Sunday, March 14, 2010

Top medical professionals dispute extent of x-ray crisis

‘It was like a media tsunami," said consultant radiologist Dr Riste├írd O’Laoide about reaction to the news that thousands of x-rays had not been reviewed by radiologists at Tallaght Hospital.

O’Laoide, dean of the faculty of radiologists at the Royal College of Surgeons in Ireland, expressed concern about the ‘‘sensationalist’’ portrayal of the facts.

He said the media coverage and public debate had left the public confused and misinformed, with many people left with the mistaken impression that thousands of x-rays had not been examined by any doctors.

The comments come despite the fact that management at Tallaght Hospital acknowledged that it was a serious issue that had to be rectified.

‘‘To describe it as a national catastrophe was completely over the top. There is also no evidence whatsoever to suggest that this is a misdiagnosis scandal," said O’Laoide.

His views were echoed by the HSE’s national director of clinical care, Dr Barry White.

‘‘As a practice the unopened GP referrals was a more serious issue than the x-rays. That cannot be defended, but the unopened letters was an imperfect response to significant pressure on outpatient waiting lists at the hospital," he said.

Tallaght Hospital chief executive Kevin Conlon said last week that Tallaght Hospital had reviewed 34,752 x-rays of some 57,921 adult x-rays that had not already been reviewed by a consultant radiologist.

Two cancer patients received a delayed diagnosis as a result of the failure to have their x-rays reviewed by radiologists at the hospital. One of these patients has since died, while the other is being treated at the hospital.

‘‘It is very unfortunate that they had a delayed diagnosis. That is extremely difficult for them and their families, but it does not necessarily mean the same thing as a misdiagnosis," O’Laoide said.

The difference between a delayed diagnosis and a misdiagnosis is fairly immaterial to a patient with cancer whose tumour was not spotted at the outset, however.

‘‘In a properly functioning department chest x-rays should always be reviewed by radiologists," O’Laoide said.

It is understood that most of the 57,000-plus x-rays which were not reported on by consultant radiologists at the hospital between 2005 and 2009 related to orthopaedic work, but it remains unclear how chest x-rays slipped through the net.

‘‘I suspect that what happened in Tallaght was that they did some degree of risk stratification and decided that, because of the heavy work load, they would leave orthopaedic x-rays with the orthopaedic consultants at the hospital," said O’Laoide.

He said it was not uncommon for this to happen in hospitals.

‘‘This issue is not unique to Tallaght. Some hospitals have radiologists report everything.

Others do not," he said.

Orthopaedic consultants, for their part, maintained they were well equipped to read the vast majority of orthopaedic x-rays.

David Moore, a consultant orthopaedic surgeon at Tallaght Hospital, said orthopaedic surgeons were more than capable of reading x-rays in 95 per cent of cases.

‘‘We spend a good deal of our time studying x-rays. An opinion from a consultant radiologist [for orthopaedic patients] is necessary only in a small number of difficult cases," he said.

‘‘There are no absolute rules," said another doctor. Neurologists, for example, are adept at interpreting CT and MRI scans of the brain. Intensive care specialists often interpret their own xrays. Respiratory physicians interpret their patients’ x-rays.

Dr Tony Holohan, chief medical officer at the Department of Health said: " In situations where there is a clear agreement policy in place between radiologists and other consultants, it is perfectly appropriate for those consultants to review x-rays."

However, it is unclear whether there was a clear agreement at Tallaght. While it is understood that a significant number of the controversial x rays were of orthopaedic patients, that was not the case for all of them. It may well emerge that a significant number of x rays in that 58,000 should have been read by a radiologist.

Tallaght Hospital did not respond to numerous requests from this newspaper for clarification regarding the cohorts of patients involved.

The fact that there were no national guidelines or protocols to dictate best practice has confused the public and muddied the waters, but national protocols are being established by a group which had just been set up by the Health Service Executive.

‘‘The Faculty of Radiologists is leading a new National Quality Assurance programme in conjunction with the National Cancer Control Programme and the Royal College of Physicians of Ireland.

This will hopefully help to reassure patients, radiologists themselves and the wider public," O’Laoide said. Many jurisdictions have different protocols in place to dictate best practice.

‘‘There is a shortage of radiologists in England. One of the ways they decided to tackle it was to introduce a protocol under which orthopaedic films can be reviewed by orthopaedic consultants. In the United States, they say every x-ray should be reported by a radiologist," said O’Laoide.

Some observers have criticised the workload of radiologists at Tallaght Hospital.

Donal Duffy, assistant general secretary of the Irish Hospital Consultants Association, said he had spoken to radiologists at Tallaght who said the hospital did not have enough consultant radiologists to cover the workload. The hospital is now recruiting more staff.

‘‘What happened at Tallaght is a symptom of a wider problem - resources," Duffy said.

While there is a shortage of radiologists in Ireland, O’Laoide said the failure to deploy radiologists to areas of most demand was of greater concern. He said there was a high concentration of radiologists in the breast area, but a shortage of neuro-radiologists.

He said the workloads of radiologists had increased greatly in recent years, due to more advanced imaging and the time devoted to multidisciplinary team meetings in the cancer arena.

It may well emerge that a significant number of x-rays within the 58,000 x-rays at Tallaght should have been interpreted by a radiologist.

A number of those patients may well have been referred for x ray by GPs. Mistakes were undoubtedly made, but the real scale of the problem and the number of x-rays that fell into that category has yet to become clear.

While it maybe of little comfort to patients and families involved, there is an accepted level of error in radiology. To put it in perspective, the British Institute of Radiology recently held a meeting entitled ‘‘How much error is acceptable in radiology?"

According to O’Laoide, an error incidence of 2 per cent is deemed acceptable.

‘‘People miss cases. I do. Am I alone? No. Everyone does. It can be very difficult to convey that to the media at times like this. The debate is often brought down to individual patients and it is very emotive. It is impossible to advance a good debate on the back of that," he said.

‘‘If the miss rate at Tallaght is two out of some 34,752 x-rays it can only be described as remarkably low. That said, all chest x-rays should be reported by radiologists and that did not happen."

Psychopaths' brains wired to seek rewards, no matter the consequences

Abnormalities in how the nucleus accumbens, highlighted here, processes dopamine have been found in individuals with psychopathic traits and may be linked to violent, criminal behavior. Credit: Gregory R.Samanez-Larkin and Joshua W. Buckholtz brains of psychopaths appear to be wired to keep seeking a reward at any cost, new research from Vanderbilt University finds. The research uncovers the role of the brain's reward system in psychopathy and opens a new area of study for understanding what drives these individuals.

"This study underscores the importance of neurological research as it relates to behavior," Dr. Francis S. Collins, director of the National Institutes of Health, said. "The findings may help us find new ways to intervene before a personality trait becomes antisocial behavior."
The results were published March 14, 2010, in Nature Neuroscience.
"Psychopaths are often thought of as cold-blooded criminals who take what they want without thinking about consequences," Joshua Buckholtz, a graduate student in the Department of Psychology and lead author of the new study, said. "We found that a hyper-reactive dopamine reward system may be the foundation for some of the most problematic behaviors associated with psychopathy, such as violent crime, recidivism and substance abuse."
Previous research on psychopathy has focused on what these individuals lack—fear, empathy and interpersonal skills. The new research, however, examines what they have in abundance—impulsivity, heightened attraction to rewards and risk taking. Importantly, it is these latter traits that are most closely linked with the violent and criminal aspects of psychopathy.
"There has been a long tradition of research on psychopathy that has focused on the lack of sensitivity to punishment and a lack of fear, but those traits are not particularly good predictors of violence or criminal behavior," David Zald, associate professor of psychology and of psychiatry and co-author of the study, said. "Our data is suggesting that something might be happening on the other side of things. These individuals appear to have such a strong draw to reward—to the carrot—that it overwhelms the sense of risk or concern about the stick."
To examine the relationship between dopamine and psychopathy, the researchers used positron emission tomography, or PET, imaging of the brain to measure dopamine release, in concert with a functional magnetic imaging, or fMRI, probe of the brain's reward system
"The really striking thing is with these two very different techniques we saw a very similar pattern—both were heightened in individuals with psychopathic traits," Zald said.
Study volunteers were given a personality test to determine their level of psychopathic traits. These traits exist on a spectrum, with violent criminals falling at the extreme end of the spectrum. However, a normally functioning person can also have the traits, which include manipulativeness, egocentricity, aggression and risk taking.
In the first portion of the experiment, the researchers gave the volunteers a dose of amphetamine, or speed, and then scanned their brains using PET to view dopamine release in response to the stimulant. Substance abuse has been shown in the past to be associated with alterations in dopamine responses. is strongly associated with substance abuse.
"Our hypothesis was that psychopathic traits are also linked to dysfunction in dopamine reward circuitry," Buckholtz said. "Consistent with what we thought, we found people with high levels of psychopathic traits had almost four times the amount of dopamine released in response to amphetamine."
In the second portion of the experiment, the research subjects were told they would receive a monetary reward for completing a simple task. Their brains were scanned with fMRI while they were performing the task. The researchers found in those individuals with elevated psychopathic traits the dopamine reward area of the brain, the nucleus accumbens, was much more active while they were anticipating the monetary reward than in the other volunteers.
"It may be that because of these exaggerated dopamine responses, once they focus on the chance to get a reward, psychopaths are unable to alter their attention until they get what they're after," Buckholtz said. Added Zald, "It's not just that they don't appreciate the potential threat, but that the anticipation or motivation for reward overwhelms those concerns."

Schizophrenia Takes Major Toll on Children

It's an illness that doesn't strike often, but one that inevitably has a tremendous effect on the lives of those few children who suffer from it.

Schizophrenia is diagnosed in fewer than 1 in 30,000 American kids each year. Symptoms are similar to those seen in the around 1 percent of Americans who suffer from adult-onset schizophrenia: hallucinations, irrational thoughts and even violent behavior.

But schizophrenia will have an added impact on kids, because of the developmental delays it causes. Schizophrenic children won't learn social cues or proper hygiene, and often fail to make friends or perform academically.

Symptoms can also be mistaken for typical childhood phases. Kids often create imaginary worlds, struggle with bed-wetting and cleanliness, or act out in ways that seem irrational to adults.

But while the figments of childhood imagination are usually friendly, kids with schizophrenia often experience violent, scary and threatening delusions. An ABC News report on childhood schizophrenia described the plight of 9-year-old Rebecca Stancil, who "has been haunted by images of wolves, men with monster faces, and shadows and shapes that scamper around a darkened room."

"A lot of the time, the children will say that they have voices that are telling them very unpleasant things," Dr. Judith Rapoport, director of the National Institutes of Mental Health's childhood psychiatry division, said in an interview with Oprah Winfrey. "Often the voices are telling them very bad things -- talking about death, talking about things that a child should do or that might be done to them."

And while adult sufferers often have sudden "episodes" that signal a problem, schizophrenia seems to develop progressively in children. Often parents don't recognize that something is seriously wrong until their child experiences a fundamental break from reality.

The root cause of schizophrenia at any age remains unknown. Researchers suspect that brain dysfunction is the culprit, but don't know the precise mechanism, or why it strikes so early in some patients.

Studies have identified several risk factors, including some that might help explain schizophrenia's early onset. A family history of the illness, malnutrition in the womb, and childhood abuse or trauma have all been linked to the development of schizophrenia.

In January, a study of rhesus monkeys confirmed that those whose mothers suffered the flu while pregnant exhibited brain changes typically seen in schizophrenic patients.

Treating childhood schizophrenia is another challenge. Most anti-psychotic drugs haven't been tested on kids, because so few ever need them. Doctors often prescribe the medications off-label, meaning drugs are doled out to an age group that hasn't been FDA approved.

Children also often require special academic, social and hygienic training to grow into adults who can cope with the world around them.

And they'll likely spend the rest of their lives struggling with some degree of dysfunction.

"Very few really ever reach a point that no one knows they have schizophrenia," Rapoport said. "Some degree of impairment remains, and the degree of support that they have from their school, their family, their community, makes a huge difference on what the rest of their life is going to be like."