Subsequent Invasive Procedures Research Articles

Estimating the Effects of Cancer Screening in Clinical Practice Settings: The Role of Selective Uptake and Suboptimal Adherence along the Cancer Screening Continuum.

Randomized controlled trials (RCT) are the gold standard in determining efficacy of cancer screening tests. Yet, systematic differences between RCT and the general populations eligible for screening raise concerns about the generalizability and relevance of RCT findings to guide the development and dissemination of cancer screening programs. Observational studies from clinical practice settings have documented selective uptake in screening-i.e., variation across subgroups regarding who is screened and not screened-as well as suboptimal adherence to screening recommendations, including follow-up of positive findings with subsequent imaging studies and diagnostic invasive procedures. When the effectiveness of a screening intervention varies across subgroups, and there is selective uptake and suboptimal adherence to screening in clinical practice relative to that in the RCT, the effects of screening reported in RCTs are not expected to generalize to clinical practice settings. Understanding the impacts of selective uptake and suboptimal adherence on estimates of the effectiveness of cancer screening in clinical practice will generate evidence that can be used to inform future screening recommendations and enhance shared decision-making tools.

Efficacy and Safety Analyses of Recombinant Factor VIIa in Severe Post-Partum Hemorrhage.

Background: Despite a range of available treatments, it is still sometimes challenging to treat patients with severe post-partum hemorrhage (sPPH). Objective: This study evaluated the efficacy and safety of recombinant activated factor VIIa (rFVIIa) in sPPH management. Methods: An open-label, multi-center, randomized controlled trial (RCT; NCT00370877) and four observational studies (OS; OS-1 (NCT04723979), OS-2, OS-3, and OS-4) were analyzed regarding efficacy (need for subsequent invasive procedures, including uterine compression sutures, uterine or iliac artery ligations, arterial embolization, or hysterectomy) and safety (incidence of thromboembolic events (TE) and maternal mortality) of rFVIIa for sPPH. The RCT, and OS-1 and OS-2, included a control group of women who did not receive rFVIIa (with propensity score-matching used in OS-1 and OS-2), whereas OS-3 and OS-4 provided descriptive data for rFVIIa-exposed women only. Results: A total of 446 women exposed to rFVIIa and 1717 non-exposed controls were included. In the RCT, fewer rFVIIa-exposed women (50% [21/42]) had an invasive procedure versus non-exposed women (91% [38/42]; odds ratio: 0.11; 95% confidence interval: 0.03-0.35). In OS-1, more rFVIIa-exposed women (58% [22/38]) had an invasive procedure versus non-exposed women (35% [13.3/38]; odds ratio: 2.46; 95% confidence interval: 1.06-5.99). In OS-2, 17% (3/18) of rFVIIa-exposed women and 32% (5.6/17.8) of non-exposed women had an invasive procedure (odds ratio: 0.33; 95% confidence interval: 0.03-1.75). Across all included women, TEs occurred in 1.5% (0.2% arterial and 1.2% venous) of rFVIIa-exposed women and 1.6% (0.2% arterial and 1.4% venous) of non-exposed women with available data. Conclusions: The positive treatment effect of rFVIIa on the RCT was not confirmed in the OS. However, the safety analysis did not show any increased incidence of TEs with rFVIIa treatment.

Capsule endoscopy and panendoscopy: A journey to the future of gastrointestinal endoscopy

In 2000, the small bowel capsule revolutionized the management of patients with small bowel disorders. Currently, the technological development achieved by the new models of double-headed endoscopic capsules, as miniaturized devices to evaluate the small bowel and colon [pan-intestinal capsule endoscopy (PCE)], makes this non-invasive procedure a disruptive concept for the management of patients with digestive disorders. This technology is expected to identify which patients will require conventional invasive endoscopic procedures (colonoscopy or balloon-assisted enteroscopy), based on the lesions detected by the capsule, i.e., those with an indication for biopsies or endoscopic treatment. The use of PCE in patients with inflammatory bowel diseases, namely Crohn’s disease, as well as in patients with iron deficiency anaemia and/or overt gastrointestinal (GI) bleeding, after a non-diagnostic upper endoscopy (esophagogastroduodenoscopy), enables an effective, safe and comfortable way to identify patients with relevant lesions, who should undergo subsequent invasive endoscopic procedures. The recent development of magnetically controlled capsule endoscopy to evaluate the upper GI tract, is a further step towards the possibility of an entirely non-invasive assessment of all the segments of the digestive tract, from mouth-to-anus, meeting the expectations of the early developers of capsule endoscopy.

Unexpected Movement of the Esophagus across the Aorta

Tumor regression throughout treatment would induce organ movement, but little is known of this in the esophagus. To achieve successful tumor regression, radiation therapy requires several weeks of radiation to be delivered accurately to the tumor. Usually, a 5–10 mm margin is allowed for set-up error and internal organ motion. Our case exhibited an unexpectedly large movement of the esophagus across the aorta with tumor regression that extended outside the margin and thus outside the radiotherapy field. These movements may affect subsequent invasive procedures or treatment during cancer therapy. After the unexpected large movement of the esophagus due to tumor regression, we revised the radiotherapy plan to reflect the new esophageal position. This implied that regular imaging and close monitoring are required during treatment of esophageal cancer.

Outcomes in patients with history of cocaine use presenting with chest pain to the emergency department: Insights from the Nationwide Emergency Department Sample 2016-2018.

ObjectivesCocaine use (CU) related chest pain (CP) is a common cause of emergency department (ED) visits in the United States. However, information on disposition and outcomes in these patients is scarce. We conducted a nationwide study to assess disposition from ED, hospitalization rates, in‐hospital outcomes, and health care costs in patients with history of CU who presented to the ED with CP.MethodsWe queried the Nationwide Emergency Department Sample database from 2016–2018 for adult patients with CU presenting to the ED with CP. International Classification of Diseases, Tenth Revision codes were used to identify study patients.ResultsWe identified 149,372 patients. The majority were male (76%), presented to metropolitan centers (91.3%), and had a high prevalence of cardiovascular risk factors (48.1% with hypertension, 24.4% with coronary artery disease, 18.2% with diabetes) and psychiatric illnesses (21%). Overall, 21.4% of patients were hospitalized, 68.6% were discharged from ED and 6.6% left against medical advice. Patients requiring admission were older (51.8 vs 45.0; P < 0.0001) and had a higher prevalence of coronary artery disease, peripheral arterial disease, hypertension, diabetes, and chronic kidney disease. Of those admitted, 45.7% were diagnosed with myocardial infarction (MI), constituting 9.7% of the total study population. Over 80% of these patients underwent coronary angiography and 38.6% had coronary intervention. Mortality was 1.2%.ConclusionCU patients who present to ED are predominantly male, are from lower economic strata, and have significant comorbidity burden. One in 5 patients requires hospitalization and has more prevalent cardiovascular risk factors and comorbidities. In‐hospital mortality is low, but incidence of MI and subsequent invasive procedures is high. CU may be considered a cardiac risk factor as it is associated with high rates of in‐hospital MI.

Sonographic septation: a useful diagnostic predictor of complicated parapneumonic effusion

Sonographic septation is associated with prolonged hospitalization and increased mortality in patients diagnosed with empyema. However, it is unknown whether sonographic septation is associated with complicated parapneumonic effusion (CPPE) or...

Do Acupuncture Services Reduce Subsequent Utilization of Opioids and Surgical Interventions Compared to Noninvasive Therapies among Patients with Pain Conditions?

ObjectiveTo compare prescribed opioid use and invasive surgical interventions between patients using acupuncture and those using non-steroidal anti-inflammatory drugs (NSAIDs)/physical therapy (PT).DesignRetrospective observational study of administrative claims.SettingLarge commercial insurance plan.Subjects52 346 each treated with either acupuncture or NSAIDs/PT.MethodsUsers of acupuncture and NSAIDs/PT were identified from January 1, 2014, to December 31, 2017. The first date of each service was defined as the index date. Acupuncture patients were 1:1 propensity score matched to the NSAIDs/PT group on baseline characteristics. Outcomes included opioid use, subsequent invasive surgical procedures, healthcare utilization such as hospitalizations or emergency department (ED) visits, and costs. These were assessed in the 12-month period before index date (baseline) and 12-month period following index date (follow-up) using difference-in-difference (DID) analysis. Results for opioid use were stratified by those with and without baseline opioid use.ResultsThe acupuncture group had fewer patients initiating opioids post-index both among those with (49.2% vs 56.5%, P < .001) and without (15.9% vs 22.6%, P < .001) baseline opioid use. There was a small increase in invasive surgical procedures with acupuncture (3.1% vs 2.8%, P = .006). A reduction in ED visits was observed with acupuncture (DID −4.6% for all-cause; −3.3% for pain-related, all P < .001). Acupuncture was associated with higher total medical and pharmacy costs (DID +$1331 per patient, P = .006).ConclusionsAcupuncture showed a modest effect in reducing opioid use and ED visits. More research on acupuncture’s place in emergency care, pain relief, and comparison to other types of non-opioid treatment is needed.

Clinical outcomes after increasing bladder outlet resistance without augmentation cystoplasty in neurogenic bladder

Patients with neurogenic bladder (NGB) and urinary incontinence (UI) due to low bladder outlet resistance may require bladder neck procedures (BNPs) to achieve continence. These patients may also have reduced bladder capacity and or elevated detrusor storage pressures that require augmentation cystoplasty (AC). AC is not without complications that include risks for bladder rupture, urolithiasis, urinary tract infections and metabolic issues. Avoidance of AC would be helpful in patients with neurogenic urinary incontinence that have safe bladder parameters in the setting of low bladder outlet resistance. To determine if pre-operative urodynamics could select children with NGBs and UI for isolated BNPs without AC. Additionally we sought to determine the safety of BNPs without AC and future need of AC with long-term follow-up. This is an IRB-approved retrospective analysis of all patients undergoing BNPs for management of neurogenic UI over a 17-year period. We separated these BNP patients into two groups: No AC+BNP (Group 1) vs. AC+BNP (Group 2). Our primary analyses focused on postoperative outcomes for patients in Group 1. Outcomes assessed included additional surgical procedures, urodynamic changes, development of CKD, new hydronephrosis (HDN) and vesicoureteral reflux (VUR). Secondary analysis included the timeline for the development of any bladder deterioration that necessitated AC in Group 1. 93 patients underwent BNP at a mean age of 10.8 years. Thirty did not have AC at the time of surgery (Group 1). These children had larger (p<0.001) and more compliant (p<0.001) bladders than Group 2 having simultaneous augmentation. At 6 years mean follow-up in Group 1 patients, three developed new reflux and three had new hydronephrosis. Nine (30%) had additional continence procedures. Twelve required (40%) AC at a mean of 23 months after the initial BNP. No patients had AC after 5 years. Detrusor end filling pressure increased 14.8cmH2O (p=0.028) and expected bladder capacity decreased 26.1% (p=0.005) after isolated BNP. We found that from our cohort of patients who had normal bladder compliance and normal/near normal expected capacity preoperatively 40% required subsequent AC. We were unable to find pre-operative clinical parameters which predicted failure or conversion to AC. We found that 43.3% of our BNP without AC patients had no subsequent invasive procedures with mean 6-year follow-up. We found that none of our patients developed any degree of CKD. Finally, we found that the majority of patients that converted to AC after their BNP did so within the first 2 years after their initial BNP and no patients required augmentation 5 years post their initial BNP. This data validates that these patients require very strict follow up, particularly in the first 5 years after surgery. BNP without AC is safe in only a few selected patients with NGB. Despite preoperative selection, there are significant changes in bladder dynamics and 40% required subsequent augmentation. Bladder deterioration occurs early and generally in the first 2 years. Since there are no apparent reliable pre-operative variables predicting the need for subsequent AC, parents should be counseled regarding vigilant post-operative follow-up.

VALIDITY OF DIFFUSION WEIGHTED MAGNETIC RESONANCE IMAGING AND APPARENT DIFFUSION COEFFICIENT MAP IN DIFFERENTIATING BENIGN FROM MALIGNANT UTERINE ENDOMETRIAL PATHOLOGIES

Endometrial pathologies represent a diagnostic challenge for radiologist and gynecologist due to dynamic changes of the endometrium, wide variability in imaging appearance and overlap between benign and malignant causes of endometrial abnormalities. Although tissue analysis via dilatation and curettage, endometrial biopsy or hysteroscopy is the backbone in the diagnosis, these tests are invasive, not without complications and may be difficult to perform in certain circumstances, hence the need for noninvasive imaging methods to aid in the diagnosis and triaging the patient for subsequent invasive procedures as well as contribution in treatment planning. This study aimed to evaluate the role of diffusion weighted imaging (DWI) with apparent diffusion coefficient (ADC) value measurement in differentiating benign from malignant uterine endometrial lesions. The study included 47 patients with endometrial lesions divided into two groups according to the result of histopathological analysis; the malignant group consisting from 18 cases and the benign group consisting from 29 cases, the latter was further subdivided into: polyp, hyperplasia and other benign entities. Pelvic magnetic resonance imaging with DWI performed for each patient with visual evaluation of signal intensity on diffusion and ADC value measurement. Subsequently mean ADC values for each group were calculated and compared, and validity measures for the optimal cut-off values for differentiating benign from malignant lesions were determined. The mean±standard deviation for ADC value (x10-3mm2/sec) for malignant group was 0.71±0.12, and for benign group was 1.52±0.42, with a significant difference between the two groups (P value <0.01), there was no significant difference in ADC value between the subdivision of benign group. At ADC cut-off value of 0.976x10-3mm2/sec, the sensitivity, specificity, positive predictive value and negative predictive value and accuracy of DWI in detecting endometrial carcinoma were 100%, 89.6%, 85.71%, 100% and 93.62% respectively. In conclusion, DWI with ADC value measurement is a valuable non-invasive diagnostic test, aiding in the differentiation of benign from malignant uterine endometrial cavity lesions. Key words: diffusion weighted imaging, apparent diffusion coefficient map, benign endometrial lesions, malignant endometrial lesions.

Drug-induced sleep endoscopy compared with systematic adenotonsillectomy in the management of obstructive sleep apnoea in children: a systematic review and meta-analysis protocol

IntroductionObstructive sleep apnoea affects up to 6% of children worldwide. Although current guidelines recommend systematic tonsillectomy and adenoidectomy, many children do not benefit from these interventions. Drug-induced sleep endoscopy (DISE)...

A pragmatic application of endobronchial ultrasound-guided transbronchial needle aspiration: a single institution experience

BackgroundEndobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is minimally invasive technique used for diagnosis and/or staging of benign and malignant pulmonary and non-pulmonary disease. Previous studies have established the utility of EBUS-TBNA in narrowly defined indications and populations. In this pragmatic ‘real world’ study we have analysed the use of EBUS-TBNA for a variety of clinical presentations and its clinical application in conjunction with other invasive investigations.MethodsAll EBUS-TBNA procedures performed at Sir Charles Gardiner Hospital in 2012–2014 were reviewed retrospectively, using relevant hospital databases.ResultsA total of 327 patients underwent 337 EBUS-TBNA procedures. EBUS-TBNA procedures were used to diagnose a wide spectrum of benign and malignant conditions. The main application was in the diagnosis and staging of malignant conditions (70.6%), and in the diagnosis of benign conditions such as sarcoidosis 40 (12.2%), and silicoanthracosis 17 (5.2%). EBUS-TBNA was sufficient to diagnose and stage the disease as a single stand-alone invasive procedure in 191 (59.2%) patients. EBUS-TBNA was the final invasive procedure undertaken in 283 (87.6%) patients. Only 13.3% of non small cell lung cancer (NSCLC) patients who had EBUS-TBNA as a first investigation required multiple procedures compared to 51.1% of all NSCLC patients undergoing EBUS-TBNA. Overall sensitivity, specificity, NPV and diagnostic accuracy for EBUS-TBNA were 89.7, 100, 85.1 and 89.9%, respectively and three minor complications (0.9%) occurred as a result of the procedure.ConclusionsEBUS-TBNA was undertaken for a wide variety of clinical conditions. Good diagnostic accuracy and safety profiles were demonstrated for the procedure, supporting its application as a first line investigation in the diagnosis and/or staging of a range of malignant and benign conditions. Our study was unique in its documentation of the use of EBUS-TBNA in a real-world setting in conjunction with other invasive modalities. EBUS-TBNA was utilised as a stand alone invasive procedure in more than half of the patients. Importantly, in NSCLC, when EBUS-TBNA was performed as primary diagnostic and staging investigation, less patients underwent subsequent invasive procedures.

Complication Rates and Downstream Medical Costs Associated With Invasive Diagnostic Procedures for Lung Abnormalities in the Community Setting

The Centers for Medicare & Medicaid Services added lung cancer screening with low-dose computed tomography (LDCT) as a Medicare preventive service benefit in 2015 following findings from the National Lung Screening Trial (NLST) that showed a 16% reduction in lung cancer mortality associated with LDCT. A challenge in developing and promoting a national lung cancer screening program is the high false-positive rate of LDCT because abnormal findings from thoracic imaging often trigger subsequent invasive diagnostic procedures and could lead to postprocedural complications. To determine the complication rates and downstream medical costs associated with invasive diagnostic procedures performed for identification of lung abnormalities in the community setting. A retrospective cohort study of non-protocol-driven community practices captured in MarketScan Commercial Claims & Encounters and Medicare supplemental databases was conducted. A nationally representative sample of 344 510 patients aged 55 to 77 years who underwent invasive diagnostic procedures between 2008 and 2013 was included. One-year complication rates were calculated for 4 groups of invasive diagnostic procedures. The complication rates and costs were further stratified by age group. Of the 344 510 individuals aged 55 to 77 years included in the study, 174 702 comprised the study group (109 363 [62.6%] women) and 169 808 served as the control group (106 007 [62.4%] women). The estimated complication rate was 22.2% (95% CI, 21.7%-22.7%) for individuals in the young age group and 23.8% (95% CI, 23.0%-24.6%) for those in the Medicare group; the rates were approximately twice as high as those reported in the NLST (9.8% and 8.5%, respectively). The mean incremental complication costs were $6320 (95% CI, $5863-$6777) for minor complications to $56 845 (95% CI, $47 953-$65 737) for major complications. The rates of complications after invasive diagnostic procedures were higher than the rates reported in clinical trials. Physicians and patients should be aware of the potential risks of subsequent adverse events and their high downstream costs in the shared decision-making process.

Successful treatment of liver abscesses with corticosteroids and antibiotics in an infant with chronic granulomatous disease

Liver abscesses occur in up to one-third of patients with chronic granulomatous disease (CGD). Surgery has traditionally been considered the cornerstone of management. Emerging reports in older children and adults, however, have demonstrated successful treatment of CGD-related liver abscesses with corticosteroids and antibiotics alone. We describe the safe and effective use of corticosteroids and antibiotics for CGD-related liver abscesses in an infant with X-linked CGD who had high surgical risk for hepatic resection. Medical management was started at 11 months of age and the abscesses resolved without requiring any subsequent invasive surgical procedures. This case report highlights that corticosteroids and antibiotics may be considered in the management of CGD-related liver abscesses in the infant age group, especially when surgical management is not an option.

Influence of irregular heart rhythm on radiation exposure, image quality and diagnostic impact of cardiac computed tomography angiography in 4,339 patients. Data from the German Cardiac Computed Tomography Registry

BackgroundCoronary computed tomography angiography (coronary CTA) provides non-invasive evaluation of the coronary arteries with high precision for the detection of significant coronary artery disease (CAD). AimTo investigate whether irregular heart rhythm including atrial fibrillation and premature beats during data acquisition influences (i) radiation and contrast media exposure, (ii) number of non-evaluable coronary segments and (iii) diagnostic impact of coronary CTA. MethodsTwelve tertiary care centers with ≥64 slice CT scanners and ≥5 years of experience with cardiovascular imaging participated in this registry. Between 2009 and 2014, 4339 examinations were analysed in patients who underwent clinically indicated coronary CTA for suspected CAD. Clinical and epidemiologic data were gathered from all patients. In addition, clinical presentation, heart rate and rhythm during the scan, Agatston score, radiation and contrast media exposure and the diagnostic impact of coronary CTA were systematically analysed. ResultsOf 4339 patients in total, 260 (6.0%) had irregular heart rhythm, whereas the remaining 4079 (94.0%) had stable sinus rhythm. Patients with irregular heart rhythm were older (63.2 ± 12.5yrs versus 58.6 ± 11.4yrs. p < 0.001), exhibited a higher rate of pathologic stress tests before CTA (37.1% versus 26.1%, p < 0.01) and higher heart rates during CTA compared to those with sinus rhythm (62.5 ± 11.6bpm versus 58.9 ± 8.5bpm, p < 0.001). Both contrast media exposure and radiation exposure were significantly higher in patients with irregular heart rhythm (90 mL (95%CI = 80–110 mL) versus 80 mL (95%CI = 70–90 mL) and 6.2 mSv (95%CI = 2.5–11.7) versus 3.3 mSv (95%CI = 1.7–6.9), p < 0.001 for both). Coronary CTA excluded significant CAD less frequently in patients with irregular heart rhythm (32.9% versus 44.8%, p < 0.001). This was attributed to the higher rate of examinations with at least one non-diagnostic coronary segment in patients with irregular heart rhythm (10.8% versus 4.6%, p < 0.001). Subsequent invasive angiography could be avoided in 47.2% of patients with irregular heart rhythm compared to 52.9% of patients with sinus rhythm (p = NS), whereas downstream stress testing was recommended in 3.2% of patients with irregular heart rhythm versus 4.0% of patients with sinus rhythm (p = NS). ConclusionA significant number of patients scheduled for coronary CTA have irregular heart rhythm in a real-world clinical setting. In such patients, heart rate during coronary CTA is higher, possibly resulting in (i) higher radiation and contrast agent exposure and (ii) more frequent coronary CTA examinations with at least one non-diagnostic coronary artery segment. However, this does not seem to lead to increased downstream stress testing or subsequent invasive procedures.

Functional Testing or Coronary Computed Tomography Angiography in Patients With Stable Coronary Artery Disease

BackgroundThe choice of either anatomical or functional noninvasive testing to evaluate suspected coronary artery disease might affect subsequent clinical management and outcomes. ObjectivesThis study analyzed the association of initial noninvasive cardiac testing in outpatients with stable symptoms, with subsequent use of medications, invasive procedures, and clinical outcomes. MethodsWe studied patients enrolled in a Danish nationwide register who underwent initial noninvasive cardiac testing with either coronary computed tomography angiography (CTA) or functional testing (exercise electrocardiography or nuclear stress testing) from 2009 to 2015. Further use of noninvasive testing, invasive procedures, medications, and medical costs within 120 days were evaluated. Risks of long-term mortality and myocardial infarction (MI) were analyzed using adjusted Cox proportional hazard models. ResultsA total of 86,705 patients underwent either functional testing (n = 53,744, mean age 57.4 years, 49% males) or coronary CTA (n = 32,961, mean age 57.4 years, 45% males), and were followed for a median of 3.6 years. Compared with functional testing, there was significantly higher use of statins (15.9% vs. 9.1%), aspirin (12.7% vs. 8.5%), invasive coronary angiography (14.7% vs. 10.1%), and percutaneous coronary intervention (3.8% vs. 2.1%); all p < 0.001 after coronary CTA. The mean costs of subsequent testing, invasive procedures, and medications were higher after coronary CTA ($995 vs. $718; p < 0.001). Unadjusted rates of mortality (2.1% vs. 4.0%) and MI hospitalization (0.8% vs. 1.5%) were lower after coronary CTA than functional testing (both p < 0.001). After adjustment, coronary CTA was associated with a comparable all-cause mortality (hazard ratio: 0.96; 95% confidence interval: 0.88 to 1.05), and a lower risk of MI (hazard ratio: 0.71; 95% confidence interval: 0.61 to 0.82). ConclusionsIn stable patients undergoing initial evaluation for suspected coronary artery disease, coronary CTA was associated with greater use of statins, aspirin, and invasive procedures, and higher costs than functional testing. Coronary CTA was associated with a lower risk of MI, but a similar risk of all-cause mortality.

Echo color Doppler ultrasound: a valuable diagnostic tool in the assessment of arteriovenous fistula in hemodialysis patients.

A functioning vascular access is a critical requirement to improve the quality of life in hemodialysis patients, so monitoring and surveillance of vascular access play key roles in identifying all dysfunctions and reducing the huge economic cost as well as adequacy of dialysis.In our five-year experience, a study protocol has been used and improved with the help of ultrasonography.Doppler ultrasound is an excellent and sensitive modality for hemodialysis access evaluation, one of techniques employed for arteriovenous fistulae (AVF) study, not only as a preoperative tool, but also in post-operative monitoring of AVF maturation. In addition, the current guidelines recommend AVF surveillance by access blood flow measurement and the correction of hemodynamic stenosis in order to prolong access survival. Doppler ultrasound is readily available, directly used by nephrologists, non-invasive, safe, inexpensive, reproducible, although it requires more clinical skill and time to perform and proper equipment. Ultrasonography imaging can substantially reduce the number of subsequent invasive angiographic procedures. In our opinion, Doppler ultrasound should have a crucial place in the interdisciplinary cooperation in AVF monitoring and it should be included as part of an integrated vascular access management program.

Clinical Utility of a Bronchial Genomic Classifier in Patients With Suspected Lung Cancer

Bronchoscopy is often the initial diagnostic procedure performed in patients with pulmonary lesions suggestive of lung cancer. A bronchial genomic classifier was previously validated to identify patients at low risk for lung cancer after an inconclusive bronchoscopy. In this study, we evaluated the potential of the classifier to reduce invasive procedure utilization in patients with suspected lung cancer. In two multicenter trials of patients undergoing bronchoscopy for suspected lung cancer, the classifier was measured in normal-appearing bronchial epithelial cells from a mainstem bronchus. Among patients with low and intermediate pretest probability of cancer (n= 222), subsequent invasive procedures after an inconclusive bronchoscopy were identified. Estimates of the ability of the classifier to reduce unnecessary procedures were calculated. Of the 222 patients, 188 (85%) had an inconclusive bronchoscopy and follow-up procedure data available for analysis. Seventy-seven (41%) patients underwent an additional 99 invasive procedures, which included surgical lung biopsy in 40 (52%) patients. Benign and malignant diseases were ultimately diagnosed in 62 (81%) and 15 (19%) patients, respectively. Among those undergoing surgical biopsy, 20 (50%) were performed in patients with benign disease. If the classifier had been used to guide decision making, procedures could have been avoided in 50%(21 of 42) of patients undergoing further invasive testing. Further, among 35 patients with an inconclusive index bronchoscopy who were diagnosed with lung cancer, the sensitivity of the classifier was 89%, with 4 (11%) patients having a false-negative classifier result. Invasive procedures after an inconclusive bronchoscopy occur frequently, and most are performed in patients ultimately diagnosed with benign disease. Using the genomic classifier as an adjunct to bronchoscopy may reduce the frequency and associated morbidity of these invasive procedures. ClinicalTrials.gov; Nos. NCT01309087 and NCT00746759; URL: www.clinicaltrials.gov.

Comparação entre as vias de acesso femoral e radial em procedimentos coronários invasivos após cirurgia de revascularização miocárdica

BackgroundInvasive coronary procedures are common in patients with previous coronary artery bypass graft surgery. Data on the actual role and possible limitations of the radial approach in this subgroup of patients are sparse. The objective of this study was to evaluate the feasibility and safety of radial access in patients surgically revascularized and who underwent subsequent invasive diagnostic or therapeutic coronary procedures, comparing it to the femoral access. MethodsBetween May 2008 and November 2014, 959 procedures were included; 539 performed by radial access and 420 by femoral access. All operators were familiar with both vascular accesses, and the final decision on the route to be used was left to the operators discretion. ResultsThe failure rate was 6.1% vs. 0.5% (p < 0.0001), favoring the femoral approach. Major adverse cardiac events (0.4% vs. 0.7%) and vascular complications (1.5% vs. 1.9%) rates were low, with no difference between groups. The choice of the radial approach resulted in greater fluoroscopy time and crossover rate between access routes, especially in diagnostic procedures. ConclusionsThe radial approach was a safe and effective option for invasive coronary procedures in postcoronary artery bypass graft patients, especially for therapeutic procedures.

Comparison between femoral and radial approach in invasive coronary procedures after coronary artery bypass grafting

BackgroundInvasive coronary procedures are common in patients with previous coronary artery bypass graft surgery. Data on the actual role and possible limitations of the radial approach in this subgroup of patients are sparse. The objective of this study was to evaluate the feasibility and safety of radial access in patients surgically revascularized and who underwent subsequent invasive diagnostic or therapeutic coronary procedures, comparing it to the femoral access. MethodsBetween May 2008 and November 2014, 959 procedures were included; 539 performed by radial access and 420 by femoral access. All operators were familiar with both vascular accesses, and the final decision on the route to be used was left to the operators discretion. ResultsThe failure rate was 6.1% vs. 0.5% (p < 0.0001), favoring the femoral approach. Major adverse cardiac events (0.4% vs. 0.7%) and vascular complications (1.5% vs. 1.9%) rates were low, with no difference between groups. The choice of the radial approach resulted in greater fluoroscopy time and crossover rate between access routes, especially in diagnostic procedures. ConclusionsThe radial approach was a safe and effective option for invasive coronary procedures in post- coronary artery bypass graft patients, especially for therapeutic procedures.

EUS-FNA During Initial ERCP for Obstructive Jaundice From Pancreatic Head Adenocarcinoma Results in Fewer Subsequent Invasive Procedures

Introduction: Patients with pancreatic masses presenting with obstructive jaundice often need both tissue diagnosis and biliary decompression prior to initiation of treatment. Where available, EUS-FNA for tissue diagnosis is often performed during the same session as the initial ERCP with stenting. The aim of this study is to determine whether performing EUS-FNA with the initial ERCP leads to patients undergoing fewer diagnostic and therapeutic invasive procedures. Methods: Patients with pancreatic head adenocarcinoma presenting with jaundice referred to a comprehensive cancer hospital between Feb 2005 and Sep 2013 were identified by chart review. Patients were classified into two groups based on initial endoscopic procedure; 1) combined EUS-FNA plus ERCP with biliary stenting (combined group) or 2) ERCP with brushings and biliary stenting (ERCP group). The primary outcome was the number of subsequent invasive procedures for tissue diagnosis and biliary decompression patients needed to have prior to initiation of cancer treatment. Statistical analyses were done using Fisher’s exact test to compare categorical variables and Wilcoxon rank sum test to compare numeric variables. All associations were considered statistically significant at an alpha error <0.05 (P value 0.05). Results: Overall, 161 patients met study criteria (combined = 57, ERCP = 104). Cytology was diagnostic for adenocarcinoma in 82.5% of the combined group vs. 19.8% in the ERCP group (p<0.0001). The combined group required fewer subsequent diagnostic interventions (10 vs. 100, p<0.001). Biliary cannulation rates were similar in both groups (82.1% vs. 71.2%, p=0.18). Due to information gained from rapid on-site cytologic evaluation of FNA specimens and EUS staging, more patients in the combined group received metal biliary stents than in the ERCP group (74.5% vs. 40.5%, p=0.004). The combined group required fewer subsequent biliary drainage procedures (19 vs. 47, p=0.03). Complications were similar in both groups (6 vs. 9, p=0.18). The type of initial cancer therapy was not statistically different between the two groups. Median time to treatment (in days) between the two groups was 28 vs. 49 for chemotherapy (p<0.001), 25 vs. 34 for surgery (p=0.917) and 7 vs. 31 for hospice referral (p=0.002). Conclusion: Pancreatic cancer patients presenting with obstructive jaundice who undergo EUS-FNA with the initial ERCP are subjected to fewer subsequent invasive diagnostic and therapeutic procedures resulting in sooner initiation of cancer treatment. Further studies are needed to determine if this expedited treatment influences survival.