Optimization of the "Perth CT" Protocol for Preoperative Planning and Postoperative Evaluation in Total Knee Arthroplasty.

Background and Objectives: Total knee arthroplasty (TKA) has become the treatment of choice for advanced osteoarthritis. The aim of this paper was to show the possibilities of optimizing the Perth CT protocol, which is highly effective for preoperative planning and postoperative assessment of alignment. Materials and Methods: The cross-sectional study comprised 16 patients for preoperative planning or postoperative evaluation of TKA. All patients were examined with the standard and optimized Perth CT protocol using advance techniques, including automatic exposure control (AEC), iterative image reconstruction (IR), as well as a single-energy projection-based metal artifact reduction algorithm for eliminating prosthesis artifacts. The effective radiation dose (E) was determined based on the dose report. Imaging quality is determined according to subjective and objective (values of signal to noise ratio (SdNR) and figure of merit (FOM)) criteria. Results: The effective radiation dose with the optimized protocol was significantly lower compared to the standard protocol (p < 0.001), while in patients with the knee prosthesis, E increased significantly less with the optimized protocol compared to the standard protocol. No significant difference was observed in the subjective evaluation of image quality between protocols (p > 0.05). Analyzing the objective criteria for image quality optimized protocols resulted in lower SdNR values and higher FOM values. No significant difference of image quality was determined using the SdNR and FOM as per the specified protocols and parts of extremities, and for the presence of prothesis. Conclusions: Retrospecting the ALARA ('As Low As Reasonably Achievable') principles, it is possible to optimize the Perth CT protocol by reducing the kV and mAs values and by changing the collimation and increasing the pitch factor. Advanced IR techniques were used in both protocols, and AEC was used in the optimized protocol. The effective dose of radiation can be reduced five times, and the image quality will be satisfactory.

Intercomparison and performance assessment of radionuclide calibrators used in nuclear medicine departments in Serbia.

The purpose of this work is to assess accuracy and compare the performance of radionuclide calibrators (RNCs) used in nuclear medicine departments in Serbia. Testing of the RNCs included verification of measurement accuracy, as well as analysis of routinely used quality control protocols, by using the certified radioactivity standards (57Co, 137Cs). RNCs performances were assessed with 99mTc through comparison of reference value for radionuclide activity and RNC measurements. Results of the intercomparison revealed that RNCs, 15 in total, are accurate within 10% in vial geometry and within 15% in syringe geometry. Most of them showed similar performance. The results revealed that container geometry is an important influencing parameter in the accuracy of activity measurement. Obtained results indicate a need for regular calibration and implementation of Quality Control program in order to achieve and maintain the accuracy of activity measurements in nuclear medicine.

UNCERTAINTY ASSOCIATED WITH THE USE OF SOFTWARE SOLUTIONS UTILIZING DICOM RDSR FOR SKIN DOSE ASSESSMENT IN INTERVENTIONAL RADIOLOGY AND CARDIOLOGY.

PURPOSE: The purpose of this work is to provide a comprehensive analysis of uncertainties associated with the use of software solutions utilizing DICOM RDSRs for skin dose assessment in the interventional fluoroscopic environment. METHODS AND RESULTS: Three different scenarios have been defined for determining the overall uncertainty, each with a specific assumption on the maximum deviations of factors affecting the calculated dose. Relative expanded uncertainty has been calculated using two approaches: the law of propagation of uncertainty and the propagation of distributions based on the Monte Carlo method. According to the propagation of uncertainty, it is estimated that the lowest possible relative expanded uncertainty of ~13% (at the 95% level of confidence, i.e. with the coverage factor of k = 2 assuming normal distribution) could only be achieved if all sources of uncertainties are carefully controlled, whereas maximum relative expanded uncertainty could reach up to 61% if none of the influencing parameters are controlled properly. When the influencing parameters are reasonably well-controlled, realistic relative expanded uncertainty amounts to 28%. Values for the relative expanded uncertainty obtained from the Monte Carlo propagation of distributions concur with the results obtained from the propagation of uncertainty to within 3% in all three considered scenarios, validating the assumption of normality. CONCLUSIONS: The overall skin dose relative uncertainty has been found to range from 13 to 61%, emphasizing the importance of adequate analysis and control of all relevant uncertainty sources.

Use of out-of-field contact shielding on patients in medical imaging: A review of current guidelines, recommendations and legislative documents.

The use of patient contact-shielding has become a topic of intensive scientific debate. While it has been common practice during the last decades, some studies have questioned the efficiency of using such shielding while others have highlighted the inconsistencies in its application. The objective of this work is to review current recommendations and legislative documents on the use of out-of-field shielding in X-ray imaging, including those from national authorities and from international and national organisations and professional bodies. The review, performed within the framework of the activities of EURADOS Working Group 12, covers available recommendations on use of contact shielding in adult, pregnant and paediatric patients in general radiography, fluoroscopy, computed tomography, mammography and dental radiology. It includes a comprehensive search of 83 documents from 32 countries and 6 international organisations over the last 39 years. In general, using shielding is recommended only under two conditions: if it does not compromise the diagnostic task and the performance of the procedure and/or if it reassures the patient and comforters that they are appropriately protected against potentially harmful effects of radiation. There are very few specific regulatory requirements to use shielding in a particular imaging modality, although they may consider use of shielding either as part of good radiological practice or as requirements for availability of protective or ancillary tools, without further specification of their use. There is a wide variety of positions among documents that recommend out-of-field shielding, those that do not recommend it and those that are not specific. Therefore, evidence-based consensus is still needed to ensure best and consistent practice.

Accuracy of skin dose mapping in interventional cardiology: Comparison of 10 software products following a common protocol.

PURPOSE: Online and offline software products can estimate the maximum skin dose (MSD) delivered to the patient during interventional cardiology procedures. The capabilities and accuracy of several skin dose mapping (SDM) software products were assessed on X-ray systems from the main manufacturers following a common protocol. METHODS: Skin dose was measured on four X-ray systems following a protocol composed of nine fundamental irradiation set-ups and three set-ups simulating short, clinical procedures. Dosimeters/multimeters with semiconductor-based detectors, radiochromic films and thermoluminescent dosimeters were used. Results were compared with up to eight of 10 SDM products, depending on their compatibility. RESULTS: The MSD estimates generally agreed with the measurements within ± 40% for fundamental irradiation set-ups and simulated procedures. Only three SDM products provided estimates within ± 40% for all tested configurations on at least one compatible X-ray system. No SDM product provided estimates within ± 40% for all combinations of configurations and compatible systems. The accuracy of the MSD estimate for lateral irradiations was variable and could be poor (up to 66% underestimation). Most SDM products produced maps which qualitatively represented the dimensions, the shape and the relative position of the MSD region. Some products, however, missed the MSD region when situated at the intersection of multiple fields, which is of radiation protection concern. CONCLUSIONS: It is very challenging to establish a common protocol for quality control (QC) and acceptance testing because not all information necessary for accurate MSD calculation is available or standardised in the radiation dose structured reports (RDSRs).

Vendor-independent skin dose mapping application for interventional radiology and cardiology.

PURPOSE: The purpose of this paper is to present and validate an originally developed application SkinCare used for skin dose mapping in interventional procedures, which are associated with relatively high radiation doses to the patient's skin and possible skin reactions. METHODS: SkinCare is an application tool for generating skin dose maps following interventional radiology and cardiology procedures using the realistic 3D patient models. Skin dose is calculated using data from Digital Imaging and Communications in Medicine (DICOM) Radiation Dose Structured Reports (RDSRs). SkinCare validation was performed by using the data from the Siemens Artis Zee Biplane fluoroscopy system and conducting "Acceptance and quality control protocols for skin dose calculating software solutions in interventional cardiology" developed and tested in the frame of the VERIDIC project. XR-RV3 Gafchromic films were used as dosimeters to compare peak skin doses (PSDs) and dose maps obtained through measurements and calculations. DICOM RDSRs from four fluoroscopy systems of different vendors (Canon, GE, Philips, and Siemens) were used for the development of the SkinCare and for the comparison of skin dose maps generated using SkinCare to skin dose maps generated by different commercial software tools (Dose Tracking System (DTS) from Canon, RadimetricsTM from Bayer and RDM from MEDSQUARE). The same RDSRs generated during a cardiology clinical procedure (percutaneous coronary intervention-PCI) were used for comparison. RESULTS: Validation performed using VERIDIC's protocols for skin dose calculation software showed that PSD calculated by SkinCare is within 17% and 16% accuracy compared to measurements using XR-RV3 Gafchromic films for fundamental irradiation setups and simplified clinical procedures, respectively. Good visual agreement between dose maps generated by SkinCare and DTS, RadimetricsTM and RDM was obtained. CONCLUSIONS: SkinCare is proved to be very convenient solution that can be used for monitoring delivered dose following interventional procedures.

A European perspective on dental cone beam computed tomography systems with a focus on optimisation utilising diagnostic reference levels.

Cone beam computed tomography (CBCT) has been available since the late 1990s for use in dentistry. European legislation requires optimisation of protection and the use of diagnostic reference levels (DRLs) as well as regular quality control (QC) of the imaging devices, which is well outlined in existing international recommendations. Nevertheless, the level of application is not known. Earlier studies have indicated that few European countries have established DRLs and that patient doses (exposure parameters) have not been properly optimised. The EURADOS Working Group 12-Dosimetry in Medical Imaging undertook a survey to identify existing practices in Member States. Questionnaires were developed to identify equipment types, clinical procedures performed, and exposure settings used. The surveys were circulated to 22 countries resulting in 28 responses from 13 countries. Variations were identified in the exposure factors and in the doses delivered to patients for similar clinical indicators. Results confirm that patient doses are still not properly optimised and DRLs are largely not established. There is a need to promote the importance of performing QC testing of dental CBCT equipment and to further optimise patient exposure by establishment and use of DRLs as a part of a continuous optimisation process.

EVALUATION OF RADIATION DOSE FOR PATIENTS UNDERGOING MAMMOGRAPHY IN QATAR.

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.

IAEA survey of dental cone beam computed tomography practice and related patient exposure in nine Central and Eastern European countries.

OBJECTIVES: Cone beam CT (CBCT) in dentistry and maxillofacial surgery is a widely used imaging method for the assessment of various maxillofacial and dental pathological conditions. The objective of this study was to summarize the results of a multinational retrospective-prospective study that focused on patient exposure in this modality. METHODS: The study included 27 CBCT units and 325 adult and paediatric patients, in total. Data on patients, clinical indications, technical parameters of exposure, patient dose indicator, or, alternatively, dose to phantom were collected. The dose indicator used was air kerma-area product, PKA. RESULTS: In most scanners operators are offered with a variety of options regarding technical parameters, especially the field of view size. The median and the third quartile value of PKA for adult patients in 14 different facilities were 820 mGy cm² and 1000 mGy cm² (interquartile range = 1058 mGy cm²), and 653 mGy cm² and 740 mGy cm² (interquartile range = 1179 mGy cm²) for children, as reported by four different institutions. Phantom dose data were reported from 15 institutions, and median PKA ranged from 125 mGy cm² to 1951 mGy cm². Median PKA values varied by more than a 10-fold between institutions, mainly due to differences in imaging protocol used, in particular field of view and tube current-exposure time product. CONCLUSIONS: The results emphasize the need for a cautious approach to using dental CBCT. Imaging only when the clinical indications are clear, accompanied with the appropriate radiographic techniques and the optimum imaging protocol, will help reduce radiation dose to patients.

OCCUPATIONAL EYE LENS DOSE ESTIMATED USING WHOLE-BODY DOSEMETER IN INTERVENTIONAL CARDIOLOGY AND RADIOLOGY: A MONTE CARLO STUDY.

Medical personnel performing interventional procedures in cardiology and radiology is considered to be a professional group exposed to high doses of ionizing radiation. Reduction of the eye lens dose limit made its assessment in the interventional procedures one of the most challenging topics. The objective of this work is to assess eye lens doses based on the whole-body doses using methods of computational dosimetry. Assessment included different C-arm orientations (PA, LAO and RAO), tube voltages (80 -110 kV) and efficiency of different combinations of protective equipment used in interventional procedures. Center position at the height of the thyroid gives best estimate of eye lens dose, with spreads of 11% (13%), 13% (17%) and 14% (13%) for the left (right) eye lens. The conversion factors of 1.03 (0.83), 1.28 (1.06) and 1.36 (1.06) to convert whole body to eye lens dose were derived for positions of first operator, nurse and radiographer, respectively. The eye lens dose reduction factors for different combinations of applied protective equipment are 178, 5 and 6, respectively.

Past and present work practices of European interventional cardiologists in the context of radiation protection of the eye lens-results of the EURALOC study.

This paper investigates over five decades of work practices in interventional cardiology, with an emphasis on radiation protection. The analysis is based on data from more than 400 cardiologists from various European countries recruited for a EURALOC study and collected in the period from 2014 to 2016. Information on the types of procedures performed and their annual mean number, fluoroscopy time, access site choice, x-ray units and radiation protection means used was collected using an occupational questionnaire. Based on the specific European data, changes in each parameter have been analysed over decades, while country-specific data analysis has allowed us to determine the differences in local practices. In particular, based on the collected data, the typical workload of a European cardiologist working in a haemodynamic room and an electrophysiology room was specified for various types of procedures. The results showed that when working in a haemodynamic room, a transparent ceiling-suspended lead shield or lead glasses are necessary in order to remain below the recommended eye lens dose limit of 20 mSv. Moreover, the analysis revealed that new, more complex cardiac procedures such as chronic total occlusion, valvuloplasty and pulmonary vein isolation for atrial fibrillation ablation might contribute substantially to annual doses, although they are relatively rarely performed. The results revealed that considerable progress has been made in the use of radiation protection tools. While their use in electrophysiology procedures is not generic, the situation in haemodynamic procedures is rather encouraging, as ceiling-suspended shields are used in 90% of cases, while the combination of ceiling shield and lead glasses is noted in more than 40% of the procedures. However, we find that still 7% of haemodynamic procedures are performed without any radiation protection tools.

Use of active personal dosimeters in hospitals: EURADOS survey.

Considering that occupational exposure in medicine is a matter of growing concern, active personal dosimeters (APDs) are also increasingly being used in different fields of application of ionising radiation in medicine. An extensive survey to collect relevant information regarding the use of APDs in medical imaging applications of ionising radiation was organised by the EURADOS (European Radiation Dosimetry Group) Working Group 12. The objective was to collect data about the use of APDs and to identify the basic problems in the use of APDs in hospitals. APDs are most frequently used in interventional radiology and cardiology departments (54%), in nuclear medicine (29%), and in radiotherapy (12%). Most types of APDs use silicon diodes as the detector; however, in many cases their calibration is not given proper attention, as radiation beam qualities in which they are calibrated differ significantly from those in which they are actually used. The survey revealed problems related to the use of APDs, including their reliability in pulsed x-ray fields that are widely used in hospitals. Guidance from regulatory authorities and professional organisations on the testing and calibration of APDs used in hospital would likely improve the situation.

Feasibility of setting up generic alert levels for maximum skin dose in fluoroscopically guided procedures.

PURPOSE: The feasibility of setting-up generic, hospital-independent dose alert levels to initiate vigilance on possible skin injuries in interventional procedures was studied for three high-dose procedures (chemoembolization (TACE) of the liver, neuro-embolization (NE) and percutaneous coronary intervention (PCI)) in 9 European countries. METHODS: Gafchromic® films and thermoluminescent dosimeters (TLD) were used to determine the Maximum Skin Dose (MSD). Correlation of the online dose indicators (fluoroscopy time, kerma- or dose-area product (KAP or DAP) and cumulative air kerma at interventional reference point (Ka,r)) with MSD was evaluated and used to establish the alert levels corresponding to a MSD of 2 Gy and 5 Gy. The uncertainties of alert levels in terms of DAP and Ka,r, and uncertainty of MSD were calculated. RESULTS: About 20-30% of all MSD values exceeded 2 Gy while only 2-6% exceeded 5 Gy. The correlations suggest that both DAP and Ka,r can be used as a dose indicator for alert levels (Pearson correlation coefficient p mostly >0.8), while fluoroscopy time is not suitable (p mostly <0.6). Generic alert levels based on DAP (Gy cm2) were suggested for MSD of both 2 Gy and 5 Gy (for 5 Gy: TACE 750, PCI 250 and NE 400). The suggested levels are close to the lowest values published in several other studies. The uncertainty of the MSD was estimated to be around 10-15% and of hospital-specific skin dose alert levels about 20-30% (with coverage factor k = 1). CONCLUSIONS: The generic alert levels are feasible for some cases but should be used with caution, only as the first approximation, while hospital-specific alert levels are preferred as the final approach.

Performance Testing Of Selected Types of Electronic Personal Dosimeters in X- and Gamma Radiation Fields.

Electronic personal dosimeters (EPDs) are increasingly being used alongside conventional thermoluminescent dosimeters to measure the dose of legal record in terms of personal dose equivalent. Therefore, it is of great importance to execute performance tests of these dosimeters in photon fields of various energies and at various angles of incidence. This testing is done in order to simulate the behavior of these dosimeters in realistic multidirectional polyenergetic ionizing radiation fields. Tests of accuracy, linearity, energy response, and angular response have been performed on 10 EPDs from multiple manufacturers. Various radiation qualities have been used in the energy range from 33 keV to 1.33 MeV and for angles of incidence 0° to 80°. This research proves that many of the EPDs tested performed according to the manufacturer's specifications and the requirements of the international standards regarding personal dosimetry.

Occupational Exposure of the Eye Lens in Interventional Procedures: How to Assess and Manage Radiation Dose.

Occupational exposure from interventional x-ray procedures is one of the areas in which increased eye lens exposure may occur. Accurate dosimetry is an important element to investigate the correlation of observed radiation effects with radiation dose, to verify the compliance with regulatory dose limits, and to optimize radiation protection practice. The objective of this work is to review eye lens dose levels in clinical practice that may occur from the use of ionizing radiation. The use of a dedicated eye lens dosimeter is the recommended methodology; however, in practice it cannot always be easily implemented. Alternatively, the eye lens dose could be assessed from measurements of other dosimetric quantities or other indirect parameters, such as patient dose. The practical implementation of monitoring eye lens doses and the use of adequate protective equipment still remains a challenge. The use of lead glasses with a good fit to the face, appropriate lateral coverage, and/or ceiling-suspended screens is recommended in workplaces with potential high eye lens doses.

EYE LENS EXPOSURE TO MEDICAL STAFF PERFORMING ELECTROPHYSIOLOGY PROCEDURES: DOSE ASSESSMENT AND CORRELATION TO PATIENT DOSE.

The purpose of this study was to assess the patient exposure and staff eye dose levels during implantation procedures for all types of pacemaker therapy devices performed under fluoroscopic guidance and to investigate potential correlation between patients and staff dose levels. The mean eye dose during pacemaker/defibrillator implementation was 12 µSv for the first operator, 8.7 µSv for the second operator/nurse and 0.50 µSv for radiographer. Corresponding values for cardiac resynchronisation therapy procedures were 30, 26 and 2.0 µSv, respectively. Significant (p < 0.01) correlation between the eye dose and the kerma-area product was found for the first operator and radiographers, but not for other staff categories. The study revealed eye dose per procedure and eye dose normalised to patient dose indices for different staff categories and provided an input for radiation protection in electrophysiology procedures.

Sensitivity and fading of pMOS dosemeters irradiated with X-ray radiation doses from 1 to 100 cGy.

In this paper, the results of pMOS dosemeters sensitivity to X-ray radiation and 28-d fading at room temperature are presented. Two types of dosemeters were used, which differ in gate oxide layer thickness. The sensitivity of pMOS dosemeters with gate oxide layer thickness of 1 µm was followed in the dose intervals of 1 to 10 cGy and 10 to 100 cGy, whereas that of 400 nm was in the interval of 10 to 100 cGy. The sensitivity was characterised by the threshold voltage shift, which was determined as a function of absorbed radiation dose and time after irradiation. Linear dependence between threshold voltage shift and absorbed radiation dose was established, as well as that considerable fading occurs during the first few days after irradiation. The mechanisms responsible for threshold voltage shift during irradiation and latter annealing have been also discussed.

Comparison of pencil-type ionization chamber calibration results and methods between dosimetry laboratories.

A comparison of calibration results and procedures in terms of air kerma length product, PKL, and air kerma, K, was conducted between eight dosimetry laboratories. A pencil-type ionization chamber (IC), generally used for computed tomography dose measurements, was calibrated according to three calibration methods, while its residual signal and other characteristics (sensitivity profile, active length) were assessed. The results showed that the "partial irradiation method" is the preferred method for the pencil-type IC calibration in terms of PKL and it could be applied by the calibration laboratories successfully. Most of the participating laboratories achieved high level of agreement (>99%) for both dosimetry quantities (PKL and K). Estimated relative standard uncertainties of comparison results vary among laboratories from 0.34% to 2.32% depending on the quantity, beam quality and calibration method applied. Detailed analysis of the assigned uncertainties have been presented and discussed.

HAND DOSE EVALUATION OF OCCUPATIONALLY EXPOSED STAFF IN NUCLEAR MEDICINE.

Manipulation of unsealed radiation sources in nuclear medicine (NM) departments involves non-uniform exposure to staff and high skin doses to the upper extremities from direct and scattered radiations. Conducted studies have shown that the annual dose limits could be exceeded and the continuous dose monitoring of NM worker's hands is needed. The aim of this article is to show results of hand dose monitoring in terms of operational quantity Hp(0.07) for occupationally exposed NM workers to beta and gamma radiations in the largest NM centre in Serbia. Dose assessment was done by means of thermoluminescent ring dosemeters DXT-RAD (LiF:Mg,Ti). Monthly and annual doses were evaluated for a 5-y period (2010-14). Monitored NM staff was categorised according to the type of work, as nurses, radiographers, laboratory technicians and radiochemists. Performed evaluation showed that annual hand doses were within the annual limit for all staff categories, but further optimisation of working practice is needed.

Radiation exposure during X-ray examinations in a large paediatric hospital in Serbia.

Objective of this work is to evaluate radiation exposure from X-ray examinations in a large paediatric hospital in Serbia, including radiographic, fluoroscopic and computed tomography (CT) examinations in four age groups: 0-1, 1-5, 5-10 and 10-15 y. Incident air kerma was assessed for the following radiographies: chest (AP, PA, LAT), spine (AP, LAT), pelvis (AP), urinary tract (AP, PA) and skull (AP, PA, LAT). Kerma-area product was measured for the fluoroscopy examinations: barium swallow, barium meal, barium enema and micturating cystography. Dose in CT was assessed in terms of volume CT dose index and dose-length product for examinations of the head, chest and abdomen. The collected data were compared with other similar studies, which indicated a need to expand such survey to other paediatric hospitals in Serbia.