text:
Review Safavieh Madison Area Rug, Navy/Creme, 6'7"x9'2"
Webmaster Talk Online shopping is becoming the trend these days especially for those who are constrained by time to freely do so. This is the most convenient way to shop when you are always on the rush. If you are looking for Safavieh Madison Area Rug, Navy/Creme, 6'7x9'2 then it is best to search for it online. Here you can buy Safavieh Madison Area Rug, Navy/Creme, 6'7x9'2 at much affordable price. Also, you can get your desired Safavieh Madison Area Rug, Navy/Creme, 6'7x9'2 at discounted price which will make your shopping easy and affordable. You will find it interesting and will wish online shopping might have been here plenty of years back. You can even get a chance to win free shipping by booking your product here.
Safavieh Madison Area Rug, Navy/Creme, 6'7"x9'2"
Construction: Power Loomed / Description: The sophisticated look of traditional area rug artistry is marvelously updated for today's eclectic home decor in the mod styling and vibrant coloring of this marvelously decorative carpet. Classic floral motifs in vivid orange hues are surrounded by an intricate border and set against the rich navy pile of this metro-mod rug. Constructed from durable yet soft synthetic yarns for a luxurious feel underfoot and easy-care maintenance. Care: Vacuum Regularly To Prevent Dust And Crumbs From Settling Into The Roots Of The Fibers. Avoid Direct And Continuous Exposure To Sunlight. Use Rug Protectors Under The Legs Of Heavy Furniture To Avoid Flattening Piles. Do Not Pull Loose Ends; Clip Them With Scissors To Remove. Turn Carpet Occasionally To Equalize Wear.Remove Spills Immediately
Safavieh Madison Area Rug, Navy/Creme, 6'7"x9'2" Tips & Ideas
Buy New Furniture The Easiest Way By Making Use Of The Following TipsSeeking the perfect chair, sofa, loveseat or table for your home is definitely a task. Whether you have lived at home for several years, or maybe you have just moved in, buying new furniture will take forever. However, if you arm yourself with the following tips, the job can be a lot easier.If you find a piece of furniture that you prefer, inquire if your furniture store offers price matching. This can be a wonderful way to save you money while allowing you to remain faithful for your local furniture store. This can make your business in your neighborhood which helps grow local businesses.Retain the future location of the furniture piece under consideration while shopping. This factor should affect the fabric colors you end up picking. Light color fabrics are ideal for bedrooms, foyers as well as formal living spaces. On the flip side, any furniture probably be used frequently is way better served with darker colors.If you're searching for wood furniture, especially older furniture, inspect over the surface. Look at the inside, underneath along with the drawers. Often, this inspection is going to enable you to create a better assessment from the furniture than you'd get by simply inspecting the surface wood. Inspecting the secondary woods allow you to determine age and quality.When purchasing new furniture or used furniture, make sure every one of the drawers and cabinet doors work correctly before purchasing. Ensure that the cabinet doors close securely and open easily. Test all the drawers to ensure they pull out correctly and close properly. If you find everything that is not working, obtain it fixed before choosing.When you think of investing in a single piece of furniture, think of the way will easily fit into with your entire decor. It's something to discover a flamingo side table out while you're shopping, but it's one other thing to take it home and then try to make it work with everything else you may have. Think carefully before you buy.With regards to looking for leather furniture, be sure to keep your different leather grades at heart. There are both high and low quality leathers out there to match a variety of tastes and budgets. From highest to lowest quality is: top grain, pure aniline, semi aniline, nubuck, distressed, and suede. Choosing better quality leather ensures that you will have furniture that lasts for a long time.Decide what material you would like before starting looking. In the event you only want oak tables, for example, that may stop you from wasting time considering many other materials that you simply won't need. If you prefer a candle chandelier, know that before you start looking which means you get what you wish. When you enter a shop without having a goal, you'll feel much more uncertain.The better you understand about shopping for furniture, the more effective. By learning more about what to consider, it is possible to avoid many of the headaches that furniture shopping might cause. The preceding information is going to be of great value for you the very next time that you should find new furniture for your residence.


text:
When it comes to a company's work from home policy, everyone is different. Your productivity and overall success as a remote employee depends entirely on your preferred work style. That's also the reason it's hard to find any solid data on whether or not people are more productive at home. Anecdotally, it seems to boil down to personality type and the job you do. We're all different, and some of us can't fathom getting work done with a TV nearby and all our comforts of home surrounding us, while others find it a struggle to stay focused among office chatter and other distractions.
Analyze on-demand. If you're a marketer or entrepreneur, use our Google Sheets integration to manage your results or share them with someone who doesn't have a Typeform account. If you're sending out customer satisfaction survey questions, you'll want to know where the most pain points are. If you're a teacher, you may want to track student results or feedback for you.
Taking paid surveys can become a well paying job if you work hard enough at it but you won't start bring in buckets of money right from the start. But don't let that demotivate you to start taking paid surveys. In the beginning you don't have control over the survey offers you receive, but if you keep at it then after some time your per-survey-rate will go up as you become a more reliable source for paid survey companies. Then you'll be surprised how much extra money you can make without putting in very much effort at all.
A well known survey panel, Valued Opinions is owned by leading market research company ResearchNow and is open to people in more than 20 countries around the world, including the USA, UK and Australia. The site uses a range of different languages and has around three million members busily filling in surveys and questionnaires. Most surveys taken will reward you between $1 and $5 and take up to around 20 minutes to complete, asking you about marketing, brands and products and even news events. There is a steady rate of invites to surveys, but you won't always be qualified for them, which can become tiresome.
Return on Time: 3.5/5.0- Their payrate isn't overwhelming- the average per hour hovers around $3. Depending on the user's activity on the website, it can take anywhere from a couple of days to as long as a month just to earn CashCrate's cash-out amount of $20. You certainly won't be making top-dollar with this site, but despite their low pay they do pay their members consistently.
When asking closed-ended questions, the choice of options provided, how each option is described, the number of response options offered and the order in which options are read can all influence how people respond. One example of the impact of how categories are defined can be found in a Pew Research poll conducted in January 2002: When half of the sample was asked whether it was "more important for President Bush to focus on domestic policy or foreign policy," 52% chose domestic policy while only 34% said foreign policy. When the category "foreign policy" was narrowed to a specific aspect – "the war on terrorism" – far more people chose it; only 33% chose domestic policy while 52% chose the war on terrorism.
A wide range of businesses need workers to enter various data into their systems, whether that data are used to track inventory or shipments, create business plans, or measure performance or output. And since a computer and typing skills are the most important requirements for this job, many data entry workers are able to work at home, and on a schedule that fits their lives.
Yet there are plenty of companies you've probably never heard of, too. Appen, which tops the list, develops high-quality training data for machine learning and artificial intelligence; not surprisingly, they're hiring web search evaluators and a slew of linguists in lesser known languages like Sudanese Arabic and Xhosa. BCD Travel, the Dutch managed travel provider, is hiring remotely for their customer service, business development and travel consultant roles. Three universities—Grand Canyon, Western Governors and Walden—make the list as well. To say there's an abundance of work from home jobs available out there would be an understatement. For most people, there are more than they could ever imagine.
The point of each survey is to present you with a topic you're interested in and qualified to discuss for the benefit of the researcher. Surveys range in time required, from very short to quite long. Because researchers are looking for opinions only from certain segments of people, you may find you have to try a few surveys before you're qualified to give your opinion on one. Keep at it, and you'll eventually find one that's right up your alley.
While product testing is offered, you'll only get sent items if you qualify, and then it will only be a couple over the space of several months, so think of this as a bonus, rather than a regular part of your work. Some users get frustrated at the length of time they have to wait for vouchers to arrive after they order them – especially when somewhere like Opinion Outpost will pay out straight away. However it is unfortunately quite standard to have to wait weeks for payment from survey sites. Surveys range in duration from about 15 to 30 minutes and there are mini polls on the website which can help you tot up small amounts of extra points. Points do sometimes take days or even weeks to appear in Toluna accounts, which is worth noting.
There's a decent rate of surveys pinged your way as you can expect two or three emails a day inviting you to fill in particular questionnaires. In addition to this, there are freely offered surveys on their cleanly designed website each day which you can look through and decide if they take your fancy. Surveys on CashCrate are often outsourced to third parties though, so you can make more money on the survey side from other websites. Similarly they are known for passing your information on to other people, so to avoid the irritations of endless spam, make sure you set up a dedicated email address for your CashCrate account.
One nice feature is the ability to shop through Vindale, as they often have offers available through affiliate links. Before buying something new, like an appliance, it is worth signing into their easy to use website and checking if you can get it for less through Vindale. There's also a popular daily consumer survey paying $1.50 which you can complete every day, for an easy and reliable boost.
The tech industry is well known for its flexible schedules and telecommuting opportunities, which makes sense, considering most tech companies are web-based and technology is the greatest resource when working from home. With video chats, conference calls, VPN networks, and wireless Internet, we can constantly stay connected as though we were sitting in our office, rather than at home.
Analyze on-demand. If you're a marketer or entrepreneur, use our Google Sheets integration to manage your results or share them with someone who doesn't have a Typeform account. If you're sending out customer satisfaction survey questions, you'll want to know where the most pain points are. If you're a teacher, you may want to track student results or feedback for you.
If you can't find any information on other sites or forums, there are some things about the website you can check for yourself. The first thing we recommend is to look for a privacy policy. Having one on the site that is easily accessible to users is a clear sign of credibility. It shows that the company is at least making some promises as to how your information will be used. Lacking a privacy policy is a clear red flag and often signifies a scam.
After joining a survey site, you provide some personal and demographic information, which legitimate survey sites will keep private. That information will be used in choosing participants to take surveys on certain goods and services. If you get selected to take part in a survey, you will be notified through mail to take a short survey to see if your profile suits that survey. When you are deemed qualified, you will be requested to take a longer survey.
While this is not technically "at home," you can still earn great money without ever getting on the phone using your personal car, bike, or scooter to deliver food, give people rides, and even picking up groceries. The great thing about these companies is that it's also very flexible work. No one is telling you when to start and stop. You just do as much work as you can, when you can.
An example of a contrast effect can be seen in a Pew Research Center poll conducted in October 2003 that found that people were more likely to favor allowing gays and lesbians to enter into legal agreements that give them the same rights as married couples when this question was asked after one about whether they favored or opposed allowing gays and lesbians to marry (45% favored legal agreements when asked after the marriage question, but 37% favored legal agreements without the immediate preceding context of a question about gay marriage). Responses to the question about gay marriage, meanwhile, were not significantly affected by its placement before or after the legal agreements question.
How to Get It: Begin with sites like UserTesting.com, YouEye.com and Userlytics.com. Register with multiple companies for opportunities to test as many websites as possible. Once you're in the system, you'll be emailed when testers are needed, and if you're one of the first to respond, expect to spend 15 to 20 minutes completing the test. Many sites require a microphone and/or webcam, which are built into most laptops—but if you need to buy one, they aren't expensive. The tester sites typically pay within a week or two via PayPal.
Ever wanted to ask people what they thought about your business as they walk out the door, or survey people about their preferences as they're walking around your event table? QuestionPro makes that possible with its mobile apps and iBeacons support. With iBeacons placed throughout your location, and QuestionPro surveys embedded in your mobile app or the QuestionPro app installed, you can send push notifications and ask people to complete surveys based on where they are.
This is a job with much potential, in part because the title description covers many things. "You can fit your offerings to what you know how to do," says Stephanie Foster, a former medical transcriptionist who runs the website HomeWithTheKids.com. One can own a virtual assistant business or work from home for a company that makes you available to other employers or clients. HomeWithTheKids.com, for example, currently features several such companies.
Swagbucks remains popular as they are a reliable site, offering novel ways to earn rewards, including playing games and watching videos. Completing polls and surveys for money takes around 10 minutes each and can make up the bulk of your time on the site. You won't always qualify, and getting to a late stage in a survey application process and then finding out you're not qualified can be pretty galling. The slickly designed website is straightforward and pleasing to use and also allows you to make money on your shopping by offering a range of affiliate links. By simply clicking on the Swagbucks link and shopping at sites including Amazon, Walmart and Nike, you will earn points, as those companies are paying Swagbucks to link to them, and you get a share of their fee.
By filling out your user profile thoroughly, you'll be able to make sure you get invites to surveys which are actually suitable for you. There are basic qualification questions at the start of each questionnaire too, to ensure you are suited to filling it out before you get going. And you can make the most of the huge Toluna community yourself too – if you want, you can create your own polls on the site to ask people about anything and everything! It's a nice addition to be able to get involved and have in-depth conversations with fellow users.
"I love working for TTEC@home. I get to interact with and help others from the comfort of my own home. (Have you ever been in Houston traffic rush hour? That says it all!) Plus, they have some of the most amazing people I've ever had the privilege of working with. They aren't just here to draw a paycheck. They truly care about their co-workers. I work many miles from the brick and mortar buildings, but I have a sense of security that my coworkers have my back and I'm not alone."
2. Distribution. Once a questionnaire is complete, it is ready to be let out into the world or at least into the small part of it you wish to survey. At the very least, all packages will provide a web link that can be posted on a website or social media. Some packages will go the extra step by providing direct links into a range of social media networks, and some will include integrated contact managers and email campaign trackers. While this can make it easier to track how particular respondents answered in a non-anonymous survey, many offerings will require extra payment once an email list gets too large, whereas generic links can be shared with no respondent limit.
Just like the other survey sites, every time you complete one of the surveys, you'll receive anywhere from 35-250 points, which equals about $1.50 to $1.75 per a survey. Once you rack up enough cash to payout (which you'll have to accumulate at least $50), you'll have several different options to receive your money. You can get your money through a check, through your PayPal account, or redeem it for gift cards.
It's a good idea to keep a record of all the paid surveys you're doing, so you make sure you are being paid for all your efforts. Whether taking paid surveys is a full-time or part-time job, you should keep track of your progress. That way you can organise your paid surveys and never miss an opportunity to make money online from your paid survey offers.
For some companies, working from home can be a matter of more hours in the day. This is especially true for small businesses and new companies where they can't afford to waste even one minute of the workday. "Being a small startup, every hour of the day is important," says Tim Segraves, co-founder and CTO of Revaluate, "If we all spent an hour of day commuting, that would be almost 20 hours a week that would go to commuting instead of building out our product and business."
Looking for a survey tool you can run on your own server? LimeSurvey is the app for you. It's an open-source survey project that lets you build detailed surveys, host them on your own, or embed them in Drupal or WordPress sites. Surveys have just about any feature you could want, though you'll have to dig through menus to set them up, add question sections, and then tack on individual questions.
Unlike many sites, Valued Opinions doesn't offer you the chance to take cash rewards, at the moment limiting users to retail vouchers and gift cards. Electronic vouchers are usually with you within 24 hours but gift cards can take four to six weeks to arrive in the post. Once $10 has been earned, you can claim Amazon vouchers, Macy's gift cards and Visa promo codes, among many other reward options dependant on your location. Surveys are said to be varied, but the gift card options less so, so check they are for stores you'll want to shop in before you tot up lots of points.
I appreciate the idea behind this, but I'd like more information on where these jobs can be found. I am a writer and would like to do freelance writing work, but while you mentioned that there are such jobs available, there wasn't much to say where to find those jobs. I've tried to seek them out before, and done writing for places where I got paid (usually not very well), but many of those have dried up or weren't much to begin with. Are there suggested places to go to do some freelance writing? I'd love to ditch my poorly-paying job, where I have to spend a lot of time away from my family, and do something I actually enjoy doing. Thanks.
Like many survey sites, Toluna rewards you with points, which you can then cash out for vouchers for the usual suspects like Amazon and iTunes, or money through PayPal. A slightly novel element of the site's payment plan is to offer the chance to take your points out early if you gamble them for prizes. While you have to store up a grand total of 60,000 points before you can claim vouchers for around $12 – something some people find to be a downside of the site – if you are willing to settle for a prize, you can play with just 500 points. You can decide to try your luck with a "giftie", a kind of scratch card game. By gambling some points, you can see if you have won the gift or lost your points – so it is not one for the faint hearted!
They used to be cash-only, but in 2013 they switched over to a points system. Panelists can share their opinions in surveys and complete other various offers in exchange for points. 100 points is equal to $1, and most of their surveys pay up to $3. Survey topics are diverse and cover a variety of different topics. Pinecone Research is unique in that they emphasize consumption related surveys more than other panels.
Companies are certainly catching onto the trend, and most have the flexibility to work from home, if not at all the time, at least when needed. It's changing the way we work, especially in the tech sphere. And while it may not be for everybody, employers may find they can save money and increase productivity for some workers. And for some employees, work-from-home benefits may be the difference between an enjoyable and stressful work life.
PollDaddy doesn't allow data exporting, meaning you can only see responses in the aggregate. This view is sufficient if you're just looking for the big picture, or aren't confident in your analytical skills. The type of survey you need to run often determines whether you need data exporting functionality or not, so be sure to think through your survey plan in advance.

subset: commoncrawl


text:
With thousands of tradies across NZ, Builderscrack has your job covered
We need ceiling insulation supplied and installed. Prefer polyester, but if you quote on fibreglass and polyester we will choose. There is old insulation up there, which we would ideally like vacuumed out before the new insulation goes in. No downlights, but the insulation should go right to the edges. 2.9 required. The area of the ceiling is approximately 140 square metres. Good access to the house and off-street parking. Can measure by arrangement. Work to be done mid June.
|Tradie #1
|27 jobs
|No longer in contact
|Tradie #2
|7 jobs
|No longer in contact
|Tradie #3
|39 jobs
|No longer in contact


text:
0 Members and 1 Guest are viewing this topic.
Goddamnit kitkat, you make me look late
This creation is incredibly well thought out and creative. I love it, but I assume Proteus is large than earth due to the high population, right?
Anyway, I'm looking forward to more in hope of RPing with them.
Obviously UFO, you haven't snuck into Micheal Bay's house and stolen his version of Citizen Kane. Giant radioactive exploding ninjas are the least silliest parts.
There is, of course, a difference between having a laugh with someone, and having a laugh at their expense
Page created in 0.126 seconds with 22 queries.


text:
Last Ads
Black cock Columbia sex Bellingham. Girls x honest in sincere. partner seeking woman hi i'm sure a x season old white a woman seeking swf for the purpose of fun dating sexual an relationship. i'm sure a big women with heart about gold an yes i've got good looks to help if interested mail me back but needs to be drug free problem free an won't mind my , who live when camping ty. I am not even into games and also cybering i am inside the real thing girl on woman sexual cuddling an rapport plz if u are into video game titles an cybering really don't reply. i am looking for authentic i have by myself place so privacy isnt a major issue cuz i do not have small . U can dispatch ur pic the i send mine oh no - u ty.. looking for a good homie lover buddy horny chat line South Bend Indiana. Looking for your nicce akron young teen girls looking for older man dating com exciting girl and appears to be dont matter opinion.
Businessguy seeking personalized lunch. Adult flirting Franklinville NC Single women looking sex Pelly Bridging Yukon Find having sex Bunceton MO Singles xxx Chorley.. Collins Beach Feb 5th and Saturday sex shamle bbw. teaching a women to eat pussy and delusion.
Black cock Columbia Midvale nude st Midvale. Still hunting for coachathlete. Somewhat lonley. New to area. So i am x. x'x" writer/musician. having their first go the area. you shouldn't really know anyhere yet. could really have a friend for certain touching and closeness. Anyone out there on the mood? please have the ability host. .. Spinning Instructor inside the Y sex chat Saanich. placing myself around.
Is it possible to at least explain to me what manifested. More mature Older top dude wanted for common oral maybe further if it can feel right.. Married 28 yr old in search of fun fucking women in Falkirk. UNCG visitors circle tues..
people are already here!
persons want chat right now!
Most interesting, 7944 photos.
Sex massage Kaneohe Local sluts Paradise Dating a cougar Free adult cams Girl looking for sex in Rio Rancho Nude massage Allentown Girls that want to fuck Vancouver Washington Big cock in Tampa Florida Xxx sex Albuquerque New Mexico Xxx chat Tallahassee Nude girls in Meridian Idaho Japanese women in Grand Rapids Michigan Free adult chat Parkersburg Free xxx in Las Vegas Massage man women sexNew Members
Mature free chat Brookings South Dakota
Women looking for sex Fabre, Quebec
Grannies wanting sex Birmingham Alabama
Town whore Grand Forks North Dakota ga
Adult personal ad in Minneapolis Minnesota
Big tits grannys for sex in Due West ms
Free local sex near Chambersburg
Sexy moms in Syracuse New York
Older women looking to fuck in Frankfort Kentucky
i love black color women but for no reason had one. Braless inside pink. I love to go down in women. Mature swinger ready date hookup. Yarra Japan girls naked. Porn stars from 19706 maine.


text:
Clinical UM Guideline
This document addresses the medical imaging technique in which the results obtained from a single photon emission computed tomography (SPECT) scan are merged with those obtained from a computed tomography (CT) scan (also known as hybrid imaging). This fusion may occur by the combining of images from two separate devices, or by the use of specialized equipment designed to perform both SPECT scanning and CT scanning simultaneously.
Note: Please see the following related document for additional information:
|Clinical Indications
Medically Necessary:
The use of SPECT/CT fusion imaging is considered medically necessary in the evaluation of parathyroid glands in individuals with hyperparathyroidism when used for anatomic localization prior to parathyroid surgery.
Not Medically Necessary:
The use of SPECT/CT fusion imaging is considered not medically necessary for all other indications.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
Parathyroid Imaging:
Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization
ICD-10 Diagnosis
Benign neoplasm of parathyroid gland
Primary hyperparathyroidism
Secondary hyperparathyroidism, not elsewhere classified
Other hyperparathyroidism
Hyperparathyroidism, unspecified
All other SPECT/CT Fusion Imaging:
Note: imaging other than parathyroid is considered not medically necessary for all indications
Unlisted miscellaneous procedure, diagnostic nuclear medicine [specified as SPECT/CT fusion scan other than parathyroid]
ICD-10 Diagnosis
All diagnoses
|Discussion/General Information
SPECT/CT fusion refers to the imaging technique that combines the functional information from SPECT with the anatomical information from CT into one set of images. The SPECT and CT images are either "fused" by a software package that superimposes two digital images together or are processed simultaneously by combined SPECT/CT scanners. In either case, SPECT/CT fusion has been purported to allow for more accurate diagnosis and thus improved outcomes and treatment.
Some SPECT procedures utilize whole body scanning (such as bone scans), SPECT studies typically focus on the function of specific organs, such as the thyroid, heart, lungs, gallbladder, liver and kidneys. SPECT agents (radiopharmaceuticals) incorporate antibody and peptide formulations that can be targeted to specific tissue receptors, allowing one to discriminate healthy from diseased tissue. SPECT agents can also be monitored for tissue changes over time, allowing physicians to narrow down the characteristics of a specific disease process. Because SPECT tracers have very specific characteristics, more than one agent, each emitting a particular energy level, can be injected to track related processes simultaneously. The goal is to be able to pinpoint both the disease process and its ongoing response to treatments. However, because there are fewer landmarks using SPECT, the more specific the targeting agent is, the more difficult it is to interpret its anatomical position. This may make it difficult for physicians to accurately interpret certain SPECT images.
A CT scan is a painless, noninvasive diagnostic procedure that uses x-ray equipment to obtain cross-sectional images of the body. With the aid of a computer, each cross-sectional image of the body is added together to create a tomogram, (a 3-D image of the internal structures and organs in the body). CT scans are performed to analyze the internal structures of various parts of the body. For example, in the event of traumatic injuries, CT scans may be taken to identify blood clots or fractures. CT scans are also used to aid radiologists in performing procedures such as the biopsy of suspected cancers, the removal of internal body fluids for testing, and the draining of abscesses located deep within the body. With regards to cancer, CT scans are used to detect or confirm the presence of a tumor, its size, location, whether it has metastasized (spread) and to monitor the body's response to treatment.
By fusing SPECT and CT scans into a single procedure, researchers hope to obtain the superior metabolic information provided by SPECT studies with the clear anatomical information gained from CT scans. Performing the two exams while the individual remains on the table increases the likelihood of good image registration.
Parathyroid Imaging
The parathyroid glands are four small glands in the neck which control the body's calcium level. Keeping a proper balance of calcium is essential to the normal functioning of other organs in the body including the heart, kidneys, bones, and the nervous system. Due to the size and location of the parathyroid glands, localization is important preoperatively. In a 2007 study by Lavely and colleagues, 98 participants had a diagnosis of primary hyperparathyroidism and single adenoma. Each participant had planar imaging, SPECT scanning, and SPECT/CT fusion imaging and comparisons were made to compare the accuracy of parathyroid SPECT/CT imaging to SPECT and planar imaging for localization of parathyroid adenomas. The overall sensitivity for localization for all modalities was 60%, specificity was 99%, positive predictive value (PPV) was 80%, negative predictive value (NPV) was 97%, and area under the curve (AUC) was 80%. When SPECT/CT was compared to planar imaging, the single-phase SPECT/CT was not significantly superior to dual-phase imaging for sensitivity, AUC or PPV of localization. The dual-phase SPECT/CT did have a higher sensitivity, AUC and PPV than the dual-phase planar imaging. When SPECT/CT was compared to SPECT scan, the dual-phase SPECT/CT was superior to dual-phase SPECT sensitivity and AUC for localization. The most superior method found was early SPECT/CT in combination with any delayed imaging when compared to a single- or dual-phase planar or SPECT scan for localization of parathyroid adenoma.
A study by Prommegger and colleagues (2009) evaluated 116 participants with primary hyperparathyroidism who had a SPECT scan and CT scan compared to SPECT/CT scan to determine whether the SPECT/CT fusion scan was superior in detecting abnormal parathyroid glands. The CT scan alone predicted the position of the abnormal gland in 75 participants, the SPECT scan alone predicted the position in 64 participants and the SPECT/CT fusion scan predicted the position of the abnormal gland in 102 participants. The sensitivity for CT scan was 70% and specificity was 94%. Sensitivity for SPECT scan was 59% with a specificity of 95%, SPECT/CT scan showed sensitivity of 80% with a specificity of 99%. A total of 62 participants underwent surgery. The authors concluded that the use of SPECT/CT fusion imaging had a higher sensitivity and specificity than CT or SPECT imaging alone when used for preoperative localization of parathyroid glands in those individuals with hyperparathyroidism.
In a 2015 meta-analysis by Wong and colleagues, the authors sought to determine the diagnostic utility of parathyroid scintigraphy with SPECT/CT fusion imaging for localization of parathyroid adenoma when compared to older planar and SPECT scans. A total of 24 articles were included in their analysis. Sensitivity of SPECT/CT was found to be 0.86 (confidence interval [CI], 0.81-0.90) compared to sensitivity of SPECT at 0.74 (CI, 0.66–0.82) and planar imaging at 0.70 (CI, 0.61–0.80). Using SPECT/CT imaging with parathyroid scintigraphy improves performance when compared to older planar and SPECT imaging.
Another meta-analysis by Treglia and colleagues (2016) reported on 23 articles in which participants with primary hyperparathyroidism had SPECT/CT fusion imaging prior to surgery. The pooled detection rate of SPECT/CT in preoperative planning of individuals with primary hyperparathyroidism was 88% (95% CI, 84% to 92%) on a per participant-based analysis and 88% (95% CI, 82% to 92%) on a per lesion-based analysis.
Based on expert opinion and guidance, SPECT/CT is found to be medically necessary for certain parathyroid indications, especially when compared with other imaging modalities. In a 2006 study by Sharma and colleagues, the authors compared the accuracy of four types of sestamibi-based scans for preoperative parathyroid localization. A total of 138 participants underwent planar imaging, 165 participants underwent SPECT scanning, 350 participants underwent SPECT with thyroid I-subtraction phase, and 180 participants underwent SPECT/CT imaging. False negative scans were noted in 38% of planar scans, 27% of SPECT scans, 4% of SPECT with thyroid I-subtraction phase, and 17% in SPECT/CT. The accuracy of each scan was determined based on intraoperative parathyroid pathology. When a single focus of uptake was noted on scan, a single adenoma was found at that location in 77% of planar imaging, 85% of SPECT imaging, 68% SPECT with thyroid I-subtraction, and 87% with SPECT/CT. A 2009 European Association of Nuclear Medicine parathyroid guideline notes that "Use of integrated SPECT/CT with a high spatial resolution, spiral CT used for anatomical localization, improves accuracy and reporter confidence in clinical practice."
In a 2017 study by Sandqvist and colleagues, the authors reported on 249 participants who were biochemically diagnosed with primary hyperparathyroidism and received SPECT/CT imaging. A total of 200 participant records were reviewed following parathyroidectomy and compared to SPECT and CT images. The sensitivity for SPECT/CT was 83% with a specificity of 96% when compared to SPECT alone. SPECT alone sensitivity was 80% with a specificity of 93%. For small adenomas (less than 210 mg), SPECT/CT showed 67% which were graded with the highest confidence score, compared to 53% with SPECT alone.
Other Clinical Conditions
The use of SPECT/CT fusion has been studied for other clinical conditions. A 2011 guideline by the European Association of Nuclear Medicine (Flotats), reported on hybrid imaging for individuals with known or suspected coronary artery disease. In terms of cardiac imaging, the hybrid systems are not routinely used because of the difficulty in determining which individuals would benefit from the dual scanning and radiation exposure is reported as a concern.
Computed tomography (CT): An imaging technique that creates multiple cross-sectional images of the body by using special x-rays and computer enhancement to detect disease or abnormalities.
Single Photon Emission Computed Tomography (SPECT): An imaging technique that measures the concentration of chemicals injected into the body, and provides images of the chemical function of body parts of interest.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Medical Policy & Technology Assessment Committee (MPTAC) review. Initial document development. Moved content of RAD.00042 SPECT/CT Fusion Imaging to new clinical utilization management guideline document with the same title.