# Nuclear Medicine/Print version

The current, editable version of this book is available in Wikibooks, the open-content textbooks collection, at
https://en.wikibooks.org/wiki/Nuclear_Medicine

# Standards

* Welcome!
* Wikibooks textbooks, including this Nuclear Medicine textbook, are open source works
* The template for the design of this wikibook is drawn from the Radiation Oncology Wikibook. For inspiration or ideas, please visit that site.
* Anyone is welcomed and encouraged to contribute anytime and anything related to Nuclear Medicine :)
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## General

This list of standards is meant to provide a uniform look and conformity for this book but is not meant to be inflexible or immutable. Please feel free to make suggestions on the talk page about how you think this book could be improved. This is a work in progress.
* Do not plagiarize!!! This includes cutting and pasting an abstract. Abstracts are copyrighted material.
* Keep it simple and easy to read. The fewer details the better.
* Subpages shall use the "/" directory-style hierarchy, e.g. Nuclear Medicine/Prostate.
    All new pages should be made to use the "/" format.
* Cite your sources!
** Use the automatic PMID link to link to articles references in PubMed. Just type the PubMed ID (PMID) like this PMID 11697327 and it will be formatted like this: PMID 11697327. This is recommended because it makes the source code much easier to read than if external links to pubmed were used.
** In addition to PubMed (www.pubmed.org), another very helpful search tool is Google Scholar. In particular, it shows (somewhat comprehensively?) other future papers that have cited the "Googled" paper.
* You are highly encouraged to create your own user account and log in before making any edits. See how to login for information.
* At the top of each page in the book, attach the template for the Table of Contents header -- type {{:Nuclear Medicine:TOC}}. This allows for easy jumping back to the main page and other important pages (such as RTOG studies).
** Certain complex topics that are divided into several pages may have their own sub-Table of Contents for -- e.g. see the subpages of Radiation Oncology/Breast and Radiation Oncology/Prostate.
* It is great to link to the full text version / PDF of an article, but try to do this only if there is free access for everyone and it doesn't require an institutional subscription.
* Ordering of articles within a section: it makes logical sense for the studies to be ordered chronologically (earliest studies listed first), since in general, the results of one study influence the results of subsequent studies.
** An exception is the page listing all RTOG studies, which is in descending order. The reason for that is that it's just more convenient to have the newer studies listed at the top so you don't have to scroll all the way to the bottom to get to the current studies.
* P-values: don't say p<0.000000001. Just say "S.S." or "SS" for statistically significant. If it's not statistically significant, say "N.S." An exception is if there's a trend toward significance, then you can put the p value. On a similar note, there's no need for confidence intervals.

## Editing

* Here is a link to Help:Editing
* To start, click the edit this page button on top of the page
* When done with changes, click the Save Page button underneath
* In general, there are only a few symbols that are used

## Page entry

Try to give the pages a consistent look. If in doubt, look at other pages within the wiki.
As a guide, use the following example:
* Name of study, Date (Date range of study) - PMID 12345 — "Title of publication." Author's name. Publication citation.
e.g.
* INT 0123 / RTOG 94-05, 2002 (1995-99) - PMID 11870157 — "INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy." Minsky BD et al. J Clin Oncol. 2002 Mar 1;20(5):1167-74.
For a study that has several publications stemming from it:
* Name of study (date range)
** 10-year update (2000): PMID 12345 — "Title of publication." Author's name. Publication citation.
*** Results
** 5-year results (1995): PMID 123456 — "Title of publication." Author's name. Publication citation.
*** Results
** Original publication (1993): PMID 1234567 — "Title of publication." Author's name. Publication citation.
*** Results
** Etc.
This Nuclear Medicine/Standards page is the Wikibooks:Local manuals of style for the Nuclear Medicine wikibook.

# Bone Mineral Density

Bone Mineral Density

# DXA Scan
## Indications
### Established Risk Factors for Osteoporosis

* Age greater than 65
* Gender - At the same age, females are at higher risk than males for an osteoporotic fracture in general. However, males are at higher risk for a hip fracture specifically.
* Weight and Height (Body Mass Index)
* A personal or family history of fracture from something simple like a fall or minor bump (also described as a "fragility fracture")
* Other causes such as certain drugs like steroids or chemotherapy
* Various metabolic conditions that put one at risk for low bone density:
** Type I Diebetes
** Long-standing untreated Hyperthyroidism
** Hyperparathyroidism
** Hypogonadism - high risk for males but normal if a female has had menopause after the age of 45
** Rheumatoid arthritis
* Smoking
* Consuming >3 alcoholic beverages per day

### Appropriate ordering of DXA scans

* In any patient, there are certain indications for scanning that do not require further stratification:
** Any personal history of fragility fractures?(like a fracture from a simple bump or low-impact fall) -> Scanning is appropriate.
** Prior scanning showing low bone density? -> Follow up scanning is appropriate.
** Prior scanning normal but secondary causes for potential interval bone loss are significant and/or expected.
* All other patients:
** Males
*** Low risk factors? -> Follow up visit for reevaluation only, no definite age is known for screening DXA
*** High risk factors (as above) or with clinical suspicion of low bone density -> Scanning is appropriate
** Females
*** Greater than 65 y/o? -> Scanning is appropriate
*** Less than 65 y/o?:
**** High risk factors (as above) or with clinical suspicion of low bone density -> Scanning is appropriate.
**** Low risk factors -> Follow-up reevaluation only.

## How To Read a DXA scan
### Visual Analysis

* Hip
** Attention needs to be given to anything which might alter the BMD, such as overlap of the hip with the ischium or dense foreign bodies. Anything aberrant density that exists within the background ROI or the ROI that draws the total hip or femoral neck will change bone density.
** If a corner of the femoral neck ROI does include part of the ischium, this usually can be manually excluded by the technologist performing the exam.
** Optimal rotation of the hip allows you to just see the lesser trochanter, which helps the computer to draw the ROIs correctly.
** Many hips have prostheses such as a hip replacement. Obviously, this cannot be used and the other hip or the forearm should be used for analysis instead.
* Spine
** Significant sclerosis or scolioses should be noted and likely elevates the bone density in the spine. When describing these findings, try to not use clinical diagnoses such as "osteoarthritis of the spine," which is a clinical diagnosis and not a radiological finding. The correct term could be "sclerosis." When there is a significant amount of sclerosis, this could be due to compression fracture (see below) or degenerative changes. As patients age, sclerosis may sequentially increase over time which may cause longitudinal measurements to increase or stay the same in cases when the patient's overall bone density is decreasing over time. For these reasons, it is wise to image more than one region of the body.
** Compression fractures need to be described. There is some controversy about whether or not interpreting clinicians should use DXA to screen for fractures, but it is possible with with alternate techniques. Using appropriate scanning technique, this is sometimes called visual fracture analysis (VFA) and can be billed for in some cases. Please note that a compression fracture may be a sole indicator for treatment despite a normal DXA measurement. It is especially important to carefully observe any changes in the angle of the spine or clear changes in vertebral height. One can correlate these changes with a new-onset back pain. Most clinicians order a diagnostic radiograph of the lumbar spine if something is concerning on the DXA.

### T vs Z scores

* T-scores
** Used for women
*** Postmenopausal - no longer having periods
*** Peri-menopausal - periods becoming irregular or becoming more spaced in interval
** Used for men ≥ 50 y/o
* Z-scores
** Used for pre-menopausal women, children, and all men < 50 y/o

### WHO Classification

* See the table at the bottom of this page for WHO classification for postmenopausal osteoporosis
| Diagnosis | T-score |
| Normal | ≥ -1.0 |
| Low Bone Mass ("Osteopenia," "Low Bone Density") | > -2.5 and < -1.0 |
| Osteoporosis | ≤ -2.5 |
| Severe ("Established") Osteoporosis | ≤ -2.5 for young-adult women, with a history of fragility fracture |

## FRAX Calculation
### WHO Fracture Risk (FRAX)

* WHY USE THIS?
** There confusion about when to treat patients pharmacologically in borderline cases.
** FRAX calculation is used to make pharmacologic treatment decisions which can be defined as treatment outside of Calcium and Vitamin D supplementation such as with a bisphosphonate. This definition is often insufficient because of other new types of treatment (i.e. Evista)
** Calculation can be applied to all patients aged 40-90 y/o.
** A known fragility fracture is a sole indication for treatment and should be included as a disclaimer when FRAX risk does not meet the threshold for treatment.
** It is found that simply using a T-score in bone mineral density (BMD) has been shown to be insufficient in assessing fracture risk in patients and is not ideal as a sole indicator in guiding bone-building or bone-retaining pharmacological treatment outside of normal vitamin D and calcium supplementation. Additionally, there is a general feeling in the public and in medicine that if you have "Osteopenia" or "Low bone density" that these are entities that require treatment. However, solely using these diagnoses for treatment decisions is controversial and does not carry the best support in the evidence-based literature.
** FRAX is a means to add clinical risk factors to the measurement of bone density, as a means for making treatment decisions. A study of approximately 60,000 patients (40-90 yr old men and women) was used to stratify the risk of fracture as it applied to the BMD of the femoral neck and/or various indicators in the patient's past medical history. This data was used to form a calculation tool to help guide treatment, called FRAX (Fracture Risk Assessment Tool). This tool can be found online and can give very helpful specified information with variables including race and nationality.
* A calculated 10 year FRAX risk of fracture of at least 3% at the hip, and at least 20% for a "major osteoporotic fracture," would indicate that the patient would benefit from pharmacological treatment.
* It must be noted that FRAX is not intended to be used as a sole determinant in "treat vs not treat." The consensus appears to be that a variety of clear indications for treatment exist, that may include:
** History of vertebral or hip fracture that is felt to be caused by low BMD.
** A diagnosis of primary osteoporosis - This diagnosis is made only if other treatable, non-primary causes of osteoporosis have been ruled out and the patient has a T-score that is less than or equal to -2.5 (also signifying -2.5 standard deviations from the mean).
** It must be remembered that the first consideration for treatment in patients with secondary osteoporosis (caused by hyperparathyroidism or corticosteroid use, for example) should be focused on approach to correct the secondary cause. However, it is yet reasonable to pharmacologically treat the patient if the clinical scenario indicates it. This must be approached on an individual, clinical basis.
** It is also reasonable to initiate pharmacologic treatment if any of the above criteria are not completely satisfied, based upon additional risk factors that may or may have not been included in the WHO fracture study. These decisions are usually up to the patient's primary care provider.

### Interpreting FRAX calculation

* Using a DXA measurement of the femoral neck, FRAX is calculated with at least the following information:
** Current Smoking
** Consumption of >3 alcoholic beverages a day
** Rheumatoid Arthritis
** Glucocorticoid use such as Prednisone, at any time of life - 5mg/day for equal to or more than 3 months (not necessarily consecutive).
** Personal history of fracture not caused by a minor incident such as a low-impact fall. For example, high impact fractures.
** Family history of fracture not caused by a minor incident such as a low-impact fall.
** Age
*** FRAX cannot be calculated for any patient less than 40 y/o or above 90 y/o.
** Weight
*** If the patient's weight is greater than 125Kg the patient's FRAX can be calculated, but is assumed to be a maximum weight of 125Kg for calculation.
** Race
*** This is key! For example, African-Americans have been found to have less risk of fracture at the same BMD.
** FRAX can be calculated without the DXA scan BMD of the femoral neck; however, it may be more desirable to apply an objective measurement.
*** In order to calculate FRAX without the DXA, personal risk factors and any and all causes of secondary osteoporosis must be comprehensively inquired in order to correctly stratify the patient's fracture risk. This can be done in the primary care setting without the need for any equipment other than internet access. This particular information is important to the interpretation of the DXA scan because with the use of a femoral neck BMD, it is no longer necessary to consider causes of secondary osteoporosis other than those listed above.

## Reporting Findings
### A brief outline of the findings should include:

* A declaration of the body part(s) studied using a definable type of equipment and technique.
* Any visual deformities of the body parts of interest or issues precluding diagnosis.
* The densities of the areas of interest and associated T or Z scores.
* The change in bone densities since last study and/or since the highest/lowest density the patient has had in the past.
* FRAX calculation (if indicated)
* Recommendations

## Follow-Up scanning

* According to the ISCD Follow-up is appropriate when the expected change in BMD is ≥ the LSC
* Using the LSC alone as an indication of when to call something "significantly changed" is erroneous information and does not account for the expected change in BMD for a certain ROI with a certain type of therapy.
* The Monitoring Time Interval (MTI) can be calculated using the LSC:
$MTI={\frac {LSC}{(expected\ \%\bigtriangleup peryear)}}\$
* When the MTI is ≤ 1.0 the measured change has exceeded the expected change for a given institution, treatment, and patient. Therefore, a repeat BMD at or after this time will result in clinically relevant information.
* LSC is calculated per the standards laid out by the ISCD (see iscd.org).
* Expected change per year is dependent on therapy type and where you measure.
* A simple method is to scan one year after initiating or changing therapy, and then at less frequent intervals once a pattern is evident.

## Abreviations used in this document

* BMD - Bone Mineral Density
* DXA - also known as DEXA; bone density scan
* FRAX - Fracture Risk Assessment Tool
* ISCD - International Society for Clinical Densitometry
* LSC - Least Significant Change (Usually at the 95% confidence interval)
* ROI - Region of interest
* VFA - Visual Fracture Analysis

## References

* ^ PMID 19426925 - "2008 Santa Fe Bone Symposium: update on osteoporosis." Lewiecki EM, Baim S, Bilezikian JP, Eastell R, LeBoff MS, Miller PD. (J Clin Densitom. 2009 Apr-Jun;12(2):135-57.)
* WHO publication - Kanis JA, on behalf of the World Health Organisation Scientific Group. Assessment of osteoporosis at the primary health care level. WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield 2007 (available on request from the WHO Collaborating Centre or the IOF).
* ^ Online FRAX calculation tool
* ^ iscd.org - International Society of Clinical Densitometry

# Infection

Nuclear Medicine:TOC
Infection

## Immunocompromised Infection

* (Please add info)

## Post Transplant/Operative
### Cardiac

* Scintography of post heart transplant infections have not been extensively studied, however, Gallium, Indium-111 WBC, and Tc99m HMPAO have been used.
** PMID 16485569 -- "Value of radionuclide studies in cardiac transplantation." (Flotats A, Carrió I. 2005 Ann Nucl Med. 2006 Jan;20(1):13-21.)

## Central Nervous System

* (Please add info)

## Cardiovascular

* Also see above "Post Transplant/Operative" - Cardiac

## Appendicitis

** ^ SAMPLE PMID 19426925 - "2008 Santa Fe Bone Symposium: update on osteoporosis." Lewiecki EM, Baim S, Bilezikian JP, Eastell R, LeBoff MS, Miller PD. (J Clin Densitom. 2009 Apr-Jun;12(2):135-57.)
Acronyms used:
* MDP - Medronate or
* 18F-FTG PET - (18)Fluorine-fluorodeoxyglucose Positron Emission Tomography

# Nuclear Cardiology

Nuclear Cardiology

# EKG stress testing
## Indications

* (Please add info)

## Guidelines for EKG Stress Testing
### Blood Pressure

* If the systolic BP is >200 or the diastolic >110 before exercise, the exercise test should not be done.
* In normal individuals, systolic BP can raise 160 to 220 mmHg. However, diastolic BP may not raise at all because the body is trying to open up the peripheral vessels to allow for the increased flow of blood rich with oxygen.
* If systolic BP falls by more than 10mmHg or if systolic BP does not exceed 130mmHg then this would be suggestive of myocardial damage. If the BP does indeed fall more than 10mmHg then the test should then be stopped if there is also other indications of ischemia.
* In any patient, if the systolic BP goes >250 or diastolic >115 then the test should be stopped.
* In normal individuals, exercise will raise blood pressure in order to supply extra oxygen to tissues. After exercise, the normal individual's blood pressure (BP) will quickly drop back down as the need goes away. However, in some individuals with ischemia, their BP will not drop rapidly. If at 3 minutes post-exercise the BP remains at approximately 90% of the maximum BP during exercise, this is a sensitive (>80%) but not specific indication of ischemia.

### Heart Rate

* More than a few things can cause excessive tachycardia during treadmill stress testing. However, at this time research has not outlined an objective quantitative prognostic value for what would be considered an abnormally high chronotropic response.

### ST Depression

* The more coronary artery disease the patient has, the greater the sensitivity of ST depression in diagnosing ischemia.
* The "location" of the ischemia on EKG does not truly localize the area affected, with the slight exception of lead V1 (this assumes the leads were placed correctly).
* ST depression in contiguous leads (like V4-V5-V6) is more likely to be true ischemia.
* ST depression at maximal stress that corrects quickly after cessation of exercise is more likely to be a false positive. However, if ST depression continues long after exercise (more than 8 minutes), it is more likely a true positive.
* T wave inversion that happens with ST depression is indicative of true ischemia.
* If ST depression comes after exercise (>2-3min) it is likely a false positive.
* True ischemia usually has an onset at a given rate and then goes away at the same rate.
* Chest pain that happens with ST depression is likely to be true ischemia.
* False positivity is more likely to happen in women, perhaps because women are less likely to have chest pain that is caused by cardiac ischemia.
* More than 1mm of "downsloping" or "horizontal" ST depression is more likely to be true ischemia.
* Upsloping ST depression, in general, is less likely to be a true event. However, if there is upsloping ST depression that is 1.5mm at or after 80ms (two small bars) from the J point, it is more likely to be true ischemia.

### ST Elevation

(Please Insert Info)

## Pharmacologic Stress Testing

* Medications such as Dipyridamole, Adenosine, and Regadenoson(Lexiscan) are used instead of exercise stress testing because they have the ability to "mimic" the hemodynamic state of the heart during normal stress. The primary mechanism of action is to dilate the cardiac vessels in general, thereby unmasking defects in vessels that may not be able to dilate and/or have blockage by atherosclerosis or plaque/embolus. See more detailed descriptions below.
* Dobutamine's mechanism of action is to directly produce stress by beta agonism and increasing chronotropic and inotropic activity in the heart. See more detailed descriptions below.

### Regadenoson (Lexiscan)

* A new medication that can be used instead of Adenosine for pharmacologic stress testing. It is "selective" for A2A receptors with lower affinity for receptors that cause unwanted side effects (A2B, A3, A1) It is reputed to be better tolerated by patients and has is a non-inferior stress agent to Adenosine.
* Indications - pharmacologic stress agent for patients that either cannot tolerate exercise portion entirely or has attempted exercise stress and is unable to reach optimal stress. There is a new suggestion that Lexiscan can be used as a primary agent without the need to fail the exercise portion first.
* Administration - 5mL quick bolus after a saline flush; wait 10 to 20 seconds then give stress radiotracer. All of these injections may go through the same IV access.
* Absolute Contraindications
** Second or third degree AV block or sinus note dysfunction (with the exception of patients that have a working pacemaker)
** Bronchospasm - patients with COPD or asthma should not use this med
** Systolic BP less than 90mmHg
** Dipyridamole use within 48 hrs.
** Aminophylline use within 24 hrs.
** Caffeine use within 12 hrs.
** Any known hypersensitivity to Regadenoson
* Relative Contraindications
** Sinus bradycardia less than 40 beats per minute.
* Advantages over Adenosine
** Reduced chance of error with single bolus dose of 0.4 mg of medication in a 5mL syringe for all patients and does not require a pump infusion.
** Lower side-effect profile
** Less activity in receptors that cause adverse side effects (A2B, A3, A1)
** Less flushing 16% vs 25%
** Less 1st degree block than Adenosine (3% vs 7%)
** Less 2nd degree block (0.1% vs 1%)
* Disadvantages from Adenosine
** Dyspnea - Reputed to cause more dyspnea than Adenosine, especially in patients with COPD but not necessarily an increase in bronchoconstriction.
** Headache - causes more headache than Adenosine (26% vs. 17%)
** Adenosine can be easily cut off by stopping infusion at any time. The half life of Lexiscan is much longer and if there are severe or prolonged side effects, the patient must receive IV Aminophylline to reverse the effects.
* When to give Aminophylline to halt side effects:
** Hypotension with SBP less than 80 BPM
** 2nd degree heart block that does not go away and is symptomatic or 3rd degree heart block.
** Chest pain with >2mm ST depression
** If patient asks to halt the test

### Dobutamine

* Quality of images compared to Adenosine and Dipyridamole are inferior because it does not create as large of a difference in blood flow in ischemic vs normal myocardium. Also, it is not as studied as the more traditional stress agents.
* Mechanism - Beta agonist of the Beta 1 and Beta 2 receptors to create increased chronotropic and inotropic stress on the heart.
* Indications
** For patients that cannot tolerate Adenosine, Regadenoson, or Dipyridamole because of a contraindication.
* Contraindications
** MI within last week.
** Pharmacologic Beta-Blockade
** Aortic dissection or sizeable aortic aneurism
** History of ventricular tachycardia
** Atrial tachyarrhythmias with uncontrolled ventricular response.
** Aortic stenosis that is severe
** Left ventricular outflow obstruction such as Hocm obstruction seen in hypertrophic cardiomyopathy.
** SBP >200 or DBP>110
* Main side effects
** Chest pain - 31%
** Palpitations - 29%
** Headache/flushing - 14% each
* When to terminate infusion and reverse with beta blocker
** Ventricular tachicardia
** Of note: the likelihood of any ST depression is greater with dobutamine.

# MUGA
## Ejection Fraction Monitoring with Doxorubicin

* Adriamycin (Doxorubicin) is a chemotherapeutic agent used in treating various cancers. It has been shown to cause significant impairment of cardiac function. The drug's effect can be measured well by the MUGA scan which is very accurate.
* Heart failure has been shown to develop in some patients at a cumulative dose of >500 mg/m², and the risk increases with even higher doses.
* It is shown that a decrease in EF will precede irreversible heart failure.
* Two factors are important in monitoring these patients, the absolute EF and the change in EF.
** If there is a >10% fall in EF below 50% or
** If there is an absolute EF of 40% or
** If there is a fall of >20% in EF at any time then there is said to be an impact by doxorubicin and the cessation of the medication should be considered based upon the given clinical scenario.

# Attenuation Correction

* There is some controversy about the accuracy of attenuation correction.
* It is commonly done with either a CT attenuation map or by gadolinium-153 source rods.
** ^ PMID 11243976 -- "Stress testing in cardiac evaluation : current concepts with emphasis on the ECG." (Tavel ME. Chest. 2001 Mar;119(3):907-25.)
** ^ PMID 15998671 -- "Exercise testing in asymptomatic adults: a statement for professionals from the American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention." (Lauer M, Froelicher ES, Williams M, Kligfield P. Circulation. 2005 Aug 2;112(5):771-6. Epub 2005 Jul 5.)
** ^ PMID 17174798 -- "Stress protocols and tracers." (Henzlova MJ, Cerqueira MD, Mahmarian JJ, Yao SS; Quality Assurance Committee of the American Society of Nuclear Cardiology. J Nucl Cardiol. 2006 Nov;13(6):e80-90.)
** ^ PMID 19356442 -- "Effects of age, gender, obesity, and diabetes on the efficacy and safety of the selective A2A agonist regadenoson versus adenosine in myocardial perfusion imaging integrated ADVANCE-MPI trial results." (Cerqueira MD, Nguyen P, Staehr P, Underwood SR, Iskandrian AE; ADVANCE-MPI Trial Investigators. JACC Cardiovasc Imaging. 2008 May;1(3):317-20.)
** ^ ISBN 0-323-02946-9 -- "Nuclear Medicine: The Requisites, Third Edition (Requisites in Radiology)." (Harvey A. Ziessman, Janis P. O'Malley MD, James H. Thrall MD. 2006. Mosby, Inc.)
BP - Blood Pressure BPM - Beats Per Minute DPB - Diastolic Blood Pressure EF - Ejection Fraction MI - Myocardial Infarction SBP - Systolic Blood Pressure
Acronyms used:

# Thyroid Ablation
## Indications

* Thyroid cancer - Either localized or metastatic
* Benign disease refractory to conservative treatment and/or causing symptoms or complications

## Procedure

* Calculation of dose
** The dose should be calculated with two different variables: The weight of the gland(in grams), and how much it's 24 hr uptake is (For example, 24% would be 0.24). You can then use the following formula:
** The weight of the gland is a very subjective measurement. One can attempt to approximate the gland weight with the following guidelines:
*** A regular non-palpable thyroid gland weighs approximately 15-20 grams.
*** A thyroid that you cannot see but is palpable weighs approximately 30-40 grams (needs verification)
*** A gland that is easily seen and palpated can be anywhere from 40-200 grams (needs verification)
** ^ ISBN 0-323-02946-9 -- "Nuclear Medicine: The Requisites, Third Edition (Requisites in Radiology)." (Harvey A. Ziessman, Janis P. O'Malley MD, James H. Thrall MD. 2006. Mosby, Inc.)
Acronyms used:

# Vascular/Shunting
## Shunting

* An abnormal communication between arterial and venous circulation.

### Procedure

** ^ "Hepatopulmonary Syndrome: A Prospective Study of Relationships Between Severity of Liver Disease, Pa02 Response to 100% Oxygen, and Brain Uptake After 99mTc MAA Lung Scanning." (Krowka MJ, et al. Chest/118/3/Sept 2000.)
** ^ ISBN 0-323-02946-9 -- "Nuclear Medicine: The Requisites, Third Edition (Requisites in Radiology)." (Harvey A. Ziessman, Janis P. O'Malley MD, James H. Thrall MD. 2006. Mosby, Inc.)
Acronyms used:

# Introduction

Template:Nuclear Medicine/TOC
Nuclear Medicine is a rapidly changing field with new advances being made daily. As a consequence, any textbook becomes out-of-date almost immediately after it is published. Thus, the WikiBook format is ideal for a textbook of nuclear medicine, as updates can be made constantly as new information becomes available.
This textbook is meant to be used by residents, medical students, and practicing physicians in radiation oncology.
At the creation of this textbook, the emphasis is placed on keeping the content up-to-date in terms of publishing the results of major trials. It is not meant to be an encyclopedic work. It is impossible to include the results of all trials relating to radiation oncology. Publishing every little detail of each and every trial would bog down this resource and make it difficult to use. Its main purpose is to be a useful reference for those wishing to gain knowledge about clinical nuclear medicine.
As it is a WikiWork, its purpose may change.
This book is dedicated to the patients who are the inspiration to those of us involved in this field, as well as to the pioneers in medicine, without whom this textbook could not exist.
If you wish to contribute to this wiki, please see the instructions to authors at the following pages:
* a working list of standards
* Talk page.

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# Standards

* Welcome!
* Wikibooks textbooks, including this Nuclear Medicine textbook, are open source works
* The template for the design of this wikibook is drawn from the Radiation Oncology Wikibook. For inspiration or ideas, please visit that site.
* Anyone is welcomed and encouraged to contribute anytime and anything related to Nuclear Medicine :)
* We appreciate both small contributions (correcting typos etc.) as well as larger content contributions
* Feel free to add yourself to the Author List; the more the merrier :)

## General

This list of standards is meant to provide a uniform look and conformity for this book but is not meant to be inflexible or immutable. Please feel free to make suggestions on the talk page about how you think this book could be improved. This is a work in progress.
* Do not plagiarize!!! This includes cutting and pasting an abstract. Abstracts are copyrighted material.
* Keep it simple and easy to read. The fewer details the better.
* Subpages shall use the "/" directory-style hierarchy, e.g. Nuclear Medicine/Prostate.
    All new pages should be made to use the "/" format.
* Cite your sources!
** Use the automatic PMID link to link to articles references in PubMed. Just type the PubMed ID (PMID) like this PMID 11697327 and it will be formatted like this: PMID 11697327. This is recommended because it makes the source code much easier to read than if external links to pubmed were used.
** In addition to PubMed (www.pubmed.org), another very helpful search tool is Google Scholar. In particular, it shows (somewhat comprehensively?) other future papers that have cited the "Googled" paper.
* You are highly encouraged to create your own user account and log in before making any edits. See how to login for information.
* At the top of each page in the book, attach the template for the Table of Contents header -- type {{:Nuclear Medicine:TOC}}. This allows for easy jumping back to the main page and other important pages (such as RTOG studies).
** Certain complex topics that are divided into several pages may have their own sub-Table of Contents for -- e.g. see the subpages of Radiation Oncology/Breast and Radiation Oncology/Prostate.
* It is great to link to the full text version / PDF of an article, but try to do this only if there is free access for everyone and it doesn't require an institutional subscription.
* Ordering of articles within a section: it makes logical sense for the studies to be ordered chronologically (earliest studies listed first), since in general, the results of one study influence the results of subsequent studies.
** An exception is the page listing all RTOG studies, which is in descending order. The reason for that is that it's just more convenient to have the newer studies listed at the top so you don't have to scroll all the way to the bottom to get to the current studies.
* P-values: don't say p<0.000000001. Just say "S.S." or "SS" for statistically significant. If it's not statistically significant, say "N.S." An exception is if there's a trend toward significance, then you can put the p value. On a similar note, there's no need for confidence intervals.

## Editing

* Here is a link to Help:Editing
* To start, click the edit this page button on top of the page
* When done with changes, click the Save Page button underneath
* In general, there are only a few symbols that are used

## Page entry

Try to give the pages a consistent look. If in doubt, look at other pages within the wiki.
As a guide, use the following example:
* Name of study, Date (Date range of study) - PMID 12345 — "Title of publication." Author's name. Publication citation.
e.g.
* INT 0123 / RTOG 94-05, 2002 (1995-99) - PMID 11870157 — "INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy." Minsky BD et al. J Clin Oncol. 2002 Mar 1;20(5):1167-74.
For a study that has several publications stemming from it:
* Name of study (date range)
** 10-year update (2000): PMID 12345 — "Title of publication." Author's name. Publication citation.
*** Results
** 5-year results (1995): PMID 123456 — "Title of publication." Author's name. Publication citation.
*** Results
** Original publication (1993): PMID 1234567 — "Title of publication." Author's name. Publication citation.
*** Results
** Etc.
This Nuclear Medicine/Standards page is the Wikibooks:Local manuals of style for the Nuclear Medicine wikibook.

# Authors

Template:Nuclear Medicine/TOC
Author List
* There is one registered users who have contributed to this wiki textbook as of July 8, 2009
* Those below have chosen to declare their personal information here
* Please feel free to add yourself to the author list, when you contribute
Some Guy, M.D. - Dr.Unclear
    First authorship: July 8, 2009
    Contributions: Original concept. Inspired by Wikibook Radiation Oncology and giving full recognition to their hard work for their excellent book.

# CNS

Central Nervous System

# PET/CT
## For Tumor
### INDICATION

* For the evaluation or diagnosis of tumors of the central nervous system

### PROCEDURE

* Alternate techniques exist. We describe the more common methods.

#### Dimension

* In 2D mode, septa are usually used to collimate using coincidental detection between 2 adjacent detector rings.
* In 3D mode, all the detector rings are used, which does not necessitate septum separation.

#### Static Imaging

* The traditional method of acquisition

#### Dynamic imaging

* A newer, and less used method for detection. Using this approach, there is the potential to measure the metabolic kinetics of a region of interest over time. A time-activity curve can be generated using definable ROIs, which has been used to pre-stage tumors with imaging alone.
* Limitations of this technique includes the (1) highly difficult and technical nature of the technique; (2) somewhat longer time in which the patient needs to keep their head motionless; (3) reliance on arterial input function for metabolic analysis which can be an invasive procedure; (4) lack of compensation for the increased expertise and time needed to acquire and interpret scans; (5) limited outcomes-based research to validate the technique for standard practice.

### INTERPRETATION
## For Cognitive
### INDICATION

* For the evaluation or diagnosis of tumors of the central nervous system

### PROCEDURE
#### Static imaging

* Stuff

### INTERPRETATION

** ^ -- "Society of Nuclear Medicine Procedure Guideline for PDG PET Brain Imaging" (Waxman A.D. Online PDF. Ver 1.0. Feb 9, 2009.

## Acronyms used

ROI - Region of Interest

# Gastrointestinal
## Neonatal Jaundice

* Neonatal jaundice is a difficult problem for many pediatricians. Scintigraphy has been shown to be useful in diagnosis in the pediatric population. Differential diagnosis in this age group can include Biliary atresia (BA) and neonatal hepatitis syndrome (NHS)

## Cholecystitis

References
* ^ PMID 16967250 - "Biliary atresia in infants with prolonged cholestatic jaundice: diagnostic accuracy of hepatobiliary scintigraphy." Esmaili J, Izadyar S, Karegar I, Gholamrezanezhad A. (Abdom Imaging. 2007 Mar-Apr;32(2):243-7. Epub 2006 Sep 12.)
Acronyms used:
* BA - Biliary atresia
* NHS - neonatal hepatitis syndrome

# Vascular
## Mycotic Aneurism

* A mycotic aneurism is an infection of the arterial wall of an aneurism. It can be somewhat confusing but infections can happen in aneurisms or an infection of the artery can cause an aneurism.
^ - PMID 2919901 "In situ prosthetic graft replacement for mycotic aneurysm of the aorta." (Chan FY; Crawford ES; Coselli JS; Safi HJ; Williams TW Jr. Ann Thorac Surg 1989 Feb;47(2):193-203.)