Chapter One

Introduction
1.1. An overview:
Medical imaging of the human body requires some form of energy. In the medical
imaging techniques used in radiology, the energy used to produce the image must be
capable of penetrating tissues. In diagnostic radiology, the electromagnetic spectrum
outside the visible light region is used for X-ray imaging, including mammography and
computed tomography, magnetic resonance imaging, and nuclear medicine. Mechanical
energy, in the form of high-frequency sound waves is used in ultrasound imaging [1].
Radiography was the first medical imaging technology, made possible when the
physicist Wilhelm Roentgen discovered X-rays on November 8, 1895 Roentgen also made
the first radiographic images of human anatomy. Radiography is performed with an x-ray
source on one side of the patient, and a (typically flat) X-ray detector on the other side, The
detector used in radiography can be photographic film (e.g., screen-film radiography) or an
electronic detector system (i.e., digital radiography) [1]. Radiation that has passed through
a patient will strike a cassette containing a fluorescent phosphorous screen and
subsequently expose the X-ray film. The areas on the film, which were exposed to the light
coming from the fluorescent phosphorous screen (created by the X-rays striking the
screen), will be blackened after the development of the film and the unexposed areas will
remain white. The degree of blackening on the developed film thus depends on the amount
of exposure to radiation [2].
With the exception of nuclear medicine, all medical imaging requires that the
energy used to penetrate the body's tissues also interact with those tissues. If energy were
to pass through the body and not experience some type of interaction (e.g., absorption,
attenuation, scattering), then the detected energy would not contain any useful information
regarding the internal anatomy, and thus it would not be possible to construct an image of
the anatomy using that information. In nuclear medicine imaging, radioactive agents are
1

injected or ingested, and it is the metabolic or physiologic interactions of the agent that
give rise to the information in the images [1].
The medical procedures causing patient exposures have to be justified and are
usually for the direct benefit of the exposed individual and consequently somewhat less
attention has been given to optimization of protection in medical exposure of patients than
in other applications of radiation sources [3].
Medical exposure is exposure incurred by patients as part of their own medical or
dental diagnosis and treatment by persons, other than occupationally exposed, knowingly
while voluntarily helping in support and comfort of patients by volunteers in a program of
biomedical research involving their exposure [4].
The optimization of protection in patient exposures does not necessarily mean the
reduction of doses to the patient. It is difficult to make a quantitative balance between loss
of diagnostic information and reduction in dose to the patient. In the case of exposure from
diagnostic medical procedures, the diagnostic reference level has as its objective the
optimization of protection, but it is not implemented by constraints on individual patient
doses. It is a mechanism to manage patient dose to be commensurate with the medical
purpose [3].
With increasing awareness of the need for radiation protection, a paradigm shift can
be absorbed from the principle of image quality as good as possible to image quality as
good as needed. The radiation dose to patients should follow the ALARA principle as
low as reasonably achievable while still providing image quality adequate to enable
accurate diagnosis, ALARA des not necessarily mean the lowest radiation dose, nor, when
implemented, dose it result in the least desirable radiographic image quality. Redaction of
patient dose according to the ALARA principle is not only a question of selection the right
detector, but also requires the optimization of the whole imaging chain and the selection of
appropriate imaging parameters [5] [6].
The limitation of the dose to the individual patient is not recommended because it
may, by reducing the effectiveness of the patients diagnosis or treatment, do more harm
2

than good. Diagnostic reference levels (DRLs) apply to medical exposure of patients, not
to occupational and public exposure [3].
The reasons for evaluating skin doses is that; the physical parameter recommended
for monitoring the DRLs in convention radiography was the Entrance surface dose (ESD),
the effective dose (E) can be calculated from ESD and the dose is greatest at the surface
where radiation enters the body of the patient therefore the skin is the main organ for
which there is a possibility of deterministic effect i.e., skin burn . The (ESD) is defined as
the absorbed dose to air where the X-ray beam intersects the skin surface of the patient
[7]. The ESD can be measure indirectly using the following equation:
2
100 2
= ( ) (
)
80

Where ESD is the Entrance surface dose, OP is the output of the X-ray tube (in GymAs -1)
at 80 kVp at distance of (100 cm) normalized to 20 mAs, kVp is the tube potential (in kV),
mAs is the product of the tube current (in mA ) and the exposure time (in ms), FSD is the
focal spot-to-skin distance and BSF is the backscatter factor [8] [9].
Image quality in the Computed Radiography (CR) can be evaluating by evaluate
the image noise using ImageJ software.

1.2. Problem of the study:

Despite the fact that in general the benefits derived from medical radiation exposure
outweighs the associated risks to the patients, there is a growing concern among the
patients about the ill-effects of radiation [2]. The choice of an X-ray technique can affect or
even eliminate the dose to the patient. It is the responsibility of the radiologist to choice an
examination method which will give adequate image quality for diagnosis with the
minimum dose to the patient [10].
Inappropriate exposure factors chosen by the radiological technologist lead to give the
patients overexposure or produce bad image quality, that lead to repeated the image and

give the patients overdose. Special in case the part of the body undergoing to be imaged
contain sensitive organ to the effect of radiation.

1.3. Significance of the Study:

The Significance of this Study is optimized the exposure factors used for imaging
the skull and the cervical spine, because it contains the lens of the eyes and the thyroid
gland respectively and both of them consider as the sense organs to the effect of radiation.

1.4. Objectives of the study:

1.4.1. General objective:
To optimize the patient dose and image quality in the X-ray examinations of the
skull and the cervical spine in Computed Radiology (CR).
1.4.2. Specific objectives:
1. To estimate the dose received by the skull and the cervical spine during X-ray
examinations in Computed Radiography (CR) and compare the value with the
internationally diagnostic reference dose levels (RDLs).
2. To estimate the dose received by the lens of the eyes and the thyroid gland in each
projection.
3. To evaluate the image quality using imageJ software.
4. To optimize the parameters used to obtain good image quality and avoid repetition
of image and unnecessary dose to the patient.

1.5. Thesis outline:

The remainder of this dissertation provides a detailed description of the equipment
utilized, approach and methods used, tools developed, results and conclusions reached.
Chapter two contains background information, a review of the current literature that
describes the calculation of the patient dose and image quality and then some of the
Sudanese and national previous study. Chapter three provides a detailed description of the
equipment used in this study and the experimental methodologies utilized to answer the
4

questions at the heart of the objectives of this study. Chapter four provides the results and
discussion of the experiments that were carried. Chapter five summarizes the findings of
this study and recommendations.

Chapter Two
Theoretical Background
2.1. Background:
Most radiology departments are making a transition from screen-film technology to
digital radiography. Digital radiography can be divided into two classes, namely,
Computed Radiography (CR), which is photostimulable phosphor detector based and
Direct digital Radiography (DR), which is flat panel imaging based [2].
2.1.1. Computed Radiography (CR):
The CR is a marketing term for photostimulable phosphor detector (PSP) systems
[1]. The phosphors used in CR imaging plates are usually europium doped barium
fluorohalides, for example, BaFBr and BaFI. During X-ray exposure to the imaging plate,
electrons are excited from the valence band to the conduction band, and some of these are
trapped in the F-centers. After X-ray exposure, the latent image exists as a spatially
dependent distribution of electrons trapped in high-energy states. During readout, laser
light is used to stimulate the trapped electrons back up to the conduction band, where they
are free to transition to the valence band so blue-green light is emitted; the light intensity
emitted by the imaging plate is proportional to the absorbed X-ray energy [1].

Figure (2.1): Illustration of the sequence of events during the x-ray exposure and readout
of a photostimulable phosphor [1].
The blue-green photostimulated luminescence signal is collected by a light guide,
which eventually feeds the signal to a photomultiplier tube (PMT). The PMT signal is then
digitized to form the image on a point-by-point basis [11]. The digital image that is
generated by the CR reader is stored temporarily on a local hard disk. Many CR systems
are joined directly to laser printers that make film hard copies of the digital images [1].

Figure (2.2): A representation of the CR imaging plate reading process workflow [2]
2.1.2. Direct Digital Radiography (DR):
Direct digital radiography does away with the read out process by providing for
instantaneous display of images. In digital radiography, the digitization of the X-ray
projection image occurs within the image receptor. Detectors in digital radiography can be
in the form of charged coupled devices (CCD) or flat panel imagers (FPI). Furthermore
FPIs are generally of two types namely, direct detection or indirect detection flat panel
imagers[2].

2.2. The biological effects of ionizing radiation:

The biological effects of ionizing radiation can be grouped into two kinds:
deterministic effects (tissue reaction) and stochastic effects (cancer and heredity effects)
[12].
8

2.2.1. Deterministic effects (tissue reaction):

Deterministic effects are largely caused by the death or radiation-induced
reproductive sterilization of large numbers of cells. This is not expressed clinically until
these cells unsuccessfully attempt division or differentiation. The severity of the effect
varies with radiation dose. A dose threshold usually exists. The threshold dose is subject to
biologic variation[13].
2.2.2. Stochastic effects (cancer and heredity effects):
Stochastic injuries (e.g., cancer induction) arise from misrepair of damage to the
DNA. The result is a genetic transformation. The likelihood of stochastic effects increases
with the total radiation energy absorbed by the different organs and tissues of an
individual, but their severity is independent of total dose [13].

2.3. Patient dosimetry in radiological imaging:

The objective of dosimetry in radiological imaging is the quantification of radiation
exposure within an approach to optimize the image quality to absorbed dose ratio [14].
2.3.1. Basic dosimetric quantities and units:
2.3.1.1. Fluence ():
The fluence, , is the quotient by , where is the number of particles
incident on a sphere of cross-sectional area , thus:
=

dN
da

Unit: m2 [15][16][17].

(2.1)

2.3.1.2. Energy fluence ():

The energy fluence, , is the quotient by , where is the radiant energy
incident on a sphere of cross-sectional area , thus:
=

dR
da

(2.2)

Unit: J.m-2 [15][16][17].

2.3.1.3. Exposure (X):
Exposure X is the quotient of by dm, where is the absolute value of the total
charge of the ions of one sign produced in air when all the electrons and positrons liberated
or created by photons in mass dm of air are completely stopped in air, thus: [16]
=

(2.3)

Unit: in the SI system of units C/kg. The unit used for exposure is the roentgen R, where:
1 R = 2.58 104 C/kg [16][17].
2.3.1.4. Kerma (K):
The kerma, K, is the quotient by dm, where is the sum of the initial
kinetic energies of all the charged particles liberated by uncharged particles in a mass dm
of material, thus:
=

(2.4)

Unit: J.kg-1. The special name for the unit of kerma is gray (Gy) [16][17].
2.3.1.5. Mean energy imparted ():
The mean energy imparted, , to the matter in a given volume equals the radiant
energy, , of all those charged and uncharged ionizing particles which enter the volume
10

minus the radiant energy, , of all those charged and uncharged ionizing particles
which leave the volume, plus the sum, Q, of all changes of the rest energy of nuclei and
elementary particles which occur in the volume, thus:
= +

(2.5)

Unit: J. [17].
2.3.1.6. Absorbed dose (D):
The absorbed dose, D, is the quotient by dm, where is the mean energy
imparted to matter of mass dm, thus:
=

(2.6)

Unit: J.kg-1. The special name for the unit of absorbed dose is gray (Gy) [16][17].
2.3.2. Application specific dosimetric quantities:
Application specific quantities relevant to radiography will be discussed below; air
kerma instead of absorbed dose is used. Figure (2.3) demonstrates the various application
specific dosimetry quantities and their position with respect to the geometry of an imaging
system.

11

Figure (2.3): A diagram showing various patient related dosimetric quantities [2].
2.3.2.1. Incident air kerma ( ):
The incident air kerma, , is the kerma to air from an incident X-ray beam
measured on the central beam axis at the focal spot-to-surface distance, at the position
of the patient or phantom surface (figure 2.3). Only the radiation incident on the patient or
phantom and not the backscattered radiation is included.
Unit: J.kg-1. The name for the unit of kerma is gray (Gy) [14][17].
2.3.2.2. Entrance surface air kerma ( ):
The entrance surface air kerma, , is the kerma to air measured on the central
beam axis at the position of the patient or phantom surface (figure 2.3). The radiation
incident on the patient or phantom and the backscattered radiation are included.

12

The entrance surface air kerma is related to the incident air kerma by the
backscatter factor, B, thus:
=

(2.7)

Unit: J.kg-1. The name for the unit of kerma is gray (Gy) [14][17].
2.3.2.3. Air kermaarea product ( ):
The air kermaarea product, , is the integral of the air kerma over the area of
the X-ray beam in a plane perpendicular to the beam axis (figure 2.3),thus:
= (, )

(2.8)

Unit: J.kg1.m2. If the special name gray is used, the unit of air kermaarea product is
Gy.m2 [17].
2.3.2.4. Air kermalength product ( ):
The air kermalength product, , is the integral of the air kerma over a line of
length, L, thus:
= ()

(2.9)

Unit: J.kg1.m. If the special name gray is used, the unit of air kermalength product is
Gy.m [17].
2.3.2.5. X-ray tube output (Y(d)):
The X-ray tube output, Y(d), is defined in ICRU 74 as the quotient of the air kerma
at a specified distance, d, from the X-ray tube focal spot (usually 1 m) by the tube current
exposure time product, , thus:
() =

13

()

(2.10)

Unit: J.kg-1.C-1. If the special name gray is used, the unit of X-ray output is Gy.C-1 , Gy.A1 -1

.s or Gy.mA.s-1 [14][17].

2.3.3. Quantities related to stochastic and deterministic effects:

2.3.3.1. Organ and tissue dose ( ):
The mean absorbed dose in a specified tissue or organ is given the symbol in
ICRU 51 [15]. It is equal to the ratio of the energy imparted, to the tissue or organ to
the mass, of the tissue or organ, thus:
=

(2.11)

Unit: J.kg-1. The special name for the unit of absorbed dose is gray (Gy)[17].
2.3.3.2. Equivalent dose ( ):
The equivalent dose, , to an organ or tissue, T, is defined in ICRP 60 [18] and
ICRU 51 [15]. For a single type of radiation, R, it is the product of a radiation weighting
factor, , for radiation R and the organ dose, , thus:
=

(2.12)

Unit: J.kg-1. The special name for the unit of equivalent dose is sievert (SV ).
The radiation-weighting factor, , allows for differences in the relative biological
effectiveness of the incident radiation in producing stochastic effects at low doses in tissue
or organ, T. For X-ray energies used in diagnostic radiology, is taken to be unity
[15][17].

14

Table (2.1): Radiation weighting factors for some types of radiation (ICRU 60) [16].
Type of radiation

Weighting factor ( )

X and rays, all energies

Electrons positrons and muons, all energies

Neutrons
< 10 keV

10 keV to 100 keV

10

> 100 keV to 2 MeV

20

> 2 MeV to 20 MeV

10

> 20 MeV

Protons, (other than recoil protons) and

2-5

energy > 2 MeV

Alpha particles, fission fragments, heavy

20

nuclei

2.3.3.3. Effective dose (E):

The effective dose, E, is defined in ICRP 60 [18] and ICRU 51 [15]. It is the sum
over all the organs and tissues of the body of the product of the equivalent dose, , to the
organ or tissue and a tissue weighting factor, , for that organ or tissue, thus:
=

(2.13)

Unit: J.kg-1. The special name for the unit of effective dose is sievert (SV ).
The tissue weighting factor, , for organ or tissue T represents the relative
contribution of that organ or tissue to the total detriment arising from stochastic effects for
uniform irradiation of the whole body.
The sum over all the organs and tissues of the body of the tissue weighting factors, , is
unity [15][17].

15

Table (2.2): Tissue weighting factors for some types of radiation (ICRP publication
103) [3].
Tissue

tissue weighting factor ( )

Bone-marrow, Colon, Lung, Stomach, Breast,

Remainder Tissues*

0.12

Gonads

0.08

Bladder, Oesophagus, Liver, Thyroid

0.04

Bone surface, Brain, Salivary glands, Skin

0.01

Total

*Remainder Tissues: Adrenals, Extrathoracic (ET) region, Gall bladder, Heart, Kidneys,
Lymphatic nodes, Muscle, Oral mucosa, Pancreas, Prostate, Small intestine, Spleen,
Thymus, Uterus/cervix.

2.4. The factors affecting patient dose:

The factors that affect the dose to the patient in diagnostic x-ray examination are
many and varied, and often interrelated. Within the guidelines for the examination set by
the radiologist, the radiographer has range of technique available. The expertises of the
radiographer and the equipment available have a considerable influence on the Conduct of
the examination and the consequent dose to the patient [10].
2.4.1. Choice of screen/film combination:
The choice of high-speed calcium tungsten or rare earth film screen combination
rather than slow-speed system, can result in substantial dose reduction [10]. The speed
numbers are relative; that is, a 400-speed system requires half the dose used with a 200speed system, which requires half the dose used with a 100 speed system [19].

16

2.4.2. Technique factor (kVp):

Beam energy primarily depends on the peak kilovoltage (kVp) and the amount of
filtration Beam energy primarily depends on the peak kilovoltage (kVp) and the amount of
filtration in the beam. If all other variables are held Constance, ESD will change as the
square of the change in peakkilovoltage. The selection of higher peakkilovoltage increases
the average energy of the X-rays and therefore beam penetrability. As the beam became
more penetrating, more X-ray reaches the image receptor during the same period of time.
In practice, this may allow for use of a lower tube current or a shorter exposure, thus
reducing the dose to the patient [19].
2.4.3. Technique factor (mAs):
The aspect to choosing the mAs setting to ensure that the optimum optical density
is achieved. The optical density is proportional to the log of the patient dose, small
increases in optical density achieved with larger increases in mAs. The patient dose is
directly proportional to the mAs [10].
2.4.4. Focus to film distance (FFD):
The X-ray beam originates at the focal spot, which behaves approximately as a
point source. The X-ray beam intensity decreases with distance from the focal spot
according to the inverse square of the distance. Therefore the free-in-air (i.e., without the
2

patient) exposure at the position of the film by the factor( ) . As the

ratio of the focus-to-film distance to focus-to-skin distance is decreased (by moving the xray tube further from the patient), the entrance-skin to film-plane exposure ratio is
improved. It is also improved by ensuring that the patient is as close to the film
plane/image receptor possible [10].

17

2.4.5. Scatter reduction techniques:

Grids and air gap are techniques using in radiography to reduce the amount of
scatted radiation that reached the image receptor and improve the image contrast.
Unfortunately, the grid absorbs a portion of primary radiation. The way to achieve the
degree of the exposure required to produce the image is increase the amount of the
radiation incident and consequence the dose to the patient [19].
2.4.6. Filtration:
The filtration preferentially absorbs the low-energy X-ray in the beam. Without
filtration, this low-energy radiation would most likely completely absorbed in the patient
and contribute to patient dose without contributing to the image [10][19].
2.4.7. Collimation and filed size:
Ideally, the X-ray beam should be limited to the area of clinical interest. In
practices this is equivalent to choosing a film size or imaging plate (in CR) to cover the
region of clinical interest and then collimated the beam to the film size or imaging plate (in
CR) [10]. Aggressive collimation reduces the irradiated area as well as scatter radiation
[20].
2.4.8. The patient:
As the area being imaged increases, the amount of radiation incident on the patient
increases because adequate X-ray penetration is needed to create an acceptable image [19].
It is beneficial to optimize the technique chart for various patient size and anatomic areas
[20].
The patient in Computed Radiography (CR) is affected by all the factors listed as
well as other considerations. Typical CR systems operate at a speed equivalent to an
approximately 200-speed screen film combination. The CR system is much more tolerant
of inappropriate technique because of high latitude of digital detectors and phosphor plate
which makes possible systematic over-exposure or unnecessary high doses with a good or
18

even perfect image quality [21]. This wide range, or latitude, may allow the operator to use
lower peak kilovoltage and tube current, since the images can be manipulated to adjust
contrast and brightness after the image data have been obtained (i.e., post processing).
However, if very lower peak kilovoltage and tube current are used, substantial levels of
noise can be introduced into the image [19].

Figure (2.4): The greater dynamic range for the CR system [1].

2.5. The factors affecting image quality:

The good radiographic image should have sufficient sharpness and radiographic
contrast [22].
19

2.5.1. The unsharpness:

The unsharpness of the radiographic image can be divided into three main groups:
2.5.1.1. Geometrical factors:
Geometric factors of unsharpness depend upon:
i.

The size of the X-ray source (target or the focal spot) the smaller the focal spot
the lesser the image unsharpness.

ii.

The distance between the X-ray source and the recording surface which is the
film (larger the distance lesser the unsharpness).

iii.

The distance between the film and the subject being radiographed. (Closer the
distance between the film and the subject lesser the unsharpness) [22].

2.5.1.2. Motional factors:

Factors connected with the subject and its movement known as motional factors:
i.

Involuntary: Peristaltic action in the abdominal viscera and the heartbeat.

ii.

Voluntary: Movement of the body sufficiently blurs the shadows outline

[22][23].

2.5.1.3. Photographical factors:

Factors connected with the recording of the image known as photographic factors:
i.

Intensifying screen: Influenced by grain size, contrast and the extent to which it
may absorb or scatter light.

ii.

Emulsion factors: Film base is coated with light sensitive material called silver
bromide crystals. These silver bromide crystals on being struck by the X-rays
produce light, whose sideways dispersion leads to unsharpness of the image
[22].

20

2.5.2. Primary image quality metrics:

The three primary image quality indicators are contrast, resolution and noise.
2.5.2.1. Contrast:
This quantity shows how well two adjacent objects can be distinguished as separate
entities. Contrast can be said to show the differences in the attenuation properties of
objects. Any perception of contrast will be due to the difference in the transmitted
intensities through the attenuating materials. As beam energy increases, the Compton
effect becomes predominant, leading to increased scattered radiation which will ultimately
reduce the contrast. In simple terms, contrast is a measure of the difference between
densities on an exposed detector [2].
=

(2.14)

Where and are the average pixel intensities in the object and its background. No
imaging method works without contrast and no imaging method is free of noise [21].
2.5.2.2. Resolution:
This is the capability of an imaging system to distinguish between two adjacent
structures as separate entities. The spatial resolution of an X-ray unit can be measured
using bar patterns. It is measured in line pairs per millimeter. The higher the number of
line pairs per millimeter the superior the resolution of the system [1][24].
2.5.2.3. Noise:
Noise degrades image quality and limits the ability to visualize low contrast
objects. There are several sources of noise in an image (e.i., quantum noise, electronic
noise and anatomic noise). The electronic noise comes from hardware associated with
signal detection, amplification, recording and also by influence of electromagnetic
radiation from external sources. The anatomical noise is given by the overlaying of
21

structure within the patient resulting in image components that cannot be distinguished and
therefore recognized as structure or some part of the scatter caused by the patient. The
quantum noise is an example of measurement noise that is an inevitable consequence of the
use of electromagnetic radiation as the imaging energy sources [21].
2.5.3. Methods of assessing image system performance:
A number of complementary metrics are available to assess the performance of
digital X-ray imaging systems. Below is a discussion of various methods of assessing
image system performance.
2.5.3.1. Contrast-to-noise ratio (CNR):
Contrast and noise are two basic measures of image quality that are commonly used
to describe image quality. The CNR metric is used to evaluate the degradation of contrast
and is an estimate of noise in the image. CNR is defined as the ratio of the difference of
signal intensities of two regions of interest to the background noise.
CNR =

(Sa Sb )
Nbg

(2.15)

Where Sa is the signal intensity of region a, Sb is the signal intensity of region b and Nbg is
the background noise [25].
2.5.3.2. Signal-to-noise ratio (SNR):
The SNR of a radiographic system describes the ability of the system to reproduce
low-contrast objects. Signal-to-noise ratio is defined as
SNR =

1 2
( 2 (1 )

1
2 (2 ))2

(2.16)

Where 1 and 2 represent the mean signal intensity in background and signal regions of
the image respectively, (1 ) and (2 ) are the standard deviation in the mentioned
regions respectively [2].
22

2.5.3.3. Modulation transfer function (MTF):

The resolution of a CR system is commonly estimated using a line pair phantom,
but the line pair phantom only helps in estimating the limiting spatial resolution of the
system. The MTF is a more comprehensive metric, which describes the behavior of spatial
resolution at all available frequencies. The MTF is a quantitative measure and a single
analysis in the spatial frequency domain that can be used to predict performance of all
possible objects [25].
2.5.3.4. Noise power spectrum (NPS):
The CNR metric evaluates noise based on the standard deviation of pixel values in
an image. This is only an estimate of the noise in an image. NPS is a metric of image
quality used to measure the noise characteristics and patterns in all frequencies of the
image, and provides us with a more complete description of noise in an image [25].
2.5.3.5. Detective quantum efficiency (DQE):
DQE is a measure of the efficiency of a detector when using the input signal-tonoise ratio (SNR) provided by a limited number of X-ray photons to form an image at a
certain exposure or dose level [26]. This metric of image quality measures the transfer of
signal to noise ratio from the input to the output of a detector [27]. Hence, this metric
describes the efficiency of the detector of the system. This metric is obtained by using the
MTF and the NPS.
=

. ()2
. ()

(2.17)

Where G is the gain factor and considered 1, MTF(f) is presampled modulation transfer
function, NPS(f) is the noise power spectrum in mm2 measured at a given exposure and q
is the square of ideal signal to noise ratio in mm2. The variable q in the equation is
calculated as
= . 2
23

(2.18)

Where is the measured Air Kerma in Gy and 2 in is the squared signal to noise
ratio per Air Kerma1 and is given by the IEC standard [25].

2.6. The previous studies:

These are many studies that were carried out in this field local and broad for
optimization of patient dose and image quality in diagnostic radiology. In order to evaluate
the entrance surface doses (ESDs), Jumaa Yousif Tamboul et al (2014) [9], estimated the
Entrance Surface dose for the patients from common radiology examinations in Sudan for
adults patients undergoing common X-ray examinations in two hospitals in Khartoum,
namely Khartoum Teaching Hospital and Academy Teaching Hospital. Their study was
performed in four X-ray machines and contained 191 patients. They calculated the ESD
with the use of the DoseCal software. Their results showed that; the ESDs ranged from
0.02-0.31 mGy for chest PA, 0.06-0.23 mGy for chest AP, 0.08-3.1 mGy for skull OF,
0.20-2 mGy for skull LAT, 1.4-2.6 mGy for abdomen, 0.14-1.1 mGy for pelvis, 0.31-4.2
mGy for lumbar spine AP and 0.54-6.6 mGy for lumbar spine LAT [9].
Habbani and Suliman (2010) [8], compared between two methods used to calculate
the effective dose (ED) in diagnostic radiology and evaluated ED distribution in
radiological departments in four major hospitals in Khartoum. Their study included a
sample of 346 patients. The first method in their study calculated the ED from entrance
skin dose using NRPB-SR262 Monte Carlo data and the second method is calculated the
ED from the energy imparted () using projection specific ED/ conversion factors. They
calculated the ESDs using the same equation used in this study and their study results
showed that, the ESDs were 0.22 mGy for chest PA, 1.41 mGy for skull AP/PA, 0.99 mGy
for skull LAT, 1.5 mGy for pelvis AP, 2.06 mGy for lumbar spine AP and 5.2 mGy for
lumber spine LAT [8].
Suleiman et al (2007) [28], evaluated the entrance surface doses ESD to patients
undergoing selected diagnostic X-ray examinations in major Sudanese hospitals. Their
study Conducted in four hospitals and included a sample of 346 radiographs. They
estimated the ESD from the X-ray tube output parameters and their study results founded
24

to be range from 0.17-0.27 mGy for chest AP, 1.04-2.26 mGy for Skull AP/PA, 0.83-1.32
mGy for Skull LAT, 1.31-1.89 mGy for Pelvis AP, 1.46-3.33 mGy for Lumbar Spine AP
and 2.9-9.9 mGy for Lumbar Spine LAT [28].
Olivera Ciraj et al (2004) [29], assessed the patient doses for most frequent x-ray
examinations in Serbia and Montenegro, their study included a total of 491 procedures for
11 different examination categories. They calculated the ESD mathematically from the Xray tube output data and the patient parameters as the effective dose for each patient. Their
study results showed that the ESDs are 1.3 mGy for cervical spine AP, 1.03 mGy for
cervical spine LAT, 2.07 mGy for Pelvis AP, 1.5 mGy for Thoracic spine AP, 2.8 mGy for
Lumbar spine AP, 4.4 mGy for Lumbar spine LAT, 0.4 mGy for Chest PA, 0.3 mGy for
Chest LAT, 1.15 mGy for Skull PA and 0.95 mGy for Skull LAT [29].
Soheyl Sheikh et al (2010) [30], evaluated of surface radiation dose to the thyroid
gland and the gonads during routine full-mouth intraoral periapical and maxillary occlusal
radiography. There were estimated the dose to the thyroid gland and the gonads in fullmouth IOPA radiography using 10 IOPA (E speed films) and in maxillary occlusal
radiography using a digital pocket dosimeter (PD-4507). Their study included a total
number of 120 subjects. their result showed that, The average dose at the thyroid gland
level during full-mouth intraoral and maxillary occlusal radiography 0.01093 mGy and
0.04 respectively [30].
I ZAMMIT et al (2003) [31], evaluated the radiation dose to the lens of eye and the
thyroid gland in paranasal sinus multislice CT in the axial and coronal planes on a Siemens
Volume Zoom quad slice scanner at 140 kVp and effective mAs of 100 using 1 mm
collimation by use Thermoluminescent dosimeters. Their study included a total of 29
patients scanned axially in the supine position and a further 28 patients scanned coronally
in the prone position with gantry tilt. Their results showed that, the mean doses of 35.1
mGy (lens) and 2.9 mGy (thyroid gland) in the coronal plane compared with 24.5 mGy
(lens) and 1.4 mGy (thyroid gland) in the axial plane [31].

25

Chapter Three
Materials and Methods
3.1. Materials:
3.1.1. Introduction:
This study was intended to evaluate the Entrance Surface Dose (ESD), eye lens
dose, thyroid gland dose and image quality in Computed Radiography (CR). The organs
chosen for this study are the cervical spine and the skull. The following projections types
of X-ray examinations were studied: cervical spine AP, cervical spine LAT and skull LAT.
The survey was conducted between August 2015 and October 2015. The patients were
randomly selected from adult patients of both sexes attending medical investigations in
three radiological centers, all patients who have been selected their weight 70 kg15. The
X-ray centers used in this study are Antalya Medical Center (Hospital 1), Bahery Accident
& Emergency Hospital (Hospital 2) and Sharg Alneal Hospital (Hospital 3).
3.1.2. The X-ray system:
For each hospital, available machine specific data such as type, model, filtration,
focal spot size, year of manufacture were recorded from the manufacturer information
written on the machine, all X-ray machines are fixed. These data are presented in table
(3:1).

26

Table (3.1): Personnel and specific data of X-ray machines used in the hospitals
Hospital 1

Hospital 2
SHIMADZU

Hospital 3

Manufacturer

TOSHIBA

Model

E7239X

P18DE-85

9890 000 86101

Focal spot size

2.0/1.0

0.6/1.2

0.9 mm AL at

1.5 mm AL at

2.5 mm AL at

75 kVP

75 kVP

75 kVP

Added filtration

1.0mm AL

1.0mm AL

Maximum KVp

125 kVP

150 kVP

September 2010

CORPORATION

PHILIPS

Inherent filtration

Year of
manufacture
Generator
Manufacturer
Generator Model
Image receptor

CR reader

ALLENGERS

SHIMADZU
CORPORATION

525/FC/FLOHTex/V

PHILIPS

D15L C-40E

9890-010-83821

Phosphor plate

Phosphor plate

Phosphor plate

Fujifilm FCR

Fujifilm FCR

Fujifilm FCR

PRIMA 3543cm

PRIMA 3543cm

PRIMA 3543cm

1417Inch

1417Inch

1417Inch

BS

3.1.3. The patients population:

A total of 120 patients and 150 X-ray images were included in this study. For each
studied examination, personal data (sex, age, weight and height) and technical parameters
(kVp, mAs and FSD) have been collected according to the data collection sheet designed
by the patient dosimetry protocol TRS NO. 457 [17] and also it has been collecting images
for each patient in CD disk from the CPU of the CR system. The kVp and mAs values for
each examination were written directly from the control panel of the X-ray machine.
27

3.1.4. Image protocol:

In X-ray imaging the exposure parameters used are selected according to patient
weight and organ size. The Standard (FFD) of 100 cm for anterioposterior projection AP
and 110 cm for lateral LAT projection were used for all routine.

3.2. Methods:
3.2.1. The patients dose calculation:
The entrance surface dose (ESD) for each patient was calculated using real
examination data, according to Eq (3.1).
2
100 2
= ( ) (
)
80

(3.1)

Where ESD is the entrance surface dose, OP is the output of the X-ray tube (in Gy mAs 1

) at 80 kVp at a distance of (100 cm) normalized to 20 mAs, kVp is the tube potential (in

KV), mAs is the product of the tube current (in mA) and the exposure time (in ms), FSD is
the focal spot-to-skin distance and BSF is the backscatter factor. The backscatter factor
was 1.35 suggested in European guidelines (EC, 1996) [7].
The X-ray tube output (OP) was measured at a distance of 100 cm from the tube focus
using 80 kVp and 20 mAs using the DIAVOLT. The DIAVOLT was exposed three times
and the mean value was taken. Table (3.2) represents the characteristics of the DIAVOLT
device used to measure the X-ray tube output.
The FSD was calculated using Eq (3.2)
= ( + )

(3.2)

Where FFD is tube focus-to-image receptor distance, b is the patient thickness and d is
image receptor-to-top table distance. b and d were measured using meter ruler.

28

The eye lens dose and thyroid gland dose for each projection were calculated using
X dose software.
Table (3.2): Characteristics of the device used to measure the X- ray tube output
Type

DIAVOLT universal

Model

T43014-01292

Certificate number

0912762

Manufacture date

July 2008

3.2.2. Analysis of the data:

The ESDs were used as input to the Microsoft Excel and SPSS software for
analysis. The images for each projection were used as input to the ImageJ software to
evaluate the quality of the images in the term of the image noise; the obtained image noise
was used as input to the Microsoft Excel to make a correlation between the image noise
and the ESD.

Figure (3.1): Illustration of noise measurement using ImageJ software

29

Chapter Four
Results and Discussion
4.1. Results:
The results were presented for optimization of patient dose and image quality for
X-ray examination of the skull and the cervical spine in CR, three X-ray machines covered
in the three selected hospitals.
Table (4.1): Characteristics of the patients and technical parameters selected for various
examinations types in the three hospitals

Hospital 3

Hospital 2

Hospital 1

Sample
size
C/S
AP
C/S
LAT
Skull
LAT
C/S
AP
C/S
LAT
Skull
LAT
C/S
AP
C/S
LAT
Skull
LAT

15
15
15
15
15
15
15
15

KVP
meanSD
(min-max)
67.61.45
(65-70)
701.06
(68-72)
70.063.12
(64-75)

mAs
meanSD
(min-max)
150.0
(15-15)
150.0
(15-15)
14.261.57
(10-15)

FSD (cm)
meanSD
(min-max)
85.21.41
(82-87)
88.133.58
(81-92)
83.231.33
(86.5-92)

57.62.13
(54-60)
51.532.66
(48-55)
64.461.72
(60-66)
68.931.38
(66-70)
691.195
(66-70)

9.060.7
(8-10)
4.960.12
(4.5-5)
9.660.48
(9-10)
9.730.88
(8-11)
14.81.2
(12-16)

87.22.67
(83-91)
83.21.53
(86.5-91)
84.661.55
(81-87)
87.933.34
(83-92)
83.561.68
(82-88)

(AP) anterioposterior and (LAT) lateral

30

Grid
No
Yes
Yes
Yes
Yes
No
Yes
Yes

Table (4.2): The DIAVOLT reading for each X-ray tube at 80 kVp in (GymAs -1)
normalized to 20 mAs.
DIAVOLT

Hospital 1

Hospital 2

Hospital 3

M1

33.66

46.69

54.25

M2

33.98

47.965

54.3

M3

34.085

48.1

54.3

mean SD

33.9083 0.221378

47.585 0.778026

54.2833 0.028868

reading

Table (4.3):The mean ESD (in mGy) (SD) in the three hospitals
ESD (mGy)
meanSD
(min-max)
C/S AP

C/S LAT

Skull LAT

0.6760.032

0.6790.053

0.7310.135

(0.627-0.7201)

(0.621-0.8012)

(0.396-0.908)

0.3990.0561

0.1920.0278

(0.293-0.472)

(0.140-0.228)

0.5440.0536

0.6910.107

1.1610.152

(0.4701-0.615)

(0.481-0.854)

(0.828-1.318)

Hospital 1

Hospital 2

Hospital 3

31

Table (4.4): The mean eye lens and thyroid dose (in mGy) (SD) in the three hospitals

C/S AP

C/S LAT

Skull LAT

meanSD

0.01650.001

0.000760.0001

0.2828670.054

(min-max)
Thyroid dose

(0.0154-0.0183)

(0.0001-0.0009)

(0.149-0.357)

meanSD

0.4360.022

0.0150.0012

0.01130.003

(min-max)
Eye lens dose

(0.408-0.47)

(0.0145-0.0187)

(0.0049-0.0162)

0.00037.99E-05

0.070820.01

(0.0002-0.0004)

(0.051-0.0848)

0.007160.001

0.001620.0004

(0.0047-0.0092)

(0.001-0.0024)

Hospital 1

Eye lens dose

Hospital 2

meanSD
(min-max)
Thyroid dose
meanSD

Hospital 3

(min-max)
Eye lens dose
meanSD

0.01360.001

0.00090.0001

0.4570.061

(min-max)
Thyroid dose

(0.011-0.0159

(0.0005-0.0012)

(0.322-0.521)

meanSD

0.3560.043

0.01770.003

0.01850.003

(min-max)

(0.29-0.411)

(0.0113-0.0224)

(0.0124-0.0225)

32

90
80
70
60
50

KV

40

mAs

30

FSD

20
10
0
Hospitale 1

Hospitale 2

Hospitale 3

Figure (4.1): The exposure parameters of the cervical spine AP in the three hospitals.

100

90
80
70
60

KV

50

mAs

40

FSD

30
20
10
0

Hospitale 1

Hospitale 2

Hospitale 3

Figure (4.2): The exposure parameters of the cervical spine LAT in the three hospitals.

33

90
80
70
60
50

KV

40

mAs
FSD

30
20
10
0
Hospitale 1

Hospitale 2

Hospitale 3

Figure (4.3): The exposure parameters of the skull LAT in the three hospitals.

1.4
1.2

ESD (in mGy)

1
0.8

cervical spine AP

0.6

cervical spine LAT

skull LAT

0.4
0.2
0
Hospitale 1

Hospitale 2

Hospitale 3

Figure (4.4): The mean ESD (in mGy) in the three hospitals.

34

Cervical spine
Table (4.5): The ANOVA test for ESD for the cervical spine
Sum of
Squares

Df

Mean Square

Sig.

Between Groups

.817

.408

69.531

.000

Within Groups

.247

42

.006

Total

1.064

44

Figure (4.5): The ESD for the cervical spine in the three hospitals

35

Skull
Table (4.6): The ANOVA test for ESD for the skull
Sum of

Mean

Squares

Df

Square

Sig.

Between Groups

7.073

3.537

250.224

.000

Within Groups

.594

42

.014

Total

7.667

44

Figure (4.6): The ESD for the skull in the three hospitals

36

1.8
1.6
y = 0.1717x - 0.1001
R = 0.9803

1.4

ESD

1.2
1

y = 0.0916x
R = 1
ESD Vs KV

0.8
0.6
0.4

ESD Vs mAs

0.2

ESD Vs Output

0
0

10

Figure (4.7): Illustration of the strong relationship between the ESD and the kVp, mAs and
the X-ray tube output.

Image noise Vs ESD

100

y = -40.225x + 108.79
R = 0.0276

Image noise

80
60
Hospital 1

40

y = 18.39x + 38.536
R = 0.0334

20

Hospital 3

0
0

0.2

0.4
ESD

0.6

0.8

Figure (4.8): Relationship between the image noise and ESD for the cervical spine AP

37

Image noise Vs ESD

120
100
Image noise

y = -36.881x + 113.3
R = 0.0516

y = 176.58x - 0.1593
R = 0.3324

80
60

Hospital 1

40

Hospital 2
y = 12.654x + 38.681
R = 0.0237

20

Hospital 3

0
0

0.2

0.4

0.6

0.8

ESD

Figure (4.9): Relationship between the image noise and ESD for the cervical spine LAT

Image noise Vs ESD

80

y = 2.5733x + 58.851
R = 0.0012

70
Image noise

60

50

y = 0.8857x + 61.919
R = 4E-05

40

Hospita 1

30

Hospital 2

20

Hospital 3

y = -3.0181x + 39.991
R = 0.0037

10
0
0

0.5

1.5

ESD

Figure (4.10): Relationship between the image noise and ESD for the skull LAT

38

4.2. Discussion:
This study was intended to evaluate the radiation Entrance Surface Doses (ESDs)
and the image quality in Computed Radiography (CR) for the adult patients undergoing
diagnostic skull and cervical spine X-ray examinations in Sudan to help in applying
optimization of radiation protection of the patients. The data were collected from three
hospitals in Khartoum, including three X-ray machines. The exposure parameters (kVp,
mAs and FSD) were collected during the examinations in the selected hospitals. The mean,
minimum and the maximum exposure parameters were recorded in table (4.1). Figure (4.1)
showed that, the highest kVp and mAs for the cervical spine AP were observed in hospital
1. Figure (4.2) showed that, the highest and the lowest kVp and mAs for the cervical spine
LAT were observed in hospital 1 and hospital 2 respectively. Figure (4.3) showed that,
hospital 2 observed lowest kVp and mAs for the skull LAT. This variation in the exposure
parameters (kVp and mAs) mine is being due to the variations in the patients weights,
thicknesses and radiographic techniques employed by the operators. Table (4.3) and figure
(4.4) showed that, the highest ESD for the cervical spine AP 0.676 mGy was observed in
hospital 1, the highest ESD for the cervical spine LAT 0.691 mGy and the skull LAT 1.161
mGy were observed in hospital 3. The lowest ESD for the cervical spine LAT 0.399 mGy
and the skull LAT 0.192 mGy were observed in hospital 2. Table (4.1) showed that, The
FSD was almost constant for the same test between the three hospitals. Hospital 2 and
hospital 3 used approximately the same exposure parameters (kVp, mAs and FSD)
although it was noted a different ESD for the skull LAT, This difference may be due to the
difference in the X-ray tube output between the two hospitals. Figure (4.7) illustrates the
strong relationship between the ESD and the KV (R2 =0.98), mAs (R2 =1) and the X-ray
tube output (R2 =1); therefore the observed variation in ESD may be due to the variation in
the exposure parameters (KV, mAs) at the same hospital or due to the variation in the Xray tube output between the three hospitals. The ESDs values obtained from this study
were compared with the international diagnostic dose reference levels (DRLs) [35] and
other studies in the Sudan [9] [8] [28] [32] and other countries [29] [33] [34], the results
showed that; all estimated ESDs values within the scope of the DRLs and lower than the
range of some previous studies, the data are represented in table (4.7).
39

Table (4.7): Comparison of ESD (in mGy) with the DRLs and some previous studies
Cervical

Cervical spine

spine (AP)

(LAT)

Hospital 1

0.676

0.679

0.731

Hospital 2

0.399

0.192

Hospital 3

0.544

0.691

1.161

Jumaa Yousif et al (2014) [9]

2.1

Habbani and Suliman (2010) [8]

0.99

Suleiman et al (2007) [28]

1.075

M.A. Halato et al (2008) [32]

1.13

Olivera Ciraj et al (2004) [29]

1.3

1.03

0.95

A. Beganovi et al (1997) [33]

0.76

0.195

0.909

A. Aroua et al (2004) [34]

3.1

3.5

IAEA (BSS) (1996) [35]

The Studies

This study

Skull (LAT)

Table (4.4) showed that, the maximum eye lens dose 0.457 mGy was observed for the
skull LAT in hospitable 3 and the maximum thyroid gland dose 0.436 mGy was observed
for cervical spine AP in hospitable 1. The dose for the thyroid gland 0.436 mGy is higher
than the values enrolled in the study carried out by Soheyl Sheikh et al (2010) [30] 0.01093
mGy and 0.04 mGy for the thyroid gland in full-mouth intraoral and maxillary occlusal
radiography respectively. That may be mainly due to the lower tube output for the X-ray
machine designed for the dental purpose. The eye lens dose 0.457 mGy is lower than the
eye lens dose values enrolled in the study carried out by I ZAMMIT et al (2003) [31], that
may be due to the high exposure parameter that is used in CT. Figure (4.8), (4.9) and
(4.10) showed the weak relationship between the image noise and the ESD; for the cervical
spine AP (R = 0.027 and 0.033), for the cervical spine LAT (R = 0.332, 0.051 and 0.023)
and for the skull LAT (R = 0.001, 4E-05 and 0.003 ) for hospital 1, hospital 2 and hospital 3
respectively.

40

Chapter Five
Conclusion and Recommendations
5.1. Conclusion:
This study was intended to evaluate the radiation doses and image quality for adult
patients undergoing diagnostic X-ray examinations of the skull and the cervical spine in
Computed Radiography (CR) in Sudan to help in applying optimization of radiation
protection of the patients. The results showed that, the ESD depends upon the exposure
parameters (kVp, mAs and FSD) and the X-ray tube output, the eye lens dose and thyroid
gland dose increases with increase the ESD for the same projection. The results showed
that; the estimated ESDs values within the range of the international diagnostic dose
reference levels (DRLs) and below the range of some previous studies. The dose to the eye
lens and the thyroid gland in the X-ray imaging of the cervical spine and the skull in the
Computed Radiography (CR) is less than that cause deterministic effect. The correlation
between the image noise and ESD is less significant and all images that have been
evaluated in this study have acceptable diagnostic information and acceptable image noise.

5.2. Recommendations:

Keeping exposure parameters (kVp and mAs) As Low As Reasonably Achievable

(ALARA) principle in diagnostic radiology to reducing the radiation dose for the
patients.

Using the appropriate Filtration and collimation of the X-ray beam to the region of
interest.

Long focus to patient distances could be used when possible to minimize patient
entrance surface dose.

High kVp techniques should be used when possible.

The image can be produced using the lowest possible exposure parameters (kVp
and mAs) and then enhance the image contrast by using the algorithm of CR
software.
41

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