Radiation Exposure in Interventional Pain Management Physicians: A Systematic Review of the Current Literature
BACKGROUND:Millions of interventional pain procedures are performed each year to address chronic pain. The increase in these procedures also raises the concern of health risks associated with ionizing radiation for interventional pain management physicians who perform fluoroscopy-guided operations. Some health concerns include cancers, cataracts, and even pregnancy abnormalities. Little is known regarding the long-term and cumulative effects of small radiation doses. OBJECTIVES/OBJECTIVE:The objective of this systematic review was to identify common body parts that are exposed to ionizing radiation during interventional pain procedures and examine methods to help physicians reduce their radiation exposure. STUDY DESIGN/METHODS:The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was used to comprehensively identify articles from 2 medical databases. The radiation dose to interventional pain management physicians obtained from relevant peer-reviewed articles were aggregated and used for analysis. METHODS:PubMed was first used to collect the articles for two broad keyword searches of "radiation exposure pain management" and "radiation exposure interventionalist" with years ranging from 1956 - February 2023. EMBASE was also used to collect the articles for the two keyword searches of "radiation exposure pain management" and "radiation exposure interventionalist" with years ranging from 1969 - February 2023. This systematic approach yielded a total of 2,736 articles; 24 were included in our paper. The risk of bias for these articles was performed using the Cochrane Risk of Bias tool and the National Institutes of Health tool. RESULTS:Through our systematic literature search, more than 3,577 patients were treated by 30 interventional pain management physicians. Some areas of exposure to radiation include the physician's neck, chest, groin, hands, and eyes. One common body region that is exposed to radiation is the chest; our review found that wearing lead aprons can lower the radiation dose by more than 95%. Wearing protective equipment and managing the distance between the operator and fluoroscope can both independently lower the radiation dose by more than 90% as well. Our literature review also found that other body parts that are often overlooked in regard to radiation exposure are the eyes and hands. In our study, the radiation dose to the outside (unprotected) chest ranged from 0.008 ± 27 mrem to 1,345 mrem, the outside neck ranged from 572 mrem to 2,032 mrem, the outside groin ranged from 176 mrem to 1,292 mrem, the hands ranged from 0.006 ± 27.4 mrem to 0.114 ± 269 mrem, and the eyes ranged from 40 mrem to 369 mrem. When protective equipment was worn, the radiation exposure to the inside chest ranged from 0 mrem to 108 mrem, the inside neck ranged from 0 mrem to 68 mrem, and the inside groin ranged from 0 mrem to 15 mrem. LIMITATIONS/CONCLUSIONS:Limitations of this study include its small sample size; only the radiation exposure of 30 interventional pain management physicians were examined. Furthermore, this review mainly consisted of observational studies rather than randomized clinical trials. CONCLUSION/CONCLUSIONS: Implementing safety precautions, such as wearing protective gear, providing educational programs, and keeping a safe distance, demonstrated a significant decrease in radiation exposure. The experience of interventional pain management physicians also factored into their radiation exposure during procedures. Radiation is a known carcinogen, and more research is needed to better understand its risk to interventional pain management physicians.
Radiofrequency Ablation's Effectiveness for Treating Abdominal and Thoracic Chronic Pain Syndromes: A Systematic Review of the Current Literature
BACKGROUND:Many patients suffer from abdominal and thoracic pain syndromes secondary to numerous underlying etiologies. Chronic abdominal and thoracic pain can be difficult to treat and often refractory to conservative management. In this systematic literature review, we evaluate the current literature to assess radiofrequency ablation's (RFA) efficacy for treating these debilitating chronic pain conditions in the thoracic and abdominal regions. OBJECTIVES/OBJECTIVE:The objective of this study is to determine the pain relief efficacy of RFA on chronic thoracic and chronic abdominal disease states. STUDY DESIGN/METHODS:This study is a systematic literature review that uses the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method to gather academic literature articles through a methodical approach. The numbers obtained from each academic manuscript were then used to calculate the percent efficacy of radiofrequency ablation on thoracic and abdominal pain relief. METHODS:Articles from 1992 through 2022 were gathered using PRISMA guidelines. The search terms "Radiofrequency Ablation Thoracic Pain" and "Radiofrequency Ablation Abdominal Pain" were used to identify articles to include in our study. Our search yielded a total of 575 studies, 32 of which were included in our study. The articles were then categorized into pain causes. The efficacy of RFA for each qualitative study was then quantified. Risk of bias was also assessed for articles using the Cochran Risk of Bias tool, as well as a tool made by the National Institutes of Health. RESULTS:The PRISMA search yielded a total of 32 articles used for our study, including 16 observational studies, one cohort study, 6 case reports, 6 case series, and 3 clinical trials. Twenty-five articles were labeled good quality and one article was labeled fair quality according to the risk of bias assessment tools. The studies examined RFA efficacy on chronic abdominal and chronic pain syndromes such as spinal lesions, postsurgical thoracic pain, abdominal cancers, and pancreatitis. Among these etiologies, RFA demonstrated notable efficacy in alleviating pain among patients with spinal osteoid osteomas or osteoblastomas, lung cancer, and pancreatic cancer. The modes of RFA used varied among the studies; they included monopolar RFA, bipolar RFA, pulsed RFA, and RFA at different temperatures. The average efficacy rate was 84% ranging from 55.8% - 100%. A total of 329 males and 291 females were included with ages ranging 4 to 90 years old. LIMITATIONS/CONCLUSIONS:Limitations of this review include the RFA not being performed at the same nerve level to address the same pathology and the RFA not being performed for the same duration of time. Furthermore, the efficacy of RFA was evaluated via large case series and single cohort observational studies rather than control group observational studies and clinical trial studies. CONCLUSION/CONCLUSIONS:A systematic review of the literature supports RFA as a viable option for managing abdominal and thoracic pain. Future randomized controlled trials are needed to investigate the efficacy of the various RFA modalities to ensure RFA is the source of pain relief as a large body of the current literature focuses only on observational studies.
Video Consent for Upper Endoscopy and Colonoscopy Improves Patient Comprehension in a Safety-net, Multi-lingual Population
The challenges of consenting for procedures are well documented and are compounded when patients have limited English proficiency (LEP). Standardized video consent has been studied, but research in gastroenterology is limited. We created educational videos in English and Spanish covering the elements of traditional consent for colonoscopy and upper endoscopy. All participants underwent traditional verbal consent and a subset viewed the language and procedure specific video. Participants from a multilingual, safety-net hospital patient population were then given a questionnaire to assess their comprehension and satisfaction. Participants who watched the video had higher comprehension scores than those who received traditional verbal consent alone. This difference persisted when data was stratified by language and procedure, and when controlled for educational level and prior procedure. Video consent improves comprehension and satisfaction for endoscopy and may mitigate some of the challenges encountered when consenting patients with LEP.
Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: Prospective Improvement Study
Background: The introduction of electronic workflows has allowed for the flow of raw uncontextualized clinical data into medical documentation. As a result, many electronic notes have become replete of "noise" and deplete clinically significant "signals." There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating. Objective: This study aims to describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation. Methods: This is a multihospital nonrandomized prospective improvement study conducted on the inpatient general internal medicine service across 3 hospital campuses at the New York University Langone Health System. A group of physician leaders representing each campus met biweekly for 6 months. The output of these meetings included (1) a conceptualization of the note bloat problem as a dysfunction in information flow, (2) a set of guiding principles for organizational documentation improvement, (3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations, and (4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience was measured using the System Usability Scale (SUS). Primary outcome measures after go-live include template utilization rate and note length in characters. Results: In usability testing among 22 medicine providers, the new progress note template averaged a usability score of 90.6 out of 100 on the SUS. A total of 77% (17/22) of providers strongly agreed that the new template was easy to use, and 64% (14/22) strongly agreed that they would like to use the template frequently. In the 3 months after template implementation, general internal medicine providers wrote 67% (51,431/76,647) of all inpatient notes with the new templates. During this period, the organization saw a 46% (2768/6191), 47% (3505/7819), and 32% (3427/11,226) reduction in note length for general medicine progress notes, consults, and history and physical notes, respectively, when compared to a baseline measurement period prior to interventions. Conclusions: A bundled intervention that included the deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency, and patient outcomes.
Outstanding research award in the interventional endoscopy category (trainee) new automated cleaning system is more effective in reducing bioburden vs standard manual clean in duodenoscopes [Meeting Abstract]
Introduction: Multiple recent outbreaks of multidrug resistant organisms (MDRO) related to contaminated duodenoscopes have led to increased scrutiny of duodenoscope standard reprocessing methods. A key component of duodenoscope reprocessing is the cleaning step that occurs before high-level disinfection (HLD) or sterilization. Perfect adherence to manufacturer Instructions for Use (IFU) for manual cleaning can be difficult to achieve due to technical complexity and is open to human factor error. Adequate cleaning is measured against FDA and industry maximum allowed contaminants post cleaning of protein<6.4 ug/cm^2 and carbohydrates<2.2 ug/cm^2. Inadequate cleaning increases the risk for inadequate high-level disinfection and the possibility of procedures being performed with contaminated duodenoscopes. A new cleaning process has been developed to fully automate the cleaning step using turbulent flow technology.
Method(s): A total of 48 therapeutic ERCP procedures were performed utilizing Olympus TJF-Q180V duodenoscopes. After bedside point of use cleaning, 21 duodenoscopes were manually cleaned by trained technicians following the manufacturer IFU. 27 duodenoscopes were cleaned using the automated cleaning system. Duodenoscope instrument channels and distal elevator areas were sampled for residual protein and carbohydrates after cleaning.
Result(s): The automated cleaning process resulted in a lower average level of residual protein and carbohydrate compared to standard manual cleaning (Table 1). Using FDA and industry standards as a benchmark, the automated cleaning process reduced levels of protein and carbohydrate below safety threshold levels on all study duodenoscopes, while manual cleaning resulted in 4/21 (19%) duodenoscopes having protein or carbohydrate levels above FDA standards (p= 0.03).
Conclusion(s): Recent outbreaks of MDRO organisms transmitted after ERCP have brought to light the risk to patients when reusable duodenoscopes are not sufficiently reprocessed. The complex design of the device-involving multiple channels and an elevator mechanism at the distal tip-makes proper cleaning difficult. Without sufficient cleaning, subsequent HLD or sterilization can fail to adequately remove contaminants. As seen in this study, manual cleaning can be prone to error. With no incidents of elevated bioburden post cleaning, a fully automated cleaning technology appears to be a viable alternative for replacement of manual cleaning of duodenoscopes
Medical device safety in gastroenterology: FDA recalls of duodenoscopes, 2015-2020 [Meeting Abstract]
Introduction: Duodenoscopes are used in more than 500,000 procedures annually in the US as a minimally invasive diagnostic and therapeutic modality for hepatobiliary and pancreatic diseases. Traditionally, these devices have been intended for re-use after undergoing strict cleaning and disinfection protocols to reduce the risk of infection between patients. However, since 2008, several major outbreaks of infections linked to duodenoscopes have resulted in devices recalled from the market. Understanding what occurred in instances of device failure leading to recalls is important to improve the safety and efficacy of these devices.
Method(s): This institution review board-exempt study reviewed the FDA Center for Devices and Radiologic Health database for all duodenoscope-related recall events from November 1, 2002 through December 31, 2020. Market entry data, recall characteristics, and adverse reports were collected for each device.
Result(s): Seventeen class II duodenoscope-related recall events were identified, affecting at least 24,611 units in distribution. 12 out of the 17 (70%) recall events were for duodenoscopes, 3 out of 17 (18%) recalls were for operation manuals, and 2 out of 17 (12%) recalls were for reprocessors. 15 out of 17 recalled devices (88%) had at least 1 documented occurrence of an adverse event at the time of recall. All recall events were approved via the 510k pathway, however postmarket-related issues accounted for 88% of recalls.
Conclusion(s): Given the wide utilization of duodenoscopes in treating pancreaticobiliary diseases, an understanding of their recall events and associated public health impact are important for endoscopists to have a greater awareness of potential safety concerns. Recalls by three duodenoscope manufacturers and one scope reprocessor manufacturer highlight the need for innovation in design and improved post-marketing surveillance mechanisms
Gastrostomy tubes in patients with COVID-19: Reduction of in-hospital mortality with a multidisciplinary team-based approach [Meeting Abstract]
Introduction: Critically-ill patients with COVID-19 often require long-term enteral access due to prolonged ventilator support and slow recovery from neurologic injury. The outcomes of hospitalized patients with SARS-CoV-2 who received gastrostomy tubes (GTs) are unknown and limited guidance exists on how to safely triage GT placement in this population. The Enteral Access Team (EAT) is a multidisciplinary team led by an attending gastroenterologist (GI) hospitalist with advanced practice providers who collaborate with Palliative Care, Geriatrics, Speech-Language Pathology, and Nutrition to reduce unnecessary feeding tube placements at the end-of-life. The EAT reviews the appropriateness of GT placement and triages each case to the indicated procedural service. The EAT's multidisciplinary approach was applied for patients with COVID-19.
Method(s): We performed a retrospective study of 135 hospitalized patients with positive PCR tests for SARS-CoV-2 who received GTs between 3/2020 and 4/2021. The GTs were placed by 3 services (gastroenterology, interventional radiology and surgery) at 3 hospitals within 1 health system in New York. One of the hospitals employed the multidisciplinary EAT approach to its triage of GT placement. Outcomes were compared between the EAT site and control sites where GT placement was decided through direct consultation by the primary team with one of the procedural services.
Result(s): Demographics for the two groups, including overall numbers of COVID-19 admissions, can be seen in Table 1. At the EAT site (n =43) 5% of patients expired prior to discharge following GT placement compared with 25% at the control sites (P <0.05). Patients at the EAT site were older with a mean age of 70 years compared to the control sites with a mean age of 63 years (P=0.01). There was no significant difference in the percentage of COVID-19 patients who received GTs, length-ofstay, or time from gastrostomy to discharge or death. Multivariable analysis showed the odds of in hospital mortality were 10.1 times greater with the standard workflow than with the EAT workflow (OR 10.1, [95% CI: 1.7-60.6], P <0.05).
Conclusion(s): The EAT's novel multidisciplinary team-based approach helps to appropriately select hospitalized patients with SARs-CoV-2 for long-term enteral access leading to reduced in-hospital mortality following GT placement. Additionally, this approach may help to mediate the national shortage of GTs and reduce the risk of exposure to providers involved in GT placement
Endoscopic part-task training box scores correlate with endoscopic outcomes
BACKGROUND:Competency in endoscopy has traditionally been based on number of procedures performed. With movement towards milestone-based accreditation, new standards of establishing competency are required. The Thompson Endoscopic Skills Trainer (TEST) is a training device previously shown to differentiate between novice and expert endoscopists. This study aims to correlate TEST scores to other markers of performance in endoscopy. METHODS:Trainees of a gastroenterology fellowship program were guided through the TEST. Their scores and sub-scores were correlated to their endoscopic metrics of performance, including adenoma detection rate, cecal intubation rate, cecal intubation time, withdrawal time, fentanyl usage, midazolam usage, pain score, overall procedure time, and performance on the ASGE Assessment of Competency in Endoscopy Tool (ACE Tool). RESULTS:The Overall Score positively correlated with the ACE Tool Total Score (râ€‰=â€‰0.707, pâ€‰=â€‰0.010) and sub-scores (Cognitive Skills Score: râ€‰=â€‰0.624, pâ€‰=â€‰0.030; Motor Skills Score: râ€‰=â€‰0.756, pâ€‰=â€‰0.004), and negatively correlated with cecal intubation time (râ€‰=â€‰-Â 0.591, pâ€‰=â€‰0.043). The Gross Motor Score positively correlated with cecal intubation rate (râ€‰=â€‰0.593, pâ€‰=â€‰0.042), ACE Tool Total Score (râ€‰=â€‰0.594, pâ€‰=â€‰0.042) and Motor Skills Score (râ€‰=â€‰0.623, pâ€‰=â€‰0.031), and negatively correlated with cecal intubation time (râ€‰=â€‰-Â 0.695, pâ€‰=â€‰0.012). The Fine Motor Score positively correlated with the ACE Tool Polypectomy Score (râ€‰=â€‰0.601, pâ€‰=â€‰0.039), and negatively correlated with procedure time (râ€‰=â€‰-Â 0.640, pâ€‰=â€‰0.025), cecal intubation time (râ€‰=â€‰-Â 0.645, pâ€‰=â€‰0.024), and withdrawal time (râ€‰=â€‰-Â 0.629, pâ€‰=â€‰0.028). CONCLUSION/CONCLUSIONS:This study demonstrates that performance on the TEST correlate to endoscopic measures. Given these results, the TEST may be used in conjunction with existing assessment tools for demonstrating competency in endoscopy.
Social Determinants of Weight Loss Following Transoral Outlet Reduction (TORe) at a Safety-Net Hospital [Meeting Abstract]
Gastrointestinal endoscopy during the coronavirus pandemic in the New York area: results from a multi-institutional survey
Background and study aims â€‚The coronavirus disease 2019 (COVID-19), and measures taken to mitigate its impact, have profoundly affected the clinical care of gastroenterology patients and the work of endoscopy units. We aimed to describe the clinical care delivered by gastroenterologists and the type of procedures performed during the early to peak period of the pandemic. Methods â€‚Endoscopy leaders in the New York region were invited to participate in an electronic survey describing operations and clinical service. Surveys were distributed on April 7, 2020 and responses were collected over the following week. A follow-up survey was distributed on April 20, 2020.â€ŠParticipants were asked to report procedure volumes and patient characteristics, as well protocols for staffing and testing for COVID-19. Resultsâ€‚ Eleven large academic endoscopy units in the New York City region responded to the survey, representing every major hospital system. COVID patients occupied an average of 54.5â€Š% (18â€Š-â€Š84â€Š%) of hospital beds at the time of survey completion, with 14.5â€Š% (2â€Š%-23â€Š%) of COVID patients requiring intensive care. Endoscopy procedure volume and the number of physicians performing procedures declined by 90â€Š% (66â€Š%-98â€Š%) and 84.5â€Š% (50â€Š%-97â€Š%) respectively following introduction of restricted practice. During this period the most common procedures were EGDs (7.9/unit/week; 88â€Š% for bleeding; the remainder for foreign body and feeding tube placement); ERCPs (5/unit/week; for cholangitis in 67â€Š% and obstructive jaundice in 20â€Š%); Colonoscopies (4/unit/week for bleeding in 77â€Š% or colitis in 23â€Š%) and least common were EUS (3/unit/week for tumor biopsies). Of the sites, 44â€Š% performed pre-procedure COVID testing and the proportion of COVID-positive patients undergoing procedures was 4.6â€Š% in the first 2 weeks and up to 19.6â€Š% in the subsequent 2 weeks. The majority of COVID-positive patients undergoing procedures underwent EGD (30.6â€Š% COVIDâ€Š+) and ERCP (10.2â€Š% COVIDâ€Š+). Conclusionsâ€‚ COVID-19 has profoundly impacted the operation of endoscopy units in the New York region. Our data show the impact of a restricted emergency practice on endoscopy volumes and the proportion of expected COVID positive cases during the peak time of the pandemic.