Adding fuel to the flames:
The German follow-up

Rinckside 2016; 27,1: 1-3.

ast December I wrote a detailed article about gadolinium-based con­trast agents [1]. It made the news in the United States and I got se­ve­ral requests for interviews.

I don't give interviews. One never knows how the final printed form will look like. Si­lence is golden.

   In Germany, there was a reaction from an unex­pected corner. I don't know if it was my article or the general uproar about contrast agents that made the German Society of Nuclear Medicine move. Al­though they are not involved in MRI, they jumped on the band­wagon and released a comment to the press in early February [2].

It's headlines and first paragraph read as follows:

“MRI contrast agents may remain in the brain. Nu­clear medicine physicians recommend alternative tests for the heart. – The metal gadolinium, a compo­nent of contrast agents for imaging diagnostics by magnetic resonance can accumulate in the brain after the examination. So far it is unclear whether the de­posits cause health problems. However, the Profes­sional Association of Ger­man Nuclear Physicians (BDN) recommends to employ the contrast agents at present only for unavoidable investigations. Accord­ing to the Asso­cia­tion, heart studies can also be per­formed by myocardial scintigraphy or ultrasound.”

The rest of the press release refers to the latest an­nouncements of the US-American Food and Drug Administration (FDA) concerning gadolinium agents and describes in detail radioisotope imaging of the heart.

Gadolinium is described as highly toxic – however, this is an argument like "electricity is deadly"; it always depends on how it's administered. The high toxicities of technetium and of thallium – both applied for myocardial scin­ti­gra­phy in nuclear medicine – were ignored. By the way, thallium competes with potassium in the body [3] and, at high dose, used to be a well-known rat poison.

The turf war between nu­clear medicine and radiology has returned with offi­cial backing and is up to new heights. A lot of money is at stake.

The Deutsche Roentgen Gesellschaft (German Roentgen Society, DRG) reacted slowly on the latest developments, playing their cards close to their chests [4]. They didn't want to hurt anybody, neither the German ra­dio­lo­gists, nor the manufacturers. Even not their patients. Unfortunately they missed the boat, because their brothers in nuclear medicine were faster: they smell new business.

The radiologists in Germany have had that business for more than 20 years. Germany has about 2,500 MR systems; 1,500 would be more than enough for the popu­lation of the country. The greater Berlin area is said to have the world's highest number of MR studies: Statistically 11% of the population get a scan per year, nearly half of them with contrast en­hance­ment. Even stubborn financial achievers among the MR entrepreneurs (including not only radiologists) admit that a high percentage of exa­mi­na­tions and contrast injections is of no clinical significance. Nuclear physicians know that too.

   However, the main point I want to make here concerns the outcome of the press release of the Association of Nuclear Physicians.

Hildegard Kaulen, a science correspondent from the Frank­fur­ter All­ge­mei­ne Zeitung (FAZ), considered a serious and reliable daily in Germany, and Anna Kröning, writing for Die Welt, a slightly yellower paper, took that release and reeled off two articles [5, 6].

Die Welt:“During MR examinations metal is deposited in the brain.”

Neither grammar nor facts are emphasized, and the statements of the pre­si­dent of the Nuclear Medicine Association, Dr. Detlef Moka, are stretched around two corners. Admittedly, Moka's generalizing remarks about ga­do­li­nium contrast agents were off the scientific grounds and quite daring; but the processed articles in the two dailies mixed facts and opinion in a simplistic way and made sweeping judgments: bad news is good news.

Frankfurter Allgemeine Zeitung: “Magnetic resonance therapy contrast agents dangerous for the brain?”

Even worse, Frau Kaulen tarted up and re-published her article a month after the printed version as an e-version [7]. Headline and first paragraph now read like this:

"Magnetic resonance therapy contrast agents dangerous for the brain? – The contrast agent gadolinium used in magnetic resonance therapy (MRT) was believed to be harmless although it is toxic. There is now protest against its frequent use."

MRI's acronym in German is MRT: magnetic resonance tomography; but that definitely doesn't mean "MR therapy". It's not used for treatment, but it's a diagnostic tool.

Frau Kaulen describes gadolinium as a "contrast agent", it's not – it's an element; she also postulates that gadolinium is taken up and stored in the kidneys. Again, that's her invention. Writing science articles for a newspaper is a difficult task; being simple without being wrong requires talent and a lot of practice ... as well as having sufficient time to research and polish an art­icle. Usually journalists are under time pressure. This might be an excuse for the rather garbled accounts.

Nobody mentions that there are several groups of gadolinium-based con­trast agents, cyclic and linear, as well as those excreted by the kidneys only and those ex­creted by both kidneys and liver. There are safe and unsafe con­trast agents and procedures – not only a single defective and wrongly applied compound call­ed "gadolinium".

Inaccuracies – by mistake, by ignorance, or for personal or political rea­sons – are human. For years I read in both papers mentioned here state­ments like Calais being a Central European city and Budapest being a place in East Europe. Geography is not a strong side of journalists. History is a rather "rubbery" subject too.

Not only on the editorial pages are facts often fiction, and opinions offered as facts, but also on the front pages. Somewhere one has to draw conclusions from contorted and misconstrued articles and finally to draw a line.

During the last decades I have learned that I cannot trust publications I read in Nature or, in the case of medical imaging, Radiology or any other "high class" science or medicine journals; that one cannot believe dailies and news magazines; and that Wikipedia articles are deeply suspect and not cit­able. Still, I had some respect for the science section of certain newspapers and scientific magazines. FAZ had a famous science editor, Rainer Flöhl. He could compete with British and US-American science editors. He died re­cent­ly. When he retired some years ago, it was the end of an epoch in German journalism.

   A tip for science journalists: Always use two inde­pendent sources to check the facts; don't rehash press releases on which you lack the background, and don't add random unconnected information. It shouldn't be “all the free press releases we get we'll print”.

   A tip for press releases: Think twice before you make oafish statements. Remember: Silence is golden.

However, the damage is done. Meanwhile patients get uneasy and scared (“I had four MRIs – am I gadolinium toxic now?”). Even if you know that some journalists are irresponsible and completely unreliable: the doubt, the fear remains. Spreading fear is intentional – it attracts readers. Yet, the for­mer­ly good reputation of a "quality" newspaper has suffered severely.

By the way, MR contrast agents applied according to the recommendations are still safer than x-ray contrast agents and radioisotope tracers – not vice versa.

References

1. Rinck PA. Gadolinium – will anybody learn from the debacle? Rinckside 2015; 26,9: 23-26.
2. BDN – Berufsverband deutscher Nuklearmediziner. MRT-Kontrastmittel kann im Gehirn zurückbleiben; Nuklearmediziner empfehlen alternative Untersuchungen fürs Herz. Berlin. 5 February 2016. www.bdn-online.de.
3. Rinck PA, Beckmann HO. New aspects of the uptake of thallous ion into myocardial tissue. Eur J Radiol. 1981; 1: 173-177.
4. DRG – Deutsche Röntgengesellschaft. Vorwerk D. Gadoliniumhaltige Kontrastmittel in der Magnetresonanztomographie. Berlin. 15 February 2016. www.drg.de.
5. Kaulen H. Kontrastmittel für das Hirn gefährlich? Frankfurter Allgemeine Zeitung. 17 February 2016. Page N1.
6. Kröning A. Beim MRT lagert sich Metall im Gehirn ab. Die Welt. 8 February 2016.
7. Kaulen H. Kontrastmittel für das Hirn gefährlich? Frankfurter Allgemeine Zeitung | FAZ NET. 18 March 2016.

Citation: Rinck PA. Adding fuel to the flames:Gadolinium – the German follow-up. Rinckside 2016; 27,1: 1-3.

A digest version of this column was published as:
Rinck PA. Gadolinium: row intensifies in Germany
Aunt Minnie Europe. Maverinck. 22 March 2016.