Design, analysis and simulation for development of the first clinical micro-CT scanner

Clinical Micro-CT Empowered by Interior Tomography, Robotic Scanning, and Deep Learning

While micro-CT systems are instrumental in preclinical research, clinical micro-CT imaging has long been desired with cochlear implantation as a primary application. The structural details of the cochlear implant and the temporal bone require a significantly higher image resolution than that (about 0.2 mm) provided by current medical CT scanners. In this paper, we propose a clinical micro-CT (CMCT) system design integrating conventional spiral cone-beam CT, contemporary interior tomography, deep learning techniques, and the technologies of a micro-focus X-ray source, a photon-counting detector (PCD), and robotic arms for ultrahigh-resolution localized tomography of a freely-selected volume of interest (VOI) at a minimized radiation dose level. The whole system consists of a standard CT scanner for a clinical CT exam and VOI specification, and a robotic micro-CT scanner for a local scan of high spatial and spectral resolution at minimized radiation dose. The prior information from the global scan is also fully utilized for background compensation of the local scan data for accurate and stable VOI reconstruction. Our results and analysis show that the proposed hybrid reconstruction algorithm delivers accurate high-resolution local reconstruction, and is insensitive to the misalignment of the isocenter position, initial view angle and scale mismatch in the data/image registration. These findings demonstrate the feasibility of our system design. We envision that deep learning techniques can be leveraged for optimized imaging performance. With high-resolution imaging, high dose efficiency and low system cost synergistically, our proposed CMCT system has great promise in temporal bone imaging as well as various other clinical applications.

Cochlear implant phantom for evaluating computed tomography acquisition parameters

Cochlear implants (CIs) are surgically implantable neuroprosthetic devices used to treat profound hearing loss. Recent literature indicates that there is a correlation between the final intracochlear positioning of the CI electrode arrays and the ultimate hearing outcome of the patient, indicating that further studies to better understand the relationship between electrode position and outcomes could have significant implications for future surgical techniques, array design, and processor programming methods. Postimplantation high-resolution computed tomography (CT) imaging is the best modality for localizing electrodes and provides the resolution necessary to visually identify electrode position, although with an unknown degree of accuracy depending on image acquisition parameters, like the hounsfield unit (HU) range of reconstruction, orientation, radiation dose, and image resolution. We report on the development of a phantom and on its use to study how four acquisition parameters, including image resolution and HU range of reconstruction, affect how accurately the true position of the electrodes can be found in a dataset of CT scans acquired from multiple helical and cone beam scanners. We also show how the phantom can be used to evaluate the effect of acquisition parameters on automatic electrode localization techniques.

Contemporary imaging of auditory implants

There have been significant advances in the diversity and effectiveness of hearing technologies in recent years. Implanted auditory devices may be divided into those that stimulate the cochlear hair cells (bone conduction devices and middle ear implants), and those that stimulate the neural structures (cochlear implants and central auditory implants). Contemporary preoperative and postoperative imaging may be used to help individualise implant selection, optimise surgical technique and predict auditory outcome. This review will introduce the concepts behind auditory implants, and explains how imaging is increasingly used to aid insertion and evaluation of these devices.

Enhanced repair of segmental bone defects in rabbit radius by porous tantalum scaffolds modified with the RGD peptide

Fast and stable repair of segmental bone defects remains a challenge for clinical orthopedic surgery. In recent years, porous tantalum has been widely applied in clinical orthopedics for low modulus of elasticity, with three-dimensional microstructures similar to cancellous bone and excellent biocompatibility. To further improve bone the repairing ability of porous tantalum, the cyclo(-RGDfK-) peptide was coated on the surface of porous tantalum scaffolds. A model of 15 mm segmental defect was made at the midshaft of right radius in New Zealand White rabbits. In the experimental group, defects were implanted (press-fit) using porous tantalum scaffolds modified with cyclo(-RGDfK-) peptide. Control animals were implanted with non-modified porous tantalum scaffolds or xenogeneic cancellous bone scaffolds, respectively. No implant was provided for the blank group. Bone repair was assessed by X-ray and histological observations at 4, 8, and 16 weeks post-operation, with biomechanical tests and micro-computed tomography performed at 16 weeks post-surgery. The results showed that bone formation was increased at the interface and inside the inner pores of modified porous tantalum scaffolds than those of non-modified porous tantalum scaffolds; biomechanical properties in the modified porous tantalum group were superior to those of the non-modified porous tantalum and xenogeneic cancellous bone groups, while new bone volume fractions using micro-computed tomography analysis were similar between the modified porous tantalum and xenogeneic cancellous bone groups. Our findings suggested that modified porous tantalum scaffolds had enhanced repairing ability in segmental bone defect in rabbit radius, and may serve as a potential material for repairing large bone defects.

High-Resolution Methods for Diagnosing Cartilage Damage In Vivo

Advances in current clinical modalities, including magnetic resonance imaging and computed tomography, allow for earlier diagnoses of cartilage damage that could mitigate progression to osteoarthritis. However, current imaging modalities do not detect submicrometer damage. Developments in in vivo or arthroscopic techniques, including optical coherence tomography, ultrasonography, bioelectricity including streaming potential measurement, noninvasive electroarthrography, and multiphoton microscopy can detect damage at an earlier time point, but they are limited by a lack of penetration and the ability to assess an entire joint. This article reviews current advancements in clinical and developing modalities that can aid in the early diagnosis of cartilage injury and facilitate studies of interventional therapeutics.

X-ray CT geometrical calibration via locally linear embedding

For X-ray computed tomography (CT), geometric calibration and rigid patient motion compensation are inter-related issues for optimization of image reconstruction quality. Non-calibrated system geometry and patient movement during a CT scan will result in streak-like, blurring and other artifacts in reconstructed images. In this paper, we propose a locally linear embedding based calibration approach to address this challenge under a rigid 2D object assumption and a more general way than what has been reported before. In this method, projections are linearly represented by up-sampled neighbors via locally linear embedding, and CT system parameters are iteratively estimated from projection data themselves. Numerical and experimental studies show that images reconstructed with calibrated parameters are in excellent agreement with the counterparts reconstructed with the true parameters.

Microarchitectural and mechanical characterization of the sickle bone

Individuals with sickle cell disease often experience acute and chronic bone pain due to occlusive events within the tissue vasculature that result in ischemia, necrosis, and organ degeneration. Macroscopically, sickle bone is identified in clinical radiographs by its reduced mineral density, widening of the marrow cavity, and thinning of the cortical bone due to the elevated erythroid hyperplasia accompanying the disease. However, the microstructural architecture of sickle bone and its role in mechanical functionality is largely unknown. This study utilized micro-CT and biomechanical testing to determine the relationship between the bone morphology, tissue mineral density, and trabecular and cortical microarchitecture of 10- and 21-week-old femurs from transgenic sickle male mice and littermates with sickle trait, as well as a wild-type control. While bone tissue mineral density did not vary among the genotypes at either age, variation in bone microstructure were observed. At 10 weeks, healthy and trait mice exhibited similar morphology within the cortical and trabecular bone, while sickle mice exhibited highly connected trabeculae. Within older femurs, sickle and trait specimens displayed significantly fewer trabeculae, and the remaining trabeculae had a more deteriorated geometry based on the structure model index. Thinning of the cortical region in sickle femurs contributed to the displayed flexibility with a significantly lower elastic modulus than the controls at both 10- and 21-weeks old. Wild-type and trait femurs generally demonstrated similar mechanical properties; however, trait femurs had a significantly higher modulus than sickle and wild-type control at 21-weeks. Overall, these data indicate that the progressive damage to the microvasculature caused by sickle cell disease, results in deleterious structural changes in the bone tissue׳s microarchitecture and mechanics.

Monte Carlo-based assessment of the trade-off between spatial resolution, field-of-view and scattered radiation in the variable resolution X-ray CT scanner

OBJECTIVE

The purpose of this work is to evaluate the impact of optimization of magnification on performance parameters of the variable resolution X-ray (VRX) CT scanner.

METHODS

A realistic model based on an actual VRX CT scanner was implemented in the GATE Monte Carlo simulation platform. To evaluate the influence of system magnification, spatial resolution, field-of-view (FOV) and scatter-to-primary ratio of the scanner were estimated for both fixed and optimum object magnification at each detector rotation angle. Comparison and inference between these performance parameters were performed angle by angle to determine appropriate object position at each opening half angle.

RESULTS

Optimization of magnification resulted in a trade-off between spatial resolution and FOV of the scanner at opening half angles of 90°-12°, where the spatial resolution increased up to 50% and the scatter-to-primary ratio decreased from 4.8% to 3.8% at a detector angle of about 90° for the same FOV and X-ray energy spectrum. The disadvantage of magnification optimization at these angles is the significant reduction of the FOV (up to 50%). Moreover, magnification optimization was definitely beneficial for opening half angles below 12° improving the spatial resolution from 7.5 cy/mm to 20 cy/mm. Meanwhile, the FOV increased by more than 50% at these angles.

CONCLUSION

It can be concluded that optimization of magnification is essential for opening half angles below 12°. For opening half angles between 90° and 12°, the VRX CT scanner magnification should be set according to the desired spatial resolution and FOV.

A comparative study of diagnostic and imaging techniques for osteoarthritis of the trapezium

OBJECTIVES

The aims of this study were to determine whether micro-CT is a reliable investigation method to evaluate the severity of OA in the trapezium and to develop a novel micro-CT scoring system based on a quantitative assessment of the subchondral bone thickness in order to better assess OA through an objective parameter.

METHODS

We compared different diagnostic and imaging techniques performed consecutively on each sample: X-ray, visual analysis, micro-CT and histology. OA and healthy trapezia were subjected to semi-quantitative and quantitative analyses to be classified in four degrees of severity in OA (control, OA-2, OA-3 and OA-4). Specifically, samples were analysed using Dell's score for X-ray, Brown's score for visual analysis and Mankin's score for histology. Micro-CT was scored using a novel quantitative scoring system based on subchondral bone thickness measurements. Results obtained with each technique were then compared and correlated.

RESULTS

X-ray analysis showed a higher frequency of OA-2 (27%) and OA-3 (32%) compared with OA-4 (5%), whereas visual analysis, micro-CT and histology showed a lower percentage for OA-2 (18%, 18% and 14%) and OA-3 (23%) and increased frequency for OA-4 (45%, 32% and 40%). Only the micro-CT score of subchondral bone thickness correlated significantly with all the other techniques (P < 0.05).

CONCLUSION

This is the first comparison of techniques proposing a novel scoring system based on objective and quantitative micro-CT data that can be applied as a useful diagnostic tool for OA, providing a deeper comprehension of the pathophysiology of OA in trapezium.

The meaning of interior tomography

The classic imaging geometry for computed tomography is for the collection of un-truncated projections and the reconstruction of a global image, with the Fourier transform as the theoretical foundation that is intrinsically non-local. Recently, interior tomography research has led to theoretically exact relationships between localities in the projection and image spaces and practically promising reconstruction algorithms. Initially, interior tomography was developed for x-ray computed tomography. Then, it was elevated to have the status of a general imaging principle. Finally, a novel framework known as 'omni-tomography' is being developed for a grand fusion of multiple imaging modalities, allowing tomographic synchrony of diversified features.

Novel detector design for reducing intercell x-ray cross-talk in the variable resolution x-ray CT scanner: a Monte Carlo study

PURPOSE

The variable resolution x-ray (VRX) CT scanner provides substantial improvement in the spatial resolution by matching the scanner's field of view (FOV) to the size of the object being imaged. Intercell x-ray cross-talk is one of the most important factors limiting the spatial resolution of the VRX detector. In this work, a new cell arrangement in the VRX detector is suggested to decrease the intercell x-ray cross-talk. The idea is to orient the detector cells toward the opening end of the detector.

METHODS

Monte Carlo simulations were used for performance assessment of the oriented cell detector design. Previously published design parameters and simulation results of x-ray cross-talk for the VRX detector were used for model validation using the GATE Monte Carlo package. In the first step, the intercell x-ray cross-talk of the actual VRX detector model was calculated as a function of the FOV. The obtained results indicated an optimum cell orientation angle of 28 degrees to minimize the x-ray cross-talk in the VRX detector. Thereafter, the intercell x-ray cross-talk in the oriented cell detector was modeled and quantified.

RESULTS

The intercell x-ray cross-talk in the actual detector model was considerably high, reaching up to 12% at FOVs from 24 to 38 cm. The x-ray cross-talk in the oriented cell detector was less than 5% for all possible FOVs, except 40 cm (maximum FOV). The oriented cell detector could provide considerable decrease in the intercell x-ray cross-talk for the VRX detector, thus leading to significant improvement in the spatial resolution and reduction in the spatial resolution nonuniformity across the detector length.

CONCLUSIONS

The proposed oriented cell detector is the first dedicated detector design for the VRX CT scanners. Application of this concept to multislice and flat-panel VRX detectors would also result in higher spatial resolution.

Fast exact/quasi-exact FBP algorithms for triple-source helical cone-beam CT

Cardiac computed tomography (CT) has been improved over past years, but it still needs improvement for higher temporal resolution in the cases of high or irregular cardiac rates. Given successful applications of dual-source cardiac CT scanners, triple-source cone-beam CT seems a promising mode for cardiac CT. In this paper, we propose two filtered-backprojection algorithms for triple-source helical cone-beam CT. The first algorithm utilizes two families of filtering lines. These lines are parallel to the tangent of the scanning trajectory and the so-called L lines. The second algorithm utilizes two families of filtering lines tangent to the boundaries of the Zhao window and L lines, respectively, but it eliminates the filtering paths along the tangent of the scanning trajectory, thus reducing the required detector size greatly. The first algorithm is theoretically exact for r < 0.265R and quasi-exact for 0.265R <or= r < 0.495R, and the second algorithm is quasi-exact for r < 0.495R , where r and R denote the object radius and the trajectory radius, respectively. Both algorithms are computationally efficient. Numerical results are presented to verify and showcase the proposed algorithms.

A scheme for multisource interior tomography

Currently, x-ray computed tomography (CT) requires source scanning so that projections can be collected from various orientations for image reconstruction. Limited by the scanning time, the temporal resolution of CT is often inadequate when rapid dynamics is involved in an object to be reconstructed. To meet this challenge, here the authors propose a scheme of multisource interior tomography for ultrafast imaging that reconstructs a relatively small region of interest (ROI). Specifically, such a ROI is irradiated in parallel with narrow x-ray beams defined by many source-detector pairs for data acquisition. This ROI can be then reconstructed using the interior tomography approach. To demonstrate the merits of this approach, the authors report interior reconstruction from in vivo lung CT data at a much reduced radiation dose, which is roughly proportional to the ROI size. The results suggest a scheme for ultrafast tomography (such as with a limited number of sources and in a scanning mode) to shorten data acquisition time and to suppress motion blurring.

Self-calibration of a cone-beam micro-CT system

Use of cone-beam computed tomography (CBCT) is becoming more frequent. For proper reconstruction, the geometry of the CBCT systems must be known. While the system can be designed to reduce errors in the geometry, calibration measurements must still be performed and corrections applied. Investigators have proposed techniques using calibration objects for system calibration. In this study, the authors present methods to calibrate a rotary-stage CB micro-CT (CBmicroCT) system using only the images acquired of the object to be reconstructed, i.e., without the use of calibration objects. Projection images are acquired using a CBmicrouCT system constructed in the authors' laboratories. Dark- and flat-field corrections are performed. Exposure variations are detected and quantifled using analysis of image regions with an unobstructed view of the x-ray source. Translations that occur during the acquisition in the horizontal direction are detected, quantified, and corrected based on sinogram analysis. The axis of rotation is determined using registration of antiposed projection images. These techniques were evaluated using data obtained with calibration objects and phantoms. The physical geometric axis of rotation is determined and aligned with the rotational axis (assumed to be the center of the detector plane) used in the reconstruction process. The parameters describing this axis agree to within 0.1 mm and 0.3 deg with those determined using other techniques. Blurring due to residual calibration errors has a point-spread function in the reconstructed planes with a full-width-at-half-maximum of less than 125 microm in a tangential direction and essentially zero in the radial direction for the rotating object. The authors have used this approach on over 100 acquisitions over the past 2 years and have regularly obtained high-quality reconstructions, i.e., without artifacts and no detectable blurring of the reconstructed objects. This self-calibrating approach not only obviates calibration runs, but it also provides quality control data for each data set.

Visualization of Reissner membrane and the spiral ganglion in human fetal cochlea by micro-computed tomography

PURPOSE

Although visualization of fine structures in the cochlea such as Reissner membrane (vestibular membrane) is important for elucidation of the mechanism and the establishment of therapy for inner ear diseases, they cannot be visualized by even the most advanced high-resolution medical computed tomography (CT) and magnetic resonance imaging. Visualization of Reissner membrane in dissected animals by micro-magnetic resonance imaging has been reported, but bone could not be visualized. We attempted to visualize human fetal Reissner membrane and the spiral ganglion by micro-focus x-ray CT (micro-CT), which has a spatial resolution several hundred times greater than the conventional medical CT.

MATERIALS AND METHODS

Serial tomograms of a dissected pyramis, including the cochlea of human fetuses (stillborn specimens), were obtained by micro-CT, and 3-dimensional reconstruction was performed by a volume-rendering method.

RESULTS

Clear tomograms (theoretical spatial resolution, 12.2 x 12.2 microm; slice thickness 77.5 microm) and 3-dimensional reconstructed images (theoretical spatial resolution, 6.8 x 6.8 microm; slice thickness, 40.0 microm) of Reissner membrane and the spiral ganglion with a bony labyrinth (cochlear bone) were successfully obtained for the first time. The thickness of Reissner membrane obtained by the tomogram was 12 microm, which corresponds to the optical macroscopic value from resin-embedded histologic sections.

CONCLUSIONS

This study showed that micro-CT enables us to visualize the internal fine structure of the human cochlea. As the success rate of the visualization of Reissner membrane is not high, it is necessary to improve the image quality and contrast resolution of micro-CT to enable stable visualization of fine structures. The development of imaging equipment such as micro-CT for medical use should play an important role in the elucidation of the mechanism and the establishment of therapy for inner ear diseases.

An outlook on x-ray CT research and development

Over the past decade, computed tomography (CT) theory, techniques and applications have undergone a rapid development. Since CT is so practical and useful, undoubtedly CT technology will continue advancing biomedical and non-biomedical applications. In this outlook article, we share our opinions on the research and development in this field, emphasizing 12 topics we expect to be critical in the next decade: analytic reconstruction, iterative reconstruction, local/interior reconstruction, flat-panel based CT, dual-source CT, multi-source CT, novel scanning modes, energy-sensitive CT, nano-CT, artifact reduction, modality fusion, and phase-contrast CT. We also sketch several representative biomedical applications.

Digital tomosynthesis aided by low-resolution exact computed tomography

Tomosynthesis reconstructs 3-dimensional images of an object from a significantly fewer number of projections as compared with that required by computed tomography (CT). A major problem with tomosynthesis is image artifacts associated with the data incompleteness. In this article, we propose a hybrid tomosynthesis approach to achieve higher image quality as compared with competing methods. In this approach, a low-resolution CT scan is followed by a high-resolution tomosynthesis scan. Then, both scans are combined to reconstruct images. To evaluate the image quality of the proposed method, we design a new breast phantom for numerical simulation and physical experiments. The results show that images obtained by our approach are clearly better than those obtained without such a CT scan.

Modeling and measurement of the detector presampling MTF of a variable resolution x-ray CT scanner

The detector presampling modulation transfer function (MTF) of a 576-channel variable resolution x-ray (VRX) computed tomography (CT) scanner was evaluated in this study. The scanner employs a VRX detector, which provides increased spatial resolution by matching the scanner's field of view (FOV) to the size of an object being imaged. Because spatial resolution is the parameter the scanner promises to improve, the evaluation of this resolution is important. The scanner's pre-reconstruction spatial resolution, represented by the detector presampling MTF, was evaluated using both modeling (Monte Carlo simulation) and measurement (the moving slit method). The theoretical results show the increase in the cutoff frequency of the detector presampling MTF from 1.39 to 43.38 cycles/mm as the FOV of the VRX CT scanner decreases from 32 to 1 cm. The experimental results are in reasonable agreement with the theoretical data. Some discrepancies between the measured and the modeled detector presampling MTFs can be explained by the limitations of the model. At small FOVs (1-8 cm), the MTF measurements were limited by the size of the focal spot. The obtained results are important for further development of the VRX CT scanner.

Data consistency based rigid motion artifact reduction in fan-beam CT

It is well known that a rigid in-plane motion can be decomposed into a translation and a rotation around an origin. Based on our previous work, we first extend the Helgason-Ludwig consistency condition (HLCC) to cover a general rigid motion in fan-beam geometry. Then, we model the general motion by several parameters, and develop an iterative scheme for estimation of the in-plane motion parameters. This scheme determines the motion parameters by numerically minimizing an objective function constructed based on the HLCC. After the motion parameters are estimated, image reconstruction can be performed to compensate for the motion effects. Finally, we implement the algorithm and evaluate its performance in numerical simulations.

Vertebral osteoporosis and trabecular bone quality

Vertebral fractures due to osteoporosis commonly occur under non-traumatic loading conditions. This problem affects more than 1 in 3 women and 1 in 10 men over a lifetime. Measurement of bone mineral density (BMD) has traditionally been used as a method for diagnosis of vertebral osteoporosis. However, this method does not fully account for the influence of changes in the trabecular bone quality, such as micro-architecture, tissue properties and levels of microdamage, on the strength of the vertebra. Studies have shown that deterioration of the vertebral trabecular architecture results in a more anisotropic structure which has a greater susceptibility to fracture. Transverse trabeculae are preferentially thinned and perforated while the remaining vertical trabeculae maintain their thickness. Such a structure is likely to be more susceptible to buckling under normal compression loads and has a decreased ability to withstand unusual or off-axis loads. Changes in tissue material mechanical properties and levels of microdamage due to osteoporosis may also compromise the fracture resistance of vertebral trabecular bone. New diagnostic techniques are required which will account for the influence of these changes in bone quality. This paper reviews the influence of the trabecular architecture, tissue properties and microdamage on fracture risk for vertebral osteoporosis. The morphological characteristics of normal and osteoporotic architectures are compared and their potential influence on the strength of the vertebra is examined. The limitations of current diagnostic methods for osteoporosis are identified and areas for future research are outlined.

Data consistency based translational motion artifact reduction in fan-beam CT

A basic assumption in the classic computed tomography (CT) theory is that an object remains stationary in an entire scan. In biomedical CT/micro-CT, this assumption is often violated. To produce high-resolution images, such as for our recently proposed clinical micro-CT (CMCT) prototype, it is desirable to develop a precise motion estimation and image reconstruction scheme. In this paper, we first extend the Helgason-Ludwig consistency condition (HLCC) from parallel-beam to fan-beam geometry when an object is subject to a translation. Then, we propose a novel method to estimate the motion parameters only from sinograms based on the HLCC. To reconstruct the moving object, we formulate two generalized fan-beam reconstruction methods, which are in filtered backprojection and backprojection filtering formats, respectively. Furthermore, we present numerical simulation results to show that our approach is accurate and robust.

Intraoperative cone-beam CT for guidance of temporal bone surgery

OBJECTIVES

To describe our preclinical experience with Cone Beam CT (CBCT) in image-guided surgery of the temporal bone.

STUDY DESIGN AND SETTINGS

A mobile isocentric C-arm (PowerMobil, Siemens Medical Systems, Erlangen, Germany) modified to include a flat-panel detector (Varian Imaging Products, Palo Alto, CA) and a motorized orbit was developed to acquire multiple projections in rotation about a subject. Initial experiments imaging steel wire in air were used to investigate the system's spatial resolution in 3D image reconstruction. Subsequently temporal bone dissection was performed on five cadaver heads using the modified C-arm as an image guidance system.

RESULTS

We obtained a spatial resolution of 0.85 mm. The image acquisition time was 120 seconds and the radiation dose approximately one-tenth of a conventional CT scan.

CONCLUSION

CBCT provided submillimeter accuracy at high speed with low radiation dosage to offer utility as an intraoperative imaging system.

SIGNIFICANCE

CBCT offers technology that approximates "near-real-time" image guidance.

EBM RATING

C-4.

Evolving and experimental technologies in medical imaging

Medical images are created by detecting radiation probes transmitted through or emitted or scattered by the body. The radiation, modulated through interactions with tissues, yields patterns that provide anatomic and/or physiologic information. X-rays, gamma rays, radiofrequency signals, and ultrasound waves are the standard probes, but others like visible and infrared light, microwaves, terahertz rays, and intrinsic and applied electric and magnetic fields are being explored. Some of the younger technologies, such as molecular imaging, may enhance existing imaging modalities; however, they also, in combination with nanotechnology, biotechnology, bioinformatics, and new forms of computational hardware and software, may well lead to novel approaches to clinical imaging. This review provides a brief overview of the current state of image-based diagnostic medicine and offers comments on the directions in which some of its subfields may be heading.