Radioprotection 2026, 61( 2), 82 – 83 © A. K Gupta et al., Published by EDP Sciences 2026 https:// doi. org / 10.1051 / radiopro / 2026008
Available online at: www. radioprotection. org
LETTER
Comments on“ Diagnostic reference levels based on clinical indications for paediatric computed tomography examinations at the Mohammed VI University Hospital Center in Marrakech-Morocco”
A. K Gupta 1, P. R Kokiwar 2,*, A. Kavya 3 and A. Dhyani 4, 5
1 Department of Radiology, School of Medical Sciences and Research, Sharda University, Greater Noida, India. 2 Department of Community Medicine, Malla Reddy Institute of Medical Sciences, Malla Reddy Vishwavidyapeeth, Suraram, Hyderabad
500055, Telangana, India. 3 Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth( Deemed-to-be-University), Pimpri, Pune 411018, Maharashtra, India. 4 Faculty of Pharmaceutical Sciences, Graphic Era Hill University, Dehradun, India. 5 Centre for Promotion of Research, Graphic Era Deemed University, Dehradun, India.
Received: 17 December 2025 / Accepted: 18 March 2026
Dear Editor,
We read with interest the recent report by Boulanouar et al., entitled“ Diagnostic reference levels based on clinical indications for paediatric computed tomography examinations at the Mohammed VI University Hospital Center in Marrakech- Morocco” published in Radioprotection( Boulanouar et al., 2025). The investigators retrospectively analysed 1,730 pediatric CT examinations across head, chest, abdomen-pelvis, and chest-abdomen-pelvis, proposing age-stratified diagnostic reference levels( DRL-CI) using CTDIvol and DLP percentiles and comparing results with international benchmarks.
Although this work fills a gap, as DRL-CI for pediatric CT is valuable for dose optimization and benchmarking across institutions, we identify issues that warrant clarification before the findings can be translated into practice. Key concerns include inconsistent reporting of age stratification between the methods and results and discordant statements between the abstract and the main text regarding statistical significance for CTDIvol versus DLP. Age stratification and denominators. The methods describe three age bands, yet the results summarize a different grouping( including an infant category). A brief reconciliation of inclusion criteria and denominators( e. g., whether 1-year scans were excluded or merged) would improve interpretability, particularly for DRLs where size effects are most pronounced. Statistical interpretation of DRL variation. The article states that DRLs were defined by medians and third quartiles, while hypothesis testing is justified as median comparison. However, DRLs are typically operationalized as
* Corresponding author: kokiwar @ mrvv. edu. in the 75th percentile; testing medians does not directly test differences in the 75th percentile. A more coherent report would have been preferable to improve interpretability and would have included( i) a single, consistent DRL definition;( ii) effect sizes with confidence intervals to manage uncertainty; and( iii) sensitivity analyses focused on upper-tail measures( e. g., quantile regression or 75th percentile bootstrap comparisons), as well as an adjustment for scan length and multiphase acquisition, the main drivers of DLP. Clinical translation in an evolving technology landscape. Population-level modeling underscores why CT dose optimization remains clinically important( Smith-Bindman et al., 2025), yet contemporaneous correspondence highlights how post-2020 reconstruction and protocol advances may materially change dose distributions( Hsu et al., 2025). Reporting scanner generation, reconstruction approach, and protocol standardization, and presenting size surrogates( if weight is unavailable) would strengthen external generalizability.
Examining these points would have allowed readers to better judge whether the observed differences reflect a clinical indication, the structure of the protocol, or a reporting artifact, thereby strengthening confidence in the proposed DRL-CI, facilitating safer and more generalizable implementation, i. e., improving application to practice, and paving the way to future DRL initiatives.
References
Boulanouar A, Khajmi H, Jalal H, Tounsi A. 2025. Diagnostic reference levels based on clinical indications for paediatric computed tomography examinations at the Mohammed VI University Hospital
This is an Open Access article distributed under the terms of the Creative Commons Attribution License( https:// creativecommons. org / licenses / by / 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.