Unnecessary Radiation Exposure Research Articles

Unnecessary diagnostic imaging requested by medical students during a first day of residency simulation: an explorative study

BackgroundPhysicians’ choice of appropriate tests in the diagnostic process is crucial for patient safety. The increased use of medical imaging has raised concerns about its potential overuse. How appropriately medical students order diagnostic tests is unknown. We explored their ordering behavior of diagnostic imaging during a simulated first day of residency.MethodsIn total, 492 undergraduate medical students participated in the simulation. After history taking with simulated patients, the students used an electronic system for requesting diagnostic tests. The analysis focused on 16 patient cases, each managed by at least 50 students. We calculated the total number of ordered images and unnecessary radiation exposure in millisievert per patient and performed one sample t-tests (one tailed) with an expected mean of zero on a Bonferroni-corrected alpha level of 0.003 for the independent variable of unnecessary radiation exposure.ResultsUnnecessary diagnostic imaging was ordered across all patient cases. Ultrasound, especially abdominal ultrasound, X-rays of the thorax, and abdominal CTs were notably overused in 90.9%, 80.0%, and 69.2% of all patient cases, respectively. Unnecessary requests of imaging related to radiation resulted in radiation over-exposure for nearly all patients, with 37.5% of all patients being exposed to a significant radiation overdose on average.ConclusionMedical students’ overuse of diagnostic imaging can be explained by patient-related factors like anxiety and medical factors like missing clinical information leading to cognitive biases in patient workup. This suggests the need for interventions to improve students’ clinical decision-making and reduce cognitive biases. Investigating student-specific factors being associated with overuse of diagnostic imaging would be of additional interest.

Diagnosis and evaluating the urgent CT KUB at king Fahad specialist hospital, Buraydah, Saudi Arabia 2022.

PURPOSE: The aim of this research was to evaluate the diagnostic yield of urgent CT KUBs and assess the appropriateness of their use in the investigation of acute renal colic at King Fahad specialist hospital , Buraydah, Saudi Arabia 2022. METHODS: All data were collected retrospectively from patient’s records including all patients who presented to the emergency and inpatients undergo unenhanced CT KUB to rule out urinary tract stones . Follow-up requests of known urolithiasis and any scan done for other clinical indications were excluded ,representing 3.7% . RESULTS: This study reviewed 1671 patients, 24.9% were aged between 31 and 40 years old, with nearly 60% being males. Most patients were admitted to ER (98%) and referred by non-urology physicians (99%). The prevalence of patients who were diagnosed with renal stones was 38.7%. Among patients who were presented with acute renal colic and CT scan revealed no urolithiasis, there was 11% with incidental and other alternative diagnosis. The most common finding was genitourinary diseases (48.9%), followed by gastrointestinal diseases (27.2%). CONCLUSION: The significant percentage of negative CT KUB of the examined patients reflects the physicians misapplication with this technique with a subsequent reduction in the rate of renal calculi detection with unnecessary radiation exposure as well as increased the alternative/incidental of extraordinary findings, which may indicate further emergency abdominal CT studies. Therefore, urology opinion before CT-KUB requested for patients with atypical presentation is highly advised. Additionally , departmental ultrasound is suggested mainly for the young females prior to CT scan to rule out any gynecological conditions that can mimic renal stones.

Clinical imaging guidelines: current status and challenges

Background: Advances in medical technology and health insurance coverage policies have significantly promoted radiological examinations in Korea. In 2019, the number of computed tomography examinations performed in Korea was approximately 1.5-times higher than the Organisation for Economic Co-operation and Development average. This surge in radiological examinations has raised concerns regarding inappropriate imaging practices that may lead to unnecessary radiation exposure and increased healthcare cost.Current Concepts: Two fundamental principles guide the radiation safety practices in medicine: Optimization and justification. Optimization, represented by the “As Low As Reasonably Achievable” principle, minimizes the radiation dose while maintaining the diagnostic quality. Justification ensures that the benefits of radiological procedures outweigh their potential risks. Evidence-based clinical imaging guidelines, such as the UK iRefer guidelines and USA American College of Radiology Appropriateness Criteria, have been internationally proposed to implement these principles. In Korea, collaborative efforts between the National Evidence-based Healthcare Collaborating Agency and Korean Society of Radiology have led to the development of Korean evidence-based clinical imaging guidelines.Discussion and Conclusion: Implementation of evidence-based imaging guidelines is crucial to reduce unnecessary radiation exposure and optimize resource utilization. However, various challenges, including the adaptation of the guidelines to individual patient needs and successful integration of rapidly advancing medical technologies, remain. Continuous updates, professional education, and system-wide support are essential to ensure the effective implementation of these guidelines. Future studies should focus on enhancing the precision and applicability of these guidelines in clinical practice to improve the patient safety and healthcare efficiency.

8737 Primary Hyperparathyroidism (PHPT) “Phenotypes” and the Results of Parathyroid [99mTc]Tc-Sestamibi SPECT/CT Scintigraphy: Minimizing the Risk of Negative Imaging Results

Abstract Disclosure: K. Kucharczyk: None. A. Drynda: None. J. Podlewski: None. M. Trofimiuk-Muldner: None. A. Hubalewska-Dydejczyk: None. Introduction. Primary hyperparathyroidism (PHPT) is a prevalent endocrinopathy typically identified through biochemical testing. PHPT is characterized by hypercalcemia accompanied by increased or inappropriately normal plasma parathyroid hormone (PTH) concentrations. Preoperative imaging is conducted when surgery is indicated to pinpoint parathyroid adenomas. [99mTc]Tc-Sestamibi scintigraphy is highly specific and sensitive in diagnosing PHPT, with a higher adenoma detection rate demonstrated for patients with larger lesions or higher blood calcium concentrations. The study aimed to investigate the relationship between the results of biochemical tests and clinical manifestations (PHPT “phenotype”) and the rate of positive results of parathyroid [99mTc]Tc-Sestamibi scintigraphy. Materials and methods. This was a retrospective study of patients suspected of PHPT who underwent parathyroid [99mTc]Tc-Sestamibi SPECT/CT scintigraphy between 2010 and 2022. Patients’ cluster analysis was conducted based on PTH, serum calcium (Ca), and phosphate (Pi) concentrations to find distinct patterns in these parameters. Furthermore, we compared the distributions of additional patients’ attributes, including gender, lesion size, serum vitamin D, ALP concentrations, urinary calcium, urolithiasis prevalence, as well as parathyroid scintigraphy results. Results. 513 patients were divided into 5 clusters using different algorithms. Finally, clusters from K-means methods were selected based on statistical metrics and expert interpretation. Those were organized in ascending order of positive scintigraphy results, with Cluster 5 reaching a 79.5% positivity rate and median values of PTH - 315.5 pmol/L, Ca - 2.96 mmol/L, and Pi - 0.7 mmol/L. As the proportion of positive imaging outcomes declined, median PTH and calcium concentrations decreased while phosphate concentrations increased. In Cluster 1, with 30% of positive imaging results, medians were as follows: PTH - 79.06 pmol/L, Ca - 2.55 mmol/L and Pi - 1.1 mmol/L. A comparative analysis of various clinical and biochemical parameters revealed statistically significant differences between clusters. Patients from Clusters with a higher frequency of positive scintigraphy were significantly more likely to be males, vitamin D deficient, with higher ALP concentrations, diagnosed with urolithiasis, and harbouring larger lesions. Conclusions. PHPT “phenotypes” correlated with disease severity are evidently linked to parathyroid scintigraphy detection rate. Therefore, it is crucial to know that false-negative imaging is more likely in PHPT patients with minor deviations in laboratory tests. Judicious assessment of biochemical and clinical features may limit the number of redundant parathyroid scintigraphies and, in consequence, reduce healthcare costs and unnecessary radiation exposure. Presentation: 6/2/2024

A-090 Performance of GFAP and UCH-L1 Biomarkers for Traumatic Brain Injury in the ARCHITECT i1000SR TBI Test

Abstract Background Traumatic Brain Injury (TBI) has been recognized as an important cause of death and disability and is a growing public health problem. An estimated 69 million people globally experience a TBI annually. The vast majority (80%) of patients evaluated for TBI in the Emergency Department will receive head CT scans, however less than 10% will have findings of acute traumatic abnormalities. This highlights the need for objective, rapid, accurate tools to help clinicians evaluate and triage patients with suspected TBI and reduce unnecessary radiation exposure. Blood based biomarkers such as glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1) have shown utility to predict acute traumatic intracranial injury on CT scan after TBI. Methods The ARCHITECT TBI test is a panel of in vitro diagnostic chemiluminescent microparticle immunoassays for the measurement of GFAP and UCH-L1 in plasma and serum. A method comparison study was performed to compare the GFAP and UCH-L1 assays on ARCHITECT i1000SR to the FDA cleared Alinity i assays. Performance characteristics such as detection limits, imprecision, linearity, and measuring interval were established following CLSI guidance. Results The analytical measuring interval (AMI) extends from the limit of quantitation (LoQ) to the upper LoQ and is determined by the range that demonstrates acceptable performance for linearity, imprecision, and bias. The AMI is 6.1 to 42,000 pg/mL for GFAP and 26.3 to 25,000 pg/mL for UCH-L1. Within-laboratory imprecision ranged from 2.2 to 6.2% CV for GFAP and 2.2 to 4.5% CV for UCH-L1. The Overall Reproducibility (includes repeatability, between-run, between-day, between-instrument variance components) results ranged from 2.7 to 6.8% CV for GFAP and 2.4 to 3.9 %CV for UCH-L1. The method comparison study evaluated 123 specimens across the range of 6.5-32,548.6 pg/mL for GFAP, and 51.5-24,127.7 for UCH-L1. The correlation coefficients were 1.0, with a slope of 1.03 and 1.06, an intercept of -0.6 and -6.0, for GFAP and UCH-L1, respectively. The results support use of the established GFAP and UCH-L1 cutoffs and clinical performance findings in a multi-site pivotal study which enrolled 1899 mild TBI (Glasgow Coma Scale score 13 to 15) subjects. 116 of the 120 specimens with a positive CT scan had a positive TBI interpretation (Sensitivity 96.7%). Of the 1779 subjects with negative CT scan results, 713 had a negative TBI interpretation (Specificity 40.1%). The negative predictive value (NPV) of the test was 99.4% (713/717). Conclusions The ARCHITECT TBI test performance was evaluated compared to the Alinity i TBI test across a broad concentration range of GFAP and UCH-L1. The results support equivalence of the ARCHITECT TBI test to the Alinity i TBI test. The established cutoffs were evaluated in a prospective cohort of mild TBI subjects and demonstrated high sensitivity and NPV relative to head CT scan results, supporting the utility to rule out the need for CT scan in mild TBI subjects presenting to the emergency department. Funding This work is in collaboration with the US Army Medical Materiel Development Activity, US Army Medical Research and Development Command CRADA 20-1266-CRA.

Diagnostic Accuracy of X-Ray PNS for Paranasal Sinuses (X-Ray PNS) Sinus Pathologies with Computed Tomography Paranasal Sinuses (CT PNS) A The Gold Standard

OBJECTIVES To determine the diagnostic accuracy of X-ray PNS in different pathologies of paranasal sinuses, using CT PNS as the gold standard, and establishing X-ray PNS as a potential first-line screening tool. METHODOLOGY This cross-sectional study was conducted over two years in the Department of Radiology, Rehman Medical Institute Peshawar. 100 patients in the sample with suspected PNS pathologies were selected through the purposive sampling technique, aged 18-70. All patients underwent X-ray PNS initially, followed by CT scans. CT PNS was performed even in cases with normal X-ray findings to check for false negatives or positives. RESULTSOut of 100 patients, 56% were male. Most PNS pathologies (55%) were in the 15-35 age group (mean age 24 years, SD ±3.89). The most common symptoms were nasal obstruction (40%) and headache (39%). X-ray PNS showed 67% sensitivity, 60% specificity, 85% PPV, and 64% NPV. The overall diagnostic accuracy of X-ray PNS was 66% compared to CT PNS. CONCLUSION X-ray PNS demonstrates a diagnostic accuracy of 66% in diagnosing PNS pathologies. While not as comprehensive as CBCT, X-ray PNS shows potential as a first-line screening tool, particularly for larger sinuses, potentially reducing unnecessary radiation exposure from CT scans.

Incidence and Prevalence of Concussion in Denmark from 1999-2018: A Nationwide Cohort Study.

Concussion is a common diagnosis in emergency rooms, yet contemporary incidence and prevalence estimates are sparse and rely on self-reported data. A nationwide cohort study was conducted to provide up-to-date information, covering the entire Danish population from 1999 to 2018. Hospital contacts with a concussion diagnosis, including emergency room visits, hospital admissions, and outpatient contacts, were retrieved from the Danish National Patient Registry (DNPR), and incidence rates were age-standardized and stratified. The 20-year prevalence was defined as the percentage of Danes alive in 2018 who had experienced a concussion since 1999. The diagnostic codes used were the ICD-10 code S06.0 and a local Danish code for 'observation for concussion' (DZ033D). Additional data on activities related to concussion injuries were obtained from the Accident Analysis Group at Odense University Hospital through DNPR. Findings from the study indicated that during the period 1999-2018, the total age-standardized concussion incidence rate increased by 10% to 308 per 100,000 person-years (95% confidence interval (CI): 304-313). Notable time trends included 1) a reduced sex difference from 40% to 6% (95% CI: 3%-9%), 2) a doubled incidence rate in children aged 0-1 and in seniors aged over 80, 3) an increased utilization of head imaging across all age groups, except children, 4) a decline in the proportion of traffic-related concussions, and 5) a prevalence of concussion of 4.9% (95% CI: 4.89% - 4.93%) in 2018. The increasing incidence of concussions among the elderly is concerning in light of an aging population, and warrants further investigation, as evidence-based preventive interventions for falls exist. Additionally, the increased utilization of head imaging across all age groups except children calls for attention toward avoidance of unnecessary radiation exposure. Despite a drop in traffic-related cases, concussions remain highly prevalent. In conclusion, these findings indicate that concussions are an important public health concern, necessitating ongoing surveillance, research, and targeted resource allocation to address concussion management and prevention effectively.

Evaluation of X-ray Beam Collimation in Adult Chest Radiography.

Restricting the irradiated volume can reduce X-ray scattering incidents on the image receptor. Proper X-ray collimation during medical imaging reduces a patient's dose while improving image quality. Even though the patient radiation dose due to chest X-ray imaging is low, the 'as low as reasonably achievable' (ALARA) principle should be satisfied, especially for young patients. To evaluate the accuracy of collimation in digital chest radiography. Ninety-eight chest radiographs were studied retrospectively from February 2021 to December 2021. Chest images were collected from three main centers in the Madinah region of Saudi Arabia. The ratio of the field of interest area to the field of view (FOV) was measured and calculated to determine the accuracy of X-ray beam collimation. Out of 98 chest radiographs enrolled in the study, 87.8% (n=80) were adequately collimated, while 12.2% (n=18) were rejected due to inadequate collimation. The ratio of the field of interest collimated area of chest radiographs was 0.547, which indicated an acceptable value. Among the three centers, Center 2 showed higher, significant, adequate collimation than Center 1 (P<0.001) and Center 3 (P=0.007). There was a significant gender difference in collimation levelsas the level of collimation of female chest radiographs is inferior to that of males (P>0.001). The collimation of chest radiographs among the three centers was adequate. Based on the study findings, the X-ray beam collimation was sufficient, indicating good optimization and no unnecessary radiation exposure to patients and staff. The collimation of chest radiographs in females was significantly inferior to that of males.

Deep Learning-Based Denoising Enables High-Quality, Fully Diagnostic Neuroradiological Trauma CT at 25% Radiation Dose

Traumatic neuroradiological emergencies necessitate rapid and accurate diagnosis, often relying on computed tomography (CT). However, the associated ionizing radiation poses long-term risks. Modern artificial intelligence reconstruction algorithms have shown promise in reducing radiation dose while maintaining image quality. Therefore, we aimed to evaluate the dose reduction capabilities of a deep learning-based denoising (DLD) algorithm in traumatic neuroradiological emergency CT scans. This retrospective single-center study included 100 patients with neuroradiological trauma CT scans. Full-dose (100%) and low-dose (25%) simulated scans were processed using iterative reconstruction (IR2) and DLD. Subjective and objective image quality assessments were performed by four neuroradiologists alongside clinical endpoint analysis. Bayesian sensitivity and specificity were computed with 95% credible intervals. Subjective analysis showed superior scores for 100% DLD compared to 100% IR2 and 25% IR2 (p<0.001). No significant differences were observed between 25% DLD and 100% IR2. Objective analysis revealed no significant CT value differences but higher noise at 25% dose for DLD and IR2 compared to 100% (p<0.001). DLD exhibited lower noise than IR2 at both dose levels (p<0.001). Clinical endpoint analysis indicated equivalence to 100% IR2 in fracture detection for all datasets, with sensitivity losses in hemorrhage detection at 25% IR2. DLD (25% and 100%) maintained comparable sensitivity to 100% IR2. All comparisons demonstrated robust specificity. The evaluated algorithm enables high-quality, fully diagnostic CT scans at 25% of the initial radiation dose and improves patient care by reducing unnecessary radiation exposure.

Implementing safety standards in radiographic practices: challenges and solutions

Ensuring the safety of patients and healthcare workers in radiographic practices is a critical concern in modern healthcare. The use of ionizing radiation, while invaluable for diagnostic and therapeutic purposes, carries inherent risks that necessitate stringent safety standards. Despite advances in technology and regulatory frameworks, the consistent implementation of these safety standards remains a challenge across various healthcare settings. The discussion addresses the complexities of navigating diverse regulatory environments, where enforcement and adherence to safety guidelines can vary significantly. These inconsistencies are particularly pronounced in low-resource regions, where limited access to modern radiographic equipment and inadequate training further exacerbate the risks of radiation exposure. Technological advancements in radiography, such as digital radiography, dose-reduction software, and advanced imaging modalities, offer significant benefits in terms of diagnostic accuracy and efficiency. However, they also introduce new challenges in maintaining up-to-date safety protocols. The rapid pace of innovation often outstrips the ability of regulatory bodies to update guidelines, leading to gaps in safety practices. Additionally, the effectiveness of these technologies depends heavily on proper usage and understanding by radiographic professionals, highlighting the need for continuous education and training. A strong safety culture within radiographic practices is essential for minimizing radiation risks. Leadership commitment, ongoing education, effective communication, and the empowerment of radiographic professionals are critical components of this culture. When these elements are in place, they foster an environment where safety is prioritized, and all staff members are actively engaged in maintaining and improving safety standards. The multifaceted approach required to enhance radiographic safety underscores the importance of harmonizing regulatory efforts, investing in modern technologies, and cultivating a safety-first mindset among healthcare professionals. These efforts collectively contribute to the safe and effective use of radiographic technology, ultimately protecting both patients and healthcare workers from unnecessary radiation exposure.

Challenges were faced during radiography of pregnant women

Radiography of pregnant patients poses significant challenges to radiographers due to the need to balance diagnostic requirements with the safety of the developing foetus. This article explores the challenges faced by radiographers when conducting radiographic procedures on pregnant women and their foetus and discusses strategies employed to minimize radiation exposure. Key challenges include the risk of foetal radiation exposure, timing of examination, proper positioning of the patient and patient anxiety. Strategies such as radiation shielding, collimation, low-dose techniques and alternative imaging modalities are crucial for minimizing radiation exposure while obtaining diagnostic information. Clear communication between radiographers and patient is essential to ensure the safety and well-being of both the mother and the foetus during radiographic procedure. Radiographers knows the dangers of radiation exposure to fetal health. Now days, diagnostic imaging of pregnant women is increasing. X-ray risks depending on the gestational age of the pregnancy, and other potential health effects. In addition, ethical issues have been considered by improving overall communication to minimize unnecessary radiation exposure to pregnant women and fetuses.

Efficacy of ultrasound in the evaluation of iliac vein stenting.

Objectives: The current study evaluated the efficacy of iliac and IVC ultrasound alone for follow-up evaluation of iliac vein stents in patients with pelvic venous disorders or iliac occlusion from chronic deep vein thrombosis. Methods: A retrospective single site cohort study was conducted by evaluating the most recent 100 iliac vein and inferior vena cava ultrasounds in patients who had undergone iliac vein stenting. Inclusion criteria included a history of iliac vein stent placement. Exclusion criteria included patients under 18-years-old, duplicates of the same patient, and pregnancy at the time of ultrasound. The degree of visualization for color flow, gray scale, and phasicity were determined and classified into the following categories: complete, partial, or none. In addition, each chart was assessed for external compression, in-stent narrowing, and requirements for further imaging. Results: Of the 100 iliac vein and IVC ultrasounds assessed in this review, 99 of the ultrasounds were sufficient for evaluation during follow-up visits without requiring further investigation. Within this study cohort, the average follow-up time was 22months. The average participant body mass index was 27.6. One iliac vein and IVC ultrasound was considered inadequate for follow-up evaluation and required further imaging. Conclusion: The use of iliac and IVC venous doppler ultrasound alone in the follow-up evaluation of iliac stent patency is effective and noninvasive and avoids unnecessary radiation exposure and cost.

Survey of CT radiation doses and iodinated contrast medium administration: an international multicentric study.

To assess the relationship between intravenous iodinated contrast media (ICM) administration usage and radiation doses for contrast-enhanced (CE) CT of head, chest, and abdomen-pelvis (AP) in international, multicenter settings. Our international (n = 16 countries), multicenter (n = 43 sites), and cross-sectional (ConRad) study had two parts. Part 1: Redcap survey with questions on information related to CT and ICM manufacturer/brand and respective protocols. Part 2: Information on 3,258 patients (18-96 years; M:F 1654:1604) who underwent CECT for a routine head (n = 456), chest (n = 528), AP (n = 599), head CT angiography (n = 539), pulmonary embolism (n = 599), and liver CT examinations (n = 537) at 43 sites across five continents. The following information was recorded: hospital name, patient age, gender, body mass index [BMI], clinical indications, scan parameters (number of scan phases, kV), IV-contrast information (concentration, volume, flow rate, and delay), and dose indices (CTDIvol and DLP). Most routine chest (58.4%) and AP (68.7%) CECT exams were performed with 2-4 scan phases with fixed scan delay (chest 71.4%; AP 79.8%, liver CECT 50.7%) following ICM administration. Most sites did not change kV across different patients and scan phases; most CECT protocols were performed at 120-140 kV (83%, 1979/2685). There were no significant differences between radiation doses for non-contrast (CTDIvol 24 [16-30] mGy; DLP 633 [414-702] mGy·cm) and post-contrast phases (22 [19-27] mGy; 648 [392-694] mGy·cm) (p = 0.142). Sites that used bolus tracking for chest and AP CECT had lower CTDIvol than sites with fixed scan delays (p < 0.001). There was no correlation between BMI and CTDIvol (r2 ≤ - 0.1 to 0.1, p = 0.931). Our study demonstrates up to ten-fold variability in ICM injection protocols and radiation doses across different CT protocols. The study emphasizes the need for optimizing CT scanning and contrast protocols to reduce unnecessary contrast and radiation exposure to patients. The wide variability and lack of standardization of ICM media and radiation doses in CT protocols suggest the need for education and optimization of contrast usage and scan factors for optimizing image quality in CECT. There is a lack of patient-centric CT protocol optimization taking into consideration mainly patients' size. There is a lack of correlation between ICM volume and CT radiation dose across CT protocol. A ten-fold variation in iodine-load for the same CT protocol in sites suggests a lack of standardization.

Failure to Significantly Reduce Radiation Exposure in Children with Suspected Appendicitis in the United States

BackgroundUltrasound (US) or magnetic resonance imaging (MRI) is recommended over computed tomography (CT) as the initial imaging modality when considering a diagnosis of appendicitis in children. This reduces unnecessary radiation exposure and has excellent accuracy. We hypothesized a significant increase in US utilization and a reduction in CT utilization in hospitals across the United States. MethodsWe retrospectively reviewed NSQIP-P data from 2015 to 2021 for patients <18 years undergoing appendectomy for acute appendicitis. Rates of US, CT, and MRI usage were compared between NSQIP-P hospitals and referring non-NSQIP-P hospitals. ResultsOf the 115,186 children included, 66,303 (57.6%) were imaged in NSQIP-P hospitals, 37,962 (33.0%) in non-NSQIP-P hospitals, and 7947 (6.9%) in both. US alone was used in 53.3%, followed by CT alone in 25.1%, both US + CT in 16.4%, and MRI ± CT/US in 2.6%. Non-NSIQP-P hospitals used less US than NSQIP-P centers (38.6% vs 90.8%, P < 0.0001) and more CT (74.0% vs 25.4%, P < 0.0001). From 2015 to 2021, overall US utilization increased from 68.5% to 72.3% (p < 0.0001) while CT utilization remained unchanged (43.1%–43.2%, P = 0.07). US use increased in non-NSQIP-P centers (18.8%–25.7%, P < 0.0001) but not in NSQIP-P (71.7% vs 70.9%, p = 0.28), while CT alone decreased in both (NSQIP-P: 10.1%–7.7%, P < 0.0001; non-NSQIP-P: 71.0%–59.8%, P < 0.0001). ConclusionUS and MRI remain underutilized in diagnosing pediatric appendicitis, especially in non-NSQIP-P hospitals. Trends show modest increase in US utilization; however, CT alone remains a highly used modality in non-NSQIP-P hospitals. Adopting diagnostic strategies from NSQIP-P centers could optimize diagnostic imaging in children. Level of EvidenceIII.

Strategies for minimizing repeated exposures in diagnostic radiography

Advancements in diagnostic radiography have significantly improved medical imaging, yet the associated radiation exposure poses health risks, particularly with repeated examinations. Technological innovations, including the transition from analog to digital radiography, have led to substantial reductions in radiation doses while enhancing image quality. Digital systems, coupled with automatic exposure control (AEC), dynamically adjust radiation levels based on patient size and diagnostic requirements, minimizing unnecessary exposure. Iterative reconstruction algorithms in CT imaging further reduce radiation doses by efficiently processing images and reducing noise. Hardware improvements, such as high-efficiency detectors, capture high-quality images with lower radiation levels, contributing to dose reduction. Standardizing radiographic protocols across healthcare settings ensures consistent practices, reducing variability in radiation doses. Techniques such as beam collimation and appropriate shielding protect surrounding tissues and enhance image quality, while continuous education for technologists maintains proficiency in dose-reduction strategies. Patient education is crucial for minimizing repeated exposures. Informing patients about the risks of ionizing radiation and the importance of adhering to follow-up schedules can reduce unnecessary examinations. Electronic health records (EHRs) facilitate the tracking of cumulative radiation doses, enabling informed decision-making regarding additional imaging studies. Adherence to the ALARA principle (As low as reasonably achievable) in clinical practice ensures that radiation exposure is minimized while achieving diagnostic goals. Special considerations for vulnerable populations, such as children and pregnant women, further enhance safety. Implementing radiation safety measures and maintaining a commitment to ongoing professional development for healthcare providers fosters a culture of safety within radiology departments. By integrating these strategies, healthcare providers can balance the diagnostic benefits of radiography with the imperative to protect patients from unnecessary radiation exposure, ultimately enhancing patient safety and improving diagnostic outcomes. This comprehensive approach ensures that radiographic procedures remain both effective and safe, optimizing patient care in medical imaging.

Evidence-based radiology 5years on-a single-centre review of image referral appropriateness.

The iRefer guidelines provide evidence-based recommendations on imaging and are designed to facilitate appropriate referrals and limit unnecessary radiation exposure. In 2017, a review at this institution assessed the appropriateness of imaging referrals. This study provides an update 5years later on the referral appropriateness and aims to assess what impact the previous review has had on referral appropriateness. A retrospective study of 945 referrals across GPs, ED, and inpatients was audited against the iRefer guidelines with costs and cumulative dose estimates calculated for inappropriate referrals considering salaries of those involved, the average time spent performing and reporting radiographs, and the median effective dose values. Results show a decrease in the volume of requests overall with the relative proportion of inappropriate requests rising significantly. Inappropriate requests for abdominal X-rays from GPs decreased from 72 to 37.5%, whereas inappropriate ED referrals increased from 38 to 46% and inappropriate inpatient requests remained static at 30%. The proportion of inappropriate GP requests for spinal radiographs significantly increased for cervical, thoracic, and lumbar spine radiographs, respectively (18 to 66%; 47 to 72%; 53 to 80%; p-value < 0.001). Inappropriate radiographs represent an increased financial and dose-based burden. The volume of radiograph requests reduced after over a 5-year interval; however, the relative proportion of inappropriate requests rose significantly. The iRefer guidelines provide a useful resource to ensure that imaging is used appropriately, effectively, and safely; however, more work is needed to ensure that requests are adhering to these guidelines.

Guideline for Minimizing Radiation Exposure of Interventionalists during Fluoroscopy-Guided Interventional Procedures

As fluoroscopy-guided interventional procedures gain popularity, the associated health threats from radiation exposure to interventionalists during these procedures are increasing. Therefore, an understanding of the potential risks of radiation and careful consideration on minimizing exposure to radiation during the procedures are of paramount importance. The Korean Pancreatobiliary Association has developed a clinical practice guideline to minimize radiation exposure during fluoroscopy-guided interventional procedures. This guideline provides recommendations to deal with the risk of radiation exposure to interventionalists who perform fluoroscopy-guided procedures, and emphasizes the importance of proper and practical approaches to avoid unnecessary radiation exposure.

Treatment response assessment of acute pyelonephritis: A multi-reader DWI-based MRI approach

PurposeTo evaluate the diagnostic accuracy of a structured reporting score (SRS) in treatment response assessment for acute pyelonephritis (APN) using a diffusion-weighted imaging (DWI) -based MRI approach. Additionally, we explored the influence of reader experience on the interpretation of SRS and DWI, including lesion conspicuity and measurements of Apparent Diffusion Coefficient (ADC) maps. MethodsFollow-up DWI-based MRIs of 36 patients treated for APN between September 2021 and June 2023 were retrospectively reviewed by three readers. Follow-up blood inflammatory markers were used as reference standard. Treatment response was assessed using a structured reporting score (SRS). Each reader assigned a score from 1 to 3 to the "conspicuity" of the residual disease on DWI. Quantitative ADC measurements were compared with the Mann-Whitney U test. Descriptive statistics and Intraclass Correlation Coefficient (ICC) were calculated. ResultsThe diagnostic accuracy of SRS was 80.6 %, 76.9 %, and 72.2 % for the Reader 1, 2, and 3 respectively. ICC decreased from 0.82 (Reader 1 and 2), to 0.68 when considering all readers. The average conspicuity varied between 2.3 and 2.7. ADC values were significantly higher in complete responders for Reader 1 and 2 (153.5-154.5 vs 107.7-116.2, p < 0.001). The ICC was good (0.89) for Reader 1 and 2 and moderate (0.60) when considering all readers. ConclusionsTreatment response of pyelonephritis can be accurately assessed by a DWI-based MRI, potentially avoiding unnecessary contrast agent administration and radiation exposure. SRS and DWI analysis showed a good inter-observer agreement but a certain learning curve may be necessary for less expert readers.

Optimizing precision rhinoplasty: comprehensive preoperative planning with nasal computed tomography for functional and aesthetic enhancement

BackgroundThe evolving field of rhinoplasty increasingly recognizes the importance of clinical expertise over routine preoperative nasal computed tomography (CT) for planning surgical interventions. This study evaluates the clinical utility of preoperative nasal CT in enhancing the precision of open structured rhinoplasty, focusing on both functional and aesthetic outcomes without compromising patient safety through unnecessary radiation exposure. The study aimed to assess the impact of preoperative nasal CT on surgical planning and intraoperative maneuvers.MethodsA prospective cohort study involved patients undergoing open structured rhinoplasty with or without preoperative nasal CT. Participants were divided into a study group, receiving preoperative nasal CT, and a control group, undergoing rhinoplasty without such imaging. Surgical modifications were tailored based on CT findings, with outcomes evaluated through postoperative nasal airflow and aesthetic satisfaction.ResultsThe study included 205 patients in the CT group and 514 in the control group, with comparable demographics. The CT group demonstrated significant improvements in nasal breathing and higher aesthetic satisfaction postoperatively, with a notable decrease in the NOSE score and an increase in the ROE score compared to the control group. Minor complications were observed in a small percentage of the CT group, showcasing a nuanced approach to addressing individual anatomical variations.ConclusionsPreoperative nasal CT in open structured rhinoplasty significantly enhances surgical precision, optimizing functional and aesthetic outcomes. This study underscores the utility of preoperative CT in individualized surgical planning, suggesting its pivotal role in the advancement of rhinoplasty practices. Future research should explore long-term benefits and further validate these findings across diverse populations.

Diagnostic Accuracy of Renal Artery Resistive Index in Diagnosing Obstructive Uropathy

Background: Obstructive uropathy, a common cause of acute and chronic kidney disease, poses diagnostic challenges, particularly when non-invasive methods are preferred to reduce patient exposure to ionizing radiation from CT scans. The renal artery resistive index (RI) measured by Doppler ultrasound presents a potential non-invasive diagnostic tool, yet its accuracy and utility in clinical practice require further elucidation. Objective: To assess the diagnostic accuracy of the renal artery resistive index (RI) as measured by Doppler ultrasound in identifying obstructive uropathy, using CT scans as the gold standard for comparison. Methods: This cross-sectional study included 201 patients presenting with symptoms indicative of obstructive uropathy at a tertiary care hospital. Participants underwent both Doppler ultrasound to measure the renal artery RI and non-contrast CT scans of the kidneys, ureters, and bladder (KUB). The diagnostic performance of the RI was evaluated in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy, with CT scan findings serving as the benchmark. Results: The study cohort had a mean age of 43.02±15.62 years, with a male predominance (64.7%). The renal artery RI demonstrated a sensitivity of 81.13%, specificity of 85.81%, PPV of 67.19%, NPV of 92.70%, and an overall accuracy of 84.58% in diagnosing obstructive uropathy. Calculi were more frequently located in the right urinary tract (54.2%) than the left (45.8%), with the majority being smaller than 1 cm (79.1%). Conclusion: The renal artery resistive index (RI) measured by Doppler ultrasound is a highly accurate diagnostic tool for detecting obstructive uropathy, offering a viable, non-invasive alternative to CT scans. This method could significantly reduce unnecessary radiation exposure in patients, aligning with current healthcare priorities for safety and efficiency.