Concept Of Diagnostic Reference Levels Research Articles

Actualization of methodology of diagnostic reference levels establishment for interventional radiological procedures

Interventional procedures are accompanied with high levels of patient exposure and even with the possibility of radiation skin damage. That’s why any actions leading to reduction of patients’ exposure levels are of utmost importance. Implementation of diagnostic reference levels is considered to be one of the most successful actions to reduce patient exposure levels. However the basic concept of diagnostic reference levels cannot be used for interventional radiology due to fact that procedures are not standardized. The article studies the main difficulties in applying the standard concept of diagnostic reference levels for interventional radiology procedures and proposes a new concept, taking into account the specifics of these procedures; the domestic and international documents are analyzed. The list of interventional procedures for diagnostic reference levels establishment is suggested based on the statistical data on performed procedures in the Russian Federation. The results of this study were used for the new Russian guidelines “Optimization of radiation protection of patients undergoing medical radiation diagnostic examinations through the use of diagnostic reference levels”.

A follow‐up questionnaire survey 2022 on radiation protection among 464 medical staff from 34 endoscopy–fluoroscopy departments in Japan

We surveyed and reported low protective equipment usage and insufficient knowledge among endoscopy-fluoroscopy departments in Japan in 2020. Two years later, we conducted a follow-up survey of doctors, nurses, and technologists in Japan. We conducted a questionnaire survey on radiation protection from May to June 2022. The participants were medical staff, including doctors, nurses, and radiological and endoscopy technicians in endoscopy-fluoroscopy departments. The questionnaire included 17 multiple-choice questions divided into three parts: background, equipment, and knowledge. We surveyed 464 subjects from 34 institutions. There were 267 doctors (58%), 153 nurses (33%), and 44 technologists (9%). The rate of wearing a lead apron was 98% in this study. The rates of wearing a thyroid collar, lead glasses, and radiation dosimeter were 27%, 35%, and 74%, respectively. The trend of the protective equipment rate was similar to that of our previous study; however, radiation dosimetry among doctors was still low at 58%. The percentage of subjects who knew the radiation exposure (REX) dose of each procedure was low at 18%. Seventy-six percent of the subjects attended lectures on radiation protection, and 73% knew about the three principles of radiation protection; however, the concept of diagnostic reference levels was not well known (18%). Approximately 60% of the subjects knew about the exposure dose increasing cancer mortality (63%) and the 5-year lens REX limit (56%). There was some improvement in radiation protection equipment or education, but relatively little compared to the 2020 survey of endoscopy departments.

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

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. 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. 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. 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.

Long-term experience and analysis of data on diagnostic reference levels: the good, the bad, and the ugly.

To analyze 11-year data of France for temporal trends in dose indices and dose optimization and draw lessons for those who are willing to work on creation and update of diagnostic reference levels (DRLs). The data from about 3000 radiology departments leading to about 750,000 imaging exams between 2004 and 2015 was analyzed, and patterns of reductions in dose for those below and above the DRLs were estimated and correlated with technology change. Dose optimization achieved was important and significant in departments which were above or just below the DRL (p = .006) but not in those which were around half of the DRL values. The decrease in 75th percentile value of Kerma air product (KAP) for chest radiography by 27.4% between 2004 and 2015 was observed with the number of flat panel detectors increase from 6 to 43%. A good correlation between the detector type distribution and the level of patient radiation exposure is observed. Otherwise, setting DRLs for standard-sized patient excludes patients lower and higher weighted than "standard." The concept of DRL may become obsolete unless lessons drawn from the experience of users are taken into account. While establishing DRLs should be part of the regulations, setting up and updating values should be governed by bodies whose decision-making cycle is short, at the most 1year. A local rather than national approach, taking into account body habitus and image quality, needs to be organized. • The technology changes faster than regulations. Requirement of DRL establishment should be part of the regulations; however, setting and updating values should be the role of professional societies. • The concept of DRL, highlighting the 75th percentile values and dedicated to standard-sized adult, misses optimization opportunities in the majority of patients who are below the 75th percentile value and outside the range of standard-sized adult. • The ugly aspects of the DRL concept include its non-applicability to individuals, no customization to clinical indications, and lack of consideration of image quality.

Expanding the Concept of Diagnostic Reference Levels to Noise and Dose Reference Levels in CT.

OBJECTIVE. Diagnostic reference levels were developed as guidance for radiation dose in medical imaging and, by inference, diagnostic quality. The objective of this work was to expand the concept of diagnostic reference levels to explicitly include noise of CT examinations to simultaneously target both dose and quality through corresponding reference values. MATERIALS AND METHODS. The study consisted of 2851 adult CT examinations performed with scanners from two manufacturers and two clinical protocols: abdominopelvic CT with IV contrast administration and chest CT without IV contrast administration. An institutional informatics system was used to automatically extract protocol type, patient diameter, volume CT dose index, and noise magnitude from images. The data were divided into five reference patient size ranges. Noise reference level, noise reference range, dose reference level, and dose reference range were defined for each size range. RESULTS. The data exhibited strong dependence between dose and patient size, weak dependence between noise and patient size, and different trends for different manufacturers with differing strategies for tube current modulation. The results suggest size-based reference intervals and levels for noise and dose (e.g., noise reference level and noise reference range of 11.5-12.9 HU and 11.0-14.0 HU for chest CT and 10.1-12.1 HU and 9.4-13.7 HU for abdominopelvic CT examinations) that can be targeted to improve clinical performance consistency. CONCLUSION. New reference levels and ranges, which simultaneously consider image noise and radiation dose information across wide patient populations, were defined and determined for two clinical protocols. The methods of new quantitative constraints may provide unique and useful information about the goal of managing the variability of image quality and dose in clinical CT examinations.

I251] Introduction and preliminary results of the euclid european project

The concept of Diagnostic Reference Levels (DRLs) is well-established and has been widely accepted for many years. Most of existing DRLs were built for specific anatomical locations. However, some limitations of this approach were pointed out as for the same anatomical location one could have several clinical indications with consequently different protocols corresponding to different exposure levels. The EUCLID project is a European Commission (EC) tender project that will provide up-to-date DRLs for the most important, from a radiological perspective, X-ray imaging tasks in Europe. The project is led by the European Society of Radiology (ESR). A European DRL survey on Computed Tomography (CT) and Interventional Radiology (IR) procedures on adult patients is being conducted. In order to identify the clinical indications to be studied, a comprehensive literature review is undertaken and information from the European national competent authorities is collected. A questionnaire is prepared that includes hospital data as well as patient clinical and technical data on exams of standard-size (Body Mass Index 18.5–25 kg/m2 or 70 ± 15 kg if height is not available) adult patients (age > 18 y) performed during the study period, but not less than 30 patients. For each examination, the anonymized Radiation Dose Structured Report or any other DICOM report available in X-ray machine (e.g. DICOM image) is also required in order to verify data collected for the establishment of clinical DRLs. A subjective image quality evaluation (perfect, good, moderate, inadequate) was also included in the questionnaire. In fluoroscopy, additional to all the above data, procedure complexity grading related to anatomy (normal/moderately difficult/very difficult) and pathology (normal/moderately difficult/very difficult) as well as data related to the skills of the operator (trainee, operator who has performed less than 5 procedures of this kind, and experienced operator) are also collected. Preliminary results of the survey will be presented.

21. Comparison of abdominal CT protocols: A multi-center study on image quality and radiation dose levels

Introduction (1) To highlight the spread of patient exposure and image quality performances for various abdominal protocols. (2) To ensure that radiation dose reductions in abdominal CT protocols do not impair the detection of low-contrast structures. Methods An anthropomorphic abdominal phantom (QRM, Moehrendorf, Germany) with two optional rings (2.5 cm and 5 cm), representing the attenuation of an adult abdomen of 50 kg (small phantom), 75 kg (medium phantom) and 100 kg (large phantom), was scanned on 70 CT machines in the Western part of Switzerland. The phantom contains in the axial plane four spheres of 5, 6 and 8 mm in diameter with a contrast of 20 HU relative to the background at 120 kV. For statistical reasons, each phantom size was systematically scanned 10 times using local clinical settings of the portal phase for the detection of focal liver lesions (FLL); 40 regions of interest (ROIs) including the target and 150 ROIs with background noise only were extracted. Low contrast detectability (LCD) was objectively assessed using a Channelized Hotelling mathematical model Observer (CHO) with ten dense differences of Gaussian channels for the calculation of a receiver operating characteristic (ROC) curve. For each lesion size, the area under the ROC curve (AUC) was used as a figure of merit (FOM). A new image quality metric, called the weighted AUC (AUC), was proposed to combine the AUC results of all 3 different lesion sizes in a single metric. The displayed CTDIvol was used as a radiation dose metric. Results The median dose used for acquisitions is equal to 5.8 mGy, 10.5 mGy and 16.3 mGy, respectively for the small, medium and large phantoms. For the small phantom, the median image quality is equal to 0.977 with an interquartile range (IQR) equal to 0.027. For the medium phantom the dispersion increased and the median image quality decreased (AUCw = 0.926 and IQR = 0.05). For the large phantom, despite a large range of CTDIvol, the median image quality also decreased (AUCw = 0.89 and IQR = 0.068) and six centers appeared as outliers with relatively limited AUCw scores (AUCw inferior to 0.75), due to very low CTDIvol values. Conclusions The use of a CHO model showed that the majority of institutions performed reasonably well when searching FLL. However, for some outliers, the CTDIvol values were so small that image quality outcomes were clearly not adequate for the intended task. Moreover, the spread of image quality levels was associated with a large CTDIvol distribution, showing that the concept of diagnostic reference levels should be revisited to take into account the image quality aspect. This would ensure comparable diagnostic performance image information content whatever the type of CT unit.

Estimation of entrance surface air kerma due to diagnostic X-ray examinations of adult patients in Uttarakhand, India and establishment of local diagnostic reference levels.

It is well established that diagnostic X-ray practices must be optimised to keep patient radiation dose as low as compatible with providing the diagnostic information required. For effective optimisation of diagnostic exposures, the International Commission on Radiological Protection (ICRP) introduced the concept of diagnostic reference levels (DRLs) in 1996. The present study aimed to carry out an extensive dose survey of diagnostic radiography installations in the Uttarakhand region of India to establish local DRL Values for the different diagnostic practices. During the survey, air kerma values were measured for 297 diagnostic X-ray machines installed at 270 medical centres in the region and the entrance surface air kerma (K a,e) was estimated for ten commonly performed radiographic projections. These included chest posterior-anterior (PA), cervical spine anterior-posterior (AP), skull PA, abdomen AP, KUB (kidney, ureter and bladder), lumbar spine AP, lumbar spine lateral (LAT), pelvis AP, thoracic spine AP, and thoracic spine LAT. Wide variations were observed in the estimated values of K a,e for individual projections. The third quartile of the distribution of the median values of the estimated K a,e for a given projection was calculated to establish local DRL Values. The majority of the acquired dose data were found to be comparable to or less than the proposed national and international DRLs. The local DRL Values reported in this study may be used to improve radiological practice by reducing patient doses during radiography examinations. The obtained data may also contribute to a national patient dose database for establishing future national DRLs.

Practical implementation of the diagnostic reference levels concept for the common radiographic examinations

The modern approach to the radiation protection of the patients from medical exposure is mainly based on the principle of optimization using diagnostic reference levels. Implementation of diagnostic reference levels and optimization in Russian radiological practice is limited due to lack of methodology of data collection and patient dose assessment, investigation and management of abnormally high and low patient doses. Current study is focused on the justification of the diagnostic reference levels concept and practical aspects of establishment of diagnostic reference levels for common radiographic X-ray examinations and their use in clinical practice. It is proposed to establish diagnostic reference levels as the 75%-percentiles of X-ray unit distribution by the patient standard doses for a given X-ray examination. Methodology for standard doses assessment is presented for different types of X-ray units. Based on the results of dose data collection in different regions of the Russian Federation in 2009–2014, the national diagnostic reference levels values are estimated in terms of effective dose for the radiographic examinations of skull, chest, cervical, thoracic and lumbar spine, abdomen and pelvis. The methodology of the optimization process is developed for the hospital use. It includes a comparison of the patient standard doses with the national diagnostic reference levels, investigation and correction of abnormally high and low patient doses. A list of corrective measures is proposed: from additional training of the staff and manual adjustment of the parameters of examinations to the replacement of an X-ray unit. It is conferment that even a limited implementation of the optimization methodology would allow to reduce standard doses with a factor of 1,5.

THE APPLICATION OF DIAGNOSTIC REFERENCE LEVELS FOR OPTIMISATION OF X-RAY IMAGING IN THE UK.

The concept of diagnostic reference levels (DRLs) has been introduced to provide standard doses against which hospital patient dose measurements can be compared to evaluate practices. DRLs are defined in terms of measured dose quantities. National DRLs can be derived from surveys of patient doses for common types of examinations in 20-30 large hospitals. The International Commission on Radiological Protection proposes that median doses for each type of examination at every hospital be collated and DRLs based on the third quartile value of the distribution. Once DRLs have been set, periodic audits of patient dose should be undertaken for examinations that reflect the clinical workload. Median doses from these distributions should be compared with relevant DRLs to identify procedures for which further optimisation is required and appropriate corrective action taken. This paper discusses factors that should be considered in the optimisation process and gives examples of experiences in application of DRLs in Scotland.

The ‘European Diagnostic Reference Levels For Paediatric Imaging’ Project

s / Physica Medica 30 (2014) e1ee15 e12 THE ‘EUROPEAN DIAGNOSTIC REFERENCE LEVELS FOR PAEDIATRIC IMAGING’ PROJECT John Damilakis. Professor of Medical Physics, University of Crete, Greece Despite a large number of studies available from European countries, the DRLs for paediatric patients are only available for some common radiological examinations. There is a need to consolidate what is available and to provide guidance on what actions are needed in using Diagnostic Reference Levels (DRLs) to further enhance radiation protection of children. The ‘European DRLs for Paediatric Imaging’ project is aimed to attend to this situation. The professional organisations involved include ESR as coordinator as well as EFOMP, EFRS, and ESPR, covering the key European stakeholders and professional groups with relevance to radiation protection of paediatric patients. The project is divided into 4 Work Packages (WPs); each work package covers specific tasks contributing to the common objective of enhancement of radiation protection of paediatric patients through the concept of DRLs. WP0, chaired by the coordinator of the project, is responsible for the management and general coordination of the project. WP1 is responsible for assessing and agreeing on a methodology for establishing and using DRLs for paediatric imaging, and for producing European guidelines including data provided by WP 2. WP2 is responsible for updating and extending the existing European DRLs to cover more procedures and a wider patient age/weight range. WP 3 chaired by the scientific coordinator will organize the European workshop in Lisbon, Portugal from October 15th to October 17th 2015 to discuss the findings of the studies conducted under the project and to subject the draft European Guidelines to critical review and discussion. SYNERGY BETWEEN NUCLEAR RESEARCH, INNOVATION AND EDUCATION IN EURATOM PROGRAMMES, WITH EMPHASIS ON SAFETY CULTURE Georges Van Goethem. European Commission, DG Research and Innovation, Dir Energy G.4 / Fission Energy, B-1049 Brussels, Belgium In a rapidly changing multicultural world full of political and economic uncertainties, research, innovation and education (RIE), in particular, in nuclear fission and radiation protection are faced with a number of scientific-technological and socio-political challenges. In the European Union (EU), these challenges are, for example, breakthrough technological developments of interdisciplinary type and enhanced public engagement in nuclear matters. The aim is to continuously improve applications of nuclear fission energy and ionising radiation in the medical and industrial fields for the benefit of all people. In the EU, the recent “Council Directive 2013/59/Euratom laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation” has a new Chapter IV “Requirements for Radiation Protection Education, Training and Information” requiring Member States to have systems in place for the education, training and recognition of specific experts (in particular, “Medical physics experts” Article 83). For power generation or for medical applications, experts with highly qualified nuclear and radiation safety culture competences will be needed over a long time period, in particular, to deal with radiation protection issues in modern diagnosis and treatment. Safety culture is usually defined as “an organisation’s values and behaviours modelled by its leaders and internalised by its members that serve to make nuclear safety the overriding priority.” In this context, the main stakeholders of Euratom RIE programmes have developed a common approach regarding needs, vision and implementation instruments. Focussing on knowledge creation and competence building, their common approach can be summarized as follows: 1e Analysis of needs: e.g. what kind of knowledge, skills and competences (KSC) should be taught in order to continuously improve technical, human and organisational aspects ? 2 e Convergence towards a common vision: e.g. towards a new type of governance for RIE in the EU, integrating expert, policy and public knowledge to support decision making processes 3 e Development of instruments: e.g. synergy of national and Euratom RIE programmes aiming at preparing a new generation of experts in a global economy (EU and beyond). Making lifelong learning and cross-border mobility a reality is an important objective of the Education, Youth and Culture policy of the EU (e.g. “European Credit system for Vocational Education and Training” /ECVET/). Lessons will be drawn from the preliminary application of ECVET tools and methodology, such as the description of qualifications in terms of “units of learning outcomes” related to KSC, in Euratom projects. INVOLVEMENT OF AAPM IN EUROPE Gene Lief. White Plains Hospital, Radiation/Oncology Department, New York,

WE-G-144-01: The Management of Imaging Procedure Dose 4: National, International & Local Perspectives

Richard Morin: The American College of Radiology Dose Index Registry The American College of Radiology Dose Index Registry, part of the ACR National Radiology Data Registry, provides the infrastructure platform for institutions, hospitals, and clinics to report dose indices from Computed Tomography (CT) clinical exams by body part / exam type, and allows those facilities to compare their CT dose indices to regional and national values through periodic feedback reports. This presentation describes the current state of the registry, how the data can be used to establish national benchmarks, to improve patient safety through identification of outlier protocols, and to demonstrate how participation in the registry can be part of a professional Maintenance of Certification effort. Learning Objectives: 1. Understand how registries perform. 2. Understand the way in which registries have altered physician behavior and improve patient care. 3. Identify the parameters involved in optimizing radiation dose in clinical practice. 4. Apply this knowledge by participating in a dose index registry and utilizing these techniques in Maintenance of Certification. Madan Rehani: The International Perspective on Recording and Reporting Dose There are no common regulations valid for all of Europe, but there are a number of initiatives and concepts in place which originated here. Among these are primarily the generation of conversion coefficients k for estimating values of the effective dose E from the dose length product (DLP) by E = k*DLP and the concept of dose reference levels (DRL). DRLs for radiological examinations in the European Union were demanded by law in 2000. DRL values are considered advisory and aim at identifying practices with dose levels exceeding the 75 percentile level of reference distributions. Member states have installed the concepts and specific values to different degrees. A drawback is that both the values of k and DRL relate to CTDI and DLP. There is no major debate regarding the validity of the computed tomography dose index (CTDI) because it is mostly considered as a tool for scanner acceptance and constancy testing. Its use for that purpose is undisputed. More accurate measures for patient dose are still to be established in an international consensus. The lecture will review the above concepts and will point to both strengths and weaknesses. Learning Objectives: 1. Understand that CTDI is merely a technical concept for scanner acceptance and constancy testing, but not a measure for patient dose. 2. Learn about concepts for patient‐and scanner‐specific patient dose estimates. 3. Learn about the concept of diagnostic reference levels and its strengths and weaknesses. Kevin O'Donnell: Informatics Tools for Recording/Tracking Dose Informatics tools are available to assist in the recording and tracking of patient radiation doses, and notification to system operators about potentially high dose settings prior to scanning a patient. This presentation describes the DICOM Radiation Dose Structured Report (RDSR), its characteristics, and modality‐specific information contained in the RDSR object. Coordinating the capture and management of such objects can be accomplished with the Integrating the Healthcare Enterprise Radiation Exposure Monitoring (REM) profile. These topics, in addition to how to incorporate of legacy system dose reporting into the RDSR, as well as how to set up the new “Dose Check” standard on CT scanners are presented. Learning Objectives: 1. Understand how DICOM Radiation Dose SR (RDSR) captures procedure dose information, the modalities and details covered. 2. Understand how the IHE Radiation Exposure Monitoring Profile (REM) coordinates the capture and management of RDSR objects and how it can be applied in a radiology practice. 3. Understand how “CT dose screens” from legacy scanners can be ported into RDSR. 4. Understand how to apply the pre‐scan dose pop‐ups on the CT console specified in the MITA CT Dose Check (XR‐25) standard. 5. Understand how to specify the above standards & features when purchasing and integrating radiology systems. Kevin O'Donnell, Toshiba America Medical Systems

TU-D-217A-01: CTDI and Patient Dose: A European Perspective.

1. Understand that CTDI is a technical concept for scanner acceptance and constancy testing 2. Learn about concepts for patient- and scanner-specific patient dose estimates 3. Learn about the concept of diagnostic reference levels and its strengths and weaknesses Research sponsored by Siemens Healthcare and by CT Imaging GmbH, both in Erlangen, Germany.

TH-C-211-01: International Perspectives on Radiation Protection

There are some actions which require international cooperation. An example of good cooperation can be found in the largely seamless international use of credit cards and ATM machines. Conversely, an example where international cooperation has not been effective can be found in the diversity of electricity plugs and sockets in different countries. In the area of radiation protection, there are also examples of good and bad cooperation. The global acceptance of concepts and principles of radiation protection as developed by the International Commission on Radiological Protection (ICRP) such as justification, optimization and dose limitation is a good example. Conversely, there are quite a few examples of non-agreement or partial agreement of issues in the field of radiation protection, such as dose limits for workers and members of the public, and acceptance of SI units e.g. Sv and Gy against rem and rad. When it comes to radiation protection of patients, there is Universityersal agreement that there should be no dose limits and that the concept of diagnostic reference levels (DRLs) should be used with flexibility. International actions are needed not only to create harmonization of concepts but also to give impetus to some areas, raise awareness about emerging issues and forewarn about upcoming dangers if actions are not initiated by countries well in time. The talk will cover “How does the International System of Radiation Protection work” and inform about an International Action Plan on Radiation Protection of Patients of the IAEA. Is the international system binding or national systems are?. How harmonization is achieved through the work of the IAEA. Ultimately, the role medical physicists and health physicists in implementing the radiation protection requirements for staff and patient protection shall be discussed. Learning Objectives: 1. To understand the system of radiation protection in international and national context 2. To become familiar with international action plan on radiation protection of patients 3. To become familiar with international organizations in the area of medical radiation protection 4. To understand the potential role you can play in international activities

Patient doses in CT examinations in Switzerland: implementation of national diagnostic reference levels

Diagnostic reference levels (DRLs) were established for 21 indication-based CT examinations for adults in Switzerland. One hundred and seventy-nine of 225 computed tomography (CT) scanners operated in hospitals and private radiology institutes were audited on-site and patient doses were collected. For each CT scanner, a correction factor was calculated expressing the deviation of the measured weighted computed tomography dose index (CTDI) to the nominal weighted CTDI as displayed on the workstation. Patient doses were corrected by this factor providing a realistic basis for establishing national DRLs. Results showed large variations in doses between different radiology departments in Switzerland, especially for examinations of the petrous bone, pelvis, lower limbs and heart. This indicates that the concept of DRLs has not yet been correctly applied for CT examinations in clinical routine. A close collaboration of all stakeholders is mandatory to assure an effective radiation protection of patients. On-site audits will be intensified to further establish the concept of DRLs in Switzerland.

Development of an online automatic diagnostic reference levels management system for digital radiography: A pilot experience

The diagnostic reference levels (DRLs) concept is a methodology proposed by the International Commission on Radiological Protection (ICRP) for identifying any unusual high patient doses involved in radiological examinations. However, some challenges are anticipated in the DRLs concept including resource demand for running the audit cycle by individual imaging departments and availability of DRLs. The objective of this study was to develop an online automatic DRLs management system for digital radiography (DR) with the aim of addressing the challenges of the DRLs obligation. An online automatic DRLs management system for DR composed of freeware was developed. The system was tested with 75 DR images. This pilot experience shows that the system successfully addresses the challenges in the DRLs management, i.e. resource demand for running the audit cycle by individual imaging departments and availability of DRLs. It can provide at a low cost an efficient and effective solution to the implementation of regular audits of patient doses using DR in busy clinical departments. It can also contribute to the development of DRLs at local and national levels. In this way, any unacceptable radiological practice (examination used unjustified high radiation dose) can be identified.

Quality Initiatives Radiation Risk: What You Should Know to Tell Your Patient

The steady increase in the number of radiologic procedures being performed is undeniably having a beneficial impact on healthcare. However, it is also becoming common practice to quantify the health detriment from radiation exposure by calculating the number of cancer-related deaths inferred from the effective dose delivered to a given patient population. The inference of a certain number of expected deaths from the effective dose is to be discouraged, but it remains important as a means of raising professional awareness of the danger associated with ionizing radiation. The risk associated with a radiologic examination appears to be rather low compared with the natural risk. However, any added risk, no matter how small, is unacceptable if it does not benefit the patient. The concept of diagnostic reference levels should be used to reduce variations in practice among institutions and to promote optimal dose indicator ranges for specific imaging protocols. In general, the basic principles of radiation protection (eg, justification and optimization of a procedure) need to be respected to help counteract the unjustified explosion in the number of procedures being performed.

Is patient size important in dose determination and optimization in cardiology?

Patient dose determination and optimization have become more topical in recent years with the implementation of the Medical Exposures Directive into national legislation, the Ionising Radiation (Medical Exposure) Regulations. This legislation incorporates a requirement for new equipment to provide a means of displaying a measure of patient exposure and introduces the concept of diagnostic reference levels. It is normally assumed that patient dose is governed largely by patient size; however, in cardiology, where procedures are often very complex, the significance of patient size is less well understood. This study considers over 9000 cardiology procedures, undertaken throughout the north of England, and investigates the relationship between patient size and dose. It uses simple linear regression to calculate both correlation coefficients and significance levels for data sorted by both room and individual clinician for the four most common examinations, left ventrical and/or coronary angiography, single vessel stent insertion and single vessel angioplasty. This paper concludes that the correlation between patient size and dose is weak for the procedures considered. It also illustrates the use of an existing method for removing the effect of patient size from dose survey data. This allows typical doses and, therefore, reference levels to be defined for the purposes of dose optimization.