Most important I hope you all have an interesting and successful 2020.

New Year is of course the time we make resolutions though one wise head said the only New Year’s resolution worth making was to resolve not to make a New Year’s resolution so at least you can keep that one.

Anyway this is my list

1. Do not eat cakes or biscuits left in the department tea room for sharing*
2. Do not get cross when supposedly intelligent doctors cannot order a simple bone scan correctly on the electronic patient record*
3. Do not ask for too many extra SPECT-CTs on a patient study and cause extra stress to the technologists*
4. Do not ask why I cannot have Ga-68 DOTATATE everyday*
5. Cycle a bit faster so to burn off more energy each commute
6. Do not go to Marks and Spencer’s to buy lunch and then end up buying an extra snack for the afternoon* (We have an M&S food store in the hospital now)
7. Do not write snide comments on report of MIBI parathyroid scans when they are negative and Calcium levels are only 2.6*

Ones my wife has requested of me

1. Do not get admitted to hospital and have open heart surgery-I am working on this one but this may not be up to me.
2. Invite her to the Gala Dinner at the Spring Meeting of the BNMS and actually be well enough to go- see above on this one
3. Complete clearing out the garage a true task of Hercules but at least you can see the floor now.
4. Clear out and redecorate the “spare” bedroom (similar to 3 but also includes wall papering and painting)
5. Do not agree to do so much work that I am unable to complete tasks 3 and 4*- This one seems difficult as recently my understanding of retirement is working 6 days a week at different hospitals

Now for some BNMS based resolutions.

1. Remember to register for the spring and Autumn meetings of the BNMS in time to get early bird discount
2. Actually get to Spring meeting (see resolutions 1 and 2 above)
3. Discuss with IPEM, RCR and RCP how we can deliver molecular radiotherapy such as radium-223 Lu-177 DOTATATE and SIRT to patient’s without excessive wait times and distances travelled
4. Try not to get angry with the Department of Health and Social Care over Brexit
5. Try to get NHS England to cough up money for the extra delivery costs of radiopharmaceuticals caused by Brexit
6. Complete a month without using the word Brexit*

The resolutions I have already broken in 2020 are marked with a *

Dr John Buscombe

BNMS President

I thought of celebrating the 50^th Anniversary of Sesame Street with another letter in this case the letter “L”. This is because I wanted to write about Liverpool. When I was young ,half a century ago Liverpool was the place everyone wanted to go to. First of all was the Music which was not just the Beatles but by song you could even travel across on the Ferry across the Mersey in your own sitting room. Then each week there would be an episode of the “Liver Birds”. With exotic accents and story lines about living in a flat and having all sorts of fun. Funny how your memory works but it was the favourite programme of my oldest sister. The opening sequence showed the pierhead and the Liver buildings. Then there was one of the very early “pop videos” of what was essentially a film of buses driving up and down Penny Lane as John Lennon and Paul Macartney sang about its residents as though they were most exciting people you could ever want to meet. By my teens Liverpool was already in decline. It became a bye-word for football hooliganism. Television comedians would make fun of Liverpudlians assuming they were all crooks who spoke funny. Then came the Toxteth riots and the closing of the docks. It seemed no-one cared for Liverpool and now if it was in any pop videos it was to show the effects of dereliction and decay normally to some loud punk band.

About 10 years ago I went for the first time to the Conference Centre in Liverpool. All my southern prejudices were blown away. I found an amazing city vibrant, full of friendly and welcoming people. The dockhead was spruced up, Albert Dock was back in business with restaurants and museums. The Beatles were not forgotten but had come alive in their links with different parts of the city. The world’s best collection of pre-Raphaelite art is in the Walker Gallery. I have been back 7 or 8 times since and I always look forward to seeing what is new and finding another amazing building or museum is open. You too can share my excitement by coming to our BNMS Spring meeting in May. If you know Liverpool you will want to come, if you do not know Liverpool an absolute treat awaits you. If you cannot come make sure as many people from your department come. Also remember we have the innovative department award running again and we would love for you to share your research and experience in an oral presentation or poster. Details are in our web site of course.

My second “L” ended up as an “M”. I now mean the M of mandatory training. After 10 years my work in Cambridge draws to a close, my successor has been appointed and she will make a great success of the job. So as they say I am surplus to requirements. I have a great 10 years in Cambridge and I will miss the staff there a great deal, even though I will not miss the daily 140 mile round trip commute. So I need to look for a job. I am considering offers from 2 hospitals closer to home but before I can do anything there is about 20 forms to fill in. HR has been privatised and the people who run those have no idea about anything other than the tick boxes they need to fill in. Whilst I am up to date with my Mandatory Training it all has to be repeated. For example there is Health and Safety. Cambridge does not have this so I asked what it contained and was told Fire training, Manual handling and hand washing. In triumph I showed that I was up to date on all three. Nope that will not do it has to be something called Health and Safety so I have to go on a course so the box can be ticked. My Basic life support is valid till November 2020 but nope it is not the right basic life support. Maybe my Cambridge CPR to “Staying Alive” does not work in London. I must go on a special 3 hour course. The course is free but a certificate to prove I have been costs £50. The privatised HR stated that without the actual certificate from their own course I cannot work. I am beginning to smell a scam here.

My greatest problem however is my MMR certificate. I am clearly not an anti-Vaxxer. Anti-Vaxxers are sadly misinformed by people who generally prey on the natural fears of people to make money. To be honest those who perpetrate these lies about MMR are putting children at risk. My children all had their MMR done all on time and this was at the height of the MMR controversy. However, I myself do not have an MMR vaccination certificate. For the simple reason I am too old. I was already an adult when the MMR vaccine was approved. Also I was the generation that just got Measles, Mumps and Rubella. Unfortunately the HR form has a box on it that cannot remain empty. I was Called into an interview by a very nice person half my age. When I explained this she clearly did not believe me. For some reason I was hiding my MMR certificate from her. I was asked 10 times in a 30 minute interview for my MMR certificate because without that the box could not be ticked. I tried to be helpful and pulled out a yellowed piece of paper. It had on the top the crest of the Royal Navy underneath was my name in copperplate calligraphy and under that the date in 1964 I received my smallpox vaccination. It is the only vaccination certificate I have except for an expired yellow fever certificate from 2009 and a sticker of a smiling bug on my hospital ID to show I have had this year’s flu jab. Nope it would not do. Again I was asked to hand over my MMR certificate sadly again I could not. I fear this will not be resolved. Maybe I can work at the local branch of MacDonald’s but even then I fear the question “Can I see your MMR vaccination certificate”.

Dr John Buscombe

BNMS President

Firstly I promise not to use the B word in this month’s blog. September brings a new energy to our work. The weather gets colder, the DNA rate falls as patients think that coming to the hospital is more exciting than watching the next episode of “homes under the hammer”. No more do they sit in the gardens or down the park enjoying the sunshine. However, a new season brings new challenges and we need to think about how we will shape our work over the next few months.

Well a great start has been the Autumn BNMS which we have just had in Nottingham. We met at Albert Hall a wonderful Edwardian building that has been beautifully restored by City of Nottingham. We had some excellent session including one on sentinel nodes, another on PET-CT and PET-MR. A session on theranostics and a very well attended session on how new regulations may affect the practice of nuclear medicine. There were 90 delegates which worked very well for the room sizes and there was an excellent commercial exhibition and poster area that could be visited during the coffee, lunch and tea breaks. A massive congratulations to Charnie and Racheal for all their hard work setting the meeting up.

If you are now wishing you could have come to the BNMS meeting after all can I commend an upcoming meeting from one of our sister organisations. The Cyprus Society of Nuclear Medicine is having their 20^th birthday this year and a brilliant conference including nuclear medicine talent from around the world is being held in Cyprus from November 6^th-10^th. Details are on our website.

There has been some good news in that NHS England has agreed at last to fund F-18 Fluciclovene imaging in prostate cancer. We are hoping that funding can also be extended to those sites who perform PSMA PET. There are still some issues with availability of the product across England and training but we do hope that PET imaging of prostate cancer will be as easy to obtain for our patients and FDG imaging for other cancers.

A few of our longer term plans are also coming to completion over the next few weeks. The joint report on molecular radiotherapy will be published. The BNMS fellowships will start, look at the BNMS web site for details. We hope to have the Lutathera web site up and running. We are lobbying the government concerning the proposed 10% cut in nuclear medicine tariffs for next year and working with NICE on guidelines for the treatment of benign and malignant thyroid disease. It has been a busy few months but we are hoping for positive outcomes for the specialty.

See I got through this whole blog without mentioning Brexit. Oops broken my promise.

Dr John Buscombe

BNMS President

Sally Bowles’ character in the musical cabaret sings that “money makes the world go round” and despite many wishing that was not the case the harsh reality is that for nuclear medicine in 2019 it is very true. Over the past few weeks I have spent many an hour in meetings discussing money and the impact of various pressures on nuclear medicine.  There are significant upcoming price pressures which we all need to be aware of. Their impact will depend on the service you and your department will provide. The one price pressure we all hope for is a staff pay rise though I think we all know that what politicians promise rarely happens unless it is to their advantage. There are other issues one of most fundamental is that the price paid for Mo-99 is only 67% of the cost of production. The rest is made up from government subsidies. This effectively means that a few countries taxpayers are subsidising the rest of us. The unfairness of this system is not the main issue. The primary issue is it discourages other players to invest in the market. Why invest in making something you can only make a loss on? This can be seen in the slowing of investment in accelerator based production of Mo-99 that 5 years ago was going to save us all but in reality may still be 5 years away. As this situation is not sustainable there will be price increases in Mo-99 over the next few years. However, the effect on total costs of any Tc-99m scan will be on average £3 per test which we can probably cope with. Unless ,the economics attract investment the supply of Tc-99m will dry up as aged reactors go off line.

A second cost pressure is that it appears that transporting radiopharmaceuticals around the UK is likewise not sustainable at present costs and we must expect an increase in the cost of delivery over the next few years. Again without this the provision of radiopharmaceuticals will not be sustainable.

I will not even mention Brexit and the possible cost pressures that will bring which at present are unknowns.

So what can the BNMS do? Firstly communicate these likely pressures as pre warned is pre-armed when you are negotiating budgets with your Trust or hospital. Secondly we are actively trying to get NHS England to recognise these price pressures in the tariffs that are offered for tests with hope a similar re-calculation will occur in the devolved nations. The third action is to collect and collate information. So if you find the total cost of radiopharmaceuticals you use changing, please let us know as this data is vital in our fights with our paymasters.

On a more optimistic note, I wish all of you that can get away on holiday a wonderful break and all those who cannot get away not too much additional work.

Dr John Buscombe

BNMS President

Last month I indulged myself by being somewhat political in what I wrote. What I wrote is still true and we still seem to have a political system which has in modern parlance become “not fit for purpose”. However, this month I will write about something very different.

The use of radioisotopic imaging in brain disease remains a bit if a Cinderella area. It has not received the same level of investment as cancer imaging or the clinical exposure of cardiac disease. Partly this is because brain diseases tend to be chronic and patients die with them and not because of them. If they involve symptoms which distress the patients or their carers it is often not talked about openly. This seems to be much more of a problem with us men and much of this has been highlighted in mental illness awareness week in May.

The other silent disease has been the degenerative diseases of the brain. Here nuclear medicine can have a great input though for many working in nuclear medicine it is not an area of great interest. This was changed with the introduction of ioflupane imaging in Parkinson’s disease and Parkinson plus disorders. Nuclear medicine could offer something unique which could not be offered by other modalities. DAT scanning remains a nice money earner for my department with about 5-10 scans a week mainly for outside providers which have to pay handsomely for the service (mainly due to contracts drawn up before tariffs started).

NHS England will also fund FDG imaging in some cases with suspected Alzheimer’s disease despite the fact the product has not been through a randomised controlled trial which the unfunded amyloid agents have! Though not perfect FDG imaging can provide a diagnosis when MRI has been unhelpful. It is clear that PET agents are most useful in early disease and we often find ourselves scanning patients in their 40s and 50s.

Research using PET is helping us to understand more about dementias develop. Tau proteins seem to signal damage in the brain and recent work has shown that even in young people with brain injuries tau can be seen, though in most patients it resolves in 6-12 months. In early dementia the tau seems to persist and increase in a cycle of inflammation signalling but these seems to result in more inflammation which results in neuronal loss as well as amyloid being laid down. We are also beginning to understand that there is a vascular component to the development of dementia which can be seen by increasing T lymphocyte vascular trapping in the brain which can be visualised using C-11 PK11195. New and more precise probes are being developed to try and understand the mechanism by which dementia develops and why its outcome is so devastating.

Though nuclear medicine techniques are not the only method by which these mechanisms and their effect measured it remains a vital tool as absolute quantification remains possible. At present these diseases have no effective treatment but what we can learn from oncology is that effective treatment depend on understanding why a disease occurs and how it progresses.

Therefore, we should embrace fully the role nuclear medicine has in looking at neurology and hopefully in the future allow us to monitor the effectiveness of disease modifying treatment.

Dr John Buscombe

BNMS President