Search

The article reviews the historical developments in radiation dose metrices in medical imaging. It identifies the good, the bad, and the ugly aspects of current-day metrices. The actions on shifting focus from International Commission on Radiological Protection (ICRP) Reference-Man-based population-average phantoms to patient-specific computational phantoms have been proposed and discussed. Technological developments in recent years involving AI-based automatic organ segmentation and 'near real-time' Monte Carlo dose calculations suggest the feasibility and advantage of obtaining patient-specific organ doses. It appears that the time for ICRP and other international organizations to embrace 'patient-specific' dose quantity representing risk may have finally come. While the existing dose metrices meet specific demands, emphasis needs to be also placed on making radiation units understandable to the medical community., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

In the absence of information on radiation doses in mammography in the Gulf countries, this study was designed to assess patient dose in terms of entrance surface air kerma and average glandular dose (AGD) in three mammography units in Qatar that covers 21% of all mammography systems in the country. The study of 150 patients involving 600 projections indicated that the average value of AGD in patients was 2.2 mGy for cranio-caudal and 2.5 mGy for mediolateral-oblique views, respectively. Dose assessment was also performed for polymethyl methacrylate phantoms of thicknesses, ranging from 20 to 80 mm. Comparing the patient dose values with several other publications in literature for full-field digital mammography, our values are typically higher, which can be likely attributed to the larger compressed breast thickness., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

A survey was conducted through the International Atomic Energy Agency (IAEA) to assess the use of older imaging technologies and availability of dose information in radiography, computed tomography (CT), mammography and interventional machines. Responses from 55 countries indicated 55.8% having non-digital radiography systems, only 9.1% having all systems that are digital (CR and DR), nearly one-third (36.4%) still use calcium tungstate screens in radiography cassettes and only 16.9% having all mammography systems as digital. On the dose features, not all CT machines provide CTDI, DLP values directly as only about half (50.6%) stated all machines having CTDI and DLP display, nearly half (46.8%) indicated the absence of KAP meters in radiography systems. Only 53.2% stated all angiography machines having DAP/KAP display. Only about a quarter (23.4%) having picture archiving and communication system in all hospitals in the country. Nearly one-third (36.4%) have no difficulty in maintaining patient identification number while sending dose data.

Radiation protection in medicine is becoming more and more important with increasing wider use of X-rays, documentation of effects besides the potential for long-term carcinogenic effects. With computed tomography (CT) likely to become sub-mSv in coming years, positron emission tomography (PET), single photon emission computed tomography (SPECT) and some of the nuclear medical examination will become focus of attraction as high-dose examinations, even though they are less-frequent ones. Clarity will be needed on radiation effects at levels of radiation doses encountered in a couple of CT scans and if effects are really cumulative. There is challenge to develop radiation metrics that can be used as easily as units of temperature and length and avoidance of multiple meaning of a single dose metric. Other challenges include development of biological indicators of radiation dose, transition from dose to a representative phantom to dose to individual patient, system for tracking of radiation exposure history of patient, avoidance of radiation-induced skin injury in patients and radiation cataract in staff, cutting down inappropriate referrals for radiological examinations, confidence building in patient and patient safety in radiotherapy., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The authors report here their successful experience of communicating information to health professionals, patients and the public on benefits and risks of ionising radiation in medical applications. The approaches used have been based on giving importance to clinical benefits against risks, as well as safety in use against risk of use. Communicating brief messages against catchy questions with positive and pragmatic approach resulted in making website on radiation protection of patients (RPOP) as the top website of the world in this area. Credibility of information has been maintained. The results show immense outreach in 213 countries/territories., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Uncertainty provides opportunities for differences in perception, and radiation risks at low level of exposures involved in few computed tomography scans fall in this category. While there is good agreement among national and international organisations on risk probability of cancer, risk perception has barely been dealt with by these organisations. Risk perception is commonly defined as the subjective judgment that people make about the characteristics and severity of a risk. Severity and latency are important factors in perception. There is a need to connect all these. Leaving risk perception purely as a subjective judgement provides opportunities for people to amplifying risk. The author postulates a risk perception index as severity divided by latency that becomes determining factor for risk perception. It is hoped that this index will bring rationality in risk perception., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The main purpose of dose surveys has been to detect and bring down wide variation in radiation doses for any particular radiological examination and to avoid doses that are on higher side. Diagnostic reference levels (DRLs) have been used for over two decades as an aid in this objective. With very limited success that has been achieved through DRL, the author has recently described a new term 'acceptable quality dose' (AQD) that is aimed at optimisation within the DRL, is facility initiated and takes into account all three important parameters-image quality, dose and patient's body build. It is hoped that AQD will be found easy to establish, will be a useful tool to achieve optimisation in the facilities and will serve as the standard dose., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

This paper reviews the developments in tracking of patient exposures and dose after the earlier paper published in the same journal in 2011. A global survey in which 76 countries responded indicated strong interest in programme and another survey among referring physicians showed vast majority (71.7 %) of physicians expressing that awareness of previous history of CT scans would always or mostly lead them to a better decision on referring patients for CT scans. A sizable number of countries have system of assigning permanent ID to individuals and nearly half of them use this ID in medical records. This can easily permit tracking of exposures. Templates for tracking at different levels of health care have been provided, and experience from a country where tracking is routinely practised has been published., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Some publications have shown that Hp(0.07) or even Hp(10) can be used as good operational quantities for X-rays in view of difficulties with Hp(3). With increasing awareness, there is tendency to use whatever dosimeter is available with correction factor to estimate eye lens dose. The best position for an eye lens dosimeter has been reported to be at the side of the head nearest to the radiation source, close to the eye. Recent studies have reported eye doses with cone beam CT (CBCT) both for patients and staff, and there are many papers reporting eye lens doses to staff in nuclear medicine. To minimise the dose to eyes, the user can take advantage of a feature of CBCT of projections acquired over an angular span of 180° plus cone angle of the X-ray tube and with tube under scan arcs., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Interventional radiology and cardiology are areas with high potential for risk to eye lens. Accurate assessment of eye dose is one of the most important aspects of correlating doses with observed lens opacities among workers in interventional suites and ascertaining compliance with regulatory limits. The purpose of this paper is to review current approaches and opportunities in eye dosimetry and assess challenges in particular in accuracy and practicality. The possible approaches include practical dosimetry using passive dosemeters or active dosemeters with obvious advantage of active dosimetry. When neither of these is available, other approaches are based on either retrospective dose assessment using scatter radiation dose levels or correlations between patient dose indices and eye doses to the operators. In spite of all uncertainties and variations, estimation of eye dose from patient dose can be accepted as a compromise. Future challenges include development of practical methods for regular monitoring of individual eye doses and development of better techniques to estimate eye dose from measurements at some reference points., (© The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

There is wide interest currently in patient exposure tracking. This paper provides templates for implementation of tracking at the practice (hospital) level, multi-practice level, national level and international level. It provides suggestions for implementation in less-resourced countries. It includes elements such as patient identifier, dose quantities that should be covered and how to make sense from dose figures, availability of digital imaging and communications in medicine files with dose information or structured dose reports and capabilities of picture archiving and communication system (PACS). While tracking at several hospitals in a country connected by PACS and nationwide PACS is also a reality, tracking at the international level is currently a challenge. Guidance provided in this paper will facilitate its implementation at all levels.

Interest in medical radiation protection today is the same as what it would have been almost a century ago. After many decades of relatively safe application of radiation in medicine, the recent spurt in over exposures, over-use of imaging and accidental exposures has created the need for stakeholders to join hands and contribute towards increasing radiation safety levels. Whether it be the need for technological developments to achieve sub-mSv CT scans, tracking of patient exposure history, accounting for repeated exposures of the same patient, specific consideration of requests for radiological examinations that deliver few mSv of dose, or utilization of regulatory approaches, radiological equipment will need to alert users whenever the radiation dose to the patient is above a defined value. The current decade will focus increasingly on carcinogenic effects in patients.

In the 1990s, there was a lack of information on patient doses in most developing countries. In 2004, the International Atomic Energy Agency initiated projects aimed at assessing 'how safe are patients in radiological procedures and how to make them safer'. The major obstacle was a lack of medical physicists with patient dosimetry skills and a lack of dosimetry facilities. Actions taken were such as to yield results within a short span of time and a number of publications with interesting findings. Results showed that while patient doses in radiography are largely within diagnostic reference levels (DRLs), poor image quality is rampant. In mammography, CT and interventional procedures, doses higher than DRLs were observed. Dose management actions were implemented and significant improvements emerged. Utilising existing manpower (physicists, regulators, radiographers, radiologists), preparing detailed guidelines and data collection forms, focussing training on acquiring dosimetry skills, a system of periodic reports with mentoring and motivating collaborations within each country are some of the reasons for the success of the project.

Radiation-induced skin injuries to patients in interventional procedures have been reported since the early 1990s, but the number reported is far less than what might be occurring around the world. There is a gross lack of awareness resulting in patients suffering. A case of severe injury observed in multiple percutaneous coronary interventions for chronic total occlusion is reported in this paper. Further, the paper summarises the existing knowledge on radiation dosimetry in interventional procedures, factors involved in skin injury, guidance on detection, and avoidance and management of injury when it occurs. Information on a recently launched international anonymous reporting system of the International Atomic Energy Agency is also included.

The existing approach of radiation protection is largely based on the collective dose to the population with provisions for protection at an individual level through justification and optimisation. With the individual patient dose now exceeding the life-long occupational dose to a worker in a typical radiology practice, there is a need to establish approaches based on the protection of an individual patient. Radiation exposure tracking seems a way forward in this respect. Technological advances in recent years have provided opportunities for tracking to becoming a reality. The IAEA project on Smart Card/SmartRadTrack is described in this paper. The tracking is now a reality in a few dozen centres in many countries connected by picture archiving and communication systems, and there is hope that this will extend to cover other countries and continents.

Realising that the major part of radiation protection efforts had been directed for over half a century at radiation protection of workers, and that there are major issues in relation to medical exposure, which contributes to over 95 % of the dose to the global population from man-made sources, with increasing individual patient doses in diagnostic examinations, unnecessary or inappropriate examinations and continued accidents in radiotherapy, the International Atomic Energy Agency established an International Action Plan (IAP) in 2002 in cooperation with international organisations and professional bodies. The achievements of the IAP, which include harmonised training material, guidance documents, a number of publications, a website on radiation protection of patients (http://rpop.iaea.org) and a series of actions in Member States that have shown positive impacts on patient protection, are summarised in this paper.

When this paper was about to go to press, the International Commission on Radiological Protection released a statement recommending a change in the threshold dose for the eye lens and dose limits for eye for occupationally exposed persons. It is clear that the earlier published threshold for radiation cataract is no longer valid. Epidemiological studies among Chernobyl clean-up workers, A bomb survivors, astronauts, residents of contaminated buildings, radiological technicians and recent surveys of staff in interventional rooms indicate that there is an increased incidence of lens opacities at doses below 1 Gy. Nevertheless, eye lens dosimetry is at a primitive stage and needs to be developed further. Despite uncertainties concerning dose threshold and dosimetry, it is possible to significantly reduce the risk of radiation cataract through the use of appropriate eye protection. By increasing awareness among those at risk and better adoption and increased usage of protective measures, radiation cataract can become preventable despite lowering of dose limits.

The aims of this study were to investigate the frequency of computed tomography (CT) examinations for paediatric patients below 15 y of age in 128 CT facilities in 28 developing countries of Africa, Asia and Eastern Europe and to assess the magnitude of CT doses. Radiation dose data were available from 101 CT facilities in 19 countries. The dose assessment was performed in terms of weighted CT dose index (CTDI(w)), volume CT index and dose length product (DLP) for chest, chest (high resolution), lumbar spine, abdomen and pelvis CT examinations using standard methods. The results show that on average the frequency of paediatric CT examinations was 20, 16 and 5 % of all CT examinations in participating centres in Africa, Asia and Eastern Europe, respectively. Eleven CT facilities in six countries were found to use adult CT exposure parameters for paediatric patients, thus indicating limited awareness and the need for optimisation. CT images were of adequate quality for diagnosis. The CTDI(w) variations ranged up to a factor of 55 (Africa), 16.3 (Asia) and 6.6 (Eastern Europe). The corresponding DLP variations ranged by a factor of 10, 20 and 8, respectively. Generally, the CTDI(w) and DLP values in Japan are lower than the corresponding values in the three regions in this study. The study has indicated a stronger need in many developing countries to justify CT examinations in children and their optimisation. Awareness, training and monitoring of radiation doses is needed as a way forwards.

Not even a week passes without a paper getting published in peer reviewed journals on radiation protection in newer imaging technologies that either did not exist 10 y ago or were not established for routine use. Computed tomography (CT) happens to be a common element in most of these technologies. Radiation protection is high on the agenda of manufacturers and researchers and that is becoming a driving force for users and international organisations. The media and thus the public have their own share in increasing the momentum. The slice war seems to be shifting to dose war. Manufacturers are now chasing the target of sub-mSv CT. The era of two digit mSv effective dose for a CT procedure is far from losing ground, although cardiac CT within 5 mSv seems possible. A few years ago the change in technology was faster than adoption of dose management but currently even the development of dose reduction techniques is faster than its adoption. There is dearth of large-scale surveys of practice and lack of surveys with change in technology.

The purpose of this prospective study at 73 facilities in 18 countries in Africa, Asia and Eastern Europe was to investigate if the CT doses to adult patients in developing countries are higher than international standards. The dose assessment was performed in terms of weighted computed tomography dose index (CTDIw) and dose length product (DLP) for chest, chest (high resolution), lumbar spine, abdomen and pelvis CT examinations using standard methods. Except in one case, the mean CTDIw values were below diagnostic reference level (DRL) while for DLP, 17 % of situations were above DRLs. The resulting CT images were of adequate quality for diagnosis. The CTDIw and DLP data presented herein are largely similar to those from two recent national surveys. The study has shown a stronger need to create awareness and training of radiology personnel as well as monitoring of radiation doses in many developing countries so as to conform to the ALARA principle.

The success achieved to minimise the radiation exposure to staff to levels much below the prescribed dose limits encourages a similar approach in patient protection where dose limits do not exist but where reference levels are provided. A number of radiation injuries among patients have been reported, per capita dose is increasing and medical exposure has become the largest contributor to population dose. The International Atomic Energy Agency (IAEA) has supported a number of research projects, produced a wide range of guidance publications, conducted over 60 training courses in the past 5 y, produced for free dissemination training CDs on radiation protection and established a dedicated Web site on the radiological protection of patients (http://rpop.iaea.org). The number of countries that is currently receiving assistance in this field exceeds 80, as compared to about half a dozen 5 y ago. Significant results on patient dose management, demonstrating dose reduction of more than 30% while maintaining image quality, have been made available through IAEA projects.