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Radiologists and Primary Care Physicians Must Talk

Recently, I spoke with a primary care physician (PCP) about a young runner who had a syncopal episode. Because of the increasing awareness of sudden cardiac death in athletes, she had an electrocardiogram and an echocardiogram to look for structural abnormalities of the heart. The PCP was inclined to dismiss the syncope as an isolated episode. However, the echocardiogram, otherwise normal, equivocated: “possible hyper trabeculation of the left ventricular apex, consider cardiac MRI to exclude non compaction of the left ventricle”. The PCP was inquiring how to order a cardiac MRI. For reasons unbeknownst to me, for I do not habitually question clinicians why they are ordering tests, I should as a matter of clinical engagement but don’t, I asked about the circumstances that led to the echocardiogram. With the absence of a family history, no palpitations and a normal left ventricular function (she ran 5-minute miles, enough said), I speculated that the finding on the echocardiogram was most likely an overcall. The cardiac MRI would likely overcall as well, as these diseases are defined by numbers that are inevitably shared with normal individuals. I expressed lukewarm enthusiasm for the cardiac MRI. The PCP agreed. The athlete was spared another diagnostic test, a cardiology referral and possibly a life-long label. “One silver lining of the preceding decade of over utilization of imaging is that radiologists have developed a rich mental atlas of imaging findings of clinical irrelevance.” This is not a discussion of overdiagnosis of non-compaction. This is to restate a banal truism: physicians should speak to one another. In particular, PCPs and radiologists should talk to one another,...
Advances in Adolescent Idiopathic Scoliosis

Advances in Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a lateral and rotational deformity of the spine that afflicts roughly 2.5% of the population across most cultures. Only 10% of those diagnosed with AIS will actually need treatment, and few will require surgical management of their curves. Since no cause to date has been pinpointed, the vast majority of resources for treating AIS is based on the premise of following all patients closely until skeletal maturity. This means using periodic x-rays and office visits—usually at intervals of 4 to 6 months—to ensure that aggressive curves don’t get missed. The treatment regimen to this day has been to work reactively rather than proactively. This approach subjects patients to numerous x-rays, which can be deleterious and may increase the incidence of breast cancer over the long term. A newer, saliva-based genetic test called ScoliScore (Transgenomic, Inc.) may change the way we manage scoliosis patients. Based on the discovery of 53 genetic markers that have been linked to progressive scoliosis, this test compares the patient’s DNA against these markers. A score between 1 and 200 is generated. Those scoring 50 or below—roughly three-fourths of patients who are screened—will have less than a 1% chance of developing a curve that will require surgical management. Those who score 180 to 200—only about 1% of those who are screened—are at high risk for developing a curve that would require surgery. Patients with test scores falling between 50 and 180 are at intermediate risk of developing an aggressive curve. Shifting Focus of Care for Adolescent Idiopathic Scoliosis The true benefit of having an accurate and reliable saliva-based genetic test for...
Extending Survival After Inoperable Pancreatic Cancer

Extending Survival After Inoperable Pancreatic Cancer

Surgical resection of adenocarcinoma can significantly improve survival, but only 20% of patients are candidates to undergo this treatment. Typically, patients with unresectable pancreatic adenocarcinoma receive palliative, non-curative therapy. Recent research, however, suggests that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients who have been previously deemed unresectable the possibility for curative salvage pancreatectomy. A New Approach for Pancreatic Cancer In the Journal of the American College of Surgeons, my colleagues and I at MD Anderson reported results from a study cohort of 88 high-risk patients who had been informed that their tumors were inoperable after an initial surgical attempt at removal. Of these patients, 66 completed a multidisciplinary treatment protocol with successful tumor removal. Risk for metastatic disease was stratified based on tumor involvement with local blood vessels, biopsy results and the nature of the tumor, and overall health status aside from pancreatic cancer. Patients who met these criteria underwent the MD Anderson protocol, which involved the following: A collaborative interpretation of pancreas-specific CT scans by surgeons and radiologists. Carefully administered preoperative chemotherapy and radiation treatment with multidisciplinary restaging prior to surgery. Use of advanced surgical techniques with planned removal and vascular reconstruction of involved blood vessels near the tumor. Using this protocol, we achieved survival numbers that are comparable to those of patients receiving surgery for clearly operable tumors. On average, patients undergoing the MD Anderson protocol lived about 30 months after tumor removal, which is almost three times longer than the average survival of 11 months for patients who do not undergo tumor resection. Key Considerations: Patient Selection & Imaging Our findings...
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