Journal of Radiation Research and Applied Sciences 10 (2017) 183e187

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Journal of Radiation Research and Applied Sciences

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Assessment of patients X-ray doses at three government hospitals in

Duhok city lacking requirements of effective quality control
Haval Y. Yacoob Assistant Prof of Radiation Biophysics a, *,
Hariwan A. Mohammed Assistant Physics b
a
Department of Physics, College of Science, University of Duhok, Iraq
b
College of Medicine, University of Duhok, Kurdistan region, Iraq

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The research presented in this article aimed at evaluating patient doses including entrance
Received 23 December 2016 surface dose (ESD) and effective dose (E) in government hospitals that lack the requirements of quality
Received in revised form control standards.
23 March 2017
Materials and methods: Three major government hospitals with 409 patients in Duhok were involved in
Accepted 11 April 2017
Available online 19 April 2017
the study. The X-ray diagnostics included five routine radiographic examinations. ESD was determined
indirectly by measuring the entrance surface air kerma with a solid state dosimeter. E was calculated
from the tissue weighting factor and the equivalent dose.
Keywords:
Entrance surface dose
Results and conclusion: s: Significant variations between exposure factors recorded in this study and
Effective dose those recommended in the context of quality criteria and standards were shown. The results have also
Quality control shown that about twenty percent of the patient doses (ESD and E) were equal or below the recom-
CALDose eX software mended values of the diagnostic reference levels (DRLs). For abdomen, pelvis and skull examinations, the
ESD values were slightly above the diagnostic reference levels. For chest and cervical the ESD values were
much higher than diagnostic reference levels. These values were more reasonable only in one hospital.
High ESD values can be attributed to the slightly higher tube voltages and lower mAs values that were
used. The high patient dose values suggest that any adequate change of the exposure parameters that
aims at the reduction of dose must be done without compromising the image quality. This study rec-
ommends a quick action toward implementing a quality control program and employing special staff of
medical physicists in the evaluated hospitals.
© 2017 The Egyptian Society of Radiation Sciences and Applications. Production and hosting by Elsevier
B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

1. Introduction increased investigation volume and unnecessary investigations.

Radiology has earned a vital place in modern medicine where it
has become one of the most powerful and indispensable diagnostic
tools (Linton, 1995). It has been estimated that about 30%e50% of
critical medical decisions are based on x-ray examinations
(Tavakoli, SeilanianToosi, & Saadatjou, 2003). For instance, in a
questionnaire radiologist members of the Norwegian Medical As-
sociation were asked to rate potential causes (fifteen items) of
* Corresponding author. Zakho Street 38, P.O Box 78, 1006 AJ Duhok, Kurdistan
Region, Iraq.
E-mail address: yacoobaldosky@uod.ac (H.Y. Yacoob).
Peer review under responsibility of The Egyptian Society of Radiation Sciences
and Applications.
The results showed that the highest rated causes of increasing the
use of radiological investigations were the new radiological tech-
nology, people demands, clinicians’ intolerance for uncertainty,
expanded clinical indications, and availability (Lysdahl & Hofmann,
2009). This prevalence was accompanied with a quality control
(QC) program which ensures a clear image as well as a small dose to
the patient. Effective optimization in medical exposures means
maintaining the radiation dose as low as reasonably achievable and
ensuring that the image quality is sufficient for diagnostic pur-
poses. This optimization could be controlled by a QC program.
Without such a program the consequences may be regrettable.
Unfortunately, nowadays some government and private hospitals
and local health centers ignore the regulations of QC. This igno-
rance is always justified by the availability of new digital X-ray
machines and/or non-availability of inspection devices and

http://dx.doi.org/10.1016/j.jrras.2017.04.005
1687-8507/© 2017 The Egyptian Society of Radiation Sciences and Applications. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
184 H.Y. Yacoob, H.A. Mohammed / Journal of Radiation Research and Applied Sciences 10 (2017) 183e187

specialist staff. Hence, the standards and the preparing of the
  

specialist staff were not taken into account. mGy 100 2
ESD ¼ BSF  Tube Output   mAs (1)
Initial results of a multinational research study on x-ray QC and mAs FSD
patient dose conducted by the International Atomic Energy Agency
where Tube Output is the beam output in mGy/mAs measured
(IAEA) revealed that up to 50% of x-ray exams performed in less
from the X-ray tube at different kvp settings at distance of 1 m
developed countries are of substandard quality (Keen, 2008). Many
divided by mAs which is the product of the tube current (mA) and
patients in these countries are being exposed to unnecessary ra-
the exposure time in seconds. The focus-to-skin distance (FSD/cm)
diation doses due to the need to repeat procedures (World Health
was calculated from the Focus Film Distance (FFD/cm) for all pro-
Organization. 2008). A study done by al. (Korir et 2007) revealed
jections by subtracting the standard patient thickness for each
that radiation doses from non-calibrated x-ray equipment excee-
projection. The patient thickness of 20 cm for all examinations was
ded the International Atomic Energy Agency guidance levels by a
used (Kim et al., 2007). The backscatter factor values (BSF) of 1.25
factor of one to five. Meanwhile, a patient dose reduction range of
was used for skull and cervical, 1.3 was used for chest and 1.4 was
31%e77% without compromising good image quality was achieved
used for abdomen and pelvic examinations (Martin, 2011).
through a quantitative QC assessment of processes involved in
For the digital Siemens, ESD was recorded directly when the
producing radiographs (Korir, Wambani et al., 2010). Likewise, the
tube current exposure time (mAs) value governed by the automatic
lack of a QC program in Tanzania revealed poor image quality and/
exposure control unit is displayed. Whereas, the DR x-ray equip-
or higher doses to patients (Ngoye et al., 2015).
ment provides the user with an exposure index for each clinical
Duhok city which is located in the north of the Kurdistan region
image, which is a calibrated measure of the exposure incident on
of Iraq has 1,300,000 inhabitants. The prevailing X-ray investigation
the detector (AAPM REPORT NO. 116). The risk in medical imaging is
rate was 1855 per 10,000 enrollees per year before 2014. In October
quantified using effective dose. However, measurement of effective
2014 More than 860,000 internally displaced people (IDP) moved
dose is rather difficult and time consuming. Therefore, energy
out of their war-torn towns and cities to the Kurdistan region and
imparted and entrance surface dose are obtained then converted to
the majority of them are now living in the Duhok governorate. This
effective dose using the appropriate software CALDose_ X, version
led to an increase in the population by about 25% and raised the rate
5. CALDose_X is a software tool that enables the calculation of the
of conventional x-ray examinations to more than 2000 per 10,000
Entrance surface dose (ESD) based on the output of an X-ray tube as
enrollees per year according to the Ministry of Health, Iraq (Annual
well as organ and tissue absorbed doses and effective doses (E) for
Report, 2010). Despite this, neither patient dose recording nor
posture-specific female (FASH) and a male (MASH) adult phantoms,
image quality control in medical X-ray examinations are considered
Additionally, CALDose_X determines the risks of cancer incidence
in Duhok hospitals. The aim of this study is to evaluate the patient
and cancer mortality for the examination selected by the user
entrance surface (ESD) dose and effective dose (E) in the govern-
(Kramer, Khoury et al., 2008).
ment hospitals that did not follow a quality control (QC) program or
Twenty-four different X-ray examinations with various pro-
protocols. In this study the image quality was not under
jections can be simulated using spectra with 2.0e5.0 mm Al
consideration.
filtration between 60 and 150 kvp and different focus-to-detector
distances (FDD). Once the organs and tissues are determined, the
2. Material and methods
effective dose is calculated using equation (2):
Four X-ray machines in three major and busy government X X X
E¼ wT wR DT R ; E ¼ wT HT (2)
hospitals were included with an average workload of 140 patients
T R T
per week for each equipment. These x-ray machines are Siemens
Germany (automatic exposure control- AEC) and EcoRay Co Ltd where WT is the tissue weighting factor, and HT or WR DT,R is the
Korea at Azadi, and Shimadzu Kyoto-japan at Emergency hospital equivalent dose in a tissue or organ. The unit for the effective dose
while Doban hospital was equipped with EcoRay Co Ltd Korea as is the same as for absorbed dose, J kg1, and it is commonly known
demonstrated in Table 1. as Sievert (Sv). Based on CALDose_X, E is then calculated from the
X-ray exposure parameters such as kvp, mA, mAs, and focus to average of the sex-specific weighted doses by this expression (3),
skin distance (FSD) were recorded directly from the control panel of (Valentin, 2007)
each patient and projection. Entrance Surface Dose (ESD) values
were measured for 409 patients undergoing five routine radio- 1 X WT½HTðFemaleÞ þ HTðMaleÞ
E¼ ½F þ ME ¼ (3)
graphic examinations: chest (AP), abdomen (AP), pelvis (AP), skull 2 2
(AP), and cervical spine (LAT) from the three hospitals.
The entrance surface air kerma was measured using calibrated
dosimeter (DOSIMAX- WELLHOFER DOSIMETRIE) placed on the
patient table (Focus to Skin Distance) at the center of the entrance 3. Results
surface in the X-ray beam field. The ESD was calculated for all x-ray
machines except the digital Siemens through entering parameters Table 2 presents the relative contributions of different X-ray
of X-ray tube output, backscatter factor and focus to skin distance in examinations at the three hospitals. It seems that the majorly
equation (1) (Ofori, Antwi et al., 2012). performed X-ray examinations were cervical spine AP, and Chest PA

Table 1
Features of X-ray machines in the five examinations used for the study.

Hospital Manufacturer/country Type Max kV Max mA Total filtration mm Al Date of installation

Azadi-Duhok Siemens- Germany Digital 150 1000 1.9 May 2011

EcoRay Co Ltd Korea Computed Radiography 150 600 2 March 2015
Emergency-Duhok Shimadzu Kyoto- japan Computed Radiography 150 630 1.5 October 2013
Doban- Sumial EcoRay Co Ltd Korea Computed Radiography 150 600 2 March 2015
 H.Y. Yacoob, H.A. Mohammed / Journal of Radiation Research and Applied Sciences 10 (2017) 183e187 185

Table 2
Summary of patients' characteristics.

Examination Projection Patient age (years) Number of patients Frequency of examination Percentage (%)

Range Median Male Female Total

Abdomen AP 18e63 33 54 36 90 21.22

Chest PA 18e76 36 58 52 110 25.94
Pelvis AP 18e70 34 54 36 90 21.22
Cervical LAT 18e70 36 50 60 110 25.94
Skull AP 18e48 30 14 10 24 5.68
Total 230 194 424

with percentage contributions of 25.94%. However, the lowest
contribution came from skull AP which is about 5.66%. The Sum-
mary of exposure parameters used in different types of radio-
graphic examinations at the three hospitals were showed in Table 3.
The mean values of ESD and E for patients for all examinations
were presented in Table 4. The ESD values at Azadi hospital were
found to be the highest for abdomen with a value of 4.36 mGy and
skull with value of 4.14 mGy. While at Emergency hospital, the
highest ESD was found for pelvis examination with value of
5.09 mGy and the lowest ESD values were recorded in all other
examinations. However, at Doban hospital two highest values of
ESD were detected for chest with value of 3.74 mGy and cervical
with values of 3.54 mGy. Table 4 also shows, the values of the
effective dose (E) for all examinations except skull which were
estimated by CALDose- X software. The derived effective doses
varied from 0.24 mSv for chest and cervical examinations to
2.35 mSv for abdomen. A comparison of the calculated ESDs with
the corresponding values reported by (Seo, Jang et al., 2014), (Kim,
Choi et al., 2007) and (Korir et al., 2007) were shown in Table 5. The
values of ESD were likely to be comparable to the recorded doses in
developed countries for abdomen, pelvis and skull examinations.
Moreover, these values were tended to be higher than that recor-
ded in the previous studies by 5 fold till 15 fold increased for chest
and a 1.5 fold increased for cervical as listed in Table 5.
Concerning the effective doses in the current study, overall the
values were slightly higher than levels that reported by European
Commission except at Azadi hospital for pelvis and at Emergency
hospital for cervical examination which were within the average
doses comparing to that recorded in 10 European countries. These
values indicate 17 fold increased than the typical effective dose for
PA chest digital radiography (Hart, Hillier, & Wall, 2007). While, an
overdose exhibits 5-fold that the typical values for abdomen. A
comparison of the estimated values of E with published data were
shown in Table 6. The comparative data included the European
Commission (European Commission, 2008), (Zenone, Aimonetto
et al., 2012) and (Osei & Darko, 2013). It is worth mentioning that
the last column in Table 6 represents the values of E for those
countries who did not take in account the quality control program
(Muhogora, Ahmed et al., 2008).
4. Discussion
A dramatic increase in the frequencies of the examinations in
diagnostic imaging during the past decade was reported. However,
in most parts of the world, this increment was made under moni-
toring of quality control program to ensure sufficient image quality
with a reasonable amount of patient dose, except for some places,
including Kurdistan region of Iraq. In Kurdistan region, not much
effort has been done for calculating the radiation dose of patients in
diagnostic radiology. As a pilot study, this is the first attempt to
measure the entrance surface doses and estimate the effective dose
for patients enrolled in conventional radiographic examinations at
three government Hospitals. The results of the ESDs for different X-
ray examinations were significantly greater than those recorded in
other countries especially at Doban hospital for both chest and
cervical examinations. Although the digital X-ray system was used
at Azadi hospital but it was not shown any reduction in patient
dose. Nowadays, the DR system is preferred to use by of health
centers because of the existence of the automatic exposure device
feature that intended to take some of the human errors out of
through exposure factors selection. But sometimes, this feature
may lead to disaster, overriding a detrimental dose effect to the
patient. This inconsistency may be due to the staff who had not
been well trained in the use of automatic exposure devices there-
fore defaulted to the original methods of manual selection of
exposure factors which is well agreement with previous study
(Ofori et al., 2012). The DR system was consistently being incor-
rectly used or was frequently exceeded normal limits by the radi-
ographers as illustrated from the results. The radiographer get used
to set low tube voltage, which in turns the unit automatically set at

Table 3
Summary of examination technique parameters from conventional radiograph examinations.

Examination Projection Hospital

Azadi - Duhok Emergency- Duhok Doban- Sumial

Tube voltagea kV mAsa FFD Tube voltagea kV mAsa FFD Tube voltagea kV mAsa FFD
(cm) (cm) (cm)

Abdomen AP 83 ± 9.60 (67 16 ± 2.67 (8.96-24) 97 82.5 ± 4.41 (75 28 ± 4.01 (20 115 74 ± 3.43 (72 20.8 ± 2.55 (17.6- 80
e103) e92) e36) e80) 24)
Chest PA 60 ± 10.37 (60 23.96 ± 17.72 (9.04- 160 80 ± 4.46 (70 12.5 ± 1.28 (9 120 70.5 ± 3.04 (66 22.4 ± 3.34 (16- 95
e120) 92.7) e88) e14) e79) 28.6)
Pelvic AP 80 ± 9.6 (60e98) 14.65 ± 2.41 (7.5-18.7) 97 80 ± 4.38 (70 25 ± 3.26 (18 90 72.5 ± 3.16 (70 17.6 ± 3.43 (16- 80
e85) e32) e80) 25.6)
Cervical LAT 70 ± 4.69 (55e75) 17.79 ± 14.57 (2.49- 160 73 ± 4.37 (65 10 ± 1.72 (8e14) 120 70 ± 2.09 (65 20.8 ± 3.6 (12.8- 95
59.13) e84) e74) 25.6)
Skull AP 80 ± 2.1 (80e85) 13 ± 2.01 (16e11.2) 80 64.5 ± 2.98 (58 6.3 ± 1 (7.1e3.6) 85 70 ± 1.78 (68 12.2 ± 2.89 (16 80
e67) e72) e9.6)
a
The range from minimum to maximum of individual examination is given in brackets.
186 H.Y. Yacoob, H.A. Mohammed / Journal of Radiation Research and Applied Sciences 10 (2017) 183e187

Table 4
Entrance surface dose (ESD) calculated by indirect method and effective dose (E) estimated simultaneously by software for all types of radiographic examinations at three
hospitals.

Examination Hospital

Azadi- Duhok Emergency- Duhok Doban- Sumial

ESD (mGy) Effective dose E (mSv) ESD (mGy) Effective dose E (mSv) ESD (mGy) Effective dose E (mSv)

Abdomen AP 4.36 1.62 2.09 2.35 3.97 1.52

Chest PA 1.43 0.45 0.79 0.24 3.74 0.42
Pelvis AP 4.71 0.83 5.09 1.23 4.78 0.93
Cervical LAT 1.45 0.37 0.47 0.24 3.54 0.35
Skull AP 4.14 - 0.63 - 2.54 -

Table 5
Comparison of median values of ESDs per examination and median± SD for exposure conditions (kvp and mAs) of this study and those reported by references [12, 13 and 4].

Examination Parameters This study Ref-Seo et al., 2014 Ref-Kim et al., 2007 Ref-Korir et al., 2007

Azadi- Duhok Emergency- Duhok Doban - Sumial

Abdomen AP Kvp 83 ± 9.60 82.5 ± 4.41 74 ± 3.43 76 74 72

mAs 16 ± 2.67 28 ± 4.01 20.8 ± 2.55 42 33 45
FFD (cm) 97 115 80 101 101 e
ESD (mGy) 4.36 2.09 3.97 2.46 2.33 9.07
Chest PA Kvp 60 ± 10.37 80 ± 4.46 70.5 ± 3.04 100 106 78
mAs 23.96 ± 17.72 12.5 ± 1.28 22.4 ± 3.34 12 9 32
FFD (cm) 160 120 95 178 178 e
ESD (mGy) 1.43 0.79 3.74 0.37 0.21 1.85
Pelvis AP Kvp 80 ± 9.6 80 ± 4.38 72.5 ± 3.16 75 72 72
mAs 14.65 ± 2.41 25 ± 3.26 17.6 ± 3.43 42 31 40
FFD (cm) 97 90 80 101 101 e
ESD (mGy) 4.71 5.09 4.78 2.34 2.4 9.02
Cervical LAT Kvp 70 ± 4.69 73 ± 4.37 70 ± 2.09 74 74 66
mAs 17.79 ± 14.57 10 ± 1.72 20.8 ± 3.6 29 25 32
FFD (cm) 160 120 95 178 178 e
ESD (mGy) 1.45 0.47 3.54 1.21 0.48 3.89
Skull AP Kvp 80 ± 2.1 64.5 ± 2.98 70 ± 1.78 74 72 81
mAs 13 ± 2.01 6.3 ± 1 12.2 ± 2.89 34 28 45
FFD (cm) 80 85 80 100 101 e
ESD (mGy) 4.14 0.63 2.54 2.08 2.04 14.16

Table 6
Comparison of estimated mean effective dose for all examinations and projections of this study and those reported by references (EC-2008, Zenone et al., 2012, Osei and Darko,
2013 and Muhogora et al., 2008).

Examenation Effective dose E (mSv)

This study Other studies

Azadi- Duhok Emergency- Duhok Doban- Sumial Ref-EC-2008 Ref-Zenone et al., 2012 Ref-Osei & Darko, 2013 Ref-Muhogora et al., 2008

Abdomen AP 1.62 2.35 1.52 1.5 0.58 0.14 1.232a

Chest PA 0.45 0.24 0.42 0.1 0.17 0.0204 0.094b
Pelvis AP 0.83 1.23 0.93 0.9 0.88 0.16 1,120c
Cervical LAT 0.37 0.24 0.35 0.27 0.29 0.0025 e

high mAs that lead to high patient surface doses. This is mainly
reason to the slightly high doses for chest examinations. While, the
short distance from tube focus to film (FFD) in cervical might be the
main reason behind this high dose. However, it cannot overlook the
lack of quality control as a key factor behind the increase in the dose
to the patient. Largely, the absence or ineffectiveness of the QC
program at the hospitals interpreted the high values of ESD. This
probably due to the shortage of medical physicist staff in the
radiology department at the hospitals. The same explanation for
such results was adopted by (Korir et al., 2007). Concerning the
digital unit, the elevation in values of ESD might be due to the fact
that the implementation of digital radiography techniques entails
increasing patient doses in order to improve the image quality as it
reported previously by (ICRP, 2004). The same case was noted for
abdomen, pelvis and skull using CR X-ray units. The ESDs were
slightly higher than those reported in previous studies.
In addition, these values were remarkable difference amongst
the three hospitals for the same projection. Nevertheless, the
lowest ESD variation was observed in pelvis. This dissimilarity may
be due to various physical conditions of exposure (kvp, mAs and
FFD), human fitness, and, importantly, the status of implementa-
tion of radiation protection standards which vary from one hospital
to another. Moreover, the different kinds of X-ray machines (ie CR
and DR) that used at the hospitals may also interpret the significant
differences in ESD values. Data reported in Table 6 shows that the
results of the effective doses were not better off than ESD. This is
very logical, because the work has been done in an environment
that the radiation protection rules were not considered. The
effective dose values of all examinations were higher than those
reported in the previous studies. Generally speaking, the alterations
in the exposure parameters such as kvp and mAs may be explained
all these elevation in both ESD and E. The values of kvp were more
 H.Y. Yacoob, H.A. Mohammed / Journal of Radiation Research and Applied Sciences 10 (2017) 183e187
or less than those used by the previous studies, while mAs values
were about half value of that used in the previous studies. Modi-
fying mAs values could be possible, but this may require a careful
consideration to avoid high doses to the patient as well as a sig-
nificant degradation of image quality. Moreover, the estimated
effective dose in this study were higher even than those studies
which were not controlled by quality program. It could be
concluded that the patient dose levels associated with an effective
program of quality control and not with just its presence. Finally, in
spite of the notable increase in the effective doses, it should not
create radiophobia among the public but, quick actions should be
taken.
5. Conclusions
5.1. This study concluded that:
1 The patient doses were obtained are tended to be more than
DRLs for most common diagnostic radiographic examinations
2 effective dose values estimated in this study were higher than
the values reported in the previous studies
3 The results suggest the necessity for applying of QC program in
any medical imaging procedure to optimize the doses delivered
to patients for the given purpose
4 A well-trained staff of medical Physicists must be employed at
the radiology department to implement an optimized QC pro-
gram for ensuring low dose patient as well as high image
quality.
5.2. Limitations of the study
First, the major limitation is, although the total filtration is less
than the minimum total filtration prescribed internationally, it was
not possible to modify these values by the authors. The second
limitation is the different output parameters at each x-ray unit
which probably causes the variation in ESD among the three hos-
pitals. This is due to the fact that the authors were not authorized to
any adjustments required in these hospitals.
Funding
This work was supported by a grant from the College of Medi-
cine, University of Duhok under the Special Account for Research
Grants (Master Program) at the university. The funder had no role
in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Conflicting interest
The authors declare that there is no conflict of interests
regarding the publication of this paper.
Acknowledgements
This study was supported by the College of Medicine, University
of Duhok. The authors of this article would like to express their
gratitude to the staff of radiology departments at (Azadi, Emer-
gency and Doban) hospitals for their support during the period of
187
data collection. Great thanks are also due to Professor Martin Fie-
bich (University of Applied Sciences, Giessen, Germany) for
providing the necessary equipment for the conduction of this study.
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