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Vano E, Fernandez-Soto JM, Ten JI, Sanchez Casanueva RM. Occupational and patient doses for interventional radiology integrated into a dose management system. Br J Radiol 2023; 96:20220607. [PMID: 36533561 PMCID: PMC9975364 DOI: 10.1259/bjr.20220607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/30/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The International Commission on Radiological Protection recommends managing patient and occupational doses as an integrated approach, for the optimisation of interventional procedures. The conventional passive personal dosimeters only allow one to know the accumulated occupational doses during a certain period of time. This information is not enough to identify if there is a lack of occupational radiation protection during some procedures. This paper describes the use of a dose management system (DMS) allowing patient and occupational doses for individual procedures to be audited. METHODS The DMS manages patient and occupational doses measured by electronic personal dosimeters. One dosemeter located at the C-arm is used as a reference for scatter radiation. Data have been collected from five interventional rooms. Dosimetry data can be managed for the whole procedure and the different radiation events. Optimisation is done through auditing different sets of parameters for individual procedures: patient dose indicators, occupational dose values, the ratio between occupational doses, and the doses measured by the reference dosemeter at the C-arm, and the ratio between occupational and patient dose values. RESULTS The managed data correspond to the year 2021, with around 4500 procedures, and 8000 records on occupational exposures. Patient and staff dose data (for 11 cardiologists, 7 radiologists and 8 nurses) were available for 3043 procedures. The DMS allows alerts for patient dose indicators and occupational exposures to be set. CONCLUSIONS The main advantage of this integrated approach is the capacity to improve radiation safety for patients and workers together, auditing alerts for individual procedures. ADVANCES IN KNOWLEDGE The management of patient and occupational doses together (measured with electronic personal dosimeters) for individual interventional procedures, using dose management systems, allows alerting optimisation on high-dose values for patients and staff.
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Affiliation(s)
| | - José M Fernandez-Soto
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos and Medical Physics Service, Madrid, Spain
| | - José I Ten
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos and Medical Physics Service, Madrid, Spain
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Sun J, Wu Z, Yu Z, Chen H, Du C, Xu L, Zhong J, Feng J, Coatrieux G, Coatrieux JL, Chen Y. Automatic video analysis framework for exposure region recognition in X-ray imaging automation. IEEE J Biomed Health Inform 2022; 26:4359-4370. [PMID: 35503854 DOI: 10.1109/jbhi.2022.3172369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The deep learning-based automatic recognition of the scanning or exposing region in medical imaging automation is a promising new technique, which can decrease the heavy workload of the radiographers, optimize imaging workflow and improve image quality. However, there is little related research and practice in X-ray imaging. In this paper, we focus on two key problems in X-ray imaging automation: automatic recognition of the exposure moment and the exposure region. Consequently, we propose an automatic video analysis framework based on the hybrid model, approaching real-time performance. The framework consists of three interdependent components: Body Structure Detection, Motion State Tracing, and Body Modeling. Body Structure Detection disassembles the patient to obtain the corresponding body keypoints and body Bboxes. Combining and analyzing the two different types of body structure representations is to obtain rich spatial location information about the patient body structure. Motion State Tracing focuses on the motion state analysis of the exposure region to recognize the appropriate exposure moment. The exposure region is calculated by Body Modeling when the exposure moment appears. A large-scale dataset for X-ray examination scene is built to validate the performance of the proposed method. Extensive experiments demonstrate the superiority of the proposed method in automatically recognizing the exposure moment and exposure region. This paradigm provides the first method that can enable automatically and accurately recognize the exposure region in X-ray imaging without the help of the radiographer.
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Vano E, Fernández JM, Ten JI, Sanchez RM. Benefits and limitations for the use of radiation dose management systems in medical imaging. Practical experience in a university hospital. Br J Radiol 2022; 95:20211340. [PMID: 35007182 PMCID: PMC10993955 DOI: 10.1259/bjr.20211340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Radiation dose management systems (DMS) are currently used to help improve radiation protection in medical imaging and interventions. This study presents our experience using a homemade DMS called DOLQA (Dose On-Line for Quality Assurance). METHODS Our DMS is connected to 14 X-ray systems in a university hospital linked to the central data repository of a large network of 16 public hospitals in the Autonomous Community of Madrid, with 6.7 million inhabitants. The system allows us to manage individual patient dose data and groups of procedures with the same clinical indications, and compare them with diagnostic reference levels (DRLs). The system can also help to prioritise optimisation actions. RESULTS This study includes results of imaging examinations from 2020, with 37,601 procedures and 286,471 radiation events included in the radiation dose structured reports (RDSR), for computed tomography (CT), interventional procedures, positron emission tomography-CT (PET-CT) and mammography. CONCLUSIONS The benefits of the system include: automatic registration and management of patient doses, creation of dose reports for patients, information on recurrent examinations, high dose alerts, and help to define optimisation actions.The system requires the support of medical physicists and implication of radiologists and radiographers. DMSs must undergo periodic quality controls and audit reports must be drawn up and submitted to the hospital's quality committee.The drawbacks of DMSs include the need for continuous external support (medical physics experts, radiologists, radiographers, technical services of imaging equipment and hospital informatics services) and the need to include data on clinical indication for the imaging procedures. ADVANCES IN KNOWLEDGE DMS perform automatic management of radiation doses, produces patient dose reports, and registers high dose alerts to suggest optimisation actions. Benefits and limitations are derived from the practical experience in a large university hospital.
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Affiliation(s)
- Eliseo Vano
- Instituto de Investigación Sanitaria del Hospital
Clínico San Carlos and Medical Physics Service,
28040, Madrid,
Spain
- Department of Radiology, Medical School. Complutense
University, 28040 Madrid,
Spain
| | - José M Fernández
- Instituto de Investigación Sanitaria del Hospital
Clínico San Carlos and Medical Physics Service,
28040, Madrid,
Spain
| | - José I. Ten
- Instituto de Investigación Sanitaria del Hospital
Clínico San Carlos and Medical Physics Service,
28040, Madrid,
Spain
| | - Roberto M. Sanchez
- Instituto de Investigación Sanitaria del Hospital
Clínico San Carlos and Medical Physics Service,
28040, Madrid,
Spain
- Department of Radiology, Medical School. Complutense
University, 28040 Madrid,
Spain
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Vassileva J, Holmberg O. Radiation protection perspective to recurrent medical imaging: what is known and what more is needed? Br J Radiol 2021; 94:20210477. [PMID: 34161167 DOI: 10.1259/bjr.20210477] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
This review summarises the current knowledge about recurrent radiological imaging and associated cumulative doses to patients. The recent conservative estimates are for around 0.9 million patients globally who cumulate radiation doses above 100 mSv, where evidence exists for cancer risk elevation. Around one in five is estimated to be under the age of 50. Recurrent imaging is used for managing various health conditions and chronic diseases such as malignancies, trauma, end-stage kidney disease, cardiovascular diseases, Crohn's disease, urolithiasis, cystic pulmonary disease. More studies are needed from different parts of the world to understand the magnitude and appropriateness. The analysis identified areas of future work to improve radiation protection of individuals who are submitted to frequent imaging. These include access to dose saving imaging technologies; improved imaging strategies and appropriateness process; specific optimisation tailored to the clinical condition and patient habitus; wider utilisation of the automatic exposure monitoring systems with an integrated option for individual exposure tracking in standardised patient-specific risk metrics; improved training and communication. The integration of the clinical and exposure history data will support improved knowledge about radiation risks from low doses and individual radiosensitivity. The radiation protection framework will need to respond to the challenge of recurrent imaging and high individual doses. The radiation protection perspective complements the clinical perspective, and the risk to benefit analysis must account holistically for all incidental and long-term benefits and risks for patients, their clinical history and specific needs. This is a step toward the patient-centric health care.
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Affiliation(s)
- Jenia Vassileva
- Radiation Protection of Patients Unit, International Atomic Energy Agency, Vienna, Austria
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Morota K, Moritake T, Nagamoto K, Matsuzaki S, Nakagami K, Sun L, Kunugita N. Optimization of the Maximum Skin Dose Measurement Technique Using Digital Imaging and Communication in Medicine-Radiation Dose Structured Report Data for Patients Undergoing Cerebral Angiography. Diagnostics (Basel) 2020; 11:E14. [PMID: 33374876 PMCID: PMC7824295 DOI: 10.3390/diagnostics11010014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/04/2020] [Accepted: 12/18/2020] [Indexed: 11/24/2022] Open
Abstract
Understanding the maximum skin dose is important for avoiding tissue reactions in cerebral angiography. In this study, we devised a method for using digital imaging and communication in medicine-radiation dose structured report (DICOM-RDSR) data to accurately estimate the maximum skin dose from the total air kerma at the patient entrance reference point (Total Ka,r). Using a test data set (n = 50), we defined the mean ratio of the maximum skin dose obtained from measurements with radio-photoluminescence glass dosimeters (RPLGDs) to the Total Ka,r as the conversion factor, CFKa,constant, and compared the accuracy of the estimated maximum skin dose obtained from multiplying Total Ka,r by CFKa,constant (Estimation Model 1) with that of the estimated maximum skin dose obtained from multiplying Total Ka,r by the functional conversion factor CFKa,function (Estimation Model 2). Estimation Model 2, which uses the quadratic function for the ratio of the fluoroscopy Ka,r to the Total Ka,r (Ka,r ratio), provided an estimated maximum skin dose closer to that obtained from direct measurements with RPLGDs than compared with that determined using Estimation Model 1. The same results were obtained for the validation data set (n = 50). It was suggested the quadratic function for the Ka,r ratio provides a more accurate estimate of the maximum skin dose in real time.
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Affiliation(s)
- Koichi Morota
- Department of Radiology, Shinkomonji Hospital, 2-5 Dairishinmachi, Moji-ku, Kitakyushu, Fukuoka 800-0057, Japan; (K.M.); (S.M.)
- Department of Radiobiology and Hygiene Management, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japan; (K.N.); (K.N.)
| | - Takashi Moritake
- Department of Radiobiology and Hygiene Management, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japan; (K.N.); (K.N.)
| | - Keisuke Nagamoto
- Department of Radiobiology and Hygiene Management, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japan; (K.N.); (K.N.)
- Department of Radiology, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8556, Japan
| | - Satoru Matsuzaki
- Department of Radiology, Shinkomonji Hospital, 2-5 Dairishinmachi, Moji-ku, Kitakyushu, Fukuoka 800-0057, Japan; (K.M.); (S.M.)
- Department of Radiobiology and Hygiene Management, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japan; (K.N.); (K.N.)
| | - Koichi Nakagami
- Department of Radiobiology and Hygiene Management, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japan; (K.N.); (K.N.)
- Department of Radiology, Hospital of the University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8556, Japan
| | - Lue Sun
- Health and Medical Research Institute, Department of Life Science and Biotechnology, National Institute of Advanced Industrial Science and Technology (AIST), Central 6, 1-1-1 Higashi, Tsukuba, Ibaraki 305-8566, Japan;
| | - Naoki Kunugita
- Department of Occupational and Community Health Nursing, School of Health Sciences, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka 807-8555, Japan;
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O'Hora L, Ryan ML, Rainford L. SURVEY OF KEY RADIATION SAFETY PRACTICES IN INTERVENTIONAL RADIOLOGY: AN IRISH AND ENGLISH STUDY. RADIATION PROTECTION DOSIMETRY 2019; 183:431-442. [PMID: 30247702 DOI: 10.1093/rpd/ncy162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/06/2018] [Accepted: 09/11/2018] [Indexed: 06/08/2023]
Abstract
Interventional radiology is a rapidly evolving speciality with potential to deliver high patient radiation doses, as a result high standards of radiation safety practice are imperative. IR radiation safety practice must be considered before during and after procedures through appropriate patient consent, dose monitoring and patient follow-up. This questionnaire-based study surveyed fixed IR departments across Ireland and England to establish clinical practice in relation to radiation safety. Pre-procedure IR patient consent includes all radiation effects in 11% of cases. The patient skin dose surrogate parameter of Kerma to air at a reference point (Kar) is under-reported. Only 39% of respondents use a substantial radiation dose level and inform patients after these have been reached. Poor compliance with unambiguous, readily available best practice guidance was observed throughout highlighting patient communication, patient dose quantification and subsequent patient dose management concerns.
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Affiliation(s)
| | - M L Ryan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - L Rainford
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
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Tsalafoutas IA. Electronic collimation of radiographic images: does it comprise an overexposure risk? Br J Radiol 2018; 91:20170958. [PMID: 29544343 PMCID: PMC6223295 DOI: 10.1259/bjr.20170958] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/21/2018] [Accepted: 03/13/2018] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To investigate whether electronic collimation software, which is available in all digital X-ray systems, may comprise an overexposure risk. METHODS In the context of surveys on Diagnostic Reference Levels carried out in two radiographic facilities, along with data on exposure factors, the radiographic field sizes were also recorded. In one facility (Unit A), a wireless flat panel detector is used with a conventional X-ray unit, while in the other, a fully digital system is installed (Unit B). The electronically collimated image sizes were compared with the original radiation field sizes. The differences between these two systems concerning the field sizes and the mode of electronic collimation utilization were investigated. RESULTS In Unit A, manual electronic collimation was extensively used and cases where the radiation field size was up to three times larger than that electronically collimated, were identified. On the contrary, in Unit B radiation fields were smaller and electronic collimation was automatic. CONCLUSION When electronic collimation is used in manual mode instead of proper pre-exposure collimation, then it does comprise an overexposure risk. The risk is larger in radiographic units where the field size is not automatically selected according to the examination protocol and no interlocks against oversized collimation settings exist. Advances in knowledge: When radiologists review masked images to make the diagnosis, possible suboptimal X-ray field collimation practices may go unnoticed for long. Therefore, radiologists and medical physicists should periodically survey the original images to determine the actual radiation field sizes used for each radiographic examination type.
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Affiliation(s)
- Ioannis A Tsalafoutas
- Medical Physics Department, General Anticancer Oncology Hospital of Athens ‘Agios Savvas’, Athens, Greece
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8
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National survey on dose data analysis in computed tomography. Eur Radiol 2018; 28:5044-5050. [DOI: 10.1007/s00330-018-5408-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 01/04/2023]
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9
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Jaschke W, Schmuth M, Trianni A, Bartal G. Radiation-Induced Skin Injuries to Patients: What the Interventional Radiologist Needs to Know. Cardiovasc Intervent Radiol 2017; 40:1131-1140. [PMID: 28497187 PMCID: PMC5489635 DOI: 10.1007/s00270-017-1674-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/24/2017] [Indexed: 12/11/2022]
Abstract
For a long time, radiation-induced skin injuries were only encountered in patients undergoing radiation therapy. In diagnostic radiology, radiation exposures of patients causing skin injuries were extremely rare. The introduction of fast multislice CT scanners and fluoroscopically guided interventions (FGI) changed the situation. Both methods carry the risk of excessive high doses to the skin of patients resulting in skin injuries. In the early nineties, several reports of epilation and skin injuries following CT brain perfusion studies were published. During the same time, several papers reported skin injuries following FGI, especially after percutaneous coronary interventions and neuroembolisations. Thus, CT and FGI are of major concern regarding radiation safety since both methods can apply doses to patients exceeding 5 Gy (National Council on Radiation Protection and Measurements threshold for substantial radiation dose level). This paper reviews the problem of skin injuries observed after FGI. Also, some practical advices are given how to effectively avoid skin injuries. In addition, guidelines are discussed how to deal with patients who were exposed to a potentially dangerous radiation skin dose during medically justified interventional procedures.
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Affiliation(s)
- Werner Jaschke
- Department of Radiology, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Matthias Schmuth
- Department of Dermatology, Venereology and Allergology, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Annalisa Trianni
- Department of Physics, Udine University Hospital, Piazzale S. Maria Della Misericordia, n. 15, 33100, Udine, Italy
| | - Gabriel Bartal
- Department of Radiology, Meir Medical Center, Street Tchernichovsky 59, 44281, Kfar Saba, Israel
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10
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Implementation of a patient dose monitoring system in conventional digital X-ray imaging: initial experiences. Eur Radiol 2016; 27:1021-1031. [DOI: 10.1007/s00330-016-4390-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/01/2016] [Accepted: 04/28/2016] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Radiation safety in conventional X-ray diagnostics is based on the concepts of justification, optimization of an X-ray examination and limitation of the radiation exposure achieved during the examination. Optimization of an X-ray examination has to be considered as a multimodal process in which all technical components of the X-ray equipment have to be adapted to each other and also have to be adapted to the anthropometric characteristics of patients and the clinical indications. OBJECTIVES In this article the technical components of a conventional pediatric chest X-radiograph are presented, and recommendations for optimizing chest X-rays in children are provided. RESULTS AND DISCUSSION The following measures are of prime importance: correct x-ray beam limitation, using the posteroanterior projection when possible and not using anti-scatter grids in children under approximately 8 years old. In pediatric radiology chest x-rays that are taken not at the peak of inspiration can also be of some diagnostic significance. Optimization of an X-ray examination inevitably results in the limitation of radiation exposure.
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Affiliation(s)
- M C Seidenbusch
- Institut für Klinische Radiologie - Kinderradiologie, Dr. von Haunersches Kinderspital, Klinikum der Universität München, Lindwurmstr. 4, 80337, München, Deutschland,
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12
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Tuncel N. Assessment of patient dose in medical processes by in-vivodose measuring devices: A review. EPJ WEB OF CONFERENCES 2016. [DOI: 10.1051/epjconf/201612804002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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13
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Dosismanagement in der Radiologie. Radiologe 2015; 55:673-81. [DOI: 10.1007/s00117-015-2817-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fernandez-Soto JM, Ten JI, Sanchez RM, España M, Pifarre X, Vano E. Benefits of an automatic patient dose registry system for interventional radiology and cardiology at five hospitals of the Madrid area. RADIATION PROTECTION DOSIMETRY 2015; 165:53-56. [PMID: 25802463 DOI: 10.1093/rpd/ncv043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The purpose of this article is to present the results of connecting the interventional radiology and cardiology laboratories of five university hospitals to a unique server using an automatic patient dose registry system (Dose On Line for Interventional Radiology, DOLIR) developed in-house, and to evaluate its feasibility more than a year after its introduction. The system receives and stores demographic and dosimetric parameters included in the MPPS DICOM objects sent by the modalities to a database. A web service provides a graphical interface to analyse the information received. During 2013, the system processed 10 788 procedures (6874 cardiac, 2906 vascular and 1008 neuro interventional). The percentages of patients requiring clinical follow-up due to potential tissue reactions before and after the use of DOLIR are presented. The system allowed users to verify in real-time, if diagnostic (or interventional) reference levels are fulfilled.
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Affiliation(s)
- J M Fernandez-Soto
- Medical Physics Service, Hospital Clinico San Carlos, IdISSC, Madrid, Spain Radiology Department, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - J I Ten
- Radiology Service, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - R M Sanchez
- Medical Physics Service, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - M España
- Radiation Physics Service, Hospital U de La Princesa, Madrid, Spain
| | - X Pifarre
- Radiation Physics Service, Hospital U Puerta de Hierro-Majadahonda, Madrid, Spain
| | - E Vano
- Medical Physics Service, Hospital Clinico San Carlos, IdISSC, Madrid, Spain Radiology Department, Facultad de Medicina, Universidad Complutense, Madrid, Spain
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