JCPM2023.02.14

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JCPM2023.02.14

Thank you for being on the webinar tonight. We're going to go over some research regarding COVID. Not related directly to what we normally do, but I think it's worth looking at because it's a question that comes up every day in our office.

I put the paper that we're talking about in the handout section together with some that we discussed last week. So if you click on that, it's open source, so you'll be able to download it without breaking any rules.

Business Lessons from Those Who Grew Their Business and Those Who Went Broke During the COVID Pandemic

I think part of the reason it's worth discussing is that it relates very strongly to some of the business ideas that are worth thinking about. During the worst of COVID, we had some people who actually made more business, more money, and more business than before COVID, and others went completely broke and out of business.

Looking at it, what was happening, I was able to see physicians doing the same thing in similar towns and having dramatically different results. Some were doing very well, and others, like I said, just had to close the shop.

So it might be worth thinking about that in concert with this paper that came out, the review paper. You can see the lead author is out of Oxford and extremely well-respected contributors from around the world. They looked at what's the effectiveness of masks versus no masks. I don't want to get too deep into this. I'll tell you the results. And before we get to the results, let's talk about the business side of it.

For example, there was a time when Botox was considered not medically necessary. So in most places in the U.S., you weren't able to do it. But Botox is also a known treatment for depression. Very strong studies, 9 or 10 of them now that we've covered here in the journal club, about using Botox for depression (see references at the end of this note).

Here are some of them. It's thought to be related to a feedback effect from the facial muscles, and that keeps a cold emotion from turning into a hot emotion due to a negative feedback loop that goes on.

So anyway, so what some of our people did was they continued to do Botox, but they sent out an email and let people know, "Hey, I know you're probably depressed with everything that's going on in the world, but Botox helps with depression, not just with your wrinkles."

That was a legitimately scientifically supported reason for having people come into the office when the powers that were supervising us were telling us only to do medically necessary things and not cosmetic work.

Anyway, so even to the present day, I just traveled and saw some people were still wearing masks, and I'm sure it'll be up and down about whether it's something we should do or not, so I thought I would give you guys this paper because it's a really strong review article where they looked at multiple studies. And all together, it was over 600,000 people involved in the multiple studies they looked at, comparing mask versus no mask and regular surgical mask versus the respirators, the N95 respirators. The conclusion was that, basically, they couldn't reach a conclusion because they could not show that the masks were helping.

Proof vs. Lack of Disproof—the difference matters

Let me stop for a second. I called a physician, who was interested in our group a number of weeks ago, and the first thing out of his mouth was, "Well, tell me the research that proves it works."

I started just to end the conversation there because, really, the way science works is we never really prove anything. We have research that supports what we're doing, and it only stands until someone disproves it.

So that's the best we have. And as you guys know, things have changed and often do change. But Dr. Planck, the great physicist, said that they really change one funeral at a time. That was his writing in his biography, his autobiography, that really, nobody really changes their mind, but we die off, and the new generation starts to believe the new literature.

So how does that relate to COVID and our business of medicine?

If you made the statement that masks do not change the outcome at all, whether it's a cloth mask or a respirator, here are multiple studies, randomized controlled studies that involved a total of over 600,000 people that were not able to prove you wrong. And I'm not even going to start going to what that affects whatever political views you might have. But as physicians, I think that's a strong thing to know, that people have tried to prove that postulate wrong, and they can't. S

o at the present moment, you can say that a mask doesn’t make a difference.

Washing hands seem to make a difference. And we also know that just being generally healthy and at a close to normal weight makes a difference. But masks don't. At least no one's proven that wrong yet.

So there you have it. And again, I don't think that changes what you do in the office tomorrow, except that it makes you perhaps feel more secure if you're okay with people coming and going from your office without wearing masks. However, we should all be diligent with hand washing.

What about Pain after a P-Shot® Procedure?

Okay, so you have that. There was a question that came up that I wanted to cover, and then I want to show you a little trick in our websites that will help us move forward, and then I think that's it.

This question involves the P Shot. Let me pull it up where you can... It was texted to me today. I want to show it to you. Right there. I left out the names, but it's a couple of questions regarding the P Shot. "For the first time, a patient complained of pain," and this is someone who's been doing the procedure for a number of years. Continuing, “Three days after the procedure, with no signs of infection. Any suggestions? I use Emcyte."

Here's what I have noticed. I did the first P Shot on myself 12 years ago, and our group has now done many, many thousands of procedures. And I never heard anything about pain, continuing pain post-procedure with a P Shot or the O-Shot until the past six months. And I'm only hearing it with PureSpin or EmCyte kits. But the problem, you realize a kit is just a container. The only thing that makes it something useful is the centrifuge and the knowledge of knowing how long and how fast to spin it. The only difference between the kits is the anticoagulant.

And I don't know; it may be a coincidence, but we have thousands of procedures being done, and I never heard that complaint until six months ago, and I've yet to hear that complaint from anyone using anything other than an EmCyte or PureSpin. S

o if you have one of those kits, keep the kit. They're great at isolating platelet-rich plasma, but call the company and tell them to substitute ACD solution instead of sodium citrate because whatever source of sodium citrate they have... And now I'm just postulating. I don't know. Everything else I might say is postulating, but all I know is that until six months ago, I never heard this complaint once, and now I've heard it probably a couple of dozen times, and only with an EmCyte or a PureSpin kit. So ask them to send you a different anticoagulant, and you should be good to go. It's a great kit. Don't give up the kit; just change the anticoagulant.

The Survey that Helps Us Think about Our Procedures

Now, again, could be just a coincidence that all the other kits just coincidentally never had that problem, or maybe they've had it every day, and no one's ever just told me about it. But here's a way that we can make some more conclusions, and I'll show you where it lives. We can make some strong conclusions, actually. So hold on a minute. And then this is the last thing, I think, I have, unless you guys have questions for me or comments.

If you log into the P Shot website... T

his also lives in the O-Shot website as well, the membership side. I get a lot of surveys from the O-Shot side, but very seldom from the P Shot side. But if you go to the dashboard and then click on patient survey, this pops up. It allows you to put in the person's name, email, your patient, and cell phone number, and then with a click down menu, you can put in these other things.

This is connected to software that is HIPAA-compliant that will then send the person open-ended questions together with the SHIM score. So it'll survey what symptoms they might have with open-ended questions, but it also administers the erection scale, 5 to 25 scale. And you can see it has in here which PRP kit did you use.

Also, I use the HIPAA-compliant, double password-protected part of SurveyMonkey, and the survey is administered to the patient through a text message that comes from Ontraport. The person's name and phone number is not connected to their answer in any way. In other words, when they click the button on the text message, it takes them to the survey for SurveyMonkey, but SurveyMonkey has no way to attach it to anyone's name.

So anyway, that's not a double-blind placebo prospective study, but if we get enough numbers, it's still something very, very useful. And considering what I just told you, it might be useful for us to all make a goal of putting at least four or five people into this survey.

What I do on the O-Shot side is, I'll just show you, if someone puts in five people, then I put a little icon by their name as a reward. So I'll show you where that lives when you click on "Find Provider."

By the way, I did some things to speed up the website slightly, too, so hopefully, you'll see that coming, making life easier. But if you put in... Well, I'm not seeing any right now. But I'll show it to you in the legend that if you put five people into our survey, I put that in there, showing that you're participating. It's not really... T

his isn't, again, a double-blind placebo prospective study. And because the name is not attached to the survey, in those cases, there's not even a need for an IRB. You don't need an IRB to survey your own patients, and you don't need an RB if you're not tying the name to the questions with the survey.

So anyway, hopefully, if you guys will help me with that. So you can see here's someone who put some people in. And after you put five people in, let us know, and we'll add that to your icon on the directory.

What is the risk from the needle when giving a P-Shot® procedure?

With that, I have covered everything I intended to cover tonight. See if anyone has questions. If not, we'll call it a night. Let's see. We're seeing nodule growth.

I have seen people complain of some lumps after a P Shot, occasionally. Not in my own practice, but I've heard of it. That's the question.

Let's talk about what's there. When you look at the research that's been going on for many years, looking at men who do Trimix, so they're giving their own injections every time they have sex. They have a 10% incidence of Peyronie's disease. But the general population has close to about 8% incidence of Peyronie's disease. So putting a needle in the penis every time you have sex doesn't really do anything to increase your incidence of Peyronie's or scarring from the needle, which is part of what gave me the encouragement to do the thing the first time to my own self, the needle.

And then you add to that, PRP is used to treat scarring. So you wouldn't expect PRP to cause a scar. And when you look through the literature, you can't find that. You can find multiple studies treating scars but not causing a scar.

So I don't know why it happens. I know that it goes away with time in every case I know about so far. And my guess, and I'm just guessing, is that it may relate to some sort of hematoma or perhaps the use of the pump itself. But hearing from our people, I don't know of anyone who had any sort of nodule that persisted or turned anything serious.

Which is the best anticoagulant for making PRP?

Which anticoagulant is better?

There are different theories about which anticoagulant, and I know the PRF people are saying, "Well, you don't need any anticoagulant at all." We covered one of those papers here several weeks ago. The problem or the challenge with PRF is that if you're using a gel to pack a wound, it's great, but if you're going to inject it, you have to micronize it. And hopefully, you guys are using tiny needles to inject the clitoris. I might use a 27 to inject the penis, but never anything bigger. So most people think, when I read the research anyway, seems that the consensus is you're better off with PRP if you're injecting. But I know people will argue with that. And if you're getting great results with the PRF, go for it.

But if you're using PRP, which is what I still recommend for our procedures, then the anticoagulants or ACD or sodium citrate.

Regen comes with sodium citrate, but for some reason just doesn't hurt. The sodium citrate can be of different types and different concentrations, and I have trouble getting plain answers. And I've called around to the top of the pyramid at EmCyte/PureSpin, and I don't know, I can't get an answer for what's the concentration.

But Magellan or Truprp uses ACD solution. Selphyl uses ACD.

So those are the two main anticoagulants. And like I said, I know Selphyl and Regen both don't hurt, and one uses ACD and the other users sodium citrate. But there's different types of sodium citrate, different concentrations, and I don't know what changed, but I know that at least if you're working with Jeff Petrillo and his group, they'll swap you out to ACD, no questions asked, and no charge to the doctor at all, which is what I recommend you do if you have one of those kits.

How to decrease pain when treating hair

For hair PRP, if you go online, and I won't make you watch me click around, but if you go to our hair, what's the best way to keep it from hurting, if you go to our hair section, you'll see one of the top hair experts that I've ever met, who's been doing it for 20 years, block the scalp. I usually don't. But when I treat the scalp, it's 45 seconds. Usually, 30 to 45 seconds when you treat the whole scalp. Not because I'm particularly fast, but just because I don't think that's something that requires a lot of contemplation.

So I usually use ice and numbing cream, and it's fine. But for others, those little vibrating things help a lot. Some use nitrous. I'm all for using nitrous if you have someone who's anxious.

The top question I like for the patient is, "Do you need nitrous when you go to the dentist?"

And if their answer is yes, even if they say they just like it, they don't really need it, then you're probably going to need something when you do our facelift or hair.

The P Shot and the O-Shot are usually less painful, and so you probably want... For the face and for hair, you might want to have them take a Valium or a whatever you like of people to take, or have the nitrous in your office.

But you can do a ring block, and that's demonstrated on our website. Some just do injections. Catching the ostium as it comes out over the brow on both sides and in the occiput. But my preference is if I'm going to block the scalp is to do a ring block. But in my opinion, with just a little practice, you can do the whole procedure in less than a minute and with an ice pack or maybe a little nitrous. You don't really need anything else.

Now, that would be different if you're doing a hair transplant. But for our procedure, I don't think you need anything else.

Improving the Outcome after an O-Shot® Procedure

Okay, let's see. Let's read this next question. Okay, so a patient with an O-Shot two weeks later stated 90% improved and orgasm improved. Four weeks later, patient very happy. Three and a half months later, urine leakage returned. Second O-Shot given at four weeks. And at four weeks after the second O-Shot, has occasional leaks. What advice do you have for improved outcome?

There's a couple things. If the outcome we're talking about is incontinence, well, even if it's sexual function, it's definitely additive. So much so that some people just require everybody to sign up for two.

And I just mentioned our survey. In our O-Shot surveys of our patients, which we now have a couple of thousand people who've answered it... I guess it's more than that. Maybe pushing 3,000 now. But it's around 60%, for every reason you might get an O-Shot, love it on the first one, and 85 on the second one. But that's including people with anorgasmia or some of the more difficult to treat cases. If you look at just urinary incontinence, many of our people claim to get close to a hundred percent.

The trick or I think the knack to it, is that when you do the procedure, to be very, very distal to the bladder. In other words... I'll pull it up for you. More and more of my talking to people who get great results and those who don't have found that the key is to put your needle really... I'll pull it up for you so I can show you. But really just on the other side of the hymenal ring, into the introitus, so that your needle is going in in those first one or two rugae that you see.

We covered the anatomy here of... I guess it's two weeks ago. But if you look at what's happening there, we're probably even injecting the actual muscle itself. Let's see if I can pull one of those up. In other words, I used to... Let me pull it up for you. I used to imagine that there was a space between the urethra and the anterior vaginal wall. But by looking at some of the more recent published work in regards to the anatomy of that area, the muscle of the...

That's what I was looking for. The muscle of the urinary sphincter and the muscle of the vagina, actually, there's no space between those two structures distal to the bladder. And then there becomes a separation as you get closer to the bladder.

I don't have a good explanation for why. I just know that when you look in here, so you see the hymenal ring. If you start looking... This is actually... It's hard to see there, but it appears to be going deeper than I'm even recommending. But you'll see horizontal rugae. Out here, this tissue's very smooth and glistening. Here, there's horizontal ridges. And if you just go to about the second one and put your needle, I mean, that distal to the bladder or that proximal to the introitus, you get a better result. So that's my best tip for how to make it work better.

The other thing is not going too deep with the needle. So you can see that's a 27 1.5 inch needle, one and a quarter needle. But literally just... It's almost subdermal.

And when you get it right, you'll see this tissue start to bulge down. So you've created this hematoma, basically. Not because you hurt the person, but you injected material that would represent a hematoma had the person been injured to cause it. Which is really kind of the point, right?

We're tricking the body into thinking this area needs to be repaired because there's a bruise there or a hematoma or activated platelets with all the cytokines and growth factors.

So that's two tips. Don't go too deep. Stay distal to the bladder. And then, of course, the other is just realize that there are... I often see people that the first one will make their incontinence better, and then the second one will make their sex better. Or the first one starts to wane sooner, somewhere between three to six months, and then the second one lasts longer.

And then other things are affected, of course, depending on what you're treating. If the woman has... If you're treating scarring from an episiotomy, she's likely to stay well for many years, unless she has another baby. If you're treating dyspareunia because she can't be on hormones because she had breast cancer and is afraid to take estrogens or use estrogen creams, then she'll probably need a repeat treatment 9 months to 18 months later.

So if the etiology is present, that's about how long it lasts, 9 to 18 months. Still life-changing if you have someone who... What's her alternative if she doesn't want to use hormones and it hurts to have sex? You could use lidocaine, where she can't feel anything, or lubrication from KY or something. But as you guys know, often that doesn't work. So anyway, hopefully that helps.

What to expect after an O-Shot® procedure

The other thing that I like to do to set expectations is if you just go to our website made for the O-Shot, and you scroll down, I have here an audio entitled What to Expect After the O-Shot, that I made for patients. So one way, of course, to get great results is just to set the expectations properly. And if you listen to this and then do your version of that recording, or you could post it on your website, either way and you have people listen to your version of this or to mine either immediately before or after the procedure, they'll have a different idea about what working looks like, depending on what their problem is. Was it dyspareunia or incontinence or anorgasmia or lichen sclerosus or just things work great, and I want to see if I can make them work better? Those are all different scenarios, and I cover all that there, so that hopefully your people are more expecting what might work.

Free Press You can use

Let's see. I'm reading another question. Yeah, I think that's... Okay. All right, I think with that, I don't see any more questions, so thank you.

I forgot I was going to show you one other thing that you could show your people. Hold on a minute. We had some good press come out. Remember, I want you, when you do these things, of course, I want you to learn something, but I also want you to make money. You need money to, of course, run your practice.

Here's a nice little article that came out. And making money by... The way I like to think about it is marketing is educating people about their disease so they trust you to treat it, so that you're treating the right person and you're giving them enough value they're happy to pay you for it, and the value they get is worth a lot more than what they paid you. And now you deserve your reward, and everybody's happy. Versus treating a person, you can't help or treating them and not charging them what you're worth.

So this is a nice little article that came out about what celebrities are doing. And you can see it's something you could share if you guys are doing our vampire procedure and say, "Hey, this is still hot, and you might want to do it, and we do it."

So I will put this... And literally, it could be a one-line... I'm putting this in the chat box. It could be a one-line email that says, "Hey, I don't know if you've seen this, but this is still a hot thing. It's hot because it works, and we do it," and put a link to your vampire website. Or it could be a social media post with a link to that article. I just put it in the chat box. So all the research and the handouts will go away when I shut this down.

Thank you, guys. I hope this was of help to you. And if you do that tonight, I hope that you'll get some new patients from it. You guys have a good night. Bye-bye.

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References

Jefferson T, Dooley L, Ferroni E, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Acute Respiratory Infections Group, ed. Cochrane Database of Systematic Reviews. 2023;2023(1). doi:10.1002/14651858.CD006207.pub6

Botox for Depression

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