1. Joy Yvette Payne, PhD Student Walden University PUBH 8165-1
Be Your Own Advocate: Understanding Ionizing Radiation and Exposure from Medical Imaging
Joy Yvette Payne, PhD Student
Walden University PUBH
Dr. Robert Marino
Fall, 2011
Thank you for joining me for this presentation today on ionizing radiation and exposure from medical imaging. My name is Joy Payne and I am a Walden University student pursuing a doctorate degree in public health. The purpose of this presentation is to increase your knowledge about ionizing radiation and medical imaging so that you can communicate effectively with your health care practitioners and make informed decisions about medical imaging for yourself and your family.

2. Objectives At the end of this presentation you will be able to:
Converse about key points of ionizing radiation
Describe the short and long-term health effects associated with ionizing radiation
Identify medical imaging procedures that may increase exposure to ionizing radiation
Advocate for self and family when medical imaging is recommended
As adult members of communities across the United States, you have varying backgrounds and experiences. Therefore I will start this presentation with an explanation of the basics necessary to understand and converse about ionizing radiation. Over the next 30 minutes I will discuss the short and long term effects of radiation, review some of the common medical imaging procedures that emit radiation, and share some tools with you so that you can make informed decisions about undergoing medical imaging procedures and thereby advocate for yourself and your family.

3. Introduction
There is a lot of information in the news about the effects of radiation. We hear about radiation from living near power plants or even from our mobile phones. Recently the news has focused on the radiation effects from scans used to diagnose illness. Many people are worried about radiation exposure and the harm that it may cause to them or our environment.
But, what exactly is radiation?
References
Natural News. (2010). Use of high-radiation CT scans in emergency rooms triples over nine years. Retrieved October 20, 2011 from
New York Times. (2010). Radiation, Risks Are Focus of Breast Screening Study. Retrieved October 21, 2011 from
USA Today. (2010). Cancer risks prompt doctors to try to lower imaging scan radiation. Retrieved October 21, 2011 from
Natural News. (2010). Use of high-radiation CT scans in emergency rooms triples over nine years. Retrieved October 20, 2011 from New York Timers. (2010). Radiation, Risks Are Focus of Breast Screening Study. Retrieved October 21, 2011 from USA Today. (2010). Cancer risks prompt doctors to try to lower imaging scan radiation. Retrieved October 21, 2011 from

4. Radiation Waves Penetration Power
Paper
Foil
Concrete
Alpha
Beta
Gamma
Energy
Low
Medium
High
Radiation is energy traveling through space in the form of a wave. Some of the waves have low energy while other waves have high energy. Only those with high energy can change (ionize) atoms (the building blocks of matter) and cause harm in humans. Sunshine is a familiar from of radiation that heats the earth and; therefore, is beneficial. At the same time, too much sunshine is harmful so we cover up or wear sunscreen to protect ourselves.
The radiation we typically encounter is called alpha, beta, or gamma radiation, and there is also x-radiation – these are all classified as ionizing radiation. Their energy determines how far they can go into tissue (what the body is made of), how much energy they deliver, and the resulting damage. The alpha particle will deposit all of its energy in a very small volume of tissue. The gamma radiation will spread energy over a much larger volume and cause more damage.
Radiation is not detectable by the human senses. Special instruments, like a Geiger counter, are required to determine if radiation is present.
Reference
U.S. Environmental Protection Agency (EPA). (2011e) . Why are some atoms Radioactive. Retrieved October 13, 2011 from
U.S. Environmental Protection Agency (EPA). (2011e) . Why are some atoms Radioactive. Retrieved October 13, 2011 from

5. Common Radiation Units and Symbol
Sievert (Sv)1 – unit of equivalent dose (international)
1 Sv = 100 rem (0.001 Sv = 1mSv)
Rem1 - US unit of measurement
Millirem (mrem) = 1/1000 of a rem
Gray (Gy) 1 – unit of absorbed dose (international)
Used to describe radiation treatment dose
Rad1 – US unit of absorbed dose
1 Gy = 100 rad
Tri-foil2
To be able to understand how much radiation may be too much, you must have knowledge of how it is measured. A sievert (Sv) is the international unit to express the damage caused by radiation to the human body. The rem is the unit of measurement commonly used in the United States. One sievert is equal to 100 rems. A millirem is 1/1000 of a rem. To put this in perspective, a person would receive 1 millirem (mrem) from one coast to coast airline flight or from wearing a watch with a luminous dial for one year. The gray is the international unit of absorbed radiation and you may have heard this used in describing the dose of radiation treatment a cancer patient is receiving. The rad is the US measure for absorbed dose. There are other measurements, but these are the ones that you are most likely to encounter.
Of note, the tri-foil is the international symbol for radiation. It is posted where radioactive materials are handled, or where radiation-producing equipment is used. This sign is used as a warning to protect people from being exposed to radioactivity.
References
U.S. Environmental Protection Agency (EPA). (2011a). Radiation Protection Basics. Retrieved October 7, 2011 from
U. S. Environmental Protection Agency (EPA). (2011d). Radiation Protection. Radiation Symbols. Retrieved October 7, 2011 from
U.S. Nuclear Regulatory Commission. (2011). Radiation Exposure and Cancer. Retrieved October 3, 2011 from
1. U.S. Environmental Protection Agency (EPA). (2011a). Radiation Protection Basics. Retrieved October 7, 2011 from U. S. Environmental Protection Agency (EPA). (2011d). Radiation Protection. Radiation Symbols. Retrieved October 7, 2011 from

6. Exposure Limits and Averages
Annual Radiation Dose Limits
Agency
Radiation Worker - 5,000 mrem
NRC, "occupationally" exposed
General Public mrem
NRC, member of the public
General Public - 10 mrem
EPA, air pathway
General Public - 4 mrem
EPA, drinking water pathway
U.S. Environmental Protection Agency (EPA)
U.S. Nuclear Regulatory Commission (NRC)
Radiation is all around us. It comes from space, the ground, it is in the air we breathe, the water we drink and is even within our own bodies.
About half of our yearly exposure, or 310 millirem, comes from natural sources. No adverse health effects are known to come from these low levels of natural radiation exposure. The Nuclear Regulatory Agency has adopted a 100 mrem per year dose limit for each individual in the general public. This dose limit does not include the dose of radiation from natural sources. The average radiation exposure for most Americans is 620 millirem per year. This is a conservative number when it is compared to the annual dose limit set for radiation workers of 5000 millirem.
Reference
U.S. Environmental Protection Agency (EPA). (2007). Radiation Risks and Realities. Retrieved October 7, 2011 from
U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 14, 2011 from
Average Annual Dose
Natural Sources
310 mrem
Average Annual Dose
All Sources
620 mrem
U.S. Environmental Protection Agency (EPA). (2007). Radiation Risks and Realities. Retrieved October 7, 2011 from U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 14, 2011 from

7. Biological Effects of Radiation
Outcomes of living cells:
Cells die and replace themselves (normal process)
Cells repair themselves - no left-over damage
Cells incorrectly repair themselves – biophysical changes
Doses around 1 Sievert (Sv) may lead to heart disease, stroke, digestive disorders and respiratory disease. The exact effects of the cumulative health effects of exposure to ionizing radiation are difficult to determine.
The radiation protection community assumes that any amount of radiation exposure causes a risk to humans. All cells are susceptible to damage by ionizing radiation. For low levels of radiation exposure this biological damage to humans may not even be detectable.
The potential outcomes of radiation, to human cells include:
cells die, which is a normal process that happens every day, and they are replaced by the body; or
Cells or injured and repair themselves, resulting in no left-over damage; or
cells incorrectly repair themselves, resulting in a changes or defects in the cells (genetic changes).
The exact effect depends on the specific type and intensity of the radiation exposure. Based on history, such as survivors of nuclear weapons detonations in Japan and from cancer patients receiving radiation, a dose around 1 Sievert may lead to heart disease, stroke, digestive disorders and respiratory disease. As a reminder 1 Sievert equals 100,000 millirem.
Reference
U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from
U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from

8. Health Effects Based on Acute Exposure
Exposure (rem)
Health Effect
Time to Onset (without treatment)
5-10
changes in blood chemistry
50  
nausea
 hours
55  
fatigue 70
vomiting 75
hair loss
2-3 weeks 90
diarrhea
100
hemorrhage
400
possible death
within 2 months
1,000
destruction of intestinal lining
internal bleeding and death
 1-2 weeks
2,000
damage to central nervous system
loss of consciousness; death
Minutes/hours to days
It is rare for humans to experience high doses of radiation due to the strict regulations imposed internationally. We know from the Chernobyl nuclear power plant accident that high doses can cause an acute radiation sickness. Around 134 plant workers and emergency responders received radiation doses from 70,000 to 1,340,000 millirem and of those 28 died. Without medical treatment, it is believed that a dose around 500 rem (or 500,000 mrem), all at once, will cause death. A dose of 50 rem (or 50,000 mrem) will cause nausea. Spread out over time, instead of given all at once, these doses would be much less severe.
References
U.S. Environmental Protection Agency (EPA). (2011c). Radiation Protection. Health Effects. Retrieved October 1, 2011 from
U.S. Nuclear Regulatory Commission. (2011b). Radiation Exposure and Cancer. Retrieved October 3, 2011 from
U.S. Environmental Protection Agency (EPA). (2011c). Radiation Protection. Health Effects. Retrieved October 1, 2011 from

9. Estimated Health Effects of Radiation in Pregnancy
Increased Cancer Risk
Depends on amount of radiation and amount of time exposed
If acute exposure = to 500 Chest X rays, increased risk about 2%
Other health effects are unlikely when the dose to the fetus is very low
During 1st two weeks of pregnancy – greatest concern is death
Weeks 2-18 – birth defects, especially mental retardation
If fetuses exposed to 1 rem radiation 1 to 4 would be born with mental retardation
Week 18 to birth – unlikely effects, unless dose is very high
Genetic mutations – both parents exposed to 1 rem of radiation
In 1 million births, 50 severe hereditary effects expected
Compared to 100,000 other cases of genetic defects
Radiation can cause harm to an unborn baby (or fetus). These health effects can be severe depending on the amount of exposure and the age of the fetus when exposed. The biggest risk is the development of cancer. There is about a 2% increased chance of cancer for the baby with an acute radiation exposure equal to about 500 chest x-rays. Health effects from low doses are unlikely. During the 1st two weeks of pregnancy there is a risk of death if radiation exposure occurs. With a high dose of radiation, birth defects and mental retardation may occur, if the exposure is received sometime during weeks 2 to 18. Weeks 18 to birth the dose would have to be very high to effect the unborn baby. Genetic effects can occur if both parents are exposed to at least 1 rem of radiation. The risk is estimated to be that about 50 babies in one million would be born with severe genetic defects.
While radiological imaging should be avoided when possible, examinations that may provide significant diagnostic information during pregnancy are supported by the International Commission on Radiological Protection, the National Council on Radiation Protection, the American College of Radiology, and the American College of Obstetrics and Gynecology. The exposure should be kept as low as reasonably achievable.
References
McCollough, C. H., Schuler, B. A., Atwell, T. D., Braun, N. N., Regner, D. M., Brown, D. L., & LeRoy, A. J. (2007). Radiation Exposure and Pregnancy: When Should We Be Concerned? Radiographics, 27, doi: /rg
Centers for Disease Control and Protection (CDC). (2011). Emergency Preparedness and Response. Radiation and Pregnancy: A Fact Sheet. Retrieved October 3, 2011 from
U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from
Centers for Disease Control and Protection (CDC). (2011). Emergency Preparedness and Response. Radiation and Pregnancy: A Fact Sheet. Retrieved October 3, 2011 from U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from

10. Estimated Health Effects of Exposure to Ionizing Radiation – Lifetime Exposure
Cancer – increased risk of developing cancer with increasing doses of radiation
10,000 people exposed to 1 rem in small doses over their lifetime
2000 non-radiation deaths expected (baseline)
5 or 6 radiation deaths would occur
Indistinguishable from cancer from other causes
Normal exposure to background radiation per year is 3/10 of a rem (300mrem)
Cancers do not appear until many years after the radiation has been received
The radiation protection community assumes that any amount of radiation may pose some risk for causing cancer and hereditary effects. Again, the development of cancer is thought to be the biggest risk. The risk is cumulative, building over a lifetime. Multiple cancers have been associated with radiation exposure. Cancers that may develop as a result of radiation exposure are indistinguishable from those that occur naturally or as a result of other chemical exposures. It is estimated that if 10,000 people are exposed to just 1 rem over a lifetime, 5 or 6 radiation related cancer deaths would occur.
References
U. S. Environmental Protection Agency (EPA). (2007). Radiation Risks and Realities. Retrieved October 7, 2011 from
U.S. Nuclear Regulatory Commission. (2011b). Radiation Exposure and Cancer. Retrieved October 3, 2011 from
U. S. Environmental Protection Agency (EPA). (2007). Radiation Risks and Realities. Retrieved October 7, 2011 from U.S. Nuclear Regulatory Commission. (2011b). Radiation Exposure and Cancer. Retrieved October 3, 2011 from

11. Benefits / Uses of Radiation
Some televisions and computers
Smoke detectors
Power (illumination)
Steel and paper factories
Inspection
Security - Airport
Welds – airplanes/boats
Sterilization of hospital supplies
Diagnostic imaging
Therapeutic
Medicine
Treatment (XRT)
While there are risks associated with radiation exposure there are also multiple benefits or uses of radiation in our society. Radiation is found in our daily lives. It is part of the smoke detectors in our homes, our television sets, the luminous parts of our watches and illuminated signs and in a variety of glass products we use. Radiation is found in our factories, used in research and is part of security at our nation’s airports. Radiation is a great contributor to our healthcare system, where it is used in both the treatment of disease and the diagnosis of disease.
Reference
American Nuclear Association. (2008). Societal Benefits of Radiation Position Statement. Retrieved Oct 7, 2011 from
American Nuclear Association. (2008). Societal Benefits of Radiation Position Statement. Retrieved Oct 7, 2011 from

12. U.S. Population Exposed to Increased Radiation
In March, 2009, the National Council on Radiation Protection and Measurement released a critical report that indicated that radiation dose to the United States population had risen dramatically since the early 1980’s.
Unfortunately, these benefits are contributing to increased radiation in our environment. In 2009, the National Council on Radiation Protection and Measurement reported that the radiation exposure to people in the Unites States had risen dramatically. It was found that the exposure from ionizing radiation from medical procedures was 7 times higher in 2006 than it was in the early 1980s.
References
Schauer, D. A. & Linton, O. W. (2009). National Council on Radiation Protection and Measurements Report shows substantial medical exposure increase. Radiology, 253 (2),
ScienceDaily. (2009). Medical Radiation Exposure Of The U.S. Population Greatly Increased Since The Early 1980s. Retrieved October 14, 2011 from
Schauer, D. A. & Linton, O. W. (2009). National Council on Radiation Protection and Measurements Report shows substantial medical exposure increase. Radiology, 253 (2),

13. Sources of U.S. Radiation Exposure
In 2006, radiation exposure from man made sources was 50%, exactly that from natural sources. 48% of the exposure from manmade sources came from medical and nuclear medicine procedures. The increase was mostly due to higher use of CT scans and nuclear medicine. 67 million CT scans were done and 18 million nuclear medicine procedures were done in 2006.
References
ScienceDaily. (2009). Medical Radiation Exposure Of The U.S. Population Greatly Increased Since The Early 1980s. Retrieved October 14, 2011 from
U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from
U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from

14. Medical Imaging Procedures / Examples
Standard projection x-rays
Chest, hip, dental x-rays,
Mammogram
CT scan (CAT Scan)
Head, chest, abdomen
Nuclear medicine procedures
Angiogram
Fluoroscopy
Used in cardiac catherazation
There are many different types of medical imaging procedures and some do not use radiation. For example, ultrasounds use high-frequency sound waves and MRIs use radio waves and magnetic fields to image the bodies structures, not ionizing radiation.
All of the examples of medical procedures on this slide use ionizing radiation to image the body, but the amount of radiation differs. Standard projection radiation makes up about 74% of all medical procedures and CAT (CT) scans, fluoroscopy, and nuclear medicine procedures make up 26% of these procedures. 89% of the yearly exposure from medical imaging comes from the CAT (CT) scans, fluoroscopy, and nuclear medicine procedures.
Reference
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from

15. Radiation Doses of Medical Imaging Procedures
Dose Range, mSv
Average Dose, mSv
Chest X-ray Equivalent Dose
X-rays
Chest
0.34 1
L-spine
1.6
4.7
Hip
0.4
1.1
Barium enema
7-9 8
23.5
Mammography
0.48
1.4
Upper GI tract
3.6
10.6
Dental
0.18
0.53
CT scans
Thoracic 10
29.4
Abdomen
7.6-16
11.8 35
Pelvis
10-13
11.5
33.8
Angiographs
Cardiac
71.9
211.5
This chart lists some of the more common medical imaging procedures and the amount of radiation that a person may be exposed to if they have one of these procedures. The amounts differ based on the individual person, the equipment settings, the technique, device and even the institution where the test is being conducted. The number in the far right column shows chest x-ray equivalents for each procedure. For example someone having one CT scan of the abdomen will be exposed to as much radiation as someone having 35 chest x-rays. Someone undergoing one cardiac angiography, or an examination of the heart’s blood vessels, will be exposed to as much radiation as someone having 211 chest x-rays.
Reference
Medscape Reference. (2011). Ionizing Radiation Exposure with Medical Imaging . Retrieved October 12, 2011 from
Medscape Reference. (2011). Ionizing Radiation Exposure with Medical Imaging . Abbreviated from Table 4. Retrieved October 12, 2011 from

16. Increased lifetime cancer risk
Public Health Concern
More Medical Procedures
Increased Exposure to Ionizing Radiation
More Ionizing Radiation
More DNA damage
More DNA Damage
Increased lifetime cancer risk
Due to levels of exposure from individual medical imaging exams, the increase in these exams over the past 20 years, and the damage that can be caused by ionizing radiation, concerns have been raised about the risks associated with peoples’ exposure to radiation from medical imaging.
Millions of these exams are now performed each year. It is estimated that 29,000 future cases of cancer could be related to CT scans performed in 2007 (Berrington de González et al.) and that 1 in 270 women and 1 in 600 men who undergo CT coronary angiography at age 40 will develop cancer from that CT scan (Smith-Bindman et al.). There is agreement that the medical necessity of imaging procedures should be carefully considered by the health care provider and patient due to the increased risk of radiation exposure.
References
Berrington de González, A. & Darby, S. (2004). Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet, 363,
Smith-Bindman, R., Lipson, J., Marcus, R., Kim, K. P., Mahesh, M., & Gould, R. (2009). Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine, 169(22),
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from
Millions of exams performed each year
Estimates that 1 in 270 Women & 1 in 600 Men who undergo CT coronary angiography at age 40 will develop cancer from that CT scan1
1. Smith-Bindman, R., Lipson, J., Marcus, R., Kim, K. P., Mahesh, M., & Gould, R. (2009). Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine, 169(22), U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from

17. Balance Risk and Benefits
Some level of exposure is necessary
Determine extent of injury
Determine extent of disease
Support diagnosis or treatment
Exposure from medical procedures should not be feared – but must be respected
ALARA Principle – as low as reasonably achievable
Risks reduction by decreasing unnecessary exposure
In making decisions about medical imaging the risk and the benefits must be balanced. Medical imaging procedures can provide physicians with important clinical information. They can help diagnose disease, determine the extent of disease or injury, and can assist with treatment planning. In fact, the use of medical imaging procedures, when conducted appropriately, may help reduce the incidence of disease and death. It is important to follow the ALARA principle to keep the exposure “as low as reasonably achievable”. An optimal radiation dose is one that is as low as reasonably achievable while maintaining sufficient quality to meet the clinical need. Unnecessary radiation exposure may result when a procedure is not medically justified or when an alternative method might be preferable based on a persons lifetime history of radiation exposure. There is broad agreement by the regulatory agencies and medical community that steps should be taken to reduce unnecessary exposure to radiation.
Reference
Medscape Reference. (2011). Ionizing Radiation Exposure with Medical Imaging . Retrieved October 12, 2011 from
Medscape Reference. (2011). Ionizing Radiation Exposure with Medical Imaging . Retrieved October 12, 2011 from

18. Radiation Protection Principle
SHIELDING
TIME
A universal principle of radiation protection is that of time, distance and shielding.
If you decrease the amount of time you spend near a radiation source, you will decrease your amount of radiation exposure. If you spend 4 hours in the sun you are likely to get a sunburn. Alternatively, if you spend 15 minutes in the sun you are unlikely to be burned. Your distance from the radiation source changes your exposure. The further away you are the less radiation you receive. Compare this to the sound coming from your television. If you are sitting in the room with the television you will hear the sound. However, as you walk further away, into another room, the sound is harder to hear. Being close to a radiation source may cause more damage to your tissue. The third part of this principle is shielding. As we discussed earlier in this talk, if you spend the day in the sun with clothes on, you will receive less of a sunburn than if you are uncovered. This is because the clothes shield your body from the sun’s radiation. If you have had an x-ray, you probably noticed that the radiation technologist moved behind a protective wall before taking the picture or x-ray of your body. In doing so, the technologist was “shielding” themself from the radiation waves.
Reference
U.S. Environmental Protection Agency (EPA). (2011a). Radiation Protection Basics. Retrieved October 7, 2011 from
DISTANCE
U.S. Environmental Protection Agency (EPA). (2011a). Radiation Protection Basics. Retrieved October 7, 2011 from

19. Safe Use of Medical Imaging Devices
Improved Quality Assurance
Standardization
Safety
Training
The FDA reports that health care practitioners using medical imaging equipment may not have adequate information or a comprehensive understanding of radiation dose and quality assurance processes to provide for the safest possible imaging. The FDA is putting efforts toward improving and establishing standards, especially for pediatric imaging, and standardizing safety features. They have found that even when equipment safeguards are in place, the users may not have received adequate training to reduce the radiation dose to the lowest achievable dose.
Reference
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from
U. S. Food and Drug Administration. (2010)b. White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from

20. FDA and Partners Initiative
Reduce Unnecessary Radiation Exposure from Medical Imaging:
Promote safe use of medical imaging devices
Support informed clinical decision making
Increase patient awareness
Due the these findings the Food and Drug Administration in collaboration with the healthcare professional community has announced the launch of an initiative to reduce unnecessary radiation exposure from medical imaging. The FDA will take steps to promote safe use of medical imaging devices, to support informed clinical decision making, and to increase patient awareness. This initiative is expected to maximize the benefits of imaging while reducing the risks.
Reference
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from

21. Image Gently Campaign
Primary Objective: raise awareness of the opportunities to lower radiation dose in the imaging of children
Ultimate Goal: change practice
Strategy: straightforward information provided to every member of the care team
A number of other campaigns are underway that support the goals of the FDA program. The Alliance for Radiation Safety in Pediatric Imaging has campaigns called Image Gently and Step Lightly to change clinical practice by raising awareness of the opportunities to lower the radiation exposure of children from medical imaging . They have developed educational materials for pediatricians, radiologists, radiologic technicians, and parents to understand and encourage the careful use of medical imaging with children. The same principles are being applied to adults in the Image Wisely campaign (FDA, 2010). Resources for these programs can be found on line and links to both programs are provided for you in this slide. Keep these links handy to find information about safe imaging for yourself, your children or friends and family. You may also ask your health care provider if they are familiar with these programs.
References
Image Wisely. (2010b). Radiation Safety in Adult Medical Imaging. Retrieved October 15, 2011 from
The Alliance for Radiation Safety in Pediatric Imaging. (2011). Image Gently. Retrieved October 12, 2011 from
The Alliance for Radiation Safety in Pediatric Imaging. (2011). Image Gently. Retrieved October 12, 2011 from Image Wisely. (2010b). Radiation Safety in Adult Medical Imaging. Retrieved October 15, 2011 from

22. Informed Clinical Decision Making
FDA Actions / Recommendations
Establish requirements for manufacturers of imaging equipment to record radiation dose information for use in patient charts or in a dose registry
Recommend continued development of criteria for appropriate medical imaging use
Concerns have been raised that physicians may lack or do not have access to information that could inform their decisions in ordering medical imaging exams using radiation. There is not a consolidated place where the lifetime history of medical imaging is recorded for a patient, nor is there consistency in the amount of radiation exposure for each imaging procedure or machine. If radiation exposure from imaging was available, the physician decision to use a particular imaging procedure might change.
Additionally, physicians are not aware that criteria may be are available to guide their decisions to use a particular imaging procedure. Their decision may or may not be justified and the patient may be exposed to unnecessary radiation.
The FDA has launched a collaborative initiative to reduce unnecessary radiation exposure from medical imaging with a focus on CT scans, fluoroscopy, and nuclear medicine procedures. It is important to note that the Food and Drug Administration does not oversee the practice of medicine and must work with other groups, health care providers and the public to make recommendations about medical imaging.
The FDA’s Center for Devices and Radiological Health has recommended that manufacturers establish radiation dose information for their equipment to be used in patient charts or in a dose registry. They have recommended that development of criteria for appropriate medical imaging use be continued.
Reference
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from

23. American College of Radiology Appropriateness Criteria
Interventional Radiology Topics
Radiation Oncology Topics
Bone Metastases
Brain Metastases
Breast
Gynecology
Head & Neck
Hodgkin’s Lymphoma
Lung
Prostate
Rectal/Anal
Diagnostic Imaging Topics
Breast
Cardiac
Gastrointestinal
Musculoskeletal
Neurologic
Pediatric
Thoracic
Vascular
Women’s
The American College of Radiology has developed national guidelines to assist physicians to make the most appropriate imaging decisions for their patients. The guidelines were developed by panels of experts in diagnostic imaging, interventional radiology, and radiation oncology and are based on scientific evidence. There are over 175 topics, some of which are listed on this slide. These guidelines, which are easily searchable, are available on line, and can be accessed in making decisions about medical imaging. A link has been provided to you in the slide for easy access to the guidelines and is one mechanism for you to advocate for yourself during your healthcare journey.
Reference
American College of Radiology. (2011). ACR Appropriateness Criteria®. Retrieved October 7, 2011 from
American College of Radiology. (2011). ACR Appropriateness Criteria®. Retrieved October 7, 2011 from

24. Ask your doctor… Why do I need this exam?
How will information from this exam improve my health?
Are there others tests , as good, that do not use radiation?
Before undergoing an X-ray or procedure, be sure to ask your doctor:
Why do I need this exam?
How will having this exam improve my health care?
Are there alternatives that do not use radiation and which are equally as good?
Reference
Image Wisely. (2010a). Patients. Retrieved October 15, 2011 from
Image Wisely. (2010a). Patients. Retrieved October 15, 2011 from

25. Increase Patient Awareness
FDA collaboration with American College of Radiology and Radiological Society of North America to develop medical imaging card tool for tracking medical procedures
Paper tracking
Electronic tracking
Radiation dose calculators
The FDA recognizes the importance of empowering people with information and tools to help manage their unique exposure to radiation from medical imaging. The FDA ultimately wants this information to be part of a patient’s electronic medical record or health chart. This will take some time.
Reference
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from
U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from

26. My Medical Imaging History
In the interim, they have developed a medical imaging history card that can be used to record x-rays or treatment procedures. This card can be printed from the Image Wisely website and is also available in wallet size. You can advocate for yourself by keeping track of your medical imaging and by sharing the information with your doctor or health care provider.
Before the examination, make sure to tell your doctor or technologist if you are pregnant or might be pregnant. Do not insist on or decline an examination before having you doctor explain the reasons a test was or was not ordered for you. Discuss any fears or hesitations you have about a procedure with your doctor or technologist or both.
To link directly to the “My Medical Imaging History” card, click on the link found in the reference area of the slide.
References
Image Wisely. (2010). Radiation Safety in Adult Medical Imaging. Retrieved October 15, 2011 from
U.S. Food and Drug Administration. (2010a). My Medical Imaging History. Retrieved October 11, 2011 from
U.S. Food and Drug Administration. (2010a). My Medical Imaging History. Retrieved October 11, 2011 from

27. Calculate Your Radiation Dose
Open this hyperlink to the EPA website
Source
Your Average Annual Dose (mrem)
Cosmic radiation at sea level (from outer space) 26
What is the elevation (in feet) of your town?
 Choose from dropdown
Terrestrial (from the ground):
What region of the US do you live in?
EX; Gulf Coast Region
Internal radiation (in your body):
From food and water, (e.g., potassium) 40
From air, (radon)
200
Do you wear a plutonium powered pacemaker?
 Choose from dropdown (Y/N)
Do you have porcelain crowns or false teeth?
  Choose from dropdown (Y/N)
The last tool that I will talk about is an online tool that allows you to enter information about yourself and then it calculates the estimated amount of radiation you are exposed to annually. Earlier we discussed that an average American is exposed to about 620 millirem per year. This is far below levels that cause immediate health effects (U.S. EPA, 2011c).
This, easy to use, dose calculator is based on the American Nuclear Society's brochure, “Personal Radiation Dose Chart” and the values used in the calculator are general averages. They do not provide precise individual dose calculations (U. S. EPA, 2011b). An example of the questions in the calculator are provided to you on the slide as is the link directly to the calculator. It takes less than a minute to complete and provides you an idea about your radiation exposure. If your dose is higher than expected then be sure to discuss this with your physician, particularly if greater than 50% of your exposure is coming from medical or nuclear imaging procedures. This is a great resource for the whole family.
References
U.S. Environmental Protection Agency. (2011b). Radiation Protection. Calculate Your Radiation Dose. Retrieved Oct 1, 2011 from
U.S. Environmental Protection Agency (EPA). (2011c). Radiation Protection. Health Effects. Retrieved October 1, 2011 from
U.S. Environmental Protection Agency. (2011b). Radiation Protection. Calculate Your Radiation Dose. Retrieved Oct 1, 2011 from

28. Know Your Risks and Advocate!
48% of radiation exposure in the U.S. is from medical procedures
Cumulative exposure may lead to long term health problems, especially cancer
Document and share your medical imaging history with your doctor
Calculate and know your estimated annual radiation exposure
Discuss, with your doctor, the need for imaging or alternatives that may be available
Have a healthy respect for radiation; it provides great benefit to our society
In the last 30 minutes, we have reviewed the basics of ionizing radiation and have discussed both the short and long term risks of exposure. I have shown you that radiation exposure in the US from medical imaging has risen 7 fold since the 1980s and is now is responsible for 48% of our total radiation exposure. A number agencies are concerned about this increase and are involved in assuring the appropriate use of medical imaging to decrease exposure from this manmade radiation source. There are many ways that you can advocate for yourself and your family if you find that you are at an increased risk of exposure from medical imaging. First, be sure to know your estimated annual risk of exposure by using the calculator shared in this presentation. Print the medical imaging wallet card and record the procedures that you undergo. Discuss the need for imaging with your doctor. Several resources about imaging, shared in this presentation, have patient information about imaging procedures to help you better understand the risks and benefits of certain procedures. Have a healthy respect for radiation and the cumulative health effects that it can cause, but recognize the benefits that radiation brings to our society.
Thank you for your time and attention today.

29. References
American College of Radiology. (2011). ACR Appropriateness Criteria®. Retrieved October 7, from
American Nuclear Association. (2008). Societal Benefits of Radiation Position Statement. Retrieved October 7, 2011 from
Berrington de González, A. & Darby, S. (2004). Risk of cancer from diagnostic X-rays: Estimates for the UK and 14 other countries. Lancet, 363,
Centers for Disease Control and Protection (CDC). (2011). Emergency Preparedness and Response. Radiation and Pregnancy: A Fact Sheet. Retrieved October 3, 2011 from
Health Physics Society. (2011). Radiation Basics. Retrieved October 9, 2011 from
Image Wisely. (2010a). Patients. Retrieved October 15, 2011 from

30. References
Image Wisely. (2010b). Radiation Safety in Adult Medical Imaging. Retrieved October 15, from
McCollough, C. H., Schuler, B. A., Atwell, T. D., Braun, N. N., Regner, D. M., Brown, D. L., & LeRoy, A. J. (2007). Radiation Exposure and Pregnancy: When Should We Be Concerned? Radiographics, 27, doi: /rg
Medscape Reference. (2011). Ionizing Radiation Exposure with Medical Imaging. Retrieved October 12, 2011 from
Natural News. (2010). Use of high-radiation CT scans in emergency rooms triples over nine years. Retrieved October 20, 2011 from
New York Timers. (2010). Radiation, Risks Are Focus of Breast Screening Study. Retrieved October 21, 2011 from
Schauer, D. A. & Linton, O. W. (2009). National Council on Radiation Protection and Measurements Report shows substantial medical exposure increase. Radiology, 253 (2),

31. References
Smith-Bindman, R., Lipson, J., Marcus, R., Kim, K. P., Mahesh, M., & Gould, R. (2009). Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Archives of Internal Medicine, 169(22),
The Alliance for Radiation Safety in Pediatric Imaging. (2011). Image Gently. Retrieved October 12, 2011 from
USA Today. (2010). Cancer risks prompt doctors to try to lower imaging scan radiation. Retrieved October 21, 2011 from radiation05_st_N.htm
U. S. Environmental Protection Agency (EPA). (2007). Radiation Risks and Realities. Retrieved October 7, 2011 from
U. S. Environmental Protection Agency (EPA). (2011a). Radiation Protection Basics. Retrieved October 7, from
U.S. Environmental Protection Agency (EPA). (2011b). Radiation Protection. Calculate Your Radiation Dose. Retrieved Oct 1, 2011 from

32. References
U.S. Environmental Protection Agency (EPA). (2011c). Radiation Protection. Health Effects. Retrieved October 1, 2011 from U. S. Environmental Protection Agency (EPA). (2011d). Radiation Protection. Radiation Symbols. Retrieved October 7, 2011 from U. S. Environmental Protection Agency (EPA). (2011e) Why are some atoms Radioactive. Retrieved October 13, 2011 from U.S. Food and Drug Administration. (2010a). My Medical Imaging History. Retrieved October 11, 2011 from EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM pdf U. S. Food and Drug Administration. (2010b). White Paper: Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging Retrieved October 1, 2011 from EmittingProducts/RadiationSafety/RadiationDoseReduction/UCM pdf U. S. Nuclear Regulatory Commission. (2011a). Fact Sheet on Biological Effects of Radiation. Retrieved October 10, 2011 from sheets/bio-effects-radiation.htmlh U.S. Nuclear Regulatory Commission. (2011b). Radiation Exposure and Cancer. Retrieved October 3, 2011 from cancer.html

33. Additional Resources
American Academy of Pediatrics. (2009). Imaging and Medical Radiation Safety: Important Information for Parents. Retrieved October 21, 2011 from Furry Elephant. (n.d.). Lesson 5: How radiation harms. Retrieved October 21, 2011 from RadiologInfo.org. (2011). Patient Safety: Radiation Exposure in X-ray and CT Examinations. Retrieved October 21, 2011 from U.S. Food and Drug Administration. (2009). FDA Makes Interim Recommendations to Address Concern of Excess Radiation Exposure during CT Perfusion Imaging. Retrieved October 21, 2011 from U.S. Food and Drug Administration. (2010). Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010. Retrieved October 21, 2010 from World Health Organization. (2011). Ionizing Radiation. Retrieved October 21, 2011 from