Underutilized Modality Research Articles

Bronchoscopic bronchial brush cytology: an underutilized modality for diagnosing lung cancer in resource limited facilities: a case series of nine patients

Lung cancer incidence is on the rise with increasing industrialization across the globe. Early diagnosis is the key to a better prognosis. In the current scenario, in developing countries, the majority are diagnosed late, when surgical or curable treatment is not possible, and only palliative treatment options are left. Bronchoscopy is the most widely used modality for the diagnosis of lung cancer. Perhaps, all its accessories are not widely used. Bronchial brush is an easy, cost effective, easily available, without significant complication rates, safe, feasible, with high specificity which offers early preliminary report where biopsy is not possible. It should be used along with biopsy to increase the yield and accuracy in all suspected lung cancer patients who require bronchoscopy.

757. Bridging the Gap: An Educational Intervention to Increase HIV PrEP Access in Resident Primary Care Clinics

Abstract Background HIV Pre-Exposure Prophylaxis (PrEP) is a safe and effective way to prevent HIV acquisition. Yet, in 2020, only 25% of individuals in the US and Puerto Rico who had an indication for PrEP received a PrEP prescription. While PrEP is accessible to primary care clinicians, many do not feel comfortable prescribing PrEP. Clinician education has been identified as a key opportunity to increase access and comfort in prescribing PrEP. Methods An educational intervention was designed aiming to increase PrEP knowledge and prescribing among residents and preceptors in the primary care clinics at Brigham and Women’s Hospital (BWH). The intervention followed the six steps described in Kern’s model of curriculum development (Figure 1). After formal needs assessment, an in-person interactive teaching session was designed and presented. This was supplemented by an online reference guide and note template dot phrases accessible in the electronic medical record (EMR). The curriculum was evaluated with pre and post intervention surveys. Survey data were analyzed using descriptive statistics and one tailed T tests. Results Of the approximately 30 residents and preceptors who participated in the intervention, 19 completed the pre survey and 9 completed the post survey. Only 37% (7/19) of pre survey respondents reported having had PrEP education in the past. 21% (4/19) had prior teaching during medical school, 21% (4/19) during residency, and 16% (3/19) in continuing medical education courses. Participants indicated that their comfort with prescribing PrEP increased overall after the intervention with a statistically significant increase in reported confidence in their ability to prescribe PrEP (mean Likert scale value of 3.88 vs 2.95, p = 0.03) (table 1). Conclusion PrEP is an underutilized modality in preventing HIV transmission, but many primary care clinicians do not feel comfortable prescribing PrEP even though it is accessible in primary care settings. Systematic PrEP education is lacking in the UME, GME, and CME settings. Targeted, interactive, multimodal educational interventions can be effective in increasing comfort with PrEP prescribing. Support from leadership and learner buy-in is critical for effective training. Disclosures All Authors: No reported disclosures

Nature As a "Lifeline": The Power of Photography When Exploring the Experiences of Older Adults Living With Memory Loss and Memory Concerns.

The visual is an underutilized modality through which to investigate experiences of memory loss in older people. We describe a visual ethnography with older adults experiencing subjective or objective memory loss, receiving a cognitive well-being group intervention designed to prevent cognitive decline and dementia (APPLE-Tree program). We aimed to explore lived experiences of people with memory concerns, how participants engaged with this photography and codesign project, and how collaboration with an artist/photographer enhanced this process. Nineteen participants shared photographs reflecting what they valued in their daily lives, their experiences of memory concerns, and the intervention. Fourteen participated in qualitative photo-elicitation interviews, and 13 collaborated with a professional artist/photographer to cocreate an exhibition, in individual meetings and workshops, during which a researcher took ethnographic field notes. Eight participants were reinterviewed after the exhibition launch.We contextualize images produced by participants in relation to discourses around the visual and aging and highlight their relationship with themes developed through thematic analysis that interconnects photographic, observational, and interview data. We present themes around the use of photographs to: (1) celebrate connections to nature as a lifeline; (2) anchor lives within the context of relationships with family; and (3) reflect on self and identity, enduring through aging, memory concerns, pandemic, and aging stereotypes. We explore visual research as a powerful tool for eliciting meaningful accounts from older adults experiencing cognitive change and to connect the arts and social sciences within aging studies.

574: SAFE AND EFFECTIVE VOCALIZATION IN MECHANICALLY VENTILATED PATIENTS WITH TRACHEOSTOMY

Introduction: As many as 10-15% of patients admitted to the intensive care unit (ICU) will require a temporary tracheostomy. Verbal communication, however is still difficult and often ineffective. Certain tracheostomy tubes have added a subglottic port similar to endotracheal tubes for suctioning above the cuff. This above the cuff (ACV) port can also be used for vocalization by instilling air through this port which passes through the larynx and vocal cords to allow for phonation. Studies have been limited with very small sample sizes and ACV remains an underutilized modality for communication in patients with tracheostomy. Methods: An IRB approved retrospective review was performed in all adult patients admitted to any ICU requiring tracheostomy from November 2019 to October 2021. All patients receiving tracheostomy were identified. Patients with a tracheostomy tube with an above the cuff suction port were then evaluated 48 hours after surgery and underwent ACV. Major and minor complications and level of phonation achieved were recorded. Speech effectiveness was stratified by no voice, whisper, word level and sentence level performance with ACV. Major and minor complications were recorded. Results: 48 patients underwent 139 interventions. 100% of patients identified were able to attempt ACV. 20 patients (42%) achieved word-level speech and 10 (21%) reached sentence-level speech. Word-level speech was achieved in 52% of all interventions and sentence-level in 17.5%. 95.7% reported no complications and there were no major complications. Comparison to a hypothetical 1% major complication rate using a one-sample binominal test was significant. (P < 0.000) The most common minor complications was excessive oral secretions occurring in 2 patients (1.4%). Conclusions: ACV is a valuable procedure that can result in effective communication for patients with tracheostomy still requiring mechanical ventilation. The procedure is simple and safe to perform and tolerated very well by patients even early after tracheostomy.

Radiation Therapy for Cutaneous Squamous and Basal Cell Carcinomas of the Face Treated with HDR Brachytherapy Using Custom Thermoplastic Applicators

<h3>Purpose/Objective(s)</h3> Non-melanoma skin cancer (NMSC) of the face is prevalent and increasing in incidence with cosmetic outcome and functionality of utmost importance. We report on an underutilized modality of radiation treatment with HDR brachytherapy custom thermoplastic applicators. <h3>Materials/Methods</h3> A total of 301 cutaneous carcinomas of the face with a mean tumor size of 1.4cm (0.2cm-8cm) were treated with HDR brachytherapy Ir-192 custom thermoplastic applicators (CTA). Most commonly, hypofractionated radiation regimens included 40Gy in 8 fractions delivered twice weekly or 48Gy in 16 fractions delivered four times weekly. <h3>Results</h3> Mean follow up was 28.2 months (range, 1-149 months). Of the 301 facial lesions treated, local control was 95.7% with most recurrences being salvaged by either re-irradiation in 30.7%, wide local excision (WLE) 23.1%, or Moh's micrographic surgery 23.1%. 65% were basal cell carcinomas and the most common sites of disease were the nose (33.9%), cheek (20.9%), forehead (18.6%), and ear (17.3%). At first follow up, Grade 0-1 acute radiation dermatitis was observed in 66.1% of lesions, grade 2 in 27.4%, grade 3 in 6.2% (n=18) and grade 4 toxicity was seen in one patient (0.34%). Chronic toxicity included erythema (8.2%), fibrosis (7.4%), telangiectasia (4.1%), and hypo/hyperpigmentation (1.7%). No patients exhibited chronic ulcers. The median number of catheters used was 4 (range, 1-17), and the largest diameter treated was a median of 2.5cm (0.2-14.2cm). <h3>Conclusion</h3> Non-melanoma skin cancer of the face can be successfully treated with HDR brachytherapy custom thermoplastic applicators with low toxicity and excellent outcomes.

Assessment of the Left Atrial Reservoir Function and Left Atrial Volume After Percutaneous Balloon Mitral Valvuloplasty Using Peak Atrial Longitudinal Strain.

ObjectiveTo evaluate the impact of successful percutaneous balloon mitral valvuloplasty (BMV) on left atrial (LA) reservoir function and LA volume in patients with severe mitral stenosis (MS) using peak atrial longitudinal strain (PALS).MethodThis was a prospective, non-randomized observational study conducted at the Laxmipat Singhania (LPS) Institute of Cardiology, Kanpur from August 2018 to February 2020 among patients with severe rheumatic MS undergoing BMV to assess LA reservoir function and its volume after BMV using PALS. Inclusion criteria were symptomatic severe rheumatic MS (NYHA ≥II), normal ventricular systolic function, and suitable valve morphology. Exclusion criteria were the coexistence of aortic valve involvement, left atrial appendage clot, mitral leak more than mild, pregnancy, hypertension, diabetes, and coronary artery disease. To assess LA reservoir function and its volume after BMV, PALS was used. LA was divided into six regions of interest and longitudinal strain curves of individual segments together with global strain were recorded. PALS was calculated at baseline 24 hours following the intervention, and at three months of follow-up.ResultSuccessful BMV was performed in 260 patients (109 or 41.9% males and 151 or 58.1% females), resulting in significant improvement in mitral valve area (MVA) (0.89±0.11 cm2 vs. 1.83±0.3 cm2; p<0.001). The mean age of patients was 26.7±4.7 years; 214 (82.3%) patients were in normal sinus rhythm (NSR) while 46 (17.7%) had atrial fibrillation (AF).Significant improvement in PALS was noted immediately following the procedure (6.5±11.6% vs. 7.7±10.5%; p< 0.001) and it continued to improve at three months of follow-up (6.5±11.6% vs. 11.3±12.5%; p<0.001), which was 24% and 74% improvement from baseline respectively. Significant reduction in indexed left atrial (LA) volume was observed immediately following the procedure (56.8±14.3 ml/m2 vs 48.4±12.5 ml/m2; p=0.003), and at three months of follow-up (56.8±14.3 ml/m2 vs. 45.4±13.3 ml/m2; p=0.002). Those with AF had lesser improvement in PALS in comparison to those with NSR (60% vs. 84%; p=0.044) at three months of follow-up. At three months, the increase in PALS was also lower in patients with a history of stroke as compared to those without it (55% vs 80%; p=0.039). Both LA volume and indexed LA volume reduced significantly immediately at 24 hours and during follow-up.ConclusionLA reservoir function, as assessed by PALS, is reduced in patients with severe MS. It improved significantly within 24 hours following BMV and continued to improve at three months of follow-up. It is an underutilized modality among patients of MS for decision-making prior to intervention and to assess the effect of the intervention.

Brachytherapy in children, adolescents, and young adults: An underutilized modality in the United States?

Brachytherapy (BT) delivers highly conformal radiation and spares surrounding tissues, which may limit late effects in pediatric, adolescent, and young adult (AYA) patients. We aimed to characterize trends in BT use for this population in the United States, focusing on patients with rhabdomyosarcoma (RMS). The National Cancer Database was queried to identify patients≤21 who were treated for solid tumor malignancies in the United States from 2004 to 2016. We obtained disease, treatment, and outcome data for patients treated with BT, in particular for RMS. 99506 pediatric and AYA patients met study inclusion. Of these, 22586 (23%) received radiation therapy (external beam radiation therapy [EBRT] and/or BT) and 240 (0.2%) received BT. Among patients treated with BT, 139 (58%) underwent surgery and 58 (24%) received EBRT. A total of 3836 patients were treated for RMS during this period. Of these, 2531 (66%) received any radiation and 37 (1%) received BT (EBRT + BT in 3, BT in 34). Of patients treated with BT for RMS, 28 (76%) underwent surgery + BT. Survival data were available for 31 patients treated with BT for RMS. With a median follow-up of 63 months, overall survival was 100% for patients with RMS of a favorable site treated with BT. BT is rarely used to treat pediatric and AYA patients in the United States. Patients treated with BT for RMS experienced favorable survival, suggesting that this approach may not compromise oncologic outcomes and warrants further study as a therapeutic option in pediatric and AYA patients, specifically in RMS.

Vertebroplasty as a palliative treatment option for intractable pain in pediatric patients with spinal tumors.

Primary and secondary malignant tumors of the spine are relatively uncommon in the pediatric population but are associated with high morbidity and significantly decreased quality of life due to pain. Local management of these tumors is often challenging due to the importance of maintaining vertebral mechanical integrity as well as the spinal growth potential. Typically, surgery and/or radiation therapy have been used in the primary management of these tumors. However, treatment options become more limited when there is relapse or refractory disease, with re-resection or additional radiotherapy often not being viable therapies. Vertebroplasty is a currently underutilized modality that might provide significant pain palliation in cases of relapsed cancer in the spine.

Practical protocol for lung magnetic resonance imaging and common clinical indications.

Imaging speed, spatial resolution and availability have made CT the favored cross-sectional imaging modality for evaluating various respiratory diseases of children — but only for the price of a radiation exposure. MRI is increasingly being appreciated as an alternative to CT, not only for offering three-dimensional (3-D) imaging without radiation exposure at only slightly inferior spatial resolution, but also for its superior soft-tissue contrast and exclusive morpho-functional imaging capacities beyond the scope of CT. Continuing technical improvements and experience with this so far under-utilized modality contribute to a growing acceptance of MRI for an increasing number of indications, in particular for pediatric patients. This review article provides the reader with practical easy-to-use protocols for common clinical indications in children. This is intended to encourage pediatric radiologists to appreciate the new horizons for applications of this rapidly evolving technique in the field of pediatric respiratory diseases.

Exploring the Resourcefulness of an Underutilized Modality

ABSTRACT Ductography (DG), also called galactography, is an important imaging diagnostic tool for evaluating patients with suspicious nipple discharge (SND). It is practical and cost-effective yet it is heavily underutilized in resource-constrained countries. The aim of this review was to explore the use of conventional DG as a diagnostic tool in the management of patients with pathologic or SND. This is a review of available literature on DG and SND over the past 36 years. In patients with SND, conventional DG is still a valuable, simple, and cost-effective imaging tool for the accurate localization of causal intra-ductal lesions including breast cancer. In resource-challenged environments, therefore, promoting ductographic diagnosis is cost-effective and attractive because it also affords curative targeted duct excisions.

Putting Theory Into Practice: A Conceptual Framework for Career Group Counseling in School Settings

ABSTRACT Given the known benefits of group counseling for school-aged individuals, career group counseling has arguably been an under-utilized modality for providing career development services in school settings. This article synthesizes concepts from Social Cognitive Career Theory, constructivism, and group process to provide a conceptual framework for this work. An illustrative example provides a detailed description of a career counseling group for practitioners in schools to reference in their own approach to career group counseling. Practical and theoretical considerations and implications for this work are discussed.

Predictors of Minimally Invasive Myomectomy in the National Inpatient Sample Database, 2010-2014.

Background and Objectives:This study aims to characterize the utilization of minimally invasive myomectomy in the United States and to identify the patient and hospital factors associated with surgical approach to myomectomy.Methods:This is a cross-sectional study using the National Inpatient Sample database. We extracted women aged 18–50 years who underwent open and minimally invasive (laparoscopic and robotic) myomectomy (MIM) from January 1, 2010–December 31, 2014. Descriptive statistics were obtained for patient and hospital characteristics. We then performed multivariable logistic regression to examine the association of patient (age, race, insurance status, median household income) and hospital (bed size, teaching status, for-profit status, census region, cases volume) characteristics with the likelihood of undergoing MIM.Results:Of 114,850 myomectomy cases, 8,330 (7%) underwent MIM and 106,520 (93%) were open. Over time, the proportion of MIM remained very low and slightly decreased from 8.2% in 2010 to 6.1% in 2014 (p-for-trend: 0.001). Most hospitals performed few MIM per year, with 50% performing five or less, and 25% performing three or fewer per year. African American, Hispanic, and women of other races were less likely to undergo MIM compared to Caucasian women (adjusted odds ration [OR] 0.57, 95% confidence interval [CI] 0.50–0.64; 0.71, 95% CI 0.60–0.83; 0.62, 95% CI 0.52–0.74, respectively). Women in the West (adjusted odds ratio (aOR) 1.23, 95% CI 1.04–1.46) and Midwest (aOR 1.27, 95% CI 1.07–1.52) had higher odds of undergoing MIM.Conclusion:MIM appears to be an underutilized modality, accounting for less than10% of myomectomies. This underutilization disproportionally affects minority women.

SEPSIS – HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS OVERLAP: A RARE OVERLOOKED ENTITY AND ROLE OF PLASMAPHERESIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is characterized by pathologic immune activation leading to multiorgan failure. In sepsis, it presents due to an infectious trigger resulting in overwhelming cytokine release. This is known as sepsis-HLH overlap syndrome (SHLHOS)(1). We present a case of septic shock with HLH overlap successfully treated with therapeutic plasma exchange (TPE). CASE PRESENTATION: A 61 year old male was admitted for obstructive uropathy. He was febrile to 102.5F, HR was 133 bpm and BP 141/93 mmHg. He had a leukocytosis of 21.2 k/uL, lactic acidosis and procalcitonin of 49.2 ng/mL. Imaging showed an obstructive 4.1 mm ureteral stone with hydronephrosis. Broad spectrum antibiotics were initiated and a nephrostomy tube was placed. Despite fluids, hemodynamics declined and he required supratherapeutic doses of 5 different vasopressors. He had shock liver, progressive acidosis and oliguric renal failure requiring continuous renal replacement therapy. Blood cultures showed gram negative rods and procalcitonin remained >200 ng/L. Due to a lack of improvement, there was concern for immune dysregulation. Ferritin was elevated at 21,197 ng/ml, IL-2 receptor alpha was 4,398 u/ml, LDH was >2,250 U/L and IL-6 level was elevated at 44.5 pg/m. This, along with anemia and thrombocytopenia was supportive of a diagnosis of SHLHOS. Due to continued declining status, and a relative contraindication of pulse steroids in active bacteremia, TPE with fresh frozen plasma was initiated. After two sessions he was weaned off all vasopressors over 72 hours. His ferritin improved to 1,700 ng/ml, procalcitonin decreased to 29 ng/L and lactic acidosis resolved. He was extubated and antibiotics were tailored to his E. Coli bacteremia. DISCUSSION: Sepsis-HLH overlap syndrome is under recognized and undertreated. Hemophagocytosis can be present in a large number of sepsis patients. Biomarkers including IL-6, IL-2 receptor alpha, IFN-gamma and ferritin may be useful in identifying these patients early. Higher levels of ferritin, typically >10,000 ng/mL have been associated with HLH. These elevated biomarkers have correlation with clinical status as well as response to therapy and mortality(2). The target of therapy in SHLHOS is to suppress the immune response which includes steroids, anakinra and immunoglobulins. TPE has the potential to improve hemodynamics and survival by removing inflammatory cytokines and replacing protective factors and may represent an effective, yet underutilized modality of therapy (3). It is important to recognize sepsis patients who are at high risk of developing SHLHOS in order to provide timely and potentially life-saving intervention. TPE may be beneficial in SHLHOS resulting in improved hemodynamics. CONCLUSIONS: Therapeutic plasma exchange may be beneficial in sepsis-HLH overlap syndrome resulting in improved hemodynamics. Reference #1: Weitzman S. Approach to hemophagocytic syndromes. Hematology Am Soc Hematol Educ Program 2011;2011:178–83 Reference #2: Kuwata K, Yamada S, Kinuwaki E, Naito M, Mitsuya H. Peripheral hemophagocytosis: An early indicator of advanced systemic inflammatory response syndrome/hemophagocytic syndrome. Shock. 2006 Apr;25(4):344-50 Reference #3: Demirkol D, Yildizdas D, Bayrakci B, et al. Hyperferritinemia in the critically ill child with secondary hemophagocytic lymphohistiocytosis/sepsis/multiple organ dysfunction syndrome/macrophage activation syndrome: what is the treatment?. Crit Care. 2012;16(2):R52. Published 2012 Dec 12 DISCLOSURES: No relevant relationships by Muhammad Ibrar Islam, source=Web Response No relevant relationships by Paul Marik, source=Web Response No relevant relationships by Mit Patel, source=Web Response No relevant relationships by Nina Swiacki, source=Web Response

P1227SURVIVAL OF PATIENTS TRANSFERRED FROM HEMODIALYSIS (HD) TO CHRONIC AMBULATORY PERITONEAL DIALYSIS (CAPD) DUE TO POOR ARTERIOVENOUS (AV) ACCESS

Abstract Background and Aims This study was carried out to ascertain the 6 month survival of patients who were transferred from hemodialysis to peritoneal dialysis due to poor vascular access at tertiary care facility in Pakistan. PD remains an under-utilized and unpopular modality of renal replacement therapy. One of the major reasons for its unpopularity remains poor patient selection. Furthermore PD is used as a last resort when AV access for HD becomes impossible in Pakistan. Method This study was carried out over a 4 year period. All patients transferred from hemodialysis onto peritoneal dialysis were included in the study. A total of 23 patients of Pakistani decent were switched to peritoneal dialysis from hemodialysis because of poor AV access. All patients included in the study had undergone venograms and consultation with vascular surgeons to confirm that AV access henceforth was inadequate for hemodialysis to continue. After placement of the peritoneal dialysis catheter a 2 week rest period was given to each patient before CAPD was initiated. The 6 month survival of each patient from the point of being transferred to CAPD was noted. Results The mean age of patients included in the study was 58 years. 80% of the participants were known to have diabetes mellitus. 15 out of the 23 patients included in the study died within 6 months of starting peritoneal dialysis. 12 out of the 23 patients included had difficulties in achieving either required ultrafiltration or KT/V despite ensuring correct catheter placement and following standard CAPD good practices. Conclusion Patients being switched from hemodialysis to CAPD due to poor AV access carry a greater than 50% 6 month mortality rate. In a country where PD struggles to gain popularity, we need to be very selective in starting patients on this modality with a realization that PD cannot be kept as a last resort rather should be advocated as the first choice therapy. Only then can the true benefits of PD be exhibited.

Acceptance and Decline of Pap Smear in a Tertiary Care Setup

Cervical carcinoma is the second most common malignancy of genital tract. Risk factors include early age at first intercourse, smoking and multiple sexual partners. Cervical cancer can be prevented by Pap smear screening test. Pap smear is still an underutilized diagnostic modality in under developed countries. Provision and appropriate treatment should be offered in female. Objective of this study was to address the mindset of our females about pap smear screening and spreading awareness. This descriptive study was done in Obstetrics and Gynecology department of Sharif Medical City Hospital Lahore from January 2017 to January 2018 on 180 patients. Age, parity and duration of marriage were expressed as mean and frequency with percentages. Reasons of acceptance and decline were also expressed as frequency with percentage. The age range of the patient in present study was between 18-62±8.565 years. Regarding marital status, all the recruited females were married. Parity range was from 0-9±2.101 with a mean parity of 3.03. There were 129 females who accepted Pap smear. The most frequent reason for acceptance was recommendation by doctor in 93 (72%) patients. Out of 180 patients, 51 patients were those who decline Pap smear. The reason of decline was fear of pain in 17 (33.3%) patients, fear of a positive result and lack of knowledge. Cervical cancer is a deadly disease which affects the females in their early reproductive year. Screening should be offered in all reproductive females and it should be promoted through media campaigns. It is the responsibility of doctors as well to offer this screening test to all the female coming with or without gynecological complaints.

A Surgical Snapshot of Myomectomies in the United States from 2010-2014 using the National Inpatient Sample

Study Objective To examine the surgical approach to myomectomy and describe patient factors including geography, race, and length of stay. Design Data was abstracted from the 2010-2014 National Inpatient Sample of women ages 18-50 years undergoing myomectomy for fibroids. We used weighted statistics to characterize the number and proportion of women undergoing inpatient myomectomy (abdominal, laparoscopic, and robotic) as well as geographic and racial subgroups. We used multivariate logistic regression to analyze trends in myomectomy route over time. Setting United States. Patients or Participants 124,880 women ages 18-50 years undergoing inpatient myomectomy for fibroids. Interventions N/A Measurements and Main Results Of 124,880 women undergoing myomectomy for fibroids, 7% underwent minimally invasive myomectomy (MIM) and 93% underwent abdominal myomectomy. Over time, the proportion of MIM remained low and decreased slightly from 8.2% in 2010 to 6.0% in 2014 (p-for-trend: 0.001). The majority of hospitals perform very few MIM per year, with 75% performing three or fewer per year, and 25% performing less than one per year. The largest percentage of MIM were performed in the South (37.6%; 95%CI 35.4-39.8) followed by the West (22.7%; 95%CI 20.8-24.6) and North (21.8%; 95%CI 19.9-23.7) and the least amount in the Midwest (17.9%; 95%CI 16.1-19.6). The largest percentage of MIM were performed in white women (41.4%; 95%CI 39.1-43.8) followed by black (34.3%; 95%CI 32.1-36.6), Hispanic (13.6%; 95%CI 12.0-15.2) and women of other races (10.7%; 95%CI 9.2-12.1). Average length of stay regardless of approach was 2.62 days (95%CI 2.59-2.65) and marginally different for MIM versus abdominal myomectomy (2.51 days; 95%CI 2.42-2.61 and 2.63 days; 95%CI 2.60-2.66, respectively). Conclusion Despite availability and patient benefit, MIM remains an underutilized modality, accounting for

Urgent-start peritoneal dialysis results in fewer procedures than hemodialysis.

BackgroundPeritoneal dialysis (PD) is an underutilized modality for hospitalized patients with an urgent need to start renal replacement therapy in the USA. Most patients begin hemodialysis (HD) with a tunneled central venous catheter (CVC).MethodsWe examined the long-term burden of dialysis modality-related access procedures with urgent-start PD and urgent-start HD in a retrospective cohort of 73 adults. The number of access-related (mechanical and infection-related) procedures for each modality was compared in the first 30 days and cumulatively through the duration of follow-up.ResultsFifty patients underwent CVC placement for HD and 23 patients underwent PD catheter placement for urgent-start dialysis. Patients were followed on average >1 year. The PD group was significantly younger, with less diabetes, with a higher pre-dialysis serum creatinine and more likely to have a planned dialysis access. The mean number of access-related procedures per patient in the two groups was not different at 30 days; however, when compared over the duration of follow-up, the number of access-related procedures was significantly higher in the HD group compared with the PD group (4.6 ± 3.9 versus 0.61 ± 0.84, P < 0.0001). This difference persisted when standardized to procedures per patient-month (0.37 ± 0.57 versus 0.081 ± 0.18, P = 0.019). Infection-related procedures were similar between groups. Findings were the same even after case-matching was performed for age and diabetes mellitus with 18 patients in each group.ConclusionsUrgent-start PD results in fewer invasive access procedures compared with urgent-start HD long term, and should be considered for urgent-start dialysis.

Rectal ultrasound with fine needle aspiration: an underutilized modality for delineating and diagnosing perirectal, presacral, and pelvic lesions.

Background and study aims The merits of rectal ultrasound for rectal cancer staging are well documented. Conventional approaches to accessing perirectal and presacral lesions entail computed tomography guidance via a transgluteal approach or frank surgical exploration. We report on the safety and efficacy of performing rectal ultrasound with fine-needle aspiration (RUS-FNA) for evaluating perirectal, presacral, and pelvic abnormalities. Patients and methods Patients who underwent RUS-FNA of perirectal, presacral, or pelvic lesions between August 2005 and September 2016 were identified using an institutional database. Subjects were all individuals treated at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, United States. Patient demographics and imaging characteristics were noted. Procedural details included lesion size, location, echo appearance, and technical information. Patients were given antibiotics prior to FNA attempt and for 3 days after. Diagnostic yield, clinical utility, and complications were noted. Results Twenty-seven patients met criteria during the specified study time period. The cohort consisted of 12 males (44.4 %) and 15 females (55.5 %). RUS-FNA was diagnostic in 24 patients (88.8 %) and obviated the need for surgery in 14 patients (51.9 %). There were four complications (14.8 %): two perirectal and two presacral abscesses. Conclusion While the diagnostic yield of RUS-FNA is high and the potential to affect clinical decision-making is substantial, risk of complication is not negligible. RUS-FNA should only be performed if the result will substantially alter clinical management, and the decision to perform RUS-FNA should be made with close consultation between the endosonographer, surgeon, and/or medical or radiation oncologist.

Role of ECMO in life threatening intoxication

Acute severe poisoning may lead to life threatening situation or death due to cardiovascular dysfunction or stunning, arrhythmia or cardiogenic shock. These substances include medications, substances used for addiction, house hold chemicals, industrial, plants and animal or vegetable toxicants. The poison profile varies in different parts of world; drugs with cardiotoxic potential are the common poisoning substances while pesticides and other house hold toxins are common in the other part of the world. Irrespective of the type of the poison, these patients are relatively young and usually healthy. Extracorporeal Life Support (ECLS) has become popular in the management of acute severe intoxication induced cardiogenic shock, arrhythmia or cardiac arrest as bridge therapy. The management of poisoning include further reduction of absorption or enhancing the elimination; antidote administration (if available); and supportive therapies including resuscitation. ECMO helps in maintaining adequate cardiac output and tissue perfusion and enhances the toxic substance metabolism. However most of the available literature is based on case reports, case series and retrospective cohort study. In spite of high mortality with severe poisoning and encouraging outcome with use of ECMO, it is underutilized modality across the world. The available literature shows a favourable outcome with ECMO in severely intoxicated patients with cardiovascular collapse, however, there are no clear guidelines for the time of initiation of ECMO on the basis of clinical, metabolic and echocardiographic parameters. Even prognostication prior to initiation of ECMO is difficult to predict. ELSO (Extracorporeal Life Support Organization) may support the global data collection on acute intoxication requiring ECMO, which may address some of these issues.

Nocturnal hemodialysis: an underutilized modality?

There is increasing evidence that extended-hours regimens are associated with improved outcomes for patients on maintenance hemodialysis programs. Home hemodialysis programs are a well established way for patients to benefit from extended-hours dialysis overnight; however, there are significant barriers to home hemodialysis, which means that for many this is not an option. In center, nocturnal hemodialysis is an increasingly recognized way of offering extended-hours treatment to patients unable to undertake home-based programs and is an underutilized modality for such patients to gain from the physiological benefits of extended-hours dialysis regimens. Recent data suggest that nocturnal dialysis programs confer a significant survival advantage over both standard dialysis and short-daily dialysis regimens with evidence proposing that this is mediated through beneficial cardiovascular remodeling. Moreover, there is strong evidence that nocturnal dialysis regimens associate with significant improvements in quality-of-life measures and social well being. Nocturnal hemodialysis is an underutilized way of offering extended-hours hemodialysis to patients in both the home and in-center environments. As the evidence base around nocturnal dialysis grows, clinicians and dialysis providers are becoming increasingly obliged to investigate implementation strategies for nocturnal dialysis services to improve patient outcomes and experience of care.