A Multimedia Strategy to Integrate Introductory Broad-Based Radiation Science Education in US Medical Schools

US physicians in multiple specialties who order or conduct radiological procedures lack formal radiation science education and thus sometimes order procedures of limited benefit or fail to order what is necessary. To this end, a multidisciplinary expert group proposed an introductory broad-based radiation science educational program for US medical schools. Suggested preclinical elements of the curriculum include foundational education on ionizing and nonionizing radiation (eg, definitions, dose metrics, and risk measures) and short- and long-term radiation-related health effects as well as introduction to radiology, radiation therapy, and radiation protection concepts. Recommended clinical elements of the curriculum would impart knowledge and practical experience in radiology, fluoroscopically guided procedures, nuclear medicine, radiation oncology, and identification of patient subgroups requiring special considerations when selecting specific ionizing or nonionizing diagnostic or therapeutic radiation procedures. Critical components of the clinical program would also include educational material and direct experience with patient-centered communication on benefits of, risks of, and shared decision making about ionizing and nonionizing radiation procedures and on health effects and safety requirements for environmental and occupational exposure to ionizing and nonionizing radiation. Overarching is the introduction to evidence-based guidelines for procedures that maximize clinical benefit while limiting unnecessary risk. The content would be further developed, directed, and integrated within the curriculum by local faculties and would address multiple standard elements of the Liaison Committee on Medical Education and Core Entrustable Professional Activities for Entering Residency of the Association of American Medical Colleges.

IEEE Committee on Man and Radiation-COMAR Technical Information Statement: Health and Safety Issues Concerning Exposure of the General Public to Electromagnetic Energy from 5G Wireless Communications Networks

This COMAR Technical Information Statement (TIS) addresses health and safety issues concerning exposure of the general public to radiofrequency (RF) fields from 5G wireless communications networks, the expansion of which started on a large scale in 2018 to 2019. 5G technology can transmit much greater amounts of data at much higher speeds for a vastly expanded array of applications compared with preceding 2-4G systems; this is due, in part, to using the greater bandwidth available at much higher frequencies than those used by most existing networks. Although the 5G engineering standard may be deployed for operating networks currently using frequencies extending from 100s to 1,000s of MHz, it can also operate in the 10s of GHz where the wavelengths are 10 mm or less, the so-called millimeter wave (MMW) band. Until now, such fields were found in a limited number of applications (e.g., airport scanners, automotive collision avoidance systems, perimeter surveillance radar), but the rapid expansion of 5G will produce a more ubiquitous presence of MMW in the environment. While some 5G signals will originate from small antennas placed on existing base stations, most will be deployed with some key differences relative to typical transmissions from 2-4G base stations. Because MMW do not penetrate foliage and building materials as well as signals at lower frequencies, the networks will require "densification," the installation of many lower power transmitters (often called "small cells" located mainly on buildings and utility poles) to provide for effective indoor coverage. Also, "beamforming" antennas on some 5G systems will transmit one or more signals directed to individual users as they move about, thus limiting exposures to non-users. In this paper, COMAR notes the following perspectives to address concerns expressed about possible health effects of RF field exposure from 5G technology. First, unlike lower frequency fields, MMW do not penetrate beyond the outer skin layers and thus do not expose inner tissues to MMW. Second, current research indicates that overall levels of exposure to RF are unlikely to be significantly altered by 5G, and exposure will continue to originate mostly from the "uplink" signals from one's own device (as they do now). Third, exposure levels in publicly accessible spaces will remain well below exposure limits established by international guideline and standard setting organizations, including ICNIRP and IEEE. Finally, so long as exposures remain below established guidelines, the research results to date do not support a determination that adverse health effects are associated with RF exposures, including those from 5G systems. While it is acknowledged that the scientific literature on MMW biological effect research is more limited than that for lower frequencies, we also note that it is of mixed quality and stress that future research should use appropriate precautions to enhance validity. The authorship of this paper includes a physician/biologist, epidemiologist, engineers, and physical scientists working voluntarily and collaboratively on a consensus basis.

Summary of NCRP 2019 Annual Meeting, NCRP Meeting the Challenge at 90: Providing Best Answers to Your Most Pressing Questions About Radiation

The National Council on Radiation Protection and Measurements (NCRP) held its 55 Annual Meeting 1-2 April 2019 in Bethesda, Maryland. The 2019 meeting was a special year for NCRP as it marked the 90 Anniversary of the founding of the predecessor organization, US Advisory Committee on X-Ray and Radium Protection. Leaders for the scientific portion of the meeting were Fred A. Mettler, Jr., M.D. (Chair), University of New Mexico School of Medicine; Jerrold T. Bushberg, Ph.D. (Co-Chair), University of California Davis; and Richard J. Vetter, Ph.D. (Co-Chair), Mayo Clinic. The meeting was designed to explore important areas of inquiry associated with use of ionizing radiation relevant to radiation protection, addressing frequently asked questions and concerns from both members of the public and radiation professionals. The meeting was organized into six sessions plus three honorary lectures and a special presentation. This paper summarizes the scientific content of the six sessions and is based on the notes of the co-chairs and the slides of the speakers. The three honorary lectures are included as other papers in this issue.

Uses of Effective Dose: The Good, the Bad, and the Future

Effective dose (E) is a risk-adjusted dosimetric quantity developed by the International Commission on Radiological Protection. It is a key metric for practical management of the risk of stochastic health effects in a comprehensive radiation protection program. The International Commission on Radiological Protection and others have emphasized repeatedly that E is not intended to represent an actual radiation dose and should not be used as a risk-related metric for a specific person or population. The cancer risk uncertainties in the low-dose range and the underlying approximations, simplifications, and sex- and age-averaging used in generating E make it unsuitable for this purpose. However, in practice, medical imaging professionals and authors of peer-reviewed medical publications frequently and incorrectly use E as a surrogate for whole-body dose in order to calculate cancer risk estimates for specific patients or patient populations. This frequent misuse has popularized E for uses for which it was neither designed nor intended. Alternatives to E have been proposed that attempt to account for known age and sex differences in radiation sensitivity. E has also been proposed as a general indicator for communicating radiation risk to patients, if its limitations are kept in mind. Forthcoming guidance from the International Commission on Radiological Protection will likely clarify if, when, and how some form of E may be used as a rough indicator of the risk of a stochastic effect, possibly with some modifications for the substantial variations in risk known to exist with respect to age, sex, and population group.

RF Safety Analysis of a Novel Ultra-wideband Fetal Monitoring System

The LifeWave Ultra-Wideband RF sensor (LWUWBS) is a monitoring solution for a variety of physiologic assessment applications, including maternal fetal monitoring in both the antepartum and intrapartum periods. The system uses extremely low power radio frequency (RF) ultra-wide band (UWB) signals to provide continuous fetal heart rate and contractions monitoring during labor and delivery. Even with the incorporation of three very conservative assumptions, (1) concentration of the RF energy in 1 cm, (2) minimal (2.5 cm) maternal tissue attenuation of fetal exposure, and (3) absence of normal thermoregulatory compensation, the maternal whole body spatial-averaged specific absorption rate (WBSAR) would be 34,000 times below the FCC public exposure limit of 0.08 W kg and, at 8 wk or more gestation, the peak spatial-averaged specific absorption rate (PSSAR) in the fetus would be more than 160 times below the localized exposure limit of 1.6 mW g. Even when using very conservative assumptions, an analysis of the LWUWBS's impact on tissue heating is a factor of 7 lower than what is allowed for fetal ultrasound and at least a factor of 650 compared to fetal MRI. The actual transmitted power levels of the LWUWBS are well below all Federal safety standards, and the potential for tissue heating is substantially lower than associated with current ultrasonic fetal monitors and MRI.

Answers to Common Questions About the Use and Safety of CT Scans

Articles in the scientific literature and lay press over the past several years have implied that computed tomography (CT) may cause cancer and that physicians and patients must exercise caution in its use. Although there is broad agreement on the latter point--unnecessary medical tests of any type should always be avoided--there is considerable controversy surrounding the question of whether, or to what extent, CT scans can lead to future cancers. Although the doses used in CT are higher than those used in conventional radiographic examinations, they are still 10 to 100 times lower than the dose levels that have been reported to increase the risk of cancer. Despite the fact that at the low doses associated with a CT scan the risk either is too low to be convincingly demonstrated or does not exist, the magnitude of the concern among patients and some medical professionals that CT scans increase cancer risk remains unreasonably high. In this article, common questions about CT scanning and radiation are answered to provide physicians with accurate information on which to base their medical decisions and respond to patient questions.

IEEE Committee on Man and Radiation--COMAR technical information statement radiofrequency safety and utility Smart Meters

This Technical Information Statement describes Smart Meter technology as used with modern electric power metering systems and focuses on the radio frequency (RF) emissions associated with their operation relative to human RF exposure limits. Smart Meters typically employ low power (-1 W or less) transmitters that wirelessly send electric energy usage data to the utility company several times per day in the form of brief, pulsed emissions in the unlicensed frequency bands of 902-928 MHz and 2.4-2.48 GHz or on other nearby frequencies. Most Smart Meters operate as wireless mesh networks where each Smart Meter can communicate with other neighboring meters to relay data to a data collection point in the region. This communication process includes RF emissions from Smart Meters representing energy usage as well as the relaying of data from other meters and emissions associated with maintaining the meter's hierarchy within the wireless network. As a consequence, most Smart Meters emit RF pulses throughout the day, more at certain times and less at others. However, the duty cycle associated with all of these emissions is very small, typically less than 1%, and most of the time far less than 1%, meaning that most Smart Meters actually transmit RF fields for only a few minutes per day at most. The low peak power of Smart Meters and the very low duty cycles lead to the fact that accessible RF fields near Smart Meters are far below both U.S. and international RF safety limits whether judged on the basis of instantaneous peak power densities or time-averaged exposures. This conclusion holds for Smart Meters alone or installed in large banks of meters.

Eleventh annual Warren K. Sinclair keynote address-science, radiation protection and NCRP: building on the past, looking to the future

The many reports and other authoritative documents developed and published by the National Council on Radiation Protection and Measurements (NCRP) have been of great service to the nation and the radiation protection community since its Congressional charter was signed into law 50 y ago. There will be a continuing need for NCRP to identify the principles upon which radiation protection is to be based and to provide guidance on best practices for the practical application of those principles for the many beneficial uses of radiation in society. The unique and invaluable resource that is NCRP is in large part due to the selfless dedication and numerous contributions of its Council and scientific committee members. The multidisciplinary composition of these leading experts and their collective input on complex questions provide a unique synergy that results in a comprehensive and well-balanced approach to addressing current and future radiation protection challenges. Subsequent articles in these proceedings covering a broad range of relevant topics will review sentinel accomplishments of the past as well as current work and future challenges that are in keeping with NCRP's mission to advance the science of radiation protection in the public interest.

Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine

Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.

Applications of justification and optimization in medical imaging: examples of clinical guidance for computed tomography use in emergency medicine

Availability, reliability, and technical improvements have led to continued expansion of computed tomography (CT) imaging. During a CT scan, there is substantially more exposure to ionizing radiation than with conventional radiography. This has led to questions and critical conclusions about whether the continuous growth of CT scans should be subjected to review and potentially restraints or, at a minimum, closer investigation. This is particularly pertinent to populations in emergency departments, such as children and patients who receive repeated CT scans for benign diagnoses. During the last several decades, among national medical specialty organizations, the American College of Emergency Physicians and the American College of Radiology have each formed membership working groups to consider value, access, and expedience and to promote broad acceptance of CT protocols and procedures within their disciplines. Those efforts have had positive effects on the use criteria for CT by other physician groups, health insurance carriers, regulators, and legislators.

Nuclear/radiological terrorism: emergency department management of radiation casualties

Recent world events have increased concern that hospitals must be prepared for radiological emergencies. Emergency departments (EDs) must be ready to treat patients suffering from injuries in combination with radiation exposure or contamination with radioactive material. Every hospital should have a Radiological Emergency Medical Response Plan, tested through periodic drills, which will allow effective handling of contaminated and injured patients. Treatment of life-threatening or severe traumatic injuries must take priority over radiation-related issues. The risk to ED staff from radioactive contamination is minimal if universal precautions are used. The likelihood of significant radiation exposure to staff under most circumstances is small. Educating medical staff on the magnitude of the radiological hazards allows them to promptly and confidently provide the necessary patient care. Measures must be taken to prevent the "worried well" and uninjured people with radioactive contamination from overwhelming the ED.

The AAPM/RSNA physics tutorial for residents. X-ray interactions

The diagnostic information in a radiograph or fluoroscopic image is largely the result of the quantity of x rays that are not removed from the incident x-ray beam. The information content of the image is delivered by the percentage of noninteracting photons that are successfully recorded. There are four major x-ray interactions: Rayleigh (coherent) scattering. Compton scattering, photoelectric absorption, and pair production. The degree of attenuation and the predominant mechanisms involved in the interactions are influenced by the x-ray energy and tissue composition. In the diagnostic energy range, photoelectric absorption and Compton scattering are the predominant modes of attenuation. One of the challenges in diagnostic imaging is to optimize image acquisition by controlling x-ray attenuation to obtain the appropriate contrast between the tissues while minimizing patient dose and scattered radiation in the image. Imaging techniques such as use of contrast material and dedicated mammography equipment exploit the differences in these types of x-ray interactions to improve the quality and diagnostic utility of the examination. Rayleigh scattering and pair production are presented but do not occur to any significant degree in diagnostic radiography.

Clinical immunoscintigraphy of recurrent ovarian cancer with indium 111-labeled B72.3 monoclonal antibody

OBJECTIVE

To prospectively evaluate the ability for immunoscintigraphy with monoclonal antibody CYT-103 labeled with indium 111 to detect tumor presence in 15 patients with ovarian cancer undergoing second-look surgery.

DESIGN

Prospective, open-label, nonrandomized trial.

SETTING

Hospital-based nuclear medicine facility and operating room.

STUDY PARTICIPANTS

Patients with previous ovarian cancer scheduled for second-look surgery.

MAIN OUTCOME MEASURE

Correctness of prediction of immunoscintigraphy for presence or absence of ovarian cancer compared with serum CA 125 titer and computed tomography.

RESULTS

Immunoscintigraphy, computed tomography, and serum CA 125 titer had respective sensitivities of 92%, 42%, and 42%; specificities of 67%, 100%, and 100%; accuracies of 87%, 53%, and 53%; and diagnostic values of 59%, 42%, and 42%. The full regional extent of recurrent tumor was correctly detected in 45% of patients by immunoscintigraphy and in none of the patients by computed tomography. Immunoscintigraphy detected miliary tumor in two of four patients and computed tomography, as expected, was unable to detect miliary disease.

CONCLUSIONS

Recurrent ovarian cancer often presents as multiple small lesions throughout the abdominal cavity. In this subset of patients, immunoscintigraphy may be particularly well suited for detection of the presence of recurrent tumor.

Exposure rates in high-level-control fluoroscopy for image enhancement

High-level fluoroscopic boost options that exceed conventional exposure limits are available as a means of reducing quantum mottle during angiography. Federal law does not specify exposure limits for such high-level controls but requires specific means of activation to safeguard against inadvertent use. The American Association of Physicists in Medicine recently recommended that high-level exposure rates not exceed 2.58 mC/kg/min (10R/min). At six institution surveyed, maximum exposure rates ranged from 5.42 to 24 mC/kg/min (21-93 R/min). Activation of high-level capability varied from a simple foot switch to a keyed interlock requiring a second operator to engage. There appears to be no industry coherence in high-level control exposure limits as yet, although the Center for Devices and Radiological Health recently initiated an investigatory program.

Comparative uptake of 67Ga and 99mTc MDP in rabbits with a benign noninfected bone lesion (fracture)

Mid-shaft fractures of the radius and ulna were produced in 3 to 4 kg New Zealand white rabbits and quantitative uptake of 99mTc MDP and 67Ga determined at 11, 18, 25, 32, 51, and 78 days following fracture. Two hundred microCi of 67Ga was administered 24 hours prior to sacrifice and 1.5 mCi 99mTc MDP 2 hours prior to sacrifice. Specific activity ratios (SARs) were determined between fracture and control sides for bone, muscle and skin. SARs for bone were surprisingly similar for 99mTc MDP and 67Ga, reaching peak values of 6.07 +/- 0.64 (99mTc 18 days); 6.58 +/- 0.90 (67Ga 32 days), subsequently decreasing to minimum values at 78 days postfracture (99mTc MDP 2.25 +/- 0.14; 67Ga 2.18 +/- 0.08). There was no statistically significant difference in SAR for 99mTc MDP vs. 67Ga in bone at any time after fracture. Whole sections of limb were resected on selected animals and activity ratios determined for these sections as a function of the contribution of activity from the various tissues in the volume of interest. Total activity ratios of 67Ga were lower than bone SARs as a result of the contribution of activity from muscle and skin. Thus the apparent lower activity ratios noted on 67Ga images compared with 99mTc MDP images in this fracture model were not due to differences in bone SARs but rather due to the higher soft tissue background activity contribution in the 67Ga images.

Compounds which mediate gallium-67 transfer from lactoferrin to ferritin

The influence of various low molecular weight compounds on the transfer of 67Ga from human lactoferrin (LF) to horse spleen ferritin (HoFE) has been examined in vitro. When LF*67Ga complex was placed in competition with HoFE using a dialysis system the initial transfer rate (TR) of 67Ga to HoFE was slow and continuous. In the presence of 1 mM pyrophosphate (PPi) ascorbate and adenosine triphosphate (ATP), the TR was dramatically enhanced. This effect was concentration sensitive since reduction of the ATP to 0.1 mM eliminated the enhancement. Other intracellular compounds did not significantly influence the TR. Although PPi and ascorbate ions yielded larger TR's, ATP was more effective in the promotion of 67Ga transfer to HoFE. When the LF/HoFE concentration ratio was decreased, in the presence of ATP, the transfer of 67Ga was significantly increased. These results suggest that ferritin present intracellularly could remove and retain 67Ga entering the cell in the form of a LF*67Ga complex. Moreover, increased synthesis of ferritin and cytosolic phosphate compounds would appear to enhance this process.

Desferoxamine mesylate (Desferal): a contrast-enhancing agent for gallium-37 imaging

Desferal (desferoxamine mesylate) was investigated as a contrast-enhancing agent for tumor and abscess imaging with 67Ga-citrate. Tumor studies were performed in mice with Cloudman S-91 melanoma. Abscess studies were performed with a subcutaneous abscess model in rabbits. When Desferal is administered 16 to 18 hours after injection of 67Ga, rapid blood clearance of 67 Ga occurs with only slight (tumor) or no (abscess) loss of activity from the lesion. Retention in other organs is variable. Tumor-to-blood ratios are improved eightfold in tumor and fourfold in abscess in studies performed with single Desferal injections of 150 mg/kg. Blood and total body clearance studies in rabbits reveal that maximum Desferal effect is achieved in the 17 to 50 mg/kg dose range and that only minimal improvement occurs at higher doses.

Effect of desferoxamine on tissue and tumor retention of gallium-67: concise communication

Desferoxamine (DEF) was administered intramuscularly (0.25 mg/g body weight) to mice harboring a Cloudman's melanoma S-91 3 hr before, simultaneously with, and 3 hr after i.v. injection of Ga-67 citrate (approximately 1 microCi/g body weight). Relative Ga-67 retention was compared with that in non-DEF controls at 24 hr. The chemical nature of Ga-67 excreted in urine following DEF was also studied in healthy mice. Desferoxamine administered 3 hr before Ga-67 had little effect on radiogallium localization; administration coincident with or 3 hr after radiogallium resulted in decreased retention at 24 hr. The effect was most profound when Ga-67 and DEF were administered simultaneously. In DEF-injected animals Ga-67 was excreted in the urine as a Ga-67-DEF complex. When DEF was administered 3 hr after Ga-67, there was a trend to greater tumor-to-blood activity ratios (.2 > p > .1).

Indium-111-labeled autologous platelets for location of vascular thrombi in humans

Twenty-two patients suspected of having either venous or arterial thrombi were studied with In-111-labeled autologous platelets. Whole-body scans were performed 3, 24, and 48 hr following i.v. injection. Twelve patients studied with saline-washed platelets had unsatisfactory 15-min recovery and biologic half-time. When the labeling was carried out in plasma, these values compared favorably with normal values reported for Cr-51-labeled autologous platelets. Of ten patients studied using platelets labeled in plasma, three had normal scans, six had abnormal scans, and one had an equivocal scan. All six abnormal scans were confirmed with corresponding positive findings in either the venogram, arteriogram, or lung scan. J Nucl Med 19: 626-634, 1978.

The use of indium-111-labeled leukocytes for abscess detection

A case is reported in which a labeled white cell scan was helpful in the diagnosis of a periappendiceal abscess. The method of labeling is described and the usefulness of the technique discussed.