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MySpine Operative Pearls
MySpine Operative Pearls
2016bonycadaverchaptercontactguideimperativelaminaMedactaNASSnoindexposteriorscrewsoftstarttissuetrocarvertebra
Needle Guidance | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Needle Guidance | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018ablationalignarinAVIRchapterfull videoguidancehydrodissectionnarrowneedleoverlayplacementstraight
Dealing With Pain | Rapid Resilience for Staff and Patients in IR
Dealing With Pain | Rapid Resilience for Staff and Patients in IR
2018anxietyarinAVIRaxisbreastcarechaptercomfortdrugsfull videopainpainfulparanoidpatientstandardtumorworst
Disc Decompression Techniques, Indications and Contraindications | Disc Intervention
Disc Decompression Techniques, Indications and Contraindications | Disc Intervention
angulationanteriorchapterchemicalcoagulationcontraindicationsdecompressiondiscfluoroscopyforaminalfull videoherniationherniationsincludeindicationsintervertebralintradiscallateralmechanicalmidlineneurologicpercutaneouspercutaneouslyposteriorprojectionpulsedradiofrequencysegmentalsphincterstenosissymptomaticsystemictechniquestechnologistvertebralvisualization
Evidence for Comfort Talk | Rapid Resilience for Staff and Patients in IR
Evidence for Comfort Talk | Rapid Resilience for Staff and Patients in IR
2018anchoranesthesiaarinAVIRbasedbostonchaptercomfortfull videohospitalMRIpatientpatientsreimbursementsedationsettingstimulustrainedunanticipated
Male | 53 | Myeloma | Augmented/Semented Screw | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Male | 53 | Myeloma | Augmented/Semented Screw | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018arinAVIRbonycementchaptercoronalcortexdehiscencefull videoneedleposteriorradiationramusscrewsegmentationsystemictechnologisttherapy
Q&A: Balancing Managing Preoperative Anxiety Against Informed Consent | Rapid Resilience for Staff and Patients in IR
Q&A: Balancing Managing Preoperative Anxiety Against Informed Consent | Rapid Resilience for Staff and Patients in IR
2018arinAVIRchapterembolizationexperiencefull videoinformedlymphpainfulpromise
Celiac Plexus Nerve Block - Pancreatic Ca c Intractable Pain and Nausea | Nerve Blocks, Neurolysis, and Rizotomies
Celiac Plexus Nerve Block - Pancreatic Ca c Intractable Pain and Nausea | Nerve Blocks, Neurolysis, and Rizotomies
2018anterioraortaarinAVIRceliacchapterconductioncurvedfull videogaugelidocaineneedlenerveplexusposterior
Point and Polyline Overlay | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Point and Polyline Overlay | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018ablationablationsarinAVIRbonechaptercrossexamplesfluoroscopicfull videomarkingoverlayportalprobesciaticsectionalstructurestumor
Paraplegia in the Literature | Disc Intervention
Paraplegia in the Literature | Disc Intervention
chapterembolifull videoinjectionsparaplegia
Renal Scans - MAG3 | Technetium-99 (Tc-99m): A Versatile Isotope
Renal Scans - MAG3 | Technetium-99 (Tc-99m): A Versatile Isotope
2018arinbloodcaptoprilchapterdoseflushfull videoinfectioninitialinjectinjectingkidneyliterminutesnursepatientpatientsperfusionrenalrenovascularscanwalk
Pudendal Nerve Block and Rectal Ca | Nerve Blocks, Neurolysis, and Rizotomies
Pudendal Nerve Block and Rectal Ca | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRblockbupivacainecervixchapterfull videolidocainemedialnervepatientperinealperineumposteriorpudendalrectalsciatic
Introduction | Rapid Resilience for Staff and Patients in IR
Introduction | Rapid Resilience for Staff and Patients in IR
2018arinAVIRchapterdeaconessdoctorfull videoharvardintestinallang
Laser Guidance Imaging and CBCT  | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Laser Guidance Imaging and CBCT | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018advancedarinAVIRcenterchaptercrossfluorofluoroscopicfull videoimaginglasersneedleorthogonaloverlaysiemenstechniquestrocar
How To Treat Labial Varices: Sclerotherapy, USG Sclerotherapy And Or Phlebectomy
How To Treat Labial Varices: Sclerotherapy, USG Sclerotherapy And Or Phlebectomy
anesthesiaanteriorcomplaintsdyspareuniahemorrhageiliacincisionincludelabialLabial Varices + Leg VVligationLocal SclerotherapymalformationpatientpelvicperforatorsperformedphlebectomypolidocanolposteriorpostpartumrefluxrefluxingsaphenofemoralsclerosclerotherapysulfatesuperficialsymptomaticsymptomstetradecylultrasoundvaricositiesveinsVeithvenogramvenousversusvulvar
DEBATE: When Does The Angiosome Concept Make A Difference And When Not: What Explains Discordant Results And Opinions
DEBATE: When Does The Angiosome Concept Make A Difference And When Not: What Explains Discordant Results And Opinions
arteryassignedbypasscadavercadavericdirectdistinctendovascularhealingindirectpaperspedalperonealposteriorrapidrevascularizationrevascularizestandardizedsubsequenttibialwoundwounds
Nursing Considerations for Nuclear Medicine Procedures | Technetium-99 (Tc-99m): A Versatile Isotope
Nursing Considerations for Nuclear Medicine Procedures | Technetium-99 (Tc-99m): A Versatile Isotope
2018arinchapterdependingfaintfull videomedicinenuclearpatientpatientsscantechs
SoundBite Active Wire Technology Crossing Peripheral CTO
SoundBite Active Wire Technology Crossing Peripheral CTO
activationactiveadversecalcifiedcrosscrossingctosdeviceendpointguideGuide wirelesionpoplitealreentryRutherford IIIsoftSounbite Active wireSoundbite Active Wire TechnologySoundbite Crossing SystemsteerStiff WiretherapeutictissueVeithwire
Dealing With Pain: Communication Pitfalls & Pearls | Rapid Resilience for Staff and Patients in IR
Dealing With Pain: Communication Pitfalls & Pearls | Rapid Resilience for Staff and Patients in IR
2018arinAVIRchaptercomfortcoolfull videomeasurementspainpatientstrippingtinglingvein
Segmentation/ Volumetric Overlay | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Segmentation/ Volumetric Overlay | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018ablatearinAVIRchaptercontourfull videomarkoverlaysectionalsegmentationvolumevolumetric
Transcript

operative pearls for while for the time you spend on a cadaver and if you

do your first cases. It's really imperative that you spend extra time getting all the soft tissue of the bone. These guides sit on top of the vertebra and if there's any soft tissue left it's gonna impact the contact of the guide with the bone and throw off

your guidance afterwards. So you have to spend a lot of extra time dissecting all the soft tissue off for every spot that there's going to be contact with the guide. At the same time you need to avoid bony disruption because those.. you're relying on that

bony anatomy that the CT scan is used to put the guide on and if you disrupt the bone then it's going to throw off the guide as well. Next is learning from our experience you need to really make sure that you know the level you start out on.

These guides are individual per vertebra. So if you think you're starting a T10 and you're really at T11 whereas that wouldn't normally cause any problem if they had you the guide for the wrong

level then it's not gonna match as well. You need to take extra time to really know for sure that you know where you are when you start before you start. Next the way the guide is.. because of the shingling effect of the vertebra and the lamina on every level

the guides dock onto the posterior planus process in the tip caudally. So if you have a screw there already then that guide is going to impinge on that screw and you're not gonna be able to accurately dock it. So you need to start from the top and work

your way down as you go. It's not a bad idea to initially confirm your position with the c-arm. We did that initially we do it less and less as time has gone on but just for confidence purposes put the guide on. Dock it. Visually look at it

and then put a trocar in and make sure it still looks good where you want in. Finally and this is really critical don't try to do this free hand with just yourself. It's really imperative that you have

someone there to dock the guide and hold the guide in position where you want it to be able to look at all the different docking points. You know during surgery and in a deep hole it's slippery and blood it's really easy for it to rotate and to slip

slightly and you have to have it perfectly positioned. Anybody has experience using trocars or K-wires things like that the real worry is always skiving. This slide is just trying to show how that can happen.

So before we start this hole if there's a situation like this where it's really a steep incline like that we'll start a make a little starting point with either a burr or an awl just so it doesn't skive off. Again this is a slide

illustrating that the guides are very very sensitive to position. Just because there's contact everywhere does not necessarily mean that the guide is well seated. So you can see in this particular situation there's contact all around but

the guide is not seated the way it is and directly affects it propagates the effect of the trajectory of the screw in the trocar. Here's an example how it's supposed to look. So all the different docking points are perfectly positioned. Same thing in the oblique view.

Most of my experiences with the standard guides but the My

Questions? Again, that's Max, that little baby. That's the dose that's in the syringe that the pharmacy gives us. Nothing, only for GFR, but then I talked about the residual.

For most, that's 20, 10% up or down. Their body acts as, almost, kinda a little bit of shield. So if I'm giving 20, in six hours it will be 10. That's the half life. But it won't go anywhere else.

It stays in the system. And again, it does get eliminated through urine, but nothing that fast. Yeah, it's still the same dose. It's not going anywhere else. That's our policy and procedures.

Our doctors have made, I'm not sure if there's a specific reason for that, but that's how, that's what our policy is. As we are injecting, I'm keeping an eye on it. There's always that you don't, I'm not looking at someone else,

I'm looking at the vein as I'm injecting to keep on assessing it as I'm doing it. Also, that eight millicuries that's in there, I take it to the pharmacy because I don't know if it's eight. They calculate that and then our doctors decide

if they want something comparable, if they want eight, or if they wanna add a couple more to it, write a new order, and then whatever is the new order, I inject according to that. It's actually a very small volume.

For, I think, bone scan, we get fresh doses throughout the days, it could be up to one milliliters, maximum. It's very tiny amount. - [Audience] How would you even know if it's a tiny amount that you did infiltrate the line?

- Because you're paying attention, well again, I'm trying to pay attention to the site of injection. No. I personally have not injected a patient who was intubated. Like I said, if they can't follow the instructions,

it's kinda hard to do it. We, about three to four, and there are days we have done more. We also do them for pre-surgical reasons, so there's that. - [Audience] Not necessarily (mumbles). - No more questions?

Okay, thank you.

We do use, particularly in interventional radiology we use a script

that somebody reads at the beginning of the case because not everybody has to work simultaneously at the beginning and we're reading this while the patient's prepped. I mean nobody stops, if we do large core breast biopsy we also do it while the patient's being compressed.

I mean nobody stops. So let's say perhaps nursing starts putting the blood pressure on, putting the probes on and all that, the technologist may start reading and then when those roles reverse the script allows that and somebody else reads.

If let's say you're in MRI, you just kind of may use some wording of it and you should theoretically be done by the time you walk the patient from the waiting room to the procedure room. Somebody's really claustrophobic you may need

to do a little bit more. But what I thought I'm gonna do with you, the basic of the script if somebody isn't too anxious takes you 90 seconds, we once timed it. If you wanna put in some extra provisions

like in IR that you wanna get somebody ready that there might be some potentially painful stimuli then you add a few of those what they can about, either mention some hot or cold pack and work on that and then if the patients already present with pain at the onset there's an extra little option for that.

If on the other hand they're really anxious and worried out of their senses there's another little piece and then at the end how we would reorient them. In that context it already has the explanation of what you do.

So the way this works, I'm gonna give you a little example of that, but what I'm gonna do is I'm gonna include what we call an insert. If you wanna do something special, you add a little thing in the middle and since this talk is about resilience

I thought to give you a little piece for if you need to get your confidence up like right at this moment. Either to walk in that waiting room to this patient who is already crying or you're walking in to your boss and you wanna have a salary increase

or let's say your chief of surgery who is throwing a tantrum in the hallway and you're gonna explain that this is not how it goes. So okay, and so basically what we would say to patients, well, and again there's a little confusion element

in the beginning, all we want to do is we want to help you so that you can help us so that we can help you to be more comfortable through this procedure. It's just a way of focused concentration like reading a book or watching a movie

or surfing the web and kind of forgetting where the time went and most people have this experience and, you know, you're fully in control of it. If it's a book you don't like you close it, same with TV you change the channel

and just use all the sounds and noises in the room to have your own experience and use only suggestions that are helpful for you. There are many ways to do this but there's a very simple way and on one you do just one thing, you look up and on two you do two things,

you slowly close your eyes and take a deep breath in, (inhales) and on three you do three things, breath out (exhales), relax your eyes and let your body float. That's right, just floating nice and safely, floating right through your chair or the table

and with each breath in take in strength and each breath out let go whatever is not helpful. Each breath in strength (inhales) and each breath out just let go whatever is not helpful. And just floating safe and comfortably like in a bath, the lake, or a hot tub.

That's right, and just with your eyes open or your eyes closed just focus on where you imagine yourself being now, what is it like? What do you see around, what do you hear, how does it feel like?

And you can make this your safe and comfortable place, you can always return to and play a trick on this whole procedure because your body has to here but you can be anywhere where you would rather be. And right now you may just focus on the moment

where everything just works out perfectly. One of these magic moments where everything comes together. You might have worked for it a long time or it just comes like a pot of gold at the end of a rainbow, and there you say, yes this is it

and it may be a private moment or a public achievement. While you're right in that just look a bit around a look at the colors that might permeate the scene and you can make these your colors so that whenever you need to get again into this state of confidence and peace and success

you just need to think of this color or you might get a pen or a pair of socks or just something to remind you of it. Or for some it may be a sound around, perhaps a song so that every time, at a moment's notice you need to get back into that state

you just think of the song or hum it for yourself. Or perhaps you enjoy just the way things feel and you can, you know, touch your thumb and forefinger together or you can do a very discrete, just curl your toes and then anytime you need it to get back in a state of confidence,

resourcefulness and brilliance all you need to do is just think of the color or the sound or of this movement that you gave yourself as a symbol. And now this was quite a lot to assimilate because sometimes in the conscious mind we have our own thoughts about whether subconsciously

we're assimilating all that into some new learning and while consciously there are all these logic things that go through one's mind, subconsciously one really knows how to move forward and which aspects to use and to learn. And now you can again gently float back

up over yourself and perhaps count backwards from three, like at three you can relax your eyes again and on two, start opening up your eyes and on one feel absolutely refreshed and delighted and ready to go on with the day

and you can even wiggle a little bit after in your room and go around and be all alert again, ready for the day to continue. Okay everybody back in the room. It got really quiet, very quiet.

So that was the deluxe version, that had the extra insert for the confidence. By the way, anyone of you who liked the color the best to remember? Or the sound? Or the movement, you can think a little bit

about how that works. You're really nice and quiet now. (audience laughs) It's amazing, you can have that in the IR suite where suddenly everybody just does their thing. Pretty good huh?

Alright so now if there's still a bit of disbelief in, oh let's just look a bit how it can normally look,

and how you might be able to change it, there we go.

Now, to become resilient and manage stress if you're in IR this is not something you can do by taking a 20 minute meditation break for yourself and typically by the time you're done with your day, your weekend,

you're coming home and there's a life too so just focusing on yourself and working really hard on meditation may not do the trick because there are other people around you who very much determine how your day goes. And we've published just last year in the JVIR

where we looked, well what happens if a patient walks in the door and they have this really negative affect. I'm getting more and more intrigued by the whole issue of mood contagion and if you look at that the people who come in like that, they actually

have more adverse events, they get about three times the amount of drugs and if you just look at anxious people it's those persons who come in and they look at you with these big, fearful eyes and they tell you I'm gonna die today,

how is that going to affect you? They are gonna experience more pain and above all, their procedures are gonna take much, much longer. The good news though is, what we've found out in this IR room with the multiple players

where there is one person feeding off the stress of the other it is enough to actually just relax one person and with that you can break this cycle. Yeah and then we have relatives that may make some pertinent remarks there

and there was actually a pretty cute study done by a NICU team where they randomized and had a simulated relative say something as kind as, oh if I would have known that you're doing here like third world medicine I would have brought my relative somewhere else.

Just something that pushes all your buttons and they found out that this whole team suddenly couldn't work as well anymore. Now it's not that easy to change what other people do but, you know, you're within this whole setup,

you may be the manager of your division or you have a manager whom you have to report to and there's a lot of other things that goes through your head. I mean this morning you heard about MACRA is in full swing, payment big time depends on it

and the satisfaction ratings and yes, you do wanna retain your staff because you need to have happy staff otherwise your patient's not gonna be happy either.

So let's look at this very last video we had about the heavy patient.

So needle guidance is one of the main tools that we use. This is basically a straight line overlay.

Distinct starting and ending points. We draw this again on cross sectional imaging. Automatically, you can align the C-arm to the, to kind of align with the path that you've drawn, in either a bullseye line of sight orientation, or also a kind of tangential view.

And really you can use this for anything that has straight line geometry. Bone trocars, cement cannulae, ablation probes, screws, temperature probes, hydrodissection needles, anything that more or less is straight line geometry. Just a couple examples of this.

On the right side you can see an example of bullseye needle guidance orientation, and then a more tangential view from the side of the same pathway, so that you can have real time kind of overlay guidance of needle placement as you rotate the II, with a detector,

back and forth real time. And one of the benefits of this is to be able to achieve placements within narrow corridors. Example on the left is placing a screw through a scapular body, which

you know, is pretty thin with a narrow corridor, but this really facilitates placement in this circumstance.

I mean I just thought I'll show you that second clip, how natural it can actually look to cross one's arms but then she opened it up and it's very hard to then not follow along, so that's how you sometimes can save the day

in a fast way. Now dealing with pain and that's something I think that gets to all of us emotionally, I mean we are gonna be poking people and there's certain things of how we feel about

what the patient should be experiencing. We've done several large clinical trials so we had the opportunity to look at the standard of care groups of those where patients could get as many drugs as they wanted and if I were to ask you, just by show of hands,

what do you think hurts the most? Okay angiography? Large core breast biopsy? Tumor embos? Okay well it's kind of like, what I thought too. However if you plot onto this graph

on the X axis is the time zero you wheel a patient into the room and on the Y axis is their self reported pain. We ask them like every end of 15 minutes, by the way we don't say how bad is your pain, we say what is your comfort level on a scale

of zero to 10, no pain at all and worst possible, and zero no anxiety at all, 10 worst possible. And what you find out is, I mean there are these three curves going up over time and the blue line is the tumor embos, the red one is the angio renal and the yellow

is the breast biopsies, there's really no difference. And furthermore when we dug deeper into this data not only is this increase in pain over time, this trend relatively independent of how hard you poke somebody, but also independent of how many drugs they get.

Actually there's a somewhat inverse relationship between the amount of drugs people get and how much pain they experience over time that is sent. And the question is why is that the case? So from nature we are used to always assume the worst

and similar curve applies, although with some differences for anxiety but there's an increase in anxiety over time in the case under standard of care and I think it goes all down, that's one explanation (mumbles), he's a surgeon in (mumbles) uses,

he says, you know, hundreds and thousands of years our ancestors, let's say who walks through the Savannah and one behind hears a little noise and says, oh this could be a tiger, perhaps I should look around and do something about it and the other one says it's just the wind it's not a big deal.

You can see that being a little paranoid over time still probably translates into higher longevity and the ability to create offspring so we are all deriving from the somewhat more paranoid people that particularly, in a setting of ambiguity, we assume it's hurting

or it's bad or it's dangerous to us and it's a protective mechanism of the subconscious. That is going to happen. Furthermore, once there had been one painful stimulus then all subsequent stimuli are going to be interpreted as being painful or even more painful

and there have been studies done where they hook people up to a machine with little flashing lights and the first time they got a little shock and the next time just the little lights were flashing and they experiencing more and more pain with the little lights flashing even though

there weren't any more shocks. So that's what you have to deal with and this is what we all know. If you do a case that's over in 15 minutes it's not that big a deal. It's like you're in hour number one,

where you now are number two or in hour number three. That's when certainly everybody can get really, really stressed out. However, the good news is if right at the beginning you do something, you say to the patient something in words but also in your behavior

that reframes this experience this doesn't happen. And this is kind of the secret sauce, all you need to do is do something at the beginning, at time zero, and then you don't get this blue line on the standard of care where the pain keeps going up

over time, time, time, time. If you do some empathic attention the increase is not as steep but if you do some comforting words at the beginning, these are IR data in interventional radiology, you can go on for ever.

I mean it's just like a very different atmosphere in the room and very similar for anxiety. We've found similar responses in a trial we did with breast biopsies and tumor embolizations under standard of care pain to go up,

getting better if you give some empathic attention but anxiety dropping down very quickly while this patient is still on your table and actually even though the whole thing is called Comfort Talk you're gonna end up to talk much less

because the idea is to get that patient on autopilot as fast as you can, particularly in MRI. You wanna have them in there doing their own thing, having, as we shall say, their own experience while you can start to do all your paperwork

and your reconstructions and whatever you need to do.

Policies and procedures in nuclear medicine. Pregnancy and breastfeeding. Pregnancy, we assess every female

from the age of 11 to 50 years old. Adults get a pregnancy questionnaire and pediatric review is done for pediatric patients in the pediatric area. Their doctors do it before they send the patient to us. If the patient has had a sterilization procedure,

they automatically get pregnancy exemption in their chart so that we don't keep asking them for the same thing over and over again. If the patient is not sure, and trust me, this has happened to me multiple times, the patient will come in, "Maybe I'm pregnant,"

just do the test, it's so much easier to just do the test and if they are hesitating, just be like, "Listen, we understand, "but if you have even 1% chance, let's take the test." It's easier than taking, doing this test and then finding out your pregnant, not worth it.

Breastfeeding. MSK policy at this point is to pump and store the milk for 96 hours. You can, after you pump it, you can date it, time it, and remember, these are isotopes. Even if you're not doing anything, they will decay.

So the milk will be good to use in 96 hours. Again, it is also up to mothers how comfortable they feel, but that's a policy.

Moving on to percutaneous decompression techniques for the discs, we can have decompression and we can have regeneration techniques for the discs. Specifically for the decompression techniques we can have thermal techniques using laser, continuous or pulsed radiofrequency and plasma energy ablation.

We can have mechanical decompression using a wide variety of devices and we can have chemical decompression by means of Discogel or ozone intradiscal injections. All these techniques, what they are actually based on is that fact that a intervertebral disc is a closed hydro-ablic space and when you are removing a small

part from the nucleus, you are actually causing a significant decrease in the intradiscal disc and this disc pressure actually is what makes the herniation move inwards. And we have these techniques from back in the 1940s. The indications for these kind of treatments

in the intervertebral discs include patients who are capable of providing consent with a symptomatic small to medium-sized herniation and when we are speaking about the size of the herniation, if you have a theoretical line between the facet joints, all herniations which do not cross this line,

they can be percutaneously treated. And when we are speaking about symptomatic cases, symptoms should be consistent with the segmental level where the herniation is located on the MR imaging. For example, if you have a left L4-L5 foraminal herniation, you are expecting the patient

to report a left L4 root neuralgia. Absolute contraindications include sphincter dysfunction, extreme sciatica and progressive neurologic deficit. And actually all these are indications for surgery. Additional absolute contraindications include sequestration or the presence

of asymptomatic herniation, local or systemic infection, spondylosthesis and stenosis of the vertebral canal, anticoagulants, coagulation disorders and the patient refusing to provide informed consent. Most of these techniques are performed under fluoroscopy so we (mumbles) projection with 45-degrees angulation

of the fluoroscopy beam and as far as the lumbar spine is concerned, we perform a direct posterior lateral (mumbles) in the disc. In the final position, we need to have the needle in the anterior third of the disc in the lateral projection towards the midline in the AP projection and you can see

how important the technologist is because we need to have good visualization of what we are doing. Once you are there, you have access to the disc and you can insert any kind of product that you are familiar with, starting from thermal, going to mechanical or chemical decompression.

The magic number for all these techniques concerning success rate is around 80%. The complication rate is very low, between 0.5%. What we do know so far from the literature is that there are no studies of evidence of superiority of one technique over the other.

As we've already said, complications are really rare. Spondylodiscitis is the most fearsome one with a percentage of 0.24% per patient.

Leave that a bit for later. While we were doing all the work in interventional radiology

we were asked to train a private practice MRI team north of Boston because they further wanted to reduce their claustrophobia rate and that's how we got into this whole issue of using Comfort Talk in the MRI setting

and what we are finding out now more and more is that patients who are claustrophobic it's PTSD. So for the one's of you who are doing nursing and are called in there, that's what it is. The situation, in one way shape or the other reminds them of past trauma.

There is now a fair amount of trauma exposure therapy, particularly these veterans who are coming back from the various wars where they go to the psychologist's office and they are re-introduced to the setting and this is reframed and then the hope is that they walk out of the office and feel better.

That's hard to do. However, when the patient shows up at your doorstep and is completely freaked out, they are in the trauma, they're in it, and all you can do is actually make it better because it is the setting where they are the very most motivated to improve it

and this is also why it kind of works. We had done a recent trial at Boston Medical Center, Tufts and Ohio State where we basically just look at what happens if you train a team in just changing their vocabulary a little bit, sometimes they would read a script

but most often not, what is gonna happen to the outcomes? And we didn't even insist that people would use the techniques, we said okay you get the training, do with it what you want but it kind of changes after you see how things work

that you are gonna see your results and then adaption becomes more. So we saw the incomplete and no show rates going down and a significant improvement in patient satisfaction and there's nothing that improves your stress level

more than if a patient comes and says, hey thank you very much you really helped me through that. Or they really express their appreciation. And we then moved on and did a randomized trial and I think that gets a bit back to the original slides I did

in you are not alone in this. You are in this environment of commercial pressures of patients who come in who are not coming and then what is happening to your practice base. The fascinating thing about this, and that was in Columbus, Ohio, that the trial,

we trained three teams in Comfort Talk and three teams we didn't and that was in one healthcare system of MRI and what had happened at time zero is a fascinating event which I call the adverse effects

that philanthropy can have. For those of you who have come from the Columbus area there is so much money out there, there are more wealthy people probably than in New York that don't show it, but there is a lot of richness, so for somebody to give a hundred million

to build a new tower for the hospital is not a big deal. So they build a new tower but then the competitor in town obviously couldn't let this go by and they also got this beautiful nine story newer tower. Obviously all of them having MRI.

Same thing happening in Boston. I mean it's amazing how many millions, hundred millions in philanthropy for new stuff and everybody has a new MRI. So now suddenly, and it was at time zero you have more scanners in an area than you have

patients to go around. And what happens, what we found is, and that's the blue line, the people who were trained in Comfort Talk, were able to keep their volume and the others lost volume. So even in big urban areas word gets around

of like where do people go or we see impact on no shows. Most no show are people are frequent offenders but in any event we saw that. So now obviously if you are working in an area where you have fewer and fewer patients showing up

your equipment utilization is going down. And keep in mind that the current regulations are you are supposed to have your equipment running 90% of time, that's what payment is based on, that CMS payment is based on. So if you see this line going down

and you work in a place like that you can count on your five fingers that somebody's gonna get fired making things even worse because that's how administrators really high up solve that situation. And what we have seen is that, in other settings

where we had trained people whose patients are happy and actually send that in, that's actually a very good insurance against being, quotation mark downsized and this is what happened with patient satisfaction. So once you stress out the personnel,

patient satisfaction is gonna go downhill and we had done that and seen that in a prior study too where, in that very first place that had hired us it was a joint venture of two hospitals for an outpatient facility and at the moment the reimbursement changed

to have more reimbursement hospital wise. They told everybody they'll get fired or transfer. That obviously did make a dip down in the patient satisfactions but then they came up again and at least throughout stayed longer than before training. I thought I'm gonna just share this

because that got published last week and our first author, who's actually at UCLA in economics, already has given three press interviews. So you might be hearing about that in the weeks to come. We trained a team at Duke and we looked at,

where do people waste, where does extra time go, where does extra expensive time go? And the two columns on the left side are the hospital based facilities and the two right columns are the free standing facilities.

Pre is before training, post is after training. Now the interesting thing is that in the hospital based places the amount of general anesthesia and conscious sedation didn't change because there are fixed slots, and every month, interestingly enough,

it's exactly the same. But that comes from the fact that places that don't have anesthesia and don't have sedation send them there until the slots are filled. But you might notice that green bar, the oral sedation went down, and particularly

disruptive motion. So the whole idea that you put somebody under general anesthesia and their breathe to you on command is not necessarily going to happen. If you look particularly at the freestanding places you've got a pretty big decrease in all these issues

that cost you extra time and run into money. So if you look at all, I think a paper that came out at Emory, what they call unanticipated events, I mean I don't call it unanticipated if a patient moves around, that's kind of life,

but if you look at those we found a drastic reduction but then also found even if you use Medicare reimbursement data quite a lot of more money. If you do 25,000 patients a year, and you make 12,800 times 25,000

that's nearly 300,000 for that you can keep some extra staff without anything else happening, or at least you can keep your structure intact or invest in new equipment. I think, since now we are all kind of really quiet,

I wasn't sure whether I would be showing you another video but I think you really need it with another great trick which is, if you're doing something and there's a repeat thing gonna happen again, some stimulus that's unpleasant,

and this actually really happened, the one we're playing now. Let's say you have the patient and let's say they're heavy and you know they take a breath in and they're gonna hit the equipment, which is kind of a bit scary for the patient,

or let's say you do a biopsy and you use the gun and it's gonna shoot all the time. So you have repeating, or you do a laser, you have a repeating stimulus coming, you can actually interestingly enough use that stimulus to make what we call an anchor.

Remember when I did the little hypnosis script with you, where I asked you to think either of a color or a sound or of a movement to anchor that with something really pleasant, the same you can use a stimulus that happens to anchor the patient in either getting more relaxed

or use that as a sign to numb the area around even more. It sounds spooky but it works.

So what I thought is perhaps to just look a little bit

around and think a little bit of what happens when you are in a situation let's say, where you do feel comfortable, where things kind of go their usual ways and what do you do then, what are your coping mechanisms in that?

So I'm just watching something very interesting, there is three ladies in the third row and one of them took her arm up and the next one did exactly the same and you're looking at me somewhat astonished and scared. (audience laughs)

But this is something people to tend to do when they're in rapport. We do this very, very intuitively and you may perhaps even look a little bit around of how you're sitting there, the two ladies there who have their arms just like perfectly folded

in the right way, I mean one of them is completely not watching what her neighbor does because she's doing her iPhone but both of them are having their hands exactly in the same way. So you know while you're sitting there it's kinda of like a little spooky thing

of what we do when we feel safe and comfortable we do tend to match the body positions of others. So now, okay you gotta work now. So I would like now every second person of you to get up, if you don't have a partner look behind you, every second person gets up and you're gonna be

playing yourself and the person who remains sitting is going to be your patient in the waiting room. Okay, it's work time, yeah yeah work time. Little stretch time, so find yourself a patient victim and the idea is that your patient has been waiting patiently for getting their PICC line

and you had all these emergencies come in and they've already been in the waiting room for over an hour and now you got this neuro case being wheeled in and you're gonna explain now this is gonna take at least another hour, you can't even say how long it's gonna take,

and your patient is allowed to misbehave. So let's go, see how this works. Just keep talking to them, I mean you do, you've got that lingo down all the time. (audience chatters) Alright, and now just kind of freeze in

the body position you have. How much matching is going on right now? (audience chatters) So number one, your patient is kind of sitting and you are, many of you, standing. So you're right on top of them

and there's actually some research that shows that if you sit down, people think you spent more time with them. So, if now you all sit down and this may feel a little unnatural, match whatever your patient's doing. If they do that, you can do that a little bit.

If they do that, you can be a little copying it. The whole thing they tell you in medical school about this open positive section and never raise your voice, does not work. You do want to match, that is like the big secret. So you match a little bit in the beginning.

Now the idea is not that both of you are screaming at the end, but you just follow it a little bit. Oh really, you have to wait long and then you go and go down. If on the other hand your patient is deeply depressed, oh I can't do that, and then you say, ah and then

take your breath up. Okay I'll give you two minutes to continue your conversation with your unwilling patient. So also if your patient has their legs crossed you cross them, if they don't have the legs crossed you uncross yours.

Just do what they do and then the patients you can try to stay nasty but see what happens in trying to stay nasty or unhelpful if the other person matches you.

And it's a big case where, or a big example where the technologist can add a lot of value and help out a lot. So just a case example that kind of ties together. This was a 53 year old male. He's doing pretty good, except he kinda had

some progressive right hip pain for a few months, but was still walking and able to kind of do most things. Was diagnosed with myeloma. And this was his CT scan, kind of a coronal projection. You can see this large lytic destructive lesion

over his right acetabulum. With extensive kind of bony dehiscence and thinning of the cortex throughout. And so this was the plan to stabilize this. And help his pain from kind of a combined augmented screw, cement and screw approach.

These were the needle paths, and the screw paths that we used on pre-procedural imaging. You can kind of see representations of these here. So again it gives you a good idea of where these screws are gonna go, and in the case of the bottom right image

through a narrow corridor, this really allows us to achieve that. Using this live kind of overlay needle guidance. Several of these screws were placed. Again, up on the I guess top left, you can see this narrow ramus corridor,

that this kind of allows us to find. So again, just kind of more examples of how this case progressed. Registration is a key part again. This was the segmentation that I showed you earlier. And then kind of used this in real time

as we filled this entire area with cement. Again, given the bony destruction, at least the kind of posterior aspect of it was extremely difficult to see. Just under fluoroscopy, and I think without this nice contouring of our target lesion,

in cases that we've had, you know, previously, we would have stopped a lot earlier, thinking that we'd filled it. Whereas here we have kind of that confidence that there's a little bit more to go, a little bit more to fill.

So you can kinda see it, as this goes on, we are able to fill most of the target volume. And this was kind of the completion, you can kinda see that these are screws, and then the cement area here, kind of reforming almost the acetabulum roof.

So he did well, so this was all done percutaneously. He basically had three Band-aids from his three different screw entry sites. And was weight bearing within two hours. Afterwards, he underwent radiation therapy. He was on systemic therapy.

He's starting a Zometa for his kind of overall bone health, and he really doesn't have any specific right hip pain. And the biggest thing for him was that he was able to kind of move on to his systemic therapy and radiation therapy almost immediately afterwards. So a really good outcome, and one that I think that

without a lot of these advanced imaging techniques, we either wouldn't have been able to accomplish or probably would not have been able to provide as much structural reinforcement as we were.

- [Audience member] How about children?

- [Elvira] Children, the beauty with children is that they have a very great imagination. I mean they are Batman, they are whatever they want to be and you can get them very quickly into their state. So for a kid, all you may need to do is,

oh what do you like to do? And then when they tell you what they like to do we use a little, how shall we say, ego strengthening piece in it. So for example, we do work a lot with Toronto Hospital for SickKids

and obviously what kids love there to do is play hockey, and so they go and play hockey and all the sounds there is your fans cheering you on and then they're gonna hit a goal and that kind of makes them really proud. What I may also add to that,

I've been thinking about this earlier to include in that is landscape in medicine is really, really shifting and what is happening that nursing and technologists, frontline staff are gonna be determining what is happening with patients.

We see this more and more, I mean doctors don't have really that much to say anymore and at Toronto Hospital for SickKids the nurse is running an absolutely landmark study. She's 11 patients away from 170 and this is gonna be the very first trial

that shows can you actually, if you decrease pre-operative anxiety, and that's kids who have cardiac ablations under general anesthesia, can the pre-intubation anxiety reduction, is that gonna result in better post operative behavior? Because there's a lot of research that you basically

create PTSD in these kids who come, they're in this environment the next time it's gonna be worse and worse. So she follows them up. But the other thing too is there always has been some thought about how much do patients

actually hear? When they are under, so with those kids we're actually also looking at not only a script at the onset but right before extubation. How is that gonna affect how they recover in recovery? What's it gonna do afterwards, what's it gonna do

for the whole safety? So I think particularly in kids, anesthesia is a problem because brain development can be affected depending on the age so we are very much into, hopefully soon, knowing exactly what is happening

in the pediatric population on a broad scale there.

Yes. - [Audience member] So we do lymph nodes integrity

inductions in the breast. They're extremely painful and patients come not prepared for a discussion about what's gonna happen to them. How would you give informed consent to let them know what's gonna happen

without giving them negative stimulus? - [Elvira] Well typically in those settings when you do your informed consent, whether it's something painful or where you potentially might kill somebody you still obviously have to describe what might happen

but what you're gonna do about it. Say, okay you know, and you explain what's happening, so say we'll be numbing up the skin and then we'll be injecting the material and you might feel that. Some people experience it as warm, some as hot,

some as a sense of tingling yeah, but the key thing is we want you to be comfortable and it's very, very important that you always tell me what is happening. If something, let's say your risk of killing somebody during your procedure, you say, and I've done

a fair amount of high risk cases. If, for example, while we're going through your heart and do that your heart stops we are going to resuscitate you and while we can never guarantee any outcomes I can promise you we will be doing everything known to mankind

to make this go well. I mean that is all I can promise so one can go somewhere deeper into that but I am open and some people in embolization say well, is it gonna hurt? I say well you know, different patients

experience it very different. The key thing is you are gonna let me know anytime how you feel like. I do not want you to be a hero, even if you say I do not want you to be a hero, still the hero is still in there,

I really want you to work with me and I'm gonna do whatever I can to make this a good experience for you. Which is, I mean it's honest, it's what you really want.

This is where the celiac plexus lives, so it's around the celiac artery, usually just slightly above, but is actually a mantle of nerve tissue that is from the celiac down to the SMA. You can see on the image on the right,

we've approached from the posterior paraspinous approach and we're using a curved needle where we basically dock the base needle which is a 22 gauge needle adjacent to the aorta and then we take a 25 gauge needle that's curved and bring it anterior to the aorta and that's where we can eject the contrast.

You can see the contrast now layering just anterior to the aorta, hopefully not in the aorta. But the beauty is, you're using a 25 gauge needle, so you really can't do much harm. Once you've injected the contrast, the lidocaine and bupivacaine, you can then either move directly

to giving the neurolytic which is absolute alcohol, usually about 15 to 20 CCs, or you can use phenol, which is more commonly used in Europe. This basically denatures the myelin, destroys the myelin sheath, and stops the conduction of those nerve fibers.

Point overlay is pretty simple. Again drawn on cross sectional imaging. These are just specific points. Can mark bone cortex.

You can mark kind of ablation probe stations if you're doing multiple overlapping ablation zones. Again this can be very helpful when, perhaps in a tumor case where there's been some bone destruction, you don't have good bony fluoroscopic landmarks that you might have in a normal patient.

Polyline overlay is kind of a similar technique. It's basically drawing a curvilinear line, again on a cross sectional imaging. And this is for more curvilinear structures such as perhaps marking nerves or neuroforamina. Estimating ablation zones,

marking out portal veins or other targets that you might use for even non MSK procedures. These are just a couple examples of this. You can kind of see a schematic representation on the left of what an ablations zone might look like. Also, some examples on the right of marking out a

sciatic nerve particularly, and then down on the right side, it's a little bit hard to see, but some green kind of cross hair point marks, just in terms of where you're gonna pull back your ablation probe along the path.

There just kinda different ways that you can utilize these, you know, these tools. These are examples again of the kind of curvilinear marking of neuroforamina. Whether it's ablation or cementation or such. That these are maybe structures

that you wanna know where they are under fluoro and stay away from.

And what are the cases you can have a Black Swan Effect. These are the 12 cases of paraplegia reported out of the hundreds of thousands of spinal injections performed. And the most logical pathophysiological explanation was the particles in the steroid where are injected intervascularly and they acted as an emboli

resulting in paraplegia of the patient. The success rate for all these injections ranges between 75 and 87% in the literature in clinical practice. I guess that the magic number is around 70%.

Renal scans.

I'll be talking about MAG 3 renal scan. It can use furosemide and captopril. We don't use captopril as much at MSK. I've only used it twice in the two and a half, three years I've been there. I'll just quickly touch on it.

We use captopril to diagnose either renovascular hypertension or renal stenosis. Again, we don't use it as much. Furosemide is our choice of drug that we use. GFR scan that uses D.T.P.A in IV form. Renal scan MAG 3.

This was, when I put it off, Vera went like, "Is this an infection control slide?" It is not an infection control slide. It's just, I though it was really cute, because-- - [Audience] Are those supposed to be kidneys? - Yes, these are two kidneys.

One is kinda healthy, and the second is very sick, and that's what sometimes you find in the renal scans, that one kidney is working great and the second is just, I don't know, feeling all that hot. Indications. For perfusion and, renal perfusion and function,

renal obstruction, renal trauma, or renovascular hypertension. Renal scan is done in three parts, pre-procedure, peri and post, and I'll go over each one of them. Pre-procedure we try to hydrate our patients

with one liter of water as quickly as they can tolerate. If the patient has any contraindication to that much fluid, our doctors change the order for the fluids. Pediatric, the hydration is done on the pediatric floor by their doctors, and the dose is based on BSA. Initial blood pressure is needed on all of our patients

who are going through the renal scan. Again, education, I like to educate my patients before I start doing anything so that they know what we are doing. Most of the patients, as I'm talking to them, that yes, we will be placing an IV,

I would like you to use the restroom before you go on to the scanner. We will be injecting you under the scanner. And someone will take pictures for about 20 minutes before I come in and inject lasix or furosemide. They cannot move after I inject 40 milligrams

of IV furosemide for about 20 minutes. At that point, I offer them a brief. I try not to call it a diaper, because, I mean, come on, how many adults here wants to listen to the fact that, "Hey do you guys wanna wear a diaper?"

- [Audience] Are you hydrating them orally? - Orally. If they can take it, then definitely orally. Another nurse actually calls the diaper a disposable underwear. - Oh, I like that. - Yeah, right?

Education, because as an adult, if I go for a scan, if someone tells me, "Hey, there's a diaper, please wear it," I would not like it. It's just letting them know why you're giving it to them. They don't have to use it, it's just in case,

it's to protect them, because they will not be able to move for about 20 minutes after the furosemide injection. At that point, it might be 40 minutes. They've already had a liter of water in them. Even then, I always tell my patients,

even when you're wearing a brief, we would still want you to hold it. Because it they do void, or if they have an accident, it creates a background radioactive isotope imaging in the scanner, it can get on the scan, and we would rather just avoid all of that.

I'm pretty sure most patients wants to go home in their own clothes, so that's really important. Just in case. Truthfully most of my adult patients opt to wear it. Renal scan for peri-procedure, again, this is a flow study,

so you're talking with a nuclear medicine technologist. Nurse and the technologist have to be on the same page, ready when you inject. So you confirm with the technologist, are you ready, the scanner is in the right place, one, two, three, go.

You inject your dose eight millicuries, and then you flush it with about 50 to 60 milliliters of normal saline. After that, 20 minutes of imaging, the nurse can usually leave, come back in 20 minutes, inject 40 milligrams of furosemide,

which can be based, it can be increased if the createnine is higher. And then flush it with another 10 milliliter of saline. Leave, they do another 20 minutes of pictures, stop, the patient gets off the scanner, uses the bathroom, comes back

for another five minute picture to make sure the bladder did empty out. These are the imaging. As you can see, there's a really cool, and this is as you're injecting the isotope and the saline. It just gives that picture.

See, going back to my kidney slide, we have left kidney that's pretty healthy and the right kidney is not doing so hot. Actually that darkened area up there is the kidney not able to eliminate all of the urine so it's holding on to the isotope.

20 minutes later, as you can see in the end, lasix is given and slowly they're gonna clear out. Post-procedure, you assess the patient, you get another blood pressure, because you really don't want them to tank. I'll make sure they're all great,

the blood pressure is good, you gave them furosemide. Also, assessing, another assessment, that's really important is their ability to ambulate. You don't ask them, "Do you think you can walk fine? "You think you feel safe?" Walk with them for that initial thing,

for the initial walk to the bathroom or to the hallway because I know that if I really have to go, I'm probably not looking very far. (mumbles). You do not want the patient to fall. So just make sure that they are able

to ambulate independently and you're walking with them. You're not just letting them walk by themselves right after the scan.

The pudendal nerve block is also sort of a deeper block that can help in perineal pain. It's the block that's used actually by the obstetricians in child delivery if you're not having an epidural. They do an internal block through the cervix and vagina

and basically block the pudendal nerve there just medial to the acetabulum and the ischium. We can do this block under CT guidance and you can see I've done the block here on the right hand image from a posterior approach, avoiding the sciatic nerve, obviously,

and injecting a little bit of contrast and then the bupivacaine and the lidocaine and you can get a nice deep block. This is an actual case of a patient who had profound rectal cancer invading the perineum and actually passing through the skin, unfortunately.

The patient was in extreme pain, couldn't get out of bed, just absolutely miserable. And by doing the block and then neurolysis where we actually inject alcohol, you can actually improve this patient's pain syndrome and that in fact is what happened.

- [Moderator] It is my pleasure to introduce Doctor Lang today. Doctor Lang is a national and international expert and pioneer in the application of hypnosis. She is also the founder of Comfort Talk. She has held faculty positions in Stanford, Iowa and Harvard and she's been in practice

for over 30 years. She has abundant government research funding, she has over 150 publications and she has received the Ernest Hilgard Achievement Award for a lifetime of published experimental work. So please welcome Doctor Lang today.

(audience applauds) - [Elvira] Well thank you very much. I'm really delighted to be here and share with you some coping strategies. When we were originally thinking what should the title be, the original title

was about resilience and stress management in IR which is for patients and at the same time for staff because as you will see they are just very, very much interrelated. Now all this work started back when I was at Stanford and at the VA in Palo Alto

and there was a young Vietnam veteran who was very difficult to even get on the table and he needed a repeat change of his intestinal tube and it was this huge production with tons of drugs and it would really delay the whole day and that's where I saw the first time

how some imagery process or hypnosis process or whatever you wanna call it could make a difference. So I said hmm, very, very interesting but is this gonna work for other people and where is this all gonna lead to,

does it work also within a team without making extra issues of their own? So I set up a research program surrounding that which I then took to Iowa and also to the Beth Israel Deaconess in Boston which ultimately then led to me founding the company.

And after pretty much NIH and DOD spent about 5.2 million on all the clinical trials we did we can say yes it works and yes we can train teams in it, but then there comes the moment where you have to jump into the ice cold water and say, okay you're gonna leave this

high paying job at the Harvard teaching hospital as division chief and you set up your own company. So (laughs) that's my disclosure, and we now focus on training frontline medical staff and a lot of insight I'm gonna share with you here today comes from this activity.

I also do receive royalties on two books I've written.

- [Instructor] Thank you for the invitation. It's great to be here, lots of energy in the room. I'm gonna talk briefly on some advanced imaging guidance that we've used in some MSK applications in the angiosuite. So really I think of this as augmented reality in the IR suite.

(laughing) Next, next says no disclosures here. Yeah, we're just gonna go over some advanced fluoroscopic overlay techniques really. Touch on needle guidance, some polyline point overlay,

volumetric segmentations, some registration. And then tie it together with a case example, just so that you guys have some exposure to this, and understand what we're doing with some of these advanced imaging techniques. So kind of the basic, one of the basic techniques

is laser guidance, that is available in our system, which is, most of these images are gonna be Siemens systems, but I know that there are other applications and other vendors and such. Really, this is orthogonal lasers that are attached to the imaging detector.

And the cross point is really in the center of the field of view. These two orthogonal lasers will cross at a point that's directly in the center of the field of view. Again, and you can line up a needle or any kind of bone trocar of sorts,

just using the lasers. So actually reduces the need for fluoroscopy. You can do a lot of needle placement, really without having fluoro on. Really the mainstay of a lot of these overlay techniques is having good cross sectional imaging.

The easiest way to do this is with cone-beam CT, at the beginning of a procedure. Automatically registers to the patient location in space, at the time of the procedure. Again this is non-contrast imaging with limited resolution.

But then on this 3D dataset, more stack of CT images, is you can then draw annotations, different objects that you can then project live on fluoroscopy.

- Like to thank Dr. Veith and the committee for asking me to speak. I have no conflicts related to this presentation. Labial and vulvar varicosities occur in up to 10% of pregnant women, with the worst symptoms being manifested in the second half of the pregnancy.

Symptoms include genital pressure and fullness, pruritus, and a sensation of prolapse. These generally worsen with standing. Management is usually conservative. Between compression hose, cooling packs, and exercise, most women can make it through to the end of the pregnancy.

When should we do more than just reassure these women? An ultrasound should be performed when there's an early presentation, meaning in the first trimester, as this can be an unmasking of a venous malformation. If there are unilateral varicosities,

an ultrasound should be performed to make sure that these aren't due to iliac vein thrombosis. If there's superficial thrombosis or phlebitis, you may need to rule out deep venous extension with an ultrasound. When should we intervene?

You may need to intervene to release trapped blood in phlebitis, or to give low molecular weight heparin for comfort. When should a local phlebectomy or sclerotherapy be performed? Should sclerotherapy be performed during pregnancy?

We know very little. Occasionally, this is performed in a patient who is unknowingly pregnant, and there have been no clear complications from this in the literature. The effectiveness of sclero may also

be diminished in pregnancy, due to hormones and increased venous volume. Both polidocanol and sodium tetradecyl sulfate say that there is no support for use during pregnancies, and they advise against it. So what should you do?

This following case is a 24 year old G2P1, who was referred to me at 24 weeks for disabling vaginal and pelvic discomfort. She couldn't go to work, she couldn't take care of her toddler, she had some left leg complaints, but it was mostly genital discomfort and fullness,

and her OB said that he was going to do a pre-term C-section because he was worried about the risk of hemorrhage with the delivery. So this is her laying supine pre-op, and this is her left leg with varicosities visible in the anterior and posterior aspects.

Her ultrasound showed open iliac veins and large refluxing varicosities in the left vulvar area. She had no venous malformation or clot, and she had reflux in the saphenofemoral junction and down the GSV. I performed a phlebectomy on her,

and started with an ultrasound mapping of her superficial veins and perforators in the labial region. I made small incision with dissection and tie ligation of all the varicosities and perforators, and this was done under local anesthesia

with minimal sedation in the operating room. This resulted in vastly improved comfort, and her anxiety, and her OB's anxiety were both decreased, and she went on to a successful delivery. So this diagram shows the usual location of the labial perforators.

Here she is pre-op, and then here she is a week post-op. Well, what about postpartum varicosities? These can be associated with pelvic congestion, and the complaints can often be split into local, meaning surface complaints, versus pelvic complaints.

And this leads into a debate between a top down treatment approach, where you go in and do a venogram and internal coiling, versus a bottom up approach, where you start with local therapy, such as phlebectomy or sclero.

Pelvic symptoms include aching and pressure in the pelvis. These are usually worse with menstruation, and dyspareunia is most pronounced after intercourse, approximately an hour to several hours later. Surface complaints include vulvar itching, tenderness, recurrent thrombophlebitis, or bleeding.

Dyspareunia is present during or at initiation of sexual intercourse. I refer to this as the Gibson Algorithm, as Kathy Gibson and I have talked about this problem a lot, and this is how we both feel that these problems should be addressed.

If you have an asymptomatic or minimally symptomatic patient who's referred for varicosities that are seen incidentally, such as during a laparoscopy, those I don't treat. If you have a symptomatic patient who has pelvic symptoms, then these people get a venogram with coils and sclerotherapy as appropriate.

If they are not pregnant, and have no pelvic symptoms, these patients get sclero. If they are pregnant, and have no pelvic symptoms, they get a phlebectomy. In conclusion, vulvar varicosities are a common problem, and usually conservative management is adequate.

With extreme symptoms, phlebectomy has been successful. Pregnancy-related varicosities typically resolve post-delivery, and these can then be treated with local sclerotherapy if they persist. Central imaging and treatment is successful for primarily pelvic complaints or persistent symptoms.

Thank you.

Alright, so you know in conclusion,

if you have a happy patient you're going to have a happy staff and the key ingredient really is this rapid rapport piece, to reframe the experience, avoid these negative suggestions and you can use a bit of this hypnotic language and it doesn't need to take extra time.

Thank you. (audience applauds)

So and now I'm just gonna show you another video where we'll, just as an example how to go about the tips because you can't get anesthesia at four in the afternoon. That's when script reading really comes in handy, okay.

- [Speaker] Well, thank you very much, Dr. Manzi, and not so opposite. I'm not sure we have much of a debate. I'd agree with many of the conclusions you've already heard here this afternoon. Nothing to disclose in regards to this lecture. But I would say that, we did look at this back in the year 2006,

and we did because the plastic surgeon in my group said that he wanted the blood put to a certain particular artery where he thought the wound was located. And I said, "No, no, no, we can just bypass "to the best artery available, "and that will work just fine."

And we had this big disagreement, so we went to the cadaver lab and we actually defined in the cadaver lab six angiosomes distinct to the lower extremity, one off the dorsalis pedis, two off the peroneal, and three off the posterior tib.

Here's our cadaveric dissections. And it is actually fairly distinct in terms of these latex injections, and the borders are actually fairly distinct. Here's the two off the peroneal, and the three off of the posterior tib.

The problem is, there are indirect connections, and they're called choke vessels, and there's no question that you see these arteriographically, and you can see these in the cadaveric dissections as well.

We were able to identify them here. And there's no question they play a role, and we'll talk a little bit about more of those at the end of the talk. There's also the question of the intact pedal arch. Does the pedal arch play any role

in this particular paradigm? So we looked at 60 consecutive wounds, and as you previously saw, we only had 58 patients to actually analyze. There was some mortality. But these were patients, they were a rarefied group,

these were patients that all had a tibial bypass, all done with vein, all bypasses remain patent, and in whom we had good definition of the wound angiosome and the bypass anatomy. And as you can see, here's the tibial bypass distribution, interestingly, mostly to the anterior tibial artery.

I don't know why that happened to be, just worked out that way. And we had, if you looked at this particular group, we had about half that were done with an indirect revascularization, and half had a direct revascularization.

The important thing you have to think about when you look at some of these trials is also what kind of wound care and wound healing they had subsequent to their procedure. If you're going to look at amputation prevention and wound healing and wound healing time, as a metric,

then you need to know that they did have a standardized wound care protocol, subsequent to their revascularization. That's very important, and when you look at the methodology of some of these papers make certain that you read that.

We did have a standardized wound care protocol, and there was no difference between the groups. And this was what we found, you've seen this slide. We had more complete healing and a trend towards more rapid healing when I could perform a bypass with vein to the artery

that fed the angiosome where the wound was located. Other people have shown the same thing. You've seen the meta-analysis. I've tried to tease out some of the papers that actually have specified some of the parameters that I mentioned earlier in terms of their methodology.

This is a group from Oregon Health Sciences University, all bypasses, where they showed more complete healing in the direct group, more rapid time to healing, and thought that it was a significant predictor for healing and reduced healing time.

Another bypass group which showed more rapid healing in the direct revascularization group, and higher limb salvage, although that can also be impacted by the wound care protocols. And this group also thought

that achieving direct arterial flow, based on the angiosome concept, is important. It's not the be-all, end-all. I would never deny someone a revascularization because I can't revascularize the artery to the appropriate angiosome.

But I think it does have an impact. It also has been shown to have an impact in endovascular therapy. Here's the group from Belgium showing that they had more complete healing after direct revascularization with diabetic foot ulcers

performed with an endovascular revascularization. Here's Iida's group, also showed 203 ischemic ulcers, improved healing with endovascular therapy if the artery could be revascularized that directly fed the angiosome where the wound was located. Here's the group from Helsinki,

we already talked about this. Interestingly, if you look at some of these things, you'll also find many of these papers will indicate that, certainly, all these wounds can't be assigned to a particular angiosome so you have to consider that as well.

About, if you look in the literature, anywhere between 30 to 60% of cases will have wounds that can't be assigned to a particular angiosome. And obviously, in that context, the angiosome concept won't have as much import.

That was found in this particular group which just published their paper in Journal of Vascular Surgery. They looked at their peroneal bypasses, and applied the angiosome theory to their peroneal bypasses. As you can see,

only 46% of the wounds could actually be assigned to a particular peroneal angiosome. So you must take that into account as well. This is a compilation of the data that I could compile in terms of the papers that I thought were done with methodologic good technique.

And you can see the numbers are actually pretty reproducible. So if you can perform a direct revascularization, there's fairly good homogeneity in terms of your percentage of healing compared to indirect revascularization,

whether that's done with bypass or endovascular therapy. But there are discordant results. You've heard them presented here this afternoon. There's no question about it. Why does this occur? Well, I think it occurs because, again,

not all wounds are located in a single, distinct angiosome. Their specific angiosome revascularization should be performed, I believe, when possible. And maybe, there's a paper that has proposed a new category. Maybe we need to be thinking about that. This is an indirect revascularization,

but with these choke vessel connections. And when this particular author compared those two groups, there was actually no difference between direct and indirect if they had the presence of these collateral choke vessels. It was the indirect group that could not define and show these choke vessels

that had the real difficulties. And that's maybe where we are. So I think in conclusion, revascularization of the direct angiosome does result in increased healing, I think trends towards increased healing.

I think it should be considered, although I would never deny someone a revascularization because we can't revascularize the artery where the angiosome is located. And I think when we think about it, it does make a difference,

but without sacrificing any of the other key principles that we all utilize for revascularization. Thank you very much Mr. Chairman.

Nursing consideration. Claustrophobia, needlestick, results, and first experience. Anxiety has its own, again, claustrophobia.

Most patients have come to us after MRI. I understand. And I usually let them take a peek at our scanner and be like, listen, see? Open scanner. Our techs are really good.

They have dimmed the light for some patients, they have turned on the music that the patient likes, it's pretty good. And sometimes if I'm still talking to the patient, and they're like, I'm not sure, and I told them to go to the zen zone,

or as I call it Rainaland, it's the best place to be. It has exactly everything that I like. Because it's my land. It knows what makes me happy, what makes me anxiety-free, it's the best land to be. It helps patients.

You know, you're laughing, but laughing also helps patient. For needlesticks, we always get those patients and they come in and it's obviously it's the big burly guys who are coming in. "Just so you know, I'm gonna faint on you. "I don't like needles."

I'd tell them, "If you faint on me, "I'm putting your picture up on the hall of fainters." Again, they laugh, they let go of that little bit of anxiety, makes my life very easy. Some patients actually have bad pains.

These are breast patients who only have one arm, who have been stuck multiple times, and you just try to be patient with them, warm them up, educate, and then get the IV. Don't hurry, take your time. Results, some of these patients have had chemotherapy,

other treatments, they are coming in to see, do they still have the cancer. What is it gonna say? Has it spread? Just being sensitive to the fact and not trying to rush them through this

can be very helpful. Also, first scan experience. I've had multiple patients who have come in, "I'm having a nuclear medicine scan." Great, I'm a nuclear medicine nurse. You're in a nuclear medicine department.

Which one? They have no clue, except that their doctor told them they're having a nuclear medicine scan. So just educating them at every point of the process while you're with them is really important and really helpful to them.

Infiltration. You can use a warm or a cool compress depending on the patient preference. There's no solid research out there. Isotope will absorb or decay, this is not (mumbles). The Technetium, it's almost fluid-like,

if you have ever seen it, it's almost like saline. It doesn't actually kinda sit there and can harm the tissues. Our problem come from the based dose, so if I've inject, now we are a big pharmacy, we always have extra, so if I see I've injected some

and there's still some in the saline, in the syringe, and IV has infiltrated, I'll stop, I'll cap the syringe, put it in the appropriate container, take it to the pharmacy, and be like, "Hey the IV infiltrated, can you just help me, "how much is in there?"

They'll do the calculations. So I gave you a dose of 20, there's only eight in here. I can go to our MDs and be like, okay, there was an infiltration, there's eight in the syringe, do you wanna write an extra order for eight? 'Cause I cannot reuse that isotope.

I need a new one. And they'll write it, depending on, if they want seven, they want 10, I'd go back, I inject, and the patient can still have the scan. At any point, I mean if they have had an infiltration, it's better for me, especially with our pharmacy

to just then give them the rest of the dose rather than have them not take the test or take the test and not have good pictures later on. Comfort, environment, bladder, positioning. Environment, I already said, our techs are really good with it.

I've had patients who have actually left feeling great because they have taken a nice 20 to 30, 40 minute nap in the middle of the day. They were really happy about it. Especially the in-patients. They come in, they were like, "Wow,

"that was actually quiet. "I've not slept this good since I've been in this hospital." So we're always happy about that fact. Bladder, we like them to use the restroom about five to 10 minute before they go on to the scanner, not just because we don't want them to move

but also if the bladder is full, it can cover the pelvic area and we don't get the great pictures that we do need. Positioning, we have multitudes of pillows and positioning devices. Our technologists make sure that the patient is comfortable

before they start the scanning so that we don't have to move them later on. - [Audience] You don't really need to explain this one. - Radioactivity. Patients, "I'm gonna pee, glow in the dark urine?" No.

All I can say is, yes, if you see something on the seat, you're not sure, clean the seat up, but that's something you should be doing anyways. The family member does not have to use another bathroom, another toilet, or flush it 10 times. We can still use the same bathroom.

Again, it's not glow in the dark. I know we all wish it, but it's not true. No one is also turning into a superhero, unfortunately. Otherwise I'll be first in line, I'll say that. Well, kind of, probably. Actually this happen, I put that picture up

because we had, I was doing another scan injecting a kid, and the kid comes, and he almost goes on to his four trying to look for something. I'm like, "What are you looking for?" He goes, like, "A spider."

I'm like, "Oh God, I know what you're gonna say." But I still have to ask him, like, "Why are you looking for a spider? "We're really clean, we don't "keep those things around here." He's like, "No I have to catch one,

"and as soon as I catch one, I'm gonna have it bit me, "'cause I wanna turn into Spiderman." Again, like I said, if anyone was turning into superhero, I'll be first one in the line. Yeah, yeah, movies. But again, no one is turning into Spiderman there.

So nursing consideration, we have talked about the kids and the adults, and the patients. For yourself, remember the principal of ALARA. Minimize time near the patient, appropriately shield the procedure room, and increase distance from the patient, distance after the injection.

Don't run away from them beforehand. Wait until you have injected. These are clinic patients. They usually leave anyway, so they go to the scan rooms depending on what it is.

Post-procedure, also at MSK, we give them

a radioactivity card, what that card stands for is it has their name, it has a date, up until the time it will be good for. Since Technitium is six hours half life, and it's good for 10 hour half life, it's good for four days.

When I give this card, I tell them this is your get-out-of free jail card only for radioactivity though. If they are stopped by cops or any other security personnel for radiation only, they can use this card. Behind this card, there are a lot of numbers

for, at MSK, if they are not satisfied, they can always give us a call. And we have gotten those calls. Increased fluid intake, again, Technitium does not affect the kidneys, it's only to get rid of any extra isotope

that's hanging around faster than what it usually would go.

- Yeah, thank you very much. Once again thank you to Doctor Veith for inviting me to this meeting once again. So I'm reporting you about completely new technique on behalf of my colleagues from, and co-PIs from Canada. This the so-called SoundBite technique. The SoundBite Crossing System is based on

a shockwave technology. You see how this system looks like. We have the console and then we have a SoundBite Active Wire which is a wire for single usage and these shock waves create a micro-jackhammer effect. They are hard on hard tissue and they are soft

on soft tissue as you can see here so we also do the soft tissue test and they are really do not any harm to soft tissue but they are able to go through hard material. We conducted the so called Prospector Peripheral Clinical Trial.

Refer the primary endpoint was a 30-day device success with the ability to facilitate the treatment of target lesion by allowing additional crossing and or treatment devices to cross the CTO and freedom of major adverse events. We had included 52 subjects, 56 CTOs in Canada

and in Europe. The CTO length was from one to 32 centimeters with a mean of 10 centimeters. The trial results. We had a 30-day device success of 92.3%, no major adverse events.

The mean Active Wire activation time was 3.58 minutes. The median CTO crossing time was 10 minutes and in 85.7% of all cases, the Active Wire alone crossed the full CTO length and you can see that more than 60% of the cases were moderate to severely calcified.

So this is just one example from our lab. 77-year-old male, Rutherford three. He had a short popliteal CTO we were not able to cross with the conventional methods. It was either there was really severe bony calcium. We had a crossing time of 12 minutes with the

SoundBite guide wire as you see here it's, once again, readjusting the guide wire and once again trying to push and then finally to get through and after the time I have mentioned we were able to get through the whole lesion and cross the lesion successfully.

You see it takes a little bit of time and you have to be very patient but at the end I hopefully am able to show that it doesn't last too long that we'd be able to get through. And we were able to pass through

and you can also see that the guide wire is not too stiff, that it's able to steer the guide wire and steer the guide wire where you want to need. So what we have learned. There is no need to push hard.

Let the device bore into the lesion. It has really good steerability. It's easy to change the point of attack to cut. The active guide wire has also a shapeable tip so that helps to steer the guide wire through the CTO and can help reentry

into the true lumen if subintimal. We need catheter support for the shaft stiffness. The tip stiffness is as effective for CTO with flush collateral. A five minute maximum activation time for one guide wire and usually one guide wire

is enough in most of the cases and it's really effective to cross calcified CTO lesions. We had a very high device success, no safety issues. It was easy and fast to operate and the coronary trial is presently ongoing using O14 guide wire. Thank you very much.

And again I'm gonna go later a bit more in what we do in interventional radiology where we do use some script reading but sometimes it's just very important what you say or that there is something you don't say.

So let's look at a situation, at a video that you kind of all know, like you have to put this IV in. And that's no uncommon and she's actually a very, very compassionate nurse but I mean this is replayed.

So you know the big question is, what do you actually believe happens when you say oh it's not going to hurt that much? What the patient hears is hurt, they don't hear that much, or it's just a little pinch and we had, when we did our breast biopsy study,

a very hard time because the team really believe that you have to use all these negative statements so we said okay, you know what, let's just get the data. So we listened to about 160 tapes in IR, what were people saying?

Just naturally what were they saying? And we listened for their statements that included pain or heat or bad or any other undesirable sensations and we were taking pain measurements every 10, 15 minutes and anxiety measurements and what we found

that if you warn for a stimulus with these kind of words they actually are gonna experience more pain than if you didn't say it and the same with the anxiety. If afterwards you sympathize and say oh that wasn't all that bad,

or how bad was that, it doesn't affect subsequent pain experiences but it will get the anxiety up. So what can you then actually say? I'm gonna show you another little video. Oops perhaps not, one moment we'll go back here

and yeah we can show the video now. Again Comfort Talk doesn't make things longer. You noticed what she did the second time? Right, okay she didn't say anything negative. She actually got the needles out of sight a little bit from the sight

and then she used something very tricky. She said well you might, because I always say give the patient the right to their own experience. You actually don't know what they're gonna feel. I never say this is not going to hurt, I mean what do I know, I don't.

So we call this a very permissive approach, we give some options. You might feel a sensation of cool or warmth or a delicious sense of tingling which we call a confusional type of induction because nobody really knows what that is

but now the brain is suddenly thinking, is it gonna be cool is it gonna be warm or is it delicious sense of tingling? (audience laughs) And that is the really very powerful phrase you can use in two settings.

One of the technologists at Boston Medical Center we trained said she had this patient come in with a real attitude, kinda under the whole idea. Oh you're putting that IV in, since how long are you in the business, do you know how to do this, yeah I'm a really hard stick, nobody does that

I don't see how you can do it, well she just put what we always say, put the confidence on and said, oh yeah and she put it in and when she said her thing, you might feel some cool or warmth or delicious tingling she said that patient suddenly went quiet

and was extremely cooperative till everything was completed. The other time this statement is extremely helpful when you are having a procedure. Somebody told me she had a vein stripping done, I mean not stripping but vein ablation,

you know you give a lot of local along the vein all the way up and down and she actually brought one of her colleagues with her because she wanted her colleague to do some Comfort Talk for her. But just in the preparation the doc was telling her the whole time, oh it's gonna hurt

and she said don't say that to me because I'm gonna be just fine. Said no, no, no but it's gonna hurt and she said, no you got this all wrong I will have a delicious sense of tingling. (audience laughs)

And I use that with my dentist too. I kind of just makes it quiet and you can have your own experience and cruise along. When we train the teams, now it's about the book, the key thing is this instant rapport and a lot of it is the matching

and leading to a more relaxed state. You shape the experience by the kind of wording you give but again the whole idea is to help these patients help themselves, to get them on autopilot because that's when they walk out the door, that's how they'll feel

the proudest of themselves. You're not doing it for them and I think sometimes it may interfere with your image as the giving healthcare provider. This is not about you, this is helping them to do their own stuff and what it does

in a very miraculous way that it actually cuts your stress level way down. And again with the self-hypnotic experience, I'm gonna show you in a little moment what it is because I'm gonna walk you through a little script we do. You can even, once you know how to do that,

support a stable physiology, get blood pressure a bit up and down although I always say this should not be your only way of keeping your patient stable.

Segmentation or volumetric overlay is basically overlaying either a shaded volume or a contour of a volume. The edges of the overlay volume can kind of be tangential to whichever orientation of the detector,

as it changes in real time. Again, drawn on the cross sectional CT data, using kind of segmentation type software. The use of this is really to mark a volume, or kind of a curvilinear surface. So you can either use this as to mark target volumes

that you're intending to ablate or cavities that you're intending to fill with cement. But you can also mark areas that you want to stay away from. Particularly in say the joint space, or the acetabulum or such. So this is an example, kind of on the left,

of you know, two different areas, volumetric areas kind of segmented out on the cross sectional data and how this looks on the three dimensional volumetric model on the right. So the yellow would be kinda this area of tumor, and destruction in the bone that we're intending to fill,

and the red being the actual joint space itself, that we wanna stay out of.

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