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Benefit vs[1][1][2][1]. risk in children's exposure to radiation for medical diagnosis purposes
Benefit vs[1][1][2][1]. risk in children's exposure to radiation for medical diagnosis purposes
Benefit vs[1][1][2][1]. risk in children's exposure to radiation for medical diagnosis purposes
Benefit vs[1][1][2][1]. risk in children's exposure to radiation for medical diagnosis purposes
Benefit vs[1][1][2][1]. risk in children's exposure to radiation for medical diagnosis purposes
Benefit vs[1][1][2][1]. risk in children's exposure to radiation for medical diagnosis purposes
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Benefit vs[1][1][2][1]. risk in children's exposure to radiation for medical diagnosis purposes

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  • 1. BENEFIT VS. RISK IN CHILDREN’S EXPOSURE TO RADIATION FOR MEDICAL DIAGNOSIS PURPOSES Elena Dădulescu, Ioana Şorop, Daniela Mossang, Corina Pera, E. Pătru, D. Bondari, I. Prejbeanu Abstract: The increasing and diversified access to the medical diagnosis using ionizing radiation sources and otherepidemiologic studies drew atention to international organizations about the long term risk of developing cancer producedby exposure to ionizing radiation. Medical exposure to ionizing radiation in childhood requires special caution becausechildren represent the age group with the highest radiosensibility, and therefore the risk of cancer is 2-3 times greatercompared to the adult. The risk is determined partly by the child’s anatomical, pathological, biochemical and physiologicalpeculiarities and partly by their increased life expectancy. In order to assess the potential risk among the child population,we considered the physiological developement of breast, gonades and the largest distribution of the bone marow in theskeleton. The great number of exposures, the inappropriate use of physical parameters of the radiological equipament, theirperformances, lead to great entrance surface doses in the patients. For this reason, it is becoming increasingly important to guarantee to the patient the fact that the medical diagnosis withionizing radiation is not associated with great risks due to irradiation. The present study was conducted in the Anesthesiaand Intensive Care Department (ATI) and in the Pediatric Department in the County Dolj Hospital (2005-2007), followingthe frequency and distribution of radiological examinations and the entrance surface dosese for patients in the mostimportant radiological exaninations. We found out that the chest X-ray exams were the first in all age groups, even thoughmore than 50% had no diagnostic benefit whatsoever. The absorbed doses by the children were three to four times greaterthan the reference values. That’s why we need hospital work protocols which might represent a better instrument to improvethe clinical system and the patient medical care. Key words: medical exposure, entrance surface dose, reference levelsElena Dadulescu: MD, Student PhD Faculty of Medicine Craiova, The Authority of Public Health Dolj, Laboratory ofIonizing Radiation Hygiene ;liricv@yahoo.comIoana Sorop: physicist, Student PhD Faculty of Physics Bucharest; The Authority of Public Health Dolj, Laboratory ofIonizing Radiation Hygiene; liricv@yahoo.comDaniela Mossang: Assistant Professor Faculty of Physics, Student PhD Faculty of Physics Bucharest; The Authority ofPublic Health Dolj, Laboratory of Ionizing Radiation Hygiene; liricv@yahoo.comCorina Pera: medical physicist, County Hospital ResitaDan Bondari: MD, Assistant Professor, Student PhD Faculty of Medicine Craiova UMFEmilia Patru: MD, Associated Professor ;UMF CraiovaIleana Prejbeanu: MD, Associated Professor ;UMF Craiova
  • 2. Introduction It has been a long time since the use of radiation sources for diagnostic purposes first proved their benefits. Theincreasing and diversified access to these sources, as well as the developed epidemiologic studies, have drawn attention tointernational organizations, regarding the long term risk to develop cancer due to exposure to ionizing radiation [2]. For thisreason, the patient’s right to a minimal exposure to ionizing radiation is becoming increasingly important so as to ensure thelowest risk possible. Medical exposure to ionizing radiation in all children age groups requires increased caution becausethey represent the category of patients with the highest radio sensibility, and therefore the risk of cancer is 2-3 times greatercompared to the adult [7, 8]. This risk is determined partly by the child’s anatomical, pathological, biochemical andphysiological peculiarities and partly by their increased life expectancy. During the medical observation of newborns andsmall children, frequent radiological investigations, especially chest and abdomen, are performed. On the other hand, thosewho present clinical complications, require longer hospitalization, which can take even several months, which can increasethe number of X-ray examinations. Every exposure means a new radiation dose for the child [1, 19]. The increased numberof exposures, misuse of physical parameters of the radiological equipment and its technology may lead to high entrancesurface doses at the patient [9, 10]. It is necessary to know the present trends of the absorbed doses by patients duringradiological examinations in every medical section. This represents a guide for optimizing the patient’s radioprotection so asto minimize the risks involved [13]. Material and method The present study was conducted in the Anesthesia and Intensive Care Department (ATI) and in the PediatricDepartment in the county hospital, between 2005-2007. The study has two main directions: on the one hand, it describes thefrequency and distribution of radiological exams, and on the other hand, it estimates entrance surface doses for patients whohave been exposed during the most important medical procedures. The radiological examinations are conducted with twotypes of equipment:  mobile X-ray unit, Polymobile 10 Type with a total filtering of 3.4mm Al  fix X-ray unit, ELTEX 400 type with a total filtering of 2.5mm Al The physical parameters are measured with a multifunctional measuring instrument which tests the quality of typeRMI-242 radiological systems, with a flat ionization chamber with a volume of 51cc and a standard phantom. The statistic evaluation was made using a Student Test comparing the obtained average values for the entry surface dosewith the reference values [14]. Results and discussions 1. Frequency of radiological examinations in the ATI department Table 1. Frequency of radiological examinations on years and type of procedure Graph 1. Frequency of radiological examinations on years and type of procedure A slight variation of the frequency of the radiological exam can be observed during the three years assessed. Theobvious decrease in 2007 can be attributed to a better collaboration between doctors who requested the procedures, andpractitioners regarding the standards of medical exposure to ionizing radiation. 2. Number of children that have undergone a radiological exam out of the total of newborns
  • 3. Graph 2. The number of newborns that have been radiologically examined out of the total number of new-bornbabies Out of the 8785 newborns in the studied period, 9.8% had at least one radiological exam. The average number ofradiological exams conducted on a single child is 1.8, the highest number of radiological exams being 9. 3. the distribution of the radiological examinations in the pediatric department, sorted by age and procedures Table 2. Frequency of radiological examinations Graph 3. Frequency of radiological examinations The largest number of chest X-rays is conducted on the 0 - 3 age group, the value dropping significantly in thesubsequent age groups. One of the causes could be the much more varied pathology of this age group, but also the doctors’habit of repeating the clinical exams more than once before the treatment shows any improvement. 4. Ratio between the number of chest X-rays performed and the confirmed examinations Table 3. Ratio between the number of chest X-rays performed and the confirmed examinations Graph 4. Ratio between the number of chest X-rays performed and the confirmed examinations Besides the fact that the number of chest X-rays is extremely high in comparison to other procedures, the percentage ofconfirmed examinations is mostly below 50%. 5. Comparing the used kilo-voltage values to the reference values for chest X-rays Graph 5. Kilo-voltage For all age groups, excepting that of 12-15, the kilo-voltage values used surpasses the recommended values for a chestX-ray, which are between 60 and 80kV 6. The average entrance surface doses values for the children in ATI and the comparison with the referencevalues specified in the Order no. 285/79/2002 of the Ministry of Health and Family and of the president of theNational Committee for the Nuclear Activities Control regarding the radioprotection of people in the event of themedical exposures to ionizing radiations. Table 4. The entrance surface doses Graph 6. The entrance surface doses For chest X-ray, the value of the entrance surface dose is the highest compared to the other two types of exams and 1.08times higher than the reference values. For other examination types there are no reference values whatsoever. 7. Average values of the entrance surface doses per exam type and age groups for the children in the pediatricdepartment and the comparison with the reference values Table 5. Average values of the entrance surface doses per exam type and age groups for the children in thepediatric department and the comparison with the reference values It has been observed that one exposure of a 5 year old child determined 4 times greater chest irradiation values, 3 timesgreater for two exposures and 2 times greater in the pelvic area, compared to the reference values. Values close to thereference values have been found for the skull X-ray. The values of the Student Test point out statistically significant differences for the chest and pelvic X-rays (p<0.001)and statistically insignificant ones for the skull X-rays (p>0.05). For other types of procedures reference values are notspecified [16, 19]. Conclusions
  • 4. 1. Of all investigations, chest X-ray is ranked first in all age groups, even though more than 50% had no diagnosticbenefit whatsoever. Therefore, “better” can easily become “worse”, if neglecting that any radiation dosage may be harmfuland may have long term repercussions, considering the very high latency of the effects inflicted by the ionizing radiation[17]. 2. The radiological equipment used in Children’s ATI and also in the Pediatric Departments are not designedpurposely for pediatric radiology. In addition, it does not comply with the standards regarding technical parameters, whichultimately may have a crucial impact on the radiation dose received by the patient [3, 4]. 3. In order to gather correct diagnostic information, a crucial part is played by the quality of the radiography, stronglylinked to the previously mentioned parameters [5, 15]. 4. The doses absorbed by the children (three or four times greater than the reference values) can be explained by theuse of low kilo-voltage (which implies the use of ‘soft” X-ray fascicles, associated with the release of higher doses), thevalues of this physical parameter in the 0 - 11 age group being below the recommended values [6, 7, 12]. 5. In the case of newborns, the most worrying aspect is not the dose the child is exposed to, but the fact that clinicalX-rays are repeated during hospitalization. This leads to cumulative doses, which are likely to increase during thenewborn’s childhood [18]. 6. To reduce the exposure of the child to radiation, it’s important that the medical staff have special training regardingthe anatomy and physiology of the child, and that the medical care takes place in a friendly environment [17, 12]. 7. Hospital protocols may improve the healthcare system and ultimately lead to a better care for the patient [11]. 8. Every clinician will have to be aware of his responsibility as well as the collective responsibility to ensure thequality of the medical act. All these suggestions, if followed, could lead to the decrease of ineffective investigations, and particularly to decreasingthe radiation doses per patient. Bibliography [1] Bahnarel I., Coretchi L., Dimov N., Quality Control and Quality Assurance in Radiation Medicine in theRepublic of Moldova, IRPA Regional Congress for Central and Eastern Europe, 2007, pg.173-174; [2] ***Biological Effects of radiation, USNRC Technical Training Center Biological Effects of Radiation,http://www.nrc.gov/reading-rm/basic-ref/teachers/09.pdf, accessed 06.10.2008; [3] Cook J.V., Shah K., Pablot S., Kyriou J., Pettet A., Fitzgerald M., Guidelines on best practice in the x-rayimaging of children. London St. George, s Hospital & St Helier Hospital, 1998; [4] Cook J.V., Kyriou J.C., Pettet A., et al., Key factors in the optimization of pediatric X-ray practice, Br JRadiology 2001; 74(887):1032-40; [5] ***Commission of European Communities. European Guidelines on Quality Criteria for DiagnosticRadiographic Images in Pediatrics, Report EUR 16261. EN, Luxembourg: Office for Official Publications of theEuropean Communities, 1996; [6] Gray J., Archer B., Butler P., et al., Reference values for diagnostic radiology: application and impact,Radiology, 2005, 235: 354-358;
  • 5. [7] Iacob O., Popescu I., Iacob M., Population exposure from diagnostic radiology in Romania :2005 update,IRPA Regional Congress for Central and Eastern Europe, 2007, pg.161-162; [8] Kaplanis P., Christofides S., Christodoulides G. (eds), Evaluation of the Radiation dose in a Pediatric X-rayDepartment, Radiological Protection of Patient in Diagnostic and Interventional Radiology, Nuclear Medicine andRadiotherapy, 2001, 1: 544 – 547; [9] Kyriou J.C., Fitzgerald M., Pettet A., et al., A comparison of doses techniques between specialist and non-specialist centers in diagnostic X-ray imaging of children, Br J Radiology 1996; 69(821); 437-50; [10] Lindskoug B.A., Exposure parameters in x-ray diagnosis of children, infants and the newborns. RadiationProtection Dosimetry 1992; 43:289-92; [11] Martin C.J., Darragh C.L., McKenzie G.A., et. al., Implementation of a program for reduction of radiographicdoses and results achieved through increases in tube potential. Br. J Radiology 1993; 66(783):228-33; [12] Mooney R., Thomas P.S., Dose reduction in a pediatric X-ray department following optimization ofradiographic technique. Br J Radiology 1998; 7 (848):852-60; [13] Picano E., Sustainability of medical imaging, BMJ 2004, 328:578-580; [14] Petru M., Manual de metode matematice în analiza stării de sănătate, Editura Medicală Bucureşti, 1989, pg.532-533; [15] Regulla D., Eder H., Patient exposures in medical X-ray imaging in Europe. Radiation Protection Dosimetry,2005, pg.11-25; [16] Schreiner - Karoussou A, Back C, Harpes N (eds), Practical Implementation of the Medical ExposureDirective ( 97/43) in Luxembourg with special reference to diagnostic reference level, Radiological Protection ofPatient in Diagnostic and Interventional Radiology, Nuclear Medicine and Radiotherapy, 2001, 1: 403 – 406; [17] Scripcaru Gh., Bioetica între ştiinţele vieţii şi drepturile omului, Revista Română de Bioetică, vol. 1, nr.2,2008, pg. 2; [18] Stern.S, Tucker S, Gagne RM (eds), Estimated Benefits of Proposed Amendments to the FDA Radiation-Safety Standard for Diagnostic Y- Ray Equipment, Science Across the Boundaries, February, 2001, pg.1-27; [19] Tschurlovits M., A proposal to prove compliance of ESD with EU – Guideline, Radiological Protection ofPatient in Diagnostic and Interventional Radiology, Nuclear Medicine and Radiotherapy, 2001, 1:407 – 410; [20] Wraith C.M., Martin C.J., Stockdale E.J., et. al., An investigation into techniques reducing doses from neo-natal radiographic examinations, Br. J Radiology 1995, 68(814):1074-82.
  • 6. [7] Iacob O., Popescu I., Iacob M., Population exposure from diagnostic radiology in Romania :2005 update,IRPA Regional Congress for Central and Eastern Europe, 2007, pg.161-162; [8] Kaplanis P., Christofides S., Christodoulides G. (eds), Evaluation of the Radiation dose in a Pediatric X-rayDepartment, Radiological Protection of Patient in Diagnostic and Interventional Radiology, Nuclear Medicine andRadiotherapy, 2001, 1: 544 – 547; [9] Kyriou J.C., Fitzgerald M., Pettet A., et al., A comparison of doses techniques between specialist and non-specialist centers in diagnostic X-ray imaging of children, Br J Radiology 1996; 69(821); 437-50; [10] Lindskoug B.A., Exposure parameters in x-ray diagnosis of children, infants and the newborns. RadiationProtection Dosimetry 1992; 43:289-92; [11] Martin C.J., Darragh C.L., McKenzie G.A., et. al., Implementation of a program for reduction of radiographicdoses and results achieved through increases in tube potential. Br. J Radiology 1993; 66(783):228-33; [12] Mooney R., Thomas P.S., Dose reduction in a pediatric X-ray department following optimization ofradiographic technique. Br J Radiology 1998; 7 (848):852-60; [13] Picano E., Sustainability of medical imaging, BMJ 2004, 328:578-580; [14] Petru M., Manual de metode matematice în analiza stării de sănătate, Editura Medicală Bucureşti, 1989, pg.532-533; [15] Regulla D., Eder H., Patient exposures in medical X-ray imaging in Europe. Radiation Protection Dosimetry,2005, pg.11-25; [16] Schreiner - Karoussou A, Back C, Harpes N (eds), Practical Implementation of the Medical ExposureDirective ( 97/43) in Luxembourg with special reference to diagnostic reference level, Radiological Protection ofPatient in Diagnostic and Interventional Radiology, Nuclear Medicine and Radiotherapy, 2001, 1: 403 – 406; [17] Scripcaru Gh., Bioetica între ştiinţele vieţii şi drepturile omului, Revista Română de Bioetică, vol. 1, nr.2,2008, pg. 2; [18] Stern.S, Tucker S, Gagne RM (eds), Estimated Benefits of Proposed Amendments to the FDA Radiation-Safety Standard for Diagnostic Y- Ray Equipment, Science Across the Boundaries, February, 2001, pg.1-27; [19] Tschurlovits M., A proposal to prove compliance of ESD with EU – Guideline, Radiological Protection ofPatient in Diagnostic and Interventional Radiology, Nuclear Medicine and Radiotherapy, 2001, 1:407 – 410; [20] Wraith C.M., Martin C.J., Stockdale E.J., et. al., An investigation into techniques reducing doses from neo-natal radiographic examinations, Br. J Radiology 1995, 68(814):1074-82.

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