Dr. Chang Makes Front Page News in Local Newspaper with Practice Merger

On January 31, 2014, Dr. Chang made front page news of the Fauquier Times local newspaper with his planned practice merger with Blue Ridge Orthopaedics and Spine Center to become part of the Greater Piedmont Medical Association. With this merger, he will be also joining Dominion Internal Medicine (Drs. Robert Lin and Michael & Jennifer Ackerman) as well as Urological Associates of the Piedmont (Dr. Pfeffer). In spite of this merger, the practice name, addres, location, staff, phone number, etc will all still remain the exactly same.

Read the article here!

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Aspirin Slows Brain Tumor Growth (Acoustic Neuroma)

Image from Wikipedia

There is a type of benign brain tumor called acoustic neuroma or vestibular schwannoma that causes progressive hearing loss on just one side. This non-cancerous tumor which arises off the balance/hearing nerve (cranial nerve 8) typically grows larger in size over time leading to not only hearing loss, but also dizziness, facial paralysis, and even death if large enough.

Harvard researchers, however, have recently reported that aspirin may appear to slow and perhaps even halt the growth rate of this benign brain tumor. This is exciting news given that the alternative options include either brain surgery or radiation therapy with all its attendant risks.

Their conclusion was determined by looking at 347 patients diagnosed with this tumor who were followed by serial MRI scans. In this group, 81 took aspirin and 266 did not.  Of those who took aspirin, 33 demonstrated tumor growth whereas 48 did not. Of the 266 non-aspirin users, 154 demonstrated tumor growth and 112 did not. These numbers indicate a significant inverse association among aspirin users and tumor growth which was not confounded by age or sex.

It is hypothesized to work by targeting COX-2 which is a key enzyme in prostaglandin synthesis. This enzyme is also found at high levels in most vestibular schwannomas.

Given aspirin is a relatively benign drug, it certainly can't hurt to start aspirin on all patients who are diagnosed with this condition.

However, there are some key answered questions:

1) What dose of aspirin?
2) Is aspirin effective when started at time of diagnosis, or does it help when a patient has already been on it long-term?

As such, larger study groups in prospective clinical trials would be best to answer these questions as well as confirm whether aspirin truly has a therapeutic role in the management of these tumors.

Reference:
Aspirin Intake Correlates With Halted Growth of Sporadic Vestibular Schwannoma In Vivo. Otology and Neurotology: February 2014 - Volume 35 - Issue 2 - p 353-357 doi: 10.1097/MAO.0000000000000189

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New Ragweed Under the Tongue Pill Instead of Allergy Shots Recommended by FDA Panel

Yesterday, the FDA Allergenic Products Advisory Committee supported approval for a new sublingual allergy tablets (Ragwitek) that work the same way allergy shots do... but instead is dissolved under the tongue at home instead of a shot in the arm in a medical office. Given this is only a panel recommendation, final "official" FDA approval may not occur for another year or so for sale/distribution under prescription in the United States.

Ragwitek is made by ALK-Abello and Merck and treats patients aged 18-65 years who are allergic to only short ragweed pollen. The way Ragwitek is taken is placement of 1 sublingual tablet daily starting 12 weeks before and continued until the end of the ragweed pollen season. The first dose is given in a medical office to ensure safety with all other doses taken at home. The tablet dissolves in less than 10 seconds.

Epipen needs to be available at home due to possible risk of anaphylaxis. As with allergy shots, patients on beta-blockers for high blood pressure are not eligible to undergo this treatment.

Ragwitek is similar to Oralair and Grastek which treat only grass allergy. Oralair and Grastek were both recommended by the FDA panel last year.

Source:
Sublingual Ragwitek Backed FDA Panel for Ragweed Allergy. Medscape 1/28/14

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Lisa Marie Presley Throat Cancer Scare

Image from Wikipedia

The National Enquirer reported 1/20/14 that Lisa Marie Presley suffered a throat cancer scare when she was told by a medical expert that "the 45-year-old singer’s throat is so severely ravaged that ... the damage could lead to deadly esophageal cancer!" [link]

The National Enquirer, which is not know for stellar journalism, goes on to report that she has been pushing her voice hard in order to succeed as a singer like her more famous father Elvis.

In spite of what the story implies, although singing can lead to vocal cord damage (i.e., nodules)... singing in and of itself does not cause or lead to increased risk of cancer.

However, uncontrolled reflux which can cause throat and vocal cord damage CAN lead to throat cancer. In one report, reflux can increase the risk of throat cancer by 78% (this risk is separate from esophageal cancer).

Source:
WORLD EXCLUSIVE: LISA MARIE THROAT CANCER NIGHTMARE. National Enquirer 1/20/14.

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Is Your Metal Implant MRI Safe? There's a Website for That...

Although one could always contact the manufacturer or surgeon who performed your metal implantation directly to determine whether it is MRI safe or not, there's also a website that contains a comprehensive database of metal implants and how compatible they are with MRI scans.

Who knew that certain metal implants are compatible with MRI scans up to a certain strength?

Who knew a metal implant that may not necessarily be compatible with MRI, but given enough time after implantation (usually 6 weeks), it is still safe to get an MRI scan?

Check this website www.MRIsafety.com out!

The actual searchable list of implants is here.

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Dr. Chang Contributor to New Textbook on Singing

Released on January 6, 2014, a new textbook on singing "The Ultimate Guide to Singing," was published with numerous contributors ranging from singing stars, engineers, and even Dr. Christopher Chang.

Most of Dr. Chang's contributions to the textbook are in Chapter 11: Staying Healthy.

You can buy the textbook on Amazon.com!

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ENT Question Bank iPhone App for Physicians and Residents

The AAO-HNS has released a nifty iPhone app that contains 400+ Q&A to test one's knowledge in the field of otolaryngology. Called AcademyQ, it is free for 10 sample questions, but $49.99 to access the entire question bank.

Although anybody can download the app (link to app store), it's really meant for busy ENT surgeons. This app may be worthwhile to quiz oneself on esoteric ENT trivia in between surgical cases and patient office visits where one might have a minute or two to go through a few questions.

The questions are similar to the ones one may encounter in the Home Study Course.

More debatable is whether such a question bank is helpful in preparing for Board-Certification or Recertification.

In any case, for example, one of the sample questions is:

Whether you get the question right or wrong, an extensive answer is provided to explain further:

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NFL Player Derrick Coleman Has Been Deaf Since Childhood [video]

Derrick Coleman, who plays fullback for the Seattle Seahawks, was born with a genetic mutation that  caused his deafness since he was a toddler. Even with powerful hearing aids, he still needs to lip-read in order to understand what is being said. [link]

Although the exact genetic mutation is not known thru media reports, it is most likely a connexin 26 mutation which is the most common genetic cause for early onset hearing loss and can be tested for through a simple blood draw. He is also probably a candidate for cochlear implants, but given the high impact nature of his profession, it is was likely a good decision he did not get one due to breakage concerns.

Just FYI... with cochlear implants, his hearing could potentially be restored back to normal.

Obviously, he has had to work even harder to make it into the NFL with his legally deaf ears.

Watch this Duracell commercial about his hearing loss.

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Soft Teddy Bear that Measures Pulse, Temperature, and Oxygen Saturation When Held

At the CES 2014, a company introduced a soft, plush teddy bear that children (and even adults) all over would love. For physicians who care for children, it's not so much on the outside that matters, but what is in the inside as apparently, it is full of sensors that enables the teddy bear to pick up essential vital signs of the child who is playing with it.

Called "Teddy the Guardian," it is unclear from reports exactly how pulse, temperature, blood pressure, and oxygen saturation are measured (and how reliable it is compared to more traditional tools). However these measurements via bluetooth can be collected, structured, analyzed, visualized and interpreted on a tablet, web or mobile app.

According to news reports, the "sensors are scattered around the bear’s body; pressing a finger to the bear’s paw, for instance, takes heart rate and oxygen levels" [TechCrunch].

If used in a medical office or hospital setting, it is unclear how the teddy bear can be decontaminated between child patients to prevent spread of disease. Even if parents purchase one, cleaning would still be important.

Apparently, the company is short on cash and their creation may never make it to market unless it manages to receive enough venture capital or gets bought out by a larger company.

In any case, check it out!

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Bracelet that Measures Your Sun Exposure

June is being worn on this model's wrist.

At the CES 2014, an interesting bracelet made an appearance that purportedly is able to measure sun intensity in real time and monitor total daily sun exposure. Even better, it is able to provide sun protection advice via smartphone app based on your habits and skin type, get notifications when you need to apply SPF, wear a hat, or put on sunglasses…

Made by Netatmo, the bracelet is called "June" and may be beneficial for those individuals who are prone to sunburn,  out in the sun a lot, and/or concerned about skin cancer due to UV exposure.

It comes in three different colors and will soon be available for purchase.

Watch a video about this product.

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Risk of Death From... Is...

Image courtesy of noomh / FreeDigitalPhotos.net

When it comes to risk of death from surgical procedures, it is illustrative to compare it to more common experiences.

Patients often become unduly concerned with certain risks including death without any true understanding of how rare the risk may be. Unfortunately, such rare risks may be THE reason why a patient may refuse a needed procedure in the erroneous belief that something rare has an unacceptably high chance of occurring to them.

In such situations, it may be beneficial to compare the chance of a rare risk with more common scenarios that a patient may be more familiar with.

The risk of death is... (In bold are surgical procedures)

Death from major surgery if performed within 30 days after a heart attack	1 in 7
Death from high risk open-heart surgery	1 in 20
Dying on the road over 50 years of driving	1 in 85
Dying from any cause in the next year	1 in 100
Annual risk of death from smoking 10 cigarettes per day	1 in 200
Death from UPPP surgery	1 in 500
ER treatment in the next year after being injured by a can, bottle, or jar	1 in 1,000
ER treatment in the next year after being injured by a bed mattress or pillow	1 in 2,000
Death by an accident at home	1 in 7,100
Death from tonsillectomy	1 in 10,000 - 35,000
Death by an accident at work	1 in 40,000
Death playing soccer	1 in 50,000
Death by murder	1 in 100,000
Being hit in your home by a crashing aeroplane	1 in 250,000
Death by rail accident	1 in 500,000
Being struck by lightning	1 in 10,000,000
Death from a nuclear power accident	1 in 10,000,000

References:

Surgery and the D-Word: Approaching the Topic of Death and Dying with Surgical Patients. J Palliative Care Med 2:108. doi:10.4172/2165-7386.1000108

Risk perception and communication: recent developments and implications for anaesthesia. Anaesthesia 2001;56:745-55.

Risk language and dialects. BMJ 1997;315:939-42.

Safety of Adult Tonsillectomy: A Population-Level Analysis of 5968 Patients. JAMA Otolaryngol Head Neck Surg. 2014 Jan 30. doi: 10.1001/jamaoto.2013.6215.

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Should Risk of Death Always be Part of the Surgical Consent?

Ever since reports of alleged medical negligence came up in the case of 13 years old Jahi McMath who suffered cardiac arrest and subsequent brain death after a "routine" tonsillectomy that occurred Dec 9, 2013, the question has come up whether risk of death should become part of every single surgical procedure's informed consent no matter how rare that risk might be.

It also brings up the question whether patients would want to hear every single possible conceivable risk that may occur (which could ALWAYS include some infinitesimal risk of death) with even simple surgical procedure like ear tube placement for chronic ear infections.

[Disclaimer... I am not a lawyer and this is not legal advice.]

From the physician's perspective, Duke surgeons have thought about this quandary and here were their suggestions of what is considered "reasonable" when it comes to risk of death and the consent process:

• When the risk of death is so low as to be unexpected and highly improbable, including it as part of the consent may actually be misleading (may cause a patient not to pursue a needed surgical procedure due to unreasonable concern for a remote risk of death)
• When the risk of death is felt to be “high enough” to disclose, then this adverse outcome should be discussed among the risks, and the patient must be informed.
• How high should the risk of death be before one would want to include it as part of the consent process? This risk could be any chance at all to about 0.1% risk as a reasonable threshold.

From the patient's perspective, when it at least comes to anesthesia risks with children (which also has a remote risk of death), researchers were able to provide some numbers when it comes to consent:

• 87% of parents wanted to know the risk of death as a result of anesthesia. 13% did not.
• 68% of parents knew that risk of death was "extremely rare." 19% believed that risk of death occurs "once in a while," and 13% thought there was "no chance."
• 74% of parents wanted to know "all possible risks," 24% wanted to know only "those that are likely to occur," and 2% wanted to know only about those that would "result in significant injury."
• Mothers were more likely to want to hear all possible risks, whereas fathers were more likely to want to know only about those that are likely to occur.

Although media reports stated that Jahi underwent a "routine" tonsillectomy, that was actually not true. She underwent a UPPP surgery which is much more aggressive throat surgery than tonsillectomy alone. The reported risk of death with UPPP is around 0.2%. As such, disclosure of possible low risk of death would have been not unreasonable.

The risk of death for routine tonsillectomy is somewhere between 0.003% to 0.01%.

Just for comparison, the risk of dying from driving a car for over 50 years is 1.1% and annual risk of death from smoking 10 cigarettes per day is 0.5%. [Link] Note that these "mundane" risks of driving and smoking are higher than the risk of death associated with tonsillectomy or UPPP.

In the end, there is no set policy about when risk of death should be discussed. This disclosure has been left up to individual surgeons who use their professional judgement when that risk becomes large enough to merit discussion as part of the informed consent.

What do you think?


References:
Parental knowledge and attitudes toward discussing the risk of death from anesthesia. Anesth Analg. 1993 Aug;77(2):256-60.

Surgery and the D-Word: Approaching the Topic of Death and Dying with Surgical Patients. J Palliative Care Med 2:108. doi:10.4172/2165-7386.1000108

Risk perception and communication: recent developments and implications for anaesthesia. Anaesthesia 2001;56:745-55.

Risk language and dialects. BMJ 1997;315:939-42.

Safety of Adult Tonsillectomy: A Population-Level Analysis of 5968 Patients. JAMA Otolaryngol Head Neck Surg. 2014 Jan 30. doi: 10.1001/jamaoto.2013.6215.

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Normal Appearance After Turbinate Reduction

Normal mucosal blistering (turbinate reduction
done only on right side)

Often, patients become disturbed with the way the inside of their nose looks after a turbinate reduction to improve nasal breathing. However, many of the concerns are unfounded and the appearance though disturbing, is actually normal. It usually takes a FULL 2 weeks for the turbinate mucosa to heal to a more normal (and reduced) appearance. It is around 2 weeks that nasal breathing also markedly improves.

In any case, during the first week, white plaques that may appear on the turbinates (picture below) are actually scabs which when wet turn white. It should be wet (and white) due to the regular use of saline nasal spray and/or flushes along with normal nasal secretions.  The turbinate mucosa may also occasionally even blister (picture above/right) producing a pale appearance like the inside of a grape. These are pictures of what the inside of the nose may look like about 5-8 days after a coblation turbinate reduction.

Be assured that such appearances are NORMAL and will typically resolve to a more normal appearance 2 weeks after the procedure. At that time any residual scabbing is typically removed.

White eschar/plaques (normal).

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Why Do Babies Hate Getting Their Nose and Face Wiped???

I have often been asked this question by parents... and even more so by my wife as we try to clean the snot off our little kids' noses as they shriek as if we're torturing them.

Given it seems ALL young kids have this nose-wiping aversion across cultures and racial ethnicities, it would seem that this reflex reaction is hard-wired into human babies. But why would evolution favor this reaction?

I tried to find an answer to this question to see if any bright researchers actually studied this topic, but was unable to find any. So... here are my thoughts on this topic.

To warn other healthy humans

Evolutionarily, it may have been helpful for the human population as a whole if it was obvious to others when an individual was sick. To see a toddler with snot running out the nose, that would have been a pretty clear sign for other children and their parents to stay away lest they also get sick. This isolation of a sick child would have been nature's way of quarantining to prevent spread of illness to the rest of the human group.

To get eaten by predators

Not to be morbid, but predators tend to feed on the sick. It is nature's cruel way of removing the weakest in an animal population which over time will only strengthen the prey animal population as a whole (Darwin's theory of only the fittest survive). Back in the REALLY old days (caveman era), sick humans would have been just such a prey that would have been targeted by wild predator animals. To be not just a young human, but one that also shows signs of illness would be indicators to a predator of who to go after.

Protect the airway

This is my wife's favorite theory who feels the last idea to be horrible and inhuman (never mind that just because evolution is horrible and inhuman does not make it false). This airway idea is based on the fact that breathing is essential to life. Anything that covers the nose or mouth, even briefly, is a potential hazard that may lead to death. Evolutionarily, this reflex would be favored and strengthened over time... even if avoidance involves just a quick wipe. Who knows? Perhaps SIDS (Sudden Infant Death Syndrome) would be much more prevalent if the nose/face wipe aversion was not present.

Any other ideas? Even better, does anybody know of any studies that actually looked into this topic?

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