PATIENT DOSE IN DIGITAL RADIOGRAPHY UTILISING BMI CLASSIFICATION

The impact of X-ray scatter correction software on abdomen radiography in terms of image quality and radiation dose

INTRODUCTION

The conventional anti-scatter grid is widely used in X-ray radiography to reduce scattered X-rays, but it increases patient dose. Scatter-correction software offers a dose-reducing alternative by correcting for scattered X-rays without a physical grid. Grids and software correction are necessary to reduce scatter radiation and improve image quality especially for the large body parts. The scatter correction can be beneficial in situations where the use of grid is challenging. The implementation of grids and advanced software correction techniques is imperative to ensure that radiographic images maintain high levels of clarity, contrast, and resolution, and ultimately facilitating more accurate diagnoses. This study compares image quality and radiation dose for abdomen exams using scatter correction software and physical grids.

METHODS

An anthropomorphic phantom (abdomen) underwent imaging with varying fat and lean tissue layers and body mass index (BMI) configurations. Imaging parameters included 70 kVp tube voltage, 110 cm SID, and Automatic Exposure Control (AEC) both lateral and central chambers. AP abdomen X-ray projections were acquired with and without an anti-scatter grid, and scatter correction software was applied. Image quality was assessed using contrast to noise ratio (CNR) and signal to noise ratio (SNR) metrics. The tube current mAs was considered an exposure factor that affected radiation dose and was used to compare the VG software and physical grid. Radiation dose was measured using Dose Area Products (DAP). The effective dose was estimated using Monte Carlo simulation-PCXMC software. Paired t-tests were used to investigate the image quality difference between the Gridless and VG software, Gridless and PG, and VG software and PG approaches. For the DAP and effective dose, paired t-test was used to investigate the difference between VG software and PG.

RESULTS

Images acquired with a grid had the highest mean CNR (71.3 ± 32) compared to Gridless (50 ± 33.8) and scatter correction software (59.3 ± 37.9). The mean SNR of the grid images was (82.7.3 ± 38.9), which is 18% higher than the scatter correction software images (70.4 ± 36.7) and 29% higher than in the Gridless images (62.9.3 ± 34). The mean DAP value was reduced by 81% when the scatter correction software was used compared to the grid (mean: 65.4 μGy.m2 and 338.2 μGy.m2, respectively) with a significant difference (p = 0.001). Scatter correction software resulted in a lower effective dose compared to physical grid use, (mean difference± SD = -0.3 ± 0.18 mSv) with a significant difference (P = 0.02).

CONCLUSION

Scatter correction software reduced the radiation dose required but images employing a grid yielded higher CNR and SNR. However, the radiation dose reduction might affect the image quality to a level that impacts the diagnostic information available. Thus, further research needs to be conducted to optimise the use of the scatter correction software.

IMPLICATION FOR PRACTICE

Objectively, X-ray scatter correction software might be promising in conditions where a grid cannot be applied.

Towards the establishment of national diagnostic reference levels for abdomen, KUB, and lumbar spine x-ray examinations in Sri Lanka: a multi-centric study

Diagnostic reference levels (DRLs) and achievable doses (ADs) provide guidance to optimise radiation doses for patients undergoing medical imaging procedures. This multi-centre study aimed to compare institutional DRLs (IDRLs) across hospitals, propose ADs and multi-centric DRLs (MCDRLs) for four common x-ray examinations in Sri Lanka, and assess the potential for dose reduction. A prospective cross-sectional study of 894 adult patients referred for abdomen anteroposterior (AP), kidney-ureter-bladder (KUB) AP, lumbar spine AP, and lumbar spine lateral (LAT) x-ray examinations was conducted. Patient demographic information (age, sex, weight, BMI) and exposure parameters (tube voltage, tube current-exposure time product) were collected. Patient dose indicators were measured in terms of kerma-area product (PKA) using a PKAmeter. IDRLs, ADs, and MCDRLs were calculated following the International Commission on Radiological Protection guidelines, with ADs and MCDRLs defined as the 50th and 75th percentiles of the median PKAdistributions, respectively. IDRL ranges varied considerably across hospitals: 1.42-2.42 Gy cm2for abdomen AP, 1.51-2.86 Gy cm2for KUB AP, 0.83-1.65 Gy cm2for lumbar spine AP, and 1.76-4.10 Gy cm2for lumbar spine LAT. The proposed ADs were 1.82 Gy cm2(abdomen AP), 2.03 Gy cm2(KUB AP), 1.27 Gy cm2(lumbar spine AP), and 2.21 Gy cm2(lumbar spine LAT). MCDRLs were 2.24 Gy cm2(abdomen AP), 2.40 Gy cm2(KUB AP), 1.43 Gy cm2(lumbar spine AP), and 2.38 Gy cm2(lumbar spine LAT). Substantial intra- and inter-hospital variations in PKAwere observed for all four examinations. Although ADs and MCDRLs in Sri Lanka were comparable to those in the existing literature, the identified intra- and inter-hospital variations underscore the need for dose reduction without compromising diagnostic information. Hospitals with high IDRLs are recommended to review and optimise their practices. These MCDRLs serve as preliminary national DRLs, guiding dose optimisation efforts by medical professionals and policymakers.

Establishment of local diagnostic reference levels for abdomen and chest radiographies in the region of Algarve, Portugal

PURPOSE

To assess doses variabilities in the same abdomen and chest RX exams for adults, to check the need for dose harmonization. To calculate Diagnostic Reference Levels (DRL), mandatory in the European Union, for the Algarve district in Portugal. Our results can be a valuable reference for the Portuguese official determination of DRLs, still in progress.

METHOD

We considered 4,936 abdomen and 41,320 chest radiographs of adults, covering 7 health centres and 35 radiographers in Algarve. Entrance skin dose (ESD) was calculated for each radiograph and the corresponding uncertainty estimated. Mean doses per centre and per technician, and their uncertainties, were calculated to access dose variabilities. DRLs, set at the 3rd quartile of the total ESD distribution, were determined for a standard patient and for intervals of body mass index (BMI) to study their correlation with patient anatomical variations. Standard quartile errors were estimated.

RESULTS

Our results suggest significant dispersion in applied ESDs among different centres and radiographers. Estimates of DRLs also show small fluctuations across years and an important dependence on BMI intervals. For a standard patient, they are 8.7 ± 0.1 (abdomen) and 0.44 ± 0.01 (chest), while the European DRLs are, respectively, 5.1 and 0.2 (all in mGy).

CONCLUSIONS

Results suggest that there is room for dose optimization and harmonization with European DRLs, urging a national dose survey and the establishment of official national DRLs. Official DRLs in intervals of BMI would be quite beneficial, to avoid unnecessary dose exposures.

Erect pelvic radiography with fat tissue displacement: Impact on radiation dose and image quality

INTRODUCTION

Pelvic radiography is one of the most frequent general radiography imaging procedures. Pelvic radiography is usually performed in the supine position, but in some cases erect imaging is performed. The aim of this study was to determine whether radiation dose and image quality differ between two different erect pelvic radiographic procedures in overweight and obese patients, with and without displacement of anterior adipose tissue.

METHODS

This research was a two-part study. The first part of the study was to determine a suitable fat displacement band that would not produce artifacts on the resulting radiograph when fat tissue was displaced. The second part of the study was performed in a clinical setting on 60 overweight or obese patients (BMI ≥25) referred for erect pelvic imaging. Patients were randomly divided into two equal groups, half of which displaced adipose tissue from the region of interest and the other group did not. Waist and hip circumference, height, weight, dose-area- product (DAP), primary field size, source-to-skin distance, mAs, and kV were measured. Body Mass Index (BMI), entrance surface dose (ESD), and effective dose (ED) were then calculated. The resulting images were evaluated by three radiologists.

RESULTS

It was found that a thin cotton triangular bandage produced no visible radiographic artefacts. In the group of patients using the fat displacement protocol, a statistically significant reduction in waist circumference (4.7%), DAP (38.5%), ESD (44%) and ED (38.7%) were observed (p < 0.05). In addition, a significant (p < 0.05) increase was found for all the observed image quality criteria and overall total image score with exception of sacroiliac joint, iliac crest and pubic/ischial rami.

CONCLUSION

Based on the results, the use of the adipose tissue displacement protocol for radiography of the pelvis and hip in the erect position in overweight and obese patients is recommended.

IMPLICATIONS FOR PRACTICE

The use of cotton bands to remove adipose tissue during pelvic imaging in obese and overweight patients results in a reduction of radiation dose received by the patient and improves image quality. This technique is quick, easy, and inexpensive.

The reliability of video fluoroscopy, ultrasound imaging, magnetic resonance imaging and radiography for measurements of lumbar spine segmental range of motion in-vivo: A review

BACKGROUND

Lower back pain (LBP) is a principal cause of disability worldwide and is associated with a variety of spinal conditions. Individuals presenting with LBP may display changes in spinal motion. Despite this, the ability to measure lumbar segmental range of motion (ROM) non-invasively remains a challenge.

OBJECTIVE

To review the reliability of four non-invasive modalities: Video Fluoroscopy (VF), Ultrasound imaging (US), Magnetic Resonance Imaging (MRI) and Radiography used for measuring segmental ROM in the lumbar spine in-vivo.

METHODS

The methodological quality of seventeen eligible studies, identified through a systematic literature search, were appraised.

RESULTS

The intra-rater reliability for VF is excellent in recumbent and upright positions but errors are larger for intra-rater repeated movements and inter-rater reliability shows larger variation. Excellent results for intra- and inter-rater reliability are seen in US studies and there is good reliability within- and between-day. There is a large degree of heterogeneity in MRI and radiography methodologies but reliable results are seen.

CONCLUSIONS

Excellent reliability is seen across all modalities. However, VF and radiography are limited by radiation exposure and MRI is expensive. US offers a non-invasive, risk free method but further research must determine whether it yields truly consistent measurements.

An audit of patient radiation doses in interventional radiology at a South African hospital

Background

Interventional radiology (IR) is becoming more relevant in patient care and is associated with increased patient radiation exposure and radiation-induced adverse effects. Diagnostic reference levels (DRLs) are crucial for radiation control. There is a paucity of published DRLs for IR in South Africa and sub-Saharan Africa.

Objectives

This study aimed to determine local DRLs for fluoroscopically-guided IR procedures and compare the achieved DRLs with published local and international DRLs.

Method

Retrospective, descriptive, single-centre study. Kerma air product (KAP), reference point air kerma (K_a,r) and fluoroscopy time (FT) were collected for patients (12 years and older) who underwent IR procedures at a university hospital from 01 January 2019 to 31 December 2019. The 75th percentile of the distribution of each dose parameter (KAP, K_a,r and FT) per procedure was calculated and taken as the local diagnostic reference levels (LDRL). The established LDRLs were compared to published DRLs.

Results

A total of 564 cases were evaluated. The 13 most frequent procedures (with 15 or more cases) represented 86.1% (487/564). Percutaneous transhepatic biliary drainage was the most common procedure (n = 146, 25.9%). Diagnostic cerebral angiogram DRLs exceeded the published DRL data ranges for all parameters (DRL 209.3), and interventional cerebral angiogram exceeded published ranges (DRL 275). Uterine artery embolisation (UAE) exceeded these ranges for KAP and K_a,r. (KAP-954.9 Gy/cm², K_a,r-2640.8 mGy).

Conclusion

The LDRLs for diagnostic cerebral angiogram, interventional cerebral angiogram and UAE exceeded published international DRL ranges. These procedures require radiation optimisation as recommended by the International Commission on Radiological Protection (ICRP).

Contribution

In addition to informing radiation protection practices at the level of the institution, the established LDRLs contribute towards Regional and National DRLs.

The impact of body mass index on patient radiation dose in general radiography

The aim of the present study was to determine the influence of the body mass index (BMI) on the dose area product (DAP) and effective dose (ED) in overweight and obese patients. We also wanted to determine the typical dose values as well as suggest adjustments to clinical practice for overweight and obese patients. In this study we considered 597 patients referred for imaging of the chest in posteroanterior and lateral projection, the lumbar spine in anteroposterior (AP) and lateral projection, the pelvis, the knee in AP and lateral projection, and the shoulder in AP projection. For each examination, the image field size, tube voltage, mAs product, source-to-image receptor distance and values of DAP were collected. Based on their BMI, the patients were divided into three groups (normal weight, overweight and obese). At the end, PCXMC 2.0 software was used to calculate the ED. The study showed a statistically significant DAP and ED increase in overweight and obese patients by 28.9% up to 275.4% in the case of DAP and an increase in ED from 11.0% to 241.9% in all mentioned examinations except knee and shoulder imaging. Typical DAP values ranged from 2.2 to 54.8µGym²for normal-weight patients, from 2.2 to 87.6µGym²for overweight patients, and from 2.2 to 172.5µGym²for obese patients. Spearman's correlation coefficient revealed very weak to very strong correlations when comparing BMI and DAP, as well as when comparing BMI and ED. A strong and very strong correlation was found in the case of examinations of the torso (except for the comparison of BMI and ED in the case of lateral lumbar spine projection).

Clinical utility of postprocessed low-dose radiographs in skeletal imaging

OBJECTIVES

Radiography remains the mainstay of diagnostic and follow-up imaging. In view of the risks and the increasing use of ionizing radiation, dose reduction is a key issue for research and development. The introduction of digital radiography and the associated access to image postprocessing have opened up new opportunities to minimize the radiation dosage. These advances are contingent upon quality controls to ensure adequate image detail and maintenance of diagnostic confidence. The purpose of this study was to investigate the clinical applicability of postprocessed low-dose images in skeletal radiography.

METHODS

In our study setting, the median radiation dose for full dose X-rays was 9.61 dGy*cm2 for pelvis, 1.20 dGy*cm2 for shoulder and 18.64 dGy*cm2 for lumbar spine exams. Based on these values, we obtained 200 radiographs for each anatomic region in four consecutive steps, gradually reducing the dose to 84%, 71%, 60% and 50% of the baseline using an automatic exposure control (AEC). 549 patients were enrolled for a total of 600 images. All X-rays were postprocessed with a spatial noise reduction algorithm. Two radiologists assessed the diagnostic value of the radiographs by rating the visualization of anatomical landmarks and image elements on a five-point Likert scale. A mean-sum score was calculated by averaging the two reader's total scores. Given the non-parametric distribution, we used the Mann-Whitney U test to evaluate the scores.

RESULTS

Median dosage at full dose accounted for 38.4%, 48 and 53.2% of the German reference dose area product for shoulder, pelvis and lumbar spine, respectively. The applied radiation was incrementally reduced to 21.5%, 18.4% and 18.7% of the respective reference value for shoulder, pelvis and lumbar spine. Throughout the study, we observed an estimable tendency of superior quality at higher dosage in overall image quality. Statistically significant differences in image quality were restricted to the 50% dose groups in shoulder and lumbar spine images. Regardless of the applied dosage, 598 out of 600 images were of sufficient diagnostic value.

CONCLUSION

In digital radiography image postprocessing allows for extensive reduction of radiation dosage. Despite a trend of superior image detail at higher dose levels, overall quality and, more importantly, diagnostic utility of low-dose images was not significantly affected. Therefore, our results not only confirm the clinical utility of postprocessed low-dose radiographs, but also suggest a widespread deployment of this advanced technology to ensure further dose limitations in clinical practice.

ADVANCES IN KNOWLEDGE

The diagnostic image quality of postprocessed skeletal radiographs is not significantly impaired even after extensive dose reduction by up to 20% of the reference value.

Comparative outcomes of Inferior Vena Cava filters placed at bedside using digital radiography versus conventional fluoroscopy

Purpose

To retrospectively assess the outcomes of Inferior Vena Cava (IVC) filters placed in critically ill patients in the ICU at bedside using digital radiograph (DR) guidance with previous cross-sectional imaging for planning, compared to IVC filters placed by conventional fluoroscopy (CF).

Method and materials

The cohort consisted of 129 IVC filter placements; 48 placed at bedside and 81 placed conventionally from July 2015 to September 2016. Patient demographics, indication, radiation exposures, access site, procedural duration, dwell time, and complications were identified by the EMR. IVC Filter positioning with measurements of tip to renal vein distance and lateral filter tilt were performed when cavograms or post placement CTs were available for review. Statistical analysis was performed using Stata IC 11.2.

Results

Technical success of the procedure was 100% in both groups. Procedural duration was longer at the bedside lasting 14.5 +/- 10.2 versus 6.7 +/- 6.0 ​min (p<0.0001). The bedside DR group had a median radiation exposure of 25 ​mGy (15–35) and the CF group had mean radiation exposure of 256.94 ​mGy +/- 158.6. There was no significant difference in distance of IVC tip to renal vein (p=0.31), mispositioning (p=0.59), degree of filter tilt (p=0.33), or rate of complications (p=0.65) between the two groups.

Conclusion

IVCF placement at the bedside using DR is comparable to CF with no statistical difference in outcomes based on IVCF positioning, degree of lateral tilt or removal issues. It decreased radiation dose, but with overall increased procedural time.

Influence of the use of various imaging units and projections on the radiation dose received by children during chest digital radiography

Objective

To investigate the impact of the use of different imaging units and projections on radiation dose and image quality during chest digital radiography (DR) in 3- and 4-year-old children.

Methods

Two hundred forty 3- and 4-year-old participants requiring chest DR were included; they were divided into three groups: supine anterior-posterior projection (APP), standing APP and standing posterior-anterior projection (PAP). Each group included 40 participants who were evaluated using the same imaging unit. The dose area product (DAP) and the entrance surface dose (ESD) were recorded after each exposure. The visual grading analysis score (VGAS) was used to evaluate image quality, and the longitudinal distance (LD) from the apex of the right lung to the apex of the right diaphragm was used to evaluate the inspiration extent.

Results

DAP and ESD were significantly lower in the standing PAP and APP groups than in the supine APP group (P<0.05), but LD was significantly higher in the standing PAP and APP groups than in the supine APP group (P<0.05). Additionally, the pulmonary field area was significantly higher for the standing PAP group than for the standing and supine APP groups (P<0.05). The correlations between ESD, DAP, and VGAS were positive (P<0.001), showing that larger ESD and DAP correspond to higher VGAS. The correlations between ESD, DAP, and body mass index (BMI) were also positive (P<0.05), indicating that higher BMI corresponds to larger ESD and DAP. Finally, no differences in DAP, ESD, VGAS, LD, pulmonary field area, or BMI were noted between males and females (P>0.05).

Conclusion

The radiation dose to superficial organs may be lower with standing PAP than with standing APP during chest DR. Standing PAP should be selected for chest DR in 3- and 4-year-old children, as it may decrease the required radiation dose.

PROPOSED NATIONAL DIAGNOSTIC REFERENCE LEVELS FOR STANDARD RADIOGRAPHIC X-RAY PROCEDURES IN SUDAN

This study aimed to calculate patient radiation doses for adults during the seven most commonly performed conventional X-ray procedures, and to propose national diagnostic reference levels (DRLs). A representative sample of patients from 29 hospitals was included. The entrance surface air kerma (ESAK) was calculated by measuring X-ray tube output and the corresponding technical and exposure factors for each patient. Third-quartile values of the mean ESAK distributions were proposed as DRL values. The DRLs in mGy were as follows: 0.6 for chest postero-anterior (PA), 3.5 for skull AP, 1.7 for skull lateral (LAT), 2.7 for abdominal, 2.6 for pelvic AP, 3.7 for lumbar spine AP and 8 for lumbar spine LAT. Compared with literature, the maximum percentages increase were in chest PA (329%) and skull AP (187%). Since the suggested DRL for chest PA was higher than literature values, dose optimization and a review of its value is recommended.

ESTIMATES OF PATIENT DOSES AND KERMA-AREA PRODUCT MONITORING IN DIGITAL RADIOGRAPHY

The application of the kerma-area product (PKA) meter is increased rapidly in dosimetry. This study presents measurements of PKA in adherence to the International Atomic Energy Agency protocol for 300 adult patients in digital radiographic procedures. Effective doses (ED) were calculated from PKA measurements and conversion coefficients (E-103/PKA) obtained from the International Commission on radiological protection 103. In skull posteroanterior (PA), skull lateral (LAT), cervical spine anteroposterior (AP), cervical spine LAT, chest PA, abdomen AP, lumbar spine AP, pelvis AP and lumbar spine LAT, the third-quartile PKA values were found to be 0.2, 0.28, 0.33, 0.19, 0.26, 0.95, 0.93, 0.96 and 3.15 Gycm2, and estimated mean EDs were 0.005, 0.008, 0.056, 0.021, 0.037, 0.146, 0.165, 0.097 and 0.258 mSv, respectively. The third-quartile PKA values were suggested as local diagnostic reference levels (LDRLs). Results were compared with the diagnostic reference levels (DRLs) of the UK, the European Commission, previously published LDRLs in Greece and China by Metaxas et al. and Zhang and Chu, respectively. The PKA (third-quartile) value for cervical spine AP was 120% higher than UK 2010 DRLs, lumbar spine LAT was 123% higher than LDRLs given by Metaxas et al. and chest PA was 160% higher than UK 2010 DRLs and 225% higher than Metaxas et al. provided LDRLs. The PKA results were lower than the UK, and two studies in Greece by Metaxas et al. except for chest PA, cervical spine AP and lumbar spine LAT showed the need for further optimization. The LDRLs reported in this study may further contribute to establishing future national DRLs.

RADIATION DOSE DURING PELVIC RADIOGRAPHY IN RELATION TO BODY MASS INDEX

The purpose of this research was to investigate the impact of body mass index (BMI) on dose area product (DAP), effective dose (E), dose to the organs and image quality (IQ) on 200 patients referred to pelvic radiography. Patients were classified into three groups according to BMI: normal (<24.99), overweight (25.0-29.99) and obese (>30). The results showed 52% and 135% higher DAP for overweight and obese patients compared to normal-weight patients (p < 0.001). A 46 and 123% rise of E for overweight and obese patients compared to normal-weight patients (p < 0.001) was discovered. Overweight patients received 37% higher dose and obese patients 107% higher dose to the organs compared to normal-weight patients. There were no statistically significant differences between IQ, except between normal weight and overweight patients. A strong correlation (r = 0.733) was found between BMI and DAP and between BMI and E (r = 0.776).

Radiation exposure in endovascular stroke treatment of acute basilar artery occlusions-a matched-pair analysis

Abstract

Purpose

To determine the radiation exposure in endovascular stroke treatment (EST) of acute basilar artery occlusions (BAO) and compare it with radiation exposure of EST for embolic middle cerebral artery occlusions (MCAO).

Methods

In this retrospective analysis of an institutional review board−approved prospective stroke database of a comprehensive stroke center, we focused on radiation exposure (as per dose area product in Gy × cm², median (IQR)), procedure time, and fluoroscopy time (in minutes, median [IQR]) in patients receiving EST for BAO. Patients who received EST for BAO were matched case by case with patients who received EST for MCAO according to number of thrombectomy attempts, target vessel reperfusion result, and thrombectomy technique.

Results

Overall 180 patients (n = 90 in each group) were included in this analysis. General anesthesia was conducted more often during EST of BAO (BAO: 75 (83.3%); MCAO: 18 (31.1%), p < 0.001). Procedure time (BAO: 31 (20–43); MCAO: 27 (18–38); p value 0.226) and fluoroscopy time (BAO: 29 (20–59); MCAO: 29 (17–49), p value 0.317) were comparable. Radiation exposure was significantly higher in patients receiving EST for BAO (BAO: 123.4 (78.7–204.2); MCAO: 94.3 (65.5–163.7), p value 0.046), which represents an increase by 23.7%.

Conclusion

Endovascular stroke treatment of basilar artery occlusions is associated with a higher radiation exposure compared with treatment of middle cerebral artery occlusions.

LOW BMI PATIENT DOSE IN DIGITAL RADIOGRAPHY

In this study, the radiation dose received by 364 low body mass index (BMI) adult patients undergoing chest, abdomen, lumbar spine, kidneys and urinary bladder (KUB) and pelvis X-ray examinations in an X-ray room with a digital radiography system was evaluated. The patients' kerma area product (KAP) values were recorded, and the entrance surface air kerma (ESAK) was calculated based on the X-ray tube output, exposure parameters and technical data. The 75th percentiles of the distribution of ESAK and KAP values were also estimated. The dose values were compared with the corresponding values for normal patients obtained from a previous survey in our hospital, as well as with the national and UK diagnostic reference levels (DRLs). The correlation of dose values with patient size metrics (mass, height, BMI) was also investigated. A statistically significant difference was found in KAP and the ESAK values between low BMI and normal patients (Mann-Whitney test, p < 0.05), for all examinations studied. The percentage difference for chest PA, chest LAT, abdomen PA, lumbar spine AP, lumbar spine LAT, pelvis AP and KUB AP examinations was 40, 36, 48, 68, 57, 46 and 67% for median KAP and 26, 43, 52, 48, 19, 44 and 51% for median ESAK, respectively. The corresponding 75th percentiles for low BMI patients were 0.065, 0.349, 0.683, 1.54, 3.92, 1.11, 0.67 mGy and 0.042, 0.218, 0.450, 0.280, 0.598, 0.597, 0.267 Gycm2 in terms of ESAK and KAP values, respectively. They were 74-90% lower compared to the national diagnostic reference levels (DRLs), 35-84% and 58-82% compared to the UK DRLs, for ESAK and KAP values, respectively. Regarding the gender of the patients, no statistically significant difference was found in the dose values between female and male patients (Mann-Whitney test, p > 0.05), for all examinations studied. A statistically significant correlation was found between ESAK and KAP values with BMI for KUB AP, pelvis AP, lumbar spine AP, lumbar spine LAT and chest PA, while for chest LAT examinations, only the ESAK were significantly correlated with BMI. They also significantly correlated with the mass for KUB AP, lumbar spine LAT, abdomen PA and chest PA examinations, while no significant correlation was found between the dose values and patients' height. It can be concluded that the low BMI patients received a significantly reduced radiation dose compared to normal patients. Additional studies need to be conducted for these patient groups, which could contribute to the further development of a radiation protection culture in diagnostic radiography.