BackTable Vascular & Interventional

In this episode, guest host Dr. Sean Tutton interviews Dr. Bill Rilling and Dr. Sarah White about the history of the Society of Interventional Oncology (SIO), their current research and volunteer involvement, and future directions of the society. --- CHECK OUT OUR SPONSOR Varian, a Siemens Healthineers company https://www.varian.com/ --- SHOW NOTES We begin by discussing how the Society of Interventional Oncology (SIO) began. It started as the World Conference of Interventional Oncology (WCIO), but was formed into an official society with the goal to become the fourth pillar of oncology care, in addition to surgical oncology, medical oncology and radiation oncology. At the time of its inception, the group asked themselves whether interventional oncology would be bettered by the addition of a professional membership society, and there was a thoughtful and unified decision that it would be. Next, we discuss what goes into forming a society? When asking people to become members, pay money and give their time, they will expect some return on their investment. It's important to have a formal society, as it greatly advances the field forward. The ability to focus resources and effort completely on what you're passionate about is what having SIO allows. At SIO, we want people to be members of both SIR and SIO, it should be both, not one or the other. Finally, we talk about some of the current research funded by SIO. SIO fulfills the research aspect of the society by creating data, currently via the Ablation with Confirmation of Colorectal Liver Metastasis (ACCLAIM) Trial. This trial uses software to determine post-treatment margins in percutaneous microwave ablation for colorectal metastasis of the liver. With this trial, they hope to prove that this procedure results in high rates of clear margins, which will make it a minimally invasive alternative to surgical resection. Future research efforts will likely focus on coupling locoregional therapy with targeted immunotherapy. They aim to start treating new cancers, develop further partnerships with industry and pharma, and continue to produce quality data on response rates to promote interventional oncology as the well respected and accepted fourth pillar of oncology. --- RESOURCES SIO: www.sio-central.org ACCLAIM Trial: www.sio-central.org/p/cm/ld/fid=809

24 Loka 202239min

In this back to the basics episode, Dr. Christopher Beck interviews Dr. Aaron Fritts about his standard procedure for nephrostomy tube placement, preferred tools, and troubleshooting tips. --- CHECK OUT OUR SPONSOR Reflow Medical https://www.reflowmedical.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/yEfEUY --- SHOW NOTES Dr. Fritts says that most of his referrals come from urology, and patients need treatment for hydronephrosis, kidney stones, and pre-operative access for lithotripsy. He goes over his workup, which can be expedited in emergency cases. He checks for normal coagulation tests and anticoagulation medications, since bleeding is the most common and dangerous complication of the procedure. Both doctors prefer to use CT imaging to map out the procedure, identify stone burden, and decide which calyx to access. It is important to use CT to make note of and avoid the colon (lateral) and paraspinal muscles (medial) when choosing an access site. Dr. Fritts also marks the access site before the patient gets prepped for the procedure, in order to ensure that the correct area is cleaned. Patients are usually under moderate sedation with versed and fentanyl. Then the doctors walk through a typical nephrostomy tube placement under ultrasound guidance. They emphasize that lidocaine needs to be injected all the way down to the cortex to maximize patient comfort and decrease the likelihood of patient movement during the procedure. Then, the needle is inserted into a calyx. While it is standard to access the lower pole to minimize bleeding risk, Dr. Beck sometimes prefers mid-pole access since this provides a shorter distance from skin to target and a more favorable angle to enter the ureter from the renal pelvis. The upper pole is generally avoided due to risk of diaphragmatic puncture, but it can be accessed if a stone is present there. Dr. Beck shares a tip about injecting saline to plump up the calyces and allow for better access. Dr. Fritts describes the two-stick technique that was primarily used before ultrasound access was available. He also recommends communicating with urologists in lithotripsy patients to identify optimal access sites for each patient’s lithotripsy. If the wire is placed directly on top of the stone and you have difficulty maneuvering the wire around the stone, you can inject saline to dilate the system and obtain a better angle for the wire. Finally, the doctors talk about drain selection, which is usually an 8Fr or 10Fr. The drain is secured with stitches, and possibly a bumper stitch. Pyonephrosis patients are usually kept inpatient, while other patients can get discharged after two hours. It is important to watch for hematuria and distinguish between mildly red venous blood from minor procedural trauma (which will subside) and bright red blood from arterial damage. --- RESOURCES SIR Now: https://sirnow.sirweb.org/ Ep. 97- Nephrostomy Tube Placement with Dr. David Feld: https://www.backtable.com/shows/vi/podcasts/97/nephrostomy-tube-placement-basic-to-advanced Diuretic agent and normal saline infusion technique for ultrasound-guided percutaneous nephrostomies in nondilated pelvicaliceal systems: https://pubmed.ncbi.nlm.nih.gov/22893420/ Bumper Stitch for Drainage Tube Securement: https://www.jvir.org/article/S1051-0443(11)01353-4/pdf

21 Loka 20221h 25min

In this episode, Dr. Aaron Fritts interviews Dr. Christopher Beck about gastrostomy tubes, including the evolution of his method, tips for patients who pull their tubes out, and why g-tubes are such a controversial topic in IR. --- CHECK OUT OUR SPONSOR Laurel Road for Doctors https://www.laurelroad.com/healthcare-banking/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/B9TbcW --- SHOW NOTES We begin by discussing indications and contraindications for gastrostomy tubes. Frequent indications are stroke patients, head and neck cancer patients, and trauma patients. Contraindications include uncorrectable coagulopathy, ascites, peritoneal carcinomatosis, or something interposed between the abdominal wall and the stomach, such as liver or bowel. Dr. Beck prefers having imaging to review, which most patients have. If no prior imaging is available, he will get a non-contrast CT abdomen the day of the procedure. He likes all his patients to drink barium for visualization of bowel during the procedure, but will not cancel the procedure if they didn’t drink it, as the insufflation should move bowel out of the way and there should be enough bowel gas to identify and avoid the bowel. Next, Dr. Beck reviews the details of his method. He likes to use monitored anesthesia care (MAC), because frequently he has patients with bad Mallampati scores. Additionally, anesthesia is very helpful with NG placement. Furthermore, it makes the procedure much more comfortable for the patient. He always checks liver margins with ultrasound prior to starting the procedure. He always gives 1 mg glucagon before insufflation and antibiotics per the SIR Guidelines App. As for equipment, he uses t-fasteners from Avanos, a dilator set, and a 20Fr G-tube. He used to start with 16Fr but found he frequently had to size up to a 20Fr. He uses a 24Fr peel away sheath. For the procedure, he insufflates, marks his entry point with a hemostat, and then numbs in all 3 spots where he will place his gastropexies. He uses 1/2 syringe of contrast for his gastropexy placement. He uses 2 t-tags, and prefers the C-arm in RAO rather than AP during this step. For G-tube placement, he aims 20 degrees toward the pylorus, and always makes sure he sees wire touching two walls of the stomach to ensure he is intraluminal. He uses sterile water to inflate the balloon rather than saline or contrast. Lastly, he always makes sure to get a good final image to confirm placement in the stomach. For post-care, on inpatients he rounds the next morning, checking that the tube flushes and then clears it for use. For outpatients, he recommends no feeding (via G or NG) for three hours and a consult with a dietician before discharge. After this, the patient can receive nutrition via NG. If the patient has no peritoneal signs, the G-tube can be used the next day. For tube management, he exchanges the tube every 6 months or sooner if there is an issue, such as the tube being pulled out or becoming clogged beyond the point of a bedside fix. --- RESOURCES BackTable YouTube Gastrostomy Tube Demo: https://www.youtube.com/watch?v=17ep0AEkKqs Early Initiation of Enteral Feeding: https://pubmed.ncbi.nlm.nih.gov/24674218/ SIR Guidelines App: https://apps.apple.com/us/app/sir-guidelines/id1552455529

17 Loka 20221h 9min

In this episode, Dr. Ally Baheti interviews interventional radiologist Dr. Judy Gichoya about her recent paper on artificial intelligence (AI) and the use of a deep learning model to recognize patients’ self-described racial identity, based on radiology images. --- CHECK OUT OUR SPONSORS Medtronic Concerto https://mobile.twitter.com/mdtvascular Viz.ai https://www.viz.ai/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/XIPsKR --- SHOW NOTES Dr. Gichoya had started by tackling the original problem of bias in diagnoses for chest X-rays, since it has always been difficult to tell whether something is a real diagnosis, or simply just a finding. Her team built a deep learning model; however, they saw that it did not work well for black patients. With further investigation, they discovered that their model had learned signals that correlated with self-identified race. Intrigued by this finding, Dr. Gichoya and her team sought to identify the factors that the model used when making its race determination. Because AI is black box in nature, the methods by which the algorithm learns remains largely unknown. When tested in other imaging modalities (mammogram, chest CT, spine imaging), the model still showed high accuracy. Additionally, the model retained accuracy when different information was eliminated from the images (ex. age, disease distributions, bone densities). The model was also able to predict race in healthy patients, showing that it did not rely on patterns of disease prevalence in specific ethnic groups. Next, we spoke about the implications of this research in developing risk scores. Deep learning models are able to look at factors that humans are not trained or able to see. Dr. Gichoya highlights the model’s potential effectiveness in predicting osteoarthritis risk in black patients. We also look at applications in opportunistic screening and information about social determinants of health. For example, most patients presenting with chest pain often get chest CTs. Dr. Gichoya thinks that these images can be used by the model to learn about patients’ environmental exposures, like pollution. We finish the episode with a discussion on the changing landscape of IR and how AI can be used as an assistive technology. Interventional cardiologists are already using AI to dictate their procedural reports in real-time. In the interventional oncology space, AI could help integrate imaging and pathology findings to determine personalized treatment courses. All of these applications depend on researchers’ ability to market their findings to peers and the public, Dr. Gichoya gives tips on how to do this. --- RESOURCES AI recognition of patient race in medical imaging: a modelling study: https://www.thelancet.com/journals/landig/article/PIIS2589-7500(22)00063-2/fulltext

14 Loka 202233min

In this episode, Dr. Vishal Kumar interviews Dr. Mark Wilson, vice chair and professor of radiology and biomedical imaging at UCSF, and chief of diagnostic and interventional radiology at the Zuckerberg San Francisco General Hospital and Trauma Center about the evolution of trauma care in interventional radiology, translational research, and the impact of mentorship and student outreach. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/0RPqzN --- SHOW NOTES We begin by discussing how Dr. Wilson discovered radiology, and how he has come to be a leader in IR. He started out with an interest in psychiatry, and became involved in research on psychiatric brain imaging. As he delved deeper into biomedical imaging, his fascination grew. With help from his mentor, he began publishing, which motivated him to further pursue his passion for research. He learned about IR, and then got into UCSF for his radiology residency. Being at the frontier of innovations, Dr. Wilson has been involved in research on MR guided interventions, remote navigation, and percutaneous venous chemo filters. He says these projects have reinforced that radiology and research isn’t done in a vacuum. He depends on his collaborators in material science, chemistry, and other fields to successfully innovate. One thing he loves about the research lab is the student involvement, and getting to see high school and college students get their name on a paper. This is one area of student outreach that has an incredible impact and shapes future leaders in radiology and medicine. Finally, we discuss how Dr. Wilson spearheaded the role of radiology within the hospital infrastructure when they created the new SF General Hospital, the Zuckerberg San Francisco General Hospital and Trauma Center. He collaborated with hospital leadership and architects, as well as emergency medicine, surgery, anesthesia and nursing to build a state of the art trauma care center to serve the people of San Francisco. It fulfills its goal of bringing the services to the patient to deliver better and more efficient care. From CT scanners in the ED, to a hybrid trauma OR, this new center is one of the leading IR and trauma centers in the world. --- RESOURCES The History of the Zuckerberg San Francisco General Hospital and Trauma Center: https://zuckerbergsanfranciscogeneral.org/about-us/our-history/

10 Loka 202245min

In this episode, BackTable is on location in Barcelona for CIRSE 2022! Dr. Aaron Fritts conducts a live video interview with interventional radiologist Dr. Lorenzo Patrone. They discuss their experiences with balancing clinical, academic, and family responsibilities, as well as differences in the American and European physician work environments and the use of social media in medicine. --- CHECK OUT OUR SPONSORS Reflow Medical https://www.reflowmedical.com/ Medtronic Chocolate PTA Balloon https://www.medtronic.com/peripheral --- SHOW NOTES Dr. Patrone recounts his entry into the European IR speaking circuit. Through networking, he continues to meet speakers, learn from their experiences, and gain effective communication and presentation skills. He speaks about normalizing the feeling of imposter syndrome, especially when being invited to speak among IR founders and luminaries. He emphasizes personal growth and identifying where your passion and talent overlaps with lecture content. Dr. Patrone highlights the fact that the field of IR revolves around three different aspects: First, the pioneering phase to innovate new procedures, then the research/evidence phase to demonstrate reproducible results, and finally, the education phase to disseminate knowledge and inspire new generations of IRs. It is common for IRs to feel overwhelmed when trying to commit to all of these fields. Instead of trying to master all aspects of the job, Dr. Patrone recommends that clinicians find different angles of their jobs and hone in the aspects that make them enthusiastic to come to work. Personally, he prioritizes clinical care and teaching. We discuss how time is the ultimate luxury, and how to avoid over-commitment and burnout. We also consider societal gender roles and talk about unjust extra pressures faced by female physicians. Then, we look at some key differences between a physician career in the US, versus one in Europe. Dr. Patrone comments on the pay gap, training pathway, and overall philosophy of the Italian and British healthcare systems. Finally, we discuss benefits and misuses of social media within the medical community. Dr. Patrone emphasizes that social media should be used as a tool to teach and inspire, rather than a platform to criticize individuals or specialties. Regarding case-based posts and feedback, he highlights the point that every clinician could have a different but valid approach to each case, based on the practice setting and operator skill. He also encourages other posters to talk about case complications, which can provide enormous educational value for learners.

7 Loka 202252min

In this episode, Dr. Aaron Fritts interviews Dr. Peder Horner about the impact of staff culture on patient care, how to manage bad players, and how to maintain an active role in shaping a healthy work culture. --- CHECK OUT OUR SPONSORS Accountable Physician Advisors http://www.accountablephysicianadvisors.com/ Accountable Revenue Cycle Solutions https://www.accountablerevcycle.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/49cHUg --- SHOW NOTES We begin by discussing why staff culture is important. In IR, many people are coming out of a toxic training program and are now expected to be department leaders. We take after our mentors, and we pick up both good and bad habits. So where does healthy staff culture start? Dr. Horner explains that it starts from the top. You have to play an active role in molding the culture, otherwise it will remain toxic or simply be uninspiring. Next, we ask Dr. Horner how he inspires his staff. He shares many values as a parent and a leader. If he is tired and as a result doesn’t smile while at work, it can set the mood for a case, similarly to how it can add up and impact a home relationship on a day to day basis. When employees have negative feelings at work, this results in worse patient care. Lastly, we talk about how to maintain culture once you have a good team onboard. Dr. Horner believes in checking in frequently by asking his techs and nurses how they are doing. He prioritizes their career growth and mobility, which he says may lose him employees over time, but in turn makes people enjoy coming to work because they feel like they are improving and advancing. He says you must be selfless as a leader. If you expect everything to stay static, you’re doing your staff and patients a disservice. Even a great team, if left static, will not go far. He encourages personal and professional development among his staff which is a huge part of the culture of growth he believes in. --- RESOURCES Harvard Business Review: https://hbr.org Paper on Work Culture and Patient Care: https://asqblog.com/2015/02/25/barsade-oneill-2014-whats-love-got-to-do-with-it-a-longitudinal-study-of-the-culture-of-companionate-love-and-employee-and-client-outcomes-in-a-long-term-care-setting/

3 Loka 202249min

In this episode, Dr. Vishal Kumar interviews trauma surgeon Dr. Andre Campbell about his career path and policy interests, including gun safety, nationwide access to trauma care, and diversity and inclusion within surgical subspecialties. --- CHECK OUT OUR SPONSOR RADPAD® Radiation Protection https://www.radpad.com/ --- EARN CME Reflect on how this Podcast applies to your day-to-day and earn AMA PRA Category 1 CMEs: https://earnc.me/oKVBfW --- SHOW NOTES Dr. Campbell starts the conversation by explaining how he was exposed to early mentorship, which guided him towards pursuing his interest in medicine. He outlines his journey, including his childhood in the Bronx, medical school at UCSF, and residency training. Dr. Andre emphasizes the importance of mentorship at all stages of one’s career. He personally became interested in medicine due to a sixth-grade teacher who sparked his interest in science. Next, we discuss his journey of choosing trauma surgery as a specialty. He found it difficult to decide between medicine and surgery, so he first completed a medicine residency, and then applied to match into surgery afterwards. Dr. Campbell found himself gravitating towards ICU and trauma care, which led him to specialize in trauma surgery. He currently performs trauma, acute care, and elective surgery. Dr. Campbell also talks about the importance of allowing himself to feel the pain of trauma patients and their families, instead of keeping a distance. With every patient loss, he steps back and thinks about lessons that he could learn and how he could do better next time. Then, we shift to a conversation on gun violence, a health emergency in 2022. The incidence of gun violence has rebounded to a higher level than it was before the COVID-19 pandemic started. Dr. Campbell has served as an advocate for gun control, and he highlights the fact that shootings happen every day, but it is only high profile mass shootings that get media attention. He emphasizes that as healthcare providers “staying in our lane” means taking a stance on firearm laws, since our jobs are centered around taking care of injured people. He also talks about respecting gun owners and the complex role that guns play in American culture and symbolism. Dr. Campbell highlights recent progress being made with laws requiring stricter background checks, allocating more funds for hospital based violence intervention programs and psychiatric care, and continuing efforts for gun safety research. We look at the role of Level One trauma centers in providing care for the US population, including people who live in “trauma deserts” with no easy access to a trauma center. Dr. Campbell speaks about the benefits of implementing a nationwide trauma system. Finally, Dr. Campbell shares his observations about increasing diversity within surgical subspecialties. Again, he notes that mentorship is a large factor, as well as intentional initiatives to build supportive environments for underrepresented minorities.

30 Syys 202251min