ISMRM Day 4: Dale a Tu Cuerpo AlegríaHonolulu, April 23, 2009 It wasn't the first Dancing MR Tech video I'd ever seen. But it was probably the best. And I almost missed it. Thursday morning. The excellent Lauterbur Lecture (including the soon-to-be-classic Toilet analogy for T2 and T1) and the "MRI Scanners in 2025" plenary session had come to a close. The moderator asked us to hold still for a moment longer as he made a couple of announcements, but I needed to get to the hotel to gather my belongings before check-out time. I stood up and crept toward the back of the ballroom. I had almost reached the door when I heard the familiar strains of "The Macarena," the Los del Rio song that became a worldwide hit in 1996. Unable to resist the insanely catchy intro, I turned to see what it could possibly foretell here at ISMRM 2009. A video was playing on one of the screens at the front of the room, and it mesmerized me. It opened with an MR tech leading a patient into the magnet room. Before he could enter, though, the patient needed to be sure he had removed all metal from his person. Anyone who works with MRI (or has been an MRI study volunteer on numerous occasions…ahem) will surely recognize the dance that followed: one hand on the breast pocket, one on the hip pocket, pat several times, and so on. From there, of course, it was a short step – and a logical leap – to a full-blown production number with the members of what I believe to be the Singapore Bioimaging Consortium performing the Macarena dance. In the lab. In the hallways. On the lawn in front of the Center. On the playground. Is there anything more charming than a bunch of scientists dancing to one of the most awesomely bad songs of all time (according to VH1) with varying degrees of skill and abandon? Especially this one fellow who, despite a notable absence of technical proficiency, was totally…rocking…out. Clearly, these guys were having a blast. And why not? Researchers work tirelessly, ceaselessly, making the world a better place for you and for me. Why shouldn't they be allowed to let loose every now and then? The ISMRM attendees kept plenty busy this week. Days began at 7 a.m. with "Sunrise Educational Courses" and ended as late as 8:30 p.m. The hours in between were filled with plenary lectures, myriad other talks, electronic poster sessions, traditional poster sessions, lunchtime symposia and many coffee breaks, during which attendees clustered together to discuss what they had just seen or any ideas it might have sparked. By all accounts they found the meeting very fruitful. But they also enjoyed themselves. I encountered MRI folk up and down Kalakaua Avenue in Waikiki, and even on other parts of the island. And I know some of them are sticking around for a while after the conference. A friend from my time in Boston told me, for example, that he's planned several diving trips next week - on Maui and, if memory serves, the big island of Hawaii. As for myself, I am, as they say, out of here. I've had a great time at the meeting - and in Hawaii generally. Thanks for reading along. I'll see you next time. P.S. - I never did get a photo at the meeting, but my sister-in-law, Mari, forwarded this picture of me on the beach in Waikiki: Garygboas@eggship-media.comISMRM Day 3: MRI looks inward (figuratively this time)Honolulu, April 23, 2009It was late Sunday evening, maybe about 10pm, and I was sitting with my laptop in the well-appointed lobby of the Ala Moana Hotel. I was clacking away on the keyboard, preparing a story for publication the following afternoon, when a woman took a seat next to me. She smiled and, after a moment, introduced herself as Lorraine*, from Lubbock, Tex. Though she had spent the early part of her life in the suburbs of Los Angeles, Lorraine was now an amiable, agreeable West Texas type. We chatted for some time. I learned that she was in Honolulu to visit her ailing mother. And that she herself had recently been diagnosed with breast cancer. Later, when I said that I had come to Hawaii to attend the magnetic resonance in medicine conference, she recounted some of her own experiences with MRI. She told me, for example, that only weeks before she had refused a contrast-enhanced MR scan because she didn't want to be injected with gadolinium. We talked about toxicity levels and FDA approvals but, on this, she remained unconvinced. "Call me paranoid," she said. "I just don't think it's safe." On Wednesday morning, in the Kalakaua Ballroom in the Hawaii Convention Center, I listened as a series of researchers discussed an unanticipated danger of using gadolinium for contrast. They spoke with - not with contrition; I don't think contrition was warranted - but certainly with humility. The danger wasn't cancer, as Lorraine had feared, but rather nephrogenic systemic fibrosis (NSF), a debilitating disorder found in renally compromised patients that has been linked to gadolinium-based contrast agents. The identification of gadolinium as a trigger, in 2006, created "a real maelstrom in the field," said Vivian S. Lee, president of ISMRM and one of the moderators of the Wednesday morning plenary lectures, and forced a re-evaluation of using gadolinium for contrast. Lee and the three other speakers, therefore, sought to answer the following questions: why did this happen, and what have we learned? The first gadolinium-based contrast agent received FDA approval in 1988. Though gadolinium is a toxic rare-earth metal, investigators believed it was safe in the compound form in which it was administered. Nine years later, in 1997, the first known cases of NSF were reported. Yet another nine years passed before the first paper identifying gadolinium as a trigger of NSF was published, in early 2006. Several months later, in June 2006, the FDA issued an advisory about this. Nearly 500 cases of NSF have been reported in peer-reviewed literature. Some have suggested that many thousands of additional, relatively mild cases have gone undiagnosed. The number of new cases of NSF has dropped precipitously since 2007. This indicates that researchers and physicians now have "a pretty good idea" how to prevent it, said Jeffrey C. Weinreb of Yale University School of Medicine, one of the morning's speakers. Still, identification of gadolinium as a trigger has led to a great deal of "confusion, conflict, accusations and incriminations" -and, in the States in particular, a number of lawsuits. So, why did this happen? Was it simply a matter of greed, stupidity and negligence, as has been suggested? Weinreb believes the answer is more complex. He listed several reasons. Because gadolinium was considered low risk, for example, screening patients for those who might experience adverse effects was considered unnecessary. Also, gadolinium might not have been identified as a trigger earlier because of poor documentation - incorrect dosages and even the agent used are sometimes noted on medical records - and because of regulation changes, including the HIPAA privacy rules that have governed the use and disclosure of health information since 2003. In reality, he continued, the delay in discovering the cause of NSF was "not unique or even unusual." Many serious adverse drug reactions have gone unnoticed for years, he said. Nonetheless, the association of NSF with gadolinium-based contrast agents led to some soul-searching within the MRI community. Researchers and clinicians are seeking ways to assess the risk of NSF in renally compromised patients, and to raise awareness of the disorder generally - but they are also trying to look past use of contrast agents, to eliminate the risk altogether. "This has launched a renaissance of non-contrast agent MR imaging techniques," Lee said. "If there's a silver lining to the situation, that's it." (*I've changed her name to protect her privacy. I didn't know at the time -- nor did she -- that I'd be writing about this later.)Day 2: Still Life With GaryHonolulu, April 22, 2009 A couple of weeks ago I picked up a worn copy of Tom Robbins' Still Life With Woodpecker. As it happens, a significant portion of the book is set at a conference on the island of Maui: the Geo-Therapy Care Fest, the aim of which is the coordination of a diversity of planetary rescue missions. Robbins doesn't provide attendance numbers, but he does note that the conventioneers include experts in the fields of alternative energy, organic farming and space colonization; champions of contemporary Californian self-help systems; a smattering of invited futurists, artists and shamans; a man and woman from the planet Argon; a self-proclaimed outlaw; and an idealistic, red-haired princess. Oh, and Ralph Nader.I have some information about attendees of that other conference in Hawaii (ISMRM, for those not paying attention). Jennifer Olson, ISMRM associate executive director, told me on Tuesday that approximately 5040 people were already here, and still more were expected. The organization had forecast between 4500 and 5000.Olson attributed the robust attendance in part to the location. Everyone likes Hawaii, she said - especially, perhaps, those in the Northeast, who are just now emerging from a long, difficult winter. Also, the relative proximity to Asia makes the meeting more accessible to researchers and clinicians from that part of the world. For example, she said, "we have many, many attendees from China."ISMRM expects to have final attendance numbers, as well as breakdowns by country, by the end of the week. In the meantime, I'm hoping I can somehow dry my copy of Still Life With Woodpecker, as I inadvertently dropped it in the ocean yesterday. Don't ask.GaryConsciousness Redefined (Sort Of)Honolulu, April 21, 2009 I'm in the midst of a complete technology breakdown. On Sunday my cell phone decided to devote itself to continued, unsuccessful attempts to HotSync with my desktop computer, and still refuses to do anything else. And my efforts to remedy the problem somehow wiped my address book, my e-mail settings and all the photos I'd snapped with the phone at the beach. Then the battery in my camera died and I discovered that I'd left the charger at home. (Admittedly, this isn't the camera's fault. But I'm going to blame "technology" anyway.) Finally, the WiFi connection at the hotel started hassling me: Instead of providing unfettered access to the interwebs - part of the deal, I assumed, when I gave it my credit card number - it crashed my laptop. The connection at the convention center, thus far, is only marginally better. So bear with me. The good news out of Honolulu is, the ISMRM Scientific Meeting kicked off with an engaging series of lectures on Monday morning. In the Mansfield Lecture - named for Sir Peter Mansfield, one of the pioneers of MRI - Robert G. Shulman of Yale University School of Medicine posed the question: What is the relationship between neuronal energy and cerebral function? Shulman and colleagues addressed this question by probing the mother of all such functions: consciousness itself. Using functional imaging, they showed that a state of consciousness - as defined by anesthesiologists, the ability to respond to simple questions such as "What day of the week is it?" - is supported by a high baseline energy consumption and characterized by particular fMRI activation patterns and neuronal firing patterns. Why is this important, Shulman asked (presumably, aside from the fact that it offers an answer to one of the most burning epistemological and philosophical questions of the past several millennia: what, in fact, is consciousness)? Not least, he said, because understandings of the relationship between neuronal energy and cerebral function can contribute to a range of applications: for instance, interpretation of PET and NMR data in studies of coma and sleep states. Next up were the opening day plenary lectures, collectively titled: "Stroke: A Forward Looking Retrospective on the Role of MR." A. Gregory Sorensen of Massachusetts General Hospital took the stage first, listing a number of recent advances in this area before turning to the question of what changes are still necessary. With respect to the latter, he noted, for example, that greater availability and speed of MR imaging are required. Time is brain, he said. During a stroke, two million neurons are lost every minute. So it's crucial that no time is lost in getting a patient to a scanner, or in making treatment decisions. Finally, Rudiger J. Seitz of Heinrich Heine University addressed the role of MR in promoting long-term recovery from stroke. Here, he described various mechanisms of recovery - for example, reactivation of the ischemic penumbra and use-dependant plasticity - and how magnetic resonance imaging can contribute to each. I'll check in again tomorrow - assuming no further difficulty on the technology front. And I'll see if I can get my hands on a camera so I can share a few photos of the meeting. Gary ISMRM PreludeHonolulu, April 20, 2009 I stepped off the crowded Boeing 767 into the terminal at Honolulu International Airport. The scene there wasn't at all like what you might see on television. There was no Ricardo Montalbán in a crisp, white suit, smiling broadly and raising a glass topped with a tiny umbrella; no Herve Villechaize tugging excitedly at his boss' sleeve. No, the only person I saw when I stepped off the plane was a listless attendant in a faded floral-print shirt. Within an hour, I had checked into my hotel, a stone's throw from Ala Moana Park and the small, tranquil beach just beyond. A half block in the other direction, at the Hawaii Convention Center, the 17th annual meeting of the International Society for Magnetic Resonance in Medicine (ISMRM) was already under way. Even as I unpacked, a high school classmate whom I hadn't seen in years was giving a tutorial on positive contrast for cell imaging, as part of the Weekend Educational Program. The Scientific Meeting was set to begin two days later, on Monday. That's when I would start my coverage. MRI isn't my usual beat. But I was intrigued by a number of sessions and individual talks here, especially those devoted to functional MRI and to multimodal imaging. Anyway, I live in San Diego – only 2560 miles from Honolulu. You really can't get any closer without forfeiting your right to call in or text your vote to American Idol. So why not thumb a ride on the nearest jumbo jet and see what the meeting is all about? I've sketched out a plan for the week. In addition to the plenary lectures, I'm hoping to attend sessions such as "The Addictive Brain" and "Hybrid & Unconventional Systems." I'll report in when I can, with updates as to what I've seen. Gary Boas gboas@eggship-media.comAfter working in the research community as a writer and editor, Gary Boas joined Laurin Publishing in 2001. Today, he is a news editor for BioPhotonics magazine and a contributing editor to Photonics Spectra. In addition, he continues to crash as many academic cocktail parties as he can.