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close this book8th Coordination Meeting of World Health Organization Collaborating Centres in Radiation Emergency Medical Preparedness and Assistance Network, REMPAN (WHO - OMS, 2002, 145 p.)
View the document(introduction...)
View the document1. Programme of the 8th WHO/REMPAN Meeting
View the document2. Summary - Souchkevitch, G.N.
View the document3. National Radiological Protection Board - History, Structure, Functions of Radiation Protection at National and International Levels - Clarke, R.H.
View the document4. Second Henri Jammet Memorial Lecture. Radiation Accidents - an Overview and Feedback, 1950 - 2000 - Nénot, J-C.
View the document5. Aims of the 8th Rempan Meeting and Global Strategy - Repacholi, M.
Open this folder and view contents6. Reports of REMPAN Collaborating Centres and Liaison Institutions
View the document7. REMPAN: Overview Since the 7th Meeting - Souchkevitch, G.N.
Open this folder and view contents8. Agency Programmes
Open this folder and view contents9. Case Studies in Recent Radiation Accidents
Open this folder and view contents10. Public Health Aspects of Radiation Accidents
Open this folder and view contents11. REMPAN Database
View the document12. Future of REMPAN Session
View the documentQuality practice opportunities
View the documentHow to recognize and initially respond to an accidental radiation injury

Quality practice opportunities

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1. Major Radiation Exposure

Forman S. J., Petz L. D., Powles R., Apperley J., van Bekkum D. W., Noteboom J. L, Goddard C. M., Turai I., Veress K., Günalp B., Souchkevitch G., Mettler F. A. Jr., Voelz G. L.

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N Engl J Med 2002; 347:944-947, Sep 19, 2002. Correspondence

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amifostine is not only dangerous, but even contraindicated). Emergency personnel entering areas of critical exposure should be prepared with appropriate head and thoracic shielding. Medical personnel dealing with critically exposed victims should be aware of the hyperacute radiation syndromes so that they are not confused with nonspecific trauma and treated inappropriately.

CHRIS M. GODDARD, M.D., PH.D.
2301-1166 Melville St.
Vancouver, BC V6E 4P5, Canada
cgoddard@direct.ca

To the Editor: Physicians must be able to recognize a radiation injury in patients who are not aware of their contact with a source of radioactivity. Analysis of recent radiation accidents shows that exposed patients usually first present to general practitioners, dermatologists, or surgeons. The sudden onset of malaise, nausea, vomiting, and fatigue in a patient usually leads a doctor to consider food poisoning or an infectious disease. The late recognition of lymphopenia and severe bone marrow aplasia contributed to the deaths of a number of victims of radiation accidents in Thailand and Egypt in 2000. Thus, it is of utmost importance to improve the knowledge of all medical specialists with regard to the recognition of the effects of exposure to ionizing radiation caused by an accident or a terrorist or criminal act, as well as their understanding of how to provide early assistance.

We would also be more cautious than Mettler and Voelz, who write that "there is not likely to be synergism between radiation and other agents." Synergism has been observed in the health effects of combined exposure to chemicals and radiation. Thermal burns or trauma may increase the severity of radiation injuries. The biologic, chemical, traumatizing, and radiation components of "dirty bombs" in combination can certainly worsen the health consequences.

We do not completely share the view that "major radiation exposure due to a terrorist attack should be easier to manage than chemical or biologic attacks." External and especially internal contamination by sources of nonpenetrating ionizing radiation would not be so easy to handle, even in very-well-equipped countries.

ISTVÁN TURAI, M.D., PH.D.

World Health Organization
CH-1211 Geneva 27, Switzerland
turaii@who.int

KATALIN VERESS, M.D.

Semmelweis University
1445 Budapest, Hungary

BENGÜL GÜNALP, M.D.

Gülhane Medical Academy
06018 Ankara, Turkey

GENNADI SOUCHKEVTTCH, M.D., D.Sc.

World Health Organization
CH-1211 Geneva 27, Switzerland

The authors reply:

To the Editor: We appreciate the interest in our article. It is, of course, difficult to cover such a vast topic in a short review.

On the basis of a 1988 article related to bone marrow transplants, Forman and Petz suggest that hematopoietic-cell transplantation may be useful in patients who have been exposed to 6 to 15 Gy of radiation. Since 1988, experience with accidents (as opposed to controlled therapeutic radiation) has shown that at doses in excess of 10 Gy, ultimate survival is a function of damage to organs other than marrow. Use of stem-cell transplantation has prolonged survival for several additional months but has not changed overall mortality.

Powles and Apperley argue that hematopoietic support without transplantation could be lifesaving for selected patients who have been exposed to doses of 2 to 8 Gy of total-body radiation. We agree completely with this argument in the context of an accident at a nuclear power plant or the deployment of a nuclear weapon. Doses high enough to cause major bone marrow depression are unlikely to result from either a radiation-dispersion device or a "dirty bomb."

Van Bekkum and Noteboom write that potassium iodide should be given to pregnant women with lower projected doses of radiation to the thyroid (50 mGy) than that used as the threshold for other adults (100 mGy). The guidelines of the Food and Drug Administration do not address use of potassium iodide during pregnancy. Van Bekkum and Noteboom may be correct, although there is no international consensus on this matter. Projecting thyroid doses is an imperfect art, and in cases of radioiodine-dispersal accidents, the distribution and administration of potassium iodide has not had much relation to the projected dose of radiation.

Goddard points to the existence of effects of very high doses of radiation that include cardiovascular and central nervous system findings. These effects are invariably fatal but are rare. In the aftermath of accidents that have occurred during the past 50 years, there have been only about 10 patients with these findings.

Turai et al. argue that it is difficult for physicians to recognize the effects of radiation when there is no obvious context. We agree. A very helpful pamphlet and poster are produced by the International Atomic Agency and the World Health Organization1 and are available free of charge. Turai et al. also indicate that there may be synergism between the effects of radiation and those of chemical or biologic agents. We believe that although synergism is possible, it would be difficult to achieve in many people, given probable terrorist scenarios. Certainly, in patients with substantial bone marrow depression, concurrent additional sources of infection would reduce survival.

1. World Health Organization. How to recognize and initially respond to an accidental radiation injury. Vienna, Austria: International Atomic Energy

FRED A. METTLER, JR., M.D., M.P.H.
GEORGE L. VOELZ, M.D.

University of New Mexico Health Sciences Center
Albuquerque, NM 87131
fmettler@salud.unm.edu