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Prot."],"published-print":{"date-parts":[[2023,12,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:p>The diagnostic reference level (DRL) is an effective tool for optimising protection in medical exposures to patients. However regarding air kerma at the patient entrance reference point (<jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub>), one of the DRL quantities for endoscopic retrograde cholangiopancreatography (ERCP), manufacturers use a variety of the International Electrotechnical Commission and their own specific definitions of the reference point. The research question for this study was whether <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub> is appropriate as a DRL quantity for ERCP. The purpose of this study was to evaluate the difference between <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub> and air kerma incident on the patient\u2019s skin surface (<jats:italic>K<\/jats:italic>\n                  <jats:sub>a,e<\/jats:sub>) at the different height of the patient couch for a C-arm system. Fluoroscopy and radiography were performed using a C-arm system (Ultimax-i, Canon Medical Systems, Japan) and a over-couch tube system (CUREVISTA Open, Fujifilm Healthcare, Japan). <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,e<\/jats:sub> was measured by an ion chamber placed on the entrance surface of the phantom. Kerma-area product (<jats:italic>P<\/jats:italic>\n                  <jats:sub>KA<\/jats:sub>) and <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub> were measured by a built-in <jats:italic>P<\/jats:italic>\n                  <jats:sub>KA<\/jats:sub> meter and displayed on the fluoroscopy system. <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,e<\/jats:sub> decreased while <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub> increased as the patient couch moved away from the focal spot. The uncertainty of the <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,e<\/jats:sub>\/<jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub> ratio due to the different height of the patient couch was estimated to be 75%\u201394%. <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub> may not accurately represent <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,e<\/jats:sub>. <jats:italic>P<\/jats:italic>\n                  <jats:sub>KA<\/jats:sub> was a robust DRL quantity that was independent of the patient couch height. We cautioned against optimising patient doses in ERCP with DRLs set in terms of <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub> without considering the patient couch height of the C-arm system. Therefore, we recommend that <jats:italic>K<\/jats:italic>\n                  <jats:sub>a,r<\/jats:sub> is an inappropriate DRL quantity in ERCP using the C-arm system.<\/jats:p>","DOI":"10.1088\/1361-6498\/ad0a9d","type":"journal-article","created":{"date-parts":[[2023,11,8]],"date-time":"2023-11-08T17:21:16Z","timestamp":1699464076000},"page":"041510","update-policy":"https:\/\/doi.org\/10.1088\/crossmark-policy","source":"Crossref","is-referenced-by-count":8,"title":["Fundamental study on diagnostic reference level quantities for endoscopic retrograde cholangiopancreatography using a C-arm fluoroscopy system"],"prefix":"10.1088","volume":"43","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1018-9145","authenticated-orcid":true,"given":"Hiroki","family":"Ishii","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0913-2777","authenticated-orcid":true,"given":"Koichi","family":"Chida","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yohei","family":"Inaba","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Keisuke","family":"Abe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shu","family":"Onodera","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masayuki","family":"Zuguchi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"266","published-online":{"date-parts":[[2023,11,23]]},"reference":[{"key":"jrpad0a9dbib1","doi-asserted-by":"publisher","first-page":"W335","DOI":"10.2214\/AJR.13.12029","type":"journal-article","article-title":"Patient skin reactions from interventional fluoroscopy procedures","volume":"202","author":"Balter","year":"2014","journal-title":"Am. 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