IRMER update

29 SepteMber 2014

Bayer HealthCare has provided sponsorship for the cost of the exhibition stand only at this meeting.

Dosimetry Services Division

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IRMER UPDATE Venue: The Royal Society of Medicine, London CPD: 5 CREDITS

BIR Annual Congress 2014: 22-23 October, London

Welcome and thank you for coming to the ‘IRMER update’ event organised by the British Institute of Radiology.

This booklet contains the abstracts and biographies for each speaker.

This meeting has been awarded 5 RCR category I CPD credits.

CPD certificates will be distributed by email within two weeks of the meeting once the online delegate survey has been completed.

Please complete the online delegate survey using the below link. We will use your valuable feedback to improve future conferences. https://www.surveymonkey.com/s/IRMER_2014 We hope you find the day interesting and enjoyable.

We are most grateful to

Bayer HealthCare has provided sponsorship for the cost of the exhibition stand only at this meeting.

Dosimetry Services Division

PYCKO SCIENTIFIC LTD

Your Alternative

To The Obvious

for supporting this conference

Programme 09:30 Registration and refreshments SESSION 1: REGULATIONS AND SYSTEMS Chair: Mr Andy Rogers, Head of Radiation Physics,

Nottingham University Hospitals NHS Trust 10:00 IRMER – what impact will the BSS have?

Mr Steve Ebdon-Jackson, Head of Medical Exposures,

Public Health England 10:30 MPE update – will imaging departments notice any difference?

Dr Derek Pearson, Professional Adviser to the Chief Scientific Officer of

NHS England 10:50 Referral guidelines – will they deliver?

Dr Denis Remedios, Consultant Radiologist, Northwick Park Hospital 11:10 Systems for non-medical referrers

Mr Andy Rogers, Head of Radiation Physics,

Nottingham University Hospitals NHS Trust 11:30 IRMER guidance in diagnostic and interventional radiology

Dr Peter Riley, Consultant Interventional Radiologist,

Queen Elizabeth Hospital, Birmingham 12:00 Lunch SESSION 2: OPTIMISATION – THE FORGOTTEN HOLY GRAIL? Chair: Mrs Mary Cocker, Consultant Clinical Scientist, Radiation Physics and

Protection, Oxford University Hospitals NHS Trust 13:00 Optimisation and DRLs – current best practice

Dr Colin J Martin, International Commission on Radiological Protection 13:20

National dose registries – an update Ms Sue Edyvean, Head of Medical Dosimetry Group, Centre for Radiation, Chemical and Environmental Hazards (CRCE), Public Health England

13:40 Patient dose management software – a radiographer’s perspective

Mrs Elaine Holt, Cardiac Radiographer,

University Hospital of South Manchester 14:00 Management of tissue reactions in high dose procedures

Mr Mark Bowers, Cardiac Cath Lab Service Manager,

Royal Brompton & Harefield NHS Foundation Trust 14:20 Refreshments

SESSION 3: THE BIGGER PICTURE – IMAGING ALL ROUND Chair: Mr Peter Hiles, Head of Radiation Physics, North Wales 14:40 Never mind the dose – feel the image quality!

Dr Elly Castellano, Head of the Diagnostic Radiology Physics Group,

The Royal Marsden NHS Foundation Trust 15:00 Nuclear medicine – can we reduce administered activity?

Ms Sarah Allen, Consultant Clinical Scientist in Nuclear Medicine,

Guy’s & St Thomas’ NHS Foundation Trust 15:20 Hybrid imaging – optimisation challenges

Ms Kathryn Adamson, Principal Physicist,

Guy’s & St Thomas’ NHS Foundation Trust 15:40 Imaging in radiotherapy – who should optimise?

Dr Andrew Reilly, Consultant Physicist,

The Clatterbridge Cancer Centre NHS Foundation Trust 16:00 Conclusions and future possibilities

Mrs Mary Cocker, Consultant Clinical Scientist, Radiation Physics and

Protection, Oxford University Hospitals NHS Trust 16:15 Close of meeting _______________________________________________________________________

Please remember to complete the online delegate survey using the below link: https://www.surveymonkey.com/s/IRMER_2014 Your certificate of attendance will be emailed to you within the next two weeks once these have been completed.

BIR Annual Congress 2014: 22-23 October, London

Speaker profiles Ms Kathryn Adamson Principal Physicist, Guy’s & St Thomas’ NHS Foundation Trust Kathryn has 20 years’ experience working as a Clinical Scientist in Nuclear Medicine in two major London teaching hospitals. Since 2006 Kathryn has been involved in the acceptance testing, routine QC and SPECT/CT protocol development on all the SPECT/CT systems at Guy’s and St Thomas’ (GE Infinia Hawkeye, Philips Precedence and Siemens T16). She has presented talks on SPECT/CT locally, nationally at the BNMS and internationally at the 2008 Asia Oceania Congress of Nuclear Medicine in Delhi.

Kathryn currently works closely with nuclear medicine and radiation safety staff to develop and optimise the CT protocols for SPECT/CT imaging at Guy’s and St Thomas’, and assesses the doses delivered to patients as a result. She has also worked collaboratively on producing imaging protocols on SPECT/CT scanners in other south London hospitals.

Ms Sarah Allen Consultant Clinical Scientist in Nuclear Medicine, Guy’s & St Thomas’ NHS Foundation Trust Consultant Clinical Scientist in Nuclear Medicine Head of Nuclear Medicine, Guy’s and St Thomas’ NHS Foundation Trust Honorary Secretary, British Nuclear Medicine Society (BNMS) Long career as a Nuclear Medicine Physicist. Extensive experience in a large nuclear medicine department within a teaching hospital. Expertise in service delivery, research procedures within nuclear medicine, radionuclide therapies, equipment procurement and management, workforce planning and development and education for the nuclear medicine workforce.

Mr Mark Bowers Cardiac Cath Lab Service Manager, Royal Brompton & Harefield NHS Foundation Trust Mark graduated as a diagnostic radiographer in Perth, Western Australia before joining the Royal Brompton Hospital in 1995. In 2009 he was appointed Cardiac Catheter Lab Service Manager at Harefield Hospital.

Mark served as Chairman of the Cardiac Radiographers Advisory Group and is currently joint Chairperson for the Cath Lab Managers Network Group.

Recently he has taken a position on the steering group for the National Cardiac Benchmarking Collaborative and BIR Radiation Protection SIG Panel.

Dr Elly Castellano Head of the Diagnostic Radiology Physics Group, The Royal Marsden NHS Foundation Trust Dr Elly Castellano is a Consultant Clinical Scientist working at The Royal Marsden NHS Foundation Trust as Head of the Diagnostic Radiology Physics Group. Elly was educated in physics and medical physics at the universities of Oxford, Surrey and London. She trained at St Mary’s Hospital, London, in nuclear medicine, radiotherapy and diagnostic radiology physics, and thereafter specialised in the latter. She is a registered clinical scientist, chartered scientist and chartered radiation protection professional. She is a corporate member of the IPEM, a corporate member of the SRP, and a member of the BIR. She has chaired the CT Users Group, the IPEM Diagnostic Radiology Special Interest Group, and will be director of the IPEM Science, Research and Innovation Council imminently.

In addition to her clinical work Elly is active in research with over 20 publications to date. Her main research interests are in CT dosimetry and CT optimisation, although she has several published papers in the fields of mammography and fluoroscopy. She runs the advanced x-ray and CT imaging module of the MSc Clinical Sciences (Medical Physics) at King’s College, London, and lectures extensively in the UK and abroad. She is a contributing author to several text books and handbooks on CT and patient radiation dosimetry.

Mrs Mary Cocker Consultant Clinical Scientist, Radiation Physics and Protection, Oxford University Hospitals NHS Trust Mary Cocker has worked as a Consultant Clinical Scientist in the field of imaging physics and radiation protection for more than 30 years. Mary’s recent research interests have included collaboration with the University of California involving the use of dose management systems for CT optimisation. Mary is a member of the BIR Radiation Protection Special Interest Group.

Mr Steve Ebdon-Jackson Head of Medical Exposures, Public Health England Steve Ebdon-Jackson is currently head of the Medical Exposure Radiation Infrastructure Team at CRCE Chilton – part of Public Health England.

His key activities include: • Providing advice on the revision of the IR(ME)R and MARS Regulations to ensure that the UK transposes the new Euratom Basic Safety Standards Directive 2013/59/Euratom • Providing support to ARSAC and the certification process under the MARS Regulations • Engaging with international organisations in relation to medical exposures

This third activity includes being a member of the EC’s Article 31 Group of Experts and co-Chair of the HERCA Medical Applications Working Group. He is also working with WHO on Individual Health Assessment and risk communication and IAEA on a range of activities including justification.

Ms Sue Edyvean, Head of Medical Dosimetry Group, Centre for Radiation, Chemical and Environmental Hazards (CRCE), Public Health England Sue Edyvean has specialised in computed tomography scanners in terms of technology, radiation dose and image quality for most of her career.

For over twenty years she headed up the ImPACT (Imaging Performance Evaluation of CT) group at St George’s Hospital, London. This group produced many technical reports on CT scanners, the widely used ‘ImPACT CTDosimetry’ calculator, and extensive educational material including their successful course for radiology professionals.

She is currently the head of the Medical Dosimetry Group at Public Health England (PHE), based in Chilton, Oxfordshire. Her responsibilities in this role include national radiation patient dose surveys, MonteCarlo dosimetry in diagnostic imaging, and expertise in CT scanner technology, image quality and radiation dose.

Sue has sat on various international committees (IEC and ICRU), is a contributor to two IAEA (International Atomic Energy Authority) reports on CT, and a co-author of the ICRU Report on CT Image Quality and Dose. She is currently a member of two AAPM committees; CT and Fluoroscopy patient dose, and CT scanner protocols and nomenclature, and is also on the panel of advisors to the HERCA CT Manufacturers work package. She has presented extensively at many conferences and courses, nationally and internationally.

Mr Peter Hiles Head of Radiation Physics, North Wales Peter is Head of Radiation Physics in North Wales and the current Chair of the BIR’s Radiation Protection Special Interest Group.

He has over 30 years experience in Medical Physics and has acted as an adviser to the IAEA and EU on radiation protection and quality assurance.

He was the chair of the working party which produced the popular IPEM report 91 on X-ray equipment testing.

Mrs Elaine Holt, Cardiac Radiographer, University Hospital of South Manchester Trained at Lincolnshire School of Radiography, DCR(R) obtained in 1991. In 1992 employed as radiographer in General X-ray at Wythenshawe Hospital, South Manchester before commencing as a Cardiac Radiographer in the Cardiology X-ray department until 2002. During this time, she attended Salford University and obtained an MSc in Advanced Radiography Practice. Following a year working in New Zealand, she took up the position of MR radiographer with Lodestone until 2005.

She then returned to University Hospital of South Manchester as a Senior Cardiac Radiographer and Radiation Protection Supervisor where she helped to formulate the North West Skin Dose Group and developed the Skin Dose Clinic at UHSM. Dr Colin J Martin International Commission on Radiological Protection Dr Martin has worked as a hospital-based Medical Physicist in Radiation Protection and Diagnostic Radiology in the Scotland for 30 years, and is a Senior Lecturer with the University of Glasgow. His research interests involve optimisation of radiation protection in diagnostic radiology, nuclear medicine, and non-ionising radiations. Dr Martin is a member of Committee 3 of ICRP (Protection in Medicine) and of IAEA committees. He has close links with UK Medical Radiation Protection Committees for BIR, IPEM and SRP and is a member of Editorial Boards for the Journal of Radiological Protection and Radiation Protection Dosimetry.

Dr Derek Pearson Professional Adviser to the Chief Scientific Officer of NHS England Derek Pearson was Head of Medical Physics and Clinical Engineering in Nottingham until his retirement at the end of 2012. He is currently a Professional Adviser to the Chief Scientific Officer of NHS England (Professor Sue Hill) working on a number of projects associated with the Modernising Scientific Careers programme. One of these is to establish an education and training framework for MPEs in the NHS. He is also Head of Education for the Academy for Healthcare Science.

Dr Andrew Reilly Consultant Physicist, The Clatterbridge Cancer Centre NHS Foundation Trust Andrew Reilly is a Consultant Clinical Scientist in the Radiotherapy Physics Department at the Clatterbridge Cancer Centre. His primary role is to support the clinical use and development of radiotherapy imaging technologies and work towards improved systems integration. He has a particular interest in bridging the gap between different imaging disciplines and optimising imaging across the radiotherapy process.

He is founder of the IQWorks project, leads the Radiotherapy Imaging User Group and provided physics support under the national NRIG mentoring programme for IGRT implementation. Andrew served as Chairman of the BIR Radiation, Physics & Dosimetry Committee until 2009, was a member of BIR Council from 2010-2013 and represents the BIR on the DH Medical Physics Expert working group.

Dr Denis Remedios Consultant Radiologist, Northwick Park Hospital Denis Remedios is a Clinical Radiologist working at Northwick Park Hospital, London. A graduate of Cambridge University and Westminster Medical School, his clinical interests include Musculoskeletal and Sports Imaging, helping at the 2008 and 2012 Olympic Games. He has chaired the Royal College of Radiologists’ Guidelines Working Party since 2003, for the 6th, 7th and forthcoming 8th Editions of iRefer: Making the best use of clinical radiology. He has also been a member of the RCR Clinical Radiology Audit Committee for over 10 years. International work includes European Society of Radiology Lead for the European Commission Guidelines Project, RP178 in 2012-3 and helping with several IAEA and WHO consultations.

Dr Peter Riley Consultant Interventional Radiologist, Queen Elizabeth Hospital, Birmingham Dr Peter Riley is a Consultant Interventional Radiologist at Queen Elizabeth Hospital, Birmingham. He has been a member of the BIR Radiation Protection Committee for a number of years as well as past Chair and currently represents and advises RCR on radiation safety issues.

Mr Andy Rogers Head of Radiation Physics, Nottingham University Hospitals NHS Trust I am Head of Radiation Physics at Nottingham University Hospitals NHS Trust and also the retiring Chair of the British Institute of Radiology’s [BIR] Radiation Protection Committee and BIR Vice-President External Affairs. I represent BIR on the working group that will advise the DH on the EU Basic Safety Standards revision as well as the National Research Ethics Service. I have recently joined the international standards organisation IEC to represent the UK in a project looking at the use of dose data held in digital imaging modalities along with being a member of an ICRP working group drafting a report on Diagnostic Reference Levels. My current research interests are observer studies, skin dose assessment and optimisation in interventional cardiology. __________________________________________________________________ Abstracts IRMER – what impact will the BSS have?

Mr Steve Ebdon-Jackson The revised Basic Safety Standards Directive 2013/59/Euratom was published on 17 January 2014. It replaces a range of existing directives including those addressing the dangers arising from exposure to ionising radiation in relation

to occupational and public exposure (96/29/Euratom) and medical exposure (97/43/Euratom). This new Directive must be transposed by 6 February 2018 within European Union Member States.

While the Directive includes many familiar principles and approaches regarding medical exposure, it includes some additional requirements with greater detail than previously. Practice has changed since the current regulations came into force and as a consequence, new regulations will be required within the United Kingdom. This will require cross-government discussions and agreement before the detail of new regulations can be decided.

The Department of Health has previously announced it intends to use this opportunity to review requirements for prior authorisation (now licensing) of the administration of radioactive substances to humans and to combine within one set of regulations the key elements of the existing Medicines (Administration of Radioactive Substances) Regulations 1978 and the Ionising Radiation (Medical Exposure) Regulations 2000, albeit within an agreed regulatory framework intended to implement the new Basic Safety Standards Directive.

This paper will provide information on early progress with this process, outlining key areas of change in new regulations and describing initial discussions with professional bodies. It will enable professionals to understand the next steps in the transposition of Chapter VII (Medical Exposures) of the new Directive.

MPE update – will imaging departments notice any difference?

Dr Derek Pearson The requirement for imaging departments to optimise investigations and have access to expert physics advice has been in place since the PoPUMET regulations in 1988. IRMER further strengthened the regulatory framework to clarify the requirements for optimisation, machine surveillance and patient dose measurement. The new BSS further clarifies the role of the MPE in optimisation, patient dose measurement, the radiological equipment lifecycle and training. If imaging departments implemented the spirit of the PoPUMET regulations in 1988 and they are properly supported by their medical physics service then the new BSS should be business as usual.

From a personal viewpoint, however, implementation of PoPUMET and then IRMER has failed to deliver on the key objective of optimisation. Of the 1271 primary articles in BJR in the last 5 years, only 74 have been on optimisation in imaging departments. Medical Physics departments have concentrated on the procedural aspects of IRMER and machine surveillance without much evidence that quality assurance programmes are effective in delivering improved outcomes. If imaging and medical physics departments are to notice a difference they need to properly engage with the optimisation process. At the same time, the MPE project within the Modernising Scientific Careers Programme is putting in place a training framework for MPEs in the NHS in England that ensures that weight is put on optimisations and image quality as components of the curriculum.

Referral guidelines – will they deliver?

Dr Denis Remedios Evidence-based imaging referral guidelines have been published for 25 years by the RCR. The need for guidance is based on good medical practice, radiation safety and cost effectiveness. Powerful drivers in Europe and abroad have been: imaging overutilization (cost) and increasing collective dose, with diagnostic exposures now matching natural background radiation in some countries.

Challenges to implementation of referral guidelines include availability, distribution, resource, acceptance by referrers and obtaining evidence of outcome. Strategies for promoting guidelines’ use include: increased awareness, educational initiatives, clinical decision support and feedback.

International efforts to aid justification include the IAEA campaign of “awareness, appropriateness and audit”, the WHO Global Initiative for Radiation Safety in Healthcare Settings, the Bonn Call-to-Action, the European Commission’s Guidelines Project RP178, and the European Society of Radiology’s Eurosafe campaign. The term, referral guidelines (rather than criteria) is used in the Basic Safety Standards and the Euratom BSS Directive.

Educational efforts include formal teaching eg MEDRAPET in Europe, campaigns such as Eurosafe and Choosing / Image Wisely and webbased learning eg IAEA’s Radiation Protection of Patients. Computerised clinical decision support in workflow has much interest and should support professional decisions with less need for later change through vetting. Feedback through clinical meetings and in reports offers learning opportunities to promote a radiation safety culture.

Evidence shows 20% sustainable reduction in utilisation is possible using guidelines. Appropriate imaging is now possible in >90% of GP-exams through meticulous vetting, thus making the best use of clinical radiology.

Systems for non-medical referrers Mr Andy Rogers This short talk will put the issue in to a legal and best-practice context regarding EU, UK and professional body legislation and guidance and, from the speaker’s perspective, lay out what a best-practice system to manage the issue would look like. This system will address issues of scope of referrals, information and training required and management. It will also briefly highlight areas of current variation in practice where the speaker feels a more uniform approach would benefit practice.

IRMER guidance in diagnostic and interventional radiology Dr Peter Riley Guidance to understanding IR(ME)R for radiotherapy practitioners was published in 2008. RCR felt that a similar document related to the diagnostic side of practise would be helpful. A multi-disciplinary working group was set up in November 2012 consisting of radiologists, radiographers, medical physicists and Public Health England to discuss topics for inclusion, how they might differ from guidance for radiotherapy and receive offers for

writing various sections. The document explains the terms and emphasises the importance of entitlement, justification and authorisation, optimisation, clinical evaluation and health screening, amongst others, by the inclusion of clinical scenarios as well as well as providing a resume of IR(ME)R 2000 regulations. Consideration has also been given to reportable errors and incidents requiring investigation by regulators. The presentation will discuss reasons for inclusion and clarify understanding of terms used in the regulations as interpreted by members of the working group and their legal advisors as well as demonstrations of how records may be kept by imaging departments.

Optimisation and DRLs – current best practice Dr Colin J Martin The objective of a Diagnostic Reference Level (DRL) is to aid in optimisation of radiation protection in medical imaging by providing a dose standard against which performance can be compared. DRLs should be based on measurements of patient doses for specific examination with dose metrics that are readily measureable. DRLs have proved an effective tool for optimisation, and patient doses for UK radiographic and fluoroscopic examinations have reduced to half the original values in the NRPB survey of the 1980s. An ICRP Task Group is preparing a publication on DRLs, and recommends use of DRLs set at the 3rd quartile and Achievable Doses at the median of the national dose distribution of median doses for individual hospitals. The use of electronic data collection through Radiology Information Systems or dose management software allows retrospective review of data for greater numbers of patients. ICRP recommend that the median dose from such data surveys are used by hospitals for comparison with the relevant DRL. The main growth in procedures has been in CT and interventional.

For CT, patient size now plays a significant role in determining dose, and comparisons for several weight groups are recommended. For interventional procedures use of dose values for all cases of a particular procedure in a large number of facilities to generate a national Advisory Data Set (ADS) is recommended. A Facility Data Set (FDS) consisting of all patients undergoing the procedure in a hospital would be compared with the ADS, particularly the FDS median and the ADS 75th percentile. DRLs provide Medical physicists, radiographers and radiologists a valuable tool in their collaboration to optimise radiation protection, while maintaining image quality.

National dose registries – an update Ms Sue Edyvean National dose surveys in radiology in the UK have been carried out for over thirty years by Public Health England CRCE and its predecessor bodies; the latest of these - General Radiology and Fluoroscopy, and CT - being published in 2012 and 2014 respectively[1,2]. The data from these surveys are valuable for establishing a snapshot of current practice, can be used as one of the tools for optimisation, and inform the DH for the establishment of National

Diagnostic Radiation Levels (DRLs).

In recent years the use and development of digital radiological imaging techniques, together with new standards for recording radiation doserelated metrics, such as the Radiation Dose Structured Report (RDSR), has allowed the routine recording of comprehensive information relating to almost every single radiation exposure. The management of these data can be achieved with a range of commercial, open source or in-house dose management software solutions, which are already proving their worth in local optimisation. The volume of data and their timeliness bring a number of advantages that can also be taken through to regional and national dose registries.

The current status of national dose surveys is discussed in the context of utilising all methods of sampled data extraction, whilst also embracing the concept and potential of a national dose registry whereby all data is collected.

References: 1. Hart D, Hillier MC and Shrimpton PC. Doses to Patients from Radiographic and Fluoroscopic X-ray Imaging Procedures in the UK - 2010 Review. Chilton: Health Protection Agency, 2012. HPA-CRCE-034.

2. Shrimpton P C, Hillier M C, Meeson S and Golding S J (2014). Doses from Computed Tomography (CT) Examinations in the UK – 2011 Review. PHE-CRCE-013. PHE CRCE, Chilton.

Patient dose management software – a radiographer’s perspective Mrs Elaine Holt This presentation aims to provide a radiographer’s experience in the day to day use of Dose Management Software.

The advent of Dose Management Software provides a system with the potential to accurately and consistently record and analyse patient dose, not just within a Department but Hospital wide (and possibly inter Hospital wide).

This will be discussed along with the issues and considerations when using the software on a daily basis.

It is hoped the presentation will give an insight into the use of dose management software and how it can be utilised to provide complete patient dose records. It is also hoped to demonstrate how the software can be used as a tool for dose optimisation and training purposes.

With further European Legislation regarding patients exposed to ionising radiation, and the possible introduction of a National Dose Register, Dose Management Systems may become more widely used.

Funding such systems however, may always be an issue for most Healthcare establishments.

Management of tissue reactions in high dose procedures Mr Mark Bowers Radiation induced hair loss and injuries of the skin and subcutaneous tissues, collectively termed “tissue reactions” are rare complications of fluoroscopy guided interventional procedures. While only a small fraction of these complications are severe enough to result in serious long-term clinical consequences, the impact on the patient’s quality of life from severe injuries (e.g., disfigurement, functional impairment and chronic pain) can be devastating.

In the recent past, sometimes cardiologists have been unaware of the radiological dose of the examination they prescribe or practice, but they should make every effort to reduce unnecessary radiation exposure from medical imaging.

A good cardiologist - and even more so, a good imaging or interventional cardiologist - cannot be afraid of radiation, but must be very afraid of radiation unawareness.

This talk aims to show areas of best practice for reporting high dose radiation procedures from various centres in the UK. We will also look at efforts that the manufacturers are making in assisting the end user to compile information for sharing with the consultants, GP’s and even the patient.

Never mind the dose – feel the image quality!

Dr Elly Castellano The learning objectives of this presentation are to: • Appreciate that dose optimisation does not necessarily mean dose reduction: images must always be adequate for the diagnostic task.

More clinical harm can be done through inadequate image quality than radiological damage caused through high radiation doses; • Reflect that there may be a “right” radiation dose for a given diagnostic task, and this could be evidence-based; • Understand that individual radiation doses can and should go up as well as down, e.g. by using size-specific protocols, in order to ensure adequate image quality across the board; • Appreciate that, within the context of optimisation, radiation doses may need to go up before they go down in order to ensure diagnostic confidence; • Consider that the effect of novel dose reduction features on image quality needs to be evaluated before use.

Nuclear medicine – can we reduce administered activity?

Ms Sarah Allen In nuclear medicine image quality depends on many factors. One crucial parameter is the administered radioactivity to the patient. This not only contributes to final image quality but is the critical factor determining the radiation dose to the patient. Ensuring the radiation dose is as low as possible whilst maintaining image quality is a fundamental requirement of IRMER. Reconstructing image data using iterative methods including Resolution Recovery (RR) has been a theoretical solution to improving the quality of patient images and the possibility of reducing the injected activity for many years. However, its introduction into the clinical setting was accelerated when concern over shortages of 99mTc lead to departments wanting to use their daily allowance of 99mTc more efficiently and inject less activity per patient. If the administered activity to the patient is maintained the technique can be used to reduce scanning times. This alternative use is becoming a popular option as the demand on services increases and there is pressure to scan more patients per day. Also the option of shortened scan times is of benefit when imaging older and frailer patients. For all these reasons, RR has become an accepted technique within routine nuclear medicine with reduced radiation doses to the patient a by-product. In practice RR is vendor specific and comes at a price, purchasing the software within a main equipment tender makes it affordable. Clinical images reconstructed using RR methods must be optimised to ensure acceptable image quality. Image acquisition and data reconstruction parameters must be validated for each centre where it is used. When switching to this technique the process must be validated for each procedure separately. Literature suggests that bone and cardiac procedures are the most often validated with the reasons for use being reduced administered activity or shortened imaging time.

Hybrid imaging – optimisation challenges Ms Kathryn Adamson Hybrid imaging presents an enormous scope for optimisation. The balance between image quality and dose is more fluid than in diagnostic CT alone and multiple reconstructions offer the chance for localisation-CT and/or characterisation CT as well as attenuation correction CT to be generated all from the same CT exposure.

It is important to appreciate that hybrid imaging is an imaging modality in its own right, and conventional CT scanning protocols and patient positioning techniques can not always be directly applied. Different imaging centres may have a different view on the balance of image quality and patient dose, but the challenges for all staff groups within imaging centres remain the same.

The clinicians/radiologists must decide what they want from the image and how good it needs to be in order to answer the clinical question. Physicists need to be able to understand the clinical requirements, determine if it is actually possible on the scanner, and if so, interpret the request in terms of acquisition parameters to obtain an adequate CT image with the lowest dose to the patient. Nuclear Medicine technologists must learn a new

imaging modality and understand how their actions have a direct impact on the patient dose. Manufacturers also have their part to play through making software and hardware improvements, such as auto mA and iterative reconstruction.

Hybrid imaging optimisation is a multi-disciplinary team challenge. There is no single perfect solution, and as the imaging goals themselves are constantly evolving, optimisation is inevitably a lifelong task.

Imaging in radiotherapy – who should optimise?

Dr Andrew Reilly Optimisation of imaging in radiotherapy is challenging!

Optimisation involves balancing competing factors: ensuring images acquired are suitable for the clinical task whilst minimising the burden to the patient. This presentation explores the complex nature of the overall task being performed in radiotherapy and how images acquired at one stage of the patient journey may contribute to multiple discrete tasks being performed over an extended time period. Balancing the relative importance of the various tasks is an important element of optimisation in radiotherapy imaging.

Radiotherapy is planned and delivered by a multi-professional team of oncologists, radiographers and physicists. Each team member has a distinct role to play in the optimisation process, with good communication between team members crucial for success. Although imaging underpins the majority of radiotherapy treatments delivered today little specific formal training is provided for any of these staff groups, with competence and responsibility for imaging generally being considered an advanced role. Opportunities for developing robust optimisation strategies through close working with peers in diagnostic imaging are considered.

There is significant debate within the radiotherapy community regarding the measurement, quantification and management of concomitant dose from imaging. A pragmatic approach to this is suggested by building on experience gained through clinical trials and harnessing data automatically collected through routine workflow activities. The potential role of imaging dose reference levels is considered and the development of peer support networks is suggested, encouraging cancer centres with similar equipment and case loads to share protocols and experiences.

A variety of real-world clinical examples is used to illustrate the challenges and opportunities discussed throughout the presentation.

Conclusions and future possibilities Mrs Mary Cocker IRMER 2000 made it a legal requirement to optimise medical exposures using ionising radiation. The UK is therefore in an excellent position to take forward optimisation to the next stage under the new legislation. This talk will provide a few pointers as to how this is best achieved and where our priorities should lie. Within each organisation, responsibilities for dose management need to be clearly defined under a robust governance structure. Patient risks and the justification of exposures also require a greater understanding by a wide multidisciplinary team. __________________________________________________________________ Please remember to complete the online delegate survey using the below link: https://www.surveymonkey.com/s/IRMER_2014 Your certificate of attendance will be emailed to you within the next two weeks once these have been completed.

BIR Annual Congress 2014: 22-23 October, London

BIR Events 2014

Optimisation in interventional radiology 10 October 2014 IET Birmingham: Austin Court 5 CPD credits (applied for)

After this course attendees should be able to: • Explain the key steps of optimisation • Identify optimisation issues specific to fluoroscopically guided procedures • Describe practical methods for optimising fluoroscopically guided procedures • Identify sources of information for use in optimisation

Spaces still available, book now: www.bir.org.uk REGISTRATION FEES: BIR Consultant member £125 BIR Non-consultant member £95 Non-member £195

BIR Trainee member £60 BIR Retired/Student member £50

Sponsor profiles

Bayer HealthCare has provided sponsorship for the cost of the exhibition stand only at this meeting.

The NHS faces many challenges today around the increasing need for governance in order to demonstrate best patient care within increasing financial constraints. Bayer Radiology and Interventional (R&I) is well placed to be the partner in helping Trusts to address these challenges. With market leading contrast media and power injector systems, Bayer is able to offer innovative patient care, and with the launch of its informatics platform, it can support radiology departments in driving protocolstandardisation and easily accessible audit data that enable departments to meet further challenges faced around radiation dose.

To find out more about our R & I solutions please contact 01635-563999. www.bayer.co.uk

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As part of this mission we are committed to fuelling a revolution in imaging solutions, designed to deliver greater collaboration and integration, increased patient focus, and improved economic value. We provide advanced imaging technologies you can count on to make confident and informed clinical decisions, while providing more efficient, more personalised care for patients.

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FORTHCOMING EVENTS East of England branch event: paediatric imaging 3 October 2014 Norwich Midlands Branch Launch Event: Military Trauma Imaging 9 October 2014 Birmingham Optimisation in interventional radiology 10 October 2014 birmingham

BIR Annual Congress 2014 22-23 October, London BIR UK MRI course 4-7 NOVEMBER 2014 LONDON WELSH BRANCH MEETING: TO REPORT OR NOT TO REPORT....WHAT IS THE ANSWER? 11 NOVEMBER 2014 SOUTH WALES THE JOURNEY FROM research to publication 20 november 2014 london the future of radiology in the nhs: top topics for interviews 21 november 2014 london Diagnostic radiology for advanced head and neck cancer planning 26 November 2014 london state of the art radiotherapy education day 10 december 2014 london WESSEX BRANCH event 10 DeCEMBER 2014 SOUTHAMPTON advances in radiotherapy for prostate cancer: from theory to practice 12 december 2014 cardiff The spine in health and disease 21 January 2015 London Contrast study day and essential physics for FRCR 29 - 30 January 2015 Sheffield VISIT: WWW.BIR.ORG.UK FOR MORE INFORMATION AND TO REGISTER!

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