We're Already Hearing About It .....

The Holiday Season often brings stress and depression for some. Here are a few tips, from the Mayo Clinic site, to help minimize the negative impact of the Holidays.

Mayo Clinic: Health And Stress

Are Two Pictures Worth 2000 Words?

Please click on each photo to make these important messages easier to read

Blame It On The Diabetes?

The Chicago Bears are 0-3 this season in night games this year so far and their starting quarterback, Jay Cutler (a Type 1 diabetic) has thrown 11 of his league-leading 17 interceptions in those three games under the lights.

Cutler is also 4-9 all-time in his career under the lights.

He says, "it doesn't really matter to me what time we play", but some are beginning to ask if his diabetes has anything to do with it.

Jay Leeuwenburg, an offensive lineman for the Bears from 1992-95 and a nine-year NFL veteran who coauthored the book "Yes I Can! Yes You Can! Tackle Diabetes and Win!" about playing with the same Type 1, insulin-dependent diabetes as Cutler, said it was a challenge adjusting to weeks in which schedules and game times changed.

"For me, it took a long time, not until my fourth or fifth year, that I felt comfortable with all the different start-time schedules and what I had to
do for a 4 p.m. kickoff as opposed to a Sunday day game or a Sunday night game," he said. "It's possible [Cutler] hasn't played enough games to where he has the routine down."

But while some diabetics experience difficulties with night vision or controlling their blood-sugar levels more at night, Leeuwenburg stressed that everyone with the disease is different. "It's like saying that all vegetarians eat the same, and that's not the case," he said. "Everyone manages the disease in a different manner."

"There are also so many different variables and different symptoms for everyone if they have low or high blood sugars. I could have low blood sugar and my symptoms could be that I shake or it's hard for me to concentrate. Jay's symptoms could be his eyesight is off. It's so individualized, you don't know. When I played, I prided myself on being one of the most physically fit players, so when I was winded when after a series, I knew I had to check my blood sugar."

"And even if Jay has to miss a series or even a half, it doesn't mean he's not going to be able to come back and play great the next week. It's a day-to-day disease."

Leeuwenburg is now in his 28th year of Type 1 diabetes and is working as a 3rd grade teacher in Colorado (he probably didn't make $6.4 million per season, not including any potential bonus money). It's great to hear he does not exhibit any significant diabetes-related problems to this day.

Leeuwenburg didn't blame the diabetes and we've not heard Cutler use it as an excuse to date.

"It was always a bone of contention of mine that if I gave up a sack, it was, 'Is it because he's having a low blood sugar day?'" Leeuwenburg said. "No, it was because my technique sucked on that play. My guess is that Jay just didn't play particularly well on those nights."

The full ESPN article is here.

We'll Let Someone Else Say It

First, we'd like any of our patients to honestly inform us if they believe we have been spending less time with them in the recent past. It has not been planned to do so to date, but, it may come to that if some changes are not made.

Almost one-third of doctors in an industry-sponsored survey said they didn't spend enough time with their diabetic patients and blamed low reimbursement rates for diabetes care, researchers said.

In a survey of 200 primary care physicians and 100 endocrinologists, 32%
reported an inability to provide comprehensive diabetes care, Alyssa Pozniak,
PhD, of Abt Associates in Cambridge, Mass., and colleagues reported online in
American Health & Drug Benefits.

A lack of time and reimbursement rates were provided as the two most common explanations for reduced care. The study was funded by Novo-Nordisk and it is noted that treatment guidelines developed by the American Diabetes Association were considered to be impractical (no argument comes from our office on that).

The full article, with some suggestions to improve the situation, is here.

I'll Pass On A Comment Here

An Asheville eye doctor said he is prepared to go to court against the N.C. Medical Board if it reprimands him for telling a patient she was fat.

Dr. Earl Sunderhaus, of Asheville Eye Center on Tunnel Road, is awaiting word from the board about any actions it may take against him for making cutting criticisms of a female patient, including telling her she was fat and poking her thigh.

The Medical Board will decide if Sunderhaus overstepped the bounds of
professional decency. Sunderhaus could lose his medical license.

"They are chastising me for telling her she should lose some weight because it is raising the cost of health care and it is also bad for her children and she is
going to end up with diabetes," Sunderhaus said. "I had to take three days out
of my practice and go down to Raleigh, losing income, just because somebody didn't like that I told her that she was fat."

The full article is here and there is another version here.

Unlucky Diabetic?

Yes, I state that Alice Halstead is a "diabetic" rather than referring to her as a "person of the female persuasion that has been afflicted with diabetes" as some seem to prefer. It's amazing how many negative e-mails we get when we state someone is a "diabetic".

However, this seems to be a very interesting case, but we don't hear any truly specific details that permit us to make an educated guess as to what is going on. In the "old days", before human insulin, an occasional diabetic would have large titers of anti-insulin antibodies that might serve to bind significant quantities of insulin at any one time, thus making theinsulin "inactive". However, there was always the potential for dissociation of insulin from the antibodies with the possibility of hypoglycemia (low blood sugar).

We're told, in this article, that Alice Halstead, of Skipton, North Yorks in the UK, has a "condition" that might be seen in one out of 6.7 billion people. As a result, she spends each night in a hospital.

Once again, we're just not given enough specific information in the article. In addition to anti-insulin antibodies, there is also a very rare situation in which patients may develop antibodies to the insulin receptors on cells. I had been involved in some research regarding this topic during my diabetes training in the late 1980s. At that time, a literature search had revealed only 40 reported individuals worldwide in which this problem had been identified.

The story about Alice Halstead is here.

For iPhone Users

That doesn't include me .... but, if you're diabetic and use an iPhone, Sanofi-Aventis presents a a new application that helps you calculate the nutritional content of a meal.

"GoMeals™” is a food tracking tool that allows you to search more than 25,000 foods and more than 200 restaurant menus to see breakdowns of carbohydrate, fat and protein content presented in a pie-chart fashion. A restaurant locator function is also included.

Check out GoMeals.com that includes a demo.

Islet Cell Transplants To Be Offered In Scotland

Type 1 diabetic patients in Scotland may be eligible to receive "insulin-producing cells from donated pancreas in the first service of its kind in the UK".

Islet cells are implanted (via injection) into the patient's liver.

"The Scottish government are investing in a range of initiatives designed to increase the number of actual organ and tissue donors in Scotland so programmes like this can continue to save and improve lives."

Read the full article, including some patient profiles, here.

Back From Barcelona .....

..... following a meeting and a few days of sightseeing, we'll be geting back to posting more regularly.

Watch for a few photos from the trip in the next few days or weeks.

World Diabetes Day -- November 14th

Check out the website here.

One Possible Swine Flu Protocol?

Veterans Day -- Remember What It's All About

The Korean War Memorial
Washington, DC

We salute all that have served our nation in times of war and peace

Check out the Department of Veterans Affairs website here.

Check out some Veterans Day quotations here.

It's Known As "DAFFYD" In Wales

However, even though it is available to everyone, it looks like it's used with as much enthusiasm as we see in the United States.

Dose Adjustment For Your Daily Diet

But despite recommendations by the National Institute for Health and Clinical Excellence (Nice) that structured education is available for everyone with diabetes in Wales, only 2% of people with the condition have completed a course.

Check out the full story here.

Six Common Myths And Misconceptions About Diabetes

There's a real lull in the diabetes-related news lately. You can tell when they recycle this one:

Six Common Myths And Misconceptions About Diabetes

FDA Warns Of "Kidney Problems" With BYETTA?

There were 78 reports of "problems with kidney function" in patients taking BYETTA during a 42 month period ending October 2008. Seven million prescriptions for the drug were written during the same time period.

That's one out of every 89,744 prescriptions and it is not specified whether this includes only new, or all, prescriptions.

Two things are interesting here. The first is that the announcement comes 3 days after the drug was approved as stand-alone therapy for Type 2 diabetes. The second is ... how can you prove loss of kidney function in the patients representing the 1 out of 89,744 prescriptionse is solely due to BYETTA. Diabetes itself is the leading cause of kidney failure.

The Reuters article does not shed any light on that.

A legal website claims the FDA claims "some of those patients already had underlying kidney disease or other factors that put them at increased risk of kidney problems".

How did the FDA sort out which cases were due to BYETTA only?

Once again, the Attorney At Law has no information about this.

Does anyone else have a very puzzled look on their face?

Something Else To Do At The Mayo Clinic?

A 90 year old couple (married 62 years) found something else to do in the Mayo Clinic atrium.

Now, the big question. Will they get some positive adjustment to their QALY score if anything resembling "Obama-Care" is adopted?

Diabetes Still On The Rise In The United States

Diabetes now affects 11.4% of the American population. That's up from 10.4% in the 1st quarter of 2008. This number translates to 26 million individuals ... and we always must consider there are usually a million or so individuals that are diabetic, but are not yet aware of it.

The obesity rate has also increased by approximately 1 percent since last year. More than 21% of obese adults are diabetic.

As would be expected with the rising numbers noted above, the percentage of Americans getting a recommended level of exercise is falling.

Check out the full WebMD article here. It includes the list of the top ten states showing the greatest, and least, change in obesity rates. New Jersey is not on either list.

"Pay For Performance"?

Check out the Medicare "Pay For Performance" Initiative that has been proposed.

We've previously made note of this here and here.

Imagine, if you're concerned about this situation, and you then read this.

Here's an excerpt for those that don't like to access the linked articles:

"We found a measurement system that is both redundant and inconsistent, with many different measures assessing the same clinical indicators,'' says Dr.
Nash, one of the study's authors and Dean of the Jefferson School of
Population Health. "Methods and assessment goals vary among different
organizations, as do, in some cases the sources of data (for example, patient
or health plan level data) making uniform standards more difficult to achieve."

"This study demonstrates that current measurement of diabetes care quality is
far too complex and disjointed, and at the same time lacking in a number of
key areas, particularly at the population level," says Dana Haza, senior
director of NDCP.

It's always interesting to read a study about a study.

Groups Develop New Algorithm For Type 2 Diabetes

An algorithm is "a precise rule (or set of rules) specifying how to solve some problem".

The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) have released new treatment algorithms for Type 2 diabetes.

"We believe that this algorithm represents the treatment preferences of most clinical endocrinologists, but in the absence of meaningful comparative data, it is not necessarily an official AACE position," they noted.

Lifestyle changes (diet and exercise) are still stressed. Three separate, and perhaps "over-simplified", pathways are proposed:

(1) Monotherapy (one drug) for patients with HbA1c levels under 7.5%
(2) Two drugs for HbA1c values between 7.65 and 9.0%
(3) Three drugs for HbA1c levels greater than 9.0%

Patients with sub-optimal control with "triple therapy" should get a basal insulin. Specifically, the use of "NPH" insulin is now downplayed.

Whatever treatment regimen is begun, they said, its effectiveness should be monitored every two to three months by measuring hemoglobin A1c. Therapy should be regularly intensified, if necessary, to reach the target.

Newer drugs are more highly recommended as a result of better safety profiles, primarily less hypoglycemia (low blood sugar).

Because of this stratification, they said, "we have given sulfonylureas much less priority because use of these agents is associated with hypoglycemia, weight gain, and limited duration of effectiveness after initiation of therapy."

On the other hand, the algorithm "favors the use of glucagonlike peptide-1 (GLP-1) agonists and dipeptidyl-peptidase-4 (DPP-4) inhibitors with higher priority because of their effectiveness and overall safety profiles," the authors
said.

Gee, the insurance providers aren't going to like that.

We would add that drugs should be added one at a time. In that way, you can better gauge the individual impact of each drug and sort out any drug-related adverse events.

The full article is here.

We're Still Waiting For VICTOZA (Liraglutide)

VICTOZA is more effective at promoting weight loss than an established weight loss drug known as XENICAL (orlistat) according to a recently published study.
VICTOZA had been launched in Europe this past summer, but we wait for a deadlocked FDA Advisory Panel to make some move on this highly anticipated drug.

Three quarters of people on Victoza lost more than five per cent of their body weight, compared with less than half than orlistat and less than a third who were given a placebo.

The jab, given once daily works by intensifying the 'full' feeling patients get after eating, and by reducing the speed at which their stomach empties.

The manufacturers may need to apply for a new licence for Victoza to be used solely for obesity, however the majority of cases of type 2 diabetes are linked to being overweight.

Yes, they do refer to an injection as a "jab" in the United Kingdom.

The full article is here.

Just As We Always Say ....

"Sliding Scale" insulin therapy, a favorite in the hospital setting, is rarely, if ever, adequate or appropriate. But, it has been maintained for decades and will likely continue.

The Medical Center of Plano (Texas) randomized non-critically ill, but hospitalized, patients into "sliding scale" and "tight control" groups. They chose 80-150 mg/dl as the target range for blood sugars and looked at the first 48 hours of admission.

There was an almost 50% higher rate of target blood glucose achievement in the non-"sliding scale" (NSS) group. Rates of hypoglycemia were higher in the NSS group, but none were considered significant.

The study abstract is here.

We'll continue to cringe upon hearing that a hospitalized diabetic has been subjected to sliding scale insulin. Patients, however, should still expect to be subjected to this "inferior" method of managing diabetes in the hospital setting if not being managed by an endocrinologist or diabetologist.

Laughter, The Best Medicine

Thanks to BA !