RE-NEGOTIATING YOUR EMPLOYMENT CONTRACT

Renegotiating Your Contract

When it comes time to renegotiate your contract of employment, you can be faced with both opportunities and risks. It is important to maintain your employment while you negotiate to fairly reflect changed circumstances or improvements in your terms and conditions.

Contract renegotiations are not always formal reviews.

Some take the form of a letter from the employer announcing a change of conditions. Others result from a changed work environment - such as changed staffing levels, changed rosters or changed expectations of overtime. Some contracts build into their terms a process of renegotiation of the conditions of employment. This is quite common, particularly after the first year of employment and often includes a salary review.

Contract reviews

In law everyone has a contract - oral or in writing. Reviews of written contracts are easier as everyone is usually working with the same understanding of the status quo.

Disagreements in contract reviews often centre around items that were agreed at the time of employment but were not reflected in writing - and the recollections of the agreement differ.

In law the changing of contract terms requires offer and acceptance - in the same way as the original contract was formed. Let us say your firm advises you that it will no longer provide the Christmas bonus previously agreed and states that no other recompense will be offered in lieu.

If you say nothing and the firm implements this policy, in law you will have tacitly agreed to the change. If you disagree or seek a form of recompense you will have commenced a process that will either change or protect your prior conditions - and there will probably be some bargaining along the way.

Positive bargaining

Because employment is based upon a relationship between you and your employer, it is important to undertake bargaining in a positive and open manner leading to increased understanding and outcomes which are a win-win for both parties. The obligation to create this environment rests on both parties - no one can do it alone.

The employer has the power over your future employment and needs to exercise this power fairly - some do, some don’t. You need to get to know your employer to make informed judgements about your bargaining tactics and prospects.

Common features of private industry contracts include: job title and classification job description location of employment expectations/conditions re relocation salary pay period and mode method of salary adjustment performance appraisal method and targets performance/bonus plans access to salary packaging provision of company vehicle of use/reimbursement re private vehicle payment of out of pocket expenses payment for professional development payment for membership of professional associations professional indemnity insurance public holidays sick leave and its accumulation annual leave, its accumulation and payout on termination annual leave loading long service leave paid bereavement leave paid leave to attend professional development activities paid leave to care for family members payment re jury service higher duties allowance cost of travel on business superannuation life assurance disability and income protection insurance isolated establishment allowance notice of termination and payments in lieu of notice additional notice and/or payments in the case of redundancy disputes settlement procedure period of contract variation/extension of existing agreement etc... There are as many clauses as circumstances

Being well Informed

When entering into bargaining, employers and employees should both be well informed about the legal underpinnings to the terms and conditions of employment, such as statutory provisions, awards etc. and to know the market rates of pay, terms and conditions, and the status of the job market. Otherwise mistakes can be made.

As an employee it helps to be positive and assertive, not aggressive. Employees who are well informed can also avoid areas of unnecessary disagreement with an ill-informed boss. Recent graduates have avoided disputes with their employers about basic entitlements such as annual leave, notice periods etc. by seeking information through APESMA on their legal entitlements.

When the going gets tough, talk to APESMA early

If negotiations are getting tough, employees who wish to protect their ongoing employment should, if appropriate, advise their employer in writing that they are prepared to work to the terms of their pre-existing contract. Employees must be careful not to communicate to their employer that the employment relationship has broken down, otherwise your position may be jeopardised.

APESMA handles unfair dismissals where professionals have proceeded with negotiations without our advice and have found themselves in difficulty. It is better to talk with us before a problem arises.

When you are in the process of negotiations it is important that you take full advantage of your APESMA membership to maximise and protect your position.

Some members seek copies of legislative provisions or award clauses to show their employer, others ask for advice on draft contracts, salary packaging or market rates, others want to talk confidentially to an expert who knows their industry.

Recently a senior employee sought market rate advice as his employer was quoting a particular industry survey about the benefit of the provision of a vehicle as part of a salary package. We gave this member a copy of this same survey - which also included information about his market rate - he got a pleasant surprise, cited the source to his employer and successfully bargained a much improved package.

The key is to get the right advice when you need it and to make well informed judgements when bargaining. As a professional employee you have invested a lot of energy and resources in your career. Satisfy yourself that you have taken all of the necessary steps to maximise your investment.

Designing & Managing Your Contract

Professional employees sometimes ask APESMA for a standard contract of employment. Our response is usually to advise you of the standard features of contracts and then discuss the specific circumstances required in your case. We help you to achieve a unique contract which meets your needs as each contract is different.

Each contract should specify the registered name and business address of the employer and should include as a term of the contract any award which applies.

The amount of detail in a contract will depend on whether an industrial award applies to the work. If so, minimum provisions will apply to many terms and conditions of employment. In this instance it will be important to determine what matters are already covered by the award and to formalise in writing any unique or above award features in your contract.

All contract provisions should exceed minimum entitlements — either award or statutory. Where you are unsure about these provisions, please check with us.

Legislative support for your employment

In addition to awards, basic minimum legal entitlements for all employees are provided through federal and state laws such as superannuation, long service leave, workers compensation. The table below indicates where such laws are present.

If you are not covered by an award, you may need advice on the contents of these provisions when negotiating a contract. Again please contact us for further information.

One example which illustrates the importance of familiarity with legal entitlements is annual leave. A loop-hole in state annual leave legislation is the failure to require accrued annual leave to be paid out on termination. This entitlement should not be taken for granted by award-free staff and should be specified in the employment contract.

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REF : Quiz Of The Week

REF : Quiz Of The Week

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List of blogs

http://www.iradix.in/component/option,com_bookmarks/Itemid,105/mode,2/catid,-1/navstart,4/search,*/

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The Radiology Assistant

This is a great teaching website with plenty of beautiful illustrations

http://www.radiologyassistant.nl/en/

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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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