Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine.

Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.

Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine.

Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.

Communication of benefits and risks of medical radiation: a historical perspective.

X-rays were discovered by Wilhelm Röntgen in 1895. Within one year, benefits of x-rays, such as visualization of fractures, and detriments, such as x-ray dermatitis, were recognized. Nobel Laureates Pierre and Marie Sklodowska Curie discovered the radioactive element radium in 1898, and a year later the application of radiation to cure cancer was reported. A significant price was paid for this: Marie Curie died of aplastic anemia related to her radiation exposure, and her daughter Irene Joliot Curie, Nobelist for radiochemical research, died of radiation-induced leukemia. Internationally developed radiation protection recommendations were formalized starting in the late 1920s. The increasing use of ionizing radiation in medical diagnosis and radiation therapy has brought significant societal benefits. Known risks of therapeutic radiation include coronary artery disease and secondary malignancy. However, recently concerns have been raised of possible very small but incremental increases in malignancies due to diagnostic medical radiation. Patients are largely unaware of, and referring physicians and even radiologists often underestimate, the carcinogenic effects of radiation. There is a need to determine the appropriateness of imaging tests that use ionizing radiation prior to performance; optimize imaging protocols to reduce unnecessary radiation; include patients in the decision process and encourage and enable them to track their radiation exposure; and promote education about medical radiation to patients, referring physicians, radiologists, and members of the public. The basic radiation protection principles of justification, optimization, and application of dose limits still pertain.

Controversies in mammography.

Concerns about screening mammography include questions of efficacy, high recall rates, false positives, and age at which to institute annual screening. Annual screening mammography can decrease breast cancer mortality by 45% in women over fifty and 23% in women between forty and fifty years of age. Patient recall rates and accuracy of interpretation vary among radiologists. Suggestions for improving accuracy of mammographic interpretation include continuing education with emphasis on quality of interpretation, computer-assisted detection, double reading, increased volume per reader, and performance-related skills testing. Having fewer radiologists reading more mammograms may result in decreased patient access to mammography services. Poor reimbursement for mammography and high prevalence of breast cancer-related litigation are disincentives for radiologists to provide mammography services; these issues must be addressed to ensure patient access to mammography. The public must be educated so that reasonable expectations on the benefits and limitations of mammography will develop.

Current issues in hormone replacement therapy.

Initially used to treat the vasomotor and vaginal symptoms of menopause, hormone replacement therapy (HRT) appeared to have many unexpected beneficial effects in early observational trials. It was hailed as a deterrent of atherosclerosis, osteoporosis, cognitive impairment, and Alzheimer disease. While its salutary effects on bone mass were substantiated, randomized clinical trials noted an increased risk of breast cancer, coronary artery disease, and thromboembolism, and raised doubts about the efficacy of HRT in improving quality of life. This article summarizes the literature and discusses current recommendations on the use of HRT.

Radiological terrorism.

A radiological terrorist attack on the United States is a possibility. This could involve the dispersal of radioactive material by an attack on a nuclear facility, deployment of a radiation dispersal device, or, less likely, detonation of a nuclear weapon. To decrease our vulnerability to this type of threat, the medical community should have a basic understanding of radiation hazards and their medical management, and it should be prepared to interact with appropriate federal agencies to facilitate the employment of emergency response plans.