The Health Records Challenge of 2015

The Health Record for 2015 Challenge requested that a cost-effective, platform-agnostic electronic health record system be conceived to enable patient fill in registration information themselves on a tablet. The caveat was that such liberty given to patient must not compromise database security or integrity. 

A simple solution to this challenge, as conceived by me is as follow:

1. The back end of the database is Apache server and MySQL. PostgreSQL is an alternative option. For this experiment, I used XAMPP combo. 

2. The front end of the database is html pages interacting with the server through PHP. 

3. Now the tricky part is bringing in the tablet interface to input the data. A simple solution is to use VNC apps communicating via WiFi to 'share' desktop interface. This is like extending a longer hand to the patient to work on the desktop using the computer. The privileges set for the desktop is what is assessed. 

The attached video is a demo of this simple concept:

http://m.youtube.com/watch?v=JmRUOj-nyw0 

Will 3D Printing Significantly Affect our Life & Health?

I spent the last few days (of Xmas holiday) exploring the roles the mobile technology is playing in our health / wellness. Specifically, using my 1-month old iPhone 6 plus (128Gig), I downloaded and tried out a couple of mobile Apps that claimed to be designed to measure Pulse rate, Blood Pressure, and hearing loss. I was amazed at the ingenuity app developers put into making otherwise complicated gadgets for vital signs and hearing loss measurement much simpler using deeper familiarity with how mobile phone hardwares work. And then it was Xmas and people are jokingly asking friends and acquaintances to email / FB / Tweet their Xmas cakes. And then reflecting on the recent news of 3-D Printing of anatomical parts (calvarium, false teeth, hip and knee replacement prosthesis, and ceramic jaws, among others) and juxtaposing that on another more recent news of astronauts on the ISS making a 3-D printed wrench from the email specifications sent from ground station, simply put everything together like missing parts of a jigsaw puzzle: 2015 is likely going to be a year in which the expression 'emailing / Facebooking / Tweeting Xmas or BDay cakes' may move away from the realm of cursory jokes to reality. 

    

References:

1. The Guardian Sunday 24 August 2014. (theguardian.com)

2. NASA Makes 3D Printed Wrench Model Available. (science.slashdot.org )

3. 3D Printing - Wikipedia. en.wikipedia.org 

Can your neck pain make everywhere "spinny"

While the influence of neck position on equilibrium  has been known and documented since 1800s, it is often difficult to assume any relationship in situations of neck pain or stiffness associated with dizziness. 

That was until 1955 when Ryan & Cope described a syndrome of disequilibrium and disorientation in patients with many different diagnoses of neck pathology including cervical spondylosis, cervical trauma, and cervical arthritis. They labelled this syndrome cervical vertigo. 

A flurry of publications on cervical vertigo was to follow. The argument for the existence of this diagnosis was premised on the fact that Proprioceptive input from the neck participates in the coordination of eye, head, and body posture as well as spatial orientation. 

However, the interesting fact is that true spinning vertigo is rarely associated with this disease,making some worker to suggest alternative diagnosis of cervicogenic dizziness for this condition. 

Also interesting is the fact that  while some entities previously defined as cervical vertigo have survived the test of time and may be found in the literature today for example  rotational vertebral artery syndrome, post-traumatic cervical vertigo, and cervicogenic proprioceptive vertigo, others such as cervical sympathetic syndrome (Barré-Lieou syndrome), have been discredited. 

It was also subsequently elaborated that since neck contains mechanisms directly involved in balance control (neck afferents), cardiovascular control (carotid bodies), and purely vascular structures (carotid and vertebral arteries), and since neck movements are also invariably associated with head movements, then perhaps experiencing unsteadiness or vertigo associated with neck movements could be due to a disorder in vestibular, visual, vascular, neurovascular, or cervicoproprioceptive mechanisms.

The interesting aspect of this exposition is that currently there is no consensus concerning how one diagnoses cervical vertigo, and the literature is replete with poorly carried out studies as well as studies containing strange suggestions regarding mechanism or treatment.

As such the publications on "cervical vertigo" has plummeted in the last half decade. 

         

References:

1. J Neurol Neurosurg Psychiatry 2001;71:8-12 doi:10.1136/jnnp.71.1.8

2. Neurologia. 2012 Sep 13. pii: S0213-4853(12)00211-3. doi: 10.1016/j.nrl.2012.06.013

3. Cervicogenic Dizziness. http://vestibular.org/cervicogenic-dizziness

4. Cervical Vertigo. http://www.dizziness-and-balance.com/disorders/central/cervical/cervical.html 

Will HNS replace CPAP in OSAS?

Obstructive sleep apnoea syndrome (OSAS) is characterized by repeated episodes of pharyngeal obstruction during sleep, including airway collapse or narrowing resulting in recurrent airflow cessation. 

Identified risk factors include obesity, male sex, Craniofacial and upper airway anomalies, increasing age, and alcohol consumption. 

Traditional  approach to treating OSAS focused on weight reduction (occasionally easy to prescribe, but hard to comply with), removal of obstructive airway lesions (adenotonsillectomy), palatal implants, mandibular advancement surgery (for retrognathia), our own UPPP (uvulopalatopharyngoplasty)  and of course the popular (GPs) option - the CPAP. The interesting fact is compliance rate with CPAP is just about 40-60% (can you stand mask and tubes coming between you and your spouse while on bed?). 

Recent interest in OSAS focuses on genioglossus muscle as therapeutic target, for simple reason: if you get the tongue out of the way, the oropharyngeal airway blockage is removed. 

Devices that stimulate this muscle directly were demonstrated to improve disease severity in OSAS sufferers. However, the interesting aspect is that such direct stimulation would often arouse the patient!!!

This led to the choice of targeted electrical stimulation of the hypoglossal nerve which is directly motor to the genioglossus fibers, with little or no sensory innervation. 

The Hypoglossal Nerve Stimulation (HNS) system is currently undergoing trials in several countries and may be the next interesting toy for treatment of OSAS, though its current cost puts it far beyond the reach of all but very endowed OSAS cases with mild to moderate ( not severe) OSAS. Maybe for severe OSAS, we are stuck with CPAP for some time to come!!!

References:

1. Health Policy Advisory Committee on Technology - Technology Brief: hypoglossal nerve stimulation for sleep apnoea. http://health.qld.gov.au/healthpact/docs/briefs/WP097.pdf

2. Cure Opin Pulm Med. 2011;17(6):419-424

Confusion from Ear-Brain Dissociation

Auditory neuropathy spectrum disorders (ANSD) is an interesting relatively recent diagnosis whose recognition was made possible by advances in electrophysiologic acoustic measurement, specifically the ABR and the OAE. However the interesting fact was the first audiologic description of ANSD was believed to be by Hinchcliffe et al in 1972, six years before Kemp described Otoacoustic emissions. 

ANSD is characterized by normal OAES, presence of cochlear microphonics, absent middle ear muscle reflexes at 95 dB and below, and abnormal ABR. In simple terms, the brain in ANSD appears to be detached from the auditory pathway and /or the inner ear appears not to communicate with the auditory nerve (depending on the variant). 

ANSD is believed to consist of variant of disorders with lesions in either of several locations - inner hair cells, inner hair cell-auditory nerve synaptic junctions and the ascending auditory neuron. 

The other interesting aspect is in the nomenclature itself. A neuropathy usually refers to a disease of the peripheral nerve or nerves, but the auditory nerve itself is not always affected in Auditory Neuropathy Spectrum Disorder (ANSD). Also while the pure tone audiometry finding may vary from normal to near normal, there is consistent difficulty in perceiving speech in ANSD. 

Also referred to as auditory dyssynchrony, numerous risk factors reportedly associated and varying clinical presentation characterizing ANSD make the management options also as varied and controversial. Hearing aids and cochlear implants have been prescribed for ANSD with mixed outcome. Current effort is geared towards developing animal models that can precisely replicate findings in ANSD cases to assist further understanding and better management approach. 

References:

1. Auditory Neuropathy. Emedicine. http://emedicine.medscape.com/article/836769-overview 

2. Multi site diagnosis and managent of 260 patients with ANSD. http://csd.cbcs.usf.edu/an/Berlin_ANSD.pdf 

Ssssooo Mmmmmumumuch To Tttttalk Abababout

Normal speech production involves a balanced coordination between muscle movements involving breathing, phonation (voice production), and articulation (movement of the throat, palate, tongue, and lips). The speech cycle essentially incorporates input (hearing, vision, proprioception), central processing (receptive and expressive speech areas of the brain) and output (phonation, articulation and resonation). 

The precise mechanism of what led to stuttering is unknown but has long been thought to be disorder of the central speech processing. The advent of advanced imaging techniques  like PET Scan and functional MRI in investigation of stuttering revealed interesting facts that people who stutter show  hypoactivity in cortical areas associated with language processing, such as Broca's area, but hyperactivity in areas associated with motor function. 

A puzzling aspect of stuttering is the various conditions which can temporarily alleviate dysfluency in most cases: the rhythm effect (speaking to the pace of a metronome), singing (remember the dude at just-ended American Idol season?), chorus speech, and altered auditory feedback.  Another interesting aspect of stuttering is that in some sufferers, there is spontaneous resolution either during childhood, or even during adult life! But we currently have no clue as to in which subject stuttering will spontaneously resolve. Another interesting fact is that this recovery can be induced by therapy in few cases. Both spontaneous and assisted recoveries also appear to be heritable. More interesting still is  that children with early onset of stuttering tend to show precocious language development.

Stuttering, long thought to be largely psychogenic is now believed to consist of 3 types - developmental, neurogenic and functional. 

Further Readings:

1. Journal of Communication Disorders 37 (2004) 325–369

2. Stuttering 

http://www.medicinenet.com/stuttering/article.htm

3. How the brain repair stuttering. http://m.brain.oxfordjournals.org/content/132/10/2747.long 

Stop that Q-tip, Please!

It is commonplace for clinicians to counsel patients against use of cotton buds or Q-tips to clean the ear. 

The reason for such advice lies in the unique situation of the epidermis lining the external ear canal. 

Whilst epidermis lining the surface of skin elsewhere in the body is subjected to friction (surface contact) to remove keratinocytes that have desquamated from the surface stratum corneum, evolution of deeper ear canals in land animals for protection of tympanic membrane presents a challenge for achieving that 'shedding of skin'. 

This implies an alternative mechanism  of removal of the superficial layer of stratum corneum of the tympanic membrane and the protected deep portion of EAC. 

The interesting fact is that while skin cells elsewhere migrate vertically from the dermis to the epidermis (epithelial maturation), the ear canal skin, in addition, works like a 'conveyor belt' migrating the skin cells from the center of ear drum (tympanic membrane) outwards along the ear canal. This rate of this 'conveyor belt' motion is timed to coordinate rate of normal epithelial maturation. 

Hence the instruction on the box of Q-tip: only use around outside of ear canal. 

Reference:

1. An Ode To Ear Wax. http://variationselectioninheritance.podbean.com/2012/03/10/episode-35-an-ode-to-earwax/

2. Physiology of The Ear. Google Books. http://books.google.co.uk/books?id=giFuKH5u7O0C&pg=PA30&lpg=PA30&dq=ear+canal+skin+migration+evolution&source=bl&ots=x-RdGPxYrE&sig=9_oRdcdtA-cFjv-ZfZxcitlad28&hl=en&sa=X&ei=97rGUfa0AebE0QW7w4D4Cw&ved=0CCoQ6AEwAA