Risk for radiation-induced cataract for staff in interventional cardiology: is there reason for concern?

Orthopaedic Surgeon Brain Radiation During Fluoroscopy: A Cadaver Model

BACKGROUND

The aims of this study were to quantify exposure of the surgeon's brain to radiation during short cephalomedullary (SC) nailing, to extrapolate lifetime dose, and to determine the effects of personal protective equipment (PPE) on brain dose.

METHODS

Two cadaveric specimens were used: (1) a whole cadaveric body representing the patient, with a left nail inserted to act as the scatter medium, and (2) an isolated head-and-neck cadaveric specimen representing a surgeon, with radiation dosimeters placed in specific locations in the brain. The "patient" cadaver's left hip was exposed in posteroanterior and lateral radiographic planes. Measurements were performed without shielding of the head-and-neck specimen and then repeated sequentially with different PPE configurations. An average surgeon career was estimated to be 40 years (ages 25 to 65 years) with the caseload obtained from the department's billing data.

RESULTS

The mean radiation dose to the surgeon brain without PPE was 3.35 µGy (95% confidence interval [CI]: 2.4 to 4.3) per nail procedure. This was significantly reduced with use of a thyroid collar (2.94 µGy [95% CI: 1.91 to 3.91], p = 0.04). Compared with use of the thyroid collar in isolation, there was no significant additional reduction in radiation when the collar was used with leaded glasses (2.96 µGy [95% CI: 2.15 to 3.76], p = 0.97), with a lead cap (3.22 µGy [95% CI: 2.31 to 4.13], p = 0.55), or with both (2.31 µGy [95% CI: 1.61 to 3.01], p = 0.15). The extrapolated lifetime dose over 40 working years for SC nailing without PPE was 2,146 µGy (95% CI: 1,539 to 2,753), with an effective dose of 21.5 µSv.

CONCLUSIONS

The extrapolated cumulative lifetime radiation to a surgeon's brain from SC nailing based on our institution's workload and technology is low and comparable with radiation during a one-way flight from London to New York. Of note, we studied only one of many fluoroscopy-aided procedures and likely underestimated total lifetime exposure if exposures from other procedures are included. This study also demonstrates that thyroid collars significantly reduce brain dose for this procedure whereas other head/neck PPE such as lead caps appear to have minimal additional effect. This study provides a methodology for future studies to quantify brain dose for other common orthopaedic procedures.

CLINICAL RELEVANCE

This study, based on our institutional data, demonstrates that although the lifetime brain dose from SC nailing is low, thyroid collars significantly reduce this dose further. As such, in accordance with the "as low as reasonably achievable" radiation exposure principle, radiation safety programs and individual surgeons should consider use of thyroid collars in this setting.

Fluoroscopically-guided interventions with radiation doses exceeding 5000 mGy reference point air kerma: a dosimetric analysis of 89,549 interventional radiology, neurointerventional radiology, vascular surgery, and neurosurgery encounters

PURPOSE

To quantify and categorize fluoroscopically-guided procedures with radiation doses exceeding 5000 mGy reference point air kerma (Ka,r). Ka,r > 5000 mGy has been defined as a "significant radiation dose" by the Society of Interventional Radiology. Identification and analysis of interventions with high radiation doses has the potential to reduce radiation-induced injuries.

MATERIALS AND METHODS

Radiation dose data from a dose monitoring system for 19 interventional suites and 89,549 consecutive patient encounters from January 1, 2013 to August 1, 2019 at a single academic institution were reviewed. All patient encounters with Ka,r > 5000 mGy were included. All other encounters were excluded (n = 89,289). Patient demographics, medical specialty, intervention type, fluoroscopy time (minutes), dose area product (mGy·cm2), and Ka,r (mGy) were evaluated.

RESULTS

There were 260 (0.3%) fluoroscopically-guided procedures with Ka,r > 5000 mGy. Of the 260 procedures which exceeded 5000 mGy, neurosurgery performed 81 (30.5%) procedures, followed by interventional radiology (n = 75; 28.2%), neurointerventional radiology (n = 55; 20.7%), and vascular surgery (n = 49; 18.4%). The procedures associated with the highest Ka,r were venous stent reconstruction performed by interventional radiology, arteriovenous malformation embolization performed by neurointerventional radiology, spinal hardware fixation by neurosurgery, and arterial interventions performed by vascular surgery. Neurointerventional radiology had the highest mean Ka,r (7,799 mGy), followed by neurosurgery (7452 mGy), vascular surgery (6849 mGy), and interventional radiology (6109 mGy). The mean Ka,r for interventional radiology performed procedures exceeding 5000 mGy was significantly lower than that for neurointerventional radiology, neurosurgery, and vascular surgery.

CONCLUSIONS

Fluoroscopically-guided procedures with radiation dose exceeding 5000 mGy reference point air kerma are uncommon. The results of this study demonstrate that a large proportion of cases exceeding 5000 mGy were performed by non-radiologists, who likely do not receive the same training in radiation physics, radiation biology, and dose reduction techniques as radiologists.

Risk of cataract in health care workers exposed to ionizing radiation: a systematic review

Background:

The eye is an important sensory organ occupationally exposed to ionizing radiation (IR) in healthcare workers (HCWs) engaged in medical imaging (MI). New evidence highlights the possible induction of cataract at IR exposure levels to be much lower than expected in the past.

Objective:

Conduct an updated review on the current evidence on cataract risk in healthcare workers exposed to IR.

Methods:

Published scientific studies on cataract risk in IR exposed healthcare workers were collected through a systematic search of two biomedical databases (MEDLINE and Scopus). Data from included studies was extracted and summarized. Study quality was also assessed.

Results:

All 21 eligible studies reported an increased prevalence of cataract, especially posterior subcapsular cataract, in IR exposed HCWs with a higher prevalence in interventional cardiology staff.

Discussion:

Our review synthesizes the latest evidence to support the hypothesis of a significantly increased risk of occupational cataract in healthcare workers operating MI and exposed to IR, especially in interventional cardiologists. Data also support a dose-response relationship between IR exposure and the prevalence of opacities, especially posterior subcapsular opacities.

Conclusions:

Findings highlight the need for effective control measures including appropriate training, adherence to protective procedures, and a constant use of shields and eye personal protective equipment in healthcare workers with optical exposure to IR. Periodic health surveillance programs, possibly including lens evaluation, are also important to monitor cataract risk in these MI operators.

The association between exposure to radiation and the incidence of cataract

OBJECTIVE

To examine the association between exposure to radiation from computed tomography (CT) studies and the incidence of cataract.

METHODS

In a nested case-control study, all cataract cases and their matched controls were sampled from a retrospective cohort of Israeli residents who underwent CT scans or ultrasonic tests in Soroka Medical Center, Beer-Sheva, Israel, between the years 1996 and 2014. The risk of cataract associated with head, neck or the rest of the body CT was assessed using Poisson survival analysis.

RESULTS

The nested matched sample included 3841 cataract cases and their age- and sex-matched controls (n = 228,743). CT radiation exposure was more frequent in the cataract group, with 9.7% head CT, 1.2% neck CT and 6.6% other CT, compared to 5%, 0.7% and 3.7% among person-years without cataract (p < 0.001). In a multivariate analysis, a similar increased risk of cataract associated with head (hazard ratio (HR): 1.24, 95% confidence interval (CI): 1.11; 1.38) and other CT (HR: 1.25, 95% CI: 1.10; 1.43) was found. No association with neck CT (HR: 1.07, 95% CI: 0.80; 1.43) was observed.

CONCLUSION

In our study population, a similar risk of cataract with head, neck or the rest of the body CT was detected.

Calibration of the LiF - thermoluminescent detectors used for personal dose equivalent Hp(3) assessment

AIMS

The issue of exposure of eye lenses of employees exposed to ionizing radiation is an interesting topic not only from the point of view of deterministic effects related to the occurrence of cataracts, but also dosimetric aspects, in particular the calibration of detectors in units enabling the assessment of eye lens exposure or personal dose equivalent Hp(3). The paper presents the idea of calibrating thermoluminescent detectors designed for the Hp(3) values measurement of gamma radiation, which the source is the process of annihilation of positrons emitted by the deoxyglucose marker - 18F radionuclide.

METHODS

The method was based on the value of air kerma Ka to Hp(3) conversion coefficients (Hp(3,0°)/Ka) developed as part of the ORAMED project. High-sensitivity thermoluminescent detectors (MCP-N) produced in Poland were used in the measurements. During the exposure of the detectors, a 137Cs gamma radiation source (irradiator 137Cs/60Co) and a 20cm diameter cylinder filled with water were used.

RESULTS & CONCLUSIONS

The value of conversion coefficient Hp(3,0°)/Ka for energy 511 keV is 1.31Sv/Gy and the calibration factor is (3.46±0.03)·10-4 mSv/N (N - number of counts). Verification of the value of the obtained coefficient carried out using a cylinder with a diameter of 20cm showed a difference of less than 2% in relation to the value obtained by the method described in this paper.

Rogue cell-like chromosomal aberrations in peripheral blood lymphocytes of interventional radiologists: A case study

We report two cases of interventional radiologists who had been exposed to radiation while performing fluoroscopically-guided interventional procedures (FGIPs), mainly transcatheter arterial chemoembolization, percutaneous catheter drainage, and percutaneous transhepatic biliary drainage procedures, for over 10 years. They had a unique multi-aberrant cell type with not only high numbers of dicentrics and/or centric rings but also excess acentric double minutes, similar to a rogue cell. As revealed in a self-administered questionnaire, they wore personal dosimeters and protective equipment at all times and used shielding devices during interventional fluoroscopy procedures. However, the exposed dose levels derived from cytogenetic dosimetry were much higher than the doses recorded on their personal dosimeters. A large number of unstable and stable chromosomal aberrations that were found in the peripheral blood lymphocytes of these interventional radiologists might be due to repeated and long-term exposure to ionizing radiation while performing FGIPs. Further investigations of chromosomal aberrations in interventional radiologists may improve the understanding of the long-term effects of radiation exposure on medical personnel.

A study of the underestimation of eye lens dose with current eye dosemeters for interventional clinicians wearing lead glasses

The reduction in the occupational dose limit of the eye lens has created the need for optimising eye protection and dose assessment, in particular for interventional clinicians. Lead glasses are one of the protection tools for shielding the eyes, but assessing the eye lens dose when these are in place remains challenging. In this study, we evaluated the impact of the position of H _p (3) dosemeters on the estimated eye lens dose when lead glasses are used in interventional settings. Using the Monte Carlo method (MCNPX), an interventional cardiology setup was simulated for two models of lead glasses, five beam projections and two patient access routes. H _p (3) dosemeters were placed at several positions on the operator and the obtained dose was compared to the dose to the sensitive part of the eye lens (H _lens). Furthermore, to reproduce an experimental setup, a reference dosemeter, H _p (3)_ref, was placed on the surface of the eye. The dose measured by H _p (3)_ref was, on average, only 60% of H _lens. Dosemeters placed on the glasses, under their shielding, underestimated H _lens for all parameters considered, by from 10% up to 90%. Conversely, dosemeters placed on the head or on the glasses, over their shielding, overestimated H _lens, on average, up to 60%. The presence or lack of side shielding in lead glasses affected mostly dosemeters placed on the forehead, at the left side. Results suggest that both use of a correction factor of 0.5 to account for the presence of lead glasses in doses measured outside their shielding and placing an eye lens dosemeter immediately beneath the lenses of lead glasses may lead to the underestimation of the eye lens dose. Most suitable positions for eye lens dose assessment were on the skin, unshielded by the glasses or close to the eye, with no correction to the dose measured.

Strategies to Reduce Radiation Exposure in Electrophysiology and Interventional Cardiology

Clinical diagnosis sometimes involves the use of medical instruments that employ ionizing radiation. However, ionizing radiation exposure is a workplace hazard that goes undetected and is detrimental to patients and staff in the catheterization laboratory. Every possible effort should be made to reduce the amount of radiation, including scattered radiation. Implementing radiation dose feedback may have a role in reducing exposure. In medicine, it is important to estimate the potential biologic effects on, and the risk to, an individual. In general, implantation of cardiac resynchronization devices is associated with one of the highest operator exposure doses due to the proximity of the operator to the radiation source. All physicians should work on the principle of as low as reasonably achievable. Methods for reducing radiation exposure must be implemented in the catheterization laboratory. In this article, we review the available tools to lower the radiation exposure dose to the operator during diagnostic, interventional, and electrophysiological cardiac procedures.

The use of intracardiac echocardiography catheters in endocardial ablation of cardiac arrhythmia: Meta-analysis of efficiency, effectiveness, and safety outcomes

Aims

The optimal use of intracardiac echocardiography (ICE) may reduce fluoroscopy time and procedural complications during endocardial ablation of cardiac arrhythmias. Due to limited evidence in this area, we conducted the first systematic literature review and meta‐analysis to evaluate outcomes associated with the use of ICE.

Methods and Results

Studies reporting the use of ICE during ablation procedures vs without ICE were searched using PubMed/MEDLINE. A meta‐analysis was performed on the 19 studies (2186 patients) meeting inclusion criteria, collectively representing a broad range of arrhythmia mechanisms. Use of ICE was associated with significant reductions in fluoroscopy time (Hedges' g −1.06; 95% confidence interval [CI] −1.81 to −0.32; P < .01), fluoroscopy dose (Hedges' g −1.27; 95% CI −1.91 to −0.62; P < .01), and procedure time (Hedges' g −0.35; 95% CI −0.64 to −0.05; P = .02) vs ablation without ICE. A 6.95 minute reduction in fluoroscopy time and a 15.2 minute reduction in procedure time was observed between the ICE vs non‐ICE groups. These efficiency gains were not associated with any decreased effectiveness or safety. Sensitivity analyses limiting studies to an atrial fibrillation (AF) only population yielded similar results to the main analysis.

Conclusion

The use of ICE in the ablation of cardiac arrhythmias is associated with significantly lower fluoroscopy time, fluoroscopy dose, and shorter procedure time vs ablation without ICE. These efficiency improvements did not compromise the clinical effectiveness or safety of the procedure.

Radiation exposure to the eyes and thyroid during C-arm fluoroscopy-guided cervical epidural injections is far below the safety limit

Background

The aim of this study was to evaluate radiation exposure to the eye and thyroid in pain physicians during the fluoroscopy-guided cervical epidural block (CEB).

Methods

Two pain physicians (a fellow and a professor) who regularly performed C-arm fluoroscopy-guided CEBs were included. Seven dosimeters were used to measure radiation exposure, five of which were placed on the physician (forehead, inside and outside of the thyroid protector, and inside and outside of the lead apron) and two were used as controls. Patient age, sex, height, and weight were noted, as were radiation exposure time, absorbed radiation dose, and distance from the X-ray field center to the physician.

Results

One hundred CEB procedures using C-arm fluoroscopy were performed on comparable patients. Only the distance from the X-ray field center to the physician was significantly different between the two physicians (fellow: 37.5 ± 2.1 cm, professor: 41.2 ± 3.6 cm, P = 0.03). The use of lead-based protection effectively decreased the absorbed radiation dose by up to 35%.

Conclusions

Although there was no difference in radiation exposure between the professor and the fellow, there was a difference in the distance from the X-ray field during the CEBs. Further, radiation exposure can be minimized if proper protection (thyroid protector, leaded apron, and eyewear) is used, even if the distance between the X-ray beam and the pain physician is small. Damage from frequent, low-dose radiation exposure is not yet fully understood. Therefore, safety measures, including lead-based protection, should always be enforced.

Assessment of the Annual Eye Lens Dose for Cardiologists During Interventional Procedures Using Anthropomorphic Phantoms and mEyeDose_X Tool

OBJECTIVES

In this study, eye lens dose measurements were performed using two anthropomorphic phantoms simulating the cardiologist and patient during interventional procedures.

BACKGROUND

Interventional procedures known as areas with high potential risk and the cardiologists can receive relatively high doses to their eyes.

METHODS

This study was comprised of both phantom and computer simulations. Thermoluminescent dosimeters (TLDs) and mEyeDose_X tool were used to measure and calculate eye lens doses for the cardiologist. 144 TLDs measurements were performed using cardiac protocol for three angiographic projections: anterior-posterior (AP), left anterior oblique 90° (LAO90) and left anterior oblique 45° with cranial 30° (spider) angulations. All cine and fluoroscopy modes including the projections used in this study performed with and without protection tools.

RESULTS

The annual equivalent doses with protective tools using mEyeDose_X were found to be 1.831 and 1.424 mSv/year, whereas the values using phantom were found to be 2.204 and 1.802 mSv/year for the lens of lift and right eye respectively.

CONCLUSION

The annual doses reported in this study are almost comparable to other studies performed on interventional cardiology (IC) procedures. The highest dose rate in the lens was 20.21 ± 0.015 mSv/h without protective tools in cine mode for spider projection. Cardiologists may therefore easily exceed the lens dose limit if protective tools are not used.

IMPACT OF THE TABLE HEIGHT AND THE OPERATOR'S HEIGHT ON THE LEVEL OF RADIATION DELIVERED TO INTERVENTIONAL CARDIOLOGISTS

Interventional cardiologists count among the health professionals that are most exposed to ionising radiation. To minimise exposure, it is recommended that the patient be placed at the maximum distance possible from the X-ray source, but this recommendation has not been clinically validated. We aimed to investigate the impact of the average table height on the level of radiation delivered to cardiologists performing coronary interventions. The population for analysis included all invasive coronary procedures performed in our centre from March to June 2017. The primary endpoint was operator radiation exposure, as assessed using personal electronic dosimeters located on the operator's left arm. In total, 225 invasive coronary procedures were analysed. When the average table height was 1126 mm or more, the operators received a radiation dose that was, on average, 53% lower than when the table was lower than 1126 mm. This reduction remained significant by multivariate analysis adjusted for the operator.

A PHANTOM STUDY TO DETERMINE THE OPTIMAL PLACEMENT OF EYE DOSEMETERS ON INTERVENTIONAL CARDIOLOGY STAFF

The International Commission on Radiological Protection has substantially reduced the recommended maximum annual eye lens dose for workers. Use of a dedicated eye dosemeter is one method for accurate dose monitoring. The main aim of this study was to yield recommendations for optimal placement of eye dosemeters to estimate the eye dose to interventional cardiology physicians and nurses. A phantom measurement was conducted to simulate typical interventional cardiology procedures. Considering eight X-ray tube angulations, the left side of the head position provide good estimates for physician, and the forehead position provide good estimates for nurse.

OCCUPATIONAL EYE LENS DOSE ESTIMATED USING WHOLE-BODY DOSEMETER IN INTERVENTIONAL CARDIOLOGY AND RADIOLOGY: A MONTE CARLO STUDY

Medical personnel performing interventional procedures in cardiology and radiology is considered to be a professional group exposed to high doses of ionizing radiation. Reduction of the eye lens dose limit made its assessment in the interventional procedures one of the most challenging topics. The objective of this work is to assess eye lens doses based on the whole-body doses using methods of computational dosimetry. Assessment included different C-arm orientations (PA, LAO and RAO), tube voltages (80 -110 kV) and efficiency of different combinations of protective equipment used in interventional procedures. Center position at the height of the thyroid gives best estimate of eye lens dose, with spreads of 11% (13%), 13% (17%) and 14% (13%) for the left (right) eye lens. The conversion factors of 1.03 (0.83), 1.28 (1.06) and 1.36 (1.06) to convert whole body to eye lens dose were derived for positions of first operator, nurse and radiographer, respectively. The eye lens dose reduction factors for different combinations of applied protective equipment are 178, 5 and 6, respectively.

Standing CT of the equine head: Reducing radiation dose maintains image quality

Multiple published studies involving computed tomographic (CT) examinations of the equine head utilise a wide range of mAs parameters for image acquisition. This prospective, experimental study assessed the effects of lowering mAs during CT image acquisition on image quality and scatter radiation on 10 cadaver equine heads. Each head was scanned three times at 300, 225, and 150 mAs, with all other scanning parameters remaining constant between series. An anthropomorphic phantom was positioned adjacent to each equine head during image acquisition, mimicking a human bystander, with an ionization chamber attached to the phantom at eye level. Each series was reconstructed using filtered back projection, using medium (H30) and high (H80) frequency reconstruction algorithms. Quantitative image quality assessment was performed by calculating signal to noise ratio (SNR) and contrast to noise ratio (CNR). Two qualitative image quality assessments were performed independently by three blinded board certified veterinary radiologists with a 4 week interval, using a visual grade analysis model adapted from peer reviewed medical literature. Ionization chamber measurements, calculated volume CT dose index (CTDIvol), and dose-length product (DLP) were recorded. Halving radiation dose during image acquisition from 300 to 150mAs resulted in comparable image quality between series. There was a statistically significant and linear relationship between mAs and scatter radiation to the bystander; halving mAs during image acquisition resulted in halving of scatter radiation. Results of this cadaveric study support the use of lower mAs settings during standing CT examinations of the equine head.

Assessment of Genomic Instability in Medical Workers Exposed to Chronic Low-Dose X-Rays in Northern China

The increasing use of ionizing radiation (IR) in medical diagnosis and treatment has caused considerable concern regarding the effects of occupational exposure on human health. Despite this concern, little information is available regarding possible effects and the mechanism behind chronic low-dose irradiation. The present study assessed potential genomic damage in workers occupationally exposed to low-dose X-rays. A variety of analyses were conducted, including assessing the level of DNA damage and chromosomal aberrations (CA) as well as cytokinesis-block micronucleus (CBMN) assay, gene expression profiling, and antioxidant level determination. Here, we report that the level of DNA damage, CA, and CBMN were all significantly increased. Moreover, the gene expression and antioxidant activities were changed in the peripheral blood of men exposed to low-dose X-rays. Collectively, our findings indicated a strong correlation between genomic instability and duration of low-dose IR exposure. Our data also revealed the DNA damage repair and antioxidative mechanisms which could result in the observed genomic instability in health-care workers exposed to chronic low-dose IR.

Development of a realistic 3D printed eye lens dosemeter using CAD integrated with Monte Carlo simulation

Recent epidemiological studies suggested to lower the threshold dose for radiation induced cataract in the eye lens. Therefore, eye lens radiation protection became to play a more important role in personal dosimetry. The main objective of this work is to propose a new methodology for prototyping and benchmarking of an eye lens dosimter based on the equivalent dose to the sensitive part of the eye lens, using CAD Software and Geant4 Monte Carlo simulations with mesh modelling and 3D printing. A 3D printed dosemeter was type tested based on IEC 62387:2012, in terms of energy and angular dependence for the measurements of Hp(3). The results show that the methodology employed is suitable for the development of new eye lens dosemeters.

Ophthalmic manifestations of ionising radiation among interventionalists

Background: Ionising radiation (IR) is an occupational hazard for interventionalists. Dry eye syndrome may develop. There may be damage to the corneal epithelium, causing irritation and ulceration. Radiation-induced cataracts commonly develop in the posterior sub-capsular (PSC) region of the lens and are more common in the left eye.Aim: The aim of this study was to describe the ophthalmological findings in South African interventionalists occupationally exposed to IR.Setting: This study was conducted in South Africa.Methods: A prospective cross-sectional study was conducted. Interventional radiologists (25), adult cardiologists (42) and paediatric cardiologists (31) were recruited at conferences and included in the study. Convenience sampling was used. Participants completed a survey that collected data on their demographics, their cataract risk factors and co-morbid diseases, their occupational history, their radiation safety practices and their training in occupational history. Participants’ eyes were examined using a slit lamp after dilation of the eyes. Ethics clearance was obtained and each participant gave informed consent. A descriptive analysis was done.Results: The median age of the 98 interventionalists screened was 43.5 years. They worked with radiation for a median of 7.5 years. Cataracts occurred in the left eye of 17 (17.3%) participants and in the right eye of nine (9.2%). There were five (5.1%) PSC cataracts in the left eye and one (1%) in the right eye. The vitreous was abnormal in 19.4% of participants. The tear break-up time was abnormal in 48% of participants.Conclusion: Ionising radiation is an occupational hazard posing a risk to interventionalists’ eyes. They are at increased risk of cataracts and dry eye syndrome, which can affect their occupational performance and quality of life. Education can positively influence the radiation safety practices of interventionalists that could reduce the detrimental effects of IR on their eyes.

Ionising radiation and lens opacities in interventional physicians: results of a German pilot study

We assessed the feasibility of an epidemiological study on the risk of radiation-related lens opacities among interventional physicians in Germany. In a regional multi-centre pilot study associated with a European project, we tested the recruitment strategy, a European questionnaire on work history for the latter dosimetry calculation and the endpoint assessment. 263 interventional physicians and 129 non-exposed colleagues were invited. Questionnaires assessed eligibility criteria, risk factors for cataract, and work history relating to occupational exposure to ionising radiation, including details on type and amount of procedures performed, radiation sources, and use of protective equipment. Eye examinations included regular inspection by an ophthalmologist, digital slit lamp images graded according to the lens opacities classification system, and Scheimpflug camera measurements. 46 interventional (17.5%) and 30 non-exposed physicians (23.3%) agreed to participate, of which 42 and 19, respectively, met the inclusion criteria. Table shields and ceiling suspended shields were used as protective equipment by 85% and 78% of the interventional cardiologists, respectively. However, 68% of them never used lead glasses. More, although minor, opacifications were diagnosed among the 17 interventional cardiologists participating in the eye examinations than among the 18 non-exposed (59% versus 28%), mainly nuclear cataracts in interventional cardiologists and cortical cataracts in the non-exposed. Opacification scores calculated from Scheimpflug measurements were higher among the interventional cardiologists, especially in the left eye (56% versus 28%). Challenges of the approach studied include the dissuading time investment related to pupil dilatation for the eye examinations, the reliance on a retrospective work history questionnaire to gather exposure-relevant information for dose reconstructions and its length, resulting in a low participation rate. Dosimetry data are bound to get better when the prospective lens dose monitoring as foreseen by 2013 European Directives is implemented and doses are recorded.

New Eye Lens Dose Limit: Status of Knowledge in Campania Hospitals

The International Commission on Radiation Protection (ICRP) in 2011 recommended the lowering of the annual eye lens dose limit from 150 mSv/year to 20 mSv/year in order to reduce the risk of X-ray-induced lens opacity in medical staff. The purpose of this study was to assess the status of knowledge of the new eye lens dose limit and of the radioprotection culture among operators. To this end, a questionnaire was administered to physicians, X-ray technicians, and nurses working in five hospitals of the Campania region, Italy. A total of 64 questionnaires were collected in the hospital departments in which procedures involving ionizing radiation were routinely performed. The data analyzed yielded the following results: 12 operators affirmed to know the new eye lens dose limit, 53 operators routinely wore lead aprons, and 23 operators used lead glasses. Four workers performed eye lens dosimetry through specific dosimeters. A significant lack of knowledge of the reduced eye lens dose limit suggests the need to implement radioprotection-training programs aimed at raising awareness about the importance of health care in the workplace and at reducing the risk of radio-induced effects to the eye lens.

Demonstrating Compliance With Proposed Reduced Lens of Eye Dose Limits in Nuclear Medicine Settings

Based on ongoing research on ionizing radiation thresholds for cataracts, the International Commission on Radiological Protection has proposed new guidelines lowering the annual occupational lens of eye dose limit from 150 mSv to 20 mSv. The International Atomic Energy Agency has operationalized these new guidelines. Subsequently, national/regional radiation protection regulators are reviewing their lens of eye dose limits with an aim of moving towards the proposed new limits, resulting in licensees having to demonstrate compliance. In health care settings, fluoroscopic interventional practices generally have higher lens of eye doses and nuclear medicine settings generally have lower doses. A prospective cohort (n = 19) of nuclear medicine technologists wore dedicated lens of eye dosimeters for a 3 mo period synchronized with their body dosimeter schedules. The lens of eye dosimeters were validated to have a linear response in the anticipated dose ranges. The participants worked in a relatively high-volume nuclear medicine practice, which included general and cardiac, positron emission tomography/computed tomography, radiopharmacy, and cyclotron operations. The annualized dose ranges were 0.0-3.68 mSv (lens of eye) and 0.48-4.72 mSv (whole body). There was a good correlation between lens of eye and body dosimeter readings (R = 0.67). There were no significant differences in lens of eye dose by work type, worker sex, or side on which the dosimeter was worn. The findings should be generalizable to other similar practices, especially in North America, and should be sufficient to demonstrate regulatory compliance in nuclear medicine settings with the proposed new lens of eye dose limits.

Reducing radiation exposure during atrial fibrillation ablation using lectures to promote awareness

Objective

Recently, concern has increased regarding the hazards of radiation exposure in patients and laboratory staff. Since the numbers of complex catheter ablations (CA) performed, duration of procedure times, and need for multiple sessions have increased, radiation exposure during each session needs to be minimised. Our study aimed to assess the impact of awareness on radiation exposure during CA for atrial fibrillation (AF).

Methods

Mini-course lectures was delivered to the physicians and staff in the electrophysiology division. Its effect on the fluoroscopic time and radiation dose during AF ablation before (Group I, n=70), shortly after (Group II: n=70) and remotely after the mini-lecture (Group III, n=70) were evaluated. Patient demographics, preoperative testing and procedural parameters were collected.

Results

The fluoroscopic time significantly reduced after the lecture (Group I and II: 25.1±10.0 and 15.1±7.3 min, respectively (p<0.0001)), and remained so in Group III (13.0±5.4 min), despite the increase in the number of persistent AFs. The radiation dose also significantly reduced (Groups I, II, III: 295.0±263.0, 109.6±103.5 and 110.1±89.6 mGy, respectively (p<0.0001)).

Conclusion

Awareness on radiation exposure led to a significant reduction in fluoroscopic time and radiation dose during CA for AF, the effect of which persisted even to remote periods following the procedure.

Physicians' exposure to radiation during electrophysiology procedures

PURPOSE

Cardiologists are among the health professionals that are most exposed to ionizing radiation, but there is no study comparing the level of exposure of physicians during different electrophysiology procedures. We aimed to measure and compare cardiologists' exposure to radiation during different electrophysiology procedures.

METHODS

The study population comprised all electrophysiology procedures performed over a 6-month period in a large referral centre. The endpoint was operator radiation exposure, assessed using a personal electronic dosimeter located on the operator's left arm.

RESULTS

In total, 150 electrophysiology procedures were analyzed. Compared with electrophysiology studies (reference category), physician radiation exposure was 3-fold greater during ablation of atrial fibrillation, 9-fold greater during ablation of atrioventricular nodal reentrant tachycardia (AVNRT)/atrioventricular reentrant tachycardia (AVNT), and 10-fold greater during ablation of atrial flutter (p < 0.001). Physician exposure was mainly related to X-ray time (R² = 0.28).

CONCLUSIONS

Our study showed significant differences in cardiologists' exposure to ionizing radiation depending on the type of electrophysiology procedure. Atrial flutter and AVNRT/AVNT ablations are the procedures in which operators are most exposed to ionizing radiation.

Radiation in Spine Deformity: State-of-the-Art Reviews

STUDY DESIGN/METHODS

Review article.

OBJECTIVES

This article will provide an overview regarding measurement of radiation exposure and effects on patients with spinal deformity.

SUMMARY OF BACKGROUND DATA/RESULTS

Pediatric and adult spinal deformity patients are frequently exposed to diagnostic studies exposing them to ionizing radiation. There is a concern that medical radiation can result in increased cancer risk, particularly in children who will live for a long period of time in which cancer may develop and who have rapidly dividing cells that may be more susceptible to DNA damage. CT imaging imparts 10-100 times higher radiation dosing than standard radiographs. Usage of CT imaging studies is growing in the United States and represents 50% of medical imaging exposure. In addition to the 3 millisieverts (mSv) mean natural background exposure, in the United States, the average American experiences an additional 3 mSv of exposure primarily due to medical diagnostic imaging. Early-onset scoliosis patients are at risk of high cumulative radiation exposure given the young age at diagnosis and frequency of multiorgan system involvement in the case of neuromuscular, congenital, and syndromic patients. Biplanar slot scanning reduces patient radiation exposure, and overall levels of exposure from radiographic imaging is quite low compared with CT imaging or historic radiographs. Specialized pediatric CT dosing protocols result in lower patient absorbed dose. Surgeon and team intraoperative exposure to radiation should always be a concern. Appropriate shielding with a lead apron and minimizing radiation exposure are appropriate strategies.

CONCLUSIONS

This article will help guide surgeons to make appropriate decisions regarding the need for imaging studies and advocate for low-dose imaging protocols within their facilities.

LEVEL OF EVIDENCE

V.

Impact of cardiac resynchronisation therapy on cardiologists' exposure to radiation during implantation of pacemakers and implantable cardioverter-defibrillators

Cardiologists are among the health professionals that are most exposed to ionizing radiation, but there is no recent study quantifying overexposure of physicians during cardiac resynchronisation therapy (CRT) procedures compared to 'classical' implantation of pacemakers (PMs) or implantable cardioverter-defibrillators (ICDs). We aimed to measure and compare operator exposure to radiation during implantation of PM and ICD with or without CRT. The study population comprised all PMs and ICDs implanted in a large referral centre over a six months period. The endpoint was operator radiation exposure, assessed using a personal electronic dosimeter located on operator's chest. In total, 169 PM/ICD implantations were analysed, 19 of which included CRT. Compared with 'classical' implantation, cardiologist radiation exposure was 9-fold greater during CRT procedures (p < 0.001). Physician exposure was related to dose-area product (R² = 0.21 during 'classical' implantations and R² = 0.57 during CRT procedures). Our study shows that cardiologists' exposure to radiation during CRT implantation was 9-fold greater than during procedures without CRT.

A European survey on the regulatory status for the estimation of the effective dose and the equivalent dose to the lens of the eye when radiation protection garments are used

Following the proposal of the ICRP for the reduction of the dose limit for the lens of the eye, which has been adopted by the International Atomic Energy Agency and the European Council, concerns have been raised about the implementation of proper dose monitoring methods as defined in national regulations, and about the harmonisation between European countries. The European Radiation Dosimetry Group organised a survey at the end of 2017, through a web questionnaire, regarding national dose monitoring regulations. The questions were related to: double dosimetry, algorithms for the estimation of the effective dose, methodology for the determination of the equivalent dose to the lens of the eye and structure of the national dose registry. The results showed that more than 50% of the countries that responded to the survey have legal requirements about the number and the position of dosemeters used for estimation of the effective dose when radiation protection garments are used. However, in only five out of 26 countries are there nationally approved algorithms for the estimation of the effective dose. In 14 out of 26 countries there is a legal requirement to estimate the dose to the lens of the eye. All of the responding countries use some kind of national database for storing individual monitoring data but in only 12 out of 26 countries are the estimated effective dose values stored. The personal dose equivalent at depth 3 mm is stored in the registry of only seven out of 26 countries. From the survey, performed just before the implementation of the European Basic Safety Standards Directive, it is concluded that national occupational exposure frameworks require intensive and immediate work under the coordination of the competent authorities to bring them into line with the latest basic safety standards and achieve harmonisation between European countries.

Prevalence of Lens Opacity in Interventional Cardiologists and Professional Working in the Hemodynamics in Brazil

Background

Posterior subcapsular cataract is a tissue reaction commonly found among professionals exposed to ionizing radiation.

Objective

To assess the prevalence of cataract in professionals working in hemodynamics in Brazil.

Methods

Professionals exposed to ionizing radiation (group 1, G1) underwent slit lamp examination with a biomicroscope for lens examination and compared with non-exposed subjects (group 2, G2). Ophthalmologic findings were described and classified by opacity degree and localization using the Lens Opacities Classification System III. Both groups answered a questionnaire on work and health conditions to investigate the presence of risk factors for cataract. The level of significance was set at 5% (p < 0.05).

Results

A total of 112 volunteers of G1, mean age of 44.95 (±10.23) years, and 88 volunteers of G2, mean age of 48.07 (±12.18) years were evaluated; 75.2% of G1 and 85.2% of G2 were physicians. Statistical analysis between G1 and G2 showed a prevalence of posterior subcapsular cataract of 13% and 2% in G1 and G2, respectively (0.0081). Considering physicians only, 38% of G1 and 15% of G2 had cataract, with the prevalence of posterior subcapsular cataract of 13% and 3%, respectively (p = 0.0176). Among non-physicians, no difference was found in the prevalence of cataract (by types).

Conclusions

Cataract was more prevalent in professionals exposed to ionizing radiation, with posterior subcapsular cataract the most frequent finding.

Frequency and Diagnostic Implications of Image Artifacts by Eye-Lens Shielding in Head CT

OBJECTIVE

The eye lens is one of the most radiosensitive organs, and medical radiation is one of the main causes of cataracts. To protect the lens during head CT examinations, protectors have been developed; however, they can lead to image artifacts, which is a major disadvantage of their use. This study retrospectively evaluates the frequency and extent of artifacts caused by these protectors related to three anatomic regions (eye, brain, and bone) and their dependence on protector positioning.

MATERIALS AND METHODS

Datasets from 261 consecutive head CT examinations obtained during 3.5 months of routine clinical imaging were assessed. Diagnostic quality of the images was evaluated by objective measuring and subjective scoring on a 5-point Likert scale. Furthermore, the position of the lens protector in correlation to the eye lens and the intensity and frequency of artifacts were analyzed.

RESULTS

Only 4.6% of all analyzed examinations were completely free from artifacts; 95.4% showed artifacts at least in the orbital cavity. Although the brain was affected in 27.8% of cases, in only 5.8% of cases was there a risk of misinterpretation, such as suspected intracranial bleeding. In 24.9% of cases, the lens was not properly covered by the protector. A too cranial position of the protector was identified as the main risk factor for cerebral artifacts.

CONCLUSION

Eye shielding for brain CT examinations often leads to artifacts. However, in only a small percentage of cases do these artifacts affect tissue depiction in regions beyond the eye (i.e., brain or bones). Correct positioning is mandatory to minimize artifacts.

OCCUPATIONAL DOSES FOR THE FIRST AND SECOND OPERATORS IN LEBANESE INTERVENTIONAL CARDIOLOGY SUITES

The study monitored occupational dose for 12 interventional cardiologists (first operators) and 10 technicians (second operators), from 10 different Lebanese hospitals performing coronary angiography and precutaneous coronary interventions exclusively on adult patients. Each individual wore dosemeters under and over the lead apron at chest and collar level, respectively, on the wrist and next to the left eye. The total follow-up period for each first/second operator varied between two to six bimonthly monitoring periods. For the first operator, the mean (range) effective, hand and eye lens doses were of 6 (1-41), 112 (10-356) and 15 (5-47) μSv/procedure, respectively. These were of 2.3 (0.1-8), 16 (2-109) and 7 (2-14) μSv/procedure for the second operator. Extrapolated annual eye lens doses revealed that both first and second operators may exceed 3/10th of the annual eye lens dose permissible limit thus supporting the need for dedicated eye lens monitoring.

Feasibility of using ultra-low pulse rate fluoroscopy during routine diagnostic coronary angiography

INTRODUCTION

Coronary angiogram, while a powerful diagnostic tool in coronary artery disease, is not without an associated risk from ionising radiation. There are a number of factors that influence the amount of radiation the patient receives during the procedure, some of which are under the control of the operator. One of these is an adjustment of the fluoroscopic pulse rate. This study aims to assess the feasibility of using ultra-low pulse rate (3 pulses per second(pps)) fluoroscopy during routine diagnostic coronary angiogram procedures and the effect it has on fluoroscopy time, diagnostic clarity and radiation dose.

METHODS

A retrospective study of three operators each undertaking 50 coronary angiogram procedures was performed. One of the operators used a pulse rate of 3 pps and 6 pps for fluoroscopic screening while the control groups used the standard 10 pps mode utilised at this centre.

RESULTS

Results demonstrated no reduction of diagnostic clarity, up to a 58% reduction in Dose Area Product and no increase in fluoroscopy time with the 3 pps setting.

CONCLUSIONS

Findings from this pilot study suggest that utilisation of ultra-low pulse rate fluoroscopy in routine transfemoral diagnostic coronary angiography in the catheterisation laboratory is feasible.

A novel technique for performing transseptal puncture guided by a non-fluoroscopic 3D mapping system

BACKGROUND

Transseptal puncture (TSP) is commonly performed under fluoroscopic guidance in left atrial ablation procedures. This exposes patients and healthcare professionals to deleterious ionizing radiation. We describe a novel technique for performing TSP non-fluoroscopically using a three-dimensional (3D) mapping system only. The safety and efficacy of this technique is compared to traditional fluoroscopy guided TSP.

METHODS

Retrospective, single-center study of patients undergoing TSP for left atrial ablation. Those undergoing TSP using 3D mapping system alone (nonfluoroscopy group) were compared to those undergoing fluoroscopic guided TSP (Fluoroscopy group). Clinical, procedural data and complications were analyzed from a prospective registry.

RESULTS

Twenty patients (32 TSPs) in the nonfluoroscopy (NF) group were compared to 14 patients (25 TSPs) in fluoroscopy (F) group. TSP success rates were similar across the groups (88% vs 96% in the NF and F groups, P = 0.97). In the NF group, there was one cardiac tamponade, two unsuccessful TSPs (previous cardiac surgery-required TOE guided TSP), and one patient required fluoroscopy on a background of CRTD device to avoid lead displacement. The mean fluoroscopy time and dose were significantly lower in the nonfluoroscopy group (0.75  ±  0.50 vs 5.32 ± 3.23 min, P  <  0.001; 92.5 ± 60.7 vs 394.3 ± 182.7 cGy/cm² , P < 0.001).

CONCLUSION

Our study shows that TSPs can be performed safely and effectively using this non-fluoroscopic novel technique in a select group of patients. Radiation exposure is reduced significantly without compromising patient safety. Larger studies are required to substantiate these results. Patients with cardiac implantable devices and previous cardiac surgery may pose a challenge to using this technique.

Strategies to optimise occupational radiation protection in interventional cardiology using simultaneous registration of patient and staff doses

The International Commission on Radiological Protection recommends that occupational protection and patient protection be managed in an integrated approach. This paper describes the experience and the initial results of a system able to register and to process simultaneously staff and patient doses in interventional cardiology and the practical use of this system in the optimisation of occupational exposure. The system used simultaneously collects and manages patient and staff doses for all radiation events. The personal electronic dosimeters worn over the protective apron of health professionals working inside catheterisation laboratories can send (wireless) doses and dose rate values to an X-hub and provide the operators inside the catheterisation rooms with real-time information. Individual and global reports for all the health professionals may be periodically obtained from the system to help with the optimisation. The results for eight cardiologists, one fellow and four nurses for a total of 2468 interventional cardiology procedures and 3207 occupational dose values collected over one year are presented here. Annual doses Hp(10) measured over the apron for cardiologists ranged from 0.3 to 6.3 mSv. For the cardiologist, the ratio between occupational doses (over the apron) and patient doses ranged from 0.05 to 0.23 μSv Gy^-1 cm^-2, with a mean value of 0.12 μSv Gy^-1 cm^-2. The system allows defining optimisation strategies by comparing the results between the different operators while considering the workload and complexity of the procedures (based on the total Kerma Area Product managed by the different operators). The registration of the date and time of the occupational radiation doses allows auditing the use of the personal dosimeters worn by the various operators.

Past and present work practices of European interventional cardiologists in the context of radiation protection of the eye lens-results of the EURALOC study

This paper investigates over five decades of work practices in interventional cardiology, with an emphasis on radiation protection. The analysis is based on data from more than 400 cardiologists from various European countries recruited for a EURALOC study and collected in the period from 2014 to 2016. Information on the types of procedures performed and their annual mean number, fluoroscopy time, access site choice, x-ray units and radiation protection means used was collected using an occupational questionnaire. Based on the specific European data, changes in each parameter have been analysed over decades, while country-specific data analysis has allowed us to determine the differences in local practices. In particular, based on the collected data, the typical workload of a European cardiologist working in a haemodynamic room and an electrophysiology room was specified for various types of procedures. The results showed that when working in a haemodynamic room, a transparent ceiling-suspended lead shield or lead glasses are necessary in order to remain below the recommended eye lens dose limit of 20 mSv. Moreover, the analysis revealed that new, more complex cardiac procedures such as chronic total occlusion, valvuloplasty and pulmonary vein isolation for atrial fibrillation ablation might contribute substantially to annual doses, although they are relatively rarely performed. The results revealed that considerable progress has been made in the use of radiation protection tools. While their use in electrophysiology procedures is not generic, the situation in haemodynamic procedures is rather encouraging, as ceiling-suspended shields are used in 90% of cases, while the combination of ceiling shield and lead glasses is noted in more than 40% of the procedures. However, we find that still 7% of haemodynamic procedures are performed without any radiation protection tools.

Impact of patient obesity on radiation doses received by scrub technologists during coronary angiography

BACKGROUND

The impact of patient obesity on scrub technologist radiation dose during coronary angiography has not been adequately studied.

METHODS

Real-time radiation exposure data were prospectively collected during consecutive coronary angiography cases. Patient radiation dose was estimated by dose area product (DAP). Technologist radiation dose was recorded by a dosimeter as the personal dose equivalent (H_p (10)). Patients were categorized according to their body mass index (BMI): <25.0, lean; 25.0-29.9, overweight; ≥30.0, obese. The study had two phases: in Phase I (N = 351) standard radiation protection measures were used; and in Phase II (N = 268) standard radiation protection measures were combined with an accessory lead shield placed between the technologist and patient.

RESULTS

In 619 consecutive coronary angiography procedures, significant increases in patient and technologist radiation doses were observed across increasing patient BMI categories (p < 0.001 for both). Compared to lean patients, patient obesity was associated with a 1.7-fold increase in DAP (73.0 [52.7, 127.5] mGy × cm² vs 43.6 [25.1, 65.7] mGy × cm², p < 0.001) and a 1.8-fold increase in technologist radiation dose (1.1 [0.3, 2.7] μSv vs 0.6 [0.1, 1.6] μSv, p < 0.001). Compared to Phase I, use of an accessory lead shield in Phase II was associated with a 62.5% reduction in technologist radiation dose when used in obese patients (p < 0.001).

CONCLUSIONS

During coronary angiography procedures, patient obesity was associated with a significant increase in scrub technologist radiation dose. This increase in technologist radiation dose in obese patients may be mitigated by use of an accessory lead shield.

Cataract risk of neuro-interventional procedures: a nationwide population-based matched-cohort study

AIM

To demonstrate the risk of cataract associated with radiation exposure from neuro-interventional procedures.

MATERIALS AND METHODS

This was a nationwide population-based, matched-cohort study. The exposed group (group E) comprised patients diagnosed with an aneurysm, cerebrovascular system anomaly, or subarachnoid haemorrhage who underwent a neuro-interventional procedure, such as brain digital subtraction angiography or endovascular embolisation. The comparison group (group C) included subjects who were never exposed to radiation from neuro-interventional procedures and were propensity score-matched by the date of enrolment, age, sex, and associated comorbidities. Multiple Cox proportional hazard regression analysis was used to estimate the hazard ratio (HR) of cataract risk due to radiation exposure while adjusting for potential confounding factors.

RESULTS

There were 838 patients and 3,352 matched subjects in groups E and C, respectively. The incidence of cataracts was significantly greater among subjects in group E (adjusted HR [aHR] = 1.88; 95% confidence interval [CI] = 1.08-3.26), especially those aged >40 years (aHR = 2.14; 95% CI = 1.16-3.94). The number of computed tomography examinations was positively correlated, but not statistically significant, with an increased risk of cataract occurrence.

CONCLUSIONS

Neuro-interventional procedures might be significantly associated with an increased risk of cataract occurrence.

The International Atomic Energy Agency action plan on radiation protection of patients and staff in interventional procedures: Achieving change in practice

INTRODUCTION

The International Atomic Energy Agency (IAEA) organized the 3rd international conference on radiation protection (RP) of patients in December 2017. This paper presents the conclusions on the interventional procedures (IP) session.

MATERIAL AND METHODS

The IAEA conference was conducted as a series of plenary sessions followed by various thematic sessions. "Radiation protection of patients and staff in interventional procedures" session keynote speakers presented information on: 1) Risk management of skin injuries, 2) Occupational radiation risks and 3) RP for paediatric patients. Then, a summary of the session-related papers was presented by a rapporteur, followed by an open question-and-answer discussion.

RESULTS

Sixty-seven percent (67%) of papers came from Europe. Forty-four percent (44%) were patient studies, 44% were occupational and 12% were combined studies. Occupational studies were mostly on eye lens dosimetry. The rest were on scattered radiation measurements and dose tracking. The majority of patient studies related to patient exposure with only one study on paediatric patients. Automatic patient dose reporting is considered as a first step for dose optimization. Despite efforts, paediatric IP radiation dose data are still scarce. The keynote speakers outlined recent achievements but also challenges in the field. Forecasting technology, task-specific targeted education from educators familiar with the clinical situation, more accurate estimation of lens doses and improved identification of high-risk professional groups are some of the areas they focused on.

CONCLUSIONS

Manufacturers play an important role in making patients safer. Low dose technologies are still expensive and manufacturers should make these affordable in less resourced countries. Automatic patient dose reporting and real-time skin dose map are important for dose optimization. Clinical audit and better QA processes together with more studies on the impact of lens opacities in clinical practice and on paediatric patients are needed.

Track, calculate and optimise eye lens doses of interventional cardiologists using mEyeDose and mEyeDose_X

The European epidemiological study EURALOC aimed to establish a dose response relationship for low dose radiation induced eye lens opacities using interventional cardiologists as the study group. Within the EURALOC project, two dosimetry methodologies were developed serving as the basis for cumulative eye lens dose assessment. Besides being the cornerstone of the epidemiological part of the project, these dosimetry methodologies were also used to develop two calculation tools, 'mEyeDose' and 'mEyeDose_X' which enable to track, calculate, optimise and analyse eye lens doses in interventional cardiology. mEyeDose was developed as a Mobile Web App and serves as a readily accessible, highly didactic educational tool for interventional cardiologists whereas the user-friendly desktop application mEyeDose_X is designed for radiation protection professionals. Both tools are freely available and can be used for a wide range of purposes such as optimisation of working practices, calculation of cumulative eye lens doses or risk assessment prior to routine eye lens dose monitoring.

C-arm fluoroscopy in orthopaedic surgical practice

The use of C-arm fluoroscopy in intraoperative orthopaedic procedures has become an important tool in modern orthopaedic surgical practice. It enhances the technical proficiency of the surgeon in addition to reducing the morbidity and length of hospital stay of the patient. Despite the documented benefits of this device, there has been a growing concern about the increased radiation exposure to the surgical team. We therefore present the review of the literature on the usefulness of C-arm fluoroscopy, pitfalls in application of the machine as well as the harmful radiation effects and precautionary measures that need to be observed when using the C-arm fluoroscopy in orthopaedic surgical procedures.