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An Overview of Fibroids | Uterine Artery Embolization The Good, The Bad, The Ugly
An Overview of Fibroids | Uterine Artery Embolization The Good, The Bad, The Ugly
benignbleedingcancerchapterdiseasefibroidfibroidsgrowshysterectomieshysterectomykindsmenstrualmuscleNonepelvicportionsymptomstreatmenttumorsuterineuteruswebsitewomen
Project Interventions & Improvements- Lab Reduction | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Lab Reduction | IR Lean Sigma Team Improves Patient Experience and Throughput
biliarybleedingchaptercriticallygastrointestinalguidelinesimproveinterventionallabsneurosurgeryNonepatientprocedureproceduresrisksocieties
UFE Summary | Uterine Artery Embolization The Good, The Bad, The Ugly
UFE Summary | Uterine Artery Embolization The Good, The Bad, The Ugly
chaptercomplicationembolizationfibroidfibroidshysterectomiesNone
Symptoms of Uterine Fibroids | Uterine Artery Embolization The Good, The Bad, The Ugly
Symptoms of Uterine Fibroids | Uterine Artery Embolization The Good, The Bad, The Ugly
blackchapterclassificationsdiarrheaembolizationestrogenfiberfibroidfibroidsgynecologistintramurallocationmucosalNonenormalsymptomsuterineuterus
Review of Abnormal Capnography Readings | Respiratory Compromise: Use of Capnography During Procedural Sedation
Review of Abnormal Capnography Readings | Respiratory Compromise: Use of Capnography During Procedural Sedation
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PET/MRI Case Study #3 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI Case Study #3 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Tarlov Cyst | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
Tarlov Cyst | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
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Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
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Low Dose Radiation Exposure | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
Low Dose Radiation Exposure | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
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Pre-procedure Assessment | Procedural Sedation: An Education Review
Pre-procedure Assessment | Procedural Sedation: An Education Review
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Pulmonary Ablation | Interventional Oncology
Pulmonary Ablation | Interventional Oncology
ablationactivitycancercandidatechaptercolorectalcryodiseaselesionslobelungmetastaticnodulepatientpulmonaryrecurrecurredresectionresidualscansurgical
PET/MRI Case Study #2 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI Case Study #2 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
chaptercontrastfrontalgadoliniumglioblastomalesionlesion located on the left frontal lobelobemalignancyMRINonepatientradiationsurgerytreatmentuptakeviable
Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Patient Education PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Patient Education PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Ideal Uterine Fibroid Embolization Candidates | Uterine Artery Embolization The Good, The Bad, The Ugly
Ideal Uterine Fibroid Embolization Candidates | Uterine Artery Embolization The Good, The Bad, The Ugly
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Extending Our Reach | Twitter Case Files: Impact on our specialty and how to expand our reach
Extending Our Reach | Twitter Case Files: Impact on our specialty and how to expand our reach
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Q&A- Procedural Sedation | Procedural Sedation: An Education Review
Q&A- Procedural Sedation | Procedural Sedation: An Education Review
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PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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What are the Options? | Uterine Artery Embolization The Good, The Bad, The Ugly
What are the Options? | Uterine Artery Embolization The Good, The Bad, The Ugly
chapterconsequencecontinuingdiseaseembolizationfibroidhydronephrosishysterectomymyomectomyNoneoptionspatientsperiodstransvaginal
PET/MRI Case Study #4 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI Case Study #4 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
cervicalCervical CancerchapterlesionmodalityMRINonenormalsurgeryuptakeuterus
Outcome data | Uterine Artery Embolization The Good, The Bad, The Ugly
Outcome data | Uterine Artery Embolization The Good, The Bad, The Ugly
arterybleedcentimeterchapterdatadysfunctionalembolizationfertilityfibroidfibroidsMRImyomectomyNonepatientsretainsurgeryuterineuterus
UFE and Adenomyosis | Uterine Artery Embolization The Good, The Bad, The Ugly
UFE and Adenomyosis | Uterine Artery Embolization The Good, The Bad, The Ugly
accessadenomyosisarteryaxisbifurcationcardiaccathetercatheterschaptercharacteristiccomplicationsdiameterdimeembolizationfemoralfibroidfibroidshematomahydrophiliclabsNonepatientspracticeradialsheathulnaruterine
Project Interventions & Improvements- Patient e-Surveys | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Patient e-Surveys | IR Lean Sigma Team Improves Patient Experience and Throughput
chaptercommentsdynamicemailimprovementmultidisciplinaryNonepatientpilotprocedurequestionsscoresslidesurveysurveysteamwebsite
Fibroid or Cancer | Uterine Artery Embolization The Good, The Bad, The Ugly
Fibroid or Cancer | Uterine Artery Embolization The Good, The Bad, The Ugly
abnormalaggressivebleedingcancercancerschapterclinicdevicefibroidfibroidsgynecologyhelpsMRINoneobstetricsoutcomespatientssymptomsuterineuterus
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
arterycenterschapterembolizationfibroidgooglegynecologistgynecologistsgynecologyhysterectomieshysterectomyinterventionalMRINonepainfulpatientsprocedureproceduresseansmartersurgeryuterine
An Overview of PET, MRI and PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
An Overview of PET, MRI and PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
cancerchapterdiagnosticglucosehypermetabolicmodalitiesMRINonepatientpelvicpositronscantomography
The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
chapterembolizationfibroidfibroidsgynecologistgynecologyhysterectomyinterventionalNoneobgynPathophysiologypatientpatientsprocedureproceduresprogramsurgicallyworkup
Background on Interventional Oncology | Interventional Oncology
Background on Interventional Oncology | Interventional Oncology
bloodcarcinomachapterdilatorinterventionalischemiaoncologypatientsradiologistresectionspecialtystenosistreatmenttumortumors
Transcript

establishing a few things I know that we may have a mixed crowd here and so if I'm saying things that you're like oh come on Newsome we already know that

just just rush me along but if I'm if I'm repeating some other things that that are more interesting then you can slow me down so it is no surprise and I'm often frightened when people say that fibroids

are along the spectrum of cancer fibroids are non-cancerous tumors of the uterine muscle if you remember a little thing about Anatomy that the uterus is made of three specific layers the myometrium which is the main muscle of

the uterus the endometrium wishes the inside part of the uterus and the serosa wishes like a saran wrap of sorts that keeps the whole thing together fibroids are made of the main muscle portion of the uterus and we don't know what it is

but something happens and it turns that muscle portion of the uterus on and when it over grows it grows into a ball and we refer to that ball as a fibroid fibroids are the most common pelvic tumors in women it is the leading cause

of hysterectomy in the US and even though we've been doing hysterectomies forever one third of all hysterectomies that are done in the United States are done for benign disease and we know all kinds of sexy ways now to stop bleeding

you freeze it you make it cold you make it hot we have Lube cautery and all kinds of things and still in 2019 we can't stop the bleeding from fibroids which then result in women who are scheduled for

myomectomy to have a hysterectomy as a way of controlling the bleeding so there are a few other things that we know about fibroids we know that the symptoms are very varied depending on where these fibroids actually end up and

the symptoms of heavy bleeding still remains the most common symptom dysfunctional uterine bleeding abnormal heavy menstrual pain menstrual cycles pelvic pain and symptoms of bulk that is I cannot drink a can of coke before I've

got to go to the bathroom I know every rest stop between my house and where I've got to be every time I laugh or sneeze I pee on myself I'm doing 200 sit-ups a day and I'm wearing two Spanx if that is happening to you that's not

normal we also know that fibroids have a high impact on the quality of our patients lives and their productivity because if you can't go to work and you take off from work and you're really not able to

take your kids to the soccer game or do all the other things that you really want to do then I think that that is really quite disruptive of your life and yet women year after year suffer from these types of symptoms and do not come

to getting any type of treatment at all in fact they don't even tell their doctors about it because they just accept that as kind of normal and the average time from when women start suffering from these symptoms to when

they actually seek treatment is around three and a half years and I work in Atlanta and the average time is away above that and I would say to you that just go with me here and I'm sorry for any male that is in the audience that

will be offended but if you could imagine now now just use my own husband for example if he could not have an erection for two weeks in a row I think he would see the doctor immediately however women will wait for five years

with all kinds of symptoms and not actually seek any treatment forget an erection if they're constipated for two weeks in a row they go to see the doctor this is a real public health burden and I know that I talked about the survey in

2013 and where si are is doing a big thing called a fibroid fix it's available on the website we'll see if there's a way that we could link it to the avir website but just last year they repeated this survey of around a

thousand women but guess what these statistics had not changed around a third of the women continued to complain of this interruption in the quality of their life due to fatigue or cramping and three-quarters of these women still

prefer a minimally invasive uterine sparing procedure they still want to preserve their uterus even if fertility is not an issue and although I just told you that like 80% of black women will have fibroids by the time they're 50 and

70% of white women there's around a quarter of all women that have never ever ever even heard the term fibroids for a disease that is so common and this affects so much whim so many women and it is still so costly in terms of how

much days they have to take off from work and what they have to do in order to get treated we spend around thirty four billion dollars a year in the u.s. that is on par for the amount that we spend for colon cancer and ovarian

cancer combined for benign disease and yet not much has been done so if you're

little survey to for everyone here does which groups do pre-procedure labs on everybody yeah okay so that's important right because that's one of the things that we really took a good look at to

see how we could improve throughput and improve patient satisfaction so Hopkins has a institution-wide initiative where they really want to look at how we can improve the patient experience and part of that is to reduce

unnecessary lab work we have patients that can come from a distance and that can really affect their interface with us over their experience so there's a choosing wisely initiative that allows practices to look at how they operate

and where they think they need to get labs versus where they may not be necessary labs that are drawn on the day of the procedure can cause delays as we wait for results if we have to send patients to a outpatient lab somewhere

that can also cause a significant inconvenience for them for getting labs that may not necessarily be needed so the Society of interventional radiology has a guideline that was first written in 2009 and updated in about 2012 where

they go through what they consider to be different types of procedures guidelines are always very good but guidelines are just that they're just guidelines and I think every practice should be critically evaluating what they're doing

and who they seem to have procedural issues with related to their to their labs so they break it down into low bleeding risk moderate bleeding risk and significant bleeding risk and you notice that the significant bleeding risk

procedures include any type of procedure where we're making a new hole in somebody for some reason whether it's into the kidney or the biliary system or into the arterial system particularly I would have to tell

you that there are lots of societies that are reeling the use of pre procedure labs just an example here from the Journal of neurosurgery this was actually published in 2012 they looked

s and one drawing their pre procedure labs they found that they had not a very good sensitivity and specificity and because of that if you looked at it critically you would save over eighty million dollars annually

with no difference in the bleeding rates during their procedures I will tell you that there actually have been other societies that have published papers since this one that actually are following that lead the most recent one

that I saw was the American Society of gastrointestinal endoscopy you know something probably a little closer to the types of procedures that we're gonna see and obviously neurosurgery is very different from what we see but you have

to look for things that might be more similar and I would suspect that that group has procedures that are more similar to ours particularly in the low risk group and they have stopped looking at their pre procedure labs most of

these papers have repeated over and over that the conversation with the patient and looking at what their pathway to your door has been as as important as the procedure itself okay with that I'd like to stop and I'll and invite Kerry

to come up and talk about improvements thank you

being your sister's keeper this is my last two slides uterine fibroid embolization is effective and it's durable we do know that we although 300 000 hysterectomies are done in the country Stella for benign disease of

fibroids we are making dent in that doing around 30 000 UFE procedures annually in the u.s. we know that the procedure is clinically successful for bleeding in bulk and there are several several clinical studies that have shown

that compared to surgery that you can have less recovery time and complication that outpatient service is going to now become the standard of what the population is asking for no one wants to be in the hospital unless they have to

do it and that we could return patients to a better quality of life faster going back to work and around a week with a low complication rate thank you for your time and for your attention and doctor and I would be available for questions

Thanks

in the audience here I'm actually trying to engage you and recruit you as ambassadors even if you are not a woman you have a mom you have a wife you have

a sister I am My Sister's Keeper and I will ask you to be the same a lot of women are just embarrassed about this they don't even know if it's normal or not and if you're a black girl and 80%

of black women have this problem you kind of start thinking it's normal and you don't start thinking it's so abnormal until you run into another demographic or you casually mention it to your gynecologist and they tell you

that none of these symptoms are normal if you don't own a pair of black of white pants or white dress that is also not normal so I don't single my patients out as much I just have them look you're not alone these are some more prominent

black women that suffered publicly from uterine fibroids probably the most noted is Condoleezza Rice who had uterine fibroid embolization performed by dr. Spees and went on to talk about it but so did some lanta housewives who had

their fibroid embolization done on TV by dr. Lipman there's some other things that we do know about it that it doesn't matter if you're like a black girl in the US or in in Africa or in Jamaica like we do know that fibroids have

something to do with fat because estrogen is stored in fat but it really doesn't seem to follow much about where you live we actually know a few other things that plant-based diet if you eat a plant-based diet then your symptoms

tend to be a little less but it doesn't really protect you from having a fibroid so on this slide we have basketball players models politicians people that exercise feverishly and people who don't exercise at all this slide again is to

remind me to say that this is probably the only thing I think every fibroid has in common with Donald Trump and it's all about location location location because it's all about the real estate that you take up in the uterus

that's how it tells us what kind of symptoms you will have so if we recap there are three layers of the uterus and fibroids are actually from the muscle portion of the uterus but the symptom that you end up with depends on where

the fibroids end up so if you have a fibroid and I'm hoping there's a pointer somewhere and there isn't but if you have a fibroid that kind of pooches in towards the inner lining of the uterus we refer to that as a sub mucosal

fibroid it touches that mucosal surface and if you have a fibroid that is totally within the muscle it doesn't seem to push in or out that is considered an intramural fibroid it just makes the whole thing go big but it

doesn't have a propensity for one side or the other or a sub serosa fibroid is a fibroid that pushes out towards the outside it's touching that saran wrap layer of the uterus and we refer to that as a sub serosa fibroid and these are

just like really cheap way of figuring it out now there are other classifications we call the FICO classifications that is subdivided but no need to know all of that but the symptoms follow these where these

fibroids live so it's easy to see that like what kind of fibroid would this be a sub serosa fibroid is practically like it is hanging off there's a normal uterus with fallopian tubes on the side the suspensory ligaments and then here

is that fibroid that is like just hanging out on the outside and that's the kind of fiber that can cause constipation diarrhea bowel symptoms if that fibroid was touching the bladder then that's a fibroid that would cause

urinary symptoms that is a sub serosa fibroid so now we've talked about the

equipment so first when you have a patient that comes down look at your patient look at

the vital signs Mental Status baseline lung sounds baseline ventilation status do they have a blood gas that's on record do they have they been monitored of capnography are you putting them on it for the first time yourself and

putting the sample line on get your baseline breathing get your baseline reading after a few breaths have them take some nice deep breaths look at their baseline waveform look at their baseline values but consider the

physiology it's okay if they come down and they have a low value or a high value because you're looking for changes and trends in the value second look at the effectiveness of your ventilation so that's a problem sometimes people will

come up to me and say you know this stuff doesn't work yeah I put this thing on the patient and I see their chest going up and down but I'm not getting anything in the monitor well guess what you know and I see this in the recovery

rooms and then I go and like well let's go if I'm clinical well let's go look at the patient and the patient is like slumped down in the bed your head is like this and they're snoring I was like well how about we boost the patient up

we prompt the patient's airway open and all of a sudden our waveform improves so look at your patients right look at the effectiveness of ventilation you know do you need to supplement their ventilation all of a sudden you see their waveform

come right back up right and then finally equipment okay it's not it's it's a little cut and dry yes we use capnograph we put capnography on the gas does the analyzing of the gases for us but you need to understand the the

mechanics of it right and using now capnography with different flow rates and with BiPAP and leak rates and different measures of you know different flow rates of oxygen blowing by so look at your equipment what are the

limitations of the equipment that you're using are your connections tight are you sampling right at the airway or are you sampling distal to the airway some of you may not have a choice right you might only have the mask connections or

for whatever reason you can't you if you have a burn patient or somewhere where you can't put something a patient it's okay but just think about the equipment think about the limitations think about the challenges

you may have with somebody you're doing a te eon or you're flipping somebody prone and they're breathing kind of sideways you're looking at the equipment in conjunction with the patient and the challenges you face so I hope that

putting it together in a format of first looking at physiology second looking at the quality of ventilation but third looking at the equipment interfaces and then passing around some of these devices and such kind of helps to take

it to an advanced level and put some troubleshooting and with that we have time we actually have if we have at least five minutes for questions I'm gonna leave this up on the screen and these are some really great resources so

there are plenty of things online they're free there's no charge some things have C II credits affiliated with them the California burden Board of Nursing but the pace website has a ton of information I apologize I don't have

a handout for you but you can come up take pictures of this go online see any of us after at the booth we can show you some of the equipment we could to answer more questions if you have another session you want to run off to but now

we have time for any questions and the microphones in the middle so don't be shy I don't have any prizes like like prices right but I'd be happy to answer some questions

I good afternoon everyone my name is Ross Lozada and today with Murphy Aldana we will be presenting pet MRI and you technique to obtain high quality diagnostic images for oncology patients we have no disclosures Murphy and I live in New York City it is the place with

over 8 million in population 3 million of which are foreign-born about 800 different languages are being spoken other than English and they love in floor MRI of Memorial sloan-kettering Cancer Center we are reflection of these

statistics we speak about 10 languages which includes Sigala Chinese Russian Korea and Albanian just to name a few and about 70% of our staff are foreign-born actually I can count in one hand or how many are born in the United

States but despite our differences we have a few things in common one is that we all love our jobs and we take pride at what we do and T in taking care of our cancer patients and also we love food

this is a typical potluck in our Union we love our pot Luck's we do it for every holiday for every birthday in even random days where we just say hey you want to eat here we have some stuffed cabbage some rice biryani some mac and

cheese and quiche some caldereta and adobo some curry goat and a Haitian rice called John John but back to our topic our objectives for today is to provide an overview of pet and MRI imaging modalities discuss the application of

pet MRI imaging of oncology patients describe the care of the patient undergoing paddan-aram identify the nursing implications and to review some case studies so what is pet pet or

guidelines so what I did when I created these was try to really simplify them Terry and I have given all this information to our staff nurses we've

this was a two and a half year project we took in feedback from our radiologists obviously went on off of their clinical best practice and their clinical experience this table here is a table for our low-risk bleeding

procedures I've already given you the list but within our guidelines I've created hot links where they can just click on whatever procedure they're doing in it it'll bring them to the appropriate table but as you can see for

our lowest bleeding procedures we currently we are no longer really gathering much from our patients we've deemed that it is safe for these patients to have this procedure this is also in the journal article so I would

recommend that you guys read that here's our moderate to high risk procedure again like I shared earlier we've decided to combine moderate to high risk versus having two separate tables so this one is where we also need to take

into consideration our patients and their disease processes and why they're on certain medications but this allows for our nurses to look at this list for these patients and determine how we triage this patient next it allows for

these pre procedure phone calls and our pre procedure screenings assessments that we're doing to be more expedited

study I would like to share to you in personal note that my training school

books and experiences never prepared me for all the different types of cancer I have seen while working at Memorial sloan-kettering I have come to realize that cancer does not discriminate it doesn't matter how old you are

socioeconomic status gender race color of your skin and geographical location and religious beliefs and taking care of the young pediatric patients makes me the saddest if cancer hits you it hits you

the youngest patient that ever took care of is two months old infant diagnosed with glioblastoma I remember that day clearly because I booboo the whole day based on this here comes the third case study this is a four year old child

diagnosed with hepatoblastoma a pet MRI with anesthesia is done the image to your left is pet and on the right is pet MRI you see the difference in the images this scan is done for the doctor to evaluate the extent of the disease you

could see there is a hypermetabolic uptake in the liver and in the pelvic area the color red on top of the head the patient that's normal that's a normal uptake there is no increase in the uptake so this considered normal

we're gonna do our closer look and I would like to show you the difference between the PET CT and the pet MRI the image on the middle is the PET CT done on March you could see how where are the areas that are you could see all the

increased uptake on the areas like the chest the neck thoracic region and the abdominal region the the bright area there at the bottom Dustin or my bladder up take look at the image on to your right that's a close-up loop of the

sagittal PET CT done on same month you could see clear I could see where the location of the abnormal act uptake are circled by the the white circle there is abnormal uptake in the spine and in the chest and

of course where the hepato blastoma is located but looking to your left that's the bet MRI you see how the image is so clear and defined you could now count from the you could count where the exact location is it's on T 11 and is in the

vertebra and there's evidence of the actual cord compression with all you know all you know is a neuro emergency this is a four year old child and the other abnormal app takes you could see also so this child don't only have

hepatoblastoma but also have OSHA's metastases so the scan is done to evaluate the extent of the cancer the last cases study is the 41 year old

projects that I care about I've become very involved in the treatment of back pain in women women get back pain for

different reasons than men twenty percent of the time the cause of the back pain is not in the vertebral column of the neural foramina or the disc it's in the paravertebral soft tissues or the soft tissues anterior to the sacrum in

the pelvis so every tuesday i see five to seven women who've been told they're crazy by orthopedic or neurosurgeons because they have sciatica but their MRI is normal because they looked there and they don't look over there

so I just published a paper on gender bias and female back pain and it's taken me 12 years of work this began as you guys remember me doing tarlof cysts and then it's expanded into other causes of sciatica like endometriosis cyclicals

sciatica in women from endometriosis on their lumbosacral plexus now most people have never even heard of that but it's a real thing so and this in the BMJ when you publish there has to be a patient impact statement so the patient in the

case report wrote this wonderful letter so this is a series of six papers that has taken me ten years to write so when you have these ongoing projects it gets you up in the morning it keeps you engaged and so um I've worked very hard

on this area of tart of cysts and it'll take about ten or fifteen years to change medical practice because it takes about that long for physicians to change what they do I'll skip through this but this is how you treated you put in two

needles into the cyst you aspirate fluid from one air goes in the other then you inject fibrin glue and it works about 72 percent of the time it's really easy

questions comments and accusations please hello this topic is very personal to me I've had it actually had a UFE so this is like one of my big things I work in the outpatient center as well as a

hospital where we perform you Effy's and frequently the radiologist will have me go in and talk to the patient it's from a personal perspective one of the issues which it may just have been from my situation was pain control post UFE

whether you normally tell your patients about pain control after the UFE someone say we are all struggling with this yeah oh it's not what's your question is going to be okay good I'm gonna get doctor Dora to answer Shawn the question

is what do you what do we do with this pain issue you know what are you doing for the home there at Emory there you know and a lot of practices we we don't rely on one magic bullet for pain control recently we've been doing

alternate procedures for two adjunctive procedures to help with pain control for example there are nerve blocks that you can do like a superior hypogastric nerve block there's there's Tylenol that can be given intravenously which is seems to

be a little more effective than by mouth there's there's a you know it and a lot of times it's it's a delicate balance right between pain post procedural pain because you can often get the pain well controlled with with narcotics opioid

with a pain pump but the problem is 12 hours later the patients is extremely nauseous and that's what keeps her in the hospital so it's a it's a balance between pain control and nausea you can you can hit the nausea

beforehand using a pain and scopolamine patch that that'll get built up in the system during the procedure and that kind of obviates the nausea issues like I said that the the nerve blocks the the tile and also there are some other

medicines that can can be used adjunctive leaf or for pain control in addition to to the to the opioids so the answer the question is there are multiple there multiple answers to the question there's not one magic bullet so

that helped it did one of the things that I tell the patients is that you know everyone is different and yet some people I've seen patients come out and they have no pain they're like perfect and then some come out and they are

writhing in the bed and they're hurting and they're rolling all around what and I always ask the acid docs are you telling them they could possibly have you know pain after the procedure because some have the expectation that

I'm going to be pain-free and that's not always the case so they have an unrealistic expectation that I'm gonna have the UFE but not have pain what I also tell them is that the pain it's kind of like an investment right and

this is easy for a guy to say that right but but it's it's an investment the worst part the worst pain you should be feeling is the first 12 12 hours or so every day I tell my patient you're gonna be getting better and better and better

with far as the pain as long as you is you follow our little cookbook of medicines that we give you on the way home and I want you to make sure that you fill these prescriptions on the way home or you have someone fill those

prescriptions for you before he or she picked you up in the hospital and lately we have been and I see that you're there as well lots of other little tricks that are out there right and again there are all

little tricks so ensure arterial lidocaine doctor there is near alluded to and if you're on si R Connect you may it may spill over on some of your chat rooms here people have been using like muscle relaxant like flexural or

robertson with some success but just know that we don't have any studies that tell us how that's supposed to do so when i have someone that is like writhing in pain i just use everything so i do it superior hypogastric nerve

vlog and i actually will do some intra-arterial lidocaine although not so much lately i have been using the muscle relaxant but i will warn you that i've had two patients with extreme anticholinergic effects where they are

now not able to pee from that so you know where we're doing that balance act I see that you're there can I take that question here first just so we're we're doing the same thing we're using the multimodal just throwing all these

things at people and we're trying the superior hypogastric blocks but we're collaborating with anesthesia to do that right now do you all do your own blocks or do you collaborate with anesthesia we do our own blocks okay it isn't it is

not that difficult I would tell you that but again it's kind of like you know you got to do if you start feeling better and then you're like we don't really need them we'll just do it on our own okay thank you again yes what's the

acceptable interval between UFE and for IBF oh that's a your question what is the interval between UFE and IVF so if you wanted to get pregnant yeah and can you have a you Fe and then have an IVF like how long would you have to wait

wait and tell you before you can have that the IBF it I guess it really depends on the age of the patient because we know that that the threshold for which patient tend to have that inability to conceive

is around 45 years old so you know it did below the you know below the age of 45 the risk of causing ovarian failure or or the inability to conceive is significantly less it's zero zero to three percent so I would say that you

know you probably want the effects of the fibroid embolization to two to take effect it takes around 12 months for these fibroids to shrink down to their most weight that they're gonna they're going to shrink down the most I wouldn't

say you need to wait 12 months to put our nine vitro fertilization there's no good there's no good literature out there I don't believe that's your next and so I would say just remember that if you came to my practice and you said you

wanted to get pregnant I will be sending you to talk to fertility specialists beforehand we do not perform embolization procedures as a way to become pregnant there's no data to support that but if you saw your

gynecologist and they said let's do this then I'm sure they'll be doing lots of adjunct things to figure out what would be an ideal time then to for you to have IVF and if I dove not having any data to inform me I would ask you to wait a year

and what will be the effect of those hormones that they gave you if for example a patient has existing fibroids what would be the effect of those hormones that IVF doctors prescribed their patients yeah so fibroids actually

can grow during pregnancy so I would say that most of those hormones are pro fertility hormones so I would expect that maybe you can see some of that effect as well yeah alright if you have any other questions you can grab me oh

you're I'm sorry go with it okay yes we we have time I don't want to keep anybody here for that so I have a two-fold question the first one is post-procedure can you use a diclofenac patch or a 12-hour pain

patch that is a an NSAID have you have any experience with that and your next question my second part of the question is there a patient profile or a psychological profile that tips you that the patient is not going to be able to

candidate because of their issues around pain so they're two separate but we have in success sending people home that first day so I'm looking to just make it better I haven't had experience with the Clos

phonetic patch it's in theory it seems ok you know these are all the these are they're all these are non-steroidal anti-inflammatory drugs so there are different potency levels for all of them they you know they range from very low

with with naproxen to to a little bit higher with toradol like that clover neck I think is somewhere in between so we found that at least I found that that q6 our our tour at all it tends to help a lot so with that said I I don't have

much experience with it with the patch in answer to your second question the only thing I can say is there there is a strong correlation between size of fibroids and the the amount of a post procedural pain and post embolization

syndrome so there really you know we often say we don't really care too much about the number of fibroids but the size of the fibroid is is is should be you know you should you should look at that on pre procedural imaging because

if it gets too big it may not be worth it for the patient because they may be in severe pain the more embolic you put into the blood supply's applying the the fibroid the the greater the pain post procedural pain

are there multiple other factors that would contribute to pain but that's that's one aspect you can you can look at post procedurally on imaging okay thank you very much yes ma'am hi what what kind of catheter do you use

to catheterize the fibroid artery when you pass by radio access yeah so over the last three years the companies have been really very good about that so there are a few things that I without endorsing one company or the other that

you need to make sure that the sheath that you're using is one of those radial sheets a company that makes a radio sheath you should not use a femoral sheath for radial access so no cheating where that's concern you may get away

with it once or twice but it will catch up to you and you need a catheter that is long enough to go from the radio to the to the groin so I'm looking for like a 120 or 125 centimeter kind of angled catheter whether it's hydrophilic the

whole way or just a hydrophilic tip or not at all you can you can choose which one in our practice most of us still tend to use a micro catheter through that catheter although if I'm using a for French and good glide calf and it

just flips into like a nice big juicy uterine artery then I may just go ahead and take that and do the embolization if the fellow is not scrubbed in as well so thanks a lot but they make they make many different kinds like that and more

of those are to come all right I'm you can please please please send us any other questions that you have thanks for your time and attention and enjoy the rest of the living

chronically exposed to low-dose radiation and that brings with it cancer

risk cardiovascular risk chronic inflammation and this is fully regulated most of the information around radiation exposure is around high-dose radiation major events like Fukushima or things in Belarus or the Ukraine are nuclear power

accidents but our kind of chronic radiation exposure is not well regulated it's not just the cancer risks it's the heart attacks the strokes the chronic inflammation there's literature showing that 10 millisieverts of low-dose

ionizing radiation which is not a lot has a 3% increase in risk of age and sex adjusted cancer this paper that I mentioned earlier showed that different people vary in their responsiveness of vulnerability I published a paper on

cataracts and where they occur radiation induced cataracts and most of people that are know will get cataracts in about 50 younger than the conventional seen all cataracts radiation cataracts occur in the posterior aspect of the

lens not the middle of the lens that most cataracts are like it's in the posterior chamber if you measure radiation dose to the operator during a procedure the dose to the left side of our head is 6 times higher than the

right and there are a series of papers showing elevated radiation dose to flight crews from the FAA so when you look at these flights if you go over the North Pole you get more dose than if you go around the equator and if you go in a

solar flare like last weekend do you get more dose than if it's not a solar flare if you take a 17-hour f feet from New York to Perth or Singapore you get seriously large amounts of dose

your annual allowable radiation exposure would be 5 flights to Japan so flight crews are known to have cancer risks more cancer risks than ground crews and that literature exists but the doses we get

far exceed what flight crews get and when you run well say you've got a chronic cardiac condition or an autoimmune disease condition or you're on methotrexate which impairs DNA damage or tetracycline are you chronically

stressed then the damage the DNA does to you the radiation dust you to your DNA

includes an interview of the patient abnormalities of major organ systems like cardiac status do they have a reduced ejection fraction do they have coronary artery disease I want to know

if they have an EF of 10% because if they become hemodynamically unstable and I want to give them fluids I'm not going to bolus a patient with a very low ejection fraction with two liters of fluid you're gonna cause

pulmonary edema and you're going to worsen the situation renal status is huge a lot of our patients are renal e impaired and that can affect the way that they clear the sedation medications that we're giving pulmonary status do

they have COPD asthma or sleep apnea sleep apnea is major in procedural sedation neurologic status do they have a history of seizures endocrine status hyper or hypo metabolism of medications can occur if they have a thyroid

disorder we want to know about adverse experiences with sedation in the past do they have a history of a difficult airway for us at NYU if they have been already been identified as a difficult airway that automatically means we're

doing the procedure with anesthesia current medications potential drug interactions is very important we'll go over that a few slides drug allergies and herbal supplements that they're taking tobacco alcohol or

substance use and frequent or repeated exposure to sedation agents is just going to increase their tolerance of the medications physical exam vital signs auscultation of heart and lungs and then their airway assessment sorry excuse me

do they have any Strider snoring or sleep apnea advanced RA they're gonna have a hard time tilting their neck back if they have cervical spine disease or they have rheumatoid arthritis chromosomal abnormalities like

trisomy 21 patients with Down syndrome can have an enlarged tongue that can impair your ability to manually ventilate them if respiratory depression wants to occur body habitus if they have significant obesity especially of the

head and neck areas and head and neck limited neck extension short neck decreased ornamental distance which is basically just looking at how far back they can tilt their head any neck mass and then again cervical spine disease or

trauma do they have a c-spine collar are they on c-spine precautions that's not a patient we're going to be able to manipulate their airway and then mouth opening we do use Mallampati and I'll review

that in a couple of slides so the AFC classification is a categorization of the patient's physiologic status that can be helpful in predicting operative risk it is recommended by the AFA that if a patient is an Asaf or that that

should prompt an evaluation by an anesthesiologist I will tell you at NYU we will still get procedural sedation to some patients who are in Asaf or but we like to identify it ahead of time because if they have significant

comorbidities that will potentially increase their likely hurt likelihood of having an adverse outcome we then have a lower threshold for activating a rapid response or a code if something was to happen if we got concerned about

something so the airway assessment is

blasian it's well tolerated and folks with advanced pulmonary disease there's a prospective trial that showed that

there are pulmonary function does not really change after an ablation but the important part here is a lot of these folks who are not candidates for surgical resection have bad hearts a bad coronary disease and bad lungs to where

a lot of times that's actually their biggest risk not their small little lung cancer and you can see these two lines here the this is someone who dr. du Puy studied ablation and what happens if you recur and how your survival matches that

and turns out that if you recur and in if you don't actually a lot of times this file is very similar because these folks are such high risk for mortality outside or even their cancer so patient selection is really important for this

where do we use it primary metastatic lesions essentially once we feel that someone is not a good surgical candidate and they have maintained pulmonary function they have a reasonable chance for surviving a long

time we'll convert them to being an ablation candidate here's an example of a young woman who had a metastatic colorectal met that was treated with SPRT and it continued to grow and was avid so you can see the little nodule

and then the lower lobe and we paste the placement prone and we'd Vance a cryo plugs in this case of microwave probe into it and you turn off about three to five minutes and it's usually sufficient to burn it it cavitate s-- afterwards

which is expected but if you follow it over time the lesion looks like this and you say okay fine did it even work but if you do a PET scan you'll see that there's no actually activity in there and that's usually pretty definitive for

those small lesions like that about three centimeters is the most that will treat in a lot of the most attic patients but you can certainly go a little bit larger here's her follow-up actually two years

that had no recurrence so what do you do when you have something like this so this is encasing the entire left upper lobe this patient underwent radiation therapy had a low area of residual activity we followed it and it turns out

that ended up being positive on a biopsy for additional cancer so now we're playing cleanup which is that Salvage I mentioned earlier we actually fuse the PET scan with the on table procedural CT so we know which part of all that

consolidated lung to target we place our probes and this is what looks like afterwards it's a big hole this is what happens when you microwave a blade previously radiated tissue having said that this

was a young patient who had no other options and this is the only side of disease this is probably an okay complication for that patient to undergo so if you follow up with a PET scan three months later there's no residual

activity and that patient actually never recurred at that site so what about

year old patient diagnosed with

glioblastoma lesion is located on the left frontal lobe this is done after radiation and surgery the image to your left is just a regular MRI with contrast gadolinium is the one used this time we always be the drum in the context of

choice is gadolinium in our institution you could notice the big size of the glioblastoma lesion onto the left frontal lobe of the patient as indicated in the round ring patient went for treat radiation and surgery look at the two

images to your right the one in the middle is done Pet MRI without the contrast take a note on the area where the lesion was before there is normal uptake but you don't notice any abnormal uptake and on to your right is post

treatment MRI is that those two are done the same day and with gadolinium the deletion the area where the the ring it is enhanced by the contrast but look at it there is no hypermetabolic uptake that means that the lesion is not viable

so the malignancy is not viable this time this scan is done to evaluate the effectiveness of the treatment it's a good sign before I go to the third case

some of the contributing factors to hypoventilation well certainly will we give sedation we give you know a benzodiazepine we give other medications we combine those with opioids right that

decreases our responsiveness to elevated co2 levels but we also have muscle relaxation certainly in patients with obstructive sleep apnea history undiagnosed or undiagnosed they lose their muscle tone in the airway patency

kind of diminishes very very quickly and they also have a decreased response to hypoxia all again creating that perfect storm of an adverse event waiting to happen and even patients that have don't normally have obstructive sleep apnea

can have it under our sedation so the key signs and symptoms you know clearly respiratory rate is one that we monitor but we also want to monitor the quality of ventilation right one look at patients tidal volumes and how much

they're expiring with each breath we want to look at their sedation scores whether you're using the rasp score or any of the other standardized scores spo2 less than 90 for at least thirty seconds that's pretty significant

hypoxia especially if somebody's on oxygen and hopefully you would detect somebody who's deteriorating much earlier than that but that certainly would be a terminal sign before they became bradycardic and you were pulling

out the code card but certainly using capnography you could tell breath by breath right instantaneous looking at those waveforms and look to see if the patient is not only taking enough breaths per minute but are they

taking quality ones so let's look at a little bit of a case study here we're gonna kind of look at this case study throughout so this is Jane Doe she's 39 years old she's being worked up for a nonspecific abdominal pain they've ruled

her out for gallbladder issues and appendicitis and they want to do an upper endoscopy in a colonoscopy she's treated with chronic pain medications gabapentin and oxycodone and she's had some surgeries in the past no allergies

to anything so concerns with this patient so what risk factors does this Jane Doe have for during for at risk for respiratory compromise during sedation possibility of undiagnosed OSA be a bio t mass index obesity high risk

comorbidities medical condition or advanced age there's more than one right answer so just make mental note here and these are the correct ones so she potentially has obstructive sleep apnea she does have an elevated BMI and she

has medical conditions she's sick acutely and she has pain medications as part of her chronic therapy so now let's look into solutions so again with our case studies after we give her some versed and a hundred Mike's of fentanyl

the patient develops the following pattern on the monitor so what should your first step be in this scenario nothing because her pulse oximetry is normal be stimulate the patient to take a deep breath perform jaw thrust and

place patient at a sniffing position to open the airway give a reversal agent or D intubate the patient good B you guys are all anesthetists now we have a bunch of positions open at Yale if you're

gets pet MRIs right now our main focus are our oncology patients it helps us

determine the type of cancer they have the diagnosis of cancer assess disease progression treatment therapy and treatment planning and some antecessor treatment response so let's say a lesion is FDG avid and

has low blood perfusion that would help our physicians to us to say what kind of treatment they can give to the patient pet MRI is also good for patients who can tolerate longer scans right now it's a very young modality

there's still a lot of research goes on with this and coupled with that is advantage of research right now we actually in the Memorial sloan-kettering we have started using this instead of FDG we've used gallium 68 of to assess

neuroendocrine tumors who have also done cervical lymph Austin Tiger phim where FDG is injected directly at the patient's cervical cavity and that helps map out the lymph nodes in the survey in the pelvic area this can be used by the

surgeon and see what lymph nodes can be sampled during the surgery we provide some education and assessment before during and after the pet MRI we assess for the patient's allergies we tell the patient's they have to be NPO at least

six hours prior to FDG injection as for our anxious patients they often come pre-medicated and this just comes with some care coordination with their physician the physician would prescribe some low-dose anti-anxiety medications

and the patient would take it an hour before their test as for our claustrophobic patients we what we have done is we let them see the Machine we let we let them feel the Machine we put them inside if they would want to and it

would be up to them if they would be tolerating the scan we assess for their diabetes regimen and my refe will speak more about that later we assess for patients pregnancy status on patients loving to fifty years old process for

their breastfeeding status and screen their implants during the pet MRI we tell them about the coil placement we give them an emergency call bell and we tell them to decrease their movement well being is like although our some of

our patients would say I didn't move but then the image so differently there there's a possibility that the magnet can induce some involuntary twitching after the MRI we tell them that they can resume their

diet they can resume their diabetic diabetes regimen and as if they get MRI contrast they can pump and dump for about 24 hours after the test but if they don't get a contrast they can keep their breast milk inside the fridge just

to help to decay just to decay the isotope that was given to the patient it doesn't give any harm to the baby

so who are the most ideal candidates for fibroid embolization obviously I would say the most ideal candidates are patients that are symptomatic and I've told you already that 80% of black women

have fibroids but guess what only half of those will be so symptomatic that they would need to be even treated so just because fibroids exist don't mean that they need to actually be treated already so you

to actually have symptoms most patients that are symptomatic will again wait to getting treatment for like three and a half to five years but when they come we want to make sure that they're symptomatic and that they're not trying

to become pregnant and I know somebody in the audience has a question around that already so let's hold your high horses I'm coming to that how about patients that don't want to have surgery or just don't have time to

have surgery they don't have time for long recovery if you don't care if you have your uterus or not then I'm not so sure that you need to be pursuing a uterine sparing procedure okay and I'm gonna pause here to address one other

thing that it's a myth it is a myth that if you do not need to have children then you do not need your uterus I beg to differ and when we talk to women they are quite upset about this preposition that the uterus is only there for

baby-making purposes in fact there have been several studies now that have come out to say that women that have had early hysterectomy even with their ovaries in place are predisposed to coronary artery disease or

cardiovascular events we would like patients that are poor surgical candidates because if they can have surgery then they may be able to have surgery or patients that do not desire future fertility patients that have

already concerns about hysterectomy because of religious reasons or don't want to have hormonal therapy and I actually like patients that have have a have obesity because if we are able to do this procedure then they're spared

more complications related to surgery so the ideal patient then and this is a very important point said all three criteria would need to be fit that if you're a patient in order to be offered embolization number one

you have to have fibroids believe it or not you have to have symptoms that are related to fibroids and then you have to have some MRI that says that the location of where your fiber it is is causing that symptom and that these

fibroids are vascular let me explain okay and I'm going to skip this so I've been working with people for a long enough time and I've work of Julie for years I've worked with Diane and Anna and some other people for like ten years

and imagine if you're working with me for ten years you know that you're probably going to be able to do this procedure too like you're scrubbing right next to me eventually like you pick these things up what I get paid for

is not to do that and for the experienced nurses and techs that are in the room you know exactly what I'm talking about you're better than the doctors half of the time you really could do this procedure but what I get

paid for is to decide who does not even get to come on the table to get this procedure done so pay attention to this slide and these this criteria is being challenged every day and we're getting more and more data to say that this is

old information that we used to say if the uterus was like more than six months then you probably shouldn't have a uterine sparing procedure but we know that we do in embolization all the time in patients that have large fibroids

anyway but there's no data to actually give us that information most of the trials that we have and we have had a lot of them they have excluded patients where their individual fibroids were greater than 12 centimeters if you have

had an indeterminate and de metrio biopsy or you're having abnormal pap smear doing a uterine sparing procedure makes no sense so we use these imaging to really help us to determine which patients really

deserve to be treated so everybody can see that that image on the Left where it says submucosal refers to and I'm gonna try and come down so I can see these images here and you can see that there is a fibroid that is in

truck hava teri do you see that that round thing that is surrounded by the white fluid that is someone that has what we would call a type zero fibroid completely within the unit of course this is going to cause bleeding but

should this person have a uterine artery embolization or a hysterectomy Gail no this patient should have like hysteroscopic resection like a D&C and they would just scrape that thing out and then their symptoms would go away or

the patient on the right that has a normal appearing uterus and then this pedunculated gigantic thing that has bled into itself that is like a sub serosa fibroid of the extreme just hanging off on the outside now should

this patient have embolization no someone can tie a string right at that little connection and take that thing out so using our imaging to help us to decide which patients should be treated is very important or this patient who

came with Oh dr. Newsome I've been bleeding for 10 weeks in a row I have reversed cycles I have bulk I have bladder symptoms and yet they have that little dot that little black thing there that little dot

at the top that is the only place where there's a fibroid so this patient should not be a candidate for embolization either because yes they have symptoms and they have that little tiny daughter for fibra but that is not what's causing

those symptoms so it is important that we're not doing procedures on patients just because we can but because we're using our imaging and the patient's symptom to decide which patients are the best candidates for these procedures

little bit about extending our reach so how can we tap into a population that were not necessarily tapping into

currently and the two populations I wanted to speak about we're medical students and patients so when this last match almost 40 000 seniors applied for the match and that's just the seniors we have first second and third years and

these people are already a part of the medical community they already understand our jargon so this is going to be a really easy transition for us so how do we do that by tailoring on posts in a way that they can understand and

that would be useful to them so here's a really good recent post I think it was just a couple days ago and this gives a clinical scenario it gives us four images that we can make a diagnosis we can ask them Anatomy I think that's a

great medical student question just taking off all the identifiers and putting on ABCD what are these things asking what is the next step those things are really valuable questions to ask for medical students and to get more

involvement I'm just a suggestion and the caption we could say tagged someone who might know the answer or do you know someone who would be interested in this so just getting people to move in a shake and interact it's also really

important and to extend our reach to patients so more and more patients want to play a more active role in their care and we should meet patients on platforms that they already used so we are literally placing the information at

their fingertips so they're scrolling through our feed or through their feed they'll see information about disease processes and our procedures and with that we want to tailor it do it in a different way educate them in a

different way than we would for medical students right they can get lost in the details of a case or procedures we want to do this in a more broad sense starting off with maybe dress symptoms or we're just starting off with symptoms

and here's a good example so the eye eye has this mips can open blocked blood vessels in the legs without a scalpel so you can get back into the swing of things learn more at the i i'd org so a couple

of things about this post it gives you one symptom maybe just one thing that their doctor told him that they had that's it and then it tells you this procedure is minimally invasive it's without a scalpel it's not scary yeah

and then it tells it gives you a call to action go to this website to learn more perfectly tailored quick hit and they can see it as they're scrolling through their feet before bed and if we want to extend our reach we want to make sure

that people see our posts so posting time it really matters so take a look at the dips right from 12 a.m. to 1 a.m. who's on twitter and no one probably just the night shift so you don't want to you know post at that time um but if

you think about who you want to reach what is your population so if we're trying to reach each other we're usually done with our first case around what 10 or 11 right unless you're really fast 830 so if when we're done with our cases

we take a break we take a sip of water and then we check our phones so that would be a good time 10 or 11 for us to post if you're reaching your patient the first time they get a break is maybe lunchtime so think about posting at noon

and finally linking your platform so if you're on multiple avenues of social media think about cross promotion so someone that uses Twitter 50% of those users are also using Instagram so you can link it to it maybe put a story

on your post and say hey guys I'm talking about DVTs in my Twitter post today go check it out other avenues Facebook YouTube Pinterest LinkedIn there's a high concurrent use of users with all of these platforms so really

take advantage of that so in conclusion Twitter is broaden the horizons of our specialty and the benefits will continue to unfold and expand and I really encourage us to continue building community support each other's posts and

work to expand our reach thank you [Applause]

are there any questions yeah yes that's a really good sure so the question was do you have any rules or guidelines in my institution about how long the procedure can be before you start

talking about anesthesia versus sedation is that right and positioning prone supine we did come up with a guideline with within our department we looked at a little bit of research but honestly was more expert opinion just best

practice and experience I in in general I would say if the procedure is 3 plus hours the patient should know they're going to be on the table not asleep for three plus hours and talk to them about what that means and if they're ok with

that I just think again that comes into setting realistic expectations that's one of the reasons actually that we're very interested in using Dex med otama Dean because that's going to be a better

drug for those longer procedures first was giving functional and versed for four hours it's just not it's not appropriate but you know and some people would say we'll just get an anesthesiologist them but a lot of these

patients are really thick so in our institution anesthesia is just really super regulated and they require all of these clearances for their involvement no matter what they're giving sometimes they'll require all these clearances and

they give exactly what we were going to give so you know it's it's really a juggling act I would say in our department we really just make sure the patient knows what the expectation is and then we'll usually say to the

provider to if if something goes like if anything looks a little concerning during the case we're stopping and they have to be ok with that and they are they really are but that took a lot of work to get everybody on board with that

type of communication yeah we don't know so they I know I think Sloane is anyone here from Sloane no I think Sloane has with dedicated anesthesiologists they work really closely with them and it's easier for

them to get cases scheduled they will give us they will assign us an anesthesiologist for the day but if we don't have any anesthesia cases they get reassigned somewhere in the o.r and it's a different analysis every time it tends

to be the same group some are stricter than others some will have a patient say I really want anesthesia and we can call up the provider and there they say no problem let me do a quick chart review whereas the next day the provider goes

no absolutely not send them for clearances that's a little tricky yeah right so what I showed you is from the american society of anesthesiology i am not affiliated with them at all i just think they bide non anesthesiologist

sedation so i rely heavily on what they say and they recommend waiting till peak effects so i would look at the pharmacokinetics so for versed it's 3 to 5 minutes so i would wait at least 3 minutes before your readmit a stirring I

think a good example with that is when diazepam with the sedative of choice the on the peak effect for diazepam is 1 minute so when midazolam came onto the market there were a lot of adverse outcomes

with patients because providers administering it weren't familiar with the pharmacokinetics and assumed that the peak effect for versed was the same for diazepam so in theory you could give a patient in 5 minutes 5 milligrams of

versed so by the time that fully hits them they could be in a negative 5 on your raft scale so you know just look at those pharmacokinetics look at that peak effect and I would use that to drive your dosing scheme Atlee that's what I

do and I think since we've done that we've seen better meet info cities and better safety outcomes yes okay yeah we don't do that we do one thing with uterine fibroid embolization swear they'll do a superior mesenteric block

but otherwise we don't do any other type of regional blocks but I have read about that I think that's really are the IR providers giving the block okay right I've seen two with uterine fibroid embolization we'll do an epidural in

advance some I think some institutions or some literature exists about that it's interesting it would be interesting if the IR providers could actually give it though I'm not sure if that's kosher in the anesthesia world but they're

certainly qualified to do it they they do already kind of do it really but so I mean that's certainly something interesting and if you have a provider that is comfortable taking that on and their institution I think it's worth

looking at because anything that's sort of I think mixes things up and and provides a different Avenue especially for high-risk patients is worth looking into definitely yes I believe it yeah

mm-hm right so I'll just repeat what she said so just jumping on the talk about blocks so in her institution they the providers to administer blocks and I think you said

coleus estas Tamizh and PTC's and biliary dream placements they'll use that and it will decrease the amount of sedation that's required sedation being versed and fentanyl that's required during the case which like yes like you

said is really great for patients who are already on opioids previously and habit aller ins yes [Music] something right so we again he left same provider though had a patient on Groupon

or Fein and it was our first experience within about a year ago and it was terrible and she did not have realistic expectations going in of how sedated she would be and she was very very unhappy

afterwards so we talked a lot about that and in that guideline I had mentioned that we made about when we involve anesthesia and when we don't there's a caveat about that that says that if a patient is on

methadone or buprenorphine that a discussion needs to take place making them aware that they will probably not feel very sedated but we will try our best and if they're not comfortable with that we reschedule the procedure with

anesthesia but they have to know going into it that they they may not feel completely sedated and we just keep that open and honest communication but we haven't really come up with a scheme of what's best we did actually try with her

we had her come in one day having taken her buprenorphine the day of the procedure and she seemed okay with that and then we tried having her go off of it so that the receptors wouldn't be blocked she was not happy with that

experience so that's really when a person like that probably would do great with propofol but we can't give propofol so you know if the and if the patient tells us no then we just reschedule with the anesthesia

right - hmm right right right you could at least if they're if they're on an opioid uh if they're on people nor Fein then in theory they should respond to the verse said you could go heavier hand it on the

versed just to get them sedated but they will probably still feel pain but it they hopefully won't remember it that's true I you know with the Richmond agitation sedation scale that's not going to fit every patient that's a

really good point I gave a patient seven of versed during an adrenal vein sampling and she was just talking my ear off I got I fed are you okay you know do you need me to give you anything else no no I'm good I'm good and then I wheeled

her out we got her in the recovery area and she goes sit over I said yeah she said wow I don't I don't remember anything the power of her said that that was like a true and music effect I hadn't seen that so strongly in a

patient before but if you if I had done you know I was documenting that she was a zero it looked like I wasn't doing much for her but then I was putting comments you know patient comfortable denying needing any more sedation so

won't fit every patient so it is good to look at that but yeah as far as the buprenorphine I mean it's it's it's tough yeah if they have an addiction specialist I would say talk to them and they might be

able to come up with a scheme that works for them and if there's a lot of pain expected afterwards those patients are gonna have to be on parenteral opioid therapy they'll probably have to stay you know if you're in a hospital they

would have to stay overnight so those are all things you have to consider yeah yes hmm yeah I'm like it so Adam and Alexa are nurse practitioners that we work with and I'm looking at Adam because

this is actually was a very hot topic for us in the last six months so we actually cheat we met with our sedation committee that's run by that in a physiologist who's blocking us from using pres of X and discuss with him

that in the protocol that guides our practice it's said that you did the timeout and then gave sedation but Ari anesthesiologists don't do that right so they intubate the patient and everything and then and they and then the provider

comes in and does the timeout right before the puncture or incision so we talked about to him about how well if we're gonna do the latency to peak effect it's not enough time right so we do now bring the patient in and start

sedation right away our orders are put in in advance I know some by the attending or the Li P so we have a PRN dose and with an a certain number of occurrences and a titrate to a certain Ross scale

yes yeah so and that our anesthesiologist mentions that our providers are present but it's it's a certain use of the language I think it might be like direct observation or immediately available and our providers

are immediately available it's up to your hospital so our profit our providers aren't like down the street on their way in to work with coffee and street clothes and we're sedating they're they're just down the hall maybe

or the way our department looks is we have a control area and it's like the you know the Central Station and you can see all of the rooms so they might be in the Central Station but just haven't gone in to do the time out yet that

being said I always talk to them before I bring the patient in and say what's the goal Rath and I address any concerns that I have and I think people think I'm a little kooky when I do that for every case but it I think it works really well

and I think the providers really like it so we just already start from the Gecko our line of communication I tell them the patient seems really anxious this is my plan what do you think agree disagree yes the procedural if does the procedure

list or the Lak but I've sedated the patient so the patient if you look at what Jayco describes in the universal protocol it's ideal if they can participate in the timeout however not required because then when they do the

timeout they're right there stabbing them with lidocaine so I like to you know I mean I would argue that by starting I would argue about that by starting at the sedation earlier and getting the patient into a comfortable

state you're more safe because you're doing the dosing appropriately according to the a sa yeah correct right right right

okay I think it's important to say though it's not about getting around Joint Commission this is what Joint Commission says you may feel uncomfortable with it and that's okay

but it is what our accrediting body says is okay we're also not intimating the patient and paralyzing them like an Asst the anesthesiologist is now having said that it's not like we walk the patient in and we go oh I think you're mr. Jones

we throw you on the table there is an initial timeout that's done with the nurse and the technologist and the other people in the room shaking his head yes as so the acceptable amount of time after reversal

yes so if it happens if it happens mid procedure you need to it's I believe the language the a sa uses that you have to have a discussion amongst the care team about whether or not you're going to proceed if it happens after the

procedure in the recovery area or it happens mid procedure and you abort then it has to be at least two hours before you discharge that patient or move them back to their unit where they came from because of that recitation effect and

because you can have really adverse effects from sedation like flumazenil can cause serious delirium I had a patient like that one time it was it was awful and it can cause serious cardiac arrhythmia so at least two hours if you

continue with the procedure I would just make sure everyone knows that you have to be really careful with recitation effects and and all of the adverse effects that you'd be looking at yes I think one more question I'm sorry

with hyperkalemia I have come across I want to say it was in perioperative guidelines when I was looking at the labs that we do cuz we do a lot of unnecessary labs in our department you guys might - I feel like we just really

overdo it I believe the perioperative recommendations are to check a serum potassium if the patient has a reason to have hyperkalemia however right if their hyperkalemic and

they develop a cardiac arrhythmia you know could hypoxia also precipitate that cardiac arrhythmia the results from the hyperkalemia maybe I just went in I wouldn't take an ounce

I would I would consider hyperkalemia severe hyperkalemia and unstable patient because that patient could go into a fatal arrhythmia so I would correct that before you bring them into an elective Percy what's often an elective procedure

so if you're doing a fistula gram you know right five point yeah why are we will go up to five point eight we personally will go up to five point eight because a lot of times they're hyperkalemic

because they're fish too less clothes now and we need to open it right so just again it I don't think there's ever going to be any hard and fast data that you see it's all about making sure everyone knows this patient has a serum

potassium of five point eight we're going to be really closely watching the ECG monitoring yeah thank you everyone thank you so much [Applause]

there are advantages of this modality one there's less radiation exposure for

the patient we receive about three millisieverts of background radiation every year with one PET scan a patient can get up to eight years worth of background radiation in just one skin the only exposure of radiation a patient

gets in a pet MRI is through the isotope pet MRI has a better disease characterization especially for areas in a Patou biliary region the pelvic areas and the kidneys information and the relationship between lesions and

adjacent tissue is better delineated with the pet MRI so it's easier to see which part is cancerous and which partners normal cells there are varying opinions and research studies are being done to make a determination if pet MRI

is a better modality than pet CTS well PET CT is a lower-cost skin has increased accessibility there are more PET scanners available and more more technologists are trained for this modality PET CT is a shorter skin there

are no contraindications for affairs implants pet CTS are preferred method for imaging the lungs of thoracic nodules and bone structures however with a pet MRI it's good for soft tissue organs such as the brain the muscle

delivered the kidneys the pancreas our GYN pelvic structures such as ovaries the uterus and cervix and also the prostate there are limitations of this skin one it is a much longer skin one whole body pet MRI can last at least

about an hour there are contraindications with certain implants due to the magnetic factor of the of this test and is not preferred for imaging air-filled structures because it can give off artifacts there

are weight limitations for our machine our machine holes can hold up to about 500 pounds of weight it is this our machine as smaller bore compared to the white board MRI the MRI whiteboy is about 70 centimeters in diameter

our pet MRI machine is only 60 centimeters in diameter in this picture the difference of the 10 centimeter difference doesn't seem much however if you put a patient in there and this is one of our coworkers

he is 270 pounds and 6 feet tall and the white board MRI his shoulders fit comfortably well inside it in the sky inside the scanner however in this pet MRI machine he said he did feel a little snug and a little tight inside

but you also have to take an account that we have to put coils on top of our patients that 10 centimeters does make a big difference the coils will help us give the good quality images that we like and I also have to note that we

have to put the head coil or the helmet on top of the patient's head to give good images of the brain the reason why the pet MRI scanner is smaller is because we have to make room for the pet detectors we try to make it bigger the

gradient coil on the radiofrequency coil have to be further away from the center of the magnet and that compromises the quality of our images so which patient

symptoms we've talked about the location so what are the options now I've kind of scared everybody enough said okay fine if my periods are last in more than

seven days if I have pain with my periods if I have clawed if I have painful sexual intercourse back pain hydronephrosis and sciatica all kinds of these little things then maybe I could be having fibrous what do I do about it

and there are several options obviously I'm here to talk about embolization but because everybody in this room is talking about informed consent every day we have to be able to talk to our patients about what are the options and

I always try to start off with the simplest of options doing something or doing nothing remember this is not a cancer this is a benign disease and it's important that we explain to our patients that they also have the option

of doing nothing although doing nothing has some consequences right every action has a consequence and the consequence of doing nothing includes continuing to have your disease continuing to be sick and abnormal and if you chose to do

something let's say a surgical option then obviously you can have hysterectomy or myomectomy now Maya met to me is just where you're cutting out the fibroid hysterectomy is taking the whole uterus out and then there's a whole series of

other things whether you're having it laparoscopically or transvaginal Eeyore I'm here to talk about uterine artery embolization we offer all of these options to our patients though because it's important that we at least know

that there are other options to be done

female recently diagnosed with cervical cancer this is the baseline imaging the

one on the left is pet the one on to your right is pet MRI which one you think the doctor likes better so there is a cervical lesion you could see the abnormal uptick or hypermetabolic uptake in the cervical area that's what we call

hot spots but we do a closer look because the pet MRI this time is used or done for planning for surgery or treatment look at the actual pet MRI you could see the hypermetabolic uptake in the cervical area the normal bladder

and normal uterus those are normal updates under your right you could see the uterus full the full outline of the uterus and exactly where the cervical lesion is located and the bright one at

the bottom is the normal blood er this scan is done to help the doctors plan for the surgery and to check if there is metastasis at this time there's none and the path MRI is choice of modality of choice for this reason because MRI is

the only modality that could do all the planes and it does very good in differentiation of tissues this is the end of our presentation and if you have any questions feel free to do so I did not pass out thank you

[Applause] [Music] [Applause]

new data of the Emmy trial that came out last year our ten-year results saying

that after ten years after ten years women who wanted to retain their uterus they looked at them in ten years three-quarters of those women were still very very satisfied and also were still able to retain their uterus so ten-year

data came out randomizing people for uterine artery embolization versus hysterectomy of the women who chose you to an artery embolization ten years later they were still very happy so I tell my patients that this is what you

should expect that you will have symptomatic improvement in 12 months around 85 to 95 percent of the patients are pretty happy there is a entry intervention rate it is not zero and it can be higher than ten

depending on what kind of Imogen is seen ahead of time and that we know that dysfunctional uterine bleed tend to do a little bit better than bulk type symptoms and that's partly because of subjective nature of that so this is one

of the patients that I treated when I was in in Virginia and Riverside and she's a former miss Brazil and she came to see us with what she also called reversed cycles like she would bleed more than she would not and she was

wearing depends and it took everything to just coach her out of the car to come inside to do a consultation because she was so afraid that if she got out she would be sitting in a pool of blood and she had an MRI showing what looked like

a eleven point seven centimeter fibroid she had embolization and that was her six month follow-up MRI to the right which looks like a very impressive result they don't all look this way which is why I save this image something

that looks like a normal uterus now I for the persons that I told to hold your high horse here is the time okay so what happens if I want to have a baby because these are the things you remember we're being ambassadors for this procedure we

need to be having the answers for the things that are our friends and family members are going to be asking us so if you want to have a baby I would say that the data that informs us as to what to do with you is still very weak but the

only randomized prospective trial that we have out there says that you should actually have myomectomy and a Cochrane review was also done and it still says that there's very low level evidence suggesting that myomectomy may be

associated with better fertility outcomes as opposed to UAE but more research is needed and we still require more research so at the very least what I have to do and now you feel compelled to do is to send my patients to see

someone who is a fertility specialist in consultation so we can make this decision together so if your poor surgical candidate if you have the gazillion fibroids and if you've had surgery before a hostile

abdomen and the patient says you know what dr. Newsome there's nothing that you can tell me ever to say that I'm going to have surgery then we're going to be doing something else that is not surgery okay the other thing that your

patients may be asking you is like what about adenomyosis and I've been hearing something about that which is not exactly fibroids right it's a different entity though the symptoms could be kind of the same and for the years and years

and years we wouldn't have any options for patients who had adenomyosis in fact the only option for patients with adenomyosis is surgery but adenomyosis can coexist with fibroids and sometimes patient presents with adenomyosis alone

so we've had some studies now that have looked at that and although the data is not as robust and not as awesome as for patients with fibroids we do provide a performing bolas Asian for those patients with particles that are little

smaller than what we would use for fibroids with results as you're seen there before now the only other new thing that's on the market and it's not so new to you guys that are probably doing radial in femorals anyway working

in cardiac labs and IR labs it's actually what we call the trophy if you go back one slide for me mr. a the person and press play then we will be able to see that radial access I do not work for Merritt they don't give me a

dime I just thought that this was a good video is there volume on that at all if not I can just talk about it and really what it says is that if you need to a radial UFE or have radial axis for a uterine embolization patients just love

it more they and especially like patients that are already just intimidated they don't want you going near their groins at all they actually could just lay on the table we don't have to put up we don't put a Foley in

they just get a radial access the same way that you would just be starting in a line except we have special types of radial catheters and and sheaves to do that and I don't offer a radial access to

patients who are too tall for our catheters or if they've had multiple prior radial access and don't have an intact ulnar artery to complete their hand but it's much like any of that femoral access that you would normally

see they make special hydrophilic sheaths now they're called from this particular company slender technology where the inner diameter of the sheath essentially the sheath is the same like five French on the outside but they have

cored out the inside so it's a bigger diameter so it's a five six so on the outside it's a five but it will take a six French in the inner inner lumen and you know my practice we do more than 80% of all our arterial punctures with a

radial access and everybody here comes dr. Sean Deroche Nia who is the leading author of that paper for SI R and one of my esteemed partners so most patients are able to get up and walk out if you are go from a radial access the access

is actually closed with just a radial band and the complications of having a hematoma or having the patient's bleed out those just all go away but radial axis have their own complications so I'm not here to say that it is not that but

in our practice we found it to be safe and effective our patients want it and it's become like a practice differentiator so if you're working in a practice that don't do radial you EFI's right now you should mention it because

if you're in a population where the other providers are only doing femoral then you will automatically get the patients that only want that so here's a patient that had a radial access you can see a catheter that is coming from the

aorta while you can't see that it's not up and over the bifurcation but maybe you do can see that and there's a catheter in the uterine artery with the characteristic

shape of the uterine artery and the characteristic curlicue vessels of of the fibroid and on the left you can see the Imogen for beforehand and the Imogen on the right of post embolization where there is stagnant flow in the main

uterine not main uterine artery in the horizontal portion of the uterine artery for greater than five cardiac beads and again there's there's no reason that you have to know that level of detail except that you're scrubbing in but if you're

in the audience you're looking at this you're like dr. Newsome I see an air bubble there as well then I'd say good because because I do see it too so you can see the preimage and you can see the post image for pre and post embolization

these these procedures can be quick these procedures are very very rewarding and and I love to do it

morning I'm Molly Perdue ba I'm one of the procedure nurses and one of the best

things we ever did was to adopt this smart dynamic electronics patient surveys previously we used the regular paper service that most hospitals use and they were mailed to the patients about four weeks after the procedure and

I tell you no one ever mailed them back to us so we are lucky if we get one or two each month so we we never had a real patient feedback so we got lucky our hospital was starting a small pilot for this brand-new East surveys and they let

us join the pilot group it was really fascinating it turned out that these two doctors from North Carolina invented this and these are like short dynamic smart service that are texted or emailed to the patient the day after the

procedure so the survey consists of 10 quick questions in the free text box so no more paper no more snail mail and the patient's get the survey right away well it's still fresh in their minds and not four weeks later so on this slide are

our 10 current survey questions and one cool feature is that we can change these questions at any time and we can that we can pull from a large question Bank but for a clear project we use the same 10 questions so we had consistent pre and

post data they also have a great website that we can access so we can see the patient scores patient comments and they even have everything graphed with trends over time so we can see whether we have improved this slide all the patient

comments are emailed out to the multidisciplinary multi-departmental team every month so when I opened my email I see more than a hundred patient comments so the team is usually excited about

opening the email every month and you look for their names and staffer of often mention and compliment complimented by patients so for this graph it represents patient East Survey top box scores for the questions in a

timeliness category so we saw 24 percent improvement for the question my care team kept me informed of delays and we we also saw 36 percent improvement for the question my procedure started on time so now I'm gonna hand it back to

Allison to share additional project results in our conclusion

so one of my favorite age-old questions is okay so how do you know that I don't have a cancer and I don't know because cancers can exist were there fibroids and we know a few years ago there was a black box warning put out for a more

salacious device which is how most UI ends remove large fibroids and that was due to the fact that if you go it looks like a blender of source like a handheld blender and it just kind of blends up big fibroids so that they can move it

out in chunks but if a fiber but if a fibroid existed in the uterus where there was an indolent cancer and you blend that whole thing up then you've just made everything a little bit blood-borne then something that was not

meant to be an aggressive disease process is now accelerated to an aggressive process and now those patients who had worse outcomes and that's why the device is still having a black box warning and is off the market

but it has really not that much to do with fibroids becoming cancer it's just that they both can exist in the uterus and if you are doing a uterine sparing procedure you could be missing a cancer having an MRI beforehand helps us out

just a little bit and we have discovered many cancers of patients that are asymptomatic in that way and they look kinda like this so when you look at these two and I'm telling you that the person on the left

those dark round things that that's a fibroid then you could probably see the thing on the right and say well that doesn't look quite like the thing on the left one looks like it could be a fibroid one maybe not so much so this is

a patient that came to see me in clinic and she had bulk symptoms she brave though she had bleeding symptoms she decided she was going to have a pair of white pants and she worried that day two clinic

but you can see where and I'm not able to point this out so I'm hoping that you can really do see that where she has her navel which is a dot that little crease on the MRI and then her uterus is above her navel and II and you can see that on

her and when I touched her abdomen I could tell that this was no fibroid at all so we had her image and done on the right hand side and it too looked very abnormal and so she went on to have a hysterectomy this was a cancer again

two other images that really talking about how MRI although it helps us to tell whether the fibers of vascular or not that it can also help us to find other things such as this person that has an endometrial cancer also very

aggressive cancer and they presented the exact same way abnormal bleeding and painful bleeding with clots so blood bulk symptoms with bleeding MRI not so much this is a cancer all right so what do I tell my patients when I see them

and they say dr. Newsome could I have a cancer I tell them what the FDA says the FDA says that there's a one in 350 chance that's what's on their website that you have a cancer and you have a fibroid at the same time but that's

really really high the American College of obstetrics and gynecology actually put out a position statement and revised that and they said that's way too high and they said it was somewhere between one and five hundred and the SI are with

dr. Spees looked at that number and said well we didn't think that it was that high either it's somewhere one in 750 or 800 so sadly I'm into big numbers so I just round it up I tell patients that's like a one in a thousand chance that you

can have a fibroid there and I'm gonna get an MRI and I'm gonna see if there is any chance if anything looks suspicious and the good thing is that I'm gonna keep seeing you for a year in a year after so that if I've missed something

then we're gonna be able to see it I said before that I'm super proud that I'm from Emory I'm from the home of dr. Chandra schnell who I had told to come and help me to give this talk but because I was running behind I hope he

doesn't feel compelled to come but we have put out our criteria and standards of practice for years that helps to inform us this is not something that is oh so new this is something that has level

evidence to support one of the the procedures that we do and this is very unusual for the things that we do in NIR where we have level 1 or level A's evidence that says that and because of the work that the society has done and

no doubt some of the people that are in this room I know for sure Julie was involved because we were doing these when I was in Alexandria the the trials to answer this question the American College of obstetrics and gynecology had

to adopt this as a part of their position statement to say that based on the long and short term outcomes uterine artery embolization is proven to be safe and effective option for appropriate patients in selected women who would

like to retain their uterus and that is still there a position statement today although I'm aware that they're revising it they're revising it because of the

Sean I know you have not seen these slides at all you wanted I John can talk about this with his eyes closed so it's

not like there's anything but this is the data that was published from the Jade publishing jvi are from what Sean has written and it's just the current standards relating to what you should be expecting what we tell our patients that

they should expect for outcomes as it relates to uterine artery embolization again I'm not really here to try to point this I know you can google these you can get the information yourself but just to say that all of our procedures

have risk and we need to be clear with our patients about them now I believe that with all of these risks combined the benefits of doing uterine fibroid embolization for most patients is far greater than the risk and that's why I

really do have my practice so these are the benefits right shorter hospital stay and I would say more cost-effective and that is really debatable because gynecologists have become smarter and smarter now they're doing like same-day

hysterectomies if you have a vaginal hysterectomy then maybe a UFE is not as cost-effective because they don't have to do an MRI beforehand and they don't get an MRI afterwards and do all of that anyway and if you look at the long-term

cost of that then maybe having a hysterectomy in some patients could be that but we know for sure that patients are more satisfied when they get a embolization procedure than in my MEC to me not in the beginning run because the

procedure can be very painful that is not the procedure itself is painful but post embolization syndrome which could last anywhere from five to seven days can can be very painful again this is the comparative data that was published

by dr. Spees who is our gold medal winner this year understand a lot a lot of work in this space has allowed us to have this conversation with our gynecology partners but also with our patients as we talked about like when

can you return to work how long are you going to be all for you know am I going to need extra child care or whatever how long would I be in the hospital this information helps us to inform our patients about that then on average

you'll stay in the hospital around you know a day or so and most uterine artery embolization procedures are same-day procedures and interventional radiologists are doing these in freestanding centers as well as other

providers without any issues so we're almost down to the end we know that fibroid embolization is proven to be an effective and durable a procedure for controlling patient symptoms it's minimally invasive and it's outpatient

most patients can go back to some normal activity in one to two weeks it has a low complication rates and some patients mein neatest to surgery and should have surgery so in our practice we send around 1/3 of our patients or so to

surgery and the reason that that is that high is that patients are allowed to come and see myself or dr. de riz Nia from the street they do not have to be referred from their gynecologist and so they're just coming from the street then

you will be referring them to a gynecologist because of some of the things that may not make them a good candidate for embolization such as this

positron emission tomography is the use

of a radioactive tracer in this case FD gee her fluorodeoxyglucose to assess the metabolic activity of ourselves ftg is tagged with glucose and glucose is used by our body for energy cancer cells are thought to be our Armour hypermetabolic

so if we inject FDG to our patients it goes to areas with hyper metabolic activity this area is called a hotspot and when a hotspot is noted in a PET scan its it's thought to be cancerous this is an example of a hyper metabolic

region noted in the pelvic area of the patient this patient is diagnosed of cervical cancer and what is MRI as you all know MRI is the use of radio frequency currents produced by strong magnetic fields to provide detailed

anatomical structures it is the preferred method for imaging soft tissue organs and there's no ionizing radiation present now what is pet MRI pet MRI is a combination of these two modalities instead of going to two scans using two

scanners we have one scanner that is able to obtain pet and MRI images simultaneously so why can't we just call this pet well we run through a few problems we have fdg-pet CT where it's a PET scan with low-dose CT accompanying

it and there's fdg-pet CT with diagnostic CT we're full sequences of CT is coupled with a scan and a pet MRI always has a diagnostic MRI done with it

patient who did not come from the street so if you've been here for a few years

you've heard me talk about you know some of my friends this is also one of my other friends who has large fibroids but her fibroids were so big and they were not all very vascular and so I sent her to have surgery and she ended up having

a hysterectomy with removal of her cervix because of abnormal pap smears but her ovaries were left in place so our path forward after doing this procedure from 1995 a procedure that is not experimental a procedure that has

had a lot a lot of research done on it more research than most procedures that are done surgically or by interventional radiologists I'd say that it would require a partnership it is true that we can see patients on our own and we can

manage mostly everything but at the end of the day uterine artery embolization is still a palliative procedure because we don't know what causes fibroids to begin with and as long as the uterus is still there there's always a chance that

new fibroids will come back so in your practice and in mind I believe that a path forward is a sustaining program embolization program which is built on a relationship with the gynecologist that yes

I am as aggressive as any other interventionist that is out there but if this were my mom and that is my usual test for things I would say that where we would like to position ourselves is in the business of informing the

patient's as much as possible so that they can make an informed decision and that we're asking our gynecology partners to do the same is that if you're going to have a hysterectomy for a benign disease that you should demand

and we as a society and you as your sisters keeper should be asking for why am I not eligible for an embolization so si R is actually embarking on a major campaign in the next year or so it's called the vision to heal campaign and

it's all around providing education for this disease stage what I like to tell our patients and I'm almost finished here is when I talk to our gynecologist and to techs and nurses as well I said woody woody what should I expect right

that's what they want to know when I send my patient to you what should I expect and I say that what you should expect that Shawn and myself we're gonna tell the patient everything about fibroids we're gonna talk to them about

what the fibroids are the pathophysiology of it the same things I told you we're gonna tell them about the procedures that treat it we tell them about the options to do nothing we talk about all of the risk and the benefits

of the procedures especially of fibroid embolization and we start the workup to see if they're an appropriate candidate when they're an appropriate candidate we communicate with them and their OBGYN and then we schedule them for their

procedure in our practice there are a few of us who send our patients home on the same day and we let our patients know no one is kicking you out of the hospital if you can't go home that day then you'll get to stay but

most of our patients are able to go home that day and then we see our patients back in clinic somewhere between two and four months three months and six months and we own that patient follow-up their visits and after their year we have them

follow back up with their gynecologist and so that we're managing all of these sites and it comes back to that new again may not be so new for some of the people that have been doing clinical IR four years that shift that we own these

patients if you're a nurse in this room these are our patients these questions need to be answered by us in our department we do not believe that these patients should be calling their gynecologist for the answers to that

like what should I be doing right now should I be taking I haven't had a bowel movement and like that is something that we answer we're the ones that are given them the discharge instructions and we set them back up for their follow-up so

no thanks to the avir we really wouldn't be able to do anything that we can without y'all so I take great great pride in sharing things from our perspective said you folks can start contributing your own thoughts your own opinions and your own vision during

these cases I think it's certainly something that I've appreciated since the first day of doing invention where do you all do so having said that we're just a smidge in the behind side so we'll try to focus today is mainly a

survey to stimulate everyone in terms of what's actually happening on the other end of the catheter with respect to the patient why are we doing these things where's our role and I think that's gonna add hopefully some value the next

time you folks step in on one of these cases alright so as you know dr. daughter first was able to visualize the inside of a blood vessel and find a stenosis and a lady who had limb ischemia and then was able to use a

dilator to fix that so obviously that gave birth to interventional radiology so we started taking pictures of tumors just to diagnose tumors back in the day before we had actual imaging and what we found

was well if tumors have a high demand for blood just like anything else what happens if we take away that blood and this is a 1975 image of renal cell carcinoma is to call them hyper and if Roma's back then but basically the

concept of interventional ecology was born the moment you could do something to make the environment for the tumor less hospitable and to try to palliate patients if they weren't subject to the the gold treatment standards like

resection in this case so fast forward to 2016 there was a huge study was International where they looked at over 3 000 patients who have primary liver cancer or her pata cellular carcinoma and what they found was that regardless

of where but if you sum all the treatment decisions that are related to those patients about 70% will see treatment by an interventional radiologist as you know that was a astounding amount

so si are listened to a lot of these types of messages even outside of obviously oncology basically we realize that there's a tremendous responsibility and the best thing to do is to dedicate ourselves fully to that and that's why I

think with IR now is a separate medical specialty we're going to start seeing more of the clinical involvement of this and certainly think the caseloads going to go up so why interventional oncology

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