A Scalable Database of Organ Doses for Common Diagnostic Fluoroscopy Procedures of Children: Procedures of Historical Practice for Use in Radiation Epidemiology Studies - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Radiat Res . Author manuscript; available in PMC: 2026 Apr 17. Published in final edited form as: Radiat Res. 2019 Oct 14;192(6):649–661. doi: 10.1667/RR15445.1 Search in PMC Search in PubMed View in NLM Catalog Add to search A Scalable Database of Organ Doses for Common Diagnostic Fluoroscopy Procedures of Children: Procedures of Historical Practice for Use in Radiation Epidemiology Studies Emily L Marshall Emily L Marshall a J. Crayton Pruitt Family Department of Biomedical Engineering, College of Medicine, University of Florida, Gainesville, Florida Find articles by Emily L Marshall a, 1 , Dhanashree Rajderkar Dhanashree Rajderkar b Department of Radiology, College of Medicine, University of Florida, Gainesville, Florida Find articles by Dhanashree Rajderkar b , Justin L Brown Justin L Brown c Medical Physics Program, College of Medicine, University of Florida, Gainesville, Florida Find articles by Justin L Brown c , Elliott J Stepusin Elliott J Stepusin a J. Crayton Pruitt Family Department of Biomedical Engineering, College of Medicine, University of Florida, Gainesville, Florida Find articles by Elliott J Stepusin a, 2 , David Borrego David Borrego d Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Find articles by David Borrego d , James Duncan James Duncan e Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri Find articles by James Duncan e , Christina L Sammet Christina L Sammet f Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois Find articles by Christina L Sammet f , Julie R Munneke Julie R Munneke g Division of Research, Kaiser Permanente Northern California, Oakland, California Find articles by Julie R Munneke g , Marilyn L Kwan Marilyn L Kwan g Division of Research, Kaiser Permanente Northern California, Oakland, California Find articles by Marilyn L Kwan g , Diana L Miglioretti Diana L Miglioretti h Department of Public Health Sciences, University of California Davis School of Medicine, Sacramento, California i Kaiser Permanente Washington Health Research Institute, Seattle, Washington Find articles by Diana L Miglioretti h, i , Rebecca Smith-Bindman Rebecca Smith-Bindman j Department of Radiology and Biomedical Imaging, Epidemiology, and Biostatistics, and the Phillip R. Lee Institute for Health Policy Studies, The University of California - San Francisco School of Medicine, San Francisco, California Find articles by Rebecca Smith-Bindman j , Wesley E Bolch Wesley E Bolch a J. Crayton Pruitt Family Department of Biomedical Engineering, College of Medicine, University of Florida, Gainesville, Florida Find articles by Wesley E Bolch a, 3 Author information Article notes Copyright and License information a J. Crayton Pruitt Family Department of Biomedical Engineering, College of Medicine, University of Florida, Gainesville, Florida b Department of Radiology, College of Medicine, University of Florida, Gainesville, Florida c Medical Physics Program, College of Medicine, University of Florida, Gainesville, Florida d Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland e Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri f Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois g Division of Research, Kaiser Permanente Northern California, Oakland, California h Department of Public Health Sciences, University of California Davis School of Medicine, Sacramento, California i Kaiser Permanente Washington Health Research Institute, Seattle, Washington j Department of Radiology and Biomedical Imaging, Epidemiology, and Biostatistics, and the Phillip R. Lee Institute for Health Policy Studies, The University of California - San Francisco School of Medicine, San Francisco, California 1 Current address: Diagnostic Physics Residency Program, Department of Radiology, University of Chicago, Chicago, IL. 2 Current address: Data analyst, Chicago, IL. 3 Address for correspondence: Department of Biomedical Engineering, University of Florida, Gainesville, FL 32611-6550; [email protected] . Issue date 2019 Dec. PMC Copyright notice PMCID: PMC13086021 NIHMSID: NIHMS2158324 PMID: 31609677 The publisher's version of this article is available at Radiat Res Abstract Assessment of health effects from low-dose radiation exposures in patients undergoing diagnostic imaging is an active area of research. High-quality dosimetry information pertaining to these medical exposures is generally not readily available to clinicians or epidemiologists studying radiation-related health risks. The purpose of this study was to provide methods for organ dose estimation in pediatric patients undergoing four common diagnostic fluoroscopy procedures: the upper gastrointestinal (UGI) series, the lower gastrointestinal (LGI) series, the voiding cystourethrogram (VCUG) and the modified barium swallow (MBS). Abstracted X-ray film data and physician interviews were combined to generate procedure outlines detailing X-ray beam projections, imaged anatomy, length of X-ray exposure, and presence and amount of contrast within imaged anatomy. Monte Carlo radiation transport simulations were completed for each of the four diagnostic fluoroscopy procedures across the 162-member (87 males and 75 females) University of Florida/National Cancer Institute pediatric phantom library, which covers variations in both subject height and weight. Absorbed doses to 28 organs, including the active marrow and bone endosteum, were assigned for all 162 phantoms by procedure. Additionally, we provide dose coefficients (DCs) in a series of supplementary tables . The DCs give organ doses normalized to procedure-specific dose metrics, including: air kerma-area product (μGy/μGy · cm 2 ), air kerma at the reference point (μGy/μGy), number of spot films (SF) (μGy/number of SFs) and total fluoroscopy time (μGy/s). Organs accumulating the highest absorbed doses per procedure were as follows: kidneys between 0.9–25.4 mGy, 1.1–16.6 mGy and 1.1–9.7 mGy for the UGI, LGI and VCUG procedures, respectively, and salivary glands between 0.2–3.7 mGy for the MBS procedure. Average values of detriment-weighted dose, a phantom-specific surrogate for the effective dose based on ICRP Publication 103 tissue-weighting factors, were 0.98 mSv, 1.16 mSv, 0.83 mSv and 0.15 mSv for the UGI, LGI, VCUG and MBS procedures, respectively. Scalable database of organ dose coefficients by patient sex, height and weight, and by procedure exposure time, reference point air kerma, kerma-area product or number of spot films, allows clinicians and researchers to compute organ absorbed doses based on their institution-specific and patient-specific dose metrics. In addition to informing on patient dosimetry, this work has the potential to facilitate exposure assessments in epidemiological studies designed to investigate radiation-related risks. INTRODUCTION High-quality dosimetry information pertaining to medical exposures, especially of children, are important for epidemiological studies designed to quantify radiation-related health risks ( 1 – 9 ). This dosimetry information is also vital in the clinic for imaging system optimization, clinical guidance on imaging modality selection, protocol refinement of patient population-specific imaging and overall patient dose and risk management ( 10 , 11 ). The goal of the current study was to develop organ doses amenable to children and adolescents undergoing common diagnostic fluoroscopic procedures. Pediatric patients typically undergo diagnostic fluoroscopy imaging to assess in vivo structure and organ system function. In children, these procedures most commonly focus on identifying problems in either gastrointestinal (GI) or urinary tract organs. Medical complications with swallowing, aspiration, GI pain, bowel distention/obstruction and urinary tract abnormalities can be identified and resolved under fluoroscopic guidance. While diagnostic fluoroscopy procedures typically result in lower patient dose than from other imaging procedures, such as computed tomography and interventional fluoroscopy, they are nevertheless an important contributor to overall medical exposures. While modern interventional fluoroscopic imaging systems provide documentation of the patient exposure via the radiation dose structured report (RDSR), diagnostic fluoroscopy systems, including both legacy and non-upgraded current systems, do not permit RDSR reporting as would be needed for skin and organ dose assessment ( 12 – 18 ). To overcome this limitation, we have previously developed reference clinical procedure outlines (analogous to standardized RDSRs) for six common diagnostic fluoroscopy procedures performed currently on pediatric patients at the University of Florida (UF; Gainesville, FL) ( 19 ), namely: the voiding cystourethrogram (VCUG), gastric tube placement (GTP), lower gastrointestinal series (LGI), rehabilitation swallow (RS), upper gastrointestinal series (UGI) and the UGI with follow-through (UGI-FT). For each procedure, representative field placements, field sizes, imaging times and contrast percentage presented within the imaging field were specified by the UF Chief of Pediatric Radiology, and subsequently verified through clinical observation. Monte Carlo radiation transport simulations were performed for procedure-specific imaging fields (both fluoroscopic and radiographic) across the 162-member UF/NCI pediatric phantom library ( 20 ), thus giving organ doses for a variety of combinations of patient height, weight and sex. Both absolute and normalized procedural organ doses are published elsewhere ( 19 ). While this recently published organ dose database ( 19 ) is extensive and useful to contemporary (2010–present) patient dose tracking, it has potentially limited use for reconstructing historical fluoroscopic exposures of children. Prior to 2010, less dose-conscious imaging protocols with higher fluoroscopy times, less tightly collimated fluoroscopic fields and greater numbers of radiographic spot films, were used in clinical practice. Therefore, the goal of this study was to refine the contemporary procedure outlined elsewhere ( 19 ) to better reflect pre-2010 clinical practice in pediatric diagnostic fluoroscopic imaging for use in historical dose reconstruction efforts. MATERIALS AND METHODS Study Overview In this study, we analyzed procedure frequency data obtained from the Radiation-Induced Cancer (RIC) Study. The RIC Study is a NCI-funded study focused on examining imaging trends and quantifying associated cancer risks in children exposed in utero and/or postnatally to ionizing radiation via computed tomography, nuclear medicine, radiography and fluoroscopic imaging. The study includes data from seven U.S. integrated healthcare systems and Ontario, Canada. Participating U.S. systems are Kaiser Permanente (KP) Hawaii, KP Northern California, KP Northwest, KP Washington, Geisinger in Pennsylvania, Harvard Pilgrim Health Care in Massachusetts and Marshfield Clinic Health System in Wisconsin. Participating U.S. sites have healthcare information on enrollees available through the Virtual Data Warehouse (VDW), a collaborative data model structure developed by the National Cancer Institute-supported Cancer Research Network and the Health Care Systems Research Network ( 21 ). The VDW is a series of data files that capture and integrate data on all utilization, including imaging, among enrollees. For pediatric diagnostic fluoroscopy, the top four most frequently performed procedures across the participating RIC Study sites over the study period of 1996–2010 were VCUG (also called a micturating cystourethrogram or cystography) (38% of fluoroscopic examinations across the U.S. study sites), UGI (also called barium meal) (38%), LGI (also called barium enema) (9%) and MBS (also called modified barium swallow with esophagogram or video fluoroscopic swallowing examination) (7%). It was not possible to differentiate UGI examinations from UGI with small bowel follow-through (which comprised a very small fraction of UGI studies across the U.S. study sites), and these two examination types were thus included together to constitute our defined UGI study. Gastric tube placements were observed to comprise a much smaller fraction of diagnostic fluoroscopy studies, and thus were not included in the current study. Procedure Outline Development Procedure outlines were established for the four primary procedures, i.e., VCUG, UGI, LGI and MBS, through a detailed review of 40 abstracted patient image sets across the pediatric age groups (<1 year to 16 years) from 1996 to 2010. Images were selected from KP Northern California, one of the largest U.S. integrated healthcare systems. The examinations were reviewed to determine the anatomic areas imaged, number of spot films and total fluoroscopy time. The resulting procedure outlines are shown graphically in Figs. 1 – 4 for VCUG, UGI, LGI and MBS studies, respectively. These outlines were subsequently applied across the complete UF/NCI pediatric phantom library; however, for demonstration purposes, Figs. 1 – 4 show them only for our reference 5-year-old computational phantom. Each outline includes the nominal field-of-view (FOV) defining the specific anatomy of the computational phantom for both fluoroscopic sequences and radiographic spot films, the total fluoroscopy time for both the complete procedure and per individual FOV, the concentration of contrast agent (relative scale 0–100%) that is typically present in that FOV, along with the anatomical organ location of the contrast agent. FIG. 1. Open in a new tab Procedure outline for a voiding cystourethrogram (VCUG) as applied to the 5-year-old male reference phantom. Black rectangular areas denote the projected field of view. FIG. 4. Open in a new tab Procedure outline for a modified barium swallow (MBS) series as applied to the 5-year-old male reference phantom. Characterization of the Clinical Source The iterative methodology of Turner et al. ( 22 ) was applied in this study to construct a series of clinically realistic X-ray spectra for Monte Carlo radiation transport simulation on our pediatric phantoms. Half-value layer measurements were performed on a clinical fluoroscopic unit (GE Precision ™ 500D; General Electric Healthcare, Waukesha, WI) which was installed in 2004 at the UF Health Department of Radiology. The unit is an under-table X-ray system with right-to-left, superior-to-inferior and anterior-to-posterior movement of either or both the X-ray unit and table. Half-value layer measurements were performed using the 10X6-6 ionization chamber and an ACCU-Dose control unit (both from Radcalt ™ , Monrovia, CA) using high-purity aluminum sheets (AL 1100) and following the protocol of AAPM Report No. 25 ( 23 ).in Measurements were performed in service mode across the tube voltage range of 60–120 kVp and added filtration selections of 0.1–0.3 mm Cu, the results of which are shown in Table 1 . TABLE 1. Physical Measurements of Half-Value Layer at Each Tube Potential and Filtration Combination on the GE Under-Table Fluoroscope Tube potential (kVp) Filter (mm copper) HVL (mm aluminum equivalent) 60 0 2.52 80 0 3.33 a 120 0 4.95 60 0.1 3.79 a 80 0.1 4.89 120 0.1 7.11 60 0.2 4.93 a 80 0.2 6.08 120 0.2 8.37 60 0.3 5.00 80 0.3 6.43 a 120 0.3 9.27 Open in a new tab a These values were obtained via interpolation. Characterization of the Clinical Automatic Exposure Control For each of the four imaging protocols modeled in this study, fluoroscopic and radiographic exposure profiles were characterized to properly model the automatic exposure control (AEC) system of the GE Precision 500D unit. System-defined protocols for these four procedures were assigned at an imaging rate of 7.5 frames per second. Exposure profiles were quantified through physical measurement, by stacking 0.25 # high-density polyethylene (HDPE) blocks within the X-ray beam. The unit’s image receptor was extended to the maximum source-to-image distance (SID) and the Radcal Ionization Chamber was placed in front of the detector surface. As each 0.25″ block of HDPE was placed within the beam values of machine filtration, applied tube potential (kV), tube current (mA) and exit plane cumulative dose were recorded. This process was completed with 0–18″ of HDPE for each of the four separate protocols, resulting in four discrete exposure profiles. Computational Phantom Models of the Patients In this study, the pediatric members of the UF/NCI hybrid computational phantom library were used, consisting of 87 males and 75 females of various height and weight combinations as described by Geyer et al. ( 20 ). This phantom library was built via volumetric scaling of the UF series of reference phantoms of the newborn, 1-year-old, 5-year-old, 10-year-old, 15-year-old, and adult male and female as described by Lee et al. ( 24 ). Height, weight and body regional circumferential data used in phantom library construction were taken from the National Health and Nutrition Examination Surveys of the U.S. population for the period 1999–2006. In this study, organ doses were computed for 28 tissues throughout the body: breast, colon, lung, stomach, ovaries/testes, urinary bladder, esophagus, liver, thyroid, brain, salivary glands, skin, adrenal glands, extra thoracic, gall bladder, heart, kidneys, lymph nodes, muscle, oral mucosa, pancreas, uterus/prostate, small intestines, spleen, thymus, lens of the eye, active marrow and bone endosteum. Modeling of GI and Urinary Bladder Organ Contrast We included the presence of contrast agents within the X-ray imaging fields in our patient radiation transport models. For VCUG studies, the presence of iodine-based water-soluble contrast was included within the urinary bladder content, and for LGI, MBS and UGI studies, the presence of barium sulfate was included within the GI tract lumen. Further details are given by Marshall et al. ( 19 ). As shown in Fig. 2 of the current study for the UGI procedure, we modeled 100% barium contrast within the lumen of the esophagus for fluoroscopic sequence no. 1, and spot film image nos. 2–7. The barium was then portioned as 75% within the stomach content and 25% within the small intestine content for fluoroscopic sequence no. 8 and spot film image nos. 9–20. FIG. 2. Open in a new tab Procedure outline for a upper gastrointestinal (UGI) series as applied to the 5-year-old male reference phantom. Modeling of the Automatic Exposure Control For accurate estimates of patient organ dose, the automatic exposure control system of the GE Precision 500D unit had to be properly modeled during radiation transport simulation. For each procedure-specific X-ray field-of-view on each phantom from the UF/NCI phantom library, a ray-tracing algorithm was developed and applied to assign an equivalent thickness of HDPE from which values of X-ray tube technique factor (kVp, mA and beam filtration) and exit plan dose rate were assigned, based on previous clinical measurements (described above). The details of this procedure are shown graphically in Fig. 5 , and are described in detail by Marshall et al. ( 19 ). FIG. 5. Open in a new tab High-density polyethylene (HDPE) equivalent thickness determination required to equally attenuate the simulated X-ray beam for the VCUG FOV 1. The ray-tracing algorithm first opens the FOV on the phantom, a central 2.5-cm-radius cylinder is identified, and linear attenuation coefficients for all voxels encountered within this cylinder are used to compute an equivalent thickness of HDPE. The beam energy and filter are unknown at this time, so the ray-tracing algorithm computes all possible combinations (blue table). Once the theoretical thickness is computed across all possible combinations, an average thickness is computed (6.7″ in this example). This average thickness (6.7″) is then identified within the clinically measured data (white table), and filter (0.3 mm copper) and kVp (70) from the measured data which correlate to that specific thickness (6.7″) is then fed back into the theoretical thickness table. A new average thickness (6.8″) is then calculated with this kVp and filter information, and that result is fed back into the clinically measured data table. This process, back and forth between theoretical and clinically measured data, continues for 100 iterations until a reasonable estimate is found between the two datasets. Detriment-Weighted Dose In this study, organ absorbed doses were further scaled by ICRP Publication 103 tissue-weighting factors to compute a detriment-weighted dose ( E D W S , H , W ) per procedure for each phantom. The detriment-weighted dose is similar to the effective dose ( E ), but without sex-averaging of the organ-equivalent doses, and without the restriction of a 50th percentile height/weight reference phantom. The effective dose and detriment-weighted dose are thus computed, respectively, as: E = ∑ T w T ∑ R w R [ D T , R M + D T , R F 2 ] , (1) E D W S , H , W = ∑ T w T ∑ R w R D T , R S , H , W , (2) where w T is the tissue-weighting factor (relative contribution of tissue or organ T to the total health detriment resulting from uniform whole-body irradiation), w R is the radiation-weighting factor (dimensionless factor by which the organ- or tissue-absorbed dose is scaled to reflect potentially higher values of biological effectiveness for different forms of radiation type R), and D T , R M and D T , R M are the absorbed dose to tissue or organ T by radiation type R as assessed in a male ( M ) or female ( F ) hybrid computational phantom. The detriment-weighted dose, D T , R S , H , W , is the absorbed dose to a tissue or organ T by radiation type R for a specific sex ( S ), height ( H ) and weight ( W ) computational phantom. RESULTS Procedure Organ Doses Organ absorbed doses were computed for 87 male and 75 female pediatric phantoms from the UF/NCI pediatric computational phantom library for each of four fluoroscopic procedures ( Figs. 1 – 4 ). The UF/NCI pediatric phantoms range in height from 51 to 185 cm and in weight from 3 to 125 kg, thus providing a comprehensive organ dose database to which individual cohort members may be assigned on a height/weight-matching basis. Details of the four simulated procedures in this work are provided in Table 2 , and comprise the following: contrast agent, fluoroscopy time, number of spot films, average cumulative kerma-area product, average cumulative air kerma to the reference point and maximum organ dose. The diagnostic fluoroscopy system is an under-table unit, with the source emitting from under the patient lying supine on the table; thus, this geometry results in peak doses occurring in the kidneys for three of the four studies considered. The exception to this is the MBS procedure, in which the table is rotated to an upright position with the patient standing between the table and detector, where the peak dose occurs in the salivary glands as the beam primarily intercepts the patients’ right lateral side. TABLE 2. Simulated Procedure Details Procedure Contrast Fluoroscopy time (s) Spot films (no.) Kerma-area product (mGy · cm 2 ) Kerma to reference point (mGy) Maximum organ dose (mGy) VCUG Iodine 71 11 3,103 (145–15,002) 6.9 (1.2–33.5) Kidneys (9.70) UGI Barium 86 18 3,442 (187–24,841) 9.2 (1.1–66.8) Kidneys (25.4) LGI Barium 113 14 5,207 (185–28,470) 10.4 (1.5–57.0) Kidneys (16.7) MBS Barium 104 0 291 (87–798) 1.7 (0.4–5.1) Salivary glands (3.72) Open in a new tab Notes . Shown here are the contrast agent used, nominal fluoroscopy time, numbers of spot films and dosimetry results, i.e., the kerma-area product, average cumulative air kerma to the reference point (with ranges) and maximum organ dose for both pediatric males and pediatric females in the UF/NCI phantom library. VCUG=voiding cystourethrogram; UGI=upper gastrointestinal study; LGI=lower gastrointestinal study; MBS=modified barium swallow study. Detailed values of organ dose are provided in Table 3 for the VCUG procedure across the female phantoms of the UF/NCI library for the abdominopelvic region, excluding reproductive organs. A full list of organ doses, as well as detriment-weighted doses, for all procedures and all UF/NCI male and female pediatric phantoms, is provided in Supplementary Table S1 ( https://doi.org/10.1667/RR15445.1.S1 ). Figure 6 graphically compares the four highest dose organs and active marrow, per procedure, for the female phantoms closest in size to the UF age-reference phantoms. The UF/NCI library was developed down to 2 years of age, thus the reference UF hybrid (UFH) phantoms were selected for the 0-year-old (UFH00MF) and 1-year-old (UFH01MF) age points. TABLE 3. Organ Doses for Pediatric Female Patients Undergoing VCUG Fluoroscopy Exams: Abdominopelvic Excluding Reproductive Organs Phantom Organ dose (mGy) Height (cm) Weight (kg) Liver Gall bladder Pancreas Stomach Small intestines Colon Bladder Spleen Kidneys Adrenals 51 3 795 757 1,237 794 853 743 674 1,008 1,734 1,230 76 10 823 900 1,206 839 1,265 1,163 1,319 1,141 1,797 1,350 85 10 500 580 776 535 835 752 944 722 1,189 887 85 15 658 833 1,014 717 1,160 1,044 1,329 891 1,566 1,099 95 15 733 940 1,119 698 1,360 1,393 1,370 1,176 1,729 1,349 95 20 1,142 1,437 1,705 1,039 1,686 1,653 1,259 1,581 2,719 2,150 105 15 586 709 907 575 1,080 1,083 992 1,056 1,447 1,130 105 20 842 1,079 1,368 831 1,709 1,791 1,712 1,412 2,177 1,551 105 25 1,510 1,889 2,326 1,485 2,095 2,105 1,795 2,466 3,570 2,811 115 20 708 971 1,142 681 1,522 1,546 1,137 1,213 1,790 1,325 115 25 1,418 1,761 2,030 1,343 2,000 1,996 1,414 2,344 3,121 2,751 115 30 2,265 2,892 3,329 2,147 2,886 2,836 1,813 3,758 5,139 4,355 125 20 607 621 985 670 1,054 955 983 1,052 1,841 1,311 125 25 639 696 1,016 693 999 925 948 1,144 1,917 1,406 125 30 1,009 1,032 1,640 1,117 1,540 1,389 1,328 1,774 3,041 2,176 125 35 1,397 1,549 2,267 1,497 1,959 1,781 1,875 2,425 4,118 2,998 125 40 1,500 1,640 2,403 1,596 2,068 1,888 1,709 2,585 4,399 3,229 135 25 696 822 1,119 700 1,191 1,103 1,149 1,228 2,197 1,498 135 30 788 879 1,217 779 1,248 1,135 1,067 1,351 2,424 1,662 135 35 1,308 1,349 2,107 1,274 1,851 1,680 1,551 2,279 4,156 2,892 135 40 1,249 1,423 2,077 1,275 1,940 1,771 1,639 2,177 3,982 2,702 135 45 1,468 1,586 2,322 1,439 2,120 1,927 1,619 2,428 4,440 3,056 135 50 1,257 1,419 2,070 1,289 1,750 1,618 1,394 2,156 3,906 2,690 145 30 699 788 1,093 725 1,143 1,046 892 1,227 2,174 1,511 145 35 821 951 1,299 874 1,251 1,129 867 1,482 2,536 1,823 145 40 1,374 1,371 2,108 1,340 1,830 1,635 1,297 2,522 4,308 3,172 145 45 1,233 1,407 1,889 1,207 1,800 1,644 1,306 2,163 3,790 2,651 145 50 1,265 1,377 1,937 1,231 1,891 1,745 1,448 2,108 3,839 2,659 145 55 1,353 1,625 2,069 1,291 1,785 1,603 1,189 2,257 4,060 2,800 145 60 1,441 1,491 2,173 1,362 1,820 1,636 1,251 2,417 4,239 2,928 145 65 1,250 1,340 1,872 1,209 1,626 1,525 1,370 2,222 3,620 2,585 145 70 1,215 1,348 1,919 1,226 1,636 1,470 1,015 2,232 3,765 2,459 155 35 683 787 1,417 732 1,580 1,297 1,303 1,394 2,592 1,549 155 40 746 915 1,604 827 1,745 1,445 1,114 1,570 2,982 1,785 155 45 889 1,021 1,928 988 1,978 1,602 1,401 1,894 3,664 2,164 155 50 1,073 1,144 2,312 1,114 2,044 1,566 1,401 2,461 4,483 2,779 155 55 886 1,021 1,919 910 1,648 1,310 887 2,036 3,850 2,382 155 60 867 1,010 1,914 940 1,570 1,255 1,074 2,029 3,747 2,312 155 65 775 891 1,728 854 1,548 1,284 1,123 1,800 3,412 1,997 155 70 874 968 1,849 918 1,713 1,420 1,,219 1,878 3,610 2,127 155 75 816 916 1,701 859 1,536 1,282 1,160 1,742 3,259 1,979 155 80 789 882 1,640 833 1,433 1,196 1,048 1,702 3,142 1,926 155 85 880 1,016 1,888 981 1,604 1,321 1,079 1,994 3,646 2,197 155 90 952 1,094 2,080 1,061 1,865 1,530 1238 1,995 4,233 2,391 155 95 1,071 1,237 2,389 1,184 1,996 1,561 1,131 2,337 4,774 2,704 165 40 1,023 1,155 1,758 947 1,867 1,759 1,191 1,899 3,528 2,078 165 45 1,233 1,451 2,134 1,148 1,939 1,709 968 2,448 4,317 2,638 165 50 1,165 1,274 2,059 1,062 1,776 1,563 865 2,380 4,190 2,601 165 55 1,204 1,427 2,158 1,102 1,751 1,543 793 2,455 4,286 2,692 165 60 976 1,248 1,798 867 1,546 1,403 705 2,083 3,771 2,291 165 65 1,116 1,322 2,053 981 1,776 1,604 939 2,259 4,508 2,646 165 70 1,030 1,241 1,889 893 1,519 1,370 802 2,121 4,066 2,469 165 75 1,084 1,255 1,924 942 1,536 1,375 815 2,187 4,117 2,518 165 80 1,064 1,276 1,934 876 1,569 1,403 871 2,028 4,198 2,578 165 85 980 1,180 1,788 812 1,475 1,328 840 1,875 3,898 2,370 165 90 869 1,025 1,549 739 1,278 1,165 773 1,699 3,474 2,116 165 95 1,172 1,361 2,080 988 1,641 1,477 952 2,223 4,587 2,889 165 100 1,258 1,557 2,332 1,041 2,002 1,809 1,091 2,352 5,425 3,164 165 105 1,115 1,343 1,981 878 1,684 1,550 1,018 1,999 4,589 2,734 165 110 1,506 1,806 2,714 1,215 2,195 2,006 1,284 2,835 6,193 3,752 165 115 1,551 1,795 2,748 1,260 2,028 1,832 1,118 3,062 6,109 3,904 175 50 756 826 1,340 727 1,234 1,115 494 1,566 2,703 1,607 175 55 844 981 1,540 803 1,307 1,170 635 1,821 3,071 1,898 175 60 888 977 1,627 830 1,346 1,205 573 1,869 3,345 2,014 175 65 928 1,029 1,698 827 1,513 1,361 729 1,940 3,615 2,173 175 70 789 881 1,465 717 1,240 1,110 621 1,679 3,130 1,863 175 75 723 752 1,358 644 1,143 1,011 550 1,534 2,954 1,739 175 80 643 744 1,192 561 1,024 959 570 1,373 2,619 1,517 175 85 842 945 1,504 722 1,197 1,104 682 1,810 3,237 1,964 175 90 802 923 1,489 702 1,167 1,092 661 1,770 3,208 1,932 175 95 894 1,022 1,665 798 1,338 1,215 702 1,942 3,628 2,132 175 100 831 955 1,543 745 1,229 1,119 638 1,818 3,357 1,979 175 105 912 958 1,737 852 1,373 1,219 698 2,027 3,811 2,257 175 110 969 1,015 1,847 908 1,480 1,320 761 2,155 4,063 2,389 175 115 1,094 1,286 2,062 992 1,684 1,534 884 2,404 4,622 2,670 Open in a new tab FIG. 6. Open in a new tab Organ dose variations with age across the four highest dosed organs and active marrow in five female phantoms. Phantoms displayed are those closest in size to reference ages: 0-year-old (UFH00MF), 1-year-old (UFH01MF), 5-year-old (UFHPF-105 × 20), 10-year-old (UFHPF-135 × 30) and 15-year-old (UFHPF-165 × 55). Panels A–D: VCUG, UGI, LGI and MBS, respectively. Figures 7 and 8 display values of E D W S , H , W for both the UGI and LGI studies for the pediatric female phantoms and pediatric male phantoms, respectively. Figures 7A and 8A show plots of values of E D W S , H , W with respect to phantom height, while the Figs. 7B and 8B show plots of values of E D W S , H , W with respect to phantom weight. The spread of the data at any individual height or weight value thus indicates the variability within the opposite parameter, weight or height. FIG. 7. Open in a new tab Values of detriment-weighted dose ( E DW ) for the female computational phantoms by height (panel A) and weight (panel B) for the UGI and LGI diagnostic fluoroscopy procedures. FIG. 8. Open in a new tab Values of detriment-weighted dose ( E DW ) for the male computational phantoms by height (panel A) and weight (panel B) for the UGI, and LGI diagnostic fluoroscopy procedures. Phantoms 175 × 120 [ E DW (UGI) = 3.8] and 175 × 125[ E DW (UGI) = 3.7] have been omitted from this graph for enhanced visualization. Value of E D W S , H , W for the female phantom population ranged from 0.4–2.5 mSv, while the male phantoms displayed values ranging from 0.35–3.8 mSv (maximal value was seen for the 175-cm, 120-kg male phantom undergoing the UGI procedure). Color backgrounds in Figs. 7A and 8A indicate the reference phantom from which the range of UF/NCI library phantoms was originally scaled, as described by Geyer et al. ( 20 ) (blue: 1-year-old; teal: 5-year-old; yellow: 10-year-old; orange: 15-year-old; purple: adult). Organ doses and detriment-weighted doses provided in the study are a result of the procedures outlined in Figs. 1 – 4 . Scalable Organ Doses in the Form of Organ Dose Coefficients We normalized the dosimetry data to various dose metrics including: 1. air kerma at the reference point; 4 2. air kerma-area product; 3. number of spot films (SF); or 4. total fluoroscopy time. These normalized organ doses, also termed dose coefficients (DCs), can be used to estimate the organ absorbed dose when any of the given four parameters is known. Supplementary Tables 2A – D ( https://doi.org/10.1667/RR15445.1.S2A ; https://doi.org/10.1667/RR15445.1.S2B ; https://doi.org/10.1667/RR15445.1.S2C ; https://doi.org/10.1667/RR15445.1.S2D ) provide organ dose coefficients for each of the four procedures with normalization to fluoroscopy time (μGy/s), air kerma to the reference point (μGy/μGy), air kerma-area product (μGy/mGy · cm 2 ) and number of spot films (μGy/no. SF). A major caveat for the use of these dose coefficients is that it is implicitly assumed that the only difference between the actual patient exposure and the procedural outlines of Figs. 1 – 4 is the normalizing dose metric for that set of dose coefficients. For example, let us suppose that organ doses are needed for a past VCUG patient of a given sex, height and weight, but that the only historical information available for organ dose reconstruction is a total fluoroscopy time of 92.3 s. The procedural outline for the VCUG exam shown in Fig. 1 indicates a total fluoroscopy time of 71 s. Consequently, the organ dose coefficients (units of μGy/s) from Supplementary Table S2A ( https://doi.org/10.1667/RR15445.1.S2A ) may be used where the product of the dose coefficient and the 92.3 s of total fluoroscopy time would yield estimates of organ doses in μGy (a factor of 92.3/71 or 1.3 times higher than reported in Supplementary Table S1 ; https://doi.org/10.1667/RR15445.1.S1 ). Nevertheless, these efforts at organ dose reconstruction make the implicit assumption that the relative time per radiation event, entrance dose rates (fluoroscopy) and entrance doses (spot films), and presence of image contrast in the urinary bladder, remain the same as assumed in this study for historical imaging practice. Similarly, one may multiply the dose coefficients of Supplementary Tables S2B ( https://doi.org/10.1667/RR15445.1.S2B ) or S2C ( https://doi.org/10.1667/RR15445.1.S2C ) by reported values of either air kerma at the reference point or total kerma-area product, respectively. In the latter two cases, however, it is assumed that the 71 s of total fluoroscopy time remain fixed. As organ doses are least correlated with total fluoroscopy time, use of dose coefficients from Supplementary Tables S2B and S2C are recommended over those of Supplementary Table S2A , but this assumes that historical values of total reference point air kerma or total air kerma-area product are known for the patient in question. DISCUSSION This work provides a robust database of organ doses and dose coefficients for use in epidemiologic studies of pediatric patients undergoing diagnostic fluoroscopy procedures. The study data provided online in Supplementary Tables S1 and S2A – D offers enhanced utility over previously reported studies, in that the organ dosimetry is reported across the entire UF/NCI pediatric phantom library to include 87 males and 75 females of various height and weight combinations. Previously published studies of organ dosimetry in diagnostic fluoroscopy have typically reported organ doses to only a few reference (50th percentile) computational phantoms at fixed reference ages. Accessibility to an organ dose database of this magnitude enables both enhancement in patient specificity and consistency in dosimetry methods for application towards large cohort studies. Comparison of Imaging Protocols and Doses to Patients from Historical and Contemporary Practices Overall, the historical procedure outlines shown in Figs. 1 – 4 differ from those of contemporary practice (2010–present) at UF Health in the following ways: 1. an increased use of radiographic spot film images; 2. an increased imaging time per fluoroscopic sequences, and 3. Wider collimation for many of the fluoroscopic fields. Total fluoroscopy times for the historical UGI, LGI and MBS procedures are 86, 113 and 104 s, respectively, while they are 60, 25 and 15 s in contemporary procedures ( 19 ). It is not clear whether these changes reflect a national trend towards using lower doses in fluoroscopy due to a greater awareness of optimization in current day practice, or if they reflect differences in practice representative of geographic location. However, based on the steep increase in the amount of published literature and public campaigns surrounding dose awareness, after induction of the Image Gentlyt ® program, it is expected that a heightened awareness is driving these differences ( 25 – 28 ). Total fluoroscopy time of the historical VCUG procedure is lower than in its contemporary procedure (71 s vs. 120 s), which may reflect the current-day practice of minimizing spot-film exposures. The UF Health protocol for the VCUG procedure assigns ten fluoroscopic fields and zero radiographic spot images, while the current study assigns only two fluoroscopic fields and eleven radiographic spot images. In Table 4 , we report values of fluoroscopy time, numbers of spot films and the detriment-weighted dose by reference age (averages values for the male and female phantoms at each reference age) for each of the four historical diagnostic fluoroscopy procedures considered in the RIC Study. Additionally, we compare these values to their corresponding contemporary values at UF ( 19 ). The procedure outlines in this study are associated with historical radiology practice in which fluoroscopy times were noted to be substantially longer for the LGI and MBS studies, and the number of spot films were substantially higher for the VCUG, UGI and LGI studies. Organ doses, and subsequently detriment-weighted dose, are noted to differ accordingly, with dose increases (historical over contemporary procedures) from 8.5% to a maximal value of 771%. The VCUG procedure on the newborn phantom showed the smallest percentage increase in E DW , from 0.471 mSv (contemporary) to 0.512 mSv (historical). Changes in the procedure outline for the VCUG study between historical and contemporary clinical practice are shown to be relatively minimal. The irradiated anatomy is similar, and fluoroscopy times decrease to 71 s, but in this study 11 spot films were taken (historical), compared to the none reported elsewhere ( 19 ) (contemporary). This large number of spot films likely compensates for the lower fluoroscopy time, ultimately resulting in a higher value of E D W S , H , W to all phantoms undergoing historical fluoroscopic imaging procedures. The LGI procedure on the 5-year-old reference phantom is reported to produce a detriment-weighted dose ( Table 4 ) of 0.074 mSv (contemporary) compared to 0.648 mSv (historical), the largest percentage difference (771%) observed. TABLE 4. Comparison of Detriment-Weighted Dose (Average of Male and Female Phantoms at each Age) Procedure Fluoroscopy time (s) Spot films (no.) Detriment-weighted dose E DW (mSv) 0 year (51 cm, 3 kg) 1 year (76 cm, 10 kg) 5 years (105 cm, 20 kg) 10 years (135 cm, 30 kg) 15 years (165 cm, 55kg) VCUG Current study 71 11 0.512 0.628 0.752 0.655 0.930 UF 120 0 0.471 0.714 0.665 0.806 0.851 UGI Current study 86 18 0.830 0.893 0.462 0.509 0.676 UF 85 1 0.310 0.364 0.294 0.266 0.284 LGI Current study 113 14 0.564 0.607 0.648 0.673 1.143 UF 25 1 0.132 0.126 0.074 0.092 0.163 MBS Current study 104 0 0.301 0.437 0.279 0.186 0.213 UF 15 0 0.043 0.063 0.040 0.027 0.031 Open in a new tab Notes . Comparisons are given for the current study representing historical practice, and values reported for current clinical practice at the University of Florida (UF), as reported elsewhere ( 19 ). VCUG = voiding cystourethrogram; UGI = upper gastrointestinal series; LGI = lower gastrointestinal series; MBS = modified barium swallow; UF = University of Florida. Figure 9 displays the E DW data shown in Table 4 across the two studies. Points along a unit-slope line would suggest no differences in E DW values between contemporary clinical practice (abscissa) and historical clinical practice (ordinate). The majority of data points lie above this line, indicating that patient organ doses and thus, detriment-weighted doses, are higher when historical clinical imaging procedures are applied. Each procedure includes five dose data points corresponding to the phantoms of closest anatomical match to the reference UF/NCI newborn, 1-year-old, 5-year-old, 10-year-old and 15-year-old phantoms. When comparing the UGI procedures between these two data sets, the dose values from UGI with follow-through (UGI-FT), from the prior work (contemporary), were used for comparison. It was unclear in the historical review if studies were exclusively of the upper GI component or if they included a follow-through component. For this reason, it is assumed that they likely were a combination of the two and thus, doses are compared here to the values reported in ( 19 ) for UGI-FT studies. FIG. 9. Open in a new tab Visual representative dose comparison between the work presented in this study and previously published work to reflect current radiology department imaging practices. Comparisons with Literature Values To date, multiple studies employing a wide variety of dosimetry techniques have quantified values of effective dose ( E ) to pediatric patients undergoing diagnostic fluoroscopy procedures. Values of E S,H,W DW in this study may be compared to values of E reported in published literature. In making these comparisons, it is important to note that diagnostic fluoroscopy units come in two broad configurations: those with the X-ray tube underneath the patient table (more common in North America) and those with the X-ray tube over the patient table (more common in Europe). Over-table X-ray systems generally result in higher doses to organs which lie anterior within the body. These differences in system and irradiation geometries will affect which patient organs receive maximal dose from a given procedure, and thus will affect the values of both effective and detriment-weighted dose. Studies by Emigh et al. ( 29 ) and Lee et al. ( 30 ) of organ dose estimates were performed for patients imaged with the same under-table GE Precision 500D fluoroscopy system as investigated in the current study. Their studies sought to report values of effective dose for both pediatric UGI and VCUG procedures, respectively. They applied Monte Carlo methods, with in-clinic phantom and MOSFET dosimeter validation, for the calculation of pediatric effective dose to newborns, 1-year-olds, 5-year-olds and 10-year-olds. Emigh et al. ( 29 ) developed a standard procedure for UGI studies of 3.6 min of fluoroscopy time with four spot films, with the resulting effective dose ranging from 0.27 mSv to 0.77 mSv and a peak organ dose to the liver. This standard procedure made use of tightly collimated fields and two projection angles, a lateral and a posterior-anterior view, creating variations in the posterior and lateral organ proximities to the source. Percentage differences between the detriment-weighted dose reported here and the effective dose of the Emigh et al. findings were between −32% to +200%, with negative and positive percentage differences implying that detriment-weighted doses were lower or higher, respectively, than effective doses reported in their study. Several other studies utilizing over-table systems cite UGI effective doses between 0.3 mSv to 5.4 mSv for patients under 5 years of age ( 31 – 33 ). Lee et al. ( 30 ), also investigating patient doses imaged with the GE Precision 500D under-table system, developed a standard procedure for the VCUG, citing 1 min of fluoroscopy time with five spot films for which the effective dose ranged from 0.1 mSv to 0.55 mSv with peak doses occurring in the gonads and colon. Differences in collimation behavior between the VCUG protocols again contributed to large differences in doses, with the study by Lee et al. applying a narrow collimation area to the pelvic region, thus steeply increasing dose to the organs in this region of the patient. In the literature the over-table systems effective doses for VCUG studies cited are from 0.56 mSv to 1.12 mSv for patients under 5 years of age ( 32 , 34 ). Few studies have been published on the two remaining procedures, the LGI and MBS, for the pediatric patient population. In their published study, Sulieman et al. computed pediatric effective dose, for the LGI (i.e. barium enema) and MBS, as 0.3 ± 0.9 mSv and 0.2 ± 1.6 mSv, respectively, using reference point air kerma to effective dose conversion coefficients (mean ± standard deviation) ( 33 ). These values are comparable to the historical imaging data of this study, where we report an LGI detriment-weighted dose of 0.99 ± 0.36 mSv and a MBS detriment-weighted dose of 0.19 ± 0.12 mSv, for phantoms classified as less than 15 years of age. High inter-study organ dose variability is a result of differences in fluoroscopy systems, measurement techniques or even the population-averaged procedure protocols developed for each respective clinical site. Much like our current work, all previously published studies have generated an average procedure protocol to quantify the dose from diagnostic fluoroscopy procedures. While the protocols across the different studies share similarities, minor differences in FOV, beam on time and use of contrast agent, likely contribute to variations in the reported values of effective dose to pediatric patients. Study Limitations There are several limitations of the current study that should be noted. One limitation is that the rigidly defined irradiated FOVs within each procedure outline make scaling of organ-specific doses difficult. For this reason, after completing the prior work on current-day procedures (2016–present), we made the effort to develop outlines representative of an earlier era, one prior to the introduction of the Image Gently and Step Lightly campaigns ( 27 , 35 ). The large differences in reported effective doses identified during this study’s comprehensive literature review demonstrate the reality of this prediction. Small changes in different institutions’ procedurally defined FOVs are manifesting in differences of up to 200% in organ dose differences. In addition, since the UF/NCI phantom library is based upon U.S. body morphometry data for patients 2 years and older, we were limited to using only the UF/NCI reference newborn and 1-year-old in the current datasets. The definitive methods by which contrast is modeled across each procedure may also be considered a limitation, as individual variations in contrast tissue distribution cannot be addressed without reconstructing different tissue models and re-transporting the X-ray photons. These limitations are consistent with those we have outlined previously ( 19 ). CONCLUSIONS In the current study, Monte Carlo radiation transport simulations were used, along with standardized imaging procedure outlines, to estimate organ and detriment-weighted doses ( E DW ) for pediatric patients undergoing four common diagnostic fluoroscopy procedures for historical clinical practice (approximately 1996–2010). Procedure outlines were developed and validated through a comprehensive retrospective review of patient procedure data spanning from the late 1990s to the late 2000s within a large-scale epidemiology study. Procedures ranged in fluoroscopic beam-on time from 71 to 113 s supplemented with 0 to 18 spot films. Mean values of sex-averaged detriment-weighted doses were 0.83 mSv for the voiding cystourethrogram, 1.16 mSv for lower GI studies, 0.15 mSv for modified barium swallows and 0.99 mSv for upper GI studies. This work provides a comprehensive pediatric organ dose database tailored to cover a range of patient body sizes, and allows clinicians and researchers to compute organ absorbed doses based on available procedure-specific metrics. In addition to informing patient dosimetry, this work may help facilitate the exposure assessment in epidemiological studies designed to investigate radiation-related health risks. Supplementary Material Annex B.1 NIHMS2158324-supplement-Annex_B_1.xlsx (183.2KB, xlsx) Annex B.2 NIHMS2158324-supplement-Annex_B_2.xlsx (154.4KB, xlsx) Annex A NIHMS2158324-supplement-Annex_A.xlsx (170.9KB, xlsx) Annex B.3 NIHMS2158324-supplement-Annex_B_3.xlsx (165.1KB, xlsx) Annex B.4 NIHMS2158324-supplement-Annex_B_4.xlsx (139.6KB, xlsx) Editor’s note. The online version of this article (DOI: https://doi.org/10.1667/RR15445.1.S1 ) contains supplementary information that is available to all authorized users. FIG. 3. Open in a new tab Procedure outline for a lower gastrointestinal (LGI) series as applied to the 5-year-old male reference phantom. ACKNOWLEDGMENTS This work was supported by the National Cancer Institute (NCI grant no. R01 CA185687). The work of the first author (ELM) was further supported by a Selected Professions Graduate Fellowship from the American Association of University Women. The work of the second author (DR) was supported in part by fellowship 1F31CA159464 from the NCI. We acknowledge University of Florida Research Computing for providing computational resources and support that have contributed to the research results reported in this published study ( http://researchcomputing.ufl.edu ). Footnotes 4 The reference point is defined as 15 cm from the isocenter (X-ray tube side) along the central axis of the X-ray field. REFERENCES 1. Linet MS, Kim KP, Rajaraman P. Children’s exposure to diagnostic medical radiation and cancer risk: epidemiologic and dosimetric considerations. Pediatr Radiol 2009; 39:S4–26. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Linet MS, Slovis TL, Miller DL, Kleinerman R, Lee C, Rajaraman P, et al. Cancer risks associated with external radiation from diagnostic imaging procedures. CA Cancer J Clin 2012; 62:75–100. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012; 380:499–505. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013; 346:f2360. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Journy N, Ancelet S, Rehel JL, Mezzarobba M, Aubert B, Laurier D, et al. Predicted cancer risks induced by computed tomography examinations during childhood, by a quantitative risk assessment approach. Radiat Environ Biophys 2014; 53:39–54. [ DOI ] [ PubMed ] [ Google Scholar ] 6. Huang WY, Muo CH, Lin CY, Jen YM, Yang MH, Lin JC, et al. Paediatric head CT scan and subsequent risk of malignancy and benign brain tumour: a nation-wide population-based cohort study. Br J Cancer 2014; 110:2354–60. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Krille L, Dreger S, Schindel R, Albrecht T, Asmussen M, Barkhausen J, et al. Risk of cancer incidence before the age of 15 years after exposure to ionising radiation from computed tomography: results from a German cohort study. Radiat Environ Biophys 2015; 54:1–12. [ DOI ] [ PubMed ] [ Google Scholar ] 8. Bosch de Basea M, Pearce MS, Kesminiene A, Bernier MO, Dabin J, Engels H, et al. EPI-CT: design, challenges and epidemiological methods of an international study on cancer risk after paediatric and young adult CT. J Radiol Prot 2015; 35:611–28. [ DOI ] [ PubMed ] [ Google Scholar ] 9. Berrington de Gonzalez A, Salotti JA, McHugh K, Little MP, Harbron RW, Lee C, et al. Relationship between paediatric CT scans and subsequent risk of leukaemia and brain tumours: assessment of the impact of underlying conditions. Br J Cancer 2016; 114:388–94. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 10. ICRP. ICRP Publication 105: Radiation protection in medicine. Annals of the ICRP. 2007; 37:1–63. [ Google Scholar ] 11. ICRP. ICRP Publication 135: Diagnostic reference levels in medical imaging. Ann ICRP. 2017; 46:1–143. [ Google Scholar ] 12. Johnson PB, Borrego D, Balter S, Johnson K, Siragusa D, Bolch WE. Skin dose mapping for fluoroscopically guided interventions. Med Phys 2011; 38:5490–9. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 13. Johnson PB, Geyer A, Borrego D, Ficarrotta K, Johnson K, Bolch WE. The impact of anthropometric patient-phantom matching on organ dose: a hybrid phantom study for fluoroscopy guided interventions. Med Phys 2011; 38:1008–17. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 14. Dashkoff N, Bednarek D, Rana V, Rudin S. TCT-317. Implementation of a real-time skin dose tracking system in a cardiac catheterization laboratory (Abstract). J Am Coll Cardiol 2012; 60:B90. [ Google Scholar ] 15. Rana V, Bednarek D, Wu J, Rudin S. Development of graphic patient models for a real-time skin dose tracking system (DTS) for fluoroscopic interventional procedures (Abstract). Med Phys 2012; 39:3631. [ Google Scholar ] 16. Borrego D, Siragusa DA, Balter S, Bolch WE. A hybrid phantom system for patient skin and organ dosimetry in fluoroscopically guided interventions. Med Phys 2017; 44:4928–42. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 17. Marshall E, Borrego D, Tran T, Fudge J, Bolch W. Evaluation of the UF/NCI hybrid computational phantoms for use in organ dosimetry of pediatric patients undergoing fluoroscopically guided cardiac interventions. Phys Med Biol 2018; 63:055006. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 18. Marshall EL, Borrego D, Fudge JC, Rajderkar D, Bolch WE. Organ doses in pediatric patients undergoing cardiac-centered fluoroscopically guided interventions: Comparison of three methods for computational phantom alignment. Med Phys 2018; 45:3926–38. [ Google Scholar ] 19. Marshall E, Rajderkar D, Brown J, Stepusin E, Borrego D, Bolch W. A scalable database of organ doses for common diagnostic fluoroscopy examinations of children: Procedures of current practice at the University of Florida. Phys Med Biol 2019; 64:134023. [ Google Scholar ] 20. Geyer AM, O’Reilly S, Lee C, Long DJ, Bolch WE. The UF/NCI family of hybrid computational phantoms representing the current US population of male and female children, adolescents, and adults–application to CT dosimetry. Phys Med Biol 2014; 59:5225–42. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 21. Ross TR, Ng D, Brown JS, Pardee R, Hornbrook MC, Hart G, et al. The HMO Research Network Virtual Data Warehouse: A public data model to support collaboration. Egems 2014; 2:1049. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 22. Turner AC, Zhang D, Kim HJ, DeMarco JJ, Cagnon CH, Angel E, et al. A method to generate equivalent energy spectra and filtration models based on measurement for multidetector CT Monte Carlo dosimetry simulations. Med Phys 2009; 36:2154–64. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 23. Protocols for the radiation safety surveys of diagnostic radiological equipment. AAPM Report No. 25. Alexandria, VA: American Association of Physicists in Medicine; 1988. [ Google Scholar ] 24. Lee C, Lodwick D, Hurtado J, Pafundi D, Williams JL, Bolch WE. The UF family of reference hybrid phantoms for computational radiation dosimetry. Phys Med Biol 2010; 55:339–63. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 25. Goske MJ, Applegate KE, Boylan J, Butler PF, Callahan MJ, Coley BD, et al. The ‘Image Gently’ campaign: increasing CT radiation dose awareness through a national education and awareness program. Pediatr Radiol 2008; 38:265–9. [ DOI ] [ PubMed ] [ Google Scholar ] 26. Strauss KJ, Goske MJ, Frush DP, Butler PF, Morrison G. Image Gently Vendor Summit: working together for better estimates of pediatric radiation dose from CT. AJR Am J Roentgenol 2009; 192:1169–75. [ DOI ] [ PubMed ] [ Google Scholar ] 27. Sidhu M, Coley BD, Goske MJ, Connolly B, Racadio J, Yoshizumi TT, et al. Image Gently, Step Lightly: increasing radiation dose awareness in pediatric interventional radiology. Pediatr Radiol 2009; 39:1135–8. [ DOI ] [ PubMed ] [ Google Scholar ] 28. Sidhu MK, Goske MJ, Coley BJ, Connolly B, Racadio J, Yoshizumi TT, et al. Image gently, step lightly: increasing radiation dose awareness in pediatric interventions through an international social marketing campaign. J Vasc Interv Radiol 2009; 20:1115–9. [ DOI ] [ PubMed ] [ Google Scholar ] 29. Emigh B, Gordon CL, Connolly BL, Falkiner M, Thomas KE. Effective dose estimation for pediatric upper gastrointestinal examinations using an anthropomorphic phantom set and metal oxide semiconductor field-effect transistor (MOSFET) technology. Pediatr Radiol 2013; 43:1108–16. [ DOI ] [ PubMed ] [ Google Scholar ] 30. Lee R, Thomas KE, Connolly BL, Falkiner M, Gordon CL. Effective dose estimation for pediatric voiding cystourethrography using an anthropomorphic phantom set and metal oxide semiconductor field-effect transistor (MOSFET) technology. Pediatr Radiol 2009; 39:608–15. [ DOI ] [ PubMed ] [ Google Scholar ] 31. Damilakis J, Stratakis J, Raissaki M, Perisinakis K, Kourbetis N, Gourtsoyiannis N. Normalized dose data for upper gastrointestinal tract contrast studies performed to infants. Med Phys 2006; 33:1033–40. [ DOI ] [ PubMed ] [ Google Scholar ] 32. Dimitriadis A, Gialousis G, Makri T, Karlatira M, Karaiskos P, Georgiou E, et al. Monte Carlo estimation of radiation doses during paediatric barium meal and cystourethrography examinations. Phys Med Biol 2011; 56:367–82. [ DOI ] [ PubMed ] [ Google Scholar ] 33. Sulieman A, Elhag B, Alkhorayef M, Babikir E, Theodorou K, Kappas C, et al. Estimation of effective dose and radiation risk in pediatric barium studies procedures. Appl Radiat Isot 2018; 138:40–4. [ DOI ] [ PubMed ] [ Google Scholar ] 34. Yakoumakis E, Dimitriadis A, Makri T, Karlatira M, Karavasilis E, Gialousis G. Verification of radiation dose calculations during paediatric cystourethrography examinations using MCNP5 and PCXMC 2.0 Monte Carlo codes. Radiat Prot Dosimetry. 2013; 157:355–62. [ DOI ] [ PubMed ] [ Google Scholar ] 35. Goske MJ, Frush DP, Schauer DA. Image Gently campaign promotes radiation protection for children. Radiat Prot Dosimetry. 2009; 135:276. [ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. 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