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Submitted by Silvia Maria Velasques de Oliveira, Institute of Radiation Protection and Dosimetry, Brazil
   Commenting as an individual
Document Recommendations
 
SPECIFIC COMMENTS ABOUT MEDICAL EXPOSURES

1) Justification of radiological procedures (subtopic 6.1):
Are there three levels of justification (#191) or only two (# 247)?
My feeling is that physicians don't understand these concepts because "speficity", "sensibility" and "predictive value" are their "general justification". In a strict sense, personnal history and health status of each patient constitutes "individual justification". So, it would be better recommend that "the protocols may adopt procedures using radiation when there are sufficient knowledge about their speficity and sensibility" (first level of justification). Among justified protocols, a specific procedure not justified before may be used due to the clinical status of a specific patient and requested by the physician (second level of justification)".

2) Diagnostic regerence levels (subtopic 6.2.1):
I suggest to include this statment: "For nuclear medicine procedures, the maximal usual activity for each procedure can vary also according to the patients clinical conditions, the clinical question and the protocol and instrumentation used" (IAEA, 2005).
It is important to consider not only adults exposures, but children exposures, since these are bigger and more dangerous to future generations. "For paediatric patients, the dosage should be modified according to age and/or weight (IAEA, 2005).
Maybe is it time to change from "diagnostic reference levels"t o "guidance levels" ?
I think that is import to garantee that regulatory authorities not confund the concept of "reference levels" with limits. Also, it is import to point out the qualitative approch, not specific values for all countries.

3) Add to subtopic (6.3) Exposure of pregnant patients, recommendations of cessation of breast feeding following administration of various radiopharmaceuticals (ICRP Publication 84, 2000).

4) Add recommendations on education and training in medical exposures, with special emphasis on medical staff, in order to really implement the justification principle.

5) Add recommendations on quality assurance in medical exposures, either by operators and by regulatory agencies, for instance, establishing internal audits and practical systems for assuring compliance with standards and good practice.

6) Release of patients (subtopic 6.5):
"The decision to hospitalise or release a patient after therapy should de made on an individual basis" (# 276).
In developing countries like Brazil, social aspects and health and geographical inequities should also be considered since there are limited resources for hospitalisation. Regulatory authorities may balance the radiation risks of releasing patients against the benefits of increasing health public assistance.