Imaging

GAITHERSBURG, MD. — Black box warnings that have been added to the labels of all gadolinium-based MRI contrast agents have reduced the number of reported nephrogenic systemic fibrosis events to almost none during the past year, according to an analysis by Dr. James Kaiser.

“The numbers of new events have tapered dramatically, probably due to public awareness of the association of NSF [nephrogenic systemic fibrosis] with GBCA [gadolinium-based contrast agent] administration,” he said at a joint meeting of the Food and Drug Administration's Cardiovascular and Renal Drugs and Drug Safety and Risk Management advisory committees.

Event dates are based on either the date of administration of contrast or the date of diagnosis of NSF.

The FDA began receiving reports of NSF possibly being linked to gadolinium-based contrast agents in 2006, when 194 event dates were reported.

This reporting “probably reflects awareness of the medical community of the potential connection between GBCA administration and NSF and changes in radiologic practice,” said Dr. Kaiser of the FDA's office of surveillance and epidemiology. There were 128 reported events in 2007, 55 in 2008, and 6 in 2009 (through September).

In 2007, the FDA asked manufacturers to include a boxed warning on the product labels of all gadolinium-based contrast agents. The warnings caution that patients with severe kidney insufficiency who receive gadolinium-based agents are at increased risk for the development of NSF.

In addition, patients who are in need of a liver transplantation, those who have just undergone liver transplantation, patients who have chronic liver disease, and patients experiencing kidney insufficiency of any severity also have an increased risk of NSF.

Five gadolinium-based contrast agents have been approved for use in the United States: Magnevist (gadopentetate dimeglumine); Omniscan (gadodiamide); OptiMARK (gadoversetamide); MultiHance (gadobenate dimeglumine); and ProHance (gadoteridol).

As of September 2009, a total of 382 reports of NSF had been associated with Omniscan (GE HealthCare), 195 with Magnevist (Bayer HealthCare), 35 with OptiMARK (Covidien), 1 with MultiHance (Bracco Diagnostics), and 0 with ProHance (Bracco Diagnostics). These numbers are based on reported cases in which a patient had known exposure to only one gadolinium-based contrast agent.

Although there was no formal vote during the committee meeting, the FDA asked the committees to consider whether warning labels should continue to be grouped together as a class or if there was adequate evidence to single out contrast agents that increase the risk of NSF.

“The majority of the group feels that at least two of the agents appear to be different from the other agents,” said Dr. Robert A. Harrington, who chairs the Cardiovascular and Renal Drugs Advisory Committee. The majority of the committee members recommended that the use of Omniscan and OptiMARK be contraindicated in patients who have severe kidney dysfunction. However, there was uncertainty as to how to define severe kidney dysfunction.

There was less consensus on whether a third agent, Magnevist, might also warrant contraindication language. As for the other agents, “there was no clear evidence that any one single agent was safe in this patient population,” Dr. Harrington noted.

GAITHERSBURG, MD. — Black box warnings that have been added to the labels of all gadolinium-based MRI contrast agents have reduced the number of reported nephrogenic systemic fibrosis events to almost none during the past year, according to an analysis by Dr. James Kaiser.

“The numbers of new events have tapered dramatically, probably due to public awareness of the association of NSF [nephrogenic systemic fibrosis] with GBCA [gadolinium-based contrast agent] administration,” he said at a joint meeting of the Food and Drug Administration's Cardiovascular and Renal Drugs and Drug Safety and Risk Management advisory committees.

Event dates are based on either the date of administration of contrast or the date of diagnosis of NSF.

The FDA began receiving reports of NSF possibly being linked to gadolinium-based contrast agents in 2006, when 194 event dates were reported.

This reporting “probably reflects awareness of the medical community of the potential connection between GBCA administration and NSF and changes in radiologic practice,” said Dr. Kaiser of the FDA's office of surveillance and epidemiology. There were 128 reported events in 2007, 55 in 2008, and 6 in 2009 (through September).

In 2007, the FDA asked manufacturers to include a boxed warning on the product labels of all gadolinium-based contrast agents. The warnings caution that patients with severe kidney insufficiency who receive gadolinium-based agents are at increased risk for the development of NSF.

In addition, patients who are in need of a liver transplantation, those who have just undergone liver transplantation, patients who have chronic liver disease, and patients experiencing kidney insufficiency of any severity also have an increased risk of NSF.

Five gadolinium-based contrast agents have been approved for use in the United States: Magnevist (gadopentetate dimeglumine); Omniscan (gadodiamide); OptiMARK (gadoversetamide); MultiHance (gadobenate dimeglumine); and ProHance (gadoteridol).

As of September 2009, a total of 382 reports of NSF had been associated with Omniscan (GE HealthCare), 195 with Magnevist (Bayer HealthCare), 35 with OptiMARK (Covidien), 1 with MultiHance (Bracco Diagnostics), and 0 with ProHance (Bracco Diagnostics). These numbers are based on reported cases in which a patient had known exposure to only one gadolinium-based contrast agent.

Although there was no formal vote during the committee meeting, the FDA asked the committees to consider whether warning labels should continue to be grouped together as a class or if there was adequate evidence to single out contrast agents that increase the risk of NSF.

“The majority of the group feels that at least two of the agents appear to be different from the other agents,” said Dr. Robert A. Harrington, who chairs the Cardiovascular and Renal Drugs Advisory Committee. The majority of the committee members recommended that the use of Omniscan and OptiMARK be contraindicated in patients who have severe kidney dysfunction. However, there was uncertainty as to how to define severe kidney dysfunction.

There was less consensus on whether a third agent, Magnevist, might also warrant contraindication language. As for the other agents, “there was no clear evidence that any one single agent was safe in this patient population,” Dr. Harrington noted.

GAITHERSBURG, MD. — Black box warnings that have been added to the labels of all gadolinium-based MRI contrast agents have reduced the number of reported nephrogenic systemic fibrosis events to almost none during the past year, according to an analysis by Dr. James Kaiser.

“The numbers of new events have tapered dramatically, probably due to public awareness of the association of NSF [nephrogenic systemic fibrosis] with GBCA [gadolinium-based contrast agent] administration,” he said at a joint meeting of the Food and Drug Administration's Cardiovascular and Renal Drugs and Drug Safety and Risk Management advisory committees.

Event dates are based on either the date of administration of contrast or the date of diagnosis of NSF.

The FDA began receiving reports of NSF possibly being linked to gadolinium-based contrast agents in 2006, when 194 event dates were reported.

This reporting “probably reflects awareness of the medical community of the potential connection between GBCA administration and NSF and changes in radiologic practice,” said Dr. Kaiser of the FDA's office of surveillance and epidemiology. There were 128 reported events in 2007, 55 in 2008, and 6 in 2009 (through September).

In 2007, the FDA asked manufacturers to include a boxed warning on the product labels of all gadolinium-based contrast agents. The warnings caution that patients with severe kidney insufficiency who receive gadolinium-based agents are at increased risk for the development of NSF.

In addition, patients who are in need of a liver transplantation, those who have just undergone liver transplantation, patients who have chronic liver disease, and patients experiencing kidney insufficiency of any severity also have an increased risk of NSF.

Five gadolinium-based contrast agents have been approved for use in the United States: Magnevist (gadopentetate dimeglumine); Omniscan (gadodiamide); OptiMARK (gadoversetamide); MultiHance (gadobenate dimeglumine); and ProHance (gadoteridol).

As of September 2009, a total of 382 reports of NSF had been associated with Omniscan (GE HealthCare), 195 with Magnevist (Bayer HealthCare), 35 with OptiMARK (Covidien), 1 with MultiHance (Bracco Diagnostics), and 0 with ProHance (Bracco Diagnostics). These numbers are based on reported cases in which a patient had known exposure to only one gadolinium-based contrast agent.

Although there was no formal vote during the committee meeting, the FDA asked the committees to consider whether warning labels should continue to be grouped together as a class or if there was adequate evidence to single out contrast agents that increase the risk of NSF.

“The majority of the group feels that at least two of the agents appear to be different from the other agents,” said Dr. Robert A. Harrington, who chairs the Cardiovascular and Renal Drugs Advisory Committee. The majority of the committee members recommended that the use of Omniscan and OptiMARK be contraindicated in patients who have severe kidney dysfunction. However, there was uncertainty as to how to define severe kidney dysfunction.

There was less consensus on whether a third agent, Magnevist, might also warrant contraindication language. As for the other agents, “there was no clear evidence that any one single agent was safe in this patient population,” Dr. Harrington noted.

Findings: No new cases of nephrogenic systemic fibrosis were reported after reduction in use of gadolinium-based contrast agents, as well as substitution of new agents.

Data Source: Patient records at two tertiary care centers.

Disclosure: One study author received research support from GE Healthcare, Bayer Healthcare Pharmaceuticals, and Bracco, makers of gadolinium-based contrast agents used in the study.

No new cases of nephrogenic systemic fibrosis occurred at two large tertiary care facilities after more restrictive policies on the use of gadolinium-based contrast agents were introduced.

Before the changes, the incidence of nephrogenic systemic fibrosis (NSF) was 1 in 33 in high-risk patients. In patients on dialysis, the incidence of NSF was 1 in 35, according Dr. Ersan Altun, a radiologist at the University of North Carolina in Chapel Hill, and his coauthors.

“The absence of NSF cases in the postadoption period may reflect the effect of the use of different GBCAs [gadolinium-based contrast agents] and the adoption of restrictive GBCA policies on the incidence of NSF,” they wrote (Radiology 2009;253:689–96).

In 2006, reports to the Food and Drug Administration suggested a strong association between NSF and gadolinium-based contrast agents used in MRI. The exact mechanism remains unknown; however, GBCAs vary in their dissociation rates, and dissociation of the gadolinium ion from the chelating ligand may be a risk factor for NSF, the researchers said.

Cases of NSF were documented at two tertiary care centers for three periods: before the adoption of restrictive GBCA policies and a change in agents, during the transition period, and after the adoption of these policieschanges.

The new policies included careful screening of patients for risk factors for NSF such as renal disease, hypertension, dialysis, and diabetes before they underwent gadolinium-enhanced MRI. If GBCA-enhanced imaging was unavoidable in a patient deemed to be at high risk, a half dose of gadobenate dimeglumine was used. The policies also specified greater use of other types of imaging that don't require contrast agents.

In addition, gadolinium-enhanced MRI was not performed in pregnant women unless maternal survival was at stake, was not performed in any patient twice within 48 hours unless absolutely necessary, and was not done twice within 48 hours in any patient deemed to be at high risk of NSF.

Before the adoption of the changes, both of the centers used gadodiamide (Omniscan, GE Healthcare). After the adoption of revised policies, both centers used either gadobenate dimeglumine (Multihance, Bracco Diagnostics) or gadopentetate dimeglumine (Magnevist, Bayer Healthcare Pharmaceuticals). Gadobenate was used for all MRI studies of adults, patients younger than 1 year, and pediatric patients at risk for the development of NSF. Gadopentetate was used for pediatric patients 1 year and older who were not at risk for NSF. Both of the agents have lower dissociation rates than gadodiamide.

Patients considered to be at high risk for NSF were defined as having stage 4 or 5 chronic renal disease, undergoing dialysis, having acute renal insufficiency (including patients with hepatorenal syndrome), and being in the perioperative liver transplantation period. Patients considered to be at low risk were those who had stage 3 chronic renal disease, children less than 1 year of age, and pregnant patients. NSF was diagnosed by clinical findings and histopathologic evaluation of deep-skin biopsy.

At center A, 35 patients with NSF were identified in the preadoption period; of these, 28 underwent MRI with gadodiamide. The benchmark incidence of NSF at center A was 1/1,750 and the NSF incidence in high-risk patients was 1/33.

At center B, 14 patients with NSF were identified in the preadoption period; of these, 9 underwent MRI with gadodiamide. The benchmark incidence of NSF at center B was 1/1,803 and the NSF incidence in dialysis patients was 1/35.

There were no cases of NSF in the transitional and postadoption periods at either center.

My Take

Prevention of NSF Remains a Challenge

It's important to note that the reported decrease in NSF may not have occurred simply because new contrast agents were used. The more restrictive policies on the use of contrast agents might account for the improvement.

Companies that manufacture alternative contrast agents have a clear financial incentive in conducting and reporting such research. This study is by no means definitive, nor should the findings be construed to mean that a flat-out switch to an alternative agent is recommended.

That being said, we've only begun to scratch the surface of NSF. We don't understand the pathophysiology of the disorder, nor do we have any factor other than known renal disease that we can use to stratify patients for NSF risk.

Clearly, we still have a long way to go in addressing the problem of NSF.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

Findings: No new cases of nephrogenic systemic fibrosis were reported after reduction in use of gadolinium-based contrast agents, as well as substitution of new agents.

Data Source: Patient records at two tertiary care centers.

Disclosure: One study author received research support from GE Healthcare, Bayer Healthcare Pharmaceuticals, and Bracco, makers of gadolinium-based contrast agents used in the study.

No new cases of nephrogenic systemic fibrosis occurred at two large tertiary care facilities after more restrictive policies on the use of gadolinium-based contrast agents were introduced.

Before the changes, the incidence of nephrogenic systemic fibrosis (NSF) was 1 in 33 in high-risk patients. In patients on dialysis, the incidence of NSF was 1 in 35, according Dr. Ersan Altun, a radiologist at the University of North Carolina in Chapel Hill, and his coauthors.

“The absence of NSF cases in the postadoption period may reflect the effect of the use of different GBCAs [gadolinium-based contrast agents] and the adoption of restrictive GBCA policies on the incidence of NSF,” they wrote (Radiology 2009;253:689–96).

In 2006, reports to the Food and Drug Administration suggested a strong association between NSF and gadolinium-based contrast agents used in MRI. The exact mechanism remains unknown; however, GBCAs vary in their dissociation rates, and dissociation of the gadolinium ion from the chelating ligand may be a risk factor for NSF, the researchers said.

Cases of NSF were documented at two tertiary care centers for three periods: before the adoption of restrictive GBCA policies and a change in agents, during the transition period, and after the adoption of these policieschanges.

The new policies included careful screening of patients for risk factors for NSF such as renal disease, hypertension, dialysis, and diabetes before they underwent gadolinium-enhanced MRI. If GBCA-enhanced imaging was unavoidable in a patient deemed to be at high risk, a half dose of gadobenate dimeglumine was used. The policies also specified greater use of other types of imaging that don't require contrast agents.

In addition, gadolinium-enhanced MRI was not performed in pregnant women unless maternal survival was at stake, was not performed in any patient twice within 48 hours unless absolutely necessary, and was not done twice within 48 hours in any patient deemed to be at high risk of NSF.

Before the adoption of the changes, both of the centers used gadodiamide (Omniscan, GE Healthcare). After the adoption of revised policies, both centers used either gadobenate dimeglumine (Multihance, Bracco Diagnostics) or gadopentetate dimeglumine (Magnevist, Bayer Healthcare Pharmaceuticals). Gadobenate was used for all MRI studies of adults, patients younger than 1 year, and pediatric patients at risk for the development of NSF. Gadopentetate was used for pediatric patients 1 year and older who were not at risk for NSF. Both of the agents have lower dissociation rates than gadodiamide.

Patients considered to be at high risk for NSF were defined as having stage 4 or 5 chronic renal disease, undergoing dialysis, having acute renal insufficiency (including patients with hepatorenal syndrome), and being in the perioperative liver transplantation period. Patients considered to be at low risk were those who had stage 3 chronic renal disease, children less than 1 year of age, and pregnant patients. NSF was diagnosed by clinical findings and histopathologic evaluation of deep-skin biopsy.

At center A, 35 patients with NSF were identified in the preadoption period; of these, 28 underwent MRI with gadodiamide. The benchmark incidence of NSF at center A was 1/1,750 and the NSF incidence in high-risk patients was 1/33.

At center B, 14 patients with NSF were identified in the preadoption period; of these, 9 underwent MRI with gadodiamide. The benchmark incidence of NSF at center B was 1/1,803 and the NSF incidence in dialysis patients was 1/35.

There were no cases of NSF in the transitional and postadoption periods at either center.

My Take

Prevention of NSF Remains a Challenge

It's important to note that the reported decrease in NSF may not have occurred simply because new contrast agents were used. The more restrictive policies on the use of contrast agents might account for the improvement.

Companies that manufacture alternative contrast agents have a clear financial incentive in conducting and reporting such research. This study is by no means definitive, nor should the findings be construed to mean that a flat-out switch to an alternative agent is recommended.

That being said, we've only begun to scratch the surface of NSF. We don't understand the pathophysiology of the disorder, nor do we have any factor other than known renal disease that we can use to stratify patients for NSF risk.

Clearly, we still have a long way to go in addressing the problem of NSF.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

Findings: No new cases of nephrogenic systemic fibrosis were reported after reduction in use of gadolinium-based contrast agents, as well as substitution of new agents.

Data Source: Patient records at two tertiary care centers.

Disclosure: One study author received research support from GE Healthcare, Bayer Healthcare Pharmaceuticals, and Bracco, makers of gadolinium-based contrast agents used in the study.

No new cases of nephrogenic systemic fibrosis occurred at two large tertiary care facilities after more restrictive policies on the use of gadolinium-based contrast agents were introduced.

Before the changes, the incidence of nephrogenic systemic fibrosis (NSF) was 1 in 33 in high-risk patients. In patients on dialysis, the incidence of NSF was 1 in 35, according Dr. Ersan Altun, a radiologist at the University of North Carolina in Chapel Hill, and his coauthors.

“The absence of NSF cases in the postadoption period may reflect the effect of the use of different GBCAs [gadolinium-based contrast agents] and the adoption of restrictive GBCA policies on the incidence of NSF,” they wrote (Radiology 2009;253:689–96).

In 2006, reports to the Food and Drug Administration suggested a strong association between NSF and gadolinium-based contrast agents used in MRI. The exact mechanism remains unknown; however, GBCAs vary in their dissociation rates, and dissociation of the gadolinium ion from the chelating ligand may be a risk factor for NSF, the researchers said.

Cases of NSF were documented at two tertiary care centers for three periods: before the adoption of restrictive GBCA policies and a change in agents, during the transition period, and after the adoption of these policieschanges.

The new policies included careful screening of patients for risk factors for NSF such as renal disease, hypertension, dialysis, and diabetes before they underwent gadolinium-enhanced MRI. If GBCA-enhanced imaging was unavoidable in a patient deemed to be at high risk, a half dose of gadobenate dimeglumine was used. The policies also specified greater use of other types of imaging that don't require contrast agents.

In addition, gadolinium-enhanced MRI was not performed in pregnant women unless maternal survival was at stake, was not performed in any patient twice within 48 hours unless absolutely necessary, and was not done twice within 48 hours in any patient deemed to be at high risk of NSF.

Before the adoption of the changes, both of the centers used gadodiamide (Omniscan, GE Healthcare). After the adoption of revised policies, both centers used either gadobenate dimeglumine (Multihance, Bracco Diagnostics) or gadopentetate dimeglumine (Magnevist, Bayer Healthcare Pharmaceuticals). Gadobenate was used for all MRI studies of adults, patients younger than 1 year, and pediatric patients at risk for the development of NSF. Gadopentetate was used for pediatric patients 1 year and older who were not at risk for NSF. Both of the agents have lower dissociation rates than gadodiamide.

Patients considered to be at high risk for NSF were defined as having stage 4 or 5 chronic renal disease, undergoing dialysis, having acute renal insufficiency (including patients with hepatorenal syndrome), and being in the perioperative liver transplantation period. Patients considered to be at low risk were those who had stage 3 chronic renal disease, children less than 1 year of age, and pregnant patients. NSF was diagnosed by clinical findings and histopathologic evaluation of deep-skin biopsy.

At center A, 35 patients with NSF were identified in the preadoption period; of these, 28 underwent MRI with gadodiamide. The benchmark incidence of NSF at center A was 1/1,750 and the NSF incidence in high-risk patients was 1/33.

At center B, 14 patients with NSF were identified in the preadoption period; of these, 9 underwent MRI with gadodiamide. The benchmark incidence of NSF at center B was 1/1,803 and the NSF incidence in dialysis patients was 1/35.

There were no cases of NSF in the transitional and postadoption periods at either center.

My Take

Prevention of NSF Remains a Challenge

It's important to note that the reported decrease in NSF may not have occurred simply because new contrast agents were used. The more restrictive policies on the use of contrast agents might account for the improvement.

Companies that manufacture alternative contrast agents have a clear financial incentive in conducting and reporting such research. This study is by no means definitive, nor should the findings be construed to mean that a flat-out switch to an alternative agent is recommended.

That being said, we've only begun to scratch the surface of NSF. We don't understand the pathophysiology of the disorder, nor do we have any factor other than known renal disease that we can use to stratify patients for NSF risk.

Clearly, we still have a long way to go in addressing the problem of NSF.

FRANK MICHOTA, M.D., is the Director of Academic Affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reports no relevant conflicts of interest.

The American College of Rheumatology is billing its new online image bank as the “most comprehensive online collection of rheumatology-related images,” running the alphabet from avascular necrosis to vasculitis.

The collection includes more than 1,500 clinical, pathological, and radiologic images of both common and rare rheumatic disorders. The primary purpose of the image bank is as a teaching tool. “It's a great teaching tool for people training in rheumatology,” said Dr. Alan Baer, chair of the ACR's Audiovisual Aids Subcommittee, which is the arm of ACR that oversaw the development of the image bank.

In addition to their usefulness in training the next generation of rheumatologists, the images can also be used when rheumatologists “go out into the community to give talks to their colleagues or laypeople.”

The images are arranged in sections by type of disorder—soft-tissue rheumatic syndromes, for example. Within a section, images are presented alphabetically by condition.

The image bank is the descendant of the college's slide collection, which got its start in 1958 with a collection of pathology slides. The collection has been revised and supplemented several times since then. “For many years, it was a 35-mm collection. But within the past decade, it became a CD-ROM collection,” said Dr. Baer, who is both chief of rheumatology and director of the Johns Hopkins University Clinical Practice, both at Good Samaritan Hospital, Baltimore. “For a number of years, we have recognized the need to put the image bank online and make it Internet accessible. That's what we've accomplished in the last year.”

Certainly it's easy enough to find rheumatology images through search engines, such as Google. However, the committee makes “a very concerted effort to ensure that these are top-quality images that are carefully annotated.” In fact, the images and any accompanying material are carefully scrutinized for accuracy, and additional information may be requested.

“It's a very reliable source of images,” said Dr. Baer.

Over the years, the collection has grown from pathology, histology, clinical photos, and x-rays to include newer imaging modalities such as MRI, CT, and sonography.

Dr. Baer hopes to expand the online collection to include video in the future. “We want to move to some of the new imaging formats.”

Video “opens up a whole new arena for us.” For example, “you could watch someone examine a certain joint or watch procedures being performed.”

Video would be particularly useful for including ultrasound imaging in the collection.

Ultrasound is dynamic by nature and it's hard to capture the diagnostic process with a static image, he noted.

“This is a great opportunity to create a whole new type of educational tool,” said Dr. Baer.

The image bank can be found at www.rheumatology.org

These images from a patient with Wegener's granulomatosis illustrate what the ACR has on offer.

Source American College of Rheumatology Image Bank

The American College of Rheumatology is billing its new online image bank as the “most comprehensive online collection of rheumatology-related images,” running the alphabet from avascular necrosis to vasculitis.

The collection includes more than 1,500 clinical, pathological, and radiologic images of both common and rare rheumatic disorders. The primary purpose of the image bank is as a teaching tool. “It's a great teaching tool for people training in rheumatology,” said Dr. Alan Baer, chair of the ACR's Audiovisual Aids Subcommittee, which is the arm of ACR that oversaw the development of the image bank.

In addition to their usefulness in training the next generation of rheumatologists, the images can also be used when rheumatologists “go out into the community to give talks to their colleagues or laypeople.”

The images are arranged in sections by type of disorder—soft-tissue rheumatic syndromes, for example. Within a section, images are presented alphabetically by condition.

The image bank is the descendant of the college's slide collection, which got its start in 1958 with a collection of pathology slides. The collection has been revised and supplemented several times since then. “For many years, it was a 35-mm collection. But within the past decade, it became a CD-ROM collection,” said Dr. Baer, who is both chief of rheumatology and director of the Johns Hopkins University Clinical Practice, both at Good Samaritan Hospital, Baltimore. “For a number of years, we have recognized the need to put the image bank online and make it Internet accessible. That's what we've accomplished in the last year.”

Certainly it's easy enough to find rheumatology images through search engines, such as Google. However, the committee makes “a very concerted effort to ensure that these are top-quality images that are carefully annotated.” In fact, the images and any accompanying material are carefully scrutinized for accuracy, and additional information may be requested.

“It's a very reliable source of images,” said Dr. Baer.

Over the years, the collection has grown from pathology, histology, clinical photos, and x-rays to include newer imaging modalities such as MRI, CT, and sonography.

Dr. Baer hopes to expand the online collection to include video in the future. “We want to move to some of the new imaging formats.”

Video “opens up a whole new arena for us.” For example, “you could watch someone examine a certain joint or watch procedures being performed.”

Video would be particularly useful for including ultrasound imaging in the collection.

Ultrasound is dynamic by nature and it's hard to capture the diagnostic process with a static image, he noted.

“This is a great opportunity to create a whole new type of educational tool,” said Dr. Baer.

The image bank can be found at www.rheumatology.org

These images from a patient with Wegener's granulomatosis illustrate what the ACR has on offer.

Source American College of Rheumatology Image Bank

The American College of Rheumatology is billing its new online image bank as the “most comprehensive online collection of rheumatology-related images,” running the alphabet from avascular necrosis to vasculitis.

The collection includes more than 1,500 clinical, pathological, and radiologic images of both common and rare rheumatic disorders. The primary purpose of the image bank is as a teaching tool. “It's a great teaching tool for people training in rheumatology,” said Dr. Alan Baer, chair of the ACR's Audiovisual Aids Subcommittee, which is the arm of ACR that oversaw the development of the image bank.

In addition to their usefulness in training the next generation of rheumatologists, the images can also be used when rheumatologists “go out into the community to give talks to their colleagues or laypeople.”

The images are arranged in sections by type of disorder—soft-tissue rheumatic syndromes, for example. Within a section, images are presented alphabetically by condition.

The image bank is the descendant of the college's slide collection, which got its start in 1958 with a collection of pathology slides. The collection has been revised and supplemented several times since then. “For many years, it was a 35-mm collection. But within the past decade, it became a CD-ROM collection,” said Dr. Baer, who is both chief of rheumatology and director of the Johns Hopkins University Clinical Practice, both at Good Samaritan Hospital, Baltimore. “For a number of years, we have recognized the need to put the image bank online and make it Internet accessible. That's what we've accomplished in the last year.”

Certainly it's easy enough to find rheumatology images through search engines, such as Google. However, the committee makes “a very concerted effort to ensure that these are top-quality images that are carefully annotated.” In fact, the images and any accompanying material are carefully scrutinized for accuracy, and additional information may be requested.

“It's a very reliable source of images,” said Dr. Baer.

Over the years, the collection has grown from pathology, histology, clinical photos, and x-rays to include newer imaging modalities such as MRI, CT, and sonography.

Dr. Baer hopes to expand the online collection to include video in the future. “We want to move to some of the new imaging formats.”

Video “opens up a whole new arena for us.” For example, “you could watch someone examine a certain joint or watch procedures being performed.”

Video would be particularly useful for including ultrasound imaging in the collection.

Ultrasound is dynamic by nature and it's hard to capture the diagnostic process with a static image, he noted.

“This is a great opportunity to create a whole new type of educational tool,” said Dr. Baer.

The image bank can be found at www.rheumatology.org

These images from a patient with Wegener's granulomatosis illustrate what the ACR has on offer.

Source American College of Rheumatology Image Bank

NEW ORLEANS — Abdominal computed tomography limited to the region of tenderness accurately delineates acute pathology while reducing radiation exposure, according to a double-blind study.

A standard abdominal CT scan covers an area from above the diaphragm to the mid-thigh. But in the study, limiting the scan to the tender area cut radiation exposure by a mean of 69% while preserving 96% sensitivity, Dr. Joshua Broder said at the annual meeting of the Society for Academic Emergency Medicine.

The 93 patients in the single-center study underwent standard abdominal CT after presenting to the emergency department with nontraumatic abdominal tenderness. Before imaging, emergency physicians placed skin markers to delineate the cephalocaudad extent of tenderness. Then they added coded meaningless markers so radiologists would remain blinded to the region of tenderness, said Dr. Broder of Duke University Medical Center, Durham, N.C.

Of the 93 patients, 51 ultimately were found to have abdominal pathology, most commonly acute appendicitis. In one-third of cases, the pathology identified by radiologists was completely contained in the area highlighted by the skin markers of abdominal tenderness; in another 51%, the pathology was partially located in the marked zone and would have been readily detected by a scan limited to the region of abdominal tenderness.

Although in 16% of cases, the pathology wasn't even partially in the skin marker zone, in most of those instances it was doubtful that the pathology actually caused the abdominal pain. The rate of clinically relevant false-negative abdominal CT scans limited to the area of pain and tenderness was only 4%.

Dr. Broder and his associates also tested intermediately restricted CT, in which the entire abdomen and pelvis below the most cephalad skin marker of tenderness was scanned. This reduced radiation exposure by 38% and increased test sensitivity to 98%.

Based on the encouraging results in a nonconsecutive series, Dr. Broder plans to perform a larger, double-blind study in a consecutive series of similar patients.

NEW ORLEANS — Abdominal computed tomography limited to the region of tenderness accurately delineates acute pathology while reducing radiation exposure, according to a double-blind study.

A standard abdominal CT scan covers an area from above the diaphragm to the mid-thigh. But in the study, limiting the scan to the tender area cut radiation exposure by a mean of 69% while preserving 96% sensitivity, Dr. Joshua Broder said at the annual meeting of the Society for Academic Emergency Medicine.

The 93 patients in the single-center study underwent standard abdominal CT after presenting to the emergency department with nontraumatic abdominal tenderness. Before imaging, emergency physicians placed skin markers to delineate the cephalocaudad extent of tenderness. Then they added coded meaningless markers so radiologists would remain blinded to the region of tenderness, said Dr. Broder of Duke University Medical Center, Durham, N.C.

Of the 93 patients, 51 ultimately were found to have abdominal pathology, most commonly acute appendicitis. In one-third of cases, the pathology identified by radiologists was completely contained in the area highlighted by the skin markers of abdominal tenderness; in another 51%, the pathology was partially located in the marked zone and would have been readily detected by a scan limited to the region of abdominal tenderness.

Although in 16% of cases, the pathology wasn't even partially in the skin marker zone, in most of those instances it was doubtful that the pathology actually caused the abdominal pain. The rate of clinically relevant false-negative abdominal CT scans limited to the area of pain and tenderness was only 4%.

Dr. Broder and his associates also tested intermediately restricted CT, in which the entire abdomen and pelvis below the most cephalad skin marker of tenderness was scanned. This reduced radiation exposure by 38% and increased test sensitivity to 98%.

Based on the encouraging results in a nonconsecutive series, Dr. Broder plans to perform a larger, double-blind study in a consecutive series of similar patients.

NEW ORLEANS — Abdominal computed tomography limited to the region of tenderness accurately delineates acute pathology while reducing radiation exposure, according to a double-blind study.

A standard abdominal CT scan covers an area from above the diaphragm to the mid-thigh. But in the study, limiting the scan to the tender area cut radiation exposure by a mean of 69% while preserving 96% sensitivity, Dr. Joshua Broder said at the annual meeting of the Society for Academic Emergency Medicine.

The 93 patients in the single-center study underwent standard abdominal CT after presenting to the emergency department with nontraumatic abdominal tenderness. Before imaging, emergency physicians placed skin markers to delineate the cephalocaudad extent of tenderness. Then they added coded meaningless markers so radiologists would remain blinded to the region of tenderness, said Dr. Broder of Duke University Medical Center, Durham, N.C.

Of the 93 patients, 51 ultimately were found to have abdominal pathology, most commonly acute appendicitis. In one-third of cases, the pathology identified by radiologists was completely contained in the area highlighted by the skin markers of abdominal tenderness; in another 51%, the pathology was partially located in the marked zone and would have been readily detected by a scan limited to the region of abdominal tenderness.

Although in 16% of cases, the pathology wasn't even partially in the skin marker zone, in most of those instances it was doubtful that the pathology actually caused the abdominal pain. The rate of clinically relevant false-negative abdominal CT scans limited to the area of pain and tenderness was only 4%.

Dr. Broder and his associates also tested intermediately restricted CT, in which the entire abdomen and pelvis below the most cephalad skin marker of tenderness was scanned. This reduced radiation exposure by 38% and increased test sensitivity to 98%.

Based on the encouraging results in a nonconsecutive series, Dr. Broder plans to perform a larger, double-blind study in a consecutive series of similar patients.