Establishing local diagnostic reference levels for computed tomography examinations using size-specific dose estimates

OBJECTIVES

To establish local DRL (LDRL) for computed tomography (CT) examinations based on size-specific dose estimates (SSDEs), which consider patient size. The concept of diagnostic reference level (DRL) was introduced to limit patient exposure to unnecessary radiation. However, traditional DRL values do not consider patient size.

METHODS

Following institutional committee approval, data were collected from CT examinations of adult patients at Madinah General Hospital, Al Madinah Al Munawwarah, Saudi Arabia from January to March 2023. The SSDE was calculated for each patient using the effective diameter (Deff).

RESULTS

The LDRLs of the brain, cervical spine, chest, thoracic spine and kidneys, ureters, and bladder (KUB) examinations were 118 mGy, 12 mGy, 8 mGy, 17 mGy, and 7 mGy, respectively. A strong correlation was observed between SSDEs and the volume computed tomography dose index (CTDIvol) for all examinations except chest scans (p<0.05). Size-specific dose estimates were higher than the CTDIvol, with a greater difference for patients with smaller Deff (p<0.05).

CONCLUSION

The established LDRL was within the international DRL. The use of SSDE has the potential to provide more accurate and relevant data for radiation safety practices; however, widespread adoption of SSDE in new CT scanners is necessary for promoting consistency and standardization methodologies.

Application of 3D Scanning Method to Assess Mounting Holes' Shape Instability of Pinewood

Swelling and shrinkage anisotropy affect the susceptibility to an assembly of wooden elements by changing designed clearances or interference fits. This work described the new method to measure mounting holes' moisture-induced shape instability and its verification using three sets of twin samples made of Scots pinewood. Each set of samples contained a pair with different grain patterns. All samples were conditioned under reference conditions (relative air humidity-RH = 60% and temperature 20 °C), and their moisture content (MC) reached equilibrium (10.7 ± 0.1%). On the side of each sample, the seven mounting holes of 12 mm in diameter were drilled. Immediately after drilling, Set 1 was used to measure the effective hole diameter with 15 cylindrical plug-gauges with diameters of 0.05 mm step, while Set 2 and Set 3 were separately re-seasoned by six months in two extreme conditions. Set 2 was conditioned with air at 85% RH (reached an equilibrium MC of 16.6 ± 0.5%), while Set 3 was exposed to air at 35% RH (reached an equilibrium MC of 7.6 ± 0.1%). Results of the plug gauge tests highlighted that holes in the samples subjected to swelling (Set 2) increased an effective diameter in the range of 12.2-12.3 mm (1.7-2.5%), while samples subjected to shrinking (Set 3) reduced the effective diameter to 11.9-11.95 mm (0.8-0.4%). To accurately reproduce the complex shape of the deformation, gypsum casts of holes were made. The 3D optical scanning method was used to read the gypsum casts' shape and dimensions. The 3D surface map of deviations analysis provided more detailed information than the plug-gauge test results. Both the shrinking and swelling of the samples changed the shapes and sizes of the holes, but shrinking reduced the effective diameter of the hole more than swelling increased it. The moisture-induced changes in the shape of holes are complex: the holes ovalized with a different range, depending on the wood grain pattern and hole depth, and were slightly extended in diameter at the bottom. Our study provides a new way to measure 3D hole initial shape changes in wooden elements during desorption and absorption.

Development of size-specific dose estimates for common computed tomography examinations: a study in Ghana

This study determined the size-specific dose estimate (SSDE) of computed tomography (CT) examinations and derived mathematical expressions for dose output estimation and optimization in a teaching hospital in Ghana. Demographic and scanner output indices, including CT dose index (CTDI_vol) and dose length product for adult head, chest and abdominopelvic (ABP) CT examinations carried out at the hospital from 2018 to 2020, were retrieved from the picture archiving and communication system of the CT scanner machine. Other indices such as the antero-posterior diameter (D_AP), lateral diameter (D_L) and diagonal diameter (D_dia) of the patients' bodies were measured on the mid-slice axial image using a digital caliper. The effective diameter (D_eff) was then calculated as the square root of the product of theD_APandD_L. The SSDEs were calculated as the product of the CTDI_voland the size-specific conversion factors obtained from Report 204 of the American Association of Physicists in Medicine. Regression analyses were performed to find the relationship between SSDE and the various parameters to derive mathematical equations for the dose estimations. There were more female samples (n= 468, 56.3%) than male samples (n= 364, 43.7%) for each CT procedure. The SSDEs and size-specific diagnostic reference levels (SSDRLs) were: head (83.9 mGy; 86.9 mGy), chest (8.1 mGy; 8.7 mGy) and ABP (8.4 mGy; 9.2 mGy). The variations between CTDI_voland SSDEs for head (2.50%), chest (25.9%), and ABP (26.2%) showed an underestimation of radiation dose to patients, especially in chest and ABP examinations, if CTDI_volis used to report patient doses. The SSDEs of the chest and ABP CT examinations showed linear correlations with the CTDI_vol. The estimated values could be used to optimize radiation doses in the CT facility. The SSDE and SSDRLs for head, chest and ABP CT examinations have been developed at a teaching hospital in Ghana. The SSDEs of chest and ABP examinations showed linear correlations with the CTDI_voland hence can be calculated using the mathematically derived equations in the study.

Dose reference level based on size-specific dose estimate (SSDE) and feasibility of deriving effective body diameter using tube current and time product (mAs) for adult chest and abdomen computed tomography (CT) procedures

This study aimed to establish dose reference level (NDRLSSDE) based on size-specific dose estimate (SSDE) derived using effective diameter (Deff) for adult chest and abdomen computed tomography (CT) procedures and to explore the feasibility of drivingDeffusing the product of tube current and time (mAs). In this retrospective study, dose data, scan parameters and patient body dimensions at the mid-slice level from 14 CT units (out of 63 total) were extracted. Additionally, the mAs values of the axial slice at the samez-location where the diameter measurements were made (mAs_z) were recorded. Pearson's correlation (r) analysis was used to determine the relationship ofDeffwith patient BMI, weight, and mAs_z. The NDRLSSDEfor the chest and abdomen were 9.72 mGy and 13.4 mGy, respectively. The BMI and body weight were less correlated (r= 0.24 andr= 0.33, respectively) withDeff. The correlation between mAs_zandDeffwas considerably strong (r= 0.78) and can be used to predictDeffaccurately. The absolute dose differences between SSDEs calculated using the AAPM-204 method and mAs_zwas less than 1.1 mGy (15%). Therefore, mAs_zis an efficient parameter to deriveDeff. Further, the direct conversion factors to estimate SSDEs at different locations along thez-direction in the scan region from corresponding mAs and CTDIvolwere calculated. The NDRLSSDEsuggested in the present study can be used as a reference for size-dependent dose optimisation in Sri Lanka, and existing NDRL based on CTDIvolunderestimate the average adult CT dose by 36.0% and 39.7% for chest and abdomen regions respectively. The results show that using mAs_zto determine SSDE is a simple and practical approach with an accuracy of 95% and 85% for abdomen and chest scans, respectively. However, the obtained linear relationship betweenDeffand mAs is highly dependent on the ATCM technique and the user-determined noise levels of the scanning protocol. Finally, the phantom study resulted in the strongest correlation (r= 0.99) between theDwzand mAs_z, and the prediction of patient size would be more precise thanDeffmethod.

Comparison of Application Value of Different Radiation Dose Evaluation Methods in Evaluating Radiation Dose of Adult Thoracic and Abdominal CT Scan

Objective

To explore the differences among volumetric CT dose index (CTDI_vol), body-specific dose assessment (SSDE_ED) based on effective diameter (ED), and SSDE_WED based on water equivalent diameter (WED) in evaluating the radiation dose of adult thoracic and abdominal CT scanning.

Methods

From January 2021 to October 2021, enhanced chest CT scans of 100 patients and enhanced abdomen CT scans of another 100 patients were collected. According to the body mass index (BMI), they can be divided into groups A and D (BMI < 20 kg/m²), groups B and E (20 kg/m² ≤ BMI ≤ 24.9 kg/m²), and groups C and F (BMI > 24.9 kg/m²). The CTDIvol, anteroposterior diameter (AP), and the left and rght diameter (LAT) of all the patients were recorded, and the ED, water equivalent diameter (WED), the conversion factor (f _size,ED), (f _{size, WED}), SSDE_ED, and SSDE_WED were calculated. The differences were compared between the different groups.

Results

The AP, LAT, ED, and WED of groups B, E, C, and F were higher than those of groups A and D, and those of groups C and F were higher than those of groups B and E (P < 0.05). The f _size,ED and f _{size, WED} of groups B, E, C, and F are lower than those of groups A and D, and those of groups C and F are lower than those of groups B and E (P < 0.05). CTDI_vol, SSDE_ED, and SSDE_WED in groups B, E, C, and F are higher than those in groups A and D, and those in groups C and F are higher than those in groups B and E (p < 0.05). In the same group, patients with chest- and abdomen-enhanced have higher SSDE_WED and SSDE_ED than CTDI_vol, patients with chest-enhanced CT scans have higher SSDE_WED than SSDE_ED, and patients with abdomen-enhanced CT scans have higher SSDE_ED than SSDE_WED (P < 0.05).

Conclusion

CTDIvol and ED-based SSDEED underestimated the radiation dose of the subject exposed, where the patient was actually exposed to a greater dose. However, SSDE_WED based on WED considers better the difference in patient size and attenuation characteristics, and can more accurately evaluate the radiation dose received by patients of different sizes during the chest and abdomen CT scan.

Simplified approach to estimation of organ absorbed doses for patients undergoing abdomen and pelvis CT examination

The volumetric computed tomography (CT) dose index (CTDI_vol) is the measure of output displayed on CT consoles relating to dose within a standard phantom. This gives a false impression of doses levels within the tissues of smaller patients in Southeast Asia. A size-specific dose estimate (SSDE) can be calculated from the CTDI_volto provide an assessment of doses at specific positions within a scan using size-specific conversion factors. SSDE is derived using the water equivalent diameter (D_w) of the patient, but calculation ofD_wrequires sophisticated computer software. This study aimed to evaluate relationships betweenD_Wand effective diameter (D_Eff), which can be measured more readily, in order to estimate SSDE at various positions within a routine clinical abdomen and pelvis CT examination for Thai patients. An in-house ImageJ algorithm was developed to measureD_w, effective diameter (D_Eff), and SSDE on CT slices located at the heart, liver, kidneys, colon, and bladder, on 181 CT examinations of abdomen and pelvis. Relationships betweenD_EffandD_wwere determined, and values of organ absorbed dose usingD_Effwere estimated. This approach was validated using a second cohort of 54 patients scanned on a different CT scanner. The results revealed that ratios betweenD_EffandD_wat the heart level were 1.11-1.13 and those for the others were about 1.00. Additionally, the SSDE/CTDI_volratio was estimated for each organ in terms of exponential functions using the relationships betweenD_wandD_Efffor individual organs. In summary, this study proposed a simple method for estimation of organ absorbed doses for Southeast Asian patients undergoing abdomen and pelvis CT examinations where sophisticated computer software is not available.

Method of determining geometric patient size surrogates using localizer images in CT

Purpose

Size‐specific dose estimates (SSDE) requires accurate estimates of patient size surrogates. AAPM Report 204 shows that the SSDE is the product of CTDIvol and a scaling factor, the normalized dose coefficient (NDC) which depends on patient size surrogates for CT axial images. However, SSDE can be determined from CT localizer prior to CT scanning. AAPM Report 220 charges that a magnification correction is needed for geometric patient size‐surrogates. In this study, we demonstrate a novel “model‐based” magnification correction on patient data.

Methods

573 patient scans obtained from a clinical CT system including 229 adult abdomen, 284 adult chest, 48 pediatric abdomen, and 12 pediatric chest exams. LAT and AP dimensions were extracted from CT localizers using a threshold extraction method (the ACR DIR). The model‐based magnification correction was applied to the AP and LAT dimensions extracted using the ACR DIR. NDC was calculated using the effective diameter for the ACR DIR only, the model‐based localizer‐based and axial‐based approaches. The LAT and AP dimensions were extracted from the “gold” standard CT axial scans. Outliers are defined as points outside the 95% confidence intervals and were analyzed.

Results

NDC estimates for the localizer‐based model‐based approach had an excellent correlation (R² = 0.92) with the gold standard approach. The effective diameter for ACR DIR and model‐based approaches are 8.0% and 1.0% greater than the gold standard respectively. Outliers were determined to be primarily patient truncation, with arms down or with devices. ACR DIR size extraction method fails for bariatric patients where the threshold is too high and some of their anatomy was included in the CT couch, and small patients due to the CT couch being included in the size measurement.

Conclusion

The model‐based magnification method gives an accurate estimate of patient size surrogates extracted from CT localizers that are needed for calculating NDC to achieve accurate SSDE.

Evaluation of AAPM Reports 204 and 220: Estimation of effective diameter, water-equivalent diameter, and ellipticity ratios for chest, abdomen, pelvis, and head CT scans

Purpose

To confirm AAPM Reports 204/220 and provide data for the future expansion of these reports by: (a) presenting the first large‐scale confirmation of the reports using clinical data, (b) providing the community with size surrogate data for the head region which was not provided in the original reports, and additionally providing the measurements of patient ellipticity ratio for different body regions.

Method

A total of 884 routine scans were included in our analysis including data from the head, thorax, abdomen, and pelvis for adults and pediatrics. We calculated the ellipticity ratio and all of the size surrogates presented in AAPM Reports 204/220. We correlated the purely geometric‐based metrics with the “gold standard” water‐equivalent diameter (D_W).

Results

Our results and AAPM Reports 204/220 agree within our data's 95% confidence intervals. Outliers to the AAPM reports’ methods were caused by excess gas in the GI tract, exceptionally low BMI, and cranial metaphyseal dysplasia. For the head, we show lower correlation (R² = 0.812) between effective diameter and D_W relative to other body regions. The ellipticity ratio of the shoulder region was the highest at 2.28 ± 0.22 and the head the smallest at 0.85 ± 0.08. The abdomen pelvis, chest, thorax, and abdomen regions all had ellipticity values near 1.5.

Conclusion

We confirmed AAPM reports 204/220 using clinical data and identified patient conditions causing discrepancies. We presented new size surrogate data for the head region and for the first time presented ellipticity data for all regions. Future automatic exposure control characterization should include ellipticity information.