Leading the Nation’s Only Military Radiobiology Research Facility

Mohammad Naeem, MD, FACR, Co-Chair of the American College of Radiology® (ACR®) General, Small, Emergency and/or Rural Practice (GSER) Network Military Subcommittee, contributed this piece.

In July 2020, I was tapped to be the 20th director of America’s most prestigious military radiobiology research facility, the Armed Forces Radiobiology Research Institute (AFRRI). AFRRI is a unique national asset, celebrating its 60th anniversary this May 2021. The institute, under the command and control of the Uniformed Services University of the Health Sciences (USUHS), is responsible for preserving and protecting the health and performance of U.S. military personnel operating in potentially radiologically-contaminated multidomain conventional or hybrid battle spaces and urban environments. AFRRI engages in research, education and operational training to advance the understanding of the effects of ionizing radiation, in line with the 21st-century dynamic threat landscape and national security threats posed by non-state actors, hostile state actors and near-peer adversaries. In addition, AFRRI provides rapidly deployable radiation medicine expertise in response to a radiological or nuclear event domestically or abroad.

Radiologists and radiology organizations are in a unique position to be leaders in radiation accident preparedness and response. Our in-depth understanding of ionizing radiation, radiation-induced injury and principles of radiation protection postures us well to serve as experts to our hospitals and other medical authorities. As the first radiologist and first ACR Fellow to lead AFRRI, I feel that AFRRI and the ACR can very closely cooperate in the arenas of emergency radiology and disaster preparation education at the national level.

On May 12, 1961, Secretary of Defense Robert McNamara established AFRRI based on two cold war ground realities of that time – the threat scenario of numerous Soviet infantry divisions overcoming the Fulda Gap defenses in West Germany and overtaking western Europe, and the use of nuclear weapons on the battlefield by the North Atlantic Treaty Organization forces particularly enhanced radiation weapons rich in neutron output, to halt such a massive assault from the Warsaw Pact countries.[i]

AFRRI is the U.S. Department of Defense’s (DoD’s) only medical research and development facility dedicated to nuclear and radiological defense. The Institute’s touchstone research projects, as a key component of USUHS, include biodosimetry, combined injury, internal contamination and metal toxicity, effects of low dose radiation and radiation medical countermeasures development. It routinely collaborates with other military and government organizations in the arenas of civilian radiological-accident response and with the National Aeronautics and Space Administration on the safety of astronauts exposed to cosmic radiation.[ii]

The Institute has also been at the center of medical and radiobiological matters pertaining to radiological-nuclear incident response, maintaining a rapidly-deployable team of radiation subject matter experts, including physicians and physicists, to support medical response and actions taken in military and civilian nuclear or radiological incidents, either domestically or abroad. During the U.S. DoD response to the Fukushima Daiichi reactor incident, Operation Tomodachi, the Medical Radiobiology Advisory Team, which is the operational arm of AFRRI located at Naval Support Activity Bethesda in Maryland, provided guidance and advice to the U.S. military leaders in Japan. This support helped ensure the safety of U.S. service members, family members and civilians, and supported the humanitarian relief in a coordinated effort with the Government of Japan.[iii]  AFRRI routinely trains military and civilian healthcare providers, disaster-preparedness personnel and operational planners on the medical effects of ionizing radiation and the logistical and medical responses to radiation exposures.

In today’s complex international security environment, non-state actors may attempt to detonate radiation dispersal devices, such as dirty bombs or improvised nuclear devices, in major urban centers. [iv] Near-peer adversaries or hostile state actors may use tactical or low-yield nuclear weapons in a battlespace against the U.S. and its allies. A nuclear weapon detonated in earth’s low orbit by a near-peer adversary can create a massive electromagnetic pulse, rendering the electronic equipment ineffective on an unimaginable scale.[v] This clear and present danger needs our immediate attention and preparation. AFRRI proudly stands ready as the frontline radiobiological research center and medical operational asset in the radiological defense of the nation for 60 years.

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[ii] National Research Council 2014. Research on Health Effects of Low-Level Ionizing Radiation Exposure: Opportunities for the Armed Forces Radiobiology Research Institute. Washington, DC: The National Academies Press. https://doi.org/10.17226/18732.

[iii] VanHorne-Sealy J, Livingston B, Alleman L. DoD’s Medical Radiobiology Advisory Team: experts on the ground. Health Phys. 2012 May;102(5):489-92. doi: 10.1097/HP.0b013e31824acb08. PMID: 22469928.

[iv] https://www.wjperryproject.org/

[v] https://www.militaryaerospace.com/communications/article/16709112/todays-battle-for-the-electromagnetic-spectrum

Why Radiology Care Is Central to Population Health

Syed F. Zaidi, MD, MBA, Chair of the Population Health Management (PHM) Committee of the American College of Radiology® (ACR®) Commission on Patient- and Family-Centered Care and Associate Chief Medical Officer of Integrations with Radiology Partners, contributed this piece.

The goal of population health management is to keep a population as healthy as possible, minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging tests and procedures. Population health management requires healthcare providers to develop new skillsets and infrastructures for delivering care. The field of radiology has an opportunity to bring additional value to this developing enterprise.

The continuum of PHM can be broken up into 3 major portions:

  • Surveillance/Prevention, which includes screening and AI tools;
  • Acute Care, which includes Imaging 3.0, Choosing Wisely, best practice recommendations, CDS and IP care coordination; and
  • Chronic Disease Management, which includes follow-up programs, oncology intervention and findings which predispose to chronic disease such as fatty liver and metabolic syndrome.

Providing continuity of care to our patients often presents a challenge for radiologists. However, the screening avenues of breast imaging, virtual colonoscopy and lung cancer screening CT afford us an opportunity to consistently engage with our patients and manage their care. By employing image-based screening to deliver quality patient care, we can meet and even exceed strategic health system needs to ultimately deliver quality patient care.  By working with payers and health systems, radiologists can participate in alternative payment models and risk-sharing arrangements with our value recognized in providing high quality and cost-effective care.

I encourage you to check out the online recording of a recent PHM Committee webinar where my colleagues Cecelia Brewington, MD, FACR; Lauren Golding, MD; Debra Dyer, MD, FACR; Ryan Lee, MBA, MD, and I dive deeper into radiology’s central role in patient screening program success as one of the key foundations of successful population health management.

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Aggregating Data, Advancing Radiology

Caroline Chiles, MD, Professor of Radiology at Wake Forest University School of Medicine, contributed this post.

The American College of Radiology® (ACR®) has been working on research registries for more than 40 years, building expertise and resources as a preferred partner and center of excellence. Last week, the ACR launched its newest effort, the ACR National Clinical Imaging Research Registry (ANCIRR). The ANCIRR – pronounced ‘answer’ – provides answers to the critical questions we have, and positions us to answer questions that have not yet been formulated.

ANCIRR has the potential to efficiently move medical advances forward through federal agencies, such as the National Institute of Biomedical Imaging and Bioengineering (NIBIB)-funded Medical Imaging and Data Resource Center (MIDRC), and through technology creators. The need for such coordination when addressing complex scientific questions has perhaps never been greater.

Our fight against the COVID-19 pandemic is ongoing. As radiologists, we are uniquely positioned to aid in this battle by making significant contributions to clinical research. That’s why Wake Forest Baptist Health decided to get involved with one of the registries that make up ANCIRR.

In April 2020, the ACR COVID-19 Imaging Research Registry (CIRR) was created to collect clinical data and imaging performed as part of routine clinical care in diagnosing and treating patients throughout the United States who have tested positive for  COVID-19. In addition, CIRR will collect the same data elements on a control population of patients who have tested negative. Although there are other registries collecting clinical data in COVID-19 patients, the inclusion of imaging makes CIRR unique, fueling more robust and impactful research than clinical data collection alone. CIRR is one of two ways that COVID-19 imaging data is collected by MIDRC, funded by NIBIB.

In some instances, when testing for COVID-19 was limited, chest radiographs and chest CT were used to help identify those who were sick. The pattern of predominantly peripheral ground glass opacity, a pattern associated with organizing pneumonia, on both chest X-ray and CT, went from a fairly uncommon observation to one we were seeing every day, all day. Now we know that COVID-19 can have cardiovascular and neurologic effects as well.

The registry collects all imaging — ranging from conventional chest radiographs to brain MR — from patients of all races and ethnicities, ages, body types and geographic areas, both urban and rural. The registry will also allow researchers to query the dataset for specific types of patients or specific imaging procedures.

Wake Forest Baptist Health is proud to be the first of many sites to contribute case images and anonymized patient health information to fuel the CIRR, which will be key to a better understanding of how we diagnose, treat and ultimately eliminate this disease.

Your involvement with ANCIRR efforts will result in medical advances to further address health crises such as COVID-19 and beyond. So, how can you get started?

Our first step at Wake Forest was to submit the CIRR protocol to our Institutional Review Board (IRB). Although IRB provides permission to conduct the research, permission to share data outside your hospital must be obtained by your legal department. Getting legal approval for this Health Information Portability and Accountability Act-limited data set can be a lengthy process. While you’re waiting for approval, I recommend assembling a team of individuals who have the technical background needed for data collection and transmission. For me, that team includes a neuroradiologist co-PI, a systems analyst for clinical data extraction, and a systems manager in Radiology who facilitates upload of imaging.

Once your approvals are complete and your clinical data and imaging are gathered, ACR provides options for uploading clinical data and imaging to the registry – either the TRIAD platform, or their newer platform, ACR Connect.

At this point, our team at Wake Forest is uploading imaging on all COVID-19 positive patients seen within our network from early 2020 through January 2021. Our next step will be to upload a comparable number of COVID-19 negative patients to serve as a control population, and then move on to cases seen since February 1, 2021.

If you’re interested in joining us and being part of this very important effort – and I don’t think there has ever been a more important effort for us as radiologists – I encourage you to learn more about the CIRR and the other ANCIRR registries, and find out how you can become a data-contributing site.

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