Based on casual conversation with Canadian endovascular specialists, it seems as though when compared to Europe and the US, Canada is behind in addressing veno-occlusive disease. One of the world leaders of venous interventional medicine is Professor Gerry O’Sullivan from University Hospital Galway in Ireland. We had the pleasure of interviewing Professor O’Sullivan. 

Professor O’Sullivan is a consultant interventional radiologist at University Hospital Galway, Ireland. Previously, he held a consultant radiologist position at Rush University Medical Center in Chicago. Prof. O’Sullivan completed his basic medical training (MBBS) at University College Cork, Ireland.

CAIR: Veno-occlusive disease in Canada is under explored compared to the EU and US with many patients being left untreated. I understand this may have been the case in Ireland, where you saw a need. Can you elaborate?

GS: I think this represents a significant opportunity for Vascular positions and particularly interventional radiologists.

At the present time, venous ulcer patients are probably the most underserved and underrepresented portion of any vascular disease space, despite the fact that they suffer, often needlessly, and absorb huge taxpayer dollars and resources and clinic time and nurse time and bandages and dressings and wound care clinics etc. etc.

Interventional radiologists and other vascular experts can certainly help with these patients, and they are incredibly grateful; and with the skill set that most IRs already have, they are in a position to profoundly and positively affect patients’ lives.

After my initial IR training in England, I went to Stanford in California where I was exposed to, at the time, some very forward thinking people back in 1998. I then spent 3 1/2 years in Chicago and realized that my future lane was not so much an aortic dissection, which is what I had intended, but more so venous disease.

When I came back to Ireland in 2002 I could see that, frankly, it was pretty neglected. Acute thrombotic events patients at that time were simply offered anticoagulation, and we have managed to change this to some extent.

I now offer the full gamut of venous interventions apart from arteriovenous malformations which I referred to a colleague in Dublin, two hours away. Apart from that, I do venous reflux disease, SVC obstruction, IVC obstruction, acute DVT, chronic venous obstruction, venous ulcer treatment, varicocele embolization, pelvic vein embolizations, and cancer related embolization, the list is endless. By and large I have given up arterial disease apart from embolization – I’m not saying it’s the only way to do things, it’s just the way I’ve done things and it’s work for me.

CAIR: Management of veno-occlusive disease has evolved over the years. Can you highlight some of the more significant breakthroughs and how they have changed your practice?

GS: Venous thrombosis techniques are now very efficient for removing large volumes of thrombus thanks to pharmacomechanical thrombolysis and very low-dose thrombolytics, so the days of five days of catheter directed thrombolysis are well and truly over. Around 90% of patients can be treated by thrombectomy device and occasionally in the remaining 10%, we put them on catheter directed thrombolysis overnight. After their thrombectomy Venous stents are a big help. Better diagnostics are a big help to, as we have gotten much better at MRV thanks to help from some European centres.

I think venous disease is under-represented on the diagnostic radiology and interventional radiology curriculum and I certainly have learnt a great deal after my training.

CAIR: A loaded question: How would you recommend starting up and maintaining a veno-occlusive service?

1. Educating other physicians
2. Recruiting patients
3. Multidisciplinary clinic
4. Patient follow-up

GS: All of the above. I frankly am a “vein lover” as opposed to a “vain lover”!!  I have no hesitation in making sure that the vascular lab contacts me first for acute deep vein thrombosis management, they generally do. The Vascular Surgeons are quite happy to dump all of this on me, I gladly except, be it acute events, chronic or acute on chronic thrombosis. Most interventional radiologists already have their foot in the door of the Nephrologists with AV fistula maintenance and HD line induced central veno-occlusive disease, and so it naturally leads from one to the other and there’s absolutely no shortage of work.

CAIR Express – your Canadian Interventional Radiology newsletter at your fingertips. Feel free to pass it along to others in your network, and most importantly, enjoy the content that is developed with you in mind.

Dr. Taylor Loon MBBChBAO, PGY-1 Diagnostic Radiology, SUNY Upstate Medical University

I was once in a patient handoff where the resident doctor had a transgender male patient on their service. While discussing the patients care with myself, they frequently stated the patients deadname (calling a transgender person by their birthname when they have changed their name as part of their gender transition)¹ and commonly referred to the patient as “she” rather than “he”. After multiple attempts to correct this resident’s comments, I felt unsuccessful in trying to change their outlook towards transgender patients in their care. Being a member of the LGBTQ+ community myself, I began to wonder despite commitments to patient care equity, how do we be better regarding care of our transgender and non-binary patients? 

Barriers to Access of Care

Lesbian, gay, bisexual, transgender and queer or questioning + (LGBTQ+) experience higher rates of healthcare disparities compared to their heterosexual or cisgender counterparts.  Identifying factors contributing to these disparities have included perceived discrimination from health care providers and denial of healthcare, in addition to racial identity and geographic location². Published in 2020, the Trans PULSE Canada project collected survey data from 2873 trans and non-binary people in Canada in 2019. 45% of the participants reported having 1 or more unmet healthcare needs in the year 2019.² This is compared to 4% of the general Canadian population in the year 2015.² In addition, 12% of patients avoided going to the emergency department altogether due to their trans identity, despite needing care. Past history of harassment, or fear of harassment was reported to be a major contributor to resistance to healthcare access by those patients in the study. ²

How Can We Improve?

A mini-guide into common definitions

It is without a doubt that we as medical professionals want to provide the highest quality care to our patients in an open and judgmental-free way. However, for many this may be challenging due to lack of familiarity of understanding the correct terminology regarding the patient’s gender identities. The list below is a mini-guide into common terminology.

Transgender or trans: “an umbrella term for people whose gender identity (a person’s internal, deeply held sense of their gender, their ‘maleness’ or ‘femaleness’) and/or gender expression (the external presentation of gender, such as name, clothing, hair, voice, and/or body characteristics) differs from what is typically associated with the sex they were assigned at birth”²

 A transgender patients identity does not depend on physical appearance, if they are taking hormonal therapy, or if they undergone any surgical procedures (gender confirmation surgeries). In addition, make no assumption based on their appearance alone and believe patients when they tell you that they are trans.

 Non-binary, gender non-conforming or genderqueer/genderfluid: “terms used by people who experience their gender identity and/or gender expression as falling outside or somewhere in between what is typically associated with being a ‘man’ or ‘woman’”²

These definitions are much different than transgender and should not be used interchangeably. They should only be used if the patient self-identifies as non-binary or gender non-conforming

 Two Spirit: “Two-spirit” refers to a person who identifies as having both a masculine and a feminine spirit, and is used by some Indigenous people to describe their sexual, gender and/or spiritual identity. As an umbrella term it may encompass same-sex attraction and a wide variety of gender variance, including people who might be described in Western culture as gay, lesbian, bisexual, transsexual, transgender, gender queer or who have multiple gender identities.”³

Cisgender: a term for people whose gender identity matches the sex that they were assigned at birth. ²

Using Preferred Terminology

Very commonly, the name and pronoun of the patient you are caring for may not be what they choose to identify with. Changing names and genders on medical records may often be extremely challenging for patients and thus resulting in the information not being up to date. Calling a patient by the wrong name or “deadnaming” a patient can put them in an incredibly uncomfortable position.

When first meeting a patient, ask them how they would like to be addressed and, if they are comfortable sharing, what pronouns they use. In addition to making sure other staff members in the department use the preferred pronouns and names of patients, check that medical documentation includes this information as well. If unable to change the patient’s name in a medical record, put their preferred name in parentheses beside and only use their preferred and pronouns name when dictating, writing progress notes or procedure notes.

Creating a Welcoming and Supportive Environment

So how exactly can interventional radiologists achieve this? One simple way to make your department or practice more inclusive is the use of signs, stickers, and flags such as the LGBTQ+ pride flag and the transgender and nonbinary flags. It is a small, simple gesture that can help create ease in patients and let them know that your practice is a safe space where they are able to seek care.

Another way to support patients is to avoid unnecessary gendering in forms, procedures, and medical documentation. A first step would be to avoid using gendering language such as “sir”, “maam”, or “miss” when addressing patients.  Providing gender neutral bathrooms and change rooms, having a patient write their gender identity (if needed) on any medical forms rather than a tick box of male vs female, providing patient gowns that are comfortable and covering a range of individuals are a few small steps to decrease unnecessary gendering.

Most importantly, make sure yourself, colleagues and staff are trained in these practices. Every provider in your department from radiologists to nurses to techs should be educated in how to make sure trans, two-spirit and non-binary patients are treated with respect and dignity every step in their care. Colleagues should be corrected if still using incorrect terminology in regards to a patient’s identity. Organizations such as Rainbow Health Ontario and Trans Care BC offer on-demand and scheduled courses for healthcare providers to increase both clinical and cultural competency in treating LGBTQ+ patients and creating an inclusive environment.

Inclusivity is not about creating unnecessary changes and policies to a department or practice nor is it an overnight process. By understanding the needs of our trans and non-binary patients, we can help create a strong patient-provider relationship and provide safe and welcoming interventional radiology departments.

References

¹Stowell, J. T., Grimstad, F. W., Kirkpatrick, D. L., Brown, L. R., & Flores, E. J. (2019). Serving the Needs of Transgender and Gender-Diverse Persons in Radiology. Journal of the American College of Radiology, 16(4), 533–535. https://doi.org/https://doi.org/10.1016/j.jacr.2018.12.050
²Trans Pulse Canada. (2020, March 10). Health and health care access for trans and non-binary people in Canada. Retrieved October 26, 2021, from https://transpulsecanada.ca/results/report-1/.
³Fewster, P. H. (n.d.). Two-spirit community. Researching for LGBTQ Health. Retrieved October 27, 2021, from https://lgbtqhealth.ca/community/two-spirit.php.

Dr. Charlotte Yong-Hing

All Canadians have a fundamental right to individual protection from discrimination and bias. Promoting equity and diversity within medicine fosters a just professional and learning culture that cultivates the diverse perspectives within it, reflects the communities physicians serve, and promotes professional excellence and social accountability.  Evidence indicates that when equity and diversity in medicine is achieved patients experience improved care and a more responsive and adaptable health care system.

Given that CAIR is dedicated to improving Canadians’ health and quality of life we thought a discussion about equity, diversity and inclusion in (interventional) radiology was in order.

We reached out to Dr. Charlotte Yong-Hing, who is a Clinical Assistant Professor, UBC Radiology; the Medical Director of Breast Imaging at BC Cancer Vancouver; President Elect of the BC Radiological Society; and President Elect of the Canadian Society of Breast Imaging.  Dr. Yong-Hing also co-chairs the UBC Radiology Equity Diversity and Inclusion Committee and chairs the Canadian Association of Radiologists Equity Diversity and Inclusion Working Group. She founded Canadian Radiology Women in 2018 to advocate for improved diversity in Canadian Radiology practices. Most importantly she is from Saskatchewan originally 🙂  We appreciate her taking the time to answer our questions.

CAIR: Can you describe why equity, diversity and inclusion groups are needed in (interventional) radiology?

CYH: Radiology has been identified as one of the medical specialties with the least diversity of gender and race. We know that patients receive better care when the physician population reflects the diversity of the population as a whole.  Many studies in industry and medicine have shown that increased diversity drives innovation and improves outcomes.

Specifically in regards to gender, there are documented significant positive impacts of increasing the role of women in medicine on the medical culture and practice, the quality of care, and the organization of the healthcare system, with benefits for patients, learners and the system.

In Canada, women currently represent over half the medical student population, yet women remain underrepresented in Radiology. The proportion of women radiologists has changed minimally over decades and current application trends suggest the proportion of women in radiology could decrease.

In addition, there is a marked paucity of women in political, academic and departmental radiology leadership positions across the country. Women represent 36% of Radiology faculty members in Canada.  The Radiology gender gap widens with increasing academic ranks, suggesting that women may not advance at the same academic or professional pace as men. Further, an established gender pay gap may result in retirement and lifetime wealth differences of up to $2.5 million.

In the last census in 2016, 1 Canadian out of 5 was a visible minority.  We know that underrepresented minorities in medicine in Canada include first nations (4.4%) and black people (2.9%).  There is however no data on ethnic diversity in radiology in Canada.  This is important because racial/ethnic representation of medical faculties and residency programs should resemble that of the population served.  Visible minorities are more likely to practice in areas with underserved and minority populations.  When patients and physicians are the same race/ethnicity there is improved overall patient satisfaction and compliance with medical recommendations.  Physicians’ race/ethnicity are the strongest predictors that a physician will care for more vulnerable and underserved communities, irrespective of socioeconomic status.

The Canadian Truth and Reconciliation Commission published a report in 2015 outlining a number of calls to action to increase the number of Indigenous healthcare workers.  While at the undergraduate level, faculties are collecting data on the admission of Indigenous medical students, information on post-graduate residency programs or faculty positions is largely lacking and there are no data in the literature regarding radiology and Indigenous peoples in Canada.  A necessary step in meaningful progress toward Indigenous representation and equity lies in the collection of data around Indigenous residents, faculty members, and community physicians.

CAIR: What can (interventional) radiologists do to support diversity and combat inequality in Canada?

CYH: An informal online survey of women radiologists and radiologists in training in Canada demonstrated there are many real and perceived barriers to achieving personal, professional, and academic success as a female radiologist in Canada.  The reported barriers were lack of exposure early in training; observation of gender gap; lack of female radiology mentors, lack of female radiology leaders. While some of these are general and would apply to women and men as well as other underrepresented minorities, all barriers could be addressed by increasing the engagement and visibility of the women who are already in radiology.

By increasing visibility of minorities in radiology online and in real life we can improve medical student exposure to radiology.   In particular, as has been documented repeatedly, the Covid 19 pandemic has had a disproportionate effect on women. There need to be proactive strategies to support, mentor and sponsor young female radiologists.

CAIR: How can (interventional) radiologists promote equity, diversity and inclusion in their practice?

CYH: As a radiologist, you can improve equity, diversity and inclusion in radiology. Acknowledge that radiology is not diverse and educate yourself about why this is and what can be done to improve it.  Recognize and reduce unconscious bias in your daily life.  Mentor, sponsor and champion your peers and trainees.

CAIR: How can systemic imbalances be identified in (interventional) radiology and what strategies can be introduced to rectify such imbalances?

CYH: While women are underrepresented within radiology overall, interventional radiology (IR) has the lowest representation of women among Canadian radiology subspecialties (10.6%).   Although IR, like breast and pediatric imaging, where women are well represented, has a great deal of direct patient interaction, several other potential factors have been identified that may deter women from pursuing this subspecialty. These factors include lack of scheduling flexibility and increased radiation exposure.  The risk of radiation exposure during pregnancy has been overstated and exaggerated. To our knowledge, no clear consensus, protocol or guidelines exist for pregnant women in IR.

CAIR: Why do you think diversity is extremely underrepresented in interventional radiology and what actions are being done and can be done by programs and societies to combat this underrepresentation?

CYH: Strategies to improve diversity in radiology in Canada are necessary at the national, institutional, departmental, and individual levels. National organizations can drive improvement through awareness and policy change.  I’m proud of the BC Radiological society where we have more women than men on our executive. However, some provincial radiology organizations have no women leaders at all.  Programs and societies should intentionally create diverse teams.  Look for people who will see things differently. Support junior team members and allow them the chance to grow and develop their skills.  Resist the urge to label people and check boxes.

In summary, diversity is good for patients. Women are underrepresented in Canadian Radiology, particularly in Interventional Radiology.  There is no data regarding ethnic diversity or Indigenous representation in Canadian Radiology. Actionable strategies exist at each level to improve equity, diversity, and inclusion in Canadian Radiology.

This segment will feature a unique pearl learned by a junior VIR staff during residency or fellowship to share with our community. This pearl is written by Dr. Joel Woodley-Cook from Scarborough Health Network.

Exchanging the blocked catheter (usually a gastrojejunostomy). The pull, cut and push technique.

It’s 3 PM on a Friday before a long weekend and the internist calls and says, “I think this patient’s GJ tube is blocked. The nurse keeps trying, but the semi-crushed tablet-apple sauce paste won’t go through. I need a stat change before this patient can go back to their nursing home. And they need to go back today or they will lose their bed at the nursing home and it will be all your fault”.

This exchange procedure typically goes smoothly but can go downhill quickly without a well established tract to re-enter. The technique described below is my go-to for a blocked catheter (usually GJ but sometimes nephrostomy).

I learned this technique from Dr. Martin Simons during my last month as a resident. This “pull, cut and push” technique is one I use often and is performed under fluoro (I sometimes bypass Step 1, but Step 1 does provide improved trackability of the catheter). This example will focus on a blocked GJ exchange:

1. Insert a 0.035” Amplatz through the hub or cut sidehole as far as it will go (obviously if it finds a sidehole, the procedure is likely nearly over and you can ignore steps 2+).
2. Retract the catheter under fluoro such that the pigtail lies within the 2nd segment of the duodenum.
3. Cut a side-hole close to the skin that is large enough to fit the tip of a second Amplatz but small enough such that the tip does not easily pop out. I usually insert the tip approximately 1 – 2 cm.
4. Advance the catheter under fluoro until the side hole is in the 2nd – 3rd segment of the duodenum.
5. Retract the tip of the wire that is in the side hole and voila, you have wire access into the duodenum.
6. Carefully remove the catheter under fluoro after releasing the pigtail as you normally would (don’t pull out your new exchange wire) and proceed with the exchange.

The International Day of Radiology #IDoR2021 is celebrated on November 8 with the aim of building greater awareness of the value that radiology contributes to safe patient care and improving public understanding of the vital role radiologists and radiographers play in the healthcare continuum. In 2021, the International Day of Radiology is dedicated to Interventional Radiology and its essential role in treating patients.

As the world continues to face the challenges posed by COVID-19, it is extremely important to acknowledge the key role that medical imaging has in medicine, not only during unforeseen circumstances such as the pandemic, but also on a daily basis in all areas of patient care. Interventional radiology is a unique and growing sub-specialty that helps and protects patients each and every day.

What can you do?

• Follow our social media accounts on Twitter and LinkedIn. We partnered with the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and the Society of Interventional Radiology (SIR) to share educational resources and information about the Interventional Radiology and to raise awareness about the benefits of minimally invasive treatments with patients, healthcare professionals, decisions makers, and the public at large. Check out our CAIR Initiative on the website for related content and share with your network!
• NEW! We will be creating member profiles to feature on our website and in our CAIR Express – let us know why you chose Interventional Radiology, what a typical day looks like, what are the most challenging and rewarding aspects of caring for patients and anything you’d like to share with our editors by emailing us at cairservice@cairweb.ca.

Why Interventional Radiology?

Dr. Ani Mirakhur, FRCPC (DR), FRCPC(IR), Calgary, AB

How did I become an IR?

I was first exposed to interventional radiology in my second year of medical school during a gastroenterology observership. The GI attending asked me to follow his bleeding patient (after a failed endoscopy) to IR for an embolization. I was hooked! I was fortunate enough to land a good residency and an excellent fellowship program and I have been in practice for over 5 years now.

Why I love practicing as an IR?

Diversity of disease and organ-systems:

Each day I work with a diverse group of patients and physicians. Some days are filled with complex PAD interventions (SAFARIs, DVAs, thrombolysis, etc), organ-sparing visceral aneurysm treatment , fenestrated EVARs (with vascular surgery colleagues) and dialysis interventions. On other days, I treat vascular malformations, do VTE interventions as well as PAVM, prostate, varicocele, pelvic congestion and uterine embolizations. And not to mention, bread and butter IR including venous access, drainages, biopsies and emergent embos/TIPS for bleeding patients. In my experience, very few specialists work with as broad an array of anatomy, and disease as an IR.

Diversity of practice environment:

As IRs, most of us are excited by the prospect of performing life-saving procedures in very sick patients. On the other hand, outpatient interventions to improve a patient’s quality of life can also be fulfilling.  IR is one of the very few specialties, where the practitioner can obtain a balanced exposure to both the acute care and outpatient worlds.

Innovation and collaboration:

IR, in many ways, is the wild west of medicine. You learn a core set of skills and can repurpose your skillset to solve any number of problems in real time.  There are tons of opportunities for academic research and/or working with industry. I personally have had opportunities to work with colleagues from other specialties as well as industry, on projects related to device and procedure development.

Dr. Brad Hnatiuk, FRCPC(DR), FRCPC(IR), Edmonton, AB & family

IR is the perfect combination of image interpretation, hands-on skills, and patient interaction.  Most patients are extremely happy after a minimal invasive procedure that can often greatly improve a patient’s quality of life.  This positive feedback can result in great job satisfaction.  As IRs, we are considered an integral part of many clinical pathways in Edmonton.  These are a few of the reasons why I love being an interventional radiologist.

Do you have a great case to present? Our next Virtual Angio Club (VAC) is now accepting submissions! We want to see cases with the best learning opportunities, so don’t wait and send your case today!

Who can submit a case: Canadian Interventional Radiology physicians who are CAIR members in good standing.

The best six (6) cases will be selected by Dr. Jason Wong and Dr. Amol Mujoomdar  and presented at the next CAIR VAC on November 24, 2021.

Case criteria:

• Presentation must be targeted to the Canadian IR community
• Educational value of presentation will be favored over complexity/rarity of the case
• The recommended file type to be used for presentations is PowerPoint or Portable Document Format (PDF)

A draft presentation of no more than 8-10minutes should be submitted by November 12th, 2021 via email at cairservice@cairweb.ca

The Canadian Medical Association (CMA) is inviting practising physicians, residents and medical students to participate in its 2021 National Physician Health Survey. This is a critical time to understand the key factors affecting your practice, daily interactions, lifestyle, and mental health, as well as how the pandemic has affected pre-existing challenges or brought about new ones.

By sharing your experiences, you will be supporting the CMA and other stakeholders in identifying the individual and system-level changes needed to better support physicians, create a healthier medical culture and guide our country’s post-pandemic recovery.

The survey should take less than 20 minutes and your time is greatly appreciated. If you are unable to click the button, please copy and paste the following survey link into your browser: https://surveys.ipsosinteractive.com/surveys/?pid=S21032894&supplierid=193&cultureinfo=en-ca&id=

September 30, 2021 marks the first ever National Day for Truth and Reconciliation in which we honour the lost and missing children of residential schools, the families left behind, and the survivors.

Reconciliation is the process of healing the relationship between Indigenous and Non-Indigenous Canadians, including the recognition and acknowledgement of Canada’s tragic and painful past, and the ongoing impact this history has on today. Recognizing the inequities that exist between Indigenous and non-Indigenous Canadians in health care is an essential first step.

We are committed to advancing reconciliation, better understanding the root causes of health disparities among Indigenous patients, and addressing racism within the medical profession and the health system.

We are honoring the survivors, their families and communities and we hope you join us in reflecting on the history and legacy of residential schools in Canada, and what you can do to achieve mutually respectful relationships between Indigenous and non-Indigenous peoples.

—
The National Day for Truth and Reconciliation responds to Call to Action 80 from the Truth and Reconciliation Commission of Canada – Calls to Action:

We call upon the federal government, in collaboration with Aboriginal peoples, to establish, as a statutory holiday, a National Day for Truth and Reconciliation to honour Survivors, their families, and communities, and ensure that public commemoration of the history and legacy of residential schools remains a vital component of the reconciliation process.

Orange Shirt Day – September 30th is also Orange Shirt Day.

“The annual Orange Shirt Day on September 30th opens the door to global conversation on all aspects of Residential Schools. It is an opportunity to create meaningful discussion about the effects of Residential Schools and the legacy they have left behind.  A discussion all Canadians can tune into and create bridges with each other for reconciliation.  A day for survivors to be reaffirmed that they matter, and so do those that have been affected.  Every Child Matters, even if they are an adult, from now on.”

(Orange Shirt Day)

Other useful links:

• Learn about the impacts of the Indian Residential School system by watching Residential School survivors testify for the Truth and Reconciliation Commission (content warning) and read the names of the children who were known to have died at Residential School (content warning)
• Watch films relating to Missing and Murdered Indigenous Women, Girls, and Two-Spirits (content warning).
• Educate yourself about the land you are on and the people whose land it is.

Course Description
The purpose of this one-day weekend virtual CME course is to offer attendees a comprehensive understanding of dialysis access creation and maintenance. The course has been designed to be a multi-disciplinary course, with involvement of Interventional Radiologists, Nephrologists, Vascular Surgeons, and nurses involved in dialysis access care. Our guest faculty are renowned experts in dialysis access management and will deliver several lectures and participate in complex case discussion. Audience participation is anticipated and encouraged.

Overall Course Objectives
Upon completion of this course, participants will be able to:

1. Discuss keys factors in choosing best access for dialysis
2. State at least three risks and benefits to each type of hemodialysis access
3. Review the approach (surgical and endovascular) and technique of creation of various dialysis access
4. Outline best practices to monitor immature and mature fistulas
5. Describe various challenges and techniques for management of a dysfunctional dialysis access
6. Cite three reasons why a multidisciplinary approach to hemodialysis management is important

Registration is now open!