Monday, March 9, 2020

"TEACHING" T-CELLS TO KILL CANCER TUMORS

Written by: Dr. Robert Bard, NY Cancer Resource Alliance editorial staff & AngioMed Publications


"With Immunotherapy, we take advantage of the body's own natural defenses that's a lot smarter than any doctor... (it) provides the best clues for the development for effective cancer treatments for patients who cannot be helped by current modalities"- Dr. Steven Rosenberg, Natl. Cancer Inst. ("Father of Immunotherapy")


INTRODUCTION
CAR T-cell therapy is a type of immunotherapy- otherwise called a type of adoptive cell transfer. CAR T-cell therapy is a very complex and specialized treatment where a specialist collects and makes a small change to your T cells. These then target the cancer cells.  It is available as a possible treatment for some children with leukaemia and some adults with lymphoma. People with other types of cancer might have it as part of a clinical trial. 

To understand CAR T-cell therapy more, it helps to understand what T cells do. White blood cells called lymphocytes play an important part in fighting infection and diseases, including cancer. There are different types of lymphocytes. T cells are one type. T cells move around the body to find and destroy defective cells. When you come into contact with a new infection or disease, the body makes T cells to fight that specific infection or disease. It then keeps some in reserve so that if you come across the infection again your body can recognize it and attack it immediately. [aa]

T CELLS in the immune system protect the human body from infection by pathogens and clear mutant cells through specific recognition by T cell receptors (TCRs). Cancer immunotherapy, by relying on this basic recognition method, boosts the anti-tumor efficacy of T cells by unleashing the inhibition of immune checkpoints and expands adaptive immunity by facilitating the adoptive transfer of genetically engineered T cells. T cells genetically equipped with chimeric antigen receptors (CARs) or TCRs have shown remarkable effectiveness in treating some hematological malignancies, although the efficacy of engineered T cells in treating solid tumors is far from satisfactory. (In the review from Springer Nature), we summarize the development of genetically engineered T cells, outline the most recent studies investigating genetically engineered T cells for cancer immunotherapy, and discuss strategies for improving the performance of these T cells infighting cancers. 

T cells play central roles in cell-mediated adaptive immunity. Since researchers identified the molecular evidence of T cell receptors (TCRs) in the 1980's, the recognition of antigens by TCRs has been heavily investigated, and the molecular mechanisms governing this process have been elucidated, laying the foundation for cancer immunotherapy. [2]



DR. HASAN'S T CELL ENGINEERING RESEARCH PROCESS
The pursuit of harnessing the body’s immune system to treat cancer was first established by Dr. William Coley in 1891 and continues to be applied as an expanding innovation in cancer treatment today.  Today, a vast number of immunotherapies have been developed- such as monoclonal antibodies (used to block abnormal proteins in a cancer cell), checkpoint inhibitors that remove barriers to anti-tumour immunity, oncolytic virus therapy, cancer vaccines and T-cell therapy. [1]

NYCRA NEWS features a wide set of focus points in the world of cancer care including research innovations- and the experts behind them.  This review of cancer immunotherapy brings us to the work of DR. AISHA HASAN - innovative research specialist in clinical pursuit of a cancer immunotherapy breakthrough by harnessing the body’s T-cells. 

As an oncologist, Dr. Hasan underwent her training at Sloan Kettering Cancer Center in Hematology Oncology.  She spent over 13 years researching T-cell therapies to target deadly cancers that occur in patients who have received bone marrow transplants.  Her exploratory work involved implementing T-cell therapies in human clinical trials.

Throughout her research process, T-cell therapies were applied on a broader scale to active patients who had deadly infections after receiving bone marrow transplantation and patients who developed any kind of EBV (Epstein-Barr virus) related malignancies..  Her expertise in the study of T-cell biology, immune deficiencies and cellular immunity was very insightful in developing many other modalities for treating cancer using T-cells.

Her tenure at Sloan Kettering Cancer Center was spent working with several research groups to develop bi-specific antibodies, and TCR mimic antibodies that can then be made into engineered T-cells, which would then target antigens expressed on tumor cells. One of those antigens is called WT-1. These types of engineered cells are living drugs. They are medicines that can be introduced into the body which can multiply upon encountering the targeted antigens on tumor cells, and thereby provide ongoing protection against cancer to patients in need.  As head of clinical development at GSK, she has promoted gene engineered cellular therapy and has enabled the development of novel T-cell therapies for treating solid tumors. Using innovative study designs has allowed for multiple cohorts of patients with different tumor types to be treated with T-cells.  These same therapies are now currently part of actual clinical trials.


EARLY CONCEPTS
“Adoptive cell transfer” is an immunotherapeutic approach which involves the ex vivo expansion and re-infusion of antigen-specific (AG-specific) T cells, and has been used in various forms. The first recognition that adoptive T-cell therapy could be a potentially curative treatment for cancer came with the initial reports by Steve Rosenberg et al [3], describing complete regression of bulky tumors in patients with metastatic melanoma infused with ex-vivo expanded T-cells extracted from surgically resected tumors, also called tumor infiltrating lymphocytes.  T-cells used for treatment can also be genetically redirected toward tumor associated antigens by modification with a T-Cell Receptor (TCR) or Chimeric Antigen Receptor (CAR).

Dr Hasan elected to focus the start of her career in the research study of T-Cells because of a personal belief in this avenue of treatment. Since the early days of her fellowship in oncology, she carried the immunologists' belief that cancer happens when one's immunity goes down-- giving opportunity for mutated tumor cells to grow.   The body's design is to get rid of mutated abnormal cells, thanks to specifically to the T-cells in the immune system as the main fighters against any abnormal cells.
A large portion of the insights in the biology of T-cell killing were derived from the extensive research conducted on T-cells during the AIDS epidemic in the 1980's.  These insights paved the way for the application of T-cell therapies in cancer.

Dr. Hasan expressed that during the early days of this T-cell therapy research, there was little indication that showed signs of becoming more than a theory for a viable therapy, let alone a large scale development of therapies against cancer.  Scientists saw it more as a way to understand how to influence the immune system.  "We have found the T-cells within the body to take care of cancer- and as a result of this research, one thing led to another and here we are... genetic engineering! We are now literally engineering T-cells to express molecules on their surface that arm them to then go and seek out and kill the cancer cell."


RESPONSE DRIVEN PATIENT DATA 
Currently, Dr. Hasan's research prevails the search for a constant end point within open label trials.  By this, she takes the T-cells from select patients with advanced or stage four cancers, modifying them externally and re-introducing them back into the body. They are all part of phase one trials- hence, patients who have exhausted all prior therapy options. Analysis of this defined set of patients are part of a fully powered study whereby the statistical design is already pre-established. There are planned analyses that would be conducted at different time points for the different studies that are ongoing. She and her fellow researchers expect significant data to arise in the next two years.Dr. Hasan started with a small experiment with engineering cells in a certain way. The next wave of engineering for these T-cells would address some of the barriers to the efficacy of these cells in the tumor microenvironment in order to incorporate multi-component engineering technologies in order to affect additional molecules within the cells that will address some of the limitations. Next is to work with a pre-clinical group to actually look at other targets and bring them to the clinic.  These would also be either CAR or TCR-modified T-cells (for the first time) in human studies within the next year to two.


TIP OF THE ICEBERG
The initial success achieved by all researchers during this time have set the stage for the main development of T-cell therapies for cancer.  According to Dr. Hasan, "what we've been able to do right so far with T-cell therapies is cancer antigens that are ubiquitously or constantly expressed on the surface of the cell.  However, the bulk of cancer associated antigens present on solid tumors are in fact intra-cellular, and not easily targeted. They cannot be targeted with the CAR-T that have been approved thus far.  Therefore, T-cells engineered to express TCRs are attractive as a therapeutic approach because they are able to target intra-cellular antigens associated with tumor cells. 
Meanwhile the issue still remains that (so far) we have not been able to attack, cure or get to a good efficacy with solid tumors.  Cancer cells typically have a very thick or dense conglomeration of tumor cells that are embedded within a very immune inhibitory micro-environment with very little blood supply... cells within the tumor actively inhibit the activity of T-cells.  So a lot of our efforts at the moment are focused on the issue of the tumor micro-environment and how to target solid tumors with T-cells to make them more effective."

To develop a publicly accessible (and FDA accepted) cancer immunotherapy drug, the main objective of clinical researchers needs to keep with the plan to 'make this therapy not so personalized'.  By this, they need to overcome that barrier of autologous cells to then move into creating an off-the-shelf therapy. 

During her laboratory research work at MSK, Dr. Hasan's research team led the path of experimentation toward what might just be an off-the-shelf approach.  At GSK, she is in the exploratory phase of testing  T-cells that have been  engineered in order to overcome immune inhibitory molecules within  tumors.  Combination approaches with antibodies or other small molecules with T-cells could further empower   the infused T-cells to actually overcome the inhibition within the tumor micro-environment and achieve complete remission of cancer.  Another wave of development in this space will deliver modalities that will enhance the T-cell manufacturing capability, thereby extending this therapy to many more patients in need. "We look at these T-cells as living medicine and as such,  engineering them means  they need to be grown, frozen down and preserved for future use. It's something that is quite a cumbersome process despite many companies investing in closed mechanized systems to actually grow these T-cells. But it is far from being one of those situations where it's widely applicable or  available."

In a 2018 AACR conference, Dr. Carl June started his presentation by saying “I think we’re about five years behind where checkpoint therapies are with CAR T cells.”   This mirrors Dr. Hasan's statement about the study as having 'a long way to go'.   In 2012, Dr. June achieved the first successful CAR T-cell therapy with CD19 CAR T to a patient with acute lymphoblastic leukemia who remains in complete remission today. So far, two different types of CAR T-cell therapies have been approved by the U.S. Food and Drug Administration (FDA). Both have been approved to treat blood malignancies: axicabtagene ciloleucel (Yescarta) has been approved for the treatment of a certain kind of non-Hodgkins lymphoma, and tisagenlecleucel (Kymriah) has been approved for the treatment of certain types of leukemia and Non-Hodgkins Lymphoma. [5]


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REFERENCES:

[aa] CAR T-cell therapy- (origin: Cancer RESEARCH uk)
© Cancer Research UK [2002] All right reserved. Date uploaded (3/9/2020).
Cancer Research UK is an independent organization from the NY Cancer Resource Alliance and the publisher(s) of this site- and a source of trusted public information for all.
2) https://www.nature.com/articles/s41392-019-0070-9#citeas From: "Genetically Engineered T Cells For Cancer Immunotherapy" source: https://rdcu.be/b2IJ9 by: Dan Li, Xue Li, Wei-Lin Zhou, Yong Huang... 
3) NIH; Dr. Srteven A Rosenberg, An Immunotherapy Pioneer Tells All (by Emily Petrus, NINDS)



CONTRIBUTING WRITER

ROBERT L. BARD, MD, PC, DABR, FASLMS - Advanced Imaging & Diagnostic Specialist
Having paved the way for the study of various cancers both clinically and academically, Dr. Robert Bard co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital Imaging technology has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered Sonograms, Spectral Doppler, sonofluoroscopy, 3D/4D Image Reconstruction and the Spectral Doppler are safe, noninvasive, and does not use ionizing radiation. It is used as a complement to find anomalies and help diagnose the causes of pain, swelling and infection in the body’s internal organs while allowing the diagnostician the ability to zoom and ‘travel’ deep into the body for maximum exploration.



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Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.

Friday, February 21, 2020

SENSIBLE ADVANTAGES OF ULTRASOUND IMAGING FOR BURNS AND DERMAL TRAUMAS

Written by: Dr. Robert L. Bard of the Bard Diagnostic Imaging Center

For most emergency responders and physicians, identifying the degree of any burn or dermal trauma cases starts with a visual assessment.  With professional training and enough experience, the professional eye can differentiate between first, second and third degree burns to initiate the proper treatment process. First-degree burns commonly show redness, and swelling only on the outermost skin layer; second-degree burns show surface injury to the underlying layer with blistering and Third-degree burns affect up to the deep layers of the skin.

As standard practices continue to evolve, diagnosing any advanced burns are now calling for new considerations for the prevention of burn-related complications.  As more and more after-effects from high degree burns have left patients with lasting (and sometimes fatal) results, it may no longer be enough to drive a treatment protocol based on surface topical healing. 

BURN SCANNING TECHNOLOGY: ASSURANCE AGAINST COMPLICATIONS
Second and third-degree burns may show blisters and red skin but with today’s many non-invasive subdermal technologies, you can now identify the depth of the burn and what the injury truly means under the skin. Identifying the exact DEPTH of the internal injury as well as monitoring (visually) its internal impact/effect on the body may uncover and predict other potential health issues such as:

-        Scarring and unrecoverable dead tissues
-        Damage to Nerve endings /neuropathy
-        Inflammation
-        Temporary to permanent loss of skin
-        Damage to underlying bones, muscles and tendons
-        Bacterial infections (from the broken skin) like tetanus
-        Internal Shock
-        Hypovolemia (low blood volume/ unusual blood loss from a burn)

According to Image 1A, high resolution sonogram used a standard probe for skin imaging showing the black area, which is just below the white line of the surface and the black fluid corresponds to the blister seen on the specimen of the burned area. Now below it you see the skin with the first vertical blue dotted line and it goes to the fascial plain white line, which shows swelling of the tissues. The normal skin measures 1.3 millimeters or thin as a dime and the depth of the burn itself measured is twice that, 2.6 millimeters. So we have a way of seeing the fluid. We have a way of checking the depth of the burn, which is clinically difficult because the eyes cannot see below the skin.   You can see the blister is basically gone because that's the tiny black area above the tissue line- showing almost no fluid left (represented In the blackish area)


Upon review of Day 9 diagram, see "burn healing" on the left side of this diagram where it says dermis on day 9, you can see the bottom white line under the lettering dermis, which shows the bottom of the skin, which last time was 1.3 millimeters. Then to the right of that the dermis tissue is starting to have the red and blue healing blood vessels that's coming in marked by the red arrow. And then to the right of that where it says decreased vascularity, the larger blood vessels have not yet come in, but at least we know the skin has viable feeding blood flow. So it's more likely than not to heal.

** These images are scanned with the GE Ultrasound Voluson E8.  Any machine over 15 megahertz can be used on burns- however, devices with higher the resolution improves the scan experience to get the best data.

REVIEW OF THE BLOOD FLOW INNOVATION
Today’s imaging devices cover a wide range of functions on the market carrying specific features to fit their many users specific needs.  This scan was generated by the General Electric Voluson E8 system which uses an 18 mhz probe outputting 1/10 of a millimeter of resolution.  The benefit of using this GE 3D Doppler system enables the ability to measure the depth of the burn as well as identify and record the exact amount of fluid in the surface of the burn, which is the blister. 

For many diagnostic applications, the real-time scanning ability of VASCULAR ULTRASOUND has greatly advanced the way injuries are read, identified and managed.  Vascular ultrasound uses sound waves to evaluate the body's circulatory system.  It also helps identify blockages in the arteries and veins and detect blood clots.  This innovation is not radiation based, leaving no harmful side effects and out-performs many of today’s current counterparts including accuracy in scanning soft tissues that does not appear in x-rays. 
BLOOD FLOW technology is the “diagnostician’s storyteller”.  It allows you to see which part of the skin is alive by the indication of active blood flow through the area- versus the skin that is dead or dying with no blood flow. In cases of burns, the margin of injury can extend once the burn has been completely cooled down. Since vascular ultrasound is safe sound waves, you can conduct frequent scans to monitor healing and progress every hour/every day until resolution.

The paradigm of studying blood flow allows any diagnostician to review whether the tissue is curing or not.  In the case of performing a possible skin graft, the blood flow around an injury gives more data as far as the behavior of the burn or injury as well as the condition of healthy tissue to attach to the burn.

Any inflammatory skin disease is caused by inflammatory blood vessels, which is not evident by the naked eye. This scanning modality allows you to quantify the degree of inflammation and the response to all the new treatments available. Where widely accepted optical technologies work well,  they are limited to 1/2 of a millimeter depth, so they are surface only.


SKIN LIFE VS. SCARS 
If the tissue doesn't heal with normal skin, it will scar. The scar tissue appears as black in ultrasound imaging, almost like the fluid- but with zero blood flow.  Any kind of trauma can result in healing tissue or dead tissue, which will either get infected or scar down. Imaging can also show if the area is getting inflamed as it indicates irregular volume of the blood vessels resulting in cellulitis or the inflamed skin.

Scar tissue is dead skin.  Doppler Imaging can be useful as it shows the thickness of the scar to determine if it can be treated, either with steroids, laser or any of a number of current scar treatment technologies.  The depth and the hardness of the scar determines which option to use and all these can be resolved by the various ultrasound technologies. Ultrasound is the new ‘weapon of choice’ to show depth, thickness of the scar, type of scar, how hard or elastic it is  (also see elastography).  It also allows the surgeon to clearly identify the margins you wish to attach the graph to.  


[IMAGE 2] In this image, we have a burn that came from a charcoal grill. This burn leaves a white coating (surface singe) to the red skin. (A) This white surface outline with the black arrows is the ash from the grill or the burning surface. The small yellow circle is the blister that immediately broke from the heat. So the blister burst and opened up causing the teardrop-shaped opening in the skin, which could get infected. 
Diagram B shows the two yellow arrows pointing to the white area, it's got a top white, a medium dark, and a bottom white area.  That's the appearing ash visible only on the surface but not penetrating deep (thus it is not a third-degree burn). Upon further interactive review of the burn, it was only surface ash from the surface of the charcoal grill which was easily removable. On the same image (B), we are also looking at external tendon, 1 mm wide. 
Diagram C indicates the blood vessels and the normal tissue on the side of the burn. Though the burn goes deep into the skin, it is not a complete third-degree burn in the whole area (B). Comparing B and C, the injury to the burned tissue is marked by the red arrow on top and also the tendon that raises the finger pushes 1 mm wide is completely unaffected by the dark burn area. Now below that since we weren't sure if it was a third-degree burn or we wanted to see if there was viable skin next to it, we did the blood flow technology which shows the micro vessels or the capillaries that are in the adjacent skin, so if you ever needed to graft it you'd have normal skin and also the fact that you have normal skin in the red area means that the burn in that area is a first degree or not really burned at all.

“IT’S ALL ABOUT THE PROBES”
The GE Doppler scanner can go deeper under the skin - at an estimated 5x the resolution than the average ultrasound probe (at 1/10mm resolution). The higher the megahertz, the deeper and sharper the image (like 70mhz has 1/50 of a millimeter resolution).  Such a probe is much better for imaging tendons and skin and the regular 18 or 20 megahertz (such as the GE) that we use routinely use has 1/10 of a millimeter resolution. You have better detail for seeing tendons and blood vessels.

Overall, each probe determines a specific depth, the width & range of the scan, the level of blood flow while the hardware & diagnostic software itself communicates with the probe to translate all data into recognizable images in real time.

PRE-OPERATIVE (AND RISK REDUCTION) PROTOCOL
Among its many uses, cosmetic surgeons can benefit from dermal imaging by mapping the nerves and the arteries before cutting. Also, you can find the dead skin as compared to the normal skin for doing reconstructive surgery. 

Emergency departments can more easily treat nerve trauma, burns, tendon injuries with the help of visual analysis of any affected area.  As an example,  you can see if the tendon is partly or completely torn with ultrasound more easily and effectively. you are able to move the finger because it won't be any movement of the torn part. If you move the tendon when you open up the finger from a closed fist position.


ABOUT THE AUTHOR-

ROBERT L. BARD, MD, PC, DABR, FASLMS - Advanced Imaging & Diagnostic Specialist
Having paved the way for the study of various cancers both clinically and academically, Dr. Robert Bard co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital Imaging technology has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered Sonograms, Spectral Doppler, sonofluoroscopy, 3D/4D Image Reconstruction and the Spectral Doppler are safe, noninvasive, and does not use ionizing radiation. It is used as a complement to find anomalies and help diagnose the causes of pain, swelling and infection in the body’s internal organs while allowing the diagnostician the ability to zoom and ‘travel’ deep into the body for maximum exploration.



Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.








Wednesday, October 23, 2019

PREHOSPITAL DIAGNOSTICS; THE EMERGENCY RESPONDERS’ “DIGITAL ANGEL”

By Dr. Robert Bard | Edited by: The RightWriters research staff | October 25, 2019

The saying “you can’t take it with you” is often applied to points of wisdom about letting go of your worldly possessions at the twilight of your years. In the case of emergency response, an ambulance rig is designed to simulate an ER on wheels, packing a range of life support equipment, devices and drugs for all critical rescue situations.  This includes essentials like breathing and airway clearing devices to scanning & monitoring equipment to dressing & bandaging materials.

Stories from many seasoned EMT or paramedics may include rare rescue situations that fall short of having more advanced resources and on-the-spot access to medical expertise that could have changed the course of the rescue when racing to the ER took too long.  Modern solutions to this dilemma include the expansion of field care through advanced Point-of-Care Ultrasound use and integration of TeleMedicine.  These innovations help rescuers immediately identify complex trauma including any possible ‘land mines’ through portable digital imaging technology while saving valuable time when it comes to file transfers of the patient’s condition electronically to the critical care professionals at the end of the ride.

PRE-HOSPITAL ULTRASOUND USE BY EUROPEAN RESPONDERS
Pre-hospital ultrasound has many clinical applications that may reduce morbidity and potentially improve outcomes for patients with life-threating conditions [3].  Worldwide, responders have adopted the use of a portable non-invasive, non-radiation ultrasound in their rescue rig.   For example, in Germany, the use of ultrasound in the field has focused on the FAST exam and cardiac sonography for non-traumatic patients since 2002–2003.  French prehospital clinicians have adopted ultrasound in certain areas as well, including SAMU (Service d'Aide Médicale d'Urgence). The Italian EMS system began incorporating ultrasound into prehospital care in 2005. [2]

Pre-hospital ultrasound is employed in this setting to differentiate reversible causes of pulseless electrical activity (PEA), assess for pericardial, intraperitoneal, and pleural fluid in trauma, and to differentiate between pulmonary edema and emphysema. In the USA, the focus on rapid transport and limiting on-scene time may have contributed to slower adoption of prehospital ultrasound into clinical algorithms. There is less experience in the routine use of ultrasound on ground ambulances. [2]


THE ERA OF TELEMEDICINE
By: Elizabeth Banchitta

With the combined use of remote portable ultrasound and telemedicine, the rescue unit raises the chances of the patient’s survival exponentially while significantly reducing the risks of complications during critical care. Telemedicine is the practice of medicine using technology to deliver care at a distance.  [4] Current communications technology and file-sharing allows medical doctors to consult EMTs and Paramedics to work with their patients remotely (through HIPAA compliant conferencing platforms) and software.  This revolutionary upgrade is true evidence of improving public health (and survivorship) and a significant cost reduction in medical care.

CONCEPTS REALIZED FOR A GLOBAL UPGRADE IN EMERGENT RESPONSE
On August of 1985, Mayor Ed Koch pushed a city policy to implement EMS medical control - a communications center where responders have advisory access to a medical doctor.  This originally was intended to eliminate unnecessary ambulance transports. This allowed the responder to determine and/or refuse medical attention on calls that were not actual life-threatening situation.  Koch’s idea was to keep ambulances available for the ‘real’ emergencies “and is not a free taxi service to the ER”. (NYT 7)

2019- Koch’s communications program is still technically in place, but its directives have been reshaped as TELEMED, TELEHEALTH or INTEL Communications- geared to be more about immediate access to doctors' medical guidance and data transmitting.  For the many incidences (such as heavy traffic) where time is truly of the essence, where a patient’s life is slipping away faster than the rig could cut through city streets, arming the responder with higher performance equipment and communication protocols with the ER docs has become the growing trend- or at least the sensible modern concept in motion.

Medical Control is a recorded line between the mobile unit and the hospital personnel awaiting the ‘delivery’. Thanks to TELEMED, they're there to help the responder interpret data collected and transmitted to them. Based on their findings, they may direct the rig to a specific hospital with the appropriate resources to best treat the patient. This also decreases the amount of time that will be spent on the patient running tests in the ER that could have been done during transport. For many cases, time is of the essence. TeleMed also helps responders administer certain tasks to keep patients stable from a life-or-death situation.  TeleMed also facilitates calls for a second opinion or orders allowing emergency personnel to administer additional doses of medication. There have been countless situations where ambulances are caught in terrible traffic or unforeseen road blocks that meant needing to act fast on a patient’s increasingly critical situation.  Having the doctor “present and available” (virtually) gives the responder real-time instructions on what to do.

For the sake of response time, New York City is probably one of the most densely populated areas with the highest number of hospitals and level 1 trauma centers.  But this is not the case for many areas in the country.  There are regions that experience up to an hour drive to the hospital making a patient's “golden hour” much more difficult to achieve. EMS refers to the golden hour as the time from when the incident happened to the time that the patient gets definitive care at the hospital. Getting the ball rolling by identifying exactly what is wrong with the patient during longer transport times can increase the possibilities of survival. This is where the need for additional life support technology is at its highest. 


A growing number of EMT’s in the country are allowed (and trained) to take glucose for unconscious or altered mental status patients. Some have CT Scans for possible strokes and CPAP for patients suffering from CHF or other respiratory failures. Resources like the use of EKG’s on patients that are experiencing chest pain or having heart attacks. Where proximity defines the standards, these devices and protocols may not apply for responders and units everywhere. Many of these devices are part of a “pilot program” and does not apply to all towns.  


The idea of a portable hi-powered PreHospital ultrasound that can identify traumas (including a transcranial Doppler to detect oxygen and blood flow in the brain) is something that the military and helivacs are equipped with now- and to integrate that with our com link to the doctor is such a vital game-changer as far as upgrades go!  To use that travel time to see what's going on so much earlier and transmit this data over to the doctor can be a powerful addition to the emergency response. Also, by having access to the doctor to interpret this data helps make crucial decisions such as ‘which hospital, precinct or resources would be best for handling this? Or do they need a trauma or a stroke center? Some places have certain staff members on call 24 seven whereas other hospitals do not. These are the additional directives that can change the overall direction of patient care.

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Point of care ultrasound for prehospital
applications. (Photo/Greg Friese)
Clinical applications for field ultrasound to assess, treat and monitor critically ill patients
Prehospital ultrasound is a form of medical imaging that is portable, non-invasive, painless, and does not expose the patient to ionizing radiation. With proper training and education, prehospital providers can use ultrasound to obtain immediate anatomical, diagnostic, and functional information on their patients.  In recent years, ultrasound devices have decreased in size and cost while producing images of enhanced quality.   For example, prehospital focused abdominal sonography for trauma (FAST) exams have the potential to provide valuable information in abdominal trauma with high reliability leading to more appropriate transport destination decisions. In addition, field ultrasound images can be transmitted enroute to the emergency department to facilitate further evaluation by ED physicians and trauma surgeons to expedite care ... READ MORE

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Next issue: TELEMED FOR COLLABORATION BETWEEN PROVIDERS


CONTRIBUTORS /EDITORIAL TEAM:

ROBERT L. BARD, MD, PC, DABR, FASLMS - Advanced Imaging & Diagnostic Specialist
Having paved the way for the study of various cancers both clinically and academically, Dr. Robert Bard co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital Imaging technology has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered Sonograms, Spectral Doppler, sonofluoroscopy, 3D/4D Image Reconstruction and the Spectral Doppler are safe, noninvasive, and does not use ionizing radiation. It is used as a complement to find anomalies and help diagnose the causes of pain, swelling and infection in the body’s internal organs while allowing the diagnostician the ability to zoom and ‘travel’ deep into the body for maximum exploration.

ELIZABETH BANCHITTA, Technical Contributor / EMT
Elizabeth is a New York State certified EMT-B and a two-time recipient of the St. Catherine's of Siena Award for excellence of written and verbal communication to receiving hospitals. She is the current President of GiveKindness* Organization (a partner of Quinnipiac University, Hofstra University and Farmingdale State College) dedicated to implementing Annual Food Drives for Island Harvest Food Pantry and fundraising for Sloan Kettering Cancer Center. She is currently a graduating student (with honors) of Farmingdale State College with concentrations in Bioscience and Chemistry.  She is also a current volunteer in the NY Cancer Resource Alliance as a communications assistant to the president and an assistant publisher of the monthly newsletter and educational awareness quarterly magazine-The Journal of Modern Healing.

CHERI AMBROSE, Co-editor/outreach coordinator for NYCRA
Cheri is the associate editor for various publications such as PinkSmart News, the Journal for Modern Healing and First Responders Cancer News.  She is a patient advocate for many cancer-related programs and often contributes her time in cancer research fundraising events.  As the communications director for the NY Cancer Resource Alliance, she manages community outreach, partnership missions with other cancer foundations and research organizations and attends educational functions for cancer awareness. Her latest public projects include the launch of ImmunologyFirst.org and ImplantScan.org.  She stands as the current President of the male Breast Cancer Coalition (MaleBreastCancerCoalition.org).






References:
4) Jems.com: Point-of-Care Ultrasound in the Prehospital Setting as the patient is being transported to the nearest hospital. https://www.jems.com/2018/02/01/point-of-care-ultrasound-in-the-prehospital-setting/
 5) What’s the difference between telemedicine and telehealth? https://www.aafp.org/media-center/kits/telemedicine-and-telehealth.html
7) Ambulances, Under A New Policy, Pick Up Only Emergency Patients, NYT: 8/1985-


Also see: (Coming soon: Part 2) TELEMED FOR COLLABORATION BETWEEN PROVIDERS



Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The AngioFoundation / the NY Cancer Resource Alliance /  IntermediaWorx inc). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.

Wednesday, October 16, 2019

Awareness TRULY Saves Lives- “Yes, Men Get Breast Cancer too”

Written by: Darleen Garza / TheRightWriters editorial staff

Ten years ago, if you inquired about male breast cancer at your annual physical, most doctors would likely dismiss your fears by responding about “how incredibly RARE, or improbable it was to contract this”.  This lack of public information is a common testimony from many male breast cancer survivors- the same dilemma that is now recognized as a main contributor to the expansion of this silent epidemic.

The term “RARE” is often misleading and alluding to something reversible and of little concern. When it comes to any health disorder, the limited numbers of cases showing are only the ones reported but are often skewed due to the ‘real’ count that would constitute a baseline- from the individuals that have not come forward to be counted.  According to the CDC, for any disease to capture EPIDEMIC proportions, it must “rises above the expected level, or baseline… where there is a [sudden] increase in the number of cases in that population in that area.”


BEYONCÉ'S DAD BRINGS "NEW AMMO" TO MALE BREAST CANCER BATTLE

Survivor Michael Singer (L) gives appreciation to Mathew Knowles (R) at
Dr. Oz show for going public with his breast cancer- bringing global
awareness & advocacy
Recent data reflecting actual cases about male breast cancer has finally reached the tipping point in the visibility scale as more news coverage from advocacy groups and victims finally ‘going public’ have filled the media.  Thanks to survivors like Mathew Knowles (music producer and father of Beyoncé) who elected to publicize his breast cancer significantly contributed to public awareness, identifying this issue as a serious threat to public health. 

“One of our main objectives at the Male Breast Cancer Coalition is to publish all survivor stories to alert the men at large that this is not a cancer to ignore… it’s not so RARE or IMPOSSIBLE to contact,” states Cheri Ambrose, president. “Learning about Mr. Knowles’ story from the newspapers and Good Morning America, and then sharing airtime with him at Dr. Oz was such a powerful sign of support to our advocacy mission because he elected to use his own story and his celebrity to get people to pay attention. This is the kind of generosity that can truly save a lot of lives just on pure awareness alone!” (See: Dr. Oz episode w/ Mathew Knowles interview)

In an October interview with the American Heart Association News, Mathew Knowles shared his new mission of advocacy and awareness hoping to save more lives from a disease that has now captured headlines as a global health alert. He detailed his rare gene mutation called BRCA2 as what the medical community identifies as the main cause for this cancer and possibly others. Sharing the entire road of discovering the first symptoms to having undergone a mastectomy on his right breast, Mr. Knowles has forged a national commitment to speaking out about breast cancer in men.   "My opportunity is to help people have awareness of the BRCA gene (mutation) and of male breast cancer…things happens for a reason. I'm grateful for this opportunity to save myself, hopefully save my family and hopefully impact the world in an extremely positive way."

“GET CHECKED NOW!”
The First Responders Cancer Resource was established in 2017 by a partnership between 9/11 survivors and medical experts in conventional and advanced cancer care. Their flagship catch-phrase “GET CHECKED NOW!” was partly designed for the many potential cancer targets in the firefighter community who needs to take a more proactive stance at annual exams and awareness about how cancer truly performs. Ms. Ambrose and the many ambassadors of MBCC adopted this tagline because of a similar dilemma among men who are either slow to act when it comes to finding anomalies like lumps on the chest area.  

Click to enlarge and print
“By now, we all know that dealing with cancer has everything to do with TIME… the sooner you detect it, the better the likelihood of reversing the problem,” states cancer imaging expert Dr. Robert Bard. “Where women have been conditioned to do self-exams regularly, finding irregularities (like lumps under the nipple or abnormal discharge) are not often part of a man’s health regimen.  Meanwhile, the medical community has a defined set of factors that help identify an increase in risks for breast cancer including age (60+), exposure to estrogen, obesity and liver diseases as this increases female hormones in men. The good news is that technologically, we have much more than the conventional mammograms… the cancer imaging community is equipped with new innovations such as the high-speed Advanced 3D Ultrasound that’s far more accurate and completely comfortable especially for men.”

Where the stigma of men having breasts and getting mammograms often sits awkwardly with the typical male ego, more and more victims are now sharing their stories at the MBCC website (and throughout mainstream media) with the hopes of waking up the men to GET CHECKED and accept this disease a major reality.  According to the American Cancer Society, 1 in 800 men will be diagnosed in their lifetime… and an estimated 500 men will die of breast cancer this year. From a recent interview, Dr. Stephen Chagares (breast surgeon) detailed how Male Breast Cancer is often identified and points to early detection for the best chance at survival.  “It’s either spotting a mass somewhere in the chest area or a strange discharge or a bloody nipple drainage… it’s better if you find these symptoms at an early enough stage but unfortunately it becomes actual breast cancer because they’re not identified until longer down the road.”

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Special thanks to the MALE BREAST CANCER COALITION

Disclaimer & Copyright Notice: The materials provided on this website are copyrighted and the intellectual property of the publishers/producers (The NY Cancer Resource Alliance/IntermediaWorx inc. and Bard Diagnostic Research & Educational Programs). It is provided publicly strictly for informational purposes within non-commercial use and not for purposes of resale, distribution, public display or performance. Unless otherwise indicated on this web based page, sharing, re-posting, re-publishing of this work is strictly prohibited without due permission from the publishers.  Also, certain content may be licensed from third-parties. The licenses for some of this Content may contain additional terms. When such Content licenses contain additional terms, we will make these terms available to you on those pages (which his incorporated herein by reference).The publishers/producers of this site and its contents such as videos, graphics, text, and other materials published are not intended to be a substitute for professional medical advice, diagnosis, or treatment. For any questions you may have regarding a medical condition, please always seek the advice of your physician or a qualified health provider. Do not postpone or disregard any professional medical advice over something you may have seen or read on this website. If you think you may have a medical emergency, call your doctor or 9-1-1 immediately.  This website does not support, endorse or recommend any specific products, tests, physicians, procedures, treatment opinions or other information that may be mentioned on this site. Referencing any content or information seen or published in this website or shared by other visitors of this website is solely at your own risk. The publishers/producers of this Internet web site reserves the right, at its sole discretion, to modify, disable access to, or discontinue, temporarily or permanently, all or any part of this Internet web site or any information contained thereon without liability or notice to you.

Wednesday, September 25, 2019

WHAT'S NEXT FOR ADVANCEMENTS IN IMMUNOLOGY?

Epilogue: 
CELLULAR WARFARE IN FULL SWING
By: Dr. Jesse Stoff  / Clinical Immunologist

Imagine having your own personal army of cells in your highly advanced defense system, working against outside invaders or abnormal cells where each cell type (over one hundred and eighty-seven recorded) carries their own dedicated function. This specialized team of cells work together to fulfill the complex mission of protecting the body from infection or illness each day. 

Our immunity or defense system works in three directives; the first is to (1) RECOGNIZE anything foreign and sound the alarm soon enough to thwart the invader. Molecules and cell surfaces that are identified as foreign are referred to as antigens and have the ability to elicit an immunogenic response. The second function is to (2) RESPOND to the alarm with enough of a counter attack to effectively neutralize the invader quickly. The third directive is to (3) REMEMBER what happened so that if the same situation were to arise again an effective response could be generated faster. The length and efficacy of the immune response depends upon the “intactness” of the underlying biochemistry.

During their lifetime, the cells of the immune system, based upon their experiences and exposures can change their cell surface antigens and their role in the immune response. More than any other organ or system in our body, the immune system is a dynamic system that can change. Like many other cells in our body, the cells of the immune system can be changed from the outside by drugs – Prednisone, Methotrexate, Humira, Remicade, and Plaquenil can suppress the immune system and thus, at least temporarily, help with certain inflammatory diseases, but they don’t heal or redirect the immune response.

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ENGINEERED KILLER T-CELLS COULD PROVIDE LONG-LASTING IMMUNITY AGAINST CANCER
UCLA researchers use stem cells to engineer cells that attack human tumors in mice 
Sarah C.P. Williams |

They’ve been called the “special forces” of the immune system: invariant natural killer T cells. Although there are relatively few of them in the body, they are more powerful than many other immune cells. In experiments with mice, UCLA researchers have shown they can harness the power of iNKT cells to attack tumor cells and treat cancer. The new method, described in the journal Cell Stem Cell, suppressed the growth of multiple types of human tumors that had been transplanted into the animals.  “What’s really exciting is that we can give this treatment just once and it increases the number of iNKT cells to levels that can fight cancer for the lifetime of the animal,” said Lili Yang, a member of the Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research at UCLA and the study’s senior author.

Scientists have hypothesized that iNKT cells could be a useful weapon against cancer because it has been shown that they are capable of targeting many types of cancer at once — a difference from most immune cells, which recognize and attack only one particular type of cancer cell at a time. But most people have very low quantities of iNKT cells; less than 0.1% of blood cells are iNKT cells in most cases.

Still, Yang and her colleagues knew that previous clinical studies have shown that cancer patients with naturally higher levels of iNKT cells generally live longer than those with lower levels of cells. “They are very powerful cells but they’re naturally present in such small numbers in the human blood that they usually can’t make a therapeutic difference,” said Yang, who also is a UCLA assistant professor of microbiology, immunology and molecular genetics and a member of the UCLA Jonsson Comprehensive Cancer Center. ­­

Lili Yang, UCLA Broad Stem Cell Research Center
The researchers’ goal was to create a therapy that would permanently boost the body’s ability to naturally produce more iNKT cells. They started with hematopoietic stem cells — cells found in the bone marrow that can duplicate themselves and can become all types of blood and immune cells, including iNKT cells. The researchers genetically engineered the stem cells so that they were programmed to develop into iNKT cells. 

They tested the resulting cells, called hematopoietic stem cell-engineered invariant natural killer T cells, or HSC-iNKT cells, on mice with both human bone marrow and human cancers — either multiple myeloma (a blood cancer) or melanoma (a solid tumor cancer) — and studied what happened to the mice’s immune systems, the cancers and the HSC-iNKT cells after they had integrated into the bone marrow.  They found that the stem cells differentiated normally into iNKT cells and continued to produce iNKT cells for the rest of the animals’ lives, which was generally about a year. “One advantage of this approach is that it’s a one-time cell therapy that can provide patients with a lifelong supply of iNKT cells,” Yang said. 

While mice without the engineered stem cell transplants had nearly undetectable levels of iNKT cells, in those that received engineered stem cell transplants, iNKT cells made up as much as 60% of the immune systems’ total T cell count. Plus, researchers found they could control those numbers by how they engineered the original hematopoietic stem cells. (See complete Press Release in: UCLA Newsroom)





This article is republished with the express consent of the UCLA NEWSROOM for the Journal of Modern Healing- produced by the NY Cancer Resource Alliance-for public use.  All distribution, sharing or re-posting of this article is only with the express permission of NYCRA ©2019- All Rights Reserved.    
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