Radiation in CT scans, x-ray/radiographies and PET scans (II): the socio-economic environment

This is the second of a series of 3 posts describing:

1. The value and cost/harm of medical tests involving radiation, purely from a scientific perspective.
2. Other factors affecting the prescription of these tests. This post.
3. What to do if a doctor recommends such a test.

One would think that prescribing a medical test should depend only on the scientific trade-offs. Unfortunately there is a pile of evidence pointing to this not being the case, and that other reasons like economic as well as social play a strong influence on such prescriptions. The following is mostly center in US and few of these reasons may not apply to other regions with, for instance, different healthcare systems.

One can find a good introduction in these two articles:

http://articles.latimes.com/2008/sep/07/science/sci-ctscan7
http://seattletimes.nwsource.com/html/businesstechnology/2011478296_apusradiationscansfda.html

Basically:

1. If you Google hard enough, you can find forums where doctors admit prescribing CTs to cover their ass. You can't blame only doctors for that, as the US society as a whole is prone to sue doctors, so, naturally doctors practice defensive medicine.
2. Patients are also guilty of looking for fast medicine/results. Imaging certainly can help to shorten the diagnosis (like it could do cutting you wide open) but patients just don't think or don't know the effects.
3. Doctors themselves are not the most knowledgeable out there on radiation and its effects/risks.
4. Imaging is a good source of income for the medical establishment.
5. The big imaging instrument manufacturers (GE, Philips, Siemens and Toshiba mainly) do want to sell as many of these machines as possible and apparently in some cases do practice borderline marketing.
6. Patients rely on the doctor (or the system?) warning them ahead of any risks. Unfortunately, patients do not understand that the warnings are NOT for the patients but to cover the medical establishment against law suits should something wrong happen. The awful beauty of radiation based imaging tests is that its effects can usually only be seen after many years and with no conclusive way to trace them back to the original test. As such, many hospitals, doctors, etc... do no see any reason to warn patients about these risks as they very likely will not be found guilty of a future cancer, and warning the patient may create delays, discussions, or ultimately the patient opposition to such a test. If you think this is an exaggeration, you should wonder why although in some places the consent form for a CT scan may include radiation risks (http://www.medscape.com/viewarticle/542613) on many more (see http://www.mibmri.com/ct_scan_consent_form.html or the Medical City Hospital in Dallas, which I happen to know from first hand) this may be limited to the contrast risks, which are on the same order or lower than the radiation risks.  The effects from the contrast are immediate while the effect from the radiation would take decades to manifest. 

Notice that, for instance, a different health system, like the public one where doctors get paid no matter what they prescribe and where the government is actually pressured to save costs (as taxes are paying for the tests) will create protocols where the test has to be strongly justified.

So, after all this information, what can a patient do to know if the test in needed or not? Please see the 3rd post for some suggestions...

Radiation in CT scans, x-ray/radiographies and PET scans (I): the scientific view

This is the first of a series of 3 posts describing:

1. The value and cost/harm of medical tests involving radiation, purely from a scientific perspective. This post.
2. Other factors affecting the prescription of these tests.
3. What to do if a doctor recommends such a test.

So, let's center this post around the scientific facts. The following table lists typical radiation levels for some of these imaging tests as well as other sources of radiation. Notice that these include mainly x-ray, CT, PET and variations of these. MRI and ultrasound do NOT use ionizing radiation and are considered, in principle, safe:

1. Natural background: 2.4mSv/year
2. Air travel crew: 3mSv/year 
3. Radiation worker federal limit: 50mSv/year
4. Dental radiography: 0.01mSv
5. Chest radiography: 0.1mSv
6. Mammography: 0.7mSv
7. PET/SPECT : 7mSv 
8. Chess CT: 8mSv
9. Pelvic/abdomen CT: 10mSv
10. CT Angiography: 15mSv
11. 50% of cases die in 30 days: 3Sv

Notice that:

1. Just by living, we do get a decent level of radiation (see #1)
2. That there is a very wide range between tests. For instance, a pelvic CT radiation is like 100 chest x-rays (this number is actually probably conservative).

Question comes on the relation between radiation dose and cancer. The following link can provide some guidance:
http://www.xrayrisk.com/calculator/calculator.php

Notice that:

1. Risk factors are extrapolations/guesses.
2. A ballpark is about 0.1% increase in cancer risk for a 10mSv exposure of a 30 year old person.
3. The younger the higher the risk.
4. Risk is additive. The more tests you get in your lifetime, the higher the cancer risk.

The actual dose of the test can vary even for the same test. For CT, to exactly compute the dose from a given test (once the test is done and the data of the test obtained from the radiologist), one can follow this example:
http://answers.google.com/answers/threadview/id/742075.html

So, the above would give us the "cost", the "risk" of performing such a test, but what are the benefits? In this context, we all have heard the expression "the benefits outweigh the risks". There are many conditions out there and talking about the benefits or the need of medical imaging would be plain impossible, but basically, one could say that the bigger the radiation the test carries, the better the image and the bigger the benefits, with a CT or a PET scan providing beautiful images and information. Notice that pure information does not imply need for the test. We may already know the reason for the disease (from some other diagnosis) and all what the test would do would be to confirm the diagnosis. Or we could take the path of treating the likely disease without 100% confirmation from a CT scan, and if that solves the problem, then just move on (saving with this approach the radiation and cancer risk). Ultimately, it is for the doctor to explain the benefits and alternatives of such test to the patient and for the patient to decide (see the 3rd post on this topic).

Let's move on now to other factors that may not be necessarily explained by the doctor and that do affect the prescription of imaging tests, at least in US.

Update (3/23/2013). I got across this alert from the Joint Commission  on this topic. May be useful reading...

Patientslikeme.com

Working couple of years back in the symptoms of my own illness at the time, I missed many tools that I would have certainly loved to have to find the data I needed, specially when one thinks in the times of the Internet: Free access to journal papers (of research partially paid by MY taxes), forums with good tools to search/screen through the answers, good symptoms search tools, tools to track my symptoms and any other factors and see how those correlated to my evolution or that of other similar patients, etc...

Eventually I managed to cure myself (after repeated failures of my PCP), by covering with ingenuity and hard work for some of the lack of those tools, and along the way, I thought it would be good to create those tools for many other patients. This may look like a very altruistic/philanthropic goal, but ultimately, let's be honest, I or somebody I care about would be benefiting from it in the long run, when illness strikes again.

So, while I was cooking some of those tools/sites, I failed to find a site called patientslikeme.com, till my friend, just yesterday, mentioned it to me. I was hit again by the "duh, I am late again" feeling, but at the same time, I thought that better that somebody does something instead of me thinking about it. I even looked at it with more sympathy when I read about the story of the founder, who came up with this project while fighting his brother's ALS. More here:
http://www.patientslikeme.com/about

So, just signed up and here are just quick thoughts, not so much on the tools/interface/etc (where I do have my opinions) but on the spirit of the site. Honestly, I am a bit disappointed. They do say up front (good that they don't hide that) that they are a for-profit organization. Question is at what expense, if any. Their first core value is: "putting patients first". That sounds exactly what I would have in mind for mine, so, great! So, they don't sacrifice the advance of science, a cure for those patients, etc... in order to make money, right? Errrrr... Well, not really. That's actually not what they mean for that sentence and the detailed explanation can be found here:
http://www.patientslikeme.com/help/faq/Corporate#c_corevalues

"Simply stated, this means "Patients First."  You, our patients, trust us with your most valued health information. We honor that trust, and we are dedicated to advancing the knowledge of your conditions with the information you share."

Not bad, but will they give it 100%? Not really. An example of it can be seen in their research policy:
http://patientslikeme_research.s3.amazonaws.com/Research%20Policy%20May2009.pdf

One of their assets is their patients. Yes! Patients are an asset to them. The information patients disclose is an asset too. And patientslikeme.com will no offer it for free to everybody out there. It is not about protecting patient privacy. They actually will sell it to the buyer. It is about protecting their pockets. If a professor doing a study in MS would like to run a short questionnaire or few test through 100 patients to further advance his research, he can't do that, without permission AND payment: "Please note that we do not have a patient referral service which is free of charge".

Anyhow, do not want to be too harsh on the site. I want to check few more things and I also understand that sites require money to run. Money brings also quality. But "for profit" is just not what I had in mind in this case... I got to think what I would do instead, though... I'll leave for another post thoughts on healthcare financing, but so I am not misunderstood, I do not necessarily look down on anybody that with the current society makes as much money as possible out of sick people... although I do hope for a change in society.

Firefox in-line translator add-on

Well, found something simple and good:
https://addons.mozilla.org/en-US/firefox/addon/google-translator-for-firefox/?src=ss
 
Just select what you want to translate and pick from the drop down menu "translate...". It'll place the translation where the original text was selected. It is very very similar to the example from Jetpack but I was sick that every time I was switching version of Firefox, my plug-in was not working and I had to port it. So, I though, I will gladly do a donation to this guy. When I got his thank you email, it felt good. World should work like this more... If you like it, consider too making a donation... And by the way, this is based on the free tools from Google. Thanks too!

PS.: That reminds me I still need to donate to the folks of Downloadhelper...

Ownership of an invention by an employee in Spain

Straight from the law 11/1986, BOE núm. 73, de 26 de marzo de 1986

http://www.oepm.es/cs/OEPMSite/contenidos/NORMATIVA/NormasSobrePatentes_MU_Topografias_CCP/NSPMTCCP_Patentes_Modelos/NSPMTCCP_Patentes_Modelos_Nacionales/Ley11_1986de20demarzo_dePatentes.htm#tit3

The relation is covered under Title IV:

1. Article 15: Inventions related to the work the employee does are company's ownership, and company does not need to pay anything extra unless the effect of such an invention is way beyond what the employee was paid for.
2. Article 16: Everything else belongs to the worker. Notice that there is nothing in there on "an area where the company has or may have interest in the future". Only limit is what the worker is paid for, NOT what the company is working in or has interest in.
3. Article 17: If the inventor uses the company on any way for the invention, the company has the right on the invention. Use the company means, not only using company facilities/tools, but also acquired knowledge within the company.
4. Article 18: The inventor has to provide all the info related to an invention under articles 15 and 17 to the company in 3 months.
5. Article 19: This law still applies to inventions filed for patent even a year after the employee has left the company.
6. Article 20: Details in the University context.

Conclusion: bottom line, this looks to follow the "fairness concept" defended by me in previous posts.

Razors and blades strategy

While talking to a friend of mine on Intuitive Surgical, we discussed their business model of making a killer on the disposable portions of the DaVinci robot. I can see that with patents all over, and with a high barrier of entry, it would be hard to be a competitor for a while, so, that is a place where the famous "razors and blades" strategy would work. Same for instance, on glucose meters. This is a market (health care) also were quality prevails over cost (some times too much). But then, I wonder how Gillete, the named inventor of such a strategy was surviving today? So, I did some digging:
http://www.slideshare.net/rupakfeb7/gillette-final

You can skip the whole thing and jump to page 26: "Gillette no longer had that lock after the 1904 patents expired in 1921, and yet the strategy toward which it was unwillingly pulled worked. Whether that was consumer habit, or the superior quality of the Gillette blades, or something else is something that we cannot divine from the catalogues."
And last page: "And that leaves a hole in the analysis. Gillette had not played razors-and-blades when it could have during the life of the 1904 patents and did not seem well situated to do so after their expiration, but it was exactly at that point that Gillette played something like razors-and-blades, and that was when it made the most money. Razorsand-blades seems to have worked at the point where the theory suggests that it should not have. Why is that? Did Gillette succeed because of quality, or were there powerful, even if hard-to-discern-now locks—psychological or otherwise—between the razors and the blades?"

So, basically the author himself does not know. He proposes couple of thoughts, that maybe are confirmed in slide 24 of http://www.slideshare.net/rupakfeb7/gillette-final. Advertising, branding, etc... Bottom line, it could be quality or it may be beyond quality, the people simply got too much inertia to change or simply is stupid (assuming again there is no quality difference). Seriously, has anybody done the work of evaluating the two to justify paying for the more expensive one? Why would you go through so much trouble, anyhow? I guess that you simply assume the answer and pay for what theoretically is right (more price, better quality). I wonder what would be the strategy of a competitor to take market share away from Gillette. The competitors are not small (Wilkinson, BIC...), and I think the first actually tried (more advertising), but not sure they took market share away. It would also be interesting to check their advertising budget and how much of that affects the price of the blade.


Anyhow, the following article basically seems to say that the shaving experience is truly much better and people will be willing to pay for it. It also says that there will be a huge marketing campaign.
http://www.businessweek.com/bwdaily/dnflash/sep2005/nf20050915_1654_db035.htm



My next thing to investigate ink jets... :)

Changing the language for your whole Windows XP

Wanted to change all the environment (so, forget about the "I know how to do that, just go to Language settings...") and looking around I finally found a post here:
http://www.knowledgesutra.com/discuss/tftmmm-change-windows-language.om/p_3

The only correction is to pick the right controlset folder (there a few ones). Not the one below, but the current one!

This is just for my records... I copy here his/her posting:

To Change the language of Windows XP

How To Change Windows Xp Language ?

To change the whole system language you should install newer service pack with different Language. Or Uninstall the last installed Service Pack and after change the registrysettings below install it again.

Make always a backup of your Registry at first !

For example

If you have XP SP2 in ENG and want to have it in Italian, you will have toDownload SP3 in Italian, change some registry keys (go to HKEY_LOCAL_MACHINESYSTEMControlSet001ControlNlsLanguageRegistry key, and then change the value date for �Default� and�InstallLanguage� registry value from 0409 to 0410) and you'll be able toInstall it in Italian. 

If no problems occur, you will have the whole system language changed.

Here is the List of numbers that represents each language in registry: 

1. 0436 = \"af;Afrikaans\"
2. 041C = \"sq;Albanian\"
3. 0001 = \"ar;Arabic\"
4. 0401 = \"ar-sa;Arabic (Saudi Arabia)\"
5. 0801 = \"ar-iq;Arabic (Iraq)\"
6. 0C01 = \"ar-eg;Arabic (Egypt)\"
7. 1001 = \"ar-ly;Arabic (Libya)\"
8. 1401 = \"ar-dz;Arabic (Algeria)\"
9. 1801 = \"ar-ma;Arabic (Morocco)\"
10. 1C01 = \"ar-tn;Arabic (Tunisia)\"
11. 2001 = \"ar-om;Arabic (Oman)\"
12. 2401 = \"ar-ye;Arabic (Yemen)\"
13. 2801 = \"ar-sy;Arabic (Syria)\"
14. 2C01 = \"ar-jo;Arabic (Jordan)\"
15. 3001 = \"ar-lb;Arabic (Lebanon)\"
16. 3401 = \"ar-kw;Arabic (Kuwait)\"
17. 3801 = \"ar-ae;Arabic (you.A.E.)\"
18. 3C01 = \"ar-bh;Arabic (Bahrain)\"
19. 4001 = \"ar-qa;Arabic (Qatar)\"
20. 042D = \"eu;Basque\"
21. 0402 = \"bg;Bulgarian\"
22. 0423 = \"be;Belarusian\"
23. 0403 = \"ca;Catalan\"
24. 0004 = \"zh;Chinese\"
25. 0404 = \"zh-tw;Chinese (Taiwan)\"
26. 0804 = \"zh-cn;Chinese (China)\"
27. 0C04 = \"zh-hk;Chinese (Hong Kong SAR)\"
28. 1004 = \"zh-sg;Chinese (Singapore)\"
29. 041A = \"hr;Croatian\"
30. 0405 = \"cs;Czech\"
31. 0406 = \"the;Danish\"
32. 0413 = \"nl;Dutch (Netherlands)\"
33. 0813 = \"nl-be;Dutch (Belgium)\"
34. 0009 = \"en;English\"
35. 0409 = \"en-us;English (United States)\"
36. 0809 = \"en-gb;English (United Kingdom)\"
37. 0C09 = \"en-au;English (Australia)\"
38. 1009 = \"en-ca;English (Canada)\"
39. 1409 = \"en-nz;English (New Zealand)\"
40. 1809 = \"en-ie;English (Ireland)\"
41. 1C09 = \"en-za;English (South Africa)\"
42. 2009 = \"en-jm;English (Jamaica)\"
43. 2809 = \"en-bz;English (Belize)\"
44. 2C09 = \"en-tt;English (Trinidad)\"
45. 0425 = \"et;Estonian\"
46. 0438 = \"fo;Faeroese\"
47. 0429 = \"fa;Farsi\"
48. 040B = \"fi;Finnish\"
49. 040C = \"fr;French (France)\"
50. 080C = \"fr-be;French (Belgium)\"
51. 0C0C = \"fr-ca;French (Canada)\"
52. 100C = \"fr-ch;French (Switzerland)\"
53. 140C = \"fr-lu;French (Luxembourg)\"
54. 043C = \"gd;Gaelic\"
55. 0407 = \"de;German (Germany)\"
56. 0807 = \"de-ch;German (Switzerland)\"
57. 0C07 = \"de-at;German (Austria)\"
58. 1007 = \"de-lu;German (Luxembourg)\"
59. 1407 = \"de-li;German (Liechtenstein)\"
60. 0408 = \"el;Greek\"
61. 040D = \"he;Hebrew\"
62. 0439 = \"hi;Hindi\"
63. 040E = \"hu;Hungarian\"
64. 040F = \"is;Icelandic\"
65. 0421 = \"in;Indonesian\"
66. 0410 = \"it;Italian (Italy)\"
67. 0810 = \"it-ch;Italian (Switzerland)\"
68. 0411 = \"ja;Japanese\"
69. 0412 = \"ko;Korean\"
70. 0426 = \"lv;Latvian\"
71. 0427 = \"lt;Lithuanian\"
72. 042F = \"mk;FYRO Macedonian\"
73. 043E = \"ms;Malay (Malaysia)\"
74. 043A = \"mt;Maltese\" 0414 = \"no;Norwegian (Bokmal)\"
75. 0814 = \"no;Norwegian (Nynorsk)\"
76. 0415 = \"pl;Polish\"
77. 0416 = \"pt-br;Portuguese (Brazil)\"
78. 0816 = \"pt;Portuguese (Portugal)\"
79. 0417 = \"rm;Rhaeto-Romanic\"
80. 0418 = \"ro;Romanian\"
81. 0818 = \"ro-mo;Romanian (Moldova)\"
82. 0419 = \"ru;Russian\"
83. 0819 = \"ru-mo;Russian (Moldova)\"
84. 0C1A = \"sr;Serbian (Cyrillic)\"
85. 081A = \"sr;Serbian (Latin)\"
86. 041B = \"sk;Slovak\"
87. 0424 = \"sl;Slovenian\"
88. 042E = \"sb;Sorbian\"
89. 040A = \"es;Spanish (Traditional Sort)\"
90. 080A = \"es-mx;Spanish (Mexico)\"
91. 0C0A = \"es;Spanish (International Sort)\"
92. 100A = \"es-gt;Spanish (Guatemala)\"
93. 140A = \"es-cr;Spanish (Costa Rica)\"
94. 180A = \"es-pa;Spanish (Panama)\"
95. 1C0A = \"es-do;Spanish (Dominican Republic)\"
96. 200A = \"es-ve;Spanish (Venezuela)\"
97. 240A = \"es-co;Spanish (Colombia)\"
98. 280A = \"es-pe;Spanish (Peru)\"
99. 2C0A = \"es-ar;Spanish (Argentina)\"
100. 300A = \"es-ec;Spanish (Ecuador)\"
101. 340A = \"es-cl;Spanish (Chile)\"
102. 380A = \"es-uy;Spanish (Uruguay)\"
103. 3C0A = \"es-py;Spanish (Paraguay)\"
104. 400A = \"es-bo;Spanish (Bolivia)\"
105. 440A = \"es-sv;Spanish (El Salvador)\"
106. 480A = \"es-hn;Spanish (Honduras)\"
107. 4C0A = \"es-ni;Spanish (Nicaragua)\"
108. 500A = \"es-pr;Spanish (Puerto Rico)\"
109. 0430 = \"sx;Sutu\"
110. 041D = \"sv;Swedish\"
111. 081D = \"sv-fi;Swedish (Finland)\"
112. 041E = \"th;Thai\"
113. 0431 = \"ts;Tsonga\"
114. 0432 = \"tn;Tswana\"
115. 041F = \"tr;Turkish\"
116. 0422 = \"uk;Ukrainian\"
117. 0420 = \"your;Urdu\"
118. 042A = \"vi;Vietnamese\"
119. 0434 = \"xh;Xhosa\"
120. 043D = \"ji;Yiddish\"
121. 0435 = \"zu;Zulu\"

-reply by Ing, Wop NLD

Notes: as I had my Service Pack 3 already in there, I had to uninstall it. Reboot. Did the changes above and reinstall it again. Now it´s working!! :D