Drug-eluting stents outperform bare-metal stents

New evidence from a large randomized study is answering important questions about the best approach to percutaneous coronary intervention (PCI) in patients with a type of heart attack known as ST-segment-elevation myocardial infarction (STEMI).
In the study, drug-eluting stents outperformed bare-metal stents, and high-dose tirofiban, an anti-clotting medication, proved to be equally effective and have fewer side effects than the catheter lab standard, abciximab.
The study is being reported today in a Late-Breaking Clinical Trials session at the SCAI Annual Scientific Sessions in Partnership with ACC i2 Summit (SCAI-ACCi2) in Chicago. SCAI-ACCi2 is a scientific meeting for practicing cardiovascular interventionalists sponsored by the Society for Cardiovascular Angiography and Interventions (SCAI) in partnership with the American College of Cardiology (ACC). This study is also being simultaneously published online in JAMA: Journal of the American Medical Association.
"These findings may provide a robust scientific rationale for high-dose tirofiban as an alternative to abciximab in patients with STEMI," said Marco Valgimigli, MD, PhD, a cardiologist at the Cardiovascular Institute, Azienda Opedaliera Universitaria di Ferrara, Ferrara, Italy. "In addition, at mid-term follow-up our study did not confirm some of the safety concerns over the use of drug-eluting stents in patients with myocardial infarction. These findings are very reassuring, though we need long-term follow-up to rule out the possibility of late adverse events."
Drug-eluting stents -- which not only prop open the coronary arteries but slowly release medication that prevents re-narrowing of the arteries with scar tissue, or restenosis -- are widely used when PCI is performed for stable coronary artery disease. But many cardiologists use bare-metal stents when treating patients with heart attack because studies have reported conflicting results on the benefits of drug-eluting stents in this group of patients and have raised concerns over the risk of blood clotting inside the stent, or stent thrombosis. The new study has certain design advantages over previous studies, specifically its size and an enrollment and follow-up protocol that more closely reflects everyday clinical practice.
As for tirofiban and abciximab, both are in a class of medications known as glycoprotein 2b/3a inhibitors and prevent blood clotting by blocking hyperactivation of platelets. Tirofiban is an attractive alternative for several reasons: It is shorter-acting and is cleared from the body more readily than abciximab, it is less likely to cause a dangerous drop in the number of platelets in the blood, and it is far less expensive. However, previous studies have been too small or have used too low a dose of tirofiban to reach a definitive conclusion about which medication is better, Dr. Valgimigli said.
The new study, which involved 16 medical centers, enrolled 745 patients who were set to undergo PCI for STEMI. Patients were randomly assigned to an infusion of abciximab or high-dose tirofiban (25 microgram/kg) and, in a second round of randomization, to treatment with either uncoated or sirolimus-eluting stents.
To judge the effectiveness of tirofiban and abciximab, researchers examined electrocardiograms -- 722 of which were interpretable -- to determine the proportion of patients with at least a 50 percent return of the elevated "ST-segment" to its normal baseline. The results were equivalent in the two groups (83.6 percent in the abciximab group vs. 85.3 percent in the tirofiban group). In addition, there was no significant difference in the rate of major adverse cardiac events (MACE) -- a combination of death, repeat heart attack, and repeat procedure to open the treated coronary artery -- in the two groups: 4.8 percent vs. 4.5 percent, respectively, at 30 days and 12.3 percent vs. 9.9 percent, respectively, at eight months. The rates of minor and major bleeding did not differ in the two groups, but a marked drop in the blood platelet count -- a complication that could cause uncontrolled bleeding -- was more common among patients treated with abciximab (4.0 percent vs. 0.8 percent, p=0.004).
When comparing the two types of stents, investigators found an equivalent MACE rate at 30 days (3.9 percent vs. 5.9 percent, p=0.12) with sirolimus-eluting and bare-metal stents. However, at eight months, the MACE rate was significantly lower with drug-eluting stents (7.8 percent vs. 14.5 percent, p=0.0039). This difference was mainly driven by a 69 percent reduction in the need for a repeat procedure to reopen the treated coronary artery (3.2 percent with sirolimus-eluting stents vs. 10.2 percent with bare-metal stents, p=0.0004). The rates of death and repeat heart attack were similar, as was the incidence of stent thrombosis.
"Our study shows that tirofiban is 'noninferior' in its efficacy to abciximab in this high-risk patient population, and has a better safety profile," said Dr. Valgimigli. "We have also confirmed that, even in STEMI patients, drug-eluting stents are highly effective in reducing reintervention in the target vessel. More important, this came without an extra price to pay in terms of death, myocardial infarction or stent thrombosis."
Dr. Valgimigli will present the results of this study on Sunday, March 30 at 9:00 a.m. CDT in the Grand Ballroom, S100. This study will simultaneously publish in JAMA: Journal of the American Medical Association.
About SCAI
Headquartered in Washington, DC, the Society for Cardiovascular Angiography and Interventions is a 4,000-member professional organization representing invasive and interventional cardiologists in over 60 nations. SCAI's mission is to promote excellence in invasive and interventional cardiovascular medicine through physician education and representation, and advancement of quality standards to enhance patient care. SCAI's annual meeting has become the leading venue for education, discussion, and debate about the latest developments in this dynamic medical specialty.
About ACC
The American College of Cardiology is leading the way to optimal cardiovascular care and disease prevention. The College is a 34,000-member nonprofit medical society and bestows the credential Fellow of the American College of Cardiology upon physicians who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care.
http://www.acc.org

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ASL MRI

A New Label
By Dan Harvey
Radiology Today
Vol. 9 No. 1 P. 10

A study presented in November at RSNA 2007 offered new information about the relationship existing between high blood pressure and Alzheimer’s disease. The results strongly indicated how hypertension worsens the debilitating effects of Alzheimer’s disease and underscores the value of arterial spin labeling (ASL) MRI in this research area.

ASL MRI, a relatively new and noninvasive imaging technique, can effectively measure cerebral blood flow (CBF), which has proven to be an integral parameter in the study of neurodegenerative diseases, including Alzheimer’s disease.

The study, conducted by researchers from the University of Pittsburgh, demonstrated that hypertension leads to reduced blood flow to the brain of older adults afflicted with Alzheimer’s disease. In turn, the reduced flow aggravates the condition. This revelation begged the question: Do the findings mean that individuals affected by hypertension could be more prone to developing Alzheimer’s disease compared with people with normal blood pressure?

Not necessarily, said Cyrus Raji, MD, a doctoral candidate at the University of Pittsburgh who gave the RSNA presentation. At this point, Raji said it appears that hypertension doesn’t trigger Alzheimer’s, only increases the brain’s susceptibility to the disease’s devastating effects.

“What the study really demonstrated is that hypertension only confers a vulnerability,” says study coauthor Oscar L. Lopez, MD, professor of neurology at the University of Pittsburgh.

If the disease is going to show up, he says, it will probably occur sooner in individuals with hypertension. “Then, after they develop the dementia, the blood flow compromise becomes even worse.

“The bottom line is that it is extremely important to treat hypertension,” Lopez adds, “not only when a person is cognitively intact but also when a person is going into a dementia or Alzheimer’s disease.”

According to the National Heart, Lung, and Blood Institute, approximately 50 million Americans have hypertension. It’s well-known that the condition elevates the risk of heart attack, stroke, and aneurysm. Now it appears that vascular health can significantly impact brain health. “It is important to healthy cognitive function,” says Lopez.

The ASL Factor
ASL MRI, the imaging modality that the researchers used in the study, is an effective way to measure blood flow to the brain, and it provides users with a noteworthy advantage of not requiring a contrast agent.

During the procedure, the arterial blood is magnetically labeled and then imaged. Specifically, it labels the protons in water molecules and tracks their flow. In this way, it can be effectively deployed to measure CBF, using the water molecules as natural tracers.

“ASL MRI is a part of functional MR imaging that allows you to generate an image that represents CBF without having to use radioisotopes or injected contrast agents,” explains Jeffrey Mendel, MD, chair of the department of radiology at Caritas St. Elizabeth’s Medical Center in Boston.

CBF is an important parameter in measuring patients with cognitive dysfunctions, according to William T. C. Yuh, MD, MSEE, professor and vice chair of the department of radiology at Ohio State University. “Traditionally, to acquire this kind of parameter, MR contrast agents and radioisotopes were employed,” he says. “Now, ASL MRI provides us with an endogenous contrast agent as opposed to an exogenous, or outside-the-body, contrast agent. That is, we are able to use blood inside the body as the agent. Similar to how we label the radioisotope for the nuclear medicine studies, we magnetically label the blood and, thus, use it as a contrast agent.”

ASL MRI eliminates the need for contrast injections or radioisotopes, offering a safer, more cost-efficient, and more convenient option to other imaging methods that provide the same kind of information. “You remove the radiation exposure, as well as the expense of the radioisotopes. Also, you don’t have to place an IV [intravenous] into the patient,” Mendel says.

He adds that ASL MRI is one of the most promising techniques for examining patients who either have Alzheimer’s disease or mild cognitive impairment (MCI). People with MCI have some changes in their brain processes, but they haven’t been diagnosed as having a dementia. ASL MRI is also effective in examining patients with other forms of dementia, such as frontotemporal dementia (FTD). “Without having to do a PET scan, you can see if patients have patterns of decreased blood flow into their brain that might suggest that they have Alzheimer’s or might confirm that there is something else taking place, such as FTD. So it helps to distinguish among Alzheimer’s, FTD, and MCI,” he says.

ASL Mechanics
Mendel explains that in ASL MRI, blood converts into a tracer for perfusion via a specific MRI pulse. When it comes to measuring CBF, the pulse is applied to the arteries flowing into the brain (usually in the neck) and to the arteries by the MRI unit. The radiofrequency pulse labels the blood flowing into the brain—or, more specifically, the water in the blood. “You can then use different MRI sequences to actually see the areas into which this labeled blood is flowing, and you can judge how much blood is flowing into any one area,” says Mendel.

Further clarifying the procedure, as far as CBF, Yuh explains that arterial blood is magnetically labeled before it enters the brain. “That is, we magnetically label the blood supply to the brain before it flows into the area of interest. There is a little delay after the magnetification and when the area of interest receives the blood flow or the endogenous tracer,” he says. “Subsequently, we can use that information to study the changes in the MRI signals and, thus, quantify the CBF.”

Tracking Disease Evolution
For the Pittsburgh study, which was part of the larger Cardiovascular Health Study (Cognition Study), an ongoing observational study of various risk factors, the researchers used ASL MRI to image 88 older adults with an average age of 70.

“Dr. Lopez approached me about using ASL MRI as a perfusion measurement technique to see how the blood flow changes during the disease evolution,” explains H. Michael Gach, PhD, director of imaging research at the Nevada Cancer Institute in Las Vegas, whose role in the study involved providing imaging technology expertise. “That is how we got together on this project.”

In most earlier neuroscientific studies, researchers first looked at the brain structure to determine what changes occurred as the disease developed, says Gach, whose recent research focus has involved application of imaging technologies (particularly MRI) in the in vivo measurement of venous and arterial blood flow, along with tissue perfusion and diffusion. “Changes in brain structure have been a primary marker,” he says. “In previous studies, investigators saw that the hippocampus shrinks in patients with Alzheimer’s disease. They also observed that the brain ventricles enlarged; that is, they grew as the patients’ disease progressed. But Dr. Lopez was interested in other imaging markers that may be associated with dementia progression. One of those markers is blood flow, or perfusion.”

Gach says ASL MRI can be applied to other neurological diseases, as well as diseases such as cancer. Similarly, Yuh points out that at Ohio State, clinicians have applied it to cancer studies and stroke evaluation. “We also use ASL brain perfusion to assist us in biopsies of brain tumors,” he adds. “We’re also looking at using it with other organ systems such as the renal and lung, as well as myocardial perfusion.”

In the Pittsburgh study, the cohort included 48 normal subjects (38 with hypertension and 10 without) and 20 subjects with Alzheimer’s disease (10 with hypertension and 10 without). The remaining 20 subjects (10 with hypertension and 10 without) had MCI, considered a precursor to Alzheimer’s and affecting brain functions such as language, attention, and reasoning.

ASL MRI results showed that in all patient groups, CBF was substantially decreased in individuals with hypertension. In addition, CBF was lowest among Alzheimer’s patients with hypertension. Further, the normal group with hypertension had significantly lower CBF than the normal group without hypertension. Specifically, ASL MRI showed that in patients with hypertension and MCI, CBF to the prefrontal cortex was reduced, while CBF to the posterior cingulate and thalamus was increased. And in hypertensive Alzheimer’s patients, the regions with the most restricted blood flow were the posterior cingulate, prefrontal cortex, and left thalamus.

As the researchers reported, the results suggest that hypertension, which changes CBF, may enhance Alzheimer’s pathology. “The implication is that, by using ASL MRI, we can determine that people with hypertension, with or without cognitive deficits, have abnormal CBF,” says Lopez. “This abnormal blood flow seems to be worse in people with cognitive deficits, especially those with dementia.”

Lopez says that in people with Alzheimer’s disease, it is important to detect and aggressively treat hypertension and also focus on disease prevention.

Gach also notes that the study’s hypertensive subjects had a history of hypertension and reduced CBF, but they all received treatment and were no longer hypertensive. “Thus, one cannot state definitively if it is the history of hypertension or the treatment that caused the reduced blood flow in our cohort,” he says. “Reducing the blood pressure to ‘normal’ may in turn cause hypoperfusion. In future research, we will try to determine if the hypoperfusion is caused by a long history of hypertension and its long-term impact of cerebral hemodynamics or the effects of antihypertensives.”

Clinical Frontier
While ASL MRI isn’t widely available yet, Yuh sees it as transitioning from a research to a clinical tool. “We’re now looking at a large clinical frontier,” he says. “With advances in the technique and MRI technology, I think this could eventually find routine usage. I also think that it is very exciting that we now have this alternative method to assess organ blood flow, particularly for those patients with contraindications for contrast studies, such as contrast, renal or risk nephrogenic systemic fibrosis.”

When ASL MRI does gain more widespread application, Yuh believes it’s likely that people will come to know it in the pulsed form. Currently, there are two major versions: continuous and pulsed. With continuous ASL (CASL), labeling of arterial blood continuously takes place throughout application of a long, continuous radiofrequency pulse lasting one to two seconds, Yuh explains. With pulsed ASL (PASL), labeling arterial blood uses a radiofrequency pulse with a higher peak amplitude and a shorter duration (about 100 times shorter than CASL). “The main difference is that the shorter radiofrequency pulse is applied to a thicker slab of blood in PASL. CASL involves much thinner slices of blood with a stronger radiofrequency of longer duration,” says Yuh. “As such, PASL requires less hardware.”

The pulse technique is easier to implement on the scanner, adds Gach. “It is less stressful on the MRI. It has been turned into a product, and a lot of people use it for fMRI [functional MRI]. It is not necessarily as quantitative as the continuous ASL MRI technique that we used for our study. Also, it is harder to cover the brain as quickly. But it has its uses.”

CASL typically has to be specially designed, thus requiring more specific hardware. “But it has the advantage of better signal-to-noise ratio, or contrast. Both images and the quantification are better,” says Yuh.

Getting Ready for Prime Time
Mendel agrees that ASL MRI is an exciting area. “It is certainly something that people who image patients with dementia are looking at with great interest,” he says. “Right now, the big question is, ‘When will this start filtering down to other medical centers and hospitals?’”

In the meantime, he says there’s a need for more studies that confirm the idea that it is as sensitive as something such as PET scanning. “Research experience needs to be duplicated before people start investing in the infrastructure,” Yuh says.

Another limiting factor may be MRI unit field strength. “ASL MRI appears to be more effective at higher field strengths,” Yuh says. “So, we may see greater application as more and more facilities move up to 3T units. Right now, the vast majority of MRI units in the country are 1.5T.”

That’s an important consideration, as ASL utilized in a higher magnetic field offers greater signal-to-noise ratio, and it would enhance the labeling effect. “While this is a new area, we’ve already witnessed rapid progression and recognize the enormous potential,” Yuh says.

— Dan Harvey is a freelance writer based in Wilmington, Del., and a frequent contributor to Radiology Today.

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Shoulder Relief — Intervening to Tame Tendonitis

Shoulder Relief — Intervening to Tame Tendonitis
By Beth W. Orenstein
Radiology Today
Vol. 9 No. 1 P. 18

Radiologists in Italy have developed a minimally invasive procedure for treating patients who suffer from calcific tendonitis of the shoulder. The procedure takes no more than 20 minutes and is providing many patients with long-term relief and few aftereffects at a low cost.

Calcific tendonitis causes small calcium deposit formations within the rotator cuff tendons in the shoulder. The condition is most common in adults aged 30 to 40 and seems to occur more often in women. In minor cases, physical therapy or anti-inflammatory medications may address the problem until the calcifications spontaneously break apart within a few weeks or months.

However, in many cases, the deposits become painful and can restrict shoulder mobility. Some patients have constant pain that interferes with their everyday activities, including dressing and combing their hair. Typically, the pain worsens at night.

Treatment for more severe cases has included shockwave therapy or arthroscopic surgery to remove the calcium, but both procedures have drawbacks. Approximately 50% to 70% of patients appear to benefit from two or three shockwave treatments, which stimulate blood flow in the affected area. Surgical options are expensive and require a long recovery period; shockwaves are less costly but can be extremely painful if performed when the tendonitis pain flares up.

When untreated calcifications break up, the calcium is not extracted but spreads along the tendon and lodges in the subacromial bursa, a fluid sac that helps lubricate the tendon. Calcium buildup in the tendon and bursa can cause bursitis, a painful condition with a long recovery time and a high rate of disability.

That’s why researchers from the department of radiology at A. O. Ospedale Santa Corona in Pietra Ligure and the department of experimental medicine at the University of Genoa in Italy began looking for a more effective and less costly treatment for calcific tendonitis.

Luca M. Sconfienza, MD, who presented information about the new therapy at the RSNA annual meeting in Chicago in November, says it builds on earlier work done in the field. In the 1960s, Charles S. Neer II, MD, described a technique where calcifications would be punctured under fluoroscopic guidance. However, Sconfienza explains that because it was difficult to center the calcification in the field of view, the technique was abandoned. Later, some researchers described other procedures, but the calcium amount they were able to retrieve was very small.

Sconfienza and his research team sought the best of all the previous procedures described in the literature and adapted them using high-resolution ultrasound guidance. “We modified it during the trial according to our experience,” he explains.

They started their trial in 1995 and, as of this past November, had treated 2,800 patients. The group continues to treat roughly 15 patients per week.

The procedure involves injecting a saline solution into the shoulder to break up the calcium deposits. Sconfienza says it is easy to perform and is completed in 10 to 20 minutes in the following four phases:

• The skin is cleaned with an iodine-based disinfectant, and a local anesthesia—mepivacaine—is injected into the skin, subcutaneous tissues, and subacromial bursa. “We take much care not to exceed 20 mL of mepivacaine to avoid any anesthesia-related problems,” Sconfienza says.

• The needles are then positioned. “We insert the needles in the calcification. The first needle to be inserted is the deeper one, then the other one. We take much care that the flute-beak tips are facing each other to make the water flow easier,” Sconfienza says.

• The doctor then performs the calcification rinsing, or lavage. “We connect a syringe full of saline solution to one of the needles and start to push repeatedly on the plunger,” Sconfienza says. “After a few seconds, the calcium starts to melt down and exits from the free needle. The lavage is repeated several times until the saline that comes out from the free needle is free of calcium.”

• One needle is extracted from the shoulder, and the other is retracted and inserted in the subacromial bursa, where a small amount of slow-release steroid is injected.

Outcomes
The procedure is relatively painless. “Patients experience not more than 10 seconds of soreness when local anaesthetic is injected,” Sconfienza says.

Generally, after 24 to 36 hours, patients experience a complete relief from pain. “The complete regain of upper limb mobility is strictly related to the condition of the patient before the treatment,” Sconfienza says. “In patients whose pain and functional limitation has been present for a long time, we strongly recommend two cycles of physiokinetic therapy to favor the absorption of the small amount of calcium left and to regain complete mobility.”

Sconfienza says his team has found no disadvantages, contraindications, or complications after having treated approximately 2,800 patients. In the past, he says some authors have avoided the use of two needles, thinking that this practice could lead to tendon tears. “Actually, we have reported no tendon tears in any patients after 10 years of follow-up,” he explains.

The therapy can be used to treat multiple calcifications at the same time in selected cases. “We try to treat all calcifications when they are in the same shoulder and, if they are not too big, to avoid crystal bursitis for the big amount of calcium that is mobilized,” Sconfienza says.

The only limit in treating one or both shoulders and one or many calcifications is the maximum amount of local anesthetic that can be injected. Currently, the limit is fixed at 20 mL for a single session in healthy patients, Sconfienza says.

“The treatment can be repeated, especially in cases of multiple calcifications that we prefer not to treat during a single session,” he says. In addition, the researchers have performed repeat procedures on a few patients who experienced reactive bursitis after the initial treatment, typically two months later.

Sconfienza says they found that this procedure is particularly suitable for patients with shoulder pain and upper limb functional limitation caused by tendon calcifications, and there is no age or gender limitation. “We do not treat asymptomatic patients,” he says. The best candidate is a patient in the middle of a hyperalgic pain crisis. “In these subjects, we get the best outcome.”

An ultrasound is also required to diagnose the problem, and plain film x-rays could be used as well, Sconfienza says. However, in some cases, x-rays tend to underestimate the dimensions of the calcification.

Low-cost Treatment
Sconfienza says the treatment has many advantages because it does not require pretreatment, stitches, a hospital stay, or convalescence. “Practically speaking, the procedure ends in the exact moment that patients exit our ward,” he says. Recovery time is at most one hour. Calcifications that are completely treated do not return.
Another important advantage of this treatment is its low cost—approximately $100 per treatment. That’s much lower than the $460 for a complete cycle of shockwaves and the roughly $5,100-plus surgery would cost, Sconfienza says. The procedure requires an ultrasound system equipped with a high-frequency probe. The researchers used an iU22 Ultrasound System by Philips.

A. O. Ospedale Santa Corona and the University of Genoa are among several institutions currently offering this new therapy. “Their staff trained at our hospital,” Sconfienza says. But theoretically, Sconfienza says the procedure could be performed in any hospital or clinic that has ultrasound equipment with a superficial probe. “We think that almost every sonographer could perform it after a brief training,” he says. “We currently organize short and inexpensive teaching courses at our department or abroad to make this procedure available to other colleagues.”

Calcium buildups such as the ones found in the shoulder are quite rare in other parts of the body, but the researchers have treated calcifications successfully in the patellar ligament, Achilles’ tendon, and elbow. “Generally speaking, this procedure is suitable to treat calcifications with metaplastic origin,” Sconfienza says.

He believes the procedure has the potential to become the gold standard for calcific tendonitis that is unresponsive to medical treatment. “In our hospital, orthopedic surgeons do not perform surgery on a calcific shoulder anymore, and this way of thinking is quickly spreading,” he says.

Study Results
At RSNA 2007, Sconfienza reported that he and his colleagues used ultrasound-guided percutaneous therapy to treat 2,543 shoulders in 1,607 women and 938 men (with a mean age of 42) with calcific tendonitis. All the patients had shoulder pain that was unresponsive to previous medical treatment.

One-year follow-up was reported for 2,018 of the patients in the study. The results showed that in 71.7% of the patients, the calcification was fully aspirated in one treatment with a considerable reduction in pain and significant improvement to mobility of the affected limb. In 23.6% of patients, a second procedure was performed due to the presence of more than one calcification. In 3.8% of patients, the calcification had dissolved or moved before treatment could take place. In 0.9% of patients, no resolution of symptoms occurred because of the presence of a tendon tear.

The researchers are working to eliminate those cases where they are unable to retrieve all calcium. They also are experimenting with new methods to eliminate the steroid in the bursa. “Generally speaking, we are making every effort to make the procedure more accessible for patients in terms of waiting lists,” Sconfienza says.

“As people age, many complain of pain in the shoulders. This pain is commonly caused by calcium buildup,” Sconfienza says. “This procedure can allow them to feel better immediately with little cost.”

— Beth W. Orenstein is a freelance medical writer and regular contributor to Radiology Today. She writes from her home in Northampton, Pa.

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RSNA NEWS

http://www.rsna.org/Publications/rsnanews/March-2008/upload/RSNA_News_March2008.pdf

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Compendium of Fetal MRI

http://www.bidmc.harvard.edu/content/bidmc/departments/radiology/files/fetalatlas/atlas.html

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Upcoming Radiology Refresher Course - Great topics and speakers. Heres a list of the topics to be covered over 4 days

35th Annual ISS Radiology Refresher CourseOctober 29 - November 1
Taj Palace, New Delhi

WEDNESDAY - October 29, 2008
0630 - 0800 Registration
0800 - 0810 Welcome - Jeremy J. Kaye / Michael Recht
Moderators: Murali Sundaram, MD, Jeremy J. Kaye, MD0810 - 0820 Welcome - India
0820 - 0840 Indian Healthcare - A Journalists Perspective - N. Ram, Managing Editor, The Hindu
0840 - 0900 Musculoskeletal Radiology in India - Common and Unique Pathology - Govindji Jankharia
0900-1020 Session 2: Technical Advances 1 (MR)
Moderator: Michael Recht, MD
0900-0920 New Sequences and Coils: Physics (Multi-Channel Coils, Parallel Imaging, 3D FSE, etc) - Garry Gold
0920-0940 Higher Field Strength: Potential Advantages and Drawbacks in MSK Imaging - Mark E. Schweitzer
0940-1000 Low Field Strength in MSK: Practical Tips - Michael B. Zlatkin
1000-1020 NSF - What Do We Need to Know and Do - Paula J. Richards
1020-1050 Break
1050-1210 Session 3: Technical Advances / CT/US Technique
Moderator: Kenneth A. Buckwalter, MD
1050-1110 Multi-row Detector CT and MSK Radiology: Understanding the Technology - Kenneth A. Buckwalter
1110-1130 Practical MSk Multi-row CT Imaging - George Y. El-Khoury
1130-1150 Technical Advances in US - Carlo Martinoli
1150-1210 Needle Localization: MR/CT/US - K. Gunnar Astrom
1210-1340 Lunch - Raja Bagh (Ticket Required)
Session A - held in shahjehan hall
Session B - held in Durbar hall
1340-1520 Session 4A: Spine 1
Moderator: Francisco Aparisi-Rodriguez, MD
1340-1345 Case Presentation - Francisco Aparisi-Rodriguez
1345-1400 Bulge/Protrusion, Herniation: Update on Current Nomenclature - Shigeru Ehara
1400-1415 When Not to Image the Lumbar Spine - Daniel I. Rosenthal
1415-1430 Benign vs. Malig Compression Fx - Mihra S. Taljanovic
1430-1445 Non-bony Pathology: What Does a MSK Radiologist Need to Know - Iain W. McCall
1445-1500 Infection - James Griffith
1500-1520 Case Discussion - Francisco Aparisi-Rodriguez
1340-1520 Session 4B: Ultrasound
Moderator: Ian Beggs, MD
1340-1400 Shoulder Anatomy - Robert S. D. Campbell
1400-1420 Shoulder Live Demonstration - Joseph G. Craig
1420-1440 Shoulder Pathology - Ian Beggs
1440-1500 Elbow Anatomy and Pathology - Theodore T. Miller
1500-1520 Elbow Live - Monique Reijnierse
1520-1550 Break
1550-1730 Session 5A: Spine 2- Intervention
Moderator: TBA
1550-1555 Case Presentation - Jamshid Tehranzadeh
1555-1615 Biopsy - Current Techniques and Indications - Jeffrey J. Peterson
1615-1635 Aspiration for Infections - When , How, and What to Do About Antibiotics - David J. Wilson
1635-1655 Vertebroplasty vs. Kyphoplasty - Jean-Denis Laredo
1655-1715 Discography - Wilfred C.G. Peh
1715-1730 Case Discussion - Jamshid Tehranzadeh
1550-1730 Session 5B: Ultrasound 2
Moderator: Ian Beggs, MD
1550-1605 Wrist Anatomy and Pathology - Andrew J. Grainger
1605-1620 Wrist Live - Philip J. O'Connor
1620-1635 Knee Anatomy and Pathology - Jon A. Jacobson
1635-1650 Knee Live - David P. Fessell
1650-1710 Ankle Anatomy and Pathology - Carlo Martinoli
1710-1730 Ankle Live - David J. Wilson
1930-2130 Welcoming Reception - Raja Bagh, Taj Palace (Business attire)
THURSDAY - October 30, 2008
0800-0940 Session 6A: Knee I
Moderator: Lorraine G. Shapeero, MD
0800-0805 Case Presentation - Michael J. Tuite
0805-0820 Practical Imaging of the Knee: How to Make Your Images Better and
Faster - Sequences, Coils, Field Strength - Elisabeth Dion
0820-0840 MR of Posterolateral Corner: What Can We See on MR and What Is
Important to the Orthopedic Surgeon - Klaus Bohndorf
0840-0905 MR of the Posteromedial Corner - Josef Kramer
0905-0930 Osterochondritis Dissecans and SONK/Insufficiency Fractures of the
Knee - Susan V. Kattapuram / Peter Nielson
0930-0940 Case Discussion - Michael J. Tuite
0800-0940 Session 6B: Knee MR
Moderator: Peter David Corr, MD
0800-0805 Case Presentation - Lawrence M. White
0805-0825 Knee Anatomy - Michael J. Pitt
0825-0905 How I Read A Knee MR - Javier Beltran
0905-0925 Post Op Knee - Mini N. Pathria
0925-0940 Case Discussion - Lawrence M. White
1010-1150 Session 7A: Ankle and Foot 1
Moderator: TBA
1010 -1015 Case Presentation - Hakan Ilaslan
1015-1035 Spring Ligament and Medial Arch: Anatomy, Pathology, Significance, and How to Image - Kathryn Stevens
1035-1055 Forefoot Challenges: Mortons Neuroma: Clinical or Radiologic Diagnosis, How to Image, Sesamoiditis, Fx and AVN - Can We and How to Differentiate - Simon Ostlere
1055-1115 Plantar Fascitits - Imaging and Treatment - Eugene G. McNally
1115-1135 Stress Injuries: Classification, Imaging and Clinical Impact - Franz M. Kainberger
1135-1150 Case Discussion - Hakan Ilaslan
1010-1150 Session 7B: Hip/Foot/Ankle MR
Moderator: Filip Vanhoenacker, MD
1010 -1015 Case Presentation - Vladimir Jevtic
1015-1030 Anatomy and Technique - Hip - Thomas L. Pope
1030-1055 How I Read a Hip MR/MR Arthrogram - Christian W.A. Pfirrmann
1055-1110 Normal Anatomy and Technique: MR Imaging of the Midfoot - Zehava Sadka Rosenberg
1110-1140 How I Read A Foot and Ankle MR - Marco Zanetti
1140-1150 Case Discussion - Vladimir Jevtic
1150-1330 L unch - Raja Bagh (Ticket Required)
1330 -1510 Session 8a: Foot and Ankle 2
Moderator: Lynne S. Steinbach, MD
1330 -1335 Case Presentation - Andrew J. Grainger
1335-1355 Impingement Syndromes - William E. Palmer
1355-1410 MR and US of Tendon Abnormality - What Is the Path Correlate? -
Fiona (Sally) Bonar
1410-1435 Tendon Abnormalities: Pros and Cons of US and MR - Bruce B. Forster / Andrew J. Grainger
1435-1500 Diabetic Foot - William B. Morrison
1500-1510 Case Discussion - Andrew J. Grainger
1330 -1510 Session 8b: Shoulder MR
Moderator: Josef Kramer, MD
1330-1335 Case Presentation - TBA
1335-1355 Rotator Cuff - Michael J. Tuite
1355-1415 Biceps Tendon and Rotator Cuff Interval - Michael Recht
1415-1435 Shoulder Instability - What Really Matters to the Surgeon - Lawrence M. White
1435-1455 Post Op Shoulder - Mahvash Rafii
1455-1510 Case Discussion - TBA
1510-1540 Break
1540-1730 Session 9a: Hip I
Moderator: Hakan Ilaslan, MD
1540-1545 Case Presentation - Kenneth A. Buckwalter
1545-1600 Practical Imaging of the Hip: How to Make Your Images Better and Faster - Sequences, Coils, Field Strength - Laura W. Bancroft
1600-1630 Stress Responses/Fractures About the Pelvis - Howard Galloway
1630-1700 Osteonecrosis, Bone Marrow Edema, Subchondral Fracture - Can We Tell Them Apart and Does It Matter Clinically? - Takuaki Yamamoto
1700-1720 Bursitis and Abductor Pathology of the Hip - Are They Interrelated? One Disease? - Leanne L. Seeger
1720-1730 Case Discussion - Kenneth A. Buckwalter
1540-1730 Session 9B: MR of Elbow and Hand
Moderator: Lawrence M. White, MD
1540-1550 Case Presentation - Theodore T. Miller
1550-1605 Anatomy of the Elbow - William Reinus
1605-1630 How I Read MR of Elbow - Lynne S. Steinbach
1630-1645 Anatomy and Technique of Wrist and Hand - TBA
1645-1710 MR of the Hand and Wrist - Mini N. Pathria
1710-1730 Case Discussion - Theodore T. Miller
1930-2230 C hairman's Choice Optional Evening - Spice Route Restaurant (Smart casual attire)
FRIDAY - October 31, 2008
0800-1000 Session 10A: Pelvis/Hip 2
Moderator: Seoung-Oh Yang, MD
0800-0805 Case Presentation - Marcia F. Blacksin
0805-0830 Imaging of Athletic Pubalgia - Philip Robinson
0830-0900 FAI- Anatomy/Imaging - Suzanne E. Anderson
0900-0925 FAI- Clinical and Surgical Perspectives and Controversies - Dinshaw Pardiwala
0925-0945 Pediatric Hip Disease - Cure or Delaying the Inevitable - Soroosh Mahboubi
0945-1000 Case Discussion - Marcia F. Blacksin
0800-1000 Session 10b: Arthritis
Moderator: Won-Hee Jee, MD
0800-0805 Case Presentation - Gerwin M. Lingg
0805-0820 Current Concepts in Imaging Osteoarthritis - TBA
0820-0835 MR of RA - What Is New? - Anne Cotten
0835-0850 Seronegative Spondyloarthropathies - Victor N. Cassar-Pullicino
0850-0905 US of Inflammatory Arthritis - Jean Luc Drape
0905-0945 Imaging of Gout and Related Arthropathies - George Hermann
0945-1000 Case Discussion - Gerwin Lingg
1000-1030 Break
1030-1230 Session 11a: Knee II
Moderator: Jeremy J. Kaye, MD
1030-1035 Case Presentation - Michael Recht
1035-1055 Osteoarthritis - Latest, Fact and Fiction - Adrienne M. Flanagan
1055-1115 Cartilage Imaging in Daily Practice: How To Do It and How To Report It - Christian Glaser
1115-1135 Cartilage Imaging - What Is Important To the Arthroscopist? - Dinshaw Pardiwala
1135-1155 Popliteal Fossa: Muscle and Vascular Variants and Pathology: When Do They Matter? - Frieda Feldman
1155-1215 Patellofemoral Joint and Hoffas Fat Pad Disorders - Mario Maas
1215-1230 Case Discussion - Michael Recht
1030-1230 Session 11b: Metabolism and Growth
Moderator: Gerald A. Mandell, MD
1030-1035 Case Presentation - Anne Cotten
1035-1050 Rickets and Osteomalacia - Judith E. Adams
1050-1105 Osteoprosis - Leon Lenchik
1105-1120 Beyond Bone Mineral Density: Assessment of Trabecular Bone Structure - Harry K. Genant
1120-1135 The Role of Quantitative Ultrasound in Clinical Diagnosis of Osteoporosis - Giuseppe Guglielmi
1135-1155 Imaging Approach to Stress/Insufficiency Injuries/Fractures - Lee F. Rogers
1155-1215 The Physis Normal and Abnormal - E. Michel Azouz
1215-1230 Case Discussion - Anne Cotten
1230-1400 Lunch - Raja Bagh (Ticket Required)
1400-1540 Session 12A: Muscle and Nerves
Moderator: Suphaneewan Jaovisidha, MD
1400-1405 Case Presentation - Mini N. Pathria
1405-1445 Imaging of Muscle Injury: US and MR: Temporal Changes and When to "Return to Play" - Donna Blankenbaker / David A. Connell
1445-1500 Advanced Imaging Techniques of Muscle - Robert D. Boutin
1500-1515 MR Neurography - John A. Carrino
1515-1530 Imaging of Nerves About the Hip - Carlo Martinoli
1530-1540 Case discussion - Mini N. Pathria
1400-1540 Session 12B: Bone Tumors
Moderator: Claus-Peter Adler, MD
1400-1405 Case Presentation - Rajendra Kumar
1405-1445 MR Imaging of Bone Tumors - Murali Sundaram
1445-1500 MR in Staging of MSK Tumors - Johan L. Bloem
1500-1515 Bone Tumor Mimickers - Daniel Vanel
1515-1530 Bone Biopsy and Ablation - Peter L. Munk
1530-1540 Case discussion - Rajendra Kumar
1540-1610 Break
1610-1750 Session 13a: Spine
Moderator: Javier Beltran, MD
1610-1615 Case Presentation - Niels Egund
1615-1635 C spine Trauma - Case Presentation - Herwig Imhof
1635-1655 Spinal Hardware - What Do We Need To Know - Ali Guermazi
1655-1715 Sacroiliac Joints - What Is New? When Should You Use Which Modality? - Anne G. Jurik
1715-1735 Low Back Pain In Adolescents - Robert Campbell
1735-1750 Case Discussion - Niels Egund
1610-1750 Session 13b: Soft Tissue Tumors
Moderator: TBA
1610-1615 Case Presentation - Murray K. Dalinka
1615-1635 Approach to Soft Tissue Tumors: Imaging Appearance and Clinical Implications - Mark J. Kransdorf
1635-1655 Soft Tissue Tumors: Tissue Specific Diagnosis - Mark Murphey
1655-1715 Imaging Recurrent Soft Tissue Masses - A. Mark Davies
1715-1735 MR Pitfalls in Diagnosing Sarcomas - David M. Panicek
1735-1750 Case Discussion - Murray K. Dalinka
2000-2400 Gala Dinner - Taj Palace Hotel Durbar hall (Cocktail attire)
SATURDAY - November 1, 2008 - shahjehan hall
0800-0940 Session 14: Trauma
Moderator: Klaus Bohndorf, MD
0800-0805 Case Presentation - TBA
0805-0820 Lumbar and Thoracic Spine Trauma - Akbar Bonakdarpour
0820-0840 Acetabular Fractures, Anatomy, Classification and Simple Fractures - E. Paul Nance
0840-0900 Acetabular Fracture 2, Complex Fractures - Jeremy J. Kaye
0900-0915 Child Abuse - Paul Kleinman
0915-0930 Hand and Wrist Trauma - Filip Vanhoenacker
0930-0940 Case Discussion - TBA
1000-1150 Session 15: Arthroplasty
Moderator: Ian Beggs, MD
1010-1015 Case Presentation - Ian Beggs
1015-1035 Plain Film Assessment of Hip and Knee Arthroplasty - TBA
1035-1055 MR and US of Hip and Knee Arthroplasty - Theodore T. Miller
1055-1115 Nuclear Imaging of Hip and Knee Arthroplasty - Seoung-Oh Yang
1115-1135 Arthroplasty Failure - Pathological Mechanisms - Thomas Bauer
1135-1150 Case discussion - Ian Beggs

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Interesting Cases in Diagnostic and Interventional Neuroradiology

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http://www.urmc.rochester.edu/smd/Rad/ncases.htm#head

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