Development of nuclear medicine image quality assessment criteria for use in a technologist peer review program.

INTRODUCTION/BACKGROUND: A peer learning program includes the process of peer review, which is the act of performing a secondary review of a peer's work using pre-defined criteria. The Technologist Image Quality Assessment Criteria Project (TIQACP) was initiated to develop and evaluate such criteria for use by technologists for assessment of image quality in Nuclear Medicine (NM). METHODS: A NM clinical expert panel was assembled, comprising 14 technologists, radiologists, and educators from five imaging centres and an academic institution with associated medical imaging training programs. Project design was guided by consensus-based methodology that included three phases: (1) image quality assessment criteria development, based on literature search and expert review (2) image quality assessment criteria refinement, based on consensus-building exercises (panel surveys, discussions, ranking exercise, and time trial) (3) external validation performed via a national survey of NM technologists, facilitated by the Canadian Association of Medical Radiation Technologists. RESULTS: The first phase generated 8 key evidence sources, including textbooks, NM journals and guidelines from professional associations that were reviewed by the expert panel leads and led to a preliminary list of 11 criteria. As part of the second phase, the preliminary list was reviewed via online surveys and panel discussions. Preliminary discussions led to an initial expansion of the list to include 18 criteria. This list required an average of 9 min (range: 7-11 min) for review, which was deemed prohibitive by the panel. A ranking exercise identified 'all required anatomy is clearly identified' as the most relevant criteria and 'Image quality demonstrates no breakdown of the radiopharmaceutical' as the least relevant criteria. Panel discussion also highlighted need to eliminate criteria that were not applicable to all settings. These insights led to an updated list of nine criteria organized into four categories. National validation was supported by 47 NM technologists from across Canada. Respondents were in agreement that the criteria reflected the core elements of image quality in NM (94% agree to strongly agree), were familiar (97%) and were relevant to their current practice setting (88%). The final list was thus not changed based on the survey. DISCUSSION/CONCLUSION: The TIQACP utilized an inclusive process that engaged a range of subject matter experts and the broader NM community to ensure buy-in of the final criteria. These criteria have subsequently been embedded in peer review software that has been implemented into a robust peer learning program for technologists designed to promote a culture of continuous improvement and knowledge sharing amongst front-line staff.

Hospital Radiopharmacy in Argentina during the COVID-19 pandemic. Criteria and rationale for the organization of work. / Radiofarmacia Hospitalaria en Argentina durante la pandemia de COVID-19. Criterios y fundamentos para la organización del trabajo.

This publication presents criteria and bases for the work organization in the safe practice of Hospital Radiopharmacy, in order to minimize the risk of viral transmission during the COVID-19 pandemic, in a reference facility of the National Energy Commission Atomic of Argentina, while continuing to perform essential services for the health system. For this purpose, documents from the National Energy Commission Atomic, IAEA, WHO and other scientific publications were consulted as reference. These recommendations are under constant review and are permanently updated. Within this framework, the present model of work organization for this essential activity is proposed, including general and specific recommendations and its epidemiological and immunological basis.

The 2020 national diagnostic reference levels for nuclear medicine in Japan.

The diagnostic reference levels (DRLs) are one of several effective tools for optimizing nuclear medicine examinations and reducing patient exposure. With the advances in imaging technology and alterations of examination protocols, the DRLs must be reviewed periodically. The first DRLs in Japan were established in 2015, and since 5 years have passed, it is time to review and revise the DRLs. We conducted a survey to investigate the administered activities of radiopharmaceuticals and the radiation doses of computed tomography (CT) in hybrid CT accompanied by single photon emission computed tomography (SPECT)/CT and positron emission tomography (PET)/CT. We distributed a Web-based survey to 915 nuclear medicine facilities throughout Japan and survey responses were provided by 256 nuclear medicine facilities (response rate 28%). We asked for the facility's median actual administered activity and median radiation dose of hybrid CT when SPECT/CT or PET/CT was performed for patients with standard habitus in the standard protocol of the facility for each nuclear medicine examination. We determined the new DRLs based on the 75th percentile referring to the 2015 DRLs, drug package inserts, and updated guidelines. The 2020 DRLs are almost the same as the 2015 DRLs, but for the relatively long-lived radionuclides, the DRLs are set low due to the changes in the Japanese delivery system. There are no items set higher than the previous values. Although the DRLs determined this time are roughly equivalent to the DRLs used in the US, overall they tend to be higher than the European DRLs. The DRLs of the radiation dose of CT in hybrid CT vary widely depending on each imaging site and the purpose of the examination.

The modifications brought about by the COVID-19 pandemic to Nuclear Medicine practice.

Nearly 19.9 million cases and more than 730 thousand disease-related deaths have been confirmed in the months that followed WHO's assessment that the novel coronavirus COVID-19, first emerged in Wuhan China on December 2019, could be characterized as a pandemic. The aforementioned coronavirus affected 188 countries as of 8.10.2020. Despite the continually increasing number of COVID-19 cases reported to CDC, at national level, the percentage of visits to outpatient providers and emergency departments has decreased and mortality rates attributed to COVID-19 have declined compared to the previous weeks, still above the baseline. It is common knowledge that the coronavirus pandemic has reshaped societies and economies around the globe, affecting all aspects of everyday life. Public health systems as a whole have been globally affected since they had to face extraordinary demands over a long period of time, which, in turn, required rapid adjustments in the operating procedures that were already in use, in order to provide high-standard health services, while respecting patients quality of life. Over half of deaths in low-income countries are caused by communicable diseases, maternal causes, conditions arising during pregnancy and childbirth, and nutritional deficiencies. On the contrary, this percentage is less than 7% in high-income countries. Noncommunicable diseases cause 71% of deaths globally, ranging from 37% in low-income countries to 88% in high-income countries. However, in terms of absolute number of deaths, 78% of global NCD deaths occurred in low-and middle-income countries. This partially explains why recent developments in medicine were mostly focused on chronic illnesses, including cardiovascular disease, cancer, chronic respiratory diseases and type 2 diabetes, rather than focusing on infection and inflammation progress. The COVID-19 pandemic and the subsequent burden it placed upon health systems to deal with infectious and non-infectious diseases in a poor environment, can become an opportunity to update the field of medical research and change the governmental policies in place that have been stagnant and/or inefficient and ill-managed. This way, health systems will be equipped with better and faster protocols and best practices in order to manage efficiently any other pandemic that might emerge in the future. In this context, Nuclear Medicine departments should reconsider and update their practices, by altering routines and workflows in order to comply with the new sanitary standards, triaging their appointments, or introducing new diagnostic methods like Tele-Medicine / Tele Nuclear Medicine and Artificial Intelligence applications. This special edition of Hellenic Journal of Nuclear Medicine has as its main purpose to introduce and communicate those new practices and protocols/standard operating procedures, in order for the scientific community, health public institutions, affected individuals and their families to be duly informed.

ARRONAX Cyclotron: Setting up of In-House Hospital Radiopharmacy.

Whilst radiopharmaceuticals have an important role to play in both imaging and treatment of patients, most notably cancer patients, nuclear medicine and radiopharmacy are currently facing challenges to create innovative new drugs. Traditional radiopharmaceutical manufacture can be considered as either a routine hospital production or a large-scale industrial production. The gap between these two practices has meant that there is an inability to supply innovative radiopharmaceuticals for use at the local level for mono- or multicentric clinical trials with satisfactory quality and safety specifications. This article highlights the regulatory requirements in aseptic pharmaceutical processing and in nuclear medicine to be able to locally produce radiopharmaceuticals. We validate the proof-of-concept for an "in-house" hospital-based radiopharmacy including an on-site cyclotron, that can fulfill the conflicting requirements between radiation safety and aseptic processing. The ARRONAX in-house radiopharmacy is currently able to provide sterile and pyrogenic-free injectable radiopharmaceutical compounds for both industrial and institutional clinical trials.

Automated quality control in nuclear medicine using the structured noise index.

PURPOSE: Daily flood-field uniformity evaluation serves as the central element of nuclear medicine (NM) quality control (QC) programs. Uniformity images are traditionally analyzed using pixel value-based metrics, that is, integral uniformity (IU), which often fail to capture subtle structure and patterns caused by changes in gamma camera performance, requiring visual inspections which are subjective and time demanding. The goal of this project was to implement an advanced QC metrology for NM to effectively identify nonuniformity issues, and report issues in a timely manner for efficient correction prior to clinical use. The project involved the implementation of the program over a 2-year period at a multisite major medical institution. METHODS: Using a previously developed quantitative uniformity analysis metric, the structured noise index (SNI) [Nelson et al. (2014), \textit{J Nucl Med.}, \textbf{55}:169-174], an automated QC process was developed to analyze, archive, and report on daily NM QC uniformity images. Clinical implementation of the newly developed program ran in parallel with the manufacturer's reported IU-based QC program. The effectiveness of the SNI program was evaluated over a 21-month period using sensitivity and coefficient of variation statistics. RESULTS: A total of 7365 uniformity QC images were analyzed. Lower level SNI alerts were generated in 12.5% of images and upper level alerts in 1.7%. Intervention due to image quality issues occurred on 26 instances; the SNI metric identified 24, while the IU metric identified eight. The SNI metric reported five upper level alerts where no clinical engineering intervention was deemed necessary. CONCLUSION: An SNI-based QC program provides a robust quantification of the performance of gamma camera uniformity. It operates seamlessly across a fleet of multiple camera models and, additionally, provides effective workflow among the clinical staff. The reliability of this process could eliminate the need for visual inspection of each image, saving valuable time, while enabling quantitative analysis of inter- and intrasystem performance.

Decreasing Patient Dwell Times for Outpatient Cardiac Nuclear Medicine Studies: The Benefits of SMART Goals, Scope Limitations, and Society Guidelines in Quality Improvement.

BACKGROUND: We describe a quality improvement project to improve patient dwell times for outpatient cardiac nuclear medicine exams. Preliminary data indicated that the mean patient dwell time was about 270 minutes. Our specific, measurable, achievable, relevant, and time-bound goal was to reduce patient dwell times for outpatient pharmacologically stressed cardiac nuclear medicine exams by 60 minutes over the course of 2 months. METHODS: An interdisciplinary team was formed which used staff interviews and workflow observation to create a cause and effect diagram as well as a process map. Review of the national guidelines for cardiac nuclear medicine exams identified rest and stress intervals as intervention targets. A new protocol was designed and implemented. RESULTS: The mean patient dwell time was improved from 270 to 184 minutes. CONCLUSIONS: Overall, we found that a clear specific, measurable, achievable, relevant, and time-bound goal, limited scope, and national guideline review allowed for a successful quality improvement project.

A no-reference respiratory blur estimation index in nuclear medicine for image quality assessment.

Few indexes are available for nuclear medicine image quality assessment, particularly for respiratory blur assessment. A variety of methods for the identification of blur parameters has been proposed in literature mostly for photographic pictures but these methods suffer from a high sensitivity to noise, making them unsuitable to evaluate nuclear medicine images. In this paper, we aim to calibrate and test a new blur index to assess image quality.Blur index calibration was evaluated by numerical simulation for various lesions size and intensity of uptake. Calibrated blur index was then tested on gamma-camera phantom acquisitions, PET phantom acquisitions and real-patient PET images and compared to human visual evaluation.For an optimal filter parameter of 9, non-weighted and weighted blur index led to an automated classification close to the human one in phantom experiments and identified each time the sharpest image in all the 40 datasets of 4 images. Weighted blur index was significantly correlated to human classification (ρ = 0.69 [0.45;0.84] P < .001) when used on patient PET acquisitions.The provided index allows to objectively characterize the respiratory blur in nuclear medicine acquisition, whether in planar or tomographic images and might be useful in respiratory gating applications.

Calibration of thermoluminescent detectors in Hp(0.07) units by using an X-ray tube and a 137Cs source.

BACKGROUND: The method of measuring doses based on the thermoluminescence phenomenon is not an absolute method. For this reason, to obtain correct results, it is necessary to calibrate detectors in the known radiation field. This paper presents a method for calibrating thermoluminescent detectors used in the measurement of personal dose equivalents (Hp(0.07)) obtained by nuclear medicine facility personnel when handling the 99mTc radionuclide. MATERIAL AND METHODS: The authors used self-developed high-sensitivity thermoluminescent detectors and a HF320C X-ray unit, as well as a rod phantom. Dosimeters were calibrated in accordance with the ISO 4037-3 standard. During the measurements a vial containing a 99mTc radionuclide with well-known activity was also used. The energy characteristics were supplemented by using a 137Cs source (irradiator 60Co/137Cs). RESULTS: The value of the calibration coefficient for 118 keV energy energy was (1.90±0.02)×10-5 mSv/imp. Taking into account the correction factor specified for of 140 keV energy at 0.962, the value of the calibration coefficient for 140 keV energy was determined as (1.83±0.02)×10-5 mSv/imp. CONCLUSIONS: Verification of the calibration coefficient determined for 140 keV energy carried out with a vial containing a 99mTc radionuclide confirmed the correctness of the procedure. Med Pr. 2019;70(6):669-73.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 2 of 2-Diagnostic Criteria and Appropriate Utilization.

Cardiac amyloidosis is emerging as an underdiagnosed cause of heart failure and mortality. Growing literature suggests that a noninvasive diagnosis of cardiac amyloidosis is now feasible. However, the diagnostic criteria and utilization of imaging in cardiac amyloidosis are not standardized. In this paper, Part 2 of a series, a panel of international experts from multiple societies define the diagnostic criteria for cardiac amyloidosis and appropriate utilization of echocardiography, cardiovascular magnetic resonance imaging, and radionuclide imaging in the evaluation of patients with known or suspected cardiac amyloidosis.