Thyroid Practice Enhancements ATA- 2013.
Thyroid practiceEnhancementsATA- 2013.J. Woody Sistrunk, MDJackson Thyroid & Endocrine Clinic, PLLCJackson, Mississippi1
12134KEEP THIS IN MIND!!!THYROIDOLOGYPRACTICE ENHANCEMENTSIn the order of importance.2
2 sections:1. An Introduction to Outpatient Nuclear Medicine2. An Overview of Starting a Clinical Laboratory
AN INTRODUCTION TO NUCLEARTHYROIDOLOGY IN THE OUTPATIENTPRACTICE OF ENDOCRINOLOGYJ. Woody Sistrunk, MD, FACE, ECNU Radiation Safety Officer
Why Nuclear Medicine in Endocrinology? Who knows more about thethyroid than an endocrinologist? Proper safety instructions andreassurance to YOUR patients. Making sure YOUR patients aretreated appropriately. SAFTEY INSTRUCTIONS FROMHospital NUCLEAR MEDICINE: “In that room you will find ametal box. In that box you will find a leadcontainer. In that container is a pill. Take it and leave.”PUBLIC PERCEPTION5
DID YOU KNOW THATENDOCRINOLOGISTS: Can have a Nuclear Medicine Hot lab in theoffice. Thyroid Uptakes Radioactive iodine therapy for hyperthyroidism. Radioactive iodine therapy for thyroid cancer. With these procedures, you become the nuclearmedicine physician/technologist. Maintaining complete control of quality anddecisions of your patients outcomes. Ensuring correct instructions given to patients andsafety measures followed. Verifying all questions are answered.
NUCLEAR MEDICINE IN THE OUTPATIENTPRACTICE OF ENDOCRINOLOGYOUTLINE Licensure AACE Course- Equipment7
History of 131I TherapyIt is OUR heritage and OUR History!! 1946-1970 Endocrinology 1970-1993 Nuclear Medicine 1993-Present AmericanAssociation ofClinicalEndocrinologists(AACE )Initiative.8
History—Nuclear Medicine Era Missed diagnosis Failure to discuss othertreatments Failure to discuss non-thyroidproblems Misadministration Loss to follow-up “Thyroid uptake is lowconsistent withhypothyroidism.” “Thyroid uptake is low,r/o paraneoplasticprocess.”9
LICENSURE/ DEFINITIONSNUCLEARENDOCRINOLOGY10
Agreement State vs. Non-Agreement State Agreement State A state that has signed an agreement with theNuclear Regulatory Commission under which thestate regulates the use of byproduct , source, andsmall quantities of special nuclear material in thatstate. Non-Agreement State The state is governed by the applicable laws of theNuclear Regulatory Commission(NRC).11
Agreement StatesAgreement StateNon-Agreement StateSource: www.nrc.gov12
What is a Radioactive Materials (RAM) License ? Issued to your clinic, or the hospitalwhere you have privileges, by the NRC orAgreement State. Allows the facility to: order receive possess use radioactive materials.13
Who is anAuthorized User ?Authorized Users are physicianslisted on the radioactive materialslicense who are authorized toprescribe and administer particularradiopharmaceuticals for specificdiagnostic or therapeuticprocedures.14
What will I be able to do as anAuthorized User of Radioactive iodine?1. Thyroid Uptakes (I131,I123 )NOSCANS2. Radioactive Iodine(I131)treatment forHyperthyroidism.3. Radioactive Iodine(I131)treatment for thyroidcancer / remnant ablation.NOTE: YOU WILLNOT HAVETHE ABILITY TOPERFORM THYROIDSCANS. ********15
What Do I Have To Do To Become AnAuthorized User ?80 hours of classroom instruction with anemphasis on radiation safety, physics andmath. AACE 80 HOUR COURSE.Board certification by a medical specialtyboard.Supervised treatment of 3 patients withless than 33 mCi. (Hyperthyroidism)Supervised treatment of 3 patients withmore than 33 mCi.(Thyroid cancer).16
AACE NUCLEAR MEDICINE COURSEKansas City, MissouriFall 2013Go to aace.com for details.17
How to Get Started What to Know? License requirements in your state. Equipment required. Layout of nuclear medicine hot lab. Who to contact? State nuclear regulatory agency Physicist Nuclear Pharmacy18
SIMPLE “HOT LAB” LAYOUT Essentials include a sink and a few electrical outlets. This can be the same room used for ultrasoundexams. The same stretcher can even be used.19
Nothing this Fancy, Nothing this complicated. No special leadlined room. No specialfacilities needed. But this isimpressive!!!!!!!!!!!
SIMPLE PROCEDURE ROOM LAYOUT Essentials include asink and a fewelectrical outlets. This can be the sameroom used for nuclearmedicine andultrasound exams. The same stretcher caneven be used.21
SIMPLE PROCEDURE ROOMLAYOUT22
SIMPLE PROCEDURE ROOMLAYOUT23
SIMPLE PROCEDURE ROOMLAYOUT24
PROCEDURE ROOMMICROSCOPE LAYOUT25
EQUIPMENT OVERVIEW So now it’s time to set up aHOT LAB! WHAT WILL I NEED TOPURCHASE? Uptake System Dose Calibrator Geiger Counter26
HOW MUCH WILL ALL OF THIS COST? Uptake System- 10,000- 14,000 Dose Calibrator-- 6000- 8000 Neck Phantom-- 275 Geiger Counter - 1000 Total Hot Lab Setup 20,000- 24,00027
HOW MUCH EXPOSURE WILL I RECEIVE?– Minimal !!! If any. No liquid!!!!!, all capsules arriveas pre-ordered unit doses. VERY SAFE HOW DO YOU KNOW IF YOUARE EXPOSED? Film Badges. WEEKLY Bioassay- which issimply placing the uptakeprobe over the neck will beperformed weekly to confirmthat radioactive iodine is notabsorbed.28
YES, it will pay for itself!!!!!!!!!!!3 UPTAKES/ MONTH Paying for itself. In practice 11 years. uptakes. I131 therapies.774865 PERSPECTIVE Jackson Thyroid & Endocrine Clinic-- 2011 Ultrasound onlyUS guidance with FNAFNAUptakes54Therapies451093305305 HENCE, Thyroid Ultrasound is critical first. 29
Fellows:WHILE IN TRAINING Pursue all of therequirements needed forlicensure. Review this talk with moredetail at aace.com. Get to know the radiationsafety officer at yourinstitution (who oftentimes is not a radiologist)and try to be put on theinstitution license as an“official user”.30
While Interviewing Ask about the possibilityof you having a “hot lab”and doing your ownnuclear medicineprocedures. Make sure you haveaccess to a goodultrasound machine. Be specific withmonetary figures, spacerequirement and thelong term moneymaking potential.31
PATHWAY TO LICENSURECertification, Licensure, thenAccreditation.CASES80 hourCertification3 HyperAACE/DTCcourseNuclear3 cancerICANLIntersocietalCommission for theAccreditation ofNuclear MedicineLaboratoriesBoard ofEndocrinologySTATE/ NRCRAMLICENSE(PENDING)ICANLLABAccreditation32
Getting cases:A PROBLEM AT TIMES While you are still in fellowship, if you haveany desire to become licensed in this, pursuethe required cases (3 hyperthyroidism, 3cancer. ) Assist with dose decisions, safety instructionsadministration. Have a preceptor sign theappropriate NRC preceptorattestation form.
CONCLUSIONS: Thyroid Doctorstreating ThyroidDisease. A thyroidpractice is areality if you arewilling to pursueit.AACE NUCLEAR MEDICINE COURSEKansas City, MissouriFall 2013www.aace.com34
12134THYROIDOLOGYPRACTICE ENHANCEMENTSIn the order of importance.36
IN-OFFICEPOINT OF CARE LABORATORY37
LAB OUTLINE1. Licensure2. EquipmentNever enough equipment in the practice of Thyroidology38
WHO IS THIS MAN?HINTs:S:Invented theradiation film badgeInvented polarizedlenses.Had a role in changingour lives forever.
Edwin H. Land Inventor of : The Polaroid LandCamera Polarized lenses. The radiation filmbadge. But what does hehave to do withthe practice ofmedicine?
The Polaroid Camera changed the world. Pictures were availableimmediately. Good, bad,or ugly results wereavailable immediately. No one was able wait for resultsanymore. Land was responsiblefor the expectation ofthe results in clinicalmedicine anticipatedimmediately by thepatient (and Physician/Endocrinologist.)
Why Laboratory Medicine? Laboratory Medicine isessential is the heart ofendocrinology. Without lab, we aredoomed merely to watchand guess.42
Why Laboratory Medicine in Thyroidolgy? “BUT I AM SO OBESEAND TIRED, IT MUSTBE MYTHYROID!!!!!!!!!!” The decisive “NO” PRICELESS!!!!!!!!!43
CLIA CERTIFICATIONLABORATORY MEDICINE44
LABORATORYMEDICINE IN THECLINICALPRACTICE OFENDOCRINOLOGYCLIA CERTIFICATION45
What is an OFFICE-BASED LABORATORY? Office-Based Laboratory – Defined as a clinicallaboratory used by a fullylicensed physician to testspecimens collectedprimarily from patients ofthe practice. It is usually located at thephysicians principal sightof care.46
LABORATORY DIRECTOR Responsible forthe overalloperation of thelaboratory andthe competencyfor alllaboratorypersonnel.47
HOW DO I BECOME ALABORATORY DIRECTOR? Certification in anatomic or clinicalpathology. One year of laboratory training in residency. There’s still time for this. OR 20 hours of CME credits of training on theresponsibilities of the laboratory director. –http://www.cola.org/48
http://www.cola.orgThis is the location for the Laboratory DirectorsOnline Course.49
WHERE DO I START?WHAT CAN I DO IN AN OFFICE LAB?50
LABORATORY MAKE-UP LABORATORY DIRECTOR- YOU Responsible for the overall operation of the laboratoryand the competency for all laboratory personnel. The first step of getting this designation is to finish theon-line portion of the laboratory course. TECHNICAL CONSULTANT-YOU Responsible for technical and scientific oversight ofthe laboratory. CLINICAL CONSULTANT-YOU The physician that orders the appropriate tests. TESTING PERSONEL-Hopefully someone else. GED/High School diploma and documented trainingappropriate to the test being performed. www.cola.org51
THYROIDOLOGY WITHOUT LAB IS LIKEFISHING WITHOUT WORMS. LAB is critical But the TSH/FreeT4 is theessential part ofthe enterprise. From vein to results on paperin 20 minutes. Face to face decision making. Are you taking your medicine. I will write your 90 day RX now. A note to PCP, recommendingplanned follow-up.52
A VAST MENU OF TESTS ARE AVAILABLE FORTHE OFFICE-BASED LAB TSH/ Free T4Simple ChemistryCBCCOMPLEX LABS: TSH/FT4 HgbA1c MANY OTHERS. Clia-Waved Tests. NOTE: CLIA NOTREQUIRED FOR FNAADEQUACY!!!!!!!!!!!53
LABORATORY IMPROVES CLINICAL OUTCOMES 1. FASTER DIAGNOSIS AND TREATMENT. 2. IMPROVED PATIENT COMPLIANCE. 3. LABORATORY CAN MODEL THE NATUREOF YOUR PRACTICE.“TSH and FREE T4 in 30 minutes”“You’re ONE-STOP THYROID SHOP”54
What are the advantages of having an in office laboratory? CLINICAL RESEARCH Phase 3 and Phase 4 drug studies are quicklybecoming a big part of the private practice ofEndocrinology. Having a laboratory makes your office a valuablesite for data collection in these studies. Sites with laboratories are considered “moredesirable.” MAKE YOUR LAB WORK FOR YOU!!!!!!!55
DISADVANTAGES OF AN OFFICE LABORATORY. Costs. Regulations. Personnel. Technologist Phlebotomist Laboratory Director (MD)56
My Current PracticeWith POINT OF CARE LAB Lab DrawnPatient SeenLab AvailableLAB IMPORTED INTO EMREMR Note sent to referringphysicians. RX written/ wired. Disposition MADE! Follow-up scheduled. All inside of30 minutes.
RESULTS TO PATIENTS Patients want results. Face to face results cut down onquestions and confusion. If you see 25 patients a day, youeither have to pay the salary ofthe lab tech who processes thelabs or ANOTHER nurse that willspend tomorrow tracking downthe patient, verifying results,calling the pharmacy, and rearranging follow-up. In the end, make it a timesaving, money makingproposition. Set the standard!!!!!!!!!!!58
To Recap–The Advantages of Having an in office laboratory. PATIENT SATISFACTION CONVENIENCE Changes to treatment regimen can be madeFACE TO FACE. Patient understanding is clearly better whencommunicated directly by the physician. FEWER PHONE CALLS or MAILINGprescriptions. FASTER DIAGNOSIS AND TREATMENT. LESS ANXIETY WAITING FOR RESULTS. Ability to send Obese and Tired to an Internist!59
RECAP– Many Reasons to have a lab in the office. It’s good for the patient. Convenient, faster diagnosis and treatment. It’s good for the practice. Improved efficiency, Patient Satisfaction. It’s good for revenue. It keeps the bills paid. It’s good for the physician. YOU ARE IN CONTROL!!!!!!!!!!!!!!!! IT MAKES YOU A VALUABLE COMMODITY.60
HOW PROFITABLE IS HAVING AN IN-HOUSE LAB?2008 FIGURES. – Jackson Thyroid & Endocrine Clinic, PLLCLAB TEST#PERFORMEDYOUR COSTREIMB.TSH3217 @ 1.40 4,503.80 152,775.FREE T43216@ 2.25 7, 236.00 98,455.Calcium761@ .17 129.00 8,302.HCG(Kit)86@ 1.19 102.30 1,892.61
HOW PROFITABLE IS IT FOR YOU TO BILL FOR YOUR SENDOUTLABS?2008 FIGURES. Jackson Thyroid & Endocrine Clinic, PLLCLAB TEST#PERFORMED FEEREIMB.TPO601@ 7212.00 22,838.00TG382@ 8404.00 35,908.00TSI162@ 9290.00 23,166.00TSHRab164@ 8175.40 6,396.00CBC254@ 825.00 5,334.00COMP200@ 800 9,400.0062
SO WHY DOESN’T EVERYONE HAVE A LAB? OTHER COSTS ARE SIGNIFICANT!!!!Lab Supplies 45,537.34Service Agreement 15,000.00CLIA 188.00MLE Surveys 363.00Calibration of Equipment 176.55Validation standards 946.52SALARIES 73,320.00REFERENCE LAB 95,880.91TOTAL COSTS 246,383.4563
On site Microscopy– FNA AdequacyAnother vital laboratory function. FNA adequacy doesmake a difference inthe “point of care”results. Follicular cells seenin node, then STOPSTICKING.
A GOOD MEDICAL TECHNOLOGIST IS KEY TO THEWHOLE OPERATION.FORGETTHE MONEYMADE ONLABS,I COULD PAYHER SALARYWITH FNAADEQUACYBILLINGALONE!!!
WHAT SHOULD YOU NAME YOUR CLINIC? Let them know what you do. Have THYROID in your clinicname. If you have DIABETES in yourclinic name, you will continueto be a diabetes doctor.66
Set yourself apart. WHAT MAKES YOUDIFFERENT FROM THEOTHERENDOCRINOLOGISTSIN YOUR TOWN? Be the point person. Be visionary, notreactionary. You may not be able tostart off with all of thesethings, but have adefined plan.67
“DO SOMETHING YOU LOVEAND YOU WILL NEVER WORK ADAY IN YOUR LIFE.” Confucius68
QUOTE“Do the work youlove, and you willfind joy in it” Lawrence Welk69
Thyroid practice Enhancements ATA- 2013. 1 . THYROIDOLOGY PRACTICE ENHANCEMENTS In the order of importance. KEEP THIS IN MIND!!! 1 2 1 3 4 2 . 2 sections: 1. An Introduction to Outpatient Nuclear Medicine 2. . Association of Clinical Endocr
Note The term Cisco ATA is used throughout this manual to refer to both the Cisco ATA 186 and the Cisco ATA 188, unless differences between the Cisco ATA 186 and Cisco ATA 188 are explicitly stated. Default Boot Load Behavior Before configuring the Cisco ATA, you need to know how the default Cisco ATA boot load process works.
Introduction by Suzy Cohen, RPh xiii Part I Thyroid Basics 1 Chapter 1 One Gland with a Big Job 3 Chapter 2 Thyroid Hormones Control the Show 13 Chapter 3 Thyroid on Fire 27 Part II Thyroid Testing 43 Chapter 4 Limitations of the TSH Test 45 Chapter 5 The Best Lab Tests 49 Chapter 6 5 WaysYour Doctor MisdiagnosesYou 73 Part III Drug Muggers 81
2 shows the position of the thyroid gland as well as right and left lobe for a human being. Measurement of the thyroid in-volves three measurements, which are the width, depth and length [7]. The normal thyroid gland is 2cm or less in width and depth and 4.5 – 5.5 cm in length. 2.2 Fig. 2. Position of thyroid gland. [20]File Size: 600KBPage Count: 8
In order to measure normal thyroid gland in Sudanese. 1.4 Specific objectives: -To measure thyroid gland volume (right lobe, left lobe) and isthmus. -To correlate size of thyroid gland with body characteristics (age, gender, height and weight). -To find dynamic equation to calculate measurement of thyroid using body characteristics.
Thyroid antibodies in hypothyroidism In most instances, it is not necessary or recommended to check thyroid antibodies Elevated levels of thyroid antibodies may indicate that a patient with normal TSH and normal free T4 is more predisposed to develop hypothyroidism Elevated levels of thyroid antibodies do not indicate –
of 1432 Japanese with normal thyroid function [i.e., normal range of free triiodothyronine (free T3) and free . [the first quartile, third quartile]. Normal range of measurements are ( ) Table 2 Thyroid-related hormone by anti-thyroid peroxidase antibody (TPO-Ab) Anti-thyroid peroxidase antibody (TPO-Ab) p Total No. of participants 1165 267
the adult thyroid gland varies between 15g and 30g, and each of the major lobes is around 4cm long and 2cm wide (Benvenga et al, 2018; Dorion, 2017). Embedded in the posterior portion of the thyroid are four tiny parathyroid glands, which function independently of the thyroid (Fig 1). Histology The thyroid contains two major popula-
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