Snoring is Bad for the Heart? Not so fast...

This past week, media has both aired and published a story regarding new research that suggests snoring WITHOUT obstructive sleep apnea may lead to potential increased risk of heart disease as well as stroke.

Apparently, researchers in Michigan examined the data of 913 patients between the ages of 18 and 50 who had undergone a sleep study between 2006 and 2012. None had been diagnosed with sleep apnea, but did have significant snoring. These patients underwent an ultrasound that measured the thickness of the carotid artery inner lining. The thicker the inner lining of the carotid artery, the higher the risk for carotid artery disease and stroke.

The researchers found that in their patient population, the carotid arteries were thicker in snorers than in non-snorers. In fact, these abnormal changes were comparable to smokers, diabetics, and patients with hypertension.

Unfortunately, their findings have not yet been published (though submitted to the journal Laryngoscope), but was presented at the Combined Sections Meeting of the Triological Society in Scottsdale, Arizona held between January 24-26, 2013.

However, this is not the first study to show a link between snoring and heart disease. Hungarian researchers in 2008 reported that loud snorers were at significantly higher risk for stroke and heart disease in their study population of 12,642 subjects.

Contradictory Research: Snoring is NOT Bad for the Heart

Now, before every snorer goes into a panic regarding the fact that they snore, even if there are no problems with obstructive sleep apnea confirmed on sleep study, consider this...

Australian researchers published findings in 2012 that snoring did NOT increase risk for heart disease and mortality regardless of whether the patient suffered from sleep apnea or not. Their population study group consisted of 380 subjects.

What's Going On?

Admittedly, the burden of epidemiological evidence does suggest a link between snoring alone and potential increased risks for stroke and heart disease. But the very factors that predispose to snoring are also associated with other diseases that confound a conclusive relationship. Such other confounding factors include obesity, hypertension, diet, age, smoking, and alcohol consumption. When ignoring snoring-related health issues, there are numerous other confounding factors including periodontal disease, personality, stress, sedentary lifestyle, etc.

A study I would like to see to help clear the confusion regarding the risk of snoring would be to examine a large population of subjects who snore, but who are all skinny, non-smokers, non-alcohol drinkers, not diabetic, do not have high blood pressure, eat a balanced healthy diet, do not have a type A personality, good teeth, exercise daily, and lead a relatively stress-free life.

Any takers???

Assuming Snoring DOES Lead to Elevated Risk

The simplistic reason this may occur is due to acoustic and vibrational trauma that gets transmitted from the airway to the carotid arteries located nearby in the neck. Such snore-induced vibrational trauma leads to micro-injury to the inner lining of the carotid artery leading to thickening.

With thickening, the carotid arteries in essence become more narrow leading to increased risk of stroke.

Such vascular injury can also lead to increased levels of catecholamines that can lead to similar changes elsewhere in the body including the heart.

Of course, there are more complex variables at play which requires more complex answers, but that's beyond the scope of this blog.

Treatment

Snoring is unfortunately a complex problem to fix and does require some testing to fully evaluate and treat successfully. Such tests include fiberoptic laryngoscopy, sleep study and sedated endoscopy.


Source:
Snoring May Be as Bad as Smoking for Your Heart. Medical Daily 1/24/13

References:
Cardiovascular Disease and Health-Care Utilization in Snorers: a Population Survey. Sleep 2008 Mar;31(3):411-6.

Snoring Is Not Associated With All-Cause Mortality, Incident Cardiovascular Disease, or Stroke in the Busselton Health Study. Sleep. 2012 Sep 1;35(9):1235-40. doi: 10.5665/sleep.2076.

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Infographic: HPV from Oral Sex Causes Throat Cancer

I have blogged in the past regarding how HPV transmitted through oral sex (and potentially even French kissing) has now become the number 1 cause of throat cancer in individuals under the age of 50, even more than smoking and drinking alcohol [link]. Of course, smoking and alcohol further exacerbates this risk.

Indeed, A 2007 study in the New England Journal of Medicine found that younger people with head and neck cancers who tested positive for oral HPV infection were more likely to have had multiple vaginal and oral sex partners in their lifetime. Having six or more oral sex partners over a lifetime was associated with a 3.4 times higher risk for oropharyngeal cancer; cancers of the base of the tongue, back of the throat, or tonsils. Having 26 or more vaginal-sex partners tripled the risk. The association continued to increase as the number of partners in either category increased. Of greater concern is that "French" kissing may also potentially be a mode of transmission.

In any case, Mt. Sinai Hospital published a great infographic to further educate the risks of oral sex. Needless to say, if you find/see an abnormal bump in the mouth, talk to your doctor about it!

References:
Human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 Sep 13;357(11):1157; author reply 1157-8

Human papillomaviruses in head and neck carcinomas. N Engl J Med. 2007 May 10;356(19):1993-5.

Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med. 2007 May 10;356(19):1944-56.

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Haptic Hearing Aids... The Next Generation of Hearing Aids?

If you think about it, current hearing aids are essentially just a volume knob to increase the sound volume for those hard of hearing.

However, as any audiophile will tell you, sound amplification alone does not mimic "true" sound quality as perceived in the mind. True sound quality involves not just sound, but also "sensation." That's why people still attend concerts or spend thousands of dollars on audio equipment for home sound systems. It's not just "hearing" the sound, but also "feeling" the sound.

This may sound like a trivial matter, but let's consider gaming... In the past, when manipulating a character within a video game, it required the use of a joystick. However, when using a joystick to make the character shoot a gun versus swinging a sword, it "feels" the same to the gamer. The joystick does not provide any tactile feedback to reflect what is happening in virtual reality.

Enter haptic technology. With haptics, when shooting a gun in a video game, the joystick will actually jump backwards to mimic what actually would happen in reality. When swinging a sword in a video game, the joystick will actually provide resistance to mimic the feel of swinging a sword with its weight and air resistance.

Haptic technology has also made robotic surgery a reality given it is very important for the surgeon to know that when a robotic arm/finger touches a living tissue, the surgeon is able to "feel" whether the tissue is "soft" or "hard" in order to deliver the proper amount of pressure to cut or move human tissue around.

Now consider using haptics within hearing aids. Sound would not only amplify, but also provide tactile sound sensation via bone conduction. Sound should become "alive" and more realistic, just like the difference between using a plain joystick versus one that uses haptics. Furthermore, adding bone conduction to the air conduction essentially adds 2 additional "speakers" for a total of 4 speakers (2 speakers via air conduction and 2 speakers via bone conduction). And more speakers produces more depth and realism to the sound... just like a home movie theater system which can have up to as many as 8+ speakers.

Now does this actually happen?

Well, it so happens there are regular headphones (high-end of course) to be introduced later in 2013 that incorporate haptics and for those who have used it, the experience is utterly magical.

I quote from Forbes journalist Jason Evangelho,

"I was downright giddy. I had the strongest desire to re-experience my entire music library with these headphones. I was hearing and feeling elements of the music I never knew existed..." [link]

When playing a video game with haptic headphones,

 "each cannon barrage was brutal; hearing the rapid fire of an assault rifle was crisp, pronounced, exhilarating. I could literally feel the roar and hum of the engine through both my hands and my ears." [link]

The technology marrying sound with haptics has been introduced by ViviTouch (subsidiary of Bayer) who has dubbed it "ViviTouch 4D Sound."

They have also partnered with Able Planet to create an ITC (in-the-ear) hearing-aid like device for sound delivery using Able Planet's Sound Fit ear piece. Sound Fit itself is an interesting device in that unlike ITC hearing aids which requires molding, Sound Fit literally molds to any ear canal when inserted analogous to memory foam mattresses that conform to any body shape/type when a person lays down. No customization is required. Such a form fitting device in the ear canal is important as it can transmit vibrations to the bone around the ear more effectively.

I feel that if the technology holds up and wows enough people, it will be inevitable that such haptic technology (and even Sound Fit ITC) will soon become incorporated into high-end hearing aids rather than just high-end headphones as they are now.

Of course, I could also be totally wrong...

Source:
'Deaf People Will Hear Again:' How ViviTouch and Able Planet's Haptic Technology Will Change The World. Forbes 1/25/13

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MasterChef Hopeful Bonny Porter Has Congenital Hearing Loss

Bonny Porter is a chef who is competing to become the next MasterChef hopeful in Australia. She also has congenital hearing loss being completely deaf in her left ear by the age of 3 years old and with significant hearing loss in her right ear by the time she was 7 years old.

Even with a hearing aid, lip reading is necessary and during the MasterChef show, did request the host and judge to wear special microphones to help her hear what they said better. Beyond that, she requested no other special treatment.

According to her bio, she is currently working as a chef at Sydney’s Rockpool Bar and Grill. Prior to that, she apprenticed at Park Hyatt in Canberra and Manly Wine by Gazebo.

Good luck!

Source:
Bio on MasterChef Australia.

MasterChef's Bonny Porter faces big challenge. Herald Sun 1/21/13

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Sinus Mass Chance Finding (Incidentaloma)

The New York Times published a great story on the dreaded incidentaloma on Jan 17, 2013. An incidentaloma is essentially a chance finding of a mass most likely benign, that was incidentally discovered on a CT or MRI scan ordered for a completely different reason.

With such incidentalomas, it leads to patient anxiety causing physicians and surgeons to order even more tests and procedures (which themselves may lead to other incidentalomas). The vast majority of such incidentalomas are "nothings" without any significance, but hard to persuade patients otherwise at times.

In the ENT world, incidentalomas are very common when CT and MRI scans are performed of the head for a headache, stroke, eye pain, dizziness, or some other non-sinus related complaint.

In the report, there is the statement of:

"There is an opacified mass inside the right maxillary sinus cavity [or some other sinus cavity] two centimeters [or larger] in size."

Compare the above CT scan (red arrow pointing to the mass) with a normal CT scan of the sinuses below:

IF symptoms are localized to the corresponding mass on the CT/MRI scan, than further management which may include surgery can be pursued.

However, the vast majority of patients have absolutely NO symptoms localized to the corresponding abnormality. Radiologists and ENTs report that such a mass is most likely a benign mucosal inclusion cyst for which there is no significance and nothing more needs to be done.

However, some patients due to cancer concerns, even insist on having surgery to get it removed, even in spite of the risks associated with surgery including brain fluid leakage, eye damage, etc.

I personally usually insist a patient get a 2nd opinion prior to any surgical intervention for an incidentaloma if I'm pressured to "do something" when my gut feeling is to "do nothing."

Source:
The Fallout of a Chance Medical Finding. New York Times 1/17/13

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Another Egg-Free Flu Vaccine Approved by FDA

First there was Flucelvax introduced in 2012 and now there is Flublock, both considered egg-free for those concerned with egg allergy in traditional flu vaccines.

Rather than being cultured in eggs, Flucelvax is cultured in mammalian cells and Flublock is grown in caterpillar cells injected by an insect virus containing the flu gene.

Both vaccines are approved for use in people 18 years and older.

Why the concern of egg-allergic patients with the traditional flu vaccine used to defend against both seasonal and pandemic flu virus?

Traditionally, the flu shot vaccine (both H1N1 and seasonal) are grown inside eggs which is where this concern arises. It also doesn't help that the pre-flu shot questionnaire specifically asks about egg allergy. Though egg-based, during vaccine production the egg protein is filtered out such that there should be no egg contaminants in the final vaccine. However, it is theoretically possible that some egg may still be present in the vaccine.

Although there is an infinitesimal possibility of egg contaminants, studies have shown that even patients with life-threatening egg allergy can still safely have the flu vaccine.

In spite of these reassurances, there are still concerns from patients and healthcare professionals which makes the availability of two different egg-free flu vaccines welcome news.

Source:
FDA approves next-generation, bug-based flu vaccine. MSNBC 1/16/13

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Sodium Alginate to Treat Non-Acid Reflux

Sodium Alginate specifically and by itself can be purchased to help treat non-acid reflux. This is in contrast to trying to obtain Gaviscon Advance which can be difficult to obtain for those living in North America. Skip the introduction for bottom line information...

Introduction

Over time, I have received a number of emails from patients regarding the best type of Gaviscon Advance they should purchase for relief of NON-acidic laryngopharyngeal reflux (LPR). The blunt answer is to get the Gaviscon Advance Suspension/Liquid made by Reckitt Benckiser which contains at least 500mg of sodium alginate in 5ml dose (1 tsp) or 1 gram in 10cc dose (2 tsps). This formula of Gaviscon Advance cannot be purchased in the United States, but instead overseas via online pharmacies located in the United Kingdom (link). Occasionally, Amazon.com does stock it.

The Gaviscon (without the "advance") sold in the United States is manufactured and distributed by GlaxoSmithKline (GSK) and not Reckitt Benckiser. The US brand of Gaviscon by GSK contains less of the key ingredient sodium alginate which helps with NON-acidic reflux. Alginate is a natural product derived from seaweed. The alginate reacts with the acid in the stomach to produce a "raft" barrier that acts as a physical block to reflux. It is the only non-surgical treatment that can physically prevent reflux disease regardless of whether it is acidic or not. Alginates work rapidly, are long lasting, inexpensive, and have no known side-effects.

Sodium Alginate

But because Gaviscon Advance is so hard to obtain in the United States, one of my patients suggested why not take just the sodium alginate and forget about the gaviscon? After all, it's the sodium alginate that's the key ingredient that is thought to help.

Great idea!

Even better is the fact that sodium alginate is easier to find and obtain.

If possible, I would stick to roughly the same amount of sodium alginate that would be ingested if Gaviscon Advance itself was taken:

500mg to 1000mg of sodium alginate after every meal and at bedtime.

Here's one product I found on Amazon.com.

DISCLAIMER!!! Please be aware that I can NOT vouch for overall effectiveness given these "supplements" have NOT been scientifically tested for clinical effectiveness nor is regulated by the FDA even though the same active ingredient sodium alginate is present. Use at your own risk!!!




References:
An evaluation of the antireflux properties of sodium alginate by means of combined multichannel intraluminal impedance and pH-metry. Aliment Pharmacol Ther. 2005 Jan 1;21(1):29-34

The value of a liquid alginate suspension (Gaviscon Advance) in the management of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol. 2009 Feb;266(2):243-51. Epub 2008 May 28.

The role of an alginate suspension on pepsin and bile acids - key aggressors in the gastric refluxate. Does this have implications for the treatment of gastro-oesophageal reflux disease? J Pharm Pharmacol. 2009 Aug;61(8):1021-8.

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UFC Boss Dana White Underwent Surgery for Meniere's Disease

Balance is very important in martial arts... So imagine have a condition like Meniere's Disease and being the boss of the Ultimate Fighting Championship organization.

Dana White who is the president of the UFC organization apparently has Meniere's Disease since 2011 causing  symptoms of ringing, ear fullness, fluctuating hearing loss, and spinning attacks that last for hours to days at a time. Usually, one ear is the culprit though it can occur on both sides as well.

Presumably, he already tried conservative measures without improvement and therefore underwent surgery for this condition on January 15, 2013. [link]

What is Meniere's Disease?

It is simplistically hypothesized that Meniere's Disease, also known as endolymphatic hydrops, is due to a fluid overload within the inner ear residing inside the skull (DIFFERENT location from fluid that occurs with ear infections).

When too much fluid accumulates in the inner ear, symptoms of tinnitus, ear fullness, and hearing loss occurs followed by the spinning attack. The spinning vertigo lasts until the fluid overload dissipates.

Treatment

Treatment occurs as follows (there are variations, but these are the steps overall):

Step 1: Diet Changes

Avoid all salt, caffeine, and alcohol. Salt avoidance typically means less than 1000mg of sodium per day. Caffeine avoidance is not just coffee, but also decaffeinated coffee, coke, pepsi, tea, chocolate, etc. Alcohol avoidance is pretty self explanatory.

By avoidance of these substances, it seems to substantially minimize the amount of fluid retention that occurs in the inner preventing fluid overload and the symptoms that go with it.

If symptoms persist with dietary restrictions, than...

Step 2: Diuretic Medications

In addition to dietary avoidance of salt, caffiene, and alcohol, a prescription water pill (diuretic) is added. I typically prescribe maxzide though any diuretic will do. Diuretics force the kidneys to produce more urine to be expelled from the body. If you can believe it, the inner ear also behaves like the kidney and does the same thing preventing fluid overload within the inner ear.

If step 1 and 2 do not work, than...

Step 3: Surgery

Surgical drainage of the inner ear is called endolymphatic shunt decompression (ELS surgery). This operation is what Dana White underwent. Essentially, the mastoid bone located behind the ear is completely removed and once the inner ear structure called the endolymphatic sac is reached, it is opened and a plastic-like tubing (the shunt) is placed. Risks of surgery include permanent hearing loss and facial paralysis.

Essentially, the surgery is trying to physically drain the fluid out of the inner ear rather than medications or diet adjustments which attempts to prevent fluid from building up in the first place.

Step 4: More Surgery

There are other surgical procedures that may be tried beyond step 3, but these are considered destructive procedures and have a high risk of permanent hearing loss (consider it likely to happen) as well as the possibility of making the dizziness worse. In essence, the balance system of the ear is permanently destroyed whether thru injection of a neuro-toxic drug like gentamycin into the ear itself or surgically cutting the balance nerve completely from the brain.

Source:

UFC's White hopes surgery relieves debilitating disease. USA Today 1/14/13

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Video of Epiglottitis

The normal epiglottis is a very thin flap of tissue that closes over the windpipe when swallowing preventing food/liquids from going down the wrong way. Shown by the blue arrow in the picture, when the epiglottis becomes infected, it can swell in size to even obstruct the airway leading to death by asphyxiation. Indeed, epiglottitis is what is thought to have killed our first President George Washington.

Fortunately, epiglottitis is quite rare ever since the introduction and regular use of the Hib vaccine in the 1980s. Although rare, it is a problem that still occurs intermittently even today. Each time I've encountered it in the past, I unfortunately was always in a situation whereby video recording of the endoscopic exam was not possible.

Until one day, a patient with epiglottitis did walk into my clinic and I WAS able to video-record the endoscopic exam.

Briefly, this patient developed a severe sore throat with difficulty swallowing that occurred suddenly over a 24 hour period of time. Patient reported the severe sore throat was localized to the base of tongue region.

Without further ado, here's the endoscopic examination both before treatment and than again 1 week later after a course of antibiotics and steroids.

Note the markedly swollen epiglottis before treatment. Even after treatment, the epiglottis is still mildly swollen though much improved. Normal is shown in the picture above.

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How Long Does it Take for a Cough to Clear Up?

Hypothetically speaking, how long would it take for a cough to clear up if a person comes down with an acute respiratory infection?

According to a telephone survey of 493 adults, the lay-public expect the cough to clear up in 7 to 9 days.

Now, is this one week guess actually true?

Not at all... In reality, it takes about 17.8 days on average.

This number was determined on a recent study that reviewed 19 prior studies that determined how long a cough lasts for.

It should also be mentioned that taking antibiotics does little to shorten this duration, especially given most upper respiratory infections are due to viruses.

In any case, the disconnect between patient expectations and reality in cough duration probably leads to some frustration between physicians and their patients.


Reference:
How Long Does a Cough Last? Comparing Patients’ Expectations With Data From a Systematic Review of the Literature. Annals of Family Medicine. doi: 10.1370/afm.1430 Ann Fam Med January/February 2013 vol. 11 no. 1 5-13

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Compact EMG System for Targeted Muscle Injections

An EMG system (ElectroMyoGraphy) is a critical piece of equipment when it comes to targeted muscle injections in and around the neck, especially when you cannot see or feel the muscle.

This scenario is especially true when dealing with spasmodic dysphonia for which targeted botox injections are quite helpful. Given the muscles that need to be injected are contained inside the voicebox and not able to be seen and felt from outside the neck, accurate injection is quite difficult without EMG guidance.

Watch a video of this procedure using a traditional EMG system.

However, such traditional EMG systems are "overkill" in terms of technology and cost when all it is being used for is muscle placement.

It was with great excitement that a compact EMG device has been developed for just such a need when all that is required is needle localization for directed drug delivery.

Check out the MyoGuide made by Intronix Technologies based in Canada. The US supplier is Ambu.

I've been using MyoGuide for a few months now and am quite pleased with its performance. It pretty much does exactly what I want it to do... no more or less. There is both audio and display feedback, though I mainly depend on audio. It runs only on batteries.

For head and neck muscle injections, I find that a volume setting of 8 and vertical sensitivity of 6 works best.

My personal preference is using Ambu Inoject 35mm 27G needle for ADductor spasmodic dysphonia and the Allergan EMG needle for ABductor spasmodic dysphonia.

For those interested in trying out this device, there is a 2 week free trial.

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Parkinson's Disease Diagnosed by Salivary Gland Biopsy

Taken from Wikipedia

Currently, diagnosing Parkinson's Disease (a degenerative neurological disorder) is hard, usually a clinical exam and assessment of symptoms by a neurologist with at best about an 80% accuracy rate. There is no "test" per se that can diagnose Parkinson's Disease... until possibly now.

According to a study released in advance of its presentation at the annual meeting of the American Academy of Neurology, which will be held from March 16 to 23 in San Diego, Mayo Clinic researchers have determined a submandibular gland biopsy can offer 82% certainty whether a living patient has Parkinson's Disease or not. What is so special about this particular gland located under the jawline?

In patients with Parkinson's Disease, an uniquely abnormal protein called alpha-synuclein protein can be found.

In order to "biopsy" the submandibular gland which produces saliva, it does require a head and neck surgeon given the gland's location under the jawline. Beyond the usual risks of bleeding and infection present with any type of surgery, additional risks with this biopsy include:

• Permanent lip paralysis as the nerve that goes to the lower lip is located right over this gland.
• Permanent tongue paralysis as the nerve that moves the tongue is located right under this gland.
• Permanent numbness of the mouth floor as the nerve that provides sensation in this location is also located right under the gland.

Also, there are questions that need to be answered before this test is available more widely including:

How early in the Parkinson's Disease will this protein accumulate in the submandibular gland? If there is an "accumulation" time period, when is the best time to do the biopsy than?

Does the biopsy require a bloc of tissue or can a needle biopsy be sufficient (thereby reducing some of the surgical risks)?

Will insurance pay for this procedure?

Also, when is the paper going to be published regarding these results and can others replicate these findings? Here's the presentation abstract...

Source:
New saliva gland test may better diagnose patients with Parkinson's. FoxNews 1/11/13

Salivary Gland Biopsy as a Diagnostic Test for Parkinson's Disease. AAN 65th Annual Meeting Abstract

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Anatomical Paintings on Living Humans

Came across this interesting blog article about artist Danny Quirk who specializes in scientific illustrations.

I could say more, but better to show you some of his "work"...

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Pencil Drawings of the Aging Ear, Nose, and Mouth

Came across these beautiful pencil drawings of a collection of 60 ears, noses, and mouths arranged chronologically from ages 16 to 90.

Drawn by Shawn Feeney, you can purchase your own 15" x 9" copy from his website.

Check it out!

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Arena Stage 'My Fair Lady' Laid Low by the Flu with Performance Cancellations

It has been an early and bad start to the flu season in the DC metro area. It is just the beginning of the traditional 3 month flu season and flu numbers have already exceeded last year's.

Although professional singers may feel they should have a special exemption from this debilitating illness which also adversely affects the voice, it is not to be...

The flu has literally crippled performances of "My Fair Lady" at the Arena Stage this season with two show cancellations and another possible show cancellation this past Saturday Jan 5, 2013 when both the lead singer AND understudy were unable to perform due to laryngitis. It was not just the lead singer out with the flu, but also 3 other parts which fortunately did have understudy coverage. [more]

However, rather than canceling the show, the show did go on with the lead role being performed by a member of the regular ensemble with script in hand and only a few hours of rehearsal.

Sounds like an episode of the TV show "Smash," but apparently the ensemble singer Hannah Willman did spectacularly well.

I'm also sure Arena Stage breathed a sigh of relief not just for the standing ovation, but also because it was the show's last weekend.

Source:
‘My Fair Lady’ replacement shines at Arena Stage in an unforgettable evening. Washington Post 1/6/13

Flu spreading earlier, faster than usual this season. Washington Post 1/6/13

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How To Create a Customized Fancy Email Signature

Have you ever wondered how some people obtained those really fancy looking email signatures at the end of their emails? I've always wondered how they did that as well. And until recently, I just looked on with envy until I took the time to figure it out. Here's an image of one I created for myself:

So how did I do it?

Well, there's the free way and the not-free way.

Of course, the not-free way is perhaps the easiest way to obtain a fancy email signature. Wisestamp is perhaps the best known one. Though they have a limited free version, more customization is possible if you pay a subscription fee. The other major downside (as of 1/6/13) is that there's no support for the Mac mail.app that I use 99% of the time for emails.

Than there is the free way (or ONLY way if you are a Mac mail.app user) which is the direction I took. It takes a bit more time and effort along with some basic HTML programming knowledge, but you can make it exactly the way you want it to appear.

To understand how to create customized email signatures yourself, I introduce you to Timmy Cai who has taken the time to write a how-to blog article. He also offers a service to make one for you for a single one-time set fee rather than a subscription.

In any case, here are his how-to articles depending on what email program you use:

• Gmail
• Mac Microsoft Outlook 2011
• Mac Microsoft Outlook 2010
• Mac mail.app (OS 10.8)
• Mac mail.app (OS 10.7) 
• Mac mail.app (OS 10.6)

Enjoy!

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New Webpage on Reflux Medications

Given the degree of ignorance I see about reflux medications, how they work, and limitations of such medications, our office has written up a new webpage that goes over the different categories of reflux medications with an explanation of how such medications help to address acid reflux. Such medications include:

• Antacids
• H2 Blockers
• Proton pump inhibitors
• Barriers
• Combinations

What is also explained are the limitations of such medications when it comes to disorders like non-acid reflux.

Check it out here!

Some example reflux medications that can be purchased over-the-counter:

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Dr. Chang Featured in Regional Newspaper Regarding Balloon Sinuplasty

Dr. Chang was recently featured inside a regional quarterly newspaper regarding balloon sinuplasty in the treatment of chronic sinusitis.

Sinus surgery has come a long way compared to even just 5-10 years ago and great patient experiences after this type of surgery is not uncommon now.

A few key features of sinus surgery of the 21st century that is provided at Fauquier ENT include:

• Nasal packing rarely occurs

• Most patients are surprised by how little pain there is

• No facial swelling or bruising... your best friend won't be able to tell you just had sinus surgery

• Fast recovery

• No incisions on the face or in the mouth

• GPS-like image guidance to make sinus surgery even safer is available
• In select patients, can even be performed in the office without sedation using local anesthesia only

Balloon sinuplasty is a relatively new innovation that allows sinus surgery to even be performed even more comfortably in the office without any sedation (not all patients are candidates).

Such advanced sinus surgery techniques have been available at Fauquier ENT since 2005.

Read more about sinus surgery and balloon sinuplasty.

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Miss Oregon 2013 has Thyroid Cancer

Miss Oregon Gabrielle Neilan revealed that she had thyroid cancer for which she underwent a total thyroidectomy 2 weeks before winning the Miss Oregon beauty competition on 11/25/12. [link]

She first felt the thyroid mass in September 2012. This was soon followed by a thyroid ultrasound and a biopsy (presumably via an ultrasound guided fine needle aspiration). The biopsy came back cancerous (unclear exactly what type of thyroid cancer). Given the thyroid cancer diagnosis, she underwent a total thyroidectomy. Two weeks later, she went up on-stage and became Miss Oregon 2013 without the benefit of the judges knowing what she had been going through.

She has a midline neck scar from the surgery that is clearly visible once you know it's there.

Apparently, the thyroid cancer was found in some of her lymph nodes and as such, radioactive iodine treatment is being pursued. If that fails to completely eradicate her cancer, she may need additional treatment that may include radiation therapy.

The type of thyroid cancer was never specifically mentioned, but she most likely has papillary thyroid carcinoma which is the most common form of thyroid cancer and is highly curable.

Other less common thyroid cancers include follicular thyroid carcinoma and medullary thyroid carcinoma.

Regardless of the type, thyroid cancer mandates thyroidectomy with post-operative radioactive iodine treatment to ensure complete eradication of all thyroid tissue that might contain cancer.

Given the absence of a thyroid gland, she now has to take thyroid replacement drugs which must be continued for the rest of her life.

It should be stated that until the thyroid is removed, one can NOT be absolutely sure that thyroid cancer actually truly is present. Indeed, the president of Argentina made a similar announcement of thyroid cancer only to find out after her thyroid was removed that no cancer was actually present. Read blog post about this "mistake".

Read more about the surgery here or watch the video!

Source:

Miss Oregon USA Gabrielle Neilan of Gresham will compete as she fights thyroid cancer. Oregon Live 12/7/12

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Screwdriver into the Ear of Tennis Star Rafael Nadal

On a more humorous note, take a look at this picture from Sports Illustrated...

As per the caption in SI, it is EXACTLY what it looks like except,

A worker at Madame Tussaud’s puts the finishing touches to a model of Rafael Nadal in London last May. (Kirsty Wigglesworth/AP Photo)

I did want to point out that though a screwdriver inserted into the ear canal may be OK for a wax model, it is not OK for a breathing, living human being.

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Forbes Critical of Patient Satisfaction Ratings of Physicians

Forbes on January 2, 2013 published a story critical of Press Gainey and other companies that obtain patient satisfaction scores.

Please note that the following is a reprint of prior blog articles (2/19/12 and 6/8/12) written on this subject by Fauquier ENT.

Indeed, much has been made about improving patient satisfaction in the healthcare industry in the belief that greater patient satisfaction equates with better health. To this end, patients are routinely asked to complete a survey based on their impressions on the care they received at a medical office, hospital, and/or emergency room.

BUT... does greater patient satisfaction actually result in or is the result of better care???

According to a recent study... higher patient satisfaction actually resulted in:

• Greater inpatient hospitalization
• Higher overall healthcare utilization
• Higher prescription usage
• INCREASED RISK OF DEATH!

The one and only measured benefit of higher patient satisfaction scores was decreased ER use.

Why would there be an increased risk of death with higher patient satisfaction scores?

Well, if a doctor always does what the patient wants, that would tend to lead towards higher patient satisfaction... EVEN if it's the wrong thing to do.

For example... when a patient sees a doctor for a perceived sinus infection, it is not uncommon for a patient to expect to leave with an antibiotic.

Unfortunately, many sinus infections are actually viral URI for which antibiotics is the WRONG course of action.

Inappropriate antibiotics lead to drug-resistant infections which lead to deaths.

However, if a doctor resists a patient's desire for an antibiotic, that would lead to a decrease in patient satisfaction.

Such medical decisions do not apply to just antibiotics, but also tests, procedures, and hospital admissions.

This example and others may oversimplify a very complex issue, but it does suggest that one interpretation of higher patient satisfaction scores are that doctors and hospital systems may choose to do the wrong thing in order to get a better score.

And that gets into the problems with how the surveys are obtained in the first place...

The Problem With Surveys

What if I told you 100% patient satisfaction scores were due to a survey of only two people... that I personally picked?

Welcome to the big bad world of patient satisfaction scores.

Often (well... pretty much all the time), I come across an article, bulletin posting, or meeting where patient satisfaction scores are announced... but no background information to back it up. HOW many people completed the survey? HOW were the people selected? WHO administered the survey?

HOW many people completed the survey?

The number of patients who actually completed the survey is very important. Mainly, because of the variance that may occur month-to-month as well as ease in manipulating the results.

Let's assume only TWO people completed the survey. The first month, both give me a thumbs up giving me a score of 100%.

However, the following month, another TWO people completed the survey, but only one gave me a thumbs up giving me a score of 50%.

NEWSFLASH!!! "Patient satisfaction scores plummeted 50% over a 1 month period of time!"

In order for meaningful interpretation of patient satisfaction scores, enough survey results MUST be obtained, especially when comparing scores across time.

HOW were the people selected?

Let's pick on the emergency room...

If I wanted to "pad" my results, I would tend to provide surveys to patients who had simple problems and who were seen quickly.

Child with an earache? Let's seem them immediately in Fast-Track ER. [Look in the ear! There's an ear infection.] Here's some antibiotics. Can you also complete this survey?

As opposed to...

55 year old narcotic-addicted patient with fibromyalgia demanding a prescription for 500 percocet pills for his chest pain. I would probably not want this patient to fill out the survey. Neither would the patient as he would probably toss it.

Granted these are extremes, but if performance bonuses are provided to departments with the best patient satisfaction scores and the ER staff were the ones providing the surveys, one can easily manipulate the results in their favor.

WHO administered the survey?

As mentioned above, survey results can be manipulated depending on who provides or gives the survey, ESPECIALLY if money is involved based on the results of the survey.

In order for survey results to be meaningful, a third uninvolved party should be the one to administer the test.

Survey Fatigue

Now even if the survey was done dispassionately and adequate number of surveys were completed, there's still the problem of survey fatigue...

What's that?

I don't know about you all, but I get about 3-4 letters per week and at least one phone call per day asking me to complete a survey on my car, toothbrush, tater tots... etc. You name it... there's a survey for it now.

Now add how many questions are asked... Hopefully one so it's quick.

But also HOW the questions are asked (yes/no versus a scale of 1-10).

As a person completing a survey, if I had my way, there would only be one question that is a yes/no question.

The more questions there are and if they are scaled rather than yes/no, the less likely I'm going to do it.

Now add if you are sick and in pain... How likely are you going to actually complete a 50 question survey on a scale of 1-10???

Probably not...

In fact, it's probably only going to be healthy individuals who tend to give better scores giving a skewed result.

Also, given the survey fatigue I and I bet most people have, it will be a rushed completion without much thought given. The default being five stars all the way down (I may not even bother to read the questions).

A decent way to look for survey fatigue is to have 2 randomly buried questions where rather than 5 stars being the best, 1 star is the best. Surveys where everything is 4 or 5 stars INCLUDING the reversed scale questions should be thrown out.

Summary

If surveys are accurately administered with statistical power and used in such a way that financial incentives are not so tightly linked to the outcomes, than potentially all stand to benefit.

However, performed the way they are currently, whether good or bad, patient satisfaction scores can be VERY misleading if not completely wrong...

I should also add that whenever money is involved, NO test is going to be 100% accurate due to cheating that is bound to happen one way or another... even if cheating occurs by providing healthcare not due to medical reasons.

I predict that this problem is going to get MUCH worse because health insurances will soon base how much reimbursement hospitals and physicians get based on patient satisfaction scores. We are talking about millions and millions of dollars.

Just read about the "no-child left behind" from the Bush era where student test scores influenced teacher pay leading to teachers allowing cheating on tests.


Sources:
Why Rating Your Doctor Is Bad For Your Health. Forbes 1/2/13

Greater Patient Satisfaction At Expense of Better Care? Fauquier ENT 2/19/12

100% Patient Satisfaction Scores. Fauquier ENT 6/8/12

Patient satisfaction: When a doctor’s judgment risks a poor rating. JAMA 11/26/12

Reference:
The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. Published online February 13, 2012. doi:10.1001/archinternmed.2011.1662

Patient Satisfaction and Patient-Centered Care: Necessary but Not Equal. The Journal of the American Medical Association, July 11 (jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2012.7381)

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Obtaining "Authorship" for Improved Search Rankings

As most specialists in search engines know, good and original content is important for search rankings.  However, these two elements are sorely lacking when it comes to medically-related articles.

"Good"
Medicine by its very nature is complex and full of jargon that is difficult for the lay person to understand. Furthermore, even if jargon-free many medically related articles are too ambiguous and often do not answer questions which people specifically search for. So, when a physician takes the time to create an article that is understandable and yet specific enough to answer questions searchers are looking for (it is "good"), such webpages are rewarded with higher rankings.

"Original"
Problem is, most physicians lack the time to write such "good" medical articles. However, in an attempt to be present on the internet, physicians purchase content from medical publishers including A.D.A.M. Education. The downside with such purchased articles is that many other physicians probably have purchased the same exact content resulting in thousands if not millions of duplicate articles spread throughout the internet. Such duplicate content is punished by lower search rankings... but elevates publisher status given their "authorship" and links that all go back to their main website.

"Authorship"
The concept of authorship has been around for awhile, but when Google announced in June 7, 2011 that they will begin to support markup language for identifying authors to their original content, it is important to take heed. After all, Google is by far the most often used search engine. Though nobody knows the algorithm that Google uses to rank webpages, it is safe to assume that Authorship now plays an important factor.

So, what exactly does authorship mean to search engines like Google?

We know that good and original content is important, but there is no quick and easy way to "prove" a given webpage has both elements. Authorship is an attempt to deliberately identify original content and attribute any and all webpages back to the original author regardless of where it is published. Though this system can certainly be gamed, the extra steps required to prove authorship can certainly help cull the duplicate content that inevitably occurs due to not only the selling of published content but also due to websites that scavenge content.

How to Claim Authorship
There's no way easy way to put this, but it's a pain. If the process is too easy, than it becomes worthless as it can be too easily manipulated.

Essentially what is required is a way for Google to verify and establish trust between it and an author’s published content. To participate in this program, two things are required:

1. A verified digital identify (ie, Google+ profile) that links to your published content
2. Your published content needs to reference you as the author and link back to the Google+ profile

There are 3 methods to accomplish these two steps from the most complex to the easiest. Regardless of the method, you need to first create a Google+ profile if you do not already have one. In order to create one,

1. Browse to https://profiles.google.com/.
2. Sign in to your Google account (or create one if necessary).
3. When prompted, upload a clear facial, head shot photo to the profile. No abstract art, no cartoons, etc.
4. Click Continue until Finish appears, and then click Finish.
5. Click Continue to Google+, click Profile, and then click Edit Profile.
6. Click About, click Other Profiles, click Add Custom Link, and then add labels and URLs for each of your other social media account profiles, such as Facebook, Twitter, LinkedIn, Quora, etc. Click Save when done.
7. When you are done completing your Google+ profile, be sure to click Done Editing
8. Copy the 21-digit ID number used in the URL of your Google+ profile. You’ll need it.

Now, depending on how you author your content, you will need to use one (or more) of the following methods to complete the authorship verification process.

3-Link Method
This method is ideal for a website that you have complete control over including permission rights to make source code edits and all webpages share the same domain name. Basic HTML programming knowledge is needed.

1. Create your author webpage if you do not already have one (example).
2. On this author webpage, create a link to your Google+ profile. Make sure you use the anchor text "Google+" without the quotes.
3. In the tag code for the Google+ link, add the anchor tag attribute rel="me". The following is an example of such tag source code (be sure to use your own 21-digit Google+ profile ID number):

a href="https://plus.google.com/111111111111111111111" rel="me"

4. In each content page that you authored that has the SAME domain name as your author biography webpage, edit the existing link to your biography page by adding the anchor tag attribute rel="author". The following is an example:

a href="http://www.yourwebsite.com/authorpageURL" rel="author"

5. In your Google+ profile, click Edit Profile, and then click Other Profiles.
6. Click Add Custom Link, and then add a label and the full URL for the author biography page.
7. Click Save when done, and then click Done Editing.
8. Verify authorship markup language with Google (see Validating section below).

2-Link Method
This method is best when you author content on a website that you do NOT have complete control over. However, author credit is allowed for which you have permission to edit.

1. Within the author credit, create a link to your Google+ profile. Make sure you use the anchor text "Google+" without the quotes.
2. In the tag code for the Google+ link, add the anchor tag attribute rel="author". The following is an example of such tag source code (be sure to use your own 21-digit, Google+ profile ID number):

a href="https://plus.google.com/111111111111111111111?rel="author"

3. In your Google+ profile, click Edit Profile, and then click Contributor To

4. Click Add Custom Link, and then add a label with full URL for the publishing site’s home page.

5. Click Save when done, and then click Done Editing.

6. Verify authorship markup language with Google (see Validating section below).

Email Verification Method
This method is applicable when the author has absolutely no control over the code. However, this method can be used even if permission rights to make code changes is present. The downside is that you expose to the world your email address.

In order for this method to work, however, the content page you author must include an author byline that starts with the word “By ” followed by the exact same author name used in the Google+ profile.
Also, the author name must be linked to an email address that uses the same domain name as the site hosting the content.

1. Browse to https://plus.google.com/authorship
2. In step 4, enter your email address used in your author byline and click Signup For Authorship.
3. Look for a verification email from Google sent to that email address. Once received, click the link within the email to verify you own the email address. Google will then automatically add the verified email address to the Work section of your Google+ profile. It will also add a link to the domain name used in the email address in the profile’s Contributor to section.
4. Verify authorship markup language with Google (see Validating section below).

Validating Authorship with Google

Once you have completed authorship claim by one of the above 3 methods, you now need to check that Google recognizes and verifies your authorship for the content you have produced.

1. Browse to the Google Rich Snippets Testing Tool page.
2. Type (or paste) the URL of a webpage you authored and click Preview.
3. Review the results for errors.

If all works well, you will see something that looks like this:

So there you have it... Good luck!

More Info:
Author information in search results. Google 11/7/12

Authorship. Google 11/14/11

Authorship markup and web search. Google 6/7/11

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