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December 2008 News Archives
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December 1: Workers with sleep apnea may take more sick leave, Reuters
NEW YORK (Reuters Health) - People with sleep apnea may be at increased risk of needing an extended sick leave from work or going on permanent work disability, a new study suggests.
Obstructive sleep apnea, or OSA, occurs when the soft tissues at the back of the throat temporarily collapse during sleep, causing repeated breathing interruptions. Major symptoms include loud snoring and daytime sleepiness -- the latter of which, studies show, may cause irritability, cloud thinking and concentration, or increase the risk of traffic accidents.
The extent to which OSA interferes with a person's ability to work has not been clear. But the new study, published in the European Respiratory Journal, suggests that the disorder can exact a large toll at work.
Norwegian researchers found that of more than 7,000 workers followed for four years, those with symptoms of OSA were nearly two thirds more likely to take a sick leave of more than eight weeks. They were also about twice as likely to go on permanent work disability.
The study participants ranged in age from 40 to 45 at the outset and had a variety of occupations, from professional fields to retail sales to farming. At the beginning of the study, all completed a standard questionnaire on OSA symptoms.
The researchers, led by Dr. Borge Sivertsen of the University of Bergen, found that workers with OSA symptoms were more likely to need long-term sick leave or go on work disability, even with other factors - such as lifestyle habits and other medical conditions -- taken into account.
Among OSA symptoms, daytime sleepiness was most strongly linked to sick leave and work disability, the researchers found.
Together, the results suggest that OSA itself raises the risk of long- term sick leave, according to Sivertsen's team. They also strengthen the evidence that OSA can have "serious consequences, both individual and social," the researchers note.
Earlier diagnosis and better treatment of the disorder could help reduce the social and economic costs seen in this study, Sivertsen said in a written statement.
"Where a patient complains of poor sleep," he said, "doctors should thus look for other symptoms of sleep (apnea), such as snoring, pauses in breathing and daytime sleepiness." From there, he added, patients can be referred for specialized tests in a sleep lab, if necessary.
SOURCE: European Respiratory Journal, December 2008.
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December 1: Is a child ever too young to have tonsils removed?, Boston.com
No, as long as the surgery is done in a reputable hospital with well-trained staff. In fact, in rare medical emergencies, even newborns have surgery to remove their tonsils and/or adenoids, the clump of tissue on the back wall of the throat.
These emergencies occur because newborns are "obligate nose breathers," which means they have to breathe through their nose until they learn, by six or seven weeks, to open their mouths if their nose is obstructed, said Dr. Gerald Healy, chief of otolaryngology at Children's Hospital Boston.
Once a doctor determines, by X-rays or by looking into the baby's nose with a tiny viewing tube, that the adenoids are so big that they block air flow, surgery can quickly correct this potentially life-threatening problem.
A generation ago, most older children had their tonsils and adenoids removed because of recurrent infections, says Dr. Mark Volk, an otolaryngologist at Children's and a member of the executive committee on head and neck problems for the American Academy of Pediatrics.
Now, the chief reason is upper airway obstruction, which often results in breathing problems during sleep. Typically, the signs include snoring, mouth breathing, and restless sleep. Because sleep-deprived children, unlike adults, often manifest sleep deprivation by hyperactivity during the day, many are misdiagnosed with attention deficit and hyperactivity disorder.
A large National Institutes of Health study underway at Children's Hospital Boston and elsewhere is designed to determine whether removing tonsils and adenoids from children between the ages of 5 and 10 with obstructed breathing improves learning and behavior.
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December 1: Finding, and Treating, Esophageal Cancer, The New York Times
By JANE E. BRODY
Half a century ago, my grandmother died of esophageal cancer. For decades preceding her death, a bottle of milk of magnesia was her steady companion because she suffered daily from heartburn, now known as gastroesophageal reflux disease, or GERD. But many years passed before a link was clearly established between chronic irritation of the esophagus by stomach acid and this usually fatal cancer.
Now that the role of acid reflux is well known in cancer risk and unpleasant conditions like chronic cough and hoarseness, drug companies market several products, prescription and over the counter, that are far better able to control the backup of stomach acid than milk of magnesia. And gastroenterologists now know to be on the alert for early signs of trouble among patients who suffer from GERD.
The cancer that results from chronic reflux is preceded by a benign condition called Barrett’s esophagus, a cellular abnormality of the esophageal lining that can become precancerous. If untreated, about 10 percent of patients with Barrett’s esophagus eventually develop esophageal cancer, the nation’s fastest-growing cancer. In the last four decades, the annual number of new cases has risen 300 to 500 percent.
The American Cancer Society estimates that 16,470 new cases of esophageal cancer will be diagnosed in this country this year and that more than 14,000 people will die from it.
Diagnosed early, well before patients develop swallowing problems, esophageal cancer is usually curable. A cure is most certain if the problem is detected and corrected before or during the advanced precancerous stage. But for about 90 percent of patients, early detection and treatment are missed, and the outcome is fatal.
Detecting Trouble
Unfortunately, the esophagus, unlike more accessible body parts like the breast and skin, is not very easy to monitor. In the traditional exam, called gastrointestinal endoscopy, the patient is heavily sedated, usually in a hospital, and a scope is inserted through the mouth into the esophagus.
For patients with GERD who have already developed Barrett’s esophagus, annual endoscopy is recommended to check on the health of esophageal cells. If a biopsy indicates an impending or existing cancer, the usual treatment is a rather challenging operation in which all or part of the esophagus and the upper part of the stomach are removed and the remaining parts of the digestive tract are reattached.
Another technique uses light therapy to destroy the inner lining of the esophagus, which can result in scarring and strictures that impede swallowing.
After this treatment, patients must stay out of sunlight and direct artificial light for about six weeks to avoid a severe sunburn on exposed skin.
New Methods
But now there are simpler and safer alternatives for both detecting and treating an esophageal problem even before it becomes a serious precancer.
A colleague who suffers from chronic reflux recently underwent the new detection method, called TransNasal Esophagoscopy, or T.N.E. It can be done safely and effectively in a doctor’s office, and it does not require sedation or involve loss of a day’s work. Nor does it leave the patient with a sore throat.
“Surprisingly easy,” was how my colleague described it. “I had an exam that involved sending a tube, slim as a wire, with a camera, down through a nostril.”
His doctor, Dr. Jonathan E. Aviv, medical director of the Voice and Swallowing Center at NewYork-Presbyterian Hospital/Columbia University Medical Center, said he and other ear, nose and throat doctors around the country started using the technique in the mid-1990s.
“Patients are examined awake, sitting upright in a chair,” Dr. Aviv said in an e-mail message. “An ultrathin flexible scope, the size of a shoelace, is placed via the patient’s numbed nose past the throat and then into the esophagus, thereby avoiding the powerful gag reflex which sits in the mouth.”
Dr. Aviv described the technique as a triple bonus: one that avoids the risk of anesthesia and loss of work time for patients, increases the efficiency of medical practice for doctors and reduces the costs to insurers.
Even newer than T.N.E. is a technique that can both diagnose and, using radiofrequency energy, treat abnormal cells.
Joseph Broderick of Hudson, Fla., had suffered for years with periodic attacks of reflux, especially after eating spicy foods.
“I had a bottle of Maalox at the ready to quiet it down,” Mr. Broderick, 77, said in an interview.
At his doctor’s suggestion, he underwent a traditional endoscopy and esophageal biopsy, which revealed the presence of Barrett’s esophagus. He was prescribed medical, dietary and behavioral treatment to control reflux and told to return a year later for another test.
But before the second test, he began having pain in his chest. This time, the endoscopy and biopsy found advanced dysplasia, a cellular abnormality that can progress to cancer without warning. A repeat exam three months later found no improvement, and an operation was recommended.
First Mr. Broderick sought a second opinion from Dr. John E. Carroll, a gastroenterologist and assistant professor of medicine at Georgetown University Medical Center. Given the treatment options, Mr. Broderick said the choice was a no-brainer: burn out the precancerous cells with radiofrequency energy before they become invasive cancer.
The therapy uses a device, produced by BARRX Medical of Sunnyvale, Calif., that fits on the tip of a gastroscope, with a balloon that expands to fill the esophagus. The device, which has been approved by the Food and Drug Administration, is coupled to a generator that emits radiofrequency energy deep enough to burn off the inner lining of the esophagus. Normal esophageal cells then form to replace the destroyed cells.
Prevention
In a report published this year in the journal Gastrointestinal Endoscopy, cellular abnormalities were eliminated in 98 percent of 70 patients with Barrett’s esophagus who were treated at eight medical centers around the country. The improvement lasted the duration of the study, up to two and a half years.
In a second study by the same multicenter group, 142 patients with advanced dysplasia were treated. The precancerous condition was eliminated in 90 percent, and the Barrett’s cells were destroyed in 54 percent of the patients at one year.
The question now is whom to treat with this technique, since most people with Barrett’s esophagus never get the cancer.
“The trouble is, there’s no predicting which patients will progress to cancer, and when they do, it’s a major cancer that spreads quickly,” Dr. Carroll said. “So I believe this will become a treatment option for most patients with Barrett’s.”
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December 2: MRI Scans May Cause Cochlear Implant Failure, MedPage Today
By Charles Bankhead, Staff Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.
HANNOVER, Germany, Dec. 2 -- Cochlear implants may be demagnetized during an MRI scan, possibly exposing patients to excessive magnetic force, according to a study of the hearing devices.
Action Points
* Explain to interested patients that cochlear implants with fixed batteries may fail in certain types of MRI machines.
* Note that this study involved an evaluation of device batteries, so the impact in humans could not be assessed.
Magnets from three types of cochlear implants exhibited rapid diminution of magnetic force after a single scan at an angle of 80° or greater in a 3T MRI, Omid Majdani, M.D., Ph.D., of the Medical University of Hannover, and colleagues reported in the December issue of Otolaryngology -- Head and Neck Surgery.
Little or no weakening of the magnets occurred when they were aligned at lower angles to the scanner.
"Weakening of a permanent magnet in a strong external magnetic field in anti-parallel orientation occurs immediately during first exposure, and there is almost no additional magnetic weakening with repeated exposure," the authors said.
Temperature in the magnets increased minimally during MRI scanning and remained well below the industry standard, they added.
Growing use of 3T MRI scanners, particularly for neuroimaging, increases the likelihood that patients with cochlear implants will undergo scans at some point.
The implants stimulate auditory nerves, allowing hearing-impaired individuals to hear. Internal magnets couple the external processor to the implanted components.
The static and dynamic electromagnetic fields in an MRI scanner can interfere with the cochlear implant magnet, the researchers said.
"In addition, the pulsed magnetic fields and time-variant gradient fields can induce voltages and potentially harm the implant electronics, lead to unintentional stimulation, and increase temperature of implant components," they said.
Demagnetization of a cochlear implant would lead to failure of the device, they added.
So to assess the possible effects of MRI scanning on cochlear implant magnets, investigators tested two types of fixed magnets (C and T) used in three different cochlear implant devices.
Each magnet was scanned five times in a Siemens 3T MRI machine, and six data points were recorded at angles of 0°, 80°, 90°, 100°, 110°, and 120°.
A 10% reduction in magnet strength was considered acceptable for maintaining magnetic coupling.
Demagnetization of C-type magnets averaged 5.71% at an angle of 80°, 11.68% at 90°, and 37.10% at 100°.
The corresponding values for T-type magnets were 7.35%, 28.08%, and 47.25%.
Maximum demagnetization of C-type batteries was 44.91% at an angle of 100°, and for T-type batteries the maximum was 60.50% at a 100° angle.
Temperature increases after MRI scanning never exceeded 0.5°; as much as a 2° increase is considered acceptable, the authors noted.
The results indicated that patients who have cochlear implants with fixed magnets should be imaged with a 1.5T MRI machine, they concluded.
If a 3T machine is the only option available, the angle between the implant and MRI magnets should be less than 80°. If this is not possible, they concluded that it should be clear in an individual case that the benefits of the scan far outweigh the risk of implant demagnetization.
The researchers noted that some cochlear implant magnets can be removed in an in-office surgical procedure before MRI scanning and replaced afterwards.
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December 16: Nation's first face transplant done in Cleveland, Associated Press
By MARILYNN MARCHIONE
A woman so horribly disfigured she was willing to risk her life to do something about it has undergone the nation's first near-total face transplant, the Cleveland Clinic announced Tuesday.
Reconstructive surgeon Dr. Maria Siemionow and a team of other specialists replaced 80 percent of the woman's face with that of a female cadaver a couple of weeks ago in a bold and controversial operation certain to stoke the debate over the ethics of such surgery.
The patient's name and age were not released, and the hospital said her family wanted the reason for her transplant to remain confidential. The hospital plans a news conference Wednesday and would not give details until then.
The transplant was the fourth worldwide; two have been done in France, and one was performed in China.
Details of the Cleveland surgery were not disclosed, but surgeons generally transplant skin, facial nerves and muscle, and often other deep tissue. That is done so that the new face will actually function and not just be a mask.
Surgeons not connected to the case reacted cautiously since little was known about the circumstances, but they generally praised the operation.
"There are patients who can benefit tremendously from this. It's great that it happened," said Dr. Bohdan Pomahac, a surgeon at Harvard-affiliated Brigham and Women's Hospital in Boston who plans to offer face transplants, too.
Dr. Laurent Lantieri, a plastic surgeon at Henri Mondor-Albert Chenevier Hospital, near Paris, who did a face transplant on a man disfigured by a rare genetic disease, said: "This is very good news for all of us that doctors in the U.S. have done this."
Unlike operations involving vital organs like hearts and livers, transplants of faces or hands are done to improve quality of life — not extend it. Recipients run the risk of deadly complications and must take immune-suppressing drugs for the rest of their lives to prevent organ rejection, raising their odds of cancer and many other problems.
Arthur Caplan, a leading bioethicist who has expressed grave concerns in the past about such surgery, withheld judgment on the Cleveland case but said the woman's doctors should give her the option of assisted suicide if they wind up making her life worse.
"The biggest ethical problem is dealing with failure — if your face rejects. It would be a living hell," said Caplan, bioethics chief at the University of Pennsylvania. "If your face is falling off and you can't eat and you can't breathe and you're suffering in a terrible manner that can't be reversed, you need to put on the table assistance in dying."
Siemionow's long and careful preparation should help prevent such a horrific outcome, those familiar with her said. Siemionow, (pronounced SIM-en-now), 58, a noted hand microsurgeon, has been testing the surgical approach and ways to temper the immune system's response in experiments for more than a decade.
She considered dozens of burn victims and other potential candidates over the past four years, ever since the clinic's internal review board gave her permission to attempt the operation. She said she would choose someone severely disfigured as her first case.
"She's a leader in this field. She's been investigating this for a long time. She has done the most amount of research in small animals looking at this," said Dr. Warren Breidenbach, a surgeon at Jewish Hospital in Louisville, Ky., who did the nation's first hand transplant, in 1999. Siemionow trained with him in Louisville.
The world's first partial face transplant was performed in France in 2005 on a 38-year-old woman who had been mauled by her dog. Isabelle Dinoire received a new nose, chin and lips from a brain-dead donor. She has done so astoundingly well that surgeons have become more comfortable with a radical operation considered unthinkable a decade ago.
Two others have received partial face transplants since then — a Chinese farmer attacked by a bear and a European man disfigured by a genetic condition. Both are believed to be doing well, though details, especially of the Chinese case, have been scant.
In the Cleveland case, "it is very important what kind of recipient they selected," and how great the need was, Pomahac (POE-ma-hawk) said. "Hopefully it will open the door both to the public and to other centers" wanting to do these operations.
In an interview in 2005, Siemionow spoke of the terrible need she saw in people horribly disfigured, and how badly it scarred their social and emotional lives, not just their bodies.
"There are no really good alternative therapies for the severely burned or patients with a facial injury or damage," she said.
Her task now is to prevent organ rejection while managing the risk of infection from taking strong immune-suppressing drugs.
Rejection is a possibility whenever someone receives an organ or cells from someone else because the body regards this as foreign tissue. Two types of problems can result.
The first is graft-versus-host disease, which could happen if the new facial tissue were to attack the recipient's body. The second is if the patient's body were to attack the bone marrow or the transplanted face, causing inflammation and other problems at the site of the new tissue.
Either of these can be life-threatening. They can come on suddenly, within days or weeks of the operation, or set in slowly.
AP Medical Writer Maria Cheng in London contributed to this report.
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December 16: Snorers Burn More Calories During the Day, HealthDay
But study shows it doesn't offset extra weight that often accompanies the condition
By Amanda Gardner
HealthDay Reporter
TUESDAY, Dec. 16 (HealthDay News) -- People who snore burn more calories when they're resting during the day than people who sleep quietly through the night, new research shows.
However, the calorie expenditure doesn't seem to be enough to balance the extra weight that often accompanies the condition, also known as sleep apnea.
"There are a lot of other factors that are going on that lead to a net increase in body weight," said Dr. Michael Thorpy, director of the Sleep Center at Montefiore Medical Center in New York City. "It's not enough to counteract the weight gain from other sources."
The study, published in the December issue of the Archives of Otolaryngology Head & Neck Surgery, may give insight into the basic biological underpinnings of such disorders.
"We want to figure out how to treat people with this disorder. Losing weight dramatically decreases obstructive sleep apnea in those who are overweight. But the success with behavioral interventions and bariatric surgery have been inconsistent," said study author Dr. Eric J. Kezirian, director of the division of sleep surgery at the University of California, San Francisco. "This study examined one of the important ways that obstructive sleep apnea can affect body weight. There are many things we do not understand about the relationship between obstructive sleep apnea and body weight, and this is one."
Obesity and sleep apnea are closely intertwined.
"People with sleep apnea have a greater chance of being obese, and obese patients have a greater chance of having sleep apnea," said Dr. Jordan Josephson, a sinus specialist at Lenox Hill Hospital in New York City and author of Sinus Relief Now.
But it's unclear which is the chicken and which is the egg, Kezirian said.
This cross-sectional study, conducted by Kezirian and senior study investigator Dr. Nelson B. Powell, of Stanford University, measured daytime resting energy expenditure of 212 adults both with and without sleep-disordered breathing. The mean body-mass index was 28.3 (at the high end of overweight).
Researchers measured the severity of the sleeping disorder with the apnea-hypopnea index, which records how many times per hour a person does not breathe for at least 10 seconds (apnea) or has enough of a reduction in air flow to result in a dip in oxygen levels or to wake up from sleep (hypopnea).
Every 10-point increase in the apnea-hypopnea index corresponded with a 27-calorie increase in daily resting energy expenditure. "It's not a lot, but it can add up," Kezirian said.
The results were unexpected, said Dr. David Rapoport, director of the sleep program at New York Universitys Langone Medical Center in New York City. "What they're saying is that these people have a higher metabolic rate which is not accounted for by their being overweight," he said. "People may be sleeping less and burning up more calories or are struggling to breathe and burning up more calories."
Kezirian explained that repeated awakening during the night is like an adrenaline rush, increasing the metabolic rates of even normal patients. "The combination of sleep deprivation and the surges of adrenaline could contribute to the increased metabolic rate during the day," he speculated.
"We have to do more studies to confirm this and to find out exactly what's going on," said Josephson. "[But] this study is important. It shows that people are starting to take this more seriously, and there is good reason to do so. Sleep apnea is the number one cause of heart attack and stroke in patients that have either while sleeping. We also know that snoring is the number one medical cause for divorce."
A second study found that hay fever and other allergic reactions seem not to be linked with snoring or with daytime sleepiness, unless nasal passages are obstructed.
The findings, conducted by researchers at the University of Occupational and Environmental Health in Kitakyushu, Japan, are based on interviews with almost 1,500 daytime workers at an industrial company in Japan.
People with nasal obstruction should inquire about treatment to improve the quality of both their sleeping and daytime lives, the authors stated.
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December 17: Is face transplant worth risking patient's life?, msnbc
Doctor must be willing to help patient die if procedure fails, says bioethicist
The face transplant performed a few weeks ago by Dr. Maria Siemionow, a skilled and caring surgeon, and a team of other specialists at the Cleveland Clinic went far beyond several prior experiments, including the world's first such procedure in France three years ago. The Cleveland Clinic doctors replaced nearly the whole face of a woman with one from a female cadaver.
Given the high risk of failure from the rejection of the donor's skin, is such a pioneering procedure worth the danger to the patient’s life?
When face transplants were first proposed 10 years ago I thought they were unethical. But, after the success of the French procedure, and after listening to Dr. Siemionow and other surgeons talk about their preparations for the first nearly total face transplant in the U.S., I no longer think that is so.
A transplanted face is biologically like any other transplanted organ: There is always a risk that the recipient’s body will reject it. The immunosuppressive drugs that must be used to try to prevent such a disaster are powerful, but can cause fatal cancers and other serious side-effects, such as kidney failure. Normally, transplant surgeons don’t worry much about these risks because they pale in comparison to the certain death that awaits someone whose heart or liver have stopped working. But a face transplant is intended to improve the quality of life rather than save a life, as a heart, lung, kidney or liver transplant does.
It’s important to note that the surgical skill required to transplant a face and have it function — chew, smile, frown, breathe, blink — has evolved to the point where the odds now favor success. The management of dangerous immunosuppressive drugs has also improved so that handling rejection of the facial tissue seems feasible. There is no doubt that Siemionow has the competency and her team the skills to try the experiment.
After talking to some people with severe facial disfigurement, I realize it makes ethical sense to offer a form of surgery that might kill the patient, because the suffering of the afflicted is so great that they are willing to risk death. We don’t hear much about those with facial deformities due to birth defects, burns, trauma, cancer or violence. That’s because the stigma of severe facial deformity is so enormous, so staggering, that many simply withdraw from society. Others find that, despite the best efforts of reconstructive surgeons, they are unable to eat, breathe or speak comfortably, and are condemned to lives of suffering and pain.
A face transplant, despite its very real dangers, might bring relief. The science has reached the point where trying to help those who are beyond the help of current medical treatments is not just ethical, but almost obligatory.
No second chances
Yet, even though a strong case can be made in defense of what has been tried in Cleveland, there are ethical concerns about face transplants.
If the woman who received her new face from a cadaver were to begin to lose it due to tissue rejection that could not be stopped, what will happen? There are no second chances with face transplants — the damage of rejection makes that impossible. What if someone facing this horrendous prospect – life with no face at all — says no to artificial feeding or breathing? What if they beg for morphine to help them die painlessly and more quickly? Any team undertaking face transplants must be ready to manage a failed experiment.
The only humane response to the courage it takes to be the subject of a face transplant is to be ready to help that person in any way necessary, including assistance in dying. The idea of assisted-suicide for tragic transplant failures pushes right up against the law, but insisting on life with no face, as opposed to a horribly disfigured one, is too daunting a prospect to proceed ethically — if death is not an option.
Face transplants raise another issue. When you signed a donor card or checked the box on your driver’s license, you probably were not thinking that when you died someone might want to transplant your face. We don’t know what happened in the Cleveland case, but I strongly suspect they used a donor who had a donor card and whose family also approved the removal of the face.
Do we need to insist that no faces be taken from the dead without the advance permission of both the deceased and their family? Shouldn’t the family have some input since they will have to live with the emotional turmoil of potentially seeing a face that somewhat resembles a loved one on another person? And should the laws governing organ donation be revised so donors have the option to give permission, or deny permission, for a facial transplant?
Issues of personal identity
The Cleveland transplant is a ringing alarm clock that it is time to revisit the legislation governing organ and tissue donation. Face transplants raise emotional issues that do not arise when a liver or a pancreas is transplanted. We identify ourselves and each other by our faces. We fall in love with faces. We know much about mood, emotions, and state of mind by simply looking at faces. Some may have no issue giving their liver, corneas, bones, heart or lungs to help others, but the face is simply a different matter.
Should we allow each person to set their limits on what can be taken from their body after death? Facial transplants are the cutting edge of a wave of new forms of transplantation, including hand and limb transplants, ovarian transplants, uterine transplants and testicular transplants. While it is not clear that these newer types of transplants cross ethical boundaries that ought never be crossed, they surely do raise issues of personal identity and reproductive capacities.
The transplant in Cleveland was done with the laudable goal of trying to help those who are often on the margins of society due to their appearance, or because they cannot eat, speak, drink, smile or breathe without huge effort. Some victims take their own lives in despair. These people should be able to take their chances with a facial transplant if nothing else can help them. That said, medical advances in facial transplants push us into a very new ethical world where life after failure may not be an acceptable option, and where some among us may say they are not willing to give what is required to help.
Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania
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