““Radiation Emergency Medicine at Radiation Emergency Medicine at REAC/TS” REAC/TS”

NC / VA Health Physics Society Mtg.NC / VA Health Physics Society Mtg.New Bern, NCNew Bern, NC

Mr. 12-13, 2009 Mr. 12-13, 2009

Albert L. Wiley, BNE,MD, PhD ,USNR(RET)Albert L. Wiley, BNE,MD, PhD ,USNR(RET)

Director, REAC/TS & WHO REMPAN Collaborating Center at Director, REAC/TS & WHO REMPAN Collaborating Center at Oak RidgeOak Ridge

V. Pres., Radiation Emergency Medicine, ORAUV. Pres., Radiation Emergency Medicine, ORAUEmeritus Professor, Univ. Wisconsin-MadisonEmeritus Professor, Univ. Wisconsin-Madison

albert.wiley@orise.orau.govalbert.wiley@orise.orau.gov 865- 576-3130865- 576-3130

865-576-1005 (24/7 number)865-576-1005 (24/7 number)

22

33

REAC/TS Medical Experience in Radiation REAC/TS Medical Experience in Radiation Accident Response (1976-4/2008)Accident Response (1976-4/2008)

Calls for Assistance 2416Calls for Assistance 2416

Patients seen at REAC/TS 222Patients seen at REAC/TS 222

44

Automated Cytogenetics WorkstationAutomated Cytogenetics Workstation

Slide Feeder

Microscope

Computer

REAC/TS has radiation accident cytogenetic REAC/TS has radiation accident cytogenetic biodosimetry capabilities:biodosimetry capabilities:

NewNewKaryotype

Output

Old

Labor Intensive

The new REAC/TS Automated Cytogenetic Workstation has automated slide handling and scanning. Computer karyotyping (identification/arranging) of the chromosomes and identification of aberrations, unlike the old system where the cytogeneticist had to score by hand.

ObjectivesObjectives

• Describe the signs and symptoms, diagnostic Describe the signs and symptoms, diagnostic procedures and clinical phases of the acute procedures and clinical phases of the acute radiation syndrome (ARS).radiation syndrome (ARS).

• Discuss the pathology of the various components of Discuss the pathology of the various components of the acute radiation syndrome. the acute radiation syndrome.

• Describe the current medical capabilities and role Describe the current medical capabilities and role for supportive and other medical care (drugs/ for supportive and other medical care (drugs/ procedures) in the initial management of ARS procedures) in the initial management of ARS patients.patients.

Acute Radiation SyndromeAcute Radiation Syndrome• ARS is an acute illness, which follows a generally ARS is an acute illness, which follows a generally

predictable course over a period of time ranging predictable course over a period of time ranging from a few hours to several weeks after high-level from a few hours to several weeks after high-level exposure to ionizing radiation, effecting initially exposure to ionizing radiation, effecting initially and primarily (in the lower doses) the marrow and primarily (in the lower doses) the marrow compartment.compartment.

• ARS is characterized by the dose dependent ARS is characterized by the dose dependent development of groups of signs and symptoms development of groups of signs and symptoms which are manifestations of the reactions of which are manifestations of the reactions of various body organ systems (BM, GI,CNS, various body organ systems (BM, GI,CNS, Pulmonary, SKIN) to large volume or essentially Pulmonary, SKIN) to large volume or essentially whole body irradiation.whole body irradiation.

Comparison of Lymphocyte Counts Comparison of Lymphocyte Counts with Values Predicted by Andrews’ with Values Predicted by Andrews’

ModelModel3,000

2,500

2,000

1,500

1,000

500

1000

Normal Range

Moderate

Very Severe

Lethal

SevereINJURY

0 3 6 17 24 48Hours

Ž Ž Patient, Israel 1990è Patient, Belarus 1991

Ž

ŽŽ

Ž

Patient

Abs

olut

e L

ymph

ocyt

es

From Andrews GA, Auxier, Jr.,Lushbaugh, CC.The importance of dosimetryto the medical managementof persons accidentally exposedto high levels of radiation. In: Personnel Dosimetry for Radiation Accidents.Vienna: International Atomic Energy Agency, 1965.

Time to Emesis (Function of Time to Emesis (Function of Whole Body Radiation Dose)Whole Body Radiation Dose)

AFRRI Recommendations for AFRRI Recommendations for Chromosome BiodosimetryChromosome Biodosimetry

100% death(within 2-12 days)

GI, neurological, cardiovascular damage

severe(minutes to <48 h)

PCC> 10.0

90-100% death within 1-3 weeks

combined BM and GI damage

severe(<1 h -48 h)

Lymphocyte depletion

kinetics/PCC

7.5-10.0

10-100% death within 2-6 weeks

pancytopenia, mild to moderate GI damage

severe(1-48 h)

Lymphocyte depletion

kinetics/PCC

3.5-7.5

0-10% deathmild to severe bone marrow damage

mild to moderate (1-48 h)

Lymphocyte depletion

kinetics/dicentrics/PCC

1.0-3.5

almost certainnone to slight decrease in blood count

none to mild (1-48 h)Dicentric/PCC0.1 - 1

Survival Expectancy

Manifest SymptomsProdromalEffects

Proposed Validated Dosimetry Method

Dose Range (Gy)

Serum Amylase (Tokaimura); Serum Amylase (Tokaimura); Normal ,76 -231(IU/L)Normal ,76 -231(IU/L)

Day 0 (4:00 p.m.)Day 0 (4:00 p.m.) Day 1 (7:00 a.m.) Day 1 (7:00 a.m.)

Worker AWorker A 176176 21432143Worker BWorker B 421421 24542454Worker CWorker C 104104 10941094

Prodromal Signs and Symptoms of Prodromal Signs and Symptoms of High Level Radiation ExposureHigh Level Radiation Exposure

• AnorexiaAnorexia• NauseaNausea• VomitingVomiting• DiarrheaDiarrhea• FeverFever• ConjunctivitisConjunctivitis• Skin erythemaSkin erythema

When Patient is Medically Stable, Further When Patient is Medically Stable, Further Triage Is By Estimation of Radiation Dose Triage Is By Estimation of Radiation Dose

Through Multi-Parameter TechniquesThrough Multi-Parameter Techniques

Obtain patient history, especially the time to onset Obtain patient history, especially the time to onset and severity of nausea and vomiting following the and severity of nausea and vomiting following the time of radiation exposure.time of radiation exposure.

Obtain CBC as early and as frequently as possible Obtain CBC as early and as frequently as possible after exposure for monitoring the rate of decline in after exposure for monitoring the rate of decline in absolute lymphocyte count and possibly the absolute lymphocyte count and possibly the neutrophil / lymphocyte ratio.neutrophil / lymphocyte ratio.

Obtain a blood sample for quantifying chromosome Obtain a blood sample for quantifying chromosome dicentric aberrations (the Gold Standard), or possibly dicentric aberrations (the Gold Standard), or possibly micronuclei, in the peripheral blood lymphocytes– micronuclei, in the peripheral blood lymphocytes– and, for determination of serum amylase. and, for determination of serum amylase.

Low-dose Deterministic Low-dose Deterministic Effects Effects

• < 10 cGy, whole body: no detectable < 10 cGy, whole body: no detectable difference in exposed vs. non-exposed difference in exposed vs. non-exposed patientspatients

• ~20 cGy, whole body: detectable ~20 cGy, whole body: detectable increase in chromosome aberrations. increase in chromosome aberrations. No clinical signs or symptomsNo clinical signs or symptoms

• ~ 12 cGy, whole body: sperm count ~ 12 cGy, whole body: sperm count decreases to minimum about day 45decreases to minimum about day 45

• ~75-100 cGy, whole body: detectable ~75-100 cGy, whole body: detectable bone marrow depression bone marrow depression

Acute Radiation SyndromesAcute Radiation Syndromes

Subclinical …….. 0 - 100 cGySubclinical …….. 0 - 100 cGy

Hematopoietic……100 - 800 cGyHematopoietic……100 - 800 cGy

Gastrointestinal……800 - 3000 cGyGastrointestinal……800 - 3000 cGy

CV/CNS……………> 3000 cGyCV/CNS……………> 3000 cGy

Phases of the Acute Radiation Phases of the Acute Radiation SyndromeSyndrome

• Prodromal period.Prodromal period.• Latent period.Latent period.• Period of manifest illness.Period of manifest illness.• Period of recovery or death.Period of recovery or death.

Haematopoietic syndromeHaematopoietic syndrome

Normal bone marrow cells

Survival potentialSurvival potential

Bone marrow damaged by radiation injury

Hematological response to 1-3 Gy, whole body exposure to ionizing radiation

Neutrophil Counts after Neutrophil Counts after ChernobylChernobyl

Systemic Systemic EffectsEffects of Hematopoietic of Hematopoietic

SyndromeSyndrome

• Stem cell depletionStem cell depletion• Neutropenia and often Neutropenia and often

pancytopeniapancytopenia• Increased infectious Increased infectious

complications - sepsiscomplications - sepsis• HemorrhageHemorrhage• AnemiaAnemia• Impaired wound healingImpaired wound healing

Effects of Gastrointestinal Effects of Gastrointestinal SyndromeSyndrome

• MalabsorptionMalabsorption• Ileus - vomiting; GI distentionIleus - vomiting; GI distention

• fluid and electrolyte shiftsfluid and electrolyte shifts• dehydrationdehydration• acute renal failure acute renal failure • cardiovascular collapsecardiovascular collapse

• GI bleeding GI bleeding • SepsisSepsis

Gastrointestinal Gastrointestinal (GI) (GI) syndrome syndrome (8-30 Gy)(8-30 Gy)

• Depletion of the epithelial Depletion of the epithelial cells lining lumen of cells lining lumen of gastrointestinal tractgastrointestinal tract

• Intestinal bacteria gain free Intestinal bacteria gain free access to bodyaccess to body

• HHaaemorrhage through emorrhage through denuded areasdenuded areas

• Loss of absorptive capacityLoss of absorptive capacity

Irradiated GI Mucosa

Pathophysiology of the GI Syndrome

Cardiovascular / CNS Cardiovascular / CNS SyndromeSyndrome

• Vomiting and diarrhea within Vomiting and diarrhea within minutesminutes

• Confusion and disorientationConfusion and disorientation• Severe hypotensionSevere hypotension• Cerebral edemaCerebral edema• Convulsions - comaConvulsions - coma• HyperpyrexiaHyperpyrexia• Fatal within 24 to 48 hoursFatal within 24 to 48 hours

CDCFDA03

Medical Management of the Medical Management of the ARSARS

• Primary goal of hematopoietic support Primary goal of hematopoietic support is reduction in both depth and duration is reduction in both depth and duration of leukopeniaof leukopenia

• Prevention and management of Prevention and management of infection is mainstay of therapyinfection is mainstay of therapy

• Quantitative relationship between Quantitative relationship between degree of neutropenia and increased degree of neutropenia and increased risk of infectious complications. risk of infectious complications.

• AAbsolute neutrophil countbsolute neutrophil count ( (ANCANC)) < 100/ < 100/mmmm33 is greatest risk factor is greatest risk factor

Colony Stimulating FactorsColony Stimulating Factors G-CSF -NeupogenG-CSF -NeupogenTMTM

Pegylated G-CSF - Peg-filgrastim, Pegylated G-CSF - Peg-filgrastim, NeulastaNeulastaTMTM

Granulocyte-Macrophage (GM-CSF) - Granulocyte-Macrophage (GM-CSF) - LeukineLeukineTMTM, sargramostim, sargramostim

Use G-CSF or GM-CSF as soon as Use G-CSF or GM-CSF as soon as diagnosis of serious radiation injury is diagnosis of serious radiation injury is mademade

~PBSC or cord blood transplant if > 8 Gy, ~PBSC or cord blood transplant if > 8 Gy, oror

~BMT >9 Gy~BMT >9 Gy

Time (days) after Irradiation

AN

C x

103

/µL

Absolute Neutrophil Count (ANC) for CaninesExposed to 350 cGy Cobalt

0.001

0.010

0.100

1.000

10.000

100.000

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45

Canine Serum

G-CSF 10ug/kg BID d1-23 or G-CSF 10ug/kg QD d1-23 or G-CSF 5 ug/kg QD d1-23

G-CSF 5ug/kg QD d10-23 ord9-23

Severe Neutropenia

0.500

CDCFDA03

Initiation and Initiation and DDuration of uration of CCytokine ytokine AAdministrationdministration

Benchmark absolute lymphocyte count Benchmark absolute lymphocyte count less than 500/mmless than 500/mm33 threshold for threshold for beginning cytokine therapy in first 2 beginning cytokine therapy in first 2 daysdays

Continue cytokine administration with Continue cytokine administration with daily injections to reach ANC of daily injections to reach ANC of 1000/1000/mmmm33

This regimen provides appears to This regimen provides appears to provide an optimum opportunity for provide an optimum opportunity for neutrophil recoveryneutrophil recovery

Cytokine Cytokine DDosageosage G-CSF Filgrastim (NeupogenG-CSF Filgrastim (NeupogenRR))

• 2.5-5.0 2.5-5.0 µµg/kg/day (100-200 g/kg/day (100-200 µµg/g/mm22/day)/day)

GM-CSF Sagramostim (LeukineGM-CSF Sagramostim (LeukineRR))• 5.0-10.0 5.0-10.0 µµg/kg/day (200-400 g/kg/day (200-400 µµg/g/

mm22/day) /day) • Begin therapy as early as Begin therapy as early as

practical for maximum effectpractical for maximum effect

Infection Infection MManagmentanagment of the of the ARSARS

• Antibiotic pAntibiotic prophylaxisrophylaxis• Barrier/isolationBarrier/isolation• Gut decontaminationGut decontamination• Antiviral agentsAntiviral agents• Antifungal agentsAntifungal agents• Pneumocystis prophylaxisPneumocystis prophylaxis• Early Early ccytokine therapyytokine therapy• Close woundsClose wounds• Avoid invasive proceduresAvoid invasive procedures

IsolationIsolation Issues Issues TTreat ARS patients wreat ARS patients withith estimated WB >2 estimated WB >2

Gy Gy inin isolated rooms. isolated rooms. WarnWarn nursing personnel of the need for nursing personnel of the need for

rigorous environmental control including:rigorous environmental control including: Laminar flow isolationLaminar flow isolation Strict hand washing before and after Strict hand washing before and after

patient carepatient care Surgical scrubs for staffSurgical scrubs for staff Gowns, caps, gloves, masks for staffGowns, caps, gloves, masks for staff Double bagging of all disposablesDouble bagging of all disposables

Prevention of Infection inPrevention of Infection inImmunocompromised PatientsImmunocompromised Patients

• Suppression of micro-organismsSuppression of micro-organisms• Physiological interventionsPhysiological interventions

• Maintenance of gastric acidityMaintenance of gastric acidity

• Avoidance of antacids and HAvoidance of antacids and H22 blockers blockers

• Use of sucralfate for stress ulcer prophylaxis Use of sucralfate for stress ulcer prophylaxis when indicated to reduce gastric colonization when indicated to reduce gastric colonization and pneumoniaand pneumonia

• Early oral enteral nutrition (when feasible)Early oral enteral nutrition (when feasible)• Adequate personal hygieneAdequate personal hygiene

• Povidone-iodine (Betadine) or chlorhexidine for Povidone-iodine (Betadine) or chlorhexidine for skin disinfection, shampooskin disinfection, shampoo

• Oral hygiene (brushing and flossing)Oral hygiene (brushing and flossing)

AntibioticsAntibiotics

Antibiotic prophylaxis (Gram negative, HSV, Antibiotic prophylaxis (Gram negative, HSV, fungal)fungal)

FluoroquinoloneFluoroquinolone AcyclovirAcyclovir DiflucanDiflucan Infectious Disease Society of America (IDSA) Infectious Disease Society of America (IDSA)

guidelines are helpfulguidelines are helpful Address underlying foci for neutropenic feverAddress underlying foci for neutropenic fever

• Integument and GI injuryIntegument and GI injury• Anaerobic coverage if indicatedAnaerobic coverage if indicated

Neutropenic FeverNeutropenic Fever Cultures covering all possible foci of infection should Cultures covering all possible foci of infection should

be performed.be performed. In patients who experience first fever, traditionally In patients who experience first fever, traditionally

the FQ is stopped and therapy directed at gram-the FQ is stopped and therapy directed at gram-negative bacteria (in particular, Pseudomonas negative bacteria (in particular, Pseudomonas aeruginosa) as infections of this type may be rapidly aeruginosa) as infections of this type may be rapidly lethal. lethal.

Anti-pseudomonal coverage serves as the foundation Anti-pseudomonal coverage serves as the foundation and additional coverage is then added to address and additional coverage is then added to address other foci of infection such as mucosal or integument other foci of infection such as mucosal or integument injury. injury.

Empiric therapy of patients with febrile neutropenia Empiric therapy of patients with febrile neutropenia with or without a focus of infection should be guided with or without a focus of infection should be guided by the current infectious disease recommendations. by the current infectious disease recommendations.

Any foci of infection that develops during the Any foci of infection that develops during the neutropenic period will require a full course of neutropenic period will require a full course of therapy. therapy.

Case Study: Wood River Junction, Case Study: Wood River Junction, RI, USA; U-235 Recovery Plant RI, USA; U-235 Recovery Plant

July 24, 1964July 24, 1964 Criticality excursion; patient stunned; ran Criticality excursion; patient stunned; ran

from the building; immediate vomiting.from the building; immediate vomiting. Immediate diarrhea; c/o abdominal Immediate diarrhea; c/o abdominal

cramps, HA, thirst; profuse perspiration; cramps, HA, thirst; profuse perspiration; BP160/80; P100; R20; T 38CBP160/80; P100; R20; T 38C Transient difficulty in speaking; 4h post Transient difficulty in speaking; 4h post

admission BP 85/40; P110, T 38.9 Cadmission BP 85/40; P110, T 38.9 C X-ray 16h post admission showed hilar X-ray 16h post admission showed hilar

congestioncongestion

Clinical Timeline: Wood River JunctionClinical Timeline: Wood River Junction U-235 Recovery Plant July 24, 1964 U-235 Recovery Plant July 24, 1964 Left hand and forearm edematous; Left hand and forearm edematous;

conjunctivitis and periorbital edema on conjunctivitis and periorbital edema on the left.the left.

Clinical deterioration on the 2Clinical deterioration on the 2ndnd day; BP day; BP maintained with difficulty; no urinary maintained with difficulty; no urinary output.output.

Six hours prior to dearth, patient very Six hours prior to dearth, patient very disoriented.disoriented.

Patient died 49 h after the event of multi-Patient died 49 h after the event of multi-organ failure (MOF).organ failure (MOF).

Karas, JS et al., NEJM 272:755-761, (April 15,1965)

Pulmonary injury currently seems Pulmonary injury currently seems to be the major limiting organ for to be the major limiting organ for

medical remediation. medical remediation.

30 years later ,2 workers at the 30 years later ,2 workers at the TOKAMURA ACCIDENT died 3-6 TOKAMURA ACCIDENT died 3-6

months later from a criticality months later from a criticality accident of MOF, primarily accident of MOF, primarily

pulmonary injury.pulmonary injury.

Goiania,Cs137, Accident(10/87)Goiania,Cs137, Accident(10/87)

1.3 Gy, negligible intake (left source in bag)Dr. PM

100 MBq (2.7 mCi) intake, 3 Gy , burn on shoulderGS

1Gbq (27 mCi) intake, 6 Gy external (died) 23 OCTLF2

5.3 Gy (died) 28 OCT Probable very acute dose.AS

4.5 Gy (died) 27 OCT Probable very acute dose.IS

10 MBq (270 μCi) intake, 4.3 Gy external (cytogenetics)

MA

7 Gy (lived) Possibly spent more time outside (fractionated)

DF

5.7 Gy (died) 23 OCT (27 mCi internal Cs137-enough to be lethal)

MA’s daughter

Results of Initial Cytogenetic Dosimetric Results of Initial Cytogenetic Dosimetric Estimates (External Exposure)Estimates (External Exposure)

4.293500 – 600

2.582600 – 700

Relative Frequency [%]

No. of PersonsRange [Rem]

70

3

0

5

6

8

43

0300 – 400

100.00Total

4.29400 – 500

11.4350 – 100

8.57100 – 200

7.14200 – 300

61.430 – 50

Goiania DataGoiania Data

Summary of Treatment Modes Summary of Treatment Modes (Goiania)(Goiania)

Supportive Care, GMSF, and PB Supportive Care, GMSF, and PB (An Example That Internal (An Example That Internal

Contamination Can Cause Death Contamination Can Cause Death and Medical Countermeasures and Medical Countermeasures

May Rarely Be Needed.)May Rarely Be Needed.)

4646

REAC/TS DTPA and PB IND REAC/TS DTPA and PB IND ProgramsPrograms

Maintain Registries of DTPA Maintain Registries of DTPA and PB use in US and PB use in US

Provide a stock of Provide a stock of pharmaceuticals at REAC/TS pharmaceuticals at REAC/TS and with co- investigators and with co- investigators for treatment of internal for treatment of internal contamination:contamination:• Ca- and Zn-DTPACa- and Zn-DTPA• Prussian Blue (Radiogardase®)Prussian Blue (Radiogardase®)

Through a network of Through a network of physician co-investigators, physician co-investigators, special drugs are readily special drugs are readily available in the event of available in the event of radiation emergencies radiation emergencies

including nuclear terrorismincluding nuclear terrorism

DTPA Co-investigators (24)

Prussian Blue Co-investigators (8)

4747

Methods for Assessing IntakesMethods for Assessing Intakes Whole Body or Lung CountingWhole Body or Lung Counting

• Feasible for nuclides that emit penetrating x Feasible for nuclides that emit penetrating x or gamma raysor gamma rays

• Useful also for nuclides emitting energetic Useful also for nuclides emitting energetic beta particles - can be detected by their beta particles - can be detected by their bremsstrahlung radiationbremsstrahlung radiation

BioassayBioassay• 24 hr urine collections - most widely used24 hr urine collections - most widely used• 24 hr feces collections24 hr feces collections• Excised material from woundsExcised material from wounds

Cytogenetic BiodosimetryCytogenetic Biodosimetry

4848

Am-241 Inhalation, Example Am-241 Inhalation, Example CaseCase

Two workers were transferring Two workers were transferring 241241Am Am from a shipping barrel to a disposal from a shipping barrel to a disposal container.container.

The workers were wearing The workers were wearing respiratory protection.respiratory protection.

But, a supervisor, also present, was But, a supervisor, also present, was not wearing respiratory protection.not wearing respiratory protection.

4949

Am-241 Example (continued)Am-241 Example (continued) On exit, all three workers were noted On exit, all three workers were noted

to be contaminated – and room air to be contaminated – and room air samples were positive for alpha.samples were positive for alpha.

Lung count bioassay was advised Lung count bioassay was advised and performed the next day - all 3 and performed the next day - all 3 patients were positive.patients were positive.

24 hr urine and fecal bioassay 24 hr urine and fecal bioassay collections were advised and begun.collections were advised and begun.

5050

Day 1 Bioassay resultsDay 1 Bioassay results Patient #1 (supervisor, male):Patient #1 (supervisor, male):

• Lung content: 400 BqLung content: 400 Bq• Urine: 1 Bq per dayUrine: 1 Bq per day

Patient #2 (female):Patient #2 (female):• Lung content: 200 BqLung content: 200 Bq• Urine: 0.12 Bq per dayUrine: 0.12 Bq per day

Patient #3 (male):Patient #3 (male):• Lung content: 50 BqLung content: 50 Bq• Urine: 0.06 Bq per dayUrine: 0.06 Bq per day

5151

Initial Intake and Effective Dose Initial Intake and Effective Dose EstimatesEstimates

Patient #1: 1.8 kBq, 210 mSvPatient #1: 1.8 kBq, 210 mSv

Patient #2: 0.63 kBq, 73 mSvPatient #2: 0.63 kBq, 73 mSv

Patient #3: 0.15 kBq, 17 mSv (?Stop Patient #3: 0.15 kBq, 17 mSv (?Stop DTPA?).DTPA?).

Chelation begun on day 2 with Ca-Chelation begun on day 2 with Ca-DTPA for the males and Zn-DTPA for DTPA for the males and Zn-DTPA for the female, and continued daily with the female, and continued daily with Zn-DTPA for 5-6 daysZn-DTPA for 5-6 days

Bioassay measurements continuedBioassay measurements continued

5252

Bioassay Results - Day 6Bioassay Results - Day 6 Patient #1 (supervisor, male):Patient #1 (supervisor, male):

• Lung content: 270 BqLung content: 270 Bq• Urine: 22 Bq per dayUrine: 22 Bq per day

Patient #2 (female):Patient #2 (female):• Lung content: 100 BqLung content: 100 Bq• Urine: 1.9 Bq per dayUrine: 1.9 Bq per day

Patient #3 (male):Patient #3 (male):• Lung content: 21 BqLung content: 21 Bq• Urine: 0.4 Bq per dayUrine: 0.4 Bq per day

5353

Averted DosesAverted Doses Patient #1:Patient #1:

• w/o DTPA: 210 mSvw/o DTPA: 210 mSv• w/ DTPA: 49 mSvw/ DTPA: 49 mSv

Patient #2:Patient #2:• w/o DTPA: 73 mSvw/o DTPA: 73 mSv• w/ DTPA: 38 mSvw/ DTPA: 38 mSv

Patient #3:Patient #3:• w/o DTPA: 17 mSvw/o DTPA: 17 mSv• w/ DTPA: 10 mSvw/ DTPA: 10 mSv