healthy vs not sick and symptom suppression

[DocWils]

Glad to help Mark.

BTW, rule of thumb - if the neck is over 40 cm around, then there is a good likelihood they have OSA, whether they admit it, feel it or not. I asked my brother the other (I haven't seen or spoken to him in many years, but I called him for his 70th) if he had been diagnosed with SA, given his considerable heft, and he said he didn't have a problem, and didn't snore as badly as he used to (he could shake the house, as I recall). It was his birthday, I was thousands of kilometres away, so I didn't nag him about it, but there is little chance that he does not have it. What can I do? What can any of us do, if they don't want to listen?

[Mosquitobait]

"5" is just a number that everybody can point to and declare "success". It's by no means "as good as it can get"

Terry

True, but like with diabetes, they found that there is a point of diminishing return. For instance, if your A1c is 6 or below, you will not get more medication to get you below 5.6 (A1c for nondiabetics is between 4 and 5.6). For older people (I think over 65), it is 7 or 8. Why? Because the medications cause more complications. I don't know enough about the complications you could get from a cpap, but increasing pressures may cause more problems than the gain in lower episodes. Even in the medical field they fight about it. My doc goes with the least amount of intervention that resolves the problem to a manageable state. BTW, he's been after me to get a cpap for a couple of years. Had I known that there were options to full faced masks, I would have bought one then.

[Sleepster]

For an event to counted in the AHI calculation it has to last for at least 10 seconds. Even if you had a AHI of zero you might wonder what would happen if you counted events that last only nine seconds. Or eight.

And during that 10 seconds the breathing level must fall below some percentage, 30% for a hypopnea, I think. So you might wonder how often your breathing falls below 31%, or 32%.

There's no end to it.

Suppose you had a car that started every time by turning the key for the shortest fraction of a second possible. Then you notice that every once in a while it doesn't work and you have to turn the key and hold it there for half a second to make the car start. If you took the car to an honest shop they'd tell you the car is starting normally. Like it's supposed to, and there's no need to try and fix what isn't broken.

[DocWils]

Mosquitobait,

The reason we discuss it (not fight, we don't need to fight about such things in the medical field) is that we practice evidence based medicine, and so as there is a constant stream of new data flowing in, it refines our models of how we see things and what threshold levels have - in diabetes, for instance, there was a time, not all that long ago, when we made no distinction between sugar tolerances of healthy and diabetic people, now we do as the evidence mounted that there is a functional difference that we must be aware of. There is always new things to learn - in a science as young as sleep science and the even far younger apnoea treatment branch, the data mounts even more quickly to refine our models and how we understand it and what treatment levels are. I don't know if you realise just how young CPAP is, but it wasn't even a glimmer in the eye of the creator of it when I was graduated from med school, and I was a very established physician when the first papers came out with the reversed hoover experiments and we all reacted with "oh, that's interesting....". And now we have data capable machines that stream data back to the labs and manufacturers, PSG studies that are light years more complex than when they first began, you name it, so we continue to refine our models. We know more about how the throat collapses on a typical simple weight related OSA problem (in goes in a cycle of 4 to 6 breaths, for instance, not a collapse on every breath, but an increasing narrowing over a breathing cycle) and that changes how we look at SA and how the machines detect it (and why you have flow rate and shape on Sleepyhead - it is more than just a statistic, it is a predictive for a collapse, and the PSR uses it in their calculations to predict and head off a collapse) and so from a reactive machine, acting after the fact, these machines now try to predict a problem before it happens and prevent it. All in the space of around two decades, and the latter part in the space of less than a decade. So, pretty neat, altogether - we don't need to argue in the medical field, we don't need to fight, we just look at the data and revise our knowledge. That is why medicine is a science, not an art (although there is a bit of art in it - I was always tempted to sign my stitches )

[Sleepster]

So, pretty neat, altogether - we don't need to argue in the medical field, we don't need to fight, we just look at the data and revise our knowledge. That is why medicine is a science, not an art (although there is a bit of art in it - I was always tempted to sign my stitches )

Argument is necessary for the advancement of science. I'm sure it's the same in medicine. In fact, I've seen it first hand. There is disagreement, and evidence is used in an attempt to settle these arguments to reach a consensus.

Look at the example of hand-washing and maintaining sterility. Prior to about 100 years ago there was disagreement and argument about that practice. Now there's an overwhelming consensus that sterility is important whereas 200 years ago it was dismissed as unimportant. Those kinds of changes don't occur without argument between practicing physicians.

[DocWils]

Actually, it was the overwhelming evidence in favour of it that changed minds. No one got into fisticuffs over it. But some bright boys got the idea to see what happens if you DO wash your hands, etc (you would be surprised how much medicine is advanced because of statistical analysis - scary, really). What made the difference in hand washing was the Semmelweis' germ theory, introduced in the 1840's or so, near as I can recall. He did it by crunching numbers and ask which of these things is not like the others? It took a while to catch on, not least because despite his delivering the paper, he did not follow up, having been committed to a mental asylum not long after delivering the paper (some suspect he had syphilis, which can cause erratic behaviour) and he died in the asylum, probably from sepsis, which is somewhat ironic for the discoverer of germ theory. Let me rephrase that - his ideas became quickly accepted, but the practice didn't - getting people to change their habits when there was no one to force them to, unlike today, was very hard, and is one reason I am glad we have some overseers in the government, even above the medical licensing board and the FHM (or version of the ACP and FCP). Sure the BAG can be a pain at times, but it is an important pain, so long as there are real scientists an doctors advising it and it is not just a bunch of functionaries and bureaucrats.

While the habits and practices he recommended eventually caught on and by the early 20th century had more or less become recognised, there was no standard of hand hygiene in medicine until 1980, when clear guidelines were established, again based on number crunching. M&M statistics were analysed from participating clinics world wide, and, after various practices were taken into account, clear indications of procedure were arrived at (and not just for hand hygiene, btw, but for a lot of areas). In the process, long held ideas about certain sterile practices were also forced to be abandoned in favour of new models, which are being refined even today. I point out, for instance that liquid hand disinfectant dispensers only became common in hospitals, clinics and public buildings very recently, many in response to the bird-flu epidemic and the swine flu before it. In fact, new guidelines are constantly being handed down as evidence becomes clearer as to the most effective procedures. I had to attend a new hand washing clinic a few months back to acquaint our staff with new methods and procedures deemed more effective than our normal standards (based on a study of all the major Swiss clinics and their procedures, and comparing them to other studies in 30 other countries, after which the BAG (our version of the Health Administration in the US, or whatever you call it (I have forgotten tonight - senior moment) decided on new guidelines, then tested them on one hospital that was showing poorer results than others, saw the improvement, tried it on the top of the league, saw the improvement again then handed it down to all hospitals as new guidelines)..

If you want a good snapshot of what medicine was like in Semmelweis' time, look no further than The Doctor's Dilemma, a play by Shaw that shows how much quackery was going on at the time (there is a wonderful film version with the amazing Dirk Bogarde) - the story concerns the moral dilemma of who to save given limited resources, but it is the collection of doctors, most of them quacks, that is of interest here - it took some time before medicine became the standardised system we see today, based exclusively on evidence based science. To compare modern medicine to how it was at the beginning of the 20th century is to compare modern computing to Victorian computing. Medicine was one of the last industries to benefit from the boon of the Industrial Revolution, namely, standardisation in all areas - training, procedure and technology. I think the last time I saw a near knock down drag out fight amongst doctors was back in the early days of the AIDS epidemic, when some Wisenheimer or other tried to advance the idea that it was based solely on lifestyle and not on immunological infection (which it was pretty clearly based on from the earliest description of it). That was a pretty wild conference. I was tempted to punch a colleague in the nose because he was convinced that genital herpes was treatable by anti-fungal creams, but that was because I thought he was a quack and dangerous to his patients. He now runs a massive walk in clinic sponsored by one of the biggest insurers in this country. Go fig.... I should have tried to get him struck off. Ah well, so long he doesn't treat anyone with herpes, I guess he's harmless. The rest of his medicine was more or less in line with standard procedure.

[eseedhouse]

Actually, it was the overwhelming evidence in favour of it that changed minds. No one got into fisticuffs over it.

I think there are several meanings of "argument". One is a fight. Another is a reasoned discussion. A third is a collection of accepted propositions that necessarily imply another proposition, the "conclusion" (example: a syllogism).

Doctors and other scientists are still human. In the history of Science in general and Medicine in particular there have I think, people being people, plenty of arguments of all types.

Science, including Medicine, has the distinction that the latter two meanings of "argument" tend to win out over the first. Not always, but by and large.

But that doesn't mean Scientists are infallible. There have been plenty of rather loud and emotional arguments among scientists, a certain Mr. Newton being well known for a bad temper and a sharp tongue, for example. There were several other scientists of the day that he refused to speak to for years because they did not agree with him. But still he stands out as perhaps the greatest Scientist of all time in spite of that.

[Sleepster]

Actually, it was the overwhelming evidence in favour of it that changed minds.

That's my point. It's the changing of the minds that's associated with the arguing.

No one got into fisticuffs over it.

Uhhh .... Maybe they did. But it doesn't matter. Science progresses through argument. That's my point. Evidence doesn't just appear one day and change everyone's mind the next. Arguments are as much a part of the process as evidence, because a consensus much be reached about what the evidence implies before knowledge can be gained. Until that happens there is argument. Without that argument there wouldn't be advancement in knowledge. This is why it's important that scientists retain the freedom to argue. When governments impose laws that prevent the free exchange of ideas the advancement of science stops. It happened in Germany during WWII. And in Russia during the Cold War. It's happening now in Iran.

[DocWils]

This might be a language issue - I have a feeling that you and I understand the word differently, but of course, I am coming from a fully different language.

After all, you are all foreigners....

[SaldusMiegas]

"You keep using that word. I do not think it means what you think it means." -- Inigo Montoya