HOW TO RECOGNIZE POTENTIALLY CRITICAL SLEEP DISORDER CASES

from Florida MD MayJune 2022

MITIGATING THE RISKS OF CERVICAL INSUFFICIENCY

How to Recognize Potentially Critical

Sleep Disorder Cases By Orlando Ruiz-Rodriguez, MD

As a pulmonary sleep disorder specialist, a common complaint I treat is snoring. It’s probably no surprise that it’s among our most prevalent sleep disorder complaints. A snoring issue may sound minor — merely an inconvenience to spouses and partners whose sleep patterns are disrupted due to resulting noise and movement.

Sleep issues, however, become problems when they disrupt a person’s ability to safely and successfully perform normal activities such as working, driving or going to school. And, many cases of snoring and other sleep disturbances are associated with potentially critical cardiopulmonary medical conditions. Left untreated, severe sleep disturbances can result in cardiac-related complications including sudden cardiac death, stroke, atrial fibrillation, ventricular tachycardia and all-cause mortality, according to data from the Wisconsin Sleep Cohort, an ongoing longitudinal study of the causes, consequences and natural history of sleep disorders, particularly sleep apnea.

Potentially serious sleep conditions can go undetected if not for the keen ears of an exhausted spouse or partner who, out of sheer frustration, reaches out for medical assistance, paired with the diligence of healthcare providers who know how to identify warning signs.

Treatments for sleep issues, depending on their severity and potential to contribute to cardiopulmonary problems, vary. For sleeplessness, treatments may include short-term medication therapy and (preferably) talk therapy for long-term relief without the risk of drug dependencies and side effects. For more serious sleep breathing problems, treatments are more aggressive and may require sleep studies, physical therapy, supportive appliances — such as CPAP machines, MAD devices (mouth guards) and airway stents — or even nerve stimulation surgery.

Here, I’ll help you identify sleep issues and triage potentially life-threatening signs that might need a referral to a pulmonary sleep specialist.

THE WIDE RANGE OF SLEEP DISORDER PATIENTS

There’s not a single population that’s exclusively prone to potentially dangerous sleep disorders. In my practice, I see a very wide range of patients: from their teens into their 20s, all the way into their 90s and beyond. But, as people age, more males present with a sleep disorder spectrum.

According to population data from the Wisconsin Sleep Cohort, as many as 15-30% of males and 10-30% of females meet a broad definition of obstructive sleep apnea (OSA). LOW INCIDENCES OF SELF-REPORTING

Cases are not always self-reported. Only 20% of the OSA affected population reports sleep disordered breathing to a physician. (This includes about 9% of males, 5% of females reporting a spouse or partner’s problem, and 5% of females reporting their own issues).

That’s why it’s important for your practice to triage sleep disorders and identify red flags warning of potentially serious cardiac and pulmonary conditions. Because odds are, they may go unreported. WHAT SLEEP SPECIALISTS ENCOUNTER

As I mentioned earlier, initial sleep complaints — snoring, insomnia and next-day tiredness — often only scratch the surface of a potentially serious cardiopulmonary problem.

An abbreviated list of sleep complaints referred to me include: • Insomnia • Snoring with difficulty sleeping • Obstructive sleep apnea (OSA) • Hypersomnia, including narcolepsy, idiopathic hypersomnia,

Klein Levin Syndrome and other related disorders • Sleep Paralysis • Movement disorders • Spectrum conditions

DIAGNOSIS METHODS

To diagnose a patient’s sleep disorder and rank its severity and risks for cardiopulmonary events, even if not self-reported, I triage them through precise assessment tools. In particular, I use two assessment tools: the Epworth Sleepiness Scale (ESS) and the STOP-Bang Questionnaire.

The ESS is a self-administered questionnaire built on eight key questions. It asks patients questions about their levels of daytime sleepiness while engaged in eight different activities. These activities range from sitting and reading, watching television, sitting in a public place, riding in a car as a passenger and lying down, to sitting and talking with someone, sitting after a meal without alcohol consumption and sitting in a stopped car in traffic. Questions are ranked from 0-3. The higher a patient’s overall ESS score, the more likely their average sleep propensity in daily life (ASP) is high, which can signal a potential sleep disorder that prompts further evaluation.

The STOP-Bang Questionnaire digs deeper into potential inpatient and outpatient medical issues such as blood pressure, breathing issues, BMI, birth gender, and more to gain a more precise assessment and objective data on a patient’s overall health risks.

There also is another useful sleep disorder screening tool, known as the POPPY Study, an acronym for the Pharmacoki-

netics and Clinical Observations in People Over Fifty Study. Often used to screen for comorbidities in patients over 50 with or without HIV infection, the POPPY Study takes into account quality of life and is also used to more broadly evaluate factors such as the prevalence of Restless Legs Syndrome, insomnia and sleep apnea.

These scales are valuable not only for specialists, but for primary care providers who may know about other patient conditions and complaints that can serve as guides for sleep disorder diagnoses. EARLY RECOGNITION OF SLEEP DISORDERS CAN IMPROVE PATIENT OUTCOMES

With an understanding of sleep disorder diagnosis tools and their associated rankings, providers — from general practitioners to specialists — can make more precise data-driven health assessments when forming patients’ treatment plans and gauging the potential need for more advanced care.

Solving for more than a ‘bad night’s sleep’ or loud snoring, the use of tools, such as the ESS, BANG-Stop and POPPY Study, serves to fill in the blanks of sleep disorders and their possible connections to more serious cardiopulmonary comorbidities, even in patients with unreported sleep disturbances. Consider working these tools into your practice. And, if in doubt, contact a pulmonary sleep specialist to help rule out or establish the presence of a life-threatening cardiopulmonary cause of sleep disturbances.

Orlando Ruiz-Rodriguez, MD, FCCP, is a board-certified pulmonary/critical care/sleep medicine specialist with Orlando Health Medical Group Pulmonology and Sleep Medicine. He specializes in pulmonary, critical care and sleep medicine. He also provides critical care to patients with critical medical illness and acute or life-threatening pulmonary conditions. Dr.

Ruiz may be contacted at (321) 841-7856. 

Check out our redesigned website at www.floridamd.com!

What Does Your Branding Say About Your Medical Practice?

By Sonda Eunus, MHA, CMPE

Your brand is the identity that you create for your practice. It is crucial to identify the core values that you want your brand to represent, because this is how it will be perceived by your target audience and the community at large.

Here are some questions to consider when building your brand:

• How do you want your practice to be perceived? • What core values do you hold most important to your WHY? • What does your brand look like? Colors, fonts, and shapes matter. • What does your brand sound like?

When choosing your brand colors, be aware of the following color associations:

• Red — Red stands for passion, excitement, and anger. It can signify importance and command attention. • Orange — Orange stands for playfulness, vitality, and friendliness. It is invigorating and evokes energy. • Yellow — Yellow evokes happiness, youth, and optimism, but can also seem attention-grabbing or affordable. • Green — Green evokes stability, prosperity, growth, and a connection to nature. • Light Blue — A light shade of blue exudes tranquility, trust, openness. It can also signify innocence. • Dark Blue — Dark blue stands for professionalism, security, and formality. It is mature and trustworthy. • Purple — Purple can signify royalty, creativity, and luxury. • Pink — Pink stands for femininity, youth, and innocence. It ranges from modern to luxurious. • Brown — Brown creates a rugged, earthy, old-fashioned look or mood. • White — White evokes cleanliness, virtue, health, or simplicity. It can range from affordable to high-end. • Gray — Gray stands for neutrality. It can look subdued, classic, serious, mysterious, or mature. • Black — Black evokes a powerful, sophisticated, edgy, luxurious, and modern feeling.

(www.99designs.com)

WHAT IS YOUR BRAND’S PERSONALITY?

Think of your Business brand as a person. What is this person’s personality like? How does he or she dress, talk, and act in public? Here are just a few examples of a personality that your brand may have: • Serious and Professional • Warm and Friendly • Cool and Quirky • Funny and Playful

However, you choose to represent your brand, make sure that it is authentic to who you are. For example, if you are playful and like to crack jokes, infuse your marketing with humor and you will find that people respond positively to jokes, memes, and quotes that are applicable to them. For example, for pediatric practices, we have found that moms just can’t get enough of memes that make fun of their kids! You can add some (goodnatured) jokes and memes to your social media posts and you will see some great engagement.

Similarly, if you want your brand to be viewed as serious and professional, you will want to consistently share valuable and informative content that educates your audience. You can choose to do so by looking for speaking opportunities to help build credibility and position you as the expert in your field, making educational videos and sharing them on your website, Youtube, and social media, or by writing educational articles and contributing to reputable publications.

If you’re going for warm and friendly, you will want to be seen engaging with your social media followers, being active in Facebook groups and other online groups, hosting community events, supporting great causes, etc.

If cool and quirky is your thing, you want to stand out from your competitors. You can use some colors that are not typical for your industry, create and share some fun videos, such as “funny (HIPAA-compliant) things that patients say”, paint your waiting room to inspire awe upon arrival, etc.

Keep in mind that for any brand personality, it is important to keep it consistent across your website content, social media posts, marketing materials, and any other communication that you may have with your audience.

Sonda Eunus is the Co-Founder of Pro Medical Marketing – an Internet Marketing Agency specializing in Medical practices. She has a Masters’ in Healthcare Management and is a MGMA Certified Medical Practice Executive. She has been heavily involved in operating her family’s Pediatric practices from an early age. She is passionate about helping medical practices grow and does so by sharing her experience in her writing, speaking, and consulting. Learn more about Sonda and Pro Medical

Marketing at www.promedicalmarketing.com. 

Not All Basal Cell Carcinomas Are Created Equal

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

Occasionally a patient will tell me their “doctor friend” recommended that they don’t need treatment for a basal cell carcinoma because it will never hurt you. “Doc, he said it’s only a basal cell carcinoma.” Dermatologists fully recognize this as a genuinely cringe-worthy statement. You don’t need to see too many people missing various parts of their facial anatomy to know this advice is blatantly wrong. Even in this modern time of medical miracles, people still die from neglected basal cell carcinomas. When pressed for the name of their “doctor friend,” it usually comes up as I don’t remember their name, or it ends up being “Doctor Google.”

It is true a superficial basal cell carcinoma on the torso probably would take years and years for it to cause any sort of significant morbidity to a patient. But, on the other hand, even a small basal cell on the torso will continue to grow if left untreated slowly. What might have been a simple, inexpensive procedure now, a decade later, has turned into a monster of aggravation, discomfort, and cost.

Although metastatic disease risk is low with basal cell carcinomas, it is certainly not zero. Several people die each year from basal cell carcinoma. Even more, patients can have disfiguring bouts with cancer losing various parts of anatomy such as nose, ears, eyes, etc. What a lot of patients and even some physicians are not aware of is that not all basal cell carcinomas are created equal. There are several different histologic growth patterns. These varying histologic types can each behave differently and require different treatment plans. As mentioned before, a superficial basal cell carcinoma is probably not going to cause a great deal of physical damage unless neglected for long periods. There are other types of basal cell carcinomas; morpheaform and sclerosing basal cell carcinomas with infiltrating growth patterns. These cancers left untreated can cause a significant amount of morbidity in shorter periods measured in months, not years. Aggressive basal cell cancers can also become neurotropic, meaning that they “wrap” around a nerve and can track down its Pathology of an infiltrative basal cell carcinoma. length. Neurotropism can be particularly dangerous, especially if this is on the face and affecting a nerve that happens to pass through a foramen into the brain. Clearly, not a good scenario. Basal cell carcinomas, limited to the skin, tend to be very amenable to treatment in a variety of different ways. Even as a Mohs surgeon I can think of at least half a dozen different ways that I have treated basal cell carcinomas. Not all basal cell carcinomas need Mohs surgery. Each case of basal cell carcinoma should be evaluated individually and in consideration as to the best method of treatment based on its histologic growth pattern, location, and physical condition of the patient. The great news about basal cell carcinoma, even though it is the most common type of skin cancer and millions are treated each year, only a tiny percentage of these end up causing death in patients. When someone says I would much rather have a basal cell carcinoma than a melanoma, there is a caveat; if you die from a basal cell carcinoma, you are just as dead as if you were to die from melanoma. Happily, most of the time, with early diagnosis and treatment, you don’t have to die from either. Basal cell carcinoma is called cancer for a reason. Give it its respect that it is due, or otherwise, you may regret saying, “oh, you don’t have to worry about it, it’s only a basal cell carcinoma.”

Infiltrative Basal Cell carcinoma of the forehead. Superficial Multifocal BCC. Sclerosing basal cell Neurotropic basal cell carcinoma. carcinoma. Nodular basal cell carcinoma.

Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John

Meisenheimer, VII is a medical student at USF. 

Infantile Scoliosis

By: Joseph G. Khoury, MD

WHAT IS INFANTILE SCOLIOSIS?

Infantile Scoliosis is a curvature of the spine that develops during the first few years of a patient’s life with no structural abnormalities of the spine. The child is not born with scoliosis. There is likely to be a subtle underlying genetic abnormality in the structure of collagen, but the exact cause is not yet known. This is combined with environmental factors such as back sleeping and hypotonia/hypomobility in the first months of life which leads to the curvature. WHAT MAKES INFANTILE SCOLIOSIS DIFFERENT FROM OTHER KINDS?

Children in the first few years of life are growing at nearly twice the rate of those in their adolescent growth spurts. Scoliosis worsens with growth. Therefore, because of the rate of growth and large amount of growth remaining, the potential for curve progression into a very severe range is higher with infantile scoliosis than with adolescent scoliosis. In addition, the alveoli are still multiplying and growing during this period of growth so the potential for infantile scoliosis to affect lung function is very high. With severe curves, cardiac functional can also be affected (cor pulmonale). Also, this type of scoliosis is often noticed much later, and curves can be improperly attributed to poor trunk control or simply dismissed by health care providers as developmental variations that the child will outgrow. WHAT IS THE TREATMENT FOR INFANTILE SCOLIOSIS?

Unlike adolescent scoliosis, infantile scoliosis can be treated with casting, rather than bracing, to reduce the size of the curve or even cure many curves completely. This type of casting is called Mehta casting after the doctor who popularized this technique. This is only possible because of the rapid rate of growth in the first few years of life. If children are referred promptly to a physician with experience in Mehta casting, the chances of reducing or curing the curve are much higher. Mehta casting first became available in the United States in 2004 when the mother of a patient with Infantile Scoliosis noticed the excellent results reported by Dr. Mehta in the United Kingdom and requested this treatment be done for her child. This mother funded a trip by Dr. Mehta to the United States to teach several physicians who then spread the knowledge and techniques to others. Before this, treatment in the United States often consisted of bracing or sometimes Risser casting, both of which were far less effective and often resulted in early surgery called “growing rod surgery” (figure 4). WHAT ARE THE RESULTS OF MEHTA CAST TREATMENT?

If casting begins before 18 months of age, the chances of curing the curve completely are 75%. The cure rate drops to 35% for patients between 18 and 36 months and 23% for those over 36 months of age at the beginning of treatment. For those who are not cured, many experience significant reductions in the size of the curve and therefore respond better to bracing and/or experience significant delays to growing rod surgery. Early referral to a Mehta trained physician is critical to get the best results. Even for those that are detected and referred later, significant benefits are experienced but the best results come from early detection and referral. WHAT IS MEHTA CASTING LIKE FOR THE CHILD AND FAMILY?

It is definitely not easy to be in a Mehta cast. The cast is applied under general anesthesia every 2-3 months depending on age. The cast cannot get wet. There are only a few days break between removing a cast and applying the next one so that the curve doesn’t have a chance to relapse. Bathing must be done with wash clothes or wipes. Hair must be washed in the sink. There is a robust support community of other parents that help the new patients get adjusted and helps answer other questions.

Despite these hardships, young children are very resilient and adapt quickly to the cast. These children run and play with other children very soon after adapting to the cast. WHAT IS THE TAKEAWAY MESSAGE?

Scoliosis screening should be a part of every well child evaluation regardless of age. It is frequently included for older children (forward bending test) but not considered part of the newborn or infantile well child visits. This can easily be accomplished by

laying the newborn prone across the examiners lap to look at the spine and can take just 5 seconds. Any curvature noted or certainly any concern on the part of the parent should prompt a referral to a Mehta casting trained specialist or at least a supine AP scoliosis X-ray should be obtained because early detection and referral are key to the success of treatment.

Case Study: This patient was referred to me at 13 months of age with a 33-degree curvature which was first noticed by his parents at 10 months of age (figure 1). Mehta casting was initiated immediately. His first in cast x-ray shows partial improvement of the curve in cast (figure 2). His final in cast x-ray shows near complete resolution of the curve (figure 3). This patient was able to avoid early growing rod surgery and its associated complications. He will likely wear a brace part FIGURE 1 FIGURE 2 FIGURE 3 time throughout his growing years, but he is likely to be able to avoid surgery completely because of his early referral.

Example of growing rod surgery (figure 4). Implants are present at the top and bottom only to avoid early fusion of the spine which will result in loss of spinal growth. The implants need to be lengthened at the overlapped connector section every 6 months throughout growth until the patient is old enough for a final fusion surgery. FIGURE 4