Mark O. Baerlocher

Discussing Radiation Risks Associated With CT Scans With Patients

TECHNOLOGICAL ADVANCEMENTS IN DIAGNOSTIC AND therapeutic imaging have greatly increased physicians’ ability to care for patients. As a result, use of medical imaging has increased exponentially. For example, Prokop estimated that since the 1980s, use of computed tomography (CT) has doubled almost every 2 years. The increase in utilization has led to a parallel increase in concern regarding radiation risks. Almost half (48%) of the total dose of ionizing radiation exposure for individuals in the United States (including background radiation) has been attributed to medical tests and procedures. It is estimated that use of CT may be associated with 1.5% to 2% of all cancers in the United States in the future. There is evidence suggesting that too many imaging examinations are being performed. Potential causes of overuse include fear of litigation, miscommunication, and selfreferral among non–radiologist-owned imaging clinics. Also, there is a general lack of awareness regarding radiation risks among both health care workers and patients. For example, one study suggested that approximately 92% to 95% of patients are not informed of any radiation risks prior to their CT scan.

The Meaning of Author Order in Medical Research

Background Manuscript authorship and author placement have important implications for accountability and allocation of credit. The objective of this study was to assess the relationship between an authors place in the author list and the type of contribution reported by that author. This pattern was then used to develop a method by which author responsibility and accountability can be clarified. Methods The published contributions of each author of original research articles with a minimum of four authors published in the Journal of the American MedicalAssociation, the British Medical Journal, TheLancet, and the Canadian Medical Association Journal in a 3-year period after author contribution forms were required were coded into 1 of eleven contribution categories. The contributions were grouped according to first, second, middle, and last author and compared by position. Results For most categories of contribution, the levels of participation were highest for first authors, followed by last and then second authors. Middle authors had lower levels particularly in conception, drafts of the manuscript, supervision, and being a guarantor. Conclusions Current patterns of author order and contribution suggest a consistent theme. Based on the results, a proposal is put forth by which author accountability is clarified. In this proposal, authors are classified as either “primary,” “contributing,” or “senior or supervisory,” each with specified contributions. More than one author may be classified into each author category.

Clinical Utility of Vertebroplasty: Need for Better Evidence

Two recent randomized controlled trials found vertebroplasty to be no better than a sham procedure; however, both trials included major deficiencies and are against the vast preponderance of evidence published to date.

The feminisation of Canadian medicine and its impact upon doctor productivity.

Objective  We examined the differences in work patterns between female and male doctors in Canada to gain insight into the effect of an increased number of female doctors on overall doctor productivity.

International medical graduates (IMGs) needs assessment study: comparison between current IMG trainees and program directors.

BackgroundInternational Medical Graduates (IMGs) training within the Canadian medical education system face unique difficulties. The purpose of this study was to explore the challenges IMGs encounter from the perspective of trainees and their Program Directors.MethodsProgram Directors of residency programs and IMGs at the University of Toronto were anonymously surveyed and asked to rate (using a 5-point Likert scale; 1 = least important – 5 = most important) the extent to which specific issues were challenging to IMGs and whether an orientation program (in the form of a horizontal curriculum) should be implemented for incoming IMGs prior to starting their residency.ResultsAmong the IMGs surveyed, Knowledge of the Canadian Healthcare System received the highest mean score (3.93), followed by Knowledge of Pharmaceuticals and Hospital formularies (3.69), and Knowledge of the Hospital System (3.69). In contrast, Program Directors felt that Communication with Patients (4.40) was a main challenge faced by IMGs, followed by Communication with Team Members (4.33) and Basic Clinical Skills (4.28).ConclusionIMGs and Program Directors differ in their perspectives as to what are considered challenges to foreign-trained physicians entering residency training. Both groups agree that an orientation program is necessary for incoming IMGs prior to starting their residency program.

Perception of radiation exposure and risk among patients, medical students, and referring physicians at a tertiary care community hospital.

Background It is important for physicians to be aware of the radiation doses as well as the risks associated with diagnostic imaging procedures that they are ordering. Methods A survey was administered to patients, medical students, and referring physicians from a number of specialties to determine background knowledge regarding radiation exposure and risk associated with commonly ordered medical imaging tests. Results A total of 127 patients, 32 referring physicians, and 30 medical students completed the survey. The majority of patients (92%) were not informed of the radiation risks associated with tests that they were scheduled to receive and had false perceptions about the use of radiation and its associated risks. Physicians and medical students had misconceptions about the use of ionizing radiation in a number of radiologic examinations; for example, 25% and 43% of physicians and medical students, respectively, were unaware that interventional procedures used ionizing radiation, and 28% of physicians were unaware that mammography used ionizing radiation. Computed tomographies and barium studies were thought to be associated with the least ionizing radiation among physicians. Conclusion There is a need for educating the public, medical students, and referring physicians about radiation exposure and associated risk so that (1) patients receiving multiple medical imaging tests are aware of the radiation that they are receiving and (2) physicians and future physicians will make informed decisions when ordering such tests to limit the amount of radiation that patients receive and to promote informed consent among patients.

Meta-analysis of drug-eluting balloon angioplasty and drug-eluting stent placement for infrainguinal peripheral arterial disease.

PURPOSE To perform a meta-analysis of randomized controlled trials (RCTs) of drug-eluting balloon (DEB) angioplasty and drug-eluting stents (DESs) for infrainguinal peripheral arterial disease. MATERIALS AND METHODS Systematic searches were performed for all relevant RCTs. RESULTS Eight RCTs for DEB angioplasty and 12 RCTs for a DES in peripheral arterial disease were identified. Meta-analysis demonstrated statistically significant superiority of DEB over plain balloon angioplasty of femoral-popliteal disease for late lumen loss, restenosis, and target lesion revascularization, with no benefit in major amputation or mortality. Statistically significant superiority of DEB over percutaneous transluminal angioplasty (PTA) was demonstrated for infrapopliteal disease for restenosis and target lesion revascularization. Drug-eluting stents showed statistically significant superiority over bare metal stents (BMSs) of femoral-popliteal disease for late lumen loss and restenosis, with no benefit in mortality or amputation. Drug-eluting stents showed statistically significant superiority over BMSs of infrapopliteal disease restenosis and target lesion revascularization, with no benefit in amputation or mortality. CONCLUSIONS Drug-eluting balloon angioplasty and DESs demonstrated superior outcomes compared to PTA and BMS, with no difference in amputation or mortality.

Effectiveness of Vertebroplasty: A Recent Controversy

Many of you are already well acquainted with the procedure known as vertebroplasty, which has become a significant contributor to the management of both osteoporotic and malignant compression fractures. Under imaging guidance, a needle is placed within the collapsed vertebrae and acrylic orthopaedic bone cement is injected. The vast majority of patients with osteoporotic fractures (>90%) report significant and durable pain relief at the treated levels. The procedure was first devised in France in the mid 1980s and by the late 1990s had become widely used not only throughout Western Europe but North America and other parts of the world. Hundreds of thousands of these procedures have been performed, and interventional radiologists who perform vertebroplasty acknowledge that it is one of the most effective and dramatically satisfying procedures they perform. Because of the improvement in patient pain and its excellent safety profile, this procedure has become widely adopted. However, it has been recognized that the accrued experience with vertebroplasty has not included a double-blinded randomized control trial to document efficacy. In the current evidence-based environment of modern medicine, this deficit must be addressed. It is noted that several practical barriers exist to performing a randomized trial of this procedure. The most problematic barrier is a historical one, secondary to the rapid acceptance of this procedure by not only interventional radiologists, referring clinicians, and patients, but by many third-party payers who saw it as a way of quickly resolving an often difficult medical problem. In spite of these issues, 2 double-blind randomized trials were recently published in the New England Journal of Medicine [1,2]. Consistent with this rigorous study design, both trials compared vertebroplasty in the treatment arm with a sham procedure that mimicked vertebroplasty on the nontreatment arm, with random allocation to either arm. Consent for the trial was performed before allocation, with the result that prospective volunteers have only a 50% chance of receiving verte-

Quality Improvement Guidelines for Percutaneous Vertebroplasty

PREAMBLE The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally, Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid broad expert constituency of the subject matter under consideration for standards production. Technical documents specifying the exact consensus and literature review methodologies as well as the institutional affiliations and professional credentials of the authors of this document are available upon request from SIR, 3975 Fair Ridge Dr., Suite 400 N., Fairfax, VA 22033.

Changing author counts in five major general medicine journals: effect of author contribution forms

OBJECTIVES Objective and indirect evidence was used to determine whether required author contribution forms were associated with a decrease in author counts in four major general medicine journals (British Medical Journal [BMJ], Journal of the American Medical Association [JAMA], Canadian Medical Association Journal [CMAJ], and the Lancet). The number of authors listed per article before and after the introduction of explicit author contribution requirements were counted and compared with that found for the New England Journal of Medicine (NEJM) that did not require such disclosure. The primary hypothesis was that author counts decreased more in the BMJ, CMAJ, JAMA, and the Lancet after introduction of the rules than they did in the NEJM. STUDY DESIGN AND SETTING The number of authors listed per original research article published in the five general medical journals with the greatest 2004 Impact Factors in the first issue of each month in the years before and after introduction of required author contribution forms was compared. RESULTS Introduction of the required author contribution forms by the four leading general medical journals did not result in a drop in the rate of increasing authors per article per year, or in the number of authors per article compared with the control. Overall, there was a trend of an increasing number of authors listed per article. CONCLUSION Based on the presented objective and indirect evidence, required author contribution forms were not associated with a decrease in author counts.