Volume 4, Number 1 AUTUM N / WINTER EDITION 20 10
President's Report
SPECT/CT Bone Scan Skull
Overview of RAINS
What The ….?
Interesting Image
CPD Article
Crossword Puzzles
CPD Initiatives

2010 Conference
2009 Report
Submission Guidelines
Membership Form

New slett er: seasonal@rains.asn.au
PO Box U102
M embership: membership@rains.asn.au
Wagga W agga
Other: enquiry@rains.asn.au
Seas RAINS, vol. 4, no. 1 President's Report The Australian health care system has been Welcome to the Autumn edition of Seasonal RAINS. I described or defined by the „inverse care law‟; those trust that the ANZSNM ASM in New Zealand will Australians in the most need of health services provide an opportunity for members and the RAINS receive the least. This might equally reflect life for Committee to exchange ideas. There are some rural Nuclear Medicine professionals; those with the important announcements in this edition so please read greatest need for support and representation actually have the least. It is true that the rural Nuclear Medicine professional develops unique skills and I would like to warmly welcome our new members, capabilities not generally manifest in metropolitan thank you for your interest and support. We now have counterparts; an evolutionary adaptation („survival 155 associate members and 88 ordinary members. This of the fittest‟). Despite these attributes, rural Newsletter's success in previous years has been based Nuclear Medicine professionals are confronted with around the contributions of other members. I would professional isolation that fosters a number of like to encourage you all to send in those Interesting Cases or Images we all stumble upon from time to  Professional representation at state and time. It doesn't take much of an effort to email them through for all of your colleagues to appreciate and  Accreditation and continuing professional development (CPD).  Diffusion of innovation, technology and The 2009 Annual CPD conference was held in October last year at Diamond Beach near Forster. By all  Support for training, leave (illness or accounts it was a huge success, with some great recreation) and workload. contributions from a broad spectrum of our regional  Career development pathways. bases. It was located slightly off the beaten track, and RAINS aims to quench the thirst of rural Australia this assisted us with the decision to base this years left parched by professional under representation. conference in Sydney, providing all of our rural and regional members more direct access. RAINS Management Committee The 2010 conference will be held at the Stamford Mr Matt Ayers (NSW North) - president Grand in North Ryde, adjacent to the new Macquarie Mr Michael Crook (Qld South) – vice president University Hospital. This year the theme is Integrative Dr Geoff Currie (NSW South) - secretary Imaging, and we are sure this will generate a great deal Ms Narelle Harrison (Vic / Tas) - treasurer of interest from all facets of Diagnostic Imaging, so Mr Peter Tually (WA / SA) don't miss out on the early bird deal. A brochure and Mr Nathan Cassidy (QLD North / NT) registration form has been included in this issue. Please Mr Russell Pearce (associate member rep.) encourage your CT, MRI and ultrasound colleagues to Ms Annah Skillen (associate member rep.) Easter is upon us already, this first quarter has literally Dr Geoff Currie (editor-in-chief) flown! For those of you fortunate enough to have an Dr Janelle Wheat affluent department, or generous boss, we may see you Mr Michael Crook in New Zealand for the Annual ANZSNM meeting. For Mr Nathan Cassidy the rest of us hard workers, the perfect opportunity to get the CPD points and catch up on the latest with your colleagues from around the country awaits in November with our RAINS conference. See you all there! Start Collecting 2010 is also an election year for RAINS. This means that members will be asked to nominate committee members soon. Voting will then take place so that the new committee can take charge on 1 July 2010. Matt Ayers Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Purpose of RAINS  Provide a network for support and collaboration  The purpose of RAINS is to offer a support network Integrate student clinical placements for rural and remote Nuclear Medicine Lobby professional bodies on rural issues professionals. The support network aims to engage  Promote Nuclear Medicine services in the rural with and develop strategies to overcome the unique professional difficulties encountered in rural and  Inform and lobby, where appropriate, legislative remote Australia. and regulatory processes impacting on rural Nuclear Medicine RAINS does not stand as an alternative to ANZSNM state branch membership, but as an Membership to RAINS is open to those Nuclear Medicine professionals sharing the needs and RAINS offers a seamless representation of rural and philosophies characteristic of rural Australia; remote Nuclear Medicine professionals. That is, underpinned by "professional, social and cultural RAINS is a single unified group of individuals with isolation". To that end, membership is open to those common needs and philosophy. There are neither Nuclear Medicine professionals employed in a state borders nor division between the private and Nuclear Medicine practice that satisfies any one of public sectors nor delineation based on corporate the following criteria: ownership. RAINS does respect and honour 1. Practice located in a centre that the Federal commercial in-confidence and intellectual property Government Rural, Regional and Metropolitan Area (RRMA) classification deems either rural or remote. 2. Practice located in a centre that is more than Equitable provision of representation and 200 km from the state capital. professional opportunities for rural and remote 3. Practice located in a centre that is more than Nuclear Medicine professionals. Strategic 100 km from nearest other nuclear medicine networking and support to foster professional development, continuing education and collaborative solutions to issues of isolation. Associate membership to RAINS is open to: Recognition and exploitation of distinctive 1. Students not actively employed in Nuclear competencies of rural practitioners. Medicine who are undertaking undergraduate or post graduate studies in Building A Future For Rural Nuclear Medicine
Nuclear Medicine at any Australian university and who come from a RRMA RAINS Core Values classified rural or remote centre. 2. Nuclear Medicine professionals employed Innovate, adapt, overcome. in a Nuclear Medicine centre that does not  Be committed, meet our commitments. meet the criteria for ordinary membership  Perform beyond industry norms. but who believe issues of professional  Invest in our work, invest in ourselves. isolation have a deleterious impact on  Improve, continually. Embrace innovation, professional development. Examples of embrace challenge. such isolation include, but are not limited  Support CPD. to; academics, researchers, company  Demand equity for rural Australia. representatives and regional isolation with  Offer support, ask for support. a small Nuclear Medicine network (e.g.  Exploit strengths, overcome weaknesses. Newcastle, Central Coast, Gold Coast). Membership entitlements include, but are not limited  Provide a voice and representation  Newsletter (electronic)  Overcome barriers to CPD  Networking (eg. research, problem solving,  Promote equity of service provision reduce professional isolation)  Undertake research on rural issues  CPD activities (e-journal club, e-grand  Respect issues of commercial in-confidence rounds, conferences) BUT remove borders on core rural activities  Representation  Highlight and exploit the distinctive competencies of the rural Nuclear Medicine  Full voting rights (ordinary members only) Copyright 2010. All rights reserved.

Seas RAINS, vol. 4, no. 1 Interesting Image PRP Diagnostic Imaging, Sydney and Central Coast. Whole body bone scan on 72 yr old female with suspicious lesions in the cervical spine and possibly T4 on a recent MRI. No history of cancer. Incidental fall 1 week prior to scan. Clinical
1. No evidence of skeletal metastatic disease. No Fibrous dysplasia is monostotic in 70% of patients, osteoblastic reaction in the cervical spine or T4. with a predilection for long bones such as the femur, 2. Recent fracture involving the left trapezoid. tibia, humerus, and rib. Most of these lesions are 3. Fibrous dysplasia in the inferior aspect of the left found incidentally. Polyostotic fibrous dysplasia may frontal bone (frontal sinus). be extensive and frequently involves the femur 4. Subacute fractures in the 4th and 5th left ribs (91%), tibia (81%), pelvis (78%), ribs, skull, facial anterolaterally and 8th left rib laterally. bones (50%), and less often the upper extremities, lumbar spine, clavicle and cervical spine. Overview
Fibrous dysplasia is a benign, intramedullary, fibro- Monostotic fibrous dysplasia is craniofacial in 10%- osseous lesion of bone that develops during skeletal 25% of patients but occurs in 50% with the formation and growth and can be monostotic or polyostotic disease. In the skull, the frontal, polyostotic. Most often diagnosed in adolescents sphenoid, maxillary, and ethmoidal bones are and young adults, fibrous dysplasia accounts for involved more often than the occipital and temporal 5%-7% of benign bone tumours. Most patients are bones. Deformities include hypertelorism, cranial asymptomatic and lesions are found incidentally, asymmetry, facial deformity, visual impairment, but patients can present with nonspecific swelling, exophthalmos, and blindness due to orbital and peri deformity or pain. Fibrous dysplasia is also orbital bone lesions. Sphenoid wing and temporal associated with several endocrine and non- bone lesions may result in vestibular dysfunction, endocrine disorders. tinnitus and hearing loss. The risk of malignant transformation is low (0.4%- 4.0%), but is more common in the polyostotic form. Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 disease in complex anatomic locations such as the facial bones, pelvis, and spine. Attenuation of the The typical radiographic appearance of fibrous characteristic ground-glass portions is 70-130 dysplasia consists of a medullary-based, minimally Hounsfield units (HU), in contrast to normal expansile lesion with "ground-glass" opacity and trabecular bone that is >250 HU. Lesions may irregular but well-defined borders. In long bones, expand bone. The mixed density of these lesions has the location usually is diaphyseal or been described as "whorls and swirls." Computed diametaphyseal, and the epicentre is centric or tomography can show compromise of the spinal eccentric. More expansile lesions cause endosteal canal and evaluate neural foraminal compromise in scalloping and thinning that weakens the cortex. the skull. In addition, signs of malignant Lesional radiopacity is variable depending on the transformation, including extraosseous soft-tissue ratio of fibrous and osseous tissue. Homogeneous, mass and aggressive bone destruction, can be shown. featureless grey opacity is the classic "ground- glass" appearance of fibrous dysplasia, a term Bone Scan borrowed from the appearance of frosted or ground Fibrous dysplasia in general appears as an area of window glass that is uniformly opaque. Lesions are markedly increased uptake on bone scintigraphy, less commonly homogeneously lucent or sclerotic. however uptake may be normal or decreased. Barely Chronic changes secondary to bone weakness may increased bone uptake in fibrous dysplasia may be lead to bowing of weight-bearing structures, associated with decreased vascularity and fracture, and remodelling. osteoblastic activity of the lesion as a result of concurrent bone infarction. Bone scans are not Computed Tomography helpful in diagnosing these lesions but can be useful Computed tomography is not required for diagnosis in identifying asymptomatic lesions. but can be valuable in evaluating the extent of Do you have an interesting image to share? Email the image and brief overview with author details to seasonal@rains.asn.au Do you have a book review in mind or in progress? Email the final draft with author details to seasonal@rains.asn.au and collect 2 CPD points. Do you have a journal article review in mind or in progress? Email the final draft with author details to seasonal@rains.asn.au and collect 2 CPD points. Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Continuing Professional Development Brown Adipose Tissue and 18F-FDG PET. Nuclear Medicine and PET, Hunter New England Imaging, Newcastle. INTRODUCTION
muscular tension (Nedergaard, Bengtsson, & The use of Fluorine-18 fluoro-2-deoxy-D-glucose Cannon, 2007). The presence of BAT in these areas (18F-FDG) in Positron Emission Tomography (PET) has recently been confirmed histologically by is now considered to be routine practice in oncology Virtanen, et al. (2009) (Virtanen, et al., 2009). as a tool for diagnosis, staging and assessment of treatment response. 18F-FDG is used to assess the BAT has been proven to exist in rodents throughout function of active tumour cells through their life and in human infants and young children uncontrolled glucose metabolism (Evans, Tulloss, & (Cypess, et al., 2009). However, it was a long held Hall, 2007). Whilst 18F-FDG PET has a high belief that in adult humans BAT was relatively non- sensitivity for this purpose but specificity can be existent with no physiological significance (Cypess, problematic due to accumulation within several et al., 2009). As a direct consequence of the normal cells that also metabolise glucose, along emergence of PET/CT technology, this belief was with inflammatory and infective processes (Evans, determined to be no-longer valid. In fact, Cohade, et et al., 2007). The appearance of the brain and al. (2003) documented the appearance of BAT on myocardial cells on 18F-FDG PET is accepted, as a PET/CT confirming its presence within adult result of their glucose energy demands. Also not humans, coinciding with the findings of other studies uncommon is the visualisation of skeletal muscle, (Cypess, et al., 2009; van Marken Lichtenbelt, et al., gastrointestinal tract, genitourinary tract, bone 2009; Virtanen, et al., 2009). Five common areas of marrow, and lymphoid tissue for the same reasons BAT have been identified (Nedergaard, et al., 2007) (Evans, et al., 2007). Nuclear Physicians have also to be within the neck and supraclavicular areas (more noted areas of 18F-FDG accumulation within the common) and the mediastinal (para-aortic), supraclavicular and mediastinal areas that is not paravertebral, and suprarenal areas (less common) identified to corresponded to any areas of abnormal (Nedergaard, et al., 2007). Hypermetabolic BAT tissue on correlative imaging (Yeung, Grewal, within these areas can affect the overall accuracy of Gonen, Schoder, & Larson, 2003). This specific 18F-FDG PET in the investigation of lymphoma, pattern was initially described to correspond to oesophageal, stomach and lung cancers and also muscular uptake in anxious patients, as the metastatic lymph node involvement within the neck administration of oral diazepam; a muscle relaxant, and mediastinum (Cohade, Osman, et al., 2003). and a repeat PET scan resulted in the reduction of this uptake (Yeung, et al., 2003). Although Hypermetabolic BAT is manageable and there is considered normal variants, 18F-FDG uptake in potential to eliminate the appearance on PET these areas described can cause false-positive imaging, but the nature and appearance BAT must be findings (Williams & Kolodny, 2008) on PET well understood. Non-Shivering Thermogenesis
The introduction of PET/CT (Computed Two types of adipose tissue exist; white adipose Tomography) has allowed the fusion of PET and CT tissue and brown adipose tissue (BAT), with two images, allowing superior accuracy in the types differing on a cellular level and also in their localisation of abnormalities found on PET imaging functionality (Cypess, et al., 2009). The primary – a technique that cannot be achieved with such purpose of white adipose tissue is the storage of accuracy when PET and CT scans are undertaken energy, whilst also providing insulation and individually (Yeung, et al., 2003). Since PET/CTs cushioning (Cypess, et al., 2009). On the other hand, advent in 2001, several studies have been the primary function of BAT is to provide warmth undertaken to accurately localise the increased 18F- through non-shivering thermogenesis (Cypess, et al., FDG accumulation within the supraclavicular and 2009). Microscopically, BAT is uniquely mediastinal areas described above (Cohade, Osman, characterised by abundant mitochondria and high Pannu, & Wahl, 2003; Paidisetty & Blodgett, 2009; vascularisation (giving the tissue its brown Yeung, et al., 2003). This accumulation has been appearance), and the presence of uncoupling protein reported to correspond to areas of adipose tissue, 1 (UCP1) (Agrawal, Nair, & Baghel, 2009). specifically hypermetabolic brown adipose tissue Non-shivering thermogenesis is the process by (BAT); as opposed to the previous conclusions that which newborn infants and hibernating mammals the accumulation is the result of anxiety induced maintain normal body temperature through the Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 production of heat (Virtanen, et al., 2009; Weber, The patterns of 18F-FDG uptake in BAT have been 2004). The identification of BAT on PET has further defined (Yeung, et al., 2003) through an proven that adults also have the potential to analysis of 863 PET/CT examinations. This maintain their body temperature through this investigation determined four distinct areas of uptake related to BAT, which was also described during other investigations (Nedergaard, et al., 2007). 32 Adenosine triphosphate (ATP) is used an energy patients were found to have hypermetabolic BAT transporter between cells (Weber, 2004). In cells (3.7%), which is a similar proportion of patients other BAT, a proton gradient is observed across the compared to previous investigations (Yeung, et al., mitochondrial membrane within the cell (Weber, 2003). Of significance is that 26 of these patients 2004). Energy derived from the flow of protons were paediatric, which can be expected given that it across this membrane allows adenosine diphosphate is known that BAT is present within the younger (ADP) to undergo oxidative phosphorylation and population (Cypess, et al., 2009). This investigation form ATP (Weber, 2004). In BAT cells, the demonstrated a tendency towards female patients presence of UCP1 allows protons to move along the demonstrating higher BAT accumulation than males protein gradient without causing ATP synthesis (P<0.01) and no significant relation was found (Weber, 2004). This process uncouples oxidative between BMI and the appearance of BAT. Standard phosphorylation and energy is converted to heat, Uptake Value‟s (SUV) were calculated in patients rather than being used for ATP synthesis (Celi, demonstrating neck accumulation that was localised 2009; Weber, 2004). to BAT (SUVmax average = 7.7), and compared to a small proportion of patients demonstrating muscular Weber (2004) reports that non-shivering uptake (SUVmax average = 5.8) within the same thermogenesis is triggered by the sympathetic region. These similar figures indicate that it may be nervous system, in response to cold temperatures. difficult to assess the difference between 18F-FDG Norepinephrine is released and binds to the β3- accumulation in BAT and muscle and further adrenergic receptors on the BAT cell surface emphasise the benefit of anatomical localisation causing enzyme action, which in turn begins the provided by PET/CT. heat production process. Glucose transport is also initiated by the release norepinephrine. Glucose In a similar analysis, of the 359 patients who transporter 1 (GLUT1) and glucose transporter 4 underwent PET/CT, 49 patients (14.1%) were found (GLUT4) are primarily involved and it is the to have abnormal 18F-FDG accumulation within the activation of these glucose transporters by which supraclavicular area (Cohade, Osman, et al., 2003). 18F-FDG uptake into BAT is mediated (Nedergaard, Abnormal tracer accumulation was compared to et al., 2007; Weber, 2004). corresponding tissue on the CT images with the CT tissue densities used to delineate between fat, muscle Brown Adipose Tissue on 18F-FDG PET
and lymph tissue (Fat density -75.9 ± 24 HU, Muscle PET/CT imaging has been used extensively to 31.9 ± 14 HU and lymph tissue 29.8±12 HU correctly localise areas of normal 18F-FDG (Cohade, Osman, et al., 2003)). Results demonstrated accumulation to anatomical structures. Several 14 patients with BAT accumulation. No statistically analyses have been performed, all supporting the significant difference was found between the BMI or claim that areas of increased BAT accumulation are the age of patients that demonstrated hypermetabolic due to hypermetabolic BAT. Hany, et al. (2002) BAT when compared to those that demonstrated performed an investigation of 638 consecutive muscular or lymph tissue uptake. A comparison was patients who underwent PET/CT and reported made between the SUVmax for BAT, muscle and increased symmetrical 18F-FDG accumulation lymph tissue. The SUVmax of muscle was within the shoulder area in 17 patients (2.5%). significantly lower than that of lymph tissue and PET/CT localised this accumulation to the fatty BAT (Cohade, Osman, et al., 2003). These findings tissue of the shoulders in all patients. Two distinct are comparable with the SUV measurements gained patterns of accumulation were noted: The first in other investigations (Yeung, et al., 2003). within the shoulder area (supraclavicular) and the second within the neck, shoulder and thoracic spine In the investigation of 845 performed by Truong, et areas (neck, supraclavicular and paravertebral). al. (2004), similar appearances of abnormal 18F-FDG Interestingly, the latter pattern was demonstrated uptake was found in 25 patients that correlated to within 7 female patients. Investigators also note a hypermetabolic BAT. Interestingly, the results probable link between body mass index (BMI) and indicated that there is a female predominance for the the appearance of BAT, although no statistical presence of BAT (Truong, et al., 2004), a finding testing was performed. In four out of the seven that has not been demonstrated by other investigators patients that demonstrated the latter pattern of (Cohade, Osman, et al., 2003; Hany, et al., 2002; uptake the BMI was within the underweight range Yeung, et al., 2003). However, other investigations (<18.5), with the average BMI of all other patients into the appearance of BAT in rodents have also being 22.7 (Normal range was defined as 18.5- suggested a female predominance (Nedergaard, et Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Investigators have identified and described five incidence rate of 23.8% in patients less than 18 years typical areas of increased 18F-FDG accumulation of age was demonstrated, compared to 5.9% in that can be localised to BAT through the use of patients over the age of 18. PET/CT. Of these five areas, it appears more common to find hypermetabolic BAT within the A similar investigation by Kim, et al. (Kim, supraclavicular and neck areas, when compared to Krynyckyi, Machac, & Kim, 2008) analysed 1495 the mediastinal, paravertebral and suprarenal areas. PET scans that were performed in 1159 patients (566 There is evidence to suggest that female patients are men, 593 women and 22 patients less than 18 years more likely to demonstrate hypermetabolic BAT, of age). 42 scans were found to be positive for when compared to their male counterpart. As it is hypermetabolic BAT. A higher incidence was once known that younger members of the population again demonstrated within patients less than 18 years have BAT, it is not surprising that investigations of age, with an incidence of 13.6% compared to that show that hypermetabolic BAT is of a higher of the adult population at 2.8%. A comparison was proportion within the paediatric population, made between the incidence of hypermetabolic BAT compared with adults. Only limited evidence exists to the outdoor temperature on the day of PET that the appearance of hypermetabolic BAT is imaging, and 2, 3, 7, 14, 30 and 60 days prior to related to BMI, with some investigations suggesting imaging. BAT appearance was found to be more that patients with a lower BMI are more likely to common when the outdoor temperature was lower on demonstrate BAT. Similar SUVs have been the day of the scan and up to a week prior. obtained for BAT, muscle and lymph tissue, which Incidences were more common during the winter places emphasis on the importance of PET/CT months. There was no significant relationship anatomical localisation to delineate between the demonstrated between the appearance of BAT and three tissue types. the temperature 14, 30 and 60 days prior to the PET scan. Kim, et al. (2008) concluded that the In addition to sex and age, the two main causes of appearance of BAT was more likely as a hypermetabolic BAT on PET/CT are environmental consequence of exposure to acute cold conditions, temperature and diet (Nedergaard, et al., 2007). Of rather than as a result of prolonged cold exposure as the investigations studied, it is unlikely that diet has proposed by Cohade, Mourtzikos, et al. (2003). As had any effect on the activation of BAT. All patients CT localisation was not available during this were fasted for a period between four and six hours investigation, Kim, et al. relied upon the knowledge prior to the administration of 18F-FDG. In trusting that BAT is found in several common locations to that all patients had fully complied with preparation interpret and assess their PET scans. Whilst this instructions, this effectively eliminates patient diet method cannot be regarded as accurate as Cohade, as a probable cause for hypermetabolic BAT. It is Mourtzikos, et al.‟s (2003) for the determination of more likely that the environmental temperature of BAT appearance, and consequently, the influence the patients prior to administration and during the that outdoor temperature has on BAT; the findings of uptake period of 18F-FDG has resulted in BAT the study are considerable. Despite the evidence from Cohade, Mourtzikos, et al. The effect of cold exposure on FDG distribution
(2003) and Kim, et al. (2008) that cold exposure, Cohade, Mourtzikos,et al. (Cohade, Mourtzikos, & whether it be acute or prolonged, can cause BAT Wahl, 2003) performed a retrospective analysis of appearance of 18F-FDG PET there is limited 1017 PET/CT scans and compared those that literature on the topic. The most probable cause for demonstrated BAT with the outdoor temperature. the lack of investigations are the ethical BAT was identified in 68 patients (6.7%), with 11 considerations surrounding humans undergoing PET being male and 52 being female. The incidence of for research purposes only, and it is difficult to the appearance of BAT was compared with the justify their unnecessary radiation exposure. Two outdoor temperature during the month of the groups of investigators have conducted studies using patients scan, and one, two and three months prior simulated cold environments in attempt to reproduce to the month of the scan. Cohade, Mourtzikos, et al. the appearance of hypermetabolic BAT. (2003) deduced that the occurrence of BAT is more likely to occur in the month‟s directly succeeding Baba, et al. (Baba, Engles, Huso, Ishimori, & Wahl, the onset of winter (February and March: Study 2007) conducted an investigation to assess the completed in Northern Hemisphere), (Cohade, appearance of multiple radiotracers in BAT at room Mourtzikos, et al., 2003). In turn, it may be possible temperature and cold environments, using rats at that the appearance of hypermetabolic BAT on 18F- their subject. 18F-FDG was injected intravenously FDG is due to the activation of BAT due to into two groups of rats, the first group exposed to prolonged cold exposure, rather than as a 22.5°C for four hours prior to injection, and the consequence of direct cold exposure. Additionally, second exposed to 4°C for the same time. One hour Cohade, Mourtzikos, et al.‟s investigation further post injection, the rats were sacrificed; interscapular emphasised that BAT appearance is more likely to BAT extracted, assessed under microscope and be encountered in the paediatric population. An measured for the presence of 18F-FDG. Baba et al. Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1
(2007) determined that there was a statistically
occurrence which initially led researchers to believe significant increase (26 times greater; P < 0.01) in that what we now understand to be BAT, to be the presence 18F-FDG in BAT for the cold exposed muscle uptake in anxious patients (Yeung, et al., rats, when compared to the control group. This 2003). Despite this, there has been limited success study effectively demonstrates that acute cold using diazepam for this purpose. Gelfand, et al exposure can induce 18F-FDG presence in BAT. (Gelfand, O'Hara, Curtwright, & MacLean, 2005) Despite this, the conditions represented within the performed 118 PET scans in 69 paediatric patients investigation can be considered „extreme‟, and it is (average age was 12.9 years of age, 76 male and 42 unlikely that patients would encounter similar female). In 88 studies, premedication was conditions prior to routine PET scanning. administered. 44 patients received intravenous The most relevant investigation into the effect of fentanyl (dose 0.75-1 μg/kg), 34 received oral cold exposure on the appearance of 18F-FDG in diazepam at a dose of 0.06mg/kg and 9 received BAT has been conducted by van Marken 0.10mg/kg. 29.4% of patients who received low Lichtenbelt, et al. (van Marken Lichtenbelt, et al., dose diazepam demonstrated BAT and of the patients 2009). 24 healthy male patients were investigated that received fentanyl only 6.7% demonstrated BAT. (10 with a BMI <25 and 14 with a BMI 25) with Of the patients that received no premedication, 18F-FDG during exposure to mild cold (16°C). Prior 26.1% demonstrated BAT. None of the patients that to PET/CT imaging, all subjects were fasted for the received moderate dose diazepam demonstrated same duration and wore standardised clothing. The BAT, but it is likely that the result may be skewed subjects were placed in a climate chamber for 1 due to a small sample size. No difference was hour at 22°C and were then exposed to cold reported between male and female patients and those conditions at 16°C for a further two hours. After the that received low dose oral diazepam and those that first hour of cold exposure the subjects were received no premedication. Although Gelfand, et al. administered 74MBq of 18F-FDG intravenously. (2005) demonstrated that the administration of PET/CT scanning occurred after the second hour. fentanyl was able to reduce the incidence of BAT Three of the subjects were then re-evaluated using a they did not report complete effectiveness. constant temperature of 22°C. 23 patients were confirmed to have hypermetabolic BAT on PET/CT Jacobsson (Jacobsson, Bruzelius, & Larsson, 2005) to varying degrees with the exception being one reported the use of propranolol was successful in subject with a BMI of 38.7 - the highest BMI of all reducing the appearance of BAT. A male patient who subjects. A higher amount of BAT was underwent a PET examination was reported to have demonstrated in subjects with a lower BMI in extensive BAT that could not be distinguished from keeping with the findings of previous investigations actual disease. The patient underwent a repeat (Hany, et al., 2002), although no statistically examination 3 weeks later following the oral significance difference was reported. There was no administration of 80mg of propranolol. Jacobsson, et BAT observed within the patients that underwent al. (2005) reported a compete resolution of the re-evaluation at 22°C. The investigation by van hypermetabolic BAT. Following Jasobsson, et al.‟s Marken Lichtenbelt, et al. (2009) depicts similar (2005) revelation several groups of investigators conditions that may be encountered during routine have conducted studies into the use of propranolol as PET scanning when compared to that of Baba, et al. an effective means of preventing hypermetabolic (2007). Although there is this discrepancy, the BAT on 18F-FDG PET. conclusions of both investigations are similar and both demonstrate the effect that cold exposure has Soderlund (Soderlund, Larsson, & Jacobsson, 2007) on 18F-FDG imaging and confirm the presence of investigated 11 patients that were reported to have hypermetabolic BAT. BAT on their PET scans by performing a second examination 5 days post the first PET study. Prior to Reduction of BAT on 18F-FDG PET
the administrated of 18F-FDG the patients were given Recently, the majority of investigators have focused 80mg of propranolol orally. All patients showed a on the administration of pharmaceuticals with the complete or almost complete disappearance of BAT attempt of reducing the appearance of BAT on on the second PET examination (P< 0.001) 18FDG PET. These pharmaceuticals include (Soderlund, et al., 2007). Disease that was present propranolol; a β-blocker and diazepam; a with some of the patients on their first PET scan benzodiazepine and fentanyl; an opiate. Other remained unchanged, suggesting that the oral methods reported have included controlling the administration of propranolol prior 18F-FDG does not environmental temperature of the patient and alter the biodistribution within tumours. Soderlund, controlling the diet of the patient. All techniques et al. (2007) also reported that propranolol had the have varying reports of success in reducing the ability to reduce cardiac uptake of 18F-FDG, appearance of BAT. although the difference was not significant. Agrawel (Agrawal, et al., 2009) reported a similar Diazepam was the first pharmaceutical to show success rate in the reduction of hypermetabolic BAT effectiveness in reducing BAT appearance - an following the administration of propranolol. 40 Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 patients (14 females and 26 males) who the effectiveness of controlling the temperature of demonstrated BAT on an initial PET scan were re- the patients environment prior to 18F-FDG examined following the oral administration of 40mg administration has been under investigated. of propranolol. The repeat PET scan was repeated 48 hours post the initial scan, and the propranolol Christensen, et al. (Christensen, Clark, & Morton, was administered 60 minutes prior to 18F-FDG. 2006) proved that by attempting to control the Patients taking β-blockers were excluded from the patients environmental temperature prior to 18F-FDG study. 90% of patients demonstrated a complete injection, hypermetabolic BAT could be reduced just clearance of 18F-FDG from BAT on their second as effectively as with the administration of PET scan. Agrawel, et al. (2009) suggest that the propranolol. During the investigation, 10 patients BAT observed in 10% of patients may have been were selected that had previously demonstrated BAT due to the external influences on hypermetabolic on their PET scan. 3 patients were provided with BAT such as anxiety level, temperature and blood warm blankets from a blanket oven during the uptake glucose level; as these factors were not controlled period, 4 patients were instructed to stay in a warm during the investigation. environment for 48 hours prior to their scan and 3 patients were instructed to stay in a warm Parysow (Parysow, et al., 2007) also investigated environment for 48 hours prior to their scan and the effectiveness of oral propranolol and reported a given 5mg of oral diazepam at the time of 18F-FDG similar success rate as Agrawel, et al. (2009) and injection ((Christensen, et al., 2006). Patients Soderlund, et al. (2007). 26 patients that had been underwent PET/CT at 60mins following injection. previously identified at having hypermetabolic BAT All but one patient (90%) showed complete on PET were administered 20mg of oral propranolol resolution of hypermetabolic BAT on their second 60mins prior to 18F-FDG. 24 patients (92.3%) scan. This success rate in the reduction of BAT is demonstrated no BAT after being administered with comparable with that achieved using propranolol, the propranolol. The remaining 7.69% of patients although the sample size within this study is small. still demonstrated BAT, although the distribution In a similar sized study Garcia, et al. (Garcia, et al., and SUVmax was reduced, but not significantly. 2006) re-evaluated 10 patients who were reported to have hypermetabolic BAT on an initial PET scan. Tatsumi (Tatsumi, et al., 2004) conducted an Patients were instructed to wear warm winter-type extensive investigation using rats, similar to that of clothing prior to their scan and during transit from Baba, et al. (2007). Three groups of rats were home to the PET centre and pre-warm their car‟s anaesthetised and each of the groups were interior to room temperature. Upon arrival to the administered propranolol, diazepam or reserpine (an PET centre, patients were placed in a temperature antihypertensive) intraperitoneally post anaesthesia. controlled room and provided with warm blankets. The dose administered were 5mg/kg of propranolol Warm blankets were also provided during the uptake 20mins prior to 18F-FDG, 4mg/kg of reserpine 4 h period. Four observers assessed the PET scans for prior to 18F-FDG, and 2.5mg/kg of diazepam 30min any presence of hypermetabolic BAT and reported prior to 18F-FDG. A control group was also included no BAT visualisation in 70-90% of patients and received no medication prior to 18F-FDG. 60 (allowing for inter-observer variability). minutes following 18F-FDG injection, the rats were sacrificed, interscapular BAT removed and Both Christensen, et al. (2006) and Garcia, et al. examined under microscope and measured for the (2006) have reported a high level of success (70- presence of 18F-FDG. Tatsumi, et al. (2004) 90%) in reducing hypermetabolic BAT on 18F-FDG demonstrated propranolol to be the most effective PET through simply attempting to control the medication in reducing the 18F-FDG uptake in BAT, patients environmental temperature prior to their reducing it to just 16% of the control value. scan. These figures are despite small sample sizes and are comparable with that achieved using Reserpine was also effective, reducing BAT activity pharmaceuticals such as propranolol. Surprisingly, to 28% of the control. Diazepam was also effective despite a similar success rate there have been limited in reducing the 18F-FDG uptake in BAT, but the investigations into the use of warming techniques. result was not statistically significant, achieving only a 64% reduction when compared to the control. Conclusion
The administration of propranolol one hour prior to Hypermetabolic BAT, when present, has the the administration of 18F-FDG has been potential to reduce the accuracy of 18F-FDG PET. demonstrated at the most effective pharmaceutical Whenever possible, an attempt must be made to in reducing the incidence of hypermetabolic BAT reduce its appearance. Hypermetabolic BAT has on PET. The reported success rate is approximately been visualised in all types of patients but a higher 90% (Agrawal, et al., 2009; Parysow, et al., 2007; incidence has been observed in female patients, the Soderlund, et al., 2007; Tatsumi, et al., 2004). paediatric population and those patients with a low Given the evidence that there is a strong relationship BMI. The appearance of BAT appears to be as a between temperature exposure and BAT appearance consequence of the environmental temperature of the (Cohade, Mourtzikos, et al., 2003; Kim, et al., 2008) patient prior to their PET scan. Pharmaceutical Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 intervention has proven to be successful in reducing to patients does not come without risks or the need to the appearance, with oral propranolol proving the manage outpatients following administration. The most successful. Several small studies into use of warming techniques comes with relative ease environmental temperature control prior to scanning when compared to pharmaceutical intervention and have demonstrated a similar success. Although there is a need to conduct further investigations to highly effective, the administration of propranolol emphasise their effectiveness. REFERENCES
Agrawal, A., Nair, N., & Baghel, N. S. (2009). A novel approach for reduction of brown fat uptake on FDG PET. [Journal Article]. The British Journal of Radiology, 82, 626-631. Baba, S., Engles, J. M., Huso, D. L., Ishimori, T., & Wahl, R. L. (2007). Comparison of Uptake of Multiple Clinical Radiotracers into Brown Adipose Tissue under Cold-Simulated and Nonsimulated Conditions. [Journal Article]. J Nuclear Medicine, 48, 1715-1723. Celi, F. (2009). Brown Adipose Tissue - When it Pays to Be Inefficient. [Journal Article]. New England Journal of Medicine, 306(15), 1553-1556. Christensen, C. R., Clark, P. B., & Morton, K. A. (2006). Reversal of Hypermetabolic Brown Adipsoe Tissue in F-18 FDG PET Imaging. Clinical Nuclear Medicine, 31(4), 193-196. Cohade, C., Mourtzikos, K. A., & Wahl, R. L. (2003). "USA-Fat": Prevalence Is Related to Ambient Outdoor Temperature - Evaluation with 18F-FDG PET/CT. [Journal Article]. J Nuclear Medicine, 44, 1267-1270. Cohade, C., Osman, M., Pannu, H. K., & Wahl, R. L. (2003). Uptake in Supraclavicular Area Fat ("USA-Fat"): Description on 18F-FDG PET/CT. [Journal Article]. J Nuclear Medicine, 44, 170-176. Cypess, A. M., Lehman, S., Williams, G., Tal, I., Rodman, D., Goldfine, A. B., et al. (2009). Indentification and Importance of Brown Adipose Tissue in Adult Humans. New England Journal of Medicine, 360(15), 1509-1517. Evans, K. D., Tulloss, T. A., & Hall, N. (2007). 18FDG Uptake in Brown Fat: Potential for False Positives. [Journal Article]. Radiologic Technology, 78(5), 361-366. Garcia, C. A., Nostrand, D. V., Acio, A. E., Bulter, C., Esposito, G., Kulkarni, K., et al. (2006). Reduction of Brown Fat 2-Deoxy-2-[F-18] fluoro-D-glucose Uptake by Controlling Environmental Temperature Prior to Positron Emission Tomography Scan. Molecular Imaging and Biology, 8, 24-29. Gelfand, M. J., O'Hara, S. M., Curtwright, L. A., & MacLean, J. R. (2005). Pre-medication to block [18F]FDG uptake in the brown adipose tissue of pediatric and adolescent patients. Pediatric Radiol, 35, 984-990. Hany, T. F., Gharehpapagh, E., Kamel, E. M., Buck, A., Himms-Hagen, J., & von Schulthess, G. K. (2002). Brown adipose tissue: a factor to consider in symmetrical tracer uptake in the neck and upper chest region. European Journal of Nuclear Medicine, 29(10), 1393-1398. Jacobsson, H., Bruzelius, M., & Larsson, S. A. (2005). Reduction of FDG upatke in brown adipose tissue by propranolol. Eur J Nucl Med Mol Imaging, 32, 1130. Kim, S., Krynyckyi, B. R., Machac, J., & Kim, C. K. (2008). Temporal relation between temperature change and FDG uptake in brown adipose tissue. Eur J Nucl Med Mol Imaging, 35, 984-989. Nedergaard, J., Bengtsson, T., & Cannon, B. (2007). Unexpected evidence for active brown adipose tissue in adult humans. Am J Physiol Endocrinol Metab, 293, E444-E452. Paidisetty, S., & Blodgett, T. M. (2009). Brown Fat: Atypical Locations and Appearances Encountered in PET/CT. AJR, 193, 359-366. Parysow, O., Mollerach, A. M., Jager, V., Racioppi, S., Roman, J. S., & Gerbaudo, V. H. (2007). Low-Dose Oral Propranolol Could Reduce Brown Adipose Tissue F-18 FDG Uptake in Pateints Undergoing PET Scans. Clinical Nuclear Medicine, 32, 351-357. Soderlund, V., Larsson, S. A., & Jacobsson, H. (2007). Reduction of FDG Uptake in brown adipose tissue in clinical patients by a single dose of propranolol. Eur J Nucl Med Mol Imaging, 34, 1018-1022. Tatsumi, M., Engles, J. M., Ishimori, T., Nicely, O., Cohade, C., & Wahl, R. L. (2004). Intense 18F-FDG Uptake in Brown Fat Can Be Reduced Pharmacologically. J Nuclear Medicine, 45, 1189-1193. Truong, M. T., Erasmus, J. J., Munden, R. F., Marom, E. M., Sabloff, B. S., Gladish, G. W., et al. (2004). Focal FDG Uptake in Mediastinal Brown Fat Mimicking Malignancy: A Potential Pitfall Resolved on PET/CT. AJR, 183, 1127-1132. Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 van Marken Lichtenbelt, W. D., Vanhommerig, J. W., Smulders, N. M., Drossaerts, J. M. A. F. L., Kemerink, G. J., Bouvy, N. D., et al. (2009). Cold-Activated Brown Adipsoe Tissue in Healthy Men. New England Journal of Medicine, 360(15), 1500-1508. Virtanen, K. A., Lidell, M. E., Orava, J., Heglind, M., Westergren, R., Niemi, T., et al. (2009). Functional Brown Adipose Tissue in Healthy Adults. New England Journal of Medicine, 360(15), 1518-1525. Weber, W. A. (2004). Brown Adipose Tissue and Nuclear Medicine Imaging. J Nuclear Medicine, 45(7), 1101-1103. Williams, G., & Kolodny, G. M. (2008). Method for Decreasing Uptake of 18FDG by Hypermetabolic Brown Adipose Tissue on PET. AJR, 190, 1406-1409. Yeung, H. W., Grewal, R. K., Gonen, M., Schoder, H., & Larson, S. M. (2003). Patterns of 18F-FDG Uptake in Adipose Tissue and Muscle: A Potential Source of False-Positives for PET. J Nuclear Medicine, 44, 1789-1796. Continuing Professional Development – Question and Answer Sheet Article title: Brown Adipose Tissue and 18F-FDG PET. Your name: RAINS Member Number: _ Answer the following questions and return the completed sheet before the middle of the month to: RAINS Charles Sturt University seasonal@rains.asn.au Wagga Wagga NSW 2678 1). Initially, the appearance of BAT was thought to be what? 2). What are the five common locations of BAT? 3). What are the unique characteristics of BAT? 4). How does 18F-FDG localise in BAT? 5). Describe some characteristic s of a patient that may be more likely to have activated BAT on 18F-FDG PET. 6). Describe the relationship between temperature and the incidence of BAT. 7). What is the proposed action by which the administration of propranolol appears to block the appearance of BAT on 18F-FDG PET? 8). Soderlund, et al. (2007) administered 80mg of propranolol to patients prior to their PET scan. What was their success rate in reducing the appearance of BAT? 9). What effective technique that can be utilised in the reduction of BAT on 18F-FDG PET has been under-investigated? Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Crossword Puzzles The ANZSNM is now accepting a broader variety of CPD activities. Crossword puzzles now attract 1 CPD point when completed. You are not required to submit them for marking. The CPD requirements of the ANZSNM simply require that you record in your CPD diary that a CPD activity was undertaken. This has been confirmed in writing by the ANZSNM. So complete the crosswords below (and other CPD activities) and record these activities in your diary as proof in the event that you are audited. Submit your crossword. You can use the free puzzle maker at Save the puzzle and solutions as a webpage and send to seasonal@rains.asn.au Charles Sturt University. Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Radiopharmacy Clues 3 Approximate half life of 99Tc hours
1 How 99Mo is produced
6 Approximate half life of 11C minutes
2 67Ga radiochemical gallium _
7 Principle of radiation safety
4 Approximate half life of 13N minutes
10 Transition metal that is element 43 on periodic
5 Method of disposal of 99mTc waste; decay by
8 The 'm' in 99mTc
11 Half lives required to decay to 'background'
9 System imaged using mertiatide
12 'D' in TDS
13 How 89Sr is produced activation
15 18F based dopamine receptor tracer
14 Type of equilibrium for the Mo/Tc generator
17 201Tl produced in a _
16 Imaged with medronate
20 'S' in TDS
18 System imaged with 99mTc disofenin
23 Decay constant
19 201Tl radiochemical thallous _
24 'T' in TDS
21 'G' in FDG
25 Generator based PET blood flow agent 82-
22 More common abbreviated name fro exametazime
27 Approximate half life of 15O minutes
26 Where 99Mo is produced
1 Positron emission tomography
2 Ethane-1-hydroxy-1, 1-diphosphonate
3 Magnetic resonance imaging
5 As low as reasonably achievable
8 Diethylenetriamine pentaacetic acid
6 Region of interest
9 Not for resusitation
8 Digital imaging and communications in medicine
12 Rural alliance in nuclear scintigraphy
10 Mini-mental state examination
11 Meta-iodobenzylguanidine
18 Hydroxymethan diphosphonate
13 Carcinoembryonic antigen
14 O-(2-[18F]fluoroethyl)-L-tyrosine
25 Roentgen absorbed dose
27 Prospective investigation of pulmonary embolism 16 [18]F-3'-deoxy-3'-fluorothymidine
19 Counts per minute
30 Pulomonary embolism
22 Coronary artery disease
31 Methylene diphosphonate
32 Dimercaptosuccinic acid
24 Blood pressure
33 Radiology information system
26 Australian and New Zealand society of nuclear
35 Gastrointestinal tract
29 Alzeimer's disease
38 Chronic obstructive pulmonary disease
34 Single photon emission computed tomography
40 Heart rate
36 Bismuth germinate
41 Fluorine-18 2-fluoro-deoxyglucose
38 Cerberal blood flow
43 Myocardial infarction
39 Neck of femur
46 Ethyl cysteinate dimer
40 Hexamethylpropyleneamine oxime
47 Statim (immediately)
42 Glioblastoma multiforme
48 Monoclonal antibody
43 Methoxy isobutyl isonitrile
44 Ethylene-diamine-tetra-acetic acid
45 Picture archiving and communication system
Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Charles Sturt University. Submit your crossword. You can use the free puzzle maker at Save the puzzle and solutions as a webpage and send to seasonal@rains.asn.au Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Musculoskeletal Gross Anatomy Charles Sturt University. Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Musculoskeletal Gross Anatomy Clues 1 Finger and toes
2 Bum muscle (7,7)
3 Abdominal muscle (6,9)
4 C2 spine
8 Calf muscle
5 Upper jaw
10 Forearm bone
6 Lower leg muscle
12 Shoulder muscle
7 Carpal bone (l )
13 C1 spine
9 Hip bone
14 Pelvic based section of spine
11 Lower leg bone
15 Spine region of rib attachment
18 Chest muscle
16 Midfoot bone
19 Lower jaw
17 Thigh muscle
20 Carpal bone (p )
21 Upper arm bone
23 Bones of the wrist
22 Heel bone
24 Shoulder girdle
26 Irregular midfoot bones
25 Sub unit of spine
27 Tip of spine
29 Pelvic bone
28 Upper arm muscle
30 Region of upper spine
33 Carpal bone (s _)
31 Knee bone
34 Lower non fused spine region
32 Upper arm muscle
35 Carpal bone (c _)
36 Skull bones
40 Collar bone
37 Forearm bone
41 Bones of the ankle
38 Carpal bone (h )
42 Midfoot bone
39 Bones protecting the chest contents
43 Bone of the hind foot
41 Lower leg bone
44 Midline pelvic bone
45 Breast bone
46 Upper leg bone
Crossword Puzzle Challenge The crossword puzzle offers a very efficient tool for gaining CPD points. It does not take long to create. The puzzles below were team efforts from the respective departments and the authors (and their departments) issue a challenge to other nuclear medicine departments to form a team and create a better crossword puzzle for the next newsletter. There should, however, be some ground rules. Firstly, the crossword needs to be on a specific theme (eg. PET, GIT imaging, SPECT/CT etc) not just general nuclear medicine. Secondly, the puzzle needs to contain between 30-40 clues. Submit your department crossword for the next edition of the newsletter. Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 PRP Diagnostic Imaging Team Effort 3 The bone of insertion of the Achilles tendon.
1 Primary malignant tumour of bone whose cells
4 Pathology indicated if myocardial perfusion at
produce hyaline cartilage resulting in abnormal rest is normal while the stress shows an area of cartilage and - or bone. decreased perfusion. 2 The medical term for the symptom of difficulty
6 Type of ultrasound used to diagnose DVT.
9 Liver mass detected on a Tc-RBC scan.
5 Process of separating blood.
12 Most likely cause of fractures.
7 imaging: A technique used in
13 Isotope used for bone palliation.
myocardial perfusion imaging to correct for 15 Likely pathology demonstrated on Bone scan
diaphragmatic attenuation. as hot spots in the ribs which appear to be in a 8 What does the E stand for in VEB in relation to
16 Increased alkaline phosphate is an indicator for
10 Term used to describe a WB bone scan
which common bone pathology. showing diffusely increased bony uptake with 17 Interventional drug commonly used in renal
absent or near complete absence of soft tissue, imaging for PUJ obstruction. renal, and bladder tracer activity. 11 Initials for the agent used in
lymphoscintigraphy. 14 Pharmaceutical used in evaluating loss of or
decrease blood supply in cerebral perfusion Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Nuclear Medicine Toowoomba Nuclear Imaging. 1 Nuc med techs always work _?
1 Antibody response
2 Haemangiomas are deficient in these cells
3 Neural crest tumour
5 Spinal joint
4 Liver-spleen mechanism of uptake
6 Needed to reduce pertechnetate prior to tagging
5 A response which occurs following Metastron
7 Mechanism of lung perfusion
10 Tl-201 is a potassium ?
radiopharmaceutical localisation. 11 Time magazines year 2000 invention of the
8 PET pharmaceutical
13 Bone scan agent
9 Conceived the tracer principle
14 Autoimmune condition
12 Early bone imaging agent
16 DMSA (dimercaptosuccinid _)
15 Treated with P32
17 Imaged with MIBG
18 Pelvic bone
19 Required in Gallium localisation
Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 MASTER OF MEDICAL RADIATION SCIENCE
Flexible delivery entirely by distance education.
May attract higher award wages.
Contributes to CPD.
Update your qualifications to match the new postgraduate technologists.
Generic Master of Medical Radiation Science for 100% coursework.
Nuclear Medicine specialisation for a mix of coursework and research project.
Applications made directly to the University.
For details visit www.csu.edu.au.
Course Coordinator Specialisation Coordinator Master of Medical Radiation Science Nuclear Medicine Email: haswan@csu.edu.au Email: gcurrie@csu.edu.au Tel: 02 6933 2500 Tel: 02 6933 2822 Other study options include:
 CT for Nuclear Medicine (NMT415) – associate subject or elective in the Masters – approved by NSW EPA for SPECT/CT and PET/CT licence. Copyright 2010. All rights reserved.

Seas RAINS, vol. 4, no. 1 What The ……. ? Charles Sturt University. Chest statics from a wholebody bone scan. Solution in the next issue. Send your ‘What The …… ?' image, solution and author details to seasonal@rains.asn.au What The ….? Solution For Last Edition
Monostotic Paget‟s disease of the heel RAINS CPD Initiatives. The following initiatives have been developed by RAINS to facilitate achievement of the 30 CPD points for RAINS members. These are proposed activities that mirror activities approved by the ANZSNM with some modification for more ready use in the rural environment. Activity
CPD Points
RAINS members can submit a power point presentation of one or more clinical 2 presenter points cases. Content should include patient history, scan methodology, other imaging procedures, relevant technical information, final report and patient outcomes of 20- 1 attendee point View, read and submit review questions (80% pass mark). Continuing Education Each issue of Seasonal RAINS will contain 1 or more continuing education articles Articles and Tests with tests. Completion of the tests and submission back to RAINS with an 80% pass mark will attract CPD points. Writing CPD articles/tests RAINS members are encouraged to write fully referenced and scientific continuing education articles accompanied by 10 „test‟ questions and submit for distribution in Short Courses and CSU in conjunction with RAINS and the ACT Branch of the ANZSNM organise an annual 2 day CE workshop in Wagga. In-service Education Provide 30 minute power point presentation with narration for inclusion on CPD CD, including written question). View, read and submit review questions (80% pass mark). Book / journal review Write a considered book review (nuclear medicine) or journal article review for inclusion in Seasonal RAINS (1 page). Professional Development RAINS will develop and circulated a professional development plan template for members wishing to use it. Complete the crossword and make a notation in your CPD diary. Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 The Doctor of Health Science

The Doctor of Health Science (DHlthSc) at CSU is a
professional doctorate that allows candidates to pursue
a research higher degree of the same standard as the
PhD but within a structure that is aimed at improving
professional practice. Specifically, it offers a research
based approach for provision of solutions relevant to
the professions and industry.
Professional doctorates aim to provide a tool for
advanced research enabling candidates to contribute in a significant way to the knowledge and practice in their profession or discipline area. Consequently, Admission Requirements
candidates enrolled in professional doctorates tend to For admission to the DHlthSc applicants would need to be more intrinsically motivated aiming to improve demonstrate that they: professional practice and enhance job satisfaction.  are working in an appropriate field within, or relevant to, the Health Professions and can Course Structure
demonstrate they have the opportunity and The DHlthSc is offered by part-time distance facilities to complete the applied education mode and is composed of coursework and research/investigation components of the an applied research/professional component. Student‟s progress through the research/professional component  have had a minimum of 3 years of relevant of the DHlthSc is monitored by the requirement that professional and/or vocational experience students complete subjects in sequence thus meeting (with relevance being determined by the pre-defined milestones. The applied DHlthSc Course Coordinator in conjunction research/investigation allows students to develop a with the proposed principal supervisor); and research question or topic for investigation by  normally hold a Masters degree or equivalent conducting an intensive literature review, critique and (by coursework) in an approved area of Health reflecting on their professional practices. Sciences, with credit grades or above in all subjects undertaken. The DHlthSc culminates in a professional portfolio (including an exegesis), which integrates the Course Aims and Objectives
research/investigation within their professional The DHlthSc promotes an advanced, critical reflection practice. The professional portfolio incorporates on professional practice in the health sciences and aims reports, papers and publications prepared throughout the course with an exegesis to link the results back to  provide opportunity for the candidates to the profession and professional practice, and original continue lifelong learning in keeping with the question on which the research or investigation is university‟s mission statement; based. The professional portfolio with exegesis is  satisfy the educational needs of professionals subjected to external examination in accordance with working in or aspiring to work in the most University regulations. senior tiers of the health sciences and related The duration of the DHlthSc is the equivalent of 4.5  promote the acquisition of advanced analytical years part time enrolment. and problem solving skills and conceptual insights that enhance the capacity of the Enrolment Pattern candidate to undertake positions of significant HSC700 Research Critique and Publication responsibility in the health sciences; HSC701 Reflective Practice in Health Science  encourage excellence in scholarship and HSC702 Proposal For Applied Research focused research within the candidates HSC703 Research Project and Report 64 Points discipline area. HSC704 Health Science Portfolio / Exegesis Course Coordinator
For all inquiries please contact info.csu on: Dr Janelle Wheat Telephone: 1800 334 733 (free call within Australia) Senior Lecturer, Faculty of Science Telephone: 61 2 6338 6077 (outside Australia) Telephone: 61 2 69332750 Email: inquiry@csu.edu.au Email: jwheat@csu.edu.au Web inquiry: www.csu.edu.au/student/contact Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Guidelines for Submissions to Seasonal RAINS Seasonal RAINS will accept a number of types of In-Service Education submissions. All work must be written in English Seminars should be submitted as power point and submitted in Microsoft Word. All submission presentations with audio narration. Audio recordings must be accompanied by a cover letter (email is should be embedded in the power point presentation sufficient) indicating the type of submission, details (not linked) using a radio quality setting (22kHz, 16 of authors and departments, contact details of the bit, mono). Ensure sound quality is suitable for corresponding author and a statement indicating that circulation. Valuable presentation might only be the submission is not subject to copyright included if narration is re-recorded. Accepted presentations will be included on the RAINS CPD in-service CD. All presentations should be All submissions will be reviewed for accompanied by 10 review questions. Presentations appropriateness and accuracy (where relevant). should be sent by mail to: The Editor, PO Box U102, Inclusion in Seasonal RAINS remains the discretion CSU, Wagga Wagga, 2678. of the editorial board. Preference will be given to submissions consistent with the philosophy and purpose of RAINS. Submissions should provide an educational review of All submissions should be sent by email to: an area of interest. The reviews should be well seasonal@rains.asn.au researched and present all valid perspectives. CPD articles may be accepted after review by the editorial Letter To Editor board. Alternatively, the submission may be accepted with some suggested revision or deemed 300-500 word limit. not suitable for the purpose intended (CPD). All submission must adhere to the guidelines provided Interesting Image by the Journal of Nuclear Medicine Technology; 1 JPG image and 300 word limit case presentation. available on the SNM web site (www.snm.org). CPD articles should be made available for publication without copyright authority elsewhere. 1 JPG image and 100 word limit solution. Submitting authors accept responsibility for ensuring News and Events manuscripts do not breach copyright laws. Seasonal RAINS does not, however, ask that you transfer Summary of recent or upcoming events. Update copyright to RAINS. Thus authors are free to re- RAINS member achievements; publication, publish manuscripts in whole or in part in subsequent conference presentation or scholarship. Book or Journal Article(s) Review Review of a recently released nuclear medicine text Advertisement of activities, products or events or journal article(s) related to nuclear medicine. consistent with the philosophy and purpose of Minimum of 1 page. RAINS will occur without charge (including positions vacant). Commercial advertisements may be included at a 20-30 minute power point presentation of a relevant cost of $100 per half page (190x125 mm landscape) journal article in Nuclear Medicine. Submissions and $200 per full page (190x270 mm portrait). should include written text and discussion for each slide plus 10 test questions. Advertisements will not be reformatted. Advertisements should be submitted electronically in PDF or JPG. This is an electronic newsletter so colour is permitted at no additional cost. Submit a 20-30 minute review summary and presentation (power point) of one or more clinical Advertisements should be emailed to: cases. Content should include patient history, scan seasonal@rains.asn.au no later than 4 weeks prior to methodology, other imaging procedures, relevant technical information, final report and patient outcomes. Submissions should include written text Start Collecting Your CPD Points and discussion for each slide plus 10 test questions. Copyright 2010. All rights reserved.

7th Annual CPD/CME Conference: IIS2010
Stamford Grand, North Ryde
(Adjacent to Macquarie University, Sydney)
Saturday 13th & Sunday 14th November, 2010
The scis.
Integraonthe mod • • • • • • There is eythrough anatomntenters Each sentdiagno.
The pndand CReprogram s,radiolog CT and PET in diagnosis and management of Transition from SPECT to PET Medical oncology PET Novel peptides in cancer therapy; the role of Endocrine imaging Coronary artery disease PACS/RIS, ECG Tutorial or Cross sectional PET and MRI in dementia Pre-dinner drinks Conference dinner Morning tea from 1030am-11amLunch from 1230pm-130pmAfternoon tea from 3pm-330pm Scientific Program Registration
Registration fee includes:
• All scientific program sessions
• Morning tea Saturday and Sunday
• Buffet lunch Saturday and Sunday
Early Bird
• Afternoon tea Saturday and Sunday Conference dinner: • 3 course buffet meal at the Stamford Grand• 3 hours of superior beverage service during dinner• 1 hour of superior beverage service at pre-dinner drinks Note:
• Day registration includes morning tea, lunch and afternoon tea on the day of registration.
• Early bird registration discounts apply before the end of the financial year.
• CE and CPD point applications pending.
• Book accommodation directly with Stamford Grand , North Ryde using the conference discount rates of $170 for a
superior room (02 9888 1077). Executive and family suites are also available.
• Alternative accommodation can be organised at the Travelodge at Macquarie University.
• Send a RAINS membership application (free) with this form and receive the member discount (www.rains.asn.au).
Check Appropriate Box
RAINS Member before 1/7/10 Preferred Saturday workshop:
Non Member before 1/7/10 Conference Dinner (Saturday night) Please return this form with payment (cheque or money order made payable to ‘RAINS') to:
The Secretary, RAINSPO Box U102, CSU, Wagga Wagga 2678.
Direct Deposit Payments:
Account name: RAINS BSB: 033253Account number: 195900 Title: Surname: _ Given Name: _ Identifier: Your surname and initial Please send completed registration form ASAP after
direct deposit, and provide the date of direct deposit
and amount.

Email (print clearly): Please circle an appropriate descriptor: Medical Technical Nursing Scientist Other: Please circle appropriate expertise: SPECT PET CT MRI US Therapy Please check this box if you do not want your details made available to sponsors: □ Seas RAINS, vol. 4, no. 1 2009 Conference Report B2B09: Back to Basics CPD Conference Matt Ayers, RAINS President. On the weekend of the 10/11 October, Charles Sturt evenings festivities. The social dinner was a culinary University and RAINS co-hosted the annual CPD delight in the award winning resort restaurant conference. The 'Back to Basics' theme aimed to 'surpassed' only by the unsolicited entertainment of a discuss and disseminate knowledge and skills number of delegates who will remain unnamed transferable to actual clinical practice. The venue (singing, dancing and instrument playing). Despite was ideal at the Diamond Beach Resort near the social activities, for many, extending into the Forster, although the weather was disappointing. early hours of Sunday morning, delegates faced Sunday breakfast and session three with vigour. Based on delegate, sponsor and committee feedback, the weekend was an enormous success; Prof Doug Howarth provided an enlightening surpassing both plenary and social program analysis of lung scintigraphy and encouragement to all to "get off the PIOPED fence". Dr Emlyn Jones mediated discussion on renovascular hypertension Welcome drinks on Friday night were largely which was absorbing. Llewelyn Clack and Melissa prohibitive of most attending the Saturday morning Earl presented stimulating interesting case studies. beach Tai Chi although most managed to find their way to the buffet breakfast. The Saturday sessions The final session saw a riveting presentation from commenced with Professor Hosen Kiat, who Nathan Cassidy on breast lymphoscintigraphy and regaled delegates with some wonderful anecdotes sentinel node biopsy followed by an insight into before taking us on a journey from our cardiac making the transition from NMT to MRI imaging roots to the latest in cardiac molecular technologist from Coralea Kaaser and finishing with imaging; painting an optimistic picture of the Dr Geoff Currie presenting the pharmacological evolving role of myocardial perfusion imaging. basis of interventional nuclear cardiology. A Professor Doug Howarth reminded delegates of the scrumptious BBQ lunch followed the RAINS AGM role and power of oesophageal transit studies and before delegates departed well informed, well fed, GIT bleeding scintigraphy. and not so well rested. Morning tea freshened the palate for an insightful The enthusiasm of attendees and the robust examination of bone scintigraphy and the role of discussion generated by each of the speakers SPECT/CT by Dr Shane Morony. Dr Emlyn Jones highlighted the importance and relevance of the followed with a captivating presentation of the topics to current clinical practice. importance of parathyroid imaging. Ian Turner from ARI/PETNET (our major sponsors) rounded out the The organising committee would like to extend a session with an overview of the changing world of warm thank you to presenters, delegates and our Mo-99 and a comparative situation analysis between sponsors (ARI,PetNet, InMed, GMS, Cyclomedica, Australia and our international colleagues. RAINS, Siemens, GE Healthcare, Insight and Charles Sturt University,) without whom the Lunch and an afternoon of social activities (tennis, program could not have been achieved. We invite all volleyball, dayspa, beach) afforded an opportunity ANZSNM members and colleagues to participate in to digest and discuss delivered content. InMed kindly provided pre-dinner drinks to lubricate the Copyright 2010. All rights reserved. Seas RAINS, vol. 4, no. 1 Rural Alliance In Nuclear Scintigraphy - (RAINS)

There are no membership fees for RAINS in 2008.
Please send complete forms to:

Or email to:
PO Box U102
Charles Sturt University

I wish to apply for membership to RAINS and, if accepted as a member, I undertake to
comply with the RAINS Charter.
See membership guidelines (please tick):
Ordinary member …………………
Associate member …………. Professional Category (please tick): Technologist/Scientist ……………. Physician ……………………. Physicist …………………………. Radiologist …………………… Nurse ……………………………… Registrar ……………………… Radiopharmacist …………………. Student Technologist (specify uni) Other (please specify) ………. Are you a member of (please tick): ANZSNM ………………………… AIR …………………………. Title: _ Given Name: _ Surname: _ Business Address: _ _ Telephone: _ Email: I agree to have my telephone number and email address included on the RAINS database and circulated amongst RAINS members. Signature: ANZSNM Member? YES / NO Rurality Criteria Satisfied? 1 / 2 / 3 / 0 Member number issued? _ Copyright 2010. All rights reserved.

Source: http://rains.asn.au/wp-content/uploads/2014/04/seasonal_rains_v4_n1_final.pdf


Dr. med. Guy Bourgeois Dr. med. Reto Engel FMH Innere Medizin FMH Kardiologie & Innere Medizin Praxisgemeinschaft Webersbleiche, Schützengasse 2, 9000 St. Gallen Tel 071 227 40 60 Fax 071 227 40 61 Generika Wenn es Diskussionen über mögliche Kosteneinsparungen im Gesundheitswesen, insbesondere bei den Medikamenten geht, fällt schnell einmal der Begriff „Generikum". Worum handelt es sich aber dabei? Sind Generika Billigmedikamente, echte Alternativen zu teuren Originalen oder liegt die Wahrheit irgendwo dazwischen? Tatsächlich legten die kassenpflichtigen Generika in der Schweiz 2006 erneut kräftig zu. Seit dem Jahr 2001 hat sich der Markt der Generika auf 381.2 Millionen Franken mehr


CHECKLIST & INFORMATION SHEET Catalina Adventurer Volunteer  Payment – Cost for 2008 is $180. This price does not include boat transportation. Make checks payable to the Catalina Island Conservancy.  Application – Complete application and mail to Santa Catalina Island Conservancy; Volunteer Services; PO Box 2739; Avalon, CA 90704