Diagnostic Imaging Updates from Dr Iain Duncan
I hope 2019 is going well for you all. As you can see from the lack of updates it has been pretty busy for me. Professionally my life is “full” and my personal life is fulfilling but mostly supports my busy professional life. Can’t always separate the two -sometimes that’s good and sometimes not. For those who are interested in mental health, anxiety, and the dysfunction spreading through western liberal democracies I suggest the following are excellent reading: Lost Connections by Johann Hari, and Australia Reimagined by Hugh Mackay. Though these are two very different books the reader will immediately see a common underlying thread in terms of the epidemic of anxiety/depression within our (lack of) communities.
I have been able to make time to attend the ANZSNM annual conference in Adelaide and travel to speak at The World Molecular Imaging Summit hosted by Siemens in Lausanne, Switzerland. The latter provided a great excuse for a (well deserved?) break in Northern Europe (Switzerland, Germany, Czech Republic, and Norway). The Norwegians do interesting modern apartments (see photo) and have lots of electric cars.
My talk on xSPECT/CT bone in Lausanne was very well received and reinforced to me that what we do at Garran Medical Imaging is really the cutting edge in bone scan technique. I will share the link to my talk if and when it is available online. While the science is complex and obscure for most (both patients and doctors) I have seen how it is really making a difference at the clinical level. It was a great pleasure to present the GMI experience (in Switzerland) to an appreciative audience.
I am hoping to spend some time in the latter part of 2019 reviewing our extensive data that we are continuing to accumulate in various research projects, but I’m not so good at the looking through the data as accumulating it! Need some help there.
I have been invited to participate in Siemens World Molecular Imaging Summit in Switzerland next year, a great honour for me and an accolade for the high quality work we are doing at Garran Medical Imaging. I will be sharing my experience with xSPECT/CT bone scans in arena of musculoskeletal medicine with our molecular imaging leaders from around the world.
2018 has been another in which I hope we have continued to serve our patients and referrers with world class service and medical imaging. Particular medical communities we have made special efforts for in 2018 include long-term renal patients (dialysis patients and those on the transplant list), rheumatology patients, those suffering from prostate cancer, and those with chronic musculoskeletal disorders. If you think we can help, please email us at [email protected].
I have and will continued to travel to Bega to provide cardiac testing and medical imaging support to the region. I was delighted to talk and catch-up with many local practitioners about my experience in Prostate Cancer Imaging and Diagnosis. This in colourful Merimbula, in October this year. I hope it was a helpful update in a rapidly changing field.
I can’t believe Christmas is nearly here. The last few months have been busy enough to prevent me doing any updates! Garran Medical Imaging and our work with xSPECT/CT bone has been noted at several “locations” around the globe, such as in Medical Imaging Life -see the online article here. Mostly the latter part of this year has been about consolidation and improvement rather than new stuff. Collecting data and refining our systems so that we can be sure we are delivery world’s best care.
I have noted increasing referral for articular therapies for Osteoarthritis -mostly for PRP and viscosupplementation (eg. duralane, synvisc and monovisc). These therapies provide additional options for those suffering from significant pain related to their osteoarthritis. All of the options are safe but involve some cost to the patient with limited and variable health fund reimbursement. The clinical response are very mixed, but for some the result is quite amazing, with surprising improvement seen on scans in parallel with clinical changes.
Our Tc-PSMA scan data is also accumulating and some initial data is being looked at by the urology registrars at The Canberra Hospital. We have improved our scan parameters substantially over the last two years and I am proud of the technical results. I am sure local analysis of the clinical data will go a long way to improving the management of prostate cancer, and ultimately outcome for patients both locally and elsewhere. Hopefully some publications may result in 2019.
New to the site: Osteoporosis screening tools and links to recent recommendations.
June has been filled with chores and commitments and challenges that I’d rather not deal with, but alas are part of life’s administrative burden. The winter in Canberra has made Cairns feel so long ago. I have been able to maintain great fitness with my HIIT (High intensity interval training) and hopefully this might delay my inevitable ageing according to a recent article in The Guardian.
On the professional front I’m seeing some commentaries spring up about xSPECT bone imaging which I hope means it will be more widely adopted around the globe. It is gratifying to see our research reaching afar. More about xSPECT bone can be found on Siemens website here. When combined with xSPECT quant this provides and much more reliable and detailed imaging landscape to assess our patients and referrers diagnostic and management problems. We continue to have great success solving cases which have proven elusive using more conventional nuclear medicine techniques (both for bone and parathyroid imaging). I am hopeful that as more and more medical imaging practices use the technology the data generated will bring new insights and clinical understanding.
I have spent some time in Adelaide, Melbourne, and Cairns during April. A mixture of business and vacation. It has been refreshing and educational. Our poster from the WFNMB Melbourne conference was on quantitative bone imaging and how it can improve and standardise the quality of reporting in nuclear medicine. The poster can be viewed here.
The symposium in Cairns was on imaging and therapy for prostate carcinoma. This had some of the foremost experts in the World and I learnt a great deal, which I can put into practice immediately. Managed to fly over the reef in a small helicopter (see my photo right) which was one of the highlights.
My time in Adelaide was a nostalgia trip visiting some old haunts including Goolwa Beach (see photo) and McLaren Vale. Drove past The Queen Elizabeth Hospital where I did my rheumatology training so many years ago….
The 12th World Congress of the Federation of Nuclear Medicine and Biology is taking place in Melbourne later this month and I am looking forward to it. I will have a Poster on xSPECT Quant (Siemens Healthineers) which will hopefully generate some interest. This technology is reshaping the way we do our scans and together with xSPECT makes nuclear medicine in general and bone scans specifically much more precise. Though this technology is not widely available I am hoping our experience will convince others of its substantial clinical benefits.
Nicholas ingold and I celebrated publication of our study “The clinical value of xSPECT/CT Bone versus SPECT/CT. A prospective comparison of 200 scans” in the European Journal of Hybrid Imaging. This was the culmination of a lot of hard work and data collection and demonstrates how it is possible to undertake quality research in a private practice setting. It is been important for us to contribute in as many ways as we can to improving medical care. In addition it helps us confirm the validity of our practices. When we adopt new techniques we to look carefully at existing research and where it is not sufficient, we try and collect our own data, or undertake our own research, to support (or refute) our current practice. We have fun too.
January was quiet in Canberra (as usual) which is a great way to start the year and collect your thoughts. I have used the available time to collect our research data, to analyse some interesting cases, and to add to this website an update on PRP therapy for osteoarthritis of the knee. For those with osteoarthritis there is also recent evidence that topical non-steroidal anti-inflammatory drugs (NSAIDS) can be effective for some, and are safer than oral equivalents.
The update shows convincing evidence of its benefit. I also read the The Checklist Manifesto: How to Get Things Right, by Atul Gawande. This is definitely recommended reading for health professionals and shows how far we have to go in placing the patient at the centre of healthcare.
The end of another year. Some landmarks for myself and Garran Medical Imaging in 2017:
A 97% satisfaction rate from our patient feedback.
80% of patients benefitted from their tendon or joint PRP therapy.
Introduced routine quantification in nuclear medicine studies -presentation about this coming at the 12th World Congress of the World Federation of Nuclear Medicine and Biology in 2018.
Passed 1000 liver elastography assessments (and did not charge a separate fee for this service).
Presented our xSPECT/CT Bone data at the ANZSNM meeting in Hobart in April.
And some firsts…
The first 40 Technetium PSMA scans in Australia
The first full study on xSPECT/CT bone in the world (in press for publication early 2018)
The first Australian practice to be featured on the European Society of Hybrid Imaging Website
I am proud to be part of an amazing innovative and committed team who provide service to the best of their ability. Their dedication to ongoing learning, patient service, and helping me with anything I throw at the them inspires me. Our shared priorities at Garran Medical Imaging go something like this:
Our priorities are friendship, adding value to people’s lives, having fun, solving problems, self-improvement, and only then making money.
We had a great year and we plan to do more of the same next year. I hope everyone has a great 2018. Seasons greetings.
Our (myself and Nick Ingold, Garran Medical Imaging) research paper on xSPECT/CT bone scans has been accepted by the European Journal of Hybrid Imaging and hopefully will be in press soon. We have also submitted an abstract on Quantitative nuclear medicine for the 12th World Congress of the World Federation of Nuclear Medicine and Biology in 2018. I am proud that we can undertake research, try new techniques, and provide a great clinical services in a small private practice. This helps us stay at the cutting edge and provide the best possible care for those that chose to use our services. We will look after you!
On the website I have posted an abstract re corticosteroid injections for osteoarthritis of the knee. The study findings more or less mirrors my years of clinical experience with this intervention -the benefits are short term and generally more effective for milder degrees of OA. No one has yet directly compared corticosteroid, viscosupplementation, and platelet rich plasma injections all of which are used in similar clinical settings. Generally a pragmatic approach is taken for treating OA knee which includes mostly “try and see” for each of the available injection options, as well as other symptomatic options (analgesia, NSAIDs, acupuncture). Everyone should be encouraged to do regular quadriceps exercises.
The last two months have been busy. Mostly finishing and upgrading our study on xSPECT bone -making it (we hope) of sufficient standard for publication. Also on PRP therapy (both undertaking injections and reviewing the literature). An update on therapy for lateral epicondylitis has been added to the website.
The latter shows that if any therapy is required for lateral epicondylitis (common extensor tendinopathy and tears) then PRP injections is the preferred option.
We also has some visitors from “over the ditch” (New Zealand) who came to learn about PSMA SPECT/CT which is an attractive option in NZ where PET scans are expensive and generally not covered by the healthcare system. We have now done about 50 scans and they are living up to our performance expectations.
I was delighted to see that the first publication from the Australasian Radiopharmaceutical Trials Network has arrived and can be found online here. ARTnet supports multi-centre research in Australian Nuclear Medicine and is a joint initiative of two organisations that I am a (proud) member of, the Australasian Association of Nuclear Medicine Specialists and the Australian and New Zealand Society of Nuclear Medicine Ltd . It was established several years ago to address the need for a formal research network in Australia for a collaborative, multicentre clinical trials utilising radiopharmaceuticals for imaging or therapy.
The trial shows the clinical value of PSMA PET scanning in the management of prostate cancer. While PET PSMA remains difficult to access for many I am confident that our recently introduced xSPECT/CT PSMA scans at GMI can prove equally useful.
We have been working hard on these since we started earlier this year (see March 2017 below), and can now produce outstanding quality images. Based on experience in Germany and several early publication (eg from New York Presbyterian ) the Tc-PSMA is providing equivalent results with a very high sensitivity and specificity for prostate cancer. For those of you who wish to know more about PSMA I will, eventually, write some more about it from a patient’s perspective. There is a brief introduction at Garran Medical Imaging.
I have also updated my post about PRP therapy for osteoarthritis after 2 years more of experience and journal monitoring.
I didn’t spend much time on nuclear medicine in July as I was best man at my brother’s wedding in Scotland. It was an awesome, auspicious, and joyful event that I thoroughly enjoyed. The summer weather wasn’t kind but the scenery spectacular.
I have updated my article on back pain and bone scans following belatedly following the publication of an article showing the utility of SPECT/CT bone scans in the clinical workup for patient with lower back pain. The practice at Garran keeps me challenged but I am off to Europe for three weeks!
A recent publication in Clinical Nuclear Medicine demonstrated that 99mTc-MIBI SPECT/CT enhanced the performance of conventional imaging for renal tumours, improving the characterisation of benign v malignant lesions and lowering the possibility of misclassification. They demonstrated that sestamibi (a tracer usually used for myocardial and parathyroid scans) has an avidity for oncoytomas but not renal cell carcinomas and this correctly predicted benign lesions pre surgery. For more information see the original article here and they Auntminnie article here.
Also from Auntminnie this month a brief comment regarding an industry-supported study of more than 600 adults with knee osteoarthritis in five countries showed that compared with placebo with a daily dose of pharmaceutical-grade chondroitin. The latter improved pain and function as much as the anti-inflammatory celecoxib. At the 1-month mark, celecoxib improved symptoms the most, but by 6 months both were similarly effective. Chondroitin is widely available and is becoming a useful adjunct in the management of knee osteoarthritis. The mainstay of early to moderate OA (more about the stages of OA knee here) of the knee remains quadriceps tone/strengthening, simple analgesia, and sometimes viscosupplemenation or PRP -more information for patients here.
I draw your attention to two recent publications that concern osteoarthritis of the knee. Published in the Journal of the American Medical Association the first study shows that frequent intra-articular steroid injections do accelerate cartilage deterioration. The second in Radiology confirms that those “who lost weight over 48 months showed significantly lower cartilage degeneration, as assessed with MR imaging; rates of progression were lower with greater weight loss.”
I presented my data on the first 200 cases of xSPECT bone at the Australian and New Zealand Society of Nuclear Medicine meeting in Hobart this month (abstract O60). A summary this research can be found here.
Diagnostic Imaging in Canberra took a leap this month when Garran Medical Imaging undertook Australia’s first Tc-PSMA scan. This will be an invaluable adjunct to assessing and managing prostate cancer. Currently it is available only under the patient special access scheme but we can aim to get approval and import the tracer within 1-2 weeks following a request. We are able to use our direct quantification to assess lesions both for diagnosis and for response to therapy.
I read an amazing book PEAK –Secrets from the new science of expertise, by Anders Ericsson and Robert Pool. I don’t generally recommend books to a wide audience but this is something everyone should read. It turns so many accepted dogmas on their heads and does it using years of research and some very careful observations. I wish I had read it when I was young, but of course it wasn’t written then! Certainly teachers and anyone trying to push themselves should read this. It is quite uplifting and empowering.
The year has moved into full-swing this month. Managed to get the years travel planning and data collection in order. I have found the memento database a great tool for data collection and/or creating reference databases. This allows you to create a database entry “app” on you android phone which you can synchronise with others and with google sheets. The latter allows you to collect data for later analysis and to update entries on a recurrent basis (for me that means subsequent treatments, visits, or scans).
February was also full of hot days and spectacular sunsets.
As a small operator in a field where large corporates and giant businesses are the norm I take some solace from the following equation (where did I read this?):
LONGEVITY + DOMINANCE = INNOVATION x GOVERNANCE
The dedicated small team at Garran use the excellent advantage we have on the right side of the above equation to compete effectively in a relatively crowded marketplace. We have clear advantages in innovation and customer/patient services and are still able to offer a better price than our larger competitors. On the innovation side we have several specific projects in 2017:
- Use of PRP therapy for unhealed split tendon tears and osteoarthritis
- xSPECT bone in musculoskeletal imaging
- Intrinsic elastography in the evaluation of tendon pain
- Shearwave elastography for liver disease
- Assessing response to denosumab (Antiresorptive) therapy in metastatic bone disease using quantitative bone imaging
- Evaluating Tc-PSMA in staging prostate carcinoma
I really enjoyed a low key Christmas and New Year. I had a chance to reflect on the highs (and lows) of 2016. I think most of us take time out during the holiday season and as I write this I am feeling that gnawing feeling that I need to start doing 2017 things. My whiteboard has been cleaned and the multiple tracks I intend to follow for 2017 are in place. So now I need to start. That means designing a lot of new tools for data collection, considering what abstracts to write and what meetings to attend, and planning any overseas trips. Our modern professional lives are information rich and time poor. Over commitment is easy and though there are useful suggestions to follow we inevitably underestimate the time commitment each project or activity requires. Annie Gibbins has some useful tips but I’m still left with the problem that I enjoy and find rewarding a long list of activities.
Reflecting on 2016 I acknowledge that the amazing xSPECT bone technology I use remains in the “wings” and that its clear superiority over conventional SPECT remains underappreciated by the professionals and patients who might most benefit. Most medical breakthroughs and new technologies have slow uptake and of note my life partner Shelley is no stranger to my “impatience”, particularly in traffic. The benefits are self evident -see images comparing SPECT and xSPECT of the same slice in a C2 vertebra. The pathology is clear in the xSPEC T image and remains undetectable in the SPECT image. I have submitted an abstract on xSPECT bone scanning for the ANZSNM scientific meeting in April, which may keep the professional interest growing.
Hoi An proved to be a food frenzy for several days with lots of wonderful local restaurants. I ate too much. The local culture, architecture were also interesting -thanks to our local guide Ruby.
Back in Canberra and back to work. Carl von Gall visited us from Siemens Healthineers and we shared our vision about the clinical potential and possibilities of both xSPECT and bone quantitation. I am hopeful we can link up with other sites around the world evaluating these technologies so we can maximise the clinical benefits.
I am also hopeful I can share on the web some of the data from many of our current projects. Soon the numbers will reach meaningful levels: PRP therapy, xSPECT bone, direct Bone quantitation, and liver elastography. We have now completed over 500 liver studies (for a simple video about liver elastography see here).
Only November but the agenda for 2017 starts…
I had the great pleasure of being asked to be the guest of honour at the Ho Chi Minh MSK Seminar, the first ever in Vietnam. Over the last month I have spent all my spare time to prepare. It has been a great deal of work to bring my entire MSK lecture syllabus into line for 2016, but this is all part of the great professional journey I’m on. No image used was more than 12 months old.
So I thought I was ready for everything when I hit the ground on Vietnam 2 days ago. Then I discovered the wide range of doctors and skill sets attending. Then I was informed there was a wide range of english comprehension. So this was a much bigger task than the usual discomfort of facing an Australasian audience.
I tried to respond as much as possible to everyone’s expectations.
It was a daunting task talking to 180 Vietnamese doctors from a wide variety of backgrounds for several hours, including live scanning.
Additionally most were wired in via live interpreters and I had to slow down as much as possible. Still it was a rewarding experience and will hopefully advance the utility and skillset of musculoskeletal ultrasound in Vietnam.
I was treated like a rock star with great hospitality from the conference organisers and from the sponsors of the meeting, Samsung Medison. My entire lectures series and live videos will be distributed to the participants and will hopefully become part of a teaching resource.
As someone who lives at the front end of technological change it is sobering to realise that most of the world cannot afford the technology we accept as “routine” in Australia. Ultrasound needs to be used to achieve much more in Vietnam as it is the most available diagnostic resource -none of Garran Medical Imaging’s high tech xSPECT scanning is available here.
I will now relax for the next few days and enjoy a short vacation here in Vietnam, below the radar as much as possible.
August came and went too fast. Demands for my time are many and prioritisation is not a natural skill. Several representatives from Samsung Medison visited Garran Medical Imaging since my July post. I delivered some data that will help ongoing work with shearwave liver elastography and I have been invited to Seoul later in the year for a meeting with the R&D team about ongoing development of another technology (can’t disclose just what). I was delighted to talk to some of the Oncology team at The Canberra Hospital about the possibilities of quantitative bone scans for evaluating metastatic disease and its response to therapy. We have also introduced TTR amyloid scans to our lineup (see image).
This was in response to a request and I was pleased we could develop the scan so quickly using a combination of old ideas and new technology. Our first totally novel application of direct quantification in soft tissue (cardiac).
I am pleased that our model at Garran Medical Imaging is showing that private medical imaging practice can provide cutting edge technology at an affordable price and accumulate data that will participate in the ongoing development of these technologies. Eventually I will be able to share some of results of our interventions (ultrasound) and data about our new technologies directly on the web.
I am looking forward to a visit to Vietnam next month where I will be giving a series of lectures on Musculoskeletal Ultrasound in Ho Chi Minh City.
Winter in Canberra has been wet but not so cold. The snow came and went briefly but is still seen atop the Brindabellas. In town we installed our direct quantitation system which allows us to measure directly the amount of technetium tracer uptake in a given volume of tissue. This in combination with our xSPECT bone system gives us a sensitivity and specificity of assessment that breaks new ground. Once again I am (excitedly) faced with assessing a significant increase in the quantity and quality of data now available in every case. It will take some years to figure out the meaning of all the detail and several years for this combination of technologies to become more widely available. I have already written a database and have commenced collecting data for later analysis, which will hopefully give us new insights and uses for this additional data. The lesion seen on the right is less than 2mm but can be shown to be a metastasis by directly measuring its uptake of technetium MDP (SUVmax=11.7). This lesion would be considered a simple bone island on almost every scan in current use. For more information about quantitative bone imaging see my post at Garran Medical Imaging here.
Also for those astrophysicists out there please note that dark energy (and matter) are a consequence of inflation (after the big bang) and only when we tie string theory to inflation will it become clear! Please remeber that you read it here first.
June is looking wet so far. So wet that I needed to do a video update on the first 154 cases of xSPECT done at Garran Medical Imaging. I review both the conventional SPECT and the new xSPECT images sequentially on every case. This data is anonymously collected and will be carefully dissected, but the big picture is already emerging. xSPECT bone imaging is awesome -check out my 1 minute video “Molecular Imaging without compromise“.
May has been my busiest month this year. I had a great break in New Zealand after the ANZSNM meeting in Rotorua. My presentation on xSPECT bone imaging was very well received and it was great to get such positive feedback. Some of the image sets will be used by Siemens at the upcoming SNMMI (Society of Nuclear Medicine and Molecular Imaging) meeting in San Diego. I hope I can help enthuse others to take up this amazing imaging technique -but as is so often the case in 2016 they will have to make a business case or convince the “purse string” holders to spend the additional money. Good luck to them. I was also invited to talk on shearwave elastography at a hepatology evening here in Canberra. The meeting was attended by about 70 local physicians interested in hepatitis C and fatty liver disease and was buzzing with the excitement about the new drugs to treat and eradicate hepatitis C which have a greater than 90% success rate.
I am pleased that the team at Garran Medical Imaging is working out so well. Everyone provides such great support to each other and the patients. Our patients/customers are our greatest promoters with over 97% recommending us as their preferred imaging provider. Our GMI facebook reviews reflect this.
I enjoyed speaking at and meeting many practitioners at an Capital Health Network event sponsored by Garran Medical Imaging . My topic was Imaging Musculoskeletal Pain. A complex topic which is difficult to simplify -but I attempted in this flowchart (click thmbnail for full image). Unfortunately there are lots of patients who don’t follow this chart! Most particularly all large joint (elbow, shoulder, hip and knee) need to head straight for MRI.
I am heading off to Rotorua in New Zealand for the ANZSNM conference and a short break. Should be great fun and I get to talk about my favourite topic xSPECT bone. Looking forward to a bit of Kiwi magic.
New evidence suggests that corticosteroid injections within 3 months of a total hip arthroplasty increases the risk of postoperative prosthetic infection. Interestingly those who had an injection between 3 and 12 months did not have this risk. I will certainly change my advice based in these findings -see this latest addition to our abstract category here.
The year accelerates in February with everyone trying to organise the year ahead as we realise we can’t put it off any longer. Trying to prioritise is difficult but once done JUST START. Be proactive not reactive.
If getting into shape is on the priority list then I recommend consider measuring your whole body fat with a body composition scan, checking your cholesterol, then start High-intensity interval training and /or one of the diets popularised by Michael Moseley, such as the (fast) 5:2 diet. If you like intstructional video check out Fitness Goat. After 2 months repeat the tests and assess your response. As well as improving your health it will improve your healing and wellbeing. If you already have problems with fat around the organs, especially liver, then this is especially important. Though not widely utilised shearwave elastography of the liver can not only assess liver damage in those with liver disease, it can also assess whether your liver improves in response to lifestyle and dietary interventions. If you want to understand more about it see my new video.
I have written an update on PRP for osteoarthritis as I have been inundated with questions and requests for this procedure. It is likely only to be useful in relatively mild or early osteoarthritis but does seem to provide some significant pain relief in many.
Happy New Year. I look forward to 2016 and completing a lot projects that are currently under way. Currently I am collecting data on xSPECT-CT nuclear medicine (in comparison with SPECT-CT), on liver shearwave elastography, on the potential applications musculoskeletal strain elastography, and on clinical outcomes from PRP injections. I will also be commencing another project in collaboration with Siemens during the 2016 year (more about that later). I anticipate this will keep me busy and fulfilled. I hope all of you can find plenty to challenge you in 2016. All of these exciting new developments are taking place in the ground-breaking Garran Medical Imaging.
For those interested in Sports Medicine check out this study on Vitamin D levels and stress fractures. I have also updated the thyroid biopsy post after reviewing several of the studies from last year and some yet to be published presented at RSNA 2015.