May 21st, 2009 by Jon LaPook, M.D. in Better Health Network, Video
Tags: Alzheimer's, Alzheimer's Disease, CBSDOC.COM, Dementia, Geriatrics, Neurology
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There are few conditions more frightening to my patients – and to me – than dementia. It’s easily the most common fear voiced in my office. One woman recently said, “I couldn’t think of her name and I’ve known her for years; I think I may have Alzheimer’s.” Another patient, a physician, half-jokingly asked, “How do I know if I’m losing it or have just misplaced it?” Behind his nervous attempt at humor was a deadly serious concern.
The most common form of dementia in the elderly is Alzheimer’s disease. According to the Alzheimer’s Association, it affects as many as 5.3 million Americans. Especially cruel is the twilight phase when patients can still understand what they are losing, when they can see the receding silhouette of their memories but cannot reclaim what they’ve lost. This was brought home to me very poignantly last year when I interviewed 65 year old Carol and her husband Mike about Carol’s Alzheimer’s. At one point, Carol could not remember how long she’d been married even though I had just reminded her two minutes earlier. At another point, Mike – a retired cop – broke down talking about his wife’s illness. All the words in the world cannot adequately describe the anguish conveyed by the looks on their faces, the tone of their voices.
Often forgotten in the tragedy of dementia are the caretakers, frequently family members whose lives are torpedoed by the devastating illness. In this week’s CBS Doc Dot Com, I speak with Gloria Signorini, an 80 year old woman with dementia and with her daughter, Joanne, who has put her life on hold to take care of her mother. Mrs. Signorini’s physician, Dr. Gayatri Devi, an expert in dementia at NYU Langone Medical Center, provides perspective about Alzheimer’s and other forms of dementia.
** Editor’s Note: Please click on this link to watch the video (I’m having technical difficulties embedding it here)**
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May 21st, 2009 by Jonathan Foulds, Ph.D. in Better Health Network, Health Tips
Tags: Addiction Medicine, Family Medicine, Internal Medicine, Pulmonology, Quit Smoking, smoking cessation, Tips
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Patients I’ve seen who succeeded in quitting, sometimes tell me what it was that enabled them to quit this time when they had been unsuccessful many times before. Sometimes it was a change in personal circumstances, sometimes an aspect of the treatment we gave them, but sometimes they tell me there was a single thought, tip or piece of information that stuck in their mind and really helped.
So I thought I’d share a few of those thoughts or tips that helped others, and ask readers to share the things that helped them most. Here are a few:
1. “Move a muscle, change a thought”
This phrase stuck on one patient’s head as a reminder that when he was sitting and bored and starting to crave a smoke, he should get up, and get busy to help shake the thought of a cigarette from his mind.
2. “My cigarettes are radioactive”
The information that cigarette smoke contains radioactive chemicals like polonium-210 really stuck in the mind of one ex-smoker and helped her stay off them.It is estimated that smokers of 1.5 packs of cigarettes a day are exposed to as much radiation as they would receive from 300 chest X-rays a year.
In case you don’t mind polonium, here are some other substances found in cigarette smoke:
Ammonia: Household cleaner
Arsenic: Used as a poison
Benzene: Used in making dyes
Butane: Gas; used in lighter fluid
Cadmium: Used in car batteries
Cyanide: Deadly poison
Lead: Poisonous in high doses
Formaldehyde: Used to preserve dead specimens
3. “Get rid of ALL tobacco and lighters from the house and car”
Many smokers have told me that this was the single most important piece of advice they followed. They said that many times the cravings were so strong that if they had cigarettes in the house they would have smoked them. But having very thoroughly cleared them out of the house gave them some peace of mind and bought them enough time to deal with the cravings when they occurred.
I’d be interested to hear from readers what their most helpful tip or piece of information was when quitting smoking. Feel free to use the comment section to post your favorites.
This post, Tips To Help You Quit Smoking, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
May 21st, 2009 by MotherJonesRN in Better Health Network
Tags: Movie Review, Nursing, Star Trek
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My husband and I did something amazing last weekend. We went out to see the new Star Trek movie before it came out on DVD. You may not find this to be mind-blowing, but we are frugal people. We don’t part with our money easily.
At first I hadn’t planned on seeing the movie. I was afraid that the new movie was going to be a crappy sequel, so I wasn’t going to waste my money on it. Like I said, I’m cheap. Then I heard some of the younger nurses on my unit talking about the movie at work. These kids couldn’t stop talking about the movie. I was amused by their verbiage as they described the movie. One nurse said that the movie was “new, different, and completely groundbreaking.” I just rolled my eyes. I guess they forgot that old nurses like me were watching Star Trek back in the 1960s on our black and white television sets. I just smiled and flashed them the Vulcan peace sign and said, “Live long and prosper.”
My husband and I bit the bullet. We bought our movie tickets, along with a $20 bucket of popcorn, and we walked into the theater just in time to catch the 11 AM matinee. There weren’t too many other people in the place, and the ones who were there were all AARP eligible just like us. I guess my husband and I weren’t the only two old timers who wanted to see what all the fuss was about. I’m not going to give away the plot, but the storyline delves into how the characters first meet up. Unfortunately, Nurse Chapel was nowhere to be seen in this movie. Maybe she’ll show up in their next movie as a student nurse. I’d love to see her in her student nurse pinafore and wearing her nurses cap. They just better not make her into some sort of sex kitten. See my previous rant about Nurse Jackie.
I give the new Star Trek Movie an arthritic thumbs up. Geezers, impress your younger coworkers at the nurses station and go see the movie. They will find it quaint you know about Captain Kirk. You don’t have to tell them that you knew who he was before they were born.
*This blog post was originally published at Nurse Ratched's Place*
May 20th, 2009 by Harriet Hall, M.D. in Better Health Network
Tags: Costs, Diabetes, Endocrinology, Evidence Based Medicine, Family Medicine, Home Monitoring, Internal Medicine, Test Strips, Type 2 Diabetes
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There is no question that patients on insulin benefit from home monitoring. They need to adjust their insulin dose based on their blood glucose readings to avoid ketoacidosis or insulin shock. But what about patients with non-insulin dependent diabetes, those who are being treated with diet and lifestyle changes or oral medication? Do they benefit from home monitoring? Does it improve their blood glucose levels? Does it make them feel more in control of their disease?
This has been an area of considerable controversy. Various studies have given conflicting results. Those studies have been criticized for various flaws: some were retrospective, non-randomized, not designed to rule out confounding factors, high drop-out rate, subjects already had well-controlled diabetes, etc. A systematic review showed no benefit from monitoring. So a new prospective, randomized, controlled, community based study was designed to help resolve the conflict.
O’Kane et al studied 184 newly diagnosed patients with type 2 diabetes who had never used insulin or had any previous experience with blood glucose monitoring. They were under the age of 70 and recruited from community referrals to hospital outpatient clinics, so they were likely representative of patients commonly seen in practice. They were randomized to monitoring or no monitoring. Patients in the monitoring group were given glucose meters and were instructed in their use and in appropriate responses to high or low readings, such as dietary review or exercise. They were asked to take four fasting and four postprandial readings every week for a year. Patients in the no monitoring group were specifically asked NOT to acquire a glucose monitor or do any kind of self-testing. Otherwise, the two groups were treated alike with diabetes education and an identical treatment algorithm based on HgbA1C levels.
Their findings:
We were unable to identify any significant effect of self monitoring over one year on HbA1c, BMI, use of oral hypoglycaemic drugs, or reported incidence of hypoglycaemia. Furthermore, monitoring was associated with a 6% higher score on the well-being depression subscale.
So home monitoring not only did no good but it made patients feel worse. Why? Perhaps because they were constantly reminded that they had a disease and worried when blood glucose levels rose, especially when the recommended responses of dietary review and exercise didn’t rapidly lead to lower readings.
We would not accept the results of one isolated study without replication, but in this case the new study adds significantly to the weight of previous evidence and arguably tips the balance enough to justify a change in practice.
The American Diabetes Association still says “Experts feel that anyone with diabetes can benefit from checking their blood glucose.” But they only recommend blood glucose checks if you have diabetes and are:
• taking insulin or diabetes pills
• on intensive insulin therapy
• pregnant
• having a hard time controlling your blood glucose levels
• having severe low blood glucose levels or ketones from high blood glucose levels
• having low blood glucose levels without the usual warning signs
Diabetes experts see the severe, complicated cases and have a different perspective from that of the family physician seeing mostly mild and uncomplicated cases. An article in American Family Physician said
Except in patients taking multiple insulin injections, home monitoring of blood glucose levels has questionable utility, especially in relatively well-controlled patients. Its use should be tailored to the needs of the individual patient.
An editorial in the BMJ pointed out that
Home blood glucose monitoring is a big business. The main profit for the manufacturing industry comes from the blood glucose testing strips. Some £90m was spent on testing strips in the United Kingdom in 2001, 40% more than was spent on oral hypoglycaemic agents.2 New types of meters are usually not subject to the same rigorous evaluation of cost effectiveness, compared with existing models, as new pharmaceutical agents are.
If the scientific evidence supporting the role of home blood glucose monitoring in type 2 diabetes was subject to the same critical evaluation that is applied to new pharmaceutical agents, then it would perhaps not have been approved for use by patients.
Conclusion
Home glucose monitoring in type 2 diabetes is not justified by the evidence. It does not improve outcome, it is expensive, and it may decrease the quality of life of patients.
Common sense suggested monitoring should improve outcome. We had assumed it would work. Scientists thought to question that assumption. They found a way to test that assumption. New evidence showed that it was a false assumption. In response to that evidence, the practice is now being abandoned. This is how science is supposed to work. Another small triumph for science-based medicine.
*This blog post was originally published at Science-Based Medicine*
May 19th, 2009 by DrRich in Better Health Network, Health Policy
Tags: Barack Obama, Featured, Healthcare Rationing, Healthcare reform, Hillary Clinton
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DrRich has been around long enough to remember the sequence of events that accompanied the collapse of healthcare reform under the Clintons in 1993 – 1994. (Heck, he has been around long enough to remember Nixon’s plans for healthcare reform, which drowned in Watergate.) When President Clinton was inaugurated, everyone agreed that the American healthcare system was in a state of crisis (e.g., spending levels could not be sustained, there were too many uninsured, there was too much waste and inefficiency, etc., etc.), and that the time for fundamental reform had finally arrived. We had a fresh, dynamic, young President with new ideas and with a solid majority in both houses of Congress, and he was armed with polls showing that the people were in favor of fundamental reform.
Accordingly, when Mrs. Clinton put together her working groups to devise a reform plan, she initially had the enthusiastic participation of numerous interest groups within the healthcare industry – notably including the insurance companies, physician groups, and drug and medical device companies.
But when she finally produced her plan – a disturbingly heavy tome filled with frightening details – everybody was horrified with at least some of the stuff they found there. Most of the big interest groups turned on her – most notably, the insurance industry, which then launched the famous Harry and Louise commercials to scare the people about government healthcare. The people, now duly scared, called their congresspersons, who (despite the Democrat majority) ended up sending Mrs. Clinton’s healthcare reform to a crushing and humiliating defeat. And the Republicans were able to capitalize on the “near miss” of the Clinton’s brazen attempt at socialism, and in 1994 ushered in 12 years of a Republican majority in both houses of Congress.
Obviously, for those Republicans and other observers who abhor Mr. Obama’s plans for healthcare reform, it is relatively easy to see parallels between what happened in the early 1990s, and what appears to be shaping up now. Those parallels, and the subsequent ignominious defeat of the Clinton plan, are the only things keeping these sorry individuals from donning sackcloth, heaping ashes upon their heads, and engaging in public self-flagellation.
So, perhaps, for such outsiders the spectacle of the major private healthcare interests this week throwing in with the Obama administration will be seen as one more sign from the gods that the parallels of 1994 are falling into place.
But they are wrong.
There are at least three important differences between the enthusiastic participation of private interests in Mrs. Clinton’s working groups on healthcare reform, and the action taken this week by representatives of insurers, doctors, drug companies, hospitals, and medical device manufacturers to pledge their undying support for President Obama’s efforts at healthcare reform.
First, in 1993 the private interests were powerful and confident. They participated in the process because they felt they could control it. It turned out they were wrong, of course – the only one who has been able to out-maneuver the Clintons is Mr. Obama – and the plan Mrs. Clinton finally produced (despite all the “input” from diverse private interests) really was a blueprint for a full government takeover of healthcare, all spelled out and wrapped with a bow. But because the private interests were powerful and confident in those days, once they figured out what the Clintons actually had in mind they were able to scuttle healthcare reform entirely.
In contrast, today the private interests have come to the table not out of strength, but out of weakness. They come not as partners in negotiation, but as vanquished foes. They come to Obama as the Carthaginians came to the Romans after the second Punic war, suing for peace, begging for terms, offering massive tribute (in this case, $2 trillion) in exchange for being permitted to eke out a meager survival, at the edge of the desert. (DrRich wonders whether the insurance companies and their friends remember the third Punic war. Surely they must know that somewhere in Congress is another Cato the Elder, ending every speech with the words, “The insurance industry must be destroyed,” and that at some point their remaining, puny base of operation will be completely sacked, and their mission statements sown with salt.)
Second, whereas Mrs. Clinton was a major policy wonk who reveled in providing a fully-fleshed-out and exquisitely detailed set of plans for healthcare reform – thus giving her foes sufficient ammunition not only to defeat her reform plan, but also to banish the Democratic Party to the wilderness for three election cycles – Mr. Obama is not. His reform plan will be bare-bones – merely an outline, more-or-less a statement of principles. There will be nothing to attack, since there will be no details, and little will be spelled out. (Implementing the plan will be left to unelected bureaucrats and regulators, who are always happy to produce prodigious amounts of undecipherable and self-contradictory detail.) This time, at least prior to its actual implementation, critics of the reform plan will be left trying to attack a phantom.
And third, this time there is no Plan B.
In 1994, once the private interests had scuttled the Clinton healthcare plan, they immediately offered an alternative. They came to us and they said: “Citizens! We have just now dodged a bullet! Thanks to us insurance companies, doctors, drug companies and other patriots, the frightening socialist machinations of the Clintons have been defeated, and the Evil Ones have been reduced to embracing our agenda of tax reform and welfare reform as if it were their own. But where does this leave our healthcare system? We stand now between Scylla and Charybdis, between the spectre of socialized healthcare on one hand, and the continued profligacy of traditional fee-for-service on the other, and we cannot survive either.
“But here,” they continued, “is a third way. A painless way, an American way, based on the principles of managed care, open markets, and free enterprise. Let healthcare become a business, like any other business, and let the natural efficiencies of the marketplace find ways to cut costs and improve quality, and with minimal government intervention.”
And thus we were launched into an era of managed care run by HMOs and other similar creatures of the insurance industry. And over the past 15 years, while managed care has utterly failed to produce any of the things it promised, it has not been for a lack of trying. They indeed have tried numerous things to control spending, from the reasonable-sounding to the absurd to the frankly murderous, and despite all their strenuous efforts the healthcare system remains a morass of confusion, waste, and inefficiency, and its costs are many times what they were in 1994.
To say it another way, the private concerns, this time, have shot their wad. They are entirely bereft of ideas. They know not what to do.
And that’s why they have now fully abandoned their old allies, the Republicans (who are off somewhere – one knows not where – muttering to each other about the efficiencies of the marketplace, and wondering why nobody is listening to them). The last thing the insurance industry wants to hear today is that the burden of figuring out how to control healthcare costs belongs to them. They’ve tried everything they know and have failed, and they are desperately seeking terms for surrender.
So there is no Plan B this time. As of this week, the private interests have formally and publicly admitted they don’t have a clue. They’re throwing in with President Obama, despite the fact that they have no leverage with him whatsoever, not because they believe in his reform plans (which have not even been described in their most skeletal form), but because there is no place else for them to go.
And so, the last obstruction to healthcare reform has been removed. The path – the only path – is clear. If we fail to get comprehensive healthcare reform now, it can only be for one reason. It can only be because Mr. Obama and the Democrats, looking down that wide open road, will be unable to avoid seeing where it leads, and will decide that they do not want to be the administration or the party that finally has to begin saying the “R” word in public.
To turn away from healthcare reform now, when the way seems so clear, would be a crushing blow to them, and would likely not be politically survivable. But to go on will likely force them to begin speaking a truth – that rationing is unavoidable – whose name is more taboo than ever was the name of Yahweh. And every high priest of the ruling class knows that even hinting about healthcare rationing is political suicide.
But still, there it is. There is no Plan B.
Talk about Sylla and Charybdis.
*This blog post was originally published at The Covert Rationing Blog*
