Current worldwide nuclear cardiology practices and radiation exposure: results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS)

Aims To characterize patient radiation doses from nuclear myocardial perfusion imaging (MPI) and the use of radiation-optimizing ‘best practices' worldwide, and to evaluate the relationship between laboratory use of best practices and patient radiation dose. Methods and results We conducted an observational cross-sectional study of protocols used for all 7911 MPI studies performed in 308 nuclear cardiology laboratories in 65 countries for a single week in March-April 2013. Eight ‘best practices' relating to radiation exposure were identified a priori by an expert committee, and a radiation-related quality index (QI) devised indicating the number of best practices used by a laboratory. Patient radiation effective dose (ED) ranged between 0.8 and 35.6 mSv (median 10.0 mSv). Average laboratory ED ranged from 2.2 to 24.4 mSv (median 10.4 mSv); only 91 (30%) laboratories achieved the median ED ≤ 9 mSv recommended by guidelines. Laboratory QIs ranged from 2 to 8 (median 5). Both ED and QI differed significantly between laboratories, countries, and world regions. The lowest median ED (8.0 mSv), in Europe, coincided with high best-practice adherence (mean laboratory QI 6.2). The highest doses (median 12.1 mSv) and low QI (4.9) occurred in Latin America. In hierarchical regression modelling, patients undergoing MPI at laboratories following more ‘best practices' had lower EDs. Conclusion Marked worldwide variation exists in radiation safety practices pertaining to MPI, with targeted EDs currently achieved in a minority of laboratories. The significant relationship between best-practice implementation and lower doses indicates numerous opportunities to reduce radiation exposure from MPI globall

Current worldwide nuclear cardiology practices and radiation exposure : results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS)

To characterize patient radiation doses from nuclear myocardial perfusion imaging (MPI) and the use of radiation-optimizing 'best practices' worldwide, and to evaluate the relationship between laboratory use of best practices and patient radiation dose. We conducted an observational cross-sectional study of protocols used for all 7911 MPI studies performed in 308 nuclear cardiology laboratories in 65 countries for a single week in March-April 2013. Eight 'best practices' relating to radiation exposure were identified a priori by an expert committee, and a radiation-related quality index (QI) devised indicating the number of best practices used by a laboratory. Patient radiation effective dose (ED) ranged between 0.8 and 35.6 mSv (median 10.0 mSv). Average laboratory ED ranged from 2.2 to 24.4 mSv (median 10.4 mSv); only 91 (30%) laboratories achieved the median ED ≤ 9 mSv recommended by guidelines. Laboratory QIs ranged from 2 to 8 (median 5). Both ED and QI differed significantly between laboratories, countries, and world regions. The lowest median ED (8.0 mSv), in Europe, coincided with high best-practice adherence (mean laboratory QI 6.2). The highest doses (median 12.1 mSv) and low QI (4.9) occurred in Latin America. In hierarchical regression modelling, patients undergoing MPI at laboratories following more 'best practices' had lower EDs. Marked worldwide variation exists in radiation safety practices pertaining to MPI, with targeted EDs currently achieved in a minority of laboratories. The significant relationship between best-practice implementation and lower doses indicates numerous opportunities to reduce radiation exposure from MPI globally

Lymphadenopathy resulting from acute toxoplasmosis mimicking relapse of non-Hodgkin′s lymphoma on fluorodeoxyglucose positron emission tomography/computed tomography

We report a case documenting fluorodeoxyglucose (FDG) accumulation in cervical, supraclavicular and axillary lymph nodes resulting from acute toxoplasmosis. A 50-year-old Indian female with history of non-Hodgkin′s lymphoma (NHL) of left breast, postchemotherapy status, was found to have hypermetabolic right cervical, supraclavicular and axillary lymph nodes on a surveillance FDG positron emission tomography/computed tomography (PET/CT) scan. Her previous two PET/CT scans were unremarkable with no evidence of metabolically active disease. Therefore, a differential diagnosis of relapse of NHL versus infectious/inflammatory pathology was raised in the report. Biopsy of axillary lymph node demonstrated features characteristic of toxoplasmosis. The serological test results were also compatible with acute toxoplasmosis infection. Infective and inflammatory diseases are known to accumulate FDG, resulting in false positives for malignancy. This case demonstrates lymph nodal toxoplasmosis as a potential cause of false positive FDG PET/CT findings in patients with known malignancy and highlights the importance of histopathological and laboratory correlation for the accurate interpretation of FDG PET/CT scans

Preferences and attitudes of physicians in India towards continuing medical education

Introduction: Physicians in India display an enthusiasm for continuing medical education (CME), however a proper system for facilitation and organisation of CME activities is yet to evolve in the country. Methods: A questionnaire-based survey was conducted among 751 physicians from eight medical specialties across India and the data retrieved was analysed at individual physician and collective specialty-specific levels. Results: The surveyed physicians considered case presentations (73%), live speaker programmes (70%) and round-table meetings/focus group meetings (70%) as the most effective CME activities. They preferred a duration of <2 h for CME activities such as webcasts (89%) and lectures (86%). Most of them considered scientific agenda (78%) and stature of speakers (77%) as the most important determinants of the quality of a CME event. Most physicians wanted topics such as disease guidelines (88%) and new drugs/devices/interventions (86%) for discussion in CME activities. Medical associations (87%) were the most desirable organisations for holding the CME activities and face-to-face modules appealed to majority of the physicians (64%). Conclusions: This study indicates that Indian physicians prefer live, interactive, short, specialty-specific educational sessions for CME activities, delivered by Indian experts and organised by medical associations at domestic destinations

Accreditation in India: Pathways and Mechanisms

Continuing medical education (CME) is a valuable mechanism to update physicians’ knowledge with ever-increasing plethora of contemporary advances within medical fraternity. Over time, scope of CME has seen change from simple clinical updates to comprehensive continuing professional development (CPD), which is accomplished with help of accredited CME programmes. The Medical Council of India, in 2011, made a mandatory resolution for doctors to attend minimum of 30 hours of CME/5 years to ensure recertification. Authorised accreditation councils and licensing authorities award CME credits for maintenance of physicians’ licensures. To date, in India, only 9 of 26 State Medical Councils have made re-registration mandatory. Although CME events benefit healthcare professionals by improving their proficiency and awareness, costs even to attend such interventions may be prohibitive. Despite financial help being received through grants and sponsorships, ethics of industry-sponsored CME remains a matter of debate. However, over past 10 years, pharmaceutical companies have started going beyond basic product information in order to focus on building physicians’ knowledge in various therapeutic areas. Though CME credit system and criteria for re-licensure for medical practice in India are evolving at a rapid pace, there is a need for harmonisation and robust implementation across all states in India

Adapting or Chasing Water? Crop Choice and Farmers' Responses to Water Stress in Peri‐Urban Bangalore, India

Unregulated groundwater extraction has led to declining groundwater tables and increasing water scarcity in the Indian subcontinent. Understanding how farmers respond to this scarcity is important from multiple perspectives—equity in access, livelihood security and resource sustainability. We present a case from the rapidly urbanizing Arkavathy sub-basin near Bangalore city in southern India where irrigation is fully groundwater dependent. Using cross-sectional data from a stratified random sample of 333 farmers from 15 villages, we investigated the factors that determine their choice of crops under conditions of water scarcity and urbanization. Binary logit analysis showed that farmers with a large landholding respond by tapping deep groundwater using borewells. Multinomial logit analysis revealed that access to groundwater, variation in the proximity to the product market (city) and labour availability influence crop choice decisions. We observe that current responses indicate what has been characterized in the literature as chasing strategies. These largely favour well-off farmers and hence are inequitable. While the choice of water-intensive crops and unregulated pumping have aggravated water stress, the uptake of watersaving technologies among irrigated farmers has been low, showing that resource sustainability may not be a concern where non-farm diversification opportunities exist