Radiation Protection Dosimetry (2010), Vol. 140, No. 2, pp. 163–165 doi:10.

1093/rpd/ncq106
Advance Access publication 23 March 2010

SURVEY OF PATIENT DOSES FROM CONVENTIONAL

DIAGNOSTIC RADIOGRAPHIC EXAMINATIONS IN SYRIA
M. H. Kharita *, M. S. Khedr and K. M. Wannus
Protection and Safety Department, Atomic Energy Commission, PO Box 6091, Damascus, Syria

*Corresponding author: scientific@aec.org.sy, prscientific@aec.org.sy

Received June 24 2009, revised January 20 2010, accepted February 23 2010

The aim of this study is to evaluate radiation doses received by adult patients undergoing eight routine common types of
X-ray examination in Syria. These types cover chest PA, lumbar spine PA, lumbar spine LAT, urography, abdomen, pelvis
and hip, head and shoulder. This work consisted of measurements for 926 X-ray examinations for patients in 26 governmental

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hospitals. The mean and third quartile of the dose area product (DAP) to each patient per examination have been measured.
The corresponding average effective doses have been computed from the DAP measurement for each examination using NRPP
X-Dose software. Comparison of the results was done with those from similar surveys published by the United Nation Scientific
Committee on the Effects of Atomic Radiation (UNSCEAR, 2000, 2007). The present measurements will provide a useful
baseline to establish, for the first time, national diagnostic reference levels. These results can be used in the future to evaluate
the collective dose to the population from medical exposure and the radiation risks from the various radiological procedures.

INTRODUCTION
Assessment and optimisation of radiation doses
received by patients are some of the most important
tasks for radiation protection of patients in diagnostic
radiology in medicine. The patient dose is dependent
on operational parameters such as kV, mAs, body
orientation (PA, AP etc.), focal-to-skin distance
(FSD), field size and filtration. Therefore, the growing
application of X-rays in medicine and the increasing
hazards of radiation medical exposure have led to
comprehensive efforts of different international com-
mittees and organisations involved in radiation pro-
tection fields for issuing reference dose values as a
guide to the levels of radiation protection of patients
undergoing X-ray examinations. In 1996, the
European Commission had issued guidelines and
quality criteria with reference doses recommended for
various types of X-ray examinations for adult and
paediatric patients(1). In 1999, Guidance on diagnos-
tic reference levels (DRLs) for medical exposure(2)
was issued including patient dose levels in medical
exposure for typical diagnostic examinations. The
United Nation Scientific Committee on the Effects of
Atomic Radiation (UNSCEAR) has collected and
published data on the medical use of radiation since
its inception in 1955, one of the important reports
was issued in 2000(3). In 1996, the International
Atomic Energy Agency (IAEA) together with other
international organisations and agencies have issued
the International Basic Safety Standards for protec-
tion against ionising radiation and for the Safety of
Radiation Sources(4). This standard includes radio-
logical protection requirements for medical use of
radiation and guidance levels concerning doses and
dose rates for various X-ray examinations. Nowadays,
in addition to application and development of quality
assurance (QA) programs in diagnostic radiology, it is
required to optimise patient doses maintaining good
image quality in order to minimise hazards to
patients. UNSCEAR has issued another report in
2007 including global data for patient doses in diag-
nostic radiology examinations(5).
Generally, the entrance surface dose (ESD) and
the dose area product (DAP) are recommended mea-
surable dose quantities for individual radiographic
projections(6, 7). The ESD can be directly measured
with thermoluminescence dosemeters (TLDs) or can
be estimated by measuring radiation output values
of the X-ray tube. The DAP has been applied in this
study (using DAP meter) and it is preferred for
complex X-ray examinations.
The ESD and DAP are directly measurable quan-
tities and can be used for comparison against refer-
ence levels; however, they are not directly risk-related
quantities. Therefore, effective doses are also needed
in order to assess the population effective dose
arising from the medical use of radiation organ dose
and effective dose cannot be measured but can be
estimated on the bases of measured ESD or DAP
values(7).
This study was carried out in 26 governmental
hospitals all over Syria in 2005. The measurements
were taken for nine common types of X-ray examin-
ations, viz. chest PA, lumbar spine PA, lumbar spine
LAT, urography, abdomen, pelvis and hip, head,
shoulder and extremities. In the future, this work
will be extended to cover the private hospitals and
other types of X-ray examinations.

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 M. H. KHARITA ET AL.
MATERIALS AND METHODS machine was taken from the comprehensive national
QA program(8). The mean and third quartile of the
The governmental hospitals covered in this survey
DAP measurements have been calculated. The effec-
(carried out in 2008) were chosen due to the very
tive dose for each X-ray examination has been evalu-
high work load for the diagnostic X-ray examin-
ated using the NRPB X-Dose software(7), and the
ations in Syria. These hospitals are using different
mean DAP and mean effective dose for each type of
X-ray equipment and a wide range of examination
X-ray examination was used in the comparison(9 – 11).
techniques. The patient dose measurements covered
42 X-ray rooms in 26 governmental public hospitals
all over Syria. The nine common types of X-ray
RESULTS AND DISCUSSION
examinations studied for adult patients (over 17 y of
age). The doses were measured and compared with The assessment of the patient radiation doses
published data(3, 5), and only diagnostically accepta- (included mean and 3rd quartile DAP (Gy cm2))
ble images were included in this study. The total due to X-ray examination types are presented in
DAP measurements for individual radiographic pro- Table 1, including the average operational infor-
jections were carried out using the same portable mation, sample size, patient thickness, applied kVp
DAP meter (PTW Diamentor M) calibrated in and mAs. While Table 2 shows the comparison

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Syrian Secondary Standard Dosimetry Laboratory
(SSDL) traceable to the IAEA SSDL Laboratories.
The meter’s ionising chamber was fixed directly on
to the collimation tube and the DAP value (in
Gy cm2) was noted for each projection. Other infor-
mation for each patient and for each X-ray examin-
ation were recorded, including sex, age, body
orientation, patient thickness, FSD, field size, kVp
and mAs. The total filtration for each X-ray
between the calculated average patient doses with
the results of similar surveys published by the
United Nation Scientific Committee on the Effects
of Atomic Radiation (UNSCEAR 2000 and
UNSCEAR 2007)(3, 5). The results for all considered
types of X-ray examinations are in agreement with
the published results. The average effective doses for
considered types of X-ray examinations, including
chest PA, lumbar spine PA, urography, abdomen,

Table 1. The mean and third quartile DAP (in Gy cm2) and X-ray operating information used in the studied radiological
examinations.

Examination Sample size Patient kVp mAs Mean DAP Third quartile
thickness (cm) (Gy cm2) DAP (Gy cm2)

Chest PA 235 23.3 77.3 30.6 1.04 1.68

Lumbar spine PA þ AP 132 23.7 83.4 94 6.77 8.62
Lumbar spine LAT 161 33.6 97.1 149 12.59 18.47
Urography 157 22.3 81.2 95 7.46 10.52
Abdomen 55 19.1 89.5 101 4.63 6.57
pelvis and hip 73 20.5 76.4 71 3.84 5.76
Head/skull 65 17 74 53 1.57 2.13
Shoulder 48 16.2 71.9 27 0.66 1.05
Extremities 382 8.9 57.5 11.7 0.09 0.13

Table 2. A comparison of the patient average doses per procedure with similar surveys reported in UNSCEAR 2000 and
2007 reports.

Examination DAP (Gy cm2) Effective dose (mSv)

Syria UNSCEAR 2007 Syria UNSCEAR 2000 UNSCEAR 2007

Chest 1.04 0.084–0.439 0.125 0.14 0.01 –0.29

Lumbar spine 6.77 0.918–5.7 1.67 1.8 0.179–1.2
Urography 7.46 3.5–13 2.7 3.7 0.168–2.5
Abdomen 4.63 0.931–3.1 1.07 0.53 0.24 –1.05
Pelvis and Hips 3.84 1.609–3.1 0.86 0.83 0.168–0.75
Head/Skull 1.57 0.352–0.566 0.052 0.07 0.01 –0.06
Shoulder 0.66 0.3 0.025 — 0.001–0.011

164
 PATIENT DOSE IN DIAGNOSTIC RADIOLOGY
Figure 1. A comparison of average effective dose from
considered diagnostic X-ray examinations with similar
surveys published by the UNSCEAR 2000. AU, Australia,
FIN, Finland, GER, Germany, JPN, Japan, NL,
Netherlands, N, Norway, P, Poland, SE, Sweden, SUI,
Switzerland, UK, United Kingdom, Average, average of
health care level I countries.
pelvis and hip, head and shoulder, are 0.125, 1.67,
2.7, 1.07, 0.86, 0.05 and 0.025 mSv, respectively.
Figure 1 shows the comparison between the calcu-
lated average patient effective doses with similar
surveys published by the United Nation Scientific
Committee on the Effects of Atomic Radiation
(UNSCEAR) 2000(3) for different countries
including Australia, Finland, Germany, Japan,
Netherlands, Norway, Poland, Sweden, Switzerland
and UK. It is clear from this figure that the results
for all considered types of X-ray examinations are in
good agreement with the results of the above-men-
tioned countries published by UNSCEAR 2000.
CONCLUSIONS
The patient effective dose for all considered types of
X-ray examinations in this study are in good agree-
ment with the values reported by the UNSCEAR
2000 and 2007 reports. The average DAP values are
in line with the values for corresponding types of
X-ray examinations reported by UNSCEAR 2007.
The results of this survey will provide useful baseline
data to establish, for the first time, national DRLs in
Syria. These results can be used in the future to
evaluate the collective dose to the population from
medical exposure and the radiation risks from the
various radiological procedures.
165
ACKNOWLEDGEMENTS
The authors wish to thank Prof. I. Othman without
whose support this work would not have been poss-
ible. They also extended their thanks to the
Ministries of Health and the Ministries of Higher
Education for their collaborations. In addition,
Prof. M. S. Al-Masri Head of Protection and Safety
Department is appreciated for his comments.
Prof. A. Alaf ’s comments are also appreciated.
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