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Read this if you cannot sleep.

posted by Thomas Stern

The good news is if you think you cannot sleep you are probably wrong.  It's not that you can't sleep - it's that you are not sleeping like you want or you are not getting the results from sleep like feeling refreshed that you expect. The reality is if you cannot sleep you die.  If you are reading this than that has not happened yet.  The only way you would die from insomnia is if you had a very rare neurological disease that affects middle age people called fatal familial insomnia. Insomnia is only one of the symptoms.  Others symptoms include hallucinations and movement problems such as difficulty walking.  I have never diagnosed fatal familial insomnia (and I hope I never will) so I am certainly not an expert on it.  I have also never seen anyone die from insomnia so I don't think I have missed a case.  Most people deal with insomnia at some point of their life.  Unfortunately when people recognize they are having trouble sleeping the first thing they do is reach for a bottle of pills. Pills do not solve the problem and the most common prescription "sleep"  medicines are associated with an increased risk of death. It does not make sense to prescribe these medicines for a condition that is not life threatening to begin with.  New data out this week suggests over the counter medications - commonly referred to as supplements - may not be safe either.  A recent JAMA article highlighted a high rate of adulterated substances in nutritional supplements.  The article was not specific to substances marketed to sleep but I think it would be naive to think they are not contaminated.  That information should make you lose sleep at night.  The reality is that when you buy a supplement you have no idea what you are putting in your body.  You are relying on the integrity of the company making the product.  Call me cynical but the first goal of most companies I encounter is not to promote my well being - it is to help me depart with some of my money. 

If you need help with your sleep instead of looking to the pill bottle approach your insomnia or poor quality sleep like any other problem - identify the underlying cause and treat it. I can't promise the process will be simple - but it will be more effective than taking pills.

The future of cancer care.

posted Jul 24, 2018, 5:47 PM by Thomas Stern

I will never forget the first child I saw die of cancer.  I was a medical student tagging along with my dad who was attending on the general pediatric medicine service at Arkansas Children's Hospital.  She was 3 years old sleeping peacefully in a crib.  She was thin and bald from chemotherapy. I thought how peaceful and almost angelic she looked.  I might have been in the room 30 seconds because she was comfort care and there was nothing left to do.  She had failed all therapies and the medical staff was resigned to her death.  The next day we came back to her room and the room was empty.  The floor nurse reported she had died the night before.  I decided for a short while I wanted to be a pediatric oncologist.  As my experience with oncology grew I observed hundreds if not thousands of people endure chemotherapy including a couple of my own family members. At that point cytotoxic drugs were the treatment.  I often wondered if chemotherapy did more harm than good.  Nausea, vomiting, hair loss, weight loss, and lethargy seemed to be an expected side effect.  My encounters were mostly in hospitalized patients so I saw the sickest subset.  Cytotoxic drugs kill all rapidly reproducing cells which is why they caused so many problems.  It was non-specific killing.  WIth a novice understanding of immunology and oncology it seemed there should be a way to direct someones immune system to knock out only the bad cancer cells.

For the first time I read about this type of approach today in this article. These researchers at NIH took lymphocytes out of a cancer patient, identified which cells were successfully attacking the cancer, mass produced these cells, and reintroduced them into the patient.   Metastatic cancer disappeared. It is only one patient.  It could be coincidence.  I really hope this is the beginning of a new age in cancer care.

Makesleepeasy.com

posted Jun 5, 2018, 11:47 AM by Thomas Stern

Medicine in 2018 is tough.  The ultimate decision maker in your care is your insurance company - not me.  In fact I have to spend considerable time arguing with insurance companies for testing and treatments that are the standard of care for sleep disorders and lung disorders. One of the common questions I get is from people who present for an assessment for sleep apnea is "If I know I have problems breathing at night why do I have to get a sleep test?".  That is a very valid question because the cost of sleep testing will often exceed the cost of treatment.  It costs between $700 and $2500 to get a sleep study in a sleep lab depending on if it is done in a physicians office or a hospital.  Even home sleep testing can cost $200-$400.  Clinical research has shown that patient's who have a high pre-test probability of sleep apnea don't benefit from testing. They do fine just being treated.  The truth is it is not up to me.  I am not allowed to order a CPAP machine through an insurance company without a sleep study documenting sleep apnea. If the cost of the study and the CPAP hit a deductible than the out of pocket cost for getting sleep apnea treated will exceed $1500.  I have seen that prevent a lot of people from getting treatment for sleep apnea.

I recently launched a website to try and combat this problem.  It is www.makesleepeasy.com. This site provides a mechanism for someone to get diagnosed and treated with sleep apnea for as little as $850.  If testing is not necessary the price drops to $650.  The good news is I am not geographically limited in providing these services. I am able to offer them in the 3 states I am licensed - North Carolina, South Carolina and Ohio. The qualifier is the site cannot accept insurance.  I also cannot treat medicare patients through the site.  You can use flexible spending or healthcare savings accounts to cover the cost. For people with high deductible insurance plans you will likely save money on diagnosis, testing and treatment. You certainly will not have to deal with the hassle of pleasing a health insurance company.  I can manage other sleep disorders such as insomnia through the site. I will not prescribe sleep medicines through the site. For those of you that know me you know I do not prescribe them in the office either. If you know someone who is not getting their sleep disorder treated because they cannot afford it - this may be an alternative. 

Is it necessary to sterilize your CPAP?

posted Mar 5, 2018, 7:01 PM by Thomas Stern

I have been fielding a lot of questions lately about the new gadget on the market that sterilizes your CPAP machine.  Patient's want to know if 1) the CPAP sterilizing machine works 2) if CPAP sterilizing machines prevent infection and 3)if health insurance plans pay for the machine.  

CPAP sterilizing machines do work.  The most popular version on the market generates ozone which circulates through the CPAP unit.  Ozone is bactericidal. White vinegar is also bactericidal.  I will never forget when I was a medical student rotating through the vascular surgery service at the VA.  Every morning we would change dressings on veterans with chronically infected leg wounds.  The wounds would be weeping pus even after several weeks of oral or IV antibiotics.   The medical students were responsible for changing out wound dressings that were soaked in a diluted vinegar solution.  In a couple days the wounds would be clean. If vinegar can take care of those wounds with hospital bacteria, it can certainly keep a home CPAP clean.  This is why we instruct our patients to wash personal CPAP with a dilute vinegar solution once a week.  

I have been practicing sleep medicine for over 15 years now.  I have never known a person to get an infection from their CPAP machine - and I have seen some nasty CPAP machines. There have been multiple occasions I have discovered roaches in CPAP machines brought to clinic (yes - some alive).  I have seen countless machines with mold growing inside of the water chamber.  Filthy masks are a daily occurrence.  I have not diagnosed one infection from CPAP.  I decided to do a literature search and did not find any medical research documenting evidence of infection being spread by a personal CPAP machine.  In fact the only paper I found on the topic suggests personal CPAP machines do not cause infection.   It is important to note a difference between a personal CPAP machine and a CPAP machine in a hospital that is used by multiple people.  Personal CPAP machines are used by one person only.  People do not catch diseases from themselves - they catch infectious diseases from other people or things.  If your immune system becomes compromised you can certainly get an infection from the bacteria that are always on your body but that is different than transmitting an infection.  Hospital CPAP machines are used over and over again by multiple different people and have been shown to harbor infection. Anything that is in a hospital can harbor an infection and should be sterilized between uses.  

I can promise you insurance companies do not pay for CPAP sterilizing machines.  The units cost about $300.

Do I recommend everyone get a CPAP sterilizing machine?  I do not.  Do I recommend keeping your CPAP clean?  I do.  Patients do find the CPAP sterilizing machines more convenient.  If the convenience is worth the price tag by all means get one.  If you are getting one because you think you need to sterilize your CPAP machine nightly then think again.  Then you also need to sterilize your pillow case because the same germs that end up on your CPAP are also on your pillow case. 

One way to Avoid Obamacare

posted Aug 30, 2017, 6:15 PM by Thomas Stern

The world is watching as the US healthcare system slowly implodes and our elected leaders do nothing to stop it.  The cost of healthcare is climbing while the access to healthcare is declining.  I am not talking about the access to health insurance - I am talking about the access to healthcare.  Most politicians and members of the media do not understand the difference.  Access to health insurance is at an all time high because it is required by law in the United States of America to purchase healthcare from a private company if you do not have an employee sponsored plan and do not qualify for a government sponsored plan.  That concept seems un-American to me.  The result is skyrocketing insurance rates.  You can't print money as fast as someone will take it from you given the opportunity and now private healthcare companies have the opportunity.  Check out the 1st quarter revenues of United Healthcare in 2017.  They were up 9.4%.  I can assure you the revenue in my practice was not up 9.4%.

So what can you do when the law requires you to purchase a product whose costs are out of control?  One option is to not get health insurance and pay a penalty.  I don't like that answer because then you pay money and assume risk for being uninsured. I think I have found a better answer called health care sharing ministries. Wikipedia does a good job describing health care sharing ministry.  There are certain requirements these organizations have to meet one of which is having similar beliefs.  The ties to a religion protects it from the requirements of Obamacare.  The down side is not everyone is eligible and pre-existing conditions and certain behaviors such as smoking and drinking are exclusive.  They function very similarly to traditional insurance companies - you have a card you present for care and claims are paid through traditional clearing houses.  The fees are a fraction of what Obamacare costs.  I have encountered several patients that belong to these organizations and they have spoken positively of them.  I personally do not belong to a health care sharing ministry but it is something you might want to consider if you are struggling to afford health insurance thanks to Obamacare.

The Beginning of an Epidemic

posted Aug 20, 2017, 7:16 AM by Thomas Stern

I am conservative when it comes to prescribing medication as a rule.  I believe in using the least amount of medication necessary for the shortest amount of time to achieve the desired outcome.  I favor non-pharmacological treatments over medicine whenever possible.  As a result I am a sleep physician that does not prescribe "sleep medicines". This may seem odd but the reason is that traditional "sleep" medicines are really sedatives. There is a difference between sedation and sleep as described by this article from the New England Journal of Medicine. These sedatives are associated with several adverse outcomes including motor vehicle accidents, dementia and death.  Sedatives are very effective at what they are designed to do which is make people unconscious. I used them routinely when I worked in the intensive care unit.  Interestingly they are also associated with adverse events in the ICU as well. Patient's who have sleep disorders like sedatives because sedatives makes them unconscious quickly and prevent awareness of poor quality sleep.  Sedatives actually hurt your quality of sleep by suppressing REM sleep and making sleep disordered breathing worse.  Sedatives cause physiologic addiction so people who use them experience withdrawl if they stop abruptly.  Long term use of sedatives will cause tolerance so that a dose that used to work no longer works and the poor sleep quality returns.  The options are to go up on the dose or go through withdrawl.  That is why the FDA has only approved sedatives for short term use - weeks to months in most cases.  Why would anyone prescribe these drugs long term?

The press is full of stories about the opioid epidemic in America right now.  Prescribed opioids are the number one cause of drug overdose death in the country. Prescribed opioids kill more people than heroin and cocaine. Why are opioids being over-prescribed by physicians? I recently read this concise review of the opioid epidemic in Medical Economics. The opioid epidemic started in the mid 1990's when The American Pain Society concluded pain was under-treated.  This lead to pain scales being incorporated into vital signs.  Then a private company called The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) decided that hospitals should not be paid by medicare unless they do a better job treating pain.  When hospitals get threatened with non-payment from medicare what do they do?  They put together committees and care plans to address that issue.  In this case hospitals made a conscious effort to address pain which resulted in physicians writing more prescriptions for opioids.  In the US there were about 80 million opioid prescriptions written in 1991 and in 2011 that grew to 220 million. Over 15,000 Americans are dying annually from prescribed opioids. This epidemic demonstrates a major failure in JCAHO and our federally funded healthcare programs.  If a physician is responsible for one death due to incompetence we get sued and can lose our license.  JCAHO promoted a practice which has influenced hundreds of thousands of deaths and still has a major influence on our healthcare system.  Why aren't regulatory bodies held to the same standard?

One more interesting fact.  The incidence of narcotic overdose is higher in patient's taking sedatives.  Don't worry - I am not going to be pressured into prescribing sedative medications.

More Fake News

posted May 31, 2017, 6:51 PM by Thomas Stern

Politicians are not the only people who have to deal with fake news.  Physicians deal with it on a regular basis as well.  The source is the same - the main stream media and the internet.  If you believed advertisements for supplements, FDA approved drugs and devices there would not be a need for physicians.  One of those 3 things can cure whatever afflicts you - whether it's obesity, insomnia, depression, anxiety, wrinkles or sexual dysfunction. The ads can be convincing.  The problem is they prey on desperate people. After trying years of things that don't work they will stumble in my door.  What greets them is not what they want to hear.  It's called reality.

There are a couple of questions I answer on a daily basis because there is so much misleading information being advertised.  One is alternative treatments to sleep apnea.  I dream of the day there is a comfortable easy to use effective treatment for sleep apnea.  There was a nerve stimulator invented a couple years ago that I really thought was going to replace CPAP.  The problem is it does not work as well as CPAP.  The only results I have seen published were in a group of mostly men that were not very obese (Average BMI of 28) and whose sleep apnea was moderate on average (AHI=29).  The AHI improved to 9 one year after the procedure.  The procedure was associated with serious adverse events and almost 1/3 were considered non-responders.  The device costs $20,000 and the procedure to put it in costs $30,000 to total $50,000.  Oh, and by the way insurance companies are not paying for it.  Still there are advertisements that paint a rosy picture.

The second question I answer frequently is the use of stem cell transplants to treat COPD.  For $7,000 cash there are clinics that will harvest your stem cells and then give them back to you to help with your COPD. Ironically the physicians working in this clinic are not even pulmonologists.  There is not one piece of credible evidence that demonstrate stem cell therapy works for COPD.  If there were - insurance companies would be standing in line to pay for it.  Two years of treatment with the currently available COPD meds costs more than $7,000. If this procedure worked I would learn how to do it myself.  Unfortunately it does not.

It seems fake news is part of our society that is here to stay.  It is bound to be part of society with free speech that values the pursuit of fame and financial gain over the truth.

How do Adverse Childhood Experiences effect my patients?

posted May 7, 2017, 6:19 AM by Thomas Stern

Poor socioeconomic status is blamed for a lot of healthcare disparities.  Poor people are more likely to be sick.  There are many theories as to why this happens.  Poverty is cited as a risk factor for mental health issues, substance abuse, and obesity.  You fix poverty and the rest of the problems will follow.  Seems logical.  What is painfully obvious is that throwing money at the problem does not work. Poverty is certainly not an absolute condemnation for further poverty.  There are so many great American stories of people starting off poor and becoming billionaires. Many of them site their childhood poverty as an inspiration for hard work. Why does poverty impair some and inspire others?

My personal belief has been that the amount of money a family has in the bank does not predict the outcome of a persons life.  I am certain part of this belief comes from the fact that I was raised by a behavioral pediatrician who was heavily influenced by a mentor who was trained by Anna Freud. I had discussions about Freud's theories with my dad as a teenager. Freud believes the unconscious mind influences behavior. He also recognized that early childhood trauma influences adult behavior.  Because of this early influence I believe that if children are neurologically normal and you keep them safe, provide basic needs (shelter, food, clothing) and an emotional connection they will become well adjusted adults. I don't think it matters how much money you have in your bank account. My residency consisted of training in internal medicine and pediatrics.  These concepts were never discussed in my residency.  They were never discussed in my pulmonary or sleep training.  I considered them  opinions.

For the first time this week I learned of the Adverse Childhood Experiences Study  .  This study was first published in 1998 and proves that adverse childhood events such as abuse, neglect or mental illness in the home when you are a child dramatically increase the risk for chronic health problems as an adult including smoking, sleep disturbances, obesity and substance abuse. You can calculate an ACE score here. Reading this study triggered a mix of emotions in me.  It was satisfying to learn my own conclusions were accurate.  I felt even more thankful for growing up with my parents.  I felt hopeful that I may be able to have more of an impact on my patients who are not able to quit smoking or have chronic insomnia.  I am absolutely terrified because there are very few medical providers who are adequately trained to deal with these issues.  I am heartbroken to think that this many people in our society suffered as children. I feel guilty because I have blamed people with some of these health conditions for their predicament because I did not know how to help them.

I strongly encourage everyone to read the article on addictiion on this web page. The physician who is interviewed suggests addiction shouldn’t be called “addiction”. It should be called “ritualized compulsive comfort-seeking” because these people are seeking comfort to help them deal from their past experiences.  He is not referring just to illegal drugs.  He treats all addictions including addictions to drugs, food, gambling and sex but most of his patients are addicted to drugs.  Over 90% of his patients addicted to opioids have an ACE score of 3 or higher.  Over 90% of patients in an eating disorders clinic in which he works suffered sexual trauma.  How differently would our society treat drug addiction if we approached the patients as terrified victims rather than blame them for what they do?


Healthcare reform

posted Mar 26, 2017, 8:13 AM by Thomas Stern

This past week our congress once again failed to fix our broken healthcare system.  The current system - referred to as Obamacare - has been described by both democrats and republicans as fatally flawed. Despite this our "leaders" can't put together a plan that will provide affordable healthcare.  Instead we all get very expensive health insurance which makes it more difficult than necessary for people to get healthcare. Sadly, our "leaders" in congress don't even realize the difference between healthcare and health insurance.  The reality is the American healthcare system is perfectly designed to do what it is doing - make certain interests a lot of money. People who have a lot of money have great influence over our "leaders".  Fixing the healthcare system is not an intellectually complicated problem. Getting our "leaders" to fix healthcare has proven to be impossible. In order to do this our "leaders" are going to have to prioritize the American people over the wealthy special interests.  

When I was working in the US Senate it did not take me long to figure out there is only one thing that matters to most of our elected officials - and that is to be re-elected. The number one thing that influences voting in our congress is the impact it will have on the next election.  The focus of our "leaders" is not to lead.  Leaders need to make tough decisions.  The last thing our "leaders" want to do is tackle a tough problem.  They would rather kick the can down the road. Our current system promotes indecision.  The healthcare system is a prime example.  The American healthcare system has been identified as a problem for more than 25 years but all that has been done is to perpetuate the system.  Our national debt has been identified as a problem for a long time too and all our leaders do is stand by and watch it grow.

The system solution is pretty straight forward - it is term limits for our "leaders".  Our founding fathers had the foresight to limit the term of president because they identified the potential for corruption.  If only they would have foreseen the same for congress. We will be waiting a long time for our healthcare fix and I predict it will come from employers - not our "leaders". I am not sure it will be in my lifetime.  I am afraid term limits are even farther away.

Actively managing your child's sleep

posted Jan 10, 2017, 11:54 AM by Thomas Stern

My children enjoy Christmas break.  As they grow up, sleeping in is one of the luxuries days off provide.  At the end of break, getting up early again for school is a struggle.  The natural predilection of staying up late and sleeping in late is called delayed sleep phase syndrome.  Delayed sleep phase syndrome is considered normal in adolescence and young adulthood.  Therefore I would argue that delayed sleep phase syndrome is not really a medical problem but describes a normal variation in sleep patterns.  It becomes a psychosocial problem when waking up for school or work is difficult.  When the holidays are winding down and the return to school is getting closer I start to wake my children up earlier than their brains are telling them to wake up.  My oldest is 11years.  He has entered adolescence.  If he does not have a reason to get out of bed he will sleep until noon.  When he sleeps until noon he will not go to bed until after midnight.  I frequently remind him to go to bed at a reasonable hour.  That does not work too well.  Humans are very bad at making other humans go to sleep earlier.  I can sedate people but sleep and sedation are two very different things.  One thing I am very good at is waking people up.  Just ask my 11 year old.  When Christmas break was winding down, I started waking him up earlier.  10AM for a couple days and then 9AM.  It made the transition to school easier.  When my oldest was an infant I did the same thing.  When we first brought him home he slept more during the day than at night.  I would get up with him at night in an effort to let my wife sleep.  She would let him sleep during the day at the insistence of other family members who declared it a mortal sin to wake a sleeping baby. Then she would struggle to get him to sleep and keep him asleep at night.  Putting the baby to sleep became very stressful for her. Over a weekend I started actively manage my sons sleep.  I limited his napping during the day.  I would gently wake him and expose him to indirect sunlight.  Needless to say I was not very popular.  I am not very popular when I wake children early over the last several days of break. I wake them up by opening their curtains and singing to them.   But it works. In a couple of days my son was sleeping more at night.  At the end of break my children fall asleep early.  There are 2 points I want you to remember: 1) Some times you have to actively manage your child's sleep. 2) When changing sleeping patterns in your child focus on when they are awake - do not try to force them to sleep.  

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