Dear Editor

We recently have read with great interest an article entitled “Ultra-Low Dose Computed Tomography Imaging in Quantifying Bone Trauma and Disorders: A Cross-Sectional Study”, by Zarei and colleagues, which was published in your esteemed journal (IJMS Volume 50, Issue 4, April 2025). ¹ They made a technically significant contribution by demonstrating the feasibility of utilizing ultra-low-dose CT (ULD-CT) protocols. Compared to standard-dose (SD) protocols, these protocols achieve a substantial radiation dose reduction (reportedly up to 98%) while maintaining diagnostically acceptable image quality for evaluating the extremities and spine. As a professor of digital health, I appreciate the significant advancements in radiological and patient safety that this represents. However, I wish to offer a perspective that focuses on the often-underestimated psychological dimensions associated with diagnostic imaging choices, radiation exposure, and diagnostic certainty.

The primary strength and clinical relevance of the study by Zarei and others ¹ lie unequivocally in the remarkable radiation dose reduction achieved using the ULD-CT protocol combined with iterative reconstruction (IMR level 2). In light of the known stochastic risks associated with ionizing radiation, particularly from cumulative exposure, the ability to drastically lower patient dose without sacrificing diagnostic utility constitutes a major clinical advancement. The authors convincingly demonstrated that for evaluating bone trauma and disorders, the ULD-CT protocol is not merely theoretical but practical, yielding images predominantly rated as acceptable or better by experienced radiologists. This technical success has clear, positive implications for reducing the population-level radiation burden.

However, the successful implementation and acceptance of ULD-CT protocols in routine clinical practice involve considerations that extend beyond technical image quality metrics and dose calculations. Firstly, patient perception and anxiety regarding radiation exposure, often termed “radiophobia”, ² represent a significant issue. As patients become increasingly aware of and concerned about the potential long-term risks of medical radiation, ³ the prospect of a substantially lower-radiation diagnostic test, as offered by ULD-CT, could significantly alleviate these anxieties. This may improve patient acceptance of necessary imaging and adherence to follow-up recommendations. While not directly measured in the study, this psychological benefit is a crucial potential advantage of ULD-CT that warrants consideration in clinical decision-making and patient communication. Effectively communicating this dose reduction could enhance trust and reduce decisional conflict for patients weighing the risks and benefits of imaging.

Conversely, the study reported an overall sensitivity range of 67%-95% for ULD-CT compared to the gold standard SD-CT, alongside a high specificity (100% for detecting normality). While this performance is deemed “acceptable,” a sensitivity at the lower end of this range, particularly for detecting subtle, yet potentially significant fractures or early-stage bone disorders, might introduce a different psychological burden: the anxiety associated with diagnostic uncertainty. Clinicians rely on imaging not just to confirm obvious pathology but also to confidently rule out significant findings. Radiologists might be less confident in their diagnoses if they perceive ULD-CT as inferior for detecting subtle lesions. This reduction in confidence, whether explicitly communicated or implicitly perceived, might increase patient anxiety and could potentially prompt recommendations for additional imaging or closer follow-up. Consequently, it would partially negate the intended benefit of a reduced initial investigation burden. The psychological impact of a potential missed diagnosis, even if statistically infrequent, versus the perceived risk of radiation exposure is a complex equation that varies among individuals and clinical scenarios.

Therefore, the term “acceptable image quality” requires careful contextualization. While technically sufficient for many diagnoses, its adequacy must also be evaluated against the psychological comfort it provides the referring clinician and the patient with the diagnostic conclusion. Future research in this area would benefit immensely from incorporating patient-reported outcomes. Studies could prospectively compare patient anxiety levels, satisfaction with the diagnostic process, and decisional conflict between those undergoing ULD-CT and SD-CT, alongside assessments of radiologists’ diagnostic confidence for specific, potentially subtle findings on ULD protocols. Understanding these human factors is critical for optimizing the implementation of dose-reduction strategies.

In conclusion, the study by Zarei and others ¹ provided compelling evidence for the technical feasibility and substantial dose-reduction potential of ULD-CT with iterative reconstruction for imaging the extremities and spine. This work represented a significant advancement towards safer radiological practice. However, adopting this technology necessitates a holistic view that extends beyond dose metrics and image quality scores. Integrating an understanding of patient anxieties regarding radiation exposure and ensuring sufficient diagnostic confidence for both clinicians and patients are vital psychological considerations. Future efforts should focus not only on further technical refinement but also on developing effective communication strategies and assessing the overall patient experience. This will ensure that the benefits of dose reduction are fully realized without introducing undue diagnostic uncertainty or psychological distress.

Acknowledgment

This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Education (RS 2023-00237287) and the professor research program of KOREATECH in 2025. Regarding AI-assisted technologies (such as LLMs, chatbots, or image creators), none were used in the production of this submitted work.

Declaration of AI

The authors declare that no AI tools were used in the preparation of this manuscript.

Conflict of Interest

None declared.

References

1. Zarei F, Ahmadi SM, Dehbani-Zadeh S, Jafari A, Akondi V, Chatterjee S, et al. Ultra-Low Dose Computed Tomography Imaging in Quantifying Bone Trauma and Disorders: A Cross-Sectional Study. Iran J Med Sci. 2025; 50:229-38. Publisher Full Text | DOI | PubMed [ PMC Free Article ]
2. Oakley PA, Harrison DE. X-Ray Hesitancy: Patients’ Radiophobic Concerns Over Medical X-rays. Dose Response. 2020; 18:1559325820959542. Publisher Full Text | DOI | PubMed [ PMC Free Article ]
3. Brower C, Rehani MM. Radiation risk issues in recurrent imaging. Br J Radiol. 2021; 94:20210389. Publisher Full Text | DOI | PubMed [ PMC Free Article ]