Yale Medicine (March 12, 2023) – As we age, are melatonin starts rising at an earlier hour in the night, thus we may tend to go to sleep earlier than when we were younger. We still require the same number of hours of sleep (7-9 hours on average), so we may also rise earlier. Our sleep is more likely to be disturbed by medical conditions, medications, or substance use.
Tag Archives: Yale Medicine
Lung Cancer: Benefits Of Robotic Bronchoscopy
Yale Medicine (February 11, 2023) – Robotic bronchoscopy, also known as robotic-assisted bronchoscopy, is a recent advancement in bronchoscopy, the procedure used to biopsy lung nodules to detect the presence of lung cancer and other lung diseases. Lung cancer is the third most common type of cancer and the leading cause of cancer-related death in the United States.
Early diagnosis and treatment often lead to better outcomes. A diagnosis of lung cancer often begins when a chest X-ray or computed tomography (CT) scan shows a nodule—an area of abnormal tissue—in the lungs. If the nodule is suspicious or grows over time, doctors will perform a biopsy to collect a tissue sample that can be tested for the presence of cancer cells. Bronchoscopy is a widely used procedure for biopsying lung nodules.
In traditional bronchoscopy, a doctor manually guides a thin tube, called a bronchoscope, into the patient’s mouth or nose, down the throat, past the vocal cords and windpipe, and into the passageways of the lungs. The bronchoscope is equipped with a light, camera, and biopsy tools that allow doctors to visually examine and biopsy nodules. But robotic bronchoscopy is different. Like traditional bronchoscopy, it’s a minimally invasive procedure that allows doctors to biopsy nodules in the lungs.
The difference is that in robotic bronchoscopy, the doctor uses a controller at a console to operate a robotic arm. The robotic arm guides a catheter—a thin, flexible, and maneuverable tube equipped with a camera, light, and shape-sensing technology—through the patient’s airways. The robotic arm’s precise movements enable doctors to accurately direct the catheter around tight turns in the airways and into the hard-to-reach areas of the lungs. This means doctors can examine and biopsy suspicious nodules—and potentially detect cancer—in parts of the lungs that may be inaccessible with traditional bronchoscopy.
What’s more, the procedure is safe—serious complications are rare—and recovery is usually quick. “As part of the comprehensive Thoracic Oncology Program, we are now able to offer patients the option of robotic bronchoscopy,” says Yale Medicine interventional pulmonologist Christopher Morton, MD. “This technology will allow us to biopsy lung nodules and masses with improved accuracy and fewer side effects, in addition to lymph node biopsies that we already do. This will get patients diagnosed and referred to the appropriate treating physician quicker.”
Insulin: Type 1 & Type 2 Diabetes Differences
When we think about insulin, we know that all of our bodies have a pancreas that sits in the middle of it and, within the pancreas, there specialized cells that go ahead and release insulin. The way I like to think about it is it’s a key that unlocks ourselves so that the food and nutrients we eat are able to be metabolized and used for fuel by our body.
In Type 1 diabetes, we always tell families it’s an autoimmune process. So for some reason, your body sees those insulin producing cells within your pancreas as being foreign, so it starts attacking those cells. So going back to that key analogy, we think about, all of a sudden there’s not a lot of keys available.
Youth with Type 2 diabetes have a different situation going on. In that situation., it’s an issue with insulin resistance and so the way that I think about it is that you still have keys, but the keys are the wrong shape now. The difference between Type 1 and Type 2 diabetes is really the fact that, in Type 1 diabetes, you are relying on exogenously administered insulin for survival.
In Type 2 diabetes, you have insulin that your body’s making. However, you cannot use it appropriately and so youth present with high blood sugars, but in conjunction with that, they often have high insulin levels and so we need to initiate insulin therapy. So giving injections, but over time we may be able to transition to alternative means to manage their glucose levels and I have to say, Yale is at the cutting edge of developing new treatments for kids diagnosed with diabetes.
When using injected insulin therapy or pumping insulin, what we’re trying to do is closely match what your body should be making and so there’s lots of different insulin therapies out there and the amazing thing to think is, you know, 100 years ago this was just discovered, it was one of the initial presentations on insulin therapy. It was here at Yale. People started on insulin therapy in 1922 and it’s come such a long way.
As somebody living with Type 1 diabetes, I can share with you that in 1987 when I was diagnosed, I was on purified pork insulin and so I don’t feel very old, but saying that I took a purified pork insulin therapy makes me feel very, very old and very grateful for how these therapies have improved and how we’re better able to match the physiologic profiles of what your body should make.
Medicine: Using Stem Cells To Treat Osteonecrosis
Daniel Wiznia, MD, an orthopaedic surgeon with Yale School of Medicine, is practicing a surgical technique designed to render 10% of hip replacements unnecessary. Regenerative properties from a patient’s own stem cells are responsible for regrowing bone, restoring blood flow, and being able to avoid further interventional surgery.
Osteonecrosis, also known as avascular necrosis, occurs in more than 20,000 Americans each year. As the condition progresses, bone cells known as osteoblasts become unable to repair themselves and sustain the integrity of the bone, and ultimately die. The bone deterioration leads to a decrease in blood flow to the area, further weakening the entire skeletal structure of the upper leg.
If unaddressed, the ball portion of the hip’s ball and socket joint will cave in on itself and collapse, requiring a total hip replacement. The fact that patients often receive this diagnosis during their 30s and 40s presents a particular challenge.
While the lifespan of hip prosthetics has dramatically increased in recent years, a patient who undergoes a total hip arthroplasty, or total hip replacement, at that age will almost certainly require a revision later in life. This redo of the same surgery at an older age comes with an entirely new set of risks and potential complications, making it that much harder to manage down the road.
Inflammation: Three Ways It Affects Your Health
Acute inflammation happens as a part of our defense mechanism to clear out pathogens. So when a virus or bacteria invades us, we need to quickly mount an acute inflammatory response to get rid of the pathogen. Sometimes, that acute immune response isn’t enough to get rid of the pathogen. That’s when we elevate the level to the adaptive immune response. That’s when you involve specific lymphocytes, T and B cells, to fight off the infection.
So inflammation is a necessary process for dealing with pathogens but sometimes, it can also turn against us. Chronic inflammation happens because the body fails to get rid of the cause of the inflammation, such as viruses and bacteria. In those conditions, such as, you know, chronic infection with HIV or hepatitis virus or lung COVID, in which case we there may be a persistent viral reservoir that’s causing this chronic inflammation, the inflammation itself becomes the enemy.
Even though inflammation evolve to counter pathogens, it’s also engaged by other causes, and so having this amount of fat, for example, alone is able to trigger the immune system and induce the chronic inflammatory response that then fuels further problems to happen because the body is sort of trying to fight off a non-existent infection and therefore, it can sort of engage a chronic state of inflammation.
I can’t think of a disease which doesn’t involve inflammation, but we are now learning more and more about the physiological role of inflammation. Homeostasis ensures that we have a normal operation of different physiological functions like heart rate, breathing and glucose levels or insulin levels. Those two system, the inflammatory system and the homeostasis, they work together to maintain each other. Sometimes, the inflammatory response has to override the homeostatic response.
That includes things like adaptation to a different diet. The immune cells are now known to be able to sense differences in dietary conditions and adapt the intestine for future absorption of nutrients. This kind of events that are not necessarily at all related to pathogens, but for maintaining physiology. Inflammatory responses are integral in order to maintain health. So a molecular-level understanding of inflammation is necessary to understand the logic by which these systems function, and also it provides the pharmaceutical target for future therapies of inflammatory diseases.
Clinical: Yale Women’s Heart Health Program
The Women’s Heart and Vascular Program provides state-of-the-art cardiac care for women with heart disease, as well as expert screening of women at risk for heart disease.
Heart disease remains the number one killer of American women and there is a great need for specialized care directed at women’s cardiac needs. The Women’s Heart and Vascular Program is dedicated to screening, educating and treating women at risk for, or with established heart disease.
Under the direction of Lisa A. Freed, MD, FACC, the Women’s Heart and Vascular Program incorporates not only her expertise in cardiology, but also collaborates with experts in diabetes, menopause, nutrition, exercise physiology, and smoking cessation. In addition, Dr. Freed consults with experts in sleep apnea and mental health professionals for intervention with co-existing depression and anxiety.
The program also focuses on clinical research in collaboration with Yale’s Women’s Health Research Center in order to advance the care of women with heart disease.
Cardiology: The Ten Types Of Heart Specialists (Yale)
1. General adult cardiologists
Why you might need one: You have symptoms of heart disease, such as chest pain, fainting, a fluttering sensation in the chest, or shortness of breath. Or, you don’t have symptoms, but you are concerned about a risk factor such as high cholesterol, a history of smoking, or a family history of heart disease.
What they do: General adult cardiologists diagnose and treat general problems that affect the heart and blood vessels, including high cholesterol and high blood pressure, as well as heart attacks, valve problems, abnormal heart rhythms, and congestive heart failure, among other conditions. Cardiologists also help to prevent the onset of heart disease.
General adult cardiologists perform physical exams and order blood work and other tests to evaluate the heart’s health and function, including electrocardiograms, echocardiograms, stress tests, and MRIs of the heart. They can help you make lifestyle changes, as well as recommend medications (such as cholesterol-lowering statins) and procedures (such as inserting stents and pacemakers, as well as performing ablations of abnormal heart rhythms and replacing heart valves).
What else you should know: If you are a woman concerned about your cardiac health, you should know that heart disease is the number 1 cause of death in women. Women may experience symptoms of heart disease differently than men commonly do—for instance, they are more likely to have symptoms other than chest pain, such as indigestion, unusual fatigue, and discomfort in the abdomen, jaw, neck, or upper back.
One type of heart disease, called “broken heart syndrome” (a temporary condition that can be caused by extreme emotions and situations), is more common in women than in men. Cigarette smoking is also a bigger risk factor for heart disease in women, especially in those who are pre-menopausal. “If you are a woman, it’s important to find a cardiologist who will listen to you and take your symptoms seriously,” says Yale Medicine cardiologist Erica Spatz, MD, MHS.
2. Cardiac imaging specialists
Why you might need one: Your doctor suspects heart disease or wants to monitor a condition that has already been diagnosed. Imaging may be used to evaluate your heart’s anatomy and function. Your doctor may want an imaging test if you have symptoms of a heart problem such as chest pain, irregular heartbeats, heart flutters, or shortness of breath. “Multimodality cardiac imaging uses a comprehensive approach to choose the best test for a patient when there is concern for cardiac disease,” says Lauren Baldassarre, MD, cardiology director of Cardiac MRI and CT at Yale Medicine. Heart imaging may also be used as part of cardiac treatment.
What they do: Cardiac imaging specialists provide imaging that can help in diagnosing, evaluating, and treating the heart. Sophisticated imaging tests use different approaches for a variety of problems, from chest pain and valvular heart disease to cardiac tumors and heart device infections, among others. For example, an echocardiogram, a common test, uses high-frequency sound waves to make pictures of the heart’s chambers, valves, walls, and blood vessels. Cardiac nuclear medicine involves an injection (depending on the type of exam) of small amounts of radioactive materials that travel to the area in the body being examined, providing a picture that helps the doctor evaluate for coronary artery disease or cardiomyopathy, among other things.
What else you should know: Today, cardiac imaging is such a broad field with so many choices that you may need to find a specialist within it that has very specific training. The appropriate imaging subspecialist can help determine whether one prescribed test might be used in combination with another to provide better information. Or an imaging specialist may provide imaging during surgical treatment—MRI and CT scans are commonly used to guide surgeons in some heart procedures, which makes the surgeon’s work more precise and less invasive, resulting in quicker recoveries for patients.
Learn about the Cardiac Advanced Imaging Program
Why you might need one: You have heart rhythm abnormalities (also known as arrhythmias), where heartbeat sequences are too fast or slow—or a heartbeat that is otherwise irregular. Your heartbeats may be traveling through the heart on an abnormal pathway, and you may be experiencing symptoms like weakness or fainting. (Arrhythmias are electrical abnormalities that can occur in the setting of heart disease, but may also occur in otherwise completely normal hearts. They can affect patients of all ages.)
What they do: Electrophysiologists diagnose and treat arrhythmias. “It can be critical to treat an abnormal heart rhythm, because some arrhythmias can be potentially life-threatening or carry an increased risk of stroke,” says Joseph Akar, MD PhD, chief of cardiac electrophysiology for Yale Medicine. Electrophysiologists may provide tests such as electrocardiography or wearable monitors—or long-term, implantable monitors—in order to record heart rhythm and diagnose the condition. They provide treatment ranging from lifestyle changes to medications to cardiac ablation, which deliberately creates scar tissue to eliminate electrical short circuits and even out erratic rhythms. Electrophysiologists also implant artificial pacemakers and cardiac defibrillators, which could be life-saving—they protect against sudden cardiac death, and improve heart function.
What else you should know: Radiation has been a recent concern with fluoroscopy, an imaging technology that provides electrophysiologists with a continuous X-ray image, so they can visualize their progress in performing a real-time procedure. Yale Medicine electrophysiologists use cutting-edge ultrasound and 3-D mapping technology to minimize radiation exposure to patients. Yale Medicine electrophysiologists have significant expertise in implanting leadless pacemakers, as well as other devices that prevent blood clots from forming in the heart and migrating to the brain during certain arrhythmias.
Learn about the Electrophysiology & Cardiac Arrhythmia Program
4. Adult congenital heart specialists
Why you might need one: If you were born with a heart issue (called a congenital heart problem), you will likely need specialized and ongoing care through adulthood. Adult congenital heart specialists help with the transition from pediatric to adult heart care—and will schedule a first visit at any age. New issues can surface at any time in life—even if you are feeling healthy—and these specialists can monitor you to detect them early and treat complications or new issues as they arise, helping to avoid urgent interventions. They can discuss exercise, fertility, and childbearing issues, and other lifestyle topics, and advise on scheduling routine checkups with them, depending on your situation.
What they do: Adult congenital heart specialists provide lifelong care if you have ever been diagnosed with a problem with your heart’s structure that developed before you were born, whether the problem was treated in childhood with surgery or catheterization procedures—or found years later. “When we routinely monitor an adult patient with a congenital heart defect and identify new symptoms as early as possible, we can limit complications or avoid them altogether,” says Robert Elder, MD, director of Yale Medicine’s Adult Congenital Heart Program.
What else you should know: A congenital heart specialist can advise on how your condition could affect the choice of medications for certain conditions—for women, for example, a congenital heart defect can affect the type of birth control they choose.
While some women who have had mild heart defects have successful pregnancies, they should still ask about any issues that could threaten their safety during pregnancy and labor—and about possible genetic risks for their baby. (Both men and women are at risk for passing congenital heart disease along to their children.)
Learn about the Adult Congenital Heart Program
5. Interventional cardiologists
Why you might need one: You are having chest pain that could indicate a blockage of an artery and you need an emergency evaluation. Or you have chronic symptoms, like chest pain or shortness of breath, and need to be evaluated for disease in the arteries or valves that call for further treatment. Interventional cardiologists treat a long list of conditions, from angina to aortic stenosis to heart attack. If you have a highly specialized condition, like congenital heart disease, valvular heart disease, or chronic total occlusion, you can seek out one with special training in that area.
What they do: Interventional cardiologists assess and treat heart conditions using nonsurgical, catheter-based procedures that involve inserting a thin, flexible tube through a small incision in the skin and through the blood vessels to the heart. They use this approach to place a stent to open a blocked artery, repair or replace a damaged heart valve, and perform other procedures. While open-heart surgery is still the most appropriate treatment in some cases, “many patients can’t undergo open-heart surgery due to their general medical health or age, and some don’t want to,” says Yale Medicine interventional cardiologist Yousif Ahmad, BMBS, PhD. “We’re able to improve their prognosis and make them feel better without open-heart surgery.”
What else you should know: There have been advances in interventional cardiology in the last five to 10 years. Notable ones are transcatheter aortic valve replacement (TAVR), which involves the insertion of a new heart valve, leaving the old one in place. (The new valve, which is collapsible, is inserted into the original valve, then expanded so that it can take over the job of controlling blood flow.)
Another is MitraClip™, a small clip that is attached to the mitral valve to help it close more completely. In addition, there is percutaneous coronary intervention (PCI), commonly known as angioplasty, for chronic total occlusion—angioplasty improves blood flow to the heart in patients with a 100% artery blockage who would otherwise need bypass surgery.
Learn about the Interventional Cardiology Program
Why you might need one: You are about to begin cancer treatment and have a personal history of cardiac disease; you are about to begin or are already undergoing cancer treatment with a therapy that has the potential for cardiac side effects; you are undergoing cancer chemotherapy, radiation, immunotherapy, or another therapy, and are experiencing cardiac issues; or, you are a cancer survivor who had these treatments at some point in the past.
What they do: Cardio-oncologists care for cancer patients by detecting, monitoring, and treating heart disease that occurs as a side effect of such cancer treatments as chemotherapy, radiation, targeted therapies, and immunotherapy. While these treatments can be effective for cancer, they can also affect organs and organ systems, including the heart and cardiovascular system. If a patient is showing signs of heart issues, cardio-oncologists may recommend closer monitoring, cardiac medications, or adjusting the cancer treatment.
What else you should know: Cardiac health is important for cancer survivors to be aware of years—and even decades—after their cancer was treated. “Survival of cancer patients has significantly improved as cancer treatment has improved,” says Dr. Baldassarre, who is also director of the Cardio-Oncology Program at Smilow Cancer Hospital. “They are living longer, and as a result, we’re now thinking about cardiac side effects not just as an immediate concern, but for years later.”
DEPRESSION: HOW KETAMINE CAN HELP (YALE MEDICINE)
Depression is one of the most common and most debilitating mental health disorders, affecting some 17 million adults in the US. It also continues to be a misunderstood, often hard-to-treat illness. Researchers have worked for decades to better understand the neurobiology underpinning depression.
For patients with severe, treatment-resistant depression, spending months or even years searching for good treatments can be totally disabling. The prevailing hypothesis for years was that depression was regulated by the neurotransmitter’s serotonin and norepinephrine.
Eventually, data began to suggest that maybe something much larger and more global was involved in the brain to account for depression, which led researchers to begin working with glutamate and GABA, the most abundant neurotransmitters in the brain. These chemicals are involved in neuroplasticity – the brain’s ability to adapt to change and protect itself against stressful events.
Neuroplasticity is a physical thing, too: it manifests itself “in terms of synapses, how these neurons are actually touching each other and communicating with each other,” explains Gerard Sanacora, PhD, MD, Director of the Yale Depression Research Program. “And we know that in depression, the number and strength of these interconnections decreases,” says Rachel Katz, MD, a professor of Clinical Psychiatry at Yale.
Ketamine – originally developed and still used as an anesthetic – works on those two neurotransmitters and was discovered to have rapid antidepressant effects. Some experience an improvement in symptoms in 24 hours or less. “We think that one of the things that Ketamine does, that helps to explain its antidepressant effects, is help the brain to regrow the synapses, the connections between nerve cells,” says John Krystal, MD, Chair of the Department of Psychiatry at Yale.
HEALTH: HOW DEPRESSION AFFECTS THE BRAIN (YALE)
For many people, depression turns out to be one of the most disabling illnesses that we have in society. Despite the treatments that we have available, many people are not responding that well. It’s a disorder that can be very disabling in society. It’s also a disorder that has medical consequences.
By understanding the neurobiology of depression we hope to be able more to find the right treatment for the patient suffering from this disease. The current standard of care for the treatment of depression is based on what we call the monoamine deficiency hypothesis. Essentially, presuming that one of three neurotransmitters in the brain is deficient or underactive. But the reality is, there are more than 100 neurotransmitters in the brain. And billions of connections between neurons. So we know that that’s a limited hypothesis. Neurotransmitters can be thought of as the chemical messengers within the brain, it’s what helps one cell in the brain communicate with another, to pass that message along from one brain region to another. For decades, we thought that the primary pathology, the primary cause of depression was some abnormality in these neurotransmitters, specifically serotonin or norepinephrine. However, norepinephrine and serotonin did not seem to be able to account for this cause, or to cause the symptoms of depression in people who had major depression. Instead, the chemical messengers between the nerve cells in the higher centers of the brain, which include glutamate and GABA, were possibilities as alternative causes for the symptoms of depression. When you’re exposed to severe and chronic stress like people experience when they have depression, you lose some of the connections between the nerve cells. The communication in these circuits becomes inefficient and noisy, we think that the loss of these synaptic connections contributes to the biology of depression. There are clear differences between a healthy brain and a depressed brain. And the exciting thing is, when you treat that depression effectively, the brain goes back to looking like a healthy brain, both at the cellular level and at a global scale. It’s critical to understand the neurobiology of depression and how the brain plays a role in that for two main reasons. One, it helps us understand how the disease develops and progresses, and we can start to target treatments based on that. We are in a new era of psychiatry. This is a paradigm shift, away from a model of monoaminergic deficiency to a fuller understanding of the brain as a complex neurochemical organ. All of the research is driven by the imperative to alleviate human suffering. Depression is one of the most substantial contributors to human suffering. The opportunity to make even a tiny dent in that is an incredible opportunity.
YALE MEDICINE: ‘WHAT CAUSES HEART FAILURE?’
The heart is a muscle and it’s main job is to pump blood but certain things can cause that muscle to fail. There are genetic reasons, there are reasons related to valve disease, and there’s a viral infection that affects the heart called myocarditis.
The most common cause of heart failure is a heart attack. Fatty plaque builds up in the blood vessel that supplies the heart itself and unless that blood vessel is opened up immediately that muscle will die. The rest of the muscle that’s not dead anymore has to do extra to keep on pumping the blood and overtime it cannot keep and that’s when heart failure develops.