Why Peritoneal Dialysis is Underutilized in the United States: A Review of Inequities.

Given a choice, most patients with end-stage renal disease prefer home dialysis over in-center hemodialysis (HD). Peritoneal dialysis (PD) is a home dialysis method and offers benefits such as absence of central venous access and therefore preservation of veins, low cost, and decreased time per dialysis session, as well as convenience. Survival rate for patients on PD has increased to levels comparable to in-center HD. Despite endorsement by leaders in the medical field, professional societies, and those in government, PD has reached only 11% adoption among incident patients according to the 2019 United States Renal Data System Annual Data Report. This figure is dwarfed in comparison to rates as high as 79% in other countries. In addition, research has shown that inequities exist in PD access, which are most pronounced in rural, minority, and low-income regions as demonstrated by trends in regional PD supplies. To complicate things further, technique failure has been implicated as a major determinant of poor PD retention rates. The low initiation and retention rates of PD in the United States points to barriers within the healthcare system, many of which are in the early phases of being addressed.

Hemodialysis Catheters: Update on Types, Outcomes, Designs and Complications.

Hemodialysis catheters (HDCs) are an essential part of kidney replacement therapy. While these catheters are considered only the bridge to long-term vascular access such as arteriovenous fistulas and grafts, they are associated with significant morbidity and mortality and subsequent increased health care expenditures. However, despite these risks, a large proportion of end stage kidney disease population initiates dialysis using these catheters. The pathogenicity of HDCs stems from its invasive nature to the venous vasculature tree resulting in both mechanical and infectious complications. Therefore, the wide use these catheters in dialysis population and the associated complications necessitated continuous innovations in the catheter material, design, and placement techniques. This review provides an update on the catheter types, catheter tip designs, and the new technologies and innovations aimed to improve the catheter functionality and mitigate its related complications.

Refractory Biliary Catheter Leak Corrected by a Hybrid Closed Loop Catheter-Pump System.

The development of inoperable biliary obstruction in patients with liver, biliary, and pancreatic neoplasia is commonplace particularly in the advanced stages of these diseases. Under these circumstances, restoring bile flow to the gut is paramount in reestablishing homeostasis. Hitherto, this has been achieved by utilizing passive, gravity-dependent bilioenteric conduits with the use of perforated plastic catheters or metallic stents inserted either in a percutaneous transhepatic fashion or via endoscopic techniques. A frequent untoward event of biliary decompression utilizing percutaneous transhepatic catheters (PTC) is the development of pain, cholangitis, hyperbilirubinemia, or pericatheter bile leak due to the suboptimal normalization of bile flow. In some instances, the etiology of PTC malfunction can be correctly ascribed to catheter malposition and/or catheter lumen obstruction; however, in the majority, it remains radiographically occult on transcatheter cholangiography-the "gold standard." Regardless of findings, the management remains fluoroscopic repositioning or exchanges for larger diameter catheters to attempt to seal the pericatheter potential space and prevent bile seepage. Unfortunately, these maneuvers are met with limited and unpredictable levels of success. We present the successful management of an instance of recalcitrant external pericatheter bile leak mitigated by employing a hybrid closed loop biliary catheter-pump system by employing an assortment of FDA approved off-the-shelf medical devices.

Recruiting Medical Students to Interventional Radiology: Current State of Affairs.

OBJECTIVE: Interventional radiology/diagnostic radiology (IR/DR) is the newest primary specialties offered to trainees, one that medical students can now apply to directly out of medical school. However, medical students are disadvantaged in that the integrated IR/DR pathway requires early decision when often radiology rotations are not part of the core clerkship curriculum. Based upon results from a survey to Integrated IR/DR Program Directors, we report strategies being used by programs to introduce and attract medical students to IR. MATERIALS AND METHODS: A questionnaire was written touching on various aspects of medical student engagement. The questionnaire was sent out electronically to 51 IR/DR Program Directors and answers were collated by the Society of Interventional Radiology Resident Fellow Student Section, IR Residency Training Committee. RESULTS: Eighteen responses were recorded from programs across the country. All programs encouraged applying to both DR and IR programs. All except one offered research opportunities (94%). The majority offered shadowing opportunities, had dedicated IR interest groups, and invited medical students to device workshops (78%). Planned informal opportunities for medical students to meet faculty and a dedicated department website were made available by most (67%). Little more than half invited medical students to journal clubs (59%). Formal medical student-faculty mentorship program and social media outreach initiatives like Facebook, Student Doctor Network, Twitter, LikedIn, Youtube, and podcasts rounded out the bottom two (50%). Importantly, respondents indicated that they were interested in hearing the results of the survey. CONCLUSION: Our survey offers a snapshot of exactly what program directors are doing to address the issue of medical student recruitment.

Trans-Hepatic Percutaneous Endoscopic Gastrostomy Tube Placement: A Case Report of A Rare Complication and Literature Review.

Percutaneous endoscopic gastrostomy (PEG) tubes have emerged as the standard of care for long-term enteral feeding. This procedure is relatively safe; however, complications do occur, and one of the most dreaded complications is trauma to the surrounding organs. Hepatic injury during PEG placement is an extremely rare complication of the PEG procedure, with a handful of cases described in the medical literature. We describe the case of an accidental trans-hepatic placement of a PEG tube in a 78-year-old morbidly obese female, even with excellent trans-illumination and manual external pressure achieved during endoscopic placement. Post-procedure, cross-sectional imaging of the abdomen showed a gastrostomy tube traversing the lateral margin of the liver with adjacent small hematoma. Physical exam was unremarkable for abdominal tenderness or guarding/rigidity, and no blood or drainage was noted at the site of PEG insertion. Enteral nutrition was started after 24 h of PEG tube insertion and patient tolerated well with no complications. The patient was discharged to a nursing home but unfortunately died the following week to an unknown cause.

Denture-Associated Oral Microbiome and Periodontal Disease Causing an Anaerobic Pyogenic Liver Abscess in an Immunocompetent Patient: A Case report and Review of the Literature.

Pyogenic liver abscesses (PLA) develop from the spread of infection through the portal circulation, biliary infections or arterial hematogenous seeding in the setting of systemic infections. PLA are often poly-microbial and are uncommonly reported to be due to anaerobic species. We report the case of a previously healthy, immunocompetent 63-year-old man with hepatic abscesses as a result of Fusobacterium nucleatum periodontal disease. In addition, a systemic review of the literature is performed. Fusobacterium is a very rare cause of PLA in immunocompetent hosts with only a handful of cases reported in the literature. Although anaerobic infections such as Fusobacterium most often occur in immunocompromised individuals, clinicians should have a high index of suspicion in immunocompetent patients with periodontal disease or chronic stomatitis.

Polytetrafluoroethylene or Acellular Dermal Matrix for Diaphragmatic Reconstruction?

BACKGROUND: We aimed to evaluate the impact of collagen matrix in the reconstruction of the diaphragm. METHODS: We queried the electronic medical record for patients who had resection of the diaphragm and simultaneous pulmonary resection between 1999 and 2016. All reconstructions were performed with either polytetrafluoroethylene or acellular dermal matrix. We evaluated the rate of empyema and herniation in each group. RESULTS: A total of 208 patients met inclusion criteria. Polytetrafluoroethylene was used in 168 cases (80.8%) and dermal matrix in 40 cases (19.2%). Dermal matrix was used in 8 extrapleural pneumonectomies (5.4%), in 26 pleurectomy decortications (55.3%), and in 6 other types of resections (40%). Follow-ups were for a median of 15.0 months in the polytetrafluoroethylene group and 11.6 months in the dermal matrix group. Patients in the dermal matrix group had a chest tube for a median of 2.5 days longer than patients with polytetrafluoroethylene (p = 0.006). Empyema occurred in 11 polytetrafluoroethylene reconstructions (6.5%) and 3 dermal matrix reconstructions (7.5%) (p = 0.735). Seven patients (63.6%) with polytetrafluoroethylene infection required removal of the graft, whereas none in the dermal matrix group needed removal (p = 0.351). There were nine herniations in the polytetrafluoroethylene group and four in the dermal matrix group (p = 0.281), all were acute and due to anchorage failure. CONCLUSIONS: Although infection rates were similar between polytetrafluoroethylene and acellular dermal matrix, re-operation for removal was not necessary in the latter. The use of a thick acellular dermal matrix may be a reasonable option when diaphragmatic reconstruction is potentially associated with a higher risk of infection.

A Rare Case of Mycosis Fungoides in the Oral Cavity and Small Intestine Complicated by Perforation.

Extracutaneous involvement in mycosis fungoides (MF) carries a poor prognosis. Oral and gastrointestinal (GI) tract lesions are both rare locations of disease. We describe the clinical findings of one case with oral and GI MF complicated by perforation after systemic antineoplastic treatment, and review the relevant literature. The patient had a 1-year history of MF before development of tongue and palate tumors. He was treated with local electron beam radiation, but re-presented to the hospital after what was found to be small intestine perforation following systemic antineoplastic therapy. The case reveals key insights into the progression and complications of lymphomas with GI tract involvement.

Mycosis Fungoides of the Oral Cavity: Fungating Tumor Successfully Treated with Electron Beam Radiation and Maintenance Bexarotene.

Oral involvement in mycosis fungoides is unusual and portends a poor prognosis. The clinical findings of three new cases are described along with a differential diagnosis and review of the literature. For brevity, only one patient is discussed in detail below whereas the other two cases are solely described in table form. The patient had a four-year history of mycosis fungoides before developing an exophytic tongue tumor. He was treated with local electron beam radiation and is disease-free to date while being on maintenance therapy with oral bexarotene. Analysis of the data collected from our review of the literature and the present cases reveal key insights.