Y-90 combined with systemic chemotherapy

Helping people fight cancer is one of the most valuable and satisfying aspects of interventional radiology (#irad). Recently, a JCO article was published which demonstrated that Y-90 radioembolization combined with systemic chemotherapy resulted in a significant delay in disease progression which resulted in a longer progression free survival, meaning patients lived longer than they otherwise would have had they not undergone the combined treatments.

How exciting.

Here is an excerpt from a Yahoo finance article on the subject:

"Lead author and the study's co-principal investigator, Prof. Guy A van Hazel of the University of Western Australia, Perth, Australia, said "In the primary endpoint of the study, patients with non-resectable liver-dominant or liver-only colorectal cancer who received FOLFOX-based first-line chemotherapy alone had a median Progression-Free Survival (PFS) at any site of 10.2 versus 10.7 months in those that received chemotherapy plus SIR-Spheres, but this difference was not statistically significant. However, the addition of SIR-Spheres Y-90 resin microspheres to chemotherapy significantly prolonged PFS in the liver, from a median of 12.6 months in the chemotherapy control arm compared to 20.5 months in the SIR-Spheres arm, which translated to a 31 percent reduction in the risk of tumour progression in the liver. Long-term disease control is critical as liver metastases eventually cause the death of the majority of the hundreds of thousands of patients who get colorectal cancer that cannot be removed by surgery."  "

Facts (excerpted from SIR-Spheres publication):

·        The majority of people with liver metastases secondary to colorectal cancer die due to liver failure due to the hepatic tumor burden

·        Chemotherapy induced parenchymal damage also significantly contributes to liver failure

·        Protecting healthy parenchyma, while effectively treating liver metastases is a key goal when treating patients with liver dominant metastases

·        SIRFLOX demonstrates that combining SIR-Spheres Y-90 resin microspheres with standard of care systemic chemotherapy resulted in:

o7.9 month improvement in median PFS in the liver

o8.7 month improvement in median PFS in the liver in liver only cohort

oNo impact on duration of systemic therapy

oIdentical results irrespective of the use of bevacizumab, baseline tumor burden and performance status

oA significantly increased ORR vs chemo alone

oA 3-fold increase in Complete Responses vs chemotherapy alone

oToxicities that were acceptable and as predicted

oGrade 5 toxicities were not statistically different between the two arms


If you or a loved one is fighting colon cancer,  ask the oncologist about Sir-Spheres treatment. Knowledge is power. Ask your oncologist to explore what interventional radiology has to offer Make sure you aren't missing a critical option in the care paradigm currently available.

Interventional Radiology is Minimally-Invasive Elegant Healing

Someone recently asked me for a simple quote to describe what is so exciting about Interventional Radiology. I found, after 15 minutes of talking, that a single quote did not fully encapsulate the breadth and depth of this remarkable field. As an interventional radiologist, I use imaging to repair, heal, treat and even cure patients of their various ailments.

Interventional Radiology touches on most medical fields. We place surgical ports to enable patient to undergo chemotherapy conveniently. We fix broken bones by injecting a small amount of what we colloquially call "cement," or methylmethacrylate. We place tiny metal coils in veins to eliminate varicoceles in men or enlarged pelvic veins, the cause of pelvic congestion syndrome, in women. We send tiny particles, sometimes laden with chemotherapy and sometimes laden with radioactive particles, into liver arteries to kill metastatic and primary cancers. We place needles into small cancers growing in, for example, kidneys, the liver or bones and freeze them so that the cancer dies. We send small particles into uterine arteries to shrink fibroids.

These are just some examples of the many ways an interventional radiologist makes a difference in the lives of his or her patients.

And we do these things using imaging to guide us and without making large incisions. Rarely is general anesthesia needed, with its associated inherent risks, and an overnight hospital stay is almost never necessary.

So in summary, Interventional Radiology is a patient-centered, technology-driven field where elegant healing occurs through the use of imaging-guided minimally-invasive treatments. 

Teamwork: Essential for Success

It's not an earth-shattering notion that teamwork is essential for success. It goes without saying, yet we benefit from reviewing the concept, that any successful venture comes from dedicated, hard-working, cooperative team-members.

Take, for instance, a radiology group. Radiologists who work in a single specialty group work in concert with each other. Each radiologist is a member of the team. The team works best when there are no weak links. When everyone pulls his or her weight equally, everyone benefits.

Just as in the game of tug-o-war, if one team member slacks their grip, the entire team begins to lose the battle. 

Early in life we are introduced to the idea of teamwork, whether it be through organized sports or other less obviously team-oriented pursuits such as music or art.  Each experience builds on itself and as adults we find harmony in working with others rather than against them. Discontent arises when we fight upstream against the crowd, detracting from a team approach that by definition would help us reach our goal easier and quicker than its alternative.

Build your team. Sow seeds of contentment and harmony with your coworkers and you will find that you are happier and more professionally satisfied as a result. 

A New #IRad Era Dawns in Cincinnati

Ok, I admit to being remiss on my blog for quite a while now. I have no particular excuse other than I've been critically busy with work and family matters.

After 10 interesting, productive and enjoyable years in Naples, Florida, I was recruited by and joined Paradigm Radiology to be the Director of Interventional Radiology in Cincinnati, Ohio. Paradigm Radiology currently services four of the Mercy Health System hospitals located in and around the Cincinnati area: Mercy-West, Fairfield, Anderson and Clermont. Each of these hospitals is unique and presents its own challenges.

The exciting thing about a new venture such as this one is that the possibilities are endless for professional growth and building new relationships. Is it difficult to leave the long-standing relationships that I worked so hard to build? You bet. But I am equally excited to build similar new relationships here in Cincinnati. I look forward to demonstrating my skills and years of expertise and will carry those forward to this new situation. 

I am tasked with building on the existing IR framework at each hospital. The goal with any new venture is to recognize what was working, identify and add what was missing, and carefully rework what was in need of improvement.

Interventional radiology (IR, and, on Twitter, #irad) is an exciting, ever-evolving field and there are numerous areas for potential growth. Cancer care ablations, chemoembolizations and radioembolizations, venous and arterial embolizations, chemotherapy port placements and treatment of spinal compression fractures (kyphoplasty and vertebroplasty) are just some of the exciting facets of Interventional Radiology.

Cancer care is an area where IR is thriving and growing. We perform thermal ablations of cancers of the kidney, liver, bone and other sites using nothing more than skinny needles attached to a gas tank. We place the needles into the targeted cancer and then freeze or heat the mass until it dies, leaving surrounding structures intact.

Liver cancers can be treated by performing "chemoembolization," or "radioembolization," where a small tube (catheter) is placed into the artery supplying the cancer. Small particles embedded with chemotherapy drugs or radioactive particles, respectively, are then delivered, which cause the cancer to die.

We have a great team of forward-thinking, progressive-minded interventionalists who are as enthusiastic as I am. I look forward to a new era in Cincinnati, where we will help people who need the kind of specialized care that IR provides.

Interventional Radiology = Elegant Healing. 

Kidney Cancer Treatment Options

How to handle refugees has been an issue since countries came into existence. In the USA, we discuss, ad nauseum, how to manage the millions of undocumented immigrants who have chosen to make America, the Land of Opportunity, their home.  we haven't come up with a fair plan to manage them, mind you, but the issue is discussed.

Clearly, the obvious solution would be to fix whatever is wrong with the countries of origin so people won't feel the need to migrate in such large numbers.  But that solution is clearly not an easy task.

Germany has an opportunity to handle the immigration of a multitude of refugees. Below is a plan. America would do well to mimic the list discussed below.

As John Mauldin says, in the introduction to the article below:

"Germany is directly in the firing line, both geographically and in terms of how many of the migrants want to settle there. Nearly 40% of migrants choose Germany as their preferred final destination, while the only other nation that is chosen by more than 10% of migrants is Hungary, at 18%.

Daniel Stelter is a very wired German economist and business thinker. "

Germany: A 10-Point Plan to Deal

With the Immigration Challenge

What does it take to make sure that the immigrants now arriving are integrated in a sustainable manner?

By Daniel Stelter
September 14, 2015

Reduce bureaucracy

The process of accepting someone as a refugee in Germany takes too long. We need to define safe countries, like Albania, and send immigrants from these countries back directly.

With all sympathy for their interest in a better living, they are not threatened by war or discrimination. On the other hand, refugees from countries in (civil) war should be accepted fast.

Get to work

It is very important to get immigrants into work once they are in Germany. It is bad for both skills and motivation levels if people cannot work.

Learning the German language is of utmost importance and should be mandatory. Ideally from day one onwards, immigrants should have to start learning the language.

And as long as the immigrants don’t have a job, they should do community service. This advances their integration into society and would give a clear signal: Everyone coming to Germany has to contribute to the common good with his or her abilities.

Significant investments in education and integration

We need to register skills in order to find the appropriate job or define the necessary next steps in education. Education will the biggest challenge.

German schools even today fail to integrate and educate the children (and grandchildren) of migrants who have been in the country in some cases for some decades.

The school performance of children from Turkey, the Arab world and Africa is significantly below the average. We need to invest significantly, as this will define which share of migrants will become productive members of our society and which share will depend on social welfare.

Defend our values

Not only skills and language are important. In addition, we need to emphasize our principles and values. This includes freedom of speech and religion, women’s rights, tolerance for minorities and non-violence.

We have to make clear that integration will only work this way and is expected from everyone. Simply arriving is not enough to stay.

Canada, while generally being very welcoming to immigration, every year sends back about 10,000 immigrants – not necessarily for lack of integration, but it is not a one-way street.

Mandatory schooling

Participation in language school and courses on values and rules in Germany need to be mandatory for every new arrivalJust as Brazil does with its bolsa familia, the payment of social welfare should be linked to language and values training.

In doing so, we would convey the image of Germany as we should – a country willing to help, but also a country in which everyone has to make a contribution. Everyone who expects help and support needs to be willing to learn the language.

Recruit qualified immigrants

It is clear that a selection process as in Canada and Australia succeeds in attracting better-qualified migrants.

Besides refugees from war and people in their home countries, who need our support and where economic considerations should play no role, Germany should become more attractive for well-qualified migrants and be more active in advertising the opportunity to build a new life here.

As a consequence, we should actively open the way for legal immigration to Germany. As a result, the applicants could spend their savings on building a new life here, instead of spending it on smugglers.


Both sides, the migrants and the German population, need to accept immigration as a lifetime decision. It is not a temporary refuge.

Again, Canada proves the point: If it is seen as permanent, both sides, the migrant and the accepting country, work harder to make integration work.

That has been a particular shortcoming of Germany’s immigration policies in the past, especially regarding Turks.

Help in the poor countries

It would be cheaper and more effective to help the people in safe countries such as Albania, who aim for a better life, with direct financial and organizational support. The EU should invest there and help to build democratic institutions and a working rule of law.

Fostering peace

The current wave of immigration is the result of conflicts which have lasted for decades already – and will likely last decades more.

This is amplified by a demographic development which leads to a high number of young people without a credible perspective of finding a job in their home country. This, in turn, increases the propensity not just for social strife, but even for (civil) war.

The West needs to reconsider its strategy fundamentally. The current U.S.-led approach of favoring military intervention over development aid only leads to even more destabilization.

Be all in

The humanitarian and financial costs of such a strategy are enormous. But if we don’t do this, we will have much higher costs to incur.

Whoever speaks of the benefits of immigration also needs to make sure that all the groundwork is laid so that the possible benefits are also realized. Making the necessary investments can by no means be taken for granted.

In conclusion, the current and future wave of immigration to Germany could be beneficial for our country – but only if we address the challenge with full force.

Unfortunately, it seems as if, just as in the eurozone crisis, that our various countries’ leaderships – Germany’s included – are failing at the task.

There is no denying that any solution involves shouldering huge costs for all citizens, natives and migrants. Those who hope that the wave will end soon should think again: Sub-Saharan Africa’s population is about to grow by 600 million over the next 20 years.

100 million or more of those mostly young people will look for a better life in the north. We had better learn now how to deal with it.

An #IRad Fosters Good Clinical Care Through Appropriate Guidance

Most people who care for patients realize that an interventional radiologist (IR) is an excellent resource to assist primary and specialty physicians with the appropriateness of radiology procedures and non-invasive tests. 

Well-positioned in the center of the care and imaging paradigm, IRs see imaging studies as potential precursors to interventional treatments. We constantly assess the imaging studies we interpret for potential ways to help people. 

For instance, a person with a diagnosis of colon cancer develops pain, undergoes a CT scan, and is found to have liver masses in the liver.  A treatment exists called Y-90 radioembolization (aka Selective Internal Radiation Therapy) that may be appropriate and can be performed with concurrent chemotherapy.

A mass is diagnosed and the primary doctor wants to know whether a biopsy can be safely performed. An interventional radiologist answers that question.

A patient with high blood pressure is diagnosed with a stenosis (narrowing) of the renal artery, a known potential cause of high blood pressure. An interventional radiologist can discuss the nuances of renal artery stenosis, and may suggest additional studies, such as a Captopril renogram, to investigate the findings and determine whether the anatomic abnormality is truly the cause of the high blood pressure. If so, the artery can be stented.

There are many additional examples that can be discussed but the bottom line is to be aware of where interventional radiology fits into patient care - and it is usually much more central and much earlier than you might realize. 

Procedure Time: A Quality Indicator

I've been a practicing interventional radiologist for 13 years. In that time I have watched my procedure times decrease without any increase in complication. Actually, the complication rate has also decreased over time. One would expect both of these things to happen with increasing experience in any field.  Such experiences make it apparent that procedure time is a quantifiable quality indicator.

It is said that it takes 10,000 hours to become expert at anything. While some may wish to debate that assertion, I can state with certainty that I have spent at least 10,000 hours in my field. In the field of medicine, 10,000 hours of "practice" becomes quite meaningful. Now, this is not a bragging rights issue. I am not writing this blog to showcase how wonderful I am. In fact, I have a friend/colleague who can perform a TIPS in less than 30 minutes! To calibrate you, that procedure routinely takes many interventionalists two hours to perform. (My time is under 45 minutes but that 30 minute time can't be beat.)

In light of the above, it seems logical that the recent move towards pay for quality should include technical expertise, and I'm sure it does. I'm also not trying to critique the finer points of any particular legislation. A quantifiable measure of quality is procedure time. So it makes sense to use it as such. The caveat however is that, as procedure time decreases, complication rate cannot increase. Complication rate increases would of course negate the quality benefit of improving procedure times.

Many healthcare workers develop a sense of who is the "go to person" for each patient care need. There can be a quality difference between doctors in a given specialty because everyone has differing levels of technical expertise, knowledge and clinical acumen.

So it makes sense that one group of doctors, for example, might excel at research while another set of doctors may excel at technical procedures. And other doctors may excel at making a diagnosis from seemingly unrelated signs and symptoms. 

Obviously not every field is quantifiable. But the more procedure-oriented fields, such as surgery or interventional radiology, are quantifiable in this respect.  Take time to delve into this topic a bit and determine for yourself whether it matters to you that the doctor who is about to remove your gallbladder can do so in less time than another doctor and with the same or fewer frequency of complications. Or whether you would prefer that the interventional radiologist can place a dialysis catheter or an IVC filter in less than five minutes without a hitch.

Being intimately connected to the field of medicine, I can say categorically it would matter to me. 

Politics, The Art of Compromise

Politics is an art and a science, according to Merriam-Webster

Politics is defined as

: activities that relate to influencing the actions and policies of a government or getting and keeping power in a government

: the work or job of people (such as elected officials) who are part of a government

: the opinions that someone has about what should be done by governments : a person's political thoughts and opinions

To me, politicians are supposed to serve the greater good. What is hoped, by all of us, is that our elected officials will put aside self-interests in favor of a desire to accomplish great things for the country they serve. 

The reality unfortunately, falls short of the ideal.

As we Americans watch the political climate heat up, as the next presidential election approaches, I fervently hope that one candidate stands out from the rest as a someone who can unite both right and left, conservative and liberal, Republican and Democrat.

We need a moderate politician who knows that the best way to get things done is by reaching out to people on both sides of an issue and finding the solution, through compromise, that leaves everyone satisfied.

Compromise, it has been told to me, leaves everyone slightly dissatisfied, because no one walks away getting everything they want.

I prefer to think of compromise as something where everyone leaves feeling satisfied that they got some of what they came for and can accept the rest.

In our world today, no one seems to want to compromise at all. Progress can only happen when both sides realize that they must find common ground on many issues. 

Let's hope a candidate rises to the top who knows who to do just that.

Young Male Smokers Beware of Buerger Disease

Most people have never heard of the vasculitis Buerger disease. It doesn't hit home...until it does. 

So what is Buerger disease and why should you care? 

Quite simply, if you don't smoke and you don't know anyone who does, feel free to ignore the rest of this commentary.

But for those of you dwindling (?) numbers of smokers out there, and your loved ones who either smoke, are too uncomfortable to save your life by convincing you to stop smoking, or are just sick of living as secondhand smokers, read on.

Vasculitis is an inflammation of the arteries. 

Buerger disease is an inflammation of the medium-sized arteries of the hands and feet. It typically manifests in young men, between the ages of 30-45, and is very closely associated with heavy smoking. Buerger disease has also been associated with cocaine and cannabis abuse as well as smokeless forms of tobacco. 

The cornerstone of treatment is "strict abstinence from exposure to all tobacco-containing products. This is the only proven strategy to prevent progression of the disease. In a large series from the Cleveland Clinic of 89 patients with Buerger disease, 43 of them stop smoking. Of those who stopped smoking, only two (5%) required major amputations, as compared with 22 (42%) in those who continue to smoke. Other therapies in patients who are unwilling or unable to abstain from tobacco are futile. Even secondhand smoking and passive exposure to tobacco must be avoided."

Any questions? 


Source: "Diagnosis and Endovascular Treatment of Vasculitides," Techniques in Vascular and Interventional Radiology, Volume 17, Issue 4, December 2014. 

Examine the Costs That Matter: Saving Lives, not Over-Diagnosis

Costs of over-diagnosis? We can do better. 

The excerpt below is a report of a "study" that suggests that the USA spends way too much on breast imaging and breast cancer diagnosis. Now I realize that, as a radiologist, people may read my comments and assume I too am biased. Obviously, it is a challenge for me to prove otherwise.

But here's a suggestion:  

Why doesn't someone do a study which looks at the cost savings from the successful diagnosis and treatment of the breast cancers that would never have been caught if mammography screening was NOT standard practice?

I suspect that such a study would more meaningfully expose the truth behind medical progress - that, despite the expenditure of billions of dollars, many more billions of dollars worth of "life years," as actuaries say, have been saved. 

Or we can just continue to become indignant when these kinds of thinly-veiled cost containment ploys are published.

Excerpt as follows: 

Report: US spending on false-positive mammograms, breast cancer overdiagnoses estimated at $4 billion annually.

According to the AP (4/7, Alonso-Zaldivar), “a new report estimates that the U.S. spends $4 billion a year on unnecessary medical costs due to mammograms that generate false alarms, and on treatment of certain breast tumors unlikely to cause problems.” The research, published in “Health Affairs, breaks the cost down as follows: $2.8 billion resulting from false-positive mammograms and another $1.2 billion attributed to breast cancer overdiagnosis,” which is “the treatment of tumors that grow slowly or not at all, and are unlikely to develop into life-threatening disease during a woman’s lifetime.”

Vaccinate. Please. Prevent Death and Disease.

It continues to amaze me that there remains any debate over child vaccinations. I have posted about this issue before. Yet today I read that over 102 cases of Measles have been diagnosed this year, 2015, and it is only the beginning of February! In fact, as you may read below, that number accounts for the typical annual number of cases for past years.

Much misinformation and disinformation has been shared about vaccines. The truth is that vaccines help prevent disease and death by creating what is known as herd immunity. If 900 out of 1000 children are vaccinated with the MMR vaccine, over time, the group develops immunity and helps prevent disease in the rest of the group. The greater the number of individuals who are immune, the smaller the chance that a susceptible individual will contract the disease.

Review the readily available public information on the CDC website. You can find it here

The following is the excerpt from the AMA Morning Rounds. It contains interesting comments about this issue.

"CDC: Measles outbreak has grown to more than 100 cases.

The measles outbreak continues to generate an extensive amount of media coverage, with reporting divided between the growing outbreak and comments regarding vaccines made by politicians. The topics were discussed on two of last night’s national news broadcasts for a total of more than three-and-a-half minutes. Meanwhile, all major US newspapers and wires offered coverage. Many of the stories focusing on the outbreak quote Anne Schuchat, director of the CDC’s National Center for Immunization and Respiratory Diseases, or CDC Director Dr. Tom Frieden. NBC Nightly News (2/2, story 4, 2:25, Williams) reported, “New numbers out from the CDC” indicate that the measles “outbreak has grown to 102 cases in 14 states.” Additionally, “we’re seeing politicians entering the fray possibly at their peril over whether children should receive the measles vaccine that once eradicated the disease.”

        ABC World News (2/2, story 7, 1:10, Muir) reported that “the American Academy of Pediatrics” is “calling for parents to vaccinate their children.”

        The Washington Post (2/3, Berman) reports, “The large number of cases so far this year has already eclipsed the number typically reported each year, according to” Dr. Schuchat.

        TIME (2/3, Sifferlin) reports that in a press conference last week, Dr. Schuchat said, “It’s only January and we have already had a very large number of measles cases — as many cases as we have all year in typical years.” She added, “This worries me, and I want to do everything possible to prevent measles from getting a foothold in the United States and becoming endemic again.”

        The New York Times (2/3, Grady) “Well” blog reports that while “most infections are linked to” the “outbreak that began in Disneyland in December,” which was “almost certainly started by someone who brought the disease in from” outside of the US, “a ‘smattering’ of other imported cases have also occurred, according to” Dr. Schuchat.

        The Los Angeles Times (2/3, Mejia, Hamilton) reports that “of the confirmed measles cases in” California, “59 can be linked to visitors or employees at Disneyland or those who came in contact with them over the holidays.”

        Bloomberg News (2/3, Edney) reports that although “the anti-vaccination campaign seemed to reach a fever pitch in recent years with the help of celebrity endorsements, the movement goes back further, and it may be that the early wave of kids who never had their shots are the adults now at greatest risk.” Dr. Schuchat said last week, “Based on what we know now, we’re seeing more adults than we have seen in a typical outbreak.” According to Dr. Schuchat, “The majority of the adults and children that are reported to us for which we have information did not get vaccinated or don’t know whether they have been vaccinated.” She added, “This is not a problem with the measles vaccine not working; this is a problem of the measles vaccine not being used.”

        The Boston Globe (2/3) editorializes that “the cause” of the measles outbreak “is clear: parents who have refused to have their children vaccinated.” According to the Globe, “A parent’s concerns for his or her children is understandable, but the fears about vaccines are simply irrational.”

        The New York Times (2/3, Subscription Publication) editorializes that “it is bad enough that many misguided parents are endangering their own children by refusing to let them be vaccinated against measles and other contagious diseases.” However, according to the Times, “it is shockingly irresponsible of them to put other children and adults at risk of catching measles from their unvaccinated children.”

        Christie, Paul spark controversy with remarks on vaccinations. The AP (2/3, Colvin) reports New Jersey Gov. Chris Christie on Monday said that “parents should have some choice on whether to vaccinate their children.” While Christie has previously expressed that stance, Monday’s remarks “drew a new level of attention amid a U.S. measles outbreak and his recent moves toward” a potential White House run. Later Monday, Christie’s office said in a statement that “the governor believes ‘with a disease like measles there is no question kids should be vaccinated.’”

        Politico (2/2, Topaz) reported that Christie, who’s in the midst of a three-day visit to the UK, said that he and his wife “have had our children vaccinated, and we think that it’s an important part of being sure we protect their health and the public health.” Christie, added, however, “I also understand that parents need to have some measure of choice in things as well, so that’s the balance that the government has to decide.” Politico said that Christie’s comments “appeared to break with President Barack Obama and public health officials worried about a measles outbreak.”

        USA Today (2/2, Camia, Today) reports, “Christie said the ‘balance’ is necessary because of different diseases and vaccines, and he stressed that his comments are not meant to suggest that vaccinations are optional.”

        The Los Angeles Times (2/3, Lauter), in a report that focuses heavily on Christie’s remarks, says that Kentucky Sen. Rand Paul on Monday also “waded into the argument over childhood vaccinations,” saying “that he had heard of ‘many tragic cases’ of children suffering harm after receiving shots.” The Times says that the remarks by the two potential GOP presidential hopefuls, in tandem with Obama’s “defense of vaccinations over the weekend, injected an unexpectedly partisan element into a policy issue – how readily to give exemptions to parents who don’t want vaccines for their children – that until now had not shown much partisan division.” The Washington Times (2/3, Pompi, Sherfinski) reports that Paul, speaking on Monday with conservative radio host Laura Ingraham, “said that while he is not ‘anti-vaccine’ at all, he does think they should be voluntary.”

        On its front page, the Washington Post (2/3, A1, Rucker, Helderman) reports that Christie’s remarks and his office’s later clarification were “a sign of the sensitivity surrounding the vaccination debate” and served to underscore “the intense scrutiny already facing the broad field of likely” GOP presidential hopefuls. The Post also notes Paul’s comments on vaccinations.

        The New York Times (2/3, Peters, Pérez-Peña, Subscription Publication) also covers the story. In an editorial, the Wall Street Journal (2/3, Subscription Publication) criticizes Christie over his remarks on vaccinations."

When the benefits outweigh the risks...Treat.

There has been much press about people with terminal illnesses who choose to forego treatment and end their lives. These reports include such words as "dignity" and "peaceful."

But we must not lose sight of the risks and benefits in these types of discussions. If a particular disease is treatable, with a high cure rate, and a low risk of death and a low risk of significant, permanent side effects from the treatment, one would hopefully see that undergoing such treatment is a reasonable decision. To the contrary, if the risks of treatment far outweigh any potential benefit, then perhaps foregoing such treatment would be the reasonable choice.

There are many factors that must be considered when one weighs the risks and benefits of a disease and various potential forms of treatment. But let us not lose sight of the big picture when considering these aspects of one's illness.

The following email, from the AMA Morning Rounds, exemplifies what I am talking about: 

Connecticut Supreme Court to decide whether 17-year-old can be forced to undergo chemotherapy.

ABC News (1/6, Lupkin) reports on its website that “a court will determine whether a 17-year-old girl, under something called the ‘mature minor doctrine,’ can be forced to undergo chemotherapy after she refused treatment for her cancer.” The case is headed “to the Connecticut Supreme Court this week to determine whether the teen...has ‘the fundamental right to have a say about what goes on with your [her] body,’ attorney Michael Taylor, who represents the teen’s mother, told ABC News.”

        Fox News (1/6) reports on its website that “the family claims that, by allowing” Connecticut’s Department of Children and Families “to use their judgment over that of” the girl’s “family, without the finding of incompetence on their behalf, the forced treatment violates the family’s constitutional rights.”

        The Hartford (CT) Courant (1/6) reports, “The lawyer representing the cancer-stricken teenager battling the state over forced chemotherapy treatments said that doctors peg” the girl’s “chances of surviving her bout with Hodgkin’s lymphoma at 80 percent to 85 percent if she continues with the court-ordered treatments.”

Whole grains are good...for longer life

We all know that we should eat foods that are healthy for us, that natural foods are better than artificial or processed foods, and that we should remember to eat and drink and exercise, basically everything, in moderation.

Now comes a nice little reminder and confirmation that whole grains are good for us and may lengthen our lives. Nice. 

From the AMA Morning Rounds email: 

Higher whole grain consumption may be linked to longer life.

The Huffington Post (1/6, Melnick) reports that research published online in JAMA Internal Medicine suggests that “eating whole grains improves health and may even help you live longer.”

        The Los Angeles Times (1/6, Bonar) “Daily Dish” blog reports that investigators “looked at data from more than 74,000 women from the Nurses’ Health Study and more than 43,000 men from the Health Professionals Follow-Up Study who filled out questionnaires about their diet every two or four years from the mid-1980s to 2010.”

        TIME (1/6, Oaklander) reports that the investigators “estimate that every 28 gram-per-day serving of whole grains was associated with a 9% lower rate of death from cardiovascular disease and a 5% lower rate of death from any cause.”

        The NBC News (1/6, Fox) website reports that the investigators “even looked at what kinds of whole grains people ate.” The study indicated that “it was definitely eating bran that seemed to keep people healthier...said” the researchers. Also covering the story are HealthDay (1/6, Thompson) and Reuters (1/6, Doyle).

Life Lessons --from Jonathan Tepper to his nephews

I wish I had written the following letter, but Jonathan Tepper did instead. Many introspective and self-aware adults with a bit of life experience could write similar thoughts down on paper. Here are a few short comments of my own:

1- Always try to do the right thing and you will never have to worry about the consequences of doing something wrong.

2- Learn something new everyday. 

3- Once you find your counterpart in life, settle down with him/her and stop looking for something better. 

4- Family comes first. All else is filler. 

I'll stop there for now but many thoughts start to come to the front of my brain. 

Here is the letter: 

"A year and a half ago, I was in a plane with very bad turbulence, and I worried that if the plane went down, many of the lessons I’ve learned in life would end up at the bottom of the ocean.  I wrote a letter to my nephews for them to read when they were older.  I hope they’ll find it useful.


Dear nephews,

I’m writing this on a plane. The reason I started writing this was that I feared the plane might go down, and if it went down, all the lessons I’ve learned in life would disappear with me. By writing this, I hope to pass on the few lessons I’ve learned.

The most important lesson is that the vast majority of things you worry about will not bother you the next day. A year later you will not even be able to remember them if you try. When you grow older, you will not worry about what grades you got. You won’t worry about games you lost.   You won’t worry about what other people thought about you. Most of the things you worry about will never happen. Even if the worst things that you worry about happen, life will still go on. Learn to enjoy every day, and try to enjoy it as if it is your last. It has taken me a long time to understand this, and I wish I had understood it sooner.

Happiness is not a destination but a journey. You will never be smart enough, rich enough, have a pretty enough girlfriend, boyfriend, husband or wife, or win enough prizes and awards. Whatever it is you want, there is always something better. Enjoy the journey of learning, working, and living. If you enjoy the journey, you’ll probably achieve a lot more than if you focused on goals.

Money can provide security, but once you have security, more money cannot buy you more happiness. If you show me someone who thinks money can buy happiness, I’ll show you someone who has never had a lot of money.

Things don’t make you happy, but memories will always stay with you. Whatever it is that you buy, you will soon get used to it. It will make you happy for a short while, but it will not make you happy forever. Experiences and memories can make you happy forever. I can’t even remember most of the toys I’ve had in my life, but I still think of my times with Timothy and your Grandmom with great happiness and fondness. I remember walking Timothy to school and how happy we were. I remember hugging your Gradmom when I came home for a weekend. Those memories will never go away. The happiest memories of my friends are my travels and dinners with them, not the things I’ve bought for myself. You’ll remember dinners and travels with friends and family more than any shiny things you’ll ever have.

Your family is the most important thing you have in life. Friends, boyfriends, girlfriends and co-workers come and go, but the only thing that you can always count on is your family. (If you find a friend who is always there for you, you’re extremely lucky. They exist, but they’re very rare.) One day, you will have your own family. You must love them and look after them. You will understand one day that just as your grandparents die, your parents will as well. Strive to be a good son and daughter. One day, you will be like your parents. Your parents are not perfect, and you will not be either. But you can be loving and be a good son and daughter. One day you can be a good parent.

Never stop learning, and always be ready to teach yourself things you don’t know. The only things you will remember are things you care about. You will forget about all the rest. You must teach yourself and care about what you learn. No one can teach you everything you need to know at school or university. You will also forget most of what you study, and that is fine. As Jacques Barzun said, “Civilization is all that remains after you have forgot all that you specifically set out to remember.”

Never live someone else’s life. Find your gifts and the things that give you pleasure, develop those gifts, and pursue them.   Do what makes you happy and be great at it. You have skills and gifts that no one will ever have or see again. If you’re a businessman, build businesses. If you’re a writer, write. If you’re a scientist, discover. If you do what you love and love what you do, you will work very hard, but you will enjoy every day.

One of the things that most influenced me was something Steve Jobs once said:

When you grow up, you tend to get told that the world is the way it is and your life is just to live your life inside the world, try not to bash into the walls too much, try to have a nice family life, have fun, save a little money. 

That’s a very limited life. Life can be much broader once you discover one simple fact, and that is that everything around you that you call life was made up by people that were no smarter than you. And you can change it, you can influence it, you can build your own things that other people can use. Once you learn that, you’ll never be the same again.

And the minute that you understand that you can poke life and actually something will, you know if you push in, something will pop out the other side, that you can change it, you can mold it. That’s maybe the most important thing. It’s to shake off this erroneous notion that life is there and you’re just going live in it, versus embrace it, change it, improve it, make your mark upon it.

I think that’s very important and however you learn that, once you learn it, you’ll want to change life and make it better, cause it’s kind of messed up, in a lot of ways. Once you learn that, you’ll never be the same again.

I hope that you will find what you love and you will change the world.

Life is full of struggle, and...bad things...happen....Many people suffer great tragedies and live full and happy lives. Remember the people you [have loved and lost] and mourn them. Accept that terrible things happen, and [these experiences may make you stronger.]

The best way to avoid anxiety, stress and unhappiness is to avoid internal contradiction. Don’t think that one thing is right and do the opposite. Listen to your conscience and obey it. Be a good person and live according to your convictions. You cannot answer for other people, but you can always answer for yourself. As long as you live according to your most basic beliefs, you will not have regrets or guilt. You will be able to die happily knowing that you looked after the poor and needy, that you were loving to those around you, and that you failed often but did your best. You will not lose a night of sleep if you always try to do your best.

I love you very much.

Much love,

Uncle Jonathan"

Concerned About Radiation? Don't Smoke!

Whaaaat?! Tobacco contains radioactive particles?! How is that even possible?

Well, as amazing as it sounds, it is true. Depending on the soil in which the tobacco is grown, scientists have discovered radioactive particles such as Lead-210 and Polonium-210 to be present on the tobacco leaves.

When you smoke cigarettes, not only do the filters only remove a "modest amount" of radioactive particles, but tar builds up in your lungs. We know this part. But what is now known is that the tar traps the radioactive particles, resulting in a huge radiation dose to your lungs over time. 

From the EPA:  

"Research indicates that lead-210 and polonium-210 are present in tobacco smoke as it passes into the lung. The concentration of lead-210 and polonium-210 in tobacco leaf is relatively low, however, this low concentration can accumulate into very high concentrations in the lungs of smokers.

As it passes into the lungs, the smoke impacts the branches of the lung passages, called bronchioles, where the branches split. Tar from tobacco smoke builds up there, and traps lead-210 and polonium-210 against the sensitive tissues of the bronchioles. Studies show filters on ordinary commercial cigarette remove only a modest amount of radioactivity from the smoke inhaled into the lungs of smokers. Most of what is deposited is lead-210, but polonium-210 (whose half life is about 138 days) quickly grows in as the lead-210 (half life = 22.3 years) decays and becomes the dominant radionuclide. Over time, the concentration of polonium-210 directly on tissues of the bronchioles grows very high, and intense localized radiation doses can occur at the bronchioles."

If you have ever questioned the amount of radiation you might receive from airport scanners, dental x-rays, mammograms, a chest x-ray or CT scan remember that, once again, cigarette smoking can kill you. And second-hand smoke can kill your loved ones and friends.

So please stop smoking. 


Greek Society of IR Wins Supreme Court Appeal!

I am stunned that the Greece Society of Vascular Surgery actually had the gall to sue the Greek Society of Interventional Radiology, stating that IRs do not have the "skills to manage patients before, during and after procedures, and that this could pose a significant public health threat."


The Greek Supreme Court upheld a lower court ruling that upheld Interventional Radiology as a true subspecialty.

"The Supreme Court decision acknowledged that our clinical training is adequate for the purpose of pre- and post-procedural care. It also valued the fact that the ministry's decision stated that interventional radiologists will practice in the context of multidisciplinary medical decision-making," Elias Brountzos, Professor, Second Department of Radiology, Attikon University Hospital, Athens Greece told "Interventional News."

Dr Scott Gottlieb's Accurate WSJ OpEd on the ACA

ObamaCare’s Threat to Private Practice

The payment system is forcing doctors to sell out to hospitals. The trend, and the law, will be unstoppable without reform.



Dec. 7, 2014 5:12 p.m. ET


Here’s a dirty little secret about recent attempts to fix ObamaCare. The “reforms,” approved by Senate and House leaders this summer and set to advance in the next Congress, adopt many of the Medicare payment reforms already in the Affordable Care Act. Both favor the consolidation of previously independent doctors into salaried roles inside larger institutions, usually tied to a central hospital, in effect ending independent medical practices.

Republicans must embrace a different vision to this forced reorganization of how medicine is practiced in America if they want to offer an alternative to ObamaCare. The law’s defenders view this consolidation as a necessary step to enable payment provisions that shift the financial risk of delivering medical care onto providers and away from government programs like Medicare. The law’s architects believe that doctors, to better bear financial risk, need to be part of larger, and presumably better-capitalized institutions. Indeed, the law has already gone a long way in achieving that outcome.

A recent Physicians Foundation survey of some 20,000 U.S. doctors found that 35% described themselves as independent, down from 49% in 2012 and 62% in 2008. Once independent doctors become the exception rather than the rule, the continued advance of the ObamaCare agenda will become virtually unstoppable. 

Local competition between providers, who vie to contract with health plans, is largely eliminated by these consolidated health systems. Since all health care is local, the lack of competition will soon make it much harder to implement a market-based alternative to ObamaCare. The resulting medical monopolies will make more regulation the most obvious solution to the inevitable cost and quality problems.

A true legislative alternative to ObamaCare would support physician ownership of independent medical practices, and preserve local competition between doctors and choice for patients.

First, Congress should remove the pervasive biases in ObamaCare that favor hospital ownership of medical practices. Payment reforms that create incentives for the coordinated delivery of medical care (like Accountable Care Organizations and payment “bundles”) all turn on arrangements where a single institution owns the doctors. They’re biased against less centralized engagements where independent doctors enter into contractual relationships among themselves.

These ObamaCare payment reforms are fashioned after 1990s-style health maintenance organizations, or HMOs, in which entities like hospitals would get a lump sum of money from Medicare (or now, ObamaCare) for taking on the risk of caring for a large pool of patients. But right now all of these payment schemes are tilted far in favor of having hospitals pool that risk, and not looser networks of doctors.

For one thing, providers who want to participate in the “reformed” physician payment plan must control their own IT infrastructure to comply, as opposed to collaborating freely across space rented in the cloud. This practical need can require IT infrastructure that costs millions of dollars. It makes participation absurdly expensive for anyone but a hospital that already has its own server hub.

Also, waivers of certain anti-kickback provisions (that prevent doctors from forming needed business partnerships) only apply when providers qualify as an Accountable Care Organization. Not surprisingly, ACA qualification is largely dependent on requirements that create the same need for physical infrastructure and bureaucratic overhead that is hard to replicate outside the hospital setting.

To implement real reform, Congress must give independent, private-practice doctors an equal footing. One legislative proposal would let a new class of “independent risk managers” act as third parties to help individual doctors analyze and share the risk of caring for these patient pools. This would make it possible for independent medical offices to band together and bid against hospitals for a pool of patients. Private companies specializing in analyzing and pricing medical risk could serve as brokers and help the doctors know what they’re getting into. But ObamaCare deliberately crowds out this sort of market innovation in favor of hospitals and their existing networks.

Individual, provider-owned medical practices also deserve equal footing when it comes to reimbursement. Right now, Medicare is paying much more for many procedures when performed in a hospital outpatient clinic rather than an independently owned medical office. Things as common as heart scans ($749 versus $503), colonoscopies ($876 versus $402) and even a 15-minute doctor visit ($124 versus $70) all pay more when done by a hospital-based doctor than a privately owned medical office. Obama officials know that hospitals are buying doctor practices to take advantage of this difference. But they favor hospital ownership of doctors and see it as a small cost to pay to drive that migration.

When I talk to physician colleagues, Republican or Democrat, a frequent refrain is that their professional strain would be the same regardless of what happens to ObamaCare. They are wrong. ObamaCare has accelerated many of the detrimental trends doctors see in their profession, and introduced new ones.

Reformers in Washington need to do a better job of explaining how market-based alternatives to ObamaCare are a better outcome for the structure and delivery of health care. And how they intend to preserve the entrepreneurship, autonomy and physician ownership that have long been the hallmark of American medicine.

Dr. Gottlieb, a physician and resident fellow at the American Enterprise Institute, is a member of the Health IT Policy Committee that advises the Department of Health and Human Services. He also invests in and advises health-care companies.

ACA - A Good Start?

I have attempted to look at the Affordable Care Act objectively, something that is almost impossible to do in today's world. But, as proponents point out, there are some good aspects to the Affordable Care Act. The inability to be denied coverage due to a pre-existing condition, and the ability of "children" up to age 26 to stay on their parents plans are two positives that come to mind.

Unfortunately, there are also negative aspects that need reworking and adjustment.

A glaring "loophole" is commented upon below - the lack of inpatient coverage for many ACA-approved plans. 

What I want to know is how did these plans ever get approved?

How could there possibly have been such a loophole?

Whose idea was it to include such a glaring lack of coverage for the recipients of such plans?

Is there any accountability for poorly written plans/acts/bills/laws?  

There doesn't seem to be. 

In my opinion, these types of loopholes and errors and oversights are exactly why there remains controversy over the entire Affordable Care Act.

We could have done better if politics didn't get in the way. Let's hope that improvements can be made before people are harmed.

Press compilation from the AMA:

HHS moves to close hospital coverage loophole.

The Hill (11/25, Viebeck) reports that Federal officials “are moving to stop some employers from cutting hospital coverage in the health insurance they provide under ObamaCare.” The Centers for Medicare and Medicaid Services issued proposed regulations on Friday to require companies with 50 or more employees to offer hospital benefits as part of their health plans. CMS stated, “A plan that excludes substantial coverage for inpatient hospital and physician services is not a health plan in any meaningful sense.” According to The Hill, the agency offered the clarification after an online “minimum value” calculator provided by HHS “approved plans that did not include hospital benefits.”

        Kaiser Health News (11/25) reports that HHS “also proposed granting temporary relief to employers that have already committed to calculator-approved plans without hospital coverage for 2015.” For 2016, however, no large-employer plan will meet the minimum-value threshold without inpatient benefits, the agency said. According to the article, “calculator-tested” plans lacking inpatient coverage “have drawn strong interest from large retailers, restaurant chains, staffing companies and other lower-wage employers seeking to control costs.”