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1.  Optimisation of Radiation Exposure to Gastroenterologists and Patients during Therapeutic ERCP 
This study intended to optimize the radiation doses for gastroenterologists and patients during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and to compare the doses based on available data obtained by other researchers. A total of 153 patients were studied in two Gastroenterology Departments, (group A, 111; group B, 42). Thermoluminescent dosimeters (TLD) were used to measure the staff and patients entrance surface air kerma (ESAK) at different body sites. The mean ESAK and effective doses per procedure were estimated to be 68.75 mGy and 2.74 mSv, respectively. Staff was exposed to a heterogonous doses. The third examiner (trainee) was exposed to a high dose compared with other examiners because no shield was located to protect him from stray radiation. Patients and examiners doses were lower compared to the lowest values found in previous studies taking into consideration the heterogeneity of patients and equipment. Staff doses during ERCP are within the safety limit in the light of the current practice.
doi:10.1155/2013/587574
PMCID: PMC3622381  PMID: 23589714
2.  Direct measurement of a patient's entrance skin dose during pediatric cardiac catheterization 
Journal of Radiation Research  2014;55(6):1122-1130.
Children with complex congenital heart diseases often require repeated cardiac catheterization; however, children are more radiosensitive than adults. Therefore, radiation-induced carcinogenesis is an important consideration for children who undergo those procedures. We measured entrance skin doses (ESDs) using radio-photoluminescence dosimeter (RPLD) chips during cardiac catheterization for 15 pediatric patients (median age, 1.92 years; males, n = 9; females, n = 6) with cardiac diseases. Four RPLD chips were placed on the patient's posterior and right side of the chest. Correlations between maximum ESD and dose–area products (DAP), total number of frames, total fluoroscopic time, number of cine runs, cumulative dose at the interventional reference point (IRP), body weight, chest thickness, and height were analyzed. The maximum ESD was 80 ± 59 (mean ± standard deviation) mGy. Maximum ESD closely correlated with both DAP (r = 0.78) and cumulative dose at the IRP (r = 0.82). Maximum ESD for coiling and ballooning tended to be higher than that for ablation, balloon atrial septostomy, and diagnostic procedures. In conclusion, we directly measured ESD using RPLD chips and found that maximum ESD could be estimated in real-time using angiographic parameters, such as DAP and cumulative dose at the IRP. Children requiring repeated catheterizations would be exposed to high radiation levels throughout their lives, although treatment influences radiation dose. Therefore, the radiation dose associated with individual cardiac catheterizations should be analyzed, and the effects of radiation throughout the lives of such patients should be followed.
doi:10.1093/jrr/rru050
PMCID: PMC4229915  PMID: 24968708
cardiac catheterization; entrance skin dose; pediatric heart disease; dosimetry
3.  Radiation exposure to personnel performing endoscopic retrograde cholangiopancreatography 
Postgraduate Medical Journal  2005;81(960):660-662.
Background: Endoscopic retrograde cholangiopancreatography (ERCP) relies on the use of ionising radiation but risks to operator and patient associated with radiation exposure are unclear. The aim of this prospective study was to estimate the radiation dose received by personnel performing fluoroscopic endoscopic procedures, mainly ERCP.
Methods: Consecutive procedures over a two month period were included. The use of thermoluminescent dosimeters to measure radiation exposure to the abdomen, thyroid gland, and hands of the operator permitted an estimation of the annual whole body effective dose equivalent.
Results: During the study period 66 procedures (61 ERCP) were performed and the estimated annual whole body effective dose equivalent received by consultant operators ranged between 3.35 and 5.87 mSv. These values are similar to those received by patients undergoing barium studies and equate to an estimated additional lifetime fatal cancer risk between 1 in 7000 and 1 in 3500. While within legal safety limits for radiation exposure to personnel, these doses are higher than values deemed acceptable for the general public.
Conclusions: It is suggested that personnel as well as patients may be exposed to significant values of radiation during ERCP. The study emphasises the need to carefully assess the indication for, and to use measures that minimise radiation exposure during any fluoroscopic procedure.
doi:10.1136/pgmj.2004.031526
PMCID: PMC1743365  PMID: 16210465
4.  Safety of endoscopic retrograde cholangiopancreatography in pregnancy: Fluoroscopy time and fetal exposure, does it matter? 
AIM: To estimate the fetal radiation exposure using thermoluminescent dosimeters (TLD’s) in pregnant patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and assess its relevance.
METHODS: Data on thirty-five therapeutic ERCPs conducted in pregnant patients from 2001 to 2009 were retrieved from a prospective database. Techniques to minimize fluoroscopy time were implemented and the fluoroscopy times captured. TLD’s were placed on the mother to estimate the fetal radiation exposure and the results were compared to the maximum allowed dose of radiation to the fetus [0.005 gray (Gy)]. Obstetrics consultations were obtained and the fetus was monitored before and after the ERCP. Fluoroscopy was performed at 75 kVp. ERCP was performed with the patients supine by dedicated biliary endoscopists performing more than 500 cases a year.
RESULTS: A total of 35 pregnant patients underwent ERCP and biliary sphincterotomy (14 in first trimester, 11 in second trimester, and 10 in third trimester). Mean maternal age was 25 years (range 16-37 years) and mean gestational age was 18.9 wk (range 4-35 wk). Mean fluoroscopy time was 0.15 min (range 0-1 min). For 23 women, the estimated fetal radiation exposure was almost negligible (< 0.0001 Gy) while for 8 women, it was within the 0.0001-0.0002 Gy range. Three women had an estimated fetal radiation exposure between 0.0002 and 0.0005 Gy and 1 woman had an estimated fetal radiation exposure greater than 0.0005 Gy. Complications included 2 post-sphincterotomy bleeds, 2 post-ERCP pancreatitis, and 1 fatal acute respiratory distress syndrome. One patient developed cholecystitis 2 d after ERCP.
CONCLUSION: ERCP with modified techniques is safe during pregnancy, and estimating the fetal radiation exposure from the fluoroscopy time or measuring it via TLD’s is unnecessary.
doi:10.4253/wjge.v5.i4.148
PMCID: PMC3627836  PMID: 23596536
Endoscopic retrograde cholangiopancreatography; Pregnancy; Fluoroscopy; Fetal exposure; Pancreaticobiliary disease
5.  Occupational radiation dose to eyes from endoscopic retrograde cholangiopancreatography procedures in light of the revised eye lens dose limit from the International Commission on Radiological Protection 
The British Journal of Radiology  2013;86(1022):20120289.
Objective:
Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that combines the use of X-ray fluoroscopy and endoscopy for examination of the bile duct. Published data on ERCP doses are limited, including staff eye dose from ERCP. Occupational eye doses are of particular interest now as the International Commission on Radiological Protection (ICRP) has recommended a reduction in the dose limit to the lens of the eye. The aim of this study was to measure occupational eye doses obtained from ERCP procedures.
Methods:
A new eye lens dosemeter (EYE-D™, Radcard, Krakow, Poland) was used to measure the ERCP eye dose, Hp(3), at two endoscopy departments in Ireland. A review of radiation protection practice at the two facilities was also carried out.
Results:
The mean equivalent dose to the lens of the eye of a gastroenterologist is 0.01 mSv per ERCP procedure with an undercouch X-ray tube and 0.09 mSv per ERCP procedure with an overcouch X-ray tube. Staff eye dose normalised to patient kerma area product is also presented.
Conclusion:
Staff eye doses in ERCP have the potential to exceed the revised ICRP limit of 20 mSv per annum when an overcouch X-ray tube is used. The EYE-D dosemeter was found to be a convenient method for measuring lens dose. Eye doses in areas outside of radiology departments should be kept under review, particularly in light of the new ICRP eye dose limit.
Advances in knowledge:
Occupational eye lens doses from ERCP procedures have been established using a new commercially available dedicated Hp(3) dosemeter.
doi:10.1259/bjr.20120289
PMCID: PMC3608047  PMID: 23385992
6.  Dosimetry during intramedullary nailing of the tibia 
Acta Orthopaedica  2009;80(5):568-572.
Background Intramedullary nailing under fluoroscopic guidance is a common operation. We studied the intraoperative radiation dose received by both the patient and the personnel.
Patients and methods 25 intramedullary nailing procedures of the tibia were studied. All patients suffered from tibial fractures and were treated using the Grosse-Kempf intramedullary nail, with free-hand technique for fixation of the distal screws, under fluoroscopic guidance. The exposure, at selected positions, was recorded using an ion chamber, while the dose area product (DAP) was measured with a DAP meter, attached to the tube head. Thermoluminescent dosimeters (TLDs) were used to derive the occupational dose to the personnel, and also to monitor the surface dose on the gonads of some of the patients.
Results The mean operation time was 101 (48–240) min, with a mean fluoroscopic time of 72 seconds and a mean DAP value of 75 cGy·cm2. The surface dose to the gonads of the patients was less than 8.8 mGy during any procedure, and thus cannot be considered to be a contraindication for the use of this technique. Occupational dose differed substantially between members of the operating personnel, the maximum dose recorded being to the operator of the fluoroscopic equipment (0.11 mSv).
Interpretation Our findings underscore the care required by the primary operator not to exceed the dose constraint of 10 mSv per year. The rest of the operating personnel, although they do not receive very high doses, should focus on the dose optimization of the technique.
doi:10.3109/17453670903350057
PMCID: PMC2823322  PMID: 19916691
7.  A comparison between low-dose and standard-dose non-contrasted multidetector CT scanning of the paranasal sinuses 
Purpose
To compare the image quality of the low-dose to the standard-dose protocol of MDCT scanning of the paranasal sinuses, based on subjective assessment and determine the radiation doses to the eyes and thyroid gland and dose reduction between these two protocols.
Materials and Methods
31 adult patients were scanned. Prior to scanning, thermoluminescent dosimeters (TLDs) were placed at 4 sites: outer canthus of right eye, outer canthus of left eye, inner canthus and anterior neck (thyroid gland). Every patient was scanned twice using the standard-dose protocol (100mAs) followed by the low-dose protocol (40mAs). The images were reviewed by 3 radiologists. Wilcoxon test was used as the test of significance for the image quality assessments. The paired sample t-test was used as the test of significance for the analysis of the radiation doses measured by the TLDs.
Results
Of the 30 patients selected for analysis, this study showed no significant difference in the scores for the diagnostic image quality and the anatomical structures assessments between the two protocols. The average calculated mean entrance surface doses and standard deviation for the standard-dose and low-dose protocols were 12.40±1.39 mGy and 5.53±0.82 mGy respectively to the lens and 1.03±0.55 mGy and 0.63±0.53 mGy respectively to the thyroid gland.
Conclusion
The reduction of mAs from 100 to 40 resulted in a significant reduction of the radiation doses to the lens and thyroid gland by 55.4% and 38.8% respectively without causing any significant effect to the diagnostic image quality and assessment of the anatomical structures.
doi:10.2349/biij.5.3.e13
PMCID: PMC3097781  PMID: 21611051
CT Paranasal sinuses; Low-dose Protocol; Chronic sinusitis
8.  A Survey of Organ Equivalent and Effective Doses from Diagnostic Radiology Procedures 
ISRN Radiology  2012;2013:204346.
The quantification of radiation risks associated with radiological examinations has been a subject of interest with the increased use of X-rays. Effective dose, which is a risk-weighted measure of radiation to organs in the body associated with radiological examination, is considered a good indicator of radiological risk. We have therefore investigated patient effective doses from radiological examinations. Organ and effective doses were estimated for 94 patients who underwent computed tomography examinations and for 338 patients who had conventional radiography examinations. The OrgDose (version 2) program was used for the estimation of effective doses. The tube potential ranges: 57 kVp to 138 kVp depending on the examination and patient size. The entrance surface doses have a wide range even for the same examination: 0.44–10.31 mGy (abdomen) and 0.66–16.08 mGy (lumbar spine) and the corresponding effective dose ranges 0.025–0.77 mSv and 0.025–0.95 mSv respectively. Effective dose for adult abdomen-pelvic CT examinations ranges 5.4–19.8 mSv with a mean of 13.6 mSv and for pediatrics ranges 2.1–5.5 mSv with a mean of 2.7 mSv. The mean effective dose for adult chest and head CT examinations are 7.9 and 1.8 mSv respectively and for pediatrics are 1.7 and 1.1 mSv.
doi:10.5402/2013/204346
PMCID: PMC4045519  PMID: 24977137
9.  Investigation of patient dose from common radiology examinations in Isfahan, Iran 
Background:
The aim of this study was measurement of the radiation doses received by patients for common radiology examinations in hospitals under control of Isfahan University of Medical Sciences, Iran.
Materials and Methods:
Thermoluminescence (lithium fluoride chips, LiF: Mg, Tl) dosimeter was used to measure patient dose for four (chest, posterior-anterior and lateral and skull anterior-posterior, or posterior-anterior and lateral) common radiographic views in six hospitals (seven X-ray machines). The entrance surface dose was measured on 20 randomly patients for each X-ray room.
Results:
The maximum (8.85 ± 0.62 mGy) and the minimum (0.62 ± 0.22 mGy) values of ESD was obtained for X-ray machines of Shimadzu and Varian located in Ashrafi-Khomeini-shahr and Kashani hospitals, respectively. As results shows, the values of ESD of skull were higher than that of chest examinations.
Conclusion:
The results of this study indicated that ESD measured doses were slightly greater than the ICRP and NRPB reference doses. Efforts should be made to further lower patient doses while securing image quality. In addition, the need to provide relevant education and training to staff in the radiology sections is of utmost importance.
doi:10.4103/2277-9175.96064
PMCID: PMC3507008  PMID: 23210070
Diagnostic radiology; patient dose; X-ray examinations
10.  Effective and organ doses using helical 4DCT for thoracic and abdominal therapies 
Journal of Radiation Research  2013;54(5):962-970.
The capacity of 4DCT to quantify organ motion is beyond conventional 3DCT capability. Local control could be improved. However we are unaware of any reports of organ dose measurements for helical 4DCT imaging. We therefore quantified the radiation doses for helical 4DCT imaging. Organ and tissue dose was measured for thoracic and abdominal 4DCT in helical mode using an adult anthropomorphic phantom. Radiation doses were measured with thermoluminescence dosimeter chips inserted at various anatomical sites on the phantom. For the helical thoracic 4DCT, organ doses were 57.2 mGy for the lung, 76.7 mGy for the thyroids, 48.1 mGy for the breasts, and 10.86 mGy for the colon. The effective doses for male and female phantoms were very similar, with a mean value of 33.1 mSv. For abdominal 4DCT imaging, organ doses were 14.4 mGy for the lung, 0.78 mGy for the thyroids, 9.83 mGy for breasts, and 58.2 mGy for the colon (all obtained by using ICRP 103). We quantified the radiation exposure for thoracic and abdominal helical 4DCT. The doses for helical 4DCT were approximately 1.5 times higher than those for cine 4DCT, however the stepwise image artifact was reduced. 4DCT imaging should be performed with care in order to minimize radiation exposure, but the advantages of 4DCT imaging mandates its incorporation into routine treatment protocols.
doi:10.1093/jrr/rrt024
PMCID: PMC3766296  PMID: 23603303
radiation dose; 4DCT; helical; cine; effective dose
11.  Dose evaluation for skin and organ in hepatocellular carcinoma during angiographic procedure 
Purpose
The purpose of this study is to evaluate the radiation dose in patients undergoing liver angiographic procedure and verify the usefulness of different dose measurements to prevent deterministic effects. Gafchromic film, MicroMOSFET data and DIAMENTOR device of the X-ray system were used to characterize the examined interventional radiology (IR) procedure.
Materials and methods
A liver embolization procedure, the SIRT (Selective Internal Radiation Therapy), was investigated. The exposure parameters from the DIAMENTOR as well as patient and geometrical data were registered. Entrance skin dose map obtained using Gafchromic film (ESDGAF) in a standard phantom as well as in 12 patients were used to calculate the maximum skin dose (MSDGAF). MicroMOSFETs were used to assess ESD in relevant points/areas. Moreover, the maximum value of five MicroMOSFETs array, due to the extension of treated area and to the relative distance of 2–3 cm of two adjacent MicroMOSFETs, was useful to predict the MSD without interfering with the clinical practice. PCXMC vers.1.5 was used to calculate effective dose (E) and equivalent dose (H).
Results
The mean dose-area product (DAPDIAMENTOR) for SIRT procedures was 166 Gycm2, although a wide range was observed. The mean MSDGAF for SIRT procedures was 1090 mGy, although a wide range was experienced. A correlation was found between the MSDGAF measured on a patient and the DAPDIAMENTOR value for liver embolizations. MOSFET and Gafchromic data were in agreement within 5% in homogeneous area and within 20% in high dose gradient regions. The mean equivalent dose in critical organs was 89.8 mSv for kidneys, 22.9 mSv for pancreas, 20.2 mSv for small intestine and 21.0 mSv for spleen. Whereas the mean E was 3.7 mSv (range: 0.5-13.7).
Conclusions
Gafchromic films result useful to study patient exposure and determine localization and amplitude of high dose skin areas to better predict the skin injuries. Then, DAPDIAMENTOR or MOSFET data could offer real-time methods, as on-line dose alert, to avoid any side effects during liver embolization with prolonged duration.
doi:10.1186/1756-9966-32-81
PMCID: PMC3832252  PMID: 24423052
Skin dose measurement; Gafchromic film dosimetry; MOSFET dosimetry; Interventional radiology; Liver embolization
12.  Radiation protection of the ovaries in young scoliosis patients 
European Spine Journal  1998;7(4):278-281.
Concerns in clinical practice arose over the amount of ovarian irradiation received from X-ray examinations in females with scoliosis. This study was instigated to assess the adequancy of ovarian protection in this young and genetically vulnerable group of patients. A total of 283 plain films in 20 patients with scoliosis were reviewed. If the area immediately adjacent to the medial wall of the acetabulum was clearly seen, then this was taken as indicative of ovarian irradiation. In a separate study, the radiation dose in the centre of the X-ray field on the surface of a tissue-equivalent anthropomorphic phantom was measured using thermoluminescent dosimeters. Standard conditions for scoliosis X-ray examination were used. The average age of patients was 21.5 years. The mean number of single X-ray exposures per patient was 14.1 over a mean of 44 months. The mean measured entrance dose to the skin in the 20 patients was 0.08 mGy (equivalent dose = 0.08 mSv). The mean percentage of examinations without lead protection was 18% per patient (range 0–40%). This would have resulted in a mean equivalent dose to the surface of the abdomen of 0.1 mSv per year per patient from the unprotected examinations. The maximum dose received in 1 year was 0.6 mSv. The maximum dose to the unprotected ovary was estimated to be 0.05 mSv from a single examination. The mean total cumulative ovarian dose was calculated as 180 μSv per patient (range 45–355 μSv) over the time period studied. The findings of this study indicate that ovarian protection should be improved. Reasons for this and suggestions for improvement are discussed.
doi:10.1007/s005860050075
PMCID: PMC3611264  PMID: 9765034
Key words Scoliosis; Radiation; dose; Ovary
13.  Occupational Radiation Exposure during Endoscopic Retrograde Cholangiopancreatography and Usefulness of Radiation Protective Curtains 
Objective. To evaluate the effectiveness of radiation protective curtains in reducing the occupational radiation exposure of medical personnel. Methods. We studied medical staff members who had assisted in 80 consecutive therapeutic endoscopic retrograde cholangiopancreatography (ERCP) procedures. Use of radiation protective curtains mounted to the X-ray tube was determined randomly for each procedure, and radiation doses were measured with electronic pocket dosimeters placed outside the protective apron. Results. When protective curtains were not used, the mean radiation doses to endoscopists, first assistants, second assistants, and nurses were 340.9, 27.5, 45.3, and 33.1 µSv, respectively; doses decreased to 42.6, 4.2, 13.1, and 10.6 µSv, respectively, when protective curtains were used (P < 0.01). When the patient had to be restrained during ERCP (n = 8), the radiation dose to second assistants without protective curtains increased by a factor of 9.95 (P < 0.01) relative to cases in which restraint was not required. Conclusions. During ERCP, not only endoscopists, but also assistants and nurses were exposed to high doses of radiation. Radiation exposure to staff members during ERCP was reduced with the use of protective curtains.
doi:10.1155/2014/926876
PMCID: PMC4247933  PMID: 25477956
14.  OCCUPATIONAL RADIATION DOSES TO OPERATORS PERFORMING FLUOROSCOPICALLY-GUIDED PROCEDURES 
Health physics  2012;103(1):80-99.
In the past 30 years, the numbers and types of fluoroscopically-guided (FG) procedures have increased dramatically. The objective of the present study is to provide estimated radiation doses to physician specialists, other than cardiologists, who perform FG procedures. We searched Medline to identify English-language journal articles reporting radiation exposures to these physicians. We then identified several primarily therapeutic FG procedures that met specific criteria: well-defined procedures for which there were at least five published reports of estimated radiation doses to the operator, procedures performed frequently in current medical practice, and inclusion of physicians from multiple medical specialties. These procedures were percutaneous nephrolithotomy (PCNL), vertebroplasty, orthopedic extremity nailing for treatment of fractures, biliary tract procedures, transjugular intrahepatic portosystemic shunt creation (TIPS), head/neck endovascular therapeutic procedures, and endoscopic retrograde cholangiopancreatography (ERCP). We abstracted radiation doses and other associated data, and estimated effective dose to operators. Operators received estimated doses per patient procedure equivalent to doses received by interventional cardiologists. The estimated effective dose per case ranged from 1.7 – 56μSv for PCNL, 0.1 – 101 μSv for vertebroplasty, 2.5 – 88μSv for orthopedic extremity nailing, 2.0 – 46μSv for biliary tract procedures, 2.5 – 74μSv for TIPS, 1.8 – 53μSv for head/neck endovascular therapeutic procedures, and 0.2 – 49μSv for ERCP. Overall, mean operator radiation dose per case measured over personal protective devices at different anatomic sites on the head and body ranged from 19 – 800 (median = 113) μSv at eye level, 6 – 1180 (median = 75)μSv at the neck, and 2 – 1600 (median = 302) μSv at the trunk. Operators’ hands often received greater doses than the eyes, neck or trunk. Large variations in operator doses suggest that optimizing procedure protocols and proper use of protective devices and shields might reduce occupational radiation dose substantially.
doi:10.1097/HP.0b013e31824dae76
PMCID: PMC3951010  PMID: 22647920
interventional procedure; fluoroscopically-guided procedure; occupational exposure; radiation protection
15.  Practical dosimetry methods for the determination of effective skin and breast dose for a modern CT system, incorporating partial irradiation and prospective cardiac gating 
The British Journal of Radiology  2012;85(1011):237-248.
Objective
For CT coronary angiography (CTCA), a generic chest conversion factor returns a significant underestimate of effective dose. The aim of this manuscript is to communicate new dosimetry methods to calculate weighted CT dose index (CTDIw), effective dose, entrance surface dose (ESD) and organ dose to the breast for prospectively gated CTCA.
Methods
CTDIw in 32 cm diameter Perspex phantom was measured using an adapted technique, accounting for the segmented scan characteristic. Gafchromic XRCT film (International Speciality Products, New Jersey, NJ) was used to measure the distribution and magnitude of ESD. Breast dose was measured using high sensitivity metal oxide semiconductor field-effect transistors and compared to the computer based imaging performance assessment of CT scanners (ImPACT) dosimetry calculations.
Results
For a typical cardiac scan the mean ESD remained broadly constant (7–9 mGy) when averaged over the circumference of the Perspex phantom. Typical absorbed dose to the breast with prospectively gated protocols was within the range 2–15 mGy. The subsequent lifetime attributable risk (LAR) of cancer incidence to the breast was found at 0.01–0.06 for a 20-year-old female. This compares favourably to 100 mGy (LAR ∼0.43) for a retrospectively gated CTCA.
Conclusions
Care must be taken when considering radiation dosimetry associated with prospectively gated scanning for CTCA and a method has been conveyed to account for this. Breast doses for prospectively gated CTCA are an order of magnitude lower than retrospectively gated scans. Optimisation of cardiac protocols is expected to show further dose reduction.
doi:10.1259/bjr/22285164
PMCID: PMC3473996  PMID: 21896660
16.  Prospective Measurement of Patient Exposure to Radiation During Pediatric Ureteroscopy 
The Journal of urology  2012;187(4):10.1016/j.juro.2011.12.013.
Objective
Little data have been reported regarding radiation exposure during pediatric endourologic procedures, including ureteroscopy (URS). We sought to measure radiation exposure during pediatric URS and identify opportunities for exposure reduction.
Methods
We prospectively observed URS procedures as part of a quality improvement initiative. Pre-operative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded. Our outcomes were entrance skin dose (ESD, in mGy) and midline dose (MLD, in mGy). Specific modifiable factors were identified as targets for potential quality improvement.
Results
Direct observation was performed on 56 consecutive URS procedures. Mean patient age was 14.8 ± 3.8 years (range 7.4 to 19.2); 9 children were under age 12 years. Mean ESD was 46.4 ± 48 mGy. Mean MLD was 6.2 ± 5.0 mGy. The most important major determinant of radiation dose was total fluoroscopy time (mean 2.68 ± 1.8 min) followed by dose rate setting, child anterior-posterior (AP) diameter, and source to skin distance (all p<0.01). The analysis of factors affecting exposure levels found that the use of ureteral access sheaths (p=0.01) and retrograde pyelography (p=0.04) were significantly associated with fluoroscopy time. We also found that dose rate settings were higher than recommended in up to 43% of cases and ideal C-arm positioning could have reduced exposure 14% (up to 49% in some cases).
Conclusions
Children receive biologically significant radiation doses during URS procedures. Several modifiable factors contribute to dose and could be targeted in efforts to implement dose reduction strategies.
doi:10.1016/j.juro.2011.12.013
PMCID: PMC3810162  PMID: 22341275
Nephrolithiasis; Pediatrics; Kidney; Stone; Urolithiasis
17.  Absorbed Radiation Dose in Radiosensitive Organs During Coronary CT Angiography Using 320-MDCT: Effect of Maximum Tube Voltage and Heart Rate Variations 
Ajr. American Journal of Roentgenology  2010;195(6):1347-1354.
OBJECTIVE
The purpose of this article is to estimate the absorbed radiation dose in radiosensitive organs during coronary MDCT angiography using 320-MDCT and to determine the effects of tube voltage variation and heart rate (HR) control on absorbed radiation dose.
MATERIALS AND METHODS
Semiconductor field effect transistor detectors were used to measure absorbed radiation doses for the thyroid, midbreast, breast, and midlung in an anthropomorphic phantom at 100, 120, and 135 kVp at two different HRs of 60 and 75 beats per minute (bpm) with a scan field of view of 320 mm, 400 mA, 320 × 0.5 mm detectors, and 160 mm collimator width (160 mm range). The paired Student’s t test was used for data evaluation.
RESULTS
At 60 bpm, absorbed radiation doses for 100, 120, and 135 kVp were 13.41 ± 3.59, 21.7 ± 4.12, and 29.28 ± 5.17 mGy, respectively, for midbreast; 11.76 ± 0.58, 18.86 ± 1.06, and 24.82 ± 1.45 mGy, respectively, for breast; 12.19 ± 2.59, 19.09 ± 3.12, and 26.48 ± 5.0 mGy, respectively, for lung; and 0.37 ± 0.14, 0.69 ± 0.14, and 0.92 ± 0.2 mGy, respectively, for thyroid. Corresponding absorbed radiation doses for 75 bpm were 38.34 ± 2.02, 59.72 ± 3.13, and 77.8 ± 3.67 mGy for midbreast; 26.2 ± 1.74, 44 ± 1.11, and 52.84 ± 4.07 mGy for breast; 38.02 ± 1.58, 58.89 ± 1.68, and 78 ± 2.93 mGy for lung; and 0.79 ± 0.233, 1.04 ± 0.18, and 2.24 ± 0.52 mGy for thyroid. Absorbed radiation dose changes were significant for all organs for both tube voltage reductions as well as for HR control from 75 to 60 bpm at all tube voltage settings (p < 0.05). The absorbed radiation doses for the calcium score protocol were 11.2 ± 1.4 mGy for midbreast, 9.12 ± 0.48 mGy for breast, 10.36 ± 1.3 mGy for lung, and 0.4 ± 0.05 mGy for thyroid.
CONCLUSION
CT angiography with 320-MDCT scanners results in absorbed radiation doses in radiosensitive organs that compare favorably to those previously reported. Significant dose reductions can be achieved by tube voltage reductions and HR control.
doi:10.2214/AJR.10.4333
PMCID: PMC3289940  PMID: 21098194
320-MDCT; absorbed radiation dose; cardiac imaging; cardiac MDCT; CT dose index; dose–length product; metal oxide semiconductor field effect transistor dosimetry
18.  Coronary CTA using scout-based automated tube potential and current selection algorithm, with breast displacement results in lower radiation exposure in females compared to males 
Purpose
To evaluate the effect of automatic tube potential selection and automatic exposure control combined with female breast displacement during coronary computed tomography angiography (CCTA) on radiation exposure in women versus men of the same body size.
Materials and methods
Consecutive clinical exams between January 2012 and July 2013 at an academic medical center were retrospectively analyzed. All examinations were performed using ECG-gating, automated tube potential, and tube current selection algorithm (APS-AEC) with breast displacement in females. Cohorts were stratified by sex and standard World Health Organization body mass index (BMI) ranges. CT dose index volume (CTDIvol), dose length product (DLP) median effective dose (ED), and size specific dose estimate (SSDE) were recorded. Univariable and multivariable regression analyses were performed to evaluate the effect of gender on radiation exposure per BMI.
Results
A total of 726 exams were included, 343 (47%) were females; mean BMI was similar by gender (28.6±6.9 kg/m2 females vs. 29.2±6.3 kg/m2 males; P=0.168). Median ED was 2.3 mSv (1.4-5.2) for females and 3.6 (2.5-5.9) for males (P<0.001). Females were exposed to less radiation by a difference in median ED of –1.3 mSv, CTDIvol –4.1 mGy, and SSDE –6.8 mGy (all P<0.001). After adjusting for BMI, patient characteristics, and gating mode, females exposure was lower by a median ED of –0.7 mSv, CTDIvol –2.3 mGy, and SSDE –3.15 mGy, respectively (all P<0.01).
Conclusions: We observed a difference in radiation exposure to patients undergoing CCTA with the combined use of AEC-APS and breast displacement in female patients as compared to their BMI-matched male counterparts, with female patients receiving one third less exposure.
doi:10.3978/j.issn.2223-3652.2014.12.07
PMCID: PMC4278037  PMID: 25610804
Coronary computed tomography angiography (CCTA); female; breast displacement; radiation exposure
19.  Establishing the radiation risk from fluoroscopic-assisted arthroscopic surgery of the hip 
International Orthopaedics  2012;36(9):1803-1806.
Purpose
The purpose of the study was to quantify patient exposure to ionising radiation during fluoroscopic-assisted arthroscopic surgery of the hip, establish a risk profile of this exposure, and reassure patients of radiation safety during the procedure.
Methods
We retrospectively analysed the dose area products for 50 consecutive patients undergoing arthroscopic hip surgery by an experienced hip arthroscopic surgeon. The effective dose and organ dose were derived using a Monte Carlo program.
Results
The mean total fluoroscopy time was 1.10 minutes and the mean dose area product value was 297.2 cGycm2. We calculated the entrance skin dose to be 52 mGy to the area where the beam was targeted (81 cm2). The mean effective dose for intra-operative fluoroscopy was 0.33 mSv, with a SD of 0.90 Sv.
Conclusion
This study confirms that fluoroscopic-assisted arthroscopic surgery of the hip is safe with a low maximum radiation dose and supports its continued use in preference to alternative imaging modalities.
doi:10.1007/s00264-012-1557-y
PMCID: PMC3427451  PMID: 22588691
20.  Surgeons' Exposure to Radiation in Single- and Multi-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion; A Prospective Study 
PLoS ONE  2014;9(4):e95233.
Although minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has widely been developed in patients with lumbar diseases, surgeons risk exposure to fluoroscopic radiation. However, to date, there is no studies quantifying the effective dose during MIS-TLIF procedure, and the radiation dose distribution is still unclear. In this study, the surgeons' radiation doses at 5 places on the bodies were measured and the effective doses were assessed during 31 consecutive 1- to 3-level MIS-TLIF surgeries. The operating surgeon, assisting surgeon, and radiological technologist wore thermoluminescent dosimeter on the unshielded thyroid, chest, genitals, right middle finger, and on the chest beneath a lead apron. The doses at the lens and the effective doses were also calculated. Mean fluoroscopy times were 38.7, 53.1, and 58.5 seconds for 1, 2, or 3 fusion levels, respectively. The operating surgeon's mean exposures at the lens, thyroid, chest, genitals, finger, and the chest beneath the shield, respectively, were 0.07, 0.07, 0.09, 0.14, 0.32, and 0.05 mSv in 1-level MIS-TLIF; 0.07, 0.08, 0.09, 0.18, 0.34, and 0.05 mSv in 2-level; 0.08, 0.09, 0.14, 0.15, 0.36, and 0.06 mSv in 3-level; and 0.07, 0.08, 0.10, 0.15, 0.33, and 0.05 mSv in all cases. Mean dose at the operating surgeon's right finger was significantly higher than other measurements parts (P<0.001). The operating surgeon's effective doses (0.06, 0.06, and 0.07 mSv for 1, 2, and 3 fusion levels) were low, and didn't differ significantly from those of the assisting surgeon or radiological technologist. Revision MIS-TLIF was not associated with higher surgeons' radiation doses compared to primary MIS-TLIF. There were significantly higher surgeons' radiation doses in over-weight than in normal-weight patients. The surgeons' radiation exposure during MIS-TLIF was within the safe level by the International Commission on Radiological Protection's guidelines. The accumulated radiation exposure, especially to surgeon's hands, should be carefully monitored.
doi:10.1371/journal.pone.0095233
PMCID: PMC3988176  PMID: 24736321
21.  Radiation Dose to Newborns in Neonatal Intensive Care Units 
Iranian Journal of Radiology  2012;9(3):145-149.
Background
With the increase of X-ray use for medical diagnostic purposes, knowing the given doses is necessary in patients for comparison with reference levels. The concept of reference doses or diagnostic reference levels (DRLs) has been developed as a practical aid in the optimization of patient protection in diagnostic radiology.
Objectives
To assess the radiation doses to neonates from diagnostic radiography (chest and abdomen). This study has been carried out in the neonatal intensive care unit of a province in Iran.
Patients and Methods
Entrance surface dose (ESD) was measured directly with thermoluminescent dosimeters (TLDs). The population included 195 neonates admitted for a diagnostic radiography, in eight NICUs of different hospital types.
Results
The mean ESD for chest and abdomen examinations were 76.3 µGy and 61.5 µGy, respectively. DRLs for neonate in NICUs of the province were 88 µGy for chest and 98 µGy for abdomen examinations that were slightly higher than other studies. Risk of death due to radiation cancer incidence of abdomens examination was equal to 1.88 × 10 -6 for male and 4.43 × 10 -6 for female. For chest X-ray, it was equal to 2.54 × 10 -6 for male and 1.17 × 10 -5 for female patients.
Conclusion
DRLs for neonates in our province were slightly higher than values reported by other studies such as European national diagnostic reference levels and the NRPB reference dose. The main reason was related to using a high mAs and a low kVp applied in most departments and also a low focus film distance (FFD). Probably lack of collimation also affected some exams in the NICUs.
doi:10.5812/iranjradiol.8065
PMCID: PMC3522370  PMID: 23329980
Intensive Care Units; Neonatal; Radiation Dosimetry
22.  Radiation risk from fluoroscopically-assisted anterior cruciate ligament reconstruction 
INTRODUCTION
Precise tunnel positioning is crucial for success in anterior cruciate ligament (ACL) reconstruction. The use of intra-operative fluoroscopy has been shown to improve the accuracy of tunnel placement. Although radiation exposure is a concern, we lack information on the radiation risk to patients undergoing fluoroscopically-assisted ACL reconstruction with a standard C-arm. The aim of our study was to determine the mean radiation doses received by our patients.
PATIENTS AND METHODS
Radiation doses were recorded for 18 months between 1 April 2007 and 30 September 2008 for 58 consecutive patients undergoing ACL reconstruction assisted by intra-operative fluoroscopy. Dose area product (DAP) values were used to calculate the entrance skin dose (ESD), an indicator of potential skin damage and the effective dose (ED), an indicator of long-term cancer risk, for each patient.
RESULTS
The median age of 58 patients included in data analysis was 28 years (range, 14–52 years), of whom 44 were male (76%). The mean ESD during intra-operative fluoroscopy was 0.0015 ± 0.0029 Gy. The mean ED was 0.001 ± 0.002 mSv. No results exceeded the threshold of 2 Gy for skin damage, and the life-time risk of developing new cancer due to intra-operative fluoroscopy is less than 0.0001%.
CONCLUSIONS
Radiation doses administered during fluoroscopically-assisted ACL reconstruction were safe and do not represent a contra-indication to the procedure.
doi:10.1308/003588410X12628812459814
PMCID: PMC3025191  PMID: 20501019
Anterior cruciate ligament; Reconstruction; Intra-operative fluoroscopy; Radiation dose; Radiation risk
23.  Radiation dose to patients during endoscopic retrograde cholangiopancreatography 
Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool for the diagnosis and treatment of the hepatobiliary system. The use of fluoroscopy to aid ERCP places both the patient and the endoscopy staff at risk of radiation-induced injury. Radiation dose to patients during ERCP depends on many factors, and the endoscopist cannot control some variables, such as patient size, procedure type, or fluoroscopic equipment used. Previous reports have demonstrated a linear relationship between radiation dose and fluoroscopy duration. When fluoroscopy is used to assist ERCP, the shortest fluoroscopy time possible is recommended. Pulsed fluoroscopy and monitoring the length of fluoroscopy have been suggested for an overall reduction in both radiation exposure and fluoroscopy times. Fluoroscopy time is shorter when ERCP is performed by an endoscopist who has many years experience of performing ERCP and carried out a large number of ERCPs in the preceding year. In general, radiation exposure is greater during therapeutic ERCP than during diagnostic ERCP. Factors associated with prolonged fluoroscopy have been delineated recently, but these have not been validated.
doi:10.4253/wjge.v3.i7.140
PMCID: PMC3159502  PMID: 21860683
Endoscopic retrograde cholangiopancreatography; Radiation dose; Fluoroscopy; Radiation exposure; X-ray
24.  Retrospective analysis of radiation exposure during endoscopic retrograde cholangiopancreatography: Critical determinants 
Although the risk of radiation-induced spontaneous malignancy and genetic anomalies from occupational radiological procedures is relatively low – and perhaps slightly lower still for the general population – patients and endoscopists in particular, should be aware of the cumulative risk associated with all exposure. Radiation dose has a direct linear relationship with fluoroscopy duration; therefore, limiting fluoroscopy time is one of the most modifiable methods of reducing exposure during fluoroscopic procedures. This retrospective study analyzed more than 1000 endoscopic retrograde cholangiopancreatography procedures and aimed to determine the specific patient, physician and procedural factors that affect fluoroscopy duration.
BACKGROUND:
Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) has a logarithmic relationship with radiation exposure, and carries a known risk of radiation exposure to patients and staff. Factors associated with prolonged fluoroscopy duration have not been well delineated.
OBJECTIVES:
To determine the specific patient, physician and procedural factors that affect fluoroscopy duration.
METHODS:
A retrospective analysis of 1071 ERCPs performed at two tertiary care referral hospitals over an 18-month period was conducted. Patient, physician and procedural variables were recorded at the time of the procedure.
RESULTS:
The mean duration of 969 fluoroscopy procedures was 4.66 min (95% CI 4.38 to 4.93). Multivariable analysis showed that the specific patient factors associated with prolonged fluoroscopy duration included age and diagnosis (both P<0.0001). The endoscopist was found to play an important role in the duration of fluoroscopy (ie, all endoscopists studied had a mean fluoroscopy duration significantly different from the reference endoscopist). In addition, the following procedural variables were found to be significant: number of procedures, basket use, biopsies, papillotomy (all P<0.0001) and use of a tritome (P=0.004). Mean fluoroscopy duration (in minutes) with 95% CIs for different diagnoses were as follows: common bile duct stones (n=443) 5.12 (3.05 to 4.07); benign biliary strictures (n=135) 3.94 (3.26 to 4.63); malignant biliary strictures (n=124) 5.82 (4.80 to 6.85); chronic pancreatitis (n=49) 4.53 (3.44 to 5.63); bile leak (n=26) 3.67 (2.23 to 5.09); and ampullary mass (n=11) 3.88 (1.28 to 6.48). When no pathology was found (n=195), the mean fluoroscopy time was 3.56 min (95% CI 3.05 to 4.07). Comparison using t tests determined that the only two diagnoses for which fluoroscopy duration was significantly different from the reference diagnosis of ‘no pathology found’ were common bile duct stones (P<0.0001) and malignant strictures (P<0.0001).
CONCLUSIONS:
Factors that significantly affected fluoroscopy duration included age, diagnosis, endoscopist, and the number and nature of procedures performed. Elderly patients with biliary stones or a malignant stricture were likely to require the longest duration of fluoroscopy. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration so that appropriate precautions can be undertaken.
PMCID: PMC3206549  PMID: 22059160
ERCP; Fluoroscopy time; Radiation
25.  Fetal radiation exposure: Is monitoring really needed? 
The effect of fetal radiation during endoscopic retrograde cholangiopancreatography (ERCP) on pregnant women is a very interesting topic. Smith et al recently estimated the fetal radiation exposure in pregnant women undergoing ERCPs using thermoluminescent dosimeters (TLDs). The authors concluded that TLDs are unnecessary during ERCP with modified techniques. We believe that an extreme caution is needed in clinical practice before drawing such conclusions when they are not strongly supported by enough experimental evidence. Therefore, we recommend that fetal radiation exposure be monitored in clinical practice by using dosimeters, bearing in mind that all relevant techniques to control and minimize the exposure must be applied.
doi:10.4253/wjge.v5.i8.366
PMCID: PMC3742701  PMID: 23951391
Endoscopic retrograde cholangiopancreatography; Pregnancy; Fetal radiation exposure; Thermoluminescent dosimeters; Post-endoscopic retrograde cholangio-pancreatography pancreatitis

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