Radiology

Radiology Resource from UCLA

2010-12-18T21:55:00.001-08:00

http://radiologyfacts.org/

2010-06-26T00:50:00.000-07:00

http://abstracts.webges.com/scot/scot.php?congress=esgar_

TYPICAL INTERVIEW QUESTIONS

2009-10-07T15:20:00.000-07:00

PART 1

1. Tell me about yourself
Keep your answer to one or two minutes; don't ramble.  Do not go back to childhood experiences, just give a brief outline of where you are from and where you want to be going.  Use your job Resume or CV introduction as a base to start.  Respond in a way that leaves no doubt that you are well adjusted, stable and positive.  Say only positive statements.

2. What do you know about our company?
Show that you have done your research, know what their products are, how big the company is, roughly what their annual revenue is, what reputation it has within the industry and on the street. Know the company's history, image, goal, and philosophy.  Project an informed interest and let the interviewer tell you some more detailed aspects about the company.

3. Why do you want to work for us?
Don't talk about what you want; first talk about their needs, what you can do for them.  You wish to be part of their company project.  You would like to solve their company problem and relish the challenge.  You can make a definite contribution to specific company goals: identify its management talent, etc.

4. What would you do for us? What can you do for us that someone else can't?
Relate past experiences that represent success in solving previous employer problems that may be similar to those of the prospective employer. Stay positive.

5. What about our position do you find the most and least attractive?
List three or more attractive factors and only one minor unattractive factor. Aspects to pick up on could include office location, company reputation, the chance to work with esteemed colleagues.

6. Why should we hire you?
Because of the knowledge, experience, abilities and skills you possess. Be very positive and confident in your reply, not vague.

7. What do you look for in a job?
An opportunity to use my skills, to perform and be recognized.  The opportunity to develop further skills, throughout life we should be constantly learning.  Vague answers such as, 'I enjoy working with people, I relish challenges in my work'  Relate it to the job to which you are applying 'I am especially interested in producing a software solution to your problem'.

8. Please give me your definition of a ... (the position for which you are being interviewed).
Keep it brief, actions and results oriented.

9. How long would it take you to make a meaningful contribution to our firm?
Very quickly after a little orientation and a brief period of adjustment on the learning curve.

10. How long would you stay with us?
As long as we both feel I'm contributing, achieving, growing etc.

PART 2

11. What is your management style?
If you've never thought about this, it's high time you did. For example familiarize yourself with 'Management by Coaching and Development (MBCD)' when Managers see themselves primarily as employee trainers. 'Open door' is a good one.

12. Are you a good manager? Give an example. Why do you feel you have top managerial potential?
Keep your answers, achievement and task oriented. Emphasize management skills - planning, organizing, controlling, interpersonal, etc.  Describe relevant personal traits.

13. What did you look for when you hired people in the past?
Skills, initiative, adaptability.

14. Did you ever fire anyone? If so, what where the reasons and how did you handle it?
You have had experience with this and it worked out well.  Describe how you spoke to the person and explained precisely but tactfully where they were under-achieving.

15. What do you see as being the most difficult task in being a manager?
Getting things planned and done on time within the budget.  Do not imply that these are insurmountable difficulties.

16. What is your biggest weakness as a manager?
Be honest and end on a positive note.  Industry trend questions.

17. How would you evaluate your present firm?
An excellent company which afforded me many fine experiences. Quantifying your experience and accomplishments.

18. Why are you leaving your present job?
No longer provides a suitable challenge, time to move on, I wish to move into …(the area this company specializes in)  Give a 'group' answer if possible, e.g. our department was consolidated or eliminated.

19. How do you feel about leaving all your benefits?
You feel the challenge and satisfaction this new role will bring outweigh benefits lost.

20. Describe what you feel to be the perfect working environment.
Where people are treated as fairly as possible.  Don't mention 'naked Fridays'.

PART 3

21. How do you resolve conflict on a project team?
First discuss issues privately and tactfully. If the problem is not resolved then action would need to be taken which could mean removing a member of the team in a severe case.

22. Have you helped increase sales? profits? how?
Imply many occasions, then concentrate on describing one in detail. Quote percentage, profit increases, facts and figures.

23. Have you helped reduce costs? How?
Same as above.

24. How much money did you ever account for?
Be specific and recount a particular contract with facts and figures.

25. How many people did you supervise on your last job?
Be specific - the more the better.

26. Do you like working with figures more than words?
Be honest but positive.  Don't say 'depends on the figures - nudge nudge wink wink…'.

27. In your current or last position, what features did you like the most? Least?
Relate your response to what the new job can offer.

28. In your current or last position, what are or were your five most significant accomplishments?
You could refer to the key accomplishments already identified in your CV or resume.  Your work style and habits.

29. If I spoke with your previous boss, what would he say are your greatest strengths and weaknesses?
Emphasize skills - don't be overly negative about your weaknesses. It's always safe to identify a lack of a skill or experience as a shortcoming rather than a personal characteristic.

30. Can you work under pressures, deadlines, etc.?
Yes. Quite simply, it is a way of life in business.

PART 4

31. In your present position, what problems have you identified that had previously been overlooked?
Keep it brief and be sure to say how you overcame the problems.

32. Don't you feel you might be better off in a different size company? Different type company?
Depends on the job - elaborate slightly.  Reiterate how your previous experience lends itself to the job you are applying for with this company.

33. What was the most difficult decision you ever had to make?
Attempt to relate your response to the prospective employment situation.  Do not mention the time you had to choose between Emmy Lou or her twin sister Scarlet O'Hara. Or whether to wear the blue or red tie to the interview.  Salary questions.

34. How much are you looking for?
Answer with a question, i.e., 'What is the salary range for similar jobs in your company?'  If they don't answer, then give a range of what you understand you are worth in the marketplace.

35. How much do you expect, if we offer this position to you?
Be careful; the market value of the job may be the key answer e.g., 'My understanding is that a job like the one you're describing may be in the range of $/ £….'

36. What kind of salary are you worth?
Have a specific figure in mind - don't be hesitant.  Personality questions.

37. What was the last book you read? Movie you saw? Sporting event you attended?
Talk about books, sports or films to represent balance in you life. Stick to something fairly mainstream or classic.

38. How would you describe your own personality?
Balanced.  Fair, honest, reliable, friendly, outgoing etc.

39. What are your strong points?
Present at least three and relate them to the interviewing company and job opening.  Tailor your answer to meet the needs of the employer. 'I see myself as a goal orientated individual…' discuss how in your previous role you achieved above projected results.

40. What are your weak points?
Don't say you haven't any.  Try not to cite personal characteristics as weaknesses, but be ready to have one if interviewer presses.  Try to transform your response and the question into strength. 'I'm the kind of person who likes challenges and gets involved. Some people may see that as butting in, ' but I'm sure it could be looked at as a strength because I like to make sure the job gets done correctly.'

Seven Deadly Sins of Job Interviews - Top Seven Things NOT to Do on an Interview

2009-10-05T20:50:00.000-07:00

Avoid These Job Interview Blunders If You Want to Get an Offer!

Here are things to avoid, if you want to get a job offer and have ultimate interview success!

Bring a List of Demands:
This sounds obvious, but you’d be surprised how many people try to negotiate more money and better perks during an interview. Hey, you don’t have the job yet! So how can you negotiate an offer you haven’t received? This is a surefire way to negotiate yourself right out of a job offer.

Surprise the Potential Employer:
The interview is not the time to drop a proverbial bomb. Don’t save any major news for the interview. For example, if you can’t start work until next year, or you have a professional or criminal background issue, or if there is anything about you that you have not shared, which would impact the potential employer in a significant way, don’t plan to bring this up at the interview! Sensitive matters should ideally be discussed prior to the interview, for the consideration of everyone involved. If being up-front causes you to be passed over for an interview, move on! Now you’ll have more time to interview with other employers who are willing to work with your situation!

Play Hard to Get:
Even in the high-demand world of clinical healthcare, employers want to hire people who want them! Therefore, you do not need to talk about all your other job offers on the interview. If you act disinterested, this will cause the employer to pass you over, even if you’re the only qualified candidate who is interviewing currently! I have personally witnessed numerous highly qualified candidates get passed over for job offers due to an overactive ego or unwillingness to show genuine interest. Even if this is your second or third choice employer, your situation could change, so interview with each employer as if it’s your only option.

Dress Down:
Interview attire may present a challenge for many healthcare professionals, who often wear scrubs or lab coats to work. However, everyone should have one professional, tailored suit or business attire, if not for interviews, then for other occasions such as conferences or presentations. Wear tailored, professional, modest clothes for an interview. A suit is ideal; however at the very least men should wear a button down and a tie, and ladies should wear a blouse and a skirt or a jacket with pants. If you have tattoos or piercings, cover them.

Show up Late:
This is a big no-no, unless you are trying to convince your potential employer that you are careless and tardy. Plan your day carefully the day of the interview. Do a test drive to your interview site if needed! Allow for traffic, parking issues, bad directions, accidents, etc. Pretend your interview is 30 minutes earlier than it is, and bring a book to read in the event that you arrive early.

Get Sloshed:
Some interviews, such as executive roles or physician interviews, take place over lunch or dinner, and really you should refrain from drinking if at all possible. If the interviewers are ordering a bottle of wine to share or something, limit yourself to one glass if at all possible.

Spew Offensive Language or Inappropriate Jokes:
No one thinks that you are going to be perfect, but if you can't refrain from offending people on an interview, then you will make people wonder what to expect when your guard is down and you are comfortable working there.

Remember - the interview is the time to show yourself at your absolute best! Yes, it is important to be yourself, but be yourself at your best. Employers know that a candidate's behavior during an interview is typically as good as it gets. Therefore, the interviewers are not going to give you the benefit of the doubt if you slip up during this crucial part of the job search process.

Before You Interview for a Medical Job - Job Interview Tips for Medical Job Seekers

2009-10-05T20:49:00.000-07:00

One of the most critical stages of the job search process is the interview. Whether you’re interviewing for an entry level, hourly wage job, a high-paying hospital executive role, or a clinical role such as nursing or physician jobs, below are a few key steps you can take to assure that you’re prepared for your interview.

Thorough preparation prior to your job interview will help ensure your success in getting the offer, or at least getting to the next step of the job interview process. An interview is a sales presentation, and the product is you.

Research the Potential Employer

Do your homework about your potential employer. This can include internet research and word-of-mouth. If you know someone who works there, spend a few minutes discussing their experience and observations of the company, including corporate culture, values, and any recent business developments. If you don’t know someone who works at the company, try to network your way to a direct connection with someone who does.

If you're interviewing for a hospital job, research its financial stability, and potential growth. Also, what is the reputation of the hospital in the general community and the medical community?

Know the Interview Process for the Position You Want

Knowing the interview process is important not only for your success, but also for your peace of mind during the interview process. If you know what to expect, you’ll be able to more easily gauge the potential employer’s interest level in you as a candidate. Ask the recruiter how many interviews are involved, who are the decision makers at each step of the interview, and what is the anticipated time-frame for hiring and on-boarding someone for this role.

If you're aware that the interview process is two interviews, or five, you won’t be alarmed when you don’t receive an offer after the first interview, for example.

Have Solid References Ready

Now that you know what to expect in the interview process, you know when to expect the background check and referencing stage. You should have a minimum of three professional references, including direct supervisors from your current and most recent jobs. (It is acceptable to ask that your current employer not be contacted until you've received an offer.) You should have the name, title, dates and company where you worked for this person, and contact numbers and email address of each person who is on your reference list. Ideally, you should be aware of what these references are going to say about you as well.

Plan Your Route and Know Where You're Going

Confirm the time and location of the interview the day before. Managers can get busy or pulled into last minute meetings, so be sure everyone is on the same page and planning to meet at the originally designated time.

If possible, drive by the interview location to be sure you know how to get there. If this isn’t possible, allow extra drive time on the way to your interview in case you get turned around or miss a turn.

Plan Your Attire

You should be dressed professionally for an interview. This is going to vary based on the type of position for which you’re applying. However, you can never go wrong with a business suit in a conservative color. A few days before your interview, select your attire and be sure it has been cleaned and pressed and you’re ready to shine! This gives you time to make a run to the drycleaners, or to make any repairs (hems, buttons, etc) or purchase missing accessories if needed.

Anticipate Job Interview Questions and Rehearse Your Best Answers

This is one of the most important things you can do prior to your interview. Most interview questions, although worded differently, seek to identify the same basic traits:

What can you contribute to the organization?
How well do you work with others and get along as part of a team?
Why should we hire you over the other candidates?
Why do you want to work here and would you be motivated to stay here?

You need to show (not tell) the interviewer that you can efficiently and effectively do your job. You can illustrate by sharing past accomplishments and achievements: quantifiable, verifiable contributions to the bottom line.

Prepare to Sell Your Strengths and Sell Around Your Weaknesses

Put together a list of specific examples of how you have improved your current and previous employers’ organizations by increasing revenue, decreasing operating costs, or a combination of both. Know your strengths and be able to sell them; know your weaknesses and be able to sell around them. How can you improve on weaker areas? How do your strengths compensate for any weak areas?

Be prepared to succintly describe two or more significant contributions you made to each employer, particularly the action you took that impacted the bottom-line of your employer. You can work these examples into multiple interview answers.

Prepare a List of Intelligent Questions for the Interviewer

The questions you ask in an interview also say a lot about you as a candidate. Therefore, your questions should focus on professional development, long-term goals for the role, and company initiatives. This is not the time to pick apart the work schedule, compensation plan, or vacation allowance. Ask questions that show the interviewer that you've researched the company. For example: "I saw on your website that (insert factoid here)...How do you think that will impact long-term growth?"

Okay, you're ready to go get that job offer! Print a few extra copies of your CV, (or resume') grab your notebook, portfolio, and go!

Corporatisation of Diagnostic Services

2009-09-20T02:42:00.001-07:00

Part I General Review

Introduction

During the 20^th century imaging, diagnostic laboratory tests, and pharmacology moved to centre stage in medicine. Few episodes of medical care occur which do not involve one of these. Experts in these fields may not make the clinical decisions but their input can be crucial to these decisions. These services gravitate to hospitals, and to the centres where doctors work.

Jun 2001 Reliance on diagnostic testing

Modern medicine increasingly depends on sophisticated testing, involving wider use of clever but expensive diagnostic equipment, to provide safer and better ways of assessing and preventing disease. In Australia, radiology is the largest category of Medicare expenditure after general practice, closely followed by pathology. Of the total Medicare expenditure of $6.9 billion last financial year, radiology accounted for $1.1 billion and pathology was $1 billion. Total Medicare money paid to general practitioners in 1999-2000 was $2.4 billion.
The Uncanny X-ray Men Business Review Weekly June 22, 2001

Radiology and pathology both require very costly equipment and, because of the rapid changes in the technology they employ, frequent upgrades are needed. To cover costs larger fees and a high turnover are required. Because of this the businesses are very profitable once the breakeven point is passed.

Mar 2005 Huge overheads

Given the huge overheads in running a laboratory (a new lab can cost $20 million to set up) and the cost of keeping pace with regulations, Dixon says many smaller players are happy to sell up and move on. "It's almost impossible for the smaller players to keep up with the corporates as you get huge economies of scale by acquiring a number of big labs," he says. He points out it's a win-win both ways.
RICH PICKINGS THE PEOPLE WHO GET RICH AS YOU GROW OLD Australian Financial Review March 19, 2005

Sep 2005 Costs of equipment

SKG (Subsidiary of Sonic Healthcare) is buying three 64-slice computerised tomography (CT) scanners, with each unit costing about $1.3 million.

This followed the installation last month of a state-of-the-art magnetic resonance imaging scanner at Hollywood, at a cost of about $2.5 million.

In addition, the company has a positron emission tomography scanner at the Subiaco hospital, installed at a cost of more than $3.5 million.
SKG spends on scanners WA Business News September 22, 2005

Both pathology and radiology have consequently become key areas for consolidation and rationalisation to ensure the most efficient use of the equipment. In our world this means that the mechanism used is corporatisation. Corporations can painlessly raise capital and there are opportunities to generate large profits for shareholders. Privately run professional services are unable to compete. They are offered large payments for their practices. Only a few privately owned and run services remain.

Mar 1989 Pathology corporatisation starts

Since that report (Government Review in 1985), the trend towards large groups grabbing the major proportion of business has continued, reflecting the need for pathology laboratories to achieve high-volume throughput.
The trend has been assisted by the widespread rationalisation in the industry, seen recently with Regional Pathology in Victoria going into receivership and its later purchase by the second largest pathology group in South Australia, Gribble.
NEW STARTER IN PATHOLOGY STAKES Australian Financial Review March 20, 1989

Jun 2001 Rapid corporatisation

With the radiology market worth $2billion and the pathology market not far behind, these have been particularly attractive to companies and have been quickly corporatised.
Firms fight for $2.7bn in doctors' fees The Weekend Australian June 16, 2001

Sep 2005 Some did much better than others

Health is a booming segment of the economy and Sonic Healthcare has positioned itself perfectly to reap the benefits of this momentum.
Overseas venture fuels Sonic boom Australian Financial Review September 7, 2005

I have always been privileged to have radiologists and pathologists I knew well "across the passage" so that I could walk over with their reports to discuss X-rays or histological findings. Diagnoses have been revised as a result. Some corporate groups have had the insight to preserve some of this professional collegiality and it has been profitable for them. Others have sought to bind their services to the doctors who use them in other ways.

One of the consequences of corporatisation, mechanisation, centralisation and an emphasis on efficiency is that the laboratory and imaging experts are removed from the clinical setting and from close contact with their clinical colleagues. Decisions are increasingly made on the basis of reports rather than consultation. While tele-radiology greatly improves the service to peripheral practitioners it can impact on collegiality.

Aug 2000 The promise of tele-radiology

Many of these benefits will be achieved through tele-radiology - the digitisation of images which can then be transferred to off-site specialists. Southernex is a market leader in the use of tele-radiology.
Development Capital Of Australia Limited (DVC.AX) DCA Expands with Healthcare Acquisition. Australian Stock Exchange Company Announcements August 9, 2000

Aug 2005 Collegiality - a US company which survived against corporate might for years

"It was just the fact that physicians know physicians doing the interpretation," Jupe said. "They talk. It's more of a close, collegial practice of medicine."
From a small medical practice a big lab grew and grew; Newly sold Clinical Pathology Labs' next test: Stay successful, independent Austin American-Statesman August 30, 2005

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Pathology generates better results from corporatisation than radiology because the expensive facilities can be centralised and the machines automated. Multiple collection centres in medical complexes and hospitals around the country can funnel specimens through these high turnover centres. The number of employees can be reduced and the costly highly trained pathologists anchored and used for maximum benefit.

It is still necessary to carry out some urgent tests on site so this centralisation must be balanced. Some facilities are required in hospitals.

Sonic Healthcare adopted this strategy very successfully setting up only a few major centres around Australia. Gribbles group had multiple scattered laboratories which did not carry out a full range of tests so benefited less. Reports indicate that they became a second tier provider and eventually came unstuck.

Jan 2002 Centralising laboratories

Automation, however, lends itself well to pathology. Effectively the unitary processing fee is the same whether a sample is examined manually as if it is one of a batch of 100 processed automatically. As a result, the Commonwealth Government and the Association of Pathology have set price and volume quotas to regulate the industry. Because volume growth per practice is limited to 5 per cent per annum, acquisition, automation and networking are the main earnings multipliers.
Pathology also lends itself well to a satellitic operating structure where a centralised lab supports numerous sample collecting outlets over a broad geographic region. What's more, the increased emphasis on cervical cancer and diabetes in the May Federal Budget should increase overall levels of pathological testing.
Predators And Prey : Gribbles in a healthy position Shares Magazine January 1, 2002

Mar 2004 Sonic's success

Diagnostic testing company Sonic has consistently delivered better margins than market rivals such as Gribbles Group , Mayne Group and MIA Group .
Consistent Performers Humming Along Australian Financial Review March 17, 2004

Aug 2000 Looking at the market's potential

What has brought about corporatisation of the pathology industry? Diagnostic testing generally has enormous potential for growth as the population ages and new technology enables more sophisticated tests, which doctors say will help in the diagnosis and treatment of illness. Increasing litigation means that doctors are likely to request more tests to protect themselves against allegations of inadequate care. With the genetics field opening up, pathologists have an increasing range of DNA and other genetically based tests, which will add new dimensions to the business.
Sonic's Boom Comes At A Cost, Business Review Weekly August 18, 2000

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Radiology in contrast is people intensive. Trained staff must operate the machines and they need oversight by radiologists. The images need skilled interpretation and the reports are not generated automatically. To get the referrals the machines must be taken to the referring doctors and their patients. The most expensive and less routinely used are usually centralised. As a consequence machines and staff are located in multiple hospitals and medical centres. As a consequence the corporatisation of radiology lagged behind that of pathology.

Dec 2000 Radiology lags behind

The trend towards listed players buying up smaller practices is mirrored in the pathology sector. Radiology is not as yet as such an advanced stage of rationalisation.
MARGIN CALL : Radiology raid ONE to watch The Australian December 1, 2000

May 2001 The companies buying radiology

Listed companies that are actively buying radiology and pathology practices include Mayne (formerly Mayne Nickless), Sonic Healthcare and Medical Care Services. The investment group DCA owns I-Med group, which on May 1 bought a radiology practice with three clinics in Queensland, adding to three other deals with radiology groups in March. Sonic announced a merger with a Queensland radiology group in March.
Taft Joins A Bigger Picture Business Review Weekly May 11, 2001

Jun 2001 Radiology compared with pathology

Macintosh (from MIA) admits that consolidating radiology practices does not reduce costs as much as in the pathology sector. Pathology labs can be automated, but radiology is a hands-on business that requires individual doctors to conduct and analyse the tests.

However, he says consolidation brings other benefits. In a business that relies on expensive technology with defined life expectancies, good management of capital expenditure and efficient use of equipment are vital. In the December half-year, MIA's capital expenditure was $7.5 million (nearly 8% of sales) and depreciation was $6 million. Macintosh says that the centralising of administration, IT and equipment purchases brings efficiencies to the group. It has recently bought software to centralise patient booking.
The Uncanny X-ray Men Business Review Weekly June 22, 2001

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Referral patterns. Fees in both radiology and pathology are set by government and overall standards are generally good. Referral of work is consequently mainly geographic to the nearest or most convenient centre - ie in the same centre or hospital. It is simply not practical to have more than one spacious radiology or pathology unit in a hospital or clinic although this can happen with pathology collection centres.

While there is much talk of competition this is primarily related to securing advantageous geographic locations, size and leverage, as well as maintaining the sort of relationships with doctors which keeps their business, and controversially might encourage increased usage. Kickbacks have been a particular problem in pathology. Person to person referrals have become less common. Companies have varied in their success in securing GP referrals to their laboratories. Primary Healthcare has been particularly successful.

Jul 2004 Primary Health's successful model

The Model
The PRY model is similar to a shopping centre business model. PRY provides a centralised medical centre for GP's to operate in. The GP's like retail tenants are charged a fee of 45 to 50% of gross revenue for operating in the facility. Other services are charged at a fixed rental fee. The leverage for PRY is to increase attendances and generate repeat visits. GP's cannot be financially induced to refer patients to internal partner service providers.
The pairing of GP facilities with related services such as pathology and radiology in the same building fosters such relationships. The convenience of in house services and connectivity of computer systems insures the majority of referral business is in house. The medical centres are run 24 hours a day, every day, offering bulk billing facilities with a policy of not giving medical test results over the phone. A patient who receives a blood test requires two visits to the GP, the first to get a referral for a blood test and the second to receive the results effectively increasing the level of billable attendances. The strategy is to lease buildings then spend $3 to $5m in converting to a medical centre which once fully operational aim to be cash flow positive within 6 to 12 months.
PRIMARY HEALTHCARE (PRY) $5.70 Smaller Companies Guide July 7, 2004

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Integrating with Referring Doctors
Avoiding Competition

There are clearly many benefits for the patient and for the health system from integrating multiple health services. The problem with integration by corporate for profit companies is that it is integration for the benefit of the shareholder rather than the patient and the system. The two interests are often very different.

The object of integrating pathology and radiology with referring doctors is to obtain their custom. If we are to adopt the sort of market principles advocated by the coalition government in 1996 or the model advocated by Graeme Samuel in 2000 then the diagnostic companies should be competing for referrals from GPs on a level and strictly regulated playing field based on the quality of service and its cost. Integrating these generaol practice services with them is essentially anti-competitive. The claimed benefits of competition will not be recognised.

It is not that the integration model is bad but that the self interested competitive framework within which integration is placed is inappropriate and dysfunctional for the health system - something which by its very nature is cooperative and humanitarian.

Integration is a profitable way of playing pass the parcel and so squeezing and stripping off as much profit from each patient parcel as possible. Work can be directed to team players - ie. those who follow practices which are profitable for the company.

These are not always the best clinicians. They can be problem doctors and even incompetent. The company typically promotes them to the public and protects them from their critics. Profitability rather than clinical competence becomes the basis for status and credibility. Spectacular examples like the unnecessary hospitalisation of large numbers of normal children and bypass surgery on normal hearts are likely to be symptomatic of a broader problem across the corporate health care sector.

Mar 2002 Opportunities to pass the parcel

Market players Mayne and Primary both follow a more vertically integrated model, where revenue is earned at each stage of a patient's treatment.
"Primary's model is a bit more vertically integrated. They do their own pathology, radiology and earn revenue through the whole process," Mr Suleski said.
Foundation rebuilds WA Business News March 21, 2002

Integration for profitability provides endless opportunities for coercing or tempting doctors to play the game - and put the interests of the company ahead of those of their patients. A policy of integration has been a key part of the success of many US health care corporations. Allegations of business arrangements which when they were uncovered were considered to be kickbacks to doctors have formed a significant component of almost all US fraud settlements.

Corporate for profit integration has consequently not worked well or consistently for patients or the health system - nor surprisingly financially for many companies in Australia. Those who have concentrated on one or two core businesses have done better. Integration for the benefits of patients and the health system is almost impossible within a corporate context as the paradigms within which the two patterns of integration operate are contradictory.

In the 1980’s and 1990s kickbacks of borderline legality to referring doctors were a major problem in pathology in Australia. Sustained regulatory pressure and a lack of support by the majority of the pathology profession resulted in most of those responsible going out of business. Instead pathology and general practice groups have adopted a policy of owning the doctors. They have integrated the services to which doctors refer their patients and which the company owns into the doctors work environment.

General practitioners act as gatekeepers and control the referral to all other services. Once they are located in corporate owned centres strategies can be developed to induce them to use those services exclusively and maximally.

Sep 2000 Reason's for GP corporatisation

If general practitioners are not great profit makers in their own right, their purchasing power is considerable. Under the current Federal Government model, general practitioners are the gatekeepers of the medical system and directly control the buying of specialist services.

"The required returns for the investor must therefore come from the centre tenants, from negotiated arrangements with other service suppliers and/or cross-subsidies from other businesses (for example, pathology and radiology) owned partially or wholly by the investor," KPMG said.
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If a medical centre has, for example, 10 full-time general practitioners, each generating $200,000 of Medicare income a year, they are also generating on average $3.2 million a year in downstream specialist billings. If a substantial part of that is picked up by businesses or specialists who work in the same corporate group, it is a good income stream.
Corporate Medicine Business Review Weekly September 29, 2000

Oct 2001 More about reasons and Foundation Health care

The main reason general practices have been bought by companies such as Foundation is their powerful role in the health system. General practitioners are the gatekeepers who control the purchasing of lucrative downstream health services, including pathology, radiology and other specialist treatments. According to a report by the accounting and consulting group KPMG last year, for every $1 in Medicare revenue paid into a general practice, the practitioner is writing out $1.60 in referrals. If Foundation earns $80 million a year in Medicare revenue, in theory, it is recording about $128 million in specialist medical services. The founder and biggest shareholder of Foundation is Michael Boyd, who is also the biggest shareholder in the pathology and radiology company Sonic Healthcare. Sonic owns 10% of Foundation.
Health's Changing Landscape Business Review Weekly October 25, 2001

One strand has been the ownership of general practices by Diagnostic groups. Another has been the ownership of laboratories, diagnostic services, as well as other ancillary services by general practice companies. In each instance the objective has been to secure the allegiance and the referrals from the general practitioners as well as profit from those referrals. General practice is person and time expensive and is seldom profitable itself.

While paying doctors kickbacks for referrals is illegal, geographic positioning is legal and is very effective in securing referrals. All of the integrated groups have built medical centres in which the general practitioners practice and which specialists visit to consult. In the same building are housed the company's radiology, pathology, physiotherapy and multiple other services which the patients or their doctors might be induced to utilise. If they do not own a service they can profitably let space to pharmacies and other groups with which they are associated and who benefit from the location.

Pathology and radiology group Sonic Healthcare was ethically opposed to owning General Practices and so competing with other general practices which referred to them. They were faced with a dilemma. If they failed to buy up General Practices then competitors would buy the doctors on whose referrals they depended and they would lose business.

Sonic resolved this problem when their major shareholder and founder, Michael Boyd, set up a separate company Foundation Healthcare in which Sonic had only a 10% holding. They made an arrangement which gave Sonic exclusive rights in Foundation’s medical centres. This was essentially deceptive as the profits from the referrals went to profitable Sonic while Foundation itself struggled. Sonic was forced to prop up the company and then buy it when a competitor launched a takeover bid. Foundation was profitable for Sonic but not to its other share holders.

There is a long tradition of owning and running general practices as a corporate business. This goes back to controversial medical entrepreneurs, Edelsten and McGoldrick in the 1980s, and to Primary Healthcare in the 1980s and 1990s. It was only in 2000 that the market enthusiasm for wringing profits from general practice and its referrals exploded. By the end of 2002 the bubble had burst. The press extracts give the flavour of what happened.

May 2000 Edelsten's views

One person who clearly understands corporatisation is medical entrepreneur Dr Geoffrey Edelsten, who reportedly told BRW last year: "The success of Ed Bateman's Primary Health Care has demonstrated the enormous economies of scale that can be reaped by merging solo practices ... If you can then vertically integrate it with pathology and radiology and visiting specialists, and have day-care and in-patient care hospital facilities, then the profitability is extraordinary.''
Big Business Targets GPs In National Buying Spree Australian Financial Review May 23, 2000

May 2000 Vertical integration

Under the vertically integrated structures rapidly being set up by companies across Australia, GPs and the services they refer to, such as pathology or radiology, are being aggregated under the one corporate roof. An obvious concern is that there may be pressure to refer patients to in-house services, potentially impinging on doctors' autonomy and perhaps draining money from Medicare.
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If Sonic stays exclusively in pathology, increasing numbers of the doctors who refer to it will be bought out by other corporates, such as Ed Bateman's Primary Health Care, buying up both medical centres and pathology companies. In an interview with the AFR, Goldschmidt (Sonic’s CEO) was extremely candid about his company's dilemma.
Owning The Whole Kit And Caboodle Australian Financial Review May 24, 2000

Aug 2000 Response when Foundation's claim to independence was challenged

"We are talking about fully integrated medical centres so they will have supporting them pharmacy, radiology, pathology and physiotherapy.''

Jones says that Foundation has "developed an alliance'' with Sonic to provide pathology services to patients at the centres.

"We don't have a commercial interest in Sonic and we don't achieve a commercial reward by our patients' use of Sonic,'' he says.

But questioned about Sonic's 10 per cent ownership of Foundation, Jones said: ``[Foundation] as a general practice provider don't have an investment in Sonic, so we receive nothing back from pathology providers.''

Asked if Boyd was a major investor in both Sonic and Foundation, he said: "He is, yes. He is a passive investor in Sonic.''
GPs Inc - Profits Or Patients Sydney Morning Herald August 10, 2000

Aug 2000 The consequence of geography and owning shares

Pathology companies compete on service, not price, and increasing the share of business you do is based on providing a quality service."

Making this more difficult is the recent trend to integration in the health sector. General practitioners order 70% of all pathology paid for by Medicare. But in the past 12-18 months, entrepreneurial health groups have been buying general practices, bringing the doctors into a corporate structure that includes a pathology business. Although the general practitioners can, in principle, send their pathology tests wherever they like, in practice they will mostly use the pathologist that is linked with their company.
Sonic's Boom Comes At A Cost, Business Review Weekly August 18, 2000

Oct 2000 A dramatic development

By far the most dramatic development is the recent growth of medical empires that have brought in general practitioners, pathology, radiology and other specialty services under the one corporate umbrella.
The Painful Opt-out Option Australian Financial Review October 11, 2000

2001 Another reason for corporatising

Another force is the race for scale economies. With continuing cuts in federal government rebates on pathology and imaging, some health care companies are seeking to lock in revenues for their pathology and imaging laboratories by owning a group of in-house referring doctors.
Health Risks For Packer And Smedley Australian Financial Review March 10, 2001

Apr 2001 General Practice corps hungry to buy diagnostic services

Nor are they making any secret of their hunger to acquire lucrative diagnostic businesses; the pathology labs, X-ray and imaging centres that rake in another $2.5billion a year, mostly through referrals from local doctors.
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Endeavour has investments in general practice, pathology, X-ray, occupational health and medicine in NSW, Victoria, SA and WA.
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Medical Care Services: Perth-based public company providing a back-door listing for Gribbles Pathology Group. MCS subsidiary Total Care Services has 15 general practice medical centres in Perth and its own radiology assets.
Medical Corporates Sing A Siren Song To Harassed Doctors The Age April 7, 2001

Jun 2001 The recipe for success

Primary Healthcare has been doing this for about 15 years and has become a sharemarket favourite because of its success in getting GPs and their patients under its banner and then selling them a huge range of services - everything from psychiatry and dermatology to dentists and plastic surgeons. It's the ultimate one-stop-shop model.
Firms fight for $2.7bn in doctors' fees The Weekend Australian June 16, 2001

Jun 2001 Some see this as managed care

With 75 per cent of the pathology industry and 40 per cent of the radiology sector in corporate hands -- not to mention 15 per cent of GPs nationwide now working within corporate structures -- some say it's only a matter of joining the dots to see managed care working here.
Script for a profit; The Weekend Australian June 23, 2001,

Nov 2001 Corporate response to criticisms

Michael Boyd dismissed Deeble's (architect of Australia's Medicare system) concerns about the pathology industry, saying the world was a vastly different place from when Medibank was set up in the 1970s. "Nowadays, people want convenience ... and the one-stop shop for medicine and health services,'' he says.
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In Boyd's case, pathology giant Sonic has formed a strategic alliance with another Boyd company called Foundation, which has almost 1,000 GPs under its corporate roof and is currently putting together medical centres across Australia.
The Rise And Rise Of Medicare Millionaires Australian Financial Review November 20, 2001

As in the USA the enthusiasm for general practice corporatisation soon came unstuck. Only Primary Healthcare was profitable for its shareholders and it went from strength to strength. The reasons for this are not clear to me. All of the others stopped buying general practices in 2002 and were soon running at a loss or just breaking even. After a period of consolidation they were either closed, sold to Primary or Foundation, or kept by a pathology company for their referrals. Sonic later purchased Foundation.

Pathology and Radiology remain very profitable.

Mar 2004 Unable to sell GP businesses

Gribbles had been searching for a buyer for the loss-making division (General Practice) for months and the sale capped its attempt to create a vertically integrated health company.
Primary A Picture Of Good Health Australian Financial Review March 5, 2004

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Over-servicing

With so much pressure directed towards profitability it seems likely that there would be over-servicing. Concerns about this go back many years and have increased since corporatisation. Kickbacks are sometimes blamed. Gribbles and Macquarie Health are the two most often accused but they have denied this and have never been convicted. This is very difficult to quantify because of the complexity of the tests and the many and varied reasons for performing them. There are other pressures such as fear of litigation. While there has been and still is anxiety about this, little hard evidence is available.

There are currently increasing concerns that the corporatisation of GP's is increasing overservicing.

Jul 1994 Kickbacks and overservicing

But one pathologist last week estimated that up to two thirds of high ordering was "induced'' - by a range of bribes and kickbacks to doctors. He said HIC figures showed that about 14 doctors a week "are being seduced, or encouraged or are naturally falling into becoming high ordering'' - that is, ordering more than $10,000 of tests per quarter.
Many of these doctors tended to cluster around certain pathology laboratories, he said. One practice allegedly got 87 per cent of its work from high-ordering GPs.
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HIC figures, based on audits of all Australian GPs and laboratories, show that in some cases, when doctors switched to an unethical pathology lab, their test bills rose to three or five times their previous levels.
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In October 1991, the HIC began its "feedback strategy'', sending letters to every GP in Australia, outlining the level of their pathology ordering. The strategy - with follow-up letters every three months - had an immediate effect of slashing referrals by high ordering GPs - from $61.5million in the second quarter of 1991 to $42million in the second quarter of last year.
Bleeding The System Sunday Age July 31, 1994

Nov 2004 There is increasing utilisation for many reasons

With payments for pathology and radiology up sharply, the big beneficiaries of this increased spending are the listed pathology and radiology companies, including Mayne, Sonic Healthcare, DCA Group and Gribbles Group, which is now the subject of a take-over bid by Healthscope.
Medicare cuts an artery Business Review Weekly November 11, 2004

Jan 2006 Signs that GP corporatisation results in overservicing - hardly surprising

THE Medicare watchdog, Tony Webber, is concerned that big medical centres have the potential to exploit Medicare's $9 billion a year in benefit payouts.

Evidence is emerging that doctors working for corporatised medical chains have geared their software and patient management systems to maximise returns from Medicare. There is evidence that some of their services, including pathology and radiology, are "inappropriate", he says.
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Dr Webber said it appeared that medical centres were automatically initiating regular "health assessments" for patients over the age of 75, whether or not they were needed. The Medicare benefit for this service is $232.
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"My concern is that where corporate medicine is having a strong influence on doctors, it raises suspicions that there is a lot of [Medicare] money potentially being wasted," he said. "Medicare benefits are not designed to give a doctor a reasonable income and give corporates a 20 per cent return on investment without compromise to standards of care.
Watchdog sees signs of overservicing Sydney Morning Herald January 12, 2006

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Medicare Payment and Medicare Millionaires

The vast bulk of the funding for doctors' consultations, imaging and laboratory testing comes from Medicare. This is a steady gravy train for the corporations, but there is always the danger that government may exercise its power to reduce fees. If companies are too greedy it will do so. Government’s ability to do so effectively is limited. Its weakness is that it has no choice but to fund these services. It can reduce funding for a while but is soon put under pressure. The voting public will be vocal if services are compromised and corporations are adept at exploiting this pressure point.

Entrepreneurs looking for opportunity have not been slow to recognise the potential of this system of funding and there are now a number of Medicare Millionaires. With wealth has come credibility and influence. The percentage of funding from Medicare has increased steadily over the last 20 years. It was estimated in 2001 that up to 90% of funding for GP, pathology and radiology services came from the taxpayer.

Oct 2001 Medicare income

Listed medical companies receive a big part of their income from Medicare benefits. An estimated 75% of the $1.2 billion the Government paid in Medicare pathology benefits last year, and an estimated 60% of the $1.2 billion for radiology work, went to corporatised medical practices. In addition, about 10% of the $2.3 billion in Medicare benefits paid to general practitioners went to companies that were listed or were planning to be listed. Overall, at least 25% of the $7.5 billion-plus that will be paid in Medicare benefits this year will go to listed companies.
Health's Changing Landscape Business Review Weekly October 25, 2001

A new breed of medical entrepreneur is quietly becoming extremely influential and wealthy, with three Australian health-care businessmen now worth more than $100 million each.
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Shy Perth accountant Michael Boyd now boasts more than $200 million through holdings in the giant Sonic Healthcare, which like all pathology companies has its revenue underwritten by growing Medicare referrals from local GPs.

Similarly, Melbourne barrister Wallace Cameron controls a $150 million stake in Gribbles Group, another highly profitable national pathology company.

In Sydney, the family interests of Dr Edmund Bateman amount to more than $110 million through his share of the medical centre and pathology business Primary Health Care.

With all three, personal fortune has come through a major holding in a listed health-care company that relies on Medicare for the bulk of its revenue.
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A recent report from brokers Burdett Buckeridge Young entitled "Making a Living From Medicare'' suggests the $55 billion Australian health-care system provides "revenue certainty'' and "comfort for investors''. It says that up to 90 per cent of pathology and general practice revenue flows from taxpayer dollars.

Medicare architect Professor John Deeble says that when universal health insurance was set up in Australia in the 1970s, large medical corporations did not exist. "When Medibank was introduced, pathology was still a medical practice ... now it's nothing like that. The regulation of this sector must change. Medical corporates must be treated as businesses, not as medical practices.''

- - - - - - - - - Deeble is concerned that despite the recently introduced caps, now extended to radiology as well, the costs of diagnostic services are out of control. In his view, "owning a pathology business has been a licence to print money''.
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As with pathology and radiology, most general practice revenue comes straight from the public purse. From its inception, Medicare has strongly subsidised the private income of individual doctors. But since the late 1990s, it has been increasingly subsidising shareholder returns as well.
The Rise And Rise Of Medicare Millionaires Australian Financial Review November 20, 2001

Apr 2004 Medicare pays for corporate pathology

In the case of pathology - the most highly corporatised of all the health sectors - only a few independent laboratories remain, and almost four out of every five dollars paid by Medicare for private pathology services goes to one of three public companies.
Grey Expectations Business Review Weekly April 1, 2004

One of the characteristics of health care entrepreneurs has been their supreme self confidence and their faith in the market solutions they espouse. They usually shield themselves from challenge by avoiding publicity and interviews. At the same time they have tended to drive their busineses wth a ruthless single mindedness. They can be very aggressive towards their critics threatening litigation. They have aggressively challenged regulators in the courts. Australian entrepreneurs are no different to their US counterparts and are variously described as publicity shire, private etc.

Nov 2001 Aggressive legal challenges

While personally shunning publicity, Bateman and Cameron have both been aggressive in their dealings with the health authorities. Both have been involved in extended legal tussles with government medical bodies often in cases initiated by the entrepreneurs themselves.
The Rise And Rise Of Medicare Millionaires Australian Financial Review November 20, 2001

The Australian Medical Association was concerned about corporatisation, particularly of General Practice. They were vigorously attacked and criticised when they resisted political and corporate pressures. When they criticised corporate practices libel actions were commenced. As a subscription based professional organizations they simply did not have the resources to take on the industry.

The AMA attempted to negotiate and to set up a code of practice to limit the consequences of corporatisation. This was voluntary and it is worth noting that those GP corporations that signed it have not been profitable.

Aug 2000 AMA comment

"What we are worried about is ... where you have a structure with GPs feeding onto the more lucrative tertiary and secondary services, the diagnostic services like pathology and radiology ...

"I can't name the areas because we have already been successfully sued ... for criticising some of them.''
GPs Inc - Profits Or Patients Sydney Morning Herald August 10, 2000

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Government and Corporatisation

Government Drives the Process

The process of consolidation had commenced some time before corporatisation. Because of the overheads, the need for staff, and the increasing specialisation pathology and radiology specialists had formed quite large partnerships to provide services - sometimes over a large area.

A number of medical and other entrepreneurs saw the potential for large profits from Medicare through corporate consolidation . They could raise the capital to buy practices and new equipment from the share market. Pathology was the first target and radiology followed a few years later.

As in the USA the relationship with government is ambivalent. On the one hand the steady funding and potential profitability engaged corporate enthusiasts. On the other the dependence on evanescent elected governments with unpredictable policies, and the regulatory strictures imposed to contain abuses, both caused periodic misgivings and concern.

The labour government in power during the late 1980s and early 1990s was not averse to market consolidation which promised to reduce costs. The coalition government elected in 1996 was ideologically disposed to corporatisation and went out of its way to encourage this. The system was fragmented and inefficient, needing change. Methods of accomplishing this were never fully debated n public. A corporatised market system was introduced and government applied pressure to accomplish this.

Fees for services were drastically reduced after a government review in 1985 and a cap was placed on increasing fees. Increased profitability could only come from mechanisation and the consolidation of services into large units which were maximally used. Government in effect wielded a heavy stick to drive the process of corporatisation.

The situation and the many points of view are reflected in press reports over the years.

Mar 1989 Impact of price cuts

Meanwhile, the industry claims it is still reeling from the 25 per cent cut in schedule fees and benefits for pathology in 1986.
NEW STARTER IN PATHOLOGY STAKES Australian Financial Review March 20, 1989

Aug 2000 Nevertheless a good income stream

Pathology businesses are also in the enviable position of having their main source of income underwritten by Medicare. Although the Federal Government has for some years put a cap on its pathology expenditure, it still allows for a 5% annual increase in its total pathology outlays.
Sonic's Boom Comes At A Cost, Business Review Weekly August 18, 2000

Dec 2000 Driving the process

It is a natural force behind consolidation at the end of the day the Government wants a more efficient and professional provision of health services. To that end the revenue cap has been successful,'' Mr O'Connell says.
Sonic Cuts A Swathe In Rationalisation Race Australian Financial Review December 2, 2000

Mar 2001 The driving force negative view

About 85 per cent to 90 per cent of the pathology and imaging sector revenues come directly from the Federal Health Insurance Commission. Alarmed at exploding diagnostic expenses in the early 1990s, in 1995 the Government began imposing rolling three-year revenue caps (averaging 5 per cent annually). In practice that means that, as demand for services rises much faster than the revenue cap, the Government cuts the price paid for each service every 6-12 months.
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Those price cuts really bite. Pathology and imaging businesses have high fixed costs and efficiency gains are difficult to achieve.
Health Risks For Packer And Smedley Australian Financial Review March 10, 2001

Jun 2001 Others see it as benefical for companies

Radiology, like pathology, is a key beneficiary of changing patterns in health-care expenditure.
The Uncanny X-ray Men Business Review Weekly June 22, 2001

Jul 2001 All about consolidation

Growth in diagnostics pathology and radiology has all been about industry consolidation. The market itself is dependent on only small annual rises in government medical funding supplemented greatly by the cost savings and margin expansion potential in corporatising the profession by building large medical empires.
XCHANGE : Sonic boon Sydney Morning Herald July 7, 2001

Sep 2002 The positive and negative views

There are two views on the attractiveness of the private health industry in Australia, which encompasses pharmacy distribution, pathology, radiology, private hospitals, and, of course, health insurance.

The negative argument and the one in the ascendant at the moment is that it is a horrible industry where pricing is dictated by politics.
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Of course, the positive argument is that the health industry is a great one for investors because it offers rates of growth in excess of GDP, partly because of the ageing population. But that's not true when the cost of blockbuster drugs and medical technology rises faster than the allowable profits.
Health Care An Ill Mix Of Politics And Business Australian Financial Review September 13, 2002

Apr 2003 The importance of government negotiations

Providers (of radiology) see the outcome (of negotiations with government) as crucial as they collectively recoup about $800 million a year from diagnostic imaging from the commonwealth, including X-rays, CT scans and ultrasounds. An unfavourable outcome when the current agreement expires on June 30 could lead to tens of millions of dollars in lost revenue and drastically alter earnings forecasts.
Radiology industry expecting a boost. Australian Financial Review April 4, 2003

Aug 2003 The power of government

The deal, which must be finalised before next year's budget, will provide about two-thirds of the sector's revenue, partly determining its profitability for the rest of the decade.
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To maintain this high bulk-billing rate, the Australian Association of Pathology Practices says commonwealth spending on the sector should rise by about 6 per cent a year, to a total of about $8.2 billion over five years.

The present five-year deal, which expires next July, is costing the government $6.2 billion, or about 15 per cent of total Medicare expenditure.

Under these funding deals, the commonwealth's pathology spending is capped regardless of how many tests are undertaken. To stay under this cap, the industry has been forced to merge, become more efficient and lower its fees.

However, AAPP chief executive David Kindon said a large rise in the number of tests being undertaken meant the industry was now doing a lot more work for no more gain.

He said this increase was being driven by medical advances and the indemnity crisis, which had prompted doctors to encourage patients to get more tests.

Dr Goldschmidt said: "There's been a huge volume explosion in pathology that we've had to absorb.

"The way we've done that is by consolidating the whole industry and Sonic has been a key part of that."
Bulk - Billed Pathology At Risk Australian Financial Review August 25, 2003

Mar 2005 Still a profitable outcome

O'Connell (Macquarie Bank analyst) says: "The revenue caps have been a key factor in forcing the consolidation. To maintain growth rates while limited to 5% increases in government rebates, the pathology and radiology providers have had to become more efficient. Pathology especially is suited to consolidation because it is a volume business, where big centralised labs offer operating benefits.

That's even with government-imposed "speed" limits. The federal government, which pays for the bulk of pathology tests, has capped annual growth at 5 per cent for the foreseeable future. Dixon (MD of Healthscope) says: "There's not too many investments where you get a guaranteed 5 per cent growth per annum." For some other diagnostic services underlying growth is even higher.
RICH PICKINGS THE PEOPLE WHO GET RICH AS YOU GROW OLD Australian Financial Review March 19, 2005

Oct 2005 Another point of view

The government is crucial in creating a positive environment. The regulation of the diagnostic industry to cap annual revenue growth 5% for a five year term adds stability. Participants generate superior returns by consolidating inefficient operators and delivering service at the lowest cost. The sector delivered more for less and the UK government will follow by opening up its giant bureaucratic National Health Service to private enterprise.
SPECIAL REPORT : HEALTH CARE A TONIC FOR AN UNHEALTHY MARKET. Your Money Weekly October 27, 2005

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Government Looks the Other Way

There has been a striking reluctance to regulate the industry and to prosecute and make examples of offenders. Part of this may be because government has so strongly supported corporatisation in the face of criticism from sections of the health professions and the public. The exposure of fraud or disservice to patients would be very embarrassing for market advocates especally for government politicians. There has been no attempt to update regulations to give them the teeth needed to deal with the emerging problems.

Without prosecutions no one dare publicly expose fraud or speak out without being sued for defamation. It is clear that kickbacks were common during the 1980s and 1990s yet I am not aware of a single conviction which is publicly available. The investigations have never been carried through to a verdict one way or the other.

The ABC Four Corners program on September 6, 2004 suggested that health care fraud was much higher than the 1% estimated; possibly close to the 10% seen in the USA. The suggestion is that regulatory bodies have been politicised and effective action has not been encouraged by the market or politicians. Both had good reason for not wanting to know. In addition investigations are carried out and resolved behind closed doors so that there is no adverse publicity. The absence of Qui Tam and proper whistleblower protection legislation in Australia is a major problem.

One of the most effective means of preserving integrity and protecting citizens has been the requirement that holders of licences be "fit and proper" people. These regulations have been disregarded, ignored and even removed. No attempt has been made to revise them to give them the teeth and the legal power to deal with large corporations against which they are currently almost powerless. They were written for a different era.

HealthSouth a company which admits to a US $4 billion fraud has been allowed to operate in Victoria. Mayne Nickless, a company guilty of deceiving its customers and making secret collusive arrangements not only retained existing licenses but was welcomed and encouraged to expand. Government supported the company giving its staff senior government appointments. It pressured doctors to enter into secret financial dealings with the company and with insurers.

When the commonwealth department licensing pathology was supplied with information about Sun Healthcare it simply sat on its hands and prevaricated until the company sold the facilities. There was no adverse finding and no publicity. The same information supplied to the aged care licensing authority was not acknowledged until they were forced to do so.

Oct 2000 Reluctance to regulate

Despite the fact that these listed corporations are run largely on taxpayer dollars, Canberra has been extremely slow to react to the market's frenetic activity, and so far shown little inclination to regulate it, despite the relevant laws clearly being outdated.
The Painful Opt-out Option Australian Financial Review October 11, 2000

Nov 2001 The importance of political support

With the re-election of a Federal Government supportive of private health care, medical corporations and the personal fortunes of their key backers look set to continue their strong growth.
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The pace of market activity, particularly the rapid movement of GPs into large corporations in recent years, has outstripped both community awareness and policy-making alike.
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Despite the sporadic outbursts of public concern over the rapid rise of corporate medicine, politicians on both sides of politics have givena virtual green light to the growth of the new medical entrepreneurs.
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By comparison, the Coalition has taken a softer self-regulatory approach. Just two weeks before the election, outgoing health minister Michael Wooldridge launched a voluntary code of conduct for the medical corporates, which he said would provide an ethical framework for the industry. Highlighting the voluntary nature of the code, two of the key players, including Primary, which had its own, did not even sign on.
The Rise And Rise Of Medicare Millionaires Australian Financial Review November 20, 2001

Sep 2004 Four Corners exposure of fraud

Health bureaucrats play down the problem and claim the amount of so-called "leakage" is less than 1 per cent. This week, Four Corners presents compelling new claims that the figure could be much higher. Reporter Ticky Fullerton speaks exclusively to former fraud investigators who claim the figure is closer to 10 per cent.
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While the Health Insurance Commission has pursued a number of cases, former HIC insiders, police and public health experts warn that the HIC is well behind the crooks and is soft on penalties.
Summary of "Doctoring the Figures" ABC Four Corners September 6, 2004 Full summary and full transcript with examples of fraud at http://www.abc.net.au/4corners/content/2004/s1191797.htm

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Diagnostic Corporatisation

The corporatisation of pathology started in the early 1990s and by 2000 the bulk of small professional businesses had been purchased with few opportunities for further expansion in Australia. Corporatisation of radiology got under way at this time and by the end of 2005 the bulk of radiology was in corporate hands. There were four major players, one concentrating on radiology, one on pathology, and two providing both.

Dec 2000 Corporatisation and business models

Sonic Healthcare's acquisition this week of the privately owned Queensland X-Ray confirmed that medicine in Australia, particularly pathology and radiology, is fast becoming a big business.
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Frenetic acquisition by listed health service companies of private practices suggests only a handful of dominant players will be left once the present spate of rationalisation ends.
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Through banding together previously fragmented private practices, a listed company can extract significant profits through cost savings and operational efficiencies.
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Each has a distinct business model and analysts say only time will tell which is the most successful.

Sonic is a two-pronged medical diagnostic business, MIA a pure radiology group, and Mayne Nickless a vertically integrated model with interests in hospitals, pathology and radiology.
Sonic Cuts A Swathe In Rationalisation Race Australian Financial Review December 2, 2000

Jun 2001 The state of corporatisation

(In terms of corporate ownership, pathology is several years ahead of the radiology sector, with 83% of practices in the hands of four groups. Sonic is the largest, with a 37% market share, followed by Mayne with 22%.)
The Uncanny X-ray Men Business Review Weekly June 22, 2001

Oct 2005 The main diagnostic players in 2006

Consolidators in the diagnostic industry deliver favourable margin growth. The number of service providers has consolidated to four major providers, DCA Group (DVC), Sonic Health Care (SHL), Mayne Group (MAY) and Healthscope (HSP).
SPECIAL REPORT : HEALTH CARE A TONIC FOR AN UNHEALTHY MARKET. Your Money Weekly October 27, 2005

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The Corporatisation of Pathology

The Early Years

During the earlier years there were a multitude of smaller private companies which gradually merged and consolidated with larger and more successful competitors. A succession of names came and went. By the late 1980s there was much talk of integration and diversification

Ariadne Australia Ltd was formed in 1987 in Queensland. It had great entrepreneurial ambitions for its health subsidiary Healthcorp Ltd. It started by buying 50% of Sullivan and Nicolaides in 1987 but did not diversify much further. This ultimately became part of Sonic Healthcare.

Oct 1987 Ariadne and Healthcorp

Ariadne property director, Mr Geoff Wilson, said the purchase of a half share in Sullivan & Nicolaides - which he described as "Australia's leading consulting pathologist" - would be the basis of a multi-disciplinary health care operation.
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He said Ariadne had established a new company, Healthcorp Ltd as of July 1 last which "is capitalised at $25 million, which we aim to position in the marketplace to take full commercial and operational advantage of imminent changes in the health care industry".
ARIADNE TAKES ON HEALTH CARE Australian Financial Review October 6, 1987

Integrated Health operated pathology, radiology and other health businesses in Western Australia. They were purchased by Markalinga Trust in 1989. It sold off some of them when it was under pressure in 1990. Markalinga was purchased by the fraud prone US group National Medical Enterprises (NME) and became Australian Medical Enterprises in 1992. It was acquired by Mayne in 1996.

A conglomerate of interconnected companies supplying pathology and other services came and went in 1989. There was Biohealth (formerly Private Blood Bank of Australia). Medical Pathology Services was purchased by a group Plutius No 28 Pty Ltd. These names soon vanished. Related to these was a group called Regional which had gone into liquidation.

Macquarie Pathology Services formed by Dr Tom Wenkart became a major operator in NSW. It adopted some controversial practices considered by many to be kickbacks and was acquired by Mayne Health in 1998.

Dorevitch, Gribbles, Unipath, and Tresize were large groups active in Victoria in the early 1990s. Dorvitch and Tresize became part of Mayne. Mayne also acquired Western Diagnostic Pathology in Western Australia, and Hampson Sugerman Pathology in New South Wales.

Gribbles continued to grow and became a lightning rod for allegations of unacceptable practices. It prospered acquiring about 15% of the pathology market and also an international empire. It collapsed financially in 2003 and was acquired by Healthscope at the end of 2004.

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The Recent Years

Consolidation and acquisitions continued but by the end of 2000 opportunities were drying up. The extracts give some insight into developments between 1999 and 2006. By the beginning of 2006 there were two large dominant pathology providers, Sonic and Symbion (the new name for the unpopular Mayne Health). Healthscope which bought Gribbles was intermediate and not performing well. General Practice company Primary Health had only 4% of the pathology market but was very profitable. The other General Practice operators had small diagnostic holdings.

Jun 1999 Still consolidating

Nevertheless, there has been a spate of mergers and takeovers in the sector, and the activity is likely to continue. Peter Kempen, national director of corporate finance for Ernst & Young, says mergers have been intense in the pathology area, with Hospital Care of Australia (a subsidiary of Mayne Nickless), Dorevitch, Gribbles and the listed company Sonic Healthcare emerging as large players. "Sonic has had an extraordinarily good growth in its share price."
Health Care, Or Wealth Care? Business Review Weekly June 11, 1999

Aug 1999 Battle for market share

And the fight for market share is fierce, with the top five companies controlling more than 70 per cent of the national market, up from 60 per cent just two years ago. Mayne Nickless is the leader, with a 23 per cent national share, followed by Sonic with 19 per cent. The next three operators are SGS (15 per cent) and Queensland Medical Labs and Gribbles, both with 11 per cent.
Profit-making: it's in the blood SYDNEY MORNING HERALD August 16, 1999

Sep 1999 Small operators squeezed out

Revenue caps are squeezing the smaller players out of the market and analysts suggest only three major operators will survive: Sonic, Mayne Nickless and Revesco (Gribbles).

"Margins, margins, margins" is the mantra for healthcare operators and on this basis Sonic has a proven track record. The 52 per cent jump in annual net profit to $17.45 million was underscored by an impressive gross margin of 20.7 per cent.
Pathological Buyer Does The Right Thing Australian Financial Review September 18, 1999

Mar 2001 Pushing prices sky high

In reality this means the only practical way to expand geographically is to spend lots of money and buy your rival. Over the last three years, more than 30 pathology or imaging businesses have been acquired by larger operators, with most of the vendors walking away with enough to pay several kings' ransoms.
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While takeovers don't offer huge savings, and the prices being asked by vendors are astronomical, right now they're the only sure-fire way to maintain profit margins. But the number of targets is shrinking fast.
Health Risks For Packer And Smedley Australian Financial Review March 10, 2001

May 2002 State of play including QML

Pathology was the first area of health care to be comprehensively corporatised. About 80% of the private market is in the hands of four companies, three of which are publicly listed. (In addition to Sonic, the main listed companies are Gribbles Group and Mayne Group).
Health is wealth. Business Review Weekly May 23, 2002

Sep 2002 After Mayne bought QML

Sonic is Australia's biggest pathology provider. Merrill Lynch estimates that Sonic has 39% of the Australian market; the next biggest player is Mayne with 26%. Mayne showed its ambitions to close the gap by acquiring Queensland Medical Laboratory in June 2002. The other big operator in pathology is Gribbles Group, with 8%. That leaves 27% of the market in other hands.
Sonic boom Business Review Weekly September 5, 2002

Jan 2004 market capitalisation

Sector Sonic Health Care has a market capitalisation of $1.7 billion. Its ASX-listed domestic competitors in pathology are Mayne Group ($2.6 billion), The Gribbles Group ($108 million) and Primary Health Care ($530 million).
Sonic Health Care Limited (ASX Code: SHL) The Sydney Morning Herald January 28, 2004

Feb 2005 State of play after Healthscope bought Gribbles

Pathology industry consolidation

Other 21%
Sonic Healthcare 36%
Mayne Group 30%
Healthscope 9%
Primary Health Care 4%

Source: UBS
Street Talk : THE VISION THING Australian Financial Review February 21, 2005

Dec 2005 Mayne Health becomes Symbion Health

Initially, Sonic focused on pathology, and after several acquisitions, mainly in the second half of the 1990s, it is now Australia's largest private pathology provider. Merrill Lynch estimates that Sonic has 38% of the domestic pathology market, Symbion (previously Mayne Health) 32%, and Gribbles (now owned by Healthscope) 9%.
Path test BRW December 1, 2005

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The Corporatisation of Radiology

The corporatisation of radiology got under way in 2000 but progressed more rapidly than pathology. There were few intermediate corporate groups. Large commercial groups grew rapidly by buying group practices directly from radiologists.

Mayne Health and Sonic were two well established health care operators that started buying into radiology.

MIA (Medical Imaging Australia) was formed by a group of radiologists. It listed on the share market to raise capital and then grew very rapidly by acquisitions. It overreached itself and was soon in trouble.

DCA was a company with multiple commercial interests. It elected to sell off its businesses in order to become almost a pure radiology and aged care company. Its subsidiary I-Med grew very rapidly and prospered. It bought MIA and became the largest of the three radiology corporations which now dominate the sector.

The press extracts give the flavour of what happened as ownership by three dominant corporations grew from 10% at the beginning of 2000 to nearly 70% buy 2006.

Aug 2000 The prospects

RADIOLOGY OUTLOOK
Radiology revenues have grown at an industry compound annual growth rate of 7.5% over the past five years (whilst general expenditure on health services has increased at 4.5% pa). This growth has been driven by:
advance in technology and more definitive diagnostic testing;
increased focus on preventative medicine and early diagnoses; and
an ageing population and their increased consumption of medical services.

The private market for diagnostic imaging in Australia is in excess of $1.5bn with government medicare outlays approximately $1.1bn.

DCA is also attracted to the fact that the industry is relatively fragmented (Medical Imaging Australasia is the largest operator yet only has a 12% market share) and the benefits of scale will drive the consolidation of practices over the next few years. These benefits include:

improved utilisation of equipment and the ability to support new advanced equipment/procedures;
improved productivity;
administration savings; and
greater purchasing power.

Development Capital Of Australia Limited (DVC.AX) DCA Expands with Healthcare Acquisition. Australian Stock Exchange Company Announcements August 9, 2000

Dec 2000 Corporatisation proceeding

Mr Vaux (MD of DCA) said despite the scramble for radiology assets now under way, the top three players still only accounted for 30 per cent of the fragmented market.
I-Med turns X-rays on float. The Australian December 5, 2000

Jun 2001 From 10% to 47% in 18 months

In January last year, less than 10% of private radiology business was in corporate hands; that figure is now close to 50%.

The chief executive of MIA, Peter Macintosh, says that even without Radclin, MIA has 17% of the $1.5-billion annual private diagnostic market. Including Radclin would take its market share to 20%. Deutsche Bank estimates that Sonic Healthcare has a market share of 11.5%, Mayne Health 8% and I-Med 7%.
The Uncanny X-ray Men Business Review Weekly June 22, 2001

Jul 2001 Potential for more

But there's still a lot of potential for industry rationalisation, even given the hectic pace of recent years. The top four players, MIA, Sonic, Mayne and I-Med, still account for less than half of the national market.
XCHANGE : Sonic boon Sydney Morning Herald July 7, 2001

May 2002 A year later its 60%

The corporatisation of the radiology business has happened more recently.

About 60% of the national radiology business is held by four public companies: Sonic, Medical Imaging Australasia, Mayne and I-Med, which is controlled by the listed investment company DCA Group. Medicare payments for radiology in 2000-01 were $1.2 billion.
Health is wealth. Business Review Weekly May 23, 2002

Oct 2002 The big players

Medical Imaging Australasia, Sonic and Mayne are the biggest companies in the radiology sector, with market shares of 20%, 14% and 10% respectively.
A sick business. Business Review Weekly October 3, 2002

Mar 2003 Changing distribution

Mayne Group's purchase in February of the last big independent radiology practice, Queensland Diagnostic Imaging (QDI), means that just over 60% of Australia's annual $1.7-billion diagnostic imaging expenditure is now in corporate hands.
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After the purchase, Mayne is a close second to the largest radiology provider, MIA, which stockbroker Salomon Smith Barney estimates to have 21% of the Australian market. Salomon says Mayne now has about 19%, Sonic Healthcare has 14% and I-Med, a subsidiary of DCA Group, has 10%.

With 60% ownership in corporate hands, the radiology business has changed dramatically in a short period. Four years ago, the corporate sector owned less than 10%. Even so, radiology is still behind the pathology sector, - - - -
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The reason large radiology practices such as QDI can command high prices is that, even with medical budgets under increasing scrutiny, diagnostic imaging is at the very profitable end of the health business.
The rise of the X-ray giants. Business Review Weekly March 13, 2003

Feb 2005 Consolidation

Radiology industry consolidation

Other 35%
Mayne 19%
DCA (I-Med & MIA) 32%
Sonic 14%

Source: UBS
Street Talk : THE VISION THING Australian Financial Review February 21, 2005

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Relationship with Doctors and the Public

The companies employed radiologists and pathologists to carry out the services. The companies were dependent on their ddication. The work came from General Practitioners and other specialists who ordered tests. They were the main customers.

There was also an effort to market screening and other procedures directly to the public, both to bring them directly for screening and to get them to pressure their general practitioners. Generally this sort of scare advertising backfired as doctors did not like it.

Specialist Radiologists and Pathologists - Joint Ventures

Corporations must employ one set of doctors to provide services to another set. Corporations pay radiologists and pathologists far more than the previous market value for their practices. They often pay with company shares. Many become overnight millionaires. Companies also offer them lucrative contracts to continue working for the companies. Most encourage them to own shares or set up the practices as joint ventures. This binds pathologists and radiologists to the corporate interest.

Dec 2000 Radiologists become millionaires

The 52 radiologists that comprised Queensland X-Ray were immediately catapulted into the ranks of millionaires with the undisclosed price tag estimated to be up to $240 million a sector record.
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Companies such as Sonic Healthcare and Medical Imaging Australasia are offering private practitioners far larger price tags than if they sold their partnership interests to another radiologist.
Sonic Cuts A Swathe In Rationalisation Race Australian Financial Review December 2, 2000

Dec 2002 Well $3.8 million each

Dr Dubois was one of Queensland X-Ray's 52 radiologists who collected an average $3.8 million in cash and stock last year after Sonic acquired their business for $200 million.
Dubois cashes in on the Sonic boom. Australian Financial Review December 6, 2002

Specialist groups that do not sell out find themselves with powerful competitors who market aggressively to GP’s. They also corporatise general practices and so control the GP referral base, as well as offering all the latest technology.

It is little wonder that these specialists sell out to corporations.

There is a corporeate down side for this in that newly wealthy specialists from whose work the profits come may no longer be as motivated. If their working conditions and remuneration are not congenial they will move elsewhere when their contracts expire. As specialists are in short supply they are in a commanding position. One strategy is to have doctors in senior positions so that the cultural ambience of the company remains unchanged.

Jun 2001 Power of radiologists -- holding shares

A key challenge for management is ensuring that the radiologists who were previously owner-operators do not become disillusioned by working as part of a corporation. Individual radiologists have an enormous amount of power because of their small numbers (about 1100 in Australia) and because Medicare payments are for services provided by the doctors, not by their employers. If a radiologist walks out the door, the company's critical income-earning asset is gone. With only about 15 radiologists graduating each year, employers have a limited pool from which to replace departing employees.
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Radiologists retained 63% of MIA when it was floated. Since then, acquisitions have been made with a combination of shares and cash, and most of the radiologists retain equity.
The Uncanny X-ray Men Business Review Weekly June 22, 2001

Apr 2002 Holding senior positions

At Sonic and MIA, for example, much is made of the fact that senior management positions (in the business units and in head office) are held by medical people. They say that, as a result, their businesses are sympathetic to clinical issues and more responsive to the needs of their clients, who are the doctors that make the decisions about where pathology and radiology tests should be done. So far, in a business in which the main clients are fellow doctors, this has been a popular sales line.
Medicine Man Business Review Weekly April 4, 2002

Apr 2002 Importance of tieing radiologists to the company

In radiology, the picture is brighter, but Mayne's performance is still a long way short of industry best-practice.
----------------------------
In view of some of the poor relationships that exist between medical staff and management, retaining senior doctors is going to be important in Mayne's pathology and radiology divisions in the next few years.

Unlike at MIA and Sonic, which have acquired their individual practices mostly through a mixture of cash and equity, Mayne's doctors do not have substantial equity positions. Most work on contract, and many contracts are due for renewal over the next year or two. Good radiologists can produce turnover of $2 million a year. If they are not tied to an organisation, they would be highly sought-after professionals.
Medicine Man Business Review Weekly April 4, 2002

Jun 2004 Unhappy Radiologists leave when contracts expire

Increasing corporatisation of health services has not suited all doctors. Over the past year, some radiologists who sold their practices to MIA or Mayne have opted out of corporate businesses as their contracts with radiology companies expired and re-established private practices.

One of these is the former chief executive of MIA, Peter McDonald. McDonald was one of the key people behind the consolidation of radiology practices into MIA and its public listing in 2000. He left the company last year after problems in its pathology businesses caused earnings to fall.

A rumor in the industry, denied by McDonald, is that he has recently been talking to radiologists with a view to establishing a new business that could operate in competition with the bigger corporate practices. McDonald says: "The cost of setting up a practice is prohibitive, the equipment is very expensive, and business is more competitive than in the past." He says he and a group of radiologists, whose corporate contracts had expired or who had retired, are working together, concentrating on the area of tele-radiology.
Stitched-up sector Business Review Weekly June 24, 2004

Many doctors are unhappy about handing medicine over to businessmen and particularly about businessmen intruding into care. Some GP’s and specialists have recently tried to set up a competitive cooperative instead of a corporate structure. How this will go remains to be seen. Similar efforts by doctors were attempted in the USA but they were unable to compete.

Oct 2005 Doctors going it alone

A report to the government has also raised concerns that a co-operative of doctors planning to start in NSW next year could encourage overservicing because the doctors would also be approved pathology providers.
The chief executive of the Diagnostic Medical Co-operative, Con Kostakis, said the co-op was designed to prevent overservicing and penalties against it were written into its constitution.

Doctors would be stopped from ordering too many tests because of the threat of losing their pathology provider status.

Still, when asked what the point of the co-operative was, Mr Kostakis said it was to "take back control of diagnostic services for the medical profession", and, in a letter to The Australian Financial Review, he said it would "bring about a lot of public good, not the least of which will be to supplement the incomes of struggling practitioners".
Rapid rise puts pathology under the microscope Australian Financial Review October 28, 2005

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Referring Doctors and Kickbacks

General Practitioners and other specialists order the diagnostic tests and are the main customers of the Diagnostic corporations. Financial success depends on securing their allegiance and their referrals. Corporations have made very effort and employed every strategy to align the interests of the referring doctors with the corporation.

During the 1980s and 1990s there was intense concern about kickbacks - ie. paying doctors for referrals. This is illegal and dysfunctional for patients and the health system. Doctors are required by law to make referrals for the benefit of their patients and not their pockets. From the many allegations made by doctors and particularly the pathology association it is clear that kickbacks were quite common although it was claimed that only a few bad apples participated. There is no clear legal dividing line between illegal kickbacks and business arrangements which are not illegal but which function as kickbacks. They have the same effect. Practices which market thinkers see as desirable, even essential business activities are interpreted as criminal activities within a professional context. As a consequence this becomes a legal minefield. In the examples in the extracts below the company stressed that what they were offering was legal. As they were never successfully prosecuted they may have been correct.

Central to this issue is a failure to distinguish between a blunt and inexact legality enshrining the rights of individuals and marketplace entrepreneural values on the one hand. On the other is the issue of probity encompasing the rights of the community and its members to services driven by a sense of responsibility and by humanitarian values. This is especially so when citizens are vulnerable because of physical or mental impairment.

The difficulty is that these bad apples gain a competitive advantage and those who behave ethically suffer unless they follow suit which the US experience suggests is the norm in the health care marketplace. When we consider the AWB, HIH, and many price fixing scandals in Australia there is no reason to believe we are different.

Pathology kickbacks took many forms. These included paying exorbitant rentals, providing GPs with staff paid for by the corporation, and even payment for participating in research and surveys.

Regulatory bodies made efforts to prosecute kickbacks and some companies, notably Gribbles were very aggressive in challenging both the jurisdiction of the regulators and the accusations. This dragged on for years. As far as I can determine there were few if any successful prosecutions of corporations for kickbacks. If there were fines then they were part of settlement agreements which were not public. In the USA most fraud and kickback allegations are settled in this way - but they are not confidential and are reported in the press. This has not happened here.

Without legal knowledge and inside information it is difficult to know whether the lack of penalties was due to legal difficulties or to the lack of support from the regulator’s political masters. It seems that during this early period regulators did try - but this was before government departments were heavily politicised. The denials and defensive position taken by the HIC’s senior staff on the December 2004 Four Corners program (see below), and the revelations on the program suggest that they are no longer committed to prosecutions.

The HIC certainly did put pressure on these practices and has used other strategies (eg. vetting licenses for collection centres) to ensure that payments made for space in medical centres are not disguised kickbacks.

These seem to have had some success as there have been few if any reports about kickbacks over the last 5 years. In addition the stand taken by the bulk of pathologists and the medical establishment may well have driven these groups out of business.

More recently other methods have been used to align the interests of the doctors with those of the company. These include owning the GP’s practices, encouraging them to own shares, and involving doctors in joint ventures. Joint ventures are more usual with specialists.

Note that there is more information about specific accusations on individual company pages - see Gribbles and Macquarie Health.

Mar 1989 Kickbacks in the 1980s

A most comprehensive analysis of the pathology industry was completed in September 1985 by a Federal Government Joint Public Accounts Committee on fraud and overservicing in the health area.
--------------------------------------
The report also revealed the widespread use of kick-backs and profiteering rackets, and promised to clean things up.
NEW STARTER IN PATHOLOGY STAKES Australian Financial Review March 20, 1989

Jul 1994 Examples of continuing kickbacks

Australia's private pathology industry is booming. So, too, according to doctors and industry insiders, is corruption. Gary Tippet explains how a minority is making big money from rorting the system.

DOCTOR D is a general practitioner in a Melbourne suburban practice with four other doctors. Two years ago he and his partners were approached by a private pathology company seeking their referrals - for which it was willing to pay almost $25,000 and the salary of a full-time nurse for the surgery.

The doctor telephoned Dr Ian Rowe, chairman of the Office Pathology Committee of the Royal Australian College of General Practitioners, for advice on the legality and ethics of such an arrangement.

"He had a contract on the desk in front of him, ready to sign,'' said Dr Rowe last week. "The pathology service had assured him the contract was legal. They were perfectly prepared to take on the Commonwealth on this.''

Dr Rowe notified the Department of Health and the Health Insurance Commission, which runs Medicare, passed on the evidence to the Australian Federal Police and the director of public prosecutions. He has heard nothing about the matter since.

"So I have to conclude that the Commonwealth is frightened to pursue this matter,'' said Dr Rowe. "And I conclude that they are scared to pursue it because they fear they will lose the case. And if they did, all hell would break loose.''

Then there is the case of Doctor B. Two years ago he worked as a general practitioner in a neon-lit, entrepreneurial medical centre in Melbourne's eastern suburbs. The clinic's pathology tests had long been done by a small local laboratory but, virtually overnight, the centre switched to a new, aggressively marketed company.

"Suddenly, in the space of a few days, without any of the medical staff being informed of what was going on, all the old lab's equipment was cleared out and the new company's stuff moved in,'' Doctor B recalled this week.

"Included in the changeover was a direct-line computer and printer which meant that when the pathology results became available they spat out downline into the surgery.

"Normally that might be all well and good, a simple commercial decision with the benefit of new technology - except there was a very strong suggestion that up to $100,000 had been paid under the counter to encourage the changeover.''

Dr B is no longer at the clinic. He rents rooms in a block of medical suites in the CBD. Down the corridor another room is being "leased'' for a substantial sum by a private pathology laboratory. The room is completely empty and unused.

AUSTRALIA'S private pathology industry has long been plagued by accusations of corruption - from kickbacks, bribes and inducements (ranging from cars and holidays to the provision of company-paid nursing sisters in doctors' rooms), and even "sink tests'', where samples were allegedly poured down the laboratory sink but claimed on Medicare. But no doctor or pathologist has been prosecuted.
------------------------------
Sources further say corrupt practices by a minority of operators are also booming. "Unethical practices and overservicing is widespread,'' one private pathologist claimed last week. "Some people are simply using out and out fraud,'' said a doctor.

Dr David Weedon, the vice-president of the Australian Medical Association, said a level of corruption was "alive and well. There are still kickbacks going on in pathology in Australia by some practices.

"What they're doing now is putting sisters into the doctors' rooms,'' he said. "These sisters collect blood for pathology, but when they're not busy collecting pathology they're filing and doing other routine jobs for the surgery. In other words, they're providing a half-time employee free of cost.''

Other inducements allegedly offered to GPs by unethical pathologists include the provision of computers, software, fax machines and medical equipment and the payment of unjustifiably high rents for the space used to collect specimens in return for the GP sending tests to their laboratory. In a case referred to the Australian Federal Police in September last year, it was alleged that one company was leasing space in one clinic, not at commercial rates but at 35 per cent of pathology referrals generated by the clinic.
--------------------------------
"Very few (doctors) would be on direct inducements such as money for referrals,'' said Melbourne pathology consultant Mr Ed Wilson. "But arrangements such as the rental of a broom cupboard in a doctor's surgery for $20,000 a year, in which the pathology provider stores jars and containers so the doctor can collect specimens, are common.''
-----------------------
That task (running them out of the industry) has so far proven to be "beyond the wit'' of the HIC and the Australian Federal Police, according to Mr David Kindon, the secretary of the Australian Association of Pathology Practices, which represents about two thirds of operators in the private pathology industry.

"We have provided evidence to the HIC in the past about some of these things and that's why we've been frustrated,'' he said. "They just seem to disappear into a black hole and once it gets into the system it becomes sub judice and, correctly I guess, we're not allowed to know where the investigation has got to.

"But nothing ever seems to pop out the other end."
----------------------------
An industry source also claimed that 32 such matters had been referred to the AFP since August 1989 with no prosecutions resulting, but neither the HIC nor the AFP would confirm or deny this. "It is policy that we do not comment either way on investigations,'' an AFP spokesman said last week.
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"Whilst in Victoria we have a minority of unethical providers, to maintain their viability all practices are being obliged to become increasingly commercial. And when you put a rotten apple in a box of apples, the other 99 apples don't turn the rotten one good. "
Bleeding The System Sunday Age July 31, 1994

Mar 2001 A strong temptation

Those price cuts really bite. Pathology and imaging businesses have high fixed costs and efficiency gains are difficult to achieve.
-----------------------------------
Paying cash or other inducements to referring GPs is illegal, and could result in jail time. But the temptation to offer inducements is great. I'd venture that it won't be long before a major pathology lab is in trouble with the law over inducements.
Health Risks For Packer And Smedley Australian Financial Review March 10, 2001

Mar 2001 Dealing with the problem using licenses

During the past six months, the HIC is understood to have knocked back more than 30 proposed rental arrangements as part of a tough new approach to enforcing the ban on inducements. In many cases pathology companies were allegedly offering doctors or medical centre operators three times what the watchdog considers market rental.
HIC Crackdown On Offers Of Inflated Rent To Medics Australian Financial Review March 28, 2001

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Marketing to the public and Whole Body Scans

One of the problems with health care entrepreneuralism is the pressure to seize new opportunities and take them to market long before their benefits and dangers have been properly evaluated. The blindly enthusiastic lacking in objectivity, the wishful believers and the out and out crooks all rush to get a first in advantage. Usually these marginal developments have great appeal and are readily marketed to the public. Some of course eventually prove to be genuine advances and early investors make a killing. Others don’t and turn out to be harmful.

Total Body CAT scans using the latest machines potentially offer an opportunity to screen for serious diseases like cancer and detect them at a stage when they can be successfully treated. They have enormous appeal to an anxious public. The problem is that while they can pick up some of the less common cancers they are not very effective for common ones. They also result in large numbers of invasive investigations for shadows which turn out to be innocuous. There are also unacceptable levels of damaging radiation.

These scans have proved very popular with the public but are an idea whose time has not come. They are opposed by radiologist bodies, medical associations, and by health departments who consider them more harmful than beneficial. It is interesting that MIA, which boasted of the influence which its radiologists exerted got into this business briefly. Few of their radiologists would have approved.

Virtual colonoscopy using CAT scanning is also very attractive because it avoids colonoscopy (but not bowel preparation) and some of its risks. It is not as accurate in detecting lesions and there is the problem of excessive radiation. While welcomed by patients it is not recommended at this time.

The extracts give some idea of the way the public falls victim to marketing in areas like this.

Jun 2004 The Total Body Scan debate

Total Health Screening performs whole-body scans of customers. The images produced by the Sydney firm's $A1.4 million computer tomography (CT) machine are studied for signs of cancer, spinal abnormality or heart disease. Total Health is the only company in Australasia still offering CT scans, following opposition from medical bodies. Gabby Freilich, the CEO of Total Health, says five per cent of the 5,000 scans he has checked since August 2002 contained abnormalities requiring immediate attention. Freilich criticises health authorities for preventing CT scanning as "some nefarious activity"
Total Health Screening Time Australia (ABIX Abstracts) June 7, 2004

Sep 2005 Criticism

FULL-body CT scans, which hit the Australian market several years ago promising to detect cancer and other illnesses before they become symptomatic, were slammed by the medical profession but proved popular with patients, new findings show.
---------------------------
The popularity of the scans comes despite criticism of the procedure from the medical profession. In 2003, the scans were made illegal in NSW without a referral from an independent GP and a detailed warning of the risks of the procedure.

The Royal Australian and New Zealand College of Radiologists has raised concerns about the level of radiation used, as well as warning the scans can lead to unnecessary follow-up examinations.
Screen testing Australian Doctor September 9, 2005

Unfortunately the opportunities presented by these potentially lucrative innovations attract the sort of people who are most likely to market them well beyond their real worth. They can be the most unsuitable people. The story of Lifespan Medical Imaging, Gold Coast Healthcare, and a host of related companies tells its own story. Note the names of the companies.

As indicated earlier the expectation that people involved in the care of their fellows would be the sort of people who could be trusted has gone out of the window. The concept of probity has gone and the dregs of the marketplace come trawling the markets for opportunities to make money. They find easy pickings in health. The public has not realised this.

Jan 2004 Lifespan Medical Imaging

FORMER TV medico and real-life GP, Dr Jeremy Cumpston has this week launched Brisbane's first medical service specialising in full-body CT scans, virtual colonoscopies and angiograms.
Dr Cumpston, who played nurse Connor Costello on the Seven Network's award-winning medical drama All Saints, said Lifespan Medical Imaging's new virtual technology could dramatically reduce the number of bowel cancer and coronary heart disease (CHD) deaths in Australia.

"Virtual colonoscopies and angiograms are fast, effective and non-invasive," he said.
------------------------------
Dr Cumptson said the company's Sydney arm had proven extremely popular.

"It is expected we will be booked solid fairly quickly in Brisbane - people really are into knowing exactly how they are travelling with regard to their health and this is a non-invasive, proven way of doing so," he said.
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Australian Medical Association of Queensland (AMAQ) president Dr Ingrid Tall said virtual colonoscopies weren't as accurate as the conventional procedure.

"However, they do have some advantages such as the fact that they're less invasive, no anaesthetic is needed, there's fewer side effects and you don't have the same risk of perforation of the bowel," Dr Tall said.

"But the virtual test still involves the same bowel-cleansing preparation as conventional colonoscopy and involves considerable radiation - more than chest X-rays."

Dr Cumpston said Lifespan's 16-slice CT scanning was the most accurate in Australia and could also be used for virtual angiograms which had the potential to diagnose CHD in patients with no symptoms.
TV medico unveils new virtual reality City News January 22, 2004

Apr 2005 Gold Coast Healthcare - a saga

Back on October 27 last year a company called Gold Coast Healthcare lodged a prospectus with the Australian Securities and Investments Commission in a bid to raise between $2.5 million and $9 million.

Under the offer that opened on November 3 last year, investors were urged to buy redeemable, convertible preference shares in Gold Coast Healthcare so it could buy Lifespan Medical Imaging, which runs a radiology practice in Nerang Street, Southport.
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The company boasted a strong board comprising NSW-based orthopaedic surgeon Gordon Slater, John Roberts who helped create the stock exchange listed company Primary Health Care, Bruce Harvey, a Sydney engineering company managing director and Paul Jones, a medical equipment service industry consultant.
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In the financial forecasts included in the prospectus, Gold Coast Healthcare was tipped to make $154,000 on revenue of $4.1 million in the year ending on June 30 this year.
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However, something has now gone terribly wrong with Gold Coast Healthcare.

On March 16, barely five months after the offer was opened, the entire board was replaced.

Michael Silver of NSW, Stephen Seeto of PNG and Robert of Woollongong became the new directors on that day.
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On March 18, with another seven months to go before the offer closes, administrators were called in - Hall Chadwick's Sydney-based Richard Albarran and Geoff McDonald. Then on March 24 a first meeting of creditors was held.

Mr McDonald says the issue has now led to litigation in the Supreme Court and there are accusations of missing money.
Health care venture's now looking like one sick puppy The Gold Coast Bulletin April 18, 2005

Apr 2005 The corporate tangle unravels -- note the names of the companies.

And it now appears that the collapse might have been the tip of the iceberg.

The corporate doctors who were called in to determine whether the situation could be salvaged - Hall Chadwick's Sydney-based Richard Albarran and Geoff McDonald - also have been appointed administrators of related companies.

A couple? Eleven to be precise.

They are: Prescription Healthcare, Digital Diagnostic Holdings, Penplaza Medical Centre, Total Body Scan, Full Body Scan, DDX Holdings (Penrith) Digital Diagnostics X-Ray, Body Scan Australia, Penplaza Medical Holdings, Lifespan Medical Imaging and Lifespan Medical Imaging (Brisbane).

Mr Albarran, in his latest report, says there appears to have been a few omissions or errors in the Gold Coast Healthcare prospectus that was used to guide investors.

Firstly, there seems to be at least three different versions of the prospectus doing the rounds.

Secondly, the company said it had an informal arrangement with Gold Coast Hospital with regard to referrals. But the hospital says it never did and even lodged a complaint about that version of the prospectus with the corporate watchdog.

But perhaps the most serious omission was that one of the directors and significant shareholder, one Jack Edward Roberts, had previously been a director of companies that had failed, were deregistered or are now under administration.

How many you ask? Well, according to Mr Albarran, a mere 29 companies. Obviously, it must have been an oversight.

The administrators have also found evidence of insolvent trading and preferential payments.
Healthcare probe reveals true hospital case The Gold Coast Bulletin April 29, 2005

The "ADC Group" seems to have been behind some of these companies as a financier and eventual purchaser. How extensive this was is unclear. Note that Stephen Seeto who became a director of Gold Coast Healthcare in March 2005 was also a director of ADV Group.

A quick search reveals that ADV Group is a company which has been on and off the stock exchange under a multitude of names since 1964. It was listed again in 1998 and has had a variety of businesses in Australia and in Asian countries of varying success. It has received queries from the stock exchange on many occasions and has been temporarily delisted for not submitting its reports on time. It is unusual for the public to be aware of the financial groups whose money is invested in health shares and who therefore own the companies, appoint executives and ultimately decide policy. Policy all too often impacts on care.

Oct 2003 ADV director shared with Gold Coast Healthcare

The ADV Group Ltd annual general meeting will be held on Novemeber 28, at Sydney.
Agenda includes: re-election of Stephen Seeto and J Dalco as directors; and to ratify the issue and listing of 500,000 ordinary shares in full consideration of a facility fee in relation to a loan made by Fair Choice Ltd of $150,000 on August 30, 2003 to provide working capital.
ADV GROUP ANNUAL MEETING AUSTRALIAN COMPANY NEWS BITES October 8, 2003

May 2005 Prescription Healthcare was the entity owning Lifespan

ADV Group Ltd has bought the Lifespan Medical Imaging business operations in Sydney and Brisbane from the Prescription Healthcare Ltd liquidator.

Prescription Healthcare was placed into administration by its secured creditor ADV, after it defaulted on loan repayments. Prescription Healthcare was then placed into liquidation by its creditors.
ADV GROUP BUYS MEDICAL IMAGING BUSINESS Australian Company News Bites May 27, 2005

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Internet Diagnosis

Internet diagnosis is a great advance in many ways. Requests and reports can be made and reports sent out very rapidly. Data collection is facilitated and this is valuable. Unfortunately information obtained from this process can be misused and privacy breached by selling this confidential information on to other commercial interests in what is claimed to be a de-identified form (see Gribbles).

Medical software used by doctors offers vendors an opportunity to beam advertisements into the doctors everyday activities and into clinical consultations. This practice has infuriated many doctors forcing the software vendors to back off.

Images from radiology and pictures of lesions and microscopic slides can be sent to remote experts for diagnosis or second opinion. International authorities are readily consulted. Rural areas without specialist support can secure early expert opinion.

Internet and computer based support for medical practice is something I strongly support but there are dangers and compromises to be made.

It does remove the expert from clinical colleagues and as such impacts on collegiality and clinical discussion. This is particularly so when radiologists in one country are offering services in another simply because the company they work for has tendered for that service more cheaply. Australian companies have targeted the NHS in the UK with plans to report in this way. Some US groups now exploit the time gap to set up offices in Australia. These provide after hours radiology services to the USA. Legally the radiologists must be registered to practice in the USA.

Jul 2002 Tele-radiology to the USA

Online diagnosis is not new, but cheaper and faster internet connection is allowing medical applications to expand globally.
Teleradiology is an example, where x-rays and scans are sent via the net for diagnosis within minutes by a radiologist thousands of kilometres away.

Monte Zarlingo is medical director of Nighthawk Radiology Services in Sydney, a team of seven US radiologists exported to Australia last October to provide after-hours radiology services for American emergency wards suffering from a shortage of experts.

The time difference allows the Nighthawks to work a 10am to 10pm shift from the 27th floor of their George Street headquarters assessing x-rays and scans taken in the US from 8pm to 8am.

"We can get a standard CT head scan sent to us within one minute and we can get the report back in five minutes," said Dr Zarlingo.

"The patient doesn't know if we're in the next room or halfway across the world.
Getting inside your head from half a world away. The Australian July 26, 2002

Apr 2004 Internet ordering and reporting

Health Communication Network Ltd announced a long term agreement with Sonic Healthcare Ltd to enable users of Medical Director electronically to send orders for pathology and radiology tests to Sonic laboratories over the internet.

Under the agreement with Sonic, revenue to HCN will increase as the number of pathology and radiology tests ordered electronically by Medical Director users increases.

HCN has agreements in place with Sonic Healthcare and Mayne Health to produce electronic pathology orders from its Medical Director application.

HCN plans to release versions of Medical Director for specialists over the next 12 months.
INTERNET ORDERING IMPLEMENTED FOR PATHOLOGY AND RADIOLOGY Australian Company News Bites April 1, 2004

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Standards of Care

Overall diagnostic standards in radiology and pathology in Australia are very good. Accreditation and process works better in these areas than in clinical activities. There are consequently few reports of systemic failures in services. Concern about the standard of reporting of PAP smears across a number of laboratories gave rise to some concern in 2002. The frequency of missed diagnoses did not meet Australian standards.

Mar 2002 Failed PAP smears

Those familiar with the process know it is not a perfect test, which is why they have been reluctant to join the chorus of outrage that has erupted since the revelations over the past 10 days that three laboratories - one in Victoria and two in New South Wales - have been stripped of their licences to conduct pathology testing by the national standards body.
General Diagnostic Laboratories in Melbourne, Medtest, which operates at Sydney's Fairfield and Westmead hospitals, and the defunct Wielebinski Pathology at Lane Cove in northern Sydney are being investigated after claims that up to 30,000 women may have received incorrect Pap smear results for cervical cancer.

The Health Insurance Commission has taken the rare step of cutting off the laboratories' Medicare accreditation, a move GDL is contesting in the Administrative Appeals Tribunal.
In The Eye Of The Beholder The Age (Melbourne) March 16, 2002

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International Expansion

Health care companies are growth companies. Their share price, and their competitiveness in raising capital is largely dependent on continued growth.

Opportunities for further expansion in pathology started running out in about 2000 and radiology a few years later.

Gribbles was once 50% owned by a Malaysian group but they soon sold out leaving Gribbles wth their regional holdings. Gribbles expanded these throughout the region and more widely. Healthscope acquired them when it bought Gribbles.

MIA purchased a radiology business in the UK and a pathology business soon after. The pathology business was sold to Sonic and DCA acquired the radiology business when it acquired MIA. These two companies have formed an alliance aimed at winning contracts from the NHS.

Sonic has used the UK business as a base from which to expand into Europe, then into the UK, and subsequently the USA.

New Zealand has been a target for expansion in radiology, pathology and aged care.

The international expansion of these companies is addressed in detail on their own web pages.

Jul 2002 Opportunities dry up in Australia

The moment of truth for Sonic Healthcare's management team has arrived. Its "phase II" expansion-by-acquisition program in Australia has come to a close and new strategies are to be employed.
Sonic refers to this new period as "phase III", in which it has promised to expand through rationalisation and overseas growth.

"Acquisition-led growth is over in Australia, which means management now has to deliver on potential," Salomon Smith Barney analyst Andrew Goodsall said.
Sonic enters next phase of growth. Australian Financial Review July 10, 2002

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Part II : The companies

This section briefly summarises each major company and provides a link to the web pages of those companies which have separate web pages. It indicates where corporate practices have given rise to concern.

There are companies which are primarily diagnostic companies and I will deal with these first. Currently (2006) there are three major corporate providers of pathology Sonic Healthcare, Symbion Health (the new name for Mayne Health), and Healthscope which purchased Gribbles in 2004. There are also three companies dominating the imaging business. DCA's subsidiary I-Med, Sonic Healthcare and Symbion Healthcare.

A second group of companies have been primarily General Practice companies which have also owned some diagnostic subsidiaries to whom they hoped their doctors would refer. Only Primary Health owns a significant slice (4%) of the pathology market. Only a brief reference is given to these groups here. There is another page written in 2002 and recently updated which examines the corporatisation of General Practice as a separate issue.

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Diagnostic Companies

Sonic Healthcare

Sonic Healthcare's success story started in 1992 when a young accountant Michael Boyd bought into a struggling small company for only a few cents per share. He switched to concentrate on pathology and appointed histo-pathologist Dr. Colin Goldschmidt as CEO.

The company divested its other interests but entered radiology in 2000. Over the 13 years since 1992 Sonic has built a massive global empire spanning Europe, the USA, Asia, New Zealand and Australia. It consistently exceeds its positive financial forecasts. Its performance has been incredible and its reputation for socially responsible conduct impeccable. It is almost too good to be true.

Most worrying about Sonic is its handling of the pressures it faced when the corporatisation of General Practice got under way. Sonic's Goldschmidt had made much of the company's relationship with doctors and its refusal to compete with its referring doctors. It was soon threatened with the potential loss of its referral base as others corporatised its customers.

The response was for Boyd to independently found two companies, Foundation Healthcare, which owned general practices and medical centres, and Lifecare which operated paramedical and related services in these centre's. Sonic took a minor investment in Foundation and reached an agreement which gave it first option in Foundations Medical Centres.

Because Foundation's income came from general practice it was never profitable. The profits came from pathology and radiology and these went to Sonic. Boyd's reputation and market enthusiasm soon boosted share prices to high levels. Foundation rapidly bought General Practices at inflated prices and paid with shares which traded at a premium.

When profits failed to materialise shareholders lost most of their money with shares ultimately trading at only a few cents. LifeCare, which was also in trouble merged into Foundation and they were renamed Independent Practitioners Network. Sonic gave support in a variety of ways and kept the company solvent.

The issue here is whether Boyd and Goldschmidt really believed that Foundation could be profitable from General Practice fees alone - particularly as they paid more than competitors for doctors practices. Alternately was this a cynical deception of investors and doctors to get them to buy and secure Sonic's referral base leaving Sonic's illusion of propriety intact? Boyd had a reputation as a very shrewd businessman and his fortune invested in Sonic was threatened.

Primary Health exposed this sham façade and put an end to it by mounting a hostile takeover of IPN. The majority of unhappy shareholders were only too eager to unload what was left of their investment. Sonic was forced to up the ante and outbid Primary, eventually acquiring the whole of IPN. It is now a wholly owned subsidiary.

The market and business capitalise on the weakness and cupidity of others - that’s the share market and the corporate marketplace. Risk is seen as an integral part of investment. Honesty is a word not a value. This was simply a shrewd business move.

The issue here is whether this is the sort of environment in which health care, a service to the vulnerable and trusting, given at a time when their resourcefulness is impaired, can fulfil its mission.

Mayne Health

Mayne Health originated in a massive trucking company which developed multiple other interests. It had a criminal history and there were multiple other worrying issues. When its practices were exposed it moved to health care and gradually sold off almost all its other businesses. It was primarily a hospital company but soon followed others into pathology in the 1990s and radiology in 2000. It also quietly bought about 50 medical centres. (There is a separate page briefly examining these sectors) It became a massive, integrated diversified health giant and bought into pharmacology as well. The General Practice section was never profitable and Mayne could not find a buyer fot it.

Mayne enjoyed close relations and support from politicians but consistently alienated the doctors on whose support it depended - so consistently under-performed financially. It seldom matched its competitors.

A newly appointed Mr Fixit in 2000 introduced management strategies which doctors considered unethical, compromised care in its hospitals and removed doctors from decision making. Doctors took their patients elsewhere and by 2002 the company was in serious trouble. In 2003 the company sold all of its hospitals to venture capitalists led by a Citigroup subsidiary. Citigroup has an dreadful track record of fraud and of facilitating fraud by its customers.

In 2005 Mayne broke up further with the pharmacology section retaining the name Mayne. The remainder including pathology, radiology and general practice sections assumed the name Symbion Health - presumably to distance itself from Mayne's tarnished record.

Gribbles Pathology

In 1987 Wallace Cameron a tax lawyer and promoter of tax schemes joined Bruce Mathieson, a Poker machine baron in a business venture. They bought Gribbles pathology practice, a private business and embarked on a program of expansion. In 1996 Mathieson sold his share to a Maylaysian company which three years later sold to oil and mining businessman Ian Trahar's Medical Care Services (MCS). MCS was a market listed General Practice company with pathology and radiology holdings. In the process the company acquired holdings in Malaysia and surrounding countries. Cameron's Gribbles listed on the share market by a reverse takeover of MCS in 2001.

Throughout this period the company was guided by Wallace Cameron. It grew rapidly in Australia and in multiple other countries. Cameron's personal record and that of the company was very controversial. It was plagued by scandal, accused of kickbacks to doctors and of a lot of other worrying practices including problems with tax schemes. Throughout Cameron's career he and Gribbles aggressively fought multiple court actions against authorities including the Health Insurance Commission and the tax office. Even though the allegations, confirmed by a senate inquiry date back to the 1980s Gribbles was never convicted of paying kickbacks. Although there is little doubt about the practices it seems that there was difficulty in proving that they were illegal.

It finally all fell apart and by 2003 Gribbles was in serious financial difficulties. Some questionable strategies to get around the problems came unstuck. Cameron was fired and the company was put up for sale. It was bought by Healthscope in December 2004.

During the sale worrying information emerged about Cameron's holdings and his actions as a director - particularly his disclosures to the market. These are currently under investigation by ASIC, the regulating authority.

This is a long and interesting story told on the Gribbles web page.

Healthscope

This was a hospital company which after a long period of losses became very profitable but by 2004 there were few opportunities to expand in Australia. It entered pathology by buying Gribbles. Some analysts had reservations about this move. Initially it claimed profitability and to have integrated Gribbles successfully. In 2006 it downgraded its forecasts and reported difficulties in its pathology operations. This was soon after it had issued an annual report and gone to the market to raise capital. No anxiety had been expressed in the prospectus. The market felt deceived and the share price plunged.

Macquarie Pathology

Macquarie was a pathology empire founded by Dr Tom Wenkart, a controversial medical colleague and early associate of the notorious Edelsten and McGoldrick. Macquarie became the largest pathology business in NSW. There were multiple disturbing matters related to the holding company Macquarie Health and the pathology company. These included allegations of kickbacks to doctors - allegations never prosecuted. By the late 1990s the pathology section was in serious trouble and this section was bought by Mayne Health.

Medical Imaging Australia (MIA)

MIA was formed by a group of doctors in 2000 in order to capitalise on the consolidation of radiology. It listed on the sharemarket, raised capital and expanded very rapidly to become Australia's largest radiology corporation. It seemed to be very profitable and analysts were upbeat. As opportunities dried up in Australia it looked at the United Kingdom and the potential profits to be gained by winning contracts from the NHS. The Blair labour government had adopted a policy of contracting out services. MIA bought into radiology and pathology in the UK.

This all came unstuck with large losses from pathology and disappointment from radiology. It was soon in trouble. It sold its pathology business to Sonic, restructured its management and then sold the entire business to DCA's I-Med in 2004.

It is a measure of the way commercial issues and growth came to dominate this group, which claimed to involve its radiologists, that it bought into Total Body Scanning.

DCA and I-Med

A condition of the acceptance of the post of Managing Director of the commercial investor DCA ,by experienced businessman and entrepreneur David Vaugh in 1998, was that the company sell of its many enterprises to focus on radiology and nursing homes.

The company was consequently cashed up and expanded very rapidly in Australia. Its rapidly growing radiology business, I-Med was very profitable. It used this profit stream to fund its expansion into nursing homes which were less profitable but a sector which Vaux seeks to dominate. DCA entered the international nursing home market buying large holdings in New Zealand.

DCA acquired MIA in 2004 making it Australia's largest imaging conglomerate. With MIA came its UK radiology business. It is now pursuing NHS contracts aggressively.

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General Practice Companies

The corporatisation of general practice is addressed on another web page. As indicated above much of this corporatisation was tied to some of the large pathology corporations.

General practice corporations also purchased a small number of pathology and/or radiology operations to which their GPs were expected to funnel referrals. Only a list and a few comments are given below.

Primary Health

This company was originally founded by GP Dr Edmund Bateman in the 1980s during the Edelsten and McGoldrick era. Unlke Edelsten and McGoldrick's general practice ventures Primary has prospered and made Bateman a millionaire. Like Gribbles Primary has had its share of controversies with allegations of five minute medicine and investigation by the Health Insurance Commission. It has been very aggressive in its legal battle with the HIC and with its critics whom it has taken to court. It has never been convicted. It now claims that its doctors spend adequate time with patients.

Primary owns 4% of the pathology market and also has some radiology. It buys GP's practices for large sums. Unlike its competitors it does not charge patients co-payments so operates in poorer areas where others who depend on co-payments cannot compete. It makes more money by charging less. It seems to have been far more successful in capturing its GPs referrals but how it accomplishes this and becomes very profitable where other fail is not clear. It refused to sign the voluntary agreement on corporate practices agreed to by the government and the AMA. Bateman is highly critical of the business model of his competitors and of the AMA. He has been commercially very successful and is the only group still buying general practices.

Foundation Healthcare/IPN

One of the largest GP companies, Foundation Healthcare was for all practical purposes Sonic's GP referral corporation (see above) created with the illusion of independence. It merged with LifeCare and became IPN and was eventually fully acquired by Sonic.

LifeCare

Also a Sonic related entity it corporatised physiotherapy, dentistry and a number of wellness and health services aiming to locate in Foundation centres. It did poorly and merged into Foundation.

Endeavour Healthcare

This was Kerry Packer and other powerful figures entry into the GP corporatisation business. It merged existing Western Australian GP corporations to form the company in 2000 and listed on the share market. It then expanded into other states. Endeavour owned pathology and probably some radiology services but unlike Primary Health failed to prosper. It eventually gave up and sold its facilities to Sonic and its medical practices to Foundation/IPN.

Revesco - Medical care Services - Gribbles

Revesco was a company acquired by Ian Trahar, a Shell trained businessman who had been in mining. It listed on the share market, bought up GP, pathology and radiology businesses and bought a 49% interest in Gribbles. It did not do well. In 2001 Gribbles executed a reverse takeover of the business and Trahar lost interest.

This section of Gribbles was not profitable but Gribbles could not find a buyer for some years. In 2004 it sold this business to the new National Medical and Imaging Group (NMIG).

National Medical and Imaging Group (NMIG)

This was formed by a number of past Endeavour Healthcare staff who felt that they could make GP corporatisation profitable. The company has not been listed and I have no more information.

Superclinics and Supercare

Superclinics and Supercare operated in the 1980s. Superclinics were founded by the notorious Dr Geoffrey Edelsten who was deregistered and spent time in prison. Almost as controversial a figure Dr McGoldrick, helped him out and was then involved in a bitter battle with him.

McGoldrick founded Supercare another chain of GP clinics where he treated patients while he was not registered as a medical practitioner. His applications to register again, after a long series of medical misadventures saw him resign, had been repeatedly rejected.

Supercare was one of a maze of complicated interlinked companies related to the McGoldrick family. They were characterised by financial problems, bankruptcy, and fraud investigations.

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Web Page History
This page created February 2006 by Michael Wynne

Overexposed to the corporates

2009-09-20T01:51:00.001-07:00

Overexposed to the corporates

12/12/2008 11:30:01 PM

In July 2000, Sydney radiologist Adam Steinberg wrote to the professional body that represents his medical specialty. At the time, it was all the rage for doctor partnerships to sell their traditional practices to sharemarket-listed companies.

Soon more than half the private X-rays, ultrasounds and other radiology services in Australia would be provided by just three companies. Investors were keen to gain economies of scale by expanding and doctors welcomed the opportunity to hand over the paperwork to professional managers, not to mention the chance to cash in.

But Steinberg's letter to the Royal Australian and New Zealand College of Radiologists called it "a new and dark era". "We are the new pariahs of the medical fraternity," he wrote. "Pseudo quasi businessmen masquerading as doctors, seen as completely money-orientated, happy, willing and seeking to sell ourselves, our services and our souls to the highest bidder."

In a comment that resonates with the crisis in child care triggered by the collapse of ABC Learning Centres, Steinberg warned of "taking money away from the public hospital system [where we all trained] to allow non-medical, non-radiology 'shareholders' and businessmen [overseas and local] to profit from taxpayers and the health-care dollar".

Eight years on, investors have done well from so-called "corporate medicine".

Sonic Healthcare and Primary Health Care - the two biggest companies running clinics staffed by general practitioners, radiologists and pathologists - have grown dramatically and profitably.

Even in these gloomy times, the sharemarket values them at $5 billion and $1.7 billion respectively, and stockbroking analysts are lauding their "defensive" or recession-proof outlook, buffered by Medicare rebates. Until the credit crunch began to bite a year ago, the sector also attracted the attention of private equity firms with billions of dollars to invest.

But it has not been a universally happy ride for doctors. On Monday the first of 15 planned radiology clinics in NSW opened its doors. The practices will be owned and run by an old-fashioned partnership of the radiologists and nuclear physicians who work in them. The 35 specialists involved have experienced three different versions of corporate medicine in the past eight years. Now they are returning to the model they discarded in 2000.

The name PRP Diagnostic Imaging is new. But the heart of the company is the long-established Pittwater Radiology Partnership. The chairman of the partnership, Michael Jones, acknowledges he and his colleagues will be returning to a system they viewed as having drawbacks in 2000. "The difficulty with our business is the extent of capital required; we need a lot of money to fund the equipment," Jones says.

The humble X-ray is now accompanied by the ultrasound, the mammogram, computerised tomography, magnetic resonance imaging and positron emission tomography. Radiology clinics are time-consuming to run, with each specialist typically supported by seven or eight technical staff, such as radiographers, and several front-office employees.

Jones says the partners were attracted to the concept of leaving business decisions to managers. "Like a lot of people in small business, they imagine that someone out there can do it better than they can, has more knowledge about how things should be done," says Jones. "I think we all went into it with great optimism; the hope was that we would have more time to spend on radiology."

Back in 2000, the partners of Pittwater Radiology merged with similar practices around the country and listed on the sharemarket as Medical Imaging Australasia. It was majority-owned by doctors and three of the six directors, including the managing director, were radiologists. Their days as an independent company ended in 2004 when, with a share price languishing well below the float price, MIA was taken over by DCA Australia, an investment company that several years earlier had decided to diversify into radiology and aged care. The Pittwater partners found themselves an even smaller part of a conglomerate.

Two years later, DCA was courted by CVC Asia Pacific, the private equity group that is now struggling to pay the interest on the billions of dollars it borrowed to buy a majority stake in the Nine Network and the Australian Consolidated Press magazine group. CVC paid $2.7 billion to privatise DCA, and last year sold the aged-care business for $1.2 billion. There is now a hole in CVC's remaining investment, thanks to the walkout by the Pittwater Radiology partners.

Back in 2000, they made a decision that would prove crucial. Unlike many of their counterparts who dissolved their partnerships and signed up individually with companies, the Pittwater partners decided to stick together. Jones says it had long been a "harmonious, productive, successful partnership" with strong social links. "We just thought there was no point in dissolving it."

The partnership signed a contract to provide radiology services to MIA, and later DCA. That meant that when they wanted to leave, they had the critical mass to start new clinics. That point came in late 2006 when they learned that DCA was selling to the private equity firm.

James Christie, a PRP partner and member of the executive committee that will oversee the new clinics, says the third change in six years came as the partners had been gradually losing enthusiasm for the corporate structure. There was too much focus on profit and too little consultation about long-term investment, particularly in equipment.

But the main trigger was that the radiologists didn't like "being bought and sold without any say in the process," Christie says. "We just decided that was going to keep happening to us and it was probably going to happen again very quickly." In 2006 the newspapers were full of articles about the modus operandi of private equity, which typically involved buying full control of a company, cutting costs away from the scrutiny of the sharemarket, and then selling for a profit within three to five years.

The Pittwater partners terminated the contract, which obliged them to give two years' notice, a period that expired in November. PRP plans by February to have clinics open on Sydney's North Shore, northern beaches and north west, on the Central Coast, in the Illawarra and in the Central West.

The partners have leased the equipment, hired the technicians and support staff and rented the 15 premises. A partnership executive committee will meet several times a month with an operational manager and financial manager. As older partners retire, young radiologists will be invited to buy their shares in the partnership.

Steinberg sees this as far preferable to older radiologists selling an entire practice to a company. "It sells the next generation into some sort of slavery," he says. "It's totally selfish and I just don't believe medicine should be like that. Everyone wants to earn a good income but one of the big things about radiology which has changed and caused a lot of upset is that radiologists have lost ownership."

He says relations with patients were not greatly affected under corporate ownership, but "the appetite for young radiologists to join if you have nothing to offer them except working for a corporate was very limited". The technical and support staff were also unsettled by "this constant cloud of uncertainty about where the business was going, who would own it and what the future was".

Naturally there is no guarantee the new venture, which requires a big upfront investment by the partners, will work. The CVC clinics with which they will compete are already established, in carefully chosen locations. Perhaps more importantly, Medicare rebates for the most lucrative radiology work - magnetic resonance imaging or MRI - are limited by a government licensing scheme.

The Pittwater partners will leave behind the MRI licences held by CVC. They will only do MRI scans for patients willing to pay the high cost from their own pockets. On the other hand, a successful radiology business depends on referrals from general practitioners and specialists.

The Pittwater partners have their own networks, and, while demand for newer technologies is increasing, X-rays and ultrasounds still account for more than 80 per cent of Medicare-funded radiology work.

Jones says the partners have come to terms with the failure of their search for a better structure. "You get to the end of that road and realise that it doesn't exist and that you did it the best way the first time around," he says. "So we have that. It's like a second marriage. You use all of the knowledge that you have gained to that point to make it work."

If the new venture succeeds, he cannot envisage PRP being tempted into a corporate expansion. "The thing that makes our partnership survive is that we all meet fairly regularly, we all know each other very well, we are all close friends," he says. "If we had twice as many or three times as many we wouldn't have that. Then we would just be an organisation."

http://gigtv.rampms.com/gigtv/Viewer/?peid=5bdb049d896245b4a93ce12a2051242d

2009-09-05T14:36:00.001-07:00

Aortic Dissection Surgical Perspectives and Intervention
Presenter(s): Ian Nixon M.D., Dept of Cardiothoracic Surgery, St Vincents Hospital, University of Melbourne
Air Date: 1/22/2009

PNEUMOTHORAX CALCULATOR

2009-06-23T13:44:00.000-07:00

http://www.chestx-ray.com/calculator/PTX.html
Size estimation
Common clinical surgical rule: pneumothorax greater than 25% requires chest tube drainage
Drainage actually depends on physiologic status of patient

Small pneumothorax may be devastating in COPD patient with little reserve and conversely a tension pneumothorax may be well tolerated in young athlete

Air slowly resorbs from the pleural space at a rate of approximately 1.5% / day. This rate will increase with use of supplemental oxygen. (Nitrogen is the largest component of the atmosphere and is not metabolized. Thus the partial pressure gradient between the air in the pleural space and capillary blood is small. If nitrogen is decreased by increasing the inspired oxygen concentration, the rate of resorption will increase.)

HISTORY OF MYSORE MEDICAL COLLEGE:

2009-02-14T04:52:00.001-08:00

HISTORY OF MYSORE MEDICAL COLLEGE:

The Mysore City once during the British rule called the Birmingham of India has been a model state under the able control of the Royal Dynasty of Wodiyars. Krishnaraja Wodiyar IV (1902 - 1940) was the model king, with his efficient efforts to improve the welfare of the citizens, like organizing proper education, schools and colleges health and welfare programmes. Although we were under the British rule, he dared to introduce bilingual system of education with Kannada besides English. Our Alma Mater Mysore Medical College is the brainchild of Krishnaraja Wodiyar.

The First 25 Years - 1924-1949

THE BIRTH OF THE COLLEGE AND THE TRANSITION PERIOD

Sri Krishnadevaraja Wodiyar was the founder of Mysore Medical College in 1924. Prior to 1924 and as far back as 1881, there were no medical institutions in the erstwhile state of Mysore, hence the concept of giving Medical education was started in 1881 and to train the personnel for this purpose students were being selected, they were called the "Hospital Assistants" and were being given scholarship and sent to places like Madras and Bombay to undergo a course in Medical Colleges.

In the course of time due to certain constraints like providing accommodation to students, the Madras Presidency expressed inability to admit Mysore State students. "Necessity was the mother of invention". The Government of Mysore sanctioned a scheme in April 1917 at Bangalore to train the then called "Sub Assistant Surgeons", and directed that the "Mysore Medical School" be started. Although it was started at Bangalore, as it was the 1st of its kind in the state of Mysore, if was named as Mysore Medical School.

To start with 16 pupils were selected and were provided teaching facility at the Victoria Hospital and the course was for 4 years to be qualified for LMP. The medical officer i/c of Victoria Hospital was the Principal. The Mysore Medical School was managed by a council consisting of the Principal and 4 Lecturers and the Senior Surgeon of Victoria Hospital was the controlling authority. In the year 1924-25 this Medical School was raised to the grade of a college called as the Mysore Medical College; then the candidates were prepared for Medical Degrees and the college was affiliated to the University of Mysore.

The King was keen on providing medical education in a serene Royal city the Birmingham of India, the pensioners paradise, the city of palaces and parks, hence at the behest of Sri Krishnaraja Wodiyar the College was shifted from Bangalore to Mysore in the year 1930.

The foundation stone was laid in 1930 by H.H. Krishnaraja Wodiyar and the Majestic looking Mysore Medical College main building was constructed by the then famous contractor of Mysore, Boraiah Basavaiah & Sons

Our Alma Mater has been a gift by our Highness to us. We are proud today, that we are the products of this illustrious college, was the 1st of its kind in the state and the 7th in the entire country in those days.

In the year 1930, 30 students were admitted to the college and to start with anatomy and physiology Departments were established and growing further they were given clinical training at the K.R. Hospital and Cheluvamba Hospital which were functioning at Mysore prior to Mysore Medical College at Mysore. The then superintendent of the K.R. Hospital and a renowned personality, Dr. J.F. Rabinson was selected as the Principal of the College after Dr. S. Subba Rao. Dr. Shyama Sastry was the 1st student to get 1st class in MBBS who retired as DMS.

From 1930 onwards for nearly 25 years our college remained as the sole medical institution in the entire state giving outstanding education with a proven excellency. During the 1st 25 years of its existence, it is worth remembering the names of the teaching faculty who were indeed stalwarts, great mentors, dedicated personalities and luminaries according to the tales I heard from my teachers and seniors who taught them and inspired.

The following are some of the names of those stalwarts.

Dr. B.K. Naraya Rao, Dr. Col. Nagendra , Dr. B.N. Balakrishna Rao, Dr. K. Srikantaiah Rao Bahadur, Dr. B.T. Krishnan, Dr. J.F. Robinson, Dr. V.R. Naidu, Dr. C. Krishnaswamy Rao, Dr. Y. Appaji, Dr. Adhikeshavalu, Dr. T. Seshachalam, Dr. Hirannaiah, Dr. R.E. Heilig.

Some of them were Palace Doctors

Silver Jubilee of the College was celebrated in 1947, inaugurated by Sri H.H. Jayachamaraja Wodiyar presided by Dr. A. Lakshmanswamy Modaliyar, the Vice-Chancellor of Madras University and a pre-eminent personality in the medical field and Dr. Amrith Kaur, the then Union Minister for health was the guest of Honour.

During the Silver Jubilee celebrations, the Student Secretary was Dr. K.C. Pani who is a living legend witnessing the Platinum Jubilee celebration along with us who contributed lot of information and portraits of the past.

The Silver Jubilee period for 25 years has been an era of Stalwarts.

The Next 25 years (1949-1975)

This period has been the era of growth and development. This has been a golden era in the history of Mysore Medical College. It is during this period many Mysore Medical College graduates moved to various parts of the world mainly USA, UK, Canada. Many of them have proved their excellence and distinguished themselves in various fields as clinicians, academicians and administrators, etc..

The teachers were eminent and devoted who had involvement in their respective fields, quotable among them were Dr. Rajagopal from the Department of Anatomy who dissected Elephant for comparative Anatomy, Dr. Krishne Urs had a Silver tongue in teaching Anatomy, Dr. Thakar Nayak as a sober Anatomy teacher.

From the Department of Physiology, Dr. Narayan Setty was famous for his explaining the "Theory of Equilibrium". Dr. B.V. Puttaraj Urs by his majestic look and teaching, Dr. Sampathkumaran, Professor of Physiology is a living legend, Dr. D.S. Shivappa from the Department of Pharmacology who had unique quality of writing medical terms in Kannada. Dr. Krishna Bhargava and Dr. Saraswathi Bhargava, Dr. Charles D'souza were committed teachers in Pathology. Dr. S.P. Anikar in the Department of P&SM was a great witty teacher.

There was a galaxy of eminent teachers and clinicians in the clinical side (other side of the road as we used to call) consisting of Medicine, Surgery, OBG, Pediatrics that included Dr. Govinda Setty, Dr. Basavaraj Urs, Dr. K.G. Das, Dr. Y.P. Rudrappa, Dr. N.A. Jadhav, Dr. M.V. Govindappa, Dr. Gurupadappa from the department of medicine and Dr. A.K. Gopal Rajan, Dr. H. Nanjarajaiah, Dr. R.H.N. Shenoy, Dr. Narayanaswamy, Dr. Jeevandharakumar, Dr. P.R. Sathyanarayan Setty from the Department of Surgery.

From the Department of OBG: Dr. Leelavathy Reddy; Dr. Vyjayanthi, Dr. Lalitha Lingaiah and Dr. Jayalakshmi Iyer.

From Pediatrics : Dr. Indira Amla, Dr. Anke Gowda and Dr. Manikya Raju.

During the first half of this quarter academically it was exemplary. Many brilliant and outstanding students like Dr. M.V. Govindappa who took 1st class in Final MBBS after a gap of 32 years next to Dr. Shama Sastry's record in the Mysore University. Many other brilliant students were trained, mentioning all names is impossible but may be available at University Gazetteer.

As there were no private teaching institutions and Corporate Hospitals were yet to come up, the Mysore Medical College with its attached Hospitals like K.R. Hospital, Cheluvamba Hospital, was in the forefront to serve the needy persons at large.

The Krishnarajendra Hospital at Mysore was constructed at a cost of Rs. 3,65,000/- and started as a 100 bedded Hospital with X-ray apparatus.

Silent tributes to the aesthetic sense of our Royal Dynasty who created things of beauty, because of the strong British influence on the Princes, the structures built during their rules are still engineering feats incorporating architectural designs, our K.R. Hospital is one among them evoking nostalgia of the past.

The royal family was very much concerned about the health of their citizens hence they built this hospital. The last ruler of Mysore Sri Jayachamaraja Wodiyar was once treated in this hospital when he got injured while hunting in the forest is an anecdote.

Cheluvamba hospital is already 120 years old, built in 1880with 24 beds, was first named as Vanivilas Hospital, when it was upgraded to 200 bedded hospital with 2 storied building in 1939 it was renamed as Cheluvamba Hospital. Further expansion in 1954 to 3 storied building named as women and children block. New OPD Block of OBG built in 1997 is added Dr. Mrs. Hanumattekar was outstanding teacher and improved the standard of Hospital.

The post of the Dean was created in 1961 vesting in him the administrative charge of both the college and the attached teaching hospitals with a view to ensure co-ordination of both teaching and hospital administration assisted by Vice-deans from K.R. Hospital and Cheluvamba hospital and this system existed for 14 years until 1974 when the post of Principal was redesignated with Superintendents I/C of the Hospital. The Unit system came into force from 1961.

Ending with platinum Jubilee and just coinciding with the end of this millennium - This era has been a vibrant period in accordance with the global changes in scientific advancements and the use of gadgets, the administration has been trying its best to march ahead, establishing cold storage mortuary, expansion of the buildings, equipping the departments with modern instruments, modernizing the blood bank, establishing Burns ward. Superspeciality departments like Plastic Surgery. Urology, nephrology, cardiology, Laser Surgery, Emergency O.T. etc., are introduced.

One of the most modern bedded Air conditioned ICCU is now established since 1998 in the ground floor of newly built multistoried OPD building towards Dhanvanthri Road is a massive structure behind the spacious special wards of our days.

For the past 25 years of the history of our Alma Mater, I have tried to narrate the story partly with the best of my knowledge and the information I gathered through the present Principal.

Mysore Medical College - our college has sailed through the SAGA of 75 years, during this journey, the various expansion programmes and academic achievements which culminated in the development of this illustrious institution that is academically on par with any in the nation, is founded by H.H. Krishnaraja Wodiyar, nurtured and guided by series of eminent teachers and 23 administrators - Deans and principals like

Dr. S. Subba Rao
Dr. H.B. Myalvagnam
Dr. B.K. Narayana Rao
Dr. J.F. Robinson
Dr. C. Krishnaswamy Rao
Dr. B.T. Krishnan
Dr. Y. Appaji
Dr. G.S. Raghunatha Rao
Dr. B.N. Lingaraju
Dr. J.J. Dharmaraj
Dr. T. Manickam
Dr. Lalitha Lingaiah
Dr. B.V. Puttaraj Urs
Dr. V. Ramachandra
Dr. Indira Amla
Dr. R.H.N. Shen
Dr. N.K. Channappa
Dr. D. Chamaraj
Dr. D. Shankar Raj
Dr. D.C. Parthasarathy
Dr. A.M. Krishne Urs
Dr. B. Lakshmi Bai
Dr. R. Seethalakshmi

Incidentally 23rd administrator of the college is the present principal Dr. R. Seethalakshmi who is blessed with 3 gifts - being the Chairperson of the alma mater celebrating Platinum Jubilee, the last Principal of this millennium and the 1st Principal of the next Millennium in a fortnight from now. We see in her the dedication and commitment to the development of our institution.

I have done my best on behalf of the Alumni of Our Alma Mater. I take this opportunity to offer pranams to all those who have rendered service to tradition, our college will grow from strength to strength and in the annals of Medical Colleges and Hospitals of the country a special place is reserved for our Alma Mater.

Text of President Obama's inaugural address

2009-01-20T11:20:00.000-08:00

My fellow citizens:

I stand here today humbled by the task before us, grateful for the trust you have bestowed, mindful of the sacrifices borne by our ancestors. I thank President Bush for his service to our nation, as well as the generosity and cooperation he has shown throughout this transition.

Forty-four Americans have now taken the presidential oath. The words have been spoken during rising tides of prosperity and the still waters of peace. Yet, every so often the oath is taken amidst gathering clouds and raging storms. At these moments, America has carried on not simply because of the skill or vision of those in high office, but because We the People have remained faithful to the ideals of our forbearers, and true to our founding documents.

So it has been. So it must be with this generation of Americans.

That we are in the midst of crisis is now well understood. Our nation is at war, against a far-reaching network of violence and hatred. Our economy is badly weakened, a consequence of greed and irresponsibility on the part of some, but also our collective failure to make hard choices and prepare the nation for a new age. Homes have been lost; jobs shed; businesses shuttered. Our health care is too costly; our schools fail too many; and each day brings further evidence that the ways we use energy strengthen our adversaries and threaten our planet.

These are the indicators of crisis, subject to data and statistics. Less measurable but no less profound is a sapping of confidence across our land - a nagging fear that America's decline is inevitable, and that the next generation must lower its sights.

Today I say to you that the challenges we face are real. They are serious and they are many. They will not be met easily or in a short span of time. But know this, America - they will be met.

On this day, we gather because we have chosen hope over fear, unity of purpose over conflict and discord.

On this day, we come to proclaim an end to the petty grievances and false promises, the recriminations and worn out dogmas, that for far too long have strangled our politics.

We remain a young nation, but in the words of Scripture, the time has come to set aside childish things.

The time has come to reaffirm our enduring spirit; to choose our better history; to carry forward that precious gift, that noble idea, passed on from generation to generation: the God-given promise that all are equal, all are free, and all deserve a chance to pursue their full measure of happiness.

In reaffirming the greatness of our nation, we understand that greatness is never a given. It must be earned. Our journey has never been one of short-cuts or settling for less. It has not been the path for the faint-hearted - for those who prefer leisure over work, or seek only the pleasures of riches and fame. Rather, it has been the risk-takers, the doers, the makers of things - some celebrated but more often men and women obscure in their labor, who have carried us up the long, rugged path towards prosperity and freedom.

For us, they packed up their few worldly possessions and traveled across oceans in search of a new life. For us, they toiled in sweatshops and settled the West; endured the lash of the whip and plowed the hard earth.

For us, they fought and died, in places like Concord and Gettysburg; Normandy and Khe Sahn. Time and again these men and women struggled and sacrificed and worked till their hands were raw so that we might live a better life. They saw America as bigger than the sum of our individual ambitions; greater than all the differences of birth or wealth or faction.

This is the journey we continue today. We remain the most prosperous, powerful nation on Earth. Our workers are no less productive than when this crisis began. Our minds are no less inventive, our goods and services no less needed than they were last week or last month or last year. Our capacity remains undiminished. But our time of standing pat, of protecting narrow interests and putting off unpleasant decisions - that time has surely passed. Starting today, we must pick ourselves up, dust ourselves off, and begin again the work of remaking America.

For everywhere we look, there is work to be done. The state of the economy calls for action, bold and swift, and we will act - not only to create new jobs, but to lay a new foundation for growth. We will build the roads and bridges, the electric grids and digital lines that feed our commerce and bind us together. We will restore science to its rightful place, and wield technology's wonders to raise health care's quality and lower its cost. We will harness the sun and the winds and the soil to fuel our cars and run our factories. And we will transform our schools and colleges and universities to meet the demands of a new age. All this we can do. And all this we will do.

Now, there are some who question the scale of our ambitions - who suggest that our system cannot tolerate too many big plans. Their memories are short. For they have forgotten what this country has already done; what free men and women can achieve when imagination is joined to common purpose, and necessity to courage.

What the cynics fail to understand is that the ground has shifted beneath them - that the stale political arguments that have consumed us for so long no longer apply. The question we ask today is not whether our government is too big or too small, but whether it works - whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified. Where the answer is yes, we intend to move forward. Where the answer is no, programs will end. And those of us who manage the public's dollars will be held to account - to spend wisely, reform bad habits, and do our business in the light of day - because only then can we restore the vital trust between a people and their government.

Nor is the question before us whether the market is a force for good or ill. Its power to generate wealth and expand freedom is unmatched, but this crisis has reminded us that without a watchful eye, the market can spin out of control - and that a nation cannot prosper long when it favors only the prosperous.

The success of our economy has always depended not just on the size of our Gross Domestic Product, but on the reach of our prosperity; on our ability to extend opportunity to every willing heart - not out of charity, but because it is the surest route to our common good.

As for our common defense, we reject as false the choice between our safety and our ideals. Our Founding Fathers, faced with perils we can scarcely imagine, drafted a charter to assure the rule of law and the rights of man, a charter expanded by the blood of generations. Those ideals still light the world, and we will not give them up for expedience's sake.

And so to all other peoples and governments who are watching today, from the grandest capitals to the small village where my father was born: know that America is a friend of each nation and every man, woman, and child who seeks a future of peace and dignity, and that we are ready to lead once more. Recall that earlier generations faced down fascism and communism not just with missiles and tanks, but with sturdy alliances and enduring convictions. They understood that our power alone cannot protect us, nor does it entitle us to do as we please. Instead, they knew that our power grows through its prudent use; our security emanates from the justness of our cause, the force of our example, the tempering qualities of humility and restraint.

We are the keepers of this legacy. Guided by these principles once more, we can meet those new threats that demand even greater effort - even greater cooperation and understanding between nations. We will begin to responsibly leave Iraq to its people, and forge a hard-earned peace in Afghanistan. With old friends and former foes, we will work tirelessly to lessen the nuclear threat, and roll back the specter of a warming planet. We will not apologize for our way of life, nor will we waver in its defense, and for those who seek to advance their aims by inducing terror and slaughtering innocents, we say to you now that our spirit is stronger and cannot be broken; you cannot outlast us, and we will defeat you.

For we know that our patchwork heritage is a strength, not a weakness. We are a nation of Christians and Muslims, Jews and Hindus - and non-believers. We are shaped by every language and culture, drawn from every end of this Earth; and because we have tasted the bitter swill of civil war and segregation, and emerged from that dark chapter stronger and more united, we cannot help but believe that the old hatreds shall someday pass; that the lines of tribe shall soon dissolve; that as the world grows smaller, our common humanity shall reveal itself; and that America must play its role in ushering in a new era of peace.

To the Muslim world, we seek a new way forward, based on mutual interest and mutual respect. To those leaders around the globe who seek to sow conflict, or blame their society's ills on the West - know that your people will judge you on what you can build, not what you destroy. To those who cling to power through corruption and deceit and the silencing of dissent, know that you are on the wrong side of history; but that we will extend a hand if you are willing to unclench your fist.

To the people of poor nations, we pledge to work alongside you to make your farms flourish and let clean waters flow; to nourish starved bodies and feed hungry minds. And to those nations like ours that enjoy relative plenty, we say we can no longer afford indifference to suffering outside our borders; nor can we consume the world's resources without regard to effect. For the world has changed, and we must change with it.

As we consider the road that unfolds before us, we remember with humble gratitude those brave Americans who, at this very hour, patrol far-off deserts and distant mountains. They have something to tell us today, just as the fallen heroes who lie in Arlington whisper through the ages. We honor them not only because they are guardians of our liberty, but because they embody the spirit of service; a willingness to find meaning in something greater than themselves. And yet, at this moment - a moment that will define a generation - it is precisely this spirit that must inhabit us all.

For as much as government can do and must do, it is ultimately the faith and determination of the American people upon which this nation relies. It is the kindness to take in a stranger when the levees break, the selflessness of workers who would rather cut their hours than see a friend lose their job which sees us through our darkest hours. It is the firefighter's courage to storm a stairway filled with smoke, but also a parent's willingness to nurture a child, that finally decides our fate.

Our challenges may be new. The instruments with which we meet them may be new. But those values upon which our success depends - hard work and honesty, courage and fair play, tolerance and curiosity, loyalty and patriotism - these things are old. These things are true. They have been the quiet force of progress throughout our history. What is demanded then is a return to these truths. What is required of us now is a new era of responsibility - a recognition, on the part of every American, that we have duties to ourselves, our nation, and the world, duties that we do not grudgingly accept but rather seize gladly, firm in the knowledge that there is nothing so satisfying to the spirit, so defining of our character, than giving our all to a difficult task.

This is the price and the promise of citizenship.

This is the source of our confidence - the knowledge that God calls on us to shape an uncertain destiny.

This is the meaning of our liberty and our creed - why men and women and children of every race and every faith can join in celebration across this magnificent mall, and why a man whose father less than sixty years ago might not have been served at a local restaurant can now stand before you to take a most sacred oath.

So let us mark this day with remembrance, of who we are and how far we have traveled. In the year of America's birth, in the coldest of months, a small band of patriots huddled by dying campfires on the shores of an icy river. The capital was abandoned. The enemy was advancing. The snow was stained with blood. At a moment when the outcome of our revolution was most in doubt, the father of our nation ordered these words be read to the people:

"Let it be told to the future world...that in the depth of winter, when nothing but hope and virtue could survive...that the city and the country, alarmed at one common danger, came forth to meet [it]."

America. In the face of our common dangers, in this winter of our hardship, let us remember these timeless words. With hope and virtue, let us brave once more the icy currents, and endure what storms may come. Let it be said by our children's children that when we were tested we refused to let this journey end, that we did not turn back nor did we falter; and with eyes fixed on the horizon and God's grace upon us, we carried forth that great gift of freedom and delivered it safely to future generations.

CT Enteroclysis

2008-12-09T10:55:00.001-08:00

http://media.medeserv.com.au/RANZCR2007/MMR-5125/viewer_lrgvid.html

Strike may cause hospital disruption

2008-11-25T23:30:00.000-08:00

Nick Miller
November 26, 2008

ELECTIVE surgery and outpatient appointments at some Victorian hospitals could be hit by cancellations for the rest of the week, because of industrial action by imaging staff.

Employees of Symbion Imaging, which does X-rays, ultrasounds and other medical imaging for the Northern and Broadmeadows public hospitals, the Epworth in Richmond and 30 other private hospitals and clinics, voted to take industrial action yesterday.

From today until the end of Friday, striking staff will work on imaging only for emergency patients, said Health Services Union national secretary Kathy Jackson. "If it is elective, rather than urgent, it won't be done," she said.

Symbion's staff, including radiographers, administrative workers and technicians, were frustrated by a long-running enterprise bargaining process.

"This is one of the worst employers I have ever dealt with," Ms Jackson said. "For months, they were not prepared to negotiate, then last week they offered a 2 per cent first-and-final offer. They are ripping their staff off." The Age attempted to contact Symbion and its parent, Primary Health Care, but calls were not returned.

However, hospitals contacted by The Age differed on the expected effect of the action.

A spokesman for Northern Health, which includes the Northern Hospital and Broadmeadows, said imaging staff involved in the action had agreed to perform X-rays that were deemed "medically urgent".

"We don't know what will be deemed medically urgent — it will be discussed between medical staff and radiologists," he said. "There will be no impact on emergency or ICU (intensive care) or (operating) theatre. It will be more other inpatient and outpatient services deemed not medically urgent." He believed elective surgery would go ahead.

A spokeswoman for the Epworth said: "We believe there will be no major disruption."

HEALTH & MEDICAL LEGISLATION New South Wales, Australia

2008-11-19T11:32:00.001-08:00

Civil Liability Act 2002 (NSW)

An Act to make provision in relation to the recovery of damages for
death or personal injury caused by the fault of a person; to amend the
Legal Profession Act 1987 in relation to costs in civil claims; and for
other purposes.

Compensation to Relatives Act 1897 (NSW)

An Act to consolidate enactments relating to compensation to relatives of person's killed by accidents.

Human Tissue Act 1983 (NSW)

Limitation Act 1969 (NSW)

An Act to amend and consolidate the law relating to the limitation of
actions; to repeal section 5 of the Imperial Act known as the Common
Informers Act 1588 and certain other Imperial enactments; to repeal the
unrepealed portion of the Act passed in the fourth year of the ...

Minors (Property and Contracts) Act 1970 (NSW)

Health Administration Act 1982 (NSW)

Health Care Complaints Act 1993 (NSW)

Human Tissue Act 1983

Medical Practice Act 1992 (NSW)

Mental Health Act 2007 (NSW)

Privacy and Personal Information Protection Act 1998 (NSW)

Virtual Colonoscopy: A Storm is Brewing

2008-11-19T10:38:00.001-08:00

Virtual Colonoscopy: A Storm is Brewing

David J. Vining, MD

Appl Radiol. 2008;37(11):12-16.

Abstract and Introduction

Abstract

The
author performed the first virtual colonoscopy (VC) in 1993. In this
article, he addresses the issues related to the turf battles between
radiologists and gastroenterologists in the use of this technology.
Reviewing common myths associated with VC, he warns that radiologists
must retain expertise in this area.

Introduction

A storm
is brewing around virtual colonoscopy (VC) and whether radiologists or
gastroenterologists will ultimately control this technology. Imagine
the following: in the near future, a patient who requires colorectal
cancer (CRC) screening walks into a local gastroenterologist's office,
obtains a VC examination, which is read by a nurse practitioner, and,
following consultation with a gastroenterologist, undergoes immediate
optical colonoscopy (OC) for evaluation of tiny polyps that either
cannot be found or turn out to be residual feces. Meanwhile, a
radiologist working with this practice interprets the CT data for
extracolonic findings in exchange for a small percentage of the total
professional fee. The patient's insurance (ie, Medicare) is billed for
both the VC and OC, which taxpayers ultimately pay. If this sounds
far-fetched, read on....

Virtual Colonoscopy Development

Colorectal
cancer is the second leading cause of cancer death in the United
States, but it is also one of the most preventable when screening is
used to detect and treat early disease. The 5-year survival rate for
early stage I CRC is 93%, but when it metastasizes to distant organs
and becomes stage IV disease, the survival rate decreases to 8%.^[1]
Unfortunately, many adults over the age of 50 do not undergo screening,
and, as a result, CRC is more often diagnosed in advanced stages.^[2] Virtual colonoscopy offers the public a more appealing and less invasive alternative for screening.

I
performed the first VC, also known as CT colonography (CTC), at the
Wake Forest University Health Sciences Center in 1993. It has taken
nearly 15 years for VC to mature and gain acceptance by policy makers.
The basic technique consists of: 1) bowel cleansing and stool tagging,
2) gas insufflation of the colon, 3) CT scanning of the abdomen/pelvis,
and 4) 2- and 3-dimensional image analysis of the data to identify
polyps and masses (Figure 1). The first VC examination took 60 seconds
to scan a patient using a single-slice helical CT scanner and nearly 8
hours to process the data for a fly-through, but today multidetector CT
scanners acquire the data in a few seconds, and processing occurs in
real time using inexpensive computers.

Despite the technological advances that have occurred during the past decade (eg, CO₂
insufflation, multidetector CT scanners, stool tagging,
computer-assisted diagnosis), a strong lobbying effort on the part of
gastroenterologists has delayed the availability of VC in the United
States. Since Congress approved reimbursement for CRC screening in the
1997 Balanced Budget Act, the number of colonoscopies conducted
annually in the United States has increased from 4 million in 2000 to
>14 million in 2002.^[3]

Handwriting on the Wall

Clinical
trials that compared VC with OC have shown a dramatic improvement in VC
accuracy in the last few years, culminating in 2 major trials that were
announced in September 2007. The ACRIN National Colonography Trial
enrolled over 2500 patients at 15 sites, and it reported that VC had a
90% sensitivity for the detection of polyps >10 mm.^[4] Within a week, Kim^[5]
published a study comparing VC screening in 3120 patients with OC
screening in 3163 patients. Remarkably, VC and OC found an equivalent
number of advanced adenomas in each group; more surprisingly, a larger
number of cancers were found in the VC group.^[5] These 2
studies plus multiple prior published trials from the United States and
abroad led the American Cancer Society, the American College of
Radiology (ACR), and the United States Multi-Society Task Force to
incorporate VC in its screening recommendations that were published in
March 2008.^[6]

As VC has gained acceptance,
gastroenterologists now realize that VC will impact their practice.
After years of bashing VC as not being good enough and requiring more
clinical data, the Future Trends Committee of the American
Gastroenterological Association (AGA) published a report in October
2006 stating that they see the handwriting on the wall.^[7]
This Committee proposed that gastroenterologists should position
themselves to play a role in performing and interpreting VC, including
advocating for CPT codes in the 91000 series that will allow
gastroenterologists to be reimbursed for interpreting and providing VC
services, as well as developing specialized training and training
requirements for those interested in performing VC interpretation. In
an effort to make good on its promise, the AGA published a set of
guidelines in 2007 listing the minimum requirements that a
gastroenterologist must satisfy in order to become certified to read VC
examinations.^[8]

Battle Lines are Drawn

Currently
the Centers for Medicare and Medicaid Services (CMS) approve
reimbursement for VC only when it follows a failed "diagnostic"
colonoscopy, not a failed "screening" colonoscopy (Figure 2).^[9]
Following the inclusion of VC in the American Cancer Society's
screening guidelines, CMS launched a National Coverage Analysis for
Screening Computed Tomography Colonography for Colorectal Cancer
(CAG-00396N) in May 2008. This seeks to expand reimbursement for
screening indications. The final report of this analysis is due in
February 2009.^[10] Expanded reimbursement could have a huge
impact on increasing screening and reducing CRC deaths, but it could
also have substantial economic consequences for CMS and taxpayers. A
public comment period held May-June 2008 drew responses from many
individuals and organizations, including the ACR and the AGA. Of
course, the ACR is in favor of expanded reimbursement, but the AGA
stated that it would support VC only if certain conditions were met,^[11] including:

1. Reporting of
ALL polyps (which is contradictory to the ACR Practice Guideline for
the Performance of CTC in Adults that states reporting of polyps <5
mm is not recommended because of the low incidence of those lesions
having malignant potential);^[12]

2. Allowing patients in consultation with their physician to determine whether or not to remove those polyps; and

3.
Enacting a coverage policy that would encourage rapid follow-up
procedures (ie, colonoscopy) and that correspondingly would not create
a disincentive for physicians (ie, gastroenterologists) who refer those
procedures.

Reading between the lines, if such conditions are
approved by CMS, then the gastroenterologists will have an unrestrained
ability to perform colonoscopy on any little lump or bump that they
might discover if they or their clinical assistant should be allowed to
read VC exams. It is also the position of many prominent
gastroenterologists to create a split-fee arrangement with radiologists
so that radiologists will be relegated to reading only the extracolonic
portions of a CT scan for a small portion of the professional fee, and,
if radiologists refuse to participate, then they will outsource
radiology services, even to foreign providers!^[13]

Dispelling Popular Myths

Gastroenterologists frequently try to discredit VC with the following myths:

1. Colonoscopy is the "gold standard."
There are no published studies to validate this claim. In fact, studies
comparing back-to-back colonoscopies on the same patients have reported
OC miss rates of 22% for polyps, even in the hands of expert
endoscopists.^[14] Studies such as Pickhardt's^[15]
landmark VC study have shown VC to outperform OC. Finally, the accuracy
of screening colonoscopy has been shown to be dependent on how much
time a gastroenterologist spends performing the examination.^[16]

2. If VC finds a polyp, then colonoscopy is needed for polyp removal, so why not undergo colonoscopy in the first place?
The vast majority of polyps are benign, hyperplastic polyps, and <5%
of the asymptomatic screening population has a significant adenomatous
polyp.^[5] Hence, if OC is the primary screening method, then
>95% of the asymptomatic population would under go OC unnecessarily
with its inherent risks of bowel perforation and anesthesia.

3. The radiation dose associated with VC is prohibitive.
Radiation dose is a valid concern, but researchers are striving to
mitigate this risk by using low-dose techniques, even as low as 10 mAs
(compared with a conventional CT scan that might use a dose of 200 mAs).^[17]
Hence, the radiation risk from VC with low-dose techniques can be on
the order of 1 to 2 mSv, which is far below the range that has been
associated with potential cancer and multidetector CT use.^[18] Alternatively, VC can be performed using MRI, but the availability of MRI scanners is a temporary hurdle, at least for today.

Actions to Take

Radiologists
are already overworked due to the exponential increase in imaging
studies during the past decade, and as a result, we have become
complacent about the ownership of new technologies. In the meantime,
gastroenterologists are purchasing CT scanners and attending training
programs to get ready for CMS approval of reimbursement for VC
screening.^[19] However, if radiologists act quickly and take
certain steps to position ourselves to maintain control of VC, we will
not risk losing this technology, as we have done with cardiac imaging.
Some initiatives include:

1. Taking a stronger, vocal interest in
VC. Radiologists are better trained to read an entire CT examination,
especially when disease crosses organ boundaries to involve both the
colon and adjacent anatomy. We need to establish ourselves as the
imaging experts in order to counter claims that endoscopists and nurse
practitioners are as good as radiologists in reading VC exams.^[20]

2.
Beginning a dialogue with community gastroenterologists and primary
care physicians. Radiology practices need to be willing to provide
same-day, on-demand VC services for failed "diagnostic" colonoscopy
examinations in advance of the anticipated reimbursement for screening
VC.

3. Developing practice guidelines for appropriately
working-up extracolonic findings. Perhaps offering immediate but
limited ultrasound evaluation to resolve indeterminate liver and renal
lesions will help to mitigate the gastroenterologists' cry that they
should be the ones performing VC in their offices.

4. Providing
consistent, high-quality reports of VC findings that can be rapidly
delivered to the patient and referring clinician. Utilization of the CT
Colonography Reporting and Data System (C-RADS) and participation in
the ACR's CTC Registry will help to strengthen our position in the
field.^[21,22]

5. Challenging any proposals by
gastroenterologists to split the professional fee for reading colonic
and extracolonic portions of a VC CT scan, including legislative
lobbying if necessary. There are many problems with fee-splitting
arrangements, not the least of which is malpractice
liability—radiologists will certainly be held liable when
gastroenterologists fail to make a correct diagnosis if they should be
allowed to interpret only the intraluminal portion of a VC scan.

All is Not Lost, at Least Not Yet

Much
of the rhetoric coming from the gastroenterology community is coming
from a few but very vocal and rabid gastroenterologists. In fact, a
survey of 2400 AGA members regarding their interest in VC resulted in
only 588 responses, of which one third said that they would want to
perform VC, another third said that they would not perform it but would
support their colleagues, and the final third said that
gastroenterologists should not perform VC.^[23] In reality,
radiologists and gastroenterologists will need to work together along
with surgeons and oncologists to provide comprehensive CRC screening
and treatment services. If CRC screening really takes off, then there
will not be enough gastroenterologists available in this country to
perform the necessary therapeutic colonoscopies that will be generated.
Although radiologists specializing in VC may eventually become
employees of large, multispecialty clinics specializing in colorectal
disease, it is paramount that the role and expertise of the radiologist
be maintained.

References

O'Connell
JB, Maggard MA, Ko CY. Colon cancer survival rates with the new
American Joint Committee on Cancer sixth edition staging. J Natl Cancer Inst. 2004;96:1420-1425.
Centers
for Disease Control and Prevention. Colorectal (colon) cancer.
Available online at:
http://www.cdc.gov/cancer/colorectal/statistics/screening%5frates.htm.
Accessed September 15, 2008.
Seeff LC, Richards TB, Shapiro JA,
et al. How many endoscopies are performed for colorectal cancer
screening? Results from CDC's survey of endoscopic capacity. Gastroenterology. 2004;127: 1670-1677.
Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas and cancers. NEJM. 2008;359:1207-1217.
Kim DH, Pickhardt PJ, Taylor AJ, et al. CT colonography versus colonoscopy for the detection of advanced neoplasia. NEJM. 2007;357:1403-1412.
Levin
B, Lieberman DA, McFarland B, et al. Screening and surveillance for the
early detection of colorectal cancer and adenomatous polyps 2008: A
joint guideline from the American Cancer Society, the US Multi-Society
task force on colorectal cancer, and the American College of Radiology.
CA Cancer J Clin. 2008;58:130-160.
Regueiro C. Will
screening colonoscopy disappear and transform gastroenterology
practice? Threats to clinical practice and recommendations to reduce
their impact: Report of a consensus conference conducted by the AGA
Institute Future Trends Committee. Gastroenterology. 2006;131:1287-1312.
Rockey
DC, Barish M, Brill JV, et al. Standards for gastroenterologists for
performing and interpreting diagnostic computed tomographic
colonography. Gastroenterology. 2007;133:1005-1024.
Knechtges
PM, McFarland BG, Keysor KJ, et al. National and local trends in CT
colonography reimbursement: Past, present, and future. J Am Coll Radiol. 2007;4:776-799.
Centers
for Medicaid and Medicare Services. NCA for Screening Computed
Tomography Colonography (CTC) for Colorectal Cancer (CAG-00396N).
Available online at: http://www.cms.hhs.gov/ mcd/viewnca.asp?
where=index&nca_id=220&basket=nca:00396N:220:
Screening+Computed+Tomography+Colonography+
%28CTC%29+for+Colorectal+Cancer:Open:New:4. Accessed September 15, 2008.
Sandler
RS. AGA Institute Comments re: NCA for Screening (CTC) for Colorectal
Cancer. Available online at: http://www.gastro.org/user-assets/
Documents/02_Clinical_Practice/CTC/AGA_Institut
e_comment_ltr_re_CTC_for_CRC_screening_6-18- 08.pdf. Accessed September
15, 2008.
ACR practice guidelines for the performance of
computed tomography (CT) colonography in adults. Amended 2006.
Available online at: http://
www.acr.org/EducationCenter/ACRFutureClassroom/ct_colonography.aspx.
Accessed September 15, 2008.
Rex DK. Clinical gastroenterologist's perspective on training in CT colonography. AGA Perspectives. December 2007/January 2008. Available online at: http://www.gastro.org/wmspage.cfm?parm1=4684. Accessed September 15, 2008.
van Rijn JC, Reitsma JB, Stoker J, et al. Polyp miss rate determined by tandem colonoscopy: A systematic review. Am J Gastroenterol. 2006;101: 343-350.
Pickhardt
PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy
to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349:2191-2200. Comments in: ACP J Club. 2004;141:22-23. CMAJ. 2004;170: 1392. Gastroenterology. 2004;126:1910-1911; discussion 1911-1912. Korean J Gastroenterol. 2004; 43:71-73. N Engl J Med. 2003;349:2261-2264. N Engl J Med. 2004;350:1148-1150; author reply 1148-1150. Rev Gastroenterol Disord. 2005;5: 227-229.
Barclay RL, Vicari JJ, Doughty AS, et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med. 2006;355;2533-2541.
Iannaccone
R, Catalano C, Mangiapane F, et. al. Colorectal polyps: Detection with
low-dose multidetector row helical CT colonography versus two
sequential colonoscopies. Radiology. 2005;237: 927-937.
Brenner DJ, Hall EJ. Computed tomography—An increasing source of radiation exposure. N Engl J Med. 2007;357:2277-2284.
American
Gastroenterological Association. CT colonography training for the
gastroenterologist: A hands-on course. Information available online at:
http://www.gastro.org/wmspage.cfm?parm1=5599. Accessed September 15,
2008.
Patrick A, Jackson L, Bell J, Epstein O. High proficiency
reading of V3D virtual colonoscopy by experienced optical endoscopists
and endoscopy nurses; A new era in colonoscopy? Gastrointest Endosc. 2007;65:AB129.
Zalis ME, Barish MA, Choi JR, et al. CT colonography reporting and data system: A consensus proposal. Radiology. 2005;236:3-9.
CT Colonography Registry. Available online at: https://nrdr.acr.org/portal/CTC/Main/page.aspx. Accessed September 15, 2008.
Springer J. Members weighing many factors associated with CT colonography. AGA Perspectives. October/November 2006. Available online at: http://www.gastro.org/wmsp. age.cfm?parm1=2788. Accessed September 15, 2008.

David J. Vining, MD
is a Professor of Diagnostic Radiology and the Medical Director of the
Image Processing and Visualization Laboratory, University of Texas M.D.
Anderson Cancer Center, Houston, TX

Disclosure:
Dr. Vining discloses that he has received royalties from Wake Forest
University and Bracco, Inc., for virtual colonoscopyrelated products.

SUPRATENTORIAL BRAIN TUMORS

2008-11-11T19:10:00.001-08:00

SUPRATENTORIAL BRAIN TUMORS

John R. Hesselink, MD, FACR and Richard J. Hicks, MD

In the diagnostic work-up of intracranial tumors, the primary goals of the imaging studies are to detect the abnormality, localize and determine its extent, characterize the lesion, and provide a list of differential diagnoses or, if possible, the specific diagnosis. Correlative studies have proved that MR is more sensitive than CT for detecting intracranial masses. Moreover, the multiplanar capability of MR is very helpful to determine the anatomic site of origin of lesions and to demarcate extension into adjacent compartments and brain structures. The superior contrast resolution of MR displays the different components of lesions more clearly. MR can assess the vascularity of lesions without contrast infusion. On the other hand, CT detects calcification far better than MR, a useful finding for differential diagnosis. Gradient-echo techniques improve MR detection of calcification by accentuating the diamagnetic susceptibility properties of calcium salts, but the observed low signal on T2-weighted images is nonspecific, in that any accompanying paramagnetic ions would produce the same effect.

Contrast enhancement with gadolinium increases both the sensitivity and specificity of MR. Gadolinium is a blood-brain barrier (BBB) contrast agent like iodinated agents for CT. It does not cross the intact BBB, but when the BBB is absent or deficient, gadolinium enters the interstitial space to produce enhancement (increased signal) on T1-weighted images. All the collective knowledge learned from contrast-enhanced CT can be applied directly to the gadolinium-enhanced MR images. Although the enhancement patterns are not tumor specific, the additional information is often helpful for diagnosis. Lesions can be classified as homogeneous or heterogeneous, and necrotic and cystic components are seen more clearly. The margins of enhancement provide a gross measure of tumor extension. Contrast MR is particularly valuable for extra-axial tumors because they tend to be isointense to the brain on plain scan.

CEREBRAL GLIOMAS

Gliomas are malignant tumors of the glial cells of the brain and account for 30-40% of all primary intracranial tumors. They occur predominantly in the cerebral hemispheres, but the brain stem and cerebellum are frequent locations in children, and they are also found in the spinal cord. The peak incidence is during middle adult life, when patients present with seizures or symptoms related to the location of the gliomas and the brain structures involved.

Astrocytomas are graded according to their histologic appearance. Grade 1 astrocytomas have well-differentiated astrocytes and well-defined margins. The clinical course often proceeds over many years and complete cures are possible. The pilocytic variant is a low-grade tumor with a distinct capsule that is commonly found in children. The giant cell astrocytoma is a specialized tumor that develops from pre-existing hamartomas in patients with tuberous sclerosis. Grade 2 astrocytomas are well-differentiated but diffusely infiltrating tumors. The fibrillary type is most common, and although initially benign, they may evolve into a higher grade tumor over time. This changing character of gliomas makes histological classification difficult from sample biopsies, because different parts of the tumor often exhibit varying degrees of malignancy. The higher grade astrocytomas are very cellular and pleomorphic. Anaplastic astrocytomas (Grade 3) are very aggressive tumors, readily infiltrate adjacent brain structures, and have a uniformly poor prognosis. Glioblastoma multiforme (Grade 4) has the added histologic features of endothelial proliferation and necrosis. Multicentric foci of tumor may be seen in 4 to 6% of glioblastomas. Gliomatosis cerebri is an unusual condition with diffuse contiguous involvement of multiple lobes of the brain.

Oligodendrogliomas are the most benign of the gliomas. Calcification is common, and they occur predominantly in the frontal lobes. The mixed neuronal and glial tumors are found mostly in children and young adults. They are slow-growing and are found predominantly in the temporal lobes and around the third ventricle. Intratumoral cysts and calcification are common.

The common signal characteristics of intra-axial tumors include high signal intensity on T2-weighted images and low signal on T1-weighted images, unless fat or hemorrhage is present. Fat and subacute hemorrhage (methemoglobin) exhibit high signal on T1-weighted images, and acute hemorrhage (deoxyhemoglobin) and chronic hemorrhage (hemosiderin/ferritin) show low signal intensity on T2-weighted scans. Gliomas have poorly defined margins on plain MR. They infiltrate along white matter fiber tracts, and the deeper lesions have a propensity to extend across the corpus callosum into the opposite hemisphere. They are often quite large by the time of clinical presentation.

The higher grade gliomas, particularly glioblastomas, appear heterogeneous due to central necrosis with cellular debris, fluid, and hemorrhage. Peritumoral edema and mass effect are common features. Following injection of gadolinium, T1-weighted images show irregular ring enhancement, with nodularity and nonenhancing necrotic foci. As mentioned above, gliomas are infiltrative lesions, and microscopic fingers of tumor usually extend beyond the margin of enhancement. Enhanced scans are particularly helpful to outline subependymal spread of tumor along a ventricular surface, as well as leptomeningeal involvement. Although highly malignant, anaplastic astrocytomas may or may not exhibit breakdown of the blood-brain barrier. In general, the presence or lack of enhancement alone is not helpful in grading astrocytomas.

The lower grade astrocytomas tend to be more homogeneous without central necrosis. Large cystic components may be present. The cysts have smooth walls, and the fluid is of uniform signal, to distinguish them from necrosis. Enhancement is variable, depending on the integrity of the blood-brain barrier.

Perfusion imaging has shown promise as a technique for determining the grade of intracranial mass lesions. Perfusion imaging relies on a first-pass susceptibility-related signal loss on T2*-weighted images, from which relative cerebral blood flow and volume can be calculated. Several studies have shown a correlation between relative cerebral blood volume and tumor grade, likely due to the relationship of blood volume to vascular proliferation in high-grade gliomas.

MR Spectroscopy

MR spectroscopy provides a measure of brain chemistry and can help characterize tumors and and grade the degree of malignancy. As a general rule, as malignancy increases, NAA and creatine decrease, and choline, lactate, and lipids increase. NAA decreases as tumor growth displaces or destroys neurons. Very malignant tumors have high metabolic activity and deplete the energy stores, resulting in reduced creatine. Very hypercellular tumors with rapid growth elevate choline. Lipids are found in necrotic portions of tumors, and lactate appears when tumors outgrow their blood supply and start utilizing anaerobic glycolysis. To get an accurate assessment of the tumor chemistry, the spectroscopic voxel should be placed over an enhancing region of the tumor, avoiding areas of necrosis, hemorrhage, calcification, or cysts.

Multi-voxel spectroscopy is best to detect infiltration of malignant cells beyond the enhancing margins of tumors. Particularly in the case of cerebral glioma, elevated choline levels are frequently detected in edematous regions of the brain outside the enhancing mass. Finally, MRS can direct the surgeon to the most metabolically active part of the tumor for biopsy to obtain accurate grading of the malignancy.

A common clinical problem is distinguishing tumor recurrence from radiation effects several months following surgery and radiation therapy. Elevated choline is a marker for recurrent tumor. Radiation change generally exhibits low NAA, creatine, and choline on spectroscopy. If radiation necrosis is present, the spectrum may reveal elevated lipids and lactate.

MRS cannot always distinguish primary and secondary tumors of the brain from one another. As mentioned above, one key feature of gliomas is elevated choline beyond the margin of enhancement due to infiltration of tumor into the adjacent brain tissue. Most non-glial tumors have little or no NAA. Elevated alanine at 1.48 ppm is a signature of meningiomas. They also have no NAA, very low creatine, and elevated glutamates.

LYMPHOMA

Primary malignant lymphoma is a non-Hodgkin's lymphoma that occurs in the brain in the absence of systemic involvement. These tumors are highly cellular and grow rapidly. Favorite sites include the deeper parts of the frontal and parietal lobes, basal ganglia, and hypothalamus. Most occur in patients who are immunocompromised secondary to chemotherapy or acquired immunodeficiency syndrome (AIDS) or in organ transplant recipients who are on immunosuppressant drugs. Cerebral lymphomas are very radiosensitive and respond dramatically to steroid therapy.

Lymphomas typically appear as homogeneous, slightly high signal to isointense masses deep within the brain on T2-weighted images. The observed mild T2 prolongation is probably related to dense cell packing within these tumors, leaving relatively little interstitial space for accumulation of water. They are frequently found in close proximity to the corpus callosum and have a propensity to extend across the corpus callosum into the opposite hemisphere, a feature that mimics glioblastoma. Multiple lesions are present in as many as 50%. Despite their rapid growth, central necrosis is uncommon. They are associated with only a mild or moderate amount of peritumoral edema. By time of presentation they can be quite large and yet produce relatively little mass effect, a feature that sets lymphoma apart from glioblastoma and metastases. Intratumoral cysts and hemorrhage are unusual. Most lymphomas show bright homogeneous contrast enhancement.

The pattern is modified somewhat in AIDS patients. Multiplicity seems to be more common. Moreover, lymphomas exhibit more aggressive behavior and readily outgrow their blood supply. As a result, central necrosis and ring enhancement are often seen in lymphomatous masses in AIDS patients. On MR spectroscopy, lymphomas exhibit elevated choline little or no NAA.

METASTATIC DISEASE

Metastases to the brain occur by hematogenous spread, and multiple lesions are found in 70% of cases. The most common primaries are lung, breast, and melanoma, in that order of frequency. Other potential sources include the gastrointestinal tract, kidney, and thyroid. Metastases from other locations are uncommon. Clinical symptoms are nonspecific and no different from primary brain tumors. If a parenchymal lesion breaks through the cortex, tumor can extend and seed along the leptomeninges.

Metastatic lesions can be found anywhere in the brain but a favorite site is near the brain surface at the corticomedullary junction of both the cerebrum and cerebellum. They are hyperintense on plain T2-weighted images. Areas of necrosis are prevalent in the larger lesions, accounting for their heterogeneous internal texture. Peritumoral edema is a prominent feature, but multiplicity is the most helpful sign to suggest metastatic disease as the likely diagnosis. Correlative studies have shown MR to be more sensitive than CT for detecting metastases, particularly lesions near the base of the brain and in the posterior fossa. One limitation of plain MR is the frequency of periventricular white matter hyperintensities found in the same older age group at risk for metastatic disease.

Gadolinium enhanced MR has resulted in improved delineation of metastatic disease compared with nonenhanced scans. Moderate to marked enhancement is the rule, nodular for the smaller lesions and ringlike with central nonenhancing areas for the larger ones. Controlled clinical trials have also shown that contrast-enhanced MR is more sensitive than both plain MR and contrast-enhanced CT for detecting cerebral metastases. In patients with a known primary, T1-weighted enhanced MR is probably sufficient to screen the brain for metastatic disease.

Hemorrhage is present in 3 to 14% of brain metastases, mainly in melanoma, choriocarcinoma, renal cell carcinoma, bronchogenic carcinoma, and thyroid carcinoma. The presence of nonhemorrhagic tissue and pronounced surrounding vasogenic edema are clues to the underlying neoplasm.

Metastatic melanoma has been a topic of special interest in the MR literature because of the presence of paramagnetic, stable free radicals within melanin. The MR appearance is variable depending on the histology of the melanoma and the components of hemoglobin. Most are hyperintense to white matter on T1-weighted scans and hypointense on T2-weighted scans. Atlas and coworkers observed three distinct signal intensity patterns. Nonhemorrhagic melanotic melanoma was markedly hyperintense on T1-weighted images and isointense or mildly hypointense on T2-weighted images. Nonhemorrhagic amelanotic melanoma appeared isointense or slightly hypointense on T1-weighted scans and isointense or slightly hyperintense on T2-weighted scans. The signal pattern for hemorrhagic melanoma was variable depending on the components of hemoglobin. Some uncertainty remains as to whether the predominant effect on signal intensity within melanomas is due to stable free radicals, chelated metal ions, or hemoglobin.

INTRAVENTRICULAR TUMORS

The intraventricular location is unique in that many of the tumor types are more commonly associated with extra-axial locations. Patients often present with obstructive hydrocephalus. Most intraventricular tumors are relatively benign and have well-defined margins. As they grow, the tumors expand the ventricle of origin. With malignant degeneration, extension into the brain parenchymal occurs. The primary blood supply to intraventricular lesions is derived from the choroidal arteries.

MENINGIOMA

Meningiomas account for 15% of all intracranial tumors and are the most common extra-axial tumor. They originate from the dura or arachnoid and occur in middle-aged adults. Women are affected twice as often as men. Meningiomas are well-differentiated, benign, and encapsulated lesions that indent the brain as they enlarge. They grow slowly and may be present for many years before producing symptoms. The histologic picture shows cells of uniform size that tend to form whorls or psammoma bodies.

The parasagittal region is the most frequent site for meningiomas, followed by the sphenoid wings, parasellar region, olfactory groove, cerebello-pontine angle, and rarely the intraventricular region. Meningiomas often induce an osteoblastic reaction in the adjacent bone, resulting in a characteristic focal hyperostosis. They are also hypervascular, receiving their blood supply predominantly from dural vessels.

Most meningiomas are isointense with cortex on T1- and T2-weighted images. A heterogeneous internal texture is found in all but the smallest meningiomas. The mottled pattern is likely due to a combination of flow void from vascularity, focal calcification, small cystic foci, and entrapped CSF spaces. Hemorrhage is not a common feature. An interface between the brain and lesion is often present, representing a CSF cleft, a vascular rim, or a dural margin. MR has special advantages over CT in assessing venous sinus involvement and arterial encasement. Occasionally, a densely calcified meningioma is encountered that is distinctly hypointense on all pulse sequences.

Meningiomas show intense enhancement with gadolinium and are sharply circumscribed. They have a characteristic broad base of attachment against a dural surface. Associated hyperostosis may result in thickening of low signal bone as well as diminished signal from the diploic spaces. Although meningiomas are not invasive, vasogenic edema is present in the adjacent brain in 30% of cases. Contrast scans are especially helpful for imaging the en plaque meningiomas that occur at the skull base. MR spectroscopy shows elevated alanine and glutamates, no NAA, and markedly decreased creatine.

PINEAL REGION TUMORS

Tumors in the pineal region can be classified into three major groups based on their origin: germ cell, pineal parenchyma, and parapineal. Germinoma is the least differentiated of the germ cell group. It occurs in children and young adults and accounts for more than 50% of all pineal region tumors. The other germ cell tumors include embryonal carcinoma, yolk-sac tumor, and choriocarcinoma. Differentiation along three germ layers results in a teratoma. The true pinealomas consist of pineoblastoma and pineocytoma. Pineoblastoma is an embryonal tumor of neuroectoderm, related to neuroblastoma and medulloblastoma, and is found primarily in young children. Pineocytomas are less cellular and exhibit benign behavior. The parapineal lesions include gliomas of the tectum and posterior third ventricle, meningiomas arising within the quadrigeminal cistern, and developmental cysts (epidermoid, dermoid, arachnoid cyst).

The clinical expression of these tumors is usually related to mass effect upon adjacent brain structures. Hydrocephalus secondary to aqueductal obstruction is a common presentation. Compression of the tectum of the midbrain can produce paralysis of upward gaze, the classic Parinaud's syndrome. Germinomas and gliomas have a propensity to grow into the third ventricle and compress the hypothalamus, resulting in endocrine dysfunction. Dissemination through the CSF pathways is a known complication of pineoblastoma and germinoma.

Pineal germinomas and primary pineal tumors are most often isointense with the brain on T1- and T2-weighted images. A few lesions exhibit long T1 and T2, which may correlate with embryonal cell elements. Despite this relative lack of contrast, with multiplanar imaging plain MR delineates pineal region masses better than CT, showing the relationships of the tumor to the posterior third ventricle, vein of Galen, and aqueduct. These tumors are well defined and enhance to a moderate degree, usually without central necrosis, cystic change, or hemorrhage. Enhanced scans are essential to assess CSF spread of tumor. In young patients with germinoma, the difficulty of visualizing calcium is a disadvantage of MR, as this may be the only evidence of tumor.

Meningiomas can appear very similar on plain scan, but their intense enhancement may set them apart from other lesions. Gliomas infiltrate the tectum and posterior walls of the third ventricle. They tend to be poorly circumscribed and produce symptoms earlier. Edema is not a consistent finding, and enhancement is variable. Larger gliomas in the splenium of the corpus callosum may present as pineal region masses.

Teratomas are of mixed signal intensity, frequently with calcification. They may also have cystic components and fat. Arachnoid cysts, epidermoid and dermoid tumors can usually be distinguished from other pineal region tumors by their increased signal on T2-weighted images.

Pineal cysts were visualized in 4.3% of normal patients in one MR study. These apparently benign lesions are seen best as areas of high signal on intermediate T2-weighted images. They are not associated with hydrocephalus or a pineal mass and are not clinically significant.

BENIGN CYSTIC MASSES

Cystic lesions occur most often in the basal cisterns, a midline location or within the ventricular system. They include arachnoid cyst, dermoid, epidermoid, and neuroepithelial cysts, including colloid cyst. These lesions are interesting in that their MR appearance is quite distinct from solid masses. Their signal characteristics depend to a large extent on the cyst contents, but associated solid components may also have specific features.

Arachnoid Cyst

Arachnoid cysts are CSF-containing cysts that are found in the middle fossa, posterior fossa, suprasellar cistern, or near the vertex. They are benign but slowly grow as they accumulate fluid, compressing normal brain structures. Remodeling of the adjacent skull is an important clue for a benign expansile process.

Arachnoid cysts are smoothly marginated and homogeneous. They are not calcified and do not enhance. The multiplanar capability of MR is particularly helpful in establishing the exact location, and the diagnosis is supported by the cyst fluid being isointense with CSF on all pulse sequences. The cysts may appear higher signal than CSF on intermediate T2-weighted images. The exact reason for this is uncertain, although it may reflect dampening of the CSF pulsations that normally results in signal loss in the ventricles and cisterns. This effect will be less apparent with pulse sequences that incorporate flow compensation techniques.

Epidermoid Cyst

Epidermoid cysts are referred to as "pearly tumors" because of their glistening white appearance at surgery. They arise from epithelial cell rests in the basal cisterns. They are benign and grow slowly along the subarachnoid spaces and into the various crevices found at the base of the brain. Intradural epidermoids are usually quite large with lobulated outer margins and an insinuating pattern of growth. They have a heterogeneous texture and variable signal intensity on MR. Most are slightly higher signal than CSF on both T1 and T2-weighted images. An occasional epidermoid has a very short T1 and appears bright on T1-weighted images. The heterogeneous signal pattern is likely related to varying concentrations of keratin, cholesterol, and water within the cyst, as well as the proportion of cholesterol and keratin in crystalline form. Calcification is sometimes present. Epidermoid tumors do not enhance with contrast.

Dermoid Cyst

Dermoid cysts have both dermal and epidermal derivatives, accounting for their more varied histologic and MR appearance. They are primarily midline lesions, occurring in the pineal and suprasellar regions. Dermoids have some distinctive features on MR. They tend to be heterogeneous owing to the multiple cell types within them. Fatty components are common, producing high signal on T1-weighted images. On axial and sagittal scans, a fat-fluid level may be seen, or a level between fat and matted hair within the cyst. Rupture of a dermoid and leakage of cyst contents into a ventricle or subarachnoid space may produce an ependymitis or meningitis, respectively.

Lipomas are also midline lesions and are often associated with partial or complete agenesis of the corpus callosum. Occasionally, an incidental lipoma will be found in the region of the quadrigeminal plate or cerebellopontine angle.

Colloid Cyst

Colloid cysts originate from primitive neuroepithelium within the roof of the anterior third ventricle. They are positioned just posterior to the foramina of Monro between the columns of the fornix. Histologically, they consist of a thin, fibrous capsule with an epithelial lining. The cysts contain a mucinous fluid with variable amounts of proteinaceous debris, blood components, and desquamated cells.

Colloid cysts are smoothly marginated spherical lesions without surrounding brain reaction. Two signal patterns have been reported on MR scans and correlated with their CT features. Those that are low density on CT are isointense on T1-weighted images and hyperintense on T2-weighted images, probably indicating a fluid composition similar to CSF. Most colloid cysts are isodense or slightly hyperdense on CT. The MR counterpart is a high signal capsule and a hypointense center on T2-weighted images. The signal characteristics of the fluid depend on the protein content of the cyst fluid and is similar to that observed in sinonasal secretions.

Dilatation of the lateral ventricles is a common finding, and the enlargement may be unequal owing to asymmetric positioning of the cyst at the foramina of Monro. The expanding cyst also enlarges the anterior third ventricle, but the posterior third, aqueduct, and fourth ventricle should be normal. Following contrast infusion, colloid cysts may show ring enhancement, due to either enhancement of the cyst wall or choroid plexus draped around the cyst.

REFERENCES

ESGAR CT COLONOGRAPHY WORKSHOP FEB 2-4 HARROGATE, UK

2008-11-06T04:15:00.001-08:00

Preliminary Programme

Group I: Monday, February 2, 2009 Day 1

Group II: Tuesday, February 3, 2008 Day 1

08:00 – 08:25 Registration

08:25 – 08:30 Introduction: Presentation of the workshop programme

A. Laghi (Latina/IT)

08:30 – 08:45 Introduction State-of-the-art CT-Colonography

D. Burling (London/UK)

08:45 – 09:10 Polyps and Colorectal Cancer (Gastroenterologist’s view)

James East (London/UK)

09:10 – 10:30 Technical basis of CTC: Preparation, image acquisition, complications

Chairman: S.Taylor (London, UK)

09:10 – 09:30 Bowel preparation and faecal tagging

P. Lefere (Roeselare/BE)

09:30 – 09:50 Practical Issues (technique, insufflation)

J. Stoker (Amsterdam/NL)

09:50 – 10:10 Image acquisition: technical parameters

P. Rogalla (Berlin/DE)

10:10 – 10:30 Complications (Perforation, cardiovascular effects)

S. Taylor (London/UK)

10:30 – 11:00 Coffee

11:00 – 12:40 2D - 3D First approach: face to face

Chairman: S. Halligan (London/UK)

11:00 – 11:20 Basic reading technique, primary 2D and 3D, normal anatomy,

C. Kay (Bradford/UK)

11:20 – 11:40 Pitfalls in interpreting CTC

S. Gryspeerdt (Roeselare/BE)

11:40 – 12:00 Teaching on workstation – easy case (based on ESGAR study)

A. Lowe (Bradford/UK)

12:00 – 12:45 Panel discussion: Q&A

Moderator: A. Laghi (Latina/IT)

Panellists: all speakers of previous three sessions.

12:45 – 14:15 Lunch

14:15 – 16:15 CTC: clinical application

Chairman: R. Frost (Salisbury/UK)

14:15 – 14:35 Study results and indications

A. Laghi (Latina/IT)

14:35 – 14:55 Extra-colonic findings

M. Hellström (Göteborg/SE)

14:55 – 15:15 How to report CTC

E. Neri (Pisa/IT)

15:15 – 15:30 How to set up a CTC service

M. Morrin (Dublin/IRE)

15:30 – 16:15 Panel discussion: Q&A

Moderator: R. Frost (Salisbury/UK)

Panellists: All speakers

16:15 – 17:00 Coffee

17:00 – 18:00 TWO PARALLEL SESSIONS:

17:00 – 18:00 CAD

Moderator: S.Halligan (Harrow/UK)

Technique and results (17:00 – 17:20)

D Regge (Turin/IT)

Integration of CAD in the workflow (17:20 – 17:40)

A. Graser (Munich/DE)

Panel discussion: CAD (17:40 – 17:50)

17:00 – 18:00 Basic teaching on workstation in hands-on workstation room

(in parallel to CAD Session)

Lead: T. Mang (Vienna/AT), A. Gupta (London/UK)

18:00 – 19:00 Moderator: D.Tolan (Leeds/UK)

Workstations are available for participants for individual familiarisation

(Application Specialists are available for questions)

Workstation Room

Group I: Tuesday, February 3, 2009 Day 2

Group II: Wednesday, February 4, 2009 Day 2

08:30 – 09:30 Familiarisation with the different workstations available for the hands-on sessions

Moderator: D.Tolan (Leeds/UK)

Introduction of the tutors and the application specialists

Introduction of each vendor by application specialists. Explanation of workflow

Teaching on workstations

(20 min for cases review on workstation + 10 min for review with faculty)

09:30 – 10:30 Cancer cases

09:30 – 10:15 Cancer cases for review

Participants to review specific cases

10:15 – 10:30 Case review and discussion

D. Hock (Liege/BE)

10:30 – 11:00 Coffee

11:00 – 12:00 Polyp cases

11:00 – 11:45 Polyp cases for review

Participants to review specific cases

11:45 – 12:00 Case review and discussion

F. Iafrate (Rome/IT)

12:00 – 13:00 Difficult cases

12:00 – 12:45 Difficult cases for review

Participants to review specific cases

12:45 – 13:00 Case review and discussion

A. Gupta (London/UK)

13:00 – 14:15 Workstations face to face (Lunch Symposium)

Moderation: G. Maskell (Truro/UK)

14:15 – 15:15 “Blind” case reviews

14:15 – 15:00 “Blinded” Cases

Participants to review specific cases

15:00 – 15:15 Case review and discussion

P. Wylie (London/UK)

15:15 – 16:15 Hands-on session: free

(Participants to use syllabus for findings and to address queries to faculty)

16:15 – 16:45 Coffee

16:45 – 17:15 2 cases prize competition

F.Iafrate/ S.Taylor (Berlin/DE)

17:15 – 17:25 Complete evaluation forms and submit them at the registration desk

Buy homes abroad, save tax here

2008-10-24T05:44:00.001-07:00

Buy homes abroad, save tax here

Wednesday, 29 August , 2007, 08:01
Last Updated: Wednesday, 29 August , 2007, 08:49

For
long-term capital gains earned on sale of property, the tax rate is 20
per cent. If the value is above Rs 10 lakh, the tax rate climbs to
22.66 per cent. This applies both to residents as well as non-resident
Indians (NRIs).

Sec. 54 of the Income Tax Act offers a way out of paying such
tax. If the capital gain amount is invested in a residential house
within one year before to two years after the sale, then the capital
gains earned are fully exempted from tax. In case the investor intends
to construct a house, the time limit is extended to within three years
of the date of sale. Of course, if only a part of the capital gain is
used, the exemption would be proportional and the excess will be
chargeable to tax.

So far, so good. Now comes the interesting part, especially for NRIs.

Nowhere does Sec. 54 specify that the new house purchased should
be within India. This means, to save capital gains earned in India, the
NRI can even purchase a house in his or her own host country abroad and
yet claim exemption. Why just NRIs, now even resident Indians can
benefit from this rule. RBI allows an Indian resident up to $1,00,000
per annum to be invested abroad. Such investment could be even in
property.

So far, this was just a theoretical possibility based on a
plain reading of the law. However, in a recent judgment, the Income Tax
Tribunal in the case of Prema P Shah (Citation 282 ITR 211) has ruled
that the exemption offered by Sec. 54 can indeed be extended to a
property purchased in a foreign country.

The brief facts of the case were that the assessee claimed the
capital gains on sale of house property situated in India as exempt. To
support her claim, she filed a photocopy of a lease agreement for a
house in London. The assessing officer disallowed the claim noting that
Sec. 54 speaks of purchase of residential property or construction
thereof. In this case, Shah had purchased only tenancy rights and hence
exemption under Sec. 54 would not be available to her.

This argument was rejected by the Tribunal based on the facts
of the case. In the UK, property belongs to the Sovereign; citizens,
instead of being allowed to purchase, are granted long-term leases. In
the instant case, the lease was valid for 150 years -- in other words,
it was in perpetuity and for all practical purposes, the assessee was
the owner of the property.

It's not even necessary that the same amount of capital gains
be used to buy the property. The assessee can very well buy the
property even on mortgage (housing finance) -- as long as the
conditions specified in Sec. 54 are satisfied, the exemption is
available. This is because, even for properties bought using mortgage,
the borrower instantly becomes the owner of the property.

That he is paying his EMIs (mortgage) on the loan taken is an
agreement between the lender and the borrower inter se. It has no
bearing on the ownership of the property. In other words, as far as
Sec. 54 is concerned, an investment has indeed been made in property.
Whether it's through the mechanism of mortgage or otherwise is
immaterial.

This judgment will have far reaching impact, especially on NRI
investments and taxation. No one is born an NRI. Indian residents
become NRIs when they go abroad for employment or business. More often
than not, such persons own property in India, either the one they left
behind when they went abroad and became NRIs, or one that is inherited.

A number of such persons, who have set up a new life abroad
definitely don't need a new property just to save on tax. Now, such
persons can actually consider buying property abroad and claiming tax
benefits in India.

NRI's - FAQs

2008-10-24T04:24:00.001-07:00

Definition of an NRI

An
Indian Citizen who stays abroad for employment/ carrying on business or
vacation outside India or stays abroad under circumstances indicating
an intention for an uncertain duration of stay abroad is a
non-resident. (Persons posted in U.N. organizations and officials
deputed abroad by Central/ State Government and Public Sector
Undertakings on temporary assignments are also treated as non-resident)
Non-resident foreign citizens of Indian Origin are treated on par with
non-resident Indian citizens.

For Investment in immovable properties:

A foreign citizen (other than a citizen of Pakistan, Bangladesh,
Afghanistan, Bhutan, Sri lanka or Nepal), is deemed to be of Indian
origin if,

(i) he held an Indian passport at any time, OR
(ii)
he or his father or paternal grand-father was a citizen of India by
virtue of the Constitution of India or the Citizenship Act, 1955 ( 57
of 1955).

FAQs

	Do non-resident Indian citizens require permission of Reserve Bank to acquire residential/commercial properly in India?
	Do foreign citizens of Indian origin require permission of Reserve Bank to purchase immovable property in India for their residential use?
	In what manner the purchase consideration for the residential immovable property should be paid by foreign citizens of Indian origin under the general permission?
	What are the formalities required to be completed by foreign citizens of Indian origin for purchasing residential immovable property in India under the general permission.
	Can such property be sold without the permission of Reserve Bank?
	Can sale proceeds of such property if and when sold be remitted out of India?
	Are any conditions required to be fulfilled if repatriation of sale proceeds is desired?
	What is the procedure for seeking such repatriation?
	Can foreign citizens of Indian origin acquire or dispose of residential property by way of gift?
	Can foreign citizens of Indian origin acquire commercial properties in India?
	Can they dispose of such properties?
	Can sale proceeds of such property be remitted out of India?
	Can the properties (residential/commercial) be given on rent if not required for immediate use?
	Can NRIs obtain loans for acquisition of a house/flat for residential purpose from financial institutions providing housing finance?
	Can authorized dealer grant loans to NRIs for acquisition of a flat/house for residential purposes?
	Can Indian companies grant loans to their NRI staff?
	What are the options available for obtaining guarantors while applying for a HDFC/LIC loan
	While purchasing real estate most developers demand a Power of Attorney in their favor, is there a way to avoid it?

ADDITIONAL DETAILS
Acquisition and Transfer of Immovable Property in India by a person resident outside India
These FAQ's have been prepared in order to address various issues relating to acquisition and transfer of immovable property in India by a person resident outside India under the provisions of the Foreign Exchange Management Act, 1999. These FAQs seek to cover the broad spectrum of issues relating to acquisition and transfer of immovable property in India by a non-resident Indian (NRI) or a foreign national of Indian origin (PIO) or a foreign national of non-Indian origin as also by a person resident in India who is not a citizen of India
1) Regulations/Directions issued by Reserve Bank of India
2) Acquisition of immovable property in India by way of purchase by a person resident outside India
3) Acquisition of immovable property in India by way of gift by a person resident outside India
4) Acquisition of immovable property in India by way of inheritance by a person resident outside India
5) Transfer of immovable property in India by way of sale by a person resident outside India

Q) Do non-resident Indian citizens require permission of Reserve Bank to acquire residential/commercial properly in India?
A)

No.

BACK ON TOP

Q)
Do foreign citizens of Indian origin require permission of Reserve Bank
to purchase immovable property in India for their residential use?

A) Yes. However, Reserve Bank has granted general permission to foreign
citizens of Indian origin, whether resident in India or abroad, to
purchase immovable property in India for their bona fide residential
purpose. They are, therefore, not required to obtain separate
permission of Reserve Bank.

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Q)
In what manner the purchase consideration for the residential immovable
property should be paid by foreign citizens of Indian origin under the
general permission?

A) The purchase consideration should be met either out of inward
remittances in foreign exchange through normal banking channels or out
of funds from NTE/FCNR accounts maintained with banks in India.

BACK ON TOP

Q)
What are the formalities required to be completed by foreign citizens
of Indian origin for purchasing residential immovable property in India
under the general permission.?

A) They are required to file a declaration in form IPI 7 with the
Central Office of Reserve Bank at Mumbai within a period of 90 days
from the date of purchase of immovable property or final payment of
purchase consideration along with a certified copy of the document
evidencing the transaction and bank certificate regarding the
consideration paid.

BACK ON TOP

Q)

Can such property be sold without the permission of Reserve Bank?

A) Yes. Reserve Bank has granted general permission for sale of such
property. However, where the property is purchased by another foreign
citizen of Indian origin, funds towards the purchase consideration
should either be remitted to India or paid out of balances in NRE/FCNR
accounts.

BACK ON TOP

Q)

Can sale proceeds of such property if and when sold be remitted out of India?

A) In respect of residential properties purchased on or after 26th
May,1993, Reserve Bank considers applications for repatriation of sale
proceeds up to the consideration amount remitted in foreign exchange
for the acquisition of the property for two such properties. The
balance amount of sale proceeds if any or sale proceeds in respect of
properties purchased prior to 26th May, 1993, will have to be credited
to the ordinary non-resident rupee account of the owner of the
property.

BACK ON TOP

Q)

Are any conditions required to be fulfilled if repatriation of sale proceeds is desired?

A) Applications for repatriation of sale proceeds are considered
provided the sale takes place after three years from the date of final
purchase deed or from the date of payment of final installment of
consideration amount, whichever is later.

BACK ON TOP

Q)

What is the procedure for seeking such repatriation?

A) Applications for necessary permission for remittance of sale
proceeds should be made in form IPI 8 to the Central Office of Reserve
Bank at Mumbai within 90 days of the sale of the property.

BACK ON TOP

Q) Can foreign citizens of Indian origin acquire or dispose of residential property by way of gift?

A) Yes. Reserve Bank has granted general permission to foreign citizens
of Indian origin to acquire or dispose of properties up to two houses
by way of gift from or to a relative who may be an Indian citizen or a
person of Indian origin whether resident in India or not,provided gift
tax has been paid.

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Q) Can foreign citizens of Indian origin acquire commercial properties in India?

A) Yes. Under the general permission granted by Reserve Bank properties
other than agricultural land/farm house/plantation property can be
acquired by foreign citizens of Indian origin provided the purchase
consideration is met either out of inward remittances in foreign
exchange through normal banking channels or out of funds from the
purchasers' NRE/FCNR accounts maintained with banks in India and a
declaration is submitted to the Central Office of Reserve Bank in form
IPI 7 within a period of 90 days from the date of purchase of the
property/final payment of purchase consideration.

BACK ON TOP

Q)

Can they dispose of such properties?

A) Yes.

BACK ON TOP

Q)

Can sale proceeds of such property be remitted out of India?

A) Yes. Repatriation of original investment in respect of properties
purchased by foreign citizens of Indian origin on or after 26th May
1993 will be allowed to be remitted up to the consideration amount
originally remitted from abroad provided the property is sold after a
period of three years from the date of the final purchase deed or from
the date of payment of final installment of consideration amount,
whichever is later. Applications for the purpose are required to be
made to the Central Office of Reserve Bank within 90 days of the sale
of property in form IPI 8.

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Q)

Can the properties (residential/commercial) be given on rent if not required for immediate use?

A) Yes. Reserve Bank has granted general permission for letting out of
any immovable property in India. The rental income or proceeds of any
investment of such income has to be credited to NRO account.

BACK ON TOP

Q)
Can NRIs obtain loans for acquisition of a house/flat for residential
purpose from financial institutions providing housing finance?

A) Reserve Bank has granted general permission to certain financial
institutions providing housing finance e.g. HDFC,LIC Housing Finance
Ltd.,etc. to grant housing loans to non-resident Indian nationals for
acquisition of houses/flats for self-occupation subject to certain
conditions.

BACK ON TOP

Q) Can authorized dealer grant loans to NRIs for acquisition of a flat/house for residential purposes?

A) Authorized dealers have been granted permission to grant loans up to
non-resident Indian nationals for acquisition of house/flat for
self-occupation on their return to India subject to certain conditions.
Repayment of the loan should be made within a period not exceeding 15
years out of inward remittance through banking channels or out of funds
held in the investments' NRE/FCNR accounts.

BACK ON TOP

Q)

Can Indian companies grant loans to their NRI staff?

A) Reserve Bank permits Indian firms/companies to grant housing loans
to their employees deputed abroad and holding Indian passport subject
to certain conditions.

Source: Reserve Bank of India

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Q)

What are the options available for obtaining guarantors while applying for a HDFC/LIC loan?

A) One will need a guarantor for a loan mainly for collateral security.
The guarantor will have to demonstrate appropriate net worth to cover
for the loan. Usually one can have a guarantor in any city where the
loan issuer has a branch. Talk to loan issuers they will work something
out for NRIs and foreign banks.

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Q) While purchasing real estate most developers demand a Power of Attorney in their favor, is there a way to avoid it?

A) One can choose not to grant the Power of Attorney (POA) to the
developers. However this will mandate the mailing of all documents to
your foreign residence and associated time delays. A good compromise is
to grant the POA to the builder only for specific necessary items.

BACK ON TOP

Regulations/Directions issued by Reserve Bank of India

Q:
Where can one find regulations/directions issued by Reserve Bank for
acquisition and transfer of immovable property in India by a person
resident outside India?

A:
Regulations regarding acquisition and transfer of immovable property in
India by a person resident outside India have been notified vide RBI
Notification No. FEMA 21/2000-RB dated May 3, 2000 as amended vide
Notification No. FEMA 64/2002-RB dated June 29, 2002 and Notification
No. FEMA 65/2002-RB dated June 29, 2002 and relevant directions issued
in the form of A.P. (DIR Series) Circulars. These are available on RBI
website: www.fema.rbi.org.in

BACK ON TOP

Acquisition of immovable property in India by way of purchase by a person resident outside India

Q:
Under the extant foreign exchange regulations to whom is general
permission available for purchase immovable property in India?

A:
General Permission is available to purchase only a
residential/commercial property in India to a person resident outside
India who is a citizen of India (NRI) and who is a Person of Indian
Origin (PIO).

Q: Who is a Person of Indian Origin (PIO)?

A:
For the purpose of acquisition and transfer of immovable property in
India, a PIO means an individual (not being a citizen of Pakistan or
Bangladesh or Sri Lanka or Afghanistan or China or Iran or Nepal or
Bhutan), who (i) at any time, held Indian passport; or (ii) who or
either of whose father or grandfather was a citizen of India by virtue
of the Constitution of India or the Citizenship Act, 1955 (57 of 1955).

Q: Is NRI/PIO
who has purchased residential/commercial property under general
permission required to file any documents with Reserve Bank of India?

A:
NRI/PIO who has purchased residential/commercial property under general
permission is not required to file any documents with the Reserve Bank.

Q: Is there
any restriction on number of residential/commercial property that
NRI/PIO can purchase under the general permission available?

A:
There is no restriction on number of residential/commercial property
that NRI/PIO can purchase under the general permission available.

Q:
Can a name of a foreign national of non-Indian origin be added as a
second holder to a residential/commercial property purchased by
NRI/PIO?

A: No.

Q:
Can a foreign national of non-Indian origin resident outside India
acquire any immovable property in India by way of purchase?

A:
No. Under section 2 (ze) of the Foreign Exchange Management Act, 1999
‘transfer' includes among others, ‘purchase'. Therefore, a foreign
national of non-Indian origin resident outside India cannot acquire any
immovable property in India by way of purchase.

Q: Can a foreign national of non-Indian origin acquire residential property on a lease in India?

A:
Yes. A Foreign National of non-Indian origin including a citizen of
Pakistan or Bangladesh or Sri Lanka or Afghanistan or China or Iran or
Nepal or Bhutan may acquire only residential accommodation on lease,
not exceeding five years for which he/she does not require prior
permission of Reserve Bank of India.

Q:
Can a person resident outside India (i.e. a NRI or a PIO or a foreign
national of non-Indian origin) acquire agricultural land/plantation
property/farm house in India by way of purchase?

A:
No. A person resident outside India cannot acquire by way of purchase
agricultural land/plantation property/farm house in India.

BACK ON TOP

Acquisition of immovable property in India by way of gift by a person resident outside India

Q: Can NRI/PIO acquire residential/commercial property by way of gift under the general permission available?

A:
Yes. Under general permission available NRI/PIO may acquire
residential/commercial property by way of gift from a person resident
in India or a NRI or a PIO.

Q: Can a foreign national of non-Indian origin resident outside India acquire residential/commercial in India by way of gift?

A:
No. Under section 2 (ze) of the Foreign Exchange Management Act, 1999
‘transfer' includes among others, ‘gift'. Therefore, a foreign national
of non-Indian origin resident outside India cannot acquire
residential/commercial property in India by way of gift.

Q:
Can a person resident outside India (i.e. a NRI or a PIO or a foreign
national of non-Indian origin) acquire agricultural land/plantation
property/farm house in India by way of gift?

A: No. A person resident outside India cannot acquire agricultural land/plantation property/farm house in India by way of gift.

BACK ON TOP

Acquisition of immovable property in India by way of inheritance by a person resident outside India

Q:
Can a person resident outside India (i.e. NRI or PIO or foreign
national of non-Indian origin) hold any immovable property in India
acquired by way of inheritance from a person resident in India?

A:
Yes. A person resident outside India can hold immovable property
acquired by way of inheritance from a person resident in India as per
the provisions of Section 6(5) of the Foreign Exchange Management Act,
1999.

Q: Can
a person resident outside India (i.e. NRI or PIO or foreign national of
non-Indian origin) hold any immovable property in India acquired by way
of inheritance from a person resident outside India?

A:
With the specific approval of Reserve Bank a person resident outside
India may hold any immovable property in India acquired by way of
inheritance from a person resident outside India, provided the bequeath
or had acquired such property in accordance with the provisions of
foreign exchange law in force at the time of acquisition or under FEMA
regulations.

BACK ON TOP

Transfer of immovable property in India by way of sale by a person resident outside India

Q: Under general permission available to whom can NRI transfer by way of sale his residential/commercial property?

A: NRI can transfer by way of sale residential/commercial property in India to a person resident in India or to a NRI or a PIO.

Q: Under general permission available to whom can a PIO transfer his residential/commercial property by way of sale?

A: PIO can transfer by way of sale residential/commercial property in India only to a person resident in India.

Q: Can a PIO transfer by way of sale his residential/commercial property to a NRI or a PIO?

A:
No. He would need to seek Reserve Bank prior approval for transfer by
way of sale residential/commercial property in India to a NRI or a PIO.

Q: Can a
foreign national of non-Indian origin whether resident in India or
outside India transfer by way of sale residential/property in India
acquired with the specific permission of Reserve Bank to a person
resident in India or outside India?

A:
No. A foreign national of non-Indian origin whether resident in India
or outside India would need to seek prior approval of Reserve Bank for
transfer by way of sale residential/property in India acquired with the
specific permission of Reserve Bank to a person resident in India or
outside India.

Q:
Under general permission available to whom can NRI/PIO transfer by way
of sale his agricultural land/plantation property/farm house in India?

A:
Under the general permission available NRI/PIO may transfer by way of
sale his agricultural land/plantation property/farm house in India to a
person resident in India who is a citizen of India.

Q:
Can a foreign national of non-Indian origin resident outside India
transfer by way of sale agricultural land/plantation property/farm
house acquired by him in India?

A:
A foreign national of non-Indian origin resident outside India would
need to seek prior approval of Reserve Bank for transfer, by way of
sale, agricultural land/plantation property/farm house acquired in
India.

RANZCR 2007 ASM MELBOURNE - MULTIMEDIA PRESENTATIONS

2008-10-22T06:56:00.000-07:00

Palatal & Mandibular Torus, & Exostosis

2008-10-21T19:23:00.000-07:00

Palatal & Mandibular Torus, & Exostosis

While not technically soft tissue masses, the torus palatinus, torus mandibularis and bony exostosis (buccal exostosis) are all lesions which present as surface masses and are removed with minimal disturbance of deeper cancellous bones. As such, they are submitted to the pathologist as palatal or alveolar masses and might be confused with peripheral ossifying fibroma or other bone-producing soft tissue masses of the oral mucosa. For this reason, it is included in the present section.

The torus is considered to be a developmental anomaly, although it does not present until adult life and often will continue to grow slowly throughout life. It may be the outcome of mild, chronic periosteal ischemia secondary to mild nasal septum pressures (palatal torus) or the torquing action of the arch of the mandible (mandibular torus) or lateral pressures from the roots of the underlying teeth (buccal exostosis), but this is largely speculation. The most similar bony growth outside the jaws is the bunion of the lateral foot, and the earliest dental journal report of a torus palatinus was probably in an 1857 essay by Parmentier relating to tumors of the palate. The prevalence rate for tori is 27/1,000 adults (Table 1).

Clinical Features: These entities are all very site-specific. The palatal torus is found only in the midline of the hard palate (Figures 1 & 2). The mandibular torus is found only on the lingual surface of the mandible, near the bicuspid teeth (Figures 3 & 4). The buccal exostosis is found only on the facial surface of the alveolar bone, usually the maxillary alveolus.7 Bony surface proliferations found in another site are typically given the generic diagnosis of bony exostosis or osteoma, i.e. are considered to be trauma-induced inflammatory periosteal reactions or true neoplasms. Unless such a bony prominence is specifically located, is pedunculated or is associated with an osteoma-producing syndrome such as the Gardner syndrome, there may be no means by which to differentiate an exostosis from an osteoma, even under the microscope.

As previously stated, these lesions are not present until the late teen and early adult years, and many, if not most, continue to slowly enlarge over time. Fewer than 3% occur in children. Taken as a group, these lesions are found in at least 3% of adults and are more common in females than in males. The torus may be bosselated or multilobulated but the exostosis is typically a single, broad-based, smooth-surfaced mass, perhaps with a central sharp, pointed projection of bone producing tenderness immediately beneath the surface mucosa. Lesions may become 3-4 cm. in greatest diameter, but are usually less than 1.5 cm. at biopsy. A definite hereditary basis, usually autosomal dominant, has been established for some cases of tori and Asians, especially Koreans, have a much higher prevalence rate than do other racial groups.

Pathology: On cut surface the torus and exostosis show dense bone with a lamellar or laminated pattern (Figure 5). They are usually comprised of dense, mature, lamellar bone with scattered osteocytes and small marrow spaces filled with fatty marrow or a loose fibrovascular stroma. Some lesions have a thin rim of cortical bone overlying inactive cancellous bone with considerable fatty or hematopoietic marrow present. Minimal osteoblastic activity is usually seen, but occasional lesions will show abundant periosteal activity. Large areas of bone may show enlarged lacunae with missing or pyknotic osteocytes (Figure 6), indicative of ischemic damage to the bone. Ischemic changes such as marrow fibrosis and dilated veins may also be found in the marrow, with rare examples showing actual infarction of fatty marrow.

Treatment & Prognosis: Neither the torus nor the bony exostosis requires treatment unless it becomes so large that it interferes with function, interferes with denture placement, or suffers from recurring traumatic surface ulceration (usually from sharp foods, such as potato chips or fish bones). When treatment is elected, the lesions may be chiseled off of the cortex or removed via bone bur cutting through the base of the lesion.

Slowly enlarging, recurrent lesions occasionally are seen, but there is no malignant transformation potential. The patient should be evaluated for Gardner syndrome should he or she have multiple bony growths or lesions not in the classic torus or buccal exostosis locations. Intestinal polyposis and cutaneous cysts or fibromas are other common features of this autosomal dominant syndrome.

New Horizons Lecture by Zerhouni

2008-10-21T13:23:00.001-07:00

http://www.rsna.org/generalsessions/zerhouni/index.html

2008-10-06T22:49:00.000-07:00

Guyon's Canal Syndrome
Guyon's Canal is a small tunnel that lies within the wrist (between the Hamate and Pisiform bones of the hand, the roof of the canal is formed by the Volar carpal ligament), it is through this tunnel that the ulnar nerve and artery pass within a neurovascular bundle. The canal is one of the principal sites of ulnar nerve compression.
Guyon's Canal Syndrome is numbness and tingling in the ring and little fingers caused by irritation of the ulnar nerve as it passes through Guyon's Canal.
Causes
Guyon's Canal Syndrome arises when there is pressure on the ulnar nerve within the canal.
This pressure can be caused by:
A cyst within the canal.
Clotting of the ulnar artery.
Fracture of the hamate bone.
Arthritis of the wrist bones.
Symptoms
No matter what the cause of compression of the ulnar nerve, the symptoms are the usually the same.
They include:
Pins and needles in the ring and little fingers.
A burning pain of the wrist and hand.
Decreased sensation and clumsiness in the hand.
In extreme cases, compression of the ulnar nerve at Guyon's Canal can result in a phenomenon known as Claw Hand.
In all cases of compression of the ulnar nerve at Guyon's Canal, sensory supply to the skin of the back of the hand is spared.
This is because the branch of the nerve that supplies this area (the dorsal cutaneous nerve) leaves the main trunk of the ulnar nerve in the arm before it reaches Guyon's Canal.

Anatomical variations of the cystic duct

2008-10-06T18:00:00.000-07:00

Anatomical variations of the cystic duct are usually of no clinical significance, occurring in 18%-23% of cases[4]. However, unrecognized variant anatomy can be a source of confusion on imaging studies. In addition, the cystic duct may be involved in a wide variety of both primary and secondary disease processes. The rate of injury varies in the medical literature from 0% to 1%[5]. The following are some of the cystic duct variations found: (1) the cystic and common hepatic duct are in parallel; (2) low confluence of the cystic duct[2]; (3) insertion of the cystic duct in the left and right hepatic ducts, and bifurcation of the left and right hepatic ducts[2]; (4) anterior, posterior spiral types of insertion of the cystic duct on the left side of the common hepatic duct; (5) parahepatic duct insertion into the cystic duct; (6) absent or short cystic duct (length <> 5 mm; (8) double cystic duct[6,7]; (9) right hepatic duct emptying into the cystic duct[8]; and (10) hepaticocystic duct[9], a very rare congenital abnormality in which the common hepatic duct enters the gallbladder. The left, right, and common hepatic ducts are all defective, with the cystic duct draining the entire biliary system into the duodenum.
Multiple modalities permit depiction of the normal anatomy, as well as disease processes of the cystic duct, including CT, PTC, ERCP, intraoperative cholangiography and MRCP. Although visualization of the dilated cystic duct is possible with US and CT, the normal-caliber cystic duct may be difficult to detect with these techniques[10]. In our first case, CT demonstrated minimal intrahepatic ductal dilatation, but failed to show low insertion of the cystic duct, as was revealed by surgery. In this case, the low insertion of the cystic duct was misdiagnosed as gallbladder and bile duct calculi. However, in the second case, ERCP showed a long cystic duct with a narrow and in-curved lumen. An anomalous cystic duct was diagnosed before surgery. Anatomical variation is readily identified at ERCP. In clinical practice, if the patient presents with intermittent non-colic right upper abdominal pain, and ultrasound, CT and endoscopy eliminate choledocholithiasis, tumor and peptic ulcer, then a narrow-winding cystic duct should be considered. ERCP is extremely helpful in diagnosis. Recent studies have demonstrated that MRCP may provide a non-invasive alternative to ERCP and PTC in diagnosis of anomalous cystic ducts[11]. Taourel and colleagues[12] evaluated the accuracy of MRCP in the diagnosis of anatomic variants of the biliary tree in 171 patients. MRCP demonstrated a cystic duct in 126 patients (74%), including low cystic duct insertion in 11 (9%) and a parallel course of the cystic and hepatic ducts in 31 patients (25%). These findings suggest that accurate preoperative assessment is very useful in providing a surgical treatment plan in addition to confirming diagnosis. During cholecystectomy, to avoid biliary tree injury, it is important to identify the common hepatic-cystic duct junction. Misidentification of the cystic duct can lead to postoperative complications. In particular, attention should pay to low medial insertion of the cystic duct because this anatomical variant may lead to misdiagnosis on imaging, and thus affect therapeutic intervention, as was seen in our first case.
A limited literature review of bile duct variation has shown that the aim of most surgeons is to identify whether there are bile duct stones. With respect to the accidental discovery of bile duct variation, it is not the nature of the variation itself but rather the existence of the bile duct variation that is the most important factor in the prevention of bile duct injury. Most injuries to the cystic duct usually occur when it runs parallel to the common bile duct and is encased in a common sheath, so that separation between the ducts is not readily apparent at surgery. T-tube placement in the cystic duct remnant is usually of no consequence; however, there may be a difficulty if retained common duct stones are present, and stone removal via the T-tube is attempted. In such cases, access to the bile duct is via a tract that enters the cystic duct, and manipulation and extraction must occur via the cystic duct across the valves of Heister. Stone extraction is more difficult or may be impossible via this route[13]. Suspicion should be raised if the cystic duct is of an unusually large calibre. Intraoperative cholangiography should be used in case of doubt and, in unusual circumstances, cholangiography can be performed via the gallbladder to aid in the identification of the cystic duct as well as the common bile duct.
In conclusion, the cystic duct may be involved in a variety of anatomical variations. Diagnostic accuracy relies on a clear understanding of the normal anatomy and anatomical variants of the cystic duct, and imaging features of calculous disease.

REFERENCES
1 Sendrath DNA. Anomalies of the bile ducts and blood vessels as the cause of accidents in biliary surgery. JAMA 1918;
71: 864-867
2 Lamah M, Karanjia ND, Dickson GH. Anatomical variations of the extrahepatic biliary tree: review of the world literature.
Clin Anat 2001; 14: 167-172 PubMed
3 Krahenbuhl L. Sclabas G, Wente MN, Schafer M, Schlumpf R, Buchler MW. Incidence, risk factors, and prevention of
biliary tract injuries during laparoscopic cholecystectomy in Switzerland. World J Surg 2001; 25: 1325-1330 PubMed
4 Shaw MJ, Dorsher PJ, Vennes JA. Cystic duct anatomy: an endoscopic perspective. Am J Gastroenterol 1993; 88: 2102-
2106 PubMed
5 Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, Knuiman MW, Sheiner HJ, Edis A. Complications of
cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-
based study. Ann Surg 1999; 229: 449-457 PubMed
6 Fujikawa T, Takeda H, Matsusue S, Nakamura Y, Nishimura S. Anomalous duplicated cystic duct as a surgical hazard:
report of a case. Surg Today 1998; 28: 313-315 PubMed
7 Bernard P, Letessier E, Denimal F, LeNeel JC. Accessory cystic duct discovered by intraoperative cholangiography during
cholecystectomy. Ann Chir 2001; 126: 1020-1022 PubMed
8 Hashimoto M, Hashimoto M, Ishikawa T, Iizuka T, Matsuda M, Watanabe G. Right hepatic duct emptying into the cystic
duct: report of a case. Surg Endosc 2002; 16: 359 PubMed
9 Losanoff JE, Jones JW, Richman BW, Rangnekar NJ. Hepaticocystic duct: a rare anomaly of the extrahepatic biliary
system. Clin Anat 2002; 15: 314-315 PubMed
10 Zeman RK, Burrell MI. Gallbladder and bile duct imaging. New York: Churchill-Livingstone, 1987: 36-46
11 Turner MA, Cho SR, Messmer JM. Pitfalls in cholangiographic interpretation. Radiographics 1987; 7: 1067-1105
PubMed
12 Taourel P, Bret PM, Reinhold C, Barkun AN, Atri M. Anatomic variants of the biliary tree: diagnosis with MR
cholangiopancreatography. Radiology 1996; 199: 521-527 PubMed
13 Ghahremani GG. Postsurgical biliary tract complications. Gastroenterologist 1997; 5: 46-57 PubMed

General keyboard shortcuts

2008-10-05T03:44:00.000-07:00

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Femoroacetabular Impingement

2008-09-30T17:10:00.000-07:00

Femoroacetabular impingement, previously termed acetabular rim syndrome, is a major factor in early development of osteoarthritis of the hip.1-7 This syndrome is caused by abnormal contact between the osseous protrusions of the acetabulum and the femur during hip joint movement.1 In patients with femoroacetabular impingement, repetitive microtrauma from the osseous impingement leads to recurring irritation, degenerative changes of the labrum, and ultimately irreversible cartilaginous damage.1,2,4,5,8-11

Femoroacetabular impingement tends to involve young, active patients and can be debilitating.4,9,10 Femoroacetabular impingement is often bilateral, but may be symptomatic on only one side.1 Femoroacetabular impingement is diagnosed and classified into two types, pincer and cam, by the clinical and radiologic presentation.8 However, most cases of femoroacetabular impingement are a combination of the two subtypes.

Pincer impingement is caused by acetabular overcoverage with normal femoral head sphericity.1,2,4,8,9 The pincer effect is the linear contact between a normal neck and an overcovering acetabular rim, which can lead to labral damage.2,8,9 Pincer impingement is more common in middle-aged women with abnormalities of acetabular morphology.4,5,8,10,11

Cam impingement arises from a prominence of the femur that leads to an abnormal, aspherical shape of the femoral head-neck junction.1,4,8 This terminology arises from the cam, which is the projecting part of a rotating wheel or shaft that strikes a lever at one or more points on its circular path. The asphericity or abnormal head-neck offset in cam impingement is thought to result from subclinical slipped capital femoral epiphysis or a growth disturbance of the proximal femur.9 The cam effect leads to abrasion and chondropathy with only partial involvement of the labrum.2 Cam impingement is more common in young males with underlying abnormalities of the femoral head morphology.4,5,8,10,11

Etiology
The etiology of femoroacetabular impingement is not entirely clear and is felt to be either developmental or related to subclinical slipped capital femoral epiphysis.5,8 A number of conditions can predispose a patient to femoroacetabular impingement including Legg-Calve-Perthes disease, congenital hip dysplasia, slipped capital femoral epiphysis, avascular necrosis of the femoral head, ununited femoral neck fractures, coxa profunda, coxa vara, protrusion acetabuli, and acetabular retroversion.2,4,5,8,12 Slipped capital femoral epiphysis and femoroacetabular impingement have been proposed to be associated due to reduced clearance of the joint and detectable abutment of the metaphysis against the acetabular rim.4 Acetabular anatomic abnormalities (ie, retroverted acetabulum) or proximal femoral anatomic abnormalities (ie, coxa profunda) lead to the pincer-type femoroacetabular impingement.8-10 Those anatomic abnormalities that lead to abnormal sphericity of the femoral head (osseous prominence at the anterolateral femoral head and neck junction, slipped capital femoral epiphysis, and developmental dysplasia of the hip) can lead to cam impingement.8-11

Diagnosis
Clinical

The gold standard is clinical diagnosis with radiographic corroboration; however, patients can have radiographic findings and be asymptomatic due to early disease or overall decreased activity.1 Patients often report intermittent pain early in the course of the disease, followed by more consistent pain after demanding activities or prolonged sitting.4,6,10,13 Other exacerbating activities can include stair climbing, prolonged sitting, and athletic events.10,11

Patients with femoroacetabular impingement typically experience groin pain. Symptoms are typically unilateral and worse after prolonged periods of sitting or when significant stress is placed on the hip.8 Impingement mainly involves the anterolateral portion of the hip joint. Therefore, flexion and internal rotation lead to symptomatic impingement due to shear forces or compression of the acetabular labrum.2,4,8

The impingement test involves rotating a supine patient’s hip internally as it is flexed passively to approximately 90° and adducted.4 A positive “impingement sign” is pain in flexion-internal rotation. On examination, limited range of motion (ROM) frequently is encountered and is described as a loss of internal rotation out of proportion with other ROM deficits.1,4,8 Additionally, a grinding or popping sensation can be felt when the femur is externally rotated and the hip is maximally abducted.8 This sign is sensitive but not specific for femoroacetabular impingement, because the anterolateral labrum is frequently involved in other degenerative diseases of the hip.2,10

Radiographs

Standard standing anteroposterior and lateral radiographs of the pelvis are necessary for radiographic evaluation.2,4 Proper technique is required, as poorly obtained radiographs may lead to over- or underestimation of the degree of disease.1 Early osteoarthritic changes associated with femoroacetabular impingement are frequently atypical.1 For example, instead of the typical joint space narrowing, osteophyte formation, subchondral sclerosis, or cysts, radiographs of femoroacetabular impingement may demonstrate reactive ossification of the labrum or possibly acetabular rim fractures from repetitive stress.1 Radiographs of both types of femoroacetabular impingement demonstrate premature degenerative arthrosis, and up to one third of patients will have fibrocystic changes at the femoral head-neck junction (Figure 1).8,10 Herniation pits also may be found in the anterolateral portion of the femoral head/neck or morphologic changes affecting the acetabulum.2,4,8,11

Radiographic signs of pincer impingement include acetabular retroversion and evidence of impaction between the anterosuperior acetabulum and anterior femoral neck.8,9 Retroversion can be diagnosed by the presence of the “crossover” or “figure-of-eight” sign, in which focal retroversion of the superior hip joint exists. The superior aspect of the anterior acetabular rim extends lateral to the posterior rim on frontal radiographs, and computed tomography may be helpful in presurgical planning. Acetabular retroversion is associated with the development of hip osteoarthritis. The prevalence of radiographic acetabular retroversion is 20% among patients with idiopathic hip osteoarthritis and 5% among the general population.14

Lateral radiographs in cam impingement can demonstrate an osseous prominence at the anterolateral head-neck junction that extends beyond the spherical portion of the femoral head. In addition, the difference between the femoral head and neck planes aligned parallel to the femoral neck axis should normally be >7 mm. Cam impingement may have reduced offset of the femoral neck and head junction. Also, a head to neck ratio can be calculated by determining the difference between the maximal anterior radius of the femoral head and the anterior radius of the adjacent femoral neck.8,12 A pistol grip deformity of the proximal femur and changes of the acetabular rim may also be detected with radiographs.4,8,9,12

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) and magnetic resonance arthrography can provide detailed views of the labrum and acetabular cartilage.4,8 Labral tears, paralabral cysts, and cartilaginous abnormalities are well evaluated with magnetic resonance arthrography.5,8,11 The degeneration of the labrum is characteristically anterosuperior (Figure 5).1,2,4,5,8-10 Acetabular cartilage lesions in cam impingement are characteristically anterosuperior, whereas lesions in pincer impingement are typically posteroinferior.6,12

Femoral head-neck morphology on MRI is assessed by measuring the anterior alpha (a) angle on the sagittal oblique image parallel to the femoral neck and passing through the narrowest portion of the femoral neck. The alpha angle is determined by first assessing the center of the femoral head. Two vectors are extended from the center of the femoral head along the femoral neck axis and the point at which the femoral neck intersects the spherical portion of the femoral head. The aspherical femoral head-neck junction due to a focal protuberance increases the alpha angle beyond 55° (Figure 6).5,6,8,10

Pincer impingement is caused by acetabular overcoverage, and MRI can demonstrate a deep acetabulum and signs of osseous impaction along the anterosuperior or superior femoral neck.6,8 The cartilage damage seen with pincer impingement tends to be smaller and more focal than the extensive cartilage abnormality seen with cam-type femoroacetabular impingement.8,10 Cartilage damage usually is adjacent to the acetabular labral tear and can be associated with subchondral cyst formation, bony sclerosis, and osteophyte formation.8

Figure 4: Pistol grip deformity of the proximal femur. Frontal radiograph demonstrates the abnormally sloped configuration of the lateral femoral neck, termed the "pistol grip" deformity. This finding may be the result of subclinical slipped capital femoral epiphysis or a growth disturbance of the proximal femur, and can be associated with femoroacetabular impingement. Figure 5: Anterosuperior labral tear associated with cam impingement. Sagittal magnetic resonance arthrogram demonstrates an anterior femoral head-neck junction protuberance (arrowhead) and associated anterior superior labral tear (arrow). Figure 6: Cam impingement. Oblique magnetic resonance arthrogram demonstrates an abnormally increased alpha angle (>55°) in this patient with cam impingement. The alpha angle is determined by first assessing the center of the femoral head (white circle). Two vectors are extended from the center of the femoral head along the femoral neck axis (line) and the point at which the femoral neck (arrow) intersects the spherical portion of the femoral head (line). The aspherical femoral head-neck junction due to a focal protuberance in this case increases the alpha angle.

Treatment
The first therapeutic step in treatment is nonsteroidal anti-inflammatory drugs and activity modification.2,9,10 Additionally, physical therapy is aimed at strengthening abdominal and gluteal musculature and stretching the paravertebral muscles to change posture or pelvic inclination.2 Specific movements that elicit symptoms should be avoided.

Surgical reconstruction is recommended as early as possible after first symptoms appear to prevent future damage.1 Surgical treatment is suitable only if there are no advanced degenerative changes or extensive articular cartilage damage.6 Once irreversible cartilage damage has occurred, pain will frequently persist after surgical intervention.8

Joint preserving surgery involves resection osteoplasty and less frequently osteotomy for reorientation.2-4,8 Surgical osteotomy involves removing the osseous protrusion by either surgical hip dislocation or arthroscopy (Figure 3).1,2,4,8-10 Surgical hip dislocation involves entering the hip joint anteriorly via a capsulotomy and reducing either the nonspherical portion of the femoral head in cam impingement or the acetabular rim portion in pincer impingement.8

Arthroscopic management involves a complete evaluation of both the central and peripheral compartments of the hip joint.9 An intertrochanteric flexion-valgus osteotomy involves increasing the distance between the femoral neck and acetabulum by performing an intertrochanteric osteotomy in patients with avascular necrosis or Legg-Calve-Perthes disease.8 Less commonly, reorientation of a retroverted acetabulum can be performed. This is called reverse periacetabular osteotomy.1,2,4,13 In patients with advanced osteoarthrosis, total hip arthroplasty is an option.2

References
Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis - what the radiologist should know. AJR Am J Roentgenol. 2007; 188:1540-1552.
Pierannunzii L, d’Imporzano M. Treatment of femoroacetabular impingement: a modified resection osteoplasty technique through and anterior approach. Orthopedics. 2007; 30:96-102.
Mardones RM, Gonzalez C, Chen Q, Zobitz M, Kaufman KR, Trousdale RT. Surgical treatment of femoroacetabular impingement: evaluation of the effect of the size of the resection. J Bone Joint Surg Am. 2006; 88:84-91.
Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003; 417:112-120.
Kassarjian A, Yoon LS, Belzile E, Connolly SA, Millis MB, Palmer WE. Triad of MR arthrographic findings in patients with cam type femoroacetabular impingement. Musculoskeletal Imaging. 2005; 236:588-592.
Pfirrmann CWA, Mengiardi B, Dora C, Kalberer F, Zanetti M, Hodler J. Cam and pincer femoroacetabular impingement: Characteristic MR arthrographic findings in 50 patients. Radiology. 2006; 240:778-785.
Klaue K, Durnin CW, Ganz R. The acetabular rim syndrome: a clinical presentation of dysplasia of the hip. J Bone Joint Surg Br. 1991; 73:423-429.
Beall DP, Sweet CF, Martin HD, et al. Imaging findings of femoroacetabular impingement syndrome. Skeletal Radiol. 2005; 34:691-701.
Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Journal of Arthroscopic and Related Surgery. 2006; 22:95-106.
Wisniewski SJ, Grogg B. Femoroacetabular impingement: An overlooked cause of hip pain. Am J Phys Med Rehabil. 2006; 85:546-549
James SLJ, Ali K, Malara F, Young D, O’Donnell J, Connell DA. MRI findings of femoroacetabular impingement. AJR Am J Roentgenol. 2006; 187:1412-1419.
Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005; 87:1012-1018.
Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. J Bone and Joint Surg Am. 2003; 85:278-286
Giori NJ, Trousdale RT. Acetabular retroversion is associated with osteoarthritis of the hip. Clin Orthop Relat Res. 2003; 417:263-269.
Authors
Drs Bathala, Bancroft, and Peterson are from the Department of Radiology and Dr Ortiguera is from the Department of Orthopedics, Mayo Clinic Jacksonville, Florida.

Drs Bathala, Bancroft, Peterson, and Ortiguera have no relevant financial relationships to disclose.

Correspondence should be addressed to: Elizabeth A. Bathala, MD, Mayo Clinic Jacksonville, 4500 San Pablo Blvd, Jacksonville, FL 32224.