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[Laughter] [Applause] [Music] [Applause] zone 3 podcast i've got reggie to my left i'm robert and across reggie to my left i'm robert and across the table we've got dr canal thank you the table we've got dr canal thank you for joining us dr canal repeat for joining us dr canal repeat thank you for bringing me memorized thank you for bringing me memorized together who doesn't know who you are so together who doesn't know who you are so but if you would we all know who you are but if you would we all know who you are as far as you know mri goes but just as far as you know mri goes but just tell us a little about yourself outside tell us a little about yourself outside of mri your family life your hobbies of mri your family life your hobbies those sort of things those sort of things wow um i think in 40 years of radiology wow um i think in 40 years of radiology nobody's ever asked me that before nobody's ever asked me that before i feel honored i i feel honored i have the most wonderful family in the have the most wonderful family in the world a wife and world a wife and six children thank god and 18
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six children thank god and 18 grandchildren grandchildren thank god and they live in six different thank god and they live in six different cities all around the world cities all around the world and i find myself interested in and i find myself interested in lots and lots of hobbies i like lots and lots of hobbies i like weightlifting i like weightlifting i like marathon running i like skiing i like marathon running i like skiing i like bicycling bicycling i'm a pilot i'm a violinist and i'm i'm a pilot i'm a violinist and i'm a photographer of sorts i love a photographer of sorts i love animal wildlife photography especially animal wildlife photography especially and and i think that's about it for now nothing i think that's about it for now nothing easy though easy though i'm guessing you're a steelers fan too i'm guessing you're a steelers fan too it's actually i think it's actually i think one of the official laws of the united one of the official laws of the united states is you can't live in pittsburgh states is you can't live in pittsburgh and not and not be a steeler fan it's it's it's be a steeler fan it's it's it's mandatory with an outcast for sure mandatory with an outcast for sure well thank you again for joining us it's well thank you again for joining us it's an honor truly truly um an honor truly truly um and we're on the rover in pittsburgh and we're on the rover in pittsburgh we're talking about residual gadolinium we're talking about residual gadolinium that's retained that's retained and how it relates to nsf like nsf being and how it relates to nsf like nsf being nephrogenic systemic fibrosis something
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nephrogenic systemic fibrosis something i know that you're very aware of i know that you're very aware of the subject itself it can be considered the subject itself it can be considered controversial as how it's viewed controversial as how it's viewed so if you would just kind of start so if you would just kind of start talking about that talking about that certainly um it's interesting that we've certainly um it's interesting that we've had gadolinium usage in the u.s since had gadolinium usage in the u.s since june of 1988 and we june of 1988 and we in fact initially we've been treating it in fact initially we've been treating it for years as one of the safest drugs for years as one of the safest drugs we've ever used in humans we've ever used in humans and i think for the most part it's still and i think for the most part it's still true but true but any drug that we give to anyone has any drug that we give to anyone has potential for adverse events potential for adverse events so when we talk about safety of so when we talk about safety of gadolinium-based contrast agents gadolinium-based contrast agents one of the categories of safety that we one of the categories of safety that we used to talk about and today is pretty used to talk about and today is pretty much ignored for some reason much ignored for some reason is um immediate adverse events the is um immediate adverse events the things that occur in the first typically things that occur in the first typically hour or two hour or two hives nausea vomiting things things of hives nausea vomiting things things of that nature and it can that nature and it can it can be from minor or irritative to it can be from minor or irritative to life-threatening anaphylaxis life-threatening anaphylaxis anaphylactoid reactions anaphylactoid reactions and how these drugs have that potential and how these drugs have that potential and how they differ or how they're and how they differ or how they're similar in in the immediate adverse
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similar in in the immediate adverse reactions and then in 2006 reactions and then in 2006 dr grobner first became aware and made the rest of the world aware world aware that um there is a connection between that um there is a connection between this this unusual disease nephrogenic systemic unusual disease nephrogenic systemic fibrosis fibrosis and gadolinium-based contrast agents in and gadolinium-based contrast agents in patients who had patients who had poorly functioning kidneys just a poorly functioning kidneys just a generic concept generic concept that their kidneys were not working well that their kidneys were not working well and and since then a massive amount of work was since then a massive amount of work was done done specifically studying nephrogenic specifically studying nephrogenic systemic fibrosis and i'm treating that systemic fibrosis and i'm treating that as a different category from the as a different category from the immediate immediate adverse events because nsf will be adverse events because nsf will be something that would take something that would take days or weeks there are always articles days or weeks there are always articles that love to say that love to say sometimes even years after sometimes even years after administration administration um personally i don't accept that i um personally i don't accept that i think that um think that um i think it's more likely that we're i think it's more likely that we're missing data than it actually missing data than it actually developed years after the last developed years after the last administration but it is a possibility
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administration but it is a possibility so we'll leave it out there and so we'll leave it out there and certainly certainly there are several articles that claim there are several articles that claim that it could be as much as years that it could be as much as years speaking to the people that are most speaking to the people that are most involved in it and speaking involved in it and speaking to the people that define the disease to the people that define the disease nephrogenic systemic nephrogenic systemic fibrosis dr sean calper a fibrosis dr sean calper a dermatopathologist dermatopathologist the exquisite majority will be the exquisite majority will be symptomatic within the first few days or symptomatic within the first few days or weeks weeks of it's being administered but not the of it's being administered but not the first few hours first few hours so that puts them in a separate category so that puts them in a separate category of adverse event so safety issues of adverse event so safety issues associated with gadolinium agents as associated with gadolinium agents as opposed to the immediate opposed to the immediate type of adverse events and um we learned type of adverse events and um we learned a lot a lot about nsf and we learned that it's about nsf and we learned that it's associated with associated with some of these drugs much more than with some of these drugs much more than with others and essentially it's others and essentially it's really been associated predominantly really been associated predominantly with with with three drugs with with um with three drugs with with um magnavist and with omniscan and with magnavist and with omniscan and with optomark optomark and those three seem to have 99 plus
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and those three seem to have 99 plus percent of all cases in the world today percent of all cases in the world today that have developed after the prior that have developed after the prior unconfounded administration of a drug unconfounded administration of a drug what does that mean what does that mean the fda i believe came up with this term the fda i believe came up with this term and i think it's a a very useful one and i think it's a a very useful one if a person gets drug a and then if a person gets drug a and then gets a disease they say that's gets a disease they say that's unconfounded there's a drug there's a unconfounded there's a drug there's a disease there's a direct connection of disease there's a direct connection of some sort that they're worried about some sort that they're worried about if a person gets drug a three months if a person gets drug a three months later they come back and get drug b later they come back and get drug b and then gets a disease they call that and then gets a disease they call that confounded confounded was it disease because of a or b or both was it disease because of a or b or both that's referred to as a confounded that's referred to as a confounded administration unconfounded nsf developing after the prior unconfounded administration of a prior unconfounded administration of a gadolinium-based contrast agent 99 gadolinium-based contrast agent 99 are with those three drugs
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an amazing thing occurred within a heartbeat heartbeat within just a few years depending on who within just a few years depending on who you you read 2009 2010 certainly by 2010 read 2009 2010 certainly by 2010 there were almost no new cases of nsf there were almost no new cases of nsf today we're getting single digit cases today we're getting single digit cases and almost all of them are cases and almost all of them are cases patients that should not have had patients that should not have had these drugs administered to them so the these drugs administered to them so the drug drug the dis association was made in 2006 the dis association was made in 2006 and within three four years the disease and within three four years the disease pretty much went away pretty much went away because society identified the because society identified the relationship thanks to dr grosner first relationship thanks to dr grosner first revealing it to all of us making the revealing it to all of us making the observation observation promulgating it immediately throughout promulgating it immediately throughout the radiologic community the radiologic community internationally and making adjustments internationally and making adjustments accordingly accordingly what adjustments were made we had to what adjustments were made we had to redefine whether we were going to give a redefine whether we were going to give a contrast agent in the first place if we were going to give a contrast agent we had to choose which one we
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agent we had to choose which one we wanted to give you couldn't treat them wanted to give you couldn't treat them interchangeably interchangeably and whether we liked it or not and whether we liked it or not we had to check renal function because we had to check renal function because this was a disease that was this was a disease that was pretty much essentially only seen if the pretty much essentially only seen if the kidneys were close to shutting down kidneys were close to shutting down it could be acute renal failure it could it could be acute renal failure it could be chronic renal failure be chronic renal failure but it was going to be seen mostly with but it was going to be seen mostly with out of five stages of chronic kidney out of five stages of chronic kidney disease it was seen mostly with stage disease it was seen mostly with stage five and a few stage four five and a few stage four and low single digits stage three just as we got our ourselves wrapped around that problem ourselves wrapped around that problem 2010 2011 is pretty much eradicated 2010 2011 is pretty much eradicated in 2013 in 2013 a new issue came up and a new issue came up and dr canda came out and found from japan dr canda came out and found from japan that there was a signal that there was a signal change in the brain of patients that
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change in the brain of patients that received received gadolinium-based contrast agents gadolinium-based contrast agents fast fast fast fast forward and let's fast fast fast fast forward and let's take from 2013 to today and super take from 2013 to today and super summarize summarize so what they found was that some of the so what they found was that some of the gadolinium that we're administering gadolinium that we're administering to our patients is staying in the body to our patients is staying in the body in different places in the body in different places in the body for weeks months maybe years for weeks months maybe years an extremely extremely small amount an extremely extremely small amount but it's not zero every single gadolinium-based contrast agent seems to leave agent seems to leave something in the body something in the body there's a lot of discussion about the there's a lot of discussion about the structure of the agent structure of the agent macrocyclic versus linear ionic versus macrocyclic versus linear ionic versus non-ionic and there are some truisms and non-ionic and there are some truisms and generalizations that we can get away generalizations that we can get away with making with making in general macrocyclic agents in general macrocyclic agents tend to leave less in the body
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tend to leave less in the body than do the linear agents but within the than do the linear agents but within the macrocyclic agents macrocyclic agents and within the linear agents and within the linear agents there seem to be significant differences there seem to be significant differences on those agents themselves on those agents themselves how much they leave is it the macroscope how much they leave is it the macroscope that's the ionic that's the ionic macrocyclics can be ionic or non-ionic macrocyclics can be ionic or non-ionic linear agents can be ionic or non-ionic linear agents can be ionic or non-ionic ionic opposite bonds attract ionic seems ionic opposite bonds attract ionic seems to be a tighter bond to be a tighter bond macrocyclic seems to be a much tighter macrocyclic seems to be a much tighter bond bond linear is a weaker bond than macrocyclic linear is a weaker bond than macrocyclic non-ionic is a weaker bond than ionic non-ionic is a weaker bond than ionic the stronger the bond the the the theory the stronger the bond the the the theory so non-ionic linear would be the weakest so non-ionic linear would be the weakest exactly non-ionic linear exactly non-ionic linear or optomark and omniscan or optomark and omniscan that's correct so having said that before residual gadolinium
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gadolinium was a topic when it came to nephrogenic was a topic when it came to nephrogenic systemic fibrosis systemic fibrosis nsf what they theorized nsf what they theorized was the transmetallation or decalation was the transmetallation or decalation theory theory and the theory there was that the and the theory there was that the gadolinium we know that gadolinium is gadolinium we know that gadolinium is toxic gadolinium is a heavy metal toxic gadolinium is a heavy metal it's no lanthanide series it's a it's an it's no lanthanide series it's a it's an element oxygen element oxygen nitrogen potassium it's an element nitrogen potassium it's an element but nobody's administering heavy metals but nobody's administering heavy metals to humans i like to tell my patients to humans i like to tell my patients that heavy metal in any form is toxic to that heavy metal in any form is toxic to humanity humanity i agree i agree [Laughter] so what we do is we take the same gadolinium gadolinium ion and we tie it up ion and we tie it up in medical speak the suture is ligated in medical speak the suture is ligated that means you tied it up so we take a that means you tied it up so we take a ligand ligand molecule to tie up the gadolinium molecule to tie up the gadolinium and you attach those together in what's and you attach those together in what's referred to as a chelated complex
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referred to as a chelated complex chelate i think it's greek and i think chelate i think it's greek and i think it means claw it means claw in any case so there's a chelated in any case so there's a chelated complex of this gadolinium ion and the complex of this gadolinium ion and the ligand molecule ligand molecule and all these different agents out there and all these different agents out there all the different competing brands all the different competing brands gadolinium is gadolinium is gadolinium gadolinium is gadolinium is gadolinium right it's it's just an element right it's it's just an element so the gadolinium is identical in all of so the gadolinium is identical in all of these agents what differs and what makes these agents what differs and what makes this drug x and this is drug y this drug x and this is drug y and this is competing drug z is the and this is competing drug z is the ligand molecule ligand molecule if this is caldi amide gadolinium with if this is caldi amide gadolinium with caldiamide and becomes omniscan caldiamide and becomes omniscan if this is dtpa gadolinium and dtpa we if this is dtpa gadolinium and dtpa we call that call that magnevist do you understand so it's just magnevist do you understand so it's just the difference in the ligand molecule the difference in the ligand molecule so the theory of nsf nephrogenic so the theory of nsf nephrogenic systemic fibrosis was that systemic fibrosis was that these different agents the affinity for these different agents the affinity for the ligand molecule the ligand molecule the tightness of that bond if you will the tightness of that bond if you will differ from agent to agent differ from agent to agent and as a result of that if they were to and as a result of that if they were to dissociate dissociate it's very very very uncommon it's a very it's very very very uncommon it's a very small amount but like any chemical small amount but like any chemical reaction is an equilibrium
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reaction is an equilibrium and some will stay the vast majority for and some will stay the vast majority for every one of these every one of these stays bound but some in equilibrium stays bound but some in equilibrium will be bouncing off and if it does will be bouncing off and if it does get released gadolinium is exquisitely get released gadolinium is exquisitely reactive and it'll find reactive and it'll find something to attach to something to attach to maybe a phosphate or carbonate it'll maybe a phosphate or carbonate it'll find something find something and the theory of transmetylation or and the theory of transmetylation or decollation is that if it does separate decollation is that if it does separate then this gadolinium will find a then this gadolinium will find a phosphate or other molecule and the two phosphate or other molecule and the two of them will waltz off to wherever of them will waltz off to wherever phosphate lives maybe bone phosphate lives maybe bone and stay there for years in a reservoir and stay there for years in a reservoir that says hidden inside bone where it that says hidden inside bone where it was never meant to go in the first place was never meant to go in the first place it was never designed it was never designed to bio distribute to bone it was to bio distribute to bone it was designed as an extracellular fluid agent designed as an extracellular fluid agent as long as it was attached to its as long as it was attached to its initial ligand initial ligand it would be extracellular fluid the it would be extracellular fluid the kidneys would kidneys would then filter it and glomerular filtration then filter it and glomerular filtration out into the urine but if it's going to out into the urine but if it's going to get attached to for example a phosphate
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get attached to for example a phosphate and then find its way into a bone and then find its way into a bone reservoir it might stay there for months reservoir it might stay there for months and years and years and not make it into the kidneys and not and not make it into the kidneys and not get excreted get excreted so who is more likely to have it so who is more likely to have it dissociate and have that happen dissociate and have that happen someone in whom you inject it and then someone in whom you inject it and then it stays in the body for longer than it it stays in the body for longer than it was initially designed was initially designed why would it stay in the body for longer why would it stay in the body for longer kidney failure kidney failure since the drugs all are these ages that since the drugs all are these ages that we're discussing for neuroradiologic we're discussing for neuroradiologic application application were excreted by the kidneys if the were excreted by the kidneys if the kidneys are not working well that means kidneys are not working well that means that they are still get excreted but that they are still get excreted but more slowly so they hang around on the more slowly so they hang around on the dance floor that is the human being dance floor that is the human being longer and eventually they may split longer and eventually they may split partners partners they may just if they're there the they may just if they're there the longer you wait the greater the chance longer you wait the greater the chance for for dissociation with perfectly normal dissociation with perfectly normal kidneys we felt kidneys we felt you give the drug you do the imaging the you give the drug you do the imaging the kidneys filter them kidneys filter them it's literally in the toilet you should it's literally in the toilet you should excuse me excuse me shortly thereafter and even if it shortly thereafter and even if it dissociates who cares it's now dissociates who cares it's now out of the human conceptually
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out of the human conceptually the normal kidney patient should not the normal kidney patient should not have to worry about it have to worry about it and the theory was that if you have bad and the theory was that if you have bad kidneys especially if they're very kidneys especially if they're very poorly functioning kidneys it sticks poorly functioning kidneys it sticks around for around for so long that some of them that so long that some of them that dissociate and maybe dissociate and maybe more permanently in a sense will stick more permanently in a sense will stick around in that human body perhaps in around in that human body perhaps in bone bone and lead to inflammatory reactions that and lead to inflammatory reactions that would eventually lead to what you and i would eventually lead to what you and i refer to as nsf refer to as nsf and that was a theory of transmetalation and that was a theory of transmetalation dechelation dissociation they all mean dechelation dissociation they all mean the same thing the same thing do people already have a lower amount of do people already have a lower amount of galilini in their system galilini in their system a human being normally does not have a human being normally does not have gadolinium in his body if there's gadolinium in his body if there's gadolinium in your body gadolinium in your body you've gotten contrast a radiologist put you've gotten contrast a radiologist put it there now there are it there now there are rare exceptions back in the old days rare exceptions back in the old days people were making cds in the process of people were making cds in the process of making cds some gadolinium exposure was making cds some gadolinium exposure was there there but the vast majority of us don't have but the vast majority of us don't have that an interesting that an interesting tangent that i've been teaching about tangent that i've been teaching about since 2014 since 2014 is that we now find
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is that we now find gadolinium in our in our drinking water gadolinium in our in our drinking water remember i told you it gets excreted by remember i told you it gets excreted by humans in humans in urine and so it goes from urine and so it goes from into the sewage and it goes to a sewage into the sewage and it goes to a sewage treatment plant treatment plant sewage treatment plant then goes through sewage treatment plant then goes through and recycles and recycles gets rid of the solid waste gets rid of gets rid of the solid waste gets rid of things that we don't want in humans things that we don't want in humans filters those out and then returns filters those out and then returns purified water back into the drinking purified water back into the drinking system studies have found that um as system studies have found that um as much as ninety much as ninety nine zero percent of the nine zero percent of the gadolinium that is urinated out gadolinium that is urinated out is returned is not filtered and is is returned is not filtered and is returned into the drinking system returned into the drinking system so literally dozens of articles so literally dozens of articles literally have appeared over the past literally have appeared over the past decade decade showing that in all the major reservoirs showing that in all the major reservoirs of the world and i do mean of the world of the world and i do mean of the world australia throughout europe throughout
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australia throughout europe throughout the united states the united states san francisco bay pittsburgh san francisco bay pittsburgh every major reservoir has gadolinium every major reservoir has gadolinium in the drinking water that the levels in the drinking water that the levels are rising the rate at which the levels are rising the rate at which the levels are rising are rising is increasing uh interestingly now is increasing uh interestingly now they're also finding it in the plants they're also finding it in the plants in the reservoirs and they're now in the reservoirs and they're now finding it in the animal kingdom finding it in the animal kingdom of the reservoir insects so it's now of the reservoir insects so it's now possibly beginning to enter our food possibly beginning to enter our food supply as well supply as well now the amount is very very small but it now the amount is very very small but it is a clear is a clear extremely noticeable spike in of all the extremely noticeable spike in of all the they they constantly check all the rare earth constantly check all the rare earth metals and gadolinium is a very metals and gadolinium is a very noticeable spike noticeable spike that has occurred in humanity in in the that has occurred in humanity in in the last few decades last few decades and it's directly and specifically and it's directly and specifically traceable to medically administered in traceable to medically administered in fact fact some of the studies have looked at urban some of the studies have looked at urban versus rural versus rural and the rural streams don't show it in and the rural streams don't show it in the water it's only in the waters of the the water it's only in the waters of the major major medical centers of the world in the medical centers of the world in the cities that have major medical centers
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cities that have major medical centers they've even gone so far in a study that they've even gone so far in a study that was published about the san francisco was published about the san francisco bay area bay area they actually show where they sampled they actually show where they sampled and those that are closer to the and those that are closer to the hospital systems have the highest values hospital systems have the highest values and and they don't in fact to make it really they don't in fact to make it really interesting is that they've sampled them interesting is that they've sampled them by by time of day and time of week time of day and time of week and you see the levels go down on the and you see the levels go down on the saturdays and sundays and go up on saturdays and sundays and go up on mondays mondays usually in the afternoon every day you usually in the afternoon every day you see that the afternoons that see that the afternoons that person gets injected starting in the person gets injected starting in the morning you wait two three hours they morning you wait two three hours they start to go to the bathroom and you see start to go to the bathroom and you see the the numbers go up in the afternoon they go numbers go up in the afternoon they go down again late evenings as you would down again late evenings as you would expect the typical patient flow expect the typical patient flow so we know that these are medically so we know that these are medically administered gadolinium levels administered gadolinium levels that having been said it's not enough to that having been said it's not enough to have reached alarm it's just that people have reached alarm it's just that people are aware that this is happening but the are aware that this is happening but the answer to your question is that answer to your question is that that not withstanding normally humans that not withstanding normally humans have no exposure to gatlini other than have no exposure to gatlini other than medically administered medically administered even this is medically administered even this is medically administered initially and now his founding is initially and now his founding is finding its way back into finding its way back into drinking water so if we find gadolinium
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drinking water so if we find gadolinium in the biopsy of a human in the biopsy of a human a radiologist put it there that's a radiologist put it there that's interesting so someone who is interesting so someone who is has a let's say renal issues right and has a let's say renal issues right and they wouldn't normally get iv they wouldn't normally get iv contrast but they drink it's just not contrast but they drink it's just not enough right enough right if they're drinking and they're not if they're drinking and they're not getting iv contrast the gadolinium that getting iv contrast the gadolinium that we measure in their bodies is what you we measure in their bodies is what you and i would call background and i would call background not sufficient for us to be concerned not sufficient for us to be concerned about or measure rise no not at all okay about or measure rise no not at all okay we'd consider that within normal limits we'd consider that within normal limits and it's near the level of and it's near the level of quantification quantification near the smallest level that we can near the smallest level that we can detect i'm curious what the half-life is detect i'm curious what the half-life is of catalinium like um of catalinium like um of these contrast agents well they're of these contrast agents well they're not radioactive so i'm sure you don't not radioactive so i'm sure you don't refer to a radioactive half-life but you refer to a radioactive half-life but you mean biologic half-heart mean biologic half-heart so that's the whole point normally the so that's the whole point normally the medically administered gadolinium agents medically administered gadolinium agents that are used for that are used for neuro-radiologic application neuro-radiologic application those have half-lives of to 90-120 those have half-lives of to 90-120 minutes what that means is that i'm minutes what that means is that i'm going to inject going to inject into that patient um 14 cc's
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into that patient um 14 cc's and half of that i expect to be in the and half of that i expect to be in the bladder in the urine bladder in the urine seven cc's approximately of that 14 in seven cc's approximately of that 14 in about an hour and a half two hours about an hour and a half two hours another two hours later three and a half another two hours later three and a half cc's cc's another two hours later approximately another two hours later approximately one and three quarter cc's addition do one and three quarter cc's addition do you understand so you understand so that's the biologic half-life that's the biologic half-life but what happens is if that's a but what happens is if that's a unicompartment model that's where unicompartment model that's where there's only there's only administered to the extracellular fluid administered to the extracellular fluid clear it from the extracellular fluid clear it from the extracellular fluid but now they're discussing as we've said but now they're discussing as we've said a second compartment a second compartment what if there's not a pure extracellular what if there's not a pure extracellular fluid fluid biodistribution what if some of it is biodistribution what if some of it is pulled off and sent into the bone pulled off and sent into the bone so that half-life is a separate small so that half-life is a separate small small small small part small small small part and that one may be there for months and and that one may be there for months and years so there's two different years so there's two different components in two different half-lives components in two different half-lives right does that make sense right does that make sense yeah interesting and that's the concern yeah interesting and that's the concern the concern is that when people have
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the concern is that when people have poorly functioning kidneys it sticks poorly functioning kidneys it sticks around for longer around for longer more of a dissociated amount might more of a dissociated amount might therefore find itself therefore find itself dissociated re-chelated with something dissociated re-chelated with something else endogenous in the body such as else endogenous in the body such as phosphate phosphate which is abnormally elevated in almost which is abnormally elevated in almost every patient with renal failure every patient with renal failure and then it might biodistribute outside and then it might biodistribute outside the extracellular fluid space the extracellular fluid space and stick around for longer than we had and stick around for longer than we had initially designed and go to places we initially designed and go to places we had not had not intended all of that theory of intended all of that theory of dissociation or dissociation or transmediation or decollation existed in transmediation or decollation existed in the nsf discussion time periods between the nsf discussion time periods between 2006 and 2013 time frame 2006 and 2013 time frame that was all attributed to how nsf might that was all attributed to how nsf might have formed when dr canda found in 2013 that we're seeing seeing gadolinium in the patient's brains gadolinium in the patient's brains a few things were startling there and a few things were startling there and the number one thing of all that people the number one thing of all that people may not have recognized but what was the may not have recognized but what was the most most concerning is that this is even in
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concerning is that this is even in patients with normal patients with normal kidneys it's an extremely small amount kidneys it's an extremely small amount but you did not need poorly functioning but you did not need poorly functioning kidneys to see gadolinium in the brain kidneys to see gadolinium in the brain if they got enough of it it would show if they got enough of it it would show up up so this is even with patients with so this is even with patients with normal renal function that's one concern normal renal function that's one concern number two it seemed initially number two it seemed initially that it wasn't happening with that it wasn't happening with macrocyclics it only happened with macrocyclics it only happened with linears linears that doesn't seem to be true either what that doesn't seem to be true either what we're finding is that every agent leaves we're finding is that every agent leaves some some but again as we started on that but again as we started on that discussion before discussion before macrocyclic agents tended to leave less macrocyclic agents tended to leave less although there are differences amongst although there are differences amongst the macrocyclics it seems the macrocyclics it seems the linear agents tend to leave more the linear agents tend to leave more but there are substantial differences but there are substantial differences amongst the linear agents and how much amongst the linear agents and how much they leave they leave beyond that what is it that you're beyond that what is it that you're leaving leaving what are you leaving for example i what are you leaving for example i injected into my patient injected into my patient gadolinium ligand as a chelated complex
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gadolinium ligand as a chelated complex remember so what are we detecting in the remember so what are we detecting in the brains of these patients brains of these patients two three years ago i would say to you two three years ago i would say to you we don't know but now we've been able to we don't know but now we've been able to find that find that there are three forms of gadolinium at there are three forms of gadolinium at least least that are being left in humans in their that are being left in humans in their brain and potentially other parts of the brain and potentially other parts of the body body one form is exactly as you had initially one form is exactly as you had initially intravenously administered it intravenously administered it meaning it's the gadolinium ion together meaning it's the gadolinium ion together with its with its ligand molecule just exactly how you ligand molecule just exactly how you took it out of the bottle and injected took it out of the bottle and injected it to the patient it to the patient that same complex it's right there can that same complex it's right there can you see it it's right there you see it it's right there that's one possible form macrocyclics that's one possible form macrocyclics that leave very little that's the form that leave very little that's the form that seems to be associated with them that seems to be associated with them the form as initially administered the form as initially administered that's how tight that bond is the bond that's how tight that bond is the bond is that tight that it seems to still be is that tight that it seems to still be intact years later intact years later linear agents have one of three linear agents have one of three identified forms so far identified forms so far the first is the same as we just
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the first is the same as we just discussed which is discussed which is exactly as administered that same exactly as administered that same gadolinium with its gadolinium with its ligand molecule intact sitting in the ligand molecule intact sitting in the brain brain that's one of the three forms another that's one of the three forms another form form is a water insoluble form what does that is a water insoluble form what does that mean mean in order for it to be water insoluble in order for it to be water insoluble it's not interacting with water it's not interacting with water well i certainly did not inject in any well i certainly did not inject in any of my patients any water of my patients any water insoluble gadolinium look at it it looks insoluble gadolinium look at it it looks like water right like water right so in order for it to have been water so in order for it to have been water insoluble in this patient right now insoluble in this patient right now it had to dissociate and reform it had to dissociate and reform with a new complex with a new complex that doesn't seem to happen with the that doesn't seem to happen with the macrocyclics the scene that happens only macrocyclics the scene that happens only with the linears a water with the linears a water in soluble form is type number two in soluble form is type number two type number three is that the gadolinium type number three is that the gadolinium is somehow associating with some is somehow associating with some macromolecule a massive molecule like a macromolecule a massive molecule like a protein protein albumin something massive
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that doesn't seem to happen with macrocyclics either that seems to happen macrocyclics either that seems to happen only with only with the linear agents so let's go through the linear agents so let's go through this again both the linear agents in the this again both the linear agents in the macrocyclics macrocyclics are found in the form initially injected are found in the form initially injected at extremely small amounts at extremely small amounts in the brain linears are also found in the brain linears are also found in a water insoluble form and they're in a water insoluble form and they're also found in a form that seems to be also found in a form that seems to be associated with some as of yet associated with some as of yet unidentified macromolecules unidentified macromolecules why am i saying this well the water in why am i saying this well the water in soluble form soluble form stay with me here is water insoluble meaning it doesn't mix with water right and if it doesn't mix with water and if it doesn't mix with water that means the water is not going to be that means the water is not going to be interacting with the gadolinium so it interacting with the gadolinium so it won't have its t1 shortened so the relaxivity meaning the ability to shorten t1
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shorten t1 the relaxivity of the water in soluble the relaxivity of the water in soluble form is almost form is almost certainly extremely poor right and certainly extremely poor right and therefore can't be accounting for what therefore can't be accounting for what they saw on the images in mri where they saw on the images in mri where they're seeing t1 shortening they're seeing t1 shortening wow the macro molecular association wow the macro molecular association that would be a powerful t1 shortening that would be a powerful t1 shortening so that may be the form that may be so that may be the form that may be accounting for why we're seeing accounting for why we're seeing t1 shortening more with the linear t1 shortening more with the linear agents than with the macromolecules agents than with the macromolecules now that we got those out of the way i now that we got those out of the way i have a question to ask you too i can't have a question to ask you too i can't i can't talk with you without testing i can't talk with you without testing you right you right so here's the question i have this so here's the question i have this syringe syringe and it's going to have gadolinium in it and it's going to have gadolinium in it and it's going to be in one of three and it's going to be in one of three forms forms it's going to be in the form of the it's going to be in the form of the initial drug with its ligand molecule initial drug with its ligand molecule or it will be dissociated or it will be dissociated and it will be attached to something and it will be attached to something that now makes it a water that now makes it a water in soluble form or
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in soluble form or it'll be get litium associated with some it'll be get litium associated with some macromolecule let's say albumin macromolecule let's say albumin i have it in this syringe i'm going to i have it in this syringe i'm going to take the syringe and stab you in the take the syringe and stab you in the head with it head with it and i'm going to inject one of those and i'm going to inject one of those three forms in your personal three forms in your personal cerebrospinal fluid right into the cerebrospinal fluid right into the ventricle take an a ventricle take an a which one do you want in other words which one do you want in other words think of the question for a moment think of the question for a moment if you had to have in your if you had to have in your cerebrospinal fluid someone was going to cerebrospinal fluid someone was going to inject inject one of those three forms one of those three forms which form would you want injected do which form would you want injected do you hear the question you hear the question right i definitely the right i definitely the in this one i would say the uh a like in this one i would say the uh a like the macrophilic the macrophilic the way that that one initially there the way that that one initially there was the initially administered was the initially administered form that the molecule the galilean with form that the molecule the galilean with its ligand molecule its ligand molecule still intact if i had to have it in me i still intact if i had to have it in me i want it still together want it still together okay that's what everybody answers and okay that's what everybody answers and there's no there's no right or wrong there's no there's no right or wrong okay but i want you to understand and
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okay but i want you to understand and dr vogler wrote an article in 1995 1995. where they injected rats with all three macrocyclics and with with all three macrocyclics and with magnavist magnavist and with omniscan the and with omniscan the neurotoxicity which is the one that neurotoxicity which is the one that killed the rats the most killed the rats the most the macrocyclics oh the macrocyclics oh by far trying to think why that may be by far trying to think why that may be why it is isn't this concerning as that why it is isn't this concerning as that it is it is and that almost nobody knows about that and that almost nobody knows about that right so i'm just saying that we have to right so i'm just saying that we have to i'm bringing out a point we have to i'm bringing out a point we have to recognize this is the key recognize this is the key the relative safety the relative safety of as initially administered together of as initially administered together intact with its ligand molecule intact with its ligand molecule versus put that down versus versus put that down versus a completely water insoluble form versus
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a completely water insoluble form versus associating with a macromolecule we associating with a macromolecule we don't have a clue don't have a clue you understand not a clue are any of you understand not a clue are any of them unsafe them unsafe and if they are is anyone more or less and if they are is anyone more or less we have no idea we have no idea i can tell you that direct neurotoxicity i can tell you that direct neurotoxicity of the macrocyclics oh we've known since of the macrocyclics oh we've known since 1995 is worse 1995 is worse than the linears magnavist and omniscan than the linears magnavist and omniscan by dr vogler and his paper and his by dr vogler and his paper and his co-workers co-workers now having said that time for a story now having said that time for a story yeah yeah it's always time for a story with me it's always time for a story with me back in 1990 of your business i was back in 1990 of your business i was sitting there learning it was 1982 i was sitting there learning it was 1982 i was my first rotations in my first rotations in radiology and radiology and a new imaging modality had arrived a new imaging modality had arrived recently to pittsburgh recently to pittsburgh you don't want to be saying anything you don't want to be saying anything right about now if you fear for your right about now if you fear for your life life this new imaging modality was called ct this new imaging modality was called ct a new test
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a new test i remember when they delivered the first i remember when they delivered the first head ctc it only did heads head ct head ctc it only did heads head ct scanner was delivered to pittsburgh scanner was delivered to pittsburgh pennsylvania and to our university pennsylvania and to our university to our institution anyway so now it's to our institution anyway so now it's 1982 and we're scanning 1982 and we're scanning with a relatively new test and i'm out with a relatively new test and i'm out there learning about it and they showed there learning about it and they showed me a me a head ct it was really cool you can see head ct it was really cool you can see cross-sectional anatomy wonderful cross-sectional anatomy wonderful we get to our second or third patient we get to our second or third patient and finally the third patient shows up i and finally the third patient shows up i said what the heck is that said what the heck is that and my attending said what and i'm and my attending said what and i'm pointing at the image and i said pointing at the image and i said that and he goes oh man you scared me that and he goes oh man you scared me it's nothing it's nothing i said well well what is it it was these i said well well what is it it was these white blobs on the on the image in the white blobs on the on the image in the head seating head seating and he said that's nothing and he said that's nothing it's calcification of the basal ganglia in my vast experience this was my third case already case already in my life in my vast experience i had
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in my life in my vast experience i had never seen never seen calcification of the basal ganglia right calcification of the basal ganglia right so i said wait a minute so i said wait a minute first of all why are there first of all why are there calcifications right calcifications right in the basal ganglia and second of all in the basal ganglia and second of all the other two patients that i've seen in the other two patients that i've seen in my life my life didn't have calcifications in the basal didn't have calcifications in the basal ganglia ganglia why did they not have it and why does why did they not have it and why does this guy have calcifications in his this guy have calcifications in his basal ganglia basal ganglia and i remember the answer like it was and i remember the answer like it was yesterday he said manny don't be a it's more normal move on normal move on like it was yesterday don't be a it's normal move on calcium as you know is a metal metals all metal seem to love basal ganglia right ganglia right calcium goes to basal ganglia catalytium calcium goes to basal ganglia catalytium goes to basal ganglia iron goes to basal goes to basal ganglia iron goes to basal ganglia manganese goes to basal ganglia
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ganglia manganese goes to basal ganglia why i'm 63 years old i have no idea why i'm 63 years old i have no idea we don't even mention it in the report i we don't even mention it in the report i don't say oh this patient has calcium in don't say oh this patient has calcium in the base the base it's a normal finding move on it may be that eight years from now they're going to say oh didn't they they're going to say oh didn't they realize i can't believe they ever realize i can't believe they ever thought it was normal holy cow thought it was normal holy cow everybody with basal gangly everybody with basal gangly calcification grows a third arm calcification grows a third arm but they didn't make the association but they didn't make the association until now okay fine but right now until now okay fine but right now right we don't even mention it right we don't even mention it it's just what should i say it's just what should i say precipitating out precipitating out it's just insoluble it's just insoluble yeah so i can make an argument if you yeah so i can make an argument if you want want this is purely as an argument i have this is purely as an argument i have zero data zero data an argument can be made that maybe the an argument can be made that maybe the water insoluble form water insoluble form is it's normal move on if it's water is it's normal move on if it's water insoluble that means it's less reactive insoluble that means it's less reactive with water right with water right right what are you worried about it just right what are you worried about it just sits there forever yes i like calcium sits there forever yes i like calcium maybe it's not a problem
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maybe it's not a problem and only the linears you know the more and only the linears you know the more dangerous ones according to so many dangerous ones according to so many people people right only the linears seem to show the right only the linears seem to show the water in soluble form water in soluble form all i'm saying is that we have such all i'm saying is that we have such dogmatic statements that we're making dogmatic statements that we're making and i'm intentionally playing devil's and i'm intentionally playing devil's advocate because i have no advocate because i have no clue which is safer if any of them are clue which is safer if any of them are safer safer if any of them has any safety issue if any of them has any safety issue all i know is there is residual all i know is there is residual gadolinium gadolinium and a lot of people seem to be awfully and a lot of people seem to be awfully confident about which one they do and do confident about which one they do and do not prefer not prefer but we don't have the science behind us but we don't have the science behind us to back whether there's any safety to back whether there's any safety issues associated with this residueum issues associated with this residueum or not let alone the subtypes that might or not let alone the subtypes that might be there from the different be there from the different agents that we might administer right agents that we might administer right if i had my druthers i don't want any if i had my druthers i don't want any gadolinium in my body that's not gadolinium in my body that's not supposed i don't want any metals in my supposed i don't want any metals in my body that aren't supposed to be there body that aren't supposed to be there so of course i would like to use as so of course i would like to use as little as possible little as possible to the extent that the agents are to the extent that the agents are interchangeable
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interchangeable just use the one that leaves the least just use the one that leaves the least that was the argument that was the argument of europe the europeans of europe the europeans had a pharmacovigilance risk assessment had a pharmacovigilance risk assessment committee prac committee prac and the formal recommendation from prak and the formal recommendation from prak was these agents was these agents are essentially interchangeable are essentially interchangeable and since they are why would you and since they are why would you possibly use one that leaves more possibly use one that leaves more let's get rid of the linear agents and let's get rid of the linear agents and for practical purposes that's exactly for practical purposes that's exactly what happened in europe and it's binding what happened in europe and it's binding so in europe the linear agents so in europe the linear agents essentially are no longer in use essentially are no longer in use and they've lost their marketing ability and they've lost their marketing ability you can't you can't use them you can't you can't you can't use them you can't sell them in most of the rest of the sell them in most of the rest of the world they did not agree world they did not agree including and especially in the united including and especially in the united states they did not agree states they did not agree and certainly they did not agree that and certainly they did not agree that the agents are the same there are the agents are the same there are massive differences in in areas such as massive differences in in areas such as relaxivity in areas such as adverse relaxivity in areas such as adverse events and areas of events and areas of even some simple things such as their even some simple things such as their osmolalities and their viscosities and osmolalities and their viscosities and we we recognize that there are
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we we recognize that there are differences amongst these agents and we differences amongst these agents and we treat them treat them as if they're drugs as if they are as if they're drugs as if they are prescription drugs prescription drugs and which one you use is based on what and which one you use is based on what that patient needs that patient needs so today yes we recognize that there can so today yes we recognize that there can be residual gadolinium be residual gadolinium we have no idea if it is or isn't a we have no idea if it is or isn't a safety issue safety issue just in case we'd like to use as little just in case we'd like to use as little as possible as possible we recognize that the macro cyclics tend we recognize that the macro cyclics tend to use then to leave less than the to use then to leave less than the linears and inside the macrocyclics and linears and inside the macrocyclics and inside the linears there are differences inside the linears there are differences in how much they give they leave in how much they give they leave but there are also differences amongst but there are also differences amongst the agents if you the agents if you are looking for relaxivity today the are looking for relaxivity today the highest relaxivity is a linear agent highest relaxivity is a linear agent if you're looking for adverse events i if you're looking for adverse events i think arguably the lowest adverse event think arguably the lowest adverse event immediate immediate adverse event the lowest adverse events adverse event the lowest adverse events would be amongst the linear agents would be amongst the linear agents today so we treat them like today so we treat them like the prescription drugs that they are and the prescription drugs that they are and the decision as to which one to the decision as to which one to whether to use it which one to use and
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whether to use it which one to use and how much to administer how much to administer should be made on a patient-by-patient should be made on a patient-by-patient basis based on the needs and specific basis based on the needs and specific clinical scenario of that patient clinical scenario of that patient well i'm curious yeah i'm sure you well i'm curious yeah i'm sure you probably don't reveal this but if you probably don't reveal this but if you have a have a preference on what gadolinium preference on what gadolinium it's okay to say you don't want to sure it's okay to say you don't want to sure absolutely absolutely that would be exactly the same as asking that would be exactly the same as asking me the patient comes into the er me the patient comes into the er and i look at them and i say you have an and i look at them and i say you have an infection infection i'm going to write you a prescription i'm going to write you a prescription for an antibiotic and i write the for an antibiotic and i write the prescription prescription and i hand it to them they go to the and i hand it to them they go to the pharmacist to fill it pharmacist to fill it and the pharmacist looks at him picks up and the pharmacist looks at him picks up the phone and calls me and says the phone and calls me and says i having trouble reading your i having trouble reading your handwriting it looks like it says give handwriting it looks like it says give this patient an antibiotic this patient an antibiotic and i said yeah that's what i wrote and i said yeah that's what i wrote and the pharmacist says well which one and the pharmacist says well which one and i say and i say what do you mean just give them an what do you mean just give them an antibiotic they're all the same my preference is determined by the patient
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i like us to make believe we're physicians and i like to make believe physicians and i like to make believe that these are prescription drugs that these are prescription drugs and i like to make believe that we can and i like to make believe that we can match what's best for the patient match what's best for the patient in a clinical scenario that they're in a clinical scenario that they're provided me with provided me with as opposed to saying that every patient as opposed to saying that every patient has to get the same drug it just doesn't has to get the same drug it just doesn't seem seem that's what europe said europe said that's what europe said europe said they're interchangeable just give them they're interchangeable just give them an antibiotic an antibiotic well so is that something that's in like well so is that something that's in like is protocol before the patient comes is protocol before the patient comes what contrast is given what contrast is given absolutely i'm in a different scenario absolutely i'm in a different scenario i'm the chief of the division of i'm the chief of the division of emergency radiology emergency radiology so every one of my pa nobody gets so every one of my pa nobody gets injected without my knowledge injected without my knowledge every single one of my patients i get a every single one of my patients i get a call about before they're injected and call about before they're injected and then i decide if i want them to be then i decide if i want them to be injected and how much and which which injected and how much and which which agent if they will be injected agent if they will be injected so for us it's a real time evaluation on so for us it's a real time evaluation on every er patient do you keep an equal amount of linear microphonics microphonics linears we have uh macrocyclics we have linears we have uh macrocyclics we have personal preferences of physicians which
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personal preferences of physicians which is exactly how the practice of medicine is exactly how the practice of medicine works works when you ask somebody to write a when you ask somebody to write a prescription for an antibiotic prescription for an antibiotic they write what they're most comfortable they write what they're most comfortable with the ones that they're most familiar with the ones that they're most familiar with they've been using for the longest with they've been using for the longest time they know it's effective they know time they know it's effective they know it's adverse events there may be it's adverse events there may be competitors for that one but if they're competitors for that one but if they're comfortable with that then they want to comfortable with that then they want to use that one that's wonderful that's use that one that's wonderful that's exactly why the art exactly why the art and science of medicine works the way it and science of medicine works the way it does we want you using what you're does we want you using what you're comfortable with and that you comfortable with and that you that you think you have a good handle on that you think you have a good handle on well that's as an ordering physician but well that's as an ordering physician but as radiologists reading those images as radiologists reading those images wouldn't you wouldn't you wouldn't you want to have more of a say wouldn't you want to have more of a say so more of an influence of what contrast so more of an influence of what contrast is given is given it's a fascinating question um as it's a fascinating question um as somebody who started out in surgery they somebody who started out in surgery they went into medicine went into medicine they went into radiology this is my they went into radiology this is my patient patient right i don't want to say so i want all right i don't want to say so i want all to say so this is my patient to say so this is my patient so i want complete control over what i so i want complete control over what i think is best for my patient and i want think is best for my patient and i want to discuss it with my patient and that to discuss it with my patient and that patient and i will determine what's best patient and i will determine what's best for them for them the more anyone else tries to butt into
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the more anyone else tries to butt into that the more that the more frustrated i personally would be but i frustrated i personally would be but i recognize the reality of the world recognize the reality of the world the reality of the world has many many the reality of the world has many many limitations placed on that scenario limitations placed on that scenario the biggest one is um the stark the biggest one is um the stark amendments the star commandments were amendments the star commandments were passed years and years ago passed years and years ago for good reason if you don't mind my for good reason if you don't mind my editorializing and they were editorializing and they were anti-kickback anti-kickback the stark amendments was essentially the stark amendments was essentially state that any physician is not state that any physician is not radiology it's any physician radiology it's any physician no physician can financially benefit no physician can financially benefit from a test that they order from a test that they order no physician can financially benefit no physician can financially benefit from a test that they order for their from a test that they order for their patients i think patients i think you need an upper gi luckily i happen to you need an upper gi luckily i happen to have a scope let me do it on you have a scope let me do it on you they're concerned about the potential they're concerned about the potential conflict of interest that maybe i'll conflict of interest that maybe i'll order order if i could earn money by ordering it if if i could earn money by ordering it if i have a i have a system that will analyze blood work system that will analyze blood work blood chemistries blood chemistries i might order a lot of blood chemistries i might order a lot of blood chemistries on patients that maybe perhaps might not on patients that maybe perhaps might not need them need them so that i can do them in my lab and i'll
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so that i can do them in my lab and i'll feel like i'm doing good medicine but at feel like i'm doing good medicine but at the same time maybe it's not the same time maybe it's not really indicating somebody else wouldn't really indicating somebody else wouldn't have done it and i'm being somehow have done it and i'm being somehow swayed by the potential profit of having swayed by the potential profit of having the machine and charging for it so the machine and charging for it so there's a the historic amendments do not there's a the historic amendments do not permit a physician to benefit permit a physician to benefit from a test financially from a test that from a test financially from a test that they themselves order they themselves order i can order an upper gi and send them to i can order an upper gi and send them to you you and you can perform the upper gi as long and you can perform the upper gi as long as there's no financial relationship as there's no financial relationship between us between us that's of course the practice of that's of course the practice of medicine and that's fine medicine and that's fine as a result of the stark amendments a as a result of the stark amendments a radiologist radiologist cannot order contrast on their patients cannot order contrast on their patients because a because a contrast enhanced examination contrast enhanced examination reimburses more and i would financially reimburses more and i would financially benefit benefit than an unenhanced study so ironically than an unenhanced study so ironically the biggest expert in the hospital as to the biggest expert in the hospital as to what how to use these tests what how to use these tests is the radiologist because they're the is the radiologist because they're the imagers right but since they can imagers right but since they can financially benefit financially benefit they've been cut off and we have to pick they've been cut off and we have to pick up the phone and call daddy
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up the phone and call daddy hello referring physician your patient hello referring physician your patient needs a contrast enhanced study because needs a contrast enhanced study because i think this is an abscess i think this is an abscess can you please order contrast so that i can you please order contrast so that i can give contrast and be can give contrast and be and bill for it and be reimbursed for it and bill for it and be reimbursed for it because that's what is appropriate for because that's what is appropriate for your patient your patient sure manny i'll be glad to so that has sure manny i'll be glad to so that has been been it's an unfortunate necessary evil it's an unfortunate necessary evil of the star commitment and so what would of the star commitment and so what would i like to do and what i can do are two i like to do and what i can do are two different things different things so today a referring physician who may so today a referring physician who may not know how to spell mri not know how to spell mri is the one that has to order not just is the one that has to order not just the mri but the contrast the mri but the contrast which one what dose what rate what route which one what dose what rate what route can i repeat it do they have kidneys do can i repeat it do they have kidneys do they know anything about any of this they know anything about any of this it's not their specialty it's mine why it's not their specialty it's mine why would you would you possibly expect them to you don't but possibly expect them to you don't but because of the legal issue of the stark because of the legal issue of the stark amendment amendment they have to order the test and i have they have to order the test and i have to implement it to implement it unfortunately what's happened over the unfortunately what's happened over the years is that
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years is that in my opinion most radiologists have in my opinion most radiologists have divorced themselves from the execution divorced themselves from the execution of the exam of the exam for most of radiology in the united for most of radiology in the united states by the time states by the time that patient's study is completed that patient's study is completed when i get that patient study that when i get that patient study that patient's already out of the room patient's already out of the room when the average not me manny the when the average not me manny the average radiologist when they see the ct average radiologist when they see the ct scan scan the study is done nobody asked them did the study is done nobody asked them did you want you want contrast and how much and what dose and contrast and how much and what dose and what concentration on what route and what concentration on what route and what rate what rate that's not up to you that's been done by that's not up to you that's been done by now now so conceptually we have in a sense so conceptually we have in a sense divorced ourselves from the patient care divorced ourselves from the patient care and as long as nobody gets hurt that's and as long as nobody gets hurt that's fine fine but if there's ever a problem that's but if there's ever a problem that's when we find out when we find out that somebody is going to be responsible that somebody is going to be responsible for the safe for the safe execution of that exam not just its execution of that exam not just its interpretation interpretation well i had a question on uh different well i had a question on uh different types of contrast when it comes to like types of contrast when it comes to like paramagnetic and then it's the paramagnetic and then it's the ferromagnetic you know contrast which
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ferromagnetic you know contrast which kind of felt like it was picking up kind of felt like it was picking up steam but i haven't really heard steam but i haven't really heard anything about anything about any of that in a while and i was any of that in a while and i was wondering if you know a lot of the stuff wondering if you know a lot of the stuff that's coming out with that's coming out with um you know that retention is kind of um you know that retention is kind of pushing pushing you know the advancement of that kind of you know the advancement of that kind of back a little bit sure so back a little bit sure so let's we talk about x-ray-based studies let's we talk about x-ray-based studies how does an x-ray based study work how does an x-ray based study work we shine an x-ray to patient and some of we shine an x-ray to patient and some of the x-rays are absorbed the x-rays are absorbed or deflected or reflected what is doing or deflected or reflected what is doing the absorbing the absorbing the reflecting the deflecting a massive the reflecting the deflecting a massive simplification of that would be simplification of that would be electrons we talk about density the electrons we talk about density the greater the density the wider it is on greater the density the wider it is on the image the image density means concentration per volume density means concentration per volume concentration of watt it ends up being concentration of watt it ends up being essentially electrons essentially electrons the greater the number of electrons in the greater the number of electrons in this cubic centimeter this cubic centimeter the wider that cubic centimeter will be the wider that cubic centimeter will be projected on that image projected on that image does that make sense so we developed does that make sense so we developed this thing called contrast agents for
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this thing called contrast agents for x-ray-based studies what are they every x-ray-based studies what are they every contrast contrast agent that you could possibly name quick agent that you could possibly name quick name a name a bunch of them as many as you can not bunch of them as many as you can not brand names but types brand names but types oh you can brand names too if you don't oh you can brand names too if you don't mind but just quit as many as you can to mind but just quit as many as you can to spit them out spit them out spit them out spit them out like contrast agents like how general like contrast agents like how general like oral iv like oral iv there's gastrographen there's iodine there's gastrographen there's iodine based there's barium based there's barium there's air con there's air so what are there's air con there's air so what are what do they all share in common what do they all share in common contrast like literally contrast within contrast like literally contrast within the image itself how does barium the image itself how does barium share anything in common with iodine or share anything in common with iodine or air right air right they're all identical in one thing what they're all identical in one thing what is it that they're changing is it that they're changing uh image contrast electron dense uh image contrast electron dense electron density electron density when i inject into you an iodine when i inject into you an iodine an iodine based contrast agent i'm an iodine based contrast agent i'm injecting injecting electrons and they bio-distribute if electrons and they bio-distribute if it's an extracellular fluid agent it's an extracellular fluid agent it biodistributes in the extracellular it biodistributes in the extracellular fluid and so the entire extracellular fluid and so the entire extracellular fluid is going to get more
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fluid is going to get more dense i'm introducing physical dense i'm introducing physical electrons if i tell you to swallow electrons if i tell you to swallow barium barium i am now making the density of your gi i am now making the density of your gi lumen lumen higher do you understand that's what it higher do you understand that's what it is so the contrast agent for any is so the contrast agent for any x-ray-based study x-ray-based study is changing the only thing x-rays detect is changing the only thing x-rays detect essentially electron density essentially electron density what is it what tissue property are what is it what tissue property are x-rays probing x-rays probing it says oh this tissue is going to be it says oh this tissue is going to be really dense we're going to make it really dense we're going to make it white a rib white a rib this tissue is really not dense lung this tissue is really not dense lung we're going to make it really black on we're going to make it really black on the image the image what is the difference who electron what is the difference who electron density density so if i do anything to change the one so if i do anything to change the one thing that modality can detect thing that modality can detect i have myself a contrast agent i could i have myself a contrast agent i could make it higher make it higher barium iodine gastrography i could make barium iodine gastrography i could make it lower air it lower air but if you change the electron density but if you change the electron density your your machine your tool your your machine your tool x-ray has the ability to detect that
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x-ray has the ability to detect that so you could a contrast agent has to so you could a contrast agent has to change change the tissue parameter the tissue parameter this test is probing now they have this test is probing now they have contrast agents for ultrasound contrast agents for ultrasound well ultrasound what are you talking well ultrasound what are you talking about all this out is echogenicity there about all this out is echogenicity there you go you just did it right you go you just did it right right the contrast agent is changing right the contrast agent is changing echogenicity echogenicity it's introducing echoes how micro it's introducing echoes how micro bubbles bubbles so it's changing the one single tissue so it's changing the one single tissue parameter parameter that it can detect and what is it that that it can detect and what is it that is detecting is detecting echogenicity what's happening in mri echogenicity what's happening in mri though is different though is different why is it different because in mri we're why is it different because in mri we're not detecting not detecting one single parameter what is it that mri one single parameter what is it that mri is detecting is detecting what is the tissue property being probed what is the tissue property being probed by the mr scanner oh yeah the precession by the mr scanner oh yeah the precession yeah yeah the procession of the hydrogen atom it's the procession of the hydrogen atom it's t1 t1 yeah oh yeah t1 relaxation t1 t1 yeah oh yeah t1 relaxation and it's also t2
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and it's also t2 weight and it's proton density weight and it's proton density and it's t2 star and it's diffusion and and it's t2 star and it's diffusion and it's perfusion and it's susceptibility it's perfusion and it's susceptibility there are a dozen every time we turn there are a dozen every time we turn around around the industry introduces another tissue the industry introduces another tissue parameter that the same exact physical parameter that the same exact physical machine machine hardware can now probe and detect do you hardware can now probe and detect do you understand understand i can use the mr scanner to detect your i can use the mr scanner to detect your temperature i can see that this tissue temperature i can see that this tissue is warmer than that based on how i is warmer than that based on how i adjust the buttons adjust the buttons do you understand so mri do you understand so mri is not a one-trick pony like ultrasound is not a one-trick pony like ultrasound it's not a one-trick pony-like ct or it's not a one-trick pony-like ct or x-ray-based studies x-ray-based studies so what is a potential contrast agent so what is a potential contrast agent for mri for mri for ct you change electron density for for ct you change electron density for ultrasound you change echogenicity ultrasound you change echogenicity for mri magnetic properties you change for mri magnetic properties you change anything anything anything anything that this machine can detect and you got that this machine can detect and you got yourself a potential contrast agent
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yourself a potential contrast agent you can change t1 or t2 or t2 star or you can change t1 or t2 or t2 star or diffusion or perfusion you can change diffusion or perfusion you can change susceptibility you can change proton susceptibility you can change proton density density any of these or any combination any of these or any combination and you got yourself a contrast agent so and you got yourself a contrast agent so until now the whole industry has been until now the whole industry has been focused on the one contrast agent focused on the one contrast agent that's essentially 100 of what we use that's essentially 100 of what we use and what is that gadolinium right and what is that gadolinium right and that's predominant t1 shortening and that's predominant t1 shortening there are there are perfusion weighted studies for example perfusion weighted studies for example are typically looking at susceptibility are typically looking at susceptibility weighting weighting grossly changing the strength of a grossly changing the strength of a magnetic field magnetic field so we could do that with gadolinium but so we could do that with gadolinium but of course of course the extreme majority of course of course the extreme majority of gadolinium usage is t1 shortening of gadolinium usage is t1 shortening making things glow in the dark on t1 making things glow in the dark on t1 weighted images but then people started to get a little bit turned off by gadolinium every time bit turned off by gadolinium every time i turn around there's something else i turn around there's something else here i don't like nsf i don't like here i don't like nsf i don't like residual gadolinium this guy had an residual gadolinium this guy had an anaphylactic reaction the heck with this anaphylactic reaction the heck with this let's use something else right let's use something else right so there is a lot of discussion about so there is a lot of discussion about other things that can be used other things that can be used and yes you're right there are some
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and yes you're right there are some agents that are agents that are super paramagnetic or ferromagnetic and super paramagnetic or ferromagnetic and people have used from people have used from from day one they've used um from day one they've used um iron people you can detect an iron pill iron people you can detect an iron pill an hour after she she swallows it 325 an hour after she she swallows it 325 milligrams of iron in the gi tract and milligrams of iron in the gi tract and it can still leave you a nice it can still leave you a nice artifact you can take iron just artifact you can take iron just drink drinks that have iron in it you'll drink drinks that have iron in it you'll see it blueberry juice we can see in mri see it blueberry juice we can see in mri so there's so many things that we can so there's so many things that we can see that are not see that are not necessarily t1 shortening it could be necessarily t1 shortening it could be anything that changes t1 or t2 or t2 anything that changes t1 or t2 or t2 star or star or susceptibility or proton density etc etc susceptibility or proton density etc etc etc etc so there are discussions about moving to so there are discussions about moving to other agents other agents and yeah there are articles being and yeah there are articles being published about them um published about them um there have been articles i don't know if there have been articles i don't know if you know this there was a contrast agent you know this there was a contrast agent that was fda approved feradex that was fda approved feradex oh ges right and either of you ever use oh ges right and either of you ever use ferrodex ferrodex 100 fda approved it was iron oxide what
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100 fda approved it was iron oxide what is iron oxide is iron oxide iron oxide is rust ferrodex iron oxide is rust ferrodex was iron oxide two to three microns in was iron oxide two to three microns in size size and if you remember from biology and and if you remember from biology and histology and some of the initial work histology and some of the initial work that you guys have done when you're that you guys have done when you're learning about how learning about how contrast agents work things that are two contrast agents work things that are two or three microns in size or three microns in size the reticuloendothelial system of the the reticuloendothelial system of the body body swallows them up and filters them so swallows them up and filters them so where are where are the reticule endothelial system in the the reticule endothelial system in the body it's in the spleen it's in the bone body it's in the spleen it's in the bone marrow marrow so when ferrodex was given it's so when ferrodex was given it's essentially iron essentially iron when it was given and that size it would when it was given and that size it would biodistribute in such a way that the biodistribute in such a way that the reticuloendothelial system would take it reticuloendothelial system would take it up up the liver would take it up the spleen the liver would take it up the spleen would take it up would take it up the bone marrow would take it up and so the bone marrow would take it up and so what would happen what would happen if the guy god forbid had liver meds if the guy god forbid had liver meds wherever there was a metastasis there wherever there was a metastasis there was not was not normal reticuloendothelial cells so the normal reticuloendothelial cells so the whole liver is going to turn whole liver is going to turn black because of the iron
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black because of the iron except where the where there's a hole except where the where there's a hole three-dimensionally of three-dimensionally of lack of reticuloendothelial cells it was lack of reticuloendothelial cells it was a tremendously sensitive marker for a tremendously sensitive marker for metastases so that's another contrast metastases so that's another contrast 100 fda approved 100 fda approved we had tesla scan it was manganese-based we had tesla scan it was manganese-based if i remember correctly if i remember correctly fairdex we no longer use it was taken fairdex we no longer use it was taken off the market off the market one of the reasons was that one out of one of the reasons was that one out of two hundred one out of two hundred two hundred one out of two hundred had a life-threatening anaphylactic had a life-threatening anaphylactic reaction reaction not one out of twenty thousand percent not one out of twenty thousand percent one out of two hundred one half of one one out of two hundred one half of one percent percent had anaphylactic reactions anaphylactoid had anaphylactic reactions anaphylactoid reactions to reactions to so it didn't ever really catch on so it didn't ever really catch on but it was fda approved that's another but it was fda approved that's another type of contrast agent type of contrast agent so will there be others others are so will there be others others are pursuing manganese-based pursuing manganese-based agents today this is just my opinion agents today this is just my opinion i don't believe that they will fare well i don't believe that they will fare well i believe that i believe that manganese-based agents are gonna it's manganese-based agents are gonna it's jumping out of the frying pan into the
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jumping out of the frying pan into the fire fire if you don't like residual gadolinium if you don't like residual gadolinium are you gonna like residual manganese are you gonna like residual manganese because we know that that happens too if because we know that that happens too if you look up in the you look up in the in the literature you'll find that in the literature you'll find that welders welders welders welders have problems with excess manganese and have problems with excess manganese and they have they have it's not that it's they have residual it's not that it's they have residual manganese and it's manganese and it's also in the basal ganglia as it's a also in the basal ganglia as it's a metal metal and it has t1 shortening but it and it has t1 shortening but it is associated with some pretty is associated with some pretty substantial symptomatology substantial symptomatology residual gadolinium we're trying to residual gadolinium we're trying to figure out is that figure out is that harmful in any way we don't know it harmful in any way we don't know it might be it might not be we have to might be it might not be we have to study this study this residual manganese that's excess residual manganese that's excess manganese in the body oh yeah that's manganese in the body oh yeah that's toxicity we know for sure that that's toxicity we know for sure that that's abnormal and that causes disease and abnormal and that causes disease and problems and symptoms problems and symptoms so from my point of view i'm not so from my point of view i'm not convinced that we're going to be convinced that we're going to be jumping from gadolinium into manganese jumping from gadolinium into manganese right but it's just an opinion and i right but it's just an opinion and i certainly don't know what it'll be it's
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certainly don't know what it'll be it's just just it's not where i would recommend placing it's not where i would recommend placing my research my research efforts right now nice well i know efforts right now nice well i know there's information out there and i know there's information out there and i know that like the chuck norris case that like the chuck norris case brought light to it um to the mainstream brought light to it um to the mainstream i had just yesterday a patient was i had just yesterday a patient was asking me about it they had concerns asking me about it they had concerns like what message would you give to like what message would you give to patients like patients like who are due to have contrast that's a who are due to have contrast that's a wonderful question wonderful question there's i think what you're bringing up there's i think what you're bringing up is the concept of um some have named a is the concept of um some have named a disease disease gadolinium deposition disease and others gadolinium deposition disease and others and they have also said there's another and they have also said there's another situation which they're willing to call situation which they're willing to call gadolinium deposition gadolinium deposition condition this is just my opinion it condition this is just my opinion it doesn't make it right doesn't make it right um i believe it's premature i don't um i believe it's premature i don't believe we have believe we have objective sufficient data to be able to objective sufficient data to be able to say that at this stage say that at this stage i do know that there are patients i do know that there are patients hundreds maybe over a thousand that feel hundreds maybe over a thousand that feel that their life has been destroyed by that their life has been destroyed by gadolinium gadolinium administration i've spoken with dozens
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administration i've spoken with dozens of them of them in detail and i will say that me in detail and i will say that me personally personally i am impressed with some of these i am impressed with some of these patients that there's something patients that there's something going on that i don't understand going on that i don't understand but we have there's no other way to say it we have hundreds of millions of patients who hundreds of millions of patients who have gotten gadolinium that have not had have gotten gadolinium that have not had this disease this disease so there's some there's a huge amount so there's some there's a huge amount here we just don't understand here we just don't understand i agree with the fda's conclusion so far i agree with the fda's conclusion so far which is that which is that so far we have no reproducible data of so far we have no reproducible data of harm harm doesn't mean that it's safe and it doesn't mean that it's safe and it doesn't mean that there won't be doesn't mean that there won't be and it doesn't mean that there will be and it doesn't mean that there will be it means exactly what it says it means exactly what it says so far we don't have reproducible data so far we don't have reproducible data that there is harm from this residual that there is harm from this residual gadolinium gadolinium europe which pulled the linears off the europe which pulled the linears off the market market agrees to that statement they said out agrees to that statement they said out of an abundance of caution of an abundance of caution why wait for there to be demonstrated why wait for there to be demonstrated harm let's take them off because they're harm let's take them off because they're all interchangeable anyway
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all interchangeable anyway which we disagree with so from the point which we disagree with so from the point of view of of view of is there harm i can't answer the is there harm i can't answer the question question i can say that there's no controlled i can say that there's no controlled data that i'm aware of data that i'm aware of that shows that is there there is harm that shows that is there there is harm and it's dose-related and it's from the and it's dose-related and it's from the gadolinium gadolinium i can't really show that i'm afraid that i can't really show that i'm afraid that i just think it's too premature i just think it's too premature it doesn't mean that there aren't it doesn't mean that there aren't patients that don't feel that way it patients that don't feel that way it means that i can't make the positive means that i can't make the positive association yet association yet and and in that area i would have to and and in that area i would have to agree with the fda that hasn't yet been agree with the fda that hasn't yet been demonstrated demonstrated but it needs to be studied what would i but it needs to be studied what would i tell the patient i tell the patient tell the patient i tell the patient exactly what exactly what i was raised to tell the patient there i was raised to tell the patient there are potential benefits and risks are potential benefits and risks anything we do in life anything we do in life i believe that you need this drug or i i believe that you need this drug or i would not be advising that you get it would not be advising that you get it if this is my family member on the table if this is my family member on the table i would be recommending that we proceed i would be recommending that we proceed with this study but you have to make the with this study but you have to make the decision as to how you decide whether decision as to how you decide whether you want or not want to have this drug you want or not want to have this drug the fda has mandated medication guides
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the fda has mandated medication guides and it's a long story we don't have time and it's a long story we don't have time to go to make great detail but to go to make great detail but medication guys essentially they're medication guys essentially they're saying saying an outpatient for the first time she or an outpatient for the first time she or he receives these drugs he receives these drugs any of them if they got this drug but any of them if they got this drug but they never got that one then if they're they never got that one then if they're gonna get that one next time they need gonna get that one next time they need to get another medication guide for that to get another medication guide for that one one the first time they get any of these the first time they get any of these drugs we drugs we must distribute who's we i believe it's must distribute who's we i believe it's the pharmacist that's not important for the pharmacist that's not important for right now right now that patient has to be handed a that patient has to be handed a medication guide and on that medication medication guide and on that medication guide guide it explains to the patient that some it explains to the patient that some will be left in the body we don't know will be left in the body we don't know if it's harmful we don't know if it's if it's harmful we don't know if it's going to be an issue going to be an issue we're going to check your renal function we're going to check your renal function before you give it to you and make sure before you give it to you and make sure that it's that it's that you're able to get this drug safely that you're able to get this drug safely as we can as we can in the discussion of the medication guys in the discussion of the medication guys i am a sge i'm a special government i am a sge i'm a special government employee i i work for the fda employee i i work for the fda as a consultant as an advisor in two as a consultant as an advisor in two areas areas mri safety is also contra and also mri safety is also contra and also contrast age safety two different contrast age safety two different entirely different unrelated divisions
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entirely different unrelated divisions drugs in contrast media on one side and drugs in contrast media on one side and cdrh center for device and radiologic cdrh center for device and radiologic health on the other health on the other i fed back formally that i was opposed i fed back formally that i was opposed to the medication guide before they said to the medication guide before they said it it was law i was opposed to it because i was law i was opposed to it because i was afraid that patients that really was afraid that patients that really needed contrast needed contrast would turn it down because you're would turn it down because you're scaring them off scaring them off right they were very open to that right they were very open to that feedback and they said well we'd be feedback and they said well we'd be interested now that we're going to interested now that we're going to implement it anyway let's i'd be implement it anyway let's i'd be interested in feedback interested in feedback so at the university of pittsburgh so at the university of pittsburgh medical center i did formally follow a medical center i did formally follow a few thousand patients few thousand patients that we gave to whom we gave the that we gave to whom we gave the medication guide medication guide and i asked for formal prospective i and i asked for formal prospective i want to know how many of our patients want to know how many of our patients are turning it down are turning it down out of a few thousand patients we had 18 out of a few thousand patients we had 18 patients that turned it down patients that turned it down so in retrospect i was wrong it is not so in retrospect i was wrong it is not causing at least an hour institution in causing at least an hour institution in our experience that's multiple ins our experience that's multiple ins multiple hospitals in my institution for multiple hospitals in my institution for several thousand patients several thousand patients it did not cause a mass exodus we did it did not cause a mass exodus we did not have
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not have huge opposition to getting contrast and huge opposition to getting contrast and in retrospect it probably was a in retrospect it probably was a perfectly appropriate thing to do perfectly appropriate thing to do without causing harm to the patients and without causing harm to the patients and they're now more they're now more aware what to do with it the medication aware what to do with it the medication guy says we have no idea what to do with guy says we have no idea what to do with it we just thought we would let you know it we just thought we would let you know right so what it sounds like is that we right so what it sounds like is that we don't really still know don't really still know anything definitive but what we do know anything definitive but what we do know is they can't duplicate or reproduce is they can't duplicate or reproduce that harm i guess that harm i guess we don't know for sure of any harm that we don't know for sure of any harm that has resulted has resulted there are a lot of complaints of there are a lot of complaints of different types of things and the things different types of things and the things that they complain about that they complain about there's nothing objective it's always there's nothing objective it's always subjective it's things that subjective it's things that cannot be objectively quantified pain is cannot be objectively quantified pain is a perfect example forgetfulness a perfect example forgetfulness brain fog haze my memory is not these brain fog haze my memory is not these are things that are very difficult for are things that are very difficult for us to objectively quantify us to objectively quantify it doesn't it it just makes it more it doesn't it it just makes it more frustrating and difficult that's all frustrating and difficult that's all that's tough that's tough well i know there's a lot of questions well i know there's a lot of questions out there from all angles we've got out there from all angles we've got patients out there who are curious about
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patients out there who are curious about this subject this subject we've got ordering physicians we've got ordering physicians radiologists techs um radiologists techs um so it's it's important to put that so it's it's important to put that information out there information out there um i'm curious though you said that like um i'm curious though you said that like patients with renal failure are patients with renal failure are at risk is there any other patients like at risk is there any other patients like for example maybe like a transplant for example maybe like a transplant patient or something like that patient or something like that so the question that's one of the the so the question that's one of the the most most common things we hear now is be careful common things we hear now is be careful on patients that are especially at risk so whenever i hear that i feel compelled to say at risk for what because we don't know what they're at risk for do you understand exactly what risk for do you understand exactly what we're saying is we're saying is if there is harm if there is harm who is more likely to experience that who is more likely to experience that harm is somebody who's going to get a harm is somebody who's going to get a lot of drug lot of drug or a lot of studies over time high dose or a lot of studies over time high dose like ms patient so there we can now show like ms patient so there we can now show you categories you categories ms patients typically are handled with ms patients typically are handled with contrast very frequently contrast very frequently in fact we made a presentation to the
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in fact we made a presentation to the national ms society national ms society and they agreed as a result of that and they agreed as a result of that presentation to change presentation to change their formal recommendation their former their formal recommendation their former recommendation was you're getting a recommendation was you're getting a contrast enhanced study every year contrast enhanced study every year whether you have symptoms or not whether you have symptoms or not that's changed they were very open to that's changed they were very open to well we're not not that it's harmful well we're not not that it's harmful it's that we don't know and if we don't it's that we don't know and if we don't know know why take a chance let's back off so why take a chance let's back off so ms patients are a perfect example of ms patients are a perfect example of patients that are likely to get contrast patients that are likely to get contrast studies more often and studies more often and would be exposed to a potential risk of would be exposed to a potential risk of what we're not sure what we're not sure children somebody can come in there a children somebody can come in there a child can come in with a child can come in with a low-grade astrocytoma you can take it low-grade astrocytoma you can take it out and even using the actual definition out and even using the actual definition of the word perhaps of the word perhaps cure them but you know they're going to cure them but you know they're going to get for the first few years multiple get for the first few years multiple times a year and maybe once a year for times a year and maybe once a year for the rest of their life they're going to the rest of their life they're going to get a contrast in hand study get a contrast in hand study kids six years old another example kids six years old another example another one which i i'd like to point another one which i i'd like to point out specifically is out specifically is women with um being screened that women with um being screened that they're at high risk for breast cancer
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they're at high risk for breast cancer i say that and this is not a popular way i say that and this is not a popular way of saying it but i'm going to put it of saying it but i'm going to put it this way anyway to make a point this way anyway to make a point well technically they're not even well technically they're not even patients right we're screening them so patients right we're screening them so that they don't become patients that they don't become patients these are just citizens that we're these are just citizens that we're giving contrast to yeah giving contrast to yeah and if they're high risk we're going to and if they're high risk we're going to do it again and again and again and do it again and again and again and again again they don't even have a disease so they don't even have a disease so they're another one that's a potential they're another one that's a potential population population at risk for we not sure for what at risk for we not sure for what but if there is a problem that's a but if there is a problem that's a population that might be exposed to a population that might be exposed to a lot of it lot of it so we've gone out of our way as an so we've gone out of our way as an industry to try to identify who are the industry to try to identify who are the most most likely populations to see a lot of likely populations to see a lot of contrast contrast i was always saying maybe be careful how i was always saying maybe be careful how we administered to them i was always we administered to them i was always curious about the breastfeeding curious about the breastfeeding because everything that i read talked because everything that i read talked about how small the dose about how small the dose that the baby would get um but yet that the baby would get um but yet there's still policies out there about there's still policies out there about that well when it comes to breastfeeding that well when it comes to breastfeeding the we have a few generalizations we the we have a few generalizations we could make but it's really based on
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could make but it's really based on adults and you'll hear in a moment adults and you'll hear in a moment the if i took a the if i took a bottle of gadolinium bottle of gadolinium and asked you to drink it and asked you to drink it we would recover approximately 100 of we would recover approximately 100 of what you what you drank in the feces it would come out in drank in the feces it would come out in the stool the stool essentially a hundred percent unabsorbed essentially a hundred percent unabsorbed now that is i grant you adult normal now that is i grant you adult normal gi tracts ah keep that in mind right gi tracts ah keep that in mind right second of all if i take a breastfeeding second of all if i take a breastfeeding mother and i inject a full dose of mother and i inject a full dose of contrast into her contrast into her less than one percent of what i injected less than one percent of what i injected will make it into her breast milk will make it into her breast milk and then the kid's gonna drink it so if and then the kid's gonna drink it so if the child's gi tract the child's gi tract is similar to an adult gi tract less is similar to an adult gi tract less than one percent of what i gave the than one percent of what i gave the mother is going to make it into the milk mother is going to make it into the milk and less than one percent of what he and less than one percent of what he drinks is going to make it absorb drinks is going to make it absorb through his gi tract through his gi tract so the and if the kid himself needed
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so the and if the kid himself needed contrast i would inject it right into contrast i would inject it right into him oh right him oh right so what we actually tell our patients is so what we actually tell our patients is that we have zero that we have zero zero not small we have zero medical zero not small we have zero medical indication to stop breastfeeding indication to stop breastfeeding but we recognize that a breastfeeding but we recognize that a breastfeeding mom mom is going to be extremely careful almost is going to be extremely careful almost all the time there's going to be a hyper all the time there's going to be a hyper level of carefulness there and we say to level of carefulness there and we say to them if you yourself them if you yourself want to not breastfeed for whatever want to not breastfeed for whatever reason it's not my business it's your reason it's not my business it's your business business we would suggest that you recognize that we would suggest that you recognize that within 24 to 36 hours for sure within 24 to 36 hours for sure 90 plus percent 95 plus percent of what 90 plus percent 95 plus percent of what we've injected we've injected is going to be out of your body so is going to be out of your body so probably if you're going to stop probably if you're going to stop breastfeeding breastfeeding maybe 24 36 hours tops is what you might maybe 24 36 hours tops is what you might want to consider but we're not even want to consider but we're not even right we do not recommend that you stop right we do not recommend that you stop breastfeeding breastfeeding we don't believe there's any medical we don't believe there's any medical reason to to make such a recommendation reason to to make such a recommendation nice it's awesome really really great nice it's awesome really really great information thank you information thank you um one question we'd like to ask all of um one question we'd like to ask all of our patients to kind of wrap it up our patients to kind of wrap it up i think might be a fun question for you i think might be a fun question for you i'm curious
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i'm curious what would you say has been the most what would you say has been the most like defining most fulfilling moment in like defining most fulfilling moment in your health care career your health care career wow what is the most defining or wow what is the most defining or fulfilling moment in my health care fulfilling moment in my health care career career you want us to get your wife on the you want us to get your wife on the phone there have been phone there have been there have been a few but they all have there have been a few but they all have this one thing in common i'll use one to illustrate uh i had a 30 something year old male something year old male who um a stoic who um a stoic who came into the hospital and said i who came into the hospital and said i don't feel good don't feel good and he ends up he has no physician he's and he ends up he has no physician he's never gone to a doc he's one of these never gone to a doc he's one of these mountain men kind of guy from west mountain men kind of guy from west virginia virginia and within 12 hours he's comatose and within 12 hours he's comatose he's got mris up the wazoo he's got he's got mris up the wazoo he's got everything done everything's negative everything done everything's negative negative negative negative negative um he was written off and they were preparing to he was they're preparing for autopsy they're preparing for autopsy and they showed me the images and one of
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and they showed me the images and one of the sets of images was had been read as the sets of images was had been read as normal normal but the flare was actually extremely but the flare was actually extremely abnormal it was abnormal it was symmetrically abnormal the entire csf symmetrically abnormal the entire csf was grossly abnormal was grossly abnormal plus there was something in the in the plus there was something in the in the vermis so vermis so i thought that he had encephalitis i thought that he had encephalitis and rhombencephalitis so i thought that and rhombencephalitis so i thought that he may have listeria and so we discussed with the neurology service service that we should put them on antibiotics that we should put them on antibiotics for listeria and i'm not going to go for listeria and i'm not going to go into the detail they didn't want to and into the detail they didn't want to and they in fact there was a note on the they in fact there was a note on the chart that they had spinal tap times 3 chart that they had spinal tap times 3 that was negative that was negative and so infectious disease did not think and so infectious disease did not think he had that but i said i'm not asking he had that but i said i'm not asking i'm telling you we can i'm looking at i'm telling you we can i'm looking at the images the images it's as abnormal as can possibly be they answered well we're going to find out shortly out shortly and i didn't understand i said what do and i didn't understand i said what do you mean and they said at post you mean and they said at post at autopsy and um
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fast forward i convinced them to um this guy needs antibiotics guy needs antibiotics and so they started antibiotics that and so they started antibiotics that night the next morning he woke up night the next morning he woke up that was a saturday morning on sunday that was a saturday morning on sunday morning morning he signed out against medical advice on he signed out against medical advice on sunday morning he said sunday morning he said um i have to leave they said no you um i have to leave they said no you should understand you you're you're should understand you you're you're you're you're dying you still need antibiotics he said dying you still need antibiotics he said i'll miss three days of work and he's i'll miss three days of work and he's he said i'm out of here he agreed to he said i'm out of here he agreed to have visiting nurse come to the house at have visiting nurse come to the house at night and give him iv antibiotic night and give him iv antibiotic because he left and he came back two because he left and he came back two weeks later and the flare is back to weeks later and the flare is back to normal normal wow and what i love about that radiology saved his life i mean you can literally we did that in surgery so literally we did that in surgery so any situation where you know it saved any situation where you know it saved his life but what made that his life but what made that different from any time i did it in different from any time i did it in surgery or anytime anything like that surgery or anytime anything like that happened in medicine
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he has no idea i even exist right that's so real yeah there's no knowledge that's so real yeah there's no knowledge if you're not doing it there's no way if you're not doing it there's no way you can say you did it for the money you you can say you did it for the money you didn't do it for the didn't do it for the for the that he owes you he doesn't even for the that he owes you he doesn't even know you're alive and that there's this know you're alive and that there's this human being out there walking around human being out there walking around because you helped yeah wow because you helped yeah wow i think that's the defining moment for i think that's the defining moment for every physician i've ever met it's every physician i've ever met it's amazing amazing is to have somebody i think that's one is to have somebody i think that's one of the best answers we've gotten of the best answers we've gotten yeah that's amazing um that's actually yeah that's amazing um that's actually that answer is the reason why we asked that answer is the reason why we asked that question that question um so what a that's a great answer yeah um so what a that's a great answer yeah thank you thank you thank you for joining us i think we're thank you for joining us i think we're going to wrap it up we're kind of going to wrap it up we're kind of getting to the end of our uh getting to the end of our uh studio time but um thank you again dr studio time but um thank you again dr canal we really appreciate your time we canal we really appreciate your time we really appreciate really appreciate you coming and talking with us and you coming and talking with us and talking to our audience it's my pleasure talking to our audience it's my pleasure thank you for inviting me thank you for inviting me yeah hanging out with us in zone three yeah hanging out with us in zone three any excuse to come visit pittsburgh we any excuse to come visit pittsburgh we love it here so love it here so um thanks again for having us thanks um thanks again for having us thanks again for watching we're zone 3 podcast again for watching we're zone 3 podcast make sure to subscribe we're trying to
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make sure to subscribe we're trying to get to a thousand subscribers get to a thousand subscribers yes and uh i guess that's it right zone yes and uh i guess that's it right zone three podcast three podcast do you have anything to say i think do you have anything to say i think we're good we're out thank you for we're good we're out thank you for watching bye watching bye you
