United Kingdom standards for non-invasive cardiac imaging: recommendations from the Imaging Council of the British Cardiovascular Society

Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives.

Review of the effectiveness of internal dosimetry monitoring regimes

Routine monitoring is an important element of any occupational radiation protection programme to be able to determine how effective this protection is in practice. As well as providing information on normal operational conditions and routine worker dose uptakes, these programmes are also required to be able to detect the occurrence of abnormal or unexpected exposures to radionuclides, where these risks are deemed to be present in the workplace. Various monitoring techniques and methods are available and can be applied to the direct monitoring of workers or of the workplace. For many of the less radio-toxic radionuclides simple monitoring programmes are often more than sufficient to demonstrate compliance with operational and regulatory controls; however, multiple programmes, operated in parallel, are often required for the more radio-toxic radionuclides-e.g. Plutonium and americium-to be able to provide assurance that the potential risks of exposure are reliably and adequately controlled. When a potential exposure event is detected then further investigations are instigated to confirm whether an intake has occurred and to estimate the resultant dose. This paper presents an empirical review of the records of all such investigations over an eighteen-year period at the Harwell site, Oxfordshire, UK. The purposes of this review were to determine the relative effectiveness of different monitoring methods in being able to detect potential exposure events; and how efficient each method was in detecting potential exposures which, following investigation, were confirmed as real intakes. The analyses revealed that routine faecal sampling provided the better performance characteristics in terms of combined effectiveness and efficiency; and that the ability to detect potential exposures (at levels of up to 6 mSv) in the absence of any routine monitoring programme was limited. There was a very low incidence of potential exposures being detected by more than one monitoring technique, which emphasises the importance of operating multiple monitoring methods in order to optimise the probability and confidence of detecting potential exposures.

MWDS-2016: THE SLOW DISSOLUTION RATE FOR PLUTONIUM NITRATE INTAKES AT THE MAYAK FACILITY

The slow dissolution rate of material deposited in the lung plays a key role in determining the eventual radiation dose received by the lung. It is therefore of great importance to establish a reliable value for this parameter, to incorporate into the latest Mayak Worker Dosimetry System (MWDS-2016). Disparate values have been obtained for the slow dissolution rate of plutonium nitrate. A volunteer study performed by Public Health England (PHE) and an analysis of United States Transuranium and Uranium Registries (USTUR) case 0269 have yielded slow dissolution rates in the region of 10-40 × 10-4 d-1. However, autopsies performed on 20 Mayak workers, exposed predominantly to nitrates, have resulted in estimates of slow dissolution rates of around 2.4 × 10-4 d-1. Three hypotheses have been proposed to explain this discrepancy: (1) a slower dissolution rate in the interstitium, (2) a third exponential component in the dissolution function and (3) a small component of oxide in the aerosol to which Mayak 'nitrate' workers were exposed. This paper describes tests of these competing hypotheses. Bayesian methods have been applied to the following datasets: PHE volunteer data; Beagle dog data; USTUR cases and Mayak worker data. It is concluded that a mixture of oxide and nitrate material, with the oxide forming ~14% of the intake, best describes the Mayak dissolution rate, without introducing values for other parameters which conflict with other studies.

Recommendations for accurate CT diagnosis of suspected acute aortic syndrome (AAS)--on behalf of the British Society of Cardiovascular Imaging (BSCI)/British Society of Cardiovascular CT (BSCCT)

Accurate and timely assessment of suspected acute aortic syndrome is crucial in this life-threatening condition. Imaging with CT plays a central role in the diagnosis to allow expedited management. Diagnosis can be made using locally available expertise with optimized scanning parameters, making full use of recent advances in CT technology. Each imaging centre must optimize their protocols to allow accurate diagnosis, to optimize radiation dose and in particular to reduce the risk of false-positive diagnosis that may simulate disease. This document outlines the principles for the acquisition of motion-free imaging of the aorta in this context.

An intake prior for the Bayesian analysis of plutonium and uranium exposures in an epidemiology study

In Bayesian inference, the initial knowledge regarding the value of a parameter, before additional data are considered, is represented as a prior probability distribution. This paper describes the derivation of a prior distribution of intake that was used for the Bayesian analysis of plutonium and uranium worker doses in a recent epidemiology study. The chosen distribution is log-normal with a geometric standard deviation of 6 and a median value that is derived for each worker based on the duration of the work history and the number of reported acute intakes. The median value is a function of the work history and a constant related to activity in air concentration, M, which is derived separately for uranium and plutonium. The value of M is based primarily on measurements of plutonium and uranium in air derived from historical personal air sampler (PAS) data. However, there is significant uncertainty on the value of M that results from paucity of PAS data and from extrapolating these measurements to actual intakes. This paper compares posterior and prior distributions of intake and investigates the sensitivity of the Bayesian analyses to the assumed value of M. It is found that varying M by a factor of 10 results in a much smaller factor of 2 variation in mean intake and lung dose for both plutonium and uranium. It is concluded that if a log-normal distribution is considered to adequately represent worker intakes, then the Bayesian posterior distribution of dose is relatively insensitive to the value assumed of M.

A Bayesian analysis of uncertainties on lung doses resulting from occupational exposures to uranium

In a recent epidemiological study, Bayesian estimates of lung doses were calculated in order to determine a possible association between lung dose and lung cancer incidence resulting from occupational exposures to uranium. These calculations, which produce probability distributions of doses, used the human respiratory tract model (HRTM) published by the International Commission on Radiological Protection (ICRP) with a revised particle transport clearance model. In addition to the Bayesian analyses, point estimates (PEs) of doses were also provided for that study using the existing HRTM as it is described in ICRP Publication 66. The PEs are to be used in a preliminary analysis of risk. To explain the differences between the PEs and Bayesian analysis, in this paper the methodology was applied to former UK nuclear workers who constituted a subset of the study cohort. The resulting probability distributions of lung doses calculated using the Bayesian methodology were compared with the PEs obtained for each worker. Mean posterior lung doses were on average 8-fold higher than PEs and the uncertainties on doses varied over a wide range, being greater than two orders of magnitude for some lung tissues. It is shown that it is the prior distributions of the parameters describing absorption from the lungs to blood that are responsible for the large difference between posterior mean doses and PEs. Furthermore, it is the large prior uncertainties on these parameters that are mainly responsible for the large uncertainties on lung doses. It is concluded that accurate determination of the chemical form of inhaled uranium, as well as the absorption parameter values for these materials, is important for obtaining unbiased estimates of lung doses from occupational exposures to uranium for epidemiological studies. Finally, it should be noted that the inferences regarding the PEs described here apply only to the assessments of cases provided for the epidemiological study, where central estimates of dose were sought. Approved dosimetry service assessments of exposures are unlikely to yield significant underestimates, as pessimistic assumptions of lung solubility would almost always be used.

Iterative reconstruction and individualized automatic tube current selection reduce radiation dose while maintaining image quality in 320-multidetector computed tomography coronary angiography

AIM

To assess the effect of two iterative reconstruction algorithms (AIDR and AIDR3D) and individualized automatic tube current selection on radiation dose and image quality in computed tomography coronary angiography (CTCA).

MATERIALS AND METHODS

In a single-centre cohort study, 942 patients underwent electrocardiogram-gated CTCA using a 320-multidetector CT system. Images from group 1 (n = 228) were reconstructed with a filtered back projection algorithm (Quantum Denoising Software, QDS+). Iterative reconstruction was used for group 2 (AIDR, n = 379) and group 3 (AIDR3D, n = 335). Tube current was selected based on body mass index (BMI) for groups 1 and 2, and selected automatically based on scout image attenuation for group 3. Subjective image quality was graded on a four-point scale (1 = excellent, 4 = non-diagnostic).

RESULTS

There were no differences in age (p = 0.975), body mass index (p = 0.435), or heart rate (p = 0.746) between the groups. Image quality improved with iterative reconstruction and automatic tube current selection [1.3 (95% confidence intervals (CI): 1.2-1.4), 1.2 (1.1-1.2) and 1.1 (1-1.2) respectively; p < 0.001] and radiation dose decreased [274 (260-290), 242 (230-253) and 168 (156-180) mGy cm, respectively; p < 0.001].

CONCLUSION

The application of the latest iterative reconstruction algorithm and individualized automatic tube current selection can substantially reduce radiation dose whilst improving image quality in CTCA.

A method for calculating Bayesian uncertainties on internal doses resulting from complex occupational exposures

Estimating uncertainties on doses from bioassay data is of interest in epidemiology studies that estimate cancer risk from occupational exposures to radionuclides. Bayesian methods provide a logical framework to calculate these uncertainties. However, occupational exposures often consist of many intakes, and this can make the Bayesian calculation computationally intractable. This paper describes a novel strategy for increasing the computational speed of the calculation by simplifying the intake pattern to a single composite intake, termed as complex intake regime (CIR). In order to assess whether this approximation is accurate and fast enough for practical purposes, the method is implemented by the Weighted Likelihood Monte Carlo Sampling (WeLMoS) method and evaluated by comparing its performance with a Markov Chain Monte Carlo (MCMC) method. The MCMC method gives the full solution (all intakes are independent), but is very computationally intensive to apply routinely. Posterior distributions of model parameter values, intakes and doses are calculated for a representative sample of plutonium workers from the United Kingdom Atomic Energy cohort using the WeLMoS method with the CIR and the MCMC method. The distributions are in good agreement: posterior means and Q(0.025) and Q(0.975) quantiles are typically within 20 %. Furthermore, the WeLMoS method using the CIR converges quickly: a typical case history takes around 10-20 min on a fast workstation, whereas the MCMC method took around 12-72 hr. The advantages and disadvantages of the method are discussed.

Empirical evaluation of lung solubilities of airborne contamination at Harwell facilities

Lung solubility is the key parameter in determining intakes and doses from inhalation of airborne contamination. However, information on lung solubility can be difficult to acquire, particularly for the historical exposures that are of relevance to lifetime-dose reconstruction. In this study, an empirical approach has been made in which over 200 dose assessments, mainly for Pu and Am, from the period 1986 to 2005 were re-evaluated and the solubility mix required for the best fit to the data was determined. The average of these solubility mixtures for any building or facility can be used as the default solubility for retrospective dose assessments for that facility. Results are presented for a radiochemistry facility, a materials development facility and a waste-storage/handling building at Harwell. The latter two areas are characterised by aerosols that are predominantly insoluble (type S), whereas the radiochemistry facility has a heterogeneous mixture of insoluble and soluble aerosols. The implications of these results for dose reconstruction are discussed in the paper.

Uncertainties in estimation of intakes of actinides for dose reconstruction cases

Intakes and doses arising from exposure to actinides must be reconstructed from historical bioassay data for the purposes of worker compensation and for epidemiology studies. The usual default assumption is that a series of urine activities is the result of a constant chronic intake. In reality, the urine activities will most likely arise from a random sequence of discrete intakes. In order to investigate the accuracy of the constant chronic assumption, we have created virtual urine datasets using Monte Carlo modelling and these were used as input to the code IMBA(1). Comparisons of estimated intakes with those used as input allow the uncertainties in the procedure to be estimated. The effects of incorrect assumptions about the scattering factors, activity median aerodynamic diameter (AMAD) and solubility can also be examined. The results show that the constant chronic assumptions leads to remarkably reliable estimates of intake, even for datasets generated by just a few intakes per year. The estimate of intake is fairly robust against mis-assignment of scattering factor and AMAD. However, as is well-known, the correct assignment of solubility is crucial in obtaining reliable estimates of intake and dose.

Characterisation of workplaces with risks of internal exposures: air sampling

The measurement of air samples may be used to assess risks of internal exposures, either by the use of workplace static air samplers (SAS) or personal air samplers (PAS). These measurements need to incorporate information on the physical and chemical nature of the aerosol, and the relationship between the sampled and potentially breathed aerosol. This paper provides an overview of methods, which are typically used in occupational dosimetry to determine these characteristics. A specific practical example is provided to illustrate how SAS are used to determine that potential personal doses are less than 1 mSv per year, and therefore do not require individual monitoring. The paper also discusses the nature and potential impact of the uncertainties associated with PAS monitoring, and how this is managed in practice.

Unexpectedly high activity of 228Th in excretion samples following consumption of Brazil nuts

A worker provided a routine faecal sample for plutonium and americium analysis. In the course of this analysis 500 mBq of (228)Th was discovered. There seemed no credible occupational route for intake of thorium. Further investigation revealed that the worker consumed approximately 25 g d(-1) of nuts, including Brazil nuts. A sample of these nuts was analysed and found to contain activities of (228)Th in sufficient quantity to account for the faecal activity. However, follow-up urine samples taken from the worker showed 0.6-0.7 mBq of (228)Th. The intake of (228)Th via nuts is insufficient to account for this activity in urine. However, it is likely that the intake of (228)Th was accompanied by similar activity of the parent (228)Ra, and biokinetic calculations show that decay of (228)Ra in vivo would produce sufficient (228)Th to account for the observed urine activity.

An intake of americium oxide powder: implications for biokinetic models for americium

A worker inhaled 241AmO2 powder. Air sampling showed low activities but a nose blow revealed 92 Bq. Results from faecal sampling and lung and whole-body monitoring indicated an intake of about 200 Bq, but urine sampling, though commencing only 1 d after intake, showed below-threshold activities (< 0.2 mBq). This conflicts with predictions based on the ICRP Publication 67 biokinetic model for americium and the ICRP Publication 66 model for the human respiratory tract, if default lung parameters are used.

Evaluation of CT in identifying colorectal carcinoma in the frail and disabled patient

Frail and physically or mentally disabled patients frequently have difficulty in tolerating formal colonic investigations. The aims of this study were to evaluate the accuracy of minimal-preparation CT in identifying colorectal carcinoma in this population and to determine the clinical indications and radiological signs with the highest yield for tumour. The CT technique involved helical acquisition (10-mm collimation, 1.5 pitch) following 2 days of preparation with oral contrast medium only. The outcome of 4 years of experience was retrospectively reviewed. The gold standards were pathological and cancer registration records, together with colonoscopy and barium enema when undertaken, with a minimum of 15 months follow-up. One thousand seventy-seven CT studies in 1031 patients (median age 80 years) were evaluated. CT correctly identified 83 of the 98 colorectal carcinomas in this group but missed 15 cases; sensitivity and specificity (with 95% confidence interval) 85% (78-92%) and 91% (90-93%), respectively. Multivariate analysis identified: (a) a palpable abdominal mass and anaemia to be the strongest clinical indications, particularly in combination (p<0.0025); and (b) lesion width and blurring of the serosal margin of lesions to be associated with tumours (p<0.0001). Computed tomography has a valuable role in the investigation of frail and otherwise disabled patients with symptoms suspicious for a colonic neoplasm. Although interpretation can be difficult, the technique is able to exclude malignancy with good accuracy.

Caecal carcinomas in the elderly: useful signs in minimal preparation CT

OBJECTIVE

Frail, elderly and immobile patients frequently have difficulty in tolerating formal colonic investigations. Caecal tumours may account for up to 35% of colonic tumours. Barium enema and colonoscopy have limitations in assessing this region. The aims of this study were to evaluate the accuracy of a minimal preparation CT technique (merely with prolonged oral contrast medium) in identifying caecal carcinomas and to determine helpful radiological signs.

MATERIALS AND METHODS

The CT technique involved helical acquisition following 2 days of preparation with oral contrast medium. The outcome of 4 years' experience (1995-1998) was reviewed. The gold-standards were pathological and cancer registration records, together with colonoscopy and barium enema where available, with a minimum of 15 months' follow-up.

RESULTS

CT correctly identified 27 of 30 caecal carcinomas, and missed three, in a total of 1077 CT studies in 1031 patients (median age 80 years). There were also 21 false-positive cases in which CT incorrectly raised the possibility of a caecal tumour. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were 90%, 98%, 99% and 56%, respectively. Serosal margin blurring, tumour length, presence of abnormal peri-colic fat and terminal ileal wall thickening were identified as useful radiological signs.

CONCLUSIONS

Minimal preparation CT is able to identify caecal carcinomas with fair accuracy. Such evaluation may become important given the increasing population age and evidence of a 'proximal shift' in the site of colonic tumours in the elderly.

Spiral CT optimization for measurement of bronchial lumen diameter using an experimental model

The aim of the study was to determine optimal parameters for demonstrating sublobar bronchi on spiral CT. Measurements were obtained from five parallel polyethylene tubes embedded in foam matrix with similar radiographic characteristics to segmental and subsegmental bronchi and to lung parenchyma, respectively. Collimation widths of 1.5, 2, 3 and 4 mm were used, with a pitch of 1 or 1.5 and a reconstruction interval of 1 mm or 2 mm. Various slice planes were used. Images acquired orthogonally were viewed normally. Images acquired in planes oblique or parallel to the long axes of the tubes were reformatted into a plane orthogonal to the long axes of the tubes to be comparable with the directly acquired orthogonal images. Tube diameters were measured at lung window settings (L, -400; W, 1300) and compared with known true inner and outer tube diameters. Measurements from images acquired orthogonal to the tube long axes were accurate regardless of slice thickness. Images acquired obliquely or parallel only produced accurate measurements at the lowest slice thickness (1.5 mm). Pitch and reconstruction interval had no effect on measurement error in any scan plane. It is concluded that a slice thickness of 1.5 mm or less, with a pitch of 1.5, should be used when acquiring images at angles other than orthogonal to the long axes of experimental tubes equivalent to the segmental and subsegmental bronchi. It is suggested that similar parameters should be used in vivo and that the examination should be targeted to the area of the bronchial tree in question to reduce patient dose and length of breath-hold.

Bone age assessment: a large scale comparison of the Greulich and Pyle, and Tanner and Whitehouse (TW2) methods

PURPOSE

Comparison of bone age assessed using either the "atlas matching" method of Greulich and Pyle or the "point scoring system" of Tanner and Whitehouse (TW2).

MATERIALS AND METHODS

362 consecutive "bone age" radiographs of the left hand and distal radius performed in a large provincial teaching hospital. Data were analysed using the "method comparison" statistical technique. Ten per cent of the radiographs were re-analysed to assess intra-observer variation.

RESULTS

The 95% confidence interval for the difference between the two methods was 2.28 to -1.52 years. Intra-observer variation was greater for the Greulich and Pyle method than for the TW2 method (95% confidence limit, -2.46 to 2.18 v -1.41 to 1.43).

CONCLUSION

The two methods of bone age assessment as used in clinical practice do not give equivalent estimates of bone age and we suggest that one method only (preferably the TW2) should be used when performing serial measurements on an individual patient.

CT measurement of main pulmonary artery diameter

The aim of this study was to determine the upper limit of the normal main pulmonary artery diameter using a modern CT system. This was measured at the level of the pulmonary artery bifurcation in 100 normal subjects using unenhanced contiguous 10 mm CT slices viewed at fixed mediastinal window settings (400/20). These normal subjects were then compared with similar unenhanced 10 mm images from 12 patients with proven pulmonary arterial hypertension (mean pulmonary artery pressure > 20 mmHg). The main pulmonary artery diameter in normal subjects was 2.72 cm (SD = 0.3). Main pulmonary artery diameter in patients with pulmonary arterial hypertension was significantly greater (p < 0.01) at 3.47 cm (SD = 0.33). A pulmonary artery diameter of 3.32 cm (main pulmonary artery diameter + 2 SD) had a 58% sensitivity and 95% specificity for the presence of pulmonary arterial hypertension. It is concluded that, using unenhanced axial 10 mm CT sections, the upper limit of normal main pulmonary artery diameter is 3.32 cm. Pulmonary arterial hypertension should be considered in patients with values above this level.

CT dimensions of the normal pericardium

Previous studies have suggested that the upper limit of the thinnest portion of the pericardium is 3-4 mm using 10 mm CT slices. However, these studies suffered from small sample sizes, long data acquisition times and unconventional viewing parameters. We have measured the width of the thinnest portion of the normal pericardium using 10 mm (100 patients) and 1 mm (100 patients) high resolution CT (HRCT) slices with modern CT equipment and fixed mediastinal window settings (400/20). The pericardium was identified in all patients and was best seen anterior to the heart. The pericardium is exceptionally well seen using 1 mm HRCT slices and this may be the optimal technique for visualization of the pericardium. The upper limit of the thinnest portion of the normal pericardium (mean value + 2 SD) was 1.2 mm (10 mm CT slices) and 0.7 mm (1 mm HRCT slices). These values are substantially lower than those previously reported and in line with anatomical findings.

Studies of aerosol distributions in a small laboratory containing a heated phantom

In order to provide information to assist in the design and planning of workplace air-sampling facilities, we have studied the variations in time and space of aerosol concentrations in a small room containing a glove-box and a heated phantom. Aerosol concentrations are reduced by factors of 10(2)-10(3) between the source and the phantom and walls of the room. Time-series plots of concentration show large departures from mean concentrations and fluctuations measured at the mouth and chest of the phantom are frequently uncorrelated. Both the average concentration around the phantom and the fluctuations in concentration tend to increase when the phantom is heated.

The human pressor response during and following voluntary and evoked isometric contraction with occluded local blood supply

1. Changes in heart rate and blood pressure were observed, in nine healthy subjects, during and after voluntary and electrically evoked isometric contractions of the triceps surae under conditions of local circulatory arrest. 2. The progressive increases in heart rate and blood pressure seen during 2 min voluntary and evoked contractions at 30% of maximal voluntary contraction were not significantly different in the two conditions. On cessation of contraction but with circulatory arrest maintained, heart rate fell to control levels while blood pressure fell to a similar though still significantly elevated level in both conditions. Elevated blood pressure was maintained for 2 min until the circulatory occlusion was removed; however it was maintained at a significantly higher level for the last 60-90 s of occlusion following electrically evoked contractions compared to voluntary contraction. 3. Comparison of the responses to voluntary and involuntary electrically evoked contractions suggest that 'central command' is not necessary for the initial increases in heart rate and blood pressure to occur. In addition the removal of central command on cessation of contraction need not account for the return of heart rate to control levels or the drop in blood pressure at that time. Maintained blood pressure elevation during circulatory occlusion would seem to be due to the trapping of chemical substances within the muscle interstitium.