THE RADIOPHARMACY QUARTERLY
Volume XVII Issue I 
March 2013
In This Issue
Cardiac CT vs. MPI
SPECT bests ECG
CZT SPECT
Adreview
Ceretec WBC
iPhone Diagnosis?
Urea Breath Test
Fiscal Cliff
Chessy Gastric Emptying
Nuclear Medicine: Sources of Error
Hope for Harlie
Join Our List
Join Our Mailing List

Case Study of the Month

   

Quick Links
Free CE

Monthly Scans

2012 3rd Quarter  

2012 2nd Quarter
2012 1st Quarter

2011 4th Quarter
2011 3rd Quarter

2011 2nd Quarter  

2011 1st Quarter   

2010 3rd Quarter

May 2010  

February 2010  

January 2010  

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 below)
 

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



 

Front
60-year-old woman with obstructive coronary artery disease in left anterior descending and left circumflex territories.  Commercially available time-volume analysis tool was used to evaluate sub-endocardial attenuation.  Automated left ventricular wall segmentation is adjusted manually to select sub-endocardium (blue outline).

 Cardiac CT vs MPI for Ischemia Detection

 

Resting cardiac CT performed on a 64-slice system does not reliably detect myocardial ischemia compared with radionuclide myocardial perfusion imaging (MPI), according to a study published in the February issue of the American Journal of Roentgenology .

 

The study found resting cardiac 64-slice CT did not reliably show differential perfusion by visual or semi-automated analysis, according to Ari J. Spiro, MD, of Montefiore Medical Center, Bronx, N.Y., and colleagues.

     "Although different attenuations were subjectively detected on visual inspection of some segments, the performance characteristics of visual analysis were not suitable for clinical diagnosis," wrote the authors.

     The standard is for ischemia to be assessed using radionuclide MPI. However, Spiro and colleagues explained that interest in the feasibility of CT detection of myocardial perfusion has been growing. Resting CT has the advantage of reduced imaging time, radiation dose and patient discomfort, and it has been hypothesized that CT may detect small areas of differential blood flow due to its high spatial resolution.

     To assess the viability of resting CT for this purpose, the authors retrospectively identified 35 patients with myocardial ischemia found on MPI who underwent retrospectively gated CT within 90 days of MPI. Perfusion on CT was evaluated using both a visual and automated method, with a sub-endocardial perfusion of the standard 17 American Heart Association segments measured with a commercial tool in both systole and diastole for the automated analysis.

     A total of 580 myocardial segments were evaluated, and 152 were ischemic on MPI. Compared with MPI, visual analysis had a sensitivity of 16 percent, specificity of 92 percent, positive predictive value (PPV) of 40 percent and a negative predictive value (NPV) of 75 percent in systole, reported Spiro and colleagues. In diastole, visual analysis had a sensitivity of 18 percent, specificity of 89 percent, PPV of 37 percent and NPV of 75 percent.

     Results showed no significant difference in sub-endocardial perfusion between ischemic and non-ischemic segments by the automated method. There was no significant difference in CT perfusion between patients with and without obstructive coronary artery disease on CT angiography using the visual or automated methods. "This finding suggests that visual analysis of resting CT datasets for perfusion abnormalities in areas of myocardium subtended by stenosed vessels may also be inaccurate," wrote the authors.

     Spiro and colleagues noted that while 64-slice CT is unsuitable for clinical use in revealing ischemia seen on MPI, ongoing investigations using 256- and 320-slice scanners with stress protocols or dual-energy CT may more effectively close the accuracy gap between CT and MPI.

 

--Molecular Imaging.com


 SPECT Bests ECG in Coronary Artery Disease

SPECT myocardial perfusion imaging (MPI) can pick up perfusion defects that don't show up with normal cardiac stress testing and can predict cardiovascular death or morbidity out to 10 years, researchers found.

     Half of 650 patients with known or suspected heart disease and normal exercise ECGs had an abnormal SPECT MPI, and 20% had indications that the ischemia was reversible, reported Arend F.L. Schinkel, MD, of the Erasmus MC Thoraxcenter in Rotterdam, the Netherlands, and colleagues.

     The summed rest score, which accounts for the amount of infarcted myocardium, was an independent predictor of death, whereas the summed stress score, which measures both infarcted and ischemic myocardium, was an independent predictor of major adverse cardiac events (MACE), they wrote in a study published in the November European Heart Journal: Cardiovascular Imaging.

     In the nearly 10 years of follow-up, 23% of patients died, 11% had a nonfatal MI, 14% underwent CABG, and 22% underwent PCI.

     The summed rest score predicted mortality, with a hazard ratio of 1.15 (95% CI 1.08 to 1.22, P<0.001). And the summed stress score predicted MACE with a hazard ratio of 1.09 (95% CI 1.04 to 1.13, P<0.001).

     "Several lines of evidence, collected with different approaches, demonstrate that a functional assessment as obtained by perfusion imaging is superior to clinical and ECG assessment in prognostic stratification of patients with known or suspected ischemic heart disease," wrote Danilo Neglia, MD, and Alessia Gimelli, MD, of Fondazione Toscana Gabriele Monasterio in Pisa, Italy, in an accompanying editorial.

     "On this basis, stress/rest myocardial perfusion abnormalities should be obtained -- whenever possible -- before coronary angiography in order to guide decision-making," they said.

     They added that the summed rest score "may be a better predictor of mortality than the left ventricular ejection fraction alone."

     One of the problems with this approach, they said, is that when facilities are tightening their budgets, a functional risk assessment after a normal ECG may seem redundant.

   Neglia and Gimelli pointed to a survey by the European Society of Cardiology that indicated an underutilization of this type of noninvasive functional testing. Such underutilization results in many patients without significant disease undergoing diagnostic catheterization.

   To help stratify patients to SPECT MPI, Neglia and Gimelli suggested having a     "better definition of pre-test probability of disease based on new predicting models incorporating clinical data, risk factors, and possibly biohumoral markers in order to exclude patients with very low probability."

     In addition, attention should be paid to lower the radiation dose of SPECT imaging as much as possible. One way to do that is to avoid a rest exam when the stress test is positive.

     For this study, Schinkel and colleagues included 650 consecutive patients who underwent exercise ECG and subsequent exercise SPECT MPI. All patients had known or suspected coronary artery disease. The mean age was 56 and 66% were men.

     A total of 8% of the 324 patients with an abnormal SPECT test had completely reversible perfusion defects, 12% had partially reversible defects, and 30% had fixed defects. However, just having an abnormal SPECT test increased the risk of death (P=0.02) or MACE (P<0.0001), wrote Schinkel and colleagues.

     Despite the recognized limitations of exercise ECG in patients with known or suspected CAD, European guidelines recommend the test as the initial evaluation.

     In the multivariable analysis, Schinkel and colleagues found that SPECT testing provided incremental prognostic information over clinical data and exercise ECG for prediction of future events.

     Along with the summed rest score, other significant predictors of death were age (HR 1.09, per one unit increment) and smoking (HR 1.95).

     And in addition to the summed stress score, other significant predictors of MACE were age (HR 1.03, per one unit increment), male gender (HR 1.47), and previous MI (HR 1.53).

 

--Medpage Today

 

 

CZT SPECT Accurately Quantifies Ejection Fraction

While myocardial perfusion imaging (MPI) using cadmium-zinc-telluride (CZT) SPECT cameras accurately measures left ventricular ejection fract CZT ion (LVEF), the method underestimates left ventricular volumes, according to a study published online Feb. 5 in the Journal of Nuclear Medicine .

     Recently developed CZT detectors offer higher count sensitivity, new camera geometry and new reconstruction algorithms, which may modify SPECT performance for analyzing LV global and regional function.

     Hubert Cochet, MD, from the department of cardiovascular imaging at Hopital cadiologique in Passac, France, and colleagues sought to evaluate the accuracy of MPI SPECT for measurement of LV global and regional function and the performance of absolute wall motion and wall thickness measurements, using cardiac MR as a reference.

     The researchers enrolled 60 patients with known or suspected coronary artery disease referred for routine SPECT from October 2010 to May 2011.

     The correlation between SPECT and cardiac MR was good for end diastolic volume and excellent for end systolic volume and EF. On regional measures, correlation between SPECT and MRI was fair for both wall motion and wall thickness.

     A total of 16 patients were found to have moderate or severe perfusion defects. Bias between the two exams for measurement of end systolic volume was greater among patients with moderate-to-severe defects than in patients with no defects, according to Cochet and colleagues.

     "Studying 60 patients with a representative range of LV dysfunction, we demonstrated that quantification of EF using quantitative-gated SPECT analysis is accurate, although it still underestimates ventricular volumes," wrote Cochet et al.

     Previous studies have indicated that MPI SPECT underestimates EF, and CZT may be more accurate. However, CZT SPECT tends to underestimate ventricular volumes, which is likely related to how SPECT datasets define the aortic and mitral planes, according to the researchers.

     "Gated MPI SPECT using CZT cameras and quantitative-gated SPECT analysis is highly accurate for the quantification of EF. However, a significant underestimation of LV volumes persists," concluded Cochet and colleagues.

-----Molecular Imaging

Adreview

I-123 iobenguane (Adreview) is utilized as an adjunct agent in the diagnosis of neuroblastomas and pheochromocytomas. This radioisotope mimics norepinephri adreview ne in the nervous system making it an ideal imaging agent for neuroendocrine tumors. The sensitivity of Adreview imaging is 79%, while the specificity is 73%. Any patient with an allergy to iodine or iodine containing products, such as fish, should not receive Adreview. Also, this imaging agent is not dialyzable, so another agent should be chosen for those patients instead. Adreview is eliminated via the kidneys. There are several medications that can interfere with Adreview imaging. Since this radioisotope mimics norepinephrine, norepinephrine uptake inhibitors, selective serotonin reuptake inhibitors, and sympathomimetic amines should be discontinued for five half lives before administering Adreview�.

    

Thyroid Blocking Agent

Amount

Lugol's solution

100 mg iodine for adults, weight based for children

Potassium iodine

130 mg for adults

65 mg for 3-18 years

32 mg for 1 month - 3 years

16 mg < 1 month

Potassium perchlorate

400 mg for adult dose

 A non-inclusive chart with medications to discontinue and for what length of time is provided below for convenience. Finally, Adreview is a Pregnancy Category C drug, so pregnant patients should speak with their physician before having this test to weigh the risks versus benefits.   I-123 appears in breast milk, so the package insert recommends discontinuing breastfeeding for at least six days after Adreview administration.  

     Patients must first be administered a thyroid blocking agent of 100 mg of iodide one hour before receiving the radioisotope and for 48 hours after the radioisotope dose. Lugol's solution, potassium iodine, or potassium perchlorate are acceptable thyroid blocking agents. A chart outlining this is provided below. Inform the patient to hydrate aggressively for 48 hours after receiving Adreview to reduce the radiation dose. The adult dose is 10 mCi for patient's either greater than 16 years old or who weigh 70 kg or more. A pediatric dose is scaled to the adult dose based on weight, approximately 0.14 mCi/kg. While this imaging agent has been found to be safe and effective in patients older than one year, the formulation does contain 10.3 mg/mL of benzyl alcohol and thus should not be used in infants due to the risk of Gasping Syndrome. The IV injection should last one to two minutes and be immediately followed by a 0.9% saline flush. Monitor the patient's blood pressure and pulse for 30 minutes after Adreview� administration. The patient should be imaged 24 hours after dose administration. Images can also occur six hours before or after the 24 hour post dose time. Patients should be informed that less than one percent of patients hexperienced itching, rash, dizziness, flushing, and hemorrhage at the injection site. The critical organ for I-123 iobenguane is the liver. Additional organs that show uptake are the urinary bladder wall, spleen, gall bladder, heart wall, lung, and osteogenic cells. Adreviewhas a half life of 13.2 hours and a gamma energy of 159 keV.

 

 

Offending Agent

Half Life

Discontinue before Adreview administration

Amitriptyline

15 hr

75 hr

Imipramine

12 hr

60 hr

Amoxapine

8 hr

40 hr

Clomipramine

32 hr

160 hr

Desipramine

20 hr

100 hr

Doxepin

15 hr

75 hr

Maprotiline

51 hr

255 hr

Nortriptyline

30 hr

150 hr

Protriptyline

74 hr

370 hr

Trimipramine

28 hr

140 hr

Citalopram

35 hr

175 hr

Escitalopram

30 hr

150 hr

Fluoxetine

5 d

25 d

Fluvoxamine

16 hr

80 hr

Paroxetine

21 hr

105 hr

Sertraline

26 hr

130 hr

Vilazodone

25 hr

125 hr

Desvenlafaxine

11 hr

55 hr

Duloxetine

12 hr

60 hr

Milnacipran

7 hr

35 hr

Venlafaxine

5 hr

35 hr

Mirtazapine

30 hr

150 hr

Labetalol

7 hr

35 hr

Reserpine

75 hr

375 hr

Phenylephrine

3 hr

15 hr

Pseudoephedrine

13 hr

65 hr

Ephedrine

3 hr

15 hr

Phenylpropanolamine

20 hr

100 hr


-PharmD. Susan Almeda

 

99mTc-Exametazime (HMPAO)-Labeled Leukocyte Scintigraphy:Interpretation Criteria

Accurate interpretation of labeled leukocyte scintigraphy requires knowledge of the normal and abnormal variants of leukocyte localization.

 

1. Normal Findings ceretec

 

  •  The blood clearance half-life of 99mTc-leukocytes is about 4 h, and delayed images (longer than 4 h) may be preferred for detection of vascular graft or dialysis shunt infection. 111In-leukocytes may be preferred for detection of vascular graft or dialysis shunt infection, because blood pool activity is much lower relative to sites of abnormal
    localization (especially on 18-24-h delayed images)
  •  Bowel activity secondary to secretion of 99mTc complexes is seen in 20%-30% of children by 1 h but is usually not seen in adults before 4 h. In adults, physiologic bowel activity is usually faint if seen at 4 h and is usually seen in the terminal ileum or right colon, increasing over time.
  •  Renal and bladder activity is seen by 15-30 min in all patients with normal renal function. The patient should try to empty his/her bladder before pelvic imaging.
  •  Uniform physiologic gallbladder activity can be seen in 4% of patients by 2-4-h and up to 10% of patients by 24 h. A curvilinear pattern at the margin is suspicious for inflammation of the gallbladder wall.
  •  The spleen, liver, bone marrow, kidneys, bowel, bladder, and major blood vessels will normally be visualized.

2. Abnormal Findings

  •  Abnormal bowel localization may be seen by 15-30 min and usually increases in intensity over the next 2-3 h.
  •  The degree and extent of bowel disease is usually demonstrated by 1-2 h.
  •  Shifting patterns of bowel activity on later images usually indicates distal transit of labeled granulocytes or, at times, bleeding within the bowel lumen.
  •  Lung activity usually clears by 4 h, unless there is pulmonary edema, diffuse inflammatory lung disease, atelectasis, renal failure, sepsis, or adult respiratory distress syndrome.
  •  Focal abdominal activity outside the liver and bowel is likely to indicate infection/ inflammation but can vary greatly in intensity depending on the degree of inflammation.
  •  Caution should be used in interpretation of a focal site of abnormal localization, as indicating a drainable abscess and correlation with other imaging modalities is recommended.
  •  Infection involving the spine may present as areas of increased or decreased activity compared with normal bone marrow localization.
  •  Photopenic or "cold" defects may indicate osteomyelitis, but other causes, such as compression fracture, neoplasm, post-irradiation changes, or postsurgical or anatomic deformities, should also be considered.    

 

Diagnosis

Early Imaging

Delayed Imaging

16-24 hr Imaging

Abdominal Abscess

0.5-1h for Adults

 

20-40 min for children

Sequential to 4 h

Rarely, if early images are negative (requires longer imaging times)

Inflammatory or Ischemic Bowel Disease

0.5 - 1 h for adults

 

20-40 min for children

Sequential up to 4 h;

physiologic bowel activity may interfere on later images

Usually not indicated, because physiologic bowel activity is present

Chest-Pulmonary infection

Physiologic lung activity may interfere

 

4-8 h

If early images are negative (requires longer imaging times)

Osteomyletis

May not have sufficient localization

 

4-8 h

If early images are negative or equivocal (requires longer imaging times)


 - SNM Procedure Guidelines

iPhone Thyroid Disease Diagnosis

An iPhone and specially designed image analysis app are able to diagnose and manage the treatment of hyperthyroidism and hypothyroidism, according to data presented at the 82nd Annual Meeting of the American Thyroid A ssociation on September 22 in Quebec City, Canada. Polson et al. from the University of Utah (Salt Lake City) reported on the development of a device that uses an iPhone's LED flash and digital camera with collimating lens to optimize illumination and focusing and a specially-designed app to collect an image of completed thyroid-stimulating hormone (TSH) assays and convert the image into quantitative TSH values. Smart phones' LED flash and cameras operate in the visible spectrum and can illuminate and detect the colloidal gold used in TSH assays. The TSH assays consisted of a blood filtration element, colloidal gold-labeled mobile-phase anti-TSH b-subunit antibodies, and nitrocellulose membranes to which were linked the anti-TSH a-subunit antibodies (test-line antibodies) and antibodies that bind the mobile-phase anti-TSH b-subunit antibodies (control antibodies). Assays used a 30-mL capillary blood sample and 100 mL phosphate-buffered saline to solubilize gold-labeled anti-TSH b-subunit antibodies, to mix the serum obtained from the blood sample with the mobile- phase antibody, and to carry the serum antibody mixture the length of the membrane. Each TSH assay incorporated 2 control antibody concentrations for a 2-point calibration. A smart phone collected an image of a completed TSH assay and converted the image into a quantitative TSH value using the test calibrators. This imaging device was able to detect whole-blood TSH concentrations as low as 0.1 mIU/L. The presenters concluded that this "inexpensive optical device, smart phone, and image analysis app can quantify an immunochromatographic TSH assay with sufficient sensitivity and precision to diagnose hyper- and hypothyroidism and monitor thyroxine therapy at the point of care.

 

---American Thyroid Association 

14C - Urea Breath Test

14C -urea breath test is a common test used to determine if an individual has an active infection caused by Helicobacter pylori. H. pylori was discovered by Dr. Barry Marshall in 1982, and is associated with stomach and duodenal ulcers.  Although H. pylori may not always manifest in ulcers, but is believed to cause inflammation in the stomach lining leading to symptoms such as nausea, bloating, and a burning sensation in the stomach between meals or at night.

 

Diagnosing H. Pylori

 

Antigen/Antibody Testing:    A stool is collected from a patient and tested for H. pylori antigens. Another test using this method is conducted by obtaining a serum sample from the patient and testing it for antibodies that fight off H. pylori. These tests do not determine if the patient has an active H. pylori infection, only that H. pylori was recently in their system. The American College of Gastroenterology stated in the 2007 guidelines, "...a positive test is no better than a coin toss in predicting the presence of active infection."   Through meta-analysis this method of testing has sensitivity and specificity of 85% and 79% respectively.

 

Biopsy: This invasive method is utilized to rule out other stomach infections and determines H. pylori through a process of elimination utilizing other testing methods. The test is performed by inserting an endoscope into the mouth and snaked down the esophagus into the stomach to closely observe the esophagus, stomach, and duodenum. Using this instrument, a sample of tissue can also be removed from these locations. This sample is then tested using the CLOtest™ for the presence of urease, an enzyme produced by H. pylori. This test is requires special training and equipment and is invasive which increases the cost and can cause discomfort to the patient. Additionally invasive methods have been shown to have 100% sensitivity and 99% specificity. However, it should be noted the sensitivity of this method is highly dependent on the skill of the person collecting the sample because sampling from a location of a small population of bacteria could lead to false positives

 

14C -Urea Breath Test: A patient swallows a capsule containing Urea labeled with Carbon-14. After three minutes the capsule is dissolved in the stomach. If the 14C -urea comes into contact with H. pylori, it will be immediately broken down to 14Carbon-dioxide and ammonia by urease. 14Carbon-dioxide then enters the blood stream and is exhaled in exchange for oxygen. Peak levels of 14

Carbon-dioxide can be measured in a person's breath 10-15 minutes following capsule ingestion. Therefore ten minutes following ingestion of the capsule a patient will exhale into a mylar balloon and again at twenty minutes. The two samples will then be analyzed. If the 15 min sample contains less than 50 DPM then it the patient is negative for H. pylori. If 50-100 DPM then intermediate, due to chemiluminescence or a cofounding factor such as medication. If greater than 100 DPM then the patient is positive for H. pylori. These results will be obtained 24 hours after the test is performed. 

 

Of the three currently used methods to determine if H. pylori is present in an individual the 14C-urea breath test is very patient friendly, the most accurate, non-invasive, with a sensitivity and specificity of 95.9% and 97.7% respectively. Moreover, unlike other noninvasive methods it can be used to monitor an active infection and confirm eradication.

It should be used after one month following triple therapy or antibiotic therapy to establish the presence or absence of H. pylori in patients that have been treated but remain symptomatic. However, some considerations must be taken into account.  
  •  The patient will receive a very small amount of radiation.
  • The patient cannot eat or drink anything for six hours prior to the exam.
  • Any proton pump inhibitors ( ie.Prilosec™ or Nexium™), sucralfate (ie. Carafate�) must be discontinued for at least 2 weeks prior to this test.
  • Bismusth (Pepto Bismol �) and any antibiotic must be discontinued for at least one month prior to this test.
  • According to a case study conducted at Kuwait University in 2000, the incidence of false positives were significantly reduced by having the patient brush their teeth

Billing and Reimbursement

Medicaid and private insurance companies accept two CPT codes for the 14C-urea breath test reimbursement, 78268 for test analysis and 78267 for drug administration and sample collection.

 

Regulations:

Your site does not need a CLIA license to perform this test nor a radioactive materials license.

 

More on 14-C Urea Breath Test 

 

Fiscal Cliff Deal Means Fiscal Squeeze for Imaging

While lawmakers managed to avert the fiscal cliff on Jan. 1, imaging took a hit. The one-year Sustainable Growth Rate (SGR) fix is partially funded by an increase in tfiscalhe imaging equipment utilization threshold. The Diagnostic Imaging Services Access  Protection Act also slipped off the radar during the last-minute scramble to pass a palatable deal. Finally, the deal cuts payments for some radiosurgery procedures.

   The American Taxpayer Relief Act of 2012 prevents a 27 percent Medicare physician payment cut for one year, but the fix dips into imaging's pockets. The deal increases the technical component equipment utilization threshold for advanced imaging modalities from the current 75 percent to 90 percent beginning January 2014. This provision will garner approximately $800 million in savings to the Medicare program over a 10-year period.

     "These cuts will ultimately damage patient access to medical imaging care and may drive up long term costs by delaying diagnosis of illness and disease to later stages where more expansive, and expensive, treatments are required. This move by congress represents a step backward in patient care," American College of Radiology's Board of Chancellors Chair Paul H. Ellenbogen, MD, said in a statement.

     Lawmakers also failed to include H.R. 3269/S. 2347, the Diagnostic Imaging Services Access Protection Act, into the final legislation. This bill would have avoided a 25 percent reduction to the professional component of certain diagnostic imaging services for multiple imaging studies administered to the same patient, by physicians in the same practice setting, on the same day.

     Finally, the American Taxpayer Relief Act of 2012 partially pays for the SGR fix by reducing Medicare payments for radiosurgery by $300 million over 10 years. The legislation would lower hospital outpatient payments for radiosurgery involving multi-sourced Cobalt 60, to the level of another treatment modality that uses a linear accelerator to deliver radiosurgery.

 

--HealthImaging.com

  

Cheese for Gastric Emptying Study

che

An article in the PubMed, U.S. National Library of Medicine evaluated the labeling stability of several alternative meals that could be used to perform solid-phase gastric emptying study. Cooked egg whites labeled with technetium-99m sulfur colloid served as a control. Packaged instant oatmeal and instant mashed potatoes were prepared by adding hot water. Cheddar cheese was melted.The different meals were mixed with technetium-99m sulfur colloid (2.2-3.7 MBq), chopped into small pieces and placed in a glass tube containing gastric juice. The percentage of initial radioactivity remaining with the meal of admixture with gastric juice was measured and the average of the two samples was taken. For egg whites and cheese, there was no significant difference between the values at 1 and 4 h (P>0.8). Oatmeal and mashed potatoes had low and variable labeling stability and are not recommended.

 

     Cheddar cheese provides an alternative meal comparable to egg whites for assessing solid gastric emptying in children. In view of the significant proportion of pediatric patients who refuse to eat scrambled eggs or have allergy to eggs, the availability of other meal choices is essential. The versatility of cheddar cheese, which can be added to macaroni or as a topping on pizza, makes it a useful alternative to labeled eggs.

 

---PubMed, U.S. National Library of Medicine

  

Nuclear Medicine: Sources of Error

Myocardial Perfusion Imaging

  •  Interstitial (non-intravenous) injection of the radiopharmaceutical due to a malfunctioning intravenous catheter will reduce delivery of the radiopharmaceutical to the myocardium and alter radiopharmaceutical uptake and clearance kinetics. A low-count imageshould raise concern regarding adequate delivery of the radiopharmaceutical. Confirmation of the infiltration by imaging of the injection site is recommended.
  •  Voluntary or involuntary patient motion during image acquisition will create image blurring and artifacts that may appear as irregularities in the myocardium or as zones of decreased uptake in the myocardium. Careful attention to patient comfort and stability during the acquisition may prevent major motion artifacts. Minor motion artifacts can often be corrected by reprocessing of data, using a motion-correction algorithm. Patients should not be released before review of raw data for patient motion.
  •  Failure to achieve the sex- and age-predicted 85% peak maximal heart rate will reduce the sensitivity of this procedure for detection of CAD. Patients who cannot achieve 85% of maximal predicted heart rate should be considered for pharmacologic stress before stress injection. Concomitant medications that attenuate or block the action of pharmacologic stress agents may have a similar effect.
  •  Inappropriate filtering of raw back-projected tomographic data may significantly degrade image quality. When possible, iterative reconstruction should be used. Inappropriate count normalization of stress and rest images may cause non-comparability of images for diagnostic analysis.
  •  Failure to recognize and account for the presence of soft-tissue attenuation (often due to the breasts, obesity, abdominal structures, etc.) can hamper accurate image analysis by creating false-positive lesions on the rest or stress images. Prone imaging, or the use of attenuation-correction hardware and software, can reduce these artifacts.
  •  SNM-approved nomenclature should be used to describe anatomic areas in each of the 3 reconstructed orthogonal tomographic planes and on each of the 3 planar images to avoid diagnostic inconsistencies and render comparisons to previous studies easier. Prior studies should be reviewed for comparison to the current study to note differences (i.e., new findings) in comparison to any prior study.
  •  Comparable views and tomographic slices should be displayed for comparison of the rest and stress (or redistribution) data.
  •  Before examination of reconstructed tomographic cuts, the raw tomographic data should be reviewed in a rotational cinematic format for the presence of attenuation artifacts and zones of increased activity (e.g., lung, liver, bowel, or renal activity and other lesions) that may alter the appearance of the myocardium on the reconstructed data. If possible, steps should be taken to compensate for these problems, or the acquisition may have to be repeated.
  •  For quantitative analysis of regional myocardial and lung activity, it is necessary to ensure that regions of interest do not include activity from adjacent structures. Calculation of the lung-to-heart activity ratio should include a similarly sized region of interest in the lung and myocardium, not including the anterior and anterolateral wall, where lung and myocardium activity overlap. Attempts should be made to include only cardiac activity in regions of interest used for quantitative analysis of radiopharmaceutical uptake and clearance.
  •  For quantitative analysis, the SPECT data must be processed in an identical fashion to the normal data file, including filtering, reorientation, and quantitative analysis.

 

Gated Equilibrium Radionuclide Ventriculography

  •  RBC labeling- Certain medications and disease processes (e.g., chronic renal failure) will decrease labeling efficiency and reduce the target-to background ratio.
  •  Patient positioning-The ejection fraction may be inaccurately calculated by inadequate separation of the left ventricle from other cardiac structures, especially the left atrium (which has a time-activity curve that is the opposite of that of the left ventricle).
  •  Gating errors-A poor ECG signal or one in which complexes other than the QRS complex are dominant may result in spurious gating and data that are not interpretable. Care should be taken to ensure that the QRS complex is the triggering signal (e.g., choosing an ECG lead in which the QRS is much larger than the T wave). The best gating can be obtained from systems that compute the rate of change of voltage on the ECG to be sure that the QRS and not the T wave is the signal used.
  •  Heart rate variability-Significant heart rate variability may compromise the determination of diastolic filling indices.
  •  Image statistics-Inadequate counts/frame may compromise image interpretation as well as decrease the statistical reliability of quantitative measurements.
  •  Processing errors-Inclusion of nonventricular activity or exclusion of ventricular activity from ventricular ROIs may cause underestimation or overestimation of the ejection fraction. Including the left atrium in the ROI my also alter the LVEF. Inclusion of structures such as the spleen or the descending aorta in the background ROI may alter the LVEF.

Brain Death Scintigraphy

  •  Substandard radiochemical purity of brain-specific radiopharmaceuticals or injection of the wrong radiopharmaceutical can result in false- positive studies.
  •  In addition, tracer can accumulate in the superior sagittal sinus from several sources, and the superior sagittal sinus activity may be mistaken as a sign of cerebral arterial flow (20). Hyperemic scalp structures may result in false-negative flow studies if nonspecific brain agents are used. Infiltration of tracer at the injection site may cause a false-positive study if the entire dose is infiltrated and not available to the vascular space; absence of activity in the carotid vessels on flow images suggests complete infiltration of the dose. Retained radioactivity from a previous study using 99mTc-HMPAO or 99mTc-ECD may impede a correct diagnosis for a repeat study on the same day (15,23).

 

Breast Scintigraphy with Breast-Specific g-Cameras 1.0

  •  Infiltration of the radiopharmaceutical administered in an arm vein may cause false-positive uptake in the axillary lymph nodes. Imaging of the injection site is helpful in evaluating the presence and extent of dose infiltration, particularly if an unsuspected breast lesion is discovered on the same side as the injection. Motion of the breast relative to the detector will decrease the accuracy of the test.
  •  The sensitivity, specificity, and accuracy of this test depend on several factors, including the size of the breast neoplasm being imaged. Although the sensitivity of this test for sub-centimeter tumors is high at around 95%, as with all radiologic examinations sensitivity decreases with lesion size.

 

--SNM Procedure Guidelines

 

 Hope for Harlie

Harlie Bryant is the 6 year old daughter of Lisa Bryant, a nuclear medicine technologist that many of you harlie know from Owensboro Heart & Vascular in Owensboro, KY. About a year ago, Harlie was having a routine eye exam, as required for admission to kindergarten, when she was diagnosed with astrocytoma, a type of brain tumor.

 

       We would like to let you know that you can help support Lisa and her family in their fight to save Harlie. Become one of "Harlie's Angels"!   Go to HopeForHarlie.org to show your support and help pay medical bills, ease their financial worries, and allow them to focus on taking care of Harlie.

 

HopeForHarlie.org
115 Green Meadows Dr.
Beaver Dam, KY 42320
(270)991-2513 
[email protected] 

 

 

Promotion Name

ELIMINATE RADIOACTIVE CONTAMINATION

 

  •  Highly effective at removing Tc99m, I131, and other isotopes bind it
  •  Pleasantly scented
  •  Decontaminites fume hoods
  •  Safe for use on syringe shields, will NOT cloud leaded glass
  •  Non-corrosive; safe on delicate detectors, probes & survey meters
  •  Clean washrooms, bench tops, fume hoods, floors-most surfaces
  •  Extremely effective on I131; clean isolation rooms & patient "accidents"
  •  Will not stain lab coats and clothing
  •  Bind-itTM Hand Soap is ideal for accidental skin contamination
  •  Economical, a little goes a long way

 

Call Radiopharmacy, Inc. for more information.

 

 

 

For Sale....Slightly used, heavily discounted
 
Lead Lined Waste Container.....$200
 
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
    
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.


 Full time postion:     
DHS:  Nuclear Medicine Technologist
Part-time prn for the Paducah area.
Contact:  Bill Gooch @ 800 322-6341

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.

Co-57 Dose Calibrator Source Rental

NRC and Agreement States require that radioisotope dose calibrators be tested for accuracy annually with at least two different sealed sources. One must have a principal photon energy between 100 and 500 keV. Because Co-57 has a photon energy close to Tc-99m it is a good choice for one of the two radionuclide sources. The NRC requires the source be at least 50 uCi but some agreement states require the Co-57 to be at least 1 mCi. However, since the half life of Co-57 is only 270 days, your source must usually be replaced every two to four years. The cost of a 5 mCi dose calibrator source is more than $700 including shipping. That makes the annual cost at least $175-$350 for the Co-57 source alone.

     Radiopharmacy Inc. would like to offer our customers who are purchasing their own Co-57 sources an option. You may "rent" a source from us for $50. We always keep on hand a Co-57 dose calibrator source that is at least 50 uCi, and we are able to deliver and retrieve it with your normal deliveries. Simply give us a call if you are interested.

  

Radiation Safety DVDs


Radiation safety training for nuclear medicine support staff is an annual requirement, and for most an annual headache. Getting staff from nursing maintenance, housekeeping, etc., together all at once is practically impossible, and buying an expensive training video is not a real attractive alternative.

     Radiopharmacy has hopefully found a better solution. We have radiation safety videos that are available for your use. One is titled "Radiation Safety and Common Sense:, and the other "Radiation Safety Training for Hospital Support Staff". Rental fee is $50 per week per video. We anticipate most people need only one video for one week.  

 

      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.

Products and Services
 
    • Radiopharmaceuticals - Diagnostic and therapeutic
    • Radioactive Sealed Sources
    • Brachytherapy Sources (I-125 and Pd-103)
    • Lab Testing
    • Nuclear Medicine Department Computer Software,
    • Reimbursement Assistance
    • Continuing Education
    • Health Physics Consulting
    • ICANL and ACR Accreditation Assistance
    • Professional Consultation regarding radiopharmaceuticals and their clinical use.

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.