Blog

10/21/2017


How do you manage your MPI patients that are severly claustrophobic without resorting to anxiolytics?  At my main employer, we've instilled a novel, ultra-low emission SPECT protocol (<6 seconds a stop if necessary) with both the rest and stress in a prone position.  Having resolution recovery, like UltraSPECT, is what allows us to lower the scan time while still preserving image quality as shown below.

This patients BMI is 39, imaged with a 7mCi (Rest), 21mCi (Stress) Sestamibi all-prone protocol on a GE MyoSight.

 

 

 

 

7/17/2017
Here's a perfect example of how understanding a radiotracers normal/abnormal biodistribution can expedite a clinical diagnosis.  
This patient had complaints of shortness of breath, and left upper quadrant pain.  

Lets take a closer look at the rotating Tc99m-Sestamibi cine.  It should be noted that the below raw images were acquired with lowered emission times using resolution recovery parameters.

Cardiac perfusion images were normal, however their spleen size was not, measuring 17cm on Ultrasound.

 

 

7/13/2017
Update: I've included a spread sheet making it easy to discern if the patient had a normal, intermediate, or blunted heart-rate response.

Is your Nuclear Cardiology Deparment documenting blunted heart rate responses?  If not, this prognostic indicator, in addition to traditional MPI findings, adds a
 modest 15% improvement to the net reclassification (NRI).

As with Adenosine, when administering Regadenoson (Lexiscan) a normal increase in heart-rate will occur. A number of studies have shown that individuals whose heart-rates don't respond, specifically anything <28%, was significantly associated with poor outcomes.  These findings were with patients who had normal and abnormal perfusion patterns.

 

This JNC article makes its case on why a BHRR should make its introduction into everyday clinical use.
 

BHRR Worksheet
Blunted HR Response.xlsx
Microsoft Excel sheet [10.8 KB]


6/21/2017
Out of all the technologies presented at this years annual SNMMI meeting, Ionetix raised the bar by displaying it's miniature on-site cyclotron providing Nuclear Cardiology departments on-demand tracer production.  This technology has the ability to address one of the biggest hurdles limiting the propogation of Cardiac PET, that being a very sparse geographic network of industrial cyclotrons.  Currently only N13-Ammonia is being offered (75mCi's every 10 minutes), but who knows what the future holds with other positron emitters.

For those of you wanting more details on the technology, here's Ionetix's patent submission from 2011.

Ionetix Patent Submission 2011
US20130009571A1.pdf
Adobe Acrobat document [1.7 MB]


 

6/2/2017

Could this device eventually deliver a novel, preferred method of stress?
Image provided from Thornhillmedical.com

 

This SNMMI featured journal article is suggesting hypercapnic stimuli, when compared to Adenosine, could possibly be the new gold-standard for stress testing.  Interesting to note that a contributing author Dr.Joseph Fisher, co-founder of Thornhill Medical, released in 2014 this paper, a conceptualized model proving CO2's vasodilatory effects on cerebral blood flow.  

 

A conceptual model for CO2-induced redistribution of cerebral blood flow
Sobczyk-Steal-NI-14-publ.pdf
Adobe Acrobat document [3.1 MB]


Highlights from the article are as follows:
 

-MBF increased under hypercapnia and adenosine (P , 0.05, for all territories), albeit the increase in the LAD territory was significantly lower than in the LCx and RCA territories (with hypercapnia and adenosine; both P , 0.05).
-Collective comparisons of regional MPR between hypercapnia and adenosine showed significant correlation (R 5 0.71, P , 0.05) and good agreement (bias 5 2.11%).
- There was a trend toward higher resting MBF before caffeine administration, but this was not statistically signifi- cant (P 5 0.09). However, the resting MBF normalized by rate–pressure product was significantly higher before caffeine (1.5 · 1025 [preadministration] vs. 1.0 · 1025 [postadministration], P 5 0.03). These observations are consistent with reports in humans (22) and are likely related to the influence of caffeine on calcium cycling at rest, which is known to promote vascular smooth muscle contraction (23,24).
-These findings of differential MBF response to hypercapnia and adenosine after the preadministration of caffeine suggest that the mechanism of action mediating myocardial hyperemia by these stimuli are at least partly different.
-Found that when the PETCO2 is altered from rest (;35 mm Hg) to about 60 mm Hg under isoxic conditions, MBF increases to levels observed with the clinical dose of adenosine. Specifically, these changes in MBF and MPR were both globally and regionally not different from those observed with adenosine in the absence and presence of coronary stenosis. Preadministration of caffeine abolished myocardial hyperemia to adenosine, as expected, but not to hypercapnia.
-Hence our finding of marked increase in MBF under isoxic hypercapnia has significant translational value especially within the framework of cardiac stress testing. Because elevated levels of PaCO2 can introduce myocardial hyperemia to the same extent as adenosine, PaCO2 has the potential to be an alternative to these pharmacologic agents.
-The major side effect of hypercapnia is the psychic feeling of dyspnea.
-There are several advantages hypercapnia would provide over adenosine: it is noninvasive, it is inexpensive, and its onset is rapid (within 1 breath). As opposed to adenosine, its blood concentration is known continuously from the end-exhaled concentration; its level is controlled within 2 mm Hg continuously throughout the test; the termination of a CO2 stimulus occurs within 10–15 s, as does its side effects; and there is no sudden severe headache, hypotension, tachycardia, diarrhea, allergy, or interaction with other drugs.
-As a further margin of safety, in the absence of hypoxia, there is no lethal level of PCO2.


Reason why A2A agonists won't be going away anytime soon:

-Notably, chronic obstructive pulmonary disease and CO2 retention would be a contraindication for a hypercapnic stimulus because they would not be able to mobilize the CO2 at the end of the test. In these patients, an alternate stimulus such as adenosine would be needed.


 

5/30/2017


Privileged, and equally flattered, to be interviewed by BC Technical for a web-site case study.

 

Atlanta Heart Specialists Case Study (2)[...]
Adobe Acrobat document [2.1 MB]

 

 

5/19/17

For those of you in the Georgia region, the GSNMT annual meeting is taking place this weekend at the Atlanta Marriott off 2000 Century Blvd.  Going by what's on the agenda, it should be extremely informative!

GSNMT 2017 Annual Meeting Agenda
2017-agenda-012617.pdf
Adobe Acrobat document [96.7 KB]

 

 

 

4/4/17

Back in January I posted a link to a JNM issue where Dr.Jeffry Siegel challenges the status quo on medical radiation:

Renowned Medical Physicist Jeffry A. Siegel dispels the 70 year old hypothesis that exposure to medical radiation could increase ones risk of cancer. In fact, he suggests it more likely helps prevent it.
He emphasizes, "This fear is unjustified by any scientific findings and is discredited by most experimental and epidemiological studies, which show that low-dose radiation, instead, stimulates protective responses provided by eons of evolution, resulting in beneficial effects."
Link to the JNM Issue can be found here.


Fast forward to the March 2017 JNM issue, and like ripples in a pond, numerous professionals in the field are siding with Dr.Siegel.  This issue alone has an astonishing five letters to the editor referencing his original article.  

The concensus thus far weighs in favor of a complete overhaul which some argue "
would likely result in the elimination of many government jobs and significantly reduce the budget of the federal and state regulatory agencies."  I for one am proud the JNM posted the controversial article. It's a long overdue conversation with the NRC/BEIR committee that needs to happen sooner rather than later.
 

 

 

3/1/17


Just to show our patients how far Molecular Imaging has come, we've hung this cerebral pefusion scan from 1973 in our testing waiting room.  The image was acquired via rectilinear scanner in 1973.
 

 

2/15/17

During the processing portion of myocardial perfusion imaging, most begin by first placing a region of interest around the left ventricle.  Next, the images are post-processed for quantitative analysis and reconstructed into short, horizontal, vertical sections. A question looms: How much time was really spent analyzing the SPECT data for normal/abnormal radiotracer biodistribution? Below is a Thallium-201 SPECT image acquired on a GE dual-headed Myosight.  How much pathology can you find? *Answers below

Right Ventricular Uptake = Right ventricular overload from right-sided heart failure
Ascites = The liver isn't visualized.  Should have hepatic/splencic radiotracer uptake.  Findings may be from complications of right-sided heart failure
Increased Lung-To-Left Ventricle Ratio = Indicative of left ventricular dysfunction
Lack of Renal Uptake = Normal functioning kidneys should have radiotracer uptake, renal disease/failure is indicated if not visualized
Thin Walled, Dilated Left Ventricle = Indicative of dilated cardiomyopathy

 

 

 

1/31/17

Dr.'s Siegel, Stabin, and Marcus take an unconventional jab at the NRC pleading they stop ignoring their published work.   Dr.Siegel specifically has been extremely vocal that current day medical radiation standards are based off unsubstantiated claims, guided by a 'radiophobic-centered,' not scientific, approach.

Binder5 Digitqal newsline feb 2017.pdf
Adobe Acrobat document [27.8 KB]



1/13/17

 

Is your Nuclear Cardiology Deparment documenting blunted heart rate responses?  If not, this prognostic indicator, in addition to traditional MPI findings, adds a 15% modest improvement to the net reclassification (NRI).

As with Adenosine, when administering Regadenoson (Lexiscan) a normal increase in heart-rate will occur. A number of studies have shown that individuals whose heart-rates don't respond, specifically anything <28%, was significantly associated with poor outcomes.  These findings were with patients who had normal and abnormal perfusion patterns.

 

This JNC article makes its case on why a BHRR should make its introduction into everyday clinical use.

 


1/10/17

Renowned Medical Physicist Jeffry A. Siegel dispels the 70 year old hypothesis that exposure to medical radiation could increase ones risk of cancer. In fact, he suggests it more likely helps prevent it.
He emphasizes, "This fear is unjustified by any scientific findings and is discredited by most experimental and epidemiological studies, which show that low-dose radiation, instead, stimulates protective responses provided by eons of evolution, resulting in beneficial effects."
Link to the JNM Issue can be found here.

 

1/6/17

Will A2A agonists be the next big weight loss drug? 

US20160067271A1.pdf
Adobe Acrobat document [3.4 MB]



12/20/2016


If you're a business owner here in Georgia, now is the time to take advantage of these two massive tax breaks before the end of the calendar year.

First on the table is Section 179, allowing businesses to deduct the total purchase price (or lease) of certain equipment and/or software.  Total allowable deduction for 2016? $500,000!  More information can be found here on the Section 179 website.

Next are the slew of Georgia State tax-credits, specifically the Job Tax Credit.  This incentive fuels companies to expand, providing as much as $4,000 in annual tax savings per job.  More information on this credit, as well as the many more that Georgia offers can be found here on the Georgia.Org website.

 

12/2/2016


Ordering Capital equipment, specifically Imaging, can be stressful, especially if you're working with a new vendor.  Over the last 15 years in my position as an Imaging Supervisor I've built a rapport with a number of major OEM's.  The thought of doing business with anyone else was very intimidating, not to mention ones credibility is on the line if anything goes awry.  With reimbursements nose-diving, staggering costs to maintain compliancy and accreditation via governing bodies, dramatic loss in productivity when dealing with insurance companies, and the growing cost to maintain billing staff - just to get paid - one has to deal with this culminated force by trimming overhead expenses. 

For those of you that don't keep a pulse on emerging trends, the refurbished medical equipment market here in the US is expected to reach 12 billion dollars by 2021, almost doubling this current years forecasts.  One can strongly assume that within the next five years if you haven't purchased a piece of refurbished medical equipment, odds are you will by 2021. 
 

The looming question remains - who can one trust?


Enter BC Technical.

Our practice just completed the installation of three major additions to our imaging portfolio; a 64 slice GE VCT, a dual-headed GE Ventri dedicated cardiac gamma camera, and an UltraSpect workstation.  The initial deal just involved the CT scanner, but because of how much they exceeded my expectations, they were invited to bid on other projects, which they were successful in procuring.  All in all, the entire process from the bidding, negotiating, financing options, and flexibility has quenched any previous reservations when doing business with a non-OEM entity.

Learn from my experience; don't be complacent.  Commit now and start saving!


 

11/4/2016
Never underestimate the power of prone imaging, otherwise known as the 'poor man's attenuation correction.'  After its implementation, our false-positives were considerably lower.

 

10/27/2016

Consistently meeting or exceeding my expectations, these companies have all made my 2016 recommended vendor list:


Inventory Distributors - Henry Schein, Lynn Medical
Pharmaceutical Distributor – Henry Schein
GPO – Intalere, Vizient
Radiopharmacy Services - Cardinal Health
Dosimetry Badges – Radiation Detection Company
Imaging Equipment Providers – GE Healthcare, BC Technical
Field Service Engineers – GE Healthcare
Power Backups - Powercom
Financing – GE Capital
Flood Source Provider – Lynn Medical
Physicist Services – Alliance Medical Physics
Radiation Monitoring Equipment Distributor – Medi-Nuclear
Scaler/GM Counter Calibration Services – Technical Services Group
Biowaste Management – MedPro
Patient Snacks/Beverages – Capital Office Products
EMR Client – eClinicalWorks
HR Services – ADP
Treadmill Stress Systems – Jaken Medical
Commercial Cleaners – Coverall
Radiopharmaceutical Management System – Syntrac
Hardware Based Resolution Recovery – UltraSPECT
Biomedical Services – Medical Maintenance Consultants
Nuclear Reporting Software – NRP by Syntermed
Nuclear Cardiology Processing – Emory Cardiac Toolbox by Syntermed
PACS – Genesis OmniVue
Linen Service – Southern Medical Linen Service
Georgia CON/LNR Legal Counseling – Ray & Sherman, LLC

 

10/10/2016
That time I asked Bracco for two vials of CardioTec.

CardioTec Request = Silence
Back in 2009, I sent Bracco a letter requesting two vials of CardioTec (Teboroxime) to use in conjunction with UltraSPECT's iterative reconstructive algorithms.
Bracco CardioTec.pdf
Adobe Acrobat document [54.2 KB]

 

 

 

10/7/2016

Ever wonder why so many Fortune 500 companies are moving to Georgia?  It's the tax exemptions and credits!

 

Here are the ones relevant to Healthcare:
(6) Sales to any Hospital Authority created by Article 4 of Chapter 7 of Title 31 of the Georgia Code. 

 

(7) Sales of tangible personal property and services used specifically in the treatment function when the sales are to a nonprofit (i.e., a tax exempt organization under the Internal Revenue Code) nursing home, inpatient hospice, general hospital or mental hospital. Application process is through Form ST-NH1. 
 

(7.05) From July 1, 2015 through June 30, 2018, sales of tangible personal property to a nonprofit health center in this state which has been established under the authority of and is receiving funds pursuant to, the United States Public Health Service Act, 42 U. S. C. Section 254b if such health clinic obtains an exemption determination letter from the commissioner. Application process is through Form ST-NHC. Annual application required. Application must be filed electronically through the Georgia Tax Center. Qualifying sales are exempt from the 4% state sales tax. These sales are subject to all local sales taxes.
 

(7.3) From July 1, 2015 to June 30, 2018, sales of tangible property and services to a nonprofit volunteer health clinic primarily treating patients with incomes below 200% of the poverty level and which property and services are used exclusively in performing a general treatment function when such clinic is a tax exempt entity under the Internal Revenue Code and obtains an exemption determination letter from the Commissioner. Application is through Form ST-NVHC. Annual application required. Application must be filed electronically through the Georgia Tax Center. 

 

(47) Sales or use of drugs that are lawfully dispensable only by prescription for the treatment of natural persons; Insulin regardless of whether the insulin is dispensable only by prescription; prescription eyeglasses and contact lenses; drugs dispensable by prescription for the treatment of natural persons without charge to physicians, hospitals, etc. by pharmaceutical manufacturers or distributors; drugs and durable medical equipment dispensed or distributed without charge solely for the purposes of a clinical trial approved by the FDA or an institutional review board. Note: This exemption does not include over-the-counter drugs, drugs sold for animal use, or nonprescription eyeglasses. 

 

(50) Sales of insulin syringes and blood glucose level measuring strips dispensed without a prescription. 

 

(51) Sales of oxygen when prescribed by a licensed physician
 

(52) Sale or use of hearing aids. 


(54) Sale to or use by a patient of any prescribed durable medical equipment or prescribed prosthetic device. 

 

(72) The sale to or use by a patient of all mobility enhancing equipment prescribed by a physician.

 

 

 

10/6/2016

One of the most frustrating, and equally confounding, challenges for Healthcare providers in Georgia (historically has been a red state, yet this law completely defies laissez faire), is the CON filing process through the Georgie Department of Community Health.  The supposed purpose behind the law is to 'ensure the availability of adequate health care services to meet the needs of all Georgians, while safeguarding against the unnecessary duplication of services that perpetuate the costs of health care services.'  Below are a list of all projects that require a CON:

  1. New hospitals, including general, acute-care and specialty hospitals
  2. New or expanding Nursing Homes and Home health agencies
  3. All multi-specialty and certain single-specialty Ambulatory Surgery Centers
  4. Providers of Radiation Therapy, Positron Emission Tomography, Open Heart Surgery, and Neonatal Services
  5. Major medical equipment purchases or leases (e.g. MRI, CT Scanners) that exceed the equipment threshold
  6. Major hospital renovations or other capital activities by any health care facility that exceed the capital expenditure threshold
  7. Before a health care facility can offer a health care service, which was not provided on a regular basis during the previous 12-month period, or add additional beds

Thresholds as of July 2016:
Capital Expenditures, O.C.G.A. § 31-6-40(a)(2) $ 2,903,530
Single-Specialty Physician-Owned Ambulatory Surgery Facilities, O.C.G.A. § 31-6-47(a)(18) $ 2,903,530
Joint Venture Ambulatory Surgery Centers, O.C.G.A. § 31-6-47(a)(19) $ 5,807,061
Equipment, O.C.G.A. § 31-6-40(a)(3) $ 1,246,165


During the filing process, what's commonly not mentioned is the legal counseling that specializes in CON/LNR law is highly recommended.  Most projects fail to take into account these costs which can easily breach five figures, even with the simplest of projects.

Recent reports have questioned this laws efficacy, 
now enforced in 35 states, with the latest stating it diminishes quality of care and in some cases even raises death rates.  The Fiscal Times has a great article shedding some light on this failed policy.

 

 

9/30/2016

Highly recommend paying Becker's website a visit.  Very few have the pulse on Healthcare like they do.

 

 

 

 

 

 

9/21/2016  

Questioning your processing techniques?  Both Cedars and Ectoolbox do a great job of supporting their users by posting tutorials and operating manuals.

Here are Cedars Tutorials

Here is Ectoolbox's operating instructions

 

 

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