As Low As Reasonably Achievable Research Articles

Prevalence of Protective Shielding Utilization for Radiation Dose Reduction in Adult Patients Undergoing Body Scanning Using Computed Tomography.

Ionizing radiation is implicated in nearly 2% of malignancies in the United States; radiation shields prevent unnecessary radiation exposure during medical imaging. Contemporary radiation shield utilization for adult patients in the United States is poorly defined. Therefore, we evaluated the prevalence of protective shielding utilization in adult patients undergoing CT scans in United States' hospitals. An online survey was sent to established radiology departments randomly selected from the 2015 American Hospital Association Guide. Radiology departments conducting adult CT imaging were eligible; among 370 eligible departments, 215 departments accepted the study participation request. Questions focused on shielding practices during CT imaging of the eyes, thyroid, breasts, and gonads. Prevalence data were stratified per hospital location, size, and type. Main outcomes included overall protective shielding utilization, respondents' belief and knowledge regarding radiation safety, and organ-specific shielding prevalence. Sixty-seven of 215 (31%) hospitals completed the survey; 66 (99%) reported familiarity with the ALARA (as low as reasonably achievable) principle and 56 (84%) affirmed their belief that shielding is beneficial. Only 60% of hospitals employed shielding during CT imaging; among these institutions, shielding varied based on CT study: abdominopelvic CT (13, 33%), head CT (33, 83%), or chest CT (30, 75%). Among surveyed hospitals, 40% do not utilize CT shielding despite the majority acknowledging the ALARA principle and agreeing that shielding is a beneficial practice. Failure to address the low prevalence of protective shielding may lead to poor community health due to increased risk of radiation-related cancers.

Knowledge and awareness of radiation hazards among Palestinian radio technologists

This study investigated 94.4% of Palestinian radio technologists and the mean percentage of correct answers for knowledge and awareness questions was 26.4%. The percentage of correct answers for questions testing knowledge of the ALARA (As Low As Reasonably Achievable) principle and hormesis hypothesis was 66.5% and 17.2%, respectively. Radio technologists with education level higher than bachelor degree and < 5 years' work experience showed a significantly higher level of knowledge. The most radiosensitive organs were correctly identified as the lungs and stomach by 6.9% and 4.9%, respectively, and 2.5% correctly identified the gonads as the next most radiosensitive organ. There was a serious deficit in knowledge and awareness of radiation hazards among Palestinian radio technologists, which may expose patients to unnecessary doses of ionizing radiation. This indicates the need for mandatory training and education about radiation protection in all Palestinian healthcare institutions.

The Lambert-Beer law in time domain form and its application

The majority of current radioisotope gauges utilize measurements of intensity for a chosen sampling time interval using a detector. Such an approach has several disadvantages: temporal resolution of the gauge is fixed and the accuracy of the measurements is not the same for different count rate. The solution can be the use of a stronger radioactive source, but it will be conflicted with ALARA (As Low As Reasonably Achievable) principle. Therefore, the article presents an alternative approach which is based on modified Lambert-Beer law. The basis of the approach is the registration of time intervals instead of the registration of counts. It allows to increase the temporal resolution of a gauge without the necessity of using a stronger radioactive source and the accuracy of the measurements will not depend on count rate.

Erratum to: Ethical Issues Related to the Promotion of a "100 mSv Threshold Assumption" in Japan after the Fukushima Nuclear Accident in 2011: Background and Consequences.

This article describes the debates in Japan regarding the 100 mSv threshold assumption and ethical issues related to it, and explores the background to distorted risk information and absence of risk communication in Japan. Then we seek proper risk communication based on scientific evidence. On March 11, 2011 an accident occurred at the Fukushima Daiichi Nuclear Power Plant due to the Great East Japan Earthquake. Since then a number of misunderstandings have become common in Japan as a result of public statements by the Japanese and local governments that have no basis in medical science or are contradictory to medical science. Consequently, not only the population of Fukushima Prefecture, but also others, have been subjected to unnecessary exposure to radiation, against the As Low As Reasonably Achievable (ALARA) principle. The number of cases of thyroid cancer has increased by one or two orders of magnitude since the accident in Fukushima. However, the population has hardly been given any correct information from the central and local governments, medical societies, and media. The center of this problem is a statement on radiation-induced cancer (including thyroid cancer) made by the Japanese Government and Japanese medical academic societies indicating that “exposure of less than 100 mSv gives rise to no excess risk of cancer, and even if there is some resulting cancer it will be impossible to detect it” (this will be referred to as “the 100 mSv threshold assumption” from now onward). They have been saying this since April 2011 and have made no effort to correct it. Many Japanese began to notice this but correct information on radiation protection has reached only one part of the population. Risk communication should be based on scientific evidence, and providing it as information for the public is a key element. In Japan, governments and academic societies tried to communicate with the public without doing it. Ethical problems after the accident in Fukushima can be understood from the consequences of the mistakes in both risk information and risk communication in Japan after 2011.

Correlation Between Perceived Versus Actual Proficiency in OBGYN Residency Training for Obstetric Ultrasounds [23I

INTRODUCTION: Accreditation Council for Graduate Medical Education (ACGME) describes “the full range of commonly employed obstetrical diagnostic procedures, including ultrasonography” as one of the critical competencies required for graduation from an Obstetrics and Gynecology (Ob/Gyn) residency program. Although evidence suggests weaknesses in ultrasound curriculum, this is primarily based on perception and not proficiency. We explored the correlation between perceived knowledge, skill/performance and comfort teaching/supervising obstetric ultrasound and actual proficiency. METHODS: A needs assessment survey was disseminated to all ACGME-approved Ob/Gyn residency programs in the U.S.A. Questions evaluating proficiency were correlated with perceived knowledge, skill/performance and comfort teaching/supervising obstetric ultrasound. RESULTS: One-hundred-forty-four residents completed the survey. A positive correlation was noted between perceived knowledge and actual proficiency in: effect of frequency on image resolution, principle of as low as reasonably achievable (ALARA), fetal heart rate assessment, components of the anatomic survey; skill/performance in performing growth survey; comfort teaching/supervising growth ultrasound, identification of appropriate images for biparietal diameter and abdominal circumference assessments and recognizing gastroschisis. There was a negative correlation in perceived skill/performance in first trimester ultrasound and identifying the correct first trimester crown rump length image. Higher PGY-level respondents tended to answer the question of effect of resolution on image quality correctly, though they also tended to answer the question regarding first trimester crown rump length incorrectly. CONCLUSION: There appears to be a correlation between perceived knowledge, skill/performance and comfort teaching/supervising and actual proficiency. Results of this study may be utilized to integrate future interventions directed towards obstetric ultrasound education.

Assessment of Fetal Ultrasound Training for Obstetrics and Gynecology Residents [24I

INTRODUCTION: Accreditation Council for Graduate Medical Education (ACGME) describes “the full range of commonly employed obstetrical diagnostic procedures, including ultrasonography” as one of the critical competencies required for graduation from an Obstetrics and Gynecology (Ob/Gyn) residency. However, prior studies identified a core curriculum deficit in residency programs. We explored these gaps to determine if they are worth addressing through future interventions. METHODS: A needs assessment survey was disseminated to all ACGME-approved Ob/Gyn residency programs in the USA. RESULTS: One-hundred-forty-four residents completed the survey. Of these, 73.6% had an ultrasound curriculum, of which 77.7% was accessible. Sonographers and faculty were rated as the principal educators. Almost half noted no checklist of competencies during their training, despite the fact that 63.2% were assessed via direct patient observations. Most frequent perceived knowledge deficits included: principle of as low as reasonably achievable (ALARA) and effect of frequency on resolution. Most frequent perceived performance deficits were skill in performing the anatomic survey and diagnosing chorionicity/amnionicity. The majority of respondents felt comfortable teaching/supervising basic obstetric ultrasound except anatomy ultrasounds and cervical length. Assessment of proficiency demonstrated weaknesses in the concept of ALARA, effect of frequency on image quality and identification of suitable crown rump length image. Overall, 76.3% desired more obstetric ultrasound training. Lack of first trimester ultrasounds and insufficient time were listed the most common obstacles to education. CONCLUSION: Additional obstetric ultrasound training for Ob/Gyn residents appears necessary. Improvements in designing an accessible curriculum and formally assessing competencies is fundamental for improving Ob/Gyn training programs.

Radiation exposure during intramedullary nailing

Surgeons should aim to keep radiation exposure “As Low As Reasonably Achievable (ALARA)” during intramedullary nailing and other minimally invasive surgical procedures. This requires understanding the principles of ionizing radiation and methods for minimizing exposure risk. The main source of radiation exposure to surgical personnel during fluoroscopy is from scattered radiation. Since radiation scatter is mainly directed towards the fluoroscopy source, the best configuration during surgery to reduce radiation dose to the surgeon is to position the fluoroscopic source below the operating room table and the image collector above the table. During cross table imaging, the surgeon should stand on the side with the image collector to minimize their exposure to radiation scatter. To reduce scattered radiation the patient must be placed as close to the image collector and as far away from the x-ray tube as possible. Standing farther away from the patient can exponentially reduce radiation exposure. The hands usually have the greatest dose exposure to radiation during surgical procedures, but they are far less radiosensitive than the eyes or thyroid. To minimize exposure to the hands, a surgeon should use the hands-off technique taking fluoroscopic images only when his or her hands are farthest from the radiographic field. Lead gowns, lead thyroid shields, and lead glasses, further reduces an individual’s exposure to radiation.

Ethical Issues Related to the Promotion of a “100 mSv Threshold Assumption” in Japan after the Fukushima Nuclear Accident in 2011: Background and Consequences

This article describes the debates in Japan regarding the 100mSv threshold assumption and ethical issues related to it, and explores the background to distorted risk information and absence of risk communication in Japan. Then we seek proper risk communication based on scientific evidence. On March 11, 2011 an accident occurred at the Fukushima Daiichi Nuclear Power Plant due to the Great East Japan Earthquake. Since then a number of misunderstandings have become common in Japan as a result of public statements by the Japanese and local governments that have no basis in medical science or are contradictory to medical science. Consequently, not only the population of Fukushima Prefecture, but also others, have been subjected to unnecessary exposure to radiation, against the As Low As Reasonably Achievable (ALARA) principle. The number of cases of thyroid cancer has increased by one or two orders of magnitude since the accident in Fukushima. However, the population has hardly been given any correct information from the central and local governments, medical societies, and media. The center of this problem is a statement on radiation-induced cancer (including thyroid cancer) made by the Japanese Government and Japanese medical academic societies indicating that "exposure of less than 100mSv gives rise to no excess risk of cancer, and even if there is some resulting cancer it will be impossible to detect it" (this will be referred to as "the 100mSv threshold assumption" from now onward). They have been saying this since April 2011 and have made no effort to correct it. Many Japanese began to notice this but correct information on radiation protection has reached only one part of the population. Risk communication should be based on scientific evidence, and providing it as information for the public is a key element. In Japan, governments and academic societies tried to communicate with the public without doing it. Ethical problems after the accident in Fukushima can be understood from the consequences of the mistakes in both risk information and risk communication in Japan after 2011.

A Multicenter Survey of Endovascular Theatre Equipment and Radiation Exposure in France during Iliac Procedures

The aim of this study is to evaluate radiation exposure, endovascular theatre equipment, and practices in France during iliac angioplasty. A prospective observational study was performed among vascular surgeons who attended a half day of radiation safety training in 2012 and 2015 and had to collect data on 3 patients undergoing iliac procedure. In 2012, 330 surgeons performed 899 procedures, compared with 114 surgeons and 338 procedures in 2015. Due to exclusions, 653 and 306 procedures were analyzed in 2012 and 2015, respectively. Endovascular environment, practices, anatomical characteristics, and radiation parameters were collected, analyzed, and compared generally and between the 2 groups. Endovascular theatre equipment significantly improved over the 3years: mobile flat-panel detector (1.1% vs. 5.9%), hybrid rooms (1.5% vs. 14.7%), and dedicated radiology tables (37.2% vs. 51.2%). Lesion's classification (Trans-Atlantic Society Consensus) was similar between groups but procedure complexity increased overtime: more than one stent implanted (32.3% vs. 41%, P<0.01), cross over (11.5% vs. 16%, P<0.05), and kissing procedures (19.3% vs. 24.2%, P=0.05). The mean dose area product (DAP) was 14.2±18.9Gy cm2 in 2012 and 21.5±37.6Gy cm2 in 2015 (P<0.01), and the mean fluoroscopy time was 4.8±5.5min and 5.2±5.9min, respectively (nonsignificant). Overall, hybrid rooms, body mass index over 25kg/m2, more than one stent implanted, and crossover technique were associated with a significantly higher DAP. Over 3years, a large population of vascular surgeons improved radiation safety knowledge, operative environment, and technical complexity. However, these changes have led to an increased DAP in 2015, which underline the outmost importance of low dose settings and application of ALARA (as low as reasonably achievable) principles in every day practice.

Residual activity evaluation: a benchmark between ANITA, FISPACT, FLUKA and PHITS codes

The activity of residual nuclides dictates the radiation fields in periodic inspections/repairs (maintenance periods) and dismantling operations (decommissioning phase) of accelerator facilities (i.e ., medical, industrial, research) and nuclear reactors. Therefore, the correct prediction of the material activation allows for a more accurate planning of the activities, in line with the ALARA (As Low As Reasonably Achievable) principles. The scope of the present work is to show the results of a comparison between residual total specific activity versus a set of cooling time instants (from zero up to 10 years after irradiation) as obtained by two analytical (FISPACT and ANITA) and two Monte Carlo (FLUKA and PHITS) codes, making use of their default nuclear data libraries. A set of ~40 irradiating scenarios is considered, i.e . neutron and proton particles of different energies, ranging from zero to many hundreds MeV, impinging on pure elements or materials of standard composition typically used in industrial applications (namely, AISI SS316 and Portland concrete). In some cases, experimental results were also available for a more thorough benchmark.

Diagnostic Roles of Color Doppler Mapping of Fetal Circulation

Prenatal assessment of primitive circulation in the human fetus with color Doppler flow mapping has added a new dimension to fetal assessment. Normal values generated from pulse-wave Doppler studies have been generated for fetal vessels. Early development of placental circulation can be evaluated with color Doppler studies, and it appears to be promising for elucidation of placental pathology as is found in a number of fetal and placental diseases Doppler color-flow mapping appears to be promising for elucidation of abnormal flow in fetuses suspected of having structural and/or functional cardiovascular disease. Certain congenital anomalies can be detected early on in gestation using color Doppler mapping, and hence provide a unique opportunity for in utero intervention. Fetal exposure to Doppler ultrasound should be as low as reasonably achievable (ALARA) because of the potential for tissue heating when the thermal index is exceeding.

The Optimization of Radiation Protection in the Design of the High Temperature Reactor-Pebble-Bed Module

The optimization of radiation protection is an important task in both the design and operation of a nuclear power plant. Although this topic has been considerably investigated for pressurized water reactors, there are very few public reports on it for pebble-bed reactors. This paper proposes a routine that jointly optimizes the system design and radiation protection of High Temperature Reactor-Pebble-Bed Module (HTR-PM) towards the As Low As Reasonably Achievable (ALARA) principle. A systematic framework is also established for the optimization of radiation protection for pebble-bed reactors. Typical calculations for the radiation protection of radioactivity-related systems are presented to quantitatively evaluate the efficiency of the optimization routine, which achieve 23.3%~90.6% reduction of either dose rate or shielding or both of them. The annual collective doses of different systems are reduced through iterative optimization of the dose rates, designs, maintenance procedures, and work durations and compared against the previous estimates. The comparison demonstrates that the annual collective dose of HTR-PM is reduced from 0.490 man-Sv/a before optimization to 0.445 man-Sv/a after optimization, which complies with the requirements of the Chinese regulatory guide and proves the effectiveness of the proposed routine and framework.

Systemization of the Establishment of Standards and Future Prospects: Toward the Establishment of Standards in Nonstationary States.

Although public interest on safety standards is increasing, the evidence and protocols associated with the standards are not known well to the public and even experts. Discussing the evidence of standards is essential for risk communication, and interdisciplinary and systematical understanding on how to establish standards are also beneficial for considering the set-up of new standards. In this article, on the basis of examples in environmental science, industrial health and safety, and radiological protection, I overview and systemize the establishment of the standards from the perspectives of three principles of risk management: 1) "zero-risk-like" standards, 2) "acceptable-risk-based" standards, and 3) "cost-balanced" standards. In this view, I point out the differences in uncertainty factors or acceptable-risk levels among individual standards and demonstrate the role of the "as low as reasonably achievable (ALARA)" concept. Then, on the basis of the problem on lack of environmental standards in nonstationary states such as disasters, I summarize elements necessary for establishing the standards. As perspectives for further study, I suggest the needs for risk assessment of chemicals having a threshold, full considerations of risk trade-offs and ethical aspects, and applications of processes to the establishment of standards through stakeholder consensus.

Linear model without trigger value, radiation visualization in pediatric oncology and related radiophobia and doubt

Personal opinion concerning ideas of Jeffry A. Siegel et al which were published in previous issue of the Russian Journal of Pediatric Hematology, Oncology and Immunology, presented in this article. The essence of the judgment of Dr. Siegel and co-authors is that the linear model with trigger values and ALARA (As Low As Reasonably Achievable) principle can bring more harm than benefits in case of diagnostics in the limits of low dose irradiation. Authors tend to agree with opinion proposed by Jeffry A. Siegel that blind following of ALARA principle without estimation of dose sizes could block the therapy process and increase the radiophobia both at physician prescribing diagnostics, and relatives of children with a history of long treatment. Herewith, there can be situations when radiophobia can led to limitation of required diagnostic procedures. Taking into account high severity of oncological patients, consequences can be very negative. Meanwhile authors think that performing of evaluation studies on structure pf dose load in pediatric hematology-oncology required. It is important to observe and foresee the situations in which the excess of low doses possible and to limit the following dose accumulation in this case if clinically possible.

Radiation dose of digital radiography (DR) versus micro-dose x-ray (EOS) on patients with adolescent idiopathic scoliosis: 2016 SOSORT- IRSSD “John Sevastic Award” Winner in Imaging Research

BackgroundPatients with adolescent idiopathic scoliosis (AIS) frequently receive x-ray imaging at diagnosis and subsequent follow monitoring. The ionizing radiation exposure has accumulated through their development stage and the effect of radiation to this young vulnerable group of patients is uncertain. To achieve the ALARA (as low as reasonably achievable) concept of radiation dose in medical imaging, a slot-scanning x-ray technique by the EOS system has been adopted and the radiation dose using micro-dose protocol was compared with the standard digital radiography on patients with AIS.MethodsNinety-nine participants with AIS underwent micro-dose EOS and 33 underwent standard digital radiography (DR) for imaging of the whole spine. Entrance-skin dose was measured using thermoluminescent dosimeters (TLD) at three regions (i.e. dorsal sites at the level of sternal notch, nipple line, symphysis pubis). Effective dose and organ dose were calculated by simulation using PCXMC 2.0. Data from two x-ray systems were compared using independent-samples t-test and significance level at 0.05. All TLD measurements were conducted on PA projection only. Image quality was also assessed by two raters using Cobb angle measurement and a set of imaging parameters for optimization purposes.ResultsEntrance-skin dose from micro-dose EOS system was 5.9–27.0 times lower at various regions compared with standard DR. The calculated effective dose was 2.6 ± 0.5 (μSv) and 67.5 ± 23.3 (μSv) from micro-dose and standard DR, respectively. The reduction in the micro-dose was approximately 26 times. Organ doses at thyroid, lung and gonad regions were significantly lower in micro-dose (p < 0.001). Data were further compared within the different gender groups. Females received significantly higher (p < 0.001) organ dose at ovaries compared to the testes in males. Patients with AIS received approximately 16–34 times lesser organ dose from micro-dose x-ray as compared with the standard DR. There was no significant difference in overall rating of imaging quality between EOS and DR. Micro-dose protocol provided enough quality to perform consistent measurement on Cobb angle.ConclusionsEntrance-skin dose, effective dose and organ dose were significantly reduced in micro-dose x-ray. The effective dose of a single micro-dose x-ray (2.6 μSv) was less than a day of background radiation. As AIS patients require periodic x-ray follow up for surveillance of curve progression, clinical use of micro-dose x-ray system is beneficial for these young patients to reduce the intake of ionizing radiation.

INTEGRATED OPERATIONAL DOSIMETRY SYSTEM AT CERN.

CERN, the European Organization for Nuclear Research, upgraded its operational dosimetry system in March 2013 to be prepared for the first Long Shutdown of CERN's facilities. The new system allows the immediate and automatic checking and recording of the dosimetry data before and after interventions in radiation areas. To facilitate the analysis of the data in context of CERN's approach to As Low As Reasonably Achievable (ALARA), this new system is interfaced to the Intervention Management Planning and Coordination Tool (IMPACT). IMPACT is a web-based application widely used in all CERN's accelerators and their associated technical infrastructures for the planning, the coordination and the approval of interventions (work permit principle). The coupling of the operational dosimetry database with the IMPACT repository allows a direct and almost immediate comparison of the actual dose with the estimations, in addition to enabling the configuration of alarm levels in the dosemeter in function of the intervention to be performed.

O54. Occupational radiation dose mapping in the hybrid interventional theatre environment evaluated at six Netcare Hospitals

Introduction The International Commission on Radiological Protection (ICRP) limits the whole body occupational exposure to < 100 mSv over five years and < 50 mSv in any single year. High occupational doses, which can exceed ICRP limits, have become a great concern in hybrid theatres due to the growing complexity of procedures and fluoroscopic time. Adherence to the As Low As Reasonably Achievable (ALARA) principle imposes that distance and shielding should be considered to avoid high staff doses. The aim of this study is to determine the high and low occupational exposure areas present in the hybrid theatres installed at Netcare Hospitals. Materials and methods Six Siemens Artis Zeego Hybrid Labs were used and 1 m2 blocks were placed in a grid pattern on the floor using masking tape. Simulation of a patient in the supine position was achieved using a PTW Normi 4 Flu Phantom. Three imaging protocols were selected for evaluation namely FL15fps, FL+30fps and LV15fps. Dose rate ( μ Gy/h) was measured inside each block at a height of 1.5 m from the floor using a RaySafe Unfors Survey Detector at three common gantry angles and the average was calculated. Results The initial results indicate that the left lateral side is the high exposure area, whereas the left posterior oblique (LPO) side is the lowest. An architectural drawing of a lab is used to illustrate results and the highest exposure for each protocol was recorded to be 257, 925 and 426 μ Gy/h, respectively. The lowest exposure area was recorded to be < 50 μ Gy/h for the outermost LPO corner. Conclusion The result is a relative approximation of high and low dose areas inside the hybrid theatres. Only scatter resulting from common projections were measured as it was not possible to measure all gantry angles. Awareness of high and low exposure areas will lead to a safer environment for radiation workers. The International Commission on Radiological Protection (ICRP) limits the whole body occupational exposure to < 100 mSv over five years and < 50 mSv in any single year. High occupational doses, which can exceed ICRP limits, have become a great concern in hybrid theatres due to the growing complexity of procedures and fluoroscopic time. Adherence to the As Low As Reasonably Achievable (ALARA) principle imposes that distance and shielding should be considered to avoid high staff doses. The aim of this study is to determine the high and low occupational exposure areas present in the hybrid theatres installed at Netcare Hospitals. Six Siemens Artis Zeego Hybrid Labs were used and 1 m2 blocks were placed in a grid pattern on the floor using masking tape. Simulation of a patient in the supine position was achieved using a PTW Normi 4 Flu Phantom. Three imaging protocols were selected for evaluation namely FL15fps, FL+30fps and LV15fps. Dose rate ( μ Gy/h) was measured inside each block at a height of 1.5 m from the floor using a RaySafe Unfors Survey Detector at three common gantry angles and the average was calculated. The initial results indicate that the left lateral side is the high exposure area, whereas the left posterior oblique (LPO) side is the lowest. An architectural drawing of a lab is used to illustrate results and the highest exposure for each protocol was recorded to be 257, 925 and 426 μ Gy/h, respectively. The lowest exposure area was recorded to be < 50 μ Gy/h for the outermost LPO corner. The result is a relative approximation of high and low dose areas inside the hybrid theatres. Only scatter resulting from common projections were measured as it was not possible to measure all gantry angles. Awareness of high and low exposure areas will lead to a safer environment for radiation workers.

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine

AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine

Counterpoint: Image Gently: Should It End or Endure?

Image Gently® should be terminated. I agree. Point: Should the ALARA Concept and Image Gently Campaign Be Terminated?Journal of the American College of RadiologyVol. 13Issue 10PreviewIt is a difficult challenge to present the argument that ALARA (as low as reasonably achievable) and Image Gently® should be terminated and that their energy should now be redirected to other methods of improving the quality and safety of care that radiologists provide to their patients. We should make changes because they are the correct thing to do, not because of a hypothetical fear of radiation. Full-Text PDF Image Gently Versus SmartTots: A Complex Safety Debate and the Need for More StudyJournal of the American College of RadiologyVol. 14Issue 3PreviewI read the debate regarding Image Gently® [1,2] with great interest. Although I support the mission of Image Gently and wholeheartedly respect the need to limit the radiation dose to children, neither author addressed the elephant in the room with regard to changes in ordering habits for pediatric examinations: the risk, benefit, and cost of CT versus the risk, benefit, and cost of sedated MRI. Full-Text PDF