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A study of the distribution of dose across the hands of interventional radiologists and cardiologists

Health Physics, Department of Clinical Physics and Bio-Engineering, West House, Gartnavel Royal Hospital, Glasgow, UK

	Abstract

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The magnitude and distribution of doses across the hands of interventional radiologists and cardiologists have been studied. The aims were to determine the region of highest dose, investigate variations in dose distribution, and propose an effective method for dose monitoring. Doses have been measured using sets of up to 18 thermoluminescent dosemeters (TLDs) for 183 single procedures. Important factors influencing the dose to the hand are the type of procedure, particularly the access route, the X-ray equipment used, and the experience of the operator. Radiologists performing percutaneous procedures received the highest doses, because of the proximity of their hands to the X-ray tube. The majority of procedures involve a combination of twisting and prodding actions, and the relative proportions of each determine the parts of the fingers which receive a higher dose. For most interventional radiology and cardiology procedures the bases of the ring and little fingers receive the highest dose. However, during percutaneous procedures the tips of the middle and ring fingers could receive doses which were 20–30% higher than this. For radiologists and cardiologists with a mixed workload, monitoring using TLD rings located at the base of the little or the ring fingers on either hand should provide a reasonable estimate of dose to the most exposed area. Monitoring is recommended for operators who may receive over 50 mSv to their hands per year, and should be considered for operators carrying out therapeutic procedures involving patient dose–area products over 500 Gy cm² per month.

	Introduction

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There is a potential for staff carrying out interventional procedures in radiology and cardiology departments to receive significant radiation doses to their hands, as they guide and manipulate needles and catheters while viewing with fluoroscopy. The monthly programme of monitoring for finger doses in hospitals in the West of Scotland has recorded doses of tens of mSv for interventional radiologists in some hospitals with annual doses occasionally exceeding 200 mSv. This has required some staff to be designated as classified radiation workers. There is a wide range of doses to the hands of interventional radiologists and cardiologists. Studies at other centres have recorded doses to the hands ranging from less than 0.1 mSv up to 4–5 mSv for individual procedures [1–13] and noted the potential for annual doses to exceed 200 mSv [2, 14–17], so monitoring of the dose to the hands needs to be considered. UK legislation [18] states that the dose limit for the skin of 500 mSv in a calendar year should be applied to the dose averaged over any area of 1 cm² regardless of the area exposed. Since the operator's hands may be close to the source of scattered radiation, there can be a large dose gradient across the hands, so a dosemeter worn at an arbitrary location will not necessarily be representative of that to the most exposed area. Thus in order to comply with the requirements of the legislation, the part of the hand likely to receive the highest dose should be identified and information obtained on the dose distribution, in order that the correct location for wearing a dosemeter can be specified. The studies carried out so far that have involved measurements at more than one location on the hand [19], have not contained sufficient data to allow the most exposed part to be identified. Moreover, since there are many types of procedure involving different manipulations which could create different distributions of dose across the hands, a standard monitoring technique may not be appropriate for all operators.

The purpose of this study was to:

• Evaluate the magnitude and distribution of doses to the hands of operators carrying out interventional procedures in radiology and cardiology in a number of centres.
  
• Determine the regions of the hand receiving the highest doses.
  
• Investigate whether there are significant variations in dose distribution with different types of procedure.
  
• Make recommendations about the most effective methods for routine monitoring of dose to the hands.
  

Routine monitoring of doses to the hands requires a measurement technique which is easy to apply. Thermoluminescent dosemeters (TLDs) are widely used and these can be worn at several different positions on the hands. Standard techniques involve incorporating TLDs into rings that are worn at the bases of fingers, into sheaths which enable dosemeters to be worn near finger tips, or into bands worn around the wrists. However, when a TLD is worn at the finger tip, the touch sensation may be impaired and this can impede the manipulations carried out. The constraints on viable options for the monitoring position have been borne in mind during the study.

	Materials and methods

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Calibration and dose distribution measurements
Doses were measured using LiF: Mg, Ti TLD 100 chips, which were read out using a Harshaw 5500 TLD reader (Harshow, Solon, OH). The TLDs were calibrated against air kerma, measured using a Keithley Triad dosimetry system (Keithley, Cleveland, OH) with a 15 cm³ chamber and a RADCAL 9010 electrometer (Radcal, Monrovia, CA) with a 60 cm³ chamber. Both systems had calibrations which were traceable to a national standard. The calibration exposures were carried out free in air in a beam of 80 kVp X-rays [20]. A conversion coefficient was applied to derive the soft tissue dose (H_p 0.07) [21]. For each procedure, 12–18 TLDs were used, 6–9 on each hand of the primary operator. No other staff members were monitored. The TLDs were sealed in plastic, wiped with a surgical solution and taped in place after the operator had scrubbed up. A surgical glove was then put on over the top. The positions of the TLDs were chosen to assess the dose gradient across and along the length of the hand, on both the dorsum and palmer aspects (Figure 1).

View larger version (78K): [in this window] [in a new window]   Figure 1. Positions of thermoluminescent dosemeters (TLDs) used for monitoring (a) the dorsum and (b) the palmer aspects of the hands. The X marks the position of the TLD that was used as the denominator when deriving ratios for doses to different parts of the hands.

The distribution of scatter air kerma close to the patient, in the positions where the operators' hands might be, was measured using a Radcal 9010 electrometer with a 180 cm³ chamber. This was achieved by irradiating a RANDO phantom in an X-ray field using typical fluoroscopic settings and positions encountered in practice [23]. A 100 mm grid marked on a polythene sheet, suspended in turn horizontally and vertically at the side of the couch, was used to aid positioning of the ionization chamber.

Procedures monitored
Studies for interventional radiology were carried out at five large teaching hospitals and five district general hospitals, with a range of different equipment, protection and operator experience. Cardiology data were collected at a large teaching hospital, with two different interventional units, which were used by cardiologists from other hospitals with a range of experience. All X-ray units studied were of an undercouch geometry. Only procedures routinely undertaken in most interventional departments were included in the study, since the aim was to establish dose distribution, which would be applicable to the majority of radiologists practising in the UK. Cardiologists were only monitored during percutaneous transluminal coronary angioplasties (PTCA), as these were common procedures which were considered to represent a "worst case scenario", involving lengthy screening times and radiographic runs, for several different views. The manipulations carried out in other cardiology procedures were similar to those in PTCA.

In order to establish the likely dose levels that would be encountered, and gain an impression of the general distribution of dose across the hand, a preliminary study was undertaken for 10 complete interventional radiology sessions. The average dose to the hand per session ranged from 0.07 mSv to 3.5 mSv. Doses from sessions, in which therapeutic procedures were performed, were significantly higher than those involving purely diagnostic angiograms. The preliminary study demonstrated that it would be difficult to establish links between dose distributions across the hand and different procedures from measurements made over complete sessions. Therefore, it was decided that the main study should concentrate on measuring dose distributions for individual procedures. During this study, measurements were made on 183 individual interventional radiology and cardiology procedures. For the purpose of analysis, these have been split into four groups (Table 1) based on the access route and the resulting position of the operator, as this appeared to have most influence on the doses recorded. The areas in which the operators hands are typically located for the four groups are shown in Figure 2, along with the typical scatter air kerma distributions derived from the ionization chamber measurements. Results from the preliminary study were not included in the final data analysis.

View larger version (45K): [in this window] [in a new window]   Figure 2. Diagram showing the positions where the hands are located relative to the patient for various points of entry for the different groups of procedures studied, (a) interventional radiology with femoral, internal jugular vein (IJV) and percutaneous access and (b) percutaneous transluminal coronary angiography (PTCA) with radial and femoral access. Contours relate to dose rate distributions measured on one unit and are given in µGy min–1.

	Results

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Magnitude of hand dose
The mean, median and range of all the mean hand doses for every procedure studied within each of the groups are given in Table 2, together with the mean ratio of mean hand dose to DAP. The left hand usually received the highest dose due to the position in which the operator stood, which was linked to the layout of the room. In most cases the dose to the hand furthest from the image intensifier was 40–50% less than to the other hand. The distribution of mean doses for the most exposed hand for all the procedures studied is shown in Figure 3. For a third of the procedures the mean dose was less than 0.02 mSv. The highest doses were recorded during percutaneous procedures and the ratio between the mean dose to the most exposed hand and the DAP for these procedures was significantly higher than for the others. Doses for procedures involving access through the internal jugular vein (IJV) (mainly involving the hepatobiliary region), which were primarily transjugular intrahepatic portosystemic shunt (TIPS), were only slightly lower than for the percutaneous group and indeed the doses to the other hand were only 10–20% less than those to the most exposed hand and the highest for any procedure. Here the DAPs were large, but the ratio between the hand dose and the DAP was almost an order of magnitude less than for the percutaneous procedures. The doses for stents and angioplasties were highest among the group using femoral access. Ratios of hand doses to DAPs for stents and angioplasties were similar to those for IJV, but the ratios for angiograms and embolisations were much lower because a significant proportion of the DAP was due to imaging runs, during which the operator could either keep their hands away from the area under investigation or move away from the couch completely.

View larger version (21K): [in this window] [in a new window]   Figure 3. Numbers of procedures where the mean doses to the most exposed hand lay in different dose ranges for each category of procedure. In 62 procedures the mean doses to the hand were below 0.02 mSv and these have been excluded (percutaneous transluminal coronary angiography (PTCA) 2, femoral 36, internal jugular vein (IJV) 12, percutaneous 12).

The distribution of dose across the hand
The distributions of dose across the hands of interventional radiologists carrying out procedures via femoral and IJV access routes normalized with respect to the dose to the back of the hand are shown in Figure 4. In all procedures the dorsum and palmer aspects of the body of the hand below the knuckles received similar doses, but the dorsum aspect of the fingers was exposed to a greater dose and the discussion briefly concentrates on this. The doses to the backs of the hands increase from the wrist to the bases of the fingers, and also across the hands rising from the base of the index finger to the base of the little finger. The doses to the tips of the fingers for femoral procedures were either similar to or slightly lower than those to the bases of the fingers. The most exposed parts of the hand for femoral procedures were the ring and little fingers with the base of the little finger receiving the highest dose. During IJV procedures, the dorsum aspect of the hand again received a higher exposure than the palmer side (Figure 4). For IJV procedures, the dose increased all the way from the wrist to the tip of the middle finger for both the palmer and dorsum aspects of the hand. Transversely, the dose across the bases of the fingers again rose from the index finger to the little, while across the tips, doses decreased from the middle finger towards the little finger. The bases of the ring and little fingers and the tip of the middle finger received the highest doses for IJV procedures. The distribution of dose for percutaneous procedures was slightly different (Figure 5). Here the palmer side for the body of the hand received a higher dose than the back, but the dorsum aspect of the fingers received the highest dose. The dose increased continuously from the wrist to the tips of the fingers. There was a small gradient of dose across the base of the fingers rising from the index finger to the little. The tip of the middle (and possibly the index) fingers received the highest dose, which was 20–30% higher than the dose to the base of the ring and little fingers.

View larger version (24K): [in this window] [in a new window]   Figure 4. Distribution of dose across the hands for interventional radiology procedures with femoral (cross-hatched) and internal jugular vein (IJV) (black) access. All doses are normalized with respect to that to the centre of the back of the hand (Figure 2). Error bars indicate ±1 standard deviation. TLD, thermoluminescent dosemeter.

View larger version (14K): [in this window] [in a new window]   Figure 5. Distribution of dose across the hands for interventional radiology procedures with percutaneous access. All doses are normalized with respect to that to the centre of the back of the hand (Figure 2). Error bars indicate ±1 standard deviation. TLD, thermoluminescent dosemeter.

View larger version (12K): [in this window] [in a new window]   Figure 6. Distribution of dose across the dorsum aspect of the hands for cardiology percutaneous transluminal coronary angiography (PTCA) procedures. All doses are normalized with respect to that to the centre of the back of the hand. Error bars indicate ±1 standard deviation. TLD, thermoluminescent dosemeter.

View larger version (18K): [in this window] [in a new window]   Figure 7. Hand positions and configurations used for performing (a) the advancing/retracting and prodding actions and (b) the twisting action required for interventional radiology and cardiology procedures with femoral access.

View larger version (22K): [in this window] [in a new window]   Figure 8. Hand positions and configurations used for performing percutaneous procedures in which the hand is required to be close to the X-ray beam.

View larger version (19K): [in this window] [in a new window]   Figure 9. Hand positions and configurations used for performing (a) the advancing/retracting and (b) the twisting actions required for interventional radiology internal jugular vein (IJV) procedures.

During percutaneous procedures, the hands take up a position much closer to the area under investigation, and so to the X-ray beam, than during femoral cases in order to manipulate the catheter/needle effectively, hence the higher ratio of hand dose to DAP (Table 2). In the procedures monitored, the area under investigation is centred around the renal and hepatic regions of the body. The movement of the hand is predominantly a prodding action combined with pushing/retracting, resulting in the tips of the fingers being held towards the X-ray field (Figure 8). Hence in these procedures, it is the tip of the middle and probably also the index finger which receive slightly higher doses than the bases of the fingers (Figure 5).

During procedures involving access through the IJV such as TIPS, the hands are located in the shaded box marked IJV (Figure 2a). These procedures involve an equal amount of both the pushing/retracting action (Figure 9a) and remote twisting of the catheter (Figure 9b). In this case the bases of the ring and little fingers and the tip of the middle finger received similar doses (Figure 4).

In cardiology there is considerable overlap between the positions adopted by the hands during procedures via both the femoral and radial access routes (Figure 2b). However, operators using the radial method need to stand closer to the area visualized in the X-ray field for longer periods and so receive higher doses. During cardiology procedures, the predominant movement is a twisting action used in manipulating the catheter (Figure 7b) and injecting contrast, and as a result the base of the little finger receives the highest dose (Figure 6).

	Discussion

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Interventional radiology
Many factors affect the magnitude and distribution of dose across the hands of interventional radiologists, and this is reflected in the variability of doses measured across all procedures (Figure 3). The following are some of the more important factors.

• The type of procedure will determine the access to the patient, whether by a percutaneous, IJV or femoral approach and this will directly influence the position of the operator in relation to the X-ray field. The hand position and the length of exposure will determine the magnitude of the dose. The type of manipulation required affects the distribution of dose across the hand.
  
• The equipment used and in particular the dose saving facilities, which will lower the dose to the patient, will reduce the exposure of the operator. Fluoroscopy times can be kept to a minimum, by pulsing the X-ray beam and using equipment software providing facilities such as road mapping [22].
  
• Operators with lower levels of experience, particularly those undergoing training tend to receive a higher dose to their hands than experienced consultant operators for similar procedures. This can be reflected in increased screening times.
  
• The room layout will influence the position of the operator and in particular the hand that receives the higher dose.
  

In addition to the hands, consideration should be given to potential exposure of the eyes, legs [23], and other areas not protected by the lead rubber apron and thyroid collar. In almost all cases the primary operator will receive the highest annual doses. Care should be taken to ensure that nursing and other medical professionals do not receive significant doses to their body or the lens of the eye, particularly when comforting patients, acting as secondary operators or in the role of scrubbed nurse.

Doses to the hands of operators during percutaneous procedures were the highest (Figure 3, Table 2), due to the proximity of the hands to the X-ray field during screening (Figures 2 and 8). Results from this study were in good agreement with results reported elsewhere [2–5, 7–11, 13]. The hands are positioned directly on the patient skin surface in an area of high scattered radiation for lengthy periods. The predominant action that the operator performs is to advance and retract the needle or catheter, and this results in the fingertips of the hand nearest the X-ray tube receiving the highest dose (Figure 5).

The doses for procedures that involved femoral access tended to be less than 0.4 mSv in good agreement with published data [1, 4, 6, 12], although there were a few procedures with doses up to 1.6 mSv (Figure 3, Table 2). The hands are positioned 200–500 mm away from the groin when manipulating the catheter for the majority of the time and therefore in an area of lower scatter. The predominant twisting action used (Figure 7b) is reflected in the distribution of dose across the hand with the most exposed areas being the bases of the little and ring fingers (Figure 4), followed closely by the finger tips, which reflects the need at times to advance/retract the catheter (Figure 7a), particularly during more complex cases or where multiple sites are being investigated.

Those procedures in which the radiologist gains access to the patient via an IJV approach expose the hands to a wide range of doses (Figure 3). Although the hands are located at a distance from the area under investigation, some procedures, in particular TIPS can be technically challenging and are associated with longer screening times giving relatively high doses. The dose distribution is more similar to that during procedures requiring femoral access with the region of highest exposure being around the base of the little and ring fingers. However, the tip of the middle finger also receives a high dose (Figure 4) because prodding and twisting actions are involved to an equal extent (Figure 9). The dose to the other hand is only 10–20% less than that to the primary hand, because the operator is near to the end of the couch and the distance of the two hands from the X-ray beam are more similar.

Cardiology
The factors which affect the magnitude and distribution of doses to the hands during cardiology procedures are similar to those in interventional radiology; namely, the position of the operator, the X-ray equipment used, the experience of the operator and the room layout. Mean doses to the hand for almost all cardiology procedures studied were less than 0.5 mSv (Figure 3). Procedures carried out via a radial access route gave a significantly higher dose to the hands of the operator than those using a femoral puncture technique (Table 2), because of the position of the operator. The advantage of the radial approach is that patient mobility may be achieved more quickly and is therefore the method of choice as it both reduces stress for the patient and increases patient throughput. However, not all patients can be treated in this way and decisions are made on a case by case basis. The increase in exposure to staff from the choice of access route was not considered and did not warrant any re-evaluation of the method.

PTCA investigations require the operator to locate and traverse the coronary artery vessels via the ascending aorta. Once this has been achieved, the operator may carry out an angiogram before progressing towards performing an angioplasty of one or more stenotic sites. The screening required to successfully advance the catheter to the origins of the coronary vessels/stenotic sites, with the operator's hands in the configuration shown in Figure 7a, is minimal relative to the whole procedure. The most time-consuming section of the examination, where most screening and radiographic runs are performed, occurs as the operator attempts to traverse the coronary artery and to visualize and perform the therapeutic part of the procedure, which involves angioplasty of any lesion(s) possibly with the placement of a stent. In this part, the hands will perform the twisting action not dissimilar to that seen in radiology (Figure 7b). The hands are also in this general position during the numerous occasions when any drug therapy or contrast injection is required. As a result, it is the base of the ring and little fingers which receive the higher radiation doses (Figure 6).

Lead screens for shielding the upper body and lens of the eye were used more in cardiology than in radiology in the hospitals studied. A common design is the ceiling suspended leaded window screen, which can also incorporate a lead acrylic skirt at the bottom. This can be placed against the patient in a range of different orientations to provide protection for the operator(s). Although such screens provide good protection to the upper body, particularly during screening or radiographic runs in oblique projections, there was little evidence from the present study to suggest that they provided any significant protection for the hands, nor do manufacturers claim this. The design of the screen must not be too restrictive. It should allow the operator to move their hands in a range of different orientations, while providing them with a clear view of the patient. The operators tend to extend their hands underneath the screen for the majority of procedures, so that although the screens shield the body, little protection is afforded to the hands. Moreover, many operators position the screens poorly, so that the protection they provide is limited.

Extremity monitoring
Implementation of an extremity dose limit relies upon staff using dosemeters on a regular basis. This can be difficult to enforce. Staff are reluctant to use dosemeters in the positions where they might affect their touch sensation and restrict the manipulations they carry out. Therefore, a method of dose monitoring, which is simple, practical and easy to implement is required in order to promote compliance.

Procedures involving femoral access make up around 80% of all interventional radiology procedures undertaken. For femoral access work, the most exposed part of the hand will be the base of the ring and little fingers, and it is recommended that this area on both hands should be monitored using TLD rings. For those procedures in which the radiologist gains access via an IJV approach, such as TIPS, the distribution is similar to that during femoral access, and TLD rings located at the bases of the little or ring fingers on both hands would again be suitable for routine monitoring.

For percutaneous procedures the fingertips of the hand nearest to the X-ray tube, in particular the tips of the middle and probably the index fingers are exposed to the greatest level of scattered radiation. For those operators with a workload that consists mainly of this type of procedure, it could be argued that the most appropriate place to monitor is the tip of the index, middle or ring finger using a TLD finger stall. However, this may be impracticable as these fingers are heavily involved in the manipulation of catheters, and the finger stall would affect the dexterity and tactile ability of the operator. A TLD ring located at the base of the ring or little finger in this situation would still give an accurate estimation of hand dose and since the ratio of the dose to the base and to the tip is approximately 1.2–1.3, an adjustment could be made for radiologists who performed primarily percutaneous procedures. However, for the radiologists performing a typical mix of interventional procedures, ring dosemeters worn on the little/ring fingers of both hands will give the best indication of the dose received by the most exposed areas.

In cardiology, the procedure that had the most potential to expose the hands of the operator to a significant dose was studied. The most exposed area is again at the base of the little finger, because the cardiologist manipulates the catheter laterally for the majority of the procedure during which fluoroscopy is used. Therefore the use of ring dosemeters worn at the bases of the little fingers on either hand are recommended for routine monitoring in cardiology.

If doses for any group exceed 4 mSv per month and 50 mSv per year, then regular monitoring should be considered [24]. Links have been established between neck dose and DAP [17] and leg dose and DAP [23], but the association is more uncertain for hand doses and will depend on both the procedure and the operator. However, the ratios in Table 2 would suggest that staff regularly performing therapeutic interventional radiology procedures, or cardiology procedures via the radial access route, with DAPs totalling over 500 Gy cm² per month could receive annual doses to the hands of 50 mSv, as could those regularly performing percutaneous procedures with DAPs over 100 Gy cm² per month. Monitoring for a period of 2–3 months is recommended for primary operators falling within these groups in order to establish dose levels and determine whether regular monitoring is required.

Dose reduction
The hands may be protected using shielding devices such as protective screens of various designs or leaded surgical gloves. Anything which could interfere with the manipulations carried out, thereby lengthening the procedure and increasing the dose to the patient, must be avoided. Drop down lead acrylic screens have been employed in radiology, but in the hospitals included in the present study they tended to be confined to use in cardiology, as most radiologists found them too intrusive, as well as raising issues of sterility and space. In cardiology the screens provided good protection for the body and head, but the hands would often be extended under the screen and so receive less protection. The possible dose reduction afforded by surgical gloves incorporating 0.02 mm of lead is debatable, since they only reduce the dose by 15–20% through attenuation [12, 25] and may give the operator a false sense of security. Since the gloves can only be used once, cost is also an issue. Thus in most cases time and distance were the primary methods used to keep hand doses to a minimum.

Feedback from TLD dose monitoring is only available some time after a dose has been received. This does not allow the operator to identify when doses are received and so take action to minimize the dose. Electronic finger dosemeters are available which emit an audible alarm tone if a pre-determined threshold is exceeded (EDD; Unfors Instruments, Billdal, Sweden). This alerts operators when their hands are in a higher dose rate field, so that they can withdraw to a greater distance, if that is appropriate. Electronic finger dosemeters can provide a valuable educational tool for increasing the radiologists' and cardiologists' awareness of when doses are received, and could be applied in training.

	Conclusions

Top Abstract Introduction Materials and methods Results Discussion Conclusions References

 
Both radiologists and cardiologists are exposed to a wide range of doses to the hand during each procedure they perform. The main factors that affect this dose are the type of procedure, their experience, the X-ray equipment and the layout of the room. Procedures in interventional radiology were divided into three categories (percutaneous, IJV and femoral) relating to the access route which determined the position of the operator. Those radiologists performing cases via percutaneous access routes received the highest doses to their hands, as they required to be closer to the X-ray tube in order to carry out the manipulations.

The distribution of dose across an operator's hands is dependent upon the hand configuration and movement as well as the site of entry. The majority of the procedures involve a twisting action or a prodding, advancing/retracting motion of the hand. The ratio of these two main movements of the hands determines the distribution of dose across the hand for any individual procedure. For a general mix of interventional radiology procedures the most exposed region of the hand is the area from the little finger to the middle finger, with the bases of the fingers often receiving the highest dose. During percutaneous procedures the most exposed parts were the tips of the middle and ring fingers, although the doses were only 20–30% higher than those to the base of the little finger.

For those radiologists whose workload consists of all three types of procedure, monitoring using TLD ring dosemeters worn at the bases of the little or ring fingers on both hands is recommended. In those cases where a radiologist's workload consists mainly of percutaneous procedures, for which the tips of the middle and index fingers may receive higher doses, TLD rings would still provide a reasonable estimate of the dose to the most exposed area. Cardiologists were exposed to doses similar to those for radiologists carrying out femoral access cases and again the most exposed areas of the hand were the bases of the little and middle fingers. Thus use of ring dosemeters on the little finger of either hand is recommended as an effective monitoring method for interventional radiologists and cardiologists.

If hand doses for any group exceed 50 mSv per year, then regular monitoring should be considered. The relationship between hand dose and DAP per procedure performed is variable, but the DAP can be used as an indicator of the likely dose level. If an individual performs a variety of therapeutic interventional procedures or performs cardiology procedures via the radial access route which give DAPs totalling over 500 Gy cm² per month, or carries out percutaneous procedures with DAPs over 100 Gy cm² per month, monitoring is recommended to establish dose levels.

	Acknowledgments

 
The authors wish to acknowledge the support of the Health and Safety Executive for this project. They also wish to thank the radiologists and cardiologists involved in the study for their forbearance during the extensive dose monitoring performed and the staff of all the radiology and cardiology departments for their support. The hospitals taking part were Gartnavel General Hospital; Southern General Hospital, Glasgow; Glasgow Royal Infirmary; the Western Infirmary, Glasgow; Edinburgh Royal Infirmary; Dumfries and Galloway Royal Infirmary; Stirling Royal Infirmary; Law Hospital; and Ayr Hospital.

	Footnotes

 
Funding for this work was provided by the UK Health and Safety Executive.

Received for publication February 3, 2004. Revision received October 4, 2004. Accepted for publication October 26, 2004.

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Top Abstract Introduction Materials and methods Results Discussion Conclusions References

 

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