I hold a different opinion to you though, I'm glad doctors are always learning more while generally operating with good /extremely good intentions.
I agree. Expecting perfection from humans, even experts, is not reasonable and is frankly counterproductive.
Willful ignorance is one thing, but people who genuinely attempt to do the right thing at worst just need to be steered slightly differently.
There's a big difference between perfection and "Statistical Literacy Among Doctors Now Lower Than Chance"[1]. I don't think their intentions are bad, but they are woefully incompetent at many basic things.
[1] https://slatestarcodex.com/2013/12/17/statistical-literacy-a...
As it happens, the daily practice of medicine does not require interpretation of p-values. Indeed, medicine existed before the p-value.
The people who create studies that ultimately guide policy decisions are specialized (much like people who write GPU drivers are different from those who run inference)
What are you talking about? Doctors refer people based on test results every single day. From what I've seen, hardly any of them understand the precision/recall of the tests that they then use to refer you (or not) to screening procedures (which are not all harmless).
What are you talking about? How is a single lab value going to generate a p-value? Why are you presuming that your family med doc should be calculating an ROC for each of her 1,500 patients?
The selection of lab critical values is performed by experts in clinical pathology. Exactly the people who were not included in the paper you cited.
You can find links to support any argument you want on the internet.
To place this in clearer HN terms, you're saying that a front end dev is trash because he didn't write his own web browser in assembly.
A year ago, one insisted vehemently—to the point of yelling—that I shouldn't be supplementing Vitamin K because my potassium levels were fine.
This paper isn’t saying that MRI contrast agent is high risk in general.
There’s a risk in misinterpreting these niche papers to overstate their relative risk. This is a common mistake when people start reading medical papers and begin overweighting the things they’ve read about as the most significant risks.
You're making me feel lucky about what was otherwise a very unpleasant experience!
Pretty much just diluting it out of your system.
There's risk in life and odds-wise if you're in the developed West, you're going to get care and medicine that will greatly prolong your life.
Also this paper is super vague. What percent of people even get this? How long does it last? They havent even done a study to see how long it lasts yet. I have a feeling this isnt going to be our generation's asbestos or thalidomide.
That being said, you should decide your own risk profile. If MRI gives you concerns there are alternatives that dont involve contrast.
But given our track record, a little humility would go along way.
When a highly educated doctor tells you that something is safe, a person is going to assume that means that someone somewhere has proven that the substance is safe. If what they really mean is that no one really knows, but so far, no experiments have been able to prove danger, then we should say that instead.
You can’t prove a negative.
But when a person who doesn’t spend their time nerding out on science goes to the doctor and hears, “the substance is safe”, it is not a guarantee that they know that you can’t prove a negative. If you can’t be sure that your audience knows that it’s not possible to prove a negative, then you should be pretty cautious with your words.
Contrast agent has been widely studied and determined to be reasonably safe. You’re not going to be administered any routine procedures or compounds that are known to be dangerous without an examination of the risks and benefits.
> If what they really mean is that no one really knows, but so far, no experiments have been able to prove danger, then we should say that instead.
“No experiments have been able to prove danger” is too generic to be usefully different than saying that it’s understood to be reasonably safe.
Even this paper isn’t saying that contrast agent is bad or dangerous in general. It’s exploring a potential effect that we can now detect and study.
Every procedure has some negligible risk, and doctors are trained to mitigate major risks to peoples' health with screenings, medications and surgeries that are of lesser risk than the alternative of inaction. "Safe" is a reasonable explanation for the vast majority of laymen they have to communicate with.
We shouldn't have to clarify that everything is only 99.999% safe and assume that everything carries some form of risk even if small.
Unfortunately, the article isn't much better. It has as an underpinning, a corrected paper: https://doi.org/10.1093/ndt/gfl294
2. I fail to see how the previous study is an “underpinning” of the new paper. The new paper is a chemistry paper about dissociation of GBCAs in the presence of certain chemicals. Maybe people care because it is a potential explanation for toxicity, but the paper is very focused on the chemistry findings.
It is underpinning, as the claims in both introduction and conclusion are precipitate to it.
The correction:
> After personal communication with the radiologists the administered Gd-contained contrast agent was documented in the MR examination reports of the mentioned nine patients incompletely and inexactly as Gd–DTPA by themselves. There is solely one MR contrast agent used in the described observation period: Gd–DTPA–BMA. Therefore, all mentioned nine patients received Gd–DTPA–BMA and not Gd–DTPA.
Means that Gd-DTPA is irrelevant. Guess which is analysed here?
Medical procedures have risk, some are small risk some are higher risk. There are none that are 100% safe. Doctors are supposed to evaluate if the risk is worth the value the procedure would supply.
What is the alternative to the status quo that you would propose?
> There's a big difference between not getting the MRI and getting the MRI without gadolinium. My suggestion is to ensure that people know the risks outside of just the people who work in it. I'm not sure how that didn't get across in my original comment. With your comprehension skills, you are at an increased risk of falling victim to this exact scenario
I don't see anything wrong with the GP's comprehension skills.
Anyway, every procedure has risk - and no procedure is recommended if there is not an offsetting clinical benefit. There are clear guidelines for when gadolinium is to be used for an MRI and the guidelines factor in risk for 'NSF'.
I don't know how the risk is actually communicated to patients. I imagine it varries by country. However, normal medical ethics would be to explain risks to the patients. Is there a reason to believe that isn't happening?
I had a couple of MRIs recently and got curious about gadolinium contrast. Again, there is a non-zero risk, but if you eliminate the cohort with reduced kidney function and those getting regular repeated MRIs, the risk is comparable to the use of an I/V, which is how it’s administered.
The only thing that upset me was that the staff didn’t ask me verbally about kidney issues to double-check. They also didn’t remind me to drink a bunch of water to flush it out of my system. (Some articles recommend administering a diuretic.)
For that matter they didn’t check me properly form metal fragments either!
Similarly, I’ve had vaccinations administered where I had to remind the doctor to clean the area with alcohol first and to tap the syringe to get rid of the bubbles.
Bad procedures are more dangerous than the drugs being administered!
I got familliar with this condition by a random persons blog who go affected by this during normal MRI and also didn't expect to be part of 1-2%. Unfortunately the blog is now gone, and that post now only lives inside my RSS reader.
My dad was in this industry when nsf first came out. We would be dragged along to after hours family things at conferences. Doctors openly said they gave contrast off label at dosages not approved by the FDA for organ systems not approved by the Fda. Even children. I'm sure they had their reasons, but I'm also sure they never disclosed the possibility of nsf and just told parents their kids needed it, because they admitted it.
Clevland Clinc says "There haven’t been any new reports of NSF in almost 15 years" [1]
[1] https://my.clevelandclinic.org/health/diseases/17783-nephrog...
I was never communicated about gadolinium pollution. Not once.
And yes, on my recent MRI, I explicitly asked why there was metal particulate in my joint. "I dont know, sometimes it happens'... No you fucking tool of a doctor. Its gadolinium.
And I finally find out here.
When my wife was under cancer treatment she had them frequently. Risking some minor reaction, which in her case was disclosed many times, was well worth the value in managing the acute and long term treatment plan.
> She said that the FDA's plan doesn't go far enough.
> "It's hard to dismiss an anecdotal report when you are the anecdote. When a patient is finally tested and found to have gadolinium retention, there's no FDA-approved antidote. So what does the patient do?"
And I want to reiterate that she was "the" no not "a" no. I don't know if her vote alone is what's caused more research into this. But it's probably the thing I brag about her the most. Even though everybody else said it was fine or abstained, she stood strong. If you look up the articles from the time of the panel (2017) you'll see a lot of articles about this panel and how she was the sole no vote. Included in that was a public post from Chuck Norris praising her. He was going to come out to meet us but I think it was a bad Texas hurricane season so that fell through
> Chuck and Gena Norris filed a lawsuit against several medical companies in 2017, alleging that a gadolinium-based contrast agent used in Gena Norris's MRIs caused her to develop a condition called gadolinium deposition disease and resulted in debilitating symptoms like cognitive issues, pain, and muscle wasting. In January 2020, the Norrises, along with their attorneys, voluntarily dismissed the lawsuit with prejudice, meaning it cannot be refiled. The dismissal was made without a settlement payment, and each party paid their own legal costs.
It might give a glimpse into his worldview to mention that during the COVID pandemic Mr Norris shared an article on social media that claimed that the COVID vaccinations killed millions of people. [0]
[0] https://m.facebook.com/story.php?story_fbid=870953857718632&...
People are told that the authorities have it all under control and the experts can be trusted. Then they discover that the experts are human, fallible, and sometimes incompetent or corrupt.
Since the original message was one of unqualified absolute faith in the experts, the backlash is to flip over to believing that the experts are satan incarnate and pure evil and always wrong.
It reminds me psychologically of the arc of an immature relationship. First they’re perfect, everything about them is perfect, they’re going to be your soul mate forever. Then you catch them in a lie or they do something embarrassing. Then you get the screaming breakup. Everything about them is the worst now and you never want to see them again.
Try
People are told that the authorities have it all under control and the experts can be trusted. Then they discover that the authorities and experts, in the name of “the greater good”, actively suppressed debate, knowingly mis-represented uncertainties, pretended reports of serious adverse reactions to vaccination were not only impossible but simply fear-mongering from the uneducated, and then pressured social-media platforms to take down factual information when it threatened the official narrative.
This without even touching on the fact that the WHO, who has one damned job, refused to even declare a pandemic and spoke against any travel restrictions or public health measures outside their lazy guidance until the virus was confirmed to be spreading out of control in nearly every nation on earth.
As long as that is true it seem naive to believe that nuanced institutions can exist as dominant entities in human societies.
Like somebody else mentioned, they swore up and down it's perfectly safe.
The reason these publications exist is that this is new knowledge
> Like somebody else mentioned, they swore up and down it's perfectly safe.
I am positive that you were not told that '[gadolinium] is perfectly safe' because there is a well-known complication of gadolinium administration. It's rare, but it's mentioned in every consent form.
Consent is not "Sign this cause its the only course of treatment". And thats what happens almost every time.
And yes, I too have gadolinium retention in my joint. 3 MRIs. And no, was not told this was a complication... But I'm sure the papers I signed included weasel words to that effect.
The presence of the gadolinium is not a complication. At best, it is an unintended side effect whose clinical significance is not known.
A complication is an unexpected/non-routine, negative outcome. We now have learned that the deposition is something to expect. There is no new information around clinical changes that one can attribute to gadolinium.
Making every future MRI worse is of large concern, especially if there are other nonmetallic contrasts.
I am sure this is true - and it also occurs in people who get braces, certain piercings, people who have had implants or (unfortunately) gun shots.
These aren't complications in any sense of the word.
https://www.frontiersin.org/journals/toxicology/articles/10....
The Cleveland Clinic has a good overview[1]. Since there have been no reports of NSF in 15 years, I don't think it's rational to avoid MRIs based on gadolinium retention concerns.
[1] https://www.ormanager.com/briefs/study-mri-contrast-agent-ca...
hereme888•6h ago
ToDougie•6h ago
hereme888•3h ago
"After ingestion, bismuth is primarily found in trace amounts within organs such as the kidney, liver, spleen, and, in rare cases, the brain, where it accumulates intracellularly—especially in lysosomes and nuclear membranes—and extracellularly in basement membranes of blood vessels.[1-4] In normal therapeutic use, the amount of tissue-bound bismuth is extremely low and is not associated with adverse effects. Potential consequences of tissue-bound bismuth are generally negligible at standard doses, but chronic or excessive exposure can lead to toxicity, most notably neurotoxicity (bismuth encephalopathy).[1][4-6] In cases of bismuth intoxication, histochemical studies have shown accumulation in neurons and glial cells, particularly in the cerebellum, thalamus, and hippocampus, with clinical manifestations including confusion, myoclonus, and encephalopathy.[1][4-6] However, these effects are reversible upon discontinuation of bismuth exposure, and recovery is typically complete within weeks.[5-6] Animal studies confirm that bismuth binds to proteins such as ferritin and metallothionein, and is retained in lysosomes, nuclear membranes, and myelin-associated proteins.[2][4][7] The kidney is the primary site of accumulation and excretion, and tissue levels decline after cessation of exposure, with little evidence of permanent retention at therapeutic doses.[2-3] In summary, permanent tissue binding of bismuth is minimal and clinically insignificant with standard use, but chronic high-dose exposure can result in neurotoxicity and other organ effects, which are reversible after stopping bismuth.[5-6][8-9]"
1. Autometallographic Tracing of Bismuth in Human Brain Autopsies. Stoltenberg M, Hogenhuis JA, Hauw JJ, Danscher G.
Journal of Neuropathology and Experimental Neurology. 2001;60(7):705-10. doi:10.1093/jnen/60.7.705.
2. Metallobiochemistry of Ultratrace Levels of Bismuth in the Rat II. Interaction of Bi With Tissue, Intracellular and Molecular Components. Sabbioni E, Groppi F, Di Gioacchino M, Petrarca C, Manenti S.
Journal of Trace Elements in Medicine and Biology : Organ of the Society for Minerals and Trace Elements (GMS). 2021;68:126752. doi:10.1016/j.jtemb.2021.126752.
3. Distribution of Bismuth in the Rat After Oral Dosing With Ranitidine Bismuth Citrate and Bismuth Subcitrate. Canena J, Reis J, Pinto AS, et al.
The Journal of Pharmacy and Pharmacology. 1998;50(3):279-83. doi:10.1111/j.2042-7158.1998.tb06861.x.
4. In Vivo Distribution of Bismuth in the Mouse Brain: Influence of Long-Term Survival and Intracranial Placement on the Uptake and Transport of Bismuth in Neuronal Tissue. Larsen A, Stoltenberg M, Søndergaard C, Bruhn M, Danscher G.
Basic & Clinical Pharmacology & Toxicology. 2005;97(3):188-96. doi:10.1111/j.1742-7843.2005.pto_973132.x.
5. Bismuth Encephalopathy- A Rare Complication of Long-Standing Use of Bismuth Subsalicylate. Borbinha C, Serrazina F, Salavisa M, Viana-Baptista M.
BMC Neurology. 2019;19(1):212. doi:10.1186/s12883-019-1437-9.
6. Bismuth Subgallate Toxicity in the Age of Online Supplement Use. Sampognaro P, Vo KT, Richie M, Blanc PD, Keenan K.
The Neurologist. 2017;22(6):237-240. doi:10.1097/NRL.0000000000000144.
7. Bismuth Tracing in Organotypic Cultures of Rat Hippocampus. Locht LJ, Munkøe L, Stoltenberg M.
Journal of Neuroscience Methods. 2002;115(1):77-83. doi:10.1016/s0165-0270(02)00004-3.
8. Bioactive Bismuth Compounds: Is Their Toxicity a Barrier to Therapeutic Use?. Gonçalves Â, Matias M, Salvador JAR, Silvestre S.
International Journal of Molecular Sciences. 2024;25(3):1600. doi:10.3390/ijms25031600.
9. Review Article: Safety of Bismuth in the Treatment of Gastrointestinal Diseases. Tillman LA, Drake FM, Dixon JS, Wood JR.
Alimentary Pharmacology & Therapeutics. 1996;10(4):459-67. doi:10.1046/j.1365-2036.1996.22163000.x.
DennisP•6h ago
> Lead author Dr Brent Wagner told Newsweek he personally avoids vitamin C when undergoing MRI with contrast, citing its potential to increase gadolinium reactivity. “Metabolic milieu,” including high oxalic acid levels, could explain why some individuals experience severe symptoms while others do not, he said.
Avoiding high-oxalic foods for a few days before the MRI also seems like a good idea. Just check the diet for calcium oxalate kidney stones.
Hemospectrum•4h ago
Tinnitus.
hereme888•3h ago