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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.

The Inter-Agency Committee on Radiation Safety (IACRS) was constituted in 1990, as a forum for collaboration and coordination between international bodies with regards to radiation safety. It consists today of representatives of eight intergovernmental member organizations (the European Commision, Food and Agriculture Organization, International Atomic Energy Agency (IAEA), International Labour Office, Organisation for Economic Co-operation and Development/ Nuclear Energy Agency (OECD/NEA), Pan American Health Organization, United Nations Scientific Committee on the Effects of Atomic Radiation and the World Health Organization) and five observer non-governmental organizations (International Commission on Radiological Protection, International Commission on Radiation Units & Measurements, International Electrotechnical Commission, International Radiation Protection Association and International Organization for Standardization). The IACRS provides a platform for interaction between these relevant international bodies to contribute to a common understanding of the scientific basis and legal framework for the application of the system of radiation protection, towards global harmonisation of radiation safety standards. The IACRS played a key role in the development of the International Basic Safety Standards (BSS) in 1996 and in its revision in 2014. Further, an IACRS specific Task Group—chaired by the IAEA—fosters the implementation of the BSS in a consistent and coherent manner in all Member States of the United Nations. The IACRS operates via a standing secretariat jointly provided by the IAEA and OECD/NEA and is chaired by one of its member organizations on a rotating basis for periods of about 18 months. This approach has proved to be effective and was the foundation for ensuring continuity of the work of the committee and at the same time allowing a rotating leadership for all member organizations. Currently, the IACRS is chaired by the WHO. The International Radiation Safety Framework under which the IACRS works is structured around four main areas: (a) science; (b) principles; (c) standards; and (d) practice. This paper presents briefly the mandates, roles and functions of the various international bodies that are relevant to the four above mentioned areas of work, discusses how these bodies coordinate their actions and complement each other to enhance radiation protection and safety worldwide and describes their contribution to the achievement of the Sustainable Development Goals. The paper also provides an overview of the main accomplishments of the IACRS since its inception 30 years ago, and an outlook on key challenges for its future activities.

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.

The World Health Organization (WHO) undertook the development of a rapid guide on the use of chest imaging in the diagnosis and management of COVID-19. The rapid guide was developed over two months using standard WHO processes, except for the use of 'rapid reviews' and online meetings of the panel. The evidence review was supplemented by a survey of stakeholders regarding their views on the acceptability, feasibility, impact on equity and resource use of the relevant chest imaging modalities (chest radiography, chest CT and lung ultrasound). The guideline development group had broad expertise and country representation. The rapid guide includes three diagnosis recommendations and four management recommendations. The recommendations cover patients with suspected or confirmed COVID-19 with different levels of disease severity, throughout the care pathway from outpatient facility or hospital entry, to home discharge. All recommendations are conditional and are based on low certainty evidence (n=2), very low certainty evidence (n=2), or expert opinion (n=3). The remarks accompanying the recommendations suggest which patients are likely to benefit from chest imaging and what factors should be considered when choosing the specific imaging modality. The guidance also offers considerations about implementation, monitoring and evaluation, and identifies research needs.

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.

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 Proteccion Radiologica 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.

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.

Contains fulltext : 165689.pdf (Publisher’s version ) (Open Access) 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.

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.

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.

Quality imaging may be described as "a timely access to and delivery of integrated and appropriate procedures, in a safe and responsive practice, and a prompt delivery of an accurately interpreted report by capable personnel in an efficient, effective, and sustainable manner." For this article, radiation safety is considered as one of the key quality elements. The stakeholders are the drivers of quality imaging. These include those that directly provide or use imaging procedures and others indirectly supporting the system. Imaging is indispensable in health care, and its use has greatly expanded worldwide. Globalization, consumer sophistication, communication and technological advances, corporatization, rationalization, service outsourcing, teleradiology, workflow modularization, and commoditization are reshaping practice. This article defines the emerging issues; an earlier article in the May 2011 issue described possible improvement actions. The issues that could threaten the quality use of imaging for all countries include workforce shortage; increased utilization, population radiation exposure, and cost; practice changes; and efficiency drive and budget constraints. In response to these issues, a range of quality improvement measures, strategies, and actions are used to maximize the benefits and minimize the risks. The 3 measures are procedure justification, optimization of image quality and radiation protection, and error prevention. The development and successful implementation of such improvement actions require leadership, collaboration, and the active participation of all stakeholders to achieve the best outcomes that we all advocate.

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) agenc...

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.

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

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."

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 today's globalized environment, collaboration is strength and provides synergy to achieve better outcomes and greater success.

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 diagnostic 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 annually means that even the small individual risks associated with diagnostic exposures could cumulate into a public health concern. Assessment of population exposures resulting from medical uses of radiation is mainly available in industrialized countries, 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 mandate to assess and report levels and effects of exposure to ionizing 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.