CEO of JPMorgan has Throat Cancer

Image from Wikipedia by Steve Jurvetson

The CEO and President of JPMorgan, Jamie Dimon, announced that he has throat cancer and is currently undergoing treatment at Memorial Sloan Kettering Cancer Center in Manhattan for the next eight weeks. According to a letter he sent to shareholders on July 1, 2014:

"I wanted to let you know that I have just been diagnosed with throat cancer. The good news is that the prognosis from my doctors is excellent, the cancer was caught quickly, and my condition is curable. Following thorough tests that included a CAT scan, PET scan and a biopsy, the cancer is confined to the original site and the adjacent lymph nodes on the right side of my neck. Importantly, there is no evidence of cancer elsewhere in my body." [link]

Based on this information, he has a Stage 3 or 4 (out of possible 4) throat cancer. Stage 1 is the early and best stage to have. It is less clear exactly where the throat cancer is whether it be tonsil, tongue, oropharynx, or some other location. Based on probabilities, he most likely has squamous cell carcinoma which is the most common type of cancer of the head and neck including the throat.

Although he states the prognosis is good, it is not as good compared to patients where no neck mass is present (Stage 1 or 2) where chemotherapy may not even be necessary.

He also mentions the word "curable" which I am leary of when he has just started treatment. Even if no cancer is detectable at the end of treatment, throat cancer, especially stage 3 or 4, has the potential to come back.

Recall the case of actor Larry Hagman of Dallas fame... He had throat cancer and was declared "cured" 8/29/12. Than on 11/24/13, he died of cancer recurrence and complications.

The risk of cancer recurrence is highest within the first 2-3 years after treatment completion, and markedly decreases after 5 years.

Typically if cancer has not come back after 5 years, the word "cure" may than be used, but even than, such patients are seen yearly for the rest of their life for cancer monitoring.

Because the risk of cancer recurrence is so high in the first few years after treatment completion, patients are seen frequently for the first 2-3 years after treatment.

Every 2 months for the first year. Every 3-4 months in the 2nd year. Every 4 months in the 3rd year. Every 6 months in the 4th year. Yearly starting at 5 years after treatment.

This type of follow-up applies to all head and neck cancer.

Source:
JPMorgan CEO Jamie Dimon has cancer. USA Today 7/2/14

JPMorgan CEO Jamie Dimon's letter to shareholders. USA Today 7/1/14

Read More

Nexium is Available Over-The-Counter

Nexium, a medication to treat acid reflux, has gone over-the-counter and joins Prilosec and Prevacid as ex-prescriptions now OTC.

It's available for purchase in most pharmacies and even on Amazon.

Read more about how reflux medications work here.

Read More

Hearing Test Administered Over the Phone

I was just made aware of this service in a Washington Post article published May 16, 2014. This screening hearing test is taken over the telephone and accomplished by listening to three-digit sequences presented in a background of white noise. The test-taker has to then enter the digits using the telephone keypad. Based on accuracy of the response, the test than adjusts the next query.

Normally, the cost to take this telephone hearing test is $8, but at least for the month of May 2014, it is free in celebration of "Better Hearing and Speech Month."

Here's how to take the test by phone:

1. Find a quiet place to take the test that is free from distractions. 
2. If you hang up in the middle of your test, you will have to start from the beginning. 
3. Use a telephone that plugs into a wall-mounted jack. Please do not use a cell phone. 
4. Dial our toll-free number: 1-866-223-7575 
5. Listen to the recorded instructions. 
6. At the end of the test, write down your test results for each ear and the date. The categories are: 

Within the Normal Range

Slightly Below the Normal Range

Poor

Further details of this test can be found here, but the test essentially is based on the speech-to-noise ratio (SNR) that is adjusted using an adaptive procedure seeking a threshold for 50% correct identification of the digit sequences. A set of 25 sequences provides a reliable SNR threshold in about four minutes of testing per ear. This method of testing is different from most hearing tests in that it uses digits in static noise, rather than pure tones. Because the test measures an SNR threshold rather than one based on the absolute level of tones, a reliable screening measure of hearing, despite the differences in sound levels produced by different telephones, can be achieved.

Of note, this method of testing was validated in Europe by scientists at VU University Medical Center in the Netherlands in 2004. The U.S. version began in 2008 with funding from the National Institute of Health and was validated in two studies performed at the Indiana University Hearing Clinic and the other in collaboration with clinics administered by the VA Health System.

If hearing is assessed to be abnormal, you can contact our office to undergo a more sophisticated hearing test for confirmation and next steps.

Source: 
Take this hearing test right now. I did, and the results were disturbing. Washington Post 5/16/14.

Read More

FDA Approves Ragwitek... Ragweed Allergy Tablet by Mouth (Instead of Allergy Shots)

The FDA formally approved Ragwitek, the third new sublingual allergy tablet to be sold in the United States this year that works 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. Ragwitek is the first sublingual allergy tablet to treat ragweed. Although Oralair and Grastek are two other sublingual tablets that have already been approved by the FDA, they treat grass allergies rather than ragweed.

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

Although in next few weeks US physicians should be able to start prescribing Ragwitek, treatment needs to actually begin in early summer thru the fall for full effectiveness.

As with Oralair and Grastek, 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.

The wholesale price of both Grastek and Ragwitek will be $8.25 per pill, or $247.50 for a 30-day supply. The wholesale price of Oralair will be $10 per pill, or $300 for a 30-day supply.

Sources:
FDA approves Ragwitek for short ragweed pollen allergies. FDA 4/17/14

Read More

FDA Approves Grastek... Grass Allergy Tablet by Mouth (Instead of Allergy Shots)

Today, the FDA formally approved Grastek, the second new sublingual allergy tablet to be sold in the United States that works 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. Although this tablet has been available in Europe for some time, only now has sale/distribution in the United States been allowed under prescription.

Just 2 weeks ago, FDA approved Oralair which also treats grass allergies.

Grastek (aka Grazax in Europe) is a tablet made by ALK-Abello and Merck and treats patients aged 5-65 years who are allergic to only Timothy Grass. Grastek has a simple regimen of 1 sublingual tablet daily starting 12 weeks before and continued until the end of the grass pollen season. As with Oralair, the first dose is given in a medical office to ensure safety with all other doses are taken at home. The tablet dissolves in less than 10 seconds.

Although in next few weeks US physicians should be able to start prescribing Oralair, it really won't do much good for this year's grass allergies because in order for this tablet to be fully effective in the treatment of grass pollen allergies, treatment needs to actually begin in December but no later than January and continue through August. Grass pollen season begins in April/May, so for at least this year, it may be too late.

For both Oralair and Grastek, 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.

Sources:
Merck's grass pollen allergy drug wins U.S. approval. Reuters 4.14.14

Read More

FDA Approves Oralair... Grass Allergy Tablet by Mouth (Instead of Allergy Shots)

Today, the FDA formally approved Oralair, the first new sublingual allergy tablet to be sold in the United States that works 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. Although this tablet has been available in Europe for some time, only now has sale/distribution in the United States been allowed under prescription.

Oralair is made by a French pharmaceutical company Stallergenes (Greer is US distributor partner) and treats patients aged 10-65 years who are allergic to 5 different grasses: Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass. Treatment is composed of a buildup and maintenance phase. Starting 4 months prior to the grass pollen season, a 100 IR tablet is administered under the tongue in a medical office to ensure no significant side effects. At home on day 2, two 100 IR tablets are administered. On day three and daily thereafter, a 300 IR tablet is placed under the tongue until the end of the grass pollen season. The tablets take about 1 minute to dissolve.

Although in next few weeks US physicians should be able to start prescribing Oralair, it really won't do much good for this year's grass allergies because in order for this tablet to be fully effective in the treatment of grass pollen allergies, treatment needs to actually begin in December but no later than January and continue through August. Grass pollen season begins in April/May, so for at least this year, it may be too late.

Another grass tablet will soon receive FDA approval called Grastek (aka Grazax in Europe). This tablet is made by ALK-Abello and Merck and treats patients aged 5-65 years who are allergic to only Timothy Grass. Grastek has a simpler regimen of 1 sublingual tablet daily starting 12 weeks before and continued until the end of the grass pollen season. As with Oralair, the first dose is given in a medical office to ensure safety with all other doses are taken at home. The tablet dissolves in less than 10 seconds.

For both tablets, 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.

Sources:
Stallergenes wins U.S. go-ahead for Oralair allergy pill. Reuters 4/2/14

Grastek Recommended by FDA Panel for Timothy Grass Allergy. Medscape 12/12/13

Read More

LeBron James and His Broken Nose

LeBron James suffered a broken nose. He first broke it Feb 2014 when playing against Oklahoma City. He than got hit to the nose again (while wearing a mask) when playing against Houston in March 2014. [link]

Regardless of whether you are an NBA player or not, treatment of most nasal and even facial fractures do NOT require surgical repair.

The key elements that lead towards a decision for facial and/or nasal fracture surgery are the following (not all-inclusive, but general pointers):

- Any functional deficit (i.e., inability to open and close the jaw)
- Change in occlusion (the way teeth come together).
- Double vision (blurry vision does not count).
- Cosmetic deformity due to nasal/facial fracture (bruising and swelling does not count).
- Nasal obstruction not due to swelling.

In any case, when a nose is broken, steps should be taken to further minimize trauma to the nose. For athletes, that usually means wearing a facial mask such that any hits to the face does not connect with the broken nose.

Although LeBron James had his facial mask custom made by Marvel, for us mere mortals, you can buy one on Amazon.

Source:
Just like every other superhero, LeBron has his Kryptonite. Fox Sports 3/5/14

Read More

Chin Strap May Help with Snoring

There is a relatively simple (and cheap) device that may help some people who snore called a chin strap. This lowly, humble, and low-tech device may benefit patients who typically snore when:

1) Lays on back, but not on side
2) Mouth-breathes when sleeping (but suffers no nasal obstruction)
3) Does not suffer from severe obstructive sleep apnea
4) Appears to be "slack-jawed" when sleeping (chin pushed back relative to upper jaw creating a pseudo-overjet dental appearance)

How (or more importantly why) does this device work?

When a person sleeps who also mouth-breathes AND has a chin that falls backwards, it also causes the tongue to fall back against the back wall of the throat causing a partial narrowing. It also causes the overall throat diameter to decrease causing the throat mucosa to loosen creating the perfect environment for snore production: a partially narrow airway resulting in negative pressure due to increased respiratory effort which triggers any loose mucosa to vibrate causing a snore sound.

A chin strap can be used to force the mouth closed into a more normal position (chin in normal forward position with teeth in normal occlusion). By preventing the chin from falling backward, it would prevent the tongue from falling backward. By preventing the tongue from falling backward, the partial airway narrowing could be avoided. By preventing the airway from narrowing, the throat mucosa would be more taught and less prone to vibrate as well as prevent increased respiratory effort and a "negative" pressure environment.

Where can you get one? There's a whole bunch that can be purchased on Amazon.com.

So there you have it... Of course, keep in mind that the chin-strap will NOT work for everybody as the snore production could be due to other factors unrelated to the chin, tongue, mouth position.

Read More

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

Read More

Acupuncture Helps with Ear Surgery Pain

Researchers at Boston Children's Hospital has found that acupuncture may be effective in diminishing both pain and post-anesthesia agitation in children after ear tube placement determined thru a prospective randomized controlled trial.

Typically, children are placed under general anesthesia in order to have this procedure performed and upon waking, are often tearful and agitated. In this study, acupuncture needles were placed at LI-4 and HT-7 immediately after anesthesia, but prior to ear tube placement.

A blinded assessor than determined that pain and agitation were significantly lower in the acupuncture group compared with controls during the 30 minutes after surgery. Furthermore, the number of patients who required analgesia was considerably lower in the acupuncture group than that in the control group.

Although promising, in order to be fully convinced of the effectiveness of acupuncture, further research by other groups in larger number of kids need to be performed.

BUT... because the risks and side effects are so nominal, it can't hurt to give it a try for those patients and families interested in doing so.

For full disclosure, I personally have no experience in providing acupuncture and I would suggest taking these research findings to a reputable and licensed acupuncturist to get this done in those who are interested.

Reference:
Acupuncture management of pain and emergence agitation in children after bilateral myringotomy and tympanostomy tube insertion. Pediatric Anesthesia. Volume 19, Issue 11, pages 1096–1101, November 2009

Read More

Acupuncture Alleviates Pain After Tonsillectomy in Children

The study showed that acupuncture significantly decreased pain after tonsillectomy in children (2-17 years of age) with reported pain levels before acupuncture of 5.52 (SD=2.28) out of 10 which fell to 1.92 (SD=2.43) after acupuncture.

This retrospective research was conducted in 31 patients who underwent a tonsillectomy within a 3 month period of time by Dr. James Ochi, one of only a handful of dual board-certified ENT and medical acupuncture in the United States. No study patients received any narcotics for pain control beyond tylenol, ibuprofen, and a single dose of intra-operative dexamethasone. The tonsillectomy itself was performed using electrocautery set at 24W.

The acupuncture points used for pain control are shown below and was performed bilaterally:

Image taken from the Research Paper

All patients received acupuncture at LI4 (between thumb and index finger). Additional points were found effective in relieving tonsillectomy pain and provided on an as needed basis at (in decreasing frequency) CV23, GV24.5 and GV20. Acupuncture points LI20, LI11, and LI10 were utilized in only a few patients.

LI4 point is hypothesized to work so well because:

"Stimulation at LI4 increases activity in the somatosensory cortex and a region of the brainstem known as the periaqueductal gray area, as revealed by functional magnetic resonance imaging, that are involved in processing pain signals." [link]

Although promising, in order to be fully convinced of the effectiveness of acupuncture for post-tonsillectomy pain, further research that is prospective, randomized, and controlled is required.

BUT... because the risks and side effects are so nominal, it can't hurt to give it a try for those patients and families interested in doing so.

For full disclosure, I personally have no experience in providing acupuncture and I would suggest taking these research findings to a reputable and licensed acupuncturist to get this done in those who are interested.


Reference:
Acupuncture instead of codeine for tonsillectomy pain in children. International Journal of Pediatric Otorhinolaryngology Volume 77, Issue 12 , Pages 2058-2062, December 2013

Read More

Two New Sublingual Allergy Tablets Approved by FDA Advisory Committee

This week, the FDA Allergenic Products Advisory Committee unanimously supported approval for two new sublingual allergy tablets (Oralair and Grastek) 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. Although both tablets have been available in Europe for some time, final "official" FDA approval may not occur until end of 2014 (or later) for sale/distribution under prescription in the United States.

Oralair is made by a French pharmaceutical company Stallergenes and treats patients aged 10-65 years who are allergic to 5 different grasses: Sweet Vernal, Orchard, Perennial Rye, Timothy, and Kentucky Blue Grass. Treatment is composed of a buildup and maintenance phase. Starting 4 months prior to the grass pollen season, a 100 IR tablet is administered under the tongue in a medical office to ensure no significant side effects. At home on day 2, two 100 IR tablets are administered. On day three and daily thereafter, a 300 IR tablet is placed under the tongue until the end of the grass pollen season. The tablets take about 1 minute to dissolve.

Grastek (aka Grazax in Europe) is made by ALK-Abello and Merck and treats patients aged 5-65 years who are allergic to only Timothy Grass. Grastek has a simpler regimen of 1 sublingual tablet daily starting 12 weeks before and continued until the end of the grass pollen season. As with Oralair, the first dose is given in a medical office to ensure safety with all other doses are taken at home. The tablet dissolves in less than 10 seconds.

For both tablets, 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.

Sources:
Grastek Recommended by FDA Panel for Timothy Grass Allergy. Medscape 12/12/13

Sublingual Oralair Recommended for Grass Pollen Allergy. Medscape 12/11/13

Read More

Nasal Spray Cure for the Common Cold?

Well maybe not cure per se, but at least effective treatment to reduce the duration and severity of the viral cold at least. Austrian researchers have reported on the results of a randomized, double-blind, placebo-controlled trial involving 211 patients suffering from early symptoms of the common cold. [link]

Treatment of the non-placebo group involved using a nasal spray containing carrageenan (a sulphated polysaccharide found in red seaweed/algae) three times per day for 7 days. Cold symptoms were found to resolve 2.1 days faster and viral loads in the nasal washings were significantly decreased compared to placebo group. At day 21 of observation, one sixth of patients given the placebo were still ill, while only one twentieth were in the treatment group.

Personally, I would like to see larger studies conducted by other independent groups to verify the findings.

So how does this nasal spray work?

The problem with the common cold is that there are SO many viruses that manifest the same disease including rhinovirus, coronavirus, parainfluenza, influenza, respiratory syncytial virus, adenovirus, enterovirus, and metapneumovirus. As such, an effective treatment should be able to disable all these virus types and not just one.

The way carrageenan works is by sticking to the virus regardless of type and preventing it from attaching to the nasal lining. As such, the virus is unable to enter into the body and cause problems. It essentially blocks the virus like the wall of a castle.

The caveat is that in order for this nasal spray to work, you have to start using the medication as soon as cold symptoms appear (within 2 days). Remember... it works by blocking the virus from entering the body. If you wait too long, the virus has already entered the body making any type of blocking medication ineffective.

Where can you buy it?

It is available over-the-counter in most European countries and Canada. But NOT available in the United States.

The nasal spray is made by Marinomed in Europe using their Mavirex technology and also licensed for marketing/distribution by Boehringer. Carragelose is the brand name of the carrageenan ingredient. Depending on the country, the actual name of the nasal spray is sold under is different.

For example, in England, the nasal spray is called "Cold and Flu Defence Nasal Spray".

To make sure you have the right nasal spray, look under ingredients and make sure carragelose is listed.

On another note... Afrin nasal spray has also been shown to have some anti-viral activity in unpublished reports. Just be aware to not use it more than 3 days or else you may get addicted to it.


References:
Efficacy of a Carrageenan nasal spray in patients with common cold: a randomized controlled trial. Respiratory Research 2013, 14:124 doi:10.1186/1465-9921-14-124

Efficacy and safety of an antiviral Iota-Carrageenan nasal spray: a randomized, double-blind, placebo-controlled exploratory study in volunteers with early symptoms of the common cold. Respir Res 2010. doi:10.1186/1465-9921-11-108

Lessons learned from a double-blind randomised placebo-controlled study with a iota-carrageenan nasal spray as medical device in children with acute symptoms of common cold. BMC Complement Altern Med 2012. doi:10.1186/1472-6882-12-147

Read More

At-Home Rapid Strep Testing

Rapid strep test kits can be purchased by anybody to be done at home which may save parents/patients a lot of money in doctor visits for those prone to strep infections. Indeed, should a rapid strep test be positive, than you know that a doctor's visit is definitely worthwhile. (A doctor visit may still be worthwhile since a sore throat may be due to something else like cancer, aphthous ulcer, sinus infection, reflux, etc).

Such home kits (which in fact are the same kits used in medical offices) can be purchased online through Amazon. The price is surprisingly affordable at around the cost of a single copay $30 to do 25 tests.

However, with the purchase of such DIY kits, there are some pitfalls patients should be aware of if they decide to proceed.

1) Perform the internal controls that come with the kit!!! The kit may be a dud and needs to be tested against itself to ensure accurate results whether negative or positive. If the controls do not work, throw the whole test kit out and buy another.
2) You must follow the directions precisely, otherwise the test results will be unreliable. In other words, if the directions call for 4 drops, than it MUST be 4 drops (not 3 drops or 5). If directions state to wait 4 minutes... you must wait exactly 4 minutes. This literally is like precision baking.
3) The test strips need to be kept in protected, sealed bag and used immediately after taking one out, otherwise the test results will be unreliable.
4) When swabbing the throat, you MUST get the cotton tip on the tonsil and/or back wall of the mouth which than must be rubbed around a couple times. Getting the tongue or cheek will increase the risk of a false negative. As such, it may be worthwhile to invest in some tongue blades to help push the tongue down in order to perform this test properly.

Should patients elect to start performing home strep tests, please be aware that physicians will be obligated to not only REPEAT the testing but also examine the patient to ensure antibiotics are appropriate. An actual throat culture may be performed as well which is the gold standard test.

1) Repeat testing is required because the patient may not have followed the instructions precisely. For example, the test strips must be read at 5 minutes (variable depending on the kit). If test results are read past 5 minutes, it may incorrectly show a positive result.
2) Some patients unfortunately fabricate test results just so they can get an antibiotic without an office visit.
3) Some patients unfortunately also fabricate test results in order to skip work or school for personal reasons not related to an actual medical condition.
4) There are situations that even though the strep test is positive, no treatment may be recommended. The patient may be a strep carrier for which treatment of any kind is not recommended.

Read More

Aspirin Allergy and Desensitization Protocols

For patients who suffer from terrible allergies, asthma, nasal polyps, and also suffer an allergy to aspirin, desensitization to aspirin can profoundly improve overall allergies and airway hyper-reactivity through an as yet unknown mechanism. It is hypothesized that aspirin desensitization works by decreasing leukotriene production and downregulating cystienyl leukotriene receptors resulting in a decrease in histamine and tryptase release from mast cells which causes allergy symptoms.

However, there are two problems regarding patients who wish to pursue aspirin desensitization: not many physicians perform it due to risk of life-threatening anaphylaxis and lack of standardized protocols.

Here are some sample published protocols for aspirin desensitization. Keep in mind that regardless of which protocol is administered, the aspirin desensitized state only exists as long as regular aspirin continues to be taken. If the patient forgets to take aspirin for a few days (typically 48 hours), the protocol has to be repeated.

Protocol #1:
Aspirin dissolved in water at 1mg/cc concentration. On day 1, patient is given 10mg, 30mg, 60mg, and 100mg of aspirin spaced 6 hours apart. On day 2, an additional 100mg, 150mg, and 300mg is given spaced 8 hours apart. The patient is discharged home on 300mg or 350mg of aspirin to be taken twice a day as well as zantac 150mg twice a day for GI prophylaxis. If needed, proton pump inhibitors can also be taken.

Protocol #2:
Aspirin is administered at intervals of 10–30 min in the following dosages: 0.1 mg, 0.3 mg, 1 mg, 3 mg, 10 mg, 30 mg, 40 mg, 81 mg, 162 mg, and 325mg. The dilution and dosing may be altered depending on the patient's clinical situation.

Protocol #3:
Aspirin is administered starting at 1 mg and doubling each dose every 30 min up to a final dose of 100 mg (therefore lasting 3.5 hours).

Protocol #4:
Aspirin given in 5 sequential doses of 5, 10, 20, 40, and 75 mg given every 30 minutes (the protocol lasting 2.5 hours).

Depending on the physician, patient's clinical characteristics, and comfort level of all concerned, these protocols may be performed in an office-setting to even in the intensive care unit of a hospital.

Pre-treatment with anti-histamines, singulair, or systemic steroids may or may not be administered. Beta-blockers typically is stopped 24 hours prior to protocol initiation. Monitoring during the protocol include blood pressure, pulse, and peak expiratory flow measurements every 30 min as well as checking for any reactions involving the skin, nose, eye, or breathing. Once the protocol is completed, monitoring is continued for an additional 3-6 hours.

Keep in mind that our office does not perform aspirin desensitization and provides this information for educational purposes. Please contact your local allergist to determine if they perform aspirin desensitization. Your best bet is your closest tertiary care academic medical center as locations where such protocols are performed.

Trivia: When a patient suffers from asthma, nasal polyps, and aspirin allergy, it is known as Samter's triad.

References:
Hypersensitivity to ASA in patients with coronary artery disease: rapid desensitisation is feasible. European Society of Cardiology Council. E-journal of Cardiology Practice 3.

Selection of patients for ASA desensitization treatment. J Allergy Clin Immunol 118: 801–804.

Rapid oral challenge-desensitisation for patients with ASA-related urticariaangioedema. J Allergy Clin Immunol 105: 997–1001.

Rational approach to aspirin dosing during oral challenges and desensitization of patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2009 Feb;123(2):406-10. doi: 10.1016/j.jaci.2008.09.048. Epub 2008 Dec 3.

Selection of aspirin dosages for aspirin desensitization treatment in patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. 2007 Jan;119(1):157-64. Epub 2006 Nov 13.

ASA sensitivity: the role for ASA challenge and desensitisation in postmyocardial infarction patients. Cardiology 91: 8–13.

Rapid desensitisation procedure for patients with ASA hypersensitivity undergoing coronary stenting. Am J Cardiol 95: 509–510.

Aspirin Hypersensitivity and Desensitization Protocols. Ther Adv in Drug Safe. 2011;2(6):263-270.

Read More

We Now Offer Rapid Saliva Test to Look for Laryngopharyngeal Reflux

When you compare a spit test to the current way of how throat level reflux (LPR) is determined via barium swallow, upper endoscopy (EGD), and 24 hour ph/impedance testing, it sounds quite attractive.

And we are one of the very few offices in the United States that offer this spit test. Even major laboratory companies like Labcorp and Quest do not offer this test yet.

How does such a test work?

It basically looks for a stomach protein called pepsin.

Given reflux is when stomach contents moves up towards the mouth and pepsin is a protein ONLY produced in the stomach... pepsin should NOT be found in the throat/mouth.

As such, the test can state yes or no whether LPR is present or not.

The steps to the test are as follows:

   

How good is the test?

Depending on the study, sensitivity ranges in the 80-100% (can actually detect reflux if truly present) and specificity is around 85% (truly no reflux if test is negative).

One test company is RDbiomed (in Europe) using their Peptest kit.

This test is currently not FDA approved yet and as such, is a test that is NOT covered by insurance at this time. Due to a special arrangement our office has with RDBiomed, the Peptest kit can be obtained in our office at a discounted price of $125 (compared to normal price of $175). Price includes the kit, test supplies, and courier shipping service.

Please note that this testing is ONLY offered to current patients of ours.

However, if you are not a current patient of ours, you can order this test yourself online as an individual without a visit to our office. It is recommended you take the standard 3 sample peptest. Click here for more information.

References:
Sensitive pepsin immunoassay for detection of laryngopharyngeal reflux. Laryngoscope. 2005 Aug;115(8):1473-8.

Rapid salivary pepsin test: Blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012 Jun;122(6):1312-6. doi: 10.1002/lary.23252. Epub 2012 Mar 23.

Read More

Treatment for Vocal Tremor

Vocal tremor is characterized by a rhythmic undulating vocal quality whenever talking, much akin to vibrato that can not be turned off. In the past, it was felt that use of botulinum toxin type A (botox) to treat vocal tremor was not possible nor realistic given the multiple muscle groups involved. This is in contrast to dystonias of the voice (i.e., spasmodic dysphonia) where only one muscle group is involved and is readily and easily treated with botox injections to the affected vocal cord muscle.

However over the past few years, several research papers have been produced that show that botox CAN alleviate (though not eliminate) vocal tremor both objectively and subjectively, though more than one site may need to be injected in order to produce vocal tremor relief. Such muscle sites include thyroarytenoid muscle, ventricularis muscle, lateral cricoarytenoid muscle, interarytenoid muscle, cricothyroid muscle, and strap muscles.

All these muscle sites are easily accessible either via, endoscopic guidance and/or EMG guidance alone. Indeed, physicians who already perform botox injections for spasmodic dysphonia should also be able to inject all the other muscle groups just as easily. [watch video]

Typically, "horizontal" vocal tremor is treated with thyroarytenoid, ventricularis, interarytenoid, and/or lateral cricoarytenoid muscle botox injections.

"Vertical" vocal tremor is treated with strap muscle botox injections.

Dosages are similar to that given to treat spasmodic dysphonia.

SO... for patients suffering from vocal tremor who do not respond well to oral medications (propranolol, primidone), consider botox injections!

Be aware that botox injections to treat vocal tremor may not be covered by insurance.

References:
A new paradigm for the management of essential vocal tremor with botulinum toxin. Laryngoscope. 2013 Apr 1. doi: 10.1002/lary.24073. [Epub ahead of print]

Botulinum toxin type A for treating voice tremor. Arch Neurol. 2004 Sep;61(9):1416-20.

Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection. Laryngoscope. 2000 Aug;110(8):1366-74.

Tremor laryngeal dystonia: treatment of the lateral cricoarytenoid muscle. Ann Otol Rhinol Laryngol. 2004 May;113(5):349-55.

Read More

At Home Allergy Testing

Recently, a new at-home allergy test can be found on store shelves throughout the United States as well as Amazon.com. It is called "MyAllergyTest" produced by ImmuneTech Corporation and it is FDA approved. The way it works is that you place a few drops of blood into the collection kit which is than mailed to a lab in a pre-paid, pre-addressed envelope.

Results are than obtained via internet or by certified mail in about one week.

What's tested? Only ten things (IgE only):

• Timothy Grass
• Bermuda Grass
• Mountain Cedar
• Short Ragweed
• Alternaria Mold
• Cat Dander
• Mite pternoyssinus
• Egg White
• Wheat
• Milk

As such, if testing comes back normal, it does not mean you do not have allergies... It just means that you do not have allergies to these 10 things only... You could be allergic to other non-tested substances.

A report is produced listing what you are allergic to and how badly:

How accurate is the testing? Apparently, it is comparable to Pharmacia CAP system (specific IgE FEIA).

In terms of actual numbers, the test has a sensitivity 88%, specificity 94%, and accuracy 91%.



Source:
FDA.gov

Company Website

Read More

Dangerous Tongue Patch Procedure for Weight Loss

Image from Wikipedia

There is a clinic in Beverly Hills who has been offering a risky "tongue patch" procedure in order to achieve weight loss of about 30 pounds in a single month. Although this clinic is currently the only one providing this "service" in the United States, it has been performed in Venezuela for quite some time.

In essence, a mesh made of marlex typically used for hernia repair is surgically sutured to the back area of the tongue and left in place for up to one month. While in place, this postage-stamp sized patch causes extreme discomfort if not pain whenever eating leading to a decrease in food ingestion and therefore weight loss. This non-FDA approved procedure is paired with a 800 calorie liquid diet.

In a normal swallow, the back of the tongue is required to help propel food down into the throat. With a patch in place, this step of the swallow becomes disrupted. Watch video to see how swallowing works here.

Does the concept work? In theory yes via starvation (hurts too much to swallow)...

Are there problems with it?

Absolutely and may even be considered highly unethical.

This procedure is associated with substantial risk including difficulty talking (you do need a tongue that moves well to enunciate words), infection, swelling, tissue overgrowth, and potential to dislodge leading to possible airway obstruction.

Why would somebody even consider this procedure? Well, if diet and exercise just doesn't work and financially, a desperate patient can't afford gastric lap band or bypass surgery... that's why some patients have pursued it.

Source:
Tongue Patch Surgery: Risky Weight Loss Procedure Draws Criticism. Yahoo News 6/5/13

Read More

Can You Spot the Gorilla in the CT Scan?

I am not going to go into too much detail regarding a recent news article regarding how 83% of radiologists (physicians who specialize is looking at radiology pictures) failed to see a gorilla on a CT scan of the chest... you can read more of the details here.

But, the question is can YOU find the gorilla in the CT Scan that was portrayed?

Still can't see it?

Look below...

Keep going...










Keep going...








Keep going...





I'll point to it...

Read More