Cumulative dose estimates rationally used have a distinct role in patient management and care.

W The review article “Utilization Strategies for Cumulative Dose Estimates: A Review and Rational Assessment” by Daniel J. Durand, MD, Robert L. Dixon, PhD, and Richard L. Morin, PhD, provides a superb review of the issues surroundingpatient radiationexposure, particularly from CT, and the risks associated with that exposure. Everyonewhohasweighedinonthis issue knows 2 clear facts: we don’t know with certainty if exposure to ionizing radiation from CT causes clinically significant carcinogenesis, and CT represents an extraordinary advance in diagnostic imaging [1]. Rarely are “exloratory” laparotomies performed, nd trauma patients are handled in an fficient and safe pathway from the ER o the CT scanner and potentially to he operating room. The explanations of statistical robability theory and the potenial stochastic effects of low-dose onizing radiation are superbly preented by the authors, and I comliment them on their articulation f these often difficult concepts. Yet he conclusions of this review miss a umber of key practical, clinical isues that a practicing radiologist, in he trenches of patient care and utiization management, will confront n almost a daily basis. First, an uneducated referring proider base will be almost as prone to radiation hysteria” as patients inunated with information from the meia. Radiation biology and physics ducation in some form for all refering providers is imperative in this ay and age. All providers need to now that there is no reason to withold a CT study from a critically ill atient on the basis of radiation risk nd virtually no reason to withhold ny CT studies from elderly patients given their minuscule risk for carcinogenesis. Only education by radiologists and physicists at all levels of provider training will change this paradigm. Cumulative dose estimates (CDE) in carefully selected young patients with benign conditions such as Crohn’s disease provide an entryway for this educational process to occur for individual practitioners and radiologists. Second, I agree strongly with the authors’ conclusions that individual CDEs have little use in estimating risk in any given patient. Yet I have seen many, many patients who have gone to multiple institutions and have had redundant and often unindicated studies performed repeatedly because of a lack of communication between patients and providers. Imaging histories and CDEs will have a role in preventing this in the future. Many of these patients are 40 years of age and have benign conditions such as nephrolithiasis and inflammatory bowel disease. Clearly, low-dose, diseasespecific protocols would be welcome in many of these patients, similar to the authors’ discussion of patients with cystic fibrosis, as would order entry systems that monitor provider ordering patterns. Because there are no universal, communicating electronic medical record and radiology information systems, this is far from a reality. Accreditation programs such as the ACR’s program for CT are clearly helpful in establishing uniform protocols, as are the Image Gently and Image isely initiatives. Third, if institutions and radiologists commit to structured programs using CDEs with admittedly arbitrary thresholds (eg, 50 or 100 mSv),