As radiologists, we insert catheters to drain collections (commonly the pleural cavity around the lungs). 

Inserting these catheters is usually the easiest part of the process. The difficult part- one that we outsource to nurses- is looking after the tubes. For example, what do you do if the catheter gets stuck, won't flush, bends/kinks or you have to change it because it's infected?

This wonderful article offers up hints and tips on the Art of Catheter Maintenance.

FDA or CE certification is not a seal of quality nor warranty.

In fact, the certification ensures that there is due process and documentation, well documented workflow, and follow up of flaws and limitations, as well as notification process to registered users. 

The certification have no rules on the accuracy or medical usefulness of the software in question. Being FDA certified does not mean that the calculations or results churned out by the program are validated or accurate!

This is very different from the drug certification process where medicines undergo trials before going to the FDA. 

DO not be fooled into thinking that FDA or CE mark approval for software means it's medically accurate.

The Food and Drug Administration issued a communication to alert the public that thermography is not a replacement for screening mammography and should not be used by itself to diagnose breast cancer. 

The FDA says it is not aware of any valid scientific data to show that thermography (when used on their own) is effective as a screening tool for any medical condition, including breast cancer.

The important representative organizations on breast imaging agree with the FDA that mammography is still the most effective method of detecting breast cancer in its earliest, most treatable stages. These organizations include the American Cancer Society, the American College of Radiology, the Centers for Disease Control and Prevention, the National Cancer Institute, and the Society for Breast Imaging.

The FDA expressed concern that women will believe misleading claims about thermography and not receive needed mammograms. 

The FDA's statement can be found here.
The Society of Breast Imaging's statement can be found here.

To learn more about mammography, visit mammographysaveslives.org.

From the New York Times

By NICHOLAS BAKALAR
The technology for measuring the magnetic properties of atomic nuclei goes back to the 1930s. But it took decades for scientists to put it to medical use.

On Feb. 9, 1974, The New York Times reported in its Patents of the Week column that Dr. Raymond V. Damadian, a physician and biophysicist at Downstate Medical Center in Brooklyn, had patented a method for distinguishing normal from cancerous tissue by what was then called nuclear magnetic resonance.

The apparatus was “still under development,” the article said, and it mentioned several other patents recorded that week, including one for a new kind of no-iron all-cotton fitted bedsheet.

On Oct. 12, 1975, The Times described one of world’s most powerful N.M.R. spectrometers, built at Stanford University. The article said nothing about its potential use in medical diagnoses.

On July 21, 1977, Dr. Damadian was in the news again. He had announced a new technique for detecting cancer, using a one-and-a-half-ton, 10-foot-high device equipped with what he called “the world’s largest magnet.” His news release apparently exaggerated a bit, and Dr. Damadian later retracted a contention that his technique had already been used to discover cancerous tissue in a living patient.

By late 1978 other imaging techniques — positron emission tomography (PET scans), computed tomography (CT or CAT scans) and ultrasound — were already being used in humans, and on Nov. 14, the lead article in the first issue of Science Times described the new procedures. Mention of nuclear magnetic resonance was relegated to the last two paragraphs, where it was called “one of the newest methods of imaging, and probably furthest from clinical application.”

But in the early 1980s magnetic scans were being performed on humans, and hospitals had begun buying the devices. As the machines became more widely used, the word “nuclear” in the name frightened some patients with its suggestion that nuclear radiation was involved. An article on March 17, 1985, explained that now most doctors were calling both the procedure and the machines “magnetic resonance imaging,” or M.R.I. It was the first time The Times used the term that is universally accepted today.

On Oct. 7, 2003, The Times reported that Paul C. Lauterbur and Sir Peter Mansfield had won the Nobel Prize in Physiology or Medicine for “discoveries of imaging with magnetic resonance,” in the citation’s words, that “have played a seminal role in the development of one of the most useful imaging modalities in medicine today.” Dr. Damadian took out full-page newspaper ads to complain that he had been unfairly denied the prize.

Philips Healthcare (Netherlands) introduced the Ingenia MR system as the world's first digital MRI. 

What this really means is that the signal digitizer is embedded at the coil itself- which means that the RF signal is immediately digitized at source. Conventional MRI systems carry the signal via copper cables (or even superconducting materials) a few meters to a digitizing box located outside the magnet room.

The result, claims Philips, is up to 40% increase in signal to noise ratio. This results in crisper images for a wide variety of applications in the realm of joint imaging and brain, as well as to support the development of cardiac and body imaging. 

They've also embedded the coil into the scanner, enabling full body coverage for whole spine imaging- which should save a considerable amount of repositioning time. Furthermore, the table the patient lies on is completely movable- so you could have a conveyor belt system of 2 beds interchanging when you have a queue of patients. 

The scanner has a short bore, and a wide aperture (70 cm)- which is right up there with the most advanced commercial systems today. The result is a more comforable scan environment for patients, even those who are claustrophobic.

It's a neat development. See enclosed video.

Philips threw a big party at the Four Seasons Hotel in Singapore to launch the new xMatrix system, and its star, the new X6-1 probe.


The system quite a step in the evolution of "premium ultrasound" (as Philips calls it). There are improvements in workflow, quantification and visualization- driven from upgrades in the IU-22's existing software architecture. The strength of this new system, though, also derives from the amazing X6-1 probe.


It's a phase array probe with 9000+ elements (vs 128 elements on current high end probes), with the capability to acquire volumetric information. Beam steering is electronically driven, and focussing can be performed in both the elevation plane (thickness of the beam) and depth. This improves on the beam uniformity (already very good on the C5-1 probe)- which gives you amazing resolution at different depths.


What struck me was the resolution at near-field (like the anterior abdominal musculature)- which means you can use this probe for musculoskeletal and small parts imaging. You can read a little bit about the system at Philips' website.


You can download my notes from the launch here.

Not very- by the results of some large high profile studies published in the last few months. The most recent study was reported in the New England Journal of Medicine (Sep 23) by a Norweigian group (n=40,075 women) from 1996 to 2005. Apparently, the reduction in breast cancer related deaths is 10%. The scientists found that the rate of death was reduced by 7.2 deaths per 100,000 person-years among those who were screened. The historical screening group however, showed a 28 percent reduction. The rate of death in the nonscreening group was reduced by 4.8 deaths per 100,000 person-years. 



The U.S. Preventative Services Task Force Agency for Healthcare Research and Quality recommended last November that women should start mammogram screening at 50.


Major medical organizations and advocacy groups including the American Cancer Society, the American Congress of Obstetricians and Gynecologists, the Susan G. Komen for the Cure breast cancer foundation have rejected the USPSTFA guidelines and said that women should start receiving mammograms at age 40. 


The issues raised are pertinent, but are also confusing because there really is no better replacement for the mammogram. A lot of us know a friend or a relative in whom early detection with a mammogram allowed a lump to be removed- and it's hard to argue with the power of such an experience. 


Anyway, October is breast screen month- and we should perhaps take the opportunity to inform, and let people decide if they want the mammogram or not. 

ABC World News (9/29, lead story, 2:30, Sawyer) reported that there is more "big news for American women who are so confused and maddened by all of those conflicting instructions on mammograms." Nearly a year ago, "a government panel said women do not need regular mammograms until the age of 50" and just last week, Norwegian researchers attributed modest reductions in the breast cancer mortality rate mostly to better treatments and increased awareness. Now, however, "a major new study says mammograms in your 40s can dramatically save lives from breast cancer."

        Indeed, the "new study has major limitations, and cannot account for possibly big differences in the groups of women it compares," the AP (9/30, Marchione) points out. "Nor does it consider the harm -- such as unnecessary stress, unwarranted biopsies and overtreatment -- of screening women in their 40s." But the "Swedish study appears to be the largest of this age group -- about 1 million women" -- and "'it captures the real-world experience' they have from regular mammograms, said Dr. Jennifer Obel, a spokeswoman for the American Society of Clinical Oncology." Similarly, Harvard's Dr. Daniel Kopans, "an American College of Radiology spokesman, said the study 'should end any debate and end the use of age 50 as a threshold for screening.'"
        The "study's authors include Dr. Stephen Duffy, an epidemiologist at the University of London, and Dr. Laszlo Tabar, professor of radiology at the University of Uppsala School of Medicine in Sweden, who have long been advocates of mammography screening," the New York Times (9/30, A24, Kolata) notes. According to the paper published online in Cancer, investigators "took advantage of circumstances in Sweden, where since 1986 some counties have offered mammograms to women in their 40s and others have not." Specifically, they "compared breast cancer deaths in women who had a breast cancer diagnosis in counties that had screening with deaths in counties that did not," eventually finding that the "rate was 26 percent lower in counties with screening."
        Thus, the authors concluded, "screening mammography saves lives in the controversial 40 to 49 age group but with a relatively high number-needed-to-screen compared with older groups," MedPage Today (9/29, Phend) reported. In other words, "to save one life, 1,250 women would have to be screened every other year from age 40 to 49." The "number-needed-to-screen is the critical issue, according to Jennifer Obel," MD, who speaking in "advance of presentation at the American Society of Clinical Oncology Breast Cancer Symposium." But "mammography has been shown in study after study to reduce the risk of breast cancer in women 40 to 49," she added. What's more, opined "Carol Lee, MD, chair of the American College of Radiology's Breast Imaging Commission," the "benefits far outweigh the potential harms."
        Still, according to HealthDay (9/29, Gardner), "the findings will no doubt do little to quell a controversy that has existed since the 1980s over the value of mammography screenings for women in their 40s."
        And. "critics...noted that the researchers did not provide mortality rates, which made it difficult to compare the results in the two groups of counties," the Los Angeles Times (9/29, Maugh) "Booster Shots" blog reported. "Moreover, they counted only the women who received a diagnosis of breast cancer and died of it but did not compare the broader cancer death rates in the two groups." Reuters (9/30, Fox) also covers the study.

This was all over the newspapers today. The National Cancer Institute released findings from a study attributing about 29000 cancer cases per year to be due to radiation exposure from CT, published in the Archives of Internal Medicine. The 3 commonest cancers to be radiation linked are lung, colon and leukaemia. There's also great variation in the amount of radiation per CT scan.


It still comes back to a risk-reward ratio. If the anticipated benefit from the scan outweighs the risk, then there's medical justification. Even then, the assumption that the scan will be useful should be challenged to see if the scan findings will likely change a course of treatment. After that, we should work to lower the dose to the patient, including scan times- and newer machines are finding clever ways to reduce the increase in radiation exposure.

I think to many radiologists, their protocol is almost sacrosanct. And many good radiologists I know keep an eye out for a phenomenon Dr William Palmer (from the Massachusetts General Hospital Radiology Department) calls "Protocol Corruption". It's when your TR or TE parameters inch away progressively so that the image no longer looks like it's PD or T2-weighted. What does it matter? It matters because protocol corruption is insidious, and you find your reporting accuracy fading away.


At the same time, it's important to stay abreast of new changes in scan parameters- particularly those that speed up the scans. A good example is isotropic intermediate weighted knee MRIs. And so, we almost have to be alert to these changes that only the practitioner can notice, and no one outside the fraternity notices. But it's there if you look hard enough.


So, while protocol corruption is a slow insidious process, a sudden unannounced change in your protocols is more likely to get noticed. Who makes these changes? Typically, your radiographer who thinks he can do it better. I think it takes a degree of trust for this to happen, but drastic changes including slice thickness, resolution and TE weighting especially should involve radiologists. And we give this up if we read outsourced scans.


Be careful: make sure the integrity of the scans are protected, and that you stay on top of developments through some of the best journals in the world.

Sometimes I wonder how the radiology business model, dominated as it is by intermediaries, has put the specialty at a distinct disadvantage in terms of influence on health care decisions. Are radiologists not doctors first? Why have we readily relinquished a clinical role for a laboratory based one? What happened to the aspiring student who did well in exams to get into medical school- because he wanted to be in control of his life?


I think radiology will be a better specialty- defined in terms of satisfaction of practice, and rewards- than it is today if radiologists embrace a clinical role. Talking to patients, clients, customers, and decision makers to raise awareness of this important specialty. It's not about interpreting and keeping images at a museum- it's a constantly changing study of human disease and evolution. There is a story to be told. Tell it.

From Auntminnie.com: The president of teleradiology services provider Reddy Solutions (RSI) of Atlanta was arraigned last week on charges filed by the U.S. government related to alleged "ghosting" activities. Dr. Rajashakher Reddy could face a maximum penalty of up to 20 years in prison and a fine of up to $250,000 if convicted.

Attended a talk on legal issues in radiology by Allen & Gledhill organised by the Singapore Radiological Society and College of Radiologists, Singapore. I tried to take as many notes as I could and put them in a mindmap. 
Here it is!

Cardiologists are increasingly adopting the radial approach for percutaneous coronary interventions. I wonder if the technique will extend to angiography is other parts of the body?


Overview of the technique here.

From the Dalai's PACS blog about competition in radiology outsourcing. Click here. (Once again, dear readers, do not confuse teleradiology for outsourcing. Tele is the backbone for transmission, outsourcing- well that's when someone else does your work for you).


Let us know your comments.

Philips' online learning website offers a variety of courses from the comfort of your home computer.
Here is the link (registration required).