RESUMEN
90Y radioembolization is a safe and efficacious treatment option for many patients with unresectable hepatocellular carcinoma. Potential candidates for radioembolization, based on clinical criteria, undergo 99mTc-labeled macroaggregated albumin imaging to determine the extent of hepatopulmonary shunting. Dose selection is based on results from shunt imaging and can exclude patients from radioembolization therapy. We present a case of miscalculated lung shunt fraction and the circumstances that led to the critical error.
Asunto(s)
Embolización Terapéutica , Pulmón/efectos de la radiación , Errores Médicos , Carcinoma Hepatocelular/diagnóstico por imagen , Carcinoma Hepatocelular/terapia , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/terapia , Pulmón/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Agregado de Albúmina Marcado con Tecnecio Tc 99m , Radioisótopos de Itrio/uso terapéuticoRESUMEN
Regadenoson is an adenosine A2A receptor agonist widely used as a pharmacologic stress agent for myocardial perfusion imaging. Approximately 3.4 million regadenoson pharmacologic stress tests were performed annually as of 2011. Caffeine is a competitive antagonist of all adenosine receptor subtypes; thus, caffeine is typically withheld 12-24 h before stress with regadenoson. However, the effects of daily caffeine intake on regadenoson stress are unknown. This study assessed the effects of daily caffeine intake on symptoms and hemodynamic changes during stress testing with regadenoson. Methods: Patients presenting for regadenoson stress myocardial perfusion imaging were asked their amounts of daily caffeine intake. Chart review was used to collect data on demographics, comorbidities, and use of ß-blockers. Data collected from the regadenoson stress test included symptoms, administration of aminophylline, heart rate, blood pressure, and arrhythmias. χ2 testing and ANOVA were used to analyze data divided into 3 categories of caffeine intake (<200, 200-400, and >400 mg daily). χ2 testing was used for nominal data, and unpaired t testing was used for continuous data. Results: In total, 101 patients were enrolled: 53% men and 47% women. Of the 101 patients, 89% reported caffeine intake, with 13% reporting heavy caffeine intake (>400 mg daily). The last intake of caffeine was at least 12 h before the test. During the test, 63% of patients reported symptoms, but the test was completed successfully in all patients. Compared with those who do not use caffeine, intake for caffeine users was associated with less chest pain (P = 0.0013), less aminophylline administration (P = 0.0371), lower resting and peak heart rate (P = 0.0497 and 0.0314, respectively), and lower diastolic blood pressure response (P = 0.0468). No associations were found between caffeine intake and arrhythmia or systolic blood pressure response. Conclusion: The use of regadenoson stress for myocardial perfusion imaging in caffeine consumers is very common, safe, and associated with a lower incidence of certain symptoms than in non-caffeine consumers. Specifically, caffeine intake was associated with less aminophylline use and chest pain.
Asunto(s)
Agonistas del Receptor de Adenosina A2/farmacología , Cafeína/metabolismo , Prueba de Esfuerzo/efectos de los fármacos , Hemodinámica/efectos de los fármacos , Purinas/farmacología , Pirazoles/farmacología , Adulto , Anciano , Aminofilina/farmacología , Arritmias Cardíacas/metabolismo , Presión Sanguínea/efectos de los fármacos , Relación Dosis-Respuesta a Droga , Interacciones Farmacológicas , Ingestión de Alimentos , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Imagen de Perfusión Miocárdica/métodos , Resultado del TratamientoRESUMEN
PURPOSE: Dopamine transporter single-photon emission computed tomography imaging utilizing iodine-123 ioflupane is accurate for differentiation of Parkinson disease from essential tremor. This study evaluates how reimbursement for I-123 ioflupane imaging changed between 2011 (year of FDA approval) and 2014 (year after loss of pass-through status for hospital-based outpatient imaging from CMS). METHODS: I-123 ioflupane reimbursement data for our institution's hospital-based imaging were compared between two periods: (1) July 2011 to October 2012, and (2) 2014. For each time period separately and in combination, averages and ranges of reimbursement for private insurance and CMS were analyzed and compared. A model to ensure recouping of radiopharmaceutical costs was developed. RESULTS: Review yielded 247 studies from July 2011 to October 2012 and 94 studies from 2014. Average reimbursement per study fell from $2,469 (US dollars) in 2011 to 2012 to $1,657 in 2014. CMS reduced average reimbursement by $1,148 in 2014 because of loss of radiopharmaceutical pass-through status. Average reimbursements from CMS versus private payors markedly differed in 2011 to 2012 at $2,266 versus $2,861, respectively, and in 2014 at $1,118 versus $3,470, respectively. Between 2011 to 2012 and 2014, the CMS percentage increased from 54% to 78%. Assuming that I-123 ioflupane cost $2,000, our model based on 2014 data predicts a practice with greater than 60% CMS patients would no longer recover radiopharmaceutical costs. CONCLUSIONS: Reimbursement levels, payor mix, scanner location, and radiopharmaceutical costs are all critical, variable factors for modeling the financial viability of I-123 ioflupane imaging and, by extrapolation, future radiopharmaceuticals.
Asunto(s)
Análisis Costo-Beneficio/economía , Accesibilidad a los Servicios de Salud/economía , Reembolso de Seguro de Salud/economía , Nortropanos/economía , Enfermedad de Parkinson/diagnóstico por imagen , Enfermedad de Parkinson/economía , Tomografía Computarizada de Emisión de Fotón Único/economía , Arizona/epidemiología , Proteínas de Transporte de Dopamina a través de la Membrana Plasmática/metabolismo , Costos de la Atención en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Medicare/economía , Modelos Económicos , Imagen Molecular/economía , Imagen Molecular/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud/economía , Radiofármacos/economía , Tomografía Computarizada de Emisión de Fotón Único/estadística & datos numéricos , Estados UnidosRESUMEN
Dopamine transporter (DAT) imaging is a valuable tool to aid in the diagnosis of Parkinson disease and other Parkinsonian syndromes. DAT imaging is special among clinical nuclear medicine scans in that the already small caudate and putamen are presented in multiple thin axial cuts. Because the imaged basal ganglia are small, slight differences in head tilt may result in a significant artifact that we have termed the semicolon sign. The semicolon sign occurs when forward head tilt creates select images that show the caudate nuclei separate from the putamen. This gives the false impression that DAT activity in the putamen is decreased or absent. To avoid falsely attributing this artifact to loss of putaminal activity, it is imperative that the interpreting physician first recognize the artifact and then mentally integrate all provided images to identify normal activity in the putamen on subsequent levels. Furthermore, quantitative software packages for automated DAT scan interpretation are now available. If images demonstrating the semicolon sign are used for automated interpretation, loss of activity in the putamen may be falsely calculated, thereby contributing to erroneous results. Quality control measures are essential to ensure that technologists correctly position each patient's head to minimize head tilt artifact on DAT scan images. A protocol to obtain optimal head positioning is presented.