User talk:LacedWithSilver

MR Neurography
Hey, thanks so much for pointing out the lack of neutral point of view in the MR Neurography page, that's a serious problem. I actually don't even remember reviewing it, or at least I have only the vaguest sliver of memory of it. I have been very busy in real life and have had no time for Wikipedia lately. Would you mind adding at least a sentence or two to the article to reflect the facts you mentioned? If you can include the references you mentioned that would be most excellent. (I might be able to get the full text, if you could email me using the email this user feature I can try.) Anyway, thanks again for helping keep the article neutral, wish I had more time to help out. But definitely let me know if you need help or advice or anything. I'm easier to reach through email these days. Peace, delldot   &nabla;.  04:27, 2 March 2011 (UTC)

MR Neurography
Thanks for your interest in this page. In 2008 this issue was addressed in considerable detail by several editors. There is a difference between - on the one hand - the value of NPOV and conflict of interest and - on the other hand - a policy by an encyclopedia to attack, stigmatize and delete any expert writing about a subject in which that person is an expert. A professor gets paid for teaching. Writers earn money for books. This gets very challenging as we move into progressively more technical subject areas. One view of an inventor is as someone who cannot be trusted for information. Another view is that this is an intelligent and creative person with a passionate interest in helping or serving a community. An invention is an enormous commitment many years of research hundreds of hours of legal wrangling with the patent office, denial of care for patients on vague and indefinite "experimental" determinations. This can represent a commitment - as in this case - to people who have nerve related disorders that are difficult to diagnose and treat.

I don't think Wikipedia has a policy of posting all of the different health care reimbursement policies for all of the different insurers for all different plans on each clinically relevant Wikipedia page. The article made clear that there was an issue of experimental determinations for reimbursement. Aetna actually classifies all of MRI as experimental because it says that no one ever did a study where, for instance, we randomly assign 50,000 people to have brain surgery without an MRI beforehand and 50,000 to brain surgery with MRI for diagnosis before surgery and then see if the use of MRI improves the surgical outcomes when the two groups are compared. The coverage of this issue was fair and balanced, adding long quotes from one insurers "experimental use" website seems to be an overboard biased attack on the procedure and is the opposite of a neutral point of view.

As I have pointed out previously, the problem arises when you have anonymous writers (as most Wikipedia writers are) and these anonymous writers don't declare a potential conflict. I am in no way anonymous here. I sign my posts. I have a user page that clearly defines who I am and has a conflict of interest statement. In academia, we understand that academics get promoted based on publication and success in their fields. Therefore everything produced in academics incorporates a conflict of interest. Some conflicts are considered obvious - such as the publish to get promoted issues - others are not obvious and must be declared - such as financial interests that may appear to affect statements or which actually affect statements. Rather than banning all individuals with conflicts (which would ban all academics from writing or publishing) we simply don't allow anonymity and insist on the declaration of non-obvious conflicts. I don't think your review identified any significant issues with point of view in this article. However, your attention is greatly appreciated. Nonetheless, there are plenty of individuals with a motive to attack or confront the technology - are they a defendant in a patent infringement lawsuit? Do they have a billing dispute with some medical provider and a personal ax to grind. Are they affiliated with an insurance company and desire to scare patients away from well documented treatments? How do you find this out from an anonymous tipster? Why must they be anonymous - what are they hiding? MR Neurography was first published in 1993 in the Lancet. Neurography and DTI - from the same patent - are now the subject of more than 6,000 peer reviewed publications including numerous large scale outcome trials. So when an insurer - who makes money by denying treatment to their client patients - states that there is no research - do you fact check them or do you quote them as an unbiased source verbatim into a Wikipedia article?

The myth/falacy article referred to is not a review of neurography. The late Dr. Tiel and I did a number of public debates at major neurosurgery meetings about the existence of piriformis syndrome. Dr. Tiel is greatly missed and I agree that those debates were very helpful. However, Wikipedia is not a debating society. The article meets high standards for Wikipedia by citing numerous peer reviewed studies by numerous different groups including a recent publication in the New England Journal of Medicine - the premier journal in medicine along with Lancet -both of which covered neurography. Although there are more than 6,000 peer reviewed articles covering DTI and neurography, there is not one single article that has ever reported any formal evaluation revealing a negative aspect or problem with the clinical validity of the technique. It is basically a higher resolution MRI that is optimized to show nerve in greatly improved detail. You would have to ask patients to knowingly volunteer to be treated with a lower quality standard MRI which is acknowlededged by the insurers to not show nerve very well or to be operated on with no imaging at all or be randomized to have a high resolution MR Neurography imaging before surgery. Dr. Tiel expressed some personal opinions -  he was an old fashioned doctor who never used imaging in his surgical planning and didn't feel he should start now. That is not a reasonable counterpoint to 6,000 formal peer reviewed publications. In the Wikipedia article I did include a discussion of possible drawbacks and concerns nonetheless.

It all comes down to whether Wikipedia wishes to ban anyone with a patent or an academic publication from contributing to Wikipedia. The NPOV/COI attack can be leveled at all of them. You just have to look for citation from multiple sources, full disclosure of authorship and open statements of conflicts all of which I have done. For anonymous non-academic contributors we need a statement of "pure" hobby interest, or we need to know why they want to write on a particular subject. in the end and NPOV or COI assessment has to flow from the content of the article from inflammatory hints about what might be wrong with the author. Afiller —Preceding undated comment added 07:17, 25 March 2011 (UTC).

Partial reimbursment
Laced with silver - I thought that most insurance payments involve deductibles, percentages of usual and customary, or copays. Do you mean to suggest that most procedures are reimbursed in full but that only MR Neurography gets "partial" reimbursement. Do you have references to support this? Should that be discussed on a Wikipedia page about health insurance reimbursement or is it a technical encyclopedia matter about MR Neurography that has no available literature reference. Are you really "neutral" in your point of view?. Can you reveal who you are and what your own biases and conflicts of interest might be? Why do you post anonymously? Have you gone through all the medical information pages on Wikipedia to assess the reimbursement status for each or do you just have a personal issue with this one service? Afiller (talk) 20:11, 25 March 2011 (UTC)

Could you please clarify a few things:

Provide reference to even one professional society or insurance company that considers magnetic resonance neurography to be the standard of care for diagnosing peripheral nerve disorders. I did search extensively and found ten major insurers who all list the procedure as experimental and not-medically necessary. I was unable to locate any insurance company or professional society that considers neurography to be anything other than experimental. There are new papers - Nu et al. 2010, and a couple others that could be added. Perhaps I will.

Please be polite and professional. I'm a new guy here, and I am following the wikipedia guidelines and protocols. Yes, I have a lot to learn, but I have a lot to contribute and can make a difference on the variety of topics. I have no conflict of interest.

Thanks - Silver

More use in the field
Silver, although you may complain that I wrote chapters for Schmidek and Sweet - the major operative neurosurgery textbook and am the section editor for Youman's Neurological surgery our principal textbook. In the new editions - coming out this year - of both textbooks, there is a chapter on MR Neurography. In the previous edition of Youman's (which I had nothing to do with) there was also a chapter on MR Neurography. There are now MR Neurography chapters in many other recent Radiology textbooks. Every other year I am invited to teach a course on MR Neurography interpretation at the annual meeting of the American Society for Peripheral Nerve. I have also been invited to give similar hour long teaching sessions - which I have done at the annual meeting of the American Association of Neurological Surgery and the annual meeting of the Congress of Neurological Surgery - the two major professional societies in this field. I did a similar invited lecture and the annual meeting of the American Society for Spine Radiology. In addition Dr. Ken Maravilla has taught a course on MR Neurography interpretation every year for the past twelve years at the annual meeting of the Radiological Society of North America - the premier society in this field. Dr. Robert Spinner taught a course on MR Neurography at the annual meeting of the International Society for Magnetic Resonance in Medicine. I don't think medical societies provide some sort of listing of what techniques in imaging or surgery are listed as "experimental." You can look through the program of these major meetings on line. I can certainly come back with a fully referenced paragraph - however, one gets attacked on Wikipedia in an article like this if you are not referencing peer reviewed publications. In Medicine, we rely on the quality of peer reviewed medical literature to decide what is useful or not. Insurance companies are in the business of denying payment to improve profits. It is fair to say that an insurance company considers a procedure experimental, but it is not fair to say that physicians or medical societies hold that position on a formal basis. Medicare considers MR Neurography to be a useful technique and does not classify it as experimental. A reimbursement request for MR Neurography sent to Medicare will get paid if it is offered by a Medicare enrolled provider. Any provider doing MR Neurography who simply bills it as a soft tissue MRI will find that it is reimbursed, but there is always a possibility that the insurance carrier will complain later that it was a class of MRI they do not approve. The Neurography Institute, Johns Hopkins, UCLA, UCSF, Mayo and University of Washington will typically describe these as MR Neurography imaging studies in order to be upfront from the start.So if all the major societies in Neurosurgery and Radiology are doing regular annual professional technical courses in this subject and the textbooks all cover it, I think that it can be said that it is not viewed as a potential or experimental technique by most specialist physicians

Here is a reference from Siemens (see page 26): http://www.medical.siemens.com/siemens/en_GLOBAL/rg_marcom_FBAs/files/apps/magazine/magnetom_flash/RSNA_2010/ The doctors from Hopkins conclude their article by saying: In summary, the 3D-PSIF sequence with high spatial resolution and high contrast provides reliable and objective identification of peripheral nerve anatomy and may be incorporated as part of the high-resolution MR study of peripheral nerves, whenever accurate nerve localization and/or pre-surgical evaluation are required.

Here is a link for the ISMRM meeting: http://www.ismrm.org/06/clinicalmri3(%2706).htm

Here is a recent overview from NYU that flatly states that MR Neurography is the clinical method of choice in the abstract: http://radiographics.rsna.org/content/30/4/983.abstract

Here is a link for the 2008 RSNA meeting: http://rsna2008.rsna.org/event_display.cfm?em_id=7002489

It is a keynote (major presentation) talk at the RSNA meeting in front of thousands of radiologists and they say: CTS MR was really the birthplace of neurography which is becoming a standard part of most skeletal imaging practices.

The position of the insurance companies on this is more or less fraud in my opinion since they call it experimental and don't pay even though all the major medical centers, society annual meetings, and textbooks consider it standard based on 20 years of extensive research. Afiller (talk) 06:02, 30 March 2011 (UTC)

Talk:Magnetic resonance neurography
Hey, I left a note on the talk page of MR Neurography. I'm going to wait to see what Afiller's response is, then figure out what to do from there. Thanks for being willing to work on the page. Peace,  delldot   &nabla;.  17:35, 29 March 2011 (UTC)

AFiller Magnetic Resonance Neurography
Your change in tone is much appreciated as is the detailed and well-researched information you provided. It presents a much clearer view of the acceptance of this novel technology. Given your potential conflict of interest as the sole license holder of the 360 patent for neurography and your current patent lawsuit(s?) against other users of the technology, I believe it is important that you present this topic on Wikipedia with a neutral point of view. Many of my edits reset the tone to neutrality, by eliminating the unnecessarily biased adjectives and overstatements of fact.

I believe the page can be improved, and your point strengthened by including new published research findings. This would include discussion of the work of Nu et al. 2010 who found that neurography of peripheral nerves was most useful in trauma cases if imaging was conducted within 12 months of injury. They also state that neurography's utility is dependent upon the size of the nerve, as do Chhabra et al., who detail the use of 3T MR technology and whereas you stated that can visualize any named nerve in the body with 1.5T neurography techniques. Hopefully someday the technology can do so, but is it accurate and neutral to state it as you have?

I don't wish to debate you, because you are correct in stating that Wikipedia is not a place for debate. But some inconsistencies remain in your statements that can be misinterpreted bias. I request clarification.

First, I do not "complain" that you wrote chapters in neurosurgery textbooks and that language is inappropriate. The textbook information is useful and I suggest it be stated neutrally but not overstated - e.g., "Neurography has recently been added to neurosurgical curriculum, major neurosurgery textbooks now contain chapters on neurography" - or something like that, with the textbook chapters cited. I can do that if you agree and would prefer.

You link the 2008 RSNA meeting: http://rsna2008.rsna.org/event_display.cfm?em_id=7002489 and state that Dr. Mark Schwitzer's keynote says: CTS MR was really the birthplace of neurography which is becoming a standard part of most skeletal imaging practices.

Dr. Mark Schweitzer actually states that neurography is becoming a standard part of most skeletal imaging practices, which indicates that it is not standard yet, and it remains novel at this time.

The work of Chhabra et al. of Johns Hopkins which you provided contradicts your statement that "Magnetic resonance neurography can only be performed in 1.5 tesla cylindrical type scanners."

You state: "Here is a recent overview from NYU that flatly states that MR Neurography is the clinical method of choice in the abstract: http://radiographics.rsna.org/content/30/4/983.abstract

The abstract does not say that. It says: Today, cross-sectional imaging, particularly magnetic resonance (MR) imaging and specifically MR neurography, 'plays an increasingly important role in the work-up of entrapment neuropathies. Per Wikipedia's verifiability tenent, "Class A methodology" requires a cited reference. It is unclear whether this a documented study design protocol (I surmise that it is), or a subjective description. A citation is needed or the reference should be deleted. This edit should not be reversed without explanation or citation.

I agree about the criminality of health insurance coverage. I have first-hand experience with fighting for what was considered novel treatment, which is now the standard of care for that particular diagnosis.

There is a page for U. S. Healthcare. Perhaps that will be my next wikipedia contribution.

Respectfully - Silver LacedWithSilver 22:07, 1 April 2011 (UTC)