This study is both fascinating and chilling. And what's up with Colorado's lack of available data? Regarding Uranium, really not that surprising. If you're really bored, check out this link and compare these documented Uranium concentrations to their Terrestrial Radiation map.


What you don't want to see while exercising a patient - ST elevation. This 66 y/o male was 1:46 into Bruce protocol when they started experiencing severe chest pain. Risk factors include hypertension, hyperlipidemia, and prediabetes. Cardiac catheterization showed a 85-90% ostial stenosis in the LAD.

This article delves into how routine caffiene consumption lowers the PCSK9 proetien in our blood streams which could potentially lower ones risk of cardiovascular disease.

It would be interesting if there was a direct comparison of PCSK9 levels between those with a high daily coffee intake versus those taking Repatha/Praluent without any coffee intake.

Something tells me Amgen/Sanofi wouldn't fund the study!




With Vyndamax and Onpattro being viable options for patients diagnosed with ATTR, our Tc-99m Pyrophosphate scans have dramatically increased over this last year.

One interesting caveat we've encountered are the number of non-cardiac findings depicted on the images. I've echoed in previous posts that it's extremely important Technologists proactively document any uptake (or lack thereof) that falls outside the norms when post-processing.

Attached are a few interesting cases including a hard-positive (actively receiving Vyndamax), non-visualization of the right kidney, and bone uptake that coincides with the left-sided ROI thereby artificially increasing the HCL ratio. 




Having worked in Georgia's healthcare system for 21 years, I've routinely had to deal with the Department of Community Health anytime our practice expands or purchases certain imaging equipment.

Since 1979 it's been enforcing CON (Certificate of need) laws that ostensibly control health care costs by restricting duplicate services and determining capital expenditures meet the communities needs.

The effectiveness of these programs are highly debated, and are often used advantageously for political influence. For example, if an organization happens to have an aggressively funded legal team, since all CON related documentation is available to the public, one could easily appeal another organizations application resulting in lofty legal fees.

Personally, since the CON application requires all equipment invoices/purchases, financial statements, and build-out expenses to be documented, I use this knowledge to leverage our own equipment/building costs.

Georgia's CON repository, dating back to 2005, can be found here.



While Lexiscan is an agonist that specifically targets the A2A receptor to induce vasodilation, it still carries an inhibitory effect on the AV node ,just not as potent as its predecessor - Adenosine.

Here's a great example of a Lexiscan induced transient second degree Mobitz II AV block, which was eventually reversed back to sinus rhythm with Aminophylline.




A direct quote from this journal article: "Normal perfusion with low or very low MBFR is commonly encountered."

In the world of SPECT, by not having MBFR capabilities, this would equate to a false-negative.

It cannot be overstated: this statement alone should be the driving force on the importance of integrating MBFR's into the average cardiac imaging environment - especially for SPECT where the false-negative rate is highly questionable.

With newer solid-state gamma camera's touting much higher sensitivity rates, is there a future for accurately quantifying SPECT derived MBFR's?

MBF Guide
Adobe Acrobat document [4.0 MB]




Do you ever wonder - how much radiation does one get from their granite countertops? Outside of the numerous sources that contribute to our background radiation exposure, naturally occurring radionuclides U-238, Ra-226, Th-232, and K-40 are well documented to be present in small concentrations, all not posing any significant radiation hazard.  Check out this article on the evaluation of radiological hazars in some Egyptian ornamental stones.

In April of 2017, I posted a controversial argument that low doses of radiation was in fact beneficial because of how it stimulates cellular protective responses. Dr. Jeffry Siegel's article supporting this theory was formally published in the JNM here.

Coincidentally enough, MIT now has free online courses available to the general public, and one of them is based entirely on Radiation. Once you get to the 33rd chapter of the course, there begins an entire discussion on Radiation Hormesis and the therapeutic qualities it has against disease, including cancer.


With Regadenoson coming off patent in 2022, is there a future 'stress' successor? Thanks to the research from Dr. Rohan Dharmakumar, he's proven that by administering controlled amounts of CO2, one can induce a hyperemic response equal-to-or-greater-than adenosine (Page 13 for comparison) when assessing for coronary artery disease.

Could this widely available, cost-effective gas be our future stress agent of choice?

Assessment of CAD With Carbon Dioxide
Adobe Acrobat document [3.8 MB]



During my many years of experience in overseeing a busy stress lab, I've only twice witnessed Brugada Syndrome (channelopathy induced EKG abnormality). Similar to other rare EKG abnormalities (WPW, dextrocardia, etc.), one has to pay very close attention to the subtle changes.

More information on this genetic disorder can be found here:


Nuclear derived ejection fraction was 43%, same patient's echocardiogram derived ejection fraction was 55-60%. Why the discordance? After checking the patients bins and trigger file, it became clear that in Lead II the R-wave trigger was mistaking the T-wave as an R-wave due to them both sharing similar amplitudes resulting in the baseline heart-rate being artificially doubled. This mixes the cardiac cycles diastolic/systolic counts which compromises the accuracy of the nuclear derived ejection fraction. Solution? Choosing a lead with more positive R-wave amplitude prior to starting the gated acquisition. In this example, either Lead I or Lead III would have been an ideal choice.



How creativity using X-rays turned 'illegal music' into an underground movement in Russia during the Cold War.

Very interesting read!

lLink to article can be found here.



82 y/o male with complaints of shortness of breath during exertion. A nuclear stress test was ordered which showed a large area of peri-cardiac uptake within the left lung. Due to the concentration of adjacent activity (red arrows), myocardial count-density was negatively impacted resulting in normalization/scaling issues. CT chest was ordered which found severe left diaphragmatic elevation with large/small bowel patterns resulting in a mild left-to-right mediastinal shift. It was suggested the primary concern was a chronic phrenic nerve paralysis.


Don't forget that there's a right-side of the heart that's often overlooked when assessing perfusion. When post-processing your MPI's, ensure staff aren't overly aggressive with volume masking, especially when it can possibly cover up right-sided pathology as illustrated in the attached example.





'Hottest' new hobby: Collection of Uranium antique glass!

Disclaimer: No, this is not my collection.


A great refresher on how myocardial perfusion can be impacted in patients with left bundle branch blocks!



43 y/o 47 BMI female with chest pain on exertion. Arrived very nervous with a resting heart-rate 134bpm. Within two minutes she developed 10/10 chest pain. EKG showed significant, diffuse ST elevation. Nitro with aspirin administered. Patient was revascularized within an hour showing a 99% ostial LAD lesion.



I really can't recommend this book enough! If you're a nuclear technologist or physician, this edition is practically the Bible of stress testing. Very easy to read, with tons of current day, relevant topics that are meticulously cited. Chapter nine really opened my eyes, especially how PR depression in combination with the Ta wave impacts ST depression accuracy.
Ellestad's Stress Testing: Principles and Practice 6th Edition




Another perfect example on why to always err on the side of clinical intuition by taking into consideration myocardial perfusion SPECT imaging's debatable false-negative rate. Here we have a 68 Y/O male for an exercise MPI. Stress EKG was extremely concerning with diffuse >2.5mm horizontal and upsloping ST depression. No chest pain noted. The patient did have EIH (exercise induced hypotension - 138mmHg baseline, to 102mmHg at peak). Surprisingly, his perfusion images and ejection fraction weren't egregiously abnormal as we were expecting, however out of clinical suspicion, the patient was scheduled for a cardiac catheterization. Subsequently, this patient did end up needing bypass.




Despite PYP-Amyloid imaging taking off, chances are, you'll run into some challenges. ASNC's got you covered with a concise blog entry adding some clarity on how to best tackle them!

Cardiac Amyloid Imaging with Tc-99m PYP - Challenges and Potential Solutions




Reverse redistribution patterns have been discussed since the mid 90's. The term itself when applied to Tc-99m perfusion agents like sestamibi/tetrofosmin is somewhat of a misnomer, as it indicates reduced regional radiotracer at rest compared to stress. This occurs in a very small percentage of imaged patients with the majority of them not having significant coronary artery lesions. So the question is: do these scintigraphic findings represent a real decrease in perfusion from stress to rest, or is it a byproduct of tracer kinetics? Unrelated to the attached example is a JNC case study of a spontaneous coronary vasospasm induced reverse redistribution pattern.




Who doesn't need a cheat sheet on how to post-process MPI's with ECTtoolbox? It's always good to have a refresher knowing how to properly set your ROI's, when and when not to mask, setting your basal/apical limits, the impact of slice/volume normalization, and pointing out visual clues on your volume activity curve that could mean the difference between an accurate/inaccurate ejection fraction.


How To Process A Nuclear Stress Test On A Xeleris ECTtoolbox System
How to Process a NST.pdf
Adobe Acrobat document [3.0 MB]




Are you using Sestamibi for your MPI's? There's more evidence that patients should be discontinuing PPIs for at least 3-5 days prior to their scan with the intentions of preventing gastric wall uptake. While this isn't the first journal article to cite this, it's perhaps the most recent and thorough.

Link to the JNC article:




47 y/o male with a history of chest-pain. The significant ST depression persisted into recovery. Expecting cardiac cath to show circumflex disease in the proximal/OM branches.


A great case study to always review your gated bins! I was asked for a second opinion on a patient's gated stress images shown in the first screenshot. Obviously something looked off, especially in the horizontal axis slices. I then reviewed the gated bins, and sure enough - we found our culprit! Luckily, when acquiring the stress gated tomos, the GE Ventri simultaneously provides a plain tomo SPECT without the gated bins. After processing, image quality is restored, however we couldn't provide an ejection fraction. Thankfully the patient had an echocardiogram the same day.




iIPhone 12's have been found to temporarily disable implantable cardiac defibrillators - iPhone 12 Disable AICD's




59 y/o male in for testing after having chest discomfort while drinking coffee. Calcium scoring came in at 211 finding three focal, densely calcified lesions in the left main, proximal LAD, and proximal circumflex. Baseline EKG shows prominent Q-waves inferiorly with a repolarization abnormality. 3 minutes into Bruce, 2-3mm's of ST elevation is seen in the same inferior leads, and diffuse reciprocal ST depression develops, more-so in leads AvL and V2. The patient ultimately refused a cardiac catheterization.


One of the best free ECG self-help guides on the internet - ECG Learning Center




Don't know how to get ahead in the work-place? 2021 is just around the corner, and you still have plenty of time to plan your New Year's resolution!


After receiving countless emails asking for advice, I figured I'd go ahead and just share my perspective on what it takes to elevate your sense of self-worth.


1. Getting comfortable with the uncomfortable.  When doing so, it means you're learning something new.  Embrace it, don't reject!

2. Treat every-single-person respectfully the same, regardless of title, or degree.

3. Don't prioritize your personal needs when on the clock. We've all been there, it's 4pm, you have personal errands to run, and a patient is being added on. Without hesitation, do you start the patient's exam or lie and say your dose expired?

4. Document. Every. Single. Contribution. That goes over-and-beyond.  This alone has doubled my net worth.  Don't know where to start? Read step one. Oh, and master the art of OCB (organizational citizenship behavior).

5. It's the small tasks that make the big picture.  Remember this the next time you're asked to help clean the bathroom, or take out the trash.

6. Obsessed with making decent money? Assuming you have mastered everything on this list, have at least 15 years under your belt, and seriously have your shit together, start building your network by consulting on the side, and aim for middle-management positions for your full-time gig. Those who refuse to work unpaid overtime (assuming salaried), the occasional weekend, and after-hours won't survive.

7.  Don't let poor money management habits fuel unrealistic upward mobility.  For those new grads - I get it.  You want that new car, house, etc. to show others how hard you've worked. But it can be a massive counterweight, especially if the pretense results in a sense of entitlement.

8.  Advocate for anyone, even if they're in another department, or business.  Recognize people when they do great work!  Want to go that extra mile?  A hand-written letter can result in extraordinary outcomes.

9.  Don't underestimate the importance of constantly refining your emotional intelligence.

10. Put the ego aside, and just admit when you're wrong.  Your staff and peers will respect you more in the long run.

11. Strive to surround yourself with the decision makers.  Yeah, that means possibly dealing with quirky, awkward, over-demanding personalities (read step 1 again!), but this will guarantee your accomplishments will be recognized.

12.  Not responding to work related emails within 48 hours.  It's the same concept as never picking up the phone. Take email etiquette seriously, and stop being rude.

13.  Don't underestimate the power of leverage when negotiating with your employer, as well as when to compromise.  Very rarely do we get everything we want, when we want it, but that doesn't mean one has to leave empty-handed.

14.  Random acts of kindness is a guaranteed way to build staff loyalty.

15.  Set clear boundaries between your work and home-life. 

16.  Creating empathy in the workplace.  Somewhat of a lost art this day and age.  Having an active role in supporting staff through extremely difficult circumstances can result in increased staff retention. 
17.  Don't make assumptions.  There's a reason why the first three letters are a-s-s.

18.  While this isn't practical given the current state of affairs, once we're all vaccinated - show off those pearly whites and try smiling more!  The old adage "happiness is contagious" couldn't be truer!



It can't be all work and no play! When I'm not overseeing the imaging logistics at Atlanta Heart Specialists nine imaging locations, I have quite a few passions that keep me busy during my spare time:
1. I'm a drummer for a 'Geek-Rock' band in Atlanta called Hyperspace:
2. I love to cook! My most prized cooking possessions are my Shun knives and 16 qt cast-iron dutch oven.
3. I build/fix computers! Anyone who has access to an AMD Ryzen 9 5900x CPU - message me ASAP!
4. I fix/tinker cars! Starters, alternators, brakes, etc. - I've done it all!
5. I'm a runner! Thanks to custom orthotics, my New Balance 840v4's feel like I'm running on clouds.
6. I'm an audiophile! Being a musician, music fidelity is something that deserves much more attention, especially during an era where all streamed music is highly compressed.

Thanks for reading and I hope all of you have a wonderful, safe holiday!



Why is it that OPPS pays out $10/Tc99m dose if it's derived from a non-HEU source by billing Q9969, but yet there's nothing comparable on the CMS fee schedule?





Xeleris is on the list......




59 y/o male in for testing after having chest discomfort while drinking coffee. Calcium scoring came in at 211 finding three focal, densely calcified lesions in the left main, proximal LAD, and proximal circumflex. Baseline EKG shows prominent Q-waves inferiorly with a repolarization abnormality. 3 minutes into Bruce, 2-3mm's of ST elevation is seen in the same inferior leads, and diffuse reciprocal ST depression develops, more-so in leads AvL and V2. The patient ultimately refused a cardiac catheterization.


45 y/o male with a history of tuberculosis induced constrictive pericarditis. Once the perfusion images were completed, without first researching the patients history, at first glance I suspected situs inversus, however the SPECT images quickly ruled that out. When comparing the mid-lateral wall between echo and perfusion imaging, the scarred, thickened pericardium is what's contributing to its 'bent in' shape.

Next food marketing trend outside of organic?

41 year old COVID+ male on day 15 after mandatory quarantine. No prior history of CAD, only risk factor was hypertension. Stress images were not completed due to patient being admitted to a local ER.

This is why we perform daily floods! Gamma camera was off for an extended period of time which resulted in our peaks swaying around -7 keV. Tune has already been scheduled!


A great case study in this months JNC depicting how long-term PPI use can cause unwanted gastric wall uptake during perfusion imaging.


Adobe Acrobat document [539.1 KB]



Classic false-positive EKG response in a 67 year old female. It's been hypothesized pre and post-menopausal women have these ST segmental changes due to estrogen fluctuations, both natural and synthetic. While adding perfusion SPECT images and the ejection fraction does appreciably increase the overall prognostic value, one has to wonder how FFR's could add a much higher specificity in the detection of present coronary disease.



As I've said before - fully understand your injected radiopharmaceuticals normal organ biodistribution and pharmacokinetics. Working in Nuclear Cardiology we tend to only focus on what's centered in our ROI's during post-processing. Take the time to keenly scower your SPECT images for anything that appears to be 'not right.' Speaking of odd uptake - ever notice right auricle uptake (atrial appendage) with certain Tc99m perfusion agents? Often confused as a mediastinal mass, it's classified as a normal variant, however if that's the case - why don't we see that uptake pattern in all studies?

New file download


Looks like GE has HeartFlow in its cross-hairs!

US20190122401A1 (1).pdf
Adobe Acrobat document [1.4 MB]


Civilian derived radioactive cloud over Europe? While Fukishima would be a likely culprit, after analyzing the isotope ruthenium-106, scientists can't pinpoint an exact culprit, however it was cited that - "The isotope signature discovered in the air filter exhibits no similarities with nuclear fuels of conventional Western pressurized or boiling water reactors. Instead, it is consistent with the isotope signature of a specific type of Russian pressurized water reactors—the VVER series. Worldwide, approximately 20 reactors of this type of VVER are currently operational,"



This patient arrived for a routine outpatient nuclear stress test. Only complaint was shortness of breath and palpitations. A quick baseline found the attached EKG. 5mg of Metoprolol and 150mg of Amiodarone put him back in sinus rhythm, however he was still rushed to the ER for further evaluation.

Imaging volumes are definitely on an upward rebound. Optimistic this trend will continue!




Spectrum Dynamics is once again pushing molecular imaging's technology to a higher echelon. Their latest patent illustrates multiple collision-free detectors having adjustable bore sizes with 'shutter-like' collimating cells granting the end user not just an unparalleled amount of configuration options, but the ability to selectively choose between SPECT, and PET imaging -- or even simultaneous!

Adobe Acrobat document [6.9 MB]




High first-pass extraction - check.
Relatively short-half life and low energy - check.
Optimal post-injection imaging time - check.
High myocardial retention - check.
Acceptable myocardial washout kinetics - check.
MBF quantification feasible - check.

These characteristics were all found with 99mTc-3SPboroxime, a novel perfusion agent that shares many similarities to 99mTc-Teboroxime.

Adobe Acrobat document [1.5 MB]




Forgive the tepid response, but this isn't exactly an earth-shattering revelation. Scroll on down to the article's disclosure and you'll see where I'm coming from.

GE: The Tetrofosmin 'interest-well' is running dry my friends. Please focus your sponsored marketing efforts into Flurpiridaz!

Adobe Acrobat document [630.7 KB]



As one of the most widely used perfusion radiotracers, Tc99m-Tetrofosmin lies at the very bottom of the 'perfusion pyramid' plateauing at 1.5 - 2mL/min/g. For comparative purposes, Tc99m-Teboroxime plateaus right around 4.5mL/min/g. What's the clinical significance? Frankly put - Tetrofosmin underestimates occlusive coronary disease with some studies measuring a 36% cause of false-negative MPI. When using this radiotracer, interpretive confidence should be multi-factorial with patients symptoms, EKG changes, TID, blunted heart rate response, and wall thickening abnormalities having a precedence in the setting of normal perfusion images.

Adobe Acrobat document [319.9 KB]



A great case study reminding us that even endurance athletes are susceptible to cardiovascular disease, albeit they are an extreme minority. The below images are from a 53 y/o male competitive marathon runner with recent complaints of fatigue and palpitations. Completed an impressive 20 minutes on the Bruce stress protocol, only symptom being fatigue, however 2-3mm of horizontal ST depression was present at peak exercise, and there was a salvo of NSVT during recovery. Perfusion images and polar maps displayed a mild, partially reversible defect in the anteroapical wall. Cardiac catheterization found a 80% mid-LAD lesion.




In this months JNC, an entry was submitted by The Cleveland Clinic stating that the H/CL ratios produced when performing a PYP-TTR Amyloid scan are not enough to conclusively diagnose TTR cardiac amyloidosis if there's presence of prior infarcts. For those of you who've been in the field long enough, this shouldn't come as a surprise when considering Tc99m-PYP was first commercially available in 1976 specifically for infarct avid and bone imaging. Prior to ordering a PYP study, providers will need to screen these patients for a recent echocardiogram, perfusion imaging, baseline EKG changes, and a cardiac biomarker lab panel for any indication of an old or recent infarction which could compromise the exams overall sensitivity/specificity.




Getting back to the basics with Dr.Ernest Garcia!

Adobe Acrobat document [1.9 MB]



Prone power! Just one extra 3-minute SPECT can avoid a potential false-positive.



A great example of clinical intuition paying off. 59 year old female in for preop evaluation. Went over 8 minutes with the Bruce protocol completely asymptomatic, however had diffuse 2.5-3mm down-sloping ST depression. Perfusion slices only within the short-axis displayed a very minuscule area of reversibility in the anteroseptal region. Ejection fraction and wall thickening were both normal at 63%. An elevated TID of 1.5 was present as well. Cardiac catheterization found a 70% occluded diagonal branch.


Being in my unique position, I have garnered over 15 years worth of structured pricing on various cardiology-centric equipment, supplies, and services.  Want reassurance you're getting most out of your money?  Click the 'Contact Us' button above or email me directly: 


For those that have your NCT or PET certification through the NMTCB, for a limited time, they are offering current active specialty certificants who can show acceptable documentation of 24 hours of specialty-specific CE credit by December 31, 2020 will have their specialty credential extended for another 7 years from the time of recertification. 

Read more here on NMTCB website




Back in January of 2017 I posted a link to a JNM issue where Dr.Jeffry Siegel challenged 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 emphasized, "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."


Not only are these articles becoming more commonplace in the JNM, the JNC now has an article (August 2019, Volume 26, Issue 4, pp 1358–1360) titled: LNT RIP: It is time to bury the linear no threshold hypothesis. To what degree are these articles challenging the status-quo? Far enough to where Springer Nature mandates the authors mention the following: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.




Nothing like a non-cardiac finding on SPECT to facilitate care when ruling out a differential diagnosis via CT. This patients main complaint was left-sided chest pain.



SPECT MIP can be found here:





Back in June of 2017, I highlighted a SNMMI article that caught my attention. The header read: Arterial CO2 as a Potent Coronary Vasodilator: A Preclinical PET/MR Validation Study with Implications for Cardiac Stress Testing Fast forward to today, and it appears Cedars is really investing the resources to confirm if carbon dioxide is a viable, cost-effective, safe alternative to A2A agonists like Adenosine/Regadenoson. They've even created an incubator program called the "Dharmakumar Laboratory."



Assessment of coronary disease with carbon dioxide
Adobe Acrobat document [5.8 MB]





True believer in the Pygmalion Effect.  Learn to become comfortable with being uncomfortable.




How often does one witness an anomolous RCA? Find out more with the case study I posted on my LinkedIN account.





Perform MPI in Georgia?  Newly assigned MAC, Palmettto GBA, slashed reimbursement for both Cardiolite and Thallium.  The cuts round out to an estimated 35% reduction.  More can be read on my LinkedIN posting.


Be vigilant in observing for incidental findings!


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.





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.



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]

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
Adobe Acrobat document [1.7 MB]



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


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
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.



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]




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
Adobe Acrobat document [96.7 KB]





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.




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.



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





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]



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.



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.



Will A2A agonists be the next big weight loss drug? 

Adobe Acrobat document [3.4 MB]


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.



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!


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.



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


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]





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.





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.




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








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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