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      Radiation Safety in Children With Congenital and Acquired Heart Disease : A Scientific Position Statement on Multimodality Dose Optimization From the Image Gently Alliance

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          Abstract

          There is a need for consensus recommendations for ionizing radiation dose optimization during multimodality medical imaging in children with congenital and acquired heart disease (CAHD). These children often have complex diseases and may be exposed to a relatively high cumulative burden of ionizing radiation from medical imaging procedures, including cardiac computed tomography, nuclear cardiology studies, and fluoroscopically guided diagnostic and interventional catheterization and electrophysiology procedures. Although these imaging procedures are all essential to the care of children with CAHD and have contributed to meaningfully improved outcomes in these patients, exposure to ionizing radiation is associated with potential risks, including an increased lifetime attributable risk of cancer. The goal of these recommendations is to encourage informed imaging to achieve appropriate study quality at the lowest achievable dose. Other strategies to improve care include a patient-centered approach to imaging, emphasizing education and informed decision making and programmatic approaches to ensure appropriate dose monitoring. Looking ahead, there is a need for standardization of dose metrics across imaging modalities, so as to encourage comparative effectiveness studies across the spectrum of CAHD in children.

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          Most cited references 108

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          Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study

          Summary Background Although CT scans are very useful clinically, potential cancer risks exist from associated ionising radiation, in particular for children who are more radiosensitive than adults. We aimed to assess the excess risk of leukaemia and brain tumours after CT scans in a cohort of children and young adults. Methods In our retrospective cohort study, we included patients without previous cancer diagnoses who were first examined with CT in National Health Service (NHS) centres in England, Wales, or Scotland (Great Britain) between 1985 and 2002, when they were younger than 22 years of age. We obtained data for cancer incidence, mortality, and loss to follow-up from the NHS Central Registry from Jan 1, 1985, to Dec 31, 2008. We estimated absorbed brain and red bone marrow doses per CT scan in mGy and assessed excess incidence of leukaemia and brain tumours cancer with Poisson relative risk models. To avoid inclusion of CT scans related to cancer diagnosis, follow-up for leukaemia began 2 years after the first CT and for brain tumours 5 years after the first CT. Findings During follow-up, 74 of 178 604 patients were diagnosed with leukaemia and 135 of 176 587 patients were diagnosed with brain tumours. We noted a positive association between radiation dose from CT scans and leukaemia (excess relative risk [ERR] per mGy 0·036, 95% CI 0·005–0·120; p=0·0097) and brain tumours (0·023, 0·010–0·049; p<0·0001). Compared with patients who received a dose of less than 5 mGy, the relative risk of leukaemia for patients who received a cumulative dose of at least 30 mGy (mean dose 51·13 mGy) was 3·18 (95% CI 1·46–6·94) and the relative risk of brain cancer for patients who received a cumulative dose of 50–74 mGy (mean dose 60·42 mGy) was 2·82 (1·33–6·03). Interpretation Use of CT scans in children to deliver cumulative doses of about 50 mGy might almost triple the risk of leukaemia and doses of about 60 mGy might triple the risk of brain cancer. Because these cancers are relatively rare, the cumulative absolute risks are small: in the 10 years after the first scan for patients younger than 10 years, one excess case of leukaemia and one excess case of brain tumour per 10 000 head CT scans is estimated to occur. Nevertheless, although clinical benefits should outweigh the small absolute risks, radiation doses from CT scans ought to be kept as low as possible and alternative procedures, which do not involve ionising radiation, should be considered if appropriate. Funding US National Cancer Institute and UK Department of Health.
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            The incidence of congenital heart disease.

            This study was designed to determine the reasons for the variability of the incidence of congenital heart disease (CHD), estimate its true value and provide data about the incidence of specific major forms of CHD. The incidence of CHD in different studies varies from about 4/1,000 to 50/1,000 live births. The relative frequency of different major forms of CHD also differs greatly from study to study. In addition, another 20/1,000 live births have bicuspid aortic valves, isolated anomalous lobar pulmonary veins or a silent patent ductus arteriosus. The incidences reported in 62 studies published after 1955 were examined. Attention was paid to the ways in which the studies were conducted, with special reference to the increased use of echocardiography in the neonatal nursery. The total incidence of CHD was related to the relative frequency of ventricular septal defects (VSDs), the most common type of CHD. The incidences of individual major forms of CHD were determined from 44 studies. The incidence of CHD depends primarily on the number of small VSDs included in the series, and this number in turn depends upon how early the diagnosis is made. If major forms of CHD are stratified into trivial, moderate and severe categories, the variation in incidence depends mainly on the number of trivial lesions included. The incidence of moderate and severe forms of CHD is about 6/1,000 live births (19/1,000 live births if the potentially serious bicuspid aortic valve is included), and of all forms increases to 75/1,000 live births if tiny muscular VSDs present at birth and other trivial lesions are included. Given the causes of variation, there is no evidence for differences in incidence in different countries or times.
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              Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians

              Objective To assess the cancer risk in children and adolescents following exposure to low dose ionising radiation from diagnostic computed tomography (CT) scans. Design Population based, cohort, data linkage study in Australia. Cohort members 10.9 million people identified from Australian Medicare records, aged 0-19 years on 1 January 1985 or born between 1 January 1985 and 31 December 2005; all exposures to CT scans funded by Medicare during 1985-2005 were identified for this cohort. Cancers diagnosed in cohort members up to 31 December 2007 were obtained through linkage to national cancer records. Main outcome Cancer incidence rates in individuals exposed to a CT scan more than one year before any cancer diagnosis, compared with cancer incidence rates in unexposed individuals. Results 60 674 cancers were recorded, including 3150 in 680 211 people exposed to a CT scan at least one year before any cancer diagnosis. The mean duration of follow-up after exposure was 9.5 years. Overall cancer incidence was 24% greater for exposed than for unexposed people, after accounting for age, sex, and year of birth (incidence rate ratio (IRR) 1.24 (95% confidence interval 1.20 to 1.29); P<0.001). We saw a dose-response relation, and the IRR increased by 0.16 (0.13 to 0.19) for each additional CT scan. The IRR was greater after exposure at younger ages (P<0.001 for trend). At 1-4, 5-9, 10-14, and 15 or more years since first exposure, IRRs were 1.35 (1.25 to 1.45), 1.25 (1.17 to 1.34), 1.14 (1.06 to 1.22), and 1.24 (1.14 to 1.34), respectively. The IRR increased significantly for many types of solid cancer (digestive organs, melanoma, soft tissue, female genital, urinary tract, brain, and thyroid); leukaemia, myelodysplasia, and some other lymphoid cancers. There was an excess of 608 cancers in people exposed to CT scans (147 brain, 356 other solid, 48 leukaemia or myelodysplasia, and 57 other lymphoid). The absolute excess incidence rate for all cancers combined was 9.38 per 100 000 person years at risk, as of 31 December 2007. The average effective radiation dose per scan was estimated as 4.5 mSv. Conclusions The increased incidence of cancer after CT scan exposure in this cohort was mostly due to irradiation. Because the cancer excess was still continuing at the end of follow-up, the eventual lifetime risk from CT scans cannot yet be determined. Radiation doses from contemporary CT scans are likely to be lower than those in 1985-2005, but some increase in cancer risk is still likely from current scans. Future CT scans should be limited to situations where there is a definite clinical indication, with every scan optimised to provide a diagnostic CT image at the lowest possible radiation dose.
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                Author and article information

                Contributors
                On behalf of : on behalf of the Image Gently Alliance
                Journal
                101467978
                35679
                JACC Cardiovasc Imaging
                JACC Cardiovasc Imaging
                JACC. Cardiovascular imaging
                1936-878X
                1876-7591
                8 June 2017
                18 May 2017
                July 2017
                01 July 2018
                : 10
                : 7
                : 797-818
                Affiliations
                [a ]Department of Pediatrics, Duke University Medical Center, Durham, North Carolina (Image Gently Alliance representative)
                [b ]Department of Radiology, Duke University Medical Center, Durham, North Carolina (Image Gently Alliance and SPR representative)
                [c ]Department of Pediatric Cardiology, Children’s Heart Clinic at The Children’s Hospitals and Clinics of Minnesota and the Minneapolis Heart Institute, Minneapolis, Minnesota (SCCT representative)
                [d ]Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island (ASNC representative)
                [e ]Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University, Columbus, Ohio (ACC representative)
                [f ]Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada (SNMMI representative)
                [g ]Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (Image Gently Alliance representative)
                [h ]Department of Radiology, Arkansas Children’s Hospital, Little Rock, Arkansas (NASCI representative)
                [i ]Department of Radiology, New York-Presbyterian Morgan Stanley Children’s Hospital, New York, New York (ASRT representative)
                [j ]Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas (SCAI representative)
                [k ]Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts (PACES representative)
                [l ]Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland (AAPM representative)
                [m ]Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
                [n ]Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois (ACR representative)
                [o ]Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia (AAP representative)
                [p ]Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Image Gently Alliance Representative)
                [q ]Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York (Image Gently Alliance representative)
                [r ]Department of Internal Medicine, Stanford University, Stanford, California (HRS representative)
                [s ]Division of Cardiology, Department of Medicine, and Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, New York (Image Gently Alliance representative)
                Author notes
                ADDRESS FOR CORRESPONDENCE: Dr. Andrew J. Einstein, Columbia University Medical Center, 622 West 168th Street PH 10-203, New York, New York 10032. andrew.einstein@ 123456columbia.edu
                Article
                NIHMS882548
                10.1016/j.jcmg.2017.04.003
                5542588
                28514670

                This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/).

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