Radiation Special Interest Section

• Carol Iddins promoted to director of the Radiation Emergency Assistance Center/Training Site
• Challenges in Initiating and Conducting Long-Term Health Monitoring of Populations following Nuclear and Radiological Emergencies in the United States: A Workshop
• CDC Fact Sheet on Radiation Exposures in Pregnancy
• NCRParticles – Spring 2019 Newsletter

REAC/TS is seeking a physician to join their staff as the Assistant Director, please see the link below to the posting.

 If you know someone who may be interested please share the posting.

 We are sending this in support of our great partners at REAC/TS and do not have any more details about the position; if you have questions please contact REAC/TS at reacts@orau.org or 865-576-3131. 

Click Here to Apply Online

• The NRC licenses and regulates the Nation’s civilian use of radioactive materials to provide reasonable assurance of adequate protection of public health and safety and to promote the common defense and security and to protect the environment. The NRC’s regulatory mission covers three main areas: reactors, materials, and waster.
  • https://www.nrc.gov

• The NRC’s REIRS system provides the latest available information on radiation exposure to the workforce at certain NRC licensed facilities. It also contains information concerning the recording and reporting requirements of NRC licensees.
  • https://www.reirs.com/reporting.html

• Radiation Emergency Medical Management: Provide guidance for health care providers about clinical diagnosis and treatment of radiation injury during radiological and nuclear emergencies. Provides resources including dose calculators, algorhitms, dose estimator calculator and many more resources.
  • https://www.remm.nlm.gov

• This Manual will assist preparedness efforts and decision making by providing readily accessible information that quickly describes critical scientific and medical aspects of a nuclear incident as well as the response organization and resources anticipated to be required or available during a response. It includes basic principles about radiation, measurement, health effects, protective actions, critical public messaging, response strategies, medical management and countermeasures, and preparedness for a nuclear detonation.
  • https://www.remm.nlm.gov/IND_Decision_Makers_Guide_2017_guides_508_2.pdf

• Calculator to calculate your personal annual average dose of radiation
  • https://www.epa.gov/radiation/calculate-your-radiation-dose
  • https://www.nrc.gov/about-nrc/radiation/around-us/calculator.html

• ATSDR Toxicological Profile for Ionizing Radiation
  • https://www.atsdr.cdc.gov/toxprofiles/tp.asp?id=484&tid=86

• CDC Radiation and Air Travel
  • https://www.cdc.gov/nceh/radiation/air_travel.html

1. 10 Years of Preparedness by the Radiation Injury Treatment Network.

Curr Hematol Malig Rep. 2017 Feb;12(1):39-43. doi: 10.1007/s11899-017-0360-7.

Abstract: The Radiation Injury Treatment Network (RITN) began in 2006 with the ambitious vision to provide a resource to help with the surge of casualties following a mass casualty incident with marrow toxic injuries. Through the efforts of the National Marrow Donor Program and American Society for Blood and Marrow Transplantation with the support of the Office of Naval Research, the initial 13 hospitals and cancer centers have grown to 76, training over 13,500 hospital staff and conducted, funded, and supported 580 disaster exercises testing preparedness. After a decade, there is more to do, but much laudatory work has been accomplished.

2. Opportunity for Collaboration Between Radiation Injury Treatment Network Centers and Medical Toxicology Specialists.

South Med J. 2017 Aug;110(8):497-501. doi: 10.14423/SMJ.0000000000000677.Davlantes E(1), Shartar S(1), Venero J(1), Steck A(1), Langston A(1), Kazzi ZN(1).

Abstract:  OBJECTIVES: The Radiation Injury Treatment Network (RITN) comprises >50 centers across the United States that are poised to care for victims of a radiation emergency. The network is organized around bone marrow transplant centers because these facilities excel in both radiation medicine and the care of patients with severe bone marrow depression. A radiation emergency may cause not only irradiation from an external source but also internal contamination with radioactive material. Because medical toxicologists are trained in radiation injury management and have expertise in the management of internal contamination, RITN centers may benefit from partnerships with medical toxicology resources, which may be located at academic medical centers, hospital inpatient clinical services, outpatient clinics, or poison control centers.

METHODS: We determined the locations of existing RITN centers and assessed their proximity to various medical toxicology resources, including medical toxicology fellowship programs, inpatient toxicology services, outpatient toxicology clinics, and poison control centers. Data were derived from publicly available Internet sources in March 2015.

RESULTS: The majority of RITN centers do not have a medical toxicology fellowship, an inpatient toxicology service, or an outpatient toxicology clinic within the same institution. Fifty-seven percent of RITN centers have at least one of these resources located in the same city, however, and 73% of centers have at least one of these resources or a poison control center within the same city. Ninety-five percent of RITN centers have at least one medical toxicology resource within the state.

CONCLUSIONS: Most RITN centers are located in the same city as at least one medical toxicology resource. Establishing relationships between RITN centers and medical toxicologists needs to be explored further.

3. Medical Countermeasures for Children in Radiation and Nuclear Disasters: Current Capabilities and Key Gaps.

Disaster Med Public Health Prep. 2018 Nov 2:1-8. doi: 10.1017/dmp.2018.112. [Epub ahead of print] Gardner AH(1), Dziuban EJ(2), Griese S(3), Berríos-Cartagena N(4), Buzzell J(5), Cobham-Owens K(6), Peacock G(2), Kazzi Z(5), Prasher JM(3).

Abstract: OBJECTIVE: Despite children’s unique vulnerability, clinical guidance and resources are lacking around the use of radiation medical countermeasures (MCMs) available commercially and in the Strategic National Stockpile to support immediate dispensing to pediatric populations. To better understand the current capabilities and shortfalls, a literature review and gap analysis were performed.

METHODS: A comprehensive review of the medical literature, Food and Drug Administration (FDA)-approved labeling, FDA summary reviews, medical references, and educational resources related to pediatric radiation MCMs was performed from May 2016 to February 2017.

RESULTS: Fifteen gaps related to the use of radiation MCMs in children were identified. The need to address these gaps was prioritized based upon the potential to decrease morbidity and mortality, improve clinical management, strengthen caregiver education, and increase the relevant evidence base.

CONCLUSIONS: Key gaps exist in information to support the safe and successful use of MCMs in children during radiation emergencies; failure to address these gaps could have negative consequences for families and communities. There is a clear need for pediatric-specific guidance to ensure clinicians can appropriately identify, triage, and treat children who have been exposed to radiation, and for resources to ensure accurate communication about the safety and utility of radiation MCMs for children. (Disaster Med Public Health Preparedness. 2018;page 1 of 8).

4. Pediatric Considerations Before, During, and After Radiological or Nuclear Emergencies.Pediatrics.

2018 Dec;142(6). pii: e20183001. doi: 10.1542/peds.2018-3001. Linet MS, Kazzi Z, Paulson JA; COUNCIL ON ENVIRONMENTAL HEALTH.

Abstract: Infants, children, and adolescents can be exposed unexpectedly to ionizing radiation from nuclear power plant events, improvised nuclear or radiologic dispersal device explosions, or inappropriate disposal of radiotherapy equipment. Children are likely to experience higher external and internal radiation exposure levels than adults because of their smaller body and organ size and other physiologic characteristics as well as their tendency to pick up contaminated items and consume contaminated milk or foodstuffs. This technical report accompanies the revision of the 2003 American Academy of Pediatrics policy statement on pediatric radiation emergencies by summarizing newer scientific data from studies of the Chernobyl and the Fukushima Daiichi nuclear power plant events, use of improvised radiologic dispersal devices, exposures from inappropriate disposal of radiotherapy equipment, and potential health effects from residential proximity to nuclear plants. Also included are recommendations from epidemiological studies and biokinetic models to address mitigation efforts. The report includes major emphases on acute radiation syndrome, acute and long-term psychological effects, cancer risks, and other late tissue reactions after low-to-high levels of radiation exposure. Results, along with public health and clinical implications, are described from studies of the Japanese atomic bomb survivors, nuclear plant accidents (eg, Three Mile Island, Chernobyl, and Fukushima), improper disposal of radiotherapy equipment in Goiania, Brazil, and residence in proximity to nuclear plants. Measures to reduce radiation exposure in the immediate aftermath of a radiologic or nuclear disaster are described, including the diagnosis and management of external and internal contamination, use of potassium iodide, and actions in relation to breastfeeding.

5. Solid cancer incidence in atomic bomb survivors exposed in utero or as young  children.

J Natl Cancer Inst. 2008 Mar 19;100(6):428-36. doi: 10.1093/jnci/djn045. Epub 2008 Mar 11. Preston DL(1), Cullings H, Suyama A, Funamoto S, Nishi N, Soda M, Mabuchi K, Kodama K, Kasagi F, Shore RE.

Abstract: BACKGROUND: In utero exposure to radiation is known to increase risks of childhood cancers, and childhood exposure is associated with increased risks of adult-onset cancers. However, little is known about whether in utero exposure to radiation increases risks of adult-onset cancers.

METHODS: Solid cancer incidence rates were examined among survivors of the atomic bombings of Hiroshima and Nagasaki who were in utero (n = 2452) or younger than 6 years (n = 15388) at the time of the bombings. Poisson regression was used to estimate and compare the levels and temporal patterns of the radiation-associated excess risks of first primary solid cancers among these survivors at ages 12-55. All statistical tests were two-sided.

RESULTS: There were 94 eligible cancers in the in utero group and 649 in the early childhood group. The excess relative risk (ERR) increased with dose for both in utero (age 50, ERR = 1.0 per Sv, 95% confidence interval [CI] = 0.2 to 2.3 per Sv) and early childhood (age 50, ERR = 1.7 per Sv, 95% CI = 1.1 to 2.5 Sv) exposures. The ERR declined (P = .046) with increasing attained age in the combined cohort. Excess absolute rates (EARs) increased markedly with attained age among those exposed in early childhood but exhibited little change in the in  utero group. At age 50, the estimated EARs per 10,000 person-years per Sv were 6.8 (95% CI = <0 to 49) for those exposed in utero and 56 (95% CI = 36 to 79) for those exposed as young children.

CONCLUSIONS: Both the in utero and early childhood groups exhibited statistically significant dose-related increases in incidence rates of solid cancers. The apparent difference in EARs between the two groups suggests that lifetime risks following in utero exposure may be considerably lower than for early childhood exposure, but further follow-up is needed.

6. NON-RADIOLOGICAL IMPACT OF A NUCLEAR EMERGENCY: PREPAREDNESS AND RESPONSE WITH THE FOCUS ON HEALTH.

Radiat Prot Dosimetry. 2018 Sep 14. doi: 10.1093/rpd/ncy163. [Epub ahead of print] PubMedPMID: 30219868. Carr Z, Maeda M, Oughton D, Weiss W.

Abstract: Available experience from Chernobyl and Fukushima clearly demonstrate that nuclear emergencies may result in low and very low exposure levels, at which psychological and social effects among the affected population will dominate over the actual biological effects of ionising radiation. International protection standards and guidelines request, that both radiological and non-radiological health consequences have to be considered in preparedness and response to an actual emergency and there is a need to broaden the radiation protection system’s philosophy beyond the metrics of radioactivity and radiation dose. During the past decade a number of multidisciplinary projects were set up with the aim of evaluating management options according to social, economic and ethical criteria, in addition to technical feasibility to achieve this goal. WHO and partners from the Inter-Agency Standing Committee Task Force on Mental Health and Psychosocial Support in Emergency Settings have developed a comprehensive framework and guidelines, which can be applied to any type of an emergency or disaster regardless of its origin. There is a need to include the available scientific expertise and the technical, managerial and personal resources to be considered within a similar ‘decision framework’ that will apply to radiation emergencies. Key areas of the required expertise needed to develop such a framework are radiation protection, medical support (especially primary care and emergency medicine, mental health support), social sciences (anthropology, psychology, ethics) and communications experts. The implementation of such a multidisciplinary concept in the operational world requires education and training well beyond the level currently available.

7. US CENTERS FOR DISEASE CONTROL AND PREVENTION EXPERIENCE IN THE JOINT EXTERNAL EVALUATION PROCESS-RADIATION EMERGENCIES TECHNICAL AREA.

Radiat Prot Dosimetry. 2018 Aug 25. doi: 10.1093/rpd/ncy148. [Epub ahead of print] PubMed PMID: 30165684. Whitcomb RC Jr, Ansari AJ, Salame-Alfie A, McCurley MC, Buzzell J, Chang A, Jones RL.

Abstract: In 2015-16, the US Department of Health and Human Services led 23 US Government (USG) agencies including the Centers for Disease Control and Prevention (CDC), and more than 120 subject matter experts in conducting an in-depth review of the US core public health capacities and evaluation of the country’s compliance with the International Health Regulations using the Joint External Evaluation (JEE) methodology. This two-part process began with a detailed ‘self-assessment’ followed by a comprehensive independent, external evaluation conducted by 15 foreign assessors. In the Radiation Emergencies Technical Area, on a scale from 1-lowest to 5-highest, the assessors concurred with the USG self-assessed score of 3 in both of the relevant indicators. The report identified five priority actions recommended to improve the USG capacity to handle large-scale radiation emergencies. CDC is working to implement a post-JEE roadmap to address these priority actions in partnership with national and international partners.

8. EPIDEMIOLOGICAL STUDY OF HEALTH EFFECTS IN FUKUSHIMA NUCLEAR EMERGENCY WORKERS-STUDY DESIGN AND PROGRESS REPORT.

Radiat Prot Dosimetry. 2018 Aug 23. doi: 10.1093/rpd/ncy136. [Epub ahead of print] PubMed PMID: 30137628. Kitamura H, Okubo T, Kodama K; Nuclear Emergency Workers Study Group.

Abstract: Between 14 March and 16 December 2011, the radiation dose limit for emergency work was tentatively raised from an effective dose of 100-250 mSv by the Japanese Government after the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident. The objective of this study is to clarify the long-term health effects of radiation on the emergency workers involved during that period, based on a detailed evaluation of the radiation exposures and long-term monitoring. The potential subjects of the study are the approximately 20 000 workers who were engaged in emergency operations at FDNPP during the period described above. During the first phase of this project, the first 5 years from 2014, we plan to set up a research scheme and establish a cohort. To date, the establishment of the scheme for general health examinations is nearly complete. As of 31 January 2017, 5419 emergency workers (27.4% of the subjects) have agreed to participate in the study. We will continue our efforts to recruit additional potential subjects during the first phase to maximize the size of the cohort.

9. RAPID MONITORING OF INTERNAL CONTAMINATION USING A MOBILE RADIOBIOASSAY LABORATORY FOLLOWING RADIATION EMERGENCIES.

Radiat Prot Dosimetry. 2018 Aug 23. doi: 10.1093/rpd/ncy132. [Epub ahead of print] PubMed PMID: 30137603. Ha WH, Kwon TE, Kim J, Jin YW.

Abstract: In any radiation emergency, it may be necessary to monitor large numbers of people or internal contamination resulting from inhalation/ingestion of radionuclides released from the accident. The National Radiation Emergency Medical Center of the Korea Institute of Radiological and Medical Sciences constructed a mobile radiobioassay laboratory for rapid field-based monitoring of internal contamination. The main features of the mobile laboratory were designed and the results of performance were tested for rapid monitoring in this paper. We found that maximum throughput for internal contamination monitoring using the whole body counter installed in the laboratory was about 200 people per day. The minimum detectable activities were estimated for the in-vivo and in-vivo radiobioassay systems in the mobile unit. This mobile unit will improve the population monitoring capabilities for internal contamination of individuals affected following nuclear or radiological emergencies.

10. Emergency Response to Radiological Releases: Have We Communicated Effectively to the First Responder Communities to Prepare Them to Safely Manage These Incidents?

Health Phys. 2018 Feb;114(2):208-213. doi:1097/HP.0000000000000757. PubMed PMID: 30086017. Ingram RJ.

Abstract: The emergency responder community trains for and responds to many types of incidents on a daily basis and has done so for years. This experience with fires, emergency medical calls, chemical spills, confined spaces, and other common calls for assistance has helped responders develop an understanding of the problems and a confidence in solving them. Radiation from an accidental release in a facility or during transportation, or from a terrorist incident that causes radioactive materials to be released from their containment vessel, remains a cause of concern and fear. Emergency responders are a segment of the general population and share some of the same fears of radioactive materials as the whole population. Radioactive material incidents are not a common 911 call type. Radiation training has been included in emergency responder training standards for several decades and covers a broad range of topics from simple awareness and recognition to technical knowledge of the materials, detection and identification capabilities, self-protection, medical effects, and countermeasures to overall public and environmental safety and health. The safety factor of the radiation community has been very good, but without the actual response confidence in handling previous incident releases, many responders remain fearful of radiation. A single source site where responders can post and read after-action reports on actual radiation incidents may help communicate health and safety information, building responder confidence. Competencies in standards do not always translate into compliance in training curriculum and exercises. The fire service has been the key local response agency to radiation accidents for many years and has developed training programs that meet the competencies found in 29 CFR 1910.120 [q], How to Determine What Training is Required for Emergency Response Team Members, and the National Fire Protection Associations Standard 472: Competence of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents. The majority of fire service responders in the United States are volunteers who often make decisions on what they train for based on the time available and their areas’ hazard assessment. This has often caused radiation training to be limited at best. Communicating timely and accurate hazards and risks associated with radiation threats and incidents may increase the amount and level of training in response to these types of incidents. Many law enforcement and emergency medical services and other key disciplines did not address these standards requirements prior to 9/11, as they were considered outside their “normal” mission space. The change in the mission space caused by the new threat of radiological terrorism has required additional training and equipment. This training has started but will take time to impact the entire responder community, it will require funding for the training and equipment, and most of all, sustainment. Communicating the broad scope of capabilities necessary to safely manage a radiation incident and the requirement for all agencies to be involved may support the effort to train these disciplines in their new mission space. The serious and much publicized radiological incidents that have occurred during the lifetime of many of today’s responder community (Chernobyl, Fukushima, and Three Mile Island) have added to this fear within the responder community. The majority of today’s responder communities are between 21 and 50 y of age. In studies conducted in recent years by federal agencies, it was identified that this group did not receive the basics of nuclear information provided to the U.S. population at the start of the Cold War and the fear of a nuclear war. These studies have identified the gap that exists in understanding basic radiation terminology, protective actions including sheltering-in-place, informed evacuation, public messaging, and others. Despite studies like this, federal, state, and local public officials have been slow to communicate emergency action plans to the public for radiological and nuclear incidents. Emergency management agencies at all levels have action plans for natural events such as hurricanes, tornadoes, and coastal storms, and now they are including biological incidents and active shooters. Nuclear and radiological incident plans and protective actions need to be included and communicated to members of the public (and responders) in all media streams. Several federal agencies have been tasked with radiological and nuclear mission space, but this appears to remain fragmented without an organizing agency. The Domestic Nuclear Detection Office (U.S. Department of Homeland Security) remains in a detection and prevention mission and has provided a good amount of equipment, training, and coordination, but primarily among law enforcement organizations. The Federal Emergency Management Agency remains in the response mission but has limited outreach to the majority of response organizations. The U.S. Department of Health and Human Services (Assistant Secretary for Preparedness and Response) has stepped up its efforts in medical countermeasures, surge capabilities, and support services. All of this information and support comes to the responder community separately, and it is left to the local-level planners to piece it together. It needs to be coordinated and communicated as one source. Communications remains the top challenge for the responder community as we look to the new administration for a plan for radiological and nuclear preparedness: communicating public messaging on radiation terminology, how members of the public can protect themselves and expected public agency actions; communicating a coordinated response plan that includes all levels and agencies; communicating the necessary training; and communicating the recovery actions that will have to take place.

11.Welcome to the 53rd Annual Meeting of the National Council on Radiation Protection and Measurements: Assessment of National Efforts in Emergency Preparedness for Nuclear Terrorism: Is There a Need for Realignment to Close Remaining Gaps?

Health Phys. 2018 Feb;114(2):116-121. doi:1097/HP.0000000000000792. PubMed PMID: 30085999. Boice JD Jr.

12. Establishment of Criteria for Skin Decontamination in a Radiation Emergency.

Health Phys. 2018 Sep;115(3):369-374. doi:10.1097/HP.0000000000000891. PubMed PMID: 30045117. Yoo J, Jin YW.

Abstract: In the event of a radiological or nuclear emergency, internal or external contamination (or both) by radionuclides can occur. In such cases, removal of the radionuclides from the injured skin is important because such surface contamination may induce skin damage such as deterministic effects at very high skin doses (2 to 3 Gy). In addition, internal contamination will occur due to radionuclide absorption through the injured skin. Previous studies have suggested various decontamination criteria. However, those criteria are impractical in the case of large-scale population monitoring. Here, to identify practical decontamination criteria, the VARSKIN 4.0 software code is used to assess skin doses originating from surface contamination by Co, I, and Cs. In addition, Integrated Modules for Bioassay Assessment dosimetry software is used to assess the effective doses following radionuclide intake through external contamination for the same three radionuclides. The effective dose dependence on the soluble material type is also assessed. In particular, the effective dose due to radionuclide absorption is found to be greater than the skin dose rate due to surface contamination for the same radioactivity levels. Based on the calculation results, decontamination criteria and actions that depend on the effective dose and surface contamination level (Bq cm) for alpha and beta or gamma radiation are suggested. Actions for contaminated injured persons are classified as no action, optional, recommended, or required.

13. Radiation Dose Considerations in Emergent Neuroimaging.

Neuroimaging Clin N Am. 2018 Aug;28(3):525-536. doi:10.1016/j.nic.2018.03.010. Review. PubMed PMID: 30007760. Wiggins WF, Sodickson AD.

Abstract: Computed tomography is often the first-line diagnostic imaging modality in the evaluation of patients with neurologic emergencies. A patient-centered approach to radiation dose management in emergent neuroimaging thus revolves around the appropriate use of computed tomography, including clinical decision support for ordering providers, thoughtful protocol design, the use of available technological advances in computed tomography, and radiation exposure monitoring at a population level. A multifaceted approach can help to minimize radiation exposure to individual patients while preserving diagnostic quality imaging.

14. Emergency preparedness: Ionising radiation incidents and medical management.

J R Army Med Corps. 2018 Jul 6. pii: jramc-2018-000958. doi:10.1136/jramc-2018-000958. [Epub ahead of print] PubMed PMID: 29982191. Foster CRM.

Abstract: Military personnel risk being exposed to ionising radiation through a variety of means, including industrial accidents with Ministry of Defence equipment, inadvertent exposure while on operations, terrorist activities and nuclear war. The aim of this review is to outline the possible acute health effects and immediate management of radiation casualties in the context of different exposure scenarios. It emphasises the most important principles for managing irradiated, and/or contaminated casualties, in the operational environment, as well as providing details of key references and other sources of reach-back support.

15. A Novel Method for Quick Assessment of Internal And External Radiation Exposure in the Aftermath of a Large Radiological Incident.

Health Phys. 2018 Aug;115(2):235-251. doi: 10.1097/HP.0000000000000858. PubMed PMID: 29894328. Korir G, Karam PA.

Abstract: In the event of a significant radiological release in a major urban area where a large number of people reside, it is inevitable that radiological screening and dose assessment must be conducted. Lives may be saved if an emergency response plan and radiological screening method are established for use in such cases. Thousands to tens of thousands of people might present themselves with some levels of external contamination and/or the potential for internal contamination. Each of these individuals will require varying degrees of radiological screening, and those with a high likelihood of internal and/or external contamination will require radiological assessment to determine the need for medical attention and decontamination. This sort of radiological assessment typically requires skilled health physicists, but there are insufficient numbers of health physicists in any city to perform this function for large populations, especially since many (e.g., those at medical facilities) are likely to be engaged at their designated institutions. The aim of this paper is therefore to develop and describe the technical basis for a novel, scoring-based methodology that can be used by non-health physicists for performing radiological assessment during such radiological events.

16. Medical management of acute radiation syndrome and associated infections in a high-casualty incident.

J Radiat Res. 2018 Apr 1;59(suppl_2):ii54-ii64. doi: 10.1093/jrr/rry004. PubMed PMID: 29509947; PubMed Central PMCID: PMC5941165. Dainiak N.

Abstract: A high-casualty incident may result in a significant human toll due to the inability of a community to meet the health care demands of the population. A successful medical response requires health care facilities to not only communicate and integrate medical services, meet surge capacity, protect health care workers and implement triage and treatment protocols, but also to provide the venue for clinical management of acute radiation injuries and their associated infections. Today, clinical management is primarily guided by the recommendations of a Consultancy that were made at the World Health Organization (WHO). This international consensus was reached on evidence-based, clinical management of each of the four sub-syndromes that compose acute radiation syndrome (ARS), including the hematopoietic subsyndrome (HS), gastrointestinal subsyndrome (GIS), neurovascular subsyndrome (NVS) and cutaneous subsyndrome (CS). Major findings in studies meeting inclusion criteria for management strategies for HS were that (i) no randomized controlled studies of medical countermeasures have been (or will likely ever be) performed for ARS cases, (ii) the data for management of HS are restricted by the lack of comparator groups, and (iii) reports of countermeasures for management of injury to non-hematopoietic organs are often incompletely described. Here, (i) recommendations made in Geneva are summarized; (ii) the analysis of countermeasures for HS is updated by review of two additional cases and extended to published reports not meeting inclusion criteria; and (iii) guidelines are provided for management of microbial infections based upon patient risk for prolonged immunosuppression.

17. Radiation-related occupational cancer and its recognition criteria in South Korea.

Ann Occup Environ Med. 2018 Feb 2;30:9. doi: 10.1186/s40557-018-0219-y. eCollection 2018. Review. PubMed PMID: 29435340; PubMed Central PMCID: PMC5797363. Seo S, Lee D, Seong KM, Park S, Kim SG, Won JU, Jin YW.

Abstract: Ionizing radiation is a well-known carcinogen, and is listed as one carcinogenic agent of occupational cancer. Given the increase in the number of workers exposed to radiation, as well as the increase in concern regarding occupational cancer, the number of radiation-related occupational cancer claims is expected to increase. Unlike exposure assessment of other carcinogenic agents in the workplace, such as asbestos and benzene, radiation exposure is usually assessed on an individual basis with personal dosimeters, which makes it feasible to assess whether a worker’s cancer occurrence is associated with their individual exposure. However, given the absence of a threshold dose for cancer initiation, it remains difficult to identify radiation exposure as the root cause of occupational cancer. Moreover, the association between cancer and radiation exposure in the workplace has not been clearly established due to a lack of scientific evidence. Therefore, criteria for the recognition of radiation-related occupational cancer should be carefully reviewed and updated with new scientific evidence and social consensus. The current criteria in Korea are valid in terms of eligible radiogenic cancer sites, adequate latent period, assessment of radiation exposure, and probability of causation. However, reducing uncertainty with respect to the determination of causation between exposure and cancer and developing more specific criteria that considers mixed exposure to radiation and other carcinogenic agents remains an important open question.

18. Overuse of CT and MRI in paediatric emergency departments.

Br J Radiol. 2018 May;91(1085):20170434. doi:10.1259/bjr.20170434. Epub 2018 Feb 5. Review. PubMed PMID: 29271231. Ohana O, Soffer S, Zimlichman E, Klang E.

Abstract:The aim of this review is to survey CT and MRI overuse in the paediatric emergency department (ED) population. CT is one of the most important modalities employed in the ED. Not surprisingly, its high accuracy, rapid acquisition and availability have resulted in overuse. An obvious limitation of CT is ionizing radiation; in addition there are economic implications to overuse. Studies from the last two decades have shown increase in paediatric ED CT utilization in the first decade, reaching a plateau forming around 2008, followed by a decrease in the last decade. This decrease occurred in conjunction with campaigns raising awareness to the risks of radiation exposure. Although a trend of decrease in overuse have been observed, great variability has been shown across different facilities, as well as among physicians, with more pronounced overuse in non-teaching and non-children dedicated EDs. The leading types of paediatric ED CTs are head and abdominal scans. Decision rules, such as PECARN for head injury and the Alvarado score for abdominal pain, as well as using alternative imaging modalities, have been shown to reduce CT overuse in these two categories. MRI has the obvious benefit of avoiding radiation exposure, but the disadvantages of higher costs, less availability and less tolerability in younger children. Although anecdotally paediatric ED MRI usage has increased in recent years, only scarce reports have been published. In our opinion, there is need to conduct up-to-date studies covering paediatric CT and MRI overuse trends, usage variability and adherence to clinical protocols.

19. Evaluation of toxicological hazards from medical radioiodine administration. J Med Toxicol. 2014;11(1):96-101.

Van Dyke M, Punja M, Hall MJ, Kazzi Z.

Conclusions: RI therapy is unlikely to involve clinically significant radiation exposures to the public, precautions can be followed in order to minimize radiation exposure. Medical toxicologists can assist the public in addressing concerns of potential radiation exposure by using calculations based on basic assumptions that will likely demonstrate the low risk of exposure from a patient treated with RI.