European consensus on patient contact shielding.

Patient contact shielding has been in use for many years in radiology departments in order to reduce the effects and risks of ionising radiation on certain organs. New technologies in projection imaging and CT scanning such as digital receptors and automatic exposure control (AEC) systems have reduced doses and improved image consistency. These changes and a greater understanding of both the benefits and the risks from the use of shielding have led to a review of shielding use in radiology. A number of professional bodies have already issued guidance in this regard. This paper represents the current consensus view of the main bodies involved in radiation safety and imaging in Europe: European Federation of Organisations for Medical Physics, European Federation of Radiographer Societies, European Society of Radiology, European Society of Paediatric Radiology, EuroSafe Imaging, European Radiation Dosimetry Group (EURADOS), and European Academy of DentoMaxilloFacial Radiology (EADMFR). It is based on the expert recommendations of the Gonad and Patient Shielding (GAPS) Group formed with the purpose of developing consensus in this area. The recommendations are intended to be clear and easy to use. They are intended as guidance, and they are developed using a multidisciplinary team approach. It is recognised that regulations, custom and practice vary widely on the use of patient shielding in Europe and it is hoped that these recommendations will inform a change management program that will benefit patients and staff.

Recommendations for the use of active personal dosemeters (APDs) in interventional workplaces in hospitals.

Occupational radiation doses from interventional procedures have the potential to be relatively high. The requirement to optimise these doses encourages the use of electronic or active personal dosimeters (APDs) which are now increasingly used in hospitals. They are typically used in tandem with a routine passive dosimetry monitoring programme, with APDs used for real-time readings, for training purposes and when new imaging technology is introduced. However, there are limitations when using APDs. A survey in hospitals to identify issues related to the use of APDs was recently completed, along with an extensive series of APD tests by the EURADOS Working Group 12 on Dosimetry for Medical Imaging. The aim of this review paper is to summarise the state of the art regarding the use of APDs. We also used the results of our survey and our tests to develop a set of recommendations for the use of APDs in the clinical interventional radiology/cardiology settings, and draw attention to some of the current challenges.

Intraoperative 2D C-arm and 3D O-arm in children: a comparative phantom study.

PURPOSE: Exposure to ionizing radiation is a concern for children during intraoperative imaging. We aimed to assess the radiation exposure to the paediatric patient with 2D and 3D imaging. METHODS: To evaluate the radiation exposure, patient absorbed doses to the organs were measured in an anthropomorphic phantom representing a five-year-old child, using thermoluminescent dosimeters. For comparative purposes, organ doses were measured using a C-arm for one minute of fluoroscopy and one acquisition with an O-arm. The cone-beam was centred on the pelvis. Direct and scattered irradiations were measured and compared (Student's t-test). Skin entrance dose rates were also evaluated. RESULTS: All radiation doses were expressed in µGy. Direct radiation doses of pelvic organs were between 631.22 and 1691.87 for the O-arm and between 214.08 and 737.51 for the C-arm, and were not significant (p = 0.07). Close scattered radiation on abdominal organs were between 25.11 and 114.85 for the O-arm and between 8.03 and 55.34 for the C-arm, and were not significant (p = 0.07). Far scattered radiation doses on thorax, neck and head varied from 0.86 to 6.42 for the O-arm and from 0.04 to 3.08 for the C-arm, and were significant (p = 0.02). The dose rate at the skin entrance was 328.58 µGy.s-1 for the O-arm and 1.90 with the C-arm. CONCLUSION: During imaging of the pelvis, absorbed doses for a 3D O-arm acquisition were higher than with one minute fluoroscopy with the C-arm. Further clinical studies comparing effective doses are needed to assess ionizing risks of the intraoperative imaging systems in children.

Eye lens radiation exposure of the medical staff performing interventional urology procedures with an over-couch X-ray tube.

The purpose of this work was to estimate the eye lens radiation exposure of the medical staff during interventional urology procedures. The measurements were carried out for six medical staff members performing 33 fluoroscopically-guided procedures. All procedures were performed with the X-ray tube positioned over the couch. The dose equivalents (Hp(0.07)) were measured at the eye level using optically stimulated luminescent (OSL) dosimeters and at the chest level with OSL dosimeters placed over the protective apron. The ratio of the dose measured close to the eye lens and on the chest was determined. The annual eye lens dose was estimated based on the workload in the service. For the physician and the instrumentalist nurse, the eye to chest dose ratios were 0.9±0.4 and 2.6±1.6 (k = 2), respectively. The average doses per procedure received by the eye lens were 78±24 µSv and 38±18 µSv, respectively. The eye lens dose per DAP was 8.4±17.5 µSv/(Gy·cm2) for the physician and 4.1±8.7 µSv/(Gy·cm2) for the instrumentalist nurse. The results indicate that the eye lens to chest dose ratio greatly varies according to the staff function and that the dose equivalent measured by the personal dosimeter worn on the chest may underestimate the eye lens dose of some medical staff members.

Occupational and patient exposure as well as image quality for full spine examinations with the EOS imaging system.

PURPOSE: EOS (EOS imaging S.A, Paris, France) is an x-ray imaging system that uses slot-scanning technology in order to optimize the trade-off between image quality and dose. The goal of this study was to characterize the EOS system in terms of occupational exposure, organ doses to patients as well as image quality for full spine examinations. METHODS: Occupational exposure was determined by measuring the ambient dose equivalents in the radiological room during a standard full spine examination. The patient dosimetry was performed using anthropomorphic phantoms representing an adolescent and a five-year-old child. The organ doses were measured with thermoluminescent detectors and then used to calculate effective doses. Patient exposure with EOS was then compared to dose levels reported for conventional radiological systems. Image quality was assessed in terms of spatial resolution and different noise contributions to evaluate the detector's performances of the system. The spatial-frequency signal transfer efficiency of the imaging system was quantified by the detective quantum efficiency (DQE). RESULTS: The use of a protective apron when the medical staff or parents have to stand near to the cubicle in the radiological room is recommended. The estimated effective dose to patients undergoing a full spine examination with the EOS system was 290 µSv for an adult and 200 µSv for a child. MTF and NPS are nonisotropic, with higher values in the scanning direction; they are in addition energy-dependent, but scanning speed independent. The system was shown to be quantum-limited, with a maximum DQE of 13%. The relevance of the DQE for slot-scanning system has been addressed. CONCLUSIONS: As a summary, the estimated effective dose was 290 µSv for an adult; the image quality remains comparable to conventional systems.

Radiation protection in digestive endoscopy: European Society of Digestive Endoscopy (ESGE) guideline.

This article expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about radiation protection for endoscopic procedures, in particular endoscopic retrograde cholangiopancreatography (ERCP). Particular cases, including pregnant women and pediatric patients, are also discussed. This Guideline was developed by a group of endoscopists and medical physicists to ensure that all aspects of radiation protection are adequately dealt with. A two-page executive summary of evidence statements and recommendations is provided. The target readership for this Guideline mostly includes endoscopists, anesthesiologists, and endoscopy assistants who may be exposed to X-rays during endoscopic procedures.

Extremity exposure in nuclear medicine: preliminary results of a European study.

The Work Package 4 of the ORAMED project, a collaborative project (2008-11) supported by the European Commission within its seventh Framework Programme, is concerned with the optimisation of the extremity dosimetry of medical staff in nuclear medicine. To evaluate the extremity doses and dose distributions across the hands of medical staff working in nuclear medicine departments, an extensive measurement programme has been started in 32 nuclear medicine departments in Europe. This was done using a standard protocol recording all relevant information for radiation exposure, i.e. radiation protection devices and tools. This study shows the preliminary results obtained for this measurement campaign. For diagnostic purposes, the two most-used radionuclides were considered: (99m)Tc and (18)F. For therapeutic treatments, Zevalin(®) and DOTATOC (both labelled with (90)Y) were chosen. Large variations of doses were observed across the hands depending on different parameters. Furthermore, this study highlights the importance of the positioning of the extremity dosemeter for a correct estimate of the maximum skin doses.

Active personal dosemeters in interventional radiology: tests in laboratory conditions and in hospitals.

The work package 3 of the ORAMED project, Collaborative Project (2008-11) supported by the European Commission within its seventh Framework Programme, is focused on the optimisation of the use of active personal dosemeters (APDs) in interventional radiology and cardiology (IR/IC). Indeed, a lack of appropriate APD devices is identified for these specific fields. Few devices can detect low-energy X rays (20-100 keV), and none of them are specifically designed for working in pulsed radiation fields. The work presented in this paper consists in studying the behaviour of some selected APDs deemed suitable for application in IR/IC. For this purpose, measurements under laboratory conditions, both with continuous and pulsed X-ray beams, and tests in real conditions on site in different European hospitals were performed. This study highlights the limitations of APDs for this application and the need of improving the APD technology so as to fulfil all needs in the IR/IC field.

Extremity and eye lens doses in interventional radiology and cardiology procedures: first results of the ORAMED project.

The main objective of WP1 of the ORAMED (Optimization of RAdiation protection for MEDical staff) project is to obtain a set of standardised data on extremity and eye lens doses for staff in interventional radiology (IR) and cardiology (IC) and to optimise staff protection. A coordinated measurement program in different hospitals in Europe will help towards this direction. This study aims at analysing the first results of the measurement campaign performed in IR and IC procedures in 34 European hospitals. The highest doses were found for pacemakers, renal angioplasties and embolisations. Left finger and wrist seem to receive the highest extremity doses, while the highest eye lens doses are measured during embolisations. Finally, it was concluded that it is difficult to find a general correlation between kerma area product and extremity or eye lens doses.

Comparison of organ doses and image quality between CT and flat panel XperCT scans in wrist and inner ear examinations.

The aim of this study was to evaluate and compare organ doses delivered to patients in wrist and petrous bone examinations using a multislice spiral computed tomography (CT) and a C-arm cone-beam CT equipped with a flat-panel detector (XperCT). For this purpose, doses to the target organ, i.e. wrist or petrous bone, together with those to the most radiosensitive nearby organs, i.e. thyroid and eye lens, were measured and compared. Furthermore, image quality was compared for both imaging systems and different acquisition modes using a Catphan phantom. Results show that both systems guarantee adequate accuracy for diagnostic purposes for wrist and petrous bone examinations. Compared with the CT scanner, the XperCT system slightly reduces the dose to target organs and shortens the overall duration of the wrist examination. In addition, using the XperCT enables a reduction of the dose to the eye lens during head scans (skull base and ear examinations).

Extremity ring dosimetry intercomparison in reference and workplace fields.

An intercomparison of ring dosemeters has been organised with the aim of assessing the technical capabilities of available extremity dosemeters and focusing on their performance at clinical workplaces with potentially high extremity doses. Twenty-four services from 16 countries participated in the intercomparison. The dosemeters were exposed to reference photon ((137)Cs) and beta ((147)Pm, (85)Kr and (90)Sr/(90)Y) fields together with fields representing realistic exposure situations in interventional radiology (direct and scattered radiation) and nuclear medicine ((99 m)Tc and (18)F). It has been found that most dosemeters provided satisfactory measurements of H(p)(0.07) for photon radiation, both in reference and realistic fields. However, only four dosemeters fulfilled the established requirements for all radiation qualities. The main difficulties were found for the measurement of low-energy beta radiation. Finally, the results also showed a general under-response of detectors to (18)F, which was attributed to the difficulties of the dosimetric systems to measure the positron contribution to the dose.

An overview of the use of extremity dosemeters in some European countries for medical applications.

Some medical applications are associated with high doses to the extremities of the staff exposed to ionising radiation. At workplaces in nuclear medicine, interventional radiology, interventional cardiology and brachytherapy, extremities can be the limiting organs as far as regulatory dose limits for workers are concerned. However, although the need for routine extremity monitoring is clear for these applications, no data about the status of routine extremity monitoring reported by different countries was collected and analysed so far, at least at a European level. In this article, data collected from seven European countries are presented. They are compared with extremity doses extracted from dedicated studies published in the literature which were reviewed in a previous publication. The analysis shows that dedicated studies lead to extremity doses significantly higher than the reported doses, suggesting that either the most exposed workers are not monitored, or the dosemeters are not routinely worn or not worn at appropriate positions.

An overview on extremity dosimetry in medical applications.

Some activities of EURADOS Working Group 9 (WG9) are presently funded by the European Commission (CONRAD project). The objective of WG9 is to promote and co-ordinate research activities for the assessment of occupational exposures to staff at workplaces in interventional radiology (IR) and nuclear medicine. For some of these applications, the skin of the fingers is the limiting organ for individual monitoring of external radiation. Therefore, sub-group 1 of WG9 deals with the use of extremity dosemeters in medical radiation fields. The wide variety of radiation field characteristics present in a medical environment together with the difficulties in measuring a local dose that is representative for the maximum skin dose, usually with one single detector, makes it difficult to perform accurate extremity dosimetry. Sub-group 1 worked out a thorough literature review on extremity dosimetry issues in diagnostic and therapeutic nuclear medicine and positron emission tomography, interventional radiology and interventional cardiology and brachytherapy. Some studies showed that the annual dose limits could be exceeded if the required protection measures are not taken, especially in nuclear medicine. The continuous progress in new applications and techniques requires an important effort in radiation protection and training.