The latest in high tech digitial hearing aids

Posted on May 20, 2013 | Leave a comment

Last month my practice partners and audiology staff went up to Minnesota to tour the Starkey headquarters.  Starkey is the leading manufacturer of fully custom and programmable off-the-shelf digital hearing aids.  Their worldwide headquarters is just outside of Minneapolis.  What an impressive facility!

It is amazing to see exactly how their 24 hour operation can receive orders and construct a 100% customized hearing device in less than 4 days.

Key technology that allows this is the massive computing and hardware power allowing for fully customized 3D digital modeling and rapid stereo lithography (“3D printing”).  Furthermore, round-the-clock engineers and technicians are manually placing the tiny microprocessors and components into your custom aid before going through a final round of quality testing.

Equally impressive are two separate wings of the campus: a truly high-tech troubleshooting and quality control lab that is charged with making aids more durable and determining causes for failure.  An array of photomicrography and cross sectioning instruments allows the lab to pinpoint potential microchip failures, while several micro environments have been created to artificially “age” devices to ensure they remain salt, water, and wax resistant.

Their second remarkable facility is full-on R&D.  Starkey spends almost $100M annually on research and development, the majority of which happens in Minnesota and California.  The labs work on tweaking current projects as well as developing the devices that won’t be ready for another 5 years or so.  This includes everything from industrial design of the shells, to microcircuitry, to microphone/receiver research, to Bluetooth wireless, to iPhone apps.

For Starkey’s robustness in quality, design, and service we see them as a strategic partner for ensuring a truly optimal experience for our patients.

The days of lousy poorly-fitting noisy hearing aids are numbered!

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Google CEO with vocal cord paralysis

Posted on May 14, 2013 | Leave a comment

http://abcnews.go.com/Technology/wireStory/google-ceo-discloses-vocal-cord-problem-19177474#.UZKrK7Wcd5A

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Feature with Dr. Forman: Cardiovascular Risk of Sleep Apnea

Posted on April 22, 2013 | Leave a comment

This week I had the opportunity to meet with Dr. Mervyn Forman, a distinguished Cardiologist and innovator in metro Atlanta.  Dr. Forman’s medical practice covers the spectrum of cardiovascular disease prevention and long-term management, while his research has focused on reducing heart muscle damage after a heart attack.  He is currently developing a drug coated guidewire for use during stent insertion. 

Dr. Forman sees a number of patients on a daily basis with obstructive sleep apnea that may be complicating their cardiac disease.  I sought Dr. Forman’s perspective on sleep apnea, as he in fact has daily hands-on experience treating the cardiovascular end-effects in his patients.  Our Q&A session is below, revised into a more printer-friendly format.  Dr. Forman can be reached at his medical practice in the Atlanta area on Northside Hospital campus: 960 Johnson Ferry Rd NE, Suite 530, (404)446-1900.  He also consults in East Cobb county.

WHAT ARE THE CARDIOVASCULAR COMPLICATIONS OF OBSTRUCTIVE SLEEP APNEA?

                Obstructive sleep apnea (OSA) is a common chronic disorder with a major effect on morbidity and mortality.  Sleep encompasses about one third of one’s life and induces physiological changes in the human body to rest the cardiovascular, respiratory, and metabolic systems.  OSA is now recognized as an important risk factor for cardiovascular disease.  Hypertension, coronary artery disease, heart failure, heart rhythm (fast and slow) abnormalities, cerebrovascular disease, and diabetes have all been shown to be linked to sleep disorders.  OSA is therefore one of the most prevalent and dangerous cardiac risk factors we know of. 

WHAT ARE THE CHANGES THAT OCCUR WITH OSA THAT AFFECT THE CARDIOVASCULAR SYSTEM?

                Repetitive closure of the upper airway during sleep results in a number of hemodynamic and biochemical derangements which effect the cardiovascular systems.

1.)     Exaggerated swings in the pressure in the chest which impairs filling on the left ventricle (pumping chamber) results in decreased blood pumped to the organs of the body.

2.)    Activation of the portions of the nervous system that affect heart rate and blood pressure (arterial and in the lung circulation).

3.)    Activation of tissue chemical factors which result in the formation of numerous inflammatory mediators and oxygen free radicals which promote damage to blood vessels, activate the blood clotting system and promote cholesterol (plaque) deposits in the blood vessel walls.

CAN UNTREATED OSA AFFECT MY BLOOD PRESSURE (BP) AND WILL TREATMENT IMPROVE THE CONTROL AND REDUCE THE NUMBER OF BP MEDICATIONS?

                There is strong evidence that OSA is an important factor in hypertension (high blood pressure).  This occurs in both sexes, all age groups, all ethnic groups and in obese and non-obese people.  OSA increases both systolic (top) and diastolic (lower number) pressure.  OSA also results in the loss of normal decrease in blood pressure that occurs at night.  It is estimated that 50% of OSA patients have hypertension and OSA often plays a role in patients whose BP is refractory to BP medications.  Treatment with continuous positive airway pressure (CPAP, a therapy for OSA) results in significant decreases in day and nighttime BP, improves control of refractory hypertension and reduces the number of medications required to achieve a normal BP. 

CAN OSA CONTRIBUTE TO CORONARY ARTERY DISEASE (CAD) AND INDUCE A HEART ATTACK?

                There is a strong correlation between OSA and the development of CAD and acute coronary syndromes (heart attack).  65% of patients admitted to the hospital with a heart attack were found to have OSA.  Patients who suffer a heart attack in the early hours of morning (midnight to 6 am) are more likely to have OSA (32%) verses those without OSA (7%).  This is due to OSA producing stress on the heart secondary to the increase heart rate and BP and by increasing the propensity of the blood to form clots.  The co-existence of CAD and OSA worsens the prognosis resulting in 70% increase in death, stroke and heart attack.  Patients with OSA undergoing stent insertions also have a higher risk of death (38%), stent narrowing (70%), and heart attack and stroke (12%).  Nocturnal angina (chest pain) is associated with OSA and CPAP diminishes the frequency of chest pain attacks.  There is also evidence that treatment of OSA may prevent heart attacks and delay progression of plaque buildup in the heart blood vessels.    

CAN OSA PRODUCE AND EXACERBATE HEART FAILURE?

                OSA affects almost half of heart failure patients.  While the relationship is complex, OSA essentially induces the risk factors that lead to the development or exacerbation of heart failure (hypertension, CAD, diabetes, pulmonary hypertension).  Furthermore heart failure can cause and worsen obstructive and central sleep apnea initiating a potentially devastating cycle.  Treatment with CPAP has been shown to significantly improve pump function (ejection fraction), reduce heart size and BP, and improve quality of life. 

CAN OSA LEAD TO HEART RHYTHM ABNORMALITUES AND CAUSE SUDDEN CARDIAC DEATH?

                OSA results in low blood oxygen, abnormalities of autonomic nervous system and changes in the structure of heart muscle which predispose to heart rhythm abnormalities.  OSA is strongly associated with the common heart rhythm abnormality, atrial fibrillation, occurring in 40-70% of patients.  Atrial fibrillation (AF) is an important cause of stroke and heart failure.  OSA is responsible for 25% greater risk of AF recurrence following catheter ablation procedure.  OSA is also linked to other cardiac rhythm abnormalities including a slow heart rate, heart block, fast heart rhythm abnormalities and malignant ventricular arrhythmias.  People with OSA have a dramatically increased risk of sudden cardiac death during sleep.  Treatment with CPAP decreases nocturnal rates of slow heart rate and cessation of electrical pacemaker activity, atrial fibrillation, and dangerous fast heart rhythm abnormalities.

WHY IS WEIGHT LOSS IMPORTANT TO REDUCE THE CARDIOVASCULAR COMPLICATIONS OF OSA?

                Obesity is the single most important risk factor in the development of OSA.   A 10% increase in weight gain is associated with a 6-fold increase in the odds of developing OSA.  Obesity and OSA often coexist with more than 40% of obese patients having significant OSA and 70% of OSA patients being obese.  The link between obesity and cardiovascular disease has been well established.  Obesity induces numerous and similar mechanisms to OSA that can lead to cardiovascular disease including hypertension, heart failure, coronary artery disease, atrial fibrillation, diabetes, and sudden cardiac death.  Therefore the pressure of OSA in obese patients would be expected to place them at higher risk for cardiovascular events than obese patients without OSA.  Aggressive weight reduction programs in addition to treatment of OSA with CPAP is essential to reduce cardiovascular complications of OSA. 

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I want to thank Dr. Forman for his kind and thorough collaboration on this post, and I encourage you to visit Dr. Forman for further assessment of your cardiovascular disease risk.

 

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My Favorite Eponymous Laws & Phenomena

Posted on April 8, 2013 | Leave a comment

Now for a break from medicine I share some of my favorite Laws named after the giants before us.  You might notice my personal technology industry bias.  I’m sure you will find more than a few that apply in your own life and work however.

  • Amara’s law – “We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run.”
  • Ben Franklin Effect - A person who has done someone a favor is more likely to do that person another favor than they would be if they had received a favor from that person.
  • Brooks’ law – “Adding manpower to a late project makes it later.”
  • Campbell’s law – “The more any quantitative social indicator is used for social decision making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.”
  • Clarke’s three laws – Formulated by Arthur C. Clarke. 
    • First law: When a distinguished but elderly scientist states that something is possible, he is almost certainly right. When he states that something is impossible, he is very probably wrong.
    • Second law: The only way of discovering the limits of the possible is to venture a little way past them into the impossible.
    • Third law: Any sufficiently advanced technology is indistinguishable from magic.
  • Classen’s law – Theo Classen’s “logarithmic law of usefulness” – ‘usefulness = log(technology)’.
  • Dunbar’s number – A theoretical cognitive limit to the number of people with whom one can maintain stable social relationships.  A commonly cited approximation is 150.
  • Gall’s law – “A complex system that works is invariably found to have evolved from a simple system that worked.”
  • Goodhart’s law – When a measure becomes a target, it ceases to be a good measure.
  • Grosch’s law – The economic value of computation increases with the square root of the increase in speed—that is, to do a calculation 10 times as cheaply you must do it 100 times as fast. [This speaks to an adage in innovation that a new disruptive product must be either 10 times better or 10 times cheaper to get market adoption.]
  • Hanlon’s razor – “Never attribute to malice that which can be adequately explained by stupidity.”
  • Herblock‘s law – “If it’s good, they’ll stop making it.”
  • Hofstadter’s law – “It always takes longer than you expect, even when you take into account Hofstadter’s Law”
  • Hooke’s law – The tension on a spring or other elastic object is proportional to the displacement from the equilibrium.  ”Ut tensio sic vis.”  [This speaks to management as well.]
  • Humphrey’s law – conscious attention to a task normally performed automatically can impair its performance.
  • Jevons paradox – The proposition that technological progress that increases the efficiency with which a resource is used tends to increase (rather than decrease) the rate of consumption of that resource. [eg as cars become more fuel efficient, we simply drive them further.]
  • Keynes’s law – Demand creates its own supply.
  • Kranzberg’s first law of technology – Technology is neither good nor bad; nor is it neutral.
  • Lake Wobegon Effect - Is the human tendency to overestimate one’s achievements and capabilities in relation to others.  [Far more than 50% of people think they are in the top 50%.]
  • Littlewood’s law – States that individuals expect miracles to happen to them, at the rate of about one per month.
  • Metcalfe’s law – In communications and network theory, states that the value of a system grows as approximately the square of the number of users of the system.
  • Moore’s law – An empirical observation stating that the complexity of integrated circuits doubles every 24 months.
  • Muphry’s law – “If you write anything criticizing editing or proofreading, there will be a fault of some kind in what you have written.”
  • Murphy’s law – “Anything that can go wrong will go wrong.”
  • Occam’s razor – States that explanations should never multiply causes without necessity.
  • Pareto optimality – Given an initial allocation of goods among a set of individuals, a change to a different allocation that makes at least one individual better off without making any other individual worse off is called a Pareto improvement. An allocation is defined as “Pareto efficient” or “Pareto optimal” when no further Pareto improvements can be made.
  • Parkinson’s law – “Work expands so as to fill the time available for its completion.”
  • Peter principle – “In a hierarchy, every employee tends to rise to his level of incompetence.”
  • Postel’s law – Be conservative in what you do; be liberal in what you accept from others.
  • Premack’s principle – More probable behaviors will reinforce less probable behaviors.
  • Roemer’s law – A hospital bed built is a bed filled.
  • Sayre’s law – “In any dispute the intensity of feeling is inversely proportional to the value of the stakes at issue.”
  • Segal’s law – “A man with a watch knows what time it is. A man with two watches is never sure.”
  • Sowa’s law of standards – “Whenever a major organization develops a new system as an official standard for X, the primary result is the widespread adoption of some simpler system as a de facto standard for X.”
  • Sturgeon’s law – “Ninety percent of everything is crud.”
  • Sutton’s law – “Go where the money is”.
  • Will Rogers Phenomenon – “When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states.”
  • Wirth’s law – Software gets slower faster than hardware gets faster.

Most of these were selected from the Wikipedia page, List of eponymous laws.

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Chronic Ear Pain: It’s Not All in Your Head, Part I

Posted on March 19, 2013 | Leave a comment

Chronic ear pressure, pain, or discomfort can be extremely frustrating.  This is especially true when there is no clear cause found by your doctor.  Usually this will result in treatment for an ear infection (otitis media or otitis externa) inappropriately and unsuccessfully.

One of the most common causes of ear pressure is eustachian tube dysfunction (ETD).  The middle ear is a closed-off space in the temporal bone behind the ear drum.  It has a single air vent, the “eustachian tube” that acts more like a pop-off valve than a true open vent.  The eustachian tube is typically in a closed position, however certain throat movements will cause it to open allow for the pressure to equalize.

Classic otitis media is due to a swelling of the eustachian tube that causes the ear pressure to never vent and never normalize.  After a few hours or so the middle ear will actually fill with fluid drained from the tissues and then may become secondarily infected.  This is a super-common problem and is the reason for ear tube placement in children and some adults.  Basically the ear tube allows for the middle ear to stay permanently ventilated, effectively bypassing the faulty eustachian tube.

A much more frustrating problem is the symptom of a mildly dysfunctioning eustachian tube coupled with an apparent heightened sensitivity to ear pressure differences.  In these cases no fluid builds up in the middle ear, and no true infection occurs.  In fact there is often no abnormality found at all.  Tympanometry, or middle ear pressure analysis, may be done and it may even reveal “normal” middle ear pressures.  This is a disorder not found in mainstream textbooks however I have been convinced it certainly exists.

Patients with what I call “subjective eustachian tube dysfunction” basically have an abnormal sensitivity to mildly altered pressures in the middle ear.  Patients will often get relief temporarily by “popping” their ear.  After evaluating for infection and other causes of ear pain, finally a tiny diagnostic myringotomy (hole placed in the eardrum) may be performed to see if this helps.  Sometimes patients with ETD will find the “new” normalized pressure almost as odd a sensation as as the previous pressure.  However I now have a regular following of patients who have had semi-permanent ear tubes placed and are quite happy with the results, even in the absence of ever having had fluid or infection in the ear.  These same patients will often be the first to notice a small plug of wax occluding their ear tube or other minor abnormality that our “regular” tube patients would never detect.

If you are not getting answers about your ear pain, I recommend you seek out a competent otolaryngologist who will take the time to evaluate the different causes and work on a treatment plan.  An evaluation may involve hearing and pressure testing, a microscope examination, and nasopharyngoscopy (to see the eustachian tubes).  Referral for allergy testing and even jaw joint mechanical evaluation may also be considered.

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Why are doctors always running late?

Posted on March 4, 2013 | Leave a comment

From day one I have sought to be an “on time” doctor.  This has been met with challenges however.  With maximum effort I still run about 15-20 minutes late every four hours (so my morning and afternoon office sessions usually are 20 minutes behind by the end).  The wait times for individual patients may vary though, with a few waiting longer, and most waiting less.  The following are some of the nearly uncontrollable reasons I find that keep us running late:

1. There is an inherent asymmetry in any type of scheduled event: the odds that something happens to make me late are about 10x the odds of something happening to make me ahead of time.  This asymmetry applies to all situations below.

2. It is very hard to accurately predict how long an individual patient evaluation will take.  Attempts to do so always fail.  We can however accurately predict averages.  The solution to this is to explicitly limit visit length, and break up complex patients into multiple visits, but I think this is poor patient service.

2b. It is hard to predict visit length because my practice encompasses a range of medical problems and levels of complexity (I enjoy the diversity).  I could probably predict visit length if all I saw were routine tonsil infections, but my patient complaints jump around from tonsils to cancer to sinuses to headaches to sleep apnea.

3. A single patient running late is impossible to “work in” to a full schedule without delaying those later patients.  The solution here is to not allow any amount of tardiness, but that isn’t exactly good service either.

4. Typical reasons a patient runs late: (a)s/he underestimates traffic, parking, and finding the suite. (b)underestimates filling out paperwork / long prescription lists. (c)forgets to check in at the front and let anyone know they are there!! (d)physical delays of “rooming” patients with mobility impairments.

5. Computer hiccups that delay processing a prescription, looking at a study, saving a note, etc.  Just one of these may delay a few minutes.

6. Having multiple internal appointments on same day in our office, such as for a hearing test and for CPAP check, exponentially increase the odds of any little something getting delayed and then running late.

7. Phone calls and same day work-ins from referring doctors.  We do stay very accessible to referring physicians but unfortunately this will always keep us a little bit behind.

8. (Uncommon) true emergencies or severely unexpected issues with a scheduled procedure.  This does not happen often, but when it does can truly wreck a schedule!

I do work my best to keep a balance of timeliness and good patient care.  And because we try to stay on top of delays I think we run a pretty tight ship.

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Oral Appliance Gaining Acceptance for Sleep Apnea & Snoring

Posted on January 31, 2013 | Leave a comment

Snoring and obstructive sleep apnea are some of the most prevalent medical conditions we face.  The causes are multiple: age, weight, upper airway anatomy, and neurological predispositions.  Continuous positive airway pressure (CPAP devices) remain the gold-standard in therapy, although compliance is still low.

Adjustable oral appliances are making a strong foothold in treatment.  These custom devices that aim to project the lower jaw forward (protrusion), tugging the tongue forward with it.  This helps to drastically improve the oropharyngeal airway.

Recently most insurance companies have recognized these as an effective treatment for snoring and mild or moderate sleep apnea.  They may also improve severe obstructive sleep apnea as well in the appropriate patient.  Our practice has been using oral appliances in patients who cannot successfully use CPAP prior to consideration for oropharyngeal surgery.  The device offers a painless reversible option to surgery with comparable long-term results.

TAP Oral Appliance

TAP Oral Appliance

 

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