engleski

Medical imaging in Croatia – Nuclear Medicine

Assist. Prof. Dražen Huić, 46, has been working in Nuclear Medicine since 1991. He is a Nuclear Medicine specialist, head of Center for Radiation Medicine and Protection in Clinical Department of Nuclear Medicine and Radiation Protection, University Hospital Rebro, Zagreb, Croatia. Dr. Huić is also involved in students’ education as an Assistant Professor on School of Medicine, University of Zagreb, Croatia. On European level he acts as a President Elect of UEMS/Section Nuclear Medicine. His main areas of interest in Nuclear Medicine are thyroid cancer, nuclear oncology, hematology and PET. 2. The department where I work, Clinical Department of Nuclear Medicine and Radiation Protection, located at the University Hospital Rebro in Zagreb, is the oldest and largest Nuclear Medicine department in Croatia. The beginnings of the department date back to 1959, which means that the Croatian Nuclear Medicine started nearly simultaneously with the appearance of other European Nuclear Medicine departments. The Department is organized in several divisions: Policlinic Division for Thyroid Diseases (consulting and ultrasound), Clinical Division with 12 beds for radioisotope therapy, Policlinic Division for Functional Investigations, Policlinic Division of Scintigraphy, Division of Biophysics, Division of Radiopharmacy and Radioimmunology and Center for Radiation Medicine and Protection. Number of staff is 84, out which there are 18 physicians (3 residents), 5 physicists or electronic engineers, and 3 chemists. Clinical Department of Nuclear Medicine and Radiation Protection now has 7 gamma-cameras ; each year about 135000 diagnostic or therapeutic procedures are performed, which makes approximately 30 % of all nuclear medicine procedures in Croatia. The most in demand procedures in my department are cardiac scan, bone scan, brain perfusion and receptor scintigraphy, PET in oncology and renal scintigraphy. There is also huge demand on thyroid studies, specially ultrasound and fine needle aspiration biopsy (about ten thousands ultrasound exams and four thousands fine needle aspirations carried out yearly). Because of sufficient number of staff we do not have long waiting lists, sometimes patients must wait for cardiac scan or thyroid ultrasound two to three months. Patients are well informed about diagnostic/therapeutic procedures they will be exposed, informed consent is required. 3. At present there are eleven Nuclear Medicine departments in Croatia (three in Zagreb, and one in Varaždin, Osijek, Rijeka, Split, Zadar, Šibenik, Dubrovnik and Pula). The development of Nuclear Medicine in Croatia is not uniform. There are some centers with very advanced equipment, but also the others with rather outdated gamma-cameras. Standard (mostly Technetium based) Nuclear Medicine is generally well covered but there is a lack of PET units and sections for radioisotope therapy. Although the first positron emission study with FDG was performed in the end of 1999 in our department (coincidence PET), advanced PET machines are at the moment available only in private facilities (PET/CT centers in Zagreb and Split). There is also problem with supply of PET tracers which are imported from Austria. Fortunately, the construction of cyclotron on Institute “Ruđer Bošković” in Zagreb will be finished soon and the production of own PET tracers will be started. The other field for further development is Nuclear Medicine therapy. Roughly half of Nuclear Medicine departments in Croatia are capable to do radiotherapy, but the limited factors are number of beds and price of differentiated therapy. The waiting list for radioiodine therapy in thyroid patients is about a few months. Others form of isotope therapy (I-131 MIBG, therapy with labeled antibodies in lymphoma, pain palliation in bone metastases and arthritis) are performed accordingly to resources available. The level of Nuclear Medicine services in Croatia is satisfactory. All departments are working accordingly to the guidelines published and recommended by EANM (European Association of Nuclear Medicine) or by SNM (USA - Society of Nuclear Medicine). Because of excellent connections with prominent Nuclear Medicine centers in Europe and USA lot of specialists have been trained abroad. 4. Majority of Nuclear Medicine procedures (including PET) are covered by health insurance and reimbursed regularly by state health insurance system. Every department has the monthly budget which is dependent on the patient number and number of studies performed. In the case of some new radiopharmaceuticals utilized in research the approval of Central Ethics Committee and Ministry of Health is needed. 5. To become Nuclear Medicine specialist in Croatia takes four years. This specialty is not very popular among young medical doctors, but at the moment we do not experienced understaffing. There is slightly predominance of female doctors probably connected with the fact that there are more women students on medical faculties in Croatia. The education program is coordinated by the recommended curriculum of UEMS/Section Nuclear Medicine. During their training young doctors spend some time in Radiology, Cardiology, Neurology, Pediatrics and some other departments. After finishing their education they mostly stay in Croatia and do not leave the country. Before 10 or 20 years many of our colleagues left Croatia to work in USA or EU. Since than the financial situation has improved but the recent onset of financial crisis may be the trigger for further migrations. The other factor influencing new migrations possibly would be the expected inclusion of Croatia in EU. At that moment the movement of specialists between our country and the other European countries will be more simplified, and some doctors will probably decide to move. Nuclear Medicine has been also incorporated in the undergraduate study of medicine at the Universities of Zagreb, Rijeka, Split and Osijek as a separate subject with 30 hours and examination. Postgraduate study in Nuclear Medicine is also available on the School of Medicine, University of Zagreb. At present we have the mixed population of technologists, some with secondary medical school and some university educated, but newly employed technologists willing to work in Nuclear Medicine must finished three years University study with the obtained title of Radiological Technologists. After completing the study they can choose between Radiology and Nuclear Medicine for further work. 6. As a part of our country preparations to join EU, medical sector is also preparing for unavoidable changes which will occur at that very special moment for Croatia. Thus, we are very interested in the organization of medical systems in EU countries, and that is a reason for our deeply involvement in UEMS (European Union of Medical Specialists) which has been enabled by giving us the status of associate member country in UEMS. I was first involved in the UEMS Committee for Syllabus and Education and after several years ended up as a President Elect (in October 2009 to become a President). Such a demanded position is a huge motive for further work and for further improvement of Nuclear Medicine service, not only in Croatia, but also in the whole of Europe. 7. If you are asking me about the future of nuclear medicine there is no a simple answer. There are brilliant research studies in neurology, cardiology, oncology, etc. utilizing new radiopharmaceuticals, but on the other hand, we are faced with the crisis of Molybdenum supply which is indispensable for Techetium-99m production. Lack of Technetium means no more bone scans, no more majorities of cardiac studies, no renal scan, etc. For highly advanced departments this is not a problem because they are able to switch effectively to other procedures (like PET), but for smaller departments whose diagnostics is 90% based on Technetium this could be a great obstacle. Luckily, there are some signals that supply will be normalized. Simultaneously, we are approaching the time of multi-modality-imaging. Some hybrid techniques are already developed (PET/CT, SPECT/CT), and some other are on horizon (PET/MRI). Close collaboration among various specialists will be needed. Thus, the representatives of EANM, ESR and UEMS sections of Radiology and Nuclear Medicine have formed special committee which main purpose is producing educational program for those from both specialties who wants to report those hybrid techniques. In my opinion only close cooperation between various experts will guarantee the final goal – best possible service for our patients.

nuclear medicine; Croatia; review

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