University of Ghana

University of Ghana http://ugspace.ug.edu.
gh
UNIVERSITY OF GHANA
SCHOOL OF NUCLEAR AND ALLIED SCIENCES
ASSESSMENT OF DIAGNOSTIC RADIOGRAPHY PRACTICE IN SOUTH OF
BENIN: APPLICATION OF QUALITY CONTROL PROCEDURES AND
ESTIMATION OF PATIENT ENTRANCE SURFACE DOSE
THESIS PRESENTED TO THE
DEPARTMENT OF MEDICAL PHYSICS,
SCHOOL OF NUCLEAR AND ALLIED SCIENCES
UNIVERSITY OF GHANA
BY
Romeo Tino SOGLO
ID: 10361536
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE
OF
MASTER OF PHILOSOPHY
MEDICAL PHYSICS
July, 2018
i
University of Ghana http://ugspace.ug.edu.gh
DECLARATION
STUDENT’S DECLARATION:
I hereby declare that, with the exception of references to other people’s work which
have been duly acknowledged, this work is the result of my own original research
undertaken under supervision, and either in whole or in part has not been presented for
any other degree at another university elsewhere.
……………………………… ..…………………………….
TINO ROMEO SOGLO Date
(STUDENT)
SUPERVISORS’ DECLARATION:
We hereby declare that the preparation and presentation of the thesis were supervised
in accordance with guidelines on supervision of thesis laid down by the University of
Ghana.
……………………………… ..…………………………….
Dr. STEPHEN INKOOM Date
(PRINCIPAL SUPERVISOR)
……………………………… ..…………………………….
Dr. FRANCIS HASFORD Date
(CO-SUPERVISOR)
……………………………… .…………………………….
Dr. EDEM SOSU Date
(CO-SUPERVISOR)
ii
DEDICATION
This thesis is dedicated to my country, my family, and in particular to all those working
tirelessly for the establishment of Nuclear Regulatory Body and Atomic Energy
Commission in Benin.
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ACKNOWLEDGEMENTS
Thanks to Almighty God for assisting me through the IAEA/BEN 6006 Medical
physics programme.
All my gratitude to IAEA, for offering me two years fellowship in Medical Physics
and Two years fellowship in Nuclear science and Technology. I also thank IAEA for
giving my country opportunity to have qualify human resources.
I would like to thank my supervisors, Dr. Stephen Inkoom, Dr. Francis Hasford and
Dr. Edem Sosu who scarified their time to help collect data in Benin and guide me
throughout the course of this research work.
Thanks to Prof. Amoussou K. Marcellin, the coordinator of the National project BEN
6006 for his effort to make establish in Benin nuclear medicine and radiotherapy
centres for cancer management.
Thanks to Prof. Pascal Houngnandan and Prof. Felix Hontinfinde, for their advice and
support.
I also want to extend my gratitude to Benin Ministry of Health who facilitated access
to the hospitals. Thanks to staff of all the seven Hospital involved in the present study.
Thanks to Ghana Atomic Energy Commission and the Dean of School of Nuclear and
Allied
Science for their contribution to knowledge and their effort in making equipment
available for data collection.
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TABLE OF CONTENTS
DECLARATION ..................................................................................................................... ii
DEDICATION ........................................................................................................................ iii
ACKNOWLEDGEMENTS .................................................................................................... iv
TABLE OF CONTENTS ......................................................................................................... v
LIST OF TABLES ................................................................................................................... x
LIST OF FIGURES .............................................................................................................. xvi
ABSTRACT............................................................................................................................. 1
CHAPTER ONE ...................................................................................................................... 2
INTRODUCTION ................................................................................................................... 2
1.1 Background .................................................................................................................. 2
1.2 Objectives .................................................................................................................... 4
1.3 Problem statement ........................................................................................................ 5
1.4 Relevance and Justification.......................................................................................... 5
1.5 Scope and Limitations.................................................................................................. 6
1.6 Organization of thesis .................................................................................................. 6
CHAPTER TWO ..................................................................................................................... 7
LITERATURE REVIEW ........................................................................................................ 7
2.1 X-rays machine and X-ray production ......................................................................... 7
2.2 Overview of quality control of radiography X-ray machine ........................................ 8
2.3 Importance of some essential quality control tests and standard limits ..................... 14
2.3.1 Accuracy of loading factors ................................................................................... 14
2.3.2 Radiation Output, kilovoltage peak and exposure time reproducibility................. 15
v
2.3.3 Radiation Output-mAs linearity ............................................................................. 16
2.3.4 X-ray beam filtration.............................................................................................. 17
2.3.5 X-ray-Light Fields Alignment and beam alignment .............................................. 18
2.3.6 X-ray tube leakage ................................................................................................. 19
2.3.7 Integrity of Protective Equipment .......................................................................... 20
2.4 Entrance surface Dose assessment ............................................................................. 20
2.4.1 Establishment of entrance surface dose. ................................................................ 20
2.4.2 Indirect measurement arrangement for entrance surface dose ............................... 23
CHAPTER THREE ............................................................................................................... 24
METHODOLOGY ................................................................................................................ 24
3.1 Equipment .................................................................................................................. 24
3.1.1 Diagnostic radiology X-ray machines.................................................................... 24
3.1.2 Radiation detectors................................................................................................. 25
3.1.2.1 Multifunction meter (Piranha) ............................................................................... 25
3.1.2.2 RDS-120 Universal survey meter .......................................................................... 26
3.1.3 Collimator and beam alignment Quality Control test tool ..................................... 26
3.1.4 Tape measure ......................................................................................................... 27
3.1.5 Lead apron ............................................................................................................. 28
3.1.6 Radiographic X-ray film, cassette and CR plate .................................................... 28
3.2 METHODS ................................................................................................................ 29
3.2.1 Equipment set up for measurement ........................................................................ 29
3.2.1.1 Set up for simultaneous measurement of kilovoltage peak, exposure time, half
value layer and dose output.................................................................................................... 29
vi
3.2.1.1.1 Equipment used .................................................................................................. 29
3.2.1.2 Setup for beam alignment and congruence of fields .............................................. 30
3.2..2.1 Equipment used .................................................................................................. 30
3.2..2.2 Procedures .......................................................................................................... 30
3.2.1.3 Setup for measuring leakage of X-ray tube housing .............................................. 31
3.2.1.3.1 Equipment used .................................................................................................. 31
3.2.1.3.2 Procedures .......................................................................................................... 31
3.2.2 Measurement for quality control tests .................................................................... 32
3.2.2.1 Accuracy of kilovoltage peak ................................................................................ 32
3.2.2.2 Accuracy of exposure time .................................................................................... 33
3.2.2.3 Reproducibility of kilovoltage peak, exposure time and dose output .................... 33
3.2.2.4 X-ray beam filtration (HVL) .................................................................................. 34
3.2.2.5 Specific dose-kVp2 linearity .................................................................................. 34
3.2.2.6 Specific dose - mAs linearity ................................................................................. 35
3.2.2.7 Leakage of x-ray tube housing ............................................................................... 35
3.2.2.8 Collimator and beam alignment ............................................................................. 35
3.2.3 Adult entrance surface dose (ESD) assessment method ........................................ 36
3.2.3.1 Measurement of X-ray tube output ........................................................................ 36
3.2.3.2 Entrance surface dose estimation. .......................................................................... 36
CHAPTER FOUR: RESULTS AND DISCUSSIONS .......................................................... 37
4.1 Results of quality control tests ................................................................................... 37
4.1.1 Results of kVp Accuracy tests ............................................................................... 37
4.1.2 Results of exposure time accuracy test ................................................................. 40
vii
4.1.2.1 Results of accuracy of exposure time less than 10 ms ........................................... 40
4.1.2.2 Results of accuracy of exposure time greater than 10 ms ...................................... 42
4.1.3 Results of reproducibility of kVp, exposure time end dose output ....................... 44
4.1.3.1 Results of kilovoltage peak reproducibility ........................................................... 44
4.1.3.2 Results of exposure time reproducibility ............................................................... 48
4.1.3.3 Results of dose output reproducibility ................................................................... 52
4.1.4 Results of X-ray beam filtration (HVL) tests........................................................ 56
4.1.5 Results of Specific dose-kVp2 linearity tests ........................................................ 59
4.1.6 Results of Specific dose-mAs linearity tests ......................................................... 62
4.1.7 Results of leakage of X-ray tube housing tests ...................................................... 65
4.1.8 Results of X-ray beam alignment tests .................................................................. 66
4.2 Entrance surface dose results ..................................................................................... 68
4.2.1 Diagnostic radiography X-ray equipment dose output .......................................... 68
4.2.2 Exposure factors (kVp, mAs), FDD and patient thickness .................................... 72
4.2.3 Estimated entrance surface dose ............................................................................ 73
4.3 DISCUSSION ............................................................................................................ 76
4.3.1 Discussion based on QC tests results ..................................................................... 76
4.3.1.1 Accuracy of kilovoltage peak ................................................................................ 76
4.3.1.2 Accuracy of exposure time .................................................................................... 78
4.3.1.2.1 Exposure time below 10 ms ............................................................................... 78
4.3.1.2.2 Exposure time above 10 ms ............................................................................... 79
4.3.1.3 Reproducibility ...................................................................................................... 80
4.3.1.3.1 Reproducibility of kilovoltage peak ................................................................... 80
viii
4.3.1.3.2 Reproducibility of exposure time ....................................................................... 81
4.3.1.3.3 Reproducibility of dose output ........................................................................... 82
4.3.1.4 X-ray bean quality.................................................................................................. 83
4.3.1.5 Specific dose-kVp2 linearity .................................................................................. 84
4.3.1.6 Specific Dose- mAs linearity ................................................................................. 85
4.3.1.7 Leakage of X-ray tube housing .............................................................................. 86
4.3.1.8 X-ray beam alignment ............................................................................................ 87
4.3.2 Discussion based on entrance surface dose estimation .......................................... 88
4.3.2.1 Specific dose output curve ..................................................................................... 88
4.3.2.2 Comparison of estimated entrance surface dose with other studies ....................... 89
CHAPTER FIVE: CONCLUSION AND RECOMMENDATION ....................................... 93
5.1 Conclusion ................................................................................................................. 93
5.2 Recommendations ...................................................................................................... 94
5.2.1 Services providers .................................................................................................. 94
5.2.2 Regulatory body ..................................................................................................... 94
REFERENCES ...................................................................................................................... 95
APPENDIX A ...................................................................................................................... 100
APPENDIX B ...................................................................................................................... 103
ix
LIST OF TABLES
Table Title Page
2.1 Minimum HVL Values 18
3.1 X-ray equipment specifications 24
3.2 Specifications of black piranha detector 25
4.1 Results of kVp accuracy for X-ray unit at Clinic Ste Anne 37
4.2 Results of kVp accuracy for X-ray unit at CNHU 37
4.3 Results of kVp accuracy for X-ray unit at Clinic Roseraie 38
4.4 Results of kVp accuracy for X-ray unit at Clinic Senande 38
4.5 Results of kVp accuracy for X-ray unit at CS-Mènontin 39
4.6 Results of kVp accuracy for X-ray unit at HZ-Porto Novo 39
4.7 Results of kVp accuracy for X-ray unit at CHU-Suru Léré 39
4.8 Results of Accuracy of exposure time less than 10 ms for X-ray
unit at Clinic Ste Anne 40
unit at CNHU 40
unit at HZ-Porto Novo 40
unit at Clinic Roseraie 41
unit at Clinic Senande 41
unit at CHU-Suru Léré 41
x
4.14 Results of Accuracy of exposure time greater than 10 ms for X-ray
unit at Clinic Ste Anne 42
unit at CNHU 42
unit at Clinic Roseraie 42
unit at Clinic Senande 43
unit at HZ-Porto Novo 43
4.19 Results of accuracy of exposure time greater than 10 ms for X-ray
unit at CHU-Suru Léré 43
4.20 Results of kVp reproducibility for X-ray unit at Clinic Ste Anne 44
4.21 Results of kVp reproducibility for X-ray unit at CNHU 44
4.22 Results of kVp reproducibility for X-ray unit at Clinic Roseraie 45
4.23 Results of kVp reproducibility for X-ray unit at Clinic Senande 45
4.24 Results of kVp reproducibility for X-ray unit at CS-Mènontin 46
4.25 Results of kVp reproducibility for X-ray unit at HZ-Porto Novo 46
4.26 Results of kVp reproducibility for X-ray unit at CHU-Suru Léré 47
4.27 Results of exposure time reproducibility for X-ray unit at Clinic
Ste Anne 48
4.28 Results of exposure time reproducibility for X-ray unit at CNHU 48
Roseraie 49
xi
Senande 49
4.31 Results of exposure time reproducibility for X-ray unit at CS-
Mènontin 50
4.32 Results of exposure time reproducibility for X-ray unit at HZ-
Porto Novo 50
4.33 Results of exposure time reproducibility for X-ray unit at CHU-
Suru Léré 51
4.34 Results of dose output reproducibility for X-ray unit at Clinic Ste
Anne 52
4.35 Results of dose output reproducibility for X-ray unit at CNHU 52
4.36 Results of dose output reproducibility for X-ray unit at Clinic
Roseraie 53
4.37 Results of dose output reproducibility for X-ray unit at Clinic
Senande 53
4.38 Results of dose output reproducibility for X-ray unit at CS-
Mènontin 54
4.39 Results of dose output reproducibility for X-ray unit at HZ-Porto
Novo 54
4.40 Results of dose output reproducibility for X-ray unit at CHU-Suru
Léré 55
4.41 HVL for X-ray unit at Clinic Ste Anne 56
4.42 HVL for X-ray unit at CNHU 56
4.43 HVL for X-ray unit at Clinic Roseraie 56
4.44 HVL for X-ray unit at Clinic Senande 57
xii
4.45 HVL for X-ray unit at CS-Mènontin 57
4.46 HVL for X-ray unit at HZ-Porto Novo 57
4.47 HVL for X-ray unit at CHU-Suru lere 58
4.48 Results of specific dose-mAs linearity for X-ray unit at Clinic Ste
Anne 63
4.49 Results of specific dose-mAs linearity for X-ray unit at CNHU 63
4.50 Results of specific dose-mAs linearity for X-ray unit at Clinic
Roseraie 63
4.51 Results of specific dose-mAs linearity for X-ray unit at Clinic
Senande 64
4.52 Results of specific dose-mAs linearity for X-ray unit at CS-
Mènontin 64
4.53 Results of specific dose-mAs linearity for X-ray unit at HZ-Porto
Novo 64
4.54 Results of specific dose-mAs linearity for X-ray unit at CHU-Suru
Lere 65
4.55 Results of leakage of X-ray tube housing for X-ray unit at CNHU,
Clinic Roseraie, Clinic Senande, HZ-Porto Novo and CHU-Suru
Lere 66
4.56 Frequently used exposures factors and FDD for radiography
projection 73
4.57 Patient thickness 74
4.58 Estimated entrance surface dose for Clinic Ste Anne 74
4.59 Estimated entrance surface dose for CNHU 74
4.60 Estimated entrance surface dose for Clinic Roseraie 75
xiii
4.61 Estimated entrance surface dose for Clinic Senande 75
4.62 Estimated entrance surface dose for CS-Mènontin 75
4.63 Estimated entrance surface dose for HZ-Porto Novo 76
4.64 Estimated entrance surface dose for CHU-Suru Lere 76
4.65 kVp accuracy range 77
4.66 Specific dose output function with percentage error 89
A.1 Results of specific dose - kVp2 linearity for X-ray unit at Clinic Ste
Anne 101
A.2 Results of specific dose - kVp2 linearity for X-ray unit at CNHU 101
A.3 Results of specific dose - kVp2 linearity for X-ray unit at Clinic
Roseraie 101
A.4 Results of specific dose - kVp2 linearity for X-ray unit at Clinic
Senande 102
A.5 Results of specific dose - kVp2 linearity for X-ray unit at CS-
Mènontin 102
A.6 Results of specific dose - kVp2 linearity for X-ray unit at HZ-Porto
Novo 102
A.7 Results of specific dose - kVp2 linearity for X-ray unit at CHU-
Suru Lere 103
B.1 Results of dose output for X-ray unit at Clinic Ste Anne 104
B.2 Results of dose output for X-ray unit at CNHU 104
B.3 Results of dose output for X-ray unit at Clinic Roseraie 104
B.4 Results of dose output for X-ray unit at Clinic Senande 105
B.5 Results of dose output for X-ray unit at CS-Mènontin 105
B.6 Results of dose output for X-ray unit at HZ-Porto Novo 105
xiv
B.7 Results of dose output for X-ray unit at CHU-Suru Lere 105
xv
LIST OF FIGURES
Figure Title Page
2.1 Interpretation of the image of the steel ball in the beam alignment
test tool 19
2.2 Diagram of measurement arrangement 23
3.1 Black Piranha Detector 25
3.2 RDS-120 Universal survey meter 26
3.3 Collimator and beam alignment QC test tool 27
3.4 Wooden ruler 27
3.5 Lead apron 28
3.6 CR plate, X-ray cassette and Film 28
3.7 Set up for kVp, time, HVL and dose measurement 30
3.8 Set up for collimator beam alignment 31
3.9 Set up for leakage of X-ray tube housing measurement 32
4.1 Specific dose versus kVp2 for X-ray unit at Clinic Ste Anne 59
4.2 Specific dose versus kVp2 for X-ray unit at CNHU 59
4.3 Specific dose versus kVp2 for X-ray unit at Clinic Roseraie 60
4.4 Specific dose versus kVp2 for X-ray unit at Clinic Senande 60
4.5 Specific dose versus kVp2 for X-ray unit at CS-Mènontin 61
4.6 Specific dose versus kVp2 for X-ray unit at HZ-Porto Novo 61
4.7 Specific dose versus kVp2 for X-ray unit at CHU-Suru Lere 62
4.8 Results of X-ray beam alignment test for X-ray unit at Clinic Ste 67
Anne
4.9 Results of X-ray beam alignment test for X-ray unit at CNHU 67
xvi
4.10 Results of X-ray beam alignment test for X-ray unit at Clinic 67
Roseraie
4.11 Results of X-ray beam alignment test for X-ray unit at Clinic 67
Senande
4.12 Results of X-ray beam alignment test for X-ray unit at CS- 68
Mènontin
4.13 Results of X-ray beam alignment test for X-ray unit at HZ-Porto 68
Novo
4.14 Results of X-ray beam alignment test for X-ray unit at CHU- 68
Suru Lere
4.15 Specific dose output versus kVp for X-ray unit at Clinic Ste Anne 69
4.16 Specific dose output versus kVp for X-ray unit at CNHU 69
4.17 Specific dose output versus kVp for X-ray unit at Clinic Roseraie 70
4.18 Specific dose output versus kVp for X-ray unit at Clinic Senande 70
4.19 Specific dose output versus kVp for X-ray unit at CS-Mènontin 71
4.20 Specific dose output versus kVp for X-ray unit at CS-Mènontin 71
4.21 Specific dose output versus kVp for X-ray unit at CHU-Suru Lere 72
4.22 Clinic Senande kVp calibration curve 78
4.23 CS-Mènontin kVp calibration curve 78
4.24 Comparison of accuracy of exposure time below with
recommended limit 79
4.25 Comparison of accuracy exposure above 10 ms with
recommended limit. 80
4.26 Comparison of kVp coefficient of variation with recommended 81
limit.
xvii
4.27 Comparison of exposure time coefficient of variation with
4.28 Comparison of dose output coefficient of variation with
4.29 Comparison of measured HVL with recommended minimum 84
HVL.
4.30 Correlation of the specific dose versus kVp square with linear 85
trendline.
4.31 Comparison of specific dose-mAs linearity coefficient with 86
recommended limit
4.32 Comparison of leakage of X-ray tube housing from the seven X-
ray unit. 87
4.33 Comparison of X-ray beam misalignment degree with
acceptable limit of 1.5°. 88
4.34 Comparison of Chest PA entrance surface dose 89
4.35 Comparison of Abdomen AP entrance surface dose 90
4.36 Comparison of Pelvis AP entrance surface dose 91
4.37 Comparison of Skull AP entrance surface dose 91
4.38 Comparison of Lumber Spine AP entrance surface dose 92
4.39 Comparison of Foot AP entrance surface dose 92
xviii
ABSTRACT
The use of X-ray equipment in diagnostic radiography increases with demographic
growth of population and Benin is not an exception. Achieving good quality image
while keeping workers, public and patient exposure to ionizing radiation at an
acceptable level has become a prerequisite for radiology department in their effort to
comply with radiation protection principle of optimization. The present research work
undertook quality control measurement of seven diagnostic radiography equipment in
south of Benin. In addition, patient entrance surface dose was also estimated in the
seven hospitals. RDS-120 universal survey meter, multifunction detector (Piranha) and
beam alignment test tool were used to perform quality control tests on the seven X-ray
units. The method used as well as the interpretation of the results was based on
AAPM, FDA, HARP, IPEM, IAEA and S.C 35 recommendations. The quality control
results showed that all X-ray equipment investigated were within standard limits for
accuracy of exposure time below 10 ms; reproducibility of kVp, exposure time and
dose output; specific dose-kVp2 linearity; specific dose-mAs linearity and leakage of
X-ray tube housing. 5/7 of diagnostic X-ray machines passed quality control tests such
as X-ray beam alignment, exposure time above 10 ms and kVp accuracy. For the seven
X-ray units, the maximum average estimated entrance surface dose for chest PA, Skull
AP, abdomen AP, pelvis AP, and lumber spine AP were respectively, 1.3922 ± 0.0217
mGy; 10.5709 ± 0.4549 mGy ; 11.2909 ± 0.5324 mGy; 10.1398 ± 0.2322 mGy;
16.1073 ±0.6931 mGy and 1.4317 ± 0.0161 mGy. The choice of radiographic
parameters needs to be improved by radiographers in their effort to optimize patient
exposure to ionizing radiation.
1
CHAPTER ONE
INTRODUCTION
The present chapter provides background, objective, the statement of research
problem, relevance and justification of the study, scope and limitation and the
organization of the thesis.
1.1 Background
Wilhelm Roentgen discovered X-rays on November 8, 1895 while
experimenting with a Crookes tube in his physics laboratory at Würzburg University
Germany [1]. X-rays are ionizing radiations. All forms of such radiation have
sufficient energy to ionize atoms that may destabilize molecules within cells and lead
to tissue damage. The harmful effects of ionizing radiation became apparent after the
discovery of X-rays and radioactivity. An American physicist, Emile Grubbe, suffered
severe burns as a result of holding the energized X-ray tube in his hands. In May 1896,
a man who had a head radiograph suffered skin burns and loss of hair [2]. From the
beginning of the use of X-rays for diagnosis, harmful effects were observed and
continued to be observed. This situation pushed various practitioners to suggest a
variety of radiation safety rules. International organizations, such as International
Commission on Radiological Protection (ICRP), International Atomic Energy Agency
(IAEA), recommend that proper management systems that include quality assurance
(QA) programme encompasses activities involving the use of ionizing radiation [3].
Quality assurance is defined as the function of a management system that provides
adequate confidence that an item, process or service will satisfy given requirements
for quality [4]. Also the World Health Organization (WHO) defines a QA programme
in diagnostic radiology as an organized effort by the staff operating a facility to ensure
that the diagnostic images produced are of sufficiently high quality so that they
2
consistently provide adequate diagnostic information at the lowest possible cost and
with the least possible exposure of the patient to radiation [5]. As part of QA, quality
control (QC) intends to verify that structures, systems and components corresponding
to predetermined requirements [4]. Quality control techniques are those techniques
used in the monitoring (or testing) and maintenance of the technical elements or
components of an X-ray system. The QC techniques are concerned directly with the
equipment performance that can affect patient dose and the quality of the radiographic
image [6]. X-rays machines are used in diagnostic radiology departments to produce
images of anatomical structures through a variety of examinations including
radiography, fluoroscopy, computed tomography (CT) and others. Diagnostic
radiology equipment are made of an X-ray tube mounted in such a way that allows the
tube to be moved in any direction. The production of X-rays by such machine is
regulated by a control console that allows the selection of radiographic parameters
(kilovoltage peak, milliamperes, exposure time) and the ability to choose between
small and large focal spot. The QC tests related to those radiographic parameters as
well as the measurement of the focal spot size is of importance to ensure safe use of
the machine and protection of patients, workers and the public. The quality and
quantity of X-ray beam that is produced should allow good image to be obtained while
keeping patient dose as low as reasonably achievable (ALARA) [7].
Benin Republic, is a West African country that shares boarder with Nigeria in
the east, Togo in the west, Niger and Burkina Faso in the north. The Health system of
the country is composed in decreasing order of the Ministry of health, twelve (12)
departmental divisions of health and hospitals. Public as well as private hospitals use
conventional X-ray machines to perform patient diagnosis. Most of the radiography
centres are concentrated in Cotonou and Porto Novo. Because of the lack of
3
radiological regulation in the country, QC of radiation emitting equipment are mostly
overlooked. The equipment are repaired by biomedical engineers only when there is
mechanical or electrical fault. After repair no quality control is undertaken to ascertain
the state of the equipment. In order to solve this problem, a law was enacted in October
2017 by the Parliament for regulation of activities involving the use of ionizing
radiation. A national project designed with the support of IAEA is aimed at building
human capacity to perform quality control tests on medical imaging equipment.
There are several research works which have been done on quality control of
diagnostic X-ray equipment and patient entrance surface dose assessments. The QC
tests are performed and evaluated based on kVp and exposure time accuracy
(Akpochafor et al., 2016); output linearity with mAs (Rasuli et al., 2015); beam
alignment and congruence (Ismail et al., 2015); focal spot size; linearity of output with
kVp2 (Azzoz et al., 2014); screen-film contact uniformity (Begum et al., 2011);
reproducibility of kVp and output (Korir et al., 2011). Entrance surface dose was
measured either with a direct measurement method using a TLD (Jibiri et al., 2016),
or the indirect estimation from X-ray equipment output variation (Ackom et al., 2017;
Taha et al., 2014).
This research study is intended to undertake QC tests on X-ray machines in
selected hospitals in South of Benin, assess their performances and establish baseline
data for future work. The study also assesses patient radiation dose in terms of entrance
surface dose.
1.2 Objectives
The primary objective of this study is to implement a comprehensive quality control
programme on X-ray systems in selected diagnostic radiology centres in Benin. To
achieve the above objective the following specific objectives will be addressed.
4
i) Perform QC checks with emphasis on the following tests and tube QC tests.
o X-ray beam filtration
o Light-X-ray fields congruence and beam alignment
o Radiation leakage of tube housing
o Reproducibility of kilovoltage peak (kVp), dose output and exposure time
o Accuracy of kVp and exposure time
o Specific dose –mAs linearity
o Specific dose-kVp2 linearity
ii) Estimate entrance surface dose (ESD)
1.3 Problem statement
In Benin Republic, more than one hundred X-ray machines are in operation
daily for diagnosis of medical conditions of patients. Since there is no regulatory
system in the country, regarding the use of these machines, acquisition of such
equipment is not under proper control. Most of the equipment are not subjected to
acceptance test and the X-ray machines are not inspected during operation. The
reproducibility and accuracy of selected imaging parameters are known when regular
QCs are performed. Due to the lack of QCs performed on the equipment a big doubt
exists on the level of doses received by patients, staff and the public as satisfying the
ALARA principle. Ionizing radiations induce health effects. It is a risk related to
medical imaging. To ensure continuing production of diagnostic images with optimum
quality, using minimum necessary dose to the patient and surrounding individual,
equipment performance needs to be monitored [8].
1.4 Relevance and Justification
The use of X-ray machines for radiography is good for patient’s diagnosis, but
when not held in check, it can induce severe health effects to patients, radiographer
5
and the general public. The adverse health effects associated with ionizing radiation
do not allow it to be used without balancing between risk and benefit. To achieve
proper use of those machines, protocols and guidelines have been developed at both
international and national levels for diagnostic equipment QC. In Benin no QC tests
have been performed for decades, and the machines are only repaired when there are
mechanical and electrical defaults. This study is relevant and justified in the sense that
it will provide for the first time, information regarding the state of some X-ray
machines used in most popular hospitals in Benin.
1.5 Scope and Limitations
The present study will cover:
i) X-ray systems’ quality control tests except focal spot size determination
and automatic exposure control assessment.
ii) The entrance surface dose will be estimated from radiation output
measurement.
1.6 Organization of thesis
The present research thesis is composed of five chapters. Chapter one covers
Introduction. Chapter two provides an overview of X-ray machine quality control and
review of work done on patient radiation dose assessment. Chapter three outlines the
materials and the experimental methods used to perform quality control of X-ray
equipment in South of Benin. Chapter four covers results obtained from data
collection, their interpretation and discussion drawn from them. In chapter five,
conclusion is made and recommendations are proposed. References used as well as the
appendix are the last pages of the present work.
6
CHAPTER TWO
LITERATURE REVIEW
This chapter provides an overview of X-ray machine quality control and review
of work done on patient radiation dose optimization through quality control. The
chapter also focuses on studies done regarding entrance surface dose in radiographic
procedures.
2.1 X-rays machine and X-ray production
X-ray machine consisted essentially of X-ray generator, X-ray tubes,
collimator system and image receptor. Other parts of the machine include the tube
support mechanism that allows movement of the tube to be correctly positioned at the
patient’s anatomical part to be imaged.
The generator is the source of electrical energy to the X-ray tube and ensures
how long an exposure will take. The tube of the diagnostic X-ray machine is made of
the filament (cathode); target material (anode), focusing cup, and the glass envelop
[9]. By thermionic emission, electrons are expelled from the cathode, concentrated in
the focusing cup, these electrons are accelerated by an electrical field applied between
cathode and anode. Electrons interact with the anode material and X-rays are
generated. Two types of interactions occur, including electron-electron interaction
which give rise to characteristic X-ray and electron-nucleus interactions which
produce breaking X-ray radiation [10]. The production of X-rays depends on the
selection of radiographic parameters. The tube current (mA) selection is commanded
by the filament circuit and its product with the exposure time (mAs) determines the
quantity of the diagnostic X-ray machine output. The kilovoltage peak (kVp) supplied
by the cathode–anode circuit, creates the electrical field that accelerates electron
7
between anode and cathode [11]. Because of the need of uniform electrical field to
accelerate electrons, a constant potential is of interest. This is achieved by step up
transformer and rectifying circuit to correct the alternative current supplied by the
generator. The focal spot, point of interaction of electron beams with anode material
inside the X-ray tube, releases the X-rays produced and its size influence the image
resolution. During the production of X-ray heat is generated more than the X-ray itself.
For example at 100 kVp, only about 1% X-rays are produced in form of combination
of Bremsstrahlung and characteristic X-ray [12]. The pulse duration timer controls the
exposure time to optimize patient dose, film exposure and heat generated in the tube.
Low energy X-rays are attenuated from the beam spectrum by aluminum filters to
minimize patient entrance surface dose. The collimator system confines the radiation
only to the region of interest so that unnecessary exposure to other parts of patient
body is eliminated. Anti-scatter grid removes scatter radiation that will reach the film
and affect image quality. The intensifying screen and the film combination allow the
detection of the beam transmitted through the patients and the formation of the image.
2.2 Overview of quality control of radiography X-ray machine
Diagnostic X-ray machines are man-made sources of radiation that are commonly
used in hospitals and radiological research institutions. The use of such machines that
deliver ionizing radiation may induce health effects not only to patients but also to the
radiographer as well as the surrounding individuals when not held in control. Rules
and regulations are designed by national regulatory authorities, inspired by the
recommendations of international organization such as the International Commission
on Radiological Protection (ICRP), International Atomic Energy Agency (IAEA) and
World health Organization (WHO) to ensure that X-ray system perform satisfactorily
in service [3]. To achieve the goal of good image at low patient dose, regular quality
8
control checks of diagnostic equipment is required. Quality control allows to detect
machine defects and to initiate corrective actions in order to ensure a safe working
environment. Equipment quality control tests includes in general, acceptance, routine
and status tests. Acceptance tests are performed at equipment installation or after
important repair to verify machine specifications as indicated by manufacture. Status
test is applied to already installed equipment and is similar to acceptance test. Routine
test is applied to important parameters that determine good functioning of the
equipment. Those parameters are tested to verify change that may occur during
equipment operation [13]. To comply with the principles of optimization which imply
obtaining a good image quality at low patient dose, a lot of studies have been done
worldwide on diagnostic X-ray machine quality control.
In 2016, Akpochafor et al, performed kVp accuracy test in ten X-ray centres. This
study conducted in Nigeria, analysed 40 kVp accuracy results. Some machine were
above acceptable accuracy limit of ± 5%. One fifth of those equipment that failed the
test were at least ten years old [14]. In the same country in 2015, Godfrey et al., worked
on radiography X-ray machine kVp accuracy, reproducibility in some Zaria hospitals.
The importance of kVp is brought out in the sense that if kVp is out of range or limits,
it can bring about either over exposure or under exposure which in turn increases the
level of rejects, retake or unwanted exposure to radiation. The study was conducted on
five X-ray machines, and it was found out that none of the machines demonstrated
complete compliance to Nigeria Nuclear Regulatory Authority standard guidelines
[15].
In Iran, Gholami et al., in 2015, assessed tube voltage and exposure time of
conventional X-ray machines in six hospitals, including governmental and private
hospitals. A total of seven X-ray units in Lorestan province were involved in the study.
9
The detector used was a Barracuda dosimeter. From their work evaluation of kVp
accuracy showed values out of therequired limit of accuracy Exposure time accuracy
evaluation showed that some hospitals complied with the requirements. The highest
X-ray tube output was 147×10-3 mGy/mAs. From their conclusion, age of X-ray
machines and the rate of their maintenance are likely the causes that affect patient
radiation dose and radiographic image quality [16]. Mehrdad Gholami et al work done
in Lorestan province, Iran is similar to Behrouz Rasuli et al study published in the
Iranian Journal of medical physics in September 2015. They performed ten standard
quality control tests on fifteen conventional radiology devices in Khuzestan province,
Iran. Reproducibility test for kVp, dose exposure output and time as well as linearity
test were successful, for all devices. There was poor beam alignment in 3/5 of the units.
The results revealed, X-ray machines met the standard criteria despite the fact that the
machines were relatively old with high workload. Such result were due to the
implementation of after-sale services, including quality control of X-ray machines in
the province [17]. In the same country Iran but in a third province, Golestan et al 2013,
performed quality control on forty-four X-ray units. kVp accuracy and reproducibility;
mA-time reciprocity, exposure linearity and reproducibility, timer accuracy, X-ray
beam quality, and beam alignment were assessed. 100% of equipment kVp were
reproducible. Exposure linearity, mAs reciprocity, kVp accuracy, light field-beam
alignment, and reproducibility of exposure were found to be acceptable [18].
In Sudan, Ismail et al 2015, performed quality control tests on eighteen X-Ray
Units at Khartoum State Hospitals. The QC tests performed were, kilovoltage peak
and exposure time reproducibility and accuracy; mAs linearity; of light beam
coincidence with radiation beam and fog level in darkroom. CONNY II QC dosimeter
made by PTW was used to achieve measurements. It was found out that two of
10
hospitals had a problem in mAs linearity, also two out of eighteen unit had a problem
in kVp accuracy and one had a problem in kVp reproducibility. Light field and
radiation beam alignment were successful for 15 machines. Only few darkrooms are
free from fog level problems; time accuracy and time reproducibility were in the
acceptable limit. From their results it was necessary to spread the quality control
programme to the whole Sudan [19].
In the same year 2015, Ngoye et al. published in the Journal of Medical Imaging
and Radiation Sciences, a research work done to verify how quality control measures
are implemented in Tanzania by radiographers. From the study it is found out lack in
implementing QC programme by radiographers despite benefit related to it to reveal
equipment malfunction at an early stage [20].
In Egypt, Azzoz et al. 2014, evaluated ten stationary X-ray units in eight hospitals.
The quality control tests performed included, beam Alignment and collimator accuracy
for radio-diagnostic machine; output reproducibility and linearity of kVp2 versus
exposure per mAs for small and large focus; beam quality; focal spot size;
reproducibility and accuracy of exposure time; amount of leakage radiation and
scattered radiation. From their results the total beam filtration was 2.5 mm aluminum.
Their study revealed that optimization of radiographic parameters is important for dose
reduction. Azzoz et al recommend that workers should be provided with specific
training programmes to enhance diagnosis [21].
In Ghana, Inkoom et al. published in 2011 a chapter on QA and QC of diagnostic
radiology machines. The study was based on experience gained in Ghana. From their
study, the importance of quality assurance programmes in terms of patient dose
reduction, image quality, medical costs reduction and improving diagnostic radiology
department management is not to be underestimated. In addition to the components of
11
QC procedures all the quality control tests performed in Ghana were documented in
the regulations that allow those tests to be performed anywhere ionizing radiation is
used [6].
In Bangladesh, Begum et al, 2011, assessed forty X-ray units. The tests that were
carried out are light field and radiation beam congruence; focal spot size; half value
layer and film-screen contact test. Each parameter was assessed with a specific quality
control tests tool. The method used in their work was based on existing standard
quality control protocol. Investigation of half value layers (HVL) revealed all the forty
diagnostic X-ray machines were out of range. Only 7.5% machines failed the focal
spot size test. Congruence between light field and radiation beam was satisfactory in
more than 75% of cases while 65% of machines achieved the expected screen film
contact uniformity. It is clear that from Begum et al studies, quality control actions
need to be performed regularly for safe and proper operation of the X-ray units [22].
Gholamhosseinian-Najjar et al, 2014, conducted research on eleven X-ray units.
Exposure time and kVp accuracy, mAs linearity with exposure, and exposure
reproducibility were measured using Unfors Mult-O-Meter model 303. Results
obtained revealed many faults on equipment. It was recommended not to use the
devices in the regions where those errors were found and it was suggested that some
X-ray units should undergo repair or substitution [23].
In Brazil, Ebisawa et al, 2009, conducted a retrospective study on QC acceptance
indices. About 1177 reports on conventional diagnostic X-ray equipment recorded
over a seven year period in the state of São Paulo were analysed. Results on half value
layer assessment conformed to required standards accepted values in the proportion of
89% in 2000 to 94% in 2006. The satisfactory results obtained throughout the period
of study was attributed to the compliance with the state regulation. Worker integrated
12
quality assurance in their working culture, this induced natural observance of the
regulations and the development of safety culture [24].
In Kenya, Korir et al., 2011 conducted a research work on the protection of patients
by establishing QA baseline for diagnostic radiology. The study was done on four X-
ray machine. Each machine was used over 1 month with 400-speed film/screen system.
Quality control tests were performed on each diagnostic X-ray machine.
Reproducibility, accuracy, linearity and beam quality are some of the QC tests
performed. The results revealed that the machines were in good status with faults
observed for the light/radiation beam alignment where the bottom and top as well as
cathode side showed deviation from the standard limits. From their conclusion patient
overexposure was due to equipment age [25].
In Nigeria, Akaagerger et al, 2015, assessed HVL and beam alignment using
collimator tests tool. The study was made on two X-ray machines, using DIAVOLT
universal model 43014 dosimeter. It was found out that light-radiation field
misalignment was within the acceptable limit of 2.0cm as specified by ICRP.
Comparing the two diagnostic X-ray machines, one of them had higher probability of
poor image contrast [26].
Sungita et al, 2006, worked on QC of X-ray machines in Tanzania. This study was
conducted because of the increasing number of X-ray machines in the country and the
little availability of technical support to operate and maintain them adequately. Four
QC tests were performed on 196 diagnostic X-ray units. The tests included beam
alignment and collimation test made on 80 X-rays units; timer accuracy test performed
on 120 X-ray units; radiation leakage test assessed on 47 X-ray units and preventive
maintenance tests evaluated on each of the 196 diagnostic X-ray units. The outcome
revealed that 41% of equipment passed kVp tests, 43% passed exposure time accuracy,
13
60% satisfied conformity with beam alignment tests standards, and 20% failed the
radiation leakage of tube housing test. From their research report, governmental
authorities in charge of regulation, took actions in improving radiological services in
Tanzanian hospitals [27].
Hassan et al 2012, in Egypt assessed absorbed dose to patient and diagnostic X-
ray units. Five groups of five X-ray equipment were involved in the study. It was found
out that the absorbed dose to different organs was a function of the X-ray tube loading
factors (kVp and mAs). Leakage radiation tests were acceptable and the measured at
1 m was far below the acceptable limit of 1 mGy/h at 1m. Tests of X-ray field
alignment with light field as well as focal spot position were satisfactory. Accuracy
tests for kVp showed the deviation was within standards limit [28].
In Turkey, Sezdi from Istanbul University wrote in 2011, a chapter on QC tests of
diagnostic X-ray units to optimize radiation dose. The QC tests carried out included,
accuracy, reproducibility and linearity tests of radiographic parameters. Beam quality
test as well as image quality was performed in five hospitals on ten diagnostic
radiology X-ray units. The objective was to determine the tube loading factors that will
be suitable for quality control tests [8]. The parameters setting values of 70 kVp-(20,
40, 50mAs) were recommended for the acquisition of high quality image
2.3 Importance of some essential quality control tests and standard limits
2.3.1 Accuracy of loading factors
Loading factors are radiographic parameters including kilovoltage peak (kVp),
tube current and exposure time. The kVp is very important parameter, since it account
for X-ray beam quantity and quality. Variation of kilovoltage peak influences the mean
energy of photon emitted and thus affects the subject contrast of radiographic image
produced. It is therefore necessary that kVp be accurate as much as possible. The dose
14
output is proportional to the square of kVp. The product of tube current and exposure
time is proportional to the quantity of X-ray produced during an exposure. If the
measured exposure time is lower than the selected, then mAs is small and this induces
quantum mottle which affects radiograph by noise. When the exposure time is greater
than the selected, patients will be overexposed. It is important to verify variations
between indicated and measured kVp and exposure time for diagnostic X-ray
equipment calibration [30].
Accuracy is the degree of agreement between the measured radiographic
parameters (kilovoltage peak/ time) and the indicated or selected values. According to
AAPM [31], FDA [32] and IPEM [33], the measured kVp accuracy limit is set to be
±5% of the indicated or selected kVp . Based on the Healing Arts Radiation Protection
Act, the kVp should also be assessed at most commonly used milliamperage stations.
According to Canadian’s Safety Code S.C. 35, deviation of the measured exposure
time should not exceed ±10% +1 ms of the time selected [29]. Similarly H.A.R.P Act
set the limit to be ±10% [34]. More precision was provided by AAPM report 74 which
specify limit for exposure below 10 ms and exposure above 10 ms. Above 10 ms, the
limit for time accuracy is set to be ±5% while below 10 ms it is ±10%. The tube
current, limit was set to be 20% while that for mAs is 10% +0.2 mAs [31].
2.3.2 Radiation Output, kilovoltage peak and exposure time reproducibility
When several measurements of radiographic parameters (kVp, exposure time or
dose output) are taken in the same conditions, the degree of agreement between
measurements is called reproducibility [30]. It is mainly done to ensure that a set of
radiographic parameters can be repeated without major deviation. The same or very
close exposure can be obtained each time from an X-ray machine. Reproducibility is
important because it guarantees that the X-ray machine is capable of delivering dose
15
to the specifications for which it is rated and help to detect operator error when the X-
ray machine performs perfectly. Reproducibility is determined by calculating the
coefficient of variations which is the standard deviation divided by the mean of ten
consecutive measurements taken within a time period of 1 hours at same source-to-
detector distance.
Limit for reproducibility was recommended by the United State Food and Drug
Administration (FDA) to be 5% [32]. S.C.35 set the coefficient of variation limit to
5% and each measurement should not exceed 15% of the average value. H.A.R.P is in
agreement with S.C.35 and AAPM coefficient of variation but allows 20% deviation
between each measured value and the average value [34].
2.3.3 Radiation Output-mAs linearity
It is expected for a fixed value of mAs obtained from any combination of
milliamperage and exposure time, a constant amount of radiation is produced [30]. The
selection of milliamperage and exposure time product determines the number of
electrons that interact with the target material (anode). Thus mAs is related directly to
the quantity of radiation that is produced. Even if these interactions of incident
electrons with both target material electrons and nucleus are probabilistic, it is
expected that the radiation output to be the same for a constant film density. In the
clinical setting, if milliamperage (mA) and time product varied, a proportional
variation of X-ray output should be obtained. Linearity tests are essential in the
detection of change in image quality and monitoring of patient dose in the sense that
poor quantity of X-ray beam reaching the film will induce- noise in the image and this
will produce image reject and repeat of patient examination. According to Canada
safety code 35 and FDA, for a fixed value of kVp, the difference between two specific
doses should be less or equal to 0.10 times their sum.
16
2.3.4 X-ray beam filtration
Filtration exists to cut off low energy X-rays by the mean of a layer of material.
The purpose is to reduce dose to the skin and shallow tissues induced by low energy
X-rays which cannot reach image receptor. They increase patient dose unnecessarily
and contribute nothing useful to the image. Radiographic images are obtained by
transmission of X-ray beam through patient. It is important that the X-ray beam has
just enough ability to penetrate deeper into tissue so that patient dose can be reduced
and image contrast to be maintained [1]. Total filtration consists of inherent filtration
and added filtration. Attenuation by housing oil; the thickness of glass envelop of the
tube and collimator assembly field light mirror are the inherent filtration components.
Added filtration use metal filters, intentionally insert in the X-ray field to modify it
effective energy. Generally the filters used are plates made of aluminum to remove
low energy X-ray with little diagnostic value.
In radiography, the quality control test of X-ray beam quality is determined by
measuring the half value layer (HVL). HVL of an X-ray beam is the thickness of filter
that will halve the initial intensity of the beam. X-ray beam quality test is done to check
the minimum half value layer necessary to remove low energy radiation.
According to FDA the following minimum HVL are defined for various kVp setting
(table 2.1).
17
Table 2.1 Minimum HVL Values [32]
Minimum HVL (mm

X-ray tube voltage (kVp)
of Aluminum)
Designed Measured
X-ray systems
Operating Range operating potential
30 0.3
Below 51 40 0.4
50 0.5
51 1.3
51 to 70 60 1.5
70 1.8
71 2.5
80 2.9
90 3.2
100 3.6
Above 70 110 3.9
120 4.3
130 4.7
140 5.0
150 5.4
2.3.5 X-ray-Light Fields Alignment and beam alignment
Collimators localize and modify the dimensions and form of the X-ray field rising from
the tube port. In the apparatus design, collimator assembly is hooked up to the tube
housing with a swivel joint. A rectangular X-ray field is set by means of lead shutters.
Collimator housing includes a light bulb and mirror. Le light emitted by the bulb is
reflected by a mirror to simulate the X-ray emission from the tube [35]. Collimator’s
shadows help identify the collimation of the X-ray field. Congruence between light
field and radiation field help practitioner to position well the anatomical part to be
18
imaged. In case of misalignment there will be cut-off of anatomical structures, leading
to repeat of examination and unnecessary increase of patient radiation dose.
Coincidence checking is a necessary evaluation of any quality control program.
According to safety code S.C 35 and AAPM report n° 74, the limit that should not be
exceeded is 2% deviation of the radiation field perimeter from the light field perimeter.
This limit is in an agreement with FDA and H.A.R.P policies. For X-ray beam
alignment the following criterion is applied for a source-table distance of 100 cm [35].
Figure 2.1 Interpretation of the image of the steel ball in the beam alignment test tool
2.3.6 X-ray tube leakage
The X-ray tube housing shield, supports and protects the X-ray tube insert. All X-rays
in the direction other than the exiting window are attenuated by a lead shielding. A
small fraction of these X-rays, known as leakage radiation may escape from the
housing [36]. Leakage radiation quality control test is necessary to minimize the risk
of unnecessary patient radiation exposure, loss of image quality, overexposure of
workers and surrounding individuals. It is recommended in the safety code 35 a limit
of 1.0 mGy/h at a distance of 100 cm from the position of the focal spot and at
maximum specified energy input. In standby the limit is 20 μGy/h at a distance of 5cm
from any accessible surface [29].
19
2.3.7 Integrity of Protective Equipment
Protective equipment used in diagnostic radiology include aprons, gloves and
gonadal shields. The protective equipment are lead-impregnated materials worn by
radiologists, radiologic technologists in some radiographic procedures. In the absence
of mechanical immobilization devices to maintain in required position those that are
not physically able to support themselves, comforters may also wear protective
equipment to provide help. To detect defects of protective equipment, it is necessary
to perform radiography of these equipment. In case of detection of cracks or holes
greater than 670 mm2 the protective devices should not be used. If the cracks or holes
are close to the thyroid or gonads, it should not exceed 5 mm in diameter. When not
in use, protective apparel must be kept on properly designed racks [29].
2.4 Entrance surface Dose assessment
2.4.1 Establishment of entrance surface dose.
Entrance surface dose or entrance surface air kerma is the absorbed dose to air
at point of intersection of X-ray beam central axis with patient or phantom. It takes
account of incident and backscatter radiation. There are two ways of establishing
entrance surface dose including, the direct method and the indirect assessment method.
Entrance surface dose determination by the direct method is based on
thermoluminescence dosimeter reading on patient or phantom. Indirect assessment use
recorded tube loading factors and specific dose variation curve with kVp to estimate
entrance surface dose [37].
In Ghana, Ackom et al, estimated in 2017, entrance surface dose of adult
patients undergoing computed radiography examinations in two hospitals. 619 patients
including 39.3% males and 376 (60.7 %) females with age ranging from 18 to 82 years
20
old were investigated. Indirect assessment method was used to estimate the entrance
surface dose with backscatter factor equal to 1.35 as recommended by European
Commission in 1996. From their study it was found out that, calculated mean ESD
were within the recommended references values except chest PA and range from 0.29±
0.0041 mGy to 6.08 ±0.55 mGy for all the diagnostic examinations including chest
PA, lumber spine AP and LAT, skull LAT and AP, cervical spine LAT and AP, and
abdomen AP. Their results compared with publications from Inkoom et al, IAEA and
Public Health of UK respectively, revealed that values they obtained were lower than
those published [38].
In 2016, Jibiri et al, conducted research work on investigating patient dose for
radiographic examination. The method applied was direct assessment using
thermoluminescence dosimeters (TLDs). Twelve hospitals and a total of fifteen
diagnostic X-ray equipment were involved in the study. Seven different types of
examinations were investigated. The results showed from comparison with
NRPBHPA 2010 review for UK, lower values of entrance surface dose for pelvis AP
and lumber spine AP. For the other five examinations, ESD were higher. This
difference in results was related to the tube loading (mAs) used [39].
In 2014, Ofori et al., estimated entrance surface dose for patients aged over 18
years old. A total of 320 patients were considered in the research work. The mean
entrance surface dose (ESD) was estimated using caldose_x 5.0 software. Input data
were patients’ data (age, sex) and exposure parameters. It was found out that the
highest mean ESD was 3.25 mGy for lumber spine examination. For all examinations,
ESD ranged from 0.27 mGy to 3.25 mGy. The entrance skin doses for thorax was
slightly higher than published works. From the study it was confirmed that
21
optimization of technical and clinical factors will reduce substantially patient doses
[40].
In the same year 2014, Taha et al, investigated entrance skin dose for 500
patients undergoing diagnostic examination in King Abdullah medical city in Egypt.
Six different examinations were considered in the study. The methods applied was
indirect assessment using mathematical model. The input for the model included X-
ray dose output, backscatter factor, tube current-time product, focus to skin distance
patient thickness and kilovoltage peak. Taha et al study was within the range of
reported international organizations value [41].
In Nigeria, in 2013, Ademola et al, assessed ESD resulting from children
chest, skull, abdomen and pelvis radiography. Five radiology centres were considered
in the research, with 450 patients with ages ranging from 0 to 15 years old. In their
work, indirect assessment method was used to estimate entrance skin dose (ESD)
based on standard exposure data because of the lack of TLD system. The results
revealed that there was no standard procedure used in the hospitals due to the wide
variation in technical parameters (kVp and mAs) for the same examination and
patients’ data [42].
Tamboul et al 2014, assessed in Sudan ESD of 191 patients by the means of
indirect method. Satisfactory results were obtained during the study [43].
In Serbia and Montenegro, Ciraj et al, 2004, estimated patient dose for eleven
different X-ray examinations. A total of 419 patients were considered in the study.
Results revealed that only entrance surface dose from chest PA was above stated
reference level for plane film examination. The study underlined the importance of the
survey data in the establishment of national radiation protection and quality control
programme for medical exposures [44]
22
2.4.2 Indirect measurement arrangement for entrance surface dose
Figure 2.2: Diagram of measurement arrangement [37]
The entrance surface dose given by the equation (2.1) :

2
d
ESD = B × Output(mGy/mAs) × mAs × ( ) ( 2.1) [41]
dFTD − t p
Where B is backscatter factor, mAs is milliamperes second used for a given
examination, d is the distance at which dosimeter reading was made, d FTD is focus to
patient table top distance and tp is patient thickness.
23
CHAPTER THREE
METHODOLOGY
The main objective of this study was to perform quality control of seven X-ray
machines in south of Benin. This chapter outlines the materials and the experimental
methods used to achieve this objective. The methods used for each quality control test
is based on recommendations of American Association of Physicist in Medicine
(AAPM), Healing Arts Radiation Protection Act (H.A.R.P), Safety code 35,
International Atomic Energy Agency (IAEA), United States, Food and Drug
Administration (FDA) and Institute of Physics and Engineering in Medicine (IPEM).
3.1 Equipment
3.1.1 Diagnostic radiology X-ray machines
Seven x-ray units were used. Their specifications are indicated in table 3.1
Table 3.1: X-ray equipment specifications
Tube Range
Tube Type of
Manufacturer Manufacture
Hospitals serial X-ray
& Country date
number system* kVp mAs
SIEMENS
Ste ANNE 579502 Not visible SF 40-125 0.5-800
Germany
SHIMADZU
CNHU November
Japan 75178 CR 40-150 0.5-800
2007
COMET
ROSERAIE ROHRE 348482 Not readable SF 40-125 0.1-400
Germany
SENANDE VARIAN - - SF 40-125 1-500
PERLONG
MENONTIN 820017131 June 2017 DR 40-130 0.4-360
China
BMI
SURU-LERE 12799 January 2007 CR 40-150 0.5-630
Italy
HZ- DMS APELEM

71k061 June 2010 SF 40-150 0.4-1000
Porto Novo FRANCE
(*) SF: Screen Film; CR: Computed Radiography; DR: Digital Radiography
24
3.1.2 Radiation detectors
3.1.2.1 Multifunction meter (Piranha)
Piranha is a solid-state detector designed to detect mostly X-ray radiation (figure 3.1).
It is manufactured by RTI group based in Sweden. The black Piranha used in the
present study is manufactured in Sweden and its serial number is CB2-11020219. It
was used for seven diagnostic radiography equipment to measure kilovoltage peak,
exposure time, half value layer and dose output of the equipment simultaneously. The
OCEAN Software associated with the detector allows the selection of the
simultaneous measurement [45]. According to the specifications of the detector the
following inaccuracies are related to each type of measurement as indicated in table
3.2 below
Table 3.2 Specifications of Piranha detector [46]
Measurements Range Inaccuracy
Kilovoltage peak 35-160 kVp 1.5%
Exposure time 0.1 ms-2000s 1%
Half value layer 0.72-13 mm Al 10%
Dose output 0.1nGy-1500Gy 5%
Figure 3.1: Black Piranha Detector
25
3.1.2.2 RDS-120 Universal survey meter
The serial number of RDS-120 universal survey meter used is 20563054.It was
manufactured by RADOS Technology Oy in Finland (figure 3.2) and can measure
dose rate in the range 0.05μSv/h − 10Sv/h. RDS-120 universal survey meter, is
designed for X-ray and gamma radiation detection. When used with beta probe it can
detect beta radiation. The RDS-120 universal survey meter can detect photon energy
ranging from 50 keV to 3 MeV. The maximum X-ray energy generated by the
diagnostic X-ray equipment involved in the present research work is 150 keV. The
survey meter was suitable for measuring dose rate for leakage radiation of X-ray tube
housing.
Figure 3.2: RDS-120 Universal survey meter
3.1.3 Collimator and beam alignment Quality Control test tool
The test tool allows the performance both QC for light field and X-ray field congruence
and central beam perpendicularity with image receptor. The test tool consists of flat
plate (20 × 25 cm) made of brass and contains rectangular outline and marking
etched. The main component of beam alignment tool is the sixteen centimeter high
26
acrylic cylinder. Each end of the cylinder holds one steel ball. The superimposition of
the steel ball determines the alignment of central X-ray beam. The test tool also
includes a leveller for checking whether patient table top is horizontal (figure 3.3) [47].
Figure 3.3: Collimator and beam alignment QC test tool
3.1.4 Tape measure
Tape measure with minimum count of 0.1 cm was used in the present research work
(figure 3.4). It was used in focus to table top distance (FTD) checking, measurement
of distance for leakage radiation and the setting up of detector.
Figure 3.4: Wooden ruler
27
3.1.5 Lead apron
At each diagnostic radiology department, at least one lead apron was available (figure
3.5). The radiation leakage test was performed in the X-ray room outside the
radiographers bunker. Lead apron was used to protect against X-ray in case of leakage.
Figure 3.5: Lead apron
3.1.6 Radiographic X-ray film, cassette and CR plate
The types of X-ray systems used in the study include Screen-Film (SF), Computed
Radiography (CR) and Digital Radiography (DR) system. The CR plate and the
cassette used for light field and X-ray field alignment tests was the plate or cassette
available that can contain the alignment test tool (figure 3.6). For screen film system
the film used were processed manually in two centres and automatically in one centre.
For CR and DR systems, the obtained image of the tests tool setting was printed on
radiographic film.
Figure 3.6: CR plate, X-ray cassette and Film
28
3.2 METHODS
3.2.1 Equipment set up for measurement
3.2.1.1 Set up for simultaneous measurement of kilovoltage peak, exposure time,
half value layer and dose output
3.2.1.1.1 Equipment used
Below are the equipment used for simultaneous measurement of kilovoltage peak,
exposure time, half value layer and dose output
1 Diagnostic radiography X-ray machines (table 3.1)
2 Piranha multifunction meter (figure 3.1)
3 Tape measure (figure 3.4)
4 Computer with Ocean software
3.2.1.1.2 Procedures
1 Piranha, multifunction meter was connected to the computer.
2 Ocean software was started on the computer to select parameter to be
measured. These parameters include, kilovoltage peak, dose output, exposure
time and half value layer.
3 X-ray machine was warmed up with three exposure parameters [(50kVp, 50
mA, 100 ms); (50kVp, 100 mA, 200 ms); (70kVp, 100 mA, 200 ms)] and with
5 minutes interval between exposures.
4 Collimator of X-ray machine was set at 0° to face the patient table in such a
way that X-ray source assembly was centred over the table.
5 Focus to table top distance (FTD) was set to be 100 cm and it was verified
using the tape measure.
29
6 X-ray field was collimated where possible to just cover the sensitive area of
the detector, to achieve conditions of narrow beam geometry (figure 3.7).
7 The detector was placed in the center of the X-ray field.
Figure 3.7: Set up for kVp, time, HVL and dose measurement
3.2.1.2 Setup for beam alignment and congruence of fields
3.2..2.1 Equipment used
The following equipment was used to undertake the test

1 Diagnostic radiography X-ray machines
2 Congruency tool (figure 3.3)
3 Perpendicularity tool (figure 3.3)
4 Loaded cassette or CR plate and film (figure 3.6)
5 Tape measure
3.2..2.2 Procedures
1 Patient table was levelled to verify its horizontality and X-ray tube was centred
to the table so that the central beam was perpendicular to the table.
2 Loaded cassette or CR plate was placed on the table in the center of the light
field. FTD was kept to 100 cm
30
3 The congruency tool was placed on the cassette in the center of the light field
and the perpendicularity tool in the center of the congruency tool (figure 3.8).
4 Collimator shutters were adjusted so that edges of the rectangular field coincide
with the rectangular outline of the congruency tool.
Figure 3.8: Set up for collimator beam alignment
3.2.1.3 Setup for measuring leakage of X-ray tube housing
3.2.1.3.1 Equipment used
The following equipment was used to perform test

1 Diagnostic radiography X-ray machines
2 RDS-120 Universal survey meter (figure 3.2)
3 Lead apron (figure 3.5)
4 Tape measure
3.2.1.3.2 Procedures
1 The collimator was shut off such that no primary X-ray was emitted.
2 The tube assembly was placed down on the X-ray table
3 The tape measure was used to define the position of 1 meter distance in front,
behind, left, right and on top away from the focal spot (figure 3.9).
31
Figure 3.9: Set up for leakage of X-ray tube housing measurement
3.2.2 Measurement for quality control tests
For each quality control, radiation detector was exposed with exposures parameters
and data were recorded.
3.2.2.1 Accuracy of kilovoltage peak
Accuracy of kilovoltage peak was performed on all the seven diagnostic X-ray
machines involved in the present study. The radiographic parameter mAs, was kept at
a constant value (20 mAs), and clinically used kilovoltage peak accuracy was
investigated. The value of kVp tested ranged from 50 kVp to 120 kVp. For each kVp
value, three measurement were recorded. The focus size was the frequently used in the
radiology department. Accuracy of the measured values were calculated by the means
of the equation 3.1:
̅̅̅̅
Xm − Xs
E=| | × 100% ( 3.1) [17]
Xs
Where E is error on kVp selected, ̅̅̅̅

Xm is the mean of the three measurement and Xs is
the selected kVp value
Results of the tests are indicated from tables 4.1 to 4.7
32
3.2.2.2 Accuracy of exposure time
Exposure time accuracy was conducted on six diagnostic X-ray machines. The QC test
takes account of two intervals of exposure time, exposure time below 10 ms and
exposure time above 10 ms. For each interval, three values of exposure times were
selected and each of them was measured three times. The mean exposure time was
used to determine accuracy of each measurement using the formula:
̅̅̅̅
tm − ts
E=| | × 100% (3.2)
ts
̅̅̅̅ is the mean of the three

Where E is error on exposure time set or display, tm
measurements and ts is the selected exposure time.
Measurements were done at a constant and most commonly used kVp. The focal size
was which is frequently used in the radiology department. Results of the tests are
indicated from tables 4.8 to 4.19
3.2.2.3 Reproducibility of kilovoltage peak, exposure time and dose output
At the frequently used focal size, ten consecutive exposures of the Black Piranha were
performed at constant mAs, kVp and exposure time. The most commonly used kVp
was the one used for the reproducibility test. All seven X-ray units kilovoltage peak as
well as dose output and exposure time reproducibility were tested. For the Unit at
radiology department of Mènontin it was not possible to select exposure time. But at
the constant parameter setting exposure time was measured and its reproducibility was
checked. At Senande clinic exposure was display by the X-ray units after each
exposure. 122 ms was the exposure time used at this radiology department to perform
reproducibility test. The Coefficient of variation of the ten measurements of each
reproducibility test was calculated using the equation:
33
n
SDx 1 xi 2
CVx = =√ [∑ ( − 1) ] (3.3) [17]
x̅ n−1 x̅
i=1
Where CVx is coefficient of variation, x̅ is the mean value of measurement, SDx is the
standard deviation, n is the total number of measurement, xi is the ith measurement and
x is time or kVp or dose output.
Deviation of each measurement from the mean measurement was also calculated based
on the equation:
xi
E = | − 1| × 100% (3.4)
x̅
Results of the tests are shown in tables 4.20 to 4.40
3.2.2.4 X-ray beam filtration (HVL)
Half value layer was measured by direct reading for all seven X-ray units. The tube
current and exposure time product were kept constant. Kilovoltage peak was varied in
increments of 10 from 40 to 90 kVp. For each kVp value the half value layer was
recorded three times. The mean of the three measurements was the HVL at the specific
kVp. Results of the tests are indicated from tables 4.41 to 4.47
3.2.2.5 Specific dose-kVp2 linearity
mAs was kept constant. kVp was varied from 40 to 90 with increments of 10. The
dose output and kVp were measured. The specific dose expressed in mGy/mAs was
plotted against the square of measured kVp. Results of the tests are indicated from
figures 4.1 to 4.7
34
3.2.2.6 Specific dose - mAs linearity
Kilovoltage peak was kept constant (the most commonly used kVp) and mAs was
varied. Dose output was recorded for each mAs value and specific dose output (𝑫′𝒊 )
was calculated by dividing the dose output value by the corresponding mAs value. To
check for linearity, the linearity coefficient (LC) was calculated using the equation 3.5
below for two consecutive mAs values.
|D′ i − D′ i+1 |
𝐿𝐶 = ′ (3.5)
|D i + D′ i+1 |
Where D′i is the ith specific dose, D′i+1 is the i + 1th specific dose
Results of the tests are indicated from tables 4.48 to 4.54
3.2.2.7 Leakage of x-ray tube housing
Leakage test was done at 80 kVp and mAs ranging from 60 to 63 for six X-ray units.
The X-ray unit at Ste Anne collimator was not able to select field size. The collimator
cannot be shut off. It was clear that the parameter selected for leakage tests did not
reflect the standard recommendation, but because on the X-ray unit console indication
of error appear at the highest kVp and mAs when exposure was undertaken, the
leakage tests was done with these factors to have at least an idea on leakage value for
each machine. Results of the tests are indicated in table 4.55
3.2.2.8 Collimator and beam alignment
At each radiology department the exposure factors for extremity radiography were
used to expose the collimator and beam alignment test tool. Beam alignment was
performed in all centre while for light field and radiation field congruence the image
obtained cannot allow to distinguish the radiation field edges (we should use coins to
35
delimit the edges for a better results). Results of the beam alignment tests are indicated
from figures 4.8 to 4.14.
3.2.3 Adult entrance surface dose (ESD) assessment method
3.2.3.1 Measurement of X-ray tube output
Measurement was done on all seven X-ray machines. After setting up the Piranha
detector, different exposure factors were selected to expose the detector. The X-ray
tube output graph was generated by plotting the specific dose against the kVp. Results
of the measurements are indicated from figures 4.15 to 4.21
3.2.3.2 Entrance surface dose estimation.
The chief radiographer in each diagnostic radiology department was asked to provide
the range of kVp and mAs used for six radiography examinations. The examination
included chest PA, abdomen AP, pelvis AP, skull AP, lumber spine AP and foot AP.
The Focus to detector distance was also provided for each examination. Twenty
patients thicknesses were measured for each radiography projection. To calculate the
entrance surface dose, average kVp value and average mAs value were introduced in
the mathematical equation defined by:
2
−1 )
d
ESD = B × Output(mGy ∗ mAs × mAs × ( ) (3.6) [41]
dFDD − t p
Where B is backscatter factor, mAs is milliamperes second used for a given
examination, d is the distance at which dosimeter reading was made, dFTD is focus to
patient table top distance and tp is patient thickness.
Results of the estimated entrance surface dose are indicated from tables 4.58 to 4.64
36
CHAPTER FOUR: RESULTS AND DISCUSSIONS
In the present study, dose is measured in mGy and specific dose which is dose
measured divided by the mAs used is expressed in mGy/mAs. Distances are in
centimeter (cm), exposure time is expressed in millisecond (ms).
4.1 Results of quality control tests
The choice of focal spot size was based on the most commonly used in the radiology
department. For Clinic Ste Anne, CNHU, Clinique Senande and HZ-Porto Novo, broad
focus was used while for Clinic Roseraie and CHU-Suru Léré, fine focus was used.
The focus at CS-Mènontin was not defined.
4.1.1 Results of kVp Accuracy tests
The test was undertaken using 20 mAs. Tables 4.1 to 4.7 indicate kVp accuracy results.
Table 4.1: Results of kVp accuracy for X-ray unit at Clinic Ste Anne
Set kVp Measured kVp Mean kVp Deviation (%)
50.00 49.34 49.32 49.33 49.33 1.34

60.00 59.03 59.13 59.27 59.14 1.43
70.00 69.31 69.28 69.35 69.31 0.98
81.00 80.06 80.28 80.12 80.15 1.05
90.00 89.15 89.05 89.26 89.15 0.94
Table 4.2: Results of kVp accuracy for X-ray unit at CNHU
60.00 59.87 59.87 60.05 59.93 0.12

70.00 69.98 69.71 69.86 69.85 0.21
80.00 79.74 79.98 79.89 79.87 0.16
90.00 90.15 90.03 90.27 90.15 0.17
120.00 119.42 119.27 119.59 119.43 0.48
37
Table 4.3: Results of kVp accuracy for X-ray unit at Clinic Roseraie
kVp Set kVp Measured Mean kVp Deviation (%)
50.00 49.70 49.78 49.74 49.74 0.52

60.00 59.53 59.66 59.75 59.65 0.59
70.00 69.75 69.72 69.74 69.74 0.38
80.00 79.64 79.72 79.69 79.68 0.40
90.00 89.85 89.92 89.90 89.89 0.12
Table 4.4: Results of kVp accuracy for X-ray unit at Clinic Senande
kVp Set kVp Measured Mean kVp Deviation (%)
50.00 47.02 46.78 47.26 47.02 5.96

60.00 56.90 53.59 56.83 55.77 7.04
70.00 65.77 63.91 63.97 64.55 7.79
80.00 76.44 74.50 72.98 74.64 6.70
90.00 80.55 79.47 79.47 79.83 11.30
Table 4.5: Results of kVp accuracy for X-ray unit at CS-Mènontin
Set kVp kVp Measured Mean kVp Deviation (%)
50.00 48.22 48.33 48.28 48.28 3.45

60.00 57.51 57.61 57.59 57.57 4.05
70.00 66.43 66.56 66.65 66.55 4.93
80.00 75.79 75.89 75.91 75.86 5.17
90.00 84.36 84.68 84.55 84.53 6.08
38
Table 4.6: Results of kVp accuracy for X-ray unit at HZ-Porto Novo
50.00 49.96 49.91 49.94 49.94 0.13

60.00 60.29 60.37 60.30 60.32 0.53
70.00 70.15 70.16 70.16 70.16 0.22
80.00 80.03 80.09 79.87 80.00 0.00
90.00 90.35 90.40 90.41 90.39 0.43
Table 4.7: Results of kVp accuracy for X-ray unit at CHU-Suru Léré
Set kVp kVp Measured Mean kVp Deviation (%)
50.00 49.75 49.88 49.82 49.82 0.37

60.00 60.37 60.32 60.51 60.40 0.67
70.00 70.16 70.04 70.08 70.09 0.13
80.00 80.23 81.19 80.29 80.57 0.71
90.00 91.58 91.14 91.19 91.30 1.45
39
4.1.2 Results of exposure time accuracy test
4.1.2.1 Results of accuracy of exposure time less than 10 ms
Quality control tests were performed using 60 kVp for Clinic Ste Anne and 80 for the
others X-ray units. Tables 4.8 to 4.13 indicate exposure time less than 10 ms accuracy
results
Table 4.8: Results of accuracy of exposure time less than 10 ms for X-ray unit at
Clinic Ste Anne
Set Time Measured Time Average time Deviation

(ms) (ms) (ms) (%)
7.67 7.02 7.23 6.81 7.02 8.47

8.63 8.19 8.55 8.93 8.56 0.85
9.72 9.02 8.98 9.05 9.02 7.24
CNHU

(ms) (ms) (ms) (%)
2.50 2.51 2.48 2.55 2.51 0.53

6.30 6.01 6.04 5.97 6.01 4.66
8.00 8.03 8.01 8.06 8.03 0.42
HZ-Porto Novo

(ms) (ms) (ms) (%)
2.5 2.52 2.58 2.47 2.52 0.93

5 5.01 5.03 4.98 5.01 0.13
8 8.04 8.03 8.06 8.04 0.54
40
Clinic Roseraie
(ms) (ms) (ms) (%)
2.50 2.02 2.08 1.97 2.02 19.07

5.00 4.41 4.62 4.51 4.51 9.73
9.00 8.52 8.47 8.58 8.52 5.30
Clinic Senande

(ms) (ms) (ms) (%)
5.00 5.03 4.9 5.17 5.03 0.67

7.00 6.03 6.09 5.98 6.03 13.81
9.00 8.02 8.09 7.95 8.02 10.89
CHU-Suru Léré

(ms) (ms) (ms) (%)
4.00 4.00 4.03 3.98 4.00 0.08

6.30 6.51 6.48 6.53 6.51 3.28
8.00 8.00 8.02 7.99 8.00 0.04
41
4.1.2.2 Results of accuracy of exposure time greater than 10 ms
The test was performed at constant kVp, 60 kVp for one hospital and 80 for the other
facilities. Tables 4.14 to 4.19 indicate exposure time greater than 10 ms accuracy
results
Table 4.14: Results of accuracy of exposure time greater than 10 ms for X-ray unit at
Clinic Ste Anne

(ms) (ms) (ms) (%)
50.00 56.18 56.11 56.26 56.18 12.37

100.00 123.93 124.2 123.66 123.93 23.93
140.00 167.61 169 166.22 167.61 19.72
CNHU

(ms) (ms) (ms) (%)
40.00 39.63 39.70 39.57 39.63 0.92

80.00 80.31 80.57 80.06 80.31 0.39
100.00 99.88 99.87 100.1 99.95 0.05
Clinic Roseraie

(ms) (ms) (ms) (%)
20.00 19.58 19.64 19.53 19.58 2.08

40.00 40.16 40.09 40.23 40.16 0.40
80.00 79.82 78.89 80.75 79.82 0.23
42
Table 4.17: Accuracy of exposure time greater than 10 ms for X-ray unit at Clinic
Senande

(ms) (ms) (ms) (%)
22.00 22.1 22.05 22.07 22.07 0.33

74.00 25.10 25.05 25.16 25.10 66.08
132.00 29.60 29.72 29.49 29.60 77.57
Table 4.18: Accuracy of exposure time greater than 10 ms for X-ray unit at HZ-Porto
Novo

(ms) (ms) (ms) (%)
20.00 20.08 20.10 20.17 20.12 0.58

50.00 49.67 49.80 49.55 49.67 0.65
100.00 99.45 99.36 99.28 99.36 0.64
Table 4.19: Accuracy of exposure time greater than 10 ms for X-ray unit at CHU-Suru
Léré

(ms) (ms) (ms) (%)
20.00 20.06 20.07 20.09 20.07 0.37

40.00 40.21 40.12 40.16 40.16 0.41
80.00 79.80 79.77 79.84 79.80 0.25
43
4.1.3 Results of reproducibility of kVp, exposure time end dose output
Constant kVp and 20 mAs was used to perform reproducibility tests. 60 kVp was
used at clinic Ste Anne and 80 for the others X-ray units. 100 ms was used for the
exposure time reproducibility except for CS-Mènontin and Clinic Senande
4.1.3.1 Results of kilovoltage peak reproducibility
Tables 4.20 to 4.26 indicate results of kVp reproducibility of the seven x-ray units
Table 4.20: Results of kVp Table 4.21: Results of kVp
reproducibility for X-ray unit at reproducibility for X-ray unit at
Clinic Ste Anne CNHU
Deviation Deviation
Measured kVp (M) from Measured kVp (M) from
mean (%) mean (%)
M1 58.83 0.32 M1 79.74 0.32

M2 58.87 0.56 M2 79.04 0.56
M3 58.86 0.00 M3 79.48 0.00
M4 58.92 0.48 M4 79.86 0.48
M5 58.93 0.38 M5 79.78 0.38
M6 59.11 0.70 M6 78.92 0.70
M7 59.01 0.30 M7 79.24 0.30
M8 59.04 0.03 M8 79.50 0.03
M9 58.92 0.14 M9 79.59 0.14
M10 58.93 0.19 M10 79.63 0.19
Mean 58.94 Mean 79.48
𝑺𝑫𝒙 𝟎. 𝟎𝟖𝟕 𝑺𝑫𝒙 𝟎. 𝟑𝟐
𝑪𝑽𝒙 (%) 𝟎. 𝟏𝟓 𝑪𝑽𝒙 (%) 𝟎. 𝟒𝟎
44
Clinic Roseraie Clinic Senande
Deviation Deviation
mean (%) mean (%)
M1 79.73 0.11 M1 72.89 0.75

M2 79.69 0.07 M2 72.75 0.94
M3 79.56 0.10 M3 72.87 0.77
M4 79.64 0.00 M4 73.01 0.59
M5 79.67 0.04 M5 72.80 0.87
M6 79.56 0.10 M6 75.15 2.32
M7 79.58 0.08 M7 75.21 2.41
M8 79.66 0.03 M8 74.96 2.07
M9 79.68 0.04 M9 72.70 1.01
M10 79.68 0.05 M10 72.06 1.88
Mean 79.64 Mean 73.44
𝑺𝑫𝒙 𝟎. 𝟎𝟔 𝑺𝑫𝒙 𝟏. 𝟏𝟖
𝑪𝑽𝒙 (%) 𝟎. 𝟎𝟕 𝑪𝑽𝒙 (%) 𝟏. 𝟔𝟎
45
reproducibility for X-ray unit at CS- reproducibility for X-ray unit at HZ-
Mènontin Porto Novo
Deviation Deviation
mean (%) mean (%)
M1 74.24 1.82 M1 80.02 0.06

M2 75.11 0.67 M2 80.19 0.15
M3 75.77 0.20 M3 80.09 0.03
M4 75.85 0.31 M4 80.02 0.06
M5 76.10 0.63 M5 80.12 0.06
M6 75.77 0.20 M6 80.05 0.02
M7 75.79 0.22 M7 80.04 0.04
M8 75.86 0.31 M8 80.04 0.04
M9 75.83 0.28 M9 80.04 0.04
M10 75.92 0.39 M10 80.08 0.01
Mean 75.62 Mean 80.07
𝑺𝑫𝒙 𝟎. 𝟓𝟓 𝑺𝑫𝒙 𝟎. 𝟎𝟓
𝑪𝑽𝒙 (%) 𝟎. 𝟕𝟐 𝑪𝑽𝒙 (%) 𝟎. 𝟎𝟕
46
Table 4.26: Results of kVp
reproducibility for X-ray unit at
CHU-Suru Lere
Deviation
Measured kVp (M) from
mean (%)
M1 80.91 0.26
M2 80.93 0.29
M3 80.46 0.30
M4 80.45 0.31
M5 80.41 0.36
M6 81.30 0.74
M7 81.19 0.61
M8 80.77 0.09
M9 80.39 0.39
M10 80.18 0.64
Mean 80.70
𝑺𝑫𝒙 𝟎. 𝟑𝟖
𝑪𝑽𝒙 (%) 𝟎. 𝟒𝟕
47
4.1.3.2 Results of exposure time reproducibility
Tables 4.27 to 4.33 indicate results of exposure time reproducibility of the seven x-ray
units
Table 4.27: Results of exposure time Table 4.28: Results of exposure time
Measured time (M) Deviation Measured time (M) Deviation

from from
(ms) mean (%) (ms) mean (%)
M1 123.97 0.07 M1 99.8800 0.0030

M2 123.95 0.09 M2 99.8795 0.0034
M3 123.93 0.10 M3 99.8800 0.0030
M4 123.97 0.07 M4 99.8897 0.0068
M5 123.97 0.07 M5 99.8800 0.0030
M6 124.49 0.35 M6 99.8795 0.0034
M7 123.97 0.07 M7 99.8897 0.0068
M8 124.49 0.35 M8 99.8804 0.0025
M9 123.95 0.09 M9 99.8800 0.0029
M10 123.93 0.10 M10 99.8900 0.0071
Mean 124.06 Mean 99.8829
𝑺𝑫𝒙 𝟎. 𝟐𝟑 𝑺𝑫𝒙 𝟎. 𝟎𝟎𝟒𝟖
𝑪𝑽𝒙 (%) 𝟎. 𝟏𝟖 𝑪𝑽𝒙 (%) 𝟎. 𝟎𝟎𝟒𝟖
48

from from
M1 99.86 0.29 M1 142.52 0.25

M2 99.38 0.19 M2 143.04 0.11
M3 99.88 0.31 M3 142.52 0.25
M4 99.36 0.21 M4 143.03 0.10
M5 99.36 0.21 M5 144.05 0.82
M6 99.35 0.22 M6 142.52 0.25
M7 99.39 0.18 M7 142.52 0.25
M8 99.89 0.32 M8 143.03 0.10
M9 99.88 0.30 M9 143.04 0.11
M10 99.39 0.18 M10 142.52 0.25
Mean 99.58 Mean 142.88
𝑺𝑫𝒙 𝟎. 𝟐𝟔 𝑺𝑫𝒙 𝟎. 𝟒𝟗
𝑪𝑽𝒙 (%) 𝟎. 𝟐𝟔 𝑪𝑽𝒙 (%) 𝟎. 𝟑𝟒
49

from from
M1 84.83 0.25 M1 99.36 0.47

M2 84.31 0.36 M2 99.86 0.03
M3 84.81 0.22 M3 99.89 0.06
M4 84.83 0.25 M4 99.88 0.05
M5 84.30 0.38 M5 99.89 0.06
M6 84.80 0.22 M6 99.86 0.03
M7 84.31 0.37 M7 99.89 0.06
M8 84.82 0.24 M8 99.87 0.04
M9 84.83 0.25 M9 99.88 0.05
M10 84.31 0.36 M10 99.88 0.05
Mean 84.62 Mean 99.83
𝑺𝑫𝒙 𝟎. 𝟐𝟕 𝑺𝑫𝒙 𝟎. 𝟏𝟔
𝑪𝑽𝒙 (%) 𝟎. 𝟑𝟏 𝑪𝑽𝒙 (%) 𝟎. 𝟏𝟔
50
Table 4.33: Results of exposure time
CHU-Suru Lere
Measured time (M) Deviation

from
(ms) mean (%)
M1 100.39 0.16
M2 99.89 0.34
M3 99.89 0.34
M4 100.39 0.16
M5 100.36 0.13
M6 100.34 0.11
M7 100.39 0.16
M8 100.38 0.15
M9 100.39 0.16
M10 99.89 0.34
Mean 100.23
𝑺𝑫𝒙 𝟎. 𝟐𝟒
𝑪𝑽𝒙 (%) 𝟎. 𝟐𝟒
51
4.1.3.3 Results of dose output reproducibility
Tables 4.34 to 4.40 indicate results of dose output reproducibility of the seven x-ray
units
Table 4.34: Results of dose output Table 4.35: Results of dose output
Measured dose (M) Deviation Measured dose (M) Deviation

from from
(mGy) mean (%) (mGy) mean (%)
M1 0.697 0.145 M1 0.787 0.481

M2 0.695 0.205 M2 0.792 0.106
M3 0.696 0.010 M3 0.790 0.169
M4 0.695 0.161 M4 0.797 0.769
M5 0.697 0.126 M5 0.794 0.395
M6 0.695 0.214 M6 0.787 0.481
M7 0.696 0.040 M7 0.787 0.481
M8 0.697 0.145 M8 0.790 0.169
M9 0.696 0.010 M9 0.794 0.395
M10 0.695 0.214 M10 0.792 0.106
Mean 0.696 Mean 0.791
𝑺𝑫𝒙 𝟎. 𝟎𝟎𝟏 𝑺𝑫𝒙 𝟎. 𝟎𝟎𝟑
𝑪𝑽𝒙 (%) 𝟎. 𝟏𝟓𝟎 𝑪𝑽𝒙 (%) 𝟎. 𝟒𝟑𝟐
52
Table 4.36: Results dose output Table 4.37: Results of dose output

from from
M1 1.281 0.148 M1 1.121 1.634

M2 1.281 0.133 M2 1.155 1.279
M3 1.283 0.016 M3 1.164 2.123
M4 1.283 0.001 M4 1.121 1.662
M5 1.282 0.077 M5 1.143 0.301
M6 1.282 0.104 M6 1.149 0.787
M7 1.285 0.185 M7 1.121 1.662
M8 1.281 0.132 M8 1.121 1.634
M9 1.283 0.001 M9 1.155 1.279
M10 1.285 0.185 M10 1.149 0.787
Mean 1.283 Mean 1.140
𝑺𝑫𝒙 𝟎. 𝟎𝟎𝟐 𝑺𝑫𝒙 𝟎. 𝟎𝟏𝟕
𝑪𝑽𝒙 (%) 𝟎. 𝟏𝟐𝟑 𝑪𝑽𝒙 (%) 𝟏. 𝟒𝟗𝟎
53
Table 4.38: Results of dose output Table 4.39: Results of dose output

from from
M1 0.604 0.144 M1 0.971 0.080

M2 0.603 0.031 M2 0.970 0.132
M3 0.602 0.122 M3 0.971 0.006
M4 0.601 0.257 M4 0.972 0.037
M5 0.603 0.025 M5 0.972 0.043
M6 0.601 0.394 M6 0.971 0.024
M7 0.612 1.418 M7 0.972 0.042
M8 0.601 0.276 M8 0.972 0.053
M9 0.602 0.243 M9 0.972 0.029
M10 0.601 0.257 M10 0.972 0.025
Mean 0.603 Mean 0.971
𝑺𝑫𝒙 𝟎. 𝟎𝟎𝟑 𝑺𝑫𝒙 𝟎. 𝟎𝟎𝟏
𝑪𝑽𝒙 (%) 𝟎. 𝟓𝟐𝟒 𝑪𝑽𝒙 (%) 𝟎. 𝟎𝟔𝟏
54
Table 4.40: Results of dose output
CHU-Suru Lere
Measured dose (M) Deviation

from
(mGy) mean (%)
M1 0.8882 0.0281
M2 0.8888 0.0472
M3 0.8887 0.0353
M4 0.8878 0.0723
M5 0.8885 0.0142
M6 0.8876 0.0878
M7 0.8883 0.0065
M8 0.8885 0.0142
M9 0.8885 0.0142
M10 0.8885 0.0142
Mean 0.8884
𝑺𝑫𝒙 𝟎. 𝟎𝟎𝟎𝟒
𝑪𝑽𝒙 (%) 𝟎. 𝟎𝟒𝟒𝟒
55
4.1.4 Results of X-ray beam filtration (HVL) tests
HVL was measured at 20 mAs. Tables 4.41 to 4.47 indicate X-ray beam filtration
quality control test results.
Table 4.41: HVL for X-ray unit at Clinic Ste Anne
kVp designed Operating HVL Measured Mean HVL

operating range potential (mm Al) (mm Al)
40 1.4 1.5 1.6 1.5
𝐤𝐕𝐩 < 𝟓𝟏
50 1.8 1.7 1.9 1.8
60 2.1 2.2 2.1 2.1
𝟓𝟏 ≤ 𝐤𝐕𝐩 ≤ 𝟕𝟎
70 2.4 2.4 2.5 2.4
80 3.0 2.9 2.9 2.9
𝐤𝐕𝐩 > 𝟕𝟎
90 3.3 3.2 3.0 3.2
Table 4.42: HVL for X-ray unit at CNHU

40 1.2 1.4 1.3 1.3
𝐤𝐕𝐩 < 𝟓𝟏
50 1.8 2.1 1.9 1.9
60 2.3 2.2 2.4 2.3
𝟓𝟏 ≤ 𝐤𝐕𝐩 ≤ 𝟕𝟎
70 2.7 2.7 2.7 2.7
80 3.1 3.1 3.3 3.2
𝐤𝐕𝐩 > 𝟕𝟎
90 3.5 3.6 3.5 3.5
Table 4.43: HVL for X-ray unit at Clinic Roseraie

40 1.3 1.2 1.3 1.3
𝐤𝐕𝐩 < 𝟓𝟏
50 1.8 1.9 1.9 1.9
60 1.9 2.3 2.3 2.2
𝟓𝟏 ≤ 𝐤𝐕𝐩 ≤ 𝟕𝟎
70 2.5 2.5 2.4 2.5
80 3.1 2.9 3 3.0
𝐤𝐕𝐩 > 𝟕𝟎
90 3.5 3.4 3.4 3.4
56
Table 4.44: HVL for X-ray unit at Clinic Senande

40 0.9 1.0 1.0 1.0
𝐤𝐕𝐩 < 𝟓𝟏
50 1.9 1.8 1.7 1.8
60 2.0 1.9 2.3 2.1
𝟓𝟏 ≤ 𝐤𝐕𝐩 ≤ 𝟕𝟎
70 2.3 2.3 2.4 2.3
80 2.7 2.5 2.6 2.6
𝐤𝐕𝐩 > 𝟕𝟎
90 2.9 2.9 2.9 2.9
Table 4.45: HVL for X-ray unit at CS-Mènontin

40 1.4 1.6 1.4 1.5
𝐤𝐕𝐩 < 𝟓𝟏
50 2.4 2.2 2.4 2.3
60 2.7 2.7 2.7 2.7
𝟓𝟏 ≤ 𝐤𝐕𝐩 ≤ 𝟕𝟎
70 3.3 3.1 3.2 3.2
80 3.5 3.6 3.6 3.6
𝐤𝐕𝐩 > 𝟕𝟎
90 4.0 3.9 4.0 4.0
Table 4.46: HVL for X-ray unit at HZ-Porto Novo

40 1.5 1.5 1.5 1.5
𝐤𝐕𝐩 < 𝟓𝟏
50 2.2 2.1 2.3 2.2
60 2.4 2.6 2.5 2.5
𝟓𝟏 ≤ 𝐤𝐕𝐩 ≤ 𝟕𝟎
70 3.1 2.9 3.1 3.0
80 3.5 3.4 3.3 3.4
𝐤𝐕𝐩 > 𝟕𝟎
90 3.9 3.8 3.9 3.9
57
Table 4.47: HVL for X-ray unit at CHU-Suru Lere

40 1.5 1.6 1.5 1.5
𝐤𝐕𝐩 < 𝟓𝟏
50 2.2 2.1 2.3 2.2
60 2.6 2.8 2.6 2.6
𝟓𝟏 ≤ 𝐤𝐕𝐩 ≤ 𝟕𝟎
70 3.1 2.9 3.0 3.0
80 3.5 3.4 3.5 3.5
𝐤𝐕𝐩 > 𝟕𝟎
90 3.9 4.0 4.0 4.0
58
4.1.5 Results of Specific dose-kVp2 linearity tests
Figures 4.1 to 4.7 indicate the results of specific dose-kVp2 linearity tests for the
seven X-ray units.
Figure 4.1: Specific dose versus kVp2 for X-ray unit at Clinic Ste Anne
Figure 4.2: Specific dose versus kVp2 for X-ray unit at CNHU
59
Figure 4.3: Specific dose versus kVp2 for X-ray unit at Clinic Roseraie
Figure 4.4: Specific dose versus kVp2 for X-ray unit at Clinic Senande
60
Figure 4.5: Specific dose versus kVp2 for X-ray unit at CS-Mènontin
Figure 4.6: Specific dose versus kVp2 for X-ray unit at HZ-Porto Novo
61
Figure 4.7: Specific dose versus kVp2 for X-ray unit at CHU-Suru Lere
4.1.6 Results of Specific dose-mAs linearity tests
The tests were performed at constant kVp. 60 kVp was used for clinic Ste Anne and 80
kVp for the other X-ray units. Tables 4.48 to 4.54 indicate results of specific dose-
mAs linearity quality control tests.
Table 4.48: Results of specific dose-mAs linearity for X-ray unit at Clinic Ste Anne
Dose Specific dose

Set mAs Linearity coefficient (10-2)
(mGy) (10-1mGy/mAs)
2.50 0.08 0.34 0.25
50.00 0.17 0.33 0.06
10.00 0.33 0.33 0.19
20.00 0.67 0.33 0.10
32.00 1.07 0.33 0.06
40.00 1.34 0.33 -
62
Table 4.49: Results of specific dose-mAs linearity for X-ray unit at CNHU
Dose Specific dose

(mGy) (10-1mGy/mAs)
5.00 0.31 0.61 0.97
10.00 0.63 0.63 0.08
16.00 1.00 0.62 0.16
20.00 1.24 0.62 1.89
22.00 1.42 0.65 1.25
25.00 1.57 0.63 -
Table 4.50: Results of specific dose-mAs linearity for X-ray unit at Clinic Roseraie
Dose Specific dose

(mGy) (10-1mGy/mAs)
2.50 0.16 0.63 0.71
5.00 0.32 0.64 0.39
10.00 0.65 0.65 0.23
16.00 1.03 0.64 0.08
20.00 1.29 0.64 0.31
28.00 1.79 0.64 -
Table 4.51: Results of specific dose-mAs linearity for X-ray unit at Clinic Senande
Dose Specific dose

(mGy) (10-1mGy/mAs)
2.50 0.12 0.49 0.10
5.00 0.24 0.48 0.52
10.00 0.48 0.48 2.90
15.00 0.68 0.45 1.91
20.00 0.87 0.44 2.89
28.00 1.29 0.46 -
63
Table 4.52: Results of specific dose-mAs linearity for X-ray unit at at CS-Mènontin
Dose Specific dose

(mGy) (10-1mGy/mAs)
2.50 0.06 0.25 5.28
5.00 0.14 0.28 2.46
10.00 0.29 0.29 1.02
16.00 0.47 0.30 1.50
20.00 0.61 0.31 0.16
25.00 0.76 0.30 -
Table 4.53: Results of specific dose-mAs linearity for X-ray unit at HZ-Porto Novo
Dose Specific dose

(mGy) (10-1mGy/mAs)
2.50 0.12 0.48 1.15
5.00 0.24 0.49 0.41
10.00 0.49 0.49 0.10
16.00 0.79 0.49 0.00
20.00 0.98 0.49 0.00
25.00 1.23 0.49 -
Table 4.54: Results of specific dose-mAs linearity for X-ray unit at CHU-Suru Lere
Dose Specific dose

(mGy) (10-1mGy/mAs)
2.50 0.11 0.45 0.90
5.00 0.22 0.44 0.57
10.00 0.44 0.44 0.11
16.00 0.70 0.44 0.00
20.00 0.87 0.44 0.00
25.00 1.09 0.44 -
64
4.1.7 Results of leakage of X-ray tube housing tests
For all the five X-ray units involved in the leakage test, 80 kVp was used to perform
the tests. The mAs was set to be 63 at CNHU and 60 for the others X-ray units. Leakage
radiation was measured in μSv/h. Background dose rate was 0.05 μSv/h except at
HZ-Porto Novo and CHU-Suru Lere where it was 0.06 μSv/h
Table 4.55: Results of leakage of X-ray tube housing for X-ray unit at CNHU, Clinic
Roseraie, Clinic Senande, HZ-Porto Novo and CHU-Suru Lere
Dose rate (μSv/h)

X-ray units
Front behind Right Left Top
CNHU 0.155 1.030 1.850 3.235 1.125
Clinic Roseraie 0.830 0.075 2.045 1.010 0.055
Clinic Senande 5.240 5.990 1.515 23.240 1.250
HZ-Porto Novo 0.060 0.050 0.060 0.450 0.060
CHU-Suru Lere 0.050 0.050 0.050 0.430 0.050
65
4.1.8 Results of X-ray beam alignment tests
Figure 4.8 to 4.13 indicate the results of beam alignment tests.
Figure 4.8: Results of X-ray beam Figure 4.10: Results of X-ray beam
alignment test for X-ray unit at alignment test for X-ray unit at Clinic
Clinic Ste Anne Roseraie
alignment test for X-ray unit at alignment test for X-ray unit at Clinic
CNHU Senande
66
alignment test for X-ray unit at CS- alignment test for X-ray unit at CHU-
Mènontin Suru Lere
Figure 4.13: Results of X-ray beam

alignment test for X-ray unit at HZ-
Porto Novo
67
4.2 Entrance surface dose results
4.2.1 Diagnostic radiography X-ray equipment dose output
Figures 4.15 to 4.21 indicates the results of the seven X-ray units dose output curve
Figure 4.15: Specific dose output versus kVp for X-ray unit at Clinic Ste Anne
Figure 4.16: Specific dose output versus kVp for X-ray unit at CNHU
68
Figure 4.17: Specific dose output versus kVp for X-ray unit at Clinic Roseraie
Figure 4.18: Specific dose output versus kVp for X-ray unit at Clinic Senande
69
Figure 4.19: Specific dose output versus kVp for X-ray unit at CS-Mènontin
Figure 4.20: Specific dose output versus kVp for X-ray unit at HZ-Porto Novo
70
Figure 4.21: Specific dose output versus kVp for X-ray unit at CHU-Suru Lere
71
4.2.2 Exposure factors (kVp, mAs), FDD and patient thickness
Table 4.56 below shows information obtained from radiographers at each Radiology
Department.
Table 4.56: Frequently used exposure factors and FDD for radiography projection
Departmen
Factors Projections
Radiology
&
t
Chest PA Abdomen Pelvis Skull Lumber Foot

FDD AP AP AP Spine AP AP
kVp 109-125 75-96 70-96 70-77 75-96 60-66
Clinic Ste
Anne
mAs 10-20 25-45 25-40 16-25 25-45 2.5-7
FDD 200 100 100 100 100 100
kVp 115-125 75-100 65-100 70-95 70-100 47-55

CNHU
mAs 10-20 40-90 40-80 40-80 50-160 6.3-10
FDD 180 100 100 100 100 100
kVp 100-105 65-75 70-75 70-75 70-75 45-60

Roseraie
Clinic
mAs 10-14 72-90 90-106 90-100 90-126 32-36
FDD 180 100 100 100 100 100
kVp 70-90 80-100 80-90 70-80 80-95 50-60

Senande
Clinic
mAs 50-70 50-85 50-70 30-60 60-85 4-10
FDD 180 100 100 100 100 100
kVp 120 90-94 75-84 85-90 78-85 60-65

Mènontin
mAs 10-14 63-80 50-56 50-63 45-80 10-18
FDD 180 100 100 100 100 100
kVp 104-112 72-78 72-77 70-72 75-90 51-53

HZ-Porto
Novo
mAs 4-12 50-80 32-64 16-25 50-80 3.2-4
FDD 180 100 100 100 100 100
kVp 110-115 70-80 70-85 65-70 70-85 50-55

CHU- Suru
Lere
mAs 3.2-6.3 32-50 32-63 12.5-16 32-63 4-5
FDD 180 100 100 100 100 100
72
The table 4.57 below indicates the thickness of patients obtained.
Table 4.57: Patient thickness
Patient thickness
Projection Range Mean SD
Chest PA 19.50 - 26.00 22.75 1.20
Abdomen AP 21.00 - 26.00 23.50 1.60
Pelvis AP 20.00 - 26.00 23.00 1.80
Skull AP 17.00 – 23.00 20.00 0.90
Lumber Spine
21.00 - 26.00 23.50 1.60
AP
Foot AP 7.00 - 9.00 8.00 0.50
4.2.3 Estimated entrance surface dose
Tables 4.48 to 4.64 show the results of estimated entrance surface dose.
Table 4.58: Estimated entrance surface dose for Clinic Ste Anne
Chest Abdomen Pelvis Skull Lumber
Projection Foot AP
PA AP AP AP Spine AP
Mean kVp 117.0000 85.5000 83.0000 73.5000 85.5000 63.0000
Mean mAs 15.0000 35.0000 32.5000 20.5000 35.0000 4.7500
Specific Dose
0.1332 0.0702 0.0661 0.0516 0.0702 0.0376
(mGy/mAs)
FSD (cm) 177.2500 76.5000 77.0000 80.0000 76.5000 92.0000
ESD (mGy) 0.8585 5.6678 4.8914 2.2313 5.6678 0.2849
Error 0.0122 0.2411 0.2321 0.0518 0.2411 0.0033
Table 4.59: Estimated entrance surface dose for CNHU

Projection Foot AP
Mean kVp 120.0000 87.5000 82.5000 82.5000 85.0000 51.0000
Mean mAs 15.0000 65.0000 60.0000 60.0000 105.0000 8.1500
Specific Dose
0.1318 0.0705 0.0627 0.0627 0.0665 0.0242
(mGy/mAs)
FSD (cm) 157.2500 76.5000 77.0000 80.0000 76.5000 92.0000
ESD (mGy) 1.0793 10.5709 8.5659 7.9355 16.1073 0.3146
Error 0.0178 0.4549 0.4108 0.1881 0.6931 0.0038
73
Table 4.60: Estimated entrance surface dose for Clinic Roseraie

Projection Foot AP
Mean kVp 102.5000 70.0000 72.5000 72.5000 72.5000 52.5000
Mean mAs 12.0000 81.0000 98.0000 95.0000 108.0000 34.0000
Specific Dose
0.1017 0.0471 0.0506 0.0506 0.0506 0.0264
(mGy/mAs)
FSD (cm) 157.2500 76.5000 77.0000 80.0000 76.5000 92.0000
ESD (mGy) 0.6663 8.8007 11.2909 10.1398 12.6062 1.4317
Error 0.0104 0.3717 0.5324 0.2322 0.5324 0.0161
Table 4.61: Estimated entrance surface dose for Clinic Senande

Chest Abdomen Pelvis Skull
Lumber Foot
Projection
PA AP AP AP Spine AP AP
55.000
Mean kVp 80.0000 90.0000 85.0000 75.0000 87.5000
0
Mean mAs 60.0000 67.5000 60.0000 45.0000 72.5000 7.0000
Specific Dose
0.0425 0.0591 0.0504 0.0355 0.0546 0.0149
(mGy/mAs)
92.000
FSD (cm) 157.2500 76.5000 77.0000 80.0000 76.5000
0
ESD (mGy) 1.3922 9.2024 6.8855 3.3697 9.1315 0.1664
Errror 0.0217 0.3877 0.3240 0.0768 0.3847 0.0019
Table 4.62: Estimated entrance surface dose for CS-Mènontin

Chest Abdomen Pelvis Skull
Lumber Foot
Projection
PA AP AP AP Spine AP AP
62.500
Mean kVp 120.0000 87.0000 79.5000 87.5000 81.5000
0
14.000
Mean mAs 12.0000 71.5000 53.0000 56.5000 62.5000
0
Specific Dose
0.0597 0.0313 0.0261 0.0317 0.0275 0.0161
(mGy/mAs)
92.000
FSD (cm) 157.2500 76.5000 77.0000 80.0000 76.5000
0
ESD (mGy) 0.3911 5.1625 3.1497 3.7780 3.9648 0.3595
Error 0.0065 0.2227 0.1514 0.0899 0.1710 0.0044
74
Table 4.63: Estimated entrance surface dose for HZ-Porto Novo

Projection Foot AP
Mean kVp 108.0000 75.0000 74.5000 71.0000 82.5000 52.0000
Mean mAs 8.0000 65.0000 48.0000 20.5000 65.0000 3.6000
Specific Dose
0.0966 0.0448 0.0442 0.0399 0.0548 0.0207
(mGy/mAs)
FSD (cm) 157.2500 76.5000 77.0000 80.0000 76.5000 92.0000
ESD (mGy) 0.4219 6.7174 4.8308 1.7254 8.2168 0.1189
Error 0.0066 0.2837 0.2278 0.0395 0.3470 0.0013
Table 4.64: Estimated entrance surface dose for CHU-Suru Lere

Projection Foot AP
Mean kVp 112.5000 75.0000 77.5000 67.5000 77.5000 52.5000
Mean mAs 4.7500 41.0000 47.5000 14.2500 47.5000 4.5000
Specific Dose
0.0882 0.0365 0.0392 0.0290 0.0392 0.0168
(mGy/mAs)
FSD (cm) 157.2500 76.5000 77.0000 80.0000 76.5000 92.0000
ESD (mGy) 0.2287 3.4521 4.2397 0.8717 4.2953 0.1206
Error 0.0035 0.1447 0.1986 0.0197 0.1801 0.0013
75
4.3 DISCUSSION
4.3.1 Discussion based on QC tests results
4.3.1.1 Accuracy of kilovoltage peak
Table 4.65 kVp accuracy

Radiology department kVp deviation range (%) Mean kVp deviation (%)
Clinic Ste Anne 0.94 - 1.43 1.15
CNHU 0.12 - 0.48 0.23
Clinic Roseraie 0.12 - 0.59 0.40
Clinic Senande 5.96 - 11.30 7.76
CS-Mènontin 3.45 - 6.08 4.74
HZ-Porto Novo 0.00 - 0.53 0.26
CHU-Suru Lere 0.13 - 1.45 0.67
The results obtained in assessing the kilovoltage peak accuracy in the seven radiology
departments revealed that five out of the seven diagnostic radiology departments
passed the quality control tests (table 4.65). The kVp deviation range for all kVp
selected for these five departments were far below the 5% limit recommended by
international organizations. These five X-ray units, when efficiently used would
produce the desired good quality X-ray for a given examination. 28.57% of the X-ray
units that were involved in the kVp accuracy tests have all or at least one of their
accuracy deviation values above 5%. Radiographic image contrast may be affected
because selected kVp is no longer the optimum kVp for a specific examination as the
radiographer thought. In Mènontin Hospital, it was found out that as the kVp increased
the deviation also increased and the inaccuracy is mainly observed at high kVp values
above 70 kVp. The minimum deviation calculated represent 69% of required limit.
The mean deviation of all kVp measured in this hospital, represent 94.8% of the
required limit. In clinic Senande, the kVp measurement showed inaccuracy for all kVp.
76
Because of lack of QC equipment, cross check after repair is not possible. It was
proposed to the Radiology Department the use of calibration curve to adjust the kVp
selected between 50 and 90 to the desired one.
Figure 4.22: Clinic Senande kVp calibration curve
Figure 4.23 : CS-Mènontin kVp calibration curve
77
4.3.1.2 Accuracy of exposure time
4.3.1.2.1 Exposure time below 10 ms
Figure 4.24: Comparison of accuracy of exposure time below 10 ms with
recommended limit.
Accuracy of exposure time below 10 ms was investigated for six X-ray units
including the X-ray unit at Clinic Senande where exposure time selection was not
possible. At Senande Radiology Department the control console indicates the exposure
time after exposure. The measurement done with the Piranha multifunction meter was
compared with the exposure time display on the X-ray unit control console. For all
measurements of exposure time below 10 ms, the X-ray units were within required
limit set by Safety Code S.C 35 (figure 4.24). For 66.67% of diagnostic radiology X-
ray units, the AAPM recommended limit was above all measured exposure time
deviation, meaning that in those X-rays units exposure time was accurate according to
78
AAPM standard limit. Two X-ray units present both accuracy and inaccuracy for some
exposure time selected below 10ms.
4.3.1.2.2 Exposure time above 10 ms
Figure 4.25: Comparison of accuracy of exposure above 10 ms with recommended
limit.
Average percentage deviation of exposure time in the different diagnostic
radiology departments showed that 66.67% of the X-ray units passed the quality
control test of exposure time accuracy. The five X-ray units’ average deviation are all
below standards limits recommended by international regulators, such as AAPM (5%),
HARP (10%), and Safety Code S.C35 (10% + 1ms) as indicated in figure 4.25. Two
X-ray units failed the QC test. Clinic Senande, X-ray unit accuracy tests revealed that
exposure time display by the control console was far different from the measured one.
Further investigation is required.
79
4.3.1.3 Reproducibility
4.3.1.3.1 Reproducibility of kilovoltage peak
Figure 4.26: Comparison of kVp coefficient of variation with recommended limit.
For all X-ray units involved in the present study, kilovoltage peak coefficient
of variation ws within standard limit specified by AAPM (5%) as shown in figure 4.26.
Average deviation of each measurement from the mean measurement ranged from
0.06% to 1.36%.This is far below the deviation limit recommended by S.C 35 (15%)
and HARP (20%). All the X-ray units passed the reproducibility tests. This mean that
in all the radiology department kVp can be repeated without any major deviation.
80
4.3.1.3.2 Reproducibility of exposure time
Figure 4.27: Comparison of exposure time coefficient of variation with
recommended limit.
The maximum deviation of each measurement from the mean measurement
value was 0.36% for all X-ray units. It represent 2.4% and 1.8% of limit respectively
recommended by S.C 35 and HARP. In the seven departments of diagnostic radiology,
reproducibility coefficient of variation of exposure time was far below 5% limit
recommended by AAPM (figure 4.27). All the X-ray units successfully passed the
quality control tests in terms of reproducibility of exposure time.
81
4.3.1.3.3 Reproducibility of dose output
Figure 4.28: Comparison of dose output coefficient of variation with recommended
limit.
Dose output reproducibility QC tests revealed that all the X-ray units involved
in the present research work, reproduced dose output within the specified limit
recommended by AAPM and S.C35. Maximum dose output coefficient of variation
recorded was 1.49% (figure 4.28). This value represent 29.8% of AAPM limit.
Deviation between mean dose output calculated and each measured dose output range
from 0.03% to 1.36%. The maximum deviation of measurements from their mean
value is within S.C 35 required limit.
82
4.3.1.4 X-ray bean quality
Figure 4.29: Comparison of measured HVL with recommended minimum HVL.
According to FDA, HVL which determines beam quality should not be below
a specific minimum value of HVL for a given kVp. In the figure 4.29 above, the red
points indicate the minimum values. All average HVL measured at kVp ranging from
40 to 90, for the seven diagnostic X-ray units are above the minimum required value
of FDA. All X-ray units involved in the present study passed successfully the QC
tests of beam quality. Entrance surface dose that a patient received from dose
machine will mainly depend on operator errors for a specific examination because
soft X-rays are efficiently removed from the beam spectrum before they reach the
patient.
83
4.3.1.5 Specific dose-kVp2 linearity
Figure 4.30: Correlation of the specific dose versus kVp2 with linear trendline.
The kVp squared versus specific dose was plotted. Linear trendline was selected to see
how linear the variation of specific dose with kVp square was. For all the seven
diagnostic X-ray units, very high correlation was obtained as indicated figure 4.30.
The square of correlation coefficient ( R2) when taken at two decimal places, is equal
to 1 for all diagnostic radiology X-ray units. This means that variation of specific dose
with kVp square was linear for all kVp selected between 40 and 90. The error on
linearity ranged from 0.01% to 0.18% for all seven X-ray units. Specific dose from
each X-ray unit could be expressed as a linear function of the kVp2.
84
4.3.1.6 Specific Dose- mAs linearity
Figure 4.31: Comparison of specific dose-mAs linearity coefficient with
recommended limit
All 35 linearity coefficients obtained by keeping kVp constant and varying
mAs, are less than 0.1. All seven X-ray units in the diagnostic radiology departments
passed the specific dose-mAs linearity test (figure 4.31). This means that for screen
film system the same density can be achieved if the mAs is kept constant. According
to HARP regulation if linearity does not meet this standard, the unit must be serviced
and retested.
85
4.3.1.7 Leakage of X-ray tube housing
Figure 4.32: Comparison of leakage of X-ray tube housing from the seven X-ray
unit.
Five hospitals were involved in leakage of X-ray tube housing verification. The
highest dose rate at 1m from focal spot was recorded at Clinic Senande at the left side
of the collimator assembly (figure 4.32). This maximum dose rate of 23.24 μSv/h
obtained at 80 kVp and 60 mAs represent 2.32% of the recommended limit if the
measurement was done at the highest kVp (125) and mAs (500) of the X-ray unit at
Clinic Senande. For all other four X-ray units considered for leakage test in the present
study all dose rates recorded from all side of the X-ray units were below 2.5 μSv/h. It
is highly possible that leakage radiation level be below the required limit of 1 mSv/h
if the measurements was done at the highest parameter setting. Operators are safe from
overexposure due to leakage radiation from X-ray tube housing.
86
4.3.1.8 X-ray beam alignment
Figure 4.33: Comparison of X-ray beam misalignment degree with acceptable limit
of 1.5°.
From beam alignment quality control test of the seven X-ray units, 71.43% of the
diagnostic radiography equipment can be considered in the acceptable range of
misalignment. The best beam alignment among the seven units was obtained at the
main public hospital (CNHU) which has the highest workload of about 80 patients a
day. Two X-ray units ( CS-Mènontin and CHU Suru Lere) are out of acceptable range
of misalignment. There was a need to repair. But because of the unavailability of
equipment cross check after repair, maintenance cannot be performed. Staff at those
two hospitals have to work with the image distortion due to misalignment. The highest
misalignment were observed with the digital X-ray unit. This may be caused by the
fact that the leveller indicated some inclination of the image receptor.
87
4.3.2 Discussion based on entrance surface dose estimation
4.3.2.1 Specific dose output curve
The specific dose output curve generated for each X-ray unit, was a power curve that
estimated the dose output per mAs as proportional to a power function of the kVp.
This power curve was confirmed by the correlation coefficient ranging from 99.87%
to 99.99%. Thus from the equations, for any kVp a corresponding specific dose can be
generated to calculate the entrance surface dose with very small error.
Table 4.66: specific dose output function with percentage error.

Diagnostic radiology Equation of specific dose (y) in Percentage
department mGy/mAs (x=kVp) error (%)
Ste Anne 𝒚 = (8 × 10−6 )𝒙2.0411 0.07
CNHU 𝒚 = (10−5 )𝒙1.9815 0.12
−6 )𝒙2.0157
Clinic Roseraie 𝒚 = (9 × 10 0.04
Clinic Senande 𝒚 = (2 × 10−7 )𝒙2.7994 0.03
−6 )𝒙2.0076
CS-Mènontin 𝒚 = (4 × 10 0.13
−6 )𝒙2.1078
HZ-Porto Novo 𝒚 = (5 × 10 0.04
CHU-Suru Lere 𝒚 = (3 × 10−6 )𝒙2.1785 0.01
88
4.3.2.2 Comparison of estimated entrance surface dose with other studies
Figure 4.34 to 4.39 indicate the comparison of ESD with others studies
Figure 4.34: Comparison of Chest PA entrance surface dose [48, 49]
Figure 4.35: Comparison of Abdomen AP entrance surface dose
89
Figure 4.36: Comparison of Pelvis AP entrance surface dose
Figure 4.37: Comparison of Skull AP entrance surface dose
90
Figure 4.38 Comparison of Lumber Spine AP entrance surface dose
Figure 4.39 Comparison of Foot AP entrance surface dose
The chest PA entrance surface dose estimated in the seven radiology
departments involved in the present research work compared with UK, Australia, Taha
et al and Inkoom et al ESD values reveal that higher entrance surface doses are
91
delivered in South of Benin in chest X-ray examination of patients. In clinic Senande
the higher result was due to the fact that the radiographer uses kVp below 100 and
higher mAs for all chest examinations. In the main public hospital, CNHU, where the
workload was the highest, patient doses from chest radiography projection represent
6.75 times the UK ESD value. These higher values were caused by the higher mAs
used by radiographers during chest X-ray examination. For clinic Ste Anne the result
could be attributed to both the large field size and the higher mAs used for chest X-ray
examination. It is urgent for the radiology department to solve the collimator blades
movement to allow X-ray field selection. At CHU-Suru Lere, the selected mAs values
ranged from 3.2-6.3 mAs and the mean entrance surface dose represent 1.63 times the
ESD value from Taha et al and Inkoom et al. This observation showed that patient
dose optimization could be achieved if in the radiography departments mAs was
reduced.
Entrance surface dose estimated for all the six X-ray projections, showed that
the choice of radiographic parameter was the main reason for high ESD value obtained
in some radiology department.
92
CHAPTER FIVE: CONCLUSION AND RECOMMENDATION
5.1 Conclusion
The present study investigated seven diagnostic radiography X-ray machines in South
of Benin, to check compliance of important quality control parameters with standard
requirement and their influence on radiation dose received by patient while undergoing
some radiography examination. All the X-ray machines investigated have shown
acceptable performance for quality control parameters such as accuracy of exposure
time below 10 ms; reproducibility of kVp, exposure time and dose output; specific
dose-kVp square linearity; specific dose-mAs linearity and leakage of X-ray tube
housing. 2/7 of diagnostic X-ray machines failed quality control tests such as X-ray
beam alignment, exposure time above 10 ms and kVp accuracy. Estimated entrance
surface dose revealed that patients received compared with others publication very
high radiation dose in some Benin hospitals for chest PA, skull AP, abdomen AP,
pelvis AP, lumber spine AP and foot AP. The choice of radiographic parameters need
to be improved by radiographers in their effort to optimize patient exposure to ionizing
radiation. The good result obtained in some hospitals can be used as reference in others
radiology departments in the choice of radiographic parameters. It is important that for
each radiology department in Benin a quality assurance programme is established to
ensure that X-ray machines perform satisfactory in service.
93
5.2 Recommendations
5.2.1 Services providers
Management of service providers should
1. Ensure that safe light and door interlock are fixed and functioning
2. Avoid several patients in the examination room, for chest X-ray radiography
3. Keep lead apron as recommended when not in use
4. Establish a local Diagnostic Reference Level (DRL) to improve choice of
radiographic exposure parameters
5. Establish a Quality Assurance Programme to guide the practice of X-ray in their
facilities
6. Perform daily, weekly, monthly, quarterly, and yearly quality control tests to detect
faults as early as possible.
7. For optimization purposes, radiographers should use radiographic parameters ranges
that provide lower average entrance surface dose to patients. For chest PA, abdomen
AP, foot AP and skull AP, radiographic parameter used at CHU-Suru Lere could be
applied to the other centres, if image quality will not be affected. Radiography
performed at CS-Mènontin for pelvis AP and lumber spine AP could be used as an
example in optimizing patient dose in the other radiography departments.
5.2.2 Regulatory body and Benin Ministry of Health
1. Establish policy and regulation for diagnostic radiology practice
2. Perform regular inspection of radiology department to ensure compliance with
regulation
3. Ministry of Health should pay more attention on radiology practice to held in patient
dose optimization through quality assurance programme
94
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99
APPENDIX A
Table A.1: Results of specific dose - kVp2 linearity for X-ray unit at Clinic Ste Anne
Set kVp Measured Specific dose

Dose output (D) 𝒌𝑽𝒑𝟐
kVp (𝑫𝒔 = 𝑫/𝒎𝑨𝒔)
40 39.27 0.23 1541.95 0.0116
50 49.32 0.45 2432.70 0.0224
60 59.01 0.66 3481.78 0.0331
70 69.31 0.92 4803.29 0.0459
80 80.28 1.21 6445.11 0.0607
90 89.63 1.47 8034.40 0.0737
Table A.2: Results of specific dose - kVp2 linearity for X-ray unit at CNHU

40 40.32 0.17 1625.72 0.0084
50 50.02 0.31 2502.35 0.0154
60 59.87 0.46 3584.93 0.0231
70 69.98 0.63 4897.07 0.0314
80 79.98 0.80 6396.74 0.0399
90 90.15 1.02 8126.12 0.0511
Table A.3: Results of specific dose - kVp2 linearity for X-ray unit at Clinic Roseraie

40 39.42 0.23 1553.81 0.0114
50 49.70 0.46 2470.57 0.0229
60 59.66 0.71 3559.86 0.0357
70 69.74 0.98 4863.60 0.0492
80 79.68 1.29 6348.13 0.0643
90 89.90 1.62 8081.69 0.0808
100
Table A.4: Results of specific dose - kVp2 linearity for X-ray unit at Clinic Senande

40 35.96 0.10 1293.35 0.0050
50 47.02 0.28 2210.73 0.0138
60 54.56 0.45 2976.35 0.0223
70 63.97 0.66 4092.73 0.0328
80 72.79 0.87 5298.21 0.0437
90 80.85 1.09 6537.41 0.0545
Table A.5: Results of specific dose - kVp2 linearity for X-ray unit at Clinic CS-
Mènontin

40 39.97 0.10 1597.55 0.0049
50 48.33 0.19 2335.62 0.0094
60 57.60 0.31 3317.24 0.0155
70 66.56 0.45 4430.81 0.0227
80 75.87 0.61 5756.18 0.0304
90 84.55 0.78 7148.70 0.0392
Table A.6: Results of specific dose - kVp2 linearity for X-ray unit at HZ-Porto Novo

40 40.05 0.17 1603.94 0.0087
50 49.91 0.33 2490.86 0.0166
60 60.37 0.53 3644.40 0.0263
70 70.16 0.73 4922.94 0.0367
80 79.96 0.97 6394.25 0.0485
90 90.41 1.24 8174.16 0.0618
101
Table A.7: Results of specific dose - kVp2 linearity for X-ray unit at CHU-Suru Lere

40 40.05 0.17 1603.94 0.0087
50 49.88 0.30 2488.21 0.0149
60 60.41 0.48 3649.06 0.0239
70 70.04 0.67 4906.08 0.0335
80 80.27 0.89 6443.40 0.0444
90 91.14 1.13 8305.94 0.0565
102
APPENDIX B
Table B.1: Results of dose output for X-ray unit at Clinic Ste Anne
Set kVp Set mAs Dose output (D) Specific dose (𝑫𝒔 = 𝑫/𝒎𝑨𝒔)
55 40 1.17 0.029
60 32 1.15 0.036
66 22 0.97 0.044
70 20 1.00 0.050
77 16 0.97 0.061
81 10 0.67 0.067
90 6.3 0.51 0.081
96 4 0.37 0.092
Table B.2: Results of dose output for X-ray unit at CNHU
55 40 1.15 0.029
60 32 1.09 0.034
66 22 0.96 0.044
70 20 0.96 0.048
77 16 0.92 0.058
81 10 0.64 0.064
96 4 0.35 0.089
102 2 0.20 0.098
Table B.3: Results of dose output for X-ray unit at Clinic Roseraie
55 40 1.18 0.029
60 32 1.15 0.036
66 22 0.96 0.044
70 20 0.98 0.049
77 16 0.95 0.060
80 10 0.64 0.064
90 6.4 0.52 0.081
96 4 0.37 0.091
103
Table B.4: Results of dose output for X-ray unit at Clinic Senande
56 40 0.69 0.017
60 35 0.73 0.021
66 25 0.69 0.028
70 20 0.65 0.032
76 15 0.60 0.040
80 10 0.47 0.047
95 4 0.30 0.075
Table B.5: Results of dose output for X-ray unit at CS-Mènontin
55 40 0.54 0.013
60 32 0.51 0.016
70 22 0.50 0.023
80 10 0.29 0.029
90 5 0.18 0.036
Table B.6: Results of dose output for X-ray unit at HZ-Porto Novo
55 32 0.70 0.022
60 25 0.67 0.027
70 20 0.75 0.037
80 16 0.79 0.049
90 8 0.50 0.062
Table B.7: Results of dose output for X-ray unit at CHU-Suru Lere
55 40 0.77 0.019
60 32 0.75 0.024
70 25 0.82 0.033
80 20 0.87 0.044
90 6.3 0.36 0.057
104
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SCHOOL OF NUCLEAR AND ALLIED SCIENCES

ASSESSMENT OF DIAGNOSTIC RADIOGRAPHY PRACTICE IN SOUTH OF

BENIN: APPLICATION OF QUALITY CONTROL PROCEDURES AND

ESTIMATION OF PATIENT ENTRANCE SURFACE DOSE

THESIS PRESENTED TO THE

DEPARTMENT OF MEDICAL PHYSICS,

SCHOOL OF NUCLEAR AND ALLIED SCIENCES

Romeo Tino SOGLO

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

any other degree at another university elsewhere.

TINO ROMEO SOGLO Date

in accordance with guidelines on supervision of thesis laid down by the University of

Dr. STEPHEN INKOOM Date

Dr. FRANCIS HASFORD Date

Dr. EDEM SOSU Date

giving my country opportunity to have qualify human resources.

throughout the course of this research work.

centres for cancer management.

available for data collection.

DEDICATION ........................................................................................................................ iii

TABLE OF CONTENTS ......................................................................................................... v

LIST OF TABLES ................................................................................................................... x

LIST OF FIGURES .............................................................................................................. xvi

CHAPTER ONE ...................................................................................................................... 2

1.1 Background .................................................................................................................. 2

1.2 Objectives .................................................................................................................... 4

1.3 Problem statement ........................................................................................................ 5

1.4 Relevance and Justification.......................................................................................... 5

1.5 Scope and Limitations.................................................................................................. 6

1.6 Organization of thesis .................................................................................................. 6

CHAPTER TWO ..................................................................................................................... 7

LITERATURE REVIEW ........................................................................................................ 7

2.1 X-rays machine and X-ray production ......................................................................... 7

2.2 Overview of quality control of radiography X-ray machine ........................................ 8

2.3.1 Accuracy of loading factors ................................................................................... 14

2.3.2 Radiation Output, kilovoltage peak and exposure time reproducibility................. 15

2.3.3 Radiation Output-mAs linearity ............................................................................. 16

2.3.4 X-ray beam filtration.............................................................................................. 17

2.3.5 X-ray-Light Fields Alignment and beam alignment .............................................. 18

2.3.6 X-ray tube leakage ................................................................................................. 19

2.3.7 Integrity of Protective Equipment .......................................................................... 20

2.4 Entrance surface Dose assessment ............................................................................. 20

2.4.1 Establishment of entrance surface dose. ................................................................ 20

2.4.2 Indirect measurement arrangement for entrance surface dose ............................... 23

CHAPTER THREE ............................................................................................................... 24

3.1 Equipment .................................................................................................................. 24

3.1.1 Diagnostic radiology X-ray machines.................................................................... 24

3.1.2 Radiation detectors................................................................................................. 25

3.1.2.1 Multifunction meter (Piranha) ............................................................................... 25

3.1.2.2 RDS-120 Universal survey meter .......................................................................... 26

3.1.4 Tape measure ......................................................................................................... 27

3.1.5 Lead apron ............................................................................................................. 28

3.1.6 Radiographic X-ray film, cassette and CR plate .................................................... 28

3.2 METHODS ................................................................................................................ 29

3.2.1 Equipment set up for measurement ........................................................................ 29

value layer and dose output.................................................................................................... 29