1 American College of Clinical ThermologyTermografía Digital Infrarroja para la detección más temprana del Cáncer de Mama Dr. Kenneth Fernández-Taylor American College of Clinical Thermology Dr. Kenneth Fernández-Taylor, MD Vice Presidente del ACCT Tel: Cdad. De Panamá, 18 de Mayo, 2016

2 La Termografía Clínica o TermoScan es una prueba sencilla de fisiología que se basa en el control de los nervios simpáticos de la piel y de la habilidad del sistema simpático para responder y reaccionar a las patologías en cualquier parte del cuerpo. Clinical Thermography is just a simple test of physiology that relies on the sympathetic nerve control of skin blood flow and the ability of the sympathetic system to respond and react to pathology anywhere in the body. Questions : ………

3 ¿Por qué es importante la Termografía?Debido al daño que causa la exposición a la radiación, falsos positivos, y daños psicológicos en el Grupo de Trabajo de Servicios Preventivos de los Estados Unidos (U.S. Preventive Services Task Force , USPSTF) recomendó: Inicio de toma de mamografía a los 50 años en mujeres con riesgo promedio.

4 Mamografía de una mama con tejido graso (izquierda) y una mama densa (derecha). Las áreas grandes de tejido denso aparecen blancas en una mamografía, lo que puede ocultar tumores y hacerlos más difíciles de detectar

5 Tejido mamario denso y Ca de mama40% de las mujeres a quienes se les realiza mamografía tienen tejido mamario denso. El tejido denso se ve blanco en una mamografía, lo cual dificulta el diagnóstico. ¾ partes de las mujeres con cáncer de mama tienen tejido mamario denso. (Mayo Clinic, 2011).

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7 Historia

8 Sir William Herschel. En 1800 descubrió la radiación infrarroja.

9 Uno de los experimentos de Herschel para detectar calorHerschel used a prism to divide the spectrum of colors from sunlight. He then used thermometers to measure the temperature of each individual color and found that they had different temperatures. This led to the quantification of the infrared range of light. Uno de los experimentos de Herschel para detectar calor en el espectro.

10 Sir John Herschel. Contruyó el primer termógrafo en 1840. Utilizando papel sensible al calor determinó el movimiento del sol en el cielo.

11 Fisiologia

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13 La termografía solo registra la temperatura de la superficie de la piel ( 5mm de la circulación microdérmica). Todos los hallazgos térmicos son producidos por una respuesta ‘simpatica’ procesada a través del Sistema Nervioso Central. No hay conducción directa de calor o frío a la superficie de la piel. La termografía NO ‘ve’ estructura alguna o anatomía. La termografía SI muestra resultados objetivos relacionados a la fisiología del dolor, patología, lesión y disfunción de cualquier area del cuerpo.

15 There are areas of skin that relate neurologically (sympathetically) to specific structures and functions. The areas do correspond with general dermatomes but are more specific. Doctors have used these areas of skin routinely for palpation when performing differential diagnosis, …… Take for example McBurneys point for appendicitis. Doctors trained in the interpretation of thermograms can report thermal findings that correlate with history and symptoms.

16 Using DITI for breast screening provides a totally safe and non invasive method of detecting changes in the breasts that can result in the earliest possible detection of breast disease. DITI can detect and record physiological changes years before there is any clinical evidence of disease. Being able to detect and monitor suspicious changes at a very early stage gives us the opportunity for intervention and far greater treatment options. The complete test only takes ten minutes, there is no body contact, no radiation of any kind and once a baseline has been established a comparison study is performed annually. El rol de la termografía en el cáncer de mama y otras enfermedades de la mama es ayudar a la detección mas temprana (8-10 años antes que una mamografia) y monitorear la fisiología anormal y la evolución de marcadores de riesgo para el desarrollo de cáncer. Para hacer una mejor evaluación lo importante es utilizarla en combinación con otras pruebas.

17 Journal of Clinical Oncology, Vol 13, 765-782,1995.Importancia clínica de la determinación de angiogenesis en el carcinoma de mamas: mucho más que una herramienta prognóstica Although the primary focus is on detecting angiogenesis…….. Other changes are detected and factored into a risk evaluation, including inflammation and lymph changes. CONCLUSIÓN: La mayoria de estudios retrospectivos muestran que la agiogenesis es un indicador prognostico nuevo importante en un carcinoma de etapa temprana.

18 AJR 2003; 180: CONCLUSIÓN: Las imagenes infrarrojas ofrecen un procedimiento no invasivo que es muy valioso como complemento para las mamografías para ayudar a determinar si una lesion es benigna o maligna. There are numerous published studies that support the use of thermography as a useful adjunctive test.

19 Ohsumi S, Takashima S, Aogi K, Usuki H.Breast Cancer Res Treat Jun;74(3): Importancia prognóstica de los hallazgos termográficos en pacientes con cancer de mamas. Ohsumi S, Takashima S, Aogi K, Usuki H. Findings are useful in the management and decision making process.

20 Thermografía. Su relación con características patológicas, vascularidad, tasa de proliferación y sobrevida en pacientes con carcinoma ductal invasivo de la mama. Sterns EE, Zee B, SenGupta S, Saunders FW. Cancer 1996;77: Algunas de las caracteristicas histopatologicas de la angiogenesis son dilatacion microvascular, hiper-permeabilidad, deposicion extravascular de fribrina y edema.” Thermography has been used for many years in angiogenesis research and in clinical application to monitor the efficacy of angiogenesis inhibiting treatments.

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23 Screening thermography has the opportunity to detect changes at any stage in the development from the first year through to when a tumor has established and is dense enough to be seen with mammography. This early indication can lead to earlier diagnosis and better treatment options.

24 40 duplicaciones, aproximadamente 10 años, es considerado letal.

25 El Cáncer de mama tiende a crecer significativamente más rápidamente en mujeres jóvenes menores de 50 años. EDAD PROMEDIO DEL TIEMPO DE DUPLICACIÓN DEL TUMOR Menor de 50 80 días Entre 157 días Mayor de 70 188 días Because pre-menopausal breast tissue is denser and more vascular than post menopausal breast tissue, any pathology taking place will have a better vascular supply and there will be increased cell changes and faster development of pathology in the younger women. The disadvantage with mammography is that with radiographically dense breasts it is difficult to differentiate between normal and abnormal density in the early stages of pathology. (It is also necessary to use more radiation to properly image dense breasts). Thermography is better suited to detect the physiological changes in the denser and more vascular pre-menopausal breast, with positive findings, months and sometimes years before the pathology becomes dense enough to be seen with mammography. Thermal studies improve the detection rates and accuracy of mammography. Fuente: Cancer 71: , 1993

26 Procedimiento: Fácil y rápido 100% seguro, sin radiación Sin dolorNo tiene contacto con el cuerpo Único método disponible para visualizar dolor Aprobado por la F.D.A. (Administración de alimentos y medicamentos de Estados Unidos).

27 TermoScan de senos normalThe five views necessary for a breast study provide the findings to evaluate, brachial plexus, lymph in axilla, sternum and below the breast, and vascular activity throughout the breasts and surrounding regions. The findings are not restricted to just tissue that can be compressed for mammography.

28 Thermograms are images compiled from usually between 40 to 60 thousand individual temperature measurements that should be sensitive to within one hundredth of a degree centigrade. A color scale, normally 16 colors is divided between a range of temperature. In this case the 16 colors are divided into an 8 degree range which gives half a degree per color for visual interpretation.

29 20 Year stable follow-up with clinical correlation of negative findingsCase history: Patient ID Practitioner ID 548 Year of birth 1960. History of fibrocystic pain and tenderness. Mammogram at year 1 followed by Ultrasound diagnosing small fluid filled cyst at 11 O’clock in right breast. Also multiple areas of fibrocystic tissue in both breasts. Mammogram at year 20 : no suspicious findings. Within normal limits. Thermography shows no clinically significant changes over time and no indication of developing pathology. Within normal limits. Negative Mammogram

30 10 Year evolving change with diagnosis of malignancy at year 7Case history: Patient ID Practitioner ID 554 Year of birth 1955. No significant history or symptoms. Mammogram at year 1. Within normal limits. Thermography established a baseline at year 1 but classified left breast at risk for developing pathology and recommended clinical correlation. Thermography reported suspicious change between year 2 and year 3 in left breast. Clinically no findings. Continued thermal changes reported year 4, 5, and 6. Mammogram Ultrasound and MRI at year 7 : Diagnosed small suspicious pea sized lump likely malignant in left breast. Patient refused biopsy. Thermography reported significant change and vascular activity consistent with angiogenesis and active pathology, suspicious for malignancy. Year 9 MRI and Ultrasound diagnosed carcinoma 8cm x 3cm in left breast. Thermography findings correlate with aggressive malignant pathology. Later diagnosed as invasive ductal carcinoma. Year 9 diagnosed with Invasive ductile carcinoma 8cmx3cm

31 17 Years of Annual ScreeningCase history: Patient ID Practitioner ID 548 Year of birth 1949. No significant history or symptoms. Mammogram at year 3. Within normal limits. Mammogram at year 17 : No suspicious findings. Within normal limits. Thermography shows no clinically significant changes over time and no indication of developing pathology. Report: Stable and Within Normal Limits. Mammograms Normal Thermograms Normal

32 Patrones térmicos normalesEvery individuals breast patterns are unique ……. Just like a fingerprint. No two are the same. Once a stable baseline thermogram has been established, annual screening can detect any changes that justify additional testing which can lead to early diagnosis and better outcome.

33 El TermoScan o Termografía detecta los cambios fisiológicos sutiles que acompañan las enfermedades de mamas, ya sea cáncer, enfermedad fibroquística, una infección o una enfermedad vascular. Los médicos pueden planificar de acuerdo a los resultados y diseñar un plan para profundizar el diagnóstico, dar terapia preventiva y/o monitorear hasta que otra prueba estandar resulte positiva. This is local infection after a biopsy.

34 Detección más TempranaEl TermoScan es especialmente apropiado para mujeres jóvenes entre 20 y 50 años cuyo tejido mamario es más denso, por lo que es más difícil encontrar lesiones a través de una mamografía. Esta prueba puede proporcionar al doctor un marcador clínico, que indique que un area específica de las mamas necesita ser examinada con más atención. This 37 year old patient presented for routine thermographic breast screening, she was not in a high risk category and had no family history. No breast exams had been performed previously. The vascular asymmetry in the upper left breast and the local hypothermia at 11 O’clock was particularly suspicious and subsequent clinical investigation indicated a palpable mass at the position indicated. A biopsy was performed and a DCIS of 2 cm was diagnosed. Unfortunately this patient only survived for 12 months after diagnosis.

35 La termografía de tamizaje aporta la oportunidad de detectar cambios en su etapa temprana desarrollo, desde el primer año hasta cuando el tumor es tan denso (1 cm) que ya se vuelve visible para la mamografía o ultrasonografía (0.5 cm). La detección temprana de estos cambios puede conducir a un diagnóstico más temprano y a mejores opciones terapéuticas así como a intervenciones preventivas por parte de la paciente o de su médico.

36 Linea Base 3 meses 6 meses 9 meses 12 mesesThis patient was also age 37 when her first baseline thermogram showed a slight hyperthermic asymmetry in the upper right breast. The follow-up study showed the pattern had become more well defined and although clinical correlation did not find anything remarkable it was decided to repeat the exam again in a further 3 months, when again significant changes were seen. Mammography was performed at this stage with the thermographic guidance of the locally suspicious area at 1 O’clock to the right nipple. The mammographic findings were inconclusive and the patient was referred for a repeat mammogram in 12 months. Thermographic monitoring was continued and at the fifth comparative study at 12 months significant changes were still evident and the hyperthermic asymmetry (temperature differentials) had increased. Immediate further investigation was strongly recommended despite a scheduled mammogram in 6 months, and at the patients insistence a repeat mammogram was performed which clearly showed a small calcification (1 mm) at 1 O’clock. Within one week a lumpectomy had been performed with good margins and the pathology confirmed as a malignant carcinoma (DCIS). This patient has now had stable thermograms for the last 2 years and is expected to remain healthy. 3 meses 6 meses 9 meses 12 meses

37 This is the specific area of the small DCISThis is the specific area of the small DCIS. We can see the vascular feed and the discreet area of hypothermia that is displacing the surrounding hyperthermia.

38 The results of this routine study led to the diagnosis of inflammatory carcinoma in the right breast. There were no clinical indications at this stage. (Thermography can show significant indicators several months before any of the clinical signs of inflammatory breast disease, skin discoloration, swelling and pain). Inflammatory breast disease cannot be detected by mammography and is most commonly seen in younger women, the prognosis is always poor. Early detection provides the best hope of survival.

39 This significant thermal asymmetry is caused by an early stage DCIS and was only just dense enough to be seen with thermography guided mammography. There was nothing palpable and this patient was 10 years away from her first routine mammogram.

40 Advanced angiogenesis in the upper left breast relating to a DCIS.

41 DCIS Thermography can show suspicious findings that are outside the range of mammography…… this tumor was missed by a mammogram as it was just outside the boarder of the medial left breast. Greyscale

42 The very significant vascular activity in the left breast justified clinical correlation and close monitoring which returned an opinion of fibrocystic changes taking place. These changes can be monitored thermographically at regular intervals until a stable baseline is established and is reliable enough for annual comparison.

43 The increased vascular activity in both breasts is consistent with the hormonal changes in pregnancy. This patient was unaware that she was 4 weeks pregnant at the time of her scan. The thermography tech was an experienced operator who asked the patient….. “your not pregnant are you ?” The patient was amused and said that she wasn’t but phoned the clinic a few days later to tell them the good news.

44 The majority of suspicious findings are benign but it is important to identify anything that needs further investigation or to be monitored more closely until there are findings that can be used in the decision making process. The hyperthermic findings in this breast did not cause concern in conjunction with the history and clinical information relating to symptoms. These findings were consistent with this patients mastitis.

45 Cáncer de seno en hombresOne per cent of breast cancers are found in men. The survival rate is much lower than in women as most breast cancers in men are only detected in advanced stages. This tumor was palpable at the time of imaging, there is a well established vascular feed which has even caused increased blood flow at the left brachial plexus and there is also drainage toward the sternum that extends to below the left breast. Metastasis were later found in other organs and this patient did not survive. Cáncer de seno en hombres

46 DITI Mammography / Ultrasound / MRI 3 months 12 months Integrated Progression Flow Chart with DITI as part of a Breast Screening Program Positive Findings Within normal limits Normal baseline Continue with standard annual screening which may include mammography or other tests to monitor for change Positive Findings leading to Biopsy and diagnosis Negative Findings Continue with monitoring and any additional testing as recommended by physician Correlation with other tests to monitor response to treatment Post treatment / surgery monitoring. Establish new baseline before continuing with ongoing annual screening Mammography / Ultrasound / MRI / DITI As considered appropriate and justified by physician DITI Mammography / Ultrasound / MRI 3 months 12 months Integrated Progression Flow Chart with DITI as part of a Breast Screening Program Positive Findings Within normal limits Normal baseline Continue with standard annual screening which may include mammography or other tests to monitor for change Positive Findings leading to Biopsy and diagnosis Negative Findings Continue with monitoring and any additional testing as recommended by physician Correlation with other tests to monitor response to treatment Post treatment / surgery monitoring. Establish new baseline before continuing with ongoing annual screening Mammography / Ultrasound / MRI / DITI As considered appropriate and justified by physician

47 Evaluación a tratamiento con Quimioterapia

48 Serial thermography can be used to monitor the response to treatments like chemo and radiation as well as angiogenesis inhibiting drugs. This is the first study pre diagnosis and shows vascular activity relating to a palpable mass. A mammogram correlated with the mass and FNB confirmed malignancy. The decision was to reduce activity before surgery and thermography was used to monitor the chemo before surgery. The tumor is above the left nipple. Hallazgo positivo térmico en la parte superior de la mama izquierda con asimetría de 2.2 grados ˚C.

49 The mammogram shows the extent of the tumor and the density.La mamografía de diagnóstico resultó positiva. Se encontró un carcinoma grande que fue confirmado con Biopsia de Aguja fina.

50 The first follow-up shows a reduction of 1 Deg C.Se tomó la decisión de reducir y consolidar el tumor antes de la cirugía. Después de dos meses de quimioterapia, el termoscan mostró una reducción de actividad y la asimetría se redujo a 1.2˚C ( una reducción de 1.0 ˚C)

51 American College of Clinical ThermologyTermografía Digital Infrarroja para la detección más temprana del Cáncer de Mama Dr. Kenneth Fernández-Taylor American College of Clinical Thermology Dr. Kenneth Fernández-Taylor, MD Vice Presidente del ACCT Tel: (503)

52 Otras aplicaciones clínicas del TermoScan

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54 60 % oclusión de la arteria carótida derechaIsotherm Escala médica de 16 colores 60 % oclusión de la arteria carótida derecha

55 Oclusión arteria carótida (lado derecho)A unilateral inflammation over a carotid artery is more suspicious for clinically significant occlusion than a bilateral finding which could be caused by elevated CRP levels. Oclusión arteria carótida (lado derecho)

56 Asimetría Carotida D>I

57 The skin as an organ (the largest) has specific regions that, through the autonomic system, relate to every internal organ and structure. This patient with a hypothermic asymmetry over the left lower chest has a history of CAD. “He also has an abscess at the upper left 4 tooth” ! Disfuncion cardiaca

58 Accidente automovilísticoAccidente automovilístico. El timón hizo impacto en la parte baja del pecho. Como resultado de la termografía se realizaron rayos X, los cuales mostraron fracturas en el esternon bajo y la última costilla de la izquierda. MVA, Steering wheel impacted the low chest, subsequent x-ray as a result of thermal findings showed fractures in the low sternum and left last rib. This patient presented two days after accident with pain and breathing difficulty. Refused x-ray before thermography findings.

59 Hipotermia focal relacionada con un quiste malignoPequeños tumores metastasicos indicados por areas focales de hipotermia sobre la columna lumbar Detection and monitoring of all cancers with DITI relies on the body’s sympathetic response to the pathology. Early stage cell changes generally produce heat and vascular patterns caused by angiogenesis. Later stage pathologies that have become ‘structural’ or dense enough to displace the normally perfuse surrounding tissue will show as locally cool areas.

60 Apendicitis : Cuatro casos. Hipertermia local sobre el punto de McBurney. These images are from an old study demonstrating the correlation between sympathetic response and pathology.

61 The primary finding here is the local area of hyperthermia over the hepatic flexure of the colon. Diverticulitis was diagnosed after clinical correlation with thermographic findings. Diverticulitis

62 Termograma muestra una varicosidad con perforadorThe anterior view of the upper legs shows a patient who had unexplained pain in the right leg for over a year. The thermogram shows a varicosity with a perforator that a vascular surgeon was able to treat with minimal intervention due to the accuracy of the localization. The image showing the vascular pattern in the right lateral leg was of a patient who had a 3 year history of pain in the mid lateral thigh and knee. Nerve conduction tests and a full range of anatomical imaging tests failed to find any cause for the pain. This thermographic study led to a confirmed diagnosis of phlebitis. Termograma muestra una varicosidad con perforador

63 Pcientes con Síndrome de Fatiga Crónica diagnosticada y Fibromialgia100% of patients with positively diagnosed auto-immune related conditions exhibit local hypothermia over T1, T2. These patients all suffer from CFS and Fibromyalgia. The reliability of this phenomena allows us to monitor the response to treatment and rehabilitation over periods of time … days, weeks, or months. Pcientes con Síndrome de Fatiga Crónica diagnosticada y Fibromialgia

64 Hipotermia local sobre T1 / T2Thermography uses the body's sympathetic control of skin blood flow as a window into the Autonomics ! A compromised immune function will always produce a distinct area of hypothermia over the T1 / T2 region. Hipotermia local sobre T1 / T2

65 Hiperthermia sobre ambos lóbulos de la tiroides. Indicando disfunción de la tiroides.

66 Paciente con hepatitisThis thermogram shows the abdomen of a patient with hepatitis. The hepatic blood vessel (closed after birth) has now opened from the liver to the umbilicus. Paciente con hepatitis

67 This elderly lady had undergone a left hip replacement surgery 3 months previously and her continued leg pain raised a suspicion for DVT. The thermographic findings were not consistent with DVT, but showed a focal area of inflammation that guided a sonographer to a deep abscess near the bone. This was lanced and successfully treated with antibiotics. El área focal de inflamación guió al sonografista a un abceso profundo.

68 Disfuncion TemporomandibularTMJ can be difficult to diagnose. This patient had classic symptoms and also classic thermographic findings consistent with TMJ which helps to confirm a diagnosis. Disfuncion Temporomandibular

69 Parálisis facial (parálisis de Bell)

70 Atrapamiento del plexo braquialAtrapamiento del plexo braquial del lado derecho. Reacción simpática de la parte inferior del brazo derecho. Referred pain syndromes can also be difficult to diagnose. This patient presented with non specific pain in the lower right arm which had been investigated with a number of different modalities. Thermography showed thermal asymmetries that led to a positive diagnosis.

71 Punto trigger Miofascial-en semispinalis cervicus By using anatomical landmarks or placing IR markers on the patient, thermal asymmetries relating to specific structures can be included in reports.

72 Punto trigger MiofascialPunto trigger en la parte superior del Romboide izquierdo. This athlete had a history of a recurring ‘niggle’ and stiffness in his upper left shoulder…… one treatment guided by thermography resolved the problem permanently.

73 Gluteus maximus Nadador profesional con dolor en gluteus maximus izquierdo (Nemesis de nadador) A common problem in competitive swimmers. The Physiotherapists treating this Olympic swimmer were able to monitor the results of their treatments using thermography at regular intervals. Shorter recovery times and better end results can be achieved when treatments can be modified due to the information provided by thermography.

74 Fractura por estrés Jugador de fútbol con fractura por estrés, confirmada por cintigrafía. X-ray showed no abnormality, thermography correlated well with the patients report of pain and provided justification for the more invasive test of scintigraphy which clearly showed a stress fracture in the exact location indicated by the thermograms.

75 Fractura del tobillo izquierdoSympathetic shutdown in affected limb Being in the right place at the right time resulted in this study taken within a few minutes of a fracture injury. A very significant sympathetic ‘shutdown’ occurred instantly with a hypothermic asymmetry of 11 ºc but within 3 hours inflammatory processes had reversed the asymmetry to one of a hyperthermia of 5 ºc.

76 Tres fracturas de estrés en los procesos transversos de la columna lumbar.This patient fell from a ladder. X-ray was inconclusive, Scintigraphy showed the fractures.

77 Post fractura Respuesta pobre de recuperación del tobillo izquierdo después de remover el yeso. Thermographic evidence can positively influence decision making in case management. X-ray evidence confirmed complications with this ankle that required surgery.

78 Fractura del tobillo derecho6 semanas post fractura tobillo derecho Transferencia del peso a la chimpinilla izquierda. Thermography was performed after cast removal, providing a baseline for comparative studies during the healing process. Indications of non healing fractures and other complications can be detected at an earlier stage during rehabilitation.

79 Síndrome T4 It can be reassuring and beneficial to both the patient and clinician to have objective conformation of a previous or new diagnosis.

80 Post cirugía Rodilla derecha despues de 3 semanas de artroscopíaThis Patient did not believe that the level of pain following his arthroscopy was reasonable to except. The thermography report of inflammation consistent with infection justified sending him back for further investigation which resulted in an appropriate anti-biotic being prescribed.

81 Ligamento cruzado Esguince posterior de ligamento cruzado de la rodilla izquierda Daño vascular debajo de la rodilla Confirming a clinical diagnosis with objective evidence has many benefits. The vascular damage was not initially identified with this sporting injury.

82 Ligamento Medial Tension en ligamento medial de la rodilla izquierdaThis woman's basketball player had been carrying an injury to her right foot (stress fracture in the navicular). Thermography showed the effects of the weight transfer to her left knee.

83 Dolor simpático Irritación simpática del talón del pie izquierdoAlthough this hypothermic pattern resembles an S1 radiculopathy it is a sympathetic reaction to the pain caused by a bony spur on the left heel. The hyperthermia in the right plantar foot is likely to be a result of a long term weight transfer off the left heel.

84 Síndrome Regional Doloroso ComplejoSRDC en dedos pie izquierdo Thermography is the most objective diagnostic test for CRPS. Treatment options and success rates depend on early detection, (in the first 3 months). The sympathetic ‘shutdown’ is so sever in this foot that the toes look thermally amputated.

85 SRDC del pie derecho

86 Thermal asymmetries and their relationship to anatomical structures can be correlated with postural (structural) asymmetry and other clinical and imaging modalities. This is the Thermographic results from a patient with SI pain and a tilted pelvis, (the right leg is shorter than the left).

87 Radiculopatía de la pierna derecha de L3 L4 dañoThe cold pattern in the right lateral thigh is consistent with a radiculopathy. Radiculopatía de la pierna derecha de L3 L4 daño de nervio raíz

88 Neuropatía en los dedos de la mano derehaTemperature differentials are important when reporting…..the Objective evidence of thermography supports subjective opinion and can help in decision making.

89 Etapa temprana de síndorme de tunel carpal bilateral Sindrome de tunel carpal derecho crónico

90 Sindrome Regional doloroso complejo en la mano izquierda.Hipotermia de guante. El regreso de la función simpática normal después del tratamiento a corto plazo. RSD of the left hand. The return of normal sympathetic function after treatment was short term.

91 Estrés post frío dorso de la mano de 20 ˚C.1 minuto después Hipertermia normal reactiva ocurre después de un minuto. Después de 3 minutos After a baseline is established ….. This would be the normal response to a cold stress of the hand. Initial cooling and then return of skin blood flow. (A sympathetic bounce) Después de 6 minutos

92 Mordida de escorpión. Pulgar derecho.We do need to have accurate and specific history and symptoms to be able to provide useful results when interpreting images. The thermal findings are correlated with given history and symptoms. Mordida de escorpión. Pulgar derecho.

93 E-mail: [email protected]Centro Comercial Villas Españolas. Local D-5, Paseo General Escalón, San Salvador, El Salvador. Tels.: (503) , Cel.: ,