Comparison of radioiodine ablation rates between low versus high dose, and according to the surgeon's expertise in the low-risk group of differentiated thyroid cancer.

Radioiodine ablation following surgery is the accepted treatment for patients with differentiated thyroid cancer (DTC). Since that surgical volume and radioiodine dose can have impact on treatment outcome, we aimed to evaluate them on the treatment outcome of low-risk DTC patients. Low-risk DTC patients were classified into four groups, including (1) thyroidectomy was performed by thyroid surgeon and low-dose (1850 MBq [30 mCi]) radioiodine was administered (n = 17), (2) thyroidectomy was performed by thyroid surgeon and high-dose (3700 MBq [100 mCi]) radioiodine was administered (n = 10), (3) thyroidectomy was performed by general surgeon and low-dose radioiodine was administered (n = 22), and (4) thyroidectomy was performed by general surgeon and high-dose radioiodine was administered (n = 29). All patients were followed at least for 6 months and also for evaluation of treatment success, neck sonography, thyroid-stimulating hormone-off, thyroglobulin (Tg)-off, and anti-Tg-off tests were performed. Furthermore, two common radioiodine treatment-associated side effects, including dry mouth, and nausea/vomiting were assessed for all patients. Seventy-eight low-risk DTC patients (female: 70 [89.7%]; male: 8 [10.3%]) aged from 18 to 78 years old with mean of 41.96 ± 13.42 years were enrolled in this study. In total, the treatment was successful in 96.2% of patients. There was no significant difference in treatment success among groups (P > 0.05), while there was a significant association among administered activity and side effects. In low dose patients, only one patient complained from dry mouth; however, 11/39 patients who received high dose of iodine complained from dry mouth (P = 0.002). In addition, 9/39 high dose patients suffered from vomiting/nausea, while none of low-dose patients suffered from vomiting/nausea (P = 0.001). In low-risk DTC patients, surgical volume and amounts of radioiodine had no significant impact on treatment results; therefore, low dose radioiodine following thyroidectomy may be preferable to low-risk DTC patients to avoid side effects.

Technical and patient-related sources of error and artifacts in bone mineral densitometry using dual-energy X-ray absorptiometry: A pictorial review.

Dual-energy X-ray absorptiometry is currently the standard and validated tool for measurement of bone mineral density and for the evaluation of osteoporosis. Current densitometry scanners based on dual-energy X-ray absorptiometry method produce two X-ray beams with different energies to differentiate the overlapped soft tissue and bony structures, by creating two different attenuation profiles. Procedural guidelines are available to technicians and physicians to guarantee the best practice, including consistent positioning during scanning and standard reporting. However, similar to other imaging modalities, dual-energy X-ray absorptiometry may be influenced by technical errors, and thus, imaging artifacts may arise and accuracy and precision of the results may be influenced. This issue may, in turn, affect the final result and interpretation. Hence, the article is arranged with the intention of presenting some less common and rare technical and patient-related sources of error and resultant artifacts, from poor patient preparation to acquisition and data processing. Where appropriate, the corresponding tables of densitometric results (bone mineral density) and statistical parameters (T- and Z-scores) are provided.

Shifting paradigms in the management of pediatric differentiated thyroid cancer from static to dynamic risk stratification: a step forward toward precision medicine.

INTRODUCTION: This study aimed to assess the usefulness of a risk-adopted management system known as dynamic risk stratification (DRS) in comparison with the American (ATA) and European Thyroid Associations' (ETA) risk classifications in the management of pediatric patients with differentiated thyroid cancer (DTC). MATERIALS AND METHODS: The current study included 50 pediatric patients with DTC who were treated with total or near total thyroidectomy and radioiodine ablation whose risk assessment was initially defined according to the ATA and ETA guidelines. During the two years after initial treatment, patients were reclassified according to their DRS. RESULTS: The study showed that the ability of the DRS system to predict the final outcome was superior to that of the ATA and ETA guidelines. The observed variance in predicting final outcome was 2.3 % for ETA, 14.8 % for ATA, and 83.4 % for DRS. In intermediate/high-risk patients, according to the ATA/ETA guidelines, an excellent response to initial therapy resulted in a noteworthy reduction (about 40 %) for detection of structural disease at the time of final follow-up. The risk of structural disease at the time of final follow-up was significantly higher in the structural incomplete response group (HR = 23.34, P = 0.00) and biochemical incomplete response group (HR = 13.83, P = 0.03) than in the excellent response group. CONCLUSION: The data documented the significance of re-stratifying pediatric patients with DTC on the basis of the findings obtained at the time of or after their initial therapy (total thyroidectomy and radioiodine ablation), predominantly in the intermediate/high-risk patients. In addition, DRS helped to better modulate the later follow-up, excluding a large number of intermediate/high risk patients from needless intensive workups, allowing personalization of follow-up management.

Jaffe-Campanacci syndrome: Any role for 99mTc-methylene diphosphonate bone and 99mTc-octreotide scans for evaluation of the disorder?

Jaffe-Campanacci syndrome (JCS) is a rare clinical disorder with almost unknown etiology. The main feature of this syndrome is skeletal involvement as nonossifying fibroma which may cause severe morbidity to these patients. X-ray imaging is the widely available modality for evaluation of skeleton, but radionuclide imaging modalities may have a role in workup. Herein, we present a case of JCS evaluated with 99mTc-methylene diphosphonate bone and 99mTc-octreotide scans for the extent of skeletal involvement. To the best of our knowledge, from over than 30 cases reported in the literature, no evaluation with radionuclide imaging has been done.

Quantitation in Dextrocardia on myocardial perfusion imaging: how to perform quantitative analysis using Cedars-Sinai software.

Dextrocardia, although a rare cardiac abnormality, carries the same risk for cardiac events as other people. SPECT Myocardial perfusion imaging is a potentially helpful diagnostic tool in patients with dextrocardia. Because of swapping of lateral and septal walls on SPECT slices, although visual analysis is possible, quantitation is substantially limited. Here, we introduce a simple practical method to make quantitative analysis feasible and accurate.

POPULATION RADIATION EXPOSURE FROM DIAGNOSTIC NUCLEAR MEDICINE PROCEDURES IN TEHRAN 2011-14; TRENDS IN THE LAST 3 DECADES.

This study represents an update of Tehran population exposure from the diagnostic nuclear medicine procedures and the annual collective effective dose during 2011-14. The diagnostic nuclear medicine procedures data were collected from 58 out of 60 nuclear medicine centers in Tehran and were composed of the type and frequency of diagnostic examinations, radiopharmaceuticals used, administered activities, and age distribution of the patients. The annual number of examinations per 1000 population increased from 13.73 in 2011 to 22.59 in 2014 with an increase of 64.53% during 4 years. Most frequent examinations were cardiac (71.05%), bone (9.80%) and thyroid (7.26%) averaged over the 5 years. The collective effective dose increased from 807.74 person-Sv in 2011 to 1413.81 person-Sv in 2014. The effective dose per capita increased from 44.06 µSv in 2011 to 120.91 µSv in 2014, could be because of 70% increase of examinations, but ~3.42% increase in the population of Tehran.

An Unexpected and Less Recognized Altered Distribution on Bone Scintigraphy; Possibility of 99mTc-Dextrose Complex as a Cause.

Optimal performance of diagnostic tests and correct interpretation depend on multiple factors, one of which is proper radiopharmaceutical preparation. Unwanted impurities result in altered distribution of radiopharmaceuticals and then poor-quality or uninterpretable studies. Therefore, following the reconstitution steps according to standard and validated protocols by the technologist is mandatory. Here, we present 2 cases with unexpected and less recognized distribution of Tc-methylene diphosphonate on bone scintigraphy.

Radioactive Iodine Therapy and Glucose Tolerance.

Radioactive iodine therapy is commonly used as an adjuvant therapy in follicular and papillary thyroid carcinoma (PTC) and in the treatment of Graves' disease (GD). The basis of this therapy is the accumulation of radioactive iodine by the sodium-iodide symporter (NIS) in the thyroid gland. Expression of NIS by extrathyroidal tissues such as islets of pancreas has been reported. Radioactive iodine uptake by pancreatic beta-cells can potentially damage these cells. In this study, we discuss the possible associations between radioactive iodine and glucose intolerance. Overall, radioactive iodine uptake by the pancreas may damage beta-cells and predispose patients to glucose intolerance or type 2 diabetes, particularly in patients exposed to radioactive iodine therapy following total thyroidectomy. Further studies are needed to clarify and confirm this association.

High dose of radioactive iodine per se has no effect on glucose metabolism in thyroidectomized rats.

PURPOSE: Thyroid concentrates radioactive iodine by sodium-iodide symporter; this is used for treating hyperthyroidism and thyroid cancer. Pancreas expresses NIS and radioactive iodine uptake may damage pancreatic beta-cells and predispose patients to type 2 diabetes. The aim of this study was to determine whether radioactive iodine is associated with glucose metabolism in thyroidectomized rats. METHODS: Forty male Wistar rats were divided into four groups (n = 10/each); control, thyroidectomized, thyroidectomized-treated with 131-I (TX+I), and thyroidectomized-treated with 131-I and L-thyroxine (TX+I+T4). At the end of study, serum fasting glucose, insulin, thyroid-stimulating hormone, and free tetraiodothyronine were measured, intraperitoneal glucose tolerance test was performed, and homeostasis model assessment-insulin resistance was calculated. In in vitro experiments, glucose-stimulated insulin secretion from pancreatic islets and sodium-iodide symporter mRNA expression in thyroid and islets were determined. RESULTS: Compared to control group, free tetraiodothyronine was lower by 41 and 77% and thyroid-stimulating hormone was higher by 36 and 126% in thyroidectomized and TX+I groups, respectively. Compared to controls, rats in TX+I group had glucose intolerance as assessed using the area under curve of intraperitoneal glucose tolerance test (12,376 ± 542 vs. 20,769 ± 1070, P < 0.001) and L-thyroxine replacement therapy restored the value (14,286 ± 328.24) to near normal. Fasting insulin and homeostasis model assessment-insulin resistance were comparable in all groups, however fasting glucose was higher in TX+I group. In in vitro experiments, glucose-stimulated insulin secretion from islets did not differ between groups. CONCLUSION: Radioactive iodine therapy per se had no effect on glucose metabolism, just intensified thyroid hormone deficiency and the alterations on glucose metabolism in thyroidectomized rats. L-thyroxine therapy restored the glucose intolerance observed in radioactive iodine-treated thyroidectomized rats.

The electromagnetic interference of mobile phones on the function of a γ-camera.

PURPOSE: The aim of the present study is to evaluate whether or not the electromagnetic field generated by mobile phones interferes with the function of a SPECT γ-camera during data acquisition. METHODS: We tested the effects of 7 models of mobile phones on 1 SPECT γ-camera. The mobile phones were tested when making a call, in ringing mode, and in standby mode. The γ-camera function was assessed during data acquisition from a planar source and a point source of Tc with activities of 10 mCi and 3 mCi, respectively. A significant visual decrease in count number was considered to be electromagnetic interference (EMI). RESULTS: The percentage of induced EMI with the γ-camera per mobile phone was in the range of 0% to 100%. The incidence of EMI was mainly observed in the first seconds of ringing and then mitigated in the following frames. CONCLUSIONS: Mobile phones are portable sources of electromagnetic radiation, and there is interference potential with the function of SPECT γ-cameras leading to adverse effects on the quality of the acquired images.

Phase 2 study of a high dose of 186Re-HEDP for bone pain palliation in patients with widespread skeletal metastases.

UNLABELLED: (186)Re-1-hydroxyethylidene-1,1-diphosphonate (HEDP) is an attractive radiopharmaceutical for the treatment of bone pain arising from skeletal metastatic lesions. Currently, (186)Re-HEDP is most commonly used in European countries. The aim of this study was to investigate the palliative efficacy and adverse effects of (186)Re-HEDP in patients with different types of cancers and skeletal bone pain. METHODS: Nineteen (8 male, 11 female) patients with various cancers (breast, prostate, renal cell carcinoma, colon, and neuroendocrine tumors) and painful bone metastases were included in the study. A dose of 1,480-3,330 MBq (40-90 mCi) of (186)Re-HEDP was administered intravenously. The patients' level of pain relief was assessed by the Visual Analog Scale for 8 wk after treatment and by a weekly blood cell count to evaluate for hematologic toxicity. RESULTS: The overall response rate was 89.5%, and the mean pain score assessed by the Visual Analog Scale was reduced from 9.1 to 5.3 after 1 wk (P = 0.003). No adverse effects were reported by patients during intravenous administration or for up to 24 h after administration. A flare reaction was seen in 63.2% of patients, mainly during days 1-3, and lasted for 2-4 d. There was no significant correlation between the response to therapy and the flare reactions (P > 0.05). The nadir of platelet reduction occurred at the fourth or fifth week and led to platelet infusion in only 4 patients with a low baseline platelet count and diffuse skeletal metastases. Bone marrow suppression occurred in patients receiving higher doses, but no clinical problems were seen except in 2 patients who required packed cell transfusion similar to their prior transfusions. CONCLUSION: (186)Re-HEDP is an effective radiopharmaceutical for the palliative treatment of metastatic bone pain and has minimal adverse effects.

A study of the time of hospital discharge of differentiated thyroid cancer patients after receiving iodine-131 for thyroid remnant ablation treatment.

The aim of this study was to measure the radiation exposure rate from differentiated thyroid carcinoma (DTC) patients who had received iodine-131 ((131)I) treatment, and to evaluate hospital discharge planning in relation to three different sets of regulations. We studied 100 patients, 78 females and 22 males, aged 13 to 79 years (mean 44.40±15.83 years) with DTC, in three Groups who were treated with 3.7, 5.5 or 7.4GBq of (131)I, respectively. The external whole-body dose rates following oral administration of (131)I were measured after each one of the first three hospitalization days. A multivariant linear analysis was performed, considering exposure rates as dependent variables to the administered dose for treatment, age, gender, regional and/or distant metastases, thyroglobulin (Tg), antibodies to Tg and thyroid remnant in the three dose groups. We found that the exposure rates after each of the three first days of hospitalization were 30, 50 and 70µSvh-1 at 1m. All our DTC patients had an acceptable dose rate on days 2 and 3 that allowed their hospital discharge. After only 1 day of hospitalization, just 3/11 cases showed not permissible exposure rates above 70µSvh-1. In conclusion, it is the opinion of the authors that after measuring the exposure rates, most treated, DTC patients could be discharged after only one day of hospitalization, even some of those treated with high doses of (131)I (7.4GBq). Patients, who received the higher doses of (131)I, should not be released before their individual exposure rate is measured.

Preoperative 99mTc-sestamibi scintigraphy in patients with primary hyperparathyroidism and concomitant nodular goiter: comparison of SPECT-CT, SPECT, and planar imaging.

BACKGROUND: Investigations using a hybrid single photon emission computed tomography/computed tomography (SPECT-CT) scanning technique have been carried out in limited studies and have shown mixed results. However, the assessment of this technique for the detection of parathyroid adenoma in patients with a nodular goiter was performed in only one study with a small sample size. The aim of this prospective study was to assess the role of 99mTc-sestamibi parathyroid SPECT-CT scans for localization of parathyroid adenomas with a concomitant nodular goiter using 99mTc-methoxyisobutyl isonitrile (MIBI) scintigraphy and to compare it with SPECT and planar imaging. METHODS: This study was conducted on 48 patients with primary hyperparathyroidism and nodular goiter, who were candidates for parathyroid surgery and had been referred for parathyroid scintigraphy. The patients underwent an early set of planar 99mTc-MIBI scanning procedures first, followed by SPECT and CT scannings, and finally a delayed set of planar 99mTc-MIBI scannings. Sensitivity, specificity, negative and positive predictive values, and accuracy were determined on a per-parathyroid-gland basis for each scanning method, as defined by histology and follow-up. RESULTS: The surgery was successful in 48 out of 50 patients with primary hyperparathyroidism concomitant with thyroid nodularity, and data were completed for 80 sites in 48 patients. The accuracy of SPECT-CT in correctly identifying a parathyroid adenoma was 85.00, versus 75.00% for SPECT (P=0.01, significant). The sensitivity and specificity for SPECT-CT were 77.55 and 96.77%, respectively, versus 67.34 and 87.09%, respectively, for SPECT (P=0.12 and 0.12, not significant). There were nine sites that showed better localization on SPECT-CT scans relative to SPECT images, of which five sites were located in the ectopic regions. CONCLUSION: The results of our study indicate that SPECT-CT is more accurate than sestamibi planar imaging and SPECT for the preoperative identification of parathyroid lesions in patients with primary hyperparathyroidism concomitant with thyroid nodularity. Also, we would recommend the use of SPECT-CT for a workup of all patients with ectopic glands who are scheduled for minimally invasive parathyroid surgery.

99 mTc-MIBI washout as a complementary factor in the evaluation of idiopathic dilated cardiomyopathy (IDCM) using myocardial perfusion imaging.

Rapid technetium-99 m methoxyisobutylisonitrile (99 mTc-MIBI) washout has been shown to occur in impaired myocardia. This study is based on the hypothesis that scintigraphy can be applied to calculate the myocardial 99 mTc-MIBI washout rate (WR) to diagnose and evaluate heart failure severity and other left ventricular functional parameters specifically in idiopathic dilated cardiomyopathy (IDCM) patients. Patients with IDCMP (n = 17; 52.65 ± 11.47 years) and normal subjects (n = 6; 49.67 ± 10.15 years) were intravenously administered 99 mTc-hexakis-2-methoxyisobutylisonitrile (99 mTc-MIBI). Next, early and delayed planar data were acquired (at 3.5-h intervals), and electrocardiogram (ECG)-gated myocardial perfusion single photon emission computed tomography (SPECT) was performed. The 99 mTc-MIBI WR was calculated using early and delayed planar images. Left ventricular functional parameters were also analyzed using quantitative gated SPECT (QGS) data. In target group, myocardial WRs (29.13 ± 6.68%) were significantly higher than those of control subjects (14.17 ± 3.31%; P < 0.001). The 99 mTc-MIBI WR increased with the increasing severity of the NYHA functional class (23.16 ± 1.72% for class I, 30.25 ± 0.95% for class II, 32.60 ± 6.73% for class III, and 37.50 ± 7.77% for class IV; P = 0.02). The WR was positively correlated with the end-diastolic volume (EDV) index (r (2) = 0.216; ß = 0.464; P = 0.02 [ml/m(2)], the end-systolic volume (ESV) index (r (2) = 0.234; ß = 0.484; P = 0.01 [ml/m(2)]), the summed motion score (SMS) (r (2) = 0.544; ß = 0.738; P = 0.00), and the summed thickening score (STS) (r (2) = 0.656; ß = 0.810; P = 0.00); it was negatively correlated with the left ventricular ejection fraction (LVEF) (r (2) = 0.679; ß = -0.824; P = 0.00). It can be concluded that 99 mTc-MIBI scintigraphy might be a valuable molecular imaging tool for the diagnosis and evaluation of myocardial damage or dysfunction severity.

Bone single photon emission computed tomography (SPECT) in a patient with Pancoast tumor: a case report.

CONTEXT: Non-small cell lung carcinomas (NSCLCs) of the superior sulcus are considered to be the most challenging type of malignant thoracic disease. In this disease, neoplasms originating mostly from the extreme apex of the lung expand to the chest wall and thoracic inlet structures. Multiple imaging procedures have been applied to identify tumors and to stage and predict tumor resectability in surgical operations. Clinical examinations to localize pain complaints in shoulders and down the arms, and to screen for Horner's syndrome and abnormalities seen in paraclinical assessments, have been applied extensively for differential diagnosis of superior sulcus tumors. Although several types of imaging have been utilized for diagnosing and staging Pancoast tumors, there have been almost no reports on the efficiency of whole-body bone scans (WBBS) for detecting the level of abnormality in cases of superior sulcus tumors. CASE REPORT: We describe a case of Pancoast tumor in which technetium-99m methylene diphosphonate (Tc-99m MDP) bone single-photon emission-computed tomography (SPECT) was able to accurately detect multiple areas of abnormality in the vertebrae and ribs. In describing this case, we stress the clinical and diagnostic points, in the hope of stimulating a higher degree of suspicion and thereby facilitating appropriate diagnosis and treatment. From the results of this study, further clinical trials to evaluate the potential of SPECT as an efficient imaging tool for the work-up on cases of Pancoast tumor are recommended.

Bone single photon emission computed tomography (SPECT) in a patient with Pancoast tumor: a case report / Tomografia óssea computadorizada por emissão de fóton único (SPECT) em paciente com tumor de Pancoast: um relato de caso

CONTEXT: Non-small cell lung carcinomas (NSCLCs) of the superior sulcus are considered to be the most challenging type of malignant thoracic disease. In this disease, neoplasms originating mostly from the extreme apex of the lung expand to the chest wall and thoracic inlet structures. Multiple imaging procedures have been applied to identify tumors and to stage and predict tumor resectability in surgical operations. Clinical examinations to localize pain complaints in shoulders and down the arms, and to screen for Horner's syndrome and abnormalities seen in paraclinical assessments, have been applied extensively for differential diagnosis of superior sulcus tumors. Although several types of imaging have been utilized for diagnosing and staging Pancoast tumors, there have been almost no reports on the efficiency of whole-body bone scans (WBBS) for detecting the level of abnormality in cases of superior sulcus tumors. CASE REPORT: We describe a case of Pancoast tumor in which technetium-99m methylene diphosphonate (Tc-99m MDP) bone single-photon emission-computed tomography (SPECT) was able to accurately detect multiple areas of abnormality in the vertebrae and ribs. In describing this case, we stress the clinical and diagnostic points, in the hope of stimulating a higher degree of suspicion and thereby facilitating appropriate diagnosis and treatment. From the results of this study, further clinical trials to evaluate the potential of SPECT as an efficient imaging tool for the work-up on cases of Pancoast tumor are recommended.

CONTEXTO: Carcinomas pulmonares de células não pequenas (NSCLCs) do sulco superior são considerados como o maior desafio nos tumores malignos torácicos. Nesta doença, as neoplasias se originam principalmente do ápice do pulmão e se expandem pela parede e pelas estruturas torácicas. Diversas técnicas de imagem têm sido utilizadas para identificar e estagiar os tumores, permitindo um prognóstico para a sua ressecção em procedimentos cirúrgicos. O exame clínico tem sido bastante usado para diagnóstico diferencial de tumores do sulco superior nas queixas de dores no ombro, síndrome de Horner e anormalidades observadas em exames paraclínicos. Embora diversos tipos de exames de imagem sejam utilizados para diagnóstico e estadiamento de tumores de Pancoast, praticamente não existem relatos sobre a eficácia do exame ósseo do corpo todo (WBBS) na detecção do nível de anormalidade em casos de tumores do sulco superior. RELATO DE CASO: Descrevemos um caso de tumor de Pancoast, em que foi realizada a tomografia computadorizada óssea por emissão de fóton único (SPECT) com metileno difosfonato de tecnécio-99 (Tc-99m MDP). Este exame foi capaz de detectar com acurácia as múltiplas áreas de anormalidade em vértebras e costelas. Ao descrever este caso, os autores ressaltam os pontos clínicos e diagnósticos, esperando estimular maior grau de suspeita, facilitando assim o diagnóstico e tratamento apropriados. A partir dos resultados deste trabalho, outros estudos clínicos podem avaliar o potencial do SPECT como uma ferramenta eficiente de imagem a ser recomendada na investigação de casos de tumor de Pancoast.

Huge Varicose Inferior Mesenteric Vein: an Unanticipated (99m) Tc-labeled Red Blood Cell Scintigraphy Finding.

Ectopic varices (EcV) are enlarged portosystemic venous collaterals, which usually develop secondary to portal hypertension (PHT). Mesocaval collateral vessels are unusual pathways to decompress the portal system. Here we report the case of a huge varicose inferior mesenteric vein (IMV) that drained into perirectal collateral veins, demonstrated by (99m)Tc-labeled red blood cell (RBC) scintigraphy performed for lower gastrointestinal (GI) bleeding in a 14-year-old girl. This case illustrates the crucial role of (99m)Tc-labeled RBC scintigraphy for the diagnosis of rare ectopic lower GI varices.

Relation between clinical and laboratory parameters with radiation dose rates from patients receiving iodine-131 therapy for thyroid carcinoma.

Three days following administration of radioactive iodine in 38 patients, exposure rates such as dose rate close to the dress (D0), dose rate of dress at 1 m (D1), dose rate close to the bedsheet (B0), dose rate of bedsheet at 1 m (B1), dose rate of patient at 1 m (P1) and also sum of D1 and B1 (S1) were measured using a radiation detection survey metre with a calibrated ionisation chamber. The patient population consisted of 36 females and 2 males with mean age 38.92 +/- 15.76 y. A considerable correlation was found between age and P1 (r = 0.37 and p = 0.02), and administered dose and P1 (r = 0.43 and p = 0.006). It is recommended that a document should be prepared for practitioners and also all individuals coming in contact with older patients are to be made aware of the contamination and radiation hazards.