PRACTICE PARAMETER - PDF document

PRACTICE PARAMETER TheAmericanCollegeRadiology,withmorethan30,000members,theprincipalorganizationradiologists,radiationoncologists,andclinical medicalphysiciststheUnitedStates.TheCollegenonprofitprofessionalsocietywhoseprimarypurposesareadvancethescienceradiology, improveradiologicservicesto thepatient,studythesocioeconomicaspectsthepracticeradiology,andencouragecontinuingeducationforradiologists, radiationoncologists,medical physicists, and personspracticing alliedprofessional fields. TheAmericanCollegeRadiologywill scienceradiologyandimprovethequalityservicepatientsthroughouttheUnitedStates.Existingpracticeparametersandtechnicalstandardswill reviewedforrevisionrenewal,appropriate,theirfifth anniversarysooner,if indicated. Each practice parameterand technicalstandard,representing policystatement theCollege,hasundergone thorough consensusprocesswhichhasbeen subjectedextensivereviewandapproval.Thepracticeparametersandtechnicalstandardsrecognizethat therapeuticradiologyrequiresspecifictraining,skills,andtechniques,describedeachdocument.Reproductionmodificationthepublished practiceparameterand technical standard those entitiesnot providingthese servicesis not authorized. Revised(Resolution ACRPRACTICE PARAMETER FORTHE PERFORMANCEENERGY RAYABSORPTIOMETRY (DXA) PREAMBLEThisdocumenteducationaltooldesignedassistpractitionersprovidingappropriateradiologiccareforpatients.PracticeParametersandTechnicalStandards Thepracticemedicineinvolvesonlythescience,alsotheartdealingwiththeprevention,diagnosis,alleviation,andtreatmentdisease.Thevarietyandcomplexityhumanconditionsmakeimpossiblealwaysreachthemostappropriatediagnosispredictwithcertaintyparticularresponsetreatment.Therefore,shouldrecognizedthatadherencetheguidancethisdocumentwillassureaccurate IowaMedicalSocietyandIowaSocietyAnesthesiologistsIowaBoardNursingN.W.2d.826(IowaIowaSupremeCourtrefusesfindthat theACRTechnicalStandardfor ManagementtheUseRadiation specialtymedicalorganizationsareusefuldeterminingthedutyowedthestandardcareapplicablegivensituation”eventhoughACRstandardsthemselvesnot establish thestandardcare. PRACTICE PARAMETER INTRODUCTIONThispracticeparameterwasrevisedcollaborativelyby the AmericanCollegeRadiology(ACR),the SocietyforPediatricRadiology(SPR), andtheSocietySkeletalRadiology(SSR).Dualenergyrayabsorptiometry(DXA)[1]clinicallyproven,accurate,andreproduciblemethodmeasuringmineraldensity(BMD)thelumbarspine,proximalfemur,forearm,andwholee-7]. It is usedprimarilytheiagnosisandmanagementosteoporosisandotherdiseasestatescharacterizedabnormalBMD,wellto monitorresponsetherapyfortheseconditions[8,9]mayalsousedmeasurewholecomposition[10includingnonboneleanmass(LM)andfatmass(FM).DXAmeasuredandmayhelpfulassessingnumberconditions,includingsarcopeniaandcachexia.ThispracticeparameteroutlinestheprinciplesperforminghighqualityDXA.INDICATIONS CONTRAINDICATIONSDXAmeasurementBMD,indicatedwheneverclinicaldecisionlikelydirectlyinfluencedtheresultthetest[13]Indicationsforinclude,arelimitedto,individualswithsuspectedabnormalBMD,LM,FM,including[2,5,7,14 Allwomenagedyearsandolderandmenagedyearsandolder(asymptomaticscreening)Allpostmenopausalwomenyoungerthan 65yearsand

menyoungerthanyearswhohaveriskfactorsforosteoporosisincluding:historyfracturethewrist,hip,spine,proximalhumeruswithminimaltrauma,excludingpathologicfracturesFamilyhistoryosteoporoticfractureLow mass(lessthan127lbs57.6CurrentusecigarettesExcessiveusealcoholLossheight,thoracickyphosisIndividualsanyagewithfindingssuggestivedemineralizationfragilityfracturesimagingstudiessuchradiographs,computedtomography(CT),magneticresonanceimaging(MRI)Individualsreceiving(orexpectedreceive)glucocorticoid therapyformorethanmonthsIndividualsbeginningreceivinglongtermtherapywithmedicationsknownadverselyaffectBMD(eg,anticonvulsantdrugs,androgendeprivationtherapy,aromataseinhibitortherapychronicheparin)Althoughprotonpumpinhibitors(PPIs)mayassociatedwith increasedriskfragilityfractures,routinescreeningBMDrecommendedpatientsreceivingPPIstheabsenceotherriskfactor[24] Individualswithan endocrinedisorderknownto adverselyaffectBMD(eg,hyperparathyroidism,hyperthyroidism,Cushing’ssyndrome)PostpubertalhypogonadalmaleswithsurgicallychemotherapeuticallyinducedcastrationIndividualswithmedicalconditionsassociatedwithabnormalBMD,suchas:ChronicrenalfailureRheumatoidarthritisandotherinflammatoryarthritides PRACTICE PARAMETER Eatingdisorders,includinganorexianervosaand bulimiaGastrointestinalmalabsorptionsprueOsteomalaciaAcromegaly,chronicalcoholism,establishedcirrhosisMultiplemyelomaGastricbypassforobesity.Theaccuracyin thesepatientsmightbe affectedobesityOrganTransplantationProlongedimmobilizationProlongedpoornutritionIndividualsbeingmonitoredto:Assesstheeffectivenessof osteoporosisdrugtherapy[25]FollowmedicalconditionsassociatedwithabnormalBMDmayindicatedtoolmeasureregionalandwholefatand(eg,forpatientswithmalabsorption,cancer, eatingdisorders)[22,26PediatricIndicationsandConsiderationsIndicationsforperformingBMDexaminationsandsubsequentassessmentchildrendiffersignificantlyfromthoseadults.InterpretingBMDmeasurementschildrencomplicatedthegrowingskeleton.unabletakeintoaccountchangesbody and skeletalsizeduringgrowth,limitingits usefulnesslongitudinalstudies.Forexample,increaseDXAmeasuredarealBMDthespinemorelikelyreflectionthechangevertebralsizethanchangeBMD.Becausequantitativecomputedtomography(QCT)assessbothvolumeanddensitytheaxialandappendicularskeleton,maymoreusefulthanchildren.Becauselowerradiationdose,peripheralQCT,whichassessestheextremities,maypreferableto centralQCTin pediatricpatients. childrenandadolescents,BMDmeasurementindicatedwheneverclinicaldecisionlikelydirectlyinfluencedtheresultthetest.IndicationsforDXAinclude,butarelimited[29]Individualsreceiving(orexpectedreceive)glucocorticoidtherapyformorethanmonthsIndividualsreceivingradiationchemotherapyformalignancyIndividualswithan endocrinedisorderknownto adverselyaffectBMD(eg,hyperparathyroidism,hyperthyroidism,growthhormonedeficiency,Cushing’ssyndrome)Individualswithbone dysplasiasknownto haveexcessivefracturerisk(osteogenesisimperfecta,osteopetrosis)highbonedensitysuchwithprolongedexposurefluorideIndividualswithmedicalconditionsthatcouldalterBMD,suchas:ChronicrenalfailureRheumatoidarthritisandotherinflammatoryarthritidesEatingdisorders,includinganorexianervosaand bulimiaOrgantrans

plantationProlongedimmobilizationGastrointestinalmalabsorption,includingthatrelatedCysticFibrosisSprueInflammatoryboweldiseaseMalnutritionOsteomalaciaVitamindeficiencyAcromegalyCirrhosis PRACTICE PARAMETER HIVinfectionProlongedexposurefluoridesContraindicationsThereareabsolutecontraindicationsperformingDXA[30]However,examinationmaylimitedvaluerequiremodificationthetechniquereschedulingtheexaminationsomesituations,including:RecentlyadministeredoralcontrastradionuclidesPregnancySeveredegenerativechangesfracturedeformityin themeasurementareaImplants,hardware,devices,otherforeignmaterialin themeasurementareaThepatient’sinabilityattaincorrectpositionand/orremainmotionlessforthe measurementExtremeshighlowmassindexthatmayadverselyaffecttheabilityobtainaccuratemeasurements.QCT maydesirablealternativetheseindividuals[31Forthepregnantpotentiallypregnantpatient,seethe ACRSPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation [34] QUALIFICATIONS ANDRESPONSIBILITIESOF PERSONNELFor physicianregistered radiologist assistant, and radiologic technologist qualifications see the ACRAAPMSIIM SPR Practice Parameter for Digital Radiography [35]For Qualified Medical Physicist qualifications, see the For Qualified Medical Physicist qualifications see the ACRAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of DualEnergy XRay Absorptiometry (DXA) Equipment [36]Additional specific qualifications and responsibilities include: Physicia[37Theexaminationmustperformedunderthesupervisionandinterpretedlicensedphysicianwiththefollowingqualifications:Knowledgeand understandingbonestructure,metabolism,and osteoporosisDocumentedtrainingandunderstandingthephysicsrayabsorptionandradiationprotection,includingthepotentialhazardsradiationexposurebothpatientsandpersonnelandthemonitoringrequirementsKnowledgeandunderstandingtheprocessDXAdataandimageacquisition,includingproperpatientpositioningand placementregionsinterest,and artifactsandanatomicabnormalitiesthatmayfalselyincreasedecreasemeasured valuesKnowledgeandunderstandingtheanalysisandreportingincluding,limitedto,BMD,score, score,WHO fractureriskassessmenttool(FRAXandtheWHO classificationsystemKnowledgeand understandingthe criteriaforcomparisonserialmeasurements,includinglimitationscomparingmeasurementsmadedifferenttechniquesanddifferentdevices,therationalebehindprecisiontesting,andthestatisticalsignificanceserialchangesBMDAwarenessotherbone densitometrytechniques,includingQCT,peripheralQCT,peripheralDXA,andquantitativeultrasound(QUS),fulfillconsultativerolerecommendingfurtherstudies,futuremeasurements,diagnosticproceduresto confirmsuspectedabnormalitiesseenimages PRACTICE PARAMETER Whenperformingfortheassessmentcomposition,thephysicianshouldhaveadditionalknowledgeand understandingof:Analysisandreportingincludingnotlimitedappendicularleanmass(ALM),and visceraladiposetissue(VAT)Othermodalitiesusedassesscomposition,includingCT,MRI,QUS,bioelectricalimpedanceanalysis,andanthropomorphicanalysisThe supervising physician must be responsible for overseeing the DXA facility and its equipment quality control program.

The physician accepts final responsibility for the quality of all DXA examinations.The physician’s continuing medical education should be in accordance with the ACR Practice Parameter for Continuing Medical Education (CME) [40] Radiologic and Nuclear Medicine TechnologistTheexaminationmustbe performedtechnologistwiththefollowingqualificationsandresponsibilities:Responsibilityforpatientcomfortandsafety,preparingandproperlypositioningthepatient,placementregionsinterestforBMDmeasurements,monitoringthepatientduringthemeasurements,andobtainingthe measurementsprescribedthesupervisingphysicianDocumentedformaltrainingtheusetheDXAequipment,includingallmanufacturerspecifiedqualityassuranceprocedure[41]Knowledgeandfamiliaritywiththemanufacturer’soperatormanualforthespecificscannermodelbeingusedResponsibilityfordeterminingprecisionerrorandcalculatingleastsignificantchange(LSC)(seesectionVII.Statelicensureand/orcertification,required.Organizationsprovidingcertificationin bone densitometryincludetheAmericanRegistryRadiologicTechnologists(ARRT),theNuclearMedicineTechnologyCertificationBoard(NMTCB),andthe InternationalSocietyforClinicalDensitometry(ISCD)Thetechnologist’scontinuingmedicaleducationshouldaccordancewiththenationalregistrystatelicensurerequirementswhereapplicable.SPECIFICATIONS OFTHE EXAMINATIONThe writtenelectronicrequestfora DXAexaminationshouldprovidesufficientinformationto demonstratethe medicalnecessitytheexaminationandallowforproperperformanceandinterpretation. Documentationthatsatisfiesmedicalnecessityincludessignsandsymptomsand/orrelevanthistory(includingknowndiagnoses).Additionalinformationregardingthespecificreasonfortheexaminationprovisionaldiagnosiswouldhelpfulandmaytimesneededallowfortheproperperformanceandinterpretationof the examination.Therequestfortheexaminationmustoriginatedphysicianotherappropriatelylicensedhealthcareprovider.Theaccompanyingclinicalinformationshouldbe providedphysicianotherappropriatelylicensedhealthcareproviderfamiliarwiththepatient’sclinicalproblemquestionandconsistentwiththestatescopepracticerequirements.(ACR Resolutionadopted2006 revised2016, Resolutionhistoryshouldbe obtainedfromthe patientregardingriskfactors(aslistedin sectionIII),and priorsurgerythatcouldpotentiallyaffecttheaccuracymeasurements.Questionnairesfoundwww.iscd.org or www.nof.org . PRACTICE PARAMETER Standardexaminationadultsshould,minimum,consistposteroanteriorscanthelumbarspineandeitherhip[7,42However,imagingbothhipswouldprovideinformationthelowesthipBMD,andthefuturehipbecomesunavailableutilize(eg,fractureand/orsurgery),therewouldcomparisoninformationavailablefortheunaffectedhipdetermineBMDchange.instanceswherethisfeasible(extensiveabdominalaorticcalcification,degenerativediseasethelumbarspinehip,scoliosis,fractures,implants),alternatesitescanusedforevaluatingthepatient,includingtheotherhip,nondominantforearm,whole[46]thenondominantforearmmayusefulindividualswhoexceedtheweightlimitthe DXA tableandindividualswithhyperparathyroidism[7]childrenandadolescents,DXAexaminationshouldconsistexaminationthelumbarspineandwholebody[7,4750]Whatacquiredmayvarywiththeindication.individualswithquadriplegi

ccerebralpalsy,oftenwithspinalfusionhardwareandproximalfemoralhardwarehippointcontracture,thedistalfemurthelateralpositioncanusedformeasurementBMDandfollowtherapy.Thepediatricnormativedatabaseforthistechniquevendorspecific[51TherelationshipBMDfracturechildrenclearlyestablished[26,48] examinationincludesimagestheareaswhereBMDmeasured.priorimages(eg,radiographs,CT,MRI)theseanatomicareasareavailable,theyshouldrevieweddeterminespecificsitesshouldbe analyzed using[54]Positioningandsofttissueequivalentdevicesissuedthemanufacturermustusedconsistentlyandproperly.Comfortdevices,suchpillowsundertheheadknees,mustinterferewithproperpositioningand mustneverappearthescanfield.Forthelumbarspine,vertebraemayexcludedtherescoredifferencemorethan1.0comparedtheadjacentvertebrae,therearefocalstructuralabnormalitiesoverlyingthevertebra,suchfractures,previoussurgery,degenerativechanges,otherinternalexternal,artifacts.Theremainingvertebrae(minimumtwolevels)areusedfordiagnosisandmonitoring.Diagnosticclassificationshouldmadeusingsinglevertebra.Fordiagnosispostmenopausalwomenandmenagedyearsandolder,measuredBMDvaluesmustcomparedwiththosetheadultreferencepopulationvalues,yieldingscorethatcorrespondsWHOdiagnosticcategory Fordiagnosischildren,premenopausalwomen,andmenyoungerthanyears,measuredBMDvaluesmustcomparedwithpopulationspecificagematchedvalues,yieldingscore[7]Typically,scoreslowerareconsideredto bebelowtheexpectedrangeforage.Fordiagnosischildrenandadolescents,measuredBMDvaluesmustcomparednormativepediatricdatabaseyieldinggenderspecificscore.ethnicityspecificdatabaseshouldbe usedavailableandadjustmentforheightwhenpossible.BMDvaluesandscoresfortotalbodylessheadregioninterestarecommonlyreported.Reportsshouldalsoincludemineralcontent(BMC)[55]Typically,scoresbeloware consideredabnormal.Whenmonitoringpatients,comparisonshouldmadepriorexaminationsthesameskeletalsite,regioninterest,andareasize.Theprecisionerrorandthespecificscanner(s)shouldascertaineddeterminemeasuredchangesare statisticallysignificant[7,56the priorexaminationwasperformedthesamedevice(notjustthesamemanufacturermodel),quantitativecomparisontheexaminationsperformed.theexaminationwasdifferentdevice,thencomparisonqualitativeunlesscrosscalibrationcalculationhasbeenperformed [41,60Comparabilityscans,in orderdecreasingvalidity,follows: PreviousexaminationsthesamewellmaintaineddevicePreviousexaminationsanotherdevicewithcrosscalibrationcalculationperformedPreviousexaminationsanotherdevicefromthe samemanufacturerPreviousexaminationsdevicefromanothermanufacturer(notrecommended) PRACTICE PARAMETER Vertebralfractureassessment(VFA)lowdoselateralimagethethoracicandlumbarspinethatmayadded to astandardDXAdeterminewhethervertebralfracturesare present[63,64]VFAshouldconsideredpatientswithheightlossbackpainwhohavebeenassessedconventionalradiographs,CT,MRI.VFAintendedsolelyidentifywhetherspinecompressionpresentanddoesreplaceconventionaldiagnosticimagingforotherpurposes.TrabecularBoneScore(TBS)methodobtainingquantitativedatatexturefromDXAspineimages.TBSrequiresspecializedsoftwarethatmeasuresrelativepixelamplitudevariationssummingthesquaredgrayleveldifferences[65]TBShasbeenshownimprovefractureriskpre

dictionusingtheFRAXtool.TBSadjustedfractureriskcalculationusingtheFRAXtoolespeciallyvaluablepatientswithtypediabetes,whofracturehigherBMDlevelsthannondiabetics[66]WhenassessingcompositionusingDXA,additionalfactorsshouldconsidere[22,28]Somepatientsmaytootalltoowideincludedthescannedfield.patientswhoaretootall,parttheheadexcluded,thepatientimagedwithbentknees.patientswhoaretoowide,halfthecan imaged,and theotherhalfbe estimatedbecauseof symmetry. Anythingthatalterswaterimpactmeasurements.Forinstance,overhydratedpatientmayresultdecreasedandincreasedScansobtainedsoonafterovernightfastingbeforethe patienthas consumedanythingallow formostreproduciblemeasurements.Whenassessingmusclemassmeasurements,suchtotalLM/height2,armslegs(ALM),ALM/totalweight,andALM/height2areusefuldetectingsarcopeniaandotherchronicconditionsthataffectAdipositymeasurements,includingVAT,subcutaneousadiposetissue,andindex(FM/height2),mayusedevaluatingpatientswithcancer,cachexia,andotherchronicconditionsthataffectanddistribution.DOCUMENTATIONReportingshoulddoneaccordancewiththe ACR Practice Parameter for Communication of Diagnostic Imaging Findings [67] permanentrecord mustmaintained,and shouldinclude:Patientidentification,facilityidentification,examinationdate,imageorientation,andunitmanufacturerand modelClinicalnotesor patientquestionnairecontainingpertinenthistoryPositioning,anatomicalinformation,and/ortechniquesettingsneededforerformingserialmeasurementsPrintoutstheirelectronicequivalenttheimagesand regionsinterestprovidedthescannerForpostmenopausalwomenandmenagedyearsandolder,thereportsshouldincludetheBMDg/cm²),score,andclassificationaccordingWHOcriteria.Onediagnosticcategorynormal,osteopenia(lowbonemass),osteoporosisassignedpatientbasedthelowestscorethelumbarspine,totalhip,femoralneck,radius(radius33%,radius1/3).WHOclassificationis assignedonlyto the lowestscore,siteevaluated.OsteoporosisWHOcategoryfurtherdefinedmild,moderate,severe.Theonlyexceptioncombinationscoreconsistentwithosteoporosisandfragilityfracturethatdiagnosed“severeosteoporosis.”statementaboutfractureriskrecommended,appropriate.ThemostcommonlyusedmodelforcalculatingabsoluterisktheWHOFractureriskassessmenttool(FRAXtool).TheFRAXtoolprovidesyearriskhipfractureandglobalfracture(hip,spine,forearm,humerus),hasbeenFDAapprovedandmayappliedmen PRACTICE PARAMETER womenwhomeetcriteria[68]theUnitedStates,FRAXtypicallyreported patientsalreadyreceivingtheraforosteoporosis,patientswithknownvertebralhipfractures,patientsyoungerthanyears.OtherconsiderationsfortheuseFRAXareavailabletheInternationalSocietyforClinicalDensitometryOfficialPosition StatementFRAX[69]Forpremenopausalwomenand menyoungerthan 50 years,the BMD and scoreshouldbe reportedforskeletalsite examined.TheWHOclassificationdoesapplyto theseindividuals(exceptforwomenmenopausaltransition).scoresabove2.0areconsideredwithintheexpectedrangefortheirage.Individualswith scores2.0 andlowerareconsideredto havelowdensityfortheirage.Forchildrenandadolescents,scoresshouldreported.TheWHOclassificationdoesapply;theterms“osteopenia”and“osteoporosis”shouldusedwhenBMCarealBMDscoresarelessthanequal“Lowmineralmassmineral

density”thepreferredterminologyforpediatricDXAreports[70]Forallexaminations,thereportshouldindicatewhetherartifactsothertechnicalissuesmayhaveinfluencedthereportedmeasurementsBMD. statementcomparingthecurrentstudyprioravailablestudiesshouldincludestatementwhetheranychangesmeasuredBMDarestatisticallysignificant.Recommendationsfor,andthetimingof,followDXA scanmayalso be included.Whenappropriate,suggestionsforfurtherimaging(eg,radiography,CT,MRI)otherancillarytestsshouldbe provided.EQUIPMENT SPECIFICATIONSVariousequipmentdesignsthataccuratelyandreproduciblymeasureBMDusingareavailable.Theequipmentshouldprovidethefollowing:Normaladultandagematchedreferencepopulationvaluesmatchedforandapplicabletheequipmentbeingused.Somedevicesalsoprovidereferencevaluesmatchedforethnicityandbodyweight.Labeledimagestheanatomicsitemeasuredandmeasurementresults.Theseshouldrecordedpermanentlyforpatientrecords.Precisionerrorsmeasurementphantomstandardthatexceedthespecificationsrecommendationsthemanufacturerandarelessthan1%.vitro(phantom)precisionshouldequatedwithvivo(patient)precision,therolethetechnologistpatientpositioningandanalysiscritical.phantomotherstandardmustbe measuredaccordingto the manufacturer’srecommendationsordermonitorinstrumentcalibration. EQUIPMENT QUALITYCONTROLDXAequipmentqualitycontrolespecially importantformonitoringthe effectivenesstherapyprogressiondisease[41]EachDXA facilityshould havedocumentedpoliciesandproceduresforevaluatingtheeffectivemanagement,safety,andoperationDXAequipment.ThequalitycontrolprogramshoulddesignedconsultationwithQualifiedMedicalPhysicistminimizerisksforpatients,personnel,andthepublicandmaximizethequalitythediagnosticinformation.installationDXAunit,environmentalradiationsafetysurveyshouldconductedQualifiedMedicalPhysicist.Thesurveyshould includeanyadditionalevaluationrequiredstateregulations. PRACTICE PARAMETER Qualitycontrolproceduresshouldperformedandpermanentlyrecordedtrainedtechnologist.Theseproceduresaregenerallyrequiredleastdaysweekandalwaysbeforethefirstpatientmeasurementtheday.Theyshouldinterpretedimmediatelyuponcompletion,accordingtheguidelinesprovidedthemanufacturer,ensurepropersystemperformance.problemdetected,accordingmanufacturerguidelines,theservicerepresentativeshouldnotifiedandpatientsshouldbe examined untiltheequipmenthasbeenclearedforuse.EachfacilityshoulddetermineprecisionerrorandcalculateLSC.facilityhasmorethanDXAtechnologist,thesevaluesshouldrepresentan averagepooleddatafromalltechnologists.Uponreplacementthe DXA unit,precisionerrorandLSC shouldcrosscalibratedandrecalculated[71]RADIATION SAFETYIN IMAGINGRadiologists,medicalphysicists,registeredradiologistassistants,radiologictechnologists,andallsupervisingphysicianshaveresponsibilityforsafetytheworkplacekeepingradiationexposurestaff,andsocietywhole,“aslowreasonablyachievable”(ALARA)andassurethatradiationdosesindividualpatientsareappropriate,takingintoaccountthepossibleriskfromradiationexposureandthediagnosticimagequalitynecessaryachievetheclinicalobjective.Allpersonnelthatworkwithionizingradiationmustunderstandthekeyprinciplesoccupationalandpublicradiationprotection(justification,optimizationprotectionan

dapplicationdoselimits)andtheprinciplespropermanagementradiationdosepatients(justification,optimizationandtheusedosereferencelevels) http://wwwpub.iaea.org/MTCD/Publications/PDF/Pub1578_web57265295.pdf Nationallydevelopedguidelines,suchtheACR’sAppropriatenessCriteriashouldusedhelpchoosethemostappropriateimagingprocedurespreventunwarrantedradiationexposure.Facilitiesshouldhaveandadherepoliciesandproceduresthatrequirevaryingionizingradiationexaminationprotocols(plainradiography,fluoroscopy,interventionalradiology,CT)takeintoaccountpatienthabitus(suchpatientdimensions,weight,bodymassindex)optimizetherelationshipbetweenminimalradiationdoseandadequateimagequality.Automateddosereductiontechnologiesavailableimagingequipmentshouldbe usedwheneverappropriate.suchtechnologyis notavailable,appropriatemanualtechniquesshouldused.AdditionalinformationregardingpatientradiationsafetyimagingavailabletheImageGently®forchildrenwww.imagegently.organdImageWisely®foradultswww.imagewisely.org websites.Theseadvocacy andawarenesscampaignsprovidefreeeducationalmaterialsforallstakeholdersinvolvedimaging(patients,technologists,referringproviders,medicalphysicists,andradiologists). RadiationexposuresotherdoseindicesshouldmeasuredandpatientradiationdoseestimatedforrepresentativeexaminationsandtypespatientsQualifiedMedicalPhysicistaccordancewiththeapplicableACRtechnicalstandards.Regularauditingpatientdoseindicesshouldperformedcomparingthefacility’sdoseinformationwithnationalbenchmarks,suchtheDoseIndexRegistry,theNCRPReportNo.ReferenceLevelsandAchievableDosesMedicalandDentalImaging:RecommendationsfortheUnitedStatestheConferenceRadiationControlProgramDirector’sNationalEvaluationrayTrends.(ACR Resolutionadoptedin revisedin 2013, Resolution52).QUALITYCONTROL ANDIMPROVEMENT,SAFETY,INFECTION CONTROL,ANDPATIENT EDUCATIONPolicies and procedures related to quality, patient education, infection control, and safety should be developed and implemented in accordance with the ACR Policy on Quality Control and Improvement, Safety, Infection Control, and Patient Education appearing under the heading Position Statement on Quality ontrol& Improvement, Safety, Infection Controland Patient Education on the ACR website ( https://www.acr.org/ClinicalResources/PracticeParameters andTechnicalStandards ). PRACTICE PARAMETER Equipment performance monitoring should be in accordance with manufacturer’s recommendations and applicable aspects of the ACRAAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of Radiographic Equipment [72] ACKNOWLEDGEMENTSThispracticeparameterwasrevisedaccordingtheprocessdescribedundertheheadingTheProcessforDevelopingACRPracticeGuidelinesandTechnicalStandardsthewebsite https://www.acr.org/Clinical Resources/PracticeParametersandTechnicalandards theCommitteeMusculoskeletalImagingthe CommissionBodyImaging,CommitteePracticeParametersGeneral,Small,Emergencyand/orRuralPracticetheCommissionGeneral,Small,Emergencyand/orRuralPractice,andtheCommitteePracticeParametersPediatricRadiologytheCommissionPediatricRadiologyin collaborationwiththe SPR andthe SSR. DanielWessell,MD,Ph.D Committee on Body Im

aging (Musculoskeletal) (ACR Committee responsible for sponsoring the draft through the process) William B. Morrison, MD, Chair Kambiz Motamedi, MD Dawn M. Hastreiter, MD, PhD Mary K. Jesse, MD Catherine C. Roberts, MD Kenneth S. Lee, MD David A. Rubin, MD, FACR Suzanne S. Long, MD Naveen Subhas, MD Jonathan S. Luchs, MD, FACR Committee on Practice Parameters – General, Small, Emergency and/or Rural Practices (ACR Committee responsible for sponsoring the draft through the process) Sayed Ali, MD, Chair Marco A. Amendola, MD, FACR Pil S. Kang, MD Gory Ballester, MD Jason B. Katzen, MD Lonnie J. Bargo, MD Serena McClam Liebengood, MD Christopher M. Brennan, MD, PhD Steven E. Liston, MD, MBA, FACR Resmi A. Charalel, MD Gagandeep S. Mangat, MD Charles E. Johnson, MD Tammam N. Nehme, MD Candice A. Johnstone, MD Jennifer L. Tomich, MD Padmaja A. Jonnalagadda, MD CollaborativeCommitteemembersrepresenttheirsocietiestheinitialandfinalrevisionthis practice parameter ACR SPR SSR Leon Lenchik, MD Marguerite T. Parisi, MD, MS Mary G. Hochman, MBA, MD Robert D. Boutin, MD Jeannette M Perez - Rossello, MD Tony T. Wong, MD Jonathan Flug, MD, MBA Richard E. A. Walker, MD Kevin B. Hoover, MD Sue C. Kaste, DO Robert J. Ward, MD PRACTICE PARAMETER Committee on Practice Parameters – Pediatric Radiology (ACR Committee responsible for sponsoring the draft through the process) Beverley Newman, MB, BCh, BSc, FACR, Chair Lorna P. Browne, MB, BCh Sue C. Kaste, DO Timothy J. Carmody, MD, FACR Tal Laor, MD Brian D. Coley, MD, FACR Terry L. Levin, MD Lee K. Collins, MD Marguerite T. Parisi, MD, MS Monica S. Epelman, MD Sumit Pruthi, MBBS Lynn Ansley Fordham, MD, FACR Nancy K. Rollins, MD Kerri A. Highmore, MD Pallavi Sagar, MD LincolnBerland,MND,FACR,Chair, CommissionBodyImagingRobertPyatt,Jr,MD,FACR,Chair, CommissionGeneral,Small,Emergencyand/orRuralPracticeartaHernanzSchulman,MD,FACR,Chair,CommissionPediatricRadiologyJacquelineAnneBello,MD,FACR,Chair, CommissionQualityand SafetyMatthew S.Pollack,MD,FACR,Chair, CommitteePracticeParametersTechnicalStandards Comments Reconciliation Committee Samir Patel, MD, FACR, Chair James L. McAnally, MD Johnson Lightfoote, MD, FACR, Co - Chair William B. Morrison, MD Sayed Ali, MD Beverley Newman, MB, BCh, BSc, FACR Jacqueline Anne Bello, MD, FACR Marguerite T. Parisi, MD, MS Lincoln L. Berland, MD, FACR Jeannette M. Pérez - Rosselló, MD Robert D. Boutin, MD Matthew S. Pollack, MD, FACR Richard Duszak, Jr., MD Robert S Pyatt Jr, MD, FACR Jonath

an Flug, MD, MBA Humberto G. Rosas Wolfgang Gowin, MD, PhD Sandra Rutigliano, MD Marta Hernanz - Schulman, MD, FACR Timothy L. Swan, MD, FACR, FSIR Mary G. Hochman, MBA, MD Michael J. Ulissey, MD, FACR Kevin B. Hoover, MD Robert J. Ward, MD Sue C. Kaste, DO Richard E. A. Walker, MD Paul A. Larson, MD, FACR Roland Wong, ScM Leon Lenchik, MD REFERENCESGowin W, Felsenberg, D,. Acronyms in osteodensitometry. Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry1998;1:137Brown JP, Josse RG, Scientific Advisory Council of the Osteoporosis Society of C.2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne2002;167:S1Genant HK, Cooper C, Poor G, et al. Interim report and recommendations of the World Health Organization TaskForce for Osteoporosis. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the U1999;10:259Kanis JA, Gluer CC. An update on the diagnosis and assessment of osteoporosis with densitometry. Committee of Scientific Advisors, International Osteoporosis Foundation. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA2000;11:192202.Link TM, Lang TF. Axial QCT: clinical applications and new developments. Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry2014;17:438Mazess R, Collick B, Trempe J, Barden H, Hanson J. Performance evaluation of a dualenergy xray bone densitometer. Calcified tissue international1989;44:228Schousboe JT, Shepherd JA, Bilezikian JP, Baim S. Executive summary of the 2013 International Society for Clinical Densitometry Position Development Conference on bone densitometry. Journal of clinical densitometry : the official journal of the International Societyfor Clinical Densitometry2013;16:455 PRACTICE PARAMETER Adams JE. Advances in bone imaging for osteoporosis. Nat Rev Endocrinol2013;9:2842.Cummings SR, Bates D, Black DM. Clinical use of bone densitometry: scientific review. JAMA : the journal of the American Medical Association2002;288:188997.Mazess RB, Barden HS, Bisek JP, Hanson J. Dualenergy xray absorptiometry for totalbody and regional bonemineral and softtissue composition. The American journal of clinical nutrition1990;51:1106WattsNB. Fundamentals and pitfalls of bone densitometry using dualenergy Xray absorptiometry (DXA). Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA2004;15:847Wells JC, Haroun D, Williams JE, et al. Evaluation of DXA against the fourcomponent model of body composition in obese children and adolescents aged 521 years. Int J Obes (L

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