Pediatric Radiation Exposure Research Articles

Risks of leukemia, intracranial tumours and lymphomas in childhood and early adulthood after pediatric radiation exposure from computed tomography.

Children are more susceptible to radiation-induced damage than adults, but little research has compared the risk of cancer after exposure to radiation during computed tomography (CT) among children at different ages. We aimed to explore the risk of intracranial tumours, leukemia or lymphoma among children, adolescents and young adults (aged < 25 yr) after radiation exposure from CT at or before the age of 18 years. We conducted a nested, population-based case-control study using data from Taiwan's publicly funded health care system. We identified participants younger than 25 years with newly diagnosed intracranial tumours, leukemia or lymphoma, from Jan. 1, 2000, to Dec. 31, 2013. We assigned 10 non-cancer controls for each case, matching by sex, date of birth and day of entry to the cohort. We considered CT scans received at or before the age of 18 years and 3 or more years before the index date (the date of cancer diagnosis for cases) as exposure. We used conditional logistic regression models and incidence rate ratios (IRRs) to estimate the relationship between risk of these cancers and CT radiation exposure. We identified 7807 cases and matched to 78 057 controls. Compared with no exposure, exposure to a single pediatric CT scan did not increase risk of intracranial tumours, leukemia or lymphoma. However, participants exposed to 4 or more CT scans had an elevated incidence (IRR 2.30, 95% confidence interval 1.43-3.71) of one of the cancer outcomes of interest. Receiving 4 or more CT scans at or before 6 years of age was associated with the highest risks of cancer, followed by ages 7-12 years and 13-18 years (p for trend < 0.001). Exposure to a single CT scan was not associated with increased risks of subsequent intracranial tumours, leukemia or lymphoma among children; however, we observed increased cancer risks among those with 4 or more CT scans, especially among younger children. Although these cancers are uncommon, the findings of this study underscore the importance of prudent use of CT in the pediatric population.

Decreasing Radiation Exposure in Pediatric Clavicle and Metatarsal Fractures: A QI Initiative.

Protecting the pediatric population from unnecessary medical radiation is an important public health initiative. Efforts have been made to reduce radiation exposure in the treatment of pediatric fractures without compromising quality of care. Using a standardized protocol for imaging of pediatric clavicle and metatarsal fractures is a reliable method for reducing pediatric radiation exposure in the management of these fractures. In the year 2015, the senior author altered follow-up imaging practices for 2 common pediatric fractures: metatarsal and clavicular. Initial radiographic evaluation included the standard 3 views for metatarsal fractures and 2 views for clavicle fractures. This standard diagnostic procedure remained constant throughout the study. Follow-up x-rays from 2009 to 2014 routinely included 3 views of the foot and 2 views of the clavicle. The protocol was changed and from 2016 to 2019, follow-up x-rays for fractures routinely included 2 views of the foot and 1 view of the clavicle, thereby decreasing the number of x-rays utilized to manage these fractures. There was a significant reduction in the number of clavicle x-rays (P<0.001) and metatarsal x-rays (P=0.004) taken in follow-up between the time-periods. Median values for metatarsal views decreased by 1, matching the adjustment in protocol. In addition, the vast majority of clavicle fractures (90.80%) were managed with 1 follow-up view in 2016 to 2019 compared with 2 views (72.48%) from 2009 to 2014. This study achieved a reduction in radiation exposure in pediatric patients with nonoperatively managed clavicle and metatarsal fractures. Improving the quality of care of patients through decreasing the number of x-rays taken protects individuals from adverse side effects, as well as offers various public health benefits in terms of reduction in expenditures. Level III-retrospective comparative study.

National Imaging Trends in Pediatric Traumatic Brain Injury and Hydrocephalus

Reduction in use of computed tomography (CT) in favor of rapid-sequence magnetic resonance imaging (MRI) to decrease pediatric radiation exposure has varied across institutions in the United States. The aims of this study were to understand national trends in CT and rapid-sequence MRI usage and identify variables affecting imaging practices and obstacles to CT reduction. This was a retrospective review of deidentified discharge data for children with hydrocephalus and traumatic brain injury (TBI) in the Healthcare Cost and Utilization Project Kids' Inpatient Database in 2000, 2003, 2006, 2009, 2012, and 2016. Utilization of MRI without contrast and CT was extracted using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, codes. Hospital region and age cohorts were extracted and used to categorize data. χ2 tests and logistic regression were used for analysis. Hospitalizations utilizing CT decreased (P < 0.05) and hospitalizations utilizing MRI increased (P < 0.05) overall in both diagnosis groups throughout the years analyzed. However, there was significant regional variation in imaging. The Northeast had higher CT rates (P < 0.05) and the South had lower CT rates in patients with hydrocephalus and TBI (P < 0.05). No regional variation was found for rates of MRI use in patients with TBI. Nationwide, the average number of discharges after hospitalizations utilizing CT in patients with hydrocephalus and TBI has decreased, while discharges after hospitalizations utilizing MRI as an alternative imaging modality have increased. Despite successful overall CT reduction, significant regional variation exists within this trend showing inconsistent reduction of CT use.

Targeted head CT reduction for pediatric patients with hydrocephalus and traumatic brain injury: academic center institutional experience as an example of opportunities for further improvement

Recent studies aim to reduce radiation exposure associated with computed tomography (CT) using rapid-sequence magnetic resonance imaging (MRI). We evaluated imaging modalities used for hydrocephalus and traumatic brain injury (TBI) to identify opportunities for further radiation exposure reduction. Pediatric (≤ 18 years) patients, with either hydrocephalus or TBI receiving a head CT or head MRI from 2009 to 2017, were quantified using ICD9, ICD10, and CPT codes at a large university hospital. The odds ratios of receiving each imaging modality year-to-year and receiving a MRI or CT in a given year with each diagnosis were calculated. Beginning in 2015, hydrocephalus patients were more likely to receive a MRI vs CT (p < 0.0001), with likelihood increasing in the following 2 years. TBI patients were more likely to receive a CT than an MRI from 2009 to 2017. There was a smaller overall decrease in CT scans in TBI patients (p < 0.05) than hydrocephalus patients (p < 0.0001) and a larger increase in MRI use in hydrocephalus patients (p < 0.05) than TBI patients (p < 0.05) from 2009 to 2017. Use of CT to evaluate hydrocephalus significantly decreased over the last 3-year time period. However, CT use for TBI patients was inconsistent and did not decrease proportionally, potentially representing a belief that CT is more effective than MRI for detecting hemorrhage. There was greater use of MRI as an alternate imaging method in hydrocephalus patients than TBI patients. Head injury remains an area of improvement to decrease pediatric radiation exposure at our institution and may be an area in need of attention more broadly.

Radiation exposure during videofluoroscopic swallowing studies in young children

ObjectivesSwallowing difficulties are best assessed by videofluoroscopic swallowing studies (VFSS). However, limiting radiation exposure is important, especially in young children. The purpose was to evaluate radiation dose in young children during VFSS, and to investigate factors associated with it. MethodsChildren with swallowing difficulty who underwent VFSS from February 2012 to July 2014 were recruited. Dose area product (DAP) and screening time were offered by the fluoroscopy machine, and effective dose was calculated from the DAP using a conversion coefficient published by the National Radiological Protection Board (NRPB-R262). The age, gender, height, weight, body mass index (BMI), body surface area (BSA), underlying disease of the subject children, and results of VFSS were investigated. ResultsIn 89 children (mean age 1.57 ± 2.17, 55 boys and 34 girls), mean effective dose was 0.29 ± 0.20 mSv, mean DAP was 2.41 ± 1.65 Gy cm2, and mean screening time was 2.24 ± 0.99 min. The effective dose correlated with the screening time (r = 0.598, p < 0.001), age (r = 0.210, p = 0.049), height (r = 0.521, p < 0.001), weight (r = 0.461, p < 0.001), and BSA (r = 0.493, p < 0.001). There was no such correlation with gender, BMI, underlying disease, or the results of VFSS. ConclusionsThe effective dose during VFSS (0.29 mSv) in young children, which is affected by screening time, age, and body size, is considerably lower than the pediatric radiation exposure limit of 1 mSv per year. However more than 4 VFSS annually would exceed this limit. Our findings will help physicians to reduce the radiation exposure and provide a useful references for future pediatric VFSS guidelines.

Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types

BackgroundTrauma is a common indication for computed tomography (CT) in children. However, children are particularly vulnerable to CT radiation and its associated cancer risk. Identifying differences in CT usage across trauma centers and among specific populations of injured children is needed to identify where quality improvement initiatives could be implemented in order to reduce excess radiation exposure to children. We evaluated computed tomography (CT) rates among injured children treated at pediatric (PTC), mixed (MTC), or adult trauma centers (ATC) and estimated the resulting differential in potential cancer risk. MethodsWe identified children age ≤18 years with blunt injury AIS ≥2 treated from 2010 to 2013 at 130 U.S trauma centers participating in the Trauma Quality Improvement Program. CT rates were compared across center types using Chi-square analysis. Stratified analyses in children with varying injury severity, mechanism, and age were performed. We estimated the impact of differential rates of CT scans on cancer risk using published attributable risks. ResultsAmong 59,010 children identified, CT rates were higher among injured children treated at ATC and MTC versus PTC. Findings were consistent after stratified analyses and were most striking in children with chest and abdomen/pelvis CT, adolescent age, low injury severity and fall injury mechanism. We estimated that for every 100,000 injured children, imaging practices in ATC and MTC would lead to an additional 17 and 16 lifetime cancers, respectively, when compared to PTC. ConclusionCT use among injured children is higher at ATC and MTC compared to PTC. Children with low injury severity, fall injury mechanism, and adolescent age are most vulnerable to differential imaging practices across centers. Quality improvement initiatives aimed at reducing heterogeneity in CT usage across trauma centers are required to mitigate pediatric radiation exposure and cancer risk.

Decreasing Radiation Exposure in Pediatric Trauma Related to Cervical Spine Clearance: A Quality Improvement Project.

Quality improvement project. Reduce the amount of radiation exposure in the pediatric trauma population 5 years of age and older in relation to cervical spine clearance. The evaluation of pediatric cervical spine injuries must be accurate and timely to avoid missed injuries. The difficult clinical examination in pediatric trauma patients necessitates the use of radiologic examinations to avoid missing catastrophic injuries. However, exposure to radiation at an early age increases the pediatric patients' risk of developing cancer (R. A. ). A retrospective chart review was conducted to assess radiation exposure in pediatric patients requiring evaluation for cervical spine clearance. Surgical staff and emergency department physicians received education on the risks related to pediatric radiation exposure and information related to the institution's diagnostic trends for cervical spine clearance. An algorithm was then developed to assist with determining the necessary imaging study for cervical spine clearance. Radiation exposure was monitored following initial education and use of the algorithm to determine its effect on radiation exposure. The retrospective chart review identified cervical spine computed tomography (CT) in 34%, with an average radiation exposure of 3.5 mSv. Following education and introduction of an algorithm, 18% of patients underwent CT for cervical spine clearance with an average radiation exposure of 3.2 mSv, representing a 47% decrease in the use of CT. Staff education and the use of an algorithm show promise in the reduction of radiation exposure and provide safe, effective clearance of the cervical spine in pediatric trauma.

Estimation of effective dose and radiation risk in pediatric barium studies procedures

The objectives of this study are to assess pediatric radiation exposure in certain barium studies and to quantify the organ and effective doses and radiation risk resultant from patients' irradiation. A total of 69 pediatric barium studies for upper and lower gastrointestinal tract. Patients' radiation dose was quantified in terms of Entrance surface air kerma (ESAKs) using exposure parameters and DosCal software. Organ and effective doses (E) were extrapolated using national Radiological Protection Board software (NRPB-R279). The mean ± (SD) and the range of patient doses per procedure were 3.7 ± 0.4 (1.0–13.0) mGy, 7.4 ± 1.7(5.5–8.0) mGy and 1.4 ± 0.9 (0.5–3.6) mGy for barium meal, swallow and enema, respectively. The mean effective doses were 0.3 ± 0.03 (0.08–1.1) mSv, 0.2 ± 1.6 (0.44–0.7) mSv and 0.3 ± 0.9 (0.1–0.8) mSv at the same order. The radiation dose were higher compared to previous studies. Therefore, pediatrics are exposed to avoidable radiation exposure. Certain optimization measures are recommended along with establishing national diagnostic reference level (DRL) to reduce the radiation risk.

Evaluation of an imaging protocol using ultrasound as the primary diagnostic modality in pediatric patients with superficial soft tissue infections of the face and neck

ObjectiveTo determine the clinical impact of an initiative to use ultrasound (US) as the primary diagnostic modality for children with superficial face and neck infections versus use of computed tomography (CT). MethodsChildren with a diagnosis of lymphadenitis, face or neck abscess, or face and neck cellulitis were retrospectively evaluated by the otolaryngology service. Patients were separated into two groups based on implementation of a departmental initiative to use US as the primary diagnostic modality. The pre-implementation cohort consisted of patients treated prior to the initiative (2006–2009) and the current protocol cohort consisted of patients treated after the initiative was started (2010–2013). Demographics, use of US or CT, necessity of surgical intervention, and failure of medical management were compared. ResultsThree hundred seventy three children were evaluated; 114 patients were included in the pre-implementation cohort and 259 patients were included in the current protocol cohort for comparison. Patients presenting during the current protocol period were more likely to undergo US (pre-implementation vs. current protocol, p-value) (12% vs. 49%, p < 0.0001) and less likely to undergo CT (66% vs. 41%, p < 0.0001) for their initial evaluation. There were no differences in the percentage of children who underwent prompt surgical drainage, prompt discharge without surgery, or trial inpatient observation. There were also no differences in the rate of treatment failure for patients undergoing prompt surgery or prompt discharge on antibiotics. For those patients who underwent repeat evaluation following trial medical management, US was used more frequently in the current protocol period (4% vs. 20%, p = 0.002) with no difference in CT use, selected treatment strategy, or treatment failure rates. ConclusionIncreased use of US on initial evaluation of children with superficial face and neck infections resulted in decreased CT utilization, without negatively impacting outcome. Decreasing pediatric radiation exposure and potential long-term effects is of primary importance.

Measurements of pediatric radiation exposure during barium imaging procedures

Radiological imaging has been considered a vital tool in the diagnosis of gastrointestinal tract (GIT) disorders. Gastrointestinal radiography (GIR) has been a major and first-choice method for diagnosing GIT diseases with barium as contrast media since its emergence in 1910. Radiographic examination of children, especially neonates, attracts particular interest because of the increased opportunity for expression of delayed radiogenic cancers as a consequence of relative longer life expectancy. Barium studies are of particular interest because it constitutes 5% of the total number of radiological examinations and 17% of the collective doses. Although, the task is important, there are few data on radiation doses to infants and children undergoing barium procedures. The current study intends to evaluate the radiation dose to pediatric patients during barium studies and to estimate the effective doses and radiation risk of the aforementioned procedures. A total of 43 pediatric barium procedures were performed in this study. 21.7% of the sample was barium meal, 8.6% were undergone barium swallow while 69.5% of the sample were barium enemas. Entrance surface air kerma (ESAKs) were calculated from patient exposure parameters using DosCal software. Effective doses (E) were calculated using published conversion factors and methods recommended by the national Radiological Protection Board (NRPB). The mean film numbers was 12.4, 8.9 and 8 for barium meal, barium enema and barium swallow, respectively. The maximum number of X rays was obtained in barium meal (21 film per a single procedure). The mean patient doses per procedure were 2.1 ± 0.8 mGy, 3.0 ± 23 mGy and 1.2 ± 0.2 mGy for barium meal, swallow and enema, respectively. The mean effective doses were 0.3 mSv, 1.0 mSv and 0.2 mSv at the same order. The dose values in this study were higher than previous studies. The unnecessary radiation exposure can be reduced significantly by reducing the number of films and screening time. Diagnostic reference level is recommended to improve the practice. Disclosure Authors have nothing to disclose.

Prospective Assessment of Radiation in Pediatric Urology: The Pediatric Urology Radiation Safety Evaluation Study

Pediatric tissues are exquisitely sensitive to ionizing radiation from diagnostic studies and therapies involving fluoroscopy. We prospectively monitored radiation exposure in our pediatric urology patients during fluoroscopy guided operative procedures with single point dosimeters to quantify radiation dose. Children undergoing fluoroscopy guided urological procedures were prospectively enrolled in the study from 2013 to 2015. Single point dosimeters were affixed to skin overlying the procedural site for the durations of the procedures to record dosimetry data. Patient demographics, procedural variables and fluoroscopic settings were recorded. A total of 78 patients underwent 96 procedures, including retrograde pyelography, ureteral stent insertion, ureteroscopy and percutaneous nephrolithotomy. Median patient age was 12 years (range 0.3 to 17) and median body mass index percentile for age was 70.7 (1.0 to 99.1). Median skin entrance radiation dose for all procedures performed was 0.56 mGy. Median dosages associated with the 29 diagnostic procedures and 49 definitive interventions were 0.6 mGy (mean 0.8, range 0.1 to 2.2) and 0.7 mGy (1.1, 0.0 to 5.5), respectively. The dose associated with the 18 procedures of temporization was significantly higher by comparison (median 1.0 mGy, mean 2.6, range 0.1 to 10.7, p = 0.02). Pediatric radiation exposure is not insignificant during urological procedures. Further multi-institutional work would provide context for our findings. Protocols to optimize fluoroscopic settings and minimize patient exposure, and guidelines for radiation based imaging should have a key role in all pediatric radiation safety initiatives.

Evaluation of an initiative to reduce radiation exposure from CT to children in a non-pediatric-focused facility.

We would like to share our experience of reducing pediatric radiation exposure. Much of the recent literature regarding successes of reducing radiation exposure has come from dedicated children's hospitals. Nonetheless, over the past two decades, there has been a considerable increase in CT imaging of children in the USA, predominantly in non-pediatric-focused facilities where the majority of children are treated. In our institution, two general hospitals with limited pediatric services, a dedicated initiative intended to reduce children's exposure to CT radiation was started by pediatric radiologists in 2005. The initiative addressed multiple issues including eliminating multiphase studies, decreasing inappropriate scans, educating referring providers, training residents and technologists, replacing CT with ultrasound or MRI, and ensuring availability of pediatric radiologists for consultation. During the study period, the total number of CT scans decreased by 24 %. When accounting for the number of scans per visit to the emergency department (ED), the numbers of abdominal and head CT scans decreased by 37.2 and 35.2 %, respectively. For abdominal scans, the average number of phases per scan decreased from 1.70 to 1.04. Upon surveying the pediatric ED staff, it was revealed that the most influential factors on ordering of scans were daily communication with pediatric radiologists, followed by journal articles and lectures by pediatric radiologists. We concluded that a non-pediatric-focused facility can achieve dramatic reduction in CT radiation exposure to children; however, this is most effectively achieved through a dedicated, multidisciplinary process led by pediatric radiologists.

MP40-12 THE EFFECT OF RACE AND SKIN COLOR ON NEAR-INFRARED SPECTROSCOPY READINGS IN PEDIATRIC PATIENTS WITH UNILATERAL ACUTE SCROTUM

fluoroscopic settings were recorded. Dosimetry data was recorded after analysis of single point dosimeters. RESULTS: Seventy-one patients underwent 75 operative procedures including retrograde pyelogram, ureteral stent insertion ureteroscopy and percutaneous nephrolithotomy (PCNL) with dosimeter placement. Underlying diagnoses included nephrolithiasis, calyceal diverticulum, hematuria, hydronephrosis and ureteropelvic junction obstruction. Mean age was 10.8 years, and mean BMI was 21.4 (62nd percentile for age). Dosimetry data demonstrated overall cohort average dose of 210 mrad per procedure. When divided by procedure, patients received a mean dose of 2,887 mrad per PCNL, 315 mrad per ureteroscopy, 149 mrad per stent insertion and 160 mrad per retrograde pyelogram. Radiation dose was significantly higher in patients undergoing PCNL when compared with ureteroscopy, stent insertion and retrograde pyeologram. CONCLUSIONS: Pediatric radiation exposure during urologic procedures is not insignificant, approaching and exceeding the recommended limit of 500mrad/year for patients under 18 years of age. Further study characterizing pediatric urologic exposure across multiple institutions would provide context for our findings. Protocols to optimize fluoroscopic settings and minimize patient exposure continue to be refined, andshouldplayakey role inall pediatric radiationsafety initiatives.

MP40-11 PROSPECTIVE ASSESSMENT OF PEDIATRIC RADIATION EXPOSURE: THE PEDIATRIC UROLOGY RADIATION SAFETY EVALUATION (PURSE) STUDY

You have accessJournal of UrologyPediatrics: Testis & Varicoceles, Stones1 Apr 2015MP40-11 PROSPECTIVE ASSESSMENT OF PEDIATRIC RADIATION EXPOSURE: THE PEDIATRIC UROLOGY RADIATION SAFETY EVALUATION (PURSE) STUDY Anne Dudley, Moira Dwyer, Pankaj Dangle, Omaya Banihani, Heidi Stephany, Glenn Cannon, Francis Schneck, and Michael Ost Anne DudleyAnne Dudley More articles by this author , Moira DwyerMoira Dwyer More articles by this author , Pankaj DanglePankaj Dangle More articles by this author , Omaya BanihaniOmaya Banihani More articles by this author , Heidi StephanyHeidi Stephany More articles by this author , Glenn CannonGlenn Cannon More articles by this author , Francis SchneckFrancis Schneck More articles by this author , and Michael OstMichael Ost More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1193AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pediatric urologic patients often undergo procedures guided by fluoroscopy. Pediatric tissues are exquisitely sensitive to ionizing radiation, and patients are at risk for detrimental long term effects throughout their lifetimes. We sought to prospectively monitor radiation exposure in our pediatric urologic patients using single point dosimeters during fluoroscopic guided operative procedures. METHODS Pediatric patients undergoing fluoroscopic guided urologic procedures from August 2013 through October 2014 were prospectively enrolled in the IRB approved study. After obtaining informed consent from the patient's guardian, single point dosimeters were affixed to the flank of the planned procedural side with a transparent adhesive dressing. Patient demographics, procedural variables, fluoroscopic settings were recorded. Dosimetry data was recorded after analysis of single point dosimeters. RESULTS Seventy-one patients underwent 75 operative procedures including retrograde pyelogram, ureteral stent insertion ureteroscopy and percutaneous nephrolithotomy (PCNL) with dosimeter placement. Underlying diagnoses included nephrolithiasis, calyceal diverticulum, hematuria, hydronephrosis and ureteropelvic junction obstruction. Mean age was 10.8 years, and mean BMI was 21.4 (62nd percentile for age). Dosimetry data demonstrated overall cohort average dose of 210 mrad per procedure. When divided by procedure, patients received a mean dose of 2,887 mrad per PCNL, 315 mrad per ureteroscopy, 149 mrad per stent insertion and 160 mrad per retrograde pyelogram. Radiation dose was significantly higher in patients undergoing PCNL when compared with ureteroscopy, stent insertion and retrograde pyeologram. CONCLUSIONS Pediatric radiation exposure during urologic procedures is not insignificant, approaching and exceeding the recommended limit of 500 mrad/year for patients under 18 years of age. Further study characterizing pediatric urologic exposure across multiple institutions would provide context for our findings. Protocols to optimize fluoroscopic settings and minimize patient exposure continue to be refined, and should play a key role in all pediatric radiation safety initiatives. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e466-e467 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anne Dudley More articles by this author Moira Dwyer More articles by this author Pankaj Dangle More articles by this author Omaya Banihani More articles by this author Heidi Stephany More articles by this author Glenn Cannon More articles by this author Francis Schneck More articles by this author Michael Ost More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Incidence and Pathology of Repeat Computed Tomography of the Abdomen and Pelvis in a Pediatric Emergency Department Population

Computed tomographic (CT) scanning is increasingly prevalent in emergency departments (EDs). It is a moderate- to high-radiation diagnostic technique that exposes more than 1 million children per year to unnecessary radiation. Repeat CT of the abdomen and pelvis (CTAP) among pediatric patients who return to the ED within 1 year may be an example of unnecessary pediatric radiation exposure. The objectives of this study were to identify the incidence of pediatric patients who undergo more than 1 CTAP within 1 year and to detect the incidence of significant pathology on these repeat scans. This was a retrospective review of subjects younger than 18 years with an initial CTAP as an ED patient, inpatient, or outpatient and a second CTAP within 12 months and during an ED visit. During the observation period, 172 pediatric ED admissions had at least 1 repeat admission involving an abdominal CT scan. Thirty-seven of the CT scans (19.3%) were positive. Sixty percent of the positive cases (n = 22) were attributable to the 3 most prevalent diagnoses: appendicitis in 8 cases (21.6%), kidney stone in 8 cases (21.6%), and colitis in 6 cases (16.2%). Approximately, one third of repeat CT scans occurred within the first month of the initial CT scan, and two thirds occurred within 6 months of the initial CT scan. A substantial percentage of pediatric patients undergo more than 1 CTAP within a 1-year time frame. Among these patients, a large portion were diagnosed significant pathology.

Initiatives Focus on Limiting Radiation Exposure to Patients During CT Scans

IN THE PAST DECADE OR SO, EMERGING data have raised concerns about increased cancer risk attributable to the radiation doses experienced by patients who undergo computed tomographic (CT) scanning. More than 80 million CT scans are performed annually in the United States. Limiting radiation exposure is a consideration for anyone, but the concern is heightened for children, who undergo about 6 million CT scans per year, according to the American College of Radiology (ACR). Children are growing, their tissues may be more radiosensitive, and their smaller size makes them more vulnerable if dosing is not adjusted accordingly. In addition, compared with adults, children who undergo a CT scan typically have many more years of life ahead of them and thus have a wider window of opportunity for the manifestation of radiation injury. One of the first reports on estimated risks of fatal cancer resulting from pediatric CT radiation exposure, by David Brenner, PhD, DSc, director of the Center for Radiological Research at ColumbiaUniversityMedicalCenterinNewYork City,andcolleagues,estimatedriskusing doses derived from studies of those exposedtoatomicbombsinJapan(Brenner DJ et al. AJR Am J Roentgenol. 2001;176: 289-296).Lastyear, researchersreported evidence of a relationship between leukemia incidence and estimated CT scan radiation doses to bone marrow during childhood, as well as between brain tumor incidenceandestimatedCTscanradiation doses to the brain (Pearce MS et al. Lancet. 2012;380[9840]:499-505).

Diagnostic Imaging Studies Performed in Children Over a Nine-Year Period

Diagnostic imaging procedures (DIPs) producing radiation exposure in children have been associated with increased cancer risk. To develop effective clinical practice interventions that reduce pediatric radiation exposure, a longitudinal assessment of DIP ordering practices in the current clinical climate was performed. Our objective was to determine the prevalence and characteristics of DIPs ordered by physicians in an independent physicians association treating a general pediatric population. DIP insurance claims from 2001 to 2009 were obtained from an independent physicians association in a large metropolitan area. Current Procedural Terminology codes, associated International Classification of Diseases, Ninth Revision codes, and patient demographics associated with DIPs were retrieved from insurance claim data and analyzed. Overall, 214,538 DIPs were performed on 63,116 children from 2001 to 2009 at a rate of 1 DIP associated with ionizing radiation per 21 patient-months. Over the study period, performance of computed tomography, MRI, ultrasound, and radiography all significantly increased (P < .001 for all). Higher radiation DIPs were most frequently performed in the inpatient and emergency settings on older boy patients for gastrointestinal and congenital disorders. The 3 most common International Classification of Diseases, Ninth Revision codes associated with higher radiation DIPs were abdominal pain, headache, and head injury. DIPs are frequently performed in children and higher radiation DIPs account for an increasing proportion of DIPs performed, especially among children evaluated in the inpatient and emergency department settings and those with gastrointestinal and neurologic symptoms, and congenital anomalies. Our findings may help guide development of clinical practice interventions to reduce DIP-related radiation exposure in youth.

Avaliação de exposições médicas em procedimentos pediátricos de radiologia intervencionista

OBJETIVO: Avaliar as exposições pediátricas de radiologia intervencionista em dois hospitais do Estado da Bahia, visando contribuir para a construção de um cenário estadual e nacional, possibilitando o conhecimento das exposições e da necessidade de sua otimização, visto que as peculiaridades que envolvem a radiologia e a pediatria se potencializam quando se trata de procedimentos de radiologia intervencionista, em razão das doses elevadas de radiação. MATERIAIS E MÉTODOS: Foram avaliados 32 procedimentos em quatro salas nos dois principais hospitais que realizam procedimentos de radiologia intervencionista pediátrica na Bahia. Foram avaliados os valores de kerma no ar incidente e o produto kerma-área no ar de 27 procedimentos cardiológicos e 5 procedimentos cerebrais. RESULTADOS: Os valores máximos de produto kerma-área e kerma obtidos para procedimentos cardiológicos foram, respectivamente, 129,9 Gy.cm² e 947,0 mGy, e para procedimentos cerebrais, 83,3 Gy.cm² e 961,0 mGy. CONCLUSÃO: Os resultados deste estudo mostraram valores de exposições superiores em até 14 vezes os obtidos em estudos realizados em outros países, chegando próximos de resultados obtidos para procedimentos em adultos. Isto revela quão elevadas podem ser as exposições pediátricas, indicando a necessidade de constante otimização dos procedimentos e avaliação das exposições.

Radiation Exposure During Pediatric Videourodynamics

Videourodynamics is useful for evaluating and treating neurological disorders in children. Traditional urodynamic parameters can be obtained while simultaneous visualization of the urinary system can reveal anatomical anomalies. This additional information comes at the cost of radiation exposure to the child. We characterized radiation exposure from videourodynamics. We reviewed all recent videourodynamic studies and recorded patient demographics, urological diagnoses, physical attributes, total fluoroscopy time, total radiation exposure in mGy, bladder capacity and the number of filling cycles performed. Multivariate linear regression was used to identify patient factors that independently influenced total radiation exposure. A total of 64 videourodynamic studies were performed in 34 female and 28 male patients with a mean age of 8.6 years (95% CI 7.2-10.0). The most common diagnosis was neurogenic bladder in 40 patients, although 49 had multiple diagnoses. Mean total fluoroscopy time was 1.8 minutes (95% CI 1.4-2.1) and mean total radiation exposure was 10 mGy (95% CI 7.5-13.3). On multivariate linear regression patient weight and bladder capacity were the only independent predictors of total radiation exposure. Videourodynamics entail significant radiation exposure. Patient weight and bladder capacity were independent predictors of total radiation exposure. Physician awareness of radiation exposure may result in the judicious use of fluoroscopy and aid in counseling parents on the risk of videourodynamics. Further research is needed to quantify organ specific doses of radiation due to medical imaging in children and the associated cancer risks.

CT dose reduction in practice

Greater than 10% of diagnostic imaging studies performed in developed countries are CT examinations. In the United States, as many as 60 million CT studies are performed each year, up to 7 million of which are performed in pediatric patients. In the spirit of the ALARA principle, both adult and pediatric radiologists should strive to decrease pediatric radiation exposure whenever possible. This can be achieved by utilizing imaging studies that do not require the use of ionizing radiation, thus decreasing the number of CT studies performed. If a CT study is indicated, the delivered dose should be optimized to use the lowest possible dose level while still answering the clinical question.