June 16, 2019

The Benefits of Microprocessor Knee Technology

By: John Robb, CPO
Reach Orthotic & Prosthetic Services

Photo courtesy of Ottobock

Photo courtesy of Ottobock

In recent years, there has been a lot of media publicity around computer controlled prosthetic devices. These devices are quite controversial, both in the health insurance industry and health care community alike. Paired with this improved technology is an increased price tag.  Rising healthcare costs across the healthcare continuum fuel discussions as to whether or not these devices improve function consistent with that higher price tag.  As a result, microprocessor controlled knees for transfemoral amputees are carefully examined, since they utilize this costly technology.

While it is a reality that microprocessor controlled knees are expensive, they can significantly the improve quality of life for the amputee.

A prosthesis incorporating this technology can cost between $40,000-$120,000, depending on the type of knee and components chosen to complement the knee. There are a variety of these devices on the market, and while most are quality products, each has nuances that make it unique and specific to the patient.

What does this technology do?
The integrated computer helps the prosthesis react to the many different conditions the amputee is exposed to when walking throughout the day. For example, the able-bodied person takes for granted the ability to deal with changing conditions while walking.  However, for the amputee, things like carpet, steps, slopes (even subtle), grass, gravel, and crowds can present significant challenges.  Conventional prosthetic devices are unable to change and react to these changing environments, creating a problem, since the efficiency with which the knee swings through, and weight bearing, are critically important.  The computer, by analyzing data in the knee in real time, predicts what is going to happen on the next step and adjusts the knee resistances accordingly. For the amputee, this superior functionality increases trust in the prosthesis to perform reliably in various conditions.

Who is it right for?
This technology will not help the amputee who is severely physically debilitated or only uses the limb to ambulate in the home on consistent and level surfaces. These devices are generally not designed for high-impact sporting activities, such as running or water sports. However, this device can make a substantial difference in the life of an amputee who regularly walks in the community or has to deal surface changes regularly. Regardless of whether the amputee uses a walker, cane, or other assistive device, it can be the difference in making the transition to an increased level of independence. The literature backs up the benefits of these devices.

What’s the issue?
Because of the cost and moniker of “advanced technology,” most insurances, including Medicare, only make these devices available to the most functional and active amputees. This is unfortunate, because they may be of the most benefit to the amputee whose goals are simply to be efficient while using a cane.

There are questions that remain in all of healthcare. Who are the improving technologies appropriate for, and who’s going to pay for those technologies? In the meantime, prosthetic technology is making great strides in restoring mobility to our patients.

43John Robb, CPO is certified by the American Board for Certification in Orthotics & Prosthetics. He has been practicing in orthotics & prosthetics since 1990. He regularly speaks for medical professionals. He currently serves on the board for the Virginia Orthotic & Prosthetic Association and is a member of the medical operations committee for Physicians for Peace. reachops.com

Benign Prostatic Hyperplasia

By Lawrence Volz, MD

PillsVoiding complaints are found in both sexes and all age groups, and can have a multitude of causes, or a combination of causes.  Classic urinary complaints include “irritative” symptoms of frequency (urgency, urge incontinence, nocturia or nighttime urination) and “obstructive” symptoms (incomplete bladder emptying, slow stream, postvoid dribbling, and hesitancy.)  Entire books have been written describing the pathophysiology, diagnosis, and treatment of urinary complaints.

One of the most common reasons for worsening urinary symptoms in men as they age is BPH (benign prostatic hyperplasia), more commonly known to the layman as “enlarged prostate.”  That term can be somewhat misleading, however.  Although it’s universally true that as most men age, their prostates enlarge, there’s more to the story.  It is certainly the case that in general, the larger the prostate is, the more compression it will have on the outlet from the bladder.  However, it’s not uncommon for some men with large prostates to have little or no urinary complaints, while others with smaller prostates may suffer greatly.  The reason has been thought to be because some men may have smaller but more constrictive prostates, while other prostates may grow outward rather than inward as they enlarge, therefore minimally constricting the central channel.

The cause of the obstructive symptoms is self-explanatory.  As the urethral channel narrows and the stream slows, it may take longer to initiate urination, and men may be unable to empty the bladder fully.  The irritative symptoms are thought to possibly result from the bladder having to generate higher pressures to empty.  As with any muscle having to work harder, the bladder wall thickens over time, becomes less “stretchable”, and therefore holds a lower volume of urine before needing to empty, causing frequency and urgency.

All treatments for BPH-related voiding complaints ultimately focus on reversing the obstruction of the urethra from the prostate.  In general, a stepwise progression of treatments should be pursued, moving from least aggressive to most aggressive.  These include the medication class of alpha blockers such as tamsulosin (Flomax) which relax constriction of the prostate channel.  These medications work on both large and small prostates, and symptom improvement is quick, typically as early as two-to-four weeks.

The other class of medication, “5 alpha reductase inhibitors,” is used to shrink the enlarged prostate.  However,  it may take 4-6 months to see the beginning of symptom improvement.  These medications also tend not to have significant effect on smaller constricted prostates, but have been shown to reduce a man’s long-term risk of urinary retention and the need for future prostate surgery.

Lastly, there are many surgical options, all of which aim to open the prostate channel.  This includes the very effective transurethral resection of the prostate or “TURP” that has been performed for years, now with recently improved equipment and technique.  Prostate vaporization and laser treatments are available, along with a recently FDA-approved minimally invasive procedure that “pulls” the prostate channel open without removing or destroying tissue.

Patients should be reassured that effective treatment options exist, from well-tolerated daily medication to minimally invasive and more permanent treatments.

37Lawrence Volz, MD has returned to Williamsburg. He is seeing patients in the new Urology of Virginia Williamsburg location. He earned his medical degree from the University of Pennsylvania.  He completed his urologic residency at the Hospital of the University of Pennsylvania after two years of general surgery training at that institution. urologyofva.net

Chronic Pain and Sleep Disturbances:

The Chicken or the Egg?
By Raj N. Sureja, MD and Jenny L. F. Andrus, MD

BackAs Interventional Pain Management Specialists, we frequently hear patients complain that they cannot fall asleep, or are awakened during the night by pain.  Most practitioners know that lack of sleep can increase pain, and that restorative sleep can be the best medicine for relief.  Our challenge is to break the cycle of sleep disruption, so our patients get the rest they need when pain is present.

Some statistics:
• Pain is the number one medical condition to cause insomnia.

• A new study found that approximately two-thirds of all chronic back pain sufferers have sleep disorders.

• About 65 percent of those who report chronic pain experience non-restorative or disrupted sleep.

• The most prevalent complaint is difficulty falling asleep due to pain.

• Surveys revealed that waking too early due to pain (62 percent of respondents) and waking during the night (65 percent) are reported by chronic pain patients.

Many patients with chronic pain had sleeping problems before their pain started. The pain then turned a moderate sleep issue severe.

To help our patients sleep more deeply and efficiently, with fewer arousals and awakenings, we first determine which came first – the sleep disturbances or the pain.  We address the older problem first, and handle each condition differently.  If the predominate problem is pain, we address the painful process first; fixing the pain often corrects the impaired sleep.  When sleep issues predate the pain, both issues must be addressed.

We start by counseling patients on proper sleep hygiene.  We may suggest Cognitive Behavioral Therapy.  If they adapt these behavior changes and still have difficulty, we may order a sleep study.  A qualified sleep medicine physician can usually pinpoint the problem, whether sleep apnea, restless legs syndrome, periodic limb movement disorder or any other condition.  Once a diagnosis is made, appropriate treatment can be recommended.

Sleep apnea is particularly important to diagnose.  If severe, it can be dangerous, and is linked to many health problems, including chronic pain. We have seen patients with a chronic pain disorder become almost pain-free after their sleep apnea was addressed. Additionally, sedative medications are riskier when used in a patient with under-treated sleep apnea. These drugs include narcotic pain medications, as well as some commonly-used prescriptions for sleep. It’s important to evaluate for sleep apnea before using these medications.

We more commonly prescribe medications for sleep that have less risk to the patient and that may also address pain. These include some medications used for neuropathic pain.

For patients whose pain is causing the sleep disruption, we can treat the pain through a variety of techniques, including:

• Interventional pain treatments like steroid injections or nerve blocks;

• Pain medications, most typically non-narcotic;

• Physical therapy;

• Structured exercise to promote pain reduction and well-being;

• Cognitive behavioral therapy;

• Regenerative medicine techniques, including proliferant therapy, PRP, stem cell injections.

Managing pain involves much more than treating the pain generator.  When sleep is impaired, pain worsens and patients don’t have the energy to deal with the important things in life, like their family and work.  An effective mullti-disciplinary pain management program addresses all aspects of pain – including sleep – so the patient can return to wellness.

35Raj N. Sureja, MD and Jenny L. F Andrus, MD are fellowship-trained, Board-certified Interventional Pain Management Specialists and practice at Orthopaedic & Spine Center in Newport News, VA.

osc-ortho.com

Treating Hip Fracture

In the Older Patient — It’s not just a question of orthopaedic expertise
By Ali R. Jamali, MD, FACS, Sports Medicine & Orthopaedic Center

caneAccording to the Centers for Disease Control, at least 250,000 older Americans (defined as 65 and older) are hospitalized for hip fractures every year.  The chances of a senior sustaining a hip fracture increase with every year of life, so much so that the National Institutes of Health predicts the number of hip fractures in the United States could total 840,000 by the year 2040.

Three-quarters of those fractures will occur in women, in part because of their increased risk for osteoporosis.  Eight million American women have osteoporosis, which weakens bones and makes them more likely to break.  In fact, the National Osteoporosis Foundation claims a osteoporotic woman’s risk of breaking her hip is equal to her combined risk of breast, uterine and ovarian cancer.

Unfortunately, the most troubling statistic comes from a study funded by the the National Institutes of Health and published in the Archives of Internal Medicine:  women ages 65–69 who break a hip are five times more likely to die within a year than women of the same age who don’t break a hip.

The problem lies not so much with the hip fracture itself, but with the sequelae of the trauma.  When the body responds to such a trauma, it goes through a transformation and begins to excrete proteins and hormones that affect all of the organs in the body, the endocrine system, the gastrointestinal system, and the inflammatory and immune responses.

It is this multiple-organ pathological response to trauma that we need to take into consideration when we care for older patients, over and above correcting the original fracture, because elderly patients are often already suffering medical problems and diseases associated with age.  For instance, diabetic patients may suddenly have trouble regulating their blood sugar after a hip fracture.  A thyroid patient may have a similar experience with thyroid hormone.  A patient with a queasy stomach may see that turn into an ulcer because of excess acid production.  In short, many chronic conditions can be exacerbated by the trauma.

Surgery for the elderly patient.
When surgery is indicated for such patients, the type of procedure will depend on the nature and extent of the fracture, whether intertrochanteric, subtrochanteric or subcapital.  No matter what the procedure, I consider it essential to have the safest possible anesthesia for my elderly patients, which is most often a spinal or a regional block –  and I want the patient anesthetized for the shortest possible period of time.  It can sometimes take an older patient a few days to shake off the effects of anesthesia, and we watch them very carefully during their post-op recovery.

These older patients are especially vulnerable, and they face a long road ahead as other medical issues resulting from the trauma may impair their ability to heal and recover hip function.  But paying attention to the whole patient, not just the fracture, can make all the difference.

33Ali R. Jamali, MD joined SMOC in January 2016.  He completed medical school at Tabriz University Medical School in Tabriz, Iran.  He took post-graduate training in London, England and Seattle, Washington, and completed a combined orthopaedic residency training program at EVMS affiliate Children’s Hospital, Richmond, Virginia.  smoc-pt.com

You’ve been asked to serve as an expert witness in a medical malpractice case

Nurse– What it really means in terms of your commitment of time and energy
By Jessica Flage, Attorney at Law Goodman Allen Donnelly PLLC

You’ve been asked to review a chart and serve as an expert witness in a case of medical malpractice.  Do you understand the full extent of the commitment of time and energy you’re being asked to make?

It can be tempting to think of it as easy money:  you review a chart and give your expert opinion about the care rendered, and the sequelae of that care.  But it doesn’t end there: at the very least, you will have to meet with the lawyer to understand what is being alleged.  You will have to educate the attorney about the medicine and what constitutes negligence in a particular medical setting.  I can tell you that nothing is more frustrating than sitting down with a physician who’s agreed to be an expert witness, but who has clearly not read the chart.

It’s essential to dedicate time for meetings, depositions, and other pre-trial preparations.   A word about depositions:  in a malpractice case, testifying is unlike what you may be familiar with from appearing as a treating physician.  In those cases, you refer to the chart to explain what you found and what you did.  However, when you testify as an expert in a malpractice case, the attorney’s job on the opposing side is to attack your opinion, and make a jury feel your position is unfounded and unjustifiable.  For physicians who are unaccustomed to being challenged by someone outside the medical field, these depositions can be very uncomfortable.

Before the designation of expert witnesses, you can expect the attorney who hired you to barrage you with questions about the case.  Many of those questions will begin with the phrase, “Can you say that…” or “In this particular instance, did the actions of the physician result in…”

You must be prepared to be available to state your opinion and explain your answer, a week or days, or even the day of the designation.  These events happen at a very fast pace, and on a very strict deadline.

It’s true that many cases never go to trial, but it is disheartening to engage an expert who then clearly demonstrates no desire to testify at trial, or who aggressively attempts to avoid court.  It can be even more stressful when an expert insinuates that it’s an inconvenience to rearrange schedules and patients.  Most often, trial dates in Virginia are scheduled at least eight months in advance, so physicians and their offices should have ample notice of impending court dates.

Even then, it’s rarely possible to state definitively when an expert will be called to testify.  Lawyers make every effort to accommodate their experts’ calendars, but in malpractice cases, which in Virginia can last a week to 10 days, flexibility is required on the part of every witness.

If you are asked to serve as an expert, be sure you understand the extent of the commitment. Your own attorney can be a vital resource in determining whether to agree.

31Jessica Flage earned her law degree in 2007 at American University Washington College of Law. She focuses her practice primarily in the areas of medical malpractice defense litigation, healthcare and product liability defense. www.goodmanallen.com

Creating an Effective Employee Handbook

HandbookAny size medical practice can benefit from having an employee handbook. An employee handbook tells employees what’s expected of them and what they can expect from the employer in regard to working hours, conditions, vacations, and other benefits.

By outlining in detail the employer’s policies and procedures, an employee handbook can help minimize disagreements and avoid legal disputes when it comes to discipline and dismissal policies. An effective employee handbook should cover certain core subjects.

What To Include
Your handbook should include sections on your practice’s policies and rules regarding:

• Payment schedules, work periods, and working hours

• Lunch breaks, paid time off, vacations, sick leave, and time off for military service or jury duty

• Unapproved absences and tardiness

• Workplace conduct standards, including policies on workplace violence, harassment, and dress codes

• The practice’s information security policies

• The use of cell phones or other personal communication devices during working hours

• Health and retirement benefits

Have a lawyer review the handbook before printing to ensure it complies with applicable laws. After it’s approved and printed, make sure each employee receives a copy. Human resource professionals suggest each copy include a receipt that employees are required to sign and return to you. This confirms that they’ve read and understood the handbook.

Keep It Updated
Medicine is forever changing. With new laws and policies from federal and state regulators and constant shifts in the way medicine is practiced, an employee handbook may not stay legal, timely, or appropriate for long. The handbook should be reviewed annually and updated to reflect current conditions.

MRDPict

For more information please contact the McPhillips, Roberts & Dean Healthcare Team Leaders.  mrdcpa.com/Industries/Healthcare

Copyright 2015 by DST. All rights reserved.

The general information in this publication is not intended to be nor should it be treated as tax, legal, or accounting advice. Additional issues could exist that would affect the tax treatment of a specific transaction and, therefore, taxpayers should seek advice from an independent tax advisor based on their particular circumstances before acting on any information presented. This information is not intended to be nor can it be used by any taxpayer for the purpose of avoiding tax penalties.

Perchance to dream…

Why it can be so hard to get a good night’s sleep…and why it matters

Sleep01People have been sleeping, not sleeping, and chronicling their sleep (or lack thereof) throughout recorded history.  In 450 BC, the Greek physician Alcmaeon produced the earliest documented theory of sleep, which he described as a loss of consciousness as blood retreats from the surface of the body.  Fifty years later, Hippocrates theorized that sleep was due to blood retreating to the inner regions of the body.  Still fifty years after Hippocrates, Aristotle saw sleep as caused by warm vapors rising from the heart during digestion, and concluded that sleep is a time of physical renewal.  It was nearly another 200 years before Galen established that consciousness resides in the brain, not the heart.

“I couldn’t sleep at all last night…”
– Bobby Lewis, “Tossin’ and Turnin’”

What we know of early sleep medicine comes from the Edwin Smith, Ebers and Kahun papyri. These documents refer to Egyptian remedies for insomnia, which consisted of poppy seeds out of which the then current recipe for opium was prescribed.

What these early healers didn’t know, however, was that many cases didn’t require medication at all.  Instead, those early Egyptians were experiencing paradoxical insomnia, that is, complaining they weren’t sleeping when in fact, they were.  In fact, the most common cause of most insomnia is psychological: it can be related to some underlying anxiety, a stressful life event like divorce, death or trauma – sufferers develop poor sleep hygiene and eventually become chronic insomniacs.

Those early healers had no way to diagnose narcolepsy until 1888, when it was identified by Gelineau.  Similarly, they had no name for restless legs syndrome, which was described in 1945 by Ekborn.

“How blessed are some people … to whom sleep is a blessing that comes nightly.”
– Bram Stoker, Dracula

Sleep02The modern approach to sleep disorders research began in 1913 with the publication of Le problem physiologique du sommeil, the first text to examine sleep from a physiological perspective.  Dr. Nathaniel Kleitman, known as the Father of American sleep research, began questioning the regulation of sleep and wakefulness and of circadian rhythms in the 1920s. In 1953, he and Dr. Eugene Aserinsky made the landmark discovery of rapid eye movement (REM) during sleep.

Three years later, Aaron Lerner named the sleep disorder that is experienced by more than 18 million Americans today.  Obstructive sleep apnea can cause fragmented sleep and low blood oxygen levels.

One of the most common signs of obstructive sleep apnea is loud and chronic snoring, but snoring is the least of these poor sleepers’ problems.  Obstructive sleep apnea is linked to car crashes, high blood pressure, diabetes, stroke and heart disease.  And there is increasing literature that demonstrates that treating sleep apnea accrues benefits in all sorts of different areas, whether lowering incidences of automobile crashes, lowering blood pressure, protecting the cardiovascular system.

In addition, according to the New York University Medical Center website, a 2015 study found “a troubling link between abnormal breathing patterns like snoring and brain function.” They studied the medical histories of more than twenty-four hundred people between the ages of 55 and 90. They found that those who snored or who had sleep apnea were diagnosed with mild cognitive impairment at an average age of 77. For those without sleep-related breathing problems, cognitive problems didn’t appear until an average age of 90.

And, the researchers found, those with breathing problems during sleep were also more likely to suffer from Alzheimer’s disease at an earlier age. For snorers, the Alzheimer’s diagnosis came at an average age of 83. For those without breathing problems, the average age for Alzheimer’s onset was 88.

“Leave me where I am; I’m only sleeping.”
– Lennon-McCartney, “I’m only sleeping.”

In dreaming sleep, with the exception of eye muscles and the diaphragm, the body is intended to be paralyzed.  In REM sleep behavior disorder, an interesting condition predominantly seen in older men, sleepers will act out their dreams, often those with violent content.  They lose the normal paralysis that is supposed to be present in dreaming sleep.  A typical example: the patient dreams he is being chased by a bear, and he “reacts” by punching the bear in the snout.  Unfortunately, it’s his wife who receives the blow.  And while some defendants in criminal cases have used the “REM sleep behavior disorder defense,” few have done so successfully.

“I don’t sleep at night. The doctor can’t tell why. He’s a clever fellow, or I shouldn’t have him, but I get nothing out of him but bills.”
– John Galsworthy, The Forsyte Saga

Fortunately, the science of sleep medicine has grown far beyond the understanding of Galsworthy’s luckless physician.  With backgrounds in psychiatry, neurology, neurophysiology, and pulmonology, as well as Board certifications in sleep medicine, the three physicians featured on our cover – Dr. Soham Sheth, Dr. Patrick Harding, and Dr. Robert Vorona – have the most current and reliable knowledge of the mysteries of sleep and its disorders, and many more options to help their patients achieve what Shakespeare referred to as “Sleep that knits up the ravell’d sleave of care … chief nourisher in life’s feast.”

“Even a soul submerged in sleep is hard at work and helps make something of the world.”
– Heraclitus, “Fragments”

The body is far from inactive during sleep.  In the deepest and most restorative stage of sleep, the blood pressure drops, breathing is slower, muscles are relaxed and blood supply to the muscles increases – and importantly, it’s when tissue growth and repair occurs.  It’s vital for the restoration of brain function.  It is, as one of our doctor honorees says, “when the trash is taken out, when the body has maximal benefit in terms of recovery.”

Sleep Apnea Might Not Just Take Our Breath Away

– It Can Also Take Our Sight
By Kapil G. Kapoor, M.D.

Recently, increasing evidence is highlighting the importance of good sleep hygiene for our visual health. Our eyes need sleep with uninterrupted REM cycles to allow a system restart. In sleep apnea, the tissues of the throat collapse and occlude the airway, causing repeated interruptions leading to rapid drops in oxygen levels. The brain responds by releasing compensating circulatory hormones that cause rapid blood pressure spikes.

EyePictThe retinal blood vessels are extremely sensitive to these fluctuations, putting them at risk of micro-infarct or occlusion – the equivalent of mini-strokes. Even more concerning, obstructive sleep apnea may have a triggering role in cases of retinal vascular occlusions, which may explain why many patients with retinal vascular occlusions notice visual loss upon awakening.

Mini-strokes can affect the microcirculation surrounding the optic nerve as well, known as ischemic optic neuropathy. A stroke at the level of the optic nerve undermines the main transmission pathway between the eye and the brain.  Research has linked oxygen and vascular irregularities secondary to sleep apnea as important risk factors for ischemic optic neuropathy.

Sleep apnea has also been associated with open-angle glaucoma, which puts the optic nerve at risk for damage due to elevated pressure within the eye. Chronically elevated intraocular pressure can lead to gradual loss of peripheral vision, and frequently goes undiagnosed until advanced stages.

The most classic ocular association with sleep apnea is floppy eyelid syndrome, almost universally present in apneic patients. The oxygen and breathing changes throughout the night lead to frequent positional shifts and repeated friction on the eyelids against pillows and blankets.  This mechanical stress leads to a breakdown in the structural tissues of the upper eyelids, which are no longer able to provide the support the eyes need for maintaining tear film – leading to chronic dryness, irritation, and sometimes blurred vision.

Sleep apnea has been further linked with acceleration of other retinal vasculopathies – notably diabetic retinopathy. Vascular damage inherent to retinal capillaries in diabetic retinopathy can be compounded by damaging factors released in obstructive sleep apneic episodes. These all accentuate hypoxia, a critical driving stimulus for diabetic macular edema and proliferative diabetic retinopathy, in which the retina produces new blood vessels to compensate for the decreased blood flow and oxygen levels.  This neovascularization can be sight-threatening, potentially resulting in vitreous hemorrhages or tractional retinal detachments, often requiring an increased treatment burden to preserve sight.

While our treatments for preserving sight continue to advance, with multiple options of anti-VEGF intravitreal injections, focal or panretinal photocoagulation laser treatments, and the latest equipment for microincisional sutureless surgery, it’s clear that more attention needs to be shifted toward prevention. As we understand the risks of sleep apnea more, we need to improve patient screening and lower our threshold for patients who may be at risk. Patients should be asked about gasping or choking while sleeping, loud snoring, or daytime sleepiness. Also, it’s critical to engage a family member in the screening process, as patients are often unaware that they snore.  Working together as a healthcare team will allow us to optimize treatment for these patients, preserve their sight, and give them all of the benefits of a good night’s sleep.

KapoorKapil G. Kapoor, MD completed medical school at Ohio State University, residency at the University of Texas Medical Branch-Galveston and a fellowship at The Mayo Clinic.
Dr. Kapoor is a Board certified ophthalmologist specializing in vitreoretinal surgery.  www.wagnerretina.com.

Unraveling the Mysteries of the Thyroid

By Bobbie Fisher

ButterflyThe thyroid gland is often described as butterfly shaped, but the comparison doesn’t stop there.  Although relatively small (.03-.04 grams), the average butterfly provides a wide range of environmental benefits, including pollination and natural pest control (in addition to being a food source itself), making it one of nature’s workhorses.  Similarly, despite its own relative small size (20-60 grams), the human thyroid produces and stores the hormones that regulate metabolism and influence the function of every cell, tissue and organ in the body, including the heart, the brain, the liver, kidneys, intestines and skin.

For all its importance, the butterfly is a fragile and delicate creature, susceptible to many natural predators and having a very short lifespan.  The thyroid, while not as fragile, is likewise subject to a variety of conditions, many of which are complex, and can be challenging to understand.

David C. Lieb, MD

David C. Lieb, MD

“Thyroid disease is very common,” says David C. Lieb, MD, an associate professor of internal medicine and program director of the Endocrinology Fellowship Program at Eastern Virginia Medical School.  More than 12 percent of the US population will develop a thyroid condition at some point during their lives. That is, an estimated 20 million Americans have some form of thyroid disease.  “As many as 60 percent of them are unaware of their condition,” Dr. Lieb says, “which could be too much or too little thyroid hormone, a thyroid nodule or thyroid cancer.  And untreated thyroid disease can put patients at risk for serious conditions, such as cardiovascular disease, osteoporosis, infertility, depression, mental slowing and others.”

Jennifer Wheaton, DO

Jennifer Wheaton, DO

Women are five to eight times more likely to have hypothyroidism.  “Despite the research, we still haven’t figured that out,” says Jennifer Wheaton, DO, an endocrinologist with Bayview Physicians Group.  However, hypothyroidism is often caused by an autoimmune process (termed ‘Hashimoto’s thyroiditis’).  For unclear reasons, women are often more likely to develop autoimmune disease compared with men. “It’s also worth noting that the symptoms of menopause are almost identical to the symptoms of hypothyroidism: fatigue, weight changes, mood swings, difficulty sleeping.  I’ve seen women who experienced these symptoms and assumed they were caused by menopause, and thus their diagnosis was delayed.”  That happens less these days, she adds, as physicians and patients are more aware of hypothyroidism and its symptoms.

TSH Screening.
The routine test is the thyroid stimulating hormone, or TSH, taken from a blood sample. It’s considered the gold standard.  From the American Thyroid Association:

A high TSH level indicates that the thyroid gland is failing because of a problem that is directly affecting the thyroid (primary hypothyroidism). The opposite situation, in which the TSH level is low, usually indicates that the person has an overactive thyroid that is producing too much thyroid hormone (hyperthyroidism). Occasionally, a low TSH may result from an abnormality in the pituitary gland, which prevents it from making enough TSH to stimulate the thyroid (secondary hypothyroidism). In most healthy individuals, a normal TSH value means that the thyroid is functioning normally.

Because thyroid disease is so common, it can be challenging to determine exactly who needs to be screened, and when.  “When something is so prevalent, you could easily say that everyone should be screened,” Dr. Lieb says.  The United States Public Health Service Task Force argues there is insufficient evidence to screen anybody, while the American College of Physicians says every woman over 50 should be screened.  The American Thyroid Association guidelines indicated screening for anyone at risk.

Additionally, Dr. Wheaton explains, the TSH number can fluctuate: “There are definitely things that can affect it, especially if the patient is sick.  There’s an entire condition called euthyroid sick syndrome, which results in abnormal thyroid function tests during a nonthyroidal illness in patients without pre-existing hypothalamic-pituitary or thyroid disorder.”  When the patient recovers from the nonthyroidal illness, she says, the abnormalities resolve.

Similarly, in thyroiditis, when the thyroid is being destroyed by a viral infection, it will release a substantial amount of thyroid hormone because the cells are breaking apart as they’re dying, Dr. Lieb explains: “So these patients become hyperthyroid for a period of time, and then it peaks, and they come back to normal.  But sometimes rather than remaining at normal levels, they can get too low and become hypothyroid, requiring thyroid hormone.”

There are other factors that can result in abnormal TSH results, as well – even a patient’s (non)compliance with a thyroid hormone replacement regimen before testing.

Fortunately, most thyroid diseases can be managed with medical attention.

Most of the time, once patients have thyroid disease, they have it for life; however, because it’s an autoimmune disease, it can sometimes resolve itself.  “We more commonly see that in hyperthyroidism due to Graves’ disease,” Dr. Wheaton says, “and some patients with Graves’ can be treated for a year or two with medication to normalize their thyroid, and then go into a kind of remission with thyroid levels that will stay normal on their own.”

With hyperthyroidism, treatment options include anti-thyroid medications – propylthiouracil and methimazole – but because of their side effects, they are not recommended for life-long use, particularly at the higher levels.  Another option is radioactive iodine ablation, which causes the thyroid gland to shrink and thyroid activity to slow down.  One of the sequelae of radioactive iodine is that it can cause hypothyroidism, requiring treatment for that condition.

The standard treatment for patients with hypothyroidism, whether as a result of radioactive iodine for hyperthyroidism or of Hashimoto’s disease, is to replace the thyroid hormone the body can no longer make with a daily dose of levothyroxine.  To ensure the patient is receiving the proper dose, levels are monitored after initiating treatment and whenever the dose is changed.

Goiter is another presentation of thyroid disease that requires skill to diagnose.  A patient can have a goiter with a normal TSH, or a goiter with hypothyroidism or a goiter with hyperthyroidism, or a goiter with several nodules that are inactive or a goiter with nodules that are producing too much thyroid hormone.  In some cases, a patient with nodules and Graves’ disease may have a goiter so large that it interferes with swallowing or breathing.  In this case, surgical removal of the thyroid is indicated.

There has been an increase in both the incidence of thyroid nodules and the incidence of thyroid cancer in the United States over the last five to 10 years. Thyroid nodules are generally incidental findings, as the majority are asymptomatic.  They are usually diagnosed when a patient has a head or chest CT scan or x-ray.  “Thyroid nodules are more common as patients age,” Dr. Lieb says.  “In fact, if we did an ultrasound on everybody in their 60s and 70s, at least half of them would have nodules.”

The determination at that point is how best to proceed, particularly in light of the fact that fully 90 percent of thyroid nodules are benign.  “We’ll do a biopsy to determine whether there is cancer,” Dr. Lieb says, “and do another ultrasound at six months to see if it’s changing.  And we’ll check thyroid labs to see if it’s overactive, and treat accordingly.”

Thyroid cancer is one of the fastest rising cancers, especially in women, but mortality from thyroid cancer has not increased; the rate of death is actually very low.  Of the four types of thyroid cancer – papillary, medullary, anaplastic and follicular – papillary is the most common, Dr. Wheaton explains.  “The majority of patients with papillary cancer have their thyroid removed, maybe radioactive ablation afterward, and they do well,” she says, emphasizing that it always depends on the patient.

Medullary thyroid cancer is a more aggressive disease, with a higher mortality rate, tending to be a genetic cancer that has often metastasized before it’s found.  Similarly, anaplastic thyroid cancer, which claimed the life of Supreme Court Justice William Rehnquist, is very aggressive and almost always fatal.

Rebecca Britt, MD

Rebecca Britt, MD

When Surgery is Indicated.
With a diagnosis of cancer, removal of the entire thyroid is indicated, as well as some of the surrounding lymph nodes, says Rebecca Britt, MD, a fellowship trained general and laparoscopic surgeon and associate professor at Eastern Virginia Medical School.  “From a recovery standpoint, most patients do extremely well with thyroid surgery,” Dr. Britt says.  “Our most common complications are low calcium after surgery.  In about three percent of surgeries, patients experience recurrent laryngeal nerve injury, or hoarseness, which is permanent less than one percent of the time.”

“It’s a very delicate operation,” explains Doris Quintana, MD, a general and endocrine surgeon with Riverside Surgical Specialists, who did additional training in thyroid and parathyroid.  “Keen attention to the finest details really makes a difference in how the patient does, particularly because of the presence of the four small parathyroids that are crucial to survival.”

Doris Quintana, MD

Doris Quintana, MD

The surgery is traditionally done through a transverse incision across the front of the neck.  Today, surgeons like Dr. Britt and Dr. Quintana can perform the operation with much smaller scarring than in previous years, but for some female patients, they both agree, there is a concern about any scar on the neck.  In some cultures, for instance, where any imperfection is considered to render a woman unmarriageable, some surgeons are doing the procedure endoscopically, with tiny incisions in the axilla or underarms, or even around the areola of the nipple.  “A tunneling device is then used to come up to the neck,” Dr. Quintana says.  “It’s been done some in this country as well, but not extensively.”

Sometimes, Dr. Britt explains, the diagnosis of cancer isn’t easily made. “We do surgery because despite the workup we’ve done, we can’t tell for sure whether something is a cancer or not,” she says.  “Some patients have a nodule or nodules, and when we biopsy them, they come back with follicular cells.  Frequently those are not cancer, but in order to definitively diagnose, we have to take the whole lobe of the thyroid out and have a pathologist look at it.”  If the pathology indicates cancer, the surgeon will then return to the OR to remove the remaining thyroid.

In the absence of cancer, when only one lobe of the thyroid is affected, surgeons can remove only the involved lobe.  Patients can do quite well with one functioning lobe, Dr. Quintana says, “particularly because the residual lobe preserves parathyroid function, and the native gland is still potentially putting out enough hormone to sustain a normal level.”

The Connection with Breast Cancer.
A recent study suggested that women being treated for breast cancer have a higher than normal risk of developing thyroid cancer.  “It’s vitally important for primary care physicians and anyone treating women to understand that connection,” Dr. Quintana says.  “And women should not only be urged to have their screening mammograms regularly, but also to examine their necks for lumps that could indicate nodules.”

Final Thoughts.
The availability of ultrasound and other advanced diagnostic tools are largely responsible for the increase in the diagnosis of thyroid nodules and thyroid cancer. “It’s always been there; we’re just better able to recognize it,” Dr. Lieb says.  “As an endocrinologist, I feel like a part of my job is to stay on top on developments in the management of all aspects of thyroid disease, because our primary care physician colleagues have more to do than ever.  For those physicians, and for interested patients, Dr. Lieb and the other contributors to this article recommend these websites:

The American Thyroid Association
www.thyroid.org

Thyroid Cancer Survivors’ Association
www.thyca.org

American Association of Endocrine Surgeons
www.endocrinesurgery.org

The Group for Women

No Wonder Women are Smiling

MonaLisa Touch® is quick, virtually painless, and effective therapy for postmenopausal dyspareunia

MachineAsk any woman “of a certain age” (i.e., menopausal and post-) what she dreads the most about getting older, and you wouldn’t be surprised if “Wrinkles!” were the first word she uttered.  Close behind might be, “Sagging!  Nothing is where it used to be!”  Or the ever-higher number that seems to greet her every time she steps on the scales.

A more thoughtful woman might respond that the loss of independence, or her memory, or a loved one, was her greatest fear.  Or perhaps the possibility of loneliness.

Women have no trouble expressing these concerns about the aging process.  They are, after all, part of life, and therefore, can be shared and discussed without embarrassment.

What women have been less inclined to talk about openly as they get older are the symptoms that accompany an aging female body, and their effects on a woman’s emotional and physical comfort.  Women can feel these symptoms are too embarrassing to mention, even to a gynecologist or other physician.  They needn’t be, as they, too, are part of life – and neglecting them can lead to unnecessary discomfort.

Atrophic vaginitis.
As a woman ages and approaches menopause, she experiences a drop in estrogen that can lead to atrophic vaginitis, the lack of nourishment and hydration of the cells of the vaginal mucosa.  She may experience some or all of these symptoms:

• thinning of the vaginal walls;

• shortening and tightening of the vaginal canal;

• vaginal dryness and/or burning;

• vaginal burning (inflammation)

• pain or burning with urination;

• more frequent urinary tract infections.

Jeffrey Wentworth, MD

Jeffrey Wentworth, MD

Dyspareunia.
The atophic vagina is thin, fragile, lacking elasticity, and above all, dry and unlubricated.  Consequently, postmenopausal women often experience pain (sometimes severe) during intercourse, and may even notice some spotting blood after sex.  These women learn to fear sexual intimacy, which is often mistaken for lack of sexual desire by an uncomprehending partner.  The damage to these women’s self esteem – and to their relationships – can be devastating.

Until now, physicians have had little to offer these women.
The treatment has generally been prescription vaginal estrogen creams.  Many women, however, concerned about the use of hormones and the threat of associated cancers, prefer not to use these.  While some of their fears might be unfounded, it can be an unsurmountable mental block.  And breast cancer patients and survivors cannot use them at all.

Additionally, there are no generic options in this drug class, so all prescriptions are branded and tend to be very expensive.  Even with co-pays, women can spend upwards of $50 to $100 every time she fills her prescription.

And then, there is the “ick factor.”  Vaginal estrogen creams are messy, and unpleasant to administer, which far from enhancing pleasure, can actually diminish it.  Women don’t like them, and are thus less likely to use them.

WomenFigMonaLisa Touch® is a quick, virtually painless, and effective therapy for postmenopausal dyspareunia.
In December 2014 the U.S. Food and Drug Administration cleared a new laser therapy for gynecologic health.  Developed in Italy, and named for one of Italy’s most enticing women, the treatment was introduced in the United States by internally renowned urogynecologist Dr. Mickey Karram, a clinical professor of obstetrics and gynecology, and urology, at the University of Cincinnati.  Learning about the new treatment, Dr. Karram visited the manufacturer to observe the MonaLisa Touch® and evaluate its application for his own patients.  So impressed was he with what he found that he acquired the laser from Cynosure and began to experience the same remarkable results in the United States.

The MonaLisa Touch® is based on a special fractional CO2 laser that was specifically created for the vaginal mucosa.  The therapy both resolves and prevents estrogen drops in the vaginal tissue by re-activating the production of new collagen and reestablishing the conditions the vaginal mucosa once had.

In menopausal women, the lining of the vagina is about a millimeter thick.  The laser acts on the vaginal lining through a special scanner, creating micro-lesions that trigger the production of new collagen, reorganizing and re-equilibrating the components of the vaginal mucosa.  It is the body’s response – increasing blood flow and collagen to heal the wound inflicted by the laser – that allows the vagina to normalize.

The laser’s action reactivates and reestablishes the proper function of the relative urogenital structures, while also improving symptoms associated with urinary dysfunction (mild incontinence due to stress).

Quick, virtually painless and safe.
The treatment takes no more than five to seven minutes, and is performed in the office.  There is no need for anesthesia, no need to insert a speculum.  Women report that the physical experience is very much like having a vaginal probe ultrasound – something almost every woman is familiar with.  Some have reported a tingling sensation while the probe is in place.

To this point, thousands of women in America, Italy, Australia and throughout Europe have had the procedure.  To date, not one case of adverse side effects has been reported.  Some women note a small amount of irritation a day or two after the treatment, but that soon resolves.

The proof is in the results.
The therapy regimen consists of three treatments, six weeks apart.  The tissue regeneration process lasts a number of weeks, but stimulation occurs immediately.  Women have reported experiencing significant improvement of their symptoms as early as days after first treatment with the MonaLisa Touch® – improvement that has translated into an invigorated, almost youthful approach to an activity they found painful just weeks before.  Husbands and partners are thrilled, not just with a revitalized sex life, but also with the re-energized woman who has emerged.

The results are far-reaching.
Even beyond the bedroom, women are experiencing relief from virtually all of the vaginal symptoms of menopause.  UTIs are resolved, the burning and itching that often accompany urination are gone.  Additionally, the MonaLisa Touch® works very well in treating the vulva for a very specific non-hormonal condition called lichen sclerosis, a chronic skin condition that may be caused by a too active immune system, almost like lupus. Lichen sclerosis in the genital area can create patches that left untreated can cause problems with urination or sex. There is also a very small chance that skin cancer may develop in the patches.

Truly a remarkable breakthrough.
For so long, we have seen our patients suffer the sequelae of menopause.  The MonaLisa Touch® – a therapy that is effective and safe and proven – heralds a new age for gynecologists and the women they treat.

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