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Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice

Published online by Cambridge University Press:  04 March 2015

Justin S. Ahn ,
Marcia L. Edmonds ,
Shelley L. McLeod  and
Jonathan F. Dreyer
Justin S. Ahn*
Affiliation:
Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON
Marcia L. Edmonds
Affiliation:
Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON
Shelley L. McLeod
Affiliation:
Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON
Jonathan F. Dreyer
Affiliation:
Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON
*
Division of Emergency Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 5W9; [email protected]

Abstract

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Objective:

To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE).

Methods:

An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs.

Results:

The survey response rate was 72.1% (31 of 43 physicians). For patients < 30 years old, 83.9% of physicians chose V/Q scanning as their test of choice, regardless of gender. Although only a third of respondents knew the estimated radiation dose of a V/Q scan (37.5%) and a CTPA (32%), the majority were aware that V/Q scans involved less ionizing radiation than CTPAs. In the retrospective review, 663 charts were reviewed, including 201 CTPAs and 462 V/Q scans. V/Q scanning was the preferred modality in female patients (75.9% v. CTPA 24.1% [OR 2.1; 95% CI 1.5–2.9]) and in patients < 30 years old (87.9% v. CTPA 12.1% [OR 4.8; 95% CI 2.4–9.4]).

Conclusions:

Although surveyed physicians possessed limited knowledge of radiation doses of CTPA and V/Q scans, they preferentially used the lower radiation V/Q scans in younger patients, particularly females, in both the survey vignettes and in clinical practice. This may reflect efforts to reduce radiation exposures at our institution.

Keywords

computed tomographic pulmonary angiographydiagnostic imaging testspulmonary embolismradiation exposureventilation-perfusion scan
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 16 , Issue 5 , September 2014 , pp. 393 - 404
Copyright
Copyright © Canadian Association of Emergency Physicians 2014

References

REFERENCES

1. Ron, E. Cancer risks from medical radiation. Health Phys 2003;85:47–59, doi:10.1097/00004032-200307000-00011.CrossRefGoogle ScholarPubMed
2. Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation. Health risks from exposure to low levels of ionizing radiation. BEIR VII Phase 2. Washington (DC): The National Academies Press; 2006.Google Scholar
3. Amis, ES Jr, Butler, PF, Applegate, KE, et al. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol 2007;4:272–84, doi:10.1016/j.jacr.2007.03.002.Google ScholarPubMed
4. Brenner, DJ, Hall, EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med 2007;357:2277–84, doi:10.1056/NEJMra072149.Google Scholar
5. Griffey, RT. Cumulative radiation exposure and cancer risk estimates in emergency department patients undergoing repeat or multiple CT. AJR Am J Roentgenol 2009;192:887–92, doi:10.2214/AJR.08.1351.Google ScholarPubMed
6. Brenner, DJ, Doll, R, Goodhead, DT, et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A 2003;100:13761–6, doi:10.1073/pnas.2235592100.Google Scholar
7. Tokunaga, M, Land, CE, Tokuoka, S, et al. Incidence of female breast cancer among atomic bomb survivors, 1950-1985. Radiat Res 1994;138:209–23, doi:10.2307/3578591.CrossRefGoogle ScholarPubMed
8. Parker, MS, Hui, FK, Camacho, MA, et al. Female breast radiation exposure during CT pulmonary angiography. Am J Radiol 2005;185:1228–33.Google Scholar
9. Hurwitz, LM, Reiman, RE, Yoshizumi, TT, et al. Radiation dose from contemporary cardiothoracic multidetector CT protocols with anthropomorphic female phantom: implications for cancer induction. Radiology 2007;245:742–50,doi:10.1148/radiol.2453062046.Google Scholar
10. Kessler, N, Cyteval, C, Gallix, B, et al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology 2004;230:472–8, doi:10.1148/radiol.2302021520.CrossRefGoogle ScholarPubMed
11. Edmonds, ML, Yan, JW, Sedran, RJ, et al. The utility of renal ultrasonography in the diagnosis of renal colic in emergency department patients. CJEM 2010;12:201–6.Google Scholar
12. Anderson, DR, Kahn, SR, Rodger, MA, et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA 2007;23:2743–53, doi:10.1001/jama.298.23.2743.Google Scholar
13. Anderson, DR, Barnes, DV. Computerized tomographic pulmonary angiography versus ventilation perfusion lung scanning for the diagnosis of pulmonary embolism. Curr Opin Pulm Med 2009;15:425–9, doi:10.1097/MCP.0b013e32832d6b98.Google Scholar
14. Sostman, HD, Stein, PD, Gottschalk, A, et al. Acute pulmonary embolism: sensitivity and specificity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology 2008;246:941–6, doi:10.1148/radiol.2463070270.Google Scholar
15. Mettler, FA Jr, Huda, W, Yoshizumi, TT, et al. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 2008;248:254–8, doi:10.1148/radiol.2481071451.Google Scholar
16. The PIOPED Investigators. Value of the ventilation/ perfusion scan in acute pulmonary embolism: results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 1990;263:2753–9, doi:10.1001/jama.1990.03440200057023.Google Scholar
17. Leung, AN, Bull, TM, Jaeschke, R, et al. American Thoracic Society documents: an official American Thoracic Society/ Society of Thoracic Radiology clinical practice guideline— evaluation of suspected pulmonary embolism in pregnancy. Radiology 2012;262:635–46, doi:10.1148/radiol.11114045.Google Scholar
18. Pierce, DA, Preston, DL. Radiation-related cancer risks at low doses among atomic bomb survivors. Radiat Res 2000;154:178–86, doi:10.1667/0033-7587(2000)154[0178:RRCRAL]2.0.CO;2.Google Scholar
19. Preston, DL, Shimizu, Y, Pierce, DA, et al. Studies of mortality of atomic bomb survivors. Report 13: solid cancer and noncancer disease mortality: 1950-1997 Radiat Res 2003;160:381–407, doi:10.1667/RR3049.CrossRefGoogle ScholarPubMed
20. Pearce, MS, Salotti, JA, Little, MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukemia and brain tumours: a retrospective cohort study. Lancet 2012;380:499–505, doi:10.1016/S0140-6736(12)60815-0.Google Scholar
21. Berrington de Gonzalez, A, Mahesh, M, Kim, KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 2009;169:2071–7, doi:10.1001/archinternmed.2009.440.Google Scholar
22. Lee, CI, Haims, AH, Monico, EP, et al. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology 2004;231:393–8, doi:10.1148/radiol.2312030767.Google Scholar
23. Lee, RKL, Chu, WCW, Graham, CA, et al. Knowledge of radiation exposure in common radiological investigations: a compromise between radiologists and non-radiologists. Emerg Med J 2012;29:306–8, doi:10.1136/emermed-2011-200481.Google Scholar
24. Baumann, BM, Chen, EH, Mills, AM, et al. Patient perceptions of computed tomographic imaging and their understanding of radiation risk and exposure. Ann Emerg Med 2011;58:1–7.e2, doi:10.1016/j.annemergmed.2010.10.018.Google Scholar
25. Cassel, CK, Guest, JA. Choosing wisely. Helping physicians and patients make smart decisions about their care. JAMA 2012;307:1801–2, doi:10.1001/jama.2012.476.Google Scholar
26. American College of Physicians. Choosing wisely. Available at: (accessed February 23, 2013).Google Scholar
27. Neeman, N, Quinn, K, Soni, K, et al. Reducing radiology use on an inpatient medical service: choosing wisely. Arch Intern Med 2012;172:1606–7, doi:10.1001/archinternmed.2012.4293.Google Scholar
28. Venkatesh, AK, Kline, JA, Courtney, M, et al. Evaluation of pulmonary embolism in the emergency department and consistency with a national quality measure. Quantifying the opportunity for improvement. Arch Intern Med 2012;172:1028–32, doi:10.1001/archinternmed.2012.1804.Google Scholar
29. Stein, EG, Haramati, LB, Chamarthy, M, et al. Success of a safe and simple algorithm to reduce use of CT pulmonary angiography in the emergency department. AJR Am J Roentgenol 2010;194:392–7, doi:10.2214/AJR.09.2499.Google Scholar
30. Prasad, KN, Cole, WC, Haase, GM. Radiation protection in humans: extending the concept of as low as reasonable achievable (ALARA) from dose to biological damage. Br J Radiol 2004;77:97–9, doi:10.1259/bjr/88081058.Google Scholar
31. Schembri, GP, Miller, AE, Smart, R. Radiation dosimetry and safety issues in the investigation of pulmonary embolism. Semin Nucl Med 2010;40:442–54, doi:10.1053/j.semnuclmed.2010.07.007.Google Scholar
32. Stein, PD, Matta, F. Noninvasive imaging in pulmonary embolism according to age and gender. Clin Appl Thromb Hemost 2012. DOI:10.1177/107602961262763.Google Scholar
33. He, J, Wang, F, Dai, H, et al. Chinese multi-center study of lung scintigraphy and CT pulmonary angiography for the diagnosis of pulmonary embolism. Int J Cardiovasc Imaging 2012;28:1799–805, doi:10.1007/s10554-012-0013-9.Google Scholar
34. Miniati, M, Pistolesi, M, Marini, C, et al. Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the prospective investigative study or acute pulmonary embolism diagnosis (PISA-PED). Am J Respir Crit Care Med 1996;154:1387–93, doi:10.1164/ajrccm.154.5.8912753.Google Scholar
35. Carrier, M, Righini, M, Le Gal, G. Symptomatic subsegmental pulmonary embolism: what is the next step? J Thromb Haemost 2012;10:1486–90, doi:10.1111/j.1538-7836.2012.04804.x.Google Scholar
36. Carrier, M, Righini, M, Wells, PS, et al. Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost 2010;8:1716–22, doi:10.1111/j.1538-7836.2010.03938.x.Google Scholar
37. Stein, PD, Goodman, LR, Hull, RD, et al. Diagnosis and management of isolated subsegmental pulmonary embolism: review and assessment of options. Clin Appl Thromb Hemost 2012;18:20–6, doi:10.1177/1076029611422363.Google Scholar
38. Miles, S, Rogers, KM, Thomas, P, et al. A comparison of singlephoton emission CT lung scintigraphy and CT pulmonary angiography for the diagnosis of pulmonary embolism. Chest 2009;136:1546–53, doi:10.1378/chest.09-0361.Google Scholar
39. Hurwitz, LM, Toshizumi, TT, Goodman, PH, et al. Radiation dose savings for adult pulmonary embolus 64-MDCT using Bismuth breast shields, lower peak kilo voltage and automatic tube current modulation. AJR Am J Roentgenol 2009;192:244–53, doi:10.2214/AJR.08.1066.Google Scholar
40. Heyer, CM, Mohr, PS, Lemburg, SP, et al. Image quality and radiation exposure at pulmonary CT angiography with 100- or 120-kVp protocol: prospective randomized study. Radiology 2007;245:577–83, doi:10.1148/radiol.2452061919.Google Scholar
41. Woo, JKH, Chiu, RYW, Thakur, Y, et al. Risk-benefit analysis of pulmonary CT angiography in patients with suspected pulmonary embolus. AJR Am J Roentgenol 2012;198:1332–9, doi:10.2214/AJR.10.6329.Google Scholar