Showing posts with label health & fitness. Show all posts
Showing posts with label health & fitness. Show all posts

COVID-19, a Nurse, her Mother, and Monoclonal Antibody Treatments

In an Oklahoma Watch feature “A Mile In Another’s Shoes,” an initiative to give voice to the voiceless or call attention to the plight of those affected by public policy, Davis, talks about treating COVID-19 patients and the personal tragedy that motivates her.


Registered nurse Jennifer Davis runs Norman Regional Hospital's COVID-19 Infusion Unit for patients on Sept. 3, 2021. Davis has been treating nearly 100 patients a week since June with monoclonal antibody infusions.
Whitney Bryen/Oklahoma Watch (CC BY-ND 4.0)
By Whitney BryenOklahoma Watch
September 6, 2021

Less than a month after losing her mother to COVID-19, registered nurse Jennifer Davis provided the first monoclonal antibody treatment to a patient at Norman Regional Hospital’s COVID Infusion Unit. Davis couldn’t save her own mother, but she is on a mission to save others from the virus, even if it means putting herself at risk. 

I’ve been in health care all of my career, ever since I was 15. I worked in nursing homes as a nurse aid and worked my way up from nurse aid, to home health aide to licensed practical nurse to registered nurse. Truly, medical is all I’ve ever wanted to do. When I was young, my grandma worked in a hospital and I thought “I want to work in a hospital and be a nurse too.” And then as I got a little older, my mom had cancer. Dad would come home from the hospital and say how wonderful the nurses were. And that really geared me into, “I wanted to be an oncology nurse” because I wanted to return that favor. So, oncology was where I went. 

I’ve been with Norman Regional for more than seven years. I worked with the oncology group so we did chemotherapy treatments, and I worked in outpatient infusion. It’s a plethora of anything that we can infuse you with and then send you home. I stayed with the infusion as oncology opened their own little area. I helped them get that started and then I stayed where I was at with the infusion center. But that was all prior to COVID. 

I was a supervisor and didn’t have to do patient care day in and day out. But since November, I’ve gone into full-time patient care again. The monoclonal antibodies were emergently approved by the FDA for treatment of outpatient COVID for high risk, mild to moderate patients that would risk being put into the hospital for severe COVID-related symptoms. The first infusion we gave was Nov. 23. In November, December, January and February we were pretty much nonstop. And then as the numbers declined and things kind of leveled off and we started getting the vaccines, we didn’t see as much COVID. We went from probably 80 or 90 patients a week to maybe two and three. And then COVID resurged with the variants and since mid-June, we’ve been nonstop. We’re doing over a hundred infusions a week. 


"if I can save one person’s life, I’ve done it in honor of my mom."

If you just can imagine a piece of pie and there’s one slice missing that piece of pie is the cells in your body. And COVID attaches and fills in that one piece that’s missing. Your cells then continue to multiply so every day you’re multiplying COVID cells. In essence, that first 10 days is when you’re building the most cells and when the people that get the sickest typically go to the hospital. If we treat those patients within the first 10 days, that monoclonal antibody goes in there and attaches to that same spot on that piece of pie that COVID wants to attach to. So now it’s fighting with an antibody that’s like, “I’m bigger than better than you.” Then COVID can’t multiply anymore. And now your body is multiplying and making antibody cells. It neutralizes the growth of the COVID and kick starts your body into making more antibodies to fight it. Therefore it reduces the length of the symptoms, the amount of symptoms. And hopefully you don’t get symptomatic enough to have to go to the hospital. 

I have a lot of patients actually that are so thankful that we’re there. They’re concerned with us nurses who are seeing them face to face every day. They want to know “why are you putting your life on the line for us?” And I can’t answer for anyone else, but mine becomes personal because I lost my mom to COVID before this drug was out. And I just feel like, if I can save one person’s life, I’ve done it in honor of my mom.

Last October, my mom and I both became COVID positive. My daughter had surgery the last week of September and mom and I were at the hospital with her. We became symptomatic together. On Saturday, Oct. 3, she couldn’t go and get her nails done because she was tired and didn’t feel good. And on Sunday the fourth, I remember my preacher asking me, “how are you doing?” And I go, “I don’t feel good today. I’m just tired.”

I woke up on the fifth with night sweats and body aches, and I thought it  was just related to the stress. I have an autoimmune disorder and I thought it was just a flare up from the stress of my little one having a bad surgery and complications to her surgery the week before. And mom was still not feeling good either. I lost my taste on the eighth of October and that’s when I knew. 

I was in denial and didn’t get tested until I had to be tested before I had surgery on my thumb. And when it came back positive, I cried and I told mom, we had COVID. And the next day mom was just getting weaker and weaker. I had asked her mom, when was the last time you had your inhaler? She said, “Oh, I haven’t had it in a week or so. It’s at the pharmacy.” So I drove to the pharmacy and we went through the drive-through and got her inhaler. She took two puffs and in 30 minutes she had chest pain and couldn’t catch her breath. I called 911 and sent her to the hospital by ambulance.

From Oct. 14 until the 30th, I studied COVID, because I was going to tell these doctors how they were going to fix my mom. It doesn’t work that way, but I tried. I studied COVID and talked to mom as much as I could. On the 16th, on the way back to her bed from the bathroom she accidentally knocked her oxygen off and her oxygen levels went down. They couldn’t get them back up and she was struggling so they sent her to the ICU.


And I don’t think that I’ve had one person die from COVID related symptoms after these infusions. That’s what I call a miracle drug.

We weren’t allowed to visit her so it was really hard to have good communication. She couldn’t keep the oxygen on with her glasses to be able to read text messages. We were very dependent on the nurses to be able to do FaceTime. And then on Oct. 30, which is my birthday, the ice storm happened that week so we were all at her house because she had tons of tree damage. I had a hard time getting a hold of the nurse that day for an update. And finally around 4 p.m. I was able to get a hold of the nurse and he said, “well, she’s not doing well.” I told them I wanted to talk to her and she gets on the phone and she says, “I can’t do this anymore. I’m tired.”

I told my family it was time and we needed to go to the hospital. It was my son, my brother and my aunt and they would only let two of us in to see her. My brother and my aunt were on FaceTime with one of the hospital computers. My son and I geared up and when we walked in the door, I knew she was done. But I was able to hold her hand and brush her hair, change her clothes and talk to her about planning her funeral for the last four hours of her life. And she didn’t die on my birthday. She held on until the next day.

The hardest thing I’ve had to do is lose my best friend. But God knows what he’s doing. If I hadn’t gone through that, I wouldn’t be where I’m at now with my COVID patients that I’ve taken care of. I wouldn’t have the passion. I wouldn’t have the ability. I wouldn’t have the knowledge of knowing why COVID does what it does or the understanding. It put me where I need to be to be able to reach out and touch these people and help them heal. And to be that sense of comfort for the ones that are terrified dropping their moms off for a COVID infusion. It’s full circle. 

This work is tiring, but it’s so fulfilling. If I stay an extra 15 minutes, we can see one more patient. If someone will go get my daughter, I can see three more patients. It becomes an obsession because you want to help as many people as possible. And then if I can help all of these people stay out of the hospital, I’m also helping my colleagues that are seeing the ones that are dying. And I feel like if I can get these people in the first 10 days, they’re not going to end up at the hospital and they’re going to die. 

I have given probably 1,800 to 2,000 doses of monoclonals since November. And I don’t think that I’ve had one person die from COVID related symptoms after these infusions. That’s what I call a miracle drug. 


This article first appeared on Oklahoma Watch and is republished here under a Creative Commons license.


Microbiome Startups Promise to Improve Your Gut Health, but Is the Science Solid?

 

After Russell Jordan sent a stool sample through the mail to the microbiome company Viome, his idea of what he should eat shifted. The gym owner in Sacramento, California, had always consumed large quantities of leafy greens. But the results from the test — which sequenced and analyzed the microbes in a pea-sized stool sample — recommended he steer clear of spinach, kale and broccoli.

“Things I’ve been eating for the better part of 30 years,” said Jordan, 31. “And it worked.” Soon, his mild indigestion subsided. He recommended the product to his girlfriend.

She took the test in late February, when the company — which sells its “Gut Intelligence” test for $129 and a more extensive “Health Intelligence” test, which requires a blood sample, for $199 — began experiencing hiccups. Viome had promised results within four weeks once the sample arrived at a testing facility, but Jordan said his girlfriend has been waiting more than five months and has submitted fresh blood and stool samples — twice.

Other Viome customers have flocked to social media to complain about similar problems: stool samples lost in the mail, months-long waits with no communication from the company, samples being rejected because of shipping or lab processing snafus. (I, too, have a stool sample lost in transit, which I mailed after a first vial was rejected because it “leaked.”) The company’s CEO, Naveen Jain, took to Facebook to apologize in late July.



Viome’s “Gut Intelligence” test includes detailed instructions for collecting and mailing a stool sample. (HANNAH NORMAN / KHN)


Viome’s troubles provide a cautionary tale for consumers in the wild west of microbiome startups, which have been alternately hailed for health breakthroughs and indicted for fraud.

The nascent industry offers individualized diet regimens based on analyzing gut bacteria — collectively known as the gut microbiome. Consumers pay hundreds of dollars for tests not covered by insurance, hoping to get answers to health problems ranging from irritable bowel syndrome to obesity.

Venture capitalists pumped $1 billion into these kinds of startups from 2015 to 2020, according to Crunchbase, buoyed by promising research and consumers’ embrace of at-home testing. PitchBook has identified more than a dozen direct-to-consumer gut health providers.

But not all the startups are equal. Some are supported by peer-reviewed studies. Others are peddling murky science — and not just because poop samples are getting lost in the mail.

“A lot of companies are interested in the space, but they don’t have the research to show that it’s actually working,” said Christopher Lynch, acting director of the National Institutes of Health Office of Nutrition Research. “And the research is really expensive.”

With nearly $160 million in government funding, the NIH Common Fund’s Nutrition for Precision Health research program, expected to launch by early next year, seeks to enroll 1 million people to study the interactions among diet, the microbiome, genes, metabolism and other factors.

The gut microbiome is a complex community of trillions of bacteria. Research over the past 15 years has determined that these microbes, both good and bad, are an integral part of human biology, and that altering a person’s gut microbes can fundamentally change their metabolism, immune function — and, potentially, cure diseases, explained Justin Sonnenburg, a microbiology and immunology associate professor at Stanford University.

Metagenomic sequencing, which identifies the unique set of bugs in someone’s gut (similar to what 23andMe does with its saliva test), has also improved dramatically, making the process cheaper for companies to reproduce.

“It’s seen as one of the exciting areas of precision health,” said Sonnenburg, who recently co-authored a study that found a fermented food diet increases microbiome diversity — which is considered positive — and reduces markers of inflammation. That includes foods like yogurt, kefir and kimchi.

“The difficulty for the consumer is to differentiate which of these companies is based on solid science versus over-reaching the current limits of the field,” he added via email. “And for those companies based on solid science, what are the limits of what they should be recommending?”

San Francisco-based uBiome, founded in 2012, was one of the first to offer fecal sample testing.

But as uBiome began marketing its tests as “clinical” — and seeking reimbursement from insurers for up to nearly $3,000 — its business tactics came under scrutiny. The company was raided by the FBI and later filed for bankruptcy. Earlier this year, its co-founders were indicted for defrauding insurers into paying for tests that “were not validated and not medically necessary” in order to please investors, the Department of Justice alleges.

But for Tim Spector, a professor of genetic epidemiology at King’s College London and co-founder of the startup Zoe, being associated with uBiome is insulting.

Zoe has spent more than two years conducting trials, which have included dietary assessments, standardized meals, testing glycemic responses and gut microbiome profiling on thousands of participants. In January, the findings were published in Nature Medicine.



Screenshots from Zoe’s app show how my gut health and blood sugar and fat levels may react to eating my breakfast one day, a Nature’s Bakery Fig Bar. The 1-to-100 scale is based on the company’s analysis of my stool and blood tests. (HANNAH NORMAN / KHN)


The company offers a $354 test that requires a stool sample, a completed questionnaire, and then a blood sample after eating muffins designed to test blood fat and sugar levels. Customers can also opt in to a two-week, continuous glucose monitoring test.

The results are run through the company’s algorithm to create a customized library of foods and meals — and how customers are likely to respond to those foods.

DayTwo, a Walnut Creek, California, company that recently raised $37 million to expand its precision nutrition program, focuses on people with prediabetes or diabetes. It sells to large employers — and, soon, to health insurance plans — rather than directly to consumers, charging “a few thousand dollars” per person, said Dr. Jan Berger, chief clinical strategist.

Based on a decade of research, DayTwo has worked with nearly 75,000 people. It sends participants a testing kit and survey, and arranges for them to chat with a dietitian while their stool sample is processing. Then, when the results come in, it makes recommendations, Berger said.

“I can still eat two scoops of ice cream, but I need to add walnuts in it to regulate my blood sugar,” she offered as an example.

Viome says it has tested more than 200,000 customers and has published its methodology for analyzing stool samples, which is different from other gut health companies. But the paper does not address Viome’s larger claims of connecting the microbiome to dietary advice, and researcher Elisabeth Bik called the claims “far-fetched” in a 2019 review of the preprint version.

Viome makes additional money by selling supplements, probiotics and prebiotics based on consumers’ test results. It has also rebranded as Viome Life Sciences, expanding into precision diagnostics and therapeutics, such as saliva tests to detect throat cancer. Meanwhile, its gut health program has been mired in logistical missteps.

One customer who posted on Facebook tracked her sample through the U.S. Postal Service as it boomeranged between Los Alamos, New Mexico, and Bothell, Washington, where it was supposed to be picked up. Another fought for a refund after waiting six weeks to hear her sample was not viable and learning a second attempt had expired after spending too long in transit. The company’s expected lab processing time jumped from four weeks in February, when Jordan said his girlfriend took her first test, to six in summer. (Three weeks after I mailed my second sample in July, it still hadn’t made it to the lab, so I called it quits and asked for a refund.)

In CEO Jain’s July apology posted to the private Facebook group for Viome users, he said the company recently moved its lab from New Mexico to Washington state, close to its headquarters, which prompted a mail-forwarding fiasco. It bought new robotics that “refused to cooperate,” he wrote. “Many things didn’t go as planned during the move.”

Spokesperson Kendall Donohue said Viome has been working on the problems but laid much of the blame on the Postal Service.

She also said Viome has been notifying customers — even though many (including myself) had not been contacted.

It is Viome’s “top priority right now to ensure complete customer satisfaction, but unfortunately USPS needs to sort the issue internally for further action to be taken,” she said.

She also offered me a free “Health Intelligence” test. I declined.




KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Subscribe to KHN's free Morning Briefing.




Addiction and Withdrawal - Why It's So Hard to Quit Sugar

We all know how important it is to cut back on sugar consumption. But your body can hit you with withdrawal-like symptoms when you do.


Photo by  Sharon McCutcheon from 
Pexels

















This article was originally published in  The Conversation


It might surprise you to learn that sugar consumption has actually been steadily decreasing since 2008. This could be happening for any number of reasons, including a shift in tastes and lifestyles, with the popularity of low-carbohydrate diets, like keto, increasing in the past decade. A greater understanding of the dangers of eating excess sugar on our health may also be driving this drop.

Reducing sugar intake has clear health benefits, including reduced calorie intake, which can help with weight loss, and improved dental health. But people sometimes report side-effects when they try eating less sugar – including headaches, fatigue or mood changes, which are usually temporary. The reason for these side-effects is poorly understood. But it’s likely these symptoms relate to how the brain reacts when exposed to sugary foods – and the biology of “reward”.

Carbohydrates come in several forms – including as sugars, which can naturally occur in many foods, such as fructose in fruits and lactose in milk. Table sugar – known as sucrose – is found in sugar cane and sugar beet, maple syrup and even honey.

As mass production of food has become the norm, sucrose and other sugars are now added to foods to make them more palatable. Beyond the improved taste and “mouthfeel” of foods with high sugar content, sugar has profound biological effects in the brain. These effects are so significant it’s even led to a debate as to whether you can be “addicted” to sugar – though this is still being studied.

Intense sweetness surpasses even cocaine in terms of the internal reward it triggers.





Sucrose activates sweet taste receptors in the mouth which ultimately leads to the release of a chemical called dopamine in the brain. Dopamine is a neurotransmitter, meaning it’s a chemical that passes messages between nerves in the brain. When we’re exposed to a rewarding stimulus, the brain responds by releasing dopamine – which is why it’s often called the “reward” chemical.

The rewarding effects of dopamine are largely seen in the part of the brain involved in pleasure and reward. Reward governs our behaviour – meaning we’re driven to repeat the behaviours which caused dopamine to be released in the first place. Dopamine can drive us to seek food (such as junk food).

Experiments in both animals and people have shown how profoundly sugar activates these reward pathways. Intense sweetness surpasses even cocaine in terms of the internal reward it triggers. Interestingly, sugar is able to activate these reward pathways in the brain whether it’s tasted in the mouth or injected into the bloodstream, as shown in studies on mice. This means its effects are independent of the sweet taste.

In rats, there’s strong evidence to suggest that sucrose consumption can actually change the structures in the brain that dopamine activates as well as altering emotional processing and modifying behaviour in both animals and humans.

Quitting sugar

It’s obvious that sugar can have a powerful effect on us. So that’s why it’s not surprising to see negative effects when we eat less sugar or remove it from our diet completely. It’s during this early “sugar withdrawal” stage that both mental and physical symptoms have been reported – including depression, anxiety, brain fog and cravings, alongside headaches, fatigue and dizziness. This means giving up sugar can feel unpleasant, both mentally and physically, which may make it difficult for some to stick with the diet change.

A change in the brain’s chemical balance is almost certainly behind the symptoms reported in humans who remove or reduce dietary sugar.






The basis for these symptoms has not been extensively studied, but it’s likely they’re also linked to the reward pathways in the brain. Although the idea of “sugar addiction” is controversial, evidence in rats has shown that like other addictive substances, sugar is able to induce bingeing, craving and withdrawal anxiety. Other research in animals has demonstrated that the effects of sugar addiction, withdrawal and relapse are similar to those of drugs. But most of the research that exists in this area is on animals, so it’s currently difficult to say whether it’s the same for humans.

The reward pathways in the human brain have remained unchanged by evolution – and it’s likely many other organisms have similar reward pathways in their brains. This means that the biological impacts of sugar withdrawal seen in animals are likely to occur to some degree in humans too because our brains have similar reward pathways.

A change in the brain’s chemical balance is almost certainly behind the symptoms reported in humans who remove or reduce dietary sugar. As well as being involved in reward, dopamine also regulates hormonal control, nausea and vomiting and anxiety. As sugar is removed from the diet, the rapid reduction in dopamine’s effects in the brain would likely interfere in the normal function of many different brain pathways, explaining why people report these symptoms. Although research on sugar withdrawal in humans is limited, one study has provided evidence of withdrawal symptoms and increased sugar cravings after sugar was removed from the diets of overweight and obese adolescents.

As with any dietary change, sticking to it is key. So if you want to reduce sugar from your diet long term, being able to get through the first few difficult weeks is crucial. It’s important to acknowledge, however, that sugar isn’t “bad” per se – but that it should be eaten in moderation alongside a healthy diet and exercise.


This article is republished from The Conversation under a Creative Commons license. The Conversation is a nonprofit organization working for the public good through fact and research based journalism.
The Conversation

Harvard Researchers Say This One Tiny Life Adjustment Can Reduce Depression Risk

Researchers from Harvard found there’s an easy step we can all take to help prevent depression

BY HANNAH COX - August 10, 2021

This article was originally published by the  Foundation for Economic Education

In any given year, one in five Americans will have a diagnosable mental health condition, and 2020 and 2021 were anything but “any given years.”

Research continues to pour in showing an increase in mental health problems from the COVID-19 pandemic (and government policies resulting from it). One medical study found that depression symptoms were three times higher than before the pandemic. A separate survey published by the Washington Post found one third of Americans now show symptoms of anxiety, depression, or both.

Left untreated, depression exacts a severe toll in our communities, economy, and daily lives. In some ways it is as costly as heart disease or AIDS, costing over $51 billion in work absenteeism and lost productivity, and another $26 billion in direct treatment.

“We found that even one-hour earlier sleep timing is associated with significantly lower risk of depression.”




Fortunately, new research shows there’s an easy step we can all take to help prevent depression. Wake up an hour earlier.

That’s right, just one hour of sleep reduces a person’s risk of major depression by a whopping 23 percent.

The study, conducted by researchers from Harvard, MIT, and the University of Colorado Boulder, studied 840,000 individuals, and its findings are some of the strongest evidence that a person’s sleep schedule influences depression risk.

“We have known for some time that there is a relationship between sleep timing and mood, but a question we often hear from clinicians is: How much earlier do we need to shift people to see a benefit?” said Celine Vetter, assistant professor of integrative physiology at CU Boulder. “We found that even one-hour earlier sleep timing is associated with significantly lower risk of depression.”

The discovery is especially important as the increase in remote-working schedules has led many to sleep in later, which could have important implications on their mental health.

It’s also important because it’s a cheap and readily accessible option for treatment.

Americans face many barriers to mental healthcare. First and foremost, it is expensive. An hour-long therapy session costs between $65 - $250 per session without insurance. And thanks to bad government policies meddling in the insurance market, many therapists do not accept insurance at all. Furthermore, a more severe mental health diagnosis can be even more costly. Patients with severe depression who receive medical care spend nearly $11,000 a year on average, according to a report by CNBC.

The expense, coupled with a shortage in providers and medical deserts throughout large parts of the US, lead many to forgo treatment altogether. According to the National Council on Behavioral Health, 56 percent of patients want to access a mental health provider but face barriers.

Those barriers were of course increased during COVID as facilities were shut down and non-COVID patients were denied care. The numbers have already begun trickling in showing lockdowns led to greater drug use, youth suicides, and increases in depression and anxiety.

When one is struggling with depression, it is especially hard to overcome external barriers to care. Making a phone call can feel like climbing a mountain, and if you are rejected it can be all but impossible to summon the energy to keep looking and asking for help. But this new research shows individuals have the ability to take charge of their own circumstances by making small, daily changes that can help them fight their disease.

Alice Walker, the author of the Pulitzer Prize-winning novel The Color Purple, famously said, “People give up their power by thinking they don’t have any.” People often forget that they have power within themselves to confront their problems and in turn, seek protection from other external, earthly things—namely the government or their leaders. But this cycle produces dependency, not empowerment, which is not the life we as individuals were intended for.

Ultimately, your mental health is your responsibility and no one can do that work for you.




In The Law by Frederic Bastiat he says, “Life, faculties, production—in other words, individuality, liberty, property—this is man. And in spite of the cunning of artful political leaders, these three gifts from God precede all human legislation, and are superior to it.”

When dealing with mental health issues—as full disclosure, I do—an important guiding principle is self-responsibility. Yes, you may face additional burdens that others do not in your daily life. But it is still your responsibility to confront them, work through them, and move forward. Ultimately, your mental health is your responsibility and no one can do that work for you.

This same principle can be applied more broadly to those without mental health issues too. Yes, there may be circumstances that are unjust or unpleasant, yes we may have barriers placed on our paths that are outside of our control (especially by the government). But we can control how we face (and hopefully overcome) those circumstances.

We can’t turn back the clocks on all that has happened over the past year and a half, but if we turn the alarm clock one hour back we just might be a step closer to regaining control of our health.

Hannah Cox

Hannah Cox is the Content Manager and Brand Ambassador for the Foundation for Economic Education.

This article was originally published by the  Foundation for Economic Education and is licensed under a Creative Commons Attribution 4.0 International License.

One Billion People Worldwide Stop Breathing While They Sleep. Are You One of Them?

If you have sleep apnoea, chances are you don’t realise it. But it’s linked to diabetes, heart disease and other conditions, and it can put your life at risk.


BY NEIL STEINBERG - August 9, 2021

This article first appeared on Mosaic and is republished here under a Creative Commons licence.

I thought I was dying.

During the day, I was so tired my knees would buckle. Driving the car, my head would dip and then I would catch myself. My face was lined with exhaustion. 

At night, I would sleep fitfully, legs churning, then snap awake with a start, gasping for breath, heart racing.

My doctor was puzzled. He ordered blood tests, urine tests, an electrocardiogram – maybe, he thought, the trouble was heart disease; those night-time palpitations…

No, my heart was fine. My blood was fine.

He ordered a colonoscopy. It was late 2008 and I was 47 years old – almost time to be having one anyway. So I forced down the four litres of Nulytely to wash out my intestines so a gastroenterologist could take a good look inside.

My colon was clean, the doctor told me when I regained consciousness. No cancer. Not even any worrisome polyps.

However. There was one thing.

“While you were under,” he said, “you stopped breathing at one point. You might want to check that out. It could be sleep apnoea.”

I had never heard of it.

§

Sleep is marked by dynamic changes throughout the body. It’s made up of different phases, and as you move through them, your breathing, blood pressure and body temperature will all fall and rise. Tension in your muscles mostly stays the same as when you are awake – except during REM phases, which account for up to a quarter of your sleep. During these, most major muscle groups ease significantly. But if your throat muscles relax too much, your airway collapses and is blocked. The result is obstructive sleep apnoea – from the Greek ├ípnoia, or ‘breathless’.

With sleep apnoea, your air supply is continually interrupted, causing blood oxygen levels to plummet. You then stir, gasping, trying to breathe. This can happen hundreds of times a night, and the ill-effects are many and severe.

Apnoea puts strain on the heart, as it races to pump blood more quickly to compensate for the lack of oxygen. Fluctuating oxygen levels also cause plaque to build up in the arteries, increasing the risk of cardiovascular disease, hypertension and stroke. In the mid-1990s, the US National Commission on Sleep Disorders Research estimated that 38,000 Americans were dying every year of heart disease worsened by apnoea.

There’s also growing evidence that the condition affects glucose metabolism and promotes insulin resistance – leading to type 2 diabetes – and encourages weight gain. 

Then there’s the exhaustion of never having a full night’s sleep, which is associated with memory loss, anxiety and depression. Lack of sleep also causes inattention that can lead to traffic accidents. A 2015 study of drivers in Sweden found that those with sleep apnoea are 2.5 times more likely to have an accident than those without. It also fuels absenteeism, and people with apnoea are fired from their jobs more frequently than those without.

One study found that people with severe sleep apnoea were, all told, three times as likely to die during an 18-year period as those without.

But, as with smoking during the first decades after it was discovered to be lethal, there’s a disconnect between the harm that the condition causes and the public’s perception of it as a threat. “They fail to link sleep apnea with its many serious comorbidities,” says a report commissioned by the American Academy of Sleep Medicine, which estimates that it affects 12 per cent of US adults – but 80 per cent go undiagnosed. This prevalence is also found globally: nearly a billion people around the world suffer from mild-to-severe sleep apnoea, according to a 2019 study.

Research is now scrambling to catch up. Medical science has been working overtime to find a solution, from in-depth studies of hypoxia – how the body reacts to lack of oxygen – to new types of surgeries and appliances for treating the condition. But at the highest medical levels, interest is lacking. In the announcement that the 2019 Nobel Prize in Physiology or Medicine had been awarded for work on how cells adapt to changes in oxygen levels, diseases such as cancer and anaemia were mentioned, but the most common hypoxia-related ailment of all, sleep apnoea, was ignored.

Of the billion or so people across the globe struggling with sleep apnoea – most probably not even aware of it, never mind receiving treatment – I have deep psychological insight into just one: me. As the possibility that I could be facing an under-researched but potentially life-threatening health problem dawned on me, my central concern was simple: how can I fix this?

§

While there are enduring risk factors for sleep apnoea – such as obesity, a large neck or large tonsils, a small jaw, or getting older – it doesn’t present itself until after an individual falls asleep. The only way to diagnose it is to monitor someone’s sleep.

So in early 2009, prompted by both exhaustion and the suggestion from my doctor, I made an appointment at a place called Northshore Sleep Medicine in Northbrook, Illinois.

I was met by Lisa Shives, a specialist in sleep medicine. She peered down my throat, then suggested I take a polysomnogram – a sleep study, where my breathing, blood oxygen levels, heart rate, and brain and muscle activity would be recorded.

I returned for this a few weeks later, on a Thursday at 9pm – an odd time for a medical appointment. It was dark outside.

A technician showed me into a small bedroom containing a double bed and an armoire. Behind the bed, a horizontal window looked into a lab-like room stuffed with equipment. I changed into some flannel sleep pants and called the technician back in. She stuck electrodes over my chest and head, then gave me a fishnet shirt to put on to hold the wires in place.

I caught sight of myself in the armoire mirror. “A bad look,” I muttered to my reflection. With my haggard round face, electrodes held on by squares of tape on my forehead, cheek and chin, I looked irretrievably middle-aged. And tired.

At about 10pm I clicked off the light and soon fell asleep.

I woke up at 4.30am and fuzzily volunteered to try to go back to sleep, but the technician said they had six hours of data and I was free to go. After I got dressed she told me that my apnoea was “severe” and that Dr Shives would give me the details later. I had planned to take myself out to a celebratory breakfast, but instead I just went home. I wasn’t hungry; I was scared.

Several weeks later I was back at Northshore, this time during daylight. Shives sat me down in front of a screen full of multi-coloured squiggles and numbers, with a small black-and-white video of me sleeping in the corner. It was unsettling, like seeing a crime scene image of myself, dead.

Speaking of death, I had stopped breathing, Shives told me, for as long as 112 seconds – almost two minutes.

A normal level of blood oxygen saturation, as measured by a pulse oximeter, is between 95 and 100 per cent. People with chronic obstructive pulmonary disease might have a reading in the upper 80s. Mine at times had dipped to 69 per cent.

How bad is that? The World Health Organization, in a surgical guide, suggests that should a patient’s blood oxygenation fall to 94 per cent or below, they should immediately be checked to see whether an airway is blocked, a lung has collapsed or there is a problem with their circulation.

My options were few. I could, Shives said, have a uvulopalatopharyngoplasty, a procedure as ghastly as its name: removing tissue from my soft palate and widening my airway at the back of my throat. But it would be bloody, and recovery could be long and troublesome. Shives raised the possibility only to immediately dismiss it, which I later suspected was to take the sting off the second option: the mask.

§

For the first decade and a half after sleep apnoea was identified, there was only one treatment option. You could have a tracheotomy – a surgical procedure where a hole called a tracheostomy is cut low in your throat to bypass your collapsing upper airway. It offered reliable relief but had significant complications of its own.

“In the early days, doctors didn’t know much,” says Alan Schwartz, who recently retired as a professor of medicine at Johns Hopkins University in Baltimore after years of pioneering exploration on sleep ailments. “In the Eighties, when I began, we were seeing the tip of the iceberg, the most severe apnoea patients. They’d wake up with a headache, from their bodies’ tissues not getting enough oxygen. Feeling very fatigued, as you might expect. They’d become depressed, there were mood changes, short temper.”

Despite these woes, patients were understandably wary of having a tracheotomy, which today is “a surgical option of last resort” performed only in cases of extreme medical urgency. 

One study found that people with severe sleep apnoea were, all told, three times as likely to die during an 18-year period as those without.






“I was always a very loud, aggressive snorer, waking up in the middle of the night, gasping,” says Angela Cackler of Hot Springs, Arkansas, who was diagnosed with sleep apnoea in 2008, though she believes it began when she was “tiny”.

By 2012 her heart was failing.

“I went into the emergency room because I was really tired, not feeling well,” Angela says. “I found out it was heart failure. The next morning, they said, ‘We are going to do a tracheotomy.’”

And how has she adjusted to the tracheostomy after seven years?

“It’s a battle to deal with,” she says. “There is a lot of cleaning. It’s nasty. It’s work. You don’t breathe normally. Your natural humidifier is completely gone. You have to supplement that. You’re susceptible to infections.” The biggest drawback for her is that it keeps her from swimming, a recreation she once enjoyed. She also hates the looks she gets from people.

That said, the procedure did eliminate her apnoea. “I don’t snore and I can breathe and sleep better.”

Would she have it done again?

“If I had to do it again, yeah, absolutely,” she says. “It has saved me.”

Though they work in treating sleep apnoea, the life-altering drawbacks of tracheotomies inspired Colin Sullivan, today a professor of medicine at the University of Sydney, to invent the Continuous Positive Airway Pressure machine, or CPAP, that would become the new first-line treatment.

In the late 1970s, he had gone to the University of Toronto to help a sleep researcher, Eliot Phillipson, investigate respiratory control in dogs during sleep. The research involved delivering experimental gases to dogs through a tracheostomy. Returning to Australia, Sullivan designed a mask that could fit around a dog’s snout to deliver the gases that way instead.

A human patient scheduled for a tracheotomy but “eager to know if there was anything else that might work” – Sullivan’s words – inspired him to try to modify the dog mask for use by people.

Sullivan took plaster casts of patients’ noses, creating a fibreglass mask that tubing could be attached to. The blower was salvaged from a vacuum cleaner, with a head harness crafted from the inside of a bicycle helmet.

In a 1981 paper, he and his colleagues described how, when fitting the mask over the noses of five patients, CPAP “completely prevented the upper airway occlusion”.

Sullivan patented the device, and after a few years of development, he had a version that could be given to people with apnoea for use outside a lab. Today, millions use CPAP machines, though success often requires perseverance.

“There was an adjustment period,” says Steve Frisch, a Chicago-area psychologist who began using the mask in 2002. “The first two years, not every night but often, I would wake up and the mask wasn’t on me. I don’t have any memory of taking it off.”

Once he became used to the mask, his condition improved dramatically.

“The benefits of it are I get a more restful sleep,” says Frisch. “I sleep for longer periods. I don’t wake up with a racing heart. I don’t wake up gagging for air the way I do during the day when I nod off.” 

But as more patients were treated and the CPAP machines’ technology was refined – they can now upload data automatically to the cloud for analysis – doctors made an unwelcome discovery: their primary treatment often didn’t work.

“In the late Eighties, we’d sit down with a patient and ask, ‘How’s it going with the mask?’” recalls Schwartz. The patient would report, falsely, how well the mask was working. “Until we began to put electronic chips in the machines in the late Nineties, we never appreciated how little they were using their machines.”

The chips tracked how long the masks were used, and doctors found out they frequently weren’t being worn at all. “The mask is like something from a bad science fiction movie: big, bulky and obtrusive,” a New York Times article reported in 2012. Studies suggest somewhere between a quarter and half of users abandon their machine within the first year.

I certainly did. 

The CPAP did make me feel better the first night I wore it – again under observation at Northshore. I woke refreshed, alert, feeling more energised than I had in years.

But the positive effect of the mask tapered off considerably after that first deliciously restorative night. Outside of the lab I couldn’t reproduce the benefits. That first C in CPAP is for continuous, meaning that it pushes in air when you breathe in but it also pushes in air when you breathe out. You are fighting against it as you exhale, and I would wake up suffocating. There was the continual embrace of the mask, clamped to my face. Air would leak out around the edges and dry my eyes, even though they were closed.

Then there was the unspoken shame of getting into bed next to my wife and tethering myself to this breathing machine with what looked like a ribbed hairdryer hose. She tried to put a bright spin on the situation.

“You look like a fighter pilot!” she said, gamely. I didn’t realise how lucky I was: spouses of other mask-users ridicule them. (“Elephant nose!” one Polish user recalled her husband calling her – “Alien!” – before he went off to sleep in the guest room.)

Despite their drawbacks, the masks have become commonplace. But I was among the many who couldn’t wear one. Most nights at some point I would wake up and rip the mask off. In the morning, I would check the stats and see how little it was working. I went back to Northshore, where Shives would fiddle with the pressure settings or encourage me to try other masks. I returned several times, and began to feel like a regular. Nothing seemed to work. 

Finally Shives, exasperated, said, “You know, if you lost 30 pounds, the problem might go away.”

That seemed like a plan.

§

While it is possible to be thin and have sleep apnoea, obesity multiplies the probability.

I’m 5'9 and weighed 150 pounds when I graduated from college. In 2009, I weighed 210 pounds.

So in 2010, I decided to lose the weight. I had a goal – the 30-pound figure Shives recommended. And I had a plan, what I called the ‘Alcoholism Diet’. In 2006 I had stopped drinking, learning two vital things about shedding addictive substances like alcohol or sugar. 

First, you need to cut them out, not a bit, not mostly, but entirely. You can’t drink just a little; it doesn’t work. You have to eliminate the danger completely. Ditto for high-calorie foods. So no cookies, cake, candy, ice cream or donuts. Zero. To check myself, I counted calories and vigorously exercised. 

The second important factor was time. The weight took years to go on; I had to give it time to come off – a full calendar year to lose the 30 pounds. And I did it, going from 208 pounds on 1 January 2010 to 178 pounds on 31 December. It helped that I had a sharp opener I planned to use in my newspaper column crowing about the triumph, but only should I succeed.

“Unlike you, I kept my New Year’s resolutions…” it began. 

“What else helped?” I wrote. “I had a debilitating condition – sleep apnea – and a doctor said, if I lost 30 pounds, it might go away.”

The apnoea, in a rare twist, was now a positive, an inspiration to dieting. And losing the weight did the trick. No more mask.

I’m surprised I admitted in print that I had apnoea. It was embarrassing. I’m not sure why. It wasn’t as if it were an ailment classically suffused with shame. It wasn’t like having gonorrhoea. I suppose it just seemed a feeble ageing fat man’s complaint. I’d see the elastic marks on the red flabby faces of my fellow commuters at the train station in the morning and I’d pity them for it. I hated the thought of being among them.

But it turns out I mistook winning a single year’s battle with victory in the war. The pounds I had lost somehow found me again, 20 of the 30 creeping slowly back on over the next decade. And with them, the apnoea came back. Not that I realised it until the summer of 2019, when I underwent spine surgery. The pre-surgery questionnaire at Northwestern Memorial Hospital in Chicago asked if I sometimes snored, if I was often tired and if I had ever been diagnosed with sleep apnoea. 

Yes, yes and yes. 

With sleep apnoea, your air supply is continually interrupted, causing blood oxygen levels to plummet. You then stir, gasping, trying to breathe. This can happen hundreds of times a night, and the ill-effects are many and severe.







“It’s important to screen people for sleep apnoea because it could be a risk when having surgery,” says Phyllis Zee, director of the Center for Circadian and Sleep Medicine at Northwestern University’s Feinberg School of Medicine. It can be a risk factor for poor outcomes afterwards as well.

The questions about snoring and exhaustion are important because, despite the efforts of medical science to spread the word, most people with apnoea don’t realise they have it. 

A 2017 German study found that while obstructive sleep apnoea might be present in as much as 40 per cent of the general German population, only 1.8 per cent of hospital in-patients were identified as having it, which the authors said was possibly due to low awareness of the condition among both patients and hospital staff.

“Our choice of anaesthesia might change based on sleep apnoea,” says Ravindra Gupta, anaesthesiologist and medical director of the post-anaesthesia care unit at Northwestern Memorial Hospital. “Several medications can cause the airway to collapse, or when you start adding multiple medications, those effects build up and layer one on another.”

After surgery, people with apnoea have to be monitored longer, Gupta says.

According to an article in the New England Journal of Medicine, there’s an “epidemic” of sleep apnoea among US surgical patients. One in four candidates for elective surgery have it, but for certain groups, the rate is even higher – eight in ten patients being treated for obesity, for instance, have it, resulting in a range of risks.

“Patients with sleep apnea undergoing orthopedic or general surgery appeared to be at increased risk for pulmonary complications and need for intensive care services, which significantly increase health care costs,” the authors noted.

My revealing on the pre-surgical questionnaire that I previously was diagnosed with sleep apnoea had immediate effects. My spine surgery was done quickly – taking place a week after I first went over my MRI with a surgeon – but in that brief period the hospital insisted I undergo a home sleep study to gauge the severity of the apnoea. Instead of going to a sleep centre, I brought home a kit that instructed me how to place sensor bands around my chest, a pulse oximeter on my finger, and a clip under my nose to monitor breathing. There was no EEG, and one drawback of these take-home tests is the units never know if you are actually asleep or not while the readings are being made.

Still, lowering the cost and inconvenience of diagnosis offers hope that more people will discover they have apnoea – the expense and time needed to have an in-lab polysomnogram is thought to be one reason diagnosis rates are so low. 

The test found I had moderate apnoea – perhaps a function of keeping that last 10 pounds off – information the anaesthesiologist used when putting me under.

§

“Weight loss is curative,” says Philip Smith, a professor of medicine at Johns Hopkins School of Medicine and a specialist in pulmonary disease and sleep apnoea. “The problem is, people can’t do it.” 

Add to this the fact that many patients can’t use CPAP, and it becomes clear that there’s a “critical unmet need,” says Schwartz. So over the past two decades, a series of other treatments have been rolled out.

In the mid-1990s, a dental appliance began to be used by those who couldn’t tolerate the mask.

“Obstructive sleep apnoea happens in the back of your mouth,” says David Turok, a general dentist with a practice concentrating on apnoea. “Basically, your tongue doesn’t have enough room in your mouth and pushes back into your airway. CPAP forces the tongue out of the way by forcing air down. An oral appliance brings the lower jaw forward, and the tongue comes with it.”

Think of it as a brace, using upper teeth as an anchor to push the lower teeth, and with them the lower jaw, forward, widening the airway at the back of the throat.

Like CPAP, the oral appliance is also an imperfect solution. It holds the jaw in an unnatural position, so it can be uncomfortable, and prolonged use can change your bite, leaving the jaw forward. The pressure of it can also alter the position of your teeth a little bit.

Yet in his years of working on apnoea treatments, the majority of Turok’s patients have had success with an oral appliance.

“But these are mild-to-moderate cases,” he says. “For someone with severe sleep apnoea, CPAP is preferred. I never say you have a choice. You’ve got to try CPAP first.”

He says that the surest way to address apnoea, for patients who can’t adjust to either CPAP or oral appliances, is jaw-advancement surgery, a better procedure than widening the soft tissue of the throat.

“Recovery is easier because it is bone healing instead of tissue healing,” Turok says. Though the surgery is not without drawbacks, including the need to break your lower jaw in two places and have your mouth wired shut after surgery.

Treatments are moot, however, if you don’t know you have apnoea. Turok observes that since the problem still goes undiagnosed in so many for so long, dentists have an important role to play in identifying it.

“Sleep apnoea is very much an oral condition,” he says. “Not every dentist should be treating sleep apnoea, but every dentist should be looking for it.”

A further strategy is, in essence, an electrical version of the oral appliance: hypoglossal nerve stimulation (HNS), where a small electrical charge is used to make the tongue contract and stop it falling backward during sleep.

“We started the original work about 20 years ago,” says Smith. It uses “a very small pacemaker – the same as a cardiac pacemaker.”

The pacemaker device is implanted in soft tissues just below the collarbone, with an electrical lead tunnelled under the skin, and near the jaw it is attached to the hypoglossal nerve – which controls the tongue – with a cuff electrode. The patient using the device activates it before sleep by pressing a button on a remote control.

A 2014 study – funded by Inspire Medical Systems, a company that makes HNS devices – found that this “upper-airway stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea”.

“It’s actually quite well tolerated,” says Schwartz, who has consulted for a number of companies exploring HNS. “If you are awake, you feel your tongue is stiffening up or moving a little bit forward. In general, patients sleep through it really quite well.”

The UK’s National Institute for Health and Care Excellence, though, urges caution. “Current evidence on the safety and efficacy of hypoglossal nerve stimulation for moderate to severe obstructive sleep apnoea is limited in quantity and quality,” it says.

§

Despite the range of treatments, there’s a general consensus about how to approach obstructive sleep apnoea – use the mask, and try to lose weight.

If that doesn’t work, then you’ll have to find something else that does. 

Lawrence Epstein, assistant medical director of the Sleep Disorders Service at Brigham and Women’s Hospital in Boston and past president of the American Academy of Sleep Medicine, calls CPAP “the recommended first-line therapy,” but says treatment ultimately is “more about knowing all the options and trying to tailor the therapy both to what the patient has and what they would be willing to use”.

He points out that while obstructive sleep apnoea is viewed as a single condition, it is prompted by a multitude of causes – facial and throat configuration, muscle tension, obesity – and so not every treatment works the same for every patient.

“We have very effective treatments, but all have some downsides. It’s a matter of matching the right treatment to the right patient.”

There really is only one test: “Make sure it works,” he says, noting that “we still have a ways to go” when it comes to perfecting treatment.

Much hope is centring on that treatment someday being a pill.

“The future is neurochemical,” says Smith of Johns Hopkins. “We can treat apnoea in a mouse. Probably in the next ten years, maybe five, you’ll be able to take medication for sleep apnoea, because it’s a neural-chemical problem. It’s not obesity itself, not fat pressing on the airway, but fat excreting certain hormones that makes the airway collapse.” Schwartz is more circumspect – he thinks “it’s a combination of the two” – but has also been investigating hormones secreted by fat cells.

There are also promising human trials. Phyllis Zee was co-lead author of a 2017 paper that found that dronabinol, a synthetic version of a molecule found in cannabis, is “safe and well tolerated” and lowers the severity of sleep apnoea compared to a placebo. 

“The CPAP device targets the physical problem but not the cause,” Zee said at the time of publication. “The drug targets the brain and nerves that regulate the upper airway muscles. It alters the neurotransmitters from the brain that communicate with the muscles.”

There are other hopeful signs. A small double-blind international study of two drugs used in combination – atomoxetine and oxybutynin – found that they “greatly reduced” apnoea, cutting airway obstructions during sleep by at least 50 per cent in all of the participants.

But for a person like me, struggling with apnoea now, the wait might be a long one.

“They’ve been predicting in 20 years we’re going to have some drug to deal with the problem,” says Schwartz. “The only problem is, it’s been a rolling 20-year backlog. We’ll get there, I have no doubt. There are a couple of promising pharmacological approaches that may be on the horizon.” 

Patience and healthcare are often linked, whether waiting for new treatments creeping to market, waiting for changes in lifestyle to bear fruit, or even waiting to see the right specialist. For me, it was back to long-term dieting and an appointment with a sleep specialist at Northwestern.

As an indicator of just how many people are dealing with this condition, I got in touch with Northwestern in July, when I had my surgery and learned the apnoea had returned. They said they would schedule me for the first available appointment – not until late October.


This article first appeared on Mosaic and is republished here under a Creative Commons licence.

Popular Posts