Recently, the quantity of requests by clinicians for pediatric computed tomography (CT) has elevated, with such requests now representing about 11% of the overall CT examinations which are performed.1 This enhance is probably going associated to the revolutionary CT know-how that has been produced in recent times—notably, helical CT and multislice CT, which offer a better decision and quicker scanning compared to different imaging modalities.1–3 However, the calculated radiation dose required for a single CT examination ranges between 1.0 mSv and 27 mSv,4 which is about 70% increased than the collective dose required by different diagnostic radiation examinations.4 Hence, when present process extra advanced procedures, akin to computed tomography angiography (CTA), pediatric sufferers are uncovered to a better dose of radiation than they might be when present process examinations utilizing different imaging modalities.5
In pediatric CT, most cancers results are the first concern as a result of of the excessive radiation dose related to CT imaging, the higher sensitivity to ionizing radiation inside CT for pediatric sufferers, the sufferers’ longer remaining life span, and the sufferers’ small measurement.6 For pediatric sufferers present process CT, the chance of lifetime radiation-induced most cancers and danger of mortality are increased in contrast with adults as a result of of the upper lifetime danger per unit dose.7 Radiation safety for pediatric sufferers is the primary concern in pediatric CT as a result of their delicate organs, such because the mind and the thyroid glands.5 Accordingly, an optimization of pediatric CT practices is significant to attenuate the radiation dose for this inhabitants.
The optimization of pediatric CT practices is significant to permit radiologists and technologists to make sure affected person security and cut back pointless doses to pediatric sufferers. As such, CT protocols and doses are always being evaluated and reevaluated.6,8,9 The International Atomic Energy Agency (IAEA) has launched tips for performing pediatric CT, to assist radiologists and technologists administer the bottom attainable radiation dose to their sufferers.10,11 The IAEA’s steerage contains performing solely essential pediatric CT examinations, changing CT examinations with these requiring no radiation or a low radiation dose (eg, ultrasound [US] or magnetic resonance imaging [MRI]), using safety gadgets (eg, lead safety), and checking every affected person’s information for earlier examinations. A latest examine at Saudi Arabia investigated the CT doses obtained from mind, chest and stomach examinations collected from three native hospitals, indicated that the technologists present a very good follow and used radiation safety when scanning the sufferers.5
In addition to the IAEA’s steerage, a number of research associated to dose measurements in diagnostic and pediatric CT have been performed in Saudi Arabia;10,11 nonetheless, no examine has but reviewed the analysis practices of radiologists and technologists in pediatric CT in Saudi Arabia.12 Therefore, the intention of this examine is to evaluate the pediatric CT practices of radiologists and technologists in a CT unit.
Materials and Methods
For information assortment, a web-based questionnaire was created utilizing the survey software program QuestionPro. Two totally different surveys have been designed, focusing on radiologists and technologists, respectively, in pediatric CT. The questionnaire adopted the suggestions of the IAEA for lowering pediatric CT doses.12
The questionnaires consisted of 3 sections and 15 questions: 13 have been a number of alternative, whereas 2 have been open-ended questions. The first part requested the individuals’ employment info, together with the identify and area of the hospital at which they have been employed, their job description, and, for the radiologists, their subspecialty (eg, neurology). No figuring out info was requested. The second part associated to the individuals’ common demographic info, akin to their gender, age group, and years of expertise as a radiologist or technologist. The third part included questions referring to the practices the individuals adopted when performing pediatric CT. All information have been inserted and populated right into a Microsoft Excel spreadsheet for evaluation.
The examine was performed amongst 26 hospitals, situated in varied areas in Saudi Arabia. A complete of 200 laborious copies of the questionnaire have been distributed manually and have been collected for evaluation. Emails containing a hyperlink to the questionnaire have been additionally despatched to the individuals. Before distribution, the survey was edited to take away any typographic errors and to reinforce the formatting. The participation interval lasted two months, from April 15, 2021, to the top of July 2021. In complete, 117 accomplished surveys have been gathered from applied sciences, whereas 49 have been gathered from radiologists.
Residency applications from R1-R4, the radiologists, consultants and technologists who labored at CT models.
Technologists who will not be labored at CT models.
Imaging Modalities Criteria Decision and Radiation Protection Protocols
This examine follows the protocols by American College of radiology (ACR)13 for the radiologists and radiation safety in pediatric radiology by worldwide atomic vitality company (IAEA)14 for the technologists as a standards reference. The reader could confer with that papers for additional info.
A descriptive cross-sectional design was adopted for this examine. Descriptive statistics and graphical displays of the survey information have been expressed as frequencies and percentages. Two sorts of checks have been used on this evaluation:
One-Sample Binomial Test (One-Tailed)
This take a look at was used to find out whether or not a sure share considerably exceeded a sure degree, akin to figuring out whether or not the share of individuals who said that they use US/MRI (from query 8 of the radiologist questionnaire) considerably exceeded 50%.
Pearson’s Chi-Squared Test (One-Tailed)
This take a look at was used to find out whether or not the best way during which solutions have been distributed for a sure query differed considerably amongst two classes of individuals (or extra).
In all analyses, p < 0.05 was thought of vital. All statistical analyses have been carried out utilizing the software program Statistical Package for Social Science (SPSS) Statistics, model 22.
The outcomes of this examine have been labeled in keeping with the diagnostic requests ordered by the radiologists for pediatric sufferers and by the present practices the technologists used to attenuate the radiation doses they administered.
Radiologists’ Practices in Pediatric CT
In this examine, the requests by radiologists used to diagnose illnesses amongst pediatric sufferers included head, neck, chest, and stomach scans. In the case of infants with hydrocephalus, 65% of the radiologists ordered a US, 24% ordered a head CT scan, and 10% ordered an MRI and common X-ray for analysis. For pediatric sufferers complaining of persistent headache, 59% and 27% of the radiologists beneficial CT and MRI, respectively, for analysis. US was beneficial by 59% of the radiologists to detect congenital torticollis, exceeding the odds of these recommending different modalities together with X-ray, CT, and MRI. For pediatric sufferers with suspected pleural effusion, the radiologists sought analysis utilizing X-ray (73%) and US (20%) examinations (Table 1).
Table 1 Radiologists’ Responses to the Survey Evaluating Practices in Pediatric CT
For kids with indicators of a choledochal cyst in stomach imaging, most of the radiologists requested a US (90%) for analysis, whereas 10% beneficial different modalities for analysis. For different stomach illnesses, the most typical radiologist advice was a US, being beneficial by 86% of radiologists for diagnosing biliary atresia and by 88% for diagnosing appendicitis or acute stomach ache. Similarly, for intussusception and stomach mass illness, US was mostly beneficial by the radiologists (65%) as the primary method for analysis. For ventriculoperitoneal shunt (VPS) malfunction, the radiologists’ protocols various in relation to the primary method used for analysis: CT was the primary method of 41% of radiologists, adopted by US (33%), X-ray (16%), and MRI (10%) (Table 1).
When analyzing the radiologists’ responses, the one-sample binomial take a look at (one-tailed) confirmed that almost all of the introduced percentages (apart from these of 2 questions) associated to the individuals’ beneficial imaging modality considerably exceeded 50%, with p values of < 0.05. Exceptions to these significant results occurred in the questions related to diagnosing pediatric patients with suspected congenital torticollis and with features of VPS malfunction. Overall, most of the radiologists’ answers indicated that they would utilize the recommended imaging modality for diagnosis. Pearson’s chi-squared test (one-tailed) showed that the radiologists’ responses did not vary significantly across experience levels. However, the percentage of radiologists who stated that they would select the recommended imaging modality was higher (ie, greater than 60%) for those who had > 6 years of expertise in contrast with those that had < 6 years of expertise, for every query (Figure 1).
Figure 1 The expertise ranges of the individuals within the survey, together with these in radiology years R1–R4, radiologists, and consultants.
Technologists’ Practices in Pediatric CT
When requested whether or not they would use the anterior-to-posterior (AP) scout view, lateral scout view, or each scout views for pediatric head CT scans, 23.93% of the technologists opted for the AP view, 34.19% for the lateral view, and 41.88% for each. About 71.8% of the CT technologists indicated that they might make use of affected person sedation for these below the age of 5 years. As half of the radiation safety protocol, 63.25% of the technologists agreed that utilizing a lead apron or radiation safety methodology to guard pediatric sufferers in CT departments is important (Table 1). However, 42.74% responded that they’d no data of bismuth protect utility throughout pediatric CT scanning, whereas 34.19% disagreed that the appliance of a bismuth protect decreases the radiation dose to pediatric sufferers. About 67.52% of the technologists responded that they preserve information of pediatric sufferers’ doses of their CT Departments; these information are reviewed by the radiologists and technologists weekly (22.22% of radiologists and 28.21% of technologists) or yearly (35.90% of radiologists and 29.91% of technologists). By distinction, 27.35% of radiologists and 24.79% of technologists said that they carry out no opinions of affected person dose information at any time within the yr (Table 2).
Table 2 Technologists’ Responses to the Survey Evaluating Practices in Pediatric CT
The one-sample binomial take a look at (one-tailed) confirmed that almost all of the technologists’ responses (apart from the responses to the primary query) mirror the beneficial practices in CT departments, considerably exceeding 50% (with p values < 0.05). Pearson’s chi-squared test (one-tailed) showed that the technologists’ responses did not vary significantly across experience levels. However, the percentage of technologists who stated that they would follow the recommended practices was higher (ie, greater than 60%) for those who had > 6 years of expertise in contrast with those that had < 6 years of expertise, for every query (Figure 2).
Figure 2 The expertise ranges of the technologists who participated within the survey, together with these of their internship yr and people with lower than 1 yr to greater than 10 years of expertise.
The position of radiologists and technologists is significant to lowering the potential radiation hazards in pediatric CT. For instance, when requesting further examinations of pediatric sufferers, radiologists can keep away from exposing sufferers to pointless ionizing radiation by making certain that they choose the beneficial picture modality, which is able to present a very good analysis and remove pointless radiation doses. The outcomes of this examine present that radiologists and technologists do comply with good practices in pediatric CT.
However, the radiologists’ responses associated to move scans (Q1–Q3) indicated that they have an inclination to decide on imaging modalities that aren’t beneficial, akin to CT scans, over different modalities for pediatric instances. For diagnosing hydrocephalus through a head scan, the individuals chosen US as the primary method, adopted by CT. Utilizing CT for preliminary and subsequent assessments of pediatric hydrocephalus could not provide adequate anatomical particulars to assist in neurosurgical administration methods, akin to endoscopic third ventriculostomy (ETV) procedures.15,16 Moreover, evaluating kids with hydrocephalus requires a number of investigations and a long-term follow-up interval to watch shunt perform. Despite that, low-dose CT protocols have been used within the analysis of hydrocephalus to lower dose accumulation, dangerous results on the growing mind, and associated lifetime oncologic dangers that include repeated publicity as a result of a number of examinations.15,16
Radiologic analysis is crucial within the analysis of VPS malfunction. The analysis begins with a plain radiograph to make sure the structural integrity of the shunt catheter. A pediatric head CT scan is usually used to evaluate the rise in ventricular measurement, a sign of VPS malfunction.17 An various methodology for attaining that is MRI, which might present acceptable photographs for diagnosing VPS malfunction in pediatric sufferers.18 Margaret et al instructed that MRI scans must be used extra typically within the analysis of VPS malfunction, as they don’t require radiation publicity, in contrast to CT scans.18 Moreover, if a radiologist should request a CT scan, it is strongly recommended to make use of a restricted 4-slice CT head scan, as this reduces the efficient dose to 87% of the dose required in a full CT scan.17
According to Sarma and Poussaint, non-contrast MRI and CT scans are beneficial in diagnosing persistent headache in pediatric sufferers.19 MRI is the preliminary modality that must be utilized in evaluating most sorts of pediatric headache as a result of of its superior tissue distinction decision, which permits for higher tissue characterization and the detection of small lesions.19 Unlike CT, MRI makes use of electromagnetic radiation, which confers no carcinogenic dangers.20,21 The outcomes of the present examine present that, normally, the radiologists will not be following these suggestions. Most of the radiologists chosen CT as first alternative for diagnosing persistent headache, adopted by MRI. This is probably going as a result of velocity of the scan; as a result of CT scans are comparatively fast, there may be much less want for pediatric sedation. CT can also be clinically helpful for unstable sufferers or sufferers with implanted gadgets akin to cochlear implants.19,22
A retrospective examine by Boyko et al investigated 683 toddler sufferers who have been referred for the administration of torticollis. They beneficial that neither radiography, CT, nor MRI are essential for evaluating torticollis in infants; a medical examination alone is adequate for analysis.23 Applying this examine’s ends in the analysis protocol utilized by radiologists might assist to restrict the publicity of pediatric sufferers to ionizing radiation, as 13 out of 49 responses in our examine (about 27%) instructed utilizing X-ray and CT scans within the analysis course of.
In kids, a chest radiograph can point out the presence of parapneumonic assortment, and it’s subsequently thought of the primary device for evaluating the suitable therapy response. Following the therapy of the parapneumonic effusion (PPE), US is used to substantiate the presence of pleural fluid. CT is a useful gizmo when these much less invasive modalities are inconclusive, but it surely shouldn’t be thought of a routine investigation as a result of related radiation publicity.24,25
In relation to stomach scans, most of the radiologists’ responses on this examine concurred with the literature that US must be the primary method used for diagnosing a choledochal cyst, biliary atresia, intussusception, and an stomach mass.26–35 For pediatric sufferers with suspected appendicitis, the primary method also needs to be US.36 If a radiology report is inconclusive, a US will be adopted up with a CT scan. A CT scan will also be carried out to additional assess the findings of a US or if the pediatric affected person has a physique mass index of > 30.36 However, six radiologists within the present examine said that they would choose an X-ray and CT as their first selections for diagnosing appendicitis, which can lead to pointless radiation doses being administered to pediatric sufferers. In addition, 4% to 16% of the radiologists said that they might make the most of a CT scan as a substitute of a US to diagnose stomach pathologies. Changing these tendencies in diagnostic procedures might lower the publicity of pediatric sufferers to ionizing radiation.
The outcomes from the present examine concurred with the outcomes from D. Kostova-Lefterova and J. Vassileva.3 For each research, the reference standards was based mostly on American school of radiology,13 and the tendencies for the primary method of examination for hydrocephalus, VPS malfunction, pleural effusion and signs of appendicitis have been related (Table 3). However, the Bulgarian examine utilized non-ionized radiation imaging modalities akin to MRI and US as second alternative for pediatric imaging (Table 3).
Table 3 A Comparison Between the Radiologists’ Responses to the Survey Evaluating Practices in Pediatric Imaging Modalities
In CT examinations, the scout view is utilized in kids with suspected shunt malfunction brought on by hydrocephalus, and it ends in no further radiation publicity.37 According to earlier research, the scout view is used for the right planning of CT photographs; clinically, irregular findings are recognizable solely in scout view in about 20% of instances.37,38 Another benefit of scout view is that it will probably present details about pathologies occurring outdoors the area coated by cross-sectional imaging, which is very helpful within the diagnostic comply with up of suspected shunt malfunction.37,39,40 The present examine exhibits that almost all of the technologists surveyed (42%) are making use of the scout view in each the AP and lateral view, broadening their subject of view protection and the medical advantages. However, many research recommend that the lateral scout view alone is adequate to acquire these benefits and cut back the radiation publicity.37,39,40
Pediatric sedation is required throughout a CT examination for infants and youngsters youthful than 5 years outdated to make sure that the picture obtained is of good diagnostic high quality and to lower the presence of movement artefacts.41 The outcomes of this examine exhibit that the technologists comply with the identical methodology throughout CT departments for pediatric instances. However, antagonistic occasions following sedation can happen even when a pediatric anesthesia group is current.42 For instance, pediatric publicity to common anesthesia can have a damaging long-term impact on cognitive growth.43,44 As such, it’s preferable to make the most of CT scanning methods which are quick sufficient that movement artefacts will not be an issue, that permit sufferers to be awake throughout scanning, that permit free respiratory throughout scanning. Currently, two methods permit this stuff: 1) the use of an ultra-high desk pitch (pitch > 3) and a couple of) the use of broad space detectors.41
CT doses for pediatric sufferers will be decreased utilizing bismuth organ shields, notably for anterior organs. These shields are thought of to mitigate the radiation dangers to particular radiosensitive organs. The shields are made of bismuth-impregnated latex, with every protect containing 0.85 to three.4 g/cm of bismuth. They are designed to be positioned over the organ of curiosity (eg, the gonads, thyroids, breasts, or eyes) throughout a CT scan.45–48 In this examine, most of the technologists indicated that they’d a very good degree of data about bismuth protect functions for pediatric sufferers. This data is necessary as a result of, in keeping with Samei, the improper use of a bismuth protect could cause the affected person to be overexposed to radiation.49 Moreover, the quantitative accuracy of the CT quantity will be affected by the shields, particularly within the space closest to the protect. Finally, when a protect is Applied, there’s a chance that some of the dose could possibly be wasted.49
According to the individuals on this examine, most of the sufferers’ dose information are stored by the CT departments and checked month-to-month by the radiologists and technologists. Because some of the hospitals taking part on this examine will not be linked to the central system for dose information, ≤ 38% of the of the survey individuals indicated that they didn’t preserve sufferers’ dose information.
Based on findings from radiologists and technologists, this examine offers suggestions for the use of various, safer imaging modalities, akin to non-ionized radiation US and MRI, as a substitute of CT to scale back the radiation dose given to pediatric sufferers. Following this survey, additional investigation of the precise dose information of pediatric sufferers who’ve undergone widespread pediatric CT is required.
Most of the radiologists make the most of CT head scan to diagnose persistent headache (by 59%) and VPS malfunction (by 41%) in pediatric sufferers in contrast with the opposite modalities. The use of CT can enhance the chance of later malignancy amongst pediatric sufferers as a result of radiation publicity. Alternative imaging modalities akin to US and MRI (non-ionized radiation) must be thought of to scale back the ionizing radiation hazards and optimize the present practices of radiologists. Most of the technologists comply with radiation safety protocols on this examine as 63% of the technologists used lead apron for pediatric affected person’s safety. Radiation consciousness coaching for the technologists might enhance the data about the advantages of utilizing lead apron and cut back the radiation dangers in pediatric sufferers.
This examine was accredited by IRB committee at Imam Abdulrahman bin Faisal college, reference quantity is: IRB-2022-03-036.
The knowledgeable consent was obtained from the examine individuals. All individuals agreed to contribute on the analysis.
This analysis obtained no particular grant from any funding company within the public, business, or not-for-profit sectors.
The authors report no conflicts of curiosity for this work and declare no battle of curiosity in getting ready this text.
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