Reported Radiation Overexposure Accidents Worldwide, 1980-2013: A Systematic Review

Abstract

Background

Radiation overexposure accidents are rare but can have severe long-term health consequences. Although underreporting can be an issue, some extensive literature reviews of reported radiation overexposures have been performed and constitute a sound basis for conclusions on general trends. Building further on this work, we performed a systematic review that completes previous reviews and provides new information on characteristics and trends of reported radiation accidents.

Methods

We searched publications and reports from MEDLINE, EMBASE, the International Atomic Energy Agency, the International Radiation Protection Association, the United Nations Scientific Committee on the Effects of Atomic Radiation, the United States Nuclear Regulatory Commission, and the Radiation Emergency Assistance Center/Training Site radiation accident registry over 1980-2013. We retrieved the reported overexposure cases, systematically extracted selected information, and performed a descriptive analysis.

Results

297 out of 5189 publications and reports and 194 records from the REAC/TS registry met our eligibility criteria. From these, 634 reported radiation accidents were retrieved, involving 2390 overexposed people, of whom 190 died from their overexposure. The number of reported cases has decreased for all types of radiation use, but the medical one. 64% of retrieved overexposure cases occurred with the use of radiation therapy and fluoroscopy. Additionally, the types of reported accidents differed significantly across regions.

Conclusions

This review provides an updated and broader view of reported radiation overexposures. It suggests an overall decline in reported radiation overexposures over 1980-2013. The greatest share of reported overexposures occurred in the medical fields using radiation therapy and fluoroscopy; this larger number of reported overexposures accidents indicates the potential need for enhanced quality assurance programs. Our data also highlights variations in characteristics of reported accidents by region. The main limitation of this study is the likely underreporting of radiation overexposures. Ensuring a comprehensive monitoring and reporting of radiation overexposures is paramount to inform and tailor prevention interventions to local needs.

About the Authors:

Karen Coeytaux

* E-mail: [email protected]

Affiliation: Episight Consulting, Summit, New Jersey, United States of America

Eric Bey

Affiliation: Plastic and Reconstructive Surgery Department, Percy Military Hospital, Clamart, France

Doran Christensen

Affiliation: Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee, United States of America

Erik S. Glassman

Affiliation: Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee, United States of America

Becky Murdock

Affiliation: Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee, United States of America

Christelle Doucet

Affiliation: Celogos, Paris, France

Introduction

Radiation overexposure accidents are uncommon, but can have severe long-term health consequences. Radiation is used in various settings. Major sectors include industrial, medical, and military. Some key applications are electricity production, sterilization of material equipment or food, development of nuclear weapons, radiography imaging techniques for welds inspection, radiation therapy, and radiology imaging techniques (e.g. X-ray radiography, fluoroscopy, computed tomography). These last decades, the medical sector in particular experienced a fast growth in the use of ionizing radiation that allowed better diagnostics and treatments [1–2]. In order to guide all facets of prevention, it is critical to understand the reasons and events behind radiation overexposures.

Radiation-related harms have been reported over the years in all sectors, along with those resulting from orphan sources. Harmful effects of radiation overexposure include deterministic effects (e.g. radiation sickness, skin radiation burn, cataracts, infertility) and stochastic effects (e.g. cancer). These effects can take from weeks to years to manifest, with severity depending upon multiple parameters including the total radiation absorbed dose, the radiation dose rate, the volume of body exposed, the parts of the body and tissues involved, the radiation source at stake, as well as personal characteristics of overexposed people (e.g. age, health status) [3].

Furthermore, local and global overexposures to the body translate into different health outcomes and therefore different treatment needs. Global overexposure of 1 Gray (Gy) or above induces acute radiation syndrome (ARS) characterized by consecutive hematopoietic, gastrointestinal, and neurovascular syndromes [3]. Local skin overexposures of 3 Gy or more are likely to lead to acute local radiation injuries (LRI), which may be associated with extreme pain. Local organ overexposures of typically 2–8 Gy are likely to result in organ dysfunction (e.g., permanent sterility of ovaries and testes, acute pneumonitis, renal failure, cognitive defect) [4]. In addition, this type of injuries often progresses over time due to inflammatory waves, inducing the spread of radionecrosis, and requires long-term treatment [5].

In order to decrease the risk of harm associated with ionizing radiation, its use is often regulated at the country level. At the international level, the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR), the International Atomic Energy Agency (IAEA), and the International Commission on Radiological Protection (ICRP) play a central role. They evaluate radiation risks, provide recommendations, and promote safe use of radiation technologies, which evolve rapidly and gain in complexity. Yet, in an era where resources are scarce, it is essential to identify the most pressing issues in order to better target prevention actions such as training, which can lead to dramatic improvements in the safe use of radiation [6].

Several non-systematic reviews of radiation overexposure accidents have been published in the literature. The UNSCEAR organization performed the most extensive review, which it considers "a sound basis for conclusions regarding the number of significant radiation accidents that have occurred, the corresponding levels of radiation exposures and number of deaths and injuries, and the general trends for various practices", despite unavoidable underreporting [7]. Additionally, several voluntary registries of radiation overexposures have been developed. The Radiation Emergency Assistance Center/Training Site (REAC/TS) at the US Department of Energy's (DOE) Oak Ridge Institute for Science and Education (ORISE) maintains the largest US national and international radiation accident registry to our knowledge [8]. Other registries focus only on the medical sector. For example, the Radiation Oncology Safety Information System (ROSIS) and Safety in Radiation Oncology (SAFRON) register incidents and near incidents in radiation therapy [9–10].

To build further on the existing work and provide new information on characteristics and trends of reported radiation accidents worldwide, we performed a systematic review of reports published between 1980 and 2013 by querying the peer-reviewed literature, national and international reports, and the REAC/TS registry. Our objective was to evaluate the impact of past prevention programs and potential remaining needs for prevention planning. In this report, we present the search strategy and results of our review, and a descriptive analysis of the retrieved radiation overexposure accidents.

Methods

Sources

A protocol was developed for the conduct of this systematic review and is detailed in S1 PRISMA Checklist and S1 Protocol.

Reported radiation overexposure accidents from 1980 to present were searched using MEDLINE, EMBASE, the IAEA publications, the congress proceedings of the International Radiation Protection Association (IRPA), the collection of UNSCEAR reports, the United States Nuclear Regulatory Commission (US NRC) reports on abnormal occurrences, and the REAC/TS registry.

For the purposes of this review, we elected to use the IAEA definition of accident, which is "Any unintended event, including operating errors, equipment failures or other mishaps, the consequences or potential consequences of which are not negligible from the point of view of protection or safety" [11]. Our study focused on radiation accidents resulting in one or several people overexposed and meeting our inclusion and exclusion criteria.

Search strategy

We conducted an electronic search in MEDLINE and EMBASE on March 27th 2014 for all relevant articles published since January 1^st 1980, in the English or French languages. The MEDLINE search strategy included a first keyword search in titles using: cause of overexposure (radiation, nuclear) AND type of injury (overexpos*, accident*, injur*).

A second keyword search in titles was performed as follows: cause of interventional radiology overexposure (fluoroscop*, diagnostic, imaging, angioplast*, catheter*, coronar*, arter*, endovasc*, cardiac, stent*, cardiol*, shunt*) AND type of injury (radiodermatitis, "radiation dermatitis", radionecrosis, "radiation necrosis", "radiation injury", "radiation injuries", "radiation effect", "radiation effects", erythem*, "radiation-induced skin", “skin injury", “skin injuries", ulceration) NOT (erythematosus or lupus).

The third search was based on the following Mesh terms: (("Radiodermatitis"[Mesh] OR "Acute Radiation Syndrome"[Mesh] OR ("Radiation Injuries/mortality"[Mesh] OR "Radiation Injuries/radiation effects"[Mesh] OR "Radiation Injuries/radiography"[Mesh] OR "Radiation Injuries/radionuclide imaging"[Mesh] OR "Radiation Injuries/radiotherapy"[Mesh]) OR ("Radiotherapy, Computer-Assisted/adverse effects"[Mesh] OR "Radiotherapy, Computer-Assisted/mortality"[Mesh]) OR "Radiotherapy, Image-Guided"[Mesh] OR "Whole-Body Irradiation/adverse effects"[Mesh] OR "Fluoroscopy/adverse effects"[Mesh])) AND ("case reports"[Publication Type] OR "review"[Publication Type]) AND "humans"[Mesh].

The EMBASE search strategy used the following words of major interest: 'radiation accident'/exp/mj OR 'radiation injury'/exp/mj OR 'acute radiation syndrome'/exp/mj OR 'radiation dermatitis'/exp/mj OR 'radiation sickness'/exp/mj OR 'radiation necrosis'/exp/mj AND [humans]/lim AND ([english]/lim OR [french]/lim) AND [1980–2014]/py AND [embase]/lim NOT ([medline]/lim AND [1980–2014]/py OR 'radiation recall' OR 'pneumonitis'/exp/mj OR 'nephrititis' OR 'efficacy' OR 'trial' OR 'sodium arsenite'/exp/mj OR 'neurofibromatosis'/exp/mj OR 'cisplatin'/exp/mj OR 'vinorelbine'/exp/mj OR 'enteritis'/exp/mj OR 'experimental' OR 'bevacizumab'/exp/mj OR 'chemoradiotherapy'/exp/mj OR 'simvastatin'/exp/mj OR 'cetuximab'/exp/mj OR 'cefotetan'/exp/mj OR 'gemcitabine'/exp/mj).

Reference titles and summaries were screened manually and discarded if not relevant. Selected publications were read in full text for data extraction. Cross-referencing was used to retrieve additional relevant articles.

The IAEA publications (nuclear safety reviews, safety reports series, and non serial publications on radiological accidents from 1980 to 2013), the IRPA congress proceedings(1980–2008), the UNSCEAR reports (1980–2013) and the US NRC reports to congress on abnormal occurrences (1980–2012) were systematically read in full text and extracted when relevant.

Finally, radiation overexposure accidents that occurred on or after January 1^st, 1980 and reported in the REAC/TS registry were retrieved using filters against our inclusion criteria. Full reports were read for retrieved cases and extracted if relevant.

Inclusion and exclusion criteria

A case of radiation overexposure was defined as presenting at least one of the following criteria: (i) unintended global overexposure of 1 Gy or more, (ii) unintended local skin overexposure of 3 Gy or more, (iii) unintended local organ overexposure (e.g. brain, thyroid, prostate) of 5 Gy or more, or (iv) description of clinical presentation providing reasonable index of suspicion for unintended ionizing radiation overexposure (i.e., acute radiation syndrome, radiodermatitis, permanent alopecia, dry or moist desquamation, blister formation, skin ulceration, dermal atrophy, invasive fibrosis, organ failure, radio-necrosis). The thresholds used in this review are based on the literature, keeping in mind that these thresholds are not absolute boundaries [3], [4], [12–18]. Cases that met none of these criteria were excluded, as were suicide and criminal acts.

For cases without occurrence date, we used date of first symptoms as first proxy and date of report as second proxy.

Finally, similar cases issued from different reports but with insufficient information to decipher whether they were different or not, were not integrated in the database to prevent duplicates.

Selection process

Two independent researchers screened and reviewed data sources against the inclusion criteria. For selected reports, full-text documents were evaluated and extracted manually by one reviewer and double-checked by a second reviewer. Any divergence between reviewers regarding selection process was resolved through discussion.

Extracted data items

For each accident, select information was extracted into a data sheet. Selected data included date and place of occurrence, number of overexposed people and number of people dying from their overexposure, days between exposure and death, type of overexposed people (i.e., patient, public, or worker if dose was received in the course of employment), estimated global and local dose received, type of source, type of overexposure (i.e., local skin, local organ, or global), and documents in which the accident was reported. Reported symptoms, course of treatment, and treatment outcomes were also recorded when available. Finally, accidents were categorized by sector of occurrence: "industrial" including industrial irradiator, production, and radiography; "radiation therapy" including teletherapy, brachytherapy, and therapeutic nuclear medicine; "fluoroscopy" used to support diagnostic and interventional radiology; "military" (e.g. nuclear testing, submarine accidents), and "orphan sources" for overexposures caused by sources fallen outside of regulatory control [19]. A category "others" included overexposure accidents resulting from scientific experiments and unknown causes. For cases with incomplete information, missing data were reported as unknown in our extraction sheet.

Quality of selected articles and reports

Only cases published in peer-reviewed journals or reported by official experts in radiation management (e.g., IAEA, US NRC, UNSCEAR, REAC/TS) were considered, to ensure the quality of the study. Furthermore, all sources selected for data extraction addressed our review question, which was to understand the characteristics of reported radiation overexposure accidents worldwide and their evolution between 1980 and 2013. Among these, only sources showing evidence of radiation overexposure, as defined in our inclusion criteria, were considered for extraction.

Analysis

Our extraction sheet was used to assess the distribution of reported radiation overexposure accidents along recorded items and over time.

Results

Study selection process

Out of 5189 articles and reports identified, 296 met our eligibility criteria and were extracted (Fig. 1). In addition, 194 records of the REAC/TS radiation accidents registry also met our eligibility criteria and were considered for data extraction. 70 of these 194 records were not reported in any other data source considered for this review. For the period 1980–2013, 634 reported radiation overexposure accidents were identified, encompassing 2390 overexposed people, of whom 190 (8%) died from their overexposure.

[Figure omitted. See PDF.]

Fig 1. PRISMA flow chart.

Search strategy for retrieving reported radiation overexposure accidents worldwide, 1980–2013.

https://doi.org/10.1371/journal.pone.0118709.g001

Extracted cases were categorized by sector in which the accident occurred and by type of overexposure (Table 1).

[Figure omitted. See PDF.]

Table 1. Reported radiation overexposure accidents by sector and type of overexposure worldwide, 1980–2013.

https://doi.org/10.1371/journal.pone.0118709.t001

Characteristics of reported radiation overexposure accidents and evolution over time

Among the 634 reported radiation accidents identified, most of them occurred in the industrial sector (27%) and in the medical sector through the use of radiation therapy (32%) or fluoroscopy (31%) (Table 1). Reported accidents in radiation therapy were greater in terms of number of overexposed people (47%), followed by accidents in the industrial sector (22%), fluoroscopy (17%) and orphan sources (9%). Finally, the number of deaths resulting from radiation overexposure, was the greatest for accidents reported in radiation therapy (51%), followed by those reported in the industrial sector (24%) and accidents involving orphan sources (19%).

Over the 1980–2009 period, the number of reported radiation accidents and the number of overexposed people by decade exhibited an overall downward trend (Fig. 2a—b). The same trend held for each sector separately, except for accidents reported in radiation therapy and medical fluoroscopy. The number of reported radiation therapy accidents per decade increased along the three decades, however the number of overexposed people experienced an overall decrease within the same period. Moreover, the number of reported fluoroscopic accidents increased significantly from the decade 1980–1989 to 1990–1999. Then, while reported fluoroscopic accidents decreased during the decade 2000–2009, the number of overexposed people increased. While industrial and orphan sources accidents accounted together for most reported accidents between 1980 and 1989 (60%), their proportion sharply decreased afterwards, reaching 17% of reported accidents between 2000 and 2009. Radiation therapy and fluoroscopy accidents experienced the opposite trend and ultimately accounted for most reported accidents and most of overexposed people between 2000 and 2009 (respectively 80% and 87%).

[Figure omitted. See PDF.]

Fig 2. Reported radiation overexposure accidents worldwide and sector involved, 1980–2013.

(a) number of reported radiation accidents (b) number of reported overexposed people.^aPartial decade.

https://doi.org/10.1371/journal.pone.0118709.g002

Among reported overexposed people, patients represented the largest share (Fig. 3a). Additionally, the share of patients among overexposed people increased along the three decades 1980–1989 (44%), 1990–1999 (71%), and 2000–2009 (87%), while the share of public and workers decreased along the same period.

[Figure omitted. See PDF.]

Fig 3. Evolution of type of overexposed people and type of injuries in reported radiation accidents worldwide, 1980–2013.

(a) Type of overexposed people (b) Type of overexposure.^aPartial decade.

https://doi.org/10.1371/journal.pone.0118709.g003

Finally, the types of overexposure in reported accidents also changed (Fig. 3b). Among retrieved cases, the share of overexposures with a combined local skin and global overexposure decreased from 40% to 6% between the periods 1980–1989 and 2000–2009. The share of global radiation overexposures remained low (below 4%) since the 1980s. However, the share of local organ or local skin overexposures increased over the same period. Local skin overexposures had the highest share during 1980–2013 (46%).

Profiles of reported radiation overexposures by region

The number of cases retrieved varied greatly across geographic regions (Fig. 4). Altogether, North America, South America, Europe and North & Central Asia accounted for 90% of reported overexposures retrieved for the period 1980–2013. Furthermore, the distribution of sectors involved was different from one region to another. Among the four regions with the highest number of reported cases retrieved, the medical sector accounted for most radiation overexposures reported in North America (663 cases, 91%), Europe (642 cases, 93%), and South America (163 cases, 61%). Within the medical sector, the share of reported cases resulting from fluoroscopic overexposures was higher in North America (297 cases, 41%) compared to Europe (55 cases, 8%) and South America (1 case). In contrast, the leading sector of reported radiation overexposure was the industrial one in North and Central Asia (316 cases, 69%).

[Figure omitted. See PDF.]

Fig 4. Distribution of sectors involved in reported overexposed people by region, 1980–2013.

https://doi.org/10.1371/journal.pone.0118709.g004

Discussion

This review explored a wide array of information sources. It included the assessment of peer-reviewed literature, reports from key national and international organizations in radiation management, and the review of the largest international radiation accidents registry, REAC/TS, for the period 1980–2013.

This review showed that a limited and decreasing number of worldwide radiation accidents have been reported by decade since 1980 and that these accidents can be dramatic, as observed previously [271]. Furthermore, this review suggested that the characteristics of reported radiation overexposure accidents differ over time and across regions. These new findings are important for future interventions in radiation protection.

Overall downward trends

Our results indicated that the number of reported radiation accidents and overexposed people have decreased over the 1980–2013 period. This likely reflects the impact of continuous efforts in radiation protection. Along the years, the IAEA in conjunction with new ICRP recommendations, has updated safety standards [303]. In 1989, it introduced the Safety Standards Series, which includes Safety Fundamentals, Safety Requirements, and Safety Guides [304]. These standards are used to improve regulation and radiation protection worldwide [305]. For example, ample documentation including lessons learned from accidents in industrial radiography, guidance on safe work practices and training material, have been developed to promote safety prevention in the industrial sector [306–308]. The downward trend in reported radiation accidents could also reflect a decrease in the reporting level. However, this explanation is less likely as the decrease is not observed in all sectors.

Singularity of the medical sector

This review suggested that the medical sector accounted for most reported radiation overexposures along 1980–2013. Consistently, most reported cases involved patients and a local skin overexposure component.

Unlike other sectors, reported radiation therapy accidents increased along the three last decades, while the number of reported overexposed people tended to decrease. Still, for each decade, radiation therapy accidents represented the highest share of overexposed people.

This upward trend in reported radiation therapy accidents could result from improved reporting or growing use of radiation therapy. UNSCEAR estimated that 5.1 million of radiation therapy treatments were delivered annually worldwide over the 1997–2007 period compared to 4.7 million annually for the period 1991–1996 [158]. The introduction of new technologies (e.g., gamma knife, intensity modulated radiation therapy or IMRT) produced new types of accidental exposures and could also have contributed to this upward trend observed in reported radiation therapy accidents [309–310].

Furthermore, the average number of people involved per reported accident decreased from the 1980’s to the 2000–09 decade. This figure typically varies according to the cause of the accident. While some errors such as errors in treatment site or dose administered, affect a single patient, other errors such as software issue, calibration or treatment programming errors, can affect multiple patients before the issue comes to light. Error reporting systems such as ROSIS allow learning from the past through knowledge of near-misses, incidents or accidents and constitute essential prevention tools [311].

As the use of radiation therapy is expected to grow even more in the future, it is crucial to ensure high quality assurance standards in order to avoid the multiple possible errors in the course of treatment and thus optimize all benefits of radiation therapy [309–311].

This review also brings attention to medical fluoroscopy, which ranked second in number of reported accidents for 1980–2013. Corresponding reported radiation accidents increased significantly from the 1980s to the 1990s, and then decreased. This was consistent with the literature [17–18], [312]. This increase could reflect the expanded use of fluoroscopy since the 1990s. Although fluoroscopy was initially used primarily for diagnostic procedures, it then became widely used during therapeutic interventions (e.g. coronary angioplasty), as it provided a less invasive and costly solution than classic surgery [313]. Potential serious adverse effects of fluoroscopy, however, were rapidly encountered and acknowledged. In 1994, the FDA issued a warning following the reporting of several injuries resulting from the prolonged use of fluoroscopic procedures [312], [314]. Thereafter, the risks of cumulative radiation exposure through fluoroscopy have been documented. Also, important efforts to track and decrease patients' overall exposure to imaging radiation following the ALARA (As Low As Reasonably Achievable) safety principle were initiated worldwide and some programs have been implemented successfully at the sub-national level [315–317].

Of note, the increase in number of reported overexposed people through fluoroscopy from 1990–1999 to 2000–2009 despite the decrease in reported accidents over the same period, is primarily due to a single accident involving 206 patients. Its cause was an error in resetting a CT scan, which went undetected for 18 months [318]. This accident also accounted for about two thirds of reported fluoroscopic overexposure cases in North America.

Geographic differences

Our exploratory analysis suggests that the causes of reported radiation overexposure accidents differ across regions. One possible explanation relates to variations in radiation equipment and radiation use across countries. The review conducted by UNSCEAR for the period 1991–2007 emphasized that the level of X-ray equipment, radiological examinations, and radiation therapy differ greatly from one country to another and tend to be concentrated in a limited set of countries [158]. For example, during 1997–2007 three-quarters of all radiation therapy treatments were received in countries, which have at least one physician for every 1,000 people in the general population. Still, these countries only represented 24% of the overall surveyed population [158].

Additionally, differences in reporting by country could also account for the observed differences in causes of overexposure. For example, Baeza highlighted the lack of reports from developing countries when going through ROSIS [311].

Thus, these geographic differences should be monitored and accounted for in prevention strategies. Identifying specific needs and practical challenges in the implementation of the safety standards is cornerstone to adjust prevention efforts adequately and efficiently reduce the incidence of radiation injuries.

Challenges in reporting radiation injuries

The reporting of radiation overexposure injuries faces unique challenges even when a well-established regulation and a solid reporting system network are in place. Indeed, the latency period before the appearance of radiation-related adverse effects varies from days to years [5]. Thus, people can easily go undiagnosed or be misdiagnosed. Furthermore, radiation injuries are uncommon, which can contribute to diagnostic errors [17], [201]. Additionally potential lack of knowledge or access to reporting systems and fear of legal liabilities can be other causes of underreporting [7].

Another major difficulty rises for radiation overexposure accidents resulting from orphan sources or medical fluoroscopy. In these contexts, the exposed subjects often cannot directly relate their injuries to their radiation exposure as they are not aware that they have been exposed to radiation. Even among medical professionals performing procedures assisted by fluoroscopy, a lack of awareness of risks associated with radiation imaging can still exist [209], [244], [319]. Additionally, patients noticing their skin lesions usually seek advice from a dermatologist, but without necessarily providing information about their history of prior fluoroscopy. They might think this information irrelevant or simply forget it. This makes the diagnostic of radiation injury even more challenging for dermatologists [13], [16], [209], [215]. Thus, reported radiation accidents are undoubtedly underestimated.

Limitations

This review offers a solid basis of reported radiation overexposure accidents to inform radiation protection planning. Still, it has several limitations.

Our literature search only included publications written in English and French languages, which might introduce some publication bias. Moreover, our review was limited to sources of information that were publicly available, with the exception of the REAC/TS registry, which has limited public access. Hence, our review does not capture cases that are exclusively reported in private databases (e.g. hospital registries). Thus, our review likely underestimates the number of reported radiation accidents. Additionally, when the date of overexposure was not reported (125 cases out of 2390), date of first symptoms was used as first proxy (11 cases) and date of report as second proxy (114 cases). This might introduce some bias as symptoms can appear months or years following the overexposure. Finally, reporting country was also used as a proxy for country of occurrence when not mentioned explicitly (116 cases out of 2376 with some localization information).

Despite these limitations, this review captured reported radiation accidents in systematic and consistent way, enabling valuable analysis to support future prevention actions.

Conclusion

This systematic study updates and broadens the view of reported radiation overexposure accidents. It indicates that reported radiation overexposure accidents are rare and decreased from 1980–1989 to 2000–2009. However, their potential dramatic outcomes stress the importance of radiation protection regulations. This review suggests the greater share of the medical sector in reported overexposures, for which the use of radiation has become central and is expected to grow even more in the future. Thereby, it confirms the importance of quality assurance programs in radiation therapy and medical fluoroscopy.

Finally, this review suggests that the characteristics of reported accidents vary by geography and over time, and are thereby likely to require different interventions. A close reporting and monitoring of radiation overexposure accidents is of great value to inform and prioritize prevention interventions adequately and ultimately reducing further the incidence of these accidents.

Supporting Information

[Figure omitted. See PDF.]

S1 PRISMA Checklist.

https://doi.org/10.1371/journal.pone.0118709.s001

(PDF)

S1 Protocol.

https://doi.org/10.1371/journal.pone.0118709.s002

(PDF)

Acknowledgments

We thank Dr Andre Ulmann, MD, PhD, Chairman of HRA Pharma, France, for providing valuable and extensive comments on the document.

Author Contributions

Conceived and designed the experiments: KC EB DC ESG CD. Performed the experiments: KC BM EB CD. Analyzed the data: KC. Contributed reagents/materials/analysis tools: KC EB DC BM CD. Wrote the paper: KC EB DC ESG BM CD. Data collection: KC BM EB CD. Analysis and interpretation of the data: KC EB DC CD. Drafting article: KC. Critical review of the article: KC EB DC ESG BM CD. Final approval of the version to be published: KC EB DC ESG BM CD. Agreement to be accountable for all aspects of the work: KC EB DC ESG BM CD.

Citation: Coeytaux K, Bey E, Christensen D, Glassman ES, Murdock B, Doucet C (2015) Reported Radiation Overexposure Accidents Worldwide, 1980-2013: A Systematic Review. PLoS ONE 10(3): e0118709. https://doi.org/10.1371/journal.pone.0118709

References

1. . Holmberga O, Czarwinskia R, Mettler F. The importance and unique aspects of radiation protection in medicine. Eur J Radiol. 2010;76(1): 6–10. pmid:20638808

2. US Nuclear Regulatory Commission. Use of radiation. 2013. Available: http://www.nrc.gov/about-nrc/radiation/around-us/uses-radiation.html. Accessed 2015 Jan 28.

3. Mettler FA. Medical effects and risks of exposure to ionising radiation. Journal of radiological protection. J Radiol Prot. 2012;32(1): N9–N13. pmid:22395124

4. ICRP. ICRP Publication 118: ICRP Statement on Tissue Reactions and Early and Late Effects of Radiation in Normal Tissues and Organs—Threshold Doses for Tissue Reactions in a Radiation Protection Context, 1st Edition. Ann ICRP. 2012;41(1–2). pmid:23089033

5. IAEA. Diagnosis and treatment of radiation injuries. Safety Reports Series No. 2. Vienna: IAEA; 1998.

6. Carpeggiani C, Kraft G, Caramella D, Semelka R, Picano E. Radioprotection (un)awareness in cardiologists, and how to improve it. Int J Cardiovasc Imaging. 2012;28(6): 1369–1374. pmid:21850411

7. UNSCEAR Sources and effects of ionizing radiation. Volume II. Annex C: Radiation exposures in accidents. Report to the General Assembly; 2008. pp 1–43.

8. Oak ridge institute for science and education. Radiation Accident Registries. Available: http://orise.orau.gov/reacts/capabilities/radiological-incident-medical-consultation/radiation-accident-registries.aspx. Accessed 2015 Jan 28.

9. Cunningham J, Coffey M, Knöös T, Holmberg O. Radiation Oncology Safety Information System (ROSIS)-profiles of participants and the first 1074 incident reports. Radiother Oncol. 2010;97(3): 601–607. pmid:21087801

10. IAEA. Radiation protection of patients—SAFRON. Available: https://rpop.iaea.org/RPOP/RPoP/Modules/login/safron-register.htm. Accessed 2015 Jan 28.

11. IAEA. Glossary. Available: http://www.iaea.org/ns/tutorials/regcontrol/intro/glossarya.htm. Accessed 2015 Jan 28.

12. Aerts A, Decraene T, van den Oord JJ, Dens J, Janssens S, Guelinckx P, et al. Chronic radiodermatitis following percutaneous coronary interventions: a report of two cases. J Eur Acad Dermatol Venereol. 2003;17(3):340–343. pmid:12702082

13. Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair. Radiology. 2010;254(2): 326–341. pmid:20093507

14. Garcia Reitbock J, Feldmann R, Ruhringer K, Breier F, Steiner A. Chronic radiodermatitis following percutaneous transluminal coronary angioplasty. J Dtsch Dermatol Ges. 2013;11(3): 265–266. pmid:23279977

15. ICRP. ICRP Publication 85: Avoidance of Radiation Injuries from Medical Interventional Procedures. Ann ICRP. 2000;30(2). pmid:11459599

16. Koenig TR, Wolff D, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. Am J Roentgenol. 2001;177(1): 3–11. pmid:11418388

17. Otterburn D, Losken A. Iatrogenic fluoroscopy injury to the skin. Ann Plast Surg. 2010;65(5): 462–465. pmid:20948414

18. Rehani MM, Srimahachota S. Skin injuries in interventional procedures. Radiat Prot Dosimetry. 2011;147(1–2): 8–12.

19. Ortiz P, Friedrich V, Wheatley J, Oresegun M. Lost and found dangers. Orphan radiation sources raise global concerns. IAEA bulletin.1999. Available: http://www.iaea.org/sites/default/files/publications/magazines/bulletin/bull41-3/41302081821.pdf. Accessed 2015 Jan 28.

20. UNSCEAR. Sources and effects of ionizing radiation. Annex D: Occupational radiation exposures. Report to the General Assembly; 1993. pp 507–549.

21. UNSCEAR. Sources and effects of ionizing radiation. Volume I. Annex E: Occupational radiation exposures. Report to the General Assembly; 2000. pp 497–654.

22. ALARA. Study case n° 16: Incident in a textile treatment plant in France. 1995. Available: http://www.eu-alara.net/index.php/incidents-lessons-learned-mainmenu-45.html. Accessed 2015 Jan 28.

23. ALARA. Study case n° 9: Radiography incident in Italy. European ALARA Newsletter. 1997; Issue 6. Available: http://www.eu-alara.net/index.php/incidents-lessons-learned-mainmenu-45.html. Accessed 2015 Jan 28.

24. Aydin A, Tumerdem B, Tuncer S. Consequences of radiation accidents. Ann Plast Surg. 2004;53(3): 300–301. pmid:15480026

25. Aydin A, Tumerdem B, Tuncer S, Erer M. Accidental radiation injury to the hand: A case report. Eur J Plast Surg. 2005;27(7): 341–343.

26. Becker J, Rosen T. Acute radiodermatitis from occupational exposure to iridium 192. South Med. 1989;J 82(12): 1561–1563. pmid:2688134

27. Belliniani SA, Sahyun A, Graciotti ME, Santos OR, Alvares R. Study of an accidental exposition of three workers during a gammagraphy with 192Ir source, 8th IRPA Congress Proceedings, Montreal. 1992; M1–197. Available: http://www2000.irpa.net/irpa8/cdrom/VOL.1/M1_197.PDF. Accessed 2015 Jan 28.

28. Berger ME, Hurtado R, Dunlap J, Mutchinick O, Velasco MG, Tostado RA, et al. Accidental radiation injury to the hand: anatomical and physiological considerations. Health Phys. 1997;72(3): 343–348. pmid:9030835

29. Chanteur J. Forbach: un accident d’irradiation. Médecins et Rayonnements Ionisants. 1992;3:5–6.

30. Conde-Salazar L, Guimaraens D, Romero LV. Occupational radiodermatitis from Ir192 exposure. Contact Dermatitis. 1986;15(4): 202–204. pmid:2948756

31. Da Silva FC, Hunt JG, Ramalho AT, Crispim VR. Dose reconstruction of a Brazilian industrial gamma radiography partial-body overexposure case. J Radiol Prot. 2005;25(3): 289–298. pmid:16286691

32. Gonzalez AJ. Timely Action. Strenghthening the safety of radiation sources & the security of radioactive materials. IAEA bulletin. 1999;41(3):2–15.

33. Guimaraens D, Conde-Salazar L, Sanchez Yus E. Radiodermatitis from iridium-192 exposure and allergic contact dermatitis. Contact Dermatitis. 1992;26(4): 266. pmid:1395569

34. Hosoda M, Tokonami S, Akiba S, Kurihara O, Sorimachi A, Ishikawa T, et al. Estimation of internal exposure of the thyroid to (131)I on the basis of (134)Cs accumulated in the body among evacuees of the Fukushima Daiichi Nuclear Power Station accident. Environ Int. 2013;61: 73–76. pmid:24103348

35. Ilyin LA, Soloviev VY, Baranov AE, Guskova AK, Nadezhina NM, Gusev IA. Early Medical Consequences of Radiation Incidents in the Former URRS Territory. 11th International Congress of IRPA. 2002. Available: http://irpa11.irpa.net/pdfs/7c20.pdf. Accessed 2015 Jan 28.

36. Institut de Radioprotection et de Sûreté Nucléaire. Rayonnements ionisants et accidents d’irradiation. 2006. Available: http://www.irsn.fr/FR/connaissances/Sante/effet-sur-homme/accidents-sanitaires/aide-au-diagnostic/Documents/irsn_aide-au-diagnostic_rayonnements-ionisants-accidents-irradiation.pdf. Accessed 2015 Jan 28.

37. Institut de Radioprotection et de Sûreté Nucléaire. Les Accidents Dus Aux Rayonnements Ionisants—Le bilan d'un demi-siecle. 2007. Available: http://www.irsn.fr/FR/Larecherche/publications-documentation/collection-ouvrages-IRSN/Documents/IRSN_reference_les_accidents_dus_aux_rayonnements_ionisants.pdf. Accessed 2015 Jan 28.

38. IAEA. An electron accelerator accident in Hanoi, Viet Nam. Vienna: IAEA; 1996.

39. IAEA. Planning the Medical Response to Radiological Accidents. Safety Reports Series No. 4. Vienna: IAEA; 1998.

40. IAEA. Nuclear Safety Review for the Year 2007. 2008. Available: http://www.iaea.org/Publications/Reports/. Accessed 2015 Jan 28.

41. IAEA. Nuclear Safety Review for the Year 2010. 2011. Available: http://www.iaea.org/Publications/Reports/. Accessed 2015 Jan 28.

42. IAEA. Overexposure to a Radiographer Trainee's Extremities. 2011. Available: http://www-news.iaea.org/ErfView.aspx?mId=d8a69871-04f2-414d-8164-a9e350da0e30. Accessed 2015 Jan 28.

43. Lee JI, Park JH, Kim YJ, Park JW. Thumb reconstruction with a wrap-around free flap in hand radiation injury. Microsurgery. 2012;32(5): 401–405. pmid:22422545

44. Matsuda N, Kumagai A, Ohtsuru A, Morita N, Miura M, Yoshida M, et al. Assessment of internal exposure doses in Fukushima by a whole body counter within one month after the nuclear power plant accident. Radiat Res. 2013;179(6): 663–668. pmid:23642080

45. Nakagawa K, Aoki Y, Kozuka T, Sakata K, Tago M, Muta N, et al. Argatroban in the treatment of radiation injury of the hand: a case report. Current Therapeutic Research. 1997;58: 323–329.

46. Natsoulas A. The Dangers of Food Irradiation Facilities Worldwide Provided by Public Citizen. 2002. Available: http://www.citizen.org/documents/australialawsuit.pdf. Accessed 2015 Jan 28.

47. OTHEA-RELIR. Deterministic effects to worker's hand during unauthorised density gauge disassembly. 1995. Available: http://www.othea.net/index.php/en/reports-industrial/78-jauges/36-manipulation-dune-jauge-dans-une-usine-de-traitement-de-textile.html. Accessed 2015 Jan 28.

48. Parajuli D, Tanaka H, Hakuta Y, Minami N, Fukuda S, Umeoka K, et al. Dealing with the aftermath of Fukushima Daiichi nuclear accident: decontamination of radioactive cesium enriched ash. Environ Sci Technol. 2013;47(8): 3800–3806. pmid:23484742

49. Raina S, Samuel AM. Isotope angiography and blood pool imaging as a procedure for assessing radiation-induced injuries to the hands. Clin Nucl Med.1992;17(8): 646–651. pmid:1324128

50. Schauer DA, Coursey BM, Dick CE, McLaughlin WL, Puhl JM, Desrosiers MF, et al. A radiation accident at an industrial accelerator facility. Health Phys. 1993;65(2): 131–140. pmid:8330958

51. Schauer DA, Desrosiers MF, Kuppusamy P, Zweier JL. Radiation dosimetry of an accidental overexposure using EPR spectrometry and imaging of human bone. Appl Radiat Isot. 1996;47(11–12): 1345–1350. pmid:9022195

52. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1981. NUREG-0090. 1981;v4(2).

53. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1981. NUREG-0090. 1982;v4(3).

54. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March. 1985. NUREG-0090. 1985;v8(1).

55. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March. 1986. NUREG-0090. 1986;v9(1).

56. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March. 1988. NUREG-0090. 1988;v11(1).

57. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September. 1987. NUREG-0090. 1988;v10(3).

58. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1990. NUREG-0090. 1990;v13(2).

59. US Nuclear Regulatory Commission. Accidental Radiation Overexposures to Personnel due to Industrial Radiography Accessory Equipment Malfunctions. Information Notice No. 91–23; 1991. Available: http://www.nrc.gov/reading-rm/doc-collections/gen-comm/info-notices/1991/in91023.html. Accessed 2015 Jan 28.

60. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1990. NUREG-0090. 1991;v13(4).

61. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1992. NUREG-0090. 1993; v15(3).

62. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1994. NUREG-0090. 1994; v17(2).

63. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1993. NUREG-0090. 1994;v16(3).

64. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 1999. NUREG-0090. 2000;v22.

65. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2002. NUREG-0090. 2003;v25.

66. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2006. NUREG-0090. 2007;v29.

67. Valverde NJ, Lucena MC, Briglian CH, Oliveira AR. Accidental exposure to X-ray from a diffractometer. Rev Assoc Med Bras. 2000;46(1): 81–87. pmid:10770908

68. WHO. Global report on Fukushima nuclear accident details health risks. Wkly Epidemiol Rec. 2013;88(10): 115–116. pmid:23544237

69. Ziqiang P, Shengen F, Huiling C. Exposure dose assessment and discussion on radioisotope production and application. J Radioanal Nucl Chem. 1996;206(2): 239–249.

70. Akita S, Yoshimoto H, Ohtsuru A, Hirano A, Yamashita S. Autologous adipose-derived regenerative cells are effective for chronic intractable radiation injuries. Radiat Prot Dosimetry. 2012;151(4): 656–660. pmid:22914335

71. Barriga LE, Zaharia M, Pinillos L, Moscol A, Heredia A, Sarria G, et al. Long-term follow-up of radiation accident patients in Peru: review of two cases. Radiat Prot Dosimetry. 2012;151(4): 652–655. pmid:22914334

72. Bertho JM, Roy L, Souidi M, Benderitter R, Bey E, Racine R, et al. Initial evaluation and follow-up of acute radiation syndrome in two patients from the Dakar accident. Biomarkers. 2009;14(2): 94–102. pmid:19330587

73. Clairand I, Huet C, Trompier F, Bottollier-Depois JF. Physical dosimetric reconstruction of a radiological accident due to gammagraphy equipment that occurred in Dakar and Abidjan in summer 2006. Radiation Measurements. 2008;43(2–6): 698–703. pmid:20862212

74. Commission des Communautés européennes. Radioprotection—n° 39. Acte du seminaire: Problèmes d'intervention médicale à mettre en oeuvre en cas de surexposition aux rayonnements ionisants. Luxembourg, 19–21 février 1986. Bruxelles, Luxembourg: Office des publications officielles des Communautés européennes; 1989.

75. Gourmelon P, Benderitter M, Bertho JM, Huet C, Gorin NC, De Revel P. European consensus on the medical management of acute radiation syndrome and analysis of the radiation accidents in Belgium and Senegal. Health phys. 2010;98(6): 825–832. pmid:20445389

76. Gregoire E, Hadjidekova V, Hristova R, Gruel G, Roch-Lefevre S, Voisin P, et al. Biological dosimetry assessments of a serious radiation accident in Bulgaria in 2011. Radiat Prot Dosimetry. 2013;155(4): 418–422. pmid:23460030

77. Hadjidekova V, Hristova R, Ainsbury EA, Atanasova P, Popova L, Staynova A. The use of the dicentric assay for biological dosimetry for radiation accidents in Bulgaria. Health Phys. 2010;98(2): 252–257. pmid:20065690

78. IAEA. The Radiological Accident in San Salvador. Non-serial Publications. Vienna: IAEA; 1990

79. IAEA. The Radiological Accident at the Irradiation Facility in Nesvizh. Non-serial Publications. Vienna: IAEA; 1996.

80. IAEA. The Radiological Accident in Yanango. Non-serial Publications. Vienna: IAEA; 2000.

81. IAEA. The Criticality Accident in Sarov. Non-serial Publications. Vienna: IAEA; 2001.

82. IAEA. Follow-up of delayed health consequences of acute accidental radiation exposure Lessons to be learned from their medical management. Vienna: IAEA; 2002.

83. IAEA. The Radiological Accident in Gilan. Non-serial Publications. Vienna: IAEA; 2002.

84. IAEA. Nuclear Safety Review for the Year 2008. 2009. Available: http://www.iaea.org/Publications/Reports/. Accessed 2015 Jan 28.

85. IAEA. The Radiological Accident in Nueva Aldea. Non-serial Publications. Vienna: IAEA; 2009.

86. IAEA. Nuclear Safety Review for the Year 2009. 2010. Available: http://www.iaea.org/Publications/Reports/. Accessed 2015 Jan 28.

87. IAEA. Accident in Industrial Radiography. 2012. Available: http://www-news.iaea.org/ErfView.aspx?mId = aedb233e-67a2-4786-a1c8-903592619080. Accessed 2015 Jan 28.

88. Jose de Lima Valverde N, Ferreira da Silva J, Tantalean OB. An update on three radiation accidents in South America. Health Phys. 2010;98(6): 868–871. pmid:20445396

89. Ketiku KK, Ogunleye OT. Radiation accidents in a developing country: the Nigerian experience. West Afr J Med. 1994;13(1): 63–65. pmid:8080836

90. Kramer R, Santos AM, Brayner CA, Khoury HJ, Vieira JW, Lima FR. Application of the MAX/EGS4 exposure model to the dosimetry of the Yanango radiation accident. Phys Med Biol. 2005;50(16): 3681–3695. pmid:16077221

91. Lataillade JJ, Doucet C, Bey E, Carsin H, Huet C, Clairand I, et al. New approach to radiation burn treatment by dosimetry-guided surgery combined with autologous mesenchymal stem cell therapy. Regen Med. 2007;2(5): 785–794. pmid:17907931

92. Lloyd DC, Edwards AA, Fitzsimons EJ, Evans CD, Railton R, Jeffrey P, et al. Death of a classified worker probably caused by overexposure to gamma radiation. Occup Environ Med. 1994;51(10): 713–718. pmid:8000499

93. Lloyd D. A gamma radiography accident in Russia—a lesson learned the hard way. E-bulletin No 2. Radiological protection bulletin. 2002. Available: http://webarchive.nationalarchives.gov.uk/20140714084352/http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1211528166125. Accessed 2015 Jan 28.

94. Pass B. Collective radiation biodosimetry for dose reconstruction of acute accidental exposures: a review. Environ Health Perspect. 1997;105 Suppl 6: 1397–1402. pmid:9467051

95. Pass B, Baranov AE, Kleshchenko ED, Aldrich JE, Scallion PL, Gale RP. Collective biodosimetry as a dosimetric "gold standard": a study of three radiation accidents. Health Phys. 1997;72(3): 390–396. pmid:9030840

96. Sevan'kaev AV, Lloyd DC, Edwards AA, Moquet JE, Nugis VY, Mikhailova GM, et al. Cytogenetic investigations of serious overexposures to an industrial gamma radiography source. Radiat Prot Dosimetry. 2002;102(3): 201–206. pmid:12430960

97. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March 1981. NUREG-0090. 1981;v4(1).

98. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1984. NUREG-0090. 1985;v7(4).

99. UNSCEAR. Sources and effects of ionizing radiation. Report to the General Assembly; 1988. pp 1–46.

100. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1993. NUREG-0090. 1994;v16(4).

101. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 1997. NUREG-0090. 1998;v20.

102. UNSCEAR. Sources and effects of ionizing radiation. Volume II. Annex J: Exposures and effects of the Chernobyl accident. Report to the General Assembly; 2000. pp 453–566.

103. UNSCEAR. UN Scientific Committee on Effects of Atomic Radiation confirms earlier IAEA assessments of radiological consequences of Chernobyl accident. Sci Total Environ. 2000;258(3): 209. pmid:11007292

104. Vargo GJ. A brief history of nuclear criticality accidents in Russia-1953–1997. Health Phys. 1999;77(5): 505–511. pmid:10524503

105. Akashi M, Hirama T, Tanosaki S, Kuroiwa N, Nakagawa K, Tsuji H, et al. Initial symptoms of acute radiation syndrome in the JCO criticality accident in Tokai-mura. Journal Radiat Res. 2001;42 Suppl: S157–166. pmid:11791749

106. Bertho JM, Roy L, Souidi M, Gueguen Y, Lataillade JJ, Prat M, et al. New biological indicators to evaluate and monitor radiation-induced damage: an accident case report. Radiat Res. 2008;169(5): 543–550. pmid:18439044

107. Chiba S, Saito A, Ogawa S, Takeuchi K, Kumano K, Seo S, et al. Transplantation for accidental acute high-dose total body neutron- and gamma-radiation exposure. Bone Marrow Transplant. 2002;29(11): 935–939. pmid:12080361

108. Federal register. 1995 July 25;60(142): 38059.

109. Fujimoto K. Nuclear accident in Tokai, Japan. J Radiol Prot. 1999;19(4): 377–380. pmid:10616783

110. Fujimoto K. Nuclear Accident in Tokai, Japan, 10th IRPA Congress Proceedings, Hiroshima. S-1; 2000. Available: http://www2000.irpa.net/irpa10/cdrom/01329.pdf. Accessed 2015 Jan 28.

111. Guo M, Dong Z, Qiao J, Yu C, Sun Q, Hu K, et al. Severe acute radiation syndrome: treatment of a lethally 60Co-source irradiated accident victim in China with HLA-mismatched peripheral blood stem cell transplantation and mesenchymal stem cells. J Radiat Res. 2013;55(2): 205–209. pmid:23979075

112. Hoashi T, Okochi H, Kadono T, Tamaki K, Nishida M, Futami S. A case of acute radiation syndrome from the dermatological aspect. Br J Dermatol. 2008;158(3): 597–602. pmid:18275523

113. Igaki H, Nakagawa K, Uozaki H, Akahane M, Hosoi Y, Fukayama M, et al. Pathological changes in the gastrointestinal tract of a heavily radiation-exposed worker at the Tokai-mura criticality accident. J Radiat Res. 2008;49(1): 55–62. pmid:17938558

114. IAEA. The Radiological Accident in Soreq. Non-serial Publications. Vienna: IAEA; 1993.

115. IAEA. Report on the Preliminary Fact Finding Mission Following the Accident at the Nuclear Fuel Processing Facility in Tokaimura, Japan. Non-serial Publications. Vienna: IAEA; 1999.

116. IAEA. Nuclear Safety Review for the Year 2006. 2007. Available: http://www.iaea.org/Publications/Reports/. Accessed 2015 Jan 28.

117. Ishii T, Futami S, Nishida M, Suzuki T, Sakamoto T, Suzuki N, et al. Brief note and evaluation of acute-radiation syndrome and treatment of a Tokai-mura criticality accident patient. J Radiat Res. 2001; 42 Suppl: S167–182. pmid:11791750

118. Kaga K, Maeshima A, Tsuzuku T, Kondo K, Morizono T. Temporal bone histopathological features of a worker who received high doses of radiation in a criticality accident: a case report. Acta Otolaryngol. 2011; 131(4): 451–455. pmid:21162658

119. Kanamori M. Dose Assessment for Workers in the Site and Neighboring Residents in the JCO Critically Accident, 10th IRPA Congress Proceedings, Hiroshima. S-2; 2000. Available: http://www2000.irpa.net/irpa10/cdrom/01330.pdf. Accessed 2015 Jan 28.

120. Reitan JB, Brinch L, Beiske K. Multi-organ failure aspects of a fatal radiation accident in Norway in 1982. BJR. 2005;supplement 27: 36–40.

121. Repacholi M, Souchkevitch G, Turai I. Proceedings of the 8th Coordination meeting of WHO Collaborating Centres in Radiation Emergency Medical Preparedness and Assistance Network, REMPAN. 4–7 June 2000, NRPB, Chilton, UK. Geneva: WHO; 2002.

122. Stavem P, Brogger A, Devik F, Flatby J, van der Hagen CB, Henriksen T, et al. Lethal acute gamma radiation accident at Kjeller, Norway. Report of a case. Acta Radiol Oncol. 1985;24(1): 61–63. pmid:2984904

123. Suzuki T, Nishida M, Futami S, Fukino K, Amaki T, Aizawa K, et al. Neoendothelialization after peripheral blood stem cell transplantation in humans: a case report of a Tokaimura nuclear accident victim. Cardiovasc Res. 2003;58(2): 487–492. pmid:12757883

124. US Nuclear Regulatory Commission (1981) Report to congress on abnormal occurrences. Quarterly report, July-September 1980. NUREG-0090. 1981;v3(3).

125. Yao B, Jiang BR, Ai HS, Li YF, Liu GX, Man QH, et al. Biological dose estimation for two severely exposed patients in a radiation accident in Shandong Jining, China, in 2004. Int J Radiat Biol. 2010;86(9): 800–808. pmid:20636236

126. Yao B, Li Y, Liu G, Guo M, Bai J, Man Q, et al. Estimation of the biological dose received by five victims of a radiation accident using three different cytogenetic tools. Mutat Res. 2013;751(1): 66–72. pmid:23201537

127. Cosset JM, Gourmelon P. Accidents in radiotherapy: historical account. Cancer Radiother. 2002;Suppl 1: 166s–170s. pmid:12587395

128. Derreumaux S, Etard C, Huet C, Trompier F, Clairand I, Bottollier-Depois JF, et al. Lessons from recent accidents in radiation therapy in France. Radiat Prot Dosimetry. 2008;131(1): 130–135. pmid:18725379

129. IAEA. Applying Radiation Safety Standards in Radiotherapy. Safety Reports Series No. 38. Vienna: IAEA; 2006.

130. Miura N, Kusuhara Y, Numata K, Shirato A, Hashine K, Sumiyoshi Y, et al. Radiation pneumonitis caused by a migrated brachytherapy seed lodged in the lung. Jpn J Clin Oncol. 2008;38(9): 623–625. pmid:18676993

131. Stabin MG, Watson EE, Marcus CS, Salk RD. Radiation dosimetry for the adult female and fetus from iodine-131 administration in hyperthyroidism. J Nucl Med. 1991;32(5):808–813. pmid:2022987

132. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1985. NUREG-0090. 1985;v8(2).

133. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1986. NUREG-0090. 1987;v9(3).

134. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March 1990. NUREG-0090. 1990;v13(1).

135. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1991. NUREG-0090. 1992;v14(4).

136. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1993. NUREG-0090. 1993;v16(2).

137. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March 1993. NUREG-0090. 1993;v16(1).

138. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1992. NUREG-0090. 1993;v15(4).

139. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March 1994. NUREG-0090. 1994;v17(1).

140. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1995. NUREG-0090. 1995;v18(2).

141. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March 1995. NUREG-0090. 1995;v18(1).

142. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1994. NUREG-0090. 1995;v17(3).

143. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1994. NUREG-0090. 1995;v17(4).

144. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1995. NUREG-0090. 1996;v18(3).

145. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 1996. NUREG-0090. 1997;v19.

146. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 1998. NUREG-0090. 1999;v21.

147. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2000. NUREG-0090. 2001;v23.

148. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2003. NUREG-0090. 2004;v26.

149. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2004. NUREG-0090. 2005;v27.

150. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2005. NUREG-0090. 2006;v28.

151. US Nuclear Regulatory Commission. Gamma knife treatment to wrongside of brain. Event notification No 43756; 2007. Available: http://www.nrc.gov/reading-rm/doc-collections/event-status/event/2007/20071029en.html. Accessed 2015 Jan 28.

152. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2007. NUREG-0090. 2008;v30.

153. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2008. NUREG-0090. 2009;v31.

154. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2009. NUREG-0090. 2010;v32.

155. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2010. NUREG-0090 2011;v33.

156. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2011. NUREG-0090. 2012;v34.

157. US Nuclear Regulatory Commission. Report to Congress on abnormal occurrences. Fiscal year 2012. NUREG-0090. 2013;v35.

158. UNSCEAR. Sources and effects of ionizing radiation. Volume I. Annex A: Medical radiation exposures. Report to the General Assembly; 2008. pp 21–220.

159. Borras C. Overexposure of radiation therapy patients in Panama: problem recognition and follow-up measures. Rev Panam Salud Publica. 2006;20(2–3): 173–187.

160. IAEA. Nuclear Safety Review for the Year 2001. 2002. Available: http://www.iaea.org/Publications/Reports/. Accessed 2015 Jan 28.

161. IAEA. Accidental Overexposure of Radiotherapy Patients in Bialystok. Non-serial Publications. Vienna: IAEA; 2004.

162. IAEA. Severe radiotherapy accident involving 23 patients. 2005. Available: https://rpop.iaea.org/RPOP/RPoP/Content/ArchivedNews/3_SevereRadiotherapyAccident23patients.htm. Accessed 2015 Jan 28.

163. Kusama T, Besho Y, Ohta K, Kai M, Yoshizawa Y. Overexposure cases on the extremities in radiological accidents, 8th IRPA Congress Proceedings, Montreal. 1992; M1–199. Available: http://www.irpa.net/irpa8/cdrom/VOL.1/M1_199.PDF. Accessed 2015 Jan 28.

164. Leveson NG, Turner CS. An investigation of the Therac-25 accidents. IEEE Computer. 1993;26(7): 18–41.

165. Nenot JC. Radiation accidents over the last 60 years. J Radiol Prot. 2009;29(3): 301–320. pmid:19690364

166. Ortiz P, Oresegun M, Wheatley J. Lessons from Major Radiation Accidents. 2000. Available: http://www.irpa.net/irpa10/cdrom/00140.pdf. Accessed 2015 Jan 28.

167. Peiffert D, Simon JM, Eschwege F. Epinal radiotherapy accident: passed, present, future. Cancer Radiothe. 2007;11(6–7): 309–312.

168. Rojkind RH, Kunst JJ, Gisone P, Palacios E. Accident in a linear electron accelerator for medical use, 7th IRPA Congress Proceedings. V3–197. 1996. Available: http://www.irpa.net/irpa9/cdrom/VOL.3/V3_197.PDF. Accessed 2015 Jan 28.

169. Tobias JS. What went wrong at Exeter? BMJ. 1988;297(6645): 372–373. pmid:3408974

170. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1985. NUREG-0090. 1986;v8(4).

171. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1985. NUREG-0090. 1986;v8(3).

172. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1987. NUREG-0090. 1987;v10(2).

173. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1986. NUREG-0090. 1987;v9(4).

174. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1989. NUREG-0090. 1989;v12(2).

175. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1988. NUREG-0090. 1989;v11(4).

176. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March 1991. NUREG-0090. 1991; v14(1).

177. Vatnitsky S, Ortiz Lopez P, Izewska J, Meghzifene A, Levin V. The radiation overexposure of radiotherapy patients in Panama 15 June 2001. Radiother Oncol. 2001;60(3): 237–238. pmid:11514002

178. Wack G, Lalande F. Inspection générale des affaires sociales. Résumé du rapport ASN n° 2006 ENSTR 019—IGAS n° RM 2007–015P sur l’accident de radiothérapie d’Epinal. 2007. Available: https://rpop.iaea.org/RPOP/RPoP/Content/Documents/Whitepapers/rapport_IGAS-ASN.pdf. Accessed 2015 Jan 28.

179. Woudstra E, Huizenga H, van de Poel JA. Possible leakage radiation during malfunctioning of a Sagittaire accelerator. Radiother Oncol. 1993;29(1): 39–44. pmid:8295986

180. Cosset JM. ESTRO Breur Gold Medal Award Lecture 2001: irradiation accidents—lessons for oncology? Radiother Oncol. 2002;63(1): 1–10. pmid:12065098

181. IAEA. Accidental Overexposure of Radiotherapy Patients in San José, Costa Rica. Non-serial Publications. Vienna: IAEA; 1998.

182. Johnston AM. Unintended overexposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006. 2006. Available: http://www.scotland.gov.uk/Resource/Doc/153082/0041158.pdf. Accessed 2015 Jan 28.

183. Loria D. Lesson from the past: Radiation Therapy Overexposure. Science 20. 2009. Available: http://www.science20.com/medical_physics_notes/blog/lesson_past_radiation_therapy_overexposure. Accessed 2015 Jan 28.

184. Nenot JC. Clinical management for localised overexposure. J Soc Radiol Prot. 1985;5(2): 55–58.

185. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1986. NUREG-0090. 1986;v9(2).

186. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March 1987. NUREG-0090. 1987;v10(1).

187. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, January-March 1989. NUREG-0090. 1989;v12(1).

188. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1988. NUREG-0090. 1989;v11(3).

189. US Nuclear Regulatory Commission. Errors in the Use of Radioactive Iodine-131. Information Notice No. 90–59; 1990.

190. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1989. NUREG-0090. 1990;v12(3).

191. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, October-December 1989. NUREG-0090. 1990;v12(4).

192. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, July-September 1990. NUREG-0090. 1991;v13(3).

193. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1992. NUREG-0090. 1992;v15(2).

194. Allen B, Cuzzone D, Rowin C, Perdrizet G, Babigian A. Fluoroscopic radiation burn after embolization of a spinal arteriovenous malformation. J Burn Care Res. 2009;30(2): 349–351. pmid:19165100

195. Archer BR, Wagner LK. Protecting patients by training physicians in fluoroscopic radiation management. J Appl Clin Med Phys. 2000;1(1): 32–37. pmid:11674817

196. Banaag LdeO, Carter MJ. Radionecrosis induced by cardiac imaging procedures: a case study of a 66-year-old diabetic male with several comorbidities. J Invasive Cardiol. 2008;20(8): E233–236. pmid:18688069

197. Banic B, Meier B, Banic A, Weinand C. Thoracic radionecrosis following repeated cardiac catheterization. Radiol Research Pract. 2011;201839. pmid:22091376

198. Barnea Y, Amir A, Shafir R, Weiss J, Gur E. Chronic radiodermatitis injury after cardiac catheterization. Ann Plast Surg. 2002;49(6): 668–672. pmid:12461452

199. Bassas Freixas P, Bartralot Soler R, Aparicio Espanol G, Garcia-Patos Briones V. Radiodermatitis after fluoroscopy-guided diagnostic and therapeutic procedures. Med Clin 2007;129(10): 397–398.

200. Berlin L. Radiation-induced skin injuries and fluoroscopy. Am J Roentgenol. 2001;177(1): 21–25. pmid:11418391

201. Boncher J, Bergfeld WF. Fluoroscopy-induced chronic radiation dermatitis: a report of two additional cases and a brief review of the literature. J Cutan Pathol. 2012;39(1): 63–67. pmid:21752059

202. Cante V, Doutre MS. Chronic radiodermatitis after a transjugular intrahepatic portosystemic shunt. Ann Dermatol Venereol. 2011;138(5): 424–425. pmid:21570570

203. Carstens GJ, Horowitz MB, Purdy PD, Pandya AG. Radiation dermatitis after spinal arteriovenous malformation embolization: case report. Neuroradiology. 1996;38 Suppl 1: S160–164. pmid:8811705

204. Dandurand M, Huet P, Guillot B. Secondary radiodermatitis caused by endovascular explorations: 5 cases. Ann Dermatol Venereol. 1999;126(5): 413–417. pmid:10434104

205. Dehen L, Vilmer C, Humiliere C, Corcos T, Pentousis D, Ollivaud L, et al. Chronic radiodermatitis following cardiac catheterisation: a report of two cases and a brief review of the literature. Heart. 1999;81(3): 308–312. pmid:10026359

206. Dichtl W, Sipotz J. Radiation dermatitis. Circulation. 2012;126(11): 1407. pmid:22965781

207. D'Incan M, Roger H. Radiodermatitis following cardiac catheterization. Arch Dermatol. 1997;133(2): 242–243. pmid:9041845

208. Fierens H, Goffette P, Tennstedt D, Lachapelle J. Radiodermatitis after transjugular intrahepatic portosystemic shunt: 4 cases. Ann Dermatol Venereol. 2000;127(6–7): 619–623. pmid:11187212

209. Frazier TH, Richardson JB, Fabre VC, Callen JP. Fluoroscopy-induced chronic radiation skin injury: a disease perhaps often overlooked. Arch Dermatol. 2007;143(5): 637–640. pmid:17515515

210. Garnacho GM, Amorrich MV, Salido R, Espejo J. A case of transient rectangular alopecia after aneurysm embolization. Actas Dermosifiliogr. 2009;100(10): 909–910. pmid:20038373

211. Gironet N, Jan V, Machet MC, Machet L, Lorette G, Vaillant L. Chronic radiodermatitis after heart catheterization: the contributing role of ciprofibrate (Lipanor)? Ann Dermatol Venereol. 1998;125(9): 598–600. pmid:9805549

212. Glazier JJ, Dixon SR. Skin injury following prolonged fluoroscopy: early and late appearances. QJM. 2012;105(6): 571–573. pmid:21622539

213. Granel F, Barbaud A, Gillet-Terver MN, Reichert S, Weber M, Danchin N, et al. Chronic radiodermatitis after interventional cardiac catheterization. Four cases. Ann Dermatol Venereol. 1998;125(6–7): 405–407. pmid:9922866

214. Hashimoto I, Sedo H, Inatsugi K, Nakanishi H, Arase S. Severe radiation-induced injury after cardiac catheter ablation: a case requiring free anterolateral thigh flap and vastus lateralis muscle flap reconstruction on the upper arm. J Plast Reconstr Aesthet Surg. 2008;61(6): 704–708. pmid:18492595

215. Henry MF, Maender JL, Shen Y, Tschen JA, Subrt P, Schmidt JD, et al. Fluoroscopy-induced chronic radiation dermatitis: a report of three cases. Dermatol Online J. 2009;15(1): 3. pmid:19281708

216. Huda W, Peters KR. Radiation-induced temporary epilation after a neuroradiologically guided embolization procedure. Radiology. 1994;193(3): 642–644. pmid:7972801

217. Iorio ML, Endara M, Desman E, Fontana L, Attinger C. Occult radiation injury following angiographic procedures: recognition and treatment of an evolving complication. Ann Plastic Surgery. 2011;67(2): 109–113. pmid:21346526

218. Jeskowiak A, Hubmer M, Prenner G, Maechler H. Radiation induced cutaneous ulcer on the back in a patient with congenital anomaly of the upper cava system. Interac Cardiovasc Thorac Surg. 2011;12(2): 290–292.

219. Kato M, Chida K, Sato T, Oosaka H, Tosa T, Munehisa M, et al. The necessity of follow-up for radiation skin injuries in patients after percutaneous coronary interventions: radiation skin injuries will often be overlooked clinically. Acta Radiol. 2012;53(9): 1040–1044. pmid:23024180

220. Kawakami T, Saito R, Miyazaki S. Chronic radiodermatitis following repeated percutaneous transluminal coronary angioplasty. Br J Dermatol. 1999;141(1): 150–153. pmid:10417533

221. Kim HS, Lee JY, Park HJ, Cho BK. Two cases of radiation-induced skin injuries occurring after radiofrequency catheter ablation therapy for atrial fibrillation. J Am Acad Dermatol. 2005;53(6): 1083–1084. pmid:16310075

222. Knautz MA, Abele DC, Reynolds TL. Radiodermatitis after transjugular intrahepatic portosystemic shunt. South Med J. 1997;90(3): 352–356. pmid:9076314

223. Koenig TR, Mettler FA, Wagner LK. Skin injuries from fluoroscopically guided procedures: part 2, review of 73 cases and recommendations for minimizing dose delivered to patient. Am J Roentgenol. 2001;177(1): 13–20. pmid:11418390

224. Krasovec M, Trueb RM. Temporary roentgen epilation after embolization of a cerebral arteriovenous malformation. Hautarzt. 1998;49(4): 307–309. pmid:9606632

225. Lee J, Hoss D, Phillips TJ. Fluoroscopy-induced skin necrosis. Arch Dermatol. 2003;139(2): 140–142. pmid:12588219

226. Lee WS, Lee SW, Lee S, Lee JW. Postoperative alopecia in five patients after treatment of aneurysm rupture with a Guglielmi detachable coil: pressure alopecia, radiation induced, or both? J Dermatol. 2004;31(10): 848–851. pmid:15672718

227. Levine N. Ulcerated papule on vertex of the scalp. Geriatrics. 2008;63(5): 33. pmid:18447410

228. Lichtenstein DA, Klapholz L, Vardy DA, Leichter I, Mosseri M, Klaus SN, et al.Chronic radiodermatitis following cardiac catheterization. Arch Dermatol. 1996;132(6): 663–667. pmid:8651716

229. Litzner B, Kantrow SM. Reticulated erythematous plaque on the back-quiz case. Arch Dermatol. 2009;145(7): 829–834. pmid:19620570

230. Lopez Aventin D, Gil I, Lopez Gonzalez DM, Pujol RM. Chronic scalp ulceration as a late complication of fluoroscopically guided cerebral aneurysm embolization. Dermatology. 2012;224(3): 198–203. pmid:22677971

231. Marti N, Lopez V, Pereda C, Martin JM, Montesinos E, Jorda E. Radiation-induced temporary alopecia after embolization of cerebral aneurysms. Dermatol Online J. 2008;14(7): 19. pmid:18718203

232. Miralbell R, Maillet P, Crompton NE, Doriot PA, Nouet P, Verin V, et al. Skin radionecrosis after percutaneous transluminal coronary angioplasty: dosimetric and biological assessment. J Vasc Interv Radiol. 1999;10(9): 1190–1194. pmid:10527196

233. Monaco JL, Bowen K, Tadros PN, Witt PD. Iatrogenic deep musculocutaneous radiation injury following percutaneous coronary intervention. J Invasive Cardiol. 2003;15(8): 451–453. pmid:12890877

234. Mundi JP, Kanchanapoomi M, Boyd KP, Patel RR, Kamino H, Cohen DE. Fluoroscopy-associated radiation dermatitis. Dermatol Online. 2013;J 19(12): 20712. pmid:24365003

235. Nahass GT. Acute radiodermatitis after radiofrequency catheter ablation. J Am Acad Dermatol. 1997;36(5 Pt 2): 881–884.

236. Nahass GT, Cornelius L. Fluoroscopy-induced radiodermatitis after transjugular intrahepatic portosystemic shunt. Am J Gastroenterol. 1998;93(9): 1546–1549. pmid:9732942

237. Nannapaneni R, Behari S, Mendelow D, Gholkar A. Temporary alopecia after subarachnoid haemorrhage. J Clin Neurosci. 2007;14(2): 157–161. pmid:17107802

238. Perrot P, Ridel P, Visee E, Dreno B, Duteille F. Chronic radiodermatitis following coronaroplasty. Ann Chir Plast Esthet. 2013;58(6): 700–703. pmid:23791328

239. Petit F, Flageul B, Gerbault O, Sarfati F, Revol M, Servant JM. Dorsal and laterothoracic radiodermatitis after interventional cardiography. Plast Reconstr Surg. 2002;109(5): 1655–1657. pmid:11932612

240. Pezzano M, Duterque M, Lardoux H, Louvard Y, Morice MC, Lefevre T, et al. Radiodermite thoracique en cardiologie interventionnelle: a propos de 6 cas. Arch Mal Coeur Vaiss. 1999;92: 1197–1204. pmid:10533668

241. Phend C. CT Safety Warnings Follow Radiation Overdose Accident. Medpage Today; 2009. Available: http://www.medpagetoday.com/Radiology/DiagnosticRadiology/16455. Accessed 2015 Jan 28.

242. Poletti JL. Radiation injury to skin following a cardiac interventional procedure. Australas Radiol. 1997;41(1): 82–83. pmid:9125082

243. Rosenthal LS, Beck TJ, Williams J, Mahesh M, Herman MG, Dinerman JL, et al. Acute radiation dermatitis following radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia. Pacing Clin Electrophysiol. 1997;20(7): 1834–1839. pmid:9249839

244. Sajben FP, Schoelch SB, Barnette DJ. Fluoroscopic-induced radiation dermatitis. Cutis. 1999;64(1): 57–59. pmid:10431676

245. Schecter AK, Lewis MD, Robinson-Bostom L, Pan TD. Cardiac catheterization-induced acute radiation dermatitis presenting as a fixed drug eruption. J Drugs Dermatol 2003;2(4): 425–427. pmid:12884469

246. Schmoor P, Descamps V, Crickx B, Steg PG, Belaich S. Chronic radiodermatitis after cardiac catheterization. Catheter Cardiovasc. 2001;52(2): 235–236. pmid:11170337

247. Shope TB. Radiation-induced skin injuries from fluoroscopy. Radiographics. 1996;16(5): 1195–1199. pmid:8888398

248. Slovut DP. Cutaneous radiation injury after complex coronary intervention. JACC. Cardiovasc Interv. 2009;2(7): 701–702. pmid:19628196

249. Soga F. A case of radiation ulcer following transcatheter arterial embolization. Jpn J Clin Dermatol. 2004;58: 908–910.

250. Sovik E, Klow NE, Hellesnes J, Lykke J. Radiation-induced skin injury after percutaneous transluminal coronary angioplasty. Case report. Acta Radiol. 1996;37(3 Pt 1): 305–306. pmid:8845258

251. Spiker A, Zinn Z, Carter WH, Powers R, Kovach R. Fluoroscopy-induced chronic radiation dermatitis. Am J Cardiol. 2012;110(12): 1861–1863. pmid:22980965

252. Srimahachota S, Udayachalerm W, Kupharang T, Sukwijit K, Krisanachinda A, Rehani M. Radiation skin injury caused by percutaneous coronary intervention, report of 3 cases. Int J of Cardiol. 2012;154(2): e31–33.

253. Stone MS, Robson KJ, LeBoit PE. Subacute radiation dermatitis from fluoroscopy during coronary artery stenting: evidence for cytotoxic lymphocyte mediated apoptosis. J of American Academy of Dermatology 1998;38(2 Pt 2): 333–336. pmid:9486710

254. Thomadsen BR, Paliwal BR, Petereit DG, Ranallo FN. Radiation injury from x-ray exposure during brachytherapy localization. Med Phys. 2000;27(7): 1681–1684. pmid:10947273

255. Thorat JD, Hwang PY. Peculiar geometric alopecia and trigeminal nerve dysfunction in a patient after Guglielmi detachable coil embolization of a ruptured aneurysm. J Stroke Cerebrovasc Dis. 2007;16(1): 40–42. pmid:17689391

256. Vano E, Arranz L, Sastre JM, Moro C, Ledo A, Garate MT, et al. Dosimetric and radiation protection considerations based on some cases of patient skin injuries in interventional cardiology. Br J Radiol. 1998;71(845): 510–516. pmid:9691896

257. Vlietstra RE, Wagner LK, Koenig T, Mettler F. Radiation burns as a severe complication of fluoroscopically guided cardiological interventions. J Int Cardiol. 2004;17(3): 131–142. pmid:15209575

258. Wagner LK, McNeese MD, Marx MV, Siegel EL. Severe skin reactions from interventional fluoroscopy: case report and review of the literature. Radiology. 1999;213(3): 773–776. pmid:10580952

259. Wagner LK, Archer BA. Minimizing risks from fluoroscopic x rays, 3rd ed. Houston, Texas: RM Partnership; 2000.

260. Wagner LK. Radiation injury is potentially a severe consequence of fluoroscopically guided complex interventions. Health Phys. 2008;95(5): 645–649. pmid:18849698

261. Wen CS, Lin SM, Chen Y, Chen JC, Wang YH, Tseng SH. Radiation-induced temporary alopecia after embolization of cerebral arteriovenous malformations. Clin Neurol Neurosurg. 2003;105(3): 215–217. pmid:12860517

262. Wong L, Rehm J. Images in clinical medicine. Radiation injury from a fluoroscopic procedure. N Engl J Med. 2004; 350(25): e23. pmid:15201428

263. Yoneda K, Nakai K, Demitsu T, Moriue T, Moriue J, Yokoi I, et al. Late radiation dermatitis of the right arm after cardiac catheterization. Eur J Dermatol. 2010;20(5): 654–656. pmid:20610375

264. Aslan G, Terzioglu A, Tuncali D, Bingul F. Consequences of radiation accidents. Ann Plast Surg. 2004;52(3): 325–328. pmid:15156991

265. IAEA. The Federal State Unitarian Enterpise «RosRAO»—Russian RW management operator. 2009. Available: http://www.iaea.org/OurWork/ST/NE/NEFW/documents/ENVIRONET/kickoff_meeting_2009/day2/Russia.pdf. Accessed 2015 Jan 28.

266. Milacic S, Simic J. Case report: Iridium 192-health effects during 20 years after irradiation. Kobe J Med Sci. 2008;54(2): E108–113. pmid:18772612

267. Mosokotso EA, Mogoru W, Sikakana I, Neeson H. Radiation Safety Practices of Industrial Radiography license holders in South Africa. Proceedings 18th World Conference on Nondestructive Testing, 16–20 April 2012, Durban, South Africa; 2012. Available: http://www.ndt.net/article/wcndt2012/papers/629_wcndtfinal00629.pdf. Accessed 2015 Jan 28.

268. Carsin H, Stephannazi J, Gourmelon P. Advances in the Medical Management of The Severe Cutaneous Radiation Syndrome, 10th IRPA Congress Proceedings, Hiroshima. T-21–3; 2000. Available: http://www2000.irpa.net/irpa10/cdrom/00718.pdf. Accessed 2015 Jan 28.

269. Gottlober P, Bezold G, Weber L, Gourmelon P, Cosset JM, Bahren W, et al. The radiation accident in Georgia: clinical appearance and diagnosis of cutaneous radiation syndrome. J Am Acad Dermatol. 2000;42(3): 453–458. pmid:10688716

270. Gupta ML, Srivastava NN, Dutta S, Shukla SK, Dutta A, Verma S, et al. Blood biomarkers in metal scrap workers accidentally exposed to ionizing radiation: a case study. Hum Exp Toxicol. 2013;32(12): 1311–1322. pmid:23698832

271. Gusev IA, Guskova AK, Mettler FA. Medical Management of Radiation Accidents. 2nd ed. Boca Raton, Florida: CRC Press; 2001.

272. Norwegian Radiation Protection Authority. Assessment of environmental, health and safety consequences of decommisioning radioisotope thermal generators (RTGS) in Northwest Russia.Strålevern Rapport 4. 2005. Available: http://www.nrpa.no/dav/c600d1d288.pdf. Accessed 2015 Jan 28.

273. Hutt G, Brodski L, Polyakov V. Gamma-ray dose assessment after the 1994 radiation accident in Kiisa (Estonia): preliminary results. App Radiat Isot. 1996;47(11–12): 1329–1334.

274. IAEA. The Radiological Accident in Goiânia. Non-serial Publications. Vienna: IAEA; 1988.

275. IAEA. The Radiological Accident in Tammiku. Non-serial Publications. Vienna: IAEA; 1998.

276. IAEA. The Radiological Accident in Istanbul. Non-serial Publications. Vienna: IAEA; 2000.

277. IAEA. The Radiological Accident in Lilo. Non-serial Publications. Vienna: IAEA; 2000.

278. IAEA. The Radiological Accident in Samut Prakarn. Non-serial Publications. Vienna: IAEA; 2002.

279. Jamshed N, Bhasin A, Ekka M, Aggarwal P. Young man with skin discoloration. Acute radiation syndrome caused by exposure to radioactive cobalt. Ann Emerg Med. 2011;58(4): 395–406. pmid:21943577

280. Liu Q JB, Jiang LP, Wu Y, Wang XG, Zhao FL, Fu BH, et al. Clinical report of three cases of acute radiation sickness from a (60)Co radiation accident in Henan Province in China. J Radiat Res. 2008;49(1): 63–69. pmid:18187937

281. Liu Q, Cao J, Liu Y, Lu WM, Qin B, Jiang B, et al. Follow-up study by chromosome aberration analysis and micronucleus assays in victims accidentally exposed to 60Co radiation. Health Phys. 2010;98(6): 885–888. pmid:20445399

282. Mahmoud NS. Safety assessment methodology in management of spent sealed sources. J Hazard Mater. 2005;118(1–3): 1–8. pmid:15721552

283. Marshall E. Morocco reports lethal radiation accident. Science. 1984;225(4660): 395. pmid:17813248

284. Norwegian Radiation Protection Authority. NRPA Bulletin 7.04: Dismantling of RTGs on the Kola Peninsula. 2004. Available: http://www.nrpa.no/dav/40851f744b.pdf. Accessed 2015 Jan 28.

285. Socie G, Medhi Sohrabi K, Carosella ED, Cosset JM, Hervatin F, de Cremoux P, et al. Hematopoiesis research in aplastic anaemia induced by accidental protracted radiation. CR Acad Sci. III. 1996;319(8): 711–716. pmid:8949395

286. Xu ZY, Zhang LA, Dai G. The estimation of absorbed doses received by a victim of a Chinese radiation accident. Radiat Prot Dosimetry. 2003;103(2): 163–167. pmid:12593436

287. Baranov AE, Guskova AK, Davtian AA, Sevankaev AV, Lloyd DC, Edwards AA, et al. Protracted Overexposure to a 137Cs Source: II, Clinical Sequelae. Radiat Prot Dosimetry. 1999;81(2): 91–100.

288. Lister BAJ. Contaminated Mexican steel incident. J Soc Radiol Prot. 1985;5: 145–147.

289. Marshall E. Juarez: an unprecedented radiation accident. Science. 1984;223(4641): 1152–1154. pmid:6701516

290. Marshall E. Juarez radiation accident. Science. 1984;224(4645): 110. pmid:17744661

291. Ogunranti JO. Haematological indices in Nigerians exposed to radioactive waste. Lancet. 1989;2(8664): 667–668. pmid:2570910

292. Security and Nonproliferation. 2005;Issue 2(8). Available: http://www.ntc.kiev.ua/download/arh/BTN/8.pdf. Accessed 2015 Jan 28.

293. Sevan'kaev AV, Lloyd DC, Edwards AA, Mikhailova GF, Nugis VY, Domracheva EV, et al. Protracted Overexposure to a 137Cs Source: I, Dose Reconstruction. Radiat Prot Dosimetry. 1999;81(2): 85–90.

294. Compton KL, Novikov VM, Parker FL, Sivintsev YV. The Radioactive Legacy of the Russian Pacific Fleet Operations and its Potential Impact on Neighboring Countries. Interim Report IR-03–009; 2003. Available: http://webarchive.iiasa.ac.at/Admin/PUB/Documents/IR-03-009.pdf. Accessed 2015 Jan 28.

295. Corbett RH, Fong RY, Lewis CA. IRPA-10: 10th International Congress of the International Radiation Protection Association. Br J Radiol. 2001;74(886): 883–885. pmid:11675302

296. Lisovsky IV. The Analysis of Risk of the Radiation Failures in Russian Navy. Experience of International Cooperation, 10th IRPA Congress Proceedings; 2000. Available: http://www2000.irpa.net/irpa10/cdrom/01200.pdf. Accessed 2015 Jan 28.

297. Bomben A, Gregori B, Massera G, Righetti M, Thomasz E. Accident in a critical facility: physical dosimetry, 7th IRPA Congress Proceedings, Sydney. S2–77; 1988. Available: http://www2000.irpa.net/irpa7/cdrom/VOL.2/S2_77.PDF. Accessed 2015 Jan 28.

298. Dousset M, Jammet H. Les accidents humains d'irradiation d'origine nucléaire. In: Les irradiations thérapeutiques et accidentelles Créteil 6–8 Juin 1984. Creteil, France: P. Galle,R. Masse, JC Nenot; 1984

299. McLaughlin N. Do attempt to adjust the picture. Technology is a good thing; snooping, radiation overexposure are not. Mod Healthc. 2009;39(50): 24. pmid:20092009

300. Soleo L, Basso A, Di Lorenzo L, Bukvic N, L'Abbate N. Acute radiodermatitis from accidental overexposure to X-rays. Am J Ind Med. 1996;30(2): 207–211. pmid:8844051

301. Sugawara Y, Takahashi K, Matsuta M, Akasaka T. An x-ray exposure accident in a high school student. Dermatology. 2005;211(3): 293–295. pmid:16205079

302. US Nuclear Regulatory Commission. Report to congress on abnormal occurrences. Quarterly report, April-June 1991. NUREG-0090. 1991;v14(2).

303. ICRP. The 2007 Recommendations of the International Commission on Radiological Protection. Publication 103. Ann ICRP. 2007;37(2–4): 1–332. pmid:18082557

304. Gonzalez AJ. Radiation safety standards and their application: international policies and current issues. Health Phys. 2004;87(3): 258–272. pmid:15303062

305. IAEA. Radiation Protection and Safety of Radiation Sources: International Basic Safety Standards. General Safety Requirements Part 3. IAEA safety standards; 2011.

306. IAEA. Radiation protection and safety in industrial radiography. Safety reports series No.13; 1999. Available: http://www-pub.iaea.org/MTCD/Publications/PDF/P066_scr.pdf. Accessed 2015 Jan 28.

307. IAEA. Radiation safety in industrial radiography. Specific safety guide. No. SSG-11; 2011. Available: http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1466_web.pdf. Accessed 2015 Jan 28.

308. US Nuclear Regulatory Commission. Consolidated Guidance About Materials Licenses Program-Specific Guidance About Industrial Radiography Licenses. NUREG-1556. 1998; 2. Available: http://pbadupws.nrc.gov/docs/ML0103/ML010370172.pdf. Accessed 2015 Jan 28.

309. ICRP. ICRP Publication 86: Prevention of accidents to patients undergoing radiation therapy. Ann ICRP. 2000;30(3): 7–70. pmid:11711147

310. Ortiz Lopez P, Cosset JM, Dunscombe P, Holmberg O, Rosenwald JC, Pinillos Ashton L, et al. Preventing Accidental Exposures from New External Beam Radiation Therapy Technologies. ICRP Publication 112. Ann ICRP. 2009;39(4).

311. Baeza M (2012) Accident prevention in day-to-day clinical radiation therapy practice. Ann ICRP. 2012;41(3–4): 179–187. pmid:23089036

312. FDA. Avoidance of serious x-ray induced skin injuries to patients during fluoroscopically guided procedures. Public Health Notification; 1994. Available: http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm116677.pdf. Accessed 2015 Jan 28.

313. Mahesh M. Fluoroscopy: patient radiation exposure issues. Radiographics. 2001;21(4): 1033–1045. pmid:11452079

314. Wagner LK, Eifel PJ, Geise RA. Potential biological effects following high X-ray dose interventional procedures. J Vasc Interv Radiol.1994;5(1): 71–84. pmid:8136601

315. Rehani MM, Frush DP, Berris T, Einstein AJ. Patient radiation exposure tracking: worldwide programs and needs—results from the first IAEA survey. Eur J Radiol. 2012;81(10): e968–976. pmid:22840382

316. Sung DW, Shin KE. Reduced Radiation Dose in Diagnostic Radiology. J Korean Med Sci. 2013;28(4): 495–496. pmid:23580865

317. Task Force for Monitoring Patient Dose during Fluoroscopy. Technical White Paper: Monitoring and Tracking of Fluoroscopic Dose. 2010. Available: http://www.crcpd.org/Pubs/WhitePaper-MonitoringAndTrackingFluoroDose-PubE-10-7.pdf. Accessed 2015 Jan 28.

318. FDA. Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010. 2010. Available: http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm185898.htm. Accessed 2015 Jan 28.

319. Brown N, Jones L. Knowledge of medical imaging radiation dose and risk among doctors. J Med Imaging Radiat Oncol. 2013;57(1):8–14. pmid:23374547