Nuclear Medicine Clinical Practice in the United States During the COVID-19 Era and Beyond.

Traditionally, practice in nuclear medicine has involved strong emphasis on radiation safety principles. Nuclear medicine technologists (NMTs) focus on practices that keep patients, the public, and the technologist safe from potentially harmful effects of unnecessary radiation exposure using concepts of time, distance, and shielding as well as ALARA (As low as reasonably achievable) principles. The current COVID-19 pandemic has brought to light the need to apply focus on infection prevention in practice and update knowledge and procedures on such measures. In this article, the authors outline the need for NMTs to develop practices and values focused on infection prevention measures.

DOSIS: An integrated computational tool for patient-specific dosimetry in nuclear medicine by Monte Carlo and dose point kernel approaches.

The use of radiolabeled molecules for tumor targeting constitutes a remarkable technique for the treatment of systemic malignancies. An accurate patient-specific dosimetry in nuclear medicine procedures should be a relevant pre-requisite in order to achieve the required lethal damage to tumor cells while maintaining possible side-effects to normal tissues at tolerable levels. It is desired to assess in vivo the radiopharmaceutical distribution for further estimation of absorbed dose released to target and involved organs. In this context, it was developed a computational toolkit, called DOSIS, in order to perform patient-specific dosimetry based on personalized patient anatomy and biodistribution of radionuclides both obtained by currently available dual PET/CT or SPECT/CT facilities. This work is focused on comparing 3D dose distributions obtained by DOSIS performing full stochastic Monte Carlo simulations versus analogue distributions obtained with analytical approaches like dose point kernel convolution and local energy deposition, when considering non-homogeneous activity or density distributions at different scales. Mathematical virtual phantoms were created for this study in order to compare results with other calculation methods. Some of the beta-emitters radionuclides commonly used for therapy (90Y, 131I, 177Lu) were investigated, and emissions of beta-particles, conversion electrons, gamma radiation, and characteristic X-rays were considered. DOSIS implements a novel code devoted to managing radiation transport simulation by means of PENELOPE Monte Carlo general-purpose routines on voxelized geometries defined by 3D mass and activity distributions. Both distributions can be defined through patients-specific images, or pre-defined virtual phantoms. Results preliminary confirmed DOSIS as a reliable and accurate toolkit for personalized internal dosimetry along with highlighting advantages/drawbacks of the different calculation schemes proposed.

The Physician Payment Sunshine Act: Evaluating Industrial Payments in Radiology.

RATIONALE AND OBJECTIVES: The characterization of payments made to physicians by pharmaceutical companies, device manufacturers, and group purchasing organizations is crucial for assessing potential conflicts of interest and their impact on practice patterns. This study examines the compensation received by general radiologists (GR) in the United States, as well as radiologists in the following five subspecialties: body imaging, neuroradiology, pediatric radiology, nuclear radiology and radiological physics, and vascular and interventional radiology. MATERIALS AND METHODS: Data were extracted from the Open Payments database for radiology subspecialists in the United States who received installments in calendar year 2015 from pharmaceutical and device manufacturing companies. RESULTS: In 2015, a total of $43,685,052 was paid in 65,507 payments (mean $667/payment; median $32/payment) to radiologists, including 9826 GR, 362 body imaging radiologists, 479 neuroradiologists, 127 pediatric radiologists, 175 physicians in nuclear radiology and radiological physics, and 1584 vascular and interventional radiologists. Payments were unequally distributed across these six major subspecialties of radiology (p < 0.01), with GR receiving the largest number of total payments (44,695), and neuroradiologists receiving significantly higher median payments than any other subspecialty ($80 vs $32 for all radiologists; p < 0.01). Medtronic Neurovascular was the single largest payer to all radiologists combined. CONCLUSION: Commercial entities make substantial payments to radiologists, with a significant variation in payments made to the different radiology subspecialties. While the largest number of total payments was made to GGR, the highest median payments were made to neuroradiologists, and significant dispersion in these payments was seen across different geographic regions. The impact of these payments on practice patterns remains to be elucidated.

Micro-dosimetry calculation of Auger-electron-emitting radionuclides mostly used in nuclear medicine using GEANT4-DNA.

A large number of nuclear medicine radionuclides are Auger-electron-emitters and internal conversion electrons which can transmit significant doses to the patient during diagnosis. Therefore, the dosimetry of these radioisotopes is necessary for the evaluation of their biological effects and their use for treatment and targeted-radiotherapy. In this study, dosimetry calculation of a number of widely used radioisotopes in nuclear medicine was performed on a cellular scale using Geant4-DNA simulation. S-values of some of the diagnostic radioisotopes, including 123I, 125I, 99mTc, 67Ga, 201Tl, and 111In, were evaluated in a homogeneous spherical geometry model with unit density in which the cell and nucleus were concentric. The results revealed that S-values of these diagnostic radioisotopes were mainly greater than S-values of the radioisotope 131I, which emits ß-particles; they were lower but can be compared with 211At (emitter of alpha particles) in the cellular scale. It shows better the importance of dosimetry calculation of diagnostic Auger-electron-emitting radioisotope in a cellular scale and their applicability in treatment. It should be noted that the S-values obtained out of the Geant4-DNA simulation are in line with the values of the other codes and the MIRD technique.

Physician Specialty and Radiologist Characteristics Associated with Higher Medicare Patient Complexity.

RATIONALE AND OBJECTIVES: Meaningfully measuring physician outcomes and resource utilization requires appropriate patient risk adjustment. We aimed to assess Medicare patient complexity by physician specialty and to further identify radiologist characteristics associated with higher patient complexity. MATERIALS AND METHODS: The average beneficiary Hierarchical Condition Category (HCC) risk scores (Medicare's preferred measure of clinical complexity) were identified for all physicians using 2014 Medicare claims data. HCC scores were compared among physician specialties and further stratified for radiologists based on a range of characteristics. Univariable and multivariable analyses were performed. RESULTS: Of 549,194 physicians across 54 specialties, the mean HCC risk score was 1.62 ± 0.75. Of the 54 specialties, interventional radiology ranked 4th (2.60 ± 1.29), nuclear medicine ranked 16th (1.87 ± 0.45), and diagnostic radiology ranked 21st (1.75 ± 0.61). Among 31,175 radiologists, risk scores were higher (P < 0.001) for those with teaching (2.03 ± 0.74) vs nonteaching affiliations (1.72 ± 0.61), practice size ≥100 (1.94 ± 0.70) vs ≤9 (1.59 ± 0.79) members, urban (1.79 ± 0.69) vs rural (1.67 ± 0.59) practices, and subspecialized (1.85 ± 0.81) vs generalized (1.68 ± 0.42) practice patterns. Among noninterventional radiology subspecialties, patient complexity was highest for cardiothoracic (2.09 ± 0.57) and lowest for breast (1.08 ± 0.32) imagers. At multivariable analysis, a teaching affiliation was the strongest independent predictor of patient complexity for both interventional (ß = +0.23, P = 0.005) and noninterventional radiologists (ß = +0.21, P < 0.001). CONCLUSIONS: Radiologists on average serve more clinically complex Medicare patients than most physicians nationally. However, patient complexity varies considerably among radiologists and is particularly high for those with teaching affiliations and interventional radiologists. With patient complexity increasingly recognized as a central predictor of clinical outcomes and resource utilization, ongoing insights into complexity measures may assist radiologists navigating emerging risk-based payment models.

Analysis of factors correlating with medical radiological examination frequencies.

The European Commission (EC) funded project Dose Datamed 2 (DDM2) had two objectives: to collect available data on patient doses from the radiodiagnostic procedures (X-ray and nuclear medicine) in Europe, and to facilitate the implementation of the Radiation Protection 154 Guidelines (RP154). Besides the collection of frequency and dose data, two questionnaires were issued to gather information about medical radiological imaging. This article analyses a possible correlation between the collected frequency data, selected variables from the results of the detailed questionnaire and national economic data. Based on a 35 countries dataset, there is no correlation between the gross domestic product (GDP) and the total number of X-ray examinations in a country. However, there is a significant correlation (p < 0.01) between the GDP and the overall CT examination frequency. High income countries perform more CT examinations per inhabitant. That suggests that planar X-ray examinations are replaced by CT examinations.

[Inventory resources of nuclear medicine]. / Mandat(e) für die Nuklearmedizin. Eine Inventur der Ressourcen.

AIM: The first survey of the German Society of Nuclear Medicine (DGN) to assess the resources of our speciality named "Inventory Resources of Nuclear Medicine" aims to provide a reliable data basis for existing and future activities of the DGN. The involvement and participation of as many colleagues as possible will play an important role for the success of the development of our profession. METHODS: 214 leading nuclear medicine professionals were identified as the target group. The questionnaire contained 13 different categories. Apart from individual-related questions, memberships in other societies as well as activities in federal or governmental boards, professional self-government or support groups were inquired. Participation in guideline programmes as well as other special experiences, knowledge or contacts, which could be relevant for the work of our boards and working groups, were also subject of the survey. RESULTS: The data of 112 (52.3%) returned questionnaires were analysed. 57 persons state that they have already been involved in the activities of the DGN. Almost three quarters of these persons (n = 42) explicitly affirm their further commitment to the DGN in the future. Another 35 respondents can envisage such a future commitment for themselves. More than half of all colleagues (n = 69) are members of a regional society of nuclear medicine, and 80 are members of at least one professional society or association. This amounts to 3.3 memberships per person. 43 respondents are or have been involved in the clinical guideline development by the DGN or by other medical disciplines. In the future more than half of these persons are willing to participate in the guideline development furthermore. 13 colleagues have participated in the 30 reviews or official hearings concerning the clinical evidence evaluation of PET/CT by the German Institute for Quality and Efficiency in Health Care (IQWiG) (effective date: January 15, 2012). 21 (18.8%) persons are members of 23 federal, governmental or other political boards with relevance for research. 38 persons (33.9%) are committed to professional self-governmental bodies. 14 colleagues stated that they support the work of patient interest groups or other non-profit organisations as consultants or advisors. In most cases, this work is related to the patient interest group "Living without Thyroid". 14 colleagues report special experiences or knowledge that could be helpful for our DGN working groups. In the same manner, good contacts to government departments and agencies or representatives of politics and economy (stated by 24 respondents) can be of advantage to further shape the DGN's professional profile in the German health care sector. CONCLUSION: As the result of a continuously advanced professionalization (2), the DGN has a good infrastructure concerning the political and professional work of its boards (executive committee and working groups). The operational and administrative work of the society and its boards is carried out or coordinated entirely by the society's office. Especially the development of the professional potential within the DGN by increasingly involving leaders working in clinical routine or research is the basis for the future of nuclear medicine.

Radioimmunotherapy in non-Hodgkin lymphoma: opinions of nuclear medicine physicians and radiation oncologists.

UNLABELLED: Despite approval by the Food and Drug Administration and consistent reports of the efficacy and safety of (90)Y-ibritumomab tiuxetan and (131)I-tositumomab, these therapies are infrequently used. This study investigates the opinions and patterns of the use of radioimmunotherapy by nuclear physicians, affiliated researchers, nuclear medicine technologists, and radiation oncologists and aims to identify possible barriers to the use of this promising therapy. METHODS: An e-mail-based survey with 13 broad questions related to radioimmunotherapy was sent electronically to 13,221 Society of Nuclear Medicine members and radiation oncologists throughout the United States. RESULTS: Six hundred thirteen individuals (4.6%) responded to the electronic survey. Two hundred fifty-one responders (40.9%) had treated patients with non-Hodgkin lymphoma (NHL) with radioimmunotherapy in the last 24 mo. Of the responders, 29.5% used only (90)Y-ibritumomab tiuxetan, 7.6% used only (131)I-tositumomab, and 24.9% used both radiopharmaceuticals; 37.9% did not treat NHL with radioimmunotherapy. Most responders said their patients came from university hospitals (33.9%) or private offices (25.6%), and they mainly treated in a second-line (42.9%), third-line (35.6%), or consolidation (23.5%) setting. Major concerns were that referring oncologists and hematologists wanted to treat by themselves with nonradioactive compounds (mean ± SD, 3.418 ± 1.49) and that (90)Y-ibritumomab tiuxetan and (131)I-tositumomab were expensive (mean ± SD, 3.413 ± 1.35). Of the responders and involved physicians, 40.4% and 35.2%, respectively, did not know if their institution accepted Medicare patients for radioimmunotherapy. Almost 30% (29.6%) of the responders thought radioimmunotherapy would probably grow and 38.0% thought it would grow in importance in the future. Responders who did not administer radioimmunotherapy for NHL thought it took too much time to administer radioimmunotherapy (P < 0.01) and had concerns about the dosimetry procedure (P < 0.01) and radiation safety (P < 0.01). Individuals who perceived a negative future for radioimmunotherapy had significantly more concerns about the time-consuming administration process (P < 0.05) and the high cost of radioimmunotherapy (P < 0.05). Responders from academic centers had significantly fewer concerns about payment (P < 0.01), dosimetry (P < 0.01), and radiation safety (P < 0.01). CONCLUSION: Radioimmunotherapy was generally viewed positively by the surveyed population. However, limited referrals due to alternative nonradioactive therapies and logistic, educational, and economic concerns played an important role for subgroups in the perception of radioimmunotherapy for NHL.

A 2009 survey of the Australasian clinical medical physics and biomedical engineering workforce.

A survey of the Australasian clinical medical physics and biomedical engineering workforce was carried out in 2009 following on from a similar survey in 2006. 621 positions (equivalent to 575 equivalent full time (EFT) positions) were captured by the survey. Of these 330 EFT were in radiation oncology physics, 45 EFT were in radiology physics, 42 EFT were in nuclear medicine physics, 159 EFT were in biomedical engineering and 29 EFT were attributed to other activities. The survey reviewed the experience profile, the salary levels and the number of vacant positions in the workforce for the different disciplines in each Australian state and in New Zealand. Analysis of the data shows the changes to the workforce over the preceding 3 years and identifies shortfalls in the workforce.

Assessing the need for nuclear cardiology and other advanced cardiac imaging modalities in the developing world.

BACKGROUND: In 2005, 80% of cardiovascular disease (CVD) deaths occurred in low- to middle-income countries (i.e., developing nations). Cardiovascular imaging, such as myocardial perfusion SPECT, is one method that may be applied to detect and foster improved detection of at-risk patients. This document will review the availability and utilization for nuclear cardiology procedures worldwide and propose strategies to devise regional centers of excellence to achieve quality imaging around the world. METHODS: As a means to establish the current state of nuclear cardiology, International Atomic Energy Agency member and non-member states were queried as to annual utilization of nuclear cardiology procedures. Other sources for imaging statistics included data from medical societies (American Society of Nuclear Cardiology, European Society of Cardiology, and the European Association of Nuclear Medicine) and nuclear cardiology working groups within several nations. Utilization was calculated by dividing annual procedural volume by 2007 population statistics (/100,000) and categorized as high (>1,000/100,000), moderate-high (250-999/100,000), moderate (100-249/100,000), low-moderate (50-99/100,000) and low (<50/100,000). RESULTS: High nuclear cardiology utilization was reported in the United States, Canada, and Israel. Most Western European countries, Australia, and Japan reported moderate-high utilization. With the exception of Argentina, Brazil, Colombia and Uruguay, South America had low usage. This was also noted across Eastern Europe, Russia, and Asia. Utilization patterns generally mirrored each country's gross domestic product. However, nuclear cardiology utilization was higher for developing countries neighboring moderate-high "user" countries (e.g., Algeria and Egypt); perhaps the result of accessible high-quality training programs. CONCLUSIONS: Worldwide utilization patterns for nuclear cardiology vary substantially and may be influenced by physician access to training and education programs. Development of regional training centers of excellence can guide utilization of nuclear cardiology through the application of guideline- and appropriateness-driven testing, training, continuing education, and quality assurance programs aiding developing nations to confront the epidemics of CVD.

A survey of nuclear medicine services in Scotland 2004-2005.

OBJECTIVE: Audit Scotland has recommended that NHS boards should ensure that medical equipment performance information is used to assess whether the local area is making the best use of its medical equipment. A survey of nuclear medicine departments in Scotland was carried out to provide a benchmark. METHOD: A questionnaire was sent to every nuclear medicine department in Scotland. Information requested included the amount, type and age of equipment and its service support. It also requested information to assess cost-effectiveness and quality measures such as waiting times. RESULTS: The response rate to the survey from the 21 nuclear medicine departments in Scotland was 100%. During 2004/2005, there were 71 426 nuclear medicine procedures carried out in Scotland, just over 14 per 1000 of population. A mean of 1619 procedures per imager was found. The mean number of procedures per whole time equivalent member of staff was found to be 499 and the mean cost per procedure, excluding radiopharmaceutical costs, was pound82. Relatively, long waiting times were found for bone scans, myocardial perfusion imaging and brain single-photon emission computed tomography. CONCLUSION: The survey shows that nuclear medicine activity in Scotland is higher than in the United Kingdom as a whole. The move from single-to dual-headed gamma cameras in recent years is demonstrated. The total number of staff employed in nuclear medicine departments in Scotland is only 143 whole time equivalent divided amongst several staff groups. Performance indicators have been identified and a report has been issued to participating departments enabling them to benchmark themselves as recommended by Audit Scotland.

[Nuclear-medical irradiation during pregnancy. Risk assessment for the offspring]. / Nuklearmedizinische Strahlenexpositionen während der Schwangerschaft. Risikoabschätzungen für die Leibesfrucht.

UNLABELLED: AIM To estimate and evaluate the risks for the offspring due to the administration of radiopharmaceuticals to women during the first pregnancy weeks after conception (weeks p.c.). METHODS: The in-utero exposition of the embryo due to diagnostic nuclear medicine procedures, for which diagnostic reference levels (DRL) are specified, as well as due to radio iodine therapy (RIT) was determined. To this end, it is assumed that the activity of the diagnostic radiopharmaceuticals administered to the mother corresponds with the DRL and amounts to 600 MBq or 4 GBq 131I for RIT of benign or malignant thyroid disease, respectively. Based on these data, the radiation risk for the offspring was assessed and compared with the spontaneous risks (R0). RESULTS: The dose for the offspring does not exceed 7.8 mSv for the diagnostic procedures considered, resulting in an excess risk for the offspring of less than 0.12% (R0 approximately 25%) to die from cancer during life, of less than 0.07% (R0 approximately 0.2%) to develop cancer up to the age of 15 years, and of less than 0.16% (R0 approximately 2%) for hereditary effects. RIT during the first 8 weeks p.c. results in doses for the offspring of about 100-460 mSv, resulting in an excess risk for malformations of the child of 3.4%-22% (R0 approximately 6%). CONCLUSIONS: The risk of stochastic radiation effects for the offspring due to a diagnostic nuclear medicine procedure of the mother during the first 8 weeks p.c. is--compared with the spontaneous risks--very small; deterministic effects are unlikely. In contrast, deterministic effects for the offspring may occur following RIT. In order to decide on a possibly indicated abortion after RIT, an individual risk assessment is mandatory.

Trends in the utilization of medical procedures that use ionizing radiation.

Medical procedures that use ionizing radiation have grown rapidly in volume over the last two decades and constitute a substantial portion of the collective radiation doses to the U.S. population. The purpose of this study is to describe the components of this growth. Summarized claims data from Medicare are used to describe trends for the period 1986-2005; supplemental data from other payers and surveys are used for verification and to describe age distributions of those who have these procedures. A notable trend is the rapid growth of CT and nuclear medicine, with CT volume per fee-for-service Medicare enrollee growing, on average, at 8% per y and nuclear medicine at 7% per y during the period 1986-2005. Cardiac procedures-nuclear medicine and interventional radiology-grew at over 15% per y per fee-for-service enrollee during the same period. The share of nuclear medicine procedures performed in physician offices increased from 10% in 1986 to 55% in 2005; the share of CT in the emergency room increased from 3% in 1992 to 17% in 2005. With this expansion in imaging volumes across practice settings, there is an increased need for radiation safety education of ordering physicians, imaging physicians, and patients, so that adequate consideration is given to radiation risk when determining the appropriateness of a prescribed procedure.

A survey of incidents in radiology and nuclear medicine in the West of Scotland.

Data on 606 incidents in radiology and nuclear medicine departments reported to a central health physics service have been analysed and causes reviewed. 85% of incidents in radiology departments and 37% in nuclear medicine were overexposures of patients. 80% of these resulted from human error or procedural failure, and of these 32% were mistakes by the referrer. Other incidents in nuclear medicine were contamination events (49%) and failure in management of radioactive materials (10%). Effective doses for patient overexposures covered a broad range with those for CT being 1 mSv and above, while those for other radiology examinations were mostly less than 2 mSv. Reporting of patient overexposure incidents in radiology has increased by four-fold in recent years. The average numbers reported during the last 3 years were 91 per year in radiology and 12 per year in nuclear medicine, for hospitals with a population base of 2.8 million. Incident investigations demonstrated the importance of robust procedures and defences to identify mistakes that could lead to incidents. The central incident reporting and investigation system has raised the awareness of staff about the type of mistakes which could lead to incidents and promoted the introduction of recommended actions to reduce these risks.

[Cost-effectiveness of radiopharmaceuticals in the hospital].

To the Editor: We would like to thank Dr Markou for highlighting the important issue of medical economics. Dr. Markou suggested some basic principles of economic methodologies and tools that are useful in assessing the costs of nuclear medicine procedures. In our paper (Hell J Nucl Med 2004; 7:158-161), we have thoroughly described the framework we used for the economic evaluation of some of the most common nuclear medicine procedures. Moreover, the purpose of our study was to compare actual cost estimates for common diagnostic procedures in the nuclear medicine department, with current hospital prices. Our results have recognized the need to consider the actual costing of nuclear medicine tests and to allocate health care resources on the basis of these economic evaluations. Alphas Dr Markou has pointed out, we apologize for the fact that in Figure 1 instead of (99m)Tc-MAG-3, we mistakenly wrote (99m)Tc-DTPA both in the actual figure and in its footnote.

[Costing nuclear medicine diagnostic procedures].

To the Editor: Referring to a recent special report about the cost analysis of twenty-nine nuclear medicine procedures, I would like to clarify some basic aspects for determining costs of nuclear medicine procedure with various costing methodologies. Activity Based Costing (ABC) method, is a new approach in imaging services costing that can provide the most accurate cost data, but is difficult to perform in nuclear medicine diagnostic procedures. That is because ABC requires determining and analyzing all direct and indirect costs of each procedure, according all its activities. Traditional costing methods, like those for estimating incomes and expenses per procedure or fixed and variable costs per procedure, which are widely used in break-even point analysis and the method of ratio-of-costs-to-charges per procedure may be easily performed in nuclear medicine departments, to evaluate the variability and differences between costs and reimbursement - charges.