The audit report cited two main reasons for the “unnecessary” expenditures: a lack of state laws or regulations against self-referrals, and a reimbursement rate that’s higher than the federal Medicare reimbursement rate. You can find the report here and a news release about it here.

A July article in CommonWealth magazine (which covers “politics, ideas & civic life in Massachusetts”) described the state as “a medical imaging mecca.” It reported that Massachusetts has 42 MRI machines for every million residents, compared with the national average of 26, which itself is higher than that of any other country. According to the magazine, Massachusetts (population 6.5 million) has more MRI units than Australia and Canada (total population 55 million) combined.

The article also states:

Medical experts say the explosion in medical imaging facilities is fueling a dramatic increase in scans, many of them unnecessary and, in fact, harmful.

In the next few years, whatever the resolution of this particular issue, we can be sure that advanced imaging will be a major target for health care cost-cutters—and not just in Massachusetts.

To close the week, a couple of updates:

• The FDA is warning of mammography problems at another Florida clinic, this time at Medisound, Inc., in Kissimmee (near Orlando). Because of “poor quality mammograms with possibly unreliable results,” the agency recommends that anyone who received a Medisound mammogram anytime from June 10, 2008, through July 12, 2010, should have her mammogram reevaluated and possibly repeated. (We recently mentioned a similar FDA announcement about another Florida clinic.)
• To address medical isotope needs (which we also recently discussed), two Belgian groups and a French group announced on Thursday a partnership to manufacture and distribute molybdenum-99 when a new French reactor goes online in 2015. The National Institute for Radioelements (IRE) of Belgium, one of the partners, says it produces about one third of the world’s molybdenum-99 supply. “There are currently five reactors in the world [producing molybdenum-99], and most of them are 40 years old,” Gregory Delecaut of IRE told DOTmed News. “In the near future, they will be closed, and there will be a problem in the supply chain.”

Related seminar: The Business of Radiology

The study, published online this week in the journal Cancer, found that:

• Among Mexican-origin women with breast cancer who were surveyed, half were diagnosed before age 50. That’s years earlier than the national average for non-Hispanic white women.
• Their strongest risk factor was family history, which increased the odds of getting cancer fourfold. Of the women with breast cancer, 85 percent had a family history.
• Mexican-born women who spoke English well had two and a half times the risk of Mexican-born women who did not.
• Single women were almost twice as likely as married women to develop breast cancer.
• Women without insurance were one and a half times more likely to be diagnosed with breast cancer than those who had insurance.

For this population, at least, the researchers rejected the controversial U.S. Preventive Task Force guidelines released last year that recommend that mammograms (or other breast cancer screening) begin at age 50 for the general population. MD Anderson has continued to recommend that screening begin at age 40.

“Under the revised Task Force guidelines, up to half of Mexican-origin women with breast cancer may be undiagnosed or diagnosed in late stages, possibly increasing disparities in rates of breast cancer mortality,” said Patricia Miranda, PhD, the study’s lead author. “Hispanic women are not recognized in the guidelines as a high-risk group, and we would like to see that decision revisited.”

Dr. Miranda is a Kellogg Health Scholar postdoctoral fellow in the Department of Health Disparities Research at MD Anderson. She was quoted in an MD Anderson news release.

According to MD Anderson, previous studies have shown that Hispanic women in the United States are more likely to be diagnosed with advanced breast cancer than non-Hispanic white women, and 20 percent more likely to die from breast cancer.

Said Dr. Miranda:

Going forward, we believe it’s essential to create education programs specifically for this population, especially if any of the screening guidelines change.

The study also recommends that Hispanic women receive help in getting health insurance so they can have increased access to screening and early detection.

Many mysteries remain. Why does cancer occur earlier in Mexican-born women, for example, and why would acculturation (i.e., fluency in English) make a difference? MD Anderson is currently involved in a major study of Hispanic women in Mexico, Arizona, and Texas that may address those questions.

In the meantime, the new study reminds us again that to increase rates of breast-cancer screening will require many different solutions tailored to specific communities, and not a one-size-fits-all strategy.

Related seminar: Breast Imaging and Digital Mammography

Michael T. Mertz, an attorney for the patient’s family, said the settlement would be paid on behalf of radiologist Mark Kelly, MD, and his practice, Winfield Radiology Consultants in Winfield, Illinois; neurologist Henry Echiverri, MD, and his practice, NeuroMed Clinic in Warrenville, Illinois; and Central DuPage Hospital in Winfield. The case had been set for trial October 25 in DuPage County Circuit Court.

On December 10, 2006, 24-year-old Samantha Medina of Carol Stream, Illinois, in suburban Chicago, presented at nearby Central DuPage Hospital. She had a headache, slurred speech, double vision, nausea, and numbness on her right side. She lost consciousness the next day and died on December 27. She left a young son, now 6, and a husband, Chris.

Chris Medina filed suit. The lawsuit said that Samantha had a congenital clotting condition that resulted in slowed blood flow to her brain. Attorney Michael T. Mertz, who represented Chris Medina, said that an MRI on December 10 revealed the problem, but that Samantha did not receive proper treatment.

According to Mertz, Dr. Kelly said in pretrial depositions that he never read the MRI results because of miscommunication among staff. However, the attorney said, a review of Dr. Kelly’s computer use proved otherwise.

“Samantha went to the right hospital at the right time, was seen by the right specialists, and had the right tests performed,” Mertz said, according to the Daily Herald newspaper of Arlington Heights, Illinois. “If anybody had been paying attention to the MRI results, she still would be alive today.”

An attorney representing Dr. Kelly declined to comment. According to the Chicago Tribune, Dr. Echiverri’s attorney, Rodney E. VanAusdal, said, “All of Dr. Echiverri’s care was completely appropriate. In this climate, sometimes doctors are forced to compromise and settle to avoid even the small risk of a runaway jury verdict.”

Representatives from Central DuPage Hospital told the Lombard Spectator newspaper they were “deeply sorry for the family’s loss, but are unable to comment further regarding this matter.”

Related seminar: Diagnostic Imaging Review: For Residents, Fellows, and Radiologists

Researchers at the Max Planck Institute for Biophysical Chemistry in Göttingen, Germany, have cut the time required for recording MRI images to one 50th of a second—20 milliseconds. This should make MRI exams easier and more comfortable for patients (who will no longer need to “hold still”), as well as much more informative and useful for medical personnel. According to an institute news release, the researchers believe the new method could improve the diagnosis of coronary heart disease and other heart problems, and could substitute for X-rays in guiding minimally invasive interventions.

“However, as it was the case with FLASH, we must first learn how to use the real-time MRI possibilities for medical purposes,” said Jens Frahm, PhD, head of the nonprofit Biomedical NMR Research Inc. at the Max Planck Institute. “New challenges therefore also arise for doctors. The technical progress will have to be translated into clinical protocols that provide optimum responses to the relevant medical questions.”

Dr. Frahm and his then-colleague Axel Haase, PhD, developed FLASH (the “fast low-angle shot” MRI method, which greatly shortened MRI measuring times) in 1985 at the institute. The new method, developed by Dr. Frahm, Martin Uecker, PhD, and Shuo Zhang, PhD, builds on FLASH and can create real-time film of a beating heart, without artifacts. “We developed a new mathematical reconstruction technique which enables us to calculate a meaningful image from data which are, in fact, incomplete,” Dr. Frahm said.

The measurements can be implemented on today’s MRI devices, but image reconstruction requires formidable computing power. The researchers used fast graphical-processing units that were developed for computer games and three-dimensional visualization. Even so, “our computer system requires about 30 minutes at present to process 1 minute’s worth of film,” Dr. Uecker said.

An article about the research was published online late last week in the journal NMR in Biomedicine.

Related seminar: Cardiac Imaging

One of the patients, according to the clinic, died at least partly because of the disease.

Mayo administrators said on Wednesday that they had fired an employee who had admitted injecting himself with syringes of the painkiller fentanyl. The drug was intended for patients undergoing invasive procedures at the radiology unit where the employee worked. They said the employee, who had hepatitis, filled the emptied syringes with saline, changed the needles, and left the syringes to be used on the patients. Some of the syringes apparently became contaminated with the hepatitis virus despite the needle change.

The clinic did not identify the fired employee. However, shortly after the announcement, Steven Beumel, a state-licensed radiologic technologist and married father of two, was arrested at his lawyer’s office and charged with fraudulently obtaining a controlled substance.

A police report says Beumel acknowledged that he was addicted to fentanyl and had been stealing drugs while at the clinic since 2006. He had worked at Mayo since early 2005.

Beumel’s attorney told the Florida Times-Union newspaper that his client didn’t know that he had hepatitis. That fact, said attorney Adam Sacks, should make make a crucial difference in whether additional charges are brought regarding the patient infections and death. Said Sacks:

From my standpoint, if you don’t know you’re sick, you’re not being reckless in what you’re doing.

WJXT TV (Channel 4) in Jacksonville reported that William Rupp, MD, CEO of Mayo Clinic in Florida, said the hospital first discovered several cases of hepatitis C in transplant patients in 2007. “Because we had tested these patients before the treatment and after the treatment, we believed that this was a health-care-acquired infection,” Dr. Rupp said. “Over the ensuing couple of years, several more cases appeared.”

Eventually, the clinic discovered that at least three of the hepatitis viral samples were almost identical genetically. Employee tests for hepatitis turned up a positive result. “When we did that genetic testing on his hepatitis C, it matched the hepatitis C of the three patients,” Dr. Rupp said.

Related seminar: The Business of Radiology

Just last month, a study published in The Journal of the National Cancer Institute concluded that computed tomographic colonography (CTC), also known as virtual colonoscopy, was “not cost-effective when reimbursed at the same rate as colonoscopy.”

Now comes an Italian study, published online tomorrow in the World Journal of Gastroenterology, suggesting that CTC should replace colonoscopy as the first option for colorectal cancer screening. “In this setting,” the study concludes, “CTC has clear advantages, such as accuracy, safety and subject acceptance.” The study did recommend further research regarding the screening rates that would result from adopting CTC over colonoscopy and “the real cost and benefits derived from a CTC screening program.”

The researchers analyzed three large recent studies and a number of smaller studies. They concluded that CTC is highly accurate, with the only trouble spot being too many false positives for polyps smaller than 10 mm. On the other hand, they say, there were very few false negatives, and “this is extremely important in order to reassure negative patients about the significance of the examination.”

The researchers note that “colonoscopy … suffers from a very low participation rate,” with potential patients complaining about the required bowel preparation, embarrassment, and fear of discomfort. CTC is perceived to be more comfortable, but as to whether its widespread use would increase screening rates, “we need data resulting from real screening experience.”

The researchers flatly state: “CTC is a safe test, definitely safer than colonoscopy.” CTC, they say, has a much lower perforation rate. Concerning CTC’s radiation exposure and the accompanying risk of cancer, they say, “The risk is theoretical because there are still many uncertainties with regard to the true effects of ionizing radiation at low doses, such as those used in diagnostic radiology.” They say that the mean exposure of a CTC screening exam has recently been calculated to be only about twice the normal yearly background radiation exposure in the United States, and that screening CTCs would take place only once every five years.

Frankly, the researchers dance around the cost issue, saying, “Cost analysis is a very difficult task, especially in the absence of real data and based only on mathematical models.” They do suggest that the cost-benefit analysis should take into account the ancillary ability of CTC to detect “previously unknown life-threatening diseases” such as abdominal aortic aneurysm and renal cancer.

So where does that leave us? Waiting for more research, of course. Also, probably, waiting for costs to come down. Still, if CTC can be sold to the public as more comfortable than colonoscopy, and if that leads to significantly higher screening rates, then it probably does have a bright future.

Related seminar: Imaging Advances: Abdominal, Thoracic, Skeletal (brand new release)

This could have tremendous implications for both neuroscience researchers and clinical neurology. For example, people at risk of carrying the gene for Huntington’s disease, which usually doesn’t cause symptoms until middle age, could elect to be screened before deciding whether to have children. Treatment for a wide range of neurological disorders could begin early enough to delay or ameliorate symptoms.

Neurological degenerative disorders, such as Huntington’s, are difficult to diagnose. MRI can reveal loss of brain tissue, but cannot distinguish the disease that is causing the loss—Huntington’s, Alzheimer’s, Parkinson’s, or whatever it may be.

“We discovered that MRS can reliably identify brain pathology in Huntington disease model mice by measuring 17 different brain metabolites at the same time,” said Jason B. Nikas, MD, the project leader, as quoted in a news release. “This technology, if expanded to humans and applied to a range of neurological disorders, could potentially provide diagnostic information to distinguish different causes of dementia and other forms of neurological illness, rapidly and noninvasively, with current-generation MR scanners.”

Dr. Nikas is with the department of neurosurgery at the University of Minnesota Medical School.

Unlike MRI, which detects the response of hydrogen atoms in water molecules in tissue, MRS can read and quantify complex biological molecules. Dr. Nikas and his colleagues measured the amounts of 17 different biochemical substances in the brains of mice and found that the Huntington mutation R6/2 caused a signature change in the levels of those substances. Using MRS, they were able to successfully identify which mice had the mutation 100 percent of the time.

“Scanning animals noninvasively by MRS could be useful in the monitoring of various interventions in mice with genetic disorders,” Dr. Nikas said. “However, it could be even more valuable for identifying human subjects who were asymptomatic but showed the MRS signature of a particular disease, which they might develop years later; moreover, it could be very valuable in assessing disease progression and/or the efficacy of an applied medical treatment.”

The research will be published in the October 15 issue of The Journal of Comparative Neurology.

Related seminar: Review for Practicing Radiologists

Of course it would have the “latest advancements”; after all, it’s in Beverly Hills, California.

Actually, the high-end address is attributable to the fact that it is inside the headquarters location of the Pink Lotus Breast Center, founded by Kristi Funk, MD, who performed Crow’s lumpectomy surgery following the singer’s breast-cancer diagnosis.

In a Tuesday post on her Web site, Crow said, “Many of the problems with the breast health system in this country are inherently due to a disunited approach—for the most part, centers ignore the value of comprehensive care, they employ failing business models and lack technological sophistication.”

She described the Pink Lotus Breast Center as “the only fully integrative and comprehensive solution for breast cancer patients available today.”

Crow said her purpose in putting her name on the center was “not financial gain.” Instead, she said:

As a breast cancer survivor myself, helping other women catch the disease early, and helping them through treatment, is something I am proud to fully support with my name.

The singer was diagnosed with Stage I breast cancer following a routine mammogram in February 2006, at age 43. She underwent successful surgery and radiation therapy.

The clinic is to be the first of many. Said Dr. Funk in a news release: “The Sheryl Crow Imaging Center is an essential component of every breast center we build, and we look forward to bringing our unique approach to breast health to more women as the Pink Lotus Breast Center expands to other parts of the country.”

The announcement followed unrelated news about another breast imaging clinic that apparently was not state-of-the-art. The Food and Drug Administration last week issued an alert about mammograms performed from May 21, 2008, through September 30, 2009, at Med Pro Imaging in Plantation, Florida (near Fort Lauderdale). The FDA said that because of “possible problems with the quality of mammograms,” it suggested that “patients might need to have their mammograms reevaluated and possibly repeated.” According to the FDA, the facility is under new management and operating as Rivero Diagnostic Center.

We’ll conclude by borrowing the closing line of Crow’s post: “Much health to all of you!”

Related seminar: Breast & Women’s Imaging Seminar

A new report in the journal Radiology, being published in the October issue and in advance online today, raises that issue. “A single breast-specific gamma imaging (BSGI) or positron emission mammography (PEM) examination carries a lifetime risk of inducing fatal cancer greater than or comparable to a lifetime of annual screening mammography starting at age 40,” said the study’s author, R. Edward Hendrick, PhD, as quoted in a Radiological Society of North America press release. Dr. Hendrick is clinical professor of radiology at the University of Colorado Denver School of Medicine in Aurora, Colorado.

Such tests are generally used only when a mammography or ultrasound screening uncovers a possible problem—not for routine screening themselves. Dr. Hendrick told the New York Times that he’s not suggesting that the tests not be used, just that their added risk be taken into account before they are ordered.

“I would go to the international breast meeting and the big radiology meetings, and nobody had a clue what the doses and risks were,” he said. “They’re treating the tests as if they have the same radiation dose and risk as mammography, and the truth is that they have a much, much higher risk. The point of the paper was to say that not all the breast imaging procedures have comparable risks and doses.”

But what about other risk factors over which medical personnel have no control? A study published online this week in the Journal of the National Cancer Institute finds that nicotine may not only promote smoking addiction but also may directly promote the development of breast cancer.

In the same issue, another article suggests that alcohol consumption increases the risk of invasive lobular and hormone receptor-positive breast cancer, but not necessarily of invasive ductile carcinoma.

So patients depend on their health-care providers to inform them about the risks of medical procedures. But patients also need to know about other risk factors that crop up outside the clinical setting. And they’re continually being bombarded with “information” from TV commercials, their cousin whose niece once worked at a hospital, and, of course, the ever-reliable Internet.

There is one thing that just about everyone can agree on: mammograms save lives. “The primary tool for breast cancer screening is still mammography, which has a very low radiation dose and a very low lifetime risk of cancer induction,” Dr. Hendrick said. “The risk of missing a breast cancer because mammography is not done far outweighs the tiny risk of mammography causing a breast cancer.”

Related seminar: Pittsburgh Breast Imaging Seminar

Before it was unexpectedly shut down in May 2009, the Chalk River plant had produced up to a third of the world’s medical isotopes—and half of the U.S. supply of the precursor for technetium-99m, used in 80 percent of diagnostic and therapeutic procedures that require isotopes. With repairs of a heavy-water leak completed at last, the reactor restarted last week.

Lantheus Medical Imaging of North Billerica, Massachusetts, which supplies radiopharmaceuticals, told DOTmed News that  it expected that the first isotopes would start reaching U.S. clinics about now. “Lantheus will manufacture their first lot of TechneLite produced with NRU-sourced material this weekend,” Bill Dawes, a Lantheus vice president, said last week. “This material will be in hospitals and clinics on Monday.”

Another isotope-producing plant, the High Flux Reactor in Petten, Netherlands, closed for repairs in February. It is scheduled to resume production next month.

At a symposium during yesterday’s opening session in Boston of the 240th National Meeting of the American Chemical Society, scientists said the isotope shortage could jeopardize patient care, increase health care costs, and also threaten such nonmedical endeavors as scientific research and oil exploration.

In an interview at the meeting, Robert Atcher, PhD, said, “Although the public may not be fully aware, we are in the midst of a global shortage of medical and other isotopes. If we don’t have access to the best isotopes for medical imaging, doctors may be forced to resort to tests that are less accurate, involve higher radiation doses, are more invasive and more expensive.”

Dr. Atcher directs the National Isotope Development Center, which is part of the U.S. Department of Energy and is responsible for production of isotopes nationwide. He was quoted in an American Chemical Society news release.

He said the shortage was forcing some doctors to order fewer imaging procedures:

“Doctors have been trying everything they can think of to meet the needs of patients, including the use of other, less-than-ideal isotopes, but it has been a real struggle.”

He noted that the United States produces only 10 to 15 percent of the medical isotopes it needs domestically, and that the nuclear medicine community has been lobbying the U.S. government to increase domestic production capability.

“The challenge we have is to produce enough materials to meet commercial needs as well as the needs of the research community—from nuclear physics to environmental research to medical research—amid increasing demands and fewer isotope sources,” Dr. Atcher said. “The long-term solution to this crisis remains to be seen.”

Well, that’s not exactly reassuring, is it? Nor is this bit of information: the Canadian government plans to close the Chalk River plant permanently in 2016.

Related seminar: Radiology Review