Readers and Tweeters Take Positions on Sleep Apnea Treatment

Letters to the Editor is a periodic characteristic. We welcome all feedback and can publish a variety. We edit for size and readability and require full names.

On a ‘Woke’ Journalist’s Journey

I discovered Jay Hancock’s piece moderately intriguing (“Extreme Sleep Apnea Prognosis Panics Reporter Till He Finds a Easy, No-Value Answer,” Oct. 3). Whereas I agree that positional remedy is commonly neglected as a first-line therapy for obstructive sleep apnea, one has to take a look at this severe, life-threatening well being concern in a bit extra element. First, Mr. Hancock’s prognosis was central sleep apnea, which suggests both a neurologic and/or respiration management etiology. Sleeping on the facet might stop airway obstruction, however the underlying trigger has probably not been addressed. Second, the hazard right here is that — a bit like hypertension, with which there are little or no perceived signs — a catastrophic occasion would possibly happen with little or no warning. Third, it appears the positional remedy on this case alleviated the situation — however as one will get older, the situation will probably worsen.

Backside line: Why does this specific affected person have this situation and what could be accomplished to deal with the foundation trigger as a substitute of taking a symptomatic strategy? My concern is that, left untreated, the sufferers go to sleep with a false sense of safety to by no means get up the subsequent morning.

— Dr. Dave Singh, an adjunct professor in sleep drugs at Stanford College, Stanford, California

Not loving the tone right here. For each Jay Hancock, there are what number of lives modified/saved by CPAP remedy? https://t.co/28XDe3JZib

— Liz Beaulieu (@hmeliz) October 4, 2022

— Liz Beaulieu, Yarmouth, Maine

Lastly! Jay Hancock uncovered the sleep apnea medical racket. I’ve one other therapy choice: Throughout covid, many inpatients have been intubated within the susceptible place. I used to be interested in that and did some Googling. Not solely does sleeping in your abdomen enhance lung capability, the gravity on the throat is a pure therapy for sleep apnea. Whereas troublesome to adapt to, it’s higher than a CPAP. Once more, medical doctors don’t point out it. No cash in a easy gravity answer.

— Peg Keohane, Syracuse, New York

A reminder of how medical suppliers work to drive up prices for therapy leading to diminished pay for working Individuals!”Pointless care is an enormous motive Individuals’ insurance coverage prices — premiums, copays, and deductibles — are likely to rise 12 months after 12 months.)”https://t.co/F0zqPfGApS

— Stanley Morrical (@StanMorrical) October 3, 2022

— Stanley Morrical, San Francisco

I wish to thanks for this very well timed article. I’ve suspected there was extra to the query of apnea than was being reported. As acknowledged, it’s a huge trade that perpetuates the concept that everyone seems to be affected.

The reporter’s discovery that side-sleeping is the reply is completely legitimate, as I made up my mind way back. The article must be extensively disseminated as it’s of utmost significance to tens of millions who’re falling for the hype!

— Lawrence Dee, Chino Valley, Arizona

Sleep apnea is over-diagnosed, primarily based on pointers set by a corporation funded partly by makers of CPAP machines used to… deal with sleep apnea, @JayHancock1 stories. An alternate “therapy” is commonly neglected: Sleep in your facet! https://t.co/29lohfjI6i by way of @khnews

— Robert Roy Britt (@RobertRoyBritt) October 4, 2022

— Robert Roy Britt, Phoenix

My mouth dropped open after I learn Jay Hancock’s piece about sleep apnea. You’re the harbinger of a tidal wave, my good friend. The occasion is simply getting began.

Empowered Sleep Apnea is a mission we created to guard particular person sufferers from the “conveyer belt” of the American well being care system, because it’s poised to take care of tens of tens of millions of latest diagnoses of sleep apnea, which is able to quickly be made in major care and dental places of work throughout our nice land, utilizing automated, wearable know-how. That point is coming inside 18 months.

You suffered as a result of there was insufficient teaching for a really sophisticated illness. Easy as that. All those that shall be subjected to a cloudburst of automated diagnostics may have the identical journey to make. Out of necessity, your answer was to slog by your personal analysis to get your self some sane course. You empowered your self. Good on you.

My answer was to take my life’s work as a patient-centered sleep drugs doctor and switch it into one thing lovely to behold, so that everybody can profit from sane teaching. Our mission hinges on affected person empowerment. Our web site is a pleasant introduction. Our podcast can be a blast that I believe your readers would discover very fascinating.

— Dr. David E. McCarty, proprietor and CEO of Empowered Sleep Apnea, Boulder, Colorado

I’m certain it really works – wonderful abstract of messy #sleep #apnea ‘therapies’ and 0 prices answer for many individuals https://t.co/6Jt09rbtf1

— Artwork Sedrakyan (@ArtsyTwits) October 6, 2022

— Dr. Artwork Sedrakyan, New York Metropolis

As president of the American Academy of Sleep Medication (AASM), I write to deal with a number of issues in regards to the current article “Extreme Sleep Apnea Prognosis Panics Reporter Till He Finds a Easy, No-Value Answer” (Oct. 3). Whereas I commend the creator for in search of medical assist for his daytime drowsiness and loud night breathing, I concern his article might mislead readers in a method that would jeopardize not solely their very own well being and security however that of others as properly.

The creator is clearly dissatisfied with the care he obtained; nevertheless, utilizing this to recommend that almost everybody recognized with sleep apnea ought to merely deal with it on their very own “free of charge” is harmful. Sleep apnea is a standard and persistent medical situation that will increase the dangers for quite a few bodily and psychological well being penalties, diminished high quality of life, motorcar crashes, and untimely demise.

Positional remedy (which generally requires using a tool to take care of a side-sleeping place), although helpful for some sufferers with sleep apnea, will not be the perfect therapy for many sufferers, particularly these with reasonable to extreme sleep apnea. Constructive airway strain (PAP) remedy is the best-supported, evidence-based therapy for sleep apnea. The latest systematic overview and meta-analysis included 80 randomized managed trials investigating using PAP remedy to enhance outcomes. Hundreds of thousands of sufferers with sleep apnea can attest to the life-changing — and even lifesaving — impression of PAP remedy. Remedy choice is a vital resolution that must be made collectively by a affected person and their treating supplier.

Moreover, it’s inappropriate for the creator to make use of his expertise as justification to malign our whole group and our 12,000 members. AASM strongly refutes the implication that help from trade biases our medical apply pointers and insurance policies. Our pointers are primarily based on a overview of the newest analysis by a process pressure of consultants who decide the power of proof for a given therapy. The AASM additionally ensures conflicts of curiosity are mitigated by a stringent medical apply guideline improvement course of. Whereas the creator claims our group “funds its operations” with trade help, that is merely unfaithful. Trade help represents roughly 1% of our annual income and is guided by a transparent coverage that helps guarantee clear interactions to forestall undue affect and help public well being. Likewise, the implication that our members are prescribing PAP remedy as a part of a revenue-generating scheme is fallacious. The overwhelming majority of PAP units are bought by sturdy medical tools suppliers, not by sleep facilities or sleep medical doctors.

I hope that readers struggling to get a very good evening’s sleep will search data from credible sources and speak with a trusted well being care skilled to find out which therapy greatest addresses their particular conditions.

— Jennifer L. Martin, president of the American Academy of Sleep Medication, Darien, Illinois

Psst. Sleep apnea is sort of a racket. https://t.co/PHepAmgLaz

— Timothy Noah (@TimothyNoah1) October 4, 2022

— Timothy Noah, Washington, D.C.

I simply noticed Jay Hancock’s article on my Google feed and browse it, as I endure from severe sleep apnea as properly. I’ve obtained tailored mouthguards, so to talk, which seem to work moderately properly.

However I’ve additionally been studying books on respiration, beginning with “Breath, the New Science of a Misplaced Artwork” by James Nestor, after which on to “The Oxygen Benefit” by Patrick McKeown. I spotted I used to be a mouth breather and that that contributes to the apnea drawback as properly and have since been attempting to be taught to breathe by my nostril always — to date with blended outcomes, however the topic could be very fascinating because it pertains to much more than simply easy methods to get a very good evening’s sleep.

— Dimitri F. Frank, Málaga, Spain

Increasingly hospital programs personal pressing care facilities which have limits on who they deal with — for each monetary causes. Pressing care facilities are a brand new excessive income stream for a well being system to generate quick cash making a pipeline of latest sufferers.https://t.co/GQU1HDQC3T

— James Hughes (@JamesHu29812484) September 30, 2022

— James Hughes, Savannah, Georgia

Treating Trauma — Adopted by Billing Trauma

I’m an emergency doctor who additionally works at pressing care. Whereas I admire sufferers attempting to be fiscally accountable with their decisions, the pressing care did exactly the fitting factor on this case (Invoice of the Month: “Turned Away From Pressing Care — And Towards a Large ER Invoice,” Sept. 29). Pressing care can sometimes handle fender benders or different minor accidents, however somebody whose airbags deployed and whose automobile rolled 3 times and wound up “crushed” up right into a tree ought to at all times go to the emergency room. The mechanism of such accidents could be very regarding and sometimes justifies a trauma activation and CT scans to guage for inner accidents. Pressing care will not be geared up to deal with sufferers in the event that they develop life-threatening problems from a extreme damage.

— Dr. William Weber, Harvard Medical College / Beth Israel Deaconess, Boston

Extra proof that we want an everybody coated for every thing, zero copay, federal single payer well being care system financed by truthful taxes. https://t.co/NNhMceezD0

— James Conner (@jrcflatheadmemo) September 29, 2022

— James Conner, Kalispell, Montana

This text is lacking the angle of a medical supplier. I’m a retired board-certified emergency doctor with 33 years within the emergency division and greater than 5 years in pressing care and really feel the necessity to tackle the medical care variations between the ED and pressing care.

I agree with the details of your article and don’t dispute the monetary points, issues, inequities of the damaged system. However there’s extra to the story.

The information, skill, talent, and expertise of the supplier are key. The situation of care predisposes to the skills of the supplier however doesn’t assure them. Chances are you’ll obtain wonderful to below-average care relying on the supplier. I’ve seen individuals die from auto accidents that have been despatched residence from pressing care after receiving an analysis by a basic practitioner not skilled in trauma. Some ED physicians miss issues, however the odds are higher that the ED physician won’t miss important instances.

Conversely, you would possibly get care from an skilled ED doctor at an pressing care.

Then there are the personnel and sources offered. If it’s a easy “pressing” drawback, no vital distinction in consequence is prone to end result.

There’s the dilemma. What’s an emergency? This has been argued in Congress: to err on the facet of not lacking severe issues for which a “prudent layperson” might observe signs. So an emergency is what a “prudent layperson” believes it’s.

Among the pressing care facilities I labored in turned away “third-party” instances however most didn’t — even inside the identical hospital-owned pressing care chain. An choice could be to supply to pay money, asking for the cash-upfront worth. Tough to be correct in predicting the price forward of time, however an estimate will not be unreasonable. As a substitute of a low four-figure invoice, the household may need turned out to have a low three-figure invoice if not referred to the hospital after the pressing care analysis.

In my expertise, I’ve by no means seen a affected person despatched from pressing care (owned by or affiliated with a hospital) to the hospital for the only motive of the hospital billing a second cost. Many sufferers are despatched as a result of they want the next degree of care that isn’t out there, reminiscent of hospitalization, injectable drugs, specialty care, imaging, and “stat” lab work not out there.

Certain, the hospital makes use of the pressing care as a feeder website, however the affected person (or the paramedic) will get to decide on which hospital to go to, if they’ve a choice.

Please do not forget that not all hospitals or pressing cares are the identical. Many smaller hospitals do not have some/many specialists required to again up the emergency division. Some pressing cares use primarily basic practitioners, whereas others use solely board-certified emergency physicians, nurse practitioners, or doctor assistants.

Sure, the system is damaged. Per a current webinar by the California Medical Affiliation: Up to now 50 years, the rise within the variety of physicians was 2%. Administrative well being care personnel elevated greater than 3,000%. (That features each the supplier and the payer facet.)

— Dr. Mickey Kolodny, Palos Verdes Peninsula, California

The US healthcare system is so dysfunctional, it nonetheless staggers me at instances.https://t.co/nU3nZG94rE

— Donald Farmer (@DonaldTreeHive) October 3, 2022

— Donald Farmer, Woodinville, Washington

After 40 years as a board-certified emergency drugs doctor, I consider the article by Sam Whitehead could be very deceptive. To begin with, the affected person ought to by no means have gone to an pressing care. Had she known as 911 as she ought to have, simply due to the mechanism of the crash, she would have been dropped at an emergency room. The ER clearly believed two CT scans have been wanted, which the pressing care wouldn’t have been capable of present. The reporter didn’t dig into the small print of the acute trauma care this affected person wanted — apart from understating her post-accident scenario, which was self-defined. The creator writes as whether it is strictly an insurance coverage concern or a method for the pressing care/hospital system to realize sufferers.

There isn’t any indication of this occurring provided that the affected person wanted, by protocol, Superior Trauma and Life Help (ATLS). By EMS protocol and by malpractice case regulation, this affected person wanted a go to to a trauma middle emergency room. And the invoice is a completely completely different concern. In different phrases, the creator completely missed the medical points to overstate and sensationalize billing points.

— Dr. Anthony F. Graziano, Oconomowoc, Wisconsin

assume twice earlier than heading to an pressing care https://t.co/ixllGV7a1d by way of @khnews

— kendra lee (@kendraedits) October 3, 2022

— Kendra Lee, Woodbridge, Virginia

I listened to your story as retold on NPR a few younger girl who had a excessive invoice for an ER go to after a automobile accident. I felt that the story was editorially biased, because it talked about nothing in regards to the necessities for look after traumatically injured sufferers. It appeared to advocate visiting pressing care facilities as a substitute of emergency rooms. Though cheaper, such services usually shouldn’t look after sufferers with severe accidents. Most hospitals require board-certified emergency drugs physicians and have in depth sources whereas an pressing care physician might not have accomplished a residency. The “doctor knowledgeable” within the story clearly had no expertise within the care of traumatically injured sufferers. Having such perception would lend depth to what I noticed as a superficial take a look at a nuanced concern. Clearly the general public must be higher knowledgeable about cost-effective care, however an analysis after a severe automobile crash is inappropriate to be despatched to an pressing care.

— Dr. Christopher Goltz, Flint, Michigan

A Wealth of WISDOM

Good article (“Genetic Exams Create Remedy Alternatives and Confusion for Breast Most cancers Sufferers,” Sept. 21). With breast most cancers consciousness month upon us, I’d additionally level out the existence of the WISDOM examine funded by the Nationwide Institutes of Well being, which is taking a look at completely different approaches to utilizing genetic testing to display ladies for breast most cancers. Test it out at www.thewisdomstudy.org.

— Dr. Daniel Halevy, New York Metropolis

Let the customer beware. The truth that a marker could be detected doesn’t imply that it’s going to enable you optimize remedy. #snakeoil #breastcancer@acog @apha_mch @aafphttps://t.co/oyixlxBwRH

— Cee A. Davis,MD,MPH (@cdBRComHealth) September 22, 2022

— Dr. Cee A. Davis, Winchester, Virginia

On the Delivery of Obstetrics Emergency Departments

I used to be disenchanted by your article “Child, That Invoice Is Excessive: Personal Fairness ‘Gambit’ Squeezes Extreme ER Fees From Routine Births” (Oct. 13). Whereas I acknowledge that medical billing is commonly complicated and at instances even alarming to sufferers, I wish to share a couple of factors that I really feel have been downplayed or omitted:

• The article gives the look that the obstetrics emergency division, or OBED, is created just by rebranding an current course of inside hospitals. The creator neglects to say that earlier than the OBED, most hospitals didn’t have OB-GYN hospitalists stationed in-house 24/7 to deal with emergencies. Previous to the implementation of the OBED, many expectant moms, involved that one thing is likely to be unsuitable, weren’t capable of see a doctor after they visited a hospital emergency room. As a substitute, they have been transferred to the labor and supply division to be evaluated by a nurse taking directions over the telephone from a doctor. If the affected person and her child have been in severe misery, it grew to become a ready sport, with the danger escalating each minute she waited for medical consideration from her physician — or any physician. A whole lot of 1000’s of life-threatening emergencies are managed annually by OB-GYN hospitalists who workers obstetrics emergency departments.
• Reporter Rae Ellen Bichell appears to have a beef with the apply of hospitals charging for an emergency analysis when unscheduled pregnant sufferers arrive on the hospital with medical complaints. Whether or not we prefer it or not, that’s merely the way in which that well being care works in America. In the event you present up unexpectedly at a hospital for analysis of a well being concern, you can be handled as an emergency — and you’ll probably obtain a big invoice akin to the unscheduled care you obtained.
• The creator works onerous to ascertain or indicate a causal relationship between the non-public fairness backing of medical staffing firms and the truth that hospitals are billing sufferers for emergency medical providers. Nevertheless, hospital service suppliers and distributors have completely no management over a hospital’s billing practices. This bit about non-public fairness appears to serve no logical function on this article besides to make the story seem as a “whodunit,” casting non-public fairness companies within the position of immoral shadow bosses turning a revenue on the expense of unwitting expectant moms, when the truth is they play no position in establishing the billing insurance policies that Ms. Bichell incorrectly and maybe unfairly characterizes as “moneymaking ‘emergency’ occasions.”

I’ve devoted my profession to the event and implementation of obstetrics emergency departments in a whole lot of hospitals throughout the U.S., however I’m unaware of any hospital turning routine births into moneymaking emergency occasions as claimed within the title and deceptive argument of this text. I stand by my assertion — and my honest perception — that having skilled medical doctors out there 24/7 on the labor-and-delivery flooring has considerably enhanced the standard of care out there to expectant moms at among the most difficult and medically consequential hours of their lives.

Thanks for contemplating my perspective.

— Dr. Christopher C. Swain, Charleston, South Carolina

Healthcare hyper-capitalism goes simply greathttps://t.co/oZWmp5EFVL

— Adam W Gaffney (@awgaffney) October 13, 2022

— Adam W. Gaffney, Boston

Taking pictures Craps?

On-line inventory brokerage homes have made all cellphones into “playing units” years in the past (“Habit Consultants Worry the Fallout if California Legalizes Sports activities Betting,” Oct. 5). What a load of crap that California gaming would all of the sudden create new instances of dependancy. Cease the crap stories.

— Matt McLaughlin, Carpinteria, California

I am already battling display dependancy with my 13 yr outdated boy. last item i want is to fret about on-line sports activities betting as he will get older. No method on #Prop27. Habit consultants concern the fallout if California voters legalize sports activities betting https://t.co/v9ECIhNn6w

— Kristina Bas Hamilton (@kbashamilton) October 6, 2022

— Kristina Bas Hamilton, Sacramento, California

Measuring Fats: A Intestine Verify

Julie Appleby offered helpful data on how fashionable drugs misclassifies sufferers’ well being standing by using the physique mass index (“BMI: The Mismeasure of Weight and the Mistreatment of Weight problems,” Oct. 12). She included feedback advocating using waist circumference (WC, by tape measure within the standing place) moderately than physique weight to point extra particularly the place the metabolic issues could be discovered. She’s heading in the right direction, however her article may need gone additional to discover different, extra centered indicators of extra adiposity.

Anatomically, greater than 90% of human physique fats could be categorized into three important depots: gluteo-femoral (hips, buttocks, and thighs) subcutaneous adipose tissue, stomach subcutaneous adipose tissue, and visceral (contained in the stomach) adipose tissue. Of those three, solely the visceral fats is clearly related to cardiac and metabolic issues. Elevated gluteo-femoral subcutaneous fats has been proven repeatedly to be related to improved well being outcomes. Belly subcutaneous fats tends to have impartial, benign results for most people.

What we want is an easy adiposity indicator that may estimate the burden of visceral fats. Three a long time of analysis suggests {that a} easy measure of the supine sagittal stomach diameter (SAD, generally known as the “stomach top”) predicts poor well being higher than the standing WC. When individuals are within the supine place, their benign, stomach subcutaneous fats falls to the perimeters of the midline. Because of this, variation within the SAD, moderately than within the WC, is extra strongly related to the variation in visceral fats quantity. The SAD/top ratio (SADHtR) is arguably even higher than SAD alone. The SADHtR has been proven within the federal Nationwide Well being and Diet Examination Survey (NHANES) to be considerably higher than BMI for figuring out main cardio-metabolic threat elements, i.e., insulin resistance or serum triglycerides.

There’s a easy instrument that researchers or clinicians can use to measure the SAD: a low-cost, transportable, sliding-beam caliper. Numerous calipers can be found, all of that are cheaper than a high-quality scale. And the calipers are simpler to calibrate, too.

Selecting between the adiposity indicators SAD or WC might rely on the strategy’s simplicity and replicability. Particularly amongst individuals with giant bellies, the reliability of the standing WC is challenged by conflicts between minimizing pressure on the measuring tape and the tape’s tendency to droop unpredictably under the horizontal aircraft. For the SAD, each the examinee and the examiner can chill out because the higher arm of the sliding-beam caliper descends simply to the purpose the place it touches the stomach. No additional judgment is required.

— Dr. Henry S. Kahn, Atlanta

Now can we cease speaking about #BMI and begin utilizing metabolic scores as measures of well being? And should you’re not somebody’s private doctor, your opinion is neither wished nor warranted.https://t.co/ep8eYbN4SK

— Morgan Harlan (@baiacou) October 13, 2022

— Morgan Harlan, Washington, D.C.

Revisiting the Homelessness Conundrum

To me, there is just one answer to serving to our homeless get off the streets and into an atmosphere that’s protected, that may present them with meals, medical consideration, and safety, in addition to present them a method to regain the lack of shallowness of so most of the homeless (“Sobering Classes in Untying the Knot of a Homeless Disaster,” June 21). Our army bases might present all of the above, in fact, with the permission of the Division of Protection and base commanders. I see so many efforts at attempting to make the most of motels, condominium buildings, and the like, which might be costing our cities, states, and federal authorities a lot cash that basically is only a waste of time. We have to present our homeless that our authorities and all of us actually care about them. We have to supply them the chance to settle in on a army base. They’ve the human sources and monetary sources to essentially do one thing, and in a brief time period. These homeless might even be supplied up some duties to do on the bases. Please help this effort. Thanks to your efforts, too. I believe each coronary heart cries once we see this tragic scenario on our avenue, and leaves us feeling helpless and hopeless for them.

— Mike Stalsby, La Jolla, California

Incredible article exploring the intersection of excessive dwelling prices, drug use, and coverage to clarify the homelessness disaster in Portland. https://t.co/RVg0BwSABsBut how does a lot funding yield such restricted outcomes? $36 million interprets to 1500 mini properties/RVs?

— Arielle Kane (@ariellesophia) June 21, 2022

— Arielle Kane, Washington, D.C.