(2) = 98%). In 38 studies (15,752 children), the combined estimate of perforation rate for air enema was 0.39% (95% CI, 0.23- 0.55%; I(2) = 40%), and in 30 studies (9429 children) of liquid enema, it was 0.43% (95% CI, 0.24- 0.62%; I(2) = 9%). Among 10,494 children (26 studies) undergoing air enema reduction, the rate of first intussusception recurrence was 6% (95% CI, 4.5-7.5%; I(2) = 89%), similar to the 7.3% (95% CI, 5.8-8.8%; I(2) = 71%) found for 4004 children (24 studies) undergoing liquid enema reduction.Air enema was superior to liquid enema for intussusception reduction. The success rate was higher without a difference in perforation rate. Limitations included heterogeneity and publication bias.

The purpose of this study was to estimate the prevalence of reported near-miss wrong-patient events in radiology at two large academic hospitals and its relation to imaging modality, clinical setting, and time of occurrence.An institutional imaging report database was searched for reports between January 1, 2009, and May 30, 2013, that contained the phrases "incorrect patient" or "wrong patient." These imaging reports were categorized into either mislabeled or misidentified patient or wrong dictation or report events. The mislabeling-misidentification events involved patients whose images were incorrectly placed in another patient's folder. In wrong dictation or report events, a patient's images were placed in the correct imaging folder, but another patient's images were used in error for dictation of the report. The time to detect each of these events was also evaluated.Overall, 67 eligible reports were identified among 1,717,713 examinations performed during the study period. The estimated event rate was 4 per 100,000 examinations (mislabeling-misidentification, 52%; wrong dictation, 48%). The monthly mean of mislabeling-misidentification events was 0.7 (SD, 0.9) and of wrong dictation events was 0.6 (SD, 0.7). The median time for mislabeling-misidentification reports to be identified was 22 hours and for wrong dictation reports was 0 hours. Portable chest radiography was the modality involved in 69% (24/35) of reported mislabeling-misidentification and 44% (14/32) of wrong dictation events (p = 0.08); 43% (15/35) of mislabeling-misidentification and 28% (9/32) of wrong dictation events occurred during off hours; 63% (22/35) of mislabeling-misidentification and 56% (18/32) of wrong dictation events occurred in the inpatient setting.Despite use of the dual-identifier technique mandated by The Joint Commission, the number of near-miss mislabeled patient events for imaging tests and the delay in awareness of these events were substantial, especially for radiography.

We developed a longitudinal care coordination service to proactively deliver high-quality and family-centered care in patients receiving radioiodine therapy for thyroid cancer. In an iterative, multidisciplinary team manner, a pretherapy consultation service, which included scripted interactions, documentation, and checklists for quality control, evolved over time into a robust patient-centered longitudinal care coordination nuclear medicine service. Radiation safety precautions, the rationale for therapy, and management of patient expectations were addressed through the initial consultation, and discharge and posttreatment care were managed during subsequent follow-up. The patient-physician relationship created during longitudinal nuclear medicine therapy care is one tool to help counteract the growing commoditization of radiology. This article describes the process that the nuclear medicine specialists in our department established to enhance radiologist value by providing both exceptional thyroid cancer treatment and continuity of care.

OBJECTIVE. The purpose of this article is to examine the variation in radiation dose, CT dose index volume (CTDIvol), and dose-length product (DLP) for pediatric head CT examinations as a function of hospital characteristics across the United States. MATERIALS AND METHODS. A survey inquiring about hospital information, CT scanners, pediatric head examination protocol, CTDIvol, and DLP was mailed to a representative sample of U.S. hospitals. Follow-up mailings were sent to nonrespondents. Descriptive characteristics of respondents and nonrespondents were compared using design-based Pearson chi-square tests. Dose estimates were compared across hospital characteristics using Bonferroni-adjusted Wald test. Hospital-level factors associated with dose estimates were evaluated using multiple linear regressions and modified Poisson regression models. RESULTS. Surveys were sent out to 751 hospitals; 292 responded to the survey, of which 253 were eligible (35.5% response rate, calculated as number of hospitals who completed surveys [n = 253] divided by sum of number who were eligible and initially consented [n = 712] plus estimated number who were eligible among those who refused [n = 1]). Most respondents reported using MDCT scanners (99.2%) and having a dedicated pediatric head CT protocol (93%). Estimated mean reported CTDIvol values were 27.3 mGy (95% CI, 24.4-30.1 mGy), and DLP values were 390.9 mGy × cm (95% CI, 346.6-435.1 mGy × cm). These values did not vary significantly by region, trauma level, teaching status, CT accreditation, number of CT scanners, or report of a dedicated pediatric CT protocol. However, estimated CTDIvol reported by children's hospitals was 19% lower than that reported by general hospitals (p0.01). CONCLUSION. Most hospitals (82%) report doses that meet American College of Radiology accreditation levels. However, [corrected] the mean CTDI(vol) at children's hospitals was approximately 7 mGy (21%, adjusted for covariates), lower than that at nonchildren's hospitals.

Every year, multiple open-microphone sessions are hosted at the ACR AMCLC. These sessions allow members of the College to offer opinions, experiences, and questions regarding challenges facing radiologists and the future of the profession. At the 2014 AMCLC, 3 such sessions focused, respectively, on radiology's workforce, the obstacles slowing the shift from volume to value, and alternative reimbursement models and the shifting physician employment landscape. These open-microphone sessions framed contemporary obstacles and emerging challenges that professional radiology societies, such as the ACR, should target with new initiatives and use of resources; in addition, the sessions revealed opportunities for members, councilors, and state chapters to respond with meaningful resolutions and policy proposals.

Aim: To investigate determinants of receiving cancer-directed therapies and their potential survival impact in nonresected hepatocellular carcinoma (HCC) Materials & methods: Nonsurgically resected HCC patients between 2000 and 2010 were stratified by American Joint Committee on Cancer staging and the type of therapy. Predictors of receiving therapy were identified and implication on survival was evaluated. Results: Out of 9239 patients included, those receiving any therapy demonstrated prolonged overall survival with following median overall survival (months): ablation (30.8), Yttrium-90 (15.6), transcatheter arterial chemoembolization (15.5), Sorafenib (5.6), versus no cancer-directed therapy (3.7; p-values

The purpose of this study was to evaluate the impact of trainee involvement and other factors on addendum rates in radiology reports.This retrospective study was performed in a tertiary care pediatric hospital. From the institutional radiology data repository, we extracted all radiology reports from January 1 to June 30, 2016, as well as trainee (resident or fellow) involvement, imaging modality, patient setting (emergency, inpatient, or outpatient), order status (routine vs immediate), time of interpretation (regular work hours vs off-hours), radiologist's years of experience, and sex. We grouped imaging modalities as advanced (CT, MRI, and PET) or nonadvanced (any modality that was not CT, MRI, or PET) and radiologist experience level as ≤ 20 years or20 years. Our outcome measure was the rate of addenda in radiology reports. Statistical analysis was performed using multivariate logistic regression.From 129,033 reports finalized during the study period, 418 (0.3%) had addenda. Reports generated without trainees were 12 times more likely than reports with trainee involvement to have addenda (odds ratio [OR] = 12.2, p0.001). Advanced imaging studies were more likely than nonadvanced studies to be associated with addendum use (OR = 4.7, p0.001). Reports generated for patients in emergency or outpatient settings had a slightly higher likelihood of addendum use than those in an inpatient setting (OR = 1.5, p = 0.04; and OR = 1.3, p = 0.04, respectively). Routine orders had a slightly higher likelihood of addendum use compared with immediate orders (OR = 1.3, p = 0.01). We found no difference in addendum use by radiologist's sex, radiologist's years of experience, emergency versus outpatient setting, or time of interpretation.Trainees may add value to patient care by decreasing addendum rates in radiology reports.

The radiology community (medical physicists, radiologic technologists, radiologists, and interventional proceduralists) has led the educational and awareness efforts in the medical arena to reduce radiation dose to patients through effective collaborations that bridge traditional medical specialty silos to reach health worker stakeholders. These successful collaborations have also included both vendors and regulators, with the overarching goal of radiation protection of patients (justification, optimization, and use of dose reference levels). This focus on patients often raises overall safety awareness and lowers occupational radiation doses as well. It is critical that the entire radiology community continue to act as leaders in these radiation safety efforts for both employees and patients. In order to be successful, it is important to understand safety culture and the growing, worldwide, multimedia resources that are available. There is little time or budget to recreate or duplicate training materials or risk communication information that may already exist. Together with the increasingly fast-paced and demanding healthcare environment and sharp focus on quality, it has never been more important to understand how to achieve better quality care for radiology departments. It is also important to measure and report quality for many customers, including patients, referring providers, and many other stakeholders. This short report will briefly define safety culture and describe methods for using collective learning tools that document radiation protection of patients in diagnostic and interventional imaging. These tools include the use of imaging modality registries, such as the Computed Tomography Does Index Registry, peer review of imaging reports, the use of clinical decision support, and guidelines. Finally, the Image Gently and Image Wisely campaigns provide examples of cross-disciplinary collaboration to improve radiation protection of patients.

Assess the added value of nonenhanced computed tomography (NECT) to contrast-enhanced CT (CECT) of the abdomen for characterization of hypervascular liver metastases and incidental findings. Institutional review board approved, Health Insurance Probability and Accountability Act compliant, retrospective study of patients with melanoma, neuroendocrine tumor, or thyroid cancer. First available triphasic abdomen CT after initial diagnosis was reviewed by 3 radiologists. The 3 most suspicious lesions were characterized on the CECT as benign or malignant and then recharacterized after reviewing the NECT with CECT. Incidental renal and adrenal lesions were characterized similarly. Diagnostic performance of CECT vs its combination with NECT was assessed. Statistical significance level was set at P < 0.05. A total of 81 patients were included (mean age = 55 years; 52% male; 64% with liver lesions; 27% and 11% with incidental renal and adrenal lesions, respectively). Percentage area under the curve and 95% CI of CECT vs combination with NECT for characterization of liver metastases was 98(94–100) vs 99(96–100) for reviewer 1 (P = 0.35), 93(86–100) vs 94(87–100) for reviewer 2 (P = 0.23), and 96(90–100) vs 99(97–100) for reviewer 3 (P = 0.32). Mean difference in area under the curve and 95% CI between 2 protocols for characterization of liver, renal, and adrenal lesions were −0.007(−0.05 to 0.04) (P = 0.63), −0.09(−0.25 to 0.07) (P = 0.22), and −0.01(−0.05 to 0.02) (P = 0.27), respectively. After addition of NECT, confidence level for lesion characterization increased 4%–15% for liver metastases, 18%–59% and 33%–67% for renal and adrenal lesions, respectively. In conclusion, while addition of NECT to CECT improved radiologist' confidence, there was no statistically significant change in characterization of hypervascular liver metastases or incidental renal and adrenal lesions.

The purpose of the International Commission on Radiological Protection (ICRP) Committee 3 Working Party was to update the 2001 web-based module ‘Radiation and your patient: a guide for medical practitioners’ from ICRP. The key elements of this task were: to clearly identify the target audience (such as healthcare providers with an emphasis on primary care); to review other reputable sources of information; and to succinctly publish the contribution made by ICRP to the various topics. A ‘question-and-answer’ format addressing practical topics was adopted. These topics included benefits and risks of imaging using ionising radiation in common medical situations, as well as pertaining to specific populations such as pregnant, breast-feeding, and paediatric patients. In general, the benefits of medical imaging and related procedures far outweigh the potential risks associated with ionising radiation exposure. However, it is still important to ensure that the examinations are clinically justified, that the procedure is optimised to deliver the lowest dose commensurate with the medical purpose, and that consideration is given to diagnostic reference levels for particular classes of examinations.

To increase detection of mislabeled medical imaging studies evidence shows it may be useful to include patient photographs during interpretation. This study examined how inclusion of photos impacts visual search. Ten radiologists viewed 21 chest radiographs with and without a photo of the patient while search was recorded. Their task was to note tube/line placement. Eye-tracking data revealed that presence of the photo reduced the number of fixations and total dwell on the chest image as a result of periodically looking at the photo. Average preference for having photos was 6.10 on 0-10 scale and neck and chest were preferred areas.

To increase detection of mislabeled medical imaging studies, evidence shows it may be useful to include patient photographs during interpretation. This study examined how inclusion of photographs impacts visual search.Ten radiologists participated. Average age was 43.00 years and average years Board-certified was 9.70, with 2 residents, 1 general, 2 abdominal, 4 cardiothoracic, and 1 pediatric radiologist. They viewed 21 portable chest radiographs with and without a simultaneously acquired photograph of the patient while visual search was recorded. Their task was to note placement of lines and tubes.Presence of the photograph reduced the number of fixations (chest radiograph only mean 98.68; chest with photograph present 80.81; photograph 10.59; p 0.0001) and total dwell (chest radiograph only mean 30.84 seconds; chest radiograph with photograph present 25.68; photograph 3.93; p 0.0001) on the chest radiograph as a result of periodically looking at the photograph. Overall viewing time did not increase with addition of the photograph because time not spent on the radiograph was spent on the photograph. On average, readers scanned from the radiograph to the photographs about four times during search. Men and non-cardiothoracic radiologists spent significantly more time scanning all the images, including the photographs. Average preference for having photographs was 6.10 on a 0-10 scale, and neck and chest were preferred as areas to include in the photograph.Photographs may help with certain image interpretation tasks and may help personalize the reading experience for radiologists without increasing interpretation time.

With the goal of raising awareness and developing stakeholder educational tools for the appropriate imaging of children, the Image Gently campaign was launched in 2007. This campaign is a product of a multidisciplinary alliance with international representation which now numbers nearly 100 medical and dental professional societies and organisations, and includes regulatory organisations. The alliance focuses on increasing awareness and developing education materials that support the protection of children worldwide from unnecessary radiation in medicine. The alliance members work with agencies and regulatory bodies to improve standards and measures that are specific to children. The campaign has produced open source modules for all stakeholders regarding CT, fluoroscopy, nuclear medicine, interventional radiology, digital radiography and dental imaging. The philosophy of the Image Gently steering committee is to collaborate, to share information freely, to keep messaging simple and to commit to lifelong learning. Many healthcare practitioners may not understand how to decrease children’s radiation exposure; the goal of Image Gently is to increase all stakeholders’ understanding of both the benefits and the risks and to encourage radiation reduction strategies. This article summarises the rationale and goals of the global campaign to date.

Waardenburg syndrome (WS) is a rare genetic disorder secondary to neural crest cell developmental abnormalities. It is predominantly described as an auditory–pigmentary syndrome with diverse patient presentation, typically involving congenital sensorineural hearing loss and pigmentation abnormalities of the skin, hair, and iris. Other developmental abnormalities that may be associated with this syndrome are Hirschsprung's disease and a myriad of cardiovascular congenital defects. We present a case of a young girl with WS who found to have a persistent left superior vena cava (PLSVC) draining into the coronary sinus. The prevalence of PLSVC is increased in patients with chromosomal and genetic abnormalities. However, we are the first to report its presence in association with WS while discussing the challenges that may arise during central venous catheter placement in patients with PLSVC.