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Leading the News
Researchers Review Nuclear Medicine Studies in the United States and Worldwide
The U.S. National Council on Radiation Protection and Measurements and the United Nations Scientific Committee on Effects of Atomic Radiation have completed two studies assessing all radiation sources in the United States and worldwide. The studies, reviewed in the November 2009 issue of Radiology, found that in 2006, there were approximately 377 million diagnostic and interventional radiologic examinations and 18 million nuclear medical examinations performed. The United States accounts for about 12 percent of radiologic procedures and about one-half of nuclear medicine procedures performed worldwide. The study also found that the frequency of diagnostic radiologic examinations increased almost 10-fold between 1950 and 2006 and that the U.S. per-capita annual effective dose from medical procedures increased about sixfold.
From "Radiologic and Nuclear Medicine Studies in the United States and Worldwide: Frequency, Radiation Dose, and Comparison With Other Radiation Sources"
Radiology (11/01/09) Vol. 253, No. 2, P. 520; Mettler, Fred A.; Bhargavan, Mythreyi; Faulkner, Keith; et al.
Research
CDT Is Effective in Treating PE
Systemic thrombolysis for the treatment of acute pulmonary embolism (PE) carries an estimated 20 percent risk of major hemorrhage, including a 3 percent to 5 percent risk of hemorrhagic stroke. Researchers have found that catheter-directed therapy (CDT), or catheter-directed thrombolysis, is a safe and effective treatment for acute massive PE. The 594-patient study showed that the procedure was life saving in 86.5 percent of the cases studied and had only a 2.4 percent chance of major complications.
From "Catheter-Directed Therapy for the Treatment of Massive Pulmonary Embolism: Systematic Review and Meta-Analysis of Modern Techniques"
Journal of Vascular and Interventional Radiology (11/09) Vol. 20, No. 11, P. 1431; Kuo, William T.; Gould, Michael K.; Louie, John D.; et al.
MRS Used to Diagnose Acute Disseminated Encephalomyelitis
Acute disseminated encephalomyelitis (ADEM) is a demyelinating disorder of the central nervous system. Conventional MRIs cannot always differentiate ADEM from other inflammatory disorders, like multiple sclerosis. Researchers conducted a study to evaluate if longitudinal magnetic resonance spectroscopy (MRS) changes are better able to distinguish ADEM from other inflammatory disorders. MRI and MRS scans were performed on seven patients with ADEM during the acute and chronic phases of the disease, and partial recovery was detected between the acute and chronic phases in choline/creatine ratio. Patients in the acute phase also exhibited major elevation of lipids and a reduction in myo-inositol/creatine ratio, followed by a reduction in lipids peak and an elevation in myo-inositol/creatine ratio during the chronic phase. The researchers concluded that consistent and unique MRS changes in metabolite ratios between the acute and chronic presentations of the disease were found. To the best of their knowledge, these patterns have not been described in other inflammatory disorders and might assist in the early diagnosis of ADEM.
From "MRS for the Diagnosis of Acute Disseminated Encephalomyelitis: Insight Into the Acute-Disease Stage"
Pediatric Radiology (10/21/2009) Sira, Liat Ben; Miller, Elka ; Artzi, Moran; et al.
Technology
Nomogram Accurately Predicts Likelihood of Having Four or More Positive Nodes in Patients With SLN-Positive Breast Cancer
The Katz nomogram has been found to be helpful to clinicians making adjuvant treatment recommendations to patients. This conclusion is based on a review of the records of 309 patients with breast cancer who had undergone an axillary lymph node dissection. The Katz nomogram was effective in detecting several factors that increase the probability of four or more involved nodes, including increased number of positive sentinel lymph nodes (SLNs), increased overall metastasis size, increased tumor size, and extracapsular extension. The negative predictive value for the nomogram was 91.7 percent, and sensitivity was 80 percent. The nomogram was also accurate and discriminating.
From "Predicting Likelihood of Having Four or More Positive Nodes in Patient With Sentinel Lymph Node-Positive Breast Cancer: A Nomogram Validation Study"
International Journal of Radiation Oncology, Biology, Physics (11/09) Vol. 75, No. 4, P. 1035; Unal. Bulent; Gur, Akif Serhat; Beriwal, Sushil; et al.
Medical-Legal Issues
Can Bundled Payments Help Slash Health Costs?
Bundled payments—in which Medicare makes a single reimbursement for all the hospital and physician care for heart and joint procedures rather than making separate payments to the facility and doctors—are seen as a tool for encouraging hospitals and doctors to cooperate to keep down costs and improve patient care. A bundled care experiment is underway at a number of U.S. hospitals in which patients who use the facilities for most heart and orthopedic procedures receive up to $1,157 for participating. The incentive payment is designed to help increase admissions to participating hospitals in the program, and the purpose of the pilot is to test whether paying Medicare beneficiaries from $250 to $1,157 influences their choice of hospitals. The bundled payment system shifts medical charges away from the traditional fee-for-service system that pays providers separately for individual services, which critics say results in physicians and hospitals providing more but not necessarily better care. Undergoing debate in the U.S. Congress is health care legislation that would promote bundling by urging more Medicare pilot projects and permitting Medicare to broaden the concept if they are successful. Infectious disease specialist Larry Martinelli is worried that payment bundling would put pressure on hospitals to try to trim costs by bringing on fewer specialists as consultants.
From "Can Bundled Payments Help Slash Health Costs?"
USA Today (10/26/09) Galewitz, Phil
State to Require OK for Medical Scans
A new program in North Carolina will require brain scans and high-tech body screenings for North Carolina Medicaid patients to be cleared by a private management company. The new system is supposed to save state taxpayers tens of millions of dollars on unnecessary CT scans, MRIs, and ultrasounds. MedSolutions, a private company, will handle most of the North Carolina's Medicaid program's diagnostic imaging services, for a cost of $230 million over two years. Mammograms will not require approval. The contract had not been signed as of Oct. 29, but state officials say that it is essentially a done deal. "We want to provide the highest possible quality medical care that we can, while at the same time be good stewards of taxpayer resources," says Brad Deen, a spokesman for the state Division of Medical Services, which manages Medicaid. "We think we have a way here to reduce costs." Some health care economists have praised the plan as a timely strategy during a weak economy, but the plan has also raised concerns from people who may need scans that could be denied. "What they're being asked to do is make sure people are only getting what is needed and what's medically appropriate," says Sandra Greene, a director of health care economics and finance at UNC Chapel Hill's Cecil G. Sheps Center for Health Services. "When you look at what's driving health care costs over a number of years, one of the areas is imaging." Some estimates place the national cost of medical imaging at $100 billion and rising, and diagnostic tools have become a way to make profits at some doctors' offices, stand-alone clinics, and hospitals. North Carolina's Medicaid program was predicted to spend $135 million next year on radiological scans and $149 million in 2011. MedSolutions will make a profit by keeping the costs of scans under the state's contracted payment, which gives the company an incentive to deny requests. However, the company advertises that its cost savings are achieved by limiting waste and abuse. Many privately insured patients already have to obtain approval before receiving diagnostic imaging. The program is unpopular with the state's radiologists, who worry that MedSolutions will deny needed scans, including repeat images that are necessary when a first round of tests is not sufficient.
From "State to Require OK for Medical Scans"
Charlotte Observer (NC) (10/29/09) Avery, Sarah
Clinical Practice
Air Embolism and Needle Track Implantation Complicating CT-Guided Percutaneous Thoracic Biopsy
Researchers conducted a study to present the details and incidence of air embolism and needle track implantation in patients who underwent percutaneous CT-guided thoracic biopsy. The researchers reviewed 1,400 percutaneous CT-guided thoracic biopsies that took place between August 2003 and August 2008. Any case with air embolism was considered to be a patient with hypotension during or after their biopsy and with an air embolism confirmed on CT. A needle track implantation was considered to be a mass in the needle track on the postbiopsy follow-up CT. The researchers found that there were three cases of air embolism, or 0.21 percent. Air embolisms were confirmed in the left ventricle, coronary artery, ascending aorta, and pulmonary vein, with the pulmonary venous wall being pathologically identified in one case. While there were no fatalities, two of the patients required resuscitation. In one case, left hemiplegia occurred but eventually disappeared. There were four cases, 0.56 percent, of needle track implantation in 713 pathologically proven malignant thoracic biopsy cases with follow-up CT scans. Two of the cases were primary lung cancer and the others were lung metastasis, specifically renal cell carcinoma and osteosarcoma. Implantation was discovered four to seven months after the biopsy, with the size ranging from 2.5 cm to 5.6 cm. The researchers conclude that the incidence of air embolism with clinical symptoms and needle track implantation complicating percutaneous thoracic biopsy is more frequent than previously reported.
From "Air Embolism and Needle Track Implantation Complicating CT-Guided Percutaneous Thoracic Biopsy: Single-Institution Experience"
American Journal of Roentgenology (11/01/2009) Vol. 193, No. 5, P. W430; Ibukuro, Kenji; Tanaka, Rei; Takeguchi, Takaya; et al.
High-Definition Colonoscopy Detects More Polyps
A study of high-definition (HD) colonoscopy conducted by Mayo Clinic researchers has determined that the technique is more sensitive than standard colonoscopy in identifying polyps that could become cancerous. "There hasn't been a definitive trial to see whether high-definition colonoscopy detects more polyps or not, and this was a natural experiment, designed to ask if use of one endoscope or another makes a difference in day-to-day clinical practice," notes senior investigator Michael Wallace, MD. "Based on these results, it appears that high-definition colonoscopy detects more precancerous polyps." Wallace says that an HD endoscope employs both an HD video chip and HD monitors that amplify the image's resolution. "There was a natural randomization of patients to either standard or high-definition endoscopes, and physicians were not able to cherry-pick their patients," he points out. "No doctors used high definition more than any other and, in this way, you can eliminate most of the variables that can bias results of a clinical trial." The rate of detection of adenomas was 29 percent among patients scanned with HD endoscopes, compared to 24 percent for those scanned with standard endoscopes. "While that may seem small, in light of the 14 million colonoscopies that are performed each year, even small differences add up to important improvements," Wallace says. The study's findings were presented at the yearly conference of the American College of Gastroenterology in San Diego on Oct. 28.
From "High-Definition Colonoscopy Detects More Polyps"
Newswise (10/28/09)
Age and Gender Useful in the Identification of Patients Who Could Benefit Most from CTA
Researchers attempted to identify the age- and gender-specific subpopulations of patients with acute chest pain in whom coronary computed tomographic angiography (CTA) will yield the greatest diagnostic benefit. In order to determine these subpopulations, researchers performed CTA on patients with acute chest pain and inconclusive initial evaluations. Of 368 patients, 8 percent had acute coronary syndrome (ACS). The presence of significant coronary stenosis on the CTA increased with age for both men and women. Furthermore, in these patients, coronary CTA led to restratification from low to high risk for positive findings on CTA or from low to very low risk for negative findings on CTA. In contrast, a negative result on CTA did not result in restratification to a low-risk category in women under age 65 or men under age 55. Based on these results, the researchers believe that men over age 55 and women over age 65 would benefit most from CTA.
From "Usefulness of Age and Gender in the Early Triage of Patients With Acute Chest Pain Having Cardiac Computed Tomographic Angiography"
American Journal of Cardiology (11/09) Vol. 104, No. 9, P. 1165; Bamberg, Fabian; Truong, Quynh A.; Blankstein, Ron; et al.
RSNA Weekly is a briefing of the latest radiology-related news selected from hundreds of sources by the editors of Information, Inc. While care is taken to use good sources, inaccuracies in source material are not the responsibility of RSNA or Information, Inc.
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