Molecular imaging outlook

A new set of articles related to molecular imaging, published by Diagnostic Imaging on a regular basis, is just out.

These articles examine a fascinating range from near-infra red (NIR) imaging for breast cancer and rheumatoid arthritis, to USPIO imaging & hyperpolarized C-13 imaging with MRI and of course some aspects of PET imaging with tracers other than FDG.

These are some of the procedures that we will be conceivably performing in the future and it makes sense for the time being, to at least know that they exist. And for those who would love to do research in these fields, these are nascent technologies just waiting for people to make their name in.

In-flight radiation risk...we may be asked this question by patients

There is a recent news report based on an article in Obstet Gynecol regarding the risk to pregnant women of in-flight radiation.

In brief, the risk is negligible. Though the amount of cosmic galatic radiation that travellers are exposed to during flights, is more than at ground level, it is not considered significant enough. They do make a mention of being more careful during solar flares when background radiation activity can be many times higher.

The risk to frequently flying in-flight personnel such as stewardesses, air-hostesses, pilots etc is not known, but needs to be considered.

Just a caveat. When asked about the risk of radiation from a bone densitometry scanner, we have always been saying that it is lesss than the radiation you would get from a round-trip flight between Mumbai and Calcutta (extrapolated from a Hologic statement that mentioned a transcontinental flight in their literature). This normally allays the fears of women who come for DXA scans (since many of them are highly aware of these issues)...though I am sure they have no idea about in-flight radiation issues.

Hospital administrators

This is what hospital adminstrators are generally like. Its amazing how often Dilbert gets it just right.

But interventional radiologists do need to be careful about their eyes

A paper presented during the Society of Interventional Radiology (SIR) meeting in March 2004 has been reported upon by RSNA News this month. It talks about the increased incidence of posterior subcapsular cataract formation in interventional radiologists and the need for better eye protection to prevent this from occurring.

Fibroids...hot news for radiologists

Fibroids are in the news these days for radiologists. Apart from the fact that they provide bread and butter imaging for ultrasonologists, the treatment of fibroids is also coming into our domain.

Uterine fibroid embolization is increasingly becoming one of the most common interventional radiology procedures being performed by interventional radiologists. Unlike vascular intervention, the only turf battle here is with the gynecologists who treat them either with laparoscopy or open surgery. As awareness of the ease and usefulness of this procedure increases, it is likely that more and more patients will be referred or may refer themselves to interventional radiologists. It is unlikely that gynecologists will ever start performing embolization. This is one area that interventional radiologists need to target very aggressively.

Another treatment method that may become popular in the future is the use of focussed high-energy ultrasound treatment guided by MRI imaging. This has been developed by an Israel company called Insightec in conjunction with GE. It is likely that this technique may receive FDA approval in the near future. This may be a boon for MRI centres willing to perform this procedure as a therapeutic alternative to both embolization and surgery.

And for either method, if marketed well, there is no dearth of patients....

4th AUC - registrations are finally closed...whew! One more in December.

Yesterday we finally closed registrations for the 4th AUC. Just before closure, the 36th registrant mailed us his completed form. The last four seats have been taken up by GE for their 3D ultrasound customers, since the majority of programs left are 3D based.

The list of registrants is up here.

We are still getting calls for registration. Many people are still in the process of receiving their brochures by mail and cannot believe that the registrations are already over. We have been explaining to all those who call that the online community will always get a 10 days to two weeks' head start over those who register only through "paper" mailers. Hopefully more people will try to register online for the next course.

The next course will be in the middle of December and we will open registrations in the last week of October.

An apt Dilbert strip

Never trust colleagues or business people who offer to buy you a free lunch.

As a corollary, never get drunk during a conference banquet. The consequences are always disastrous.

Exercise is better than intervention in patients with stable coronary artery disease

This is a landmark article published in Circulation recently. It shows that in patients who have stable, single vessel coronary artery disease (CAD), with minimal symptoms, without a history of acute coronary syndrome, MI, ejection fraction < 40%, left main stem block or a high-grade proximal LAD stenosis, an exercise regimen that reaches the target heart rate for 20 minutes every day is better than stenting.

This should give many radiologists who are planning to perform CT coronary angiograms a little food for thought. If patients and their treating physicians start adopting this protocol, then it stands to reason that these patients will be followed up using CT coronary angiography and not catheter angiography.

The use of statins has also been previously shown to be as good as intervention in this sub-group of patients. It is possible that a combination of statin therapy, vigorous exercise in motivated patients and other life-style changes would obviate the need for any kind of intervention in this subgroup of patients.

Vascular calcification on mammograms

There is a new report in the May issue of Journal of Women's Health that shows that there is an increased risk of an adverse cardiovascular outcome (stroke, heart disease) with increased breast calcification detected on a mammogram.

This is a retrospective study and the authors, Irribarren et al have made a case for a new prospective study to further evaluate these results. There is a longer discussion of this article at Aunt Minnie as well. The article is also available as a free full-text .pdf file.

The question that comes to mind immediately is whether we need to report these calcifications and if so what weightage to give them and whether a disclaimer needs to be added to the report regarding their prognostic significance. My feeling is that we may have to wait for some more data to do this.

We are not alone with a mess of an anti-abortion law...

In the US there is a law that prevents dilatation and evacuation in the 2nd trimester. The Bush administration pushed it through in November last year. Yesterday, in California, this law was overturned by a judge on the grounds that it infringed on the rights of a woman and was medically a necessary procedure given the correct indications. Doctors had started become apprehensive about carrying out this procedure, as the penalty for "partial-birth abortion" (as the procedure was labelled by the Bush administration) was a prison sentence of two years.

There are similar law suits against this Act in Nebraska and New York, which will probably yield similar judgements.

At least there is debate and people are trying to work things out, unlike in our country where things are just foisted on us. Things have become so bad that I've been advised not to even mention the act by name or to say anything about it, because the authorities are just waiting to swoop on radiologists/ultrasonologists at the slightest excuse.

4th AUC registration problems...still going on

Somehow the problems with registration just don't seem to end. The instructions are explicit and written down in detail, both on the site as well as in the mailer. Yet, people are sending drafts, cheques and cash or calling up to provisionally register without bothering to check on the website what the current status is. When we finally tell them that of the 8 sessions, 5 are 3D USG based, its only then that they finally back out. On top of that, two prospective delegates just sent in their registrations electronically without selecting a single program. What are we supposed to do with that? At last count, more than 40 radiologists have sent in registrations since we started three weeks ago, without bothering to follow up with payments - its just so much extra effort to keep track of all these potential registrants.

Wipro GE will probably wrap up the remaining five registrations this evening, so that we can finally close registrations for this conference and concentrate on getting patients, volunteers, etc for the workshops and make this a memorable event.

We are also very sure that we will repeat this program in December, with a few changes to make the selection of sessions better. This will probably be in the middle of December and as we did this time, online registrations will start at least two weeks before the mailers go out. As far as we at REF are concerned, anything online will always get first preference.

4th AUC - registrations almost over....and about ultrasound groupies

Since the time the brochures have started reaching radiologists, we've had a chaotic time the last couple of days. Radiologists have sent in money and then called in to register, since many don't have online access. The choices available now have reduced considerably and it's been taking quite some time to sort out the registrations.

We started online registrations about two weeks before we sent off the mailers, precisely because we anticipated this kind of a problem and wanted our online subscribers to have first shot at registration. The first 25 odd registrations went off reasonably peacefully.

Currently only 5 registrations are available, mostly for 3D-related topics. We will in all probability be closing registrations today.

Funny things happen. One radiologist kept insisting for an explanation as to why we were restricting registrations to only 10 per program, when in Delhi they had unlimited numbers. It is only when I asked him as to how he expected the speaker to help more than 10 radiologists scan in 2 hours, did he stop. And moreover, we don't owe anyone any explanations. Many radiologists have not bothered to read the instructions and keep asking why we have only 10 radiologists for each "lecture". We have to spend at least another few minutes explaining that there are no lectures, just "hands-on" sessions. One radiologist told us that it didn't matter what he registered for currently, because eventually he was going to armtwist Wipro GE and attend exactly what he wanted to. I wonder how he thinks he's going to be able to do that.

I wonder why ultrasound conferences and meetings provoke such reactions. There are enough programs now being held, from the annual conferences, to CUSP, to the IFUMB meetings, to regional and local conferences.... And yet, whenever an ultrasound conference is announced, people behave like lemmings. And if they can't get in, its as if the world has come to an end.

I remember during the last conference in Hyderabad, there was a bunch of ultrasound groupies that went from session to session to attend only the ultrasound lectures. As soon as the ultrasound lecture was over, they would leave en masse, disrupting the next speaker's lecture. The session to which they went next was also disrupted, during the time it took for them to settle in. And the room would suddenly be filled beyond capacity. In all national conferences, with parallel sessions, ultrasound lectures should be held separately, in the largest hall available, to accomodate the ultrasound fans, so that the rest of the sessions can also be conducted without disruption.

One more contraindication for MRI?

There have been reports coming in of first and second degree burns with transdermal patches of various kinds. Dr. Frank Shellock has also tested a few of these and mentioned them at www.mrisafety.com.

Over the past few years, many issues with respect to metalllic implants, etc. have been sorted out. Currently as we know, except for rare cases of moving metallic bodies (pellets, bullets, etc) and electromechanical devices (e.g. pacemakers, cochlear implants), which if they stop can kill or severely affect an individual, there are no serious contraindications to the use of MRI.

Now we need to start asking patients about the presence of patches and especially if they contain metal or aluminium foil, it may become necessary to get the patch removed prior to performing an MRI examination.

Nailed

Two extremely interesting skull radiographs have been posted here, of a man who was accidentally hit by a nail-gun. The nails went into his skull and cervical spine.

The worst similar trauma that I remember was a tooth-brush that went into the skull of a patient through the nose. The radiograph was a big hit at the time and was eventually put in the KEM film archives...I wonder if it's still there.

Anyone's seen anything better...worse...

Calcium scoring at "Indian" rates in the US...what's next!

Two new hospitals in Wisconsin are offering "heart scans" (i.e. calcium scoring) at prices of 99$ and 49$ respectively. This has made the news in two separate reports in the lay press. Click here and here to read them.

Calcium scoring in India costs around Rs 5000, i.e. 110$ or so and to be able to do it at such a low cost in a country such as the US where healthcare costs are skyhigh, is amazing. Of course, when you read the articles in more detail, it is apparent that these are marketing gimmicks to get patients coming into the hospitals, both of which are "cardiac" hospitals. Abnormal calcium scores can serve as a basis for further testing, which can then generate more revenues.

This also makes sense in a setting where calcium scoring is not reimbursed by insurance. In situations where patients have to pay for the services directly, it is unlikely that they will fork out large sums of money for screening tests. Though we've heard in the past that people were paying upto 1500$ for "whole body" CT screening, these businesses are now failing and the whole CT screening industry in the US is on oxygen.

In our country, whole body screening has never taken off. There are many reasons, but the prime one seems to be that no one has actually tried to market it aggressively. Moreover bypassing referring doctors and going directly to patients, is not an easy task especially for service providers such as radiologists and pathologists.

Even calcium scoring has not really taken off and it does not seem that it will become very popular in the near future. The main reason for this now seems to be that if we can perform CT coronary angiograms well with 16 and 64 slice scanners and a calcium score is thrown in anyway, it makes no sense to perform just calcium score studies.

8th Residents Review Course

The program for this is now slowly shaping up. It will be held from 14-18 October, at KEM Hospital, Mumbai. We hope to have the program and registration details up by next week, so that, unlike last time, there is enough time to plan everything.

We are planning a few changes. We hope to have a residents' paper presentation session and we'll have the details up as well. If anyone has any suggestions, it would be great to read them.

We are also toying with the idea of having an online preliminary round for the quiz. There are many logistical issues involved with the implementation of such a project, but if we can get around them, we might actually do this as well.

Just like last time, there will be no mailer and all details will be distributed only online.