Evaluating Radiation Exposure for Patients During Pelvic X-ray Exams in Dhaka Metropolitan Area, Bangladesh

Objectives: This study aims to comprehensively assess Entrance Skin Dose (ESD) variability across diverse age groups in various diagnostic areas such as RGU, MCU, Fistulogram, Sinogram, and radiography of SI Joint, Coccyx, and Hip Joint in the pelvic region. The investigation delves into elucidating the range and mean ESD values while identifying factors contributing to fluctuations, enabling precise understanding and strategies for managing radiation exposure in pelvic X-ray examinations.

Method & Materials: A qualitative research study took place in one of the hospitals in Dhaka City, Bangladesh, with participation from 138 patients. Radiation protocols in Dhaka City used consistent methods for diverse ages during X-ray examinations. Detailed data on Entrance Skin Dose for various exams like pelvic, SI joint, and fistulogram were meticulously collected and analyzed, aiding in understanding demographic-specific radiation variations.

Result: The diverse dataset of Entrance Skin Dose (ESD) measurements across varying age groups in pelvic X-ray examinations reveals a range of ESD values, highlighting fluctuations within specific ages. The overall mean ESD averages approximately 1.87, indicating a moderate consistency in radiation exposure across ages. Notably, certain age brackets, such as patients aged 24 and those in their early teens, exhibit higher ESD values, while others, like ages 15 and 72–76, showcase notable variability. These findings underscore the need for tailored imaging protocols and monitoring strategies in clinical practice.

Conclusion: In conclusion, this comprehensive examination underscores the intricate relationship between age, diagnostic areas, and the variability of ESD values, highlighting the need for nuanced approaches in healthcare management to ensure optimized patient outcomes while minimizing radiation exposure risks.

Introduction

Ionizing radiation, particularly X-rays, is extensively utilized across hospitals and clinics for diagnostic imaging needs, especially when precise disease identification is crucial in everyday medical practice. X-ray examination stands as a vital and potent diagnostic tool in modern healthcare. Utilizing advanced diagnostic machinery, these examinations generate detailed images of patients, providing practitioners with crucial information of sufficient quality to facilitate effective diagnosis and treatment across various medical conditions during examinations [1]–[3].

Roughly 30–50% of crucial medical decisions hinge on the findings from X-ray examinations, highlighting their immense value in serving humanity. However, the growing use of X-ray radiation in radio-diagnostic procedures carries potential health risks for both patients and medical staff due to its ionizing nature [4]. There has been significant global focus on monitoring radiation release and establishing limits on public exposure doses. This initiative aims to safeguard individuals, including patients and personnel, from potential radiation hazards [5].

Safeguarding the reproductive organs of both children and adults is crucial during pelvic diagnostic imaging, as studies indicate that X-rays might directly harm these organs, potentially leading to mutations [6]. It’s essential to protect the reproductive organs of both children and adults during pelvic diagnostic imaging because research suggests that X-rays could directly damage these organs, potentially causing mutations [7].

Due to the potential risks linked to ionizing radiation exposure, it’s crucial not only to offer protection for the reproductive organs but also to assess patient doses and minimize them whenever feasible [8].

ESD (Entrance Skin Dose) is highly recommended as the most suitable dosimetry measurement for basic X-ray procedures as it fulfils three fundamental criteria outlined by the International Atomic Energy Agency (IAEA): ease of measurement, direct applicability for patient assessment during the examination, and accurate representation of the patient’s received dose. The Commission of the European Communities (CEC) also advocates for ESD in their guidelines concerning quality standards for prevalent radiographic images.

A study of the literature indicates that pelvic region X-rays rank as the third most common X-ray examination in the United Kingdom, with an annual frequency of 39 per 1,000 people, following the highest dose-contributing X-ray examinations. Thus, implementing measures to protect patients’ reproductive organs from unnecessary radiation exposure during pelvic X-rays is crucial. Many studies aimed to measure patient doses during these examinations, while others focused on optimizing radiographic practices to reduce patient radiation exposure. From a radiation protection standpoint, the effective dose is used to compare the stochastic risk in cases where the received dose varies, yet remains low enough to prevent deterministic effects of radiation. Stochastic risks can potentially induce genetic effects. This article aims to investigate the entrance surface dose for patients undergoing pelvic region X-ray examinations at selected diagnostic hospitals in Dhaka.

Objectives

Demographic Analysis

• Compare gender proportions.
• Highlight specific symptoms reported across age groups and genders.
• Emphasize the diversity of reported symptoms and their prevalence within different demographics.

ESD Analysis Across Ages

• Varying ranges within age groups.
• Consistent mean values across several diagnostic areas.
• Highlight fluctuations and ranges among specific ages within datasets.

Radiation Exposure in Various Exams

• RGU, MCU, SI Joint, Coccyx, Fistulogram, Sinogram, Hip Joint.
• Note variations within age groups, highlighting specific ages with notable variability.

Consistency and Variability in ESD

• Emphasize the overall mean ESD across different age groups.
• Discuss the consistency in mean values but note the significant fluctuations within specific age brackets.

Factors Affecting ESD Variation

• Environmental conditions, equipment discrepancies, and work practices.
• Proposed strategies for ESD reduction
• Targeted training, standardized procedures, consistent monitoring, and calibration.

Methodology

Study Type/Design: The study is a cross-sectional type of study design.

Study Place: The study was conducted from one selected diagnostic hospital in Dhaka city.

Study Population: Patient Radiation dose assessment was conducted on 138 patients 04–76 years old, who underwent pelvic region examinations during the study population.

Sample Size: 138.

Sampling Technique: Simple Random Sampling.

Research Instruments and Research Tools (X-ray Equipment): In this study, we use a 1000 mA X-ray machine in a selected diagnostic hospital. Data was collected from 138 patients who underwent pelvic region X-ray examinations at a selected diagnostic hospital, involving two radiographers and two radiographic technicians in this study. The X-ray exposure parameters like tube potential (kVp), tube current-time product (mAs), for each patient and projection were directly recorded from the control panel. FFD (Focus-Film Distance) were recorded from irradiation geometry as shown in Fig. 1.

Fig. 1. Irradiation geometry and dose quantities used in this work [9].

The Focus-Skin Distance (FSD) was determined in centimetres across 138 patients who underwent diverse X-ray examinations with varying projections. Patient dosimetry involves operational parameters like high voltage (kilovolt, kVp), current intensity (milli-amperage, mAs), focus-skin distance (FSD), filtration, and thickness. Determining the patient dose typically involves specifying the entrance surface dose (ESD) for individuals exposed to diagnostic X-rays.

ESD values for patients receiving different routine X-ray tests at the hospital were determined through mathematical computations based on recorded output information, encompassing parameters like kVp, mAs, and FSD, utilizing a distinct formula. This formula [10] is given as follows: ESD(mGy)=c(KVpFSD)2(mAsmm.Al)

Result and Discussion

In Table I, the comparison between genders in this dataset showcases a slightly higher proportion of females (57%) compared to males (43%). While there are fewer males overall, it’s important to note that both genders contribute significantly to the total population studied.

Table I. Show the Gender Distribution Frequency and Percentage

Gender	Frequency	Percentage %
Male	60	43%
Female	78	57%

In Table II, age range of 01–10, there were two male patients reporting symptoms like burning micturition, pain, and obstructive voiding. No female patients within this age group reported symptoms.

Table II. Distribution of Patient’s Symptoms

Age range	Male	Symptoms	Female	Symptoms
01–10	02	Burning micturition (2)	00	-
		Pain (2)
		Obstructive voiding (2)
11–20	03	BM (1)	06	Burning micturition (1)
		Perineal region fistula (1)	Urethral stricture (1)
		Trauma (1)	Trauma (2)
		Sitting pain (1)	Sitting pain (4)
21–30	15	Low back pain (4)	20	Sitting pain (3)
		Pain (4)	LBP (14)
		Osteoarthritis (1)	Sacralization (1)
		Sacralization (2)	Trauma (3)
		Vit-D deficiency (1)	Osteoarthritis (1)
31–40	10	LBP (7)	16	LBP (8)
		Trauma (3)	Pain (2)
		Pain (4)	Trauma (6)
41–50	11	Trauma (4)	14	LBP (12)
		LBP (6)	Pain (1)
		Pain (1)	Trauma (1)
		Vit-D deficiency (1)
51–60	10	Pain (7)	06	Trauma (1)
		BM (3)	LBP (1)
		OV (1)	Post operative pain (1)
		Pus (2)	Urinary infection (2)
61–70	08	Pain (6)	10	Pain (2)
		LBP (3)	POP (2)
		Joint fusion (2)	Fusion (1)
		Abscess (2)	Sitting pain (3)
			Trauma (1)
71–80	01	Trauma (1)	06	–

For ages 11–20, three male patients reported symptoms including bowel movement issues, perineal region fistula, trauma, and sitting pain. Six female patients reported symptoms like burning micturition, urethral stricture, trauma, and sitting pain.

The subsequent age groups showcase varying symptoms reported by both males and females. For instance, in the 21–30 age range, males reported symptoms like low back pain, osteoarthritis, and sacralization, while females reported symptoms including sitting pain, low back pain, trauma, and osteoarthritis. As the age groups progress, the reported symptoms vary, encompassing a range of conditions from back pain to trauma and infections. The number of patients reporting these symptoms also fluctuates across different age brackets and between genders.

This data reflects a diverse array of symptoms reported within different age groups and genders. Analyzing these trends aids in understanding the prevalence of various conditions across different demographics, which can be crucial for healthcare practitioners in diagnosing, treating, and managing these symptoms effectively.

The causes of lower back pain include diabetes, higher BMI, reduced physical activity, prolonged sitting for about 6 hours per day, insufficient rest, ergonomic aspects of chairs like inadequate back support, and continual vibrating sitting positions, particularly for drivers [11], [12].

For the 21–30 age range, ESD values in the pelvic area vary between 1.621 and 2.417 for females and between 1.774 and 2.415 for males, resulting in an overall mean ESD of approximately 1.995 (Table III).

Table III. ESD for Pelvic Area

Age range	Diagnostic area	Female	Mele	Overall mean
21–30	Pelvic area	8	3	1.995299
31–40		16	10	1.7737689
41–50		14	11	2.030242
51–60		2	0	1.384567

In the subsequent age groups (31–40, 41–50, and 51–60), diverse ESD values are observed across diagnostic areas for both genders. The ESD range in different diagnostic areas reflects variability, with some areas showing higher ESD values compared to others within the same age range.

Comparing the ESD values, it’s apparent that there’s diversity within the dataset (Fig. 2). For instance, patients aged 60 have varying ESD values, ranging from 1.48 to 2.8416. Diverse health conditions, medication intake, and individual physiological differences among 60-year-old patients contribute to varying ESD values within the same age group. Similarly, among patients in their early teens (ages 11–13), the ESD values hover around 2.02 to 2.10. Meanwhile, patients aged 4 and 5 both have ESD values exceeding 2.14. The mean value calculated for this dataset appears to be around 2.07.

Fig. 2. ESD for RGU and MCU. Mean value 2.07162054.

This dataset captures the Entrance Skin Dose (ESD) measurements corresponding to different ages, along with the overall mean ESD, which seems to be approximately 1.87 (Fig. 3). Examining the ESD values reveals a range from 1.26 to 2.53 among various ages, with the majority falling between 1.50 and 2.53.

Fig. 3. ESD for SI joint modified fergusion view. Mean value1.87037.

Specifically, patients aged 22 exhibit ESD values between 1.61 and 2.10, while those aged 23 have values spanning 1.26 to 2.13. The highest ESD values are recorded for patients at the age of 70, varying between 1.74 and 2.53, showcasing variability within this age group.

The overall mean ESD of approximately 1.87 suggests a consistent level of radiation exposure across these different ages. However, it’s essential to note that the ESD values fluctuate significantly among individuals within specific age groups. Overall, the mean ESD is around 1.87, indicating a general consistency, but there are notable fluctuations within specific age groups.

Specifically, patients aged 15 exhibit ESD values ranging from 0.83 to 1.05, while those aged 72 to 76 show values fluctuating between 1.38 and 2.15 (Fig. 4). Notably, patients aged 74 have ESD values of 1.62 and 2.08, showcasing variability within this age group.

Fig. 4. ESD for Coccyx. Mean value 1.663589.

The overall mean ESD of about 1.66 suggests a moderately consistent level of radiation exposure across these ages.

Patients aged 13 show an ESD of 2.27, while individuals aged 54 and 55 exhibit values fluctuating between 2.01 and 2.67 (Fig. 5). The overall mean ESD of about 2.35 suggests a consistent level of radiation exposure across these ages.

Fig. 5. ESD for fistulogram. Mean value 2.351117.

ESD values for ages 55 to 60 range from 1.62 to 2.03, with an overall mean of about 1.92, indicating consistent radiation exposure across this age span (Fig. 6).

Fig. 6. ESD for sinogram. Mean value 1.92024.

This dataset provides Entrance Skin Dose (ESD) measurements across various ages, resulting in an overall mean ESD of approximately 1.76 (Fig. 7). Analyzing the ESD values, there’s a range from 0.41 to 2.33 observed among ages 24 to 70, indicating diverse radiation exposure levels.

Fig. 7. ESD for hip joint. Mean value 1.758419.

The variability in ESD values at the age of 24, ranging from 1.98912 to 1.447454, may be attributed to diverse environmental conditions, equipment discrepancies, and differing work practices. To ensure ESD reduction and enhance accuracy in measurements, it’s essential to implement strategies such as targeted ESD training, standardized procedures, consistent monitoring, calibration, and environmental controls. Patients aged 28 exhibit higher values, between 2.10 and 2.33, and those aged 66 and 67 show values around 1.18 to 2.10. Additionally, patients aged 70 have ESD values around 1.33 to 1.67.

The overall mean ESD of approximately 1.76 implies a moderately consistent level of radiation exposure across these ages.

Conclusion

The analysis of diverse ESD values across multiple age groups and diagnostic areas within pelvic X-ray examinations in Dhaka City reveals intriguing patterns. Variation in symptoms reported among different age brackets and genders underscores the multifaceted nature of healthcare challenges. The dataset exhibits nuanced insights into radiation exposure, evident in the variability of ESD values among distinct age segments. Within this examination, age appears to correlate with varying ESD levels, potentially influenced by individual physiological differences, health conditions, and diagnostic procedures. Notably, some age cohorts, such as individuals aged 60 and those in their early teens, manifest considerable diversity in ESD values, highlighting the complexity of factors contributing to radiation exposure variations within specific age groups.

Moreover, while an overall mean ESD provides a generalized understanding of radiation exposure, it’s imperative to acknowledge the substantial fluctuations within specific age brackets. Factors like health conditions, diagnostic procedures, and individual physiological differences significantly impact ESD values, as evidenced by the wide range of measurements within certain age clusters. Understanding these nuances is crucial for healthcare practitioners in tailoring diagnostic and therapeutic approaches effectively. Implementing strategies to standardize procedures, enhance monitoring, and address environmental factors can contribute to mitigating ESD variations, promoting more consistent radiation exposure levels across different age groups.

The Internal Atomic Energy Agency (IAEA) stipulates an internal Equivalent Dose (ESD) limit of 4 mGy. However, my comprehensive study revealed that across all pelvic region examinations, the recorded ESD consistently remained below 3 mGy. This finding not only demonstrated compliance with stringent safety standards but also showcased the efficiency of the procedures employed in minimizing radiation exposure during these examinations. The consistent maintenance of ESD levels below the IAEA threshold underscores the meticulous attention to safety protocols within the study’s framework. These results not only validate the efficacy of our approach but also emphasize the commitment to ensuring patient welfare by prioritizing radiation safety measures in diagnostic procedures [13].

In conclusion, this comprehensive examination underscores the intricate relationship between age, diagnostic areas, and the variability of ESD values, highlighting the need for nuanced approaches in healthcare management to ensure optimized patient outcomes while minimizing radiation exposure risks [14].