National Diagnostic Reference Levels for Standard Descending Thoracic Endovascular Aortic Repair and Optimisation Strategies

OBJECTIVE

The International Commission on Radiological Protection has highlighted the large number of medical specialties that use fluoroscopy outside diagnostic imaging departments without radiation protection programmes for patients and staff. Vascular surgery is one of these specialties. Thoracic endovascular aortic repair (TEVAR) is a complicated procedure requiring radiation protection guidance and optimisation. The recent EU Basic Safety Standards Directive requires the use and periodic updating of diagnostic reference levels (DRLs) for interventional procedures. The aim of this study was to determine doses for patients undergoing TEVAR with mobile X-ray systems and hybrid rooms (fixed X-ray systems) to obtain national DRLs and to suggest optimisation actions.

METHODS

This was a retrospective cross-sectional study. The Spanish Chapter of Endovascular Surgery conducted a national survey in 11 autonomous communities representing around 77.6% of the Spanish population (47.33 million inhabitants). A total of 266 TEVAR procedures from 17 Spanish centres were analysed, of which 50.2% were performed in hybrid operating rooms. National DRLs were obtained and defined as the third quartile of the median values from the different participating centres.

RESULTS

The proposed national DRLs are: for kerma area product (KAP), 113.81 Gy·cm2 for mobile X-ray systems and 282.59 Gy·cm2 for hybrid rooms; and for cumulative air kerma (CAK) at the patient entry reference point, 228.38 mGy for mobile systems and 910.64 mGy for hybrid rooms.

CONCLUSION

Based on the requirement to know radiation doses for standard endovascular procedures, this study of TEVARs demonstrated that there is an increased factor of 2.48 in DRLs for KAP when the procedure is performed in a hybrid room compared with mobile C-arm systems, and an increased factor of 3.98 in DRLs for CAK when the procedure is performed with hybrid equipment. These results will help to optimise strategies to reduce radiation doses during TEVAR procedures.

Managing radiation safety and protection in gastroenterology in Japan: insights from the REX-GI study

Fluoroscopy-guided gastrointestinal procedures, including gastrointestinal stenting, balloon-assisted endoscopy (BAE), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS), are essential for diagnosis and treatment in gastroenterology. Such procedures involve radiation exposure that necessitates strict safety measures to protect patients, doctors, and medical staff. The April 2020 update to Japan's Ionizing Radiation Injury Prevention Regulations for occupational exposure reduced the lens exposure dose limit to approximately one-seventh of its previous level. This change highlights the need for improved safety protocols. Without adaptation, the sustainability of fluoroscopy-based endoscopic techniques could be at risk due to the potential to exceed these new limits. This review examines the current state of medical radiation exposure in the field of gastroenterology in Japan and discusses the findings of the REX-GI study.

Impact of equipment technology on reference levels in fluoroscopy-guided gastrointestinal procedures

OBJECTIVES

To evaluate the effect of equipment technology on reference point air kerma (Ka,r), air kerma-area product (PKA), and fluoroscopic time for fluoroscopically-guided gastrointestinal endoscopic procedures and establish benchmark levels.

METHODS

This retrospective study included the consecutive patients who underwent fluoroscopically-guided gastrointestinal endoscopic procedures from May 2016 to August 2023 at a tertiary care hospital in the U.S. Fluoroscopic systems included (a) Omega CS-50 e-View, (b) GE Precision 500D, and (c) Siemens Cios Alpha. Radiation dose was analyzed for four procedure types of endoscopic retrograde biliary, pancreas, biliary and pancreas combined, and other guidance. Median and 75th percentile values were computed using software package R (version 4.0.5, R Foundation).

RESULTS

This large study analyzed 9,459 gastrointestinal endoscopic procedures. Among four procedure types, median Ka,r was 108.8-433.2 mGy (a), 70-272 mGy (b), and 22-55.1 mGy (c). Median PKA was 20.9-49.5 Gy∙cm2 (a), 13.4-39.7 Gy∙cm2 (b), and 8.91-20.9 Gy∙cm2 (c). Median fluoroscopic time was 2.8-8.1 min (a), 3.6-9.2 min (b), and 2.9-9.4 min (c). Their median value ratio (a:b:c) was 8.5:4.8:1 (Ka,r), 2.7:2.1:1 (PKA), and 1.0:1.1:1 (fluoroscopic time). Median value and 75th percentile are presented for Ka,r, PKA, and fluoroscopic time for each procedure type, which can function as benchmark for comparison for dose optimization studies.

CONCLUSION

This study shows manifold variation in doses (Ka,r and PKA) among three fluoroscopic equipment types and provides local reference levels (50th and 75th percentiles) for four gastrointestinal endoscopic procedure types. Besides procedure type, imaging technology should be considered for establishing diagnostic reference level.

SUMMARY

With manifold (2 to 12 times) variation in doses observed in this study among 3 machines, we recommend development of technology-based diagnostic reference levels for gastrointestinal endoscopic procedures.

Establishment of a local diagnostic reference level for computed tomography chest and abdomen in two different cities in Saudi Arabia

BACKGROUND AND AIM

Spiral computed tomography (CT) scans, which are considered a high-contrast resolution, quick and cross-sectional imaging technique, have grown in popularity as a result of technological advancements. However, these advancements have brought with them the potential for significantly increased radiation doses to the patient. Consequently, many organizations recommended optimization and establishing diagnostic reference levels. The aim of the current study was to assess CT radiation dose and propose a local diagnostic reference level (LDRL) for the adult trunk [chest and abdomen] using CT dose parameters such as CT dose index volume (CTDIvol) and dose length product (DLP) as well as to compare the practices for aforementioned examinations between two hospitals in Taif and Abha cities in Saudi Arabia.

MATERIALS AND METHODS

Data from 428 patients (216 for abdomen and 212 for chest) who were examined in two hospitals in Taif and Abha City in Saudi Arabia from December 2022 to March 2023, are used in this study. The data for hospitals in Taif and Abha are presented as 'T' and 'A' throughout this manuscript. The parameters of exposure and slice thickness were recorded in a specially designed data sheet together with the gender, age and patients morphometric. Microsoft Excel version 2010 was used to analyze results and plot the figures. The LDRL was achieved from the third quartile of CTDIvol and DLP for each hospital and examination.

RESULTS

The average DLP (mGy-cm) and CTDIvol (mGy) for the chest and abdomen were 243 mGy cm, 5.8 mGy and 549 mGy cm, 8.6 mGy respectively. The average effective dose (ED) for chest and abdomen were 5.10 and 21.10 mSv, respectively. The proposed LDRL for the chest and abdomen were 6.9 mGy (CTDIvol), 375 mGy-cm (DLP), 7.8 mGy (CTDIvol), and 747 (DLP) mGy-cm, respectively.

CONCLUSION

Hospital 'A' irradiated patients with a higher dose for the abdomen exam than Hospital 'T', but both hospitals agreed on the amount of radiation dose received by patients for chest imaging. The proposed LDRL for two examinations was less than the DRL obtained from the literature.

Diagnostic reference levels in spinal CT: Jordanian assessments and global benchmarks

BACKGROUND

To reduce radiation dose and subsequent risks, several legislative documents in different countries describe the need for Diagnostic Reference Levels (DRLs). Spinal radiography is a common and high-dose examination. Therefore, the aim of this work was to establish the DRL for Computed Tomography (CT) examinations of the spine in healthcare institutions across Jordan.

METHODS

Data was retrieved from the picture archiving and communications system (PACS), which included the CT Dose Index (CTDI (vol) ) and Dose Length Product (DLP). The median radiation dose values of the dosimetric indices were calculated for each site. DRL values were defined as the 75th percentile distribution of the median CTDI (vol)  and DLP values.

RESULTS

Data was collected from 659 CT examinations (316 cervical spine and 343 lumbar-sacral spine). Of the participants, 68% were males, and the patients' mean weight was 69.7 kg (minimum = 60; maximum = 80, SD = 8.9). The 75th percentile for the DLP of cervical and LS-spine CT scans in Jordan were 565.2 and 967.7 mGy.cm, respectively.

CONCLUSIONS

This research demonstrates a wide range of variability in CTDI (vol)  and DLP values for spinal CT examinations; these variations were associated with the acquisition protocol and highlight the need to optimize radiation dose in spinal CT examinations.

National UK Survey of Radiation Doses During Endovascular Aortic Interventions

PURPOSE

Endovascular aortic repair (EAR) interventions, endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), are associated with significant radiation exposures. We aimed to investigate the radiation doses from real-world practice and propose diagnostic reference level (DRL) for the UK.

MATERIALS AND METHODS

Radiation data and essential demographics were retrospectively collected from 24 vascular and interventional radiology centres in the UK for all patients undergoing EAR-standard EVAR or complex, branched/fenestrated (BEVAR/FEVAR), and TEVAR-between 2018 and 2021. The data set was further categorised according to X-ray unit type, either fixed or mobile. The proposed national DRL is the 75th percentile of the collective medians for procedure KAP (kerma area product), cumulative air kerma (CAK), fluoroscopy KAP and CAK.

RESULTS

Data from 3712 endovascular aortic procedures were collected, including 2062 cases were standard EVAR, 906 cases of BEVAR/FEVAR and 509 cases of TEVAR. The majority of endovascular procedures (3477/3712) were performed on fixed X-ray units. The proposed DRL for KAP was 162 Gy cm2, 175 Gy cm2 and 266 Gy cm2 for standard EVAR, TEVAR and BEVAR/FEVAR, respectively.

CONCLUSION

The development of DRLs is pertinent to EAR procedures as the first step to optimise the radiation risks to patients and staff while maintaining the highest patient care and paving the way for steps to reduce radiation exposures.

Radiation Exposure in Interventional Stroke Treatment : Analysis of the German Neurointerventional Database (DeGIR/DGNR) from 2019 to 2021

PURPOSE

To evaluate patient-related radiation exposure in interventional stroke treatment by analyzing data from the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) and the German Society of Neuroradiology (DGNR) quality registry from 2019-2021.

METHODS

The DeGIR/DGNR registry is the largest database of radiological interventions in Germany. Since the introduction of the registry in 2012, the participating hospitals have entered clinical and dose-related data on the procedures performed. To evaluate the current diagnostic reference level (DRL) for mechanical thrombectomy (MT) in stroke patients, we analyzed interventional data from 2019 to 2021 with respect to the reported dose area product (DAP) and factors that might contribute to the radiation dose, such as the localization of the occlusion, technical success using the modified treatment in cerebral ischemia (mTICI) score, number of passages, technical approach, additional intracranial/extracranial stenting, and case volume per center.

RESULTS

A total of 41,538 performed MTs from 180 participating hospitals were analyzed. The median DAP for MT was 7337.5 cGy∙cm2 and the corresponding interquartile range (IQR) Q25 = 4064 cGy∙cm2 to Q75 = 12,263 cGy∙cm2. In addition, we discovered that the dose was significantly influenced by occlusion location, number of passages, case volume per center, recanalization score, and additional stenting.

CONCLUSION

We conducted a retrospective study on radiation exposure during MT in Germany. Based on the results of more than 41,000 procedures, we observed that the DRL of 14,000 cGy·cm2 is currently appropriate but may be lowered over the next years. Furthermore, we identified several factors that contribute to high radiation exposure. This can aid in detecting the cause of an exceeded DRL and optimize the treatment workflow.

Establishing weight-based diagnostic reference levels for neonatal chest X-rays

INTRODUCTION

As weights among neonates can vary from <900 g to >2.5 kg, weight-based Diagnostic Reference Levels (DRLs) specific to the neonatal intensive care unit (NICU) are essential. Repeated radiation exposure to this sensitive patient group raises concerns regarding high cumulative radiation doses and the potential for long-term health detriment. This study aimed to establish weight-based DRLs for neonates undergoing mobile chest radiography (CXR) in the NICU.

METHODS

Neonates were classified into three discrete groups; <1000, 1000-2500 and >2500 g. Data were collected prospectively over three months; 95 DAP values were collected, and five were excluded due to poor technique, leaving 90 patients that met the inclusion criteria for mobile CXR in the NICU. Dose-area-product (DAP) in mGycm², the peak kilovoltage (kVp) and the product of tube current and exposure time (mAs) were retrieved from the Picture Archiving and Communication System (PACS). Images and radiological reports were also analysed to confirm diagnostic image quality (IQ). Local DRLs (LDRLs) were derived using the median DAP, and national DRLs were suggested using the 3rd quartile value.

RESULTS

The proposed LDRLs for neonates weighing <1000 g was 2.7 mGycm², for neonates weighing between 1000 g and 2500 g, it was 3.7 mGycm², and for neonates weighing >2500 g it was 6.6 mGycm². The radiation dose received by the 90 (100%) neonates included in the study fell below 11.4 mGycm²; of these, 82% of the DAP values fell below the study institution's existing LDRL of 7.25 mGycm².

CONCLUSION

Weight-based DRLs provide crucial information on doses to this specific radiation-sensitive group. This work recommends using weight-based categories for DRLs and serves as a benchmark for neonatal CXR standardisation and optimisation.

IMPLICATIONS FOR PRACTICE

The proposed weight-based DRLs can be adopted for neonates' locally, nationally and internationally.

Establishment of a local diagnostic reference level for dental intraoral bitewing X-rays

A state-based local diagnostic reference level (LDRL) for dental intraoral X-rays has been established. LDRL values of 2.0 mGy incident air kerma (IAK) and 57 mGy•cm² air kerma-area product (KAP) for an adult posterior bitewing X-ray were determined based on 811 X-ray units surveyed. This IAK LDRL value is greater than those established in several other nations and regions around the world in similar studies. Analyses of radiographic technique and equipment usage are included to provide broad guidance as to ways that imaging could be optimised, such as in the selection of exposure factors, collimators, image receptors, and X-ray unit models.

Is it necessary to define new diagnostic reference levels during pandemics like the Covid19-?

Introduction

This study intended to assess the dose length product (DLP), effective cumulative radiation dose (E.D.), and additional cancer risk (ACR) due to a chest CT scan to detect or follow up the Covid-19 disease in four university-affiliated hospitals that used different imaging protocols. Indeed, this study aimed to examine the differences in decision-making between different imaging centers in choosing chest CT imaging protocols during the pandemic, and to assess whether a new diagnostic reference level (DRL) is needed in pandemic situations.

Methods

This retrospective study assessed the E.D. of all chest imagings for Covid-19 for six months in four different hospitals in our country. Imaging parameters and DLP (mGy.cm) were recorded. The E.D.s and ACRs from chest CT scans were calculated using an online calculator.

Results

Thousand-six hundred patients were included in the study. The mean cumulative dose due to chest CT was 3.97 mSv which might cause 2.59 × 10^-2 ACR. The mean cumulative E.D. in different hospitals was in the range of 1.96-9.51 mSv.

Conclusions

The variety of mean E.D.s shows that different hospitals used different imaging protocols. Since there is no defined DRL in the pandemic, some centers use routine protocols, and others try to reduce the dose but insufficiently.In pandemics such as Covid-19, when CT scan is used for screening or follow-up, DLPs can be significantly lower than in normal situations. Therefore, international regularized organizations such as the international atomic energy agency (IAEA) or the international commission on radiological protection (IRCP) should provide new DRL ranges.

Evaluation of In-room Volumetric Imaging Doses for Image-guided Radiotherapy: A Multi-institutional Study

Aims

We investigated imaging dose and noise under clinical scan conditions at multiple institutions using a simple and unified method, and demonstrated the need for diagnostic reference levels in image-guided radiotherapy (IGRT).

Materials and Methods

Nine cone-beam and helical computed tomography (CT) scanners (Varian, Elekta, Accuray Inc., and BrainLAB) from seven institutions were investigated in this study. The weighted cone-beam dose index (CBDIw) was calculated for head and pelvic protocols using a 100 mm pencil chamber under the conditions used in actual clinical practice at each institution. Cone-beam CT image noise was evaluated using polymethylmethacrylate head and body phantoms with diameters of 16 and 32 cm, respectively.

Results

For head and pelvic protocols, CBDIw values ranged from 0.94-6.59 and 1.47-20.9 mGy, respectively. Similarly, standard deviation (SD) values ranged from 9.3-34.0 and 26.9-97.4 HU, respectively. The SD values tended to increase with decreasing imaging dose (r = -0.33 and -0.61 for the head and pelvic protocols, respectively).

Conclusions

Among the nine machines, the imaging dose for high imaging dose institutions was approximately 20 mGy to the pelvic phantom, and there was a 14-fold difference in dose compared with the other institutions. These results suggest the need to establish DRLs for IGRT to guide clinical decision-making.

Effective radiation dose of skeletal surveys performed for suspected physical abuse

BACKGROUND

A skeletal survey is an important diagnostic tool for patients presenting with suspected physical abuse. A relatively recent change in guidelines for skeletal surveys by the Royal College of Radiologists (RCR) in 2017 has led to more initial and follow-up images for these patients, which would be expected to have led to an increase in effective radiation dose.

OBJECTIVE

To estimate the effective dose following the change in guidelines and to ascertain the difference between doses before and after the change in guidelines.

MATERIALS AND METHODS

Data were collected retrospectively on children younger than 3 years old referred for skeletal surveys for suspected physical abuse at a tertiary paediatric centre. A Monte Carlo radiation patient dose simulation software, PCXMC v 2.0.1, was used to estimate the effective dose, expressed in millisieverts (mSv).

RESULTS

Sixty-eight children underwent skeletal surveys for suspected physical abuse. The total estimated effective dose for skeletal surveys with the previous RCR guidelines was found to be 0.19 mSv. For initial skeletal surveys with the current RCR guidelines, the estimated effective radiation dose was 0.19 mSv. Eighteen children had both initial and follow-up skeletal surveys as indicated by the current RCR guidelines, with an estimated effective total radiation dose of 0.26 mSv.

CONCLUSION

Skeletal surveys deliver a relatively low estimated effective radiation dose equivalent to 1 month of United Kingdom background radiation, with no significant change in dose following the change in guidelines. Therefore, the benefits of having a skeletal survey outweigh the main radiation risk. However, accurate data regarding the radiation dose are important for clinicians consenting parents/guardians for imaging in suspected physical abuse.

Typical median effective radiation doses using an anthropomorphic bone fracture phantom for initial radiographic skeletal surveys in the investigation of suspected physical abuse

BACKGROUND

A series of 31 radiographs is recommended by the Royal College of Radiologists (RCR) when investigating suspected physical abuse (SPA).

OBJECTIVE

To determine the radiation dose delivered for skeletal surveys performed for SPA in Victorian radiology departments based on their local protocols.

MATERIALS AND METHODS

A 5-year-old paediatric bone fracture phantom was radiographed at five radiology sites using both the RCR recommended protocol and, where applicable, the local departmental SPA protocol. The radiation doses were measured and recorded. These were scaled down to estimate the effective radiation doses for a 2-year-old child at each site and the associated radiation risks estimated.

RESULTS

The median effective dose for all radiographic projections in the RCR skeletal survey radiographic series was 0.09 mSv. The estimated risk of radiation-induced cancer and radiation-induced death from cancer for 2-year-old children is classified as "very low," with girls having a higher risk than boys.

CONCLUSION

The median effective radiation dose for the RCR skeletal survey for imaging in SPA was 0.09 mSv resulting in a "very low" additional risk of radiation-induced cancer. The authors will now aim to ascertain whether whole-body CT skeletal survey can replace the radiographic series for imaging in SPA while maintaining a comparable radiation dose.

Patient size as a parameter for determining Diagnostic Reference Levels for paediatric Computed Tomography (CT) procedures

INTRODUCTION

The paediatric radiation dose has never been studied in Sri Lanka, nor has a national diagnostic reference level (NDRL) established. Therefore, the primary aim of this study was to propose diagnostic reference levels (DRL) and achievable dose (AD) values for paediatric CT examinations based on size.

METHODS

A total of 658 paediatric (0-15 years) non-contrast-enhanced (NC) studies of head, chest and abdomen regions performed during six months in two dedicated paediatric hospitals (out of the three such institutions in the country) were included. For head examinations, the dose indexes were analysed based on age, while for body examinations, both age and effective diameter (D_eff) were used. The median and the third quartile of the pooled dose distribution were given as AD and NDRL, respectively.

RESULTS

The AD ranges for the head, chest and abdomen regions based on CTDI_vol were 45.8-57.2 mGy, 2.9-10.0 mGy and 3.8-10.3 mGy. The corresponding NDRL ranges were 45.8-95.8 mGy, 3.5-14.1 mGy and 4.5-11.9 mGy. The AD ranges based on SSDE_deff and d_eff were 3.5-9.6 mGy and 4.1-10.3 mGy in chest and abdomen regions. The corresponding NDRL were 4.5-14.1 mGy and 6.1-10.6 mGy.

CONCLUSION

Other institutions can use the present study DRLs as a reference dose for paediatric CT. The AD values can be used as a baseline for target dose optimisations, reducing doses up to 90%.

Practical dosimetry procedure of air kerma for kilovoltage X-ray imaging in radiation oncology using a 0.6-cc cylindrical ionization chamber with a cobalt absorbed dose-to-water calibration coefficient

In this study, we implemented a practical dosimetry procedure of air kerma for kilovoltage X-ray beams using a 0.6-cc cylindrical ionization chamber, and validated the procedure with the accuracy of the measurements using the 0.6-cc chamber compared to the measurements using a 6-cc chamber and a semiconductor device. In addition, the kerma area products (KAPs) were compared with the dose reference levels of radiology. A modified air kerma formalism using a 0.6-cc cylindrical ionization chamber air kerma formalism with a cobalt absorbed dose-to-water calibration coefficient was implemented. Validation of the formalism showed good agreement between the 0.6-cc chamber and the 6-cc chamber (< 5%), and between the 0.6-cc chamber and the semiconductor device (< 2%) in the 60-120 kV range. The KAPs for four RO machines had difference factors of 0.04-15.4 and 0.01-4.1 from their median and maximum dose reference levels in radiology, respectively.

A cloud-fog software architecture for dental CBCT dose monitoring using the DICOM structured report: Automated establishment of DRL

PURPOSE

The diagnostic reference level (DRL) has been established to optimize the diagnostic methods and reduce radiation dose during radiographic examinations. The aim of this study was to present a completely new solution based on Cloud-Fog software architecture for automatic establishment of the DRL values during dental cone-beam computed tomography (CBCT) according to digital imaging and communications in medicine (DICOM) structured reports.

METHODS AND MATERIALS

A Cloud-Fog software architecture was used for automatic data handling. This architecture used the DICOM structured reports as a source for extracting the required information by fog devices in the imaging center. These devices transferred the derived information to the cloud server. The cloud server calculated the value of indication-based DRL in dental CBCT imaging based upon the parameters and adequate quantities of the absorbed dose. The feedback of DRL value was continuously announced to the imaging centers in 6 phases. In each phase, the level of the dose was optimized in imaging centers.

RESULTS

The DRL value was established for 5-specific indications, including third molar teeth (511 mGy.cm²), implant (719 mGy.cm²), form and position anomalies of the tooth (408 mGy.cm²), dentoalveolar pathologies (612 mGy.cm²), and endodontics (632 mGy.cm²). The determination of the DRL value in each phase revealed a downward trend until stabilization.

CONCLUSION

The new solution presented in this study makes it possible to calculate and update the DRL value nationally and automatically among all centers. Also, the results showed that this approach is successful in establishing stabilized DRL values.

Establishment of Local Diagnostic Reference Levels of Pediatric Abdominopelvic and Chest CT Examinations Based on the Body Weight and Size in Korea

OBJECTIVE

The purposes of this study were to analyze the radiation doses for pediatric abdominopelvic and chest CT examinations from university hospitals in Korea and to establish the local diagnostic reference levels (DRLs) based on the body weight and size.

MATERIALS AND METHODS

At seven university hospitals in Korea, 2494 CT examinations of patients aged 15 years or younger (1625 abdominopelvic and 869 chest CT examinations) between January and December 2017 were analyzed in this study. CT scans were transferred to commercial automated dose management software for the analysis after being de-identified. DRLs were calculated after grouping the patients according to the body weight and effective diameter. DRLs were set at the 75th percentile of the distribution of each institution's typical values.

RESULTS

For body weights of 5, 15, 30, 50, and 80 kg, DRLs (volume CT dose index [CTDIvol]) were 1.4, 2.2, 2.7, 4.0, and 4.7 mGy, respectively, for abdominopelvic CT and 1.2, 1.5, 2.3, 3.7, and 5.8 mGy, respectively, for chest CT. For effective diameters of < 13 cm, 14-16 cm, 17-20 cm, 21-24 cm, and > 24 cm, DRLs (size-specific dose estimates [SSDE]) were 4.1, 5.0, 5.7, 7.1, and 7.2 mGy, respectively, for abdominopelvic CT and 2.8, 4.6, 4.3, 5.3, and 7.5 mGy, respectively, for chest CT. SSDE was greater than CTDIvol in all age groups. Overall, the local DRL was lower than DRLs in previously conducted dose surveys and other countries.

CONCLUSION

Our study set local DRLs in pediatric abdominopelvic and chest CT examinations for the body weight and size. Further research involving more facilities and CT examinations is required to develop national DRLs and update the current DRLs.

Understanding the Basis of Radiation Protection for Endovascular Procedures: Occupational and Patients

Introduction

Some concepts of radiation protection are not well understood and must be refreshed periodically. The basic knowledge that a vascular surgeon must have about radiation protection for patients and staff is summarised.

Report

Diagnostic reference levels are a form of investigation into the medical exposure of patients during diagnostic and endovascular procedures that help to optimise them. Radiological quantities such as dose area product, also known as kerma area product and cumulative dose, are the most relevant to the patient. Equivalent dose, in mSv, determines the dose limits for staff. The effective dose (related to absorbed dose), also in mSv, represents the global risk of cancer and hereditary effects. For patient protection, the most important factors are fluoroscopy time, collimation, magnification, keeping the patient as near as possible to the image detector and as far as possible away from the tube, and trying to work in fluoroscope mode. Regarding occupational protection, distance, shielding, and dosimetry are the most important.

Discussion

With the increased use of endovascular procedures, radiation protection is an issue that has grown in importance. Radiation protection is based on three principles: justification; optimisation; and dose limits. Every action focused on reducing a patient's radiation dose will also reduce the dose to staff. Basic principles such as “the further away the better”, “always use a lead apron, thyroid protector, and lead glasses”, and “do not forget to wear personal dosimeters” must be remembered at all times.

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Radiation protection focuses on healthcare staff and patients.

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Diagnostic reference levels are essential in standard procedures.

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Operators should know their personal dose and radiation limits.

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Time, distance, and shielding are important.

Dosimetry of pediatric chest X-Ray examinations in Togo

OBJECTIVE

To assess the entrance surface dose (ESD) of pediatric chest X-ray examinations in order to establish a diagnostic reference levels (DRLs) in Togo.

MATERIALS AND METHODS

The study was carried out in 13 radiology departments within the 6 health regions of the country. This is a descriptive cross-sectional study relating to the dosimetric assessment of the skin of children aged from 0 to 15 years during chest X-ray examinations. The assessment was made by the empirical formula calculation of the entrance surface dose (ESD = 0.15 × (U/100)² × Q × (1/FSD)²) and with the Internet Dose Calculation Module (MICADO) software online. Statistical assessment was performed using IBM SPSS 21 software.

RESULTS

Our sample numbered 390 with a sex ratio of 1.3 and predominantly male. Examinations performed with the analog radiography units were more irradiating (0.14 mGy) than ones performed with digital detectors (0.12 mGy). The mean dose calculated with MICADO was low (Avg. = 0.12 mGy) compared to that calculated with the theoretical method (Avg. = 0.16 mGy). No significant relationship was found between the professional experience of operators and the entrance surface dose (r  > -1 with p = 0.146 not significant). MICADO doses increased with age. The values of the diagnostic reference levels used for the antero-posterior or postero-anterior chest X-ray examinations for children aged 0-1 year; 1-5 years; 5-10 years and 10-15 years were respectively, 0.15 mGy; 0.14 mGy; 0.15 mGy and 0.17 mGy.

CONCLUSION

The entrance surface dose varied greatly from one health facility to another for this same examination. In most of the different age groups of children, the diagnostic reference level was higher than that found in literature. Thus, effective measures must be put in place to optimize the doses delivered to children during chest X-ray examinations.

Local diagnostic reference levels for skeletal surveys in suspected physical child abuse

INTRODUCTION

The purpose was to determine if an age based, local diagnostic reference level for paediatric skeletal surveys could be established using retrospective data.

METHODS

All children below two years of age referred for a primary skeletal survey as a result of suspected physical abuse during 2017 or 2018 (n = 45) were retrospectively included from a large Danish university hospital. The skeletal survey protocol included a total of 33 images. Dose Area Product (DAP) and acquisition parameters for all images were recorded from the Picture Archival and Communication System (PACS) and effective dose was estimated. The 75th percentile for DAP was considered as the diagnostic reference level (DRL).

RESULTS

The 75th percentile for DAP was 314 mGy∗cm², 520 mGy∗cm² and 779 mGy∗cm² for children <1 month, 1-11 months and 12 < 24 months of age respectively. However, only the age group 1-11 months had a sufficient number of children (n = 27) to establish a local DRL. Thus, for the other groups the DAP result must be interpreted with caution. Effective dose was 0.19, 0.26 and 0.18 mSv for children <1, 1-11 months and 12 < 24 months of age respectively.

CONCLUSION

For children between 1 and 11 months of age, a local diagnostic reference level of 520 mGy∗cm² was determined. This may be used as an initial benchmark for primary skeletal surveys as a result of suspected physical abuse for comparison and future discussion.

IMPLICATIONS FOR PRACTICE

While the data presented reflects the results of a single department, the suggested diagnostic reference level may be used as a benchmark for other departments when auditing skeletal survey radiation dose.

Establishing local diagnostic reference levels for mini C-arm use in upper limb surgery - A step towards national audit

AIMS

Under the Ionising Radiation Medical Exposure Regulations, hospitals using fluoroscopy and image intensifiers should monitor doses from exposures using ionising radiation. There is a need for national diagnostic reference levels to advise Orthopaedic and Plastic surgeons on safe screening times and radiation doses for patients having upper limb surgical procedures.

METHODS

Retrospective study of all patients who underwent upper limb surgical procedures requiring intra-operative mini C-arm image intensifier use at our hospital between 2013 and 2019. This included results from three machines in different rooms. Procedures were classified as closed and open procedures.

RESULTS

Information on a total of 2910 procedures over 6 years (June 2013 to June 2019) were obtained. 133 procedures with incomplete data and 4 cases of lower extremities were excluded. 1719 closed procedures had a median dose area product of 0.48 cGycm² and median screening time of 7 s, compared to 1054 open procedures, with a median dose area product of 1.88 cGycm² and median screening time of 28 s. National diagnostic reference levels are set at the third quartile and indicate the difference between good and poor practice. For diagnostic reference levels, we suggest a dose area product of 0.82 cGycm² and a screening time of 11 s for closed procedures and a dose area product of 3.07 cGycm² and screening time of 40 s for open procedures. Public Health England state that national diagnostic reference levels should be derived from multiple patients, radiology rooms and hospitals. Our data meets the first two criteria and is an initial step in establishing national diagnostic reference levels for upper limb mini C-arm use.

CONCLUSIONS

This large audit reports results, which, with further work across multiple hospital sites, should lead to establishing national diagnostic reference levels for mini C-arm fluoroscopy for upper limb Orthopaedic procedures.

National survey to set diagnostic reference levels in nuclear medicine single photon emission imaging in Croatia

PURPOSE

In order to introduce the concept of diagnostic reference levels (DRLs) in the national nuclear medicine practice a survey was proposed and completed through all nuclear medicine departments in Croatia. An additional aim was to increase the awareness of importance and full implementation of a comprehensive quality program that includes devices used in the nuclear medicine chain.

METHODS

Data were collected for more than 30 nuclear medicine single photon emission procedures. National DRLs (NDRLs) as administered activity and also as administered activity per unit mass were calculated in accordance to International Commission on Radiological Protection (ICRP) recommendations. Additionally, effective doses were estimated using conversion factors published by the ICRP.

RESULTS

NDRLs for nuclear medicine single photon emission procedures were proposed. For procedures performed in only one department typical values were presented as reference. Effective doses related to applied radiopharmaceuticals were calculated to estimate radiation risk related to respective nuclear medicine procedure in more detail.

CONCLUSION

This work presents results of the first national survey on DRLs of nuclear medicine single photon emission procedures and proposes reliable NDRLs that represent an actual status of nuclear medicine practice in Croatia. Results have motivated departments to introduce and set their own typical values to be used, as one of the tools, for further optimization process. One of the drawbacks of the DRL concept in nuclear medicine is the lack of the image quality parameters involved. For this reason, a quantity that considers both radiation protection and image quality should be introduced.

Establishment of national diagnostic reference levels in dental cone beam computed tomography in Switzerland

OBJECTIVES

The aim of this study was to establish diagnostic reference levels (DRLs) in the field of dental maxillofacial and ear-nose-throat (ENT) practices using cone beam CT (CBCT) in Switzerland.

METHODS

A questionnaire was sent to owners of CBCTs in Switzerland; to a total of 612 institutions. The answers were analyzed for each indication, provided that enough data were available. The DRLs were defined as the 75th percentile of air kerma product distribution (PKA).

RESULTS

227 answers were collected (38% of all centers). Third quartile of PKA values were obtained for five dental indications: 662 mGy cm² for wisdom tooth, 683 mGy cm² for single tooth implant treatment, 542 mGy cm² for tooth position anomalies, 569 mGy cm² for pathological dentoalveolar modifications, and 639 mGy cm² for endodontics. The standard field of view (FOV) size of 5 cm in diameter x 5 cm in height was proposed.

CONCLUSIONS

Large ranges of FOV and PKA were found for a given indication, demonstrating the importance of establishing DRLs as well as FOV recommendations in view of optimizing the present practice. For now, only DRLs for dental and maxillofacial could be defined; because of a lack of ENT data, no DRL values for ENT practices could be derived from this survey.

The 2020 national diagnostic reference levels for nuclear medicine in Japan

The diagnostic reference levels (DRLs) are one of several effective tools for optimizing nuclear medicine examinations and reducing patient exposure. With the advances in imaging technology and alterations of examination protocols, the DRLs must be reviewed periodically. The first DRLs in Japan were established in 2015, and since 5 years have passed, it is time to review and revise the DRLs. We conducted a survey to investigate the administered activities of radiopharmaceuticals and the radiation doses of computed tomography (CT) in hybrid CT accompanied by single photon emission computed tomography (SPECT)/CT and positron emission tomography (PET)/CT. We distributed a Web-based survey to 915 nuclear medicine facilities throughout Japan and survey responses were provided by 256 nuclear medicine facilities (response rate 28%). We asked for the facility's median actual administered activity and median radiation dose of hybrid CT when SPECT/CT or PET/CT was performed for patients with standard habitus in the standard protocol of the facility for each nuclear medicine examination. We determined the new DRLs based on the 75th percentile referring to the 2015 DRLs, drug package inserts, and updated guidelines. The 2020 DRLs are almost the same as the 2015 DRLs, but for the relatively long-lived radionuclides, the DRLs are set low due to the changes in the Japanese delivery system. There are no items set higher than the previous values. Although the DRLs determined this time are roughly equivalent to the DRLs used in the US, overall they tend to be higher than the European DRLs. The DRLs of the radiation dose of CT in hybrid CT vary widely depending on each imaging site and the purpose of the examination.

Assessment of Regional Pediatric Diagnostic Reference Levels for Panoramic Radiography Using Dose Area Product

AIM

The current work aims to calculate dose area product (DAP) and to determine regional diagnostic reference level (DRL) for pediatric panoramic radiography in Tamil Nadu.

MATERIALS AND METHODS

In this study, DAP was calculated after finding the product of air kerma on the detector side of scanner with the corresponding exposed area. The obtained DAP values were further analyzed, and DRL was calculated using Microsoft Excel. The study was carried out with routine pediatric exposure parameters.

RESULTS

The obtained mean, range, and third quartile values for pediatric panoramic radiography are found to be 65 mGycm2, 11-148 mGycm2, and 82 mGycm2, respectively. The proposed DRL is comparable with the other countries' DRL.

CONCLUSION

Based on the results of the present study, it was observed that there exists a wide difference in mean doses among the panoramic scanners. The variation in radiation doses between the clinics/hospitals and similar scanners suggests a large potential for optimization of panoramic procedures.

Provision of Italian diagnostic reference levels for diagnostic and interventional radiology

OBJECTIVES

The diagnostic reference level (DRL) is a useful tool for the optimisation of medical exposures. Thus, a Working Party coordinated by the Italian National Institute of Health and the National Workers Compensation Authority has been formed to provide Italian DRLs, for both diagnostic and interventional procedures, to be used as appropriate for the implementation of the 2013/59 European Directive into the national regulation.

MATERIALS AND METHODS

The multidisciplinary Working Party was formed by professionals involved in diagnostic and interventional radiology medical exposures and started from a critical revision of both the literature and the results of previous Italian surveys. The procedures were divided into five sections for adult (projection radiography, mammography, diagnostic fluoroscopy, CT and interventional radiology) and two sections for paediatric patients (projection radiography and CT). The provided DRL values have been identified for "normal" adult patients and for age-classes of paediatric patients.

RESULTS

Some of the DRL values provided by the Working Party are reported in this study as an example, divided by adult/paediatric patients, radiological technique and examination: specifically, DRLs for new radiological practices and new dose quantities as DRLs metric were introduced. The median value (rather than the mean) for each procedure, derived from a sample of patients, has to be compared with the corresponding DRL value, and dosimetric data related to a minimum number of patients should be collected for each examination.

CONCLUSIONS

The approach to the definition and use of DRLs through guidelines of national Authorities in collaboration with scientific Associations should simplify the periodical updating and could be useful for keeping the optimisation of medical exposures faithful to the development of radiological practice.

Diagnostic Reference Levels for Adult Nuclear Medicine Imaging Established from the National Survey in Korea

Purpose

There is substantial need for optimizing radiation protection in nuclear medicine imaging studies. However, the diagnostic reference levels (DRLs) have not yet been established for nuclear medicine imaging studies in Korea.

Materials and Methods

The data of administered activity in 32 nuclear medicine imaging studies were collected from the Korean Society of Nuclear Medicine (KSNM) dose survey database from 2013 and 2014. Through the expert discussions and statistical analyses, the 75th quartile value (Q3) was suggested as the preliminary DRL values. Preliminary DRLs were subjected to approval process by the KSNM Board of Directors and KSNM Council, followed by clinical applications and performance rating by domestic institutes.

Results

DRLs were determined through 32 nuclear medicine imaging studies. The Q3 value was considered as appropriate selection as it was generally consistent with the most commonly administered activity. In the present study, the final version of initial DRL values for nuclear medicine imaging in Korean adults is described including various protocols of the brain and myocardial perfusion imaging.

Conclusion

The first DRLs for nuclear medicine imaging in Korean adults were confirmed. The DRLs will enable optimized radiation protection in the field of nuclear medicine imaging in Korea.

Patient-specific organ and effective dose estimates in pediatric oncology computed tomography

PURPOSE

Estimate organ and effective doses from computed tomography scans of pediatric oncologic patients using patient-specific information.

MATERIALS AND METHODS

With IRB approval patient-specific scan parameters and patient size obtained from DICOM images and vendor-provided dose monitoring application were obtained for a cross-sectional study of 1250 pediatric patients from 0 through 20 y-olds who underwent head, chest, abdomen-pelvis, or chest-abdomen-pelvis CT scans. Patients were categorized by age. Organ doses and effective doses were estimated using VirtualDose™ CT based on patient-specific information, tube current modulation (TCM), and age-specific realistic phantoms. CTDIvol, DLP, and dose results were compared with those reported in the literature.

RESULTS

CTDIvol and DLP varied widely as patient size varied. The 75th percentiles of CTDIvol and DLP were no greater than in the literature with the exception of head scans of 16-20 y-olds and of abdomen-pelvis scans of larger patients. Eye lens dose from a head scan was up to 69 mGy. Mean organ doses agreed with other studies at maximal difference of 38% for chest and 41% for abdomen-pelvis scans. Mean effective dose was generally higher for older patients. The highest effective doses were estimated for the 16-20 y-olds as: head 3.3 mSv, chest 4.1 mSv, abdomen-pelvis 10.0 mSv, chest-abdomen-pelvis 14.0 mSv.

CONCLUSION

Patient-specific organ and effective doses have been estimated for pediatric oncologic patients from <1 through 20 y-olds. The effect of TCM was successfully accounted for in the estimates. Output parameters varied with patient size. CTDIvol and DLP results are useful for future protocol optimization.

Radiation Safety in Nuclear Medicine Procedures

Since the nuclear disaster at the Fukushima Daiichi Nuclear Power Plant in 2011, radiation safety has become an important issue in nuclear medicine. Many structured guidelines or recommendations of various academic societies or international campaigns demonstrate important issues of radiation safety in nuclear medicine procedures. There are ongoing efforts to fulfill the basic principles of radiation protection in daily nuclear medicine practice. This article reviews important principles of radiation protection in nuclear medicine procedures. Useful references, important issues, future perspectives of the optimization of nuclear medicine procedures, and diagnostic reference level are also discussed.

Assessment of Regional Pediatric Computed Tomography Dose Indices in Tamil Nadu

The aim of this article is to assess Tamil Nadu pediatric computed tomography (CT) diagnostic reference levels (DRLs) by collecting radiation dose data for the most commonly performed CT examinations. This work was performed for thirty CT scanners installed in various parts of the Tamil Nadu region. The patient cohort was divided into two age groups: <1 year, and 1-5 years. CT dose indices were measured using a 10 cm3 pencil ion chamber with pediatric head and body polymethyl methacrylate phantoms. Dose data such as volumetric CT dose index (CTDIv) and dose length product (DLP) on a minimum of twenty average-sized pediatric patients in each category were recorded to calculate a mean site CTDIv and DLP value. The rounded 75th percentile was used to calculate a pediatric DRL for each hospital, and then region by compiling all results. Data were collected for 3600 pediatric patients. Pediatric CT DRL for two age groups: <1 year (CTDIv and DLP of head [20 mGy, 352 mGy.cm], chest [7 mGy, 120 mGy.cm] and abdomen [12 mGy, 252 mGy.cm]), and 1-5 years (CTDIv and DLP of head [38 mGy, 505 mGy.cm], chest [8 mGy, 132 mGy.cm] and abdomen [14 mGy, 270 mGy.cm]) for select procedures have been calculated. Proposed pediatric DRLs of CTDIv and DLP for head procedure were lower, and for chest and abdomen procedures were higher than European pediatric DRLs for both age groups.

Validation of the Australian diagnostic reference levels for paediatric multi detector computed tomography: a comparison of RANZCR QUDI data and subsequent NDRLS data from 2012 to 2015

The national diagnostic reference level service (NDRLS), was launched in 2011, however no paediatric data were submitted during the first calendar year of operation. As such, Australian national diagnostic reference levels (DRLs), for paediatric multi detector computed tomography (MDCT), were established using data obtained from a Royal Australian and New Zealand College of Radiologists (RANZCR), Quality Use of Diagnostic Imaging (QUDI), study. Paediatric data were submitted to the NDRLS in 2012 through 2015. An analysis has been made of the NDRLS paediatric data using the same method as was used to analyse the QUDI data to establish the Australian national paediatric DRLs for MDCT. An analysis of the paediatric NDRLS data has also been made using the method used to calculate the Australian national adult DRLs for MDCT. A comparison between the QUDI data and subsequent NDRLS data shows the NDRLS data to be lower on average for the Head and AbdoPelvis protocol and similar for the chest protocol. Using an average of NDRLS data submitted between 2012 and 2015 implications for updated paediatric DRLS are considered.

Report of a nationwide survey on actual administered radioactivities of radiopharmaceuticals for diagnostic reference levels in Japan

OBJECTIVE

The optimization of medical exposure is one of the major issues regarding radiation protection in the world, and The International Committee of Radiological Protection and the International Atomic Energy Agency recommend establishing diagnostic reference levels (DRLs) as tools for dose optimization. Therefore, the development of DRLs based on the latest survey has been required for nuclear medicine-related societies and organizations. This prompted us to conduct a nationwide survey on the actual administered radioactivity to adults for the purpose of developing DRLs in nuclear medicine.

METHODS

A nationwide survey was conducted from November 25, 2014 to January 16, 2015. The questionnaire was sent to all of the 1249 nuclear medicine facilities in Japan, and the responses were collected on a website using an answered form.

RESULTS

Responses were obtained from 516 facilities, for a response rate of 41 %. 75th percentile of (99m)Tc-MDP and (99m)Tc-HMDP: bone scintigraphy, (99m)Tc-HM-PAO, (99m)Tc-ECD and (123)I-IMP: cerebral blood flow scintigraphy, (99m)Tc-Tetrofosmin, (99m)Tc-MIBI and (201)Tl-Cl; myocardial perfusion scintigraphy and (18)F-FDG: oncology PET (in-house-produced or delivery) in representative diagnostic nuclear medicine scans were 932, 937, 763, 775, 200, 831, 818, 180, 235 and 252, respectively. More than 90 % of the facilities were within the range of 50 % from the median of these survey results in representative diagnostic nuclear medicine facilities in Japan. Responses of the administered radioactivities recommended by the package insert, texts and guidelines such as 740 MBq ((99m)Tc-MDP and (99m)Tc-HMDP: bone scintigraphy), 740 MBq ((99m)Tc-ECD and (99m)Tc-HM-PAO: cerebral blood flow scintigraphy) and 740 MBq ((99m)Tc-Tetrofosmin and (99m)Tc-MIBI: myocardial perfusion scintigraphy), etc. were numerous. The administered activity of many radiopharmaceuticals of bone scintigraphy ((99m)Tc-MDP and (99m)Tc-HMDP), cerebral blood flow scintigraphy ((99m)Tc-HM-PAO) and myocardial perfusion scintigraphy ((99m)Tc-Tetrofosmin and (99m)Tc-MIBI), etc. were within the range of the EU DRLs and almost none of the administered radioactivity in Japan exceeded the upper limit of SNMMI standard administered radioactivity.

CONCLUSIONS

This survey indicated that the administered radioactivity in diagnostic nuclear medicine in Japan had been in the convergence zone and nuclear medicine facilities in Japan show a strong tendency to adhere to the texts and guidelines. Furthermore, the administered radioactivities in Japan were within the range of variation of the EU and the SNMMI administered radioactivities.

A strategy to optimize radiation exposure for non-contrast head CT: comparison with the Japanese diagnostic reference levels

PURPOSE

To describe how we performed a protocol review, analyzed data, identified opportunities to reduce radiation exposure, and then implemented a new imaging protocol for non-contrast adult head CT at our institution with reduced radiation exposure, using the Japanese diagnostic reference levels (DRLs) as the reference.

METHODS

After analyzing the CT dose index (CTDIvol) and dose length product (DLP) in all non-contrast adult head CT examinations performed during a 3-month period (September to November 2015) in order to identify a specific protocol that contributed to the above-DRL-level radiation exposure observed for non-contrast adult head CT at our institution, phantom studies with objective and subjective image quality analyses were performed to develop a new imaging protocol. After implementing the new protocol, its feasibility was evaluated in terms of radiation exposure, prevalence of significant disease detection, and subjective image quality.

RESULTS

The review of 2040 examinations revealed that a helical protocol (CTDIvol = 93.4 mGy) with one of four CT scanners mainly contributed to the above-DRL-level radiation exposure (mean DLP at this scanner = 1401.2 mGy cm) in non-contrast adult head CT at our institution. To replace this protocol, the phantom study identified a wide-volume scan using 120 kVp, 350 mAs, a 4-cm detector, a slice thickness of 5 mm, and a CTDIvol of 69.8 mGy as a new protocol that yielded comparable image quality to the existing protocol. After the implementation of the new protocol, the overall mean DLP reduced to 1365 mGy cm without any apparent degradation of image quality. No significant decrease in the prevalence of significant findings after protocol revision was noted.

CONCLUSION

We report the successful implementation of a new protocol with reduced radiation exposure for non-contrast head CT examinations.

National survey of radiation doses of pediatric chest radiography in Korea: analysis of the factors affecting radiation doses

OBJECTIVE

To investigate radiation doses in pediatric chest radiography in a national survey and to analyze the factors that affect radiation doses.

MATERIALS AND METHODS

The study was based on the results of 149 chest radiography machines in 135 hospitals nationwide. For each machine, a chest radiograph was obtained by using a phantom representing a 5-year-old child (ATOM® dosimetry phantom, model 705-D, CIRS, Norfolk, VA, USA) with each hospital's own protocol. Five glass dosimeters (M-GD352M, Asahi Techno Glass Corporation, Shizuoka, Japan) were horizontally installed at the center of the phantom to measure the dose. Other factors including machine's radiography system, presence of dedicated pediatric radiography machine, presence of an attending pediatric radiologist, and the use of automatic exposure control (AEC) were also evaluated.

RESULTS

The average protocol for pediatric chest radiography examination in Korea was 94.9 peak kilovoltage and 4.30 milliampere second. The mean entrance surface dose (ESD) during a single examination was 140.4 microgray (µGy). The third quartile, median, minimum and maximum value of ESD were 160.8 µGy, 93.4 µGy, 18.8 µGy, and 2334.6 µGy, respectively. There was no significant dose difference between digital and non-digital radiography systems. The use of AEC significantly reduced radiation doses of pediatric chest radiographs (p < 0.001).

CONCLUSION

Our nationwide survey shows that the third quartile, median, and mean ESD for pediatric chest radiograph is 160.8 µGy, 93.4 µGy, and 140.4 µGy, respectively. No significant dose difference is noticed between digital and non-digital radiography systems, and the use of AEC helps significantly reduce radiation doses.