The American Brachytherapy Society and Indian Brachytherapy Society consensus statement for the establishment of high-dose-rate brachytherapy programs for gynecological malignancies in low- and middle-income countries.

PURPOSE: The global cervical cancer burden is disproportionately high in low- and middle-income countries (LMICs), and outcomes can be governed by the accessibility of appropriate screening and treatment. High-dose-rate (HDR) brachytherapy plays a central role in cervical cancer treatment, improving local control and overall survival. The American Brachytherapy Society (ABS) and Indian Brachytherapy Society (IBS) collaborated to provide this succinct consensus statement guiding the establishment of brachytherapy programs for gynecological malignancies in resource-limited settings. METHODS AND MATERIALS: ABS and IBS members with expertise in brachytherapy formulated this consensus statement based on their collective clinical experience in LMICs with varying levels of resources. RESULTS: The ABS and IBS strongly encourage the establishment of HDR brachytherapy programs for the treatment of gynecological malignancies. With the consideration of resource variability in LMICs, we present 15 minimum component requirements for the establishment of such programs. Guidance on these components, including discussion of what is considered to be essential and what is considered to be optimal, is provided. CONCLUSIONS: This ABS/IBS consensus statement can guide the successful and safe establishment of HDR brachytherapy programs for gynecological malignancies in LMICs with varying levels of resources.

Multi-institutional dose audit in radiotherapy facilities using in-house developed optically stimulated luminescence disc dosimeters.

Aim: The aim of this study was to carried out the audit of radiotherapy centers practicing conformal radiotherapy techniques and demonstrate the suitability of this indigenous optically stimulated luminescence (OSL) disc dosimeters in beam quality audit and verification of patient-specific dosimetry in conventional and conformal treatments in radiotherapy. Materials and Methods: Dose audit in conventional and conformal (intensity-modulated radiotherapy and volumetric-modulated arc therapy) radiotherapy techniques was conducted using in-house developed Al2O3:C-based OSL disc dosimeter and commercially available Gafchromic EBT3 film in 6 MV (flat and unflat) photon and 6 and 15 MeV electron beams. OSL disc dosimeter and Gafchromic EBT3 film measured dose values were verified using the ionization chamber measurements. Results: Percentage variations of doses measured by OSL disc dosimeters and EBT3 Gafchromic film for conventional radiotherapy technique were in the range of 0.15%-4.6% and 0.40%-5.45%, respectively, with respect to the treatment planning system calculated dose values. For conformal radiotherapy techniques, the percentage variations of OSL disc and EBT3 film measured doses were in the range of 0.1%-4.9% and 0.3%-5.0%, respectively. Conclusion: The results of this study supported by statistical evidence provided the confidence that indigenously developed Al2O3:C-based OSL disc dosimeters are suitable for dose audit in conventional and advanced radiotherapy techniques.

Evaluating the Impact of Ionization Chamber-Specific Beam Quality Correction Factor in Dosimetry of Filtered and Unfiltered Photon Beams.

Aim: The response of ionization chamber changes when used at beam quality Q which is different from beam quality Qo (usually 60Co) that was used at the time of its calibration. Hence, one needs to apply beam quality correction factor (kQ, Qo) during dosimetric measurements. However, kQ, Qo data are unavailable for novel ion chambers in the literature. Moreover, most of such data do not differentiate between filtered (flat) and unfiltered (unflat) beams. In addition, literature-based data do not differentiate among different pieces of the ion chambers of the same make and model. Hence, the purpose of our study was to determine the ion chamber-specific experimental values of kQ, Qo and to evaluate their impact in dosimetry. Materials and Methods: In this work, the value of kQ, Qo were measured for six ionization chambers of three different types in 6, 10, and 15 MV filtered (with flattening filter [WFF]) as well as 6 and 10 MV unfiltered (flattening filter free [FFF]) photon beams. The measured values of kQ, Qo were compared with Monte Carlo-calculated values available in the literature. The uncertainties in measurement of kQ, Qo values were also evaluated. Results: For 6 MV FFF beam, the measured value of kQ, Qo was found to be consistently lower than 6 MV WFF beam for all Sun Nuclear Corporation ion chambers, while it was higher as per the theoretical data. The inter-chamber variation in kQ, Qo values was observed for the same model of the ion chambers. The maximum difference between absolute dose values on using the theoretical and experimental kQ, Qo values was up to 3.23%. Conclusion: The measured absolute dose values by the ion chamber of a given make and model were found different due to the use of its theoretical and experimental kQ, Qo values. Furthermore, the variation in response of different pieces of ion chambers of the same make and model cannot be accounted for theoretically, and hence, the use of theoretical kQ, Qo data may introduce an inherent error in the estimation of absorbed dose to water. This necessitates the use of measured value of kQ, Qo for each ionization chamber.

Assessment of Regional Diagnostic Reference Levels in Dental Radiography in Tamil Nadu.

Aim: The aim of this article is to assess Tamil Nadu adult diagnostic reference levels (DRLs) by collecting radiation dose data from the four different dental modalities. Materials and Methods: The study was carried out using routine adult exposure settings in 131 intraoral, 75 panoramic, 35 cephalometric, and 10 dental cone beam computed tomography (CBCT) X-ray devices. DRLs were assessed for intraoral and extraoral (panoramic, cephalometric, and CBCT) examinations in terms of incident air kerma (Ka, i) and kerma area product (PKA), respectively. Air kerma measurements, for all dental units, were made using calibrated RTI black Piranha 557 dosimeter (RTI Electronics AB, Sweden). The dosimeter was kept at the exit cone of the X-ray tube and on the detector side of the X-ray unit for intraoral and extraoral air kerma measurements, respectively. The obtained air kerma in extraoral modalities is multiplied with the beam area to evaluate PKA. Results: The third quartile values calculated from the median for adult intraoral (mandibular molar), panoramic, cephalometric, and CBCT were 1.5 mGy, 116 mGycm2, 40 mGycm2, and 532 mGycm2, respectively. The proposed DRL in the present study was comparable to those reported in Germany, Greece, the UK, Japan, and Korea. Conclusion: This study revealed the need for dose management and radiation dose optimization, in various dental facilities in the state. It was also found that dental facilities employed with the digital type of detector are not always related to lower exposure.

Survey of the Use of Diffusion-Weighted Imaging for Cholesteatoma in the United Kingdom.

BACKGROUND: Non-echoplanar diffusion-weighted MRI (DWMRI) has a role in the surgical planning for cholesteatoma. AIMS/OBJECTIVES: The aim of the study was to assess the use of DWMRI in the management of cholesteatoma across the UK, and measure clinicians' confidence in the use of DWMRI. MATERIALS AND METHODS: Telephone survey in 139 Otolaryngology Departments in the United Kingdom between March 2017 and July 2017, and asking radiology delegates at the British Society of Head and Neck Imaging 2017 meeting. RESULTS: The response rate was 101 out of 139 Trusts (73%). Of those respondents who did have DWMRI available, 68/88 respondents (77%) use it for cholesteatoma. The mean confidence (±standard deviation) of the respondents with DWMRI in identifying cholesteatoma presence was 7.3 ± 2.1, in identifying volume of cholesteatoma was 6.8 ± 1.8, and in identifying subsites of cholesteatoma was 4.6 ± 2.1. CONCLUSIONS AND SIGNIFICANCE: DWMRI has a well-defined role in the follow-up of patients after cholesteatoma surgery, and those primary cases of cholesteatoma where the diagnosis is in question. The use of DWMRI for cholesteatoma is variable across the UK, but there are certain clinical scenarios where there is not enough awareness regarding the benefits of imaging (such as petrous apex cases of cholesteatoma).

Sinogenic Intracranial Suppuration in Children: Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate temporal trends in the management of sinogenic intracranial suppuration and its outcomes in children. DATA SOURCES: A systematic search of databases was performed (Medline, Embase, Cochrane, ClinicalTrials.gov). REVIEW METHODS: Studies in children (age <18 years) with sinogenic subdural empyema, extradural abscess, and intraparenchymal abscess were included. Data on treatment strategies were extracted. Primary outcome was death <90 days. Secondary outcomes were return to theater, neurologic disability at 6 months, and length of stay. Random effects meta-analysis and meta-regression were performed to investigate the effect of time and endoscopic sinus surgery (ESS) on these outcomes. RESULTS: A total of 32 retrospective observational studies involving 533 patients recruited across a 45-year period (1975-2020) were included. The pooled estimates for 90-day mortality, permanent neurologic disability, and return to theater were 2.3% (95% CI, 1.1%-3.6%; I2 = 0, P > .99), 21.3% (95% CI, 15.3%-27.3%; I2 = 75.2%, P < .001), and 37.3% (95% CI, 29.5%-45%; I2 = 71.2%, P < .001), respectively, with no significant differences found across the study period. The pooled estimate for ESS was 58.4% (95% CI, 44.2%-72.6%; I2 = 97.1%, P < .001) with a significantly increasing trend in its use in the more recent years. ESS was not associated with improved mortality, reduced need for revision surgery, or neurologic disability. CONCLUSION: The outcomes of sinogenic intracranial complications have not changed over the last 45 years, and ESS was not associated with improved patient outcomes. Further high-quality studies are required to determine the most appropriate treatment modalities to improve the burden of morbidity associated with sinogenic intracranial suppuration in children.

In-vivo dose measurements with MOSFET dosimeters during MV portal imaging.

BACKGROUND: The purpose of this study was to investigate the feasibility of MOSFET dosimeter in measuring eye dose during 2D MV portal imaging for setup verification in radiotherapy. MATERIALS AND METHODS: The in-vivo dose measurements were performed by placing the dosimeters over the eyes of 30 brain patients during the acquisition of portal images in linear accelerator by delivering 1 MU with the field sizes of 10 × 10 cm2 and 15 × 15 cm2. RESULTS: The mean doses received by the left and right eyes of 10 out of 30 patients when both eyes were completely inside the anterior portal field were found to be 2.56 ± 0.2 cGy and 2.75 ± 0.2, respectively. Similarly, for next 10 patients out of the same 30 patients the mean doses to left and right eyes when both eyes were completely out of the anterior portal fields were found to be 0.13 ± 0.02 cGy and 0.17 ± 0.02 cGy, respectively. The mean doses to ipsilateral and contralateral eye for the last 10 patients when one eye was inside the anterior portal field were found to be 3.28 ± 0.2 cGy and 0.36 ± 0.1 cGy, respectively. CONCLUSION: The promising results obtained during 2D MV portal imaging using MOSFET have shown that this dosimeter is well suitable for assessing low doses during imaging thereby enabling to optimize the imaging procedure using the dosimetric data obtained. In addition, the documentation of the dose received by the patient during imaging procedure is possible with the help of an in-built software in conjunction with the MOSFET reader module.

Demineralization of tooth enamel following radiation therapy; An in vitro microstructure and microhardness analysis.

OBJECTIVE: The objective of this study is to evaluate the effects of radiotherapy doses on mineral density and percentage mineral volume of human permanent tooth enamel. MATERIALS AND METHODS: Synchrotron radiation Xray microcomputed tomography (SRµCT) and microhardness testing were carried out on 8 and 20 tooth samples, respectively. Enamel mineral density was derived from SRµCT technique using ImageJ software. Microhardness samples were subjected to Vickers indentations followed by calculation of microhardness and percentage mineral volume values using respective mathematical measures. Data were analyzed using paired t-test at a significance level of 5%. Qualitative analysis of the enamel microstructure was done with two-dimensional projection images and scanned electron micrographs using µCT and field emission scanning electron microscopy, respectively. RESULTS: Vickers microhardness and SRµCT techniques showed a decrease in microhardness and an increase in mineral density, respectively, in postirradiated samples. These changes were related to mineral density variation and alteration of hydroxyapatite crystal lattice in enamel surface. Enamel microstructure showed key features such as microporosities and loss of smooth homogeneous surface. These indicate tribological loss and delamination of enamel which might lead to radiation caries. CONCLUSIONS: Tooth surface loss might be a major contributing factor for radiation caries in head-and-neck cancer patients prescribed to radiotherapy. Such direct effects of radiotherapy cause enamel abrasion, delamination, and damage to the dentinoenamel junction. Suitable measures should, therefore, be worked out to protect nontarget oral tissues such as teeth while delivering effective dosages to target regions.

Relative energy response of indigenously developed optically stimulated luminescence dosimeters Al2 O3 :C, LiMgPO4 :B and LiCaAlF6 :Eu,Y in therapeutic photon and electron beams.

The relative energy responses of three indigenously developed optically stimulated luminescence (OSL) phosphors in the disc form were studied in therapeutic photon and electron beams. Calibration in terms of absorbed dose was carried out in the dose range 5-500 cGy in 60 Co gamma rays, high energy X-rays, and electron beams used in radiotherapy. The combined standard uncertainty in the estimation of absorbed dose using these OSL discs (OSLDs) was 3.3%. Dose-response curves of these OSLDs in 60 Co gamma rays, 6 and 10 MV (flat and unflat), 15 MV and 6 and 15 MeV electron beams were found to be linear. Furthermore, these OSLDs exhibited a relative energy-dependent response for both photon and electron beams. The relative energy response correction factor for photon and electron beams were in the range 1.01-1.05 and 1.03-1.06, respectively.

PATIENT-SPECIFIC DOSIMETRY USING IN-HOUSE DEVELOPED OSL DISC DOSEMETERS.

Circular discs of diameter 5 mm were made from three indigenously developed optically stimulated luminescent (OSL) phosphors for medical dosimetry. Dosimetric characteristics of these discs were evaluated for their use in machine and patient-specific dosimetry in radiotherapy. Uncertainty in dosimetric measurements using these discs was also estimated, and combined standard uncertainty in measurement of absorbed dose was found to be 3.34%. Characterisation studies indicate that OSL discs are suitable for dosimetric application in radiotherapy. These discs were also used for patient-specific dosimetry in conventional and conformal radiotherapy treatments (five different cases) vis-à-vis ionisation chamber and Gafchromic EBT3 film. Doses measured by OSL discs were found comparable to ionisation chamber and Gafchromic EBT3 film measured values and radiotherapy treatment planning system (TPS) calculated dose values in all the cases. The variation between TPS calculated dose values and OSL discs measured dose values was found within the measurement uncertainty.

Surgical mapping of middle ear cholesteatoma with fusion of computed tomography and diffusion-weighted magnetic resonance images: Diagnostic performance and interobserver agreement.

OBJECTIVE: To assess the diagnostic performance in detecting primary cholesteatoma at various anatomical subsites using Computed Tomography (CT), Diffusion-weighted Magnetic Resonance Imaging (DWMRI) and Fusion of CT and DWMRI (Fusion CT-MRI) images. STUDY DESIGN: A retrospective study of 22 children identified from a prospective database of surgically treated cholesteatoma cases over a five year period. All cases underwent pre-operative CT, non-echo planar DWMRI and Fusion CT-DWMRI, and with clearly documented surgical findings. For each imaging modality, two radiologists scored for the presence or absence of cholesteatoma with confidence levels at different anatomical subsites. The radiologists were blinded to the surgical findings to which their findings were compared. SETTING: Large Teaching Hospital in London. PATIENTS: 22 children with cholesteatoma confirmed surgically. INTERVENTION: CT, DWMRI imaging and fusion CT-MRI. MAIN OUTCOME MEASURE: Diagnostic performance of subsite localisation of cholesteatoma by CT, DWMRI and fusion CT-MRI imaging with intra-operative findings. RESULTS: Twenty-two patients were included (12 women and 10 men). The median age of patients was 11 years. When considering all subsites combined, the result for all imaging methods suggested 'good' agreement between both observers. When all subsites were examined together, all methods had relatively high sensitivity values (87% for CT vs 84% for DWMRI vs 85% for fusion CT-DWMRI). Specificity was highest with fusion CT-DWMRI (46% for CT vs 76% for DWMRI vs 97% for fusion CT-DWMRI), as was accuracy (66% for CT vs 80% for DWMRI vs 91% for fusion). CONCLUSIONS: Our study has demonstrated that fusion CT-DWMRI is superior to DWMRI or CT separately in localizing cholesteatoma at various middle ear cleft subsites and bony relations, making it a valuable tool for surgical planning.

Pretreatment Dose Verification in Volumetric Modulated Arc Therapy Using Liquid Ionization Chamber.

PURPOSE: The purpose of the present study was to evaluate the practicability of liquid ionization chamber (LIC) for pretreatment dose verification of the advanced radiotherapy techniques such as volumetric modulated arc therapy (VMAT). MATERIALS AND METHODS: The dosimetric characteristics of LIC such as repeatability, sensitivity, monitor unit linearity, dose rate dependence, angular dependence, voltage-current response, and output factors were investigated in 6 MV therapeutic X-ray beams. The LIC was cross-calibrated against 0.125-cc air-filled thimble ionization chamber. A dedicated dosimetry insert made up of Perspex to incorporate the LIC at proper location in the intensity-modulated radiation therapy thorax phantom was locally fabricated. The collection efficiency and ion recombination correction factor was determined using the two-dose rate method. Pretreatment dose verification measurement of VMAT treatment plans were carried out using the liquid ionization chamber as well as small volume (0.125 cc) air-filled thimble ionization chamber. The measured dose values by the two dosimeters and TPS calculated dose at a given point were compared. RESULTS: The relative percentage differences between the TPS calculated and measured doses were within ± 1.57% for LIC and ± 2.21% for 0.125 cc ionization chamber, respectively. CONCLUSIONS: The measured dose values by the two dosimeters and TPS calculated dose at a given point were found comparable suggesting that the LIC could be a good choice of dosimeter for pretreatment dose verification in VMAT.

Underdosing of the maxillary sinus for small fields used in newer radiotherapy techniques: Comparison of thermoluminescent dosimeter and Monte Carlo data.

AIMS: To evaluate the underdosing of the maxillary sinus at its distal end produced by air cavity in the path of the 6 MV photon beam. MATERIALS AND METHODS: A cubic solid water slab phantom of dimensions 18 cm × 18 cm × 18 cm with 4 cm × 4 cm × 4 cm air cavity 3 cm away from its anterior surface was used in this study. The percentage depth dose (PDD) for 6 MV X-rays along the central axis of the cubical air cavity was measured using thermoluminescent dosimeter-100 chips. The EGSnrc/DOSXYZnrc Monte Carlo (MC) code was used to estimate the PDD values in both homogeneous and inhomogeneous conditions. The dose data were generated for 1 cm × 1 cm, 2 cm × 2 cm, 3 cm × 3 cm, and 5 cm × 5 cm field sizes. RESULTS: Average percentage dose reductions at 1 mm beyond the distal surface of the maxillary sinus for the field sizes 1 × 1, 2 × 2, and 3 × 3 cm2 are 42.4%, 39.5%, and 29.4%, respectively. However, for 5 cm × 5 cm field size, there is a dose enhancement (i.e., overdosing) at 1 mm from the distal surface of the maxillary sinus and the average percentage dose enhancement is 5.9%. Also, beyond 1 cm from the air-water interface, there is dose enhancement for all the field sizes. CONCLUSION: This study showed that the significant dose reduction occurs near the air-water interface for the treatment techniques using small photon fields such as intensity-modulated radiotherapy or other newer techniques. MC-based treatment planning calculation predicts realistic dose distribution while using small photon fields in the treatment of maxillary sinus.

CT- and MRI-based gross target volume comparison in vestibular schwannomas.

AIM: This study represents an enumeration and comparison of gross target volumes (GTV) as delineated independently on contrast-enhanced computed tomography (CT) and T1 and T2 weighted magnetic resonance imaging (MRI) in vestibular schwannomas (VS). BACKGROUND: Multiple imaging in radiotherapy improves target localization. METHODS AND MATERIALS: 42 patients of VS were considered for this prospective study with one patient showing bilateral tumor. The GTV was delineated separately on CT and MRI. Difference in volumes were estimated individually for all the 43 lesions and similarity was studied between CT and T1 and T2 weighted MRI. RESULTS: The male to female ratio for VS was found to be 1:1.3. The tumor was right sided in 34.9% and left sided in 65.1%. Tumor volumes (TV) on CT image sets were ranging from 0.251 cc to 27.27 cc. The TV for CT, MRI T1 and T2 weighted were 5.15 ± 5.2 cc, 5.8 ± 6.23 cc, and 5.9 ± 6.13 cc, respectively. Compared to MRI, CT underestimated the volumes. The mean dice coefficient between CT versus T1 and CT versus T2 was estimated to be 68.85 ± 18.3 and 66.68 ± 20.3, respectively. The percentage of volume difference between CT and MRI (%VD: mean ± SD for T1; 28.84 ± 15.0, T2; 35.74 ± 16.3) and volume error (%VE: T1; 18.77 ± 10.1, T2; 23.17 ± 13.93) were found to be significant, taking the CT volumes as the baseline. CONCLUSIONS: MRI with multiple sequences should be incorporated for tumor volume delineation and they provide a clear boundary between the tumor and normal tissue with critical structures nearby.

Radiation dose measurements during kilovoltage-cone beam computed tomography imaging in radiotherapy.

OBJECTIVE: The use of image guidance during radiotherapy for accurate localization and setup has become the standard care of practice in radiotherapy. This mostly involves the use of kilovoltage-cone beam computed tomography (kV-CBCT) for verification of patient setup on the first few days and on a weekly basis. Some protocols require this to be performed daily and also before and after the treatment. Though the radiation due to this kV-CBCT is small, the repeated use could deliver a dose that could increase the probability of the stochastic effect. The main purpose of this work is to measure radiation dose during image guidance with kV-CBCT. MATERIALS AND METHODS: In this work, we have attempted to measure the dose during kV-CBCT for different sites both on a humanoid phantom and on patients undergoing image-guided radiotherapy with MOSFETs calibrated against an ion chamber. RESULTS: The dose measurement on patients during kV-CBCT resulted in mean doses of 0.19 and 0.3 cGy to the ipsilateral and contralateral eyes, 0.625 and 1.097 cGy to the surface of the ipsilateral and contralateral breasts, and 3.01 cGy to the surface of the pelvis. CONCLUSION: Radiation dose to the eye, breast, and the surface of the pelvis have been arrived at during CBCT. The doses measured on patients agreed closely with those measured on humanoid phantom and with published values.

Radiological safety features of indigenously developed radiotherapy simulator.

OBJECTIVE: To study the radiological safety feature of indigenously developed radiotherapy simulator. MATERIALS AND METHODS: A comprehensive study for radiological safety features of the unit were carried out as per the standard protocol/guidelines. NERO mAx X-ray test device was used for KVp, mA, mAs, and X-rays output related test of the units along with other required test device. RESULTS: All the measurement results indicate that all the tested parameters of this simulator are well within the prescribed tolerance limit. CONCLUSION: The simulator is safe for routine clinical use.

Hyperthyroidism in patients with thyroid cancer.

We present a retrospective case series of patients with hyperthyroidism and thyroid cancer. Our goal was to look at their clinical characteristics and outcomes to determine which patients would require further investigation. We reviewed the case notes of all patients with a histopathologic diagnosis of thyroid cancer and biochemical evidence of hyperthyroidism who had been treated at a thyroid cancer center from January 2006 through October 2013. During that time, 66 patients had been diagnosed with thyroid cancer. Of these, 8 patients (12%)-all women, aged 29 to 87 years (mean: 55.6; median: 50.5)-had biochemical evidence of hyperthyroidism. Among these 8 patients, 4 had an autonomously functioning toxic nodule (AFTN), 3 were diagnosed with Graves disease, and 1 had a toxic multinodular goiter. Five patients had suspicious features on preoperative ultrasonography. All 8 patients were diagnosed with the papillary type of thyroid carcinoma. The mean size of the tumor in the 4 patients with AFTN was significantly larger than it was in those with Graves disease (42.3 ± 23.8 mm vs. 3.8 ± 1.6; p = 0.04). The 3 patients with Graves disease all had incidentally found papillary microcarcinoma. Between these two groups, the patients with AFTN had a poorer prognosis; 2 of them had extracapsular invasion and lymph node metastasis, and another died of her disease. We found that the incidence of hyperthyroidism in thyroid cancer patients was relatively high (12%). In contrast to what has previously been reported in the literature, patients with AFTN seem to have more aggressive disease and poorer outcomes than do patients with Graves disease. Any suspicious nodule associated with hyperthyroidism should be evaluated carefully.

Radiation dose to patients from X-ray radiographic examinations using computed radiography imaging system.

The screen-film system is replaced by computed radiography system for recording the images of the patients during X-ray radiography examinations. The change in imaging system requires the re-establishment of the institutional diagnostic reference levels (DRLs) for different types of X-ray examinations conducted at the hospital. For this purpose, patient specific parameters [age, height, weight, body mass index (BMI), object to image distance (OID)] and machine specific parameters (kVp, mAs, distance and field sizes) of 1875 patients during 21 different types of X-ray examinations were recorded for estimating the entrance skin dose (ESD). The ESD for each of these patients were estimated using measured X-ray beam output and the standard value of the back scatter factor. Five number summary was calculated for all the data for their presentation in the Box-Whisker plot, which provides the statistical distribution of the data. The data collected indicates that majorly performed examinations are cervical spine AP, Chest PA and Knee Lat with percentage contributions of 16.05, 16 and 8.27% respectively. The lowest contribution comes from Hip Lat which is about 1.01%. The ratio of measured ESD (maximum to minimum) for these examinations is found to be highest for the cervical spine AP with a value of 50 followed by Thoracic spine AP of 32.36. The ESD ratio for Chest PA, Knee Lat and Lumbar Spine AP are 30.75, 30.4 and 30.2 respectively. The lowest ESD ratio is for Hip Lat which is 2.68. The third quartile values of ESDs are established as the institutional DRLs. The ESD values obtained for 21 different X-ray projections are either comparable or lesser than the reported national/international values.