Index

A

Access. See Patient access to radiation medicine

Accreditation Council on Graduate Medical Education, 127

Administrative Procedure Act, 18, 177

Adverse events.

See also Misadministration

anesthesia, 123

blood transfusions, 123-124

data availability, 120-121, 153, 171

human error, 117

iatrogenic injury, 117

inappropriate and unnecessary care, 125-127

nonradiological medical interventions, 121-125

prescription drugs, 122-123

rates, 118 n.3, 124-125, 136

reduction strategies, 126-127

Agreement State Program (NRC)

administration, 3, 8-9, 19, 42

brachytherapy regulation, 73

costs, 19, 91, 108, 146, 177-178

establishment, 256

and Medical Use Program, 7, 28

and misadministrations, 118, 119

NRC oversight, 6, 8-9, 28, 85-86

participants and nonparticipants, 244-245

performance indicators, 86

and quality management rule, 84, 256

radionuclide regulation, 61

teletherapy regulation, 69-70

American Association for Nuclear Cardiology, 279

American Association of Physicists in Medicine, 73, 269, 273, 274, 275, 277, 280

American Board of Nuclear Medicine, 267, 268, 269, 272, 273, 275, 277, 279, 280

American Board of Radiology, 267-268

American Cancer Society, 64

American College of Medical Physics, 268, 274, 275, 277, 279

American College of Nuclear Physicians, 34, 267, 275, 277

American College of Radiology, 12, 34, 47, 67-69, 73, 90, 144, 145 , 165, 267, 269-270, 271, 272, 274, 275, 276, 277-278, 279, 280

American Medical Association, 268, 276



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Radiation in Medicine: A Need for Regulatory Reform Index A Access. See Patient access to radiation medicine Accreditation Council on Graduate Medical Education, 127 Administrative Procedure Act, 18, 177 Adverse events. See also Misadministration anesthesia, 123 blood transfusions, 123-124 data availability, 120-121, 153, 171 human error, 117 iatrogenic injury, 117 inappropriate and unnecessary care, 125-127 nonradiological medical interventions, 121-125 prescription drugs, 122-123 rates, 118 n.3, 124-125, 136 reduction strategies, 126-127 Agreement State Program (NRC) administration, 3, 8-9, 19, 42 brachytherapy regulation, 73 costs, 19, 91, 108, 146, 177-178 establishment, 256 and Medical Use Program, 7, 28 and misadministrations, 118, 119 NRC oversight, 6, 8-9, 28, 85-86 participants and nonparticipants, 244-245 performance indicators, 86 and quality management rule, 84, 256 radionuclide regulation, 61 teletherapy regulation, 69-70 American Association for Nuclear Cardiology, 279 American Association of Physicists in Medicine, 73, 269, 273, 274, 275, 277, 280 American Board of Nuclear Medicine, 267, 268, 269, 272, 273, 275, 277, 279, 280 American Board of Radiology, 267-268 American Cancer Society, 64 American College of Medical Physics, 268, 274, 275, 277, 279 American College of Nuclear Physicians, 34, 267, 275, 277 American College of Radiology, 12, 34, 47, 67-69, 73, 90, 144, 145 , 165, 267, 269-270, 271, 272, 274, 275, 276, 277-278, 279, 280 American Medical Association, 268, 276

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Radiation in Medicine: A Need for Regulatory Reform American National Standards Institute, 73 American Radium Society, 249 American Roentgen Ray Society, 34, 249, 267, 270, 272, 273, 274-275, 276, 278, 279, 280 American Society for Therapeutic Radiology and Oncology, 34, 268, 275, 278 American Society of Radiologic Technologists, 268, 272-273, 275, 276, 278, 279, 280 Americium-241, 100-101 Anesthesia, 123, 124 Angiography, 45-46, 192 Angioplasty, 45 n.3 Appropriateness of care, 125-127 Association of Health Services Research, 34 Association of University Radiologists, 34 Atomic Energy Act of 1954, as amended, 1, 8, 23-24, 28, 80, 85, 251 -252, 256 Atomic Energy Commission, 6, 27 n.6, 28, 61, 81, 82, 90, 251, 252, 256, 286 B Biologics Act of 1902, 79, 86 Blood transfusions, 123-124 Boron neutron capture therapy, 6 n.4, 41, 80 n.1, 108 Brachytherapy applications, 40, 64, 65 defined, 193 dose rates, 71, 72 misadministration, 24-25, 26, 83 overview, 70-72 patient outcomes, 68 radionuclides used in, 71-72 regulation and control, 7, 72-73, 84, 89 risks, 273 types of procedures, 72 utilization, 119 Breast cancer, 44, 63, 64, 69, 72 Bureau of Medical Devices, 254 Bureau of the Budget, 253 Byproduct material. See also Radionuclides defined, 23-24 n.3, 193 medical applications, 40, 27 n.7 C Cancer. See also Breast cancer; Prostate cancer; Radiation oncology cases, by site, 66 defined, 193 radiogenic, 69, 112-113, 134, 136, 287-288 Carter, President, 253 Cesium-137, 71 Chemotherapy, 124, 193 Cholecystogram, 45 Code of Federal Regulations, Title 10 Part 20, 9, 16, 61-62, 100, 161, 174, 202-211, 274 Part 30, 101 Part 35, 6, 9, 15-16, 17, 61-62, 70, 80, 81, 83, 105, 108, 144, 14 , 174-175, 176, 177, 212-243; see also Quality Management (QM) Rule Part 50, 286 Parts 170 and 171, 94 recommended revisions, 15-16, 18, 176-177 Code of Federal Regulations, Title 21 Part 900, 51-52 Part 1020, 52 Committee on Interagency Radiation Research and Policy Coordination , 253, 271 Committee on the Biological Effects of Ionizing Radiation, 286, 287 -288 Committee on the Pathological Effects of Atomic Radiation, 285 Computed tomography, 40, 43-44, 45, 47, 48, 57, 90, 193

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Radiation in Medicine: A Need for Regulatory Reform Conference of Radiation Control Program Directors evolution of, 30, 254, 256 funding, 149, 151, 155-156, 166, 175 Profile of State and Local Radiation Control Programs, 90 regulations, 52, 90 role, 4-5, 12, 16, 17, 18, 19-20, 21, 88-89, 143, 145, 149, 150 n.1, 156, 165-166, 170, 172, 177-178, 268, 280 Congress hearings on medical radiation regulation, 30-31 Joint Committee on Atomic Energy, 251, 285 recommendations to, 15-17, 20-21 Consumer-Patient Radiation Health Safety Act, 276-277 Coronary artery bypass graft, 125 Cost-benefit analysis, 36-37, 267 Costs of regulation and access to radiation medicine, 269 in alternative systems, 146, 177-178 federalization alternative, 159-160 fees, 37, 94-96, 102, 108, 142, 267 fines collected, 96, 98, 99, 108 full-time-equivalent employees, 94, 96 misadministration rule, 83 nonfee, 98, 100-102 Nuclear Waste Fund appropriations, 94 radioactive waste management, 101-102 recordkeeping requirements, 98, 100 reforms in, 102-104 savings from deregulation (estimated), 102, 103 security requirements, 100-101 separation of, 18-19 Council of State Governments, 19, 90, 178, 256 Council on Radionuclides and Radiopharmaceuticals, 267, 275 Cyclotrons, 40, 41, 53, 194 D Dana-Farber Institute, 117 de Planque, E. Gail, 124 Department of Defense, 4, 142, 154, 157, 166, 254 Department of Education, 278-279 Department of Energy, 3, 61, 79, 94, 149, 252, 287 Department of Health and Human Services accreditation standards for radiologic personnel, 30 authority, 3, 14 oversight shifted to, 10, 16-17, 156, 158, 159, 160, 161, 271 recommended role, 16-17, 20, 151, 166, 175 Department of Transportation, 3, 4, 16, 61, 73, 79, 142, 147, 149, 157, 160, 172, 175 Department of Veterans Affairs, 4, 121, 142, 154, 157, 166 Diagnostic nuclear medicine. See also Radiopharmaceuticals misadministrations, 118, 119 radiation doses, 56, 57, 61 regulation and control, 61-62 types of procedures, 40, 52-55 utilization rates, 55, 57, 118 Diagnostic uses of ionizing radiation. See Nuclear medicine; Radiology Dose. See Radiation dose Drug Amendments of 1962, 86-87 DuPont Merck, 268 Dynamic conformal radiation therapy, 64 Dysprosium-165, 74 E Education and training accreditation, 276-279

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Radiation in Medicine: A Need for Regulatory Reform health care professionals, 126-127, 152 n.2, 255, 272-273 patient, 273 public, 145, 153 recertification and ongoing training, 279 and risk, 272-273 Eisenhower, President, 251-252, 253 Embolotherapy, 45 n.3 Energy Reorganization Act of 1974, 28, 252 Energy Research and Development Agency, 61, 252 Environmental Protection Agency, 3, 4, 16, 61, 79, 88, 142, 160, 172, 175, 253, 254, 255, 286 Exposure to radiation. See also Radiation dose ALARA concept, 105, 115, 172, 274, 285, 286 assessment, 112 background, 42, 50 criteria and standards, 89, 105, 106-107 entrance skin air kerma index, 42, 48, 49 entrance skin exposure index, 39, 42 human studies of, 113-114 low-level, 112-113, 115 measures of, 39, 42, 50 n.4 occupational, 52 unintended, 116-117 External beam x-ray therapy, 40 F Federal Food, Drug, and Cosmetic Act of 1938, 86, 145, 255 Federal Radiation Council, 253, 271, 285 Florida State Department of Health and Rehabilitative Services, 268 , 270, 273, 275, 276, 278, 279 Fluoroscopy, 40, 43, 50, 104 n.8, 128, 195 Food and Drug Administration Adverse Drug Reaction Voluntary Reporting Program, 122 authority, 3, 4, 12, 16, 17, 70, 79, 86-89, 142, 146, 172, 175, 271 Bureau of Radiologic Health, 29-30, 254 Center for Biologics Evaluation and Research, 123 Center for Devices and Radiological Health, 17, 29-30, 33, 50 n.4, 159, 175, 254-255 NRC cooperation with, 18, 33, 88, 145, 176 proposed roles, 145, 147, 149, 156-157, 177 radiation dose tables and codes, 42 reporting requirements, 120, 122, 145, 153, 294 utilization surveys, 47 G Gallium-67, 53, 61 Gamma camera, 53, 54-55 General Accounting Office, 8, 35, 82, 86, 120, 257 German Roentgen Society, 249 GI series, 45 Glenn, John (NRC), 124 Glenn, John H., 1, 23, 30, 31 Gold-198, 72, 74, 82 H Harvard Medical Practice studies, 117, 122 Health Care Financing Administration, 5, 123, 142, 147 Health Finance Agency (hypothetical), 10-11, 161-162, 163-164 Health Physics Society, 272, 274 Hearings. See Public hearings Hodgkin's disease, 69 I Illinois Department of Nuclear Safety, 269 Illinois, State of, 267, 268, 273, 274, 276-277, 278-279, 279, 280

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Radiation in Medicine: A Need for Regulatory Reform Indiana Regional Cancer Center, 25 Indium-111, 61 Injury. See Radiation injury International Atomic Energy Agency, 73 International Commission on Radiological Protection, 42, 112, 114, 115, 250, 251, 274, 286 Intraluminal thrombolytic therapy, 45 n.3 Intraoperative radiation therapy, 63 Iodine-123, 53 Iodine-125, 26, 71, 72, 84 Iodine-131, 53, 57, 62, 74, 75, 84 Ionizing radiation in medicine benefits/applications, 3, 26-27, 39, 40-41, 52-55, 62-63, 171, 172 -173, 291 defined, 24, 195-196 source-specific regulation, 15, 16, 24, 36, 75, 173-174 units, 250 Iridium-192, 25, 71, 72 Isotopics, 34 J Joint Commission of the Accreditation of Healthcare Organizations, 18, 20, 50 n.4, 84, 121, 122, 144, 145, 177, 274-275, 276 K Kansas, State of, 274, 280 Kentucky, State of, 268 L Legislation federal; see individual statutes state, 19-20 Leukemia, 69 Lewis, E. B., 285 Linear accelerators, 26, 29, 37, 40, 41, 63-64, 70, 105, 119, 196, 268, 273 M Magnetic resonance imaging, 41, 43, 44, 45, 47, 48, 57, 196, 272 Mallinckrodt Medical Inc., 267 Mammography, 12, 26, 44, 51, 274 Mammography Quality Standards Act, 37, 51-52, 88, 90, 142, 151, 158 , 165, 255 Manhattan Project, 61, 196, 250 Manufacture of byproduct material, 13, 16, 151, 152, 154, 165-166, 175 of equipment, 51 Medicaid, 4, 147, 161 Medical Device Amendment, 87, 255. See also Safe Medical Device Act Medical Use Program (NRC) administration, 6, 27-28, 80-81 Agreement States and, 7, 28, 81, 172 elimination of, 4, 15-16, 144-145, 173, 174-175, 296, 297 n.14 enforcement, 7, 17, 81, 98-100, 144, 295 inspections, 6-7, 81 internal review, 1, 31 Institute of Medicine review, 1, 2, 24, 27, 30-37 reporting requirements, 18, 121, 144, 176, 294, 295 responsibilities and activities, 28-29, 80 sanctions, 7, 81, 96, 98, 99, 108 scope, 5-6, 80-81 violations, 7; see also Misadministration Medicare, 4, 147, 161 Meetings. See Public meetings Misadministration. See also Adverse events causes, 83 defined, 1 n.1, 23 n.1, 62, 82, 83, 197, 269 examples, 25-26, 84 human error, 117 Indiana, Pennsylvania, incident, 1, 2, 23, 24-25, 27, 152 investigation, 152

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Radiation in Medicine: A Need for Regulatory Reform notification of patients, 295-296 rates, 17, 18, 37, 39, 83, 104, 117-121, 136, 143, 270, 272, 292-293 reporting, 8, 70, 73, 82-83, 84, 86, 88, 119 n.4, 153, 269-270, 292 n.5, 294, 295 rule, 82-84 Models/modeling linear, no-threshold, 112-113, 115, 116, 128, 136, 196, 251, 284-288 linear-quadratic, 287 tolerance dose, threshold, 114 Morgan, K. Z., 285 Myelogram, 45 N Naturally occurring and accelerator-produced radioactive materials (NARM) defined, 2 n.2, 24 n.5, 197 jurisdiction over, 28, 36, 89, 90, 92-93, 146, 154, 158, 293 medical applications, 40 National Advisory Committee on Radiation, 254 National Bureau of Standards, 250 National Center for Radiological Health, 254 National Council on Radiation Protection and Measurements, 34-35, 46, 50, 57, 73, 112, 114, 115, 160, 250, 251, 253, 256, 274, 284, 286 National Electrical Manufacturers Association, 267-268, 270, 271, 274, 275, 278 National Institute of Standards and Technology, 73 National Institutes of Health, 153 National Physical Laboratory (Great Britain), 250 National Research Council Committee on the Biological Effects of Ionizing Radiation, 112, 115 National Science and Technology Council, 271 National Transportation Safety Board, 152 Nationwide Evaluation of X-Ray Trends program, 90 New York Hospital-Cornell Medical Center, 267, 269, 273, 278, 279 New York State Department of Health, 267-268, 274 Nixon, President, 253 North Carolina State Department of Environment, Health and Natural Resources, 267-268 North Shore University Hospital, 267, 276 Nuclear imaging, 53-54 Nuclear medicine. See also Brachytherapy; Diagnostic nuclear medicine; Radiation oncology; Teletherapy; Therapeutic nuclear medicine benefits, 3 defined, 197 dosage levels, 56, 57, 61 NRC regulation of, 29 therapeutic applications, 40 Nuclear power, 129, 130, 131-132, 134, 136, 251-252, 255, 293 Nuclear Regulatory Commission (NRC). See also Agreement State Program; Costs of regulation; Medical Use Program; Regulation and control adequacy of regulation, 290-291 Analysis and Evaluation of Operational Data, office for, 83 authority, 3-4, 13, 16, 23-24, 28-29, 30, 61, 69-70, 73, 79, 80-86, 141, 142, 144, 147, 151, 152, 154, 159, 165-166, 175, 256-257, 262 , 297 Authorized Nuclear Pharmacy Rule, 278

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Radiation in Medicine: A Need for Regulatory Reform Food and Drug Administration cooperation with, 18, 33, 88, 145, 176 Final Statement of Principles and Policy for the Agreement State Program, 8-9, 86, 257 history, 251-252, 287 licensing of health care personnel, 126-127 Management Review Board, 85, 256-257 Medical Use Policy Statement, 17, 32, 82, 176, 294 Nuclear Medicine Safety and Safeguards division, 28 Office of Nuclear material Safety and Safeguards, 83 Office of Policy and Planning, 120 recommendations to, 17-19, 21, 154, 176-178 request to IOM, 1, 2, 24, 27, 30-37, 262, 290-291 O Oak Ridge National Laboratory, 134, 251 Occupational Safety and Health Administration, 3, 52, 79, 160-161 Office of Management and Budget, 254 Oncology. See Radiation oncology Outcomes. See Patient outcomes Overuse of radiation medicine, 48 P Palladium-103, 71-72 Patient access to radiation medicine, 3, 147, 173, 269 Patient outcomes, 68 Performance indicators, 86, 120, 153 n.3, 257, 271 Pfahlerm, George, 249-250 Phosphorus-32, 74 Plaques, radioactive, 26 Prostate cancer, 64-65, 68-69, 72 Pollycove, Myron, 124 Positron emission tomography, 53, 198 Prescription drugs, 122-123 Public Health Service, 29, 90, 142, 154, 157, 166, 253-254 Public Law 83-703, 85 Public hearings participants, 265-266 scope of, 33 Public meetings announcement and request for testimony, 262-263 elements of, 33 invited organizations, 259-262 summaries, 266-280 topics, 264-265 Pure Food and Drugs Act of 1906, 79, 86 Pyelogram, 45 Q Quality assurance programs, responsibility for, 274-275 Quality Management (QM) Rule in Agreement States, 84, 256 costs of, 100, 108 intrusion into practice of medicine, 4, 18, 142, 269, 294-295 objectives, 7, 36, 85 Part 35 provisions, 6, 81, 84-85 program requirements, 62, 70, 73, 84, 269-270 Quality of care, 13, 17, 34 R Radiation Control for Health and Safety Act, 29, 87, 254 Radiation dose annual limit on intake, 100-101 brachytherapy, 71, 72 calculation, 42 collective, 42, 48, 50-51, 57, 61, 69 defined, 194 determinants, 48, 50 n.4 dose-response assessment, 112 effective dose equivalent, 42, 48, 49, 50, 57, 69, 193, 194, 251

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Radiation in Medicine: A Need for Regulatory Reform maximum permissible, 196, 251, 253, 284 nuclear medicine procedures, 56, 57 patient-specific, 49-50, 57 radiation oncology, 65, 69 radiation protection guides, 253 radiology, 46-48 roentgens, 250 threshold, 114, 115 tolerance, 114, 250, 251 utilization and, 51 Radiation injury. See also Misadministration acute, 113, 192 iatrogenic, 117 late, 113, 115, 196 models of, 114-115 Radiation oncology dose, 65, 69 defined, 198 examples of clinical use, 64-66 facilities and equipment, 67-68 general approach, 62-63 misadministrations, 118 outcomes, 68 palliative treatment, 63, 65, 198 Patterns of Care Studies, 67-69 regulation and control, 69-70 and secondary cancer, 69 therapeutic nuclear medicine, 74, 119 utilization rates, 65-69, 118, 119 Radiation Policy Council, 253 Radiation protection history of, 114-115, 249-257 private and voluntary involvement in, 172, 177, 249-251; see also individual organizations standards, 274, 286-287 Radiation safety officers, 98, 100-102, 105 Radiation synoviorthesis, 74 Radioactive waste management costs of, 101-102 half-life and, 55 n.5 risk perceptions, 131-132 Radiography, 40. See also Mammography contrast studies, 45-46 conventional examinations, 44 physical principles, 43 utilization rates, 45 Radioimmunotherapy, 74 Radiological Society of North America, 35, 267, 270, 272, 275, 278 Radiology. See also Computed tomography; Fluoroscopy; Radiography benefits, 3, 26-27 nonhospital-based, 47 radiation doses, 48-51 regulation and control, 51-52 types of procedures, 43-46 utilization rates, 46-48 Radionuclides accelerator-produced, 40, 60-61, 73, 80, 92-93 annual limits on exposure, 100-101 biomedical applications, 58-61 brachytherapy, 71-72 defined, 2 n.2, 24 n.5, 199 half-life, 54-55, 71, 74 licensing, 62 reactor-produced, 58-59 regulation and control of, 61-62 risks from, 14-15, 75 in therapeutic nuclear medicine, 65, 73-74 transportation of, 79 Radiopharmaceuticals applications, 40 defined, 52-53, 199 misadministration, 83 regulation, 88 standards, 91 tracer compounds, 53 Radium, 40, 80 Radium-226, 71 Radon, 131, 132 RAND Corporation, 125 Reagan, President, 253 Recommendations to Conference of Radiation Control

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Radiation in Medicine: A Need for Regulatory Reform Program Directors, 19-20, 21, 178, 179 to Congress, 15-17, 20-21, 174-175 to NRC, 17-19, 21, 176-178 NRC-requested, 32-33 to states, 19-20, 21, 178 Regulation and control. See also Costs of regulation; Nuclear Regulatory Commission adequacy of safeguards, 266-268 administrative requirements, 105, 108 brachytherapy, 72-73, 84 chronology, 246-248 cobalt teletherapy, 84 committee concerns, 116 diagnostic x-rays, 51 fragmentation and disproportionality in, 105, 144, 146, 171 goals, 77-78, 173, 179 of health care delivery, 78-79 professional self-regulation, 249-251 radiation oncology, 69-70 radionuclides and radiopharmaceuticals, 61-62 report premises, 170 and risks from radiation, 14-15, 16, 24, 31, 37-38, 75, 111, 128, 132, 143, 170, 171, 272-273, 279-280, 291-292 therapeutic nuclear medicine, 75, 84 Regulations. See Code of Federal Regulations Regulatory systems. See also Regulation and control alternative, 9-14, 143-167 assessment of, 162-167 criticism of, 104-108, 141-142 evolution of, 29-30 federal limited authority, 12, 156-158, 165 federal centralized authority, 11, 158-161, 164, 270-272 framework (current), 3-9, 78-91 Health Finance Agency approach, 10-11, 161-162, 163-164 market-based (laissez faire) approach, 9-10, 146-148, 163 overlapping jurisdictions, 88 sources of ionizing radiation and, 15, 16, 24, 36, 75, 173-174 state regulation exclusively, 11-12, 148-151, 164-165 state regulation with federal guidance, 12-14, 15-22, 151-156, 165 -167, 174-180, 296-298 status-quo alternatives, 10, 143-146, 163 Research, radiation medicine, 153 Risks from radiation. See also Adverse events; Misadministration assessment, 111-116, 127-128, 136 asymmetry principle, 134 characterization, 112; see also Models/modeling coefficients, 51, 199 communication and trust, 133-134, 163 comparisons, 124-125, 133 dread factor, 129, 136 education and training and, 272-273 nuclear power, 129, 130, 131-132, 134, 136 patient education, 273 psychometric paradigm, 129 public perceptions of, 128-135, 153 radon, 131, 132 regulation and, 3, 14-15, 16, 24, 31, 37-38, 75, 111, 128, 132, 143 , 170, 171, 272-273, 279-280, 291-292 ''signal value" of events, 133 source of exposure and, 130-131 unintended exposures, 116-117, 127 unknown factor, 129, 136 x-rays, 129, 130, 132 Riverside Methodist Hospital, 82

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Radiation in Medicine: A Need for Regulatory Reform S Safe Medical Device Act, 29, 70, 88, 156-157 Selin, Ivan, 31 Single photon emission computed tomography, 54 Sloan-Kettering Memorial Cancer Center, 279 Society for Nuclear Medicine, 35, 267 Society of Medical Physics, 35 State regulation. See also Agreement State Program authority and responsibility, 88-91, 170 brachytherapy, 73 federal assistance to, 152 fees, 91 framework, 79-80 history, 255-257 legislative authority for licensing and registration, 92-93 proposed roles, 147, 148-158, 164-165, 167 radiography, 51, 52 radiation health programs, 30 recommendations to, 19-20, 21, 178-179 teletherapy, 69-70 Stereotactic radiosurgery, 63-64, 65 Strontium-89, 74 Strontium-90, 72 Suggested State Regulations for the Control of Radiation, 4-5, 12, 16, 19, 52, 90, 149, 150, 152, 154, 156, 157, 165, 170, 172, 178, 256 Syncor, 267, 271, 272, 274, 278 T Taylor, Lauriston, 250 Technetium-99m, 53, 55 Teletherapy applications, 40 cobalt, 68, 70, 82, 84, 273 defined, 200 general approach, 63, 72 misadministration, 25-26, 82, 83 regulation, 7, 69-70, 84, 89, 273 utilization, 119 Texas Department of Health, 267, 270, 273, 274 Thallium-201, 53, 61 Therapeutic nuclear medicine misadministrations, 118, 119 overview, 73-74 radionuclides used for, 74-75 regulation and control, 7, 75, 84, 89 types of procedures, 74 utilization, 118 Three Mile Island accident, 132, 136 Tracer principle, 53 U Ultrasound, 41, 43, 45, 47, 48, 272 United Nations Scientific Committee on the Effects of Atomic Radiation , 115, 284-285, 288 United States Pharmacopoeia, 91, 118 n.2 University of Chicago Hospital, 117 Utilization rates dose and, 51 nuclear medicine procedures, 55, 57, 118 Patterns of Care Studies, 67-69 radiation oncology, 65-69, 118 radiology, 45, 46-48, 51 W Washington Hospital Center, 84 Washington State Department of Health, 267-268, 280 Waste disposal. See Radioactive waste management X Xenon-133 X-ray defined, 200 equipment, 51, 52, 200, 250 procedures, 27 n.7, 40 risk perceptions, 129, 130, 132 standards, 89, 255, 273