Understanding Radiation Risk from Diagnostic Imaging

Wednesday, July 23, 200812:00 – 1:00 p.m. EDT

© American Academy of Pediatrics 2008

Moderator: Marlene R. Miller, MD, MSc, FAAPVice President, Quality - NACHRIDirector of Quality and Safety & Associate ProfessorJohns Hopkins Children’s CentersBaltimore, Maryland

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Speaker: Alan S. Brody, MD, FAAPProfessor of Clinical Radiology and PediatricsDivision Chief of Thoracic ImagingAssociate Director of Radiology Research, IRCCincinnati Children’s Hospital Medical CenterCincinnati, Ohio

LEARNING OBJECTIVESUpon completion of the webinar, participants will be able to:

Discuss the radiation risk from CT scanning with patients and families.

Compare the amount of radiation from different ionizing radiation exposures.

List methods that should be used to limit radiation exposure from CT scanning.

Understanding Understanding Radiation Risk From Radiation Risk From Diagnostic ImagingDiagnostic Imaging

Alan S. Brody, MDAlan S. Brody, MDProfessor of Radiology and PediatricsProfessor of Radiology and Pediatrics

Chief, Thoracic ImagingChief, Thoracic Imaging

Cincinnati Children’s HospitalCincinnati Children’s Hospital

DisclosuresDisclosures

I have no financial disclosuresI have no financial disclosures

DisclosuresDisclosures

I have no financial disclosuresI have no financial disclosures

butbut

DisclosuresDisclosures

I have no financial disclosuresI have no financial disclosures

butbut

I use CT scanning in my clinical I use CT scanning in my clinical practicepractice

My research interests include CT My research interests include CT scanning in cystic fibrosis and scanning in cystic fibrosis and interstitial lung diseaseinterstitial lung disease

OverviewOverview

Radiation risk from diagnostic Radiation risk from diagnostic imagingimaging

Benefits of diagnostic imagingBenefits of diagnostic imaging Maximizing the benefit/risk ratioMaximizing the benefit/risk ratio Discussing risk with patients and Discussing risk with patients and

familiesfamilies

Why the Recent Why the Recent Concern?Concern?

Increasing CT ScansIncreasing CT Scans

CT scanning is almost universally CT scanning is almost universally availableavailable

The number of CT scans is increasing The number of CT scans is increasing every yearevery year

Indications for CT use are increasing, Indications for CT use are increasing, and may not consider possible risksand may not consider possible risks

New Risk InformationNew Risk Information

Low dose radiation risk estimates Low dose radiation risk estimates from atomic bomb data are now from atomic bomb data are now available for radiation dose levels available for radiation dose levels similar to the radiation dose from similar to the radiation dose from one CT scanone CT scan

One Paper Started it AllOne Paper Started it All

Estimating Risks of Radiation-Estimating Risks of Radiation-Induced Fatal Cancer from Pediatric Induced Fatal Cancer from Pediatric CTCT– David J. BrennerDavid J. Brenner– Carl D. EllistonCarl D. Elliston– Eric J. HallEric J. Hall– Walter E. BerdonWalter E. Berdon

AJR 2001:176:289-296AJR 2001:176:289-296

CT Scans in Children Linked To CT Scans in Children Linked To Cancer Later Cancer Later

““Each year about 1.6 million children Each year about 1.6 million children in the USA get CT scans to the head in the USA get CT scans to the head and abdomen -- and about 1,500 of and abdomen -- and about 1,500 of those will die later in life from those will die later in life from radiation-induced cancer”radiation-induced cancer”

Steve Sternberg, front page, USA Steve Sternberg, front page, USA Today, January 22, 2001Today, January 22, 2001

American Journal of American Journal of Roentgenology February, 2001Roentgenology February, 2001

One CT scan carries a 1 in 1000 One CT scan carries a 1 in 1000 risk of a fatal cancer risk of a fatal cancer – Brenner, et al.Brenner, et al.

CT dose for children is often higher CT dose for children is often higher than necessarythan necessary– Patterson, et al.Patterson, et al.

Simple methods can decrease CT Simple methods can decrease CT dose for childrendose for children– Donnelly, et. alDonnelly, et. al

Radiation Risk Radiation Risk from from

Diagnostic ImagingDiagnostic Imaging

Ionizing RadiationIonizing Radiation

Radiation capable of producing ionization Radiation capable of producing ionization in tissues and which can be absorbedin tissues and which can be absorbed

Continuously present in our environment Continuously present in our environment – background radiationbackground radiation

Average exposure 3 mSv/year in US, Average exposure 3 mSv/year in US, varies widelyvaries widely– Cosmic rays, radon, radiation from rock, Cosmic rays, radon, radiation from rock,

natural radionuclides natural radionuclides – 4-5 mSv in Denver4-5 mSv in Denver

Ionizing RadiationIonizing Radiation

Used in diagnostic imagingUsed in diagnostic imaging– Radiography, fluoroscopy, angiography, Radiography, fluoroscopy, angiography,

nuclear medicine, CT scanningnuclear medicine, CT scanning Medical radiation is the largest Medical radiation is the largest

source of man-made radiationsource of man-made radiation

Radiation from Radiation from Diagnostic ImagingDiagnostic Imaging

CT Scanning UseCT Scanning Use

From 1991 to 1999 CT scans increased From 1991 to 1999 CT scans increased from 6.1% to 11% of radiology from 6.1% to 11% of radiology procedures in a busy academic centerprocedures in a busy academic center

CT scanning accounted for 67% of the CT scanning accounted for 67% of the effective dose from diagnostic radiologyeffective dose from diagnostic radiology

11% of the patients were less than 1611% of the patients were less than 16

Mettler, J. Radiol. Prot. 20 (2000) 353-359Mettler, J. Radiol. Prot. 20 (2000) 353-359

CT ScanningCT Scanning

2000 – 11% of exams, 67% of dose2000 – 11% of exams, 67% of dose– Mettler, J. Radiol. Prot. 20 (2000) 353-359Mettler, J. Radiol. Prot. 20 (2000) 353-359

2002 – 15% of exams, 75% of dose2002 – 15% of exams, 75% of dose– Weist Semin Ultrasound CT MR. 2002;23:402-10Weist Semin Ultrasound CT MR. 2002;23:402-10

Why Emphasize CT?Why Emphasize CT?

CT provides 75% of the current US CT provides 75% of the current US population radiation exposure from population radiation exposure from diagnostic imagingdiagnostic imaging

CT use continues to growCT use continues to grow

Methods are available to markedly Methods are available to markedly reduce dosereduce dose

Radiation from Diagnostic ImagingRadiation from Diagnostic Imaging

Upper GI series and VCUG have Upper GI series and VCUG have radiation doses similar to CT radiation doses similar to CT scanningscanning

One CT can has the same One CT can has the same radiation dose as about how radiation dose as about how many chest radiographs?many chest radiographs?

1.1. 0.50.5

2.2. 1010

3.3. 5050

4.4. 100100

Estimated Medical Radiation Doses Estimated Medical Radiation Doses for 5 Year-Old Childfor 5 Year-Old Child

Imaging AreaImaging Area

Effective Dose Effective Dose (mSV)(mSV)

EquivalentEquivalent

Number of CXRSNumber of CXRS3-view ankle3-view ankle .0015.0015 1/14th1/14th

2-view chest2-view chest .02.02 11

Anteroposterior and lateral abdomenAnteroposterior and lateral abdomen .05.05 2.52.5

Tc-99mTc-99m22 radionuclide cystogram radionuclide cystogram .18.18 99

Tc-99m radionuclide bone scanTc-99m radionuclide bone scan 6.26.2 310310

FDG PETFDG PET3 scanscan 15.315.3 765765

Upper GI/small bowel follow throughUpper GI/small bowel follow through 11 5050

Head CTHead CT 44 200200

Chest CTChest CT 33 150150

Abdomen CTAbdomen CT 55 250250

CXR, chest radiograph; Tc99m, technetium 99m; FDG PET, fluorodeoxygluecose positron emission tomography.

Data provided by R. Reiman MD. Personal Communication. Duke Office of Radiation Safety. http://www.safety.duke.edu/RadSafety/

Things We Know About Ionizing Things We Know About Ionizing RadiationRadiation

High dose radiation (> 100 mSv) is High dose radiation (> 100 mSv) is known to increase the risk of cancerknown to increase the risk of cancer

Children are at higher risk than Children are at higher risk than adultsadults

Radiation Risk for ChildrenRadiation Risk for Children

Cancer risk increases with Cancer risk increases with decreasing agedecreasing age

The smaller the patient the higher The smaller the patient the higher the exposure from the same the exposure from the same technique technique

Risk is Age DependentRisk is Age Dependent

Cancer risk forCancer risk for

a 4 year old isa 4 year old is

likely 3-5 timeslikely 3-5 times

greater than forgreater than for

a 40 year old a 40 year old

_____ ICRP 60_____ ICRP 60

_ _ _ _ BEIR V_ _ _ _ BEIR V

Dose is Size DependentDose is Size Dependent

Dose in aDose in a

4 year old4 year old

is up to is up to

two timestwo times

higher thanhigher than

in a 40in a 40

year oldyear old

Things We Don’t Know About Things We Don’t Know About RadiationRadiation

How low level radiation (below 100 How low level radiation (below 100 mSv, especially below 10 mSv) mSv, especially below 10 mSv) affects the risk of canceraffects the risk of cancer

Risk from Low Dose RadiationRisk from Low Dose Radiation

The body of literature on low level The body of literature on low level radiation is large and confusing radiation is large and confusing

Data are available to support Data are available to support increased, decreased, or no risk of increased, decreased, or no risk of cancercancer

Few of these data are taken from Few of these data are taken from diagnostic imaging exposurediagnostic imaging exposure

All of the data are open to All of the data are open to interpretationinterpretation

Consensus Statements Consensus Statements on Radiation Riskon Radiation Risk

Biological Effects of Ionizing Radiation Biological Effects of Ionizing Radiation Report VII Report VII

US National Academy of Science US National Academy of Science

“ “A comprehensive review of the A comprehensive review of the available biological and biophysical available biological and biophysical data supports a “linear no threshold” data supports a “linear no threshold” (LNT) risk model-that the risk of cancer (LNT) risk model-that the risk of cancer proceeds in a linear fashion at lower proceeds in a linear fashion at lower doses without a threshold and that the doses without a threshold and that the smallest dose has the potential to smallest dose has the potential to cause a small increase in risk to cause a small increase in risk to humans”humans”

Health Physics SocietyHealth Physics Society

““There is substantial and convincing There is substantial and convincing scientific evidence for health risks scientific evidence for health risks following high-dose exposures. following high-dose exposures. However, below 50-100 mSv, risks of However, below 50-100 mSv, risks of health effects are either too small to health effects are either too small to be observed or are nonexistent” be observed or are nonexistent”

Health Physics SocietyHealth Physics Society

““The Society has concluded that The Society has concluded that estimates of risk should be limited to estimates of risk should be limited to individuals receiving a dose of 50 individuals receiving a dose of 50 mSv in one year or a lifetime dose of mSv in one year or a lifetime dose of 100 mSv in addition to natural 100 mSv in addition to natural background.” background.”

The Definitive StudyThe Definitive Study

The background fatal cancer rate is The background fatal cancer rate is approximately 20% approximately 20%

Assume a 1 in 2000 risk of a fatal Assume a 1 in 2000 risk of a fatal cancer from diagnostic imagingcancer from diagnostic imaging

The study must detect the difference The study must detect the difference between 0.2000 and 0.2005between 0.2000 and 0.2005

Millions of subjects would be neededMillions of subjects would be needed

Land, Science 1980;209:1197-1203Land, Science 1980;209:1197-1203

The Definitive StudyThe Definitive Study

Other methodologies, such as case Other methodologies, such as case control studies, require fewer control studies, require fewer subjectssubjects

These studies are open to additional These studies are open to additional methodological criticismmethodological criticism

A convincing answer is unlikely soonA convincing answer is unlikely soon It is impossible to prove a negativeIt is impossible to prove a negative

Land, Science 1980;209:1197-1203Land, Science 1980;209:1197-1203

I Need a NumberI Need a Number

The most widely used estimate of The most widely used estimate of risk of cancer from ionizing radiation risk of cancer from ionizing radiation is 5% per sievert (Sv).is 5% per sievert (Sv).

Diagnostic imaging doses are in the Diagnostic imaging doses are in the millisievert (mSv) range (5 mSv for millisievert (mSv) range (5 mSv for abdominal CT)abdominal CT)

Risk for 1 CT = 1 in 4,000Risk for 1 CT = 1 in 4,000

What Should We Do?What Should We Do?

Is it reasonable to believe that Is it reasonable to believe that ionizing radiation from diagnostic ionizing radiation from diagnostic

imaging can increase cancer?imaging can increase cancer?

Is it reasonable to believe that Is it reasonable to believe that ionizing radiation from diagnostic ionizing radiation from diagnostic

imaging can increase cancer?imaging can increase cancer?

What is the benefit that What is the benefit that justifies this risk?justifies this risk?

Benefit of CT ScanningBenefit of CT Scanning

CT Alters TreatmentCT Alters Treatment

Children with seizuresChildren with seizures Adults with strokeAdults with stroke Blunt abdominal traumaBlunt abdominal trauma AppendicitisAppendicitis Spine traumaSpine trauma Diffuse lung diseaseDiffuse lung disease

Avoiding SurgeryAvoiding Surgery

29,200 children undergoing general 29,200 children undergoing general anesthesiaanesthesia

95% normal or mild systemic disease95% normal or mild systemic disease

Cohen MM, Anesth Analg 1990;70:160-167Cohen MM, Anesth Analg 1990;70:160-167

Risk of SurgeryRisk of Surgery

29,200 children undergoing general 29,200 children undergoing general anesthesiaanesthesia

95% normal or mild systemic disease95% normal or mild systemic disease 1 in 30 risk of a “major event”1 in 30 risk of a “major event”

Cohen MM, Anesth Analg 1990;70:160-167Cohen MM, Anesth Analg 1990;70:160-167

Risk of SurgeryRisk of Surgery

29,200 children undergoing general 29,200 children undergoing general anesthesiaanesthesia

95% normal or mild systemic disease95% normal or mild systemic disease 1 in 30 risk of a “major event”1 in 30 risk of a “major event” 1 in 2500 risk of death1 in 2500 risk of death

Cohen MM, Anesth Analg 1990;70:160-167Cohen MM, Anesth Analg 1990;70:160-167

Risk of HospitalizationRisk of Hospitalization

33,000,000 hospital admissions 33,000,000 hospital admissions annually in the United Statesannually in the United States

44,000 to 98,000 deaths from 44,000 to 98,000 deaths from medical errorsmedical errors

> 1 in 1000 risk of death from a > 1 in 1000 risk of death from a medical error per hospitalizationmedical error per hospitalization

Kohn, National Academy Press 2000 Kohn, National Academy Press 2000 http://newton.nap.edu/books/0309068371/html/ http://newton.nap.edu/books/0309068371/html/ index.htmlindex.html

If an institution performs 300 CT If an institution performs 300 CT scans per year, the risk benefit scans per year, the risk benefit

equation balances if CT saves one equation balances if CT saves one life every 4 yearslife every 4 years

““a no brainer”a no brainer”

Haaga AJR 2001;177:289-291Haaga AJR 2001;177:289-291

Maximizing the Maximizing the Benefit/Risk RatioBenefit/Risk Ratio

Maximizing the Benefit/Risk RatioMaximizing the Benefit/Risk Ratio

Consider modalities that do not use Consider modalities that do not use ionizing radiationionizing radiation

Optimize imaging protocolsOptimize imaging protocols Decrease unnecessary examinationsDecrease unnecessary examinations ALARAALARA Image qualityImage quality

Is Radiation Necessary?Is Radiation Necessary?

Magnetic resonance imagingMagnetic resonance imaging UltrasoundUltrasound Non-imaging evaluationNon-imaging evaluation

Is Radiation Necessary?Is Radiation Necessary?

Magnetic resonance imagingMagnetic resonance imaging UltrasoundUltrasound Non-imaging evaluationNon-imaging evaluation

Not doing a CT scan reduces the Not doing a CT scan reduces the radiation by 100%radiation by 100%

Maximizing the Benefit/Risk RatioMaximizing the Benefit/Risk Ratio

ALARA (As low as reasonably ALARA (As low as reasonably achievable) CT techniqueachievable) CT technique

Designing imaging protocols to Designing imaging protocols to reduce radiation exposurereduce radiation exposure

Reducing unnecessary imagingReducing unnecessary imaging

CT Scanning and DoseCT Scanning and Dose

Changing CT dose primarily affects Changing CT dose primarily affects images by altering image noiseimages by altering image noise

Higher dose results in decreased Higher dose results in decreased image noiseimage noise

The larger the patient, the higher the The larger the patient, the higher the dose needed to produce the same dose needed to produce the same amount of noiseamount of noise

CT #1

CT #2

Which CT Is Noisier?

#1 #2

#1 Had Twice the Dose of #2

#1 #2

CT #5

CT #6

Which CT Is Noisier?

#5 #6

#5 Had Three Times the Dose of #6

#5 #6

#5 Had Three Times the Dose of #6

21 years old 4 years old

Technique for Technique for High–Resolution High–Resolution

Chest CTChest CT

Weight Weight (kg)(kg)

mAsmAs kVpkVp Slice Slice Interval Interval

(mm)(mm)

1-7.51-7.5 10-2010-20 100100 55

7.5-107.5-10 20-2520-25 100100 7.57.5

10-12.510-12.5 3030 100100 7.57.5

12.5-1512.5-15 2525 120120 1010

15-2015-20 3030 120120 1010

20-2520-25 3535 120120 1010

25-3525-35 4040 120120 1010

35-5035-50 4545 120120 1010

50-7050-70 5050 120120 1010

AdultAdult 100100 120120 1010

Imaging ProtocolsImaging Protocols

Imaging Protocols that Reduce Imaging Protocols that Reduce Radiation ExposureRadiation Exposure

Scan only the area of interestScan only the area of interest Use techniques that require less Use techniques that require less

radiationradiation

6 Year Old, Pulmonary Cavity6 Year Old, Pulmonary Cavity

? Underlying congenital abnormality? Underlying congenital abnormality

CT scan showed no other diseaseCT scan showed no other disease Chest radiograph showed improvementChest radiograph showed improvement CT scan requested to re-evaluateCT scan requested to re-evaluate

6 Year Old, Pulmonary Cavity6 Year Old, Pulmonary Cavity

? Underlying congenital abnormality? Underlying congenital abnormality

CT scan showed no other diseaseCT scan showed no other disease Chest radiograph showed improvementChest radiograph showed improvement CT scan requested to re-evaluateCT scan requested to re-evaluate

Limit CT to upper lobes, avoid thyroidLimit CT to upper lobes, avoid thyroid Use breast shieldsUse breast shields

Pulmonary Embolism Imaging at Pulmonary Embolism Imaging at a Children’s Hospitala Children’s Hospital

Increasing requests for CT pulmonary Increasing requests for CT pulmonary angiograms in children prompted a review angiograms in children prompted a review of imagingof imaging

Most pediatric chest radiographs are Most pediatric chest radiographs are normal or minimally abnormal, decreasing normal or minimally abnormal, decreasing the number of indeterminate ventilation the number of indeterminate ventilation perfusion scansperfusion scans

Additional diagnoses such as heart disease Additional diagnoses such as heart disease and cancer rare in childrenand cancer rare in children

Pulmonary Embolism ImagingPulmonary Embolism Imaging

15% of ventilation perfusion scans 15% of ventilation perfusion scans indeterminateindeterminate

10% of CT pulmonary angiograms 10% of CT pulmonary angiograms technically limitedtechnically limited

Breast dose with CT 30X greater than Breast dose with CT 30X greater than with ventilation/perfusion scanwith ventilation/perfusion scan

Pulmonary Embolism ImagingPulmonary Embolism Imaging

15% of ventilation perfusion scans 15% of ventilation perfusion scans indeterminateindeterminate

10% of CT pulmonary angiograms 10% of CT pulmonary angiograms technically limitedtechnically limited

Breast dose with CT 30X greater than Breast dose with CT 30X greater than with ventilation/perfusion scanwith ventilation/perfusion scan

Perfusion scanning recommended as Perfusion scanning recommended as first study in patients with normal first study in patients with normal CXRsCXRs

Limiting ExaminationsLimiting Examinations

Limiting ExaminationsLimiting Examinations

1/3 of diagnostic examinations in the 1/3 of diagnostic examinations in the United States are estimated to be United States are estimated to be inappropriate or noncontributoryinappropriate or noncontributory

National Imaging Associates web siteNational Imaging Associates web site

6 Year Old, Pulmonary Cavity6 Year Old, Pulmonary Cavity

6 Year Old, Pulmonary Cavity6 Year Old, Pulmonary Cavity

CT scan ordered “just to check”CT scan ordered “just to check” Child doing clinically wellChild doing clinically well No surgery plannedNo surgery planned

CT Scan Cancelled

Pulmonary EmbolismPulmonary Embolism

Deep vein thrombosis on ultrasoundDeep vein thrombosis on ultrasound– Positive in 11 of 15 patients with Positive in 11 of 15 patients with

pulmonary embolismpulmonary embolism D-dimer levelD-dimer level

– Normal in 0 of 10 patients with Normal in 0 of 10 patients with pulmonary embolismpulmonary embolism

– Elevated in 9 of 12 patients without Elevated in 9 of 12 patients without pulmonary embolismpulmonary embolism

Victoria, et al. Society for Pediatric Radiology Victoria, et al. Society for Pediatric Radiology Annual Meeting, Miami, FL USA; 21 April 07Annual Meeting, Miami, FL USA; 21 April 07

CT for Pulmonary EmbolismCT for Pulmonary Embolism

IF D-dimer is negative IF D-dimer is negative oror if if ultrasound is positive, no chest ultrasound is positive, no chest imaging other than chest radiograph imaging other than chest radiograph is neededis needed

GuidelinesGuidelines

Many guidelines are available that Many guidelines are available that include recommendations for include recommendations for imagingimaging

The National Guideline ClearinghouseThe National Guideline Clearinghouse– Worldwide guidelines includedWorldwide guidelines included– Over 2000 guidelinesOver 2000 guidelines– www.guideline.govwww.guideline.gov

Gastroesophageal RefluxGastroesophageal Reflux Upper GI radiation dose approximately Upper GI radiation dose approximately

1.5 mSv1.5 mSv Recommendations of the North American Recommendations of the North American

Society for Pediatric Gastroenterology and Society for Pediatric Gastroenterology and NutritionNutrition

““A thorough history and physical A thorough history and physical examination is generally sufficient to examination is generally sufficient to allow the clinician to establish the allow the clinician to establish the diagnosis of uncomplicated GER (the diagnosis of uncomplicated GER (the ‘happy spitter’).”‘happy spitter’).”

““An upper gastrointestinal series is not An upper gastrointestinal series is not required unless there are signs of required unless there are signs of gastrointestinal obstruction.”gastrointestinal obstruction.”

Image QualityImage Quality

Chest CT RequestChest CT Request

5 yo with chronic cough and failure 5 yo with chronic cough and failure to thriveto thrive

On treatment for gastroesophageal On treatment for gastroesophageal refluxreflux

Fundoplication planned if CT shows Fundoplication planned if CT shows bronchiectasis bronchiectasis

5 Year Old, ? Bronchiectasis

Speaking to Patients Speaking to Patients and Familiesand Families

Speaking to Families and Speaking to Families and PatientsPatients

Participation in medical care should Participation in medical care should include the decision to perform include the decision to perform diagnostic imagingdiagnostic imaging

15% informed of radiation risk of CT15% informed of radiation risk of CT 9% informed of alternatives to CT 9% informed of alternatives to CT

scanningscanning

Lee CI AJR 2006;187:282-7 Lee CI AJR 2006;187:282-7

Explaining Radiation RiskExplaining Radiation Risk

Families are more interested in Families are more interested in efforts to control the risk than the efforts to control the risk than the actual numberactual number

After reading a handout on radiation After reading a handout on radiation risk, preference for CT over no risk, preference for CT over no imaging decreased, but no families imaging decreased, but no families refused CTrefused CT

Larson, et al. AJR 2007:189;271-275Larson, et al. AJR 2007:189;271-275

What Do Families Want to What Do Families Want to Know?Know?

The examination is needed to best The examination is needed to best care for their childcare for their child

The risk of the examination is real, The risk of the examination is real, but very lowbut very low

The examination is being performed The examination is being performed with the lowest possible riskwith the lowest possible risk

SummarySummary

Ionizing radiation from diagnostic Ionizing radiation from diagnostic imaging may cause a very small imaging may cause a very small increase in the risk of cancer increase in the risk of cancer

For an indicated CT scan, the likely For an indicated CT scan, the likely benefit is far greater than the benefit is far greater than the estimated riskestimated risk

Pediatricians and radiologists should Pediatricians and radiologists should work together to make the work together to make the population exposure ALARApopulation exposure ALARA