Volume 26, Issue 2
SNMMI-TS is dedicated to the advancement of molecular and nuclear medicine technologists by providing education, advocating for the profession, and supporting research to achieve clinical excellence and optimal patient outcomes.
IN THIS ISSUE
|Chest radiograph showing normal findings (TOP) and V/Q scan showing segmental mismatch (BOTTOM) in 22-y-old man whose previous CT scan a year and a half previously had shown bilateral central pulmonary embolism. Four months after the initial CT scan, CT showed marked improvement, with some residual emboli, and right heart catheterization showed pulmonary artery pressure of 53/15 mm Hg. Normal chest radiography findings with segmental V/Q mismatch are compatible with chronic thromboembolic pulmonary hypertension. Ant = anterior; LAO = left anterior oblique; Lat = lateral; LPO = left posterior oblique; Post = posterior; RAO = right anterior oblique; RPO = right posterior oblique.|
This article discusses 2 recent developments related to lung scintigraphy: The coronavirus disease 2019 (COVID-19) pandemic and the increase in requests for lung ventilation/perfusion scintigraphy for the diagnosis and management of chronic thromboembolic pulmonary hypertension.
Knowledge about COVID-19 is evolving rapidly. Specific recommendations made in this article about ventilation–perfusion (V/Q) scintigraphy during the pandemic may be obsolete by the time the article is in print. However, the current situation allows an opportunity to review basic principles regarding V/Q scintigraphy and pulmonary infectious disease. A good overall medical resource that is often updated may be found at UpToDate.com (uptodate.com/contents/coronavirus-disease-2019-covid-19). If this resource is not available at your institution, the SNMMI has a frequently updated page addressing the concerns of the nuclear medicine community (snmmi.org/COVID-19).
The symptoms of COVID-19 are fever (99%), fatigue (70%), dry cough (59%), loss of appetite (40%), muscle pain (35%), dyspnea (31%), and sputum production (27%) (1). Some of these symptoms can easily be confused with pulmonary embolism, especially dyspnea. Fever is not a prominent symptom of pulmonary embolism; however, about 20% of patients with COVID-19 have a very low-grade fever. Because pulmonary embolism is difficult to diagnose clinically and its symptoms may overlap with those of infectious lung diseases such as COVID-19, we should expect to see V/Q scintigraphy ordered for patients who either have a known diagnosis of COVID-19 or are infected with the virus but have not yet been diagnosed with COVID-19.
At the time of this writing, the literature does not yet contain any descriptions of the findings for COVID-19 on V/Q scintigraphy; however, CT findings have been described (www.rsna.org/covid-19). Similar to other viral pneumonias, CT shows patchy ground-glass lesions with or without consolidative lesions. (The term ground glass is used in CT to mean lower density than in soft tissue. Vessels, which are of soft-tissue density, can be seen running through ground-glass lesions.) Compared with other causes of viral pneumonia, CT findings in COVID-19 patients are more likely to be peripheral and ground glass and to show fine reticular opacity, vascular thickening, and the reverse halo sign. They are less likely to show air bronchograms, pleural thickening, pleural effusion, and lymphadenopathy. These findings can help to suggest a diagnosis of COVID-19, but none are specific for the diagnosis.
On the basis of the typical CT findings in infected patients, we may surmise what may be seen on V/Q scintigraphy. V/Q defects should be patchy, more likely in the lower lobes, and peripheral. As in other patients with airway disease, the perfusion may be less affected than the ventilation. At times, in other patients with airway disease, the perfusion findings on V/Q scintigraphy are considerably better than the findings on CT, especially when the CT findings are of lower density, suggesting less comprehensive airway obstruction. Thus, we should not be surprised if perfusion is less affected than ventilation with COVID-19.
There is lack of clarity about the safety of reusing V/Q equipment in patients diagnosed with COVID-19. In the past, we have been less concerned about use of V/Q scintigraphy in patients with other infectious respiratory diseases, such as influenza; however, the current extensive awareness of the COVID-19 pandemic and our drastic attempts to stop spread of the disease have heightened our concern about spread of this virus specifically. As a result, some institutions are not performing V/Q scintigraphy on any patients, despite the loss of important information about airway physiology. In addition, the effort needed to completely decontaminate ventilation equipment after use by a patient with COVID-19 is not adequately known for any of the many types of ventilators (e.g., 133Xe, 99mTc-diethylenetriaminepentaacetic acid aerosol, or 99mTc-labeled carbon gas) with variable filtration systems. In addition, V/Q scintigraphy is more likely to generate patient aerosols, increasing the risk that the imaging suite and the external components of the ventilator will become contaminated. At the time of this writing, the SNMMI position is posted at www.snmmi.org/NewsPublications/NewsDetail.aspx?ItemNumber=33543, but the main COVID-19 site at SNMMI (www.snmmi.org/COVID-19) should be consulted for updates.
Pulmonary embolism can result in serious and potentially fatal acute complications but can also lead to chronic pulmonary hypertension, which also can subsequently result in death. After a single episode of acute pulmonary embolism, a patient can develop pulmonary hypertension, but this development occurs more frequently in those patients who have more than one episode of acute pulmonary embolism. The mechanism by which patients with pulmonary embolism develop pulmonary hypertension is complex and not completely clear. What is more important from our point of view is that some patients with chronic thromboembolic pulmonary hypertension have residual obstruction of the large pulmonary arteries and some do not, but almost all patients have a residual segmental decrease in pulmonary perfusion.
In the past few years, evaluation of patients for chronic thromboembolic pulmonary hypertension has been a more common indication for V/Q scintigraphy. However, scattered reports of V/Q scintigraphy for pulmonary hypertension have been appearing since shortly after the time that V/Q scintigraphy was introduced. In 1988, Moser and the San Diego group demonstrated the value of V/Q scintigraphy for selecting pulmonary hypertension patients for pulmonary angiography (2). In 1992, this group wrote a review article about the value of V/Q scintigraphy for selecting patients for surgical pulmonary embolectomy (3). Normally, as an episode of pulmonary embolism resolves, the defects decrease in size and lose their segmental character, but Moser et al. showed that in chronic thromboembolic pulmonary hypertension the defects remain typical of defects seen during the acute phase of embolism.
Somewhat more recently, the Thromboembolic Pulmonary Hypertension Study Group published an influential report in The New England Journal of Medicine (4) that showed pulmonary hypertension to occur in about 4% of patients with an episode of pulmonary embolism. The patients who developed pulmonary hypertension had larger defects, and more of these patients had a history of prior pulmonary embolism. It had been thought that pulmonary hypertension developed slowly; however, most patients were found to have developed pulmonary hypertension within the first year after an acute episode of pulmonary embolism. From registry data, this paper showed that patients treated with pulmonary embolectomy had a significantly better survival than those without surgery. However, this was a registry study, not a randomized trial.
More recently, in 2019, Marconi et al. (5) determined the rate of recovery of perfusion defects seen on V/Q scans obtained at 1 wk, 1 mo, 6 mo, and 1 y, using a semiquantitative scale. Of the defects that resolved, there was considerable improvement during the first week, with resolution essentially complete by 6 mo. The authors concluded that the rate of resolution of defects seen on V/Q scans may be an important predictor of subsequent development of pulmonary hypertension.
The most important study about V/Q scintigraphy in chronic thromboembolic pulmonary hypertension was published in 2007 by Tunariu et al. (6). They showed that the best combination of sensitivity (96%) and specificity (95%) was achieved by considering high-likelihood-ratio studies positive and all other outcomes negative. This result is important because there is relatively good interobserver agreement about high-likelihood-ratio studies. Tunariu et al. also showed that V/Q scintigraphy was more accurate than CT pulmonary angiography, which had a sensitivity of 51% and a specificity of 99%.
The much better performance of V/Q scintigraphy than of CT pulmonary angiography may be surprising, but one should remember that the development of pulmonary hypertension is complex. The embolus may completely resolve, but vessels distal to the location of the embolus may become abnormal, and segmental perfusion remains abnormal.
In patients suspected of having chronic thromboembolic pulmonary hypertension, current guidelines recommend first documenting the presence of hypertension, for example by echocardiography. Once hypertension is established, the next step is V/Q scintigraphy. Pulmonary embolism is the cause of pulmonary hypertension in a small fraction of patients. It is more common if the patient has a history of pulmonary embolism, especially recurrent pulmonary embolism, but pulmonary embolism is still the cause of pulmonary hypertension in a minority of patients. Thus, most V/Q scans will not have a high likelihood ratio. However, testing patients for chronic thrombotic pulmonary hypertension is still important, since it is one of the few treatable causes of pulmonary hypertension.
Because CT pulmonary angiography is less sensitive than V/Q scintigraphy, the former is not used for screening patients. If pulmonary embolectomy is considered, then CT pulmonary angiography will be important to determine whether embolectomy is possible. In some patients, obstruction of the proximal pulmonary arteries will have resolved, and only the distal vessels remain abnormal. Those patients cannot be treated surgically.
1Department of Nuclear Medicine, Royal Free London NHS Foundation Trust, London, United Kingdom; 2Institute of Nuclear Medicine, University College London Hospital, London, United Kingdom; and 3Harley Street Clinic, HCA Healthcare United Kingdom, London, United Kingdom
The new coronavirus pneumonia (coronavirus disease 2019 [COVID-19]) was first reported in Wuhan, China, in December 2019; the virus was extracted from lower-respiratory tract samples from humans (1). The World Health Organization officially announced COVID-19 to be a pandemic on March 11, 2020 (2).
This novel coronavirus is spreading rapidly despite precautions. The most common symptoms of COVID-19 include severe pneumonia (fever, dry cough, dyspnea) and fatigue (1). Sore throat, headache, loss of taste and smell, rhinorrhea, and diarrhea can occur uncommonly (1). Lymphopenia is common (3,4). The mean incubation period is reported to be 5.2 d, and transmission can occur during that period in asymptomatic patients (5). The virus is reported to be transmitted via respiratory droplets and fomites during unprotected close contact with an infected individual (6,7).
Spread of the infection has been reported in 212 countries and regions (2). Throughout time, humans have encountered epidemics and pandemics, and several of these have changed the course of history. Pandemics increase morbidity and mortality and cause significant economic, political, and social disruption (8).
The aim globally is to encourage physical distancing in order to slow disease transmission and avoid increased strain on local health-care systems. The significant health-care challenges are in the production, supply, and availability of equipment for patient care and staff during this pandemic. A coordinated response and responsibility should be emphasized and implemented on time to maintain public health awareness and information, reduce transmission, and care for and treat the patients with COVID-19 (2). Significant gaps, misunderstandings, and challenges exist in global pandemic preparedness. To compound the problem further, the guidance and recommendations are rapidly changing as new evidence emerges and evolves. Local policy should be adopted in consensus with national and international recommendations. People must follow the recommendations and restrictions of the local government or health department.
Hospitals and departments should have a standard operating procedure in place for staff who image patients suspected or confirmed to have COVID-19, and systems should be in place to ensure that these procedures are regularly updated. This article is based on the currently available literature. Our purpose is to discuss and review precautions and safety measures for nuclear medicine department staff in managing patients with known or suspected COVID-19. The situation is changing rapidly, and there is every chance that discussion stemming from this article will change over the coming days and weeks. The responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country.
COVID-19 is caused by a novel β-coronavirus (1) that has been given the name ‘‘severe acute respiratory syndrome coronavirus 2’’ (SARS-CoV-2) (2). It belongs to the Coronaviridae family and is an enveloped positive-strand RNA virus (1,9). Coronaviruses are named for the crownlike spikes on their surface (9,10). The most likely origin of the novel coronavirus is zoonotic, given it has a genome 96% identical to that of a severe acute respiratory syndrome–like coronavirus found in bats (6,11). The novel virus has been detected in respiratory, fecal, and blood specimens of infected patients (6,11) and is reported to remain viable as an aerosol for up to 3 h (12). There are reports that transmission can occur via ocular surfaces, as infected droplets and bodily fluids might contaminate the human conjunctival epithelium (13). The virus was reported to be found in upper respiratory samples 1–2 days before the onset of symptoms (14) and is thought to be spread mainly via asymptomatic carriers (5,15,16).
In terms of personal protective equipment (PPE), the World Health Organization recommends taking contact and droplet precautions before entering the room of a suspected or confirmed COVID-19 patient. These include wearing disposable gloves to protect the hands; a clean, nonsterile, long-sleeved gown to protect clothing; medical masks to protect the nose and mouth; and eye protection such as goggles or a face shield (17,18). Respirators (e.g., N95) are recommended for aerosol-generating procedures (17). With the increasing number of cases and the shortage of testing kits for COVID-19, there should be greater emphasis on infection-control and social-distancing measures for both the public and staff members in the health-care environment. Effective and efficient use of both staff and equipment in nuclear medicine departments is crucial for patient care and workplace safety. Several national and international bodies have reported numerous measures that might be implemented nationally and regionally (2,17–19). However, the policies and their implementation will vary from region to region. Departments should be aware of their national or local hospital policies and follow them accordingly. Numerous articles about radiology procedures on COVID- 19 patients have appeared, but there is limited advice and information related to nuclear medicine services. Compared with conventional radiological imaging, the requirements and logistics for nuclear medicine imaging are relatively complex, such as scheduling appointments, contacting patients, maintaining regulatory compliance, prioritizing procedures, limiting the duration of scans, and preventing infection (Table 1) (20–25). Our top priorities should be ensuring the personal wellness of our staff and providing sufficient training and staff coverage to manage patients with suspected or confirmed COVID-19.
Consensus Guidance for Nuclear Medicine Departments, Staff, and Patients (6,17,20–25)
|These are examples based on consensus only, and responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country and hospital.|
The team should be made aware that there are asymptomatic carriers of the virus, and a good contact history is of use. We should also ensure that, in the waiting areas, patients have access to alcohol gel, hand-washing facilities, tissue boxes, and masks. Nuclear medicine reception staff should self-protect and be vigilant at all times and encourage patients to self-declare if they or any family members have symptoms or have recently traveled from places affected by COVID-19. The staff should ask specific and direct questions such as about a history of fever, dry cough, dyspnea, and fatigue. Patients should be encouraged to follow basic hygiene practices (26). The patient waiting area should be large enough for patients to maintain distance while seated, or patient appointments should be scheduled so as to avoid having too many patients in the waiting area at a given time.
In general, the nuclear medicine staff, which includes technologists, nurses, and health-care assistants, are at risk of exposure to COVID-19. Unlike radiologic procedures, nuclear medicine procedures require radiotracer injection, and contact between the staff and patient is essential. In most cases, nuclear medicine procedures are outpatient-based; under limited circumstances, they are inpatient-based. Inpatients will be a combination of oncology and nononcology patients. There is a probability that patients with COVID-19 may be asymptomatic at the time they are in the department for their scan. Furthermore, it is possible that not all inpatients have been tested for COVID-19 before they are sent to the department for their scan. These scenarios pose a risk for all staff, from the reception area to the scanning room. In general, most nuclear medicine scanners are not portable, unlike radiography or ultrasound devices; therefore, the need for patients to come to the department for their scan is inevitable. Consequently, we should have a stringent mechanism in place to protect our staff and patients, as well as a contingency plan if staff are temporarily absent because of illness or quarantine, which might affect regular work in the department.
Under the current circumstances, most departments based in hospitals that are COVID-19 hubs are postponing routine elective scans while continuing to provide urgent nuclear medicine scans (e.g., PET/CT scans for oncology patients) (Tables 2–4). Given the widespread transmission and the increased risk of asymptomatic patients, staff should use PPE according to the local policy. The PPE items must be donned before entering the patient area, and the donning and doffing procedure should be performed correctly. In general, the team should minimize the number of staff in each clinical encounter to reduce unnecessary movement into and out of injection or scanning rooms, and staff should wear PPE while escorting patients.
Scheduling Nuclear Medicine Procedures That Use SPECT Tracers
Referrals must be reviewed by nuclear medicine consultants or in multidisciplinary setting. These are examples based on consensus only, and responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country and hospital.
99mTc04 = 99mTc-pertechnetate; MIBI = methoxyisobutylisonitrile; MIBG = metaiodobenzylguanidine; DPD = 3,3-diphosphono-1,2-propanodicarboxylic acid; [123I]β-CIT = [123I]2β-carboxymethoxy-3β-(4-iodo-phenyl)tropane; [123I]FP-CIT = [123I]N-ω-fluoropropyl-2β-carbome-thoxy-3β-(4-iodophenyl)nortropane; MUGA = multigated acquisition; SIRT = selective internal radiation therapy; PE = pulmonary embolism; HIDA = hepatobiliary iminodiacetic acid; SeHCAT = selenium homocholic acid taurine; GFR = glomerular filtration rate; MAG3 = ercaptoacetyltriglycine; DMSA = dimercaptosuccinic acid; PRRT = peptide receptor radionuclide therapy; NET= neuroendocrine tumor; DXA = dual-energy X-ray absorptiometry; RBC = red blood cells.
Scheduling Nuclear Medicine Studies That Use PET/CT
|These are examples based on consensus only, and responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country and hospital.
FDG = fluorodeoxyglucose; PSMA = prostate-specific membrane antigen; PRRT = peptide receptor radionuclide therapy; DOPA = 3,4-dihydroxyphenylalnine; CABG = coronary artery bypass grafting; NaF = sodium fluoride.
Airborne transmission of COVID-19 continues to be debated. There is an ongoing dilemma on whether to do ventilation–perfusion scans. It is reported that airborne viruses can spread in air-conditioning and ventilation systems. Medical procedures associated with the generation of aerosols, such as ventilation scans and oxygen supplementation, might carry an increased risk of transmission. Therefore, some have suggested stopping ventilation–perfusion scan services because the ventilation scan is aerosol-based. In addition, the use of perfusion-only scans is unlikely to be of any benefit if COVID-19 is suspected, as the COVID-19 response might alter the macroaggregated albumin distribution (20).
Others have proposed several alternatives, such as performing only perfusion imaging in, for example, pregnant patients or performing perfusion SPECT or SPECT/CT. Overall, it depends on the local conditions. Decisions should be based on national or regional policies (22), and special precautions, especially for personnel conducting these tests, must be taken. A chest radiograph should be mandatory before a ventilation–perfusion scan. The current reports suggest that asymptomatic COVID-19 carriers may have positive chest radiography results after 14 d of quarantine, even with no reverse-transcription polymerase chain reaction testing for COVID-19 (27). The chest radiography findings in COVID- 19 patients are reported to frequently show bilateral lower-zone consolidation (peaking at 10–12 d from symptom onset) (28).
Nuclear medicine departments perform various radionuclide therapies for both benign and malignant disease. The hospital and department providing these services should have a practical and realistic solution. The multidisciplinary team (MDT) must make a pivotal decision to continue or stop therapy service temporarily. The radionuclide therapy service depends on multiple factors, such as whether the treatment is outpatient or inpatient, the availability of beds for inpatient-based treatments, regular supply and delivery of radiopharmaceuticals, the risk of a patient contracting COVID-19 during the hospital stay, the staff skill mix (in case therapy staff is infected with the virus and substitute staff must be enlisted), robust selection criteria, and treatment of elderly cancer patients with comorbidities. Finally, when patients are treated, they should additionally consent to the risk of COVID-19 during their stay in the hospital, and the need for radionuclide therapy should balance against the risk of contracting COVID-19 (Table 4).
Scheduling Radionuclide Therapy (20,22)
|Referrals must be reviewed by nuclear medicine consultants or in multidisciplinary setting. These are examples based on consensus only, and responsibility lies with each institution or hospital to ensure its written policy adheres to that outlined by national public health guidance in its respective country and hospital.|
Physical isolation or distancing of staff from one another is crucial to prevent transmission from asymptomatic carriers. In the scan-reporting rooms, it is suggested that the workstations be separated by at least 2 m or 6 ft (23–25). First, the department should consider providing alternative technologic solutions that allow remote or off-site work for nuclear medicine consultants and residents (e.g., reporting of scans and protocolling procedures). Second, multidisciplinary meetings or case discussions should be web-based or teleconferenced (23–25). Several departments have opted for flexible rotations or schedules, such as by working in small teams or by working for 1 wk on-site and then 1 wk remotely. Establishing a group email list or a social media group to keep in touch and communicate effectively is essential.
Local hospitals should have clear policies and procedures in place for nuclear medicine staff who image suspected or confirmed COVID-19 patients. The standard operating procedures of the department or health-care system should be updated regularly as evidence evolves. van Doremalen et al. (12) have studied how long the virus survives in the air and on surfaces. They confirmed that the novel coronavirus remained active for 48–72 h on plastic and stainless steel surfaces, 24 h on cardboard, and 4 h on copper (12). However, these times will vary under real-world conditions and might depend on the temperature, humidity, ventilation, and amount of virus deposited (12).
The most important COVID-19 factors related to nuclear medicine include clean imaging techniques and decontamination of imaging equipment (e.g., SPECT/CT and PET/ CT scanners), in addition to decontamination of any surface that may have come into contact with respiratory droplets. In general, after the patients are scanned, the scanner and room surface should be disinfected to prevent potential spread, and appropriate training of environmental maintenance staff is recommended (Fig. 1) (20). Public Health England has published guidance entitled, ‘‘COVID-19: Cleaning in Non- Healthcare Settings’’ (29). The risk of infection depends on several factors, such as the type of surfaces contaminated, the amount of virus shed from the individual, the time the individual spent in the setting, and the time since the individual was last in the environment (29). All surfaces that the symptomatic person might have come into contact with must be cleaned and disinfected (e.g., visible body fluids, imaging equipment, chair, bathrooms, door handles, telephones, and grab-rails in corridors and stairwells) (29). The PPE should be worn for cleaning an area where a person with possible or confirmed COVID-19 has been (29). Public Health England recommends the use of a combined detergent disinfectant solution at a dilution of 1,000 parts per million available chlorine; if an alternative disinfectant is used within the organization, this alternative should be checked to ensure that it is effective against enveloped viruses (29).
|FIGURE 1. Basic contingency for nuclear medicine imaging. (Adapted from (41).)|
The British Society of Thoracic Imaging has produced action cards to assist with designing local radiology standard operating procedures for patients who have or are at risk of COVID-19 (e.g., transferring a patient to a CT scanner or performing a CT scan) (30). These action cards might be applied to nuclear medicine departments as well. However, they are examples only, and the responsibility lies with each institution or hospital to ensure that its written policy adheres to the national public health guidance in the respective country.
The functioning of nuclear medicine procedures depends on the availability of radioisotopes and kits. These are not always locally produced; nuclear medicine centers might have to rely on obtaining them from national or international supply-and-distribution channels. In the current scenario, with land and air traffic lockdowns, a shortage of radioisotopes and kits is expected, and it is difficult to predict when the shortage will occur or for how long. For efficient use of kits, block booking of specific procedures should be envisaged. Alternately, PET/CT scans can be used in place of single-isotope methods for some indications (e.g., bone imaging with 18FNaF and infection imaging with 18F-FDG). Myocardial perfusion imaging can be performed as a 1-d protocol (stress–rest). Local radiopharmacists or managers of nuclear medicine departments should contact the suppliers and update the local team so that bookings can be planned accordingly. In comparison to SPECT services, PET centers with local cyclotrons might continue to function as usual in most cases. For departments without cyclotrons, the availability of 18F-FDG will depend on local conditions.
The current scenario might cause psychologic distress, social insecurity, and financial insecurity. Staff coming to work at the hospital are concerned that they might contract the virus and expose their friends or family. We should try to provide relevant and reliable information to allay their fears (e.g., social distancing, infection control, and self-quarantine). There should be specific local guidelines for viral testing of staff returning to work after illness. The team should remain connected with one another or with their friends and families by such means as group email, e-portals, and social media.
|FIGURE 2. (A) Unenhanced axial CT image from 36‐year‐old man shows bilateral ground‐glass opacities in upper lobes with rounded morphology (arrows). (B) Axial CT image from 44‐year‐old man shows larger ground-glass opacities bilaterally in lower lobes with rounded morphology (arrows). (C) Axial CT image from 65‐year‐old woman shows bilateral ground‐glass and consolidative opacities with striking peripheral distribution. (Reprinted with permission of (32).)|
|FIGURE 3. Unenhanced axial CT image from 56‐year-old woman shows ground-glass opacities with rounded morphology (arrows) in right middle and lower lobes. Left lung was normal. (Reprinted with permission of (32).)|
|FIGURE 4. Unenhanced axial CT image from 42‐year-old man in late time group (10 d from symptom onset to this scan) shows bilateral consolidative opacities with striking peripheral distribution in right lower lobe (solid arrows) and with rounded morphology in left lower lobe (dashed arrow). (Reprinted with permission of (32).)|
|FIGURE 5. (A) Unenhanced axial CT image from 43-y-old woman shows crazy‐paving pattern as manifested by right-lower-lobe ground‐glass opacification with interlobular septal thickening (arrows) and intralobular lines. (B) Axial CT image from 22‐year-old woman shows area of faint ground‐glass opacification in left upper lobe, with ring of denser consolidation (arrow, reverse halo sign). (Reprinted with permission of (32).)|
Chest CT is reported to be an essential component in the diagnostic algorithm for patients with suspected COVID-19 (32,33). The reported sensitivity of chest CT in detecting COVID-19 at the initial presentation is 56%–98% during the early stages of disease development (34,35), and the specificity is low (25%) (36).Chest CT has limited sensitivity and a low negative predictive value early after symptom onset and is unlikely to be used as a reliable independent tool to rule out COVID-19 (32).The initial findings in infected patients from Wuhan have shown bilateral lung opacities. The typical features include lobular and subsegmental areas of consolidation (31,32). Other groups have reported high rates of ground-glass opacities and consolidation, sometimes with a rounded morphology and peripheral lung distribution (31,37). The more extensive disease is reported to be seen on CT approximately 10 d after the onset of symptoms (37).The frequency of CT findings is related to the infection time course (31,32). On the basis of the current evidence, there are ground-glass abnormalities in the early disease phase, followed by crazy paving and increasing consolidation later in the disease course (32,37).Multifocal involvement is reported to be common, and the CT signs gradually improve approximately 14 d after symptom onset (31,32,36,37).The hallmark of COVID-19 on CT is ground-glass opacities and consolidation or pulmonary opacities (often with a bilateral and peripheral lung distribution) (31,32). Bernheim et al. have reported the absence of ancillary CT findings such as pleural effusions, lung cavitation, pulmonary nodules, and lymphadenopathy (31,32). Bai et al. have assessed the performance of U.S. and Chinese radiologists in differentiating COVID-19 from viral pneumonia on chest CT and found high specificity but moderate sensitivity (38). The British Society of Thoracic Imaging has published reporting guidance and a proforma document (which might help to report findings with speed and accuracy) (39), as well as a teaching library. Its content will be accessible without a log-on via the British Society of Thoracic Imaging website (39). COVID-19–suspected pneumonia is 18F-FDG–avid and might be detected as an incidental finding in asymptomatic patients undergoing PET/CT (40). The nuclear medicine community should be vigilant about looking for other unexpected scan findings that might reflect the effects of COVID-19 exposure or infection.
COVID-19 has changed the way we work. We should stay informed, support each other, and provide practical solutions for safety and social well-being during these uncertain times. We should adhere to our national and international recommendations. The health-care system and professionals must aim to deliver safe patient care, maintain a safe workplace, and ensure personal wellness.
Life imposes things on you that you can’t control, but you still have the choice of how you’re going to live through this.
No potential conflict of interest relevant to this article was reported.
We thank all medical and nuclear medicine professionals worldwide for their dedication and commitment to publishing numerous documents and sharing their experience to fight COVID-19.
This article was published ahead of print on May 1, 2020, in the Journal of Nuclear Medicine Technology.
The SNMMI-TS Leadership Academy: Essential Training for Technologist Leaders
|Mark H. Crosthwaite, CNMT, FSNMMI-TS|
The SNMMI-TS Leadership Academy, which was held January 23-25, 2020, in Tampa, FL (in conjunction with the SNMMI Mid-Winter Meeting), is the cornerstone of the SNMMI-TS leadership development portfolio.
The academy is a two-day leadership development program featuring current SNMMI-TS Leadership, key members of the SNMMI-TS, and staff who have dedicated themselves to improving SNMMI-TS achievement in nuclear medicine and related fields. Lectures are complemented by team-building exercises and networking opportunities. Each lecture considers a different aspect of leadership and is led by technologists or keynote speakers who have an intimate knowledge of the subject. The overall goal is to assemble a group of SNMMI-TS leaders who understand the crucial role of leadership development and who are eager to begin the path to SNMMI-TS leadership and organizational success.
The SNMMI-TS Leadership Academy has seen 183 graduates since its inception in 2007. These highly competitive leadership development workshops accept only a limited number of applicants each year and are considered the cornerstone of SNMMI’s governance training for committee chairs, council and center leadership, and the SNMMI and SNMMI-TS executive boards.
SNMMI-TS is pleased to announce the 2020 SNMMI-TS Leadership Academy graduates:
|Roberta Alvarez, MS, ARRT(N)(MR)||Hartford Healthcare Medical Group|
|Rebecca Gallagher, CNMT||Jeanes Hospital|
|Jose Meza, CNMT, PET, NCT, RT(N)||VA North Texas Healthcare System|
|Samantha Miller, RT(N)||Gottlieb Memorial Hospital|
|Christopher Owens, CNMT, PET,
|Florida Cancer Specialist and Research Institute|
|Laura Wotta, CNMT||CentraCare Health|
|Garrett Anderson||Loma Linda University|
|Taylor Steenburgen||Kaiser Permanente School Of Allied Health|
|Thalia Zolis||Robert Morris University|
|Nicole LaBrecque||Massachusetts College of Pharmacy & Health Sciences|
Over the past several years, we have seen a decline in the number of technologist submissions to the Leadership Academy. Based on the annual call for committee volunteers, it seems that interest in getting involved is growing—yet the Leadership Academy applicant pool is declining. The Professional Development Committee (PDC) has discussed this issue over the past several years and has received feedback from individuals who have started applications, but not finished them. There seems to be one major barrier to increased Leadership Academy applications: the requirement for three references. The PDC is reviewing the reference requirement and will be making changes to the application for the next Leadership Academy.
On the positive side, the number of student applications continues to grow, and they are the future of SNMMI-TS! This year, there were more student applications than technologist applications. Thus, the PDC and the SNMMI-TS Executive Board have been discussing the need to create a unique program for students. While there is still much to discuss, the SNMMI-TS is eager to create a program that will fit the growing needs of technologist students!
We encourage anyone who is interested to apply for the Leadership Academy. Travel to the academy (flight, 2 nights hotel, ground transportation and meals not already provided by SNMMI) is paid for by SNMMI. The application will be live on our website in June. The submission deadline is September 15 for technologists and October 15 for students. Please visit www.snmmi.org/leadershipacademy on or around June 10 for more information on the 2021 academy.
Over the past weeks, as everyone’s life has changed, I have found that I have become more and more humbled by the amazing professionals in the nuclear medicine community. Since mid-March, I have heard from nuclear medicine technologists in the clinic, managers, program directors, and students, and I wanted to let you know that we are eagerly trying to create and enhance products and services to assist you during this time of crisis.
In April, SNMMI-TS hosted the executive directors of the American Registry of Radiologic Technologists (ARRT), Nuclear Medicine Technology Certification Board (NMTCB), and JRCNMT in a program director webinar to provide important information to program directors regarding modifications to assist current nuclear medicine technologist students through the pandemic. The webinar recording can be found under the “Training and Certification” tab in the SNMMI COVID-19 Resource Center.
The SNMMI-TS has converted more than 80 educational activities—including webinars, journal articles, and online sessions—for student access to allow program directors to build this already-created education into their curricula and to provide students a platform for continuing their learning.
As I write this message, we are working to identify whether students can still obtain their clinical competencies if they were unable to complete them before clinic closures and are scheduled to graduate this spring/summer. We are also working to “beef up” the Student Review Course to ensure that students who have been out of the classroom for weeks/months will be prepared for the certification exam(s). To students whose graduation ceremony has been cancelled, we want you to know that while you may be missing that special moment of walking across the stage, we are still planning some pretty special moments for our graduating nuclear medicine seniors!
To assist nuclear medicine technologists and managers, we have developed an article focused on specific hot topics technologists are dealing during the COVID crisis: “From One Technologist to Another—What you Need to Know Through COVID-19 and Beyond.” Specific topics include:
The article was released ahead of print on May 1 in the Journal of Nuclear Medicine and Technology (JNMT).
During the pandemic, we also offered three weeks of free access for all nuclear medicine technologists to online continuing education (CE) that is usually only available for free to members. We know that many spring meetings have been cancelled, and technologists need CE to maintain certification. We don’t want CE to be something that technologists have to worry about. Technologists had access to hundreds of available online courses for VOICE credit. Throughout the summer, technologist members will receive notice of additional new free CE offerings.
I find so much comfort in knowing that the nuclear medicine technology community has banded together—helping each other, connecting with each other, and checking in on each other. We are all in this together, and I want you to know that you can count on your professional organization to help get you through this! We are here for you! We want to serve you! Most important—we want to hear from you. Post on SNMMI Connect or e-mail me directly.
Thank you for all you do, wherever you find yourself today. I am praying for you, your family, your friends and all of our colleagues around the world. Stay healthy, stay safe and God bless!
|Elizabeth C. Romero, RT(N)(CT), FSNMMI-TS|
The American Registry of Radiologic Technologists (ARRT) was founded in 1922 by the Radiological Society of North America, the American Roentgen Ray Society, and the American Society of X-ray Technicians. It is a leading credentialing organization with more than 330,000 members worldwide, promoting safety and helping to advance the radiological sciences profession. ARRT's mission states that the registry promotes the Gold Standard of patient care.
In 1936 ARRT was incorporated and established a board of trustees. In the 84 years since that board existed, there has been never been a president who was a nuclear medicine technologist and who was officially nominated by the SNMMI-TS to sit on the ARRT’s board … that is, until now.
To celebrate this momentous occasion, Uptake decided to ask soon-to-be president and current vice-president Elizabeth Romero 84 questions. I called Liz on a Saturday and rapid-fired these questions at her, much like Vogue does with its 73 questions to celebrities on YouTube (yes, I completely borrowed their idea, and if you don’t know what I’m talking about, definitely check it out).
It was an honor to be able to rapidly fire questions at Elizabeth Romero on a Saturday, and I am grateful that she allowed us this rare glimpse into her professional and private life.
Congratulations to Liz! We look forward to following your presidency and seeing your take on how to uphold that Gold Standard.
SNMMI is excited to be celebrating the 50th anniversary of the formation of our Technologist Section! Since 1970, our mission remains unchanged: Technologists working together to advance, educate, and protect our profession.
From the beginning, the SNMMI-TS established that it was THE organization for nuclear medicine technologists. We LOVE our members—you are why the Technologist Section exists! Today we are 10,000 members strong, and together we have advanced the field.
Some highlights of the value of the SNMMI-TS:
We invite you to join the celebration with activities, publications, and events planned throughout the year.
To commemorate this impressive achievement, SNMMI-TS is developing a History of the Technologist Section supplement to the Journal of Nuclear Medicine Technology (JNMT), to be published in June 2020.
As part of the year-long celebration for our SNMMI Technologist Section 50th Anniversary, we're looking to highlight a technologist, group of technologists, technologist students, and/or nuclear medicine technology programs on our social media channels every Tuesday in 2020! Submit a photo from work or school and you may see your picture featured on Instagram and Facebook this year. Follow the form instructions to enter!
To say that the SNMMI-TS has been the cornerstone and backbone of the nuclear medicine technologist profession would be a vast understatement. Fifty years—it’s been scintillating!
A Day in the Life of a TAG
Over time several articles have been printed in UPTAKE about Advocacy, especially the Technologist Advocacy Group, the TAGs. Many have read these articles and have wondered what exactly are the real-life duties of a TAG. In this issue, we have decided to feature the work of two TAGs. One article demonstrates the work being performed to address a specific issue within one state. The other features work that has been done and continues to be done for state licensure for not only nuclear medicine technologists but also all of the medical imaging professionals.
What each article will demonstrate is the dedication of the one individual, a volunteer CNMT, and the power of determination and perseverance. They also demonstrate how a profession becomes more than “just a job.” The CNMTs living and working both of these states owe a debt of gratitude to these two individuals for the positive outcomes that will benefit all CNMTs.
Please take the time to read about the work performed and still being performed for the betterment of our profession and the lives of our CNMTs.
After I became certified in computed tomography, I soon realized that the laws in the state of Maryland were outdated in regard to nuclear medicine technologists and the performance of CT. I started a journey to change these laws, but I soon realized that I alone could not change regulations for the entire state.
I volunteered as the Maryland SNMMI TAG (Technologist Advocacy Group) representative, a position that taught me the ins and outs of advocacy and connected me with technologists from across the U.S. who shared my passion for nuclear medicine. I was also nominated as the nuclear medicine technologist on the Radiologic Technologist Committee for the Maryland Board of Physicians, and a year later, I became the chair of the committee. Through my experiences with both of these committees, I was able to utilize countless resources and professionals in order to facilitate a change. Today I am happy to share that the laws have changed regarding CT and nuclear medicine technologists. Nuclear medicine technologists can perform diagnostic CT on hybrid as well as stand-alone CT machines (with either ARRT CT or NMTCB CT post-primary credentials). The scope of practice can be found here: http://www.dsd.state.md.us/comar/comarhtml/10/10.32.10.10.htm
Michael R. Vogel BS, CNMT, RT (N)(CT), RSO
Lead Nuclear Medicine Technologist
Radiation Safety Officer
Clinical Education Supervisor
University of Maryland St. Joseph Medical Center
During the past three years as the Pennsylvania TAG representative, I have been advocating for mandatory state licensure for all RTs. I am excited to share with everyone that there has been a lot of positive activity at the state level.
Currently, in Pennsylvania, a uniform standard does not exist to assure patients that individuals operating medical imaging or radiation therapy equipment and performing medical imaging or radiation therapy procedures have the appropriate education, training, and certification. Of specific interest, Pennsylvania’s surrounding six states all have state licensure requirements for medical imaging professionals.
Rep. Bryan Cutler (R), majority leader and a current RT(R)(ARRT), introduced and sponsored House Bill 1545 (Regular Session 2017-2018): The Medical Imaging and Radiation Therapy Health and Safety Act (MIRTHSA).
On June 13, 2017, HB 1545 was referred to Rep. Mark Mustio (R), Chairman of the Professional Licensure Committee. SNMMI Technologist Section (SNMMI-TS) joined many organizations in sending letters to Rep. Mustio stating our support for the MIRTHSA.
On February 27, 2018, on behalf of the SNMMI-TS and the PSRT Legislative Committee, colleagues and myself were invited to give testimony before the Committee of Professional Licensure. Rep. Mustio and fellow committee members were very engaging and keenly interested in the absence of state licensure for the imaging professional. Although HB 1545 did not move out of the Committee of Professional Licensure, this did not discourage or slow down our efforts.
On April 18, 2019, working with our associates from PSRT Legislative Committee and Triad Strategies, we met with the Deputy Secretary of Legislative Affairs and the Director of Legislative Affairs. During this meeting, we were advised to submit a Sunrise Evaluation Report. The Sunrise Evaluation is a questionnaire designed to obtain information that will assist the Department of State in evaluating the need for regulation of an occupation or profession and in analyzing proposed legislation seeking to establish a new regulation under the Department of State, Bureau of Professional and Occupational Affairs. In the fall of 2019, we successfully submitted to the Pennsylvania Secretary of the Commonwealth our 22 pages of the Sunrise Evaluation Report for review.
The new Medical Imaging and Radiation Therapy Licensure HB 1811 (Regular Session 2019-2020) was introduced by Rep. Tedd Nesbit on September 11, 2019, and referred to the Professional Licensure Committee.
Since 2013, there have been two new pieces of legislation introduced. SNMMI-TS continues to collaborate with our affiliate societies, the Nuclear Medicine Technology Certification Board, American Society of Radiologic Technologists, Pennsylvania Society of Radiologic Technologists, American Registry of Radiologic Technologists, Society of Diagnostic Medical Sonography, American Registry for Diagnostic Medical Sonography, Society of Radiology Physician Extenders, American Society of Podiatric Medical Assistants, Pennsylvania Medical Society, Philadelphia Society of Radiologic Technologists, and Pennsylvania Radiological Society in support of HB 1811.
Advocacy plays a crucial role in educating and ensuring patient safety. I encourage all SNMMI-TS members to add your voice by contacting your representative with your support. Think like a proton—“stay positive” and keep moving forward. It’s not too late to support the 2020 vision.
Cheryl Rickley, CNMT
Pennsylvania TAG Representative
I would like to thank both Cheryl and Michael for their tireless work. They are a credit to our profession and an example of the efforts one person can make and the powerful results that can be achieved.
Congratulations to both.
July 11 – 14, 2020
SNMMI 2020 Annual Meeting—Virtual Edition!
New Orleans, LA
July 11 – 12, 2020
Viva Las Vegas 2020 (Pacific Southwest Technologist Chapter)
Las Vegas, NV
October 9, 2020
2020 Southeastern Chapter Meeting
October 17, 2020
2020 Eastern Great Lakes Chapter Meeting
Niagara Falls, Canada
October 24, 2020
2020 Central Chapter Fall Symposium
Traverse City, MI
October 24, 2020
Mid-Eastern Chapter Meeting
November 6, 2020
Western Region SNM Meeting
Vancouver, BC, Canada
December 5, 2020
Back to Basics 2020 (Pacific Southwest Technologist Chapter)