In this issue:

2009 NHSPA President's Health Initiative Project
As mentioned in a previous newsletter and BOD minutes, I wanted to support an organization or project that focused on healthy initiatives. I chose the national group Girls on the Run. This organization targets girls ages 8-13 and through a spring and fall 10 week training program, builds self esteem, self confidence and healthy habits by working with them in a walking/running program. read more >>

Congressional Visit
As you may know, the AAPA has conducted this program for several years now, bringing PAs from around the country to Washington throughout the year to speak one-on-one with legislators and staff about issues of concern to the PA profession. read more >>

Clinical Corner
Laryngopharyngeal reflux is a condition brought about by the regurgitation of stomach acid and pepsin on to the laryngeal structures causing caustic damage, irritation and edema. Less than half of patients with this condition actually complain of any typical gastroesophageal reflux type symptoms (i.e. heartburn). Patients will generally present with complaints of chronic cough, throat clearing, dysphonia and a globus sensation. LPR mimics symptoms of vocal abuse, postnasal drip, allergic rhinitis, asthma, sinus disease and cancers of the hypopharynx. read more >>

Silent Auction

A Day in the Life of a Second Year PA Student

Election 2010

Fall Conference
We are looking forward to the 10th Annual NHSPA Primary Care Conference scheduled for Friday and Saturday October 23rd and 24th at the Lake Opechee Inn and Spa in Lakeport, NH.  The Inn is nestled in the Lakes Region not far from Laconia and is an idyllic location for a conference. read more>>

Membership Renewal
Don't forget that you can renew your NHSPA membership online at www.nh-spa.org. read more>>

2009 NHSPA President's Health Initiative Project

As mentioned in a previous newsletter and BOD minutes, I wanted to support an organization or project that focused on healthy initiatives. I chose the national group Girls on the Run. This organization targets girls ages 8-13 and through a spring and fall 10 week training program, builds self esteem, self confidence and healthy habits by working with them in a walking/running program. Many schools throughout the state participate in this program. At the end of the 10 week session, a 5K road race is held in Hampton, NH for all participating groups.

On 6/20/09, Christina Dickey (a new NHSPA member transplanted from CA, working in Manchester at DHMC and residing in New Boston) and I, travelled to Hampton to work the race with the Girls on the Run organizers. We helped set up stations at the start of the race, and helped the girls get into the spirit of the race by putting tattoos on their faces and arms. As a runner myself, I love the hype before the race, the spectators who cheer the runners on and the finish line festivities.

After getting the runners decked out with their tattoos, Christina and I took our places along the route as cheering spectators. We were well positioned to cheer early but most importantly given the sun had come out and the temperature had risen, to encourage and motivate the girls to finish the last ¼ mile. We even chose to run to the last turn with several of those who looked tired and unsure of being able to finish running this race. Remember these are 8- 13 yr old girls, many of whom had never run 3 miles before!

We had a great time and the race coordinators were much appreciative of the health care professionals who chose to support their cause. I look forward to working with them in the fall. My thanks to Christina for getting up at about 5 am on a Saturday and driving out to Hampton with me for this event! For more information, check out www.girlsontherunnh.org.

Congressional Visit

As you may know, the AAPA has conducted this program for several years now, bringing PAs from around the country to Washington throughout the year to speak one-on-one with legislators and staff about issues of concern to the PA profession. A typical congressional visit involves about 24 hours in Washington, DC, with PAs flying into the city one evening, having an early morning briefing with AAPA staff, visiting legislators, then spending a little time debriefing and evaluating the meeting before flying home. Travel and expenses are paid for by AAPA. Appointments with lawmakers typically are scheduled mid-week, such as Tuesday, Wednesday, or Thursday, although some flexibility is possible. Each appointment also includes a member of the AAPA federal affairs staff. We welcome PAs with experience in legislative advocacy and established connections, as well as political novices. This year on May 5th, Susan Finerty PA-C, Moe Paquette PA-C, and Sarah Bean PA-S traveled to DC and met with Jeanne Shaheen’s legislative aide, Carol Shea Porter’s legislative aide and Paul Hodes along with his legislative aide. The message we delivered was that PAs can and should be part of the health care reform legislation. In addition, we asked for support for federal worker’s compensation language to include PAs, for funding for title VII for PA programs, and to include PAs in medicare language that will allow us to write orders for skilled nursing care. All those we met with were supportive of our efforts, the PA profession and expressed that they felt we would be a necessary part of health care reform as it relates to access to care for our NH citizens.

Pictured above from left: Moe Paquette, PA-C, AAPA Federal Staff, Sarah Bean, PA-S, and Susan Finerty, PA-C

Clinical Corner

Laryngopharyngeal Reflux (LPR)

By Sarah Lynch, MPAS, PA-C

Laryngopharyngeal reflux is a condition brought about by the regurgitation of stomach acid and pepsin on to the laryngeal structures causing caustic damage, irritation and edema. Less than half of patients with this condition actually complain of any typical gastroesophageal reflux type symptoms (i.e. heartburn). Patients will generally present with complaints of chronic cough, throat clearing, dysphonia and a globus sensation. LPR mimics symptoms of vocal abuse, postnasal drip, allergic rhinitis, asthma, sinus disease and cancers of the hypopharynx.

The purpose of the larynx is to protect the lower airway from aspiration. It contains a multitude of nerve endings and is extremely sensitive to approaching material. It is thought that sensory issues of the larynx may contribute to LPR. Symptoms of LPR can be brought about by direct or indirect causes. Direct causes involve pepsin and acid washing up and coating the laryngeal structures causing irritation and resulting in inflammation and edema of the structures. The indirect mechanism involves irritation of the esophagus when refluxate does not come as high as the hypophaynx but causes triggering of the laryngeal reflexes due to esophageal irritation. This results in symptoms such as chronic cough due to bronchoconstriction and other asthma-like symptoms.

It was once thought that LRP was simply an extraesophageal manifestation of GERD. There are many significant differences that make LPR its own distinct condition. Heartburn, which is a classic symptom of GERD, is only seen in about 40% of patients with LPR. On biopsy of the esophagus, the majority of GERD patients have evidence of esophagitis while only about ¼ of LPR patients have the same finding on biopsy.

Significantly less acid exposure is needed to create the irritation of LPR than GERD. This is due to the fact that the larynx lacks any sort of peristaltic activity which would aid in removing acid from the larynx. This allows acid and pepsin to sit on the laryngeal tissues for a longer period of time. The epithelium of the larynx is very thin and not structured to deal with the injury that pepsin and acid cause.  The upper limit of normal reflux episodes into the esophagus for GERD episodes is 50 events per 24 hour period. In LPR, greater than 4 events of reflux into the hypopharynx is abnormal.

Symptoms of LPR include hoarseness and dysphonia. Cough, chronic throat clearing, globus pharyngeus and dysphagia are all common complaints. It is also believed that LPR plays a role in the development of vocal fold granulomas, development of subglottic stenosis and laryngospasm.

Diagnosis

The majority of patients are diagnosed on the basis of history and findings on nasopharyngolaryngoscopic examination. Findings that are associated with LPR on laryngeal examination exam include evidence of pseudosulcus (subglottic edema), true vocal fold edema and post cricoid edema. There is controversy as to the reliability of physical exam findings of LPR as these findings are also common in the general population. There is no test that is easy to perform and also highly reliable. The Reflux Symptom Index Score is an eight question validated severity scale that is a way to standardize diagnosis for LPR.

24 hour dual sensor pH probe is often considered the gold standard for diagnosis of LPR. The downfall is that so little acid is required to cause damage to laryngeal structures that the exposure may not register as positive on the sensor probe.
Trial of proton pump inhibitors (PPI) therapy has been suggested but in controlled studies PPIs have been found to provide significant benefits in placebo groups. Other potential routes of diagnosis that are being explored include evaluation of salivary epidermal growth factor concentration and laryngeal mucosa gene expression.

Treatment

Initially treatment is aimed at dietary and lifestyle changes. Medication therapy typically involved high dose PPI. The American Academy of Otolaryngology-Head and Neck Surgery recommends twice daily treatment of a PPI for no longer than 6 months for the majority of patients with LPR. It can take about 6-8 weeks up to 12 weeks on twice daily therapy for healing to occur and for patients to notice an improvement of symptoms. H2 blockers and antacids may be used to help provide additional relief.

Franco,RA. “Laryngopharyngeal Reflux”. Up to Date. May 7, 2009. Accessed July 22, 2009. http://www.utdol.com/.

Amirlak, B, Mudd, PA, Shaker, R. “Reflux Laryngitis”. Emedicine. May 11, 2009. Accessed July 22, 2009. http://emedicine.medscape.com/article/864864-overview.

Silent Auction
Anyone interested in participating in the silent/live auction should prepare to pay via check, made out directly to the charity the students have designated as this year’s recipient of the monies raised.

A Day in the life of a Second Year PA Student

Sarah Bean, PA-S

The alarm goes off and I awake to unfamiliar surroundings. The day before I packed up everything I would need for five weeks and headed north of the notch to live in a home and with people whom I had never met. As I get ready for the day, questions constantly cross my mind and accompany the butterflies that have taken up residence in my stomach. What is this office going to be like? What will my preceptor be like? Am I going to fit in here? Do I have what it takes to be a great PA? I hop into the car, put the address into my GPS and start the first day of a new clinical rotation. When I arrive at the office, I have the typical, “I’m new and have no idea where I’m going,” look on my face, which usually gets you the directions I’m in need of. Once in my preceptor’s office, I put my bag down, grab my stethoscope, take a deep breath and wait for him to arrive. We introduce ourselves and he gives me a brief description of the type of patients we will be seeing, then I get a laptop and I’m on my way. As I open the patient’s door, I hope that I will ask the questions I need to, that I’ll come off as having a clue as to what I’m doing rather than being all thumbs. Ten patients into the day and I feel like I’ve been working here for months rather than hours. Throughout the day, I present my patients to my preceptor and he pushes me to make a plan for each of them. At the end of the day, I finish up my paperwork and let the butterflies leave, since I have managed to survive the first day. The driver’s seat in my car feels so welcoming after being on my feet all day. I shut the door, turn the key and hope that I have the knowledge, ability, and stamina to make it through the next five weeks and then to do it all over again after that.

Election 2010

Watch your e-mail inbox for the official 2010 ballot for the NHSPA Board of Directors election. In about a week, you will be receiving a message calling for nominations for next year’s Board of Directors.  Please feel free to nominate yourself or someone else (you may want to ask them if they are interested first) for these positions that are vital to the smooth operation and progress of YOUR state organization.

Please seriously consider running for one of these positions.  The NHSPA needs YOU!

Fall Conference

We are looking forward to the 10th Annual NHSPA Primary Care Conference scheduled for Friday and Saturday October 23rd and 24th at the Lake Opechee Inn and Spa in Lakeport, NH.  The Inn is nestled in the Lakes Region not far from Laconia and is an idyllic location for a conference.  If you have not already done so save the dates in your calendar and make a reservation at the Inn.  The Inn is saving a block of rooms for the conference but will release the rooms to the general public on September 9, 2009.

The NHSPA CME committee has put together a great conference with 12 hours of category I CME (pending AAPA approval).   We will have our traditional silent auction on Friday and a live auction at the reception.  We hope to see you in October in the Lakes Region.   

Membership Renewal - Refresher
If you are due for renewal, there are easy to follow instructions to renew your membership online at http://www.nh-spa.org/component/option,com_docman/task,doc_download/gid,14/Itemid,56/.