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Philips Forte Recall and Stop Use Order: What You Need to Know

Posted on: 12.05.19

Philips Forte Recap and Stop Use Order

If your practice is using the Philips Forte Gamma Camera, then you should have been in receipt of an urgent stop use notice as of September 19, 2019.

Philips’ Senior Manager of Post Market Surveillance issued an urgent field safety notice to all users of the Forte family of cameras to discontinue use until further notice. This applies to all Forte cameras, including the Powerpack, the Jetstream, or systems refurbished by Philips.

This obviously has a major impact across the imaging world – many of these cameras are still in regular use across the U.S., Canada and other countries.

Here’s what you need to know:

What is happening?

Philips issued the stop use order on September 19, following an incident that was reported by a customer in Germany. Philips warns in their stop use notice:

“There is a possibility that a detector may fall unimpeded vertically to the end stops of its travel limit, due to mechanical failure, possibly making contact with a patient that could result in entrapment, serious injury, or death.”

This raises some serious questions for facilities that rely on the Forte family of cameras for nuclear imaging. What is being done about it and how long is it likely to take?

Get the bonus content: What to Look for in a Mobile Imaging Provider

First of all, Philips has been working to offer a field repair, however, at this stage, there is no timeline for this or information on how it will work. One thing to remember is that any field repair they propose will have to be scrutinized and approved by the FDA first. This means it is difficult to put any kind of timeline on repairs prior to approval.

Most sources close to the stop order say “months” if asked to give an estimation. The earliest we’ve heard is March 2020. This has affected hundreds of users across the country and of course, their patients. The talk in forums has included backlogs of patients and potentially lost referrals due to reliance on a Forte camera. A wait of months really won’t work for many facilities.

The bottom line is if you’re relying on a Philips Forte gamma camera, your imaging services could be out of commission for an untold period of time. If it is going to drastically affect your ability to serve patients and continue to receive referrals, then you may need to look at alternative choices.

A note on camera age

One thing that is noteworthy about the Philips Forte series of cameras is that it has been several years since the company declared them “end of life” (EOL). However, facilities that still operate the cameras have been able to do so by getting parts and servicing through third-party providers.

The newest Forte model hasn’t been manufactured since 2004, so all cameras are fifteen years old or more. Generally speaking, when you have a camera that is approaching the ten-year mark (since its manufacture), then it will be almost EOL.

It is risky to continue using a camera beyond this point because the manufacturer has already declared that they can’t support it anymore. This means the manufacturer has made the decision that they can no longer reliably repair and maintain the system. It isn’t necessarily about planned obsolescence – sometimes there are subcomponents that are no longer being made, meaning the manufacturer couldn’t make repairs even if they wanted to.

The risk is highlighted here with this stop use order. If you’ve been relying on third-party suppliers to maintain and repair your camera, they can’t do anything about it once a stop use order has been sent out. You’re left waiting for a field repair that may be difficult to make happen.

What do we recommend? If you have cameras that are approaching ten years old, you should be making plans to replace it. While third-party suppliers might keep you going for a bit longer, you can’t always find reliable repair and maintenance. There’s a real mixture out there in terms of quality and availability. If you’re running a state-of-the-art medical practice with patient care at the center, then taking heed of manufacturer’s EOL for devices is essential.

What are your options?

For most imaging facilities, a wait of months is simply not going to work for their business. It will mean loss of patients and significant backlogs for imaging studies. This means that if you have no other cameras available, you’re going to have to look for alternative options.

There are basically three ways you can go:

Buy a new camera

This is definitely the most costly option upfront. However, if you conduct an analysis of the volume of studies that you need to perform each month, it may make sense to purchase a new camera.

As a general rule, we’ve observed that a facility that conducts more than 100 studies per month tends to have the financial viability for purchasing a camera. Below that, you have to look at temporary staffing, or hybrid approaches to make financial sense.

If you’ve decided that buying a camera is the way to go, then you’ve got another choice to make; buy new or buy refurbished?

A new camera will, of course, cost more, however, you have the advantage that you’re getting it right at the beginning of its service life. You have the choice to get something with the latest technology embedded and you know that the camera is actively being maintained and managed by the manufacturer (hence avoiding a Forte scenario).

A refurbished camera is generally a cheaper option and may make sense for medical facilities that just don’t have the budget for new. You can still get some very high-quality imaging equipment, however, there are a few key things to be aware of:

  1. The age of the camera. Does it still have a significant amount of time before its end of life?
  2. The technology and operating systems – how do these compare with the technology in brand new cameras?
  3. Maintenance and repairs. Are parts readily available and will the manufacturer still service it?
  4. Image quality. Does the camera still produce images of a quality that is acceptable for the types of studies you usually conduct?
  5. Connectivity. Many older cameras can’t be upgraded to current software versions or patched securely. This would mean they can’t be connected online due to the risk of data being accessed improperly.
Get the bonus content: What to Look for in a Mobile Imaging Provider

Rent a camera

Gamma camera rentals can be looked at in a similar way to how you’d compare either buying or leasing a new car. Leasing gives you the advantage of access to a new model without the large payments of purchasing.  There can also be incentives to buy, just like with a car.

Rental terms can be virtually anything – weeks, months or years. Like most rental agreements, there’s usually incentive to rent for a longer period with cheaper payments.

Another plus on the side of rentals is that they can give you the opportunity to “try before you buy.” You might want to test out a type of camera before committing to purchasing it and rentals give you the opportunity to do so.

Of course, if you’re leasing a camera that is nearing its end of life, you can simply rent a newer camera without the financial commitment of purchasing.

Mobile service

A mobile service (such as that offered by Digirad) offers you flexibility in terms of timing and location for the service. You get to have state-of-the-art equipment available to your patients and you could choose to use this type of service as a stop-gap while you’re waiting on your Forte repair.

Opting for a mobile service also means that you don’t need to reconfigure your imaging suite for a different camera, especially if you’re using the mobile service while you decide on a new purchase or while you wait for repairs.

For some medical facilities, analysis of study numbers might reveal that it’s not worth the cost of buying or renting across fixed periods of time. Perhaps it makes more sense for a mobile service to come in at certain intervals and take care of all of your imaging needs. For example, you might have a mobile gamma camera come out every two weeks.

Final thoughts

The Philips Forte stop use order is having a major impact on many imaging facilities. For some, this will lead to backlogs and lost patients. A wait of months for a fix simply isn’t a feasible option.

We see this as a cautionary tale about what can happen when you continue to use cameras past their manufacturer’s end of life. It’s always better to be using equipment that will still be maintained by the manufacturer.

For facilities that can’t wait for a repair, your options are to either buy a camera, rent a camera or hire a mobile imaging service. From the information we have, any of these options will at least have you up and running well before a repair is available.



How Old Is Too Old for a Nuclear Cardiology Gamma Camera?

Posted on: 09.12.19

Is your practice running an older gamma camera and, if so, how old is “too old” when it comes to those systems?

If you think that manufacturers simply want you to keep upgrading you’re right, but there’s much more to the equation. Here’s when you should be considering upgrading your old camera for a new model:

1. The camera is reaching the ten-year mark

Technologists are very familiar with the cameras they use and any limitations that go with them, so what should cause them to decide it’s time to buy a new camera?

One of the first things is if the camera is ten years old or more. When you’re approaching the ten-year mark, you’re reaching “end of life” support provided for the camera by the manufacturer.

When a camera reaches this age, the original manufacturer has determined that the vintage of the parts is such that they can no longer reliably repair and maintain the system. The OEM is saying that they can’t support the machine anymore to the standards of the industry should be a huge red flag to your clinic.

What happens once the OEM has decided they’re no longer able to offer maintenance for the machine? There is a third-party parts market available – some of those businesses are great, but some are questionable. The specific part you need to repair your older nuclear camera may be available out there somewhere. There are warehouses full of them – some refurbished, say from machines that were sold for parts. It’s a real mixed bag in terms of what’s available.

Get the bonus content: How to Choose a Nuclear Cardiology Gamma Camera

A lesser-known reason that OEMs declare products as “end of life” is at the subcomponent level rather than the main part. Let’s say there’s a multiplier tube where the tube itself is still available, but there will be a specific connector or other subcomponent that’s no longer available. Once those small pieces can’t be found, that multiplier tube can’t be repaired. While of course manufacturers want you to buy their new equipment, those subcomponents are the greater reason for OEMs ceasing to support the machine.

It’s important to note too, that when we say ten years, we mean ten years since the date of manufacture. If you bought a camera five years ago refurbished and it was ten years old at the time, you have a fifteen-year-old device. This is a risky proposition when you consider needing to make repairs for things like routine wear and tear. As soon as your camera is nine years old, you should be seriously making plans for what you’re going to do about replacing it.

Plan to replace gamma cameras that are approaching ten years old Click To Tweet
How old is too old for a nuclear gamma camera?

2. The camera is becoming inconsistent

Every day, technologists perform a set routine of quality control tasks to ensure that the system is operating as it should be. They check that it is performing to its original specifications and that it’s performing well enough to provide diagnostic quality studies.

What can happen is that over time they start to see “specification drift.” The tolerance level (such as for intrinsic spatial resolution) might drift to within plus or minus 10%, then all of a sudden shift outside of those bounds. Now there is a need to get the system serviced, so they’ll be calling in a service person to do this.

While drift does happen, it’s not something that should be common – maybe once or twice a year at the most. If a system starts to drift outside of tolerance levels every couple of weeks or monthly, then it’s suggesting there is an issue with it starting to wear out.

When you reach this stage and you have an older machine, you can face the scenario where it takes several days of your system being down for repairs to be made. Often one thing leads to another and more than one part or subcomponent needs repair or replacing. This is a risk for doctors, especially in competitive markets. If they’re having to ask patients to reschedule, there’s a chance they may go elsewhere. It’s a sign that the machine really is reaching the end of its life when repairs take longer than usual. Regular repairs on a healthy system usually take less than a day.

3. Results are questionable

Another issue related to consistency is if clinicians start to notice that they get a lot of positive studies, or (possibly worse) a lot of negatives. One thing that no one wants is for treatable conditions to be missed because of false negatives. If clinicians are starting to question their confidence in what they’re looking at, then this can be a sign that the camera is too old. Sometimes there will be a noticeable decline in image quality.

4. Further spend on the machine doesn’t make sense

If there is a serious malfunction with the camera, such as where a crystal cracks and you’re looking at putting tens of thousands of dollars into fixing the camera, it is worth pausing.

If you’re going to put $30,000 or more into a camera that is ten years old or more, you’re potentially putting good money after bad. It should give you pause to consider whether that money is better spent being put toward new equipment.

There is often a tendency to grind the most possible use out of any camera. It makes sense when you consider how much is usually invested in the camera. New nuclear gamma cameras can cost over $200,000, so clinics want to get the most they can from them.

On top of that, many physicians assume that “paid for” can’t be beaten. So if they’ve paid off their current camera, they see it as purely producing them profit. However, you need to look very carefully at those numbers.

Get the bonus content: How to Choose a Nuclear Cardiology Gamma Camera

Let’s say you’re used to doing ten studies per day and your camera goes down for a week. You’re now behind 50 studies. If you’re charging $800 per study, that’s $40,000 behind. You might assume you can simply reschedule patients and make that back, but the reality of any rescheduling situation is that you almost never get all back that you started with. Life happens and people fall through the cracks, while others will be anxious to get their study done and will schedule elsewhere.

If you would have been paying $3,000 per month for a new camera, it only takes four missed studies on the “paid for”, older camera to put you behind where you would be financially with a new camera. These are the kinds of things that need to be factored in, but are often missed by clinics.

Nuclear Gamma Camera purchase planning

5. Newer technology could be a game-changer

Most practices will have their “norms” based on the equipment and processes that they have. For example, if you have an older machine, perhaps six studies per day is normal.

However, newer systems can help to shift the boundaries of what has become the norm for the practice. Instead of six studies per day, you might be able to do twelve or fifteen, significantly improving output.

This plays out with the differences between single, double and triple-head cameras. Over time, more heads win. With a single head, you might try to move patients through more quickly, but as a general rule image quality will suffer.

Newer technology can improve the quality of your outcomes for patients as well as the speed with which you’re able to get results. Let’s just say right now – if you’re still running a single head camera, those were great machines in the 1980s. Newer technology means that it makes little sense to continue running the single head.

Summary: The obvious signs you need a new gamma camera

  1. The system goes down often
  2. When the system goes down it takes longer to repair
  3. The camera was manufactured ten years or more ago
  4. You want to realize some residual value and the age of the camera is approaching the “sweet spot” of seven years old or less.
  5. You sense that your practice could benefit from the flexibility offered by newer technology.



Enhancing the Pediatric Patient Experience with Point-of-Care Imaging

Posted on: 08.01.19

If you work in children’s healthcare – especially within radiology and nuclear imaging department of the hospital – you know from personal experience that pediatric patients can be anxious around large machines, new people, and even the clinical environments of the radiology department itself.

You’ve tried your best to make both children and their parents feel at ease, but you know that even the most soothing bedside manner can only do so much when dealing with children who are scared and don’t fully understand what’s going on.

Point-of-care imaging is a proven way to make the imaging process easier for both pediatric patients and nuclear technologists. A portable camera allows you to perform many studies bedside and avoid having to bring the child to the radiology department.

In this post, we explore five critical ways that point of care imaging affects pediatric radiology.

1. Pediatric Patients Receive Care in a Familiar Environment

The nuclear medicine department can be an intimidating place for children. There are new care providers involved and the unfamiliar environment can create uncertainty.

When a portable camera is brought to a young patient’s room, you’re starting off on a much better foot. Even if they don’t fully understand the process, they stay in a familiar and safe environment.

In many cases, you’ll only need one nuclear tech to perform the study, which can help to alleviate a child’s anxiety.

2. Reduces the Need for Transport

Physical comfort is an essential part of any patient care in the hospital, but it’s especially key when you’re working with children. When providing nuclear imaging, it’s essential to keep the child’s movements to a minimum.

Depending on the severity of a child’s case, even a short trip to the radiology department could require careful planning and multiple team members. Portable cameras, like the Digirad Ergo, can come directly into a child’s room in the hospital so they don’t need to travel for imaging.

Because the Ergo has an open gantry, working around the patient is flexible. You can position the camera in many different ways so that you can move the Ergo instead of the patient. This way, you have much more flexibility when it comes to capturing the images you need.

In some cases, parents and loved ones may even be able to hold their child while the imaging happens.

3. The Ergo Camera Minimizes Time Spent Under Anesthesia

Perhaps one of the most valuable things about point-of-care pediatric imaging is that it helps children spend less time under anesthesia.

The Ergo can be used in the operating room and allows for visual confirmation of results in real time so that you can ensure the surgery was a success the first time.

The ability to image in the operating room removes the need to transport the patient, while under anesthesia, to the radiology department.

4. Custom Graphics Make Imaging Fun

Digirad created a pediatric version of the Ergo camera with wrapped graphics that feature our favorite character, Gina the Giraffe. The truth is that fun graphics featuring characters and animals can help children to stay calm and even distract them during the imaging process.

Children can ask Gina questions and look to her to help them to stay still and relaxed. It’s one little way to make an intimidating experience fun for children!

5. Children Can Stay With Family Members

Many children experience separation anxiety from their parents and other family members over the course of a normal day. When they think they’re going to be left at a hospital and have to undergo procedures on their own they may feel upset or even scared.

Because the Ergo nuclear medicine camera is portable and can be brought directly to the child’s room, parents can stay with the child throughout the process (depending on the specific scan).

Anything that you can do to keep the child feeling safe and secure will make the scan much easier on everyone.

Making the Move to Point-of-Care

As a medical professional, you’re committed to making all of your patients feel safe and well cared for, but it’s especially important when working with pediatric patients.

We hope this post has helped you to understand how point-of-care imaging can improve the patient experience for both children and adults (after all, everyone can benefit from its portability.)

For patients that need nuclear imaging, Digirad’s Ergo camera can give you the best possible outcomes while also keeping your patients comfortable and relaxed.



A Successful Stress Test Beyond Meeting Minimums

Posted on: 05.30.19

The 85% minimum is well known for administering a stress test, but is it really achieving what you need? Are we best serving our patients if we push for that 85% minimum and no more?

There are many reasons for a patient to go through an MPI stress test, with each patient having their own story and set of circumstances. Our view is that the best possible stress tests are planned in collaboration with the patient and take their individual case into consideration.

There are other important factors to look at and some good reasons to go beyond minimums – let’s take a closer look:

The 85% minimum for stress tests

The main part of a stress test is the treadmill exercise portion, where the patient progresses through levels of difficulty. At a minimum, they need to reach 85% of their predicted heart maximum. This maximum is calculated using a formula based on their age and heart rate.

85% is the minimum expected to achieve an adequate test and for the technologist to give the injection of the radioactive isotope. In the field, most technologists tend to follow this 85% rule, give the injection immediately, then terminate the test.

Get the bonus content: Steps for Preparing Patients for an MPI Stress Test

However, there are so many other things besides that 85% that you should be watching. For example, the EKG, how well the patient is doing, their blood pressure and their METS. Also, if you can reach 90% or more instead, why not go for what you can? 85% is just a minimum and you have the potential to learn more and get better data to make better-informed decisions for the patient if you go for more (within reason, of course!)

When I posted some of my thoughts on this on LinkedIn, I got this response from Gautham Ravipati, Interventional Cardiologist at Texas Health Resources:

“The validity of an exercise stress test with and without imaging regarding true sensitivity [negative predictive value] for ischemic heart disease is

1]Not only dependent on THR achieved/and or double product above intermediate hemodynamic response

2] But robust data clearly shows the significance of METS achieved and this must be reported in results so a provider can realize that despite negative imaging…METS <7 decreases sensitivity to rule out IHD, and clinical pre test probability should truly dictate whether invasive strategy is necessary for definitive diagnosis and prognosis”

These are some great points that can support the idea that there is more to it than meeting that minimum.

Here are some aspects that are vital to a successful stress test outside of that 85% minimum:

Communication with the patient

One of the most vital facets outside of that 85% minimum is your communication with the patient. In fact, how well you communicate can aid in achieving better than minimum results. For example, your preparation of the patient ahead of the test can make a big difference.

Get our steps to prepare your patients for stress testing here

This includes communicating all of the information that will make them better prepared for the test and more comfortable during it. For example, here are some things you should talk with them about or help them with in preparation for the test:

  • The clothing and footwear they should wear. Sometimes people are coming to a stress test straight from work and may not be wearing the most appropriate items. Let them know they will need clothing and footwear suitable for a treadmill.
  • The procedure itself and how it will work. Patients are often nervous or feeling stressed over having to be tested. It can help if they feel confident that they know what will happen during the test.
  • Set their expectations for what a stress test can and can’t tell them. For example, an abnormal result may point to a risk of CAD, but then again, a normal result doesn’t rule out the risk of a plaque later rupturing.
  • How the treadmill works and getting a feel for it. Patients are usually much more comfortable if you give them the chance to spend a little time on the treadmill before actually starting the test. Some people will never have used a treadmill before and this can be a source of anxiety.
  • A target heart rate for the test. See if you can get them to go for a stretch target, rather than simply a minimum, otherwise there is often a tendency for people to reach the minimum and decide they are done.
  • Give them some level of control to help them feel comfortable. You can talk with them about their part and what they can do to have some control over the situation. For example, point out the emergency stop button and explain that they can hit it any time they feel the need. You can also help them out during the test by letting them know before the transition to each stage.

Communicating with the patient can also help for pushing them that little bit farther to get a good test done. Here’s what Andrea Brumfield, Lead Certified Cardiovascular Technician at Digirad has to say:

“Patients can reach the 85% mark easily within a few minutes if the patient is out of shape, but that doesn’t mean you get a good study by injecting at that point. Most won’t even have symptoms at all, so why not push them a little? Make them feel short of breath and fatigue. See how far they can push themselves (within reason). Personally, I won’t have the patient injected until at least 7.0-10.1 METS and that’s only if they are visibly working hard.

Communication is the key though. Talk with the patient about anything other than what they are doing at that moment and you’ll be surprised to see how much farther they can go.”

Give the patient something to focus on

It can help the patient to go further if they have something they can focus on while they do their test. Too many clinics have blank walls for patients to stare at with nothing to keep them occupied.

If you don’t have the option of facing equipment toward a window, put something engaging on the wall. We recommend interesting posters with scenery that might hold their attention, such as the one shown below.

Want a poster for your office? We are happy to send you a print of our posters if you don’t have any. Contact us here to request your poster.

Final thoughts

There is more to MPI stress tests than simply meeting that 85% minimum. In fact, you may have a better test if you’re able to push above minimums, as well as monitor important aspects such as METs and EKG readings.

Communication with the patient is the key ingredient for a successful stress test. You can do a lot to prepare the patient ahead and ease any fears they may have about doing the test. You can also keep them informed during the test so that they are as comfortable as possible.

Often you can achieve much better than the 85% minimum just by communicating with the patient and giving them something else to focus on during the test other than their current situation.

Should you push past the 85% minimum? If you can do so safely, yes, absolutely.



How is patient obesity affecting cardiac imaging?

Posted on: 05.16.19

Obesity rates in the United States are the highest in the world and a growing health concern. In fact, according to data published by the Centers for Disease Control, 67% of men and 62% of women are overweight. Thirty-four percent of women and 28% of men could be further classified as obese. It’s a contributing factor in numerous diseases like Type 2 diabetes, cancer, stroke, and coronary artery disease.

Because obesity puts patients at greater risk for a host of other medical conditions, they’ll ultimately require more tests and scans during their lifetime in comparison to leaner patients. When it comes to nuclear imaging, obese patients and the unique challenges their weight presents can further hinder an accurate diagnosis and an optimal treatment plan.

How to perform cardiac imaging on obese patients

Imaging and obesity-related challenges

Consider something as simple as diagnostic testing. Most nuclear cameras are designed to accommodate the standard, ideal-weighted patient. With obesity rates climbing at an alarming rate, physicians need to think about whether their equipment can adequately serve this growing population.

Many of today’s SPECT cameras still have a maximum weight capacity of 250-300 pounds. This standard feature can make imaging impossible for larger patients and can put both the patient and the technologist at risk.

For example, an obese patient will have difficulty getting up on, positioning and balancing themselves, and remaining still as they lay on a standard imaging table. They’ll also have to turn over or step down from the table, which could be equally as dangerous. Obese patients have a different center of gravity, which is a significant safety concern that needs to be addressed.

Some SPECT cameras, like the Digirad X-ACT+, utilize the more patient-friendly, seated position, which all but eliminates the patient’s risk of injury from climbing up on, balancing, turning, and stepping down from a supine-positioned table. It also has a maximum weight allowance of 500 pounds, a larger gantry for ingress and egress, and handrails for support.

Orbital space, girth, and field of view

Another issue is reduced orbital space. If the distance between the patient and the detectors is not sufficient, the detectors may not be able to rotate properly. Especially when imaging larger patients, the risk of truncation occurs if the detectors are not able to clear the distance, or cover the girth.

Many of today’s SPECT cameras also have a fixed detector design, which challenges the ability to position the heart of an obese patient in the “sweet spot.” A leaner patient’s heart is more likely to be ideally positioned because today’s cameras are designed for their average body type.

With any size patient, a technician should be able to center the heart in the field of view with relative ease, like with the Digirad X-ACT+ camera. Once the patient is seated, the chair can be moved forward and backward and from left to right in order to optimally position the heart inside the field of view and with enough distance from the detectors.

Attenuation, radiation, and scan time

Images with excessive attenuation and scatter are also more prevalent with obese patients. Dense breast tissue, for example, in both male and female patients, makes it more difficult to acquire accurate quantitative information. Attenuation correction has significant diagnostic value for all patients, but especially obese patients. With it, image clarity and quality are improved, which can result in fewer false positives and fewer unnecessary cardiac catheterizations.

Radiation dosage and scan times for obese patients can be an issue too. While there are standard imaging protocols, they were created for an average weighted patient. Dosage calculations are higher and scan times are longer for obese patients, but those estimated amounts can miss the mark. A low estimate compromises the quality of the images and a high estimate unnecessarily increases the radiation burden to the patient.

The Digirad X-ACT+ camera not only performs attenuation correction with a radiation dose of less than five microsieverts, it also uses TruACQ Count Based Imaging™ software to calculate dosing and scan times. Without the guesswork, technologists can proceed with confidence and ultimately work to deliver higher quality images.

Many of the imaging problems that accompany obese patients can be overcome with the right equipment and software. In reality, though, technicians and cardiologists will simply work with the equipment they have to do the best job they can. At Digirad, we believe that every patient deserves the highest quality of care, regardless of their weight.

Digirad can help

The fact that an imaging system can easily accommodate obese patients may not be the sole reason you choose a camera. However, when that benefit is paired with state-of-the-art technology that can help deliver a higher level of quality of care for a broader group of patients, it’s hard to ignore.



Are all SPECT MPI cameras the same?

Posted on: 05.13.19

It’s safe to say that SPECT is a well-established and widely used modality in diagnostic cardiac imaging. While some cameras may be younger than others or have more bells and whistles, is it also safe to say that they’re generally the same?

With rapidly advancing technology, the real question comes down to how; How much more convenience and comfort does a particular model provide? How much higher is the image clarity and quality? How much faster is the scan time and how does that affect the radiation exposure to the patient? Overall, how much difference do these answers make in the quality care you provide?

Anger vs. solid-state technology

The biggest distinction between a SPECT camera is its base technology, which can be either Anger or solid-state. Anger technology gamma cameras use vacuum tube photomultipliers (PMTs) and hygroscopic sodium iodide (NaI) crystals. These cameras were designed by Hal Anger more than 50 years ago. Although the technology is antiquated, there are a surprising number of Anger-based imaging systems still in operation today.

Solid state, on the other hand, is the more advanced technology that uses a pixilated detector. It provides benefits over Anger-based systems including, its compact and lightweight design, higher quality images, enhanced patient experience, and the ability to be employed in both fixed and mobile configurations.

For example, one of the most noticeable differences between solid-state and Anger is the size of the detector heads. Anger’s PMTs and NaL crystals require a significant amount of space. The solid-state detectors, however, are a fraction of Anger’s size and contribute to its more ideal, compact feature. The weight of a solid-state detector is also over 600% lighter than that of an Anger head too.

Solid-state technology

There are two types of solid-state nuclear imaging technology, direct and indirect conversion. Direct conversion uses cadmium zinc telluride (CZT). When the crystal absorbs a photon, it creates an electric charge directly, hence the term direct conversion. Direct conversion is effective but the manufacturing cost of CZT can be expensive.

Indirect conversion uses cesium iodide (CsI) with a photodiode. When a photon comes in contact with the crystal it produces light, which is converted to an electronic signal. This process is faster and the manufacturing cost of CsI detectors is significantly less than that of CZT.

With Digirad’s technology, each solid-state gamma detector is comprised of thousands of individual detector elements, or pixels. Each pixel is isolated from the other. When a scintillation event occurs on a particular crystal, its exact location can be quickly and accurately identified, making the detector substantially faster and more accurate.

Solid-state technology allows for lower levels of radiation to be used in imaging. And, attenuation correction can be performed using the same detectors for both the transmission and emission in a single sitting, thereby reducing scan time.

Attenuation correction

On the surface, many solid-state SPECT camera systems may look similar. But, if you compare their individual design, functionality, and features more closely, you’ll see that they can differ significantly.

For example, the Digirad X-Act+ camera uses CsI photodiode and employs triple head cardio-centric imaging. The Spectrum Dynamics D-SPECT camera uses CZT and relies on high efficiency moving column detectors. Both CsI and CZT crystals are effective, and both acquisition methods are fast imaging.

The distinguishing features are those that are absent. Although both types of detector geometries mentioned are efficient, moving columns have a higher potential for truncation.

Consider the fully integrated micro-low dose fluorescence attenuation correction feature of the X-ACT+. The D-SPECT imaging system does not offer any built-in process that identifies and corrects for soft tissue artifacts in their SPECT images. Given the fact that attenuation correction results in higher reading confidence, improved diagnostic accuracy, and a lower incidence of false positive studies, Digirad’s methodology is able to offer a significant improvement from a reliability, exposure, and cost standpoint.

In the end

All SPECT cameras are not the same. Whether it’s the number of detectors, technology, maximum weight supported, or the additional features provided – your best decision will be made by weighing the advantages and disadvantages of each model and manufacturer.



How does the Digirad Cardius X-ACT+ compare to the GE NM 530c

Posted on: 04.18.19

On the surface, many solid-state SPECT camera systems may look similar. But, if you compare their individual design, functionality, and features more closely, you’ll see that they can differ significantly.

Whether it’s the number of detectors, the method by which they image patients, the maximum weight they can support, or the size of the imaging sweet spot, your best decision will be made by weighing the advantages and disadvantages of each model and manufacturer.

In this post we compare the Digirad Cardius X-ACT+ to the GE NM 530c:

SPECT Imager Comparison: Digirad X-ACT+ vs. GE NM 530c

Comparison between the Digirad X-ACT+ and the GE NM 530c SPECT imagers



UPMC Launches First Mobile Xe-133 Lung Ventilation Scan System in the United States

Posted on: 01.24.19

In a recent issue of Pediatric Insights, Michael R. Czachowski, MBA, CNMT, NCT, PET, ASCP(N), R.T.(N)(BD) (ARRT), discussed the idea and the execution of the first portable Xenon-133 lung ventilation exam performed in the United States on a patient in a pediatric cardiac intensive care unit.

Czachowski is the supervisor of the Nuclear Medicine and Molecular Imaging Departments at UPMC Children’s Hospital, where the groundbreaking procedure was performed. The process, which was implemented to allow technicians to perform portable ventilation lung exams in the CICU and to alleviate the need to move medically fragile patients to the nuclear medicine department, was made possible with the use of the Digirad Ergo™ portable nuclear camera.

Ventilation lung exams the CICU were previously prohibited because of the inability to safely deliver the Tc-99m DTPA (diethylenetriamine pentaacetic acid) aerosol and the risk of radiation contamination.

Collaboration overcomes obstacles

During a previous portable perfusion lung exam in the CICU, Czachowski’s team was questioned about the possibility of performing a portable ventilation lung exam. The challenge sparked some thought–and a lot of innovation among his team. Through much discussion, brainstorming, option searching, and evaluation, Czachowski and his collaborators agreed that the use of Xenon-133 gas in conjunction with the patient’s ventilator and the Pulmonex system was the most highly viable solution.

The Pulmonex system, which when used in the nuclear medicine department, safely captures exhaled radioactive Xenon-133 through a lead-lined trap. The hurdle was finding a way to capture the gas from the patient, contain it, and maintain the patient’s ventilator dependency, all while remaining in the CICU.

Leveraging the expertise of Alvin Saville, RRT, Respiratory Education Coordinator at UPMC Children’s Hospital, a tubing adaptor placed between the patient’s ventilator circuit and the endotracheal tube was added. It successfully trapped the patient’s exhaled radioactive Xenon-133 inside the Pulmonex system, which ensured a safe environment for the patient, staff, and family.

Innovation pays off in the CICU

In April 2018, after months of development and testing, the successfully modified system was used for the first time on a patient in the CICU. Although they continue to refine the protocol, “to do the lung ventilation exam with no interruption of the patient’s physiological and physical environment in the CICU or elsewhere is quite an accomplishment,” said Czachowski. It has created a seamless process that is both safe and efficient.

You can find the original announcement about the First Mobile Xe-133 Lung Ventilation Scan System in the United States here.



How to Reduce Gut Activity with Myocardial Perfusion Imaging

Posted on: 11.15.18

We’re all familiar with the obstacles that radiotracers and subsequent gut activity presents during Myocardial Prefusion Imaging. When the radioisotope expands beyond the coronary arteries, it’s difficult to obtain quality SPECT MPI imaging of the heart. It’s a common problem that plagues many patients and physicians. So what do we do?

We’ve heard of everything from half & half, cold water, and even a certain type of soda post injection to reduce the dreaded gut activity. Since we weren’t aware of any tried and true solution, we polled our fellow nuclear specialists on LinkedIn to see if they could provide some tips, tricks and home remedies.

Wait Time is always going to be your best practice to assist with clearance but if that or your go-to response doesn’t always work, check out these suggestions and add them to your list:

Katrina B.
If it is a bowel loop, we give them another cup of cold water and have them walk the hallway if they can. If they have a hiatal hernia or liver disease, we give them a longer wait time prior to scan to try to avoid the need for rescan. And we ask them all not to lay down, but to sit up instead when possible when waiting.

Rhevon L.
In my experience, the most effective method for reducing gut uptake and obtaining separation from the inferior margin is the combination of walking and ice cold water consumption. I have also heard of technologist giving patient’s Boost/Ensure after rest dosing and obtaining great images. This is done at the discretion of exercise stress, however.

Kim L.
Additional cold water – approximately 8 ounces. Drink fast. Walk around for 5-10 minutes, then have the patient lay on their right side to see if the loop will pull away from the bottom half of the heart. I had a tech that worked for me that came from Ohio State, and they would try this. Sometimes it would work and sometimes it wouldn’t. Always feed them. That, of course, helps for most.

Michael B.
We find that waiting is the best remedy but not always practical. Cold water gulped down for resting scan. Snack and a drink for the stress scan. Sometimes, particularly with hot livers, lying the patient on 2 pillows behind the shoulders, raising them will drop the activity away from the heart.

Neda S.
I have used carbonated sodas if walking and drinking water didn’t help. I used to use Diet Sprite, but I guess ginger ale is an option too. For stress images, fatty foods, ice cream, coffee, anything that helps bowel movement.

Patrick B.
I’ve often placed a broad strip of pliable soft lead shielding over the patient’s abdomen at an angle, and this has often helped mitigate proximal intestinal activity. Otherwise, if you have the time, waiting 45-60 minutes post-injection to perform resting MPI has been fairly beneficial.

Jeremy W.
I like for my patients to have a drink of their choice (soda, water, coffee, etc.) and some crackers or small snack before their stress images. Some water only before rest images. Extra wait time for Cardiolite vs. Myoview, especially for liver clearance.



Practical pre-authorization tips for nuclear imaging

Posted on: 10.25.18

In today’s economy, everyone is looking to save money and reduce costs, including insurance companies. This has translated into an increasing level of scrutiny when it comes to ordering nuclear imaging studies.

Pre-authorization is now an accepted part of the process, but the requirements and rules are getting more and more complex. In this post, we’ll take a look at ways to better navigate the process.

The pre-approval process

The pre-approval process is used by health insurance companies to verify that certain drugs, procedures, and services are medically necessary before they’re completed.

The quickest way to gain approval is through strict adherence to appropriate use criteria, but it also requires detailed, clear, and complete documentation in the patient’s clinical record.

Documented records should include the patient’s chief complaints, diagnosis, and the results of prior testing that are consistent with a particular treatment plan.

Major roadblocks and how to avoid them

One of the major hurdles is the amount of time that pre-approvals consume and thus detract from other patient-centered tasks in the office. It’s important for staff to have all the information handy before they start the process. The insurance company will have detailed questions, and the staff will need to provide the appropriate answers in a timely manner.

If an insurance company representative senses any lack of confidence, disorganization, or hesitation on the part of the office staff, they can use that to their advantage, which can quickly slow down the approval process.

It’s expected for insurers to require additional information, and sometimes a peer-to-peer review, when the conversation offers up the opportunity to ask for more. You need to be prepared for the possible roadblocks ahead of time.

If your organization is large enough, staff members tasked with managing pre-authorization can work at developing relationships with insurance representatives from particular companies. Leveraging that relationship and specific payer protocol is a smart idea. Chances are they’ll have a higher rate of success because they’ll know what the insurer is looking for and how to manage it.

The benefits of outsourcing pre-authorization

Frustration and the time investment are some of the most common reasons a practice gives up pursuing in-house pre-approval. To combat those hurdles, many practices outsource the approval process to a third-party, like MDBoss for instance, who specializes in pre-certification.

For a practice that lacks the manpower, does not have experienced staff, or the time to spend on the phone with insurers, it can be a cost-effective solution. Many outsourced providers charge based on a per-study basis so even small clinics can leverage the service without worrying about minimums or expensive retainers.

The insurance landscape is continually changing. Many insurers are hiring third-parties themselves to manage their approval process. There is also a push from some insurers, like Humana, BCBS, and Cigna, for locations to become approved test sites. It requires a lengthy summary that includes camera serial numbers, staff credentials, certifications, and other key information, that can easily overload small practices.

The pre-certification or pre-authorization process is an essential part of the services that a physician’s office provides to their patients. There are ways to make the process run smoother, but it takes time, dedicated staff, and a lot of patience.

If your in-house attempts are not producing the desired results, determine the most common hurdles and work quickly to overcome them. It’s in the best interest of your business, your patient’s health, and their financial well-being.



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