Patient and staff dosimetry problems in interventional radiology

Interventional radiology has developed into a dynamic part of radiology over the past twenty years, combining diagnostic and therapeutic methods. On the other hand, it is associated with high radiation doses to patient and staff, due to extended fluoroscopy times and the large number of radiographs. Also, occupational exposures from interventional radiology procedures have a tendency to be greater than other radiological examinations. The need for measuring and evaluating patient and staff doses is apparent. However, dose estimations depend on a large number of factors making these procedures very complex. The aim of this study is to review all the different approaches that appear in the literature on this matter, to delineate the different dosimetry protocols that are proposed and to focus on the practical problems that arise when an evaluation or comparison of dosimetry results is attempted.     

Intercomparison of active personal dosemeters in interventional radiology

The use of active personal dosemeters (APD) in interventional radiology was evaluated by Working Group 9 (Radiation protection dosimetry of medical staff) of the CONRAD project, which is a Coordination Action supported by the European Commission within its sixth Framework Programme. Interventional radiology procedures can be very complex and they can lead to relatively high doses to personnel who stand close to the primary radiation field and are mostly exposed to radiation scattered by the patient. For the adequate dosimetry of the scattered photons, APDs must be able to respond to low-energy [10-100 keV] and pulsed radiation with relatively high instantaneous dose rates. An intercomparison of five APD models deemed suitable for application in interventional radiology was organised in March 2007. The intercomparison used pulsed and continuous radiation beams, at CEA-LIST (Saclay, France) and IRSN (Fontenay-aux-Roses, France), respectively. A specific configuration, close to the clinical practice, was considered. The reference dose, in terms of H(p)(10), was derived from air kerma measurements and from the measured and calculated energy distributions of the scattered radiation field. Additional Monte Carlo calculations were performed to investigate the energy spectra for different experimental conditions of the intercomparison. The results of this intercomparison are presented in this work and indicate which APDs are able to provide a correct response when used in the specific low-energy spectra and dose rates of pulsed X-rays encountered in interventional radiology.     

Induction of chromosome aberration in human lymphocytes and its dependence on X ray energy

The variations of dose response with X ray energy observed with the human lymphocyte dicentric assay is examined. In order to determine reliably the initial slopes (RBEm) many cells need to be analysed at low doses. Insufficient analysis may explain some reported interlaboratory differences in fitted dose-response coefficients. One such discrepancy at 150 kVp, E = 70 keV is examined. Data are also presented for an X ray spectrum of 80 kVp, E = 58 keV. Over the photon energy range 20 keV X rays to 1.25 MeV gamma rays RBEm varies by about a factor of 5, with the lower energies being more effective. This is consistent with microdosimetric theory. By contrast, in radiological protection a radiation weighting factor of 1.0 is assumed for all photons when assessing the risk of inducing cancer at low doses. The measured variations of biological effect with photon energy have led to suggestions that the lower energies, as used for some diagnostic radiology, carry a greater risk per unit dose than is normally assumed by those involved in radiological protection. Interpretation of the data reported in this paper does not support this view.     

Assessment of medical occupational radiation doses in Costa Rica

Participation of the University of Costa Rica (UCR) in activities in an IAEA Regional Project RLA/9/066 through training, equipment and expert missions, has enabled to setting up of a national personal monitoring laboratory. Since 2007, the UCR has been in charge of monitoring around 1800 medical radiation workers of the Social Security System. Individual external doses are measured with thermoluminescent dosemeter using a Harshaw 6600 Plus reader. The service has accreditation with ISO/IEC 17025:2005. Distribution of monitored medical personnel is as follows: 83 % in diagnostic radiology, 6 % in nuclear medicine and 6 % in radiotherapy. Preliminary values for the 75 percentile of annual H(p)(10) in mSv are: radiology 0.37; interventional radiology 0.41; radiotherapy 0.53 and nuclear medicine 1.55. The service provided by the UCR in a steady and reliable way can help to implement actions to limit the doses received by the medical workers and optimise their radiation protection programs.     

Training and accreditation in radiation protection for interventional radiology

Training in radiation protection is a basic aspect of the optimisation of medical exposures. Council Directive 97/43/EURATOM establishes the need for an adequate theoretical and practical training of the staff working in radiological practices, and competence in radiation, for which Member States shall ensure the establishment of appropriate curricula. Keeping in mind the different specialities and professional responsibilities, training curricula must be proposed and endorsed to achieve a common core of knowledge in radiation protection throughout Europe, for different groups of health workers. In interventional radiology, previous initiatives led to the definition of a syllabus of educational objectives and to its testing in a specific course. The present paper presents educational objectives for interventional radiology, developed in the framework of the DIMOND European concerted action.     

Personal dose monitoring in hospitals: global assessment, critical applications and future needs

It is known that medical applications using ionising radiation are wide spread and still increasing. Physicians, technicians, nurses and others constitute the largest group of workers occupationally exposed to man-made sources of radiation. Many hospital workers are consequently subjected to routine monitoring of professional radiation exposures. in the university hospital, UZ Brussel, 600 out of 4000 staff members are daily monitored for external radiation exposures. The most obvious applications of ionising radiation are diagnostic radiology, diagnostic or therapeutic use of radionuclides in nuclear medicine and external radiation therapy or brachytherapy in radiotherapy departments. Other important applications also include various procedures in interventional radiology (IR), in vitro biomedical research and radiopharmaceutical production around cyclotrons. Besides the fact that many of the staff members, involved in these applications, are not measurably exposed, detailed studies were carried out at workplaces where routine dose monitoring encounters difficulties and for some applications where relatively high occupational exposures can be found. most of the studies are concentrated around nuclear medicine applications and IR. They contain assessments of both effective dose and doses at different parts of the body. The results contribute to better characterisation of the different workplaces in a way that critical applications can be identified. Moreover, conclusions point out future needs for practical routine dose monitoring and optimisation of radiation protection.     

Dose quantities in radiation protection and their limitations

For more than 50 years the quantity absorbed dose has been the basic physical quantity in the medical applications of ionising radiation as well as radiological protection against harm from ionising radiation. In radiotherapy relatively high doses are applied (to a part of the human body) within a short period and the absorbed dose is mainly correlated with deterministic effects such as cell killing and tissue damage. In contrast, in radiological protection one is dealing with low doses and low dose rates and long-term stochastic effects in tissue such as cancer induction. The dose quantity (absorbed dose) is considered to be correlated with the probability of cancer incidence and thus risk induced by exposure. ICRP has developed specific dosimetric quantities for radiological protection that allow the extent of exposure to ionising radiation from whole and partial body external radiation as well as from intakes of radionuclides to be taken into account by one quantity. Moreover, radiological protection quantities are designed to provide a correlation with risk of radiation induced cancer. In addition, operational dose quantities have been defined for use in measurements of external radiation exposure and practical applications. The paper describes the concept and considerations underlying the actual system of dose quantities, and discusses the advantage as well as the limitations of applicability of such a system. For example, absorbed dose is a non-stochastic quantity defined at any point in matter. All dose quantities in use are based on an averaging procedure. Stochastic effects and microscopic biological and energy deposition structures are not considered in the definition. Absorbed dose is correlated to the initial very short phase of the radiation interaction with tissue while the radiation induced biological reactions of the tissue may last for minutes or hours or even longer. There are many parameters other than absorbed dose that influence the process of cancer induction, which may influence the consideration of cells and/or tissues at risk which are most important for radiological protection.     

Occupational exposure doses in interventional procedures in Bosnia and Herzegovina

Monitoring of occupationally exposed workers in Bosnia and Herzegovina started in 1960s and it was interrupted in 1992. Dosimetry service resumed in 1999 when the International Atomic Energy Agency provided Radiation Protection Centre with Harshaw 4500 Thermoluminescence dosemeter (TLD)-reader and the first set of TLDs. The highest doses are received by professionals working in interventional procedures (radiology, cardiology, gastroenterohepatology etc.). Number of these procedures is increasing each year (just in cardiology this increase is 24 % per year). Results from two TLDs are used to estimate effective dose. One is worn under the apron (chest level), and the other above (neck level). Calculation is performed using Niklason's methodology. Total number of occupationally exposed persons in interventional radiology is 90. The collective dose they receive is 67 person mSv, while the mean dose is 0.77 mSv (based on 12-month period). Highest doses are received by physicians (3.7 mSv), while radiographers and nurses receive 2.1 and 1.9 mSv respectively. This occurs due to the fact that physicians stand closer to the source (patient). The lead apron is proven to be the most efficient radiation protection equipment, but, also, lead thyroid shield and glasses can significantly lower doses received by professionals. The use of this equipment is highly recommended.     

Transition in occupational radiation exposure monitoring methods in diagnostic and interventional radiology

Radiation exposure monitoring is a traditional keystone of occupational radiation safety measures in medical imaging. The aim of this study was to review the data on occupational exposures in a large central university hospital radiology organisation and propose changes in the radiation worker categories and methods of exposure monitoring. An additional objective was to evaluate the development of electronic personal dosimeters and their potential in the digitised radiology environment. The personal equivalent dose of 267 radiation workers (116 radiologists and 151 radiographers) was monitored using personal dosimeters during the years 2006-2010. Accumulated exposure monitoring results exceeding the registration threshold were observed in the personal dosimeters of 73 workers (59 radiologists' doses ranged from 0.1 to 45.1 mSv; 14 radiographers' doses ranged from 0.1 to 1.3 mSv). The accumulated personal equivalent doses are generally very small, only a few angiography radiologists have doses >10 mSv per 5 y. The typical effective doses are <10 μSv y(-1) and the highest value was 0.3 mSv (single interventional radiologist). A revised categorisation of radiation workers based on the working profile of the radiologist and observed accumulated doses is justified. Occupational monitoring can be implemented mostly with group dosimeters. An active real-time dosimetry system is warranted to support radiation protection strategy where optimisation aspects, including improving working methods, are essential.     

Why can't we find a better biological indicator of dose?

The three general principles of the International Commission on Radiological Protection (ICRP) are: justification, optimisation (ALARA) and dose limitation. The principle application of optimisation (ALARA) for occupational exposures of workers or the public to external radiation is reliant on low doses being assessed accurately, which could be achieved using biological dosimetry. Although cytogenetic analyses for dicentrics and translocations are the most useful techniques for biological dosimetry, these were initially developed for and have been applied to middle and high range dose exposures; the range where deterministic injury is possible. Application of these techniques for biomonitoring or screening of relatively large groups of low exposed people is possible but limited as chromosome analysis is time-consuming and requires highly skilled personnel. In addition, some technical considerations constrain dose estimation in the low dose range. This paper considers the advantages of cytogenetic techniques for biodosimetry and also highlights their limitation at low doses. However, optimisation of low dose assessment could be obtained by improvement in the technique perhaps in combination with other approaches that consider variations in individual sensitivity. Developments in modern molecular biology have brought new approaches into prospect but so far they are not routinely applicable. The potential use and throughput of these new technologies is discussed.     

Retrospective study of the iodine-131 contamination of workers in the radiopharmaceutical industry

A dose reconstruction study was performed for personnel occupationally exposed to 131I in radiopharmaceutical production, during the years 1981 to 1994, with the objective of estimating committed effective doses and critically reviewing the main causes of their exposures. The workers were selected from a group responsible for the production, labelling and distribution of all radiopharmaceutical material in Brazil. Best estimates of intakes and doses were derived from the examination of the individual monitoring records and the reports from the radiation protection supervisor, complemented by interviews with the workers and with radiation protection officers. Over this time period workers had chronic as well as acute intakes of 131I. Committed effective doses were found to be dependent on the task performed by the worker and the site of operation and inversely correlated with the amounts of iodine handled. Intakes in general were a consequence of inadequate radiation protection control.     

An assessment of annual whole-body occupational radiation exposure in Ireland (1996-2005)

Whole-body occupational exposure to artificial radiation sources in Ireland for the years 1996-2005 has been reviewed. Dose data have been extracted from the database of the Radiological Protection Institute of Ireland, which contains data on >95% of monitored workers. The data have been divided into three sectors: medical, industrial and education/research. Data on exposure to radon in underground mines and show caves for the years 2001-05 are also presented. There has been a continuous increase in the number of exposed workers from 5980 in 1996 to 9892 in 2005. Over the same time period, the number of exposed workers receiving measurable doses has decreased from 676 in 1996 to 189 in 2005 and the collective dose has also decreased from 227.1 to 110.3 man millisievert (man mSv). The collective dose to workers in the medical sector has consistently declined over the 10-y period of the study while that attributable to the industrial sector has remained reasonably static. In the education/research sector, the collective dose typically represents 5% or less of the total collective dose from all practices. Over the 10 y of the study, a total of 77 914 annual dose records have been accumulated, but only 4040 (<6%) of these represent measurable radiation doses in any given year. Over the same time period, there were 283 instances in which exposed workers received individual annual doses >1 mSv and 21 of these exceeded 5 mSv. Most of the doses >1 mSv were received by individuals working in diagnostic radiology (which also includes interventional radiology) in hospitals and site industrial radiography. There has been only one instance of a dose above the annual dose limit of 20 mSv. Evaluating the data for the period 2001-05 separately, the average annual collective dose from the medical, industrial and educational/research sectors are approximately 60, 70 and 2 man mSv with the average dose per exposed worker who received a measurable dose being 0.32, 0.79 and 0.24 mSv, respectively. Diagnostic radiology and site industrial radiography each represents >60% of the collective dose in their respective sectors. Available data on radon exposure in one underground mine and in three show caves indicate an annual collective dose of 75 man mSv from these work activities. By comparison, previous estimates of exposure of Irish air crew to cosmic radiation have given rise to an estimated collective dose of 12 000 man mSv. It can be concluded therefore that the natural radioactivity sources account for well >90% of all occupational exposure in Ireland. This evaluation does not include an estimate of exposure to radon in above-ground workplaces-these data are currently being evaluated and their inclusion will increase both the total occupational collective dose as well as the percentage of that dose due to natural radiation.     

The design of Radiation Accident Registry

In order to provide effective monitoring and follow-up on the health effects of individuals accidentally exposed to ionising radiation, a Radiation Accident Registry (RAR) has been designed and constructed as an extension to the existing National Dose Registry (NDR). The RAR has basic functions of recording, monitoring and reporting. This type of registry is able to assist responders in preparing for and managing situations during radiological events and in providing effective follow-up on the long-term health effects of persons exposed to ionising radiation. It is especially important to register radiation-exposed people in vulnerable population groups, such as children and pregnant women, to ensure proper long-term health care and protection. Even though radiation accidents are rare, a registry prepared for such accidents could involve a large population and, in some cases, require lifetime monitoring for individuals. One of the most challenging tasks associated with RAR is the assessment of radiation dose resulting from accidents. In some cases, the assessment of radiation doses to individuals could be a process requiring the involvement of various methods. The development of fast and accurate dose assessment tools will remain a long-term challenge associated with the RAR. To meet this challenge, further research activities in radiation dosimetry for individual monitoring are needed.     

Determination of ambient and personal dose equivalent for personnel and cargo security screening

In the past few years, imaging technology using ionising radiation has been gaining in importance for the screening of goods and persons for security reasons and in order to detect contraband. For radiation protection purposes it is extremely important to know that dose persons are exposed to when passing through a personnel scanner or, as a stowaway, in a cargo scanner, so as to remain within the prescribed dose limits. Within the scope of a research project, measurements were performed on different types of personnel X-ray scanners as well as cargo X-ray scanners, using the transmission and/or the backscattering method. All scanners investigated operate with a high dose rate and use short irradiation time. Owing to this method of scanning reliable values can only be determined for the personal and ambient dose equivalents, H(p)(10) and H(*)(10), by using a specially developed measuring system. The aim of this project was to determine the range of magnitudes of doses for representative personnel and cargo X-ray scanner systems. Depending on the type of scanner, the determined dose values for personnel scanners range from 0.07 microSv to 6 microSv. Measurements and instruments used in this study are described and the dose values obtained are discussed in detail.     

IRSN methodological guide to conducting workplace studies in compliance with French regulations

Under French regulations governing radiation protection of workers, dosimetric workplace studies are mandatory. However, their practical implementation is not described. IRSN has developed a guide to help stakeholders in the radiological protection of workers conduct such studies. It proposes a general methodology applicable to most cases and 'workplace sheets', which apply this methodology to specific occupational settings. At present, two sheets are available: conventional radiology and interventional radiology.     

Patient exposure in medical X-ray imaging in Europe

Patients are exposed to X rays when undergoing medical examinations in diagnostic radiology. Exposure data acquired and assessed in Germany for the year 1997 resulted in a mean annual effective dose of 2 +/- 0.5 mSv per head of the population, thereby reaching or exceeding the average level of environmental radiation in many cases. The underlying frequency of medical X-ray examinations was approximately 136 million, i.e. approximately 1.7 examinations annually per head of the population. For comparison, corresponding data of other countries were extracted from the UNSCEAR 2000 report or originate from the literature. Data analysis shows significant differences in national radiological practices and a very uneven distribution of patient doses amongst the world population. The mean annual effective dose per head of the population varies by up to a factor of 60 between health care level I and IV countries, and still by a factor of approximately 6 within health care level I countries. While projection radiography has succeeded in reducing dose consumption, computed tomography and radiological interventions have given rise to a significant growth of patient exposure, and interventional radiology can even exceed thresholds for deterministic radiation effects. Patient exposure is further shown to result from misadministration and retakes of X-ray examinations, usually not registered, as well as from technical failures of X-ray facilities, which can cause significantly enhanced exposure times. Corresponding data are presented and comments are made on the international situation of non-harmonised data collection on patient exposure as well as of parameters affecting the assessment of exposure and risk.     

ICRP special radiation protection issues in interventional radiology, digital and cardiac imaging

The International Commission on Radiological Protection (ICRP) has published two reports giving recommendations dealing with the avoidance of deterministic injuries in interventional radiology and the management of patient dose in digital radiology in 2001 and 2004, respectively. Another document, on radiation protection for cardiologists performing fluoroscopically guided procedures, will be produced during 2005. This paper highlights some of the topics of the published reports, their relevance to European legislation on medical exposures and the importance of radiation protection research in underpinning the ICRP task groups' work in to producing these documents. It is also anticipated that the results, obtained in the cardiology work package of the European research project, will be used in the new document on radiation protection for cardiologists.     

Occupational exposure in Greek industrial radiography laboratories (1996-2003)

More than 40 industrial radiography laboratories are operating in Greece using X-ray or gamma-ray sources and more than 250 workers occupationally exposed to ionising radiation in these facilities are monitored on a regular basis. This study presents the evolution of individual doses received by radiographers during the past years. The mean annual dose (MAD) of all workers as well as of exposed workers is estimated, and correlated to the types of laboratories and practices applied. The MAD of the exposed workers in industrial radiography is compared with the doses of workers in other specialties and with the doses of radiographers in other countries. Furthermore, the study attempts to propose dose constraints for the practices in industrial radiography, according to the BSS European directive and the relevant Greek radiation protection legislation. The proposed value was defined as the dose below which the annual doses of 75% of the exposed radiographers are expected to be included.     

An overview of the use of extremity dosemeters in some European countries for medical applications

Some medical applications are associated with high doses to the extremities of the staff exposed to ionising radiation. At workplaces in nuclear medicine, interventional radiology, interventional cardiology and brachytherapy, extremities can be the limiting organs as far as regulatory dose limits for workers are concerned. However, although the need for routine extremity monitoring is clear for these applications, no data about the status of routine extremity monitoring reported by different countries was collected and analysed so far, at least at a European level. In this article, data collected from seven European countries are presented. They are compared with extremity doses extracted from dedicated studies published in the literature which were reviewed in a previous publication. The analysis shows that dedicated studies lead to extremity doses significantly higher than the reported doses, suggesting that either the most exposed workers are not monitored, or the dosemeters are not routinely worn or not worn at appropriate positions.     

Personnel doses in haemodynamic units in Greece

Personnel of haemodynamic and interventional radiology units receive continuously increasing radiation doses due to extended fluoroscopy. Moreover, there is not a parallel increase in the number of cardiology specialists involved. Doses received by 15 cardiologists and 5 nurses, in 5 Athenian hospitals were measured using thermoluminescence dosemeters (TLD) and film badges. The workload and examination protocol of each cardiologist, the technical characteristics of the X ray unit, as well as availability and use of protective equipment were recorded. Results show that doses measured by TLD and film badges differ due mainly to the irregular wear of the latter. Although X ray units performed comparably with each other, dose per procedure received by each cardiologist varied widely, due to differences in examination protocol and beam collimation used. In all cases, nurses' dose was approximately one fourth of cardiologists' dose. In half of the cases assessed, the protective equipment available was not in full use. Estimation of dose per procedure, taking into account personnel's workload assesses annual personnel doses. Evaluation of risk level and check of compliance with regulatory dose limits should be part of continuing radiation protection education.