Gage was a railroad worker. The accident took place during construction of a roadbed in Vermont. He not only survived but also went on to work at several jobs and travel widely (always carrying the rod with him) before dying 12 years later in San Francisco, apparently as a result of epileptic seizures related to his injury.

For more than a century and a half, scientists have argued about the precise location of the injury, the degree of brain damage, and the exact cause of the behavioral changes seen in Gage after the accident. (The physician who treated him said that the formerly hard-working, responsible man became fitful, impatient, and profane.)

To settle the disputes, UCLA researchers obtained modern brain images of men who matched Gage’s age at the time of the injury (25) and right-handedness. They used software to position a composite of 110 such images onto Gage’s virtual skull, constructed from CT scans taken in 2001 of the actual skull, which is displayed in the Warren Anatomical Museum in Boston.

The study determined that the accident damaged 4 percent of Gage’s cerebral cortex but nearly 11 percent of his brain’s white matter. Jack Van Horn, PhD, lead author of the study, summarized the findings:

Our work illustrates that while cortical damage was restricted to the left frontal lobe, the passage of the tamping iron resulted in the widespread interruption of white matter connectivity throughout his brain, so it likely was a major contributor to the behavioral changes he experienced.

Dr. Van Horn is an assistant professor of neurology and a member of UCLA’s Laboratory of Neuro Imaging. He was quoted in a UCLA news release. The study was published Wednesday in PLoS ONE.

“Connections were lost between the left frontal, left temporal, and right frontal cortices and the left limbic structures of the brain, which likely had considerable impact on his executive as well as his emotional functions,” Dr. Van Horn said.

The behavioral changes might have been familiar to doctors today. “The extensive loss of white matter connectivity, affecting both hemispheres, plus the direct damage by the rod, which was limited to the left cerebral hemisphere, is not unlike modern patients who have suffered a traumatic brain injury,” Dr. Van Horn said.

“And it is analogous to certain forms of degenerative diseases, such as Alzheimer’s disease or frontal temporal dementia, in which neural pathways in the frontal lobes are degraded, which is known to result in profound behavioral changes.”

Related seminar: Neuro & Musculoskeletal Imaging

The tool asks the physician a series of questions designed to clarify exactly why the physician is ordering the CT scan. Doctors are asked, for example, what diagnosis they suspect and how likely it is that the patient actually has that problem. In addition, if a medical resident orders the test, an attending physician has to approve.

The study found that use of the tool reduced CT scans by 10 percent. Because there was no corresponding increase in the number of patients who were admitted to the hospital, which commonly happens if a diagnosis remains elusive, the study presumed that the eliminated scans would have been unnecessary.

One author of the study told HealthImaging that the questions involve four screens and that it takes less than 20 seconds to click through the screens.

Abdominal pain is the most common complaint in U.S. emergency departments, accounting for 10 million visits each year, according to a Penn Medicine news release. A wide variety of problems, from minor to life-threatening, can cause such pain. Doctors often order CT scans to sort out the diagnosis. But there are no clear guidelines as to when CT use is indicated, and the scans expose patients to ionizing radiation.

“Most patients with abdominal pain aren’t in major danger, but some of the conditions that are on the list of things we consider as causes can be fatal within a short amount of time,” said Angela M. Mills, MD, an assistant professor of emergency medicine and medical director of the emergency department at the Hospital of the University of Pennsylvania. She added:

We need to be sure about our diagnosis in order to keep patients safe, but we need to balance the risks of giving a test like a CT scan with the chance that the test will truly provide us with information we could not get in some other way with less risk to the patient.

Dr. Mills was an author of the study, which was presented last week at the annual meeting of the Society for Academic Emergency Medicine in Chicago.

The study involved 11,176 patients seen in two Penn Medicine emergency rooms from July 2011 through March 2012. Before implementation of the new “accountability tool,” 32.3 percent of the patients received CT scans. After the tool was adopted, the percentage dropped to 28. After adjusting for various confounding factors, researchers determined that the usage of CT scans for abdominal patients decreased by 10 percent.

An enhanced version of the tool, adopted after  the study was completed, provides information about how many abdominal imaging tests the patient has previously undergone at Penn and totals the patient’s radiation exposure from previous CT scans.

“For many patients, like those who are older or have cancer, this tool might not make a difference,” Dr. Mills said, “but there are many abdominal patients who are younger, healthier, and who have things that are usually not life-threatening, like kidney stones, for whom we are hoping this will reduce their exposure to unnecessary radiation.”

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Prolonged exposure to mildly elevated radiation doses may be no big deal. Find out more on our Facebook page.

Related seminar: Imaging Advances: Abdominal, Thoracic, Skeletal

Now a research team based at Massachusetts General Hospital in Boston has found a promising new technique that doesn’t require a laxative. Maybe that will finally make virtual colonoscopy a mainstream screening tool.

Michael Zalis, MD, director of CT colonography at Massachusetts General, led the study. He said:

While we know that colon screening can save lives, not enough people participate, in part because of the discomfort of the required laxative preparation. In our study, the laxative-free form of CT colonography performed well enough that it might someday become an option for screening, which we hope would increase participation.

Dr. Zalis was quoted in a Massachusetts General news release.

Note that he said “someday.” The new technique uses a computer both to virtually cleanse fecal material from the images and to analyze those images. It did well at detecting larger adenomas, the type of polyps most likely to become cancerous. It was not as good at detecting smaller lesions.

The new procedure involves two days of a low-fiber diet and oral ingestion of small doses of a contrast agent to label fecal material. The computer program subtracts the feces from the image and looks for lesions.

In the study, published Tuesday in Annals of Internal Medicine, laxative-free CT colonographies were done on 604 patients within five weeks before scheduled traditional optical colonoscopies. Patients completed written surveys about the two procedures and were asked which they preferred. Not surprisingly, 62 percent preferred the CT procedure.

Three cases of colon cancer were found among the group, all of which were detected by both screening methods.

Dr. Zalis noted that radiation levels for virtual colonoscopies are much lower than for diagnostic CT scanning and would be considered safe for widespread screening of adults 50 or older—the target colonoscopy screening demographic. He was hopeful about the study’s implications:

If these results hold up in larger trials, we would expect this procedure would first be offered to moderate-risk patients who are otherwise unable or unwilling to be screened. If we can validate that this form of CT colonography performs reasonably well for screening and is easier for patients, it could have a significant impact on reducing the incidence of colon cancer and related cancer deaths.

Related seminar: Abdominal and Pelvic Imaging: CT/MR/US (all-new release)

In an interview with imagingBiz, BrianBaker, Regents’ president, said:

There will be plenty of work if you want it. We’re going to need the leadership and involvement of the radiologist community to help us define how to accommodate patient access to health reform volume.

Baker pointed out that, according to a study by the medical staffing company Staff Care in late 2011, 46 percent of radiologists are 56 or older and thus nearing retirement age. That should mean increased demand for new radiologists and increased work for current radiologists to make up for staffing shortages.

He also cited data from the Medical Imaging & Technology Alliance (MITA) indicating a 13 percent decline on per-beneficiary spending on imaging since 2006 and a 3 percent decline in Medicare imaging utilization in 2010. Those numbers contradict the notion that imaging is significantly overused.

And then there’s the PPACA. In late April, Regents forecast its potential impact for Radiology Business Journal. Assuming that the act’s current provisions remain in place, an estimated 31 million formerly uninsured people will become insured in 2015. That, Regents said, would trigger a 13.6 percent growth in imaging use nationally.

Imaging would increase the most in Texas (22.7 percent), the study found, and the least (3.7 percent) in Massachusetts, which already has near-universal health insurance coverage. The study predicted that MRI volume would grow faster than CT volume.

The predictions are for those under 65; the study removed those 65 or older because they are already covered under Medicare. It corrected for uncompensated care already delivered to the uninsured in emergency rooms and other settings. To counterbalance the effect of utilization management, which was considered likely to increase, the study did not take into account the impact of the aging of the population. Therefore, the study says, “these projections could be conservative.”

The study notes that certificate-of-need and construction regulations in some states “raise questions about whether those states have the capacity to address the needs of the new patients—and if not, whether capacity can be increased quickly enough to absorb the predicted volumes.”

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Mammograms should be read by radiologists who specialize in just that, says a mammography pioneer. Read more on our Facebook page.

Related seminar: UCSF Radiology Review: CLINICAL HIGHLIGHTS

The trial, at a state Common Pleas Court in Philadelphia, involved the case of Parrys Nicholson-Upsey, a now-3-year-old girl. According to lawyers for her parents, Victoria Upsey and Steven Nicholson, of Pottstown, Pennsylvania, she suffered spastic quadriplegic cerebral palsy as a result of negligence before and after her birth.

Court records and a statement from the parents’ attorneys indicate that Upsey was about 36 weeks pregnant when she went to Pottstown Memorial Medical Center in August 2008, according to The Pennsylvania Record, a legal journal. She complained of abdominal pain.

Obstetrician Charles V. Touey, MD, lead defendant in the case, performed an ultrasound and found no detectable heartbeat, according to the lawsuit. He ordered further testing, the lawsuit said.

It took more than an hour for a second ultrasound, according to court records. A statement by the parents’ attorneys said no ultrasound technician was at the hospital because it was Sunday. A technician had to be called from home.

After the second ultrasound, the baby was delivered by emergency Cesarean section. According to the lawsuit, the newborn was “hypotonic and lethargic” and was transported to Thomas Jefferson University Hospital in Philadelphia for treatment. The lawsuit alleged that further problems during the transport contributed to the child’s disabilities.

According to the parents’ attorneys, Dr. Touey maintained both before and during the trial that he had performed the ultrasound properly and that the baby died and then came back to life. Daniel S. Weinstock said in the attorneys’ statement:

He actually told my client her baby had died, then, 81 minutes later, the baby had come back to life.

According to the attorneys’ statement, Weinstock got the hospital’s risk manager to admit in court that there was no evidence the ultrasound equipment had been serviced in more than 10 years, although the manual recommends annual maintenance.

The $78.5 million jury award, announced last week, included payments for future medical care, lost earnings, pain and suffering, and emotional distress, according to the parents’ attorneys.

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Infrared thermography gets another test as a possible mammogram replacement. And flunks. See our Facebook page for details.

Related seminar: Maternal Fetal Imaging™

Zita Astravas, spokeswoman for provincial Health Minister Deb Matthews, justified the cuts by saying that new technology allows radiologists to conduct 25 to 30 percent more MRI scans in a day than previously. Canada’s national health system works primarily on a fee-for-service basis, with care provided by private entities and the government acting as insurer for most services. So, theoretically, radiologists have been able to make more money by squeezing more paying services into each day.

The Ontario Association of Radiologists says that if the government’s proposed cutbacks become reality, clinics would close, doctors would flee the province, and wait times for services would sharply increase. Ray Foley, executive director of the association, told the Toronto-based National Post newspaper:

They’re basically trying to trash the medical profession, for reasons that don’t make a lot of sense. We think it’s going to be devastating. It’s not going to cause an erosion of patient care; it’s going to create a chasm in patient care.

The government says tight budgets mean everyone has to sacrifice. It has proposed a pay cap for all public-sector workers and wants to freeze physician payments at the current $8 billion over the next two years. Because of new doctors entering the market and an aging population needing increased care, that means less money for each individual physician.

The government also says physician pay has more than doubled in the province since the early 1990s.

Neither the government nor the Ontario Medical Association has revealed specifics of the government’s proposal. However, Foley did. He said the government wanted to cut all radiologists’ fees by 5 percent and stop paying for diagnostic imaging of patients with chronic back pain and ultrasound scans for certain vascular conditions.

He said the government also proposed “clawbacks” of 5 percent on billings of $400,000 to $750,000, 10 percent on billings of more than $750,000 to $1 million, 25 percent on billings of more than $1 million to $2 million, and 40 percent on billings of more than $2 million.

Collectively, the Ontario Medical Association estimates, radiologists in the province would lose $61 million in income.

The Post quoted Mark Baerlocher, MD, as saying the proposed cuts had sparked a “huge amount of anger” in the medical community. Dr. Baerlocher is an interventional radiologist in Barrie, Ontario. He said he received an average of one unsolicited job offer a week from U.S. clinics.

“I’m 33,” he said. “I’m coming out of 15 years of training with a debt of $225,000. If they actually pushed these cuts through, it would be pretty tempting to leave.”

Related seminar: The Business of Radiology

Every second counts in minimizing brain damage for stroke patients. So the American Heart Association (AHA) created a quality-improvement program called Get with the Guidelines, with 1,199 enrolled hospitals at the time of the study. The researchers used Get with the Guidelines data for 40,777 stroke patients who were candidates for the tissue plasminogen activator  (tPA) clot-busting drug. They had a clot-related ischemic stroke, they had arrived at the hospital within three hours of symptom onset, and they had no other conditions that precluded the use of tPA.

The AHA guidelines call for CT or MRI imaging within 25 minutes of hospital arrival to confirm the diagnosis of stroke and determine whether it’s ischemic or hemorrhagic. But the study found that only 41.7 percent of suspected stroke patients actually received scans within that time. Adam Kelly, MD, the lead author, said:

We were struck by the fact that more than half of patients with acute stroke symptoms did not receive a brain scan within recommended guidelines. This was the performance of hospitals who are actively participating in a national quality improvement program, so rates in nonparticipating hospitals may be even worse.

Dr. Kelly is a University of Rochester Medical Center neurologist. He was quoted in a medical center news release.

Some of the same researchers were involved in another study, this one published online April 26 in Stroke, also using Get with the Guidelines data. It found that more than one fourth of ischemic stroke patients arrived at a hospital within the three-hour window during which tPA use is most effective at saving brain cells.

However, that percentage remained unchanged over the six-year period of the study. The study concluded: “Further efforts are needed to increase the portion of patients with acute ischemic stroke presenting within the time window for acute interventions.”

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In Berlin, Germany, emergency workers take treatment to stroke patients rather than the other way around. Learn about Berlin’s CT-equipped stroke ambulance on our Facebook page.

Related seminar: Emergency Radiology

The device was developed by researchers at the University of Twente and Medisch Spectrum Twente Hospital, both of Enschede, Netherlands. It uses photoacoustics to detect breast tumors. The proof-of-concept study found that the mammoscope could detect breast tumors in 10 women and benign cysts in 2 more, and could distinguish between the two.

In all cases the lesions had already been detected by conventional X-ray mammograms. The depths of the lesions were estimated using ultrasound.

Researcher Michelle Heijblom, a PhD student at the university and lead author of the study, explained the significance of the trial:

While we’re very early in the development of this new technology, it is promising. Our hope is that these early results will one day lead to the development of a safe, comfortable, and accurate alternative or adjunct to conventional techniques for detecting breast tumors.

Heijblom was quoted in an Optical Society news release.

The mammoscope uses photoacoustics, the hybrid optical and acoustical imaging technique in which laser light triggers pressure waves detected by ultrasound. Blood hemoglobin readily absorbs the longer, redder wavelengths of light, so the technique shows a clear contrast between tumors, dense with blood vessels, and normal tissue. The Dutch device uses ultrasound to target specific areas of the breast to scan.

The mammoscope is built into a hospital bed. The patient lies face down so the breast to be scanned protrudes through a hole. The breast is slightly compressed by a glass plate—not as much as during a conventional mammogram.

As Heijblom suggested, the mammoscope remains a good distance from clinical readiness. Scans were confined to a “region of interest,” about 40 by 40 millimeters, that had already been flagged by mammography or ultrasound. The reason was to reduce scan time. But scans still took close to 25 minutes.

Of the 17 original study subjects, 3 could not be scanned because they found the mammoscope too uncomfortable or because the device did not allow for complete access to the region of interest (ROI)  in the breast. Two more subjects’ results “were technically unacceptable due to poor acoustic contact between breast and detector in the ROI,” according to the study.

But a technology that does not involve ionizing radiation and shows promising imaging ability is definitely worth watching. Heijblom acknowledged that the mammoscope “needs some technical improvements before it is a really valuable clinical tool.” She added: “Our next step is to make those improvements and then evaluate less-obvious potential tumors, benign lesions, and normal breasts with it.”

Related seminar: Breast Imaging and Intervention: A Comprehensive Review

Neuroscientists at Emory University in Atlanta hope to answer those and other questions about canine cognition through functional MRI scans of dogs’ brains. So far, they’ve learned that when a dog receives a hand signal indicating that it is about to receive a treat, the caudate region of the brain, which is associated with rewards in humans, shows activity. A hand signal indicating that the dog will not be getting a treat does not trigger caudate activity.

Well, it’s a start.

If you’re remembering the old Far Side cartoon about what dogs hear, we can’t exactly blame you. But Gregory S. Berns, PhD, MD, the neuroeconomist who led the study, argues that the mental processes of the first animal species that humans domesticated—as long as 30,000 years ago—are certainly worth investigating:

The dog’s brain represents something special about how humans and animals came together. It’s possible that dogs have even affected human evolution. People who took dogs into their homes and villages may have had certain advantages. As much as we made dogs, I think dogs probably made some part of us too.

Dr. Berns was quoted in an Emory news release, which includes video.

The researchers used two dogs trained to be still in an MRI machine (with the aid of earmuffs to attenuate the noise). Callie is a 2-year-old feist (a squirrel-hunting breed) that Berns adopted from a shelter. McKenzie is a 3-year-old border collie trained by her owner, Melissa Cate, for agility competitions.

The dogs enter the scanner willingly and are not restrained. They have been trained to hold their heads motionless on a chin rest during the scans.

A paper about the study is scheduled to be published through the Public Library of Science (PLoS ONE). It’s available here.

Emory, incidentally, seems to be something of a pioneer in using dogs for higher education. The university also has made canine therapy available in its law library for stress relief during studying for finals.

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Radiologists are generally happy people who politically are both more conservative and more liberal than average. That, at least, is what a Medscape survey found earlier this year. For all the happy details, see our Facebook page.

Related seminar: Musculoskeletal MR Imaging (all-new release)

Therefore, maybe, slacking is hard-wired and not just a lifestyle choice.

So indicates a study based on PET brain scans. Vanderbilt University researchers in Nashville carried out the study, which was published Wednesday in The Journal of Neuroscience. David Treadway, PhD, one of the study’s authors, said:

Past studies in rats have shown that dopamine is crucial for reward motivation, but this study provides new information about how dopamine determines individual differences in the behavior of human reward-seekers.

Dr. Treadway, a postdoctoral student, was quoted in a Vanderbilt news release.

The researchers offered study subjects a choice of an easy or a hard game. The easy game could earn them $1. The hard game could win them as much as $4. Those willing to work harder for higher rewards had a greater release of dopamine in the striatum and ventromedial prefrontal cortex. Those areas of the brain are known to play an important role in reward and motivation.

The subjects who didn’t want to work as hard and settled for a lesser reward had high dopamine levels in the anterior insula, an area of the brain that plays a role in emotion and risk perception.

The finding that dopamine can have different effects in different areas of the brain surprised—and excited—the researchers. It implied the possibility of objectively measuring depression and other psychological disorders that involve reduced motivation.

“Right now, our diagnosis for these disorders is often fuzzy and based on subjective self-report of symptoms,” said David Zald, PhD, a Vanderbilt professor of psychology and associate professor of psychiatry. “Imagine how valuable it would be if we had an objective test that could tell whether a patient was suffering from a deficit or abnormality in an underlying neural system. With objective measures, we could treat the underlying conditions instead of the symptoms.”

Dr. Zald is an author of the study.

Some additional research is under way, and Dr. Zald said more was needed. In the meantime, the unmotivated might find it easiest just to say that they can’t help it; their brains make them that way.

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The American Cancer Society recommended prostate cancer screening without sufficient data. Who says so? The society’s chief medical officer, Otis Brawley, MD. See our Facebook page for more of his outspoken comments.

Related seminar: Neuroradiology Review