Updated National Diagnostic Reference Levels and Achievable Doses for CT Protocols: A National Survey of Korean Hospitals

Round 1

Reviewer 1 Report

Reviewer: Overall this article reports on CT doses for common exams in a nationwide survey. If the data as presented represents wide range of scanners in this country, then this sample is an excellent collection of national data on which to base DRLs.

 

1-    However, the methodology as presented needs significant clarification to outline how these values were calculated and whether the methodology follows current ICRP (135) advice in terms of using the 75th centile of the median values reported by each site.

 

2-    Secondly, what QA if any was performed to ensure accuracy of data. Was the CTDI and DLP simply read out from the displays on the CT scanners? Were these calibrated? Was the data checked for errors prior to analysis?

 

 

3-    Thirdly please explain the rationale for including patients of all sizes in this data collection - when current advice would be to include just standard size patients? Has this impacted on results - it is unclear until further clarification is provided on the method
of DRL calculation.

 

4-    Also the discussion lacks analysis of the data in particular on differences between sites - which is reported as a study highlight but not touched on at all in the discussion. Given the relative homogeneity of equipment included in this survey would have been opportune to examine the causes for any differences between sites and whether this was due to simple differences in patients.

 

5-    The study highlights mention the potential for optimization but again this is not really discussed or presented to the reader

 

6-    Add the current study results to table 7 and it is preferable to add more countries for the comparison

 

7-    In table 6 some of the data cited old from 2010, and it is preferable to cite some Asian countries with similar and recent results

Author Response

Response to review

 

To the editor and participating reviewers of this manuscript.

We would like to thank you for the review of this manuscript, and for giving us an additional opportunity to clarify our intent.

Following the editor and reviewer's comments we have revised the manuscript accordingly

Reviewer 1

Overall this article reports on CT doses for common exams in a nationwide survey. If the data as presented represents wide range of scanners in this country, then this sample is an excellent collection of national data on which to base DRLs.

 

1-    However, the methodology as presented needs significant clarification to outline how these values were calculated and whether the methodology follows current ICRP (135) advice in terms of using the 75th centile of the median values reported by each site.

 

Added sentence : This study obtained at least five patient data per CT device in each exam protocol in accordance with the recommendations of ICRP [9].

2-    Secondly, what QA if any was performed to ensure accuracy of data. Was the CTDI and DLP simply read out from the displays on the CT scanners? Were these calibrated? Was the data checked for errors prior to analysis?

Added sentence : In addition, all the CT devices which were surveyed in this study passed the CT quality control program conducted by the Korea Centers for Disease Control and Prevention, which included evaluating the accuracy of CTDI_vol and DLP.

3-    Thirdly please explain the rationale for including patients of all sizes in this data collection - when current advice would be to include just standard size patients? Has this impacted on results - it is unclear until further clarification is provided on the method of DRL calculation.

Patients were selected by body weight based on 5–95% of Korean standard body types taken from a Korean body type survey from the Korean National Statistical Office.

Added Sentence : Patients were selected by body weight based on 5–95% of Korean standard body types taken from a Korean body type survey from the Korean National Statistical Office. In the 7th Korean Standard Body Survey 2015, the quintiles value and 95 quartile value of height and weight were 151.2 cm, 179.8 cm, 47.0 kg, and 87.0 kg respectively in 15 to 70 years old [11]. Patients’ data within this range were collected, and this study did not calculate the DLP separately, and used the value which displayed in the CT device.  

4-    Also the discussion lacks analysis of the data in particular on differences between sites - which is reported as a study highlight but not touched on at all in the discussion. Given the relative homogeneity of equipment included in this survey would have been opportune to examine the causes for any differences between sites and whether this was due to simple differences in patients.

        Added Sentence : The purpose of the exam and using the CT device might be different depending on the size of the medical institutions. In the results of this study, it was confirmed that CTDIvol was ra-ther higher at the university general hospital level than at the clinic level. Table 8 shows the comparison of DRLs for the medical institutions site size group. 

5-    The study highlights mention the potential for optimization but again this is not really discussed or presented to the reader

In the third survey compared with the second survey, in the case of adult brain CT and intracranial CT angiography, the CTDIvol and the DLP of AD value were lowered to 11.60 mGy, 181.90 mGy·cm, 0.13 mGy, and 31.20 mGy·cm, respectively. In the case of the cervi-cal spine CT, the CTDIvol and DLP of AD value were raised to 1.92 mGy, 53.00 mGy·cm. In case of the lumbar spine CT, the CTDIvol of AD value was lowered 0.12 mGy, however, the DLP of AD value was raised to 34.98 mGy·cm compared with the second survey.

In case of the neck CT with contrast, low dose screening chest CT, abdomen-pelvis CT with contrast, and abdomen 4 phase dynamic CT with contrast, the CTDIvol and DLP of AD value were lowered to 0.97 mGy, 21.71 mGy·cm, 0.15 mGy, 3.09 mGy·cm, 0.85 mGy, 4.31 mGy·cm, 1.75 mGy, 92.60 mGy·cm, respectively compared with the second survey.

However, in the case of chest CT with contrast and coronary artery calcium score CT, only DLP were raised to 9.27 mGy·cm and 268.10 mGy·cm, respectively. In case of the ab-domen-pelvis CT without contrast for urinary system, the CTDIvol and DLP of AD value were raised to 1.01 mGy and 64.36 mGy·cm, respectively. In case of coronary artery CT angi-ography, the CTDIvol and DLP of AD value were lowered to 14.11 mGy and 230.72 mGy·cm, respectively. In most protocols, the AD values of the third survey were decreased compared to the second survey, however, the increment of AD DLP in cervical spine CT, lumber spine CT, abdomen-pelvis CT without contrast for urinary system, and coronary artery calcium score CT meant that the scan area became widened. Therefore, in case of these protocol, lowering the target value by bewaring to setting the scan range will be the way to achieve optimization.[10] 6-    Add the current study results to table 7 and it is preferable to add more countries for the comparison

Add reference

Korea 2021 is the This study’s result, and we changed the title from Korea 2021 to this study. And Added the reference.

7-    In table 6 some of the data cited old from 2010, and it is preferable to cite some Asian countries with similar and recent results

Added reference

 

 

Reviewer 2

Title:  the title is informative:

Abstract

 The abstract is presented in a structured format

Remove most pronounce (we) from the abstract and substituted them by authors or any suitable sentence link.

Corrected it

 Suggest any future study in this line specifically parts include radiosensitive organs

Added sentence: This DRLs will be used for radiation optimization and effective dose calculation for radio-sensitive organs.

From abstract reader feel the study performed for jut brain CT adult and pediatric, please explain the examinations clearly.

Corrected sentence more clearly:  This study investigated the CTDIvol and DLP of the 12 types of CT protocols for adult and brain CT protocol for pediatric. A total of 7,829 CT examinations were performed using 225 scanners.

 INTRODUCTION

Add sentence to explain the importance of your study and also the importance of DRL.

The DRLs has proven to be an effective tool that aids in optimization of protection during medical exposure of patients for diagnostic and interventional procedures. The DRLs is a supplement to professional judgement and does not provide a dividing line between good and bad medical practice. All individuals who have a role in subjecting a patient to medical ex-posure should be familiar with DRLs as a tool for optimization of protection [9].

 Also, you can explain in short paragraph different ways to achieve DRL as NDRL or nationwide DRL. And how DRL contribute in reducing or optimizing procedures with suitable citations.

Added Sentence: National DRLs should be compared with regional or local DRLs, and if the DRLs of individual medical institutions are higher than the national DRLs, each center should implement the quality control procedures to keep their DRLs lower than the national DRLs, and the proce-dures should be established to optimize.

MATERIALS AND METHODS

Is the Body mass index BMI have in role (impact) in determining the DRL?

BMI was not considered in this study.

following up and quality control tests for these CT machines when performed and do they pass these tests? to remove any inconsistency

Added Sentence: In addition, all the CT devices which were surveyed in this study passed the CT quality control program conducted by the Korea Centers for Disease Control and Prevention, which included evaluating the accuracy of CTDIvol and DLP.

The methodology is written properly.

RESULTS

‘This survey collected data from 7,186 CT examinations using 12 CT protocols’. I think this is not result it should be added in Methodology section.

Delated it

 Have you evaluated the effective dose which considers an important quantity in protection. To determine do you need to establish DRL as result of higher dose or wide variation of E.

Added Sentence:  In addition, based on the results of this study, the effective dose evaluation with tissue weighting factor will be easily used as a tool for evaluating the patient effective dose in clinical area [8].

DISCUSSION

Discussion is rich and informative

Conclusions

In my opinion the manuscript as whole is -Informative, but still require editing, and revision as mentioned above in details in each section.

Thanks for your review, Edited and proofread by native speakers

Edit some typos

 

 

 

Reviwer 3

Thank you for the material sent. This is a desirable research. We are pleased with the size of the tested sample of devices and patients. The only thing that could add value to the work is a more in-depth analysis of the state of the art. Highlight the summary.
Best regards.

Thanks for your review, we added sentence in conclusion: “Besides the DRL of this study, the utilization of advanced dose reduction technologies such as using AI will be used as a useful way to reduce patients' dose.”

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

Proposed recommendation: The manuscript may become acceptable after minor revisions of content

Title:  the title is informative:

Abstract

-          The abstract is presented in a structured format

-          Remove most pronounce (we) from the abstract and substituted them by authors or any suitable sentence link.

-          Suggest any future study in this line specifically parts include radiosensitive organs

-          From abstract reader feel the study performed for jut brain CT adult and pediatric, please explain the examinations clearly.

 INTRODUCTION

-          Add sentence to explain the importance of your study and also the importance of DRL.

-          Also, you can explain in short paragraph different ways to achieve DRL as NDRL or nationwide DRL. And how DRL contribute in reducing or optimizing procedures with suitable citations.

MATERIALS AND METHODS

-Is the Body mass index BMI have in role (impact) in determining the DRL?

- following up and quality control tests for these CT machines when performed and do they pass these tests? to remove any inconsistency

The methodology is written properly.

RESULTS

-          ‘This survey collected data from 7,186 CT examinations using 12 CT protocols’. I think this is not result it should be added in Methodology section.

-          Have you evaluated the effective dose which considers an important quantity in protection. To determine do you need to establish DRL as result of higher dose or wide variation of E.

DISCUSSION

-          Discussion is rich and informative

Conclusions

-          In my opinion the manuscript as whole is -Informative, but still require editing, and revision as mentioned above in details in each section.

-          - Edit some typos

Author Response

Response to review

 

To the editor and participating reviewers of this manuscript.

We would like to thank you for the review of this manuscript, and for giving us an additional opportunity to clarify our intent.

Following the editor and reviewer's comments we have revised the manuscript accordingly

Reviewer 1

Overall this article reports on CT doses for common exams in a nationwide survey. If the data as presented represents wide range of scanners in this country, then this sample is an excellent collection of national data on which to base DRLs.

 

1-    However, the methodology as presented needs significant clarification to outline how these values were calculated and whether the methodology follows current ICRP (135) advice in terms of using the 75th centile of the median values reported by each site.

 

Added sentence : This study obtained at least five patient data per CT device in each exam protocol in accordance with the recommendations of ICRP [9].

2-    Secondly, what QA if any was performed to ensure accuracy of data. Was the CTDI and DLP simply read out from the displays on the CT scanners? Were these calibrated? Was the data checked for errors prior to analysis?

Added sentence : In addition, all the CT devices which were surveyed in this study passed the CT quality control program conducted by the Korea Centers for Disease Control and Prevention, which included evaluating the accuracy of CTDI_vol and DLP.

3-    Thirdly please explain the rationale for including patients of all sizes in this data collection - when current advice would be to include just standard size patients? Has this impacted on results - it is unclear until further clarification is provided on the method of DRL calculation.

Patients were selected by body weight based on 5–95% of Korean standard body types taken from a Korean body type survey from the Korean National Statistical Office.

Added Sentence : Patients were selected by body weight based on 5–95% of Korean standard body types taken from a Korean body type survey from the Korean National Statistical Office. In the 7th Korean Standard Body Survey 2015, the quintiles value and 95 quartile value of height and weight were 151.2 cm, 179.8 cm, 47.0 kg, and 87.0 kg respectively in 15 to 70 years old [11]. Patients’ data within this range were collected, and this study did not calculate the DLP separately, and used the value which displayed in the CT device.  

4-    Also the discussion lacks analysis of the data in particular on differences between sites - which is reported as a study highlight but not touched on at all in the discussion. Given the relative homogeneity of equipment included in this survey would have been opportune to examine the causes for any differences between sites and whether this was due to simple differences in patients.

        Added Sentence : The purpose of the exam and using the CT device might be different depending on the size of the medical institutions. In the results of this study, it was confirmed that CTDIvol was ra-ther higher at the university general hospital level than at the clinic level. Table 8 shows the comparison of DRLs for the medical institutions site size group. 

5-    The study highlights mention the potential for optimization but again this is not really discussed or presented to the reader

In the third survey compared with the second survey, in the case of adult brain CT and intracranial CT angiography, the CTDIvol and the DLP of AD value were lowered to 11.60 mGy, 181.90 mGy·cm, 0.13 mGy, and 31.20 mGy·cm, respectively. In the case of the cervi-cal spine CT, the CTDIvol and DLP of AD value were raised to 1.92 mGy, 53.00 mGy·cm. In case of the lumbar spine CT, the CTDIvol of AD value was lowered 0.12 mGy, however, the DLP of AD value was raised to 34.98 mGy·cm compared with the second survey.

In case of the neck CT with contrast, low dose screening chest CT, abdomen-pelvis CT with contrast, and abdomen 4 phase dynamic CT with contrast, the CTDIvol and DLP of AD value were lowered to 0.97 mGy, 21.71 mGy·cm, 0.15 mGy, 3.09 mGy·cm, 0.85 mGy, 4.31 mGy·cm, 1.75 mGy, 92.60 mGy·cm, respectively compared with the second survey.

However, in the case of chest CT with contrast and coronary artery calcium score CT, only DLP were raised to 9.27 mGy·cm and 268.10 mGy·cm, respectively. In case of the ab-domen-pelvis CT without contrast for urinary system, the CTDIvol and DLP of AD value were raised to 1.01 mGy and 64.36 mGy·cm, respectively. In case of coronary artery CT angi-ography, the CTDIvol and DLP of AD value were lowered to 14.11 mGy and 230.72 mGy·cm, respectively. In most protocols, the AD values of the third survey were decreased compared to the second survey, however, the increment of AD DLP in cervical spine CT, lumber spine CT, abdomen-pelvis CT without contrast for urinary system, and coronary artery calcium score CT meant that the scan area became widened. Therefore, in case of these protocol, lowering the target value by bewaring to setting the scan range will be the way to achieve optimization.[10] 6-    Add the current study results to table 7 and it is preferable to add more countries for the comparison

Add reference

Korea 2021 is the This study’s result, and we changed the title from Korea 2021 to this study. And Added the reference.

7-    In table 6 some of the data cited old from 2010, and it is preferable to cite some Asian countries with similar and recent results

Added reference

 

 

Reviewer 2

Title:  the title is informative:

Abstract

 The abstract is presented in a structured format

Remove most pronounce (we) from the abstract and substituted them by authors or any suitable sentence link.

Corrected it

 Suggest any future study in this line specifically parts include radiosensitive organs

Added sentence: This DRLs will be used for radiation optimization and effective dose calculation for radio-sensitive organs.

From abstract reader feel the study performed for jut brain CT adult and pediatric, please explain the examinations clearly.

Corrected sentence more clearly:  This study investigated the CTDIvol and DLP of the 12 types of CT protocols for adult and brain CT protocol for pediatric. A total of 7,829 CT examinations were performed using 225 scanners.

 INTRODUCTION

Add sentence to explain the importance of your study and also the importance of DRL.

The DRLs has proven to be an effective tool that aids in optimization of protection during medical exposure of patients for diagnostic and interventional procedures. The DRLs is a supplement to professional judgement and does not provide a dividing line between good and bad medical practice. All individuals who have a role in subjecting a patient to medical ex-posure should be familiar with DRLs as a tool for optimization of protection [9].

 Also, you can explain in short paragraph different ways to achieve DRL as NDRL or nationwide DRL. And how DRL contribute in reducing or optimizing procedures with suitable citations.

Added Sentence: National DRLs should be compared with regional or local DRLs, and if the DRLs of individual medical institutions are higher than the national DRLs, each center should implement the quality control procedures to keep their DRLs lower than the national DRLs, and the proce-dures should be established to optimize.

MATERIALS AND METHODS

Is the Body mass index BMI have in role (impact) in determining the DRL?

BMI was not considered in this study.

following up and quality control tests for these CT machines when performed and do they pass these tests? to remove any inconsistency

Added Sentence: In addition, all the CT devices which were surveyed in this study passed the CT quality control program conducted by the Korea Centers for Disease Control and Prevention, which included evaluating the accuracy of CTDIvol and DLP.

The methodology is written properly.

RESULTS

‘This survey collected data from 7,186 CT examinations using 12 CT protocols’. I think this is not result it should be added in Methodology section.

Delated it

 Have you evaluated the effective dose which considers an important quantity in protection. To determine do you need to establish DRL as result of higher dose or wide variation of E.

Added Sentence:  In addition, based on the results of this study, the effective dose evaluation with tissue weighting factor will be easily used as a tool for evaluating the patient effective dose in clinical area [8].

DISCUSSION

Discussion is rich and informative

Conclusions

In my opinion the manuscript as whole is -Informative, but still require editing, and revision as mentioned above in details in each section.

Thanks for your review, Edited and proofread by native speakers

Edit some typos

 

 

 

Reviwer 3

Thank you for the material sent. This is a desirable research. We are pleased with the size of the tested sample of devices and patients. The only thing that could add value to the work is a more in-depth analysis of the state of the art. Highlight the summary.
Best regards.

Thanks for your review, we added sentence in conclusion: “Besides the DRL of this study, the utilization of advanced dose reduction technologies such as using AI will be used as a useful way to reduce patients' dose.”

 

 

Author Response File: Author Response.docx

Reviewer 3 Report

Thank you for the material sent. This is a desirable research. We are pleased with the size of the tested sample of devices and patients. The only thing that could add value to the work is a more in-depth analysis of the state of the art. Highlight the summary.
Best regards.

Author Response

Response to review

 

To the editor and participating reviewers of this manuscript.

We would like to thank you for the review of this manuscript, and for giving us an additional opportunity to clarify our intent.

Following the editor and reviewer's comments we have revised the manuscript accordingly

Reviewer 1

Overall this article reports on CT doses for common exams in a nationwide survey. If the data as presented represents wide range of scanners in this country, then this sample is an excellent collection of national data on which to base DRLs.

 

1-    However, the methodology as presented needs significant clarification to outline how these values were calculated and whether the methodology follows current ICRP (135) advice in terms of using the 75th centile of the median values reported by each site.

 

Added sentence : This study obtained at least five patient data per CT device in each exam protocol in accordance with the recommendations of ICRP [9].

2-    Secondly, what QA if any was performed to ensure accuracy of data. Was the CTDI and DLP simply read out from the displays on the CT scanners? Were these calibrated? Was the data checked for errors prior to analysis?

Added sentence : In addition, all the CT devices which were surveyed in this study passed the CT quality control program conducted by the Korea Centers for Disease Control and Prevention, which included evaluating the accuracy of CTDI_vol and DLP.

3-    Thirdly please explain the rationale for including patients of all sizes in this data collection - when current advice would be to include just standard size patients? Has this impacted on results - it is unclear until further clarification is provided on the method of DRL calculation.

Patients were selected by body weight based on 5–95% of Korean standard body types taken from a Korean body type survey from the Korean National Statistical Office.

Added Sentence : Patients were selected by body weight based on 5–95% of Korean standard body types taken from a Korean body type survey from the Korean National Statistical Office. In the 7th Korean Standard Body Survey 2015, the quintiles value and 95 quartile value of height and weight were 151.2 cm, 179.8 cm, 47.0 kg, and 87.0 kg respectively in 15 to 70 years old [11]. Patients’ data within this range were collected, and this study did not calculate the DLP separately, and used the value which displayed in the CT device.  

4-    Also the discussion lacks analysis of the data in particular on differences between sites - which is reported as a study highlight but not touched on at all in the discussion. Given the relative homogeneity of equipment included in this survey would have been opportune to examine the causes for any differences between sites and whether this was due to simple differences in patients.

        Added Sentence : The purpose of the exam and using the CT device might be different depending on the size of the medical institutions. In the results of this study, it was confirmed that CTDIvol was ra-ther higher at the university general hospital level than at the clinic level. Table 8 shows the comparison of DRLs for the medical institutions site size group. 

5-    The study highlights mention the potential for optimization but again this is not really discussed or presented to the reader

In the third survey compared with the second survey, in the case of adult brain CT and intracranial CT angiography, the CTDIvol and the DLP of AD value were lowered to 11.60 mGy, 181.90 mGy·cm, 0.13 mGy, and 31.20 mGy·cm, respectively. In the case of the cervi-cal spine CT, the CTDIvol and DLP of AD value were raised to 1.92 mGy, 53.00 mGy·cm. In case of the lumbar spine CT, the CTDIvol of AD value was lowered 0.12 mGy, however, the DLP of AD value was raised to 34.98 mGy·cm compared with the second survey.

In case of the neck CT with contrast, low dose screening chest CT, abdomen-pelvis CT with contrast, and abdomen 4 phase dynamic CT with contrast, the CTDIvol and DLP of AD value were lowered to 0.97 mGy, 21.71 mGy·cm, 0.15 mGy, 3.09 mGy·cm, 0.85 mGy, 4.31 mGy·cm, 1.75 mGy, 92.60 mGy·cm, respectively compared with the second survey.

However, in the case of chest CT with contrast and coronary artery calcium score CT, only DLP were raised to 9.27 mGy·cm and 268.10 mGy·cm, respectively. In case of the ab-domen-pelvis CT without contrast for urinary system, the CTDIvol and DLP of AD value were raised to 1.01 mGy and 64.36 mGy·cm, respectively. In case of coronary artery CT angi-ography, the CTDIvol and DLP of AD value were lowered to 14.11 mGy and 230.72 mGy·cm, respectively. In most protocols, the AD values of the third survey were decreased compared to the second survey, however, the increment of AD DLP in cervical spine CT, lumber spine CT, abdomen-pelvis CT without contrast for urinary system, and coronary artery calcium score CT meant that the scan area became widened. Therefore, in case of these protocol, lowering the target value by bewaring to setting the scan range will be the way to achieve optimization.[10] 6-    Add the current study results to table 7 and it is preferable to add more countries for the comparison

Add reference

Korea 2021 is the This study’s result, and we changed the title from Korea 2021 to this study. And Added the reference.

7-    In table 6 some of the data cited old from 2010, and it is preferable to cite some Asian countries with similar and recent results

Added reference

 

 

Reviewer 2

Title:  the title is informative:

Abstract

 The abstract is presented in a structured format

Remove most pronounce (we) from the abstract and substituted them by authors or any suitable sentence link.

Corrected it

 Suggest any future study in this line specifically parts include radiosensitive organs

Added sentence: This DRLs will be used for radiation optimization and effective dose calculation for radio-sensitive organs.

From abstract reader feel the study performed for jut brain CT adult and pediatric, please explain the examinations clearly.

Corrected sentence more clearly:  This study investigated the CTDIvol and DLP of the 12 types of CT protocols for adult and brain CT protocol for pediatric. A total of 7,829 CT examinations were performed using 225 scanners.

 INTRODUCTION

Add sentence to explain the importance of your study and also the importance of DRL.

The DRLs has proven to be an effective tool that aids in optimization of protection during medical exposure of patients for diagnostic and interventional procedures. The DRLs is a supplement to professional judgement and does not provide a dividing line between good and bad medical practice. All individuals who have a role in subjecting a patient to medical ex-posure should be familiar with DRLs as a tool for optimization of protection [9].

 Also, you can explain in short paragraph different ways to achieve DRL as NDRL or nationwide DRL. And how DRL contribute in reducing or optimizing procedures with suitable citations.

Added Sentence: National DRLs should be compared with regional or local DRLs, and if the DRLs of individual medical institutions are higher than the national DRLs, each center should implement the quality control procedures to keep their DRLs lower than the national DRLs, and the proce-dures should be established to optimize.

MATERIALS AND METHODS

Is the Body mass index BMI have in role (impact) in determining the DRL?

BMI was not considered in this study.

following up and quality control tests for these CT machines when performed and do they pass these tests? to remove any inconsistency

Added Sentence: In addition, all the CT devices which were surveyed in this study passed the CT quality control program conducted by the Korea Centers for Disease Control and Prevention, which included evaluating the accuracy of CTDIvol and DLP.

The methodology is written properly.

RESULTS

‘This survey collected data from 7,186 CT examinations using 12 CT protocols’. I think this is not result it should be added in Methodology section.

Delated it

 Have you evaluated the effective dose which considers an important quantity in protection. To determine do you need to establish DRL as result of higher dose or wide variation of E.

Added Sentence:  In addition, based on the results of this study, the effective dose evaluation with tissue weighting factor will be easily used as a tool for evaluating the patient effective dose in clinical area [8].

DISCUSSION

Discussion is rich and informative

Conclusions

In my opinion the manuscript as whole is -Informative, but still require editing, and revision as mentioned above in details in each section.

Thanks for your review, Edited and proofread by native speakers

Edit some typos

 

 

 

Reviwer 3

Thank you for the material sent. This is a desirable research. We are pleased with the size of the tested sample of devices and patients. The only thing that could add value to the work is a more in-depth analysis of the state of the art. Highlight the summary.
Best regards.

Thanks for your review, we added sentence in conclusion: “Besides the DRL of this study, the utilization of advanced dose reduction technologies such as using AI will be used as a useful way to reduce patients' dose.”

 

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The manuscript improved and all the comments addressed 

Author Response

We would like to thank you for the review of this manuscript. We were checked your comment. We attached new version file.  

 

Author Response File: Author Response.docx