Purpose: Exposures to medical ionizing radiations elevate the risk of stochastic effects such as cancer in exposed individuals. It is of utmost importance to monitor the radiation doses delivered to patients and their optimization to reduce the associated radiation risks without limiting the diagnostic information. Methods: Entrance surface air kerma (ESAK) in a total of 64 adult patients in diagnostic digital Xray examinations were calculated and effective doses were estimated as per International Atomic Energy Agency (IAEA). Results: Median ESAK (mGy) and associated effective doses obtained were skull PA (0.45mGy, 0.005mSv) and skull Lat (0.25mGy, 0.003mSv). Results were compared with UK diagnostic reference levels and studies in India.Conclusion: The comparison revealed that the calculated ESAK and effective dose values wereless than the published literature. ESAK values reported in this study could further contribute toestablishing LDRLs

AK Srivastava

Chanchal Kaushik

Inderjeet Singh Sandhu

English

Journal of Multidisciplinary Research in Healthcare

J. Multidiscip. Res. Healthcare. Vol. 5, No. 2, April 2019, pp.51–56Journal of Multidisciplinary Research in HealthcareJournal homepage: https://jmrh.chitkara.edu.in/©2019. This article is published with open access at https://jmrh.chitkara.edu.in.ISSN No.: 2393-8536 (Print) ISSN No.: 2393-8544 (Online) Registration No. : CHAENG/2014/57978Vol. 5 | No. 2 | April 2020Evaluation of Patient Radiation Doses in Skull RadiographyChanchal Kaushik1*, Inderjeet Singh Sandhu2 and AK Srivastava31Chitkara School of Health Sciences, Chitkara University, Punjab-140401, India 2Chitkara University Institute of Engineering & Technology, Chitkara University, Punjab-140401, India3Department of Radiology, University College of Medical Sciences, Delhi-110095, India*Email: chanchal.kaushik@chitkara.edu.in1. IntroductionMedical ionizing exposures elevate the risk of stochastic effects in exposed individuals (Hall et al., 2005). National and international bodies such as National Radiological Protection Board (NRPB), Atomic Energy Regulatory Board (AERB), European Commission (EC), International Atomic Energy Agency (IAEA) and International Commission on Radiological Protection (ICRP) have recommended the establishment of diagnostic reference levels (DRLs) (IAEA, 2005; Hart, 2002; Gray, 2005). They suggest calculation of patient radiation doses and their comparison with DRLs (Vano et al., 2017). DRLs can be local, regional and national. International bodies in radiation protection suggests each country to set up their own DRLs and update them periodically. Also, due to the technological advancements, there has been a shift from the film-screen radiography to the digital radiography (DR) in recent years. DR uses flat panel detectors for capturing the image. DR has its own advantages such as faster acquisition, and contrast adjustment even after the exposure has been made. This creates the need for optimization of patient doses and establishments of guidance levels for radiation protection of patients (Matthews et al., 2009). Doses can be monitored by measuring the kerma area product (KAP) or by calculating the entrance surface air kerma (ESAK). ESAK is measured at a point where X-ray beam enters the patient on the beam axis. It includes the backscatter factor (Zoetelief, 2005; IAEA, 2007). Published literature was reviewed and research gaps showed limited work in dose evaluation in skull radiography, in spite of being the common radiological exam performed (IAEA, 1995). Literature also showed that poor quality skull radiographs were obtained due to low technical standards used and the lack of expertise by the operator and sometimes resulting into repeat exposures. Repeat exposures account to the increased radiation dose (Jennett, 1980; Bell, 1971). The frequency of these examinations is also high (Desmet et al., 1979). Present study aims to calculate the ESAK values and estimate the effective doses in adult patients undergoing ARTICLE INFORMATION  ABSTRACTReceived: October 12, 2018 Revised: December 20, 2018 Accepted: January 24, 2019Published Online: April 08, 2019 Purpose: Exposures to medical ionizing radiations elevate the risk of stochastic effects such as cancer in exposed individuals. It is of utmost importance to monitor the radiation doses delivered to patients and their optimization to reduce the associated radiation risks without limiting the diagnostic information.Methods: Entrance surface air kerma (ESAK) in a total of 64 adult patients in diagnostic digital X- ray examinations were calculated and effective doses were estimated as per International Atomic Energy Agency (IAEA).Results: Median ESAK (mGy) and associated effective doses obtained were skull PA (0.45mGy, 0.005mSv) and skull Lat (0.25mGy, 0.003mSv). Results were compared with UK diagnostic reference levels and studies in India. Conclusion: The comparison revealed that the calculated ESAK and effective dose values were less than the published literature. ESAK values reported in this study could further contribute to establishing LDRLs.Keywords: Quality assurance and quality control,  Skull X-ray, digital radiography,  entrance surface air kerma, effective dose, diagnostic reference levelsDOI: 10.15415/jmrh.2019.52006 ISSN No.: 2393-8536 (Print) ISSN No.: 2393-8544 (Online) Registration No. : CHAENG/2014/57978Chanchal Kaushik et al., J. Multidiscip Res. Healthcare Vol. 5, No. 2, April 2019 p.52digital skull radiographic examinations. The skull X ray examinations with projection postero-anterior (PA) and lateral (Lat) were considered for the study.2. Materials and MethodsTotal 64 radiographic skull (PA and Lat) examinations were enrolled in the study (27 male and 64 female). Patient doses were calculated with the IAEA protocol (minimum 10 patients per radiographic examination) in a teaching hospital in Delhi, India for a period of 2 months (IAEA, 2007). Weight restriction criteria of 70 ±10 kg was considered and informed consent was taken. In order to compare our doses with other countries, the reference weight of 70 ±10 kg is required. Ethical approval was obtained from institutional ethical committee. A caliper scale was used for measuring patient thickness (tp). Demographic and technical data i.e., patient’s weight, age, height, sex, tube current (mA), mAs,  tube voltage (kVp), exposure time (s), patient thickness and focus to detector distance (FDD) was recoded. Patient thickness (measured for each patient) and bucky thickness (5cm) were subtracted from FDD to evaluate FSD. The ESAK was determined (equation 1) as described in international protocols (Gonzalez et al., 2004). Radiographic examinations were performed on digital radiography machine make GE healthcare. X-rays were performed by radiographers on duty. Quality control tests were performed before recording the data.  ESAK TO mGy mAs mAsFSD BSF= × ×× ×( )( )//1002  (1)Where,ESAK :   entrance surface air kermaTO :   tube output in mGy/mAs, mAs :   tube current x exposure time, FSD :   the patient thickness and BSF :   the backscatter factor. Table 2: ESAK (mGy) values obtained in the study and comparison with published literature.This study ExaminationESAK (mGy) UK  2010Bhupendra et al.  2018Satish et al.2017mean ± SD Min- max 25 percentile Median 75 percentileHPA-034 India India75th PercentileSkull PA 0.471 ± 0.125 0.272-0.848 0.387 0.454 0.55 1.8 ** 4.7Skull Lat 0.263 ± 0.077 0.133-0.441 0.192 0.252 0.324 1.1 2.38 **The effective dose (equation 2) was evaluated using conversion coefficients from UK HPA -012 (Hart et al., 2010). Descriptive statistics of the collected data were performed in SPSS statistics 23.0 for windows. E mSv CV mSvmGy ESAK mGyESAK-1( ) ( )( )=× (2)3. Results and DiscussionDemographic information and technical parameters are presented in Table 1. Table 2 presents mean ±SD, median, 25th, and 75th percentile values of ESAK (mGy). It also presents a comparison with 75th percentile values of studies by Bhupendra et al. and Satish et al. in India, and UK 2010 Table 1: Patient demographic information and technical factors.Examination   Skull PA Skull LatNo. of exposures (n) 30 34Gender M 12 15F 18 19age (years)mean 36.67 35.41range 18-52 19-60Weight(kg)mean 63.83 65range 60-80 60-80Height (cm)mean 158 161range 140-174 140-170m A smean 4.09 3.24range 2.0-7 1.62-5.54FSD (cm)mean 76 79range 73-83 75-82Patient thickness (cm) mean 18.96 16.36k V mean 80 70FDD (cm) mean 100 100ISSN No.: 2393-8536 (Print) ISSN No.: 2393-8544 (Online) Registration No. : CHAENG/2014/57978Chanchal Kaushik et al., J. Multidiscip Res. Healthcare Vol. 5, No. 2, April 2019 p.53review (Rana, 2018; Uniyal, 2017; Hart, 2010). Table 3 presents the effective doses its comparison with mean doses of UK 2011. The linear relationship observed between mAs and ESAK is presented in figure 1 with R2 values. R2 values calculated were 0.9623 and 0.9992 for skull PA, skull Lat.The ESAK values of skull PA and skull LAT are lower in comparison with earlier studies. On comparing doses of present study with UK HPA-CRCE-034, the percentage decrease of radiation dose is found to be 69% and 70% for skull PA and skull Lat. UK report HPA-CRCE-034 is a national survey with the mean patient weight of UK of 70kg (Hart et al., 2010). Our study presents ESAK values in digital radiography. The mean kVp, mAs, tube filtration (mm Al) used for radiographic examinations in UK HPA-CRCE-034 are skull PA (72kvp, 20mAs) and skull Lat (66kvp, 11mAs). It can be seen that a lower mAs is applied in present study for skull PA and skull Lat. Digital radiography uses flat panel detectors, which results in dose reduction (Hernamm et al., 2002). This reduction in patient dose by using flat panel detectors is also reported by Sjoholm et al., and Metaxas et al., (Sjöholm, 2005; Metxas, 2019). Comparing present study results with similar study in India by Bhupinder et al, it is observed that for skull Lat the percentage decrease of radiation dose is found to be 86% (Rana et al., 2018). The mean patient weight of both the studies is comparable. Satish et al., presented DRLs via dose survey of mixed type of X-ray machines. For skull PA, the percentage decrease of radiation dose is found to be 88% (Uniyal et al., 2017). Doses below DRLs indicates radiographic practice in acceptable limits, but dose audits are required to maintain ALARA. Present study provides initial baseline data for radiation protection and optimization of doses and suggests timely dose audits in digital radiography.Limitations: Radiation dose assessment was carried out in skull radiography in present study. ESAK values could further be measured in other common radiographic examinations. ConclusionThe study aimed to calculate the ESAK, and effective dose values in digital skull radiographic examinations. The results obtained are compared with ESAK and effective dose values of UK and studies in India. Study also presents the current radiographic practices in skull digital radiography. The obtained doses are lower than that of published literature which is attributed to DR system, good radiographic practices and application of dose reduction techniques. Consistent dose optimization can be achieved by timely dose audits. The values obtained in this study may further contribute to future LDRLs.Conflict of interest: The authors declare no conflict of interest.Funding source: NoneReferencesAtomic energy Regulatory Board (2001). Safety Code for medical diagnostic X-ray equipment and installation. Table 3: Effective Dose, E (mSv) in present study and comparison with UK 2011.This studyExaminationEffective Dose, E(mSv) UK 2011mean SD Min-max Median 75 percentile meanSkull PA 0.0061 0.0016 0.0035 - 0.0110 0.0059 0.0071 0.02Skull Lat 0.0031 0.0009 0.0015 - 0.0052 0.003 0.0038 0.016Figure 1: The relationship (linear) between mAs and ESAK (mGy).Figure 1: The relationship (linear) between mAs and ESAK (mGy) ISSN No.: 2393-8536 (Print) ISSN No.: 2393-8544 (Online) Registration No. : CHAENG/2014/57978Chanchal Kaushik et al., J. Multidiscip Res. Healthcare Vol. 5, No. 2, April 2019 p.54No. AERB/SC/MED-2 (Rev.1) (Mumbai, India: atomic energy regulatory board).Atomic energy Regulatory Board (2016). 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Multidiscip Res. Healthcare) by Chitkara University Publications. It is published with a Creative Commons Attribution- CC-BY 4.0 International License. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Evaluation of Patient Radiation Doses in Skull Radiography

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Evaluation of Patient Radiation Doses in Skull Radiography

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