Web-based Conferencing: What Radiology Educators Need to Know.

Advances in technology have resulted in the significant growth of web-based conferencing and teaching. While these remote sessions have many advantages, they may result in challenges and frustration for both host and attendees when there are technological issues, poor or distracting audio, or ineffective presentation styles. Knowing a few basic concepts behind web conferencing and preparing in advance can markedly improve the experience and facilitate effective distance learning and collaboration.

Insurance case managers' perception of quality in back pain programs: a focus study group.

OBJECTIVES: Insurance case managers commonly interact with physiatrists and rehabilitation programs. They influence referrals and patients' decision making. This study was designed to determine which factors affect case managers' perception of back pain program quality. DESIGN: Repeated focus group interview in a neutral facility in an urban Midwestern United States community. Subjects were two groups (n = 12 and 11) of insurance case managers employed by case management firms (large and small), insurers, and self-insured employers. Outcome measures included group and individual responses to a pre-scripted interview and were collected on tape, transcribed, and interpreted by two different persons: the independent expert interviewer and a pain psychologist. RESULTS: There was substantial agreement between the two interpreters. Both groups overwhelmingly chose physiatrists over other specialists. They emphasized timeliness, communication, functionally oriented programs, concrete program goals and time frames, physician knowledge of the legal aspects of disability, and rapid communication of patient noncompliance. CONCLUSIONS: Rehabilitation programs may strive to meet many of these qualities but, in doing so, should be aware that the legal and ethical roles of case managers differ from that of clinicians.

NSAIDs, aspirin, and esophageal strictures: are over-the-counter medications harmful to the esophagus?

There are several studies that suggest that aspirin (acetylsalicylic acid [ASA]) and nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with esophagitis or esophageal stricture formation. There are limited data on the potential of low-dose ASA and over-the-counter (OTC) NSAIDs to cause esophageal injury. The goal of this study was to determine whether there is an association between esophageal strictures and ASA/NSAID use, including low-dose ASA and OTC NSAIDs. A total of 79 consecutive patients (mean age, 52.8 years; 38 men, 41 women) referred for endoscopy from 4/1/96 to 11/15/96 for chronic gastroesophageal reflux disease symptoms were evaluated. Data collected include gender, race, and age, NSAID or ASA use, as well as an assessment of dysphagia, heartburn duration, and heartburn frequency. Patients taking NSAIDs or ASA at least twice a week were considered ASA/NSAID users. There were 46 patients without strictures and 33 patients with peptic strictures. Patients with strictures were older than patients without strictures (mean age, 58.7 versus 48.6 years; p < 0.01), had longer duration of heartburn symptoms (8.6 versus 6.4 years, p < 0.05), and were more likely to have mucosal injury (50% versus 26.1%). Stricture patients were more likely to use ASA/NSAIDs (63.6% versus 26.1%; p < 0.01). In particular, stricture patients were more likely to use low-dose ASA than patients without strictures (30.3% versus 2.2%; p < 0.01). Otherwise, there were no significant differences with regard to gender, race, or heartburn duration or frequency. Linear regression analysis showed that ASA/NSAID use had a greater influence on the incidence of peptic strictures than age. There is an association between esophageal stricture and ASA/NSAID use, which includes OTC NSAIDs and low-dose ASA.

Systemic bone-seeking radionuclides for palliation of painful osseous metastases: current concepts.

Bone metastases require multidisciplinary treatment, the primary goal of which is to relieve pain and improve quality of life. Among the options available, bone-seeking radioisotopes are attractive because they can treat several symptomatic metastases simultaneously. This therapy may have antitumor efficacy in addition to analgesic properties. Although the ultimate place of systemic radionuclides in the treatment of bone metastases has not been firmly established, some patients clearly benefit from these modalities.

Limited role of radionuclide bone scintigraphy in patients with prostate specific antigen elevations after radical prostatectomy.

PURPOSE: Bone scintigrams of patients with increasing serum prostate specific antigen (PSA) after radical prostatectomy are only rarely positive. We identify clinical parameters that would improve our ability to select patients for this imaging study. MATERIALS AND METHODS: We reviewed all bone scintigrams done at our institution between 1991 and 1996 in patients with persistently increasing serum PSA after radical prostatectomy. What prompted the clinician to obtain the bone scintigram was trigger PSA (tPSA). The rate of increase in PSA to tPSA was measured by tPSA/time from radical prostatectomy (slope 1) and tPSA/time from last undetectable PSA (slope 2). These parameters were evaluated together with standard clinicopathological data in univariate and multivariate analyses to determine the ability to predict the bone scintigram result. RESULTS: In univariate analysis tPSA (p = 0.003), slope 1 (p = 0.005) and slope 2 (p = 0.004) were useful in predicting the bone scintigram result but pathological stage, Gleason score, preoperative PSA and time to recurrence were not. In multivariate analysis the single most useful parameter in predicting the bone scintigram result was tPSA (p = 0.01). Based on a logistic regression model the probability of a positive bone scintigram was less than 5% until tPSA increased to 40 to 45 ng./ml. CONCLUSIONS: In patients with increasing serum PSA after radical prostatectomy current serum PSA is the best predictor of the bone scintigram result. Furthermore, there is limited usefulness of bone scintigraphy until PSA increases above 30 to 40 ng./ml.

The prevalence of intestinal metaplasia in patients with and without peptic strictures.

OBJECTIVE: Several studies suggest that patients with esophageal peptic strictures have a high prevalence of Barrett's esophagus. However, these studies did not include appropriate control groups, were retrospective in nature, or did not strictly define Barrett's esophagus. Our aim was to compare the prevalence of Barrett's esophagus in patients with and without gastroesophageal reflux disease strictures in a prospective study. METHODS: Seventy-nine patients referred for endoscopy for gastroesophageal reflux disease symptoms were evaluated. We collected demographic information and an esophageal symptom assessment. Biopsy specimens were obtained from peptic strictures, Schatzki rings, or from any areas of columnar-lined esophagus or mucosal injury. Barrett's esophagus was strictly defined as the presence of intestinal metaplasia from tubular esophagus. RESULTS: There were 46 patients without strictures and 28 patients with peptic strictures. Five patients had Schatzki's rings. The prevalence of intestinal metaplasia was 23.9% in patients without strictures, and 25% in patients with peptic strictures (p = NS). There was no difference in prevalence of short- or long-segment Barrett's esophagus between the groups. Patients with strictures were older than patients without strictures (mean age 58.9 vs 48.6 yr), and more likely to have mucosal injury (50% vs 26.1%). Otherwise, there were no significant differences with regards to gender, race, heartburn duration or frequency. CONCLUSIONS: Barrett's esophagus, as defined by the presence of intestinal metaplasia in the tubular esophagus, is equally common in patients with and without peptic strictures. There does not appear to be an association between Barrett's esophagus and peptic strictures.

Correlative imaging of the liver and hepatobiliary system.

Many imaging techniques can be used to assess the liver and hepatobiliary system. Each modality has individual strengths and limitations, which usually vary depending on the specific clinical situation. This review discusses several specific common clinical situations where imaging of the liver and biliary system is necessary and describes the various imaging options. Space-occupying liver lesions are discussed, and particular attention is paid to the assessment of liver metastasis, hepatoma, and incidentally discovered liver lesions such as hemangioma, adenoma, and focal nodular hyperplasia. The value of ultrasound, computed tomography, magnetic resonance imaging, and scintigraphic techniques in this patient population is described. Isolated sulfur colloid hepatic scintigraphy is not of great value in the evaluation of these patients. Therefore, this review describes in some detail the value of physiological liver scintigraphy, including gallium and iminodiacetic acid (IDA) scanning as well as dynamic flow imaging of the liver such as hepatic artery perfusion scintigraphy and tagged red cell scintigraphy. Imaging of the biliary tree also is described. The roles of ultrasound and scintigraphy are compared and contrasted as related to the diagnosis of acute cholecystitis, common duct obstruction, and postoperative complications.

Nuclear imaging in the diagnosis of the infected total joint arthroplasty.

Nuclear medicine can be of great value in diagnosing infected total joint arthroplasties. Bone scintigraphy is very sensitive for the diagnosis of prosthetic infection but is nonspecific. Gallium scintigraphy has been used in conjunction with bone scintigraphy, but this approach has not proven to be as valuable as originally anticipated. Indium leukocyte scintigraphy, especially when correlated with a bone scan and, at times, a bone marrow scan, is now the preferred scintigraphic approach for identifying the infected prosthesis. Newer imaging agents such as technetium leukocytes and radiolabeled antibodies are now being studied to determine their role in the management of prosthetic infection.

Nuclear medicine in the acutely ill patient--I.

Nuclear medicine techniques yield unique physiologic information about many organ systems. These types of studies can be extremely useful in the acutely ill patient. Pulmonary scintigraphy is the procedure of choice for screening dyspneic patients for pulmonary emboli. Hepatobiliary scintigraphy has a definite role in the evaluation of patients with abdominal pain and those with postbiliary tract surgical complications.

Nuclear medicine in the acutely ill patient--II.

This article describes the usefulness of scintigraphic techniques in the evaluation of patients with infection. Nuclear medicine procedures are of great value in the patient with a fever of unknown origin and no localizing signs, as well as those with complex pulmonary infections. These studies also are useful in identifying orthopaedic infections superimposed on other bone pathology, such as prior trauma or surgery. Finally, the role of renal scintigraphy in the evaluation of renal transplants and acute renal failure is described.

Systemic radionuclide therapy of bone metastases with strontium-89.

Bone metastases can have a devastating effect on a patient's quality of life due to pain and pathologic fractures. Local external beam radiotherapy is very effective for patients with only a few involved areas. Systemic therapy consisting of chemotherapy and hormonal therapy is extremely useful until the patient becomes refractory to treatment. Systemic radionuclide therapy using Strontium-89 has been shown to be very valuable, specifically in patients with bone metastases from hormonally-resistant prostate cancer. Studies have shown a significant improvement in analgesic requirement, time to further radiotherapy, and a reduction in tumor markers with this treatment. The use of Strontium-89 in the treatment of other bone neoplasms and the use of other radionuclides, such as Rhenium-186 HEDP and Samarium-153 EDT-MP, are still investigational.

Intestinal neoplasm mimicking a Meckel's diverticulum on scintigraphic imaging.

A 33-year-old man presented with colicky, intermittent, midabdominal pain with nausea and vomiting. A Tc-99m pertechnetate abdominal scan was performed and revealed a focal area of increased uptake in the midabdomen associated with dilated proximal loops of small bowel. Surgery revealed a high-grade partial obstruction of the midportion of the jejunum secondary to an annular adenocarcinoma of the jejunum. This is the first known report of abnormal Tc-99m pertechnetate accumulation in an adenocarcinoma of the small bowel.

Objective assessment of swallowing function in head and neck cancer patients.

Swallowing function was evaluated with scintigraphy in 37 patients with head and neck cancer. The patients were examined before and during the course of either surgery, chemotherapy, and/or radiotherapy. A total of 118 scintigraphic studies were performed. Scintigraphic results of bolus flow and aspiration were correlated with clinical findings. Both scintigraphic and clinical studies indicated a worsened swallowing function in 12 patients. These same studies indicated improvement of swallowing in another 13 patients. In 11 patients, both studies revealed either no apparent change or mixed changes in swallowing function after the course of therapy. In only 1 patient was there disagreement between the scintigraphic and clinical assessment of swallowing function. It is our opinion that scintigraphy is a useful method for objective assessment of swallowing function during and after the course of treatment of head and neck cancer patients.

Scintigraphic findings in patients with shoulder pain caused by interleukin-2.

Interleukin-2 is receiving widespread interest as an immunotherapeutic agent in the treatment of certain cancers. Severe arthralgias recently have been reported as a significant side effect, and the cause of pain is unknown. Because interleukin-2 is an immune modulator, we reviewed the 99mTc-methylene diphosphonate scintigrams in nine patients who had developed shoulder arthralgias while receiving interleukin-2 for metastatic melanoma. In eight of the patients, the scintigrams showed diffuse increased uptake of radionuclide in the shoulders. Four patients had radiographs of their shoulders, all of which were normal. Bone scintigraphy in patients receiving interleukin-2 as immunotherapy for metastatic melanoma shows increased radionuclide activity in the shoulders. This process may relate to the role of interleukin-2 as a mediator in the inflammatory response.

Sexual function after abdominoperineal resection.

A survey of the sexual changes in patients having abdominoperineal resection for ulcerative colitis was made at the Medical College of Georgia. The incidence of impotence in our series is zero. Only one of our female patients had a successful pregnancy. The other women seemed to be hampered by anatomic derangements relating to strictures, adhesions, or dislocation of the uterus, although the precise causes of infertility have not been elucidated. We suggest that in young men, fear of infertility have not been elucidated. We suggest that in young men, fear of injuring sexuality should not impede selection of appropriate surgical modality. However, we also suggest that the woman's risk of post-operative impairment of sexual function is greater than the man's.