ML21005A436
| ML21005A436 | |
| Person / Time | |
|---|---|
| Issue date: | 03/16/2021 |
| From: | Sarah Lopas NRC/NMSS/DMSST/MSEB |
| To: | Christian Einberg NRC/NMSS/DMSST/MSEB |
| Sarah Lopas, X6360 | |
| References | |
| 20201329 | |
| Download: ML21005A436 (16) | |
Text
UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20555-0001 March 16, 2021 MEMORANDUM TO: Christian Einberg, Chief Medical Safety and Events Assessment Branch Division of Materials Safety, Security, State, and Tribal Programs Office of Nuclear Material Safety and Safeguards FROM:
Sarah L. Lopas, Project Manager Medical Safety and Events Assessment Branch Division of Materials Safety, Security, State, and Tribal Programs Office of Nuclear Material Safety and Safeguards
SUBJECT:
SUMMARY
OF DECEMBER 8, 2020, U.S. NUCLEAR REGULATORY COMMISSION PUBLIC MEETING ON RADIOPHARMACEUTICAL EXTRAVASATIONS Meeting Identifier: 20201329 Date of Meeting: Tuesday, December 8, 2020; 2:00 p.m. EST Location: Webinar Type of Meeting: Category 3 Purpose of the Meeting: To provide a brief background information on the U.S. Nuclear Regulatory Commission (NRC) staffs planned evaluation of whether radiopharmaceutical extravasations should be reported as medical events, and to obtain medical community and stakeholder feedback on the issue in order to help inform the staffs evaluation.
Background Information: In a 1980 rulemaking (45 FR 31701), the Commission made the policy decision not to require licensees to report extravasations to the NRC, stating:
Extravasation frequently occurs in otherwise normal intravenous or intraarterial injections. It is virtually impossible to avoid. Therefore, the Commission does not consider extravasation to be a misadministration. New radiopharmaceuticals and advances in therapies since the Commission decision have prompted the NRC to re-evaluate whether extravasations should be reported as medical events.
Additionally, on May 18, 2020, Lucerno Dynamics submitted a petition for rulemaking (PRM-35-22) requesting that the NRC revise its regulations to require medical event reporting of extravasations that result in a localized dose equivalent exceeding 50 rem. The petition asserts that this reporting will not only alert the NRC to instances of serious misuse of byproduct Sarah Lopas Digitally signed by Sarah Lopas Date: 2021.03.16 20:53:59 -04'00'
Meeting Summary ML21005A436 material, but also will incentivize practitioners to improve injection and infusion quality, ensuring that nuclear medicine patients are protected from unavoidable irradiation and given access to information to understand when and how medical events impact their care. The NRC Medical Radiation Safety Teams evaluation of extravasations is separate from Rulemaking staffs evaluation of the merits of the petition for rulemaking, but it will help inform the Rulemaking staffs recommendation to the Commission on whether to accept or deny the petition for rulemaking.
General Details: The NRC published the official public meeting notice on November 16, 2020, providing the agenda and webinar registration instructions for attendees (Accession No. ML20321A247). The meeting was conducted remotely via webinar and began at 2:00 p.m.
EDT with a 20-minute presentation by NRC staff on some background information about radiopharmaceutical extravasations, the staffs ongoing evaluation of whether extravasations should be reported as medical events, and the petition for rulemaking and congressional interest on the matter. The staff then walked through a series of discussion questions related to injection quality monitoring, classification of extravasations as medical events, reporting extravasations as medical events, and other considerations. The staffs slide presentation is available in ADAMS at Accession No. ML20338A283. Following the staffs presentation, the meeting was then opened to receive public comments. Approximately 275 people participated in the meeting. A list of NRC and external meeting participants is enclosed. The meeting concluded at 4:06 p.m. EST. The staff has summarized the comments received and a transcript of the meeting is available in ADAMS at Accession No. ML21012A446.
Summary of Comments Received:
Opposition to Regulating Radiopharmaceutical Extravasation The majority of commenters were medical community members (physicians, nuclear medicine technicians, medical physicists, radiation safety officers, etc.) who strongly opposed regulating radiopharmaceutical extravasations. Broadly, commenters stated that significant injury from extravasation was extremely rare, requiring monitoring for extravasation would not prevent extravasation from occurring, and requiring extravasations to be reported as medical events would create undue regulatory burden for licensees without any improved safety benefit for patients.
Several commenters stated that there was no technology that would prevent extravasation from occurring, and that monitoring would allow clinicians to start corrective actions earlier, but it would not prevent extravasation. Another commenter stated that the only technology that could prevent extravasation is the use of a central line into a major vessel, and that most physicians who manage patients reserve central lines only for nutrient or lifesaving techniques, and so there effectively is no technology other than care. One commenter reiterated that nursing best practices are being implemented in nuclear medicine departments. They stated that there has been a reduction in the straight stick injection technique and the use of butterflies and IVs reduce the likelihood of extravasation. Another commenter elaborated that while no technology exists to prevent extravasations, we rarely have extravasations because we utilize catheters, such as angiocaths, to establish IV access rather than performing direct sticks.
Commenters stated that monitoring would not improve intravenous (IV) administration technique, which is a practice of medicine issue and is within the scope of practice for nuclear medicine technologists. Commenters also concluded that regulatory action requiring monitoring and reporting would not improve rates of extravasation.
Meeting Summary ML21005A436 One commenter who represents the Technologists Section of the Society of Nuclear Medicine and Molecular Imaging (SNMMI) stated that acting patients overall experience and satisfaction in the care they are extravasations are undesirable outcomes of injections, sometimes resulting in the need for another injection or even having to reschedule the patient to return, and that they have a significant detrimental effect on image quality as well as negatively impacting the patients overall experience and their satisfaction in the care they are receiving. The commenter continued by saying that nobody wants to see an extravasation, but that regardless of the extra steps and care a clinician may take, extravasations can still occur. The commenter noted that nuclear medicine patients are often seen many times over for follow-up care after a procedure, and that in the commenters and her colleagues many years of experience as nuclear medicine technicians, they had seen no evidence that diagnostic radiopharmaceutical extravasation causes harm to patients. However, the commenter stated they represent SNMMI, an organization focused on safety and quality of practice, and that they support ensuring that all technicians understand the effect of extravasation on quality and accuracy of patient studies.
Therefore, the Nuclear Medicine Technologist section of SNMMI was proposing a quality initiative that would reiterate the importance of quality injections, revisiting best practices and discussing technical considerations for optimizing venipuncture procedures. The commenter closed by stating that the issue of radiopharmaceutical extravasation is best addressed at the institutional level, and that regulatory action is not appropriate at this time. This opinion was echoed by other commenters, who repeated that extravasation is best managed locally at the institution level as a quality improvement process initiative.
Another commenter identified themselves as a physician who participated in a study sponsored by the PRM-35-22 petitioner. The commenter began by stating that in their experience, extravasation of radiotracers has never caused a medical problem, and they did not believe extravasation should be regulated. The commenter stated that while the petitioners monitoring technology is a technological improvement, monitoring for extravasation would not prevent extravasation. The commenter continued by saying they supported the other medical professional societies (SNMMI, American College of Nuclear Medicine, and the American Society of Nuclear Cardiology) in their opinions that extravasation is a practice of medicine issue that does not require regulation. The commenter stated that reporting extravasations as medical events would not improve or impact patient safety, and unnecessary medical event reporting could actually divert resources away from more important safety issues.
Another commenter, who is a former member of the NRCs Advisory Committee on the Medical Uses of Isotopes (ACMUI), emphasized the lack of clinical consequences of radiopharmaceutical extravasations and pointed out the distinction between regulatory oversight and practice of medicine. The commenter acknowledged that the major impact of extravasation is the potential compromise to the quality of a diagnostic scan, however, this is a practice of medicine issue that is beyond the scope of regulators and regulatory action. The commenter said that requiring extravasations to be reported would be a slippery slope in terms of regulators adjudicating quality of scans and measures by clinicians to improve the quality of scans. The commenter closed by reiterating that over-regulation and intervention by regulators into medical practice is one of many reasons to reject PRM-35-22.
One commenter noted that at their medical facility, a new monitoring procedure is in place for Lutathera therapy to allow for quick initiation of actions to minimize potential skin dose in the event of extravasation. Another commenter noted that their facility does not monitor for extravasation, because that would add significant time to the patient imaging procedure, and that for therapies, it would require finding camera time, which is not normally included for
Meeting Summary ML21005A436 therapy patients. Another commenter said they monitored for extravasation through routine imaging, and if there was pooling, it would be found on the images.
A commenter discussed how a partial or full extravasation can be caused by patient intervention, and that this is especially an issue for pediatric nuclear medicine, where a specialized team dedicated to pediatric venipuncture is used to establish IVs in young patients.
The commenter worried that if extravasations were classified as medical events, it would have a chilling effect and discourage physicians from going into nuclear medicine, especially pediatric nuclear medicine. The commenter also noted that external beam radiation therapy often causes wet burns, i.e., wet desquamations, and These things happen every day all over the nation. Its one of the side effects of radiation therapy. Nobody reports them. And these burns are a far, far bigger problem than anything in nuclear medicine, and they are handled at the hospital-level and are not regulated.
A current member of the NRCs ACMUI who is not a member of the extravasation subcommittee provided comments opposing the regulation of extravasation. The commenter noted that there are multiple mechanisms that exist to evaluate and promote the safe administration of radioactive materials within the broader scope and practice of medicine, including regulation and monitoring by the Centers for Medicare and Medicaid Services, the U.S. Food and Drug Administration, and the Joint Commission on Accreditation of Healthcare Organizations. In the case of the Joint Commission, the commenter said that the healthcare environment is routinely evaluated, including documented training, continued education, and competencies of staff which includes the handling of IV lines, administration of pharmaceuticals, medication management, etc. Under these quality initiatives, injection quality techniques by staff or larger process problems are investigated and remediated, and that this would certainly include any issues related to compromised IV lines or painful extravasations, and would include incident reporting, root cause analyses, and corrective and preventative action plans. The commenter went on to explain that they believed that the majority of extravasations are due to patient movement and vascular access issues, and not clinician error, and that revising the NRC rules to require monitoring, evaluation, and dosimetry for every extravasation would impose significant burdens to healthcare institutions which already have varied processes in place to minimize extravasation and/or clinical practice issues. The commenter then mentioned an often-cited study that indicates there are minimal adverse effects from diagnostic extravasations. The commenter cited another study that concluded that the incidents of radiopharmaceutical adverse events was 2.1 for every 100,000 administrations. The commenter stated that PRM-35-22 conflates diagnostic extravasation with extravasation of higher-dose therapies and the effects of vesicants in chemotherapy, and that studies support the conclusion that there are very few incidents of severe tissue damage related to even therapeutic extravasations. The commenter went on to note that tissue damage often heals without complication and no treatment is necessary. The commenter closed by saying that the petitioners injection quality monitoring device would be welcome as a quality improvement and educational tool, but that a rulemaking to require extravasations be reported as medical events would be inappropriate and unnecessary given quality improvement opportunities and practices already under the broader scope of medicine.
Another commenter strongly opposed any rulemaking related to extravasations and reiterated the low risk associated with diagnostic nuclear medicine procedures and the low probability of untoward consequences, unlike CT extravasations where large contrast loads can result in skin sloughing and compartment syndrome.
Meeting Summary ML21005A436 Another current ACMUI member, also not on the extravasation subcommittee, opposed regulating extravasations and stressed that the NRC needs to carefully assess the impact of any additional regulations. The commenter cited the chilling effect of undue regulatory burden, discouraging physicians from performing these types of nuclear medicine procedures. The commenter stated that instead of regulations, the medical community needed to focus more on better training, education, and quality management programs to create awareness, improve injections, and minimize extravasations.
A commenter said that the benefits of nuclear medicine procedures outweigh the potential risks related to extravasation, and that if additional regulation is put into place, the benefits to the patient could easily be lost because nuclear medicine traditionally operates on a thin margin and the COVID-19 public health emergency has reduced revenues of medical centers by billions of dollars. The commenter closed by saying that adding regulatory cost without a clear benefit would be harmful to the nuclear medicine field, and that the current regulatory structure is appropriate as it perfectly balances risk and benefit.
A nuclear medicine physician and radiation safety director associated with the Department of Veterans Affairs expressed deep concerns about any effort to regulate extravasations, saying it would place an undue burden on Veterans Affairs nuclear medicine departments and radiation safety officer staff throughout the nation without any clinical care benefit to be gained.
Another commenter cited that there were roughly 20 million nuclear medicine procedures per year, and that could result in about 200,000 medical events, and that the NRC needed to carefully consider the regulatory burden associated with a rulemaking to make extravasations reportable as medical events. The commented also noted that the problem with using a dose-based criterion is that dosimetry assessing extravasation would not be a trivial exercise, due to the unknown volume of extravasate and varying concentration of radioactive material into some sort of interstitial tissue. The commenter said that the dose estimate methods discussed in the studies referenced by staff and previous commenters were kind of a shot in the dark, right, because theres no good data on how quickly it was absorbed. Theres not good data on the geometry. The commenter reiterated that the NRC needed to consider these practical considerations, or the applied health physics evaluation, for how licensees would conduct dosimetry in order to screen out most extravasations, that most licensees dont have the resources to conduct complex dose reconstructions. The commenter noted that even planar imaging to estimate extravasation dose may be problematic. The commenter suggested that perhaps instead the criteria should be patient injury or something similar.
A former member of the NRCs ACMUI made a comparison of extravasation skin doses to skin doses from interventional radiology, which are typically several Gray or hundreds of rads, and when there are observable skin effects, they are mild, transient, and self-limiting. The commenter stated that extravasations, especially when mitigation measures are taken, have little-to-no clinical effects. The commenter cited another nuclear medicine therapy that involves intentional extravasation, and theres no documentation at all of any adverse skin or other effects. The commenter stated that extravasation should be put into these perspectives, and that additionally, estimating radiation dose from an extravasated radiopharmaceutical is far from trivial. The commenter closed by saying there was very little basis for regulatory oversight and categorizing extravasations as medical events.
A patient advocate commenter echoed concerns about a chilling effect on nuclear medicine, wondering what would happen to patient access to these procedures if additional regulation required the reporting of 100,000 or more medical events. The commenter wondered how
Meeting Summary ML21005A436 licensees and regulators would go through the data, and what expense would that add to patient care and availability of treatments. The commenter thought that some facilities would choose to discontinue procedures requiring that level of reporting. The commenter closed by saying that harmful extravasations should be reported, but even in that case, it appears the appropriate response would be to focus on increased training.
An Agreement State representative stated that monitoring for extravasation should not be required by regulators, but perhaps it should be a corrective action post-medical event. The commenter went on to say that a clinician will know if they had an extravasated dose or not.
Another commenter noted that other types of extravasation, such as those of chemotherapy agentswhich can result in a medical issuecannot be monitored and or always prevented, and wondered why regulators would be concerned about radiopharmaceutical extravasations because those can be detected with imaging.
One commenter thought that therapeutic extravasations would be reported under the current regulations if it caused unintended permanent damage, and noted that extra care is taken when administering therapeutic radiopharmaceuticals, but such events may happen regardless.
The commenter went on to say that the outcome of such events would depend on the activity deposited at the injection site and the removal rate, which cannot be predicted. Another commenter followed up by saying that dose estimates are theoretical, ultimately the skin will be the dosimeter, and those results may not be fully appreciated until months later. Another commenter noted that dose estimation would have to be done using some Monte Carlo-based software, because you couldnt assume it was just a point-source at the injection site.
Numerous other commenters reiterated the difficulty that most nuclear medicine facilities would have with dosimetry for extravasations, especially facilities in a community setting where they do not have access to a medical physicist to perform these types of very lengthy and involved calculations. Another commenter elaborated on problems with a dose-based criterion for reporting extravasations as medical events: One problem with the dose-based definition is that nature of extravasation itself. Every patient has a different habitus, different rate of diffusion, different volume of extravasate, different agent, and different activity. Another commenter noted extravasations that could exceed a 50-rem dose criterion seems to be a very miniscule portion of nuclear medicine radiopharmaceuticals on the market. Another commenter stated that it is very difficult to pinpoint why an extravasation occurs, and that some patients just have weaker blood vessels and are more likely to experience extravasations. The commenter went on to say that that they did not support any changes to the regulations but if the NRC required extravasations to be reported as medical events the agency would need to provide guidance on methods to calculate skin dose.
Another commenter said that medical event reporting is not a process improvement mechanism but rather a punitive system, involving public reporting of event information within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, and (for NRC licensees, at least) triggering a reactive on-site inspection. The commenter said that extravasations are already handled by internal processes for quality improvement.
Another commenter pointed out that every medical procedure has risks, and the physician is responsible for explaining the risks and benefits to the patient, and the patient accepts or not.
Another commenter pointed out that repeat scans are uncommon, and that it would be practically impossible to implement a specific threshold for reporting extravasations. This commenter went on to explain that their facility implements ongoing quality control/quality improvement initiatives, where they monitor for extravasations and address them as part of the
Meeting Summary ML21005A436 practice of medicine. The commenter then stated that they believed PRM-35-22 was an attempt to generate sales of the petitioners technology.
Support for Regulating Extravasations One commenter stated that there is technology that can prevent extravasation, and pairing that with quality improvement processes would improve injection administration techniques. This commenter supported regulating extravasations, staying that is would be appropriate and ethical. They continued by stating that data had been submitted to the NRC showing that extravasations are not rare, and questioned how anyone could assert that that patients are not harmed when clinicians have not measured the extravasation doses? Absence of evidence is not evidence of absence. The commenter said that the way to determine whether extravasation is harmful is to monitor and measure to collect data, and that monitoring for extravasations would provide feedback that would allow clinicians to improve their technique.
The commenter acknowledged that monitoring alone would not be adequate, but it was the only place to start. The commenter also clarified that monitoring for radiation exposure was not about adjudicating the quality of the imaging scan.
Another commenter identified themselves as a retired quality/compliance vice president for a large medical device company, and that a 40-year pass for extravasations that could result in a dose larger than the current reporting requirements for medical events seems wrong. The commenter said that while monitoring for extravasations may never completely prevent an extravasation, it does offer data that could be used for improvement through feedback and training, which would ultimately be better for patients. The commenter suggested that medical event reporting requirements could be delayed while clinics improved their practices, if needed, so that concern about regulatory burden could be minimized. The commenter closed by stating that it seemed very inappropriate to not want to improve, especially for the patients.
A nuclear medicine patient commenter explained their serious concerns about how extravasations are allowed to go unreported, but if the same dose of radiopharmaceutical was spilled on the skin it would require reporting. The commenter strongly supports regulating extravasations because they believe even a one percent extravasation rate is too much, let alone a 15 percent rate, and this issue is about patients.
Other Comments David Crowley, Chair of the Organization of Agreement States, noted that some Agreement State radiation control programs do require medical event reporting of extravasations that exceed the current dose criteria, its just the NRC that excludes them from the definition of medical events. Mr. Crowley encouraged licensees to reach out to their Agreement State programs to determine how extravasations should be reported to the Agreement States.
One commenter asked for more details regarding Congressional interest in extravasations.
NRC staff noted that most of the interest came from lawmakers representing North Carolina.Letters were received from Senator Thom Tillis (NC) (ADAMS Accession No. ML19311C468); Representative David Price (NC) (ADAMS Accession No. ML19353C961);
Representatives Price, Butterfield (NC), and Holding (NC) (ADAMS Accession No. ML20182A224); and comments supporting PRM-35-22 from Senator Tillis (ADAMS Accession No. ML20272A044) and from Representatives Price, Holding, Butterfield, Cline (VA), Riggleman (VA), and McBath (VA) (ADAMS Accession No. ML20336A268).
Meeting Summary ML21005A436 Another commenter questioned, We are being told the events are common and the events are rare. Which is true? The NRC staff responded that statistics from peer-reviewed studies show that overall rates of extravasation (of all pharmaceuticals) can range from 0.1 to 16 percent, however, what is rare is a radiopharmaceutical extravasation causing observable effects that require medical follow-up. Another commenter followed-up on this comment and stated that a meta-analysis from a 2017 European Journal of Nuclear Medicine and Molecular Imaging report showed radiopharmaceutical extravasation rates lower than one percent.
One commenter asked whether the NRC would be able to review the over 400 public comments received on PRM-35-22 by the end of January, when the NRC plans to provide a draft report on extravasation to the ACMUI. The staff answered that the comments were related to the petition for rulemaking, and the staffs technical evaluation effort is separate from the petition review.
However, the petition review working group in the NRCs Division of Rulemaking is summarizing and responding to the petition comments, and they are keeping the Medical Radiation Safety Team staff informed of the comments. Another commenter noted that in PRM-35-22, some of the images maybe showed lymphatic uptake of the extravasated radiopharmaceutical, and any extravasation evaluation should consider absorbed dose beyond the point of injection to axillary lymph nodes. The commenter noted that an alpha-or beta-emitting radiopharmaceutical might give high exposure to the lymph drainage.
One commenter questioned whether the staffs evaluation was considering just diagnostic administrations or also therapeutic. NRC staff clarified that the staffs evaluation included looking at that issue, i.e., if extravasation were regulated, should the regulations be inclusive of both diagnostic and therapeutic injections, or just focus on one or the other.
Another commenter asked about ACMUIs position on extravasation, which can be found in their final recommendation report at ADAMS Accession No. ML19316E067.
Two commenters stated that extravasations were already captured by regulations at 10 CFR 35.3045, Report and notification of a medical event. NRC staff clarified that extravasations are currently not required to be reported as medical events because a Commission decision in 1980 excluded extravasation from medical event reporting. The staff did note that as part of their evaluation, they are determining whether extravasations could fit under any of the existing medical event reporting criteria in 10 CFR 35.3045.
One commenter stated that they believed that the NRC staff collaborated with the petitioner and Congress, and that the NRCs Inspector General should look into this. NRC management responded to this comment by stating that there was no collaboration on the part of NRC staff, noting that this commenter had submitted these concerns to the NRC previously and that the concerns had already been sent to the NRCs Office of the Inspector General.
One commenter stated that the petitioners company approached their medical facility with their device and said that the company requested to collect patient information related to device use, which the commenter asserted was to sell patients personal information instead of determining the utility of the device, as the company maintained. A representative of the petitioners company responded to this commenter stating that the company did not request any protect health information and the insinuation that the company collects information in order to sell it is categorically false.
Next Steps: The NRC staff will determine whether extravasations should be reported as medical events, and if so, what is the appropriate reporting threshold for these events. The
Meeting Summary ML21005A436 NRC Medical Team staff is coordinating their review with NRC rulemaking staff, and will make a recommendation to the Commission on whether to accept or deny PRM-35-22. To stay updated on the staffs evaluation of extravasations and other medical regulatory items of interest, subscribe to the NRCs Medical List Server by sending an e-mail to Medical-GC.Resource@nrc.gov with the word subscribe in the subject line.
ENCLOSURE:
NRC Meeting Participants
Enclosure U.S. NUCLEAR REGULATORY COMMISSION MEETING ON RADIOPHARMACEUTICAL EXTRAVASATIONS December 8, 2020 Meeting Participants Maryann Ayoade U.S. Nuclear Regulatory Commission (NRC)
June Cai NRC Vanessa Cox NRC Said Daibes Figueroa NRC Suzanne Dennis NRC Daniel DiMarco NRC Lisa Dimmick Medical Radiation Safety Team Leader, Presenter, NRC Chris Einberg Medical Safety and Events Assessment Branch Chief, NRC Robin Elliott NRC Linda Eusebio NRC Monica Ford NRC Anita Gray NRC Vincent Holahan NRC Donna-Beth Howe NRC Ian Irvin NRC Janelle Jessie NRC Penny Lanzisera NRC Sarah Lopas Medical Radiation Safety Team, Facilitator, NRC Pamela Noto NRC Vered Shaffer NRC Jill Shepherd NRC Katie Tapp NRC John Tappert NRC Celimar Valentin NRC Weijun Wang NRC Duane White NRC Duncan White NRC Tara Weidner NRC Lynnae Wilkins NRC Irene Wu NRC Robert Ackermann Michigan Medicine Sukhjeet Ahuja SNMMI Max Amurao Janell Anderson North Dakota Dept. of Environmental Quality Sheldon Appell Baxter Christina Arenas Jaime Barnes Cook Children's Medical Center Rochelle Batdorf Ohio State University
Michael Baxter American Pharmacists Association Cheryl Beegle National Institutes of Health Michael Bellamy MSKCC Kendall Berry Fox Chase Cancer Center Bernard Bevill Arkansas Department of Health Dmitry Beyder Vihar Bhakta Robert Bicknell New Mexico Environment Department Jerry Bingaman State of Tennessee Margaret Blackwood Karen Blanchard Texas Department of State Health Services Katherine Boyd VA NHPP Becca Branum Adam Brown Andrew Brown Cardinal Health Nuclear & Precision Health Solutions Haley Brown State of Nevada Radiation Control Program Jeff Brunette Tonia Bryant Tina Buehner Society of Nuclear Medicine & Molecular Imaging Susan Bunning MITA Karen Burgard Mary Burkhart IEMA Paul Burns David Bushnell VHA Janice Campbell Beaumont Health Philip Campbell University of Washington Kari Cann Paul Carby APhA James Carey MPC, Inc Todd Carpenter Oregon Health Authority Cason Coan ADPH Radiation Control Trisha Coffman Thomas Collins NM Radiation Control Bureau Jacqueline Cook U.S. Nuclear Regulatory Commission Jim Cordes Neall Gross Whitney Cox IEMA Lee Cox State of North Carolina Elaine Crescenzi PA DEP Corey Creveling David Crowley NC Radiation Protection Section Bruce Curran VCU Health System Randal Dahlin Iowa Department of Public Health Miguel de la Guardia Cook Children's Med. Cntr.
Karen Deibert NDDEQ Matt Dennis
Terry Derstine PA DEP Lora Deuitch Ariel Doucet Virtua Jeff Dovyak Shared Health Jacob Edelman Dana-Farber Jamie Eisenberg Deirdre Elder UCHealth Jennifer Elee LDEQ Jenna Engelking William Erwin Karl F
Lynne Fairobent FDA Asfaw Fenta VDH Erik Finkelstein NY City Dept of Health Karen Flanigan NJDEP Radioactive Materials Program John Follette State of Nevada Radiation Control Program Beth Franklin Atrium Health Scott Fuller Sandy Gabriel Drew Garner Farrah Gaskins Noelle Geier Froedtert & the Medical College of Wisconsin Jen Gersman Munir Ghesani Cindi Gilbert Judy Glass SLHS Brian Goldstein Jenny Goodman NJ Department of Environmental Radiation William Gorge Johnny Graves Valerie Gray Timothy Greist Sebastien Gros Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology Nina Gutierrez-Garcia Amir H. Khandani Matt Hadden Michael Hall Emory University David Hamby Renaissance Code Development Stanley Hampton Eli Lilly and Company Barbara Hamrick UCI Health Laura Hanson UAMS Yvette Harden VA Ann Arbor Healthcare System Billie Harvey
Hillary Haskins Oregon Health Authority - Radiation Protection Services Xin He Chris Hernandez Veterans Administration Jeff Herschell Kansas Department of Health and Environment Kathleen Hintenlang James Hirn Illinois Emergency Management Agency Timothy Hooker Tom Huston Jeremy Iman Chicago Franciscan Hossein Jadvar USC Donna Janda Dan Januseski Janelle Jesikiewicz UPENN EHRS Valerie Jewells UNC Scottie Jones Hospital Tracy Jue Rebecca Junod U.S. Nuclear Regulatory Commission Lori Kaczmarek Association for Vascular Access Brian Kelley Kassia Kelly Jessica Kendrick FOX CHASE CANCER CENTER Josh Knowland Lucerno Dynamics LLC Arda Konik Catalina Kovats Children's National Hospital Christine Krieman Sasikala Krishnasarma TDEC-DRH Kevin Kunder FDOH Bureau of Radiation Control Yuji Kuzuhara Ian Lake Sue Langhorst Olusegun Larinde University of Illinois at Chicago FirstName LastName Company Ronald Lattanze Lucerno Dynamics Samantha Lav Georgia Lawrence Ivania Lazo Dao Le Bryan Lemieux University of KY HealthCare Sam Leveritt Cardinal Health NPHS #7120 Ramon Li CDPHE Ralph Lieto Samantha Lockerby Einstein Healthcare Network Nancy M Swanston UT MD Anderson Cancer Center Josh Mailman Carol Marcus UCLA
Alicia Mares Anna Marks John Martell Washington State Department of Health Jacob Martin Richard Martin American Association of Physicists in Medicine Melissa Martin Therapy Physics Inc Jeff Mason Nic Mastascusa University of Iowa Hospitals and Clinics Osama Mawlawi MD Anderson Cancer Center Candi McDowell University of Pennsylvania Michelle McGuirk Allegheny Health Network Josh McIlvain DTC Tara Medich Massachusetts General Hospital Heather Merchantz Richelle Millican Kathy Modes Angie Morgan Hill Arkansas Department of Health Les Morrison Kansas City VAMC Mitchel Muhleman Robin Muzzalupo IEMA Regen Newton michigan medicine Janice Nguyen Jennifer Noll PA DEP Jorge OIdan UNC-Chapel Hill Brooke Olson NDDEQ Elba Orduna Doctors' Center Hospital Michael Ortiz New Mexico Environment Dept.
Zoubir Ouhib SNMMI OUTREACH Society of Nuclear Medicine and Molecular Imaging Alan Packard SNMMI Virginia Pappas Society of Nuclear Medicine and Molecular Imaging Ronald Parsons State of Tennessee-Radiological Health Netra Patel S
Perrin Michael Peters American College of Radiology Tricia Peters Ridley-Tree Cancer Center Phillip Peterson Anastasia Petrova BD Neil Petry Josephine Piccone Brooke Pipes Carmine Plott Novant Health Forsyth Medical Center Jacob Powell Sandra Ramirez Kimyli Recca
Steve Regn Jennifer Rice Joseph Ring Beth Israel Deaconess Medical A. Robert Schleipman Mass General Brigham Santiago Rodriguez NMED-RCB Gloria Romanelli Michael Rubadue Ohio Department of Health Manar Sakalla Medstar Georgetown David Scalise NH DHHS Tracy Scherer Casey Schmitz University of Oklahoma Health Sciences Center David Schuster Emory University Katie Scott PA DEP Brian Serencsits Sheila Shaffer Beaumont Health System - Royal Oak Hospital Michael Sheetz Beth Shelton State of Tennessee Aaron Short KDHE Dominic Siewko Jubilant Radiopharma Michelle Simmons Roy Sions Saint Luke's Health System Roger Sit University of North carolina at Chapel Hill Eric Skotak Texas Department of State Health Services Levi Slager Susan Slane SJSlane Consulting Michael Snee Dan Snyder Geisinger Jill Southerland KDHE Nancy Stanley NJ Department of Environmental Protection Kimberly Steves Kansas Dept of Health and Environment Allyson Stout KY Department for Public Health, Division of Public Health and Safety David Stradinger ND Dept of Environmental Quality Glenn Sturchio Mayo Clinic Susan Suchan David Switzer Andrew Taylor Wendy Terrenoire Judy Thompson Michelle Thompson UPPI Christopher Tighe University of Pennsylvania Christopher Tighe University of Pennsylvania Michael Timmerman Dartmouth-Hitchcock Cindy Tomlinson ASTRO David Townsend
David Turberville AL Office of Radiation Control James Uhlemeyer KDHE Richard Wahl Mallinckrodt Institute of Radiology Paul Wallner Deborah Wenke Nancy Wersto FDA/HHS William White Rush University Medical Center Sharon White Univ. of Alabama at Birmingham Kevin Williams Mathew Williams MGUH David Williams Thomasville Pediatrics Sean Wilson Carilion Clinic Melonie Wissing VHA Ann Arbor Healthcare System John Witkowski UPPI LLC Harvey Wolkov Sutter health Terry Wong Duke University Edward Wroblewski Jason Young Mayo Clinic Christin Young UVM Medical Center Pat Zanzonico Memorial Sloan Kettering Cancer Center, Dept of Medical Physics Andrew Zimnoch University of Pennsylvania