from Dr Iain Duncan…
New to the site are some of the American Academy of Orthopaedic Surgeons’ recommendations for management of rotator cuff tears.
I have recently perused the 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee published in Arthritis and Rheumatology in January. While I agree with more than 90% of the recommendations there are a few I believe are conservative and ignore some pretty good evidence in favour of the status quo -most particularly those regarding intra-articular hyaluronic acid (HA) and Platelet-rich plasma (PRP) injections. The recommendations are based on a consensus from experts in the within the American College of Rheumatology and Arthritis Foundation after a review of the literature. In regard to specific recommendations they do not provide a formal analysis or rarely list the pivotal literature. Though generally recommending against HA the guidelines state: “In clinical practice, the choice to use hyaluronic acid injections in the knee OA patient who has had an inadequate response to nonpharmacologic therapies, topical and oral NSAIDs, and intraarticular steroids may be viewed more favorably than offering no intervention, particularly given the impact of the contextual effects of intraarticular hyaluronic acid injections (38).” The guidelines also capitulate with the longstanding belief that IA steroid injections have a better evidence track record: “In OA generally, intraarticular glucocorticoid injection is conditionally recommended over other forms of intraarticular injection, including hyaluronic acid preparations. Head-to-head comparisons are few, but the evidence for efficacy of glucocorticoid injections is of considerably higher quality than that for other agents.” I believe this statement is incorrect and that evidence standards were simply lower 30-40 years ago, when the steroid lore was established. When you go back and carefully scrutinise the evidence, the study designs are no better than recent studies of HA and PRP. Indeed this study from Gormeli et al (2017) of HA and PRP into knees is as good as it gets (randomised, double blinded, and placebo controlled) -see my brief analysis here. Furthermore this meta-analysis provides further evidence of the benefit of PRP and HA in osteoarthritis. The guidelines make no comment as to how they come to their recommendation regarding PRP, which I suspect remains in the too difficult category for analysis.
Most of the patients referred to me with osteoarthritis for intra-articular injection have failed almost all the standard recommended therapies and are either too old or too young for joint replacements. It would be hard to refuse therapies to these patients with significant pain and dysfunction on the basis of ACR guidelines, particularly where the risks are lower than with corticosteroid and the potential benefit probably higher.
January & February 2020
Summer has been a troubling time this year with ongoing bushfires, perpetual smokey haze, extraordinary temperatures, and later the spectre of a novel coronavirus. In some way these have affected us all and make it hard to adopt the “business as usual” attitude. Even when I “escaped” to the south island of New Zealand (for a family wedding) the smoke from Australia was evident on several days. Still the pack rafting was both hard work (carrying the raft upstream) and exhilarating (paddling it down again).
Like many I have been filled with some existential angst about wanting to take some action to reduce mankind’s impact on the planet, but believing I can make little difference. I also tell myself that I can work best where my skills lie, by helping those patients who come through our practice. There is much to be done in achieving better health outcomes in a caring and sensitive way. I usually focus on the technical and clinical aspects of my practice, but I am aware how much more (holistically) is needed to provide better care. For those who really want to learn more about patient centred care I recommend reading Patients For Life by Shelley Thomson.
So every year there are new challenges, some expected and some not. I will endeavour to take most of them on (or ask others to help), which is a recipe for being busy, but will it be productive? Some of what we do at GMI is generally not available in many parts of the world or even Australia. I believe I should spread our experience and (perhaps) wisdom, but in practice it is hard to do from a small, busy, single practice. This year I have submitted 3 abstracts on Tc-PSMA in prostate cancer to the ANZSNM conference in April and have agreed to giving a lecture on Quantitative SPECT: From Theory into Practice at the Society of Nuclear Medicine and Molecular Imaging in New Orleans in June (SNNMI 2020). Hopefully like my trek in NZ, if I cover the hard yards upstream then these activities will have a significant “downstream” effect, even if not for a few years.
The holiday season is upon us again, but December often turns out to be frantic before Xmas. I recently spoke at an education evening about Tc-PSMA in prostate cancer, and I include a window into our experience here. I am hopeful that I will cobble at least some of the data together for either a publication or at least an abstract at the 2020 ANZSNM meeting in Sydney. However it is likely this project will be competing with others for attention in the 2020 year. As the popular Mark Manson (Everything is F*cked) said (and I may be paraphrasing) “freedom is the ability to choose your pain.”
An update on liver elastography.
A publication in Radiology Online cautions us about significant complications following intraarticular corticosteroid injections for osteoarthritis, though the authors do concede these case studies do not necessarily imply causation. The phenomena of accelerated OA progression, subchondral insufficiency fracture, osteonecrosis, and rapid joint destruction can all be seen in patients with OA who have not had injections. Sometimes they are misdiagnosed as OA and the have an injection before the recognition of the diagnosis.
I am saddened that due to circumstances beyond my control I will no longer be travelling to Bega and the South Coast. This ends a long relationship with many people, staff, and doctors on the far South Coast. Recently South East Radiology was purchased by the Qscan group and new management has elected not to continue with the existing service arrangements with GMI (Garran Medical Imaging).
A big thanks goes to all those who worked with me at Bega over the last decade -your support and kindness was greatly appreciated. I hope to keep in touch with many of you. Of course any patients who would like to journey “up the hill” to Garran Medical Imaging are most welcome.
On another note a recent met-analysis shows there are only 4 factors that have been found to predict progression of hip joint osteoarthritis. To some extent these are not surprising and 3 of them correspond to the x-ray appearance of the hip (an x-ray is still a valuable tool). The fourth factor relates to co-morbidity, ie general health of the individual.
I will be talking at both the ANZSNM Capital Region Forum and the ASA SIG meetings this month. The former will be a lecture on xSPECT/CT bone and the latter on rheumatology ultrasound, both subjects I can get a little passionate about…
For those interested in xSPECT/CT bone imaging my lecture at the World Molecular Imaging Summit is now online here.
For those with chronic pain there is a great new system and management resource at Brain Changer.
We are now importing our Tc-PSMA from Hungary and have noticed a significant improvement in image clarity. It is very clear that these scans are having a significant impact on therapy for prostate cancer.
I was impressed by a recent paper on PRP and viscosupplementation injections for rotator cuff tears –see my comments here. I believe there is sufficient evidence to offer these injection options with some confidence about improving outcomes for patients with these smaller cuff tears, which (untreated) often progress over time. Check out the evidence for yourself here.
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 xSPECT 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.