Our region is full of top-notch doctors, hospitals, and other health care facilities providing state-of-the-art assistance for a variety of ailments. Many Valley specialists are keeping up with the newest trends and treatments, proving that you don’t always have to trek down to the Big Apple for the latest and best care.
Some of the techniques brought up in the following pages might sound a bit unusual — including the use of magnets for more than one type of treatment — but studies have shown them to be effective and safe. So, whether you’re looking for the latest in cardiac care or bladder control, foot fixes or mental health, these six cutting-edge procedures are now offered close to home.
Dr. Pardell (right) demonstrates a transcranial magnetic stimulation (TMS) session with his son Logan Pardell (center) and nurse Constance DeFreest
Photograph by Michael Polito
Severe depression cripples the lives of nearly 15 million Americans every year, according to the National Institute of Mental Health. Psychiatrist Randy Pardell, M.D. uses a new technique that he says shows great promise for many patients who suffer from major, treatment-resistant depression.
Transcranial magnetic stimulation, or TMS, uses magnetic fields to stimulate nerve cells in a region of the brain associated with mood regulation and depression. “It’s kind of like a spark plug for the brain,” explains Pardell, who heads the Poughkeepsie-based TMS Center of the Hudson Valley.
Here’s how it works: The magnetic pulses trigger gentle electrical currents in the brain, which stimulate nerve cells in the prefrontal cortex. The nerve cells release chemicals known as neurotransmitters, which affect mood and emotion.
One reason why TMS is an exciting option is because it does double duty, Pardell says: It often improves mental functioning, as well as motivation and energy, in the patient. At the same time, the procedure also appears to calm the anxiety centers of the brain, which are often overactive in people who are depressed. “Also, it’s a noninvasive, nonsystemic technique. When a patient takes a pill, it goes through the entire body. But here, the magnetic pulses are going directly to the area being treated.”
At first glance, a TMS session looks a bit like science fiction. The patient sits in what looks like a dentist’s chair; a small piece of equipment containing an electromagnetic coil is placed near the left side of the forehead. The coil emits pulses of highly concentrated magnetic fields through the skull, about three centimeters down into the brain — in a manner similar to the way an MRI unit works. “In fact, it’s the same level of magnetic intensity as an MRI — which has been used for years with very few negative consequences,” Pardell says. The patient feels a sort of tapping on the head as the magnets pulse. Afterwards, he or she can continue with normal daily activities. Side effects are mild, Pardell says: a few patients experience a mild headache or lightheadedness.
A standard TMS course involves approximately 20 sessions — five days a week for a month. “Each session takes about 37 minutes, during which about 3,000 to 4,000 pulses are given each time,” according to Pardell. The procedure has been government-approved since 2008. “The FDA approved it for use with resistant depression in adults who have tried antidepressant medication for at least a month with no improvement, or for people who have intolerance to antidepressant medication,” Pardell says.
About 200 sites across the nation now use TMS, says Pardell, who has so far treated half a dozen patients in the six months since he first brought the technique to the Valley. A course of treatment costs about $8,000-$10,000; insurance companies consider coverage for it on a case-by-case basis.
TMS is being tested, too, for its effectiveness in treating other conditions including bipolar disorder, schizophrenia, and posttraumatic stress disorder. It’s also being tested in patients suffering from Parkinson’s disease, migraines, and chronic pain.
“Many times, patients who come to us have been on 15 to 20 different medication trials,” Pardell says. “They’ve been in hospitals, sometimes had electroconvulsive [also known as shock] therapy — they’re looking for some other way to help their depression.”
Pardell cautions that TMS shouldn’t be considered a “magic bullet” therapy that eliminates depression on its own. But so far, the numbers look good. “I’ve talked to a lot of psychiatrists across the country who are doing this treatment, and the success rate seems to be somewhere between 65 and 90 percent,” Pardell says. And according to the Mayo Clinic, in cases where TMS is effective, symptoms of depression may improve for days or weeks, or may even subside completely.
“People can continue with their antidepressant medication, if needed, while undergoing TMS,” says Pardell. “And psychotherapy, along with TMS, can give many people their best chance to get well. TMS has been a wonderful adjunct to our practice.”
Randy Pardell, M.D.
Riverview Psychiatric Medicine, 845-471-1807
There’s a new twist on cardiac catheterization, a common medical procedure that’s used to help unplug clogged arteries.
Ordinarily, a tiny tube, or catheter, is placed into the body through an artery in the groin, then snaked up to the arteries surrounding the heart. This is known as the transfemoral approach. After the catheter is in place, physicians can perform an angioplasty. During this procedure, a tiny balloon-like device is inserted to open the blocked artery further; sometimes a stent (a tiny mesh tube) is placed in the artery to help keep blood flowing smoothly.
Nirav D. Shah, M.D., a cardiologist at St. Luke’s Cornwall Hospital in Newburgh, is one of the first physicians in the Valley to perform transradial catheterization — a technique that bypasses the groin and instead uses an artery in the wrist as the entry point for the catheter. First performed in 1989, the technique became popular first in Europe and Canada, and is now catching on across the U.S.
“The artery running down through the wrist — the radial artery — is smaller than the artery in the groin,” explains Shah. Thus, taking the wrist route reduces risk of bleeding during the procedure. “Transradial catheterization, however, does requires a greater learning curve for the physician” to master the technique, he says. “But it has fewer complications than going in through the groin. And it’s much more comfortable for the patient.”
Recovery is quicker, too. With standard catheterization, the patient must lie totally still throughout the procedure, then remain in a virtually prone position for several hours during post-op monitoring.
“By comparison, going in through the wrist, the patient can sit up right after the procedure. They can even walk right out of the treatment room; most go home within about two hours,” Shah says.
Transradial catheterization has proven effective for both sexes, even though women tend to have slightly smaller arteries, he says. And if a patient has multiple blockages, or clogging in the arteries recurs, it’s no problem to repeat the process. “We could even go back in for treatment the next day, using the same wrist artery,” he says.
Shah, who performs as many as 500 angioplasties a year, says transradial catheterization is indeed a breakthrough in the field of coronary care. “I’d say that 90 percent of the procedures I do are now done through the wrist,” he says.
Nirav D. Shah, M.D.
That “gotta go” feeling is no laughing matter, especially if you suffer from overactive bladder — a medical condition in which the need for frequent urination can interfere with daily life and play havoc with nighttime rest.
Treatments can range from medication to behavior modification — and now a new technique, called percutaneous tibial nerve stimulation (PTNS), can help control this common and uncomfortable bladder problem.
With PTNS, a tiny needle is used to stimulate a nerve, which helps regulate bladder function. Remarkably, the needle isn’t inserted anywhere near the bladder. “The procedure is actually done on the leg, where we stimulate the tibial nerve, just above the ankle,” says Jose Sotolongo, M.D. who is affiliated with Hudson Valley Urology in Poughkeepsie. “By stimulating the nerve, a reflex occurs in the spinal cord; the nerve originates in an area of the spinal cord that’s not far from where the nerves to the bladder also originate,” he explains. “The stimulation seems to somehow reset the electrical activity of the nerves going to the bladder.”
The procedure, done in a physician’s office, takes about 30 minutes. It’s performed once a week, usually for about six weeks or more, depending on the case. The patient sits in a comfortable position with the leg slightly raised. A tiny needle is inserted near the ankle. A gentle electrical pulse is then sent through the needle, which travels through the tibial nerve, into the region where the spinal/bladder nerve areas lie. “There’s no pain; you just feel the tiny needle prick,” says Sotolongo. “The patient can just bring a book and relax through the procedure.”
Sotolongo says the method works somewhat like acupuncture. “It certainly makes you think of acupuncture — it’s a similar approach, of stimulating one part of the body to affect another.”
PTNS can help many, but not all, cases of overactive bladder, he adds. “The only patients, in general, who aren’t candidates for the technique would be if their overactive bladder isn’t linked to a nerve problem. It might be someone whose urination is affected because they’re receiving radiation therapy in that area. Or a man may have urination issues because of an enlarged prostate.”
Sotolongo says medical studies have shown that PTNS, which is FDA-approved and is used to treat both sexes, is extremely effective. “It appears that up to 96 percent of my patients seem to respond to it, with good results still showing after about 52 weeks; it could be repeated as needed,” he says.
“The expectation is that it could take the place of medication for many patients dealing with overactive bladder. It will certainly open the door to treatment for many people.”
Jose Sotolongo, M.D.
Hudson Valley Urology, 845-339-4900
Toe fungus: It’s ugly. It’s unhealthy. “And it’s so prevalent that about 30 million people in the U.S. have it,” says podiatrist Dr. Tracey Toback, D.P.M. The common condition causes the toenail — most often on the big toe — to become hard, brittle, and yellowish. “It’s embarrassing, too. People often try to keep their toes covered up all the time, women may keep applying polish to try to hide it,” he says.
But foot fungus isn’t just a cosmetic issue. “If a person has diabetes, which can affect circulation, they may already have foot problems, and any kind of infection such as this can make matters worse,” he says.
Why is toe fungus so widespread? “The number one reason is because athlete’s foot is so common; the fungus first gets on the skin, then spreads under the nails,” Toback says. Athlete’s foot is frequently found in moist places like gym shower areas and locker rooms — and is quite contagious.
Second, folks tend to torture their tootsies. “People damage the nails, especially on the big toe,” says Toback, a board-certified foot surgeon whose main office is in Highland. “They wear tight shoes. They accidentally drop things on their toes; they kick things with their toes.” All this causes the nail to lift slightly off the nail bed. “Then fungus can get in underneath and start spreading,” he explains.
The most common antifungal treatments available today are topical creams and pills. “Creams often soften the nail, but don’t usually really get rid of the problem. And pills need to be taken under supervision; some can adversely affect the liver,” says Toback.
But now there’s another option — podiatrists can use a laser to blast that nasty fungus into smithereens. “It’s an infrared laser beam that passes harmlessly through the nail and actually vaporizes the fungus cell membrane that’s embedded under the nail,” says Toback. The procedure is done in one session, he adds, usually taking about 10 minutes to treat a big toe; and half an hour to tend to all 10 nails if needed — without pain, drugs, or anesthesia.
“Our clinical studies to date show that more than 88 percent of treated patients show significant improvement,” he says. “In most cases, the fungus is completely cured.”
Another promising breakthrough treatment can be a boon for patients with arthritis in the big toe. “This type of arthritis is similar to a bunion — when a toe joint is misaligned,” Toback says. With a typical bunion, the toe is displaced outwardly. In the case of an arthritic bunion (or arthritis in the big toe), the deformed toe tends to bulge upward.
Arthritic bunions often result from one of two causes, Toback says. “It might be due to an undiagnosed or untreated fracture of the big toe — because the toe wasn’t immobilized in order for it to heal, the bone tried to repair itself anyway and grew out of alignment.” This can cause damage to the cartilage, resulting in both misalignment and pain. Poor alignment of the toe joint can also be hereditary, he says.
Either way, for patients with arthritic big toe joints, the most common treatment has been joint fusion, in which the end of two toe bones are surgically joined. “The problem with a fusion is that the joint is no longer mobile. Also, you have to keep it in a cast for up to six weeks, without walking on the area.”
But a new technique known as the Hemicap implant allows patients to keep their ease of mobility, says Toback. “First, a small titanium screw is inserted into the bone of the toe, then a tiny cobalt chromium cap with an interlocking notch is attached on the end. Basically you’re screwing in the implant.” With a traditional implant, he says, stem-like supports would be put into the joint, and they could sometimes break or shatter — and didn’t provide mobility. The Hemicap procedure is FDA-approved for use in the shoulder, hip, and foot. “The beauty of it is that it acts like a rounded ‘cap’ that offers full mobility of the joint. You can even walk on it immediately,” he says.
Tracey Toback, D.P.M.
Toback Podiatry, 845-339-FEET
Doctors treating patients with abnormal heartbeats, or cardiac arrhythmias, can now use the power of magnets to provide a nonsurgical procedure that is safer and more precise than ever.
The new technique is a variation on a traditional method used by cardiologists, in which a tiny catheter — a tube containing electrodes at the tip — is inserted through a patient’s veins and arteries and “snaked” up to the heart. Then a diagnostic step known as mapping is often used: It measures the heart’s electrical activity and helps determine where a problem might lie.
“Traditionally, the catheter is controlled manually, by the physician,” says Sankar Varanasi, M.D., a cardiologist with a specialty in electrophysiology (the heart’s electrical activity). But now, with Stereotaxis technology, a technique known as remote magnetic navigation can be used to guide a catheter into place with pinpoint precision with the help of powerful magnets.
“Instead of the physician standing there and manually performing this step of the procedure, with Stereotaxis, they are able to manipulate it remotely. This allows us to be very precise. We can do step-by-step, accurate mapping to define the heart’s electrical signals,” says Varanasi, who is affiliated with the Heart Center in Poughkeepsie.
Science 101-type magnetic attraction lies at the core of the high-tech procedure, he explains. “Just like with a conventional magnet, you can move something toward it that responds to the magnetic field.”
With magnetic navigation (an FDA-approved procedure that is also performed by John Respass, M.D. of the Heart Center), the catheter inserted into the heart contains a magnetic sensor. Two large magnets are placed on both sides of the patient, who is lying face-down in a unit similar to an MRI machine. “One benefit is that this is an open-field unit, so patients don’t have that claustrophobic feeling of being in a closed MRI,” Varanasi says.
The physician then monitors the point-by-point cardiac mapping from an adjoining “control room.”
“Stereotaxis is actually both a diagnostic and treatment system used in the same setting,” Varanasi points out. After mapping, physicians can deliver different types of energy through the catheter to help regulate the errant heartbeat. The most common type of energy, radiofrequency ablation, emits high-frequency electrical energy to help control arrhythmias. “The advantage here is that the magnets allow us to have really precise control of where we want to deliver the energy,” he says. The entire procedure can take a few hours, according to the patient’s individual case, with recuperation usually just an overnight hospital stay.
“In the past 20 years,” Varanasi says, “physicians have tended to move away from sending patients into open-heart surgery. This type of procedure doesn’t leave anything behind in the patient, such as a pacemaker. And in certain cases, it might be the only treatment they’d need.
“This is a state-of-the-art treatment for heart arrhythmias,” says Varanasi. “It’s one of the tools in my armament as a cardiac physician, and it’s one of the most powerful.”
Sankar Varanasi, M.D.
Hudson Valley Heart Center, 845-473-1188