The value of a diagnostic test lies in its ability to detect patients with disease (its sensitivity) and to exclude patients without disease (its specificity). For tests with binary outcomes, these measures are fixed. For tests with a continuous scale of values, various cutoff points can be selected to adjust the sensitivity and specificity of the test to conform with the physician's goals. Principles of statistical decision theory and information theory suggest technics for objectively determining these cutoff points, depending upon whether the physician is concerned with health costs, with financial costs, or with the information content of the test.

This special report aims to inform the medical community about the many challenges involved in managing radiation exposure in a way that maximizes the benefit-risk ratio. The report discusses the state of current knowledge and key questions in regard to sources of medical imaging radiation exposure, radiation risk estimation, dose reduction strategies, and regulatory options.

Physicians have a specific responsibility toward patients who are hopelessly ill, dying, or in the end stages of an incurable disease. In a summary of current practices affecting the care of dying patients, we give particular emphasis to changes that have become commonplace since the early 1980s. Implementation of accepted policies has been deficient in certain areas, including the initiation of timely discussions with patients about dying, the solicitation and execution in advance of their directives for terminal care, the education of medical students and residents, and the formulation of institutional guidelines. The appropriate and, if necessary, aggressive use of pain-relieving substances is recommended, even when such use may result in shortened life. We emphasize the value of a sensitive approach to care--one that is adjusted continually to suit the changing needs of the patient as death approaches. Possible settings for death are reviewed, including the home, the hospital, the intensive care unit, and the nursing home. Finally, we consider the physician's response to the dying patient who is rational and desires suicide or euthanasia.

, and (iii) the overall radiation dose deposited by radiolabeled cells in the unlabeled cells within the growing tumor is <10 cGy, we conclude that the results obtained are a consequence of a bystander effect that is generated in vivo by factor(s) present within and͞or released from the 125 IUdR-labeled cells. These in vivo findings significantly impact the current dogma for assessing the therapeutic potential of internally administered radionuclides. They also call for reevaluation of the approaches currently used for estimating the risks to individuals and populations inadvertently exposed internally to radioactivity as well as to patients undergoing routine diagnostic nuclear medical procedures. Studies in recent years have demonstrated that a radiobiologic phenomenon termed the ''bystander effect'' can be observed in mammalian cells grown in vitro. Bystander damage describes biologic effects, originating from irradiated cells, that occur in unirradiated neighboring cells. Several investigators have reported that when ␣-particles traverse a small fraction of a cell population in vitro, lower rates of survival and higher rates of genetic change are observed than those predicted from directionization-only models (1-6). These changes include increased levels of sister chromatid exchanges, mutations, and micronuclei formation, changes in gene expression, and oncogenic transformation. Cell survival is likewise compromised when cells are cocultured with tritiated thymidine-labeled cells (7, 8) and iodine-125 (9). Similarly, the bystander effect has been reported for microcolonies that have been ␥ irradiated (10) and for cells exposed to media from ␥-irradiated cells (10, 11). Evidence from these reports challenges the past half-century's tenet that radiation produces effects only in cells whose DNA has been damaged either through direct ionization or indirectly (for example, through hydroxyl radicals produced in water molecules in the immediate vicinity of the DNA).Whether radiation-induced bystander effects represent a phenomenon that occurs only ex vivo, i.e., are a byproduct of in vitro conditions and manipulations, or whether they are factual in vivo events has not been fully examined. Consequently, the extension of conclusions derived from in vitro studies to the in vivo situation is uncertain. The demonstration of a bystander effect with an in vivo system and the elucidation of the underlying mechanisms of an in vivo bystander effect would go a long way in translating its implications for humans.Recently, Watson et al. (12) demonstrated chromosomal instability in the progeny of unirradiated bone marrow cells mixed with cells exposed ex vivo to neutrons and transplanted into recipient mice. In this novel system, a sex-mismatch transplantation protocol provides a three-way marker system and allows the investigators to distinguish not only host-derived cells from donor-derived cells, but also irradiated donor stemcell-derived cells from nonirradiated donor stem-cell-derived cells. These studies thus provide the...

Alpha particles are energetic short-range ions whose higher linear energy transfer produces extreme cytotoxicity. An alpha-particle-emitting radioimmunoconjugate consisting of a bismuth-212-labeled monoclonal immunoglobulin M specific for the murine T cell/neuroectodermal surface antigen Thy 1.2 was prepared. Analysis in vitro showed that the radioimmunoconjugate was selectively cytotoxic to a Thy 1.2+ EL-4 murine tumor cell line. Approximately three bismuth-212-labeled immunoconjugates per target cell reduced the uptake of [3H]thymidine by the EL-4 target cells to background levels. Mice inoculated intraperitoneally with EL-4 cells were cured of their ascites after intraperitoneal injection of 150 microcuries of the antigen-specific radioimmunoconjugate, suggesting a possible role for such conjugates in intracavitary cancer therapy.

The radiotoxicity of 125I in Chinese hamster V79 lung fibroblasts has been studied following extracellular (Na125I), cytoplasmic [125I]iododihydrorhodamine (125I-DR), and nuclear (125IUdR) localization of the radionuclide. Exposure of the cells for 18 h to Na125I (less than or equal to 7.4 MBq/ml) had no effect on survival. A similar exposure to 125I-DR produced a survival curve with a distinct shoulder and with a mean lethal dose (D37) of 4.62 Gy to the nucleus. While this value compares well with the 5.80 Gy X-ray D37 dose, it is in contrast to the survival curve obtained with DNA-bound 125IUdR which is of the high LET type and has a D37 of 0.80 Gy to the nucleus. Furthermore, when the uptake of 125I into DNA is reduced by the addition of nonradioactive IUdR or TdR to the medium and the survival fraction is determined as a function of 125I contained in the DNA, a corresponding increase in survival is observed. This work demonstrates the relative inefficiency of the Auger electron emitter 125I when located in the cytoplasm or outside the cell. It indicates that a high dose deposited within the cytoplasm contributes minimally to radiation-induced cell death and that radiotoxicity depends not upon the specific activity of IUdR but upon the absolute amount of 125I that is associated with nuclear DNA.

The kinetics of uptake, retention, and radiotoxicity of 125IUdR have been studied in proliferating mammalian cells in culture. The radioactivity incorporated into the DNA is directly proportional to the duration of incubation and to the extracellular concentration of 125I. The rate of proliferation of cells is related to the intracellular radioactive concentration and is markedly reduced at medium concentrations greater than or equal to 0.1 mu Ci/ml. At 37% survival the high LET type cell survival curve is characterized by an uptake of 0.035 pCi/cell, and the cumulated mean lethal dose to the cell nucleus is about 80 rad compared to 580 rad of X-ray dose for this cell line. The strong cytocidal effects of the decay of 125I correlate with localized irradiation of the DNA by the low energy Auger electrons.

The value of pediatric nuclear medicine is well established. Pediatric patients are referred to nuclear medicine from nearly all pediatric specialties including urology, oncology, cardiology, gastroenterology, and orthopedics. Radiation exposure is associated with a potential, small, risk of inducing cancer in the patient later in life and is higher in younger patients. Recently, there has been enhanced interest in exposure to radiation from medical imaging. Thus, it is incumbent on practitioners of pediatric nuclear medicine to have an understanding of dosimetry and radiation risk to communicate effectively with their patients and their families. This article reviews radiation dosimetry for radiopharmaceuticals and also CT given the recent proliferation of PET/CT and SPECT/CT. It also describes the scientific basis for radiation risk estimation in the context of pediatric nuclear medicine. Approaches for effective communication of risk to patients' families are discussed. Lastly, radiation dose reduction in pediatric nuclear medicine is explicated.