William F. Blakely, Ph.D.

Biodosimetry Recording and Assessment Tools

Armed Forces Public Health Conference, Radiation Health Track; 1020-1120 Thursday March 24, 2011;Hampton, Virginia

Armed Forces Radiobiology Research Institute, Bethesda, Maryland, USA

Biodosimetry Research Program Advisor

Email: william.blakely@usuhs.edu

BIODOSIMETRY IN THE 21st CENTURY Training Meeting

HICARE in collaboration with the International Atomic Energy Agency Hiroshima, Japan, June 10-14, 2013.

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Disclaimer

The opinions, conclusions, and recommendations expressed or implied do not necessarily reflect the views of the Department of Defense or any other department or agency of the federal government.

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Acknowledgments Co-workers: David J. Sandgren, Ira H. Levine, Sergio Gallego (AFRRI, Scientific Research Department)

John P. Madrid, Brian E. Livingston, Charles A. Woodruff (AFRRI, Military Medical Operations Department)

Ronald E. Goans (MJW Corporation; REAC/TS)

Mark A. Melanson (AFRRI, Directorate)

Support for this research under AFRRI project RAB4AL and RBB4AR.

Presentation Objectives • Review doctrine supporting biological dosimetry and

medical response recording for radiological casualties • Provide the process to access and install AFRRI’s

Biological Dosimetry dosimetry tools (Medical Guidance, Medical Data Forms, Exposure Assessment Software Applications)

• Illustrate AFRRI’s Biodosimetry Assessment Tool (BAT) software functional elements

• Describe applications of BAT’s data collection screens for selected radiation scenarios and clinical historical cases

• Compare BAT’s dose assessment algorithms with those prior published

Melanson MA (2010) AFRRI Special Issue of ORS. Health Phys. 99 Suppl 5:S169-170.

Sandgren DJ, Salter CA, Levine IH, Ross JA, Lillis-Hearne PK, Blakely WF (2010) Biodosimetry Assessment tool (BAT) software – Dose prediction algorithm. Health Phys. 99 Suppl 5:S171–183.

Blakely WF, Madrid JP, Sandgren DJ (2010) Biodosimetry medical recording – Use of Biodosimetry Assessment Tool. Health Phys. 99 Suppl 5:S184–191.

Goans RE (2010) Clinical Application of the AFRRI BAT Computer Program. Health Phys. 99 Suppl 5:S192-S192.

Frank D. Duffy – Editor and Website Design Lana Rose – Website Programmer HM2 S. Gallego – Tester William Jackson – Mathematical Data Analyst

Capt B. Livingston – BAT Team member ENS L.A. Aleman – BAT Team member Lana Rose – Website Programmer Charles Woodruff - Tester

Cover photo by Dave H. Morse

Additional Credits:

Note. Current AFRRI BAT Team Members are shown in green color.

Operational Requirement: Dose Assessment

IAEA Generic

Procedures for Medical

Response During Nuclear

and Radiological Emergency

• Need to differentiate between worried well and exposed individuals for appropriate use of medical resources.

• Need to perform and record exposure assessments for each suspected exposed individual.

• No single assay is sufficient for all complex potential radiation exposure scenarios involving mass casualties.

• Multiple bioassay and integrated approach is required for triage, clinical, and definitive radiation biodosimetry.

NATO STANAG 2474

NATO Standardization Agreement STANAG 2474 NBC/MED

Determination and Recording of Ionizing Radiation Exposure For Medical Purposes

Aim To ensure that operationally incurred ionizing radiation doses, estimated or measured, of all those presenting, whether as outpatients or inpatients, at medical facilities, are obtained and recorded, or measures taken for subsequent determination and recording, in appropriate medical records, so that medical management may be optimized and full and permanent records created.

Symptom Degree 1 Degree 2 Degree 3 Degree 4G

DiarrhoeaFrequency 2 – 4 stools / d 5 – 8 stools / d > 8 stools / d refractory diarrhoeaConsistency bulky loose sloppy wateryMucosal Loss/ d intermittent intermittent & large

amountpersistent persistent & large

amountBleeding / d occult intermittent persistent gross haemorrhage

AbdominalCramps/ Pain

minimal tolerable intense refractory

Symptom Degree 1 Degree 2 Degree 3 Degree 4H

Granulocytes(4-9 x109/l)

> 2 x109/l 1-2 x109/l 0,5-1 x109/l < 0.5 x109/l

Infection local; no antibiotictherapy required

local; only localantibiotic therapyrequired

systemic; p.o.antibiotic treatmentsufficient

sepsis; i.v. antibioticsnecessary

Thrombocytes(140-400 x109/l)

> 100 x109/l 20-50 x109/l < 20-30 x109/l < 10 x109/l

Blood loss petechiae; easybrusiability normalHb

mild blood loss with< 10 % decrease inHb

gross blood loss with10 – 20 % decreasein Hb

spontaneous bleedingordebilitating blood losswith > 20 % decreasein Hb

Lymphocytes(1.5-4 x109/l)

> 1.5 x109/l 1-1.5 x109/l 0.5-1 x109/l < 0.5 x109/l

Symptom Degree 1 Degree 2 Degree 3 Degree 4C

Erythema minimal andtransient

moderateisolated patches <10cm2, not morethan 10 % of bodysurface

marked,isolated patches orconfluent, 10 – 40 %of the body surface

severeisolated patches orconfluent, > 40 % ofthe body surface,erythroderma

Sensation/Itching pruritus Slight andintermittent pain

Moderate andpersistent pain

Severe and persistentpain

Swelling andOedema

presentasymptomatic

symptomatictension

secondarydysfunction

total dysfunction

Blistering rare, with sterilefluid

rare, withhaemorrhage

bullae with sterilefluid

bullae withhaemorrhage

Desquamation absent Patchy, moist moist moistUlcer / Necrosis epidermal only dermal subcutaneous muscle and bone

involvementHair loss thinning

not strikingpatchyvisible

completeand most likelyreversible

complete and mostlikely irreversible

Pigmentation(Hyper/Hypo)

absent slight moderate marked

Onycholysis absent partial partial/ complete complete

Symptom Degree 1 Degree 2 Degree 3 Degree 4 N

Nausea mild tolerable intense excruciating Vomiting occasional

1 / d intermittent 2 – 5 / d

persistent 6 – 10 / d

refractory > 10 / d or parenteral nutrition

Anorexia able to eat, reasonable intake

significantly decreased intake but able to eat

no significant intake parenteral nutrition

Fatigue Syndrome able to work or perform normal activity

interferes with work or normal activity

needs some assistance for self-care

prevents daily activity

Fever without infection

< 38° C 38 – 40° C > 40° C for less than 24 h

> 40°C for more than 24 h or accompanied with hypotension

Headache minimal tolerable intense excruciating Hypotension ∅ ∅ transient persistent Neurologic deficit barely detectable

neurologic deficit , able to perform normal activity

easily detectable neurologic deficit, no significant interference with normal activity

prominent neurologic deficit, significant interference with normal activity

life threatening neurologic signs, loss of conciousness

Cognitive functions minor loss of memory, reason and/or judgement

moderate loss of memory, reason and/or judgement

major intellectual impairment

complete memory loss and/or incapable of rational thoughts

• N = Neurovascular System • H = Hematopoietic System • C = Cutaneous System • G = Gastrointestinal System

Medical Treatment Protocols for Radiation Accident Victims

(METREPOL) Organ-Specific

Checklists

Publication: T. M. Fliedner, I. Friesecke, K. Beyrer (Edit.): Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome. British Institute of Radiology, London, 2001

AFRRI Website: www.usuhs.edu/afrri/

Products/Radiation Biological Dosimetry Tools for Emergency Responders

Casualty management guidance • Pocket guide to emergency procedures • Handbook on medical management of radiological

casualties • Quick Reference Information (NCRP

Recommendations) • Internal Contamination

Medical data forms • One-page emergency medical record • Six-page radiation exposure worksheet • One-page radiocesium worksheet

Exposure assessment software • Data-entry generated recording and diagnostic tools

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Actions needed in suspected overexposures: • Perform measurement and bioassay, if appropriate, to determine

radionuclide contamination • Record physical dosimetry measurements, if available • Observe/record prodromal signs/symptoms and erythema • Obtain CBC with white blood cell differential immediately, then

every 6 hours for 2-3 days, and then twice a day for 4 days • Contact qualified laboratory to evaluate performance of

chromosome-aberration cytogenetic bioassay, using the “gold standard” dicentric assay for dose assessment

• Consider other opportunistic dosimetry approaches as available

Biodosimetry — General Guidance

Blakely WF, Salter CA, Prasanna PG. Early-response biological dosimetry — recommended countermeasure enhancements for mass-casualty radiological incidents and terrorism. Health Physics 89(5):494–504, 2005. Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management of the acute radiation syndrome: recommendations of the Strategic National Stockpile Radiation Working Group. Ann Intern Med. 140(12):1037–1051, 2004.

Biodosimetry Concept of Operations – Medical Recording

Blakely et al. Health Physics 99 (suppl 3): S184-S191, 2010

Medical Recording Forms

AFRRI Adult/Pediatric Field Medical Record: This medical record provides a convenient one-page form for gathering emergency medical information in the field. It is applicable to both adult and pediatric cases. AFRRI Biodosimetry Worksheet: This data entry worksheet, recently expanded from four to six pages, provides a place for recording the facts about a case of radiation exposure, including the source and type of radiation, the extent of exposure, and the nature of the resulting injuries. Applicable to both adult and pediatric cases. Prussian blue work sheet: AFRRI Form 335 describes the initial assessment and treatment of casualties from a radiation dispersal device (RDD) event that involves the dispersal of radioactive cesium or thorium.

AFRRI website: www.usuhs.edu/afrri/

Updated worksheet includes the METREPOL ARS severity response scoring system

AFRRI Field Medical Record

• Adapted from DD 1380 “U.S. Field Medical Record”

• Adult and Pediatric

Radiocesium Worksheet & FDA Insert

Medical Recording

Forms

Updated worksheet includes radiation responsive serum/plasma biomarkers

T. M. Fliedner, I. Friesecke, K. Beyrer (Edit.): Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome. British Institute of Radiology, London, 2001

Medical Treatment Protocols (METREPOL) for Radiation Accident Victims

AFRRI website: www.usuhs.edu/afrri/

Modified original METREPOL severity score for hematology kinetics

Software Program for Collection of Radiation Exposure Medical Data

• Interprets dose-related diagnostic signs and records blood cell counts and other indices of exposure

• All file stored on local hard

drive

• BAT and other products available at AFRRI website http://www.usuhs.edu/afrri/

• Online: – Preferred distribution

method – Request online – Receive email notification

with download location and install instructions

BAT Software Download online

Note: BAT has been accessible for downloading from AFRRI’s website, since the initial release on June 17, 2002 (version 0.75).

MC4’s Release of AFRRI’s Product: eBAT

https://www.mc4.army.mil/

• MC4 trusted agent (John Hopkins Physics Laboratory) assessed the technical readiness level (TRL) of Biodosimetry Assessment Tool (BAT) at level 4

• TRL level conversion 6 achieved after information assurance changes: – AFRRI revised BAT addressing some 10 of 14 changes, provided BAT

documentation, transitioned renamed software, eBAT, source code to MC4, and provided MC4’s programmer training and guidance to further revise eBAT;

– MC4 incorporated 2nd level of encryption, username and password sign-in access, default format for filenames, and record of users’ access to individual files into Block 2 (MS Windows XP);

– AFRRI tested eBAT on Windows XP OS; – MC4 obtained CENCOM required approvals

• MC4 deployed eBAT with AHLTA-Theatre in late July 2009

BAT: Mission Statement

• Promote rapid data collection for prompt use after a radiation exposure incident

• Provide diagnostic information, such as dose estimates, using multiparameter indexes, for managing radiation casualties

• Record additional related clinical information (e.g., extent of contamination, wounds, infection) necessary for proper medical care

• Summarize (display) diagnostic and therapeutic information

• Archive collected data for later use in radiation protection matters

Program Schematic: BAT Application

Contamination/ Wound

Prodromal Symptoms

Hematology

Erythema

Physical Dosimetry

Lymphocyte Cytogenetics

Infection Summary

Overview Information

Exposure Information

Patient Report

Radioisotope Information

Physician’s Notes

BAT User Screens – Flow Chart

Sandgren et al. Health Physics 99 (suppl 3): S171-S183, 2010

Blakely et al. Health Physics 99 (suppl 3): S184-S191, 2010

Blakely et al. Health Physics 99 (suppl 3): S184-S191, 2010

Use of “tabs” to access various folders

BAT Software: Program Operations

Blakely et al. Health Physics 99 (suppl 3): S184-S191, 2010

Dose (Gy)

Table 1. Human data sets used in the development of BAT algorithms

Onset of vomiting Hematology Radiation quality Reference

+ + Photon Anno et al. 1989; Sine et al. 2001; Fig. 2b

+ + Photon, mixed photon & neutron

Goans 2001; Goans et al. 1997, 2001; Sandgren et al. 2010 (Fig. 2b)

+ + Photon, mixed photon & neutron Sandgren et al. 2010 (Fig. 2b)

- + Photon, mixed photon & neutron

Guskova et al. 1988 Guskova - personal communication

- + N/A (control) AFRRI unpublished studies

[1] The data used to create the dose predicting algorithms for the time of onset of emesis and lymphocyte kinetics consisted of a combination of data sets from the sources listed. These data are restricted information due to medical confidentiality regulations. [2] Hematology data from these sources were entered into a pooled database. The surface plots for lymphocyte changes as function of dose and time after radiation were previously published (Sine et al. 2001). [3] Personal communication with Dr. George H. Anno (Pacific-Sierra Research Corporation, USA). Time of emesis data is depicted in Fig. 2b. [4] Personal communication with Dr. Ronald E. Goans [Radiation Emergency Assistance Center/Training Center (REAC/TS), USA]. Time of emesis data is depicted in Fig. 2b. [5] Both hematology and emesis data were obtained from the REAC/TS registry. Time of emesis data is depicted in Fig. 2b. f Personal communication with Dr. Angela K. Guskova [Medical Radiological Research Center, Russian Academy of Medical Sciences (MRRC, RAMS), Russia].

Sandgren et al. Health Physics 99 (suppl 3): S171-S183, 2010

BAT Algorithms Database

Onset of Vomiting

Filter validpoints

N

N

Y

Y

Y

n ≥ 1

n < 3

pg1 calcfor 1st pt

pg1 calcfor 2nd pt

n > 1

stop

report report

Report: dose3 or more msg

Y

Y

N

BHAT≥ 0

BHAT

AHAT< 1.5

Dose< 1.5

N

Report: “0”

AHAT

N

GoansMultiple

GuskovaMultiple

Y

Dose< 1

N

Dose> 8

N

NY

YReport: “0”

Report: dose

Report: “0”

Report: “>8” Report: dose

Dose> 10

YReport: “>10”

N

N

YReport: “Evidence of exposure, butcan’t make a prediction…” msg

Report: “0 Gy”“normal range” msg“adult population” msg

+Slope &

mean lym #< 1

All lym# Normal &

T < 36h

Report dose& Confidence Interval

Y

Dose Predictions Based on Lymphocyte Counts or Lymphocyte Depletion Kinetics

Sandgren et al. Health Physics 99 (suppl 3): S171-S183, 2010

Table 2. Applicability of the seven BAT data collection screens toward medical

recording for victims of selected radiological exposure scenarios

Industrial

accident with

exposure &

contamination

Radiological

exposure

device on

bus/train

Dirty

bomb

Improvised

nuclear

device

Physical dosimetry Possibly No No No

Contamination Yes No Yes Yes

Prodromal symptoms Yes Yes Unlikely Yes

Hematology Yes Yes Unlikely Yes

Lymphocyte

cytogenetics

Yes Possibly Unlikely Unlikely

Erythema/wound Yes Yes Yes Yes

Infection Yes Yes Yes Yes

Blakely et al. Health Physics 99 (suppl 3): S184-S191, 2010

Goans, Health Physics 99 (suppl 3): S192-S197, 2010

Ronald.Goans@comcast.net

Historical Cases – U.S. Radiation Accident Registry (Radiation Emergency Assistance Center/Training Site)

Cases Exposures Incident 1 High level acute, external

exposure (2-4 Gy)

Univ. of Tennessee Comparative Animal Research Laboratory (CARL), 2 April 1971

2 Fatal criticality event (100+ 50 Gy)

Wood River Junction, 1964

3 High dose (2.7 Gy)

Y-12 criticality accident, 18 June 1958

4 Low dose (0.25 Gy)

Y-12 criticality accident, 18 June 1958

5 Fatal external gamma dose (9-11 Gy)

Cobalt sterilization accident in Belarus, 1991

Goans, Health Physics 99 (suppl 3): S192-S197, 2010

Goans, Health Physics 99 (suppl 3): S192-S197, 2010

TLD: 2.6 Gy (right hand: 12 Gy) Emesis: 2.25 h post exposure Daily CBCs Initial BAT estimate: 2.5 to 4 Gy

Univ. of Tennessee Comparative Animal Research Laboratory (CARL), 2 April 1971

Goans, Health Physics 99 (suppl 3): S192-S197, 2010

Patient B from Y-12 Criticality Accident, 18 June 1958

Emesis: 4 h post exposure and persisted; 1st day CBC: 3 Gy Initial BAT estimate: 3 Gy

Goans, Health Physics 99 (suppl 3): S192-S197, 2010

AFRRI website: http://www.usuhs.edu/afrri/outreach/

biodostools.htm

Whole-body radiation from external radiation or internal absorption

Phase of syndrome

Feature Subclinical range Sublethal range Lethal range

0-100 rad

(cGy)

100-200 rad (cGy)

200-600 rad (cGy)

600-800 rad (cGy)

600-3000 rad

(cGy)

> 3000 rad (cGy)

Initial or prodromal

Nausea, vomiting

none 5-50% 50-100% 75-100% 90-100% 100%

Time of onset 3-6 hours 2-4 hours 1-2 hours < 1 hour Minutes

Duration < 24 hours < 24 hours < 48 hours < 48 hours N/A

Lymphocyte count

Unaffected

Minimally decreased

< 1000 at 24 hours

< 500 at 24 hours

Decreases within hours

Decreases within hours

CNS function No impairment

No impairment

Routine task performance, cognitive impairment for 6-20 hours

Simple and routine task performance, cognitive impairment for > 24 hours

Rapid incapacitation, may have a lucid interval of several hours

Department of Veteran Affairs Pocket Guide Terrorism with Ionizing Radiation–General Guidance

First-responders Radiological Assessment Triage (FRAT)

Dosimetry and radioactivity

contamination Blood lymphocyte

counts

Diagnostic, hospitalization, and mortality

messages

Dose assessment

Signs, symptoms and erythema

Dosimeter readings

Location- based dose

estimate

Internal contamination

Vomiting

Diarrhea

Headache Tachycardia Consciousness Body temperature Weakness

Fatigue

Erythema

FRAT–Outline of Software Application Design

Category Dose (Gy) Ranking reliability factor Median Median absolute

deviation Vomiting onset

Within 30 minutes > 10 90 10 30-40 minutes 8-10 70 20 40-60 minutes 6-8 72.5 17.5

1 hour - 1½ hours 4.5-6 61.25 16.25 1½ - 2 hours 3.6-4.5 50 12.5 2 - 4½ hours 2-3.6 38.75 15 4½ - 9 hours 1.2-2 27.5 11.25

Body temperature severity Increased (98.6–100.4oF) 2-4 40 20

Fever (100.4-102oF) 4-6 45 15 High fever (>102oF) > 6 60 15

FRAT Expert Panelist Consensus Survey Results

0

1

2

3

4

5

6

0 10 20 30 40 50 60 70 80 90 100

Reliability Ranking Factor

Freq

uenc

y

1 Lymphocyte Count2 Lymphocyte Counts

3 Lymphocyte Counts

Blood lymphocyte counts

Frequency Distribution Diagrams of FRAT Expert Panelist Consensus Survey Results

0123456789

0 10 20 30 40 50 60 70 80 90 100

Reliability Ranking Factor

Frequ

ency dosimeter reading

location-based doseestimate

Dosimetry

Sample Data Entry Screens

FRAT Dose Assessment Report Screens

Radiation OVEREXPOSURE potential severe acute medical impact

250-285

Biodosimetry Assessment Tool

Operational Relevance BAT fulfills the requirements for the NATO STANAG 2472, NBC/MED Determination and Recording of Ionising Radiation Exposure for Medical Purposes

Pocket PC

Palm PDA

Windows OS

Windows 2002 for

Pocket PC OS

Palm OS

Website Download CDROM Release

Distributed by TSWG’s Developer’s of First Responder

Software Applications

First-responders Radiological Assessment Triage (FRAT)

Radiation Pocket Guide

The First-responders Radiological Assessment Triage (FRAT) software application for the Palm OS and Windows (WinFRAT) is being designed specifically for use by first responders and will provide general guidance and triage dose assessment tools. The information will be based on the components of the radiation pocket guide and will require minimal text entry.

Benefits of the BAT & FRAT Software Programs

• Improves medical care of irradiated patients • Is a cost-effective, simple solution • Integrates current knowledge • Provides risk management in radiation

protection analysis

• Provides multiple delivery platforms • Report features meet NATO STANAG 2472

requirements

Radiological Medical Recording Tools • Medical recording forms and BAT

accessible on MMO’s CDROM and by download from AFRRI website

• MC4 deployed eBAT (JUL09)

• AFRRI provided input on revision of NATO STANAG 2474 “Recording of Operational Ionising Radiation Exposure for Medical Purposes and Management of Dosimeters, Edition 2” (OCT09)

• Beta FRAT prototype (Palm OS, Pocket PC OS, Windows) ready for website release & transition onto MMO’s CDROM to test algorithms for multiple parameter dose assessment

Publication list available at website: http://www.usuhs.edu/afrri/research/biodos.htm

Summary • AFRRI’s radiation biological dosimetry tools facilitate

dynamic recording of diagnostic information essential to support medical response for radiation casualty incidents

• Dose assessments contribute but should not be used alone to dictate life-saving medical treatment decisions since confounding factors such as dose rate and radiation quality can profoundly influence clinical outcome

• Future updates to BAT are planned to provide individual radiation injury parameters linked to consensus guidance for specific medical treatments

• AFRRI’s tools are available at AFRRI’s website for downloading and the AFRRI’s MEIR CD-ROM

Publications Manuscripts: Sandgren DJ, Salter CA, Levine IH, Ross JA, Lillis-Hearne PK, Blakely WF (2010) Biodosimetry Assessment Tool (BAT) software—Dose prediction algorithm. Health Phys. 99 Suppl 5:S171–183. Blakely WF, Madrid JP, Sandgren DJ (2010) Biodosimetry medical recording—Use of Biodosimetry Assessment Tool. Health Phys. 99 Suppl 5:S184–191. Salter CA, Sandgren DJ, Levine IH and Blakely WF (in press) New Biodosimetry Tools to Support Mental Health in Nuclear/Radiological Accidents or Terrorism. NDU Press book title: Military Operational Psychology: Applying Research Psychology to Improve Performance and Policy. Waller E, Millage K, Blakely WF, Ross JA, Mercier JR, Sandgren DJ, Levine IH, Dickerson WE, Nemhauser JB, Nasstrom JS, Sugiyama G, Homann S, Buddemeier BR, Curling CA, Disraelly DS (2009) Overview of hazard assessment and emergency planning software of use to RN first responders. Health Physics, 97(2):145–156. Blakely WF (2008) Early Biodosimetry Response: Recommendations for MassCasualty Radiation Accidents and Terrorism. Refresher Course for the 12th International Congress of the International Radiation Protection Association, October 19–24, 2008, Buenos Aires, Argentina, accessible at website: http://www.irpa12.org.ar/PDF/RC/RC_12_fullpaper.pdf Straume T, Amundson SA, Blakely WF, Burns FJ, Chen A, Dainiak N, Franklin S, Leary JA, Loftus DJ, Morgan WF, Pellmar TC, StoIc V, Turteltaub KW, Vaughan AT, Wyrobek AJ (2008). Meeting Report-NASA Radiation Biomarker Workshop. September 27–28, 2007. Radiation Research 170:393–405. Blakely WF, Ossetrova NI, Manglapus GL, Salter CA, Levine IH, Jackson WE, Grace MB, Prasanna PGS, Sandgren DJ, Ledney GD (2007) Amylase and blood cell count hematological radiation-injury biomarkers in a rhesus monkey radiation model-use of multiparameter and integrated biological dosimetry. Radiation Measurements 42(6–7), 1164–1170.

Publications Manuscripts: Blakely WF, Salter CA, Prasanna PG (2005) Early-response biological dosimetry—recommended countermeasure enhancements for mass-casualty radiological incidents and terrorism. Health Physics 89(5):494–504. Salter CA, Levine IH, Jackson WE, Grace MB, Prasanna PGS, Solyan DK, and Blakely WF (2005) Medical recording tools for biodosimetry in radiation incidents. Published in the proceedings of the NATO Human Factors and Medicine (HFM) Panel Research Task Group (RTG) 099 Meeting, "Radiation Bioeffects and Countermeasures," Bethesda, MD, USA, June 21–23, 2005. Compact disc: AFRRI CD 05–2. Waselenko JK, MacVittie TJ, Blakely WF, Pesik N, Wiley AL, Dickerson WE, Tsu H, Confer DL, Coleman N, Seed T, Lowry P, Armitage, JO, Dainiak N: Strategic National Stockpile Radiation Working Group (2004) Medical management of the acute radiation syndrome: Recommendations of the Strategic National Stockpile Working Group. Annals of Internal Medicine 140(12):1037–1051. Salter CA, Levine IH, Jackson WE, Prasanna PGS, Salomon K, Blakely WF (2004) Biodosimetry tools supporting the recording of medical information during radiation casualty incidents. In: Public Protection from Nuclear, Chemical, and Biological Terrorism. Health Physics Society 2004 Summer School, Gaithersberg, MD: Health Physics Society, 481–488. Blakely WF, Miller AC, Grace MB, McLeland CB, Luo L, Muderhwa JM, Miner VL, Prasanna PGS (2003) Radiation biodosimetry: applications for spaceflight. Advances in Space Research 31(6):1487–1493. AFRRI (2003) Medical Management of Radiological Casualties Handbook, Second Edition. Bethesda, MD: Armed Forces Radiobiology Research Institute. Blakely WF, van der Schans GP (2002) Biodosimetry tools supporting the recording of medical casualty incidents. In: Seed TM, Blakely WF, Knudson GB, Landauer MR, McClain DE (eds), Proceedings of the International Conference on LowLevel Radiation Injury and Medical Countermeasures, Bethesda, MD, November 8–10, 1999. Sine RC, Levine IH, Jackson WE, Hawley AL, Prasanna PGS, Grace MB, Goans RE, Greenhill RC, Blakely WF (2001) Biodosimetry Assessment Tool: a postexposure software application for management of radiation accidents. In: Pastel RH, Landauer MR, Knudson GB (eds) International Conference on the Operational Impact of Psychological Casualties from Weapons of Mass Destruction—Proceedings, Bethesda, MD, July 25–27, 2000. Military Medicine 166(12):85–87.