Journal of— E n g l is h e d itioi t io n —1920※23ページから106ページまで掲載の英文コンテンツは，昨年JART会誌に掲載された学術論文を英訳したものです．

F o r e w o r dRegarding Publication of the
English Edition
Yasuo Nakazawa (President)

The journal of the Japan Association of Radiological Technologists (JART) has a monthly circulationof around 30,000 copies, and has been well received by our members and the public. The JART
journal fulfils three major roles. First, in collaboration with the Japanese public and medical
professionals, it publishes seminars on lifelong learning, thereby improving access to high-quality
medical technology. Second, it publishes field-specific information on scientific technology andclinical radiology-related research papers written by JART members. Third, through the preface andintroduction of the journal, it stimulates discussion on future possibilities for medical care in Japan,
and on how clinical radiologists can contribute to the wellbeing of the nation.
To give our radiological technologists from across the globe an insight into our business, I will
briefly explain the history of JART. In March 1896, we succeeded in taking the first X-ray image inJapan. In 1897, Shimadzu Corporation released an X-ray generator for educational use. In 1925,
there were approximately 1,500 X-ray technicians. In 1927, the first Shimadzu X-ray Technician
Training Institute was established, and evidence-based education was put in place. JART wasfounded in 1947 to make “radiological technologist” a national qualification. Since its establishment,
we have worked towards broad acceptance of this national qualification, in collaboration with thegovernment, the Diet, the Japanese Medical Association, and occupational military authorities.
As a result of our blood, sweat, and tears, in June 1951, we were finally able to see thepromulgation of the Radiology X-ray Technicians Act, Act No. 226 of 1951. Since then, we have
responded to the changing needs of the society, revising the original act to get the Radiology X-ray
Technicians Act of 1968 passed, and partially revising that to get the Radiology Technicians Act andRadiology X-ray Technicians Act of 1983 passed, and finally getting the Radiology Technicians Act,
which is in place currently, passed. Back then, the scope of work was limited to general X-ray
testing, television X-ray testing, angiography, X-ray computed tomography scanning, RI scanning,
and radiation therapy. In 1993, the Radiology Technicians Act was further revised, and MRI
scanning, ultrasonic testing, and non-mydriatic fundus camera examination were added to the list.
In 2010, image interpretation assistance, radiation examination explanation, and consultation work
were added. In April 2015, intravenous contrast agent injection using automated contrast injectors,
needle removal and hemostasis, lower digestive tract examination (anal catheter insertion andadministration of contrast medium), anal catheter insertion, and oxygen inhalation during radiation
therapy were further added as new operations that could be performed by radiological
technologists.
JART will continue to respond to the needs of the medical industry, and we hope to broaden theoperational scope of radiological technologists based on our foundation in scientific evidence. We
will feature clinical, educational, and research-based achievements by radiological technologists inthe monthly issues of the JART journal, and continually work to improve the magazine. I truly hopethat this English edition will benefit radiological technicians worldwide.

22（130）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Arts and Sciences
the original work

Received February 20, 2017; accepted October 2, 2017

Operation and accuracy verification of image
interpretation assistance by radiological technologists
Junichi Tsudukihashi1），Yoshihiro Shiroishi1），Koji Hoshi2）
1）Department of Radiological Technology, Public interest foundation corporation Hoshi General Hospital2）Department of Radiology, Public interest foundation corporation Hoshi General Hospital

Key words: image interpretation assistance, radiological technologists, image interpretation conference【Abstract】

In June 2016, our hospital initiated image interpretation assistance. As part of the procedure, image interpretation
discussions were conducted by a radiologist for 30 minutes each week for 2 years to improve the ability ofinterpreting images. I decided to include comments on image interpretation observations in the Radiology Information
System (RIS). The overall concordance rate of observations with a radiologist was approximately 88% based on the
results of the accuracy verification of images and interpretation observation comments six months since starting image
interpretation assistance. In addition, no statistically significant difference was observed between the concordance rate
and the years of experience of the radiological technologists. In the questionnaire provided to doctors, evaluation forimage interpretation assistance by the radiological technologists was high.

Introduction
On April 30, 2010, the Medical Director General of the Ministry of Health, Labour and Welfare “About promotion of team medicine bycollaboration and cooperation of medical staff ”(medical consultation 0430 No.1) clearly statedthe additional role of radiological technologists
in image interpretation assistance and explanation of examination.
I believe that radiological technologists
should be involved in medical teams. However, the implementation of such assistance inthe setting of real-life hospital management remains unknown.
There are various forms of image interpretation assistance, and description of abnormal
findings in gastric radiography, mammography,
nuclear medicine examinations, etc., which arenormally performed in the work place, are also
considered to be part of image interpretation
assistance work. At our hospital, we still cannot afford the time to implement image interpretation assistance work by radiological tech-

nologists on regular working days, and imaging diagnosis by radiologists at any time needs
to be conducted from time to time.
In the Fukushima radiological technologists
association scientific meeting in February 2014,
under the Masakazu Shinzato academic committee chairman (now Fukushima radiological
technologists association chairman), a symposium of the image interpretation assistance washeld. The contents of the symposium were as
follows: “About image interpretation assistance in diagnostic imaging”
Mr. Kyoichi Kato(Showa Graduate School of Health andMedical Science)“Practice of keeping interpretation in emergency area”
Mr. Daisuke Unai
(St. Lukeʼs International Hospital)“Efforts toward skill improvement of image interpretation assistance”
Mr. Keiji Sakashita(Rinku General Medical Center)
Arts and Sciences ◆ 23（131）07

In this symposium, it was considered appropriate to utilize image interpretation assistancein emergency medical care, and the role of image interpretation assistance work at our hospital became clear. In many institutions, although radiological technologists are in attendance at night or on closed days, radiologists
are not, and if image examination needs to bedone during this time, doctors in charge at thattime often perform the interpretation. In addition, the doctor in charge at that time often
carries out image interpretation outside his/her specialized field, and it is presumed that
his/her diagnosis will be accurate. In addition,
there are times when a doctor working at nightis a medical intern, and under such circumstances, a radiological technician who observes
images on a daily basis is required to identify
abnormal findings more efficiently.

1. Purpose
When the radiologist is absent, image interpretation assistance by radiological technologists at our hospital is performed based oncomputed tomography (CT) and magnetic resonance imaging (MRI) scans generated. In
view of this, we aimed to improve the interpretation ability of diagnostic radiological technologists and operation of image interpretation
assistance work, verify the accuracy of image
interpretation assistance work by radiological
technologists, and evaluate image interpretation assistance work performed by doctors.

2. Method
2-1. Improve interpretation ability

To perform image interpretation assistance,
we believed that the interpretation ability of
individual radiological technologists had to improve, and thus, since April 2014, in luncion
format once a week, image interpretation discussions with radiologists were initiated. The
contents of the discussion were as follows.

24（132）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

・A radiologist selected cases based on past

examination and commentary.
・Commentary repeated high frequency andurgency cases.
・Commentary on cases where radiological
technologists found it difficult to interpret
image.
・Radiological technologists are advised on image reconstruction.
・The person in charge of records and keeps
the contents on the day.
For those radiological technologists who
were unable to participate in image interpretation discussions because of being on vacation
etc., the content of the image interpretation
discussion should be checked at a later date.
Although the image interpretation discussion
is now also conducted with the aim of improving the image interpretation ability of radiological technologists, the awareness that describes
the interpretation findings comment after theexamination.
2-2. Procedure of image interpretation assistance work
To prepare the image interpretation assistance work, operating regulations were established. An accurate reporting to the doctor,
convenience of image interpretation assistancework by radiological technologists, further education of radiological technologists, etc., were
formulated, and operational policy of the following contents was formulated.
・As a form to be reflected in the electronic
medical record, a comment on the image interpretation findings is included in the examination comment column of RIS.
・Describe only the lesion and condition related to the main complaint.
・Use disease name.
・Radiological technologists describes the state
the name of its own.
・Priority is given to the examination and photography.
・Ensuring that the content and format of the

the original work
Operation and accuracy veriﬁcation of image interpretation assistance by radiological technologists

technicianʼs report will have no legal implications.
In addition, explanation was provided to thedoctor on duty to obtain approval on the secondary emergency designation day. By adding
one work system of radiological technologists,
we prepared the image interpretation assistance work system, and in June 2016, we started using the image interpretation assistanceprovided by more radiological technologists.

tion between radiological technologists andradiologists.
The data obtained were analyzed by the
Kruskal-Wallis test and the post-hoc test using
the free statistical analysis software Easy R(EZR). P <0.05 was considered significant.
The aggregation and analysis were performedby one author.
2-4. Evaluation of image interpretation assistance work by a doctor

2-3. Verification of the accuracy of image interpretation assistance by radiological technologists

In order to verify the accuracy of interpretation assistance by radiological technologists,
we verified 1,027 cases of image interpretation
assistance for which the name of the technician was specified during the 6-month period
from June 2016 when interpretation assistance
was initiated to November 2016. The referral of
the image interpretation reports was approvedby the hospital ethics committee.
The included radiological technologists weredivided into three groups depending on theyears of experience of the radiological technologists who performed image interpretation assistance:• ≥10 years (n = 6)
• 5 –10 years (n = 7)
• <5 years (n = 10)
The items to be considered were as follows:・Number and average of comments provided
during image interpretation assistance by radiological technologists.
・Number and rate of consistent comments between radiological technologists and radiologists.
・Number and rate of inconsistent comments
between radiological technologists and radiologist.
・Number and rate of over-reported comments
by radiological technologists.
・Number and rate of differences in interpreta-

A questionnaire (shown in Table 1) was administered to a doctor who analyzed the image
interpretation assistance work performed by
the radiological technologists. In addition, thequestionnaire was bearer and went in freeform submission.
Table 1 Questionnaire to medical doctors involved
in image interpretation assistance
1, Please specify your work type
Medical Doctor □ Emergency work (+)□ Emergency work ( - )□ Medical intern
2, Did you know that radiological technologists are
performing image interpretation assistance work ?
□ Known□ Neither
3, What do you think about this effort ?
□ Evaluated□ Evaluated a little□ Neither□ Not much evaluated□ Not evaluated4, What do you think about the content of thecomments ?
□ Satisfied□ Slightly satisfied□ Neither□ Not so much satisfied□ Not satisfied
5, Radiological technologists record the name of thedisease in the comment. What do you think aboutthat ?
□ Lucid□ Lucid a little□ Neither□ Better not use□ Not use
6, Do you refer to the comments ?
□ Always reference □ Rarely for reference□ Neither □ Not much reference □ Not reference
7, Are there cases in which the comments were useful?
□ Yes
□ No
8, Do you think that this approach should continue
in the future ?
□ Should continue□ Neither□ Should stop
9, If you have any other requests, please write.
()

Arts and Sciences ◆ 25（133）073. Results
3-1. Improved image interpretation ability

Since initiating interpretation discussions, it
took approximately 2 years for radiological
technologists to begin image interpretation assistance. Originally, it was planned to begin
image interpretation assistance from the firstyear since initiating interpretation discussions.
However, less-experienced radiological technologists are often hesitant to write comments
about their interpretation of the findings. Afterone yearʼs experience, we attempted to dispel
this sense of hesitance to increase their confidence in the interpretation process.

improve standards. In addition, the entry of theinterpretation in the electronic medical record
would mean easy accessibility for doctors at
any time and place.
3-3. Verification of the accuracy of image interpretation assistance work performed byradiological technologists
Table 2 shows the overall accuracy of inter-

pretation finding comments by radiological
technologists.
Table 2 Accuracy of image interpretation
assistance by whole radiological
technologists
consideration item

3-2. Performing image interpretation assistance

As a method of reflecting in the examination
field mentioned in the electronic medical record, although the interpretation finding comment is described in the examination comment
column of RIS, the description is completed
within 10 minutes after examination in almost
all cases. Because the description of the comment is completed in a relatively short time,
not all abnormal findings are described; only
the lesion and pathological condition considered to be related to the main complaint aredescribed (for example, if the chief complaintis breathing difficulty, the description would
not comment on whether liver cysts or renal
cysts existed), and because descriptive expressions are mentioned using disease names, inputs can be simplified. Furthermore, because
the number of examinations was high on thesecondary emergency designation day, it isconsidered that one of the major factors was
the increase in the number of personnel.
In contrast, by specifying the name of theperson in the examination comment column,
we believe that the quality of the interpretation
finding comment can also be ensured. Such arequirement would place an onus of responsibility on the technician and would probably

26（134）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

number of interpretation assistancenumber of comment
average number of comment
number of consistent comment
rate of consistent comment (%)
number of inconsistent comment
rate of inconsistent comment (%)
number of overreported comment
rate of overreported comment (%)
number of differences of interpretation
rate of differences of interpretation (%)

Number(rate)
1,027
1,620
1.6
1,427
88.1
377
18.9
137
8.5
55
3.4

In the 6-months from June 2016 to November 2016, the total number of image interpretation records in which the name of the radiological technologists was specified was 1,027,
among which the number of comments thatthe radiological technologists pointed out as afinding was 1,620. Each report contained anaverage of 1.6 comments. Incidentally, the caseof “no abnormal finding” was also included in
the number of comments. Among the 1,620
comments, the number of consistent comments
by the radiologist was 1,427; thus, the rate ofconsistent comment was 88.1%. In the diagnostic comments of radiological technologists,
377 items of pathological conditions that wererelated to the main complaint were considered
to be inconsistent, and the rate of inconsistentcomment (number of inconsistent comment/(number of comment + number of inconsistentcomment)) was 18.9%. The number of radio-

the original work
Operation and accuracy veriﬁcation of image interpretation assistance by radiological technologists

logical technologists with over reported comments was 137; the rate of over reported comments (number of over reported comments/
number of comments) was 8.5%. Although radiological technologists and the radiologist
identified similar findings, there were differences in the interpretation of the findings. The
number of differences in interpretation was 55,
and the rate of differences in interpretations(number of differences in interpretation/number of comments) was 3.4%.
Fig.1 shows the number of image interpretation assistance work grouped according to theyears of experience of radiological technologists and the results of examining five items.
There were 253 cases of interpretation assistance work grouped according to radiological
technologistsʼ experience of ≥10 years, 301 cases for 5 –10 years, 473 cases for <5 years. The
number of comments in image interpretation
assistance work was 405 for radiological technologists with ≥10 years of experience, 444 forthose with 5 –10 years of experience, and 771
for those with <5 years of experience. When
number of comment

100
0

10≧

800
600
400

444

10≧

10<5≧

200
0

5<

10<5≧
year of experience

85.3

10≧

10<5≧

200
150
100

Kruskal-Wallis test
P value=0.884

5<

10≧

number

rate

19.5

5<

year of experience(i) Rate of overreported comment

30
20
10
0

10
10≧

400

658

200

10≧

18.5

5<

10≧

10<5≧

10<5≧

5<

(d) Number of consistentcomment
number of overreported comment
150

19

397

372

year of consistent

19.6

19

17.5

18.4

5<

year of experience

Kruskal-Wallis test
P value=0.009

100
50
0

21
10≧

84

post-hoc test
P value=0.015
32
10<5≧

5<

year of experience(g) Rate of inconsistent comment(h) Number of overreported
comment

rate of differences of interpretation

number of differencesof interpretation
Kruskal-Wallis test40
P value=0.439

7.2

10<5≧

10<5≧

600

0

5<

18

(f) Number of inconsistentcomment

10.9

10<5≧

rate of inconsistent comment
20

174

year of experience

rate of overreported comment

10≧

10≧

(c) Average number of comment

500(e) Rate of consistent comment

5.2

1.4

800

year of experience

104

99

year of experience

12
10
8
6
4
2
0

1.48

1.45

number of inconsistent comment

Kruskal-Wallis test
P value=0.216
number

rate

89.4

1.6

1.5

5<

(b) Number of comment

rate of consistent comment
91.9

1.6
1.55

year of experience(a) Number of interpretation
assistance

94
92
90
88
86
84
82

771

405

number of consistent comment

1.63
number301

average number of comment
1.65

rate

253

200

Kruskal-Wallis test
P value=0.2

5
4

30
rate

300

numbernumber400

1000

number473

numbernumber of interpretation assistance500

the Kruskal-Wallis test was performed on thenumber of comments, the P value was 0.2,
with no significant difference observed amongthe 3 groups. The average number of comments was 1.6 for radiological technologists
with ≥10 years of experience, 1.48 for thosewith 5 –10 years of experience, and 1.63 forthose with <5 years of experience.
For the number and rate of consistent comments between radiological technologists andradiologists, the number of consistent comment was 372 for radiological technologists
with ≥10 years of experience, 397 for thosewith 5 –10 years of experience, 658 for thosewith <5 years of experience. The rate of consistent comment was 91.9% for radiological
technologists with ≥10 years of experience,
89.4% for those with 5 –10 years of experience,and 85.3% for those with <5 years of experience. P value = 0.216 next was subjected to
Kruskal-Wallis test in rate of consistent comment, there were no significant differencesamong the three groups.
For the number and rate of inconsistent com-

15

3

2.5

3.4

3.9

2
1

10<5≧

5<

year of experience(j) Number of differences ofinterpretation

0

10≧

10<5≧

5<

year of experience(k) Rate of differences ofinterpretation

Fig.1 Difference in accuracy depending on experience years of radiological technologists in image
interpretation assistance
Arts and Sciences ◆ 27（135）07

ments on findings not identified by radiological technologists but identified by radiologists,
the number of inconsistent comments was 99
for radiological technologists with ≥10 years ofexperience, 104 for those with 5 –10 years ofexperience, and 174 for those with <5 years ofexperience. The rate of inconsistent comment
was 19.6% 99 for radiological technologists
with ≥10 years of experience, 19.0% for thosewith 5 –10 years of experience, and 18.4% for
those with <5 years of experience. P value = 0.216 next was subjected to Kruskal-Wallis
test in number of inconsistent comment, there
were no significant differences among thethree groups.
For the number and rate of over reported
comments on findings identified by radiological technologists but not by radiologist, thenumber of over reported comments was 21 forradiological technologists with ≥10 years of experience, 32 for those with 5 –10 years of experience, and 84 for those with <5 years of experience. The rate of over reported comments
was 5.2% for radiological technologists with 10
years or more experience, 7.2% for those with
5 –10 years of experience, and 10.9% for thosewith <5 years of experience. When the
Kruskal-Wallis test was performed to assess thenumber of over reported comments, the P valMedical
intern12%
MedicalDoctorEmergency
work(-)
24%

MedicalDoctorEmergency
work(+)
64%

ue was 0.00946. Because a significant difference was observed among the 3 groups, thepost-hoc test was performed and analysis was
performed between the 2 groups, and a significant difference was observed (P value = 0.015)
for radiological technologists with 10 years ormore and <5 years of experience.
For the number and rate of differences in interpretation of findings by both the radiological
technologists and radiologist, the number of differences in interpretation was 10 for radiological technologists with ≥10 years of experience,
15 for those with 5 –10 years of experience, and30 for those with <5 years of experience. The
rate of differences in interpretation was 2.5% forradiological technologists with ≥10 years of experience, 3.4% for those with 5 –10 years of experience, and 3.9% for those with <5 years ofexperience. P value = 0.439 next was subjected
to Kruskal-Wallis test in number of differencesof interpretation, there were no significant differences among the three groups.
3-4. Evaluation of image interpretation assistance work by a doctor
Fig.2 shows the evaluation of image inter-

pretation assistance work performed by a doctor who worked in the hospital.
The total number of doctors who responded
Not satisfied
9%

Neither
6%
Evaluated
a little
15%

Neither
15%

Neither
6%

Known
85%

Evaluated
79%(a) Classiﬁcation of answered
doctor(b) Awareness of image
interpretation assistance byradiological technologists(c) Evaluation of image
interpretation assistance byradiological technologists

Better not use
21%

Neither
6%

Lucid
33.5%
Neither
12%

Lucid a little
33.5%(e) About description of disease
nameRarely forreference24%

Not muchreference3%

Alwaysreference
67%

No
12%

Slightly satified
39%(d) Satisfaction level of description
content

Neither
9%

Shouldcontinue
91%

Yes
88%

(f) Reference level of description (g) Presence or absence of cases
content
in which image interpretation
assistance was useful(h) Continuity of image
interpretation assistance byradiological technologists

Fig.2 Evaluation of image interpretation assistance by medical doctor

28（136）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Satisfied46%

the original work
Operation and accuracy verification of image interpretation assistance by radiological technologists

to the questionnaire was 33: 21 were engaged
in emergency services (64%), 8 were not engaged in emergency services (24%), and 4
were interns (12%). Among them, 28 doctors
recognized (85%) and 5 doctors did not recognize (15%) that radiological technologists were
doing image interpretation assistance work.
Regarding the assessment of radiological
technologists approach to image interpretation
assistance work, we evaluated 26 people(79%), evaluate a little 5 people (15%), but 2
people (6%) who do not think at all It was.
Regarding the content of the comment statedas satisfied, 15 people (45%) were slightly satisfied, 13 (39%) were neither, 2 (6%) were notsatisfied, and 3 (9%) were.
Regarding that radiological technologists describing disease names, although it is lucid tounderstand, 11 people (33%), which is lucid alittle to understand, 11 people (33%), neither tounderstand 4 people (12%), although it is preferable not to use 7 people (21%).
Regarding whether the described commentis referring, 22 people (67%) are always referring, 8 people (24%) referring rarely, 2 people(6%) but neither, 1 people (3%) not much referring.
Regarding the presence or absence of cases
in which the described comment was useful,29 people (88%) found it helpful and 4 (12%)
did not.
Regarding whether to continue this effort in
the future, 30 people (91%) responded that itshould be continued but 3 (9%) did not agree.
Several other comments described in the requested matter were as follows.
・I am worried whether the responsibility will
be imposed on the radiological technologists.
・It is received as a reference level to the last.
・Ability to interpret in emergency situations
and whether time is thus saved.
・It is very helpful in terms of preventing oversight.
・Because opinions on findings do not necessarily agree with each other, they are drawn

to the description, so I think that it would bebetter to limit the findings if possible.

4. Consideration
To initiate image interpretation assistance byradiological technologists, we started the image interpretation discussions, but the understanding and cooperation of radiologists wasindispensable for this. With the staff being
busy with daily work, we understood the purpose of our efforts, and we were extremely
fortunate to be able to continue the image interpretation discussions for 30 minutes each
week, which contributed greatly to improving
the image interpretation ability of radiological
technologists. More than anything, we believethat radiologists were actively seeking descriptions of interpretation of findings by radiological technologists.
For improving interpretation ability, study
sessions among radiological technologists
could be considered, but they were deemed to
be impractical. Although I have been going
through many times so far, there was a tendency to stay in checking the abnormality of theform by referring to the interpretation report
only between radiological technologists. A radiologist would probably teach the mechanismof production of symptoms and signs in a disease, the differential diagnosis and the prognosis. Since the expertise of radiological technologists is limited to the actual taking of X-rays,
some exposure to the principles of internal
medicine would be of benefit, and the best
professionals to instigate this are probably radiologists. There are ongoing developments inradiology in terms of new imaging techniques
and the interpretation of novel radiographs.
For example, it has become possible to makeconclusions on the basis of appropriate changes in imaging range, contrast agent concentration and injection dose for each disease, imaging timing, and number of imaging cycles.
In my opinion, increasing the degree of reliArts and Sciences ◆ 29（137）07ance on technologists should be available
when radiologists are not readily available tointerpret images. Because even if the start ofthe operation of the image interpretation assistance work only in radiological technologists
with a certain interpretation a certain level immediately, and when the other radiological
technologists is performing the work, it is notpossible to describe the interpretation comment. When the doctor side does not establish
a system, which was considered a permanent
work, for interpretation findings comment itself of the radiological technologists there is apossibility that no longer met as a system, in aradiological technologists everyone to do animage interpretation assistance work, I thinkthat must be faced.
In our hospital, it took about two years fromthe beginning of the image interpretation discussion until radiological technologists wereable to begin image interpretation assistancework. There are two possible causes for this.
First, there is scope for improvement in the interpretation ability of each individual radiological technician. Interpretation ability takes time
to be improved to a reasonable standard. It isnecessary for a radiologist to repeatedly explain similar cases for the trainees to learn fromdaily work. Second, improvement in the interpretation ability of radiological technologists
required a period of time until it became possible for them to describe comments with theawareness and conviction about their interpretation findings. In our hospital, we found thatit takes two years of supervised training in interpretation of radiographs and correct reporting of findings before a technician becomesconfident and autonomous in this role.
We also reviewed the work system. On thesecondary emergency designated day, thenumber of medical radiological technologists
on duty increased from 2 to 3. Approximately
20 cases of image interpretation assistancework occurred during the night on the secondary emergency designated day. Of course, ex-

30（138）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

amination and photographing were prioritized,
but if interpretation finding comment is delayed, interpretation assistance work will not
be established. As expected, priority is given to
examination and radiography; however, delaysin the reporting of the findings, if this is a resultof delegation to technologists, does not favor
this role for technologists. Even if CT examination or general image photographing is requested other than three persons, the othertwo correspond, so that it is possible to describe the interpretation finding comments immediately after the examination. By doing this,we can observe the image with a safety margin, believing that it leads to efficient and accurate descriptions of the interpretation. In addition, in the overall work structure, the numberof radiological technologists has not increased,
and the work will be closed the next morning.
We also examined how to convey interpretation finding comments to doctors from various
perspectives. As a method, we examined theentry into the examination comment field of
RIS actually done at our hospital, direct input
to the electronic medical record, verbal communication by telephone, paper surface transfer by memos etc. and check sheet transmission. In direct input to the electronic medical
record, we thought that there was a problem inensuring accuracy, particularly with respect tothe correct use of medical terminology. In verbal communication by telephone, dependingon the circumstances, it is not always the casethat the telephone is connected, so this option
was rejected. The possibility of using paper-based communication by memos etc. wasdismissed due to possible loss or complicationof delivered memos. The input of the interpretation finding comment in the examinationcomment column of RIS and its reflection in
the examination execution column of the electronic medical record was seen as being acceptable.
Since the technologists have no backgroundteaching in medicine or for that matter, in the

the original work
Operation and accuracy verification of image interpretation assistance by radiological technologists

basic medical sciences, a starting point would
need to include detailed teaching of the anatomy, physiology, and principles of pathophysiology, as well as the symptoms and signs ofdiseases. The following is a report of a scientific meeting in Kyoto in 2015 where Mr. Masatoshi Watanabe from the Medical Department
of Health, Labour and Welfare presided.
“Report is of a public that only wrote theopinion of doctors in the current maintenance.
In the prevailing circumstances, whereby doctors have a busy schedule yet the expertisenecessary in order to correctly interpret radiographic images is lacking among ancillary staff
members, the legal implications of delegatingsuch crucial tasks to technologists are immense.
It will be some time before this pilot scheme
might be extended to a national level 1).”
Following the viewpoint of such a country,
our hospital decided to use disease states anddisease names that are easy to understand ininterpretation finding comments. In recent
years, attention has been drawn to a new rolefor radiological technologists for image interpretation assistance, but the logistics of such aventure have yet to be elucidated. In view ofthe proposals made by the Ministry of Health,Labour and Welfare as an academic society, it
is necessary to prepare guidelines as soon as
possible. As a personal opinion, from the factthat doctors are also required to regularly andappropriately perform image interpretation assistance work in the emergency department, I
believe this new and additional role for radiological technologists should be introduced. A
certain level of procedural rules and regulations need to be formulated that include minimum standards of reporting and a protocol ofdescription of radiological signs. This should
encompass a consensus of opinion amongleading doctors at the hospital.
In the accuracy verification of image interpretation assistance work, the overall outcome
coincidence ratio was 88.1%, which is a goodresult. I believe this is an indication of the re-sults of the ongoing image interpretation discussion and the fact that each radiological
technician at our hospital seriously responds toimage interpretation assistance work.
Initially, we predicted that the accuracy ofinterpretation finding comments will dependon the years of experience of radiological technologists. However, although there were minor
difference between the reports made by technologists with varying levels of experience,these differences were not statistically significant. We would recommend that each image
be scrutinized by more than one professional,
including a radiologist in difficult cases, to preserve a healthy margin of safety.
The overall rate of inconsistent comments
was approximately 20%. One explanation forthis discrepancy might be the need for a detailed report which may not lie within the confines of expertise of a technician. Serious signs,
such as acute renal calculi or hydronephrosis,
should be brought to the attention of the radiologist.
The only item for which a statistically significant difference was recognized was the number of over reported comments in the group ofradiological technologists with 5 –10 years ofexperience. This indicated that there was a tendency to excessively over report comments if
the radiological technologistsʼ experience was<5 years. This over reporting feature that became apparent in the work of less experienced
technologists was probably a result of theseworkers having seen considerably less cases
over the years. This deficiency might be rectified in the future as their exposure to a varietyof cases increases.
Regarding the differences in interpretation,
we understand that it was not an ideal situation. There was an obvious lack of understanding of the pathological processes that indicatedvarious radiological signs, and this shortfall
could be corrected by provision of training
during the planned discussions. In the evaluation from the doctor, 85% of the recognition
Arts and Sciences ◆ 31（139）07and approximately 94% of the evaluation wereof a high standard. In the interpretation finding
comment contents, 84% were satisfactory. We
think that this improvement could be attributed to the training provided during discussions.
Moreover, we think that it was great to refer tothe interpretation report by the radiologist thandaily. However, 21% of doctors tended to discourage the use of names of diseases by technologists, and we would like to make efforts to
inform the operation within the hospital in future.
As far as the opinions of doctors on technologistsʼ reports is concerned, as many as 91%
referred to them and 88% said that the reports
were useful. The results of the questionnaire
survey on the image interpretation assistanceby the Japan Association of Radiological technologists revealed that 90% of radiological
technologists judged experience to be asked
for image interpretation assistance from doctors, among them seeking at nighttime andemergency time it is said that about 40% of thetotal was done 2).
This implies that doctors also have anxiety
about their own interpretation and that it was
an indication that needs medical advice fromradiological technologists.
Overlooking image findings is mainly a perception error (it cannot recognize abnormal
findings), cognitive error (it can recognize but
differences interpretation), alliterative error(dragged by findings of previously interpreted
people), among them, perception error (it cannot recognize abnormal findings) accounts for
80% of diagnostic errors 3). In recognition of thisabnormal finding, we believe that a radiological technician who daily observes many images
is in a position expected to be active. If thetrend of technologists performing competentimage interpretation work continues, this task

32（140）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

could be approached by the whole team andmight improve overall patient care in due
course.

5. Conclusion
At our hospital, we initiated image interpretation assistance work by radiological technologists when radiologists were absent.
To start the image interpretation assistancework, we made efforts to increase the awareness and improve the interpretation ability of
individual radiological technologists and formulated operation regulations in the hospital.
To verify the accuracy of image interpretation assistance, the overall rate of consistentcomment with radiologistʼs interpretation findings was 88.1%, and the evaluation by otherdoctors was also high.

6. Acknowledgments
I would like to express my sincere gratitude
to Mr. Kyoichi Kato, Showa Graduate School of
Health and Medical Science who drafted thismanuscript. He provided some good comments and teachings for clinical subjects.

References
1） Kyoichi Kato, et al.: Current status and future prospects of image interpretation assistance in diagnostic
imaging, Journal of Japan Association of RadiologicalTechnologists, vol.63, No.762, p.75-83, 2016.
2） Japan Association of Radiological Technologists interpretation subcommittee: About image interpretation
assistance by radiological technologists - Questionnaire survey result report - , Journal of Japan Association of Radiological Technologists, vol.60, No.727,
p.74-79, 2013.
3） Kyoichi Kato: About image interpretation assistancework by radiological technologists, Innervision, vol.28,
No.6, p.60-62, 2013.

Arts and Sciencesmaterial

Received December 28, 2016; accepted October 2, 2017

Spinal Fusion Surgery Clinically Performed in a
Hybrid Operating RoomYoshinori Takao, Shohei Sasaki, Masanobu Narasawa, Shinichiro Izuta,
Aoi Yasuge, Takao Ichida
Department of Radiology, Osaka City University Hospital

Key words: Spine surgery, Spinal fusion surgery, Image-guided surgery, Hybrid operating room, C-arm CT【Summary】

Purpose: Building of a hybrid operating room (Hybrid OR) to perform minimally invasive cardiac and aortic
surgeries is currently increasing in Japan; however, it is not effectively used for other types of surgeries. This paper
reports cases of Hybrid OR utilization for spinal fusion surgery. Clinical experience: Our Hybrid system uses the Angio
system “Allura Clarity (Philips)” and operating table “Magnus (Maquet).” We encountered 39 cases of spinal surgeries
at the Hybrid OR from April 2014 to March 2016: 33 spinal fusion surgeries (including a preoperative transcatheter
embolization case) and 6 without spinal fusion surgery (such as arteriovenous fistula). Experiences related to theradiological technology used in 32 cases of spinal fusion surgeries, excluding the preoperative arterial embolizationcase, were retrospectively evaluated. The fluoroscopy time was 2.8 ± 2.5 min, single shot was 5.3 ± 3.5, kerma area
product was 27.6 ± 37.2 Gy cm2, and the number of shot on C-arm computed tomography (CT) was 2.3 ± 1.5 times.
This study showed that using the Hybrid OR system has advantages. The angiography system has a flat panel detector
with large imaging field and no distortion. The C-arm CT is used to obtain a clear volume image in clinical cases that
require detailed visualization of the pedicle screw and bone structures. Conclusion: The Hybrid OR is a useful systemfor various spinal fusion surgeries.

Introduction
Building of a hybrid operating room (HybridOR) with high-performance imaging equipment installed in the operating room is increasing in order to perform safe surgeries, decrease
invasion during surgeries, and perform minimally invasive surgeries and other procedures.
Computed tomography (CT), magnetic resonance imaging, and the Angio system are someof the equipment found in a Hybrid OR, which
are selectively performed according to the purpose of the surgery 1). In recent years, the mainstream of a Hybrid OR is combined with theangiography system and aimed to perform
minimally invasive surgeries for cardiac or vascular diseases. Currently, the Hybrid OR is
more frequently used according to the sophistication of minimally invasive cardiovascularsurgeries. However, as the Hybrid OR is limitedly used only for cardiovascular surgeries,
monitoring its using rate is difficult 2).
Because the Hybrid OR functions as both anoperating and angiography room, it can possibly be used for various surgeries 3-6). If only one
function is used (either the operating or angiography room) and the other is not, its cost-effectiveness decreases because of not using expensive and high-functional equipment 7).
To increase the utilization of the Hybrid OR,
our hospital was performing not only cardiovascular surgeries but also other various hybrid
surgeries.
In the present study, the experiences of radiologic technologists during spinal fusion surgeries were reported, which supports the effectiveness of utilizing the Hybrid OR.

1. Experience on spinal surgeries
1-1. Specifications of the Hybrid OR

Our Hybrid OR was built by introducing anangiography system, namely, Allura Clarity
X-per FD 20 (PHILIPS Medical systems), into
an existing operating room with the surgicaltable MAGNUS (Maquet Japan). The Allura
Arts and Sciences ◆ 33（141）07Clarity X-per FD 20 has a ceiling suspension
mechanism with a wide movable range of
C-arm system called Flex-move, which effectively identifies various layouts that matchedwith various clinical needs.
1-2. Experiences

Table 1 Detail of the spine surgery *Cervical spine

11

Include thoracolumbar junction

3

Lumbar spine

12

Scoliosis

5

Related to the tumorectomy

2

Total

33

*include a preoperative transcatheter embolization case

In total, 39 cases of spinal and spinal cordsurgeries performed by neurosurgeons and orthopedics in the Hybrid OR from April 2014 toMarch 2016 were included. These cases consisted of 33 spine fusion surgeries (including acase of vascular embolization performed preoperatively) and 6 vascular diseases without
spine fusion surgery (such as spinal arteriovenous malformation and spinal arteriovenous
fistula). In total, there were 11 cases of cervicalsurgery, 3 of thoracolumbar transition, 12 oflumbar spine, 5 of idiopathic scoliosis, and 2 ofspinal tumor (Table 1).
1-3. Layout of the Hybrid OR (Fig. 1)

The protection boards were placed in frontof the anesthesiologist and the circulating
nurse. The area around the operating table wassterilized; therefore, careful attention shouldbe paid when moving the C arm. Surgeons
during a spine surgery stand at both sides ofthe patient, which is different from the usual
position of interventional radiologists. Therefore, monitors were constructed depending on
the viewing requirements of the surgeons．The
radiologic technologist operated the system ina position that can enable easy checking of thearrangement of the C arm and operating table.
In addition, some mobile radiation protection
boards were placed inside the room, and theradiation-protected area was identified andused by surgeons and scrub nurses to reduce
their radiation exposure due to fluoroscopy,
X-ray imaging, and C-arm CT.
1-4. Support by Radiologic Technologists

Spinal fusion was performed under generalanesthesia. After the induction of anesthesia in

34（142）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Fig.1 Layout of spine surgery

Fig. 1 Layout of spine surgery

Fig. 2 Preoperative photograph (Lumbar spine)patients on supine position, the surgical field
was accordingly prepared. The most common
posterior fixation surgery was performed in theprone position. However, the patientʼs thicknesses were increased due to the thick fourpoint support and operating table (Fig. 2). The

material
Spinal Fusion Surgery Clinically Performed in a Hybrid Operating RoomFig. 3 Intraoperative photographa）Scene of the spine fusion surgeryb）Scene of performing the C-arm CT

Table 2 Scan condition of C-arm CT
Scan
Voltage*

117-123 kV

Rot. Angle

180 degree

Current*

50-325 mA

Scan time

10 secPulse width*5-10 msec

ImagesInch size

19 inch

Filter320
0.9 mmCu
1.0 mmAl

Reconstruction
Filter

Stent

Matrix

5123*Automatically change according to match the patient

environment of the surgery was constructedwith careful consideration that the procedurecan be smoothly performed without altering
the safety maneuver of the C-arm before draping.
Most procedures were performed using combined fluoroscopy and navigation system 8). In
complex cases, the detailed bone structure
should be evaluated using the C-arm CT, withcareful consideration on the maintenance ofsterility in the surgical field (Fig. 3a, b).

2. Methods
Imaging methods performed during a surgery were 7.5 fps fluoroscopy, single shot, andC-arm CT for the body. This study was conducted with the approval of the Ethics Committee of our hospital (approval number: 3443).
The radiation dose in phantom-related X-ray

imaging was based on the fluoroscopic doserate, single shot, and C-arm CT imaging dosein the basic procedure. In addition, the radiation dose with spinal fusion surgery was retrospectively investigated to evaluate procedures
related to radiologic technology.

072-1. Equipment

The fluoroscopic dose rate and imaging dosewere measured using thimble Ion-chamber dosimeter: Radcal 9501, 6 cc (Radcal Co., Ltd.)and 20-cm acrylic plate (Kyoto Science Co.,
Ltd.), respectively. The C-arm CT radiationdose was measured according to the body
phantom based on JIS-4915 (Kyoto Science
Co., Ltd.). All of the phantom lumen was filledwith water because the dose was measured depending on the body trunk.
2-2. Dosimetry

The fluoroscopic dose rate and single-shotdose measurement were performed at 19, 17,
and 14.4 in. flat panel detector (FPD) size usedin spinal fusion surgery. Fluoroscopic and
X-ray imaging dose measurements were performed at the patient entrance reference point
based on the guidelines 9). The fluoroscopy
dose measurement was performed thrice with
2-min interval. The dose rate per minute wascalculated from the measured values and subsequently averaged to obtain the FPD size valArts and Sciences ◆ 35（143）ue. The X-ray imaging dose measurement was
performed three times, and the average wascalculated to obtain the FPD size value.
The C-arm CT dose measurement was performed three times based on the dose area
product meter equipped on the Angio system,
i.e., a 19-in. FPD size; in addition, the average
was calculated.
2-3．Evaluation of the procedure

Among the 33 patients who underwent spinal fusion procedures performed in the HybridOR, 32 were included, excluding one patient
who underwent vascular embolization performed preoperatively, in order to retrospectively investigate the fluoroscopic time, number of used X-ray imaging, dose area product,
and number of used C-arm CT.

3. Result

Table 3 Result of the dose measurement
FPD size (inch)
Fluoroscopy *Single shot *C-arm CT **

19

17

14.4

Voltage (kV)

76

78

79

Current (mA)

2.4

2.6

2.9

(mGy / min)3.56 4.39 4.75

Voltage (kV)

80

80

80

Current (mA)

8

11

13

(mGy / time)

0.62 0.81 0.92

FPD size (inch)

19

Voltage (kV)120

Current (mA)218

2

KAP *** (Gy cm / scan)

7.34*Measured at the patient entrance reference point**Dose indicated by the angio system***Kerma area product

Table 4 Result of the spine surgery
Contents

Mean ± SD* (n=32)

Fluoroscopy time (min)2.8 ± 2.5

Single shot (times)

5.3 ± 3.5

KAP (Gy cm2 )27.6 ± 37.2

C-arm CT (times)

2.3 ± 1.5
*SD: standard deviation

3-1. Dosimetry

The results of dosimetry are shown in Table
3. At FPD sizes of 19, 17, and 14.4 in., fluoroscopic dose rates were 3.56, 4.39, and 4.75
mGy/min with X-ray imaging doses of 0.62,
0.81, and 0.92 mGy, respectively. The dosearea product with C-arm CT imaging was 7.34
Gy cm2.
3-2. Evaluation of the procedure

The results in evaluating the procedures areshown in Table 4. Fluoroscopy was mainly
used to check the time of screw insertion. The
fluoroscopy time was 2.8 ± 2.5 min (mean ±standard deviation). During screw insertion, ashort fluoroscopy of approximately 1 s was repeated, and the tip position was confirmed. In
contrast, during detailed screw adjustment, theposition of the screw was monitored by continuous fluoroscopy. X-ray imaging was mainly
used for intraoperative or postoperative evaluation of cases that could not be evaluated withfluoroscopy. X-ray imaging was performed 5.6± 3.5 times. The C-arm CT was used in almost

36（144）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

all cases to evaluate the position of the screw
and bone structure with the three-dimensional
data. The C-arm CT was performed 2.3 ± 1.5
times, and the dose area product was 27.6 ±37.2 Gy cm2.
3-3. Clinical cases

The following clinical cases present the effectiveness of using the Hybrid OR.
Case 1: Reﬁxation surgery (Fig. 4)
Reoperation was performed due to pedicle
screw loosening. In the C-arm CT transverse
image, the pedicle screw was inserted from theoutside more than the usual procedure. In thecoronal image, the hole after screw removal
can also be seen inside the newly inserted
screw (⇧). The C-arm CT was used to maintainsafety procedures in complex bone structures.
Case 2: Pedicle screw protrusion into the spinal
cord (Fig. 5)

The pedicle screw was protruding into thespinal cord (⇧). Using the C-arm CT, the sur-material
Spinal Fusion Surgery Clinically Performed in a Hybrid Operating RoomFig. 4 Case 1: Re-operation due to loosening of thepedicle screw

Fig. 5 Case 2: Protrusion of the screw
into the vertebral foramen(C-arm CT image)a）C-arm CT image (Axial)b）C-arm CT image (Coronal)c）X-ray image (Post procedure)

07

Fig. 6 Case 3: Spine surgery in small structurea）C-arm CT image (Sagittal)b）X-ray image (Post procedure)geon quickly checked the patient condition intraoperatively. Moreover, understanding therisk of various complications is very important
for the safety the surgery.
Case 3: Spinal fusion surgery in a child (Fig. 6)

This is the case of a 6-year-old child who
underwent atlantoaxial fixation surgery. The
procedure was performed safely even in a patient with small bone structures. In the sagittal
image, the implant was inserted along the vertebral arch.

4. Discussion
In spinal surgery, a mobile fluoroscope system with an image intensifier (I.I.) is commonly used. However, this system has some limitations, particularly because of its small imaging
field and nonuniformity between the central
and peripheral areas and image distortion in
the peripheral area. On the other hand, the angiography system equipped with the large-imaging field FPD can improve various limitationsof the mobile fluoroscopic system and can easArts and Sciences ◆ 37（145）Fig. 7 Breathing controla）With ventilation controlb）Without ventilation control

ily obtain clear no-distortion images with low
radiation dose of good temporal resolution 10).
In addition, an environment that facilitates
quick performance of imaging with the C-arm
CT in the operating room is greatly advantageous because using volume data of the C-arm
CT with great spatial resolution can appropriately support the spinal fusion surgery. Furthermore, in the recent years, navigation canbe performed using volume data acquired during surgery 11, 12). Therefore, utilization of thesevolume data will advance and expand in thenear future.
Hybrid surgeries needed the same quality
support as with the interventional radiology byradiologic technologists 13, 14). In particularly, inthe spine fusion surgery, cooperation with anesthesiologists and efforts for radiation dose
reduction were essential. The image quality
can be improved by preventing respiratory arrest while performing C-arm CT and digital
subtraction angiography (Fig. 7).
The scattered radiation distributions of fluoroscopy or imaging dose and C-arm CT imaging
dose are completely different. In the C-arm CT
where X-ray tube rotates around the body, theradiation is widely distributed in the direction
perpendicular to the rotation axis and does not
spread so much in the body axis direction 15).
In particular, the scattered radiation to the footside direction is shielded by the operation ta-

38（146）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

ble and base. A management planning to protect the medical staff from radiation exposure
should be included because of the scatteredradiation distributions during the C-arm CT
procedure, in addition to the fluoroscopy andsingle shot.

5. Conclusion
In this report, examples of Hybrid OR utilization for spinal fusion surgeries were reported.
With minimally invasive treatment, which often
involves surgical field restrictions, the use ofimaging diagnostic equipment during surgery
is expected.
A Hybrid OR is also useful in spinal fusion
surgery and is one of the indispensable equipment to safely and reliably perform various
surgeries, including those in the bones andjoints.

6. Acknowledgment
The authors would like to thank all the staff
in the Radiology department of the Osaka City
University Hospital for their useful contributions through discussions. The summary waspresented at the 31st Annual Meeting of theJapanese Radiological Radiology Technologist
and 19th ISRRT World Congress.

material
Spinal Fusion Surgery Clinically Performed in a Hybrid Operating Room

References
1） T Hotta: What is a High Functional Operating Room
- Present Condition and Problems. Surgical medicine
journal (Japanese), 37(2), 81-85, 2016.
2） T Takamatsu: Construction and operational problemsof hybrid operating room. Surgical medicine journal(Japanese), 37(2), 90-94, 2016.
3） Y Murayama, T Ishibashi, I Yuki, et al.: Clinical Application of Hybrid Operating Room for Neurosurgery.
Jpn J Intervent Radiol, 31(2), 111-113, 2016.
4） N Hongo, T Hamada, I Takagi, et al.: Clinical Application of Hybrid Theater to Thoracic Aortic Repair. Jpn JIntervent Radiol, 31(2), 114-120, 2016.
5） A Ikoma, M Nakai, H Minamiguchi, et al.: Clinical Application of a Hybrid Operation Room for AbdominalIntervention. Jpn J Intervent Radiol, 31(2), 121-128,
2016.
6） M Yamaguchi, T Okada, E Ueshima, et al.: ClinicalApplication of Multiple Interventional Procedures witha Hybrid Operation System in Kobe University Hospital. Jpn J Intervent Radiol, 31(2), 129-135, 2016.
7） Y Ejima, et al.: Prospect of Hybrid Operating Room
· High Functional Surgical Room. Surgical medicine
journal (Japanese), 37(2), 86-89, 2016.
8） M Yasuda, M Takayasu: Navigation Systems for Spinal Surgery. The Japanese Congress of Neurological
Surgeon, 21(2), 96-102, 2012.

9） Radiation skin disorder accompanying IVR and protection measures review meeting: Radiation skin damage prevention guideline accompanying IVR. Radiology Frontier (Japanese), 7(4), 283-288, 2004.
10）K Okusako, M Shogaki, K Yokoyama, et al.: An experience of the clinical study with angiography systemusing a Flat panel Detecotr. Jpn J Med Phys, 22(4),255-263, 2002.
11）Wei Tian, Han Wang, Ya-jun Liu: Robot-assisted Anterior Odontoid Screw Fixation: A Case Report. Orthopedic Surgery, 8, 400-404, 2016.
12）Jared M, Nikhil R, Ryan D, et al.: Robot-assisted
Anterior Odontoid Screw Fixation: A Case Report. J
Neurosurg Spine, 8(12), 1-9, 2016.
13）T Ichida. Our thought for the best IVR. IVR academic
journal (Japanese), 16(4), 321-326, 2001.
14）T Ichida, Y Takao, T Bunya, et al.: Role sharing of radiological technologist on advanced digital angiography ―to ensure image quality of angiography and the
optimality of reduction for radiation exposure―. J Jpn
Coron Assoc, 19(2), 101-107, 2013.
15）T Norimasa, A Kakimi, Y Takao, et al.: Understanding
the Scatter Radiation Distribution during C-arm CT
Examination: A Body Phantom Study. Japanese Journal of Radiological Technology, 72(11), 1144-1151,
2016.

07

Arts and Sciences ◆ 39（147）

Arts and Sciences
note

Received November 29, 2016; accepted October 27, 2017

Development and Techniques of Using a Fixation
Device for Radiographic Imaging
Keigo Arita1），Yoshinori Takao1），Kenji Kishimoto1），Masanobu Narasawa1），
Minoru Hosogai2），Haruka Babano1），Yuji Sakai1），Mai Ishibashi1），Takao Ichida1）1）Department of Radiology, Osaka City University Hospital: Radiological Technologist
2）Department of Radiology (Retirement), Osaka City University Hospital: Radiological Technologist

Key words: fixation device, radiographic imaging, positioning, safety procedure【Summary】

Radiographic imaging is one of the conventional imaging methods that is widely used to diagnose diseases andevaluate patientsʼ response to treatment. Therefore, proper patient and equipment positioning should be establishedduring an X-ray examination, which could otherwise produce inadequate X-ray images. Hence, we developed afixation device to improve positioning. This report aims to explain the specifications and techniques of using a selfmade fixation device.
The fixation device is made of closed-cell polyethylene foam that has an L-shaped convex part at the vertical portion
and a 2.7 kg Pb block placed at the bottom portion for more stability.
The effect of using the fixation device was dramatical as proper positioning was easily achieved and maintained
during X-ray examination. Thus, the fixation device should be used while performing radiographic imaging
procedures.

Introduction
Several imaging methods pertaining to theimportance of proper positioning during an
X-ray examination have been previously published 1, 2), but it is difficult to accurately reproduce them because of the patientʼs condition
and X-ray imaging situations. Relieving andminimizing the patientʼs muscle tension are advisable in radiographic imaging 3). In fact, we
frequently encounter patients who are unable
to maintain a certain position during an X-ray
examination even for a short period of time.
X-ray examinations of the head and neck andextremities are often difficult to perform because patients tend to be nervous and extremely conscious in trying to maintain their position, which eventually causes unintentional
body movements.
An X-ray examination performed in an unnatural position increases the physical burden
on the patient and makes it difficult to establish a proper position.
Fixation devices for radiographic imaging

40（148）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

have previously been used to improve various
problems caused by motion, without causing
pain to the examinee, and enhance the qualityof radiographic images 4-7). Currently, several
fixation devices used are made of lightweightmaterials such as expanded polystyrene andurethane resin. These are designed to adjust
and stabilize the photographic position 8-11) but
not to suppress the force in the horizontal direction, such as rotation and plantar flexion,
which becomes a problem during X-ray exam-

Horizontal component force

Horizontal component forceab

Fig.1 Problematic motions in radiographic imaging

Fig.1
motions
InitialmovementProblematicof rotation and plantar
flexion has inlargeradiographic
horizontal componentimaging
force.
a) Rotation

Initial movementb)ofPlantar
rotation
flexion and plantar ﬂexion has large
horizontal component force.
b）Plantar ﬂexiona）Rotation

note
Development and Techniques of Using a Fixation Device for Radiographic Imaging

ination of the head and feet (Fig.1a, b). Therefore, we developed a fixation device for radiographic imaging that enables suppression of
the horizontal component force in various
X-ray examinations and clinically applied.
This study reports the development andtechniques of using a fixation device for radiographic imaging to improve positioning stability and promote comfort during an X-ray examination.

1. Speciﬁcations
The materials and structures of the fixation
device are described as follows:
1-1 Materials

The fixation device is made of closed-cell
polyethylene foam with a moderate flexibility
and strength and an excellent durability, which
is manufactured by mixing and thermally decomposing various raw materials such as organic foaming agents. During the process, innumerable bubbles are generated inside thematerial and resin-like features are left. It islightweight and has excellent durability as wellas water and chemical resistance 12). It is also
designed to be extremely effective in preventing various types of contamination that can occur in medical settings, and it is not sensitive tochemicals used for cleaning. Moreover, the fine
air bubbles provide softness and warmth to thepatient.
1-2 Construction

The design and shape of the fixture areshown in Fig.2a and Fig.2b. The fixation device is composed of an L-shaped pedestal witha 2.7 kg Pb block and an X-ray transmissionthat supports the patient. The support part isconvex and is positioned 8 cm above the bottom. This is designed to not interfere with thecassette or other devices that aid in efficiently
stabilizing various parts of the body. In addition, it can be easily carried because of thehandle at the back. The fixation device is 20
cm in width, 25 cm in depth including the convex part, 18 cm in height, and 2.8 kg in total
weight (Fig.3a, b).

2.7kg
2.7kg
leadleadplateplateFig.2 Fig.2
Fixation
Fixationdevicedevice
for radiographic
for radiographic
imaging
imaginga）Using two devices in the X-rayb）The 2.7 kg lead plate into thea) Usinga) Using
two devices
two devices
in the X-ray
in the examination
X-ray examination
examination
ﬁxation device
a ba bb) Theb)
2.7kg
The lead
2.7kgplate
leadinto
plate
theintofixation
the fixation
devicedevice

Fig.2 Fixation device for radiographic imaginga）Exterior of the ﬁxation device

Fig.3

Fig.3
Fig.3
Designof theof thefixation
fixationdevicedevice）LateralbDesignsideviewa) Exteriora) Exteriorof theof thefixation
fixationdevicedeviceDesign of the fixation deviceb) Lateralb) Lateralsideside
view
view

a a
b b

Arts and Sciences ◆ 41（149）072. How to use
The use of the fixation device in various imaging methods depends on the preferences of
the radiological technologist. However, thisfixation device is highly effective for radiographic imaging of the following regions: head,lateral spinal, frontal hip joint, and frontal ankle. This is because these areas require force
suppression in the horizontal direction. This
report also shows how to use the fixation device during X-ray examinations. Two fixation
devices can simultaneously be used in one setting depending on the body area and purposeof the examination.
2-1 Radiographic imaging of the head

For radiographic imaging of the head, two
fixation devices are used to stabilize the frontal
position (Fig.4, 5). Stability is achieved by

Fig.4 Anterior-posterior position of the headholding the head from both sides using two
fixation devices. The Watersʼ method, Fuegerʼs
method, and cervical spine radiographic imaging in an open recumbent position, which areinferior in the stability than the antero-posterior and postero-anterior positions, are more effective with the use of a fixation device.
2-2 Lateral radiographic imaging of the spine

In lateral radiographic imaging of the spine,
the fixation device is used to prevent body inclination (Fig.6) that is supported by the limbs.
However, this position is difficult to maintain
due to lack of support on the dorsal side of the
body. Stability in this position is achieved byusing two fixation devices to support theshoulder blades and the dorsal side of the sacrum.
2-3 Frontal radiographic imaging of the hip joint

In frontal radiographic imaging of the hip
joint, the fixation device is used to maintain the
inner rotation of the leg (Fig.7). Patients who
undergo hip joint radiographic imaging often
have muscle weakness due to aging. In addition, maintaining a position for a long time canbe difficult due to postoperative pain, such asthat caused by osteosynthesis or artificial joints.
A stable position is achieved by using two fixation devices to support the left and right soles
with inner rotation of the leg.

Fig.5 Waters position of the heada）Cranial-Caudal viewFig.6 Lateral position of the spine

42（150）◆ 日本診療放射線技師会誌 2019. vol.66 no.796b）Front viewFig.7 Anterior-posterior positon of the hip joint

note
Development and Techniques of Using a Fixation Device for Radiographic Imaging

2-4 Frontal radiographic imaging of the ankle
joint

In frontal radiographic imaging of the ankle
joint, the fixation device is used to maintain the
joint in the frontal position and prevent varus(Fig.8). Stable position during this procedure isachieved by using the fixation device to support the sole that is positioned in a slight inward rotation from the reference line of thefoot part. Varus can be caused by inner rotation by its own force but can be prevented by
supporting the sole with the fixation device.

3. Discussion
Various devices have been previously developed and clinically applied to improve thequality of radiographic images. However, many
conventional devices utilize force in a verticaldirection and none have been created to suppress it. The fixation device has a fixing effectin vertical and horizontal directions because of
its weight. It is highly versatile and can stabilize positions in various radiographic imaging
methods. The fixation device reduces extra
force exertion and promotes simple and comfortable stabilization in the photographic position for the patients. Radiologists can utilize
the fixation device at ease during busy X-ray
examination days. In addition, a material withseveral air bubbles has fine irregularities in the
cross-section that generates appropriate friction. Moreover, the contact surface of the fixa-a）Front viewtion device is not slippery.
Body movements are often observed whenmuscle weakness due to decreased momentum and suppression of the muscle output develops because of pain 13). The cause of instability of the head is due to its spherical structure and neck muscles. Furthermore, patientsare likely to move because of nonuniform distribution of the muscle mass and muscle tension of the neck in the left and right sides. On
the other hand, instability in the lower limbs isdue to suppression of the muscle output andmuscle weakness. In such cases, the position
can be maintained while reducing the burden
on the joints and muscles with a slight support
from the fixation device 14).
When the fixation device is effectively used,
the work environment can be improved 4). In
addition, accurate radiographic imaging that isdifficult to be influenced by the experiences
and skills of the technician can be realized byusing the fixation device correctly. Acquisitionof good quality images at ease improves theinspection efficiency, but the efficiency can be
reduced if the skill in using the fixation device
is insufficient. Therefore, expertise in using the
fixation device is important.
Furthermore, these fixation devices are effective for radiographic imaging in not only adults
but also children 15). Children are usuallystressed in different environments in everyday
life 16), and they cannot remain in a specific position even for a short period of time. There-b）Lateral viewFig.8 Anterior-posterior position of the ankle joint
Arts and Sciences ◆ 43（151）07fore, the fixation device can effectively maintain and efficiently support their posture without the support of their parents or guardians
during the procedure.
The fixation device is also thought to be effective during computed tomography procedures that require long X-ray irradiation timeand examination of bone mineral density(BMD). During BMD examination, the fixation
device is also expected to improve reproducibility by stabilizing the inner rotation of the hip
joint 17).

4. Conclusion
We report the development and techniquesof using a fixation device for radiographic imaging to improve positioning stability and patientʼs comfort during X-ray examinations. The
use of these fixation devices aims to suppress
the force in various directions. In cases wherestable positioning with general assistive device
is difficult, the fixation device can possibly reduce the burden on the examinee and improve
the accuracy of radiographic imaging.

5. Acknowledgments
We would like to thank the Department ofRadiology, Osaka City University Hospital. The
summary of this study was presented at the32nd Japan Conference of Radiological Technologists (September 2016, Gifu).

References
1） Oda N, et al.: Radiation Technology Series Imaging
Technology for Radiographs. 14-31, 246-258, Ohmsha, 2009.
2） Tachiiri H, et al.: Textbook of Clinico-RadiologicalTechnology. Revised 9th Edition First volume. 123-

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168, Nankodo, 1997.
3） Ando E: Illustrated Pelvis: Hip Joint Imaging Method.
88-102, Ohmsha, 2011.
4） Hosogai M: Practical Radiographic Imaging not Listed
in the Textbook. Japanese Journal of RadiologicalTechnology, 14 (3), 53-64, 2009.
5） Tani S, et al.: Availability and Improvement of a
Vacuum-Type Immobilization Device in Pediatric CT.
Japanese Journal of Radiological Technology, 58 (8),1073-1079, 2002.
6） Horio S: How to X-ray Imaging of Bones and Joints
and How to Diagnose. Eighth Edition. 308-316, 361367, Igaku-Shoin, 2010.
7） Kanamori I, et al.: Diagnostic Imaging Method Radiographic Imaging Method. 92-113, 318-321, Iryou kagakusya, 2010.
8） Minegishi K, et al.: Creation of Help Device in Axial
Knee Joint Imaging. Japanese Journal of RadiologicalTechnology, 64 (774), 397-404, 2017.
9） Yasuda Y, et al.: Proposal for an Auxiliary Tool Designed to Reduce Retake Rates for Lateral Radiography of the Knee Joint. Japanese Journal of Radiological Technology, 69 (10), 1140-1145, 2013.
10）Nakano T, Ogawa H.: Development of Unique Supporting Pad for Performing Chest Radiography on
Patients in Wheelchairs. Japanese Journal of Radiological Technology, 67 (3), 229-234, 2011.
11）Makino Y, et al.: Chest-Holder: Anovel Positioning Device in the Chest Radiography. Japanese Journal ofRadiological Technology, 42 (4), 543-547, 1986.
12）Technical Committee on Plastics Technology: Plastic
Reading. Revision 7th Edition. 139-150, Plastic Age,
2015.
13）Shimada T, et al.: Physical Therapy to Learn in Case
Clinical Thinking. 210-212, Bunkodo, 2006.
14）Hashido T, et al.: Relationship Between the Effect ofMedial Rotation of the Foot Axis by Ankle Dorsiﬂexion
and the Ability to Visualize the Femoral Neck Axis in
the Hip Joint Anterio-Posterior Radiography: Evaluation by Magnetic Resonance Images. Japanese Journal of Radiological Technology, 68 (5), 584-592, 2012.
15）Sonehara J: In-hospital Manual of Pediatric Plain Film
Examination for Radiological Technologist: to Provide
Better Images. Japanese Journal of RadiologicalTechnology, 59 (2), 268-276, 2003.
16）Funashima N: Human Development Studies for Nursing, 50-53, Igaku-Shoin, 2011.
17）Kawakatu M, et al.: Clinical Application of DEXA (Present State of Bone Mineral Measurements). Japanese
Journal of Radiological Technology, 53 (4), 489-493,
1997.

Arts and Sciences
the original work

Received October 10, 2017 ; accepted November 24, 2017

Reduction of radiation exposure in patients andcardiologists using a noise reduction techniquein cardiac catheterization and percutaneous coronary intervention
Masayuki Kumashiro1），2）, Takahiro Kataoka1）, Shinobu Yokota2）, Shinobu Nakagawa2）,
Fumiaki Kiyokawa2）, Hideki Mitsui2）, Shinji Osumi2）, Kiyonori Yamaoka1）1）Graduate School of Health Sciences, Okayama University2）Department of Radiological Technology, Kurashiki Central Hospital

Key words: radiation dose, noise reduction, percutaneous coronary intervention (PCI), occupational exposure【Abstract】

We examined the effect of reducing radiation exposure in 86 patients who underwent coronary angiography andpercutaneous coronary intervention before and after the introduction of an angiography system equipped with anoise reduction technique (NRT) based on an algorithm for noise reduction processing. Additionally, we examined
the reduction in the occupational exposure dose over the past 5 years for 50 cardiologists. Using NRT, the incident
imaging dose per frame (nGy/f) and fluoroscopic dose per pulse (nGy/p) of the flat panel detector were reduced from
120 nGy/f and 40 nGy/p to 70 nGy/f and 30 nGy/p, respectively. The dose area product (DAP) and air kerma (AK)per unit time and unit frame were calculated and compared before and after the introduction of the NRT. Significant
effects of reducing the fluoroscopic dose by 26% and the imaging dose by 40% for the DAP were confirmed (P <0.001). AK also showed a significant decrease of 28% (P < 0.001). Using the NRT, there were significant decreases inthe exposure dose of cardiologists: decrease of 43% in the effective dose (P < 0.05) and 48% in the equivalent dose tolens of the eye (P < 0.05).

1. Introduction
Percutaneous coronary intervention (PCI) in
patients with coronary artery disease has been
an important development, but the increase inradiation exposure doses to both patients andoperators is a problem in radiation protection 1-3).
In recent years, cases of skin disorders
caused by an increase in the patient exposure
dose owing to prolonged fluoroscopy times
and increased numbers of images were reported 4-8).
For this reason, the International Commission on Radiological Protection (ICRP) and the
U.S. Food and Drug Administration (FDA) havereported on the effectiveness of the measurement and recording of exposure doses for patients in order to prevent the occurrence ofskin disorders owing to radiation 9-11).
According to the guidelines of the Radiation

Safety in the Practice of Cardiology Writing
Group, PCI increases the risk of skin disorders.
Thus, it is necessary to identify the safe radiation dose for PCIs. Staying below the thresholdsafe radiation dose is important 12).
In recent years, development of a system toreduce radiation exposure has advanced and isbeing applied in clinical practice. Even in theprocedure of Interventional Radiology (IVR),
an angiography device equipped with a noise
reduction technique (NRT) based on an algorithm for noise reduction processing (Clarity
IQ) aimed at radiation exposure has been introduced and applied in clinical practice 13-14).
Many of these reports stated that the radiation dose of patients was reduced by 50% ormore 15-18).
To apply this method, we first examined theimage quality by a phantom experiment andconfirmed that it is possible to reduce the inciArts and Sciences ◆ 45（153）07

dent radiation dose to the Flat Panel Detector(FPD) to 70 nGy per a frame. This was applied
to clinical cases in follow-up patients after PCI.
In clinical practice, as a result of visual evaluation of the conventional image and the image after dose reduction, no significant difference was found, and we reported that it is possible to reduce the imaging dose to 40% while
maintaining the image quality 19).
However, there are few reports on the exposure dose to the operators.
Swady and colleagues investigated the operatorʼs occupational exposure dose but have notyet demonstrated a significant decrease owing
to the small number of subjects and a shortsurvey period 20).
In addition, the exposure of the operator is
reduced by decreasing the radiation dose to
the patient, but it is also affected by differencesin the procedure and various factors related toradiation protection.
In addition, there will be a difference between target groups to be compared depending on the number of cases, fluoroscopy time,and frame number of the exposure.
In consideration of these influences, we examined a target investigation period of 5 years
and examined a total of 50 cardiologists.
We investigated the number of cases of patients who underwent an examination and PCI,
reviewed the transition of exposure doses before and after the introduction of the new system, and examined the transition of the occupational exposure dose of the cardiologists.
This clinical study was conducted with theapproval of the Ethics Committee of Kurashiki
Central Hospital, Kurashiki Central Medical Organization, Ohara Memorial Public Corporation Foundation.

2. Method
2.1 Patients

In August 2012, the angiography system(Philips Allura Xper FD 10/10, Biplane) in the46（154）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

third room of the cardiac catheterization laboratory (cardiac catheter room) of our hospitalused the noise reduction technology (NRT)(Philips Allura Clarity FD 10/10, Biplane)equipped with an angiography device.
As follow-up after PCI at the time of introducing the new system, 86 target patients were
examined for radiation exposure reduction effects of the new system by comparing the radiation dose to that of the conventional system.
The period during which inspections and
PCIs were carried out on patients with conventional systems was from May 2011 to March
2014, and the period of the new system wasfrom January 2013 to March 2014.
In addition, the group of 86 patients wascomposed of 74 males and 12 females of age:
74 ± 11 years old and BMI: 24.4 ± 3.1 kg/m2.
The interval between the two examinations
was 11.5 ± 5.2 months.
The target examination and PCI were carriedout by 30 cardiologists with more than 5 yearsʼ
experience in the same period. The cardiologist did not necessarily match before and afterin the survey.
Injection of the contrast medium was performed using a 5 French diagnostic catheter, inwhich 7 ml in total was manually injected in
the left coronary artery and 5 ml in the rightcoronary artery.
In each case, as routine work, the LCA 8 direction, the RCA 4 direction, and the left ventriculography 2 direction angiographies were
all performed in a bi-plane system, and the respective imaging directions were as follows:
LCA (RAO - LAO cranial, RAO caudal - LAO, AP
cranial - LAO caudal, RAO cranial - AP caudal),
RCA (AP cranial - LAO, RAO caudal - LAO cranial), and LV (RAO - LAO).
A group in which cineangiography was performed using a conventional angiography apparatus was regarded as a “conventional method,” and a group examined by a device
equipped with a new system was taken as a“new method.”the original work
Reduction of radiation exposure in patients and cardiologists using a noise reduction technique in cardiac catheterization and percutaneous coronary intervention

The photographing conditions of the conventional method were set as the incident dose(ID) per pulse or one frame to the flat panel
detector (FPD), set in advance on the apparatus side in the maximum field of view (10 in).
In the conventional method, the incident dose
(IDE) to the FPD was 120 nGy/f and the perspective incident dose (IDF) was 40 nGy/p. In
the new method, the IDE was 70 nGy/f , andthe IDF was set to 30 nGy/p 19).
For both methods, the fluoroscopy pulse rate
was set at 15 p/s, and the imaging frame rate
was set at 15 f/s. In both cases, the tube voltage and tube current were given by the automatic exposure mechanism (AEC) of the biplane system.
The dose area product (DAP) in the fluoroscopy mode was DAPF (Gy·cm2), and DAP in theimaging mode was DAPE (Gy·cm2). The fluoroscopic dose per unit time (min) was the DAPF
rate (mGy·cm2/min), and the imaging dose perunit frame (f) was the DAPE rate (mGy·cm2/f).
In addition, the air kerma (AK) (mGy) andAK rate (μGy/min·f) per unit time and unit
frame were calculated. Since the value of eachdose is part of a bi-plane system, this is thesummed value of the front and side devices.
For these DAP values and AK values, the correlation between the fluoroscopy time andframe number was determined.
Incidentally, the correlation coefficient wastested using the Pearson moment correlation coefficient for a normal distribution. The non-normal distribution was performed using theSpearman rank correlation coefficient. For
each calculated value, it was confirmed that itwas normally distributed. This was evaluatedby a paired studentʼs t-test, and P < 0.05 wasregarded as a significant difference.
For the DAP, the display value obtained fromthe area dosimeter built into each device wasused. To convert the DAP to AK, we used thevalue obtained from the unique calculation
formula incorporated in the device 21).
To measure the dose rate (mGy/min) at thepatient irradiation reference point (old IVR reference point) of both systems, the reduction
rate of the dose was determined and comparedwith the value calculated from the area dosimeter (Radcal ACCU-GOLD, USA).
2.2 Operators

From September 2012, the conventional
fluoroscopic dose in our third hospital catheter
room was reduced from 40 nGy/p to 30 nGy/pin the early stage, and from 120 nGy/f to 70
nGy/f for the dose 19). From a subsequent examination, the imaging dose of the new method was set to 85 nGy/f from April 2014.
Updates were tracked from September 2014
in the fifth room, November of the same year
in the ninth room, January 2015 in the secondroom, September of the same year in the sixthroom, and in April of the same year in the seventh room. The fluoroscopic dose in all laboratories was set to 30 nGy/p, and the imaging
dose was set to 85 nGy/f. Of the operators
who performed coronary angiography andvarious IVRs (PCI, ablation, and peripheral artery IVR) in these laboratories, the following
were used: the effective dose of an individual
dosimeter (glass badge) of a total of 50 cardiologists (operators) trackable for 5 years from2012 to 2016, a glass badge attached to theneck in order to ascertain the equivalent doseof the lens of the eye, the annual integrated
value from January to December of the measured effective dose (mSv) for one month, andthe equivalent dose (mSv) of the lens of theeye (measurement was outsourced to Chiyoda
Technol, Tokyo).
The number of cases of coronary angiography, PCI, chronic total occlusion lesion (CTO),
ablation, and peripheral artery IVR were obtained. Furthermore, each annual transition in
the number of cases was compared with coronary angiography CT (CTCA) and coronary artery MRI (MRCA), respectively.
Since the numbers of PCIs and CTOs were
included in the number of coronary angiograArts and Sciences ◆ 47（155）07phy examinations, the total number of coronary angiography examinations, ablations, andperipheral artery IVRs was the total number. In
order to exclude the influence of the total
number of cases during each fiscal year, thiswas compared with records from 2012 according to the values obtained by dividing the average dose for each year by the total number.
In each group, the total number of 50 cardiologists compared with 2012 is 30 (age: 41 ±13 years) in 2013 and 2014, and 27 in 2015 and2016 (age: 42 ± 12 years old).
After confirming that this was a normal distribution, an evaluation was made by a paired
studentʼs t-test, and P < 0.05 was regarded as asignificant difference.
Furthermore, for these 10 cardiologists (average years of experience: 15 years, maximum:
34 years, minimum: 7 years) who conductedvarious IVRs with an effective dose of 3 mSv or
higher among these cardiologists, the effective
dose and the transition of the equivalent doseof the crystalline lens of the eye were examined.
In order to exclude the effect of the numberof cases of IVR during the comparison year, thetotal number of PCIs, ablations, and peripheralartery IVRs was taken as the total number of
IVRs and compared by the average dose ofeach year divided by the total number of IVRs.
In addition, the annual fluoroscopic dose,
imaging dose, effective dose, and reduction
rate of the equivalent lens dose of the eye lensin the laboratories where dose reduction was
performed in stages were compared with therespective values in 2012.
Statistical processing was performed by a
Wilcoxonʼs rank sum test, and the median was
also determined. P < 0.05 was considered to bea significant difference. The rate of reduction(De) and the rate of reduction of fluoroscopic
dose (Df) in each year were calculated using
the following equations (1) and (2), respectively:

48（156）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

De =Σ (D1e × M1e + D2e × M2e)─── (1)(D1e × 12 × 6)

Df =

Σ (D1f × M1f + D2f × M2f)
(D1f × 12 × 6)──── (2)where D1e: imaging dose of the initial stage(2012), D2e: imaging dose after update, D1f:
fluoroscopic dose of the initial stage (2012),
D2f: updated fluoroscopic dose, M1e: numberof months of initial imaging dose, M2e: numberof months performed with the updated imaging dose, M1f: number of months performed
with the initial fluoroscopic dose, and M2f:
number of months performed with the updated perspective dose.
Note that Σ represents the total dose of alllaboratories from the third room to the ninthroom.

3. Results
3.1 Patient exposure dose
3.1.1 Dose contrast in conventional and new methods

The measured value of the fluoroscopic doseat the patient irradiation reference point in theconventional method was 27 mGy/min, which
was consistent with the dose rate of 27 mGy/
min calculated from the display value (AK) of
the device. However, in the new method, themeasured value was 20 mGy/min. The calculated value was 19 mGy/min (correction ratio:
1.095).
On the other hand, in the measurement of
the imaging dose, the calculated value was almost equal to 173 mGy/min (ratio: 0.995) withrespect to the measurement value of 174 mGy/
min of the new method. However, for the calculated value of 95 mGy/min, the measured
value decreased to 91 mGy/min (ratio: 0.958).
Based on the above, in the calculation of thedose reduction rate by the new method, corrections were made for the average value of 86
cases by -9.5% for the fluoroscopic dose and+3.7% for the imaging dose.
Table 1 shows the average of the fluoroscopy
time (min), number of frames to be imaged (f),the original work
Reduction of radiation exposure in patients and cardiologists using a noise reduction technique in cardiac catheterization and percutaneous coronary intervention

average of DAP and AK, and the standard edition difference for the conventional method
and the new method.
The fluoroscopy time was 6.1 min in theconventional method and 5.6 min in the new
method, and there was no significant difference between them (P = 0.378). However, withregard to the number of frames, the new method of 1651 f against the conventional methodof 1740 f, and the significant difference (P <0.001) was observed. For that the reason, thecomparison between the two methods wasevaluated by DAPE rate and AK rate as the dose
Table 1 Average (standard deviation) of fluoroscopic time (min), number of captured
frames (f), DAP, and AK in conventional
method and new method.
Reference

Decreasing pvaluerate (%)

New

6.1(2.40)

5.6 (0.07)

―

0.378

Frame number (f) 1,740 (86)

1,651 (151)―< .001DAPF (Gy・cm2 )20.8 (0.5)

13.6 (3.7)―< .001DAPF rate(Gy・cm2/min)

3.49 (1.20) 2.48 (0.95)

26.4< .001DAPE (Gy・cm2 )43.0 (23.1) 24.8 (4.0)―< .001DAPE rate(mGy・cm2/f)

24.5 (10.7) 15.0 (0.7)

40.3< .001

AK (mGy)

845 (106)533 (13)―< .001AK rate( Gy/min・f)

102 (61)73 (8)

28.4< .001

Fluoroscopic time (min)3.1.2 Correlation between dose and perspective
time and number of frames
Fig. 1A and Fig. 1B show the correlation be-

tween the DAPF and perspective time of bothmethods. The correlation coefficients were0.857 in the conventional method and 0.829 inValues are given as mean (standard deviation) or number

B

B

100

100

90

90

90

80

90y = 2.9426x
y = 2.9426x+ 2.873+ 2.873
r = 0.857
r = 0.857
80

80

80

70

70

70

70

60

60

60

60

50

50

50

50

40

40

40

40

30

30

30

30

20

20

20

20

10

10

10

10

0

0

0

0

10

10

20

20

30

30

Fluoroscopic
Fluoroscopic
Time (min)Time (min)40

40

DAPF (Gycm2)

100

DAPF (Gycm2)

100

DAPF (Gycm2)

A

DAPF (Gycm2)A

per unit frame.
The DAPF rate shows a significant decreaseof 2.48 Gy·cm2/min (P < 0.001) in comparison
with the conventional method of 3.49 Gy·cm2/
min. Similarly, the DAPE rate is 24.5 mGy·cm2/f
in the conventional method, and the new
method showed a significant decrease of 15.0
mGy·cm2/f (P < 0.001). In addition, the AK rate
showed a significant decrease of 73 μGy/min·fwith the new method (P < 0.001), comparedwith the conventional methodʼs value of 102
μGy/min·f.
From the above, DAP in the new method hasa reduction ratio of 26.4% with a correction
obtained from the measured values in the
fluoroscopic mode, which almost agrees withthe reduction rate of the ID per pulse (25.0%).
In the exposure mode, the reduction ratio
obtained by adding the correction obtained
from the actual measurement value was 40.3%,
which almost agreed with the reduction rate of
the ID per frame (39.9%) .

0

0

0

y = 2.0005x
y = 2.0005x+ 2.3146+ 2.3146
r = 0.829
r = 0.829

0

10

10

20

20

30

30

40

40

Fluoroscopic
Fluoroscopic
Time (min)Time (min)Fig. 1A Correlation between DAPF and fluoroscopic time of conventional method.
Fig. 1B Correlation between DAPF and fluoroscopic time of new method.

Ｆｉｇ．1
Ｆｉｇ．1

Arts and Sciences ◆ 49（157）

07

BB
B B
100
100

DAPE (Gy・cm2)

100
100
y =y 0.0176x‐ 4.32989090= 0.0176x‐ 4.3298
r =ry0.627== 0.627
0.0176x90
y = 0.0176x‐ 4.3298‐ 4.3298
908080
r = 0.627r = 0.627
80
80
7070
70
70
6060
60
60
5050
50
50
4040
40
40
3030
30
30
2020
20
20
1010
10
10
00
500
1500
2000
2500
3000
1000
1500
2000
2500
3000
0 500 0 1000
5001000 1000
500
1500 1500
2000 2000
2500 2500
3000 3000
Frame
NumberFrame
NumberFrame Number
Frame Number

DAPE （Gy・cm2)

2) 2)
DAPDAPE （Gy・cm
E （Gy・cm
DAPE （Gy・cm2)

100
100
100 y = 0.0295x ‐ 8.3444
100
y = 0.0295x ‐ 8.3444
9090
r =yr 0.578= 0.5780.0295x‐ 8.3444‐ 8.3444
90 y = 0.0295x
908080
r = 0.578r = 0.578
80
80
7070
70
70
6060
60
60
5050
50
50
4040
40
40
3030
30
30
2020
20
20
1010
10
10
00
500
1500
2000
2500
3000
500
1000
1500
2000
2500
3000
0 10000500
5001000 1000
1500 1500
2000 2000
2500 2500
3000 3000
Frame
NumberFrame
NumberFrame Number
Frame Number

2) 2)
DAPDAPE (Gy・cm
E (Gy・cm
DAPE (Gy・cm2)

AA
A A

Fig. 2A Correlation between DAPE and number of frames in conventional method.
Fig. 2B Correlation between DAPE and number of frames in new method.

A

B

2000
2000

1500
1000
1000
1000
500
500
500

0

00

0

2000

1500
1000
1000

1000

1000
500
500

yy==44.676x
44.676x++572.13
572.13
rr==0.642
0.642

500
00

B

2000
1500
1500

1500
AK (mGy)

AK (mGy)
AK(mGy)
(mGy)
AK

2000
1500
1500

2000
2000

AK (mGy)
AK(mGy)
(mGy)
AK

A

BB

Ｆｉｇ．2
Ｆｉｇ．2
Ｆｉｇ．2
Ｆｉｇ．2

y = 44.676x + 572.13
y = 44.676x + 572.13
r = 0.642
r = 0.642
20
30
40
20
30
40

500

10
10
Fluoroscopic
Fluoroscopictime
time(min)
(min)

0
100

2010

3020

4030

40

0

00

0

2000

1500
AK (mGy)AA

1000
yy==33.3x
33.3x++345.48
345.48rr==0.629
0.629
500

00

y = 33.3x + 345.48
y = 33.3x + 345.48
r = 0.629
r = 0.629
10
20
30
40
10
20
30
40
Fluoroscopic
Fluoroscopictime
time(min)
(min)

0
100

2010

3020

4030

Fluoroscopic time
Fluoroscopic(min) time (min)Fluoroscopic
time
Fluoroscopic(min) time (min)Fig. 3A Correlation
betweenAK and fluoroscopic time in conventional
method.
Fig. 3B Correlation between AK and fluoroscopic time in new method.

the new method, respectively
Ｆｉｇ．3
Ｆｉｇ．3 (P < 0.001).
Fig. 2A and Fig. 2B show the correlation beＦｉｇ．3 Ｆｉｇ．3
tween the DAPE and frame number of bothmethods. The correlation coefficients were
found to be significantly correlated with 0.578
in the conventional method and 0.627 in the
new method (P < 0.001).
Fig. 3A and Fig. 3B show the correlation between the AK and fluoroscopic time in bothmethods. The correlation coefficients were0.642 in the conventional method and 0.629 in
the new method, showing a significant correlation (P < 0.001).
Fig. 4A and Fig. 4B show the correlation be-50（158）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

40

tween AK and the number of frames in bothmethods. The correlation coefficients were0.639 in the conventional method and 0.561 in
the new method (P < 0.001).
3.2 Operatorʼs exposure dose
3.2.1 Trends in examinations and IVR cases
Fig. 5 and Table 2 show the coronary angiog-

raphy examination number, PCI, CTO, ablation, peripheral artery IVR, CTCA, and MRCA
in the past 5 years.
However, the number of PCI and CTO cases
was also included in the number of coronary
angiography examinations. While the number

the original work
Reduction of radiation exposure in patients and cardiologists using a noise reduction technique in cardiac catheterization and percutaneous coronary intervention

A

A

B

B

2000

2000

2000

2000

y = ‐0.4509xy = 0.4509x211.25 ‐ 211.25
r = 0.561r = 0.561

y = ‐0.6543x
y = 0.6543x
293.74 ‐ 293.74
r = 0.639r = 0.639
1500

1000

500

500

0

0
0

0
500

500
1000

1000
1500

1500
2000

2000
2500

2500
3000

AK (mGy)

1000

1500

1500
AK (mGy)

AK (mGy)

AK (mGy)

1500

1000

1000

500

500

0

3000

0
0

0
500

500
1000

1000
1500

1500
2000

2000
2500

2500
3000

3000

Frame Number
Frame Number

Frame Number
Frame Number

Fig. 4A Correlation between AK and number of frames in conventional method.
Fig. 4B Correlation between AK and number of frames in new method.

Table 2 Number of cases of catherization and IVR
from 2012 to 2016.

Ｆｉｇ．4
Ｆｉｇ．4

5000
2012

4000

2013

2014

2015

2016

Number of Cases

Number of Cases

Year
3000

2013

2014

2015

2016

Coronary
4,704 4,368 4,044 3,665 3,494
Angiography (PCI) (1,401) (1,268) (1,217) (1,121) (1,117)

2000

Ablation
1000

0

2012

Peripheral IVR
Coronary
Angiography

PCI

CTO

Ablation

Peripheral
IVR

CTCA

MRCA

Total (All IVR)

276

368

541

484

429

138

166

150

197

203

5,118 4,902 4,735 4,346 4,126(1,815) (1,802) (1,905) (1,802) (1,749)

All IVR：total cases of PCI, Ablation and Peripheral IVR

Fig. 5 Number of cases in coronary angiography
Ｆｉｇ．5
examination,
PCI, CTO, ablation, peripheralartery IVR, CTCA, and MRCA in past 5 years.

of PCI, IVR, and CTCA were almost unchanged,
the number of coronary angiography examinations decreased from 4,704 in 2012 to 3,494 in2016 cases, and 1210 cases were decreased
compared with 2016. On the other hand, thenumber of MRCAs from 2014 increased to 599
cases in 2016, compensating for the decreasein the number of coronary angiography examinations.
3.2.2 Changes in exposure dose of operators
Table 3A shows the number of cardiologists

engaged each year, the total number of cases,
total amount of effective dose, and the averageand standard deviation per cardiologist andeach case.

As compared with 0.63 μSv in 2012, the average was 0.44 μSv in 2015 and 0.36 μSv in2016 compared to 0.63 μSv, and the reduction
rate in 2016 was 43% compared with 2012 (p <0.05).
Similarly, Table 3B shows the total equivalentdose of the lens of the eye, and the mean andstandard deviation per cardiologist and per
subject.
Compared with 2.94 μSv in 2012, the averages of 1.71 μSv in 2014, 1.60 μSv in 2015, and1.52 μSv in 2016 showed a significant decrease
compared to 2012, and the reduction rate in2016 was 48% compared to 2012 (p < 0.05).
Fig. 6 shows the transition of the effective
dose of 10 cardiologists, and Fig. 7 shows theArts and Sciences ◆ 51（159）07

Table 3A Number of cardiologists continuously engaged from 2012, total cases, average(standard deviation) of effective dose, and average (standard deviation) of effective
dose per case in each year.
Number of
Number of
Cardiologists Cases

Year

Effective Dose(mSv)

Effective Dose per p-valuea Case ( Sv)p -value

2012

34

5,118

3.24 (4.31)

2013

30

4,902

2.37 (3.19)

0.152

0.63 (0.84)
0.48 (0.65)

0.247

2014

30

4,735

2.62 (4.40)

0.192

0.55 (0.93)

0.240

2015

27

4,346

1.91 (3.42)

0.009**

0.44 (0.79)

0.020*

2016

27

4,126

1.50 (2.19)

0.014*

0.36 (0.53)

0.044** Shows significant difference (P < 0.05).
** Shows significant difference (P < 0.01).
Values are given as mean（standard deviation）or number

Table 3B Number of cardiologists continuously engaged from 2012, total cases, average(standard deviation) of equivalent dose of eye lens, and average (standard deviation)of equivalent dose of eye lens per case in each year.
Number of
Number of
Cardiologists Cases

Year

Mean Equivalentp -value
Dose of Eye(mSv)

Mean Equivalent
Dose of Eye per a p -value
Case ( Sv)

2012

34

5,118

15.02 (18.12)

2.94 (3.54)

2013

30

4,902

11.71 (17.41)

0.097

2.39 (3.55)

0.197

2014

30

4,735

8.08 (14.67)

0.004**

1.71 (3.10)

0.010*

2015

27

4,346

6.95 (13.90)

0.003**

1.60 (3.20)

0.016*

2016

27

4,126

6.29 (9.20)

0.016*

1.52 (2.20)

0.016** Shows significant difference (P < 0.05).
** Shows significant difference (P < 0.01).
Values are given as mean（standard deviation) or number

20
2013

2014

2015

15

10

5

0

80

2016
Equivalent Dose of Eye Lens (mSv)

Effective Dose (mSv)

2012

70

B

C

D

E

F

G

H

I

J

Operator
Cardiologist

2013

2014

2015

E

F

G

H

2016

60
50
40
30
20
10
0

A

2012

A

B

C

D

I

J

Cardiologist
Operator

Fig. 6 Transition of effective dose for 10 cardioloＦｉｇ．6
gists of past 5 years.

Fig. 7 Transition in equivalent dose of eye lens for
Ｆｉｇ．7
10 cardiologists of past 5 years.

transition of the equivalent dose of the eyelens.
In addition, in Tables 4A and 4B, the meanand standard deviation of the 10 cardiologists
and average and standard deviation per caseare shown.
The average effective dose per case was sig-

nificantly reduced (1.7 μSv in 2015 and 1.4 μSv
in 2016 vs. 3.3 μSv in 2012) (p < 0.01).
In addition, the average value of the equivalent dose of the lens of the eye per case significantly decreased from 16.6 μSv in 2012 to
11.3 μSv in 2014, 10.2 μSv in 2015, and 8.6
μSv in 2016 (p < 0.01).

52（160）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

the original work
Reduction of radiation exposure in patients and cardiologists using a noise reduction technique in cardiac catheterization and percutaneous coronary intervention

Table 4A Average (standard deviation) of effective
dose and effective dose per case for 10
cardiologists continuously engaged from2012 to 2016.
Year

2012

2013

2014

2015

2016

Effective Dose
(mSv)

6.0
(4.2)

5.5
(3.4)

4.8
(4.6)

3.1
(2.5)

2.4
(2.0)

Median (mSv)

5

5

3.1

2.7

1.8

0.492

0.105

0.009** 0.004**

3.1
(1.9)

2.5
(2.4)

1.7
(1.4)

1.4
(1.1)

1.5

1

p -value

Effective Doseper a Case ( Sv)

3.3
(2.3)

Median ( Sv)2.7

p -value

2.8

1.6

0.625

0.084

0.009** 0.004**** Shows significant difference (P < 0.01).
Values are given as mean (standard deviation）or number

Table 4B Average (standard deviation) of equivalent dose of eye lens and equivalentdose of eye lens per case for 10 cardiologists continuously engaged from 2012
to 2016.
Year

2012

2013

2014

2015

2016

Equivalent Doseof Eye (mSv)

30.1(16.8)

29.1(20.4)

21.6(20.4)

18.4(19.3)

15.0(9.5)

Median (mSv)

26.9

24.4

13.6

12.5

15.4

0.846

0.020* 0.002** 0.002**

p -value

Equivalent Doseof Eye Lens per a
Case ( Sv)

16.6
(9.3)

16.2
(11.3)

11.3(10.7)

10.2(10.7)

8.6(5.4)

Median ( Sv)

14.8

13.6

7.1

6.9

8.8

p -value

0.846

0.006** 0.002** 0.002*** Shows significant difference (P < 0.05).
** Shows significant difference (P < 0.01).
Values are given as mean（standard deviation）or number

70

Decreasing Rate (%)

60

Fluoroscopic Dose in Total Systems (Df)
Imaging Dose in Total Systems (De)
Effective Dose per a Case
Equivalent Dose of Eye Lens per a Case

50
40
30
20
10
0

2013

2014

2015

2016

Fig. 8 Decreasing rate of fluoroscopic dose (Df)and imaging dose (De) in total system shown
Ｆｉｇ．8
from 2013 to 2016 compared with 2012. Bycontrast, decreasing rate of effective andequivalent doses of eye lens per case arealso shown from 2013 to 2016 comparedwith those of 2012 for 10 cardiologists.

Fig. 8 shows the transition of the fluoroscop-

ic dose and photographing dose reduction rateof the entire laboratory every year, the effective dose per case of 10 cardiologists, and thedecrease rate of the equivalent dose of thecrystalline lens of the eye.
In 2016, compared to 2012, the total fluorosopic dose in the whole laboratory could be
expected to be reduced by 25% and the total
imaging dose by 29.2%, but the effective doseof the cardiologists was 57.5% and the equivalent lens of the eye the dose was 48.2%, exceeding the target dose reduction rate.

4. Discussion
The measured value of our fluoroscopic dose
was confirmed to be reduced to 27 mGy/minby the conventional method and 20 mGy/minby the new method. This was a 26% reduction.
The Medical Exposure Guidelines in 2006
(under DRLs of 2015) in the IVR of the Japan
Association of Radiological Technologists 22)
sets it to 20 mGy/min. It is assumed that an
87% tile value of the measured value wasadopted by the Institutions of Japan Professional Accreditation Board of RadiologicalTechnologists for Angiography and Intervention.
However, according to a survey of 18 angiography devices in 13 institutions by Inaba et
al. 23), of those meeting the criteria of DRLs in2015 published by the Medical Exposure Research Information Network (J-RIME) 24) andrelated specialized organizations in June 2016,
only 5 out of 18 devices (28%) reported thatthe median value was also 24.4 mGy/min, exceeding 20 mGy/min. In addition, there was adiscrepancy between the actual survey and theset value of DRL 2015 reporting.
Although we set the dose rate in the area tomaintain the visibility of various devices in PCI,
further consideration will be required on theadequacy of the set dose from the viewpoint ofdose and image quality.
Arts and Sciences ◆ 53（161）07

In this study, we evaluated the dose reduction effect by using the DAP and AK divided
by the fluoroscopy time and number of frames
for patient dose assessment. Similarly, Cate etal. 16) evaluated the DAP per frame and reported that the patientʼs DAP (average BMI = 26.4
kg/m2) in 39 cases was reduced from 55 to 26
mGy·cm2/f: “Our results show that the patientʼs
DAP (mean BMI = 24.4 kg/m2) in 86 cases was
reduced by about 42% from 24.5 to 15.0 mGy·
cm2/f.” This was presumed to be owing to thedifference in physiques between the Westernand Japanese population.
By comparing dose values per unit time divided by the perspective time and number offrames and by the dose per unit frame, a significant correlation was confirmed between eachdose, fluoroscopy time, and frame number.
The comparison of DAP and AK per time andunit frame was reasonable and was assumed tobe reliable for comparison.
According to the measurement results of
DAP in this study, the ratio per fluoroscopic
dose and imaging dose in the conventional
method and the new method was almost 1:2
and was 2/3 of the total radiation dose occupied by the imaging dose. In DRLs 2015, thetarget dose was taken as the fluoroscopic doserate, but in order to capture the entire exposure, it was necessary to add the imaging dose.
The new method seems to have contributed
to the reduction of the dose of the entire exposure as a result of the radiation dose being reduced by about 30%. On the other hand, theInternational Atomic Energy Agency (IAEA)
uses DAP as a reference value for the diagnostic reference level 25), and adopts clinically appropriate values.
In addition, ICRP states that the dose index
of DRLs should be easily evaluable. Dosimetrythat is more clinically appropriate in Japan isrecommended 26-27), and it seems that setting
DRLs by DAP and AK is worth considering in
the future as well.
With regard to the exposure dose of the car-54（162）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

diologists, we evaluated this with the value divided by the number of examinations during
the year, but since the exposure dose differs
greatly between the examination and the IVR,
it is necessary to grasp as the averaged value.
There is also a report that the radiation doseof the cardiologist is not necessarily proportional to the number of examinations, depending on protection measures such as effective
use of the protective screen, distance between
the detector and the subject, and distance tothe patient at the moment of exposure 28). However, qualified advice from radiological technologists on radiation protection seems to alleviate these effects.
In order to lower the exposure dose of patients and cardiologists, education and trainingof personnel engaged in radiation work andmonitoring of protection status during the examination are necessary.
Generally, it is said that the patient exposure
dose will increase by 15% by separating thedetector 10 cm from the patient 29).
In addition, when the irradiation field is notnarrowed, the scattered ray increases, and theradiation exposure of the patient leads to theradiation exposure of the cardiologists.
In our hospital, radiological protection was
insufficient through 2012. Radiological technologists were not placed in the heart diseasecenter except during pediatrics examinations.
In 2013, we undertook organizational reforms,
and radiological technologists were placed in
the angiography room to assist cardiologists
and cardiovascular surgeons.
We checked whether the glass badge wasappropriately installed in the hybrid operating
room, and that the endoscope center mainly inthe cardiac catheter room. We also checked
whether lead aprons, neck guards, protective
eyeglasses, protective screening, etc. were defective. We also checked that the FPD was asclose to the patient as possible for the cardiologist, and whether the irradiation field was
narrowed.

the original work
Reduction of radiation exposure in patients and cardiologists using a noise reduction technique in cardiac catheterization and percutaneous coronary intervention

In addition, beginning in 2013, we set thedose target value at IVR. For patients whoseskin dose exceeded 3 Gy, we informed the attending physician and reported this to thein-hospital medical safety committee.
In addition, the hospital received certification as a medical radiation reduction facility
accreditation facility of the Japan Associationof Radiological Technologists in March 2016.
In preparation for this accreditation, preparations for examinations began at the beginningof 2015. We examined data comparing the
DRLs 2015 in each modality such as angiography and fluoroscopic examination 30).
DRLs 2015 was announced in June 2015, asreported in our first report to the entire hospital during the preparatory period for obtaining
the certification of “Medical Exposure Reduction Facility” from the Japan Association of Radiological Technologists 31).
Furthermore, in November of the same year,
data comparing DRLs 2015 in all related modalities were gathered and reported to the entire hospital as a second report.
As concrete activities, we classified the incident skin dose (ESD) into a dose category (2 to
3 Gy, 3 to 5 Gy, 5 Gy, or higher) to be exposed
mainly to IVR patients every month. At 5 Gy or
more, the peak skin dose (PSD) was calculated
and a skin observation was conducted. Thiswas reported to the hospital safety committee.
It was thought that these efforts affected not
only the patientʼs exposure dose reduction but
also the awareness of the cardiologistʼs protection and exposure reduction. Meanwhile, under the facility accreditation of the International Medical Safety Standard (JCI) that was accepted in 2015, the radiation safety program
has been continuously strengthened. In the 6th
Edition applied beginning in July 2017, wewere obliged to set the target dose, dose assessment, and safety education 32). For the next
acceptance under the new standard that began
in April 2016, radiation workers and other staff
were given educational lectures and activities

to reduce exposure.
It was estimated that these comprehensive
efforts decreased as a synergistic effect withdose reduction by introducing the new system.
As a low-invasive examination method,
MRCA, which was fully implemented from2014, seems to be contributing to the reductionof catheter examinations for diagnostic purposes together with CTCA. In 2016, it was estimated that the number of coronary angiography.
Although the proportion of the number of coronary angiograms in MRCA was about 17%, it
was presumed that as a substitute for coronary
angiography examinations, this contributed to
the reduction in total radiation exposure.
In recent years, the equivalent dose limit of
the lens of the eye in occupational exposure
was 20 mSv over 5 years. It was proposed tolower this to a level not exceeding 50 mSv per
year 33). In our hospital, the average of 10 cardiologists declined from 30.1 mSv in 2012 to
15.0 mSv in 2016. Although this was in an areathat cleared the standards, there are still cardiologists who exceed the new standard.
The possibility of overestimating monitoringwith a glass badge has also been pointed
out 34). In the future, it will be necessary to establish an accurate method for measuring theexposure dose of the lens of the eye, and towear lightweight protective glasses with less ofa burden of attachment from the perspective ofprotection. Efforts to further reduce exposure
are necessary.

5. Conclusion
We examined the radiation reduction effectof the noise reduction technique in an angiography device and found that a significant dose
reduction effect of about 40% was observed for
86 patients.
In addition, we investigated the transition of
exposure doses of a total of 50 cardiologists
engaged in cardiac catheterization and IVR,
and found a significant radiation reduction efArts and Sciences ◆ 55（163）07fect by noise reduction technology.

6. Acknowledgments

the cardiologists and radiological technologistsof Kurashiki Central Hospital, and Mr. Hitoshi
Imao (Chuoh College of Medical Technology,
Tokyo), for their statistical analyses and advice.

I would like to take this opportunity to thankReferences
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Arts and Sciences ◆ 57（165）Arts and Sciences
the original work

Received September 11, 2017 ; accepted February 23, 2018

A survey of attitudes toward breast cancer
screening mammography in the Philippines
Tokiko Nakamura1）, 2）, Kyoichi Kato1）, Shoichi Suzuki2）, 3）
1）Showa University graduate school of Health Sciences2）Department of Radiology, Daido Hospital
3）Faculty of Radiological Technology, School of Health Sciences, Fujita Health University

Key words: breast cancer screening, mammography, examination rate, mortality rate, Philippines【Abstract】

In the Philippines, breast cancer is the most common type of cancer affecting women, and is the main cause of deathfrom cancer in women. Despite this, the rate of mammogram-based breast cancer screening is low. It is likely that therate of breast cancer screening would increase if women were more aware of its importance.
In the present study, we conducted a survey of hospital staff in the Philippines to identify the reasons for notparticipating in any breast cancer screening. Additionally, the staff was asked to suggest approaches to increase thescreening rate, to raise public awareness about breast cancer screening using mammography, and to make breast cancer
screening a regular part of medical care.
We discovered that the staff had a limited knowledge regarding breast cancer screening using mammography. Breast
cancer screening is also not widely known throughout the country and most women are unaware that this examinationis readily available.

Introduction
The size and number of medical institutions
in countries of the Southeast Asian Region varies from country to country. In Japan, there arevarious types of general hospitals, such as university hospitals. Small medical facilities suchas those found in Southeast Asia would noteven be considered a clinic in Japan. Medical
disparities exist for individuals who are unable
visit well-equipped hospitals owing to various
reasons in each country of the Region 1).
Healthcare is an essential and indispensable
necessity. The quality of healthcare that people
receive varies depending on the country, standard of living, and environmental conditions.
Therefore, we were interested in studying theefforts implemented to screen for breast cancer
using mammography −a preventive medical
screening method− primarily in women in
Southeast Asia 2-3).
Even in Japan, screening for breast cancer
using mammography has some difficulties;
these include the examination costs, physical

58（166）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

distress such as the pain that accompanies theexamination, financial burden associated with
conducting a more precise thorough examination, mental distress, fear of ionizing radiation
because of previous events in the country, therisk of radiation induced breast cancer, the inconvenience of going to a medical consultation, and discomfort from male staff members.
Various efforts have been made in Japan to improve the examination rate, such as having an
all-female staff at the examination site 4-5). Monetary subsidies provided by the local government also contributed to an increase in the examination rate. However, these subsidies are
not common in developing countries; therefore, individuals have to pay the full cost ofbreast cancer screening. Among the developing countries of Southeast Asia, we focused
our study on the Philippines. The Philippines
is classified as a middle income country whererapid economic growth has been achieved andwomenʼs advancement in society is expected 6-7).
In the Philippines, breast cancer is the mostthe original work
A survey of attitudes toward breast cancer screening mammography in the Philippines

common type of cancer in women and is also
the leading cause of death by cancer in women 8-9). However, the rate of breast cancer
screening using mammography, which has
been proven to reduce mortality, is low 10). For
several years in Japan, educational activities,
such as the Pink Ribbon campaign, have been
conducted 11), thereby increasing awareness ofbreast cancer screening using mammography 12-13). Kashiwagi et al. have shown that in
the Philippines 14), women with high educational backgrounds have knowledge about thefactors affecting breast cancer; however, approximately 42.7% of the population are unable to understand the factors affecting breast
cancer, indicating a need for intervention froma primary education perspective. Educationand effective public relations are necessary to
encourage women to understand the need fora medical examination 15). Wealthy individuals,
who are able to engage in medical tourism,
can seek medical services and examinations
without the help of international organizations,such as the World Health Organization, or other non-governmental and non-profit organizations. Middle income earners who test positive
for breast cancer following screening mammography may have the financial resources toobtain treatment, with a resulting increase in
the 10-year survival rates 16-17).
We decided to investigate the level of awareness and concerns among the hospital staff,
which are classified in the middle income
group, regarding breast cancer screening using
mammography.

of this study is to determine and clarify thereasons for not undergoing breast cancer
screening using mammography. We also aim
to raise the general awareness of the need forscreening and to improve the rate of screening.

2. Target and Methodology
2-1. Target
2-1-1. Research Facility

St. Cabrini Hospital is a general hospital witha cancer research institute located 45-minutes
from the capital city of Manila. It has 100 beds,
193 physicians, 81 nurses, 11 medical radiologists (including two women), and 8 other medical technical staff. The number of inpatientadmissions for 2015 was 5,374. There were approximately 39,354 outpatient visits and approximately 1,980 mammography examinations in 2015.
2-1-2. Target for the Survey

A total of 91 female staff was considered as
the target participants for the survey. We presumed that they fully understood the necessityof breast cancer screening using mammography.
2-1-3. Survey period

2016/03/01〜2016/03/31
2-1-4. Investigation method

Questionnaire survey about breast cancer
screening.
2-2. Method

1. Purpose of the Study
Breast cancer screening is important as it can
detect cancer at an early treatable phase. We
assumed that “medical technical staff ” 18), who
belong to the middle income group, do notneed information about the importance ofbreast cancer screening making them ideal
participants for the survey. The main objective

We obtained consent from St. Cabrini Hospital for conducting a survey among their hospital staff. Additionally, we explained the purpose and contents of the survey to the participants before conducting the survey. The questionnaires (Fig.1) could be answered anonymously and were collected by mail.

Arts and Sciences ◆ 59（167）07

Fig.1QUESTIONNAIRE▼Introduction

Breast cancer is a disease whose cure rate goes up dramatically by early
detection and early treatment. However, many women hesitate to take breast
cancer examination, for various reasons. This is an unfortunate situation.
Many lives could be saved if more effective breast cancer examinations are
made. This questionnaire would help to find ways to improve current situation.
To this end, we would like to distribute a questionnaire survey to female staffof the Cancer Institute, St. Frances Cabrini Medical Center.
There are some questions below that we expect you to answer. Please fillthem out carefully. You do not need to answer the questions if you do not want
to. To protect your privacy, we will handle the answers only statistically. We
promise that the results of this survey will not be made public in a mannerthat a respondent can be identified as a particular individual.
Thank you very much for your understanding and cooperation.

▼Basic information about yourself【Age】☐Teens☐Twenties☐Thirties☐Forties☐Fifties☐Sixties【Occupation】☐Doctors☐Pharmacists☐Nurses☐Medical technicians☐Caregivers☐Others【Years of experience under current occupation】 （）years【Your health insurance coverage】☐PhilHealth☐Other health insurance
Does it cover breast cancer examination?
☐covers☐does not cover☐I don’t know
☐No health insurance coverage▼Questions
Medical check of Mammography for detecting breast cancer..

【Q1】Do you know that Mammography is a medical test necessary for
diagnosis of breast cancer? Please choose “Yes” or “No”.
☐Yes☐No【Q2】Have you taken a Mammography before?
☐Yes
☐No

*If you have answered “Yes” to Q2, please answer Q3 to Q7. Those whohave answered “No” may proceed to Q8.
【Q3】Why have you taken a Mammography? Please check all the applicablechoices.
☐I thought it was necessary for early detection of breast cancer.
☐My family/friends recommended it to me.

Fig.1 QUESTIONNAIRE

3. Results
Questionnaires were distributed to all 91 female staff members of the hospital. The return
rate was 100%. The collected questionnaires
were randomized and the summarized data
was generated using Microsoft Excel. The age,occupation, and years of experience at St.
Cabrini Hospital of the survey participants areshown in Table 1-1.
As the targeted participants of this survey be-longed to the middle income group, physicians
were excluded. We also investigated the insurance status of the participants, which is shownin Table 1-2.
Of the 91 participants, 79.1% (n=72) had
PhilHealth insurance, which is 10 % higher
than the rate observed in the country as awhole, whereas 6.6% were not insured. The
country is currently undertaking necessary
measures to establish private health insurances. Of the 72 participants mentioned above, 12have health insurance from private companies
to compensate for areas not covered by PhilHealth insurance. Among these, only half arecovered for breast cancer. Below is a summaryof the questions and results of the questionnaire survey (Table 1-3〜Table 1-23, Fig.2).
Q1. Do you know that mammography is necessary for breast cancer detection?
The survey results showed that 69 (75.8%) of
the participants knew that mammography wasnecessary for breast cancer detection, whereas
22 (24.2%) were unaware (Table 1-3).
Of the participants, 13 were nurses in their
20s, with 0−2 years of work experience. Of
the 19 administrators who participated in the
study, 7 (36.8%) responded that they were un-

Table 1-1 Classification
Age
Teens
Twenties
Thirties
Forties
Fifties
SixtiesUnknown
Total

Age
Occupation
Number Percentage (%) Occupation Number Percentage (%)
2
2.2
Doctors
0
0.0
61
67.0
Pharmacists
7
7.7
20
22.0
Nurses
54
59.3
5
5.5
Technicians
1
1.1
3
3.3
Caregivers
6
6.6
0
0.0
Others
19
20.9
0
0.0
Unknown
4
4.4
91
100.0
Total
91
100.0

Table 1-2 Health Insurance status
Insurance Number Percentage (%) Guarantee of PhilHealth against breast cancer
PhilHealth72
79.1
Guarantee Number Percentage (%)
Other
12
13.2
covers6
50.0
does not cover5
41.7
Nothing6
6.6
Unknown1
1.1
Unknown
1
8.3
Total
91
100.0
Total
12
100.0

60（168）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Years of experience
Years
Number Percentage (%)
〜1
9
9.9
8
8.8
1〜2
12
13.2
2〜3
8
8.8
3〜4
6
6.6
4〜5
12
13.2
5〜
Unknown
36
39.6
Total
91
100.0

Table 1-3 Q1;
Do you know that Mammography isa medical test necessary for diagnosis of breast cancer?
Yes
No
Unknown
Total

Number Percentage (%)
69
75.8
22
24.2
0
0
91
100.0

the original work
A survey of attitudes toward breast cancer screening mammography in the Philippinesaware regarding the necessity of mammogranurses in their 20s, one was a nurse in her 30s,
phy for breast cancer screening; this was theand one was a pharmacist in her 30s (Table
lowest percentage observed among the differ1-6).
ent categories of participants (Table 1-4).
Q3. For those who answered “I have received it”
Fig.1
in Q2, why did you have to receive mammogQ2. Have you ever received mammography ex- QUESTIONNAIRE▼Introduction
amination before?
raphy examination?
Breast cancer is a disease whose cure rate goes up dramatically by early
early hadtreatment.
However, many
women hesitate toastakea breast
Only four (4.4%) participants answered that detection andTwoundergone
mammography
recancer examination, for various reasons. This is an unfortunate situation.
could be saved
effective
arequirement
forif morework,
onebreast
hadcancer
the examinations
procedure
they have undergone mammography previ- Many lives
made. This questionnaire would help to find ways to improve current situation.
ously, and the rest of the 95.6% answered “I To this end,
recommended
by family
and acquaintances,
we would like to distributea questionnaire
survey to female staffof the Cancer Institute, St. Frances Cabrini Medical Center.
have not received it” (Table 1-5). Two wereandonequestions
had worrisome(TablePlease1-7).fill
There
are some
below that wesymptoms
expect you to answer.
them out carefully. You do not need to answer the questions if you do not want
to. To protect your privacy, we will handle the answers only statistically. We
promise that the results of this survey will not be made public in a mannerthat a respondent can be identified as a particular individual.
Thank you very much for your understanding and cooperation.

Table 1-4 Q1; Cross tabulation of occupation and age▼Basicinformation about yourself
Pharmacists
NursesTechnicians
Clerk【Age】☐Teens☐Twenties☐Thirties
Subtotal 10ʼs☐Fifties
20ʼs 30ʼs ☐Sixties
40ʼs Subtotal
30ʼs 50ʼs Subtotal 20ʼs 30ʼs 40ʼs 50ʼs Subtotal 20ʼs ☐Forties
Yes
6
0
6
29
8
3
1
41 【Occupation】
1
1
0
9
3
0
12
☐Doctors☐Pharmacists☐Nurses
No
0
1
1
12
1
0
0
13
0 ☐Medical
0 technicians2
2 ☐Caregivers
2
1
7 ☐Others
under
Total 6
1
7
41
9
3
1
54 【Years
1 of experience1
2 current
11 occupation】
5
1 （ 19 ）years

Q1

Caregivers
Others
Q1
Total
20ʼs 40ʼs Subtotal 20ʼs 50ʼs Subtotal
Yes
4
1
5
3
1
4
69
No
1
0
1
0
0
0
22
Total 5
1
6
3
1
4
91

【Your health insurance coverage】☐PhilHealth☐Other health insurance
it cover breast cancer examination?
Table 1-6Does
Q2;
Cross☐does
tabulationof occupation
and age☐covers
not cover☐I don’t know
☐No health insurance coverage

NursesPharmacists
Q2
Subtotal
Subtotal
ʼ
s
50
ʼ
s
20
ʼ
s
30
ʼs 40ʼs 50ʼs
30
▼Questions
Yes
1
0
1
2
1
0
0
3
Medical check of Mammography for detecting breast cancer..
No
5
1
6
39
8
3
1
51
【Q1】Do you know that Mammography is a medical test necessary for
Total
6 of breast
1 cancer?
7 Please41
9 or3“No”. 1
54diagnosis
choose “Yes”☐Yes☐No【Q2】Have you taken a Mammography before?
☐Yes
☐No

Table 1-5 Q2;Have you taken a Mammography before?
Yes
No
Unknown
Total

Number Percentage (%)
4
4.4
87
95.6
0
0
91
100.0

Table 1-8 Q4;
If you have answered “Yes” to Q2,
please answer Q4: How often haveyou taken Mammography?
once every six months
Once a year
Once every two years
Once every three years
More than once every three years
Unknown
Total

Number
0
1
1
0
1
1
4

Table 1-7 Q3;*If you have answered “Yes” to Q2, please answer Q3 to Q7. Those who“Yes” to Q2, please answer Q3:
you have
haveIfanswered“No”answered
may proceed
to Q8.

【Q3】Why
haveyou
you taken
a Mammography?
Please check all the applicable
Why havetaken
a Mammography?
choices.
① ☐I thought it was necessary for early detection of breast cancer.
② ☐My family/friends recommended it to me.
③④☐I have taken Mammography before.
☐I am worried of breast cancer because I have a family member who
is/was a breast cancer patient.
⑤ ☐I have an anxious symptom.
⑥ ☐It is easy to take.
⑦ ☐It is safe to take.
⑧ ☐I can take it at my workplace.
☐
Others
（
）
Q3
1
2
3
4
5
6
7
8
Total
【Q4】How often have you taken Mammography?
Number
1 every
0 six 0months10024☐More 0than once
☐Once every six months☐Once a year
☐Once every two years☐Once every three years【Q5】Have you felt any pain when you took a Mammography?
Table 1-9 Q5;☐No pain“Yes”buttoI could Table
If you have answered ☐Yes,
endure thepain Q6;
1-10☐Yes,
so much that I could not endure the pain
Q2, please answer Q5:
Have
If you have answered “Yes” to Q2, please【Q6】Were you embarrassed when taking a Mammography before?
you felt any pain whenyouanswer Q6: Were you embarrassed☐No embarrassment
endure taking
ittook a Mammography?☐Yes, but I couldwhen
a Mammography before?
☐Yes, so much that I could not stand it
Number【Q7】How
do you consider Mammography in future?
Number☐Will take it periodicallyNo pain1
No
embarrassment
1☐Will not take it / do not want to take it

Tolerable
2
Tolerable
1*If you have answered“No” to Q2, pleaseanswer Q8
Intolerable
0
Intolerable
1【 Q8 】 Why haven’t you taken a Mammography? Please check all the
Unknown
1 choices.
Unknown
1
applicable
☐I am
Total
4 not interested in breast cancer.
Total
4☐I have no symptoms and no anxiety.
☐I have no breast cancer patients in my family.
☐I think that I will not get breast cancer in my age.
☐I think my physical makeup will not make me a ◆cancer169）
Arts and Sciences breast （patient.
☐It is too troublesome.
☐I have no time to take it.

6107

Q4. For those people who answered “I have received it” in Q2, what is the interval between
visits for mammography examination?

Among those who had received mammography, one has the procedure performed once a
year, one has it performed twice a year, one
had the procedure performed only once, andthe remaining person did not provide a response regarding the frequency of repeat exams (Table 1-8).
Q5. For those people who answered “I have received it” in Q2, What do you think about the“pain” (How is it?) felt during a mammography examination?
On enquiring about the pain felt during a
mammography examination to the four participants who had received mammography, one
had experienced no pain, whereas two people
responded that they had pain but it is tolerable
and one person did not respond (Table 1-9).
Q6. For those people who answered “I have received it” in Q2, Do you feel embarrassed☐I have taken Mammography before.
☐I am worried of breast cancer because I have a family member who
while receiving the mammography examinais/was a breast cancer patient.
☐I have an anxious symptom.
tion?
☐It is easy to take.
☐Itissafe to take.
Further,when they were asked whether theprocedure was embarrassing, one person responded as “not embarrassing,” one person responded as “it was embarrassing but tolerable,”and one person responded as “It was embarrassing, I could not stand it.” One person provided no response (Table 1-10).
Q7. For those people who answered “I have received it” in Q2, Do you have plans to have amammography examination in the future?
For those who have received mammograms,
two plan to have examinations in the future
and two people provided no response (Table
1-11). This was similar to the result of Q4.
Q8. For those who answered “I have not receivedit” in Q2, Why havenʼt you received a mammography examination? (Multiple answers☐I havetaken Mammography before.
allowed)☐I am worried of breast cancer because I have a family member who
is/wasindividualsa breast cancer patient.
41(47%) responded as “There☐I have an anxious symptom.
☐It isnoeasy symptoms
to take.
areand no worries,” whereas☐It is safe to take.
24%
as “I heard that it hurts” and☐I canresponded
take it at my workplace.
☐
Others21%
responded as “It is expensive (or I cannot（）
【Q4】How often have you taken Mammography?
affordit)” (Table 1-12).
☐More than once every six months☐Once every six months☐Once a year
Q9.☐Once
Is it every
embarrassing
that
your
breast is touched
two years☐Once every three years【Q5】Have
you
felt
any
pain
when
you
took
a
Mammography?
during a mammography examination?
☐No pain☐Yes,
but I could
endurepain
Further,59.4%
oftheparticipants
stated that it☐I can take it at my workplace.
☐Yes, so much that I could not endure the pain☐
Others【Q6】Were you embarrassed when taking a Mammography before?
（）☐No embarrassment【Q4】How often have you taken Mammography?
☐Yes, but I could endure it☐More than once every six months☐Yes, so much that I could not stand it
Table
1-11
Q7;
Table
1-13
Q9;
☐Once every six months☐Once a year
【Q7】How do you consider Mammography in future?
” to Q2,
If youhave
answered
Are you embarrassedwiththe pal☐Once
every
two years “Yes☐Onceevery three years☐Will takeit periodically【Q5】Haveyou felt any
pain
whendoyouyoutook cona Mammography?
☐Will not take it / do not want to take itpation of your mamma?
please answer
Q7:
How☐No painsider☐Yes,
Mammography
in thefuture?
but I could endurepain*If you Number
have answered“No” to (%)
Q2, please answer Q8
Percentage☐Yes, so much that I could not endure the pain
【 Q8 】 Why haven’t you taken a Mammography? Please check all the
Number
Agree
16
17.6
【Q6】Were you embarrassed when taking
a Mammography before?
applicable choices.
☐No embarrassment☐I am not interested
Take it2
Slightly agree3841.8 in breast cancer.
☐Yes, but I could endure it☐I have no symptoms and no anxiety.
Not take it
0
Barely agree
14
15.4☐Yes, so much that I could not stand it☐I have no breast cancer patients in my family.
2 future?
【Q7】How do Unknown
you consider Mammography in☐I think that I25.3
will not get breast cancer in my age.
Not agree
23☐Will take it periodically☐I think my physical makeup will not make me a breast cancer
Total
4
Total
91
100.0
patient.
☐Will not take it / do not want to take it☐It is too troublesome.
☐I have no time to take it.
*If you have answered “No” to Q2, please answer Q8☐I cannot take it because I have to take care of my children.
【 Q8
】 Why
haven’tIf you
Mammography?
Pleasecheckplease
all the answer Q8;“Ｎo” to Q2,
Table
1-12
youtakenhavea answered
Why havenʼt you taken a Mammography?
☐It is too expensive to take.
applicable choices.
⑩ ☐I have no chance to take it.
① ☐I am not interested in breast cancer.
⑪ ☐I have no idea where I can take it.
② ☐I have no symptoms and no anxiety.
⑫ ☐I could not take it at a facility I like to go.
③ ☐I have no breast cancer patients in my family.
⑬ ☐I have heard that Mammography is painful.
④ ☐I think that I will not get breast cancer in my age.
⑭ ☐I am afraid that a breast cancer could be found by the medical⑤ ☐I think my physical makeup will not make me a breast cancer
patient.
check.
⑮ ☐I will be embarrassed by a touch on my breast.
⑥ ☐It is too troublesome.
⑯ ☐It involves X-ray radiation, and I am scared of it.
⑦ ☐I have no time to take it.
⑰ ☐Others⑧ ☐I cannot take it because I have to take care of my children.
⑨ ☐It is too expensive to take.
（）☐I have no chance to take it.
☐IQ8have no idea where
I2can takethe following
1
3 it. 45
6
7
8 *To
9 all10respondents:
11 12 Please
13 answer
14 15
16 17 questions. Select only
☐I could not take it at a facility I like to go.
one choice for each question.
Number
15 Mammography
41 25 is12painful.
7
5 13 4 【Q9】Are
19 16 you1embarrassed
6 21with13
5
6of your
14mamma?
☐I have heard thatthe palpation☐I am afraid
breast 28.7
cancer13.8
could 8.0
be foundthe medical☐Agree☐Slightly☐
Percentage(%) that
17.2a 47.1
5.7by14.9
4.6 21.8 18.4
1.1 6.9 24.1
14.9agree
5.7 6.9 ☐Barely
16.1 agree
check.
Not agree☐I will be embarrassed by a touch on my breast.
【Q10】If a male Medical Radiology Technician will do the palpation for taking a☐It involves X-ray radiation, and I am scared of it.
Mammography, will you be in trouble?
☐Agree☐Slightly agree☐Barely agree☐（☐Others
170）◆ 日本診療放射線技師会誌 2019. vol.66 no.796
Not agree【Q11】I have heard that a Mammography is painful.
☐Agree☐Slightly agree☐Barely agree☐

62the original work
A survey of attitudes toward breast cancer screening mammography in the Philippines

was embarrassing that their breasts weretouched during mammography (Table 1-13).
Q10. In mammography examination, is it a problem if the radiologist or technologist is amale?
67.1% responded that they considered it to
be a problem if the radiologist or technician
were male (Table 1-14).
Q11. Do you think mammography hurts?
Moreover, 59.4% believed that mammography hurt (Table 1-15).
Q12. Are you scared if breast cancer is detected?
58.3% were scared that breast cancer might
be discovered (Table 1-16).
Q13. I am healthy and will not get breast cancer．

On the other hand, 47.3% believed that they
were healthy and will not get breast cancer(Table 1-17).
Q14. Do you think that mammography costs arehigh?
The survey revealed that 57.2% believed thatmammography costs were high (Table 1-18).
Q15. Do you think mammography examination
takes a long time?
47.3% believed that the examination is time
consuming (Table 1-19).
Q16. Do you think that if you visit the hospitalonce, you donʼt have to visit again?
When enquired whether they thought only
one exam was necessary, 70.4% percent ofTable 1-14 Q10;
If a male Medical Radiology Technician will do the palpation for taking a
Mammography, will you be in trouble?

Table 1-15 Q11;
I have heard that a Mammography
is painful.

Number Percentage (%)
Agree
30
33.0
Slightly agree
31
34.1
Barely agree
1415.4
Not agree
16
17.6
Total
91
100.0

Agree
Slightly agree
Barely agree
Not agree
Total

Table 1-17 Q13;
I am very healthy, and will not getbreast cancer.

Table 1-18 Q14;
Taking a Mammography medical
check is very expensive.

Agree
Slightly agree
Barely agree
Not agree
Total

Number Percentage (%)
16
17.6
27
29.7
26
28.6
22
24.2
91
100.0

Agree
Slightly agree
Barely agree
Not agree
Total

Number Percentage (%)
24
26.4
30
33.0
21
23.1
15
16.5
90
100.0

Number Percentage (%)
27
29.7
25
27.5
17
18.7
22
24.2
91
100.0

Table 1-16 Q12;
I am afraid that a breast cancer may
be found by the medical check.
Agree
Slightly agree
Barely agree
Not agree
Total

Number Percentage (%)
17
18.7
36
39.6
18
19.8
19
20.9
90
100.0

Table 1-19 Q15;
The time of taking a Mammography
could be long.
Agree
Slightly agree
Barely agree
Not agree
Total

Number Percentage (%)
14
15.4
29
31.9
28
30.8
20
22.0
91
100.0

Table 1-22 Q18;
How much do you think is the reasonable rate of a Mammography?
Table 1-20 Q16;
Once taking a Mammography, there
is no need to take it again.
Agree
Slightly agree
Barely agree
Not agree
Total

Number Percentage (%)
7
7.7
20
22.0
21
23.1
43
47.3
91
100.0

Table 1-21 Q17;
Are you anxious about the x-ray
radiation of a Mammography?
Agree
Slightly agree
Barely agree
Not agree
Total

Number Percentage (%)
18
19.8
28
30.8
20
22.0
25
27.5
91
100.0

100pesos
200pesos
300pesos
500pesos
1,000pesos
1,500pesos
Unknown
Total

Number Percentage (%)
4
4.4
10
11.0
9
9.9
19
20.9
22
24.2
25
27.5
2
2.2
91
100.0

Arts and Sciences ◆ 63（171）07

participants believed that only one exam was
On enquiring about the duration and cost
sufficient (Table 1-20).
that the participants considered as ideal to actively and continuously undergo mammograQ17. Are you concerned about the radiation exphy, 75.9% of participants considered that the
posure in mammography examinations?
50.6% were concerned about the radiation
appropriate price for mammography was beexposure of the procedure (Table 1-21).
tween 500 and 1000 pesos if they were goingto have the procedure on an ongoing basis,
Q18. How much do you think is the appropriate
18.5% considered approximately 1000 pesos
price or cost for a mammography examinawas appropriate whereas the remaining indition?
When asked about what they considered as
viduals considered approximately 500 pesos
an appropriate cost for a mammography exwas appropriate (Table 1-23).
amination, 51.7% believed that the procedure
Q20. What factors do you think makes it easy to（）
should cost between 1000 and 1500 pesos,
receive a mammography examination?
*To
allrespondents:
Pleaseanswerthefollowingquestions.
Selectonly
whereas 15% believed that the price should be(Multiple answers allowed)
one choice for each question.
th of that amount i.e., approximateWhen asked about the factors that the paralmost
1/10【Q9】Areyou embarrassed with the palpation of your mamma?
☐Agree☐Slightly agree☐Barely agree
☐
pesos
(
).
ly 100−200
ticipants
considered would make undergoing
Table 1-22
Not agree【Q10】If a male Medical Radiology Technician will do the palpation for taking a
mammography easier (Fig.2), 51.6% respondQ19. Howlong do will
youyouthink
you will actively and
Mammography,
be in trouble?
☐Agree☐Slightly agree☐Barely agree☐
ed as “If the medical staff were female,” 42.9%
continuously
receive mammography? What
Not agree【Q11】I have heard that a Mammography is painful.
responded as “If the examination site is nearis theideal pricefor you if you will
regularly☐Agree☐Slightly agree☐Barely agree☐
Not agree
the workplace,” 39.6% responded as “If the exhave a mammography examination.
【Q12】I am afraid that a breast cancer may be found by the medical check.

☐Agree☐Slightly agree☐Barely agree☐
Not agree【Q13】I am very healthy, and will not get breast cancer.
☐Agree☐Slightly agree☐Barely agree☐
Table 1-23
Q19; How much do you think is the maximum rate you are willing to pay if you want to take a
Not agree【Q14】Taking a Mammography
medical checkis veryand
expensive.
Mammography
actively
regularly?
☐Agree☐Slightly agree☐Barely agree☐
Not agreeFee (peso)
Number Percentage (%) Fee (peso) Number Percentage (%) Fee (peso) Number Percentage (%)
【Q15】The time of taking a Mammography could be long.
Unknown
32 ☐Slightly
35.2
1,100
0
0.0
2,100
0
0.0
☐Agreeagree☐Barely agree☐
100 Not agree 2
2.2
1,200
1
1.1
2,200
0
0.0
【Q16】Once taking a Mammography, there is no need to take it again.
200 ☐Agree 1 ☐Slightly1.1
1,300
0
0.0
2,300
0
0.0
agree
☐Barely agree☐
300 Not agree 4
4.4
1,400
0
0.0
2,400
0
0.0
【Q17】Are you anxious about the x-ray radiation of a Mammography?
400 ☐Agree 0 ☐Slightly0.0
1,500
3
3.3
2,500
3
3.3
agree
☐Barely agree☐
500 Not agree 15
16.5
1,600
0
0.0
2,600
0
0.0

600

0

0.0

1,700

0

【Q18】How much do you think is the reasonable rate of a Mammography?
700 ☐100Philippine
2 Pesos ☐2.2
0200Philippine 1,800
Pesos ☐
300Philippine
800 Pesos
5
5.5
1,900
0
☐500Philippine Pesos☐ 1000Philippine Pesos ☐1500Philippine
900 Pesos
0
0.0
2,000
5
【Q19】How
much15
do you think is16.5
the maximum rate you are willing to pay if you
1,000
want to take a Mammography actively and regularly?
() Philippine Pesos【Q20】In which situation do you think is it easy for you to take a medical check ofbreast cancer? Please check all the applicable choices.
① ☐I can take it at a place close to where I live.
② ☐I can take it at a place close to the place where I work.
③ ☐I can take it at a medical facility where I have received treatments
before.
④ ☐I can take it at a medical facility that I like.
⑤ ☐The medical staff members are females.
⑥ ☐There is no restriction on time or period.
⑦ ☐The time required for inspection is short.
⑧ ☐It is inexpensive.
⑨ ☐I can take it together with my friends/family⑩ ☐I can make reservations.
⑪ ☐I can take it with other inspections.
⑫ ☐I can take it with health insurance coverage.
⑬ ☐I can take it with a subsidy.
⑭ ☐Others（）

This is the end of the questionnaire. Thank you very much for

0.0
1.1
0.0
5.5

2,700
2,800
2,900
3,000
Total

0
1
0
2
91

0.0
1.1
0.0
2.2
100.0

Fig.2 Q20;
which andsituation
do you think is it easy for you to take a medical check of breast cancer?
yourInpatience
cooperation!

64（172）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

the original work
A survey of attitudes toward breast cancer screening mammography in the Philippines

amination site is near our residential area,”
38.5% responded as “If the price of the examination is cheap,” and 11% responded as “Ifthere were subsidies for the costs of the examination.”

4. Discussion
4-1. Results of the questionnaire survey

The target population of this survey was hospital staff, with as many as 75% of the participants acknowledging the need for breast cancer screening using mammography. However,very few of the participants have actually obtained a mammogram. This is most likely due
to the fact that most of those surveyed are in
their 20s and 30s, with some unmarried andchildless. The Philippines is a family oriented
culture. Some individuals in the middle income
class in their 20s and 30s choose not to marryand have children at an early age to support
their parents, siblings or other family members 19). The four participants who have undergone a mammography examination are in their
20s and 30s, which is not a high risk age groupfor breast cancer occurrence. Reasons for obtaining the examination were various, such asa requirement for work, recommendation by
family and acquaintances, or presence of worrisome symptoms. It is important that people
understand that breast cancer screening is necessary, even without symptoms. In addition,
the risk of breast cancer increases since the age
40 and this information is not widely known 20).
There is an overall lack of knowledge aboutbreast cancer screening using mammography.
The procedure is unfamiliar to some Filipinosin the middle income group, and mammography is not typically obtained by acquaintancesof the survey participants. Despite some individuals, including the participants, are knowledgeable about breast cancer screening using
mammography, they still have not undergone
the examination even for preventive medical
reasons. Interestingly, none of the participants

replied that the reason for not undergoing
mammography was not being of the appropriate age for the examination. Several participants stated that they had no worrisome symptoms and that was the reason they have notconsidered screening.
The cost for a mammogram at St. Cabrini
Hospital is 2,300 pesos. The response, “The examination cost is high” does not seem to bebecause of a lack of affordability in the middle
income group, which has an annual income of
250,000−600,000 pesos but because of others
factors. The results of Q18 and Q19 seem toindicate a difference between the cost considered necessary to obtain a single mammogram
and the cost considered affordable for repeat
examinations. One possible reason is that theparticipants do not understand the true valueof the examination. Question 20 revealed that
although some participants undergo screening
regularly and have the financial ability, they
still have some other concerns when being
screened. Half of the participants preferredthat the medical staff in the mammography
unit be female. This is a change that should be
implemented to decrease the embarrassmentof patients undergoing the procedure. Breast
cancer screening needs to be done regularly sothat the cancer can be detected at an earlystage and timely treatment can be provided.
Although some people understand this, they
still do not undergo regular screenings．Because
people assume that they do not have breast
cancer, they do not actively seek out mammography. There is a gap between peopleʼs knowledge and behavior, with the result showingthat they do not act as expected and cannot
reasonably calculate the possible losses 21). In
addition to the absence of symptoms, there isalso concern over the cost of the examination.
Although some people have the financial capability, they still consider it as expensive. Additional factors such as pain and embarrassment
during the procedure leads to apprehensions
about undergoing mammography.
Arts and Sciences ◆ 65（173）07

4-2. Future countermeasures and possibilities

As discussed in the previous section 4-1,
there are several factors that hinder obtaining a
mammogram in the middle income group of
the Philippines. Factors such as lack of opportunity to undergo the procedure, pain, embarrassment, and expense observed in the present
study are also applicable in Japan. Lack ofknowledge and information about breast cancer and mammography is also operative. Several individuals are unaware of the high breast
cancer mortality rate in the Philippines, thepossibility of breast cancer at a young age, different risks of breast cancer by age, and theincrease in survival rate associated with early
detection. The incidence of breast cancer increases with age, with the peak incidence between 45 and 50. We highly recommended
regular medical check-ups that include mammography.
Educating the public about breast cancer andthe importance of screening, including selfexamination, is necessary. Early treatment ofbreast cancer through screening mammography is better than trying to cure late stage
breast cancer.
In Japan, there are those who understand theimportance of breast cancer screening and canafford the expenses but still do not consult aphysician. According to a survey conducted by
the Japan Breast Cancer Screening Association,
the burden of paying the expense personally is
the main deterrent. In order to increase the examination rate, subsidies for the exam and free
medical check-up coupons were provided by
the local government. Simultaneously, the Pink
Ribbon campaign helped in spreading awareness and understanding of the need for breast
cancer screening. This helped to reduce themortality from breast cancer. In Japan, because
the local government provides subsidies andfree medical check-up coupons, people consider that mammography is important as it is apriority of the local government, and this could
lead to continuous or regular examinations. In

66（174）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

the Philippines, as we found in the results from
Q20, examinees do not rely on any subsidies.
Subsidies for breast cancer screening may not
be the priority of the local government in thePhilippines, as the mortality from other diseases is considerably higher, which is common indeveloping countries. This would indicate that,
unlike in Japan, subsidies or free coupons are
not expected in the near future in the Philippines.
This survey highlighted several difficulties
associated with undergoing screening mammography based on the answers of hospital
staff that belonged to the middle income group.
To the best of our knowledge, this is the firststep in improving the breast cancer screening
rate in the Philippines. Factors hindering an increase in the screening rate in the middle income group are complex. Although we now
know the outlook of people toward breast
cancer and mammography, certain reasons forpeople not undergoing mammography seemunreasonable.

5. Conclusion
In the Philippines, the potential demand forbreast cancer screening using mammography
is high and is necessary, but the current screening rate is low. In order to increase the screening rate, it is important for people to know
basic information about breast cancer andmammography and that breast cancer screening is important for early detection and timely
treatment, intermediate breast cancer discovery, and breast cancer screening based on preventive medicine. It is necessary to educate thehospital staff as well the general public regarding breast cancer screening using mammography.

Acknowledgements
We would like to thank and acknowledge
the following: Mr. Yukihiro Kusakabe, Manag-the original work
A survey of attitudes toward breast cancer screening mammography in the Philippines

ing Director, Social Welfare Community Seirei
Fukushi Association Board Member, Managing
Executive. St. Cabrini Hospital; Dr. Gellido，Dr.
Alonzo, and Mr. Satoru Kamiya, Department ofRadiology, Daido Hospital, Medical Corporation, Healthcare Association.
The summary of this research was presented
at the 32nd Annual Meeting of the Japanese Radiological Radiology Technologist (September
2016, Gifu).

References
1） WHO: WORLD HEALTH STATISTICS, 2015.
http://www.who.int/gho/publications/world_health_statistics/2015/en/ (26/11/2016)2） Miller BA, et al.: Cancer incidence and mortality patterns among speciﬁc Asian and Paciﬁc Islander populations in the U.S. Cancer Causes Control, 19(3): 227256, 2008.
3） Youlden DR: Incidence and mortality of female breast
cancer in the Asia-Pacific region. Cancer Biology &Medicine, 11(2): 101-115, 2014.
4） Matsuda S: Program for upgrading the screening rate
practiced by Japan Breast Cancer Pink Ribbon Movement - Present state seen there, Problems for 50% &Improvements. Japan Association of Breast Cancer
Screening, 20: 106-110, 2011．
5） Ouchi N: Guidance on breast cancer screening by
mammography, -Quality control manual-, Japan Medical Journal, 2011．
6） Yoshida I: Steady Philippine economy, Trends of domestic and foreign economies, Fukoku Life Research，
2015．
7） Ministry of Foreign Affairs of Japan: Republic of thePhilippines.
http://www.mofa.go.jp/mofaj/area/philippines/(16/11/2016)8） Philippine Statistics Authority: Philippine Statistical
Yearbook 2012, 2012．
http://www.psa.gov.ph/products-and-services/publications/philippine-statistical-yearbook/2012(27/11/2016)9） Philippine Statistics Authority: Philippine Statistical
Yearbook 2015, 2015．
https://psa.gov.ph/sites/default/files/2015%20
PSY%20PDF_0.pdf#search='2014+Philippine+Statist
ical+Yearbook' (27/11/2016)10）Cancer today: International Agency for Research on
Cancer, 2012.
http://gco.iarc.fr/today/home (18/11/2016)11）J. POSH (NPO) Japan Pink-Ribbon of Smile and Happiness campaign, 2016.
http://www.j-posh.com/ (26/12/2016)12）Fukuda M: Pink ribbon and breast cancer learning
BOOK. SHUFUNOTOMO Co., Ltd, 2013．
13）Japan Society of Breast Health (NPO): Survey onbreast cancer screening 2013.
https://breastcare.jp/report2013.html (18/11/2016)14）Kashiwagi Y, et al.：Breast Cancer Knowledge andPreventive Behavior Among Filipino Women in a Rural
Area: A Cross-Sectional Study. Nursing and Midwifery
Studies, 5(3): e34300, 2016.
15）Gibson LJ, et al.: Risk factors for breast cancer
among Filipino women in Manila, International Journalof Cancer, 126(2): 515-521, 2010.
16）Anderson BO, et al.: Optimisation of breast cancer
management in low-resource and middle-resource
countries executive summary of the breast healthglobal initiative consensus. Lancet Oncology, 12(4)pp387-398, 2011.
17）Yip CH, et al.: Guideline implementation for breast
healthcare in low -and middle- income countries early
detection resource allocation. Cancer, 113(S8): 22442256, 2008.
18）Department of Healthcare: The 2013 Philippine Health
Statistics, 2013．
h t t p s : / / w w w. d o h . g o v. p h / p u b l i c a t i o n s / s e r i a l s(31/12/2016)19）Kazuo K: Health Situations and Medical Insurance
System of the Philippine. Medical and Social, 18(1)pp189-204, 2008．
20）Japanese Breast Cancer Society: The report of clinical statistical studies on registered mammary cancer
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21）Banerjee AV, Duﬂo E, Yamagata H: POOR ECONOMICS-A Radical Rethinking of the Way to Fight Global
Poverty, Misuzu Shobo, 2012．

Arts and Sciences ◆ 67（175）07Arts and Sciencesmaterial

Received June 6, 2017; accepted November 24, 2017

Survey of Consciousness Regarding the Acquisition of a Higher Degree and Accreditation/Professional Qualifications among Radiological Technologists and Students
Masato Mizui 1）, 3）, Yuji Mizoguchi 1）, 3）, Hitomi Kitaoka 2）, Takao Tashiro4）
1）Suzuka Kaisei Hospital 2）Suzuka University of Medical Science3）Graduate School of Open University of Japan 4）Graduate School of Open University of Japan

Key words: Ph.D., Higher Degree, Radiological Technologist, Qualification【Summary】

In recent years, many institutions have adopted 4-year programs for the education of radiological technologists.
We conducted a questionnaire survey of these professionals regarding their perceptions of a higher degree andaccreditation/professional qualifications. Our results indicated that 18.9% of participants wanted to obtain a higher
degree. On average, 3.9 ± 2.3 years (median: 2 years) and 166.7 ± 143.4 million yen (median: 500,000 yen) wererequired to obtain a degree. In the questionnaire, we asked whether the participants “would like to emphasize eithera degree or certification/professional qualifications.” Notably, 21.6%, 1.4%, and 58.1% responded that they would
like to emphasize both, the acquisition of an upper-level degree, and the acquisition of certification/professional
qualifications, respectively. We conclude that radiological technologists place greater emphasis on obtaining
certification/professional qualifications than on acquiring a higher degree.

Introduction
In recent years, educational institutions thattrain radiological technologists have shiftedfrom a conventional 3-years program to a
4-year program in responses to advances inmedical treatment, the specialization of expert
technologies, and citizensʼ requests. In Japan,
14 public universities (e.g., national universities, universities in prefectures) and 19 private
universities have been designated as training
institutions by the Minister of Education, Culture, Sports, Science, and Technology. Furthermore, the Minister of Health, Labor, and Welfare has designated one vocational training
school and established 12 private vocational
training schools (as of 2017) 1). These institutions produce approximately 2,000 radiological
technologists each year. Due to the increased
number of participating universities and decreased number of 3-year educational programs in recent years, the number of radiolog-

68（176）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

ical technologists who acquire a bachelorʼs degree has increased. This era represents a transition in the tendency to acquire a bachelorʼs
degree and the increased number of radiological technologists entering society. However,
the knowledge and skills learned at each training institution do not sufficiently ensure theability of radiological technologists to performtheir work smoothly, and many such professionals gain clinical experience onsite. In addition to leveraging existing technologies used in
the field, advances in radiation technology relyon the development of new technologies,
which are transmitted from clinical sites every
day and clinically applied.
Individuals face limits in terms of the development and dissemination of new radiological
technologies, and the related methods are notacademically correct. Generally, the introduction and evaluation of novel technology involves formulating a hypothesis, performing
suitable experiments, presenting the findingsmaterial
Survey of Consciousness Regarding the Acquisition of a Higher Degree and Accreditation/Professional Qualiﬁcations among Radiological Technologists and Students

Emphasize Ph.D acquisition
5%

Other
1%

Do not want toacquire a Ph.D.
37.9%

Already acquired
Ph.D.
22.7%

Currently enrolled
in doctoral course
15.3%

Want to acquirea Ph.D.
23.3%

Can not
choice either
19%

Emphasize acquisition of
specialist doctor qualiﬁcation
76%

Fig. 1 Results of a survey regarding consciousness
about Ph.D. acquisition among medical doctors (the graph was created using data fromthe Nikkei Medical Online website)

Fig. 2 Do medical doctors emphasize the acquisition of a Ph.D. or specialist doctor qualifications? (The graph was created using datafrom the Nikkei Medical Online website)

at scientific meetings held by relevant academic societies, and publication of the findings.
However, individuals may find it difficult to acquire the techniques or methodologies needed
to write conference presentations and papers.
Accordingly, exposure to systematic education,
especially in the context of a graduate or similar program, is desirable in terms of acquiring
the methods and techniques required to write
papers. For example, a physician who wishes
to pursue a graduate degree (e.g., Ph.D. inmedicine) belongs to the university medical institution, where he or she has the opportunity
to receive such education. The same educational opportunity is often provided even whena medical doctor is transferred to another university-affiliated hospital. Some medical educational institutions may expand these opportunities by establishing Ph.D. programs including
daytime and nighttime courses that can becompleted even during the 6-year medical residency period 2).
In another environment, one can acquire accredited physician/specialist qualifications with
the intent to master the specialized skills heldby a physician. Fig. 1 presents a survey regarding consciousness about the acquisition of a
Ph.D., (doctor [medicine]), which was conduct-

ed in 2011 via an online questionnaire. Fig. 2
presents a survey of consciousness regarding
the emphasis on specialists and degrees 3). This
figure demonstrates that more than 60% of
medical doctors are interested in or have already acquired a doctorate. Particularly, 23% of
medical doctor had already obtained a Ph.D.
(medicine). However, when asked a question
regarding the importance of the Ph.D. or professional qualification, many medical doctors
responded overwhelmingly that professional
qualifications are important. This tendency has
also been observed in many other studies of
medical doctors 4) 5). Possibly, this result can be
attributed to the nature of a medical professional qualification as essential to medical doctor who is employed by a medical institutionthat provides professional medical care in aclinical setting. Still, this finding does not neglect the perceived importance of degree acquisition, as more than 60% of medical doctors
are interested in acquiring a degree. In otherwords, many medical doctors acknowledge theimportance of acquiring a degree and express
interest in pursuing such education, even whileconsidering that the necessity and utility of
their work better prioritize a professional qualification than does a Ph.D. Medical schools opArts and Sciences ◆ 69（177）07

erate on a 6-year system, and doctors who acquire higher education will receive a Ph.D.
rather than a masterʼs degree.
However, some vocational schools and universities train students to become radiological
technologists. However, these schools differ interms of the educational period (3 – 4 years)
and types of degrees. At these institutions, radiological technologists can obtain bachelorʼs
and associateʼs degrees and diplomas. A student who has acquired a diploma or associateʼsdegree would next receive a bachelorʼs or masterʼs degree, followed by the highest-ranking
Ph.D. Furthermore, in Japan, a doctoral (Ph.D.)
dissertation course that does not involve a doctorate program is available, but there is a contraction tendency and this cannot be described
as a general means of acquiring this degree. In
addition, the eligibility requirement for an examination may be questioned when a radiological technologist seeks accreditation/professional qualifications; however, no degree isrequired in many cases. As a medical doctor
does not need to obtain a doctorate to becomea specialist, a radiological technologist does
not require a degree to acquire a certification/
professional qualification.
In this study, we conducted a questionnaire
survey that compared qualifications and professional qualifications to determine the perceptions of radiological technologists and students regarding the requirement for a higher
degree to enable career advancement.

Methods
We conducted a questionnaire survey of radiological technologists and students participating in Mie Lung CT Technical Conference,
held at Suzuka University of Medical Scienceon July 4, 2015.
In the questionnaire, we first asked about theage and sex of the respondent, as well as thedegree acquired (or to be acquired).
Next, we asked “Do you want a higher de-70（178）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

gree than you acquired?” The respondent wasthen requested to select one of the following
responses: “Strongly want,” “Want,” “Cannot
say either,” “Do not want,” or “Do not want at
all.”Subsequently, we asked “Do you place importance on degrees or certifications?” The respondents were asked to select one of the following
responses: “emphasize acquiring a degree,” “emphasize the acquisition of a certification/professional qualification,” “emphasize both a degreeand certification/qualification,” or “neither is important.”
Next, we asked the following of participants
who responded positively to the first question:“Do you think that it may be possible to spend
years acquiring the degree?” and “How muchdo you think you would pay to get the degree
you want?”
The questionnaire items are listed in Table 1.
The questionnaires were completed anonymously to ensure that individuals could not be
identified. They were collected after the study
group ended, and submission was optional.
We did not collect personally identifiable information, clarified the response data would only
be used as academic material after processing,and that replies would only be accepted fromthose who consented to participate. Furthermore, although the content of the questionnaire question other than this question has
been deleted, it is a part not related to this research.

Results
A total of 147 questionnaires were distributed, and 74 valid responses were collected (collection rate = 50.3%).
The respondents included 41 men and 33
women; of these, 63.5% (47/74), 20.3% (15/74),
12.2% (9/74), and 4.1% (3/74) were aged 20–
29, 30–39, 40–49, and 50–59 years, respectively (Fig. 3).
The respondents worked in the Mie, Gifu,

material
Survey of Consciousness Regarding the Acquisition of a Higher Degree and Accreditation/Professional Qualiﬁcations among Radiological Technologists and Students

Table 1 Question contents

Aichi, Wakayama, Kyoto, and Shiga prefectures.
Regarding education levels, 39.2% (29/74),
6.8% (5/74), 5.4% (4/74), 45.9% (34/74), 2.7%
(2/74), and 0.0% (0/74) of the respondents
were currently working toward a bachelorʼs
degree (i.e., university student) or held a vocational school graduate diploma, associatebachelorʼs degree, bachelorʼs degree, masterʼsdegree, or Ph.D., respectively (Fig. 4).
Regarding the questionnaire items, 2.7%
(2/74), 16.2% (12/74), 21.6 % (16/74), 18.9%(14/74), and 4.1% (3/74) of the respondents
selected “Strongly want,” “Want,” ”Cannot sayeither,” “Do not want,” or “Do not want at all,”respectively, in response to the item “Do you
want a higher degree than you acquired?.” Additionally, this question was not answered on
36.5% (27/74) of the questionnaires (Fig. 5).
Furthermore, 1.4% (1/74), 58.1% (43/74),
21.6% (16/74), and 1.4% (1/74) of the respondents selected “emphasis on acquiring a degree,”“emphasize the acquisition of a certification/
professional qualification,” “emphasize both adegree and certification/qualification,” or “neither is important,” respectively, in response to
the item “Do you place importance on degrees
or certifications?” This question was not answered on 17.6% (13/74) of the questionnaires(Fig. 6).

Master’s degree
2.7%50yo or more
4.1%

40‒49 yo12.2%

30‒39 yo20.3%

Bachelor
45.9%
20‒29 yo
63.5%

Bachelor’s degree
is expected
to be acquired
39.2%

Vocational school
graduation diploma
6.8%
Associate Bachelor
5.4%

Fig. 3 Age distribution of the questionnaire respondents

Fig. 4 Distribution of responses regarding accepted
degrees
Arts and Sciences ◆ 71（179）07

Strongly want
2.7%

Want
16.2%
No response
36.5%
Cannot say either
21.6%
Do not want at all
4.1%
Do not want
18.9%

Fig. 5 Distribution of responses to the question“Do you want a higher degree than you acquired?”

Degree1.4%

Not importanceboth 1.4%

million yen (width 500,000–5,000,000 yen, median 500,000 yen (n=6)) (Fig. 7).

No response
17.6%

Importance both
21.6%

Fig. 7 Distribution of responses to the questionsof “Do you think that it may be possible tospend years acquiring the degree?” and“How much do you think you would pay to
get the degree you want?”

Discussion
Certiﬁcation
qualiﬁcation
58.1%

Fig. 6 Distribution of responses to the question“Do you place importance on degrees orcertifications?”

As noted, the 14 participants who responded
positively to the first question were asked additional questions about the perceived durationand cost required to acquire a degree. Thirteen
participants responded effectively to the question “Do you think that it may be possible tospend years acquiring the degree?,” with an average response of 3.9 ± 2.3 years (width 2–10
years (n=6)). Twelve participants responded
effectively to the question “How much do you
think you would pay to get the degree youwant?” The average response was 166.7 ± 143.4

72（180）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

The data in Fig. 2 and Fig. 5, suggest that
18.9% of radiological technologists who are
currently acquiring higher degrees “Strongly
want” or “Want” to acquire higher qualifications. This percentage is less than the corresponding percentage of medical doctors whocompleted the same questionnaire, as shownin Fig. 1. This difference is likely indicates thatradiological technologists consider acquiring ahigher degree less meritorious when they consider higher financial and time expenditures.
Generally, the newly acquired degrees of graduates from medical institutions are not always
reflected in terms of salary or promotions, except at the time of recruitment. However, 18.9%of radiological technologists wished to obtainhigher degrees. This indicates a demand foradvanced education among radiological technologists. According to a survey conducted by
Igarashi and colleagues, 28.8% of participantsalready held a bachelorʼs degree, while 25.0%
wished to acquire this degree 6). In addition,
1.0% of participants had already acquired amaterial
Survey of Consciousness Regarding the Acquisition of a Higher Degree and Accreditation/Professional Qualifications among Radiological Technologists and Students

masterʼs degree, while 28.8% wished to acquire
this degree. According to a survey of radiological technologists by Nakanishi et al., the ratioof radiological technologists who the ratio ofradiological technologists who answered, “I
would like to obtain a bachelorʼs degree” was
9.9%, 14.9% answered “I would like to acquire
if possible”, and 35.8% already obtained a bachelorʼs degree. In addition, the ratio of radiological technicians who answered, “I would like toobtain a masterʼs degree” is 0.9%, 14.9% answered “I would like to acquire if possible”,
4.2% have already obtained a Masterʼs degree 7).
Although these studies used different themes
and survey methods and cannot be compareddirectly, the results of both indicate only asmall proportion of radiological technologists
wish to obtain a bachelorʼs or masterʼs degree.
As noted, participants in this survey responded that a higher degree would require an average of 3.9 ± 2.3 years and an average of 166.7± 143.4 million yen. This indicates an acceptance that after graduating from college, a bachelorʼs degree would require at least 2 years. In
addition, even those who do not hold a bachelorʼs degree can obtain a masterʼs degree ifthey complete the masterʼs program after passing a pre-enrollment screening examination.
Furthermore, those who already hold a bachelorʼs degree can complete the masterʼs programand obtain a masterʼs degree. Furthermore, theaverage monetary amount stated by respondents cannot be described as a considerably
smaller burden when compared to the tuition
required to continue oneʼs education. Possibly,
some respondents reported a large financial
expenditure, and the small number of respondents biased the average toward a higher price.
Therefore, it would seem appropriate to evaluate the median response to this question,
which was 500,000 yen, or equivalent to theminimum cost (466,000 yen) necessary to complete a graduate course at the Open Universityof Japan, a graduate school of communication.
Even in s report by Igarashi et al., 44.4% ofradiological technologists replied that the economic burden made them hesitant to enter auniversity program. Economic support measures could effectively alleviate this burden andsupport the further education of radiological
technologists. In a committee report, the Japanese Society of Radiological Technology indicates the importance of creating an atmospherein which members are recommended to obtaina doctorate degree as part of their academic
achievement improvement. Various measures
toward this initiative have been implemented
over the past decade 8).
Fig. 6 demonstrates that approximately 79%
of the participants responded that they “emphasize the acquisition of a certification/professional qualification” or “emphasize both adegree and certification/qualification.” Many
respondents in this study indicated that theywould emphasize a professional qualification,in addition to a basic radiological technologist
qualification, for career improvement. By contrast, only 1.4% responded that it is only important to acquire a higher degree. This resultis overwhelmingly smaller than the 58.1% ofparticipants who responded that they “emphasize the acquisition of a certification/professional qualification.” Apparently, the respondents wished to acquire a qualification, rather
than a degree higher than their already completed educations. This trend is similar to thatseen in the results of the medical doctor awareness survey shown in Fig. 2. However, thisfinding might not be generalizable, given thelack of survey respondents, the inclusion of
students, or the administration of questionnaires to only those who participated in a conference in the CT area. Moreover, the “higher
degree” level is not clear because the results
were not aggregated by the acquired degree.
Further research is needed to address thesepoints.
In general, certifications and qualifications
prove that the awardee has achieved a certain
level of skill and knowledge about the field.
Arts and Sciences ◆ 73（181）07Degrees are given by academic institutions,such as universities, and are based on the results of research and of specific curricula intended to deepen the studentʼs academic ability and enhance specialization 9). The questionnaire results were reflective of the characteristics of both certifications/qualifications anddegrees. In the medical field, qualified people
are recognized as those qualified to do a professional job. However, a certification or qualification is not mandatory. A radiological technologist who holds a basic qualification canwork in a clinical setting. A radiological technologist who holds a certification/qualification
is expected to have experience in aspects ofhuman resources and to be capable of scientifically evaluating evaluations and improving
techniques, such as current photography methods and examinations of new technologies. An
educational environment such as graduate
school provides an optimal place to cultivate
this knowledge and conduct scientific evaluations. Therefore, We suggest that it is a good
way to graduate from graduate school to further specialize existing certification/professional qualifications or to create higher qualifica-

tions/professional qualifications than at present. According to a survey by Ochiai, pride is
reduced “when feeling legal restrictions as atechnical worker” 10). This indicates that current
radiological technologists are experiencing a
deeper level of clinical expertise and feels that
more advanced knowledge is necessary.

References

6） Igarashi Hiroshi, et al.: Investigation of Academic
Degrees Sought by Radiological Technologists:
Japanese Journal of Radiological Technology, 62. 10:
1463-1468, 2006. (Japanese)
7） Nakanishi Satoshi, et al.: Attitude Survey of Radiological Technologists toward Qualification Acquisition ofLicentiate and Degrees in Mie Prefecture. Japanese
Journal of Radiological Technology, 67. 12: 15741582, 2011. (Japanese)
8） Komizu Mitsuru, et al.: Japanese Society of Radiological Technology tayoukasuru shakai no youseini oujite:
Japanese Journal of Radiological Technology, 70. 3:
308-320, 2014. (Japanese)9） National Institution for Academic Degrees and Quality
Enhancement of Higher Education Homepage (Access 2017.5.1) http://www.niad.ac.jp/
10）Ochiai Yukiko, et al.: Process of developing occupational identity of radiological technologist throughout
life. Ibaraki Prefectural University of Health Sciences
Minutes, 11: 71-78, 2006. (Japanese)

1） Yasuo Nakazawa: 70 shunen-kinenshi-kono-10 nennoayumi. 126-127, The Japan Association of Radiological Technologists, 2017. (Japanese)2） Motokazu Hori: Learn a Prospective Way of Medical Education from the Progressing Theory of Higher
Education and Create a Practice based on It. Medical
Education Japan, 42. 5, 309-316, 2011. (Japanese)
3） Nikkei Medical online (cadetto.jp) (Access 2017.5.1)
http://medical.nikkeibp.co.jp/leaf/all/cadetto/magazine/1103-t3/201110/522011.html）
4 Sumiko NAGOSHI, et al.: Career advancement of
women in the Japanese Society of Gastroenterology(JSGE) Women Gastroenterologist Support Committee. the Japanese Society of Gastroenterology, 110.
8: 1387-1391, 2013. (Japanese)5） Takuma Kimura, et al.: Characteristics of second-year
residents intending to become a primary care physicians. Journal of General and Family Medicine, 35. 1:
6-11, 2012. (Japanese)

74（182）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Conclusion
This study demonstrated that many radiological technologists focus on certifications/professional qualifications rather than degrees.
However, some radiological technologists
would also like to obtain a higher degree.
These professionals may be limited by theamount of money that they can spend to obtain a degree. However, this suggests that more
people would consider obtaining a higher degree if there a support plan could assist withsome expenses. Few radiological technologists
did not emphasize certification/professional
qualifications. Many radiological technologists
are not only qualified for their current work,
but also want to achieve career improvement.

Arts and Sciencesmaterial

Received September 19, 2017; accepted March 30, 2018

Basic Characteristics of a General-purpose Semiconductor Detector for Diagnostic X-ray Measurements
Hiroshi Hamasaki, Toyoyuki Kato, Yoshiyuki Umezu
Radiological technologist, Division of Radiology, Department of Medical Technology, Kyushu University Hospital

Key words: semiconductor detector, energy response, dose response, dose rate response, directional response【Summary】

In the present study, we aimed to evaluate the accuracy of a general-purpose semiconductor detector (Unfors
Raysafe Xi, Unfors Raysafe AB) in the X-ray measurements of diagnostic areas and compare its accuracy with that of
an ionization chamber dosimeter. The parameters investigated included energy, dose, dose-rate responses, directional
responses, and reproducibility of the Unfors Raysafe Xi. The relative error of the Unfors Raysafe Xi with respect toenergy, dose, and dose-rate responses was within 5% of the maximum. Its reproducibility was better than that of theionization chamber dosimeter, and its direction dependance was within − 2% of the measured value from the 0°to ±20°direction. We conclude that the Unfors Raysafe Xi is a viable and highly accurate dosimeter that can be used for
X-ray measurements of diagnostic areas.

Introduction
Until now, ionization chamber dosimeters
have been generally used for X-ray dosimetry
in the diagnostic field. The ionization chamber
dosimeter is a measuring device conforming to
the definition of irradiation dose. Because it
has almost no energy characteristics (dependency), it is used as a reference dosimeter for
X-rays 1, 2). However, its disadvantage is that it
is susceptible to air temperature, atmosphericpressure, and humidity 3, 4).
In recent years, a simple invariance test of adiagnostic X-ray generator employing a non-connection-type X-ray output analyzer using a semiconductor detector has become common 5 -7).
Semiconductor detectors do not need a warmup period or bias voltage, which is an advantage because they are not significantly affectedby temperature and pressure when comparedwith ionization chamber dosimeter 8). However, the disadvantage of conventional semiconductor detectors is that their energy dependency is higher than that of ionization chamber

dosimeters.9) In addition, there are few reports
evaluating the measurement accuracy of conventional semiconductor detectors.
We introduced a semiconductor type-multifunction X-ray-measuring instrument with abuilt-in energy correction mechanism known
as the Unfors Raysafe Xi (Unfors Raysafe AB)
and evaluated its accuracy in the X-ray measurements of diagnostic areas compared withthat of an ionization chamber dosimeter.

Equipment
For the semiconductor detector, a Raysafe Xi
detector for general photography/fluoroscopic
photography was used. The X-ray high voltage
device and the X-ray tube device were the
DHF-155H (D) and UH-6FC-31E (inherent filtration: 1 mm Al), respectively, and the X-ray
movable diaphragm used ZU-L 5 KU (inherent
filtration: 1.5 mm Al).
As a reference dosimeter, we used an ionization chamber dosimeter 23344 type 0.2 cm3shallow chamber calibrated and connected to aArts and Sciences ◆ 75（183）07

RAMTEC 1000 plus electrometer (Toyo MedicCo., Ltd.). The reference dosimeter was calibrated with soft X-rays, and the calibration energy band was 8 to 35 keV.
Raysafe Xi Specifications

The basic configuration of the Raysafe Xi dosimeter consists of the Unfors Xi base and external detectors for radiography/fluoroscopic radiography (R/F), mammography (MAM), computed tomography (CT), illuminance/luminance(Light), and scattered radiation or low level radiation (Survey); it has a multiparameter measurement function.
The R/F/MAM detector is equipped withthree sensors, which are as follows: R/F high,R/F low, and MAM. In the present study we
examined two sensors, R/F high and R/F low,used for the diagnosis area. R/F high is used
for high dose rate measurements (20 [μGy/s]− 1000 [mGy/s]) generated without a phantom
between the detector and the X-ray source,with a measurement range of 10 [μGy] − 9999
[Gy]. R/F low is used for low dose rate measurements (10 [nGy/s] − 1 [mGy/s]) generated
via a phantom between the detector and the
X-ray source, with a measurement range of 10[nGy] − 9999 [Gy].
These detectors can simultaneously measuretube voltage, dose, dose rate, irradiation time,
half value layer, number of pulses, pulse

Axial(frame) rate, and dose per frame in one measurement and can automatically correct measured values. By using the attached Unfors Xi
View, data transfer of measurable items can bealso be performed automatically.10)
The Raysafe Xi base unit and the R/F/MAM
detector is illustrated in Figure 1.

Methods
To measure each characteristic evaluation,
the R/F detector and the reference dosimeter
were arranged parallel to each other in the direction orthogonal to the long axis of the X-ray
tube in consideration of the heel effect. The
R/F detector and the reference dosimeter wereplaced 3 cm from the center of the irradiation
field and measured five times. It was confirmedthat the side scattered ray from the R/F detector did not affect the reference dosimeter (lessthan 1%). To eliminate the influence of backscattering, each dosimeter was placed 60 cm
from the floor and 100 cm or more from thesurrounding wall (Fig. 2).
In the reference dosimeter, the absorbed
dose of air (absorbed dose) Dic [Gy] was obtained from the indicated value M [C/kg] by thefollowing formula.
Dic = Wair · N · M · ktp

X-ray tube

Fig. 1(b)Fig. 1（b）

Fig. 1 Overview of the Raysafe Xi.

（a）Raysafe Xi Base Unit （b）R/F detector
Fig.
1(a)

76（184）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

60 cm

Fig. 1（a）

R/F Reference
detector dosimeter

FCD 120 cm

3 cm

Radial(1)

Floor

Fig. 2 Geometrical set-up for the characteristics
evaluation. Fig. 2

material
Basic Characteristics of a General-purpose Semiconductor Detector for Diagnostic X-ray Measurements

Wair: W/e [J/C] W value of air (= 33.97 [J])N: calibration constant of reference dosimeter at each effective energy
ktp: temperature atmospheric pressure correction coefficient
Because the absorbed dose was automatically calculated by the R/F detector, the indicatedvalue was taken as the absorbed dose Dsd [Gy]in the R/F detector. The relative error of theR/F detector relative to the reference dosimeter
was determined.
Measurement of Effective Energy

Half-value layers at each tube voltage were
measured using the aluminum attenuation
method, 11, 12) and each effective energy wascalculated from photon attenuation coefficientdata. 13)
Using a reference dosimeter, the tube voltage was irradiated from 60 kV to 120 kV at 20
kV steps. The other irradiation conditions wereset as following: the tube current was 400 mA,
the irradiation time was 300 msec, the focus
chamber distance (FCD) was 200 cm, and theirradiation field at the detector position was 3
× 3 cm2.
Energy Response

FCD was 120 cm, irradiation field was at 20
× 20 cm2 at detector position, tube voltage
was changed every 20 kV from 60 kV to 120
kV, and simultaneous irradiation was carriedout with the reference dosimeter and R/F detector at each tube voltage. The tube current
and irradiation time were kept constant foreach R/F detector setting and measurements
were taken using a tube current of 200 mA andan irradiation time of 200 msec for R/F highand a tube current of 10 mA and irradiation
time of 200 msec for R/F low, respectively.

tube voltage was set at 80 kV, irradiation time
was varied, and simultaneous irradiation of theR/F detector and reference dosimeter was performed. For R/F high, the tube current was
kept constant at 200 mA and the irradiation
time was changed to 10, 20, 32, 40, 50, 100,
200, 320, 400, and 500 msec. For R/ Flow, thetube current was kept constant at 10 mA, andthe irradiation time was changed to 50, 80, 100,
160, 200, 320, 400, and 500 msec.
Dose Rate Response

Simultaneous irradiation of the R/F detector
and the reference dosimeter was performed bychanging the tube current with the same geometrical arrangement used to measure energy
response and dose response. For R/F high, thetube voltage was constant at 80 kV, the irradiation time was 100 msec, and the tube current
was changed to 50, 100, 160, 200, 250, 320,
400, 500, and 630 mA. For R/F low, the tube
voltage was constant at 60 kV, the irradiation
time was 100 msec, and the tube current waschanged to 10, 20, 32, 40, 50, and 63 mA.
Reproducibility

Simultaneous irradiation of the R/F detector
and reference dosimeter was performed tentimes by changing the tube voltage using thesame geometrical arrangement used to measure energy response and dose response. The
tube voltage was varied every 20 kV from 60
kV to 120 kV to find the variation coefficient 14)
for each tube voltage. Tube current and irradiation time were kept constant for each R/F setting, and measurements were performed witha tube current of 200 mA and irradiation timeof 100 msec for R/F high and a tube current of
10 mA and an irradiation time of 100 msec for
R/F low.
Direction Response

Dose Response

Using the same geometrical configuration
employed for measuring dose response, theDirectional characteristics were investigatedon the R/F detector. The angle perpendicularly
incident on the detector was set to 0, and theArts and Sciences ◆ 77（185）0710000R/F high (μGy)

measurement was performed by changing theangle from 0 to 350˚ with respect to the major
axis and the minor axis at intervals of 10. The
FCD was 120 cm, and the irradiation field at
the detector position was 3 × 3 cm2.
Tube voltage, tube current, and irradiation
times were 80 kV, 200 mA, and 100 msec for
R/F high and 60 kV, 50 mA, and 100 msec for
R/F low, respectively.

1000

100

10

10
100
1000
10000
Reference dosimeter (μGy)

（a）
Fig.
3(a)

Results
Measurement of Effective Energy

Energy Response
Table 1 shows the relative values of the R/F

detector with respect to the reference dosimeter at each effective energy. The relative valuesof R/F high and R/F low were close to 1.0, andthe relative error in the measured effective energy bands was within 1%.

Table 1 The relative ratio of the dose of
the Raysafe Xi（R/F high and R/Flow）for the reference dosimeterat each effective energy

Relative ratio
Effective energy (keV) R/F high R/F low
30.0

1.009

1.008

33.5

1.009

1.009

36.7

1.008

1.006

39.2

1.005

1.003

Table 1

1000

R/F low (μGy)

The effective energy at each tube voltage
was 30.0, 33.5, 36.7, and 39.2 keV at 60, 80,
100, and 120 kV, respectively.

100

10

10
100
1000
Reference dosimeter (μGy)

（b）
Fig.
3(b)

Fig. 3 Correlation between the Raysafe Xi（R/Fhigh and R/F low）and reference dosimeterat dose（irradiation time）.
（a）R/F high （b）R/F low

Dose Rate Response

The results of the dose rate characteristics ateach effective energy are shown in Figure 4.
Linearity of the R/F detector and the reference
dosimeter was maintained with respect tochanges in tube current. The relative error was−0.8% to 0.3% for R/F high and −4.3% to 0.4%
for R/F low.

Dose Response

The results of the dose characteristics at the
tube voltage of 80 kV (33.5 keV) are shown in
Figure 3. The linearity of the R/F detector andthe reference dosimeter was maintained against
the change in dose (irradiation time). The relative error was −1.3% to 2.7% for R/F high and−1.2% to 4.0% for R/F low.

78（186）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Reproducibility
Table 2 shows the results of the coefficient ofvariation for each effective energy. For R/Fhigh, the coefficients of variation in the reference dosimeter were from 0.001 to 0.003 andfrom 0.002 to 0.009, respectively. For R/F low,
the coefficients of variation in the referencematerial

R/F high (mGy/s)

Basic Characteristics of a General-purpose Semiconductor Detector for Diagnostic X-ray Measurements

100

dosimeter were from 0.026 to 0.039 and from
0.049 to 0.066, respectively.

10

Direction Response

1

0.1

0.1
1
10
100
Reference dosimeter (mGy/s)

（a）
Fig.
4(a)

R/F low (mGy/s)

10

1

0.1

Since the behaviors of R/F high and R/F low
with respect to the direction response wereidentical, the result of R/F high is shown in
Figure 5. For ±20˚ in both major and minor
axis directions, the result was within −2% of
the measured value from 0˚ direction.
However, a measured value of about 20% of
0˚ was detected at 100˚ to 110˚ in the minor
axis direction. This result suggested that theR/F detector also detected scattered rays fromthe back, so additional measurements were
made. The R/F detector was measured in airand solid water at the same distance from 0˚under the shooting conditions, but the difference between them was within 1%.

07

0.1
1
10
Reference dosimeter (mGy/s)

（b）
Fig.
4(b)

Fig. 4 Correlation between the Raysafe Xi（R/Fhigh and R/F low）and reference dosimeterat dose（dose-rate）.
（a）R/F high （b）R/F low

Table 2 Coefficient of variation of theRaysafe Xi（R/F high and R/F low）
（a）R/F high,（b）R/F low

（a）
Fig.
5(a)

Dosimeter Mode Effective energy (keV)
30.0 33.5 36.7 39.2
Reference
R/F

0.009 0.003 0.003 0.002
0.003
0.002 0.003 0.001
high
Table 2（a）

Table 2(a)Dosimeter Mode Effective energy (keV)
30.0 33.5 36.7 39.2
Reference
R/F

0.066 0.049 0.063 0.064
low 0.026 0.039 0.030 0.036
Table 2（b）

Table 2(b)（b） 5(b)Fig.

Fig. 5 Direction response of the Raysafe Xi.
（a）Axial （b）Radial

Arts and Sciences ◆ 79（187）Discussion
A non-connection-type X to ray output analyzer using a semiconductor-type detector,
such as the Raysafe Xi that we studied, enables
data including tube voltage, dose (air kerma),
half value layer, dose rate, irradiation time, output waveform, and many other types of information to be obtained. However, the semiconductor type detector has large energy dependance, leading to problems in accuracy, and an
ionization chamber dosimeter with good energy response has become the reference X to ray
dosimetry instrument in the diagnostic field.
In the energy response using the semiconductor detector in the present study, the relative value of the reference dosimeter showed atendency to approach 1.0 as the energy level
increased, but the relative error was within 1%
at 30.0 to 39.2 keV. Because the calibration energy band of the reference dosimeter is 8 to 35
keV, results at 36.7 and 39.2 keV lacked reliability, but good results were obtained with thediagnostic area X-ray device. One reason forthis is the installation of an active compensation function as part of the Unforsʼ proprietary
technology. This function automatically judges
beam energy by multiple sensors and advanced
calculation processing, eliminating the need tocorrect kVp and dose measurement values inthe diagnostic area X-ray device and mammography device. In recent years, a non-connection type X-ray measuring instrument using asemiconductor detector with or without a metal filter has been able to obtain energy information from a signal ratio multiplied with anenergy correction coefficient to obtain a constant response to energy. 15-17) We believe thatthe same method is used in the Raysafe Xi.
The R/F detector also maintained linearity
with the reference dosimeter with respect todose response and dose rate response, withthe relative error within 5% at the maximum.
The coefficient of variation of the R/F detector
was about 10 times as great as R/F high and80（188）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

R/F low, but it was 0.039 at the maximum,
which was smaller than the coefficient of variation of the reference dosimeter. On the other
hand, the mAs value error of the X-ray generator specified was JIS is ± (10% + 0.2 mAs). 18)
Assuming that the error of the mAs value is adose error, the dose measurement error of theRaysafe Xi was sufficiently small with respect
to the dose error of the X-ray generator in the
diagnostic area X-ray to consider the accuracyof the Raysafe Xi to match that of the ionization chamber dosimeter with respect to thedose measurement of the diagnostic area X-ray.
Since the direction response indicated that
the R/F detector detected scattered irradiationfrom the back, measurement of backscattering
was added, but it can be confirmed that scattering rays were seldom included even when
the R/F detector was placed on the scatterer.
This was thought to remove the scattered ray
from the back by surrounding the back of thedetector with a layer of lead 1 mm thick, butsince the direct ray from the back affected themeasurement value, we believe it is necessary
to pay attention to the geometrical arrangement.
In addition to the functions reviewed in thisstudy, the semiconductor type detector typically features temperature dependence and irradiation field size dependance. 19, 20) The active
compensation function installed in the Raysafe
XI also performs filtration and correction according to temperature, but consideration ofthese functions would requ1ire further study.

Conclusion
In the present study, we measured the basic
characteristics of the Unfors Raysafe Xi in the
X-ray diagnostic area and compared it with theionization chamber dosimeter. The same results for were obtained for energy response,
dose response, dose rate response, direction
response, and reproducibility for both devices.
The Unfors Raysafe Xi was thus shown to bematerial
Basic Characteristics of a General-purpose Semiconductor Detector for Diagnostic X-ray Measurements

useful for dose measurement. Moreover, unlike
the ionization chamber dosimeter, it is also
possible to use the Unfors Raysafe XI immediately after turning it on, it is unnecessary tocorrect every measurement, measurement data

can be transferred to a personal computer, andoperation and recording are very simple. These
facts suggest that the Unfors Raysafe Xi is also
useful for everyday QA/QC.

References

ment in mammography. Japanese Journal of Radiological Technology, 67, 1533-1539, 2011.
12）Yagi Hiroshi, et al.: A Study on Measurement of Half
Value Layer of Mammography Apparatus. Japanese
Journal of Radiological Technology, 59, 729-736,
2003.
13）SELTZER, S. M., et al.: Photon attenuation coefﬁcient
data book. Radiology and Medical Engineering Series (11) Kyoto: Japan Radiation Technology Society,
1995.
14）JIRA QA 019 Medical X-ray high voltage equipment
General rules JIS Z 4702: 1999 Guide.
15）Fuminori Shinohara, et al.: Characteristics of a new
non-connected X-ray output analyzer. Japanese Journal of Radiological Technology, 58, 479-486, 2002.
16）Toshioh Fujibuchi, et al.: Characterization of Real Time
Semiconductor Dosimeter and Measurement of Incident Surface Dose in General Photographing. Japanese Journal of Radiological Technology, 62, 9971004, 2006.
17）Toshioh Fujibuchi, et al.: Prototyping and Evaluation ofEnergy Compensated Wireless Dose Monitoring System for Medical Employee Exposure Management.
Japanese Journal of Radiological Technology, 71,
691-696, 2015.
18）JIS Z 4702: 1999. Medical X-ray high voltage equipment general rule JIS Handbook Radiation (Noh),
781-807, 2009.
19）SAINI, Amarjit S, et al.: Dose rate and SDD depen dence of commercially available diode detectors.
Medical physics, 31, 914-924, 2004.
20）SAINI, Amarjit S, et al.: Energy dependence of commercially available diode detectors for in-vivo dosimetry. Medical physics, 34, 1704-1711, 2007.

1） Iwanami Shigeru: Management of medical exposurein X-ray diagnosis - from the standpoint of quality
control Radiomedical physics, 15, 305-314, 1995.
2） Nobue Akiyama, et al.: Photon energy dependence ofionization chamber of various shapes and materials,
Health Physics, 22, 153-157, 1987.
3） Takeshi Hiraoka: Dose measurement. Japanese Journal of Medical Physics, 12, 118-121, 1992.
4） Hiroshi Oguchi: 1. Ionization chamber dosimeter forradiotherapy (various problems of dosimetry in radiation therapy: measurement theory and clinical application). Japanese Journal of Radiological Technology,
51, 472-481, 1995.
5） Toru Negishi: 8. Utilization of non-connected X-ray
measuring instrument. Japanese Journal of Radiological Technology, 68, 626-632, 2012.
6） Yoshiyuki Ioka, et al.: Accuracy evaluation of nonconnected X-ray output analyzer. Japanese Journal ofRadiological Technology, 69, 1153-1160, 2013.
7） Izumi Ogura, et al.: Development of a simple measuring system for daily management of X-ray equipment.
Japanese Journal of Radiological Technology, 70,
1403-1412, 2014.
8） Hiroshi Kato: Simple measuring instrument for QA
and QC of X-ray equipment. Japanese Journal of Radiological Technology, 61, 487-492, 2005.
9） Yamamoto Chiaki, et al.: Utilization of a silicon semiconductor (PN junction type) dosimeter in the energy
region of diagnostic X rays Medical instrument 48,
234-237, 1978.
10）Unfors Xi Platinum edition UserʼS Manual.: Torrek Corporation.
11）Ishii Rie, et al.: Accuracy of half-value layer measure-

Arts and Sciences ◆ 81（189）07Arts and Sciencesmaterial

Received June 28, 2017 ; accepted May 25, 2018

A survey conducted by coordinated, continuing,
medical staff education program (CoMSEP) graduates regarding interprofessional cooperation
between radiological technologists, medical technologists, and physical therapists
Toshiya Akatsu1），Masanori Maruyama2），Tomoko Maruyama3），Ryosuke Arai4），
Katsumi Miyamoto1），Michiharu Sekimoto5），Rumi Gotanda6），Hiroyuki Tsushima7），
Yoshiyuki Ishimori7），Yukari Ohashi8），Haruhiko Ninomiya9），Hitoshi Sato7）1）Department of Radiological Technology, Tsukuba Medical center Hospital2）Department of Rehabilitation, Aida Memorial Rehabilitation Hospital3）Social Welfare Organization Saiseikai Imperial Gift Foundation, Inc Department of Clinical Laboratory, Ryugasaki Saiseikai Hospital4）Rehabilitation Center, Ushiku Aiwa General Hospital5）Department of Radiological Technology, Niigata University of Health and Welfare6）Department of Radiological Technology, Faculty of Health Science and Technology, Kawasaki University of Medical Welfare7）Department of Radiological Sciences, Ibaraki Prefectural University of Health Sciences8）Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences
9）Faculty of Medicine, University of Tsukuba

Key words: interprofessional cooperation, multidisciplinary collaboration, team medicine, questionnaire, radiological

technologist【Abstract】

A questionnaire survey was conducted to medical staffs working with first graduates of the CoordinatedContinuing Medical Staff Education Program (CoMSEP). The target occupations were radiological technologist,
medical technologist and physical therapist. Future necessity of cooperation of three job type was 81%. However,the comprehension level of job content by job type was 43% on average, and the opportunities involved with otheroccupations in business was 5% on average. X-ray photography, CT, and MRI were recognized by 90% of staffs inother occupations, as the specialization of radiological technologists. Moreover, they wanted to learn how to interpretthese medical images. The necessity of cooperation and the requirement among professions were clarified. We wereable to obtain useful information for promotion of future interprofessional cooperation.

1. Introduction
A “Report for the Promotion of Team Medicine” 1) (Ministry of Health, Labor and Welfare)describes team medicine as the medical staff
that cooperate with each other to share information based on their expertise; sharing information to respond with the appropriate medical treatment for the patient. Team medicine is
expected to improve the quality of medical
treatment, subsequently prolonging the life of
the patient, reducing the burden to the medical
staff, and improving medical safety by stand-82（190）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

ardizing and organizing medical treatment. For
these reasons, it is necessary to improve theexpertise of each of the specialties and to promote cooperation between them.
In 2014, the Ministry of Education, Culture,
Sports, Science and Technology launched a“problem-solving for advanced medical personnel” training program in order to enrich thetraining of medical staff at the university 2). The
University of Tsukuba and the Ibaraki Prefectural University of Health Sciences have developed the Coordinated, Continuing, Medical
Staff Education Program (CoMSEP), which pro-material
A survey conducted by coordinated, continuing, medical staﬀ education program (CoMSEP) graduates regarding interprofessional cooperation
between radiological technologists, medical technologists, and physical therapists

motes team medicine by training medical staff
in strong leadership skills 3-4). This program ismainly available as an undergraduate course
for students or a certificate program for social
workers who work as medical professionals.
There are three main types of medical professions that this program is suited for. These areradiological technologist (RT), medical technologist (MT), and physical therapist (PT). The
purpose of the certificate program is to provide
the latest knowledge in the professional field,
promote understanding of other medical specialties necessary for practicing team medicine,and promote dissemination of interprofessional cooperation. In this program, there are no
restrictions in the choice of graduation college(vocational school), graduation year, or working hospital. The program includes e-learning(of the basic to the latest knowledge), intensive lectures, and open lectures. The programis offered throughout the year (Fig.1).

2. Purpose
Previous graduates of the CoMSEP certificate
program have noticed challenges that arise ininterprofessional occasions. For example, howother members of the team work and what is
expected of them is not understood wellenough. To this end, it is important to understand these challenges to aid interprofessional

RT

MT

PT

e-learning (60hours)
Certificate
programIntensive lecture (56hours)
Open lecture (4hours)

Undergraduate
education
program

Biological function diagnosis
workshop (2days)

Fig.1 Scheme of CoMSEP

cooperation. Although there have been many
reports of interprofessional cooperation between doctors and nurses 5-6), there are no reports of interprofessional cooperation between
the three aforementioned professions, RTs,
MTs, and PTs. We surveyed employees regarding interprofessional cooperation in each ofthese three professions, focusing on RTs.

3. Target・method
To evaluate the current state of interprofessional cooperation, an anonymous survey was
conducted by CoMSEP graduates (survey period: July 1–31, 2016). The questionnaires were
distributed to the three professions (RTs, MTs,and PTs in each facility) and the responses
were collected. Meanwhile, radiography was
written as roentgen so that other professions
can easily answer. The contents of the questionnaire are shown in Table 1.
The questionnaire was divided into four categories. Questions 1 to 3 involved the personal
profile of the respondents. Questions 4 and 5
were about how the respondents understoodthe duties and responsibilities of the other professions. Questions 6 and 7 involved how the
respondents currently experienced interprofessional cooperation. Questions 8 to 10 involved
the future perspectives of interprofessional cooperation. The answer format of Questions 5
and 8 was multiple choice, questions 3 and 10
required descriptive answers, and questions 6
and 7 were both multiple choice and descriptive. The responses were tallied for each job
category and the results of Questions 4 and 7
were compared for RTs, MTs, and PTs and forthe additional professions of doctor (Dr) andnurse (Ns).

4. Result
The total number of respondents was 627
from 11 facilities.
Within these 11 facilities, one facility conArts and Sciences ◆ 83（191）07

Table 1 Questionnaire including 10 questions regarding interprofessional cooperation【Profile】

Q1．

What is your gender ?
( 1. male 2. female )Q2．

What is your profession ?
( 1. radiological technologist 2. medical technologist 3. physical therapist )Q3．

How long is your experience in that profession ?
() years【About other professions】

Q4．

Do you know the work contents and roles of each job category ? (exclude your job category)
Dr ： ( 1. know well 2. know 3. do not know much 4. do not know at all )Ns ： ( 1. know well 2. know 3. do not know much 4. do not know at all )RT ： ( 1. know well 2. know 3. do not know much 4. do not know at all )MT：( 1. know well 2 .know 3. do not know much 4. do not know at all )PT ： ( 1. know well 2. know 3. do not know much 4. do not know at all )Q5．

Pick up from the following items what you know about the work contents of RT.
Do not pick up items you do not understand well．
1. Roentgen 2. CT 3. MRI 4. US 5. RI 6. IVR 7. RT 8. MMG 9. GI 10. Dose management【About interprofessional cooperation】

Q6．

Select three things that you think high priority about interprofessional cooperation.
1. Team approach by medical team 2. Information exchange/contact
3. Joint study group 4. Social gathering 5. Other (
1st (

Q7．

) 2nd ()) 3rd ()

How often do you cooperate with other profession in your work ? (exclude your job category)Also, write down about the contents of cooperation with other than doctors and nurses.
Dr ： ( 1. Quite a lot 2. Many 3. Few 4. Not at all )Ns ： ( 1. Quite a lot 2. Many 3. Few 4. Not at all )RT ： ( 1. Quite a lot 2. Many 3. Few 4. Not at all )Content ()

MT：( 1. Quite a lot 2. Many 3. Few 4. Not at all )Content ()

PT ： ( 1. Quite a lot 2. Many 3. Few 4. Not at all )Content ()

【Potential for interprofessional cooperation in the future】

Q8．

Are there any work contents that you feel necessary for enriching interprofessional cooperationin the future ?
※Items are the same as Q5

Q9．

Do you feel necessity to cooperate in three professions (RT, MT, PT) ?
1. Abusolutely necessary 2. necessary 3. Not much necessary 4. Not necessary at all

Q10． If you have any comments on the cooperation of three professions (RT, MT, PT), please fill in
below. Theme and idea of what you want to do, what you can provide about your job category,and so on.
(

84（192）◆ 日本診療放射線技師会誌 2019. vol.66 no.796)

material
A survey conducted by coordinated, continuing, medical staﬀ education program (CoMSEP) graduates regarding interprofessional cooperation
between radiological technologists, medical technologists, and physical therapists

tained up to 100 beds, two facilities had 101 to
200 beds, one facility had 201 to 300 beds, twofacilities had 301 to 400 beds, three facilities
had 401 to 500 beds, one facility had 501 to
600 beds, and one facility had 701 to 800 beds.
In terms of the classification of each of the hospitals, one was a university hospital, one was apublic general hospital, two were private general hospitals, five were general hospitals, andthere were two other facilities. In the breakdown by type of medical stage were seven facilities in the acute phase, one facility in thesubacute phase, two facilities in the recovery
phase, and one other facility. The three job categories RT, MT, and PT were enrolled in 10
facilities. There was only one facility where PT
was not enrolled.

of PTs was 245 (39%) (Fig.2).
Question 3 Experience

The average length of experience for RTs,
MTs, and PTs was 12 (median, 10 years), 14(median, 11 years), and 7 (median, 5 years)
years, respectively (Fig.3).
【About other professions】

Question 4 Work contents and roles of each job
category

The recognition of the roles and responsibilities of Drs and Nss was 85% on average, and
0% said “I didn't know it at all.” On average,
the recognition of the roles and responsibilitiesof the other three job categories was 43%. The
recognition of the roles and responsibilities of
PTs was the lowest at 31% (Fig.4).

【Profile】

Question 1 Sex

07

40
year of experience

In total, 338 males (54%) and 289 females(46%) completed the questionnaires. By job
category, there were 132 males (21%) and 41
females (7%) working as RTs, 66 males (10%)
and 143 females (23%) working as MTs, and
140 males (22%) and 105 females (17%) working as PTs (Fig.2).
Question 2 Job category

30
20
10
0

In terms of job category, the total number of
RTs was 173 (28%), of MTs was 209 (33%), and

RT

MT

PT

Fig.3 Distribution of the respondentsʼ experienceknow wellfemale
17

male
22

PT
39

male
21

%

RT
28

MT
33

do not know at all

Dr

16

70

14 0

Ns

15

69

16 0

RT

male
10

MT 4

Fig.2 Breakdown of the respondents by gender

do not know much%female7female
23

know

4

PT 3

43

51
39
28

53
63

2
5
6

Fig.4 Recognition of each job content
Arts and Sciences ◆ 85（193）

Question 5 Recognition of the roles and responsibilities of RTs

The results were divided into the answers
given by RTs and the answers given by theother respondents. Self-recognition of the roles
and responsibilities of RTs by RTs was 89% on
average. The recognition of the roles and responsibilities of RTs by the other professions
was dependent upon the situation. For example, approximately 90% of the respondents
recognized that radiography, CT, and MRI but
less than 30% recognized gastrointestinal examination and IVR (Fig.5).

with Drs and Nss (only 1% of the respondents
mentioned that they have no opportunity).
Only 5% of the respondents have many opportunities to cooperate with the three job categories. The respondents who answered that there
are many opportunities to be involved with
PTs was 1%, which was lower than for RTs andMTs (Fig.7). The main opportunities for cooperation with RTs was for “ultrasonic examination,” “cardiac catheter examination,” “consultation committee,” and “observing medical images.” The main opportunities for cooperation
with MTs was for “ultrasonic examination,”“cardiac catheter examination,” “consultation【About interprofessional cooperation】

Question 6 Priorities in interprofessional cooperation

Approximately 50% of the respondents rated“team approach by the medical team” and “information exchange/contact” as the first twopriorities of interprofessional cooperation. A“joint study group” was determined as the third
priority of interprofessional cooperation, at
72%. Other answers included “understanding
the other professionʼs roles and responsibilities” and “presenting the merit of cooperation”(Fig.6).

0Team approach by
medical team

On average, 69% of the respondents have
many opportunities to meet and communicate

Informationexchange / contact

Social gathering

2
3

Other

1
0
1

Roentgen
CT
MRI
US

60

MMG

58

RT

50

Dose Manegment

35

RI
RT

GI

MT・PT

IVR

34
25

80
%

49
44
50

5
4

Joint study group12

72
First priority

13

Second priority
Third priority

Fig.6 Priorities involved in interprofessional cooperation
as determined by the questionnaire respondents

quite a lot
%

35

10

Question 7 Opportunities to cooperate with otherprofessions

40

many

few

not at all
%

91
92
92
89
92
89
88
87

Dr
Ns

46

17

36
45

30

23

RT 16

41

52

MT 15

40

54

0
1

88
88
87
88

10

PT 0
1 19

80

91

Fig.5 Recognition of RT job content

86（194）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Fig.7 Opportunities of RTs, MTs, and PTs to be
involved with other professions

material
A survey conducted by coordinated, continuing, medical staﬀ education program (CoMSEP) graduates regarding interprofessional cooperation
between radiological technologists, medical technologists, and physical therapists

committee,” and “confirmation of clinical test
results.” The main opportunities for cooperation with PTs was for “cardiorespiratory exercise test,” “in-hospital committee activities,” and“patient transfer.” The number of answers that
related to PTs was less than that for RTs or MTs.

between the three job roles, 433 (70%) statedthat it was “necessary,” 114 (19%) stated that it
was “not very necessary,” and 0 (0%) statedthat it was “not necessary at all.” There were 11
non-respondents (Fig.9).
Question 10 Comments describing interprofes-【Potential for interprofessional cooperation insional cooperation within the three

the future】

job categories of RT, MT, and PT

Question 8 Aspects of RT work requiring interprofessional cooperation

The results were divided between answers
by RTs and answers by MTs and PTs. Similar to
the results obtained for Question 5 (Fig.5), on
average, 18% of the RTs feel necessary to cooperate with other professions in their own
work. Over 50% of the respondents from theother professions mentioned that they depended on radiography, CT, and MRI for their work
but dose management, nuclear medicine examination, and IVR accounted for less than
10% of their dependence (Fig.8).
Question 9 The demand for interprofessional
cooperation in each of the three job
categories
RTs, MTs, and PTs were questioned and 69
respondents (11%) stated that it was “absolutely necessary” for interprofessional cooperation

17

Roentgen

23

CT

21

US
MMG
RT
RI
RT
MT・PT

6

GI
IVR

4

15
11
17
14
21

%

61

22

MRI

Dose Manegment

56
60
38

13
9
15
11
18

Fig.8 Aspects of RT work demanding interprofessional cooperation

Other professionals, apart from RTs, MTs andPTs, wanted to know about how interprofessional cooperation could improve anatomical
identification through medical images (radiography, CT, MRI) because this might improve
the quality of their own work. For example,
from MTs, there were comments such as, “whatis the relation between the cytological diagnosis of mammary gland tissue and ultrasoundand mammography image interpretation?” and“when a neck ultrasound examination is conducted, it is good sometimes for the patient tobe referred for an MRI.” From PTs, the comments received included the following: “whena rehabilitation plan of rotator cuff injury is being prepared, it is good if the patient can bereferred for a shoulder MRI” and “I want toknow the interpretation of a chest X-ray to beable to make a reference to it in the process ofarranging rehabilitation for heart failure.” There

Not necessary at all0

Absolutely
Not much necessary
necessary
11
19%
Necessary70

Fig.9 The demand for interprofessional cooperation between RTs, MTs, and PTs
Arts and Sciences ◆ 87（195）07

were a minority of opinions such as demanding to know more information about ultrasound, radiotherapy, and other aspects of a
RTs work.
Examples of the demands that RTs make to
MTs were, “I would like to refer to the clinicallaboratory test results and the electrocardiogram data to assist CT and MRI interpretation”
and “I would like to know the interpretation ofpathological examinations to compare themwith medical images.” Most of the RTs comments to PTs were about safe and easy transfer
of information corresponding to the different
ways in which the patients pass through eachdepartment.

5. Discussion【Profile】

There were 10 non-respondents in Question
3, regarding the experience of the respondents. This included three RTs, five MTs, and
two PTs. This might have been because they
had forgotten the length of time in their job or
had refused to fill the question. The results
showed that RTs and MTs had a longer lengthof experience in their work than PTs and, on
average, this was about two-fold greater. RTs
and MTs with greater experience possibly findit easier to carry out their own duties and oversee not only their own job but also that of other departments or the facility as a whole.
Therefore, their realization for interprofessional cooperation might be different from that ofPTs that only have a short length of experiencein their work.
【About other professions】

As shown in the result for Question 4, sinceDrs and Nss cooperate with the three professions, RT, MT, and PT, the recognition of theirwork was high. However, since the cooperation among RTs, MTs, and PTs is almost unlikely, the recognition of each of their work waslow.

88（196）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Self-recognition of the work of RTs was below 100% (Question 5). Thirteen RTs did notrecognize all of the roles and responsibilities of
the job. If their result was excluded, theself-recognition of RTs became 97%, which isalmost that that would be expected. For theother job categories, there was variation in therecognition of the roles and responsibilities of
RTs. Medical imaging, such as radiography, CT,
and MRI provide many opportunities to be referred during clinical examination and rehabilitation planning. Conversely, gastrointestinal
examination and nuclear medicine examination have fewer opportunities to be referred.
For example, when MTs conduct ultrasonic examination, CT and MRI images are often referred to. Furthermore, image fusion is sometimes performed to identify the site of a lesion
and to determine the inspection procedures 7).
Even for PTs, the understanding of medical images is indispensable to treat stroke and joint
diseases, for example 8-11). The recognition ofultrasonic examination as a responsibility for
RTs was greater than half. Ultrasound is clinically divided into sub-territories as abdomen,
heart, neck, blood vessels, etc. MTs are also
involved in one specialized area, and PTs use
ultrasonic imaging for evaluating muscles. Approximately half of the respondents recognizedthat mammography and radiotherapy wereroles for RTs. It seemed to be an effect of theenlightenment of breast cancer screening andrecent catching attention in the media 12-13). The
breakdown of gender in the recognition of
mammography was 61% for males and 54% forfemales, showing no significant gender difference. The recognition of IVR was the lowest.
In this questionnaire, only the name of work
was presented. Therefore, it is possible that
other professionals could not understand what
an IVR examination involves. If we had inserted the description of what IVR entails then its
recognition may have been higher.

material
A survey conducted by coordinated, continuing, medical staff education program (CoMSEP) graduates regarding interprofessional cooperation
between radiological technologists, medical technologists, and physical therapists【About interprofessional cooperation】“Team approach by the medical team” and“Information exchange/contact” occupied thefirst and second priorities, respectively, in
Question 6. Many medical staff seemed to be
conscious of direct collaboration in doing work
such as IVR and nutrition support. A “joint
study group” gave a lower response than theformer two priorities. This may be due to thefact that it may be hard to imagine what kindsof themes should be discussed in such a meeting. Also, many staff may feel that there would
be no opportunity to hold a meeting because
their own job is so busy. As shown in the results for Question 7, there seem to be many
opportunities to be involved with Drs and Nss.
However, there seem to be fewer opportunities for RTs, MTs, and PTs to be involved witheach other. This result was similar to that for
Question 4 (Fig.4).
【Potential for interprofessional cooperation in

the future】

There were few responses about interprofessional cooperation by RTs in Question 8. It isconsidered that the final level of cooperation
varies between individuals. It may have beennecessary to provide appropriate criteria in thequestionnaire. The responses of the other professionals suggested that image observation isan area that would benefit from interprofessional cooperation. This result was similar tothat of Question 5 (Fig.5).
The breakdown of non-respondents in Question 9 was two RTs, six MTs, and three PTs.
They might not have known how necessaryinterprofessional cooperation is in their job or
may have refused to answer, as in Question 3.
In the case of the RTs, the transfer of a wheelchair- or bed-bound patient onto the examination table is carried out on their own or supported by Nss. When a CT/MRI examination isconducted, RTs also refer to the results ofblood tests such as inflammatory reactions, renal function, etc. Therefore, because there arethings in common with other professionals tocarry out their work, there are collaboration
demands among each of the three professions.
However, since there are few contact points inclinical practice presently, there is no opportunity for interprofessional cooperation.
In Question 10, some detailed demands fromthe three professions emerged. It is importantto understand that they want to learn about theroles of other professions and want to try to
improve the quality of their own work.
In this survey, we were able to understandthe current situation and demands of RTs, MTs,and PTs in the recognition of their roles andresponsibilities and the goal of interprofessional collaboration. As a result, there are many
parts of each profession that are not known.
From this survey, we took some hints from theresults regarding collaboration which have led
to the improvement of our own work and improvement of medical safety. Because this survey was conducted through CoMSEP graduates, the respondents were limited to only
three professions. However, team medicine
requires a wide area of cooperation regardlessof profession. For example, in the area of RT,
there are several reports from medical physicists and pharmacists in radiotherapy 14-16), andclinical engineers in IVR or MRI 17), etc. In
emergency or disaster medical care, RTs are
required to cooperate in terms of patient careand medical safety, similarly to other medical
staff 18-20). In addition, infection control andequipment management are common to all
professions 21-22). We need to consider hospital-wide problems as well. In the future, in order to develop interprofessional cooperation,
we must cooperate across all professions 23-25).
Communication is mentioned as an importantelement for interprofessional cooperation 26-27).
Each profession is independent because they
are busy and have strong technical expertise.
Interprofessional cooperation has already begun with small things such as greeting and socializing with each other. Understanding andArts and Sciences ◆ 89（197）07being interested in the work that everyone performs is important for interprofessional cooperation.

6. Summary
The recognition of the roles and responsibilities of RTs, MTs, and PTs was lower than thatof Drs and Nss. It was suggested that the strategy should be to increase awareness of theroles and responsibilities of each job category
in each facility. This survey identified the necessity and demand for cooperation among theprofessions questioned. We were able to obtain useful information to promote interprofessional cooperation.

7. Acknowledgments
We thank the CoMSEP graduates who completed the questionnaire.

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A survey conducted by coordinated, continuing, medical staff education program (CoMSEP) graduates regarding interprofessional cooperation
between radiological technologists, medical technologists, and physical therapists

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07

Arts and Sciences ◆ 91（199）

Arts and Sciences
the original work

Received March 5, 2018 ; accepted May 25, 2018

Usefulness of volunteer activities for radiological
technologist course students
Koji Nakaya，Hiroe Muto，Kanae Matsuura，Satoshi Nakanishi
Department of Radiological Technology, Faculty of Health Science, Suzuka University of Medical Science: Teacher

Key words: volunteer, communication, radiological technologist【Abstract】

The department of radiological technology of our university promotes volunteer work for first-year students. We
conducted a survey of volunteer awareness to evaluate the usefulness of the volunteer work to students. The students
indicated their reason for volunteering and their grasp of the necessary abilities of medical personnel. Some students
expressed the thought that communication was difficult as a result of their volunteer experience. In this research,
it was possible to analyze the studentsʼ understanding of the significance of volunteer work and their grasp of theabilities needed by medical staff. In addition, our results suggest that this volunteer program is beneficial to students.

1. Introduction
In our department, we are promoting volunteer
activities for one week at a special nursing
home for the elderly located in the local
community at the time of first-year. For students aiming to become medical professionals,
what they directly experience about medicalcare through volunteering will become the basis of their work as medical professionals 1) in
the future, and will be able to recognize againthat they will become medical professionals in
the future. It will also encourage their study of
specialized subjects in the future. We are promoting volunteering among first-year students
who are not knowledgeable about medicalcare to convey to them the role of medical personnel, help them acquire knowledge of medical personnel, and to cultivate the skills needed by medical personnel. Therefore, we conducted a survey of first-year students on theirawareness of the educational effect of volunteering to work as radiological technologists.

2. Material and Methods
2-1. Targets

The target of the consciousness survey was

92（200）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

the first-year students (126 people) of our department in FY 2017. We instructed the students to set the number of days for volunteering at 3–5 days. The questionnaire was conducted before and after the volunteer activities(twice total). The questionnaire was answered
through the universityʼs portal system, andtheir personal information was anonymized
and discarded.
2-2. Survey items

In the questionnaire survey before the volunteer activity, we investigated their earlier
volunteer experience, their purpose in volunteering, and their self-analysis of the abilities
necessary for medical personnel. The purposeof volunteering was to investigate three items(①I thought it would be useful to become aradiological technologist, ②I felt its significance as a medical person, ③I wanted to help
others), and the choices were “applicable” and“not applicable.” Self-analysis of the abilities
needed by medical personnel before volunteer
activity concerned nine items: ①the ability toprogress by themselves, ②the ability to arrange
their own ideas, ③the ability to verbally convey ideas to others, ④the ability to understandand listen to the opinions of others, ⑤the

the original work
Usefulness of volunteer activities for radiological technologist course students

strength to respect and listen, ⑥the power toact in the group, ⑦the size of the voice (sizeconveyed to others), ⑧the ability to act byreading ahead, and ⑨the ability to manage thephysical conditions (complete the volunteerwork). The possible responses were “Yes” and“No.”
In the questionnaire survey after the volunteer activity, we investigated their revaluation
after volunteering of their reasons for volunteering, their self-analysis of the skills neededby medical personnel, and the satisfaction theyfelt in their volunteer work. The survey itemson their re-evaluation of their reasons for volunteering and their self-analysis of the abilities
necessary to medical personnel after the volunteer activities were the same as before thevolunteer activities, while the degree of satisfaction after the volunteer activity was rated at
the four levels of “very good,” “good,” “bad,”and “very bad.”
We also investigated the impression of volunteer activities through volunteersʼ free descriptions.

Fig.1 Presence of volunteer experience

ences of the students. The number of students
who performed volunteer work in the past was
51% (52 people), and that of students who had
not was 49% (49 people).
3-3. Survey of the studentsʼ reasons for volunteer activities

The results of the questionnaire on their reasons for the volunteer activity are shown in
Fig.2. Before volunteering, the answers of “applicable” were ①71% (72 people), ②85% (86people), and ③90% (91 people), respectively,
whereas after the volunteer activities, the an-

2-3. Statistical analysis

Pearsonʼs chi-square test was used to determine statistically significant differences in the
results of the questionnaire survey before andafter the volunteer activity.

3. Results
3-1. Survey collection rate

The questionnaire response rate before thevolunteer activity was 80.2% (age: 19±0.68
years old, sex: 58 males, 43 females). The
questionnaire response rate after the volunteer
activity was 81.0% (age: 19±0.69 years old,sex: 57 males, 45 females). There was no significant difference by age or sex before andafter the volunteer activity (n.s.).
3-2. Previous volunteer experienceFig.1 shows the previous volunteer experi-

Fig.2 Answer for the purpose of doing volunteer
activities① I thought it would be useful for becoming a radiological
technologist, ② I felt the signiﬁcance as a medical person,and ③ I wanted people to help
Regarding the significant difference test of responses
before and after the volunteer, Pearson ʼ s chi-square
test was conducted. There was significant differences
between before and after of volunteer activities in item
① only（p<0.01）. There were no significant differences
between before and after of volunteer activities in item ②
and ③（n.s.）.

Arts and Sciences ◆ 93（201）07

swers of “applicable” were ①44% (45 people),②86% (88 people), and ③87% (89 people), respectively. In addition, a significant difference
was found before and after the volunteer activity ( p < 0.01) for the answer to ①.
3-4. Self-analysis of the abilities needed by
medical personnel

The questionnaire results on the studentsʼ
self-analyses of the abilities necessary for medical personnel are shown in Fig.3. Before thevolunteer activities, the responses of “Yes” were
①59% (60 people), ②78% (79 people), ③41%(41 people), ④83% (84 people), ⑤89% (90 people), ⑥77% (78 people), ⑦72% (73 people),⑧61% (62 people), and ⑨88% (89 people), respectively, while after the volunteer activities,
the responses of “Yes” were ①69% (70 people),②86% (88 people), ③61% (62 people), ④93%
(95 people), ⑤99% (101 people), ⑥84% (86people), ⑦80% (82 people), ⑧67% (68 people), and ⑨95% (97 people), respectively. We

note that in the responses to ③, ④, and ⑤ significant differences were found before and after the volunteer activities ( p < 0.05).
3-5. Volunteer satisfaction

The results of the questionnaire on their degree of satisfaction with the volunteer activities
are shown in Fig.4. The numbers of answers of“very good,” “good,” “bad,” and “very bad” were22% (23 people), 72% (73 people), 4% (4 people), and 2% (2 people), respectively.
3-6. Free description

The students provided numerous positive
comments on doing volunteer work: “I understood the importance of communication,” “I
had a good experience over a short period,”“Iʼd love to volunteer even as a second-year
student,” “I was able to experience what it islike to be a medical person,” “I found out how
to contact people,” “It was a good life experience,“ and “I realized that I do not have myown power, and I was able to look back on
how to contact people.” On the other hand,
one negative comment indicated that “I do notknow how this experience will be useful to
become a radiological technologist.”

Fig.3 Self analysis of ability necessary for medical
personnel① Ability to work on its own, ② Ability to organize mythoughts, ③ Ability to communicate your thoughts orally
to other people clearly, ④ Ability to understand and listen
to the opinions of others, ⑤ The ability to respect othersʼ
opinions and listen, ⑥ Ability to act in the group, ⑦ Sizeof voice（size conveyed to others）, ⑧ Ability to act in advance, and ⑨ I can manage physical condition（I will beable to volunteer until the end）

Regarding the significant difference test of responses
before and after the volunteer, Pearsonʼs chi-square
test was conducted. There were signiﬁcant differences
between before and after of volunteer activities in item
③ , ④ , and ⑤（p<0.01）. There were no signiﬁcant differences between before and after of volunteer activities initem ① , ② , ⑥ , ⑦ , ⑧ and ⑨（n.s.）.

94（202）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

Fig.4 Evaluation of volunteer satisfaction
Volunteerʼs satisfaction rating was done in four stages of“very good”, “good”, “bad”, and “very bad”.

the original work
Usefulness of volunteer activities for radiological technologist course students

4. Discussion
In this research, we promoted volunteer activities for first-year students aiming to becomeradiological technologist, and investigatedwhether they understood the meaning of volunteering and were able to grasp the necessary
abilities of medical professionals. About half ofthe students had volunteered in the past. Thereare elementary, middle, and high schools
whose students volunteer as a part of class 2),
and it would appear that an increasing numberof schools encourage voluntary social contributions.
Turning to the reasons for volunteering,
there were no significant differences in the answers before and after the volunteer work forthe items “I felt the significance of being a
medical person” and “I wanted to be useful”(n.s.), to which approximately 90% of the students answered “applicable.” That is, 90% of
the students worked on volunteer activities ina spirit of medical professionalism and service
and reaffirmed the significance of volunteering. However, there was a significant difference before and after volunteering on the item
“I thought it would be useful for becoming a
medical radiological technologist” (n.s.). The
number of students who replied “applicable”
decreased after volunteering. Although volunteers were able to cultivate their communication skills, there was at least one student who
did not recognize that communication abilities
are one of the necessary abilities of radiological technologist, as shown by the statementthat “I do not know how this experience will
be useful for becoming a medical radiological
technologist” on the free description. Since
first-years do not fully understand the work ofradiological technologist, there are students
who believe that communication skills are unnecessary. In addition, some students thinkthat radiological technologists only carry out
X-ray photographic work. In clinical practice,communication establishes a relationship oftrust with doctors or other professionals, which
is important in our duties of providing
high-quality medical care to patients 3). In addition, communication with staff helps prevent
medical accidents through human error andother factors 4). Therefore, it is desirable to establish relationships of trust between the staff
in various fields 5-6). Communication is regarded as a very important factor in medical welfare 7). As indicated above, the radiological
technologist is a member of the medical careteam, and communication is thus an essential
ability for the radiological technologist. If students volunteer while feeling that communication is not a necessary ability of the radiological technologist, their motivation will definitely
drop and they will fail to understand the meaning of volunteering. Therefore, in order tomaximize the significance of volunteering, it isnecessary to have students participate in volunteering only after understanding that communication is necessary to the work of radiological technologists. This is our future task.
The self-analysis of the abilities necessary for
medical staff did not show a significant difference before and after volunteering on six
items: “The ability to act by oneself,” “the ability to arrange oneʼs own ideas,” “power to act in
the group,” “size of the voice (size conveyed toothers),” “ability to act by reading ahead,” and“able to manage the physical conditions (complete the volunteer work).” It can be said thatstudents themselves understand the importance of such abilities as initiative power, group
behavior, and physical condition management.
However, there were significant differenceson the items of communication ability: “theability to verbally convey ideas to others,” “theability to understand and listen to the opinionsof others,” and “strength to respect and listen”
before and after volunteering ( p < 0.05). On
these items, the number of respondents who
answered “Yes” after the volunteer work increased. We think that this indicates an increasein the number of students who recognized andArts and Sciences ◆ 95（203）07

were able to self-analyze their own communication skills through volunteering. However,while the number of students who answered“Yes” to the item “the ability to verbally convey
the idea of others to others” increased after volunteering, the number of “Yes” answers for thisitem was the lowest of all the items. Many students think that it is difficult to communicate
their thoughts to others, which is consistent
with the fact that more students feel that communication is difficult in modern times 8). To
produce high-quality radiological technologists, we need to educate students not only inthe specialization of the radiological technologist, but also improve studentsʼ communication
skills.
In the survey on satisfaction of volunteer activities, 94% of the students felt that it was goodto conduct volunteer activities. As they described in the free description, volunteers wereable to feel the importance of communication,
which led to reinforcing their intention to become a medical professional by being able toexperience the work of a medical person. The
level of their satisfaction with volunteer activities was high because this volunteer experience helped them to strengthen their intention
to become a medical professional and to develop their requisite abilities. However, 6% of
students said that their satisfaction level as volunteers was bad. Some students offered thenegative comment that they did not understandcommunication as a necessary skill of the medical radiological technologist. We must decrease the number of such students in the future. Before participating in volunteer activities, all students must understand the importance of communication skills.
From the above, it appears that studentsʼ volunteer activities are useful in their education.
However, some students felt that volunteering
was useless in becoming a radiological technologist. Since radiological technologists areoften engaged in business in cooperation withother occupations, students need to develop a96（204）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

modicum of communication skills through volunteering. We need to make these students understand that communication is an importantability of the radiological technologist. Furthermore, all students must understand the necessity of communication and apply these skills intheir volunteer work. Volunteer work will constitute a foundation for becoming a health care
professional in the future and will be able tostrengthen the studentʼs intention of becominga radiological technologist in the future. Because doing so will also help to improve thestudy of special subjects in the future, we urge
the continued promotion of volunteer activities
to produce better radiological technologists.
This study covered first-year students. In the
future, we would like to investigate the difference in the educational effect of volunteeringon students in different years.

5. Conclusion
In the questionnaire survey before and after
the volunteer activities, we were able to analyze the perceived usefulness of volunteer
work to the students and the degree to which
they grasped the abilities needed by medical
personnel. Promoting volunteer work is usefulin training students aiming to become radiological technologists, but there were students
who did not understand that the communication skills that can be cultivated by volunteer
work are a necessary ability of radiological
technologists. This study found that improving
communication skills is an indispensable partof the education of radiological technologists.
This research was presented at the 33th Japan Conference of Radiological Technologists(Hakodate).

6. Acknowledgments
We would like to express our deepest gratitude to the members of the Department of Radiological Technology of Suzuka University of

the original work
Usefulness of volunteer activities for radiological technologist course students

Medical Science and to the members of Suzuka
University of Medical Science volunteer committee for their cooperation.

References
1） Takuya C, et al.: Educational meaning of the student
volunteer activity in the Great East Japan Earthquake.
The Journal of Kyushu University of Nursing and Social Welfare, 12; 25-37, 2012.
2） Yumiko A, et al.: The effects of volunteer activity experiences in school education on youth. Kawasaki Medical Welfare Journal, 16; 133-139, 2006.
3） Chikako S, et al.: Current status of team medicine at
M. D. Anderson Cancer Center. Hematology & Oncology, 49; 609-612, 2004.

4） Misako N, et al.: Risk sharing communication in medical settings: analyses of nursesʼ conversation. Cognitive Studies, 13; 62-79, 2006.
5） Reiko K, et al.: Preliminary survey for communicatingrisk in medical exposure: perception of risk amongnurses working in radiology. Japanese Journal of Radiological Technology, 64; 937-947, 2008.
6） Yuriko A, et al.: The role of medical staff in cancer
screening. Journal of Japan Association of Breast
Cancer Screening, 23; 239-245, 2014.
7） Noriko I, et al.: Communication education in collegesof health care and welfare. The Communication Association of Japan, 22; 31-36, 2009.
8） Sayo H, et al.: Training in communication skills forgraduate students at Kyoto Pharmaceutical University: participation of simulated patients (SPs) effective in
improving communication in practice of clinical pharmacy. Japanese Journal of Pharmaceutical HealthCare and Sciences, 30; 529-535, 2004.

07

Arts and Sciences ◆ 97（205）Arts and Sciences
the original work

Received December 5, 2017 ; accepted April 27, 2018

Comparison of measured values on 11C-methionine
and 18F-fluorodeoxyglucose PET obtained with two
different scanners in normal brain and brain tumor
Yu-ichi Yamada1），2），Yoshitaka Asano2），3），Seisuke Fukuyama1），
Ryo Tanokura1），2），Yuka Ikegame2），3），and Jun Shinoda2），3）
1）Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital, Department of Radiotechnology2）Department of Clinical Brain Sciences, Gifu University Graduate School of Medicine
3）Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital, Department of Neurosurgery

Key words: PET, acquisition system, SUV, T/N ratio, brain tumor【Abstract】

OBJECTIVE. The purpose of this study is to investigate if there were differences between the measured values
obtained with 2-dimensional (2D-system) versus 3-dimensional acquisition system (3D-system) in positron emission
tomography (PET) scans of the normal brain and brain tumors. MATERIALS AND METHODS. PET scanning with
11
C-methionine (MET-PET) or 18F-fluorodeoxyglucose (FDG-PET) was performed using two scanners which were
equipped with 2D-system and 3D-system. In 121 patients with various types of brain tumors, Regions of interest
were placed in the normal brain structures and the standard uptake values (SUVs) were measured. In 35 patientswith diffuse astrocytoma and 18 patients with meningioma, the tumor/normal brain ratio (T/N ratio) was calculatedusing the maximum SUV of the tumors and the mean SUV of the normal frontal cortex. RESULTS. The mean SUV of
the normal brain structure acquired on the 3D-system was significantly lower than those on 2D-system for both MET
and FDG-PET. The mean T/N ratio of diffuse astrocytoma from 3D-system was significantly lower than that from
2D-system with MET-PET, but there was no significant difference in the T/N ratio with FDG-PET in both brain tumors.
CONCLUSION. This study suggest that with tumors in which the SUV was higher than that of the normal brain,
which resulted in a lower T/N ratio obtained with 3D-system than that with 2D-system. With tumors in which the
SUV was equal to or lower than that of the normal brain, which resulted in a T/N ratio obtained with 3D-system wasapproximately equal to that with 2D-system.

PURPOSE
Diagnosis of brain tumor by molecular imaging is essential for the evaluation of malignancy, prognosis, and to suggest a strategy fortreatment 1-11）. Also, for brain tumors, a number of studies that report the use PET scanning have been published. In this decade, ourgroup has published several studies of brain
tumors and related diseases in which PET wasused as the critical diagnostic modality 12-15）.
Recently, the number of clinics that use PET
scanners has increased. At the present time,
there are five medical equipment production
companies producing PET scanners in theworld. We need more comparative discussions
regarding PET imaging of brain tumors ob-

98（206）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

tained from different types of scanners worldwide in the literature and at meetings. In suchsettings, the data obtained from the different
PET scanners used in the various institutes may
not correspond. This issue should be noted
and the measured values should be investigated. In our hospital, we had been using an ADVANCE NXi (NXi) Imaging System, equippedwith a 2D acquisition system, and then transitioned to an Eminence STARGATE (SG), whichis equipped with a 3D acquisition system.
There was a large amount of accumulated datain brain tumors, which could be compared anddifferences in the data characteristics obtained
from the two different PET scanners could
be evaluated. To the best of our knowledge,
there are no previous investigations compar-

the original work
Comparison of measured values on 11C-methionine and 18F-fluorodeoxyglucose PET obtained with two different scanners in normal brain and brain tumor

ing brain tumor imaging from a 2D acquisition
system to that from a 3D acquisition system.
The purpose of this study is to investigate if
there were differences between the measured
values obtained with 2D versus 3D acquisition
systems from PET scanners in the normal brain
and brain tumors.

MATERIALS AND METHODSPET scanner

Data used in this study were obtained fromtwo different PET scanners. One was an ADVANCE NXi Imaging System equipped with a
2D acquisition system that provided 35 transaxial images at 4.25 mm intervals with an inplace spatial resolution (full width on transaxial images) of 4.8 mm and an aperture width of
the Z-axis direction of 150 mm (General Electric Yokogawa Medical Systems, Hino, Tokyo,
Japan) (NXi), which had been used from 2006
to 2011. The other scanner was an Eminence
STARGATE equipped with a 3D acquisition
system that provided 99 transaxial images at
2.65 mm intervals with an in-place spatial resolution (full width on transaxial images) of 3.5mm and an effective visual field of the Z-axis
direction of 260 mm (Shimadzu Corporation,
Kyoto, Japan) (SG), which has been used since2011. The PET radiotracers, 11C-methionine(MET) and 18F-fluorodeoxyglucose (FDG) wereused in this study. Table 1 indicates the mechanical characteristics of these two scanners.

Table 1 Summary of the characteristics of the two
PET scanners

Patients

4,602 patients with brain tumors received
PET scans in the Chubu Medical Center for
Prolonged Traumatic Brain Dysfunction, Kizawa Memorial Hospital from July 2006 to March
2013. Among them, 121 randomly selectedpatients with various types of localized small
brain tumors were enrolled in this study forthe evaluation of the measured values on PET
in normal brain structures. For the PET scanning, the NXi was used in 66 patients (meanage: 42.3 ± 13.6 years, 33 males) and the SG
was used in 55 patients (mean age: 44.2 ±14.5 years, 33 males). In addition, another 35
patients with diffuse astrocytoma (DA) and19 patients with meningioma (MEN) that had
the tumor type histologically confirmed werealso enrolled in this study. For the PET scanning in patients with DA, the NXi was used in
20 patients (mean age: 47.4 ± 16.3 years, 10
males) and the SG in 15 patients (mean age:
44.5 ± 19.9 years, 8 males). For PET scanningin patients with MEN, the NXi was used in 13
patients (mean age: 68.0 ± 10.6 years, 4 males)
and the SG in 6 patients (mean age: 63.5 ± 24.2
years, 1 male). Patients with DA or MEN were
included in this study because these tumor
types were representative tumors in which theradiotracer uptake within the lesions is homogeneous from our experience. No patients had
undergone prior surgeries or adjuvant therapies. The study was approved by the institutional review board (27-025), and all subjects
signed a written informed consent [or need for
written informed consent was waived].
Data acquisition on PET

Participants were placed in the PET scannerso that axial slices were parallel to the canthomeatal line, and the head was fixed to reduce
body movement during the scan. In the NXi, agermanium-68 gallium rotating pin source wasused to obtain a 3-min transmission scan andthe radiopharmaceutical (MET: 5.0 MBq/kg,
FDG: 5.0 MBq/kg) was injected intravenously
Arts and Sciences ◆ 99（207）07via the cubital vein. With the MET-PET, westarted a 30-minute emission scan 5 minutes
after administration of the radiopharmaceuticaland with the FDG-PET, a 7-minute emission
scan was acquired at approximately 35 minutes after administration. Conversely, with theSG, a cesium-137 rotating pin source was used
to obtain a 4-min transmission scan and theradiopharmaceutical (MET: 3.5 MBq/kg, FDG:
3.5 MBq/kg) was injected intravenously via the
cubital vein. With the MET-PET, we started a
35-minute emission scan at the time of administration, and with the FDG-PET, a 10-minuteemission scan was acquired approximately 45
minutes after radiotracer administration.
The static scans were reconstructed withattenuation correction using data from thetransmission scan. The PET images were coregistered to an MRI that was performed on
the same day, for better anatomical determination. Image fusion was performed by an image analysis program in combination with Dr.
View/Linux image analysis software (Asahi Kasei Information System, Tokyo, Japan), using amethod described by Kapouleas, et al. 16）.
In the 121 patients with various brain tumors, 10 mm circular regions of interest (ROIs)
were drawn manually with reference to the
MRI which was superimposed on the PET image in normal brain structures that included thebrainstem, thalamus, grey and white matter,and cerebellum, and avoided regions whichwere shifted or invaded by brain tumors or

edema. ROIs were decided with agreementof three neurosurgeons and three radiological
technologists who are experts in PET examination. As a rule, the ROIs in the grey and whitematter were placed bilaterally in the frontal
side of the parietal lobe in which the body ofthe lateral ventricles couldnʼt be seen (Fig.1),
however if the frontal side of the parietal lobe
was shifted or invaded by brain tumor or edema, the ROIs were placed toward the occipitalside of the parietal lobe. The ROIs in the thalamus were placed at the center of the thalamus
bilaterally in the plane in which the basal ganglia could be seen (Fig.1). Eight of the ROIs
in the thalamus in NXi and eleven of thosein the thalamus in SG were omitted because
those were shifted or invaded by brain tumors
or edema. The ROIs in the cerebellum wereplaced bilaterally in the plane in which the cerebellopontine angle could be seen (Fig.1), andthe ROIs in the brainstem were placed in the
middle pons level, as reported by Uda et al. 17）(Fig.1). A summary of all the ROIs are detailedin Table 2.
The ROIs in the DAs were manually drawn
by tracing the tumor boundaries in an axial
plane of a fusion image of the T2WI/MET-PET
and the T2WI/FDG-PET (Fig.2) and those in
the MENs were also manually drawn by tracing
the boundaries in an axial plane of a fusion image of the contrast-enhanced T1WI/MET-PET
and the contrast-enhanced T1WI/FDG-PET(Fig.2).

Fig.1
The ROIs placed in the normal grey matter (a), white matter (b), thalamus (c),cerebellum (d), and brain stem (e) on FDG-PET.

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the original work
Comparison of measured values on 11C-methionine and 18F-ﬂuorodeoxyglucose PET obtained with two diﬀerent scanners in normal brain and brain tumor

Table 2 Summary of all the ROIs in the normal
brain structures

In the MET and FDG-PET, the maximum SUV
tumor/normal control cortex uptake ratios (T/Nratios) of the DAs and MENs were calculatedby the following formula;T/N ratio = the maximum SUV of the tumor /the average of the mean SUV of the contralateral normal frontal cortex
Statistical Analysis

The mean SUVs of the normal brain structures, the maximum SUVs of the DAs and theMENs, the mean SUVs of the normal control
cortex, and the mean T/N ratio of the DAs andthe MENs obtained from the NXi versus thosefrom the SG were compared statistically using
an independent t-test in the MET and FDGPET, respectively. Differences with a thresholdof p<0.05 were considered statistically significant. All data were analyzed using SPSS 2 forWindows.

The ROIs in the normal control cortex weremanually drawn by tracing the contra-lateralfrontal cortex in an axial plane of a fusion image of the T2WI/MET-PET and the T2WI/FDGPET in which the basal ganglia could be seen(Fig.2), and in the superior and inferior axial
planes of a fusion image of the T2WI/METPET and the T2WI/FDG-PET in which the basal
ganglia could be seen. We calculated the mean
SUV of the contra-lateral normal frontal cortex
from three ROIs.
The regional MET and FDG uptake in the
ROIs was expressed as a standard uptake value(SUV) calculated by the following formula;

07

RESULTS
MET-PETThe mean ( ± SD) of the mean SUVs in thenormal grey matter were 1.34 ± 0.29 versus
1.69 ± 0.45 for the NXi versus the SG, respec-

SUV = (tissue activity/ml)/(injected radiotracer activity/body weight (g))

Fig.2
The ROIs placed on the T2WI (A), the MET-PET (B), and the FDG-PET (C) in a case of DA. The ROIs
placed on the contrast-enhanced T1WI (E), the MET-PET (F), and the FDG-PET (G) in a case of MEN.
The ROIs in the normal control cortex placed on MET-PET (D, H).

Arts and Sciences ◆ 101（209）with the NXi (2.34 ± 0.74) was lower than thatfrom the SG (2.74 ± 0.67), however this result
did not reach statistical significance (p=0.112)(Fig.4). The mean ( ± SD) of the mean SUVof the normal control cortex obtained with
the NXi (1.13 ± 0.27) was significantly lower
than that from the SG (1.70 ± 0.32) (p<0.001)(Fig.4). The mean T/N ratio ( ± SD) of the DAs
obtained with the NXi (2.09 ± 0.45) was significantly higher than the T/N ratio with the SG(1.61 ± 0.23) (p<0.001) (Fig.4).
In the 19 patients with MEN, the mean ( ±tively. In the normal white matter the SUVs
were 0.84 ± 0.20 versus 1.21 ± 0.33, the normal
thalamus, 1.47 ± 0.27 versus 2.00 ± 0.52, thenormal cerebellum, 1.59 ± 0.32 versus 1.90 ±
0.49, and in the normal brainstem, the SUVs
were 1.49 ± 0.33 versus 2.13 ± 0.56 for the 121
patients with brain tumors. The mean of themean SUV in every normal brain structure
obtained with the NXi was significantly lower
than that with the SG (p<0.001) (Fig.3).
In the 35 patients with DA, the mean ( ±SD) of the maximum SUV of the DAs obtained

Fig.3
The mean SUVs of the normal grey matter (GM), white matter (WM), thalamus (Th), cerebellum(Cb) and brain stem (BS). Left: MET-PET. Right: FDG-PET. Box-and-whisker plots indicate the
distribution (mean and SD). *p <0.001.

Fig.4
The maximum SUVs of the DAs (A), the mean SUVs of the normal control cortex (B) and themean T/N ratios of DA (C) on the MET-PET. The maximum SUVs of the DAs (D), the mean
SUVs of the normal control cortex (E), and the mean T/N ratios of the DAs (F) with FDG-PET.
*p <0.001.

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the original work
Comparison of measured values on 11C-methionine and 18F-ﬂuorodeoxyglucose PET obtained with two diﬀerent scanners in normal brain and brain tumor

Fig.5
The maximum SUVs of the MENs (A), the mean SUVs of the normal control cortex (B) andthe mean T/N ratios of the MENs (C) with MET-PET. The maximum SUVs of the MENs (D),the mean SUVs of the normal control cortex (E) and the mean T/N ratios of the MENs (F)with FDG-PET. *p <0.001.

SD) of the maximum SUV of the MENs obtained with the NXi (4.63 ± 1.46) was lower
than the mean SUV with the SG (5.58 ± 2.80),
however this result did not reach statistical significance (p=0.333) (Fig.5). The mean ( ± SD)of the mean SUV in the normal control cortex
obtained with the NXi (1.12 ± 0.21) was significantly lower than that with the SG (1.59 ±0.06) (p<0.001) (Fig.5). The mean T/N ratio ( ±SD) of the MENs obtained with the NXi (4.21 ±1.36) was higher than the T/N ratio with the SG(3.50 ± 1.75), however this result also did notreach statistical significance (p=0.333) (Fig.5).
FDG

The mean ( ± SD) of the mean SUVs of thenormal grey matter were 8.08 ± 1.73 versus
11.17 ± 2.05 for the NXi versus the SG, respectively. In the normal white matter, the SUVs
were 3.56 ± 0.73 versus 5.08 ± 0.97, the normal
thalamus, 7.91 ± 1.85 versus 11.36 ± 2.24, thenormal cerebellum, 6.88 ± 1.39 versus 8.71 ±
1.62, and in the normal brainstem, the SUVs
were 5.19 ± 1.04 versus 7.71 ± 1.87 for the 119

patients with brain tumors. The mean SUV in
every normal brain structure obtained with theNXi was significantly lower than that with the
SG (p<0.001) (Fig.3).
In the 35 patients with DA, the mean ( ± SD)of the maximum SUV of the DAs obtained with
the NXi (5.78 ± 1.22) was significantly lower
than that with the SG (8.98 ± 1.83) (p<0.001)(Fig.4). The mean ( ± SD) of the mean SUVof the normal control cortex obtained with
the NXi (6.79 ± 1.46) was significantly lower
than that with the SG (11.25 ± 1.25) (p<0.001)(Fig.4). The mean T/N ration ( ± SD) of theDAs obtained with the NXi (0.87 ± 0.15) was
increased compared to the DAs with the SG(0.78 ± 0.10), however this result also did notreach statistical significance (p=0.080) (Fig.4).
In the 19 patients with MEN, the mean ( ±SD) of the maximum SUV of the MENs obtained with the NXi (5.65 ± 1.32) was significantly lower than the SUVs with the SG (7.72± 1.58) (p=0.004) (Fig.5). The mean ( ± SD)of the mean SUV of the normal control cortex
obtained with the NXi (6.66 ± 1.40) was signifiArts and Sciences ◆ 103（211）07

cantly lower than that with the SG (9.51 ± 2.39)(p=0.004) (Fig.5). The mean T/N ratio ( ± SD)
of MENs obtained with the NXi (0.87 ± 0.21)
was higher than the T/N ratio with the SG (0.83± 0.15), however this result also did not reachstatistical significance (p=0.673) (Fig.5).

DISCUSSION
In this study, in both the MET and FDG-PET,
the mean SUV of every normal brain structure
obtained with the NXi was significantly lower
than those acquired with the SG. Furthermore,in patients with DA and MEN, the mean SUVof the normal control cortex with the NXi wassignificantly lower than that with the SG inboth the MET and FDG-PET. In agreement withthese results, some related studies were foundin the literature. Kato, et al. reported that themean SUV of the normal cortex with MET-PET
was 1.25 ± 0.39 or 1.22 ± 0.37, and with FDGPET was 6.48 ± 1.51 in studies using a PET
scanner with a 2D acquisition system 14, 15）. In
addition, Miyake, et al. reported that the mean
SUV of the normal cortex with MET-PET was
1.52 ± 0.36 and that with FDG-PET was 8.90 ±8.72 in their study, which used a PET scannerwith a 3D acquisition system 4）. The resultsof these studies support our finding that themean SUV of normal brain structures with a
2D acquisition system is lower than those obtained with a 3D acquisition system. However,the limitation of these studies is that they were
performed in different patients. This finding oflower mean SUVs in normal brain structureswith 2D acquisition is likely due to differencesin the amount of true, scatter and random
coincident radiation between 2D and 3D acquisition systems 18-20）. With a 2D acquisition
system, the septa, which are situated in front of
the detectors of a PET scanner, can reduce not
only true scatter and random coincident radiation in the gantry, but also scattered radiation
outside of the gantry.
A 3D system can detect more true coincident

104（212）◆ 日本診療放射線技師会誌 2019. vol.66 no.796

radiation than a 2D system, however, at thesame time, a 3D system picks up more scattered and random coincident radiation that
increase the image noise as compared to a 2D
system. Although some devices use various
image reconstruction techniques to overcome
these noise issues and to improve image quality with 3D systems, the noise reduction is still
sub-optimal.
In this study, the maximum SUVs in the DAs
and MENs were consistently higher than themean SUV of the contralateral normal frontal
cortex in the MET-PET, however, with FDGPET, the maximum SUVs in the DAs and MENs
were consistently lower than those of thecontralateral normal frontal cortex. The maximum SUVs of the DAs and MENs in FDG-PET
obtained with the NXi were both significantly
lower than those with the SG, although there
were no significant differences between thosewith the NXi and SG using MET-PET. These
results suggest that in cases where the SUV is
the same as that of normal brain structures or
less, the SUV obtained with the NXi is lower
than that with the SG regardless of both tumor
type and PET tracer used. However, in cases
where the SUV is greater than the SUV of normal brain structures, there is no significant difference between the SUVs with the NXi versus
the SG.
In the study using a 2D acquisition system byKato, et al., the T/N ratio of DA with MET-PET
was 2.24 ± 0.90 and that with FDG-PET was
0.79 ± 0.08 14）. In the study using a 3D acquisition system by Singhal, et al., the T/N ratio of
DA with MET-PET was 1.56 ± 0.74, and thatwith FDG-PET was 0.63 ± 0.37 21）. Using METPET of MEN, Aki, et al. reported that the T/
N ratio of 5.50-6.62 was obtained using a 2D
acquisition system, and in a study using a 3D
acquisition system by Arita, et al., the T/N ratio
was 2.45 ± 0.67 12, 22）.
With regard to the SUV of the normal frontal
cortex used as the denominator of the formula
to calculate the T/N ratio, the SUV obtainedthe original work
Comparison of measured values on 11C-methionine and 18F-fluorodeoxyglucose PET obtained with two different scanners in normal brain and brain tumor

with the 3D acquisition system was significantly higher than that with the 2D acquisition
system in both the MET and FDG-PET. On
the other hand, for the SUV of tumors as thenumerator of the same formula, there was no
significant difference between the SUVs from
the MET-PET obtained with the 2D and 3D acquisition systems, because those are markedly
higher than normal brain structures in METPET. However, because the SUVs of tumors in
FDG-PET are lower than those of the normal
brain structures, the SUV obtained with a 3D
acquisition system is significantly higher thanthat with a 2D acquisition system as well as the
SUV of normal brain structures. This finding
explains why the T/N ratio obtained with a 3D
acquisition system is significantly lower thanthat obtained with 2D acquisition system in
MET-PET, however, with FDG-PET, there is no
significant difference in the T/N ratio obtainedwith either a 2D or a 3D acquisition system.
We should note that in tumors in which the
SUV is higher than that of normal brain structures in PET, the T/N ratio obtained with a
3D acquisition system is lower than that witha 2D acquisition system. However, in tumors
in which the SUV is equal to or lower thanthat of normal brain structures, the T/N ratio
obtained with a 3D acquisition system is approximately equal to that obtained with a 2D
acquisition system when the measured values
obtained with different PET scanners are comparatively evaluated. The results of this study
may contribute to the diagnostic comparison of
the results of PET examination in brain tumors
not only among institutes having different PET
scanners but also between data obtain fromtwo types (2D or 3D) of PET scanners even ina single institute.
There a two limitations in this study. First, weshould have enrolled identical patients for both
PET studies using the 2D and 3D acquisition
systems to perform the comparative study exactly. However, because the time period whenthe 2D acquisition system was used in our

hospital was different from the time when the
3D acquisition system was used, studies using
both scanners at the same time on the same
patients could not be undertaken. Second, DA
and MEN were adopted as representative brain
tumors in this study because these tumor types
are known to have homogeneous radiotracer
uptake had within the lesion. It is still uncertain
whether the relationship between the tumor
SUV and the difference in acquisition type (2Dversus 3D) shown in this study will be true incases of tumors with heterogeneous radiotracer uptake like glioblastoma 23, 24） or in tumors inwhich FDG has high uptake within the lesions
like malignant lymphoma 9）. Further investigations are warranted.

CONCLUSION
The results of this study suggest that in tumors in which the SUV was higher than that ofnormal brain structures in PET, the tumor SUVs
obtained with a 3D acquisition system might be
the same as that with a 2D resulting in a T/Nratio with 3D that might be lower than thatwith 2D. However, in tumors in which the SUV
was the equal to or lower than that of normal
brain structures, the tumor SUVs obtained with
3D might be higher than those with 2D resulting in a T/N ratio obtained with 3D that wasapproximately equal to that with the 2D acquisition system.

DISCLOSURE
The costs of publication of this article weredefrayed in part by the payment of page charges. Therefore, and solely to indicate this fact,
this article is hereby marked “advertisement”
in accordance with 18 USC section 1734. This
research was also supported by Gifu University
Graduate School of Medicine. No other potential conflict of interest relevant to this article
was reported.

Arts and Sciences ◆ 105（213）07

ACKNOWLEDGMENTS
We thank Dr. Tatsuki Aki, Dr. Shingo Yonezawa and Dr. Yu-ichi Nomura for their assistance with patient preparation, and also thank
Mr. Ryu-ji Okumura for his assistance with thetechnical support.

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