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– The International Commission on Radiological Protection (ICRP) first introduced the term ‘diagnostic reference level’ (DRL) in 1996 in Publication 73. The concept was subsequently developed further, and practical guidance was provided in 2001. The DRL has been proven to be an effective tool that aids in optimisation of protection in the medical exposure of patients for diagnostic and interventional procedures. However, with time, it has become evident that additional advice is needed. There are issues related to definitions of the terms used in previous guidance, determination of the values for DRLs, the appropriate interval for re-evaluating and updating these values, appropriate use of DRLs in clinical practice, methods for practical application of DRLs, and application of the DRL concept to newer imaging technologies. This publication is intended as a further source of information and guidance on these issues. Some terminology has been clarified. In addition, this publication recommends quantities for use as DRLs for various imaging modalities, and provides information on the use of DRLs for interventional procedures and in paediatric imaging. It suggests modifications in the conduct of DRL surveys that take advantage of automated reporting of radiation-dose-related quantities, and highlights the importance of including information on DRLs in training programmes for healthcare workers. The target audience for this publication is national, regional, and local authorities; professional societies; and facilities that use ionising radiation for medical purposes, and responsible staff within these facilities. A full set of the Commission’s recommendations is provided.

ICRP Publication 135: Diagnostic Reference Levels in Medical Imaging.

Cardiac nuclear medicine, cardiac computed tomography (CT), interventional cardiology procedures, and electrophysiology procedures are increasing in number and account for an important share of patient radiation exposure in medicine. Complex percutaneous coronary interventions and cardiac electrophysiology procedures are associated with high radiation doses. These procedures can result in patient skin doses that are high enough to cause radiation injury and an increased risk of cancer. Treatment of congenital heart disease in children is of particular concern. Additionally, staff(1) in cardiac catheterisation laboratories may receive high doses of radiation if radiological protection tools are not used properly. The Commission provided recommendations for radiological protection during fluoroscopically guided interventions in Publication 85, for radiological protection in CT in Publications 87 and 102, and for training in radiological protection in Publication 113 (ICRP, 2000b,c, 2007a, 2009). This report is focused specifically on cardiology, and brings together information relevant to cardiology from the Commission's published documents. There is emphasis on those imaging procedures and interventions specific to cardiology. The material and recommendations in the current document have been updated to reflect the most recent recommendations of the Commission. This report provides guidance to assist the cardiologist with justification procedures and optimisation of protection in cardiac CT studies, cardiac nuclear medicine studies, and fluoroscopically guided cardiac interventions. It includes discussions of the biological effects of radiation, principles of radiological protection, protection of staff during fluoroscopically guided interventions, radiological protection training, and establishment of a quality assurance programme for cardiac imaging and intervention. As tissue injury, principally skin injury, is a risk for fluoroscopically guided interventions, particular attention is devoted to clinical examples of radiation-related skin injuries from cardiac interventions, methods to reduce patient radiation dose, training recommendations, and quality assurance programmes for interventional fluoroscopy.

https://journals.sagepub.com/doi/pdf/10.1016/j.icrp.2012.09.001

ICRP PUBLICATION 120: Radiological protection in cardiology.

Purpose To develop diagnostic reference levels (DRLs) and achievable doses (ADs) for the 10 most common adult computed tomographic (CT) examinations in the United States as a function of patient size by using the CT Dose Index Registry. Materials and Methods Data from the 10 most commonly performed adult CT head, neck, and body examinations from 583 facilities were analyzed. For head examinations, the lateral thickness was used as an indicator of patient size; for neck and body examinations, water-equivalent diameter was used. Data from 1 310 727 examinations (analyzed by using SAS 9.3) provided median values, as well as means and 25th and 75th (DRL) percentiles for volume CT dose index (CTDIvol), dose-length product (DLP), and size-specific dose estimate (SSDE). Applicable results were compared with DRLs from eight countries. Results More than 46% of the facilities were community hospitals; 13% were academic facilities. More than 48% were in metropolitan areas, 39% were suburban, and 13% were rural. More than 50% of the facilities performed fewer than 500 examinations per month. The abdomen and pelvis was the most frequently performed examination in the study (45%). For body examinations, DRLs (75th percentile) and ADs (median) for CTDIvol, SSDE, and DLP increased consistently with the patient's size (water-equivalent diameter). The relationships between patient size and DRLs and ADs were not as strong for head and neck examinations. These results agree well with the data from other countries. Conclusion DRLs and ADs as a function of patient size were developed for the 10 most common adult CT examinations performed in the United States. © RSNA, 2017.

https://pubs.rsna.org/doi/pdf/10.1148/radiol.2021211241

U.S. Diagnostic Reference Levels and Achievable Doses for 10 Adult CT Examinations

Objective: To propose Irish CT diagnostic reference levels (DRLs) by collecting radiation doses for the most commonly performed CT examinations. Methods: A pilot study investigated the most frequent CT examinations. 40 CT sites were then asked to complete a survey booklet to allow the recording of CT parameters for each of 9 CT examinations during a 12-week period. Dose data [CT volume index (CTDIvol) and dose–length product (DLP)] on a minimum of 10 average-sized patients in each category were recorded to calculate a mean site CTDIvol and DLP value. The rounded 75th percentile was used to calculate a DRL for each site and the country by compiling all results. Results are compared with international DRL data. Results: Data were collected for 3305 patients. 30 sites responded with data for 34 scanners, representing 54% of the national total. All equipment had multislice capability (2–128 slices). DRLs are proposed using CTDIvol (mGy) and DLP (mGy cm) for CT head (66/58 and 940, respectively), sinuses (16 and 210, respectively), cervical spine (19 and 420, respectively), thorax (9/11 and 390, respectively), high resolution CT (7 and 280, respectively), CT pulmonary angiography (13 and 430, respectively), multiphase abdomen (13 and 1120, respectively), routine abdomen/pelvis (12 and 600, respectively) and trunk examinations (10/12 and 850, respectively). These values are lower than current DRLs and comparable to other international studies. Wide variations in mean doses are noted across sites. Conclusions: Baseline figures for Irish CT DRLs are provided on the most frequently performed CT examinations. The variations in dose between CT departments as well as between identical scanners suggest a large potential for optimisation of examinations.

https://www.birpublications.org/doi/pdf/10.1259/bjr/15839549

Establishment of CT diagnostic reference levels in Ireland.

Purpose To investigate the development of chest radiograph interpretation skill through medical training by measuring both diagnostic accuracy and eye movements during visual search. Materials and Methods An institutional exemption from full ethical review was granted for the study. Five consultant radiologists were deemed the reference expert group, and four radiology registrars, five senior house officers (SHOs), and six interns formed four clinician groups. Participants were shown 30 chest radiographs, 14 of which had a pneumothorax, and were asked to give their level of confidence as to whether a pneumothorax was present. Receiver operating characteristic (ROC) curve analysis was carried out on diagnostic decisions. Eye movements were recorded with a Tobii TX300 (Tobii Technology, Stockholm, Sweden) eye tracker. Four eye-tracking metrics were analyzed. Variables were compared to identify any differences between groups. All data were compared by using the Friedman nonparametric method. Results The average area under the ROC curve for the groups increased with experience (0.947 for consultants, 0.792 for registrars, 0.693 for SHOs, and 0.659 for interns; P = .009). A significant difference in diagnostic accuracy was found between consultants and registrars (P = .046). All four eye-tracking metrics decreased with experience, and there were significant differences between registrars and SHOs. Total reading time decreased with experience; it was significantly lower for registrars compared with SHOs (P = .046) and for SHOs compared with interns (P = .025). Conclusion Chest radiograph interpretation skill increased with experience, both in terms of diagnostic accuracy and visual search. The observed level of experience at which there was a significant difference was higher for diagnostic accuracy than for eye-tracking metrics. (©) RSNA, 2016 Online supplemental material is available for this article.

The Development of Expertise in Radiology: In Chest Radiograph Interpretation, "Expert" Search Pattern May Predate "Expert" Levels of Diagnostic Accuracy for Pneumothorax Identification.

https://www.radiographyonline.com/article/S1078-8174(09)00096-0/pdf

Image quality assessment tools for optimization of CT images

Flexible Image Evaluation: iPad versus Secondary-class Monitors for Review of MR Spinal Emergency Cases, A Comparative Study

https://www.radiographyonline.com/article/S1078-8174(15)00119-4/pdf

Louise Rainford

Papers

Establishment of CT diagnostic reference levels in Ireland.

The Development of Expertise in Radiology: In Chest Radiograph Interpretation, "Expert" Search Pattern May Predate "Expert" Levels of Diagnostic Accuracy for Pneumothorax Identification.

Image quality assessment tools for optimization of CT images

Flexible Image Evaluation: iPad versus Secondary-class Monitors for Review of MR Spinal Emergency Cases, A Comparative Study

A picture of radiography education across Europe