Maria del Rosario Perez

WHO 1st Consultation on the Development of a Global Biodosimetry Laboratories Network for Radiation Emergencies (BioDoseNet)

Abstract Blakely, W. F., Carr, Z., Chu, M. C-M., Dayal-Drager, R., Fujimoto, K., Hopmeir, M., Kulka, U., Lillis-Hearne, P., Livingston, G. K., Lloyd, D. C., Maznyk, N., Perez, M. D. R., Romm, H., Takashima, Y., Voisin, P., Wilkins, R. C. and Yoshida, M. A. WHO 1st Consultation on the Development of a Global Biodosimetry Laboratories Network for Radiation Emergencies (BioDoseNet). Radiat. Res. 171, 127–139 (2009). The World Health Organization (WHO) held a consultation meeting at WHO Headquarters, Geneva, Switzerland, December 17–18, 2007, to develop the framework for a global biodosimetry network. The WHO network is envisioned to enable dose assessment using multiple methods [cytogenetics, electron paramagnetic resonance (EPR), radionuclide bioassays, etc.]; however, the initial discussion focused on the cytogenetic bioassay (i.e., metaphase-spread dicentric assay). Few regional cytogenetic biodosimetry networks have been established so far. The roles and resources available from United Nations (UN) agencies that provide international cooperation in biological dosimetry after radiological emergencies were reviewed. In addition, extensive reliance on the use of the relevant International Standards Organization (ISO) standards was emphasized. The results of a WHO survey of global cytogenetic biological dosimetry capability were reported, and while the survey indicates robust global capability, there was also a clear lack of global leadership and coordination. The expert group, which had a concentrated focus on cytogenetic biodosimetry, formulated the general scope and concept of operations for the development of a WHO global biodosimetry laboratory network for radiation emergencies (BioDoseNet). Follow-on meetings are planned to further develop technical details for this network.

Global quality imaging : Improvement actions

Workforce shortage, workload increase, workplace changes, and budget challenges are emerging issues around the world, which could place quality imaging at risk. It is important for imaging stakeholders to collaborate, ensure patient safety, improve the quality of care, and address these issues. There is no single panacea. A range of improvement measures, strategies, and actions are required. Examples of improvement actions supporting the 3 quality measures are described under 5 strategies: conducting research, promoting awareness, providing education and training, strengthening infrastructure, and implementing policies. The challenge is to develop long-term, cost-effective, system-based improvement actions that will bring better outcomes and underpin a sustainable future for quality imaging. In an imaging practice, these actions will result in selecting the right procedure (justification), using the right dose (optimization), and preventing errors along the patient journey. To realize this vision and implement these improvement actions, a range of expertise and adequate resources are required. Stakeholders should collaborate and work together. In todays globalized environment, collaboration is strength and provides synergy to achieve better outcomes and greater success.

WHO's public health agenda in response to the Fukushima Daiichi nuclear accident.

The World Health Organization (WHO) has responded to the 2011 East-Japan earthquake and tsunami through the three levels of its decentralised structure. It has provided public health advice regarding a number of issues relating to protective measures, potassium iodide use, as well as safety of food and drinking water, mental health, travel, tourism, and trade. WHO is currently developing an initial health risk assessment linked to a preliminary evaluation of radiation exposure around the world from the Fukushima Daiichi nuclear accident. Lessons learned from this disaster are likely to help future emergency response to multi-faceted disasters.

Large-Scale Quality Improvement for Radiation Protection of Children Worldwide: Lessons From the Past Applied to the Present

OBJECTIVE The objective of this article is to highlight strategies that can be used to implement changes locally for improved safety of pediatric patients. Specific examples of international organizations engaged with quality improvement are discussed. CONCLUSION Large-scale quality improvement to promote radiation protection for children is being aggressively pursued by numerous international organizations. These international agencies use quality improvement methods on a global scale to optimize medical imaging for all diagnostic imaging modalities that use ionizing radiation with the intent of lowering radiation dose to children. This work, although vast in scope, requires highly focused project goals with access to scientific expertise. In addition, these coordinated efforts must provide education, collegial support, and resources (both financial and technical) that enable radiology professionals to implement change locally for improved safety of pediatric patients.

Children, medical radiation and the environment: An important dialogue☆

ABSTRACT There are unique considerations in the medical care of children, which includes the use of medical imaging. Medical imaging is frequently necessary and is essential in diagnosis and management of children with illness and injury. Much of medical imaging requires ionizing radiation. While virtually all diagnostic imaging radiation is considered low‐dose level, there is still a broad misperception about what modalities use ionizing radiation and how much radiation risk exists in the medical environment. A discussion of radiation exposure is especially relevant in children due to their increased vulnerability, including to radiation‐induced cancer. Ionizing radiation is both naturally occurring and man‐made, including medical sources that have been increasing over the past few decades and can vary in radiation dose both between different modalities and for similar examinations. Perspectives vary regarding cancer risk and levels of radiation resulting from diagnostic imaging, however most medical and scientific organization support the perspective that the risk of cancer at these levels is uncertain. It is important to have balanced and informed resources for the use of ionizing radiation in the care of children, and it is equally important to assure that the delivery of this content is appropriate to the audience to which it is intended. For these reasons, it is valuable to review the issues related to use of ionizing radiation in medical imaging in children.

Internet-based ICRP resource for healthcare providers on the risks and benefits of medical imaging that uses ionising radiation

The purpose of the International Commission on Radiological Protection (ICRP) Committee 3 Working Party was to update the 2001 web-based module ‘Radiation and your patient: a guide for medical practitioners’ from ICRP. The key elements of this task were: to clearly identify the target audience (such as healthcare providers with an emphasis on primary care); to review other reputable sources of information; and to succinctly publish the contribution made by ICRP to the various topics. A ‘question-and-answer’ format addressing practical topics was adopted. These topics included benefits and risks of imaging using ionising radiation in common medical situations, as well as pertaining to specific populations such as pregnant, breast-feeding, and paediatric patients. In general, the benefits of medical imaging and related procedures far outweigh the potential risks associated with ionising radiation exposure. However, it is still important to ensure that the examinations are clinically justified, that the procedure is optimised to deliver the lowest dose commensurate with the medical purpose, and that consideration is given to diagnostic reference levels for particular classes of examinations.

Clinical imaging guidelines part 4: challenges in identifying, engaging and collaborating with stakeholders.

The effective development and use of clinical imaging guidelines requires an understanding of who the stakeholders are, what their interests in the process are, and what roles they should play. If the appropriate stakeholders are not engaged in the right roles, it is unlikely that clinical imaging guidelines will be successfully developed, relied on, and actually used. Some stakeholders are obvious: for the development of clinical imaging guidelines, both imagers and those who request examinations, such as general practitioners, internists, and medical specialists, must be involved. To gain acceptance, other relevant groups are stakeholders, including medical societies, other health care professionals, insurers, health IT experts and vendors, and patients. The role of stakeholders must be dictated by their specific interest. For some, involvement in the creation of guidelines is the right role. For others, such as regulators or insurers, reviews or invitations to comment are required, and for others, such as medical educators, it is probably sufficient to provide information and create awareness. Only through a careful consideration of who the stakeholders are and what are their interests are the successful development, acceptance, and use of clinical imaging guidelines likely to occur. Future efforts must focus on collaboration, particularly among groups that create clinical imaging guidelines and those that can support their use, and on regulatory roles and mandates.

International Collaboration on Clinical Imaging Guidelines: Many Hands Make Light Work

An International Atomic Energy Agency (IAEA) TechnicalMeeting on Justification of Medical Exposure and the Use ofAppropriatenessCriteriawasheldonMarch12-14,2013with3aims: (1) to explore what clinical imaging guidelines (CIG) arecurrently available, (2) to define the problems associated withclinical imaging guideline creation and use, and (3) to begin toestablishconcreteplansforinternationalcollaborationtoachievewideruseofCIG.TheunderlyingconceptisthattheuseofCIGcan improve patient care by improving the appropriate use ofimaging. This meeting was the second of 3 annual workshops,with further ones planned [1], and was organized and supportedbytheIAEAincooperationwiththeWorldHealthOrganization.Sixty medical professionals and regulators, from more than 30countries, participated. The 4 papers that follow in this issueevolved from the meeting, based on presentations, breakoutsessions,anddiscussions.Theintentofthisintroductoryarticleisto put the 4 papers into perspective, by specifically addressingwhatCIGare,whytheyaredifficulttobothproduceanddeploy,and why and how they are important.Several terms are used to describe the concept of guidelinesforclinicalimaging,including“appropriatenesscriteria,”“referralguidelines,” and “justification criteria” [2-5]. CIG (a term usedthroughout the papers) are developed using well-described,transparent methodology and available peer-reviewed literaturetocreaterecommendationsthatindicatewhichimagingexams,ifany,aremostlikelytobeclinicallyusefulinaspecificsetting.CIGare intended to inform the decision of the health care provider,thepatient,andtheradiologistastowhichimagingtest(again,ifany)torequestandperform.Buttheguidelinesarenotabsolute:The ultimate decision is based on many factors, includingpatient-specific ones (eg, risk factors, preferences), disease prev-alence, and availability of expertise and equipment. That is, ifMRI is the best choice but no MRI unit is available, thenchoosing anotherexamis reasonable. If ultrasound wouldbe thebest choice, but no local expertise is available in this area, thenanother imaging study may be recommended.The ACR Appropriateness Criteria on low-back pain pro-vide a good example of the intent of the guidelines. This topicincludes 6 variant scenarios. They range from “acute low backpain with no red flags” (as described in the text), for which therecommendation is that no imaging be done, to cauda equinasyndromewithmultipleorprogressivedeficits,withMRIratedas“usuallyappropriate”andlumbo-sacralx-rayandCTas“possiblyappropriate.” In this setting, based on clinical judgment, ifneither MRI norCT is available, then x-ray may be appropriate.A widely held belief is that imaging is often inappropriatelyused,withbothoveruse(by20%-50%)andunderuse.Amongtheexplanations for overuse are financial self-interest, medicolegalconcerns,expedience,andpatientdesire.Concernabouttheriskofionizingradiationmayleadtoinappropriateunderuse,asmaylackof availability of equipment or expertise. All stakeholders have ahigh level of interest in improving the quality of care and makingthe practice of medicine increasingly evidence based; the use ofsound guidelines is one important approach to this goal.Basingallmedicaldecisionsonrelevantevidenceisnotalwayspossible,becauseevidenceisessentiallynevercompleteforagivendisease, patient, and setting. Many organizations have produceddocuments that provide guidance or otherwise support evidence-based medicine. For example, the Cochrane Collaboration, amultinational nonprofit organization dedicated to improvinghealthcarethroughevidence-basedmedicine,producessystematicreviewsthatcanbeusedasthebasisofcare[6].Severalsocietiesandorganizations produce methodologically sound guidelines specif-ically for imaging. These include the American College of Cardi-ology[5],thegovernmentofWesternAustralia[7],andradiologysocieties such as the Royal College of Radiologists in the UnitedKingdom [4], the Canadian Association of Radiologists [8],theFrench Radiology Society [9], and the ACR [3].Methods for guideline development for clinical care arefairly well defined, based on an approach developed by the

WHO’s Role in the Assessment of Medical Radiation Exposures and Devices

About 15% of the ionizing radiation exposure to the general public comes from artificial sources, and almost all of this exposure is due to medical radiation, largely from diag- nostic procedures. Although radiological diagnostics provide great benefits, it is generally accepted that the use of radiation involves some risk. The large number of people exposed annu- ally means that even the small individual risks associated with diagnostic exposures could cumulate into a public health con- cern. Assessment of population exposures resulting from medi- cal uses of radiation is mainly available in industrialized coun- tries, while in developing countries this information is scarce. The World Health Organization (WHO) seeks to mobilize the health sector towards safe use of radiation in medicine and to improve implementation of radiation safety standards in health care facilities. The United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) has the man- date to assess and report levels and effects of exposure to ioniz- ing radiation. Its reports constitute the most comprehensive source of compiled information on distribution of medical radiological devices and on frequency of medical procedures involving the use of radiation, as well as associated doses. WHO, jointly with UNSCEAR, have planned to conduct surveys on practice and availability of human and material resources in diagnostic radiology, nuclear medicine and radio- therapy and to act as a clearinghouse for collecting and shar- ing information on the use of radiation in health care. Earlier evaluations have demonstrated wide variations among coun- tries in the frequency of diagnostic examinations performed. This could be explained by the imbalance in availability of equipment, health workforce and health care provision and also due to differences in the ability to obtain complete data on medical radiological. WHO urges Member States to conduct regularly such surveys and offers a platform for implementing a practical approach and standardized method .

Monitoring of Clinical Imaging Guidelines Part 3: Norms, Standards, and Regulations†

It is known that the use of imaging in clinical situations is not always optimal, leading to suboptimal health care and potential radiation risk. There may be overuse of imaging, underuse, or use of the wrong modality. The use of clinical imaging guidelines is likely to improve the use of imaging, but roadblocks exist. Some of these relate to regulatory oversight and mandates. There is wide variation by country and region in the regulatory setting, ranging from actual absence of regulatory authorities to mandated availability of clinical imaging guidelines in the European Community. Collaborative efforts to ensure that clinical imaging guidelines are at least available is a good starting point. Regulatory oversight and support are necessary to ensure the use of clinical imaging guidelines. Regulations should address 3 areas: availability, clinical utilization, and adherence to and revision of guidelines. The use of both internal and external audits, with the aim of both use of and adherence to guidelines and quality improvement, is the best tool for enhancing use. The major challenges that need to be addressed, collaboratively, to ensure the dissemination and use of clinical imaging guidelines are the development of regulations, of regulatory structures that can be effectively deployed, and of benchmarks for adherence and for utility.