Sleep Apnea Common but Underdiagnosed

Posted on by Michael Chananie

Sleep medicine testing

Suspect sleep—or the lack of it.

Kirk Levy, MD
Kirk Levy, MD

That is the recommendation that Kirk Levy, MD, gives physicians when a patient complains of a variety of symptoms that can seem unrelated to obvious daytime drowsiness. Patients may report heartburn, difficulty losing weight or morning headaches. They might mention depression and anxiety, or type 2 diabetes.

Couple these seemingly unrelated symptoms with fatigue, and the patient likely has sleep apnea. Although this is the most common sleep disorder, with more than 20 million sufferers in the United States, research has shown it is vastly underdiagnosed.

Mitchell Engler, MD
Mitchell Engler, MD

Dr. Levy and Mitchell Engler, MD, the comedical directors of the Center for Sleep Medicine at Englewood Health, are working to raise the profile of sleep apnea and other sleep disorders that can result in disruptive sleep cycles recurring hundreds of times each night. “The most common problem we encounter is that sleep apnea is not diagnosed because patients are not being asked the right questions,” Dr. Levy said.

To identify sleep apnea, physicians first need to ask their patients about their quality of sleep, along with accompanying breathing patterns (sidebar). If the diagnosis is suspected, polysomnography or another at-home sleep apnea test is performed. But without proper questioning, testing may not even be conducted.

Risk factors for sleep apnea include being overweight (body mass index of 25-29.9 kg/m2 ) and obese (body mass index of ≥30 kg/m2), although 50% of people with the condition are not obese. Also included is having a large neck circumference (men, ≥17 inches; women, ≥16 inches); having large tonsils or adenoids; other distinctive physical attributes including deviated septum, specific shape of head and neck, receding chin, enlarged tongue; nasal congestion or blockage caused by a cold, sinusitis, allergies, smoking, etc.; throat muscles and tongue that relax more than normal during sleep (possibly due to alcohol use, sedatives or advanced age); and a family history of sleep apnea, which may be the result of hereditary anatomic features or medical conditions that are genetically based.

Generally, sleep apnea is treatable, according to Dr. Levy, by using a continuous positive airway pressure (or CPAP) mask over the nose. But left untreated, sleep apnea can result in serious health consequences over time—the symptoms mentioned above, and also mood change, memory loss, weight gain, risk for a cardiovascular event and impotence. Sleep apnea is even a major contributor to car accidents, as sleep-deprived drivers have up to a 15-fold greater risk for accidents. Drivers who have gone without sleep for 24 hours are equivalent to those who have a blood alcohol concentration of 0.10%, according to the CDC, which is higher than the nationwide limit of 0.08%.

“Doctors need to think about sleep apnea,” Dr. Levy said. “Most patients are not going to present with the complaints, so if you do not have it in your mind to screen for it, you’re not going to find it. Just understand it is frequent. It’s out there, and you need to keep it in the back of your mind with patients with these risk factors.”

To assist with the diagnosis and management of obstructive sleep apnea in adults, the American College of Physicians developed a clinical guideline (J Clin Sleep Med 2017;13[3]:479-504).

If patients answer yes to any of these items, they might have sleep apnea or another sleep disorder, and they should be referred to a sleep medicine specialist for evaluation:

  • I snore every night.
  • I experience daytime sleepiness.
  • I wake up gasping for air.
  • I wake up with heartburn/reflux.
  • I have trouble losing weight.
  • I have morning headaches.
  • It is hard for me to stay awake while driving.
  • I’ve been told that I fall asleep incredibly fast.
  • I’ve been told that I stop breathing while I sleep.

Insomnia as a Comorbidity
Sleep apnea has been found to coexist with insomnia, with some statistics showing that one-third to half of people with sleep apnea suffer from sleeplessness (Sleep Med Rev 2017;33:28-38). To combat insomnia, physicians at Englewood Health’s Center for Sleep Medicine recommend strategies to promote better sleep, such as abstaining from alcohol around bedtime, as metabolizing alcohol overnight can cause wakefulness, thus fracturing sleep. They also recommend limiting screen time to reduce exposure to blue light; practicing relaxation exercises; and dedicating a bed to sleeping only, keeping reading a book or watching television to another room. “Another item to ban from the bedroom is the clock radio,” Dr. Engler said. Glancing back and forth to see how much time there still is to sleep, or to count how much time was wasted in sleeplessness, can “turn your brain into overdrive,” he said. Even with dedicated efforts, a switch to more regular sleep won’t happen overnight. “This is not easy to do. I tell my patients with insomnia: ‘You didn’t get this way overnight, and it doesn’t go away overnight. It takes work, but ultimately you’re retraining your brain to associate bed with sleep

Posted August 2019

Ask the Doctor: Dr. Steven Elias

Posted on by Michael Chananie

When it comes to menstrual misconceptions, believing that chronic pelvic pain is ‘just a normal part of being a woman’ lies somewhere between thinking you’re more likely to get attacked by a shark when you have your period and believing that if your friend’s cycle doesn’t sync with your own, you’re not true friends. In fact, believing that persistent pelvic pain is normal is an even more damaging fallacy, as it often prevents women who experience pelvic pain from seeking the appropriate medical attention. For this reason, highly treatable conditions, like pelvic congestion syndrome, go woefully underdiagnosed.

What is pelvic congestion syndrome?

Dr. Elias: Pelvic congestion syndrome occurs when a damaged or diseased vein in the pelvis begins to accumulate blood, rather than transporting it back to the heart. Also referred to as pelvic venous insufficiency, it can cause pain, pressure or achiness in the pelvis, painful periods, a feeling of pelvic fullness as the day progresses, pain 15-20 minutes after intercourse or after standing for long stretches of time and a feeling of bladder pressure leading to frequent urination towards the end of the day.

Who is at high risk for developing vein disease in the pelvic area?

Dr. Elias: Premenopausal women are more likely to have pelvic venous insufficiency than post-menopausal women. The other two main risk factors for pelvic vein disease are having had multiple pregnancies or a family history of varicose veins.

How is pelvic venous insufficiency diagnosed?

Dr. Elias: First, we usually perform a vascular ultrasound (a non-invasive procedure) to look at the pelvic veins. If suspicious after the ultrasound an MRI or CT scan of the pelvis may be done. The most definitive test is a venogram, during which a dye is injected into the veins of the pelvis and the blood flow is visualized on a screen. With this test, we can evaluate how the vein is performing and which veins are leaking, causing symptoms. The test takes about 30-40 minutes and patients only have one needle stick in the upper thigh. Patients can resume normal activities immediately afterwards.

Most symptoms of pelvic vein disease go away after menopause. However, premenopausal women with symptoms that affect their quality of life such as normal activities, caring for children, or pain while working, do benefit from having their vein disease treated.

How is pelvic vein disease treated?

Dr. Elias: Treatments for pelvic vein disease are similar to those for varicose veins. These are outpatient procedures with no cuts or stitches—just a few small needle sticks. We seal any abnormal veins shut, diverting the blood flow to normal, healthy veins. When pelvic veins are narrowed because of pressure from the arteries, we can improve blood flow by using a small catheter to insert and inflate a balloon, then placing a permanent stent to widen the vein. These procedures can improve symptoms by about 75% – 80%, leading to a big improvement in a patient’s quality of life.

Posted July 2019

Ask the Doctor: Dr. Peter Kaye

Posted on by Michael Chananie

When it comes to colon and rectal health, a feeling of awkwardness can sometimes get in the way of dis-cussing problems with your doctor. It’s for this reason that a physician who specializes in these fields must have a special knack for putting patients at ease. Peter M. Kaye, MD, is a colon and rectal surgery specialist, and recently joined the Englewood Health Physician Network. At Englewood, Dr. Kaye treats a wide range of conditions—everything from hemorrhoids and fissures, to diverticulitis (inflammation or infection in the digestive tract), inflammatory bowel disease, such as Crohn’s disease and ulcerative colitis, to colon and rectal cancer.

What can people do to prevent diverticulitis, hemorrhoids, or fissures from developing?

Dr. Kaye: Many of the colon and rectal conditions I treat are highly preventable through healthy, clean living. Simple adjustments like drinking more water; eating fruits, vegetables, and fiber; avoiding empty carbohydrates; and exercising regularly are a huge help. There is evidence that a healthier lifestyle might also play a role in the prevention of colorectal cancer.

Do patients hesitate to see you because they don’t want to talk about their bowel movements?

Dr. Kaye: Absolutely! One common condition I treat is fecal incontinence (an inability to control one’s bowel) and I would say that people with this condition don’t seek medical attention for that reason alone. However, it is important for people to know that there are ways to help with this condition.

Is family history a major risk factor for colorectal cancer?

Dr. Kaye: A majority of patients diagnosed with colorectal cancer have no family history of the disease. The biggest risk factor for colorectal cancer is age. Several months ago, the recommended age to begin colon screening dropped from 50 to 45 because we’re starting to see more cases of colon cancer in younger people.

After age 45, how often should I get a colonoscopy?

Dr. Kaye: That depends on what we find in your first colonoscopy. If we find polyps (small growths that can lead to cancer), we recommend an earlier date for your next colonoscopy. But if the results are normal, you may be able to wait as long as 10 years before your next one.

Posted July 2019

Englewood Health’s Emergency Medical Services receives American Heart Association’s Mission: Lifeline EMS Gold Plus Recognition Award

Posted on by Michael Chananie

Englewood Health’s Emergency Medical Services (EMS) has received the American Heart Association’s Mission: Lifeline® EMS Gold Plus Award for implementing quality improvement measures for the treatment of patients who experience life threatening heart attacks.

Every year, more than 250,000 people experience an ST elevation myocardial infarction (STEMI) the deadliest type of heart attack caused by a blockage of blood flow to the heart that requires timely treatment. To prevent death, it’s critical to restore blood flow as quickly as possible, either by mechanically opening the blocked vessel or by providing clot-busting medication.

“Receiving the American Heart Association’s Mission: Lifeline® EMS Gold Plus Award speaks to the ongoing dedication of the entire Emergency Medical Services team at Englewood Health to providing optimal care for our patients and community members,” said Rick Sposa, director of emergency medical services at Englewood Health.

“EMTs and paramedics play a vital part in the system of care for those who have heart attacks,” said Tim Henry, M.D., Chair of the Mission: Lifeline Acute Coronary Syndrome Subcommittee. “Since they often are the first medical point of contact, they can save precious minutes of treatment time by activating the emergency response system that alerts hospitals to an incoming heart attack patient. We applaud Englewood Health EMS for achieving this award in following evidence-based guidelines in the treatment of people who have severe heart attacks.”

The Mission: Lifeline initiative provides tools, training and other resources to support heart attack care following protocols from the most recent evidence-based treatment guidelines. Mission: Lifeline’s EMS recognition program recognizes emergency medical services for their efforts in improving systems of care to rapidly identify suspected heart attack patients, promptly notify the medical center and trigger an early response from the awaiting hospital personnel.

Englewood Community Leader, Michael Gutter, Named Chairman of the Board of Englewood Health Foundation

Posted on by Michael Chananie

July 1, 2019 — Thomas C. Senter, Esq., chairman of the Board of Trustees of Englewood Health and Englewood Hospital, today announced that Michael Gutter was elected chairman of the Board of Trustees of the Englewood Health Foundation effective July 1, 2019. Gutter, a resident of Englewood, first joined the board in 2011 and most recently served as treasurer. He succeeds Jay C. Nadel, who served as chairman since 2013.

The Englewood Health Foundation is the not-for-profit organization that raises funds to support the capital, endowment and annual operating needs of Englewood Health, the health system comprising Englewood Hospital and the Englewood Health Physician Network. In his role as chairman, Gutter will spearhead philanthropic initiatives in support of Englewood Health’s strategic plan and lead a voluntary board of 40 community leaders and benefactors. He will work in close partnership with the executive leadership of the Englewood Health Foundation and the larger Englewood Health system, its physicians and community of donors.

“Englewood Health recently unveiled a 10-year strategic plan that addresses key clinical areas where need is projected to dramatically increase,” said Warren Geller, president and CEO of Englewood Health. “Philanthropy will undoubtedly provide forward momentum for planned initiatives helping our clinical care team to dream, do and deliver the highest quality, compassionate care for patients and families.”

“Friends and supporters helped the Foundation raise in excess of $100 million over the past decade,” said Debra Albanese, executive vice president of the Englewood Health Foundation. “Trustees play a vital role, engaging donors and potential donors in meaningful conversations about philanthropy and the impact it generates for our shared communities.”

About Michael Gutter

Michael Gutter graduated from SUNY Albany with a Bachelor of Science in business administration and a concentration in finance. In 2002, he founded Arista Funding, which specializes in both equipment leasing and merchant processing for small to mid-size businesses.

In addition to serving on the Englewood Health Foundation Board, Gutter is a member of the Hebrew Free Loan Society Micro Enterprise Committee, where he helps make interest-free loans to small businesses in New York, and is a board member and co-chair of the Finance Committee at Alpine Country Club.

“Shortly after moving to Englewood from New York City, my family faced a situation that put our daughter in the emergency room at Englewood Hospital,” said Gutter. “The care she received turned what could have been a horrible situation into a positive experience. Serving on the Foundation board provides a unique opportunity to broker opportunities that will help to ensure   Englewood Health remains among the leading health systems in our region so that other families have access to the same expert, compassionate care that my family received.”

Newly Appointed Vice Chairman, Treasurer and Secretary

Also effective July 1 are new appointments for the roles of vice chairman, secretary and treasurer of the Englewood Health Foundation.

Steven M. Kaplan, Esq. joined the Foundation board in 2011 and will serve as vice chairman. Kaplan, a resident of Demarest, is a founding partner of Kaplan Levenson P.C.

Serving as treasurer is Neil S. Piekny, who joined the Foundation board in 2017. He lives in Demarest and is a tax partner at Ernst and Young LLP.

Nancy G. Brown joined the Foundation board in 2012 and will serve as secretary. A resident of Cresskill, Brown has held leadership roles on numerous not-for-profit boards, including the Crohn’s and Colitis Foundation of America, Kaplen JCC on the Palisades, the UJA-Federation Women’s Board and New York-Presbyterian/Morgan Stanley Children’s Hospital.

Ask the Doctor: Dr. Rachelle Leong

Posted on by Michael Chananie

Rachelle Y. Leong, MD, is a breast surgeon at Englewood Health, where she focuses on breast cancer surgery, benign breast disease, and breast cancer in minorities and young women.“I always knew I wanted to work in cancer treatment,” says Dr. Leong. “My mother is a lung cancer survivor and has been out of treatment for over 13 years. This personal experience helps me understand both the patient and the family, and I use my family’s stories to convey to my patients that there is survivorship at the end of cancer treatment.”

How often do women need mammograms, and at what age should they start getting them?

Dr. Leong: There are conflicting recommendations, but we recommend that women with an average risk should begin having mammograms at age 40 and continue to have one every year. This helps us detect cancers as early as possible, when they are most treatable.

After some women have their annual mammogram, they are called back for an ultrasound. Why is that?

Dr. Leong: Mammograms and ultrasounds look at different things. Mammograms are great at looking at asymmetries, calcifications, and distortions while ultrasound are great at looking for cysts and solid tumors. For women with heterogeneously dense breasts, an ultrasound is recommended for further testing as a denser mammogram is harder to read.

Why do some women need a follow-up appointment after their mammogram?

Dr. Leong: We bring patients back in for a follow-up to see if anything like shape, size or appearance has changed. Such changes can be cause for concern, so sometimes we call patients back every six months to make sure everything has stayed the same.

What are the most common questions and concerns you hear from patients?

Dr. Leong: Many patients complain of breast pain and are fearful that it is a symptom of breast cancer. Breast pain is common in women, both before and after menopause. Pain can change over time with fluctuations in hormones and is not typically a cause for concern.I also see patients concerned about their family history. Because family history can increase risk, if a relative was diagnosed with breast cancer at a young age, say 45, we suggest you start yearly mammograms at age 35 rather than 40. For patients at high risk, we have genetic counselors who will help you decide whether to be tested for any abnormal gene such as BRCA and discuss the results with you if you are tested.

What are some misconceptions patients have about their breast health?

Dr. Leong: One misconception is the belief that if you have surgery for cancer , the cancer will grow when it is exposed to the open air. Exposure to air does not cause cancer to grow.
Another misconception I run across is that if you need a biopsy, it will definitely turn out to be cancer. It is human nature to believe the worst-case scenario, but often cancer is not the outcome of a biopsy. The final misconception I’ll mention occurs at the time of diagnosis. When a woman who is diagnosed with breast cancer missed her mammograms the previous year or two, she often blames herself and feels the cancer is her fault. Missing a mammogram does not cause cancer. Yes, we may have caught it earlier, but you are not to blame for the cancer.

Posted July 2019

Englewood Health Honored with Resuscitation Recognition Award

Posted on by Michael Chananie

Englewood Health has received the Get With The Guidelines®-Resuscitation Silver Award for implementing specific quality improvement measures outlined by the American Heart Association for the treatment of patients who suffer cardiac arrests in the hospital.

More than 200,000 adults and children have an in-hospital cardiac arrest each year, according to the American Heart Association. The Get With The Guidelines-Resuscitation program was developed with the goal to save lives of those who experience in-hospital cardiac arrests through consistently following the most up-to-date research-based guidelines for treatment. Guidelines include following protocols for patient safety, medical emergency team response, effective and timely resuscitation (CPR), and post-resuscitation care.

Englewood Health received the award for meeting specific measures in treating adult patients who suffer in-hospital cardiac arrests in the hospital. To receive this award a hospital must comply with the quality measures for one year.

“Receiving this award from the American Heart Association represents Englewood Health’s commitment to using the latest research-based standards for resuscitation care as well as our broader commitment to evidence-based practice,” said Hillary Cohen, MD, MPH, chief of emergency medicine and vice president of medical affairs at Englewood Health.

“We are pleased to recognize Englewood Health for their commitment in following these guidelines,” said Lee H. Schwamm, M.D., national chairperson of the Quality Oversight Committee and Executive Vice Chair of Neurology, Director of Acute Stroke Services, Massachusetts General Hospital, Boston, Massachusetts. “Shortening the time to effective resuscitation and maximizing post-resuscitation care is critical to patient survival.”

Get With The Guidelines-Resuscitation builds on the work of the American Heart Association’s National Registry of Cardiopulmonary Resuscitation, originally launched in 1999, and has collected in-hospital cardiac arrest data from more than 500 hospitals. Data from the registry and the quality program give participating hospitals feedback on their resuscitation practice and patient outcomes. The data also help improve research-based guidelines for in-hospital resuscitation.

About Get With The Guidelines

Get With The Guidelines® is the American Heart Association/American Stroke Association’s hospital-based quality improvement program that provides hospitals with the latest research-based guidelines. Developed with the goal of saving lives and hastening recovery, Get With The Guidelines has touched the lives of more than 6 million patients since 2001. For more information, visit heart.org.

Posted June 20, 2019

What You Need to Know About the Powassan Virus and Ticks This Summer

Posted on by Michael Chananie

In the wake of the recent death of an 80-year-old, Hunterdon County man from a rare but sometimes deadly virus spread by ticks, New Jersey has been forced to, once again, confront our growing tick problem.

The virus in question is called Powassan, a neuroinvasive disease, first discovered in 1958 in Powassan, Ontario—its eventual namesake.

“The Powassan virus is typically found in the northern parts of the country: Minnesota, Wisconsin and eastern Canada. It can cause encephalitis, or inflammation of the brain, and in its worst form can cause a brain infection,” Dr. Ashwin Jathavedam, Chief of Infectious Disease at Englewood Health said.

While many who contract the virus will display no symptoms at all, those who do will experience flu-like indicators, including fever, headache, confusion and even seizures. According to Dr. Jathavedam, by the time a patient seeks medical attention for the Powassan virus, they are typically quite ill.

There is no known cure for the Powassan virus and, apart from medical assistance like respiratory support and intravenous fluids, it’s up to the immune system of the individual to fight it off. For this reason, contracting the virus can be deadly for vulnerable populations including the very young, the very old and the already immunocompromised.

There are several types of ticks that have been known to carry the Powassan virus, some of which are more inclined to infect animals like rodents or groundhogs rather than humans. One tick in particular, the deer tick, which is also known for carrying Lyme disease, can be a vector for human contraction of the virus.

In the case of the 80-year-old man who recently died after contracting the Powassan virus, it is unknown what kind of tick he came into contact with and ultimately contracted the virus from.

“The overall risk for contracting this virus is quite low. In the 10 years from 2005-2015 there were only 50-60 detected cases, so it is still pretty rare,” Dr. Jathavedam said.

In total, there have been nine known cases of Powassan virus in NJ, six of which were found in Sussex County. Dr. Jathavedam explained that there is a direct correlation between how rural and forested a region is and the risk of tick-related illnesses.

“The rates of Powassan are on the incline due to an overall increase in the tick population. Climate change also contributes to this, as it affects the animal and tick populations’ natural habitats. The third factor here is that, as humans continue to encroach upon previously wooded areas, we are brought in closer proximity to these ticks,” Dr. Jathavedam said.

Powassan does not spread human-to-human; so, prevention of the virus relies on implementing tick safety measures, especially during the coming summer months, such as wearing bug spray, putting long hair in tight braids, avoiding walking in tall grass and being mindful when interacting with livestock.

“I know it’s hard during the summer, but one of the best things you can do is wear long sleeves and long pants, especially if you’re hiking or otherwise in a forested or rural area. After being in such an area, doing a full-body check on yourself and especially on children is important,” Dr. Jathavedam said.

Health officials in NJ have advised the public that an infected tick must be attached to an individual for several hours before it can transmit the virus. So, if you do find a tick on you or your child, your next step should be removing it swiftly with tweezers.

If you choose to dispose of the tick, do so in a sealed plastic bag and monitor yourself for any abnormal symptoms over the next several weeks. If you’re more inclined to worry about these things, you can choose to bring the tick (in its sealed plastic bag) to a doctor, who can send it to a lab for testing.

Dr. Jathavedam explained that, despite the rising presence of ticks, the chances of contracting Powassan are still very low and we should not allow the fear of ticks to prevent us from going on hikes and engaging in outdoor activities.

“There are bigger things to worry about. Ticks are simply something we should be aware of this summer,” Dr. Jathavedam said.

Posted June 2019

Englewood Health Vascular Surgery Fellowship Returns in July

Posted on by Michael Chananie

June 14, 2019 — For over four decades, Englewood has had a long and respected tradition of vascular training and excellence. The ACGME has now approved a two year vascular fellowship. Dr. Tom Bernik, Chief of Vascular Surgery since 2016, will serve as the program director.

The Englewood Vascular Surgical Service was created in 1976 after the hospital saw extraordinary growth in the number of limb salvage cases. This growth was the direct result of the introduction and FDA approval of the umbilical vein graft, which was invented by Englewood’s own Dr. Herbert Dardik. Prior to the development of this approach, amputation was often the only option for patients who required vascular reconstruction but lacked suitable veins, or in whom a prosthetic graft would likely fail.

Since that time, Englewood has maintained a regional, national, and international reputation in the vascular community and is well known as a respected training ground for vascular surgeons. The first Vascular Fellowship program at Englewood began on July 1, 1978 and continued for over 3 decades graduating 37 fellows under the Englewood program, and 10 fellows under the combined Englewood/Mt. Sinai program. Some of those fellowship graduates continue to be part of Englewood and have provided skilled and compassionate care to our community for years including:

In addition to these well respected clinicians, the fellowship program has also achieved academic prominence through awards, published manuscripts, and presentations based on clinical and laboratory research.   The successful Vascular Research Laboratory is a unique model of basic science and translational research in a community setting.  It has trained countless residents, pre-medical students, and high school students.

As the paradigm related to vascular surgery has dramatically changed over the years, Englewood has continued to evolve its clinical care models.  We have seen the development of the Aortic Center, Wound Care Center, and Vein Center and remained on the cutting edge of endovascular care delivery.   The recruitment of Dr. Bernik to his position as chief in 2016 has continued to drive that momentum.

The fellowship will launch next month.  It is thrilling that this fellowship will continue enhancing care for our community and contribute to the next generation of great vascular surgeons.