MONTHLY SCAN
Volume XV Issue II
February 2010
In This Issue
Tc99m Update
Sincalide-Stimulated Cholescintigraphy
Axillary Reverse Mapping
Gastric-Emptying: Sources of Error
Coding Update
Cardiac Cuts Opposed
FDA Initiative on Exposure
CE Opportunity
Featured Article

Sincalide-Stimulated Cholescintigraphy


Join Our List
Join Our Mailing List
Case Study of the Month

Sentinel Lymph Node Mapping

Quick Links
Free CE

Monthly Scans

December 2009

November 2009

October 2009

September 2009

August 2009

July 2009

June 2009


March 2009
January 2009

Previous Issues 

Free Continuing Education
(see article to right)

Anatomy and Physiology Review for Nuclear Medicine Technology - 2009 Update

Cardiac Electrophysiology for Nuclear Medicine Technology - 2007 Update

Correct Coding for Diagnostic Nuclear Medicine Procedures, Part 1
 
Myocardial Perfusion Imaging - 2009 Update

 Stress Testing in Cardiac Nuclear Medicine Technology - 2009 Update




TC99M UPDATE

Dear Radiopharmacy Customer,

The High-Flux Reactor (HFR)  in Petten, Netherlands has been shut down for planned repairs.  The NRU reactor in Canada remains shut down, but is expected to resume Molybdenum (Mo-99) production sometime in April.  The three remaining reactors in the world have worked to increase capacity, but are not able to fill the entire void left by HFR and NRU.  Covidien recently announced that they will soon have access to limited additional Mo-99 from a Polish reactor.  Although the Mo-99 situation continues to evolve daily, we would like to provide you with our most current information regarding future technetium-99m (Tc-99m) availability.

·          The week of March 1st: We have been told to expect to receive approximately 25% of our recent generator standing orders.  Radiopharmacy will likely be able to meet your patients' requirements for all non-cardiac Tc-99m doses as usual this week.  We anticipate being able to dispense Tc-99m cardiac doses on Monday (3/1/10), but will be forced to ration activity for Tc-99m cardiac doses Tuesday through Friday.  Obviously, rationing will become more severe as the week passes, and we will have very little Tc-99m available for Tc-99m cardiac doses by Friday.  As usual, we will have thallium-201 (Tl-201) available for cardiac studies during times of Tc-99m shortages.

·          The weeks of March 8th and 15th:  We expect to receive approximately 80% of our recent generator standing orders.  If we, in fact, receive this amount, Radiopharmacy will be able to meet your patients' requirements for all non-cardiac Tc-99m doses during these weeks.  However, rationing of cardiac doses for Thursdays and Fridays may become necessary.  We request that you schedule Tc-99m cardiac studies as early in the week as possible.  As usual, we will have Tl-201 available for cardiac studies during times of Tc-99m shortages.

·          NO generator production for the week of March 22.  We have been told that this lack of Mo-99 will be market wide globally. All five major medical isotope reactors in Europe, Canada and South Africa will be off-line during this period.  Unless something changes, we will have only a very limited amount or Tc-99m from the previous week's generators.  Thallium-201 will be available as usual for any cardiac studies.  Other radioisotopes (Indium-111, Iodine-123, Gallium-67, and Iodine-131) will be available as usual.  We will be forced to ration the very limited amount of Tc-99m that we will have.  We ask that you not schedule any Tc-99m studies to be performed during the week of March 21, and make your staff aware that Tc-99m may not be available at all. 

·          The weeks of March 29th and April 5th. We expect to receive no more than about 20% of generator standing orders.  If we in fact receive 20% of our standing order, we should be able to supply Tc-99m for non-cardiac studies throughout the week.  However, we will be forced to severely ration Tc-99m for cardiac studies.  Thallium-201 and other radioisotopes will be available as usual.  We again ask that you use Tl-201 for cardiac studies, schedule as lightly as possible any Tc-99m studies, and schedule any essential Tc-99m studies as early in the week as possible.

·         The weeks of April 12, 19, and 26 we expect to receive between 70-100% of our generator standing orders.  Radiopharmacy will likely be able to meet your patients' requirements for all non-cardiac Tc-99m doses.  However, rationing of cardiac doses for some days later in the week may become necessary.  We request that you schedule Tc-99m cardiac studies as early in the week as possible.  As usual, we will have Tl-201 available for cardiac studies during times of Tc-99m shortages

As the situation evolves, we will continue to keep you informed.


Sincalide-Stimulated Cholescintigraphy
The following is an abstract from the most recent JNM issue.

Sincalide-stimulated cholescintigraphy is performed to quantify gallbladder contraction and emptying. However, different infusion methods are used for this study. Our purpose was to determine the infusion method with the least variability (smallest coefficient of variation [CV]) for calculation of the gallbladder ejection fraction (GBEF) in healthy subjects and to establish normal values. Methods: Sixty healthy volunteers at 4 medical centerswere injected intravenously with 99mTc-mebrofenin. After gallbladder visualization had been confirmed at 60 min, 0.02 µg of sincalide per kilogram was administered using 3 different infusion durations, 15, 30, and 60 min, each performed on separate days.The CV, mean, SD, 1st to 99th percentile, and 5th to 95thpercentile were calculated. GBEF normal values were determined for the different infusion durations. Results: The CV was smallest for the 60-min infusion at 60 min (19%; 95% confidence interval[CI], 16%-23%), compared with the 30-min infusion at 30min (35%; 95% CI, 29.2%-42.1%) and the 15-min infusion at 15 min (52%; 95% CI, 44%-63%). These were all significantly different (P < 0.0007). For the 60-min infusion at 60 min,the lower limit of normal for the GBEF was 38% defined at the1% CI. Conclusion: The GBEF at 60 min has the lowest CV in healthy subjects, compared with shorter infusions of 15 or 30 min. This multicenter trial establishes a GBEF lower limit of normal of38% (first percentile) for a 60-min infusion of 0.02 µg of sincalide per kilogram, quantified at 60 min. Using this infusion method minimizes the variability in measured GBEFs.This sincalide infusion method should become the standard for routine clinical use.


FIGURE 2.  Images from paired oatmeal and scrambled egg studies from patient who was determined to be an outlier. Images from oatmeal study showed rapid movement of meal from fundus into body and antrum of stomach. Images from scrambled egg study showed significant retention of meal in fundus of stomach.




Axillary Reverse Mapping During Lymphadenectomy
In the October issue of the American Journal of Surgery (2009;198: 482-487), Boneti et al. from the University of Arkansas for Medical Sciences (Little Rock) reported on a study designed to assess the ability of axillary reverse mapping (ARM) to identify and preserve lymphatics draining the arm and the subsequent effect on lymphedema in patients with breast cancer. The results were recognized earlier this year with the Scientific Impact Award at the annual meeting of the American Society of Breast Surgeons. The study included 220 patients undergoing sentinel lymph node biopsy with or without axillary lymph node dissection. After sentinel lymph node localization with g imaging, blue dye was used to perform ARM of lymphatics. Variables assessed included number and variations in lymphatic drainage, crossover rate (between a hot breast node and a blue arm node), metastases, and nodal status. Crossover occurred in only 6 (2.8%) patients, and ARM lymphatics were identified in or near the sentinel lymph node field in 40.6% of patients, suggesting risk for disruption of ARM lymphatics during lymphadenectomy. ARM lymphatics near hot sentinel lymph node biopsy were preserved in 12 (5.6%) patients. Fifteen ARM nodes were excised but were negative even in positive axillae. No cases of lymphedema at 6-mo follow-up were seen in patients where ARM nodes were preserved. The authors summarized their findings that the confluence of arm and breast drainage is rarely the sentinel lymph node and that none of these nodes contained metastases. They concluded that ''preserving the ARM nodes may translate into a lower incidence of postoperative lymphedema.''

-----------------------American Journal of Surgery

Gastric-Emptying:  Sources Of Error



FIGURE 2.
  Images from paired oatmeal and scrambled egg studies from a patient.  Images from oatmeal study showed rapid movement of meal from fundus into body and antrum of stomach. Images from scrambled egg study showed significant retention of meal in fundus of stomach.

K. Sources of Error

  • Vomiting after meal ingestion
  • Poor labeling
  • A nonstandardmeal
  • A marked variation in the environment, such as noise,lighting,or temperature, during imaging
  • Emotional fluctuations,such as fear of the medical environment,anxieties about results,anger after a long wait for the studyto begin
  • Nausea causedby a meal that may be unfamiliar to the patient
  • A patientwho has eaten just before the study
  • Slow movement of the ingestedmeal from the mouth or esophagusinto the stomach
  • Gastroesophagealreflux
  • Overlap of small-bowel activity with the stomach ROI
  • Aprolonged time for the patient to ingest the meal
  • Lack ofattenuation correction, particularly in obese patients
  • Failureto recognize that the patient has not eaten the entiremeal
  • Lackof decay correction for the tracer used
  • Failure of the patientto ingest the entire meal

  • -----J Nucl Med Technol 2009 37: 196-200

    Coding Update: Only Physician Fee Schedule Services Require Advanced Imaging Accreditation

    The Centers for Medicare & Medicaid Services is reassuring hospitals that they do not have to become accredited to furnish the technical component of advanced diagnostic imaging services. Some hospitals began to query CMS about the issue after the agency published a January 26, 2010 notice approving three organizations to accredit suppliers of the technical component of advanced diagnostic imaging services under the Medicare physician fee schedule. The Medicare Improvements for Patients and Providers Act of 2008 requires these suppliers to become accredited by a designated accreditation organization by Jan. 1, 2012. The requirement does not apply to advanced imaging services paid under Medicare's hospital inpatient and outpatient prospective payment systems. Nor does it apply to physicians who only read the study and are paid for the reading only (26 professional component) under the Medicare Physician Fee Schedule.

    Bill To Stop Cardiac Imaging Cuts Gains Support

    Legislation introduced by Rep. Charlie Gonzalez, D-Texas, to hold cardiology practice expense values at the 2009 rates, while allowing other specialty practices to operate at 2010 physician practice information survey values, has garnered 82 co-sponsors in the U.S. House of Representatives.
         The legislation (HR 4371), which was initially introduced in the House on Dec. 16, 2009, had 55 bipartisan co-sponsors when it was introduced. The bill focuses specifically on the imaging cuts, including myocardial perfusion imaging, cardiac CT
         The legislation and the list of co-sponsors are available online. The American College of Cardiology (ACC) said it will continue seeking new co-sponsors.
         In the Senate, the ACC said it continues to seek help in addressing the cuts. Sen. Mary Landrieu, D-La., sent a letter to Senate Majority Leader Harry Reid, D-Nev., on Jan. 6, asking that Congress consider the impact of the fee schedule cuts on private practice cardiology and work to address the cuts.

    -----HealthImaging.com

    FDA Announces New Initiative to Reduce Radiation Exposure From Medical Imaging Procedures

    On Tuesday, February 9, 2010, the Federal Drug Administration (FDA) announced an initiative to reduce unnecessary radiation exposure from three types of medical imaging procedures: computed tomography (CT), nuclear medicine studies, and fluoroscopy.

    The FDA intends to issue targeted requirements for manufacturers of CT and fluoroscopic devices to incorporate important safeguards into the design of their machines to develop safer technologies and to provide appropriate training to support safe use by practitioners. The agency intends to hold a public meeting on March 30-31, 2010, to solicit input on what requirements to establish.

    To read the entire statement from FDA, visit http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm200085.htm

    SNM Statement

    CE Opportunity

    KSNMT SPRING SEMINAR

    March 19-20, 2010

    PROGRAM AGENDA

     

    All lectures are pending 8 SNM VOICE category A approval

     

     

    Friday Night     March 19: Comfort Suites:

     

    7:00 pm - 8:00        Radionuclide/Radiopharmaceutical Supply Chain Challenges

                                    John Haney, RPh, BCNP

                                    Learning Objectives: Identify Sources of   radionuclides for use in production of Radiopharmaceuticals.

     

     

    Saturday           March 20: Cave City Convention Center:

     

     

    7am- Registration/Breakfast

    7:45- Announcements

    8:00-9:00        2010 Changes and Challenges Reimbursement Revenue

                            Barbara Ossias

                           Learning Objective: Understand changes to payment systems, coding changes, coverage policies, understand importance for prior authorization of imaging procedures.

     

    9:00-10:00       Immunology-H1N1 and Influenza

                             Terry Congleton, ARNP

                            Learning Objective: The Learner will be able to identify the natural history and discovery of influenza, identify appropriate preventative actions, and current treatment of influenza.

                           

     

    10:00-10:30    Vendor Appreciation/Break

     

    10:30-11:30    You have the Brains..Now think from the Heart

                             (The Powerful Behavior Patterns of Health Care Workers)

                            Gina Bonner,RT (R), RDMS, RVT

                            Learning Objective: The attendee will leave with a fresh understanding of their professional responsibility to connect with the patient from a body, mind and a heart vision of health care.

     

    LEARN AT LUNCH

    11:30-12:30    Substance Abuse Awareness and Prevention, HIV, AIDS

                            Chris Hunt, Daviess County Public Schools Intervention Specialist

                            Learning Objective: receive insight regarding the involvement of teenage drug and alcohol use, gain knowledge of household items used by teens to get high, understand the pressures that lead teens to drug and alcohol use.

     

    12:30-1:30     Leadership: Do you have the right stuff?

                           Nancy McDonald, NCT, RT(R) (N), CNMT

                           Learning Objective: Define the term "Leadership", List the qualities of a good leader, Site instances of poor leadership, Outline and discuss the "Laws of Leadership"

     

     

    1:30 - 2:30     Current Practices in Renal Imaging

                            David Koerber - Covidien

                            Learning Objective: General overview of Renal    Scintigraphy

     

    2:30-2:40     Break

     

    2:45-3:45      Making Less than Perfect Patients into Perfect Exams

                          Leo Gronquist, RT(R)(N)

                         Learning Objectives: Learn to use good communication techniques and tools to gain patient confidence and allow for clear instruction, Identify problem patent behaviors and appropriate coping skills to gain compliance.

     

    3:45-4:00     Honor Presentation- Dr. George Zenger

     

    4:15             Ajourn


    Free Continuing Education
    There are currently 26 NucMed credits available on the Covidien www.nucmeded.org web site.  All classses are free of charge.  See below some of the offerings.
     
    Anatomy and Physiology Review for Nuclear Medicine  Technology - 2009 Update

    Cardiac Electrophysiology for Nuclear Medicine Technology - 2007 Update

    Correct Coding for Diagnostic Nuclear Medicine Procedures, Part 1

    Myocardial Perfusion Imaging - 2009 Update

    Stress Testing in Cardiac Nuclear Medicine Technology - 2009 Update

    Enrollment Instructions:
    Go to www.nucmeded.org
    Click on the self-enroll button
    Fill out the information and click on submit
    A link will pop up taking you back to main page
    Login into site.  Go to the site now
    For Sale....Slightly used, heavily discounted
    Lead Bricks..........$60.00 each

    Rectangular Lead Brick; 8" l x 4" w x 2" h (20 x 10 x 5 cm), 27 lb (12.5 kg)/each



    Thyroid Uptake Neck Phantom....$295.00

    (Complete with Bottle Carrier, Capsule Holder and  12 Polyethylene bottles)    


    Lead Apron...................$100.00

    ......a protective shield of lead and rubber that may be worn by a patient, radiologic technologist or radiologist.
    Technologist Job Line
    If you are interested in the following position please feel free to contact the department directly, or give us a call at the pharmacy.  Technologists looking for full-time or part-time position.  

    Karen Foncannon: 731-661-9287 Wk: 731-541-7866
    Contact info: [email protected]
    Radiopharmacy Services
    Survey Meter Calibration:  
    Radiopharmacy's price for survey meter calibration is $50.00/meter.  Shipping and handling from and back to your location is $20.00.  Shipping will be by FedEx ground unless otherwise specified.  We will pick up the instrument, send it to Mid-America Calibrations, and after calibration return it directly to you.  If required, Radiopharmacy has rental survey meters while your unit is being calibrated.

    Co-57 Flood Sources and Dose Calibrator Reference Sources
    Don't forget; Radiopharmacy, Inc. sells all types of radioactive sources for all types of cameras and equipment. We supply sources from a variety of major vendors in our efforts to pass along the best products at the lowest cost.  Just give us a call for a price quote or for information about anything your department may need.



    Linearity Check
    Radiopharmacy, Inc. has a Lineator for performing dose calibrator linearity.  The Lineator allows linearity to be performed in minutes rather than days.  Call Radiopharmacy for more information.
          Radiopharmacy, Inc. is staffed by Board Certified Nuclear Pharmacists (BCNP's) with advanced education, training and experience in the preparation, distribution, and pharmacology of radiopharmaceuticals. Our staff is always available to answer questions or research information regarding radiopharmaceuticals and nuclear medicine studies, unexpected biodistributions, adverse reactions, drug interactions, radiation safety, regulatory requirements, and reimbursement strategies.   We also offer assistance with literature searches, research design preparation, investigational drug procurement, specialized labeling procedures, pharmacokinetic analyses, and dosimetry estimations. 
          Radiopharmacy's services are designed to assist your department in offering the newest, most progressive therapies and diagnostic tests available, and to help you maximize your overall efficiency in order to improve patient satisfaction and your profitability.  To go to our website click on the image above.

    NOTE TO READERS: In an effort to keep the Monthly Scan relevant, useful and informative, feedback on the contents of the newsletter is welcome. Readers desiring to contribute articles, suggestions for future articles, bulletins, website postings, and other items of interest to the Monthly Scan readership, should contact a pharmacist at Radiopharmacy, Inc.
     
    Sincerely,
     


    CONFIDENTIALITY NOTICE
    This communication is for the sole use of the intended recipient(s) and may contain information that is confidential, privileged, or otherwise exempt from disclosure under applicable law.  If you are not the intended recipient(s), the dissemination, distribution, or copying of this message is strictly prohibited. If you have received this communication in error, please contact the sender immediately and destroy all copies of the original message and any attachments.  Receipt by anyone other than the named recipient(s) does not constitute a waiver of any applicable privilege.