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The COVID-19 pandemic has propelled an unprecedented global implementation of telemedicine and telerehabilitation as well as its integration into the healthcare system. Here, we describe the clinical implementation of the A3E framework for the deployment of telerehabilitation in the inpatient and outpatient rehabilitation continuum by addressing accessibility, adaptability, accountability, and engagement during the COVID-19 pandemic. By using an organized, coordinated, and stratified approach, we increased our telerehabilitation practice from 0 to more than 39,000 visits since the pandemic began. Learning from both the successes and challenges can help address the need to increase access to rehabilitation services even beyond the COVID-19 pandemic.

Large numbers of individuals who have been infected with SARS‐CoV‐2, the virus responsible for COVID‐19, continue to experience a constellation of symptoms long past the time that they have recovered from the acute stages of their illness. Often referred to as “long COVID,” these symptoms, which can include fatigue, shortness of breath, palpitations, cognitive dysfunction (“brain fog”), sleep disorders, fevers, gastrointestinal symptoms, anxiety, depression, and others, can persist for months and can range from mild to incapacitating. Although still being defined, these effects can be collectively referred to as postacute sequelae of SARS‐CoV‐2 infection (PASC).1 The magnitude of this problem is not yet known, but given the millions of individuals worldwide who have had, or will have, COVID‐19, the societal impacts are likely to be profound and long lasting.2, 3, 4, 5 It is widely acknowledged that systematic study is needed to develop an evidence‐based approach for caring for patients with PASC. At present, there is a dearth of rigorous scientific evidence regarding effective assessment and treatment of PASC that prevents the creation of evidence‐based clinical guidelines. However, the U.S. health system is currently seeing an increase in the number of patients presenting with PASC, and there is an urgent need for clinical guidance in treating these patients. The goal of this, and future statements, is to provide practical guidance to clinicians in the assessment and treatment of patients presenting with PASC. This Consensus Guidance Statement on fatigue is the first of a series focused on the most prominent PASC symptoms. PASC consensus guidance statement methods The American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multi‐Disciplinary PASC Collaborative (“PASC Collaborative”) was created, in part, to develop expert recommendations and guidance from established PASC centers with extensive experience in managing patients with PASC. The PASC Collaborative is following an iterative, development approach to achieve consensus on assessment and treatment recommendations for a series of Consensus Guidance Statements focused on the most prominent PASC symptoms. These statements were developed by a diverse team of experts, with input from patient representatives with a history of PASC, and integrate current experience and expertise with available evidence to provide tools to clinicians treating patients. There is an intentional focus on health equity as disparities in care and outcomes are critically important to address. Beyond patient care, the hope is that a broadened understanding of current patient care practices will help identify areas of future research. A full description of the methodology is also published in this issue.6 We acknowledge that the definition of PASC is evolving, and there are various factors that contribute to diagnosis. The PASC Collaborative sought input from patient representatives with a history of PASC and patient‐led research initiatives to inform recommendations. For example, previous literature has suggested that PASC be defined as the continuation of symptoms beyond 3 or 4 weeks from the onset of acute infection.7 Other definitions of PASC include symptoms lasting longer than 3 months.8 Based on feedback of patient representatives that earlier evaluation, diagnosis, and management can improve access to beneficial interventions, for the purpose of this Consensus Guidance Statement, we recommend expanded assessment if symptoms are not improving 1 month after acute symptom onset. These Consensus Guidance Statements are intended to reflect current practice in patient assessment, testing, and treatments. They should not preclude clinical judgment and must be applied in the context of the specific patient, with adjustments for patient preferences, comorbidities, and other factors.

The COVID-19 pandemic is having a profound impact on the provision of medical care. As the curve progresses and patients are discharged the rehabilitation wave brings a high number of post-acute COVID-19 patients suffering from physical, mental, and cognitive impairments threatening their return to normal life. The complexity and severity of disease in patients recovering from severe COVID-19 infection require an approach that is implemented as early in the recovery phase as possible, in a concerted and systematic way. To address the rehabilitation wave, we describe a spectrum of interventions that start in the ICU and continue through all the appropriate levels of care. This approach requires organized rehabilitation teams including physical therapists, occupational therapists, speech-language pathologists, rehabilitation psychologists/neuropsychologists, and physiatrists collaborating with acute medical teams. Here, we also discuss administrative factors that influence the provision of care during the COVID-19 pandemic. The services that can be provided are described in detail to allow the reader to understand what services may be appropriate locally. We have been learning and adapting real-time during this crisis and hope that sharing our experience facilitates the work of others as the pandemic evolves. It is our goal to help reduce the potentially long-lasting challenges faced by COVID-19 survivors., Highlights • Rehabilitation care of COVID-19 recovering patient can be safely provided starting in the ICU. • Redeployment of outpatient therapy workforce was useful to provide rehabilitation to patients recovering from COVID-19 in the acute medical care. • Objective functional assessments allowed for a tailored rehabilitation approach based on the individual patient’s needs. • Changes in Medicare regulation allowed for the provision of Acute Inpatient Rehabilitation Services outside of the rehabilitation unit. COVID-19 patients were able to receive ACIR level of care while still recovering from the acute infection.

This paper reviews recent evidence concerning the epidemiology, evaluation, and treatment of post-stroke dysphagia. The large variability in dysphagia severity and outcomes after stroke warrant a comprehensive evaluation and treatment approach. Screening, bedside evaluation, and instrumental assessments should be systematically and consistently used based on clinical presentation and available resources. In addition to traditional methods of diet modification and implementation of strategies and exercises, the use of novel treatments such as biofeedback and noninvasive brain stimulation may be effective in treatment, though further research is warranted. Oral hygiene regimens may be instrumental in reducing the incidence of swallowing-related respiratory compromise in patients with dysphagia. Dysphagia after stroke is optimally assessed by timely and appropriately selected screening and evaluation. Treatment depends on pathophysiology, with more research needed to assess the effectiveness of interventions as a part of an individualized treatment plan.

OBJECTIVES Dysphagia in patients with myositis is associated with an increased risk of aspiration pneumonia. However, the pathophysiology of dysphagia is poorly understood. The aim of this study was to understand how myositis affects swallowing physiology on videofluoroscopic swallow study. DESIGN This is a retrospective review of video fluoroscopic swallowing studies on 23 myositis patients with dysphagia from 2011 to 2016. Swallow studies were analyzed by timing of swallowing events and duration of swallowing events, diameter of upper esophageal sphincter opening, Modified Barium Swallow Impairment Profile, and Penetration-Aspiration Scale. The outcome measures for patients were compared with an archived videofluoroscopic swallow study from healthy, age-matched participants by Wilcoxon rank-sum tests. RESULTS Patients with myositis had a shorter duration of upper esophageal sphincter opening (P < 0.0001) and laryngeal vestibule closure (P < 0.0001) than healthy subjects. The diameter of upper esophageal sphincter opening did not differ between groups. Patients with myositis presented with higher scores on the MBSIMP than healthy subjects, indicating great impairment particularly during the pharyngeal phase of swallowing, and a higher frequency of penetration and aspiration. CONCLUSIONS Dysphagia in patients with myositis may be attributed to reduced endurance of swallowing musculature rather than mechanical obstruction of the upper esophageal sphincter.

Objective To determine differences between continuous videofluoroscopic swallow studies (VFSS) with a pulse rate and frame rate of 30 and the same swallows reduced to 15 frames per second (fps) on measures of swallowing function in patients after acute ischemic stroke. Design Blinded comparison. Setting Acute hospital. Participants Patients after ischemic stroke (N=20). Interventions Not applicable. Main Outcome Measures Single and sequential sips of thin liquids, single sips of nectar liquids, pudding, and cookie boluses were rated on measures of timing of swallowing events, Modified Barium Swallowing Impairment Profile component scores, and Penetration-Aspiration Scale scores. The ratings for videos at 15 fps and 30 fps were compared by Wilcoxon signed rank tests. Results Pharyngeal transit time was longer and bolus entry into the hypopharynx was later for 30 fps than for 15 fps. Components of Oral Residue and Pharyngoesophageal Segment Opening ratings were more severe for 15 fps than 30 fps, whereas Bolus Transport and Initiation of Pharyngeal Swallow were rated as more severe for 30 fps than for 15 fps. There was no difference between 30 fps and 15 fps on the remaining measures, including Penetration-Aspiration Scale scores. Conclusion Continuous VFSS recorded at 30 fps and their down-sampled 15 fps duplicates yielded contrasting results on certain durational and functional measures of swallowing, though not on others. VFSS should be administered continuously or at 30 pulses per second for valid assessment of swallowing while using other methods to reduce radiation exposure.

Head and neck cancers comprise 5.6% of all cancers in the developed world. Survival rates have improved to 60.6% at 5 years. The percentage of individuals with virally mediated (human papilloma and Epstein-Barr) tumors has risen, and fortunately these have a better prognosis than those induced by tobacco or alcohol abuse. The anatomy and histology of tumors are reviewed here, as well as the impact on impairments and prognosis. Common impairments of disfigurement, dysphagia, dysarthria, pain, and range of motion are delineated as they relate to tumor location and treatment side effects. These impairments may have major impacts on social participation and quality of life. Rehabilitation management strategies include speech pathology, physical therapy, bracing, medications, and injections.

Purpose Hyoid bone and laryngeal approximation aid airway protection (laryngeal vestibule closure) while moving toward their peak superior and anterior positions during swallowing. Submental surface electrical stimulation (SES) is a therapeutic technique that targets the muscles that move the hyoid bone during swallowing. It is unknown whether submental SES only increases peak hyoid bone swallowing positions but not peak laryngeal swallowing positions, which could require faster or greater laryngeal movement to achieve adequate laryngeal vestibule closure. Method We examined the effects of submental SES on hyo-laryngeal kinematics in 30 healthy adults who swallowed 50 times using an error-based learning paradigm. Results Submental SES did not alter any hyo-laryngeal swallowing kinematic. However, submental SES significantly changed the starting position of the hyoid bone just prior to the swallow onset (more anterior; p = .003). On average, submental SES immediately prior to swallow onset can position the hyoid approximately 20% closer to its peak swallowing point. Conclusions These findings indicate that electrical stimulation of the agonists for hyoid movement might not alter swallowing outcomes tested in this study. However, submental SES could have clinical utility by minimizing swallowing impairments related to reduced hyoid swallowing range of motion in individuals with dysphagia.

Older adults may evidence changes in swallowing physiology. Our goals were to identify dysphagia risk in community-dwelling older adults with no history of dysphagia, and to compare swallowing physiology and safety between older and younger adults. Thirty-two older adults with no history of dysphagia were prospectively recruited and completed the Dysphagia Handicap Index (DHI), two trials of a 3 oz. swallow screen, and videofluoroscopy (VFSS). Self-ratings of swallowing function were compared to published norms by paired t tests, and multivariate logistic regression models were generated to determine whether these ratings and VFSS analysis of swallowing function were associated with failure of one or both swallow screen trials. Archived VFSS of 33 younger adults were compared to older adults with Wilcoxon rank-sum tests. The DHI scores of older adults were higher than published non-dysphagic adults but lower than dysphagic adults. Older participants with greater Oral Residue scores were more likely to fail both swallow screen trials. Older adults received higher median MBSImP™© scores for select pharyngeal components than younger adults. The two age groups did not differ on Penetration-Aspiration Scale scores, and no aspiration was observed. Measures of swallowing in older individuals may reflect age-related sensory and motor changes in the context of functional swallowing and adequate airway protection.

Background and study aim Standard endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) procedures involve use of no-suction or suction aspiration techniques. A new aspiration method, the stylet slow-pull technique, involves slow withdrawal of the needle stylet to create minimum negative pressure. The aim of this study was to compare the sensitivity of EUS-FNA using stylet slow-pull or suction techniques for malignant solid pancreatic lesions using a standard 22-gauge needle. Patients and methods Consecutive patients presenting for EUS-FNA of pancreatic mass lesions were randomized to the stylet slow-pull or suction techniques using a 22-gauge needle. Both techniques were standardized for each pass until an adequate specimen was obtained, as determined by rapid on-site cytology examination. Patients were crossed over to the alternative technique after four nondiagnostic passes. Results Of 147 patients screened, 121 (mean age 64 ± 13.8 years) met inclusion criteria and were randomized to the stylet slow-pull technique (n = 61) or the suction technique (n = 60). Technical success rates were 96.7 % and 98.3 % in the slow-pull and suction groups, respectively (P > 0.99). The sensitivity for malignancy of EUS-FNA was 82 % in the slow-pull group and 69 % in the suction group (P = 0.10). The first-pass diagnostic rate (42.6 % vs. 38.3 %; P = 0.71), acquisition of core tissue (60.6 % vs. 46.7 %; P = 0.14), and the median (range) number of passes to diagnosis (2 1 2 3 vs. 1 1 2; P = 0.71) were similar in the slow-pull and suction groups, respectively. Conclusions The stylet slow-pull and suction techniques both offered high and comparable diagnostic sensitivity with a mean of 2 passes required for diagnosis of solid pancreatic lesions. The endosonographer may choose either technique during FNA.

This chapter will approach rehabilitation of patients with spinal tumors from the perspective of the World Health Organization’s International Classification of Function. Tumor pathology guides clinicians in prognostication. Impairments involve virtually every organ system in the body, and the rehab physician must manage and ameliorate these to enhance outcomes of the rehab program, and minimize secondary complications. The rehabilitation program must establish achievable and measurable goals for mobility and activities of daily living. Ultimately, the aim of any rehabilitation program is to enhance patient participation in society, and enable the individual to achieve their goals of maximizing their independence in home life, vocational and recreational activities.

Purpose The aim of this study was to examine the effects of frozen and mixed-consistency boluses on the swallowing physiology of younger and older adults. We also aimed to quantify factors that lead to increased variability in swallowing outcomes (i.e., age, sex, bolus type). Method Forty-one healthy adults (18–85 years old) swallowed 5 blocks of 5 different boluses: 10-ml ultrathin liquid, a teaspoon of iced barium, a teaspoon of room-temperature pudding, a teaspoon of frozen pudding, and ultrathin barium with chocolate chips. All data were recorded with videofluoroscopy and underwent detailed timing kinematic measurements. Results Neither barium ice nor frozen pudding sped up swallow responses. Many healthy adults initiated swallowing with the bolus as deep as the pyriform sinuses. Swallowing temporal kinematics for ultrathin liquid consistencies are most different from all others tested, requiring the best possible physiological swallowing performance in younger and older healthy individuals (i.e., faster reaction times, longer durations) compared with other bolus types tested. In each measure, older adults had significantly longer durations compared with the younger adults. More variability in swallowing kinematics were seen with age and laryngeal vestibule kinematics. Conclusion This study provides important contributions to the literature by clarifying normal variability within a wide range of swallowing behaviors and by providing normative data from which to compare disordered populations.

The fluid mechanics of whistling involve the instability of an air jet, resultant vortex rings, and the interaction of these rings with rigid boundaries (see http://www.canal-u.tv/video/cerimes/etude_radiocinematographique_d_un_siffleur_turc_de_kuskoy.13056 and Meyer J. Whistled Languages. Berlin, Germany: Springer, 2015, p. 74–774). Experimental models support the hypothesis that the sound in human whistling is generated by a Helmholtz resonator, suggesting that the oral cavity acts as a resonant chamber bounded by two orifices, posteriorly by raising the tongue to the hard palate, and anteriorly by pursed lips (Henrywood RH, Agarwal A. Phys Fluids 25: 107101, 2013). However, the detailed anatomical changes in the vocal tract and their relation to the frequencies generated have not been described in the literature. In this study, videofluoroscopic and simultaneous audio recordings were made of subjects whistling with the bilabial (i.e., “puckered lip”) technique. One whistling subject was also recorded, using magnetic resonance imaging. As predicted by theory, the frequency of sound generated decreased as the size of the resonant cavity increased; this relationship was preserved throughout various whistling tasks and was consistent across subjects. Changes in the size of the resonant cavity were primarily modulated by tongue position rather than jaw opening and closing. Additionally, when high-frequency notes were produced, lateral chambers formed in the buccal space. These results provide the first dynamic anatomical evidence concerning the acoustic production of human whistling. NEW & NOTEWORTHY We establish a new and much firmer quantitative and physiological footing to current theoretical models on human whistling. We also document a novel lateral airflow mechanism used by both of our participants to produce high-frequency notes.

Swallowing maneuvers are routinely trained in dysphagia rehabilitation with the assumption that practiced behaviors transfer to functional swallowing, however transfer is rarely examined in the deglutition literature. The goal of this study was to train the volitional laryngeal vestibule closure (vLVC) maneuver, which is a swallowing maneuver that targets prolonged laryngeal vestibule closure (LVC). In two different training experiments, 69 healthy adults underwent Long-hold (hold vLVC as long as possible) or Short-hold vLVC training (hold vLVC for 2 seconds). Before and after vLVC training, natural swallows (swallowing without a therapeutic technique) were completed. The outcome variables included laryngeal vestibule closure reaction time and the duration of laryngeal vestibule closure. Results indicate that during both Long-hold and Short-hold vLVC trainings, vLVC swallows had faster laryngeal vestibule closure reaction times and longer durations of laryngeal vestibule closure than in pre-training 5ml liquid swallows. However, only faster laryngeal vestibule closure reaction times transferred to post-training 5ml liquid swallows (20–24% faster), but not prolonged durations of laryngeal vestibule closure. Our findings suggest that swallowing maneuver training has the potential to induce transfer of what was practiced to functional swallowing behavior, although not all practiced behaviors may generalize. These findings are significant for bolstering the effectiveness of dysphagia management medical settings and should be tested in individuals with dysphagia.

Iatrogenic pharyngoesophageal perforations are a rare but serious complication of endoscopy. Surgical and non-surgical approaches have been reported but result in a significant morbidity and extended hospital stay. Therefore, an unmet need exists for an alternative management technique. We demonstrate a new endoscopic approach for the management of iatrogenic pharyngoesophageal perforations through the use of esophageal fully covered self-expandable metallic stents (FCSEMS). Two patients who underwent flexible endoscopy each suffered a large iatrogenic perforation detected intraprocedurally. After emergency intubation, an esophageal FCSEMS was deployed in the hypopharynx and the patient admitted to the intensive care unit. On day 3, the patients underwent an esophagogastroduodenoscopy with stent removal. There was complete closure of the perforations on day 3. The patients were extubated and subsequently tolerated a soft diet. The patients were discharged home on day 4. The placement of a removable FCSEMS in the setting of an acutely diagnosed perforation may be a suitable minimally invasive approach for the management of iatrogenic pharyngoesophageal perforations.

Submental surface electromyography (ssEMG) visual biofeedback is widely used to train swallowing maneuvers. This study compares the effect of ssEMG and videofluoroscopy (VF) visual biofeedback on hyo-laryngeal accuracy when training a swallowing maneuver. Furthermore, it examines the clinician’s ability to provide accurate verbal cues during swallowing maneuver training. Thirty healthy adults performed the volitional laryngeal vestibule closure maneuver (vLVC), which involves swallowing and sustaining closure of the laryngeal vestibule for 2 s. The study included two stages: (1) first accurate demonstration of the vLVC maneuver, followed by (2) training—20 vLVC training swallows. Participants were randomized into three groups: (a) ssEMG biofeedback only, (b) VF biofeedback only, and (c) mixed biofeedback (VF for the first accurate demonstration achieving stage and ssEMG for the training stage). Participants’ performances were verbally critiqued or reinforced in real time while both the clinician and participant were observing the assigned visual biofeedback. VF and ssEMG were continuously recorded for all participants. Results show that accuracy of both vLVC performance and clinician cues was greater with VF biofeedback than with either ssEMG or mixed biofeedback (p

Background and study aims: Precise identification of the gastroesophageal junction (GEJ) is a challenging prerequisite for adequate length of an esophageal myotomy. Multiple standard methods to identify the GEJ have been described; however, a more objective modality is needed to ensure effective peroral endoscopic myotomy (POEM). Patients and methods: In the double-endoscope transillumination for extent confirmation technique (DETECT), an ultraslim gastroscope is passed to the most distal aspect of the submucosal tunnel created during POEM. A regular gastroscope is advanced into the stomach, and the visualization of transillumination from the ultraslim gastroscope enables identification of the extent of the submucosal tunnel. Results: A total of 10 patients underwent POEM with DETECT. Initial submucosal tunneling was performed based on a determination of the GEJ location via standard methods. DETECT indicated the tunnel extent to be inadequate in 50 % of patients, and the tunnel was extended a further 1 to 2 cm. The mean initial tunnel length was 15.4 cm, with a mean initial myotomy length of 11.9 cm. DETECT was performed in less than 10 minutes without complications. Conclusion: DETECT is an objective method for determining the adequacy of the submucosal tunnel length during POEM.

Purpose The Mendelsohn Maneuver (MM) is a commonly prescribed technique that is taught to individuals with dysphagia to improve swallowing ability. Due to cost and safety concerns associated with videofluoroscopy (VFS) use, submental surface electromyography (ssEMG) is commonly used in place of VFS to train the MM in clinical and research settings. However, it is unknown whether ssEMG accurately reflects the prolonged hyo-laryngeal movements required for execution of the MM. The primary goal of this study was to examine the relationship among ssEMG duration, duration of laryngeal vestibule closure, and duration of maximum hyoid elevation during MM performance. Method Participants included healthy adults and patients with dysphagia due to stroke. All performed the MM during synchronous ssEMG and VFS recording. Results Significant correlations between ssEMG duration and VFS measures of hyo-laryngeal kinematic durations during MM performance ranged from very weak to moderate. None of the correlations in the group of stroke patients reached statistical significance. Conclusion Clinicians and researchers should consider that the MM involves novel hyo-laryngeal kinematics that may be only moderately represented with ssEMG. Thus, there is a risk that these target therapeutic movements are not consistently being trained.

Although benign, DFs are locally aggressive,withahighlikelihoodofrecurrence. Theselesionsrarelyinvolvethemaxillary bone with only a few reports in the literature of involvement of that site. Furthermore, the reports suggest that these tumors originate from the posterior part of the maxillary sinus, with extension into the skull base and nasopharynx. We present a case of a DF arising from the anteriormaxillarysinusinapediatricpatient. REPORT OF A CASE

Tu1635 A Randomized Multicenter Trial Comparing Capillary Suction and Standard Suction for Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) of Solid Pancreatic Lesions Payal Saxena*, Mohamad H. El Zein, Tyler Stevens, Ahmed Abdelgelil, Sepideh Besharati, Ahmed A. Messallam, Vivek Kumbhari, Alba Azola, Saowanee Ngamruengphong, Jennifer Brainard, Eun Ji Shin, Anne Marie Lennon, Vikesh K. Singh, Mouen Khashab Johns Hopkins, Baltimore, MD; Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, OH Background: Standard EUS-FNA procedures involve use of no-suction or suction (ST) aspiration techniques. A new aspiration method, the capillary suction technique (CT), involves pulling the needle stylet back slowly to create minimum negative pressure. A prior retrospective study showed higher sensitivity for diagnosis of pancreatic masses using the CT technique. There have been no randomized trials comparing the efficacy of the CT with standard ST Aim: 1) Primary aim was to compare the sensitivity of EUS-FNA using ST or CT for solid pancreatic lesions using a standard 22g needle. 2) Secondary endpoints were first pass diagnostic rate and acquisition of core tissue. Methods: All consecutive patients presenting for EUS-FNA of a solid pancreatic mass at two tertiary academic centers from 9/2013 to 11/2014 were randomized to CT or ST using a 22g needle (Expect, Boston Scientific). CT was performed with an assistant withdrawing 50% of the stylet length. ST was performed with a 10mL suction syringe. Both techniques were standardized to 15 to-and-fro movements for each pass until an adequate specimen was achieved as determined by rapid onsite cytology examination (ROSE). Fanning was performed at the discretion of the endoscopist. Patients were crossed-over to the alternate technique after 4 non-diagnostic passes. All visible core specimens were measured. Positive cytology or surgical histopathology was considered gold standard for malignancy. Negative cytology was confirmed with clinical data and/or imaging at 6 month followup. Results: Of 147 patients screened, 119 (mean age 65yr, 58% male) met inclusion criteria and were randomized to CT (nZ59) or ST (nZ60) (Figure 1). Baseline patient characteristics, including mean mass size, (2.9cm vs 3.2cm, pZ0.22) were similar in both groups. Malignant and benign diagnoses, use of fanning technique, technical success rates (96.6% vs 100%, pZ0.24) and cross-over rates (18.6% vs 18.3%, pZ0.97) were comparable. There were no adverse events. In an intention-totreat analysis, there was no difference in first pass diagnosis rate (40.7% vs 38.3%, pZns) or core specimen acquisition rates (59.3% vs 46.6%, pZns). Mean number of passes to diagnosis (1.9 vs 1.6, pZ 0.22) were equivalent. There was no significant difference in the sensitivity (90 % vs 89%, pZ 1.0), specificity (100% vs 100%, pZ 1.0), or diagnostic accuracy (88.1% vs 85%, pZ0.79) (table 1). Fanning was a not a predictor of diagnostic yield in either group (OR 2.29, pZ0.350 and OR 0.78, pZ0.75). Conclusion: Both capillary suction and standard suction techniques offer high and comparable diagnostic sensitivity of 90% with an average of less than 2 passes required for diagnosis of solid pancreatic lesions. The endosonographer may choose either technique; however, the suction technique may be preferable as coordination with an assistant is not required during FNA.

G A A b st ra ct s each method are shown in Table 1. Among these candidate methods, optimal discrimination from type I achalasia was achieved using the 4s-IRP method and receiver operating curve analysis revealed an optimal threshold %EGJR to be (

Sa1456 Per-Oral Endoscopic Myotomy (POEM) for Non-Achlasia Neuromuscular Disorders of the Esophagus Ahmed M. Sharata*, Christy M. Dunst, Radu Pescarus, Eran Shlomovitz, Kevin M. Reavis, Lee L. Swanstrom GMIS, Oregon Clinic, Portland, OR; GMIS, Providence Portland Medical Center, Portland, OR Background: Per-Oral Endoscopic Myotomy (POEM) has recently been described as an alternative to conventional myotomy for neuromuscular disorders of the esophagus. While efficacy and outcomes in achalasia are good, there is a paucity of literature in Non-Achalasia Neuromuscular Disorders (NAND). Historically, laparoscopic myotomies are followed by unpredictable and generally poor outcomes for NAND. The aim of this study is to review our experience with POEM in NAND patients. Methods: Comprehensive data was collected prospectively on all patients undergoing POEM for NAND between 11/2010 and 11/2013. Patients were classified as having diffuse esophageal spasm (DES), hypertensive nonrelaxing lower esophageal sphincter (LES), nutcracker esophagus with/without-relaxing LES based on manometry. Pre/postoperative symptom scores and high resolution manometry data were collected. Operative data was compared to a separate cohort of achalasia POEM patients. Results: Twenty-five patients underwent POEM for NAND with a median age was 64 years (range, 36-83 years). Twelve had nutcracker esophagus with/without nonrelaxing LES, eight had hypertensive nonrelaxing LES and five patients had DES. There was no mortality. There were no conversions to laparoscopy or thoracoscopy, no mediastinitis. Mean operative time was 128 mins. The incidence of inadvertent mucosotomy was 8% (2/25 patients) and capnoperitoneum requiring Veress decompression was 12% (3/25 patients). These were not different from POEM for achalasia despite the increased length of myotomy ( 11 cm NAND, 8 cm achalasia). Patients with DES had longer myotomies (12-23). Median follow up was 20 months (range, 7-36months). Complete resolution of dysphagia was obtained in 70% (pre/post median score 3/0) and chest pain in 71.5% (pre/post median score 1/ 0). Two patients (one nutcracker esophagus and one DES) underwent unremarkable laparoscopic Heller myotomy for refractory symptoms. Five patients underwent endoscopic dilations (1-2 episodes) for occasional dysphagia or chest pain and two other patients underwent multiple dilatations. Average LES resting pressure decreased from 44.2 to 26.6mmHg (pZ0.01). Average DECA decreased from 126.7mmHg to 53.7mmHg (pZ0.0009). Heartburn and regurgitation scores were unchanged by POEM (pZ0.94; pZ0.12). Conclusion: The POEM approach provides an avenue for long esophageal myotomies which avoids the traditional mediastinal exposure required for the treatment of patients with Non-Achalasia Neuromuscular Disorders (NAND) such as diffuse esophageal spasm and nutcracker esophagus. This early experience suggests POEM is a safe and effective treatment option for a majority of NAND patients. Sa1457 Pneumatic Dilatation (PD) Versus Laparoscopic Heller Myotomy (Lhm) Versus PerOral Endoscopic Myotomy (POEM) for the Treatment of Achalasia: a Single Center Experience Vivek Kumbhari*, Alan Tieu, Alba Azola, Mohamad H. El Zein, Eun Ji Shin, Ellen M. Stein, Bani Chander Roland, Monica Nandwani, Sameer Dhalla, Anne Marie Lennon, Vikesh K. Singh, Marcia I. Canto, Ahmed A. Messallam, Payal Saxena, Colin M. Gilmore, William J. Ravich, Anthony N. Kalloo, Pankaj J. Pasricha, John O. Clarke, Mouen Khashab AB220 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD Background: Patients who suffer from symptomatic idiopathic achalasia have a variety of therapeutic options. Pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM) and Peroral Endoscopic Myotomy (POEM) are currently the three most attractive. PD is the least invasive but symptom recurrence appears common, often necessitating repeated dilatation or an alternative therapy such as LHM. POEM may be a potential alternative to LHM in those who have relapsed after PD or in those who have not undergone prior therapy. There is no available evidence comparing outcomes of these three procedures to help guide the clinician as to which of these therapies has the highest efficacy and safety. Aims: To review the efficacy and safety of PD, LHM and POEM in patients presenting to a single tertiary-care center. Methods: A retrospective single center review was performed of consecutive patients who underwent POEM, LHM or PD between 2008 to 2013. Sequential, graded PD (30-35-40mm) and LHM have been offered to patients throughout the duration of the study. POEM has been offered at our institution since 2012. Patients that underwent PD and then subsequently either POEM or LHM were included in the PD cohort as well as their respective POEM or LHM cohort. Endoscopic and surgical procedural data were abstracted and preand post-procedural symptoms (e.g. Eckardt stage) were recorded. Clinical remission was defined by improvement of symptoms and decrease in Eckardt stage to %I and the absence of subsequent therapy at any point in time for LHM and POEM and within 1 year for the PD cohort. Adverse events were graded according to the ASGE lexicon’s severity grading system. Results: In total, there were 118 patients that had undergone PD (nZ73), LHM (nZ66) or POEM (nZ21) for their management of achalasia. There were 42 patients in the PD group that had subsequently undergone LHM (nZ33) or POEM (nZ9). The pre-procedure characteristics were similar amongst all three groups (table 1). A total of 34 patients in the PD group required LHM or POEM within 12 months of dilation. Clinical remission for PD vs. LHM vs. POEM was 45% vs. 74% vs. 95% respectively, p!0.001. The mean duration of follow up was 10 and 3 months for LHM and POEM, respectively. There was no statistically significant difference in the rate and severity of complications amongst the three groups (table 2). In particular, there was only one severe complication (perforation) which occurred in the PD group. Conclusions: This is the first study to compare the main three currently available therapies for achalasia. Our data confirms frequent early symptom recurrence in patients undergoing PD. As achalasia is a chronic relapsing condition, suitable patients should consider LHM or POEM early in their management. Table 1. Pre procedural Characteristics PD (n[73) LHM (n[66)