Electronic On-line Incident Reporting System (IRS) as a Tool for Risk Assessment in Radiation Therapy.

Background: Radiotherapy is one of the primary treatment options in cancer management, together with surgery and chemotherapy. Radiation therapy is technologically complex discipline involving professionals with various specialties, and using high energy radiation in treatment of wide range of different cancer types. Technical complexity, increasing number of patients, large workload, and delivery of radiation therapy treatment with lack of human, technical and financial resources in low and middle income countries creates environment with great potential to develop incidents. Emerging need of modern radiation therapy is to develop preventive approach to risk management i to improve the patient safety. Objective: The objective of this research is to identify and assess risk associated with radiation therapy practice in Bosnia and Herzegovina. Methods: An anonymous, voluntary electronic on-line radiation therapy incident reporting system (IRS) was created. IRS consists of four sections containing questions about working environment, incident occurrence, root causes and contributing factors, and incident severity assessment. Data collected using IRS were used to create taxonomy of incidents in radiation therapy. Risk assessment was made using Risk Matrix method. Research was made using the data collected from first 60 incidents reported to IRS. Results: Based on probability and frequency of incident occurrence and severity of consequences, it was assessed that 41.7% of incidents had low risk level (L), 50% of incidents had moderate risk level (M), and 8.3% of incidents had high risk level (H). Radiation therapy risk profile based on risk assessment results clearly shows that incidents with low frequency, low occurrence probability, but high consequences severity level have highest level of risk. Conclusion: The results of this research confirm that the electronic on-line radiation therapy IRS allows the identification and classification of the most significant risk factors in radiotherapy and prevention of serious incidents occurrence.

Radiation protection and estimate of commercial aircrew effective doses in Bosnia and Herzegovina.

Cosmic rays are the primary source of the daily exposure of aircrew and passengers to ionising radiation. This study aims to estimate the effective doses of ionising radiation for aircraft crews in Bosnia and Herzegovina by taking into consideration factors such as flight duration and altitude, as well as the geographical position of airports. The CARI-7 algorithm and neural network method were used in the analysis of data obtained from the Sarajevo International Airport. The results show that the estimated annual effective doses in 2021 range from 0.06 to 10 mSv for flights to and from Belgrade and Dubai, respectively. Both linear regression and neural network models were developed to predict the effective dose based on flight duration, average altitude, latitude and maximum altitude. The findings reveal that flight duration is the most statistically significant factor, followed by average altitude, latitude and maximum altitude.

Extremity dosimetry for exposed workers in positron emission tomography in Bosnia and Herzegovina.

Occupational exposure in Bosnia and Herzegovina is regulated by the national regulation on radiation protection for occupational and public exposure. All radiation workers are required to be monitored using whole body passive thermoluminescent dosemeters and, in case of non-uniform external exposures, by dosemeters that would indicate dose to the most affected body parts. Exposed workers are almost exclusively employed in the medical field, and some of them work in nuclear medicine departments where they handle unsealed radioactive sources. Introduction of the positron emission tomography-computed tomography (PET-CT) in two largest clinical centers in the country was expected to cause the increase of equivalent doses to hands received by staff handling the positron emitting radionuclides. Hence, routine monitoring of finger doses became a necessity. The purpose of this study was to evaluate the available data on monitoring with ring dosemeters during PET-CT procedure in two hospitals in Bosnia and Herzegovina and compare them with other practices in the nuclear medicine department, as well as with the results of monitoring in other countries. In general, results confirm that effective doses, as well as equivalent doses to hands, are well below annual dose limits. Finger dosemeters have been proven to be an invaluable asset in the incidental situations that sometimes occur in nuclear medicine departments. Different number of patients and differences in injection methodologies are identified as a possible source of differences between doses in two hospitals. Overall, routine evaluation of doses to hands provides a sound basis for possible optimization processes, as well as confirmation of good practices.

Utilisation of 3D Printing in the Manufacturing of an Anthropomorphic Paediatric Head Phantom for the Optimisation of Scanning Parameters in CT.

Computed tomography (CT) is a diagnostic imaging process that uses ionising radiation to obtain information about the interior anatomic structure of the human body. Considering that the medical use of ionising radiation implies exposing patients to radiation that may lead to unwanted stochastic effects and that those effects are less probable at lower doses, optimising imaging protocols is of great importance. In this paper, we used an assembled 3D-printed infant head phantom and matched its image quality parameters with those obtained for a commercially available adult head phantom using the imaging protocol dedicated for adult patients. In accordance with the results, an optimised scanning protocol was designed which resulted in dose reductions for paediatric patients while keeping image quality at an adequate level.

Medical personnel occupationally exposed to low-dose ionising radiation in Federation of Bosnia and Herzegovina: A cytogenetic study.

Medical radiation exposures have been reduced significantly with modern equipment and protection measures. Biomonitoring of medical personnel can provide information concerning possible effects of radiation exposure. However, chromosome aberration (CA) analysis is now recommended only when the estimated effective dose is 200 mSv or higher. In this retrospective study in Bosnia and Herzegovina, we have measured the cytogenetic status of medical workers and healthy volunteers (controls). Peripheral blood samples from 66 medical workers exposed to low-dose ionising radiation and 89 non-exposed volunteers were collected for chromosome aberrations (CA) analysis and the cytokinesis-block micronucleus (CBMN) assay. Higher rates of chromatid and chromosome breaks, acentric fragments, double minutes, micronuclei, and micronucleated binuclear cells were observed in the control group, while the rate of nucleoplasmic bridges was higher in the medical workers group.

Dose Descriptors and Assessment of Risk of Exposure-Induced Death in Patients Undergoing COVID-19 Related Chest Computed Tomography.

For more than two years, coronavirus disease 19 (COVID-19) has represented a threat to global health and lifestyles. Computed tomography (CT) imaging provides useful information in patients with COVID-19 pneumonia. However, this diagnostic modality is based on exposure to ionizing radiation, which is associated with an increased risk of radiation-induced cancer. In this study, we evaluated the common dose descriptors, CTDIvol and DLP, for 1180 adult patients. This data was used to estimate the effective dose, and risk of exposure-induced death (REID). Awareness of the extensive use of CT as a diagnostic tool in the management of COVID-19 during the pandemic is vital for the evaluation of radiation exposure parameters, dose reduction methods development and radiation protection.

INTRAORAL DENTAL X-RAY RADIOGRAPHY IN BOSNIA AND HERZEGOVINA: STUDY FOR REVISING DIAGNOSTIC REFERENCE LEVEL VALUE.

This paper presents the study that would allow a revision of the currently valid diagnostic reference level in intraoral dental X-ray radiography in Bosnia and Herzegovina. The study was conducted for six procedures that are used to capture incisor, premolar and molar teeth, of both maxilla and mandible, in adults. Measurements were performed on 41 intraoral X-ray devices, 20 of which were systems with digital image receptor and 21 film-based X-ray systems. In this study, incident air kerma (Ki) and air kerma-area product (PKA) were used as patient dose descriptors. The third quartile (Q3) of the measured incident air-kerma values was used to compare with the current national diagnostic reference level (DRL) for intraoral dental procedures. The obtained results of Q3 for both types of devices, with film-based and digital image receptors, have shown that the third quartile values are lower (3.5 and 1.2 mGy, respectively) than the current national DRL (7.0 mGy). Hence, new data can be used to re-establish the diagnostic reference levels in intraoral dental X-ray examinations in Bosnia and Herzegovina.

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.

Advantages of Combined PET-CT in Mediastinal Staging in Patients with Non-small Cell Lung Carcinoma.

INTRODUCTION: Precise mediastinal lymph node staging in patients with non-small cell lung carcinoma (NSCLC) provides important prognostic information and it is obligatory in treatment strategy planning. 18Fluoro-deoxy-glucose (18F-FDG) positron emission tomography - computerized tomography (PET-CT) based on detection of metabolic activity showed superiority in preoperative staging of lung carcinoma. MATERIALS AND METHODS: Total number of 26 patients diagnosed with NSCLC were included in this retrospective, cross-sectional study. Status of mediastinal lymph nodes was assessed in all patients comparing contrast enhanced CT and 18F-FDG PET-CT findings. DISCUSSION: We found in our study that 50% of patients had different N stage on contrast enhanced CT comparing to 18F-FDG PET-CT findings. Among the total number of patients which had different nodal status on PET-CT comparing to CT alone, we found in our study that 54% of patients had change in further therapy protocol after PET-CT change of nodal stage. CONCLUSION: Combined PET-CT which offers advantages of both modalities is excellent method for nodal (N) staging, so it is recommended in initial staging in patients with NSCLC. PET-CT used preopratively for mediastinal nodal staging has significant impact on further therapy planning and also has an consequential impact on health system savings.

Possibilities of differentiation of solitary focal liver lesions by computed tomography perfusion.

AIM: To evaluate possibilities of computed tomography (CT) perfusion in differentiation of solitary focal liver lesions based on their characteristic vascularization through perfusion parameters analysis. METHODS: Prospective study was conducted on 50 patients in the period 2009-2012. Patients were divided in two groups: benign and malignant lesions. The following CT perfusion parameters were analyzed: blood flow (BF), blood volume (BV), mean transit time (MTT), capillary permeability surface area product (PS), hepatic arterial fraction (HAF), and impulse residual function (IRF). During the study another perfusion parameter was analyzed: hepatic perfusion index (HPI). All patients were examined on Multidetector 64-slice CT machine (GE) with application of perfusion protocol for liver with i.v. administration of contrast agent. RESULTS: In both groups an increase of vascularization and arterial blood flow was noticed, but there was no significant statistical difference between any of 6 analyzed parameters. Hepatic perfusion index values were increased in all lesions in comparison with normal liver parenchyma. CONCLUSION: Computed tomography perfusion in our study did not allow differentiation of benign and malignant liver lesions based on analysis of functional perfusion parameters. Hepatic perfusion index should be investigated in further studies as a parameter for detection of possible presence of micro-metastases in visually homogeneous liver in cases with no lesions found during standard CT protocol.

Doses to skin during dynamic perfusion computed tomography of the liver.

Many new computed tomography (CT) techniques have been introduced during the recent years, one of them being CT-assisted dynamic perfusion imaging (perfusion CT, PCT). Many concerns were raised when first cases of deterministic radiation effects were reported. This paper shows how radiochromic films can be utilised as passive dosemeters for use in PCT. Radiochromic dosemeters undergo a colour change directly and do not require chemical processing. Prior to their use, they need to be calibrated. Films are placed on top and on the right side of the patient and exposed during the procedure. Readout is performed using a densitometer. Results show that average local skin doses are 0.51±0.07 and 0.42±0.04 Gy on top and on the lateral side of the patient, respectively. Results of the patient dosimetry (local skin doses) are consistent. This is due to the fact that each patient had the same CT protocol used for imaging (120 kV, 60 mA and C(vol) of 247.75 mGy). Radiochromic films designed for interventional radiology can be effectively used for local skin dose measurements in perfusion CT. Dose values obtained are below the threshold needed for deterministic effects (erythema, hair loss, etc.). These effects might happen if inappropriate CT protocol is used; one that is usually used for routine imaging.

IAEA survey of paediatric computed tomography practice in 40 countries in Asia, Europe, Latin America and Africa: procedures and protocols.

OBJECTIVE: To survey procedures and protocols in paediatric computed tomography (CT) in 40 less resourced countries. METHODS: Under a project of the International Atomic Energy Agency, 146 CT facilities in 40 countries of Africa, Asia, Europe and Latin America responded to an electronic survey of CT technology, exposure parameters, CT protocols and doses. RESULTS: Modern MDCT systems are available in 77 % of the facilities surveyed with dedicated paediatric CT protocols available in 94 %. However, protocols for some age groups were unavailable in around 50 % of the facilities surveyed. Indication-based protocols were used in 57 % of facilities. Estimates of radiation dose using CTDI or DLP from standard CT protocols demonstrated wide variation up to a factor of 100. CTDI(vol) values for the head and chest were between two and five times those for an adult at some sites. Sedation and use of shielding were frequently reported; immobilisation was not. Records of exposure factors were kept at 49 % of sites. CONCLUSION: There is significant potential for improvement in CT practice and protocol use for children in less resourced countries. Dose estimates for young children varied widely. This survey provides critical baseline data for ongoing quality improvement efforts by the IAEA.

IAEA survey of pediatric CT practice in 40 countries in Asia, Europe, Latin America, and Africa: Part 1, frequency and appropriateness.

OBJECTIVE: The purpose of this study was to assess the frequency of pediatric CT in 40 less-resourced countries and to determine the level of appropriateness in CT use. MATERIALS AND METHODS: Data on the increase in the number of CT examinations during 2007 and 2009 and appropriate use of CT examinations were collected, using standard forms, from 146 CT facilities at 126 hospitals. RESULTS: The lowest frequency of pediatric CT examinations in 2009 was in European facilities (4.3%), and frequencies in Asia (12.2%) and Africa (7.8%) were twice as high. Head CT is the most common CT examination in children, amounting to nearly 75% of all pediatric CT examinations. Although regulations in many countries assign radiologists with the main responsibility of deciding whether a radiologic examination should be performed, in fact, radiologists alone were responsible for only 6.3% of situations. Written referral guidelines for imaging were not available in almost one half of the CT facilities. Appropriateness criteria for CT examinations in children did not always follow guidelines set by agencies, in particular, for patients with accidental head trauma, infants with congenital torticollis, children with possible ventriculoperitoneal shunt malfunction, and young children (< 5 years old) with acute sinusitis. In about one third of situations, nonavailability of previous images and records on previously received patient doses have the potential to lead to unnecessary examinations and radiation doses. CONCLUSION: With increasing use of CT in children and a lack of use of appropriateness criteria, there is a strong need to implement guidelines to avoid unnecessary radiation doses to children.

Image quality and dose in mammography in 17 countries in Africa, Asia and Eastern Europe: results from IAEA projects.

PURPOSE: The objective is to study mammography practice from an optimisation point of view by assessing the impact of simple and immediately implementable corrective actions on image quality. MATERIALS AND METHODS: This prospective multinational study included 54 mammography units in 17 countries. More than 21,000 mammography images were evaluated using a three-level image quality scoring system. Following initial assessment, appropriate corrective actions were implemented and image quality was re-assessed in 24 units. RESULTS: The fraction of images that were considered acceptable without any remark in the first phase (before the implementation of corrective actions) was 70% and 75% for cranio-caudal and medio-lateral oblique projections, respectively. The main causes for poor image quality before corrective actions were related to film processing, damaged or scratched image receptors, or film-screen combinations that are not spectrally matched, inappropriate radiographic techniques and lack of training. Average glandular dose to a standard breast was 1.5 mGy (mean and range 0.59-3.2 mGy). After optimisation the frequency of poor quality images decreased, but the relative contributions of the various causes remained similar. Image quality improvements following appropriate corrective actions were up to 50 percentage points in some facilities. CONCLUSIONS: Poor image quality is a major source of unnecessary radiation dose to the breast. An increased awareness of good quality mammograms is of particular importance for countries that are moving towards introduction of population-based screening programmes. The study demonstrated how simple and low-cost measures can be a valuable tool in improving of image quality in mammography.

Radiation protection of patients in diagnostic radiology: status of practice in five Eastern-European countries, based on IAEA project.

The purpose of this work was to investigate status of imaging technology and practice in five countries in Eastern-European region and evaluate the impact of IAEA projects on radiation protection of patients. Information collected using standardized IAEA protocol included status of technology, practices and patient dose levels in interventional procedure, radiography, mammography and computed tomography (CT). In spite of increased number of digital units, single phase generators or units older than 30 year are still in use. Examples of obsolete practice such as using fluoroscopy for positioning, photofluorography, chest fluoroscopy and soft-beam technique for chest radiography are also in use. Modern multi-slice CT or digital mammography units are available; however, there is lack of adequate radiation protection and medical physics support in hospitals. Information on patient doses in interventional procedures, conventional radiography, mammography and CT was collected to have baseline data and corrective measures were proposed with appropriate follow up actions taken.

Patient doses in interventional cardiology in Bosnia and Herzegovina: first results.

Cardiologists at the Cardiac Centre of the Clinical Centre of Sarajevo University performed invasive cardiology procedures in one room equipped with a Siemens Coroskop (Siemens Healthcare, Erlangen, Germany) unit with the possibility of digital cine imaging. The number of procedures performed with this unit is 1126 per year. The number of adults performing only diagnostic procedures is 816, therapeutic procedures 62 and both diagnostic and therapeutic 228. Twenty diagnostic examinations but no therapeutic procedure are performed on children per year. The workload is increasing year by year, with an average increase of 26 % per year. The X-ray system does not have a kerma area product (KAP) meter installed; therefore an external KAP meter was mounted on the X-ray tube. Gafchromic dosimetry films (International Specialty Products, Wayne, USA) were placed under the patient to record the skin dose distribution. The peak skin dose (PSD) was calculated from the maximum optical density of the dosimetry films. Dose measurements were performed on 51 patients undergoing therapeutic procedures (percutaneous transluminal coronary angioplasty and stent placement). Two patients received doses (KAP) larger than 100 Gycm(2). The PSD was higher than 1 Gy in 3 out of 16 evaluations, and one of these patients received a skin dose >2 Gy. No deterministic skin effects were recorded. The dosimetry results are similar to results reported in other countries. Invasive cardiac procedures deliver high doses to the skin that could cause deterministic effects (erythema). Physicians performing these procedures should be aware of these risks. More efforts should be put into the training of cardiologists in radiation protection.

Radiation exposure to patients during interventional procedures in 20 countries: initial IAEA project results.

OBJECTIVE: The purpose of our study was to investigate the level of radiation protection of patients and staff during interventional procedures in 20 countries of Africa, Asia, and Europe. SUBJECTS AND METHODS: In a multinational prospective study, information on radiation protection tools, peak skin dose (PSD), and kerma-area product (KAP) was provided by 55 hospitals in 20 mainly developing countries (nine mostly in Eastern Europe, five in Africa, and six in Asia). RESULTS: Nearly 40% of the interventional rooms had an annual workload of more than 2,000 patients. It is remarkable that the workload of pediatric interventional procedures can reach the levels of adult procedures even in developing countries. About 30% of participating countries have shown a 100% increase in workload in 3 years. Lead aprons are used in all participating rooms. Even though KAP was available in almost half of the facilities, none had experience in its use. One hundred of 505 patients monitored for PSD (20%) were above the 2-Gy threshold for deterministic effects. CONCLUSION: Interventional procedures are increasing in developing countries, not only for adults but also for pediatric patients. The situation with respect to staff protection is considered generally acceptable, but this is not the case for patient protection. Many patients exceeded the dose threshold for erythema. A substantial number (62%) of percutaneous transluminal coronary angioplasty procedures performed in developing countries in this study are above the currently known dose reference level and thus could be optimized. Therefore, this study has significance in introducing the concept of patient dose estimation and dose management.

Patient doses in radiographic examinations in 12 countries in Asia, Africa, and Eastern Europe: initial results from IAEA projects.

OBJECTIVE: The purpose of this study was to survey image quality and the entrance surface air kerma for patients in radiographic examinations and to perform comparisons with diagnostic reference levels. SUBJECTS AND METHODS: In this multinational prospective study, image quality and patient radiation doses were surveyed in 12 countries in Africa, Asia, and Eastern Europe, covering 45 hospitals. The rate of unsatisfactory images and image quality grade were noted, and causes for poor image quality were investigated. The entrance surface doses for adult patients were determined in terms of the entrance surface air kerma on the basis of X-ray tube output measurements and X-ray exposure parameters. Comparison of dose levels with diagnostic reference levels was performed. RESULTS: The fraction of images rated as poor was as high as 53%. The image quality improved up to 16 percentage points in Africa, 13 in Asia, and 22 in Eastern Europe after implementation of a quality control (QC) program. Patient doses varied by a factor of up to 88, although the majority of doses were below diagnostic reference levels. The mean entrance surface air kerma values in mGy were 0.33 (chest, posteroanterior), 4.07 (lumbar spine, anteroposterior), 8.53 (lumbar spine, lateral), 3.64 (abdomen, anteroposterior), 3.68 (pelvis, anteroposterior), and 2.41 (skull, anteroposterior). Patient doses were found to be similar to doses in developed countries and patient dose reductions ranging from 1.4% to 85% were achieved. CONCLUSION: Poor image quality constitutes a major source of unnecessary radiation to patients in developing countries. Comparison with other surveys indicates that patient dose levels in these countries are not higher than those in developed countries.