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Ellen Gallagher PDF. Employers' Prerogatives PDF. En Lair! Everywhere Studio PDF. Fashion sketchbook with figure templates for girls PDF. Page Fever After Animal Exposures Page Fever and Rash Page Fever With Lymphadenopathy Page Epidemiology and Etiology Page Subdural Empyema Page Septic Cavernous Sinus Thrombosis Page Sporadic Creutzfeldt-Jakob Disease Page Complications Page Pathogenesis and Microbiology Page Bacterial Epiglottitis Page Acute Bacterial Otitis Externa Page Acute Bacterial Otitis Media Page Specific Etiologic Agents Page Clinical Manifestations Page Pathologic Manifestations Page Other Organisms Page Select Fungi and Viruses Page Special Diagnostic Considerations Page Special Treatment Considerations Page Infectious Colitis Page Clostridioides difficile Colitis Page Cholangitis Page Cytotoxin-Induced Diarrhea Page Salmonella Page Listeria Page Chlamydia Page Gonorrhea Page Vaginitis Page Syphilis Page Herpes Simplex Virus Page Pubic Lice Page Scabies Page Opportunistic Infections Page HIV and Malignancy Page Gastrointestinal Diseases Page Osteoporosis and Bone Disease Page Aging and HIV Page Laboratory Monitoring Page Immunization Page Resistance Testing Page Future Directions of Antiretroviral Treatment Page Asplenia and Complement Deficits Page Solid Organ Transplantation Page Novel Immunomodulatory Medications Page Fever of Unknown Origin Page Host Considerations Page Adjusting Immunosuppression Page Candida Page Aspergillus Page Parasites Page Immunizations Page Protozoal Infections in the United States Page Tissue Biopsies Page Imaging Studies Page Identification of Meningitis Page Aphasia Page Agnosia and Apraxia Page Alzheimer Disease Page Normal-Pressure Hydrocephalus Page Isolated Disorders of Memory Function Page Classification of Headache Page Examination of the Visual System Page Monocular Visual Loss Page Symptoms of Auditory Dysfunction Page Causes of Hearing Loss Page Prospectus for the Future Page Parkinsonism Page Tremor Page Chorea Page Dystonia Page Tics and Tourette Syndrome Page Cerebellar Ataxias Page Functional Movement Disorders Page Disorders of Dorsal Induction Page Disorders of Ventral Induction Page Autism Spectrum Disorder Page Fragile X Syndrome Page Neurofibromatosis Page Tuberous Sclerosis Complex Page Sturge-Weber Syndrome Page Clinical Implications of Vascular Anatomy Page Vascular Pathogenesis Page Injury to Brain Tissue Page Acute Treatment of Ischemic Stroke Page Treatment of Intracerebral Hemorrhage Page Secondary Stroke Prevention Page Traumatic Brain Injury Page Traumatic Spinal Cord Injury Page Acute and Subacute Management Page Seizures Page Focal Seizures Page Generalized Seizures Page Focal Epilepsy Page Combined Generalized and Focal Epilepsy Page Medication Therapy Page Epilepsy Surgery Page Status Epilepticus Page Heredity Page Prognosis of Multiple Sclerosis Page Amyotrophic Lateral Sclerosis Page Brachial Plexopathy Page Carpal Tunnel Syndrome Page Dystrophinopathies Covers the imaging of every body system, as well as inflammation, infection and tumor imaging; pearls and pitfalls for every chapter; and pediatric doses and guidelines in compliance with the Image Gently and Image Wisely programs.

Features a separate self-assessment section on differential diagnoses, imaging procedures and artifacts, and safety issues with unknown cases, questions, answers, and explanations.

Includes new images and illustrations, for a total of high-quality, multi-modality examples throughout the text. Overview: Essentials of Nuclear Medicine and Molecular Imaging - Covering both the fundamentals and recent developments in this fast-changing field, Essentials of Nuclear Medicine and Molecular Imaging, 7th Edition, is a must-have resource for radiology residents, nuclear medicine residents and fellows, nuclear medicine specialists, and nuclear medicine technicians.

Known for its clear and easily understood writing style, superb illustrations, and self-assessment features, this updated classic is an ideal reference for all diagnostic imaging and therapeutic patient care related to nuclear medicine, as well as an excellent review tool for certification or MOC preparation. Covers the imaging of every body system, as well as inflammation, infection and tumor imaging; pearls and pitfalls for every chapter; and pediatric doses and guidelines in compliance with the Image Gently and Image Wisely programs.

Features a separate self-assessment section on differential diagnoses, imaging procedures and artifacts, and safety issues with unknown cases, questions, answers, and explanations. Includes new images and illustrations, for a total of high-quality, multi-modality examples throughout the text.

Reflects recent advances in the field, including updated nuclear medicine imaging and therapy guidelines. Updated dosimetry values and effective doses for all radiopharmaceuticals with new values from the International Commission on Radiological Protection. Updated information regarding advances in brain imaging, including amyloid, dopamine transporter and dementia imaging.

New myocardial agents. Thyromegaly is usually the presenting clinical finding. LV anteroseptal myocardial ischemia. What would be the implications if the left ventricle cavity appeared dilated on the stress images?

In the presence of CAD, transient ischemic dilatation TID correlates with high-risk disease left main or multivessel involvement and a worse prognosis. Underlying mechanisms for transient ischemic dilatation include transient stress-induced diffuse subendocardial hypoperfusion, producing an apparent cavity dilatation, ischemic systolic dysfunction, and perhaps in some instances, physical cavity dilatation.

The normal ventilation with diffuse bilateral, multiple small perfusion defects is nonspecific. In this case, the diagnosis is diffuse vasculitis. Fat or tumor emboli could have a similar appearance. What methods are commonly used for disposal of radioactive syringes?

Either return to the commercial radiopharmacy that supplied the material or decay in storage. No, there is no radioactive label visible on the container. Can only be done for byproduct material with half-lives of less than days. These materials should be stored for 10 half-lives at which time the measured dose rate is indistinguishable from background.

Radioactive labels are then removed before disposal with ordinary waste. Decay and disposal records must be maintained. Case 6. Yes, the patient is likely to have less abdominal discomfort than with rapid injection. Be aware that normal gallbladder ejection fraction values vary, depending on the infusion duration.

Infected axillaryfemoral graft. Incidental note of right nephrectomy. Inhomogeneous, mild, or moderate uptake should be considered as nondiagnostic. Fibrous dysplasia, as seen on a radionuclide bone scan, and expansile lesions on rib radiograph.

What are physiologic factors that cause increased activity on bone scans? Increased osteoid formation, increased blood flow, increased mineralization of osteoid, and interrupted sympathetic nerve supply. Parathyroid adenoma, as seen on a 99mTc-sestamibi scan. Could this lesion be an atypical thyroid adenoma? What method could be used to help locate the lesion at surgery?

Often a small gamma probe is used during surgery, but the patient needs to receive 99mTc-sestamibi 2 to 4 hours before surgery. Is metastatic disease present? There are multiple hypermetabolic ipsilateral hilar and mediastinal lymph nodes.

In this case, these were a result of infected or reactive lymph nodes, not metastasis. FDG is very sensitive for the detection of both infection especially granulomatous and inflammation; however, it is very nonspecific. Hyperplastic and neoplastic lymph nodes may also be hypermetabolic. It is generally better than 67Ga-citrate in these settings. Reversible ischemia of the septum, anterior wall, apex, and distal inferior wall with septal dyskinesia, as seen on a gated 99m Tc-sestamibi scan using exercise stress.

What parameters are used to determine if physical exercise stress was adequate in this patient? If none of these conditions is met, the stress is generally deemed submaximal. Lytic sternal metastasis, as seen on a 99mTc bone scan. Kidney, lung, thyroid. Breast cancer. Toxic thyroid adenoma, as visualized on a 99mTc-pertechnetate thyroid scan. A thyroid cancer would not be hotter than the normal thyroid tissue on a I scan. The activity in the rest of the gland is decreased because of the autonomous nodule producing too much hormone and inhibiting pituitary production of circulating TSH.

Not all patients treated with high doses of I need to be hospitalized. Release of nuclear medicine patients is allowed under NRC regulations, based on a certain amount of administered activity or dose rate e. Patients also may be released with much higher activities, based on patient-specific calculations and if the effective dose to family or caregiver is not likely to exceed 0. An authorized user must complete and sign the written directive for therapy, but no RSO supervision is required.

An ionization chamber instrument is used to assess whether a patient meets the criteria for release. Case 7. Right-to-left shunt on a 99mTc-MAA lung perfusion scan. It is common practice to limit the number of particles in the presence of a right-to-left shunt from about , to about , Withdrawal of blood into the syringe containing 99m Tc-MAA before injection may result in labeling of small clots or clumping of the MAA.

Hepatobiliary scan, as evidenced by the sequential images, initial cardiac blood pool activity that gets cleared by the liver, and no visualization of the spleen. No, in contrast to bile, iminodiacetic acid agents are not conjugated before excretion. Hyperparathyroidism with 99mTc-MDP activity in the lungs, thyroid, kidneys, and stomach as a result of so-called metastatic calcification.

Inferior wall myocardial wall infarction with severe inferior wall hypokinesis. Hibernating myocardium is the result of chronic hypoperfusion and ischemia. This leads to reduced cellular metabolism that is sufficient to sustain viability but inadequate to permit contractile function. Areas of hibernating myocardium usually present as segments of decreased perfusion and absent or diminished contractility. Stunning is the result of ischemic and reperfusion injury secondary to an acute coronary artery occlusion that has reopened before significant myocardial infarction can occur.

Areas of stunned myocardium usually present with normal or near-normal perfusion but with absent or diminished contractility, which often improves spontaneously over time.

Bilateral renal artery stenosis. In renal artery stenosis, the efferent blood vessels constrict to maintain filtration pressure in the glomeruli. After administration of an ACE inhibitor, the efferent renal blood vessels become dilated, reducing glomerular filtration pressure with the affected kidney s retaining activity in the tubules because of diminished washout of the tubular activity. Yes, the drop in intrarenal blood pressure from captopril can induce acute renal failure.

Decreased metabolic activity in the left temporal lobe at the site of the seizure focus. This is a case of interictal between seizures temporal lobe epilepsy, but similar findings can be seen with a low-grade temporal tumor, stroke, or radiation necrosis. Increased activity at the site of seizure focus. Lingual thyroid, as seen on a 99mTc-pertechnetate thyroid scan. Embryologically, thyroid tissue originates near the base of the tongue and migrates caudally.

But when the migration is arrested, ectopic positioning results, commonly at the base of the tongue, producing a lingual thyroid gland. It is a Meckel diverticulum study using 99mTc-pertechnetate, as evidenced by the prompt gastric wall activity and minimal blood pool activity.

A Meckel diverticulum can still be present. However, it does mean that ectopic gastric mucosa is not likely to be present, which is generally the cause of bleeding.

H2 blockers cimetidine reduce the release and washout of pertechnetate from ectopic gastric mucosa, pentagastrin can enhance gastric mucosal uptake, and glucagon decreases contractility movement during imaging. Multivessel coronary artery disease. Large anteroapical infarct with akinesis, small inferior wall infarct, reduced left ventricle LV ejection fraction, and dilated LV.

Dipyridamole may cause chest discomfort, headaches, dizziness, flushing, and nausea. This antidote should be readily available during the procedure. Aminophylline is also used to reverse the effects of the widely used vasodilator regadenoson. The three most common side effects are flushing, shortness of breath, and chest pain. These are usually transient and require no action or treatment. An uncommon, but more serious, side effect is atrioventricular block, which usually occurs in the first few minutes of infusion and is also transient.

First-degree and second-degree block are more common. Because the biologic half-life of adenosine is extremely short less than 10 seconds , its effects may be reversed by simply stopping infusion and beginning any specific treatments, if necessary. See Appendix I and Table I. Nonaffected persons should vacate the area, the spill should be covered to prevent spread do not attempt to clean up , and the area secured. Contaminated persons should remove affected clothing and wash with soap and warm water.

Scrubbing to background activity is not necessary. From Europium New York: Society of Nuclear Medicine; Time is given in hours and minutes. Accessed June 23, A balance must be achieved between the smaller doses needed in a small patient and the minimum dose needed to get a statistically valid examination in a reasonable time.

Simple reduction of an adult dose per unit weight necessitates an extremely long imaging time during which the image may be compromised by patient motion. Surveys have indicated that doses administered to children and adolescents of the same age and size vary widely, often by a factor of 3 and sometimes more.

The suggested administered activities for 18 radiopharmaceuticals are seen in Table D. J Nuc Med. From European Association of Nuclear Medicine.

Dosage Card Version 5. Accessed June 18, Accessed June 18, mebooksfree. Some of the less common procedures have not been included, and the procedures described herein may need to be adjusted, depending on the equipment available and user preferences.

The protocols for positron emission tomography PET examinations are at the end of this appendix. Each nuclear medicine laboratory should have a standardized procedures manual; this appendix may be used as a beginning point for the development of such a manual.

Suggested administered activities for pediatric and adolescent examinations are given in Appendix D. Brainspecific single-photon emission computed tomography SPECT perfusion agents, such as 99mTchexamethylpropyleneamine oxime HMPAO and 99m Tc-ethyl cysteinate dimer ECD , also called 99m Tc-bicisate, can also be used, but there is no clear evidence that they are more accurate, although they are less dependent on an excellent bolus injection.

This should not be done in patients with a history of head trauma. Patient should be normally ventilated. Technique Collimator High-resolution or ultrahigh-resolution; field of view FOV should include from the level of the common carotids to the skull vertex.

Flow images should start before the arrival of the bolus in the neck. Routine views Immediate blood pool anterior and anterior image at 5 minutes each. Many institutions also obtain posterior and both lateral views. Note: If brain-specific images are obtained, initial images as described previously are obtained as well as planar and SPECT images obtained after 20 minutes. For unstabilized 99mTc-HMPAO, inject no sooner than 10 minutes after preparation and not more than 30 minutes after preparation.

For seizure disorders, inject mebooksfree. For stabilized 99m Tc-HMPAO, inject no sooner than 10 minutes after preparation and no more than 4 hours after preparation. For 99mTc-ECD, inject no sooner than 10 minutes after preparation and no more than 4 hours after preparation.

Method of administration Place patient in a quiet, dimly lit room and instruct him or her to keep eyes and ears open. The patient should be seated or reclining comfortably. IV access should be placed at least 10 minutes before injection.

The patient should not speak or read, and there should be little or no interaction before, during, or up to 5 minutes after injection. Minimum dose 5 mCi MBq. Injection-to-imaging time 90 minutes or later for stabilized or unstabilized 99mTcHMPAO, although images obtained after 40 minutes will be interpretable; minute delay for 99mTc-ECD, although images obtained after 20 minutes will be interpretable.

If possible, all imaging should be obtained within 4 hours of injection. Conflicting examinations and medications None Patient preparation Patient should be instructed, if possible, to avoid caffeine, alcohol, or other drugs known to affect cerebral blood flow.

If sedation is required, it should be given after the injection and after the radiopharmaceutical uptake period. Patient should void before study for maximum comfort and to prevent scan interruption. Acquisition pixel size should be one-third to one-half of the expected resolution. Low-pass Butterworth filters are preferred for processing in all three dimensions.

Attenuation correction should be performed. Routine views degree arc of rotation single head camera; however, multiple head detectors may produce better images. Known sulfa allergy is a contraindication, and the procedure is usually avoided within the first 3 days after an acute stroke. The challenge study is usually done first, and, if normal, the baseline study may be omitted. Wait 10 to 20 minutes before injecting tracer.

The patient should void immediately before acquisition. Cisternogram Procedure imaging time 30 minutes for each set of images Instrumentation Planar gamma camera Radiopharmaceutical Indium In -DTPA pyrogen free Method of administration Spinal subarachnoid space injection Normal adult administered activity 0.

Conflicting examination and medications Acetazolamide Diamox can cause false-positive results. Technique Collimator Medium energy parallel-hole Counts 1. Cobalt 57Co for k counts transmission scan if useful for anatomic definition. Routine views 1. Peak in 57Co by after photopeak determination. Set intensity, but collect only k counts. Do not advance film or image. Remove sheet source from behind patient. Peak detector for In. Collect k counts. Lateral transmission scan.

Anterior head. Lateral head same lateral as transmission scan. Patient positioning Supine. If a significant CSF leak is suspected in a specific area, the patient may be positioned with that portion dependent. Note: Remove the pledgets and place each in a separate counting vial at time of removal, labeling each vial with its location. For children, 0. Injection-to-imaging time 15 to 30 minutes Conflicting examinations and medications None Patient preparation None Technique Collimator Low-energy parallel and pinhole Counts k counts per image or 5 minutes whichever is sooner.

Patient positioning 1. Extend neck forward by placing a positioning sponge under back of neck. Anterior view of the thyroid to include salivary glands, using parallel collimator. Pinhole views of thyroid only, in anterior and both anterior oblique positions positioned so that the thyroid gland fills two thirds of the FOV.

Drinking water followed by reimaging is sometimes useful to eliminate confusing esophageal activity. Administration-to-imaging time 3 to 24 hours Conflicting examinations and medications 1. Radiographic procedures using IV iodine contrast media e. Other radiographic procedures using iodine contrast media e. Exogenous T3 or T4 liothyronine, levothyroxine. Thyroid-blocking agents such as propylthiouracil, perchlorate, and methimazole. Oral iodides in medications containing iodine e.

Patient preparation Scanning dose to be administered 3 to 24 hours before scanning. Patient should take nothing by mouth NPO overnight before examination. Iodine uptake is normally measured at 24 hours, although it may be measured at 6 hours, if appropriate.

It is measured with a sodium iodide probe. Thyroid Cancer Scan Procedure imaging time 1 to 2 hours mebooksfree. In some patients, the use of rTSH thyrogen may be useful to supplement or avoid thyroid hormone withdrawal. Some institutions use a low-iodine diet 3 to 10 days before administration of tracer. Technique Whole-body scan or spot views of head, neck, chest, and other clinically suspect areas. Absorbed dose with thyroid removed or ablated. Scanning can also be done 7 to 10 days after a cancer therapy treatment with I.

Scanning with I may prevent stunning of thyroid remnant or metastases. Occasionally, scans are done by using 18F-FDG, 99m Tc-sestamibi, or thallium Tl chloride to locate nonfunctioning nonradioiodine-avid metastases. Routine views Planar. Anterior images of the neck at 5, 20, and minutes after injection. A single anterior largeFOV image should also be obtained that includes the mediastinum.

Begin after 10 minute planar image. See RBC labeling procedures at the end of this appendix. The modified in vivo method is suitable for this examination, although some laboratories use commercial in vitro methods such as Ultratag for convenience. Shake the mixture, and let it stand for 5 minutes.

Without injecting air into the vial, withdraw the contents into a 3-mL syringe, avoiding inclusion of an air bubble. Inject patient with cold pyrophosphate 0. After 20 minutes, inject the radiopharmaceutical. Remember to abrade the skin well enough so that the leads have good contact. Place the patient in the supine position on an imaging table with left side toward the camera.

Because there is minimal redistribution with technetium agents, longer delays up to 2 hours can be used when needed. With thallium, increased myocardial uptake has been reported with dipyridamole, furosemide, isoproterenol sodium bicarbonate IV , and dexamethasone; decreased myocardial uptake with propranolol, digitalis, doxorubicin, phenytoin Dilantin , lidocaine, and minoxidil. Patient preparation NPO for 4 hours; exercise, if required.

In patients with severe coronary disease, it may be advisable to administer nitroglycerin sublingually about 3 minutes before rest injection of the radiopharmaceutical. Technique Collimator Low-energy, all-purpose Counts and time 30 to 32 stops for 40 seconds each for Tl and 25 seconds for 99mTc sestamibi Routine views or degree arc of rotation; degrees is preferred from right anterior oblique to left posterior oblique.

Either step and shoot acquisition with 32 or 64 stops separated by 3 to 6 degrees or continuous acquisition may be used. The duration for each stop varies but is generally 40 seconds per image for thallium and 25 seconds for technetium radiopharmaceuticals.

Process for short- and long-axis views. Attenuation correction significantly reduces artifacts. For 99mTc-tetrofosmin, minimum delays of 10 to 15 minutes for exercise, 30 to 45 minutes for rest, and 45 minutes for pharmacologic stress are recommended.