Patient education about Nuclear Medicine Clear apprehensions of patients and common people about Nuclear Medicine Assistance to healthcare professionals and patients:

o In preparation for particular investigation, therapy or palliation.o Guide them about cessation of breast feeding and pregnancy.o Post-procedure precautions to observed.o Explanation of Nuclear Medicine terms in brief

Guide General physicians, residents and MBBS trainees about: What is nuclear medicine?What a particular procedure is?What are indications for a particular procedure?Definition of terms used in Nuclear Medicine reports.

Assist nuclear medicine professionals in:Overall method of procedure to be performed.Set of instructions to be given to the patient before, during

and after the procedure.Type and amount of radioactivity to be used.

AIM AND OBJECTIVE OF THIS BOOK

Book can be used for :

Educating patients by keeping them in waiting room of Nuclear Medicine dept. Promote Nuclear Medicine by educating general physicians. Can be used as ready reckoner by Nuclear Medicine professionals . It can be kept in wards to be used by ward staff to prepare patients and educate themselves about radiation safety after the study.

CHAPTERS INCLUDED IN THIS BOOK Introduction to Nuclear Medicine Meet the Nuclear Medicine Common Apprehension about Nuclear Nuclear Medicine procedures Chapter 6.1 Endocrine System6.1.1 Thyroid Radioiodine Uptake6.1.2 99mTc-Thyroid Scan6.1.3 MIBG Scan6.1.4 Medullary Thyroid imaging by DMSA (V)6.1.5 T3 Suppression Test6.1.6 TSH Stimulation Test6.1.7 Perchlorate Discharge Test6.1.8 Parathyroid Imaging6.2 Skeleton System6.2.1 Bone Scan6.2.2 Bone Three Phase Scan6.2.3 Bone Marrow Scan

Likewise there are fifty procedures are explained in this book including PET and therapy

6.12 Positron Emission Tomography (PET)-CT 6.12.1 PET-CT Imaging of Brain6.12.2 PET-CT Imaging of Myocardium6.12.3 PET-CT Imaging of Whole Body6.12.4 PET-CT Imaging of Bone (F-18 Bone Scan)6.13 Therapy and Palliation6.13.1 Palliative Treatment for painful bone Metastasis6.13.2 I-131 Therapy for Thyroid Disease6.13.3 MIBG Therapy for Neuro-Endocrine Disease6.13.4 Radiosynovectomy/Radiosynoverthesis6.13.4 P-32 Therapy for Myeloproliferative Disease6.13.5 Radio-immunotherapy for B-cell Lymphoma with 90Y-Radiolabelled Itribumomab Tiuxetan (Zaveline)

Chapter 7.Definitions of Common terminologies used in Nuclear Medicine7.1 Electromagnetic Radiation & Radioactivity7.1.1 Electromagnetic Radiation 7.1.2 Radioactivity and Radioactive Materials7.1.3 Radioisotopes 7.1.4 Generators 7.1.5 Half Life 7.1.6 Radiopharmaceutical 7.2 Radiation Safety7.2.1 Energy7.2.2 Exposure (X) 7.2.3 Exposure Rate (X˚) 7.2.4 Dose (D) 7.2.5 Dose Rate (D˚) 7.2.6 Relationship between Roentgen and Rad 7.2.7 Equivalent Dose(H) 7.2.8 Effective dose (E) 7.2.9 Cumulative Dose7.2.10 Collective Dose

7.2.11 Annual limit of Intake(ALI) 7.2.12 Derived Air Concentration (DAC)7.2.13 Limits of contamination 7.2.14 Half Value Thickness or layer (HVT or HVL)7.2.15 Tenth Value Thickness or layer (TVT or TVL)7.2.16 Relationship between HVT and TVT7.2.17 Exposure Rate constant7.2.18 Discharge criteria for patient (as per Atomic energy Regulatory Board, India).7.2.19 Dose limits recommended by ICRP (2007)7.3 Endocrine System7.3.1 Grave’s Disease (Diffuse Toxic Goiter) 7.3.2 Plummers Disease (Toxic Multi Nodular Goiter) 7.3.3 Radioiodine Therapy 7.3.4 Toxic Multinodular Goitre7.3.5 Thyroiditis 7.3.6 Hashimoto's thyroiditis7.4 Skeletal System7.4.1 Arthropathy 7.4.2 Avascular Necrosis7.4.3 Hypertrophy7.4.4 Leukaemia

7.4.5 Lymphoma 7.4.6 Multiple Myeloma7.4.7 Metastasis7.5 Genito-Urinary System7.7.1 DTPA Scan 7.7.2 DMSA Scan 7.7.3 Effective renal plasma flow (eRPF)7.7.4 Glomerular Filtration Rate (GFR) 7.7.5 Renovascular Hypertension7.7.6 Pyelonephritis7.7.7 Urinary tract infection7.6 Cardiac System7.6.1 Coronary Artery Disease7.6.2 Myocardial perfusion Study/Imaging7.6.3 Multigated Acquisition7.6.4 Hibernating Myocardium7.6.5 Stunned Myocardium7.6.6 Myocardium Ischemia7.6.7 Myocardium Infarction7.6.8 Stroke Volume7.6.9 Ejection Fraction7.6.10 PCI 7.6.11 METS

CHAPTER 3:COMMON APPREHENSIONS ABOUT NUCLEAR MEDICINE

Some of the questions include:

Will Nuclear Medicine Scans have some side effects?

Will a Nuclear Medicine scan make me radioactive?

Are there people who should not undergo Nuclear

Medicine Scans?

What are Radiation effects and Risk estimates in Nuclear

Medicine scans?

What is the probability of causing Carcinoma by Nuclear

Medicine scans?

How much radiation exposure dose will I get in my

procedure?

Myocardial perfusion study evaluates the heart’s function and blood flow to the muscles of heart (myocardium). A stress myocardial perfusion scan is used to assess the blood flow to the myocardium when it is stressed by exercise or medication. It determines the areas of the myocardium which have decreased blood flow and thereby damages occurred into the myocardium with what extent. In myocardial perfusion imaging radiopharmaceutical (also called as tracer) either thallium or technetium labeled compounds is administered intravenously. Perfusion imaging identifies areas of relatively reduced myocardial blood flow associated with ischemia or scar. The relative regional distribution of perfusion can be assessed at rest, during cardiovascular stress, or both [44].

 Indications [45]

Diagnosis of coronary artery disease Evaluation of known coronary disease; location and extent of ischemia Determine the cause for change in symptom pattern in patients with known coronary artery disease. Evaluate the effectiveness of medical therapy Risk stratification post-myocardial infarction Pre-operative evaluation for major non-cardiac surgery in patient with known coronary disease. Assessment after percutaneous transluminal coronary angioplasty or coronary artery bypass grafting Guide to rehabilitation therapy

CHAPTER 6.5.1 MYOCARDIAL PERFUSION STUDY

Instructions to the patient Patients may require to stay in the dept for 3-5 hrs depending on the number of patients appointed and the study protocol in their case.They can drink 01 glass of water/milk before the test in the morning. If their appointment is after 1000 h, they can have light breakfast before 0600 h. Idea is to have 04 hrs fasting before the test.Patients are advised to bring their breakfast alongwith them. They are required to eat preferably a light fatty meal after exercise and before imaging.They should bring all previous medical documents on date of appointment.Female patients should inform about their LMP, Lactation and any chance of pregnancy. If breast-feeding, there is no need to stop it for 99mTc radiopharmaceuticals i.e. if 99mTc-SestaMIBI is used upto 1110 MBq (30 mCi) [20] and 201Tl <80MBq of activity [46]. However if 201Tl is used upto 111 MBq, breastfeeding should be stopped for 96 hrs and counseling should be done by radiation safety officer [20].Some medications such as beta-blockers may prevent achievement of maximum heart rate nitrate or calcium channel blockers may mask or prevent cardiac ischemia, limiting the test’s ability to detect coronary disease. [45] Cardiac medications should be withheld if the examination is performed to detect coronary disease. Cardiac medication should be taken as usual when the examination is performed to determine the effectiveness of medical therapy [44]. Such interruption should ideally last for five half-lives of the drug [46]. In general, the decision on whether to interrupt drug administration should be left to the referring physician.List of some common cardiac medications which may need to stop for time mentioned against each:Medication Half life Derived five half lifeBeta BlockersTab Atenolol 6-7 hrs[47] 30-35 hrs Tab Carvidelol 7-10 hrs[48] 35-50 hrsTab Metoprolol 3-7 hrs[49] 15-35 hrsTab Trimolol 2.5–5 hrs[50] 12.5–25 hrsCalcium Channel BlockerTab Amlodipine 30-50 hrs[51] 150 – 250 hrsTab Nifedipine 02 hrs[52] 10 hrsNitratesGlyceryl Trinitrate 03 min[53] 15 minutes

ProcedureOn arrival of patient on date of appointment, a detailed history of the patient is obtained. He/she is taken for fixing IV cannula. Patient undergoes either physical or pharmaceutical stress.At the peak of exercise, patient is administered with radiopharmaceutical (250-350* MBq (6.75-9.5 mCi) 99mTc-Sestamibi or 74-148* MBq (02-04 mCi) of 201TlCl).He/ She is sent for having breakfast. An oily/fatty breakfast is advised in case 99mTc- Sestamibi radiopharmaceutical is used, for draining out the liver, as it may interfere in imaging of myocardium, being an adjacent organ. Imaging should begin 30–60 min after injection to allow for hepatobilliary clearance; longer delays are required for resting images and for stress with vasodilators alone \ because of the risk of higher sub diaphragmatic 99mTc activity. However, the time of imaging for 201Tl is 15-20 min, because it does not accumulate in liver and have renal clearance.Rest injection of radiopharmaceutical (03 times the radioactivity injected at stress) is given 02 hrs after stress. In case of 201Th no second injection is given due to its \ redistribution property.Imaging of rest begins after 45 min – 01 hr of rest injection.In some cases, if there is fixed defect seen in inferior wall of myocardium, prone imaging may also be performed.

Fig 6.5.1: Normal myocardial perfusion study. Myocardial image is provided by the full thickness of the left ventricular myocardium. The right ventricular free wall and atrial walls are much thinner structures but define the outline of their cavities. Three sets of images of left ventricle is displayed for three dimensional view of heart: (1) a view gen erated by slicing perpendicular to the long axis of the left ventricle (short axis), (2) a view of long-axis tomograms generated by slicing in the vertical plane (vertical long axis), (3) a view of long-axis tomograms generated by slicing in the horizontal plane (horizontal long axis). Images are serially displayed for different sections of the heart. Figures below illustrates the image of heart showing short axis, horizontal long axis and vertical long axis and their ways of slicing for better understanding of above images.

Fig 6.5.2: Reversible perfusion defect in LAD territory. Images are serially displayed for stress and rest comparing short axis, vertical long axis and horizontal long axis views. Black arrows depicts reversibility

CHAPTER 7.5 Genito-Urinary System

7.5.1 DTPA Scan 99mTechnetium labeled Diethylene triamine pentaacetic acid (DTPA) is used to see

glomerular filtration rate (GFR). DTPA is a heavy metal chelate cleared through Glomerular filtration. Following intravenous injection of 99mTc DTPA, normal peak cortical uptake occurs by 3-4 minutes. By 5 minutes, the collecting system is seen; the bladder is typically visualized by 10-15 minutes.

7.5.2 DMSA Scan A DMSA scan is a radionucleotide scan that uses dimercaptosuccinic acid in assessing

the renal function, it is now the most reliable test for the diagnosis of Acute pyelonephritis [145]. The major clinical indications for this investigation are the detection and/or evaluation of a renal scar, the small or absent kidney, an occult duplex system, certain renal masses, systemic hypertension or suspected vasculitis[146].

7.5.3 Effective renal plasma flow (eRPF)Effective renal plasma flow (eRPF) is a measure used in renal physiology to

calculate renal plasma flow (RPF) and hence estimate renal function.ERPF = RPF x extraction ratioWhere renal plasma flow (RPF) is the volume of plasma that reaches the kidneys per

unit time and extraction ratio is the ratio of compound entering the kidney that got excreted into the final urine.

7.5.4 Glomerular Filtration Rate (GFR)Glomerular filtration rate (GFR) is the volume of fluid filtered from

the renal (kidney) glomerular capillaries into the Bowman's capsule per unit time. GFR can be calculated by measuring any chemical that has a steady level in the blood, and is freely filtered but neither reabsorbed nor secreted by the kidneys.

The GFR is typically recorded in units of volume per time, e.g., milliliters per minute ml/min.

There are several different techniques used to calculate or estimate the glomerular filtration rate (GFR or eGFR)

Source of Information/References

Society of Nuclear Medicine & Molecular Imaging procedure guidelines European Association of Nuclear Medicine procedure

guidelines ACR–SNM–SPR practice guideline International Atomic Energy Agency guidelines for radiation safety Ell PJ, Gambhir SS: Nuclear Medicine in Clinical Diagnosis and Treatment; volume III, ISBN 0-443-07312-0 Ziessman Harvey A., O’Malley Janis P., Thrall James H.,

Nuclear Medicine: The Requisites in radiology, Third Edition. ISBN 978-0-323-02946-9 Many other Nuclear Medicine books Several websites

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