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Submitted by Cari BorrĂ¡s, Radiological Physics and Health Services Consultant
   Commenting as an individual
Document Radiological Protection in Fluoroscopically Guided Procedures Performed outside the Imaging Department

General Comments


The document is a comprehensive review of radiation doses associated with medical imaging procedures usually performed outside the radiology department.  It contains information rarely presented in such a systematic way.  The ICRP is to be congratulated for its preparation.


However, it is not clear who the target audience is.  Is it intended for the physicians who perform the studies or the interventions?  For radiation protection specialists and medical physicists who may be unfamiliar with the medical aspects?  Lines 952-953 even have a recommendation for manufacturers…  Should the intended audience be the physicians, the effort to make the document didactic is hopeless.  It is impossible to teach radiological physics in a few paragraphs.  Without any prior knowledge of imaging physics, many sections of Chapter 3 will be incomprehensible, especially those regarding patient protection.  It would be better to just state what are the factors that influence dose and not to try to explain why or how.  Often the explanations are too simplistic and border on inaccuracies, such as the statements made in Lines 691-693 and 694-696 which say that doses can be reduced by a factor from 2 to 20.  These are arbitrary numbers and have no foundation.  Why 20?  Does it seem a “good” reduction factor?  The extent and depth of Chapter 3 should be re-considered and adjusted to the target audience.


I also think it would be better to title the document “Radiological protection in fluoroscopically-guided procedures performed outside the medical imaging department”, as imaging department is not a globally-recognized term involving medical procedures.


Finally, some statements in the first three chapters need language editing, as they are not clear as written. 



Specific comments

Lines 304 – 306


Table 1.1 lists some procedures which are not addressed in Chapter 4.  For example, embolization is listed under the Specialties: Radiology/Obstetrics & Gynecology, but a very common technique such as uterine artery embolization used nowadays often to treat fibroids instead of undergoing a hysterectomy is not contemplated.


Line 357

In the United States the term anaesthetists is not used (or when it is used it is a synonym of anesthesiologists); the medical practitioners who deal with pain management are usually doctors of osteopathy.


Line 521

Add “or deterministic effects” after “tissue reactions”, since both terms are used indiscriminately in the document.


Line 716


Change “optimization of the examination” to  “optimization of the protection”.


Lines 785-787


Rephrase last sentence for greater clarity.


Lines 909-1027

This is a very good section which can stay as is except for lines 911-918 that try to explain –unsuccessfully– what effective energy is and its relationship with tube potential.  It is not helpful; it should be reworded just indicating the effectiveness of shielding vs tube potential.


Line 1268


What does it mean: “conventional urography indicted significant higher effective dose”?  Reword.


Lines 1759-1785


Add appropriate paragraphs for uterine artery embolization


Line 2028


Add at the end of the sentence “or cannot have it”


Line 2097


The ALARA terminology regarding patient protection is inappropriate.  Protection optimization for medical exposures implies managing “patient dose to be commensurate with the medical purpose” (ICRP 13, 2007), not to reduce dose.


Lines 2398-2442

Should the reduction in IQ and its associated threshold dose be included?


Lines 2437-2438

Surely there are other professionals “experienced in dosimetry” who can estimate fetal dose.


Lines 2585-2586


To say “it is inappropriate to use effective dose to quantify patient dose levels for paediatric and neonatal imaging” is accurate.  But the statement is not helpful, as it does not say what dosimetric term should be used instead.  Furthermore, as Annex A so brilliantly explains, effective dose is not an adequate parameter for medical exposure…  Perhaps organ dose should be more used throughout the document…


Line 2933


The formula is wrong.  It should be: Ka,e = Ka,i  B