Technical note: Workload and transmission data for mobile C-arm fluoroscopy in gastrointestinal endoscopy.

BACKGROUND: Mobile C-arms may be used in fixed locations, and it is recommended that qualified experts evaluate structural shielding. PURPOSE: To assess clinical workload distributions for mobile C-arms used in gastrointestinal endoscopy and determine the Archer equation parameters for the C-arm beam spectra. METHODS: Consecutive (30 months) gastrointestinal endoscopic procedures on two Cios Alpha systems (Siemens) were retrospectively analyzed. X-ray tube voltage, tube current-time product, reference point air kerma (Ka,r), air kerma-area product (PKA), and fluoroscopic time were examined. The primary beam half-value layer (HVL) was measured with an ionization chamber and aluminum 1100 plates. Stray radiation fraction at 1 m from a scattering source (ACR R/F phantom) was directly measured. Monte Carlo (Geant4) simulation was performed to calculate the transmission of broad X-ray beams through lead, concrete, gypsum, and steel, with X-ray HVLs matching those of the C-arm X-ray beam. The transmission data were fitted to the Archer equation. RESULTS: The number of procedures (3509) was equivalent to 13.48 procedures per room per week. Dose quantities were 54.8 mGy (Ka,r), 18.3 Gy∙cm2 (PKA), and 7.8 min (fluoroscopic time) per procedure. X-ray beam irradiation events were recorded for 2906 (82.8%) procedures with 160,009 events, whose mA-minute weighted tube voltage was 91.0 kV and the workload was 0.68 mA-minute per procedure. The two rooms had a significant difference in the number of procedures per week, 17.3 (29) [mean (maximum)] and 9.6 (16), respectively. The stray radiation fraction was 9.7×10-4 (80 kV) and 1.25×10-3 (120 kV). Transmission fitting parameters were provided for the tube voltage (on average, 90 kV; high end, 120 kV) of the C-arm. CONCLUSIONS: This work provides workload and transmission data for mobile C-arm fluoroscopy in gastrointestinal endoscopy, which indicates a need for structural shielding evaluation of the procedure rooms.

Neurointerventions on two generations of angiography systems: Recent systems reduce radiation exposure by half.

PURPOSE: Fluoroscopically-guided neurointervention may be associated with prolonged procedure time and substantial radiation exposure to the patient and staff. This study sought to examine technological features affecting the potential radiation exposure reduction of new angiography systems, compared to older systems, for neurointerventional procedures. METHODS: Consecutive neurointerventional patients (2020-2022) were retrospectively analyzed. The air kerma at the reference point (Ka,r) and kerma-area product (KAP) were compared between Artis icono and Artis zee (Siemens) using statistical analyses (two-tailed t tests), where P < 0.05 is considered significant. X-ray tube potential and copper filtration were examined. Tests with an anthropomorphic phantom (Sun Nuclear) on Artis icono were conducted and entrance skin exposure and x-ray spectral half value layer were measured. Effective spectral filtration was characterized by x-ray spectral modeling. RESULTS: The number of procedures was 1158 [median (range) age, 59 (7-95) years] on Artis zee and 1087 [60 (1-95) years] on Artis icono, without significant difference in age (p = 0.059) between cohorts. Ka,r was 925.4 (890.6-960.1) mGy [mean (95 % CI)] and KAP was 119.8 (115-124.5) Gy∙cm2 on Artis zee. The measures were 48-50 % lower on Artis icono, 440.5 (411.7-469.4) mGy (Ka,r) and 59.5 (55.4-63.6) Gy∙cm2 (KAP); while the difference in fluoroscopic time between the two generations of angiography systems was insignificant (p = 0.55). CONCLUSIONS: The newer angiography system, with updated hardware and software, was found to result in half the radiation exposure compared to older technology of the same manufacturer, even though fluoroscopic time was similar.

Cumulative radiation exposure from multimodality recurrent imaging of CT, fluoroscopically guided intervention, and nuclear medicine.

OBJECTIVES: To assess cumulative effective dose (CED) over a 4-year period in patients undergoing multimodality recurrent imaging at a major hospital in the USA. METHODS: CED from CT, fluoroscopically guided intervention (FGI), and nuclear medicine was analyzed in consecutive exams in a tertiary care center in 2018-2021. Patients with CED ≥ 100 mSv were classified by age and body habitus (underweight, healthy weight, overweight, obese), as per body mass index percentiles < 5th, 5th to < 85th, 85th to < 95th, and ≥ 95th (age 2-19 years), and its ranges < 18.5, 18.5-24.9, 25-29.9, and ≥ 30 (≥ 20 years), respectively. RESULTS: Among a total of 205,425 patients, 5.7% received CED ≥ 100 mSv (mean 184 mSv, maximum 1165 mSv) and their ages were mostly 50-64 years (34.1%), followed by 65-74 years (29.8%), ≥ 75 years (19.5%), 20-49 years (16.3%), and ≤ 19 years (0.29%). Body habitus in decreasing occurrence was obese (38.6%), overweight (31.9%), healthy weight (27.5%), and underweight (2.1%). Classification by dose indicated 172 patients (≥ 500 mSv) and 3 (≥ 1000 mSv). In comparison, 5.3% of 189,030 CT patients, 1.6% of 18,963 FGI patients, and 0.19% of 41,401 nuclear-medicine patients received CED ≥ 100 mSv from a single modality. CONCLUSIONS: The study of total dose from CT, FGI, and nuclear medicine of patients with CED ≥ 100 mSv indicates major (89%) contribution of CT to CED with 70% of cohort being obese and overweight, and 64% of cohort aged 50-74 years. CLINICAL RELEVANCE STATEMENT: Multimodality recurrent exams are common and there is a lack of information on patient cumulative radiation exposure. This study attempts to address this lacuna and has the potential to motivate actions to improve the justification process for enhancing patient safety. KEY POINTS: • In total, 5.7% of patients undergoing multimodality recurrent imaging (CT, fluoroscopically guided intervention, nuclear medicine) incurred a dose of ≥ 100 mSv. • Mean dose was 184 mSv, with 15 to 18 times contribution from CT than that from fluoroscopically guided intervention or nuclear medicine. • In total, 70% of those who received ≥ 100mSv were either overweight or obese.

Visualization and comparison of CT dose distribution between axial and helical acquisitions.

BACKGROUND: It is challenging to assess the accuracy of volume CT Dose Index (CTDIvol ) when the axial scan modes corresponding to a helical scan protocol are not available. An alternative approach was proposed to directly measure C T D I v o l H $CTDI_{vol}^H$ using helical acquisitions and relatively small differences (< 20%) from CTDIvol were observed. PURPOSE: To visually demonstrate the 3D dose distribution for both axial and helical CT acquisitions and quantitively compare C T D I v o l H $CTDI_{vol}^H$ and CTDIvol . METHODS: 3D dose distribution within the standard CTDI phantoms (16 and 32 cm diameter) from a single CT projection, Dp (x,y,z) was first generated using Monte Carlo simulation (GEANT4) with 9×108 photons per combination of tube voltage (80-140 kV), collimation width (1-8 cm), and z-axis location of the central ray of the x-ray beam, with a spatial resolution of 1 mm3 . These dose distributions from one single projection were analytically ensembled to simulate 3D dose volumes DA (x,y,z) and DH (x,y,z) for axial and helical scans, respectively, with different helical pitches (0.3-2) and scan lengths (100-150 mm). 2D planar dose distributions were obtained by integrating the inside 100 mm of the dose volumes. CTDIvol and C T D I v o l H $CTDI_{vol}^H\;$ were calculated using the planar dose data at corresponding pencil chamber locations and the percentage differences (PD) were reported. RESULTS: High spatial resolution 3D CT dose volumes were generated and visualized. PDs between C T D I v o l H $CTDI_{vol}^H$ and CTDIvol had strong dependency on scan length and peripheral chamber locations, with subtle dependency on collimation width and pitch. PDs were mostly within the range of ± 3% for a scan length of 150 mm with four peripheral chamber locations. CONCLUSIONS: With a scan length covering the entire phantom length, C T D I v o l H $CTDI_{vol}^H$ directly measured from helical scans can serve as an alternative to CTDIvol only if all four peripheral locations were measured.

Patient follow-up for possible radiation injury from fluoroscopically-guided interventions: Need to consider high cumulative exposure from multiple procedures.

PURPOSE: Patient skin dose from interventional fluoroscopy procedures may exceed the threshold of tissue injuries and established guidelines recommend patient follow-up for air kerma at reference point (Ka,r) ≥ 5 Gy for individual procedures. Patients may undergo multiple procedures and skin injuries may be possible by cumulative exposure, even when individually insufficient to cause injury. This study sought to quantify the frequency of patients whose individual procedure doses are below 5 Gy but whose cumulative Ka,r is ≥ 5 Gy. METHODS: This retrospective study analyzed 37,917 consecutive procedures in interventional radiology and vascular surgery at a tertiary-care hospital between January 2016 and June 2021. Radiation dosage was retrieved from the fluoroscopy acquisition systems. For a patient receiving multiple procedures, but each with Ka,r < 5 Gy, cumulative Ka,r within 2, 7, 14, 30, 183, and 365 days was assessed. RESULTS: Nearly 1/3rd (37.4 %) patients underwent multiple procedures. With individual procedures of Ka,r < 5 Gy exclusively, 1.9, 4.4, and 5.6 in 1000 patients received cumulative Ka,r of 5-14.1 Gy from the procedures within 30, 183, and 365 days, respectively. From the procedures within 14 days, 1.3 in 1000 patients received cumulative Ka,r of 5-11.4 Gy; and from those within 7 days, 0.87 in 1000 patients received 5-9.1 Gy. In comparison, 4.3 in 1000 patients received Ka,r of 5-12 Gy from a single procedure. CONCLUSIONS: In the absence of guidelines on patient follow-up for multiple procedures, our study may provide good material for setting up such guidelines.

Calculation of scan length and size-specific dose at longitudinal positions of body CT scans using dose equilibrium function.

BACKGROUND: Dose evaluation at longitudinal positions of body computed tomography (CT) scans is useful for CT quality assurance programs and patient organ dose evaluation. Accurate estimates depend on both patient size and scan length. PURPOSE: To propose practical evaluation of the average dose to the transverse slab of an axial image slice for adult body CT examinations, considering not only patient size but also scan length, and to compare the results with those of Monte Carlo (Geant4) simulation [Dsim (z)] and size-specific dose estimates at longitudinal positions of scans [SSDE(z)] from international standards (IEC publication no. 62985). METHODS: In a scan series, the total dose at each z-axis location was calculated using the input information identical to the SSDE(z) evaluation. Each axial image slice (slice thickness, 2.5 or 5 mm) was first considered independently. Its z-axis coverage and CTDIvol (from the DICOM headers) were used to directly calculate a z-axis dose profile for the average dose over the cross-section of a water phantom, using the approach to equilibrium function. The phantom diameter was taken to be equal to the patient water equivalent diameter at that slice. The above was repeated at all slices and the dose at each z-axis location was accumulated from all profiles, referred to as Dcalc (z). For validation, we considered a cohort of 65 patients, who underwent chest and abdominopelvic examinations. The resultant Dcalc (z) was compared with Dsim (z) and SSDE(z), both available in a previous paper. RESULTS: Dcalc (z) evaluation could be used to accurately assess the scan range average dose, with an accuracy of 7.1%-8.7% for 65 patients in two examinations. On individual image slices, the maximum difference in magnitude between Dcalc (z) and Dsim (z) [and between SSDE(z) and Dsim (z) in parentheses] was 37.5% (85%) [two edges (2 × 5 cm) of chest scan range], 17.8% (35.2%) (the remaining central region of chest scan), 26.8% (74.1%) [two edges (2 × 5 cm) of abdominopelvic scan range], and 14.2% (22.5%) (the remaining central region of abdominopelvic scan). CONCLUSIONS: Identical input data are used for Dcalc (z) and SSDE(z) evaluations. The latter is limited to the z-axis locations within scan range. At each image slice, SSDE(z) is equivalent to the midpoint dose of a fixed-mA scan of 15-30 cm (scan length). In contrast, Dcalc (z) considers dose accumulation from varying scan length (from sub-centimeter to about 1 m) and tube current, and dose profile is also computed outside scan range. Besides greatly improving dose evaluation for individual image slices, Dcalc (z) allows for evaluating dose accumulation from multiple series, which typically span different scan ranges. Our proposal may assist CT manufacturers and dose index monitoring software in assessing dose at longitudinal positions of body CT scans.

Using barium as an internal radioprotective shield for pregnant patients undergoing CT pulmonary angiography: A retrospective study.

PURPOSE: The purpose of our retrospective study was to assess the effect of barium sulfate contrast medium on radiation dose and diagnostic quality of CT Pulmonary Angiography (CTPA) in an in-vivo study of pregnant patients. METHODS: Our retrospective study included 33 pregnant patients who underwent CTPA to exclude pulmonary embolism. The patients received oral 40% w/v barium solution just prior to the acquisition of their planning radiograph. All CTPA were performed on 64-slice, single-source CT scanners with AEC with noise index = 28.62-31.64 and the allowed mA range of 100-450. However, only 5/33 patients had mA modulation (AEC 100-450 mA range), while 28/33 patients had mA maxed out at the set maximum mA of 450 over the entire scan range. We recorded CTDIvol (mGy), DLP (mGy.cm) and scan length. The same information was recorded in weight-and scanner-matched, non-pregnant patients. Statistical tests included descriptive data (median and interquartile range) and Mann-Whitney test. RESULTS: There were no significant differences in CTDIvol and DLP between the barium and control group patients (p > 0.1). The median mA below the diaphragm was significantly higher in each patient with barium compared to the weight and scanner-matched patient without barium. Evaluation of lung and subsegmental lower lobe pulmonary arteries was limited in 85% barium group. Due to thin prospective section thickness (1.25 mm), most patients were scanned at maximum allowed mA for AEC. CONCLUSION: Use of AEC with thick barium in pregnant patients undergoing CTPA as an internal radioprotective shield produces counterproductive artifacts and tube current increments.

Technical note: Advancing size-specific dose estimates in CT examinations: Dose estimates at longitudinal positions of scans.

PURPOSE: American Association of Physicists in Medicine (AAPM) (Report 204) introduced the size-specific dose estimate (SSDE) for the average dose to the center of a fixed-mA scan. International standards establish a method that CT manufacturers and radiation dose index monitoring software may use to calculate SSDE(z) at longitudinal positions of scans with fixed mA or tube current modulation, and its scan range average SSDE ( z ) ¯ $\overline {{\rm{SSDE}}( z )} $ . We sought to test how accurate SSDE(z) is in tracking the average dose to the transverse slab of an axial image slice (Dslice ), evaluated with Monte Carlo calculation, in the chest and abdominopelvic examinations. METHODS: We retrospectively identified 65 consecutive adult patients undergoing whole-body CT for transcatheter aortic valve implantation planning. Examination parameters (kV, mA, CTDIvol ) were extracted from the DICOM headers. Patient water equivalent diameter DW (z) was calculated at each image slice, excluding the patient table. A previously validated Monte Carlo simulation (Geant4) program was used to evaluate Dslice from the chest and abdominopelvic examinations. Alternatively, SSDE(z) was calculated at each slice. The results of the two methods were compared with descriptive statistical outcomes (R, version 4.0.2). RESULTS: In chest and abdominopelvic CT examinations, Dslice largely changed with anatomic location and uniformly fell off toward scan range edges. Scan range averages SSDE ( z ) ¯ $\overline {{\rm{SSDE}}( z )} $ and D slice ¯ $\overline {{D_{{\rm{slice}}}}} \;$ were consistent within 2.5%-3.1% (median) and 6.3%-10.4% (maximum) in two examinations. On individual image slices, SSDE(z) could be lower or higher than Dslice , with deviation ranging from -18.3% to 85% in two edges (2 × 5 cm) of scan range and from -35.2% to 18.7% in the remaining central region of the scan. CONCLUSION: This study provides critical inputs for quality assurance programs. SSDE ( z ) ¯ $\overline {{\rm{SSDE}}( z )} $ is useful to track the average dose of all image slices, but further development may be useful for tracking patient dose at the level of individual image slices, especially near a scan range edge.

Depletion forces in athermally sheared mixtures of frictionless disks and rods in two dimensions.

We carry out numerical simulations to study the behavior of an athermal mixture of frictionless circular disks and elongated rods in two dimensions, under three different types of global linear deformation at a finite strain rate: (i) simple shearing, (ii) pure shearing, and (iii) isotropic compression. We find that the fluctuations induced by such deformations lead to depletion forces that cause rods to group in parallel oriented clusters for the cases of simple and pure shear, but not for isotropic compression. For simple shearing, we find that as the fraction of rods increases, this clustering increases, leading to an increase in the average rate of rotation of the rods, and a decrease in the magnitude of their nematic ordering.

Shear-driven flow of athermal, frictionless, spherocylinder suspensions in two dimensions: Spatial structure and correlations.

We use numerical simulations to study the flow of athermal, frictionless, soft-core two-dimensional spherocylinders driven by a uniform steady-state simple shear applied at a fixed volume and a fixed finite strain rate γ[over ̇]. Energy dissipation is via a viscous drag with respect to a uniformly sheared host fluid, giving a simple model for flow in a non-Brownian suspension with Newtonian rheology. We study the resulting spatial structure of the sheared system, and compute correlation functions of the velocity, the particle density, the nematic order parameter, and the particle angular velocity. Correlations of density, nematic order, and angular velocity are shown to be short ranged both below and above jamming. We compare a system of size-bidisperse particles with a system of size-monodisperse particles, and argue how differences in spatial order as the packing increases lead to differences in the global nematic order parameter. We consider the effect of shearing on initially well ordered configurations, and show that in many cases the shearing acts to destroy the order, leading to the same steady-state ensemble as found when starting from random initial configurations.

Shear-driven flow of athermal, frictionless, spherocylinder suspensions in two dimensions: Particle rotations and orientational ordering.

We use numerical simulations to study the flow of a bidisperse mixture of athermal, frictionless, soft-core two-dimensional spherocylinders driven by a uniform steady-state simple shear applied at a fixed volume and a fixed finite strain rate γ[over ̇]. Energy dissipation is via a viscous drag with respect to a uniformly sheared host fluid, giving a simple model for flow in a non-Brownian suspension with Newtonian rheology. Considering a range of packing fractions ϕ and particle asphericities α at small γ[over ̇], we study the angular rotation θ[over ̇]_{i} and the nematic orientational ordering S_{2} of the particles induced by the shear flow, finding a nonmonotonic behavior as the packing ϕ is varied. We interpret this nonmonotonic behavior as a crossover from dilute systems at small ϕ, where single-particle-like behavior occurs, to dense systems at large ϕ, where the geometry of the dense packing dominates and a random Poisson-like process for particle rotations results. We also argue that the finite nematic ordering S_{2} is a consequence of the shearing serving as an ordering field, rather than a result of long-range cooperative behavior among the particles. We arrive at these conclusions by consideration of (i) the distribution of waiting times for a particle to rotate by π, (ii) the behavior of the system under pure, as compared to simple, shearing, (iii) the relaxation of the nematic order parameter S_{2} when perturbed away from the steady state, and (iv) by construction, a numerical mean-field model for the rotational motion of a particle. Our results also help to explain the singular behavior observed when taking the α→0 limit approaching circular disks.

Shear-driven flow of athermal, frictionless, spherocylinder suspensions in two dimensions: Stress, jamming, and contacts.

We use numerical simulations to study the flow of a bidisperse mixture of athermal, frictionless, soft-core two-dimensional spherocylinders driven by a uniform steady-state shear strain applied at a fixed finite rate. Energy dissipation occurs via a viscous drag with respect to a uniformly sheared host fluid, giving a simple model for flow in a non-Brownian suspension and resulting in a Newtonian rheology. We study the resulting pressure p and deviatoric shear stress σ of the interacting spherocylinders as a function of packing fraction ϕ, strain rate γ[over ̇], and a parameter α that measures the asphericity of the particles; α is varied to consider the range from nearly circular disks to elongated rods. We consider the direction of anisotropy of the stress tensor, the macroscopic friction µ=σ/p, and the divergence of the transport coefficient η_{p}=p/γ[over ̇] as ϕ is increased to the jamming transition ϕ_{J}. From a phenomenological analysis of Herschel-Bulkley rheology above jamming, we estimate ϕ_{J} as a function of asphericity α and show that the variation of ϕ_{J} with α is the main cause for differences in rheology as α is varied; when plotted as ϕ/ϕ_{J}, rheological curves for different α qualitatively agree. However, a detailed scaling analysis of the divergence of η_{p} for our most elongated particles suggests that the jamming transition of spherocylinders may be in a different universality class than that of circular disks. We also compute the number of contacts per particle Z in the system and show that the value at jamming Z_{J} is a nonmonotonic function of α that is always smaller than the isostatic value. We measure the probability distribution of contacts per unit surface length P(ϑ) at polar angle ϑ with respect to the spherocylinder spine and find that as α→0 this distribution seems to diverge at ϑ=π/2, giving a finite limiting probability for contacts on the vanishingly small flat sides of the spherocylinder. Finally, we consider the variation of the average contact force as a function of location on the particle surface.