Arthroscopy versus sham

These are the kind of studies we need more off. Clearly, when the same was done for vertebroplasty versus sham, it raised the hackles of everyone in the radiology world, because two independent studies showed that vertebroplasty was no better than a sham procedure. Of course that controversy in no way seems to have dampened the use of vertebroplasty.

This week’s NEJM has an article that discusses the value of arthroscopic surgery for meniscal degeneration in patients with osteoarthritis and finds the results no better than sham surgery. We already know this intuitively and from anecdotal experience and this is one of the reasons not to overcall meniscal degeneration as tears to prevent unnecessary arthroscopic exploration of frankly osteoarthritic knees.

Thyroid Ultrasound Criteria to Diagnose Possible Malignant Tumors

There are so many important articles that do not get published in the radiology literature.

The recent issue of JAMA Internal Medicine has an article by Smith-Bindman R et al that discusses how to use thyroid USG signs to decide which nodules need to be biopsied.

Three criteria are important – microcalcifications, completely solid appearance and size greater than 2 cm. If we stringently follow the rule that at least two of these criteria have to be present before performing thyroid nodule biopsy, then the sensitivity would be reduced but with a high positive predictive value, but without compromising the ability to pick up malignancy. It is worth reading the article to understand the importance of large population based studies to help us use our radiology signs to better triage patients.

 

Moderate Sedation by Radiologists

There is a review article in in the November issue of the AJR by Olsen et al, discussing the various types of sedation and options available if radiologists want to perform their own analgesia, especially when it comes to moderate sedation (earlier called conscious sedation). This article is predominantly aimed at North American radiologists and specifically the context of their practice.

While I used to deliver moderate sedation on my own up to a couple of years ago, especially in patients who needed bone biopsies, I now no longer do so myself. I always have an anesthesiologist stand-by, simply because delivering and monitoring of the sedation adds another layer of stress and actually affects my ability to perform the biopsy / procedure optimally. If there is an adverse event, again, it is better to have another pair of experienced hands that can take the load off your back and allow you to focus on more important things.

Sub-centimeter Lung Nodule Biopsies

This article from the November issue of the American Journal of Roentgenology discusses the results of 305 CT guided core biopsies / aspirations of small lung nodules, less than 1.0 cm in diameter, over 13 years.

The only major variable that decided success was aspiration instead of core biopsy.

I have been very clear about doing core biopsies for lesions in the body as against FNAC / aspiration for many years now. Tissue today is needed for so much more than just establishing a diagnosis that if we are going to put a needle in the lungs, or other parts of the body, it would be a travesty to come away with only cells, without tissue.

Here is an example of a 7.5 mm lung nodule biopsied earlier this year that turned out to be tuberculosis on histopathology.

Biopsy of 7.5 mm lung nodule

Biopsy of 7.5 mm lung nodule

Does it work!

In a recent issue of JAMA, there is an editorial of whether injection therapy for low back pain works. An evaluation of previous randomised trials and a meta-analysis shows that there is no clinically significant evidence that this works. And yet, we have an entire new field of pain management populated by anesthesiologists in particular but also radiologists and orthopedic surgeons, who specialise in injecting into the epidural space, facets and foramina. A cursory Pubmed review will show a large number of articles on this subject discussing technique and the value of one particular steroid over another….when in reality the efficacy of the very concept of injecting in the spine for pain management is questionable.

This is similar to the vertebroplasty controversy that still really hasn’t died, but for all practical purposes has been subverted by those who practice vertebroplasty so that the procedure can continue to be used across board.

The New York Times last week published a blog based on a recent article in the Mayo Clinic Proceedings that showed how doctors continue to use procedures and therapies that may be ineffective or may even harm patients. This is either due to ignorance or inertia, but in the period that the practice continues, harm continues to be done.

While all of us itch to “do something” each time a patient has a problem, we should constantly be asking ourselves, whether the procedures we perform and the therapies we use, actually work!

The Vanishing Art of Clinical Science – Hyposkilia

This has been written by Dr. Anisha Sawkar Tandon, a consultant radiologist at the St. John’s Medical College, Bengaluru. You can reach her at anisha.sawkar at gmail.com

I am a practicing radiologist. Over the past few years I have noticed a disturbing trend that threatens to destroy the very nature of medicine. I have been witnessing increasing referrals for radiological investigations even before a clinical history has been taken. We radiologists are familiar with the experience of having to report radiological studies with absolutely the bare minimum clinical history or the complete lack of it. But what has begun to shake me to the core is the fact that even when I have gotten back to the referring clinician for more information, there have been innumerable instances where they simply do not know more just because they have not really talked to the patient in detail, leave alone examined the patient.

Here is an example of one of the situations that I was confronted with when reporting an MRI of the brain of a 58-years old lady who was sent from the emergency department. The referral form mentioned, “Rule out cerebral venous thrombosis (CVT)”. These were the only words of “history” provided. The MRI brain not only had no signs of CVT, but there were some symmetric basal ganglia changes that favored a metabolic encephalopathy, likely related to chronic liver disease. Since the Emergency department is easily accessible with a phone call, I could immediately contact them and ask for more details.

At first, since their question was “rule out CVT”, I attempted to elicit some history related to CVT. The disturbing answer that I got was, “The patient basically has altered sensorium and since CVT is one of the conditions that could cause CVT, we just wanted to rule it out!” I tried to find out more about the altered sensorium and the information I got in response was, “She basically looks like a psychiatric case and also has diabetes and hypertension”. After obtaining this invaluable information, I explained my findings and requested them to assess whether the patient had some form of liver dysfunction since the findings were definitely “metabolic” and not “psychiatric”.

These events had occurred at 6 pm in the evening. The next day, when I decided to follow up on what had happened to my patient, I found this sequence of events that had unfolded after my MRI brain report. The patient, had, at 7 pm undergone an ultrasound of the abdomen, which showed cirrhosis of liver with portal hypertension and ascites and suspicious nodules in the liver. At 8 pm, the patient had undergone a CT scan of the abdomen that confirmed the cirrhosis with regenerative nodules, portal hypertension and ascites. Meanwhile the results of the liver function tests showed findings consistent with chronic liver disease and the patient was known to be HbsAg positive for 5 years. The next morning, a clinical examination by a gastroenterologist and neurologist concluded that the patient was, in fact, in hepatic encephalopathy.

If you analyze this case, it worked out beautifully for the radiologist. What else could a radiologist ask for? An MRI brain, an ultrasound abdomen and a triple phase CT scan of the abdomen in one patient in one evening! What about the patient though? It’s scary to think that not one, but all of the above investigations could have been avoided by just basic history taking and an adequate clinical examination.

I understand that in a busy ER, not every patient with altered sensorium is going to undergo a 30 minutes detailed neurological exam, but a 30 minutes exam wouldn’t be needed if the simple task of talking to the patient had been accomplished which would have brought out the known Hepatitis B status. Whenever I see this kind of situation, I am appalled at what medicine has come to. There are so many more such instances in which an ultrasound of the abdomen is the first time that a large laparotomy scar has been noticed, or an MRI brain study is the first time when a craniotomy has been discovered and the referring clinician has had no knowledge of the same. It’s a different situation when such cases have been directly referred by some remote village primary health center “(PHC) and then perhaps the lack of knowledge by the referring physician can be overlooked. But it’s acutely disturbing when these cases are referred by our own colleagues, specialists in their fields and the first person to touch the patient’s hurting abdomen is a radiologist.

As a radiologist who wishes her field to thrive, I should have no cause for complaint. But as a doctor and a clinical radiologist, I am concerned about the kind of medicine we practice today, where the end result is unnecessary investigations and ultimately a burden on the patient and the system.

I would like to end by quoting Sir Robert Hutchison who said the following words, which sadly are very pertinent today

“From inability to leave well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense, from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.”

Why did the Potter’s Hand shake?

One more piece from Dr. Akhila Prasad, Sr. Specialist, Dr. RML Hospital, New Delhi that makes her think. You can reach her at akhil43 at yahoo.com. She earlier wrote the piece, “The Physician Buried Inside the Radiologist”.

 

A vessel of more ungainly make…

What! Did the Hand then of the Potter shake?

The Rubaiyat of Omar Khayyam.

 

Who among us radiologists, are not familiar with the sickening, sinking feeling we get when we are scanning a blissfully, happily pregnant woman’s abdomen and the various shades of grey slowly reveal to us, “Yes! The Potter’s Hand must have shaken while making this pot!”

This is about the number of times we have diagnosed some form of congenital anomaly on an antenatal scan! The mother is smiling and looking at us in anticipation, often in a blissfully ignorant, content state, lying in front of us, so trustingly exposing her pregnant belly carrying that magical life inside her!

We have to continue to maintain a poker face as if nothing is amiss and everything is fine and first try to figure out what the hell is happening on the screen, and having quickly figured out how the Potter’s Hand shook and having frozen all the shakings into eternity (images), comes the next issue of how to tell, what to tell and how to manage the patient!

Sometimes the patient guesses even before we say something, our body language perhaps or the facial expression or her own intuition…or the number of postgraduate students excited beyond imagination at the unimaginable cosmic mistake in front of them!

Thoughts of all kinds, all at the same moment, fleet past in our minds…to err is human, but here is where the Divine seems to have erred! Is it possible? How? But the results are in the front of us on the screen! “What was that unborn child’s fault dammit!” you ask yourself. It has not even come into this world yet, or committed any mistake and it has had to pay…like this?” your brain argues. “Karmic”, the word echoes somewhere in your brain, a general one-stop shop answer to every Indian problem! “Whose Karma?” immediately your brain asks. “The unborn body? Or the unborn soul? Or the previous birth body? Or the previous birth soul??…you don’t have any answers!

And by that time anyway you have more pressing problems at hand to handle! To handle the patient at hand! To handle her mother or husband standing next to you! To gently reveal to them that something is wrong! God forgot to put a head! Or He shortened a couple of limbs! He decided to put the baby’s abdomen into the chest! God!!! What do you say? How do you say it? And why doesn’t it get easier over the years? Why is it as troubling and as painful each time? And the irony is that despite what you feel inside, you automatically tend to stick to your professional training and duty and deal with it as if it is perfectly normal to have an abnormal unborn child. And so you write out the report and say, “Next!”

This brings us to one more core issue in our training. We must drill it into every resident’s head to mentally and morally treat every obstetric ultrasound after the relevant period of gestation, as a Level II study! The patient has come to us at this instance for a scan, after fighting God knows what odds and under what difficult circumstances. It does not matter whether the ultrasound form or receipt says, “Level II”! We have to scan her child head to toe, no matter what the form says, no matter whether it is her nth ultrasound…it has to seep into our very being, that we have to quickly and systematically declare normalcy or detect anything abnormal. The mother and the child both deserve that!

Managing a Pneumothorax – The Fear is Mostly in the Mind

Two weeks ago, in Beirut, I was speaking on the impact of modern imaging in pulmonary medicine, to a group of chest physicians from Egypt. The moment I started speaking on CT guided lung biopsies, a physician got up and started talking about the dreaded risk of pneumothorax. I have had similar reactions in other towns in India, including tier I cities like Delhi.

I explained to him that while a pneumothorax is not uncommon during CT guided biopsies, there are many ways to mitigate its seriousness; single puncture, minimal trauma, bleeding along the tract during withdrawal and arguably puncture side down for a few minutes are measures that reduce the severity and incidence of or prevent the occurrence of pneumothorax.

But even if a pneumothorax does occur, it is a slow event that takes its own time to increase, if it does. If a pneumothorax occurs during the procedure, it can be aspirated at the same time and more often than not, that cares of the problem and we can even continue with the procedure (Figure 1). In case the pneumothorax occurs after we have washed out as a delayed complication, then we can still aspirate it using an over the needle catheter. A recent video describing this procedure has been posted on The New England Journal of Medicine site. While this video shows the technique to be used in patients with spontaneous pneumothorax and describes a blind approach, we can use this simple procedure to aspirate under CT guidance as well and then check the status immediately on the CT scan table.

A and B show the start of a CT guided core biopsy of a subpleural nodule using a coaxial system. Since the nodule is immediately subpleural, the risk of pneumothorax is slightly higher than for a deeper nodule and C shows the developing pneumothorax. In D, the canula has been withdrawn into the pleural space and the pneumothorax was aspirated. E shows the biopsy continuing after the pneumothorax has been aspirated. It did not recur. Five minutes after the procedure, a scan in the supine position (G) shows a thin residual pneumothorax that was non-progressive.

A and B show the start of a CT guided core biopsy of a subpleural nodule using a coaxial system. Since the nodule is immediately subpleural, the risk of pneumothorax is slightly higher than for a deeper nodule and C shows the developing pneumothorax. In D, the canula has been withdrawn into the pleural space and the pneumothorax was aspirated. E shows the biopsy continuing after the pneumothorax has been aspirated. It did not recur. Five minutes after the procedure, a scan in the supine position (G) shows a thin residual pneumothorax that was non-progressive.

In the worst case scenario, an interventional radiologist should be able to put a tube in as well, despite the fact that the need to do this would be very low in experienced hands.

When Procedures Make Intuitive Sense, Despite the Data (or Lack of)…About IVC Filters and Vertebroplasty

Today’s (April 08, 2013) issue of JAMA Internal Medicine brings forth a new controversy regarding another common and popular interventional radiology procedure  – retrievable IVC filter placement.

A review of data in a new retrospective study on the efficacy of IVC filters, has shown that there is only one randomized control trial published in 1998 that showed a reduction in the rate of symptomatic pulmonary embolism in those with filters but with no significant long-term difference in the death rate at 8 years and with an increase in the rate of deep vein thrombosis in those who had filters.

This new retrospective study published in JAMA Internal Medicine concludes, “that the use of IVC filters for prophylaxis and treatment of venous thrombotic events, combined with a low retrieval rate and inconsistent use of anticoagulant therapy, results in suboptimal outcomes due to high rates of venous thromboembolism”

Another study in the same issue discusses the differing rates of use of this technique in California, the main factor being the particular hospital that is providing care. The Society of Interventional Radiology guidelines [4] for the use of an IVC filter list four absolute indications – “recurrent VTE (acute or chronic) despite adequate anticoagulation, contraindication to anticoagulation, complication of anticoagulation, inability to achieve/maintain therapeutic anticoagulation”.  However there is a long list of relative indications with little consensus and that is where there is significant variability, depending on the aggressiveness of the program.

It happened with vertebroplasty when two studies by Kallmes et al and Buchbinder et al, comparing sham procedures with actual procedures showed no significant difference in pain scores between the two groups at all time points. This kicked up a huge storm in the interventional radiology and spine communities, but also forced us to examine our data more objectively and spurred more hospitals and groups to perform their own double-blind control studies, a few of which like the Vertos II trial, have shown that vertebroplasty is better than controlled medical treatment, though there has been no comparison with sham procedures since the 2009 studies.

We all want to believe that “doing” something that is intuitive (cement in an acute fracture, IVC filter stopping downstream emboli) has to help, just like Dr. Zamboni’s belief in treating patients with multiple sclerosis by dilating areas of venous narrowing because of the theory he ascribes to that chronic cerebrospinal venous insufficiency is the cause of multiple sclerosis.

Procedures sometimes quickly become mainstream without data, simply because “they make sense”. Cardiac CT angiography found adopters in patients and celebrities like Oprah Winfrey, simply because it made sense to see the coronary arteries without a catheter, despite the lack of any kind of initial data.

In the end though, we as radiologists need to create compelling stories for the use of techniques, modalities and procedures by making sure that there are enough controlled studies that demonstrate efficacy and safety.

Hopefully in the near to medium future, there will be more date regarding the efficacy (or not) of IVC filters that will clear the air and help patients and the treating doctors make better decisions.

Persistence Pays with Hard Bones And Nuts

This story has been contributed by Dr. Argha Chatterjee, a third year PG in the department of Radiology at the Medical College and Hospital, Kolkata, after reading the earlier post on Tea and Fluorosis and in the spirit of this blog.

In his words…

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This is the story of a 28 year old gentleman, who presented to the general medicine out-patient department (OPD) with stiffness in both knees and spine for 2 years. He could not walk and was carried to the OPD by his neighbour. His knees were fixed at flexion and he had significant kyphosis. The doctors at the medicine OPD saw his knee radiographs done elsewhere, which showed gross osteopenia and a coarse trabecular pattern. The patient was admitted and radiographs of his knees, pelvis and lumbosacral spine were performed in our department.

A medicine post-graduate trainee (PGT) took away the “wet” films (it was a digital radiograph, so not really “wet”) and so it never came to us for reporting. After two days the radiographs were brought to our department by another medicine PGT. They were obviously confused because the pelvic and spine radiographs showed marked high bone density. They thought ofosteopetrosis but could not explain the osteopenia in the knees. They wanted to know what sclerosing bony dysplasia can cause both. In the meantime, the history had already taken a back seat.

What I saw was grossly increased bone density in the pelvis and lower lumbar spine associated with calcification and, at places, ossification at the ligamentous attachments (Figure 1). The knees showed osteoporosis, especially in the lower end of the femur (Figure 2). Calcification of the obturator membranes was present (Figure 3). There was coarsening of the trabeculae in all the visualised bones. Now, this is supposed to be a long case in the MD examination. So I said, “This is fluorosis.”

Frontal radiograph of the pelvis shows increased bone density and calcification at the ligamentous attachments (arrowheads).

Frontal radiograph of the pelvis shows increased bone density and calcification at the ligamentous attachments (arrowheads).

Frontal radiographs of both knees (fixed at flexion) show coarsening of the trabeculae and osteopenia at the lower ends of both femora.

Frontal radiographs of both knees (fixed at flexion) show coarsening of the trabeculae and osteopenia at the lower ends of both femora.

Oblique radiograph of the pelvis shows obturator membrane calcification (arrow).

Oblique radiograph of the pelvis shows obturator membrane calcification (arrow).

The PGT was not convinced. He argued for ostepetrosis. I countered that this was not dysplastic bone because the trabeculae were coarse; moreover the osteopenia and joint stiffness could not be explained by a dysplasia. He argued about the presence of coexistent osteopeia? I explained to him that osteoporosis is a known and important feature of skeletal fluorosis. In fluorosis, there is increased bone turnover. So initially there is high bone density (phase I) but later on, the long bones develop osteoporosis (phase II). He asked, “Isn’t there interosseous ligament calcification in fluorosis?” I pointed out the obturator membranes (Figure 3) and lesser trochanters. He said that his boss was not going to be convinced by just that. I agreed to arrange for a forearm radiograph free of cost.

The next morning I visited the patient’s bedside after reading up the clinical features of fluorosis. The patient had every feature. The stiffness started in the spine until he was finally immobile from knee stiffness. The PGT was there with a grin on his face. He said, “This is not fluorosis. The patient has no dental changes. I checked.”  I said that dental fluorosis occurs only when patient is exposed to high fluorine levels during the pre-eruptive stage of teeth. Then he dropped the bomb. “He is from Serampore, Hoogly!” Now this one floored me. The districts of West Bengal endemic for fluorosis are Purulia, Birbhum, Malda, Dinajpurs and South 24 PGs. Not Hoogly. I anyway asked for the forearm radiographs which were done later that evening. The forearm radiographs were classical for fluorosis (Figure 4).

Frontal radiographs of both forearm show classic interosseous membrane calcification (arrows).

Frontal radiographs of both forearm show classic interosseous membrane calcification (arrows).

Nevertheless the medicine unit did become serious about the diagnosis of fluorosis. A urine fluoride was done within the coming week but surprisingly it was normal. I thought my spot diagnosis was slipping away. About 2 weeks later, I met the same PGT in the canteen. I asked him about the case. He said a drinking water sample from the patient’s home was tested in a lab at Jadavpur University. The fluorine level was 2.5 mg/litre (WHO guideline value is less than 1.5 mg/litre). “The urine level?”, I asked. He told me that if a person is more than three weeks away from exposure, then the urine level may become normal. They finally diagnosed the case as skeletal fluorosis. He also told me that people at JU were surprised to find such high fluoride levels in Serampore.

I realised that day how important radiology can be in clinical diagnosis, sometimes against other evidence and we are, indeed, clinicians, not just image readers.

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For a comprehensive review of the radiology of skeletal fluorosis, please read this article.

Arghat’s contact: arghachat84 at gmail.com

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