Hearing Loss 2020

Hearing Wellness Exposition – 2nd Edition   |   by Shirley A. Molenich, MD

As you are probably aware, Sertoma and Hearing Loss Association of America have joined together to do a series of programs on hearing loss for the general public for the past two years. Our third program will be on March 28, 2020, at the Tarrant County Medical Society from 9am to 1pm, with registration beginning at 8:30am.

In my last article I mentioned three of our speakers – Jed Grisel, MD (ENT), Terri Jo Edwards, AuD, and Marylyn Koler, MS, CCCA, AuD. At this event, we will discuss how the brain and ear work together, give new information on prevention/treatment, and review modern research. We are also going to discuss tinnitus, which is a difficult disease both in terms of cause and treatment. 

There is a great deal of research going on in the area of hearing disorders. More information is becoming available about many chronic health issues that play a role in hearing loss. There is significant new knowledge about genetic causes of hearing loss with over 140 related gene mutations identified. With these gene mutilations identified, basic scientific research has discovered the specific biological changes that occur, yielding information which may open up the avenue for treating hearing loss. There also continues to be increasing development of technical assistance.

There is a clear need for audiologists and physicians to work together to care for patients by identifying hearing loss issues earlier, which can lead to better results for patients. Basically, when auditory hair cells are damaged, neurons in the brain will atrophy axons along with the synapses, leading to hearing loss. This means that if a person gets hearing aids, they will require regeneration of the axons with new synapses. There are areas of research now on the theories of cognitive function and hearing.

We will discuss opportunities to help the hearing impaired with school, education, and vocational rehabilitation of hearing impairment, and new technology. 

“There is a clear need for audiologists and physicians to work together to care for patients by identifying hearing loss issues earlier.”

This will be our first program in which tinnitus is discussed. There has been research conducted by the National Center for Rehabilitative Auditory Research at the V.A. Portland Health Care System in Oregon, which was founded in 1997. Tinnitus has been one of their major areas of research. Basically, tinnitus is the experience of hearing sound (such as ringing or buzzing) without an external source. Part of the problem has been that tinnitus is a chronic condition without an existing reliable treatment. There are many protocols that have been tried, i.e. nutritional, pharmacological, surgical, deep brain transcranial electrical stimulation, sound, and transcranial magnetic stimulation, among others. The one treatment concept using sound therapy is Tinnitus Retraining Therapy, which has been the gold standard in coping with but not curing tinnitus. This technology works because the brain becomes habituated to it, so the tinnitus is no longer perceived as a negative and disruptive experience.  

We want to continue to educate the public about hearing disease and to reinforce new ideas and treatment options that are coming soon. We appreciate the help of the Tarrant County Medical Society in this endeavor. 

Sources 
Reviewing Tinnitus Research as an Educator, Veteran and Parent.
Oman Rodriguez – Hearing Health Foundation. Fall 2019, pp.26-28.
Tackling Tinnitus
James A. Henry, Ph.D – Hearing Health Foundation. Fall 2018, pp. 10-12.

Opinion – Life Support

Texas’ 10-day rule regarding life support works to prevent harm.

by Stuart Pickell, MD, FACP, FAAP

We have monitored the scenario surrounding infant Tinslee Lewis at Cook Children’s Medical Center for the last two months as it has moved the issue of the Texas Advance Directives Act in general, and the 10-day rule in particular, back onto the front burner.

While we agree with the Fort Worth Star-Telegram Editorial Board’s assertion that the law is imperfect, we do not agree that extending the 10-day period that hospitals have to find an alternative facility is the solution.

As technology has advanced, so have the options available to treat critically ill patients. For many patients, aggressive medical intervention is a life-saving bridge until their bodies can recover. But there is a point at which no amount of medical intervention will help. In fact, it may hurt.

For the last 40 years, healthcare facilities have increasingly relied upon ethics committees to aid them with the unenviable task of examining clinical situations in which medical technology contributes to a moral conundrum with no good options. The typical ethics committee consists of an interdisciplinary team of healthcare workers. The members are often employees of the institution but the panels also usually include community members who have no official relationship with the facility.

Families rarely insist on aggressive treatment that the medical team believes is non-beneficial or even harmful, but when they do, either party may request a formal hearing before the ethics committee. The committee’s objective is to hear the concerns of both and discern the ethical thing to do for the patient. If the panel decides to withdraw aggressive interventions that the family wants continued, the facility may invoke the advance directives law.

Texas’ law leverages the expertise of healthcare and ethics professionals to promote a deliberative process at the bedside, carefully considering the family’s desires for treatment in light of the medical realities to discern the best treatment options available for the patient. As medical professionals we have an imperative to honor our patients’ treatment desires.

While we sympathize with the Lewis family, their desire to continue aggressive interventions does not give them — or anyone — the right to demand treatment that violates the norms of the medical profession, the caregivers’ moral integrity or the long-standing ethical precept of “do no harm.”

Much of the criticism of the directives law focuses on the section that allows a health-care facility to discontinue life-sustaining treatment 10 days after giving written notice. During this time, the treating facility and the family seek to identify another facility willing to assume care. Despite opponents’ claims, 10 days is long enough.

Every case that gets to the point of invoking the law has been thoroughly vetted by the medical team in consultation with the family. When it becomes clear that an impasse is imminent, the search for an alternative facility begins, usually weeks before any formal hearing of the ethics committee.

The law allows a judge to grant an extension if more time makes it likely that another facility would be willing to accept the patient. It’s rare for a medical team elsewhere to disagree that care is futile. Even so, judges often grant extensions, especially in high profile cases.

But many families have not dealt with the gravity of their loved one’s condition, a reality they can no longer ignore once the 10-day rule is invoked. Extending the 10-day period will not lessen their grief or increase the likelihood of finding a facility willing to assume the patient’s care.

The Texas Advance Directives Act is imperfect, but this law, including the 10-day rule, is better than what we had before: actively dying patients with no hope of recovery subjected to indefinite pain and suffering because well-meaning loved ones were unwilling to let them go.

A longer waiting period will not bring hope to a hopeless situation; it will only prolong suffering. So, while we strongly advocate for initiatives to improve the health and well-being of Texans, extending the 10-day rule is not one of them.

Stuart Pickell, MD is chairman of the TCMS Ethics Consortium, a group that seeks to ensure the application of ethical principles in health care. He wrote this piece on the group’s behalf. Dr. Pickell is a member of Cook Children’s Medical Center’s ethics committee; this piece does not necessarily reflect that committee’s views.

This article was originally printed in the Fort Worth Star-Telegram.
Reprinted with permission.

Healthcare Heroes – Tom Rogers, MD

by Paul K. Harral, Fort Worth Business Press

Tom Roger’s dedication to his patients is legendary. In a 58-year career, he has always put his patients at the center of his focus, says nominator Stuart D. Flynn, MD, the founding dean of the TCU and UNTHSC School of Medicine.

“In addition, Tom has served as a mentor to countless TCU pre-medical students who have observed his skills and compassionate practice of medicine,” Flynn said.

Rogers graduated from TCU with a degree in biology in 1957 and earned his medical degree from the University of Texas Southwestern Medical Center in Dallas.

He lettered in baseball at TCU and was inducted into TCU’s Letterman’s Hall of Fame in 1999.

Rogers has received the Gold-Headed Cane Award from both the Tarrant County Medical Society and the Cook Children’s Physician Network, a mark of respect physician to physician dating to the 18th century.

“When the winds of uncertainty and disruption swirled in the 1990s, Dr. Tom Rogers came to the president and CEO of Cook Children’s, Mr. Russ Tolman, with a new idea,” Flynn said.

“He suggested that the Cook Physician Network move quickly to harness the loyalty and influence of the pediatricians in town as an essential part of the network. In a few months the first primary care groups had joined, and Dr. Rogers became the first chairman of the board. His foresight set precedent which has made the network an integral part of the Cook Children’s system.”

He served in multiple roles in local medical associations and organizations but Rogers was and is active in the community outside medicine.

He chaired the Fort Worth ISD’s Citizen’s Advisory Committee on Desegregation in 1990 and the Citizens Advisory Committee for Facilities Improvement Program in 1985, that passed and implemented a hugh bond issue.

“The committee supervised projects for the next years and these came in under budget and completed on time,” Rogers noted.

Other community service includes the Fort Worth Heart Association, the United Way, the March of Dimes, the Lena Pope Home, the Fort Worth Opera Association, the Fort Worth Symphony Orchestra, First United Methodist Church, a variety of roles at TCU, the Child Study Center, the Parenting Center and Schola Cantorum of Texas, where he was president of the board and a member of the chorus for 20 years.

Asked if there was a specific person who influenced his decision to become a physician, Rogers said he came from a non-medical family “so I really had no background to rely on.  I just admired the medical profession.”

That “non-medical family” part ended with him. He and his wife Joan started their own family tradition with a son, a daughter, a son-in-law and a daughter-in-law in practice. And now there are two grandsons in medical school.

“I think each of us looks for two primary ingredients in our health-care providers: First, we want someone who is competent, who will make the correct diagnosis and masterfully handle the ‘science’ of medicine. Second, and equally as important, we look for someone with the communications skills and compassion, a person who truly cares about us as human beings,” Flynn said. “Tom is the epitome of both. He is a personal Health Care Hero to many in Fort Worth.”

Q & A

Q Why do you do what you do?
A I’m a physician. I do it because I love helping people with my skills.

Q What inspires you during the tough times?
A My family, especially my wife. 

Q What’s your best advice for people wanting to enter the health care profession?
A Be willing to work hard and always put the patient first. 

Q If you could make one change that would improve health care for everyone, what would it be?
A In a dream world, be able to disregard cost.

Q Is there something else that we wouldn’t have known to ask?
A What I miss most in retirement is the daily connection with my families.  I am getting into sleeping until 7:30.

This article was originally published in The Fort Worth Business Press. Reprinted with permission.

Reel Recovery

by Norm Tremblay, MD

There it was staring me in the face . . . retirement. I wanted to stay useful to mankind and not just wander off into a blank horizon. I happened to befriend a fishing buddy Mike Emerson in the Fort Worth fly fishing club, and he encouraged me to look into an organization called Reel Recovery. 

What I discovered was a story that began with four avid fly fishermen on an outing in Colorado in 2003. One of them was dealing with a brain tumor. At the end of the day, he remarked that he enjoyed the day thoroughly and didn’t think of his cancer for the first time in six months! From this sprouted an organization that has spread to 21 states and New Zealand. 

I have successfully survived five different types of cancer and therefore had motivation to get involved. There were retreats that involved participants, fishing buddies, and staff personnel. I remarked to Mike that I was an “expert” fly fisherman and could start as a buddy, at which point he promptly put me in my place and made me start as a participant at a retreat in Oklahoma coordinated by Marty Weaver (a veteran of three military branches and a really neat guy). 

There we were . . .15 guys tough on the outside and terrified on the inside . . . all strangers. Half of us were “forced” to attend by spouses or other family members. Marty Deschner, a clinical psychologist from Dallas, began a series of six “Courageous Conversations.” We were instructed to speak from the heart and given the option to answer a series of initially benign questions such as our first car and fishing experience. The questions became more serious, involving our individual dealings with cancer. 

What followed was an amazing experience where these men, many for the first time, opened up and often broke down. We bonded with and supported each other and received support from our individual fishing buddies and staff members. Two of the highlights of the retreat were the vest ceremony (vests signed by past retreat participants from all over the country, some still fighting the battle and others gone away but still alive in the signatures) and the closing ceremony where final thoughts were shared among participants, buddies, and staff, and tearful farewells were absorbed into our memories. 

Since then, I have further engrossed myself as a buddy, medical director, assistant to my dear wife Cathy who is photographer at several retreats, and retreat coordinator. I was a buddy to a fine gentleman who was at the final stages of his battle. He was too weak to fish, so we spent two days enjoying the outdoors and discussing the afterlife and other metaphysical topics. It was his first time out of the house in six months, and his wife was eternally grateful for the three-day break from having to administer his medications every three hours. 

Mike and I were manning a Reel Recovery booth last year at Troutfest near New Braunsfels when a mother and her 23-year-old son inquired about the organization. The young man had recently been diagnosed with an aggressive form of cancer. I could see in his eyes that he was just beginning to deal with this and encouraged him to attend a retreat. He signed up for the Navasota retreat, and his 22-year-old brother who had a good basic knowledge of fly fishing signed up as his fishing buddy. They both displayed tremendous courage and enjoyment throughout the retreat, caught the biggest bass, and showed us heartwarming gratitude that persisted through his family after his passing away three months later. The toughest ones are the most rewarding.

Reel Recovery exists in 21 states and New Zealand, and there are plans to expand to Canada and Australia. There are only three paid positions in the United States, and more than 600 volunteers (88 percent of donations go directly to these guys!). In Texas, we run six retreats each year in the spring and fall. Two are at Arrowhead Camp near Glen Rose, two at Camp Capers near San Antonio (one is for veterans with cancer), and two at Camp Allen near Houston. All expenses except transportation to and from the retreat are covered, and we try to carpool somehow when transportation is an issue. 

We raise funds through donations as a 501(c) (3), and we have an annual live and silent auction scheduled this year on Wednesday, May 13th, 2020, at the Firestone and Robertson Distilling Corporation (“Whiskey Ranch”). You can get involved in many ways: refer your oncology patients to our website (see below) to sign up for a retreat and help them sign the medical release form shortly before the retreat; be a participant if you qualify (it’s an unforgettable experience); donate through our website( see below) or come to our annual auction (the auction items are cool!); volunteer as a staff member or buddy; buy some gear at our website (see below); you can even tie flies for warm water fishing since we are in constant need of flies. Above all, spread the word about us. We have no advertising budget so we depend on word of mouth.

Our website is reelrecovery.org. For questions you can call me at
(817) 271-5482 or email me at
tremblay.reelrecovery@gmail.com. You can also contact Mike Emerson, our State Coordinator at 817-8947832 or at his email emerson.reelrecovery@gmail.com

Thanks for staying awake through this and catch a world record dose of good health! 

“There we were… 15 guys tough on the outside and terrified on the inside.”

Public Health Notes – Vaccine declination or hesitancy

At the intersection of individual autonomy and the ethical obligation to promote the public good.

by Catherine Colquitt, MD

According to the World Health Organization (WHO): 

“Vaccination has greatly reduced the burden of infectious diseases. Only clean water, also considered to be a basic human right, performs better. Paradoxically, a vociferous antivaccine lobby thrives today in spite of the undeniable success of vaccination programs against formerly fearsome diseases that are now rare in developed countries.” (www.who.int/bulletin/volumes/86/2/07-040089/en). 

Efforts by the WHO and its partners have helped increase global vaccination rates over the last two decades. From 2000 to 2014, annual world mortality from measles decreased from 546,800 deaths to 114,000, and an estimated 17.1 million measles deaths were prevented (MMWR 2015; 64:1246-1251).  Measles is highly infectious; one case produces an average of 18 cases through contact with the index case. The percentage of infants worldwide who received three DTPs before age one and one dose of measles vaccine before age two was 86 percent by the end of 2018.  

Experts estimate that from 2011 to 2020, 23.3 million deaths were averted by the increased vaccines in low-income countries, with the largest number of prevented deaths occurring through decreases in measles (13.5 million deaths prevented), Hepatitis B (4.8 million deaths prevented), Hemophilus influenza type B (1.4 million deaths prevented), and Streptococcus pneumoniae (1.5 million deaths prevented). (Vaccine 2013; 18:31 (Suppl 2): B61-72)

Now, the MCV 4 vaccine is widely used in central Africa as the first vaccine to gain approval outside the “cold chain,” meaning that its efficacy is preserved for up to four days without refrigeration and at temperatures up to 104 °F, allowing its delivery and administration in remote areas without access to refrigeration. 

Polio, once thought to be on the cusp of eradication worldwide, persists in Nigeria, Afghanistan, and Pakistan, but stakeholders are redoubling efforts to eradicate this scourge. The virus persists due to suspicion regarding its efficacy and intent, and myths about certain adverse effects.

Despite the successes of immunization programs, approximately 19.4 million children worldwide remain entirely unvaccinated by their first birthday, with 60 percent living in Angola, Brazil, Democratic Republic of Congo, Ethiopia, India, Indonesia, Nigeria, Pakistan, the Philippines, and Vietnam. Many are victims of drought, famine, political conflict, or internal/external displacement. 

Yet, in the face of these triumphs, measles is on the rise due to falling vaccination rates, now below the threshold needed for herd immunity—vaccine coverage of 83-94 percent (Doherty, M, et al Vaccine 34 (2016); 6707-6714). 

What are the root causes of vaccine declination and hesitancy in the face of obvious vaccination success? 

First, vaccine adverse effects, while rare, always get more publicity than successes (think swine flu of 1976). Then there are falsehoods and internet misinformation (think the disgraced British gastroenterologist who published two now-retracted papers in a British medical journal on a debunked link between MMR vaccine and autism for his own advancement). 

Vaccine hesitancy and declination can be reduced to cost, convenience, lack of confidence in the seasonal flu vaccine efficacy, concerns about potential side effects, and collective amnesia about how serious vaccine-preventable diseases can be. Many of us have never seen measles, rubella, Hemophilus B meningitis, and primary Varicella and don’t know what these diseases can do to infants, the immunocompromised, pregnant women, and persons on steroids, chemotherapy, and immunomodulating therapies. 

So what can we offer the vaccine-hesitant?

We can give them time-tested facts about vaccines, reassure them with the prospect of a longer life and lower healthcare costs. We can give them a chance to impact child mortality, play a role in slowing or reversing antimicrobial resistance and lessen the worldwide economic impact of vaccine-preventable diseases. Through vaccination, we can help them become healthier international travelers, and give them the satisfaction of knowing they are doing their part to make the world a healthier place for everyone. 

The WHO reminds us that “the benefits of vaccines extend beyond prevention of specific diseases in individuals. They enable a rich, multifaceted harvest of societies and nations. Vaccination makes good economic sense and meets the need to care for the weakest members of society.”  (www.who.int/bulletin/volumes/86/2/07-040089/en)

So far we have eradicated small pox and rinderpest (a veterinary pestilence).  

How about polio and measles next?  

President’s Page – Participation and Advocacy – Part II

by Tilden Childs III, MD

Welcome to the second part of my three-part series on participation in organized medicine with emphasis on advocacy. Participating in organized medicine has benefits for our patients and for our profession, as well as for the individual physician. In my first article, I shared my thoughts on the mechanics of how one gets involved. As I discussed, a particularly important part of participation in organized medicine is advocacy. As many of you are aware, I am a radiologist. I have been involved with my state and national radiology organizations, the Texas Radiological Society (TRS) and the American College of Radiology (ACR), as well as with the TCMS, TMA, and AMA, for many years. In this article, I would like to share some of my experiences in these organizations to highlight how, both individually and collectively, we can participate in advocating for the medical policies formulated by our medical organizations to help see them through to fruition and become law. It might surprise some of you to know that passing scientifically based medical policy can be quite challenging. My description below is somewhat detailed but this is also intentional, to give you a flavor of what it’s really like to participate. 

Some of you are familiar with the 2011 National Lung Screening Trial (NLST), a National Institute of Health funded randomized control trial which showed a 20 percent reduction in lung cancer mortality by low-dose CT scan (LDCT) screening of a specific, high-risk patient population aged 55 to 74. This was a multi-institutional trial involving 33 sites and over 50,000 patients. The evidence from this study was so compelling that the trial was terminated early by the National Cancer Institute’s Data and Safety Monitoring Board. Subsequently, in December 2013, the United States Preventive Services Task Force issued a favorable grade B rating for LDCT screening for lung cancer in high-risk patients aged 55-80, based on empirical data, including the NLST. Under the guidelines of the Patient Protection and Affordable Care Act, coverage for this screening study was mandated to be provided by private carriers by January 2015. However, this mandate did not apply to the Centers for Medicare and Medicaid Services (CMS), thereby excluding patients 65 years and older from this screening benefit.

My involvement with this issue began in April of 2014 at the ACR Annual Meeting and Chapter Leadership Conference (AMCLC) in Washington, DC. The Wednesday of each AMCLC meeting is devoted to advocacy on Capitol Hill by the meeting attendees. That year, our message included a request for representatives and senators to sign letters urging CMS to issue a favorable national coverage determination for LDCT screening for lung cancer. Ironically, on that very Wednesday, April 30, the Medical Evidence Development and Coverage Advisory Committee, which advises CMS, issued an unfavorable recommendation with regard to coverage for LDCT scanning for lung cancer. Ultimately, a bipartisan mix of 45 Senators and 134 Representatives signed these letters.

“Healthcare policy can be affected at the state and national levels, which supports both our patients and our practices, through participation in various medical organizations.

Two days later, on Friday, May 2, I attended the TMA Annual Meeting (TEXMED) in Fort Worth. Months earlier, I had volunteered to be on a reference committee for the TMA. Reference committees are tasked to take public testimony and to evaluate the evidence and testimony presented concerning committee reports and resolutions. The members then make recommendations for action by the House of Delegates. By chance, I was assigned to the Science and Public Health Reference Committee. One of the resolutions for this committee to consider was adoption of the USPSTF guidelines for LDCT screening for lung cancer. Having attended the ACR AMCLC and participated in the Capitol Hill Advocacy Day, I was familiar with the issues regarding LDCT scanning for lung cancer. Therefore, I was able to give insight to the reference committee and help shepherd the resolution through the committee to the House of Delegates. Additionally, as a TCMS alternate delegate to the TMA, I was able to participate in the Tarrant County caucus at the TMA where I provided further support for this resolution. The TMA House of Delegates subsequently passed the resolution in support of LDCT screening for lung cancer in high-risk patients. On the Monday following TEXMED, I notified the TRS of the TMA’s action on this issue. Subsequently, in the spirit of cooperation with the TRS, the TMA placed an item concerning the TMA support for this issue in the May 16 TMA Action email, thereby helping to bring this issue to the attention of the TMA membership.

Some months earlier, I had been asked to join the ACR delegation to the AMA as an alternate delegate. Consequently, I attended the annual AMA meeting in Chicago on June 7-11. A large part of ACR delegation activities is devoted to identifying and studying the issues pertinent to radiology, attending reference committees, and garnering support for the position of the ACR with respect to these issues. A resolution in support of LDCT screening for patients at high risk for lung cancer was introduced by the Florida delegation and was assigned to Reference Committee A as Resolution 114. Although the majority of the testimony heard during the reference committee was in support of Resolution 114, the reference committee subsequently recommended for referral of the resolution. This was occurring during the 90-day comment period prior to CMS making a national coverage determination in November of that year and the ACR delegation was determined to overcome the reference committee recommendation. The ACR delegation worked very hard to strategize and subsequently garner support for Resolution 114 by communicating and networking with many of the other delegations. One of the important overriding concerns voiced by the ACR delegation was the idea that evidence-based medicine should be accepted and that the NLST was indeed good evidence-based medicine. Subsequently, on the floor of the House of Delegates, a substitute resolution was introduced by the Florida delegation, again supporting LDCT screening for lung cancer. After much positive support was voiced, the resolution that Medicare (as well as Medicaid and private insurance) provide coverage for LDCT screening for patients at high risk for lung cancer was overwhelmingly passed by the AMA House of Delegates by a 73.8 percent majority. Consequently, AMA policy was influenced by the ACR delegation. This was done in a timely manner with the result being that the voice of the AMA would be heard by CMS in support of LDCT scanning during the 90-day comment period prior to the CMS national coverage determination. 

CMS subsequently approved coverage. LDCT screening for lung cancer in the properly selected high-risk patient population is now an accepted screening procedure which has been implemented in our community. As you can see by this example, healthcare policy can be affected at the state and national levels, which supports both our patients and our practices, through participation in various medical organizations.  

Thank you for this opportunity to share some insights with you. More to come, and please join us at the monthly TCMS Board of Advisors meeting at noon on the fourth Wednesday of most months. To find out more information, you can email Melody Briggs at mbriggs@tcms.org.