The rapid expansion of theranostics has increased the stress felt by many nuclear medicine departments. One significant challenge relates to the training of nuclear medicine technology students in new therapy procedures during a time when protocols and expectations are in flux. Nuclear medicine technologist education programs are being asked to graduate fully functional theranostics technologists before the resources for such training are available in the clinical sphere. This article describes the basic parameters under which education programs operate, namely the national scope of practice, programmatic accreditation standards, and credentialing examination content. The approaches and limitations of several programs around the country are presented. Despite considerable variability in the extent of student participation in theranostic procedures, the foundational elements of their nuclear medicine education remain firmly in place and reliable. Graduates will learn the specifics of each procedure in the workplace, as happens with already-credentialed nuclear medicine technologists.

The Joint Review Committee on Educational Programs in Nuclear Medicine Technology (JRCNMT) requires that each clinical affiliate have an Affiliate Education Supervisor (AES). The AES acts as a liaison between the program and the clinical affiliate and is typically a nuclear medicine technologist. The person appointed as the AES is often a department manager/supervisor, lead technologist, or staff technologist who has taken additional interest in training and mentoring students. The AES plays a vital role in student learning, student motivation, and overall student success, as does any clinical instructor (CI). Please note that an AES is often serving concurrently as a CI. The JRCNMT requires the program to provide a student handbook, clinical course syllabi, and student assessment documents to each AES. Orientation to the documents and expectations of clinical affiliates should be provided by the program. This handbook serves as a guide to help an AES understand the importance of their role, the expectations and duties of an AES, and provide the AES with resources to help them succeed in their role. Anyone serving as a CI will also find this resource valuable.

162 Objectives: COVID-19 has created difficulties for everyone, especially in the medical field. Within Nuclear Medicine, lung ventilation and perfusion (VQ) studies used to rule out pulmonary embolism (PE) have become a challenge with COVID positive patients. SPECT/CT technology provides a potential deeper look into not only physiological but anatomical information. This could prove to be advantageous for patients that are unable to receive the ventilation portion of the study. As a student, I have the advantage of seeing multiple protocols for the VQ study at different institutions. One hospital has started doing ventilation exams again. The patient must have tested negative for COVID-19 from the time of admission to the time of exam to use the ventilation machine. If a patient has not had a COVID test, the patient must do the ventilation through a single use bag. Absolutely no ventilation studies are done on COVID positive patients. Two other institutions continue to do lung perfusion only studies on all patients regardless of COVID status. Therefore, the purpose of this study is to review a SPECT/CT perfusion lung case study and evaluate the effectiveness in identifying the possibility of pulmonary embolism. Methods: An institution which is not performing ventilation is using SPECT/CT for lung perfusion only studies. These lung perfusion studies were observed and reviewed. The protocol utilized is as follows: 5 mCi Tc99m MAA, followed by 8 standard spot views taken in a supine position: anterior, posterior, oblique, and lateral views with 600k counts in a 128 x 128 matrix. The SPECT/CT portion is completed immediately after the perfusion with 15 seconds per step and 60 steps total. CT parameters include mAs: 3, kV: 120, a slice thickness of 2.5mm, and a matrix: 512x512. Results: In one case, a 76-year-old female with history of asthma, DVT and shortness of breath was evaluated using SPECT/CT perfusion study to rule out PE. The patient received 5.5mCi of Tc99m MAA and subsequent planar images were taken in the anterior, posterior, and 4 oblique views, followed by SPECT/CT. Images revealed bilateral segmental perfusion defects which were concerning for pulmonary embolism. While other pathologies were identified on the CT images, the probability of PE could not be estimated from this study . CT information from the study was reviewed for abnormalities possibly related to COVID, but nothing was conclusive. The patient was negative for COVID prior to the exam. Conclusions: Continued research is required to decide if SPECT/CT can decrease the need for a ventilation in a VQ scan; however, this hybrid scanner provides an opportunity to perform an alternative perfusion only study with added anatomical information. Even in institutions that continue to perform ventilation exams, there are occasions where a SPECT/CT may prove to be beneficial. SPECT/CT adds anatomic information to a physiological study, its use in the determination of the probability of PE is still unknown. Another consideration would be the difference in radiation dose from a SPECT/CT lung perfusion study compared to planar VQ. An initial investigation is being done by one of the institutions described in this abstract.

Within a few years of its discovery, ionizing radiation demonstrated adverse effects on biologic systems. Since that time, great strides have been made in radiation protection, detection, and personnel monitoring. Monitoring of the occupational radiation dose to individuals is enforced by several regulatory agencies in the United States and is referenced in numerous sections of the Code of Federal Regulations. A literature review with an examination of regulatory guidelines and a radiation safety officer survey was conducted to evaluate how often radiation exposure is monitored when an individual receives occupational radiation doses at more than one facility. The length of time a radiation safety officer has overseen the radiation safety program at an institution can impact whether dosimetry reports are requested for individuals who work at multiple places. Despite having safer equipment and occupational radiation exposure standards, there is no universal mechanism to track and record exposure for individuals working at more than one institution.

3047 Objectives: We are in a new age where kids have a vast array of electronics at their fingertips including smartphones, tablets, video games and the internet. Video games are increasing in usage and can be considered a major contributor to the disorder, which is acknowledged by the International Classification of Disease 11 (ICD 11) as gaming behavior that weakens one’s control over gaming and intensifies priority to gaming over other activities. We are now seeing the effects of this increased screen time. While it can provide endless hours of entertainment and education, harmful effects can also be seen. Children use these devices with their head tilted down and poor posture resulting in increased stress on the skull from attached structures and develop an exostosis at the external occipital protuberance (EOP). This is more commonly known as a bone spur, or excess bone formation on the surface of another bone. It will be painless until growth progresses leading to friction. There is no treatment for this benign growth. If discomfort remains or increases, then the bone may be shaved down to prevent chronic pain. The purpose of this study is to understand the mechanism of exostosis at the EOP and potential impact on bone scan. Methods: A literature review was conducted for the mechanism of exostosis at the EOP. In addition, pediatric patients who underwent a whole-body bone scan and between 10-19 years old were included in the study for a total of 43 unique patients. Bone scans were reviewed by a board certified Nuclear Medicine physician to assess for a focus of uptake midline in the occipital skull. Additional imaging was also reviewed for confirmation or to show progression. The most prominent case was then chosen for further investigation. The parents of the patient were contacted and gave input on the child9s lifestyle, posture, and electronic usage. Results: The EOP is a midline bony prominence in the occipital bone that ligamentum nuchae and trapezius muscle attach to its tip. The ligamentum nuchae Extends from the EOP on the skull and median nuchal line, to the spinous process of C7 (Figure 1) . Its function is to limit flexion and to provide an attachment for Trapezius and Splenius capitis. The use of electronics leading to an extended period of neck hyperflexion resulting in a gradual chronic irritation which leads to exostosis at the EOP which would result in a focus of increased MDP uptake in bone scanning that may mimic skull metastases. The parents of the pediatric case with the most prominent uptake at the EOP were contacted and confirmed slouching while staring at electronic devices which occurs for several hours a day for 3 years (Figure 2). Conclusions: The rapidly advancing technology means today’s parents are dealing with the first generation dealing with increased screen time. As new research is coming out showing the harmful effects of increased screen time, we are struggling to impose healthy limits. Our case study shows that chromic use of electronics may result into exostosis and higher MDP uptake at the EOP. We continue to analyze data regarding the frequency of encountering this uptake in our pediatric population. When present, such uptake may be a source of false positive interpretation. It is particularly important clinicians are aware of this entity when reading bone scans to distinguish it from metastasis.

3095 Objectives: Subtle Medical created the first Artificial Intelligent (AI) processing for F18-FDG (FDG) PET/CT imaging which was FDA approved in 2018. Subtle Medical specialized an AI processing technique for PET/CT imaging, called Subtle PET. The aim of Subtle Medical is to reduce noise resulting from time reduction and/or with radiopharmaceutical dose reduction. The purpose of this research is to evaluate and compare the image quality of study with standard full counts without AI processing and various count reductions with and without AI processing. Methods: The study was conducted with 15 FDG-PET/CT standard of care whole body studies from a VA population. The standard full count protocol is 3min/bed and the 50% count PET and 25% count PET were simulated to be 90 sec/bed and 45 sec/bed. Studies were reprocessed using different amount of counts: full count without AI processing, a 50% of total counts without AI processing, a 50% of total counts with AI processing, a 25% total of counts without AI processing, and 25% total of counts with AI processing. Scans were read and analyzed by two board certified nuclear medicine physicians. Image quality for each set of images was scored on a 5-points scale (1= poor and 5 = excellent image quality). BMI and age was also included in the analysis. Results: For the 15 patients, 5 image sets were evaluated and image quality was ranked (table 1). The mean image quality was as follows: 4.8 for full count scan without AI processing, 3.93 for the 50% which increased to 4.47 with AI processing, 3.00 for 25% total count which increased to 3.93 with AI processing. The data was also evaluated regarding impact of BMI on noise reduction using AI, with a BMI < 30 (table 2) and BMI of 30 or greater (table 3). Conclusions: With 50% counts, Subtle PET AI processing improves image quality to that of the standard full counts, therefore, AI processing enables either 50% reduction in image acquisition or 50% reduction in FDG injected dose regardless of BMI. However, AI noise reduction is relatively less successful if producing high quality images if only 25% of the counts in used, particularly in patients with BMI >30. Further studies are needed to test the success of AI in non FDG PET tracers and to elucidate the impact of AI on SUV quantification. Table 1: Diagnostic Image Quality of all Patients Table 2: Diagnostic Image Quality BMI less than 30 Table 3: Diagnostic Image Quality BMI 30 and greater

The digital PET/CT scanner with digital photon-counting technique promises a shorter scan time, improved small-lesion detectability, and reduced radiation dose for the PET and CT portions of the exam while improving image quality. Methods: In this single-institution retrospective review study, 84 participants who had undergone PET/CT on both analog and digital scanners were analyzed. The aim was to evaluate the impact of image field of view (FOV) and body mass index (BMI) on the digital compared with the analog PET/CT scanners. The participants were categorized into different groups based on their BMI. Total scan times, F-18-FDG doses, and dose-length products (DLP) were collected and compared. Image quality was also assessed by certified nuclear medicine physicians and graded on a scale from 1 to 5. Results: In the skull-to-mid-thigh FOVs, the digital scanner had a scan time shorter by 37% (P < 0.001), a F-18-FDG dose lower by 16% (P < 0.001), but only an 8% reduction in DLP (P = 0.2). In the head-to-toe FOV cases, the digital scanner showed reductions in scan time (33%; P < 0.001), F-18-FDG dose (13%; P < 0.001), and DLP (19%; P < 0.001). When BMI was accounted for, the digital scanner had a scan time shorter by 33% (P < 0.001), as well as a reduced DLP (P < 0.001) and F-18-FDG dose (P < 0.001), with the most prominent changes being in the overweight and obese participants. Image quality was also improved by the digital scanner, with a score of 4.5, versus 4.0 for the analog scanner. Conclusion: The digital scanner has a shorter scan time and lower DLP, requires a lower F-18-FDG dose, and provides improved image quality when compared with the analog scanner. The most impactful difference in scan time, DLP, and F-18-FDG dose were observed in obese and overweight participants.

3034 Objectives: Research has shown imaging studies at a hospital can induce anxiety, particularly to cancer patients undergoing FDG-PET/CT studies. Board-certified music therapists use music therapy to increase relaxation and decrease anxiety. Rhythmic entrainment is a form of music therapy in which the patient’s biorhythm, like their heart rate, is paired with live music of the same tempo. Person-Centered Therapy uses an empathic approach that empowers and motivates the participant in the therapeutic process. The purpose of this study was to determine if live music therapy can reduce anxiety of patients undergoing standard of care medical imaging. A secondary purpose which is ongoing is to determine if changes in anxiety can impact image interpretation. The study outcomes may help develop a more complete approach to treatment. Methods/Materials: Patients undergoing standard of care PET/CT exams who were willing and able to consent took part in this single institution IRB-approved study. In total, 25 patients were enrolled (20 with music therapy intervention and 5 controls). Patients were randomly selected to the experimental group or control group. The experimental group received 30 minutes of music therapy during the uptake phase of the scan which utilized live music and possibly vocals performed by a trained music therapist who is also the musician. The live sessions create a more individual experience that included personal music preference, rhythmic entrainment, and Person-Centered Therapy techniques. The control participants followed the standard of care protocol during the uptake phase which does not include music. Both groups had pulse, respirations per minute (RPM), and blood pressure measured before and after the 30-minute session. Both groups had RPM measured at 5 minutes and 15 minutes into the sessions. All participants were asked to complete a State-Trait Anxiety Inventory (STAI) before and after the 30-minute session. The STAI is a survey designed for patients receiving music therapy intervention to measure the anxiety level. Results: The RPM rate and the STAI showed statistical significant differences between the pre and post session measurements for the experimental group (Table 1). The STAI total score decreased by 37.7% in the experimental sample and 7.4% in the control sample. The RPM decreased by 14% in the experimental sample and did not change in the control sample. However, the STAI and RPM did not show statistically significant changes in the control group (Table 2). The heart rate measurements did not show a significant difference between pre and post measurements in either group. The blood pressure changes did not show significant differences with any of the acquired data. Conclusion: The use of music therapy showed a higher percentage decrease from the pre to post data for the STAI and the RPM compared to the control group leading to an overall greater decrease in anxiety levels.

3050 Objectives: The landscape for Nuclear Medicine is undergoing a transformation and the main driver is the emergence of Theranostics. Currently, the two main therapies are 177Lu-DOTATATE which is FDA-approved for the treatment of neuroendocrine tumors (NETs) and 177Lu-PSMA which is not FDA approved but in clinical trials for the treatment of metastatic castration-resistant prostate cancer. However, these therapies have been standard of care for many parts of the world leaving the United States to play catch-up. The objective of this study is to compare and contrast the differences of these therapies between the US and other parts of the world. Methods: Protocols, patient selection and pricing were reviewed through published literature for treatment with 177Lu-DOTATATE in the United States and compared to Australia. The same was then done with Lu-PSMA comparing the United States with Germany. Results: Comparing literature review for 177Lu-DOTATATE, we found that the FDA approved treatment for patients with NETs affecting the pancreas or gastrointestinal tract whereas in Australia all NETs can be treated. In addition, the US has a standard protocol for all treatments which does not take into account the tumor aggressiveness measured by Ki-67, does not do dosimetry, and requires only 68Ga-DOTATATE PET-CT prior to therapy. On the other hand, Australia has a more personalized treatment for the patient as it will tailor therapy based on the aggressiveness of the tumor, performs dosimetry, and may require both 68Ga-DOTATATE and 18F-FDG PET-CTs prior to therapy. The price of the study also varies significantly costing $50,000 USD per dose in the US vs $5,500 USD in Australia.Comparing the literature for 177Lu-PSMA is not as straightforward since it is still undergoing clinical trials in the US. Nevertheless, in Germany the total cost of the treatment is $16,000 USD which includes admission into the hospital for 5 days and all labs/imaging. If it is assumed the US follows the same pattern with pricing as with 177Lu-DOTATATE, it will be significantly more expensive than the German counterpart. Conclusion: The United States continues to trail behind the rest of the world in Theranostics. The therapies in the US lack personalization and are offered at a significantly higher cost. The counterparts across the world are able to tailor these therapies to their patients at a fraction of the cost. Differences such as these may leave the United States with lower success rates while having some of the highest healthcare costs in the world.