A 31-year-old woman was diagnosed with duodenal grade 1 follicular lymphoma. The patient underwent radiotherapy and on surveillance enteroscopy, the lymphoma was persistently identified in the duodenum and jejunum. Endoscopic clips were used as fiducials to better localize the tumor during radiotherapy. Endoscopic clips are increasingly used as tumor localization tools because of their favorable risk-benefit ratio. In our case, endoscopic clipping was necessary to properly localize the tumor after prior treatment failure, and the patient now has no evidence of disease. Larger studies are needed to demonstrate the efficacy of clips in tumor localization and improved disease-related morbidity.
INTRODUCTION: Fecal occult blood test (FOBT) is not recommended for the evaluation of gastrointestinal (GI) symptoms or anemia in hospitalized patients. Nonetheless, FOBT is still widely used in hospitals and a positive test is a common reason for gastroenterology consults. Our initial aim was to decrease the total FOBT orders in hospitalized patients at Baylor St Luke's Medical Center from 10/2019 to 11/2020 by 80% through provider education. The final aim was to eliminate the test from inpatient diagnostics. METHODS: Inpatient FOBT orders were extracted from 1/2017 to 9/2019, including ordering provider information, department, and nursing unit to determine a baseline. Between 10/2019 and 11/2019, agreement was achieved among gastroenterology providers to reduce and ultimately discontinue the use of inpatient FOBT. Stakeholders from hospital leadership were reached between 12/2019 and 1/2020. Providers and departments with the most orders were identified. Educational material explaining the lack of clinical of using FOBT in the inpatient setting and information about removing FOBT from inpatient diagnostics was disseminated via email to these providers from 2/2020 to 3/2020. The Diagnostic Stewardship Committee approved the elimination of the FOBT order from inpatient diagnostics in 9/2020, and the order was officially eliminated on 11/13/2020. Interval data was collected to determine trends in FOBT ordering by inpatient providers. RESULTS: A total of 6370 FOBT were ordered in 4040 unique patients between 1/2017 and11/2020. All tests were guaiacbased FOBT. The monthly average before the intervention (1/ 2017-9/2019) was 166, and post intervention (9/2020-11/ 2020) was 27, representing an 84% reduction (Figure 1). The average positivity rate was 63% without major changes over the study period (Figure 2). A total of 690 unique providers ordered at least 1 FOBT, with the top 30 users accounting for 37% of all orders. The departments with the most orders were nephrology, critical care, hospital medicine and transplant surgery. Orders were placed from 65 different nursing units in the hospital, with the top 20 responsible for 86% of all orders. The nursing units with the most orders were
A 31-year-old woman was diagnosed with duodenal grade 1 follicular lymphoma. The patient underwent radiotherapy and on surveillance enteroscopy, the lymphoma was persistently identified in the duodenum and jejunum. Endoscopic clips were used as fiducials to better localize the tumor during radiotherapy. Endoscopic clips are increasingly used as tumor localization tools because of their favorable risk-benefit ratio. In our case, endoscopic clipping was necessary to properly localize the tumor after prior treatment failure, and the patient now has no evidence of disease. Larger studies are needed to demonstrate the efficacy of clips in tumor localization and improved disease-related morbidity.
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