Patricia Mora

IAEA Survey of Pediatric CT Practice in 40 Countries in Asia, Europe, Latin America, and Africa. Part 1 : Frequency and Appropriateness

OBJECTIVE The purpose of this study was to assess the frequency of pediatric CT in 40 less-resourced countries and to determine the level of appropriateness in CT use. MATERIALS AND METHODS Data on the increase in the number of CT examinations during 2007 and 2009 and appropriate use of CT examinations were collected, using standard forms, from 146 CT facilities at 126 hospitals. RESULTS The lowest frequency of pediatric CT examinations in 2009 was in European facilities (4.3%), and frequencies in Asia (12.2%) and Africa (7.8%) were twice as high. Head CT is the most common CT examination in children, amounting to nearly 75% of all pediatric CT examinations. Although regulations in many countries assign radiologists with the main responsibility of deciding whether a radiologic examination should be performed, in fact, radiologists alone were responsible for only 6.3% of situations. Written referral guidelines for imaging were not available in almost one half of the CT facilities. Appropriateness criteria for CT examinations in children did not always follow guidelines set by agencies, in particular, for patients with accidental head trauma, infants with congenital torticollis, children with possible ventriculoperitoneal shunt malfunction, and young children (< 5 years old) with acute sinusitis. In about one third of situations, nonavailability of previous images and records on previously received patient doses have the potential to lead to unnecessary examinations and radiation doses. CONCLUSION With increasing use of CT in children and a lack of use of appropriateness criteria, there is a strong need to implement guidelines to avoid unnecessary radiation doses to children.

A study to establish international diagnostic reference levels for paediatric computed tomography

The article reports results from the largest international dose survey in paediatric computed tomography (CT) in 32 countries and proposes international diagnostic reference levels (DRLs) in terms of computed tomography dose index (CTDI vol) and dose length product (DLP). It also assesses whether mean or median values of individual facilities should be used. A total of 6115 individual patient data were recorded among four age groups: <1 y, >1-5 y, >5-10 y and >10-15 y. CTDIw, CTDI vol and DLP from the CT console were recorded in dedicated forms together with patient data and technical parameters. Statistical analysis was performed, and international DRLs were established at rounded 75th percentile values of distribution of median values from all CT facilities. The study presents evidence in favour of using median rather than mean of patient dose indices as the representative of typical local dose in a facility, and for establishing DRLs as third quartile of median values. International DRLs were established for paediatric CT examinations for routine head, chest and abdomen in the four age groups. DRLs for CTDI vol are similar to the reference values from other published reports, with some differences for chest and abdomen CT. Higher variations were observed between DLP values, based on a survey of whole multi-phase exams. It may be noted that other studies in literature were based on single phase only. DRLs reported in this article can be used in countries without sufficient medical physics support to identify non-optimised practice. Recommendations to improve the accuracy and importance of future surveys are provided.

The distribution of fallout 137Cs in Costa Rica.

Baseline levels of 137Cs on different sites throughout the Costa Rican territory are presented in this study from local and undisturbed soils. They are believed to represent the fallout input to the land surface. Seventy samples were collected from September 1991 to December 1993, and analyzed by gamma spectroscopy. The territory was divided in three regions, Caribbean, Pacific, and Central, based on meteorological and geographical conditions to study spatial distribution of cesium. The results show a higher activity in the Caribbean region perhaps due to the wind influence and higher rain precipitation throughout the year. No relevant time variation of the activity levels for each location was found. The highest value of 17.6 Bq kg(-1) of 137Cs is compared with its generalized derived limit, being only 1.97% of the generalized derived limit value. The mean country activity value ranges from 0.4 to 17.8 Bq kg(-1) with an average of 3.7 Bq kg(-1).

LATIN AMERICAN DOSE SURVEY RESULTS IN MAMMOGRAPHY STUDIES UNDER IAEA PROGRAMME: RADIOLOGICAL PROTECTION OF PATIENTS IN MEDICAL EXPOSURES (TSA3)

Latin American countries (Argentina, Brazil, Chile, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Mexico, Nicaragua, Paraguay, Uruguay and Venezuela) working under the International Atomic Energy Agency (IAEA) Technical Cooperation Programme: TSA3 Radiological Protection of Patients in Medical Exposures have joined efforts in the optimisation of radiation protection in mammography practice. Through surveys of patient doses, the region has a unique database of diagnostic reference levels for analogue and digital equipment that will direct future optimisation activities towards the early detection of breast cancer among asymptomatic women. During RLA9/057 (2007-09) 24 institutions participated with analogue equipment in a dose survey. Regional training on methodology and measurement equipment was addressed in May 2007. The mean glandular dose (DG) was estimated using the incident kerma in air and relevant conversion coefficients for both projections craneo caudal and mediolateral oblique (CC and MLO). For Phase 2, RLA9/067 (2010-11), it was decided to include also digital systems in order to see their impact in future dose optimisation activities. Any new country that joined the project received training in the activities through IAEA expert missions. Twenty-nine new institutions participated (9 analogue and 20 digital equipment). A total of 2262 patient doses were collected during this study and from them D(G) (mGy) for both projections were estimated for each institution and country. Regional results (75 percentile in mGy) show for CC and MLO views, respectively: RLA9/057 (analogue) 2.63 and 3.17; RLA/067: 2.57 and 3.15 (analogue) and 2.69 and 2.90 (digital). Regarding only digital equipment for CC and MLO, respectively, computed radiography systems showed 2.59 and 2.78 and direct digital radiography (DDR) systems 2.78 and 3.04. Based on the IAEA Basic Safety Standard (BSS) reference dose (3 mGy), it can be observed that there is enough room to start optimisation processes in Latin America (LA); several countries or even particular institutions have values much higher than the 3 mGy. The main issues to address are lack of well-established quality assurance programmes for mammography, not enough medical physicists with training in mammography, an increase in patient doses with the introduction of digital equipment and to create awareness on radiation risk and optimisation strategies.

Assessment of medical occupational radiation doses in Costa Rica

Participation of the University of Costa Rica (UCR) in activities in an IAEA Regional Project RLA/9/066 through training, equipment and expert missions, has enabled to setting up of a national personal monitoring laboratory. Since 2007, the UCR has been in charge of monitoring around 1800 medical radiation workers of the Social Security System. Individual external doses are measured with thermoluminescent dosemeter using a Harshaw 6600 Plus reader. The service has accreditation with ISO/IEC 17025:2005. Distribution of monitored medical personnel is as follows: 83 % in diagnostic radiology, 6 % in nuclear medicine and 6 % in radiotherapy. Preliminary values for the 75 percentile of annual H(p)(10) in mSv are: radiology 0.37; interventional radiology 0.41; radiotherapy 0.53 and nuclear medicine 1.55. The service provided by the UCR in a steady and reliable way can help to implement actions to limit the doses received by the medical workers and optimise their radiation protection programs.

Outdoor and indoor dose assessment using environmental thermoluminescence dosimeters (TLDs) in Costa Rica.

Costa Rica lies at the intersection of the Cocos and Caribbean plates in Central America. It has mountain ranges with many active volcanoes along its territory. Its soils are predominantly of volcanic origin. Natural radiation measurements utilising environmental CaF2:Dy thermoluminescence dosimeters were used for the first time in Costa Rica by the Dosimetry Section of the Atomic, Nuclear and Molecular Sciences Research Center of the University of Costa Rica. Seven hundred outdoor measurements were obtained in a 3.5-year period at eight different sites throughout the country. One hundred and seventy-four indoor readings were also collected at four sites for a 2-year period. Population-weighted averages give 82 nGy h(-1) for outdoors and 130 nGy h(-1) for indoors. The values lie on the upper range of worldwide reported values due to reported soil characteristics rich in uranium and potassium. A preliminary population-weighted value of 0.74 mSv/year for the effective dose is calculated for natural terrestrial gamma radiation in Costa Rica.

Determination of diagnostic reference levels in general radiography in Latin America

The International Atomic Energy Agency (IAEA) through the International Action Plan on Radiation Protection of Patients and the International Commission on Radiological Protection have for some time carried out important efforts to assure that in the medical applications of the ionising radiations, the optimisation of radiological protection of patients is fundamental, to such a point that the IAEA includes it directly as a requirement for these practices (in its International Basic Safety Standards for Protection against Ionising Radiation and for the Safety of Radiation Sources (BSS)-GSR Part 1, 2011). For this reason, among the objectives of Regional Project RLA/9/057 and Regional Project RLA/9/067, the intention was to establish the dose references in conventional radiology for Latin America, for the purposes of determining whether these doses comply with the requirements of the BSS and to tend to improve practices, in order to minimise the dose received by the patients.

Specific activity and derived intervention levels for Cesium-137 in Costa Rican export goods: Tuna fish, coffee and powdered milk

Abstract Cesium-137 is a fission product of 235 U and 239 Pu. After a major nuclear accident, it is released into the atmosphere and in the far field region it will produce radioactively contaminated food and drinking water. This paper will study the specific activity of 137 Cs in three Costa Rican export products: tuna fish, coffee and powdered milk. The average specific activities found are as follows: 0.89±0.41, 1.16±0.76 and 4.53±2.00 Bq kg −1 . They represent low values compared to their derived intervention levels: 1.25 × 10 7 , 1.25 × 10 7 and 2.44 × 10 5 Bq kg −1 , respectively.

LATIN AMERICAN IMAGE QUALITY SURVEY IN DIGITAL MAMMOGRAPHY STUDIES

Under International Atomic Energy Agency regional programme TSA3 Radiological Protection of Patients in Medical Exposures, Latin American countries evaluated the image quality and glandular doses for digital mammography equipment with the purpose of seeing the performance and compliance with international recommendations. Totally, 24 institutions participated from Brazil, Chile, Costa Rica, El Salvador, Mexico, Paraguay and Venezuela. Signal difference noise ratio results showed for CR poor compliance with tolerances; better results were obtained for full-field digital mammography equipment. Mean glandular dose results showed that the majority of units have values below the acceptable dose levels. This joint Latin American project identified common problems: difficulty in working with digital images and lack of specific training by medical physicists from the region. Image quality is a main issue not being satisfied in accordance with international recommendations; optimisation processes in which the doses are increased should be very carefully done in order to improve early detection of any cancer signs.

Patient Doses in Latin American Countries

This paper discusses the results of patient doses evaluated in the following countries in Latin American Argentina, Brazil, Chile, Costa Rica, Cuba, Ecuador, Nicaragua, Peru and Uruguay. The entrance air kerma values for PA/AP pediatric chest examinations and the average glandular dose in mammography projections are presented, as well as doses from CT procedures for pediatric and adult patients. The results of the PA/AP chest adult and pediatric procedures demonstrated a large variation of the exposure parameters used in the different countries of Latin America. Many were outside the recommend values of the European Commission. For chest pediatric examinations, the Ke values ranged from 0,01 to 0,16 mGy for the newborns and from 0,020 to 0,24 mGy for the infants. In mammography, the mean value of the average glandular dose was 2.28mGy, with a range of 0.5 to 6.42 mGy for the cranio-caudal projection; and 2.71 mGy, with a range of 0.55 to 10.65 mGy, for the medio-lateral-oblique projection. In CT, the Cw mean value for the head exam was approximately 25% higher for adults than for children. However in the other procedures, the Cw for adults was 3% lower than for children. The adult mean values of Cw and PKL for all procedures were lower than the DRL values recommended in the European guidelines