There is no known cause for TS, but it is believed to be caused by both genetic and environmental factors. ^[2] Genetically, a person with TS has about a 50% chance of passing the gene to their offspring and is a condition of variable expression and incomplete penetrance.  In lay person’s terms, not everyone who inherits the gene will show symptoms and if it does exhibit symptoms, they won’t necessarily be the same as the parent.

TS is treated by identifying and helping the individual manage the most troubling or impairing symptoms.  Medication is available when daily activity impairs functioning.  Typical and Atypical neuroleptics are used with the most identifiable being Risperdal, Geodon, and Haldol.  Receiving a diagnosis of TS is not a death sentence.  There have been many notable and accomplished athletes Tim Howard (MLS) and Steve Wallace (NASCAR), that have channeled the energy of their tics into a functional endeavor. ^[3] The Tourette’s Syndrome Association is an organization that provides a source for supports groups as well as raising awareness for this disorder.  There are several state and city TS societies that can assist you with finding a support group or educate you with this disorder.

Claghorn-Lesem Research Clinic will be enrolling in two Tourette’s studies for children and adolescents starting in September.  To see if your child qualifies, please call the clinic 713.965.7846 or visit our website, www.Claghorn-Lesem.com.

[1] http://www.ncbi.nlm.nih.gov/pubmed/17937978

[2] Walkup JT, Mink JW, Hollenback PJ, (eds). Advances in Neurology, Vol. 99, Tourette Syndrome. Lippincott, Williams & Wilkins, Philadelphia, PA, 2006, p. xv.

[3]  http://www.ncbi.nlm.nih.gov/pubmed/16536348

In the U.S. population (300 million), the prevalence of MDD is about 20 % (60 million) will have MDD at least once in their lifetime.  Of these 20%, 60% (36 million) will have only one episode.  40% (24 million) will have recurrent episodes and about 50-60% (12 -14 million) of this group will have less than 50% reduction of symptoms with adequate treatment.  So when you do the numbers, 4-6% (12 – 18 million) of the population has treatment-resistant depression (Cases of MDD that do not respond to adequate courses of at least two antidepressants).  If the average person with recurrent depression has seven episodes in their lifetime, as the demographics indicate, and the suicide rate is 2% with each episode, then recurrent depression has a 15% mortality rate.

Treatment-resistant depression is difficult to treat due to the fact that a patient has already failed to respond to at least two courses of action. Of the medication that is on the market, Prozac was the last breakthrough in medication, however Ketamine may be the next. Intravenous (IV) Ketamine at subanesthestic dosing caused 30-35 % of long term treatment resistant depressed patients to remit completely within 24 hrs of 1 treatment.  It also showed that 90% of these same patients remitted completely again after one treatment, inclusive of suicidal ideation. The challenge with Ketamine is that responders stay well an average of 2-3 weeks after the first treatment and finding a way to administer the medication in a more efficient manner without the hassle of an IV set-up.  Alexza pharmaceutical has perfected a technology called the Staccato System. When the patient draws a normal breath through the Staccato system, the substrate surface instantaneously heats to create a condensation aerosol. The patient inhales perfectly sized particles of pure drug down into the narrower, more vascularized tissue of the deep lung, allowing fast and more complete absorption into the bloodstream. ^[3] So in the next few years, we may be able to rapidly and completely treat depression without resorting to IV infusion using their simple and safe technology.  It is the hottest topic in psychiatric research now. 

In the next few days, Claghorn-Lesem Research Clinic, will be enrolling in a MDD clinical trial.  To see if you qualify, please call 713.965.7868 or visit our website at www.Claghorn-Lesem.com.

[1] http://en.wikipedia.org/wiki/Major_depressive_disorder

[2] Hersen, M., Turner, S.M. & Beidel DC (Eds). (2007). Adult Psychopathology and Diagnosis (5th ed.). Hoboken, New Jersey: John Wiley & Sons Inc

[3] http://www.alexza.com/about/the-staccato-system

Since its use by the Native Americans, tobacco has been at the forefront of our culture. Endorsed by physicians in the 1950’s and marketed by rustic cowboys and smooth cartoons, cigarettes companies have made fortunes selling their product to the masses.  Until recently, cities have instituted city-wide bans restricting the use of smoking tobacco inside public places, including bars and restaurants, due to the correlation of second hand smoke and protecting the people who choose not to smoke.

The mechanism, or pharmokinetics, of nicotine enters the body through inhalation of cigarette smoke or by contact in the mouth via: snuff, snus, dip, or chewing tobacco, and is released into the bloodstream.  It takes an average of seven seconds before it reaches the brain and has a half-life of about two hours.  Nicotine binds to receptors in the brain and increases levels of dopamine causing euphoria and relaxation that can lead to addiction and possibly death at toxic doses.  With prolonged use, smoking cessation becomes increasingly difficult and can result in withdrawal symptoms. 

There has also been an observation in the number of people diagnosed with depression and the prevalence of smoking.  It also showed that there was a higher frequency of major depression in smokers than non-smokers. Although, nicotine does not cause cancer, the smoke generated from a lit cigarette produces hydrocarbons that may cause cancer.  The chemicals in cigarette smoke may affect mood the same way an antidepressant medication called monoamine oxidase inhibitors (MAOIs).  MAOIs effectively increase levels of specific neurotransmitters involved in regulation of mood, and therefore  allows the person to self medicate.^[2]  Chantix, varenicline Tartrate, is a prescription drug that can be used to alleviate some of the withdrawal symptoms and can be used as an aversion therapy to make smoking repulsive.  Claghorn-Lesem Research Clinic, 713.965.7868, is currently enrolling in a clinical trial testing the effectiveness of Chantix in people diagnosed with depression and who would like to quit smoking.  To see if you qualify for the study, please call or visit our website, www.Claghorn-Lesem.com.

[1] http://www.ncbi.nlm.nih.gov/pubmed/17897974
[2] http://psychcentral.com/library/depression_smoking.htm

Currently there is no single accepted or consistent cause established for the cause of mental illness.  As mentioned earlier, genetics exposed to environmental stimuli may be the cause.  Some studies have shown that genes play a role in the development of mental disorders as well as; traumatic brain injury, substance misuse, abnormal functioning of neurotransmitters, abuse, and psychological mechanisms (cognitive, emotional, personality).  Mental health problems are primarily assessed and treated by family physicians, which may refer the patient to a specialist for diagnosis in acute or chronic cases. Below are the steps taken during the process:

1. Interview – mental status examination (behavior, appearance, self-reported symptoms, mental health history, and current life circumstances)
2. Physical Examination –check for ill health and effects of medication
3. Psychological Testing – computerized questionnaire and neuroimaging test (CT scan)

Some physicians may inaccurately misdiagnose a patient due to time and budgetary constraints with some involving nutritional deficiencies leading to an inaccurate diagnosis as well as comorbidity – the same person given a diagnosis in more than one category.

The DSM-IV categories mental health disorders in five different levels called Axis:

• Axis I: Clinical disorders, including major mental disorders, and learning disorders
  • Depression, bipolar disorder, anxiety, ADHD, autism, schizophrenia
  • Axis II: Personality disorders and mental retardation (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)
    • Borderline personality disorder, OCD, narcissistic personality disorder
  • Axis III: Acute medical conditions and physical disorders
    • Brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders
  • Axis IV: Psychosocial and environmental factors contributing to the disorder
  • Axis V: Global Assessment of Functioning or Childrens  for children and teens under the age of 18

For example, Bipolar disorder is a condition in which people experience abnormally elevated and abnormally depressed states for periods of time.  It is estimated to afflict 5 million Americans (1 out of every 45 adults).  Bipolar disorder is often misdiagnosed as Borderline Personality Disorder.  Both borderline personality and bipolar disorder can involve what are referred to as “mood swings”.  In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood which generally last weeks or months.  The term in borderline personality refers to the marked liability and reactivity of mood, known as emotional dysregulation, due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days.  A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.   Some hold that borderline personality disorder represents a sub-threshold form of mood disorder, while others maintain the distinctness, though noting they often coexist.

If you have been diagnosed with Bipolar Disorder and would like to see if you qualify for a clinical research study, please call 713.965.7846.

The first part of the clinical trial at the investigators site is the screening phase.  At this point the Informed consent is reviewed and includes the trial details; such as its purpose, duration, required procedures, risks, potential benefits and key contacts.  Since all clinical research is voluntary, the patient can withdrawal at any time.  If the patient meets criteria, they enter into the study phase, which is driven by the protocol – a precise study plan for executing the clinical trial, not only to assure safety and health of the trial subjects, but also to provide an exact template for trial conduct by investigators at multiple locations (in a “multicenter” trial) to perform the study in exactly the same way.  In some studies the patient will receive a placebo or the study medication. Part of the experiment involves a control group to test the efficacy of the study medication.  Usually both the investigator and patient are blinded to which of the two will be assigned during the study phase.  After the participant has successfully completed the study phase, the investigator site will follow up with the patient to observe and record any changes in appearance and to document the effects of medication.

There are five steps that a new investigational drug takes before it is approved by the FDA.

• Pre-Clinical – studies in test tubes and animals or cell cultures to obtain preliminary information.
• Phase I – Normal volunteers, First time in man. PK & toxicology
• Phase II – Safety & Efficacy with subjects who have the targeted illness and dose finding trials
• Phase III – Pivotal large scale trials. Compare to standard therapy. 70% of studies that reach this phase become approved by FDA.
• Phase IV “Post Marketing ” – Compare to competitors, explore additional patient population

The research facilities are monitors and regulated by two agencies, the FDA and the Institutional Review Board (IRB).  The FDA can audit the research clinic after a drug has been completed at random or if it suspects the clinic of fraudulent data.  The IRB monitors all advertising and the Informed Consent.   One of their main functions is to ensure that potential patients are adequately informed about the clinical trial.  All patient information is protected by Health Insurance Portability and Accountability Act (HIPPA).

Last but not least, a brief history lesson about the origins of clinical research.  In 1025 AD, Avicenna laid down rules for the experimental use and testing of drugs and wrote a precise guide.  One of the first famous clinical trials was James Lind’s demonstration that citrus fruits cured scurvy.

Currently we are enrolling in several Schizophrenia studies. Please call 713.965.7846 to see if you are eligible.

It gets confusing for patients seeking liposuction, trying to figure out which procedures are effective and also who is competent at performing these procedures. Board-certified plastic surgeons, needless to say, are the best trained and most experienced at these techniques. I have seen nice results in patients treated by “cosmetic surgeons” but there is often no way to know the quality of their work. Many physicians operate out of office suites. There is no regulatory agency, such as a hospital, to monitor the qualifications of the physician and safety of the office operating suite. Board-certified plastic surgeons ,who have office operating suites ,are required to be accredited by one of the national agencies that accredit ambulatory care centers. It behooves the patient to verify both the physician and his facility.

There are many innovative liposuction techniques that have been developed over the last 10 years. In an effort to improve results, lessen downtime, lessen pain, and make procedures more affordable, the manufacturers ,together with clinical physicians, have introduced various ways to remove the fat, both surgically and non surgically.

Early liposuction procedures in the 70s and 80s involved what was known as the dry technique ,where the cannula was introduced through a small incision ,into the fatty tissue layer and the fat was suctioned. This tended to be a very bloody procedure and blood loss limited how extensive a liposuction could be done. In the late 80s, the introduction of fluid that contained an anesthetic, as well as epinephrine to shrink blood vessels ,not only reduced pain but also significantly reduced bleeding and improved results. This is known as tumescent liposuction. Tumescent liposuction has remained a mainstay technique but new twists have been added.

Ultrasonic liposuction was developed in the 90s. This technique introduces a solid cannula after the fluid was placed into the fatty layer. The cannula emits ultrasonic sound waves that convert to heat. This breaks up the fat cells, allowing them to be suctioned out with a hollow cannula more easily. Two of the more popular models are the VASER and Lysonix. A power assisted cannula was also introduced that works like a miniature rotor to pull the fat cells out. This is called the P.A.L. system.

As more physicians started to operate out of their offices, they looked for techniques which were not as invasive or could be done with minimal anesthesia. Laser assisted liposuction (SmartLipo, SlimLipo, CoolLipo) utilized different wavelengths of light to help break up the fat cells. SmartLipo has recently come out with a new generation machine called the triplex. This machine uses three different wavelengths to break up the fat, minimize bleeding, and tighten the overlying skin. To be more effective, one follows the SmartLipo with traditional suctioning. Care must be taken when using these machines ,since they can burn the overlying skin and temperature at the tip of the cannula must be monitored.

Using a jet stream of water to break up the fat is another technique. This is called BodyJet and is relatively new. The philosophy behind it is that the cold water effectively removes the fat, kind of like pressure washing works on me driveway.

There are many physicians who are intersted in getting into the nonsurgical side of liposuction. They utilize external ultrasound to break the fat up, cold temperature (cryo- lipolysis) and external laser beams. None of these are nearly as effective as surgical liposuction.

Mesotherapy, or the injection of chemicals into the fatty layer to dissolve the fat, has become popular over the last five years. There was a national chain promoting the technique in spas and salons around town as well as in doctor’s offices. The results were disappointing and the company eventually filed bankruptcy. The problem with mesotherapy is that patients had to have five or six injections spaced four to six weeks apart. The injections were painful and the cost for the injections ended up being as much as having surgical liposuction ,where the results are seen much more quickly and much better.

Since liposuction is done in the fatty layer, it can be done successfully with local anesthetic in the infiltration solution, and oral or intravenous sedation. For large volume liposuction or liposuction where the patient is being turned from their back to their stomach, general anaesthesia allows better control of the patient’s airway.

Even though patients will see an improvement within a week, I explain to my patients that it takes up to five months to see the final result. This is especially true with large volume liposuction (I’ve done up to 17 L) ,and with liposuction on the thighs. With liposuction of more than 5 L, it is prudent to consider keeping the patient overnight in a facility to monitor their vital signs, since the local anesthetic injected takes a while to metabolize out of the system.

As I stated previously, patients seek healthcare options when local care does not meet their needs. These may be a financial issue, a quality of care issue or an accessibility issue. For most Americans going overseas it is a financial issue. Not only are cosmetic procedures less expensive but also reconstructive procedures such as joint replacement surgery, cardiac surgery, and fertility surgery. Healthcare insurance companies in the US are even encouraging their patients to have procedures done overseas where they are less expensive.

Countries such as Canada and the UK which have accessibility issues due to socialize medicine, traveling to the US, which is known as having the best care healthcare, is an important destination. So are other countries that have US trained physicians and first-rate facilities. Patients in countries that don’t have first-rate healthcare facilities will often seek healthcare in the US.

The big concern for patients seeking overseas medical care is finding a quality facility in quality healthcare provider in a country that is also safe to travel to. An organization called the World Medical Tourism Association is an organization that seeks to promote affordable quality healthcare and helps arrange for patients these services. They screen healthcare providers and facilities both domestically and in foreign countries. They also facilitate travel arrangements and postoperative care once they return to their home country. One of these companies is MedVoy, based in Denver and run by a physician will who is a professor at the University Colorado.

I have seen patients in my practice who have had cosmetic procedures done in foreign countries. Some of the results have been quite good but some have had poor results. The problem with going overseas is that patients have no recourse and that secondary reconstructive work done once the patient returns here could end up costing more than the initial surgery would’ve cost of the would’ve been done here.

If a patient is contemplating overseas surgery, they should thoroughly investigate the process, consult the Medical Tourism Association, and be fully aware of the risks and benefits involved.

It’s important that patients continue to exercise and eat properly in the perioperative period. Having good muscle tone and good cardiovascular capacity will help them through the postoperative period. Proper nutrition is essential to good healing. I encourage my patients to eat a lot of fresh fruits and vegetables, particularly during the summer, as well as have adequate protein intake with fish, meat, and soy products. Multi vitamins are also important, since many patients are lacking trace minerals such as zinc in their diet. Iron supplements are important, especially for women and for endurance athletes such as long-distance runners, cyclists and swimmers. Those athletes tend to be on the anemic side. Being anemic limits the oxygen carrying capacity of your blood and could affect wound healing.

My patients who are active exercisers always ask “When will I be able to start exercising after surgery?” I try to encourage them to be up and walking the day of surgery, to minimize the development of venous thrombosis (blood clots) in their legs as well as to improve their breathing and decrease the chance of developing postoperative respiratory problems. More extensive procedures such as tummy tucks will require limiting the exercise routine in the first 10 days. I follow my patients very closely in the early postoperative period and will gauge their progress and allow them to exercise accordingly. It’s important to start slow and gradually increase your exercise routine. I don’t want a patient to put too much stress on a suture line and increase the risk of hypertrophic scarring or wound separation.

Postoperatively, it is also important to drink a lot of water, to help flush out the anesthetic drugs from your system. Stool softeners and fresh fruits are important in patients taking painkillers like hydrocodone. High-protein diets and diets rich in vitamin C and E. are also important after surgery. I myself eat 5-6 small meals per day instead of large meals. I call it “grazing,” but it keeps your metabolism at a high rate and makes you feel less sluggish.

I always tell my patients that surgery is only part of the overall plan to improve your appearance. Proper diet, exercise, and a positive attitude are just as important in helping you to look your best and feel your best.

1. What Factors Could Keep Me from Becoming an Implant Candidate?

Most people can handle implant surgery with no problem. However, if you have certain chronic conditions, then most Houston implant dentists would advise against an implantation.

These conditions may include uncontrolled diabetes, or if you are undergoing radiation therapy or chemotherapy for cancer. If you have certain blood or bone disorders, you may not be an ideal candidate for a dental implant.

Certain physical characteristics, such as poor bone quality, lower than average sinuses, and lower than average nerve bundles can keep you from being an ideal candidate. Bone grafting can be done to help patients with poor bone structure, enabling them to have an implantation.

2. How Can I Help Make My Surgery Successful?

The best thing you can do to ensure the success of the procedure is to follow all the guidelines set forth by your cosmetic dental practice. When you begin the process, your dentist will outline a meticulous dental hygiene routine for you to follow; be sure to follow it to the letter.

Education will also go a long way to making your implantation a success, so make sure you understand the procedure well in advance. Nervous patients in particular should read up on the process; often nervousness is a by-product of not understanding a situation or feeling out of control. By reading about the procedure, patients put themselves in control.

3. How Long Do Implants Last?

If you follow your dentist’s recommendations, you should be able to keep your implants for 15 to 25 years with no problem. This means following a thorough oral hygiene routine and avoiding any foods, drinks, medications, or other potential problem-causing situations that could mar the stability of your implants.

4. Is There a Chance of Rejection?

Rejection is rare, but it is possible. If this happens, it’s not like an organ implant rejection, such as your body rejecting a transplanted kidney. Instead, what may happen is the titanium peg may fail to set properly within your jawbone. If this fails to happen, due to misalignment or any other issue, your dentist may decide to allow your mouth to heal and then give it another go.

5. Can I See the Results?

If you are unsure about having teeth implants, specialist dentists who can help you make the right decision for your needs. You should ask to see before and after photos to get an idea of the quality of work your dentist can do.

If you are worried about the procedure itself, you may want to view a video or have the process outlined so you understand what will happen in advance. You may also ask your potential dentist for patient recommendations, as it often helps to set your mind at ease if you talk with another person who has gone through a similar procedure.

Instead of sending all of the suctioned fat to the waste disposal, techniques for autologous fat grafting have been refined and its uses increased. By autologous means that the fat is your own fat. Plastic surgeons have learned that as we get older, we lose soft tissue volume such as in our face. This is one of the reasons why our face sags as we age. Fat grafts have been around for decades but they have not been very reliable. There is been discussion as to whether fat grafts live better if they are taken as actual tissue grafts versus fat that has been suctioned and then reinjected.

Dr. Sidney Coleman, a New York City based plastic surgeon, is probably the most well known developer of fat reinjection techniques. New instrumentation allows us to remove fat causing less damage to the fat cells.

When patients undergo liposuction and desire fat reinjection, the procedures are done at the same time. The removed fat is washed, centrifuged into a more concentrated volume and then reinjected with small injection cannulas.

Although reinjection into the face is the most common area, fat can be reinjected to correct defects from previous liposuction, for buttocks augmentation, and to repair traumatic soft tissue defects.

It has always been controversial as to whether fat can be reinjected into the breasts as a safe means of breast augmentation, without the necessity of breast implants. The concern is that, if some of the fat doesn’t survive, it could cause more of a deformity. In addition ,calcifications may develop in the dead fat ,which could cause confusion on future mammograms as to whether breast cancer exists.

In 2009 the American Society of Plastic Surgeons had a task force review a multitude of evidence-based cases to study this very real concern. The report stated that there was no indication that fat grafting was an unsafe procedure ,however, the report did not make strong recommendations in favor of or against fat grafting ,for specific applications or treatment regions, just that more research was needed

Plastic surgeons at the University of Tokyo has done some studies ,treating 400 patients with fat grafts augmented with stem cells, for breast augmentation and have gotten very impressive results. It would be nice if this proves to be the case, that breasts could be augmented with the patient’s own fat.

One thing that is definite, and that is that successful fat grafting is a tedious procedure that even in the best of hands may not give consistent results. If you are interested in soft tissue augmentation, consult with your plastic surgeon if using your own fat as a soft tissue graft is feasible.