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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2008.06.004 Byline: Barry D. Pressman (a), Thomas R. Hoffman (b) Keywords: Oral board examinations; American Board of Radiology; ACR white paper Abstract: The direction that the American Board of Radiology intends to follow relative to the diagnostic radiology oral board examination has risen quickly up the list of fundamental challenges for the radiology community. The formation of an ACR task force to study these changes was necessary, because this issue carries a high stake for the future of the profession and the patients we serve. After a careful review of the potential impacts, the committee discovered that consensus would be difficult to achieve relative to the merits of these changes. Accordingly, this white paper is focused objectively on the potential impacts on radiologists, practices, academic institutions, the ACR itself, and the ACR's membership. It is suggested that these concepts be used as starting points for future discussion and consideration of potential action. Author Affiliation: (a) Department of Imaging, Cedars-Sinai Medical Center, West Hollywood, California (b) Legal Department, American College of Radiology, Reston, Virginia

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2007.01.021 Byline: June Hawkinson (a), Julie Timins (b), Dennis Angelo (c), Margaret Shaw (d), Russell Takata (e), Frances Harshaw (f) Keywords: Bone densitometry; osteoporosis; bone mineral density; single-energy x-ray absorptiometry; dual-energy x-ray absorptiometry; quantitative computed tomography; quantitative ultrasound; ionizing radiation; radiation dose; radiation exposure; precision testing Abstract: The Conference of Radiation Control Program Directors (CRCPD) Task Force on Bone Densitometry (H-30) was assigned by the Healing Arts Council on Emerging Issues to address issues of bone densitometry. Issues for clarification included the practice of precision testing, in which multiple bone density determinations are performed on one patient; the use of quantitative computed tomographic (CT) densitometry; and radiation dose to patients and operators. This paper is a condensation of the white paper produced by the task force, which addresses the various methods of measuring bone density, the qualifications and responsibilities of personnel, the rationale for precision testing, and the doses patients and operators may receive. The white paper is available in its entirety on the CRCPD's Web site (http://crcpd.org). Author Affiliation: (a) Retired from Minnesota Department of Health, Minn. (b) Department of Radiology, Christ Hospital, Jersey City, NJ. (c) Department of Radiation Protection (Southwest Regional Office), Commonwealth of Pennsylvania, Pittsburgh, Pa. (d) Minnesota Department of Health, Environmental Health and Radiation Control, St. Paul, Minn. (e) Department of Health; Noise, Radiation, and Indoor Air Quality Branch, Honolulu, Hawaii. (f) Harshaw Medical Physics Consultants, Austin, Tex.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2010.06.013 Byline: Lincoln L. Berland (a), Stuart G. Silverman (b), Richard M. Gore (c), William W. Mayo-Smith (d), Alec J. Megibow (e), Judy Yee (f), James A. Brink (g), Mark E. Baker (h), Michael P. Federle (i), W. Dennis Foley (j), Isaac R. Francis (k), Brian R. Herts (h), Gary M. Israel (g), Glenn Krinsky (l), Joel F. Platt (k), William P. Shuman (m), Andrew J. Taylor (n) Keywords: Incidental findings; incidentaloma; pancreatic cyst; renal cyst; liver lesion; adrenal nodule Abstract: As multidetector CT has come to play a more central role in medical care and as CT image quality has improved, there has been an increase in the frequency of detecting 'incidental findings,' defined as findings that are unrelated to the clinical indication for the imaging examination performed. These 'incidentalomas,' as they are also called, often confound physicians and patients with how to manage them. Although it is known that most incidental findings are likely benign and often have little or no clinical significance, the inclination to evaluate them is often driven by physician and patient unwillingness to accept uncertainty, even given the rare possibility of an important diagnosis. The evaluation and surveillance of incidental findings have also been cited as among the causes for the increased utilization of cross-sectional imaging. Indeed, incidental findings may be serious, and hence, when and how to evaluate them are unclear. The workup of incidentalomas has varied widely by physician and region, and some standardization is desirable in light of the current need to limit costs and reduce risk to patients. Subjecting a patient with an incidentaloma to unnecessary testing and treatment can result in a potentially injurious and expensive cascade of tests and procedures. With the participation of other radiologic organizations listed herein, the ACR formed the Incidental Findings Committee to derive a practical and medically appropriate approach to managing incidental findings on CT scans of the abdomen and pelvis. The committee has used a consensus method based on repeated reviews and revisions of this document and a collective review and interpretation of relevant literature. This white paper provides guidance developed by this committee for addressing incidental findings in the kidneys, liver, adrenal glands, and pancreas. Author Affiliation: (a) Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama (b) Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts (c) Department of Radiology, Evanston Hospital, Evanston, Illinois (d) Department of Radiology, Brown University School of Medicine, Providence, Rhode Island (e) Department of Radiology, NYU-Langone Medical Center, New York, New York (f) Department of Radiology, University of California, San Francisco, San Francisco, California (g) Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut (h) Department of Radiology, Cleveland Clinic, Cleveland, Ohio (i) Department of Radiology, Stanford University Medical Center, Stanford, California (j) Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin (k) Department of Radiology, University of Michigan, Ann Arbor, Michigan (l) Radiology Associates of Ridgewood, PA, Waldwick, New Jersey (m) Department of Radiology, University of Washington School of Medicine, Seattle, Washington (n) Department of Radiology, Virginia Commonwealth University Medical Center, Richmond, Virginia

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2010.01.018 Byline: Daniel J. Mollura (a), Ezana M. Azene (a)(b), Anna Starikovsky (a), Aduke Thelwell (c), Sarah Iosifescu (d), Cary Kimble (e), Ann Polin (f), Brian S. Garra (g)(h), Kristen K. DeStigter (g)(h), Brad Short (i), Benjamin Johnson (j), Christian Welch (j), Ivy Walker (k), David M. White (l), Mehrbod S. Javadi (b), Matthew P. Lungren (a)(m), Atif Zaheer (a)(b), Barry B. Goldberg (n), Jonathan S. Lewin (b) Keywords: Radiology; developing countries; public health; microcredit; microfinance; residency education; international global imaging; economic development; health care policy; information technology; limited-resource regions; health care disparity; radiology readiness Abstract: The RAD-AID Conference on International Radiology for Developing Countries was an assembly of individuals and organizations interested in improving access to medical imaging services in developing countries where the availability of radiology has been inadequate for both patient care and public health programs. The purpose of the meeting was to discuss data, experiences, and models pertaining to radiology in the developing world and to evaluate potential opportunities for future collaboration. Conference participants included radiologists, technologists, faculty members of academic medical institutions, and leadership of nongovernmental organizations involved in international health care and social entrepreneurship. Four main themes from the conference are presented in this white paper as important factors for the implementation and optimization of radiology in the developing world: (1) ensuring the economic sustainability of radiologic services through financial and administrative training support of health care personnel; (2) designing, testing, and deploying clinical strategies adapted for regions with limited resources; (3) structuring and improving the role of American radiology residents interested in global health service projects; and (4) implementing information technology models to support digital imaging in the developing world. Author Affiliation: (a) RAD-AID International, Chevy Chase, Maryland (b) The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland (c) Legatum Center for Development and Entrepreneurship, Massachusetts Institute of Technology, Cambridge, Massachusetts (d) Grameen Foundation, Capital Management and Advisory Center, Washington, D.C (e) Project HOPE, Millwood, Virginia (f) Brier, Washington, D.C (g) Fletcher Allen Health Care/University of Vermont, Burlington, Vermont (h) Imaging the World, Charlotte, Vermont (i) American College of Radiology, Reston, Virginia (j) University of California, San Diego, School of Medicine, San Diego, California (k) World Health Imaging, Telemedicine & Informatics Alliance, Chicago, Illinois (l) Applied Physics Laboratory, Johns Hopkins University, Baltimore, Maryland (m) Department of Radiology, Duke University, Durham, North Carolina (n) Division of Diagnostic Ultrasound, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania Article Note: (footnote) The RAD-AID Conference on International Radiology for Developing Countries was funded in part by the William Gatewood Fellowship Fund, Baltimore, MD.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2008.06.011 Byline: Valerie P. Jackson (a), Trudie Cushing (b), Hani H. Abujudeh (c), James P. Borgstede (d), Kenneth W. Chin (e), Charles K. Grimes (f), David B. Larson (g), Paul A. Larson (h), Robert S. Pyatt (i), William T. Thorwarth (j) Keywords: Peer review; medical errors; harm score; undercalls; overcalls; misinterpretations; disagreement rates Abstract: The ACR's RADPEER.sup.acents program began in 2002; the electronic version, e-RADPEER.sup.acents, was offered in 2005. To date, more than 10,000 radiologists and more than 800 groups are participating in the program. Since the inception of RADPEER, there have been continuing discussions regarding a number of issues, including the scoring system, the subspecialty-specific subcategorization of data collected for each imaging modality, and the validation of interfacility scoring consistency. This white paper reviews the task force discussions, the literature review, and the new recommended scoring process and lexicon for RADPEER. Author Affiliation: (a) Indiana University School of Medicine, Indianapolis, Indiana (b) American College of Radiology, Reston, Virginia (c) Massachusetts General Hospital, Boston, Massachusetts (d) University of Colorado, Denver, Colorado (e) San Fernando Valley Interventional Radiology & Imaging Center, Encino, California (f) Maine Medical Center, Portland, Maine (g) The Children's Hospital, Aurora, Colorado (h) Radiology Associates of Fox Valley, Neenah, Wisconsin (i) Chambersburg Imaging Associates, Chambersburg, Pennsylvania (j) Catawba Radiological Associates, Hickory, North Carolina

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2007.03.002 Byline: E. Stephen Amis (a), Priscilla F. Butler (b), Kimberly E. Applegate (c), Steven B. Birnbaum (d), Libby F. Brateman (e), James M. Hevezi (f), Fred A. Mettler (g), Richard L. Morin (h), Michael J. Pentecost (i), Geoffrey G. Smith (j), Keith J. Strauss (k), Robert K. Zeman (l) Keywords: Radiation dose; radiation safety; radiation risk; radiation exposure; radiations; exposure to patients and personnel Abstract: The benefits of diagnostic imaging are immense and have revolutionized the practice of medicine. The increased sophistication and clinical efficacy of imaging have resulted in its dramatic growth over the past quarter century. Although data derived from the atomic bomb survivors in Japan and other events suggest that the expanding use of imaging modalities using ionizing radiation may eventually result in an increased incidence of cancer in the exposed population, this problem can likely be minimized by preventing the inappropriate use of such imaging and by optimizing studies that are performed to obtain the best image quality with the lowest radiation dose. The ACR, which has been an advocate for radiation safety since its inception in 1924, convened the ACR Blue Ribbon Panel on Radiation Dose in Medicine to address these issues. This white paper details a proposed action plan for the college derived from the deliberations of that panel. Author Affiliation: (a) Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY. (b) American College of Radiology, Reston, Va. (c) Riley Hospital for Children, Indianapolis, Ind. (d) Associated Radiologists, P.A., Nashua, NH. (e) University of Florida College of Medicine, Gainesville, Fla. (f) South Texas Radio Surgery Associates, San Antonio, Tex. (g) New Mexico Federal Regional Medical Center, Albuquerque, NM. (h) Mayo Clinic Jacksonville, Jacksonville, Fla. (i) Kaiser Permanente, Washington, DC. (j) Casper Medical Imaging, Casper, Wyo. (k) Children's Hospital Boston, Boston, Mass. (l) George Washington University, Washington, DC.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2010.07.024 Byline: Brenda M. Kopriva (a), Stephen D. Helmer (a)(b), R. Stephen Smith (c) Keywords: Trauma; Moderately injured; Blood transfusion; Complications Abstract: Previous assessments linked transfusions in trauma to increased respiratory and infectious complications. However, these studies included patients with severe trauma, brisk hemorrhage, and shock. Thus, the potentially harmful impact of transfusion was difficult to determine. Author Affiliation: (a) Department of Surgery, The University of Kansas School of Medicine - Wichita, 929 N. Saint Francis St, Room 3082, Wichita, KS 67214, USA (b) Department of Medical Education, Via Christi Regional Medical Center, Wichita, KS (c) Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA Article History: Received 5 March 2010; Revised 26 July 2010

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2010.04.006 Byline: E. Stephen Amis (a), Priscilla F. Butler (b) Keywords: Radiation dose; radiation safety; radiation risk; radiation exposure; radiations; exposure to patients and personnel Abstract: The benefits of diagnostic imaging are immense and have revolutionized the practice of medicine. The increased sophistication and clinical efficacy of imaging have resulted in its dramatic growth over the past quarter century. However, the evolution of imaging has also resulted in a significant increase in the population's cumulative exposure to ionizing radiation and a potential increase in cancer risk. The ACR, an advocate for radiation safety since its inception in 1924, convened the ACR Blue Ribbon Panel on Radiation Dose in Medicine in 2006 and issued 37 recommendations for the College to address these issues. This report updates the status of these recommendations. Author Affiliation: (a) Montefiore Medical Center, Bronx, New York (b) American College of Radiology, Reston, Virginia

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2006.06.002 Byline: James W. Moser, Pamela A. Wilcox, Sandra S. Bjork, Trudie Cushing, Maurine Dennis, John E. Greissing, Kathryn Keysor, Judith McKenzie, Jeffrey C. Weinreb Keywords: Pay for performance; quality and efficiency metrics and benchmarks; American College of Radiology; white paper Abstract: During the next few years, some portion of physician reimbursement will be increasingly based on the quality and efficiency of service, a practice commonly referred to as pay for performance (P4P). Performance benchmarks are the discrete parameters of structure, process, or outcome metrics whose attainment defines good quality care. Private payers are already rewarding primary care physicians for practices that adhere to quality standards, are efficient, involve information technology, and result in high patient satisfaction. The Centers for Medicare and Medicaid Services will have completed the development of performance measures to be used in Medicare payment strategies for all specialties by the end of 2006 and anticipates phasing in the program fully by 2008. This article describes P4P, its importance to the ACR, the organizations involved in developing it, the ACR's activities to date, and the steps the ACR must take to ensure that radiologists are remunerated fairly as physician payment becomes based, in part, on performance. Author Affiliation: American College of Radiology, Reston, Va.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2006.01.009 Byline: C. Daniel Johnson (a), Stephen J. Swensen (a), Kimberley E. Applegate (b), C. Craig Blackmore (c), James P. Borgstede (d), John F. Cardella (e), James A. Dilling (a), N. Reed Dunnick (f), Lucy W. Glenn (g), Bruce J. Hillman (h), Lawrence S. Lau (i), Frank J. Lexa (j), Jeffrey C. Weinreb (k), Pamela Wilcox (l) Keywords: Quality; safety; pay for performance; Sun Valley Group Abstract: The Sun Valley Group is an informal assembly of individuals interested in improving quality in radiology. Its first meeting was held in September 2005. The purposes of the meeting was to share quality improvement experiences, consider a strategy for promoting quality improvement initiatives across the radiology profession, and initiate quality benchmarking efforts. Representatives from private practice, academia, national quality programs, and international societies were in attendance. Four main themes were presented: the sharing of leading quality activities in radiology, the future of pay-for-performance systems, programs and future initiatives of professional radiology societies, and health services research guidelines for developing outcome metrics. This white paper summarizes information presented in each of these thematic areas and concludes with the group's plans for future activities. Among these is a formal educational program for all radiologists interested in implementing a quality improvement program within their practice, to be hosted by the ACR. Author Affiliation: (a) Department of Radiology, Mayo Clinic, Rochester, Minn (b) Department of Radiology, Indiana University, Indianapolis, Ind (c) Department of Radiology, University of Washington, Seattle, Wash (d) Department of Radiology, Colorado Springs Radiologists, Colorado Springs, Colo (e) Department of Radiology, University of Colorado Health Science Center, Denver, Colo (f) Department of Radiology, University of Michigan Health Sciences, Ann Arbor, Mich (g) Department of Radiology, Virginia Mason Medical Center, Seattle, Wash (h) Department of Radiology, University of Virginia, Charlottesville, Va (i) Department of Diagnostic Imaging, Monash Medical Centre, Victoria, Australia (j) Global Consulting Practicum, The Wharton School, University of Pennsylvania, Philadelphia, Pa (k) Department of Radiology, Yale University School of Medicine, New Haven, Conn (l) American College of Radiology, Reston, Va

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2009.06.008 Byline: Frank Lexa (a), Jonathan William Berlin (b), Giles W.L. Boland (c), Geoffrey Giles Smith (d), Mark D. Jensen (e), David J. Seidenwurm (f), Richard Hoppe (g), Robert Stroud (h) Keywords: Value added; new business models; practice changes; practice growth; extension of imaging service value Abstract: Radiology practices are seeing both evolutionary and revolutionary changes in their business models. The Task Force to Evaluate the Value Add Impact on Business Models was charged with considering how radiologists and their practices add value in these novel settings. Both traditional and novel forms of added value were considered. Types of new business models that were evaluated included hybrid groups of radiologists and other practitioners, regional or national megagroups, and novel services both within and beyond the traditional purview of radiology practice. Recommendations for both how to measure and how to capture this value were considered at both the practice and national levels. Author Affiliation: (a) Wharton School, University of Pennsylvania, Wynnewood, Pennsylvania (b) Department of Radiology, Evanston Hospital, Evanston, Illinois (c) Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts (d) Casper Medical Imaging, Casper, Wyoming (e) Charlotte Radiology, Charlotte, North Carolina (f) Radiological Associates of Sacramento, Sacramento, California (g) Department of Radiation Oncology, Stanford University Medical Center, Stanford, California (h) Advanced Imaging, Baltimore, Maryland

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2008.05.017 Byline: Lane F. Donnelly, Julie M. Dickerson, Todd W. Lehkamp, Kevin E. Gessner, Jay Moskovitz, Sally Hutchinson Keywords: Walk rounds; operational rounds; safety; quality improvement Abstract: As part of a patient safety program in the authors' department of radiology, operational rounds have been instituted. This process consists of radiology leaders' visiting imaging divisions at the site of imaging and discussing frontline employees' concerns about patient safety, the quality of care, and patient and family satisfaction. Operational rounds are executed at a time to optimize the number of attendees. Minutes that describe the issues identified, persons responsible for improvement, and updated improvement plan status are available to employees online. Via this process, multiple patient safety and other issues have been identified and remedied. The authors believe that the process has improved patient safety, the quality of care, and the efficiency of operations. Since the inception of the safety program, the mean number of days between serious safety events involving radiology has doubled. The authors review the background around such walk rounds, describe their particular program, and give multiple illustrative examples of issues identified and improvement plans put in place. Author Affiliation: Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio Article Note: (footnote) Editor's note: The International Radiology Quality Network (IRQN) offers monthly awards for the best manuscripts submitted to the IRQN on the subject of quality improvement in radiology. An annual award recognizes the best of these articles.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2008.06.003 Byline: John A. Patti (a), Jonathan William Berlin (b), Albert L. Blumberg (c), R. Nick Bryan (d), Fred Gaschen (e), Brenda M. Izzi (f), Paul A. Larson (g), Jonathan Stewart Lewin (h), Lawrence A. Liebscher (i) Keywords: Value added; radiologists; health care enterprise; future imaging trends Abstract: Radiologists represent arguably one of medicine's least heralded but most important specialties. Although they carry sterling credentials as imaging and radiation safety experts, radiologists have lacked widespread public recognition. As public and private stakeholders cast an even more intense spotlight on imaging, the vital role of radiologists must be better understood. During the January 2008 ACR Forum on Future Practice Models for Radiology, participants and ACR leaders discussed the value added that radiologists bring to the health care enterprise and recommended that the ACR further study that topic. The ACR, dedicated to providing quality patient care since its inception in 1924, convened the Task Force on Value Added to address these issues. The task force determined the component stakeholders in the health care enterprise to whom value is added, defined the nature of the value for each constituent component, described the process of adding that value, and anticipated future trends that may affect the value proposition. Recommendations to the ACR for future action are offered. Author Affiliation: (a) Department of Radiology, North Shore Medical Center, Salem, Massachusetts (b) Department of Radiology, Evanston Hospital, Evanston, Illinois (c) Department of Radiation Oncology, Greater Baltimore Medical Center, Baltimore, Maryland (d) Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania (e) Radiological Associates of Sacramento, Sacramento, California (f) Department of Radiology, University of California, Los Angeles, Los Angeles, California (g) Radiology Associates of the Fox Valley, SC, Neenah, Wisconsin (h) Department of Radiology, Johns Hopkins Outpatient Center, Baltimore, Maryland (i) Cedar Valley Medical Specialists, Waterloo, Iowa

Objectives: To describe lung function in correlation with information on exposure to dust and fibers in soft tissue paper-producing factories in Germany. Methods: Ambient monitoring was performed for inhalable, respirable [...]

Byline: Robert J. Zalenski, Harry P. Selker, Christopher P. Cannon, Helke M. Farin, W.Brian Gibler, Robert J. Goldberg, Costas T. Lambrew, Joseph P. Ornato, Robert J. Rydman, Pamela Steele Abstract: The National Heart Attack Alert Program (NHAAP), which is coordinated by the National Heart, Lung, and Blood Institute (NHLBI), promotes the early detection and optimal treatment of patients with acute myocardial infarction and other acute coronary ischemic syndromes. The NHAAP, having observed the development and growth of chest pain centers in emergency departments with special interest, created a task force to evaluate such centers and make recommendations pertaining to the management of patients with acute cardiac ischemia. This position paper offers recommendations to assist emergency physicians in EDs, including those with chest pain centers, in providing comprehensive care for patients with acute cardiac ischemia. [Zalenski RJ, Selker HP, Cannon CP, Farin HM, Gibler WB, Goldberg RJ, Lambrew CT, Ornato JP, Rydman RJ, Steele P. National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia. Ann Emerg Med . May 2000;35:462-471.] Author Affiliation: National Heart Attack Alert Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD. Article History: Received 16 September 1999; Accepted 6 October 1999 Article Note: (footnote) [star] See Appendix for affiliations, reviewers, and staff. , [star][star] Address for reprints: Mary M. Hand, MSPH, RN, National Heart Attack Alert Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Building 31, Room 4A16, 31 Center Drive, MSC 2480, Bethesda, MD 20892-2480; 301-594-2726, fax 301-402-1051; E-mail handm@nhlbi.nih.gov .

In the United States, shortages of qualified health-care professionals have created a major threat to the availability and quality of critical care services for seriously ill patients. An unprecedented, and [...]

PURPOSE: To study the accuracy of substituted judgments regarding life-sustaining therapies and other therapies made by surrogate decision makers and to investigate factors associated with more accurate predictions. PATIENTS AND METHODS: A total of 50 pairs of ambulatory patients and surrogates, chosen according to a legal hierarchy, underwent separate interviews in which surrogates were asked to predict the preferences of patients for eight modes of medical therapy in three clinical scenarios, given only yes or no as response options. Patient preferences, their surrogates' predictions, and the extent of agreement between the two were measured. The total number of correct predictions constituted the Surrogate Accuracy in Matching Patient Preferences Scale (SAMPPS). Sociodemographic factors associated with agreement were also assessed. RESULTS: Agreement between patients and surrogates ranged from 57% to 81%. The mean SAMPPS score was 17 of 24 correct. Kappa (k) coefficients, which measure inter-rater concordance, were positive for 23 of 24 items and were 0.3 or greater (P

Medium-chain acyl-coenzyme A dehydrogenase is an enzyme necessary for the breakdown of certain fatty acids, a process which is part of normal body reactions. Medium-chain acyl-coenzyme A dehydrogenase deficiency (MCADD) is inheritable only when both parents have the same gene, and it can result in encephalopathy, brain dysfunction, or in sudden infant death syndrome. A simple test for MCADD would facilitate diagnosis, and is important because relatively simple therapy may prevent illness and death, once MCADD is identified. A test is described in which blood collected in tubes or on filter paper can be processed to determine if accumulation of two fatty acids, indicative of MCADD, has occurred in a patient. In both a three-year-old patient and his newborn brother, the sum of the levels of the two fatty acids greatly exceeded that expected in healthy subjects. Urinary levels of metabolites confirmed the diagnosis of MCADD in the two patients. The results suggest that this simple procedure would facilitate identification of young children with MCADD. The two children in this case, plus a third child born after the initial diagnoses, have grown normally; treatment has consisted of avoiding fasting. More extensive studies would be desirable to show the range of normal values for blood levels of fatty acids within a large population. (Consumer Summary produced by Reliance Medical Information, Inc.)

Advances have been rapid in developing new techniques for removing urinary calculi (stones in the urinary tract); most stones can now be removed in a noninvasive or less invasive manner than open surgery. Many of these approaches use extracorporeal shock wave lithotripsy (ESWL), a method in which shock waves are focused on the stone while the patient is immersed in water. This article reviews results from studies of the effects from ESWL, including those that report adverse effects. ESWL, like open surgery, should only be used for stones that are causing symptoms, blocking or threatening to block the flow of urine, or that are a source of infection. The best results are obtained for stones two centimeters in size or smaller, located in the upper or middle segment of the ureter. Treating both kidneys at once may cause permanent impairment of kidney function; more studies of this issue are needed. Stones will form again in most patients unless the conditions that cause them are treated, and some problems, such as infection, elevated blood calcium or uric acid levels, or poor renal function, should be investigated at the time of ESWL. Patients with recurrent stones should undergo metabolic evaluation. Some kinds of stone (calcium oxalate monohydrate) are more resistant to ESWL than others (calcium oxalate dihydrate, uric acid). Acute complications of the procedure are mainly the result of the passage of stone fragments or of a large piece that will not pass. Although early evidence indicated no negative effects of shock waves, it now appears that cellular destruction can be caused by the high-energy waves. Results from animal studies are described. Acute (pooling of blood or fluid, enlargement of the kidney) and chronic (slightly impaired renal function, pancreatic inflammation) effects have been noted after ESWL, including an increased incidence of hypertension. Mortality for ESWL is approximately the same as that associated with the anesthetic used for the procedure. (Consumer Summary produced by Reliance Medical Information, Inc.)

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jacr.2006.10.010 Byline: C. Daniel Johnson (a), Stephen J. Swensen (a), Lucy W. Glenn (b), David M. Hovsepian (c) Author Affiliation: (a) Department of Radiology, Mayo Clinic, Rochester, Minn. (b) Department of Radiology, Virginia Mason Clinic, Seattle, Wash. (c) Department of Radiology, Washington University Medical Center, St. Louis, Mo.