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© 2019 Royal Australasian College of Physicians Background: Peptide receptor radionuclide therapy with 177Lu-DOTATATE is a promising treatment for inoperable or metastatic neuroendocrine tumours (NET). In 2015, the NSW Ministry of Health provided funding for 177Lu-DOTATATE treatment of NET under an evaluation framework. Aims: To examine the safety and outcomes of NET patients treated with 177Lu-DOTATATE under the evaluation framework and assess the statewide implementation of the NSW Lutate therapy referral and protocol for neuroendocrine cancer patients. Methods: A quality of care clinical audit was conducted on all NET patients treated with 177Lu-DOTATATE from October 2010 to October 2015 at St George Hospital, and from August 2013 to March 2017 at Royal North Shore Hospital. Percentage of patients who met protocol selection criteria was calculated. Survival was estimated using the Kaplan–Meier method. Adjusted regression analyses assessed associations between key clinical factors and outcomes. Results: A total of 279 patients was treated. Statewide protocol implementation led to an increase from 60.5 to 83.8% in patients meeting selection criteria. Estimated median overall survival was significantly longer for patients who met selection criteria compared with those who did not (50.7 vs 34.2 months) (P = 0.018). This was driven by the significantly worse overall survival in patients who failed exclusion criteria (P < 0.001). 177Lu-DOTATATE was well tolerated with haematological, renal and hepatic treatment-related serious adverse events experienced by 9.7, 0.4 and 0.4% of patients respectively. Conclusions: 177Lu-DOTATATE is a promising treatment for advanced NET. Superior survival in patients who met selection criteria emphasise the importance of protocol adherence.

Objectives Little data exist on the utility of fluorodeoxyglucose positron emission tomography (FDG-PET) in operable pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant (NA) therapy. Methods Consecutively treated patients with potentially operable PDAC were recruited from a quaternary referral center between 2015 and 2018. Data were collated on demographic, clinical, radiological, treatment, and disease-free and overall survival (OS) outcome measures, correlated with FDG-PET findings. Results Of 115 patients recruited, 61% were deemed upfront operable (n = 70), 33% borderline (n = 38), and 6% (n = 7) locally advanced. Ninety-five (83%) received NA chemotherapy with 23 (24%) sequential radiotherapy. Sixty-nine (73%) treated with NA were resected, 37 (54%) attained an R0 resection, 43 (62%) had N1 disease with median tumor viability of 50%. The median OS in the entire cohort was 30.48 months and in those who received NA chemotherapy followed by resection 37.98 months. Twelve percent (n = 13) were upstaged during NA therapy by PET. Preoperative standardized uptake value maximum of less than 5 versus 5 or greater after NA predicted for improved OS, 42.95 months versus 26.05 months, P = 0.02. Conclusions In this real-world cohort study of PDAC, the utility of FDG-PET in informing the patient treatment pathway was meaningfully demonstrated.

A child’s life begins at conception and from the moment of realisation that they are pregnant, the parental journey begins. Most routine antenatal care programmes include an offer of screening for foetal abnormalities, which may be screening from biological sampling or from ultrasound imaging or a combination. For some parents, the identification of a potentially life-limiting or life-threatening condition can present extremely challenging decision-making about continuing with the pregnancy or considering termination.

Background Some midwives experience work-related psychological distress. This can reduce the quality and safety of maternity services, yet there are few interventions to support midwives. Aim To explore and voice the perceptions of new mothers in relation to the barriers to receiving high-quality maternity care, the psychological wellbeing of midwives and the development and evaluation of an online intervention designed to support them. GRIPP2 reporting checklists were also used to demonstrate how patient and public involvement works in research. Methods A co-design approach was used in a discussion group to collect qualitative data from 10 participants. A framework approach was used for analysis. Findings Unique findings included midwives crying, becoming emotional and seeking support from service users. Overall, seven patient and public involvement outcomes relating to intervention development and data collection were identified. Conclusion Maternity service improvement strategies may only be wholly effective once they include the provision of effective midwifery workplace support.

AIM Positron emission tomography/computed tomography (PET/CT) can detect cranial and large vessel inflammation in giant cell arteritis (GCA). We aimed to determine the change and significance of vascular activity at diagnosis and 6 months. METHOD Newly diagnosed GCA patients underwent time-of-flight fluorine-18-fluoro-2-deoxyglucose PET/CT from vertex to diaphragm within 72 hours of commencing corticosteroids and were followed for 12 months. A 6 months scan was performed in patients with inflammatory features on biopsy or CT aortitis. Vascular uptake was visually graded by 2 blinded readers across 18 artery segments from 0 (no increased uptake) to 3 (very marked uptake). Scores were summed to give a total vascular score (TVS). RESULTS We enrolled 21 GCA patients and 15 underwent the serial scan. Twelve (57%) patients experienced a relapse and 5 of these had ischemic features of vision disturbance, jaw or limb claudication. The median TVS fell from 14 (interquartile range [IQR] 4-24) at baseline to 5 (IQR 0-10) at 6 months (P < .01) with reduction in both cranial and large artery scores. While the overall relapse rate was similar between patients with a high (≥10) and low baseline TVS, patients with high scores were numerically more likely to experience an ischemic relapse (33% vs 11%, P = .34). Five out of 15 patients had persistent uptake in at least 1 vessel on the serial PET/CT but none experienced a subsequent relapse. CONCLUSION Vascular activity decreased in cranial and large arteries between diagnosis and 6 months. Persistent activity did not predict subsequent relapse.

Background: Health mobile applications (apps) have become very popular, including apps specifically designed to support women during the ante- and post-natal periods. However, there is currently limited evidence for the effectiveness of such apps at improving pregnancy and parenting outcomes. This study aims to assess the effectiveness of a pregnancy and parenting app, Baby Buddy, in improving maternal self-efficacy at 3 months post-birth. Methods: Participants were 16 years old or over, first-time mothers, 12–16 weeks gestation, recruited by midwives from five English study sites. The Tool to Measure Parenting Self-Efficacy (TOPSE) (primary outcome) was used to compare mothers at 3 months post-birth who had downloaded the Baby Buddy app with those who had not downloaded the app, controlling for confounding factors. Results: Four hundred and eighty-eight participants provided valid data at baseline (12–16 weeks gestation), 296 participants provided valid data at 3 months post-birth, 114 (38.5%) of whom reported that they had used the Baby Buddy app. Baby Buddy app users were more likely to use pregnancy or parenting apps (80.7% vs . 69.6%, P=0.035), more likely to have been introduced to the app by a healthcare professional (P=0.005) and have a lower median score for perceived social support (81 vs . 83, P=0.034) than non-app users. The Baby Buddy app did not elicit a statistically significant change in TOPSE scores from baseline to 3 months post-birth [adjusted odds ratio (OR) 1.12, 95% confidence interval (CI): 0.59 to 2.13, P=0.730]. Finding out about the Baby Buddy app from a healthcare professional appeared to grant no additional benefit to app users compared to all other participants in terms of self-efficacy at 3 months post-birth (adjusted OR 1.16, 95% CI: 0.60 to 2.23, P=0.666). There were no statistically significant differences in the TOPSE scores for the in-app data, in terms of passive use of the app between high and low app users (adjusted OR 0.82, 95% CI: 0.21 to 3.12, P=0.766), nor in terms of active use (adjusted OR 0.47, 95% CI: 0.12 to 1.86, P=0.283). Conclusions: This study is one of few, to date, that has investigated the effectiveness of a pregnancy and early parenthood app. No evidence for the effectiveness of the Baby Buddy app was found. New technologies can enhance traditional healthcare services and empower users to take more control over their healthcare but app effectiveness needs to be assessed. Further work is needed to consider: (I) how we can best use this new technology to deliver better health outcomes for health service users and, (II) methodological issues of evaluating digital health interventions.

Objective Pregnant women and unborn babies are at increased risk of complications from influenza, including pneumonia, yet in the UK, uptake of flu vaccination amongst this population remains Methods The intervention was developed by behavioural scientists, pregnant women, midwives, clinicians and Public Health professionals, informed by Intervention Mapping. Six predefined steps were performed in line with Intervention Mapping. Results The intervention is an animation addressing beliefs about risks of flu and efficacy of vaccination. Preliminary testing using qualitative methodology indicates the information within the animation is appropriate, and the animation is acceptable to pregnant women. Conclusions This is the first known intervention for pregnant women, aiming to increase flu vaccination through addressing risk and efficacy appraisals. It has been implemented within seasonal flu vaccination campaigns during 2018/19 and 2019/20 within one geographically and ethnically diverse area of the UK.

Objective Positron emission tomography/computed tomography (PET/CT) has not been well studied as a first-line test for giant cell arteritis (GCA), due, in part, to historical limitations in visualizing the cranial arteries. The Giant Cell Arteritis and PET Scan (GAPS) study was therefore carried out to assess the accuracy of a newer generation PET/CT of the head, neck, and chest for determining a diagnosis of GCA. Methods In the GAPS study cohort, 64 patients with newly suspected GCA underwent time-of-flight PET/CT (1-mm slice thickness from the vertex to diaphragm) within 72 hours of starting glucocorticoids and before undergoing temporal artery biopsy (TAB). Two physicians with experience in PET reviewed the patients' scans in a blinded manner and reported the scans as globally positive or negative for GCA. Tracer uptake was graded across 18 artery segments. The clinical diagnosis was confirmed at 6 months' follow-up. Results In total, 58 of 64 patients underwent TAB, and 12 (21%) of the biopsies were considered positive for GCA. Twenty-one patients had a clinical diagnosis of GCA. Compared to TAB, the sensitivity of PET/CT for a diagnosis of GCA was 92% (95% confidence interval [95% CI] 62-100%) and specificity was 85% (95% CI 71-94%). The negative predictive value (NPV) was 98% (95% CI 87-100%). Compared to clinical diagnosis, PET/CT had a sensitivity of 71% (95% CI 48-89%) and specificity of 91% (95% CI 78-97%). Interobserver reliability was moderate (κ = 0.65). Among the enrolled patients, 20% had a clinically relevant incidental finding, including 7 with an infection and 5 with a malignancy. Furthermore, 5 (42%) of 12 TAB-positive GCA patients had moderate or marked aortitis. Conclusion The high diagnostic accuracy of this PET/CT protocol would support its use as a first-line test for GCA. The NPV of 98% indicates the particular utility of this test in ruling out the condition in patients considered to be at lower risk of GCA. PET/CT had benefit over TAB in detecting vasculitis mimics and aortitis.

Background Information and communication technologies are used increasingly to facilitate social networks and support women during the perinatal period. This paper presents data on how technology use affects the association between women’s social support and, (i) mental wellbeing and, (ii) self-efficacy in the antenatal period. Methods Data were collected as part of an ongoing study - the BaBBLeS study - exploring the effect of a pregnancy and maternity software application (app) on maternal wellbeing and self-efficacy. Between September 2016 and February 2017, we aimed to recruit first-time pregnant women at 12–16 gestation weeks in five maternity sites across England and asked them to complete questionnaires. Outcomes included maternal mental wellbeing (Warwick-Edinburgh Mental Wellbeing Scale), and antenatal self-efficacy (antenatal version of the Tool to Measure Parenting Self-Efficacy). Other variables assessed were perceived social support (Multidimensional Scale of Perceived Social Support), general technology use (adapted from Media and Technology Usage and Attitudes Scale). Potential confounders were age, ethnicity, education, socioeconomic deprivation, employment, relationship status and recruitment site. Linear regression models were developed to analyse the relationship between social support and the outcomes. Results Participants (n = 492, median age = 28 years) were predominantly white British (64.6%). Half of them had a degree or higher degree (49.3%), most were married/living with a partner (83.6%) and employed (86.2%). Median (LQ-UQ) overall scores were 81.0 (74.0–84.0) for social support (range 12–84), 5.1 (4.7–5.4) for technology use (range 1–6), 54.0 (48.0–60.0) for mental well-being (range 14–70), and 319.0 (295.5–340) for self-efficacy (range 0–360). Social support was significantly associated with antenatal mental well-being adjusting for confounders [adj R2 = 0.13, p

Nuclear medicine technologists are specialized health professionals who cover a wide range of tasks from clinical routine (including image acquisition and processing, radiopharmaceutical dispensing and administration, patient care, and radioprotection tasks) to leading clinical research in the field of nuclear medicine. As a fundamental concern in all radiation sciences applied to medicine, protection of individuals against the harmful effects of ionizing radiation must be constantly revised and applied by the professionals involved in medical exposures. The acknowledgment that nuclear medicine technologists play a prominent role in patient management and several procedural steps, both in diagnostic and in therapeutic nuclear medicine applications, carries the duty to be trained and knowledgeable on the topic of radiation protection and dose optimization. An overview on selected topics related to dose optimization is presented in this article, reflecting the similarities and particularities of dose reduction-related principles, initiatives, and practicalities from a global perspective.

Mycosis fungoides is the most ubiquitous form of cutaneous T-cell lymphoma. Diagnosis is arduous, as early phases often resemble common inflammatory dermatoses. The principal histologic features of MF include medium to large-sized cerebriform mononuclear cells in single or small clusters in the epidermis. Treatment modalities are prodigious and relapses are common. The authors present a case of a 69-year-old man with mycosis fungoides, followed by a review of diagnostic modalities and phototherapeutic interventions for patients with this condition. According to literature reports, monochromatic excimer light therapy is the most advantageous and well-tolerated phototherapy modality for patients with early patch stage mycosis fungoides.

Background: cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. Methods: we conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. Results: we analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12–4.02; PConclusions: a significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations.

Objective: To determine whether timing of deinfibulation influences obstetric outcomes for women with type 3 female genital mutilation (FGM). Design: A retrospective observational study comprising 94 women with type 3 FGM who gave birth from 2008–2012. Method: Outcomes described in maternity notes of women with deinfibulation performed prior to labour (n=62) compared with ‘not deinfibulated before labour’ (n=32). Secondary analysis was then performed excluding women who had caesarean sections. Findings: Women who were ‘not deinfibulated before labour’ had a significantly greater risk of episiotomy (RR 1.67, P2 days (RR 1.33, PConclusion: Type 3 FGM is associated with morbidity in childbirth. When deinfibulation is deferred until labour the risk of morbidity increases.

Background: The incidence of secondary upper limb lymphedema after treatment for breast cancer is unclear due to the wide variety of measurement tools and diagnostic thresholds that are used in both the literature and clinical practice. Furthermore, this lack of clarity in what constitutes lymphedema or not has prevented the progression of the field of lymphedema. Many of the thresholds have been chosen for ease of use only and have no evidence base to support them. The aim of this study, therefore, was to determine which clinical diagnostic threshold for unilateral upper limb lymphedema has the best sensitivity and specificity when compared to diagnosis by lymphoscintigraphy. Methods: Women with and without a history of secondary upper limb lymphedema were assessed using lymphoscintigraphy, bioimpedance spectroscopy (BIS) as well as volume and circumference measurements using the perometer. Dermal backflow score was determined as the diagnostic criteria for the lymphoscintigraphy and was assessed by an experienced nuclear medicine physician. Determination of the presence of lymphedema by lymphoscintigraphy was compared with diagnosis by both commonly-used and normatively-determined diagnostic thresholds for circumference, volume and bioimpedance. Normatively-and commonly-used diagnostic thresholds examinedWhole arm volumeCircumferenceWhole arm BISNormatively-determined thresholds examined3SD perometry threshold*Single elevated circ (3SD threshold)*3SD Cornish, 20012SD perometry threshold*Adjacent raised circ (3SD threshold)*2SD Cornish, 20013SD frustrum threshold*Single raised threshold (2 SD)*3SD, Ward 20112SD frustum threshold*Adjacent raised circ (2SD threshold)*2SD, Ward 2011 3SD SOAC* 2SD SOAC* Commonly-used thresholds examined200 ml interlimb difference2 cm single interlimb difference 10% differenceAdjacent 2 cm interlimb difference 5 cm SOAC * Dylke et al, 2012; Sum of arm circumferences (SOAC); Circumference measure (Circ) Results: For those with widespread dermal backflow, any clinical diagnostic criteria could differentiate between those with and without lymphedema. In contrast, for those with mild to moderate dermal backflow, only the normatively-determined threshold, set at 2 standard deviations above the norm, for arm circumference and full arm bioimpedance (Cornish et al 2001) had adequate sensitivity and specificity. Both of these thresholds had clinically relevant positive (23 and 10 respectively) and negative (0.2 and 0.3) likelihood ratios. Conclusion: Evidence-based diagnostic thresholds have been established for the diagnosis of secondary upper limb lymphedema. In determining if lymphoedema is present in those with mild lymphedema, normatively-determined circumference and bioimpedance thresholds that account for limb dominance should be used. Adoption of these evidence-based criteria will allow, for the first time, comparison between studies, clarifying the incidence and risk factors for lymphedema, allowing the field to make meaningful progress forward in determining who is at-risk for lymphedema and how to prevent it from developing. Acknowledgements: Cancer Australia and National Breast Cancer Foundation. Citation Format: Sharon L Kilbreath, Elizabeth S Dylke, Geoff P Schembri, Leigh C Ward, Dale L Bailey, Deborah Black, Elizabeth A Bailey, Jane M Beith, Kathryn M Refshauge. Determination of the first evidence-based diagnosis of secondary upper limb lymphedema [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-09.

Pre-capillary pulmonary hypertension (PHT) is characterised by progressive pulmonary vascular obliteration and loss of vascular reserves. In health, regional lung perfusion redistributes under the influence of gravity due to the presence of recruitable vessels. We investigated a combined single photon emission computed tomography/CT (SPECT/CT) method for assessing the pulmonary circulation by quantifying the gravity dependent redistribution of lung perfusion.Characterisation of patients versus healthy controls.15 patients with pre-capillary PHT and 11 healthy controls.University hospital clinic.Regional lung perfusion was measured using SPECT/CT in two different postures (supine vs upright). A perfusion redistribution index (PRI) was used to quantify the cranial-caudal shift in regional lung perfusion resulting from gravitational (postural) change.PRI was compared between cases and controls, and correlated with markers of disease severity in cases.Patients with pre-capillary PHT had notably reduced PRI compared to controls (0.02±0.06 vs. 0.28±0.15 normalised perfusion/cm, p0.0001). PRI was significantly associated with prognostic parameters such as 6 min walk distance (r=0.60, p=0.018), functional class (p=0.008), and tricuspid annular plane systolic excursion (r=0.58, p=0.022). The receiver operating characteristic curve showed that PRI differentiated patients with pre-capillary PHT from controls with AUC=0.94 (p0.001).With SPECT/CT, gravity dependent redistribution of lung perfusion can be quantified using the PRI derived from supine and upright perfusion analysis. The potential utility of PRI for the non-invasive detection of PHT and assessment of disease severity warrants further study.

Rationale and Objectives Lymphoscintigraphy may be used for diagnosing secondary lymphedema. Dermal backflow, the presence of radiotracer in dermal lymphatics, is a key clinical feature. Although often reported as present or absent, a scale that assesses the severity of dermal backflow has been previously developed. The aim of this study was to determine the reliability of these two methods of assessment. Materials and Methods Sixteen experienced nuclear medicine physicians assessed the quantity of dermal backflow of 57 lymphoscintigraphy scans using a 4-point descriptive scale that was dichotomized for secondary analysis. Each scan included images from four time points for women previously diagnosed with secondary lymphedema (n = 47) and controls (n = 5); five scans were presented twice to examine intraobserver reliability. This was further investigated as 13 physicians viewed the scans again on an Apple iPad2. The physicians rated their confidence in their scoring. Readers were blinded to clinical history. Results Although both the 2- and 4-point scale had moderate interobserver reliability, the reliability of the 2-point scale was slightly higher (4-point: Fleiss κ = .418, standard error [SE] = .008); 2-point: Fleiss κ = .574, SE = .013). Low interobserver reliability was found when only control subjects were considered (Fleiss κ = 0.055, SE = 0.034). Intraobserver reliability of the five repeated images varied from poor to perfect (Cohen κ = .063 to 1.00), whereas moderate to substantial intraobserver reliability (Cohen's κ = .342 to .752) was found when comparing devices. The readers were highly confident of their scores. Conclusions Overall, moderate intraobserver and interobserver reliability was found for quantifying dermal backflow with both the 2- and 4-point scale.

The Issue We needed cost effective in-house communication skills education to suit all levels of staff and volunteers to ensure they had the knowledge, skills and confidence to communicate effectively with patients, their families and with each other. Why it is important All of our staff and volunteers will at some time be supporting people in distress. Clinical staff often have ‘big’ conversations with their patients – breaking bad news etc. They can only do this if they have the right communication skills and the confidence to use them. What was done We developed a three- tier programme of interactive communication skills workshops called CLEARER. Communication CARE A two-hour workshop at an introductory level to develop basic skills for communicating compassionately and sensitively with others. CLEAR A four-hour workshop at a foundation level to develop skills to hold clear, sensitive and honest conversations about care options, explore patient experiences, needs, priorities and choices. CLEAREST A full day workshop at an intermediate level aimed at qualified clinical staff that develops skills reflecting, analysing and applying communication strategies to ensure effective compassionate conversations in challenging circumstances. Workshops have been delivered regularly since 2013. Evaluation Participants completed post workshop evaluations and were observed in practice using their skills. Outcomes Staff reported increased confidence in having ‘big’ conversations and supporting people in distress. Feedback form patients and their families indicates staff and volunteers do communicate effectively and compassionately. Future The demand for workshops from outside the hospice exceeded the capacity to provide them. To address this issue we have worked with our Clinical Commissioning Groups (CCGs) who were looking to provide communication skills education to people working in health and social care. The CCGs are adopting our CLEARER Communication Programme and supporting the training of facilitators to deliver the workshops.

The issue The need for high-quality, flexible, cost effective communication skills education for all groups of staff and all levels of experience was identified by the Clinical Commissioning Groups (CCGs) in our locality. In our hospice we deliver our own communication skills education programme (CLEARER Communication) with three levels of workshops – CARE, CLEAR and CLEAREST. These are very well evaluated and fitted the identified need. However, there was not enough capacity to meet the demand. Why it is important We can provide excellent care when staff have knowledge, skills and confidence to communicate effectively and compassionately with patients, their families and each other. Education at the right level to achieve this must be readily accessible. What is being done Working with the CCGs, we identified 10 workshop facilitators from partner organisations and planned their training. We successfully bid for funding from the Multi-Professional Education and Training (MPET) budget held by the CCGs to train facilitators, fund administrative support and deliver the workshops. The new facilitators will also build confidence by co-facilitating the CARE, CLEAR and CLEAREST workshops with the programme lead. Then they will each deliver all three workshops each quarter. Evaluation will be via pre and post course questionnaires, evaluation forms and impact assessments. Expected outcomes Workshop places will increase from 100 per year to 2000. We expect to see an increase in knowledge, skill and confidence of participants. Ways of assessing impact on patient care are under development. Consistency and quality will be monitored by the programme lead. Sustainability MPET Funding will allow the programme to be delivered free to staff of partner organisations until end 2018. Charging staff from other organisations will provide an income stream to support ongoing provision.

The regional pattern and extent of airway closure measured by three-dimensional ventilation imaging may relate to airway hyperresponsiveness (AHR) and peripheral airways disease in asthmatic subjects. We hypothesized that asthmatic airways are predisposed to closure during bronchoconstriction in the presence of ventilation heterogeneity and AHR. Fourteen asthmatic subjects (6 women) underwent combined ventilation single photon emission computed tomography/computed tomography scans before and after methacholine challenge. Regional airway closure was determined by complete loss of ventilation following methacholine challenge. Peripheral airway disease was measured by multiple-breath nitrogen washout from which Scond (index of peripheral conductive airway abnormality) was derived. Relationships between airway closure and lung function were examined by multiple-linear regression. Forced expiratory volume in 1 s was 87.5 ± 15.8% predicted, and seven subjects had AHR. Methacholine challenge decreased forced expiratory volume in 1 s by 23 ± 5% and increased nonventilated volume from 16 ± 4 to 29 ± 13% of computed tomography lung volume. The increase in airway closure measured by nonventilated volume correlated independently with both Scond (partial R2 = 0.22) and with AHR (partial R2 = 0.38). The extent of airway closure induced by methacholine inhalation in asthmatic subjects is greater with increasing peripheral airways disease, as measured by ventilation heterogeneity, and with worse AHR.

AIM A voluntary audit was undertaken to compare left ventricular ejection fraction (LVEF) calculations from gated heart pool studies using software packages currently available throughout Australia and New Zealand (ANZ). METHODS A data set previously developed by a task group of the Institute of Physics and Engineering in Medicine (IPEM) consisting of 12 planar gated studies with LVEF ranging from 17 to 67% was provided to each site with worksheets to record individual technologist's results as well as information about individual department's equipment, software used for calculation of LVEF and experience of the analysers. Data analysis included calculation of an overall mean LVEF and standard deviation (SD) for all patients, which were compared with the mean IPEM LVEF. A comparison among software packages was done to examine differences in mean LVEF. RESULTS Results were received from a total of 22 sites using six different software packages, with 187 processed studies included for analysis. Reproducibility of studies 4 and 8 showed good agreement, with an SD of 1.0 EF units (P=0.5290). Good correlation was found between the ANZ mean LVEF and the corresponding IPEM value per patient study, with R=0.98. The ANZ overall mean LVEF was 47%, which was higher that the IPEM mean by 4.9 EF units. The average difference among all software packages was +5.1 EF units. CONCLUSION Differences were found between the IPEM mean and the ANZ mean LVEF. Variability in LVEF values between software packages was demonstrated, with an average of 5.1 EF units. The ANZ overall mean for LVEF was 47.2%, being 4.9 EF units higher than the IPEM value.

The objective of the study is to retrospectively measure patient radiation dose resulting from whole body X-ray CT and FDG PET studies using a low-dose protocol performed on the Siemens Biograph mCT scanner. A total of 483 patient studies were reviewed. For each, the CT dose-length product was used to estimate radiation dose to the patient as a result of the whole body X-ray CT component of the PET/CT study. The net injected FDG dose was used to calculate the whole body effective dose based on ICRP recommendations. Dose calculations were also modified to take into account individual patient weight. The total effective dose received by each patient was taken as the sum of the PET and CT components of the study. The mean effective dose from the CT component of the diagnostic study was found to be 8.2 mSv (3.4-23.4 mSv), for a CT protocol of 120 kV(p) and effective tube current-time product of 80 mAs with automatic exposure control. For an average injected FDG activity of 304 MBq the mean PET effective dose was found to be 6.3 mSv when using the ICRP standard models, or 6.0 mSv when scaling effective dose to individual patient weight or patient blood volume. The average total effective dose across the entire patient cohort for a combined PET/CT study was found to be ~14.5 mSv (9.6-29.8 mSv). Low-dose protocols for whole-body PET/CT scanning result in an effective radiation dose to the patient of approximately 14.5 mSv. Additional reductions through the use of iterative CT reconstruction and optimized low-dose FDG protocols could see total effective doses for whole-body PET/CT fall to below 10 mSv.

Combining the functional data provided by single-photon emission computed tomography (SPECT) with the anatomical information provided by CT has been shown to improve overall diagnostic accuracy in many areas of nuclear medicine. Although planar lung scans have often relied on correlation with a chest x-ray to help optimize scan interpretation, the advent of 3D lung imaging with SPECT provides the opportunity to combine lung perfusion data with CT images. This can be done by performing the study on a hybrid SPECT/CT scanner, with the CT acquisition typically performed with the use of low-dose parameters, rather than full diagnostic quality settings, or by software fusion with a fully diagnostic CT or a contrast-enhanced CT pulmonary angiogram. Such an approach has been shown to improve specificity and overall accuracy of ventilation/perfusion scintigraphy as well as facilitating more accurate clot localization. With the increased availability of hybrid SPECT/CT scanners, such an approach can be implemented in most imaging departments with little additional acquisition time or radiation dose. Misregistration caused by respiratory motion can impact combined studies, although this can be minimized with attention to patient breathing patterns during image acquisition. For patients with lung cancer, ventilation/perfusion SPECT/CT may have a role in allowing the optimal selection of radiotherapy fields and can improve the preoperative quantification of lung function before resection.

In this article we review protocols for ventilation-perfusion (V/Q) imaging with current generation technology. Although many groups have expressed interest in moving from planar lung V/Q imaging to single-photon emission computed tomography (SPECT) methods, few resources or guidelines exist for suggested protocols. Here, we provide an introduction to help establish protocols for planar and SPECT V/Q imaging and display that should be readily transferable into a clinical department's routine practice. We emphasize, in particular, the need for a good ventilation study and that acquiring planar images as well as SPECT can be negated by producing acceptable planar-like images from the SPECT data.

Background: We have previously developed and validated a method to achieve quantitative SPECT data based on CT-derived corrections, for the radionuclide 99m Tc in phantoms and in man for lung scanning. This clinical study was performed to investigate the accuracy of this method when applied to cardiac blood pool imaging. The study involves tagging the radionuclide 99m Tc to erythrocytes in a sample of the subject’s blood before it is re-injected. After a short time, the radiolabelled cells achieve an equilibrium concentration in the blood pool, such that SPECT imaging allows the radioactivity concentration of blood present in the left ventricle to be measured. Methods and results: Absolute concentration of radioactivity inside the left ventricle of the heart was compared to true concentrations measured directly from a peripheral venous blood sample taken from the subject at the time of scanning. In 12 subjects, the average difference between the measured and true concentrations was found to be within ∼1% of the true value with a range of (-6 to +5)%. Conclusions: This study demonstrates the accuracy of CT-based quantitative SPECT in clinical cardiac blood pool imaging, and we anticipate that similar accuracy could be achieved in the myocardium.

BACKGROUND: While there was initial disregard and argument that exposure to pain, stress and discomfort experienced by NICU babies is an inevitable and an inherent consequence related to the sickness, research has shown its long lasting consequences with alterations in brain structure, function and poor neurodevelopmental outcomes. However there is a lack of measurement systems and metrics to identify the magnitude of the problem, describe patterns and follow …

Traditional palliative care services have focused on individuals with cancer. The NHS National End of Life Care Programme, launched in December 2003, has been working to address this anomaly and to try to enhance end of life care provision for other patient groups. This article reports on work in the area of renal failure at Westmorland General Hospital, Cumbria, where the Preferred Priorities for Care tool has been introduced to support patients nearing the end of life.

Brain metastases (BM) are among the most devastating and debilitating complications of melanoma. This retrospective study was conducted to gain a better understanding of patient and disease characteristics that have the greatest impact on overall survival in melanoma patients with BM; therapeutic interventions were also assessed. The records of all patients diagnosed with cutaneous melanoma and BM who were seen at Memorial Sloan-Kettering Cancer Center between 1991 and 2001 were retrospectively reviewed. A variety of factors, including age at diagnosis of stage IV disease, gender, race, disease stage at diagnosis, presence of BM at diagnosis of stage IV disease, neurologic symptoms, radiographic findings, number of BM, status and site(s) of extracranial metastasis, and treatment modalities, were analyzed for correlation with overall survival using univariate and multivariate Cox regression models. The records of 355 patients with BM were included in the analysis. On univariate analysis, seven patient and disease characteristics were significantly associated with poorer survival: age > 65 years, extracranial metastases, BM at stage IV diagnosis, neurologic symptoms, four or more BM, hydrocephalus, and leptomeningeal metastases. Of these, age, extracranial metastasis, neurologic symptoms, and number of BM were significantly associated with poorer survival in a multivariate analysis. Multivariate analysis of treatment modalities suggested that patients who had surgery, radiosurgery, or chemotherapy with temozolomide had improved survival outcomes, although this analysis has limitations. The prognostic factors identified in this retrospective study should be considered when making treatment decisions for patients with BM and used as stratification factors in future clinical trials.

Purpose Lung scintigraphy using single photon emission computed tomography (SPECT) allows accurate regional measurement of the ventilation/perfusion (V/Q) relationship. Objective V/Q analysis has been shown to be useful in the diagnosis of pulmonary embolism (PE). By using anatomical information provided by co-registered computed tomography, we describe methodology for determining the extent of V/Q heterogeneity at a lobar level. We investigate this methodology using simulated data, and demonstrate its potential application in the clinical setting of PE. Methods Data representing an incremental perfusion defect involving the right lung, together with an unaffected ventilation dataset, were modelled using Monte Carlo simulation. For each increase in the size of the perfusion defect, the whole lung V/Q relationship was objectively determined. In addition, using an image mask of the pulmonary lobes, lobar V/Q relationships were also determined. V/Q heterogeneity was characterized using the log(10) standard deviation of the V/Q ratio (log SDVQR), ventilation (log SDV) and perfusion (log SDQ) distributions. Finally, this methodology was explored in clinical cases. Results As an increasing number of segments were involved by perfusion defects, there was a progressive increase in all objective parameters of V/Q heterogeneity. The relative change was greatest for log SDV. Analysis of both the simulated and clinical studies demonstrated sensitive changes in the lobar V/Q profiles to the presence of PE. Conclusions Segmentation and analysis of SPECT ventilation-perfusion scintigraphy at a lobar level can be used to quantify regional V/Q relationships. This objective methodology is sensitive to the presence of PE, and may be useful in a clinical setting.

Ventilation-perfusion scintigraphy is highly sensitive for pulmonary embolism (PE), but its clinical usefulness is limited by its nondiagnostic rate. Objective analysis of single photon emission computed tomography (SPECT) three-dimensional scintigraphy may improve its diagnostic performance compared with subjective interpretation.To determine the diagnostic accuracy of objective SPECT analysis in PE.We determined the ventilation/perfusion (V(.)/Q(.)) relationship using SPECT scintigraphy in a retrospective cohort of 73 patients. Measures of V(.)/Q(.) heterogeneity (logSD(Q(.)), logSD(V(.)), logSD(VQR)), including a novel parameter, the weighted median V(.)/Q(.) value, were calculated. Using receiver operating characteristic (ROC) analysis, each parameter's diagnostic accuracy was determined. The weighted median V(.)/Q(.) value was then assessed prospectively in a second cohort of 50 patients.In cohort 1, all parameters of V(.)/Q(.) heterogeneity were higher in patients with PE (p0.002). The weighted median V(.)/Q(.) had the highest area under the ROC curve (0.93; 95% confidence interval, 0.87-0.98). When applied to the prospective cohort, the area under the ROC curve was 0.87 (95% confidence interval, 0.75-0.99), with diagnostic cutoff values having negative and positive predictive values of 96 and 83%, respectively. In the retrospective and prospective cohorts, 82 and 73% of initially reported intermediate or low probability scans had diagnostic weighted median V(.)/Q(.) values, with 90 and 100% accuracy, respectively.Objective analysis of SPECT scintigraphy has a high diagnostic accuracy in patients with suspected PE. Objective analysis has the potential to reduce the number of nondiagnostic scan results, and may be useful for quantifying V(.)/Q(.) mismatch in other pulmonary disorders.

Background: Precapillary pulmonary hypertension (PrecapPH), characterised by obliteration of the pulmonary arteries, alters ventilation (V)-perfusion (Q) relationships. Limited studies have explored the non-invasive quantification of VQ heterogeneity using single photon emission computed tomography (SPECT) in PrecapPH. Objective: We measured and compared SPECT-derived VQ heterogeneity in health and PrecapPH . The influence of posture on cranial-caudal V and Q gradients were also assessed. Methods: Regional V and Q were quantified in supine and upright positions in: 1. Healthy controls (n = 13), 2. Pulmonary arterial hypertension (PAH) (n = 10) and 3. Chronic thromboembolic pulmonary hypertension (CTEPH) (n = 8). Measures of VQ heterogeneity (log SD Q, log SD V) were derived from normalized VQ counts at each voxel. The influence of posture on cranial-caudal V and Q gradients were measured. Results: The distributions of log SD Q for controls, PAH and CTEPH were (0.16±0.03, 0.22±0.03, 0.26±0.06: p SD V (0.17±0.03, 0.21±0.06, 0.31±0.15: p Conclusion: Wider heterogeneity in ventilation and perfusion in CTEPH is due to non-homogenous obstruction of pulmonary vascular bed. Quantification of VQ heterogeneity using SPECT can provide insights into the pathophysiological sequalae pulmonary vascular obstruction.

OBJECTIVES In lung cancer preoperative evaluation, functional lung imaging is commonly used to assess lobar function. Computed tomography ventilation (CT-V) imaging is an emerging lung function imaging modality. We compared CT-V imaging assessment of lobar function and its prediction of postoperative lung function to that achieved by (i) positron emission tomography ventilation (PET-V) imaging and (ii) the standard anatomical segment counting (ASC) method. We hypothesized (i) that CT-V and PET-V have similar relative lobar function and (ii) that functional imaging and anatomic assessment (ASC) yield different predicted postoperative (ppo) lung function and therefore could change clinical management. METHODS In this proof-of-concept study, 11 patients were subjected to pulmonary function tests, CT-V and PET-V imaging. The Bland-Altman plot, Pearson's correlation and linear regression analysis were used to assess the agreement between the CT-V-, PET-V- and ASC-based quantification of lobar function and in the ppo lung function. RESULTS CT-V and PET-V imaging demonstrated strong correlations in quantifying relative lobar function (r = 0.96; P < 0.001). A Wilcoxon-signed rank test showed no significant difference in the lobar function estimates between the two imaging modalities (P = 0.83). The Bland-Altman plot also showed no significant differences. The correlation between ASC-based lobar function estimates with ventilation imaging was low, r < 0.45; however, the predictions of postoperative lung function correlated strongly between all three methods. CONCLUSIONS The assessment of lobar function from CT-V imaging correlated strongly with PET-V imaging, but had low correlations with ASC. CT-V imaging may be a useful alternative method in preoperative evaluation for lung cancer patients.

Smallholdings in the rural areas of northwest Syria are a result of land fragmentation that is due to inheritance. Because of rapid population growth combined with land fragmentation, these smallholdings are increasing and cannot sustain the rural households whose sizes and needs are also increasing rapidly This situation has led to increasing numbers of males migrating to urban areas in Syria and to neighbouring countries looking for work opportunities. In addition, recent agricultural intensification trends seem to have led to the emergence of a waged labour force which, in the absence of male workers owing to significant rates of migration, is now predominantly female. Agricultural labour use depends upon household characteristics and resources (type of labour used, gender of labour waged/exchanged/familial). The article attempts to present a comprehensive analysis of household labour use in distinctive farming systems in one region of Syria that has undergone great change in recent decades, and examin...

395 Background: The 5 year (yr) overall survival (OS) of pancreas cancer (PC) is < 5%. Surgical resection is the only curative treatment (tx), most relapse within 2yrs. Neoadjuvant (NA) tx can benefit by eradicating micro-metastases, avoids futile surgery if metastases develop, improves dose intensity and may down stage disease. Currently, there are no data that clearly demonstrate improved OS with NA tx. Randomised trials are in progress. Methods: A retrospective analysis of all patients (pts) who received NA therapy across campuses,in Sydney, was performed. Pt records were identified and all were discussed in a MDT by a panel of PC specialists. Results: 588 PC pts were treated between August 2011-July 2016. After consideration of anatomy, pt characteristics and preference 82 pts (14%) received NA tx, 30% were resected upfront. 26 pts were ‘borderline’ and received sequential chemo-radiotherapy (ctxRT). Median age at diagnosis (dx) was 73 yrs, 50% were men. Median follow up time was 31.2 months (m). 84% pts were resected. There was 1 death at 90 days. An R0 was achieved in 74%. A detailed tx overview will be provided. Most received gemcitabine/abraxane. For those who had PET, low SUV pre-operative correlated with high pathological regression score, 3 pts 0%. Median OS for all pts was 25.9 m (95% CI 21.2, 30.2). Survival by stage: 1- 21.2 mo (11.8, 29.5); 2- 25.2 m; stage 3-4 (not reached). Pts who received ctx alone OS 25.3mo (17.2,29.5); ctxRT 29.0 m (17.3, NA) (p = 0.03). R0 survival was 29.0 m (21.2, NA) and R1, 23 m. 30% were alive at 3 yrs. Time to recurrence was 22.3 m (14.3, NA). Weight > 74kg was predictive of survival; OS 23.0 m v 29.5m (p = 0.002). There was a trend to survival benefit in females (p = 0.099) and baseline LDH < 280 (IU/L) (p = 0.07). Age at dx, ECOG (0 v 1), baseline albumin, bilirubin, Ca 19.9, NLR ( < 3.1) and CRP and stage at dx were not predictive of survival. Conclusions: This pt cohort demonstrates superior survival with NA therapy in selected pts across stages in a high volume multi-disciplinary PC centre. Outside a clinical trial, NA therapy is evolving to be our standard of care in fit pts with any degree of vessel involvement.

Objective: The aim of this investigation is to determine the impact of hybrid single photon emission computed tomography/computed tomography (SPECT/CT) on the detection of parathyroid adenoma. Materials and methods: 16 patients presented with suspected parathyroid adenoma localised within the neck. All patients were injected with Tc-99m sestamibi and were scanned with a GE Infinia Hawkeye SPECT/CT. There were six negative and ten positive confirmed cases. Five expert radiologists specializing in nuclear medicine were asked to report on the 16 planar and SPECT data sets and were then asked to report on the same randomly ordered data sets with the addition of CT. Receiver operating characteristic (ROC) analysis was performed using the Dorfman-Berbaum-Metz multireadermulticase methodology and sensitivity and specificity values were generated. A significance level of p ≤ 0.05 was set for all comparisons. Results: ROC analysis demonstrated an AUC of 0.64 and 0.69 for SPECT and SPECT/CT respectively (p = 0.31). Mean sensitivity scores increased from 0.64 to 0.80 (p = 0.17) and specificity scores decreased from 0.57 to 0.40 (p = 0.17) with the addition of the CT data. Conclusion: This preliminary investigation suggests that extra CT information may increase lesion detection as well as false positive rates for SPECT-based investigations of a single parathyroid adenoma. However the difference in diagnostic efficacy between the two groups was not found to be statistically significant therefore requiring further investigation. These findings have implications beyond the clinical situation described here.

To develop a method of producing lung ventilation and perfusion (V/Q) planar images using forward projection of reconstructed single-photon emission computed tomography (SPECT) images through approximate attenuation (micro) maps generated from the lung emission scans alone, as transmission-based micro maps may not be routinely available.Synthetic micro maps are derived from (99m)Tc photopeak and "scatter" windows for the attenuation correction of the SPECT images. The attenuation-corrected SPECT images are forward projected at appropriate angles to give the equivalent of planar images. This method allows high-count planar images, as well as the SPECT images, to be produced from a single SPECT acquisition. In addition, isolated "single lung" views of lateral and medial projections without "shine-through" from the contra-lateral lung, which have not been available previously, can be formed.Comparison of reprojected images produced from CT-derived or synthetic micro maps displayed similar detail and radiopharmaceutical distribution. In a blinded comparison of "true" planar images with those from reprojecting the SPECT data using the synthetic micro maps, no difference in mismatched defect detection was found, and hence it was confirmed that the reprojected planar images could replace true planar images with no loss in planar diagnostic sensitivity.The reprojected planar images provide high-count, high-quality images, which are comparable with conventional 2D images.

A 29-year-old Caucasian woman had been diagnosed with Goodpasture's syndrome 12 months previously. Her renal function did not recover, she required haemodialysis and was put on the transplant list. She developed amenorrhoea on haemodialysis. She was seen at 22 weeks gestation in her second pregnancy. She was counselled regarding the high risk of fetal and maternal complications. She was offered medical termination of pregnancy but decided to continue. management plan was devised aiming to maintain the health of the mother, allow growth of the fetus and to support the patient and her partner. The plan included referral to a specialist obstetric unit. All drugs were evaluated and potentially dangerous medication, i.e. losartan, was stopped. Her haemodialysis was increased to six times a week (at least 24 h/week) to maintain a pre-dialysis urea of less than 16 mmol/litre. Her dialysate bicarbonate levels were reduced to prevent the usual post-dialysis alkalosis and avoid pre-dialysis acidosis. Intradialystic hypotension was avoided by careful fluid balance assessment and low ultrafiltration rates on dialysis, and post-dialysis hypercalcaemia was avoided by adjusting the dialysate calcium concentration. Hypocalcaemia was avoided by close monitoring of calcium and vitamin D levels and ensuring adequate doses of calcium and alfacalcidol. Hypertension was controlled with a safe antihypertensive (methyldopa), her haemoglobin was maintained between 10 and 11 g/dl with iron and erythropoietin and adequate nutrition with increased calorie and protein intake, water-soluble vitamins (B and C), and folic acid. Fetal growth and liquor volumes were monitored by regular ultrasound scanning. At 24 weeks methyldopa 250 mg twice a day was started to control her blood pressure. Her growth scan at 24 and 26 weeks was satisfactory. At 27 weeks and 2 days she was admitted with severe epigastric pain. There were no other features of pre-eclampsia. She was given a course of betamethasone for fetal lung maturity. Two days later tests revealed a low platelet count (67×109/litre; normal value 150–400×109/litre) and high alanine aminotransferase (ALT) levels (113 iu/litre; 0–40 iu/litre). The next day a repeat test showed platelet count of 47×109/litre and an ALT level of 415 iu/litre. A working diagnosis of HELLP (haemolysis, elevated liver enzyme and low platelet) syndrome was made. The multidisciplinary team decided to deliver her electively by caesarean section the next day. A healthy baby boy weighing 540 g was delivered without any difficulty. She recovered well after the operation and was back on haemodialysis three times a week. The baby was doing well at 6 months of age.

Purpose To evaluate the incremental benefit in routine clinical practice of computed tomography (CT) scans acquired for anatomical localization on an integrated SPECT/CT which incorporates a spiral CT scanner, in comparison with conventional planar and SPECT scanning. Methods The first 50 studies acquired on the integrated system were evaluated by two experienced nuclear medicine physicians who were aware of the patient's clinical history. These included bone scans, gallium scans, octreotide scans, sestamibi parathyroid scans and MIBG scans. For each patient study, abnormalities were assessed on planar and SPECT images for location and provisional diagnosis and a quantitative scale was used to assess reporter confidence. The fused SPECT/CT images were then reviewed and the location and provisional diagnosis noted and reporter confidence was assessed using the same quantitative scale. Results There were 129 abnormalities detected in 50 patient studies. For localization of abnormalities, the inclusion of the CT resulted in a minor change in 16% of cases and a significant change in 11% over planar/SPECT imaging alone. The confidence of localization was improved moderately in 19% and improved significantly in 6%. For diagnosis, SPECT/CT resulted in a minor change in 10% and a significant change in 9% over planar/SPECT imaging. The confidence of diagnosis was improved moderately in 10% and improved significantly in a further 10% of cases. For the final scan interpretation, there would have been no change in 44% patients, a minor change in 30% and a significant change in 26% with the use of SPECT/CT. Conclusion Use of integrated SPECT/CT with a high spatial resolution, spiral CT used for anatomical localization improves accuracy and reporter confidence in clinical practice. As a result, final reports were different in 56% of the cases, including being significantly different in 26% patients compared to reporting with planar/SPECT alone.

To develop a combined SPECT/CT based on a conventional gamma camera with the following design goals: (i) the subject is scanned on the same bed without moving between SPECT and CT scans, (ii) maintenance of full diagnostic utility of both scanners, (iii) a minimal equipment footprint which is adaptable to different site configurations, (iv) a modular design so that either scanner can be upgraded without impacting the other scanner and (v) cost-effectiveness. A Philips SKYLight gamma camera was combined with a single-slice helical CT. The CT bed has been modified by mounting on wheels and is attached to a track in the floor when required. The CT bed is used for both the CT and the SPECT scans. The CT bed is parked outside the SKYLight’s active area when not required. The CT data are used for anatomical localisation, attenuation correction and definition of anatomical boundaries (e.g. lobar boundaries in the lungs). The combined SPECT/CT system is installed in a 6.2 m×4.6 m room. The CT can scan up to 1.3 m of the subject, which is usually sufficient for registration with the SPECT scan. More than 200 subjects have had SPECT/CT scans in the first year of operation. Initially, the main outcome has been improved confidence of localisation of abnormalities. Attenuation correction for all relevant radionuclides has been implemented. We have developed a combined SPECT/CT using a novel approach based on a low-cost CT scanner. The design is compact, is readily upgradeable and does not compromise either machine’s diagnostic or functional capabilities.

The objective of this study was to examine the feasibility of fusing ventilation and perfusion data from single-photon emission computed tomography (SPECT) ventilation perfusion (V/Q) scintigraphy together with computed tomographic pulmonary angiography (CTPA) data. We sought to determine the accuracy of this fusion process. In addition, we correlated the findings of this technique with the final clinical diagnosis.Thirty consecutive patients (17 female, 13 male) who had undergone both CTPA and SPECT V/Q scintigraphy during their admission for investigation of potential pulmonary embolism were identified retrospectively. Image datasets from these two modalities were co-registered and fused using commercial software. Accuracy of the fusion process was determined subjectively by correlation between modalities of the anatomical boundaries and co-existent pleuro-parenchymal abnormalities.In all 30 cases, SPECT V/Q images were accurately fused with CTPA images. An automated registration algorithm was sufficient alone in 23 cases (77%). Additional linear z-axis scaling was applied in seven cases. There was accurate topographical co-localisation of vascular, parenchymal and pleural disease on the fused images. Nine patients who had positive CTPA performed as an initial investigation had co-localised perfusion defects on the subsequent fused CTPA/SPECT images. Three of the 11 V/Q scans initially reported as intermediate could be reinterpreted as low probability owing to co-localisation of defects with parenchymal or pleural pathology.Accurate fusion of SPECT V/Q scintigraphy to CTPA images is possible. This technique may be clinically useful in patients who have non-diagnostic initial investigations or in whom corroborative imaging is sought.

This work was supported by the BBSRC (BB/I019502/1) and Roslin Institute Strategic Grant funding from the BBSRC. The APC was paid through RCUK OA block grant funds. It is generally assumed that birds’ choice of structurally suitable materials for nest building is genetically predetermined. Here, we tested that assumption by investigating whether experience affected male zebra finches’ (Taeniopygia guttata) choice of nest material. After a short period of building with relatively flexible string, birds preferred to build with stiffer string while those that had experienced a stiffer string were indifferent to string type. After building a complete nest with either string type, however, all birds increased their preference for stiff string. The stiffer string appeared to be the more effective building material as birds required fewer pieces of stiffer than flexible string to build a roofed nest. For birds that raised chicks successfully, there was no association between the material they used to build their nest and the type they subsequently preferred. Birds’ material preference reflected neither the preference of their father nor of their siblings but juvenile experience of either string type increased their preference for stiffer string. Our results represent two important advances: (i) birds choose nest material based on the structural properties of the material; (ii) nest material preference is not entirely genetically predetermined as both the type and amount of experience influences birds’ choices. Publisher PDF

Purpose: The purpose of this study was to quantify the lobar lung function using the novel PET Galligas ([68Ga]-carbon nanoparticle) ventilation imaging and the investigational CT ventilation imaging in lung cancer patients pre-treatment. Methods: We present results on our first three lung cancer patients (2 male, mean age 78 years) as part of an ongoing ethics approved study. For each patient a PET Galligas ventilation (PET-V) image and a pair of breath hold CT images (end-exhale and end-inhale tidal volumes) were acquired using a Siemens Biograph PET CT. CT-ventilation (CT-V) images were created from the pair of CT images using deformable image registration (DIR) algorithms and the Hounsfield Unit (HU) ventilation metric. A comparison of ventilation quantification from each modality was done on the lobar level and the voxel level. A Bland-Altman plot was used to assess the difference in mean percentage contribution of each lobe to the total lung function between the two modalities. For each patient, a voxel-wise Spearmans correlation was calculated for the whole lungs between the two modalities. Results: The Bland-Altman plot demonstrated strong agreement between PET-V and CT-V for assessment of lobar function (r=0.99, p

9616 Background: Diagnosis of upper limb lymphedema (LE) secondary to treatment for cancer has been complicated by the range of diagnostic thresholds used. Traditional thresholds were arbitrarily chosen but recently normative-based cut-offs have been established. However, the diagnostic power of these thresholds has not been compared to changes identified with lymphoscintigraphy, the gold standard for diagnosis of LE. The aim of this study was to determine thresholds for commonly used clinical diagnostic tools based on lymphatic imaging outcomes. Methods: Women previously diagnosed with LE secondary to treatment for cancer (n=67), and women without LE (n=20) participated. Lymphoscintigraphy was completed and the presence and severity of dermal back flow qualitatively scored as none to mild or moderate to severe by an experienced nuclear medicine physician. On the same day, circumference measurements and segmental bioimpedance spectroscopy (BIS) for 10 cm intervals from the ulnar styloid to 40 cm proximal were recorded. The BIS inter-limb ratio for each segment and the inter-limb circumference differences were compared to diagnostic thresholds based on 2 and 3 standard deviations (SD) above the mean from normative data. Results: The number of BIS segments and circumferences measurements above a 3SD threshold correlated significantly with the dermal backflow score (Rs= 0.710 and 0.824 respectively).The number of abnormal BIS segments detected did not differ significantly between a 2SD and 3SD threshold (χ2=0.23 p=0.63). Of the 20 new abnormal segments detected, 7 were from participants with no or mild evidence of dermal backflow on lymphoscintigraphy including 3 from control participants. In contrast, 46 new abnormal inter-limb circumference differences, all from those with a LE diagnosis, were detected using a 2SD threshold (χ2= 31.785, p

The STARS Program Plan, September 19, 1985, is reviewed and analyzed. An IDA panel finds that the plan is a reasonable starting point, but finds problems in the areas of management, theme, strategy, execution organization, and in several of the STARS Area plans. The two major points are that the STARS program requires strong central direction with a controllable organization and strong clients and that a theme of marketplace stimulation rather than technology development should be adopted and made to permeate the program. Volume I is the Executive Briefing on the Report.