Tuesday, January 18, 2022

LIFE EXTENSION & THE HYPERVIGILANT RESEARCHER

Introduction:

Amidst our global pandemic, keeping the doctor away means heeding his or her advice and taking in their research on how to truly stay healthy.  Meanwhile, upon review of many Americans' health challenges, we analyze some of the most pertinent topics and questions that weigh in on their decision making process.  By the end of 2021, NYCRANEWS editors met with Dr. Jonathan S. Kirschner of HSS (Hospital for Special Surgery)- a specialist in Physical Medicine and Rehabilitation (PMR), Sports Medicine and Electrodiagnostic Medicine.  His clarity and insight offered significant value to the many affected by the debilitating effects of the pandemic lifestyle.


Part 1: SITTING IS THE NEXT SMOKING: THE SEDENTARY LIFESTYLE
I see two types of people; people who move less and those who move more.  Some people with more free time typically don't have to spend extra hours to commute. Now, they've got that time from themselves (instead of commuting) working from their home office.  So that frees up more time for physical activity. Upon revaluing life and lifestyle in general, some people have have the time to commit to things like learning about the importance of health and actually take actionable steps. Where people did not used to have time to join an exercise program, we now have the option (because of Covid) to watch exercise classes through Zoom and things like that.  

The sedentary lifestyle is contributing to a lot of issues- not only musculoskeletal issues like back pain, herniated discs, neck pain, neck strain with everyone at the computer because of covid, but also the metabolic effects of sitting. So if we’re not moving, we're at a high risk for gaining weight, diabetes and high blood pressure.  That’s some of the consequences of our modern lifestyle with all this technology and computers, whereas in the old days we had to forage for food. We had to farm the food, lift bales of hay, walk to the water well and come back home. So we're not doing those things now.  

The best way to communicate all this is to not throw it out to the patient all at once; sometimes it’s better to make baby steps because it can be daunting.  If the patient has a lot of weight to lose, or for anyone who has not been exercising, you want to start engaging them in an exercise program.

So every little bit that you can do helps and the first part is assessing where the patient is in their readiness to change.  Some people are really just absorbing information, but are ready to make that step -- others want actionable or things that they can do.  I can encourage them to get up and take breaks from the computer to slowly increase the amount of physical activity.  A lot of doctors encourage walking- but then again, that's good and bad because patients think that’s all you’re supposed to do.  But to walk for exercise, you have to walk briskly at a certain pace-- you have to walk a lot. So when I tell patients that they need to start exercising more, there's really four pillars; One is AEROBIC EXERCISE. One is STRENGTH TRAINING. One is working on FLEXIBILITY and then the other is BALANCE and that's especially important in our older population because that can help prevent falls. But even in the younger population, the high level athletes, they have good balance, they have good muscle control of their flexibility and strength. Walking (in and of itself) doesn't really make you stronger more flexible. So they have to do a little bit of all four. 


Part 2: MODERN HEALTH STRATEGY: INTEGRATIVE MODALITIES
There's no one-size-fits-all solution and a lot of what we're trying to do is individualize our treatments to the patient.  One of the most important things I try to assess when I'm meeting a patient is to ask “what are your goals? What are your expectations? How can we meet those?” A lot of it is education to let them know what's realistic and what's not--  but integrative medicine really broadly can involve a lot of different things. A lot that I do is therapeutic exercise, physical therapy and so there's different modalities even within that.  There's manual therapy, there are different electrical therapies, there’s ultrasound therapies-- complementary alternative medicine including mind body treatment which I'm a big proponent of because when you have physical issues, they can exacerbate the psychological side and vice-versa.  So things like acupuncture can be helpful for some people, but again, there isn't as I one-size-fits-all.  We try to follow evidence based medicines.

AVOID SURGERY: THE NON-INVASIVE MOVEMENT
We want to have the right treatment for the right patient at the right time and the number one rule of medicine is "do no harm". So typically minimally or lessen base of treatments potentially do less harm. Some people would argue that maybe there's less benefit to those- and I tend to disagree.  Anything that can help the patient in the simplest, the healthiest and most natural form I think is best. And that's why a lot of what we start with is really just education, looking at the quality of movement, doing physical therapy strengthening and then when when that doesn't help, that's when we think about more involved treatments, but overall I think yes the less invasive the better.


CELL REGENERATIVE THERAPY: WHAT IS PRP?
Since the discovery of stem cells in human cord blood in 1978, research to expand the paradigm of 'body-healing itself' without surgery has advanced this type of healing strategy.  The list so far includes pluripotent stem cell therapy, cartilage regeneration, prolotherapy and platelet-rich plasma.  All have their benefits, but for the purposes of this review, we are focusing on the PRP modality.

Platelet Rich Plasma is taking a sample of a patient's blood, spin it in a centrifuge, separate out the different components, and basically extract the growth factors, and then inject it back into the patient. So, you're using your own body in your own blood to treat things.  The idea is that we're taking a chronic injury and making it more acute. The body doesn't do a great job for as good of a job at handling chronic issues. But when you trick the bodies to thinking it's a more of an acute problem than the body, can heal that better.

So there are certain cellular growth factors called HemoFactors within the PRP, but then also you’re stimulating some of the local tissue responses as well.  PRP is used for treatment of tendons of tendon, tears or tendinosis which is chronic tendonitis- a degenerative condition around the tendon.  It is used for osteoarthritis, it's used for cartilage injuries like meniscal tears. The research shows that PRP probably is most effective for tendonopathy and specifically lateral epicondylitis- which is tennis elbow. I've done research on tendonopathy and PRP and also shoulder arthritis.  Part of the issue with PRP is there's a lot of variability in how it's made, who manufactures it, how it's being used clinically and then sort of the proportion of the different cells within it. There's Leukosite rich PRP that has a lot of white blood cells in it. Leukosite poor PRP has white blood cells taken out. By taking out blood cells, you are reducing the inflammation that's caused by the PRP so it's less painful. Some people think that might be better for osteoarthritis because you don’t want to create more inflammation- versus the Leukocyte rich PRP is perhaps better for treating tendon issues because you want some of that inflammation to help remodel and heal the area. 

SURVIVING THE CURE 
We're sort of a victim of our own success. Take cancer as an example, it's great that we can treat cancer better now- and so patients are living either with cancer or after we cancer.  Whereas in the past, they would have succumbed to it. So that that's a good problem to have, but unfortunately, patients are suffering with the consequences of either the disease or the treatment.  I treat cancer patients like my other treatments, we're trying to improve their quality of life, their function, their mobility, but cancer patients, particularly tend to have things like neuropathy related to chemotherapy. They may have issues with swelling or lymphedema due to surgery. A lot of the cancer drugs, unfortunately cause wide spread musculoskeletal pain, a lot of breast cancer patients unfortunately take medicines that block different hormones that can cause pain. Similarly, men with prostate cancer, the testosterone suppression can affect bones and joints. So it's a good problem that people are living longer with and after cancer, unfortunately they definitely suffer with pain.

ADDICTION TO PAIN MEDS
Another downfall to certain medicines are the addiction that they can cause.  In the case of pain meds, we certainly want to help our patients with their pain and suffering and medicine is one way to do that. But if we can do this in a way that doesn't involve medicine or especially dangerous potentially addictive medicine- the better.  Instead, there are modalities like heat or ice and massage meditating breathing exercise-- non-opiate medication or involved things like injections.  I think we still need to learn more about the mechanisms of pain and the different chemicals involved with that- and not treating everybody with pain the same way.  We shouldn’t just automatically give them a pill to reduce their pain.  It’s a good idea to do a deeper dive into the risk factors, what promotes you’re the patient’s pain, find ways to adjust their lifestyle-- and then explore non medication options. 


EPILOGUE
Today's conventional (ALLOPATHIC) medicine is far from the only solution to recovery from illness. The information age and technology trends have empowered the educated consumer to better explore the schools of alternative therapies: including FUNCTIONAL, OSTEOPATHIC,  INTEGRATIVE, NATUROPATHIC, ENERGY THERAPY and TRANSLATIONAL MEDICINE.  Where strictly following "doctor's orders" was once the only policy to staying healthy, personal initiative and the allure of "the second opinion" has installed the culture of questioning assumptions and forging the new type of patient as an independent, hyper-vigilant researcher in the pursuit for better answers.















Friday, December 24, 2021

2021 MEDTECH REVIEW: TRANSCRANIAL DOPPLER ULTRASOUND IMAGING

Written by:  Dr. Robert L. Bard  |  Lennard M. Gettz, Ed.D |  Noelle Cutter, PhD   

Since the advent of ultrasound scanning in the 1950's, the global movement to develop and expand its diagnostic features continue in its appeal with the medical community today.  The ultrasound design use of sound waves and echo reflection became widely accepted for being the safe (non-radiation), inexpensive, repeatable and non-invasive alternative in medical imaging.  Early clinical upgrades included the development of the pulse Doppler paradigm (1966) to enable scanning layers of the heart via blood flow. This offered diagnostic advantages to its application in the mid-seventies for live-action scans of the human fetus. These qualities earned its place as the standard in pediatric use while continuing to earn the confidence of radiologists and imaging specialists for a wide range of diagnostic applications from emergency critical care to supplemental cancer screening. 



THE SCIENCE OF BLOOD FLOW AND DOPPLER TECHNOLOGY
Hemodynamics is defined as the study of blood flow in relation to the status of the circulatory system and homeostatic mechanisms of autoregulation.   Through the monitoring of blood flow, diagnostic analysis can provide many answers to the health and physiological status of the target area scanned as well as cell-level metabolism, the regulation of the pH, osmotic pressure and temperature of the whole body, and the protection from microbial and mechanical harm.[1]   Assessing injuries, inflammation or mutative growths (like cancer tumors), assessment of blood flow provides diagnostic answers about the severity of tissue disorders or tumor malignancy.

The expansion of ultrasound research and development broke new ground in 1982 when Dr. Rune Aaslid (Norwegian Neurosurgical researcher) first introduced Cerebral Hemodynamics with the implementation of Transcranial Doppler science to offer noninvasive transcranial recorded imaging of flow velocity in basal cerebral arteries.  His report detailed that placing an accurately configured Doppler ultrasound transducer in the temporal area (just above the zygomatic arch)offers quantitative data of the blood flow velocity in the middle, proximal anterior and posterior cerebral arteries.[1.2] This scan is critical for detecting vasospasms and for reviewing circulation in the brain for potential disease of the carotid and vertebral arteries. [1.5] 

In 1989, Dr. Aaslid published the first study on dynamic cerebral autoregulation in humans - a biological and metabolic function dedicated to stabilizing cerebral blood flow. TCD detects the slightest change in perfusion-- the volumetric measure at which blood is delivered to tissue, or volume of blood per unit time per unit tissue mass. Alongside the study of blood pressure, Cerebral Autoregulation is vital to maintaining life as it supports proper delivery of adequate oxygen (in the blood) and nutrients to the brain and the removal of CO2 & other waste products.[2]  As Dr Aaslid used the TCD by scanning through the transtemporal approach, others explored the intracranial arteries through the orbital (eye socket) window. By the early 90's, the next generation of development teams (Spencer, Seidel, Dobson & Moehring) improved on the Doppler innovation to detect microemboli and hemodynamic physiology. Today, TCD is widely accepted and utilized for an expanding set of clinical and research applications including  ischemic stroke, sickle cell disease, subarachnoid hemorrhage and vasospasm. 

According to cancer diagnostic imaging expert Dr. Robert Bard, the introduction of 4D Doppler technology aligned with the ultrasound's base design concept of providing instantaneous, real time readings.  "Let's take the case of breast cancer screening, the technician simply puts the probe on the breast, finds the area, pinpoints it, presses a button and seconds later you have the map showing the types of vessels, volumetric arterial density and spatial location of the vessels in relation to the adjacent organs. You have functions that give you a vessel density measurement which shows how aggressive this is. Instead of genetic markers (which are very popular), visually displaying tumor aggression  performed in a matter of seconds to show cancer vessel invasion is a game-changer for any early detection or monitoring facility. Tumor aggression by blood flow evaluation is used worldwide in nuclear medicine, CT scans and MRI technology, however, one of the simplest and most cost-effective alternatives is the non‐invasive 3D Doppler breast procedure."


INTRACRANIAL SCANNING WITH DOPPLER ULTRASOUND
In 1982, continued advancement led to the Transcranial Doppler (TCD) ultrasonography for outpatient and inpatient settings. By integrating the ability to study BLOOD FLOW into a low-frequency transducer, placing the probe on the temporal area measures the cerebral arteries to detect and quantify cerebrovascular activities, diseases and brain injuries.   Other applications include the diagnoses of vasospasm (VSP) after an aneurysm rupture, hemorrhage or hemodynamic changes after ischemic or cryptogenic stroke. It also enables the study of cranial pressure fluctuations.  TCD also offers significant clinical benefits in the monitoring of sickle-cell disease by scanning brain stem death and elevated raised intracranial pressure (ICP).  Added features allow for surgical and post-op monitoring of vasomotor functions as well as detecting critical disorders like a microembolism.

SUMMARY OF TARGET CONDITIONS FOR TCD APPLICATIONS 
•    Vasospasm /aneurysm
•    Sickle cell anemia, to determine a patient's stroke risk
•    Ischemic stroke
•    Intracranial stenosis/ blockage of the blood vessels
•    Cerebral microemboli


PART 2: VERIFYING SIGNS OF COVID-19 STROKE THROUGH IMAGING

By: Robert L. Bard, MD  and Dr. Pierre Kory, MD

Early detection and prevention of arterial and venous disease is key to minimizing the effects of arterial obstruction & hemorrhage, brain aneurysms, and strokes from venous thrombosis.  The association of trauma to PTSD is now followed by advanced Doppler ultrasound and functional MRI. This abnormal physiology may also manifest as arterial dissection, collagen disease, inflammatory arthritis, dermatitis, ocular disorders, GI disturbances, limb pain, aneurysms of the brain and aorta. Devastating strokes in the Covid-19 era occur in the younger age group and the Latin population who are at higher risk.


INTRODUCTION
Interest in arteritis was elevated with the study of Tayakasu’s disease in the 1970's when advances in contrast arteriography diagnosed diffuse vascular involvement causing strokes and aneurysms in multiple sites. While this arterial inflammation is more common in Asians, in the US, blacks are nearly three times more likely to have a stroke at age 45 than whites. The pediatric population seems to be at higher risk for this arteritis as evidenced by their unusual rate of Covid-19 affliction affecting the vasculature and called “MULTIPLE ACUTE INFLAMMATORY SYNDROME“.  Birth control pills is a distinct cause of such disease in younger women while cancer, alcoholism and obesity raise the incidence at all ages. [3]

We have learned over the last century that blockages of coronary arteries to the heart and carotid arteries to the brain are precipitated by inflammation of the inner walls of the vessel, called the “intima”


While thickening of the interior wall of vessels gradually occurs over time and is aggravated by diet, stress and hypertension (high blood pressure), the acutely disabling event occurs when there is an abrupt tear of the overlying plaque which ruptures debris which then forms a blood clot which blocks blood flow or the clot travels deeper into the brain and blocks blood flow. Similarly, abnormal heart rhythms such as “atrial fibrillation”, causes the pooling of blood in the heart which predisposes to clot formation and the clots can then travel into the brain causing a stroke. In Covid-19, the virus causing severe inflammation in the blood which then promotes clot formation which can travel through the vascular system and affect almost every organ system in the human body, with the brain and lungs being the most vulnerable. An article in September NEUROLOGY reported by Medscape documented the incidence of large artery stroke as the presenting symptom of COVId-19 was highest in men under the age of 50 years.  [4]

HISTORY
A medical research team at Metropolitan Hospital in New York first noticed unusual neurologic symptoms in young and middle aged patients in the late 1960s. As a division of the NY Medical College system, they were fortunate to have an active interventional radiology department specializing in neuroimaging and arteriography. The observation of distortion and occlusion of arteries supplying the brain, kidneys, GI tract and lower limbs to various degrees from single to multiple locations was closely linked to the Japanese disorder known as Tayakasu’s arteritis at the time and recently renamed “arteritis.” A clinical finding of this arterial inflammation in the abdominal aorta was pain in the upper abdomen by the great vessels by palpation. Astute physicians were successfully treating this with commonly available “aspirin.”

However, the chronic and diffuse nature of arteritis often weakened the vessel wall producing aneurysmal dilation and rupture. Today we find sophisticated non-invasive or minimally invasive modalities to be the first line of interrogation of vasculitis. [5]


COVID AND STROKE
COVID-19 was rapidly understood as a disease caused by severe and widespread inflammation and “hypercoagulability” (a tendency to spontaneously form clots in the blood vessels.) Autopsies have revealed extensive small vessel strokes, with such strokes often occurring despite aggressive blood thinner treatment and regardless of the timing of the disease course, suggesting that it plays a role very early in the disease process. In one autopsy series, there was a widespread presence of small clots with acute stroke observed in over 25%. In a recent review of the incidence of stroke in COVID-19, almost 2% of all hospital patients suffered a stroke, which is 8x higher than in patients with influenza. More worrisome is that this is almost definitely a gross underestimate given the many likely missed strokes in patients who died on ventilators who were too ill to obtain imaging, the general restrictions on and lack of autopsies, and the well-recognized decrease in the number of patients with acute stroke symptoms seeking medical attention in the COVID-19 era.  Another worrisome finding from a recent study of COVID-19 cases found that 45.5% of patients reported neurologic symptoms [6,7]. This under-recognized epidemic of neurological symptoms and strokes in COVId-19 highlights the need for more intensive imaging and investigation to achieve not only earlier recognition and improved treatment of patients but in furthering understanding of COVID-19 effects on brain function.


DIAGNOSIS BY IMAGING
Blood flow abnormalities in the arterial system are best study by Doppler imaging like the weather Doppler showing tornadoes. Multiple options exist for blood flow analysis including:

- Carotid Sonogram
- Carotid Doppler
- Eye Sonography
- Transorbital Doppler
- Contrast Enhanced Ultrasound
- Transcranial Doppler
- Hybrid Imaging
- 3D/4D Vessel Density Histogram
- Endoarterial 3D Doppler
- Retinal OCT
- Soft Tissue OCT
- Reflectance Confocal Microscopy
- Small Coil MRI
- 7 Tesla MRI

CAROTID SONOGRAM: While cerebrovascular disease is often diagnosed ex post facto after a catastrophic episode with MRI and CT, the non invasive Doppler analysis of the vascularity is generally checked with ultrasound for plaque and obstruction. A useful measure of the risk of coronary and cerebrovascular disorder is the carotid intimal thickness (CIMT). Standard depth of the inner wall thickness is a measure best obtained by high resolution sonograms since a reading over 0.9mm indicates increased risk. The newer sonogram units have depth resolution of 0.02mm making this a preferred non invasive option.







DOPPLER IMAGING TECHNOLOGIES

- COLOR DOPPLER - most common application where red is flow towards the probe and blue is flow away from the probe
- POWER DOPPLER - higher spatial resolution without directional flow correlation
3D POWER DOPPLER - allows volumetric analysis of vessel density used in treatment correlation where more vessels means increased neovascularity and fewer vessels correlates with clinical improvement
- ANGIODOPPLER – similar to color Doppler with higher spatial resolution
MICROVASCULAR DOPPLER-images capillary flow
B-FLOW DOPPLER-not true flow technology but observes motion of red blood cells directly

CAROTID DOPPLER: Flow abnormalities of turbulence and absence are commonly evaluated with this modality. Plaque forms more readily in aberrant flow patterns and high velocity regions accompanying narrowing.

EYE SONOGRAPHY: Sonofluoroscopy of the orbital soft tissues and eyes is performed in multiple scan planes with varying transducer configurations and frequencies. Power and color Doppler use angle 0 and PRF at 0.9 at optic nerve head. 3D imaging of optic nerve and carotid, central retinal arteries and superficial posterior ciliary arteries performed in erect position before and after verbal communication. Retinal arterial flow is measured. Optic nerve head bulging is checked as increased intracranial pressure may be demonstrable.

TRANSORBITAL DOPPLER: R/L ciliary arteries have normal Doppler flows of 10cm/s which is symmetric.

CONTRAST ENHANCED ULTRASOUND: Widely used European nonionic contrast injection allows imaging capillary size vessels and perfusion characteristics

TRANSCRANIAL DOPPLER: This measures the flow in the anterior, middle and posterior cerebral arteries as well as Circle of Willis.

3D/4D VESSEL DENSITY HISTOGRAM: Multiple image restoration and reconstruction shows retinal vessel density of 25% at the optic nerve head and adjacent region with quantitative accuracy.[8]

ENDOARTERIAL 3D DOPPLER: Microcatheters inserted into the arterial or venous system provide measurement of wall thickness and presence of inflammatory vessels inside the intima.

RETINAL OCT: Subtraction techniques done with OCT optical coherence tomography may show changes in the caliber of the retinal vessels with verbal ideation.

SOFT TISSUE OCT: The depth of penetration may be extended to 2-3mm allowing for analysis of vascular changes in erythematous or erythropoor dermal areas. Thrombosis may be observed.

REFLECTANCE CONFOCAL MICROSCOPY: This microscopic analysis of the cells also quantifies microvascular pathology and is a potential modality for studying vasculitis.

SMALL COIL MRI: High resolution systems used for animal study and superficial organs can image the intra-arterial anatomy including dynamic contrast imaging on standard 1.5T and 3T units.

7 TESLA MRI: High field systems analyze signal abnormalites rapidly with high resolution.

HYBRID IMAGING: Hybrid imaging refers to combining diagnostic modalities to assess disease and monitor therapy. 







REFERENCES

1) Hemodynamics: https://en.wikipedia.org/wiki/Hemodynamics

2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5224659/

3). Hassani SN, Bard RL: Ultrasonic Diagnosis of  Aortic Aneurysms. J. Natl. Med. Assoc. 66:298-299, July 1974

4). Lande A, Bard RL: Arteriography of Pedunculated Splenic Cysts. Angiology 25:617-621, October 1974

5). Lande A, Bard RL, Rossi P: Takayasu's Arteritis: A World Entity. N.Y. State J. Med. 76:1477-1482, Sep 1976

6). Helbick Eur Radiol 30:5536-5538, 2020

7). Mao l  JAMA Neurol 2020 77:683-690

8). Bard RL , Gettz L, van der Bent S etal: Proceedings of the 4th Inflammatory Disease Summit at NY Academy of Medicine  Nov 2021


Thursday, December 16, 2021

MEDTECH REVIEW: Fluorescence Imaging for Inflammation and Infection (official)

Written by: Dr. Robert L. Bard

Upon review of all the imaging technologies available, clinicians are constantly in search for what provides us the most accurate quantitative data from the standpoint of non‐invasive safety. In the case of diagnosing cancers and bacterial infections, we are now exploring the potential of the intelligence behind bioluminescence and fluorescence (or autofluorescence) probes.

From a 2019 study (by Raizman et al) about use of this technology (MolecuLight i:X) with debridement, scans of 22 wounds were conducted under standard and violet light in patients after debridement. Scans, performed non-invasively at the point-of-care, demonstrated remaining bacteria/biofilm signal in 100% of wounds after sharp debridement, triggering additional removal of tissue. [1] 

Re-scanning demonstrated a marked decrease or complete removal of bacteria in most wounds, yet a subset showed persistent or increased bacterial signals post debridement. The authors, aided by the knowledge gained from this technology,  proposed “the subgroup with persistent bacterial fluorescence post-debridement was at increased risk of deep compartment infection and required more frequent debridement and/or antibiotics.” [1]. See example of this in figure 2 (tissue in green, bacteria in red). Others have demonstrated ability to markedly decrease antibiotic usage using this technology, showing great potential for stewardship efforts [2].

Currently, the technology can take direct images of the skin or mucosal surface to indicate bacteria on the tongue or oral lining. Exploratory reviews of this imaging device also shows possible benefits in scanning potential biopsy material with violet light at the tissue and see if it's suggestive for cancer or inflammatory disease. 




SCAN 1: The Test Drive

Autofluorescence has been proven and used worldwide to show inflammatory changes and bacterial infection. It's used to find both Gram‐negative bacteria and Gram‐positive bacteria, aerobic and anaerobic. (Fig‐1) The illustrated scan shows the normal skinfolds as green and the skin image is homogeneous (there's nothing dark). (Fig‐2) The scan of the finger on the opposite hand which the patient expressed chronic irritation. Upon initial observationit appears that Autofluorescence may detect inflammation through the upper dermis, a change documented visually and by ultrasound imaging as minimal epidermal thickening associated with inflammatory skin disease (mild type). When we turned on the fluorescence scan, the exact one centimeter area of redness on the skin corresponded to the one centimeter darkened area on the finger.


SCAN 2: IMAGING VALIDATION WITH ULTRASOUND 
(Fig-3) For my diagnostic research projects in dermal lesions and infections, one of my "weapons of choice" is the doppler ultrasound.  From tumors to traumas, radiologists and clinicians rely on feature-rich computerized systems that provided remarkable patient data for its non‐invasive and real-time view of inflammatory disease to align with our study of the Autofluorescence for its work on atopic dermatitis and other viral diseases (ie. Covid-19) which may affect the skin and be sampled with this noninvasive technology. Since it hasn't been clinically documented in the dermal tissues, this is an opportunity to form a new type of imaging that is non-invasive to consider avoiding biopsies on children.

In the case of Fig-3, I used a high-frequency setting on a popular handheld point of care ultrasound probe to recognize a 0.3cm depth scan of the same area of the finger that was previously scanned by the fluorescence device. The top right arrow (1a) shows the enlarging dark stripe indicating inflammatory thickening or the epidermis. The middle grey area (arrow 1b) represents subdermal inflammation of subcutaneous tissue or mild inflammatory skin disease -  confirming the prior evaluation.

EXPANSION POTENTIAL: RESEARCH 
Fluorescence imaging is proven to have a four‐millimeter depth of diagnostic accuracy in the tongue or mucous membranes‐ similar to the cervix or the vagina or the intestine lining. There is a rich literature of its use in skin wounds and wound infection. However, it's use in skin diseases has not been fully explored‐ so this is a beta test to see if and how it will work in non‐invasive diagnosis of inflammatory skin disease, especially in children. Exploring this technology is of great importance because dermatitis is recognized as a major pediatric disorder. Also disabling inflammatory chronic skin disease (psoriasis, rosacea) are a major focus of successful treatment by pharmacology companies.


AUTOFLUORESCENCE FIELD TEST   
 
by: Randall Weisel, DDS (Excerpt from Journal of Dentistry and Oral Sciences/ "Auto Fluorescence Allows Us to Detect Early Signs of Oral Cancer and Much More")

Review of autofluorescence enables us to objectively examine the oral cavity for inflammation and infection. Many systemic diseases are perpetuated by microorganisms that colonize in the oral environment. They enter the cardiovascular system by enzymatic processes that open the oral mucosa to allow their entry. A majority of the microbes are anaerobes and/or facultative anaerobes. When they enter the host, they metabolize blood. Their waste by products contains iron elements within a compound called porphyrin. Porphyrin will fluoresce when exposed to certain wavelengths of light. Healthcare providers can utilize this natural occurring process to objectively see these harmful pathogens. This may indicate that the host has a Sleep Related Breathing Disorder (SRBD). Sleep apnea is a primary disorder of SRBD’s. This technology offers medical and dental fields a screening tool for a pandemic healthcare problem.

Pathogenic microbial presences and the size of the colony (the bioload) can be relatively determined [19]. Fluorescence visualization of red-orange means bacterial pathogens are present. Presence of bluish green/bright white indicates presence of Pseudomonas [19]. The conditions for these pathogens to exist can occur within individuals with Sleep Related Breathing Disorders (SRBD). Sleep Apnea is the most prevalent of these disorders [20]. Researchers should focus their attention to the dorsum of the tongue ecosystem. Autofluorescence, performed with technology that utilizes electromagnetic spectral ranges and special filters that are components of the Velscope, allows visualization of pathogenic microbes. Scientific research demonstrates that oral pathogens (Pg, Aa, and Fn) may be direct and/or indirect causative agents of systemic diseases. These oral pathogens cause inflammation and infection.



SPECIAL THANKS to Dr. Monique Rennie, Director of Scientific Affairs and Global Engagement at Moleculight for her generous technical support and assistance greatly added  to the quality and integrity of this feature article. 


REFERENCES:

1) Raizman R et al. Use of a bacterial fluorescence imaging device: wound measurement, bacterial detection and targeted debridement. J Wound Care (2019). https://pubmed.ncbi.nlm.nih.gov/31825778/

2) Price N. Routine fluorescence imaging to detect wound bacteria reduces antibiotic use and antimicrobial dressing expenditure while improving healing rates: retrospective analysis of 229 foot ulcers. Diagnostics 2020;10:927.

19) Le, L.; Baer, M.; Briggs, P.; Bullock, N.; Cole, W.; DiMarco, D.; Hamil, R.; Harrell, K.; Kasper, M.; Li, W.; et al. Diagnostic Accuracy of Point-of-Care Fluorescence Imaging for the Detection of Bacterial Burden in Wounds: Results from the 350-Patient Fluorescence Imaging Assessment and Guidance Trial. Advances in Wound Care. 2021. https://pubmed.ncbi.nlm.nih.gov/32870774/

20) Sleep-Disordered Breathing.chapter 23.Thoracic.org. 237-247. Boillot A, Demmer RT, Mallat Z, Sacco RL, Jacobs DR, Benessiano J, et al. Periodontal microbiota and phospholipases: the oral infections and vascular disease epidemiology study (INVEST). Atherosclerosis. 2015;242(2):418-23. PubMed | CrossRef

21) Bale BF, Doneen AL, Vigerust DJ. High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis. Postgrad Med J. 2017;93(1098):215-20. PubMed | CrossRef

22. Boillot A, Demmer RT, Mallat Z, Sacco RL, Jacobs DR, Benessiano J, et al. Periodontal microbiota and phospholipases: the oral infections and vascular disease epidemiology study (INVEST). Atherosclerosis. 2015;242(2):418-23. PubMed | CrossRef

23) Desvarieux M, Demmer RT, Jacobs Jr DR, Rundek T, Boden-Albala B, Sacco RL, et al. Periodontal bacteria and hypertension: the oral infections and vascular disease epidemiology study (INVEST). J Hypertens. 2010;28(7):1413. PubMed | CrossRef


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Friday, November 26, 2021

TODAY’S CLINICAL AESTHETICS- SCIENCE AND STRATEGY





REVIEW OF AESTHETIC DERMATOLOGY
By:  Michelle P. Zappas DNP, FNP

I am a family nurse practitioner for the past 10 years. But my main expertise (and where I work clinically) is in aesthetics or aesthetic dermatology. I currently work in Luxe Aesthetics Center as a clinician or as a family nurse practitioner in Yorba Linda, CA. The CEO of The Luxe Aesthetic Center who is an awesome colleague and mentor in clinical aesthetics. So we do a lot with Botox, Neurotoxins, Fillers laser techniques to bring enhancements to patients, helping them to look and feel their best.

Thanks to the connective powers of LINKEDIN, I was approached by NY Cancer Imaging Specialist, Dr. Robert L. Bard about co-authoring in a multi-disciplinary text project about IMAGE GUIDED AESTHETIC PROCEDURES.  Having learned about him as a globally recognized figure in clinical education and medical publishing,  I also marveled at his vision to unite the many areas of medicine through collaborative research and integrative presentation concepts.  Meanwhile, to co-write about clinical aesthetics in this unique capacity was a remarkable opportunity no educator in my field could pass up.

INSIGHTS ON SAFETY
 So when doing hyaluronic acid filler, it is really important to know which areas are dangerous. Then it basically breaks down to nerves and arteries. Obviously you don't want to occlude an artery or with filler itself or too much filler into an area where that presses on an artery, because that can cause vascular compromise avascular necrosis, it can cause blindness if the artery supplies the eye with blood and also you can cause a palsy if there is occlusion or compression of the nerve.

 So those are really the major vessels and anatomic areas to avoid-- the, the big subgroups.  But obviously within the face, there are a lot of vessels and arteries to note and to avoid when you are injecting. So this chapter really breaks it down. We go through the face upper face, lower face in terms of where to inject safely, what vessels and arteries that are in that area and what to avoid- plus other clinical techniques in order to make sure that you are injecting the hyaluronic acid safely.

I am definitely interested in public education, informing patients and all providers about best practices with regard to aesthetics, other techniques and modalities.  I’d like to contribute in informing the public about aesthetics before getting these procedures, especially in support of the many patients of enhancement or regenerative professionals.  I’d also like to promote safety programs and prevention techniques because a lot of damage and injury can happen out there, particularly with fillers but also with lasers if it's not done correctly. So it's really important when we're talking about patient safety for the provider to be able to walk the line between being aggressive enough to get somebody good results but (especially in terms of lasers) not work too aggressively to burn somebody or to cause somebody scars or blisters.

IPL- INTENSE PULSE LIGHT THERAPY
 
So Intense pulse, light or IPL is a type of laser that can target the main chromophores (hemoglobin, water, and melanin) and so these are a lot of the molecules that patients complained about in chunks of  dyschromia or erythema on their face and other parts of their body. A lot of times people are coming into decrease the Pohnpeian with the little blood vessels in the skin. IPL is wonderful for that.

One of my points about my IPL chapter is that it's not just for aesthetics; there are a lot of dermatologic inflammatory.  Multi-system conditions and diseases that IPL can be used for include ROSACEA, Meibomian Gland dysfunction, Acne,  Port-Wine Stains related to Sturge–Weber syndrome and Mangiomas. There are a wide variety of conditions that can cause patients discomfort- including mental discomfort,  suicidal ideation and  depression that can be treated and a radiated with IPL as one of the modalities for treatment.  Hence, I find this to be a remarkable laser for a lot of different health conditions while also strongly making a significant difference in the areas of aesthetics as well as dermatologic conditions.

In terms of our fillers, using image guidance via ultrasound, we can visualize vessels, nerves (and) all sorts of different things that allow the practitioner to safely inject. And so that is a great technique to not occlude those vessels that you don't want to occlude. To transform somebody's face and give them a youthful appearance, but safely without the risk of blindness or vascular necrosis or any other of the potential adverse effects that can come from that kind of hyaluronic acid or other filling modalities.

ON ANTI-AGING AND REGENERATION
 
Clinical aesthetic modalities as a whole works on the visual of the patient but also greatly improving their mental wellbeing and their ability to interact with the world (resulting to improved self-esteem). And I don't want to get lost on the vanity aspect of it because aesthetics actually running a whole lot deeper than that. My philosophy behind that is to “do what the patient wants” in terms of what bothers them.  However, I do not buy into all of these new modalities necessarily without seeing the evidence. I really want the evidence to support the procedure. So patients who invest in these modalities deserve my research, my clinical understanding and I want to make sure that what I am providing them that is backed by evidence. So that is probably where I talk some patients out of some of the newer things that they see in the blogosphere and YouTube from the many influencers- and I say, “let's go back to what has been tested, where we can have the evidence—that’s what makes for a sound and professional clinical aesthetics practice!”


.

EXTRA:

Thwarting Surprise "Surgical Land Mines" with PreOp Scans

By. Dr. Robert L. Bard

For all my friends in the practice of Cosmetic Surgery, DIGITAL PRE-OP is a highly useful stage for many patients who may carry hidden issues that can turn into a pandora's box of complications. I have performed this vital service for European plastic surgeons since 2001 in their centers  while currently performing domestically as a digital diagnostics partner for serious physicians and surgeons fulfilling similar needs.  Pre-operative imaging is widely performed to verify tissue planes and measure fat depth.  Since patients may have forgotten prior treatments, new scans sometimes reveal extensive sub-dermal calcium deposition, unsuspected fluid collections or thick fibrosis distorting the expected anatomy.  Anatomic variants may be observed and avoided. Moreover, patient confidence is enhanced by the extra care provided by this advanced technology.

Some of the most common POST-PROCEDURE COMPLICATIONS include:
- Suture loosening and granuloma formation following blepharoplasty
- Lipoatrophy or fat necrosis following PRP or abdominoplasty
- Filler complications and implant migration 

- Doppler verification of vascular compromise (venous or arterial) following facial therapies allowing immediate intervention to prevent blindness or tissue necrosis (See complete article)

 




TEXTBOOK OVERVIEW: 
Springer Medical Publishing proudly presents the first installment in clinical aesthetic procedures. This detailed and up-to-date overview of image-guided procedures focuses on the many aesthetic and reconstructive strategies delivered by some of today's renowned leaders in the clinical aesthetics community. They share their valuable expertise and field-based findings throughout this feature-rich textbook. The wide list of audiences for this text (ie. dermatologists, plastic surgeons, aestheticians, general surgeons) will enjoy an insider's look at each treatment program while providing remarkable field-based knowledge for the general non-medical audience seeking the latest information in non-invasive and minimally invasive aesthetic procedures.  Produced and edited by Dr. Robert L. Bard, this collective project showcases the most highly sought-after cosmetic treatments in each priceless chapter- through detailed breakdowns, experiential insights and a generous graphic tour of before and after progress visuals.  Thanks to the additional safety benefits of clinical imaging, our treatment professionals express added confidence in the pre-operative and post-op areas. In addition, many aesthetics procedures noted also brings significant advantages (of accuracy and efficiency) to the actual treatment process from real-time image guidance. Some of our top contributors include: Dr. Beth Haney, Dr. Michelle Peters-Zappas, Mary Nielsen Aesthetics, Dr. Arun Garg, Dr. John Catanzaro, Dr. Randall Weisel, Dr. Stephen Chagares, Dr. Cari Green, Dr. Richard Kushner, Dr. Lio Yu, Dr. Peter A Everts and January Howard, CMA (this is an abridged list of our contributors).



ABOUT THE AUTHOR

Dr. Michelle (Shelly) Zappas is a Clinical Associate Professor at the USC Suzanne Dworak-Peck School of Social Work in the Department of Nursing. She received her Bachelors’, Masters’ and Doctorate in nursing from Columbia University. Dr. Zappas has nearly a decade of experience as a family nurse practitioner in primary care clinics in New York City and Los Angeles. Dr. Zappas has authored multiple publications and presents at both state and national nurse practitioner educational conferences. In aesthetics she has been trained in advanced injection techniques using neurotoxins and dermal fillers as well as training in IPL and lasers. Dr. Zappas has a profound interest in dermatology and skin care and enjoys helping her patients put their best face forward.  


Disclaimer: The information (including, but not limited to text, graphics, images and other material) contained in this article is for informational purposes only. No material on this site is intended to be a substitute for professional medical advice or scientific claims. Furthermore, any/all contributors (both medical and non-medical) featured in this article are presenting only ANECDOTAL findings pertaining to the effects and performance of the products/technologies being reviewed - and are not offering clinical data or medical recommendations in any way. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, never disregard professional medical advice or delay in seeking it because of something you read on this page, article, blog or website.


Monday, October 4, 2021

MEDTECH REVIEWS 2: Introducing TMS (Transcranial Magnetic Stimulation)

The Modern Age of Non-Invasive Mental Health Innovations: Transcranial Magnetic Stimulation
Written By: Jessica Connell-Glynn | Dr. Robert L. Bard & the editorial team of prevention101.org

In the continued expansion of the medical society to “go non-invasive” (or non-surgical) and the trending reassessment of interventional medications, the mental health community has acquired major tools in its toolbox to support clinical diagnostic and treatment efforts.  In 2008, the FDA approved the first TMS Depression Device for Depression Treatment [1]. In 2018, the FDA approved the marketing of Repeated Transcranial Magnetic Stimulation (rTMS) as adjunct therapy for of obsessive compulsive disorder (OCD) [2-3].  

Current reports have presented an est. 30% of depression cases have a resistance to antidepressant drugs, where Transcranial Magnetic Stimulation (TMS) and the application of Transcranially applied non-invasive neuro-magnetic intervention has shown positive results in combination with antidepressants in patients with treatment-resistant depression[ 4]. 

During the procedure, a magnetic coil is positioned at the head of the person receiving the treatment using anatomical landmarks on the skull, in particular the inion and nasion.[5] The coil is then connected to a pulse generator, or stimulator, that delivers electric current to the coil.[6] Single or paired pulse TMS causes neurons in the neocortex under the site of stimulation to depolarize and discharge an action potential. [7] Repetitive TMS produces longer-lasting effects which persist past the period of stimulation. rTMS can increase or decrease the excitability of the corticospinal tract depending on the intensity of stimulation, coil orientation, and frequency. [8]

Field Report: TMS Science from the Top Developers
Based on an interview with Nexstim Vice President, STEVE BELLER

TMS, or transcranial magnetic stimulation, is the use of magnets external to the body to activate tissue inside the body (so you're not having to open the patient up).  Based on Faraday’s Law, a magnetic field produced outside of a patient’s head can permeate non-invasively through a patient’s head and induce an electric field that has the capacity to activate neurons in the brain. We induce current at a distance inside the brain and cause the neurons to fire where we induce that current.  This means that where we depolarize, we cause the brains neurons to fire.  TMS artificially stimulates the brain and causes the neurons to fire.  Navigation technology allows us to see precisely where in the brain where we are stimulating.

The value of this stimulation effect is twofold; the first is DIAGNOSTIC- where we can non-invasively identify specific areas of motor function and specific areas of language function. The second function is THERAPEUTIC- where we can actually help change or fix an identified brain disease by using TMS. Right now,  we as a company hold FDA clearances for pre-operative motor and language mapping as well as treating major depressive disorder. For depression: the general understanding (still under exploration like a lot of things in medicine, particularly with the brain) is that the metabolic activity in the left dorsal lateral prefrontal cortex in a diseased or depressed patient is lower and usually significantly lower than in out of a healthy patient. In order to increase the metabolic activity and the left dorsal lateral prefrontal cortex or left DLPFC you can use TMS to artificially stimulate our cause the neurons to fire in the left DLPFC and that increases the neuronal excitability level and helps improve the depressive state of that patient.  This is one example of how to therapeutically use TMS to improve health and performance. 

You can also use a different set of TMS stimulation parameters to inhibit brain regions that may be overactive. That is, you can actually slow down the functioning of the cortical area that you're targeting. Hence, TMS in therapeutics may be a versatile option to treat a range of neurologic and psychiatric disorders in the future.


 

EXTRA:

Navigated TMS for Pre-Procedural Brain Surgery

Since 2009, Nexstim´s Navigated Brain Stimulation (NBS) has been FDA cleared for use in non‐invasive motor and language functional cortical mapping prior to radiosurgery and invasive neurosurgery. This technology allows the operator to move a hand‐held TMS coil over the patient´s head delivering a series of harmless magnetic pulses whose electric fields gently activate neurons in the cortex. Converting a standard head MRI into a 3D‐model of the patient´s brain, allows the operator to precisely navigate the coil´s electric field anywhere in the cortex, much like driving a car with the aid of GPS. Measuring patient responses by electromyography (EMG) reveals the locations of the vital motor areas inside the brain. Mitchel Berger, M.D, Past Chairman of the Department of Neurological Surgery, Past Director of the Brain Tumor Surgery Program, University of California, San Francisco, said, “What makes this so special is the ability for it to define very small, precise cortical regions on the surface of the brain, and define individual components of function which is something we never could do before." The Nexstim technology is available to patients at over 50 of the country’s top neurosurgery programs.

 

 

2021 REVIEW OF POST TRAUMATIC RECALL
 (A field report by: Jessica Connell-Glynn, LCSW)
 PTSD can occur in all different extremes with at-risk professionals (like cops, responders and veterans). The trauma that they experience are above the ordinary that they could cause extreme flashbacks, anxiety and depression—heavily affecting their quality of life. The average civilian is also prone to this disorder starting with MICRO-TRAUMAS that can happen to everybody throughout any point in their lifetime.  Usually stemmed from childhood issues, micro-traumas actually shape the way an individual reacts to other people. As an example, child bullying may lead to developing a protective or defensive personality disorder.  Anytime they feel disrespected or embarrassed by others, feelings of extreme uncontrollable anger may arise without knowing the source of the hurt or why they're acting in that way.  This dilemma often causes problems in relationships.

 

LANGUISHING: EMOTIONAL CRISIS FROM THE PANDEMIC
 By: Jessica A. Conner-Glynn, LMSW  / Edited by: Cheri Ambrose (NYCRA NEWS writing staff)
 Observing the many emotional after-effects of our ‘new Covid lifestyle’, I find a link between stepping away one's our work environment and a direct improvement in one’s well-being. The surge of the coronavirus pandemic brought a unique kind of widespread emotional disorder called LANGUISHING- an issue identified as somewhere between a downturn ‘blah’, emptiness or depression causing a type of burnout from mandatory social distancing.  Many of us are working really hard in the same place that we actually live- removing that safe separation between work and home that we once had.  The shift in working at home takes away that place to relax and shut down, eventually causing a state of emotional exhaustion from staying ON (and on guard) the whole time.  There is also a physical aspect to all this; the new sedentary lifestyle of working from home eliminates the vital energy stimulation from circulation and cardiovascular activity of physical traveling.  In addition, self-isolating has induced an unhealthy weight gain in many, also adding to this malaise.

 

HOW STRESS CAN MAKE YOU SICK By: Dr. Jesse A. Stoff 
 For our well-being, stress is so powerful that it can affect just about every function in our bodies right down to our cells. Stress can cause major weight gain, headaches, hair loss, dental problems, major fatigue, respiratory issues, digestive problems, psychological & focal disorders.  It is also known to affect the performance of our immune system - allowing for skin issues, colds, allergies and a host of chronic diseases. Stress management is important for more than psychological health; stress can greatly affect immune functioning, inflammation and even hormonal balance. Studies have shown that stress can reduce natural killer cell function. These are normally the cells that attack foreign invaders including viruses, bacteria and fungi. They are also the cells that patrol the body as the first line of defense against the development of cancer.


RETINAL & TRANSCRANIAL IMAGING By Dr. Robert L. Bard
Another device used by imaging specialists to detect mental distress is through an EYE SONOGRAM or  Real Time Sonofluoroscopy of the orbital soft tissues of the eyes.  This process is performed in multiple scan planes with varying transducer configurations and frequencies.  Power and color Doppler use angle 0 degrees and PRF at 0.9 at the optic nerve head. 3D imaging of optic nerve and carotid, central retinal arteries and superficial posterior ciliary arteries performed in erect position before & after verbal communication and orbital muscle tissue contractions may be observed as a precursor to visual changes in facial expression. Retinal arterial directional flow is also measured with peak systolic and diastolic values. Bulging of the optic nerve head is checked as increased intracranial pressure may be demonstrable in this condition. Other innovations such as the TRANSORBITAL DOPPLER, 3D/4D VESSEL DENSITY HISTOGRAM and the RETINAL OCT (optical coherence tomography) are also being explored in the pursuit of studying brain performance through the eyes.  An expanded review on these solutions will be available in part 2 of this report.



 



References:

1) “FDA OKs TMS Depression Device for Brain-Stimulating Device Cleared for Depression Treatment After 1 Drug Failure”- https://www.webmd.com/depression/news/20081008/fda-oks-tms-depression-device

2) https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-transcranial-magnetic-stimulation-treatment-obsessive-compulsive-disorder

3) https://www.hcplive.com/view/prevalence-methamphetamine-use-overdose-death

4) Biological Psychiatry (Journal) /ARCHIVAL REPORT| VOLUME 68, ISSUE 2, P163-169, JULY 15, 2010 Transcranial Low Voltage Pulsed Electromagnetic Fields in Patients with Treatment-Resistant Depression  https://www.biologicalpsychiatryjournal.com/article/S0006-3223(10)00162-9/fulltext

5) Nauczyciel C, Hellier P, Morandi X, Blestel S, Drapier D, Ferre JC, et al. (April 2011). "Assessment of standard coil positioning in transcranial magnetic stimulation in depression". Psychiatry Research. 186 (2–3): 232–8. doi:10.1016/j.psychres.2010.06.012. PMID 20692709. S2CID 25100990.

6) NICE. January 2014 Transcranial magnetic stimulation for treating and preventing migraine.  Michael Craig Miller for Harvard Health Publications. July 26, 2012 Magnetic stimulation: a new approach to treating depression?

7) Pascual-Leone A, Davey N, Rothwell J, Wassermann EM, Puri BK (2002). Handbook of Transcranial Magnetic Stimulation. London: Edward Arnold. ISBN 978-0-340-72009-7.

8) Fitzgerald PB, Fountain S, Daskalakis ZJ (December 2006). "A comprehensive review of the effects of rTMS on motor cortical excitability and inhibition". Clinical Neurophysiology. 117 (12): 2584–96. doi:10.1016/j.clinph.2006.06.712. PMID 16890483. S2CID 31458874.

9) Wikipedia: Transcranial magnetic stimulation  https://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation#cite_note-Handbook_of_Transcranial_Magnetic_Stimulation-27