The use of lung ultrasound in COVID-19.

This review article addresses the role of lung ultrasound in patients with coronavirus disease 2019 (COVID-19) for diagnosis and disease management. As a simple imaging procedure, lung ultrasound contributes to the early identification of patients with clinical conditions suggestive of COVID-19, supports decisions about hospital admission and informs therapeutic strategy. It can be performed in various clinical settings (primary care facilities, emergency departments, hospital wards, intensive care units), but also in outpatient settings using portable devices. The article describes typical lung ultrasound findings for COVID-19 pneumonia (interstitial pattern, pleural abnormalities and consolidations), as one component of COVID-19 diagnostic workup that otherwise includes clinical and laboratory evaluation. Advantages and limitations of lung ultrasound use in COVID-19 are described, along with equipment requirements and training needs. To infer on the use of lung ultrasound in different regions, a literature search was performed using key words "COVID-19", "lung ultrasound" and "imaging". Lung ultrasound is a noninvasive, rapid and reproducible procedure; can be performed at the point of care; requires simple sterilisation; and involves non-ionising radiation, allowing repeated exams on the same patient, with special benefit in children and pregnant women. However, physical proximity between the patient and the ultrasound operator is a limitation in the current pandemic context, emphasising the need to implement specific infection prevention and control measures. Availability of qualified staff adequately trained to perform lung ultrasound remains a major barrier to lung ultrasound utilisation. Training, advocacy and awareness rising can help build up capacities of local providers to facilitate lung ultrasound use for COVID-19 management, in particular in low- and middle-income countries.

An Africa point of view on quality and safety in imaging.

Africa has seen an upsurge in diagnostic imaging utilization, with benefits of efficient and accurate diagnosis, but these could easily be offset by undesirable effects attributed to unjustified, unoptimized imaging and poor quality examinations. This paper aims to present Africa's position regarding quality and safety in imaging, give reasons for the rising interest in quality and safety, define quality and safety from an African context, list drivers for quality and safety in Africa, discuss the impact of COVID-19 on quality and safety, and review Africa's progress using the Bonn Call for Action framework while proposing a way forward for imaging quality and safety in Africa. In spite of a healthcare setting characterized by meagre financial, human and technology resources, a rapidly widening disease-burden spectrum, growing proportion of non-communicable diseases and resurgence of tropical and global infections, Africa has over the last ten years made significant strides in quality and safety for imaging. These include raising radiation-safety awareness, interest and application of evidence-based radiation safety recommendations and guidance tools, establishing facility and national diagnostic reference levels (DRLs) and strengthening end-user education and training. Major challenges are: limited human resource, low prioritization of imaging in relation to other health services, low level of integration of imaging into the entire health service delivery, insufficient awareness for radiation safety awareness, a radiation safety culture which is emerging, insufficient facilities and opportunities for education and training. Solutions to these challenges should target the entire hierarchy of health service delivery from prioritization, policy, planning, processes to procedures.

Main problems and suggested solutions for improving radiation protection in medicine in Ibero-American countries. Summary of an International Conference held in Madrid, 2016.

During the International Conference on Radiation Protection in Medicine held in Bonn in 2012, several areas for improvement were identified, including specific actions related with justification, optimization, role of manufacturers, radiation protection education and training, strategic research, data collection on medical and occupational exposures, prevention of incidents and accidents, radiation safety culture, risk-benefit dialogue and implementation of the radiation safety standards. The outcomes of the Bonn Conference were summarized in the so-called 'Bonn Call for Action', identifying 10 priority actions to enhance RP in medicine. Trying to analyse the progress in the implementation of this 'Call for Action' in the Ibero-American region, several international organizations organized the 'Ibero-American Conference on Radiation Protection in Medicine' (Conferencia Iberoamericana sobre Protección Radiológica en Medicina, CIPRaM) held in Madrid, in October 2016. CIPRaM was structured in eight thematic sessions dealing with: diagnostic and dental radiology, image guided interventional radiology, nuclear medicine, radiation therapy, health authorities and radiation protection regulators, professional associations of technologists and nurses, professional associations of medical physicists and radiation protection experts, and universities and researchers in radiation protection in medicine. This paper summarizes the main results of that Conference based on the consensus achieved about main problems, solutions, and indicators to evaluate the implementation of the proposed solutions.

Justification of CT for Individual Health Assessment of Asymptomatic Persons: A World Health Organization Consultation.

An international expert consultation was convened by the World Health Organization (WHO). The purpose of the meeting was to review the use of CT in examining asymptomatic people. This is often referred to as individual health assessment (IHA). IHA was identified as a global phenomenon unenthusiastically tolerated, and not actively promoted, structured, or regulated in most countries. This paper identifies the state of the art for IHA and some considerations in relation to its justification, in different regions of the world. The outcomes reached include the following: questions around terminology and culture of IHA practice; review of IHA in some countries, regions, and international bodies; dilemmas for participants in IHA; risk communication, education, and training for professions and public; the desirability of guidelines and clinical audit; social, ethical, public health, and resource considerations; and a framework for IHA and regulatory considerations. Three subcategories of examination for asymptomatic individuals were identified: formal screening programs; examinations for which the evidence base or risk profile is incomplete; and opportunistic examinations with little or no evidence or risk profile to suggest they have any merit. The latter challenges the justification principle of radiation protection. In addition, the issue of the costs, direct and indirect, associated with false positives and/or equivocal/incidental findings were highlighted. These and other considerations make it difficult to view some IHA as a bona fide medical activity. To allow it to be viewed as such requires that it be conducted within a robust clinical governance framework that includes regulatory dimensions.

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.

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.

Clinical imaging guidelines part 2: Risks, benefits, barriers, and solutions.

A recent international meeting was convened by two United Nations bodies to focus on international collaboration on clinical appropriateness/referral guidelines for use in medical imaging. This paper, the second of 4 from this technical meeting, addresses barriers to the successful development/deployment of clinical imaging guidelines and means of overcoming them. It reflects the discussions of the attendees, and the issues identified are treated under 7 headings: ■ Practical Strategy for Development and Deployment of Guidelines; ■ Governance Arrangements and Concerns with Deployment of Guidelines; ■ Finance, Sustainability, Reimbursement, and Related Issues; ■ Identifying Benefits and Radiation Risks from Radiological Examinations; ■ Information Given to Patients and the Public, and Consent Issues; ■ Special Concerns Related to Pregnancy; and ■ The Research Agenda. Examples of topics identified include the observation that guideline development is a global task and there is no case for continuing it as the project of the few professional organizations that have been brave enough to make the long-term commitment required. Advocacy for guidelines should include the expectations that they will facilitate: (1) better health care delivery; (2) lower cost of that delivery; with (3) reduced radiation dose and associated health risks. Radiation protection issues should not be isolated; rather, they should be integrated with the overall health care picture. The type of dose/radiation risk information to be provided with guidelines should include the uncertainty involved and advice on application of the precautionary principle with patients. This principle may be taken as an extension of the well-established medical principle of "first do no harm."

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.

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.

A new handbook on triage, monitoring and treatment of people following malevolent use of radiation.

Through the Euratom 6 Framework Programme, the European Commission is co-sponsoring the specific targeted research project "Triage, Monitoring and Treatment-Handbook for management of the public in the event of malevolent use of radiation" (TMT Handbook). The main aim of the project is to produce a handbook for the effective and timely triage, monitoring, and treatment of people exposed to radiation following a malevolent act. The World Health Organization contributed to this project with development of guidelines on medical and public health response. A training course based on the TMT Handbook was developed. It will help to enhance national capacity for planning and response to acts involving the malevolent use of radiation. The course will also provide a platform to identify common challenges and discuss opportunities for harmonizing response strategies throughout the European Union. Focusing on its medical and public health response aspects, this paper introduces the TMT Handbook and its potential applicability not only as practical guidance for end-users but also as a useful tool for education and training.

Increased activity and involvement of caspase-3 in radiation-induced apoptosis in neural cells precursors from developing rat brain.

Using primary cultures of neural precursor cells of cortex from developing rat brain, we demonstrated the involvement of caspase-3 in the apoptotic process induced by gamma irradiation. The precursor nature of cells was confirmed by nestin and GFAP immunoreactivity and by the capacity of differentiation in neuronal and glial cells after 5 days in culture. Neural precursors were irradiated with single doses ranging from 0.1 to 4Gy. Cellular death, determined 24 h post-irradiation (pi) was dose-dependent and the induction of apoptosis was confirmed by nuclear condensation, DNA fragmentation and hypodiploid DNA peak represented by the "sub G1" region. For the higher doses, apoptosis was evident after 4-6 h pi and increased during 24 h. Caspase-3 activity increased with doses and was maximal at 4-6 h pi with 3Gy and remained similar with 4Gy. The protection from radiation-induced apoptosis by caspase-3 inhibitor, zDEVD-fmk, confirmed that this enzyme is involved in the apoptotic mechanism in this system. The possibility of using this tissue culture system for studying the effects of ionizing radiation on morphological and molecular differentiation was considered.