Local diagnostic reference levels in standard X-ray examinations

The national diagnostic reference levels (NDRLs) form an efficient, concise and powerful standard for optimising radiation protection of a patient. However, in a large hospital, where many radiological departments are present, it is also possible to calculate and define lower dose values as local diagnostic reference levels (LDRLs). In our hospital there are eight radiological departments; in each of these, the entrance skin dose (ESD) distributions were determined for 10 standard projections (AP Abdomen, PA and LAT Chest, AP and LAT Lumbar Spine, LAT Lumbo-Sacral Joint, AP Pelvis, PA and LAT Skull and AP Urinary tract) and then the ESDs were compared with data previously published and with Italian NDRLs. All ESD values were below the corresponding NDRLs. The maximum/minimum ratio of ESDs ranged from 3.9 (LAT Skull) to 34.3 (AP Abdomen) for individual adult patients and from 2.1 (PA Skull) to 6.5 (Urinary tract) across the mean values of the radiological departments. Finally, it is shown how LDRLs can be proposed to obtain a more fully optimised radiation protection of patients.     

Suggested diagnostic reference levels for paediatric X-ray examinations in India

Exposure of children to ionising radiation is considered to carry higher risk than that of adults; therefore a need to suggest diagnostic reference levels (DRLs) for the common paediatric diagnostic X-ray procedures was recognised for the X-ray machines meeting the requirements of the recently implemented Safety Code for Medical Diagnostic X-ray Equipment and Installations in India. Measurements were carried out for entrance surface air kerma (free in air) in conventional paediatric X-ray diagnostic examinations among four age groups: <1, 1-4, 5-9 and 10-15 y. A total of 2240 air kerma measurements at different fixed focus to skin distances were studied for 7 paediatric diagnostic examinations with 11 different projections on 62 X-ray machines installed in 22 selected hospitals in the country. The third quartile values of air kerma per paediatric examination for the age group of 5-9 y were considered as values of paediatric DRLs. The suggested values of DRLs are 0.2 mGy for chest AP/PA, 0.3 mGy for chest LAT, 0.7 mGy for lumber spine AP, 1.3 mGy for lumber spine LAT, 0.3 mGy for thoracic spine AP, 0.6 mGy for thoracic spine LAT, 0.5 mGy for abdomen AP, 0.7 mGy for pelvis AP, 0.6 mGy for skull PA, 0.5 mGy for skull LAT and 0.8 mGy for hip joints AP.     

Comparison of entrance surface doses of some X ray examinations with CEC reference doses

Entrance surface dose (ESD) measurements have been carried out in Nigeria as part of the ongoing dose reduction programme. Thermoluminescence dosemeters (TLD) were used to measure skin entrance doses for four common radiographic views in three hospitals. The mean ESD for the PA chest examination in all the participating hospitals was in the range 0.12 - 4.46 mGy. The mean ESD for the AP skull. PA skull and LAT skull were 8.55, 5.17 and 6.97 mGy respectively. The mean ESD values are greater than the CEC reference doses, except for rooms 1 and 2 in UCH where the entrance surface doses for PA chest examination are below the CEC reference dose. The QA test results show non-compliance of the accuracy of tube voltage with acceptance limit in three rooms. The timer accuracy is also not within the acceptance limit in two rooms. The reproducibility of both the kVp and timer in all the rooms is good.     

Estimation of patient doses for common diagnostic X-ray examinations in Latvian hospitals, analysis of radiographic techniques and comparison with European guidelines

This article deals with the estimation of doses received by patients undergoing radiological examinations in order to establish dose reference levels (DRLs) in Latvia. Several large hospitals, small hospitals and private practices were selected for patient dose measurements. The measurements were carried out using calibrated thermoluminiscence dosemeters attached to the patient's skin. Exposure parameters and patient's data were recorded. The entrance surface doses (ESDs) to patients undergoing several common X-ray examinations (chest AP/PA, chest LAT, lumbar spine AP/PA, lumbar spine LAT and pelvis) were measured. Data concerning the kV(p) settings, used type of films, focus-film distance and the ESD values were analysed and compared with those recommended by the European Community (EC). Among the different hospitals and private practices, discrepancies in the patient doses and techniques used for the examination were found, where the doses exceeded the EC recommended values owing to a very low kV(p) and a very low sensitivity of the screen film combinations used.     

Patient dose measurements in diagnostic radiology procedures in Montenegro

It was the aim of the study presented here to estimate for the first time patient dose levels in conventional diagnostic radiology in Montenegro. Measurements of patient dose in terms of entrance surface air kerma (ESAK) and kerma-area product (KAP) were performed on at least 10 patients for each examination type, in each of five randomly selected health institutions in Montenegro, so that a total of 872 patients for 16 different examination categories were included in the survey (817 patients for 1049 radiographies and 55 fluoroscopy patients). Exposure settings and individual data were recorded for each patient. Mean, median and third quartile values ESAK of patient doses are reported. The estimated mean ESAK values obtained are as follows: 4.7 mGy for pelvis anteroposterior (AP), 4.5 mGy for lumbar spine AP, 7.8 mGy for lumbar spine lateral (LAT), 3.1 mGy for thoracic spine AP and 4.3 mGy for thoracic spine LAT. When compared with the European diagnostic reference values, the mean ESAK for all studied examination types are found to be below the reference levels, except in chest radiography. Mean ESAK values for chest radiography are 0.9 mGy for posteroanterior (PA) projection and 2.0 mGy for LAT. The results exhibit a wide range of variation. For fluoroscopy examinations, the total KAP was measured. The mean KAP value per procedure for barium meal is found to be 22 Gy cm(2), 41 Gy cm(2) for barium enema and 19 Gy cm(2) for intravenous urography. Broad dose ranges for the same types of examinations indicate the necessity of applying practice optimisation in diagnostic radiology and establishment of national diagnostic reference levels.     

An overview of doses to patients and irradiation conditions of diagnostic chest x ray examinations carried out in hospitals of the City of São Paulo,Brazil

Recently the Brazilian health organisation published information conceming the number of hospitals, details of radiological equipment and frequency of medical examinations in the country. The information concerning the city of S?o Paulo is compiled here, complemented by a survey of absorbed doses to patients undergoing the most frequent examination: chest radiographs (postero-anterior (PA) and lateral (LAT) projections), as well as the physical parameters employed (tube voltage, current-time product, focus-film distance, field size). To collect the data, a sample of 12 hospitals (a representative sample of the 199 located in the city) was chosen, totalling 27 X ray machines. An anthropomorphic phantom was irradiated to simulate the patient. Absorbed doses were determined with thermoluminescence dosemeters placed in the phantom, externally and internally. Mean values of entrance surface dose (ESD) for PA and LAT projections were 0.22 mGy (from 0.07 to 0.61 mGy) and 0.98 mGy (from (1.30 to 4.01 mGy), respectively. The average organ doses per complete examination (PA and LAT) were 0.15 and 0.24 mGy to thyroid and lung, respectively. The thyroid was thus in the primary beam in many cases. The large variation in the ESD and organ doses indicates that much can be done in order to reduce the patient doses by adequate changes of physical parameters, without loss of image quality.     

Estimation of doses received by patients undergoing radiological examinations in Greece

This study deals with the estimation of doses received by patients undergoing radiological examinations in order to establish diagnostic reference levels (DRLs) within the process of optimisation of patients' exposure in Greece. Six large hospitals in Athens were selected and 385 patients made up the sample. The entrance surface doses (ESDs) to patients undertaking five common X ray examinations (chest, cervical spine, lumbar spine AP and LAT, pelvis) were estimated using both thermoluminescence dosemeters (TLDs) attached to the patient's skin and an ionisation chamber for air kerma measurements. Exposure settings and patient's data were recorded. Results concerning the kilovoltage and focus-to-film-distance (FFD) settings and the ESD values were analysed and compared to those recommended by the EU. Discrepancies in the patient doses and techniques used for the examinations studied were found among the different hospitals denoting the importance of establishing a national quality assurance programme and examination protocols to ensure patient doses are kept as low as possible. All the examinations studied fulfilled the EU recommendations except that for the chest where the doses were considerably higher due to the use of low kVP settings.     

Entrance surface, organ and effective doses for some of the patients undergoing different types of X ray procedures in Bangladesh

Entrance surface doses (ESDs) were measured for the most common types of X ray procedures, such as chest PA, lumber spine AP, lumber spine lateral, skull AP, skull lateral and pelvis AP in four major hospitals of Dhaka, the capital city of Bangladesh. Organ/tissue doses for 29 organs/tissues and effective doses for the patients were also calculated using the entrance surface dose as the input quantity. Organ/tissue doses and effective doses were calculated by using XDOSE software based on the Monte Carlo computation method. It was observed that the fluctuation of the entrance surface dose was too large. The ratio of maximum and minimum ESD values ranged from 4.8 to 35.9. Consequently, variation of organ doses was large even in the same type of X ray examination and in the same facility. Mean effective doses for the above mentioned X ray procedures were also determined and compared with the effective doses of some other countries. In most cases effective doses measured for the different types of X ray procedures were found to be lower than the effective doses of some other countries.     

Patient dose, image quality and radiographic techniques for common X ray examinations in two Greek hospitals and comparison with European guidelines

The radiographic technique factors and the quality of each radiographic image for three common examinations (chest PA, pelvis AP and lumbar spine LAT) were compared with the European criteria and entrance surface dose (ESD) was measured for each radiograph in two Greek hospitals. The measurements were carried out using calibrated LiF thermoluminescence dosemeters. The patients were selected so that their weight was close to 70 +/- 10 kg and their height to 170 +/- 10 cm. Effective dose values were calculated using a PC-based Monte Carlo program. All four X ray rooms in the survey achieved mean doses well below the European reference doses. However the mean doses in the X ray rooms differed by a factor of about 3.     

Entrance surface dose and image quality: comparison of adult chest and abdominal X-ray examinations in general practitioner clinics, public and private hospitals in Malaysia

This study was undertaken to compare the entrance surface dose(ESD) and image quality of adult chest and abdominal X-ray examinationsconducted at general practitioner (GP) clinics, and public andprivate hospitals in Malaysia. The surveyed facilities wererandomly selected within a given category (28 GP clinics, 20public hospitals and 15 private hospitals). Only departmentalX-ray units were involved in the survey. Chest examinationswere done at all facilities, while only hospitals performedabdominal examinations. This study used the x-ray attenuationphantoms and protocols developed for the Nationwide Evaluationof X-ray Trends (NEXT) survey program in the United States.The ESD was calculated from measurements of exposure and clinicalgeometry. An image quality test tool was used to evaluate thelow-contrast detectability and high-contrast detail performanceunder typical clinical conditions. The median ESD value forthe adult chest X-ray examination was the highest (0.25 mGy)at GP clinics, followed by private hospitals (0.22 mGy) andpublic hospitals (0.17 mGy). The median ESD for the adult abdominalX-ray examination at public hospitals (3.35 mGy) was higherthan that for private hospitals (2.81 mGy). Results of imagequality assessment for the chest X-ray examination show thatall facility types have a similar median spatial resolutionand low-contrast detectability. For the abdominal X-ray examination,public hospitals have a similar median spatial resolution butlarger low-contrast detectability compared with private hospitals.The results of this survey clearly show that there is room forfurther improvement in performing chest and abdominal X-rayexaminations in Malaysia.     

Results of a patient dose survey on diagnostic radiology in Lithuania

One of the most effective means towards optimisation of radiation protection for patients undergoing radiodiagnostic examinations are the diagnostic reference levels. In order to ensure the effective use of these levels, they have to be set properly. National characteristics, such as the conditions of the radiological equipments, the training of the staff, the availability of quality assurance systems, etc., have to be taken into account when these levels are established. Measurements under real conditions were considered as the best tools to achieve these reference levels. With an aim to establish the Lithuanian national diagnostic reference levels, the nationwide survey of entrance surface doses received by the patients during the most typical X-ray examinations has been performed. The most common types of examinations, such as chest PA, skull PA and LAT, abdomen AP, lumbar spine AP and LAT, thorax spine AP and LAT, and hip joint AP, were included in the list of procedures under consideration. Hospitals of different size and levels using different X-ray machines were represented in the survey. The standard thermoluminescence dosemeter techniques with pellets attached to the skin of the patient in the centre of radiation field were applied. The data were analysed statistically, and the averages and 75th percentile were calculated. The results show that the Lithuanian diagnostic reference levels might be rather close to the ones promoted by the International Atomic Energy Agency and the European Commission.     

Local diagnostic reference levels for some common diagnostic X-ray examinations in Tehran county of Iran

Various researchers who have carried out national and international surveys have reported wide variations in patient dose arising from specific X-ray examinations. This study was carried out as a part of a comprehensive project to establish national diagnostic reference level (NDRL), for the first time, in Iran. Seven most common X-ray examinations in 11 projections were included. Thermo luminescence dosimeters (TLD-100) were used to measure entrance surface doses (ESDs). The study group consisted of 535 patients who were referred for X-ray examinations to 12 randomly selected public hospitals in Tehran County. Minimum, median, mean, maximum, first and third quartile values of ESDs are reported. Our results are evident that mean dose values of patients undertaking a specific examination are widely different in various hospitals. Wide dose differences may emerge from complex causes, but in general, low peak kilovoltage and high milli Amperes are associated with higher doses. The results of this work together with further data expected to emerge from the work in progress will provide a useful base to establish Iran's DRLs.     

Radiation doses from some common paediatric X-ray examinations in Sudan

Radiation doses to patients from some common paediatric X-ray examinations were studied in three hospitals in Khartoum state, Sudan. Entrance surface dose (ESD) was determined from exposure settings using DosCal software. Totally, 459 patients were included in this study. Mean ESDs obtained from anteroposterior projection for chest, skull, abdomen and pelvis for neonates falls in the range of 52-100, 115-169, 145-183, 204-242 microGy, respectively. For a 1-y-old infant, mean ESD range was 80-114, 153-202, 204-209, 181-264 microGy, respectively. Some doses for neonates and infants were exceeding the reference doses by >20%. The results highlighted that a good technique has to adhere to guidelines necessarily. As demonstrated elsewhere, patients' doses were high in departments using single-phase generators compared with those using constant potential. The results presented will serve as a baseline data needed for deriving reference doses for paediatric X-ray examinations in Sudan.     

Estimation of radiation doses to patients and surgeons from various fluoroscopically guided orthopaedic surgeries

In this study, a mathematical method was used to estimate the entrance surface dose (ESD) to the patient and the scattered dose (Ds) to the operating surgeon during various fluoroscopically guided surgical orthopaedic procedures. For 204 patients, the procedure type, the fluoroscopy time and the highest tube potential and current values observed during fluoroscopy were recorded. For the most often performed procedures (intramedullary nailing of peritrochanteric fractures, open reduction and internal fixation of malleolar fractures and intramedullary nailing of diaphyseal fractures of the femur), the respective mean fluoroscopy times were 3.2, 1.5 and 6.3 min while the estimated mean ESDs were 183, 21 and 331 mGy, respectively. The estimated Ds rates for the hands, chest, thyroid, eyes, gonads and legs of the operating surgeon were on average to 0.103, 0.023, 0.013, 0.012, 0.066 and 0.045 mGy min(-1), respectively, and compare well with the literature. The mathematical estimation of doses cannot replace actual measurements; however, it can be used for a preliminary assessment of the radiation dose levels during various surgical procedures, so that the operator, the surgeon and the rest of the medical staff involved could be aware of the associated radiation risk and the radiation protection measures required.     

First results on patient dose measurements from conventional diagnostic radiology procedures in Serbia and Montenegro

The objective of this work is to assess patient doses for the most frequent X-ray examinations for the first time in Serbia and Montenegro. A total of 510 procedures for 11 different examination categories in 3 general hospitals were analysed. Mean and median entrance surface air kerma (ESAK) and kerma area product (KAP) values followed by mean effective doses were reported. Using X-ray tube output data, ESAK for each radiographic examination was calculated, as well as the effective dose for each patient. Except for chest PA examination, all estimated doses are less than stated European and International Atomic Energy Agency (IAEA) reference levels for simple radiographic examinations. For complex examinations involving fluoroscopy and radiography total KAP was measured and contributions from fluoroscopy and radiography were assessed. The study of KAP confirms that the dose level for complex fluoroscopy investigations is closely related to the technique and individual patient variation in terms of fluoroscopy time and number of radiography exposures. The obtained values are comparable to those reported in the UK. Survey data are aimed aid development of a national quality control and radiation protection programme for medical exposures.     

Comparison of patient radiation dose from chest and lumbar spine X-ray examinations in 10 hospitals in Ghana

This study estimated the patient dose in chest and lumbar spine radiographic examinations in 10 hospitals in Ghana. Dose estimations were done on 1045 patients (aged, 39.6 ± 10.6 y; range 18-85 y) involving 501 (47.9%) males and 544 (52.1%) females for a total of 1495 individual projections. The entrance surface dose (ESD) for the patients was assessed by an indirect method, using the patient's anatomical data and exposure parameters utilised for the specific examination and a Quality Assurance Dose Database software developed by Integrated Radiological Services Ltd in Liverpool, UK. The study showed variations in the ESDs for chest examinations with five of the hospitals having values above the internationally recommended levels. ESDs for lumbar spine anterior-posterior and lateral projections were within acceptable limits. Diagnostic reference levels proposed by the International Commission on Radiological Protection based on patient dose data are imperative to the current Ghanaian situation and will lead to a reduction of the radiation dose.     

Estimated fluence-to-absorbed dose conversion coefficients for use in radiological protection of embryo and foetus against external exposure to photons from 50 keV to 10 GeV

In the literature, no conversion coefficients are available for use in radiological protection of the embryo and foetus against external exposure to photons. This study used the Monte-Carlo code MCNPX to determine mean absorbed doses to the embryo and foetus when the mother is exposed to external photon fields. Monoenergetic photons ranging from 50 keV to 10 GeV were considered. The irradiation geometries included antero-posterior (AP), postero-anterior (PA), lateral (LAT), rotational (ROT), and isotropic (ISO). At each of these standard irradiation geometries, absorbed doses to the foetal brain and body were calculated for the embryo of 8 weeks and the foetus of 3, 6 or 9 months. Photon fluence-to-absorbed-dose conversion coefficients were estimated for the four prenatal ages.     

Organ and effective dose evaluation in diagnostic radiology based on in-phantom dose measurements with novel photodiode-dosemeters

Organ and the effective doses of patients undergoing clinical X ray examinations of chest and abdomen were evaluated with an anthropomorphic phantom and a new dosimetry system. The system was comprised of 34 pin photodiode dosemeters placed in/on particular tissues or organs of the anthropomorphic phantom, where the tissues and organs are defined by the International Commission on Radiological Protection (ICRP) to estimate the effective doses. Dosemeter signals were acquired on a personal computer directly, and converted into absorbed doses, from which the organ and the effective doses were evaluated on the computer. Our study showed that organ doses ranged from <0.01 to 0.72 mGy in routine X-ray radiography of chest and of abdomen and from 0.07 to 55.91 mGy in routine computed tomography (CT) examinations with current multi-slice CT scanners. The effective dose observed in the chest CT examination was approximately 300 times higher than that in chest radiography.     

The potential for reduction of radiation doses to patients undergoing some common X ray examinations in Tanzania

The potential for patient dose reduction in diagnostic radiology was investigated in five major Tanzanian hospitals. The aim of this study was to follow up previously reported suggestions for improved practices to achieve dose reductions. The suggestions were implemented and entrance surface dose measurement repeated by using well-calibrated LiF thermoluminescence dosemeters. The results show that dose reductions in chest PA X ray examinations ranged from 15% to 50%. For abdomen AP and pelvis AP X ray examinations, the dose reductions ranged from 24% to 73% and from 25% to 72%, respectively. The respective dose reductions for lumbar spine AP and LAT projections ranged from 4% to 58% and from 16% to 77%. Interestingly, the majority of radiographs obtained after the implementation of dose reduction measures were useful for intended diagnosis according to the opinion of radiologists. It is concluded that significant dose reductions can be achieved in the country without loss of diagnostic information. Such dose reductions also predict reductions of radiation risk to patients.