Readers and Tweeters Take Positions on Sleep Apnea Treatment

Letters to the Editor is a periodic function. We welcome all comments 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 (“Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution,” Oct. 3). Whereas I agree that positional remedy is usually missed as a first-line remedy for obstructive sleep apnea, one has to have a look at this critical, life-threatening well being situation in a bit extra element. First, Mr. Hancock’s analysis was central sleep apnea, which suggests both a neurologic and/or respiration management etiology. Sleeping on the aspect could stop airway obstruction, however the underlying trigger has possible 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 may happen with little or no warning. Third, apparently the positional remedy on this case alleviated the situation — however as one will get older, the situation will possible worsen.

Backside line: Why does this specific affected person have this situation and what may be achieved to deal with the basis trigger as an alternative of taking a symptomatic method? My concern is that, left untreated, the sufferers go to sleep with a false sense of safety to by no means get up the following morning.

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

— Liz Beaulieu, Yarmouth, Maine

Lastly! Jay Hancock uncovered the sleep apnea medical racket. I’ve one other remedy possibility: Throughout covid, many inpatients had been intubated within the inclined place. I used to be inquisitive about that and did some Googling. Not solely does sleeping in your abdomen improve lung capability, the gravity on the throat is a pure remedy 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

— 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 massive business 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 needs to be broadly disseminated as it’s of maximum significance to hundreds of thousands who’re falling for the hype!

— Lawrence Dee, Chino Valley, Arizona

— 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 social gathering 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 cope with tens of hundreds of thousands of recent diagnoses of sleep apnea, which can quickly be made in major care and dental places of work throughout our nice land, utilizing automated, wearable expertise. That point is coming inside 18 months.

You suffered as a result of there was insufficient teaching for a very difficult illness. Easy as that. All those that can be subjected to a cloudburst of automated diagnostics could have the identical journey to make. Out of necessity, your answer was to slog via your individual analysis to get your self some sane path. 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 website is a pleasant introduction. Our podcast can also be a blast that I believe your readers would discover very attention-grabbing.

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

— 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 concerning the current article “Severe Sleep Apnea Diagnosis Panics Reporter Until He Finds a Simple, No-Cost Solution” (Oct. 3). Whereas I commend the writer for looking for medical assist for his daytime drowsiness and loud night breathing, I concern his article could mislead readers in a approach that would jeopardize not solely their very own well being and security however that of others as properly.

The writer is clearly dissatisfied with the care he acquired; nevertheless, utilizing this to recommend that almost everybody recognized with sleep apnea ought to merely deal with it on their very own “at no cost” is harmful. Sleep apnea is a typical and persistent medical situation that will increase the dangers for quite a few bodily and psychological well being penalties, diminished high quality of life, motorized vehicle crashes, and untimely demise.

Positional remedy (which usually requires using a tool to take care of a side-sleeping place), although helpful for some sufferers with sleep apnea, shouldn’t be the very best remedy for many sufferers, particularly these with average to extreme sleep apnea. Constructive airway strain (PAP) remedy is the best-supported, evidence-based remedy for sleep apnea. The newest systematic assessment and meta-analysis included 80 randomized managed trials investigating using PAP remedy to enhance outcomes. Thousands and thousands of sufferers with sleep apnea can attest to the life-changing — and even lifesaving — impression of PAP remedy. Therapy choice is a crucial resolution that needs to be made collectively by a affected person and their treating supplier.

Moreover, it’s inappropriate for the writer to make use of his expertise as justification to malign our complete group and our 12,000 members. AASM strongly refutes the implication that assist from business biases our scientific observe tips and insurance policies. Our tips are based mostly on a assessment of the most recent analysis by a activity power of specialists who decide the energy of proof for a given remedy. The AASM additionally ensures conflicts of curiosity are mitigated via a stringent scientific observe guideline improvement course of. Whereas the writer claims our group “funds its operations” with business assist, that is merely unfaithful. Trade assist represents roughly 1% of our annual income and is guided by a transparent coverage that helps guarantee clear interactions to forestall undue affect and assist 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 gear suppliers, not by sleep facilities or sleep medical doctors.

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

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

— Timothy Noah, Washington, D.C.

I simply noticed Jay Hancock’s article on my Google feed and browse it, as I undergo from critical sleep apnea as properly. I’ve acquired 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 study to breathe via my nostril always — so far with blended outcomes, however the topic may be very attention-grabbing because it pertains to much more than simply find out how to get evening’s sleep.

— Dimitri F. Frank, Málaga, Spain

— James Hughes, Savannah, Georgia

Treating Trauma — Adopted by Billing Trauma

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

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

— 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 handle the medical care variations between the ED and pressing care.

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

The data, potential, talent, and expertise of the supplier are key. The placement of care predisposes to the skills of the supplier however doesn’t assure them. It’s possible you’ll obtain glorious to below-average care relying on the supplier. I’ve seen folks die from auto accidents that had been despatched residence from pressing care after receiving an analysis by a normal practitioner not skilled in trauma. Some ED physicians miss issues, however the odds are higher that the ED physician won’t miss crucial circumstances.

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

Then there are the personnel and assets offered. If it’s a easy “pressing” drawback, no important distinction in final result is more likely to consequence.

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

A few of the pressing care facilities I labored in turned away “third-party” circumstances however most didn’t — even throughout the similar hospital-owned pressing care chain. An possibility can be to supply to pay money, asking for the cash-upfront value. Troublesome to be correct in predicting the associated fee forward of time, however an estimate shouldn’t be unreasonable. As an alternative of a low four-figure invoice, the household might 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 real motive of the hospital billing a second cost. Many sufferers are despatched as a result of they want a better stage of care that isn’t out there, resembling hospitalization, injectable drugs, specialty care, imaging, and “stat” lab work not out there.

Positive, 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 keep in mind 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 normal 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: Previously 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 aspect.)

— Dr. Mickey Kolodny, Palos Verdes Peninsula, California

— Donald Farmer, Woodinville, Washington

After 40 years as a board-certified emergency drugs doctor, I consider the article by Sam Whitehead may be very deceptive. To start 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 had 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 — aside from understating her post-accident scenario, which was self-defined. The writer writes as whether it is strictly an insurance coverage situation or a approach for the pressing care/hospital system to achieve 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 legislation, this affected person wanted a go to to a trauma middle emergency room. And the invoice is a completely totally different situation. In different phrases, the writer completely missed the medical points to overstate and sensationalize billing points.

— Dr. Anthony F. Graziano, Oconomowoc, Wisconsin

— Kendra Lee, Woodbridge, Virginia

I listened to your story as retold on NPR a couple of younger lady who had a excessive invoice for an ER go to after a automotive accident. I felt that the story was editorially biased, because it talked about nothing concerning the necessities for look after traumatically injured sufferers. It appeared to suggest visiting pressing care facilities as an alternative of emergency rooms. Though inexpensive, such services typically mustn’t look after sufferers with critical accidents. Most hospitals require board-certified emergency drugs physicians and have intensive assets whereas an pressing care physician could 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 situation. Clearly the general public needs to be higher knowledgeable about cost-effective care, however an analysis after a critical automotive crash is inappropriate to be despatched to an pressing care.

— Dr. Christopher Goltz, Flint, Michigan

A Wealth of WISDOM

Good article (“Genetic Tests Create Treatment Opportunities and Confusion for Breast Cancer Patients,” Sept. 21). With breast most cancers consciousness month upon us, I might additionally level out the existence of the WISDOM research funded by the Nationwide Institutes of Well being, which is totally different approaches to utilizing genetic testing to display girls for breast most cancers. Test it out at

— Dr. Daniel Halevy, New York Metropolis

— Dr. Cee A. Davis, Winchester, Virginia

On the Delivery of Obstetrics Emergency Departments

I used to be dissatisfied by your article “Baby, That Bill Is High: Private Equity ‘Gambit’ Squeezes Excessive ER Charges From Routine Births” (Oct. 13). Whereas I acknowledge that medical billing is usually complicated and at instances even alarming to sufferers, I want to share a couple of factors that I really feel had been downplayed or omitted:

  • The article gives the look that the obstetrics emergency division, or OBED, is created just by rebranding an present course of inside hospitals. The writer 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 could be improper, weren’t capable of see a doctor once they visited a hospital emergency room. As an alternative, they had been transferred to the labor and supply division to be evaluated by a nurse taking directions over the cellphone from a doctor. If the affected person and her child had been in critical misery, it turned 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 every year by OB-GYN hospitalists who workers obstetrics emergency departments.
  • Reporter Rae Ellen Bichell appears to have a beef with the observe 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 case you present up unexpectedly at a hospital for analysis of a well being concern, you can be handled as an emergency — and you’ll possible obtain a big invoice similar to the unscheduled care you acquired.
  • The writer works arduous to ascertain or suggest a causal relationship between the personal fairness backing of medical staffing corporations and the truth that hospitals are billing sufferers for emergency medical companies. Nevertheless, hospital service suppliers and distributors have completely no management over a hospital’s billing practices. This bit about personal fairness appears to serve no logical objective on this article besides to make the story seem as a “whodunit,” casting personal fairness corporations within the position of immoral shadow bosses turning a revenue on the expense of unwitting expectant moms, when in truth 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 standpoint.

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

— Adam W. Gaffney, Boston

Capturing Craps?

On-line inventory brokerage homes have made all cellphones into “playing units” years in the past (“Addiction Experts Fear the Fallout if California Legalizes Sports Betting,” Oct. 5). What a load of crap that California gaming would immediately create new circumstances of dependancy. Cease the crap reviews.

— Matt McLaughlin, Carpinteria, California

— Kristina Bas Hamilton, Sacramento, California

Measuring Fats: A Intestine Examine

Julie Appleby offered helpful data on how trendy drugs misclassifies sufferers’ well being standing via using the physique mass index (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” 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 may be discovered. She’s heading in the right direction, however her article might need gone additional to discover various, extra targeted indicators of extra adiposity.

Anatomically, greater than 90% of human physique fats may be categorized into three major depots: gluteo-femoral (hips, buttocks, and thighs) subcutaneous adipose tissue, belly 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. Stomach subcutaneous fats tends to have impartial, benign results for most people.

What we want is a straightforward adiposity indicator that may estimate the burden of visceral fats. Three many years of analysis suggests {that a} easy measure of the supine sagittal belly diameter (SAD, typically known as the “belly peak”) predicts poor well being higher than the standing WC. When individuals are within the supine place, their benign, belly 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/peak 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 simple tool that researchers or clinicians can use to measure the SAD: a low-cost, transportable, sliding-beam caliper. Varied calipers can be found, all of that are inexpensive than a high-quality scale. And the calipers are simpler to calibrate, too.

Selecting between the adiposity indicators SAD or WC might rely upon the strategy’s simplicity and replicability. Particularly amongst individuals with massive bellies, the reliability of the standing WC is challenged by conflicts between minimizing stress on the measuring tape and the tape’s tendency to droop unpredictably beneath the horizontal airplane. For the SAD, each the examinee and the examiner can calm down 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

— 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 secure, that can present them with meals, medical consideration, and safety, in addition to present them a method to regain the lack of vanity of so most of the homeless (“Sobering Lessons in Untying the Knot of a Homeless Crisis,” June 21). Our navy bases might present all of the above, after all, with the permission of the Division of Protection and base commanders. I see so many efforts at attempting to make the most of resorts, condo buildings, and the like, which are costing our cities, states, and federal authorities a lot cash that actually 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 provide them the chance to settle in on a navy base. They’ve the human assets and monetary assets to essentially do one thing, and in a brief time frame. These homeless might even be provided up some duties to do on the bases. Please assist this effort. Thanks in your efforts, too. I believe each coronary heart cries after we see this tragic scenario on our avenue, and leaves us feeling helpless and hopeless for them.

— Mike Stalsby, La Jolla, California

— Arielle Kane, Washington, D.C.


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