Study objectives: To study the prevalence, risk factors, and gender differences in symptoms related to obstructive sleep apnea. A secondary objective was to study gender differences in relation to referral to a sleep clinic for sleep investigations.

Design and setting: A questionnaire study in a representative sample of the general population. A second cohort included patients referred for sleep apnea investigation between 1991 and 2000 in the same geographic region.

Participants: A representative sample of 5,424 subjects aged 20 to 69 years living in northern Sweden. Responses were obtained from 4,648 subjects (85.7%).

Results: Of the male respondents, 17.9% stated that snoring was a problem or said that they had relatives who were concerned about witnessed sleep apnea, and of the female respondents, 7.4%. The prevalence of snoring and witnessed apneas increased with age. In men, there was a peak prevalence rate at 55 to 59 years of age, while the corresponding figure in women the peak prevalence rate was at 60 to 64 years of age. Having snoring as a problem and relatives who were concerned about witnessed sleep apnea were independently associated with male gender, age, and current smoking. Snoring as a problem also was associated with higher education. Women who snored reported significantly more daytime sleepiness than did men who snored. The estimated number of subjects aged 20 to 69 years who had snoring as a problem or had relatives who were concerned about witnessed sleep apnea in the population was 21,160. During the previous decade, 3,955 subjects had been referred to sleep laboratories, so < 20% of the estimated number of symptomatic subjects in the population had been referred during this 10-year period. The referral rate ratio for men/women after correction for population and prevalence of symptoms was 1.25:1 (p = 0.012).

Conclusion: Experiencing snoring as a problem or having relatives who are concerned about witnessed sleep apnea are common findings in the population. However, during the last decade, only about 20% of the subjects with snoring as a problem or with relatives who are concerned about witnessed sleep apnea were referred to sleep laboratories. Women were significantly underrepresented in sleep laboratory referrals, even though women who snored experienced more subjective daytime sleepiness than men.

It is important to design methods to ensure that patients receive the results of laboratory reports, imaging studies, and other reports generated during the routine business of a medical office. A simple way to accomplish this is to clip a Patient Report Call-Back Sheet (PRCBS) to each report. The sheet (figure) and the report are then put on the physician’s (or physician’s designee’s) desk to route appropriately. The physician can choose to call the patient personally; direct a staff member to call the patient with results that have been “translated” into language that the patient can easily understand; or he or she might put the information directly into the chart if there is no reason to contact the patient.

Attaching the PRCBS reduces the possibility of overlooking an important report, improves communication, and might provide a market differentiator for your practice by demonstrating to patients that you are committed to keeping them informed. This requires minimal additional time from the physician and staff.The PRCB S is not perfect. It does not provide a fail-safe mechanism for a test that was ordered but never done, or for a test that was done but the report was never sent. To prevent this error, a log of ordered tests must be kept and compared with received results. Some computer software will permit certain practice management systems to compare the log with the PRCBS. Process improvements such as the PRCBS improve office efficiency and patient satisfaction while reducing errors.

St. John’s Clinic (formerly St. John’s Physicians and Clinics, SJP & C) is a multispecialty clinic employing approximately 460 physicians, 130 mid-level and allied clinical professionals, and 1,900 employees. The clinic service area is located in 13 counties within Southwest Missouri.

Partnered with St. John’s Hospital and St. John’s Health Plans, it forms St. John’s Health System (SJHS), which is one of the largest health care organizations in the state. With over 46 medical/surgical specialties housed in 70 offices, the clinic offers comprehensive medical services with special acclaim in cardiology, urology, sport medicine, oncology and pediatrics.

The system is part of the larger not-for-profit Sisters of Mercy Health System based in St. Louis, MO. SJHS has been named by Modern Healthcare magazine as 14th in the “Top 100 Integrated Healthcare Networks” in the United States.

In the beginning

In the early 1990s, SJHS embarked on a presumptive strategy to improve hospital-physician alignment by attempting to create an integrated health care delivery system (IDS) through the purchase of desirable local and regional physician offices.

Senior hospital management felt such purchases would position the hospital for the future, help gain a competitive business advantage, ensure physician referrals, provide leverage for controlling costs and access to capital and offer opportunities to improve quality of care.

Through physician employment agreements, a steady flow of hospital patients would be secured. Three years into the development of the hospital integrated health care delivery system, significant financial and physician relationship problems began to emerge.

SJHS grew quickly into the largest provider of health care within the region. The hospital had, over a two-year period, slowly begun to purchase physician practices in the rural counties of its service area. The rural network originally consisted only of 20 practices. This initial strategy seemed to provide the hospital with an improved patient flow for hospital specialty care and procedures.

INTRODUCTION: Accurate descriptions of naturopathic medicine as a whole system of medical practice are rare in the literature and non-existent for type 2 diabetes. METHODS: Using retrospective analysis of medical records at an academic naturopathic outpatient clinic, data was abstracted to investigate patterns of patient status, details of treatment recommendations, and levels of evidence. RESULTS: Most naturopathic medical care for type 2 diabetes is adjunctive, although naturopathic physicians are qualified to fill the role of primary care providers. Glycemic control and other vital statistics in patients receiving naturopathic care are comparable to published national averages. Naturopathic physicians prescribe comprehensive therapeutic lifestyle change recommendations supported by a high level of evidence–100 percent received dietary counseling, 69 percent were taught stress reduction techniques, and 94 percent were prescribed exercise. Patients additionally received prescriptions for botanical and nutritional supplementation, often in combination with conventional medication. Analysis of individual supplement effects was not performed due to inadequate records. Components of treatment recommendations are often evidence-based, with varying evidence quality. CONCLUSION: Naturopathic medicine as a whole medical system supplies evidence-based lifestyle recommendations as suggested in management guidelines for diabetes, hypertension, and hyperlipidemia set forth by the respective national organizations–the American Diabetes Association (ADA), the Joint National Committee on Hypertension (JNC-7), and the National Cholesterol Education Program results of the third Adult Treatment Panel (NCEP ATP-III). Increased research effort to determine the safety and efficacy of combinations of supplements or medications and supplements is warranted. Education of other health care providers, patients, and health policy makers regarding the value of the naturopathic approach in the treatment and prevention of type 2 diabetes is warranted, yet prospective data on efficacy must be collected.

Driving home from an outlying clinic last week, I was thinking that probably, in my almost 13 years here, I’d seen just about everything. I never learn. Thus began my week as an FNP at the Dr. Anne Wasson Rural Health Clinic. I returned that afternoon to find a child who had pushed “something” (its true nature uncertain) up his nose. A fishing expedition ensued. I took a call from the radiologist to tell me the CT scan on a “dizzy” patient revealed brain metastases - its original source unknown. I visited a patient in the hospital and we mapped out a plan for her care at home upon discharge. Numerous phone calls later there was oxygen at her home. Papers were faxed to and from to obtain a motorized wheelchair, only to be informed that, after all, I didn’t have the correct forms. I began again.

There was the woman with asthma who needed medications, but no money to pay for them. I did what any Frontier provider does almost daily……… improvise (how much can be accomplished in the clinic alone), scrounge (who has the medication samples needed and how long will it take to get them) and make do (okay…it’s not ideal, but it’s the best that can be done under the circumstances). There was the gentleman with severe weight loss, fatigue and frightfully abnormal lab values. A quick consult with Dr. Begum and he’s sent for further diagnostic testing. There was the patient with scoliosis needing a photograph of her deformed back for the medical record. (Okay, where’s the camera?). There is another suspicious CT scan of the chest -lung cancer? The 13- year-old whose parents want to take him out of public school for home schooling because of health reasons and…. what do I think? The gentleman with a massive infection of a finger occurring only 48 hours after clipping his fingernails. . . A brief search and his blood sugar is found to be 4 times the limits of normal and, at the age of 82, now a newly-diagnosed diabetic. Today, we start the process of teaching him how to live with this disease. A trip to a grade school to discuss first-aid with 4th and 5th graders. Their enthusiasm and energy are wonderful. I left the elastic bandage with them to practice wrapping wrists and ankles. (”No, this bandage cannot be wrapped around someone’s neck!”). Oh, yes…..Dr. Tan and I shared recipes for Mediterranean cooking. That was my week. Yours?

Kenny Ausubel began looking into unconventional cancer treatments in 1977, after receiving an unsolicited mailing about a nutritional program for cancer patients developed by dentist Donald Kelley. Since his father had died from cancer two weeks earlier, Ausubel felt compelled to investigate alternative therapies that claimed to help those with the ‘incurable’ disease. In 1980, he happened upon an article on the Hoxsey Cancer Clinic and Harry Hoxsey’s decades-long battle with the American Medical Association (AMA) and its allies in the federal government. Three years later, Ausubel, in collaboration with public health nurse Catherine Salveson, began meticulous research for their documentary film Hoxsey: How Healing Becomes a Crime. The 83 minute-long feature film, which took four years to complete, won the “Best Censored Stories” journalism award.

Ausubel’s new book When Healing Becomes a Crime documents how the producers went about making the film, how they tracked down information, and what they learned about Hoxsey, his cancer treatment, and the Hoxsey clinic in Tijuana, Mexico (called the Bio Medical Center). They found newspaper articles from the Hoxsey period, used the Freedom of Information Act to get the FDA’s records on Hoxsey’s treatment, and dug through the American Medical Association’s files on Hoxsey. The producers also interviewed Hoxsey patients and co-workers and asked Dr. Hugh Riordan, a former president of the American Holistic Medical Association, to validate the patients’ medical histories. For the book, Ausubel asked epidemiologist Gar Hildenbrand to reverify the medical records that were used in the film as well as to check the validity of new cases that were added to the book. In addition to the information on Hoxsey, When Healing Becomes a Crime gives a compelling portrait of the effect that cancer politics has on other alterna tive cancer therapies.

The Community Health Foundation medical clinic, which has been plagued with accusations of billing irregularities, owes up to $6.5 million or more in debt that may force it to shut down.

New management and board members appointed over the last two months at the order of federal regulators have been reviewing the clinic’s finances through internal reviews and outside audits. The nonprofit East Los Angeles clinic owes the money to vendors, employees and government agencies.

“We are all trying very hard here to ensure the clinic does continue,” said acting chief executive Richard Veloz, a health care consultant. “We are in a situation where we need to secure funding through various programs in order to start paying back some of that debt.”

The health foundation once served as many as 65,000 patients through its two main offices and more than a dozen satellite clinics in the East Los Angeles area. But allegations of billing improprieties caused the county last year to withdraw a key $3.4 million contract to serve uninsured patients.

It also lost other funding, including a MediCal contract with Health Net Inc., and is now seeing just a fraction of its former patient load largely at its two main sites. Still, its closure would be a blow to an area where many residents do not have health insurance.

Audits show that the state Department of Health Services, which matches federal funding, is owed $2.1 million for billing irregularities dating back to 1996, said Norma Arceo, a department spokeswoman.

And the county Department of Health Services seeks $1.3 million in repayment for a community outreach program that it maintains was not properly administered, said John Wallace, a department spokesman.

The clinic also owes vendors as much as $2 million, while employees are owed $1 million or more in back pay and other benefits, Veloz said.

But Stephanie Salcido, a field representative with the Service Employees International Union, which represents 55 workers at the clinic, said employees are owed significantly more.

Documents given to the union by management indicate that workers are owed $1.9 million in back wages and vacation pay, as well as for union dues and taxes that were withdrawn from paychecks but not properly deposited.

Context: Abortion induced by drugs is now a viable alternative to surgically induced abortion for U.S.women. Women’s willingness to use these new methods of medical abortion hinges on the extent to which they prove acceptable, however.

Methods: Among 304 women participating in a clinical trial of medical abortion, 186 received a methotrexate-induced abortion and 118 were offered the option of a medical abortion but chose a surgical procedure instead. Study participants completed self-administered questionnaires before the abortion and again at a follow-up visit.

Results: Women in the medical and surgical abortion groups did not differ significantly with regard to demographic and other background characteristics: Their mean age was about 27, more than two-thirds were white, and three-quarters were unmarried and worked either part-time or full-time. However, women’s ratings of seven attributes of abortion methods were significant predictors of choosing a medical abortion: Women were more likely to choose medical abortion if they placed greater importance on a method that was nonsurgical, one that resembled a miscarriage or one that could take place at home (odds ratios, 2.0-3.3). Conversely, women were less likely to choose medical abortion if they valued methods that were quick, that did not involve painful cramping or seeing blood or blood clots and that needed a doctor or nurse to be present (odds ratios, 0.3-0.5). Compared with those who had a surgical abortion, women who had a methotrexate-induced abortion expected more bleeding (mean scores, 3.5 vs. 3.1) and reported more pain (3.4 vs. 2.9), heavier bleeding (3.4 vs. 2.5) and bleeding of longer duration (3.3 vs. 2.6). The overwhelming majority of women in the medical and surgical abortion groups reported that they were either very or somewhat satisfied with their abortion method (81% and 82%, respectively), would recommend it to others (82% and 78%) and would choose the method again (89% and 93%).

Conclusions: Factors affecting the choice of abortion method appear to be numerous and complex. Providers need to be sensitive to differences in women’s values and life circumstances when counseling them about an abortion method. In particular, providers should incorporate into their counseling sessions what women need to know about the characteristics of abortion methods and help women to identify what is the best option for them.

MicroMed announced last month that surgeons at the Cleveland Clinic Heart Center installed the DeBakey VAD in two patients awaiting heart transplantation.

Patrick McCarthy, M.D., performed the surgeries on the patients, who are reported to be “recuperating well.” McCarthy is the surgical director of the George M. and Linda H. Kaufman Center for Heart Failure at the Cleveland Clinic.

Drs. McCarthy and James B. Young, head of the section of Heart Failure at the Cleveland Clinic and medical director at the Kaufman Center, said the size of the DeBakey device is one of its best attributes.

“The new generation device is significant for several reasons,” said McCarthy. “It is much smaller than its predecessors. It is quiet–it cannot be heard unless one is using a stethoscope.

“In addition, the risk of infections appears to be lower than with the earlier generation of devices.”

Dr. Young said he was “excited about the whole concept of the smaller pump.

“This definitely signals a new era in pumps and heart assist devices.”

The DeBakey VAD is a battery powered, portable device that weights less than four ounces and is approximately one-tenth the size of the majority of heart-assist devices now in use.

MicroMed said the size of the device means implantation is less invasive than with larger VADs and operating time is reduced.

Also, said the Houston company, installing the DeBakey VAD results in less tissue disruption, and surgeons can expect a lower incidence of infection and perioperative bleeding.

Young, a member of a new federal advisory committee charged with developing organ transplantation policy, said the device creates hope for people awaiting heart transplantation.

“The smaller device buys time for people, including children, who now have a better chance to survive with the support of the VAD until a donor heart is available,” he said.

Earlier last month, MicroMed said it received conditional approval from the FDA to begin its pivotal multicenter clinical study of the device.

“Commencement of the multi-center trial in the U.S. is an important milestone in our corporate history,” said Dallas Anderson, CEO and president of MicroMed.

I’M AN ADDICT. My drug of choice isn’t heroin, crystal meth, or crack cocaine, but it’s just as destructive and impossible to kick cold turkey. I’m strung out on food.

I’m 35 years old, stand 5′10″ tall, and weigh 300 pounds. I am obese. Over the years, I’ve tried every diet to hit The New York Times best-seller list, yo-yoing all over the scale, from a rotund 315 pounds down to a burly 245, and rebounding back to a plump 300. Nothing seems to work, and inevitably the jones to graze always gets the best of me.

Every evening, I eat myself into a coma, then crash in front of the TV or down enough Jack Daniels and ginger ale to dull my senses. My edibles-as-drugs problem is compounded by the fact that I live in New York City, home of the world’s best food fixes–thick, juicy steaks at Smith & Wollensky’s, the world’s greatest pizza at John’s, dry-rub baby-back ribs at Virgil’s BBQ, and the tastiest ethnic restaurants. But, let’s face it, even if I lived in a gastronomic backwater, I’d still do the same thing.

This is what it’s like being a walking fat body: I have to shop at big-and-tall stores, paying top dollar because nothing in the pages of this or any magazine fits me off the rack. I need a seat-belt extender on airplanes. And I have a hard time stuffing myself into the cheap seats at Knicks games.

Even more disturbing: My weight is harshing my sex life. Performance isn’t the issue–it’s just getting in the game. Usually hesitant to approach women, I often rely on friends to make the opening move. I shrug it off to shyness, but I know the real reason: I’m afraid to have relationships with women because I don’t find myself attractive, so why, I figure, should they?

I’m not looking for your pity. Fuck that. I’m comfortable in my skin. While the looks and sneers sting, they usually come from superficial assholes I wouldn’t want to know anyway. But the health implications do terrify me: limited mobility, diabetes, liver damage, gout (from which I already suffer), heart disease, and stroke. All point to an early grave.

Then came the assignment: Spend two weeks at the Duke University Diet & Fitness Center (DFC) in Durham, N.C., and write about it for Men’s Fitness. I felt like I had just won the lottery.