PEDIATRIC MYOCARDITIS & NATIONAL DETECTION MOVEMENT (Part 1)

Written by: Dr. Robert L. Bard

Since the advent of Covid-19 Long Haul studies in 2021, the medical diagnostic community shifted into overdrive- seeking out all available screening and examination protocols to assess health problems called POST-ACUTE SEQUELAE (PASC). One of the recent Covid-19 related headliners is the rise in cases of MYOCARDITIS in children 16 years and under. CDC Reports link the pathological impact with covid infection since it is proven that Viral infections are a common cause of myocarditis. 

Between early 2020–2021, patients with Covid-19 had nearly 16 times the risk for myocarditis[1]. According to the CDC, in a study of myocarditis cases, 2,116 (41.7%) had a history of Covid-19.  In addition, cases of myocarditis reported to the Vaccine Adverse Event Reporting System (VAERS) indicated links between Myocarditis and Pericarditis to come from the mRNA Covid-19 vaccination (especially in male adolescents and young adults) more often after the second dose.[2].

Myocarditis is defined as an inflammatory disorder of the heart muscle (myocardium) leading to cardiac dysfunction. It is also recognized as myocardial cell death [3]. Checkups for this also reviews for PERICARDITIS (the inflammation of the outer lining of the heart). Various causes of myocarditis includes: Viral Infectious including adenoviruses, echoviruses, enteroviruses like the coxsackie viruses. In addition, predisposition can occur from those with Autoimmune diseases such as Celiac disease, Churg-Strauss syndrome, Crohn disease, Kawasaki disease, lupus, rheumatoid arthritis, sarcoidosis etc. (See NIH chart for full list of causes- [4])

STANDARDIZED DIAGNOSTICS
As with any critical disorder, detecting early stages of myocarditis allows for a higher opportunity to treat and even eliminate the health risk.  In children, symptoms include: Fever, Fainting, Breathing difficulties, Rapid breathing, Chest pain and Rapid or irregular heart rhythms [5]. In adults, symptoms range from chest pain, shortness of breath, at rest or during activity and fluid buildup with swelling of the legs, ankles and feet. To prevent possible heart damage, a cardiologist may order one of a number of imaging options:

▪ Electrocardiogram (ECG or EKG)
▪ Chest X-Ray
▪ Heart MRI
▪ Blood Tests
▪ Doppler Ultrasound for Acute Myocarditis
▪ Cardiovascular MR Elastography (MRE)
▪ Ultrasound Elastography

See expanded details on diagnostic protocols, visit:  http://pediatricscan.com/myocarditis.html

MedNews Extra Saving Lives Through Advocacy & Research: FOR ELYSA FOUNDATION Around the first week of Feb, 2022, our clinical diagnostic researcher, Dr. Robert Bard launched his PediatricScan.com 2.0 in NYC‐ which included a Pilot program for Myocarditis Screening through the use of advanced Doppler Ultrasound Imaging.  To establish the clinical network for this program is to connect with ICU specialists & Cardiologists as well as all associations supporting Myocarditis research. We met the directors of a remarkable national advocacy foundation called FOR ELYSA FOUNDATION‐ a non‐profit organization dedicated to promoting Education, providing Light, and supporting Research in the areas of viral myocarditis and pediatric sudden cardiac arrest. (www.ForElysa.org). Mrs. Jana Rojas and husband Jaime Rojas from Kansas City developed this organization inspired by the loss of her vibrant little girl,  Elysa Louise Rojas who passed away at the tender age of two years old. " In Elysa’s case, a common childhood virus was responsible for her myocarditis. The virus either attacked Elysa’s heart directly or caused her immune system to attack her heart muscle in a “friendly fire” fashion while trying to fight the virus. The inflammation in her heart increased drastically and very quickly to the point of sudden cardiac arrest. Doctors and scientists do not fully understand the mechanisms within the body that cause a virus to “go haywire” in the immune systems of individuals with myocarditis. There is currently no way to predict when/if this will occur." The FOR ELYSA FOUNDATION is one of our first advocacy friends in pursuit of bringing national awareness and supportive clinical research for myocarditis diagnostics and prevention. According to the ForeElysa.org website, Myocarditis is a disease marked by inflammation and damage of the heart muscle. There are many causes of myocarditis, including viral infections, autoimmune diseases, environmental toxins, and adverse reactions to medications. The most common cause of myocarditis in North America is viral infections. Myocarditis usually attacks otherwise healthy people. It is believed that 5 to 20% of all cases of sudden death in young adults are due to myocarditis. Although the exact incidence of myocarditis is not known, it is estimated that approximately 343,000 people die of myocarditis and its major complication, cardiomyopathy, each year. The prognosis is variable but chronic heart failure is the major long term complication. Myocarditis and the associated disorder of idiopathic dilated cardiomyopathy are the cause of approximately 45% of heart transplants in the United States.   Materials in this excerpt are published with express consent from The For Elysa Foundation.  For complete Information, visit www.FORELYSA.org HOW & WHEN TO CHECK FOR PEDIATRIC MYOCARDITIS By: Jana Rojas The tricky thing with myocarditis being virally mediated is that Elysa could have had a heart scan a week before she died (the day before she contracted the virus that wrecked her heart), and it would have been normal. I am hesitant to insinuate that imaging could "clear" a patient and provide a clean bill of health without noting that this can and does occur spontaneously after viral infections, and so testing while ill or post-virally is actually the key message and window of opportunity for myocarditis detection. In my mind, the primary role for cardiac diagnostic imaging as it related to myocarditis specifically would be for:  1) acutely ill children in ED/urgent care/hospital inpatient settings 2) children exhibiting the signs and symptoms you have outlined (fainting, sudden fatigue, shortness of breath, chest pain, palpitations),  3) after known Covid or other viral infection with prolonged or delayed healing (ie ongoing fatigue, shortness of breath, etc)   4) and possibly PRE-PARTICIPATION SPORTS PHYSICALS. The pre participation screenings would be enhanced cardiac screenings in general to ideally pick up congenital heart defects and other concerns as well as myocarditis.

TROUBLESHOOTING MYOCARDITIS

By Bobbi Kline, MD (Integrative Physician / Genomic Research Specialist)

As a mom, my heart grieves for parents, including Elysa’s, who suffer such devastating tragedy. It’s the worst thing you hope never happens to your child, and I truly admire parents who turn a tragedy into something positive. It requires such amazing strength, courage and grace. As a physician, I find my self immediately asking "Why do these things happen? How can we predict or prevent them?" As clinicians, we look for patterns to help guide diagnosis and treatment. We know what to expect, but sometimes they can lull us into a false sense of security. Childhood viruses, as any parent knows, are an expected part of those early years. 

But what happens when they turn out to be something more? That’s where pattern recognition is crucial. When something obviously falls outside those patterns, it’s a signal to question and go deeper. But what happens when you don’t even recognize that deviation? What if something is so uncommon or so subtle that it’s hard to detect among all the noise? Post-viral myocarditis is one of those conditions, and I’m glad to see it now in the spotlight. Raising awareness is a key first step. While COVID-19 has certainly helped to highlight this condition, it goes further than COVID. Many common childhood viruses have been implicated in causing myocarditis, but most people are completely unaware. I admit that it was not something I ever really thought about as my kids were growing up. And I am not alone. Educating clinicians as well as parents on what to look for, when to be alarmed, when to go deeper is crucial. This alone will save lives. 

But it’s only the first step. We also need better tests and tools to quickly and easily identify who is at risk, and better treatments for helping these children. This requires a multidisciplinary approach that includes better diagnostics including noninvasive technology, along with effective medications and other treatments. It also includes the burgeoning field of genomics and personalized medicine, both to provide a better understanding of the why, as well as a powerful tool to predict and prevent. For, at the heart of this, is understanding each child’s uniqueness in a way that empowers.  Two studies have been published this year that have the potential to leverage the power of DNA to identify who is at risk for developing myocarditis after a viral infection. Not only that, but also which of those children are most likely to recover, and therefore need fewer interventions, and which of those children are most at risk for sudden death and require much more intensive treatment and support. And, in today’s world, we also need the power of legislation to make sure everyone has access to this higher level of care. There is much promise to change the trajectory of this devastating illness, and it is only through advocacy such as this that it will happen. 

1) Morbidity and Mortality Weekly Report (MMWR): Association Between Covid-19 and Myocarditis Using Hospital-based Admin Data 3/2020-1/2021) https://www.cdc.gov/mmwr/volumes/70/wr/mm7035e5.htm

2) Myocarditis and Pericarditis: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html

3) MR Imaging of Myocardial Infarction | RSNA-Radiological Society of North America  / https://pubs.rsna.org/doi/10.1148/rg.335125722

4) The Diagnostic and Clinical Approach to Pediatric Myocarditis: A Review of the Current Literature (NCBI/NIH)  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352488/

5) Diagnosis and Management of Myocarditis in Children (American Coll. of Cardiology) https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/07/09/17/31/diagnosis-and-management-of-myocarditis

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. None of the information provided should be interpreted to be or is meant to be medical advice, suggestions, or counseling.

INHERITING CANCER (feat: Genetic & Genomic Testing)

CANCER HEREDITY

(Originally published 11/2020) Cancer is a genetic disease—that is, cancer is caused by certain changes to genes that control the way our cells function, especially how they grow and divide. Genes carry the instructions to make proteins, which do much of the work in our cells. Certain gene changes can cause cells to evade normal growth controls and become cancer. For example, some cancer-causing gene changes increase production of a protein that makes cells grow. Others result in the production of a misshapen, and therefore nonfunctional, form of a protein that normally repairs cellular damage.  

Inherited genetic mutations play a major role in about 5 to 10 percent of all cancers. Researchers have associated mutations in specific genes with more than 50 hereditary cancer syndromes, which are disorders that may predispose individuals to developing certain cancers. Genetic tests for hereditary cancer syndromes can tell whether a person from a family that shows signs of such a syndrome has one of these mutations. These tests can also show whether family members without obvious disease have inherited the same mutation as a family member who carries a cancer-associated mutation. [1]

Everyone has two copies of each set of genes from both parents. If a person inherits a mutation in a Lynch syndrome gene, they still have the normal copy of the gene from the other parent. Cancer occurs when a second mutation affects the normal working copy of the gene, so that the person no longer has a copy of the gene that works properly. Unlike the inherited Lynch syndrome mutation, the second mutation would not be present throughout the person’s body, but would only be present in the cancer tissue. However, not everyone with Lynch syndrome will get cancer. You and your family members are more likely to have Lynch syndrome if your family has a strong history of colorectal cancer. Family members who inherit Lynch syndrome usually share the same mutation. If one of your family members has a known Lynch syndrome gene mutation, other family members who get genetic testing should be checked for that mutation. (source: CDC.gov)

GENETICS & GENOMICS: SIMILAR BUT DIFFERENT Excerpted from https://robertaklinemd.com Genetics and genomics sound alike and are often used interchangeably. While they both deal with changes in our DNA, there are important scientific and clinical distinctions. GENETICS CAME FIRST The science of genetics is classically defined as the study of heredity, or how traits are passed on from one generation to the next. While modern day genetics evolved from Gregor Mendel’s pea experiments in the mid-1800s, it wasn’t until James Watson and Francis Crick discovered the actual structure of DNA in 1953 that we began to understand exactly how it works.  DNA contains the genetic code, the blueprint for everything that happens in our bodies. DNA is short for deoxyribonucleic acid, and it is composed of long strands made up of four different nucleotides called adenine, guanine, thymine, and cytosine, or A, G, T, and C for short. It exists as two long strands that are paired in a specific manner. The DNA is grouped into functional units called genes, which can comprise either a small or large section of DNA. This DNA code is incredibly complex, and in order to contain all this information, the amount of DNA we each have in our cells is tremendous. In fact, every cell contains about 6 feet of DNA. That’s enough DNA in one person that, if stretched out, it would be long enough to go to the sun and back more than 300 times… or go around the earth’s equator 2.5 million times! That’s where chromosomes come in. The DNA is compressed into tightly coiled structures called chromosomes in order to fit into our cells. We each have 23 pairs of chromosomes, and they are stored in a special compartment of the cell called the nucleus.  While that solves the storage problem, it creates a different problem – how to access the instructions encoded in the DNA. Every time that cell needs to replicate itself to replace dead cells in an organ or tissue, or we need to make a certain protein, portions of the chromosome need to be unwound to expose the needed genetic code. But sometimes during that process mistakes are made, and the change in the DNA can be mild or catastrophic. GENETICS: BLACK & WHITE Genetics traditionally deals with changes in the DNA sequence called mutations that are inherited in a predictable manner. These can involve small sections of DNA all the way up to whole chromosomes. Medical genetics has traditionally focused on health conditions that are due to inherited mutations in single genes (Huntington disease), in whole chromosomes (trisomy 21 or Down syndrome) or are associated with birth defects or developmental disabilities.  With a traditional, single-gene disorder such as Tay-Sachs disease, genetic information is obtained from a patient as well as his or her immediate family members and relatives. The information is then used to diagnosis or predict the risk of an inherited genetic disorder passing from one generation to another. For many single-gene disorders, there are very limited medical interventions available. Genetic disorders are individually rare, and they account for about 5% of all human disease. That meant 95% of the diseases were due to some other mechanism. In an effort to better understand how DNA contributes to health, scientists realized that genetic mutations were only part of the story. The Human Genome Project was conceived in the late 1980’s to provide answers. One of the biggest take-aways from the Human Genome Project was that humans share 99.5% of their genome. But while this means we are far more alike with all the genes we have in common, that 0.5% difference is significant. The small differences are what make us each unique. Genomic Medicine: It is now possible to use results from clinically-based genomic testing to evaluate a person’s disease susceptibility, and develop evidence-based, personalized intervention strategies to reduce those risks. These strategies include DNA-directed lifestyle modifications, dietary recommendations, nutritional supplements and/or exercise, all of which influence how these genes function to create health or disease. Biomarker testing can then be used to evaluate whether the intervention is efficacious. With this approach, the guess-work and inefficiencies of trial-and-error strategies are greatly reduced, leading to better health more quickly and cost-effectively. A comprehensive test can provide gender-specific reports to create personalized programs for many health conditions, including: Prevent ER+ breast cancer or its recurrence in women diagnosed with the condition Reverse osteopenia and osteoporosis Prevent or treat Type II diabetes, heart disease, stroke, metabolic syndrome and obesity. Optimize athletic performance Customize nutrient requirements and resolve nutritional paradoxes Prevent, treat and manage depression and anxiety Plus many more health and wellness issues Genomic Medicine is personalizing healthcare with precision.  To see complete article, visit: https://robertaklinemd.com/ About the Author BOBBI KLINE, MD (Educational Dir. /Women's Diagnostic Group) Dr. Kline is a board-certified ObGyn physician, Integrative Personalized Medicine expert, consultant, author, and educator whose mission is to change how we approach health and deliver healthcare. She helped to create the Integrative & Functional Medicine program for a family practice residency, has consulted with Sodexo to implement the first personalized nutrition menu for healthcare facilities, and serves as Education Director for several organizations including the Women’s Diagnostic Health Network, Mommies on a Mission. Learn more at https://bobbiklinemd.com

Directory of Inherited Cancer Syndromes source: NIH LINK
• BRCA1 / BRCA2 - breast & ovarian cancer • Cowden Syndrome • Diaphyseal medullary stenosis • Duodenal carcinoid syndrome • Endolymphatic sac tumor • Familial adenomatous polyposis • Familial isolated pituitary adenoma • Gardner syndrome • Hereditary diffuse gastric cancer • Hirschsprung disease ganglioneuroblastoma • Langerhans cell histiocytosis • Li-Fraumeni syndrome	• Lynch syndrome • Multiple endocrine neoplasia: - (type 1 | type 2A | type 2B) • MYH-associated polyposis • Oslam syndrome • Paraneoplastic Neurologic Disorders • Perlman syndrome • Pheochromocytoma | islet cell tumor synd. • Premature aging Okamoto type • Stewart Treves syndrome • Von Hippel-Lindau disease • WAGR syndrome

 LYNCH SYNDROME is a hereditary cancer condition in which a mismatched repair gene, which ordinarily repairs errors in DNA duplication, is defective. As a result, individuals are predisposed at a very high lifetime risk of cancer, including an up to 85% risk for colorectal cancer, 65% risk for uterine cancer, 19% risk for gastric cancer, 13% risk for ovarian cancer and a higher than average risk for other cancer including cancers of the liver, gallbladder, kidney, bladder, prostate, pancreas, skin, brain and breasts. With genetic testing, there is hope...once diagnosed, annual cancer screenings take place and cancers can be treated or removed before becoming life threatening. By knowing our family history and having a great medical team, we live longer than ever before...as long as anyone else!

An Introduction to Lynch Syndrome

By: Lindy Bruzzone

I was diagnosed in 2007 with colorectal cancer which was tied to my having Lynch Syndrome.  There are tens of thousands of people now diagnosed with this genetic disorder which means this is NOT a RARE disorder like most might think.  It came from a defective mismatch repair gene, where instead of repairing errors in DNA replication, it puts in different proteins and create more errors than it tries to keep doing. 

I produced this video 10 years after I lost lost my father. It was just so difficult for me to lose him that way. The day before he died, he said to me, "the doctors think it's hereditary, go get checked and tell your brother and sister, to get checked."  After his funeral, my brother and I started looking for the right cancer center to get help. Knowing my father's reports, my surgeon and other doctors jumped in to get me tested, and sure enough--- it was positive. 

That's why Lynch Syndrome International was developed because nobody was getting diagnosed. NOW they are! And then when Color Genomics was developed (a Steve Jobs startup offering for FREE genetic testing), suddenly everybody started getting tested because they could finally afford it. They didn't want insurance companies involved. It took care of every barrier that we have to testing for hereditary cancers. 

tbc

References

1) Cancer Heredity / NIH: https://www.cancer.gov/about-cancer/causes-prevention/genetics

TEMP PLACEHOLDER: LIFE EXTENSION & THE HYPERVIGILANT RESEARCHER

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 observation, it 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: CLINICAL IMAGING & OBJECTIVE DATA MEASURING 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.

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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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TODAY’S CLINICAL AESTHETICS- SCIENCE AND STRATEGY

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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).

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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.

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