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September 2015 Radiology Podcast (3 discussions)

September 2015 Radiology Podcast (3 discussions)

[music] Herbert Y. Kressel, MD: Hi. This is Herb Kressel and welcome to the September Radiology podcast. This month we have discussions with authors of three provocative papers. First, I’ll be speaking with Dr. Sadhna Nandwana of Emory
University who with her colleagues wrote a very interesting study on the use of gadobenate
dimeglumine in patients with impaired renal function looking at the subsequent incidents
or potential incidents of nephrogenic systemic fibrosis. Then my colleague Dr. Deborah Levine
will be speaking with Sangeet Ghai who with colleagues from the University of Toronto
published a study looking at the quality improvement effects of thyroid biopsy specialists in terms
of wait time reduction and biopsy accuracy rates. And finally, my colleague Dr. David
Kallmes will be speaking with Dr. Chi-Jen Chen of Taipei Medical University in Taipei,
Taiwan who wrote a very stimulating article exploring the sex differences in working memory
after mild traumatic brain injury. We hope you enjoy this month’s podcast. And a special
note, this month we have available transcripts of the podcast discussions. We’ve learned
that many of our listeners and viewers may not be that familiar with English as a language
and we feel that the transcripts will be helpful in furthering their understanding of medical
English. We hope you enjoy the podcast and we hope you enjoy the transcripts. Please contact us with any suggestion for further improvement. [music] H.Y.K. Hi. This is Herb Kressel and welcome
to this month’s edition of the Radiology podcast. Today I am joined by Dr. Sadhna Nandwana,
Assistant Professor of Radiology at Emory University who with her colleagues authored
a really fascinating paper on the use of gadobenate dimeglumine in patients with impaired renal
function. As there’s a lot of interest in NSF and the gadobenate based contrast, I think this is a very, very timely article. Welcome Dr. Nandwana. Sadhna B. Nandwana, MD Thank you for having
me. H.Y.K. And in full disclosure Dr. Nandwana
trained with us in Boston and I want to welcome her to the podcast. We’re very proud of you. S.B.N. Thank you so much for having me again. H.Y.K. Sure. Okay so gadobenate is in a class
of gadolinium-based contrast agents that have been associated with few or any NSF cases
and what’s the explanation for this? Why do people feel that these are…? S.B.N. Sure that’s a great question. Basically
it comes down to two properties. One it’s felt to have a higher relaxivity profile so
that you can use smaller doses than the other agents. And then the other factor is that
gadobenate dimeglumine actually has partial hepatic clearance. That’s felt that in patients
with renal failure since it’s getting partially cleared by the liver that confers an extra
safer profile to it. H.Y.K. Okay and then I would imagine it sort of took some gumption to decide to use a gadolinium-based agent in patients. I gather these were part
of a transplant workup. So could you tell us the thinking of why you decided to do that as opposed to some of the alternatives, you know non-contrast enhanced MRI or other modalities? S.B.N. Sure. We have a very strong MR program here at Emory and it’s part of our practice pattern to image in conjunction with a nephrologist
all of our pre-transplant recipient patients with MRI and MRA with contract. We actually
started with gadodiamide prior to 2007 and had seen some cases of NSF and that’s why we switched over to gadobenate dimeglumine. We found that these patients that are getting screened prior to transplant with contrast were able to pick up unknown malignancies, some background abnormalities that would otherwise have been missed, and so we have a very strong relationship with our nephrologists and our transplant surgeons to go ahead and use the contrast and image these patients. H.Y.K. Now some people sort of looking at
sort of the same issues would try to use some of the non-contrast MRA techniques or people
are also advocating diffusion weighted imaging to look for these neoplasms, how did you kind
of weigh the two different approaches? S.B.N. We basically set out to say we want
a diagnostic study. We don’t want to have to hedge and say well there may be a neoplasm
there and especially given that we have a lot of dialysis patients that are at risk
for RCCs, we want to know about this pre-operatively. So we said well if we have a strong relationship
with our nephrologists and our transplant surgeons and we’re giving them contrast, we
can screen them effectively for NSF. We knew that we were able to detect it prior to with
gadodiamide as we were able to identify those patients. We felt pretty confident that we
could control the narrative basically. H.Y.K. And I think you’re also are you dialyzing
them soon after the contrast administration? S.B.N. Correct so if the patient’s already
on dialysis, they have to get dialyzed within 36 hours, however we do recommend with 24
hours. And so this is practiced as soon as the patient checks in, we confirm with the
patient, with their nephrologist that they are on the dialysis schedule prior to receiving
the contrast. H.Y.K. What did you actually do in your study?
What was the study design? S.B.N. So our study design was a retrospective
review of patients that had renal failure and were presenting for an MRI or an MRA for
the evaluation of a pre-transplant workup. We were looking at this patient population
specifically because they had known renal disease and we wanted to see the effects of
them having received the gadobenate dimeglumine. Once we identified those patients as patients
who had received a study during 2010, we conducted a thorough chart review and we looked at all
the clinical notes that were available in the electronic medical record for both the
presence of NSF or NSF-like symptoms in their skin exams. We recorded two, the latest follow-up
for two types, basically one type where it included a dedicated skin evaluation by a
clinician, and the then the latest communication which may or not have included a skin evaluation. H.Y.K. What was the overall length of follow-up? S.B.N. The length of follow-up for a patient
that had a dedicated skin exam by a clinician was about 2.35 years. That’s the average,
and for the follow-up with any communication, was about 3.1 years. H.Y.K. And you also in the patients examined
during the target year which was 2010, you looked at all gadolinium-based contrast administrations from 2007 through 2014. What was the logic for looking at that? S.B.N. Right so what we wanted to know was
you know these patients received, we know they received gadobenate dimeglumine on that
index scan. What we wanted to know was were there other times that they had received a
gadolinium-based contrast agent and if so could that have contributed to whether or
not they developed NSF. H.Y.K If they had developed NSF you’d be able
to see if there’s a confounding factor as opposed to just pure gadobenate. S.B.N. Correct. And so unfortunately we didn’t
have anything prior to 2007, that’s when we went electronic, so we were able to look from
2007 onwards. The other thing that it allowed us to do was to see what the effective multiple
doses had on patients. Out of the 400 patients we did find that about 66 had received additional
contrast for other unrelated studies. H.Y.K. Okay. What did you find with your review? S.B.N. We found a zero percent incidence of
NSF in our patient population of renal failure. And interestingly we had patients that were
on dialysis whether it be peritoneal dialysis or hemodialysis as well as patients that were
not on dialysis but had a very low GFR and there was no difference in the incidence of
NSF in those patient populations. H.Y.K. That’s sort of impressive. Now you
studied 400 patients but do you think that sample size is large enough for this to be
a meaningful result? S.B.N. So it’s an interesting question. You
know the incidence of NSF with gadobenate dimeglumine is really it’s unknown. I mean
we have no unconfounded cases reported. So we’re unable to really do a power calculation
to see what should the sample size be. That being said, agents that have been associated
with NSF, so agents such as gadodiamide, in a similar patient population which is renal
disease patients, we do know the rates of NSF in those patient populations. Those range
anywhere from one to about eighteen percent depending on the type of study that was performed. H.Y.K. As an incidence? S.B.N. As an incidence, correct. And so what
we assume is that if we kind of extrapolate that data out to gadobenate dimeglumine which
is they should have a similar incidence of NSF in the renal failure population, our study
of 400 patients would be powered enough to detect at least a one percent incidence. H.Y.K. Okay, that’s impressive. As I’m sure
you know there have been several recent reports about increased signal intensity in the dentate
nucleus and other nuclei in the brains in patients who have received gadolinium-based
contrast agents and it’s been shown that this is due to gadolinium deposition in the brain.
Have you had the opportunity to go back and look at the head scans of your patients in
this study if they were obtained to see if there was any increased signal?
S.B.N. Not yet and it’s a great idea and I think we definitely will be doing that in
the future. H.Y.K. Okay well good. Now here we are, I
guess the study year was 2010, so what’s your current policy regarding MRI in this patient
group? Did you just sort of continue what you were doing? Is there any further modifications? S.B.N. Yes so we are continuing what we were
doing and basically what the study showed for us was support and that we could continue
to do what we’re doing. So we’re going ahead and proceeding with our policy of imaging
all of these patients with gadobenate dimeglumine. H.Y.K. Now in the article, you suggest that
you allow a three lifetime doses of 0.15 mmol/kg of gadobenate and then how was that actually
arrived at and how do you manage it? S.B.N. Right, it’s a good question. It’s basically
trial and error and what we feel comfortable with. We can say that we’ve imaged literally
thousands of patients that have renal disease with gadobenate dimeglumine with no problem.
Now we have data that’s been published to show that. We’re not as cavalier to say we’re
just going to do it forever and ever, so we came up with a number of three. It’s been
our policy for years. And so what that really means is that when a patient comes in with
renal failure and for the first three scans the technologist does not even call us up
for approval. After the third scan, when they’re coming in for the fourth or fifth or sixth
exam, the technologist will call us up and say hey doc this patient is coming back for
X number of scans, do you still want to give contrast. At that point we don’t have a policy. It’s kind of whatever the person feels comfortable doing. H.Y.K. Someone makes a judgment at the time
but a threshold to revisit and reconsider? S.B.N. Right, which is basically what the
ACR recommends for any group 2 agent. What we do is we just push that threshold up higher
after the third scan. H.Y.K. Very good. Well Dr. Nandwana I really
enjoyed chatting with you. I thought your article will be of interest to lots of folks
who are trying to figure out how to examine patients with severe renal disease and thanks
for taking the time to join the podcast. S.B.N. Great. Thank you for having me again. H.Y.K. Bye-bye. S.B.N. Bye-bye. [music] Deborah Levine: Hi. I’m Debbie Levine. I’m
the Senior Deputy Editor for Radiology and I’m here today talking with Dr. Sangeet Ghai
who is an Associate Professor of Medical Imaging at the University of Toronto. He and his group
in Toronto devised a study to look at mid-care providers to ease the radiologists’ workload
and provide a better patient experience for thyroid biopsies. We live in a healthcare
environment where we are continually being asked to do more with less time, and in addition
thyroid biopsy rates have just exploded so I found this paper to be very interesting
and very timely as well. So welcome Dr. Ghai. Sangeet Ghai, MD Hi, thank you for having
me. It’s a pleasure to be here. D.L. So I kind of mentioned what I thought
some of the drivers were for doing this study and I’m wondering if you can mention as well
what was the impetus for having these mid-care providers? Was it financial, efficiency turf
issues? What drove you to do this? S.G. So really to go back and this is I think
we’re talking about 2009 and 2010 when we started thinking of this program. The primary
reason was we were receiving a lot of complaints from our clinical colleagues. The wait times
were going up. How we function was you know we have a biopsy, dedicated biopsy center,
and we used to do deep abdominal biopsies in the morning and do the superficial biopsies
in the afternoon so that we didn’t have any recovery time and then they could go home
immediately after that. And there are only so many we could do. Plus, if I can say it,
there really wasn’t a consistency in the program. So you know you would have a first year resident
someday who would be doing the biopsy. The second day it might be a fellow, some are
more experienced than others, and there was kind of a bit of a disinterest in a program
I would say. How we were doing it, we were really not following up getting enough follow-up
as to you know when you do a biopsy was it an adequate specimen or not and then you have
inadequate specimens and the patient comes back for a repeat biopsy that adds to their
wait time. So we were going back, we were calling up the wait times of about three months
for a thyroid biopsy even longer. So a lot of complaints coming from our physicians,
surgeons, endocrinologists, and that’s when we started thinking as to what we can do to
provide better service to our physicians and more so for our patients actually. D.L. So can you tell us a bit about what exactly
you did in this study and what you found? S.G. Absolutely. I would love to. So when
this first came up this was something as the director of the biopsy center in the hospital
the chief actually and I had a chat. And he really wanted to set this program up. The
first thing we did was bring this up in our divisional meeting to all the radiologists
in the group to see if this is something they would be interested in and surprisingly there
was an overwhelming support that yes we should do that, this would be better for us. It would
in fact free us also to do the other radiology reading scans and stuff and free up daytime
as well. So the first step was getting approval from the radiologists, but we knew that they
are going to be many, many obstacles in the path. Then I spoke with the CMPA in Canada
which is the Canadian Medical Protective Association if there would be liability coverage for the
physicians. And then if I can actually quote here from the paper, it said “It is a delegation
of a medical act could be considered part of the professional work of medicine, but
you would need to get approval from your regular party after province” which in our case was
in our case CPS, so the College of Physicians and Surgeons in Ontario and also get consent
from the sonographers or the MRTs that you would train which in this case would be the
hospital. So we knew that we had to go back CMPA would be fine if we could go back to
CPS and the hospital MAC. So the first step was to go to the College and there again have
a very clearly defined policy for delegation of controlled acts on the website which again
said that you could do it provided you include proper identification, evaluation of the individuals,
how you train them, that should be there, there should have been an established process
for the delegation. Then they should maintain competence and train them for informed consent
as well. So when we read the policy online we thought yes we could easily go through
that, it’s going to take a while, but there’s no reason why this is not possible. And the
third step was again for the medical liability of the sonographers, we had to back to the
hospital. So when we looked at all this we knew that we really needed the approval of
the hospital and the CE for them to approve for this entire process. So we put forward
a plan of how we would train the sonographers in a stepwise manner and we put this to the
hospital MAC. It did come up in the meeting. The first time actually it did not pass through
and that was because some of the pathology colleagues have concerns about if our adequacy
rates were not pretty good and is this actually going to even further make it worse or we
going to open the flood gates and start doing thyroid biopsies on each and every patient
just because we’re opening having new sonographers perform the biopsy. So it didn’t pass through
the first time. We took it again, we did have discussions with the pathology division, how
to work closely with them for on-site side of pathology and when to ask for on-site side
of pathology. I think the second time it just whizzed through. It wasn’t a problem. The
hospital approved it. So when the hospital approved it we were I think on board the whole process could get now started to train the sonographers. D.L. So you trained your sonographers and tell us about your study and what you found in your study. S.G. Sure. So initially when we initially
thought should we train MRTs, radiation technologists or our sonographers, but the fact that sonographers
already have some hand-eye coordination and the fact that their licensed to practice sonography,
to do ultrasounds and (inaudible), we thought it would be better to train them. It would
be easier actually. It could be a one step just to train them for the biopsy. So we had
our one day training program which included directive talks from the morning to the evening
actually. We showed them some, there were some video demonstrations as well. The second
step in the training was phantom training. There was a one day full of phantom training
or half a day of phantom training. The third step was having them come to the biopsy center,
observe us, how we do the procedures and the fourth step was a one-to-one training for
them. So they would all come into the biopsy center just for the afternoon and we did superficial
biopsies over a period of about three weeks and we did about 45 to 50 and then they would
be signed off by the radiologist who would have supervised them. So we did that. It took
us again a few months to train four sonographers and then we started them to do the thyroid
biopsies independently, under supervision, in a room which was made available right next
to the deep abdominal biopsy room. There’s a control room on the left hand side, we had
the deep abdominal biopsy, on the right hand side we had the ultrasound room. And so initially
we started slowly. We would only book about three patients in the morning. They would
do a full ultrasound. They would document the ultrasound. They would call us to the
room to show us the images and think what they thought which nodule should be sampled
and what should not be, and once we agreed on which nodule should be sampled, they would
go ahead and do the biopsies and only if they had an issue they would call us. We were always
there available in the very next room, you know if you’re doing an abdominal biopsy sometimes
it takes about ten, fifteen minutes, so if worse to worse you just wait for ten minutes
and then we would come across and help them if help was needed. So it’s been running well.
It’s been about three years, more than that now. What was published in the paper was our
adequacy rates just for the first year when they started. I think it went from 74 to 78
percent in the very first year, but I do have some data now from 2014 which actually says
that the adequacy rates have going up to about 90 percent. So I think this has been a very
successful program for us. Our clinicians, we keep meeting them, we keep discussing all
these in the rounds as well in (inaudible). There’s been a very good approval from them
so there’s really no complaints coming in. I must say that this has been a success for
us. D.L. So you talk about your wait times going
down in the paper which makes sense because you’ve got people dedicated to doing these
and your adequacy rates went up and I think wait time finding, as I said, makes a lot
of sense. Why do you think your adequacy rates went up with these mid-level care providers? S.G. I think it’s the consistency. It’s the
same people who have been doing it. We have the four sonographers who were trained to
do this and they kind of rotate one in four weeks, so for one full week they would do
the target biopsies and for three weeks they’ll be doing ultrasounds in the ultrasound department,
come back to do biopsies again, and you know they cover for their vacations as well. Sometimes
they will be there a little bit more than a week in a month. And I think that consistency
is what has led to this benefit. I must say it’s pretty similar to sonographers now do
the ultrasounds and they are very good at it having done it over the years. Initially
we would have some days it’s a first year resident who might be in the rotation. You
know there might be a fellow, some are trained better than the others, so I think that’s
the predominate reason, the consistency. They take pride as well that they’re doing this
and they’re doing it very well. I truly believe that this really has been one of the biggest
benefits of having them in this program. D.L. Now when you get informed consent from
the patients and when these sonographers get the informed consent, are the patients told
that it’s a non-physician who is going to be doing their biopsy? S.G. Yes, absolutely. In fact the sonographers
have been, they are able to take the informed consent and they will do it and our name,
the staff who is there, and in their names as well. Most of the patients are absolutely
fine, they are told that I’m a biopsy specialist, a thyroid biopsy specialist, and I work with
so and so, Dr. Ghai is with me today. He is in the other room and some patient’s yes they
do ask I would have thought this was going to be done by a physician and they ask for
it. And frankly speaking, if now I’m asked to come into the room at the time of the consent,
I actually tell them, I’ve done five thyroid biopsies in the year, the person here has
done over a thousand. You really want me to do the thyroid biopsy and most of the time,
in fact always, they’ve said no I’m fine with it. I just wanted to make sure of that. And
then we have to convince them that this is a program which has been approved by the hospital.
There’s been a training program and there’s an evaluation which happens every year as
well. There’s a fixed number that they have to do to maintain their competency. It’s just
that you need to go in and speak to them for a minute and everything is fine after that. D.L. Given your success with this program
with your mid-level care providers, are you using this in other areas either in ultrasound
or elsewhere in your imaging department? S.G. So in the past, you know been using them
for PIC lines as in many hospitals they provide some fluoroscopy assistance for things like
(inaudible) and (inaudible) in the past, it just frees up the radiologist, so there’s
been a precedence in the past. Have we increased it’s since (inaudible) the scope of their
practice, we really haven’t as yet, but we’re talking about things like could we add paracentesis?
Sometimes it just occupies the room for a long period of time. Is that something chronic
patients, liver patients, where you’re doing four liters, five liters, is that something
they can do? It’s just that you have to go through the whole process because again you
go back to the CMPA, the CPSO, we haven’t started it, but yes we’ve been talking about
some simple procedures such as that. D.L. You mentioned early on that you got the
radiologist acceptance very easily, pathology took just a little bit of work, what about
your referring clinicians? Were there any issues with them? S.G. Surprisingly there really wasn’t. All
the endocrinologists were on board. We kind of cater to a group the university hospitals,
it’s not just the one hospital, so we have (inaudible), we have Mount Sinai Hospital,
Women’s College, where we have the endocrinologists apart from Princess Margaret Hospital here.
All across the board, now we have not had, in fact once or twice I’ve had a positive
feedback from the clinicians saying that they were very happy with it, so surprisingly nothing
really from the other departments. Everything has been well received. D.L. Wonderful. And what are your wait times
now for these thyroid biopsies? S.G. Less than three weeks I would say. It’s
less than three weeks to the extent that we’re thinking we might start doing them four days
in a week instead of providing the service days if the wait times keep coming down. So
it’s been less than three weeks. I think today it might be about three weeks. D.L. Wonderful. Well thank you so much for
your time and this discussion. I really appreciate it. Of course we’re talking about your study
in Canada. Do you have any ideas how this might work in the United States, do you know
if we could do it? S.G. I don’t know. I would think it’s a little
different in the U.S. Having not worked in the U.S. I don’t want to be commenting too
much. I believe a lot of physicians, not only radiologists, also do these procedures in
the US in the clinics. I don’t know if they would be willing to have their assistants
do this or not. But I think here it’s been, in our experience, in our hospital, it’s really
been very good. D.L. Okay. Well again, thank you so much.
I really appreciate your time. S.G. Thank you for having me. It’s been a
pleasure. [music] David Kallmes: Hello, my name is David Kallmes,
I am Deputy Editor for neuroradiology. I’m joined today on this podcast by Professor
Chi-Jen Chen of the Department of Radiology at Taipei Medical University. Dr. Chen welcome
to the podcast. Chi-Jen Chen, MD: Thank you. D.K. We are here today to talk about your
publication entitled Gender Difference in Mild Traumatic Brain Injury, Functional MRI
Study. Congratulations on your paper. C.J.C. Thank you. D.K. So can you briefly tell us at the beginning what you did in this experiment and your major findings? C.J.C. Okay actually in our prep clinical
presence we found more females seek medical attention after mild traumatic brain injury.
However, according to our past experience and the epidemiologist study we found that
actually male MTBI patient outnumbered female. So we wondered if there might be some sex
factor difference in the MTBI outcome. When we reviewed our literature we found the result
is actually mixed. Experimental studies show that a female animal actually have better
outcome than male, however in the human study, males actually had a better outcome than female.
So we tried to understand that, so therefore we conduct a study, we studied 30 patients
with MTBI and 30 normal control. Both groups contain equal number of the men and the women
and patients under functional MRI we see in one month after injury and we follow-up function
in our study the sixth week after the first scan. All the patients also underwent new
psychological tests including digital span and continued performance tests. The initial
results shows that MTBI patients show increased activation in working memory circuit in men,
but the decreased activation in women compared to the control. As a follow-up, men with MTBI
returned to a normal activation pattern similar to the control; whereas the women show persistent
hypo-activation suggesting on-going working memory problem. Also, the neuropsychological
results shows that among the women and the total digital span scores were lower in the
MTBI group compared to the control group. This finding provides evidence that female
gender may be a risk factor for working memory impairment after MTBI. D.K. So it seems somewhat surprising that
there are differences both at baseline and at follow-up, that the activation is opposite in men and women at baseline. Was this an unexpected finding? D.J.C. Pardon? D.K. Was this finding of different activation,
of hyper-activation in men and hypo-activation in women at baseline or early after injury,
was this find a surprise to you? D.J.C. It does not surprise me, it’s only,
because it’s compatible with our clinical finding, because actually more women seeks
for medical attention after MTBI so it means usually it may seem it’s because women are
more likely to admit they have a symptom, but actually it’s not. Actually they have
real problem than men after MTBI. D.K. Is there any obvious explanation for
this? D.J.C. Until now we still don’t know what,
but there are some assumption – one possible explanation may be biomechanical, that women
may have because their head are smaller and because their neck muscle are weaker than
men, so that when it comes to MTBI their ability to absorb any shock of the impact is weaker.
That’s one explanation. And the other explanation is that maybe men and women use different
brain region in working memory tests and the brain region women use during working memory
may be more susceptible to injury, but this is only a hypothesis. It needs to be tested
in the future. D.K. And can FMRI be used for prognosis based
on your findings? That is to say can you predict what will happen to an MTBI patient early
after injury based on patterns of activation? D.J.C. Yes I believe that it seems that MRI
is very sensitive to the MTBI injury, but unfortunately at the present we are only doing
a group study. We cannot apply it to the individual label so maybe more work need to be done in
the future to extend the usage of the function of the MRI to the individual label. D.K. And in a related note, can you envision
that any type of specific therapy, either medication or other cognitive type therapy
might be individualized to men or women based on your findings? D.J.C. Unfortunately, at present the treatment
for men and women after MTBI are the same because actually no chronological or rehabilitation
treatment can benefit from this. Actually 85% of patients will recover spontaneously
within three months. Only 15% have persistent symptoms. This group of patients we need to
pay more attention, but actually we don’t know which ones to pay more attention in the
beginning, but right now we know maybe female we need to put more attention and maybe I
know have some trouble in the clinical trial, but still not have a very obvious result right
now. D.K. Could it be that the mechanism of injury
was different between the men in your study and the women in your study that might have
affected the outcome or were the mechanisms of injury similar between groups? D.J.C. Actually they both have the same, no
difference between the mechanism of injury. Most of them suffer from the motor vehicle
injury and a few are a sport injury and maybe less in an assault. So the mechanism seems no different between men and women in our study. D.K. And can you share with us studies that
are on-going at your center or studies that you would like to do in the future to elucidate
the mechanism or offer prognostic indicators? D.J.C. Okay actually the results are only
preliminary. A question remains including just as I mentioned the possible physiologic
basis of working memory and the role of the sex hormone at the time of the follow-up injury.
So we plan to combine functional MRI and the reliable neuropsychological test and the direct
measurement of the hormone label both at the injury time and the follow up stage and we
also try to combine other imaging modality such as diffusion tensor imaging tool for
the structure integrity and resting state functional MRI for the functional connectivity
susceptible with the imaging for micro-trauma and profusion study for the hemodynamic evaluation.
Also the MR special scope for the metaboli. We hope using this modality can further help
us to explore the underlying possible physiology and cause of the sex difference in the MTBI. D.K. It sounds like a very comprehensive study.
Is that ongoing now or are you planning it in the future? D.J.C. Actually we have finished a little
about (inaudible) for the micro-trauma. We didn’t find a difference. The number of micro-trauma
between these two groups actually is the same, so now we try to use functional connectively to detect any difference between these two groups. D.K. Sure. Okay. I want to thank you sincerely
for supporting our journal. A prospective study MTBI is a welcome study and it was very
well done. We look forward to receiving future papers from your excellent group. Thank you
Dr. Chen. D.J.C. Okay. Thank you. I hope our future
work we can submit to Radiology very soon. D.K. We look forward to it. D.J.C. Thank you. [music]

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