Category: For Physicians

UW Medicine team performs first-in-Pacific Northwest living-donor liver transplant for metastatic colorectal cancer.

A Washington state woman is recovering after a landmark organ transplant that she hopes will end her nearly decade-long bout with cancer. Kris Anderson, 51, of Redmond, received a lobe of the liver from her daughter Lauren, 26, on Dec. 8. It was the Pacific Northwest’s first living-donor liver transplant for metastatic colorectal cancer.

Kris Anderson was discharged from UW Medical Center on Dec. 14, two days after Lauren. Both are recovering well at the family’s home, and both their livers will grow back to approximately 90% of the original size in three months.

“This holiday season has been so different than I imagined when we learned that my chemotherapy had stopped working this summer,” Kris Anderson said. “We thought I might have six to 12 months to live. To find out right before Thanksgiving that I was approved for transplant was powerful. I realized I’d have more time to make memories, like teaching my kids how to cook a turkey dinner.”

Dr. Mark Sturdevant led the surgeries, assisted by Drs. Patrick Healey in the resection of Lauren’s liver and by Ramasamy Bakthavatsalam in the transplant. They started Kris Anderson’s procedure first to confirm their belief, based on CT and PET scans, that the cancer metastasis was confined to her liver. Neighboring lymph nodes were removed and rushed to the pathology lab for assaying; the finding would determine whether the transplant proceeded.

When no cancer cells were detected, the team removed the right lobe of Lauren’s liver and transplanted it into her mom. The two surgeries encompassed nearly 12 hours.

“The transplant of a healthy liver into what we think is a cancer-free body gives Kris the best possible chance to live a normal life,” Sturdevant said. The patient has a 60-70% chance of five-year survival, Sturdevant said, with the caveat that the prognosis is based on an extremely small set of patient-outcomes data.

Colorectal cancer is the third leading cause of cancer-related deaths in U.S. adults, according to the American Cancer Society. In approximately half of those adults, the malignant cells also metastasize to the liver, and only 10-20% of these patients are able to undergo curative attempts to remove cancer surgically. The majority of patients undergo chemotherapy and/or radiation treatment, but only 10-20% survive five years or longer.

Organ transplant has long been discounted as an option for these patients, for several reasons.

First, the perpetual shortage of organ donors demands that available deceased-donor grafts go to patients with the best chance of survival – which does not describe patients with known cancer metastases. Another concern is that the immunosuppressive drugs that transplant recipients must take to stave off organ rejection would also lower their ability to fight a re-emergence of cancer.

Even if metastases were not a consideration, colon cancer does not impair liver function at nearly the rate as diseases such as cirrhosis and hepatitis. Deteriorated organ function is the main criteria for placement on transplant waiting lists, so most people with Anderson’s cancer would die before their liver deteriorates enough to qualify for a deceased-donor organ, Sturdevant said.

Only recently, in 2013, did doctors at the University of Oslo in Norway publish the rationale and protocol for liver transplants in patients with colorectal liver metastases.  In 2018, the Cleveland Clinic claimed the first such transplant in the United States. Uptake has been slow across U.S. hospitals, amounting to fewer than 25 transplants performed for this indication so far, said Dr. Roberto Hernandez-Alejandro, chief of transplant at the University of Rochester in New York. He has led five of these transplants and is creating a national registry of U.S. cases.

Sturdevant joined UW Medicine this year after developing proficiency in living-donor liver transplantation at the King Faisal Specialist Hospital in Riyadh, Saudi Arabia, and at the University of Pittsburgh, which today is among the handful of U.S. sites that perform liver transplant for colon cancer metastases.

Patients such as Kris Anderson, who meet the strict criteria for transplant, require the extraordinary gift of a lobe of the liver from a friend or relative whose blood type matches.

Anderson’s original cancer diagnosis came in December 2011, with her first colonoscopy. The tumor was surgically removed from her colon, but a month later the liver metastasis was discovered. Doctors employed several strategies, starting with chemotherapy – there were dozens of rounds over nine years, Anderson said – as well as radiofrequency ablation and radioembolization. The treatments appeared to have kept cancer from spreading beyond the liver, but failed to eradicate it and took a toll on the organ.

This summer, soon after Anderson learned that her recent chemotherapies had not improved her condition, UW Medicine-Seattle Cancer Care Alliance oncologist Dr. William Harris connected her with Sturdevant to explore the potential of a living-donor liver transplant.  It was quickly established that her two daughters shared Kris’ blood type, and Lauren, who lives in Portland, became the designated donor.

Reflecting on what helped her manage nearly a decade of late-stage cancer, Kris Anderson first pointed to support from family and friends and her diverse medical team. She also said investing time to research treatment options empowered her to advocate for herself, not only with her care team but also with her health insurance company.

“It’s important to be educated about the options available to you, which isn’t always easy.  It’s worth fighting for things like insurance coverage because there haven’t been that many of these procedures and it’s not considered the standard of care,” she said of her transplant.

“And I think it is very important to have hope. I hit Year 9, and I’m so thankful for that time with my family and friends – and now, for the possibility of more time to make memories.”

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Johns Hopkins Medicine researchers have shown that it is possible for solid organ transplant recipients who contract COVID-19 to experience a natural immune response to SARS-CoV-2, the virus that causes the disease. In their study, published online Jan. 19, 2021, in the journal Transplantation, the researchers also suggest that measures used to provide short-term immunity against SARS-CoV-2—such as convalescent plasma (which contains antibodies from patients who have recovered from COVID-19)—may actually reduce the natural response.

“We followed 18 transplant recipients who were taking immunosuppressive medications to prevent rejection and who developed COVID-19 post-transplant,” says study co-author Dorry Segev, M.D., Ph.D., the Marjory K. and Thomas Pozefsky Professor of Surgery and Epidemiology and director of the Epidemiology Research Group in Organ Transplantation at the Johns Hopkins University School of Medicine. “Our goal was to gain a deeper understanding of the immune response in these individuals so that clinicians will be better able to treat transplant recipients who get COVID-19, prevent their disease from becoming severe and develop vaccine protocols that fit their special needs.”

The study participants, all of whom were receiving immunosuppressive medication, represented a variety of organ transplants: nine kidneys, five liver, one kidney and liver, two lungs and one composite tissue allograft (composed of different tissue types, such as skin, muscle, bone, bone marrow, lymph nodes, nerves and tendons). The median age was 56, 56% (10) were female, 33% (six) were Black and 11% (two) were Hispanic. COVID-19 occurred at a median of six years following transplant surgery, with 89% (16) experiencing symptoms and 72% (13) requiring hospitalization. Five patients received convalescent plasma during their hospital stay. When the participants were screened for SARS-CoV-2 antibodies at a median of 98 days after the COVID-19 diagnosis, the researchers observed that most had antibody levels suggesting neutralizing immunity—the ability to prevent reinfection if exposed to the virus in the future.

Transplant recipients who had more severe cases of COVID-19, the researchers say, tended to have the highest antibody levels.

Interestingly, the researchers found that transplant recipients who received convalescent plasma or intravenous immunoglobulin (to reduce the risk of a serious inflammatory response) had lower natural antibody levels against the virus and, therefore, were less likely to have immunity.

“This raises the possibility that administered antibody preparations may blunt the natural formation of antibodies against SARS-CoV-2,” says Jacqueline Garonzik Wang, M.D., Ph.D., associate professor of surgery at the Johns Hopkins University School of Medicine and study senior author. “Larger studies will be needed to substantiate this finding, which, if proven, would be invaluable to COVID-19 vaccine protocol development for the immunocompromised.”

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When kidneys are removed from deceased organ donors in the United States, they are often subjected to “procurement biopsies” and are discarded if certain abnormalities are seen in the kidney tissue—a practice that worsens the already-severe shortage of transplant-eligible kidneys in the country. However, a large portion of the discarded kidneys would function acceptably if transplanted, according to a new study from a team led by researchers in the Perelman School of Medicine at the University of Pennsylvania and the Paris Translational Research Center for Organ Transplantation.

In the study, published today in the Journal of the American Society of Nephrology, the researchers analyzed biopsy data on a series of 1,103 kidneys discarded in the U.S. between 2015 and 2016. They found that 493 of these kidneys could be matched, in terms of biopsy-evaluated quality and other donor characteristics, to 493 kidneys that were actually transplanted in France, where transplant practice is less restrictive.

The researchers then examined the performance of these 493 kidneys transplanted in France and found that their survival rates were acceptable—93 percent at one year, 81 percent at five years, and 69 percent at 10 years—indicating that many donor kidneys in the U.S. are being discarded unnecessarily.

Analyzing a larger set of kidney transplants in France for which biopsy data were available, the researchers concluded that the biopsy data added no value in terms of making predictions of transplant failure more accurate.

“These results highlight a lost transplant opportunity in the U.S., and provide a strong rationale for organ procurement organizations to reduce the practice of obtaining biopsies of deceased donor kidneys,” said study lead author Peter Reese, MD, MSCE, an associate professor of Renal-Electrolyte & Hypertension and Epidemiology in the Perelman School of Medicine at the University of Pennsylvania and a kidney transplant physician at the Penn Transplant Center.

The study was a collaboration involving several medical centers in the U.S., France, and Belgium, co-led by Olivier Aubert, MD, Ph.D. and corresponding author Alexandre Loupy, MD, Ph.D., of the Paris Translational Research Center for Organ Transplantation.

The shortage of kidneys for transplantation continues to be a public health crisis in the U.S. More than 90,000 patients are waiting for kidney transplants, yet only about 20,000 transplants are performed each year. Annually, nearly 5,000 people on the transplant waiting list die without getting a transplant.

Deceased donors provide roughly two-thirds of transplanted kidneys, but thousands of deceased-donor kidneys are discarded annually in the U.S., due to abnormalities seen in procurement biopsies. Studies suggest that most discards are due to a finding of substantial glomerulosclerosis, a condition that can be caused by age or diabetes, for example, and involves the scarring of small blood vessels in the kidney. However, research also suggests that the reproducibility of procurement biopsy findings is poor.

Moreover, kidney transplants in several European countries are usually done without procurement biopsies and are therefore less likely to be discarded. A study published last year by the same research team found that French transplant centers are much more likely that U.S. centers to accept kidneys from older deceased donors. In fact, the average age of French deceased donors is more than 15 years older than deceased kidney donors in the U.S.

The findings from this new study underscore the notion that pre-transplant biopsies don’t seem to add value to the kidney transplant process, and in fact, tend to make things worse by reducing the supply of kidneys that could benefit recipients.

“Transplant center staff should understand that procurement biopsy results only contribute limited meaningful information about kidney quality,” Reese said. “In some cases, those biopsies may add bad information. And unfortunately, those biopsies come at a cost—in terms of delays, dollars and occasionally, complications.”

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Bacterial keratitis is an infection of the cornea (the clear dome covering the colored part of the eye) that is caused by bacteria. It can affect contact lens wearers, and also sometimes people who do not wear contact lenses. Types of bacteria that commonly cause bacterial keratitis include:

• Pseudomonas aeruginosa
• Staphylococcus aureus

Bacteria are common in nature and found in the environment and on the human body. Pseudomonas bacteria can be found in soil and water.

Staphylococcus aureus bacteria normally live on human skin and on the protective lining inside the body called the mucous membrane. Bacterial keratitis cannot be spread from person to person.

Managing Bacterial Keratitis often is not a straightforward process. Several controversies surround its diagnosis and treatment.

WHAT TO DO – TO CULTURE OR NOT?

The current preferred practice recommendation for most cases of keratitis is empiric therapy without performing smears or cultures.

The cases that fall under this recommendation have a peripheral corneal ulcer smaller than 2 mm and no stromal melting, however, physicians can opt to culture with the use of vital stains for cultures and corneal scrapings.

Cultures and smears are needed in cases with a corneal infiltrate that is central; large; in the middle to deep stroma; chronic or unresponsive with atypical clinical features that suggest fungal, amoebic, or mycobacterial keratitis; and in patients with a vegetable trauma or who wore contacts while in a hot tub.

Culturing is important to identify the organism, determine antibiotic sensitivity, guide therapeutic modifications in unresponsive patients, decrease potential toxicity caused by unnecessary medications, and categorize microbial pathogens by examining stained smears of corneal scrapings.

Scanning laser confocal microscopy is useful in the diagnostic process to view the various corneal layers. Recent advances in this technology facilitate enhanced resolution and microscopic power making it useful to diagnose infectious keratitis including bacterial, fungal, and especially parasitic organisms.

IN LIGHT OF THINKING SURGERY

A therapeutic keratoplasty is indicated in patients with progressive ulceration, extensive corneal involvement, the presence of a descemetocele, and perforation. Keratoplasty is performed in 3% to 6% of all bacterial ulcers, with the most common pathogens being Staphylococcus and Pseudomonas species.

The microbial cure rates range from 90% to 100% and 69% to 100% have a clear graft at 1 year. However, the timing of the surgery can be critical. A slight delay in the surgery improves the surgical outcome.

Antibiotic administration carries the hope of sterilization and corneal transplantation before further melting, perforation, or complications develop.

THERAPHY COMBINATION OR MONOTHERAPHY?

There was always a question regarding the use of commercial fluoroquinolones or fortified antibiotics from a compounding pharmacy. Empiric therapy to treat bacterial keratitis with topical fluoroquinolones and/or fortified antibiotics, such as cefazolin, vancomycin, and tobramycin, can be considered.

This approach includes a loading dose every 5 to 15 minutes for the first hour and then applications every 15 minutes to 1 hour around the clock. The preferred treatment in most cases is topical antibiotic eye drops, which can achieve high tissue levels.

Application of ointments can be useful at bedtime for cases that are less severe, as well as an adjunctive therapy. Topical broad-spectrum antibiotics are used initially in the empiric treatment of bacterial keratitis.

For patients who have central or severe keratitis such as that extending into the deep stroma or when an infiltrate exceeds 2 mm with extensive suppuration, a loading dose as mentioned previously is needed and is followed by frequent instillations.

With less severe keratitis, less frequent dosing is appropriate. Monotherapy with fluoroquinolone is as effective as a fortified combination therapy with ciprofloxacin 0.3%, ofloxacin 0.3%, or levofloxacin 1.5%, all of which are approved to treat bacterial keratitis.

In vitro studies, besifloxacin, gatifloxacin, and moxifloxacin have been shown to cover gram-positive pathogens better compared with the earlier-generation fluoroquinolones.

However, these drugs are not FDA-approved to treat bacterial keratitis, despite the results of randomized controlled trials that reported that moxifloxacin and gatifloxacin were equivalent to the combination of fortified cefazolin/tobramycin and possibly better than ciprofloxacin.

Fluoroquinolone monotherapy to treat corneal perforation needs to be confirmed in future studies. Some retrospective studies reported concerns about increased risk associated with monotherapy in patients with severe bacterial keratitis compared with the use of fortified topical antibiotics, ie, cefazolin and tobramycin.

Combination therapy should be used to treat severe unresponsive infections, for nontuberculous mycobacteria, and for methicillin-resistant Staphylococcus aureus from a compounding pharmacy.

Systemic antibiotics, although rarely needed, can be used in severe cases of keratitis in which the infection has entered adjacent tissues, for impending or frank perforation, and for gonococcal keratitis.

ADJUNCTIVE KERATITIS TREATMENTS

These treatments include cycloplegic agents and a collagen shield or bandage contact lens to increase the antibiotic concentration. A bandage contact lens also can be considered for stromal melting as well as vitamin C, topical medroxydrogesterone, topical N-acetylcysteine, and oral tetracycline.

Crosslinking for infectious keratitis may be beneficial for treating moderate bacterial keratitis. The procedure accelerates epithelialization, shortens the treatment course, and minimizes or negates the need for surgery and other serious complications such as perforation.

The use of steroids in keratitis is controversial and remains inconclusive, in that no increased risk of adverse events has been found, and steroids may improve outcomes with large central ulcers and severely decreased visual acuity.

No benefit has been seen in Nocardia keratitis. The take-home message regarding keratitis therapy is to culture if the lesion is large, serious, or unusual; administer sufficient medication in a timely manner; carefully monitor therapeutic and adverse effects; and consider referral of Descemet’s anterior lamellar keratoplasty or penetrating keratoplasty early, but not too early.

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When we perform cataract surgery for patients with retinal disease, we must tailor the IOL type, design and power to maximize vision given the underlying pathology.
The IOL type that we will most often utilize is a monofocal optic, with or without toric correction. We will sometimes prefer a three-piece IOL design because it will give more options for placement or future suture fixation. For the IOL power consideration, a target of Plano or mild myopia is typically recommended, with care taken to adjust the dioptric strength based on the anticipated effective lens position.
For patients with

For patients with extreme myopia, cataract surgery can be a great blessing because we can correct 20 D of refractive error at the same time. We must first ensure that the retinal periphery is stable and without breaks and that the macula is free from pathology. When we replace the 4-mm thick cataractous lens with the new 1-mm thin IOL, there will be a shift of vitreous, which may induce a posterior vitreous detachment. This shifting vitreous can also place stress on the retinal periphery and can induce a retinal break or even detachment. For this reason, these patients should have their retinas examined in the postoperative period. With extreme axial myopia, lifetime follow-up with a retina specialist is recommended because the development of some degree of retinal pathology is almost certain in the future.

While there is a temptation to give these extremely myopic patients a Plano outcome with 20/20 distance vision, this is usually not the best option. IOL power estimation is less accurate in these eyes given the long axial lengths and the need for specialty lens designs such as a meniscus optic. Using modern IOL power calculation methods, it is recommended that a refractive target of mild myopia is selected. Going from –20 D to –2 D is a tremendous gift for the patient, and it ensures that a hyperopic refractive surprise is avoided. In some extremely myopic patients with macular pathology, an even closer focal point may be desired, necessitating a target of –3 D or more. Monofocal IOLs are often the best choice, particularly because other lens designs may not be available in these extreme dioptric powers.

Retinitis pigmentosa

Patients with the progressive disease retinitis pigmentosa tend to develop cataracts at an early age. There are also special considerations for their cataract surgery because they are at higher risk of capsular phimosis due to weakened zonular support and of cystoid macular edema due to chronic inflammation. Monofocal IOLs are the best choice in these patients with a target of about Plano. In some cases, three-piece IOL designs are favored because they provide more options for suture fixation in the future if there is a dislocation of the IOL-bag complex. Capsular tension rings may also be useful in some cases, and patients should be treated with topical anti-inflammatory medications for an extended period of time. While a toric IOL can be a good option for patients with a significant degree of corneal astigmatism, we should avoid using light-splitting optic designs, which can decrease contrast.

Post-pars plana vitrectomy

After performing a vitrectomy, particularly if intravitreal gas is used, a cataract tends to develop in the next year or so. If a white cataract develops within the first month after the pars plana vitrectomy, there may be a compromise of the lens capsule. This is rare, and most patients develop a nuclear cataract more gradually. While performing cataract surgery in a post-vitrectomy eye, there is less support of the crystalline lens due to the loss of vitreous and lack of anterior hyaloid face support. When we implant the IOL, we can also expect that the effective lens position will be slightly more posterior, and therefore we should increase the IOL power slightly, usually by about 0.5 D. Monofocal IOLs tend to be the best choice, particularly if there is a history of macular pathology. Three-piece IOL designs may offer more options for placement in cases of compromised zonular support.

Retinal vascular disease

The most common retinal vascular diseases that we see are related to diabetes and hypertension. These disease processes tend to occur slowly over the course of years, but acute conditions such as retinal vein occlusion can happen suddenly. Cataract surgery should be delayed until the retinal disease is treated and stabilized. Patients with preexisting macular edema may end up with more fluid accumulation and worse retinal status after cataract surgery. In addition, even when the underlying retinal vascular disease is quiescent, the retinal status may not return to normal levels. This makes placing a light-splitting lens, such as diffractive multifocal or extended depth of focus designs, a suboptimal choice. For most of these patients, a monofocal IOL with a target of about Plano is the best option.

A significant portion of our cataract surgery patients have underlying retinal pathology, and we should tailor the IOL selection and technique of phacoemulsification to their condition. In most cases, this means a monofocal IOL and a target of Plano to mild myopia. While we may not be able to return these patients to perfect vision due to the preexisting retinal disease, we can greatly improve their vision with cataract surgery and the appropriate IOL choice.

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Surgical and injectable drug approaches are equally effective for the treatment of bleeding inside the eye from proliferative diabetic retinopathy (PDR), according to a National Eye Institute (NEI)-supported clinical study from the DRCR Retina Network (DRCR.net). A consequence of diabetes, PDR involves the growth of new, abnormal blood vessels in the light-sensing retina. These blood vessels are prone to bleeding into the gel-like vitreous that fills the eye, causing vision loss. NEI is part of the National Institutes of Health.

Researchers compared anti-vascular endothelial growth factor (VEGF) eye injections versus removal of blood via vitrectomy surgery and laser photocoagulation. Both treatments improved central vision for the majority of participants, although approximately one-third of the participants needed both anti-VEGF injections and surgery. The findings will help guide treatment for people with bleeding in the eye from PDR. The results were published in the Journal of the American Medical Association.

“This clinical trial was an opportunity to compare two commonly used treatments for vitreous hemorrhage from proliferative diabetic retinopathy head-to-head. The results provide useful guidance for clinicians who are managing patients with this condition,” said Adam Glassman, Jaeb Center for Health Research, director of the DRCR.net coordinating center.

Vitrectomy surgically removes the blood from inside the eye. To prevent more blood vessels from forming, vitrectomy is usually paired with laser treatment (laser photocoagulation). This treatment often restores central vision, but the laser treatment may reduce peripheral vision. More recently, NEI-supported trials found that anti-VEGF injections into the eye help control PDR and other diabetic eye complications. These drug treatments decrease the growth of blood vessels in the eye and prevent rebleeds while the blood in the vitreous is being absorbed.

“Over the past 15 years, the DRCR Retina Network has performed trials that have helped set the standard of care for diabetic eye disease,” said Jennifer Sun, M.D., Harvard University, Cambridge, Massachusetts, chair of Diabetes Initiatives for the Network. “There have been major advances in surgical technology and technique since the initial studies that evaluated surgical treatment of PDR. This latest DRCR Retina Network study lets us understand how outcomes in the modern era of retinal surgery compare to treatment with intraocular anti-VEGF injections for vitreous hemorrhage from PDR.”

In this new clinical study, the DRCR Retinal Network team compared these two standard treatments to see if either was more effective in improving visual acuity over two years. Of 205 participants, 100 were assigned an anti-VEGF drug, aflibercept (brand name Eylea), and 105 were assigned prompt vitrectomy and laser photocoagulation. The researchers tracked best-corrected visual acuity over two years. At four weeks, visual acuity in the surgery group was significantly higher than the anti-VEGF group, but by 24 weeks, the visual acuity in the anti-VEGF group had caught up to the surgery group. Visual acuity was similar between the two groups out to two years. Approximately one in three participants in each group eventually received both types of treatments to help control their PDR during that time.

“This is a very common disease for patients with diabetes- particularly after living with diabetes over several decades. For patients who are experiencing visual loss from bleeding due to PDR, these strategies are both excellent treatments and can improve and then preserve visual acuity over six months to two years,” said Sun. “But there are some subtleties to this study that will help clinicians tailor their treatment plans for an individual patient.”

For people with severe bleeds or who need to improve their vision quickly, surgery results in more rapid improvement, Sun said. But for people who cannot receive surgery or prefer to avoid surgery if possible, anti-VEGF treatment still leads to equivalent visual outcomes over the long term.

“About a third of our study participants ended up needing both treatments,” said Glassman, “so we think it’s critical that people continue to follow up with their clinicians after starting treatment for PDR, because they may need to adjust their treatment along the way to get the best outcome.”

An estimated 30 million Americans have diabetes. Blood vessel abnormalities, including the growth of new blood vessels, are common in people with diabetes. PDR can lead to retinal tissue death, permanent vision loss, and eventually blindness in some patients. Prior to the development of surgical and laser treatments to remove the blood and regress abnormal blood vessel growth, PDR was a leading cause of blindness in the United States.

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A recent experience in the operating room helped shape my go-to answer for a question I’m frequently asked: “Why should I, as an OMS, invest in research?”

During a procedure when the pathologist had to make a “close call” assessment, I was able to provide assurance that our decision was supported by data from an IRB-approved research study of 30 patients undergoing the exact same protocol.

I also explained that by combining information from that study with our studies on the depth of invasion, we had spared numerous patients from unnecessary neck dissection. Furthermore, the chances for under-treatment (requiring a second trip to the operating room) were very small. Armed with that knowledge, we proceeded with precision and confidence in our decision.

Like you, research regularly impacts my daily practice and benefits my patients by optimizing the safety and efficiency of the care I deliver. Whether you have conducted the research yourself or learned from the work of another is not important. As OMSs, we count on the expertise of researchers to provide us with tested and verified solutions to an array of questions.

Our specialty must invest in research and discovery in order to stay relevant. We need to continually advance in every aspect of our field, and we need reliable data to support our best practices in a rapidly evolving professional and regulatory landscape.

The OMS Foundation Committee on Research is charged with evaluating every qualified grant proposal and transmitting a set of recommendations to the Board. We rate each proposal for the robustness of the science but also for the relevance and significance of the scientific question to our profession. Some of our most pressing needs are in areas in which all of us practice, such as office-based anesthesia. The committee gives significant consideration to proposals that address these shared areas of interest because they have the potential to impact the entire specialty.

In addition, it is our expectation the Foundation’s new Clinical Research Support Grant – by encouraging promising lines of patient- and outcome-oriented research – will ultimately provide higher levels of evidence to support the care we all deliver.

There is no question now is the time for all of us to invest in the future of our specialty by supporting research and discovery. The challenges we face are far too urgent to justify a delay.

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Bone disease is becoming increasingly prevalent due to population aging, among other factors, and the use of dental and orthopedic implants to treat bone disease has been on the rise. The history of implants can be traced back all the way to A.D. 1 when wrought iron dental implants were used in Ancient Rome. Despite the long history, however, there are still a number of issues associated with implant procedures, such as a loose implant resulting from slow integration into the bone tissue or inflammation necessitating a secondary surgical procedure.

To mitigate these issues, there has been an attempt to coat implant materials with “artificial bone” that has the same composition as the actual human bone. Conventional coating methods, however, require a synthesis process to manufacture the artificial bone material and a separate coating process, all of which is time-consuming. Plus, the binding between the substrate and the artificial bone coating layer tends to be weak, resulting in damage or even drop-off, and strong coating methods that could be applied to actual patients in a clinical setting were rare.

Under these circumstances, Dr. Hojeong Jeon’s research team at the Korea Institute of Science and Technology (KIST) Center for Biomaterials announced that they have developed a ceramic artificial bone coating with triple the adhesion strength compared to conventional coating materials.

The research team developed a technology to induce artificial bone coating in just one hour using a single process; such procedures had previously taken a day and required dozens of steps. There is no need to synthesize the raw material for artificial bone coating in a separate process, and it is possible to create the coating with a nanosecond laser without any expensive equipment or heat treatment.

Additionally, it is possible to form a coating layer with a stronger binding power than the few artificial bone coating techniques applied clinically today. The process results in a robust coating, not only on metal surfaces but even on the surfaces of polymer materials such as orthopedic plastic implants, which has not been possible with conventional processes.

In order to reduce the number of steps involved in the process while ensuring robust coating, Dr. Jeon’s team positioned the material to be coated in a solution containing calcium and phosphorous, the main components of bone and irradiated it with a laser. The temperature was raised in a localized manner at the target site of the laser, causing a reaction involving the calcium and phosphorous to produce ceramic artificial bone (hydroxyapatite) and the formation of a coating layer.

Unlike conventional coating methods, the synthesis of the artificial bone component is induced via laser and the surface of the substrate is heated above the melting point. The artificial bone material is adsorbed on the melted surface and becomes hardened, which maximizes the binding strength.

Dr. Jeon said, “The hydroxyapatite coating method using nanosecond laser is a simple way to induce bioactivity in non-bioactive materials such as titanium and PEEK, which are commonly used as biomaterials. I anticipate that it will become a game-changer in that it will have wide applications to diverse medical devices where osseointegration is needed.”

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The dark pigmentations that appear around the gums on dental enamel have a bacterial origin and there is currently no definitive therapy to remove it entirely. In order to find the best way to fight against the creation of these black stains on teeth, the Oral Microbiology Group of the CEU Cardenal Herrera University (CEU UCH) of Valencia, Spain, has conducted the first study in the world with adults on the metagenomics of dental black plaque, in collaboration with company Microomics Systems S.L, whose headquarters are in Barcelona. “Although in previous studies we assessed the efficiency of phototherapy in the treatment of these stains on the enamel, knowing the metagenomics of this type of dark plaque of bacterial origin will allow us to progress in finding definitive treatments for its removal,” highlight the study authors.

In their work, published in the journal Scientific Reports, the CEU UCH and Microomics Systems researchers have described and compared the microbial diversity of dental white plaque and the black stains that appear on them, on a total of 27 volunteer adults, all of which are receiving treatment at the University Dental Clinic of the CEU UCH in Valencia. The characterization of the taxonomic profile of the samples and comparing the microbiomes of white and black dental plaque is a study that had only been performed on children, who most often suffer from these types of stains.

The first map of the microbiome of dental black plaque

With this data, the CEU UCH team has created the first map of the microbiome of dental black plaque in adults, finding that the variety of bacterial species is lower than in dental white plaque. The five most common bacterial species found in the dental black plaque of the adult studies were from the Capnocytophaga, Leptotrichia, Fusobacterium, Corynebacterium and Streptococcus genuses. The study also made it possible to detect the existence of functional routes among the microbiomes of white and black dental plaque.

“We have found that the key for the formation of dental black plaque are the routes of biosynthetic compounds of the heme group, which would explain the black color,” highlight the researchers. The sequestration of iron by the bacteria of the black plaque and its subsequent metabolism towards biosynthetic routes of the heme group is essential for the formation of this type of plaque, the study reveals. This finding, along with new research for its complete description, will make it possible to progress in the designing of treatments that prevent the appearance of dental black plaque in the most effective way.

The Oral Microbiology Group of the CEU UCH published in 2018 a pioneering study on the use of antimicrobial phototherapy to fight, with light and oxygen, against the proliferation of the bacteria that cause the black stains on the enamel or dental black plaque. Using a household tooth whitening device, they managed to decrease the size, color and bacterial colonization of the dental black plaque closest to the gums in the group of patients who took part in the test. In prior studies, they also analyzed the risk factors for the appearance of these black stains, such as water with high iron contents of high pH, which is why they recommend consuming mineral water instead of tap water or osmosis water for people who are prone to having these black pigmentations appear on their enamel.

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Chronic pain can be devastating.  You wonder if you’ll ever feel normal again.  You’ve tried everything…. pills, chiropractic, miracle cures, injections.  Or you spend time trying to find the right surgical solution, but no one can guarantee that surgery will fix the problem and might even make it worse.  You wonder if you’ll have to live like this forever.

Pain is tricky.  It’s different for every human, and every human responds to pain differently.  Acute pain is typically caused by tissue damage.  Most of the time, once tissues heal, the pain goes away.  However, for some people, even though tissues are healed, the pain does not go away.  The nervous system ramps up and over-responds.  This is considered chronic pain. 

The natural response for a body in pain is to cease movement, freeze, and immobilize. This is true for both acute and chronic issues plaguing any living, breathing human. And that’s okay! It’s nothing more than our protective instinct saying, “Hey, that’s not safe, how about play over here in the baby pool,” as if your mother was giving you a gentle warning. After a few days, we go back to our normal movement tendencies and routines. But in the case of chronic issues, that voice becomes louder, like when your mother calls your first AND middle name in one warning. That’s when things begin to get serious. Your brain is simply trying to get your attention.

Chronic pain is a very complex phenomenon, and the top researchers are just starting to understand it. On one hand, you have John who broke his leg and recovered easily after two surgeries and rehab. On the other hand, you have Jane, who has never broken a bone or been in an accident but suffers from chronic back pain that has persisted for years. Why? Because chronic pain is an experience, not a tissue issue. Chronic pain evolves due to the over-amplification of our nervous system’s response to a perceived threat. It can be magnified due to physical stress on the body or even emotional stress, such as anxiety or depression with or without any actual physical injury (McGonigal 2009). Some might see this as bad news when this becomes the diagnosis, losing hope that they’ll never recover.

But there is good news.

Because experiencing chronic pain is an imperfection in the mind-body relationship, relief comes from reestablishing that relationship. This is the perfect time to involve a Physical Therapist to help you design a plan of action. You may find yourself mixing manual therapy with other treatment methods. Your brain and body can be re-trained to understand a new normal.

Advances in neuroscience have refined our understanding of chronic pain, and our physical therapists now incorporate pain neuroscience interventions into treatment for patients with Chronic Pain.

1. Chronic pain can be reduced, managed, or sometimes eliminated with pain neuroscience education (PNE).
2. Our PTs incorporate PNE into treatment in many ways.

PNE Personalized Treatment Plans 

Your Physical therapist understands all pain is real. Your PT can design a treatment plan that is specifically targeted to treat chronic pain, which they know how to deal with.  This contrasts with acute pain, which often serves a useful purpose, such as alerting us to danger or incorrect movements and is self-limiting.

The first thing physical therapists do during treatment is to do a thorough evaluation and identify causes and contributors to a patient’s pain. Once this is identified, and the patient’s mobility and functional goals are clear, the therapist will design a treatment plan that deals specifically with the patient’s pain contributors. This is often a combination of exercise, manual therapy, stress management, sleep hygiene, and pain neuroscience education. New advances in healthcare technology have allowed us to treat chronic pain even more efficiently through pain neuroscience education.

The longer you ignore pain, the worse it often gets. If you’re looking to connect with a chronic pain specialist, our team is ready to help. Reach out today for a discussion and evaluation with our Physical Therapists to find a treatment plan that works for you. We’ve made speed a priority with quick and easy scheduling.

Yoga for Chronic Pain

Yoga works to mend that connection through breath, movement, and awareness—and it doesn’t require you to sweat or stand on your head. Through physical exercise or movement, the brain can release chemicals to suppress physical pain (Dietrich, McDaniel 2004). What’s even better? Mindfulness and meditation can also play a role in reducing future pain signals by calming down that, over-amplified alarm system—all of which can be done from your home or even bed, and don’t require you to purchase the latest yoga pants.

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