ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department

Radiation dose reduction during venous access port implantation: the importance of upgrading equipment and radiation-protection training

BACKGROUND

Implantable central venous port systems are widely used in oncology. We upgraded our fluoroscopy machines, and all anesthetists completed two training courses focusing on the risks of ionizing radiation for patients and health workers.

AIMS

This study aimed to evaluate the impact of upgrading the machines and the radiation-protection training on ionizing radiation exposure during venous port system implantation.

METHODS

We retrospectively analyzed consecutive venous port implantations between 2019 and 2022. The older fluoroscopy machines were replaced by two new machines. A first training session about health worker radioprotection was organized. The medical staff completed a second training course focused on protecting patients from ionizing radiation. We defined four distinct time intervals (TI): venous port implantations performed with the old equipment, the new fluoroscopy machines, after the first training course, and after the second training course. The air kerma-area product (KAP) was compared between these four TI and fluoroscopy times and the number of exposures only with the new machines.

RESULTS

We analyzed 2587 procedures. A 93% decrease in the median KAP between the first and last TI was noted (median KAP = 323.0 mGy.cm2 vs. 24.0 mGy.cm2, p < 0.0001). A decrease in the KAP was observed for each of the 11 anesthetists. We also noted a significant decrease in the time of fluoroscopy and the number of exposures.

CONCLUSIONS

Upgrading the fluoroscopy equipment and completing two dedicated training courses allowed for a drastic decrease patient exposure to ionizing radiation during venous access port implantation by non-radiologist practitioners.

Potential risk assessment: a model for quality evaluation in fluoroscopy-guided interventional procedures

This study presented a model applied for potential risk assessment in an interventional radiology setting. The model of potential risk assessment (MARP) consisted of the creation of a scale of indicators ranging from 0 to 5. The radiation levels were categorized according to gender, kind of procedure, value of kerma air product (Pka), and accumulated radiation dose (mGy). The MARP model was applied in 121 institutions over 8 y. A total of 201 656 patient radiation doses (Dose-area product and accumulated kerma) data were launched into the system over time, with an average of 22 406 doses per year. In the context of the workers (cardiologists, radiographers, and nurses) monitored during the MARP application, 8007 cases (with an average of 890 per year) of occupational radiation doses were recorded. This study showed a strategy for quality evaluation in fluoroscopy using a model with a compulsory information system for monitoring safety.

Radiation Exposure and Safety Considerations in Interventional Radiology: Comparison of a Twin Robotic X-ray System to a Conventional Angiography System

Background/Objectives: To evaluate radiation exposure in standard interventional radiology procedures using a twin robotic X-ray system compared to a state-of-the-art conventional angiography system. Methods: Standard interventional radiology procedures (port implantation, SIRT, and pelvic angiography) were simulated using an anthropomorphic Alderson RANDO phantom (Alderson Research Laboratories Inc. Stamford, CT, USA) on an above-the-table twin robotic X-ray scanner (Multitom Rax, Siemens Healthineers, Forchheim, Germany) and a conventional below-the-table angiography system (Artis Zeego, Siemens Healthineers, Forchheim, Germany). The phantom's radiation exposure (representing the potential patient on the procedure table) was measured with thermoluminescent dosimeters. Height-dependent dose curves were generated for examiners and radiation technologists in representative positions using a RaySafe X2 system (RaySafe, Billdal, Sweden). Results: For all scenarios, the device-specific dose distribution differs depending on the imaging chain, with specific advantages and disadvantages. Radiation exposure for the patient is significantly increased when using the Multitom Rax for pelvic angiography compared to the Artis Zeego, which is evident in the dose progression through the phantom's body as well as in the organ-related radiation exposure. In line with these findings, there is an increased radiation exposure for the performing proceduralist, especially at eye level, which can be significantly minimized by using protective equipment (p < 0.001). Conclusions: In this study, the state-of-the-art conventional below-the-table angiography system is associated with lower radiation dose exposures for both the patient and the interventional radiology physician compared to an above-the-table twin robotic X-ray system for pelvic angiographies. However, in other clinical scenarios (port implantation or SIRT), both devices are suitable options with acceptable radiation exposure.

Development, Feasibility, and Knowledge Impact of a Massive Open Online Course on Radiation Safety: A Multicentre Prospective Cohort Study

OBJECTIVE

This study reports the development of an innovative, interactive Massive Open Online Course (MOOC) teaching radiation safety principles in the vascular workplace, using stepwise e-learning with multiple choice question tests (MCQs), educational videos, and a serious game. The aim was to study the MOOC impact on radiation safety knowledge and assess its feasibility and acceptability.

METHODS

An international multicentre prospective study included team members active in the hybrid operating room. The MOOC was offered voluntarily via a secure online learning platform. A standardised MCQ test (15 questions) assessed radiation safety knowledge pre- and post-course (range 0 - 100%). Acceptability and feasibility were tested via the previously validated, Evaluating e-learning system success (EESS) model, using five point Likert scales.

RESULTS

In eight centres across four countries, 150 of 203 invited endovascular team members consented. Over a seven week study period, surgeons (28%, including vascular surgery trainees and consultants), nurses (27%, including scrub, circulating and anaesthetic nurses), anaesthetists (43%, including trainees and consultants), and radiographers (3%) participated. Of those, 67% completed the course. The average radiation knowledge improved by 22.8% (95% CI 19.5 - 26.0%; p < .001) after MOOC completion, from 48% to 71% (standard deviation [SD] 14 and 15% respectively), requiring a mean time investment of 169 minutes (SD 89 minutes). In centres with a radiographer, mean knowledge gain after MOOC completion was significantly smaller (14%, SD 19% vs. 24%, SD 16%, p = .036). The course was deemed feasible and acceptable according to the EESS model with a total mean score of 3.68/5.

CONCLUSION

This newly developed, multimodal MOOC was deemed feasible and effective across multiple international centres. The MOOC significantly contributes to radiation safety education of the entire endovascular team, improving radiation safety knowledge. The course may optimise workplace radiation safety behaviour and therefore enhance team and patient safety.

Occupational Risks of Radiation Exposure to Cardiologists

PURPOSE OF REVIEW

Invasive cardiologists are exposed to large amounts of ionizing radiation. This review aims to summarize the main occupational risks in a radiation-exposed cardiology practice.

RECENT FINDINGS

We carried out a literature review on the subject. The studies reviewed allowed us to list six main health risk categories possibly associated with radiation exposure among cardiologists: deoxyribonucleic acid (DNA) and biochemical damages; cancers; ocular manifestations; olfaction, vascular, and neuropsychological alterations; musculoskeletal problems; and reproductive risks. Our descriptive analysis demonstrates higher risks of DNA damage and lens opacities among radiation-exposed cardiology staff. Surveys and questionnaires have demonstrated a higher risk of musculoskeletal disease in exposed workers. Studies reported no difference in cancer frequency between radiation-exposed workers and controls. Changes in olfactory performance, neuropsychological aspects, and vascular changes have also been reported. Limited literature supports the security of continuing radiation-exposed work during pregnancy. Therefore, there is an urgent need to increase knowledge of the occupational risks of radiation exposure and to adopt technologies to reduce them.

Optimization of radiation doses for open lumbar spinal fusion using C-arm fluoroscopy and impact on radiation-induced cancer: a pilot study

PURPOSE

Intraoperative fluoroscopy use is essential during spinal fusion procedures. The amount of radiation dose should always be minimized. This study aimed to determine the feasibility of halving the frame rate from 12.5 to 6.25 frames per second (fps) and to quantify the reduction in the risk of developing radiation-induced cancer.

METHODS

This pilot study included 34 consecutive patients operated for open lumbar posterolateral fusion (PLF) with or without transforaminal lumbar interbody fusion (TLIF). C-arm modes were changed from half-dose (12.5 frames per second (fps), group I) to quarter-dose (6.25 fps, group II). Age, body mass index, surgical procedure, number of treated levels, and complications were collected. Kerma area product (KAP), cumulative air kerma (CAK), and fluoroscopy time were compared. Effective dose and radiation-induced cancer risk were estimated.

RESULTS

Eighteen and 16 patients were, respectively, included in group I and II. Demographic, surgical data, and fluoroscopy time were similar in both groups. However, CAK, KAP, and effective dose were significantly lower in group II, respectively, 0.56 versus 0.41 mGy (p = 0.03), 0.09 versus 0.06 Gy cm2 (p = 0.04), and 0.03 versus 0.02 mSv (p = 0.04). Radiation-induced cancer risk decreased by 47.7% from 1.49 × 10-6 to 7.77 × 10-7 after optimization. No complications were recorded in either group.

CONCLUSION

This study demonstrates the feasibility of setting 6.25 fps for TLIF with and without PLF. By halving the fps, radiation-induced cancer risk could be almost divided by two, without compromising surgical outcome. Finally, after optimization, the risk of developing radiation-induced cancer was less than one in a million.

Impact of equipment technology on reference levels in fluoroscopy-guided gastrointestinal procedures

OBJECTIVES

To evaluate the effect of equipment technology on reference point air kerma (Ka,r), air kerma-area product (PKA), and fluoroscopic time for fluoroscopically-guided gastrointestinal endoscopic procedures and establish benchmark levels.

METHODS

This retrospective study included the consecutive patients who underwent fluoroscopically-guided gastrointestinal endoscopic procedures from May 2016 to August 2023 at a tertiary care hospital in the U.S. Fluoroscopic systems included (a) Omega CS-50 e-View, (b) GE Precision 500D, and (c) Siemens Cios Alpha. Radiation dose was analyzed for four procedure types of endoscopic retrograde biliary, pancreas, biliary and pancreas combined, and other guidance. Median and 75th percentile values were computed using software package R (version 4.0.5, R Foundation).

RESULTS

This large study analyzed 9,459 gastrointestinal endoscopic procedures. Among four procedure types, median Ka,r was 108.8-433.2 mGy (a), 70-272 mGy (b), and 22-55.1 mGy (c). Median PKA was 20.9-49.5 Gy∙cm2 (a), 13.4-39.7 Gy∙cm2 (b), and 8.91-20.9 Gy∙cm2 (c). Median fluoroscopic time was 2.8-8.1 min (a), 3.6-9.2 min (b), and 2.9-9.4 min (c). Their median value ratio (a:b:c) was 8.5:4.8:1 (Ka,r), 2.7:2.1:1 (PKA), and 1.0:1.1:1 (fluoroscopic time). Median value and 75th percentile are presented for Ka,r, PKA, and fluoroscopic time for each procedure type, which can function as benchmark for comparison for dose optimization studies.

CONCLUSION

This study shows manifold variation in doses (Ka,r and PKA) among three fluoroscopic equipment types and provides local reference levels (50th and 75th percentiles) for four gastrointestinal endoscopic procedure types. Besides procedure type, imaging technology should be considered for establishing diagnostic reference level.

SUMMARY

With manifold (2 to 12 times) variation in doses observed in this study among 3 machines, we recommend development of technology-based diagnostic reference levels for gastrointestinal endoscopic procedures.

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.

[The Need for Lens Radiation Protection for Healthcare Provider in Open and Internal Fixation of the Hip Joint]

Increased occupational exposure of radiation workers is a major problem during open reduction and internal fixation (ORIF) of the hip joint, as the surgeon's eye lens is in close proximity to the patient and the X-ray tube. The purposes of this study were to clarify the occupational exposure of radiation workers during ORIF of the hip joint and to examine the need for radiation protection measures. The radiation exposure of radiation workers was evaluated by making an airborne dose distribution map using phantom experiments. The radiation goggles attached with a small optically stimulated luminescence dosimeter were used in clinical practice to measure the lens dose received by the surgeon, and the necessity of radiation goggles was examined. The airborne dose distribution in ORIF of the hip joint showed a wider area of high dose rate during axial fluoroscopy of the femoral neck than during posterior-anterior fluoroscopy. In axial fluoroscopy of the femoral neck, the surgeon was always in the high dose rate range of 10 µGy/min or higher, the nurses were in the dose rate range of 4 to 10 µGy/min, and the radiologic technologists were in the dose rate range of 0.5 µGy/min or lower. The maximum 3 mm dose equivalent to the surgeon per case was 0.38 mSv. In contradiction, radiation goggles were useful in ORIF because they provided approximately 60% shielding. It is advisable to work with radiation goggles to avoid cataracts.

Directional vector visualization of scattered rays in mobile c-arm fluoroscopy

Previous radiation protection-measure studies for medical staff who perform X-ray fluoroscopy have employed simulations to investigate the use of protective plates and their shielding effectiveness. Incorporating directional information enables users to gain a clearer understanding of how to position protective plates effectively. Therefore, in this study, we propose the visualization of the directional vectors of scattered rays. X-ray fluoroscopy was performed; the particle and heavy-ion transport code system was used in Monte Carlo simulations to reproduce the behavior of scattered rays in an X-ray room by reproducing a C-arm X-ray fluoroscopy system. Using the calculated results of the scattered-ray behavior, the vectors of photons scattered from the phantom were visualized in three dimensions. A model of the physician was placed on the directional vectors and dose distribution maps to confirm the direction of the scattered rays toward the physician when the protective plate was in place. Simulation accuracy was confirmed by measuring the ambient dose equivalent and comparing the measured and calculated values (agreed within 10%). The directional vectors of the scattered rays radiated outward from the phantom, confirming a large amount of backscatter radiation. The use of a protective plate between the patient and the physician's head part increased the shielding effect, thereby enhancing radiation protection for the physicians compared to cases without the protective plate. The use of directional vectors and the surrounding dose-equivalent distribution of this method can elucidate the appropriate use of radiation protection plates.

An organ-effective modulation for non-contrast chest computed tomography imaging: effect on image quality and thyroid exposure reduction

We investigate the efficacy of organ-effective modulation (OEM) technique for thyroid dose reduction among various body habitus and its impact on image quality in chest non-contrast computed tomography (CT). We prospectively enrolled 64 patients who underwent non-contrast chest CT from January to May 2022. The skin-absorbed radiation dose over the thyroid (Dthyroid) was obtained using a thermoluminescence dosemeter. Signal-to-noise ratio and image noise was also quantitatively assessed. In subjective analyses, two radiologists independently evaluated images based on a 5-point scale. The OEM group showed a markedly decrease in Dthyroid when compared with the non-OEM group (p < 0.05). No significant difference was observed regarding the image noise (p < 0.05), except for the ventral air space. The subjective scores of two radiologists showed no significant differences between the non-OEM and OEM groups. OEM can effectively reduce the radiation exposure of thyroid without compromising on image quality in non-contrast chest CT.

Radiation shielding effects of lead equivalent thickness of a radiation protective apron and distance during C-arm fluoroscopy-guided pain interventions: A randomized trial

BACKGROUND

The present study aimed to evaluate the degree of radiation shielding effects according to lead equivalent thickness and distance during C-arm fluoroscopy-guided lumbar interventions.

METHODS

The exposure time and air kerma were recorded using a fluoroscope. The effective dose (ED) was measured with and without the shielding material of the lead apron using 2 dosimeters at 2 positions. According to the lead equivalent thickness of the shielding material and distance from the side of the table, the groups were divided into 4 groups: group 1 (lead equivalent thickness 0.6 mm, distance 0 cm), group 2 (lead equivalent thickness 0.6 mm, distance 5 cm), group 3 (lead equivalent thickness 0.3 mm, distance 0 cm), and group 4 (lead equivalent thickness 0.3 mm, distance 5 cm). Mean differences such as air kerma, exposure time, ED, and ratio of EDs (ED with protector/ED without protector) were analyzed.

RESULTS

A total of 400 cases (100 cases in each group) were collected. The ratio of ED was significantly lower in groups 1 and 2 (9.18 ± 2.78% and 9.56 ± 3.29%, respectively) when compared to that of groups 3 and 4 (21.93 ± 4.19% and 21.53 ± 4.30%, respectively). The reductive effect of a 5-cm distance was 33.3% to 36.1% when comparing the ED between groups 1 and 2 and groups 3 and 4.

CONCLUSIONS

The 0.3- and 0.6-mm lead equivalent thickness protectors have a radiation attenuation effect of 78.1% to 78.5% and 90.4% to 90.8%, respectively. The 5-cm distance from the side of the table reduces radiation exposure by 33.3% to 36.1%.

Decreasing exposure to thyroid radiation in an orthopaedic theatre setting: an educational intervention

The use of personal protective equipment (PPE) can significantly reduce staff exposure to harmful radiation and infection. Fluoroscopic procedures in orthopaedic theatre can generate high levels of radiation and good adherence to PPE use is essential to reduce long term cancer risk, including thyroid cancer. To assess baseline compliance with PPE, availability of PPE in theatre and carry out an intervention to promote greater use of PPE. This was a closed-loop interventional study set in a level 1 trauma centre and an elective/rehabilitation unit. Data were collected in 40 cases pre and post-intervention from 26th May-7th July 2017. All health care practitioners present at fluoroscopic screening were observed. PPE availability was audited daily. A questionnaire was used to assess surgical and nursing knowledge/practices regarding radiation/infection safety. An educational presentation was delivered to the groups at highest risk of exposure. 39/41 questionnaires were completed (29 surgeons, 10 nurses). 41% of respondents had taken a radiation training course or felt they had adequate training. There was a significant increase in the use of thyroid guards by surgeons 13/115 (11.3%) pre-intervention to 54/117 (46.2%) post-intervention (p<0.001) and radiographers (p=0.019) post-intervention. Logistic regression showed an 89.7% increased likelihood of thyroid guard use post-intervention and a 12.7% increased chance of thyroid guard use for each extra guard available. A short educational, easily replicated session, significantly improved compliance with thyroid guards by orthopaedic surgeons.

Fundamental study on diagnostic reference level quantities for endoscopic retrograde cholangiopancreatography using a C-arm fluoroscopy system

The diagnostic reference level (DRL) is an effective tool for optimising protection in medical exposures to patients. However regarding air kerma at the patient entrance reference point (Ka,r), one of the DRL quantities for endoscopic retrograde cholangiopancreatography (ERCP), manufacturers use a variety of the International Electrotechnical Commission and their own specific definitions of the reference point. The research question for this study was whetherKa,ris appropriate as a DRL quantity for ERCP. The purpose of this study was to evaluate the difference betweenKa,rand air kerma incident on the patient's skin surface (Ka,e) at the different height of the patient couch for a C-arm system. Fluoroscopy and radiography were performed using a C-arm system (Ultimax-i, Canon Medical Systems, Japan) and a over-couch tube system (CUREVISTA Open, Fujifilm Healthcare, Japan).Ka,ewas measured by an ion chamber placed on the entrance surface of the phantom. Kerma-area product (PKA) andKa,rwere measured by a built-inPKAmeter and displayed on the fluoroscopy system.Ka,edecreased whileKa,rincreased as the patient couch moved away from the focal spot. The uncertainty of theKa,e/Ka,rratio due to the different height of the patient couch was estimated to be 75%-94%.Ka,rmay not accurately representKa,e.PKAwas a robust DRL quantity that was independent of the patient couch height. We cautioned against optimising patient doses in ERCP with DRLs set in terms ofKa,rwithout considering the patient couch height of the C-arm system. Therefore, we recommend thatKa,ris an inappropriate DRL quantity in ERCP using the C-arm system.

Radiation dose to staff from medical X-ray scatter in the orthopaedic theatre

PURPOSE

Given the growing demand for intraoperative imaging, there is increased concern for radiation dose for orthopaedic surgical staff. This study sought to determine the distribution of scatter radiation from fluoroscopic imaging in the orthopaedic surgical environment, with particular emphasis on the positions of personnel and the type of orthopaedic surgery performed.

METHODS

A radiation survey detector was deployed at various angles and distances around an anthropomorphic phantom. The scatter dose rate in microsieverts per hour (µSv/h) was recorded using consistent exposure parameters for five common surgical procedures. A C-arm unit produced radiation for the hip arthroscopy, hip replacement and knee simulations, whilst a mini C-arm unit produced fluoroscopy for the foot and hand simulations.

RESULTS

Readings were tabulated, and coloured heatmaps were generated from scatter measurements for each of the five procedures. Positions corresponding to the typical location of the surgical staff (surgeon, surgical assistant, anaesthetist, instrument (scrub) nurse, circulation (scout) nurse and anaesthetic nurse) were superimposed on heatmaps. The surgeon's proximity to the radiation source meant this position experienced the greatest amount of radiation in all five surgical procedures. Mini C-arm doses were considered low in all procedures for positions, with and without lead protection.

CONCLUSION

This investigation demonstrated the distribution of scattered radiation dose experienced at different positions within the orthopaedic surgical theatre. It reinforces the importance of staff increasing their distance from the primary beam where possible, reducing exposure time and increasing shielding with lead protection.

Enhancing Radiation Safety Culture: Investigating the Mediating Role of Awareness Among Orthopedic Doctors and Operation Theatre Assistants

INTRODUCTION

The increasing use of minimally invasive orthopedic procedures has led to a greater reliance on fluoroscopy, resulting in elevated radiation exposure for surgeons. This study aimed to evaluate the knowledge, awareness, and daily practices of orthopedic surgeons regarding radiation safety in an academic hospital. Understanding radiation safety is crucial to minimize patient exposure and prevent adverse effects on surgeons.

METHODS

This cross-sectional study was conducted at the Department of Orthopedics of different tertiary care hospitals in Rawalpindi, Pakistan. Data were collected prospectively for two years, and a total of 505 participants, including residents, consultants, and operation theatre assistants, completed a questionnaire. The questionnaire was validated by experts and covered information on fluoroscopy usage, frequency of surgeries, awareness of radiation safety, and protective measures. Ethical approval was obtained, and data were analyzed using SPSS version 26.0.

RESULTS

The majority of participants were male (74.1%), and the sample included various ranks of orthopedic surgeons. Only 56.2% of participants were aware of the usage of fluoroscopy, and 40.2% had read some research on the topic. While 44.6% used lead aprons for radiation protection, the usage of other protective measures and dosimeters was limited. The mediation analysis showed an insignificant indirect association between the rank of orthopedic surgeons, number of surgeries performed, and fluoroscopy usage as a mediator. Awareness and reading research on fluoroscopy were significantly associated with radiation protection.

CONCLUSION

The knowledge, awareness, and daily practices of orthopedic surgeons regarding radiation safety in fluoroscopy use need improvement. The findings emphasize the importance of implementing training programs, providing radiation protection devices, and ensuring compliance with safety guidelines.

Lumbar discectomy and fusion: Organs’ dose and effective dose estimation using Monte Carlo simulation

In this study, the effect of patient- and procedure-related parameters on organs' dose (OD), peak skin dose (PSD) and effective dose (ED) during lumbar discectomy and fusion (LDF) was assessed. Intra-operative parameters obtained from 102 LDFs were inserted into VirtualDose-IR software implementing sex-specific and BMI-adjustable anthropomorphic phantoms for dosimetric calculations. Fluoroscopy time (FT), kerma-area product (KAP), cumulative and incident air-kerma (K_air) were also recorded from the dosimetric report of the mobile C-arm. An increase in KAP, K_air, PSD and ED was found for male or higher BMI patients, multi-level or fusion or L5/S1 procedures. However, a significant difference was found only for PSD and incident K_air between normal and obese patients and for FT between discectomy and discectomy and fusion procedures. The spleen, kidneys and colon received the highest doses. The BMI have a significant impact only for kidneys, pancreas, and spleen doses when comparing obese to overweight and for urinary bladder when comparing overweight to normal patients. Multi-level and fusion procedures resulted in significantly higher doses for lungs, heart, stomach, adrenals, gallbladder and kidneys, while pancreas and spleen doses significantly increased only for multi-level procedures. Additionally, a significant increase was found only for urinary bladder, adrenals, kidneys, and spleen ODs when comparing L5/S1 and L3/L4 levels. The mean ODs were lower compared to the literature. These data may aid neurosurgeons in optimising exposure techniques during LDF to keep patients' dose as low as is practicably possible.

Intraoperative fluoroscopic radiation in orthopedic trauma: correlation with surgery type and surgeon experience

Background

While fluoroscopy is widely used in orthopedic trauma surgeries, it is associated with harmful effects and should, therefore, be minimized. However, reference values for these surgeries have not been defined, and it is not known how surgeon experience affects these factors. The aims of this study were to analyze the radiation emitted and exposure time for common orthopedic trauma surgeries and to assess whether they are affected by surgeon experience.

Methods

Data from 1842 trauma orthopedic procedures were retrospectively analyzed. A total of 1421 procedures were included in the analysis. Radiation dose and time were collected to identify reference values for each surgery and compared for when the lead surgeon was a young resident, a senior resident, or a specialist.

Results

The most performed surgeries requiring fluoroscopy were proximal femur short intramedullary nailing (n = 401), ankle open reduction and internal fixation (ORIF) (n = 141), distal radius ORIF (n = 125), and proximal femur dynamic hip screw (DHS) (n = 114). Surgeries using higher radiation dose were proximal femur long intramedullary nailing (mean dose area [DAP]): 1361.35 mGycm²), proximal femur DHS (1094.81 mGycm²), and proximal femur short intramedullary nailing (891.41 mGycm²). Surgeries requiring longer radiation time were proximal humerus and/or humeral shaft intramedullary nailing (02 mm:20 ss), proximal femur long intramedullary nailing (02 mm:04 ss), and tibial shaft/distal tibia intramedullary nailing (01 mm:49 ss). Senior residents required shorter radiation time when performing short intramedullary nailing of the proximal femur than young residents. Specialists required more radiation dose than residents when performing tibial nailing and tibial plateau ORIF and required longer radiation time than young residents when performing tibial nailing.

Conclusions

This study presents mean values of radiation dose and time for common orthopedic trauma surgeries. Orthopedic surgeon experience influences radiation dose and time values. Contrary to expected, less experience is associated with lower values in some of the cases analyzed.

FACTORS INFLUENCING FLUOROSCOPY TIME IN ENDOVASCULAR TREATMENT OF ABDOMINAL ANEURYSMS: A RETROSPECTIVE STUDY

Patients who undergo endovascular aortic aneurysm repair (EVAR) may require prolonged radiation exposure affected by several factors. The objectives of this study were to document fluoroscopy time (FT) during EVAR and identify possible factors that influence it. A retrospective analysis of a 180 patients' database with abdominal infrarenal aortic aneurysms submitted to EVAR during a 7-y period was performed. The FT is evaluated regarding risk factors and comorbidities, graft type and patient-related, clinical and technical parameters. FT's median (interquartile range) was 1011 (698-1500) s. Excluder and C3 Excluder were associated with significantly lower FT values when compared with other grafts. Hypertension, dyslipidemia, age ≥ 70 y, maximum aneurysm diameter ≥ 6 cm and procedure duration ≥2 h resulted in higher FT values. A significantly lower FT was found for the operations performed in the 7th y of the study's period compared with the previous 6 y, mainly because of the use of Excluder or C3 Excluder grafts. However, these grafts did not show any significant difference in FT values during the 7 y. A significant correlation between FT with age and procedure duration was found. Nevertheless, procedure duration is a poor FT predictor in linear and logistic regressions, although is significantly correlated with FT. Dyslipidemia, procedure duration and graft type are independent predictors of FT larger than the median, whereas only the procedure duration is a predictor for FT larger than the 75th percentile value. The identified factors regarding radiation protection issues should be considered when contemplating abdominal aortic aneurysm repair, however, without compromising the procedure's efficacy. Further work is necessary to identify more potential anatomical, clinical and technical factors affecting procedures' complexity and FT and patient radiation dose during EVAR interventions.

Development of a remote-control system for catheterization capable of high-speed force feedback

PURPOSE

There is a growing interest in minimally invasive surgery as interventional radiology (IVR), which decreases the burden on a patient. However, occupational exposure is a problem because the treatment is performed using X-ray fluoroscopic images. This problem can be solved by the development of a teleoperation system, but rapid force presentation is important to perform safe surgery. The purpose of this study is to develop a new teleoperation system that can be controlled at a high speed and can provide feedback force sensation within 20 ms delay.

METHODS

A master-slave-type remote-control system for catheterization was developed. A compact and high-speed force feedback system is realized using a novel electro-attractive material (EAM) device by which the resistance force is generated by the magnitude of the voltage applied. The linear and rotational movement of master is transferred to the slave device by UDP communication with the LAN cable, and the same movement is performed by two motors. The collision force of catheter or guidewire, detected by the sensor inside the slave device, is also transmitted to the master device. Two voltage-based methods for EAM: the ON/OFF and linear control methods, were implemented.

RESULTS

After the collision force is detected by the slave sensor, the voltage is applied to the EAM in the master device for an average of 10.33 ms and 15.64 ms by the ON/OFF and linear control methods, respectively. These delays are less than required 20 ms. The movement of the master was stopped by the resistance force of EAM, and that of the slave was also stopped accordingly.

CONCLUSION

A master-slave-type remote-control system for catheterization that is capable of high-speed force feedback was developed. With a low delay, the developed system achieved the requirements of 20 ms that was aimed for this study. Therefore, this system may facilitate the realization of IVR surgery that is safe for both doctors and patients.

[Efficacy of L-shaped Shielding in Interventional Radiology by Transradial Approach and Consideration of Methods for Appropriate Use]

The present study investigated how effective an L-shaped shield was, depending on its position, in reducing a doctor's exposure to radiation during catheterization to access the transradial approach (TRA). The shield's effectiveness was evaluated by measuring the air kerma where the doctor stood under four conditions: with and without the shield, and with and without the shield in conjunction with conventional protection. To enable the shield to be positioned correctly in clinical practice, an illustrated instruction decal affixable to the shield's doctor-facing surface was produced, and the effectiveness of the decal was verified by means of a crossover test in which, as subjects of the study, different nurses set up the shield with and without the decal affixed to it. In the test, in which a human body phantom was used, the C-arm set at the PA angle, and the shield positioned 10 cm from the axilla of the phantom, the shield's effectiveness at 100 cm, 130 cm, and 160 cm above the floor where the doctor stood was 55%, 77%, and 47%, respectively. The effectiveness increased when the shield was positioned closer to the axilla. A significant difference in the positioning of the shield by the subjects was observed depending on whether or not the decal was affixed ( p<0.05, Wilcoxon signed-rank test), indicating that the use of the decal improved the positioning. It was concluded that, positioned correctly, the shield could effectively reduce the doctor's exposure to radiation during TRA.

Influence of radiation dose reduction gloves on exposure parameters, entrance dose rates and eye doses of interventionalists during mobile C-arm fluoroscopic procedures: A phantom study

INTRODUCTION

During fluoroscopic examinations, radiation dose reduction gloves (RRGs) protect the hands of the interventionalist against ionising scattered radiation from the patient. Some fluoroscopic procedures may require the hands of the interventionalist in the path of the primary X-ray beam. This study investigates the influence of RRGs in the field of view (FOV) on exposure parameters, entrance dose rates and eye doses of interventionalists during mobile C-arm fluoroscopic procedures.

METHOD

Polymethylmethacrylate (PMMA) slabs were stacked on each other to simulate patient thicknesses. The abdomen protocol of the unit was selected for the study. The entrance dose rates to the surface of the PMMA slabs and the scattered radiation were measured for an undercouch configuration with and without RRGs in the FOV. The exposure parameters were noted. The scattered radiation for an overcouch configuration was measured.

RESULTS

The entrance dose rate increases as the FOV decreases for a fixed thickness of PMMA. The presence of RRGs in the FOV increases the exposure parameters, entrance dose rates and the scattered radiation to the eyes of the interventionalist. For the first level of RRG coverage, percentage increases in entrance dose rates and eye doses for the 23 cm FOV for all thicknesses of PMMA slabs ranged from 1.0% to 17.0% and 20.0%-30.0%, respectively; for the second level of RRG coverage, the entrance dose rates ranged from 17.0% to 45.0% and the eye doses from 50.0% to 60.0%. Percentage increases depend on the FOV, the patient's thickness, and the size and orientation of the RRGs in the FOV. Scattered radiation to the eyes of the interventionalist increases with an overcouch configuration compared to an undercouch configuration.

CONCLUSION

Sterile RRGs protects the hands of the interventionalist against scattered radiation. But in the FOV, they increase the scattered radiation to the personnel and the patient entrance dose rate.

IMPLICATIONS FOR PRACTICE

For best practice in C-arm fluoroscopy-guided procedures, appropriate FOV and C-arm orientation should be selected, whilst RRGs should not be in the path of the primary beam unless necessary.

Fluoroscopically guided vascular and cardiac transcatheter procedures: a comparison of occupational and patient dose by anatomical region

X-ray guided procedures are being performed by an increasing variety of medical specialties. Due to improvements in vascular transcatheter therapies, there is an increasing overlap of imaged anatomy between medical specialties. There is concern that non-radiology fluoroscopic operators may not have sufficient training to be well informed of the potential implications of radiation exposure and mitigation strategies to reduce dose. This was a prospective, observational, single center study to compare occupational and patient dose levels when imaging different anatomical regions during fluoroscopically guided cardiac and endovascular procedures. Occupational radiation dose was measured at the level of the temple of 24 cardiologists and 3 vascular surgeons (n = 1369), 32 scrub nurses (n = 1307) and 35 circulating nurses (n = 885). The patient dose was recorded for procedures (n = 1792) performed in three angiography suites. Abdominal imaging during endovascular aneurysm repair (EVAR) procedures was associated with a comparatively high average patient, operator and scrub nurse dose despite additional table-mounted lead shields. Air kerma was relatively high for procedures performed in the chest, and chest + pelvis. Higher dose area product and staff eye dose were recorded during procedures of the chest + pelvis due to the use of digital subtraction angiography to evaluate access route prior to/during transaortic valve implantation. Scrub nurses were exposed to higher average radiation levels than the operator during some procedures. Staff should be cognizant of the potentially higher radiation burden to patients and exposed personnel during EVAR procedures and cardiac procedures using digital subtraction angiography.

Establishment of national diagnostic dose reference levels (DRLs) for routine computed tomography examinations in Jordan

Background: Dose reference levels (DRLs) are used as indicators as well as guidance for dose optimization and to ensure justification of appropriate dose for a given clinical indication. The main aims of this study were to establish local DRLs for each CT imaging protocol as a reference point to evaluate the radiation dose indices and to compare our DRLs with those established in other countries and against the internationally reported guidelines.

Materials and methods: 2000 CT dose reports of different adult imaging protocols from January 2021 until April 2022 were collected retrospectively at different hospitals in Jordan. Data were collected from CT scans that were performed using different types and models of CT scanners and included four adult non-enhanced, helical CT imaging protocols; Head, Chest, Abdomen-Pelvis, and Chest-Abdomen-Pelvis.

Results: The average doses of CTDIvol, DLP, and effective dose were (65.11 mGy, 1232.71 mGy·cm, 2.83 mSv) for the head scan, (16.6 mGy, 586.6 mGy·cm, 8.21 mSv) for the chest scan, (17.91 mGy, 929.9 mGy·cm, 13.9 mSv) for the abdomen-pelvis scan, and (19.3 mGy, 1152 mGy·cm, 17.25 mSv) for the chest-abdomen-pelvis scan. In comparison with results from different international studies, DLP values measured in the present study were lower for the chest-abdomen-pelvis and abdomen-pelvis CT scans, and higher for the head CT and chest CT scans.

Conclusions: It is very important that each country establishes its own DRLs and compares them with those reported by other countries, especially the developed ones. It is also important that these levels are regularly updated.

Risk of ionizing radiation in pregnancy: just a myth or a real concern?

There are natural concerns regarding the risks posed to the foetus by ionizing radiation exposure during pregnancy. Therefore, many female physicians select to avoid working in an environment associated with ionizing radiation exposure like the catheterization laboratory and even exclude training as electrophysiology, interventional cardiologists, or radiologists. For those already working in this field, pregnancy involves usually a 1-year interruption (pregnancy and maternity leave) to their careers, leading at times to delays in the decision to become pregnant. This review describes the low added risk of malformation/cancer in the offspring, highlight gaps in our understanding, discuss several common wrong beliefs, and recommend how to further decrease radiation dose, especially during pregnancy.

A comparison of patient dose and occupational eye dose to the operator and nursing staff during transcatheter cardiac and endovascular procedures

The number and complexity of transcatheter procedures continue to increase, raising concerns regarding radiation exposure to patients and staff. Procedures such as transaortic valve implantations (TAVI) have led to cardiologists adopting higher dose techniques, such as digital subtraction angiography (DSA). This study compared the estimated patient and occupational eye dose during coronary angiography (CA), percutaneous coronary intervention (PCI), TAVI workups (TWU), TAVI, endovascular aneurysm repairs (EVAR), and other peripheral diagnostic (VD) and interventional (VI) vascular procedures. A quantitative analysis was performed on patient dose during 299 endovascular and 1498 cardiac procedures. Occupational dose was measured for the cardiologists (n = 24), vascular surgeons (n = 3), scrub (n = 32) and circulator nurses (n = 35). TAVI and EVAR were associated with the highest average dose for all staff, and significantly higher patient dose area product, probably attributable to the use of DSA. Scrub nurses were exposed to higher average doses than the operator and scout nurse during CA, VD and VI. Circulating nurses had the highest average levels of exposure during TAVI. This study has demonstrated that EVAR and TAVI have similar levels of occupational and patient dose, with a notable increase in circulator dose during TAVI. The use of DSA during cardiac procedures is associated with an increase in patient and staff dose, and cardiologists should evaluate whether DSA is necessary. Scrub nurses may be exposed to higher levels of occupational dose than the operator.

Assessing endovascular team performances in a hybrid room using the Black Box system: a prospective cohort study

BACKGROUND

The hybrid room (HR) is a complex, high-risk environment, requiring teams (surgeons, anesthesiologists, nurses, technologists) to master various skills, including the 'As Low As Reasonably Achievable' principle of radiation safety. This prospective single center cohort reports the first use of the Operating Room Black Box (ORBB) in a HR. This medical data recording system captures procedural and audio-visual data to facilitate structured team performance analysis.

METHODS

Patients planned for endovascular repair of an infrarenal abdominal aortic aneurysm (EVAR) or treatment of symptomatic iliac-femoral-popliteal atherosclerotic disease (Peripheral Vascular Interventions or PVI) were included. Validated measures and established assessment tools were used to assess (non-)technical skills, radiation safety performance and environmental distractions.

RESULTS

Six EVAR and sixteen PVI procedures were captured. Technical performance for one EVAR was rated 19/35 on the procedure-specific scale, below the 'acceptable' score of 21. Technical skills were rated above acceptable in all PVI procedures. Shared decision making and leadership were rated highly in 12/22 cases, whereas surgical communication and nurses' task management were rated low in 14/22 cases. Team members rarely stepped back from the C-arm during digital subtraction angiography. Radiation safety behavior was scored below 'acceptable' in 14/22 cases. A median (interquartile range) number of 12 (6-23) auditory distractions was observed per procedure.

CONCLUSIONS

The ORBB facilitates holistic workplace-based assessment of endovascular performance in a HR by combining objective assessment parameters and rating scale-based evaluations. Strengths and weaknesses were identified in team members' (non-)technical and radiation safety practices. This technology has the potential to improve vascular surgical practice, though human input remains crucial. (NCT04854278).

[Intraoperative imaging of children and adolescents, for selected fractures and in follow-up after conservative and operative treatment : Part 2 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]

The indication for radiographic examinations in pediatric and adolescent trauma patients should follow ALARA (as low as reasonably achievable). Because of the effect of radiation on the growing sensitive tissues of these young patients, a strict indication should always be given for radiation use and during controls after fracture repair.

METHODS

An online survey by the Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) from Nov. 15, 2019, to Feb. 29, 2020, targeting trauma, pediatric, and general surgeons and orthopedic surgeons.

RESULTS

Participants: 788. Intraoperative applications: Collimation 50% always, postprocessing for magnification 40%, pulsed x-ray 47%, and 89% no continuous fluoroscopy; 63% osteosynthesis never directly on image intensifier. Radiographic controls after implant removal never used by 24%. After operated supracondylar humerus fracture, controls are performed up to 6 times. After distal radius greenstick fracture, 40% refrain from further X-ray controls, after conservatively treated clavicular shaft fracture, 55% refrain from further controls, others X-ray several times. After nondisplaced conservatively treated tibial shaft fracture, 63% recommend radiographic control after 1 week in two planes, 24% after 2 weeks, 37% after 4 weeks, and 32% after 6 weeks.

DISCUSSION

The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. For some indications for the use of radiography, the benefit does not seem evident. The ALARA principle does not seem to be consistently followed.

CONCLUSION

Comparing the documented results of the survey with the consensus results of the SKT, differences are apparent.

[Usefulness of Radiation Protection Cloths in Fluoroscopy with Clean Areas]

Lowering the dose limit for the lens of the eye incorporated into the Regulation on Prevention of Ionizing Radiation Hazards, effective on April 2021, and dose reduction will become more and more important in the field of radiation. Radiation protective cloth is used as a protective equipment in fluoroscopy rooms. Although it is usually used to protect staff from radiation exposure during endoscopic retrograde cholangiopancreatography, we investigated whether there is a way to use it for procedures in clean areas. Assuming ureterostomy fistula replacement in urology, the protective cloth was suspended on the side of the patient's head and posterior aspect of the tube, and the distance between the anterior aspect of the X-ray tube and the patient's foot was 55 cm. As a result of measuring the dose rate, a 10% dose reduction was obtained for the lens of the eye of the surgeon, and the distribution of air dose rate in the examination room was significantly reduced. Although scattered radiation from the radiation protection cloth appeared in some areas, the radiation dose to the patient was reduced throughout the body, and a high degree of radiation protection was obtained, especially for the lens of the eye. It is expected that the radiation protection cloths may be useful even when the length of the cloths is limited due to the cleanliness of the area.

Minimizing radiation exposure in endoscopic retrograde cholangiopancreatography: a review for medical personnel

Fluoroscopy is used frequently during endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP). However, exposure to radiation is an important health concern, primarily because of the potential increase in the lifetime risk of malignancy. This consideration is important for patients and staff exposed to radiation during ERCP. Thus, an understanding of how radiation doses are measured during ERCP and the potential risks of this radiation is important. Additionally, staff must be educated about methods used to minimize the radiation dose, such as the use of different imaging techniques, the general principles of fluoroscopy, and advances in hardware and software. The use of personal protective equipment is also essential to minimize occupational exposure. However, no comprehensive ERCP guideline on the use of X-ray systems in clinical settings or on radiation protection for operators has been established. This review focuses on the properties of fluoroscopy systems and methods of radiation protection for physicians and assistants participating in ERCP.

Safe oesophageal stent deployment using a checklist system instead of fluoroscopy

BACKGROUND

Stenting is the management of choice for many benign and malignant oesophageal conditions and in the interest of safety stent insertion has traditionally been performed under fluoroscopic guidance. But this incurs additional expense, time, radiation risk and for the foreseeable future, an increased risk of Covid infection to patients and healthcare personnel. We describe a protocol that obviates the need for fluoroscopic guidance, relying instead on a systematic checklist to ensure safe positioning of the guidewire and the accurate positioning of the stent. The aim of this retrospective study was to review our experience of stent insertion employing a checklist system and compare our outcomes with outcomes using fluoroscopy in the literature.

METHODS

We performed a retrospective review of a prospectively collected dataset of all patients undergoing oesophageal stent insertion between December 2007 and October 2019. The primary end points were patient safety parameters and complications of stent insertion.

RESULTS

Total of 163 stents were deployed of which 93 (57%) were in males and the median age was 67.9 years (25-92 years). Partially covered self-expanding metallic stents (SEMS) were used in 80% of procedures (130/163). One hundred nineteen stents (73%) were for malignant strictures and 127 (78%) were deployed for strictures in the lower third of the oesophagus. There was no stent misplacement, injury, perforation or death associated with the procedure. Vomiting was the main post-operative complication (14%). Severe odynophagia necessitated stent removal in 3 patients. Stent migration occurred in 17 (10%) procedures with a mean time to stent migration of 6.4 weeks (range 1-20 weeks).

CONCLUSIONS

Oesophageal stent placement without fluoroscopy is safe provided that a strict checklist is adhered to. The outcomes are comparable to the results of fluoroscopic stent placement in the literature, with considerable saving in time, cost, personnel, and risks of radiation and Covid exposure.

Feasibility study of computational occupational dosimetry: evaluating a proof-of-concept in an endovascular and interventional cardiology setting

Individual monitoring of radiation workers is essential to ensure compliance with legal dose limits and to ensure that doses are As Low As Reasonably Achievable. However, large uncertainties still exist in personal dosimetry and there are issues with compliance and incorrect wearing of dosimeters. The objective of the PODIUM (Personal Online Dosimetry Using Computational Methods) project was to improve personal dosimetry by an innovative approach: the development of an online dosimetry application based on computer simulations without the use of physical dosimeters. Occupational doses were calculated based on the use of camera tracking devices, flexible individualised phantoms and data from the radiation source. When combined with fast Monte Carlo simulation codes, the aim was to perform personal dosimetry in real-time. A key component of the PODIUM project was to assess and validate the methodology in interventional radiology workplaces where improvements in dosimetry are needed. This paper describes the feasibility of implementing the PODIUM approach in a clinical setting. Validation was carried out using dosimeters worn by Vascular Surgeons and Interventional Cardiologists during patient procedures at a hospital in Ireland. Our preliminary results from this feasibility study show acceptable differences of the order of 40% between calculated and measured staff doses, in terms of the personal dose equivalent quantity H_p(10), however there is a greater deviation for more complex cases and improvements are needed. The challenges of using the system in busy interventional rooms have informed the future needs and applicability of PODIUM. The availability of an online personal dosimetry application has the potential to overcome problems that arise from the use of current dosimeters. In addition, it should increase awareness of radiation protection among staff. Some limitations remain and a second phase of development would be required to bring the PODIUM method into operation in a hospital setting. However, an early prototype system has been tested in a clinical setting and the results from this two-year proof-of-concept PODIUM project are very promising for future development.

Are Indian orthopaedic surgeons aware of the health hazards of radiation exposure? A survey and review on awareness and ways to mitigate them

BACKGROUND

Standardized education on the short and long-term health hazards of radiation and thus the awareness regarding current radiation exposure limits is restricted in the field of orthopaedics. There is a lack of awareness regarding the risks related to radiation exposure amongst orthopaedic surgeons and therefore the recommended safety precautions to assess and mitigate these potential risks should be emphasized. Orthopaedic surgeons should adopt the ALARA (as low as reasonably achievable) principle. All precautions should be taken to keep all members of the operation room safe from radiation exposure and safeguard patients too.

METHODS

The survey questionnaire developed in consult with senior orthopaedic surgeons and radiation protection officer consisting of 27 questions was conducted among the orthopaedic surgeons and resident doctors.

RESULTS

15% responders were unaware about risks of radiation exposure in routine orthopaedic surgery and 82% unaware of the recommended yearly allowance per individual. 30% responders were unaware of correct positioning of the C-arm and 44% were unaware regarding the same distance to be maintained from the C-arm to reduce radiation exposure. 27% responders were unaware regarding pulsed fluoroscopy and its benefits. 45% responders were unsure regarding the thickness of the lead apron. 83% never use a thyroid gland shield and none of the responders use leaded eye glasses. Only 11% responders use lead badges for documentation of radiation exposure.

CONCLUSION

Orthopaedic surgeons should understand the basics and basis of radiation exposure limits, be familiar with this literature on the incidence of tumors, dermatitis, cancer risk and cataracts and understand the current intraoperative fluoroscopy safety recommendations. The damaging effects to human tissue caused by radiation exposure are documented since the first reports regarding use of radiographs, hence emphasis on radiation safety and protection should be universally incorporated into graduate medical education.

Radiation Exposure Among Orthopaedic Trauma Surgeons: Deconstructing Commonly Held Myths and Misperceptions

OBJECTIVES

To review and evaluate the validity of common perceptions and practices regarding radiation safety in orthopaedic trauma.

DESIGN

Retrospective study.

SETTING

Level 1 trauma center.

SUBJECTS

N/A.

INTERVENTION

The intervention involved personal protective equipment.

MAIN OUTCOME MEASUREMENTS

The main outcome measurements included radiation dose estimates.

RESULTS

Surgeon radiation exposure estimates performed at the level of the thyroid, chest, and pelvis demonstrate an estimated total annual exposure of 1521 mR, 2452 mR, and 1129 mR, respectively. In all cases, wearing lead provides a significant reduction (90% or better) in the amount of radiation exposure (in both radiation risk and levels of radiation reaching the body) received by the surgeon. Surgeons are inadequately protected from radiation exposure with noncircumferential lead. The commonly accepted notion that there is negligible exposure when standing greater than 6 feet from the radiation source is misleading, particularly when cumulative exposure is considered. Finally, we demonstrated that trauma surgeons specializing in pelvis and acetabular fracture care are at an increased risk of exposure to potentially dangerous levels of radiation, given the amount of radiation required for their caseload.

CONCLUSION

Common myths and misperceptions regarding radiation in orthopaedic trauma are unfounded. Proper use of circumferential personal protective equipment is critical in preventing excess radiation exposure.

How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology?

Fluoroscopy-guided endoscopic procedures (FGEPs) are rapidly gaining popularity in the field of gastroenterology. Radiation is a well-known health hazard. Gastroenterologists who perform FGEPs are required to protect themselves, patients, as well as nurses and radiologists engaged in examinations from radiation exposure. To achieve this, all gastroenterologists must first understand and adhere to the International Commission on Radiological Protection Publication. In particular, it is necessary to understand the three principles of radiation protection (Justification, Optimization, and Dose Limits), the As Low As Reasonably Achievable principle, and the Diagnostic Reference Levels (DRLs) according to them. This review will mainly explain the three principles of radiation exposure protection, DRLs, and occupational radiological protection in interventional procedures while introducing related findings. Gastroenterologists must gain knowledge of radiation exposure protection and keep it updated.

Impact of dose reducing software on patient and staff temple dose during fluoroscopically guided pacemaker insertion, closure devices implantation and coronary angiography procedures

The aim of this study is to investigate the effectiveness of dose reducing software (ClarityIQ) on patient and staff dose during fluoroscopically guided cardiac procedures. Dose measurements were collected in a room without dose reducing software (n = 157) and compared with similar procedures performed in two rooms with the software (n = 1141). Procedures included diagnostic coronary angiography, percutaneous coronary intervention, deployment of cardiac closure devices (for occlusion of atrial septal defect, patent foramen ovale, and atrial appendage) and insertion of permanent pacemakers. The dose reducing software was found to be effective in reducing patient and staff dose by approximately 50%. This study has added to the limited literature reporting on the capability of dose reducing software to decrease radiation exposure during the implantation of cardiac closure devices, as well as demonstrating a reduction in dose to the cardiologist and nursing staff. Administrators should ensure timely upgrades to angiographic equipment to safeguard patients and staff against the potentially adverse effects of radiation exposure. Regardless of the use of dose reducing software, the mean occupational dose during closure devices was in descending order scout > scrub > cardiologist. Scrub nurse dose was found to be higher than the cardiologist during closure devices (0.98/0.26 μSv) and diagnostic coronary angiograms (1.51/0.82 μSv). Nursing staff should be aware that their levels of radiation dose during some cardiac procedures may come close to or even exceed that of the cardiologist.

Comparison of Radiation Exposure between Endoscopic Ultrasound-Guided Hepaticogastrostomy and Hepaticogastrostomy with Antegrade Stenting

Fluoroscopy forms an essential part of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) and hepaticogastrostomy with antegrade stenting (EUS-HGAS). To date, no study has assessed and compared radiation exposure between EUS-HGS and EUS-HGAS. This study aimed to compare the radiation exposure parameters between EUS-HGS and EUS-HGAS. This retrospective single-center cohort study included consecutive patients who underwent EUS-HGS or EUS-HGAS from October 2017 to March 2019. The air kerma (AK: mGy), kerma–area product (KAP: Gycm²), fluoroscopy time (FT: min), and procedure time (PT: min) were assessed and compared between the two procedures. Altogether, 45 and 24 patients underwent EUS-HGS and EUS-HGAS, respectively. The median AK, KAP, FT, and PT were higher in the EUS-HGAS group than in the EUS-HGS group. A comparison revealed no difference in the technical success rate, complications rate, adverse event occurrence rate, and re-intervention rate between both procedures. This is the first report in which radiation exposure was used as a comparative parameter between EUS-HGS and EUS-HGAS. This study revealed that radiation exposure is significantly higher in EUS-HGAS than in EUS-HGS. Increased awareness on radiation exposure is warranted among gastroenterologists so that they choose the procedure with lower radiation exposure in cases where both procedures are indicated.

Improved Radiation Exposure Monitoring of Orthopaedic Residents After Institution of a Personalized Lead Protocol

Background:

Radiation exposure of orthopaedic residents should be accurately monitored to monitor and mitigate risk. The purpose of this study was to determine whether a personalized lead protocol (PLP) with a radiation monitoring officer would improve radiation exposure monitoring of orthopaedic surgery residents.

Materials and Methods:

This was a retrospective case-control study of 15 orthopaedic surgery residents monitored for radiation exposure during a 2-year period (March 2017 until February 2019). During the first 12-month period (phase 1), residents were given monthly radiation dosimeter badges and instructed to attach them daily to the communal lead aprons hanging outside the operating rooms. During the second 12-month period (phase 2), a PLP (PLP group) was instituted in which residents were given lead aprons embroidered with their individual names. A radiation safety officer was appointed who placed the badges monthly on all lead aprons and collected them at the end of the month, whereas faculty ensured residents wore their personalized lead apron. Data collected included fluoroscopy use time and radiation dosimeter readings during all orthopaedic surgeries in the study period.

Results:

There were 1,252 orthopaedic surgeries using fluoroscopy during phase 1 in the control group and 1,269 during phase 2 in the PLP group. The total monthly fluoroscopy exposure time for all cases averaged 190 minutes during phase 1 and 169 minutes during phase 2, with no significant difference between the groups (p < 0.45). During phase 1, 73.1% of the dosimeters reported radiation exposure, whereas during phase 2, 88.7% of the dosimeters reported radiation exposure (p < 0.001). During phase 1, the average monthly resident dosimeter exposure reading was 7.26 millirems (mrem) ± 37.07, vs. 19.00 mrem ± 51.16 during phase 2, which was significantly higher (p < 0.036).

Conclusions:

Institution of a PLP increased the compliance and exposure readings of radiation dosimeter badges for orthopaedic surgery residents, whereas the actual monthly fluoroscopy time did not change. Teaching hospitals should consider implementing a PLP to more accurately monitor exposure.

Level of Evidence:

3.

Rules and regulations for a pregnant endourologist: the European perspective

Introduction

Working in surgery while pregnant is challenging. Navigating this period safely is of paramount importance. Anecdotal observation suggests that there exists great variation among European nations in regard to maternity leave and radiation safety.

The aim of this article was to gain insight into policy patterns and variations across Europe regarding these issues.

Methods

A series of core question items was distributed to representatives across 12 nations Austria, Belgium, Germany, Greece, Iceland, Italy, Netherlands, Norway, Poland, Republic of Ireland, Spain and the United Kingdom).

Results

The total number of weeks with full pay ranged from as little as 4 weeks in Belgium to 32 and Iceland. All countries included in this study give the option of additional weeks beyond the initial period, however at reduced pay. Some offer unpaid leave beyond this. Only 5/12 countries had a specific policy on when the pregnant surgeon should come off the on-call rota. Only Austria, Italy and Poland stipulate a requirement for the pregnant clinician to be replaced or be completely exempt in cases involving radiation. Only Germany, Iceland, Norway and Poland highlight the need to limit radiation dose in the first trimester. Beyond this, Germany alone provides written guidance for reduction in gown weight and along with Poland, display arguably the most forward-thinking approach to resting.

Conclusion

There is a marked range in maternal leave policies across Europe. There also exists a lack of universal guidance on radiation safety for the pregnant urologist. There is urgent need for this void to be addressed.

Radiation exposures in pregnancy, health effects and risks to the embryo/foetus-information to inform the medical management of the pregnant patient

Generally, intentional exposure of pregnant women is avoided as far as possible in both medical and occupational situations. This paper aims to summarise available information on sources of radiation exposure of the embryo/foetus primarily in medical settings. Accidental and unintended exposure is also considered. Knowledge on the effects of radiation exposure on the developing embryo/foetus remains incomplete-drawn largely from animal studies and two human cohorts but a summary is provided in relation to the key health endpoints of concern, severe foetal malformations/death, future cancer risk, and future impact on cognitive function. Both the specific education and training and also the literature regarding medical management of pregnant females is in general sparse, and consequently the justification and optimisation approaches may need to be considered on a case by case basis. In collating and reviewing this information, several suggestions for future basic science research, education and training, and radiation protection practice are identified.

Assessment of eye doses to staff involved in interventional cardiology procedures in Kuwait

In this study, which is the first of its kind in the gulf region, eye doses of interventional cardiologists and nurses were measured using active dosimeters for left and right eyes, in 60 percutaneous coronary interventions in three main hospitals in Kuwait. The dose given in terms of H_p(0.07) per procedure when ceiling suspended screens were used by main operators ranged from 18.5 to 30.3 µSv for the left eye and from 12.6 to 23.6 µSv for the right eye. Taking into account typical staff workload, the results show that the dose limit of 20 mSv/year to the eyes can be exceeded for interventional cardiologists in some situations, which demonstrates the need of using additional effective radiation protection tools, e.g. protective eye spectacles, in addition to the regular and proper use of ceiling suspended screens. With indications of increase in workload, the need for availability of a dedicated active dosimeter for the regular monitoring of eye doses is emphasized.

The radiation doses and radiation protection on the endoscopic retrograde cholangiopancreatography procedures

Although many interventions involving radiation exposure have been replaced to endoscopic procedure in the gastrointestinal and hepatobiliary fields, there remains no alternative for enteroscopy and endoscopic retrograde cholangiopancreatography (ERCP), which requires the use of radiation. In this review, we discuss the radiation doses and protective measures of endoscopic procedures, especially for ERCP. For the patient radiation dose, the average dose area product for diagnostic ERCP was 14-26 Gy.cm², while it increased to as high as 67-89 Gy.cm² for therapeutic ERCP. The corresponding entrance skin doses for diagnostic and therapeutic ERCP were 90 and 250 mGy, respectively. The mean effective doses were 3- 6 mSv for diagnostic ERCP and 12-20 mSv for therapeutic ERCP. For the occupational radiation dose, the typical doses were 94 μGy and 75 μGy for the eye and neck, respectively. However, with an over-couch-type X-ray unit, the eye and neck doses reached as high as 550 and 450 μGy, with maximal doses of up to 2.8 and 2.4 mGy/procedure, respectively.A protective lead shield was effective for an over couch X-ray tube unit. It lowered scattered radiation by up to 89.1% in a phantom study. In actual measurements, the radiation exposure of the endoscopist closest to the unit was reduced to approximately 12%. In conclusion, there is a clear need for raising awareness among medical personnel involved endoscopic procedures to minimise radiation risks to both the patients and staff.

Occupational hazard of fluoroscopy: An invisible threat to orthopaedic surgeons

The use of fluoroscopy is widespread within different medical specialties. Improper protection may cause significant radiation hazard to medical personnel. To evaluate the concepts on radiation safety and fluoroscopy use among orthopaedic surgeons and to reflect our current training on this issue, a survey was distributed to perform an audit in our department, an academic unit. Twenty-eight orthopaedic surgeons replied. Amongst our participants, 96.4% used a lead apron at all times. Only 33% used a thyroid shield, 67% never used radiation goggles and 96% never used radiation protection gloves. 53.6% and 46.4% of participants position the fluoroscopy incorrectly in the anteroposterior and lateral positions, respectively, during use. There is clearly a need for improved safety amongst orthopaedic surgeons. A literature review was further performed, showing the hazards of fluoroscopy for doctors, including the risk of cataracts, radiation dermatitis, skin cancer and thyroid cancer. Hazards specific to females, including breast cancer risk, and in-utero irradiation of foetus were also thoroughly discussed. Recommendations towards radiation safety and practical measures to reduce fluoroscopy radiation hazard during procedure were made. Education and training to doctors on this invisible hazard is strongly advised.

Radiation protection education using virtual reality for the visualisation of scattered distributions during radiological examinations

When working in radiology and patient assistance in medical facilities, radiation workers need to understand how to properly protect themselves and others from scattered radiation. In this study, a visualisation method is examined to facilitate the understanding of the spread of scattered radiation in radiography, computerised tomography (CT), and angiography rooms, and the application of this system for radiation protection education is proposed. X-ray radiography, x-ray CT, and angiography rooms were constructed using the particle and heavy ion transport code system, and the scattered radiation distributions that occurred when a patient was irradiated with x-rays were simulated. The three-dimensional (3D) distribution of each moment was continuously displayed to create a four-dimensional (4D) distribution. Using the obtained data, a radiation protection education seminar was conducted that included exercises to allow the students to confirm the presence of scattered radiation from any direction. The effectiveness of the scattered radiation visualisation data was evaluated using an interview. The position of the assistant for conducting standing chest radiographs that experienced the least scattered radiation was determined to be at the side and foot side of the patient. As a result of an interview that was provided to the participants following the seminar, the effectiveness of this system for providing education about radiation protection was confirmed. The visualisation method allowed the students to better understand the behaviour of radiation and the sources of scattered radiation. The visualisation of 3D and 4D scattered radiation distributions in radiological examination rooms can intuitively enhance the understanding of the spread of invisible radiation and the appropriate methods of mitigating radiation exposure.

Self-reported radiation safety behaviors among veterinary specialists and residents performing fluoroscopic procedures on small animals

OBJECTIVE

To describe the radiation safety behaviors of veterinary specialists performing small animal fluoroscopic procedures and examine potential risk factors for these behaviors, including knowledge of radiation risk and training regarding machine operating parameters.

SAMPLE

197 veterinary specialists and residents in training.

PROCEDURES

An electronic questionnaire was distributed to members of the American Colleges of Veterinary Internal Medicine (subspecialties of cardiology and small animal internal medicine), Veterinary Radiology, and Veterinary Surgery.

RESULTS

The overall survey response rate was 6% (240/4,274 email recipients). Of the 240 respondents, 197 (82%) had operated an x-ray unit for a small animal fluoroscopic procedure in the preceding year and fully completed the questionnaire. More than 95% of respondents believed that radiation causes cancer, yet approximately 60% of respondents never wore hand or eye protection during fluoroscopic procedures, and 28% never adjusted the fluoroscopy machine operating parameters for the purpose of reducing their radiation dose. The most common reasons for not wearing eye shielding included no requirement to wear eyeglasses, poor fit, discomfort, and interference of eyeglasses with task performance. Respondents who had received training regarding machine operating parameters adjusted those parameters to reduce their radiation dose during procedures significantly more frequently than did respondents who had not received training.

CONCLUSIONS AND CLINICAL RELEVANCE

On the basis of the self-reported suboptimal radiation safety practices among veterinary fluoroscopy users, we recommend formal incorporation of radiation safety education into residency training programs. All fluoroscopy machine operators should be trained regarding the machine operating parameters that can be adjusted to reduce occupational radiation exposure.

Strategy to Reduce the Collective Equivalent Dose for the Lens of the Physician's Eye Using Short Radiation Protection Curtains to Prevent Cataracts

A short curtain that improves on the low versatility of existing long curtains was developed as a dedicated radiation protective device for the over-table tube fluorographic imaging units. The effect of this short curtain in preventing cataracts was then examined. First, the physician lens dose reduction rate was obtained at the position of the lens. Next, the reduction rate in the collective equivalent dose for the lens of the physician's eye was estimated. The results showed that lens dose reduction rates with the long curtain and the short curtain were 88.9% (literature-based value) and 17.6%, respectively, higher with the long curtain. In our hospital, the reduction rate in the collective equivalent dose for the lens of the physician's eye was 9.8% and 17.6% with a procedures mixture, using the long curtain where technically possible and no curtain in all other procedures, and the short curtain in all procedures, respectively, higher with the short curtain. Moreover, a best available for curtains raised the reduction rate in the collective equivalent dose for the lens of the physician's eye a maximum of 25.5%. By introducing the short curtain, it can be expected to have an effect in preventing cataracts in medical staff.

Managing occupational doses with smartphones in interventional radiology

Purpose

This study presents a prototype smartphone application for occupational dosimetry in interventional practices based on electronic personal dosimeters to assist in dose monitoring.

Methods

The prototype receives and records information from the occupational dose report containing the cumulative dose of electronic personal dosimeters worn over the apron at chest level and electronic area dosimeters located on C‐arms (reference dosimeters), for each fluoroscopy‐guided procedure. Using their smartphones, personnel involved in interventional practices can review and compare their occupational records with an investigation level, the dose limits, and their department colleagues (anonymously). The ratio between H_p(10) measured by the personal and the reference dosimeters at the C‐arm is presented as an indicator of consistent use of suspended operator shield. Some general results extracted from the first months of use are presented.

Results

The reference dosimeter located at the C‐arm (without lead protection and acting as an ambient dosimeter) recorded in one of the laboratories 217 mSv during 308 procedures over 5 months, showing an indication of the radiation risk present in an interventional laboratory. The ratio between the personal cumulative dose and the dose at a reference C‐arm dosimeter ranged from 0.2% to 1.67% (a factor of 8.5) for different interventionalists. These differences suggest different protection habits among interventional operators, as well as a target for dose reduction.

Conclusions

With this system, professionals have easy access to their occupational dosimetry records (including information on the workload) in the setting of their interventional departments, to thereby actively engage in the protection process.