Ionizing radiation exposure in complex percutaneous coronary intervention: Defining local diagnostic reference levels in the catheterization laboratory.

INTRODUCTION AND OBJECTIVES: Concerns regarding the consequences of ionizing radiation (IR) have been increasing in the field of interventional cardiology (IC). There is little information on reported national and local radiation diagnostic reference levels (DRLs) in catheterization laboratories in Portugal. This study was designed to assess the IR dose exposure during complex percutaneous coronary intervention (PCI), and to set the respective DRLs and future achievable doses (ADs). METHODS: This was a retrospective cohort study which took place between 2019 and 2020, including patients who underwent complex PCI. Complex PCI was defined as all procedures that encompass treatment of chronic total occlusions (CTO) or left main coronary artery. DRLs were defined as the 75th percentile of the distribution of the median values of air kerma area product (PKA) and cumulative air kerma (Ka,r). ADs were set at the 50th percentile of the study dose distribution. Multivariate analysis was performed using linear regression to identify predictors significantly associated with radiation dose (Ka,r). RESULTS: A total of 242 patients were included in the analysis. Most patients underwent a CTO procedure (146, 60.3%). Patients were aged 67.9±11.2 years and mostly male (81.4%). DRLs were set in Ka,r (3012 mGy) and PKA (162 Gy cm2) for complex PCI. ADs were also set in Ka,r (1917 mGy) and PKA (101 Gy cm2). Independent predictors of Ka,r with a positive correlation were PKA (0.893, p<0.001), fluoroscopy time (0.520, p<0.001) and PCI time (0.521, p<0.001). CONCLUSIONS: This study reports the results of IR in complex PCI. DRLs were set for IR dose exposure measured in Ka,r (3012 mGy) and PKA (162 Gy cm2). ADs, values to be achieved in future assessment, were set to Ka,r (1917 mGy) and PKA (101 Gy cm2).

A report on a survey among Portuguese Association of Interventional Cardiology associates regarding ionizing radiation protection practices in national interventional cath-labs.

INTRODUCTION AND OBJECTIVES: Concerns surrounding the consequences of ionizing radiation (IR) have increased in interventional cardiology (IC). Despite this, the ever-growing complexity of diseases as well as procedures can lead to greater exposure to radiation. The aim of this survey, led by Portuguese Association of Interventional Cardiology (APIC), was to evaluate the level of awareness and current practices on IR protection among its members. METHODS: An online survey was emailed to all APIC members, between August and November 2021. The questionnaire consisted of 50 questions focusing on knowledge and measures of IR protection in the catheterization laboratory. Results were analyzed using descriptive statistics. RESULTS: From a response rate of 46.9%, the study obtained a total sample of 159 responses (156 selected for analysis). Most survey respondents (66.0%) were unaware of the radiation exposure category, and only 60.4% reported systematically using a dosimeter. A large majority (90.4%) employed techniques to minimize exposure to radiation. All participants used personal protective equipment, despite eyewear protection only being used frequently by 49.2% of main operators. Ceiling suspended shields and table protectors were often used. Only two-thirds were familiar with the legally established limit on radiation doses for workers or the dose that should trigger patient follow-up. Most of the survey respondents had a non-certified training in IR procedures and only 32.0% had attended their yearly occupational health consultation. CONCLUSIONS: Safety methods and protective equipment are largely adopted among interventional cardiologists, who have shown some IR awareness. Despite this, there is room for improvement, especially concerning the use of eyewear protection, monitoring, and certification.

Establishing national clinical diagnostic reference levels and achievable doses for CT examinations in Brazil: A prospective study.

PURPOSE: Diagnostic reference levels (DRL) and achievable doses (AD) are important tools for radiation dose optimization. Therefore, a prospective study was performed which aimed to establish a multi-parametric, clinical indication based - DRL(DRLCI) and clinical indication - AD (ADCI) for adult CT in Brazil. METHODS: The prospective study included 4787 patients (50 ± 18 years old; male:female 2041:2746) at 13 Brazilian sites that have been submitted to head, paranasal sinus, cervical spine, chest, or abdomen-pelvis CT between January and October 2021 for 13 clinical indications. The sites provided the following information: patient age, gender, weight, height, body mass index[BMI], clinical indications, scanner information(vendor, model, detector configuration), scan parameters (number of scan phases, kV, mA, pitch) and dose-related quantities (CT dose index volume- CTDIvol, dose length product- DLP). Median(AD) and 75th(DRL) percentile CTDIvol and DLP values were estimated for each body region and clinical indications. Non-normal data were analyzed with the Kruskal-Wallis test. RESULTS: In majority of Brazilian sites, body region and clinical indications based DRLs were at or lower than the corresponding DRLs in the US and higher than Europe. Although radiation doses varied significantly for patients in different body mass index groups (p < 0.001), within each body region, there were no differences in radiation doses for different clinical indications (p > 0.1). Radiation doses for 7/13 clinical indications were higher using iterative reconstruction technique than for the filtered back projection. CONCLUSIONS: There was substantial variation in Brazil DRLCI across different institutions with higher doses compared to the European standards. There was also a lack of clinical indication-based protocol and dose optimization based on different clinical indications for the same body region.

Education and training in radiation protection in Europe: results from the EURAMED Rocc-n-Roll project survey.

PURPOSE: To analyse the existing radiation protection (RP) education and training (E&T) capabilities in the European Union and identify associated needs, problems and challenges. METHOD: An online survey was disseminated via the EURAMED Rocc-n-Roll consortium network and prominent medical societies in the field of radiological research. The survey sections analyse the RP E&T during undergraduate, residency/internship and continuous professional development; RP E&T problems and legal implementation. Differences were analysed by European geographic regions, profession, years of professional experience and main area of practice/research. RESULTS: The majority of the 550 respondents indicated that RP topics are part of undergraduate curricula in all courses for their profession and country (55%); however, hands-on practical training is not included according to 30% of the respondents. The lack of E&T, practical aspects in current E&T, and mandatory continuing E&T were considered the major problems. The legal requirement that obtained higher implementation score was the inclusion of the practical aspects of medical radiological procedures on education (86%), and lower score was obtained for the inclusion of RP E&T on medical and dental school curriculums (61%). CONCLUSIONS: A heterogeneity in RP E&T during undergraduate, residency/internship and continuous professional development is evident across Europe. Differences were noted per area of practice/research, profession, and European geographic region. A large variation in RP E&T problem rating was also obtained.

Education and training in radiation protection in Europe: an analysis from the EURAMED rocc-n-roll project.

BACKGROUND: A Strengths, weaknesses, opportunities and threats analysis was performed to understand the status quo of education and training in radiation protection (RP) and to develop a coordinated European approach to RP training needs based on stakeholder consensus and existing activities in the field. Fourteen team members represented six European professional societies, one European voluntary organisation, two international healthcare organisations and five professions, namely: Medical Physicists; Nuclear Medicine Physicians; Radiologists; Radiation Oncologists and Radiographers. Four subgroups analysed the "Strengths", "Weaknesses", "Opportunities" and "Threats" related to E&T in RP developed under previous European Union (EU) programmes and on the Guidelines on Radiation Protection Education and Training of Medical Professionals in the EU. RESULTS: Consensus agreement identified four themes for strengths and opportunities, namely: (1) existing structures and training recommendations; (2) RP training needs assessment and education & training (E&T) model(s) development; (3) E&T dissemination, harmonisation, and accreditation; (4) financial supports. Weaknesses and Threats analysis identified two themes: (1) awareness and prioritisation at a national/global level and (2) awareness and prioritisation by healthcare professional groups and researchers. CONCLUSIONS: A lack of effective implementation of RP principles in daily practice was identified. EuRnR strategic planning needs to consider processes at European, national and local levels. Success is dependent upon efficient governance structures and expert leadership. Financial support is required to allow the stakeholder professional agencies to have sufficient resources to achieve a pan European radiation protection training network which is sustainable and accredited across multiple national domains.

Notifications and alerts in patient dose values for computed tomography and fluoroscopy-guided interventional procedures.

The terms "notifications" and "alerts" for medical exposures are used by several national and international organisations. Recommendations for CT scanners have been published by the American Association of Physicists in Medicine. Some interventional radiology societies as well as national authorities have also published dose notifications for fluoroscopy-guided interventional procedures. Notifications and alerts may also be useful for optimisation and to avoid unintended and accidental exposures. The main interest in using these values for high-dose procedures (CT and interventional) is to optimise imaging procedures, reducing the probability of stochastic effects and avoiding tissue reactions. Alerts in X-ray systems may be considered before procedures (as in CT), during procedures (in some interventional radiology systems), and after procedures, when the patient radiation dose results are known and processed. This review summarises the different uses of notifications and alerts to help in optimisation for CT and for fluoroscopy-guided interventional procedures as well as in the analysis of unintended and accidental medical exposures. The paper also includes cautions in setting the alert values and discusses the benefits of using patient dose management systems for the alerts, their registry and follow-up, and the differences between notifications, alerts, and trigger levels for individual procedures and the terms used for the collective approach, such as diagnostic reference levels. KEY POINTS: • Notifications and alerts on patient dose values for computed tomography (CT) and fluoroscopy-guided interventional procedures (FGIP) allow to improve radiation safety and contribute to the avoidance of radiation injuries and unintended and accidental exposures. • Alerts may be established before the imaging procedures (as in CT) or during and after the procedures as for FGIP. • Dose management systems should include notifications and alerts and their registry for the hospital quality programmes.

Impact of a radiological protection campaign in emergency paediatric radiology: a multicentric observational study in Brazil.

PURPOSE: To evaluate the impact of a paediatric radiological protection campaign, implemented in the emergency units of a healthcare provider network in Brazil. This campaign aimed to promote awareness among emergency department physicians, regarding justification of paediatric X-ray referrals for paranasal sinus, chest and CT exams, as a strategy to reduce exposure to ionising radiation. METHOD: Frequency analysis of common paediatric imaging referrals from 19 emergency departments was performed for a 3-year period (2015-2018) to coincide with before, during and after the implementation of the radiation protection campaign. The campaign was multifaceted and involved dissemination of educational materials and imaging referral guidelines along with quarterly meetings with participating centres' leaderships. Additionally, patient dose cards were distributed to patients/carers. The Chi-Square test was used to examine the association between the type of examination and the patient's age group. Exact-Fisher test was performed to check for an association between participant engagement and the existence of the radiation protection committee. RESULTS: Referrals reduced by 25% following the campaign with no reports of misdiagnosis. Many referrals in the youngest age groups. In 15 units, a radiological protection committee was created to raise awareness and to create a multi professional team to communicate the risks and benefits of radiological procedure in children. CONCLUSION: The campaign resulted in a substantial reduction in radiological referrals while promoting a radiation protection culture. Simple education initiatives can contribute to savings in both finances and radiation doses, particularly important in radiosensitive cohorts.

Exploring the translational challenge for medical applications of ionising radiation and corresponding radiation protection research.

BACKGROUND: Medical applications of ionising radiation and associated radiation protection research often encounter long delays and inconsistent implementation when translated into clinical practice. A coordinated effort is needed to analyse the research needs for innovation transfer in radiation-based high-quality healthcare across Europe which can inform the development of an innovation transfer framework tailored for equitable implementation of radiation research at scale. METHODS: Between March and September 2021 a Delphi methodology was employed to gain consensus on key translational challenges from a range of professional stakeholders. A total of three Delphi rounds were conducted using a series of electronic surveys comprised of open-ended and closed-type questions. The surveys were disseminated via the EURAMED Rocc-n-Roll consortium network and prominent medical societies in the field. Approximately 350 professionals were invited to participate. Participants' level of agreement with each generated statement was captured using a 6-point Likert scale. Consensus was defined as median ≥ 4 with ≥ 60% of responses in the upper tertile of the scale. Additionally, the stability of responses across rounds was assessed. RESULTS: In the first Delphi round a multidisciplinary panel of 20 generated 127 unique statements. The second and third Delphi rounds recruited a broader sample of 130 individuals to rate the extent to which they agreed with each statement as a key translational challenge. A total of 60 consensus statements resulted from the iterative Delphi process of which 55 demonstrated good stability. Ten statements were identified as high priority challenges with ≥ 80% of statement ratings either 'Agree' or 'Strongly Agree'. CONCLUSION: A lack of interoperability between systems, insufficient resources, unsatisfactory education and training, and the need for greater public awareness surrounding the benefits, risks, and applications of ionising radiation were identified as principal translational challenges. These findings will help to inform a tailored innovation transfer framework for medical radiation research.

Strengthening radiation protection education and training of health professionals: conclusions from an IAEA meeting.

In March 2021 the International Atomic Energy Agency (IAEA) organised an online Technical Meeting on Developing Effective Methods for Radiation Protection Education and Training of Health Professionals with attendance of 230 participants representing 66 Member States and 24 international organizations, professional bodies and safety alliances. By means of a pre-meeting survey, presentations by experts, topical panel discussions and post-meeting feedback to the meeting summary, the meeting identified strengths, common weaknesses and possible solutions and actions for improving radiation protection education and training of health professionals. Available guidelines and resources for radiation protection training were also reviewed. The meeting discussion resulted in a strong consensus for the need of: (a) international guidance on education and training in radiation protection and safety for health professionals, (b) an international description of minimum standards of initial and ongoing competence and qualification in radiation protection for relevant professional groups, considering the available recommendations at international and regional levels. The proposed actions include provisions for train-the-trainer credentialing and facility training accreditation, balance betwee the online and face-to-face training, improved on-the job training, as well as improved inclusion in training programmes of aspects related to application of new technologies, ethical aspects, development of communication skills, and use of software tools for improving justification and optimisation. The need for making the ongoing training practical, applicable, and useful to the trainee was highlighted. The international consultation initiated by the IAEA was appreciated as a good approach to understand and promote coordination and collaboration at all levels, for best results in education and training in radiation protection of health professionals. Implementing such a holistic approach to education and training in radiation protection would contribute towards qualification and competence of health professionals needed to ensure application of high standards for quality and safety in medical uses of ionizing radiation.

Dosimetric quantities and effective dose in medical imaging: a summary for medical doctors.

This review presents basic information on the dosimetric quantities used in medical imaging for reporting patient doses and establishing diagnostic reference levels. The proper use of the radiation protection quantity "effective dose" to compare doses delivered by different radiological procedures and different imaging modalities with its uncertainties and limitations, is summarised. The estimates of population doses required by the European Directive on Basic Safety Standards is commented on. Referrers and radiologists should be familiar with the dose quantities to inform patients about radiation risks and benefits. The application of effective dose on the cumulative doses from recurrent imaging procedures is also discussed. Patient summary: Basic information on the measurement units (dosimetric quantities) used in medical imaging for reporting radiation doses should be understandable to patients. The Working Group on "Dosimetry for imaging in clinical practice" recommended that a brief explanation on the used dosimetric quantities and units included in the examination imaging report, should be available for patients. The use of the quantity "effective dose" to compare doses to which patients are exposed to from different radiological procedures and its uncertainties and limitations, should also be explained in plain language. This is also relevant for the dialog on to the cumulative doses from recurrent imaging procedures. The paper summarises these concepts, including the need to estimate the population doses required by the European Directive on Basic Safety Standards. Referrers and radiologists should be familiar with the dose quantities to inform patients about radiation risks and benefits.

Radiation dose and diagnostic reference levels for four interventional radiology procedures: results of the prospective European multicenter survey EUCLID.

OBJECTIVES: To assess information reflecting radiation dose and define diagnostic reference levels (DRL) on a European basis for four interventional radiology (IR) procedures considering clinical indication, anatomical region, and procedure. METHODS: A prospective European study was performed to provide data on the IR procedures percutaneous recanalization of iliac arteries, percutaneous recanalization of femoropopliteal arteries, transarterial chemoembolization of hepatocellular carcinoma, and percutaneous transhepatic biliary drainage. Hospitals were asked to complete a questionnaire giving information on procedure, equipment, and protocol. Patient size and weight, experience of the operator graded in number of procedures performed, and complexity level of each procedure were reported. Sixteen hospitals from 13 countries could be surveyed. The percentiles of the kerma-area product, fluoroscopy time, cumulative air kerma at the interventional reference point, and number of images were determined. The impact of equipment, year of installation, and complexity level of the procedure on dose were analyzed. RESULTS: DRLs based on clinical indication were defined. Dose values varied considerably within hospitals, between them, and within each subgroup of complexity level. The use of state-of-the-art equipment reduced dose significantly by 52%. Although dose also varied within each subgroup of complexity level, for transarterial chemoembolization of hepatocellular carcinoma and percutaneous transhepatic biliary drainage, dose significantly correlated with complexity. CONCLUSIONS: This was the first study reporting exposure practice and defining DRLs based on clinical indication for four IR procedures on a European basis. These DRLs can serve as a baseline for comparison with local practice, the study as a guideline for future surveys. KEY POINTS: • The use of state-of-the-art angiographic equipment reduces dose significantly. • A significant correlation between radiation dose and complexity level is found. • Dose values vary considerably, both within and between individual hospitals, and within each complexity level of interventional radiology procedure.

Get Protected! Recommendations for Staff in IR.

PURPOSE: Evaluation and registration of patient and staff doses are mandatory under the current European legislation, and the occupational dose limits recommended by the ICRP have been adopted by most of the countries in the world. METHODS: Relevant documents and guidelines published by international organisations and interventional radiology societies are referred. Any potential reduction of patient and staff doses should be compatible with the clinical outcomes of the procedures. RESULTS: The review summarises the most common protective measures and the needed quality control for them, the criteria to select the appropriate protection devices, and how to avoid unnecessary occupational radiation exposures. Moreover, the current and future advancements in personnel radiation protection using medical simulation with virtual and augmented reality, robotics, and artificial intelligence (AI) are commented. A section on the personnel radiation protection in the era of COVID-19 is introduced, showing the expanding role of the interventional radiology during the pandemic. CONCLUSION: The review is completed with a summary of the main factors to be considered in the selection of the appropriate radiation protection tools and practical advices to improve the protection of the staff.

Cumulative effective dose from recurrent CT examinations in Europe: proposal for clinical guidance based on an ESR EuroSafe Imaging survey.

In recent years, the issue of cumulative effective dose received from recurrent computed tomography examinations has become a subject of increasing concern internationally. Evidence, predominantly from the USA, has shown that a significant number of patients receive a cumulative effective dose of 100 mSv or greater. To obtain a European perspective, EuroSafe Imaging carried out a survey to collect European data on cumulative radiation exposure of patients from recurrent computed tomography examinations. The survey found that a relatively low percentage of patients (0.5%) received a cumulative effective dose equal to or higher than 100 mSv from computed tomography, most of them having an oncological disease. However, there is considerable variation between institutions as these values ranged from 0 to 2.72%, highlighting that local practice or, depending on the institution and its medical focus, local patient conditions are likely to be a significant factor in the levels of cumulative effective dose received, rather than this simply being a global phenomenon. This paper also provides some practical actions to support the management of cumulative effective dose and to refine or improve practice where recurrent examinations are required. These actions are focused around increasing awareness of referring physicians through encouraging local dialogue, actions focused on optimisation where a team approach is critical, better use of modern equipment and the use of Dose Management and Clinical Decision Support Systems together with focused clinical audits. The proper use of cumulative effective dose should be part of training programmes for referrers and practitioners, including what information to give to patients. Radiation is used to the benefit of patients in diagnostic procedures such as CT examinations, and in therapeutic procedures like the external radiation treatment for cancer. However, radiation is also known to increase the risk of cancer. To oversee this risk, the cumulative effective dose (CED) received by a patient from imaging procedures over his or her life is important. In this paper, the authors, on behalf of EuroSafe Imaging, report on a survey carried out in Europe that aims to estimate the proportion of patients that undergo CT examinations and are exposed to a CED of more than 100 mSv. At the same time, the survey enquires about and underlines radiologists' measures and radiology departments' strategies to limit such exposure. Over the period of 2015-2018, respondents reported that 0.5% (0-2.72%) of patients were exposed to a CED of ≥ 100 mSv from imaging procedures. The background radiation dose in Europe depends on the location, but it is around 2.5 mSv per year. It is obvious that patients with cancer, chronic diseases and trauma run the highest risk of having a high CED. However, even if the number of patients exposed to ≥ 100 mSv is relatively low, it is important to lower this number even further. Measures could consist in using procedures that do not necessitate radiation, using very low dose procedures, being very critical in requiring imaging procedures and increasing awareness about the issue. KEY POINTS: • A relatively low percentage of patients (0.5%) received a cumulative effective dose from CT computed tomography equal to or greater than 100 mSv, in Europe, most of them having an oncological disease. • There is a wide range in the number of patients who receive cumulative effective dose equal to or greater than 100 mSv (0-2.72%) and optimisation should be improved. • Increasing the awareness of referring physicians through encouraging local dialogue, concrete actions focused on optimisation and development of dose management systems is suggested.

CT diagnostic reference levels based on clinical indications: results of a large-scale European survey.

OBJECTIVES: The objective of this study was to investigate the feasibility of defining diagnostic reference levels (DRLs) on a European basis for specific clinical indications (CIs), within the context of the European Clinical DRLs (EUCLID) European Commission project. METHODS: A prospective, multicenter, industry-independent European study was performed to provide data on 10 CIs (stroke, chronic sinusitis, cervical spine trauma, pulmonary embolism, coronary calcium scoring, coronary angiography, lung cancer, hepatocellular carcinoma, colic/abdominal pain, and appendicitis) via an online survey that included information on patient clinical, technical, and dosimetric parameters. Data from at least 20 patients per CI were requested from each hospital. To establish DRLs, a methodology in line with the International Commission on Radiological Protection (ICRP) Report 135 good practice recommendations was followed. RESULTS: Data were collected from 19 hospitals in 14 European countries on 4299 adult patients and 10 CIs to determine DRLs. DRLs differ considerably between sites for the same CI. Differences were attributed mainly to technical protocol and variable number of phases/scan lengths. Stroke and hepatocellular carcinoma were the CIs with the highest DRLs. Coronary calcium scoring had the lowest DRL value. Comparison with published literature was limited, as there was scarce information on DRLs based on CI. CONCLUSIONS: This is the first study reporting on feasibility of establishing CT DRLs based on CI using European data. Resulting values will serve as a baseline for comparison with local radiological practice, national authorities when DRLs are set/updated, or as a guideline for local DRL establishment. KEY POINTS: • First study reporting on the feasibility of establishing CT diagnostic reference levels based on clinical indication using data collected across Europe. • Only one-fourth of the hospitals had CT machines less than 5 years old. • Large dose variations were observed among hospitals and CT protocols were quite different between hospitals.

ESR EuroSafe Imaging and its role in promoting radiation protection - 6 years of success.

This article introduces the European Society of Radiology's EuroSafe Imaging initiative in the year of its 6th anniversary. The European and global radiation protection frameworks are outlined and the role of the EuroSafe Imaging initiative's Call for Action in successfully achieving international radiation protection goals as set out by those frameworks is detailed.

The role of pediatric radiologists and radiographers: a different future from the past.

The author of this paper reflects on the reality of pediatric radiology practice and pinpoints several constraints identified in the literature, constraints that limit the development of the role of pediatric radiologists and radiographers and therefore compromise the quality of medical imaging care delivered to the children. There is a need to build a pediatric imaging family of dedicated radiographers and radiologists at every hospital that has a radiology department. This strategy could improve the quality of the 350 million pediatric imaging procedures performed every year.

Radiation Dose of Patients in Fluoroscopically Guided Interventions: an Update.

The benefits of fluoroscopically guided interventional procedures are significant and have established new standards in the clinical management of many diseases. Despite the benefits, it is known that they come with known risks, such as the exposure to ionizing radiation. To minimize such risks, it is crucial that the health professionals involved in the procedures have a common understanding of the concepts related to radiation protection, such as dose descriptors, diagnostic reference levels and typical dose values. An update about these concepts will be presented with the objective to raise awareness amongst health professionals and contribute to the increase in knowledge, skills and competences in radiation protection in fluoroscopically guided interventional procedures.

Radiation dose management systems-requirements and recommendations for users from the ESR EuroSafe Imaging initiative.

The European Directive 2013/59/Euratom requires member states of the European Union to ensure justification and optimisation of radiological procedures and store information on patient exposure for analysis and quality assurance. The EuroSafe Imaging campaign of the European Society of Radiology created a working group (WG) on "Dose Management" with the aim to provide European recommendations on the implementation of dose management systems (DMS) in clinical practice. The WG follows Action 4: "Promote dose management systems to establish local, national, and European diagnostic reference levels (DRL)" of the EuroSafe Imaging Call for Action 2018. DMS are designed for medical practitioners, radiographers, medical physics experts (MPE) and other health professionals involved in imaging to support their tasks and duties of radiation protection in accordance with local and national requirements. The WG analysed requirements and critical points when installing a DMS and classified the individual functions at different performance levels. KEY POINTS: • DMS are very helpful software tools for monitoring patient exposure, optimisation, compliance with DRLs and quality assurance. • DMS can help to fulfil dosimetric aspects of the European Directive 2013/59/Euratom. • The EuroSafe WG analyses DMS requirements and gives recommendations for users.

Diagnostic Reference Levels based on clinical indications in computed tomography: a literature review.

BACKGROUND: In August 2017, the European Commission awarded the "European Study on Clinical Diagnostic Reference levels for X-ray Medical Imaging" project to the European Society of Radiology, to provide up-to-date Diagnostic Reference Levels based on clinical indications. The aim of this work was to conduct an extensive literature review by analysing the most recent studies published and the data provided by the National Competent Authorities, to understand the current situation regarding Diagnostic Reference Levels based on clinical indications for computed tomography. RESULTS: The literature review has identified 23 papers with Diagnostic Reference Levels based on clinical indications for computed tomography from 15 countries; 12 of them from Europe. A total of 28 clinical indications for 6 anatomical areas (head, cervical spine/neck, chest, abdomen, abdomen-pelvis, chest-abdomen-pelvis) have been identified. CONCLUSIONS: In all the six anatomical areas for which Diagnostic Reference Levels based on clinical indications were found, a huge variation of computed tomography dose descriptor values was identified, providing evidence for a need to develop strategies to standardise and optimise computed tomography protocols.