Category Archives: Nuclear Medicine

Nobel Finally Does Right by Marie Curie

In 1903 the word on the street was that Pierre and Marie Curie were the front-runners for the Nobel Prize in Physics for their work on radioactivity — inherent in which was the hypothesis that the atom was not the most basic particle but could emit subatomic particles. Some were affronted by the idea that a woman could have played any significant part in this work, and they argued for awarding the prize to Pierre and French physicist Henri Becquerel, but not Marie.

Courtesy Wikimedia Commons/Witkacy/Creative Commons License

When Pierre caught wind of this, he argued vehemently on his wife’s behalf. When the award was finally presented to both Curies and Becquerel, Marie was lauded at the presentation as a “help meet” to Pierre. Thus, Marie Curie became the first woman to win a Nobel Prize. The insulting irony was that Pierre had given up his work on crystals and magnetism to literally help his wife blaze a new trail in chemistry and physics with her work on radioactivity.

Courtesy Wikimedia Commons/Author Unknown/Public Domain

This year marks the 100th anniversary of Marie Sklodowska Curie’s second Nobel Prize — this time in chemistry for the discovery of polonium and radium. The first woman to win a Nobel became the first person to win two. But the second award was not without controversy. After Pierre’s death in 1906, Marie was rumored to have begun an affair with French physicist Paul Langevin. The scandal broke around the same time as her second award.  She refused to let the slander mar her scientific work. She wrote to a critic that “I believe there is no connection between my scientific work and the facts of private life.”

One hundred years later, Madame Curie stars in an exhibit at the Nobel museum in Stockholm — giving her the credit that she was denied by many during her lifetime. Marie died in 1934 of aplastic anemia most likely due to her lifelong exposure to radiation. A year later, her daughter Irene Joliot-Curie and her husband Frederic Joliot won the Nobel Prize for Chemistry for their work on the synthesis of radioactive elements. Irene died in 1956 of leukemia, also likely due to her exposure to radioactive materials.

The opening of the exhibit coincided with the European Multidisciplinary Cancer Congress. Madame Curie’s discovery of radiation proved to be a double-edged sword. Exposure to ionizing radiation is associated with several cancers — lung, skin, thyroid, multiple myeloma, breast, and stomach. However, the physics of radiation underlie many imaging techniques that allow physicians to noninvasively identify and follow tumors in the body. Radiation also turns out to be an effective treatment of certain cancers. Her pioneering investigation provided the groundwork for cancer research that greatly increased the odds of survival for many cancer patients.

Kerri Wachter

Solvay Conference 1927, Courtesy of Wikimedia Commons/Benjamin Couprie, Institut International de Physique de Solvay/Public Domain

The Solvay Conferences in Brussels were initiated to have the brightest minds of the age work on preeminent open problems in both physics and chemistry. The most famous meeting was held in 1927 and is noted for the presence of so many scientific luminaries addressing the newly proposed quantum theory. Seventeen of the 29 members were Nobel winners or would become winners. In the photo, Marie Curie — with two Nobel prizes to her name — takes her place alongside Albert Einstein, Niels Bohr, Erwin Schrodinger, and Werner Heisenberg, among others.

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FDA Misses Lessons of Device Recalls

A new report from the U.S. Government Accountability Office (GAO), the auditing arm of Congress, found that the Food and Drug Administration isn’t doing everything it can to learn from medical device recalls. That’s despite the fact that on average more than 700 medical devices are recalled each year. The report was requested by Sen. Chuck Grassley (R-Iowa), the chairman of the Finance Committee and Sen. Herb Kohl (D-Wisc.), the chairman of the Committee on Aging.

The GAO investigators didn’t take issue with what the FDA does in initiating and classifying the mostly voluntary recalls of medical devices. Instead, they wrote that the agency took a haphazard approach to assessing the effectiveness of recalls and analyzing information after a recall. Those gaps represent a missed opportunity to learn went wrong and keep it from happening again, the GAO warned.

An open and charged AED. Image via Wikimedia Commons user Owain.davies.

Specifically, because of the FDA’s lack of analysis on medical device recalls, they couldn’t give definitive answers to questions from the GAO about the common causes of recalls, the trends in the number of recalls over time, the variation in recalls by risk level, the types of devices and medical specialties that account for the most recalls, and the length of time it takes for companies and the FDA to complete recall activities.

But the FDA told the GAO investigators that it does use recall information help target their inspections. And the GAO gave FDA a gold star from use of recall information to detect and address safety issues with automated external defibrillators. Late last year, the FDA held a conference on AEDs where in presented historical recall data to make the case for safety improvements in the device, the GAO wrote.

For its part, the FDA says it’s getting better. In statement in response to the GAO report, FDA officials said that last year launched the Recall Process Improvement Project, which is aimed at better educating the industry about the recall process. And about a year ago, the FDA began using recall data to aid in the review of devices. The agency has also developed initiatives that use recall data to help improve the safety of infusion pumps, external defibrillators, and radiation from medical procedures.

— Mary Ellen Schneider (on Twitter @MaryEllenNY)

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Whose Rights Are at Stake?

The Supreme Court heard arguments Tuesday in support of the 2007 Vermont statute limiting the release of the information detailing which drugs doctors prescribe. This information is maintained by pharmacies, which sell it to data-mining agencies, that in turn sell it to drug companies, for marketing purposes. Patient information is excluded from the data, doctor’s information is not.

Under the Vermont law, this information can be released only with the consent of the doctor. However, once data collection firms like IMS Health and interested parties like Pharmaceutical Research Manufacturers of America, challenged the statute, the issue became a question of free speech.

In the case of Sorrell v. IMS Health Inc., data-mining firms claim they have First Amendment rights to buy and sell the information for their marketing use.

However, the state’s attorney’s office likened the release of the confidential information to disclosing a doctor’s tax returns, patient files, or a competitor’s business information, arguing that First Amendment rights in the case apply to protecting doctor’s information. But since the information is given away to parties including insurance companies, journalists, and law enforcement, the court wasn’t too convinced.

” … just don’t tell me that the purpose is to protect their privacy,” said Justice Antonin Scalia. “[A doctor's] privacy isn’t protected by saying you can’t sell it but you can give it away.”

Justice John Roberts said Vermont is trying to reduce health care costs by “censoring” information doctors hear about brand-name drugs, with the intent that they will prescribe more generics, a measure Justice Scalia added was a restriction on free speech.

Vermont Assistant Attorney General Bridget Asay responded that “the purpose of the statute is to let doctors decide whether sales representatives will have access to this inside information” on the prescribing habits of physicians.

Attorneys general of several states, the federal government, AARP, medical associations, privacy groups, and the New England Journal of Medicine have filed briefs in support of the Vermont statute, according to a brief by Cornell (N.Y.) University Law SchoolThe National Association of Chain Drug Stores, the Association of National Advertisers, the Associated Press, and Bloomberg have filed in support of the data mining firms.

In an age in which personal data can mined through social networks and search engines, this case could set the precedent concerning how much personal information can be used for marketing. A decision is expected by June.

 Tell us what you think. 

–Frances Correa (@FMCReporting on Twitter)

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Renaissance RSNA

This year’s meeting of the Radiologic Society of North America felt as foreign to the current American landscape as Harry Potter’s Hogwarts School of Witchcraft and Wizardry.

While politicians in Washington played hide-and-go-seek with desperately needed government funding and unemployment benefits,  rows and rows of glistening CT and MRI machines spanned the floor of Chicago’s McCormick Place. Physicians clutching cups of made-to-order espresso were wooed into private imaging suites created with elaborate screens and partitions. One was even shaped to resemble a pagoda, with an exquisite black and floral kimono inside.

“I believe one of the exhibitors said in a meeting that we had down here that they considered this the Renaissance RSNA, everything’s back solid and strong,” says RSNA assistant executive director Steve Drew.

When asked the dollar value of the equipment on display, Drew says they’ve never stopped to calculate it, but that $100 million would probably be a “very conservative guess.”

Exhibits have remained solid in terms of the amount of space being bought and the size of the booths, with about 700 exhibitors on hand this year, down slightly from an all-time high in the mid-700s.

“We feel good about it,” he says. “Based on information gathered through partnership meetings we have with our major exhibitors and market indicators, we had actually budgeted down 7% and we’re about even with where we were last year. So, depending on how you look at it, it’s almost a 7% increase.”

RSNA isn’t the only one feeling good about this year’s meeting.

The city of Chicago, which struggled this past year to retain its competitive edge in the convention trade, anticipates that the 6-day show will bring in $120 million, says Meghan Risch, director of public relations for the Chicago Convention and Tourism Bureau.

The economic impact of RSNA, arguably one of the biggest medical meetings in the world, has remained relatively constant, she contends, despite the economic downturn.

Attendance this year was about 57,500, according to unaudited attendance figures. Of these, 36,000 were professional registrants, defined as everyone but exhibitors and guests.

“We’re running about 4% ahead on professional attendance and the really good numbers there are the non-North American registrants, which came in at 36% of the professional registrants,” Mr. Drew says.

The average hotel stay for RSNA is five days – roughly double that for most medical meetings. Its international makeup is also probably the highest of Chicago conventions, according to Ms. Risch.

“International attendance is growing and RSNA is a great example,” she says.

–Patrice Wendling (on Twitter @pwendl)

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The Isotopes Cometh

Canada’s National Research Universal (NRU) reactor appears days away from coming back on-line – a move that should temporarily alleviate a shortage of medical isotopes that has plagued clinicians for more than a year.

 The Canadian Nuclear Safety Commission gave its approval July 7 to restart the NRU reactor, with loading of molybdenum targets and reactor fuel set to begin within the next week.

 “We are still tracking to be in isotope production by the end of July,” said Dale Coffin, director of corporate communications for Atomic Energy of Canada Ltd., which operates the reactor.

 Molybdenum-99 (Mo-99) and its decay product, technetium-99m, the most widely used medical radioisotope, have been in short supply in recent years, with just five multipurpose research reactors supplying more than 95% of the world’s supply of Mo-99.

Before it shutdown in May 2009, the NRU in Chalk River, Ontario, produced roughly 30% of the global supply of medical isotopes and 50% of the United States’ supply, Mr. Coffin said.

Holland’s Petten reactor was taken out of service most recently in February 2010, and is anticipated to be restarted sometime next month.

Radioisotope generator

 The shutdown of the two reactors has forced clinicians across the globe to ration available isotope materials, reschedule nuclear imaging procedures and find alternative ways of diagnosing patients.

 According to a survey released last month by the Canadian Institute for Health Information,  the number of cardiac, bone and lung diagnostic tests on Canadian patients decreased 22% in October 2009, compared with October 2008. This represents about 12,000 fewer exams over this period. The drop in nuclear exams ranged from highs of 18% for lung perfusion and bone exams to 25% for cardiac tests.

 The resumption of operations at NRU will alleviate the shortage of Mo-99 and other reactor produced isotopes, and keep the U.S. market from experiencing the issues of transportation delays from sites in Europe and South Africa, said Robert Atcher, Ph.D., with the Los Alamos National Laboratory, past president of the Society of Nuclear Medicine and chair of its isotope task force.

 It will not, however, resolve the long-term problem of maintaining a consistent supply to the medical and veterinary communities.

 “All the reactors that are currently providing material to the U.S. market are approaching 50 years of age; they can’t be expected to operate forever,” Dr. Atcher said. “More to the point, the Canadian government has made it clear that they no longer believe that they should serve the world market with isotopes.”

 He noted that the government decided not to replace the NRU with another multi-purpose nuclear reactor, despite the recommendation of an expert panel it commissioned to examine the problem. In addition, the government is focusing its research funding on potential solutions to the problem that will only provide material for the Canadian market, a move Dr. Atcher said was reinforced at a meeting last month of the High Level Group on the Security of Supply of Medical Radioisotopes.

 “There is no question that we need to develop alternative production capacity to supply the U.S. market, which represents 50% of the world demand for Mo-99,” he said.

 – Patrice Wendling (on Twitter @pwendl)

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Hospitals Moving “Moo” Off the Menus

(Courtesy NASA Goddard Space Flight Center)

Here’s a happy Earth Day item: Four hospitals in the San Francisco Bay Area reduced their meat purchasing for menus by 28% in a pilot study, thereby avoiding significant amounts of associated greenhouse gas emissions and saving hundreds of thousands of dollars in costs.

Most of the drop in greenhouse gases came from reduced purchases of beef, which is a notorious producer of gases that contribute to global warming.

The study is the first attempt to evaluate the “Balanced Menus” program, which was created by the San Francisco Bay chapter of Physicians for Social Responsibility and has been rolled out to 32 hospitals across the United States by the nonprofit organization Health Care Without Harm. The Johns Hopkins Center for a Livable Future partnered with Health Care Without Harm to conduct the study.

A hospital meal (not in one of the study hospitals) by flickr user VirtualErn (Creative Commons).

Two hospitals reduced meat (beef, pork and chicken) in its cafeterias or cafes, one hospital reduced meat in inpatient menus/meal services, and one hospital did both. The Balanced Menu program also had them try to replace the remaining meat on their menus with purchases from sustainable and grass-fed meat producers instead of industrialized meat sources.

The study estimated that in a year’s time, the reduced meat purchases would avoid a total of 1,004 tons of carbon dioxide-equivalent greenhouse gas emissions. That’s roughly equivalent to not using 102,454 gallons of gasoline, or growing 23,354 tree seedlings for 10 years. Although the study did not account for greenhouse gases associated with whatever food replaced that meat, no food makes gas like beef, so there’s no doubt the planet came out ahead.

They also calculated that the less-meat, better-meat program saved the four hospitals $21,080 per month in costs even after including increased purchases of fish and vegetable sources of protein. My calculator suggests that’s $252,960 per year.

What about the patients? No complaints there, only anecdotal reports of compliments. Plus changing the meat-heavy U.S. diet could help combat rising rates of diabetes, obesity, and some cancers. According to Department of Agriculture statistics, the U.S. food supply contains 58% more red meat and chicken (8.7 ounces per person per day) than is called for in dietary guidelines that cover meat, poultry, nuts, beans, and eggs (5.5 ounces per person per day).

One of the lessons learned in the pilot study, the investigators noted, is that hospitals should involve clinicians early in the process of menu development. If you’re a clinician who is looking for one small, achievable Earth Day action that could make a big difference, consider showing this study to your hospital team. They (and the planet) may thank you.

–Sherry Boschert (@sherryboschert on Twitter)
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Radiation’s Double-Edged Sword

Image courtesy of IAEA

—from the International Stroke Conference in San Antonio 

Ionizing radiation—useful for imaging and therapy—has undoubtedly been a boon to medicine.  The ability to quickly and noninvasively peek inside the body has not only led to faster diagnoses, but more accurate ones.  The ability to target cancerous tissue with a beam of radiation has improved therapeutic options for many cancer patients. 

However, it comes with a cost.  In the past few months, newspaper headlines have detailed cases of accidental exposure of patients to dangerously high doses of ionizing radiation for both imaging and radiotherapy.  The cases were alarming enough that members of the  House Energy and Commerce Committee’s Subcommittee on Health called radiology organizations, manufacturers, and experts to testify on ways to improve the safety of medical technology involving ionizing radiation to prevent accidents like those in the headlines. 

As that hearing occurred in Washington, data presented at the ISC was a stark reminder that even if  procedures using ionizing radiation meet safety requirements, patients could be exposed to concerning levels of ionizing radiation over the course of diagnosis and treatment of just one condition.  At the ISC,  Dr. Venkatesh Aiyagari, a professor of neurology at the University of Illinois, presented data on cumulative radiation exposure for patients with subarachnoid hemorrhage (SAH) over the course of their hospital stay. 

In the retrospective study 107 patients with SAH underwent 1,458 CT scans.  The researchers looked at cumulative effective dose, a term which refers to the radiation risk averaged over the entire body.  Over the course of treatment, 24% received moderate effective doses (>3-20 mSv), 39% received high effective doses (>20-50 mSv), and 35% recieved very high effective doses (>50 mSv). 

Let’s put that into perspective.  The U.S. Nuclear Regulatory Commission estimates the average annual radiation exposure from natural sources to an individual in the United States is about 3 millisieverts.  The NRC requires that its licensees limit maximum radiation exposure to individual members of the public to 1mSv per year and limit occupational radiation exposure to adults working with radioactive material to 50 mSv per year. 

Of course, Dr. Aiyagari’s study looked only at effective doses for one condition.  The effects of ionizing radiation are cumulative, so all of those dental x-rays, chest x-rays, and CT scans add up.  Right now, no one is tasked with keeping track, though that may change.  Earlier this year the NIH’s Clinical Center announced that radiation exposure for procedures at the center would be documented in the patient’s EHR.   Around the same time, FDA announced an initiative to reduce unnecessary radiation exposure from CT, nuclear medicine studies, and fluoroscopy.  Possible steps may include requiring manufacturers to display, record, and report equipment settings and radiation dose. 

It seems clear that physicians can expect changes in the way that medical radiation is tracked and some rethinking about how necessary some scans are. 

—Kerri Wachter ( @knwachter on Twitter) 

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