Effects of trauma mattress on dose and image quality of paediatric whole-body computed tomography examinations

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To decrease the potential for increased spinal injury, it is recommended that bearing devices, such as trauma mattress, be used to ensure adequate immobilisation of the spine. This study assessed the effect of the use of trauma mattress on the dose and image quality of WBCT examinations. Methods This was a phantom-based experimental study. Two different paediatric whole-body anthropomorphic phantoms from Kyoto Kagaku were used: newborn (PBU-80) and 5-year-old (PBU-70). Different WBCT protocols were scanned with and without trauma mattress. The effective dose (ED) from each protocol was estimated from CT-Expo software and from the product of the dose length product and dose conversion coefficient (DLP-E(k)) method, while image quality was assessed both subjectively and objectively. Results The use of trauma mattress increased the mean ED and decreased the SNR of paediatric examinations by 7.03% ( p = 0.776) and 21.37% ( p = 0.194) respectively. Similarly, there was a 43.87% increase in ED ( p = 0.019) and a 16.5% decrease in SNR ( p = 0.221) when trauma mattress was used for newborn examinations. The differences in the mean ED from CT-Expo and the DLP-E (k) were not statistically significant (p = 0.258 and 0.278 for newborn and paediatric phantoms respectively). The use of the trauma mattress increased the average tube voltage, tube current, dose-length product (DLP), and the volume computed tomography dose index (CTDI vol ) by 1.33%, 63.91%. 47.28%, and 48.34% respectively. Conclusion The use of trauma mattress increased the ED and decreased the SNR during the WBCT examinations, albeit at different levels for the newborn and 5-year-old phantoms. Radiologists and radiographers should critically evaluate patients’ conditions and the diagnostic information required to justify the use of bearing devices. Whole-body computed tomography trauma mattress immobilising devices bearing devices anthropomorphic phantom dose optimisation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Whole-body computed tomography (WBCT) is a commonly used computed tomography (CT) technique for assessing patients with suspected multiple traumas, involving injuries to multiple body parts [ 1 – 5 ]. WBCT combines noncontrast-enhanced examination of the head and neck with a contrast examination of the trunk, including the whole spine [ 2 , 3 ]. It is highly accurate and can effectively detect life-threatening injuries with good sensitivity and specificity, thereby improving patient management [ 6 ]. Although this, along with its rapid results generation, has increased demand for treating trauma patients, where time is crucial, the increased use of WBCT has raised concerns about radiation-induced problems due to the high levels of exposure [ 7 , 8 ]. The possibility of detrimental effects associated with WBCT may be greater in paediatric population due to their increasing radiosensitivity and longer life expectancy [ 9 ]. During WBCT imaging, bearing devices such as trauma mattress are used to support and ensure adequate immobilization of the spine to decrease the potential for increased spinal injury [ 10 ]. However, reports suggest that the use of these devices may affect the radiation dose and image quality, particularly signal relative to noise [ 10 , 11 ]. To the best knowledge of the authors, the effects of the use of trauma mattress on radiation dose and image quality during paediatric WBCT examinations are less understood. This study assessed the effect of using trauma mattress on the dose and image quality of WBCT examinations from two different CT scanners. The purpose is to understand the extent to which bearing devices, such as trauma mattresses, impact WBCT regarding dose and image quality, so that appropriate recommendations can be made to support and optimize their use in newborns and paediatrics. Materials and Methods Materials Two CT scanners, anthropomorphic phantoms, trauma mattress, and CT-Expo software were the materials used for the study. In addition, a Black Piranha 657 (B2-16020228, RTI, Sweden) and Catphan 500 were used to undertake quality control activities on both scanners, following the international elctrotechnical commission (IEC) guidelines [ 12 ]. The Kyoto Kagaku newborn (PBU-80) and 5-year-old (PBU-70) whole body anthropomorphic phantoms (Kyotokagaku America Inc., Los Angeles, United States of America) (Fig. 1 ) [henceforth newborn phantom and 5-year-old phantoms, respectively] have soft tissues made with urethane-based resin and synthetic bones made with epoxy resin. Both the newborn and 5-year-old phantoms have no metal parts or liquid structures. The newborn phantom has a size of 53 cm, a weight of 3.5 kg, a packaging size of W57 X D44 X H29 cm, and a packaging weight of 8 kg. Conversely, the 5-year-old phantom has an HU number approximate to the human body and its main joints are close to human articulation. It has a height of 110 cm, a weight of 20 kg, and a packaging size of W86 X D60 X H32 cm. The newborn and 5-year-old phantoms are comparable to the infant and child mathematical phantoms, respectively, in CT-Expo. The CM TraumaMattress™ (Comfort Medical AB, Sweden) (Fig. 1 ) is a CT-compatible intrahospital mattress that helps in the immobilisation and transfer of patients. The mattress is made of polyester-weave that can be removed and a silicone-coated polyamide with low friction attributes that lies under the mattress. The core of the mattress is waterproof and is covered in a durable polyurethane-cover [ 13 ]. The CM trauma mattress weighs 8 kg in weight and measures 2000 x 530 x 60 mm in dimension. The General Electric (GE) Revolution ™ CT (GE Medical Systems, Waukesha, United States of America) and the Siemens SOMATOM Definition Edge CT scanners (Siemens Healthineers, Erlangen, Germany) were used for this study. The GE Revolution ® CT is a 250 MDCT equipment with in-built Smart technologies, which help to produce high quality images at lower radiation dose levels in the examination of various disease conditions including polytrauma and/or WBCT. The Siemens SOMATOM Definition Edge is a 128 MDCT equipment with an in-built Advanced Modelled Iterative Reconstruction (ADMIRE) technology. Both the GE and Siemens scanners have automatic attenuation-based kilo-voltage peak (kVp) selection algorithms that produce the lowest radiation dose with 70, 80, 100, 120, or 140 kVp [ 14 , 15 ]. The CT-Expo software version 2.5 (SASCRAD, Fritz-Reuter-Weg, Buchholz, Germany) was used to estimate the effective dose (ED) for all protocols and the organ doses associated with the optimized protocols. The infants (BABY) and 7-year-old children (CHILD) models were used in this study. CT Examinations The whole-body examinations were performed in two parts: non-contrast examination of the head (in head-first supine position) and contrast-enhanced examination of the chest-abdomen-pelvis (CAP) (in feet-first supine position). Twenty-seven different examinations were performed (9 without and 18 with the trauma mattress) and tested for dose and image quality. The table height was adjusted to be in isocenter for each examination, both with and without trauma mattress, to prevent possible displacement. Effective dose estimation In estimating the ED from CT-Expo software, the BABY and CHILD modules were selected for the newborn and 5-year-old phantoms respectively. In addition, both male and female genders were selected in turns while estimating the effective and organ doses. Tissue weighting factors as stated in ICRP publication 103 were used in estimating the effective doses. The scan lengths used in estimating the ED are presented in Table 1 . Additionally, the ED was estimated from a simplified method according to Eq. ( 1 ) [ 16 ]. Table 1 Scan lengths and k-values used in Dose Calculation from CT-Expo and DLP-E(k) methods respectively. Scan Range Scan Length k-values 15 From z- To z+ L (cm) Male Female Male Female Male Female Newborn Chest 14 11 25 22 11 11 0.099 Paediatric Chest 26 24 43 40 17 16 0.047 Newborn Abdomen-Pelvis 0 1 18 18 18 18 0.092 Paediatric Abdomen-Pelvis 0 1 28 27 28 26 0.043 Newborn Trunk 1 1 23 22 22 21 0.086 Paediatric Trunk 0 1 41 40 41 39 0.041 $$\:ED=kDLP$$ 1 Where k is the conversion coefficient specific to each body part. The k -factors used in this study were adopted from Romanyukha et al. [ 17 ] and are presented in Table 2 . Table 2 k -values used for the various body parts and phantoms [ 17 ]. Body part Newborn Phantom Paediatric Phantom Head 0.009 0.004 Chest 0.099 0.047 Abdomen-pelvic 0.092 0.043 Chest-Abdomen-Pelvic 0.086 0.041 Subjective image quality assessment The images were subjectively assessed by two independent radiologists, with 5 years’ and 8 years’ experience, for artefacts, image noise, contrast, organ visibility, and overall diagnosability. This was done in a blinded fashion by removing all annotations related to scan protocols and organised randomly in order to decrease expectation bias. Each category was assessed using a 5-point Likert scale (Table 3 ) adapted from Gariani et al. [ 18 ]. Inter-rater agreement between the two radiologists was assessed with the Cohen’s kappa coefficient [ 19 ]. Additionally, the assessments were combined, and the average scores computed to determine the effect of the trauma mattress on the five image quality criteria. Table 3 Five-point Likert scale for subjective image quality assessment Parameter Scale 1 2 3 4 5 Artefacts Severe unacceptable artifacts Moderate artifacts, partially degrading diagnostic capability; Slight artifacts, not significantly affecting diagnostic capabilities; Minimal artifacts Absent, no perceivable artifacts Image Noise Bad, not diagnostic Poor, definitely noisy Moderate, slightly noisy but acceptable Minimal noise, not affecting diagnostic quality No perceivable noise. Contrast Non-diagnostic image quality Severe blurring with uncertainty about the evaluation Moderate blurring with restricted assessment Slight blurring with unrestricted diagnostic image evaluation possible Excellent image quality Organ visibility Very poor, almost not visible Poor Intermediate Good Excellent Overall diagnosability Bad, not diagnostic Poor, diagnostic confidence substantially reduced Moderate, sufficient for diagnosis Good Excellent Objective image quality assessment Quantitatively, image quality was assessed using the ImageJ software version 1.54c (Wayne Rasband and Contributors, National Institutes of Health, USA). The signal-to-noise ratio (SNR) was used in the objective assessment of the image quality. In determining the SNR for body examinations, three circular regions of interest (ROIs) of equal dimensions (5.0 mm x 5.0 mm) were drawn on three different images of the liver (for the 5-year-old phantom) and heart (for the newborn phantom) at the same slice position. Figure 2 shows how the signal and standard deviations (noise) were obtained from the ImageJ software version 1.54c (Wayne Rasband and Contributors, National Institutes of Health, USA). The average values of the signal and standard deviations obtained were used to calculate the SNR according to Eq. ( 2 ) [ 18 ]. $$\:SNR=\frac{Mean\:Signal\:in\:Roi}{Standard\:Deviation\:in\:ROI}$$ 2 Data analysis The data obtained was statistically analysed with the IBM SPSS v26.0 (IBM Corp., Armonk, N.Y., USA) and Microsoft Excel 2016. Results from descriptive statistics were reported as the mean ± standard deviation for normally distributed data and median (95% confidence interval) for non-normally distributed data and presented in the form of tables and graphs. The Shapiro-Wilk test was used to determine the normality of the data. Normally distributed data sets were compared using the one-way ANOVA test whereas comparison between non-normally distributed data sets was made with the Mann-Whitney U-test and Kruskal-Wallis H test. Differences were considered significant at p < 0.05. Results Quality control tests results All quality control tests results were consistent with IEC recommendations. The results have been provided in the Supplementary File. CT scan parameters The CT scan parameters used for this study have been presented in Table 4 . The average tube voltage increased marginally by 1.33% whereas the average tube current increased substantially by 63.91% when trauma mattress was used. Additionally, the use of the trauma mattress increased both the DLP and CTDI vol by 47.28% and 48.34% respectively. Table 4 Average scanning parameters used for examinations performed with and without the trauma mattress. Parameter Mean ± Standard deviation Without trauma mattress With trauma mattress Tube voltage [kVp] 84.44 ± 8.31 85.56 ± 10.66 Tube current [mA] 129.65 ± 65.16 212.51 ± 102.34 Rotation time [s] 0.34 ± 0.09 0.37 ± 0.10 Slice thickness [mm] 0.65 ± 0.05 0.67 ± 0.06 Pitch 0.82 ± 0.36 1.00 ± 0.31 DLP [mGy.cm] 48.45 ± 38.03 71.36 ± 50.17 CTDI vol [mGy] 1.51 ± 0.88 2.24 ± 1.19 Subjective image quality assessment Cohen’s Kappa was used to determine the interobserver reliability of the subjective image quality assessment by the two observers for examinations performed with and without the trauma mattress The Cohen’s Kappa score obtained for examinations performed without trauma mattress ranged from 0.60 to 0.80 (Table 5 ) whereas examinations performed with the trauma mattress had Kappa score from 0.56 to 0.79 (Table 5 ), indicating a weak to excellent agreement between the two observers [ 19 ]. Table 5 Subjective image quality assessment scores and interobserver reliability for examinations performed with the trauma mattress. With Trauma Mattress Without Trauma Mattress Image Quality Parameters Average Ratings Kappa Score p -Value Average Ratings Kappa Score p -Value Reader 1 Reader 2 Reader 1 Reader 1 Reader 2 Artifact 2.89 2.78 0.79 < 0.001 3.11 3.00 0.80 < 0.001 Image Noise 3.39 3.22 0.58 < 0.001 3.56 3.44 0.78 < 0.001 Image Contrast 3.44 3.17 0.56 < 0.001 3.44 3.56 0.78 < 0.001 Organ Visibility 3.17 3.11 0.71 < 0.001 3.44 3.33 0.77 < 0.001 Overall Diagnosability 3.28 3.17 0.66 < 0.001 3.67 3.44 0.60 < 0.001 The examinations performed without the trauma mattress ( n = 9) had higher mean ratings than examinations performed with the trauma mattress ( n = 18) for all the image quality criteria for subjective assessment (Fig. 3 ). However, a Mann-Whitney U test revealed no statistically significant difference across all criteria (Fig. 3 ). The main type of artefact found by the two radiologists was streaking artefacts (Fig. 4 ). Comparison of SNR between examinations performed with and without trauma mattress The mean SNR of examinations performed without trauma mattress was 16.5 and 21.37% higher than examinations performed with trauma mattress for the newborn and 5-year-old phantoms respectively (Table 6 ). A Mann-Whitney U-test showed that the difference in the mean SNR of examinations performed with and without trauma mattress was not statistically significant for both the newborn phantom ( U = 16.00, p = 0.221) and 5-year-old phantom ( U = 5.00, p = 0.194) examinations. Table 6 SNR and ED of newborn and paediatric trunk examinations with and without trauma mattress Examination (n) Mean ± Standard Deviation Signal-noise-ratio Effective dose (mSv) With Trauma Mattress Without Trauma Mattress With Trauma Mattress Without Trauma Mattress Newborn Trunk (n = 11) 1.67 ± 0.65 (n = 5) 2.00 ± 0.48 (n = 11) 2.53 ± 1.31 (n = 5) 1.42 ± 0.53 Paediatric Trunk (n = 8) 5.52 ± 1.85 (n = 3) 7.02 ± 1.42 (n = 8) 3.84 ± 0.70 (n = 3) 3.57 ± 0.81 Comparison of ED between examinations performed with and without trauma mattress The mean ED for the examinations performed with trauma mattress was 43.87 and 7.03% higher than the corresponding values obtained from examinations performed without trauma mattress for the newborn and 5-year-old phantoms respectively (Table 6 ). A Mann-Whitney U test showed a statistically significant difference for examinations performed with the newborn phantom ( U = 7.50, p = 0.019) whereas the difference was not statistically significant for examinations performed with the 5-year-old phantom ( U = 10.00; p = 0.776). Comparison of ED estimated from CT-Expo and DLP-E(k) methods The median ED estimated from CT-Expo for all newborn phantom examinations was 1.65 mSv (95% CI = 1.49 to 2.67 mSv) and 2.05 mSv (95% CI = 1.81 to 3.05 mSv) for male and female anatomies respectively whereas the median effective dose for all newborn phantom examinations estimated from DLP-E (k) is 2.10 (95% CI = 1.90 to 3.59 mSv). A Kruskal-Wallis H test showed that there was no significant difference in effective dose between the methods, \(\:{\chi\:}\) 2 (2) = 2.706, p = 0.258, with a mean rank effective dose of 22.61 mSv, 29.14 mSv, and 30.75 mSv for CT-Expo (Male), CT-Expo (Female), and DLP-E (k) respectively. For the paediatric phantom examinations, a one-way ANOVA revealed that the mean effective dose from DLP-E (k) [4.39 ± 2.02 mSv] was not significantly higher than the effective doses from CT-Expo (Male) [3.35 ± 1.20 mSv] and CT-Expo (Female) [3.96 ± 1.59 mSv], (F(2, 36) = 1.325, p = 0.278). Figure 5 shows the relationship between the effective doses estimated from CT-Expo with male anatomy [CT-Expo (Male)], CT-Expo using female anatomy [CT-Expo (Female)], and DLP-E (k) methods for the newborn and paediatric phantom examinations. Discussion This phantom-based experimental study throws light on the effects of the use of trauma mattress during paediatric WBCT examinations, and whether there is a need for the use of trauma mattress during paediatric WBCT examinations. It is known that the use of WBCT examinations is associated with high radiation doses as compared to conventional X-ray examinations. However, WBCT examinations are essential in the events of poly-trauma as they potentially increase the survival rates of poly-traumatised patients [ 20 ]. Despite the level of dose associated with WBCT, studies relating to how the use of bearing devices affect the dose and image quality are scarce [ 11 ]. Neglecting the effects of these devices on the dose and image quality during WBCT examinations, especially for the paediatric population, may be detrimental. This study found a mean ED of 1.42 ± 0.53 mSv for CAP examinations performed without trauma mattress with the newborn phantom. This ED increased by 43.87% when the examination was performed with trauma mattress, albeit there was no significant difference. Similarly, this study found a mean ED of 3.57 ± 0.81 mSv for CAP examinations performed without trauma mattress for the 5-year-old phantom, with a corresponding 7.03% non-significant increase when the examination was performed with trauma mattress. Table 6 shows the difference in ED between examinations performed with and without trauma mattress. The result from this study aligns with the findings from a study by Loewenhardt et al. [ 21 ] where the use of different immobilising devices caused an increase in ED from 2.5–4.5%. Similarly, Euler et al. [ 22 ] reported that the use of immobilising devices causes an increase in radiation dose. Stokkeland et al. [ 10 ] also remarked that denser devices result in a lesser increase in ED. The increased ED estimated from DLP-E(k) method confirms the results from previous studies[ 16 , 23 ] which reported that the simplified method overestimate the ED at different levels for different body parts and sizes. A more comprehensive dosimetric approach through direct dose measurements using thermoluminescent dosimeters placed inside the phantom to quantify absorbed dose may help correct any inherent effect of the trauma mattress (through attenuation by the trauma mattress materials) on the estimated dose. The increase in ED may vary for different protocols and equipment designs. Additionally, different bearing devices may have differing effects on the extent of the increase in ED. For the different devices used in their study, Stokkeland et al. [ 10 ] reported that the highest increase in ED occurred with vacuum mattress and concluded that it may have resulted from increased photon attenuation. In a similar study, rigid spine board with soft foam headblocks increased the ED of a trauma CT examination by 1.7– 3.4 mSv [ 11 ]. In addition to increasing the radiation dose, the use of bearing devices may decrease the image quality when used in WBCT examinations. The rate at which bearing devices may decrease the image quality may differ based on the protocol, the size of the patient, the equipment design, and the type of bearing device. In this study, the objective image quality (SNR) of examinations conducted without the use of a trauma mattress showed improvements of 16.5% and 21.3% for the newborn and 5-year-old phantoms, respectively, compared to examinations performed with a trauma mattress. This result is similar to that of Euler et al. [ 22 ], which reported that the use of immobilising devices caused a decrease in image quality. In order to obtain images of comparable quality, Hemmes et al. [ 11 ] increased the exposure by 11% when studying the effects of bearing devices on the dose and image quality of trauma CT examinations with rigid spine board and soft foam headblocks. The bearing device used for this study is CT compatible and has low X-ray attenuating properties [ 13 ]. This could have resulted in the non-significant differences in the results (ED and SNR) of examinations performed with and without the trauma mattress. This study also found that the use of trauma mattress resulted in increased image artefacts and noise, and decreased contrast, organ visibility, and overall diagnosability. Consistent with a similar study [ 10 ], the main artefact found in this study for examinations performed with trauma mattress was beam hardening/streaking artefacts, although these did not significantly reduce the clinical relevance of the images. Loewenhardt et al. [ 21 ] also observed that some immobilising devices caused massive artefacts. Quantitatively, Euler et al. [ 22 ] reported a 6.6–11.2% increase in image noise following the use of immobilising devices. Limitation The study did not include results for the head CT examinations because they were all performed with trauma mattress and hence did not permit comparison to be made. All reported results are related to CAP WBCT protocols. Conclusion The use of trauma mattress affected the dose and image quality in the newborn examinations than the 5-year-old examinations. The use of trauma mattress did not significantly increase patient dose nor impeded clinical judgement. The significance of bearing devices cannot be overruled as they reduce the possibility of increasing secondary spinal injuries and reduce hospital stay times. While designers of bearing devices may consider the radiological properties of the materials used, we advise radiological professionals to consider patients’ clinical histories and to ensure appropriate justification for the use of bearing devices is maintained. This will ensure that the full benefits of bearing devices are obtained. Abbreviations Declarations Acknowledgments We are grateful to the Norwegian government, the Norwegian University of Science and Technology, and Prof. Pal Erik Goa for their support through the NORPART project. Author contributions JLA : Conceptualisation, methodology, investigation, project management, formal analysis, writing – original draft; SI : Conceptualisation, methodology, supervision, software, writing – review and editing; BOB : Conceptualisation, methodology, supervision, writing – review and editing; AL : Conceptualisation, investigation, resources, supervision; ISB : Conceptualisation, investigation, resources. Funding JLA received stipend from the NORPART Project throughout his studies at NTNU. No other funding was received. Data availability The data associated with this will be made available by the corresponding author upon reasonable request. Ethical approval Not applicable. Consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare no competing interests References Kahn J, Grupp U, Kaul D, Boning G, Lindner T, and Streitparth F. 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Supplementary Files SupplementaryFile.docx Cite Share Download PDF Status: Published Journal Publication published 06 Jul, 2025 Read the published version in BMC Medical Imaging → Version 1 posted Editorial decision: Revision requested 29 May, 2025 Reviews received at journal 28 May, 2025 Reviews received at journal 22 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviewers invited by journal 08 May, 2025 Editor invited by journal 22 Apr, 2025 Editor assigned by journal 22 Apr, 2025 Submission checks completed at journal 22 Apr, 2025 First submitted to journal 21 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6492636","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":455182500,"identity":"e96501b7-4c70-4795-a591-1c25b2556570","order_by":0,"name":"Jacob Leonard Ago","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYBACxgYGBmaGAghHAojlQIwDDwhqMUBoMQZrSSBgE4qWxAYQC58W5vbDDx8XGNjImbOffXjjxy+b9Plhhx8CbbGT023A4bCeNGPjGQZpxpY96caWvX1puRtvpxkAtSQbmx3A5ZccNmkeg8OJGw6ksUnw9hzO3Tg7AaTlQOI2XFr634C0/E/ccP4Zm+TfnsPphrPTP+DXMgNsy4HEDTfSgIwfhxPkpXMI2DLjGcgvycYGN54xW8s2pBlukM4pOJBggNsvhv3JwBCrsJMzOJ/GePPNHxt5+dnpmz98AIrg1NKAYmcbA4MBWKUBduUgII/K/QMUacCqcBSMglEwCkYwAABE5GJbm8ZbqwAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Radiography, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana","correspondingAuthor":true,"prefix":"","firstName":"Jacob","middleName":"Leonard","lastName":"Ago","suffix":""},{"id":455182501,"identity":"91fcdd00-9642-4901-af36-c1b4274650ff","order_by":1,"name":"Stephen Inkoom","email":"","orcid":"","institution":"Department of Medical Physics, School of Nuclear and Allied Sciences, College of Basic and Applied Sciences, University of Ghana, Atomic Campus","correspondingAuthor":false,"prefix":"","firstName":"Stephen","middleName":"","lastName":"Inkoom","suffix":""},{"id":455182502,"identity":"2a8dc17b-0313-44e3-8770-31367fefd737","order_by":2,"name":"Benard Ohene-Botwe","email":"","orcid":"","institution":"Department of Midwifery and Radiography, School of Health \u0026 Psychological Sciences, City, University of London","correspondingAuthor":false,"prefix":"","firstName":"Benard","middleName":"","lastName":"Ohene-Botwe","suffix":""},{"id":455182503,"identity":"0df53072-e818-4133-a3a4-e5417bac16f0","order_by":3,"name":"Alise Larsen","email":"","orcid":"","institution":"Radiology and Medical Physics Department, Innlandet Hospital","correspondingAuthor":false,"prefix":"","firstName":"Alise","middleName":"","lastName":"Larsen","suffix":""},{"id":455182504,"identity":"c517ebf1-d50d-4660-a9ee-b34f2e90c1e0","order_by":4,"name":"Ingerd Skaaret Berg","email":"","orcid":"","institution":"Radiology and Medical Physics Department, Innlandet Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ingerd","middleName":"Skaaret","lastName":"Berg","suffix":""}],"badges":[],"createdAt":"2025-04-21 05:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6492636/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6492636/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12880-025-01821-y","type":"published","date":"2025-07-06T15:58:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82792365,"identity":"11ef92ab-20da-4e8a-ac80-e74fa2b4334a","added_by":"auto","created_at":"2025-05-15 10:22:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":437005,"visible":true,"origin":"","legend":"\u003cp\u003eNewborn (L) and paediatric (R) anthropomorphic phantoms positioned on CM trauma mattress.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6492636/v1/d296ab4c59af5b34f4a802af.png"},{"id":82791962,"identity":"3da0a2a1-8413-405d-8cec-c0fffa706937","added_by":"auto","created_at":"2025-05-15 10:14:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":167201,"visible":true,"origin":"","legend":"\u003cp\u003eROI for SNR determination from ImageJ software.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6492636/v1/23c92572af67b4c52a68017b.png"},{"id":82792366,"identity":"72ad6102-d3ff-44cf-811a-9b3abe069077","added_by":"auto","created_at":"2025-05-15 10:22:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21448,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing the differences in subjective image qualities between examinations performed with and without trauma mattress.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6492636/v1/4336a9530e5a4406ea46b984.png"},{"id":82792368,"identity":"1d6eac86-13c1-4834-a0d9-d1e79e2eff7a","added_by":"auto","created_at":"2025-05-15 10:22:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":91763,"visible":true,"origin":"","legend":"\u003cp\u003eA: Examination without trauma mattress; B: Examination with trauma mattress; White arrow: Streaking/beam hardening artefact.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6492636/v1/b8938c08a35a25c4aa023e48.png"},{"id":82791960,"identity":"e89cad8f-8d04-47ee-ae23-0b540ca232cb","added_by":"auto","created_at":"2025-05-15 10:14:03","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":23776,"visible":true,"origin":"","legend":"\u003cp\u003eBox plots of effective doses from newborn phantom (left) and paediatric phantom (right) estimated from CT-Expo and DLP-E (k): \u003cem\u003ethe X in the box represents the mean effective doses while the midline in the box indicates the median effective doses, the T-bars that extend from the box denote the minimum and maximum effective doses from each method (without outliers), and the box represents the 25\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e to 75\u003c/em\u003e\u003csup\u003e\u003cem\u003eth\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e percentile.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6492636/v1/15422263ec01f0e7ae027e39.png"},{"id":86179112,"identity":"36de39e8-92ef-4125-a438-968f1d924977","added_by":"auto","created_at":"2025-07-07 16:15:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1893914,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6492636/v1/a9521f7e-d538-4c2b-9cdc-8971a1485363.pdf"},{"id":82791957,"identity":"0441f9ab-9e10-4b2f-9426-6f6057d8bf47","added_by":"auto","created_at":"2025-05-15 10:14:02","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":30827,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-6492636/v1/d2c8b16c3ac8e52774546625.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of trauma mattress on dose and image quality of paediatric whole-body computed tomography examinations","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWhole-body computed tomography (WBCT) is a commonly used computed tomography (CT) technique for assessing patients with suspected multiple traumas, involving injuries to multiple body parts [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. WBCT combines noncontrast-enhanced examination of the head and neck with a contrast examination of the trunk, including the whole spine [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is highly accurate and can effectively detect life-threatening injuries with good sensitivity and specificity, thereby improving patient management [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although this, along with its rapid results generation, has increased demand for treating trauma patients, where time is crucial, the increased use of WBCT has raised concerns about radiation-induced problems due to the high levels of exposure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe possibility of detrimental effects associated with WBCT may be greater in paediatric population due to their increasing radiosensitivity and longer life expectancy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. During WBCT imaging, bearing devices such as trauma mattress are used to support and ensure adequate immobilization of the spine to decrease the potential for increased spinal injury [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, reports suggest that the use of these devices may affect the radiation dose and image quality, particularly signal relative to noise [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To the best knowledge of the authors, the effects of the use of trauma mattress on radiation dose and image quality during paediatric WBCT examinations are less understood.\u003c/p\u003e \u003cp\u003eThis study assessed the effect of using trauma mattress on the dose and image quality of WBCT examinations from two different CT scanners. The purpose is to understand the extent to which bearing devices, such as trauma mattresses, impact WBCT regarding dose and image quality, so that appropriate recommendations can be made to support and optimize their use in newborns and paediatrics.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMaterials\u003c/h2\u003e \u003cp\u003eTwo CT scanners, anthropomorphic phantoms, trauma mattress, and CT-Expo software were the materials used for the study. In addition, a Black Piranha 657 (B2-16020228, RTI, Sweden) and Catphan 500 were used to undertake quality control activities on both scanners, following the international elctrotechnical commission (IEC) guidelines [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Kyoto Kagaku newborn (PBU-80) and 5-year-old (PBU-70) whole body anthropomorphic phantoms (Kyotokagaku America Inc., Los Angeles, United States of America) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [henceforth newborn phantom and 5-year-old phantoms, respectively] have soft tissues made with urethane-based resin and synthetic bones made with epoxy resin. Both the newborn and 5-year-old phantoms have no metal parts or liquid structures. The newborn phantom has a size of 53 cm, a weight of 3.5 kg, a packaging size of W57 X D44 X H29 cm, and a packaging weight of 8 kg. Conversely, the 5-year-old phantom has an HU number approximate to the human body and its main joints are close to human articulation. It has a height of 110 cm, a weight of 20 kg, and a packaging size of W86 X D60 X H32 cm. The newborn and 5-year-old phantoms are comparable to the infant and child mathematical phantoms, respectively, in CT-Expo.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe CM TraumaMattress\u0026trade; (Comfort Medical AB, Sweden) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) is a CT-compatible intrahospital mattress that helps in the immobilisation and transfer of patients. The mattress is made of polyester-weave that can be removed and a silicone-coated polyamide with low friction attributes that lies under the mattress. The core of the mattress is waterproof and is covered in a durable polyurethane-cover [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The CM trauma mattress weighs 8 kg in weight and measures 2000 x 530 x 60 mm in dimension.\u003c/p\u003e \u003cp\u003eThe General Electric (GE) Revolution\u003csup\u003e\u0026trade;\u003c/sup\u003e CT (GE Medical Systems, Waukesha, United States of America) and the Siemens SOMATOM Definition Edge CT scanners (Siemens Healthineers, Erlangen, Germany) were used for this study. The GE Revolution\u003csup\u003e\u0026reg;\u003c/sup\u003e CT is a 250 MDCT equipment with in-built Smart technologies, which help to produce high quality images at lower radiation dose levels in the examination of various disease conditions including polytrauma and/or WBCT. The Siemens SOMATOM Definition Edge is a 128 MDCT equipment with an in-built Advanced Modelled Iterative Reconstruction (ADMIRE) technology. Both the GE and Siemens scanners have automatic attenuation-based kilo-voltage peak (kVp) selection algorithms that produce the lowest radiation dose with 70, 80, 100, 120, or 140 kVp [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe CT-Expo software version 2.5 (SASCRAD, Fritz-Reuter-Weg, Buchholz, Germany) was used to estimate the effective dose (ED) for all protocols and the organ doses associated with the optimized protocols. The infants (BABY) and 7-year-old children (CHILD) models were used in this study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCT Examinations\u003c/h3\u003e\n\u003cp\u003eThe whole-body examinations were performed in two parts: non-contrast examination of the head (in head-first supine position) and contrast-enhanced examination of the chest-abdomen-pelvis (CAP) (in feet-first supine position). Twenty-seven different examinations were performed (9 without and 18 with the trauma mattress) and tested for dose and image quality. The table height was adjusted to be in isocenter for each examination, both with and without trauma mattress, to prevent possible displacement.\u003c/p\u003e\n\u003ch3\u003eEffective dose estimation\u003c/h3\u003e\n\u003cp\u003eIn estimating the ED from CT-Expo software, the BABY and CHILD modules were selected for the newborn and 5-year-old phantoms respectively. In addition, both male and female genders were selected in turns while estimating the effective and organ doses. Tissue weighting factors as stated in ICRP publication 103 were used in estimating the effective doses. The scan lengths used in estimating the ED are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Additionally, the ED was estimated from a simplified method according to Eq.\u0026nbsp;(\u003cspan refid=\"Equ1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScan lengths and k-values used in Dose Calculation from CT-Expo and DLP-E(k) methods respectively.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eScan Range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eScan Length\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ek-values\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFrom z-\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTo z+\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eL (cm)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNewborn Chest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric Chest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNewborn Abdomen-Pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric Abdomen-Pelvis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNewborn Trunk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric Trunk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cdiv id=\"Equ1\" class=\"Equation\"\u003e \u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equ1\" name=\"EquationSource\"\u003e\n$$\\:ED=kDLP$$\u003c/div\u003e \u003cdiv class=\"EquationNumber\"\u003e1\u003c/div\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhere \u003cem\u003ek\u003c/em\u003e is the conversion coefficient specific to each body part. The \u003cem\u003ek\u003c/em\u003e-factors used in this study were adopted from Romanyukha et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003ek\u003c/em\u003e-values used for the various body parts and phantoms [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody part\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNewborn Phantom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePaediatric Phantom\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdomen-pelvic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest-Abdomen-Pelvic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eSubjective image quality assessment\u003c/h3\u003e\n\u003cp\u003eThe images were subjectively assessed by two independent radiologists, with 5 years\u0026rsquo; and 8 years\u0026rsquo; experience, for artefacts, image noise, contrast, organ visibility, and overall diagnosability. This was done in a blinded fashion by removing all annotations related to scan protocols and organised randomly in order to decrease expectation bias. Each category was assessed using a 5-point Likert scale (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) adapted from Gariani et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Inter-rater agreement between the two radiologists was assessed with the Cohen\u0026rsquo;s kappa coefficient [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additionally, the assessments were combined, and the average scores computed to determine the effect of the trauma mattress on the five image quality criteria.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFive-point Likert scale for subjective image quality assessment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eScale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArtefacts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere unacceptable artifacts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate artifacts, partially degrading diagnostic capability;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSlight artifacts, not significantly affecting diagnostic capabilities;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimal artifacts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbsent, no perceivable artifacts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage Noise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBad, not diagnostic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoor, definitely noisy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate, slightly noisy but acceptable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimal noise, not affecting diagnostic quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo perceivable noise.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContrast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-diagnostic image quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSevere blurring with uncertainty about the evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate blurring with restricted assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSlight blurring with unrestricted diagnostic image evaluation possible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExcellent image quality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrgan visibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery poor, almost not visible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall diagnosability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBad, not diagnostic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePoor, diagnostic confidence substantially reduced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate, sufficient for diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eObjective image quality assessment\u003c/h3\u003e\n\u003cp\u003eQuantitatively, image quality was assessed using the ImageJ software version 1.54c (Wayne Rasband and Contributors, National Institutes of Health, USA). The signal-to-noise ratio (SNR) was used in the objective assessment of the image quality. In determining the SNR for body examinations, three circular regions of interest (ROIs) of equal dimensions (5.0 mm x 5.0 mm) were drawn on three different images of the liver (for the 5-year-old phantom) and heart (for the newborn phantom) at the same slice position. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows how the signal and standard deviations (noise) were obtained from the ImageJ software version 1.54c (Wayne Rasband and Contributors, National Institutes of Health, USA). The average values of the signal and standard deviations obtained were used to calculate the SNR according to Eq.\u0026nbsp;(\u003cspan refid=\"Equ2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv id=\"Equ2\" class=\"Equation\"\u003e \u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equ2\" name=\"EquationSource\"\u003e\n$$\\:SNR=\\frac{Mean\\:Signal\\:in\\:Roi}{Standard\\:Deviation\\:in\\:ROI}$$\u003c/div\u003e \u003cdiv class=\"EquationNumber\"\u003e2\u003c/div\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe data obtained was statistically analysed with the IBM SPSS v26.0 (IBM Corp., Armonk, N.Y., USA) and Microsoft Excel 2016. Results from descriptive statistics were reported as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for normally distributed data and median (95% confidence interval) for non-normally distributed data and presented in the form of tables and graphs. The Shapiro-Wilk test was used to determine the normality of the data. Normally distributed data sets were compared using the one-way ANOVA test whereas comparison between non-normally distributed data sets was made with the Mann-Whitney U-test and Kruskal-Wallis H test. Differences were considered significant at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eQuality control tests results\u003c/h2\u003e \u003cp\u003eAll quality control tests results were consistent with IEC recommendations. The results have been provided in the Supplementary File.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCT scan parameters\u003c/h2\u003e \u003cp\u003eThe CT scan parameters used for this study have been presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The average tube voltage increased marginally by 1.33% whereas the average tube current increased substantially by 63.91% when trauma mattress was used. Additionally, the use of the trauma mattress increased both the DLP and CTDI\u003csub\u003evol\u003c/sub\u003e by 47.28% and 48.34% respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAverage scanning parameters used for examinations performed with and without the trauma mattress.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard deviation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWithout trauma mattress\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWith trauma mattress\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTube voltage [kVp]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.44\u0026thinsp;\u0026plusmn;\u0026thinsp;8.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.56\u0026thinsp;\u0026plusmn;\u0026thinsp;10.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTube current [mA]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129.65\u0026thinsp;\u0026plusmn;\u0026thinsp;65.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e212.51\u0026thinsp;\u0026plusmn;\u0026thinsp;102.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRotation time [s]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlice thickness [mm]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePitch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDLP [mGy.cm]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.45\u0026thinsp;\u0026plusmn;\u0026thinsp;38.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.36\u0026thinsp;\u0026plusmn;\u0026thinsp;50.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTDI\u003csub\u003evol\u003c/sub\u003e [mGy]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.51\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSubjective image quality assessment\u003c/h2\u003e \u003cp\u003eCohen\u0026rsquo;s Kappa was used to determine the interobserver reliability of the subjective image quality assessment by the two observers for examinations performed with and without the trauma mattress The Cohen\u0026rsquo;s Kappa score obtained for examinations performed without trauma mattress ranged from 0.60 to 0.80 (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) whereas examinations performed with the trauma mattress had Kappa score from 0.56 to 0.79 (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e), indicating a weak to excellent agreement between the two observers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubjective image quality assessment scores and interobserver reliability for examinations performed with the trauma mattress.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWith Trauma Mattress\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e\u003cem\u003eWithout Trauma Mattress\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage Quality Parameters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAverage Ratings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKappa Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eAverage Ratings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eKappa Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-Value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReader 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReader 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReader 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReader 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eReader 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArtifact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage Noise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage Contrast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrgan Visibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Diagnosability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe examinations performed without the trauma mattress (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9) had higher mean ratings than examinations performed with the trauma mattress (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18) for all the image quality criteria for subjective assessment (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, a Mann-Whitney U test revealed no statistically significant difference across all criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The main type of artefact found by the two radiologists was streaking artefacts (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComparison of SNR between examinations performed with and without trauma mattress\u003c/h2\u003e \u003cp\u003eThe mean SNR of examinations performed without trauma mattress was 16.5 and 21.37% higher than examinations performed with trauma mattress for the newborn and 5-year-old phantoms respectively (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). A Mann-Whitney U-test showed that the difference in the mean SNR of examinations performed with and without trauma mattress was not statistically significant for both the newborn phantom (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16.00, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.221) and 5-year-old phantom (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.00, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.194) examinations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSNR and ED of newborn and paediatric trunk examinations with and without trauma mattress\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eExamination\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e(n) Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSignal-noise-ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eEffective dose (mSv)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith Trauma Mattress\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWithout Trauma Mattress\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWith Trauma Mattress\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWithout Trauma Mattress\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNewborn Trunk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11) 1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;5) 2.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;11) 2.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;5) 1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaediatric Trunk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8) 5.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;3) 7.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8) 3.84\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;3) 3.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eComparison of ED between examinations performed with and without trauma mattress\u003c/h2\u003e \u003cp\u003eThe mean ED for the examinations performed with trauma mattress was 43.87 and 7.03% higher than the corresponding values obtained from examinations performed without trauma mattress for the newborn and 5-year-old phantoms respectively (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). A Mann-Whitney U test showed a statistically significant difference for examinations performed with the newborn phantom (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.50, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019) whereas the difference was not statistically significant for examinations performed with the 5-year-old phantom (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.00; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.776).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eComparison of ED estimated from CT-Expo and DLP-E(k) methods\u003c/h2\u003e \u003cp\u003eThe median ED estimated from CT-Expo for all newborn phantom examinations was 1.65 mSv (95% CI\u0026thinsp;=\u0026thinsp;1.49 to 2.67 mSv) and 2.05 mSv (95% CI\u0026thinsp;=\u0026thinsp;1.81 to 3.05 mSv) for male and female anatomies respectively whereas the median effective dose for all newborn phantom examinations estimated from DLP-E (k) is 2.10 (95% CI\u0026thinsp;=\u0026thinsp;1.90 to 3.59 mSv). A Kruskal-Wallis H test showed that there was no significant difference in effective dose between the methods, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\chi\\:}\\)\u003c/span\u003e\u003c/span\u003e\u003csup\u003e2\u003c/sup\u003e(2)\u0026thinsp;=\u0026thinsp;2.706, p\u0026thinsp;=\u0026thinsp;0.258, with a mean rank effective dose of 22.61 mSv, 29.14 mSv, and 30.75 mSv for CT-Expo (Male), CT-Expo (Female), and DLP-E (k) respectively. For the paediatric phantom examinations, a one-way ANOVA revealed that the mean effective dose from DLP-E (k) [4.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02 mSv] was not significantly higher than the effective doses from CT-Expo (Male) [3.35\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20 mSv] and CT-Expo (Female) [3.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59 mSv], (F(2, 36)\u0026thinsp;=\u0026thinsp;1.325, p\u0026thinsp;=\u0026thinsp;0.278). Figure\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the relationship between the effective doses estimated from CT-Expo with male anatomy [CT-Expo (Male)], CT-Expo using female anatomy [CT-Expo (Female)], and DLP-E (k) methods for the newborn and paediatric phantom examinations.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis phantom-based experimental study throws light on the effects of the use of trauma mattress during paediatric WBCT examinations, and whether there is a need for the use of trauma mattress during paediatric WBCT examinations. It is known that the use of WBCT examinations is associated with high radiation doses as compared to conventional X-ray examinations. However, WBCT examinations are essential in the events of poly-trauma as they potentially increase the survival rates of poly-traumatised patients [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Despite the level of dose associated with WBCT, studies relating to how the use of bearing devices affect the dose and image quality are scarce [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Neglecting the effects of these devices on the dose and image quality during WBCT examinations, especially for the paediatric population, may be detrimental.\u003c/p\u003e \u003cp\u003eThis study found a mean ED of 1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53 mSv for CAP examinations performed without trauma mattress with the newborn phantom. This ED increased by 43.87% when the examination was performed with trauma mattress, albeit there was no significant difference. Similarly, this study found a mean ED of 3.57\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81 mSv for CAP examinations performed without trauma mattress for the 5-year-old phantom, with a corresponding 7.03% non-significant increase when the examination was performed with trauma mattress. Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows the difference in ED between examinations performed with and without trauma mattress. The result from this study aligns with the findings from a study by Loewenhardt et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] where the use of different immobilising devices caused an increase in ED from 2.5\u0026ndash;4.5%. Similarly, Euler et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported that the use of immobilising devices causes an increase in radiation dose. Stokkeland et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] also remarked that denser devices result in a lesser increase in ED. The increased ED estimated from DLP-E(k) method confirms the results from previous studies[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] which reported that the simplified method overestimate the ED at different levels for different body parts and sizes. A more comprehensive dosimetric approach through direct dose measurements using thermoluminescent dosimeters placed inside the phantom to quantify absorbed dose may help correct any inherent effect of the trauma mattress (through attenuation by the trauma mattress materials) on the estimated dose.\u003c/p\u003e \u003cp\u003eThe increase in ED may vary for different protocols and equipment designs. Additionally, different bearing devices may have differing effects on the extent of the increase in ED. For the different devices used in their study, Stokkeland et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] reported that the highest increase in ED occurred with vacuum mattress and concluded that it may have resulted from increased photon attenuation. In a similar study, rigid spine board with soft foam headblocks increased the ED of a trauma CT examination by 1.7\u0026ndash; 3.4 mSv [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to increasing the radiation dose, the use of bearing devices may decrease the image quality when used in WBCT examinations. The rate at which bearing devices may decrease the image quality may differ based on the protocol, the size of the patient, the equipment design, and the type of bearing device. In this study, the objective image quality (SNR) of examinations conducted without the use of a trauma mattress showed improvements of 16.5% and 21.3% for the newborn and 5-year-old phantoms, respectively, compared to examinations performed with a trauma mattress. This result is similar to that of Euler et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], which reported that the use of immobilising devices caused a decrease in image quality. In order to obtain images of comparable quality, Hemmes et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] increased the exposure by 11% when studying the effects of bearing devices on the dose and image quality of trauma CT examinations with rigid spine board and soft foam headblocks. The bearing device used for this study is CT compatible and has low X-ray attenuating properties [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This could have resulted in the non-significant differences in the results (ED and SNR) of examinations performed with and without the trauma mattress.\u003c/p\u003e \u003cp\u003eThis study also found that the use of trauma mattress resulted in increased image artefacts and noise, and decreased contrast, organ visibility, and overall diagnosability. Consistent with a similar study [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the main artefact found in this study for examinations performed with trauma mattress was beam hardening/streaking artefacts, although these did not significantly reduce the clinical relevance of the images. Loewenhardt et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] also observed that some immobilising devices caused massive artefacts. Quantitatively, Euler et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported a 6.6\u0026ndash;11.2% increase in image noise following the use of immobilising devices.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eThe study did not include results for the head CT examinations because they were all performed with trauma mattress and hence did not permit comparison to be made. All reported results are related to CAP WBCT protocols.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe use of trauma mattress affected the dose and image quality in the newborn examinations than the 5-year-old examinations. The use of trauma mattress did not significantly increase patient dose nor impeded clinical judgement. The significance of bearing devices cannot be overruled as they reduce the possibility of increasing secondary spinal injuries and reduce hospital stay times. While designers of bearing devices may consider the radiological properties of the materials used, we advise radiological professionals to consider patients\u0026rsquo; clinical histories and to ensure appropriate justification for the use of bearing devices is maintained. This will ensure that the full benefits of bearing devices are obtained.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cimg 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are grateful to the Norwegian government, the Norwegian University of Science and Technology, and Prof. Pal Erik Goa for their support through the NORPART project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJLA\u003c/strong\u003e: Conceptualisation, methodology, investigation, project management, formal analysis, writing \u0026ndash; original draft; \u003cstrong\u003eSI\u003c/strong\u003e: Conceptualisation, methodology, supervision, software, writing \u0026ndash; review and editing; \u003cstrong\u003eBOB\u003c/strong\u003e: Conceptualisation, methodology, supervision, writing \u0026ndash; review and editing; \u003cstrong\u003eAL\u003c/strong\u003e: Conceptualisation, investigation, resources, supervision; \u003cstrong\u003eISB\u003c/strong\u003e: Conceptualisation, investigation, resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJLA received stipend from the NORPART Project throughout his studies at NTNU. No other funding was received.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data associated with this will be made available by the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKahn J, Grupp U, Kaul D, Boning G, Lindner T, and Streitparth F. 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Automatic tube current modulation for whole-body polytrauma CT with immobilization devices: is there an increase in radiation dose and degradation of image quality? Emerg Radiol. 2017;24(1):31-7 https://doi.org/10.1007/s10140-016-1442-x\u003c/li\u003e\n\u003cli\u003eInoue Y, Itoh H, Nagahara K, and Takahashi Y. ESTIMATION OF RADIATION DOSE IN CT VENOGRAPHY OF THE LOWER EXTREMITIES: PHANTOM EXPERIMENTS USING DIFFERENT AUTOMATIC EXPOSURE CONTROL SETTINGS AND SCAN RANGES. Radiat Prot Dosimetry. 2020;188(1):109-16 https://doi.org/doi: 10.1093/rpd/ncz265\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Whole-body computed tomography, trauma mattress, immobilising devices, bearing devices, anthropomorphic phantom, dose optimisation","lastPublishedDoi":"10.21203/rs.3.rs-6492636/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6492636/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWhole-body computed tomography (WBCT) is the preferred first line investigation for patients with suspected multiple traumas. To decrease the potential for increased spinal injury, it is recommended that bearing devices, such as trauma mattress, be used to ensure adequate immobilisation of the spine. This study assessed the effect of the use of trauma mattress on the dose and image quality of WBCT examinations.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a phantom-based experimental study. Two different paediatric whole-body anthropomorphic phantoms from Kyoto Kagaku were used: newborn (PBU-80) and 5-year-old (PBU-70). Different WBCT protocols were scanned with and without trauma mattress. The effective dose (ED) from each protocol was estimated from CT-Expo software and from the product of the dose length product and dose conversion coefficient (DLP-E(k)) method, while image quality was assessed both subjectively and objectively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe use of trauma mattress increased the mean ED and decreased the SNR of paediatric examinations by 7.03% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.776) and 21.37% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.194) respectively. Similarly, there was a 43.87% increase in ED (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019) and a 16.5% decrease in SNR (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.221) when trauma mattress was used for newborn examinations. The differences in the mean ED from CT-Expo and the DLP-E (k) were not statistically significant (p\u0026thinsp;=\u0026thinsp;0.258 and 0.278 for newborn and paediatric phantoms respectively). The use of the trauma mattress increased the average tube voltage, tube current, dose-length product (DLP), and the volume computed tomography dose index (CTDI\u003csub\u003evol\u003c/sub\u003e) by 1.33%, 63.91%. 47.28%, and 48.34% respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe use of trauma mattress increased the ED and decreased the SNR during the WBCT examinations, albeit at different levels for the newborn and 5-year-old phantoms. Radiologists and radiographers should critically evaluate patients\u0026rsquo; conditions and the diagnostic information required to justify the use of bearing devices.\u003c/p\u003e","manuscriptTitle":"Effects of trauma mattress on dose and image quality of paediatric whole-body computed tomography examinations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 10:13:58","doi":"10.21203/rs.3.rs-6492636/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-29T13:58:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-28T15:10:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-22T05:55:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155058663364271918420322659386645840054","date":"2025-05-11T16:40:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143270959906019105749852549132067576998","date":"2025-05-11T08:06:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-09T01:42:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-22T20:07:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-22T12:46:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-22T12:45:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Imaging","date":"2025-04-21T05:25:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-imaging","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmim","sideBox":"Learn more about [BMC Medical Imaging](http://bmcmedimaging.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmim/default.aspx","title":"BMC Medical Imaging","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f1f4147-9850-4562-be1c-8990a337aab8","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:05:33+00:00","versionOfRecord":{"articleIdentity":"rs-6492636","link":"https://doi.org/10.1186/s12880-025-01821-y","journal":{"identity":"bmc-medical-imaging","isVorOnly":false,"title":"BMC Medical Imaging"},"publishedOn":"2025-07-06 15:58:08","publishedOnDateReadable":"July 6th, 2025"},"versionCreatedAt":"2025-05-15 10:13:58","video":"","vorDoi":"10.1186/s12880-025-01821-y","vorDoiUrl":"https://doi.org/10.1186/s12880-025-01821-y","workflowStages":[]},"version":"v1","identity":"rs-6492636","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6492636","identity":"rs-6492636","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}