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Submitted by Osimani Celso, International Committee of Italian Radiation Protection Association
   Commenting on behalf of the organisation
Document Radiological Protection in Fluoroscopically Guided Procedures Performed outside the Imaging Department






The International Committee of the Italian Radiation Protection Association (AIRP), also representing the Italian Medical Physics Association (AIFM) and the Italian Medical Radiation Protection Association (AIRM) appreciated the document and agreed with the motivation presented as the basis for this report.  Moreover the attention given to education and training and to the radiation protection culture including the attitude of mind is well received, and a special mention has also to be given in §1.5 for the concern in the propagation of an inadequate culture, as a responsibility of senior medical staff.

This document will be an important basis in the area of procedures performed both outside and inside the imaging department.


Of great importance is the repeated appeal for the real involvement of manufacturers, e.g. in developing systems to indicate patient dose indices with the possibility to produce patient dose reports. Due to the complexity of modern instrumentation it is essential that operators understand and "know their equipment" and this requirement should not be compromised.






- From line 375, in (7) the motivations for giving attention to patient protection are well explained with respect to recent years (patient are undergoing many examination, the types of examination  involve higher dose than in the past). However, we must not forget that, in the past and for any present procedures, the attention on justification and optimization of the procedures, for the optimization of the protection, is always required. This is especially true for patients, in order to reduce excessive dose. This concept of radiation protection of patients is always a must and not only from recent years.


- Lines 55, 231 and 484 - within the description of radiation effects, the suggestion is to use ‘deterministic effects’ rather than ‘deterministic injuries’.


- Chapter 2 is titled ‘Radiation Effects and Protection Principles’ but there is no description of the justification and optimization principles. The only mention about justification and optimization is given in ‘2.3.3. Individual differences in radiosensitivity’ with the sentence: (lines 616-619) ‘The general aspects of radiosensitivity should be taken into account in the process of justification and optimization of fluoroscopically guided procedures…’  Whereas in Chapter 3 entitled ‘Patient and Staff Protection’ the paragraphs (29) and (30) are dedicated to explain Justification and Optimisation respectively. One suggestion could be to title Chapter 2 as  ‘Radiation Effects’ or, if the existing title  remains the same, to include some reference to justification, optimization and if possible a topic about the concept of Reference Levels.  At the same time if ‘3.1 General principles of radiation protection ‘ remains as it is, one suggestion is to move the content of (25), (26), (27) and (28), which refers to the key aspects of protection time, distance and shielding, to just after the content of what is now  (29) and (30) on justification and optimization.


- Line 521 – suggestion to add circulatory diseases to the list of tissue reactions.


- Line 547 – the reference Cucinotta et al., 2001 is reported, but this reference does not appear in the reference list of  § 2.4.


-Line 613 – ‘lung cancer for a woman after an exposure of 0.1 Gy at age 60 is 126 % higher than the values for a man…’ suggestion to indicate ‘…is estimated to be 126 % higher than….’


-Line 615 – ‘lung cancer is 17% higher than…’ suggestion to change in ‘lung cancer is estimated to be 17% higher than…’.


-Lines 1005, 1011 – ‘Miler et al.,’ change in ‘Miller et al.,’


-In § 4.3.1, as a part of Orthopaedic surgery, the mean fluoroscopy times and mean entrance skin doses are reported for 3 commonly performed procedures: 1) intramedullary nailing of petrochanteric fractures, 2) open reduction and internal fixation of malleolar fractures and 3) intramedullary nailing of diaphyseal fractures of the femur.  Tab.4.4. gives typical fluoroscopy times and doses to the patient during orthopaedic procedures.  For the mentioned common procedures 1) and 2) the table reported the same data as in the text (3.2 min, 183 mGy and 1.5 min and 21 mGy respectively), while for the procedure 3) the table reported 3.0 min, 149 mGy and the text reported 6.3 min, 331 mGy. Therefore may be some comments is required on this point.


- Lines 1091, 1092 – ‘Effective radiation protection programmes will involve teamwork of clinical professionals with radiation protection experts’ suggestion to change in ‘….. teamwork of clinical professionals with radiation protection professionals’ just to avoid, in the context of radiation dose management for patients and staff, a fixed  possible correlation with RPE, with respect to the figure of MPE.


-Lines 1918-1921 -  ‘the reported dose-area product values for biliary drainage are in  the range of 51-132 Gy cm2, that, based on appropriate conversion factor from DAP to effective dose, corresponds to an effective dose of 13-33 mSv per procedure (Dauer et al., 2009; Miller et al., 2003a, NCRP, 2009).’  In the table 4.6 it is indicated for the procedure Bile duct drainage a dose-area product of 38-150 Gy cm2 and effective dose 10-38 mSv taking as references: UNSCEAR, 2010, Dauer et al., 2009, Miller et al., 2003a.  The suggestion is that, even if the differences of data reported in the text and the table are not significant for the understanding, it could be useful to consider reporting the same evaluations in the text as in the related table.


-Line 2114 – it is cited the ICRP Publication 77 and indicated as ICRP 1998. In §4.8 reporting the references related to this part, at line 2220 it is indicated: ‘ICRP, 1998. Radiological Protection Policy…..ICRP Publication 77, Ann. ICRP 27 (Supplement).’  But on the ICRP website the recommended reference format for citations of this publication is: ICRP, 1997. Radiological Protection Policy for the Disposal of Radioactive Waste. ICRP Publication 77. Ann. ICRP 27 (S).

That is year 1997.


-Line 2870 – ‘Although gray is not a SI unit, it is used as a unit in practice’, please note that gray and sievert are units of the International System of Units (SI), they are derived unit, as joule is for example.


-Lines 2879, 2880 – ‘..the organ dose modified by a radiation weighting factor’  suggestion to change in  ‘..the organ dose multiplied by a radiation weighting factor’ 


-Line 2916 –change ‘joules per kilogram’ to ‘joule per kilogram’


-Lines from 2927 to 2933 – suggestion to put on right line the formula and moreover to use consistent symbols for the quantities as in the text, e.g. Ki for the incident air kerma, Ke for the entrance surface air kerma, as already used in the IAEA, TSR 457, that is cited in the references.


-Lines 2961, 2962 – the sentence ‘Conversion coefficients to convert air kerma-area product to effective dose for selected procedures are given in Table A.1’ and moreover the caption of Table A.1, do not take into consideration the last column of the table, where the coefficient, expressed in mSv mGy-1, is not referred to conversion coefficient for air kerma-area product but probably for entrance surface dose.


-Lines 2987, 2988 –‘HAP, 2010’ change in ‘HPA, 2010’.and ‘HPA-CRECE-012’  change in ‘HPA-CRCE-012’.