Opportunities for improvement on current nuclear cardiology practices and radiation exposure in Latin America: Findings from the 65-country IAEA Nuclear Cardiology Protocols cross-sectional Study (INCAPS)

Background

Comparison of Latin American (LA) nuclear cardiology (NC) practice with that in the rest of the world (RoW) will identify areas for improvement and lead to educational activities to reduce radiation exposure from NC.

Methods and Results

INCAPS collected data on all SPECT and PET procedures performed during a single week in March-April 2013 in 36 laboratories in 10 LA countries (n = 1139), and 272 laboratories in 55 countries in RoW (n = 6772). Eight “best practices” were identified a priori and a radiation-related Quality Index (QI) was devised indicating the number used. Mean radiation effective dose (ED) in LA was higher than in RoW (11.8 vs 9.1 mSv, p < 0.001). Within a populous country like Brazil, a wide variation in laboratory mean ED was found, ranging from 8.4 to 17.8 mSv. Only 11% of LA laboratories achieved median ED <9 mSv, compared to 32% in RoW (p < 0.001). QIs ranged from 2 in a laboratory in Mexico to 7 in a laboratory in Cuba. Three major opportunities to reduce ED for LA patients were identified: (1) more laboratories could implement stress-only imaging, (2) camera-based methods of ED reduction, including prone imaging, could be more frequently used, and (3) injected activity of ^99mTc could be adjusted reflecting patient weight/habitus.

Conclusions

On average, radiation dose from NC is higher in LA compared to RoW, with median laboratory ED <9 mSv achieved only one third as frequently as in RoW. Opportunities to reduce radiation exposure in LA have been identified and guideline-based recommendations made to optimize protocols and adhere to the “as low as reasonably achievable” (ALARA) principle.

     

The regulatory background of nuclear cardiology in Europe: a survey by the European Council of Nuclear Cardiology

Purpose Nuclear cardiology is a well-validated, non-invasive imaging modality that is highly cost-effective as a diagnostic and prognostic tool in the evaluation of patients with known or suspected coronary artery disease. However, the number of procedures in Europe is very far from that which would be expected on the basis of epidemiological data, particularly when comparison is made with the USA. As a preliminary step for future action aimed at improving and increasing nuclear cardiology practice in Europe, the European Council of Nuclear Cardiology performed a survey to identify the regulatory issues and the training components pertaining to the practice of nuclear cardiology. Methods a questionnaire was sent to 31 national nuclear medicine societies and to 40 national cardiology societies. The main areas covered by the survey were: (1) the license requirements, (2) the theoretical and practical aspects of training and (3) supervision of the stress test during a nuclear cardiology study. Results The results show that, in a setting of wide heterogeneity of national regulations, education and professional practice, nuclear medicine is a restricted and closely regulated specialty. This situation guarantees the quality and safe use of radionuclides; at the same time, however, it limits integration of nuclear medicine into the clinical arena. Conclusion Cardiologists should become more involved in nuclear cardiology, to further stimulate the use of this powerful diagnostic and prognostic imaging modality. On behalf of the European Council of Nuclear Cardiology     

Myocardial perfusion scintigraphy in Europe 2007: a survey of the European Council of Nuclear Cardiology

Purpose  

This is the second of a series of surveys designed to assess myocardial perfusion scintigraphy (MPS) practice in Europe.     

Nuclear cardiology in the UK: activity and practice 1997

A questionnaire was sent to 251 nuclear medicine centres asking for details of nuclear medicine activity, and nuclear cardiology activity and practice in 1997. One hundred and seventy-one (68%) centres replied. Nuclear medicine activity was estimated at 11.8 studies/1,000 population/year, and 9.5% of these studies were within cardiology (1.12 studies/1,000/year). Myocardial perfusion imaging (MPI) studies accounted for 77% and radionuclide ventriculography (RNV) for 22% of all nuclear cardiology. On a national basis this represents activity levels of 0.86 and 0.25 studies/1,000/year for MPI and RNV, respectively. Of the 171 responding centres, 102 (60%) performed MPI studies and 81 (79%) of these reported that activity was increasing. However, MPI activity was unevenly distributed between hospitals. Two centres accounted for 13% of total MPI; others had far lower activity rates, and 51/102 (50%) centres performed less than 200 MPI studies/year. Comparison with previous surveys showed that nuclear medicine activity had almost doubled since 1990 (it was 6.0 studies/1,000 population in 1990, 9.3 studies/1,000 in 1994 and 11.8 studies/1,000 in 1997). Over the same period, nuclear cardiology activity had also risen, the greatest increase being seen for the last 3 years (it was 0.7 studies/1,000 population in 1990, 0.82 studies/1,000 in 1994 and 1.12 studies/1,000 in 1997). Despite these encouraging figures, MPI activity for 1997 remained well below that recommended by the British Cardiac Society in 1994 (2.6 studies/1,000/year) as adequate to serve the needs of patients with cardiac disease in the UK; it was also below the European average activity for the same year (2.2 studies/1,000/year). The anticipated increased workload for nuclear cardiology is encouraging despite the wide and varied practice of nuclear cardiology around the UK. The nuclear medicine community now needs to address the issues that will prevent it keeping up with demand, such as restricted camera time, excessive waiting lists and outdated equipment, but also to standardise acquisition and reporting techniques so that all studies, wherever performed, will be of a uniformly high standard.     

Image quality and dose in mammography in 17 countries in Africa, Asia and Eastern Europe: results from IAEA projects

Purpose

The objective is to study mammography practice from an optimisation point of view by assessing the impact of simple and immediately implementable corrective actions on image quality.

Materials and methods

This prospective multinational study included 54 mammography units in 17 countries. More than 21,000 mammography images were evaluated using a three-level image quality scoring system. Following initial assessment, appropriate corrective actions were implemented and image quality was re-assessed in 24 units.

Results

The fraction of images that were considered acceptable without any remark in the first phase (before the implementation of corrective actions) was 70% and 75% for cranio-caudal and medio-lateral oblique projections, respectively. The main causes for poor image quality before corrective actions were related to film processing, damaged or scratched image receptors, or film-screen combinations that are not spectrally matched, inappropriate radiographic techniques and lack of training. Average glandular dose to a standard breast was 1.5 mGy (mean and range 0.59–3.2 mGy). After optimisation the frequency of poor quality images decreased, but the relative contributions of the various causes remained similar. Image quality improvements following appropriate corrective actions were up to 50 percentage points in some facilities.

Conclusions

Poor image quality is a major source of unnecessary radiation dose to the breast. An increased awareness of good quality mammograms is of particular importance for countries that are moving towards introduction of population-based screening programmes. The study demonstrated how simple and low-cost measures can be a valuable tool in improving of image quality in mammography.     

Multimodality imaging in Europe: a survey by the European Association of Nuclear Medicine (EANM) and the European Society of Radiology (ESR)

Purpose  

Multimodality imaging represents an area of rapid growth with important professional implication for both nuclear medicine physicians and radiologists throughout Europe. As a preliminary step for future action aimed at improving the quality and accessibility of PET/SPECT/CT multimodality imaging practice in Europe, the European Association of Nuclear Medicine (EANM) and the European Society of Radiology (ESR) performed a survey among the individual membership of both societies to obtain information on the status of multimodality imaging in their facilities and their future visions on training for combined modalities.     

IAEA survey of paediatric computed tomography practice in 40 countries in Asia, Europe, Latin America and Africa: procedures and protocols

Objective

To survey procedures and protocols in paediatric computed tomography (CT) in 40 less resourced countries.

Methods

Under a project of the International Atomic Energy Agency, 146 CT facilities in 40 countries of Africa, Asia, Europe and Latin America responded to an electronic survey of CT technology, exposure parameters, CT protocols and doses.

Results

Modern MDCT systems are available in 77 % of the facilities surveyed with dedicated paediatric CT protocols available in 94 %. However, protocols for some age groups were unavailable in around 50 % of the facilities surveyed. Indication-based protocols were used in 57 % of facilities. Estimates of radiation dose using CTDI or DLP from standard CT protocols demonstrated wide variation up to a factor of 100. CTDI_vol values for the head and chest were between two and five times those for an adult at some sites. Sedation and use of shielding were frequently reported; immobilisation was not. Records of exposure factors were kept at 49 % of sites.

Conclusion

There is significant potential for improvement in CT practice and protocol use for children in less resourced countries. Dose estimates for young children varied widely. This survey provides critical baseline data for ongoing quality improvement efforts by the IAEA.

Key Points

? Paediatric computed tomography (CT) practice was audited in 40 less resourced countries. ? This audit revealed widespread (up to 100 times) variation in radiation dose. ? Specific CT protocols for certain age groups were frequently (ca. 50 %) unavailable. ? This survey demonstrates significant potential for improvement in paediatric CT practice. ? Multinational networking is an effective mechanism for quality improvement.     

Nuclear medicine and cardiology: the position of the Union of European Medical Specialists/Section of Nuclear Medicine

This paper summarizes a communication presented at the Second International Conference of Nuclear Cardiology, held in Cannes on 23–26 April 1995. The general evolution of nuclear medicine in Europe is examined within the context of European Union Directives, and the role of the Union of European Medical Specialists/Section of Nuclear Medicine is discussed. Thereafter consideration is given to the technical aspects of cardiovascular nuclear medicine procedures, and the situation with respect to such procedures in European countries is examined. In most European countries, nuclear medicine is a recognized specialty, while nuclear cardiology does not exist in its own right. In general, only nuclear medicine specialists have the responsibility for radionuclide studies, and most cardiovascular studies are performed under the direct responsibility of a licensed nuclear medicine specialist.     

Hybrid cardiac imaging: SPECT/CT and PET/CT. A joint position statement by the European Association of Nuclear Medicine (EANM), the European Society of Cardiac Radiology (ESCR) and the European Council of Nuclear Cardiology (ECNC)

Improvements in software and hardware have enabled the integration of dual imaging modalities into hybrid systems, which allow combined acquisition of the different data sets. Integration of positron emission tomography (PET) and computed tomography (CT) scanners into PET/CT systems has shown improvement in the management of patients with cancer over stand-alone acquired CT and PET images. Hybrid cardiac imaging either with single photon emission computed tomography (SPECT) or PET combined with CT depicts cardiac and vascular anatomical abnormalities and their physiologic consequences in a single setting and appears to offer superior information compared with either stand-alone or side-by-side interpretation of the data sets in patients with known or suspected coronary artery disease (CAD). Hybrid systems are also advantageous for the patient because of the single short dual data acquisition. However, hybrid cardiac imaging has also generated controversy with regard to which patients should undergo such integrated examination for clinical effectiveness and minimization of costs and radiation dose, and if software-based fusion of images obtained separately would be a useful alternative. The European Association of Nuclear Medicine (EANM), the European Society of Cardiac Radiology (ESCR) and the European Council of Nuclear Cardiology (ECNC) in this paper want to present a position statement of the institutions on the current roles of SPECT/CT and PET/CT hybrid cardiac imaging in patients with known or suspected CAD.     

Proposal for standardization of 123I-metaiodobenzylguanidine (MIBG) cardiac sympathetic imaging by the EANM Cardiovascular Committee and the European Council of Nuclear Cardiology

This proposal for standardization of ¹²³I-metaiodobenzylguanidine (iobenguane, MIBG) cardiac sympathetic imaging includes recommendations for patient information and preparation, radiopharmaceutical, injected activities and dosimetry, image acquisition, quality control, reconstruction methods, attenuation, scatter and collimator response compensation, data analysis and interpretation, reports, and image display. The recommendations are based on evidence coming from original or scientific studies whenever possible and as far as possible reflect the current state-of-the-art in cardiac MIBG imaging. The recommendations are designed to assist in the practice of performing, interpreting and reporting cardiac sympathetic imaging. The proposed standardization does not include clinical indications, benefits or drawbacks of cardiac sympathetic imaging, and does not address cost benefits or cost effectiveness; however, clinical settings of potential utility are mentioned. Standardization of MIBG cardiac sympathetic imaging should contribute to increasing its clinical applicability and integration into current nuclear cardiology practice.     

Nuclear cardiology in Europe: Nuclear medicine physicians tend to build walls around their skills and theraby limit the growth of the field

Conclusion  I strongly argue for a different approach of nuclear medicine and of nuclear cardiology in Europe. There are many arguments why we will not be able to implement the same infrastructure as in the United States. It is important that we determine strategically where we want to go and will start to work on the removal of the barriers. Meanwhile we should all focus on the common interest between cardiologists and nuclear physicians, as proposed by the EANM. An individual party can not solve the problems alone. A concerted effort from the nuclear medicine physicians, cardiologists, and industry is needed for the prosperity of nuclear cardiology in Europe, whatever form it will take.     

White paper of the European Society of Radiology (ESR) and the European Association of Nuclear Medicine (EANM) on multimodality imaging

New multimodality imaging systems bring together anatomical and molecular information and require the competency and accreditation of individuals from both radiology and nuclear medicine. This paper sets out the positions and aspirations of the European Society of Radiology (ESR) and the European Association of Nuclear Medicine (EANM) working together on an equal and constructive basis for the future benefit of both specialties. ESR and EANM recognise the importance of coordinating working practices for multimodality imaging systems and that undertaking the radiology and nuclear medicine components of imaging with hybrid systems requires different skills. It is important to provide adequate and appropriate training in the two disciplines in order to offer a proper service to the patient using hybrid systems. Training models are proposed with the overall objective of providing opportunities for acquisition of special competency certification in multimodality imaging. Both organisations plan to develop common procedural guidelines and recognise the importance of coordinating the purchasing and management of hybrid systems to maximise the benefits to both specialties and to ensure appropriate reimbursement of these examinations. European multimodality imaging research is operating in a highly competitive environment. The coming years will decide whether European research in this area manages to defend its leading position or whether it falls behind research in other leading economies. Since research teams in the member states are not always sufficiently interconnected, more European input is necessary to create interdisciplinary bridges between research institutions in Europe and to stimulate excellence. ESR and EANM will work with the European Institute for Biomedical Imaging Research (EIBIR) to develop further research opportunities across Europe. European Union grant-funding bodies should allocate funds to joint research initiatives that encompass clinical research in diagnostic imaging in conjunction with research in mechanical and electronic engineering, informatics and biostatistics, and epidemiology. This paper is a result of working party negotiations of ESR and EANM delegations throughout the period from October 2005 to February 2007. All authors contributed equally to the production of this paper. This paper was approved by the executive council of the ESR, the general assembly of the European Association of Radiology (EAR), the executive committee of the EANM and the executive committees of the UEMS sections of radiology and nuclear medicine. The document was presented at the EANM strategy committee meeting held in London in February 2007. It was also presented at both the EANM advisory council meeting and the EANM extraordinary delegates’ meeting that took place in Vienna in March 2007. Authors are listed in alphabetical order. Authors on behalf of the ESR are: Nicholas Gourtsoyiannis, Iain McCall, Maximilian Reiser and Bruno Silberman. Authors on behalf of the EANM are: Angelika Bischof Delaloye, Ignasi Carrió, Alberto Cuocolo and Wolfram Knapp. An editorial relating to this paper is available at DOI: .