Assessing Effective Doses and Proposing DRLs for Pediatric CT Procedures in Madinah (Single Hospital), Saudi Arabia
, Fahad H. Alhazmi 1, Faisal A. Alrehily 1, Nadia S. Alraddadi 2, Ahmed S. Alharbi 1, Amjad M. Alamin 1, Nawaf S. Alraddadi 1, Abaad A. Alenezi 2 and Fai H. Hadi 2
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe authors aimed to assess the effective dose for pediatric and young patients undergone CT head, chest, abdomen, abdomen/ pelvis, and chest/ abdomen/ pelvis. Further, they aimed to estimate the DRL for the CT procedures mentioned above. The study is important, relevant and appropriate for the journal of applied science, however major improvement and revision is needed. A minor professional English editing is also needed. Enclosed below are some general and specific comments for the authors to consider.
General comments
1. For chest/ abdomen CT exams, grouping pediatric based on age is not ideal. Why the authors didn’t consider to group pediatric based on weight for these CT exams? This is a major limitation in this study.
2. Why would CT result in the highest staff dose? Explain with actual scenarios. What measures taken in this study to reduce exposure to staff!
3. Effective dose (ED) is a patient dose metric that is affected by the accuracy of tissue weighting factors used. For CT exams that involve the coverage of example chest/ abdomen, how effective is reporting the ED?
4. The study is based on one single center. This cannot represent an entire city? The title and aim needs to be modified to reflect the actual representation of the data.
5. Few statements are needed to link the ED to radiation risk assessment. The introduction is a good place for this added link of information.
Specific comments:
1.Abstract: following the journal format, the abstract should not be structured.
2.Abstract line 11: since the highest ED was in abdomen, it should be listed first. Correct this throughout the text.
3. Abstract line 13: add a coma before and to separate CT head from CT abdomen data. “414 mGy.cm, and 4.2 mGy”
4. Abstract line 15: this is confusing 1 ≤ − < 5, 5 ≤ − <10. This needs to be rewritten. Perhaps 1 - < 5, 5-<10 etc. Correct this whenever it appears in the text.
5. Abstract lines 17: frequent update on not to! Correct this in section 5 as well.
6. Introduction line 27: young patients are more radiosensitive not have high radio…!
7. Citation of more than one reference can be presented e.g., [5,7]. Correct this throughout the text.
8. Introduction line 38: you need to be specific, which DRL is represented by the 75th per and which by the 50th per?
9. Table 1 is not needed.
10. Very important information is missing, the sample size per age group for each CT procedure. Lack of such information compromise the accuracy of the study findings.
11. Table 5: either report by a reference or by a country with a reference.
12. Discussion line 107: correct the citation format.
13. Discussion line 139: mentioning not mention!
14. Discussion: lines (139-141): not clear what the authors intend to declare.
15. Conclusion: the first sentence reads confusing. Rewrite!
Comments on the Quality of English Language
Minor English editing is needed
Author Response
1. Comment: For chest/ abdomen CT exams, grouping pediatric based on age is not ideal. Why the authors didn’t consider to group pediatric based on weight for these CT exams? This is a major limitation in this study. Response: Explained and highlighted lines 149 to 158. Age and weight were used equally in many published studies. though weight division could be more accurate than age division; however, in this study, we followed the American Association of Physicists in Medicine (AAPM) in pediatric age categories. Thus, it was recommended at the end of this study to add more increments to the age groups, especially for pediatrics aged >5 years, and this was considered a limitation.
2. Comment: Why would CT result in the highest staff dose? Explain with actual scenarios. What measures taken in this study to reduce exposure to staff! Response: Explained and highlighted lines 23 to 25. The statement was rewritten to show the actual relatively high occupational dose from CT compared to, for example, conventional x-ray imaging.
3. Comment: Effective dose (ED) is a patient dose metric that is affected by the accuracy of tissue weighting factors used. For CT exams that involve the coverage of example chest/ abdomen, how effective is reporting the ED? Response: Explained and highlighted lines 36 to 41
4. Comment: The study is based on one single center. This cannot represent an entire city? The title and aim needs to be modified to reflect the actual representation of the data. Response: The title and aim were edited lines 55 and the title. Also, the DRLs in this study were established at the 50th percentile instead of the 75th, as this is a recommendation in the ICRP Report 103 for local or single-center DRL establishment. lines 50 and 51
5. Comment: Few statements are needed to link the ED to radiation risk assessment. The introduction is a good place for this added link of information. Response: Explained and highlighted lines 26 to 30
Specific comments:
1. Specific comment: Abstract: following the journal format, the abstract should not be structured. Response: Explained and highlighted lines 6 to 17
2. Specific comment: Abstract line 11: since the highest ED was in abdomen, it should be listed first. Correct this throughout the text. Response: Done and highlighted line 11
3. Specific comment: Abstract line 13: add a coma before and to separate CT head from CT abdomen data. “414 mGy.cm, and 4.2 mGy”. Response: Done and highlighted line 13
4. Specific comment: Abstract line 15: this is confusing 1 ≤ − < 5, 5 ≤ − <10. This needs to be rewritten. Perhaps 1 - < 5, 5-<10 etc. Correct this whenever it appears in the text. Response: It was modified throughout the manuscript and highlighted
5. Specific comment: Abstract lines 17: frequent update on not to! Correct this in section 5 as well. Response: Corrected and highlighted lines 17 and 169
6. Specific comment: Introduction line 27: young patients are more radiosensitive not have high radio…! Response: Done and highlighted lines 32 and 118
7. Specific comment: Citation of more than one reference can be presented e.g., [5,7]. Correct this throughout the text. Response: The citation style was changed to the closest citation style suggested by the reviewer in Mendeley Desktop Reference Manager (that I’m using). The style changed to the National Library of Medicine citation style. For example, [5] and [7] were changed to (5, 7)
8. Specific comment: Introduction line 38: you need to be specific, which DRL is represented by the 75th per and which by the 50th per? Response: Explained and highlighted lines 50 and 51
9. Specific comment: Table 1 is not needed. Response: Done and highlighted Table 1 was deleted, and tables numbering was modified
10. Specific comment: Very important information is missing, the sample size per age group for each CT procedure. Lack of such information compromise the accuracy of the study findings. Response: The total sample size was 600 cases, and the sample size per age group and procedure was thirty cases, and was rewritten t 30 cases. This was highlighted lines 60 and 65
11. Specific comment: Table 5: either report by a reference or by a country with a reference. Response: Done and highlighted Table 5 number was modified to Table 4
12. Specific comment: Discussion line 107: correct the citation format. Response: Done and highlighted line 120
13. Specific comment: Discussion line 139: mentioning not mention! Response: Done and highlighted line 152
14. Specific comment: Discussion: lines (139-141): not clear what the authors intend to declare. Response: Done and highlighted lines 152 to 159
15. Specific comment: Conclusion: the first sentence reads confusing. Rewrite! Response: Done and highlighted line 166 to 169
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsI'm not sure applsci is the right journal for this, perhaps journals like Radiology or medical oriented journals would be more appropriate.
Significance and novelty are unclear to me. Since there are already international and national standards for diagnostic reference levels for pediatric CT, what's the point of re-assessing them with some local data? I'm sure it's useful for local hospitals, but it's unclear to me how this would be useful for the general readership, especially since there are no clear and quantitative conclusions in the end. The method of data analysis appears to be a standard one. Other than local data, I don't see any novelty here.
By the way, the following two papers may be worth citing.
https://pubs.rsna.org/doi/10.1148/radiol.2021211241
https://doi.org/10.1007/s00247-022-05340-8
Author Response
- Comment: I'm not sure applsci is the right journal for this, perhaps journals like Radiology or medical oriented journals would be more appropriate.
Response: Radiation dose assessment and optimization (e.g., effective dose and DRLs) seem to me to be one of the published topics at ”applsci." In addition, in 2021, I and colleagues published a paper in the same field as the current submitted manuscript: “https://doi.org/10.3390/app11062456.“. However, the suggested journals could be appropriate too. Additional examples of published papers in the same field can be found at "Applsci.“:
- https://doi.org/10.3390/app14146010
- https://doi.org/10.3390/app14031071
- https://doi.org/10.3390/app13084662
- https://doi.org/10.3390/app122211504
- Comment: Significance and novelty are unclear to me. Since there are already international and national standards for diagnostic reference levels for pediatric CT, what's the point of re-assessing them with some local data? I'm sure it's useful for local hospitals, but it's unclear to me how this would be useful for the general readership, especially since there are no clear and quantitative conclusions in the end.
Response: We tried to show the significance and novelty of this research. They were written and highlighted in the introduction, lines 40 to 48.
- Comment: The method of data analysis appears to be a standard one. Other than local data, I don't see any novelty here.
Response: In our opinion, the standard analysis was chosen because it was convenient, straight-forward, and easy to conduct.
- Comment: By the way, the following two papers may be worth citing.
https://pubs.rsna.org/doi/10.1148/radiol.2021211241
https://doi.org/10.1007/s00247-022-05340-8
Response: The references were useful and cited in the introduction part [17] and [18].
- Comment: Conclusion improvement
Response: The conclusion was rewritten lines 160 to 172
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsMost of tables present >1 instead of <1 to indicate children with ages below an year old. Revise and fix them all. No major issues were found.
Author Response
Most of tables present >1 instead of <1 to indicate children with ages below an year old. Revise and fix them all.
Response they were revised, corrected and highlighted throughout the manuscript.
Author Response File: Author Response.pdf
Round 2
Reviewer 2 Report
Comments and Suggestions for AuthorsI have no further comments about the paper's quality and appropriateness of publication in this journal. If there is precedence of such papers published in the same journal, I guess there is no reason not to accept this one.
Two minor points to consider addressing at the proofing stage:
(1) In Equation (1), that big X is meant for multiplication I believe. It should be lower case and not in the same font as the rest, to avoid confusion.
(2) Changing "5 <= - 10" to "5 <= to 10" doesn't really help. It's just as confusing, because the math convention is "a <= x < b" where "x" is the variable (in this case "age"). Having a "-" or "to" in place of the variable isn't the convention. A more concise math expression is [5,10). The square [ means inclusive, and the round ) means up to but exclusive. If the authors keep the "a to b" format, it should really be ">=5 to <10". However, after a few instances, I think the reader knows what they really meant anyway. So the suggested change is optional.
