PRESENTER 1: DR.
MENA RAMOS
Thank you so much
for, for being here. My name is Dr. Mena Ramos. I'm a family physician by
training and co-founder of the Global Ultrasound Institute. I am so honored to
be sharing the stage with Dr. Bard. We will be leading a discussion, um, about
advances in portable non-invasive imaging, specifically elastography microvascular
imaging, thermography and point of care ultrasound in the evaluation of breast
and liver disease. And we will be exploring these concepts within a global
framework. Disclosures. Um, I'm the co-founder of Gussie, and we have received
grant funding from various, um, foundations, including the Gates Foundation.
I wanted to just
start off our talk by taking a step back and, and looking at the global
landscape today. There continues to exist diagnostic deserts, meaning areas of
the world where access to diagnostic imaging continues to be a, a, a serious
limitation. In this Lancet paper, approximately half of the world, that's 4
billion people. And when we take a look at even more advanced modalities like
elastography, like thermography, microvascular imaging, that percentage is even
lower. And some places 10 to 30%, really depending on the country in which you
live, whether you live in a city or a rural area, what kind of insurance access
you have.
And so I wanted to
take a step back and frame our conversation within this larger global
framework, because I think it's important to contextualize all of these
different applications that we're gonna discuss. Typically, these advanced
applications are not, um, discussed with POCUS in the same sentence. They're
usually very separate. And so how and why are we bringing point of care
ultrasound into the conversation? And what is pocus? There have been many talks,
case studies, um, at this conference, uh, related to POCUS point of care
ultrasound. Um, and I think it's important to remember that in addition to
being, or a, in addition to, uh, displaying how technology has advanced and
become more portable, but it's also a workflow, a re-engineering of workflows
that streamline a clinical workflow wherein a clinician, a provider, a
clinician, is both gathering information, gathering data, performing a scan,
and also interpreting that scan.
We've seen how this
can and can both narrow a differential diagnosis when appropriate or expand a
differential diagnosis, lead to potential cost savings and, um, um, speed up
referrals or eliminate the need for unnecessary referrals. Um, uh, I think it's
important to just, you know, think about how streamlined workflows can be, um,
can be helpful when it comes to, to addressing this, um, this gap in access to
imaging overall. Now thinking about this, these streamlined workflows, this is,
has been accelerated by advances in technology. I was having a very interesting
conversation yesterday with Dr. Reinhardt, who I asked, what has been a
surprise over the last, you know, several decades in the, in, in, in your
experience in the ultrasound world? And it's been how, how technology
specifically image and image quality has improved every, every one to two
years. There are, there are new developments, um, uh, across the industry that
have led to improved, um, image quality portability.
Certainly. Um, we've
seen more and more, uh, options in terms of, um, uh, portable devices. And in
addition to that technological advancement, interconnectivity. So, uh,
interconnectivity that allows expertise to be paired with, um, uh, with
learners with less expertise. So it's facilitated training, it's facilitated
quality assurance, um, gathering of data and analytics and study. And I won't
even get completely dive into, um, the new advances in artificial intelligence,
um, which we are seeing more and more of. And so when we take a step back and
think about point of care ultrasound, uh, ultrasound is a paradigm, both in
terms of streamlined clinical workflows and advances in technology. What makes point
of care ultrasound, uh, powerful is that it's taken within a specific context.
So what do I mean by context? Well, first, there's the clinical context, right?
Um, it's the taking into account not only an image, but how does that relate to
a patient's presentation, history, physical exam, other ancillary studies.
What is the pretest
probability? What is the clinical question being answered here? What are the
limitations to the scan? Um, and so there's the clinical context, but there's
also the context within the system in which a patient and their healthcare
provider are working. And so how does this, how does this data impact
management? How does this data impact, um, uh, referrals or, um, what are the,
the treatment options or what is the workup that that, um, uh, can be, uh,
performed as a result of being able to answer this question? And so the
clinical context, both at an individual level, but also at a systems level, um,
are, um, are greatly impacted by and impact how point of care ultrasound as a
workflow and as a technology, um, can be utilized. And so if we continue to
take a step back and look at the big picture, the global landscape, um, looking
at and seeing the, uh, top 10 leading causes of death across, um, the world and
low income countries, we see that this is a, um, the technology itself can be
applied to a wide array of illnesses that contribute a significant burden of,
uh, of, uh, morbidity and mortality globally.
And so the, this
solution, um, or this workflow and technology combined have the potential to
impact many, many, many lives across the spectrum of care, um, across multiple,
across multiple specialties. And just to round out our, our introduction into,
um, advanced imaging at the point of care, I just wanted to take a moment to
look at, um, uh, to look at health within a global policy lens. Because how do
we transform health systems, including, uh, funding? And how do we connect
these dots to improve good health and wellbeing if we don't have the language
for it at a global scale? And so the sustainable development goals are, uh,
useful, um, uh, to give us that language. And as you can see, number three is,
is the most obvious application, good health and wellbeing, but also number 10,
reduce inequalities. We've also seen number four and number five being impacted
by, uh, point of care ultrasound, um, uh, projects.
I won't spend too
much time on po within this framework. Um, uh, but I do want to use that as a
jumping off point to begin to address, um, take one step further in, um, in
advanced noninvasive imaging. Is it audacious to even propose that this could
be a point of care tool? How can that play a role within a global health and
global framework where as we know, half of the world, if not more, still has
very limited access to imaging. Um, and so with this, you know, with this
framework of point of care ultrasound, both as a workflow and as a technology,
uh, contextualized, I wanted to take one step further and introduce advanced
noninvasive imaging, more specifically elastography, thermography and
microvascular imaging. And thank you all, um, for, for, for being here. I see
some familiar faces across both academia and industry.
So it's great to
have this, um, uh, this, this gathering of minds. Um, and, uh, without further
ado, I, um, want to, um, uh, introduce Dr. Robert Bard, uh, who has been a
pioneer in the field of radiology and ultrasound. Um, and also, uh, as a
pioneer ear in how workflows can be re-engineered, keeping the patient in the
center of the equation. How do we do what makes sense, um, and improve patient
care and push the envelope. Um, and so Dr. Bard, um, will go through a series
of cases, um, with respect to these advanced, um, par, uh, with advanced
advanced your hand.
PRESENTER 2: DR.
ROBERT BARD
I'm inviting
audience participation in this 'cause I've been around a long time. But the
more important things is we have technologies that have changed in ultrasound.
So ultrasound is replacing many technologies. Uh, point in specific example, I
wrote two textbooks on MRI of prostate ultrasound textbooks. An MRII used to
send out five MRIs a day. I send out maybe one a year now, and only for pelvic
lymph nodes because the equipment is so good. We have 3D imaging, we have
elastography. Um, one of my colleagues and I gave a talk last year on
elastography of, uh, prostate cancer. So the future is here. We simply have to
apply it. That's the <laugh>, that's the thing. Alright, let's take a
clinical case. So somebody walks into the office and everybody can see the
enlarging breast mass. Well, first of all, what can't you see in this picture?
Let's start with what you can't see. You can't see under the breast, you can't
see the xi. Of course, you look at the, uh, infraclavicular lesions and you see
there's something going on, but you don't know what. Now the, the scan itself,
we always scan the both sides first, just a simple complex hiss with hive
through transmission, not a problem.
Then we look at the,
the enlarged breast rest, and we see we have a mass lesion and notice it's
extending into the dermis. And with our imaging, we see epidermal involvement.
And that's another interesting point. If somebody's got a mass, is it affecting
the skin, which will affect treatment and prognosis? This is what you couldn't
see under the breast. There were two very small lesions. This is magnified. And
with the microvascular imaging, you can see the 3D showing that it's vascular.
And of course, the composite of 3D imaging. Now 3D imaging probes, they're big,
they cover the whole area. And we do this in 10 to 15 seconds. A thyroid, 10 or
15 seconds. The, uh, prostate maybe takes, uh, 30 seconds to get 200 imaging.
So again, the future is here. It simply has to be applied. Okay, now let, let's
look at the axilla. So once you've got the probe and a patient, tell me about
staging. What do you do next? Anybody in the audience? Nobody wants to stage
this patient.
Well, routinely,
this is what we do. You see the axilla, it's full. Here's the redness again, 3D
image, which shows irregular borders extending up to the dermal lower dermal
border. And again, the beautiful 3D composite. Now, what can you do with 3D
volumetric imaging? Once you have volumetric imaging, you can do quantitative
imaging. This is what I've been doing for
Looking at how
aggressive it is. And more importantly, for monitoring patient treatment. We
did this with, uh, say, prostate cancer. We did radio frequency ablation of it
with, um, we have a lot of vessels. And you treat it, the vessels go away. We
did later laser ablation of it in the prostate. You stick a laser needle in,
zap it, and when the blood flow goes away, finished. But this is a quantitative
way of measuring all this. So back to the, uh, left upper outer quadrant mass,
the vessel density is 2%, which is not particularly high, but it's a measure of
treatment options. The next one is, so what do you do next? Anybody? Do liver
work? Would you scan the liver? Yes. Affirmative. Okay, so we look at the
liver. First of all, we see a simple liver cyst, normal inflammation. And then
we see the hepatic and portal venous system. So we look for lesions inside,
which in this case, were clear. Now what about, here's another big problem.
Almost everybody with inflammatory skin disease is put on biologics. Now, who
knows what the side effects of biologics are? What's the possible side effect?
Cancer? Yeah, cancer
lymphoma. This is, it's stated in the brochure. You can, if you get a lump,
check it for lymphoma. This patient came in, tell me, we got a lipoma in the
breast, and this is from one of the major medical centers in New York. Tell me it's a lipoma. And I said,
well, guess what? This lipomas gonna bleed if you biopsy. So of course it was
lymphoma recurrence. Now, when a patient comes in, this is for beginners from
head to toe. How do you scan a person? We look at differential diagnosis. What
can the bump be? It can be anything from an abnormal lymph node. Um, depending
what country you're in, what climate you're in, it can be different things. We
see a lot of strange things now 'cause people come in with subsurface bumps and
nobody can see under the skin, as far as I know. So we use this and we've been using
it for, um, almost half a century in New
York City. Differential diagnosis. So what is it? Is
it a fibrous lesion, a vascular lesion? Um, neuromas are rare, but they happen.
You have to think of these things. Lymphoma is a big problem because it is completely
missed by most imaging methods. It's particularly cutaneous. Lymphoma is red.
They have no idea what's going on. And it's just a red area that sometimes
itches. We can see it, we can measure it by not using standard, uh, B flow
ultrasound. You need the vascular imaging and you need all the other
technologies. We're we're showing you.
soft tissue palpable
lesion. We do a huge amount of dermal imaging. With dermal imaging. We see the
depth, we see the margins, we see the vascularity. So if a basal cell or god
forbid, or melanoma is hypervascular, this is a killing lesion. If it's a
squamous cell, it's still treatable. 'cause we are now treating these things
without biopsy. We're doing the imaging, uh, border imaging with, uh, laser
confocal microscopy, and then we laser it. You kill it. And when there's no
more blood flow in it,
We are, we ask the
patient to come back in a come back in a year. Let's see if it regrows. So this
is what we do. We do the post laser treatment scanning for any kind of skin
cancer, and we follow it. So soft tissue mass, you look at it like any
clinician would. So be a clinician. First. Look at it, think about the
differential diagnosis. Um, see what the pathology showed and see what you can
do to see if it's involving any regional structures like nerves, subcutaneous
tissues. Uh, in the skin, you get a lot of subsurface, uh, metastases called
intrans metastases, especially with melanoma. Uh, so you ask the patient, when
did you feel it? Is it painful? And actually have them point to it. Let them
let you touch it so you feel what it is. 'cause a lot of soft tissue lesions,
if you pressing it, they move and you get a negative scan because the lesion is
out of the field.
So look at the skin.
Is it red? Is it inflamed? Are any lumps around anywhere else? Pulsitile,
pulsitile, aneurysms. When they clog, when when they get clouded anteriorly,
you can't feel them. They're non pulsitile, like non pulsitile aortic aneurysms
or anything that's clouded. It won't pulsate and no doppler 'cause it's, it's
thrombosis on top. It's a big miss. Um, okay, the transducer, you put it on
the, for the patient's comfort and your edification, you put it on the lesion
first and the patient will say, no, it's not there because it moved. It
happens. Uh, at least once a week, the patient will take the probe and say, no,
this is where it is. 'cause they can feel it. And with the transducer, you can
actually feel the lesion and the hardness.
So you are the, the
doctor and the clinician as well. Uh, see where it's involved. See, get the,
um, orthogonal measurements, at least in millimeters. Um, shape is important.
Uh, spatial orientation, like, you know, most cancers are more vertical than, than
horizontal, but it, it, it's useful, but not, not diagnostic. The shape is
helpful, but it, it's, you can't use it. So with the transducers, you see where
it is, uh, like the ganglion cyst, which is how we started 50 years ago at, um,
uh, New York Hospital,
which is now Cornell
Medical Center.
And the, we got a reaction, not from the patients who were happy to find the
gling, the ganglion cyst, but from the orthopedic surgeons who's saying, look,
we're gonna operate on this, don't touch it. So, okay, bursitis, schwans, uh,
we we're seeing a lot of these, um, neural tumors now, which are unexpected.
Lipoma is so common. Uh, hematomas resolving hematomas. Um, exostosis another
big problem in the skull, or actually any bony projection. So you tell the
patients this mass in your, um, in your neck, it's just an exostosis
Keratin cyst.
Schwannomas sebaceous cyst, particularly, a lot of people will not want their
sebaceous cyst. They say it's a cyst. But you show the patient this is the
funnel and somebody squeezes it, it's going to break out. And you'll have a
massive red arm or red, uh, red ankle, uh, for a long time. So then they get it
cut out. So this is sort of a surgical emergency. So, um, cap metastasis, we're
seeing a lot of them now. Now it's rare. Uh, breast cancer mets huge problem.
Uh, we see it everywhere. So we look for it and we scan for it. Now looking at
the transduce, so what can you do? Look for calcifications hair. Um, tail sign.
Tail sign in melanoma metastasis, because you see the tail of the tumor because
it's lymphatic involvement extending into the lymph nodes. And it's a mask with
the tail on it, which is the dilated lymphatic vessels. Uh, this was written up
in the European literature and presented here, uh, five years ago. Scars,
another big deal, scars and fibrosis, because now with the elastography, we see
scars, uh, calcification. It's important but useful, but no longer diagnostic.
'cause we have the other technologies that are more informative. This is a
pigmented lesion. It's a melanoma in the heel rare location. But melanomas of
the hand and of the soul are highly aggressive, especially in, uh, Asian, uh,
communities. These are killing cancers.
Peral flow, we look
for its seroma abscess, uh, metastatic AVMs. Now this is another cause for
tremendous concern because you have an A VM in the skull, in the spine, in the
sacrum. If it's midline, is it connected with the spinal canal? You don't know.
The patient doesn't know. You stick a needle in and it's connected with the
epidural sac. You got a patient who's paralyzed and people have died from this
because people didn't check the, uh, connection to the spinal cord.
Speaker 3 (23:33):
Okay, the, uh, this
is the a BM. Uh, we look at the blood flow. Now, uh, we all know that, um, uh,
low cancer or cancer blood flow is, has a low systolic and, uh, high diastolic
as opposed to normal. This is particularly important in fracture healing. This
was in the Italian literature 30 years ago, that you can tell non-union of
fractures because the healing will have high spikes. In other words, a high
systolic low diastolic and a fracture that will not heal will be just the
opposite. And for this, the entire field of pulse, electromagnetic scanning was
created and used for fracture healing. It was FDA approved 30 some odd years
ago. So this is important. You can look at fractures healing, uh, elastography,
again, a big breakthrough. This is, uh, we started off with sheer wave of fibro
lipomas or lipomas, uh, schwannomas.
Speaker 3 (24:43):
Uh, but the melanoma
is different also. Different countries use different color schemes. So in Asia
and different parts of the world, blue is hard in the, uh, America's,
it's, uh, hard is red colors. So you have to find out what scale is being used.
This is why quantitative elastography was developed. ShearWave. Okay, so
ShearWave, this is the cyst wall. Now what else can we use this on? How about
the wall of the carotid artery? In other words, interal thickness, you can see
it. But what's happening to somebody with high blood pressure? Are they going
to develop, uh, arteritis, wall thickening plaque because their arterial
pressure changes is causing real problem that they can't feel and the blood
pressure doesn't reveal. This shows disease before it happens.
Speaker 3 (25:44):
Okay, strain of
lithography. You, you really don't use it on cysts per se or on, uh, any bony
areas. So that's an area to be aware of. Liver elastography. This is an
interesting case because you can see this is not a normal liver by any means.
Maybe you have a little bit of normal liver up here in the midline, but huge,
this is the liver filled with metastatic lesion. And the first thing I did, I
asked the patient, how do you feel? I feel fine. They're going to, you know,
burn my liver. I feel fine. So we did the blood flow. There was no blood flow
in it. We did the elastography, which showed it's not very hide and not very
hard. In other words, this is probably a dying metastasis. And the patient's
doing well.
I think offering
quality of life to patients is the most important thing we can do as a
clinician. So liver and breast masses, uh, thyroid masses, uh, the skin, we
we're using it on the skin. The Japanese have done studies 20 years ago on skin
cancer and melanoma. I actually did the work with Hitachi in my office. My god, uh,
<laugh> a long time ago. Okay, so thermography, let me mention it. Just
the incidental, uh, it vascular lesions are hot. More temperature is a lady
with the cyst. So audience is a cyst filled with blood vessels or no blood vessels.
Is it hot or cold? Would it be Okay, this is done with a, a pocket thermal
camera. You can see it's dark, no blood flow, and it's indicative of benign
disease. So it's a simple guide and microvascular imaging. Beautiful. It's,
it's giving us, um, advanced look at blood flow.
And I know the, our
good, uh, doctor in the front row is using this for treatment follow up. When
the microvascular flow goes away, this is, uh, a sign of treatment effect. So
it's a good way to follow inflammatory disease. 'cause the clinicians can't see
it's lit. It's looks less red or it's itching less. This is quantitative
imaging. Uh, ammo completely unused because this is radio frequency imaging at
Memorial and Rockefeller
University. They're using
it experimentally. But this is an easy way to do tissue signature. And this can
be worked on in the future. Okay, more microvascular imaging. This is the same
lady with liver filled with metastases I saw a couple of months later and no
change. And she's feeling fine. She's refused chemotherapy.
So no neo vessels.
Uh, here's an interesting use. We're working with trauma victims. This is
happens to be military person and fell. So you can see that there's abnormal
flow in the forehead. That's where he fell. But notice there's abnormal flow
down here under the eye and in the head and neck. So he has from having
hypertensive heart disease, he's got abnormal flow going to the brain. He also
had a, uh, also look at the shoulder. Anybody see a difference in the shoulder
between the right and left shoulder? Okay, well, you can see the right shoulder
has more blood flow then the left, just grossly looking at it. And here's his,
uh, inflamed tendon. He, it's a simple tendonitis, supraspinatus, uh, uh,
disease. We, we see it commonly. Okay, thyroid scanning pocus. I, I've been
working with all the POCUS manufacturers for the last, oh, probably 15 years.
The comparing, uh,
high resolution POCUS with the thyroid. This is the carotid. Uh, this is a big
screen with a 18 megaherz probe showing the micro calcium, um, carotid plaque
here. We're scanning the fibroids, the fibrosis. A patient came in. Look at my
thyroid, Hashimoto's. We're seeing a lot of that, especially in the, in the OR
Florida area that we're seeing a lot of older people with Hashimoto's in the
female population. So you see that she has no cancer, but you have this, this
is some kind of fibrosis, but notice it was the, you have plaque in the carotid
artery. This is 11 to 12 millimeters thick. So these are ways to evaluate
what's going on and what's limits thermography and microvascular flow. It's
your imagination. So what's, what can we use POCUS for? Uh, Mena? Yeah. What do
you think the indications are? Yeah,
Speaker 1: Dr. Mena
Ramos
So we just wanted
to, um, that was, uh, a very, uh, rapid fire introduction to, um, some of these
advanced imaging modalities across breast, liver, skin, soft tissue. Um, and
the, you can see how these different modalities can potentially narrow down the
differential diagnosis. But I, um, wanted to take the opportunity to just ask
of these modalities, we'll say elastography, thermography and microvascular
imaging, how, how often or how widely used is this currently in your
experience? And I would also love to hear from the audience in your different
clinical settings. Um, what, what your practice experience has been.
Speaker 2: Dr. Robert
Bard
Well, you can use it
any, it's not invasive. So you can use everything you've got on every patient.
Uh, we have patients who come in, people come in mostly for breast scanning,
thyroid and skin scanning. So I ask them, do your joints hurt? So we can do
musculoskeletal imaging, like on this, uh, veteran who's injured. And, uh, we
always ask, how are your knees? 'cause we are treating with the, uh, mi micro
energy, the, um, the PMF and the red light, uh, near infrared treatments. Were
treating arthritis. This has been done by Harvard University
and they're rebuilding knee cartilage. But you have to ask the patient what
else hurts. 'cause they're worried about their, their breasts, but maybe it's a
red spot on their skin or the knees, which are really killing me. But they're
happy they don't have cancer. So ask the patient, work with the patient, say,
what else is going on? And then you can use whatever non-invasive technology
is, uh, is next. And, um, training, you know, that's, yeah.
Speaker 1: Dr. Mena
Ramos
Uh, just a, a few
other, a few other questions because, you know, I think the, in terms of
clinical applications, they are vast. Um, and specifically within the primary
care setting, um, thinking about skin, soft tissue, thyroid, breast, liver, et
cetera. Um, the, the, the scope of how these, um, these advanced imaging
modalities in, in addition adjacent to point of care ultrasound, um, is
potentially revolutionizing. Um, yet we still see very limited adoption. Um,
and I'm curious, before we, we discuss scope of practice, um, what are the kind
of primary limiting factors, um, that you see to, to more wide scale adoption?
Speaker 2: Dr. Robert
Bard
Well, I ask the
patient, what do you wanna do about this? You have a breast lump. If it's a low
grade cancer or cancer, what do you wanna do? Do you wanna treat it? Do you
wanna watch it? Do you wanna get chemo? Um, 'cause people are trying all sorts
of alternative therapies now, a lot of which work. So you ask the patient, what
do you want? And then what else bothers you? And you do whatever you have in
your arsenal of treatments to show them, well, I can do this. And you do it.
You show them, well, this shows this, but it's not conclusive. And then you do
more, we have all these imaging technologies available, and there are more
coming out, as you see at this last conference. There are things we haven't
seen before in, uh, 3D microvascular imaging of the, the, the cardiac walls
hypertrophy. This is amazing what's possible in, in ultrasound imaging. And the
future is in front of us. We just have to take hold of it.
The other
interesting thing is training. We see the ai, which is showing the chambers of
the heart, the location of the transducer, and measuring, finding the organ
systems and telling you, no, it's, it's not the liver. You having to be on a
big spleen, for example. So it, it guides you. And this has been going on for a
couple of years now, but now it's, it makes training easier and it makes the
practice of ultrasound wider. And I foresee the day where ultrasound imaging is
going to replace a lot of biopsies that are unnecessary. You don't wanna give a
woman a scar on the breast or on the, on the cheek for a benign inflammatory
red spot.
And here's the other
thing with, do you know, itching is the most common symptom worldwide,
inflammatory skin disease, cancer, everything. And it's, once you've got
psoriasis of the nail, for example, it's not a nail disease. It involves the
joint, the emphasis, the spine, everything increased incidence of cancer and
stroke. So you tell the patient, look, you have an increased, you have an
inflammatory whole body disease. And rheumatologists will say, oh, it's the
joint. A dermatologist will say it's the skin. So basically let the patient
decide, lay out the options and say, well, what do you wanna do about it? You
know, if they have your, you're, if you have consent, then you can go more and
use all the different tools, and you'll have happy patients and their primary
care physician may not like it, but you have very happy patients and you're
boost, you're boosting the future of, uh, ultrasound imaging and non-invasive
testing.
Speaker 1: Dr. Mena
Ramos
I think this is a
good moment to kind of pose a question to the audience. Um, within your different
practice settings, how feasible is, are some of these more advanced imaging
modalities alongside point of care ultrasound?
Let's talk about
cost versus lifestyle. If you go through an unnecessary biopsy and the, the
complications that can follow, we are finding that a lot of people are willing
to spend a few extra dollars to pay for a test to avoid the time, the waste of,
of their lifestyle, uh, their body motion to disfigurement. And a lot of times
the diagnosis is inconclusive anyway. So they gotta go for more tests. And
look, somebody's PSA, for example, a guy has a elevated PSA young healthy
elevated PSA, they say, PSA is high, let's do an ultrasound. No, let's do an
MRI, the MRI with infl inflammation in the breast, the neck or the prostate
will turn out positives. So then the fellow gets a biopsy, they find low grade
prostate cancer, they cut out his prostate, and he's an invalid, if not else
psychologically. And oftentimes the recovery time is, is months to sometimes a
year.
Speaker 2: Dr. Robert
Bard
And if they get
sepsis, we've seen people out in a hospital for, for nine months following a
simple prostate biopsy. The same is true of any biopsy in the breast. You're
introducing toxins, complications. There are a huge amount of misdiagnoses in,
uh, frankly, in biopsies. That's how I got started in this, in 1996. I think a
whole group of radiologists in New
York were listening to the Memorial Sloan Kettering
talk on prostate biopsies. Guess what? It was 16% accurate. What's the
inaccuracy rate? So this is memorial, who does it? At any rate, we decided
maybe there's a better way. So we started looking at advanced imaging options.
And frankly, worldwide, in, in Europe, if there's a thyroid mass with, uh, no
blood flow and lower elastography or a breast mass or uh, liver mass or kidney
masses, now you can watch the patient offer them the option, Hey, it could be a
cancer, but it could be something we can watch. So
So again, you ask
the patient, what do they want to do? They do. They wanna watch it. Do you know
that low grade prostate cancers from nine 11 from the toxic waste sites are
extremely common. And we've been following low grade cancer in the first
responders in fire department for years. And you can feel it, you can see it,
you show it to the, uh, firefighter or cop, and you say, well see, it is one
centimeter and it hasn't changed over the last 10 years. So you're giving
people options. That's what they want. And they will, frankly, they'll pay for,
for, uh, whatever's necessary if it's reasonable and the, it, it's not a waste
of their time.
Speaker 1: Dr. Mena
Ramos
I do think you bring
up a very important point about just access to equipment. You know, training is
certainly one big barrier. Um, but if you don't have the proper equipment with
the appropriate software, then how do you actually apply training? And so this
might be a great opportunity to kind of open the floor, um, to other members of
the audience, what your experiences have been, what you see kind of in the
pipeline in terms of accessibility of some of these more advanced imaging
modalities within the point of care ultrasound, uh, realm. Um,
In terms of
training, uh, from the, you know, uh, sonography training perspective, um,
there are gaps. Uh, there are gaps in training, I think kind of across the
board in multiple specialties and how this may relate to technology and the
development of technology is, it's not just a one way street, right. Training
impacts the use of technology, but the new applications that are, are
developed, I mean, I'm just walking through the exhibit hall and seeing kind of
what is now possible that wasn't possible, you know, 10, 15 years ago. I think
will also, um, uh, impact how we, we we do training. So it's a bidirectional, um,
bidirectional relationship that, um, I think those, that the, the pathways of
communication need to be open. Hence, you know, conferences such as these are
so important to have that exchange.
If we're, if we go a
step beyond the sonography schools or medical schools or residency programs,
how do you, how do you, um, uh, change workflows for people who are already in
practice, which are the vast majority of clinicians, right? They're not in,
they're not in traditional training programs anymore. So it, that poses another
set of challenges. Um, we don't have all the answers, um, but we do, I think
seeing where success has, where we've seen success in the point of care
ultrasound space, I think some of those similar, uh, concepts can apply.
Certainly there are extra limitations when it comes to what is available at,
uh, a more, uh, accessible or affordable, um, uh, price then say, uh, for some
of these advanced applications. But once again, if we take a look at what's available
today versus what was available 15, 20 years ago, it's, it's night and day. Um,
uh, DR.
Speaker 2: Dr. Robert
Bard
Another thing is
more uses. Uh, we had a lady came in from actually San Diego last week, and she had a molar
problem, an abscess tooth. So we, we did the ultrasound, then I saw no
inflammation in the tooth. 'cause she had it a month, I'm sorry, a year and one
month old. But we did the ultrasound, we sound periosteal calcification, in
other words, because of the abscess, she developed perio titis, which you can
see with very high resolution ultrasound. And then it healed over. So she had a
big hole in her jaw, but it was contained. And of course now she's got
inflammation floating around her body. And as the dentist, they will tell you,
dental disease and body health is, they're, they're, they, they're combined.
They match. It causes a lot of disease that's completely unrecognized by
dentist. The other thing is, what else can you do at, at lunch, we're sitting
with a MFM and maternal fetal medicine, uh, person.
And I said, well,
what problems do you have? Uh, no, no problems. Well, I, I thought back into my
obstetrical days. Well, what about abrupt deal placenta? Okay, think about it.
Is the placenta full of blood vessels? Lots of blood vessels. So on the imaging
and the thermography, which is non-invasive, the vascular imaging, you can see
blood vessels and if the blood vessels there will be heat. So with simple
non-invasive imaging, you can see if there's a hole in the symmetric blanket of
the, uh, placenta or not. And this will comfort women. And because you show them
everything's intact, the lack of stress will decrease the chances of an
abruptly or some preeclampsia. So it, it works in every area that you can think
of. 'cause the people who are in the area aren't thinking of the what else can
be done. They're happy with what they're, they're doing. But this society can
bring the future by advancing it.
Speaker 1: Dr. Mena
Ramos
The the applications
are, are vast. I think that's actually one of the, the challenges is that
because there are so many applications really being able to focus, um, on
certain key ones that may get the most, say, uh, number needed to scan for this
specific use case, really contextualizing can get, um, can lower the barrier
to, to initial entry for someone or a health system that might be interested in
making the investment in both training equipment, um, uh, to, to adopt some of
these, um, these technologies. Um, I'm, I'm curious to hear from anyone else in
the audience your experiences with respect to elastography microvascular
imaging, um, uh, in your clinical settings or educational settings, um, or
other research ideas. A really number needed to scan that's, that's opportunity.
We, we chose to
focus on, um, skin soft tissue, breast and, and liver. But that's certainly not
limited. The applications are not limited to those organ systems. So thank you
for, um, for, for addressing that. Um, I mean the, I think a lot of research
can come out of this. Um, but I think some of the, just to reiterate some of
these common themes that are, uh, that have come out of this conversation, um,
with respect to training, the challenges to, to adoption training, which also
goes along with awareness that hey, these things are, these applications are
possible. Um, the equipment to, to be able to support the training and, um, and
vice versa. Um, and also just multi-specialty collaboration. Um, because we're
seeing gaps, um, not just within one silo or one specialty, but we, you know,
from the sonography perspective, from the radiology perspective, from the, uh,
primary care family medicine perspective, um, I'd love to hear if, if there's
folks in terms of the engineering or um, uh, uh, technological development
industry perspective, what are some of the challenges there?
I think it would be
very difficult to find the through line and move this forward for, you know,
these technologies, I, we, you know, we say are advanced, but they have been
described for well over a decade. Um, and so I love the way you put it, Dr. Uh,
Dr. Bard. You know, it's, it's not just about, you know, this is, it's not
about what we know. It's what we can apply. Um, and so how can we apply these
known technologies that we know can benefit patients' lives, um, by connecting
these dots. Um, I hope this, I hope this has been, um, a conversation starter,
um, and a kind of a, uh, a, uh, reintroduction of, um, how, uh, these imaging
modalities could be applied at, on a, uh, in a brighter, uh, broader scope, um,
across the continuum of care. Um, um, and I just wanted to open the floor the
last few minutes we have for any thoughts, questions, comments, uh, in the
audience.
Speaker 2: Dr. Robert
Bard
Well, let me add one
thing. In the women's health community, we are imaging and treating
endometriosis, which is often misdiagnosed for years because women don't
complain about it. If they do, they complain to their physical therapist and
not their doctors. So it, it gets mistreated. The other thing is menopause. I
learned this week that working with one of the Florida, uh, thyroid experts, that
hypothyroid and hyperthyroid also cause myocardial disease and carotid artery
disease. All this thing is the, what's the biggest organ in the body? Anybody?
Hmm? Skin. The skin, the endothelium lining is 64 acres. The lining of the
endothelium, this is the most sensitive part of the body, and it's, it's a
hormonal receptor. So this is the whole key behind cardiovascular disease. We
can see it now. So, hypertension, stroke, uh, um, which is particularly
virulent after menopause. It's, there's a high rate rate of, uh, cardiovascular
disease. Uh, heart disease is killing more, uh, women and men than, uh, breast
cancer, for example. So this is an area of education. So if you have any
thoughts or ideas, email us. Give us a call, visit our center centers and, uh,
we'll see if we can move together forward.
Thank you.
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