{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T23:18:28Z","timestamp":1787786308539,"version":"build-2784847793"},"reference-count":13,"publisher":"Georg Thieme Verlag KG","issue":"09","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Rofo"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Two-view chest X-ray (CXR) is a widely utilized diagnostic tool due to its accessibility, cost-effectiveness, and ability to evaluate thoracic pathologies. The current diagnostic reference levels (DRLs) in Germany for posterior-anterior (PA) and lateral CXR are 12.0 and 40.0 cGy \u00d7 cm\u00b2, respectively. This study assessed the dose contributions of PA and lateral CXR for different body mass index (BMI) groups, aiming to determine the best possible BMI thresholds to predict exceedance of the national DRLs.<\/jats:p>\n                  <jats:p>In this retrospective study, 3,982 patients underwent a total of 4,958 two-view chest radiograms using a twin robotic X-ray system. Dose-area products (DAP) of each BMI group were compared between projections using Wilcoxon signed rank tests. Receiver operating characteristic statistics were employed to identify BMI values likely to result in doses above the DRLs.<\/jats:p>\n                  <jats:p>For each BMI group, lateral CXR resulted in higher DAP than PA radiograms (all p&lt;0.001). The smallest median DAP difference was found for underweight patients (BMI &lt;18.5 kg\/m\u00b2; 12.2 versus 4.8 cGy \u00d7 cm\u00b2; 154.2% higher DAP in lateral CXR), whereas the largest difference was observed among severely obese individuals (&gt;40.0 kg\/m\u00b2; 142.1 versus 21.7 cGy \u00d7 cm\u00b2; 554.8%). The correlation of BMI and DAP was strong for both lateral and PA CXR (r = 0.614 and 0.641, both p&lt;0.001). The best possible BMI thresholds to predict DRL exceedance were determined to be 26.5 kg\/m\u00b2 for lateral CXR (72.6% sensitivity \/ 76.1% specificity) and 27.8 kg\/m\u00b2 for PA radiograms (78.1% \/ 74.4%).<\/jats:p>\n                  <jats:p>BMI information facilitates prediction of DRL exceedance. The findings presented may serve as a basis for future discussions on whether BMI-dependent reference levels could help to optimize dose management in chest imaging.<\/jats:p>","DOI":"10.1055\/a-2810-5285","type":"journal-article","created":{"date-parts":[[2026,4,14]],"date-time":"2026-04-14T22:50:14Z","timestamp":1776207014000},"page":"1206-1212","source":"Crossref","is-referenced-by-count":0,"title":["Predicting Exceedance of National Diagnostic Reference Levels for Two-view Chest Radiography in Germany based on Patients\u2019 Body Mass Index"],"prefix":"10.1055","volume":"198","author":[{"given":"Henner","family":"Huflage","sequence":"additional","affiliation":[{"name":"University Hospital Wurzburg, BY, Germany","place":["Wurzburg"],"department":["Department of Diagnostic and Interventional Radiology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gary","family":"Razinskas","sequence":"additional","affiliation":[{"name":"University Hospital Wurzburg, BY, Germany","place":["Wurzburg"],"department":["Department of Radiation Oncology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan","family":"Weick","sequence":"additional","affiliation":[{"name":"University Hospital Wurzburg, BY, Germany","place":["Wurzburg"],"department":["Department of Radiation Oncology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas Steven","family":"Kunz","sequence":"additional","affiliation":[{"name":"University Hospital Wurzburg, BY, Germany","place":["Wurzburg"],"department":["Department of Diagnostic and Interventional Radiology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robin","family":"Hendel","sequence":"additional","affiliation":[{"name":"University Hospital Wurzburg, BY, Germany","place":["Wurzburg"],"department":["Department of Diagnostic and Interventional Radiology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tobias","family":"Wech","sequence":"additional","affiliation":[{"name":"University Hospital Wurzburg, BY, Germany","place":["Wurzburg"],"department":["Department of Diagnostic and Interventional Radiology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lukas","family":"M\u00fcller","sequence":"additional","affiliation":[{"name":"University Medical Center of the Johannes Gutenberg University Mainz, Germany","place":["Mainz"],"department":["Department for Diagnostic and Interventional Radiology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thorsten","family":"Bley","sequence":"additional","affiliation":[{"name":"University Hospital Wurzburg, BY, Germany","place":["Wurzburg"],"department":["Department of Diagnostic and Interventional Radiology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4524-1620","authenticated-orcid":false,"given":"Jan-Peter","family":"Grunz","sequence":"additional","affiliation":[{"name":"University Hospital Wurzburg, BY, Germany","place":["Wurzburg"],"department":["Department of Diagnostic and Interventional Radiology"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"194","published-online":{"date-parts":[[2026,4,14]]},"reference":[{"key":"ref1","first-page":"574","article-title":"Chest radiography in general practice: Indications, diagnostic yield and consequences for patient management","volume":"56","author":"AM Speets","year":"2006","journal-title":"Br J Gen Pract"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"1560","DOI":"10.1016\/j.acra.2010.07.004","article-title":"Lateral chest radiograph a systematic approach","volume":"17","author":"DS Feigin","year":"2010","journal-title":"Acad Radiol"},{"key":"ref3","doi-asserted-by":"publisher","DOI":"10.1259\/bjr.20160394","article-title":"The additional value of the lateral chest radiograph for the detection of small pulmonary nodules \u2013 a ROC analysis","volume":"89","author":"RA Kluthke","year":"2016","journal-title":"Br J Radiol"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"303","DOI":"10.1148\/radiology.137.2.7433659","article-title":"The epicardial fat pad sign: Analysis of frontal and lateral chest radiographs in patients with pericardial effusion","volume":"137","author":"EW Carsky","year":"1980","journal-title":"Radiology"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"184","DOI":"10.1016\/j.acra.2010.09.013","article-title":"Screening of asymptomatic children for tuberculosis is a lateral chest radiograph routinely indicated?","volume":"18","author":"EY Lee","year":"2011","journal-title":"Acad Radiol"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"625","DOI":"10.1197\/j.aem.2003.12.019","article-title":"Does the lateral chest radiograph help pediatric emergency physicians diagnose pneumonia? A randomized clinical trial","volume":"11","author":"T Lynch","year":"2004","journal-title":"Acad Emerg Med"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"2457","DOI":"10.1002\/1097-0142(20001201)89:11+<2457::aid-cncr22>3.3.co;2-z","article-title":"Radiation exposure associated with imaging of the chest: Comparison of different radiographic and computed tomography techniques","volume":"89","author":"S Diederich","year":"2000","journal-title":"Cancer"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"236","DOI":"10.1097\/MAJ.0b013e31818ad805","article-title":"Admission chest radiograph lacks sensitivity in the diagnosis of community-acquired pneumonia","volume":"337","author":"JT Hagaman","year":"2009","journal-title":"Am J Med Sci"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"401","DOI":"10.1016\/j.ajem.2012.08.041","article-title":"High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: Implications for diagnosing pneumonia","volume":"31","author":"WH Self","year":"2013","journal-title":"Am J Emerg Med"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"7294","DOI":"10.1007\/s00330-023-10334-7","article-title":"The yield of chest X-ray or ultra-low-dose chest-CT in emergency department patients suspected of pulmonary infection without respiratory symptoms or signs","volume":"33","author":"IAH den Berk","year":"2023","journal-title":"Eur Radiol"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"2809","DOI":"10.1002\/mp.14142","article-title":"Comparison of conventional chest x ray with a novel projection technique for ultra-low dose CT","volume":"48","author":"S Carey","year":"2021","journal-title":"Med Phys"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1088\/1361-6498\/aaf1dd","article-title":"Increased radiation dose and projected radiation-related lifetime cancer risk in patients with obesity due to projection radiography","volume":"39","author":"SJM Alqahtani","year":"2019","journal-title":"J Radiol Prot"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"816","DOI":"10.1007\/BF03344045","article-title":"Prevalence and time trends of obesity in Europe","volume":"25","author":"JC Seidell","year":"2002","journal-title":"J Endocrinol Invest"}],"container-title":["R\u00f6Fo - Fortschritte auf dem Gebiet der R\u00f6ntgenstrahlen und der bildgebenden Verfahren"],"original-title":[],"language":"de","link":[{"URL":"http:\/\/www.thieme-connect.de\/products\/ejournals\/pdf\/10.1055\/a-2810-5285.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T22:49:15Z","timestamp":1787784555000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.thieme-connect.de\/DOI\/DOI?10.1055\/a-2810-5285"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,14]]},"references-count":13,"journal-issue":{"issue":"09","published-online":{"date-parts":[[2026,8,26]]},"published-print":{"date-parts":[[2026,9]]}},"URL":"https:\/\/doi.org\/10.1055\/a-2810-5285","archive":["Portico","CLOCKSS"],"relation":{},"ISSN":["1438-9029","1438-9010"],"issn-type":[{"value":"1438-9029","type":"print"},{"value":"1438-9010","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,14]]}}}