a special region-specific the newsmagazine as i-pacifc ... 2012 as i-pacifc economics...

RadiogRaphic scoRing in Rheumatoid aRthRitis

January 2002

The Newsmagazine of Imaging Innovation & Economicsautumn 2012 asia-pacific

Electromagnetic Navigation Bronchoscopy P 17

a new approach to the diagnosis of peripheral pulmonary lesions.

Late adverse reactions to iodine-based contrast media P 14

Updated ESUR guidelines on LARs

The Asha Jyoti Program P 21

Women’s outreach program in India

Imaging News P 06-08

Tech update P 23

A special region-specific publication from the editors of DI Europe

asia-pacific

Poster Abstract Submission for EPOSTM: all year round!

Online Registration: open now

March 7–11

COMING SOON IN ThE wINTEr ISSuE: ElastographyPACSTech updateImaging New

COVEr STOrYRadiographic scoring methods in Rheumatoid ArthritisDespite the advent of MRI and MSK ultrasound, plain radiographs of the hands and feet remain the mainstay in rheumatoid arthritis. This mini-review article describes the most common methods used in scoring radiographs in RA,

By Dr Vinod Ravindran � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 10

IMAGING NEwS

A cardiovascular death in China every 10 seconds. . . . . . . . . . . . . . . . . 6Strong growth projected in Indian color ultrasound market. . . . . . . . . . . 6Study shows bicarb hydration therapy better than saline for CI-AKI . . . . . 6Tablet computers OK for on-call radiology but software needs improvement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7CT useful to discriminate life-threatening stercoral colitis. . . . . . . . . . . . 7China’s health-care reforms: work in progress . . . . . . . . . . . . . . . . . . . . 8Spectral CT shows potential in liver cirrhosis . . . . . . . . . . . . . . . . . . . . 8

TEChNOLOGY uPDATE

Organic-LED Monitor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23G-Arm system launched in China . . . . . . . . . . . . . . . . . . . . . . . . . . . 23New color Doppler Ultrasound system . . . . . . . . . . . . . . . . . . . . . . . . 23

Autumn 2012

rEPOrTS

CuRRent teChniques foR diAgnosing peRipheRAl pulmo-nARy lesions ARe impeRfeCt� eleCtRomAgnetiC nAvigAtion bRonChosCopy Could be An new AppRoACh�

page 17

lAte AdveRse ReACtions to intRAvAsCulAR iodine-bAsed ContRAst mediA� A summA-Ry of ReCent findings And the updAted esuR guide-lines ConCeRning lARs

page 14

rEGuLArS

04| FrOM ThE EDITOr

12| BOOk rEVIEwS

Anatomy in Diagnostic Imaging, 3rd Edition

23| TEChNOLOGY uPDATE

the AshA Jyoti women’s out-ReACh pRogRAm is Run by the postgRAduAte institute of mediCAl eduCAtion And ReseARCh (pgimeR), ChAndigARh in indiA And suppoRted by RAd-Aid And philips

page 21

VISIt US At

Autumn 2012 D I A G n O S t I C I m A G I n G A S I A P A C I F I C 3

asia-pacific

asia-pacific

By Dr Alan Barclay

On a date deliberately chosen to commemorate the day in 1895 when Wilhelm Conrad Röntgen discovered X-rays,

November 8th was proclaimed as the first International day of Radiology (IDoR), with its purpose openly described by the organisers, (ECR, RSNA and ACR), as being “to alert the world to the stunning medical, scientific and even artistic possibilities of medical imaging, the essential role of the radiologist as a part of the healthcare team in countless medical scenarios, and the high educational and professional stan-dards required of all staff working in medi-cal imaging”. No fewer than 66 medical societies in 38 countries throughout the world participated in one way or another in the initiative. In the Asia-Pacific area these included the national radiological societies of China, Japan, India, Korea and Sri Lanka. In Oceania, the Australian and New Zealand Radiological societies also endorsed the IDoR. While making radiol-ogy more visible to, and appreciated by, the public is a worthy aim common to every country, the almost total world-wide sup-port of the International Day of Radiology by the appropriate professional does not of course mean that the challenges facing the radiology profession are identical from country to country. In fact there are huge differences between countries in the cur-rent status and likely future development of all medical disciplines, not just radiology. Differences from Western style healthcare systems are particularly striking in coun-tries like India and China as they adapt their medical structures to the increasing expectations of their populations in the light of their current explosive economic growth. In China especially the need for reform in all aspects of medicine is urgent. A significant landmark was passed this year in China, when the country, with its long history and culture based in rural agriculture actually became a primarily urban society. The Chinese urban popula-tion of 680 million in 2012 exceeded the number of rural residents for the first time. Such a demographic transformation can have both advantages and disadvantages form the point of view of public health. On the one hand, access to health care and

infrastructure can be improved by popula-tion concentration but urbanisation brings with it its own challenges such as increased likelihood of pollution and detrimental changes in lifestyle and diets. Traditionally oriented toward the treatment of acute conditions, Chinese medicine is having to face a huge growth in non-communicable diseases. Conditions such as chronic kid-ney disease, diabetes and cardiovascular disease are now the country’s number one health threat.

The question is how is the country’s health system adapting to these seismic scaled shifts?

The good news is that the government recognised the challenges and, more than three years ago now unveiled an ambitious health-care reform plan which allocated an expenditure of 850 billion Yuan (approxi-mately 125 billion US dollars) with the aim of the provision of affordable and equitable basic health care for all by 2020. Given the traditional description of Chinese medical services as being too difficult to access, too expensive and too variable in quality, such a goal is not just ambitious but highly com-mendable. A recent report from a group of public health specialists from Harvard, USA, York & Oxford, UK, and Shanghai, China examined the progress that China has made three years into this eleven year program (Yip WCM, Hsiao WC, Chen W, Hu S, Ma J and Maynard A. Early appraisal of China’s huge and complex health-care reform, Lancet, 2012; 379: 833). In this period the country has achieved nearly uni-versal health insurance coverage, which in such a short time is a remarkable achieve-ment. Insurance coverage in 2003 was only 29.7 % of the population and in 2011 was 95.7 %. However as Yip and colleagues point out the transformation of money and insurance coverage into cost-effective ser-vices is difficult when the delivery of health care is hindered by waste, inefficiencies, poor quality of services and scarcity and poor distribution of the qualified work-force. So, progress so far is encouraging but the challenges remaining to be overcome are daunting. n

EDITORIAL ADVISORY BOARDDr. Jennifer Cawson, Melbourne, AustraliaProf. Yi-Hong Chou, Taipei, TaiwanProf. Jiang-Ping Dai, Beijing, ChinaProf. Hiroshi Fujita, Gifu, JapanMr. Robert George, Sturt, S. AustraliaDr. Julian He, Boston, USAProf. Jung-gi Im, Seoul, KoreaDr. Bhavin Jankharia, Mumbia, IndiaProf. Mikund S. Joshi, Mumbai, IndiaDr. George Klempfner, Melbourne, AustraliaProf. Michio Kono, Kobe, JapanDr. K. Kulaveerasingam, Kuala Lumpur, MalaysiaDr. Lillian L.Y. Leong, Hong Kong, ChinaProf. Jae Hoon Lim, Seoul, KoreaProf. Quanfei Meng, Guangzhou, ChinaProf. Wilfred C. G. Peh, SingaporeDr. Tauqir Ahmed Rana, Riyadh, Saudi ArabiaDr. Zhonghua Sun, Curtin, AustraliaProf. Lenny K. A. Tan, SingaporeDr. Chui-Mei Tui, Taipei, TaiwanProf Dr. John George, Kuala Lumpur, Malaysia

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China: meeting the health care challenges


FROM THE EDITORasia-pacific

Bracco.The Contrast Imaging Specialist.

www.bracco.com

IOMERON®: CORE SUMMARY OF PRODUCT CHARACTERISTICSName of the Medicinal Product. IOMERON® 150/200/250/300/350/400 mg/ml solution for injection. Qualitative and Quantitative Composition. IOMERON® 150/200/250/300/350/400: 100 ml contains 30.62 g, 40.82 g, 51.03 g, 61.24 g, 71.44 g, 81.65 g of Iomeprol (active ingredient). Thera-peutic indications. This medicinal product is for diagnostic use only. Iomer-on 150: infusion urography, digital substraction phlebography, CT (brain and body) cavernosography, intravenous and intraarterial DSA, ERCP, MCU, MCU in paediatrics. Iomeron 200: peripheral phlebography, digital subtraction phle-bography, CT (brain and body), cavernosography, intravenous and intraarterial DSA, ERCP, arthrography, hysterosalpingography, cholangiography, retrograde urethrography, retrograde pyelo-ureterography,myelography. Iomeron 250: in-travenous urography, peripheral phlebography, CT (brain and body), intravenous and intraarterial DSA, myelography. Iomeron 300: Intravenous urography (in adults and paediatrics), peripheral phlebography, CT (brain and body), cav-ernosography, intravenous DSA, conventional angiography, intraarterial DSA, angiocardiography (in adults and paediatrics), conventional selective coronary arteriography, interventional coronary arteriography, ERCP, arthrography, hys-terosalpingography, fistulography, discography, galactography, cholangiogra-phy, dacryocystography, sialography, retrograde urethrography, retrograde py-elo-ureterograpy, myelography. Iomeron 350: intravenous urography (in adults and paediatrics),CT (body), intravenous DSA, conventional angiography, intraar-terial DSA, angiocardiography (in adults and paediatrics), conventional selective coronary arteriography, interventional coronary arteriography, arthrography, hysterosalpingography, fistulography, galactography, retrograde cholangiogra-phy, dacryocystography, sialography. Iomeron 400: intravenous urography (in adults including those with renal impairment or diabetes), CT (body), conven-tional angiography, intraarterial DSA, angiocardiography (in adults and paedi-atrics), conventional selective coronary arteriography, interventional coronary arteriography, fistulography, galactography, dacryocystography, sialography. Contraindications. Hypersensitivity to the active principle and to any of its ingredients. Investigations of the female genitalia are contraindicated in sus-pected or confirmed pregnancy and in cases of acute inflammation. Intrathecal administration. Concomitant administration of Iomeprol with corticosteroids is contraindicated. Due to overdose considerations, immediate repeat myelogra-phy in the event of technical failure is contraindicated. Special warnings and special precaution for use. Consideration of possible serious side effects, the use of iodinated contrast media should be limited to cases for which there is a precise need for a contrast examination. Use in specific patients: Neonates, infants, children. Young infants (age <1 year) especially neonates, are particu-larly susceptible to electrolyte imbalances and haemodynamic alterations. Care should be taken regarding the dosage to be used, the details of the procedure and the patient’s status. Elderly. The elderly are at special risk of reactions due to CM high dosage. The frequently encountered combination of neurological disturbances and severe vascular pathologies constitutes a serious complica-tion. Hypersensitivity or a previous history of a reaction to iodinated contrast media also increases the risk of recurrence of a severe reaction with non ionic media. Women of child-bearing potential: appropriate investigations and mea-sures should be taken when exposing women of child-bearing potential to any X-ray, examination, whether with or without contrast medium. Caution should be used in patients to patient with allergic disposition. hay fever, hives and food allergy, asthmatic patients, hyperthyroidism, nodular goitre, renal impairment, diabetes mellitus, multiple myeloma, paraproteinaemia (Waldestroem’s para-proteinemia), myelomatosis or paraproteinaemias, myasthenia gravis, severe liver and renal dysfunctions, severe cardiovascular disease, severe and chronic hypertension, acute cerebral infarction, acute intracranial haemorrhage, and conditions involving blood-brain-barrier (BBB) damage, brain oedema and acute demyelination, presence of intracranial tumors or metastases and a history of epilepsy, neurological symptoms due to degenerative, inflammatory or neoplastic cerebrovascular pathologies, cerebrovascular diseases, recent stroke or frequent TIA (transient ischaemic attack), alcoholism. Undesirable effects: general. The use of iodinated contrast media may cause untoward side effects. They are usually mild to moderate. However, more serious re-actions up to anaphylactoid shock, with possible fatal outcome, may occur. In most cases reactions occur within minutes of dosing. However, reactions may manifest also later on up to 24 hours from the injection, depending on the administration route. Anaphylaxis (anaphylactoid/hypersensitivity reactions) may manifest with various symptoms, and rarely does any one patient develop all the symptoms. Typically, in 1 to 15 min (but rarely after as long as 2 h), the patient complains of feeling abnormal, agitation, flushing, feeling hot, sweating increased, dizziness, lacrimation increased, rhinitis, palpitations, paraesthesia, pruritus, head throbbing, pharyngolaryngeal pain and throat tightness, dys-phagia, cough, sneezing, urticaria, erythema, and mild localised oedema or angioneurotic oedema and dyspnoea owing to tongue and laryngeal oedema and/or laryngospasm manifesting with wheezing and bronchospasm. Nausea, vomiting, abdominal pain, and diarrhoea are less common. Severe anaphylac-tic reactions involving the cardiovascular system, such as vasodilatation, with pronounced hypotension, reflex tachycardia, dyspnoea, agitation, cyanosis and loss of consciousness progressing to respiratory and/or cardiac arrest may result in death. These events can occur rapidly and require full and aggres-sive cardio-pulmonary resuscitation. Primary circulatory collapse, can occur as the only and/or initial presentation without respiratory symptoms or without other signs or symptoms outlined above. Overdose. Overdose may lead to life-threatening adverse effects mainly through effects on the pulmonary and cardiovascular system. Instruction for use/handling. Vial or bottles containing contrast media solution are not intended for the withdrawal of multiple doses. Bottles of 500 ml should be used in conjunction with an injector system. After each patient examination, the connecting tubes (to the patient) and relevant dis-posable parts should be changed. Marketing Authorisation Information. The Marketing Authorisation Holder, number, and date of approval may be different in different countries. Volumes, presentations, and indications may also differ. Refer to the local Summary of Product Characteristics. Please contact Bracco Imaging SpA –Via Egidio Folli, 50 20134 Milano- Italy for further information. Date of Preparation of this Document: October 2012

WhenHighest Iodine

ConcentrationMatters1-2

In first passdynamic CT imaging,

at equal flow rateand total iodine dose,

iomeprol 400 mgI/mL,can provide better

contrast enhancement and image quality than

contrast solutions at lower iodine strength3-5

References: 1) Iezzi R, Cotroneo AR, Giammarino A, et al. Low-dose multidetector-row CT-angiography of abdominal aortic aneurysm after endovascular repair. Eur J Radiol. 2011 Jul;79(1):21-8. Epub 2009 Dec 16 2) Iezzi R, Santoro M, Marano R, Di Stasi C, Dattesi R, Kirchin M, Tinelli G, Snider F, Bonomo L. Low-dose multidetector CT angiography in the evaluation of in-frarenal aorta and peripheral arterial occlusive disease. Radiology. 2012 Apr;263(1):287-98. Epub 2012 Feb 13 3) Albrecht T., Foert E., Holtkamp R., Kirchin M.A., Ribbe C., Wacker F.K., Kruschewski M., Meyer B.C. 16-MDCT angiography of aortoiliac and lower extremity arteries: comparison with digital subtraction angiography. AJR Am J Roentgenol. 2007 Sep; 189(3):702-11 4) Schuknecht B. High-concentration contrast media (HCCM) in CT angiography of the carotid system: impact on therapeutic decision making. Neuroradiology (2007)49 (Suppl 1) 5) Marchianò A., Spreafico C., Lanocita R., Frigerio L., Di Tolla G., Patelli G., Garbagnati F., Heiman F., Taroni P., Damascelli B. Does iodine concentration affect the diagnostic effi cacyof biphasic spiral CT in patients with hepatocellular carcinoma? Abdom Imaging. 2005 May-Jun; 30(3):274-80

AD IOM 11 2012.indd 1 13/11/12 14:17

NEwSImaGInG

A cardiovascular death in China every 10 seconds

At the recent 23rd Great Wall International Congress of Cardiology held in Beijing the extent of the impact of cardiovascular disease in China was highlighted. “Every year three million Chinese people die from cardiovascular disease and every 10 seconds there is one death from CVD in China,” said Professor Dayi Hu, chief of the Heart Centre at the People’s Hospital, Peking University and president of the Chinese Society of Cardiology (CSC). He adds: “Prevention has not been a priority in China because for the last 20 to 30 years the medical system has mainly been treating the late stages of heart disease. The number of patients treated with stents has increased dramatically.” Cardiovascular disease is the top cause of death in China and causes more than 40% of all deaths.

Smoking is a massive problem in Chinese men – 54% of men smoke.

“What’s worse is that half of male phy-sicians are smokers and one-third of Chinese male cardiologists are smok-ers, so it’s a real problem,” said Professor Hu. There is an increasing epidemic of hypertension in China. Some 200 mil-lion Chinese people have hypertension and the rate of hypertension is rising in all age groups. But awareness, treatment and control of hypertension are low. Just 30% of patients with hypertension in China are aware they have it, compared to 80% awareness in the US. Only 24% of Chinese patients with hypertension receive treatment (vs 73% in the US) and only 6% of patients have their blood pres-sure under control (vs 50% in the US).

Prof Hu said “I think a healthy China has to be started from the healthy phy-sician,” said Professor Hu. “Physicians and cardiologists need to quit smoking, eat healthily, exercise and control their

body weight so that they can be a good example for patients and the public, and effectively promote CVD preven-tion measures with the government, pharmaceutical companies and food manufacturers. I believe that if there is no healthy physician there will be no healthy China.”http://tinyurl.com/int-congr-cardiology

The growing middle-class population in India is increasing demand for higher quality healthcare services and treatment, according to a new report by the inde-pendent market research group InMedica. Increasing awareness of the latest medi-cal advances is driving demand for higher specification ultrasound equipment that can be used for specialist diagnosis and procedures. Consequently, strong growth is projected in the color ultrasound mar-ket over the next five years, with revenues forecast to increase by 49 percent over this time. Due to the rising demand for improved healthcare services there is a

growing trend in India for hospitals and clinics to replace black and white ultra-sound systems with color systems that offer better image quality. The increasing functionality and technology found in low-end and mid-range ultrasound systems is driving strong growth in these markets, as many first generation users upgrade to higher specification equipment. As a result, color ultrasound equipment is forecast to account for 87 percent of unit shipments by 2016, compared to 73 percent in 2011.

As healthcare services continue to expand, the clinical expertise of physicians will diversify. This will increase demand for equipment with advanced imaging features that are commonly used in mature markets, such as 3D/4D imaging, elastography and fusion imaging. There is a growing num-ber of Chinese manufacturers entering the Indian market. Low-cost black-and-white ultrasound systems will still be necessary to improve access to basic diagnostic imag-ing services in many rural regions of India.

However, as color equipment is becoming more affordable for smaller-sized hospi-tals and demand in large and medium-sized hospitals is increasing for advanced ultrasound technology, color ultrasound systems will continue to dominate the Indian ultrasound market.http://tinyurl.com/inmedica-report

Strong growth projected in Indian color ultrasound market

Study shows bicarb hydration therapy better than saline for CI-AKI

A recently published paper from a Korean group of clinicians (Jang et al. Circ J. 2012; 76: 2255) presents a meta-analysis of the literature describing randomized controlled trials compar-ing sodium bicarbonate with sodium chloride for the prevention of contrast-induced acute kidney injury (CI-AKI). Defined as an increase in serum creati-nine level of 25%, CI-AKI is associated with a significantly increased risk of

6 D I A G n O S t I C I m A G I n G A S I A P A C I F I C Autumn 2012

continued on page 08

Tablet computers OK for on-call radiology but software needs improvement

On the face of it, tablet computers such as Apple’s iPad which have a large format, improved graphic display reso-lution and a touch screen interface seem to be more suitable for viewing radiol-ogy images than previous mobile devices such as smart phones and laptops. Uses such as emergency radiology telecon-sultation seem particularly appropri-ate. However it is necessary to verify that in reality, tablet computers can ful-fill their theoretical potential. This is

what a team from the Department of Radiology at Changi General Hospital, in Singapore set out to do (John S et al. J Digit Imaging 2012; 25: 628). They transferred to three iPAD tablet systems a total of 79 CT and MRI images taken in a range of common on-call condi-tions and which had been reported on using a full-featured diagnostic PACS workstation. The iPad ran Osirix HD DICOM software. Images were ana-lyzed by three reviewing radiologists. All three radiologist reported a favor-able user experience but noted issues with software stability and some limi-tations of image manipulations tools. The conclusions of the Change group are that emergency conditions that are

commonly met on CT and MRI can be diagnosed using tablet computers and there is a good agreement with dedi-cated PACS systems. The full potential of iPADs will however only be realized in such applications if the shortcomings in software are resolved.http://tinyurl.com/John-et-al-paper

A recent paper (Yip et al Lancet 2012; 379: 833) has attempted an early appraisal of the results so far of China’s huge health care reform program, launched in 2009 as an ambitious US$125 billion programme to ensure universal health coverage. The reform was well overdue, says Winnie Chi-Man Yip at the University of Oxford, UK. “Before the health-care reform, the Chinese Government was faced with widespread public discon-tent stemming from unaffordable access to health care, major financial risks associated with out-of-pocket medical expenses, and growing inequalities in access to health care and health status across regions and popula-tions of different socioeconomic status and between urban and rural areas.”

The authors say that, “despite its size and varied socioeconomic local condi-tions, China has made big strides towards

providing its population with affordable and equitable access to basic health care in the past few years. It has overtaken many devel-oping nations and achieved nearly univer-sal insurance coverage in less than a decade and has begun to establish some necessary foundations for primary health care and public health provision.”

There is more to be done. “China can expand its redistribution of resources by adopting funding formulas that adjust for heterogeneous needs (such as demograph-ics, health, and socioeconomic indicators) at sub-provincial or municipality level. China can also show its serious commitment to health by increasing taxes on tobacco. The medical education system has to be reformed to produce well-trained primary health-care providers, but China’s needs are vast and it will take a long time to train enough family doctors”, say the authors.

Finally, the authors say that pumping money into the healthcare system is nec-essary but needs to be carefully managed to allow development of absorptive capac-ity of service providers. Independent, out-come-based monitoring and evaluation are essential for mid-course correction and to make officials and providers accountable.http://tinyurl.com/Yip-et-al-paper


CT useful to discrimi-nate life-threatening stercoral colitis

Stercoral colitis is the focal inflamma-tory condition of the colon related with increased intraluminal pressure result-ing from impacted and dehydrated fecal material. Fecal impaction leading to colonic obstruction is seen primarily in the elderly who are neurologically impaired. Fecal impaction usually results from chronic constipation.

Fecaloma impaction associated stercoral colitis (SC) can result in cata-strophic complications such as perfora-tion and fecal peritonitis that may become life threatening with a mortality rate of 32-57%

Several reports on the usefulness of CT in stercoral colitis have already been published but so far no study has yet com-pared the CT findings in fatal SC to those of non-fatal SC. A retrospective study was carried out by a team from Chang Gung, Taiwan to evaluate the diagnostic value of CT and its ability to discriminate findings of fatal SC from those of non-fatal SC (Wu et al. Korean J Radiol 2012; 13: 283) For this study, Wu and colleagues defined fatal SC as one that may cause sepsis-related death in a patient who otherwise has no other discernible infection foci during the course of hospitalization. Their study was retrospective and a total of 23 patients

continued on page 08

China plans to rebuild its health care system by 2020. Its health reform will fuel investment in hospital expan-sion and medical equipment.

China’s health-care reforms: work in progress

IMAGING NEwS

morbidity, including prolonged hospi-talization, need for dialysis and mortal-ity and is a leading cause of hospital-acquired acute renal failure. CI-AKI occurs more frequently in high-risk patients than in low-risk patients with several predisposing factors being well recognized, such as diabetes mellitus, chronic kidney disease, nephrotoxic drugs and various other co-morbidities. Although CI-AKI is generally regarded as a transient decline in renal function

after contrast procedures, it cannot be regarded as a benign complication.

Jang and his colleagues reviewed a total of 416 articles and 56 studies were selected for inclusion and further evaluated. Subsequently, 19 papers were included in the final analysis.

They found that the use of bicar-bonate-based hydration in comparison to normal saline significantly reduces the incidence of CI-AKI. The beneficial effect of sodium bicarbonate was consis-tent across trials that included patients who had renal dysfunction at baseline and underwent elective or emergency angiographic procedures with contrast medium. A more pronounced effect of sodium bicarbonate was found in tri-als using low-osmolar contrast medium compared with those using the iso-osmolar agents. The authors recom-mend that physicians should ensure that CI-AKI is avoided by conducting a preoperative evaluation of vascular

disease with a small amount or no con-trast media in patients with preexist-ing renal insufficiency. The overall conclusion of the study is that a sodium bicarbonate-based regimen can be considered optimal hydration in high-risk patients undergoing exposure to iodinated contrast mediahttp://tinyurl.com/Jang-et-al-paper

CI - AKI : continued from page 06

Stercoral Colitis : continued from page 07


were studied. Their results clearly showed that the use of CT was statistically valu-able in the discrimination of potentially fatal from non-fatal SC, with the findings of dense mucosa, perfusion defect, ascites and abnormal gas. The authors do re cog-nise that a refined prospective evaluation of the diagnostic value of CT for SC should be carried out on a larger subject popula-tion, this time with endoscopic finding also added as additional inclusion criterion.http://tinyurl.com/Wu-et-al-paper

Monochromatic and material decomposition images of cirrhosis. transverse (Left Panel) monochromatic Ct image obtained at 70-keV energy level and iodine-based (Centre Panel) and water-based (right panel) material-decomposition images obtained from single spectral Ct acquisition.

Dual-energy computed tomography (DECT) has been around for several decades but the method has not previ-ously achieved widespread clinical use because of deficiencies inherent in the immature technology. These deficien-cies include motion-related misregis-tration, marked image noise, relatively low spatial resolution, and excessive radiation exposure. The recently intro-duced Spectral CT, a single-detector and single-source DECT system with a capability for rapid alternation between two peak voltage settings (i.e., “fast switching”), has led to renewed interest in clinical application and further inves-tigation of DECT. The high- and low-

energy datasets (140 kVp and 80 kVp) the datasets obtained using Spectral CT can be utilized to reconstruct material-decomposition images (e.g., water and iodine-based images).

CT with energy information, espe-cially spectral CT, is thus an imaging method that extends the capabilities of conventional CT. Spectral CT not only enables the estimation of full linear attenuation, as a function of X-ray pho-ton energy of the imaged subject at each voxel in the CT volume, but the method also generates material decomposition images so that the composition of the imaged subject can be represented as an equivalent mixture of two basis materials.

A team from Shanghai, China has studied the applicability of the new technique to investigate liver cirrho-sis, i.e. the late stage of hepatic fibrosis which results in widespread distortion of normal hepatic architecture (Lv P et al Korean J Radiol 2012; 13: 434). Cir-rhosis is characterized by regenerative nodules surrounded by dense fibrotic tissue. There are different uptakes of iodine contrast agents in the healthy liver and three stages of liver cirrho-sis during the arterial phase (AP) and portal venous phase (PVP).

The Shanghai team found that the combination of quantitative Spectral CT imaging parameters- provided high sensitivity and specificity for differenti-ating healthy liver from cirrhotic liver. http://tinyurl.com/Lv-et-al-paper

Spectral CT shows potential in liver cirrhosis

▼Gadovist®1.0 mmol/ml solution for injection (gadobutrol) and Gadovist®1.0 mmol/ml solution for injection pre-filled syringe/cartridge (gadobutrol) Prescribing Information (Refer to full Summary of Product Characteristics (SmPC) before prescribing) Presentation: Glass vials containing 15ml, or glass prefilled syringes containing 7.5ml or 10ml, of gadobutrol 1.0mmol/ml solution for injection (604.72mg gadobutrol/ml). Indications: Adults, adolescents and children aged 2 years and above: Contrast enhancement in cranial and spinal MRI; MRI of liver and kidneys if suspicion or evidence of focal lesions and in magnetic resonance angiography (CE-MRA). Posology and administration: Gadovist should only be administered by healthcare professionals experienced in the field of clinical MRI practice. This medicinal product is for intravenous administration only. Give required dose intravenously as bolus injection. Patient should be recumbent during administration. MRI can start immediately after injection. Optimal signal enhancement usually occurs during arterial first pass for CE-MRA and within 15 minutes of injection for CNS indications. Particularly suitable for T1-weighted scanning sequences. Observe patient for 30 minutes after administration. Intended for single use only. Visually inspect before use; do not use in case of severe discolouration, occurrence of particulate matter or defective container. Contrast medium not used in one examination must be discarded. Vials: draw up into syringe immediately before use; never pierce rubber stopper more than once. Pre-filled syringe: prepare immediately before administration. CNS indications: Adults: 0.1mmol/kg body weight (equivalent to 0.1ml/kg body weight). A further injection of 0.2ml/kg body weight may be given within 30 minutes of first injection. CE-MRI of liver and kidneys: Adults: 0.1mmol/kg body weight (equivalent to 0.1ml/kg body weight). CE-MRA: Adults: Imaging of 1 field of view (FOV): 7.5ml for body weight below 75 kg, 10ml for body weight of 75 kg and higher (corresponding to 0.1-0.15 mmol/kg BW). Imaging of >1 field of view (FOV): 15ml for body weight below 75 kg, 20ml for body weight of 75 kg and higher (corresponding to 0.2-0.3 mmol/kg BW). Impaired renal function: Only use in patients with severe renal impairment (GFR < 30 ml/min/1.73m2), and in patients in perioperative liver transplantation period after careful risk/benefit assessment and if diagnostic information is essential and not available with non-contrast enhanced MRI. If necessary to use Gadovist, dose should not exceed 0.1 mmol/kg body weight. Do not use more than one dose per scan. Do not repeat the dose for at least 7 days. Children and adolescents: For children aged 2 years and above: 0.1 mmol/kg body weight (equivalent to 0.1ml/kg body weight) for all indications. Not recommended in children below 2 years of age due to lack of data on safety and efficacy. Elderly (65+ years): No dose adjustment, exercise caution. Contra-indications: Hypersensitivity to ingredients. Warnings and precautions: If injecting into veins with a small lumen, adverse effects such as reddening or swelling may occur. Observe usual precautions for MRI (e.g. exclusion of ferro-magnetic objects). Hypersensitivity reactions, including anaphylactoid reactions ranging to shock, have been observed. Appropriate drugs and instruments must be within hand-reach. Hypersensitivity reactions are not predictable, however in patients with an allergic disposition, carefully evaluate risk-benefit ratio. In rare cases, delayed anaphylactoid reactions (after hours to days) have been observed. Prior to administration, it is recommended to screen all patients for renal dysfunction by laboratory testing. Nephrogenic Systemic Fibrosis (NSF) has been reported with gadolinium-containing contrast agents in patients with acute or chronic severe renal impairment (GFR < 30ml/min/1.73m2). Patients undergoing liver transplantation are at particular risk due to high incidence of renal failure. Only use in patients with severe renal impairment and those in the perioperative liver transplantation period after careful risk/benefit assessment and if the diagnostic information is essential and not available with non-contrast enhanced MRI. Haemodialysis shortly after Gadovist administration may be useful in removing Gadovist from the body. There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis. As renal clearance may be impaired in the elderly, it is particularly important to screen patients aged 65+ years for renal dysfunction. Use with caution in patients with a low seizure threshold. Gadovist contains less than 1mmol sodium per dose (based on average amount given to a 70kg person), i.e. essentially ‘sodium-free’. Interactions: No studies have been performed. Pregnancy and lactation: Do not use during pregnancy unless the clinical condition of the woman requires use of gadobutrol. Gadolinium containing contrast agents are excreted into breast milk in very small amounts. At clinical doses no effects on the infant are anticipated. Continuing /discontinuing breastfeeding for 24 hours after Gadovist administration should be at the discretion of the doctor and nursing mother. Undesirable effects: Most undesirable effects are of mild to moderate intensity. Common: Nausea, headache. Uncommon: dysgeusia, injection site reactions, feeling hot, dyspnoea*. Rare: Hypersensitivity/ anaphylactoid reactions (e.g. anaphylactoid shock§*†, circulatory collapse§*, respiratory arrest§*†, bronchospasm§, cyanosis§, oropharyngeal swelling*, hypotension*, blood pressure increased§, chest pain§, urticaria, laryngeal/face§/eyelid oedema, angioedema§, conjunctivitis§, flushing, hyperhidrosis§, cough§, sneezing§, burning sensation§, pallor), loss of consciousness, convulsion. Not known: Cardiac arrest*†, Nephrogenic systemic fibrosis (NSF) (isolated cases). Patients with an allergic disposition more frequently suffer from hypersensitivity reactions. §Hypersensitivity/anaphylactoid reactions identified only post-marketing (frequency not known). *These adverse reactions may have a fatal or life-threatening outcome. †These reactions are considered the most serious adverse drug reactions. Prescribers should consult the SmPC in relation to other side effects. Overdose: In case of overdose, perform cardiovascular monitoring (including ECG) and control renal function as a measure of precaution. In patients with renal insufficiency, Gadovist can be removed by haemodialysis. After 3 haemodialysis sessions approx. 98% of agent is removed from the body. However, there is no evidence that haemodialysis is suitable for prevention of NSF. Incompatibilities: Do not mix Gadovist with other medicinal products. Legal category: POM Basic NHS Price: 1 x 15ml vial £101.26, 1 x 7.5ml pre-filled syringe £50.63, 5 x 10ml pre-filled syringes £337.54 MA Numbers: 00010/0535 (vials), 00010/0536 (pre-filled syringes) Further information available from: Bayer plc, Bayer House, Strawberry Hill, Newbury, Berkshire, RG14 1JA, United Kingdom. Telephone: 01635 563000. Date of preparation: April 2012. Gadovist® is a trademark of the Bayer Group.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to Bayer HealthCare; Tel: 01635 563500,

Fax: 01635 563703, Email: [email protected]

References1. Rohrer M et al. Investigative Radiology 2005; 40(11):715 – 724.2. Bayer Data on file3. Tombach B et al. Eur Radiol 2008;18: 2610 – 2619.4. Frenzel T et al. Invest Radiol 2008; 43(12):817 – 828.

www.bayer.co.ukEnquiries: 01635 563000Calls to and from Bayer HealthCare may be recordedDate of preparation: October 2012. L.GB.10.2012.0619All rights reserved. © Bayer plc 2012

The Power of Contrast

Q Highest T1-shortening per unit volume 1,2

Q Delivering high diagnostic efficacy 3

Q Macrocyclic compound – class with highest stability 4

13359_bhc_gv_ad_poc_uk_210x297_bl.indd 1 11.10.12 11:14

RHEUMATOID ARTHRITIS


By Dr Vinod Ravindran

radiographic scoring methods in rheumatoid ArthritisDespite the advent of magnetic res-onance imaging and musculoskel-etal ultrasound, plain radiographs of the hands and feet remain an important tool in rheumatoid arthri-tis (RA) both in routine clinical and research settings. This mini-review focuses describes the most com-mon methods used in scoring radiographs in RA, and discusses pertinent issues in such scoring.

Radiographs of the hands and feet are used to evaluate the disease course of rheumatoid arthritis (RA) both in the clinical practice and research settings. Radiographic scores have

been associated with other measures of disease activ-ity, such as laboratory parameters, clinical features, and functional class, all of which are commonly used end points in clinical trials. The true efficacy of disease-modifying anti-rheumatic drugs traditionally has been viewed as their capacity to slow down radiographic dam-age. Assessment of radiographic damage could also give valuable insight into the RA disease course in different ethnicities [1]. For these reasons, the current “gold stan-dard” for radiological evaluation of disease progression in RA is by plain radiographs. It has been recommended that each clinical trial exceeding 1 year should assess radiographic damage. Magnetic resonance imaging (MRI) and ultrasound assist with the diagnostic work-up in suspected, but not definite, inflammatory joint dis-ease and early, unclassified inflammatory joint disease (by detection of presence/absence of synovitis, enthesi-tis, bone erosions, etc.). MRI and ultrasound are more sensitive than radiographs in detecting early structural changes in joints and surrounding structures however, the availability, costs and training related issues limit the use of these technologies in daily clinical practice [2].

technIcal aspects In scorInG radIoGraphs Radiographic lesions in RA include soft tissue swelling, juxta-articular osteopenia, bone erosions, joint space narrowing indicative of loss of cartilage, cysts, joint subluxations, mal-alignment, and ankylosis. All radio-graphic scoring methods assess erosions and joint space narrowing, whereas other features are not always used. Standardized patient positioning and radiographic techniques, as well as the use of fine detail screen film combinations, are important to improve the sensitivity and reproducibility of radiographic scoring.

The scoring systems that have been designed to eval-uate radiographic changes in RA can be divided into two main groups: global and detailed. Global scoring systems assign one score to the entire joint, taking into account all the abnormalities seen, whereas detailed systems assign scores on at least two separate variables for each joint evaluated. The Sharp [3, 4] and Larsen methods [5] have been developed to assess radiographs more quantitatively and they and their modifications are the two most widely used methods of scoring radiographic damage.

the sharp methodThe original Sharp method [3] included radiographs of the hands and wrists and scored features such as periosteal reaction, cortical thinning, osteoporo-sis, sclerosis, osteophyte formation, defects, cystic changes, surface erosions, joint space narrowing, and ankylosis. Limitations of several of these features led to their omission from the final score which includes two scores, one for erosions and the other for joint space narrowing (JSN) [4]. For erosions, 17 areas are considered and 18 areas for joint space narrowing. An erosion score of 0 to 5 is given to each joint that is analyzed, according to the number of erosions; “5” representing the total destruction. Similarly JSN can be scored from 1 (focal JSN) to 4 (ankylo-sis). Subluxation is not scored. The final score for erosions and JSN ranges from 0 to 170 and 0 to 144 respectively.

dr Vinod ravindran md Frcp is at Department of Rheumatology,

MES Medical College, Perinthalmanna, Kerala, 679338, India.

Phone: +91 4933-298300.

E-mail [email protected]

«... The gold standard for radiological evaluation of RA disease progression

is by plain radiographs...»


the sharp/Van der heIJde mehodBy including feet for both erosions and JSN and by omitting some areas of the hand for JSN the van der Heijde modification [6] of the Sharp method overcame major limitations of the modified version of Sharp score [4].

In this method, erosion is assessed in 16 joints and graded from 0(no erosions) to 5(extensive). The JSN is assessed in 15 areas for each hand and wrist and 6 areas for each foot and graded as 0 (normal) to 4 (bony ankylosis or complete sub-luxation). The maximum erosion score is 160 for the hands and wrists and 120

for feet. The maximum JSN score is 120 for the hands and wrists and 48 for feet. Therefore, the total Sharp/van der Hei-jde radiographic score ranges from 0 to 448. The Sharp/van der Heijde method has been used extensively in several recent landmark trials in RA including biological agents.

the larsen methodThe Larsen method [5] includes both erosions and JSN in each joint as a single score according to reference radiographs. In this method, six stages reflecting gradual, progressive dete-rioration have been recognized. As a supplement to the standard reference films, descriptions of these stages were also given to aid the scoring. The score ranges from 0 to 250. A modification of its original method to evaluate radiographs in long-term studies was proposed later by Larsen et al. [7].

Numerous modifications of the above methods have been developed

and sought to overcome some spe-cific limitations in a given method [8]. Overall, the Larsen method is more easily scored and less time consuming than Sharp method. As the Sharp and Sharp/van der Heijde methods utilize a higher degree of detail, they can be time consuming and that is the major drawback when compared to the Larsen method and its modifications.

merIts and lImItatIons Radiographs are reproducible, allow measurement of severity, and can identify single point damage and pro-gression with fairly high precision and accuracy. Characteristic X-ray findings aid in the diagnosis of RA. X-ray can be helpful in the differentiation of RA from other joint conditions includ-ing osteoarthritis, psoriatic arthritis, and neoplasms. Early bone erosions are correlated with poor long-term radiographic and functional outcome, and early progression in X-ray ero-sions is related to future impairment in physical function. Other important advantages of X-ray are the possibil-ity of standardization and blinded centralized reading and existence of validated assessment methods.

Although radiographs provide opti-mal documentation of joint destruc-tion, several important limitations are seen in the application of radiographs as a measure of clinical status in patients with RA. “Floor” and “ceiling” effects related to detection and scoring of RA-induced disease seen on conventional radiographs have been well recognized. The floor effect stems from the fact that the hallmark radiographic findings of bony erosions and joint space narrow-ing may occur late in the pathophysi-ology of the disease whereas the ceil-ing effect refers to the fact that radio-graphic progression of the disease can continue even after the highest damage score has been assigned. Radiographs change slowly in most people with RA. Modern treatment of RA requires that many patients be treated prior to any evidence of radiographic damage. Other disadvantages of X-ray include projectional superimposition due to

FIGURE 1. Radiographs of hands of a patient with rheumatoid arthritis showing extensive erosive destruction of carpal bones, joints space narrowing of proximal inter-phangeal (PIP) joints , varying degree of sub-luxation of metacarpo-phalangeal (MCP) joints, discreet erosions (right 4th and 5th metacarpal heads).

«... Any RA clinical trial exceeding one year should assess

radiographic damage...»

rhEuMATOID ArThrITIS

the two dimensional representation of three-dimensional pathology, use of ionizing radiation, relative insensitivity to early bone damage, and total insufficiency for assessment of soft tissue changes including synovitis.

reportInG oF radIGraphIc dataThere is wide variability in the methods used to report radiographic data, which hampers comparisons between trials. Adopting specific standards for reporting radio-graphic data may help overcome this. The current key recommendations regarding the scoring itself, are (1)

radiographs of the hands and feet should be included, (2) the smallest detectable difference (SDD) should be used as quality control ( SDD is the smallest change that can be reliably discriminated from the measurement error of the scoring method, which for example is 5.0 for the Sharp/van der Heijde method) ; (3) there should be preferably two or more observers; (4) kappa and/or intra-class correlation coefficient and SDD for inter-observer agreement should be used and (5) the average score of observers should be used [9]. The key recommendations in relation to report-ing the data are (1) absolute numbers should be reported for radiographic change along with the maximum score possible; (2) primary analysis should be done at group level reporting mean change in values together with the standard error or standard deviation; and (3) secondary analysis done at the patient level should give the percentage of patients with disease progression [9].

Future dIrectIonsDigital imaging techniques and the development of a number of picture archiving and communication systems have been reported to increase clinical efficiency. Use of such techniques as well as appraisal of their performance compared to MRI in both clinical and research setting could enhance the value of conventional radiography. Teaching and training of the radiographic scoring methods is important for the ongoing development of this important field.

reFerences1. Ravindran V et al. Clin Rheumatol 2008; 27:97–100.

2. Ostergaard M et al. Best Pract Res Clin Rheumatol 2008; 22:1019–1044.

3. Sharp JT et al. Arthritis Rheum 1971; 14:706–720.

4. Sharp JT et al. Arthritis Rheum 1985; 28:1326–1335.

5 Larsen A et al. Acta Radiol Diagn1977; 18:481–491.

6. Van der Heijde D et al. J Rheumatol 1999; 26:743–745.

7. Larsen A et al. J Rheumatol 1995; 22:1974–1975.

8. Ravindran V et al. Clin Rheumatol 2011; 30:1–6.

9. van der Heijde D et al. Arthritis Rheum 2002; 47:215–218.


FIGURE 2. Radiographs of feet of a patient with rheumatoid arthritis showing erosions (bilateral 1st meta-tarsal heads, right second proximal phalange base), big erosion at right second metatarsal head and subcortical cysts (bilateral 1st inter-phalangeal joints).

Anatomy in Diagnostic Imaging, 3rd EditionBy P Fleckenstein, PS Myschetzky, JTranum-Jensen Pub by Wiley-Blackwell, 2013, 512 pp €74.40

Book review

This book is a basic atlas of anatomy applied to diagnostic imaging. It covers the entire human body employing all the imaging modalities used in clinical practice; x-ray, CT, MR, ultra-sound and scintigraphy. It includes over 800 carefully selected images, which are very east to read due to their high quality and the com-prehensive anatomical interpretation that is that is drawn and labelled directly on a contact print alongside every image. The third edition will contain extended coverage of MR scanning given the great strides that have been made in this area recently. It will also cover PET scanning for the first time in recognition of the fact

that this modality has become a great deal more common.Both for medical students and doctors the book will serve as the all-round reference collection linking anatomy and modern diagnostic imaging.The technique chapter has been updated with relevant technical developments. Among oth-ers MR and PET have been elaborated more and several new figures added.The 46 images (‘twin images’, i.e. plain and interpreted) are replaced/supplemented with 86 new twins, which means a net increase of 40 images. The number of pages will be increased by 26 compared to the previous edition.

CONTRAST MEDIA


By Dr M-F. Bellin

Late adverse reactions to intravascular iodine-based contrast mediaIodinated X-ray contrast media are one of the most common administered pharmaceutical products and with the steady increase of CT and X-ray exami-nations there is a growth in the use of such media. Generally mild and self-limiting, late adverse reactions (LARs) to contrast media have long been recognized. In 2003, the Contrast Medium Safety Committee (CMSC) of the European Society of Urogenital Radiology (ESUR) isssued guidelines regard-ing LARs. However since that date, there have been many new studies pub-lished on the incidence, symptomatology and pathophysiology of LARS, as well as prospective comparative studies and reviews.

The Contrast Medium Safety Committee (CMSC) of the European Society of Urogeni-tal Radiology (ESUR) is composed of 13 radi-ologists (12 active members and one honor-

ary member) from various European countries and is chaired by Dr HS Thomsen from Denmark. In addition to this panel of clinicians, there are four consultants to the committee, representing some of the major manufacturers of contrast media products.

The committee recently reviewed the development of the situation with regard to late adverse reactions (LARs) to the administration of iodine-based contrast media since the previous publication in 2003 of ESUR’s guidelines on the subject. The methodology used was a detailed review of the relevant literature, using two litera-ture databases, PubMed and Web of Science, which were interrogated using appropriate search terms.

The results of the review were published in Eur Radiol [1].

symptoms oF late reactIonsLARs are defined as reactions occurring between 1h and 1 week after the administration of intravascular iodinated contrast medium. This broad period of time in which LARs may occur complicates detailed analysis of the nature and frequency of LARs, since it is sometimes not clear whether the contrast medium is in fact the true cause of the many symptoms that have been associated

with LAR. In addition, the collection of reliable and accurate data from patients who have been administered contrast media in the previous week is not easy and may not be totally rigorous.

This difficult situation has been greatly clarified by sev-eral studies which have compared the symptoms observed after enhanced and unenhanced CT. These studies have shown clearly that the most frequent symptoms seen in patients who had received contrast medium for enhanced scans were skin rashes.

Frequency oF lars aFter dIFFerent contrast medIaThe frequency of LARs varies with the nature of the chemical structure of the contrast agent used.

The use of non-ionic dimers is associated with a three-to four fold increase in the frequency of LARs compared to non-ionic monomers. Thus, late skin reactions occur three-four times more often with the nonionic dimer iodixanol than with nonionic monomers such as iopami-dol and iomeprol. There seems to be no significant differ-ence in the occurrence of LARs between the use of differ-ent non-ionic monomers. Likewise the rate of LARs seems to be the same whether the agent is an ionic or a non-ionic monomer. The frequency of LARs with the ionic dimer ioxalate is similar to those with non-ionic monomers.

“...The use of non-ionic dimers is associated with a three- to four-fold increase in the frequency of LARs

compared to non-ionic monomers...”

dr m-F Bellin,

Service de Radiologie Générale Adultes, Hôpital de Bicêtre, Secteur Paul Broca, Université Paris-Sud, 78 Rue du Général Leclerc, 94275 Le Kremlin-Bicêtre Cedex, France email: [email protected]


In quantitative terms, when only skin reactions to nonionic monomers are considered, the frequency of LARs is lower than 4% of all cases, although this value is significantly increased if other, non-skin, symptoms are considered as LARs.

pathophysIoloGy oF larsMuch information on the nature of the pathophysiology involved in LARs has been generated from studies involving skin tests using diluted iodinated con-trast medium. These tests are carried out on patients who have reacted to con-trast media, i.e so-called “reactors”. Such

skin tests include skin prick and delayed reading intradermal tests which can identify both IgE- and T-Cell-mediated mechanisms, as well as patch tests which only identify T-cell mediated reactions.

These studies have shown that the skin reaction seen after the administra-tion of iodinated contrast media is very similar to that seen with many other drugs, where the reaction has been shown to be mediated by T-cells.

In patients who have demonstrated LARs with non-ionic contrast agents, the skin test studies have shown that there is a significant cross-reactivity with other non-ionic agents, but that there is no reaction with inorganic iodine. This suggests that the whole molecule of the contrast agent plays an immunogenic role but free iodine does not.

The obervations that peripheral blood lymphocytes taken from patients

who have previously had LARs are acti-vated in vitro when exposed to contrast medium provide support for this puta-tive immunogenic role. Further support for this theory comes from evidence that dendritic cells from reacting patients are involved in the recognition and presen-tation of contrast medium molecules to cells of the immune system.

However it should be noted that there is an inconsistency in the skin testing studies, namely that some patients who have had late adverse reactions to the contrast agent do not react positively on skin testing with that agent. More extensive studies are needed to investi-gate this. A better understanding of this inconsistency is necessary for the estab-lishment of a reliable positive predictive value (PPV) for the use of skin tests.

Nevertheles, despite this, it has been suggested that if a patient with a

Definition a late adverse reaction to intravascular iodine-based contrast medium is defined as a reaction which occurs 1h to 1week after contrast medium injection

reactions

skin reactions similar in type to other drug-induced eruptions. maculopapular rashes, erythema, swelling and pruritus are most common. most skin reactions are mild to moderate and self-limiting.a variety of late symptoms (e.g. nausea, vomiting headache, musculoskeletal pains, fever) have been described following contrast medium, but many are not related to contrast medium.

risk factors for skin reactions

previous late contrast medium reactionInterleukin-2 treatmentuse of non-ionic dimers

Management symptomatic and similar to the management of other drug-induced skin reactions, e.g. antihistamines, topical steroids and emollients

recommendations

patients who have had a previous contrast medium reaction, or who are on Il-2 treatment should be advised that a lar is possible and they should be advised to contact a doctor if they have a problem. patch and delayed–reading intradermal tests may be useful to confirm a late skin reaction to contrast medium and to study cross-reactivity patterns with other agentsagents which have shown cross-reactivity on skin testing should be avoideddrug prohylaxis is generally not recommended

TABLE 1. the Contrast Media Safety Committee guidelines for late adverse reactions.

“...Most late skin reactions are mild, are usually self-limiting and resolve within 7 days...”

CONTrAST MEDIA

confirmed LAR to a contrast medium needs further administration of contrast medium, skin testing could be useful for choosing an alternative contrast agent.

clInIcal Features oF late skIn reactIons Most late skin reactions occur within three days of the administration of con-trast medium. Maculopapular rashes are common, often with erythema, swell-ing and pruritis although other reac-tions include urticaria, angiodema and scaling eruptions.

Most late skin reactions are mild, are usually self-limiting and resolve within seven days, with up to 75% of cases resolving within three days.

However, occasionally there are severe reactions leading to severe mor-bidity, hospital admission and even

death. In some reported cases of severe adverse reactions the patients had severe underlying medical conditions.

manaGement oF late skIn reactIons The recommended management of late skin reactions is symptomatic. Topical steroids and emollients have been used for late reactions; oral antihistamines have also been used for acute reactions.

predIsposItIon to lars Women appear more susceptible to late reactions to contrast media than men.

There have been reports that the incidence of late reactions varies in a seasonal manner, with proportionally more cases being notified in spring and early summer. This has given rise to the suggestion that contrast media may cause photosensitization or that pollen may increase the predisposition to the development of late adverse reactions.

A history of allergy appears to double the likelihood of a late reaction, with drug or contact allergies appearing to be particularly important.

The risk of late reaction is increased in patients who have had a previous late reaction to contrast media, but there appears to be no higher risk than normal of late reactions in patients who have had immediate reactions to contrast media

Several underlying medical conditions have been reported to predispose to late reactions. These include renal impairment, cardiac, liver disease and diabetes mellitus.

Severe late reactions have been reported in patients with systemic lupus erythematosus

There appears to be a two-to four-fold increase in the incidence of late reactions in patients who are receiv-ing immunotherpay with interleukin-2 (IL-2). It has also been noted that the appearance of skin rash, pruritus and flu-like syndromes after administration of contrast media are more frequent in patients who had received IL-2. In the light of the proposed mechanism involving T-cells activation in the

pathophysiology of LARs as described above, it is interesting to note that both IL-2 and the stimulation of the immune system that occurs in SLE are known to reduce the threshold for T-cell activa-tion by enhanced cytokine secretion or monocyte activation,

prophylaxIs Given the relatively low rate of occurence of late adverse reactions and the fact that they are usually mild and self-limiting, it is considered not appropriate to give any special warnings asbout LARs unless the patients have special risk factors.

On the other hand patients with increased risk, such as those undergoing IL-2 immunotherapy or who have a strong allergic history should be warned about the possibility and nature of late reactions and should be advised to contact medical help if a problem is encountered.

The value of the prophylactic use of steroid is unclear.

Further readInG This article is a short summary of the recent paper [1] which provides detailed references to the large body of published material dealing with late adverse reac-tions. A full bibliography is available in the reference below [1] or from the author.

reFerences1. Bellin M-F et al. Late adverse reactions to intra-

vascular iodine-based contrast media: an update.

Eur Radiol. 2011 Nov; 21(11): 2305.- 2310.


• Most late skin reactions

after iodinated contrast

medium are mild or moderate

and self-limiting.

• Patch and delayed reading

intradermal tests may help

diagnosis

• Drug prophylaxis is generally

not recommended

• Management of late skin reac-

tions should be symptomatic

TABLE 2. the key points of the ESUR Contrast Media Safety Committee paper [1].

Skin rashes account for the majority of true late adverse reactions to iodinated contrast agents. In general the symptoms are mild to moderate and self-limiting, although, occasionally, severe reactions occur leading to morbidity, hospital admission and even death.

Image reproduced from Loh S et al. Delayed Adverse Reaction to Contrast-enhanced Ct: a Prospective Single-Center Study. Comparison to Control Group without Enhancement. Radiology 2010; 25: 7.

“...it is considered not appropriate to give any special warnings about

LARs unless the patients have special risk factors...”

“... A history of allergy appears to double the likelihood of

a late reaction, with drug or contact allergies appearing to be particularly important...”

Electromagnetic Navigation BronchoscopyPeripheral pulmonary lesions (PPLs) are increasingly being detected, as a result of the increasing use of computed tomography scanning and will become even more prevalent if widespread CT screening is adopted for lung cancer. Current diagnostic techniques for PPLs are imperfect: radiographic surveillance is unable to provide a histological diagnosis; CT-guided transthoracic needle aspiration has a reasonable diagnostic sensitivity but suffers from high complication rates; bronchoscopy with fluoroscopic guidance is a safer approach, but has poor sen-sitivity particularly for nodules ≤ 2 cm; endobronchial ultrasound (EBUS) radial probe provides accurate confirmation of target localization, but offers no assis-tance in steering the probe through the branching bronchial tree in order to reach the target. Electromagnetic navigation bronchoscopy (ENB) is a new bron-choscopic technique that enables GPS-like navigation through the lungs, promis-ing accurate lesion localization. This review article explores this new technology and reviews the available published literature.

Detection of peripheral pulmonary lesions (PPLs) is increasingly common because of the widespread availability and use of com-puted tomography (CT) scans in lung cancer

screening research [1,2]. It has been reported that 5-18% of CT coronary angiogram and CT pulmonary angio-gram scans demonstrate incidental pulmonary nodules [3,4]. The National Lung Cancer Screening Trial (NLST) demonstrated a 20% reduction in lung cancer mortality when CT screening was used compared to CXR screen-ing. However during the screening phase of the study more than 39% of participants were shown to have one or more non-calcified pulmonary nodules ≥4 mm, the majority of which were ultimately found to be benign [5].

Several techniques have been used in the diagnosis of PPLs . CT transthoracic needle aspiration (CT TTNA) is a frequently used diagnostic technique for PPLs and has a high overall sensitivity for malignancy (0.90) [6] that decreases for lesions <2 cm (0.77) [7]. A negative

result usually leads to additional procedures in view of the high false negative rate of 20-30% for malignancy [8]. CT TTNA complication rates include pneumothorax in 5-41% and parenchymal hemorrhage rates approach 2% [6]. Transbronchial biopsy is a safer approach however sensitivity for malignancy is considerably lower when guided by fluoroscopy alone, particularly for nodules ≤2 cm [6]. Endobronchial ultrasound radial probe (EBUS RP), a newer technique with real time confirmation of target localization, increases diagnostic sensitivity to approximately 70% but is dependent on operator and lesion size, and does not allow direction of biopsy instruments [9].

enB - descrIptIon oF technoloGyElectromagnetic navigation bronchoscopy (ENB) is a relatively new technique aimed to localise PPLs through GPS-like tracking. The first human trials of ENB took place in 2005 and over 20 000 ENB procedures have since been performed [10].

In practice, the procedure consists involves three stages [11] These are :

1. CT SCANTo reconstruct multiplanar format CT data neces-sary for planning, proprietary iLogic software requires DICOM data with specific slice thickness, overlap and convolution kernel.

author drs sc leong, hm marshall, m daniels, am ree, Ia yang, rV Bowman & km Fong are at

University of Queensland Thoracic Research Centre

Department of Thoracic Medicine, The Prince Charles Hospital

Rode Rd, Chermside, Brisbane, Queensland 4032

Australia

Correspondence to: Dr Steven Leong

email: [email protected]

By Drs SC Leong, HM Marshall, M Daniels, AM Ree, IA Yang, RV Bowman & KM Fong

THORACIC RADIOLOGY


ThOrACIC rADIOLOGY

2. PLANNINGThe target lesion is outlined on axial, sagittal and coronal CT views and a pathway is mapped from the trachea to the target lesion by placing “waypoints” along the relevant bronchi. Several pathways can be planned for each target and previewed through virtual bron-choscopy animation. The pathways are exported to a removable flash drive for transfer to the procedural computer.

3. PROCEDUREThe patient lies on a location board that produces an electromagnetic field (EMF) encompassing the patient’s tho-rax. A miniaturized sensor in the locat-able guide (LG), situated at the distal end of an eight way steerable catheter, deliv-ers position (in x,y and z planes) and movement (roll, pitch, yaw) informa-tion to the procedural computer three times/second, allowing precise tracking through the EMF. [Figures 1, Left and Right panels]

Once the bronchoscope is wedged into the appropriate subsegment, the locatable guide together with an extended working channel (EWC) is passed through the bronchoscopic working channel into the lung periph-ery. The operator selects a waypoint, placed during the planning stage, and the computer provides instructions on how to steer the LG to reach that particular waypoint [Figure 3]. Once a waypoint is reached, the next waypoint is selected and the process is repeated. When the LG is in close proximity to and correctly aligned with the target lesion, the extended working channel is locked onto the bronchoscope, the LG is removed, and biopsy tools are inserted through the anchored EWC to sample the lesion.

enB lIteratureMost case series of the use of ENB for the diagnosis of PPLs report diag-nostic yields ranging between 59-74% [10, 12-22].

Only one randomized controlled trial has been published comparing ENB to other diagnostic techniques. In this study, 118 consecutive patients with PPLs ranging between 13-58 mm were randomly assigned to endobron-chial ultrasound radial probe EBUS RP (n=39), ENB (n=39) or a combined approach using ENB to navigate and EBUS RP to confirm lesion localization (n =40). Both techniques had similar diagnostic yield (68% vs. 59%) despite the mean lesion size being largest in the ENB group compared to the EBUS and combined groups (28+/-8 mm vs. 25+/-5 mm vs. 24 +/-5 mm). In con-trast, the yield in the combined group was significantly higher (88%, p=0.02) approaching that of CT TTNA. Forceps biopsy was the only sampling modality used with a range of 2-5 biopsies taken per lesion [13].

Several studies have investigated pre-dictors of ENB success. As in EBUS RP, Seijo et al found the presence of a bron-chus sign was associated with signifi-cantly higher success rate (79% vs. 31%)[20]. Eberhardt et al found ENB yield was dependent on lesion location (upper lobes vs. lower lobes = 29% vs. 89%, p=0.01) possibly because of excessive respiratory motion in lesions close to the diaphragm [23]. This is however not a universal finding [16,21]. Individual studies have not shown lesion size to be a predictor of success but this is likely due to small numbers.

ENB is a safer procedure compared to CT TTNA. Published pneumothorax

rates range between 1 - 7.5%. No major bleeding has been reported.

Most procedures involve the opera-tors climbing a learning curve. However the data regarding the learning curve of the ENB procedure vary. Makris et al even suggested that there was no need for a learning curve as evidenced by two operators achieving the same diag-nostic yields in their first/last 13 ses-sions (76.9% vs. 69.2%) and first/last 7 sessions (42.8% vs. 42.8%) respectively [24]. Lamprecht et al found an increased diagnostic yield for the first 30/last 30 procedures (n=112, 80% vs. 87.5% respectively, p=0.724) in parallel with a reduction in mean lesion size from 30.4 mm to 25.3 mm [21].

More recently a meta-analysis of

guided bronchoscopic techniques which included EBUS RP, ultrathin bronchos-copy, virtual bronchoscopy (VB), guide sheath and ENB, found that ENB alone had the lowest inverse weighted diag-nostic yield of all modalities (67% vs. 70% for all modalities) [9]. Interestingly, VB had a higher diagnostic yield than ENB (72% vs. 67%) despite VB being part of the ENB procedure.

Cost remains the most significant bar-rier to widespread ENB implementation. Capital costs and consumables per case are considerably higher than CT TTNA and EBUS RP. Consumables are single use. A recent modelling study compar-ing cost-effectiveness of CT TTNA to ENB, followed by video-assisted tho-racoscopy (VATS) if non-diagnostic, found that CT TTNA cost $US 2913 compared to $US 6633 for ENB for the diagnosis of a solitary pulmonary lesion. However CT TTNA had an increased pneumothorax rate (CT TTNA 15% vs. ENB 1.6%) [25]. The most cost effective strategy was sequential biopsy by CT TTNA followed by ENB and VATS ($US 1934); the cost of ENB followed by CT TTNA and VATS was $US 2406. The former sequential strategy still resulted in higher pneumothorax rates than the latter strategy (6.7% vs. 2.7%).

ENB is a resource-intensive proce-dure, potentially requiring an anesthetist, radiographer (for fluoroscopy), cytology technician (rapid on-site evaluation), and bronchoscopy nursing staff. ENB


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FIGURE 1. Catheter handle and locatable guide. A miniaturized sensor in the locatable guide (LG), situated at the distal end of an eight way steerable catheter, delivers regular position and movement information to the computer, allowing precise tracking through the electro magnetic field. the locatable guide is shown in the neutral position (Left Panel) and with the neck flexed (Right Panel) .

ISMRM BRIDGING THE GAP BETWEEN CLINICAL NEEDS

AND TECHNOLOGICAL SOLUTIONS

International Society for Magnetic Resonance in Medicine

ATTEND THE LARGEST MEETINGDEDICATED TO MAGNETIC RESONANCE IMAGING ISMRM is the premier INTERNATIONAL COMMUNITY of clinicians and scientists in the fi eld of magnetic resonance.

The Society hosts an ANNUAL MEETING & EXHIBITION and provides EDUCATIONAL and NETWORKING

opportunities to advance knowledge, promote discovery, encourage innovation, IMPROVE WORLD HEALTH and

further the CAREERS of its members.

Join OVER 6,000 clinicians, physicists, engineers, biochemists, technologists and radiographers from MORE THAN

60 COUNTRIES around the world at THE LARGEST MEETING dedicated to promoting communication, research,

development and applications in the fi eld of magnetic resonance in medicine and biology.

W W W . I S M R M . O R G

#ISMRM ISMRMISMRM

A majority of ISMRM members recommend membership and our annual meeting.

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TO FIND OUT MORE ABOUT UPCOMING PROGRAMS, HOUSING AND REGISTRATION, PLEASE VISIT:

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GET CUTTING-EDGE EDUCATION & GROUND-BREAKING SCIENTIFIC RESEARCH

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Education to provide continuing medical education for physicians.

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2 0 – 2 6 A p r i l 2 0 1 3

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ThOrACIC rADIOLOGY

is more time-consuming than EBUS RP with reported duration times reported as being between 25.7– 60 mins [17-20,26-28]. There are no direct compara-tive data between general anaesthesia (GA) and conscious sedation so opti-mal anesthetic strategy is uncertain. A subgroup analysis of 92 patients under-going ENB showed diagnostic yield was not affected by anaesthetic choice (GA vs. sedation, p=0.57) [23].

Similarly, the need for fluoroscopy during ENB is debatable. The author uses fluoroscopy to confirm biopsy for-ceps opening and as an additional con-firmation of target alignment. EBUS RP is commonly used as a further confir-matory technique but may increase the chance of EWC dislodgement from the leading bronchus.

Future dIrectIonsWhile most publications on ENB have addressed the diagnostic sensitivity for PPLs, its true value may lie in thera-peutic applications. Case series have demonstrated the utility of ENB for fiducial marker placement to facilitate stereotactic radiotherapy [29,30]. Fur-thermore, the placement of pulmonary brachytherapy catheters with ENB in medically inoperable lung cancer has been shown to be feasible [31. Pleural dye marking for resection of PPLs can also be achieved through ENB.

Diagnosis of PPLs remains a common yet challenging problem for clinicians. While CT TTNA is a

reasonably accurate way of diagnos-ing PPLs its major disadvantage is its high complication. Although ENB is a safer alternative with diagnostic yields that approach CT TTNA the further spread of the technique requires the production of favorable comparative evidence against CT TTNA and improved cost-effectiveness data.

reFerences1. Bach PB et al. Benefits and harms of CT screen-

ing for lung cancer: a systematic review. JAMA : the journal of the American Medical Association 2012;307:2418 -29.

2. Wood D & Eapen GA. NCCN Guidelines Version 1.2012; 2011.

3. Iribarren et al. Incidental pulmonary nodules on cardiac computed tomography: prognosis and use. The American J Med. 2008;121: 989.

4. Hall WB et al. The prevalence of clinically relevant incidental findings on chest computed tomograph-ic angiograms ordered to diagnose pulmonary embolism. Arch. Int Med. 2009;169:1961-5.

5. Aberle D et al. Reduced Lung-Cancer Mortality with Low-Dose CT Screening. NEJM 2011.

6. Rivera MP et al., Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). In: Chest; 2007:131S-48S.

7. Ohno Y et al. CT-guided transthoracic needle aspiration biopsy of small (< or = 20 mm) soli-tary pulmonary nodules. AJR Am J Roentgenol 2003;180:1665.

8. Zarbo RJ & Fenoglio-Preiser CM. Interinstitutional database for comparison of performance in lung fine-needle aspiration cytology. A College of American Pathologists Q-Probe Study of 5264 cases with histologic correlation. Arch Path & Lab Med 1992;116 :4630.

9. Wang Memoli JS et al. Meta-Analysis of Guided Bronchoscopy for the Evaluation of the Pulmonary Nodule. Chest 2011.

10. Becker HD et al. Bronchoscopic Biopsy of Peripheral Lung Lesions Under Electromagnetic Guidance: A Pilot Study. J. Bronch & Interventional Pulmo 2005;12: 9.

11. Leong S et al. Electromagnetic navigation bron-choscopy: a descriptive analysis. J Thor Dis disease 2012; 4: 173.

12. Gildea TR et al. Electromagnetic naviga-

tion diagnostic bronchoscopy: a prospec-tive study. Amer J Resp Crit Care Med 2006;174:982.

13. Eberhardt R et al. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a random-ized controlled trial. Amer J Resp Crit Care Med 2007;176:36.

14. Eberhardt R et al. Electromagnetic navigation diagnostic bronchoscopy in peripheral lung lesions. Chest 2007; 131: 1800.

15. Makris D et al. Electromagnetic navigation diag-nostic bronchoscopy for small peripheral lung lesions. Eur Resp J 2007; 29: 1187 .

16. Wilson DS & Bartlett RJ. Improved Diagnostic Yield of Bronchoscopy in a Community Practice: Combination of Electromagnetic Navigation System and Rapid On-site Evaluation. J Bronchology 2007;14:227-32.

17. Bertoletti L et al. Accuracy and feasibility of electromagnetic navigated bronchoscopy under nitrous oxide sedation for pulmonary periph-eral opacities: an outpatient study. Respiration 2009; 78: 293.

18. Lamprecht B et al. Electromagnetic naviga-tion bronchoscopy in combination with PET-CT and rapid on-site cytopathologic examination for diagnosis of peripheral lung lesions. Lung 2009; 187: 55.

19. Eberhardt R et al. Comparison of suction cath-eter versus forceps biopsy for sampling of soli-tary pulmonary nodules guided by electromag-netic navigational bronchoscopy. Respiration 2010; 79: 54.

20. Seijo LM et al. Diagnostic yield of electromag-netic navigation bronchoscopy is highly depen-dent on the presence of a Bronchus sign on CT imaging: results from a prospective study. Chest 2010;138:1316.

21. Lamprecht B et al. Electromagnetic naviga-tion bronchoscopy (ENB): Increasing diagnostic yield. Resp Med 2012; 106: 710.

22. Pearlstein DP et al. Electromagnetic navigation bronchoscopy performed by thoracic surgeons: one center’s early success. Annals Thor Surg 2012; 93: 944;

23. Eberhardt R et al. Electromagnetic navigation diagnostic bronchoscopy in peripheral lung lesions. Chest 2007; 131: 1800.

24. Makris D et al. Electromagnetic navigation diag-nostic bronchoscopy for small peripheral lung lesions. Eur Resp J 2007; 29: 1187.

25. Dale C. Navigational Bronchoscopy with Biopsy versus Computed Tomography-guided Biopsy for the Diagnosis of a Solitary Pulmonary Nodule: a cost-consequences analysis. J Bronchology 2012;19:294-303.

26. Schwarz Y et al. Real-time electromagnetic navi-gation bronchoscopy to peripheral lung lesions using overlaid CT images: the first human study. Chest 2006;129:988-94.

27. Gildea TR et al. Electromagnetic navigation diagnostic bronchoscopy: a prospective study. Amer J Resp Crit Care Med 2006; 174: 982.

28. Eberhardt R et al. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a random-ized controlled trial. Amer J Resp Crit Care Med 2007;176:36-41.

29. Schroeder C et al. Coil spring fiducial markers placed safely using navigation bronchoscopy in inoperable patients allows accurate delivery of CyberKnife stereotactic radiosurgery. J Thor Cardiovasc Surg 2010; 140: 1137.

30. Anantham D et al. Electromagnetic naviga-tion bronchoscopy-guided fiducial placement for robotic stereotactic radiosurgery of lung tumors: a feasibility study. Chest 2007; 132: 930.

31. Harms W et al. Electromagnetically navigated brachytherapy as a new treatment option for peripheral pulmonary tumors. Strahlentherapie und Onkologie 2006; 182: 108-11.


FIGURE 2. Procedure screen showing 6 viewports. top right=dynamic 3D map; Bottom right=tip view (green sphere=target); Bottom centre=local view; top centre=maximal image projection view.

women’s outreach program in India: the Asha Jyoti program

At a keynote presentation during the recent RAD-AID conference on International Radiology for Develop-ing Countries at the Johns Hopkins Hospital in Baltimore, Maryland, the results of a six-month pilot phase of the Asha Jyoti program were presented (Asha Jyoti means “Light of Hope” in Hindi and Punjabi). The program, which was developed to address sev-eral unmet healthcare needs in India, has already successfully achieved its goal to provide breast cancer, cervical cancer, and osteoporosis screening to more than 500 women in its initial pilot phase. Nearly 50% of the women seen were from the poorest socio-eco-nomic groups in India, i.e. those liv-ing in households that earn less than $1/day.The mobile unit provided an opportunity for free health screening on their doorstep.

Asha Jyoti is a Women’s Health-care Outreach Mobile program which was launched on 22 April 2012 at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. It is a population-based screening program of women aged between 40 and 60 years, which aims to ensure early detection of breast cancer, cervical cancer and osteo-porosis, even before the individual has any signs or symptoms. It was established as a model for preventive healthcare for semi-urban and rural areas in northern India and involved the creation of a special mobile out-reach van with imaging technology

and clinical referral services to effi-ciently and effectively address mul-tiple care needs. All women who visited the van received results from their tests within 7 to 10 days. Seven women with suspicious mammogra-phy findings and 41 women with sus-picious colposcopy findings received follow-up testing and treatment, if needed, at PGIMER hospital.

“Our vision for Asha Jyoti was to develop a high quality, mobile screen-ing facility to provide decentralized primary healthcare on people’s door-steps, to detect three major diseases effecting women’s health earlier, and to provide diagnostic follow-up and ther-apy to the community;” commented Dr. N. Khandelwal, Professor and Head, Department of Radiodiagnosis, PGIMER. “A multidisciplinary team of health care specialists from our Insti-tute, one of the premier institutions in India, formulated this program, and the teams from Philips Healthcare and RAD-AID supported the initiative to make it a reality and ensure that we reached the underserved population in the northern part of India.”

During the 6 month pilot phase, 615 women participated in the screen-ing, and now that the program is going into full “operational phase” the aim is to screen 2,000-3,000 women every year for at least the next 4-5 years and provide a clear plan for follow-up and further routine screening. The target population is women living in semi-urban and rural areas, and Asha Jyoti has already extended beyond the original remit to reach women across the state: Screening was originally conducted in one sector of Chandi-garh, but has also extended to two additional areas in Punjab.

“Together with our clinical partner PGIMER and with Philips Health-care, we have been able to provide a solution that has delivered some really impressive results and we are extremely proud of the impact that

the Asha Jyoti project is having on the lives of some of India’s poorest women,” stated Daniel Mollura, M.D., Founder, President and Chief Execu-tive Officer, RAD-AID. “As a result of the successes to date, we are happy to say that the program will continue and we hope that it will be successful for many years to come.”

Diego Olego, Chief Strategy and Innovation Officer, Philips Health-care added, “Asha Jyoti is an inno-vative way of delivering sustainable health care to the most needy women, by bringing state-of-the-art diagnos-tic equipment, high quality clinical care and education to rural and semi-urban areas. This initiative is one more example of how Philips creates the future of healthcare and enables clinical partners to save lives.”

In addition to being a model for integrating women’s health ser-vices, the collaboration is a unique public-private partnership between government (PGIMER) entities, non-profit non-governmental orga-nization (RAD-AID) and the pri-vate sector (Philips Healthcare). To make the Asha Jyoti program work, PGIMER delivers the clinical ser-vices, RAD-AID is providing educa-tional training and program planning support to health workers and staff and Philips has donated all the equip-ment and also donated the entire van which was designed and built in India by local suppliers. the equipment in the van was donated by Philips.

Philips donated the entire van which was designed and built in India by local suppliers.

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performance needed in diagnostic monitors while increasing the service life since LEDs deteriorate far slower than traditional CCFL (cold cath-ode fluorescent lamp) backlights. EIZO offers a 5 year full warranty for the GX540 and 5 years or 20,000 hours when used at recommended brightness 400 cd/m2 for the RX440.

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With a right mix of osmolality, viscosity and iodine concentration, Ultravist® delivers contrast for high-quality imaging results.1

www.bayer.co.ukEnquiries: 01635 563000Calls to and from Bayer HealthCare may be recordedDate of preparation: October 2012. L.GB.10.2012.0951All rights reserved. © Bayer plc 2012

Ultravist® (iopromide) Prescribing Information (Refer to Summary of Product Characteristics (SmPC) before prescribing) Presentation: Intravascular injections of non-ionic iopromide in strengths of 150mg, 240mg, 300mg and 370mg of iodine/ml. Indications: For diagnostic use only. Delineation of the vascular and renal systems and of body cavities. Posology and administration: Adults Intravenous urography: minimum doses: Ultravist 370: 0.8ml/kg body weight; Ultravist 300: 1ml/kg body weight; Ultravist 240: 1.3ml/kg body weight. Children Intravenous urography: see SmPC. Adults Computed tomography: Cranial CT: Ultravist 240: 1.5-2.5ml/kg body weight; Ultravist 300: 1-2ml/kg body weight; Ultravist 370: 1-1.5ml/kg body weight. Whole-body CT: Dosage and administration rate depend on investigation and scanner. Adults Angiography: depends on age, weight, cardiac output, general condition, clinical problem, examination technique and the nature and volume of the vascular region to be investigated. (see SmPC). Adults Checking function of dialysis shunt: Ultravist 150: 10ml. Paediatric population: young infants (age < 1 year) and especially newborns are susceptible to electrolyte imbalance and haemodynamic alterations. Care should be taken regarding the dose of contrast medium to be given, the technical performance of the radiological procedure and the patient status. Renal impairment: to reduce the risk of additional contrast media-induced renal impairment in patients with pre-existing renal impairment, the minimum possible dose should be used. Hepatic impairment: no dosage adjustment is necessary. Elderly: possibility of reduced renal function should be considered. Contra-indications: Uncontrolled thyrotoxicosis. Warnings and precautions: Can be associated with anaphylactoid/hypersensitivity reactions, ensure preparedness for institution of emergency measures. Allergy-like reactions from mild to severe possible, mostly within 30 min, but delayed reactions (hours to days) may occur. Particularly careful risk/benefit judgement required for patients with: known hypersensitivity to Ultravist or its excipients; previous reaction to any contrast medium or; history of bronchial asthma or allergic disorders (increased risk). Pre-medicate with corticosteroids if necessary. To minimise risk: administer Ultravist to recumbent patients; observe patients closely for 15 minutes and keep them in hospital for at least one hour after the last injection. Patients on beta-blockers may be resistant to the effects of beta agonists. If severe reaction occurs, patients with cardiovascular disease are more susceptible to serious or fatal outcomes. Caution in patients with: known/suspected hyperthyroidism or goitre, monitor thyroid function in neonates exposed via mother or during neonatal period. Caution in patients with cerebral arteriosclerosis, pulmonary emphysema, poor general health, renal insufficiency, dehydration, diabetes mellitus, multiple myeloma/ paraproteinaemia, repetitive and / or large doses of Ultravist. Nephrotoxicity may occur or rarely acute renal failure. Ensure adequate hydration of patients; correct water or electrolyte imbalances before administration. With cardiac or severe coronary artery disease, increased risk of haemodynamic changes or arrhythmia. Intravascular injection may precipitate pulmonary oedema in patients with heart failure. Increased risk of neurological complications in patients with seizure history or CNS disorders. Caution in patients with reduced seizure threshold. May aggravate the symptoms of myasthenia gravis. Flush intravascular catheters frequently with physiological saline (if possible with addition of heparin) and minimise procedure length to minimise procedure-related thromboembolism risk. Patients with phaeochromocytoma may be at increased risk of developing a hypertensive crisis. Minimise excitement, anxiety and pain. Do not use in myelography. Sensitivity testing is not recommended. Interactions: Consider interruption of biguanides treatment prior to Ultravist administration as a precaution against development of lactic acidosis. Prevalence of delayed reactions higher in patients who have received interleukin-2. Diagnosis and treatment of thyroid disorders with thyrotropic radioisotopes may be impeded for up to several weeks due to reduced radioisotope uptake. Pregnancy and lactation: Adequate and well-controlled studies in pregnant women have not been conducted. Safety for nursed infants has not been investigated. Effects on ability to drive and use machines: Driving or operating machinery is not advisable for 30 minutes after the last injection. Undesirable effects: Common: dizziness, headache, dysgeusia, blurred/disturbed vision, chest pain/discomfort, hypertension, vasodilatation, vomiting, nausea, pain, injection site reactions (e.g. oedema, soft tissue injury post extravasation), feeling hot. Serious side effects: cf – Warnings and Precautions – in addition: Hypersensitivity/anaphylactoid reactions (anaphylactoid shock§*, respiratory arrest§*, bronchospasm*, laryngeal*/pharyngeal* or mucosal oedema, laryngeal/pharyngeal spasm§, asthma§*, angioedema), vasovagal reactions, arrhythmia*, dyspnoea*, cardiac arrest*, myocardial ischaemia*/infarction*, thyrotoxic crisis, thyroid disorder, coma*, cerebral ischaemia/infarction*, stroke*, brain oedema*, convulsion*, transient cortical blindness (IV use only), loss of consciousness, amnesia, paresis/paralysis, hearing disorders, cardiac failure*, bradycardia*, tachycardia, cyanosis*, hypotension*, shock*, thromboembolic events (IV use), pulmonary oedema*, respiratory insufficiency*, aspiration*, bullous conditions (e.g. Stevens-Johnson syndrome or Lyell syndrome), compartment syndrome due to extravasation (IV use), renal impairment/acute renal failure (IV use). § Reactions identified only during post-marketing surveillance (frequency not known). *These adverse reactions may have a fatal or life-threatening outcome and are considered the most serious adverse drug reactions. Prescribers should consult the SmPC in relation to other side effects. Overdose: Symptoms may include fluid and electrolyte imbalance, renal failure, cardiovascular and pulmonary complications. Monitoring of fluids, electrolytes and renal function recommended in case of intravascular overdosage. Treatment of overdose should be directed towards the support of vital functions. Ultravist is dialysable. Incompatibilities: Because of possible precipitation, X-ray contrast media and prophylactic agents must not be injected as mixed solutions. Special Precautions for Storage: Protect from light and X-rays. Legal Classification: POM Package Quantities and Basic NHS Price: Ultravist 150 10 x 50ml bottles £101.57 Ultravist 240 10 x 50ml £145.86 Ultravist 300 10 x 20ml £124.63 10 x 50ml £182.03 1 x 100ml £36.16 1 x 200ml £71.98 Ultravist 370 10 x 50ml £224.94 1 x 100ml £44.68 1 x 200ml £88.78 MA Numbers: Ultravist 150: 00010/0564 Ultravist 240: 00010/0565 Ultravist 300: 00010/0566 Ultravist 370: 00010/0567 Further information available from: Bayer plc, Bayer House, Strawberry Hill, Newbury, Berkshire, RG14 1JA, Telephone: (01635) 563000 Date of preparation: August 2012 Ultravist® is a trademark of the Bayer Group.

Adverse events should be reported. Reporting forms and information can be found

at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Bayer plc.

Tel.: 01635 563500, Fax.: 01635 563703, Email: [email protected]

References1. For details and full range of indications please refer to the

Summary of Product Characteristics.

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