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Interviewer: Wave therapy for erectile dysfunction. We're going to learn more about that today, including what is it and are all wave therapy machines created equal. Dr. John Smith is a urologist at University of Utah Health.

So I've heard of this thing called wave therapy for erectile dysfunction. Can you tell me a little bit how that works? What's going on?

Dr. Smith: Yeah. So the wave therapy machines, there's a few different types and we'll get more into that later. But the idea is, these machines put off a wave similar to like an ultrasound machine where there's a wave coming out of the machine and those waves are meant to help stimulate the tissue for regrowth of blood vessels is what you hear a lot of times on a lot of the advertisements.

And that's what a lot of the research has been shown to do is as these machines are used, that it causes the body to have an increase in the factors that cause regrowth of blood vessels and that's how they work.

Interviewer: All right. And how does that help somebody who is suffering from erectile dysfunction?

Dr. Smith: So a lot of times with erectile dysfunction, you know, it can be as simple as, you know, the blood flow issues. It can be not enough going in, too much going out, those types of things. But a lot of times these wave machines will help to regrow or regrow blood vessels to help more blood go into the penis. Because the erection is pretty much the two chambers on the top of the corporate cavernosa get filled with blood. They become very erect, they become stiff and rigid and that's what gives a good quality erection. And so the more blood flow you have and the more quality blood flow you have, the better quality erections you have.

Interviewer: So individuals that have erectile dysfunction, some of them, it might be because they're not getting enough blood flow. So the sound waves, if I'm correct on this wave machine, actually it helps stimulate more blood vessels. You get more blood in there and then it's just hydraulics. You fill that up and you get a better, more sustainable erection.

Dr. Smith: There's couple of different types of machines and you mentioned sound waves. The most of the literature has been done on the mechanical wave, more of the ESWL machines, a similar type wave that they use to break up kidney stones.

However, there's multiple types of machines. Some of the machines do use acoustic waves or sound waves versus these mechanical waves to do it. And the research has been done with the mechanical wave machines, which have been shown to do a lot more. And the acoustic wave machines haven't really shown to be super beneficial in the research.

Interviewer: So an acoustic wave-like when you get super close to a speaker and you can feel the vibrations, is that what we're talking about with those machines?

Dr. Smith: Similar, yeah. It's an acoustic style wave machine, whereas a mechanical type wave machine uses more of a mechanical pulse wave similar to like I said, breaking up a kidney stone with the shock wave. So they'll call that a shockwave treatment versus the acoustic treatment. And the shockwave treatment has been the one with a lot of the research done over in Europe and other parts of the world to show improvement in regrowth of blood vessels.

Interviewer: So not all wave machines for treating erectile dysfunction are created equal. Now, how do you know the difference? How would a consumer know which machine they're getting when they show up?

Dr. Smith: You would want to be very, you know, you'd want to ask the right questions. What type of machine do you have? There's quite a few different types of machines. And, you know, you'll hear a lot of different things from different people, but the acoustic machines, if you look at the research and actually looked up the studies, the studies have been done with the shock wave machines.

And the shock wave is not new, it's been around for quite a bit of time. It started with kidney stones, where they used to put people in a big bathtub to break up kidney stones. And now they have handheld units with this shockwave therapy and it's actually used quite a bit and is FDA approved in the sports medicine arena for things like plantar fasciitis and other issues that way.

And it's still experimental and not FDA approved for erectile dysfunction, but it is being used for erectile dysfunction as kind of an off-label use because there has been good data that shows increased growth, increased rejuvenation, or neovascularization where there's new blood flow in the area.

Interviewer: And what kind of wave machine does University of Utah Health have?

Dr. Smith: We just actually got a new wave machine and it is the shockwave machine. We made sure we did as much research as we could, knowing that this is kind of a hot topic. A lot of people are very interested. And I get asked about it quite a bit.

And so, in the men's health department, we had a lot of patients who came in and asked quite a bit about it so we did the best research that we could to find a machine that could possibly give us the best benefit.

Now we're very selective with our patients at the University of Utah, for who we would recommend this to because it's not covered by insurance, it's relatively expensive. And again, you have to pick the right folks in order to get a good result. For someone who has a mild erectile dysfunction, someone who's taking pills and doing rather well with them, they may be able to come off the pills completely or need a lower dosage of the pills.

This isn't for someone who has a severe erectile issue after they've had a surgical procedure like a prostatectomy or something like that. It's not going to give them their erectile function back in those instances. This is for a very mild to mild-moderate erectile dysfunction. Those are the people who've really seen a benefit from this machine.

Now, if someone really wanted to say, hey, can you do it? We could do it, but I would very much caveat that to this likely is not going to help you.

And that's really the biggest thing for me is making sure that patients understand the expectations because this is not an FDA-approved treatment for erectile dysfunction yet. However, in the future, it may be as long as the research continues to look promising.

Interviewer: And after those treatments, you said you continue to monitor the patient to see how things go. Generally, are there a lot of follow-ups after that or once the treatments are done and those new blood vessels have grown, generally they survive pretty well and things work out?

Dr. Smith: So depending on the patient's medical history, but a lot of times, right now, we're still working out our protocols because this is relatively new that we have this machine. But again, you know, a lot of these folks, if they're rather healthy individuals who may have just had a blood flow issue, you know, they should be good and it should continue to be beneficial for them for a duration of time.

For folks who may have other medical problems, like people who are diabetics, who are going to have vascular issues, people with cardiovascular disease who are going to continue to have progression of those things over time, those would be people who are going to continue to follow up with us and make sure that, you know, things continue to stay well.

Interviewer: If somebody is having success with the pills, why would they choose the wave machine? Why are people choosing to come off the pills?

Dr. Smith: That's a long discussion that I have with patients, because the big thing is, is people are always looking for the easy, quick fix. And a lot of times the advertisements that they've heard make the wave therapy seem like a quick fix. And, you know, with the shockwave therapy, it can be beneficial, but again, a lot of these people don't understand that, you know, sometimes they may not be a good candidate or it may not be beneficial for them.

So after that discussion, a lot of them will continue with the pills, knowing, you know, the cost of the procedure is relatively, it's not covered by insurance so it costs a little bit more than everything else.

But the main people who will come in and just say, I want to get off of pills, I don't like taking pills, and if there's any possible way I can not have to take pills or not have to do that because erectile dysfunction pills can be somewhat cumbersome. If you have to take them an hour before sex on an empty stomach that can be kind of less spontaneous or, you know, other things, if you've had side effects to the medication, those would be the people who would generally look for another alternative.

I would talk with a professional. Talk with them, ask the right questions. What kind of machine is this? What can I expect? And look at the literature, you don't have to be a scientist to be able to look at it and see, but look at what's been done. And there is some good information out there about it but the shockwave machine has been the one that's shown the most promise of being able to improve erectile dysfunction. I would just say, make sure you're getting what you think you're getting.

Interviewer: We're here with Dr. Barbu Gociman, a craniofacial surgeon and the Medical Director of the Cleft Center here at the University of Utah. Dr. Gociman, when does a parent usually find out that their child might have a cleft lip or a cleft palate?

Dr. Gociman: Here in the United States, most cleft lip patients are diagnosed with their condition during pregnancy. So the parents will know that the baby is going to be born with a cleft. By contrast, when the babies have only a cleft palate, usually the diagnosis is not obvious on ultrasound and is not made prior to birth. So the diagnosis is made in the first day of birth.

Interviewer: So what are some of the things that a parent needs to be doing those first few months with their child to make sure that . . . how early are they getting surgeries? What do they need to be doing the first couple months?

Dr. Gociman: Considering what the problems are, as we said, the lip, the gum, the hard and soft palate are involved. One of those structures or all of them, you can imagine the baby will have difficulty with feeding, with suckling. If a cleft lip is present, they cannot create a seal around the nipple. If there is a clefting of the palate, the babies will have a very hard time developing suction. Specialized devices are needed to provide adequate caloric intake, meaning adequate amount of milk or formula to keep with the needs of the newborns.

Interviewer: When does the first surgery usually take place?

Dr. Gociman: For a cleft lip patient, if we assure adequate nutrition, there are no other anomalies associated with the condition, and the baby grows normally, the timing is approximately three months of age. And the reason for that is the baby has grown sufficiently enough to withstand the anesthesia without any additional risk, and all the structures that are involved in the cleft are bigger and stronger, and the operation is performed easier, with less risk of things breaking down or having other complications during the surgical procedure.

Interviewer: What happens during those first three months while you're waiting for the child to get stronger? Who should they be visiting?

Dr. Gociman: Here at the University of Utah, we have an excellent system in place to assure that all the needs of cleft patients are met. For a cleft lip patient, the diagnosis is most of the time made prenatally, so the parents already had a prenatal visit with the nurse coordinator, with the physician assistant in charge of the cleft team, and with the craniofacial surgeon that will perform the repair. So they already have a good idea of what is coming.

Once the baby is born, especially if it's born here, close, at the university hospital, or even at a hospital in close proximity, a cleft surgeon will visit with the family, evaluate the exact anatomy of the cleft, and start with the process of treatment. And this involves two major elements in the first three months of life. One is assuring adequate feeding, and, as I said, there are different modalities through which this is achieved with specialized nipples, specialized bottles, specialized techniques of holding the baby to prevent regurgitation.

And the second thing that is as important is what we called molding. We are trying to achieve normal anatomy. Due to the lack of continuity in the muscles of the lip and the palate, the elements that compose those structures can migrate apart, and the anatomy becomes very difficult to recreate. So in those first three months of life, we attempt to bring all those structures together. We try to reshape the nose, the lip, the alveolus, and the palatal shelves.

Interviewer: Seems like the treatment of cleft lip and cleft palate has more than just the surgical components and just the restructuring. There's also speech. There's also feeding. There's also socialization. What sort of resources are available to a new parent here with the cleft team?

Dr. Gociman: We have a comprehensive cleft team. First, we see the patient right after birth to assure adequate feeding and the molding has been started. And at the same time, we schedule a clinic visit with the cleft team so the family gets a chance to visit with all the members of the team. And each member has an important role in cleft care. So the team is made up of a cleft craniofacial surgeon, an ENT surgeon, pediatric orthodontist, a speech therapist, feeding specialist, and a social worker. So the reason for that is to assure that all the problems encountered in cleft are addressed from the beginning and the family has a complete understanding on all the steps and all the elements that need to be addressed.

As such, the cleft surgeon will talk about a cleft repair, the sequence of different operations based on the particular anatomy of the patient.

The ENT surgeon will talk about hearing. Most cleft babies have a hard time with draining the ears and have significant infections of the middle ears and require tubes early on. Also, they have to assure later on that the speech is adequate, possibly perform speech correction surgeries down the road.

The orthodontist, as I said before, initially will have a very significant role in performing the molding and then, later on, in assuring eruption of the teeth, orthodontic work, and help with any orthodontic operations.

The speech therapist will be there, initially, to help with feeding, assure that the method that is most effective is used, and then, later on, as the speech starts developing, address any problems, involve the patient in speech therapy, and so forth.

Finally, the social worker is there at all steps of cleft care just to address any social problems that may arise, and we have quite a long number of issues that arise in our cleft patients. So it's a very useful component of the team.

Interviewer: So I understand that cleft care can be a long process. It's years and years of treatments and procedures. But it seems like this type of team can really help set a child and their family on the right path and get them started and give them a step up.

Dr. Gociman: It has been shown over and over again that having a cleft team and having a professional cleft team makes all the difference. This is a standard across the United States. We are proud to have the largest, oldest, dare I say, the best team in Utah and in surrounding states. So we are getting patients from all the states around us. We pride ourself with our results, with innovation. We publish a lot. We are actively involved in research. And we are always trying to improve our technique and our results. We are very critical with our results, and we are trying to achieve perfect outcomes every time.

Interviewer: We're here with Dr. John Rolston, the Director of Functional Neurosurgery, and Dr. Matthew Alexander, he's an Assistant Professor of Radiology and Neurosurgery here at University of Utah Health. Let's start with just kind of talking about essential tremors. What is an essential tremor and what does that mean for patients that have it?

Dr. Rolston: So essential tremor is the most common movement disorder that anyone in the world has. So it's a movement disorder characterized by uncontrolled tremors or movements of typically the hands, but sometimes the voice and head too. These movements are pretty common around eight times per second when they happen, and they can start disrupting people's lives. So with a really bad tremor, it's hard to do things like sign your name, write checks, hard to eat or drink from a glass, hard to eat soup with a spoon. It can become so disabling that people are unable to do these activities at all. And that's when they start to, and before them, when they start to approach us for medical treatment or surgical treatment.

Interviewer: And so you're saying eight times a second? Is that all day long?

Dr. Rolston: All day long, all the time, except when you're asleep when it goes away. But when you're doing any sort of activity, it's there and prevents you from doing all these normal things you used to do like talk on the phone or type on a keyboard.

Interviewer: And what causes it?

Dr. Rolston: We don't really know yet. So even though it's the most common movement disorder, the amount of research that's been done for it is far dwarfed by the amount that's been done with other diseases like Parkinson's. So we're still trying to find out the underlying mechanisms for what causes it. But we do know that it's definitely involving circuits in the brain. We know this because changing how these circuits function can improve the tremor, which is the basis of our surgical therapies for a tremor.

Interviewer: And Dr. Alexander, when someone comes with an essential tremor, how do you diagnose it? What do you look for? What do you . . .

Dr. Alexander: So it's fairly obvious to us by the time they get to us, but it's usually a progressive disease that has gone over the course of decades. There can be familial variants. So some people experience this starting their 20s, 30s. I've heard of some people even in their teens. Most people, it's, you know, middle-aged folks start to notice it. And it's usually just kind of a tremor that they have in their hands. They might notice it gets a little worse with intentional movements. But it's a progressive disease. And so they'll notice over years that it gets worse and worse and worse. And so by the time they get to us, because we only treat the most advanced cases, it's a pretty easy diagnosis to make. And it's often been made by someone in the community, either a primary care physician or someone in neurology that that patient has been referred to.

Interviewer: And Dr. Rolston, after you have the diagnosis, you're seeing these people, they have this really debilitating tremor in their lives, what is the way that it's typically treated or used to be treated?

Dr. Rolston: Sure, that's a great question. So the way we typically start treating these patients is with medications. So there's only one FDA-approved medication for essential tremor, and that's propranolol. The brand name is Inderal. So many patients are prescribed this if they can tolerate it, if they're not forced out by the side effects of low pulse, dizziness, lightheadedness. Then, they can go and take this medication, and it might reduce the either frequency of the tremor or the amplitude of the tremor, so basically how much it's affecting them.

There's other drugs when that one doesn't work. There's another drug called Primidone, which is very common. It's actually an anti-seizure drug. This one also has a lot of side effects, so dizziness, tiredness, that a lot of people can't tolerate. Once those two medications have failed, there's a lot of other more experimental drugs people try. But when the first two primary drugs fail, the chances of one of these third or fourth-line therapies working is pretty low. And that's when surgical therapy becomes more of an indication.

Interviewer: What is the typical way of doing the surgery? I mean, we're talking brain surgery, right?

Dr. Rolston: Yeah. So they've known since the 1950s that if you go to these small little parts inside the brain . . . they're called the ventral intermediate nuclei of the thalamus. So there's two of these. They're both pea-sized little pieces of tissue deep inside the brain, kind of toward the middle of the brain. There's one on the left and one on the right.

If we damage either one of these . . . We noticed, back in the '50s again, that there was a substantial improvement in the tremor on the opposite side of the body. So if you injure or get rid of this left-sided one, you can see an improvement in the tremor on the right side and vice versa. The way we used to do that was with an open brain surgeries. We would make a hole in the skull, insert a fine needle, heat up the tip of the needle, and burn out this small little pea-sized area. This worked great, but it involves a hole in the head, which is a big deterrent for a lot of people to seek this therapy.

Interviewer: Understandably.

Dr. Rolston: Yeah. In the 1990s, they developed a deep brain stimulation, which puts a wire in the same location, but instead of damaging that part of the brain, it stimulates it electrically with a pacemaker that sits in the chest. And that's very effective. And that's what we've been mostly doing for the past couple of decades now.

Interviewer: But it's my understanding there's this new ultrasound-assisted . . . what is it called?

Dr. Alexander: MR-guided focused ultrasound. The MR is for magnetic resonance, so like an MRI machine, which is actually where we perform the surgery.

Interviewer: Inside the big tube?

Dr. Alexander: Yes.

Interviewer: Wow. Okay.

Dr. Alexander: So they go in an even smaller tube, the thing goes inside that big tube. So this utilizes the opportunity of ultrasound to be able to deliver energy to tissues in the body. So we normally think of ultrasound when it comes to diagnostic imaging, so maybe for like an obstetrical ultrasound, to look at a fetus, or maybe if somebody has gallstones, they look at the gallbladder that way. And that involves a diverging set of little sound waves that are sent out from a probe. And then, that bounces back and gets interpreted and spit out by a computer on a screen to look at an image inside the body.

We've known for a long time that each of those little sound waves can cause a little bit of energy to be deposited in the tissues. In those diagnostic scenarios, it's very safe. Again, they're diverging and it's a small amount of energy. We know that we can focus these beams much like using a magnifying glass with the sunlight. And we can use that to actually effect change. We deposit enough energy that we raise the temperature and burn that little pea-sized area just as they did back in the '50s but without actually making an incision.

Ultrasound, it's the same technology that underlies those imaging studies that people get, but it's a different way to harness that energy to use over 1,000 elements to deliver a bunch of very small things. And so you get them all converged at one area. It actually delivers a fair amount of energy. And so we go through several steps of imaging to map out where this VIM nucleus of the thalamus is using an MRI. And then, we also have a CT scan that kind of maps the skull, and then we overlay that with the MRI. And using that CT of the skull, we can direct the ultrasound to make sure that we target it precisely where we need to get.

Interviewer: Wow. And how long does the whole process take?

Dr. Alexander: So the whole process is probably about three to four hours. Part of that is spent shaving the head, getting the frame on. The actual part where they're in the scanner is probably anywhere from an hour and a half to three hours. Probably more often on the hour-and-a-half range though at this point.

Interviewer: And then what? Do you just send them home? Are they stuck in the hospital for a while or . . .

Dr. Alexander: We observe them for a little bit, make sure there are no side effects. They've gotten some of those medications. And then, there will be a little bit of swelling in the brain that makes them a little uneasy, a little wobbly. So we observe them for an hour or two, but it's an outpatient procedure. They go home that day.

Interviewer: Dr. Rolston, how long have you guys been doing this?

Dr. Rolston: So we've been doing this for about a year now. It's been FDA-approved for slightly longer than that. So we're the only place that does it in this time zone in the United States, so the only center in this region. We've had a great experience. So the patients that we've done have had fantastic outcomes.

When they did the randomized control trial to prove that this was effective, they had about, on average, a 50% improvement in the tremor. But that included patients that . . . The way they designed the study was called an intention to treat. So there were some people that didn't actually get treated that are included in that 50%. So the results, they were probably a little bit better than that. We're seeing results that are better than that still. So more like 75% or better improvement in the tremor for all the patients we've treated.

There's some thoughts and considerations we put into selecting patients. We want to make sure that they obviously have essential tremor before we do this procedure. But there's also a consideration for how dense the skull is. The skull is a big component of how we do the therapy. We try to do the therapy through the skull with the ultrasound, but sound waves travel really well through solid, dense things, but less well through kind of mushy, less solid things. So you can kind of imagine knocking on a table, and that has a nice loud echo, but if you knock on a pillow, you don't get much sound through that.

So we need to make sure the patient's skull is very dense and able to conduct these sound waves to cause the changes we're looking for. And we do this with a preoperative CT. So we get a CT scan the day before or a month before. And we measure the density of the skull to make sure that we can actually have a successful therapy. And there's some people, especially with bad osteoporosis, where we can't get the result we're looking for. So those patients, you could perform the procedure, but you might not get enough temperature increase to cause a permanent change.

The most important thing about this is we've had good surgical treatments for tremor for a long time, but many people are understandably worried about doing any invasive surgery, any sort of incision anywhere. Now that we have this non-invasive treatment, even though there are some limitations based upon skull density, some limitations on the kind of person to be best for, even though we have that, it's a wonderful new opportunity to bring people in for a treatment that otherwise would never consider any sort of invasive therapy. So there's a large population of patients that would never be able to be treated that can now be treated, which is why we have such a tremendous response to this and so many patients that are interested.

Interviewer: This seems like a technology that could be used in a lot of potential ways. What do you think the future is for this?

Dr. Alexander: Absolutely.

Dr. Rolston: Yeah.

Dr. Alexander: So it's a fantastic new tool, and we're looking for ways to apply this tool. So there are new trials that are currently underway for other things such as Parkinson's disease, mood disorders, things like that that will be on the horizon in the coming years. But then, in addition to that, and part of what's exciting to be doing this at the University of Utah, is we're looking to further expand indications. So we are working with some of our basic science and translational researchers here on campus to use animal models to try to develop new methods, new things that we can use this to tackle. And so it's a really exciting opportunity, both to be able to offer this new, really effective treatment, but also be able to try to expand the horizons so that we could offer it for, you know, a lot more people for a lot different diseases.

Dr. Gellner: When a child tells their parents they have chest pain, parents automatically think it's a heart problem or pneumonia. While those can be the cause, it's much more likely to be something more benign, like costochondritis or precordial catch syndrome.

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Dr. Gellner: Chest pain is one of those things that strikes fear in the parents. They want x-rays and EKGs and echocardiograms to make sure their child's heart is okay. The good news is if your child is going to have a worrisome heart problem, there's a good chance the OB will pick it up before the baby is even born. The heart is one of those organs that OBs scan during prenatal ultrasounds.

Something missed on that, well, the next heart test is actually done on babies 24 hours after birth. In most nurseries, this is the screen for the critical congenital heart defects. We call it the CCHD screen because it's easier. This checks the oxygen level in one arm and one leg on a baby after 24 hours old when the circulation has transitioned from fetal circulation, where the blood mostly bypasses the lungs before a baby is born, to newborn circulation. The change starts as soon as the baby takes the first breath after birth.

If the baby fails this CCHD test, they are transferred to the newborn intensive care unit, where a cardiologist gets involved to do an echocardiogram, which is an ultrasound of the heart. And they'll do an EKG to check the electrical rhythm in the baby's heart.

So if the problem isn't the heart and your child's lungs are good, then the pain is most likely coming from the ribs and muscles in your child's chest. There are two very common causes of chest pain in kids -- costochondritis and precordial catch syndrome.

Costochondritis is basically inflammation of the joints that connect the ribs to the breastbone or sternum. These joints move against each other every time your child breathes. Just like any other joints, if they are overworked, they can become irritated and they can hurt, and this causes pain along the front of the chest. We see this often when kids have been coughing a lot or breathing hard. Even laughing too much can cause it. Sometimes we have no idea what triggered the inflammation. But the good news is that costochondritis eventually goes away on its own.

The other common cause of chest pain in kids is something called precordial catch syndrome or PCS. It feels like someone is stabbing you right at the base of your heart, where you can feel your heart beat best on your chest. It's brief, sharp, and can sometimes take your breath away, but it's not dangerous. Doctors aren't really sure what causes it, and it does get worse if a person breathes in deeply, but it goes away quickly.

Pediatricians normally can tell you if your child has one of these just by asking questions about your child's symptoms and doing a physical exam. No special tests are needed unless there are other concerns that raise red flags for us. And then, we may do an x-ray or an EKG.

So how do you help your child if they have one of these going on? If your child has costochondritis, rest, ibuprofen, and avoiding heavy exercise or lifting for a few days does the trick. If your child has PCS, you don't need to do anything in particular to treat it because it doesn't really interfere with normal activity.

With both of these diagnoses, kids can continue to be kids. They can go to school. They can do all the fun things they want to. Quite often, just knowing what is going on and that they don't have anything dangerous is reassurance enough for the kids and their parents.

So if your child says they have chest pain, it's always a good idea to have your child's pediatrician get a good history and do a thorough exam to help you figure out what the real cause is.

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Interviewer: A teratoma is a congenital anomaly that can affect newborns. But what is it, and how can it be treated? I'm here with Dr. Fenton. He's an Assistant Professor of Pediatric Surgery at the University of Utah. And he's also the Director of the Utah Fetal Center. So Dr. Fenton, what is a teratoma?

Dr. Fenton: A teratoma is a collection of tissues that develop with the developing child, and it's oftentimes a remnant. So we don't exactly know why they form, but we know that they form as a result of extra developing tissue, if you will. So it can contain all types of tissue. muscle, skin, hair, teeth, has a very characteristic finding on ultrasound and on a CT or MRI because of the different types of tissue within it.

Interviewer: So you can actually see it while the fetus is developing?

Dr. Fenton: Yes. So they can be found on the screening ultrasound. Typically, it's noted to be an abnormal mass either in the chest or let's say at the end of the tailbone, more commonly at the end of the tailbone than in the chest. And because of that mass, they're usually referred to a high-risk OB or a maternal fetal medicine physician and/or a fetal center like the Utah Fetal Center, where the mom will undergo a more formal, specific ultrasound and sometimes an MRI to further characterize this mass.

Interviewer: So when you find this teratoma, what is the course of action from there on? When do you get in there to try to help treat it?

Dr. Fenton: First of all, we want to confirm what the findings are. And so again, typically they will go to, say, the Utah Fetal Center, and they'll be seen by a maternal fetal medicine physician, who will have them undergo a specialized ultrasound, which will look at the mass further. Obviously, other masses can develop. These have characteristic findings because of the multiple different tissues that are within it, which will help us kind of determine whether we feel like it's a teratoma or something else.

In that case, when we feel like it is a teratoma, we will follow the mom very carefully because we know that the teratoma will grow. And it can cause a couple of problems with growth. So let's say it's hanging off of the tailbone. The growth is not really restricted because it's not in a contained space.

But what can happen is because of excessive growth, it can actually have an increased blood flow through it, which could lead to strain on the heart and could actually cause the child to go into heart failure. We call it hydrops. So you start seeing swelling of the child's tissue fluid within the chest, fluid within the abdomen. And hydrops is obviously very dangerous for an unborn child. And so we would want to try and intervene on that before really hydrops is discovered.

And so, in the case of a sacrococcygeal teratoma, we can look at other things that tell us that the child is starting to have strain. And if that's the case, if the child is very young, let's say less than 28 weeks gestation, then we would advocate for a fetal surgery, where that portion of the child is actually delivered outside of the womb, and the tumor debulbed, or the majority of it is removed, not completely but removed to the point where it should decrease the chance or eliminate the chance of further cardiac compromise on the kid.

Interviewer: And what about if it forms in, say, the chest because that's the second most common, in the mediastinal area?

Dr. Fenton: That's correct, the anterior mediastinum, so it's in front of . . . it's right underneath the sternum or that middle chest bone. And the problem with that is usually later on in pregnancy, because as it grows, it starts to compress a couple of things. So first of all, it can compress the airway. Now, a child in the womb doesn't breathe because it has the maternal support from the placenta. But when the child is born, that can obviously cause some real problems, especially when the child tries to take the first breath.

But also, it can push on the vessels of the heart. And so the cardiac function is compromised in that the heart is really trying to pump hard but can't get blood out. And, again, we can start seeing signs of hydrops or heart failure on a child, and we would want to intervene sooner than later.

And if the kid gets to about 28 weeks, we want to try and get them as close to term as possible, but when they get to at least 28 weeks, we would advocate to deliver them early. And the way we would deliver them is by doing what we call an exit procedure, or it's an ex utero intrapartum therapy. So it's outside of the uterus, but still within the birthing process. And so we can actually deliver the head of the child in this case, leave the rest in the uterus so that the placenta still works, and put a tube in their throat to make sure that they can breathe properly before we deliver them completely. Or I was going to say in extreme cases, we could actually open the chest and take out the tumor while on placental support as well.

Interviewer: And for the mother whose newborn child may have a teratoma, what can her expectations be for her child?

Dr. Fenton: I think a lot of that depends on when it's found and the state of the child. So what I mean by that is if it's found very early in pregnancy, and there's no real compromise to the child, we can follow them closely to the point where something can happen and help that child get to delivery. A child that has hydrops has a very high mortality rate or death rate, and we want to try and intervene before that happens. In a newborn, so a child who has been born where a teratoma is found and the child is doing well, most of those can be removed. And when they're removed early, there's a smaller chance that there will be a malignant component to it or require further treatment and a higher chance that the surgery is all that is necessary.

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Interviewer: What should you do if you get a splinter? I know it sounds like a silly question, but maybe there's something we need to know. We'll find out next on The Scope.

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Interviewer: Dr. Troy Madsen's an emergency room physician at University of Utah Health. And I think, you know, everybody's gotten a splinter at some point in their life. And normally, you'd grab a safety pin or maybe your pocketknife and you just start digging. Is that okay, or is that not so good?

Dr. Madsen: Probably works okay.

Interviewer: Okay.

Dr. Madsen: It hits home for me, because just a couple days ago I was picking up some stuff and got a splinter in my finger. And it's just one of those things where you get a splinter in there, it just drives you crazy. So the reality is you probably don't have to go digging for a splinter to get it out. It will work its way out on its own. It might take a couple weeks, but if you're like me, you get that splinter in there, it's all you can think about because it hurts and it stings and it's like, "I've got to get this thing out." So I probably did everything wrong. I grabbed a thumbtack off our bulletin board and just dug at it and got it out. That's probably not the best way to do it.

Interviewer: Yeah. Because I remember my mom whenever anybody would get a splinter, she'd either take a lighter and the safety pin and burn it, or alcohol. I mean. . .

Dr. Madsen: That's right. You know it's probably best to have something that's at least sort of sterile. So if you do take a lighter and you've got a safety pin or something and just run that over the lighter or, like you said, dip it in some rubbing alcohol. Something like that is going to at least get whatever germs are on there, get that off there.

And so that'd be probably the one thing I'd say is that if you can use something that's at least reasonably clean and reasonably sterile, you're going to reduce the risk of introducing some kind of infection in there. Because as you're digging for that splinter, you're sticking that thing in there, it might go a little bit deeper. It might push something down into the wound. And you don't want to then deal with some sort of a finger infection or something more serious just because you're trying to get a splinter out.

Interviewer: All right. What about, you know, as far as getting it out, do you just start digging? Or is there a method that works better than another method?

Dr. Madsen: I'm guessing everyone has their own method.

Interviewer: Nothing you learned in med school anyway, huh?

Dr. Madsen: Well, having . . .

Interviewer: Or not a procedure you use in the ER.

Dr. Madsen: It is a procedure. You know, we do occasionally have people who come in for that sort of thing. And . . .

Interviewer: Like big splinters, I mean . . .

Dr. Madsen: Usually bigger splinters or much deeper foreign bodies. And those can be just so frustrating because I'll have people come in that say, "I know I stepped on something. I know it's in there." Sometimes I'll use an ultrasound just to see if I can see anything that jumps out on there. Sometimes I'll just go right over the point where they say, "This is where it hurts." And I'll numb it up and cut in there. But, usually, these are much deeper than anything you're going to be doing at home.

So my technique for home is to say, "Okay. I see the end of the splinter kind of sticking out right here. Or I can see kind of the tip of it there." I'll go right in that spot, try and lift up the skin a bit and just open it up along that line. And then, you know, as I'm in there, scrape around with that thumbtack or that safety pin to try to feel it and work its way out. And wash it off really well, see if I can just wash everything out. And it's kind of like what I'm doing in the ER. You know, in the ER, it's a little bit deeper. Again, I'm feeling around with some forceps as I'm going in there, hopefully feeling something that I can pull out or wash out.

Interviewer: And what is the risk of infection, really? I mean, you know, I . . . we don't want to give advice, we don't want . . . but, I mean, is it a high risk, low risk?

Dr. Madsen: I would say, if I had to put a number on it, the risk of infection with having a splinter in there is less than 5%.

Interviewer: Okay. But it is a possibility.

Dr. Madsen: There's a possibility.

Interviewer: Yeah.

Dr. Madsen: And usually, when it's infection, you're going to see a little, sort of a blister formed there, something that has what looks like pus in it. Even then, quite honestly, you're probably okay taking the safety pin, running it over the lighter, whatever to sterilize it, popping that thing open, opening it up a little bit and getting it to drain.

The biggest things I'd watch for, in terms of infection, are the hand. We always get concerned about infections in the hand. If you start to get a lot of pain along the finger or pain that's tracking up into your wrist, that's a really serious thing, because then we're worried about infection actually in the tendons. That'd be the number one thing I'd say you really need to watch out for, especially, you know, if you're digging in there with a pin or safety pin, or you start to get an infection from a splinter.

Interviewer: Got you. But otherwise, however you're doing it is probably fine.

Dr. Madsen: It's probably fine. Exactly.

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Dr. Miller: Rest, ice, and stretching are not the only ways to repair tendon injuries. We're going to talk about some of the new treatments next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Nick Monson. He's a physician here at the University of Utah in the Department of Orthopedics. He's a non-operative physician and he specializes in sports medicine. Nick, what's the story? I understand there are some new treatments out there to help with folks who have tendon injuries that have become chronic.

Dr. Monson: Well, one of the things that we've been really looking at over the last decade or two is the usage of ultrasound and the ability to find issues within tendons or joints or different areas of the body by an in-office imaging modality which is ultrasound, kind of like looking at babies. But now, rather than just looking at babies, you can actually look in and see a tendon. Then, what you can do is you find that area of pathology or the area of irritation within a tendon. You can actually see it with the ultrasound, which makes it much easier for us to actually find approaches to attack that area of issue in patients.

The areas develop typically from overuse. It also happens because tendons just notoriously don't have a great blood supply to them, and blood is what brings the healing factors to our body. So when you don't have that healing component coming to the tendon, it has a hard time healing. That's the way that we've addressed it.

Dr. Miller: So how do you use the ultrasound to guide treatment? And what are these treatments that you're using now?

Dr. Monson: Yeah. So one option is something called PRP, platelet-rich plasma. There's also another treatment option which is in the same family, which is called stem-cell therapy. These are both areas of a lot of excitement. The research on them is still forthcoming. In the orthopedic usage of it, or in the tendon issues, we've seen that it does seem to provide benefit for patients. It's a discussion I have with them. It's not always the perfect option. But for a lot of patients, it's something that we can offer where, ultimately, it involves a blood draw.

We take the blood off of a patient. We spin that blood down. We take the healing components of that blood and actually reinject that into the tendon under visualization of ultrasound so we can find that area that looks like it's irritated or has the issue. We directly inject into that area using that PRP injecdate that we've harvested from the patient by a blood draw. Then we can stimulate regrowth of the tendon as the theoretical purpose of it. But often, what it seems to do is cause the inflammatory reaction in the area, or it just kind of stimulates the healing in the area, and has provided a lot of relief for our patients.

Dr. Miller: Which tendons do you usually look at when you consider this therapy, or which tendons do you most frequently treat?

Dr. Monson: It can be done on any tendon that there is noted pathology in. So if you see an area of issue, it can be done in just about any tendon. Tendons that we typically think of, of having frequent issues are the shoulder, so the rotator cuff. We think about tennis elbow, so that's on the outside of the elbow. Golfer's elbows, on the inside of the elbow. We'll do it there. We see it in knees, particularly for people that have something called jumper's knee which is at the tendon of the knee. Achilles' tendon. Even in like the plantar fascia, this can be done.

Dr. Miller: These tendon injuries, they're not short-term injuries. Would these be folks that have chronic problems with the tendons that would be over weeks or months, perhaps?

Dr. Monson: Certainly. Yeah. Yeah. So that's usually, somebody will come to see me. They have a new injury, we'll work them through the things that we have the best evidence for, what we know works. Things like rest, avoiding aggravating activities, pain modification, medications. Then also, eccentric exercises are very important. We have good research showing that those are helpful.

Dr. Miller: What are eccentric exercises?

Dr. Monson: Yeah, so those are the exercises where the muscle is fired but it's actually lengthening at the same time. So we're lengthening a tendon and muscle unit while there is force.

Dr. Miller: Well, for stretching.

Dr. Monson: Yes, correct.

Dr. Miller: Okay. So how do you use the ultrasound to guide your therapy?

Dr. Monson: So the ultrasound, first of all, identifies the lesion. So then I know exactly where I need to go. The second thing you can do is the ultrasound will actually, if I place a needle into a patient, I can follow the course of the needle the entire time. I can see the surrounding nerves. I can see the surrounding blood vessels and I know exactly where I'm at. First of all, it's very effective for safety or avoiding those structures that we don't want to hit. But second of all, it helps us target very directly where we want to be within a tendon and make sure that we're in the correct spot.

Dr. Miller: Now, I'm assuming before you enter, you have a patient undergo this type of treatment, you have gone through the standard therapy. So they've gone through a physical therapy. They've done the stretching. They've done the icing, and they're just not getting results.

Dr. Monson: Correct. There's one other procedure that we've added to this as well. It's a needle procedure as well. So that means that it's not done in an operating room, but it is done in a procedure room where we, again, identify that area of concern. We're able to use a specialized needle tip that it pulsates at the very tip of it very quickly, about 17,000 times per second.

Dr. Miller: That's fast.

Dr. Monson: We're talking about a millimeter of movement. Yeah, it's fast. It's not a lot of movement. It's enough that it actually, you think of it as kind of pulverizing the tissue in there. It's emulsifying the tissue is the term that we use. It's the same technology that cataract doctors, or eye doctors, use to remove cataracts out of patients. It breaks up the tissue, removes it from the body, and then leaves the healthy tissue around it. This is a newer treatment, probably in about the last five years that this one's been out. For the same tendon issues that we just talked about, this is another treatment option for patients that's been very promising so far.

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Dr. Miller: Ultrasound guided procedures in orthopedics. We're going to talk about that next on The Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm here with Dr. Daniel Cushman and he's a nonoperative sports medicine physician using ultrasound guided techniques to deliver therapy to patients. Daniel, can you tell me a little bit about how ultrasound made its way into sports medicine? I mean, I think most people are aware that ultrasound is used to look at little babies in utero and to diagnose other things, but this is kind of new in sports medicine, kind of interesting and cool.

Dr. Cushman: Definitely.

Dr. Miller: Tell me a little bit about that.

Dr. Cushman: The most common joke I hear when I'm ultrasounding a patient is they say, "Is that a boy?" And I think that's what everybody knows ultrasound from is it's from babies.

Dr. Miller: You haven't found any head?

Dr. Cushman: No, fortunately not yet.

Dr. Miller: Okay, they haven't asked you just check out the probe over the area where the baby might be.

Dr. Cushman: I had a pregnant woman do that and it's kind of fun actually. But originally, the thought was you do an x-ray, you get radiation. You do a CT scan, you get radiation. But a lot of the time with ultrasound, we get the same amount of information without having to do radiation.

The other advantage that we found nowadays is that you can actually have somebody move while you're doing it. So if you're doing an x-ray, the person is standing still. If you're doing an ultrasound, you could have them move their shoulder and actually see if something is pinching up on something else or something like that. So that's kind of where it came from and it's really developed a lot over the last ten years especially.

Dr. Miller: So expand on that a little bit. The great news is that when you use ultrasound, when does the patient doesn't receive radiation nor does anyone else using the probe, what is ultrasound? Is it a sound wave?

Dr. Cushman: Yeah, good question. That's it exactly, it's a sound wave. I think about it like putting a speaker on your hand. If you think about doing that you can kind of feel those vibrations and those vibrations are what you get with an ultrasound but they're so small you don't feel them. So the machine can send out sound waves and then pick them back up. Based off of that, it can tell how tissues are looking like underneath the skin.

Dr. Miller: How long ago did the ultrasound make an appearance in the use of musculoskeletal?

Dr. Cushman: Yeah, I think it was originally in the '50s is when ultrasound was originally made and that was one of the original thoughts is that you could use it for something like this, but it never really caught on until probably the last 20 years or so is when it's really caught on.

Dr. Miller: How many doctors now are able to do this?

Dr. Cushman: So it's getting more and more common. There are two areas that it's used probably the most commonly. The rheumatologist use it a lot looking at joints and then additionally, the orthopedics specialist like myself tend to use it a lot for these sorts of things.

Dr. Miller: Now for this little podcast, I wanted to talk a bit about how you use ultrasound to deliver medication or therapy into areas that you're interested in treating.

Dr. Cushman: We do that very commonly and there are a couple of advantages we find. Number one is kind of the way we're taught in medical school is to take a needle and put it into the area based off of landmarks on the body.

Dr. Miller: That's what I used to do in injecting the shoulders, and I don't do that anymore because people like you have an ultrasound probe and do it probably a lot better than I ever did.

Dr. Cushman: Yeah, and there's been a lot of studies on this and in some places, it honestly doesn't matter. You can do for example, the knee, somewhere around 93% accurate if you just do it by landmarks. If you do it with the ultrasound, it's closer to 100%. So most of the time, you really don't need to. But in some places like the hip where only about 40% accurate, if we just put a needle down to the hip, while it's 100% accurate with an ultrasound machine.

Dr. Miller: How about shoulders?

Dr. Cushman: Shoulders, so if we're talking about the shoulder joint, it's probably in somewhere in the range of 80% accuracy without it. So a lot of the times, we'll have doctors who have done the injection and they're just not 100% sure it was in the right spot and the person didn't get better. So they will do an injection with ultrasound to make sure it's in the right spot and see if that's really helping.

Dr. Miller: How about spine? I know that some people with back pain ultimately get injections to try to get by the need for surgery. Do you use ultrasound in delivering injections into the spine?

Dr. Cushman: So for the spine, that's still what I would call in the experimental phase. So there are some people who do it, but for the most part, we still rely on x-rays to do those.

Dr. Miller: So for folks who might need some type of injection and I guess typically, you're injecting medications to reduce pain or inflammation, what would be the reason for them to seek out someone with your skills?

Dr. Cushman: I find that a lot of the times, it's more of the doctors they work with are the ones who kind of send them over to us to help out with that. But a lot of the times, I find that just from my own patients, when I see them I use these a lot of the times to help diagnose the problem. So a good example would be if somebody's shoulder hurt. Sometimes that pain is coming from their neck, not from their shoulder. So when we do an injection and it doesn't help, we know we were in the right spot so it really could be coming from somewhere else.

Dr. Miller: So it helps with diagnoses as well?

Dr. Cushman: Yeah, exactly.

Dr. Miller: So the bottom line is, if you're interested in having one of your joint pains evaluated, you could have this done under ultrasound guidance. If there's therapy that's needed, it could be injected via an ultrasound guided

Dr. Cushman: Definitely.

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