Sex: Male
Education:

• Masters of Science in Health Economics for Health Professionals, Health Economics, University of Aberdeen, 2021
• Master in Health Professions Education, University of Santo Tomas, 2007
• Doctor of Medicine, Nuclear Medicine, University of Santo Tomas, 1999
• Bachelor of Science in Biochemistry and Molecular Biology, University of Santo Tomas, 1995

Field of Specialization
Nuclear Medicine
PET Imaging
Molecular Imaging
Nuclear Imaging
Medical Imaging
Scintigraphy
PET/CT

Researches:

Article title: Validation of convolutional neural network for fast determination of whole-body metabolic tumor burden in pediatric lymphoma
Authors: Elba Etchebehere, Rebeca Andrade, Mariana Camacho, Mariana Lima, Anita Brink, Juliano Julio Cerci, Helen Nadel, Chandrasekhar Bal, Venkatesh Rangarajan, Thomas Pfluger, Olga Kagna, Omar Alonso, Fatima K. Begum, Kahkashan Bashir Mir, Vincent Peter Magboo, Leon J Menezes, Diana Paez and Thomas Pascual
Publication title: Journal of Nuclear Medicine Technology, 2022

Abstract:
INTRODUCTION: 18F-FDG PET/CT whole-body tumor burden in lymphoma is not routinely performed due to the lack of fast quantification methods. Although the semi-automatic method is fast, it still lacks the necessary speed required to quantify tumor burden in daily clinical practice.

PURPOSE: To evaluate the performance of the convolutional neural networks (CNN) software to localize neoplastic lesions in whole-body 18F-FDG PET/CT images of pediatric lymphoma patients.

METHODS: This retrospective image data set, derived from the data pool under the IAEA (CRP# E12017), included 102 baseline staging 18F-FDG PET/CTs of pediatric lymphoma patients (mean age 11 yrs). Images were quantified to determine the whole-body (wb) tumor burden (wbMTV and wbTLG) using a semi-automatic (SEMI) software and an CNN-based software. Both were displayed as wbMTVSEMI & wbTLGSEMI and wbMTVCNN & TLGCNN. The intraclass correlation coefficient (ICC) was applied to evaluate concordance between the CNN-based software and the SEMI software. RESULTS: Twenty-six patients were excluded from the analyses because the software was unable to perform calculation. In the remaining 76 patients, wbMTVCNN and wbMTVSEMI whole-body tumor burden metrics were highly correlated (ICC=0.993; 95%CI: 0.989 -0.996; p-value<0.0001) as were wbTLGCNN and wbTLGSEMI (ICC=0.999; 95%CI: 0.998-0.999; p-value<0.0001). However, the time spent calculating these metrics was significantly (<0.0001) faster by CNN (mean = 19 seconds; 11 - 50 seconds) compared to the semi-automatic method (mean = 21.6 minutes; 3.2 – 62.1 minutes), especially in patients with advanced disease.

CONCLUSION: Determining whole-body tumor burden in pediatric lymphoma patients using CNN is fast and feasible in clinical practice.
Full text available upon request to the author

Article title: Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia
Authors: Takashi Kudo, MD, PHD,Ryan Lahey, MD, PHD,Cole B. Hirschfeld, MD,Michelle C. Williams, MBCHB, PHD,Bin Lu, MD, PHD, Mirvat Alasnag, MD, Mona Bhatia, MD, Hee-Seung Henry Bom, MD, PHD, Tairkhan Dautov, MD, Reza Fazel, MD, MSC, Ganesan Karthikeyan, MD, Felix Y.J. Keng, MBBS, Ronen Rubinshtein, MD, Nathan Better, MBBS, Rodrigo Julio Cerci, MD, Sharmila Dorbala, MD, MPH, Paolo Raggi, MD, Leslee J. Shaw, PHD, Todd C. Villines, MD, João V. Vitola, MD, PHD, Andrew D. Choi, MD, Eli Malkovskiy, Benjamin Goebel, BS, Yosef A. Cohen, BA, Michael Randazzo, MD, Thomas N.B. Pascual, MD, Yaroslav Pynda, MSC, Maurizio Dondi, MD, PHD, Diana Paez, MD, MED, Andrew J. Einstein, MD, PHD, on behalf of the INCAPS COVID Investigators Group
Publication title: JACC: Asia 1(2): 187-199, September 2021

Abstract:
Background
The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives
This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods
The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results
Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions
The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.
Full text available upon request to the author

Article title: Impact of COVID-19 on the imaging diagnosis of cardiac disease in Europe
Authors: Michelle Claire Williams, Leslee Shaw, Cole B. Hirschfeld, Pal Maurovich- Horvat ,, Bjarne L. Nørgaard, Gianluca Pontone, Amelia Jimenez- Heffernan, Valentin Sinitsyn, Vladimir Sergienko, Alexey Ansheles, Jeroen J Bax, Ronny Buechel, Elisa Milan, Riemer H J A Slart, Edward Nicol, Chiara Bucciarelli- Ducci, Yaroslav Pynda, Nathan Better, Rodrigo Cerci, Sharmila Dorbala, Paolo Raggi, Todd C Villines, Joao Vitola, Eli Malkovskiy, Benjamin Goebel, Yosef Cohen, Michael Randazzo, Thomas N B Pascual, Maurizio Dondi, Diana Paez, Andrew J Einstein, On behalf of INCAPS COVID Investigators Group
Publication title: Open Heart 8(2):e001681, August 2021

Abstract:
Objectives We aimed to explore the impact of the COVID-19 pandemic on cardiac diagnostic testing and practice and to assess its impact in different regions in Europe. Methods The online survey organised by the International Atomic Energy Agency Division of Human Health collected information on changes in cardiac imaging procedural volumes between March 2019 and March/April 2020. Data were collected from 909 centres in 108 countries. Results Centres in Northern and Southern Europe were more likely to cancel all outpatient activities compared with Western and Eastern Europe. There was a greater reduction in total procedure volumes in Europe compared with the rest of the world in March 2020 (45% vs 41%, p=0.003), with a more marked reduction in Southern Europe (58%), but by April 2020 this was similar in Europe and the rest of the world (69% vs 63%, p=0.261). Regional variations were apparent between imaging modalities, but the largest reductions were in Southern Europe for nearly all modalities. In March 2020, location in Southern Europe was the only independent predictor of the reduction in procedure volume. However, in April 2020, lower gross domestic product and higher COVID-19 deaths were the only independent predictors. Conclusion The first wave of the COVID-19 pandemic had a significant impact on care of patients with cardiac disease, with substantial regional variations in Europe. This has potential long-term implications for patients and plans are required to enable the diagnosis of non-COVID-19 conditions during the ongoing pandemic.
Full text link https://tinyurl.com/45krtuyx

Article title: Reduction of cardiac imaging tests during the COVID-19 pandemic: The case of Italy. Findings from the IAEA Non-invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID)
Authors: Maurizio Dondi, Elisa Milan, Gianluca Pontone, Cole B.Hirschfeld, Michelle Williams, Leslee J. Shaw, Yaroslav Pynda,Paolo Raggi, Rodrigo Cerci, Joao Vitola, Nathan Better, ToddC. Villines, Sharmila Dorbala, Thomas N.B. Pascual, RaffaeleGiubbini, Andrew J. Einstein, Diana Paez, on behalf of theINCAPS COVID Investigators Group
Publication title: International Journal of Cardiology 341(10230), August 2021

Abstract:
Background In early 2020, COVID-19 massively hit Italy, earlier and harder than any other European country. This caused a series of strict containment measures, aimed at blocking the spread of the pandemic. Healthcare delivery was also affected when resources were diverted towards care of COVID-19 patients, including intensive care wards. Aim of the study The aim is assessing the impact of COVID-19 on cardiac imaging in Italy, compare to the Rest of Europe (RoE) and the World (RoW). Methods A global survey was conducted in May–June 2020 worldwide, through a questionnaire distributed online. The survey covered three periods: March and April 2020, and March 2019. Data from 52 Italian centres, a subset of the 909 participating centres from 108 countries, were analyzed. Results In Italy, volumes decreased by 67% in March 2020, compared to March 2019, as opposed to a significantly lower decrease (p < 0.001) in RoE and RoW (41% and 40%, respectively). A further decrease from March 2020 to April 2020 summed up to 76% for the North, 77% for the Centre and 86% for the South. When compared to the RoE and RoW, this further decrease from March 2020 to April 2020 in Italy was significantly less (p = 0.005), most likely reflecting the earlier effects of the containment measures in Italy, taken earlier than anywhere else in the West. Conclusions The COVID-19 pandemic massively hit Italy and caused a disruption of healthcare services, including cardiac imaging studies. This raises concern about the medium- and long-term consequences for the high number of patients who were denied timely diagnoses and the subsequent lifesaving therapies and procedures.
Full text link https://tinyurl.com/2fa7fdh5

Article title: International Impact of COVID-19 on the Diagnosis of Heart Disease
Authors: Andrew J. Einstein, MD, PHD,a,b,cLeslee J. Shaw, PHD,dCole Hirschfeld, MD,bMichelle C. Williams, MBCHB, PHD,eTodd C. Villines, MD,fNathan Better, MB, BS,gJoao V. Vitola, MD, PHD,hRodrigo Cerci, MD,hSharmila Dorbala, MD, MPH,iPaolo Raggi, MD, PHD,jAndrew D. Choi, MD,kBin Lu, MD,lValentin Sinitsyn, MD, PHD,mVladimir Sergienko, MD, PHD,nTakashi Kudo, MD, PHD,oBjarne Linde Nørgaard, MD, PHD,pPál Maurovich-Horvat, MD, PHD, MPH,qRoxana Campisi, MD,rElisa Milan, MD,sLizette Louw, MD,tAdel H. Allam, MD,uMona Bhatia, MD,vEli Malkovskiy,a,b,wBenjamin Goebel, BA,dYosef Cohen, BA,xMichael Randazzo, MD,bJagat Narula, MD,yThomas N.B. Pascual, MD, MHPED,zYaroslav Pynda, MSC,aaMaurizio Dondi, MD, PHD,aaDiana Paez, MD, MED,aaon behalf of the INCAPS COVID Investigators Group
Publication title: Journal of the American College of Cardiology 77(2), 2021

Abstract:
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has adversely affected diagnosis and treatment ofnoncommunicable diseases. Its effects on delivery of diagnostic care for cardiovascular disease, which remains theleading cause of death worldwide, have not been quantified.
OBJECTIVES The study sought to assess COVID-19’simpact on global cardiovascular diagnostic procedural volumesand safety practices.METHODS The International Atomic Energy Agency conducted a worldwide survey assessing alterations in cardiovas-cular procedure volumes and safety practices resulting from COVID-19. Noninvasive and invasive cardiac testing volumeswere obtained from participating sites for March and April 2020 and compared with those from March 2019. Availabilityof personal protective equipment and pandemic-related testing practice changes were ascertained.
RESULTS Surveys were submitted from 909 inpatient and outpatient centers performing cardiac diagnostic procedures, in108 countries. Procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April2020. Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78%,which varied between stress modalities. Coronary angiography (invasive or computed tomography) decreased 55%(p <0.001 for each procedure). In multivariable regression,significantly greater reduction in procedures occurred for centersin countries with lower gross domestic product. Location in a low-income and lower–middle-income country was associatedwith an additional 22% reduction in cardiac procedures and less availability of personal protective equipment and telehealth.
CONCLUSIONS COVID-19 was associated with a significant and abrupt reduction in cardiovascular diagnostic testingacross the globe, especially affecting the world’s economically challenged. Further study of cardiovascular outcomes andCOVID-19–related changes in care delivery is warranted. (J Am Coll Cardiol 2021;77:173–85) © 2021 The Authors. Pub-lished by Elsevier on behalf of the American College of Cardiology Foundation.
Full text link https://tinyurl.com/4cnyhcup

Article title: Impact of COVID-19 on nuclear medicine in Asia
Authors: Hee-Seung Henry Bom MD, PhD, FANMB, HFPSNM, Thomas N B Pascual MD, MHPEd, FPSNM, Partha S.Choudhury MBBS, DRM, DNB (nuclear medicine), AkramAl-Ibraheem MD, JBNM, FEBNM, FANMB, DCBNC
Publication title: Seminars in Nuclear Medicine 52(1): 25-30, June 2021

Abstract:
Coronavirus disease 2019 (COVID-19) was first detected in China in late 2019 and rapidly spread to nearby Asian countries in early 2020. Outbreaks occurred differently in each country and affected nuclear medicine (NM) practice significantly even before the COVID-19 pandemic. The Asian NM community has worked together from the beginning of the pandemic. Fortunately, the Asian Regional Cooperative Council for Nuclear Medicine annual general meeting and Asia Nuclear Medicine Board examination was held in Manila from January 28 to February 2, 2020; these were the last face-to-face events of these organizations to date. Members shared information about COVID-19 at the conference, and through online means afterwards. Web-based surveys performed from March to April 2020 for the Asian Regional Cooperative Council for Nuclear Medicine and Asia Nuclear Medicine Board communities showed a significant reduction of NM practice and supply of radioisotopes (RI) at the beginning of the COVID-19 pandemic. A follow-up survey in March to April 2021 clearly showed the recovery of both NM practice and RI supplies. The pattern of recovery is variable according to institutions and countries. Herein, we have reported the case-in-point operational histories of four representative institutions in the East, Southeast, South, and West Asia. The second outbreak in India is ongoing on a worrisome scale. Various communications and educational sessions were actively performed online in the Asian NM community during the pandemic.
Full text available upon request to the author

Article title: Impact of COVID-19 on Cardiovascular Testing in the United States Versus the Rest of the World
Authors: Cole B. Hirschfeld, MD, Leslee J. Shaw, PHD, Michelle C. Williams, MBCHB, PHD, Ryan Lahey, MD, PHD, Todd C. Villines, MD, Sharmila Dorbala, MD, MPH, Andrew D. Choi, MD, Nishant R. Shah, MD, MPH, David A. Bluemke, MD, PHD, Daniel S. Berman, MD, Ron Blankstein, MD, Maros Ferencik, MD, PHD, Jagat Narula, MD, PHD, David Winchester, MD, MS, Eli Malkovskiy, Benjamin Goebel, BS, Michael J. Randazzo, MD,Juan Lopez-Mattei, MD, Purvi Parwani, MBBS, MPH, Joao V. Vitola, MD, Rodrigo J. Cerci, MD, Nathan Better, MBBS, Paolo Raggi, MD, Bin Lu, MD, Vladimir Sergienko, MD, PHD, Valentin Sinitsyn, MD, Takashi Kudo, MD, PHD, Bjarne Linde Nørgaard, MD, PHD, Pál Maurovich-Horvat, MD, PHD, MPH, Yosef A. Cohen, Thomas N.B. Pascual, MD, Yaroslav Pynda, MSC, Maurizio Dondi, MD, Diana Paez, MD, Andrew J. Einstein, MD, PHD, on behalf of the INCAPS-COVID Investigators Group
Publication title: JACC: Cardiovascular Imaging 14(9), June 2021

Abstract:
Objectives This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic.

Background The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality.

Methods Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States.

Results Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis.

Conclusions We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection.
Full text link https://tinyurl.com/4vrwdkdm

Article title: Impact of COVID-19 on Diagnostic Cardiac Procedural Volume in Oceania: The IAEA Non-invasive Cardiology Protocol Survey on COVID-19 (INCAPS COVID)
Authors: Patricia O’Sullivan, MBBS, FRACP,John Younger, MBBCh, MRCP, FRACP, FRSANZ Niels Van Pelt, MBChB, Sue O’Malley, MBBS,Dora Lenturut-Katal, MD, Cole B. Hirschfeld, MD, Joao V. Vitola, MD, PhD, Rodrigo Cerci, MD,Michelle C. Williams, MBChB, PhD, Leslee J. Shaw, PhD, Paolo Raggi, MD, PhD, Todd C. Villines, MD, Sharmila Dorbala, MD, MPHm, Andrew D. Choi, MD, Yosef Cohen, BA,Benjamin Goebel, BS, Eli Malkovskiy, Michael Randazzo, MDg,Thomas N.B. Pascual, MD, MHPEdq, Yaroslav Pynda, MScr,Maurizio Dondi, MD, PhD, Diana Paez, MD,Andrew J. Einstein, MD, PhD, Nathan Better, MBBS, FRACP,on behalf of the INCAPS COVID Investigators Group
Publication title: Heart, Lung and Circulation 30(10), May 2021

Abstract:
Objectives The INCAPS COVID Oceania study aimed to assess the impact caused by the COVID-19 pandemic on cardiac procedure volume provided in the Oceania region.

Methods A retrospective survey was performed comparing procedure volumes within March 2019 (pre-COVID-19) with April 2020 (during first wave of COVID-19 pandemic). Sixty-three (63) health care facilities within Oceania that perform cardiac diagnostic procedures were surveyed, including a mixture of metropolitan and regional, hospital and outpatient, public and private sites, and 846 facilities outside of Oceania. The percentage change in procedure volume was measured between March 2019 and April 2020, compared by test type and by facility.

Results In Oceania, the total cardiac diagnostic procedure volume was reduced by 52.2% from March 2019 to April 2020, compared to a reduction of 75.9% seen in the rest of the world (p<0.001). Within Oceania sites, this reduction varied significantly between procedure types, but not between types of health care facility. All procedure types (other than stress cardiac magnetic resonance [CMR] and positron emission tomography [PET]) saw significant reductions in volume over this time period (p<0.001). In Oceania, transthoracic echocardiography (TTE) decreased by 51.6%, transoesophageal echocardiography (TOE) by 74.0%, and stress tests by 65% overall, which was more pronounced for stress electrocardiograph (ECG) (81.8%) and stress echocardiography (76.7%) compared to stress single-photon emission computerised tomography (SPECT) (44.3%). Invasive coronary angiography decreased by 36.7% in Oceania.

Conclusion A significant reduction in cardiac diagnostic procedure volume was seen across all facility types in Oceania and was likely a function of recommendations from cardiac societies and directives from government to minimise spread of COVID-19 amongst patients and staff. Longer term evaluation is important to assess for negative patient outcomes which may relate to deferral of usual models of care within cardiology.
Full text link https://tinyurl.com/mjattwkb

Article title: Coronavirus (COVID-19) pandemic mediated changing trends in nuclear medicine education and training: time to change and scintillate
Authors: Gopinath Gnanasegaran, Diana Paez, Mike Sathekge, Francesco Giammarile, Stefano Fanti, Arturo Chiti, Henry Bom, Sobhan Vinjamuri, Thomas NB Pascual, Jamshed Bomanji
Publication title: European Journal of Nuclear Medicine and Molecular Imaging 49(4), March 2021

Abstract:
No abstract available
Full text link https://tinyurl.com/25yc3hzw

Article title: Impact of the first wave of coronavirus disease 2019 (COVID-19) pandemic on the diagnosis of heart disease in the Russian Federation: results from the Russian segment of the IAEA INCAPS COVID study
Authors: Ansheles A. A., Sergienko V. B., Sinitsyn V. E., Vakhromeeva M. N., Kokov A. N., Zavadovsky K. V., Ryzhkova D. V., Karalkin A. V., Shurupova I. V., Pospelov V. A., Migunova E. V., Sayfullina G. B., Dariy O. Yu., Zhuravlev K. N., Itskovich I. E., Gagarina N. V., Hirschfeld C., Williams M. C., Shaw L. J., Malkovskiy E., Better N., Cerci R., Dorbala Sh., Pascual T. N. B., Raggi P., Villines T., Vitola J. V., Pynda Y., Dondi M., Paez D., Einstein A. J. on behalf of the INCAPS COVID research group
Publication title: Russian Journal of Cardiology 26(1):4276, February 2021

Abstract:
Aim. To assess the impact of the first wave of coronavirus disease 2019 (COVID-19) pandemic on the diagnosis of heart disease in the Russian Federation.Material and methods. Fifteen Russian medical centers from 5 cities took part in an online survey organized by the Division of Human Health of the International Atomic Energy Agency (IAEA), containing questions regarding alterations in cardiovascular procedure volumes resulting from COVID-19 in March-April 2020.Results. A number of outpatients undergoing cardiac diagnostic procedures was noted in 80% of clinics. Cardiovascular procedure volumes in the period from March 2019 to March 2020 in general decreased by 9,5%, and from March 2019 to April 2020, by 56,5%. Stress electrocardiography decreased by 38,4%, stress echocardiography by 72,5%, stress single-photon emission computed tomography by 66,9%, computed tomography angiography by 49,7%, magnetic resonance imaging by 42,7%, invasive coronary angiography by 40,7%. The decrease in diagnostic procedure volumes in selected regions (Tomsk Oblast, Kemerovo Oblast, Tatarstan) was not so pronounced compared to Moscow and St. Petersburg (-20,7%, -75,2%, -93,8% in April 2020, respectively, p<0,001).Conclusion. The first wave of the COVID-19 pandemic caused a sharp decrease in the number of diagnostic cardiac procedures in Russia. This has potential longterm implications for patients with cardiovascular disease. Understanding these implications can help guide diagnostic strategies during the ongoing COVID-19 pandemic and minimize the future losses.
Full text link https://tinyurl.com/ysn9etwz

Article title: International Impact of COVID-19 on the Diagnosis of Heart Disease
Authors: Andrew J. Einstein, MD, PHD, Leslee J. Shaw, PHD, Cole Hirschfeld, MD, Michelle C. Williams, MBCHB, PHD, Todd C. Villines, MD, Nathan Better, MB, BS, Joao V. Vitola, MD, PHD, Rodrigo Cerci, MD, Sharmila Dorbala, MD, MPH, Paolo Raggi, MD, PHD, Andrew D. Choi, MD, Bin Lu, MD, Valentin Sinitsyn, MD, PHD, Vladimir Sergienko, MD, PHD, Takashi Kudo, MD, PHD, Bjarne Linde Nørgaard, MD, PHD, Pál Maurovich-Horvat, MD, PHD, MPH, Roxana Campisi, MD, Elisa Milan, MD, Lizette Louw, MD, Adel H. Allam, MD, Mona Bhatia, MD, Eli Malkovskiy, Benjamin Goebel, BA, Yosef Cohen, BA, Michael Randazzo, MD, Jagat Narula, MD, Thomas N.B. Pascual, MD, MHPED, Yaroslav Pynda, MSC, Maurizio Dondi, MD, PHD, Diana Paez, MD, MED, on behalf of the INCAPS COVID Investigators Group
Publication title: Journal of the American College of Cardiology 7(22), January 2021

Abstract:
Background The coronavirus disease 2019 (COVID-19) pandemic has adversely affected diagnosis and treatment of noncommunicable diseases. Its effects on delivery of diagnostic care for cardiovascular disease, which remains the leading cause of death worldwide, have not been quantified.

Objectives The study sought to assess COVID-19’s impact on global cardiovascular diagnostic procedural volumes and safety practices.

Methods The International Atomic Energy Agency conducted a worldwide survey assessing alterations in cardiovascular procedure volumes and safety practices resulting from COVID-19. Noninvasive and invasive cardiac testing volumes were obtained from participating sites for March and April 2020 and compared with those from March 2019. Availability of personal protective equipment and pandemic-related testing practice changes were ascertained.

Results Surveys were submitted from 909 inpatient and outpatient centers performing cardiac diagnostic procedures, in 108 countries. Procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April 2020. Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78%, which varied between stress modalities. Coronary angiography (invasive or computed tomography) decreased 55% (p < 0.001 for each procedure). In multivariable regression, significantly greater reduction in procedures occurred for centers in countries with lower gross domestic product. Location in a low-income and lower–middle-income country was associated with an additional 22% reduction in cardiac procedures and less availability of personal protective equipment and telehealth.

Conclusions COVID-19 was associated with a significant and abrupt reduction in cardiovascular diagnostic testing across the globe, especially affecting the world’s economically challenged. Further study of cardiovascular outcomes and COVID-19–related changes in care delivery is warranted.
Full text link https://tinyurl.com/58azydjx

Article title: Worldwide Variation in the Use of Nuclear Cardiology Camera Technology, Reconstruction Software, and Imaging Protocols
Authors: Cole B. Hirschfeld MD, Mathew Mercuri PhD, Thomas N. B. Pascual MD, Ganesan Karthikeyan MD, João V. Vitol aMD, PhD, John J. Mahmarian MD, Nathan Better MD, Salah E. Bouyoucef MD, Henry Hee-Seung Bom MD, PhD, Vikram Lele MD, V. Peter C. Magboo MD, Erick Alexánderson MD, Adel H. Allam MD, Mouaz H. Al-Mallah MD, MS, Sharmila Dorbala MD, MPH, Albert Flotats MD, Scott Jerome DO, Philipp A .Kaufmann MD, Osnat Luxenburg MD, MPH, MBA, Leslee J. Shaw PhD, S. Richard Underwood MD, Madan M. Rehani PhD, Diana Paez MD, Maurizio Dondi MD, Andrew J. Einstein MD, PhD, on behalf of the
INCAPS Investigators Group
Publication title: JACC: Cardiovascular Imaging 14(9): 1819-1828, September 2021

Abstract:
Objectives
This study sought to describe worldwide variations in the use of myocardial perfusion imaging hardware, software, and imaging protocols and their impact on radiation effective dose (ED).

Background
Concerns about long-term effects of ionizing radiation have prompted efforts to identify strategies for dose optimization in myocardial perfusion scintigraphy. Studies have increasingly shown opportunities for dose reduction using newer technologies and optimized protocols.

Methods
Data were submitted voluntarily to the INCAPS (International Atomic Energy Agency Nuclear Cardiology Protocols Study) registry, a multinational, cross-sectional study comprising 7,911 imaging studies from 308 labs in 65 countries. The study compared regional use of camera technologies, advanced post-processing software, and protocol characteristics and analyzed the influence of each factor on ED.

Results
Cadmium-zinc-telluride and positron emission tomography (PET) cameras were used in 10% (regional range 0% to 26%) and 6% (regional range 0% to 17%) of studies worldwide. Attenuation correction was used in 26% of cases (range 10% to 57%), and advanced post-processing software was used in 38% of cases (range 26% to 64%). Stress-first single-photon emission computed tomography (SPECT) imaging comprised nearly 20% of cases from all world regions, except North America, where it was used in just 7% of cases. Factors associated with lower ED and odds ratio for achieving radiation dose ≤9 mSv included use of cadmium-zinc-telluride, PET, advanced post-processing software, and stress- or rest-only imaging. Overall, 39% of all studies (97% PET and 35% SPECT) were ≤9 mSv, while just 6% of all studies (32% PET and 4% SPECT) achieved a dose ≤3 mSv.

Conclusions
Newer-technology cameras, advanced software, and stress-only protocols were associated with reduced ED, but worldwide adoption of these practices was generally low and varied significantly between regions. The implementation of dose-optimizing technologies and protocols offers an opportunity to reduce patient radiation exposure across all world regions.
Full text available upon request to the author

Article title: Impact of COVID-19 Pandemic on Diagnostic Cardiac Procedural Volume in Oceania: The IAEA Non-invasive Cardiology Protocol Survey on COVID-19
Authors: P. O'Sullivan, J. Younger, N. Van Pelt, S. O'Malley, D. Lenturut-Katal, C. Hirschfeld, J. Vitola, R. Cerci, M. Williams, L. Shaw, P. Raggi, T. Villines, S. Dorbala, A. Choi, Y. Cohen, B. Goebel, E. Malkovskiy, M. Randazzo, T. Pascual, Y. Pynda, M. Dondi, D. Paez, A. Einstein, N. Better
Publication title: Heart, Lung and Circulation 30:S191, January 2021

Abstract:
Coronavirus disease 2019 (COVID-19) has had a significant impact on healthcare provision globally. The INCAPS COVID multicentre, international survey assessed the impact of the pandemic on cardiac diagnostic centres worldwide.
Full text available upon request to the author

Article title: Sequential 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scan findings in patients with extrapulmonary tuberculosis during the course of treatment—a prospective observational study
Authors: Jamshed Bomanji, Rajnish Sharma, Bhagwant R. Mittal, Sanjay Gambhir, Ahmad Qureshy, Shamim M. F. Begum, Diana Paez, Mike Sathekge, Mariza Vorster, Dragana Sobic Saranovic, Pawana Pusuwan, Vera Mann, Sobhan Vinjamuri, Alimuddin Zumla, Thomas N. B. Pascual
Publication title: European Journal of Nuclear Medicine and Molecular Imaging 47(265), December 2020

Abstract:
Background Initial studies of tuberculosis (TB) in macaques and humans using 18F-FDG positron emission tomography (PET) imaging as a research tool suggest its usefulness in localising disease sites and as a clinical biomarker. Sequential serial scans in patients with extrapulmonary TB (EPTB) could inform on the value of PET-CT for monitoring response to treatment and defining cure.

Patients and methods HIV-negative adults with EPTB from eight sites across six countries had three 18F-FDG PET/CT scans: (i) within 2 weeks of enrolment, (ii) at 2 months into TB treatment and (iii) at end of ATT treatment. Scanning was performed according to the EANM guidelines. 18F-FDG PET/CT scans were performed 60 ± 10 min after intravenous injection of 2.5–5.0 MBq/kg of 18F-FDG.

Findings One hundred and forty-seven patients with EPTB underwent 3 sequential scans. A progressive reduction over time of both the number of active sites and the uptake level (SUVmax) at these sites was seen. At the end of WHO recommended treatment, 53/147 (36.0%) patients had negative PET/CT scans, and 94/147 (63.9%) patients remained PET/CT positive, of which 12 patients had developed MDR TB. One died of brain tuberculoma.

Interpretation Current 18F-FDG PET/CT imaging technology cannot be used clinically as a biomarker of treatment response, cure or for decision-making on when to stop EPTB treatment. PET/CT remains a research tool for TB and further development of PET/CT is required using new Mycobacterium tuberculosis-specific radiopharmaceuticals targeting high-density surface epitopes, gene targets or metabolic pathways.
Full text link https://tinyurl.com/yckuzatj

Article title: Worldwide Diagnostic Reference Levels for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging: Findings From INCAPS
Authors: Cole B. Hirschfeld, Maurizio Dondi, Thomas N. B. Pascual, Mathew Mercuri, Joao Vitola, Ganesan Karthikeyan, Nathan Better, John J. Mahmarian, Salah E. Bouyoucef, Henry Hee-Seung Bom, Vikram Lele, Vincent Peter C. Magboo, Erick Alexánderson, Adel H. Allam, Mouaz H. Al-Mallah, Albert Flotats, Scott Jerome, Philipp A. Kaufmann, Osnat Luxenburg, S Richard Underwood, Madan M. Rehani, Jenia Vassileva, Diana Paez, Andrew J. Einstein, INCAPS Investigators Group
Publication title: JACC Cardiovasc Imaging 14(3): 657-665, August 2020

Abstract:
Objectives: This study sought to establish worldwide and regional diagnostic reference levels (DRLs) and achievable administered activities (AAAs) for single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI).

Background: Reference levels serve as radiation dose benchmarks to compare individual laboratories against aggregated data, helping to identify sites in greatest need of dose reduction interventions. DRLs for SPECT MPI have previously been derived from national or regional registries. To date there have been no multiregional reports of DRLs for SPECT MPI from a single standardized dataset.

Methods: Data were submitted voluntarily to the INCAPS (International Atomic Energy Agency Nuclear Cardiology Protocols Study), a cross-sectional, multinational registry of MPI protocols. A total of 7,103 studies were included. DRLs and AAAs were calculated by protocol for each world region and for aggregated worldwide data.

Results: The aggregated worldwide DRLs for rest-stress or stress-rest studies employing technetium Tc 99m-labeled radiopharmaceuticals were 11.2 mCi (first dose) and 32.0 mCi (second dose) for 1-day protocols, and 23.0 mCi (first dose) and 24.0 mCi (second dose) for multiday protocols. Corresponding AAAs were 10.1 mCi (first dose) and 28.0 mCi (second dose) for 1-day protocols, and 17.8 mCi (first dose) and 18.7 mCi (second dose) for multiday protocols. For stress-only technetium Tc 99m studies, the worldwide DRL and AAA were 18.0 mCi and 12.5 mCi, respectively. Stress-first imaging was used in 26% to 92% of regional studies except in North America where it was used in just 7% of cases. Significant differences in DRLs and AAAs were observed between regions.

Conclusions: This study reports reference levels for SPECT MPI for each major world region from one of the largest international registries of clinical MPI studies. Regional DRLs may be useful in establishing or revising guidelines or simply comparing individual laboratory protocols to regional trends. Organizations should continue to focus on establishing standardized reporting methods to improve the validity and comparability of regional DRLs.
Full text available upon request to the author

Article title: Global Impact of COVID-19 on Nuclear Medicine Departments: An International Survey in April 2020
Authors: Lutz S. Freudenberg, Diana Paez, Francesco Giammarile, Juliano Cerci, Moshe Modiselle, Thomas N.B. Pascual, Noura El-Haj, Pilar Orellana, Yaroslav Pynda, Ignasi Carrió, Stefano Fanti, Cristina Matushita, and Ken Herrmann
Publication title: Journal of Nuclear Medicine 61(9), July 2020

Abstract:
Introduction: The coronavirus disease 2019 (COVID-19) pandemic has placed significant challenges on health care systems worldwide, whether in the preparation, response, or recovery phase of the pandemic. This has been primarily managed by dramatically reducing in- and outpatient services for other diseases and implementing infection prevention and control (IPC) measures. The impact of the pandemic on nuclear medicine departments and their services has not yet been established. The aim of this online survey was to evaluate the impact of COVID-19 on nuclear medicine departments.

Materials and Methods: A web-based questionnaire, made available from April 16 to May 3, 2020, was designed to determine the impact of the pandemic on in- and out-patient nuclear medicine departments; including the number of procedures, employee health, availability of radiotracers and other essential supplies, and availability of personal protective equipment (PPE). The survey also enquired about operational aspects and types of facilities, as well as other challenges.

Results: A total of 434 responses from 72 countries were registered and analysed. Respondents reported an average decline of 54% in diagnostic procedures. Positron emission tomography / computed tomography (PET/CT) scans decreased by an average of 36%, while sentinel lymph-node procedures decreased by 45%, lung scans by 56%, bone scans by 60%, myocardial studies by 66%, and thyroid studies by 67%. Out of all participating centres, 81% perform radionuclide therapies, and they reported a reduction of 45% on average in the last four weeks, ranging from over 76% in Latin America and South East Asia to 16% in South Korea and Singapore. Survey results showed that 52% of participating sites limited their 99mTc/99Mo generator purchases and 12% of them temporarily cancelled orders. Insufficient supplies of essential materials (radioisotopes, generators, and kits) were reported, especially for 99mTc/99Mo generators and 131I, particularly in Africa, Asia, and Latin America.

Conclusion: Both diagnostic and therapeutic nuclear medicine procedures declined precipitously with countries worldwide being affected by the pandemic to a similar degree. Countries that were in the post-peak phase of the pandemic when they responded to the survey, such as South Korea and Singapore reported a less pronounced impact on nuclear medicine services however, the overall results of the survey showed that nuclear medicine services worldwide had been significantly impacted. In relation to staff health, 15% of respondents experienced COVID-19 infections within their own departments
Full text available upon request to the author

Article title: PET/CT features of Extrapulmonary Tuberculosis at first clinical presentation - a cross-sectional observational 18F-FDG imaging study across six countries
Authors: Jamshed Bomanji, Rajnish Sharma, Bhagwant R. Mittal, Sanjay Gambhir, Ahmad Qureshy, Shamim M.F. Begum, Diana Paez, Mike Sathekge, Mariza Vorster, Dragana Sobic Saranovic, Pawana Pusuwan, Vera Mann, Sobhan Vinjamuri, Alimuddin Zumla, Thomas N.B. Pascual for the International Atomic Energy Agency Extra-pulmonary TB Consortium
Publication title: European Respiratory Journal 55(2) December 2019

Abstract:
Background: A large proportion of the huge global burden of Extrapulmonary tuberculosis (EPTB) are treated empirically without accurate definition of disease sites, and extent of multi-organ disease involvement. Positron emission tomography (PET) imaging using 18F-FDG in TB could be a useful imaging technique for localising disease sites and extent of disease.

Methods: We conducted a study of HIV-negative adult patients with a new clinical diagnosis of EPTB across 8 centres located in 6 countries: India, Pakistan, Thailand, South Africa, Serbia, and Bangladesh to assess the extent of disease and common sites involved at first presentation. 18F-FDG PET/CT scans were performed within 2 weeks of presentation.

Findings: A total of 358 patients with EPTB (189 females; 169 males) were recruited over 45 months. Age range 18-83 years (females: median 30 years; males: median 38 years). 350/358 (98%) patients (183 female, 167 male) had positive scan. 118/350 (33.7%) had a single extrapulmonary site and 232/350 (66.3%) had more than one site (organ) affected. Lymph nodes, skeletal, pleura and brain were common sites. 100/358 (28%) of EPTB patients had 18F-FDG PET/CT positive sites in the lung. 110 patients were 18F-FDG PET/CT positive in more body sites than were noted clinically at first presentation and 160 patients had the same number of positive body sites. Interpretation: 18F-FDG PET/CT scan has potential for further elucidating the spectrum of disease, pathogenesis of EPTB, and monitoring the effects of treatment on active lesions over time, and requires longitudinal cohort studies, twinned with biopsy and molecular studies.
Full text available upon request to the author

Article title: Is True Whole-body FDG-PET/CT required in paediatric lymphoma? An IAEA Multicentre Prospective Study
Authors: Juliano J. Cerci1, Elba C. Etchebehere, Helen Nadel, Anita Brink, Chandrasekhar S. Bal, Venkatesh Rangarajan, Thomas Pfluger, Olga Kagna, Omar Alonso, Fatima K. Begum, Kahkashan Bashir Mir, Vincent P. Magboo, Leon J. Menezes, Diana Paez, and Thomas N. Pascual
Publication title: Journal of Nuclear Medicine 60(8), January 2019

Abstract:
Guidelines recommend true whole-body 18F-FDG PET/CT scans from vertex to toes in pediatric lymphoma patients, although this suggestion has not been validated in large clinical trials. The objective of the study was to evaluate the incidence and clinical impact of lesions outside the "eyes to thighs" regular field of view (R-FOV) in 18F-FDG PET/CT staging (sPET) and interim (iPET) scans in pediatric lymphoma patients. Methods: True whole-body sPET and iPET scans were prospectively obtained in pediatric lymphoma patients (11 worldwide centers). Expert panel central review of sPET and iPET scans were evaluated for lymphoma lesions outside the R-FOV and clinical relevance of these findings. Results: A total of 610 scans were obtained in 305 patients. The sPET scans did not show lesions outside the R-FOV in 91.8% of the patients, whereas in 8.2% patients the sPET scans demonstrated lesions also outside the R-FOV (soft tissue, bone, bone marrow, and skin); however, the presence of these lesions did not change the clinical stage of any patient and did not affect treatment decision. Among the 305 iPET scans, there were no new positive 18F-FDG-avid lesions outside the R-FOV, when compared with their paired sPET scans. A single lesion outside the R-FOV on iPET occurred in 1 patient (0.3%), with the primary lesion diagnosed in the femur on sPET that persisted on iPET. Conclusion: The identification of additional lesions outside the R-FOV (eyes to thighs) using 18F-FDG PET/CT has no impact in the definition of the clinical stage of disease and minimal impact in the treatment definition of patients with pediatric lymphoma. As so, R-FOV for both sPET and iPET scans could be performed.
Full text link https://tinyurl.com/sf4j8sxz

Article title: Challenges using PET-CT for international multicentre coordinated research projects in developing countries
Authors: Bhoil, Amita, Ferdousi Begum, Shamim M., Vinjamuri, Sobhan, Bomanji, Jamshed, Pascual, Thomas, on behalf of IAEA CRP (E15021) group
Publication title: Nuclear Medicine Communications 40(2):1, November 2018

Abstract:
No available abstract
Full text available upon request to the author

Article title: The IAEA Human Health Campus: Online Educational Resource for Health Care Professionals in Radiation Medicine
Authors: R. Núñez Miller, T. Gray, T. Pascual, E. Estrada, F. Giammarile, D. Paez
Publication title: Journal of Global Oncology 4, October 2018

Abstract:
Background: Cognizant of the educational needs of the member states, and taking advantage of the current technological advances in this digital age, the International Atomic Energy Agency (IAEA) officially launched in 2010 the Human Health Campus (HHC; http://humanhealth.iaea.org ), which is an online educational resource initiative geared toward enhancing professional knowledge of health professionals in radiation medicine.

Aim: Determine how and by whom the IAEA HHC is being visited and used since its inception in October 2010. Methods: Using the information provided by Google Analytics, determine the overall key performance indicators (KPIs) such as total sessions, total users, total page views, session duration, including daily number of visits to the HHC, county of origin, evaluation of the most popular sections and source of the traffic.

Results: Since its launch on October 6th, 2010, KPIs are as follows: total sessions 374,279, total users 243,195, total page views 1,393,310, pages/session 3.72, average session duration 00:03:08. % of new sessions 64.92%. The HHC has witnessed continual growth year on year (YoY) in total sessions (visits) since its inception in October 2010, and total users. For 2016 (the highest performing year so far) there were 201 visits/day, 40% increase in traffic YoY and 20% user growth. Traffic to the Webinar content has seen sustained growth in the number of YoY since being introduced to the HHC in 2013. 2016 saw the largest increase of over +600%. E-Learning modules have also seen growth in the traffic YoY since being introduced to the HHC in 2011. The year 2015 saw a large increase in total traffic with over +95%. E-Learning traffic accounts for almost 25% of all traffic to the Nuclear Medicine section. Visits by mobile devices have increased YoY exponentially since the launch of the HHC, with the mobile traffic growing strong through 2015-2016 with an increase of 5482 sessions, or an 81% uplift YoY. For 2017, it represented 18% of the total traffic (from 3% in 2012). There is a clear prevalence of desktop users (85.5%), as the preferred method of browsing the HHC. A total of 210 countries and overseas territories have visited the HHC. The United States is the largest contributor of traffic from a global perspective with 16.31% of total traffic, almost double the next largest which is the UK with 9.10%. India with 5.45% and Australia with 3.27% of total traffic, respectively, round out the top 4. Not surprisingly, more than 60% of users are from English-speaking countries. Spanish is the second most popular language of users with just over 6% of total traffic.

Conclusion: The HHC is an IAEA open access Web based educational resource for professionals in the field of radiation medicine being visited by as many as 210 countries. The upward trend in its use suggests that the IAEA HHC will continue to be an important player in providing educational resources for professionals worldwide.
Full text available upon request to the author

Article title: Inter-reader variability of SPECT MPI readings in low- and middle-income countries: Results from the IAEA-MPI Audit Project (I-MAP)
Authors: Maurizio Dondi, MD, Carlo Rodella, MSc, Raffaele Giubbini, MD, Luca Camoni, BSc, Ganesan Karthikeyan, MD, DM, MSc, Joao V. Vitola, MD, Andrew J. Einstein, MD, PhD, FASNC, Bertjan J. Arends, MSc, Olga Morozova,BA, MA, Thomas N. Pascual, MD, MHPED, and Diana Paez, MD, MsED onbehalf of the I-MAP investigators
Publication title: Journal of Nuclear Cardiology 27(Suppl 1), August 2018

Abstract:
Background
Consistency of results between different readers is an important issue in medical imaging, as it affects portability of results between institutions and may affect patient care. The International Atomic Energy Agency (IAEA) in pursuing its mission of fostering peaceful applications of nuclear technologies has supported several training activities in the field of nuclear cardiology (NC) and SPECT myocardial perfusion imaging (MPI) in particular. The aim of this study was to verify the outcome of those activities through an international clinical audit on MPI where participants were requested to report on studies distributed from a core lab.

Methods
The study was run in two phases: in phase 1, SPECT MPI studies were distributed as raw data and full processing was requested as per local practice. In phase 2, images from studies pre-processed at the core lab were distributed. Data to be reported included summed stress score (SSS); summed rest score (SRS); summed difference score (SDS); left ventricular (LV) ejection fraction (EF) and end- diastolic volume (EDV). Qualitative appraisals included the assessment of perfusion and presence of ischemia, scar or mixed patterns, presence of transient ischemic dilation (TID), and risk for cardiac events (CE). Twenty-four previous trainees from low- and middle-income countries participated (core participants group) and their results were assessed for inter-observer variability in each of the two phases, and for changes between phases. The same evaluations were performed for a group of eleven international experts (experts group). Results were also compared between the groups.

Results
Expert readers showed an excellent level of agreement for all parameters in both phase 1 and 2. For core participants, the concordance of all parameters in phase 1 was rated as good to excellent. Two parameters which were re-evaluated in phase 2, namely SSS and SRS, showed an increased level of concordance, up to excellent in both cases. Reporting of categorical variables by expert readers remained almost unchanged between the two phases, while core participants showed an increase in phase 2. Finally, pooled LVEF values did not show a significant difference between core participants and experts. However, significant differences were found between LVEF values obtained using different software packages for cardiac analysis.

Conclusions
In this study, inter-observer agreement was moderate-to-good for core group readers and good-to-excellent for expert readers. The quality of reporting is affected by the quality of processing. These results confirm the important role of the IAEA training activities in improving imaging in low- and middle-income countries.
Full text available upon request to the author

Article title: Implementation of Quality Systems in Nuclear Medicine: Why It Matters. An Outcome Analysis (Quality Management Audits in Nuclear Medicine Part III)
Authors: Maurizio Dondi, Diana Paez, Leonel Torres, Mario Marengo, Angelika Bischof Delaloye, Kishor Solanki, Annare Van Zyl Ellmann, Enrique Estrada Lobato, Rodolfo Nunez Miller, Francesco Giammarile, and Thomas Pascual
Publication title: Seminars in Nuclear Medicine 48(3), February 2018

Abstract:
The International Atomic Energy Agency (IAEA) developed a comprehensive program-Quality Management Audits in Nuclear Medicine (QUANUM). This program covers all aspects of nuclear medicine practices including, but not limited to, clinical practice, management, operations, and services. The QUANUM program, which includes quality standards detailed in relevant checklists, aims at introducing a culture of comprehensive quality audit processes that are patient oriented, systematic, and outcome based. This paper will focus on the impact of the implementation of QUANUM on daily routine practices in audited centers. Thirty-seven centers, which had been externally audited by experts under IAEA auspices at least 1 year earlier, were invited to run an internal audit using the QUANUM checklists. The external audits also served as training in quality management and the use of QUANUM for the local teams, which were responsible of conducting the internal audits. Twenty-five out of the 37 centers provided their internal audit report, which was compared with the previous external audit. The program requires that auditors score each requirement within the QUANUM checklists on a scale of 0-4, where 0-2 means nonconformance and 3-4 means conformance to international regulations and standards on which QUANUM is based. Our analysis covering both general and clinical areas assessed changes on the conformance status on a binary manner and the level of conformance scores. Statistical analysis was performed using nonparametric statistical tests. The evaluation of the general checklists showed a global improvement on both the status and the levels of conformances (P < 0.01). The evaluation of the requirements by checklist also showed a significant improvement in all, with the exception of Hormones and Tumor marker determinations, where changes were not significant. Of the 25 evaluated institutions, 88% (22 of 25) and 92% (23 of 25) improved their status and levels of conformance, respectively. Fifty-five requirements, on average, increased from nonconformance to conformance status. In 8 key areas, the number of improved requirements was well above the average: Administration & Management (checklist 2); Radiation Protection & Safety (checklist 4); General Quality Assurance system (checklist 6); Imaging Equipment Quality Assurance or Quality Control (checklist 7); General Diagnostic (checklist 9); General Therapeutic (checklist 12); Radiopharmacy Level 1 (checklist 14); and Radiopharmacy Level 2 (checklist 15). Analysis of results related to clinical activities showed an overall positive impact on both the status and the level of conformance to international standards. Similar results were obtained for the most frequently performed clinical imaging and therapeutic procedures. Our study shows that the implementation of a comprehensive quality management system through the IAEA QUANUM program has a positive impact on nuclear medicine practices.
Full text link https://tinyurl.com/2kcaa6dp

Article title: Impact of age on the selection of nuclear cardiology stress protocols: The INCAPS (IAEA nuclear cardiology protocols) study
Authors: Mouaz H. Al-Mallah, Thomas N.B. Pascual, Mathew Mercuri, Diana Paez, Andrew J. Einstein, The INCAPS Investigators Group
Publication title: International Journal of Cardiology 259, February 2018

Abstract:
Background: There is growing concern about radiation exposure from nuclear myocardial perfusion imaging (MPI), particularly among younger patients who are more prone to develop untoward effects of ionizing radiation, and hence US and European professional society guidelines recommend age as a consideration in weighing radiation risk from MPI. We aimed to determine how patient radiation doses from MPI vary across age groups in a large contemporary international cohort. Methods: Data were collected as part of a global cross-sectional study of centers performing MPI coordinated by the International Atomic Energy Agency (IAEA). Sites provided information on each MPI study completed during a single week in March-April 2013. We compared across age groups laboratory adherence to pre-specified radiation-related best practices, radiation effective dose (ED; a whole-body measure reflecting the amount of radiation to each organ and its relative sensitivity to radiation's deleterious effects), and the proportion of patients with ED ≤ 9 mSv, a target level specified in guidelines. Results: Among 7911 patients undergoing MPI in 308 laboratories in 65 countries, mean ED was 10.0 ± 4.5 mSv with slightly higher exposure among younger age groups (trend p value < 0.001). There was no difference in the proportion of patients with ED ≤ 9 mSv across age groups, or in adherence to best practices based on the median age of patients in a laboratory. Conclusions: In contemporary nuclear cardiology practice, the age of the patient appears not to impact protocol selection and radiation dose, contrary to professional society guidelines.
Full text available upon request to the author

Article title: Interim PET/CT Predicts Response in Pediatric Lymphoma Patients - Report of an IAEA Multicenter Prospective Study
Authors: Helen Nadel, Elba C Etchebehere, Juliano Julio Cerci, Anita Brink,Chandrasekhar S. Bal, Venkatesh Rangarajan, Thomas Pfluger, Olga Kagna, Omar Alonso, Fatima Begum, Kahkashan Bashir Mir, Vincent P Magboo, Leon Menezes, Diana Paez, Thomas Neil B. Pascual
Publication title: SSRN Electronic Journal, January 2018

Abstract:
Background: PET/CT is well established as method for prognostic stratification in adult Hodgkin (HL) and Non-Hodgkin lymphoma (NHL). In pediatric lymphoma, there is no uniform system of prognostic stratification. This study evaluates the prognosis of interim FDG-PET/CT in HL and NHL pediatric patients in a large multicenter population from low-middle, upper-middle and high income countries.

Methods: Eleven worldwide centers prospectively performed FDG-PET/CT studies on pediatric patients for staging and interim response evaluation. Clinical and PET/CT findings, events, and mortality data were collected. Expert panel performed central review of baseline and interim FDG-PET/CT examinations visually with Lugano classification (LC) and semi-quantitatively (including SUVmax and Delta SUVmax). LC scores of 1, 2, 3 and X were considered negative (LC-); LC scores 4 and 5 were considered positive (LC ). Prognostic analysis compared the 2-y event-free survival (EFS) rate to the PET2 results, and clinical data.

Findings: Whole-body FDG-PET/CT acquisitions were performed in 250 patients (183 males; mean age = 10 ± 4 years; 70% with Hodgkin lymphoma) with clinical stage I-IV represented. There were 9 deaths and 46 events during follow-up and 194 (78%) patients with LC- interim studies. LC studies were significantly and independently associated with increased overall mortality (HR=8.96; p 0.002) and more events (HR 5.80; p<0.001). At multivariate analysis neither Delta SUV nor SUVmax were predictor of events. LC studies were associated with more events in children with HL (HR=9.77; p<0.001) than in NHL (HR 2.41; p=0.10).

Interpretation: LC FDG-PET/CT scan at interim evaluation is an independent predictor of OS and EFS in pediatric lymphoma patients. LC studies are able to independently predict decreased EFS in patients with HL but not patients with NHL.
Full text link https://tinyurl.com/55d7a3jn

Article title: Nuclear cardiology practices and radiation exposure in Africa: Results from the IAEA Nuclear Cardiology Protocols Study (INCAPS)
Authors: Salah E. Bouyoucef, Mathew Mercuri, Thomas N.B. Pascual, Adel H. Allam, Mboyo Vangu, João V. Vitola, Nathan Better, Ganesan Karthikeyan, John J. Mahmarian, Madan M. Rehani, Ravi Kashyap, Maurizio Dondi, Diana Paez, Andrew J. Einstein, for the INCAPS investigators group
Publication title: Cardiovascular journal of South Africa: official journal for Southern Africa, September 2017

Abstract:
Objective While nuclear myocardial perfusion imaging (MPI) offers many benefits to patients with known or suspected cardiovascular disease, concerns exist regarding radiationassociated health effects. Little is known regarding MPI practice in Africa. We sought to characterise radiation doses and the use of MPI best practices that could minimise radiation in African nuclear cardiology laboratories, and compare these to practice worldwide. Methods Demographics and clinical characteristics were collected for a consecutive sample of 348 patients from 12 laboratories in six African countries over a one-week period from March to April 2013. Radiation effective dose (ED) was estimated for each patient. A quality index (QI) enumerating adherence to eight best practices, identified a priori by an IAEA expert panel, was calculated for each laboratory. We compared these metrics with those from 7 563 patients from 296 laboratories outside Africa. Results to that of the rest of the world [9.1 (5.1–15.6) vs 10.3 mSv (6.8–12.6), p = 0.14], although a larger proportion of African patients received a low ED, ≤ 9 mSv targeted in societal recommendations (49.7 vs 38.2%, p < 0.001). Bestpractice adherence was higher among African laboratories (QI score: 6.3 ± 1.2 vs 5.4 ± 1.3, p = 0.013). However, median ED varied significantly among African laboratories (range: 2.0–16.3 mSv; p < 0.0001) and QI range was 4–8. Conclusion Patient radiation dose from MPI in Africa was similar to that in the rest of the world, and adherence to best practices was relatively high in African laboratories. Nevertheless there remain opportunities to further reduce radiation exposure to African patients from MPI.
Full text link https://tinyurl.com/ywekw4rb

Article title: Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine (QUANUM) Program. Part 1: the QUANUM Program and Methodology
Authors: Maurizio Dondi MD, Leonel Torres PhD, Mario Marengo PhD, Teresa Massardo MD, Eyal Mishani PhD, Annare Van Zyl Ellmann MD, Kishor Solanki MD, Angelika Bischof Delaloye MD, Enrique Estrada Lobato MD, Rodolfo Nunez Miller MD, Diana Paez MD, Thomas Pascual MD, MPHEd
Publication title: Seminars in Nuclear Medicine 47(6): 680-686, November 2017

Abstract:
An effective management system that integrates quality management is essential for a modern nuclear medicine practice. The Nuclear Medicine and Diagnostic Imaging Section of the International Atomic Energy Agency (IAEA) has the mission of supporting nuclear medicine practice in low- and middle-income countries and of helping them introduce it in their health-care system, when not yet present. The experience gathered over several years has shown diversified levels of development and varying degrees of quality of practice, among others because of limited professional networking and limited or no opportunities for exchange of experiences. Those findings triggered the development of a program named Quality Management Audits in Nuclear Medicine (QUANUM), aimed at improving the standards of NM practice in low- and middle-income countries to internationally accepted standards through the introduction of a culture of quality management and systematic auditing programs. QUANUM takes into account the diversity of nuclear medicine services around the world and multidisciplinary contributions to the practice. Those contributions include clinical, technical, radiopharmaceutical, and medical physics procedures. Aspects of radiation safety and patient protection are also integral to the process. Such an approach ensures consistency in providing safe services of superior quality to patients. The level of conformance is assessed using standards based on publications of the IAEA and the International Commission on Radiological Protection, and guidelines from scientific societies such as Society of Nuclear Medicine and Molecular Imaging (SNMMI) and European Association of Nuclear Medicine (EANM). Following QUANUM guidelines and by means of a specific assessment tool developed by the IAEA, auditors, both internal and external, will be able to evaluate the level of conformance. Nonconformances will then be prioritized and recommendations will be provided during an exit briefing. The same tool could then be applied to assess any improvement after corrective actions are taken. This is the first comprehensive audit program in nuclear medicine that helps evaluate managerial aspects, safety of patients and workers, clinical practice, and radiopharmacy, and, above all, keeps them under control all together, with the intention of continuous improvement.
Full text available upon request to the author

Article title: Comprehensive Auditing in Nuclear Medicine Through the International Atomic Energy Agency Quality Management Audits in Nuclear Medicine Program. Part 2: Analysis of Results
Authors: Maurizio Dondi,MD, Leonel Torres, PhD, Mario Marengo, PhD, Teresa Massardo, MD, Eyal Mishani, PhD, Annare Van Zyl Ellmann,MD, Kishor Solanki,MD, Angelika Bischof Delaloye,MD, Enrique Estrada Lobato, MD, Rodolfo Nunez Miller,MD, Felix Barajas Ordonez, MD, Diana Paez, MD, and Thomas Pascual, MD, MPHEd
Publication title: Seminars in Nuclear Medicine 47(6), July 2017

Abstract:
The International Atomic Energy Agency has developed a program, named Quality Management Audits in Nuclear Medicine (QUANUM), to help its Member States to check the status of their nuclear medicine practices and their adherence to international reference standards, covering all aspects of nuclear medicine, including quality assurance/quality control of instrumentation, radiopharmacy (further subdivided into levels 1, 2, and 3, according to complexity of work), radiation safety, clinical applications, as well as managerial aspects. The QUANUM program is based on both internal and external audits and, with specifically developed Excel spreadsheets, it helps assess the level of conformance (LoC) to those previously defined quality standards. According to their level of implementation, the level of conformance to requested standards; 0 (absent) up to 4 (full conformance). Items scored 0, 1, and 2 are considered non-conformance; items scored 3 and 4 are considered conformance. To assess results of the audit missions performed worldwide over the last 8 years, a retrospective analysis has been run on reports from a total of 42 audit missions in 39 centers, three of which had been re-audited. The analysis of all audit reports has shown an overall LoC of 73.9 ± 8.3% (mean ± standard deviation), ranging between 56.6% and 87.9%. The highest LoC has been found in the area of clinical services (83.7% for imaging and 87.9% for therapy), whereas the lowest levels have been found for Radiopharmacy Level 2 (56.6%); Computer Systems and Data Handling (66.6%); and Evaluation of the Quality Management System (67.6%). Prioritization of non-conformances produced a total of 1687 recommendations in the final audit report. Depending on the impact on safety and daily clinical activities, they were further classified as critical (requiring immediate action; n = 276; 16% of the total); major (requiring action in relatively short time, typically from 3 to 6 months; n = 604; 36%); whereas the remaining 807 (48%) were classified as minor, that is, to be addressed whenever possible. The greatest proportion of recommendations has been found in the category "Managerial, Organization and Documentation" (26%); "Staff Radiation Protection and Safety" (17.3%); "Radiopharmaceuticals Preparation, Dispensing and Handling" (15.8%); and "Quality Assurance/Quality Control" and "Management of Equipment and Software" (11.4%). The lowest level of recommendations belongs to the item "Human Resources" (4%). The QUANUM program proved applicable to a wide variety of institutions, from small practices to larger centers with PET/CT and cyclotrons. Clinical services rendered to patients showed a good compliance with international standards, whereas issues related to radiation protection of both staff and patients will require a higher degree of attention. This is a relevant feedback for the International Atomic Energy Agency with regard to the effective translation of safety recommendations into routine practice. Training on drafting and application of standard operating procedures should also be considered a priority.
Full text link https://tinyurl.com/2s3edr3f

Article title: Nuclear Cardiology: Are We Using the Right Protocols and Tracers the Right Way?
Authors: Maurizio Dondi, Thomas Pascual, Diana Paez & Andrew J. Einstein
Publication title: American Journal of Cardiovascular Drugs 17(9), April 2017

Abstract:
The field of nuclear cardiology has changed considerably over recent years, with greater attention paid to safety and radiation protection issues. The wider usage of technetium-99m (Tc-99m)-labeled radiopharmaceuticals for single-photon emission computed tomography (SPECT) imaging using gamma cameras has contributed to better quality studies and lower radiation exposure to patients. Increased availability of tracers and scanners for positron emission tomography (PET) will help further improve the quality of studies and quantify myocardial blood flow and myocardial flow reserve, thus enhancing the contribution of non-invasive imaging to the management of coronary artery disease. The introduction of new instrumentation such as solid state cameras and new software will help reduce further radiation exposure to patients undergoing nuclear cardiology studies. Results from recent studies, focused on assessing the relationship between best practices and radiation risk, provide useful insights on simple measures to improve the safety of nuclear cardiology studies without compromising the quality of results.
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Article title: Worldwide variation in the use of nuclear cardiology camera technology, reconstruction software, and acquisition protocols: findings from the IAEA Nuclear Cardiology Protocols Study
Authors: Edward A. Hulten, Mathew Mercuri, Thomas Pascual, Joao Vitola, Nathan Better, Ganesan Karthikeyan, John Mahmarian, Madan Rehani, Maurizio Dondi, Diana Paez, Andrew Jeffrey Einstein
Publication title: Journal of the American College of Cardiology 69(11):1587, March 2017

Abstract:
Background: Although increasing attention has been drawn to medical radiation exposure, little is reported about worldwide variation in nuclear myocardial perfusion imaging (MPI) techniques that may result in differences in radiation exposure. The IAEA Nuclear Cardiology Protocols Study (INCAPS) was initiated to evaluate such differences.

Methods: Observational cross-sectional study of all MPI studies conducted at 308 nuclear cardiology laboratories in 65 countries during a single week in March–April 2013. We evaluated camera technology, reconstruction software and acquisition protocols used and their association with MPI radiation exposure.

Results: 7911 studies were included. Stress only protocols (10% of MPI), rest only protocols (4%), multiple position imaging (7%), attenuation correction (26%), avoidance of thallium (95%), advanced software processing (38%), CZT camera (10%), and PET imaging (6%) were associated with significantly lower radiation dose. Of all lab variables evaluated (Table 1), avoidance of thallium, CZT camera, and stress or rest only protocols had the largest effect size for association with radiation exposure.

Conclusions: Our findings demonstrate variable and overall low worldwide adoption of IAEA recommended best nuclear Cardiology practices. Nearly all sites have succeeded in avoidance of thallium imaging. Adherence to best practices, even low cost solutions such as multiple position imaging, could reduce worldwide radiation exposure during nuclear MPI.
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Article title: Nuclear Cardiology Practice in Asia: Analysis of Radiation Exposure and Best Practice for Myocardial Perfusion Imaging ― Results From the IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS) ―
Authors: Thomas N.B. Pascual, MD; Mathew Mercuri, PhD; Noura El-Haj; Henry Hee-Sung Bom, MD, PhD; Vikram Lele, MD; Mouaz H. Al-Mallah, MD; Osnat Luxenburg, MD; Ganesan Karthikeyan, MD; Joao Vitola, MD, PhD; John J. Mahmarian, MD; Nathan Better, MD; Leslee J. Shaw, PhD; Madan M. Rehani, PhD; Ravi Kashyap, MD; Diana Paez, MD; Maurizio Dondi, MD; Andrew J. Einstein, MD, PhD for the INCAPS Investigators Group
Publication title: Circulation Journal 81(4), February 2017

Abstract:
Background:This paper examines the current status of radiation exposure to patients in myocardial perfusion imaging (MPI) in Asia.

Methods and Results:Laboratories voluntarily provided information on MPI performed over a 1-week period. Eight best practice criteria regarding MPI were predefined by an expert panel. Implementation of ≥6 best practices (quality index [QI] ≥6) was pre-specified as a desirable goal for keeping radiation exposure at a low level. Radiation effective dose (ED) in 1,469 patients and QI of 69 laboratories in Asia were compared against data from 239 laboratories in the rest of the world (RoW). Mean ED was significantly higher in Asia (11.4 vs. 9.6 mSv; P<0.0001), with significantly lower doses in South-East vs. East Asia (9.7 vs. 12.7 mSv; P<0.0001). QI in Asia was lower than in RoW. In comparison with RoW, Asian laboratories used thallium more frequently, used weight-based technetium dosing less frequently, and trended towards a lower rate of stress-only imaging.

Conclusions:MPI radiation dose in Asia is higher than that in the RoW and linked to less consistent use of laboratory best practices such as avoidance of thallium, weight-based dosing, and use of stress-only imaging. Given that MPI is performed in Asia within a diverse array of medical contexts, laboratory-specific adoption of best practices offers numerous opportunities to improve quality of care.
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Article title: Improving Nuclear Medicine Practices in Cardiology in the Emerging Economies: Role of the International Atomic Energy Agency
Authors: Maurizio Dondi, Thomas Pascual, Diana Paez
Publication title: International Journal of Cardiovascular Sciences 31(1), January 2017

Abstract:
Low- and middle-income countries (LMICs) are particularly affected by cardiovascular diseases (CVDs), as more than 75% of all CVD deaths occur in these countries. Global prognostic figures are alarming, as an estimated 23.6 million people will die each year due to CVDs by 2030. For this reason, one of the targets of the Sustainable Development Goals (SDGs) of the agenda of the United Nations (UN) aims at reducing premature mortality due to Non-Communicable Diseases (NCDs) by 30% by 2030. Within the UN family, the International Atomic Energy Agency (IAEA) has the mandate to promote safe, secure and peaceful use of nuclear technologies. The IAEA is strongly committed to accomplish the 2030 UN Agenda and through its Human Health Division, contribute to the attainment of SDGs. One of the key objectives of the Human Health Division is to support Member States to tackle the burden of CVDs through its subprogram of Nuclear Medicine and Diagnostic Imaging. This is accomplished by supporting the establishment and strengthening of capabilities of Member States to provide appropriate and safe use of nuclear cardiology clinical applications. The support ranges from assisting countries in the planning and implementation stages, providing training, maintaining and improving quality of clinical practice, establishing quality management systems and advising on how to comply with international standards, as well as using the technology in an appropriate and safe manner. This review will cover the activities of the IAEA in promoting, implementing, and supporting nuclear applications in cardiology in LMICs.
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