Category Archives: Radiology

New Questions on Lung Cancer Screening

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening?

These are just a few of the questions tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared to chest X-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policymakers and payors are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

“That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained,” he said. “So it certainly is feasible”

Dr. Black pointed out that low-dose CT saved one lung cancer death per 346 persons screened in NLST, which again is very favorable compared to the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggest there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening.

One-quarter of the audience had no lower age limit for screening, and 34% said they did not provide either decision support or obtain informed consent.

Dr. Caroline Chiles. Image by Patrice Wendling/Elsevier Global Medical News

Radiologist and NLST collaborator Dr. Caroline Chiles said informed consent in NLST helped prepare patients for the potential risks of a screen, the likelihood of a positive result and that a positive result didn’t mean they had lung cancer.

“It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected,” she added.

What attendees and panelists could agree on is the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking compared with 3%-7% in the general public, but that participants were less likely to stay non-smokers. She also cited a recent MMWR that found 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

“We really have to think of lung cancer screening as being a teachable moment,” she said.

She suggested physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted that the NLST team is working on a lung cancer screening fact sheet for physicians and patients that will be ready in a few weeks and made available on the Internet.

—Patrice Wendling

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Filed under Cardiovascular Medicine, Family Medicine, Health Policy, IMNG, Internal Medicine, Oncology, Physician Reimbursement, Practice Trends, Pulmonary Diseases and Sleep Medicine, Radiology, Surgery, Thoracic Surgery

Hypnosis Takes the Bite Out of MRI Anxiety

I’d rather have an MRI.

OK, it doesn’t have the same ring as the traditional punch line, but for many patients the fear of being slipped in a scanner surrounded by the clicking and banging sounds of an MRI ranks right up there with a root canal.

Rather than sedating these patients, a radiology group in France has been offering hypnosis on a daily basis since 2004.

Over a 15-month period, 45 patients were identified as being claustrophobic and refused the scheduled MRI, including four patients who experienced a panic attack.

All 41 patients who agreed to undergo a brief 3- to 5-minute single session of hypnosis just before the MRI completed the exam, including those with panic attacks.

Conversely, none of the four patients who refused hypnosis were able to withstand the procedure, radiologist and co-author Dr. Bruno Suarez reported at the Radiological Society of North America  meeting.

Dr. Bruno Suarez

“The more a patient is claustrophobic, the more hypnosis is efficient,” Dr. Suarez, with L’Hôpital Privé de Thiais in the outskirts of Paris, said in an interview. “For us it’s a surprise. It’s a very interesting technique.”

The technique is based on the late American psychiatrist Dr. Milton Erickson’s approach to hypnosis, but modified to integrate the repetitive noise of the MRI. Patients are given a tour of the MRI room, assured that the scanner and its magnets are safe and prompted to mentally recall a pleasant memory involving a repetitive noise while the MRI exam is performed.

During hypnosis, the brain is more susceptible to suggestions, Dr. Suarez said, noting that a Belgian study showed that hypnosis reduces the perception of pain by 50%.

Hypnosis requires a good memory and language skills, so it’s not used on those under five years of age or those with dementia or Alzheimer’s, he added.

So far, a radiologist, two MRI technicians and even the two office receptionists have been trained in the technique.

Marc Andre Fontaine (left) and Dr. Suarez

“I like the contact with the patient, and I want the best results for the patient,” MR technician and co-author Marc Andre Fontaine said in an interview.

The 45 patients in the series represent just 1.4% of the roughly 3,300 patients seen by the group over the 15 months, but the appeal of the drug-free method has attracted referrals from other centers. It’s also a big financial boon due to shorter exam times, fewer appointment cancellations and no procedural side effects, Dr. Suarez said.

A recent study by interventional radiologist and hypno-analgesia pioneer Dr. Elvira Lang reported that self-hypnotic relaxation added an extra 58 minutes to the room time for an outpatient radiologic procedure, but still saved $338 per case compared with standard IV conscious sedation.

That’s a big savings for just getting patients to relax with a few words, especially when you consider that  nine out of ten patients are probably already muttering something under their breath during their MRI.

—Patrice Wendling

Images by Patrice Wendling/Elsevier Global Medical News

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Filed under Alternative and Complementary Medicine, Anesthesia and Analgesia, IMNG, Radiology

Those Varicose Veins Are Not Just Unsightly

Image courtesy of the NIH (via WikiMedia Commons - public domain)

Many people think of varicose or spider veins as merely ugly veins that keep them from wearing shorts and other clothes that expose their legs. Hopefully, that’s about to change thanks to a new public awareness campaign launched this week to alert people to the health dangers of these twisted and swollen blood vessels.

If left untreated, those unsightly spider veins can lead to the more serious form of vein venous disease — chronic venous insufficiency (CVI) — with symptoms that worsen over time. The Rethink Varicose Veins campaign provides an educational online hub where healthcare professionals and patients can find resources about varicose veins and CVI. 

The Physician Locator tool allows doctors to sign up to have their contact information listed on the campaign’s Web site. There is also a downloadable electronic toolkit and in-office resources, including HTML and printable flyers; banner ads; and content for physician websites and social media pages.

Resources for patients include a self-assessment tool to help individuals determine if they are candidates for further screening from a vein specialist . There is also a physician locator to find vein specialists. Patients can find background information on varicose veins, CVI, and treatment options.

The campaign and website are a joint venture from the the Society for Vascular Surgery, the American Venous Forum, and the American College of Phlebology. The program was launched at the 38th annual VEITHsymposium.

The effort is sponsored by Covidien, which makes CVI treatment products.

Kerri Wachter

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Rheumatology Rewards Innovative Imaging

Rheumatology has a been a tad slower than other specialties to adopt more advanced imaging modalities, preferring to stick with ultrasound and venturing into MRI. Based on this year’s still image winner in the “Image of the Year” contest at this year’s American College of Rheumatology meeting though, the specialty appears to be embracing innovative new ways of imaging rheumatic diseases.

Image courtesy of the American College of Rheumatology and Dr. Chaudhari

This year’s winner is a combined PET-CT image of the finger joints in patients with psoriatic arthritis. The image was submitted Abhijit Chaudhari, Ph.D. of the UC Davis School of Medicine in Sacramento.

 According to Dr. Chaudhari’s poster from the meeting, his group has built an extremity scanner that is capable of sequentially performing 3D positron emission tomography (PET) and fusing the image with a 3D anatomical CT image. In the poster, they reported their initial experience in using this system for assessing metabolic activity in RA, PsA and OA of the hand. Regions of enhancement on PET (F18-FDG) are markers of increased metabolic activity and, in turn, inflammation.
 
While the technique is still in early trials, the researchers hope that one day they will be able to not only identify the disease but also monitor early response to anti-TNF-alpha therapy in RA and characterize bone remodeling (osteoblastic) activity in early OA. 
 
The best overall submission and category winning submissions from this year’s contest will be published in a future issue of Arthritis & Rheumatism and will be featured in the online Rheumatology Image Bank.
 
You can read more about this year’s ACR meeting and watch video interviews with key presenters at Rheumatology News.com.
 
Kerri Wachter (On Twitter @knwachter)

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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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Filed under Cardiovascular Medicine, Drug And Device Safety, Emergency Medicine, Family Medicine, Health Policy, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Nuclear Medicine, Practice Trends, Primary care, Radiology

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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