title: Clinical application of 'Justification' and 'Optimization' principle of ALARA in pediatric CT imaging: "How many children can be protected from unnecessary radiation?".
abstract: OBJECTIVE
  Practice of ALARA (as low as reasonably achievable) principle in the developed world is currently well established. However, there is striking lack of published data regarding such experience in the developing countries. Therefore, the goal of this study is to prospectively evaluate CT request forms to assess how many children could be protected from harmful radiation exposure if 'Justification' and 'Optimization' principles of ALARA are applied before obtaining CT imaging in a developing country. This can save children from potential radiation risks including development of brain cancer and leukemia.
  
  
  METHODS
  Consecutive CT request forms over a six month study period (May 16, 2013 to November 15, 2013) in a tertiary pediatric children's hospital in India were prospectively reviewed by two pediatric radiologists before obtaining CT imaging. First, 'Justification' of CT was evaluated and then 'Optimization' was applied for evaluation of appropriateness of the requested CT studies. The number (and percentage) of CT studies avoided by applying 'Justification' and 'Optimization' principle of ALARA were calculated. The difference in number of declined and optimized CT requests between CT requests from inpatient and outpatient departments was compared using Chi-Square test.
  
  
  RESULTS
  A total of 1302 consecutive CT request forms were received during the study period. Some of the request forms (n=86; 6.61%) had requests for more than one (multiple) anatomical regions, hence, a total of 1392 different anatomical CT requests were received. Based on evaluation of the CT request forms for 'Justification' and 'Optimization' principle of ALARA by pediatric radiology reviewers, 111 individual anatomic part CT requests from 105 pediatric patients were avoided. Therefore, 8.06% (105 out of 1302 pediatric patients) were protected from unnecessary or additional radiation exposure.The rates of declined or optimized CT requests from inpatient department was significantly higher than that from outpatient departments (p<0.05).
  
  
  CONCLUSIONS
  A substantial number of pediatric patients, particularly coming from outpatient departments, can be protected from unnecessary or additional radiation exposure from CT imaging when 'Justification' and 'Optimization' principle of ALARA are applied before obtaining CT imaging in a developing country.
authors.affiliation: Departments of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Electronic address: sodhiks@gmail.com.
authors.forename: Kushaljit S
authors.initials: KS
authors.lastname: Sodhi
authors.affiliation: Departments of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
authors.forename: Satheesh
authors.initials: S
authors.lastname: Krishna
authors.affiliation: Departments of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
authors.forename: Akshay K
authors.initials: AK
authors.lastname: Saxena
authors.affiliation: Departments of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
authors.forename: Anindita
authors.initials: A
authors.lastname: Sinha
authors.affiliation: Departments of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
authors.forename: Niranjan
authors.initials: N
authors.lastname: Khandelwal
authors.affiliation: Departments of Radiology and Medicine, Pulmonary Division, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave. Boston, MA 02115, United States.
authors.forename: Edward Y
authors.initials: EY
authors.lastname: Lee
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003906:Developing Countries; D005260:Female; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data; D006801:Humans; D007194:India; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D000069342:Medical Overuse / Q000706:statistics & numerical data*; D011446:Prospective Studies; D011829:Radiation Dosage; D011832:Radiation Injuries / Q000517:prevention & control*; D014057:Tomography, X-Ray Computed / Q000379:methods / Q000706:statistics & numerical data*
keywords: CT imaging; Justification; Optimization; Pediatric patients; Radiation