3D Ultrasound Technology- Future Vision 4

Posted on November 28, 2006 by Steven F. Palter, MD

3D ultrasound of IUD in uterus

3D Visualization is one of the concepts I spoke about in my session on FutureVision- The Coming Radical Transformation of Surgery at the AAGL meeting. In gyn, the use of 3D ultrasound has become commonplace. In general, an imaging machine (ultrasound, CT, or MRI can all do it) takes a series of images of an entire region of the body (not just one image). Then a computer can analyze these. Since the computer knows where each images is in relation to the next it can perform complex analysis and reformat and process the images. As a result you can get any view you want from any angle as if you were looking around inside the organ. In gyn this is very valuable since the uterus is usually tilted. Regular ultrasound gives just an angled view but here the computer can fix that.

Here is the regular 2D view - the IUD is the bright central line and should be T-shaped

Here is the computer corrected straight view

What’s even more exciting for the future: The technology now exists to do this 3D manipulation in real time from ultrasound and CT scans. That means it can be used to guide surgery in another example of technology providing vision beyond that of the surgeon’s eyes alone. There is a huge field of “virtual endoscopy” where this xray technique is used to provide images as if the surgeon had inserted a tube into the body but non-invasively. As computing power expands the speed and resolution of these systems will expand according to Moore’s law. Regular endoscopy will largely be replaced for diagnostic uses.

Coming soon: more reviews of virtual endoscopy technology

Live to be 100? DITM Tells You How

Posted on November 28, 2006 by Steven F. Palter, MD

A study from the University of Chicago has been getting a lot of press attention lately. They found that your chances of living to 100 may depend on how young your mother was when she gave birth to you with chances doubled if mom was under 25. The reports do not give the explanation why.

DITM has the Answer: Buried in an IVF session at the Annual ASRM (American Society for Reproductive Medicine) meeting (and missed by most people at the meeting) was a unified theory of reproductive aging and human longevity. It was the most amazing thing I saw at the meeting.

Dr. David Keefe of U Florida (a fertility doctor and one of my former partners at Yale) presented data on the telomere and its role in reproductive aging. The telomere is a piece of repetitive DNA (the same exact little sequence over and over again) that does not code for any proteins. It is a protective cap on the end of the chromosome. Human DNA replication is tricky since the enzymes that copy DNA cannot copy the very end of the DNA strand. The body protects itself by having this telomere, or protective non-coding DNA at the end. Unfortunately as cells divide this cap starts to get lost.

It has been shown that the telomeres shorten with normal aging by two mechanisms: 1) repetitive cell and DNA division with each separation of a cell into daughter cells and 2) reactive oxygen radical induced damage (the stuff anti-oxidants are supposed to protect against) followed by excision repair by the body. Telomeres are very susceptible to this particular kind of damage.

Interestingly, developing embryos lack telomerase- one of the enzymes necessary for repair of damage to telomeres. Telomeres are also the area when chromosomes pair together – a vital step just before the cell divides. Therefore in a developing embryo with damage to the telomere the chromosomes do not pair normally and the result is uneven separation of chromosomes. This is the #1 cause of miscarriage as a woman ages and the #1 cause of birth defects that increase as a woman ages. It is also the #1 reason fertility is reduced in older moms.

Here is where it gets even more amazing. The first eggs formed in fetal life in a woman (as a fetus a woman forms all of the eggs she will ever have as an adult) have the longest telomeres and ovulate earliest in her reproductive years. The ones that are formed last have the most telomere damage because they had to divide the most times, have the shortest telomeres, and ovulate last in a woman’s late 30′s and 40′s. Eggs with shorter telomeres have been shown in IVF to be less likely to lead to a pregnancy, and more likely to lead to abnormal embryo development. So the short telomere theory completely explains reproductive aging and miscarriages and the increase in genetic abnormalities seen in offspring of older women.

Connection to Aging and Longevity: As a human ages there is further telomere damage that cannot be repaired. As this accumulates cells enter a form of cell death called apoptosis. This entire process will be accelerated in the offspring of older mothers (because all of the cells formed from an egg with shorter telomeres in the first place) leading to earlier death– exactly what this new research from U Chicago shows.

What Can Be Done: There are enzymes that COULD repair the broken telomere ends. The main one telomerase exists in some cells but is largely turned off. It will take genetic engineering to make it active in all aging cells. When that occurs older cells could be repaired to the state of younger ones. In other words a genetically engineered fountain of youth.

Scientists are actively pursuing this: Geron Corporation back as early as 1990 developed drugs that extended telomeres, and proved that they prevented cellular aging and death. In fact, When normal cells are altered in the laboratory to make the enzyme telomerase that repairs telomeres they continue to live far longer than they ever should. This remarkable demonstration (reported by Bodnar et. al. in the January 16 1998 issue of Science) provides the most compelling evidence yet that telomerase and maintenance of telomere length are the key to cell immortality.

The Problem Stopping This Treatment: The same enzymes that repair the cell when turned on excessively lead to cancer formation. To make this an effective treatment will require scientists to be able to turn the enzymes on and off or on in a regulated manner. This is all possible.

Well if the treatment is not here yet you can always trigger long term human hibernation until it is available.

Further Reading: Here is a link to telomere and life extension . Here is a highly technical review of telomeres and the problems with then leading to aging. Here is a fairly high tech paper on telomeres and aging vs cancer. If you really want the in depth science and have a PhD this is for you.

Update: The reproductive study author Dr. Keefe took the time to answer many of my questions about how all this works (and goes wrong as we age). His answers can be found here.

Grand Rounds Vol. 3, No. 10 is Up!

Posted on November 28, 2006 by Steven F. Palter, MD

Thanks to Dr. RW for an excellent Grand Rounds. I especially like this one for including a series of purely clinical posts. There has been a discussion running about the purpose of GR and some think it should only be literary pieces aimed at the lay public. I think the best of themedical blogosphere can excel with diversity and love the clinical and technical pieces. Of course I am also delighted that my post (shameless self-plug) was included! This is the post of my original research that identified a new form of uterine infertility – however the findings suggest that in cases of abnormal bleeding we may actually WANT to cause this disease to trick the uterus in shutting it own menses off.

Our “From Bench to Blogosphere” segment features docinthemachine with some original research he recently presented before the American Association of Gynecological Laparoscopists on a little appreciated variant of Asherman’s Syndrome along with discussion about potential applicability to the treatment of other gynecological disorders.

Thanks also to Roland Piquepaille for his in depth review of my prize winning research on a new type of surgical camera/laparoscope that can see disease invisible to the naked eye. For those visitors from the medical realm not ramiliar with him, he is aleading tech blogger who posts from Paris on his own blog and on the emerging technology blog at Ziff-Davis (they publish just about every computer magazine)- both worth checking out!

Docinthemachine “FutureVision” Surgery Podcast

Posted on November 23, 2006 by Steven F. Palter, MD

Here is the link to the podcast of my interview at the Global AAGL congress– we discuss my vision for the coming radical transformation of surgery. For now the society requires you to (free) register to listen. The interview is at the bottom of the podcast section under AAGL 35th Annual Meeting Presents: Ways of Seeing: Dr. Steven Palter: Future Vision, Micro-Invasive to Non-Invasive Surgery.

Everything we do is set to become obsolete…

Docinthemachine Fever Spreads- Podcasts and Video Coming Soon!

Posted on November 22, 2006 by Steven F. Palter, MD

Digital dreams

Thank you so very much to all the readers and supporters of docinthemachine. In the few short months that DITM has been up (since 9/11/06) the interest has been growing exponentially (does it follow Moore’s Law?).

Thanks to all the Grand Rounds Editors who have linked to my posts, to Kim at Emergiblog for her enthusiastic support of infertility tech advances and to Michael and the team at Medgadget for interest in all my things techno.

I am excited to announce that my entire plenary session on “FutureVision- The Revolution in Surgery” was recorded at the 35th Annual AAGL Global Endoscopy Congress and will be streamed on the net by the AAGL and obgyn.net! The session focuses on my vision that we are on the verge of a radical transformation of surgery as a result of technological advances.

Endoscopy set the stage for technology to step between the doctor and the patient. Now it will augment our vision, add capabilities that human hands do not have, and then reinvent itself into miniaturized devices inside the body coupled with noninvasive 3d reconstruced images controlled remotely on workstations. This is just the beginning and the first clinical steps have already been taken… Read about augmented surgical abilities here.

Happily AAGL and Obgyn.net chose this theme for one of their first podcasts. I hope you all enjoy it. Links to the podcast, the streaming video, and vblogs are all coming soon!

happy turkey day to all.

Update: We got Instalanched! Thanks to Instapundit for linking to us today Not to mention “neatorama” – even FArk hits have started…

PODCAST LIVE UPDATE: Don’t blink first podcast link live!!! Here is the link to the podcast of my interview at the Global AAGL congress– we discuss my vision for the coming radical transformation of surgery. For now the society requires you to (free) register to listen. The interview is at the bottom of the podcast section under “future seeing Dr Steven Palter”

Grand Rounds – Volume 3 number 9 is Up!

Posted on November 21, 2006 by Steven F. Palter, MD

Thanks to Dr. Anonymous for all his work on this edition of GR. He had the daunting task of editing a GR with a limited post number to try to keep it hot and all of outstanding caliber (and one readers could get through)

Welcome to the most anticipated Grand Rounds in a long time! These are the 27 best posts that the medical blogosphere has to offer this week. In my editor’s picks, I wanted to highlight well-written stories.

Thanks to him for including my post on alternate visualization- in the start of my FutureSurgery Series. This post reviews the cutting edge (bleeding edge?) of surgical procedures. I review ways technology augments and increases what my native body can do. It’s the future…

As far as Grand Rounds itself do check out Kim at Emergiblog’s discussion of what is the purpose of GR and should all submissions be accepted. A very hot topic. For me it’s interesting that recent editors are stressing the literary side of medical stories exclusively. I had one tell me my cutting edge post did not have a “story” besides the facts. These literary pieces are fantastic but to ignore factually and scientific posts or those directly targeted to a medical audience weakens the concept of the best of the medical blogosphere.

The Power of Genetics and IVF Embryos- and the Controversy

Posted on November 20, 2006 by Steven F. Palter, MD

I am just about to finish an IVF cycle I am doing with a lovely couple. They are in one of the best prognosis groups. He has children from a previous marriage as does she. She had a tubal ligation and “only” has blocked tubes (this is the best prognosis group for IVF). She is 37 years old and while not as young as the highest chance group her chances should be outstanding.

So why in heck am I writing this pleasant little musing on them? Where is the technology in the story? Well they decided they wanted PGS (preimplantation genetic screening). This cutting edge technology can be used to screen embryos for genetic diseases and also to test for major genetic abnormalities leading to miscarriage. Approximately 20-30% of early human pregnancies will miscarry due to genetic abnormalities. These are commonly trisomies or monosomies where there is loss of addition of a chromosome (supposed to be only 1 from mom and 1 from dad of each).

In PGS we biopsied each little embryo removing a single cell called a blastomere from an 8 cell day 3 of development embryo. It’s tested overnight and Voila! I got the report today— 10/12 of her embryos were genetically abnormal and incompatible with life! This is the power of this new genetic technology. So luckily 2 of them can lead to a live born baby and I’ll be putting those 2 in tomorrow on day 5 of development.

What’s the controvery DITM?

1) I also get information about the sex of the embryo and people are increasingly requesting this for sex-selection. Should we being doing gender selection? A leading researcher once said last time I checked “gender was not a disease”

2) It has recently been discovered that a “mosaicism” occurs in human embryos. This could lead to high rates of inaccurate results from single embryo biopsies. This is an amazing new discovery–human embryos were thought to undergo orderly cell divisions all equal. NOT TRUE! We know now that every so often (how often we do not know) there is an uneven division of just one cell so its offspring cells are abnormal but all the others are normal- and it may be that those 2 abnormal one will die but the normal cells happily grow! This means that unless we do multiple cell biopsies (and remember there are only 6-10 little cells in an embryo at this stage) we will think it’s abnormal when it is not…

The answers in the future:

1) multiple cell biopsies

2) very large cell number biopsies at the blastocyst stage of development with instant genetic results (day 5 of development cell numbers skyrocket)

3) other markers of normalcy

FutureSurgery – Alternative Visualization-Part 3 Near IR Imaging

Posted on November 17, 2006 by Steven F. Palter, MD

me and NIR microscope systemmicroscope

Example– Near IR Microscope: I have been writing on the concept of alternate visualization systems. That is, the paradigm shift that will occur when endoscopic surgery moves beyond innate human abilities and adds new capabilities. The first of these will be alternative visualizations that lets the surgeon using the scope see things that the naked eye cannot see.

Another technology that will be used in this way is NIR or near infrared. The human eye sees in the visible light spectrum. At the red end beyond our regular human vision spectrum is near infrared (800 nm to 2500 nm). This has been used medically for pulse oximeters since it passes easily through skin. This makes it ideal for imaging deep structures under the peritoneal surface or for the detection of deeper diseases.

While at Nextfest I met with a researcher from GE who was working on microscope systems based on near IR. I predict this technology will migrate down to medical endoscopic use.

Important fact: Unlike other alternate visualization systems such as fluorescence NIR requires a dye to make the image visible. Much of the NIR work I saw was based on using cyanine dyes which can be tagged to various antibodies to allow imaging of the intended disease or anatomic structure.

FutureSurgery – Alternative Visualization- Part2 Infrared

Posted on November 17, 2006 by Steven F. Palter, MD

Continuing in the series of the future of surgery (see intro to series here). I previously posted about veinviewer. This is the camera system that uses infrared light to see the veins under the skin. I wanted to post this video I made of the system being used at Nextfest to demonstrate how it works – and to provide an example of “alternate visualization”. The real exciting possibilites to me are in using this type of technology inside body cavities to see otherwise invisible deep structures or disease.

[youtube]IjEP_f_EY7U[/youtube]

Futuresurgery- The Coming Radical Transformation of Surgery

Posted on November 17, 2006 by Steven F. Palter, MD

What is the future of surgery in the next decade? This will be a series of posts I will write on my vision for the future of surgery 10 years from now. The concepts are based upon the plenary session lecture I gave at the 35th Annual AAGL Global Congress of Gyn Endoscopy 2006 in Las Vegas. The session’s title was “Future Vision”. The core concept is that surgery has undergone a series of advancements over the past 100 years but yet remains essentially the same. That is until the development of laparoscopy which is the key development leading to a paradigm shift. Why? Because for the first time the surgeon’s hands and eyes are not directly linked to the patient. There is a technological interface between doctor and patient- the surgeon operates with remote instruments and views the entire procedure on a video monitor. This sets the stage for radical transformations in the next decade as the full gamut of digital technology steps into that interface. This is not supposition or wild fantasy- I will share with you the real-life examples that exist today or are currently in development that will radically change how all surgery is performed. As I told the audience of surgeons- most of what you do is destined to become obsolete in the next decade. Let’s paint a picture of a future that does not yet exist but for which the signposts are clearly written…

Observation #1: Endoscopic technology is maxed out. Endoscopy transformed medicine by allowing surgery to become less invasive with quicker recovery and lowered costs. Almost 100% of the surgery I perform is laparoscopic or hysteroscopic. For the layperson this is surgery performed with little telescopes passed into a body opening or through a tiny incision in the abdomen. As someone closely involved in instrument and procedure development I have seen that the technology is now mature (after only 20 or so real years of intense use) and little major progress can likely be made with current configurations. Back in 2000 I performed the world’s first HDTV laparoscopy– this pushed image quality to the resolution of the human eye. These systems are commonplace now. Any further increase in electronic resolution is meaningless since it would be beyond what the eye can see. I also worked on developing tinier and tinier microlaparoscopes (down to 0.5 mm) but these cannot get any significantly smaller or they will become so flimsy as to be useless.

Prediction 1: Alternative Visualization: This will be the first radical transformation of surgery. I predict a major revolution in endoscopic surgery will be what I call alternate visualization systems. The concept is to develop scopes that can see beyond what our native eyes can see. When this is achieved the scope becomes not just an extension of our human abilities and senses but augments our native abilities — enabling new and unimagined procedures. One example of this is the autofluorescent laparoscope I used for my recently reported research on endometriosis. Previously used in the lung, I figured out a way to use this system in the pelvis where it allowed the visualization of otherwise invisible endometriosis disease. Until now the scopes just gave us ordinary vision through a tiny incision. For the first time the scope technology now sees more than what the human eye can see by itself. Today surgeons are so excited by the introduction of robots into the OR but these are simply extensions of human hands. Alternative visualization is the first step along the path that will lead to technology and robots with non-human or superhuman abilities. For examples of the augmented visualization see the following posts on:

infrared imaging – available now to see veins through your skin- check out this video of it in action on my arm

near IR imaging– cameras that can see through tissue to locate potentially any hidden organ or disease.

As this series continues I will share with you examples of military and NASA technology for robotic rovers going inside the body, x-ray machines that can provide virtual imaging, and remote controlled surgery without touching a patient, virtual reality gesture control systems and more. Surgery will change from a doctor directly operating on a patient to a doctor coordinating a technologic system that executes the procedure. It’s all becoming real now. More than anything this is an exciting time of unparalled development. Do not fear the technology – be excited about what it will enable.

Update: My podcast from AAGL global congress on this theme now up

Related Posts: Why so much of this med development comes from military research.