BJR © 2021 The Authors.

Published by the British Institute of Radiology

https://​doi.​org/​10.​1259/​bjr.​20210389
Received: Revised: Accepted:
28 March 2021 24 May 2021 25 May 2021

Cite this article as:

Brower C, Rehani MM. Radiation risk issues in recurrent imaging. Br J Radiol 2021; 94: 20210389.

CONTEMPORARY ISSUES IN RADIATION PROTECTION IN

MEDICAL IMAGING SPECIAL FEATURE: REVIEW ARTICLE
Radiation risk issues in recurrent imaging
1
CHARLES BROWER, MD and 2MADAN M REHANI, PhD
1
Harvard Medical School, Boston, MA, USA
2
Massachusetts General Hospital, Boston, MA, USA

Address correspondence to: Prof Madan M Rehani

E-mail: ​madan.​rehani@​gmail.​com

ABSTRACT
Millions of patients benefit from medical imaging every single day. However, we have entered an unprecedented era in
imaging practices wherein 1 out of 125 patients can be exposed to effective dose >50 mSv from a single CT exam and 3
out of 10,000 patients undergoing CT exams could potentially receive cumulative effective doses > 100 mSv in a single
day. Recurrent imaging with CT, fluoroscopically guided interventions, and hybrid imaging modalities such as positron
emission tomography/computed tomography (PET/CT) is more prevalent today than ever before. Presently, we do
not know the cumulative doses that patients may be receiving across all imaging modalities combined. Furthermore,
patients with diseases with longer life expectancies are being exposed to high doses of radiation enabling radiation
effects to manifest over a longer time period. The emphasis in the past on improving justification of imaging and opti-
mization of technique and practice has proved useful. While that must continue, the current situation requires imaging
device manufacturers to urgently develop imaging technologies that are safer for patients as high doses have been
observed in patients where imaging has been justified through clinical decision-­support and optimized by keeping
doses below the national benchmark doses. There is a need to have a critical look at the fundamental principles of
radiation protection as cumulative doses are likely to increase in the coming years.

INTRODUCTION measured dose quantities are involved, and many organs

In current clinical practice, it is not rare for patients to are exposed in patients undergoing recurrent imaging of
undergo recurrent high-­dose imaging exams in a lifetime.1,2 different body regions. Effective dose (E) is a dose quan-
Recent reports have shed light on the increasing frequency tity defined by the International Commission on Radio-
of CT, positron emission tomography/computed tomog- logical Protection (ICRP) representative of the stochastic
raphy (PET/CT), and fluoroscopically guided interven- risk of radiation.4 Although it is inappropriate to utilize
tional procedures. For example, a recent study comprising effective dose to determine the individual risk of radia-
2.5 million patients who underwent 4.8 million CT exams tion; it remains the best way to discuss radiation exposure
found that patients underwent a median of 6 CT exams in a to patients (or representative phantoms, to be precise) in a
year and that some patients received up to 109 exams over 5 cumulative manner.4 In the setting of recurrent imaging, as
years.3 As the radiation dose in any imaging exam may vary per current practice, organ doses cannot be meaningfully
widely, it is more appropriate to discuss this topic in terms used and thus effective dose remains a meaningful metric
of the radiation dose involved rather than the number of for discussing radiation doses.
imaging exams performed.
In the cohort study mentioned above, patients who received
It is recommended to use measured radiation dose quanti- a cumulative effective dose (CED) ≥ 100 mSv had a median
ties whenever possible for the sake of maintaining accuracy. CED of 130.3 mSv and a maximum CED of 1185 mSv over
For CT, the volume weighted CT dose index (CTDIvol) is a a period ranging from 1 to 5 years.3 Roughly, 1 out of every
quantity measured in a phantom. However, these measured 100 patients who underwent a CT exam received a CED
quantities, which represent radiation output from the ≥ 100 mSv over 1 to 5 years. Furthermore, it is estimated
machine and patient exposure, become less applicable that an additional 0.9 million patients get added to this
to real-­world clinical settings where patient dose rather CED ≥ 100 mSv cohort every year globally2,3,5 and approx-
than scanner output is needed. Typically, several types of imately, 2.5 million patients reach a CED level ≥100 mSv
 BJR Brower and Rehani

in a 5-­year period across 35 member countries of the Organi- dose tracking systems.22–24 The push by the International Atomic
zation for Economic Cooperation and Development (OECD).6 Energy Agency (IAEA) Smart Card/SmartRadTrack project
These recent studies focused on cohorts of patients with CEDs ≥ and its position statement issued jointly with other organiza-
100 mSv not because 100 mSv is a threshold for radiation effects, tions such as the European Society of Radiology (ESR), Food
but rather because CED ≥ 100 mSv correlates with many organs and Drug Administration (FDA), International Organization
receiving a dose >100 mGy at which there is a high degree of for Medical Physics (IOMP), International Society of Radiog-
confidence on radiation effects among both international and raphers and Radiological Technologists (ISRRT), World Health
national organizations.3,7 Organization (WHO), and the Conference of Radiation Control
Program Directors (CRCPD) was integral to the commercial
The purpose of this paper is to review the existing literature development of dose management systems.25 A series of papers
on recurrent imaging studies that involve X-­rays and/or radio- in the early 2010s discussed various aspects of dose manage-
pharmaceuticals resulting in high cumulative radiation doses to ment systems such as patient IDs,26 prototypes of smart cards,27
patients and the associated potential radiation risks. tracking of examinations and doses,28 templates and models for
patient exposure tracking,23 and worldwide surveys to identify
dose tracking and management needs.24 A number of publica-
HISTORICAL ASPECTS
tions of the European Commission, IAEA and a position state-
In the past, unsatisfactory image quality was a driving factor ment by Heads of European Radiological Protection Competent
for repeat imaging studies. Such imaging practices were typi- Authorities (HERCA) focussed on the issue of justification.29–33
cally discussed in terms of repeat or reject rates and significant The positive dose tracking experience from a pediatric hospital in
emphasis was placed on reject rate analysis.8 The term recur- Finland demonstrated strengthening the process of justification
rent imaging is more appropriate for situations where multiple and optimization through tracking of procedures and doses.34
imaging studies are performed for clinical reasons. Tracking
radiation doses was not routinely implemented as there were no While we progressed from an emphasis on repeat imaging and
mechanisms to facilitate tracking such as fixed patient IDs, dose reject rates, the concept of recurrent imaging was consolidated
displays on imaging machines, structured dose reports, networks with a focus on identifying patients who receive high cumula-
to transmit dose information, or automatic methods of detecting tive doses – for instance, ≥100 mSv – over a period of several
cases with repeat studies. Therefore, the focus was on quantifying years.3,35,36
radiation risk from avoidable repeats rather than the cumulative
dose to which individual patients were exposed.8
IMAGING INVOLVING X-RAYS AND
Also, prior to 2000, CT imaging using single detector scanners CONSIDERATIONS OF RADIATION RISKS
was slow requiring several minutes to scan a given body region. It is appropriate to consider various imaging modalities sepa-
As such, recurrent imaging on the same patient was not common rately to better understand the radiation risks involved.
except in the follow-­up of malignancy (although still at a much
lower rate than today in this patient population). Aside from the Radiography
speed of the exam and radiation risks, cost and availability were Radiographic studies like plain radiography, mammography, and
the primary factors limiting frequent and recurrent use of CT dental exams are recurrent, but still, they involve relatively low
imaging. However, with the advent of helical CT imaging, scan- doses. A single plain radiograph of the chest, head, abdomen, or
ners became faster and led to the erroneous perception that radi- pelvis involves an effective dose between 0.02 and 2 mSv. Thus,
ation doses might decrease with shorter scan times.9 Increased even 10 chest radiographs result only in a CED of approximately
affordability and availability of CT scanners led to drastic 1 mSv, which will, of course, depend upon the views taken. Simi-
increases in the use of CT imaging as well as the adoption of CT larly, 10 radiographs of abdomen or lumbar spine result only in
imaging covering larger body areas (e.g. abdomen/pelvis or even a CED of <10 mSv. Tables that provide radiation doses for indi-
chest/abdomen/pelvis). As a result, many radiographic exam- vidual radiographic examinations, including dental radiographs,
inations were replaced with CT imaging. Given the increasing are widely available from different publications, e.g. NCRP publi-
use of CT imaging, research in the early 2000s began to focus cation 18437 in the United States and other publications in the
on radiation risks of CT imaging and, in particular, radiation United Kingdom.38,39 For plain radiography, a publication on
risks in children.10,11 As cancer risks from CT imaging gained extremely low birth weight infants indicated a mean of 31 radio-
more attention in mainstream media, radiation dose reduction graphs performed over the first few months of life, including an
and, to some extent, dose optimization movements began to average of 17 chest radiographs, 5 babygrams, and 9 abdominal
gain momentum.12–16 With increasing emphasis on cancer risks, radiographs.40 The majority of chest radiographs and babygrams
industry responded by prioritizing radiation dose reduction and are performed in the first month of life, whereas the frequency
began competing with each other on this metric.17 of abdominal radiographs increased during the second month.
Another study found that patients in a neonatal intensive care
The concept of tracking cumulative doses appeared in the latter unit (NICU) underwent an average of 4.2 (range 1–21) radio-
half of the 2000s.18–21 During the first decade of this century, graphs during the course of their admission.41 The value of
the implementation of electronic medical records, availability of routine X-­rays in intensive care unit settings has been ques-
picture archiving and communication system (PACS), and stan- tioned, both in NICUs and adult intensive care units.42–44 Recur-
dardization of radiation units in diagnostic radiology enabled rent imaging is also common in dental radiological practices

2 of 10 birpublications.org/bjr Br J Radiol;94:20210389
 Radiation risk issues in recurrent imaging BJR

and some studies have drawn attention to potential adverse Fluoroscopically guided interventional procedures
effects.45–47 It is prudent that all exams are properly justified and (FGIs)
imaging pathways should be appropriate in terms of modality FGI procedures often replace surgical procedures that involve
and frequency irrespective of the doses involved. higher risks as compared to radiation risks associated with FGI.
In view of their utility, FGIs are employed outside radiology in
Computed tomography interventional cardiology, electrophysiology, vascular surgery,
CT imaging has been the focus of most research on recurrent orthopedic surgery, urology, gastroenterology, and in many other
imaging. In addition to the drivers listed above, the relative ease clinical specialities.56,57 Some FGIs are well known to impart
high patient doses resulting in skin injuries.56,58–63 However,
of calculating cumulative effective doses with widespread avail-
a recent study reviewing interventional radiology procedures
ability of dose information in patient files (e.g. CTDIvol and dose–
at a major hospital over 9 years found that 4% of patients had
length product [DLP]) has facilitated dose tracking in CT. Of
CEDs ≥ 100 mSv with a median CED of 177 mSv.64 Further, the
course, increasing reliance on CT imaging and relatively higher
majority (~90%) of patients had all of their procedures within 12
doses compared to radiography also contribute to the increased
months and 10.7% were under the age of 40. Patients whose age
scrutiny of recurrent CT imaging. Previously, the conversion
at first procedure was 40 years or younger most commonly had a
of DLP to effective dose required additional computer software
chronic disease of the torso (54.6%) and the percentage of cancer
that could not directly interface with radiation dose structured
was low (11.1%) among this patient population.
reports (RDSRs) from imaging machines. Since commercial dose
management systems (DMS) became available in recent years, it
has become easier to track the radiation doses patients receive, NUCLEAR MEDICINE AND HYBRID IMAGING
obtain data on patients with defined cumulative doses (such as While much attention has been focused on radiation from CT
100 mSv), and create alerts when patients receive doses above a imaging, nuclear imaging studies such as myocardial perfusion
certain threshold. Lack of availability of DMSs in certain regions imaging (MPI), PET/CT, and SPECT/CT involve high doses in
of the world contributes to a lack of understanding of cumulative individual exams. In recent years, there has been greater reali-
doses to patients globally. zation that hybrid imaging is being used in a recurrent manner
resulting in high cumulative doses. For instance, in a study it was
There has also been some resistance to tracking cumulative demonstrated that MPI contributed 22% of CED from medical
doses because of the fear that such information might be used sources in 2010 and >10% of the entire CED to the American
to prevent a clinically indicated imaging study.48,49 However, population from all sources.65,66 Interest is growing in assessing
cumulative dose data has been available via thousands of DMSs CEDs from recurrent hybrid imaging and readers should refer
installed in Europe and the United States for many years without to articles published in this issue of the journal for additional
any evidence suggesting information on cumulative doses information.
prevents necessary clinical imaging. Referring physicians play
the most significant role in referring patients for CT imaging CLINICAL CONDITIONS WITH HIGH RATES OF
in most countries with the exception of a handful countries RECURRENT IMAGING
where radiologists hold official responsibility for accepting a CT Recurrent advanced imaging with consequent radiation expo-
referral.50,51 International standards assign joint responsibility sure is widespread across various clinical conditions. In partic-
to radiologists and referring physicians for justifying a given ular, CT imaging and nuclear imaging were identified in 2009
imaging study.52,53 Referring physicians are often unaware of as the major drivers of ionizing radiation exposure in patients,
radiation risks involved with CEDs greater than 50 or 100 mSv accounting for 75.4% of CED in the United States.21 Further-
and that patients are not subject to dose limits.54 Thus, in more, CT imaging utilization across various clinical settings has
routine clinical practice, the decision to pursue an imaging been increasing over the past 40 years with concomitant increases
study is more often based on benefits rather than consider- in health-­care costs but unclear corresponding improvements in
ation of risks of radiation weighed against potential benefits.51 clinical care or outcomes.20,67–69 Patients with chronic condi-
Readers are encouraged to review the dialogs between physi- tions and recurrent disease are more likely to undergo recurrent
cian and medical physicist presented in a recent paper to gain imaging resulting in high CEDs.5,20 In particular, patients with
better understanding of dilemmas faced by physicians in the active or past malignancy are frequently exposed to recurrent
process in real-­world imaging prescribing practices.51 There- imaging to both assess for disease progression and monitor for
fore, the fears discussed above are often held by individuals who recurrence. In a recent study analyzing clinical indications for
are rarely involved in the process of referring patients for CT patients who received a CED ≥ 100 mSv over a 5-­year period,
imaging. On the contrary, resistance to measuring cumulative approximately 90% of patients had a history of malignancy.35
doses has culminated in missed opportunities to detect millions
of patients in radiation risk zones.2,3,6,32,35 Cumulative dose Aside from malignancy, various other non-­malignant chronic
research has been integral in identifying patients who receive and recurrent diseases have been identified as major drivers of
CEDs ≥ 100 mSv in a single day.3,36,55 Recent data from a study recurrent imaging. A recent review identified cardiac disease, end
of nearly 4 million patients from 279 hospitals demonstrated stage renal disease (ESRD), Crohn’s disease, and patients who had
that 0.8% of patients (1 out of 125) received ≥ 50 mSv and 0.03% undergone endovascular aortic repair (EVAR) as patient popula-
(3 out of 10,000) received ≥100 mSv in a single day from CT tions who were more likely to be exposed to high CEDs.5 Other
imaging.55 research has identified patients with abdominal pain of any cause

3 of 10 birpublications.org/bjr Br J Radiol;94:20210389
 BJR Brower and Rehani

and urolithiasis as patient populations with higher rates of repeat Furthermore, multiple MPIs were performed in 39% of patients
imaging.20,68,70 Supporting this observation, abdominal pain and and 31% of patients received CEDs > 100 mSv from all medical
flank pain are the presenting complaints with the highest like- sources.65
lihood of receiving a CT scan in the emergency department.68
Patients who undergo EVAR (e.g. for abdominal aortic aneu-
With regard to abdominal pain, the use of CT imaging has rysm repair) are another patient population for whom recur-
increased dramatically in the emergency department (ED) rent imaging is common with such patients often being
setting with associated increases in costs and length of stay but exposed to CEDs > 100 mSv in the first year following EVAR
has not resulted in lower admission rates or fewer cases of missed with substantial ongoing radiation exposure thereafter.5 More-
surgical illness.71,72 In a recent study of patients who received over, in many cases CED estimates may not include imaging
a CED ≥ 100 mSv over a 5-­year period, abdominal pain and that occurs prior to EVAR suggesting lifetime CEDs may be
related complaints were the most frequent clinical reasons for CT larger.84,85 Finally, approximately one-­third of patients with
imaging in patients without a history of malignancy.35 Patients ESRD on hemodialysis accrue CEDs > 50–100 mSv over only
with inflammatory bowel disease, in particular Crohn’s disease, 3 to 4 years.5
are likely to undergo recurrent imaging with CEDs exceeding
50 mSv in 10–30% of patients who underwent imaging.5 Small TOTAL DOSE FROM RECURRENT IMAGING
bowel obstruction (SBO) is another recurrent disease that pres- EXAMS
ents with abdominal pain for which patients are subjected to There is a paucity of research on total cumulative doses patients
recurrent CT imaging with recurrences rates for SBO from adhe- receive from different imaging modalities. A large fraction of the
sions ranging from 15 to 50% at 10 years.73 CT imaging remains current DMSs do not track dose information from FGI, nuclear
the gold-­standard for the diagnosis of SBO despite ultrasound medicine, and hybrid imaging studies. Even if one ignores radi-
demonstrating similar diagnostic test characteristics.74 ography exams that contribute small doses, it is imperative that
that DMS tracking capabilities expand to provide cumulative
Urolithiasis is another highly prevalent disease with high rates radiation dose data for individual patients across all high dose
of recurrent CT imaging.70,75–77 Current research suggests that imaging modalities. In spite of this limitation, existing research
30–50% of patients experience recurrence of urolithiasis within on cumulative doses for a variety of diseases is available and
10 years of their initial episode.76,78–80 A large-­ scale retro- summarized in Table 1 (reproduced with permission from
spective cohort study from 2017 found that 82.6% of patients Brambilla et al).5 There is further need for patient-­based research
presenting to the ED with renal colic receive an abdominal CT to identify the contribution of different imaging modalities to
scan.80 In a 2007 retrospective study of 356 patients presenting CEDs among high-­dose patient cohorts.
with suspected urolithiasis to a tertiary care ED, 79% of patients
received ≥2 abdominal CT scans over the 10-­month study and Another patient population with documented high cumulative
15% of patients received ≥4 CT scans.70 Another retrospective doses are patients with hereditary hemorrhagic telangiectasia
study from 2006 found that 4% of patients with suspected renal (HHT) who have pulmonary arteriovenous malformations.104
colic had undergone three or more CT examinations with esti- In a study of this patient population, CEDs ranged from 0.2
mated effective doses ranging from 19.5 to 153.7 mSv.75 Despite to 307.6 mSv with a mean of 51.7 mSv and the dose exceeded
such high rates of CT imaging for recurrent urolithiasis, research 100 mSv in 11% of patients. Interventional procedures and CT
suggests that only 10% of CT scans reveal alternative pathology exams were the greatest contributors to radiation exposure
(e.g. adnexal masses, pyelonephritis, colonic pathology, etc.) and accounting for 51% and 46% of the total CED, respectively.
that repeat CT scans rarely change clinical management.75,81 Factors associated with high cumulative exposure in this patient
A multicenter comparative effectiveness trial demonstrated population were epistaxis and HHT-­ related gastrointestinal
that ultrasound for suspected urolithiasis is noninferior to CT bleeding. Additionally, the number of patient-­years was signifi-
imaging for the initial diagnosis of urolithiasis and is associated cantly associated with higher CEDs, given the continued need
with lower cumulative radiation exposure for patients.82 This for imaging for the duration of patients’ lifetimes.
study was crucial in prompting the development of the Amer-
ican College of Emergency Physicians Choosing Wisely recom- Critically ill patients are another patient population with
mendation to avoid CT imaging in patients age <50 years with a high cumulative dose. For example, Kim et al studied cumu-
known history of urolithiasis presenting to the ED with symp- lative radiation exposure in critically ill trauma patients.105
toms consistent with uncomplicated renal colic.83 They report the number of studies per patient (mean ± SD)
across various modalities including plain film radiography
Beyond these clinical conditions, patients with cardiac disease, (70.1 ± 29.0), CT imaging (7.8 ± 4.1), fluoroscopy (2.5 ± 2.6),
particularly patients admitted to a hospital for acute myocar- and nuclear medicine (0.065 ± 0.33). The mean CED was 106
dial infarction or who require heart transplants, often undergo ± 59 mSv per patient (range 11–289 mSv; median 104 mSv).
recurrent imaging studies and are exposed to high CEDs.5,65 For Furthermore, the authors found that age, mechanism of injury,
instance, Einstein et al65 retrospectively reviewed procedures injury severity score, and length of stay were not statistically
involving ionizing radiation in patients who had undergone significant predictors of high CEDs. Another study of critically
MPI and found that this subset of patients underwent a median ill patients demonstrated that 6.8% of such patients had CEDs
of 16 procedures involving radiation exposure over 30 years. exceeding 50 mSv.106

4 of 10 birpublications.org/bjr Br J Radiol;94:20210389
 Radiation risk issues in recurrent imaging BJR

Table 1. Cumulative radiation exposure and patients with CED >100 mSv5

Age (years) Patients Patients

X-­ray Mean or with CED with CED Follow-­up
Author Condition No. Pts Procedures Median§ >50 mSv >100 mSv (years)
Chen et al66 Pts with cardiac 9,0121 Only cardiac 51.1  3173 (3.5%)b 75 (0.08%)d 3
imaging procedures

Einstein et al65 Pts with myocardial 1097 All medical imaging 62.2   344 (31.4%) 20
perfusion scan procedures

Stein et al86 Cardiac disease 8656 All medical imaging 65.9   533 (6.2%)   3
procedures

Kaul et al87 Acute myocardial 6,4071 All medical imaging 64.9f  1060 (1.7%)e   ---
infarction procedures

Eisenberg et al88 Acute myocardial 8,2861 Only cardiac 63.2f  1,5090 (18%)a   1
infarction procedures

Lawler et al89 Acute myocardial 1,1427 Only cardiac 68.0f  825 (7.2%)a,e   1
infarction procedures

Kinsella et al90 Haemodialysis 100 All medical imaging 58.9   26 (26%) 13 (13%)c 3.4
procedures median

De Mauri et al91 Haemodialysis 106 All medical imaging 65.3   17 (16%) 3.0
procedures median

Coyle et al92 Haemodialysis 244 All medical imaging 52.7   56 (23%)   4.0
procedures median

Kidney transplant 150 All medical imaging 45.7   12 (8%)  

procedures

De Mauri et al93 Kidney transplant 92 All medical imaging 52.4   26 (28%) 11 (12%) 4.1
procedures median

Desmond et al94 Crohn’s 354 All medical imaging 32   55 (16%)c 15

procedures

Levi et al95 Crohn’s 199 All medical imaging 39   23 (7%)   5.5

Ulcerative colitis 125 procedures (no 5.0
interventional)

Kroeker et al96 Crohn’s 371 All medical imaging 40   27 (7%) 12 (3%)c 5

procedures

Butcher et al97 Crohn’s 127 All medical imaging 45   8 (6%)   11.2

procedures

Estay et al98 Crohn’s 82 All medical imaging 36   16 (20%)   9.6

procedures

Chatu et al99 Crohn’s 217 All medical imaging 31   29 (13%)   8.3

procedures

Jung et al100 Crohn’s 777 All medical imaging 29   249 (35%)   15

procedures

Fuchs et al101 Crohn’s 171 All medical imaging 11   14 (8%)   5.3

procedures (paediatric)

Sauer et al102 Crohn’s 86 All medical imaging 12 (pediatric)   6 (7%)   3.5

procedures

Huang et al103 Crohn’s 61 All medical imaging 11§   6 (6%)   5

Ulcerative colitis 32 procedures (pediatric)
Indeterminate colitis 12

Brambilla et al85 EVAR 71 All medical imaging 74   71 (100%) 66 (93%) 1.8

procedures

CED, cumulative effective dose; EVAR, endovascular aortic repair.

a
CED > 30 mSv.
b
CED > 60 mSv.
c
CED > 75.
d
CED > 150 mSv.
e
Per admission after acute myocardial infarction.
f
Median.

5 of 10 birpublications.org/bjr Br J Radiol;94:20210389
 BJR Brower and Rehani

A study of patients with skeletally immature idiopathic scoliosis 100 mSv over a short period suggests that focus be devoted to
treated with bracing or spinal fusion underwent mean of 20.9 stochastic risks which occur with a higher frequency of 0.5% per
(range 8–43) radiographs.107 Patients who underwent surgical 100 mSv (i.e. stochastic risks occur for every 1 in 200 patients
treatment underwent significantly more X-­ rays than those who receive a CED ≥ 100 mSv). Thus, the stochastic risk is about
who were braced. Another study of patients with cystic fibrosis 35 times the risk of tissue injury. Based on a median dose of
demonstrated that 24.3%, 15.6%, and 0.43% of patients had 177 mSv in fluoroscopically guided interventions as reported in a
CEDs between 5–20 mSv, 20–75 mSv, and >75 mSv, respectively, recent study, the risk of stochastic injury could be approximately
over two decades.108 Thoracic imaging accounted for 46.9% of 62 times that of tissue injury.114 It may be noted that the risk
the total CED and abdominopelvic imaging accounted for 42.9% estimates for stochastic effects are for the general population and
of the total CED. Other research demonstrated that imaging-­ without consideration of age or sex.
related cumulative post-­transplantation radiation doses exceed
100 mSv over 5 years in 37% of patients with cystic fibrosis who The common teaching to date has been that tissue injuries are
underwent lung transplantation.109 Finally, research on recur- of greater concern in interventional procedures than stochastic
rent imaging in patients with pediatric malignancies found that risks except in the case of children. However, the risk frequencies
this patient population undergoes an average of 3.2 PET/CT estimated above suggest otherwise. The stochastic risks need to
studies per child (range 1–14). Patients received an average effec- be seen in light of a latent period of many years and reduced
tive dose of 24.8 mSv (range 6.2–60.7) per PET/CT exam and an probability of effects at higher ages as a majority of patients are
average cumulative radiation dose of 78.9 mSv (range 6.2–399) in higher age brackets. On the other hand, minor tissue injuries
from PET/CT imaging alone.110 These doses are on the higher such as transient erythema and hair loss are short-­lived but more
side for imaging in children and emphasise the need for further severe tissue injuries can be debilitating and significantly affect
imaging optimization in accordance with ALARA (as low as quality of life. As such, high radiation exposure in patients who
reasonably achievable) principle. are younger (e.g. age <40 years) and/or with diseases with normal
life expectancies warrant greater consideration of cancer risks.
RADIATION RISKS IN PERSPECTIVE Furthermore, the above risk figures apply to both CT imaging
Radiation risks have been classified by ICRP in two categories: and interventional procedures. Thus, the best way to understand
(a) tissue reactions (deterministic effects) and (b) stochastic the stochastic risks is by considering the example of smoking,
effects. Tissue injuries have been reported with interventional which also has latent period of many years before causing cancer.
procedures since the early 1990s and continue to occur today.111 Effective actions across various domains of public health to limit
Despite rotation of the beam to spread doses across larger areas smoking control have culminated in major reductions in cancer
of skin and adopting optimization strategies, there continue to risks over the past two decades. In the case of recurrent imaging,
be patients with difficult and prolonged fluoroscopy resulting the greatest intervention to limit radiation exposure likely will
in skin injuries of varying severity with more severe injuries come from advances in technology that reduce radiation risk for
requiring months to years to heal.58,59,62,63 Skin injuries are best necessary exams while we continue to focus on efforts to limit
avoided through adoption of suitable technique, particularly unnecessary recurrent imaging.115
in patients with high body mass index. Most injuries occur in
patients with recurrent procedures involving the same region of Overuse and inappropriate use of imaging has been widely
skin.112 In neuroradiological procedures, skin injury presents documented and many reasons have been identified for
with hair loss.111 There are a number of publications directed at overuse.13,16,116 Using imaging appropriateness criteria has
the avoidance of skin injury111,112 and the frequency of skin inju- been emphasized by several organizations.16,29 But, imaging
ries ranges from high of 1 in 7000 to a low of 1 in 100 000 inter- guidelines and appropriateness use criteria are not available for
ventional procedures.113 However, the risk of not performing an many conditions.35 Wherever available, they are indicated for
FGI may outweigh the potential risk of skin injury associated initial work-­up and diagnosis and there is a lack of guidance on
with FGI. Notwithstanding utilisation of all available features serial CT imaging and when different imaging modalities are
in equipment for optimization, this highlights the need for involved.35 Incorporating cumulative dose considerations into
the development of safer imaging technologies to enable safer clinical decision-­making regarding imaging practices remains
imaging of patients who are at risk of adverse radiation effects. controversial – both in terms of whether it should be considered
Similar calls for action have been voiced in recent articles and how to use it.34,48,54,117,118 There has been a recent attempt to
discussing high cumulative doses from CT3,35and by the IAEA.5 challenge professionals on making headway in this direction by
Emphasis must be placed on prospective planning of imaging taking the example of drug prescriptions.50 High dose imaging
strategies for chronic conditions as well as optimization actions should be considered somewhat similar to “controlled drugs”
in acute imaging procedures. with risk-­stratification and associated framework for prescribers
(referring physicians) and deliverers (imaging facilities). This
While skin injuries are avoidable and every precaution should issue warrants further research and discussion among interna-
be taken to avoid such injuries, increasing reports of CEDs > tional organizations.

6 of 10 birpublications.org/bjr Br J Radiol;94:20210389
 Radiation risk issues in recurrent imaging BJR

REFERENCES
1. Rehani MM. Challenges in radiation 154–60. doi: https://​doi.​org/​10.​1016/​j.​icrp.​ 2012; 81: e968–76. doi: https://​doi.​org/​10.​
protection of patients for the 21st century. 2012.​06.​029 1016/​j.​ejrad.​2012.​07.​004
AJR Am of Roentgenol 2013; 200: 762–4. doi: 13. Malone J, Guleria R, Craven C, Horton P, 25. ESR,FDA,IAEA,IOMP,ISRRT W and C.Joint
https://​doi.​org/​10.​2214/​AJR.​12.​10244 Järvinen H, Mayo J, et al. Justification position statement on the IAEA patient
2. Rehani MM, Nacouzi D. Higher patient of diagnostic medical exposures: some radiation exposure tracking. 2011. Available
doses through X-­ray imaging procedures. practical issues. Report of an international from: https://www.​iaea.​org/​sites/​default/​
Physica Medica 2020; 79(1–79): 80–6. doi: atomic energy agency consultation. Br files/​documents/​rpop/​iaea-​smart-​card-​
https://​doi.​org/​10.​1016/​j.​ejmp.​2020.​10.​017 J Radiol 2012; 85: 523–38. cited 2013 position-​statement.​pdf.
3. Rehani MM, Yang K, Melick ER, Heil J, Šalát Mar 23. doi: https://​doi.​org/​10.​1259/​bjr/​ 26. Rehani MM, Berris T. Radiation exposure
D, Sensakovic WF, et al. Patients undergoing 42893576 tracking: survey of unique patient
recurrent CT scans: assessing the 14. Image Gently.Image gently. 2014. Available identification number in 40 countries. AJR
magnitude. Eur Radiol 2020; 30: 1828–36. from: https://www.​imagegently.​org/. Am of Roentgenol 2013; 200: 776–9. cited
doi: https://​doi.​org/​10.​1007/​s00330-​019-​ 15. Image Wisely.Image Wisely. 2010. Available 2014 Sep 5. doi: https://​doi.​org/​10.​2214/​
06523-y from: https://www.​imagewisely.​org/. AJR.​12.​10246
4. Martin CJ, Harrison JD, Rehani MM. 16. IAEA.Justification of medical exposure in 27. Rehani MM, Kushi JF. A study of smart card
Effective dose from radiation exposure in diagnostic imaging. Vienna. 2011. Available for radiation exposure history of patient.
medicine: past, present, and future. Physica from: https://​www-​pub.​iaea.​org/​MTCD/​ AJR Am J Roentgenol 2013; 200: 780–2. doi:
Medica 2020; 79: 87–92. doi: https://​doi.​org/​ Publications/​PDF/​Pub1532_​web.​pdf. https://​doi.​org/​10.​2214/​AJR.​12.​10245
10.​1016/​j.​ejmp.​2020.​10.​020 17. Rehani MM. What makes and keeps 28. Rehani MM. Tracking of examination and
5. Brambilla M, Vassileva J, Kuchcinska radiation risks associated with CT a hot dose: overview. Radiat Prot Dosimetry 2015;
A, Rehani MM. Multinational data on topic? AJR Am J Roentgenol 2015; 204: 165(1–4): 50–2. doi: https://​doi.​org/​10.​1093/​
cumulative radiation exposure of patients W234–5. doi: https://​doi.​org/​10.​2214/​AJR.​ rpd/​ncv026
from recurrent radiological procedures: call 14.​12860 29. HERCA.HERCA position paper on
for action. Eur Radiol 2020; 30: 2493–501. 18. RehaniMM. Smart Protection: An electronic justification of individual medical exposures
doi: https://​doi.​org/​10.​1007/​s00330-​019-​ “Smart Card” could serve as a digital for diagnosis. 2014. Available from: https://
06528-7 medical record of radiation exposure for www.​herca.​org/​uploaditems/​documents/​
6. Rehani MM, Hauptmann M. Estimates of patients who want one. IAEA Bull 2009; 50: HERCA Position Paper on justification of
the number of patients with high cumulative 31–3. medical exposure_July ​website.​pdf.
doses through recurrent CT exams in 35 19. Rehani M, Frush D. Tracking radiation 30. European Commission.Radiation induced
OECD countries. Physica Medica 2020; 76: exposure of patients. The Lancet 2010; 376: long-­term health effects after medical
173–6. doi: https://​doi.​org/​10.​1016/​j.​ejmp.​ 754–5. doi: https://​doi.​org/​10.​1016/​S0140-​ exposure. In: RP182. 2015. Available from:
2020.​07.​014 6736(​10)​60657-5 https://​ec.​europa.​eu/​energy/​sites/​default/​
7. NCRP. Implications of recent epidemiologic 20. Sodickson A, Baeyens PF, Andriole KP, files/​documents/​RP182web.​pdf.
studies for the Linear-­Nonthreshold model Prevedello LM, Nawfel RD, Hanson R, 31. European Commission.Referral guidelines
and radiation protection. commentary No. et al. Recurrent CT, cumulative radiation for imaging; radiation protection 118. 2000.
27, Bethesda, MD, USA. 2018;. exposure, and associated radiation-­induced Available from: https://www.​zvd.​si/​media/​
8. Arvanitis TN, Parizel PM, Degryse HR, cancer risks from CT of adults. Radiology medialibrary/​2010/​11/​rp-​118.​pdf.
De Schepper AMA. Reject analysis: 2009; 251: 175–84. doi: https://​doi.​org/​10.​ 32. Jeukens CRLPN, Boere H, Wagemans
a pilot programme for image quality 1148/​radiol.​2511081296 BAJM, Nelemans PJ, Nijssen EC,
management. Eur J Radiol 1991; 12: 171–6. 21. Fazel R, Krumholz HM, Wang Y, Ross Smith-­Bindman R, et al. Probability of
doi: https://​doi.​org/​10.​1016/​0720-​048X(​ JS, Chen J, Ting HH, et al. Exposure to receiving a high cumulative radiation dose
91)​90067-6 low-­dose ionizing radiation from medical and primary clinical indication of CT
9. Rehani MM. Radiation protection in newer imaging procedures. N Engl J Med Overseas examinations: a 5-­year observational cohort
imaging technologies. Radiat Prot Dosimetry Ed 2009; 361: 849–57. doi: https://​doi.​org/​ study. BMJ Open 2021; 11: e041883. doi:
2010; 139(1–3): 357–62. doi: https://​doi.​org/​ 10.​1056/​NEJMoa0901249 https://​doi.​org/​10.​1136/​bmjopen-​2020-​
10.​1093/​rpd/​ncq005 22. Rehani MM. Patient radiation exposure and 041883
10. Rehani MM, Berry M. Radiation doses in dose tracking: a perspective. J Med Imaging 33. Frija G, Damilakis J, Paulo G, Loose R, Vano
computed tomography. The increasing doses 2017; 4: 031206. doi: https://​doi.​org/​10.​ E. Cumulative effective dose from recurrent
of radiation need to be controlled. BMJ 1117/​1.​JMI.​4.​3.​031206 CT examinations in Europe: proposal for
2000; 320: 593–4. doi: https://​doi.​org/​10.​ 23. Rehani MM, Berris T. Templates and clinical guidance based on an ESR EuroSafe
1136/​bmj.​320.​7235.​593 existing elements and models for imaging survey. Eur Radiol 2021; 30. doi:
11. Brenner DJ. Estimating cancer risks from implementation of patient exposure https://​doi.​org/​10.​1007/​s00330-​021-​07696-1
pediatric CT: going from the qualitative to tracking. Radiat Prot Dosimetry 2014; 158: 34. Seuri R, Rehani MM, Kortesniemi M. How
the quantitative. Pediatr Radiol 2002; 32: 36–42. doi: https://​doi.​org/​10.​1093/​rpd/​ tracking radiologic procedures and dose
228–31. doi: https://​doi.​org/​10.​1007/​s00247-​ nct185 helps: experience from Finland. AJR Am of
002-​0671-1 24. Rehani MM, Frush DP, Berris T, Einstein Roentgenol 2013; 200: 771–5. doi: https://​
12. Rehani MM. ICRP and IAEA actions AJ. Patient radiation exposure tracking: doi.​org/​10.​2214/​AJR.​12.​10112
on radiation protection in computed worldwide programs and needs––Results 35. Rehani MM, Melick ER, Alvi RM,
tomography. Ann ICRP 2012; 41(3–4): from the first IAEA survey. Eur J Radiol Doda Khera R, Batool-­Anwar S, Neilan

7 of 10 birpublications.org/bjr Br J Radiol;94:20210389
 BJR Brower and Rehani

TG, et al. Patients undergoing recurrent CT radiography and risk of thyroid cancer. Am J 57. Rehani MM, Ciraj-­Bjelac O, Vañó E, Miller
exams: assessment of patients with non-­ Epidemiol 2013; 177: 800–9. doi: https://​doi.​ DL, Walsh S, Giordano BD, et al. ICRP
malignant diseases, reasons for imaging and org/​10.​1093/​aje/​kws315 publication 117. radiological protection
imaging appropriateness. Eur Radiol 2020; 47. Lin MC, Lee CF, Lin CL, Wu YC, Wang HE, in fluoroscopically guided procedures
30: 1839–46. doi: https://​doi.​org/​10.​1007/​ Chen CL, et al. Dental diagnostic X-­ray performed outside the imaging department.
s00330-​019-​06551-8 exposure and risk of benign and malignant Ann ICRP 2010; 40: 1–102. doi: https://​doi.​
36. Arellano RS, Yang K, Rehani MM. Analysis brain tumors. Annals of Oncology 2013; org/​10.​1016/​j.​icrp.​2012.​03.​001
of patients receiving ≥ 100 mSv during a 24: 1675–9. doi: https://​doi.​org/​10.​1093/​ 58. Rehani MM, Srimahachota S. Skin injuries
computed tomography intervention. Eur annonc/​mdt016 in interventional procedures. Radiat Prot
Radiol 2021; 31: 3065–70. doi: https://​doi.​ 48. Rehani MM, Szczykutowicz TP, Zaidi H. Dosimetry 2011; 147(1–2): 8–12. doi:
org/​10.​1007/​s00330-​020-​07458-5 Ct is still not a low-­dose imaging modality. https://​doi.​org/​10.​1093/​rpd/​ncr257
37. NCRP.Medical radiation exposure of Med Phys 2020; 47: 293–6. doi: https://​doi.​ 59. Kostova-­Lefterova D, Vassileva J, Rehani
patients in the United States (2019). 2019. org/​10.​1002/​mp.​14000 MMM. Lessons from two cases of radiation
Available from: https://​ncrponline.​org/​shop/​ 49. Walsh C, O'Reilly G, Murphy D. Patient induced skin injuries in fluoroscopic
reports/​report-​no-​184-​medical-​radiation-​ cumulative radiation exposure-­the potential procedures in Bulgaria. J Radiol Prot
exposure-​of-​patients-​in-​the-​united-​states-​ for unintended consequences. Eur Radiol [Internet] 2017; 37: 938–46. doi: https://​doi.​
2019/. 2020; 30: 4434–7. doi: https://​doi.​org/​10.​ org/​10.​1088/​1361-​6498/​aa8ce7
38. Hart D, Shrimpton PC. Fourth review of 1007/​s00330-​020-​06800-1 60. Tsapaki V, Rehani MM. I perform more
the UK national patient dose database. Br J 50. Rehani MM. Old enemy, new threat: You than 100 interventional procedures every
Radiol 2012; 85: e957–8p.. doi: https://​doi.​ can’t solve today’s problems with yesterday’s year but have never seen radiation-­induced
org/​10.​1259/​bjr/​28778022 solution. J Radiol Prot Off J Soc Radiol Prot skin injury: am I missing something? Am J
39. GOV.UK.Dental radiographic X-­ray 2021; 41: 452–8. Roentgenol 2014; 203: W462–3. doi: https://​
imaging: dose to patients. 2019. Available 51. Rehani MM. Looking for solutions: vision doi.​org/​10.​2214/​AJR.​13.​11765
from: https://www.​gov.​uk/​government/​ 61. Rehani MM, Ortiz-­Lopez P. Radiation
and a call-­for-­attention for radiation
publications/​dental-​radiographic-​x-​ray-​ effects in fluoroscopically guided cardiac
research scientists. Int J Radiat Biol 2019;
imaging-​dose-​to-​patients. interventions—keeping them under control.
95: 793–6. doi: https://​doi.​org/​10.​1080/​
40. Wilson-­Costello D, Rao PS, Morrison Int J Cardiol 2006; 109: 147–51. doi: https://​
09553002.​2019.​1569775
S, Hack M. Radiation exposure from doi.​org/​10.​1016/​j.​ijcard.​2005.​06.​015
52. IAEAECILOOECD/ NEAPAHO
diagnostic radiographs in extremely low 62. Rehani MM. Training of interventional
W.International basic safety standards:
birth weight infants. Pediatrics 1996; 97: cardiologists in radiation protection—the
General Safety Requirements Part 3No. GSR
369–74. IAEA's initiatives. Int J Cardiol 2007; 114:
Part 3; 2014. pp. 1–471978–92–0–135310–8.
41. Bader D, Datz H, Bartal G, Juster AA, Marks 256–60. doi: https://​doi.​org/​10.​1016/​j.​ijcard.​
https://​www-​pub.​iaea.​org/​MTCD/​
K, Smolkin T, et al. Unintentional exposure 2005.​11.​061
publications/​PDF/​Pub1578_​web-​57265295.​
of neonates to conventional radiography in 63. Srimahachota S, Udayachalerm W,
pdf.
the neonatal intensive care units. J Perinatol Kupharang T, Sukwijit K, Krisanachinda A,
53. European Commission. Council directive
2007; 27: 579–85. doi: https://​doi.​org/​10.​ Rehani M. Radiation skin injury caused by
2013/59/EURATOM. Basic safety standards
1038/​sj.​jp.​7211792 percutaneous coronary intervention, report
for protection against the dangers arising
42. Oba Y, Zaza T. Abandoning daily routine of 3 cases. Int J Cardiol 2012; 154: e31–3.
from exposure to ionising radiation. 2013;:
chest radiography in the intensive care unit: cited 2013 Mar 23. doi: https://​doi.​org/​10.​
1–73.
meta-­analysis. Radiology 2010; 255: 386–95. 1016/​j.​ijcard.​2011.​05.​016
54. Rehani MM, Berris T. International
doi: https://​doi.​org/​10.​1148/​radiol.​10090946 64. Li X, Hirsch JA, Rehani MM, Ganguli S,
43. Graat ME, Stoker J, Vroom MB, Schultz atomic energy agency study with referring Yang K, Liu B. Radiation effective dose
MJ. Can we abandon daily routine chest physicians on patient radiation exposure above 100 mSv from Fluoroscopically
radiography in intensive care patients? J and its tracking: a prospective survey using guided intervention: frequency and patient
Intensive Care Med 2005; 20: 238–46. doi: a web-­based questionnaire. BMJ Open 2012; medical condition. AJR Am J Roentgenol
https://​doi.​org/​10.​1177/​0885066605277212 2: e001425. doi: https://​doi.​org/​10.​1136/​ 2020; 215: 1–7. doi: https://​doi.​org/​10.​2214/​
44. Gislason-­Lee AJ. Patient X-­ray exposure and bmjopen-​2012-​001425 AJR.​19.​22227
ALARA in the neonatal intensive care unit: 55. Rehani MM, Heil J, Baliyan V. Multicentric 65. Einstein AJ, Weiner SD, Bernheim A, Kulon
global patterns. Pediatrics & Neonatology study of patients receiving 50 or 100 mSv M, Bokhari S, Johnson LL, et al. Multiple
2021; 62: 3–10. doi: https://​doi.​org/​10.​1016/​ in a single day through CT imaging— testing, cumulative radiation dose, and
j.​pedneo.​2020.​10.​009 frequency determination and imaging clinical indications in patients undergoing
45. , Rehani MM, Gupta R, Bartling S, Sharp protocols involved. Eur Radiol 2021; myocardial perfusion imaging. JAMA 2010;
GC, Pauwels R, et al.ICRP Radiological 47(Suppl 1). doi: https://​doi.​org/​10.​1007/​ 304: 2137. doi: https://​doi.​org/​10.​1001/​jama.​
protection in cone beam computed s00330-​021-​07734-y 2010.​1664
tomography (CBCT). ICRP publication 129. 56. Rehani MM, Miller DL, Baliyan V. High-­ 66. Chen J, Einstein AJ, Fazel R, Krumholz HM,
Ann ICRP 2015; 44: 9–127. doi: https://​doi.​ Dose Fluoroscopically guided procedures Wang Y, Ross JS, et al. Cumulative exposure
org/​10.​1177/​0146645315575485 in patients: radiation management to ionizing radiation from diagnostic and
46. Neta G, Rajaraman P, recommendations for Interventionalists. therapeutic cardiac imaging procedures: a
Berrington de Gonzalez A, Doody Cardiovasc Intervent Radiol 2020;12 Nov population-­based analysis. J Am Coll Cardiol
MM, Alexander BH, Preston D, et al. A 2020. doi: https://​doi.​org/​10.​1007/​s00270-​ 2010; 56: 702–11. doi: https://​doi.​org/​10.​
prospective study of medical diagnostic 020-​02703-2 1016/​j.​jacc.​2010.​05.​014

8 of 10 birpublications.org/bjr Br J Radiol;94:20210389
 Radiation risk issues in recurrent imaging BJR

67. Mills AM, Raja AS, Marin JR. Optimizing 78. Pearle MS, Goldfarb DS, Assimos DG, with acute myocardial infarction in the
diagnostic imaging in the emergency Curhan G, Denu-­Ciocca CJ, Matlaga BR, United States. Circulation 2010; 122:
department. Academic Emergency Medicine et al. Medical management of kidney stones: 2160–9. doi: https://​doi.​org/​10.​1161/​
2015; 22: 625–31. doi: https://​doi.​org/​10.​ AUA guideline. J Urol 2014; 192: 316–24. CIRCULATIONAHA.​110.​973339
1111/​acem.​12640 doi: https://​doi.​org/​10.​1016/​j.​juro.​2014.​05.​ 88. Eisenberg MJ, Afilalo J, Lawler PR,
68. Kocher KE, Meurer WJ, Fazel R, Scott PA, 006 Abrahamowicz M, Richard H, Pilote L.
Krumholz HM, Nallamothu BK. National 79. Rule AD, Lieske JC, Li X, Melton LJ, Cancer risk related to low-­dose ionizing
trends in use of computed tomography in Krambeck AE, Bergstralh EJ. The ROKS radiation from cardiac imaging in patients
the emergency department. Ann Emerg Med nomogram for predicting a second after acute myocardial infarction. CMAJ
2011; 58: 452–62. doi: https://​doi.​org/​10.​ symptomatic stone episode. J Am Soc 2011; 183: 430–6. doi: https://​doi.​org/​10.​
1016/​j.​annemergmed.​2011.​05.​020 Nephrol 2014; 25: 2878–86. doi: https://​doi.​ 1503/​cmaj.​100463
69. Raja AS, Ip IK, Sodickson AD, Walls RM, org/​10.​1681/​ASN.​2013091011 89. Lawler PR, Afilalo J, Eisenberg MJ, Pilote
Seltzer SE, Kosowsky JM, et al. Radiology 80. Schoenfeld EM, Pekow PS, Shieh M-­S, L. Exposure to low-­dose ionizing radiation
utilization in the emergency department: Scales CD, Lagu T, Lindenauer PK. The from cardiac imaging among patients with
trends of the past 2 decades. AJR Am of diagnosis and management of patients myocardial infarction. Am J Cardiol 2012;
Roentgenol 2014; 203: 355–60. doi: https://​ with renal colic across a sample of US 109: 31–5. doi: https://​doi.​org/​10.​1016/​j.​
doi.​org/​10.​2214/​AJR.​13.​11892 hospitals: high CT utilization despite low amjcard.​2011.​07.​065
70. Broder J, Bowen J, Lohr J, Babcock A, Yoon rates of admission and inpatient urologic 90. Kinsella SM, Coyle JP, Long EB, McWilliams
J. Cumulative CT exposures in emergency intervention. PLoS One 2017; 12: e0169160. SR, Maher MM, Clarkson MR, et al.
department patients evaluated for suspected doi: https://​doi.​org/​10.​1371/​journal.​pone.​ Maintenance hemodialysis patients have
renal colic. J Emerg Med 2007; 33: 161–8. 0169160 high cumulative radiation exposure. Kidney
doi: https://​doi.​org/​10.​1016/​j.​jemermed.​ 81. Goldstone A, Bushnell A. Does diagnosis Int 2010; 78: 789–93. doi: https://​doi.​org/​10.​
2006.​12.​035 change as a result of repeat renal colic 1038/​ki.​2010.​196
71. Hastings RS, Powers RD. Abdominal pain in computed tomography scan in patients with 91. De Mauri A, Brambilla M, Chiarinotti
the ED: a 35 year retrospective. Am J Emerg a history of kidney stones? Am J Emerg Med D, Matheoud R, Carriero A, De Leo M.
Med 2011; 29: 711–6. doi: https://​doi.​org/​10.​ 2010; 28: 291–5. doi: https://​doi.​org/​10.​ Estimated radiation exposure from medical
1016/​j.​ajem.​2010.​01.​045 1016/​j.​ajem.​2008.​11.​024 imaging in hemodialysis patients. J Am Soc
72. Pines JM. Trends in the rates of 82. Smith-­Bindman R, Aubin C, Bailitz J, Nephrol 2011; 22: 571–8. doi: https://​doi.​
radiography use and important diagnoses Bengiamin RN, Camargo CA, Corbo J, org/​10.​1681/​ASN.​2010070784
in emergency department patients with et al. Ultrasonography versus computed 92. Coyle J, Kinsella S, McCarthy S,
abdominal pain. Med Care 2009; 47: tomography for suspected nephrolithiasis. MacWilliams S, McLaughlin P, Eustace
782–6. doi: https://​doi.​org/​10.​1097/​MLR.​ N Engl J Med Overseas Ed 2014; 371: J, et al. Cumulative ionizing radiation
0b013e31819748e9 1100–10. doi: https://​doi.​org/​10.​1056/​ exposure in patients with end stage kidney
73. Cappell MS, Batke M. Mechanical NEJMoa1404446 disease: a 6-­year retrospective analysis.
obstruction of the small bowel and colon. 83. An initiative of ABIM Foundation.Choosing Abdom Imaging 2012; 37: 632–8. doi:
Med Clin North Am 2008; 92: 575–97. doi: Wisely. 2021. Available from: https://www.​ https://​doi.​org/​10.​1007/​s00261-​011-​9786-x
https://​doi.​org/​10.​1016/​j.​mcna.​2008.​01.​003 choosingwisely.​org/. 93. De Mauri A, Brambilla M, Izzo C,
74. Gottlieb M, Peksa GD, Pandurangadu 84. Kalender G, Lisy M, Stock UA, Endisch Matheoud R, Chiarinotti D, Carriero A,
AV, Nakitende D, Takhar S, Seethala RR. A, Kornberger A. Long-­Term radiation et al. Cumulative radiation dose from
Utilization of ultrasound for the evaluation exposure in patients undergoing EVAR: medical imaging in kidney transplant
of small bowel obstruction: a systematic reflecting clinical day-­to-­day practice patients. Nephrol Dial Transplant 2012; 27:
review and meta-­analysis. Am J Emerg Med to assess realistic radiation burden. Clin 3645–51. doi: https://​doi.​org/​10.​1093/​ndt/​
2018; 36: 234–42. doi: https://​doi.​org/​10.​ Hemorheol Microcirc 2019; 71: 451–61. doi: gfs145
1016/​j.​ajem.​2017.​07.​085 https://​doi.​org/​10.​3233/​CH-​170344 94. Desmond AN, McWilliams S, Maher
75. Katz SI, Saluja S, Brink JA, Forman HP. 85. Brambilla M, Cerini P, Lizio D, Vigna MM, Shanahan F, Quigley EM. Radiation
Radiation dose associated with unenhanced L, Carriero A, Fossaceca R. Cumulative exposure from diagnostic imaging among
CT for suspected renal colic: impact of radiation dose and radiation risk from patients with gastrointestinal disorders. Clin
repetitive studies. AJR Am of Roentgenol medical imaging in patients subjected to Gastroenterol Hepatol 2012; 10: 259–65. doi:
2006; 186: 1120–4. doi: https://​doi.​org/​10.​ endovascular aortic aneurysm repair. Radiol https://​doi.​org/​10.​1016/​j.​cgh.​2011.​11.​007
2214/​AJR.​04.​1838 Med 2015; 120: 563–70. doi: https://​doi.​org/​ 95. Levi Z, Fraser E, Krongrad R, Hazazi R,
76. Fwu C-­W, Eggers PW, Kimmel PL, Kusek 10.​1007/​s11547-​014-​0485-x benjaminov O, meyerovitch J, et al. Factors
JW, Kirkali Z. Emergency department visits, 86. Stein EG, Haramati LB, Bellin E, Ashton associated with radiation exposure in
use of imaging, and drugs for urolithiasis L, Mitsopoulos G, Schoenfeld A, et al. patients with inflammatory bowel disease.
have increased in the United States. Kidney Radiation exposure from medical imaging Aliment Pharmacol Ther 2009; 30(11-12):
Int 2013; 83: 479–86. doi: https://​doi.​org/​10.​ in patients with chronic and recurrent 1128–36. doi: https://​doi.​org/​10.​1111/​j.​
1038/​ki.​2012.​419 conditions. J Am Coll Radiol 2010; 7: 351–9. 1365-​2036.​2009.​04140.x
77. Hyams ES, Korley FK, Pham JC, Matlaga doi: https://​doi.​org/​10.​1016/​j.​jacr.​2009.​12.​ 96. Kroeker KI, Lam S, Birchall I, Fedorak
BR. Trends in imaging use during the 015 RN. Patients with IBD are exposed to
emergency department evaluation of flank 87. Kaul P, Medvedev S, Hohmann SF, Douglas high levels of ionizing radiation through
pain. J Urol 2011; 186: 2270–4. doi: https://​ PS, Peterson ED, Patel MR. Ionizing CT scan diagnostic imaging: a five-­year
doi.​org/​10.​1016/​j.​juro.​2011.​07.​079 radiation exposure to patients admitted study. J Clin Gastroenterol 2011; 45:

9 of 10 birpublications.org/bjr Br J Radiol;94:20210389
 BJR Brower and Rehani

34–9. doi: https://​doi.​org/​10.​1097/​MCG.​ patients with hereditary hemorrhagic staff in interventional procedures: achieving
0b013e3181e5d1c5 telangiectasia and pulmonary arteriovenous change in practice. Phys Med 2018; 52:
97. Butcher RO, Nixon E, Sapundzieski M, malformations. Can Assoc Radiol J 2014; 65: 56–64. doi: https://​doi.​org/​10.​1016/​j.​ejmp.​
Filobbos R, Limdi JK. Radiation exposure in 135–40. doi: https://​doi.​org/​10.​1016/​j.​carj.​ 2018.​06.​634
patients with inflammatory bowel disease-- 2013.​02.​007 112. Cousins C, Miller DL, Bernardi G, Rehani
primum non nocere? Scand J Gastroenterol 105. Kim PK, Gracias VH, Maidment ADA, MM, Schofield P, Vañó E, et al. ICRP
2012; 47: 1192–9. doi: https://​doi.​org/​10.​ O'Shea M, Reilly PM, Schwab CW. publication 120: radiological protection in
3109/​00365521.​2012.​706829 Cumulative radiation dose caused by cardiology. Ann ICRP 2013; 42: 1–125. doi:
98. Estay C, Simian D, Lubascher J, Figueroa radiologic studies in critically ill trauma https://​doi.​org/​10.​1016/​j.​icrp.​2012.​09.​001
C, O'Brien A, Quera R. Ionizing radiation patients. J Trauma 2004; 57: 510–4. doi: 113. Guesnier-­Dopagne M, Boyer L, Pereira B,
exposure in patients with inflammatory https://​doi.​org/​10.​1097/​01.​TA.​0000141028.​ Guersen J, Motreff P, D'Incan M, D’Incan
bowel disease: are we overexposing our 97753.​67 M. Incidence of chronic Radiodermatitis
patients? J Dig Dis 2015; 16: 83–9. doi: 106. Rohner DJ, Bennett S, Samaratunga C, after Fluoroscopically guided interventions:
https://​doi.​org/​10.​1111/​1751-​2980.​12213 Jewell ES, Smith JP, Gaskill-­Shipley M, a retrospective study. J Vasc Interv Radiol
99. Chatu S, Poullis A, Holmes R, Greenhalgh et al. Cumulative total effective whole-­body 2019; 30: 692–8. doi: https://​doi.​org/​10.​
R, Pollok RCG. Temporal trends in imaging radiation dose in critically ill patients. Chest 1016/​j.​jvir.​2019.​01.​010
and associated radiation exposure in 2013; 144: 1481–6. doi: https://​doi.​org/​10.​ 114. Li X, Hirsch JA, Rehani MM, Ganguli S,
inflammatory bowel disease. Int J Clin Pract 1378/​chest.​12-​2222 Yang K, Liu B. Radiation effective dose
2013; 67: 1057–65. doi: https://​doi.​org/​10.​ 107. Luo TD, Stans AA, Schueler BA, Larson above 100 mSv from Fluoroscopically
1111/​ijcp.​12187 AN. Cumulative radiation exposure with guided intervention: frequency and patient
100. Jung YS, Park DI, Kim ER, Kim YH, Lee Eos imaging compared with standard spine medical condition. AJR Am J Roentgenol
CK, Lee SH, et al. Quantifying exposure to radiographs. Spine Deformity 2015; 3: 2020; 215: 433–40. doi: https://​doi.​org/​10.​
diagnostic radiation and factors associated 144–50. doi: https://​doi.​org/​10.​1016/​j.​jspd.​ 2214/​AJR.​19.​22227
with exposure to high levels of radiation 2014.​09.​049 115. Kachelrieß M, Rehani MM. Is it possible
in Korean patients with inflammatory 108. O'Connell OJ, McWilliams S, McGarrigle to kill the radiation risk issue in computed
bowel disease. Inflamm Bowel Dis 2013; A, O'Connor OJ, Shanahan F, Mullane D, tomography? Phys Med 2020; 71(February):
19: 1. doi: https://​doi.​org/​10.​1097/​MIB.​ et al. Radiologic imaging in cystic fibrosis: 176–7. doi: https://​doi.​org/​10.​1016/​j.​ejmp.​
0b013e31828c844f cumulative effective dose and changing 2020.​02.​017
101. Fuchs Y, Markowitz J, Weinstein T, Kohn trends over 2 decades. Chest 2012; 141: 116. Rao VM, Levin DC. The overuse of
N, Choi-­Rosen J, Levine J. Pediatric 1575–83. doi: https://​doi.​org/​10.​1378/​chest.​ diagnostic imaging and the choosing wisely
inflammatory bowel disease and imaging-­ 11-​1972 initiative. Ann Intern Med 2012; 157: 574–6.
related radiation: are we increasing the 109. Fitton I, Revel M-­P, Burgel P-­R, Hernigou A, doi: https://​doi.​org/​10.​7326/​0003-​4819-​157-​
likelihood of malignancy? J Pediatr Boussaud V, Guillemain R, et al. Cumulative 8-​201210160-​00535
Gastroenterol Nutr 2011;. radiation dose after lung transplantation in 117. Eisenberg JD, Harvey HB, Moore DA,
102. Sauer CG, Kugathasan S, Martin DR, patients with cystic fibrosis. Diagn Interv Gazelle GS, Pandharipande PV. Falling prey
Applegate KE. Medical radiation exposure Imaging 2019; 100: 287–94. doi: https://​doi.​ to the sunk cost bias: a potential harm of
in children with inflammatory bowel disease org/​10.​1016/​j.​diii.​2018.​12.​006 patient radiation dose histories. Radiology
estimates high cumulative doses. Inflamm 110. Chawla SC, Federman N, Zhang D, Nagata 2012; 263: 626–8. doi: https://​doi.​org/​10.​
Bowel Dis 2011; 17: 2326–32. doi: https://​ K, Nuthakki S, McNitt-­Gray M, et al. 1148/​radiol.​12112459
doi.​org/​10.​1002/​ibd.​21626 Estimated cumulative radiation dose from 118. Eisenberg JD, Lewin SO, Pandharipande PV.
103. Huang JS, Tobin A, Harvey L, Nelson TR. PET/CT in children with malignancies: a The fisherman's cards: how to address past
Diagnostic medical radiation in pediatric 5-­year retrospective review. Pediatr Radiol and future radiation exposures in clinical
patients with inflammatory bowel disease. 2010; 40: 681–6. doi: https://​doi.​org/​10.​ decision making. AJR Am J Roentgenol 2014;
J Pediatr Gastroenterol Nutr 2011; 53: 1007/​s00247-​009-​1434-z 202: 362–7. doi: https://​doi.​org/​10.​2214/​
502–6. doi: https://​doi.​org/​10.​1097/​MPG.​ 111. Tsapaki V, Balter S, Cousins C, Holmberg AJR.​13.​10896
0b013e31820d5d84 O, Miller DL, Miranda P, et al. The
104. Hanneman K, Faughnan ME, Prabhudesai International atomic energy agency action
V. Cumulative radiation dose in plan on radiation protection of patients and

10 of 10 birpublications.org/bjr Br J Radiol;94:20210389