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 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
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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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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Stents-on-Sticks Score for Acute Stroke

Late yesterday afternoon, I heard about the future of acute stroke treatment: retrieving the culprit blood clot with a removable stent, also known as stent retrievers, stentrievers, and stent-on-a-stick.

stent-on-a-stick; photo by Mitchel Zoler from an image shown by Dr. Aleu

Dr. Aitziber Aleu, an interventional neurologist from Hospital Germans Trias i Pujol near Barcelona, presented the combined experience from three Barcelona-area hospitals using two different brands of stentrievers to treat 89 acute stroke patients during March 2008-December 2010. This was the largest series of stroke patients yet reported who underwent this type of treatment, and a rapt, electrified audience of stroke interventionalists who heard her speak at the International Stroke Conference in Los Angeles kept her on the podium after her talk was over, peppering her with their questions.

Her most notable findings: Using an average of 1.4 passes per patient to remove the clot from a cerebral artery the stentrievers produced good blood flow, TIMI 2 or 3,  in 91% of patient, with hemorrhage occurring in 11% of patients. At 90 days after treatment, 47% had a good outcome, with a modified Rankin scale score of 2 or less, and mortality was 20%. All those numbers were either as good or better than what is routinely achieved with the main clot-removal devices now used, the MERCI clot-spearing device and the Penumbra clot-suction machine. The recannalization rate is better, the procedure time is shorter, the hemorrhage rate about the same.

“The advantage is the stents are very easy to use and they are faster, recannalizing in fewer passes,” Dr. Aleu told me. She said that the self-expanding stent quickly and effectively entangles the clot within its struts so that the clot leaves when the stent is removed.

“Stent retrievers are the next generation of tools,” said the session’s co-chair, Dr. Adnan H. Siddiqui, director of stroke and neurosurgical research at the University of Buffalo. Clot retrieval with an average of 1.4 passes “is incredible,” he said. The approved devices usually require four or five passes. He said that has used one of the two devices now in testing, the Solitaire, on about a dozen patients as part of the 200-patient, U.S.-based  SWIFT trial, which is comparing this stent retriever against the MERCI.  (The other retrievable stent used in Barcelona is the Trevo.) The stent retriever is “more maneuverable and more deliverable” than what’s out there, he told me. And he was thrilled that 47% of patients had good recoveries, with modified Rankin scores of 2 or less.

“The best results now are 40%-45% of patients” reaching this level of stroke recovery. “Fifty percent is the next target,” he said, a goal he hopes will be reached in the SWIFT trial and in other stent retriever studies now underway.

—Mitchel Zoler (on Twitter @mitchelzoler)

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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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A Physician’s New Voice

Dr. Itzhak Brook may have lost his ability to speak normally, but his personal experience with throat cancer and its aftermath has given him a stronger voice than ever.

Dr. Itzhak Brook speaking at a community center in Chevy Chase, Md. / Photo by Miriam E. Tucker

Dr. Brook is professor of pediatrics at Georgetown University, Washington, and a specialist in anaerobic bacterial infections and infections of the head and neck. He was diagnosed with hypopharyngeal squamous cell carcinoma in 2005, despite never having smoked. Surgical removal of the tumor and radiation were initially successful, but 2 years later, the cancer recurred and he underwent total laryngopharyngectomy.

In his new book, “My Voice: A Physician’s Personal Experience With Throat Cancer,” Dr. Brook recounts, in unflinching detail, the 3 years beginning with his diagnosis and culminating in his newfound role as a spokesman bridging the gap between medical professionals and patients with head and neck cancers, particularly laryngectomees.

Being a physician did not prevent Dr. Brook from experiencing the same fears and emotions felt by any patient diagnosed with cancer.  He relates these throughout the book, including his initial “inner prejudice about patients with cancer” dating back to his medical school days decades earlier when the diagnosis meant a near-certain death sentence.

Nor did possession of a medical degree protect Dr. Brook from medical errors. It just allowed him to spot more of them. Indeed, a startling proportion of the book chronicles the numerous errors — of both omission and commission — that he observed during each of his hospital stays. The majority of these — some with serious consequences — would not likely have been detected by patients without medical backgrounds.

Photo by Miriam E. Tucker

Following his radical surgery, Dr. Brook struggled to communicate with busy, overworked physicians and nurses. Describing morning rounds, he writes, “When the surgical team arrived and departed within 2 or 3 minutes without giving me time for follow-up questions, I felt ignored and frustrated … I was also afraid that if I antagonized them, I would receive even less attention.”

But his account isn’t all negative. Throughout the book, Dr. Brook praises the many “compassionate” medical professionals involved in his care — including even some who made mistakes — and documents his personal triumphs and insights in adapting to his new set of realities. He now shares his expertise with fellow laryngectomy patients at the online support community

Before his ordeal began, Dr. Brook had been a worldwide lecturer in infectious disease. Now that he uses a voice prosthesis and speaks in a “rusty whisper,” he’s found a new mission. “My wish is to use this obstacle in my life in a positive way. By lecturing and writing about my experiences and sharing them with other laryngectomees and health care providers I hope that others will learn and benefit from my experience.”

The book  is available in paperback and e-version. All proceeds go to 9114HNC, a fund that grants financial aid to patients with head and neck cancer.

-Miriam E. Tucker (@MiriamETucker on Twitter)

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