ALARA PRINCIPLE IN DIAGNOSTIC RADIOLOGY PRACTICE:A REVIEW STUDY
DOI:
https://doi.org/10.69980/w99xrh36Keywords:
ALARA principle, Diagnostic radiology, Radiation protection, Dose optimization, Computed tomography (CT), Digital radiography, Fluoroscopy, Radiation safety, Image quality, Pediatric imagingAbstract
Diagnostic radiology is based on the As Low As Reasonably Achievable (ALARA) principle that ensures the least radiation exposure to a patient and adequate diagnosis. This review paper focuses on the application of the ALARA principle in conventional radiography, computed tomography (CT), fluoroscopy and interventional radiology with particular emphasis on patient-centered dose optimization and occupational radiation safety. Methods We searched PubMed, Google Scholar, and ScienceDirect for relevant peer-reviewed articles published in English from 2000 onwards. The review discusses some of the main principles related to radiation protection—justification, optimization and dose limitation—in order to understand how unnecessary radiation exposures can be reduced. It also discusses its association with technical advancement and advances in digital radiography, automatic exposure control, iterative reconstruction, artificial intelligence, and dose monitoring systems to aid ALARA implementation. Customizable protocols are especially relevant in the field of pediatric imaging and other sub-populations who are radiosensitive, where flexibility based on risks may be necessary due to clinical findings. In addition, the review highlights that quality assurance programs, ongoing professional educational updates and collaboration of healthcare providers along with national institutional guidelines geared toward safe imaging are essential. In conclusion, the correct implementation of ALARA improves patient and occupational safety so that diagnostic accuracy is preserved and the quality of radiological services increases
References
1.ICRP PUBLICATION 154 (2023). Optimisation of Radiological Protection in Digital Radiology Techniques for Medical Imaging. Annals of the ICRP, 52(3), 11–145. https://doi.org/10.1177/01466453231210646
2.Najjar R. (2023). Radiology's Ionising Radiation Paradox: Weighing the Indispensable Against the Detrimental in Medical Imaging. Cureus, 15(7), e41623. https://doi.org/10.7759/cureus.41623
3.Berkhout W. E. (2015). Het ALARA-principe. Achtergronden en toepassing in de praktijk [The ALARA-principle. Backgrounds and enforcement in dental practices]. Nederlands tijdschrift voor tandheelkunde, 122(5), 263–270. https://doi.org/10.5177/ntvt.2015.5.14227
4.Geijer H. (2002). Radiation dose and image quality in diagnostic radiology. Optimization of the dose-image quality relationship with clinical experience from scoliosis radiography, coronary intervention and a flat-panel digital detector. Acta radiologica. Supplementum, 43(427), 1–43.
5.Larson D. B. (2014). Optimizing CT radiation dose based on patient size and image quality: the size-specific dose estimate method. Pediatric radiology, 44 Suppl 3, 501–505. https://doi.org/10.1007/s00247-014-3077-y
6.Sodhi, K. S., Krishna, S., Saxena, A. K., Sinha, A., Khandelwal, N., & Lee, E. Y. (2015). Clinical application of 'Justification' and 'Optimization' principle of ALARA in pediatric CT imaging: "How many children can be protected from unnecessary radiation?". European journal of radiology, 84(9), 1752–1757. https://doi.org/10.1016/j.ejrad.2015.05.030
7.Whitebird, R. R., Solberg, L. I., Chu, P. W., & Smith-Bindman, R. (2022). Strategies for Dose Optimization: Views From Health Care Systems. Journal of the American College of Radiology : JACR, 19(4), 534–541. https://doi.org/10.1016/j.jacr.2022.01.012
8.Kaplan, D. J., Patel, J. N., Liporace, F. A., & Yoon, R. S. (2016). Intraoperative radiation safety in orthopaedics: a review of the ALARA (As low as reasonably achievable) principle. Patient safety in surgery, 10, 27. https://doi.org/10.1186/s13037-016-0115-8
9.Frane, N., & Bitterman, A. (2023). Radiation Safety and Protection. In StatPearls. StatPearls Publishing.
10.Siegel, J. A., McCollough, C. H., & Orton, C. G. (2017). Advocating for use of the ALARA principle in the context of medical imaging fails to recognize that the risk is hypothetical and so serves to reinforce patients' fears of radiation. Medical physics, 44(1), 3–6. https://doi.org/10.1002/mp.12012
11.Siraj, A. K., Pratheeshkumar, P., Divya, S. P., Parvathareddy, S. K., Bu, R., Masoodi, T., Kong, Y., Thangavel, S., Al-Sanea, N., Ashari, L. H., Abduljabbar, A., Al-Homoud, S., Al-Dayel, F., & Al-Kuraya, K. S. (2019). TGFβ-induced SMAD4-dependent Apoptosis Proceeded by EMT in CRC. Molecular cancer therapeutics, 18(7), 1312–1322. https://doi.org/10.1158/1535-7163.MCT-18-1378
12.Dudhe, S. S., Mishra, G., Parihar, P., Nimodia, D., & Kumari, A. (2024). Radiation Dose Optimization in Radiology: A Comprehensive Review of Safeguarding Patients and Preserving Image Fidelity. Cureus, 16(5), e60846. https://doi.org/10.7759/cureus.60846
13.Vassileva, J., & Holmberg, O. (2021). Radiation protection perspective to recurrent medical imaging: what is known and what more is needed?. The British journal of radiology, 94(1126), 20210477. https://doi.org/10.1259/bjr.20210477
14.Aldrich, J. E., Duran, E., Dunlop, P., & Mayo, J. R. (2006). Optimization of dose and image quality for computed radiography and digital radiography. Journal of digital imaging, 19(2), 126–131. https://doi.org/10.1007/s10278-006-9944-9
15.Cowen, A. R., Kengyelics, S. M., & Davies, A. G. (2008). Solid-state, flat-panel, digital radiography detectors and their physical imaging characteristics. Clinical radiology, 63(5), 487-498.
16.Shrimpton, P. C., Hillier, M. C., Lewis, M. A., & Dunn, M. (2005). Doses from computed tomography (CT) examinations in the UK-2003 review (Vol. 67). Chilton: NRPB.
17.Muhogora, W. E., Ahmed, N. A., Almosabihi, A., Alsuwaidi, J. S., Beganovic, A., Ciraj-Bjelac, O., Kabuya, F. K., Krisanachinda, A., Milakovic, M., Mukwada, G., Ramanandraibe, M. J., Rehani, M. M., Rouzitalab, J., & Shandorf, C. (2008). Patient doses in radiographic examinations in 12 countries in Asia, Africa, and Eastern Europe: initial results from IAEA projects. AJR. American journal of roentgenology, 190(6), 1453–1461. https://doi.org/10.2214/AJR.07.3039
18.Zhu, T. C., & Bjärngard, B. E. (2003). Head scatter off-axis for megavoltage x rays. Medical physics, 30(4), 533–543. https://doi.org/10.1118/1.1556609
19.Granata, C., Sorantin, E., Seuri, R., & Owens, C. M. (2019). European Society of Paediatric Radiology Computed Tomography and Dose Task Force: European guidelines on diagnostic reference levels for paediatric imaging. Pediatric radiology, 49(5), 702-705.
20.Krille, L., Hammer, G. P., Merzenich, H., & Zeeb, H. (2010). Systematic review on physician's knowledge about radiation doses and radiation risks of computed tomography. European journal of radiology, 76(1), 36–41. https://doi.org/10.1016/j.ejrad.2010.08.025
21.Mettler, F. A., Jr, Bhargavan, M., Faulkner, K., Gilley, D. B., Gray, J. E., Ibbott, G. S., Lipoti, J. A., Mahesh, M., McCrohan, J. L., Stabin, M. G., Thomadsen, B. R., & Yoshizumi, T. T. (2009). Radiologic and nuclear medicine studies in the United States and worldwide: frequency, radiation dose, and comparison with other radiation sources--1950-2007. Radiology, 253(2), 520–531. https://doi.org/10.1148/radiol.2532082010
22.Pesapane, F., Codari, M., & Sardanelli, F. (2018). Artificial intelligence in medical imaging: threat or opportunity? Radiologists again at the forefront of innovation in medicine. European radiology experimental, 2(1), 35. https://doi.org/10.1186/s41747-018-0061-6
23.ICRP PUBLICATION 154 (2023). Optimisation of Radiological Protection in Digital Radiology Techniques for Medical Imaging. Annals of the ICRP, 52(3), 11–145. https://doi.org/10.1177/01466453231210646
24.Harvey, C. J., & Blomley, M. J. (2005). Principles and precautions of conventional radiography. Surgery (Oxford), 23(5), 158-161.
25.Seibert, J. A. (2009). Digital radiography: the bottom line comparison of CR and DR technology. Appl Radiol, 38(5), 21-28.
26.Seibert, J. A. (2009). Digital radiography: the bottom line comparison of CR and DR technology. Appl Radiol, 38(5), 21-28.
27.McCollough, C. H., Primak, A. N., Braun, N., Kofler, J., Yu, L., & Christner, J. (2009). Strategies for reducing radiation dose in CT. Radiologic clinics of North America, 47(1), 27–40. https://doi.org/10.1016/j.rcl.2008.10.006
28.Schindera, S. T., Winklehner, A., Alkadhi, H., Goetti, R., Fischer, M., Gnannt, R., & Szucs-Farkas, Z. (2013). Effect of automatic tube voltage selection on image quality and radiation dose in abdominal CT angiography of various body sizes: a phantom study. Clinical radiology, 68(2), e79-e86.
29.Singh, S., Kalra, M. K., Gilman, M. D., Hsieh, J., Pien, H. H., Digumarthy, S. R., & Shepard, J. A. (2011). Adaptive statistical iterative reconstruction technique for radiation dose reduction in chest CT: a pilot study. Radiology, 259(2), 565–573. https://doi.org/10.1148/radiol.11101450
30.Vañó, E., Miller, D. L., Martin, C. J., Rehani, M. M., Kang, K., Rosenstein, M., ... & Rogers, A. (2017). ICRP publication 135: diagnostic reference levels in medical imaging. Annals of the ICRP, 46(1), 1-144.
31.Rodrigues, B. V., Lopes, P. C., Mello-Moura, A. C., Flores-Fraile, J., & Veiga, N. (2024, October). Literacy in the scope of radiation protection for healthcare professionals exposed to ionizing radiation: a systematic review. In Healthcare (Vol. 12, No. 20, p. 2033). MDPI.
32.Ebdon-Jackson, S., Frija, G., & European Society of Radiology (2021). Improving justification of medical exposures using ionising radiation: considerations and approaches from the European Society of Radiology. Insights into imaging, 12(1), 2. https://doi.org/10.1186/s13244-020-00940-0
33.Yanaga, Y., Awai, K., Nakaura, T., Utsunomiya, D., Oda, S., Hirai, T., & Yamashita, Y. (2010). Contrast material injection protocol with the dose adjusted to the body surface area for MDCT aortography. AJR. American journal of roentgenology, 194(4), 903–908. https://doi.org/10.2214/AJR.09.3460
34.Kalra, M. K., Maher, M. M., Toth, T. L., Hamberg, L. M., Blake, M. A., Shepard, J. A., & Saini, S. (2004). Strategies for CT radiation dose optimization. Radiology, 230(3), 619–628. https://doi.org/10.1148/radiol.2303021726
35.Singh, S., Kalra, M. K., Gilman, M. D., Hsieh, J., Pien, H. H., Digumarthy, S. R., & Shepard, J. A. (2011). Adaptive statistical iterative reconstruction technique for radiation dose reduction in chest CT: a pilot study. Radiology, 259(2), 565–573. https://doi.org/10.1148/radiol.11101450
36.Uffmann, M., & Schaefer-Prokop, C. (2009). Digital radiography: the balance between image quality and required radiation dose. European journal of radiology, 72(2), 202–208. https://doi.org/10.1016/j.ejrad.2009.05.060
37.INTERNATIONAL ATOMIC ENERGY AGENCY, Radiation Protection and Safety in Medical Uses of Ionizing Radiation , Safety Standards Series No. SSG-46, IAEA, Vienna (2018)
38.Miller, D. L., Balter, S., Cole, P. E., Lu, H. T., Schueler, B. A., Geisinger, M., Berenstein, A., Albert, R., Georgia, J. D., Noonan, P. T., Cardella, J. F., St George, J., Russell, E. J., Malisch, T. W., Vogelzang, R. L., Miller, G. L., 3rd, Anderson, J., & RAD-IR study (2003). Radiation doses in interventional radiology procedures: the RAD-IR study: part I: overall measures of dose. Journal of vascular and interventional radiology : JVIR, 14(6), 711–727. https://doi.org/10.1097/01.rvi.0000079980.80153.4b
39.Stecker, M. S., Balter, S., Towbin, R. B., Miller, D. L., Vañó, E., Bartal, G., Angle, J. F., Chao, C. P., Cohen, A. M., Dixon, R. G., Gross, K., Hartnell, G. G., Schueler, B., Statler, J. D., de Baère, T., Cardella, J. F., SIR Safety and Health Committee, & CIRSE Standards of Practice Committee (2009). Guidelines for patient radiation dose management. Journal of vascular and interventional radiology : JVIR, 20(7 Suppl), S263–S273. https://doi.org/10.1016/j.jvir.2009.04.037
40.López, P. O., Dauer, L. T., Loose, R., Martin, C. J., Miller, D. L., Vañó, E., Doruff, M., Padovani, R., Massera, G., Yoder, C., & Authors on Behalf of ICRP (2018). ICRP Publication 139: Occupational Radiological Protection in Interventional Procedures. Annals of the ICRP, 47(2), 1–118. https://doi.org/10.1177/0146645317750356
41.ICRP, Khong, P. L., Ringertz, H., Donoghue, V., Frush, D., Rehani, M., Appelgate, K., & Sanchez, R. (2013). ICRP publication 121: radiological protection in paediatric diagnostic and interventional radiology. Annals of the ICRP, 42(2), 1–63. https://doi.org/10.1016/j.icrp.2012.10.001
42.Strauss, K. J., Goske, M. J., Kaste, S. C., Bulas, D., Frush, D. P., Butler, P., Morrison, G., Callahan, M. J., & Applegate, K. E. (2010). Image gently: Ten steps you can take to optimize image quality and lower CT dose for pediatric patients. AJR. American journal of roentgenology, 194(4), 868–873. https://doi.org/10.2214/AJR.09.4091
43.Goske, M. J., Applegate, K. E., Boylan, J., Butler, P. F., Callahan, M. J., Coley, B. D., Farley, S., Frush, D. P., Hernanz-Schulman, M., Jaramillo, D., Johnson, N. D., Kaste, S. C., Morrison, G., Strauss, K. J., & Tuggle, N. (2008). The Image Gently campaign: working together to change practice. AJR. American journal of roentgenology, 190(2), 273–274. https://doi.org/10.2214/AJR.07.3526
44.López, P. O., Dauer, L. T., Loose, R., Martin, C. J., Miller, D. L., Vañó, E., Doruff, M., Padovani, R., Massera, G., Yoder, C., & Authors on Behalf of ICRP (2018). ICRP Publication 139: Occupational Radiological Protection in Interventional Procedures. Annals of the ICRP, 47(2), 1–118. https://doi.org/10.1177/0146645317750356
45.Duncan, J. R., Balter, S., Becker, G. J., Brady, J., Brink, J. A., Bulas, D., Chatfield, M. B., Choi, S., Connolly, B. L., Dixon, R. G., Gray, J. E., Kee, S. T., Miller, D. L., Robinson, D. W., Sands, M. J., Schauer, D. A., Steele, J. R., Street, M., Thornton, R. H., & Wise, R. A. (2011). Optimizing radiation use during fluoroscopic procedures: proceedings from a multidisciplinary consensus panel. Journal of vascular and interventional radiology : JVIR, 22(4), 425–429. https://doi.org/10.1016/j.jvir.2010.12.008
46.Uffmann, M., & Schaefer-Prokop, C. (2009). Digital radiography: the balance between image quality and required radiation dose. European journal of radiology, 72(2), 202–208. https://doi.org/10.1016/j.ejrad.2009.05.060
47.Liew C. (2018). The future of radiology augmented with Artificial Intelligence: A strategy for success. European journal of radiology, 102, 152–156. https://doi.org/10.1016/j.ejrad.2018.03.019
48.Hosny, A., Parmar, C., Quackenbush, J., Schwartz, L. H., & Aerts, H. J. W. L. (2018). Artificial intelligence in radiology. Nature reviews. Cancer, 18(8), 500–510. https://doi.org/10.1038/s41568-018-0016-5
49.Dimitriou, P., & Kamenopoulou, V. (2011). Education and training issues in individual monitoring of ionising radiation. Radiation protection dosimetry, 144(1-4), 588–591. https://doi.org/10.1093/rpd/ncq431
50.Clarijs, T., Coeck, M., Van Bladel, L., & Fremout, A. (2015). Basic radiation protection training for nurses and paramedical personnel: Belgian experience and future perspectives. Radiation protection dosimetry, 165(1-4), 506–509. https://doi.org/10.1093/rpd/ncv070
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