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Image Gently: Why it Matters

Children’s Mercy Kansas City understands that children are not simply small adults.

From physical to cognitive process, pediatric medicine requires a holistic understanding of the child – including how they react to radiation.

With the guidance of staff physicist, Nima Kasraie, PhD, Children’s Mercy Kansas City radiology treatments provide the least amount of radiation possible to its patient – thought to be the least amount of radiation a child would receive from any hospital in the country.

Join Dr. Kasraie as we learn more about Image Gently and why it matters for our children.
Image Gently: Why it Matters
Featured Speaker:
Nima Kasraie, PhD
Nima Kasraie, PHD is a medical physicist at Children’s Mercy Kansas City and an assistant professor of radiology and physics at the University of Missouri-Kansas City. He has a master’s degree in nuclear and radiological engineering from the University of Tennessee and a doctorate in medical physics from the University of Texas Health Science Center at San Antonio.  He specializes in medical physics and radiation dose reduction, leading “image gently” within Children’s Mercy.

Learn more about Nima Kasraie, PHD

Dr. Michael Smith (Host):  Welcome to Transformational Pediatrics. I'm Dr. Michael Smith. Today our topic is “Image Gently:  Why It Matters.” My guest is Dr. Nima Kasraie. He is a medical physicist at Children's Mercy - Kansas City and an Assistant Professor of Radiology and Physics at the University of Missouri - Kansas City. Dr. Kasraie, welcome to the show. 

Dr. Nima Kasraie (Guest):   Good morning.

Dr. Smith:  What kinds of the changes in imaging have we seen over the years? Are we doing a lot more of these procedures? Are there issues of radiation overexposure? What are the changes you've seen over the years?

Dr. Kasraie:  Certainly. I think since the 1980’s, if you look back, background radiation constituted somewhere around maybe 83% of the total radiation that we received. The rest was medical. Nowadays, I think the last census that came out was 2006, and that percentage is up to 50%. So that means almost 50% of the total radiation that we receive is medical based. So, yes, there has been a drastic increase in the amount of radiation that we’re getting from CT scans and fluoro machines. So, that is a cause for concern. That is one of the reasons why Image Gently stepped forward with their campaign. 

Dr. Smith:  What are some of the issues you worry about when we see this amount of exposure to ionized radiation? What are some of the things that worry you about the increased use of radiology? We know it's done a lot for medicine but there is a drawback to it. What do you worry about with it?

Dr. Kasraie:  Certainly, nobody can deny that imaging has its uses. It's been established how useful imaging is. The thing is that the critical principle is to determine which radiological exams are necessary; when are they necessary; how do we ensure that they are done with the lowest radiation dose? At the place where I work at--Children's Mercy – we’re specifically pediatric. We do only pediatric patients. Those are of particular importance because there is a sensitivity that children have to radiation which adults don't have so that heightens the concern to safeguard our patients from unnecessary radiation that they may receive.

Dr. Smith:  Why is it so important to think of a child so differently from an imaging perspective?

Dr. Kasraie:  First of all, we know that children are two to ten times more sensitive to radiation than adults and that has to do with their cell cycle. There is also the idea that they are younger, so they have a lot more time for any possible detrimental outcomes like cancer to manifest themselves. So, that requires some special consideration when we image them; some tweaking of the CT scan; some particular adjustments have to be made in order to optimize the protocols, so to speak. 

Dr. Smith:  Tell us what you mean, then, by “image gently.” How do you define that?  How is Children's Mercy taking this concept into everyday radiology practice?

Dr. Kasraie:  I think it was a campaign that was started around 2006. I think it was initiated by a group of concerned pediatric radiologists. What they set out to accomplish was to promote education, and promote awareness of potential risks, and to provide education, awareness, and also share decision-making with all the parties that are involved like the patient, families, radiologists, technologists, the physicists—everybody--all the healthcare professionals. To accomplish that, they have what they call “key principles.” There is justification. Their second key principle is optimization and the third one is dose limit. So, these are the three focal points. Justification is, like I mentioned, it focuses on appropriateness. We need to ask ourselves whether the benefits outweigh the risks of performing the imaging tests on the individual patient. That question has to be first answered. Then, there is optimization which is my area where I come in and ensure that radiation protection is optimized. In other words, I focus on ensuring that imaging tests using ionizing radiation are done under optimal conditions. What do I mean by that? These optimal conditions maximize the information gained from the image while they limit the radiation exposure. It's kind of a tricky task. Finding that sweet spot because you want to lower the dose as much as possible but you also want to keep the information inside that image and the information inside intact so you don't lead to any false diagnoses. 

Dr. Smith:  What about with kids specifically, too, the fact that a lot of times in a pediatric population, they are harder to image. They are moving around a lot. There are a lot of repeat shots that have to happen even just for like a chest x-ray. Are there things that we are also doing for the kid like making the exam room more comfortable, different positions? Are we looking into that type of stuff, too?

Dr. Kasraie:  Yes. This thing that you are mentioning particularly surfaces in MRI because those exams are really long. They are like 20 or 30 minutes. In that case, if the patient moves it’s going to cause motion artifacts. But, for x-rays like millisecond long exposures, we don't particularly have that problem. If we do, like for example, some type of exam where it requires a patient immobilized, either they put them to sleep--for example, they might breast feed the patient and they fall asleep--then they put them under the scan. Or, we optimize the technique that speeds up the acquisition so that we minimize these types of problems. 

Dr. Smith:  The Image Gently guidelines that you are discussing, obviously, larger medical centers are able to apply these types of guidelines. What about the small practice? The community hospital? Do you see these types of guidelines being practiced there, too, or is there an opportunity for Children's Mercy to reach out?

Dr. Kasraie:  That's right. It's actually an opportunity. Image Gently actually was, in my opinion, designed for the latter group because, like you're saying, in the pediatric world, all the machines, all the scanners, all the techniques that we use are already designed with the pediatric patient in mind. A lot of these places that you are talking about - hospitals, these places--I think it's still even the case that they use the same protocols that they use for adults for their pediatric patients. So, Image Gently, I think, was actually designed to bring the awareness to these practitioners that if you want to image a small patient, you should make some adjustments to the techniques that you're using. They’re not really too difficult to implement, actually. It's just the awareness. That's the hard part. I think that's what they set out to do. 

Dr. Smith:  Sure. You’re a medical physicist are you seeing more opportunities for people in your profession to work with community hospitals? Are those types of smaller hospitals hiring physicists to help them with their imaging?

Dr. Kasraie: They do. Yes, they do. Usually, large or well established medical centers they hire a full-time physicist. Sometimes there is a team of physicists that work to try and address these issues. A lot of these smaller hospitals or these clinics that you are talking about, they kind of outsource this need. There are physicists that come in on a need-by-need basis. They’re called consultants. They’re actually required to come in once a year to check on the QC’s, to look at the protocols, to do the compliance work. There is state compliance and there is NRC – Nuclear Regulatory Commission. There are a bunch of Federal organizations that are watching over. There’s the Joint Commission. They require that a physicist be involved in watching over the activities of the imaging that is going on in the department.

Dr. Smith:  Dr. Kasraie, I want to thank you for the work that you are doing with the Image Gently guidelines. It is, obviously, very important, as you say, to find that sweet spot so that we get the best out of our image technology with doing the less harm to the patient. Thank you for what you are doing and thanks for coming on the show. You’re listening to Transformational Pediatrics at Children’s Mercy - Kansas City. For more information you can go to That’s I’m Dr. Michael Smith. Thanks for listening.