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Multicentre survey on patient dose in paediatric imaging and proposal for updated diagnostic reference levels for France. Part 2: plain radiography and diagnostic fluoroscopy

  • David CélierEmail author
  • Patrice Roch
  • Cécile Etard
  • Hubert Ducou Le Pointe
  • Hervé J. Brisse
Paediatric
  • 43 Downloads

Abstract

Objectives

To report on a dose survey conducted by the French societies of radiology and paediatric imaging (SFR and SFIPP) and the French public service expert in nuclear and radiological risks (IRSN), and to suggest new diagnostic reference levels (DRLs) for paediatric plain radiography and diagnostic fluoroscopy.

Methods

Dose reports concerning four radiography procedures and three diagnostic fluoroscopy procedures performed in 2015–2016 on children aged 0–15 years were collected from 16 imaging departments on a voluntary basis. Air kerma–area product (PKA) was recorded for at least 10 patients per procedure, per centre and per age group. New DRLs were calculated as the 3rd quartiles of the distributions of the median values.

Results

Results from 2249 radiography examinations and 1235 diagnostic fluoroscopy procedures were obtained. A noticeable variability in patient exposure between facilities was observed in diagnostic fluoroscopy and to a lesser extent in plain radiography. DRLs are proposed for each procedure and each age group.

Conclusions

This study showed that the applicable national DRLs in plain radiography were obsolete and its results have been recently used by the French authorities to update them. In diagnostic fluoroscopy, large differences of doses were observed, even among departments accustomed to paediatric procedures. The new national DRLs will be useful for optimising diagnostic practice.

Key Points

• New national diagnostic reference levels (DRLs) are proposed for several paediatric procedures in plain radiography and diagnostic fluoroscopy.

• Even between departments accustomed to paediatric procedures, substantial differences of practice were observed, especially in diagnostic fluoroscopy.

Keywords

Radiography Fluoroscopy Paediatrics Radiation exposure Radiation protection 

Abbreviations

CQV

Coefficient of quartile variation

CR

Computed radiography

CT

Computed tomography

DAP

Dose-area product

DR

Direct digital radiography

DRL

Diagnostic reference level

EC

European Commission

EDRL

European diagnostic reference level

GI

Gastrointestinal (tract)

HAS

Haute Autorité de Santé

HERCA

Heads of the European Radiological protection Competent Authorities

IAEA

International Atomic Energy Agency

ICRP

International Commission on Radiological Protection

IRSN

Institut de Radioprotection et Sûreté Nucléaire

Ka,e

Entrance-surface air kerma

MCU

Micturating cysto-urethrography

PKA

Air kerma–area product

Q1

First quartile

Q3

Third quartile

SFIPP

Société Francophone d’Imagerie Pédiatrique et Prénatale

SFR

Société Française de Radiologie

Notes

Acknowledgements

The authors are very grateful to the staff (radiologists, medical physicists, managers and radiographers) of the imaging departments, listed in Part 1, who participated in this study and who took the time to collect and check the data.

Funding

The authors state that this work has not received any funding.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Hervé J. Brisse.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study because this study was a survey on patient doses to assess diagnostic reference levels, carried out in accordance with DRLs national regulations and international guidance.

Ethical approval

Institutional Review Board approval was not required because this study was a survey on patient doses to assess diagnostic reference levels, carried out in accordance with DRLs national regulations and international guidance.

Methodology

• Prospective

• Multicentre study

References

  1. 1.
    Pearce MS, Salotti JA, Little MP et al (2012) Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 380:499–505CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    (2007) The 2007 Recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann ICRP 37:1–332Google Scholar
  3. 3.
    Vañó E, Miller DL, Martin CJ et al (2017) ICRP publication 135: Diagnostic reference levels in medical imaging. Ann ICRP 46:1–144Google Scholar
  4. 4.
    International Atomic Energy Agency (2014) Radiation protection and safety of radiation sources: international basic safety standards. International Atomic Energy Agency, Vienna Available via http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1578_web-57265295.pdf. Accessed 14 Jun 2018Google Scholar
  5. 5.
    International Atomic Energy Agency (2018) Radiation protection and safety in medical uses of ionizing radiation. International Atomic Energy Agency, Vienna Available via http://www-pub.iaea.org/MTCD/Publications/PDF/PUB1775_web.pdf. Accessed 25 Jan 2019Google Scholar
  6. 6.
    The Council of the European Union (2014) Council Directive 2013/59/Euratom of 5 December 2013; Laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom. Official Journal of the European UnionGoogle Scholar
  7. 7.
    European Commission (1999) Guidance on Diagnostic Reference Levels (DRLs) for Medical Exposures - Radiation Protection 109. European Commission, Brussels. Available via http://ec.europa.eu/energy/sites/ener/files/documents/109_en.pdf. Accessed 14 Jun 2018
  8. 8.
    European Commission (2018) European guidelines on diagnostic reference levels for paediatric imaging. Radiation Protection 185. European Commission, Brussels Available via http://ec.europa.eu/energy/sites/ener/files/rp_185.pdf. Accessed 19 Sept 2018Google Scholar
  9. 9.
    (2012) Arrêté du 24 octobre 2011 relatif aux niveaux de référence diagnostiques en radiologie et en médecine nucléaire. Journal officiel de la République FrançaiseGoogle Scholar
  10. 10.
    Talbot A (2008) Analyse des données relatives à la mise à jour des niveaux de référence diagnostiques en radiologie et en médecine nucléaire. Bilan 2004–2006. IRSN, Fontenay-aux-Roses. Available via http://nrd.irsn.fr/ressources. Accessed 14 Jun 2018
  11. 11.
    Roch P (2010) Analyse des données relatives à la mise à jour des niveaux de référence diagnostiques en radiologie et en médecine nucléaire. Bilan 2007–2008. IRSN, Fontenay-aux-Roses. Available via http://nrd.irsn.fr/ressources. Accessed 14 Jun 2018
  12. 12.
    Roch P, Célier D (2012) Analyse des données relatives à la mise à jour des niveaux de référence diagnostiques en radiologie et en médecine nucléaire. Bilan 2009–2010. IRSN, Fontenay-aux-Roses. Available via http://nrd.irsn.fr/ressources. Accessed 14 Jun 2018
  13. 13.
    Roch P, Célier D (2014) Analyse des données relatives à la mise à jour des niveaux de référence diagnostiques en radiologie et en médecine nucléaire. Bilan 2011–2012. IRSN, Fontenay-aux-Roses. Available via http://nrd.irsn.fr/ressources. Accessed 14 Jun 2018
  14. 14.
    Roch P, Célier D (2016) Analyse des données relatives à la mise à jour des niveaux de référence diagnostiques en radiologie et en médecine nucléaire. Bilan 2013–2015. IRSN, Fontenay-aux-Roses. Available via http://nrd.irsn.fr/ressources. Accessed 14 Jun 2018
  15. 15.
    Célier D, Roch P, Etard C, Ducou le Pointe H, Brisse HJ (2019) Multicentre survey on patient dose in paediatric imaging and proposal for updated diagnostic reference levels for France. Part 1: computed tomography. Eur Radiol.  https://doi.org/10.1007/s00330-019-06405-3
  16. 16.
    European Commission (2014) Medical radiation exposure of the European population. Radiation protection 180 part 1/2. European Commission, Brussels Available via http://ec.europa.eu/energy/sites/ener/files/documents/RP180.pdf. Accessed 14 Jun 2018Google Scholar
  17. 17.
    Dreuil S, Etard C (2017) Exposure of the French population to ionizing radiations from medical diagnostic procedures in 2012. Radioprotection 52:45–49CrossRefGoogle Scholar
  18. 18.
    (2004) Arrêté du 12 février 2004 relatif aux niveaux de référence diagnostiques en radiologie et en médecine nucléaire. Journal officiel de la République FrançaiseGoogle Scholar
  19. 19.
    Haute Autorité de Santé (2008) Indications de la radiographie du crâne et/ou du massiaf facial - Rapport d’évaluation technologique. Haute Autorité de Santé. Available via http://www.has-sante.fr/portail/jcms/c_674688/fr/rapport-indications-de-la-radiographie-du-crane-et/ou-du-massif-facial. Accessed 14 Jun 2018
  20. 20.
    Décision du 21 novembre 2016 fixant les modalités du contrôle de qualité de certaines installations de radiodiagnostic (2016) Journal officiel de la République FrançaiseGoogle Scholar
  21. 21.
    Bonett DG (2006) Confidence interval for a coefficient of quartile variation. Comput Stat Data Anal 50:2953–2957CrossRefGoogle Scholar
  22. 22.
    Dietrich TJ, Pfirrmann CW, Schwab A, Pankalla K, Buck FM (2013) Comparison of radiation dose, workflow, patient comfort and financial break-even of standard digital radiography and a novel biplanar low-dose X-ray system for upright full-length lower limb and whole spine radiography. Skeletal Radiol 42:959–967CrossRefPubMedGoogle Scholar
  23. 23.
    Luo TD, Stans AA, Schueler BA, Larson AN (2015) Cumulative radiation exposure with EOS imaging compared with standard spine radiographs. Spine Deform 3:144–150CrossRefPubMedGoogle Scholar
  24. 24.
    Law M, Ma WK, Chan E et al (2017) Evaluation of cumulative effective dose and cancer risk from repetitive full spine imaging using EOS system: impact to adolescent patients of different populations. Eur J Radiol 96:1–5CrossRefPubMedGoogle Scholar
  25. 25.
    Pedersen PH, Petersen AG, Østgaard SE, Tvedebrink T, Eiskjær SP (2018) EOS micro-dose protocol: first full-spine radiation dose measurements in anthropomorphic phantoms and comparisons with EOS standard-dose and conventional digital radiology. Spine (Phila Pa 1976) 43:E1313–E1321Google Scholar
  26. 26.
    Société Francophone d’Imagerie Pédiatrique et Prénatale (last update: Sep 2018) Références radioprotection. Available via http://sfip-radiopediatrie.org/references-radioprotection/. Accessed 25 Jan 2019
  27. 27.
    Roch P, Célier D, Dessaud C, Etard C (2018) Using diagnostic reference levels to evaluate the improvement of patient dose optimisation and the influence of recent technologies in radiography and computed tomography. Eur J Radiol 98:68–74CrossRefPubMedGoogle Scholar
  28. 28.
    Bacher K, Smeets P, Bonnarens K, De Hauwere A, Verstraete K, Thierens H (2003) Dose reduction in patients undergoing chest imaging: digital amorphous silicon flat-panel detector radiography versus conventional film-screen radiography and phosphor-based computed radiography. AJR Am J Roentgenol 181:923–929CrossRefPubMedGoogle Scholar
  29. 29.
    Paulo G, Vaño E, Rodrigues A (2016) Diagnostic reference levels in plain radiography for paediatric imaging: a Portuguese study. Radiography 22:e34–e39CrossRefGoogle Scholar
  30. 30.
    Billinger J, Nowotny R, Homolka P (2010) Diagnostic reference levels in pediatric radiology in Austria. Eur Radiol 20:1572–1579CrossRefPubMedGoogle Scholar
  31. 31.
    Bundesamt für Strahlenschutz (2016) Bekanntmachung der aktualisierten diagnostischen Referenzwerte für diagnostische und interventionelle Röntgenanwendungen. Bundesamt für Strahlenschutz. Available via https://www.bfs.de/SharedDocs/Downloads/BfS/DE/fachinfo/ion/drw-roentgen.html. Accessed 14 Jun 2018
  32. 32.
    Magistrelli A, Genovese E, Cannatà V, Cirillo M, Schingo P, Toma P (2017) Local DRL for common paediatric fluoroscopic examinations in according to PiDRL Guidelines: experience of a dedicated Italian referral center. ECR 2017 EuroSafe Imaging Poster Exhibition, Vienna.  https://doi.org/10.1594/esi2017/ESI-0043
  33. 33.
    Bibbo G, Balman D, Linke R (2016) Diagnostic reference levels for common paediatric fluoroscopic examinations performed at a dedicated paediatric Australian hospital. J Med Imaging Radiat Oncol 60:469–474CrossRefPubMedGoogle Scholar
  34. 34.
    Hart D, Hillier MC, Schrimpton PC (2012) Doses to patients from radiographic and fluoroscopic X-ray imaging procedures in the UK – 2010 review. HPA-CRCE-034 Report. Health Protection Agency, Chilton. Available via http://www.gov.uk/government/publications/diagnostic-radiology-national-diagnostic-reference-levels-ndrls/national-diagnostic-reference-levels-ndrls. Accessed 14 Jun 2018
  35. 35.
    Rehani MM (2015) Limitations of diagnostic reference level (DRL) and introduction of acceptable quality dose (AQD). Br J Radiol 88:20140344CrossRefPubMedGoogle Scholar
  36. 36.
    Heads of the European Radiological protection Competent Authorities (2012) HERCA-DAP display proposal (approved on the occasion of the 10th HERCA meeting, 31 October 2012). Heads of the European Radiological protection Competent Authorities, Paris. Available via http://www.herca.org/uploaditems/documents/HERCA-DAP%20display%20proposal%202012%2031%2010.pdf. Accessed 14 Jun 2018
  37. 37.
    (2019) Arrêté du 23mai 2019 portant homologation de la décision n°2019-DC-0667 de l’Autorité de sûreté nucléaire du 18 avril 2019 relative aux modalités d’évaluation des doses de rayonnements ionisants délivrées aux patients lors d’un acte de radiologie, de pratiques interventionnelles radioguidées ou de médecine nucléaire et à la mise à jour des niveaux de référence diagnostiques associés. Journal officiel de la République FrançaiseGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Institut de radioprotection et de sûreté nucléaireFontenay-aux-RosesFrance
  2. 2.Department of Pediatric ImagingHôpital d’enfants Armand-Trousseau APHPParisFrance
  3. 3.Université Pierre et Marie Curie, Sorbonne UniversitésParisFrance
  4. 4.French-Speaking Society for Pediatric and Prenatal Imaging (SFIPP)ParisFrance
  5. 5.Imaging DepartmentInstitut CurieParisFrance
  6. 6.Paris Sciences et Lettres Research UniversityParisFrance

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