The American College of Radiology (ACR)—a U.S. based professional organization representing more than 34,000 radiologists, radiation oncologists, interventional radiologists, nuclear medicine physicians, and medical physicists—appreciates the opportunity to provide comments on the International Commission on Radiation Protection’s (ICRP) draft report for consultation, Patient and Staff Radiological Protection in Cardiology.
The ICRP’s draft report is a comprehensive review and assessment of radiation protection as it relates to imaging procedures involving the cardiovascular system. The ACR commends the ICRP authors and contributors for the document’s depth and detail.
General Comments
- Several topics included in certain sections of the draft report apply equally to other modalities, and the ICRP should note this somewhere within the report; perhaps within the preamble or wherever these specific instances appear. For example, section 10, QUALITY ASSURANCE PROGRAMS, could benefit from clarification that certain quality assurance principles attributed to interventional radiology/cardiology apply to other modalities.
- The additional challenges concerning imaging potentially pregnant adolescents and women with ionizing radiation should be addressed in the report. First, across the modalities (fluoroscopy, nuclear, CT), laboratories need protocols for screening for pregnancy. Second, pregnancy must be taken into account when justifying the test (that is, determining its clinical appropriateness). Third, pregnant patients need to be counseled if the imaging test is to be performed. Fourth, the imaging protocol may need to be modified to limit pelvic radiation.
The authors may choose to review the ACR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation (http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/Pregnancy.aspx). Adding a brief paragraph within the ICRP report with a reference to this guideline would be helpful for readers.
Specific Comments
- Section 7.1
Nuclear medicine in the U.S. is a highly regulated subspecialty with respect to other medical subspecialties. It should be stated that nuclear medicine facilities must comply with all applicable radiation safety regulations and conditions of licensure imposed by regulatory authorities (e.g., the U.S. Nuclear Regulatory Commission, Agreement States, etc).
- Table 7.1
Add “chloride” to both “Tl-201” and “Rb-82.”
- Section 7.3
This section correctly emphasizes dosimetry for patient radiation exposure during nuclear medicine procedures, but it is similarly important to minimize staff (technologist, physician, other) exposure. While personnel exposure is highly regulated and professional guidelines for monitoring occupational dose exist, the ICRP may choose to briefly mention the importance of adhering to known radiation safely requirements with respect to personnel exposure, material spills, personnel pregnancy, and other such issues. The ICRP might also recommend continuous staff-to-staff communication and education about said requirements.
- Section 7.2 (134)
This paragraph should reference the ACR-SNM-SPR Practice Guideline for the Performance of Cardiac Scintigraphy, Res. 14 – 2009 (http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/nuc_med/cardiac_scintigraphy.aspx).
- Section 7.7.1 (147)
It should be noted that any appropriateness criteria guidelines used to support one’s clinical decisions must be transparent, evidence-based, and rigorously developed/reviewed by physician organizations with requisite expertise in the specific services/diseases addressed by the guidelines, such as those developed by the ACR (http://www.acr.org/ac).
- Section 7.7.1 (148)
In addition to the already referenced ACR Appropriateness Criteria guidelines, the authors should consider referencing the ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging. J. Am. Coll. Cardiol. 2009;53;2201-2229.
- Section 7.7.3 (154)
This paragraph should reference the ACR-SNM-SPR Practice Guideline for the Performance of Cardiac Scintigraphy, Res. 14 – 2009 (http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/nuc_med/cardiac_scintigraphy.aspx).
- Section 7.?
Equipment quality control is also important in nuclear medicine—just as it is with all other diagnostic and interventional modalities—because radiation dose can only be optimized or appropriately minimized when the imaging equipment or monitoring devices are functioning as intended. Perhaps a brief paragraph could be added to explain this.