plethysmography neck collars (Zamboni)

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Postby MrSuccess » Wed Mar 16, 2011 5:39 pm

once again ..... Mr. Success to the rescue .... and offering an understandable explanation for '' the great unwashed public '' :roll:

From the Ferrara conference : They have gathered data from numerous CCSVI-MS investigations ..... and now give the number 87% ..... as the number of pwMS that have CCSVI.

The Doeppe study reported only ONE patient with CCSVI . Can someone please supply me with the number of participants in the Doeppe study ?

As Ringleader has posted the Doeppe numericals ...... and as they match PX's numbers ...... I will accept them as correct , and no error in printing was made .... with that in mind ....

It is reported in the Doeppe CCSVI Study ..... that not only do pwMS have blood flow equal to healthy controls ..... they in fact have a recorded blood flow almost 3 times that of healthy controls.

And this of course ...... hardly raises an eyebrow in any of the Doeppe CCSVI Study investigators .

Yeah ......... right .




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Postby MrSuccess » Wed Mar 16, 2011 8:53 pm

oops .. I meant Bologna .... not Ferrara .... :roll:


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Postby Cece » Wed Mar 16, 2011 10:05 pm

Patients : IJV Supine [ laying down ] 499 ml/min.
IJV Upright [ sitting up ] 318 ml/min

Controls : IJV Supine 480 ml/min
IJV Upright 123 ml/min

So it is ml/min! That doesn't make sense to me then. Why or how could our flow be better lying down or even equal to the healthy subjects? Can we trust Doepp's numbers? He has done previous published research on the transient global amnesia type of jugular valve insufficiency, as far as I know he is a solid researcher outside of that one CCSVI paper where he did not use the now newly consensused Zamboni ultrasound methods.
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Postby MrSuccess » Wed Mar 16, 2011 11:20 pm

The Doeppe Study is deeply flawed .... starting with their inability to identify more than ONE .... test subject deemed to have CCSVI. I now forget the exact number of test subjects ..... but to only find ONE ?

According to information presented at Bologna 2011 ..... they are finding over 80% + .....pwMS having CCSVI. This suggests to me .... that the Doeppe Study investigators ....... do not know how to test for CCSVI.

To add further confusion ...... the Doeppe Study .... has produced test results that just plain and simple ..... do not make sense.

Our Dr. Zamboni - and his CCSVI colleagues - have produced viable information ...... clearly demonstrating REDUCED blood flow in the neck veins of pwMS. The Doeppe Study .... states the opposite ..... they report a blood flow rate of almost three times higher in pwMS as opposed to healthy controls . That would suggest the blood coming out of your brain ...... is like a fire hose.

Using logic and plain old horse sense ..... this cannot happen . In fluid dynamics ..... one gallon IN ...... results in one gallon OUT .

Show me how to put one gallon of fluid into a closed vessel [ your head ] and then expect three gallons to come out ....... impossible

To achieve the rate of bloodflow the Doeppe Study says pwMS have when in the IVJ upright position ....... your fluid pump [ your heart ] would be working THREE times as hard as healthy controls .

I don't believe that .

Dr. Zamboni's discovery stands .




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Postby 1eye » Thu Mar 17, 2011 8:02 am

Patients : IJV Supine [ laying down ] 499 ml/min.
IJV Upright [ sitting up ] 318 ml/min

Controls : IJV Supine 480 ml/min
IJV Upright 123 ml/min

As Dr. Rose would tell you: if inflow is greater than outflow for very long, your head explodes. If outflow is greater than inflow for very long, well, hard to implode a skull, but you get the idea.

Three things circulate blood: the heart, gravity, and other muscles.

The effect of lying down is to make the vertical distance blood has to flow less than it is when upright. So if the heart and muscles exert the same force, the blood will speed up, as there is less distance through which gravity has to be overcome.

The difference between controls and patients is in the difference between their supine and upright flows. For patients this difference was 181, for controls, 357.

That means to me that in patients, there is less effect of gravity on flow.

If gravity doesn't change and flow has a different delta due to less distance being overcome, difference must be volume being moved by gravity (drainage).

This seems like a fairly direct way of measuring the relative narrowness of the drain, since everything else, except maybe blood viscosity, is similar.

Can somebody refute that for me?
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Postby 1eye » Thu Mar 17, 2011 9:21 am

Perhaps if we arrived at a typical set of numbers for a very large number of healthy people we could tell by that one number (delta supine versus upright) if a person had BVI (Brain Venous Insufficiency). Then again, maybe plethysmography is cheaper. However, I went to get an ultrasound done on my kidneys, and guess what? The (Canadian) ultrasound guy was using a Doppler type scanner for abdominal stuff. Maybe they already are fairly common, as they are generally useful. I don't know how the flow numbers were reached in Doepp et. al. Was it a Doppler?
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Postby 1eye » Thu Mar 17, 2011 9:44 am

1eye wrote:
Patients : IJV Supine [ laying down ] 499 ml/min.
IJV Upright [ sitting up ] 318 ml/min

Controls : IJV Supine 480 ml/min
IJV Upright 123 ml/min


The difference between controls and patients is in the difference between their supine and upright flows. For patients this difference was 181, for controls, 357.



I love quoting myself :wink:

The difference also seems to be in the upright measurement more than the supine. That seems to indicate that the jugs are not collapsing as expected when upright, in the patient group. Another manifestation of cross-sectional area delta? Again, it seems this one figure, when compared to a typical healthy person (maybe there would have to be a scale that adjusts for things like age and weight) can diagnose, well since it's only IJVs, call it JVI (jugular venous insufficiency).
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Postby MrSuccess » Thu Mar 17, 2011 1:37 pm

okay .... more on this amazing discovery , the PNC .

Dr. Zamboni in the recently held CCSVI meeting in Bologna Italy , presented us with a new discovery ..... a way to measure blood flow exiting the brain. Dr. Zamboni's new '' tool '' ...... produced information that validated his discovery ....... that pwMS have - REDUCED - blood flow in the neck veins ...... that return the blood back to the heart .

We then had a TIMS member question Dr. Zamboni's discovery .

This TIMS member provided the results of a Dr. Florian Doepp study that produced TWO great discrepancies ...... that refute Dr. Zamboni's great discovery .

ONE : Dr. Doepp studied 56pwMS and 20 HC [ healthy controls ] and could only find ONE person with CCSVI. I reject that finding .

TWO : Dr. Doepp recorded blood flow volume exiting the brain of his test subjects . They were measured lying down ....... then when sitting up.
Incredibly , Dr. Doepp reported pwMS having blood flow volume almost THREE times that of his HC. I find this preposterous.

It is a fair question to ask ...... what method and equipment did Dr. Doepp use ?

Simple Fluid Dynamics :

Our bodies contain about 6 quarts of blood . So you have 12 pints of blood continually circulating in your body . [ I am going to use '' pints''to reference the blood ..... as we all are familiar with that term when either donating or receiving ]

I am guesstimating for the sake of argument ..... that at any given time ... that you have one pint of blood in your head .

Your heart [ a fluid pump] displaces a small volume of blood up and into your head . To make room for the incoming fluid .... an exact amount of fluid must now exit the head .

Pumps produce FLOW . Your heart is a fluid pump. To INCREASE flow in ANY pump ...... you increase the SPEED of the pump.

In order to increase the volume of blood your heart pumps ...... you must increase the BPM [ Beats per Minute ].

Dr. Doepp reports that pwMS have almost 3 times the amount of blood flow when sitting up ....... compared to his HC.

To achieve this ...... your heart would be racing. Remember : We are NOT talking gravity ...... when sitting ...... you are pumping UP.

I reject the Doepp Study completely.







My '' thought for the day '' is ........ can the PNC measure blood INFLOW ?





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Postby cheerleader » Thu Mar 17, 2011 2:07 pm

Forget I ever mentioned the Doepp study, this thread has veered way off-course. Make sure to read the first page, everyone. Plethysmography is the topic head.
never mind,
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Postby Cece » Thu Mar 17, 2011 2:44 pm

Plethysmography

Doppler and plethysmography measure both the quantitative and qualitative flow of blood in the arteries and capillary beds. In short, they determine if you have an adequate blood flow in the area the doctor is testing. Most commonly used for disorders such as Peripheral Arterial Disease (PAD) or "Restless Leg Syndrome" the tests are both non-invasive and painless. The tests are also useful in determining whether symptoms such as pain, tingling, or numbness, have a vascular component or cause, in addition to a multitude of other causations such as a "pinched nerve" (neurological component). People are often unaware, that after a traumatic injury, such as an automobile accident, that many of their symptoms may have a vascular component, which, if left undiagnosed or untreated, will often get worse with time. Many times these people present with headaches or coldness in their hands or feet. The upper two videos show the difference between a normal plethysmography (on top) and a patient that has decreased blood flow in the feet after experiencing a motor vehicle accident five years ago and has been complaining of "coldness" and "tingling" in the feet to their primary physician for almost eighteen months before being referred to our clinic. You will notice that the wave height is smaller in the second (bottom test). Two things to note. First, the sensitivity setting (middle row of buttons) is set at 5 (blue button) in both views so as not to distort results. Second, you should notice the absence of sound in the lower test as the blood flow at the 5 sensitivity was below the threshold to trigger the audio control.

http://www.cornerstoneclinic.net/custom ... tools.html
This is calf plethysmography, I believe. Still interesting.

Aust Crit Care. 2000 Mar;13(1):14-20.

Plethysmography: the new wave in haemodynamic monitoring--a review of clinical applications.
Dennis MJ.

Epworth Hospital, Richmond, Victoria.

Abstract
The plethysmograph, a useful, non-invasive circulatory assessment capability featured on most modern pulse oximeters, provides a waveform representation of pulsatile peripheral blood flow, from which can be drawn assessments of both the peripheral and central circulation. Implementation and maintenance of plethysmography monitoring is straightforward and uncomplicated by virtue of its non-invasiveness. Yet despite its capabilities, ease of use and widespread availability it remains an underutilised data source. Diagnostic and monitoring capabilities of the device include heart rate and rhythm monitoring, detection of myocardial and valvular dysfunction, assessment of intra-aortic balloon pump performance when pressure waveforms are unobtainable, detection and measurement of pulsus paradoxus, improved performance of the Allen's test and detection of peripheral vascular diseases, peripheral vasoconstriction and developing shock. This paper describes the range of established applications of plethysmography, reviews pertinent literature and describes the directions in which, in the absence of supportive literature, clinical practice is finding applications.

www.ncbi.nlm.nih.gov/pubmed/11271019

Plethysmography is useful but underused.
Zamboni is brilliant.

Int J Sports Med. 1999 Nov;20(8):555-9.

Reproducibility of resting peripheral blood flow using strain gauge plethysmography.
Fehling PC, Arciero PJ, MacPherson CJ, Smith DL.

Department of Exercise Science and Dance, Skidmore College, Saratoga Springs, NY 12866, USA. pfehling@skidmore.edu

Abstract
The purpose of this study was to examine the intra-tester and inter-tester reliability of strain gauge plethysmography (SGP) using the Hokanson EC-5R plethysmograph among three investigators. An arterial inflow test was performed by each of the investigators on fifteen college-aged volunteers at the forearm and calf sites. Intra-tester reliability was assessed by analyzing three serial measurements obtained at both sites. Intertester reliability was assessed in two ways: first, by having the three investigators obtain and analyze their own recordings, and, second, by having all three investigators (Testers 1, 2, and 3) analyze SGP recordings obtained by the most experienced investigator (Tester 1). The mean coefficient of variation (CV) for the intra-tester analysis was similar at the forearm (4.9%) and calf (4.0%) sites. The inter-tester analysis revealed that there were no significant differences among the three testers at either site when investigators obtained and analyzed their own waveforms. The CV calculated from the means of the three investigators was greater at the forearm site (10.7%) than at the calf site (2.5%). Similarly, when Testers 2 and 3 analyzed Tester 1's waveforms there were no significant differences found among testers at either site and the CV was less than when each investigator obtained his/her own waveforms. Strain gauge plethysmography blood flow measures obtained by experienced testers, under controlled laboratory conditions, are reproducible. The small variability in blood flow that exists is more attributable to variability in the acquisition of the waveforms than in the analysis of the waveforms.

www.ncbi.nlm.nih.gov/pubmed/10606221
The latter publication is on the reproducibility of strain gauge plethysmography measurements on the calf and forearm. It was found to have high reproducibility. I feel comfortable with the statement that the neck plethysmograph is also reproducible and relatively operator independent, in particular comparison to the doppler ultrasound.
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Postby 1eye » Thu Mar 17, 2011 2:59 pm

1eye wrote:
Quote:
Patients : IJV Supine [ laying down ] 499 ml/min.
IJV Upright [ sitting up ] 318 ml/min

Controls : IJV Supine 480 ml/min
IJV Upright 123 ml/min


The difference between controls and patients is in the difference between their supine and upright flows. For patients this difference was 181, for controls, 357.


Another observation: the difference between controls and patients here is not that patients have less flow, ever. Here they have more flow in both postures than controls. That, if anything, makes the theory of CCSVI suspect.

These patients are a completely different set of people from the controls. There may have been a skew toward (or outlier(s) with) more flow in patients, or less in controls. Without knowing the details and without knowing how anybody, patient or control, compares to an expected, typical human, can we say that over a much larger population we expect pwMS to have almost triple the typical blood flow in their IJVs when upright?

The difference occurs in the upright posture, where patients seem to have almost 3 times the blood flow of controls. These numbers do not argue in favor of hypoxia being a problem. The MS patients in this set have more flow, so more oxygen availability than this set of controls. Is such a large difference pathological in some other way, perhaps due to less slowdown when upright? I doubt it.

I find the most meaningful number is the delta from sitting to upright, because it is due to gravity which is fixed, a constant force. It has less effect on the supine than the upright posture due to less vertically moving blood in both groups. That delta is more meaningful to me than absolute flow values. It could be said it supports narrowing in all patients. Height, blood volume, viscosity, density, etc., would have effects, all potentially confounding. The factor of nearly three in the absolute flow numbers seems compelling. But three times the flow, when upright?

Forget I ever mentioned the Doepp study,


OK, plethys-ma-call-it it is.
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Postby drsclafani » Thu Mar 17, 2011 3:15 pm

1eye wrote:
1eye wrote:
Quote:
Patients : IJV Supine [ laying down ] 499 ml/min.
IJV Upright [ sitting up ] 318 ml/min

Controls : IJV Supine 480 ml/min
IJV Upright 123 ml/min


The difference between controls and patients is in the difference between their supine and upright flows. For patients this difference was 181, for controls, 357.


Another observation: the difference between controls and patients here is not that patients have less flow, ever. Here they have more flow in both postures than controls. That, if anything, makes the theory of CCSVI suspect.

These patients are a completely different set of people from the controls. There may have been a skew toward (or outlier(s) with) more flow in patients, or less in controls. Without knowing the details and without knowing how anybody, patient or control, compares to an expected, typical human, can we say that over a much larger population we expect pwMS to have almost triple the typical blood flow in their IJVs when upright?

The difference occurs in the upright posture, where patients seem to have almost 3 times the blood flow of controls. These numbers do not argue in favor of hypoxia being a problem. The MS patients in this set have more flow, so more oxygen availability than this set of controls. Is such a large difference pathological in some other way, perhaps due to less slowdown when upright? I doubt it.

I find the most meaningful number is the delta from sitting to upright, because it is due to gravity which is fixed, a constant force. It has less effect on the supine than the upright posture due to less vertically moving blood in both groups. That delta is more meaningful to me than absolute flow values. It could be said it supports narrowing in all patients. Height, blood volume, viscosity, density, etc., would have effects, all potentially confounding. The factor of nearly three in the absolute flow numbers seems compelling. But three times the flow, when upright?

Forget I ever mentioned the Doepp study,


OK, plethys-ma-call-it it is.


i am late here. you have to temper your skepticism about the upright and supine numbers by remembering that the blood volumes measured are only from jugular vein. they are not measuring other drainage such as the vertebral veins and collaterals. So forget about heads exploding.

but yes, neck plethysmography sounds like an exciting alternative to doppler as a screening test. The rest of the ultrasound would still follow when plethysmography was abnormal. So the rest of the ultrasound may steill be necessary, until we prove that plethysmography is sufficient to move to venography.

before we go further, additional studies of ccsvi and healthy control patient populations are necessary.

i was very excited if we could perform plethysmography DURING angioplasty and possibly use the results to decide when venoplasty and valvuloplasty had succeeded.
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Postby Cece » Thu Mar 17, 2011 3:32 pm

drsclafani wrote:i was very excited if we could perform plethysmography DURING angioplasty and possibly use the results to decide when venoplasty and valvuloplasty had succeeded.

That's quite an idea! Is it feasible?

I was thinking it might be an easier means of follow-up, to check for restenosis.
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Postby cheerleader » Thu Mar 17, 2011 4:05 pm

Here is Dr. Zamboni's abstract from the ISNVD conference:
http://ccsvism.xoom.it/ISNVD/Abstract-Z ... eening.pdf

Methods: 40 healthy controls (HC) matched for age and gender with 29 CCSVI-MS patients were screened for CCSVI by means of vascular Doppler sonography by an expert operator. The entire cohort blindly underwent a protocol using an original straingauge collar connected with a volume transducer and dedicated software. After calibration, the subject is tilted from the upright to the supine posture (Fig.1). The redistribution of blood volume permits to obtain a volume-time curve from which
extrapolates the venous volume (VV%), corresponding to the highest point of the filling plateau, the 90% VV and the venous filling index (VFI). The subject is tilted to up again, obtaining a reduction in venous volume defined as tilt ejection fraction (TEF and TEF 90%), with a slope curve proportional to the time of emptying. Finally, the residual volume fraction (RVF) corresponds to the cervical volume after tilting up (Fig.1).

Results: VV% measured respectively in HC 5.3±2.5 and in CCSVI-MS 6.7±2.5 (p<0.0002); VFI 0.9±0.5 and 1.3±0.8 (p<0.0001); TEF 90% 1.8±0.7 and 2.8±1.1 (p< 0.0001); TEF slope 2.6±1.7 and 1.8±1.1 (p<0.0001); RVF 0.6±1.5 and 1.7±1.7 (p<0.0001). No significant variations were found for VV 90% and TEF between the two populations
.
Conclusions: Cervical strain-gauge plethysmography showed several parameters significantly different in CCSVI respect to HC. It is a novel tool for non-invasive, nonoperator dependent screening of CCSVI. Imaging techniques remains indispensable for defining location and morphology of venous outflow obstructions.
Husband dx RRMS 3/07
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Postby patientx » Fri Mar 18, 2011 7:07 am

Cece wrote:That doesn't make sense to me then. Why or how could our flow be better lying down or even equal to the healthy subjects?

That was kinda the point. The authors acknowledge this is an anomalous finding:
Compared to the reference cohort we detected higher BVF in patients with MS in an upright position whereas in a lying position no difference emerged in BVF between patients and reference subjects (table 5). Consistent with this finding the decrease of the BVF in patients was less pronounced after moving from a lying to an upright position. We hypothesize this finding might reflect vascular dysregulation, perhaps due to MS affecting the autonomous nervous system, and this result warrants further investigation. If anything, however, higher BVF in patients should suggest an even‘better-than-normal’ cerebral venous drainage (at least in an upright position) in MS.

And in a response to Dr. Zamboni's letter:
We agree that the main difference in people with multiple sclerosis (pwMS) compared to controls in our study is the significantly less pronounced decrease of blood volume flow (BVF) in the internal jugular veins (IJVs) after changing from a supine to an upright body position, resulting in a distinctly higher BVF in the IJVs in the latter position. This finding has not been described previously in pwMS, and warrants further research. We hypothesize that this difference in BVF may be a result of vascular dysregulation secondary to MS. We disagree with Dr Zamboni that markedly higher BVF through the IJVs detected in our study underpins the presence of chronic cerebrospinal venous insufficiency (CCSVI), particularly as the increased drainage via the extrajugular venous pathways in the upright position was virtually identical in pwMS and controls.

Notice they make the point that this warrants further investigation.

If people are interested in this stuff, I'd recommend trying to read copies of the October and December 2010 issues of Annals of Neurology (maybe from a local medical library). There's a lot of back and forth in these two issues - one has Clive Beggs letter and a response to it, and the other has Dr. Zamboni's letter and the response to that.

Sorry, Cheer. That'll be my last interruption. I thought that Medscape article did a good job of presenting both sides. And that neuro crack was kinda humorous.
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