Conservative Dialysis, is the quizzical name of this week's blog host for the Carnival of the Vanities.
If you haven't been following the controversy surrounding the COTV, and last week's carnival host, you've missed a sure part of blogosphere history as this -- the first and leading web-wide "Carnival" -- reaches a crossroad in its life.
Check it all out. Read this week's COTV, then go see what Kevin at Wizbang had to say about the imbroglio; and, finally, go to the source, COTV founder Bigwig at Silflay Hraka.
GRAND ROUNDS AND SICK PARROTS
Girl Scientist, at Living the Scientific Life, hosts Grand Rounds this week -- a compilation of medical blog posts.
Ironically, in the midst of proliferating medical knowledge and advice, Girl Scientist fell ill while preparing the compendium...and so our first Grand Rounds from the sick bed!
Don't worry though, one cannot see the footprints of illness on the host's trail through this week's medical blogosphere, speaking to the fortitude and will of a:
"postdoctoral fellow who has been living in New York City since September 2002, working in my "dream job", researching the evolution of parrots from the south Pacific Ocean."
So go to the site and check out the links.
One question: If one were studying parrots from the south Pacific Ocean, in which part of Manhattan would one spend the most time working? Soho? The Upper East Side? Hell's Kitchen? Interesting...
iMammo: The Mammogram You Never Had
An article in several parts
Yesterday, in Part I:
The Music of Digital Mammography
Today, in Part II:
Breasts, Lies, and Videotapes:
The Iron Triumvirate and the Dirty Secret of Mammography
I've Got A Secret
Shhhh…What is the dirty little secret of mammography? Double reading picks up 15% more cancers.
A double reading means that a mammogram is looked at twice, by two different radiologists.
This “secret” is well known in the imaging community, and was established in the early 1990’s when a study of 11,000 mammograms confirmed that: Double reading detected 15% more cancer cases. The author's conclusion to that study?
"Independent double reading does significantly increase sensitivity of mammography screening."
If having a mammogram interpreted twice prevents 15 more women -- on top of every 100 found -- from having their breast cancer remain undiagnosed, why aren't all mammograms double-read?
Answer: It's impossible.
Have you heard of the "crisis" in mammography? What is this crisis? Well, since every woman over the age of forty needs a mammogram every year, there is a never ending -- and right now constantly enlarging -- pool of women needing mammography. There are tens of millions of mammograms that need to be done every year. However, increasingly, doctors, hospitals, and clinics are dropping the procedure from their repertoire of imaging studies. It is getting harder and harder to get routine mammograms scheduled, done, interpreted and acted upon in a timely fashion. Eh? How can that be?
The Confederacy of Dunces
There are three large, important, forces of influence that shape the face of mammography in the United States. Ten seconds to guess them.
Did you say the millions of women over age 40? Wrong.
Did you say physicians, scientists, or mammographers? Wrong.
The ruling Iron Troika of mammography consists of: The government, Mammactivists, and Torters. These are the groups that, in reality, have the most influence over how mammography gets done -- or not done -- in the United States. The "crisis" in mammography is directly related to the perverse influence of these three groups on that procedure.
In a previous post I wrote about Mammactivists Killing the Mammogram. Burdensome, expensive, superfluous and redundant anti-market legislation promulgated by "disease-specific" breast cancer lobbyists and approved by weak-kneed legislators has created thousands of pages of regulations controlling the entire process of mammography, from the building the machine is in, to the developing fluid used in the photographic process.
To comply with these regulations (the laws, that is) is expensive and time-consuming. These costs -- added to all the other fixed overhead of a women's center -- make mammography a money loser.
Medicare -- run by the federal government -- has, over the years, slashed the reimbursement for obtaining and interpreting mammograms under the claim that if the examination is too expensive, fewer women will obtain it.
Add to these factors the ever present Torters (go here if you are unfamiliar with this beast) who have turned mammography interpretation into one of the greatest liability risks in all of health care, and...voila! A crisis exists.
Low reimbursement, burdensome federal regulations and the constant threat of lawsuits make mammography an undesirable task for any radiologist. As a result, only a small percentage of radiologists will interpret mammography. In many communities it is hard enough to find one radiologist who will interpret mammography, let alone another radiologist to reread the thousands of mammograms done in any given center each year.
Ineluctable Cell Logic
This is a breast cancer cell. Some of these cells double every 120 days. So a cancer that is barely visible and highly curable -- say 3mm -- today, could have a dramatically worse prognosis in a year, at over 2 cm.
The Iron Troikites all claim that what they do is for the "good" of women.
What, actually, are the consequences of their good intentions? The "Iron" in their title stands for irony because, the consequences of these good intentions are:
In the next installment I'll discuss how digital mammography and the breast MRI fall victim to the final irony of the Troika.
iMammo: The Mammogram You Never Had
This is an article in two parts. Today, in Part I:
The Music of Digital Mammography
Tomorrow, in Part II:
The Fellowship of the Ring: Digital Mammography, Cancer Detection and Consumer Choice
From Part I:
"As a radiologist who has read mammograms for fifteen years, I cannot tell you how many times I have had to deal with a woman’s entire twenty year folder of mammograms that has been completely lost.
Not to mention the uncountable times I’ve opened a patient’s mammogram x-ray folder to find someone else’s mammograms mixed in with the folder, or the wrong name flashed onto the patient’s film, or films degraded by age, humidity or insects!"
Part I:
The Music of Digital Mammography
Make It New
In the mid 1980’s, a small display of weird and untamed jewel boxes began to crop up in an obscure corner of Manhattan’s Tower Records.
There were always people standing around the odd kiosk. Curious shoppers opened and closed the hard plastic cases (this was before the world was catastrophically altered forever by the advent of shrink-wrapped merchandise); and, occasionally, someone would stick an index finger down, bringing back a small shiny silver disc: the CD.
The whisperers in the corners were saying something bizarre and unfathomable: One day CD's would replace the beloved vinyl LP record album. To most, this seemed patent nonsense. After all, vinyl reproduced a sound that was warm and complex. The CD screeched music that was tinny, cold, shallow, and bright. Worse, the Paleolithic disc players were more like toasters than turntables: no cartridges or needles or platters…the entire system totally without character or class.The CD was ridiculed and dismissed along with the digital music it so outrageously produced from the zeroes and ones pressed into its sectors.
In just a few years the marketplace had spoken. Manufactures heeded criticisms and beefed up the sound. Hundreds of competitors -- high and low end -- vied to establish themselves all along the chain of production and sales as the entire audio industry rushed to backfit the convenience and portability of CD's with consumer taste, preference and choice. In an historic flash, the vinyl LP was a memory as quaint as the fedora.
Parallel Collision
Much the same story has played out, on a parallel course, in the history of breast imaging and mammography. Digital mammography, once a freakish technology relegated to pre-biopsy localization, has emerged on the imaging scene with full-field technology, boasting all the power of the digital technique and format. Only this time the technology has penetrated the market with less ferocity, an important catalyst to the adoption process missing: the consumer. Standing on the third-party-payer sideline, removed from the all-important feedback loop, the consumer power of the end-user is divorced from the marketplace evolution of a medical technology whose time has come.
Last month, in the American Journal of Roentgenology (abstract), researchers from the George Washington University published a powerful study demonstrating one of the great benefits of Full Field Digital Mammography (FFDM); namely, the opportunity, with the click of a mouse button, to have a computer recheck the mammogram and alert the radiologist to areas of mass or abnormal calcium that may have been overlooked. These are areas under suspicion for cancer. This technology, Computer Aided Detection (CAD) serves as a “second look” at the mammogram. “Second-looks” have long been highly recommended by the literature as a way to improve cancer detection. However, before digital imaging, a second-look required a second radiologist to read the mammogram. The high liability risk, burdensome Federal regulations, and low reimbursement that saddle mammography make it hard enough to find any radiologist to read a mammogram once. Twice is almost out of the question. But with FFDM, a second read is a mouse click away.
What are the other advantages of FFDM?
Buggy Whips and Cameras
Standard mammograms are x-rays and they are analogous to the old style cameras you used to take photographs with, only replace LIGHT with X-RAYS. An x-ray is generated and it passes through the breast taking a “picture” on a piece of photographic film on the other side of the breast. If you take a bad photo (or a bad mammogram, which is a common occurrence) you can either live with the obscured image or you can repeat the photo.
Digital images also use x-rays (and the dose is low – about the same as a mammogram) but a bad image does not have to be repeated. Think of your digital camera at home, and what you can do with the images on the computer. It’s the same case with FFDM. The radiologist simply adjusts the settings on a computer and fixes the problem. So, the first benefit is:
therefore less radiation exposure to the breast
Being able to manipulate the image (changing contrast, density, magnification and orientation), also lets one study the breast more thoroughly, changing parameters to try and better detect a cancer that may be hiding, or nested, in a confusing array of breast opacities. So digital mammography affords the radiologist
therefore potentially improving survival rates
Just as a PC’s iTunes folder – with thousands of songs – has replaced the giant shelves needed to hold and store LP records, digital mammograms can be kept and backed-up on secure computer servers: No more lost, mislabeled, mixed-up, and unretrieveable x-ray mammograms.
As a radiologist who has read mammograms for fifteen years, I cannot tell you how many times I have had to deal with a woman’s entire twenty-year folder of mammograms that has been completely lost.
Not to mention the uncountable times I’ve opened a patient’s mammogram x-ray folder to find someone else’s mammograms mixed in with the folder, or the wrong name flashed onto the patient’s film, or films physically degraded by age, humidity or insects! Digital mammography offers:
Tomorrow: Part II and the conclusion of iMammo: The Mammogram You Never Had
Includes:
WHAT DOES TERRI'S BONE SCAN MEAN?
It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.
A reader asked me to comment on Terri Schiavo's bone scan report.
Here are my initial thoughts:
It is perilous to try and interpret just the bone scan REPORT. I need to see the scan itself and the correlative X-rays.
However, that being said, several things are unusual.
First, the DATE on this bone scan is March 1991. Terri's cardiopulmonary arrest -- as far as I can tell -- was in February 1990; therefore, the abnormalities that are described occured AFTER Terri's February 1990 arrest, probably in the weeks or month(s) just prior to the bone scan, unless she had a second arrest at some point -- and I do not have that history. Certainly there was trauma. As I understand it, the issue is how the trauma occurred.
Trauma from CPR generally involves the anterior aspects of the ribs where they join the sternum. This is usually due to vigorous compression during CPR. Any other proposed trauma during CPR would need to be documented by the notes or by eye witnesses as to the mechanism (e.g.: did she fall off the stretcher?).
The bone scan report of TS describes an injury NOT to the anterior ribs, but, to a different part of the ribs-- posteriorly -- namely at the juncture of the ribs and vertebrae (the costovertebral juncture, or CVJ). In addition, although the report mentions several rib fractures, it does not specify if they were all CVJ located or in different/various locations. This is important. Finally, I do not see a report of correlative x-rays for the ribs, which would be helpful to determine the TIMING of the injury (fractures look very different depending on WHEN they occurred).
The compression fracture of L-1 is interesting. This is certainly NOT a typical injury that occurs during CPR as it generally involves an AXIAL load (i.e. on the top of the head; or from the top DOWN); a caveat here: if TS was anorectic for a prolonged period or on certain medications she could have been osteoporotic, in which case some might claim that a mild compression fracture of L-1 would not be so unusual-- however this is only true in ambulatory people, which Terri was not.
The uptake over Terri's distal right femur is the most peculiar element in this report. This is an unusual finding in ANY situation and I would have to see the scan and films to be sure of what it means; however, if there is PERIOSTEAL ELEVATION then one would have to posit (as did the person who interpreted Terri's bone scan) the possibility of bleeding underneath the thin covering of the bone (the periosteum) which is a finding that correlates highly with trauma, specifically, abuse.
It would be difficult to propose a mechanism that caused this type of problem unless a specific witness arises to declare he or she remembers a specific event that would have caused this UNUSUAL finding.
I would want to know if Terri had a BLEEDING problem at any time, because that might explain this finding.
Certainly IN A CHILD (which Schiavo, obviously was not), the combination of posterior rib fractures, vertebral compression fractures, and distal femoral periosteal elevation is ABSOLUTELY POSITIVELY DIAGNOSTIC for child abuse and any radiologist who missed this diagnosis would be subject to disciplinary action from his peers and state licensing board. SEE: http://radiographics.rsnajnls.org/cgi/content/full/23/4/811
It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.
The x-rays might make all of this clearer if we can obtain them.
n.b.
Teri's fractures could be of the "insufficiency" type (caused by prolonged immobilization/dietary irregularities) and some might posit this explanation; however, in a nonambulatory bedridden patient under careful supervision, I find this untenable, especially given their distribution which are so typical for ABUSE.
Here's the link to the bone scan report: http://www.terrisfight.org/images/bonescan.jpg
Grands Rounds is up at the Well-Timed Period. Visit this weekly compilation of the BEST of medical blogging.
The 131st edition of The Carnival of The Vanities is coming to CodeBlueBlog this week. COTV is the grandaddy of all the "carnivals" and other weekly blog compendiums. There is a link to Carnival hosts at the bottom of the left hand column of CodeBlueBlog. Click and check.
If you have a worthy post you want to share with the world, now is your chance. Send me your best by Tuesday night 3/22/2005 at 6 P.M. EST.
Here's how you do it:
Thanks to Silflay Hraka for starting the Carnival , and thanks to those who are about to send me their best work for the weekly showcase here on 3/23/05.
The Carnival of The Vanities is up at Birds Eye View. This is the 130th edition of COTV, the grandaddy of all the "carnivals" and other weekly blog compendiums. There is a link to Carnival hosts at the bottom of the left hand column of CodeBlueBlog. Click and check.
Next week the Carnival stops right here at CodeBlueBlog. This is as good a time as any to tell you what I need:
So thanks to the Radical Centrist for hosting this week's carnival, thanks to Silflay Hraka for his primary progenitor status, and thanks to those who are about to send me their best work for the weekly showcase here on 3/23/05.