Current Medical Imaging

1573-4056/24 Send Orders for Reprints to [email protected] 1 Current Medical Imaging Content list available at: https://benthamscience.com/journals/cmir RESEARCH ARTICLE Patient Radiation Doses assessment at Diagnostic X-rays Department of King Khalid hospital (KKH)-Majmaah 1 2,* 3 4 Mohammed Khalil Saeed , Yousif Abdallah , Abdelmonen Suilman , Mohamed Omer and Ali Sid Ahmed 5 1 Departement of Radiological Sciences, Applied Medical Sciences College, Najran University, Najran, Saudia Arabia Department of Radiological Science and Medical Imaging, College of Applied Medical Science, Majmaah University, Al-Majmaah 11952, Saudia Arabia 3 Department of Radiology and Medical Imaging, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, P.O.Box 422, Alkharj 11942, Saudi Arabia 4 Radiologic Sciences Program, Batterjee Medical College, Jeddah, Saudi Arabia 5 Department of Biomedical Physics, Faculty of Science and Technology, Al Neelian University, Khartoum, Sudan 2 Abstract: Background: The study was conducted on patients who received diagnostic X-rays in King Khalid Hospital (KKH), Majmaah. Introduction: The study included the seven most frequently performed investigations, which were carried out on over 1504 patients using digital radiography equipment. Methods: The X-ray tube's output and exposure parameters were used to calculate the effective dose (ED) and patient entry surface air kerma (ESAK). Additionally, based on these results, conversion coefficients were determined. This study also examined the 75th percentile distributions of ESAK and KAP. The findings of this research were compared with the findings of other researchers throughout the country and the world. The study presents the uncertainty U values, as well as the mean ESAK, KAP, and ED values. Results: The results of the ESAK, KAP, and ED values were 0.12-5.74 mGy, 0.9-1.84 Gy cm2, and 0.01-0.23 mSv, respectively. As a result, the dosages were much lower than those previously published for the European DRL, national standards, and other studies. Conclusion: The study concludes that during dose surveys, the importance of detecting and comprehending radiation doses, as well as the proper technique for taking the finest photos possible, can be emphasized to patients in order to assist them in avoiding radioactive particles and radiation exposure. Keywords: Radiation doses, Diagnostic, X-rays, Patient, Radiation, Dosage. Article History Received: August 01, 2022 1. INTRODUCTION X-ray examinations are a vital and valuable tool in medical practice. However, they are also the primary route through wh* Address correspondence to this author at the Department of Radiological science and Medical Imaging, College of Applied Medical Science, Majmaah University, Al-Majmaah 11952, Saudia Arabia; E-mail: [email protected] Revised: January 11, 2023 Accepted: January 26, 2023 ich the vast majority of people on the planet are exposed to ionizing radiation from man-made sources [1 - 4]. Thus, because of radiation concerns, their application is fraught with difficulties. As a result, each medical exposure should be justified and optimized such that any potential health hazards are exceeded by the benefits [4]. Even if radiography is required for medical reasons, further precautions should be DOI: 10.2174/1573405619666230322102011, 2024, 20, e220323214857 2 Current Medical Imaging, 2024, Volume 20 taken to minimize the procedure's dangers [5 - 7]. The purpose of the procedure is to collect high-quality medical images while exposing the patient to the lowest amount of radiation possible (ALARA). Scientists widely agree that the low radiation levels employed in diagnostic radiography cause virtually no harm to human health [8 - 10]. A global radiation protection system is currently being created, in which regulations and procedures have been established to protect both patients and medical personnel. In the majority of European countries, patients are subjected to Xrays, and doctors are required by law to monitor the amount of radiation they receive during treatment. These statutes have received widespread publicity [11 - 13]. There are a range of strategies that can be utilized to ensure that a patient receives the correct dosage of medication [3, 14]. When performing diagnostic radiology dosimetry, the kerma area product (KAP) and the entrance surface air kerma (ESAK) are considered [7, 8, 15, 16]. Over the last decade, numerous studies have been undertaken to find the most effective method of monitoring how much medication patients are taking. When the results of identical diagnostic tests performed in different X-ray departments were compared, significant variances were observed [4 7, 18]. Numerous variables affect the amount of radiation received by a patient [17, 19, 20]. The outcome is highly dependent on the radiographer's talents as well as the patient's characteristics. When the ESAK and KAP data are used to determine the amount of radiation absorbed by various areas of the body, it is possible to arrive at a more precise conclusion [21 - 23]. This can be achieved using conversion coefficients or Monte Carlo simulation tools [24]. The European Union's Ionizing Radiation Protection Regulations establish the processes to be followed when conducting dose surveys on patients in the European Union [25 - 28]. The performance of an X-ray facility can be evaluated in comparison with a worldwide standard dose for diagnostic radiology examinations [29 - 31]. The researchers determined the X-ray doses administered to patients at King Khalid Hospital (KKH), Majmaah. Additionally, the results were cross-checked against historical data using the appropriate conversion coefficients to confirm their accuracy. For each test, the ESAK and KAP 75th percentiles were found and compared with national and world averages for each test. A computed tomography scan, commonly known as a CAT scan or computed axial tomography scan, is a type of medical imaging that generates high-resolution images of human anatomical structures. CT scans are the responsibility of medical professionals such as radiologists and radiography techs [32, 33]. Computed tomography (CT) scanners use an X-ray tube mounted on a gantry and a number of detectors to calculate the quantity of Xray energy absorbed by the various organs and tissues of the body. The final phase involves employing tomographic reconstruction techniques on a computer to convert the multiple X-ray images taken from various angles into images of cross-sections (virtual “slices”) of a body. If a patient has metal implants or a pacemaker and thus an MRI could harm them, a CT scan is a better choice (Fig. 1). Saeed et al. 2. MATERIALS AND METHODS A dose survey was undertaken on 1504 patients who received diagnostic X-rays of their backs and sides, necks, spines, pelvises, and abdomens, and the results were quite alarming. Patients were dosed according to the ESAK, KAP, and ED calculations [1 - 3, 5, 28]. For each of the dosimetric parameters listed below, the mean, median, uncertainty U, and 95 percent confidence intervals were calculated and reported. The uncertainty factor, designated by letter U, was calculated by multiplying the square root of the total number of examinations by the two-sigma range of dose levels for each examination type and then dividing by the total number of examinations (95 percent confidence interval). We produced the 75th percentile values for the distributions of ESAK and KAP in order to compare them with the distributions of Saudi and European DRLs due to differences in system technology and how radiologists prepare their patients. A statistically significant difference can be found only when this study’s DRL values do not fall within the 95 percent confidence interval of the given 75th percentile values. Each examination required a minimum of ten adult patients in order to be compliant with national and international laws. Weights ranging from 70 to 105 kilograms were utilized to conduct the experiment, as described in Table 1. The study procedure was as follows: All examinations were carried out in a single room using a single digital radiography system (DR). Each patient's weight, height, and BMI were scrupulously recorded, as well as their age, name, and other identifying information (e.g., gender). The radiography system kept track of a lot of different things during each test, including geometric measurements such as field size and dosimetry parameters such as KAP. The X-ray machine was composed of three components: an anode tube, a high-frequency generator (the Philips Optimus), and a detector (Gadolinium Sulphoxylate, or GOS). The GOS detector features five AEC measurement zones, each of which is colored differently. This is performed by overlaying terbiumdoped Gadolinium Dioxide Sulfide on top of a scintillation layer, resulting in X-ray emission. During operation, the detector generates light for each photon that travels through it (Gd2O2S). In this design, an amorphous silicon layer is sandwiched between two photodetector diodes. This layer is responsible for converting visible light energy into electrical charges. There are 2869 detector components in total, each with a 43 cm2 field of view. The X-ray tube incorporates a 13degree high-speed rotating anode, a 0.6 and 1.2 mm dual focus point, and a 2 mm thick Al filter. Additionally, it performs a variety of other operations, such as collimating an image using a filter combination of 0, 2mm Al, 1, and 1, as well as 0.1mm Al + 0.2mm Cu. Numerous filter combinations based on the ARC protocols are available. Following the removal of the chest radiographs, the remaining tests were conducted using standard ARC methodologies, which did not require any extra image filtering (0mm Al). ARC procedures and automatic exposure control were used to obtain an image with an appropriate resolution according to the patient's size. Automated exposure control (AEC) is used to regulate tube voltage levels. Additionally, an integrated KAP meter (Diamentor E2, PTW) is provided, Current Medical Imaging, 2024, Volume 20 3 Patient Radiation Doses assessment at Diagnostic X-rays Department The abbreviations for the backscatter factor and focal length to skin distance are BSF and FSD, respectively. The Xray spectrum, the X-ray field strength, and the thickness of a real patient or phantom all have an effect on the BSF. which utilizes the X-ray equipment's readings to determine the patient's radiation dose in real-time (tube voltage, tube load, filtration, and the FS). The system was subjected to a routine quality control (QC) procedure to confirm that the equipment was operating properly and that the exposure and dosimetric parameters were predictable and consistent. At a distance of 100 cm from the source, X-ray inspection voltages ranging from 40 to 140 kVp, as well as filtering modes, were examined to assess the tube output. At the same distance and voltage as the other filters in the experiment, the half-value layer (HVL) of each filter was measured. The tubes were discovered to be capable of reproducible voltage and current readings. An incorrect Xray/light field indication was responsible for 1% of the total. The film should be focused one meter away from the subject for best results. Throughout the experiment, quality control personnel looked for signs that the allowable radiation dosage range had been exceeded as a result of faulty equipment at various stages. KAP meters were calibrated in the field using a portable diagnostic dosimeter and an ionization chamber. The International Atomic Energy Agency (IAEA) recommends this course of action in conformity with its code of conduct [3, 17 22]. The calibration coefficient for the KAP meter was determined by dividing the reference KAP value (PKA ref.) by the clinical KAP meter reading and multiplying it with the reference KAP value (PKA clin.). The area (A) of the measurement plane was multiplied by the air kerma (KA) along the X-ray beam's central axis to obtain the final result. As a result of this calculation, the KAP value was established (PKA ref). Backscatter radiation was eliminated by employing a Ka geometry that was free-in-air. The examination was performed around 72 inches away, and 40 inches above the patient's couch. Each test was undertaken by multiplying the calibration constants with the clinical KAP meter values and then dividing by two to obtain the real PKA values. The conversion constants and KAP values were utilized in conjunction to determine ED. 𝑚𝑆𝑣 ED (mSv) = KAP (Gycm2) * CCKAP,ED* (𝐺𝑦𝑐𝑚2 ) This equation contains two components: KAP and ED. Patients with AP/PA projections were treated separately from those with LAT projections to identify the amount of each administered. The air kerma area product PKA is defined as the integral of the air kerma over the area of the X-ray beam in a plane perpendicular to the beam axis. It is calculated as follows: PKA = ∫𝐴 𝐾 (𝑥, 𝑦)𝑑𝑥𝑑𝑦 where K(x,y) is the air kerma; A is the area of the X-ray beam in a plane perpendicular to the beam axis. 3. RESULTS ESAK and KAP were found to be less prevalent at our institution than NDRLs and the most frequently occurring European DRLs, which is consistent with previous findings. The ED was significantly lower than the European and global averages. There are two tables available. Table 1 shows patients’ features and Table 2 shows geometrical and exposure parameters classified per projection. The study enrolled 742 men and 762 women ranging in age from 17 to 95 years (mean age, 54 years). Men and women who participated in the study had mean BMIs of 24.8 kg/m2 and 25.3 kg/m2, respectively. Table 3 summarizes the tube output and HVL values for each filter used in the experiment, as well as the experiment's results. The ESAK values for male and female patients were determined. The following page contains an exhaustive list of the findings. Fig. (2) depicts the histograms of ESAK scores for each test. As a result of these findings, it was determined that the maximum and minimum values of ESAK are skewed, but the confidence intervals are more accurate. During the study, KAP levels were determined and tallied for male and female patients. The study's findings are summarized in Table 4, which is included in this section. Table 4 contains the values for ESAK and KAP. The 75th percentiles and the most common values are shown in Table 4 and Table 5, which can be found on the right (21). Table 4 summarizes the emergency department's findings for male and female patients. This study summarizes the mean and median ED values, as well as their respective uncertainty U and 95 percent confidence intervals. The calculated error of the data was 1%. When a study compares ED with natural radiation, it is listed in Table 5, regardless of the type of test. 2.1. Dose Calculations This observational study was conducted to ensure that each patient's exam had the same X-ray quality as the previous one. It was important to compare the patient's ESAK to their X-ray exposure settings and the radiography system's radiation output. The equations below are used to fit the curve that is formed when X-ray tube output numbers and voltages are graphed. Tube output (µGy/mAs) = a * (tube voltage (KVp))2 + b * (tube voltage (KVp)) + c a, b, and c were discovered to be 100 cm apart. Calculating the ESAK necessitates the use of the following formula: ESAK (µGy) = Tube output (µGy/mAs) 100 (𝑐𝑚) 2 * tube load (mAs) * (𝐹𝑆𝐷 (𝑐𝑚)) ∗ 𝐵𝑆𝐹 Table 1. Patient features. Parameters Chest PA Skull AP Skull Lat. C/S AP C/S Lat. L/S AP L/S Lat. Pelvis AP Abdomen AP KUB AP Sample 151 132 136 101 104 92 94 102 89 91 M 122 98 98 85 87 72 62 82 73 87 F 29 34 38 16 17 20 32 20 16 4 4 Current Medical Imaging, 2024, Volume 20 Saeed et al. (Table 1) contd..... Parameters Chest PA Skull AP Skull Lat. C/S AP C/S Lat. L/S AP L/S Lat. Pelvis AP Abdomen AP KUB AP Age 52 44 54 46 39 42 43 42 32 51 M 53 45 53 48 40 46 45 33 29 50 F 54 38 56 52 35 40 47 47 42 48 Weight (Kg) 72 81 78 79 87 77 79 78 76 74 M 84 94 82 86 89 98 89 83 83 76 F 70 76 71 70 80 84 85 79 70 71 Height (m) 1.68 1.72 1.69 1.72 1.73 1.68 1.71 1.76 1.74 1.74 M 1.78 1.84 1.78 1.81 1.76 1.75 1.74 1.79 1.81 1.82 F 1.64 1.7 1.63 1.66 1.62 1.63 1.64 1.62 1.64 1.66 BMI (Kgm-2) 24.8 24.6 24.6 24.5 24.8 24.6 25.1 24.8 24.6 24.4 M 25.6 25.1 24.8 24.7 25.2 25.2 25.2 24.6 25.1 24.8 F 24.8 23.7 24 24.2 24.7 24.6 24.9 23.8 23.8 24.6 Table 2. Geometrical and exposure parameters classified per projection. Parameters Chest PA Skull AP Skull Lat. C/S AP C/S Lat. L/S AP L/S Lat. Pelvis AP Abdomen AP KUB AP Tube current (mAs) 124.9 72 69.3 72.6 68.4 76 76 84 72.9 80 Tube voltage 2.1 11.1 10.2 4.2 6.3 22.5 22.6 21.4 12.6 22.6 M 2 8.4 8.4 7.4 6.3 22.4 22.6 21.4 11.8 22.6 F 3.4 7.3 13.1 5.6 6.3 18.8 22.6 21.4 13.8 22.6 FDD (cm) 180 180 180 180 180 115 115 115 115 180 M 180 180 180 180 180 115 115 115 115 180 F 180 180 180 180 180 115 115 115 115 115 FSD (cm) 159 162 165 162 162 95 95 98 99 162 M 159 161 166 158 162 98 98 96 98 158 F 158 162 162 162 158 98 98 98 98 161 FS (cm x cm) 41x42 22x30 30x28 30x28 20x30 22x42 22x42 26x43 43x42 39x42 M 41x43 22x31 30x28 30x28 20x30 22x42 22x42 26x43 43x42 39x42 F 41x44 22x32 30x28 30x28 20x30 22x42 22x42 26x43 43x42 39x42 Table 3. ESAK values obtained from the X-ray examinations studied, for male and female patients and as a total. ESAK Projection Male Female Total Mean Median 95% Confidence interval Mean Median 95% Confidence interval Mean Median 95% Confidence interval Chest PA 0.24 0.23 0.22-0.26 0.22 0.21 0.15-0.3 0.23 0.22 0.20-0.26 Skull AP 0.54 0.46 0.45-0.62 0.5 0.45 0.42-0.64 0.52 0.46 0.40-0.605 Skull Lat. 0.5 0.45 0.42-0.63 0.47 0.43 0.39-0.52 0.49 0.44 0.38-0.51 C/S AP 0.25 0.15 0.12-0.32 0.24 0.18 0.13-0.41 0.21 0.24 0.19-0.39 C/S Lat. 0.27 0.21 0.19-0.39 0.28 0.24 0.19-0.43 0.27 0.3 0.23-0.35 L/S AP 3.02 3.69 2.99-3.87 3.14 3.34 2.99-5.08 3.09 3.19 2.88-5.48 L/S Lat. 5.14 5.04 4-12-5.23 5.05 5.13 4.02-5.08 5.26 5.32 4.99-5.41 Pelvis AP 2.29 2.43 1.99-3.08 2.31 2.51 1.98-3.34 2.43 2.39 1.88-3.99 Abdomen AP 1.88 1.84 1.75-2.08 1.79 1.91 1.87-2.22 1.85 1.84 1.79-2.12 2.38 2.01-2.79 2.54 2.46 2.31-2.67 2.41 2.45 2.11-2.51 KUB AP 2.48 4. DISCUSSION The data were chosen to guarantee that the doses administered to individuals of average height and weight were representative of them. The range of the patients’ weights in this study was 70 to 105 kilograms (Table 1). According to the survey, the average weights of men and women were 74.2 kilos and 69.7 kilograms, respectively. Each time the AEC scanned a new location, it had to change its tube load levels due to differences in the patient's size, shape, and thickness. According to ARC safety requirements, all radiographs had to be taken at a certain tube voltage. The tube voltage values used in this study are presented in Table 2. As a result, lumbar spine and pelvic scans revealed a wider range of tube loads than cervical spine and skull images, which is consistent with our observation. As a result, anatomical locations varied less between patients. Current Medical Imaging, 2024, Volume 20 5 Patient Radiation Doses assessment at Diagnostic X-rays Department Table 4. KAP values obtained from the X-ray examinations studied, for male and female patients and as a total. KAP (Gy cm2) Male Projection Mean Median Female 95% Confidence interval Total Mean Median 95% Confidence interval Mean Median 95% Confidence interval Chest PA 0.04 0.04 0.02-0.05 0.034 0.04 0.02-0.05 0.03 0.04 0.02-0.05 Skull AP 0.29 0.31 0.25-0.34 0.28 0.32 0.27-0.35 0.31 0.34 0.29-0.36 Skull Lat. 0.28 0.3 0.26-0.32 0.29 0.32 0.27-0.34 0.29 0.31 0.27-0.33 C/S AP 0.23 0.28 0.21-0.27 0.25 0.28 0.23-0.30 0.24 0.25 0.21-0.30 C/S Lat. 0.25 0.29 0.24-0.33 0.25 0.26 0.24-0.32 0.26 0.27 0.24-0.3 L/S AP 1.32 1.4 1.3-1.47 1.24 1.27 1.20-1.31 1.28 1.29 1.21-1.31 L/S Lat. 1.41 1.34 1.11-1.57 1.38 1.42 1.32-1.60 1.31 1.38 1.11-1.60 Pelvis AP 1.32 1.42 1.28-1.5 1.41 1.39 1.35-1.43 1.4 1.38 1.28-1.51 Abdomen AP 1.41 1.43 1.38-1.48 1.38 1.42 1.36-1.45 1.41 1.36-1.50 1.79-2.12 1.3 1.22-1.33 1.21 1.32 1.20-1.37 1.28 1.20-1.39 KUB AP 1.24 1.35 Table 5. Comparison of the DRLs in terms of for each X-ray examination studied. This study Projection EU RP180 Efthymiou et al [1] ESAk (mGy) ESAK (mGy) Chest PA 0.03 0.22 (0.02-0.05) (0.20-0.26) 0.3 (2.5-5) 0.3 (2.5-5) 0.10 (0.10-0.11) 0.14 (0.14-0.15) Skull AP 0.31 0.46 0.3 (0.29-0.36) (0.40-0.605) (2.5-5) 0.3 (2.5-5) 1.22 (1.12-1.44) 0.37 (0.33-0.46) -- -- Skull Lat. 0.29 0.44 (0.27-0.33) (0.38-0.51) 3 (1-3) 3 (1-3) 0.94 (0.77-1.11) 0.33 (0.20-0.27) -- -- C/S AP 0.24 0.24 (0.21-0.30) (0.19-0.39) 0.3 (2.5-5) 0.3 (2.5-5) 0.93 (0.83-1.09) 0.23 (0.20-0.27) -- -- C/S Lat. 0.26 (0.24-0.3) 0.3 (0.23-0.5) 0.3 (2.5-5) 0.3 (2.5-5) 0.78 (0.73-0.87) 0.26 (0.22-0.34) -- -- L/S AP 1.28 3.19 (1.21-1.31) (2.88-5.48) 10 (5-10) 10 (5-10) 5.16 (4.73-5.73) 1.50 (1.24-1.73) 0.98 (0.534-0.676) 3.76 3.52-4.18) L/S Lat. 1.31 5.02 (2.11-2.60) (4.99-5.41) 30 (10-30) 30 (10-30) 7.24 (6.11-7.85) 2.26(2.11-2.56) 1.41 Pelvis AP 1.4 2.39 10 (1.28-1.51) (1.88-3.99) (3.5-10) 10 (3.5-10) 2.96 1.61 (2.82-3.52) (1.52-1.87)e220323214857 1.23 1.41 1.84 10 Abdomen AP (1.79-2.12) (1.79-2.12) (4.5-10) 10 (4.5-10) 2.59 (2.33-2.93) 1.67 (1.52-1.81) 1.86 1.28 2.45 10 (1.20-1.39) (2.11-2.51) (4.5-10) 10 (4.5-10) 3.07 (2.69-3.62) 1.56 (1.40-1.95) 1.27 ESAk (mGy) KAP (Gy-cm2) Metaxes et al. [2] KAP (Gy-cm2) KUB AP KAP (Gy-cm2) The chest (PA), L/S (AP,Lat.) exams were conducted at a high kVP setting, whereas the remaining exams were conducted at a low kVp setting. By increasing tube voltage, a lower tube load can be achieved, resulting in a lower patient dose. This means that patients will receive a reduced dose of radiation. Due to the variances in the radiography geometries utilized for the supine pelvis, lumbar spine, and KUB scans, it is not possible to obtain uniform FDD values. Before proceeding, it is critical to verify that the image geometry is correct for all projections, as shown by the FDD values. The ESAK system was developed by the European Commission and many scientists using a 70 kg patient with a 20 cm trunk thickness [32 - 36]. Due to the variance in trunk thickness among the group of individuals in this study, the FSD utilized to calculate the ESAK was influenced by the AP trunk KAP (Gy-cm2) 0.08 (0.039-0.045) ESAK (mGy) 0.11 (0.06-0.07) 4.47 2.28 1.23 2.52 thickness, which ranged from 19 to 37 cm. Each patient’s X-rays were performed and analyzed at the X-ray department by radiographers and radiologists to ensure they fulfilled the diagnostic criteria. To replicate the previously discovered tube output, we employed the same tubes (Table 3) and technical features as in our prior research. By examining a lateral L/S radiograph, many scientists [1, 2] determined that the average doses of ESAK and KAP were 4.47mGy, 1.41 2 2 Gy.cm and 5.16 mGy, 1.50 Gy.cm , respectively, which are greater than the values reported in the results of this study (5.02 2 mGy, 1.32Gy.cm ) (Table 4). The most frequently used tube filtration in diagnostic radiology is 2.5 mm aluminum or aluminum-based metal. Low-energy infrared light is absorbed by the patient's body and contributes no information to the 6 Current Medical Imaging, 2024, Volume 20 Saeed et al. image being formed. Filtering of X-ray beams can be used in other ways to minimize hazardous radiation. Although 1 mm aluminum and 0.1 mm copper supplemental filters are regularly employed in pediatric radiography, this approach does not work well for adult imaging since the exposure period exceeds the 20-millisecond limit for this application [35 - 38]. Although radiation reduction is achievable with flat panel detectors, precise exposure settings and the expertise of the radiographer are still necessary to obtain the desired results. Fig. (1). Diagram of CT scan process. SKULL AP 60 50 50 40 40 Frequency Frequency Chest PA 60 30 20 30 20 10 10 0 0 0.0-0.05 0.05-0.10 0.10-0.15 0.15-0.20 0.20-0.25 ESAK (mGY) 0.25-0.30 0.35-0.40 0.40-0.45 0.0-0.1 0.1-0.2 0.2-0.3 0.3-0.4 0.5-0.6 0.6-0.7 0.7-0.8 0.8-0.9 ESAK (mGY) Fig. 2 contd..... Current Medical Imaging, 2024, Volume 20 7 Patient Radiation Doses assessment at Diagnostic X-rays Department Cervical Spine AP 50 18 16 45 40 35 14 Frequency Frequency SKULL Lat. 20 12 10 8 6 4 30 25 25 15 10 5 0 2 0 0.0-0.1 0.1-0.2 0.2-0.3 0.3-0.4 0.5-0.6 0.6-0.7 0.7-0.8 0.8-0.9 0.0-0.1 0.1-0.2 0.2-0.3 ESAK (mGY) 0.3-0.4 0.5-0.6 0.6-0.7 0.7-0.8 0.8-0.9 4.5-5.0 5.0-5.5 5.5-6.0 2.5-3.0 3.0-3.5 3.5-4.0 ESAK (mGY) Cervical Spine Lat. Lumbosacral AP 45 35 40 30 25 30 Frequency Frequency 35 25 20 15 20 15 10 10 5 5 0 0 0.0-0.1 0.1-0.2 0.2-0.3 0.3-0.4 0.5-0.6 0.6-0.7 0.7-0.8 2.0-2.5 0.8-0.9 2.5-3.0 3.0-3.5 Lumbosacral Lat. 4.0-4.5 Pelvis AP 30 35 25 30 20 25 Frequency Frequency 3.5-4.0 ESAK (mGY) ESAK (mGY) 15 10 20 15 10 5 5 0 2.0-2.5 2.5-3.0 3.0-3.5 3.5-4.0 4.0-4.5 4.5-5.0 5.0-5.5 5.5-6.0 0 0-0.5 ESAK (mGY) 0.5-1.0 1.0-1.5 1.5-2.0 2.0-2.5 ESAK (mGY) KUB AP 30 25 Frequency 20 15 10 5 0 0-0.5 0.5-1.0 1.0-1.5 1.5-2.0 2.0-2.5 2.5-3.0 3.0-3.5 3.5-4.0 ESAK (mGY) Fig. (2). The ESAK of all radiographic studies of this study. The 95 percent confidence interval for the mean ESAK values ranged from 0.20 to 4.81 mGy, depending on the approach used (Table 5). Additionally, the thickness of the patient's skin and the FDD employed by the radiographers contribute significantly to this difference. Due to the increased use of DR in recent years, it is less important to direct the radiation beam to the most critical portion of the body. Some patients have been subjected to higher radiation doses as a result of such variations [7, 39 - 41]. Even though these modifications were made at the same X-ray facility, they illustrate that radiation levels can be reduced without sacrificing image quality. As a result, a huge number of dosage measurements must be collected in order to improve the technique. Each radiograph had ESK levels that were comparable to or lower than previously reported values. No statistically significant difference existed between the previously published data [1, 2, 7, 42 - 44]. Except with L/S lateral radiography, radiation doses were found to be far lower in the great majority of cases than those recommended by the International Health Protection Agency [16, 17, 43 - 45]. The radiation exposure can be re- 8 Current Medical Imaging, 2024, Volume 20 Saeed et al. duced by employing improved tube filtration and cautious exposure settings (e.g., tube voltage and tube load). reduce radiation exposure, and may even enhance radiation awareness among radiographers [9, 29]. Chest diagnostic radiographs can also be acquired using a film screen or computed radiography in conjunction with a low tube voltage and a high tube load value. Although this technique leads to decreased patient dosages, it does have certain downsides [3, 45]. According to many studies [2, 17, 34], the best chest images are acquired using computed radiography at energies between 75 and 90 kVp, rather than the higher energies frequently employed in clinical practice [2]. Rather than lowering the voltage of the tubes used in chest radiography, the authors advocate increasing the beam filtering [1, 2, 9]. However, as previously indicated, the ideal energy range for chest radiography is highly dependent on the detector type utilized. Prior to utilizing a particular energy range, it is vital to research the detector's technology. Because there is uncertainty about the outcome of pelvic examinations in some countries, ESAK scores are lower in these countries than in others [27]. Radiation exposure can be reduced for computed radiography and digital radiography pelvic examinations by orienting the patient's head toward the AEC system's two outer chambers rather than away from them. When developing pelvic tests for a particular patient, it is critical to consider the chamber location within the equipment as well as the patient's orientation [1, 37]. There should be radiation safety training for radiology residents, radiography students, and professional radiographers to make sure that patients receive the care they need during radiographic tests [30]. The study's low ESAK and KAP values were expected, given that the radiography system used digital technology, contained additional filtration, and included subjects with comparable body weights to the reference patient (Table 4). The 2% per kilogram of body weight dose-weight adjustment enables individuals who are underweight, overweight, or obese to calculate the amount of medication they will take [4, 40]. Occasionally, patients with images that are not clear enough for a doctor to evaluate may be offered too little medication to avoid this. When we examined all the tests, we discovered that the mean, median, and 75th percentiles did not exceed the EU RP108 and IAEA levels (Table 5). To assess local performance, the projected 75th percentiles were utilized to compare the DRLs across locations while accounting for differences in the radiography system technology and the radiographer’s exposure factor selection. In some investigations, there can be a big difference between the 75th percentile and the national diagnostic reference levels (NDRLs). One probable explanation for this is the employment of important and consistent methods for image quality and technical standards. The ESAK mean and median readings were lower than the DRLs in the EU RP108 study [1, 2] and IAEA levels for all investigations. One exception to this rule occurred when the chest LAT values were comparable to or greater than those of the UK DRLs. On the other hand, the measured values of the L/S AP and KUB AP were significantly greater than those in other similar studies [1] and [2]. Except for the cervical spine AP and LAT, all tests had mean and median values that were equivalent to or less than some European DRLs according to EU RP 108. The lumbar ESAK values are lower in this study due to the low voltage used to power the tubes. When the tube potential of a lumbar spine X-ray is decreased, the dose and image quality of the X-ray are reduced. Improved filtering in abdominal examinations may help to keep radiation doses to a minimum. The researchers in this study revealed that increasing the number of Cu filters reduced the quantity of light entering the room by up to 40% without compromising image quality when a 20 cm acrylic phantom was used to simulate the space. Another issue contributing to the study's poor ESAK results is the high FDD (focus-to-detector distance). Generally, utilizing less-than-optimal FDD values increases the patient's dosage while minimizing geometric unsharpness [7, 38, 39]. Disregarding the KAP meter's calibration criteria can result in KAP findings that are up to 8 percent exaggerated (Table 4). The mean KAP values range between 0.02 and 1.39 Gy-cm2 in terms of a two-sigma range, depending on the projection. These values are calculated based on the KAP value utilized. In this study, the typical KAP values for the chest, cervical spine (AP and LAT), pelvic, lumbar spine, and abdomen radiographs range between 0.03 and 2.6 Gy-cm2. Those findings fell within the permissible range compared with other studies [1, 2, 3, 7, 43]. The cervical AP and lateral radiography mean and median KAP values (Table 4) were lower than the values reported in previous studies [4, 9, 10, 11, 13, 24]. The wide range of KAP values recorded from a single patient was due to a combination of patient features, radiography equipment settings, and the radiographer’s exposure factor selection ability. A dose management system that monitors radiation exposure in a radiology department is an innovative instrument for monitoring radiation exposure. According to the manufacturer, it enables the prompt gathering of dose data, aids in attempts to The ESAK skull LAT results were compared with those of some European DRLs, which had the same level of uncertainty (0.44 mGy). As a result, the two uncertainty ranges are nearly comparable in size (0.44-0.46 mGy versus 0.3-3.0 mGy). According to EU RP 108, in some European counties, such as Austria and Poland, the DRLs and KAP values were higher compared with those of Belgium and Slovenia. The PA of the chest and the AP of the lumbar spine were the same size, but the PA and LAT of the cervical spine were much greater. This is partly due to the more complex DRLs. It has been observed that both right-biased and asymmetrical distributions exist [25, 26] (Fig. 2). Although patients with thicker skin had higher ESAK levels than those with thinner skin, the median values were greater than the extreme values [25, 26] (Tables 4 and 5). Table 1 summarizes the patients' exposure and technical features. These factors affect the results (Table 2). The ESAK's arithmetic mean, median, and 75th percentile values were all lower than the European Commission's DRLs [16]. If mean values continue to exceed their DRLs, it is vital to investigate radiography processes and equipment, in addition to executing any necessary corrective actions. Comparing the median values of dosage reduction measures demonstrates their efficacy. Reduced doses should be Current Medical Imaging, 2024, Volume 20 9 Patient Radiation Doses assessment at Diagnostic X-rays Department kept to a minimum to avoid deteriorating pictures and complicating the diseases diagnosis as a result of clinical data loss. Patients can receive lower medication dosages to achieve the therapeutic benefit, but ALARA-based initiatives to improve medicine are still required. Obtaining a careful balance is always necessary. IAEC has developed a web-based platform for conducting patient dose surveys to assist in the country's DRL development [41]. Such radiography tools should always come with the goal of achieving the greatest feasible results; thus, the platform enables users to compare their own individual dose levels to the suggested daily limits (NDRLs). National reporting systems aid in the improvement of hospital-based dosing systems' efficiency. Although the internet simplifies data collection, surveys still require a certain level of organization in order to be effective [42]. The three most common DRL values were lower than the mean, median, and 75th percentile values in Europe and other regions of the world (Table 5). The vast majority of the remaining values adhere to either the European Commission's [16] or the IAEA's (IAEA) BSS 116 requirements [15]. The European DRLs have become a widely used standard, despite the fact that public numbers frequently do not reflect actual European practice. This is because some polls use old data that does not adequately reflect current habits. In order to compare local performance with European DRLs, the 75th percentiles were used. This is because room layouts and employee behavior are different in each country, so the 75th percentiles were chosen. It was found that 2-fold and 1.5-fold increases in ESAK and KAP values were found in 75% of the lumbar spine radiographs that were studied. Most surveys omit data on participants' weight and height, as well as technical (exposure parameters, filtration) and geometrical (FDD and FSD) data, making meaningful comparisons between groups impossible. Despite the fact that we could have used a different procedure and that digital radiography and computed radiography machines operate in fundamentally different ways, our results are startlingly similar. To optimize imaging protocols and dosage, it is vital to evaluate radiography equipment technology (such as detector type). As a result, dosages may be significantly reduced [31]. The use of many frequencies has the potential to improve image quality. The debate continues over whether or not image processing can improve images while simultaneously reducing the amount of medication delivered [32]. Thus, the estimated mean total ED values were lower than the levels frequently reported globally (Table 5). To obtain radiographs of the lumbar spine, pelvis, abdomen, and KUB, a vast number of body parts were required. These radiographs have a greater ED value than those of the skull and cervical spine. This was because the ED was estimated in a variety of different ways, yielding contradictory results. Numerous scientists throughout the world have used tissue-weighting factors from Report 60 by the International Commission on Radiological Protection, but this study used conversion coefficients and tissue-weighting factors from Report 103 (by the same organization) to determine how much of the Earth's surface was covered [2]. In comparison with the Health Protection Agency (HPA), hospital emergency rooms (EDs) charge less. Many scientists have reported that pelvic AP tests have historically exhibited lower error rates than expected [1, 16]. Male patients received higher radiation than female patients for the same photos (Table 1). As a result, deeper penetrating rays were necessary to provide a sharp image appropriate for inspection by medical specialists. Changing the DRL for a certain exam requires computing the ED and comparing it with the exam's DRLs. This study compared an emergency department's X-ray dose levels and DRL values with those of similar departments nationally and internationally. If such levels are much lower or higher compared with the DRLs than anticipated, an investigation and poll should be conducted to determine whether the DRLs should be updated [2, 32]. To address this problem, it is critical to minimize radiation exposure associated with radiological testing while maintaining the diagnostic information's accuracy. An effective technique to analyze this is to compare diagnostic X-ray radiation levels with the time required to receive the same quantity of radiation from naturally occurring sources [46 - 49]. CONCLUSION The study was undertaken in order to determine how much radiation patients actually receive during routine radiography examinations performed with digital radiography (DR) equipment. If the ESAK and KAP values are greater than the 75th percentile, it is vital to inspect nearby individuals and equipment. It is critical to compare dosages with the NDRLs on a regular basis at the local level to ensure they remain within acceptable bounds. According to the researchers, this study will result in the near-future development of radiation protection technologies that keep patients safe, while also capturing high-quality images. When reviewing their own procedures to improve patient radiation safety, the researchers used the expected patient exposures as a baseline to make sure they were safe. Other diagnostic radiology departments may have done the same. LIST OF ABBREVIATIONS KKH = King Khalid Hospital ESAK = Entry surface air kerma ED = Effective dose KAP = Kerma area product CT = Computed tomography AEC = Automated exposure control QC = Quality contro HVL = Half-value layer IAEA = International Atomic Energy Agency HPA = Health Protection Agency ETHICS APPROVAL PARTICIPATE AND CONSENT TO KACST's Institute Ethics Board, KSA registration number H-01-R-012, OHRP / NIH, USA registration number IRB00010471 and NIH, USA Federal Large Insurers registration number FWA00018774 accepted the study. 10 Current Medical Imaging, 2024, Volume 20 HUMAN AND ANIMAL RIGHTS No animals were used in the studies that are the basis of this research. All human procedures followed were in accordance with the guidelines of the Helsinki Declaration of 1975. CONSENT FOR PUBLICATION Informed consent was obtained from all participants of this study. STANDARDS OF REPORTING STROBE guidelines were followed. AVAILABILITY OF DATA AND MATERIALS Not applicable. Saeed et al. [9] [10] [11] [12] [13] [14] FUNDING None. [15] CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. FUNDING The authors are thankful to the Deanship of Scientific Research, at Najran University for funding this research through Project No. NU/RG/MRC/11/3. [16] [17] [18] ACKNOWLEDGEMENTS Declared none. [19] REFERENCES [1] [2] [3] [4] [5] [6] [7] [8] Efthymiou FO, Metaxas VI, Dimitroukas CP, Panayiotakis GS. Low BMI patient dose in digital radiography. Radiat Prot Dosimet 2020; 189(1): 1-12. [http://dx.doi.org/10.1093/rpd/ncaa007] [PMID: 32043128] Vasileios IM, Gerasimos AM, Aristea NL, Theodore GP, George SP. 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Avoidance of Radiation Injuries from Interventional Procedures; International Commission on Radiation Protection, ICRP Publication 85 Annals of the ICRP. Oxford: Pergman Press 2000; pp. 30-9. © 2024 The Author(s). Published by Bentham Science Publisher. This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.