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• W4246274483 abstract "Radiation has captured our imagination and has been the fundamental source for medical diagnosis. In practicing radiology, we cannot live without radiation; in fact, no matter where we live on this planet, we are not immune, as we are constantly exposed to natural radiation. From the first x-ray until today, when more than 400 million x-ray procedures are done annually in the United States alone [1National Council on Radiation Protection and MeasurementsIonizing radiation exposure of the population of the United States NCRP Report No. 160. National Council on Radiation Protection and Measurements, Bethesda, Maryland2009Google Scholar] and nearly 1 billion worldwide, the x-ray has been a lightning rod for both favorable and unfavorable opinions. With JACR® celebrating its 10th anniversary, I decided to take stock. In the more than 6 years I have been responsible for the monthly physics columns “Technology Talk” and “The Medical Physics Consult,” more than half of all the articles published (49 of 77) have addressed topics such as radiation, CT dose, dose reduction, dose optimization, and so forth. One might ask, even though radiation has been the primary source for diagnosis for more than 100 years, why there has been so much attention on imaging-associated radiation during the past 15 years? To answer this question, I draw the reader's attention to a few significant publications and milestones occurring in that period of time, especially with the evolution of multidetector CT scanners, which first appeared in the late 1990s. The first commercial 4-slice multidetector CT scanner did not become available in the United States until 1998. Spurred by the self-evident benefits of using the technology, yielding amazing image quality at a fraction of the radiation dose, and with little formal assessment of its virtues, rapid acceptance of multidetector CT in the early 2000s led to a dramatic increase in CT utilization from nearly 26 million (1998) to nearly 85 million (2011) CT procedures in the United States. Several milestones or significant publications drew much-needed attention to the topic of radiation in medical imaging. These included articles reporting that many providers' were using the same CT scan settings for both adult and pediatric patients [2Paterson A. Frush D.P. Donnelly L.F. Helical CT of the body Are settings adjusted for pediatric patients?.AJR Am J Roentgenol. 2001; 176: 297-301Crossref PubMed Scopus (370) Google Scholar], leading to a media article implying that CT scans will result in fatal cancer in children [3Sternberg S. CT scans in children linked to cancer later.USA Today. January 22, 2001; : 1Google Scholar]. The public outcry was remarkable and caught the radiology community by surprise. Inevitably, we had to grudgingly acknowledge the lackadaisical approach to radiation in the United States, whereas our colleagues in Europe had been paying greater attention (sometimes too much) to radiation from medical imaging. The “slice wars”—companies competing over who could produce scanners with the greatest number of slices per cycle—had kept the issue of radiation on the back burner as technology dazzled us with exquisite 3-D image sets and the possibility of rapid multiple reconstruction. These revelations were followed by a series of reported incidents and pronouncements that drew further attention to radiation in medical imaging. Among them, the National Council on Radiation Protection and Measurements [1National Council on Radiation Protection and MeasurementsIonizing radiation exposure of the population of the United States NCRP Report No. 160. National Council on Radiation Protection and Measurements, Bethesda, Maryland2009Google Scholar] report 160 on radiation exposure to the US population drew considerable attention. According to the report (the results came out in 2006, and the final report was published in 2009), the radiation from medical imaging procedures accounted for nearly half of all the radiation exposure to the US population. CT procedures were responsible for nearly half of all the radiation exposure from medical procedures. This was substantially higher than stated in a previously published report. Next, a series of publications in high-impact journals sharply highlighted the radiation risks from CT procedures and the variability in CT protocols [4Brenner D.J. Hall E.J. Computed tomography—an increasing source of radiation exposure.N Engl J Med. 2007; 237: 2277-2284Crossref Scopus (6428) Google Scholar, 5Berrington de Gonzalez A. Mahesh M. Kim K.P. et al.Projected cancer risks from computed tomographic scans performed in the United States in 2007.Arch Intern Med. 2009; 169: 2071-2077Crossref PubMed Scopus (1456) Google Scholar, 6Smith-Bindman R. Lipson J. Marcus R. et al.Radiation dose associated with common computed tomography examinations and the associated lifetime-attributable risk of cancer.Arch Intern Med. 2009; 169: 2078-2086Crossref PubMed Scopus (1753) Google Scholar]. A series of articles in the New York Times [7Bogdanich W. After stroke scans, patients face serious health risks.The New York Times. July 31, 2010; (Accessed May 13, 2013)http://www.nytimes.com/2010/08/01/health/01radiation.html?pagewanted=allGoogle Scholar] citing problems associated with incorrect settings during CT perfusion studies further fueled concerns. Although one might be critical of the conclusions of these publications, there was no quelling the uproar. Perhaps this has been good for all of us. The furor has encouraged everyone involved in providing medical imaging services to work together in developing and implementing many radiation dose reduction strategies. Medical imaging manufacturers have worked with radiologists, medical physicists, and regulators alike to advance new technologies to reduce radiation dose. Progress has been significant. The developments include tube-current modulation, improved detector efficiency, wide-volume acquisition, faster gantry rotation, adaptive collimation (minimizing unused radiation at the beginning and at the end of helical acquisition), dual-energy CT, prospective gating of cardiac CT, and iterative reconstruction, to name just a few [8Sodickson A. Strategies for reducing radiation exposure in multi-detector row CT.Radiol Clin North Am. 2012; 50: 1-14Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar]. The effort of radiation dose reduction has spilled over to digital fluoroscopy, digital radiography, and nuclear medicine and produced significant improvements. Along with the technical advances, social media campaigns such as Image Gently®, Image Wisely®, and other campaigns and web resources are contributing significantly to radiation dose reduction. Convergence of medical imaging users, providers, and regulators has resulted in new ways to acquire medical x-ray images at optimal radiation dose levels [8Sodickson A. Strategies for reducing radiation exposure in multi-detector row CT.Radiol Clin North Am. 2012; 50: 1-14Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 9Singh S. Kalra M.K. Thrall J.H. Mahesh M. CT radiation dose reduction by modifying primary factors.J Am Coll Radiol. 2011; 8: 369-372Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 10Raff G.L. Radiation dose from coronary CT angiography: five years of progress.J Cardiovasc Comput Tomogr. 2010; 4: 365-374Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 11McCollough C.H. Chen G.H. Kalender W. et al.Achieving routine submillisievert CT scanning: report from the Summit on Management of Radiation Dose in CT.Radiology. 2012; 264: 567-580Crossref PubMed Scopus (232) Google Scholar]. Radiation doses are now lower than they have ever been, and they continue to decline. In fact, the achievable radiation doses for many medical imaging procedures, without jeopardizing image quality, are substantially lower than what they were even 3 years ago. For example, the radiation dose for cardiac CT angiography, previously about 10 to 15 mSv, is now 3 to 5 mSv, with no loss of image quality [10Raff G.L. Radiation dose from coronary CT angiography: five years of progress.J Cardiovasc Comput Tomogr. 2010; 4: 365-374Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 11McCollough C.H. Chen G.H. Kalender W. et al.Achieving routine submillisievert CT scanning: report from the Summit on Management of Radiation Dose in CT.Radiology. 2012; 264: 567-580Crossref PubMed Scopus (232) Google Scholar]. This doesn't mean radiation is no longer an issue. In fact, there are still areas in medical imaging that require continued monitoring, and efforts to optimize imaging protocols, principally follow-up and repeat studies, are needed. It is not the radiation dose from one CT scan or one x-ray imaging study that affects patients greatly. The greatest risk is to small segments of the patient population undergoing multiple follow-up studies. Many such studies could be avoided. In the short run, the very public issue of diagnostic radiation might have pushed physicians and the public to be too cautious about CT and other medical x-ray imaging procedures, even to the extent of jeopardizing proper care. It is incumbent upon us to educate the public and media about the benefits of the medical imaging x-ray procedures, along with the right choice to do the right examination at the right dose so that the final image quality is not compromised. In fact, we can examine this from a different viewpoint. Radiation, radiation dose measurements, the limitations of risk assessments, and how to communicate radiation dose, risks, and benefits to our colleagues and patients alike are providing a path to forge ahead and establish our role as indispensable to those around us. Actively participating in optimizing radiation in medical imaging procedures will allow young physicians, medical physicists, and technologists to carve out a niche in their practices as the go-to persons for consultation. As Brant-Zawadzki [12Brant-Zawadzki M. Being and nothingness.J Am Coll Radiol. 2013; 10: 4-5Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] noted in his rumination on the existential crisis, “our choice should be to be essential, not merely to exist.” I believe the issue of radiation in medical imaging is providing all of us the choice to be essential players." @default.
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