INFORMATION STATEMENT Guidance and Best Practices for Reestablishment of Non- Emergent Care in Nuclear Cardiology Laboratories During the Coronavirus Disease 2019 (COVID-19) Pandemic: An Information Statement from ASNC, IAEA, and SNMMI Hicham Skalia,b, Venkatesh L. Murthyc, Diana Paezd, Elisa M. Choie, Felix Y. J. Kengf, McGhie A. Iaing, Mouaz Al-Mallahh, Roxana Campisii, Timothy M. Batemang, Ignasi Carrioj, Rob Beanlandsk, Dennis A. Calnonl, Vasken Dilsizianm, Maurizio Dondid, Alessia Gimellin, Robert Pagnanellio, Donna M. Polkb, Prem Somanp, Andrew J. Einsteinq, Sharmila Dorbalaa,b, and Randall C. Thompsong aDivision of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; bCardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; cFrankel Cardiovascular Center, University of Michigan, Ann Arbor, MI; dNuclear Medicine and Diagnostic Imaging Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria; eAtrius Health, Somerville, MA; fNational Heart Centre, Singapore, Singapore; gSaint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO; hHouston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX; iDepartments of Nuclear Medicine and Cardiovascular Imaging, Diagnostico Maipu, Department of Nuclear Medicine, Instituto Argentino de Diagnostico y Tratamiento, Buenos Aires, Argentina; jUniversitat Autonoma de Barcelona, Barcelona, Spain; kDivision of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada; lOhioHealth Heart and Vascular Physicians, Columbus, OH; mDepartment of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD; nFondazione Toscana Gabriele Monasterio, Pisa, Italy; oDepartment of Radiology, Duke University Health System, Durham, NC; pDivision of Cardiology, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA; and qDepartment of Medicine, Cardiology Division, and Department of Radiology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY INTRODUCTION continue to mitigate the risk of viral transmission while also pro- viding crucial cardiovascular assessments for our patients. The The Coronavirus Disease 2019 (COVID-19) pandemic is affecting current document prepared by ASNC, SNMMI, the International healthcare systems and resources around the world in an unprece- Atomic Energy Agency (IAEA) and the Infectious Disease Soci- dented manner. Based on recommendations from the numerous ety of America (ISDA) describes potential practices for this rees- medical specialty societies and governmental agencies such as the tablishment, reflecting diverse settings from the United States and United States Centers for Disease Control and Prevention1 and Cen- worldwide. ters for Medicare & Medicaid Services2, non-urgent procedures and It is important to note that these recommendations are primarily tests were either canceled or postponed during the buildup to and based on expert opinion, not systematically tested, and may pro- decline from the pandemic’s peak. The American Society of Nuclear vide guidance to supplement guidelines, regulations and legisla- Cardiology (ASNC) and the Society of Nuclear Medicine and Mo- tion as well as institutional infection control policies.2 A survey of lecular Imaging (SNMMI) issued an Information Statement3 with the authors’ opinions regarding several issues outlined in this doc- guidance for nuclear cardiology laboratories during the COVID- ument is available in the online supplement (supplemental materials 19 pandemic in late March 2020 that also recommended delaying are available at http://jnm.snmjournals.org). all non-urgent studies. Reestablishment of non-emergent care4 in nuclear cardiology laboratories will require a careful approach to GENERAL PRINCIPLES A. Timing of Re-Opening/Resuming Activities in Received Jul. 6, 2020; accepted Jul. 6, 2020. Stress/Nuclear Cardiology Laboratory: Reprints requests: Randall C. Thompson, St. Luke’s Mid America Heart Institute, 4330 Wornall Rd, Suite 2000, Kansas City, MO 64111; rthompson@ saint-lukes.org 1. Timing should follow national, state and local regulations and Published online Jul. 24, 2020. recommendations.4–6 This article is being jointly published in The Journal of Nuclear Medicine 2. Healthcare facilities should have adequate equipment and per- (https://doi.org/10.2967/jnumed.120.251355) and the Journal of Nuclear Cardiology (https://doi.org/10.1007/s12350-020-02203-3). sonnel and not be in crisis management mode or diversion Immediate Open Access: Creative Commons Attribution 4.0 International mode. For inpatient laboratories, there should be available hos- License (CC BY) allows users to share and adapt with attribution, excluding materials credited to previous publications. License: https://creativecommons. pital beds and intensive care unit beds. org/licenses/by/4.0/. Details: http://jnm.snmjournals.org/site/misc/permission. 3. In general, we recommend that utilization of nuclear cardiology xhtml. services parallel opening of upstream and downstream resources COPYRIGHT © 2020 Society of Nuclear Medicine & Molecular Imaging and the American Society of Nuclear Cardiology. such as clinics, catheterization laboratories, operating rooms and DOI: 10.2967/jnumed.120.251355 other services, so as to facilitate uniform care delivery. 1534 THE JOURNAL OF NUCLEAR MEDICINE • Vol. 61 • No. 10 • October 2020 B. COVID-19 Testing: priorities are typically symptomatic whose risk of a cardiac event The diagnosis of COVID-19 is based on the detection and iden- is not insignificant. tification of the virus by means of the reverse transcription poly- • For patients of equal urgency, those who have been waiting merase chain reaction (RT-PCR), a molecular diagnostic technique the longest for their procedure should be the first to undergo based on the detection of specific genetic sequences of the virus. testing. Antibody tests detect immunoglobulin antibodies from an immune • Many patients have had testing delayed for several weeks response to SARS-CoV-2 and are not appropriate for diagnosing during the period of sheltering in place; it is important for current COVID-19 infection. Laboratories should rely on molec- ular tests to diagnose the presence of SARS-CoV-2 infections. the provider team to maintain contact with patients and to However, a negative molecular test result does not rule out encourage them to report changes in symptoms. COVID-19 for several reasons. Some patients may have negative • Due to the delay in testing, extra caution needs to be exer- initial tests due to low viral load during the early days of infection cised by clinical staff, including supervising physicians, as or inadequate sampling of the posterior nasopharynx. Thus, social the patient’s clinical status may have deteriorated to the point distancing and PPE are critical to prevention of laboratory where stress testing may no longer be safe or appropriate. transmission of COVID-19. When testing capacity allows, using • For some patients requiring prior approval from the insurance a molecular test to test for COVID-19 infection prior to appoint- carrier, the approval may have expired and need to be re- ments in the nuclear cardiology laboratory is recommended instated. However, some Radiology Benefit Management combined with screening patients for a fever and symptoms con- companies in the United States have recently extended the sistent with COVID-19 infection upon arrival for testing appoint- time period before expiration during the pandemic. ments. Patients who are known to have an active infection with the • Case prioritization can be performed primarily by laboratory COVID-19 virus should in the vast majority of cases have their professionals but is most commonly decided collectively and nuclear cardiology test deferred. in collaboration with other colleagues from cardiology, sur- gery, and other disciplines. C. Preventive Measures for COVID-19 Disease: • Early during the COVID-19 pandemic, many facilities prior- The implementation of preventive and mitigation measures is itized patients being scheduled and those already scheduled essential. The most effective preventive measures include perfor- according to the perceived clinical urgency of the study. mance of proper hand hygiene; avoidance of touching eyes, nose Please see an example of a prioritization scheme using four and mouth; practice respiratory hygiene when coughing or categories in Table 1. Some laboratories use a 3-category sneezing; wearing a medical mask and maintenance of physical scheme instead.3 distancing (ideally 2 meters or more).8,9 2. Scheduling a Patient: Scheduling of patients should take into D. Personal Protective Equipment (PPE): account a number of parameters including institutional and labo- The goal of PPE use is to protect healthcare providers and ratory resources for safe performance of testing during the COVID-19 patients and predominantly to minimize spread from asymptom- pandemic. atic individuals and surface exposure.10 Healthcare workers re- • Institutional policies: When increasing patient volume quire additional precautions to protect themselves and prevent through the nuclear cardiology laboratory, it is also important transmission in the healthcare environment. Precautions in- that this be coordinated with the affiliated institution to en- clude wearing proper PPE and donning and doffing items prop- sure that service delivery is consistent with their overarching erly. Recommendations for PPE use vary by institution, region plan during the pandemic. and country and the type of PPE recommended will usually be • Staff: Availability of laboratory staff is an equally important based on institutional or regional policies. Currently most consideration, especially if many have been redeployed, fur- healthcare centers in the United States require universal use of a surgical mask by staff and visitors with selective use of loughed or become ill as a result of the pandemic. more advanced PPEs. As nuclear cardiology and other labora- • Operating hours: As utilization increases, laboratories should tories re-expand their operations, a sufficient and increasing consider extending to early/late hours and/or weekend testing quantity of PPE will be required for protection for healthcare to allow the backlog of patient tests to be completed and to personnel and patients. PPE use is currently recommended allow more effective social distancing. This approach should throughout the nuclear laboratory when indicated; this use be balanced with availability of staff and key equipment, espe- should follow national, state/regional, and local public health cially PPE. policies and recommendations. • Phased opening: A phased opening with a ramp up period is generally recommended by health agencies2. For example, 25% of a standard case load might be planned for the first SPECIFIC PRINCIPLES FOR NUCLEAR CARDIOLOGY 1–2 weeks, 50% case load in weeks 3 and 4, and then greater A. Before the Test: caseloads if conditions permit. Concomitant overlapping 1. Prioritization of a Study Request: As we move into the next cases should be avoided to provide for appropriate social phase of the COVID-19 pandemic, in which newly diagnosed distancing. cases have declined in many regions, regulations are permitting • Adequacy of supplies: To reestablish operations it is neces- flexibility and allow facilities to reinstate services for patients sary to ensure the availability of radioisotopes which are pro- needing non-emergent non-COVID-19 care. Urgent patients should duced in a limited number of facilities worldwide. One of the continue to be tested first and as quickly as prudently possible effects of the pandemic has been the disruption of distribution while ensuring patient and healthcare provider safety. It is channels, including international cargo flights. In addition, important to remember that many of the patients with higher many radiopharmacies have either furloughed or laid off staff GUIDANCE AND BEST PRACTICES FOR COVID-19 • Skali et al. 1535 TABLE 1 1. Arrival/Registration: A key goal is to avoid overcrowding of An Example of a Prioritization Scheme the elevators, waiting rooms, corridors, and scanners while not delaying patient care. The test procedures need to allow for Urgent inpatient or outpatient (to be performed upon adequate social distancing between patients before and during the request): Inpatient or outpatient with a clinical scenario suggesting a moderate to high likelihood of short-term whole testing process. major adverse cardiac events, in whom the results of • Appropriate physical distancing should be maintained at all testing would have high likelihood of modifying stages of patient engagement, including registration, waiting management areas, and consent. Waiting areas and processes should be Higher priority (deferred for 1–2 months): Inpatient or arranged to allow appropriate physical distancing. In addi- outpatient who meets AUC criteria for testing, but with a tion, accompanying visitors and family members should not clinical scenario suggesting a low likelihood for short-term major adverse cardiac events be allowed or should be limited to one person and only if their presence is essential. If the facility has significant space Lower priority (deferred for 2–4 months): Outpatient, who meets AUC criteria for testing, and who is clinically stable, constraints, consideration should be to having patients wait in expected to have normal or low-risk findings that would their vehicles until contacted by cellphone by a member of not be expected to affect short-term management. Some the nuclear cardiology laboratory staff. The patient would examples are pre-operative testing for elective surgery; then be met at the entrance of the facility by the staff member surveillance testing such as in asymptomatic patients with and escorted to the laboratory. prior history of PCI or CABG, a patient already on class • The use of telehealth to assess patients for new symptoms, to 1C antiarrhythmic, a patient post cardiac transplant; register the patient, to provide them with details about the test asymptomatic patient with an elevated coronary artery to be performed, and to obtain verbal consent is generally calcium score recommended. Processes should also be automated as much Elective (deferred for 4–6 months): Screening or wellness as possible to reduce face to face interaction. Some onsite tests such as coronary artery calcium scans and treadmill exercise tests administrative steps can be performed through the patient’s smartphone. The healthcare screening questionnaire should be thorough. because of reduced demand over the period of sheltering in • Temperature measurements and a screening questionnaire for place during the pandemic. all patients are generally recommended at arrival to health- • Resources: In addition, the laboratory needs to ensure that care facility and to nuclear laboratory. they have adequate resources to safely perform testing, keep- • Face covering or masks are currently mandated at most med- ing in mind that the demand for certain equipment will grow ical centers (surgical/cloth/specific mask type as determined as other healthcare providers ramp up deferred services. by local rules and infection control) for all patients, visitors, • Communication/patient concerns: A significant proportion of and healthcare personnel. patients may decline testing because of concerns about the • Review indication for testing at registration or immediately risk of contracting COVID-19 by visiting the testing facility. upon a patient’s arrival in clinical areas to ensure that the test Institutions must provide referring physicians detailed infor- is still indicated and urgent. Changes in symptoms and/or mation about steps taken by the laboratory to minimize the health status may either render the test not indicated or de- risk of COVID-19 infection. Referring providers must remind mand a different test. patients about the real and significant risk of not undergoing testing. Staff scheduling patients should have scripting avail- 2. Imaging Considerations: The overarching goals are to per- able to screen patients for symptoms consistent with COVID-19 form rapid and hygienic imaging to minimize COVID-19 expo- to reassure patients, including a description of the additional sure to healthcare professionals and patients. precautions that are being undertaken by the laboratory a. Protocol selection to minimize COVID-19 infection risk. If a patient refuses to undergo testing it is of the utmost importance for the • For SPECT myocardial perfusion imaging studies, elect nuclear cardiology laboratory to inform the referring physi- stress first/stress only imaging when possible to potentially cian to let them know of the patient’s decision so that they decrease duration of the study, and consider rapid acquisition can contact the patient to discuss this further and make alter- protocols when feasible. nate arrangements. • For SPECT myocardial perfusion imaging studies in inpa- • Tracking: Establishment of proper systems to track canceled tients who are not eligible for stress only testing, consider or postponed studies is very important. Providers should es- performing the rest injection in the patient’s inpatient room, tablish a priority score that can include indication for testing to avoid completely or minimize waiting time in the labora- and overall CV risk, and COVID-19 risk. tory. A typical protocol would begin with a technologist bringing a dose of technetium-99m sestamibi or tetrofosmin B. Day of Testing: to the patient’s inpatient room, checking the intravenous line, Specific precautions are recommended on the day of the test at and injecting the dose. After a suitable delay, the patient is the time of arrival, during the imaging test and during the stress transported to the laboratory, directly to a waiting open cam- test to minimize COVID-19 exposure risk as outlined below. An era, where rest imaging is performed. After an appropriate important principle is to minimize the amount of time spent by delay, when the patient waits in their hospital room, he or she patients in the nuclear cardiology laboratory or at the associated is brought to an open stress room where stress testing is institution to reduce risk both for patients and staff. performed. After stress testing, the patient is transported back 1536 THE JOURNAL OF NUCLEAR MEDICINE • Vol. 61 • No. 10 • October 2020 to their room, and returns to a waiting open camera approxi- contraindicated), since it requires a single 10 second infusion, mately 1–1.5 hours after stress injection. after which providers can maintain a safe distance from the • For technetium-99m pyrophosphate (PYP) scans in inpa- patient. For adenosine and dipyridamole stress testing, extra- tients, consider injecting the patient and allowing him/her long tubing can be used to keep distance between staff and to leave the laboratory, returning for imaging after the labo- patients. ratory protocol delay. • If after careful consideration, exercise testing is determined • For N-13 ammonia PET myocardial perfusion imaging stud- to be necessary, it is recommended to use a higher-level PPE ies, consider performing a protocol facilitating a single rest/ for staff (for example N95/FFP2/P2/DS/KN95/Korea 1st class stress session on the camera with enhanced social distancing, respirator or equivalent, face shield, gloves and gown) and and avoid the patient leaving the camera room between rest surgical mask or face covering for patients, assuming these and stress sessions and the camera needing cleaning multiple supplies are available,11 and extra time should be allowed in times. A low-dose rest, high-dose stress protocol may enable order to clean the room. a more rapid single-session imaging. • Appropriate cleaning between patients is required. b. Imaging time slots may need to be expanded and extra time should be allowed for cleaning rooms, cameras, chairs, and ONGOING CONSIDERATIONS FOR THE LABORATORY other surfaces between patients. c. Appropriate cleaning of equipment between cases is essential. An important goal of an ongoing monitoring process is to refine d. For outpatients requiring rest imaging, consideration could policies and procedures as needed in response to the evolution of also be given to performing this on a separate day to give the COVID-19 pandemic as the laboratory operations resume to greater control of workflow and minimize time within the include more elective procedures. department, although this approach may be less appropriate A. Additional data collection and monitoring may be warranted. in some settings and needs to be balanced by the downside of The nuclear cardiology laboratory’s protocols and patient using more PPE for 2-day imaging. scheduling templates will need to be closely monitored and e. For laboratories with access to myocardial perfusion PET refined multiple times over the coming months as the COVID- using Rb82, this modality is preferred because of its time 19 pandemic slowly recedes, with potential for local or wide- efficiency. A complete rest-stress PET MPI study can be spread waves of new COVID-19 infections. Data collection and acquired within 30 to 45 minutes, not only minimizing ex- monitoring will be necessary to inform the need to modify posure for patients and staff, but also potentially reducing existing laboratory policies. Some suggested parameters for number of rooms and spaces which could experience surface collecting and monitoring and potential responsive changes to contamination and possibly reducing staffing needs. laboratory workflow are listed in Table 2. f. For patients tested with SPECT-CT or PET-CT instrumenta- B. Availability of laboratory personnel might be impacted by tion in regions with higher prevalence of COVID-19 infec- redeployment to other work responsibilities in the healthcare tions, some laboratories recommend a policy of reviewing system during the COVID-19 pandemic, staff quarantine to the chest CT images before the patient leaves the laboratory. home due to COVID-19 infection of the staff or their close For patients who have lung infiltrates seen on chest CT im- contacts, and other non-COVID-19 related issues. ages, they may require further evaluation for possible C. Laboratory testing hours should be adjusted as needed. COVID-19 infection.12 • Expansion of testing might need to be suspended completely 3. Stress Laboratory Considerations: The goals are to perform if essential laboratory personnel are unavailable. Similarly, if a safe test for the patient and minimize droplet exposure to the supply of PPE or COVID-19 testing is interrupted, test healthcare professionals and patients. scheduling would need to be reduced to allow for adequate • If possible, consider pharmacologic testing preferably using supply of PPE and COVID-19 testing for other patient care vasodilator stress agents to decrease droplet exposure risk,9 areas of higher priority. especially in patients who are not known to be COVID-19 • If, however, there is a large backlog of orders for nuclear negative. Patients breathing heavily during exercise may gener- cardiology procedures as a result of deferred testing during ate droplets and traditionally stress test personnel are in close the height of the COVID-19 pandemic, laboratories might proximity to patients. Pharmacologic testing is not inferior to need to consider temporarily extending weekday hours of exercise testing in terms of diagnostic performance. Regadeno- operation or weekend testing to accommodate a surge in pa- son may be the preferred stress agent (if available and not tient volume. The feasibility of extending hours of operation TABLE 2 Workflow Parameters to Monitor in the Nuclear Cardiology Laboratory Parameter for monitoring Impact on laboratory policies Decreased laboratory personnel availability Reduce hours of operation Decreased availability of PPE and COVID-19 testing Reduce hours of operation Increased test duration (including cleaning) Adjust the patient scheduling template Increased or pending orders for cardiac imaging procedures Increase hours of operation GUIDANCE AND BEST PRACTICES FOR COVID-19 • Skali et al. 1537 will depend of the availability of laboratory personnel, • Laboratory leadership should consider redeployment of phy- PPE, and COVID-19 testing. sician and nursing staff away from routine (elective) office D. Tracking of total time required for nuclear cardiology activities until backlog has been reduced, especially for procedures is desirable. This includes time required to higher priority patients. This approach will help get the fully clean and disinfect the stress testing equipment higher risk patients whose tests have been deferred com- and the imaging equipment. This information will in- pleted, while not adding more and more higher priority pa- form patient scheduling templates. tients to the schedule. • Nuclear cardiology laboratory operations, of course, are part SAFETY AND RISK FOR POTENTIAL SECOND OR of the local healthcare systems and work in conjunction SUBSEQUENT WAVES with other departments in the hospital and areas of the medical practice. Most of the suggestions outlined above While one cannot predict the potential for a second or subse- must be instituted in concert and collaboration with other quent waves of COVID-19 pandemic, numerous public health key departments. authorities are warning that it is possible, and procedures need to be in place to mitigate the adverse effects of a second wave. CONCLUSIONS Hence, it is important to follow the steps below: The unprecedented COVID-19 pandemic has disrupted health- • Providers and institutions should monitor local data and fol- care systems, including nuclear cardiology laboratories around the low national, state, and department of public health recom- world, severely reducing their services. As the health crisis recedes, mendations for possible second COVID-19 waves that may nuclear cardiology laboratories are able to gradually expand opera- require decreasing nuclear cardiology laboratory activities tions while maintaining appropriate safe practices. This document and enhanced protective measures. lays out guidance about best practices, but it is important to recognize • Physical distancing and masking should be maintained for the that conditions are quite different in various locations and will change foreseeable future. in the coming months. An individualized, adaptable, and thoughtful • Limitations on visitors and accompanying persons should be approach that coordinates with other providers and public health continued for the foreseeable future as well. authorities will be needed for the foreseeable future. NUCLEAR CARDIOLOGY TRAINING AND EDUCATION DISCLOSURES Trainees are an important part of nuclear cardiology programs and Dr. Bateman: Activities related to the present article: No laboratories. During the COVID-19 pandemic, many trainees have relevant relationships. Activities not related to the present article: been redeployed from their imaging rotations to clinical care of Research Grants: Bracco, GE Healthcare, Jubilant DraxImage. COVID-19 patients in the hospital and intensive care units. If the Consultant: AIM, AstraZeneca, Curium, GEHC. Royalties: pandemic continues, trainee education needs to be revised to use SPECT and PET software products. Ownership interest: CVIT. novel training methods including web and video-based approaches Dr. Beanlands: Activities related to the present article: No relevant to learning. New educational procedures need to be consistent with relationships. Activities not related to the present article: Grants/ policies from stakeholders such as the Accreditation Council for Honoraria from Jubilant DraxImage, LMI, GE Healthcare. Dr. Dorbala: Activities related to the present article: No relevant Graduate Medical Education, American Board of Internal Medicine, relationships. Activities not related to the present article: Grants American Board of Nuclear Medicine, American Board of Radiol- and Honoraria from Pfizer and GE Healthcare. Institution has ogy, and Nuclear Regulatory Commission. This is particularly grants/grants pending from National Institutes of Health and pertinent for hands-on education in the stress laboratory, hot International Atomic Energy Agency. Dr. Einstein: Activities laboratory, and radiopharmacy, which may need to be adapted to related to the present article: No relevant relationships. Activities video methods. The number of cases required for graduation may not related to the present article: Consultant for GE Healthcare need to include a larger percentage of virtual educational sessions, in and W. L. Gore and Associates; institution has grants/grants compliance/collaboration with certifying agencies including the pending from National Institutes of Health, International Atomic Certification Board of Nuclear Cardiology, American Board of Energy Agency, Canon Medical Systems, Roche Medical Sys- Internal Medicine, the American Board of Nuclear Medicine, and tems, and W. L. Gore and Associates; received travel/accommo- the American Board or Radiology. dations/meeting expenses unrelated to activities listed from HeartFlow. Dr. Murthy: Activities related to the present article: ADDITIONAL CONSIDERATIONS No relevant relationships. Activities not related to the present article: Owns stock in General Electric and Cardinal Health and • Staff should be monitored for wellbeing during these some- stock options in Ionetix. He has served as a paid advisor to Ionetix times-stressful times, especially if required to work long and Covidien. He has received research grants from Siemens and hours and if they are redeployed to unfamiliar areas. non-financial research support from INVIA Medical Imaging • In the United States, nuclear cardiology services are often Solutions. He has received payment on behalf of Jubilant Drax- impacted by the details of the patient’s health insurance pol- image for expert witness testimony. Dr. Soman: Activities related icy and enforcement by radiology benefits managers. More to the present article: No relevant relationships. Activities not advocacy effort will be required to convince these oversight related to the present article: Serves on the advisory board of agencies to allow relaxation of previous policies on prior Alnylam Pharmaceuticals and is the principal investigator of a authorization and flexibility for longer approval windows grant from Astellas Pharmaceuticals to the University of Pitts- and to resist one-size-fits-all prescribed approaches. burgh. The remaining authors have no relevant relationships. 1538 THE JOURNAL OF NUCLEAR MEDICINE • Vol. 61 • No. 10 • October 2020 REFERENCES www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services. pdf. Accessed April 30, 2020. 1. Center for Disease Control and Prevention. Healthcare facilities: preparing for 7. COVID-19 testing by laboratories: Q and A. https://www.cdc.gov/coronavirus/ community transmission. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance- 2019-ncov/lab/testing-laboratories.html. 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