New Clinical Practice Guidelines Issued for Tonsillectomy

The American Academy of Otolaryngology & Head and Neck Surgery (AAO-HNS) has issued new which states most children with frequent throat infections do not need tonsillectomy surgery.

The practice guidelines is published in the January issue of – Head and Neck Surgery.

Click here to read the full article.

The AAO-HNS is the world’s largest organization representing specialists who treat the ear, nose, throat, and related structures of the head and neck. The Academy represents more than 12,000 otolaryngologist—head and neck surgeons (ENTs) who diagnose and treat disorders of those areas.

The guidelines was developed using a systematic literature search which was condensed into evidence-based statements with associated balance of benefit and harm. The guideline panel members were chosen to represent fields of sleep medicine, advanced practice nursing, anesthesiology, infectious disease, family medicine, otolaryngology–head and neck surgery, pediatrics, and consumers.

The panel notes “Guidelines are never intended to supersede professional judgment; rather, they may be viewed as a relative constraint on individual clinician discretion in a particular clinical circumstance.”

The guideline panel recommendations—

1. Watchful waiting for recurrent throat infection: Clinicians should recommend watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years.

2. Recurrent throat infection with documentation: Clinicians may recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and one or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A β-hemolytic streptococcus (GABHS).

3. Tonsillectomy for recurrent infection with modifying factors: Clinicians should assess the child with recurrent throat infection who does not meet criteria in Statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of peritonsillar abscess.

4. Tonsillectomy for sleep-disordered breathing: Clinicians should ask caregivers of children with sleep-disordered breathing and tonsil hypertrophy about co-morbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems.

5. Tonsillectomy and polysomnography (sleep study): Clinicians should counsel caregivers about tonsillectomy as a means to improve in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing.

6. Outcome assessment for sleep-disordered breathing: Clinicians should counsel caregivers and explain that SDB may persist or recur after tonsillectomy and may require further management.

7. Intraoperative steriods: Clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy.

8. Perioperative antibioticse: Clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy.

9. Postoperative pain control: The clinician should advocate for pain management after tonsillectomy and educate caregivers about the importance of managing and reassessing pain.

10. Posttonsillectomy hemorrhage (bleeding): Clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually.

Source reference: ”Clinical Practice Guideline: Tonsillectomy in Children” Otolaryngoly Head Neck Surg 2011

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Braebons Sleep Sensor Technology Can Make or Break!

Braebon Medical Corp Founder Don C. Bradley has created several sleep diagnostic products, and he always starts with a fundamental question: Is what you see on the screen an accurate reflection of what is physiologically going on? If you can’t trust your equipment, says Bradley, you have a fundamental problem.

Sensors are the primary technology for obtaining signals and they must accurately reflect the physiological event being measured. When sensors are plugged into a PSG system, some technicians are simply hoping the filters and sampling rates are set right and that the sensor is working.

There are many technologies and methods for measuring airflow: pressure sensors; thermal sensors; and to name three. Whatever the method, Bradley contends that quality matters. “I could go out and buy the cheapest pressure sensor, and then I could buy a more expensive one,” says Bradley. “If you put a cannula on the patient and feed it simultaneously to both pressure sensors, you will see two totally different signals—yet people think if it is a pressure sensor, they are measuring accurately.”

In fact, the signal from the lower quality unit will be heavily filtered, as well as baseline shifted, leading to inferior and possibly inaccurate information—which in turn can lead to a poor diagnosis. On the other hand, more expensive sensors may yield a more realistic representation, but require more initial effort to set up on the PSG system. “This isn’t necessarily always the case,” cautions Bradley. “It just goes to show that you need to understand the technology being used and see if you are getting the signals you want.”

Inaccurate data collection during the sleep study causes a domino effect that wastes time. Manufacturers can halt this chain reaction through renewed efforts to educate technicians about what is really going on with their devices.

For more information about sensors, click Sensors_Braebon

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General Anesthesia is Pharmacological Coma, not Sleep

Instead of a deep , general anesthesia is more like a reversible drug-induced coma.

“General anesthesia is pharmacological coma, not ,” said Dr. Nicholas Schiff of Weill Cornell Medical College in New York, who worked on the study with Dr. Emery Brown of Massachusetts General Hospital and Dr. Ralph Lydic of the University of Michigan.

Their findings, published in the New England Journal of Medicine, represent a three-year exploration of the similarities and differences of , anesthesia and coma. They said while doctors and patients commonly describe general anesthesia as going to , there are significant differences between the states, with only a bit of overlap between the deepest states of and the very lightest phases of anesthesia. While sleeping usually involves moving through a series of phases, in general anesthesia, patients are typically taken to a specific phase or state and kept there.

The use of general anaesthesia is a routine part of surgical operations at hospitals and medical facilities around the world, but the precise biological mechanisms that underlie anaesthetic drugs’ effects on the brain and the body are only beginning to be understood. A review article in the December 30 New England Journal of Medicine brings together for the first time information from a range of disciplines, including neuroscience and medicine, to lay the groundwork for more comprehensive investigations of processes underlying general anaesthesia.

‘A key point of this article is to lay out a conceptual framework for understanding general anaesthesia by discussing its relation to and coma, something that has not been done in this way before,’ says Emery Brown, MD, PhD, of the Massachusetts General Hospital (MGH) Department of Anaesthesia, Critical Care and Pain Medicine, lead author of the NEJM paper. ‘We started by stating the specific that comprise general anaesthesia – unconsciousness, amnesia, lack of pain perception and lack of movement while stable cardiovascular, respiratory and thermoregulatory systems are maintained – another thing that has never been agreed upon in the literature; and then we looked at how it is similar to and different from the states that are most similar – and coma.’

After laying out their definition, Brown and his co-authors – Ralph Lydic, PhD, a expert from the University of Michigan, and Nicholas Schiff, MD, an expert in coma from Weill Cornell Medical College – compare the physical signs and electroencephalogram (EEG) patterns of general anaesthesia to those of . While it is common to describe general anaesthesia as going to , there actually are significant differences between the states, with only the deepest stages of being similar to the lightest phases of anaesthesia induced by some types of agents.

While natural normally cycles through a predictable series of phases, general anaesthesia involves the patient being taken to and maintained at the phase most appropriate for the procedure, and the phases of general anaesthesia at which surgery is performed are most similar to states of coma. ‘People have hesitated to compare general anaesthesia to coma because the term sounds so harsh, but it really has to be that profound or how could you operate on someone?’ Brown explains. ‘The key difference is this is a coma that is controlled by the anaesthesiologist and from which patients will quickly and safely recover.’

In detailing how different anaesthetic agents act on different brain circuits, the authors point out some apparently contradictory information – some drugs like ketamine actually activate rather than suppress neural activity, an action that can cause hallucinations at lower doses. Ketamine blocks receptors for the excitatory transmitter glutamate, but since it has a preference for receptors on certain inhibitory neurones, it actually stimulates activity when it blocks those inhibitors. This excess brain activity generates unconsciousness through a process similar to what happens when disorganised data travels through an electronic communication line and blocks any coherent signal. A similar mechanism underlies seizure-induced unconsciousness.

Brown also notes that recent reports suggest an unexpected use for ketamine – to treat depression. Very low doses of the drug have rapidly reduced symptoms in chronically depressed patients who had not responded to traditional antidepressants. Ketamine is currently being studied to help bridge the first days after a patient begins a new antidepressant – a time when many may be at risk of suicide – and the drug’s activating effects may be akin to those of electroconvulsive therapy.

Another unusual situation the authors describe is the case of a brain-injured patient in a minimally conscious state who actually recovered some functions through administration of the -inducing drug zolpidem (Ambien). That patient’s case, analysed previously by Schiff, mirrors a common occurrence called paradoxical excitation, in which patients in the first stage of general anaesthesia may move around or vocalise. The authors describe how zolpidem’s suppression of the activity of a brain structure called the globus pallidus – which usually inhibits the thalamus – stimulates activity in the thalamus, which is a key neural control centre. They hypothesise that a similar mechanism may underlie paradoxical excitation.

‘Anaesthesiologists know how to safely maintain their patients in the states of general anaesthesia, but most are not familiar with the neural circuit mechanisms that allow them to carry out their life-sustaining work,’ Brown says. ‘The information we are presenting in this article – which includes new diagrams and tables that don’t appear in any anaesthesiology textbook – is essential to our ability to further understanding of general anaesthesia, and this is the first of several major reports that we anticipate publishing in the coming year.’

Schiff adds, ‘We think this is, conceptually, a very fresh look at phenomena we and others have noticed and studied in , coma and use of general anaesthesia. By reframing these phenomena in the context of common circuit mechanisms, we can make each of these states understandable and predictable.’

Source: Massachusetts General Hospital

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Graymark Healthcare Treats Record Number of Patients in Q4 2010

Q4 2010 Sleep Apnea Re-Supply Orders up 75% Over Q4 2009

Graymark Healthcare Inc, the nation’s second largest provider of diagnostic sleep services and an innovator in comprehensive care for obstructive sleep apnea (OSA), serviced a record number of OSA patients in the fourth quarter of 2010, with a 16% increase in set-ups and a 75% increase in re-supply shipments, as compared to fourth quarter of 2009.

Graymark specializes in the diagnosis and treatment of sleep apnea, which is characterized by abnormal pauses in breathing during sleep where each pause or “apnea” can last from a few seconds to minutes, and can occur from five to more than 30 times per hour. OSA is the most common form of sleep apnea, where the soft tissue in the airway obstructs breathing. OSA correlates highly with stroke, cardiac disease, obesity and other conditions that lead to early death and morbidity. However, 80% of patients affected by OSA go completely undiagnosed and patient treatment compliance is often a challenge.

In an effort to improve clinical outcomes, Graymark has been pioneering better techniques to more quickly and effectively diagnosis and treat patients diagnosed with OSA. In the fourth quarter of 2009, Graymark Healthcare launched a new comprehensive care model to improve the conversion rate of OSA patients into successfully using a (Continuous Positive Airway Pressure) device.

Graymark’s effective five-step clinical approach to managing sleep disorders includes a convenient referral process, accurate and timely assessment, diagnosis, treatment and long-term follow-up to maximize patient compliance. All steps are managed by a board certified Sleep Medicine physician. By more completely integrating the diagnostic and treatment processes, Graymark has substantially improved patient compliance with care and overall disease management.

“There are many measures for patient compliance used in our industry, but the fact that our patients continue to buy supplies for their device is the best indicator they are using their device as intended,” said Stanton Nelson, chairman and CEO of Graymark Healthcare. “In 2010, we provided initial set-up for more than 3,000 OSA patients and shipped more than 6,400 re-supply orders.”

The Graymark Healthcare OSA therapy program ensures that patients are effectively supported in their initial use of a device and that challenges are addressed quickly and effectively to reduce rates of therapy abandonment. Similarly, the re-supply program provides regular follow-up care and ensures that disposable elements of the are cleaned and replaced consistent with manufacturer set schedules. Patients who are found not compliant with care are provided additional support to optimize their utilization of the device.

Source: Graymark Medical

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1-800-SLEEPLAB Ramping Up

A renewed commitment to a nationwide phone reference (1-800-SLEEPLAB) is just one of many projects on the Sleep Group Solutions (SGS) docket. Rani Ben-David, president of SGS, North Miami Beach, Fla, has an ambitious goal in the form of 1-800-SLEEPLAB, a work in progress that seeks to be the largest directory in the ever-growing sleep world that includes , , ENTs, dentists, and sleep physicians.

With lessons learned from 1-800-SNORING, a pilot project dedicated solely to the dental end, Ben-David hopes to be a first-call for consumers who need help. Depending on the zip code from where the call originates, inquiries would go straight to participating sleep professionals.

Sleep physicians who use SGS sleep interpretation and scoring services will also automatically be a part of the 1-800 directory. “Right now there is no one directory for everybody,” says Ben-David. “This one reference is designed to be the heart for everyone.” While the listing is for FREE the sleep labs and Physicians have the option to lease the 1-800 Sleep Lab number for the ZIP code they practice at for a very low fee.

Plans for 2010/2011 are simple: keep it going, spread the news, and take on even more projects. One such project is a partnership with Newport Beach, Calif-based Glidewell Dental Lab, which offers SGS an opportunity to double its number of educational seminars to about 80 per year.

Glidewell provides a lot of dental appliances in the vast metropolis of Southern California and throughout the world. “It’s a huge partnership because they do more than 3,000 sleep appliances per month,” enthuses Ben-David. “Those Doctors need the education, and it’s a perfect opportunity for two companies with integrity to come together for mutual benefit. Glidewell is one of the most reputable dental labs in the world.”

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