February 11, 2017

Ten Diabetes Foot Care Tips – Part 2

This is continued from yesterday's blog.

#6. Stay soft, but dry. Your skin may be dry and cracked because of high glucose levels, and cracked skin means it's easier for bacteria to get under your skin and harder for infections to heal. Use a small amount of skin lotion daily, but be sure your feet feel dry, not damp or sticky, afterward. Try not to get the lotion in between your toes.

Keep your toenails trimmed and filed smooth to avoid ingrown toenails. You may find it easier to trim your nails after using lotion, when your cuticles are softer. Use a pumice stone after showering or bathing to softly file corns or calluses.

#7. Try non-impact exercise. Swimming, cycling, yoga, and tai chi are increasingly popular ways to exercise, with minimal impact on your feet. Talk with your doctor before starting an exercise program to be confident that you will
cause injury or other problems to your health.

#8. Fix bunions, corns, and hammertoes. If your big toe slants sharply in toward your other toes, with a big bump on the knuckle of your big toe, you have a classic bunion. Corns are spots of thick, rough skin, where the tissue builds up on toes constantly barraged by too much rubbing or pressure. A buckled-under toe, called a hammertoe, can result from muscle weakness caused by diabetic nerve damage.

All of these make it hard to fit shoes comfortably. A good podiatrist can help you fix these problems and take better care of your feet.

#9. Consider fitted orthotics. A podiatrist can also fit you with shoe inserts called orthotics to support your feet if your have diabetic nerve pain or the muscles have become weak from nerve damage. If pain or weakness is so severe that it's too painful or even impossible to walk, a foot brace or orthopedic shoes might help. A podiatrist is your best source for these devices.

#10. Control your blood sugar. The best prevention for nerve pain, ultimately, is to manage your diabetes well. In fact, a 2006 study by the National Institute of Diabetes and Digestive and Kidney Diseases showed that strict blood glucose control with intensive insulin therapy lowered the chances in people with type I (insulin requiring) diabetes of having symptoms of peripheral neuropathy -- tingling, burning, and pain -- by 64%. These results have also been shown to hold true in type II diabetes, too.

The two most important determinants of whether you get diabetic neuropathy are how many years you have had diabetes and how well you control your blood sugar. Other factors, including controlling blood pressure and blood fats (cholesterol and triglycerides) and not smoking are also important to prevent diabetic neuropathy.

Controlling your blood glucose also helps reduce the symptoms of diabetic nerve pain. So, the good news is that controlling your glucose levels with diet, exercise, and if needed, medications cannot only help prevent diabetic peripheral neuropathy, but they can also help ease its effects.

Protecting your feet is important. Your feet are your source of independence, or at least its foundation. Give your feet a little tenderness, a little loving care, each day. And be sure to have your doctor take a good look at your feet during each of your diabetes checkups in case you've missed anything.

February 10, 2017

Ten Diabetes Foot Care Tips – Part 1

Diabetes can mean double trouble for your feet. First, diabetes can reduce blood flow to your feet, depriving your feet of oxygen and nutrients. This makes it more difficult for blisters, sores, and cuts to heal. Second, the diabetic nerve damage called peripheral neuropathy can cause numbness in your feet. When you can't feel cuts and blisters, you're more likely to get sores and infections.

If you don't notice or treat the sores, they can become deeply infected, and lead to amputation.

Diabetic peripheral neuropathy can also cause sharp pain in your feet. You may become excruciatingly sensitive to the lightest touch, like the sheets on your bed.

Fortunately, a little TLC goes a long way in preventing foot problems from diabetes.

#1. Check both feet daily. Look over both feet carefully every day, and be sure you check between all of your toes. Blisters and infections can start between your toes, and with diabetic neuropathy, you may not feel them until they've become irritated or infected. If a physical challenge keeps you from checking your own feet, ask a family member to help.

#2. Wash with warm -- not hot -- water. Wash both of your feet briefly each day with warm -- not hot -- water. You may not be able to feel heat with your feet, so test the water with your hands first. Avoid soaking too long in water, since waterlogged sores have a harder time healing. Dry your feet right away, and remember to dry gently between all of your toes.

#3. Make sure your shoes fit well. It's an investment worth making. Even the slightest rubbing or misfit shoe can cause a blister that turns into a sore that becomes infected and never heals.

Buy better-fitting shoes, or try different socks, even at the most minor signs of redness or irritation, since you may not be able to feel when it's getting worse. Before buying or putting on the shoes check your shoes for rough seams, sharp edges or other objects that could hurt your feet. And break your shoes in gradually.

#4. Skip the barefoot look. Always wear shoes or slippers, even around the house or apartment. Always wear socks with your shoes, since leather, plastics, and manmade shoe materials can irritate your skin and quickly bring on blisters.
While you might prefer the look of hose, nylon knee-highs, or thin socks, you may find that these don't give your toes or heels enough protection. Wear thicker socks to pad your feet and cushion any calluses or sore spots.

#5, Speak up. Nerve damage can be unpredictable. Tell your doctor about any changes in sensation in your toes, feet, or legs. Speak up if you notice pain, tingling, a pins-and-needles feeling, numbness, or any other unusual signs -- even if it seems trivial to you. There's nothing small-potatoes about a potential foot amputation.

This is continued in tomorrow's blog.

February 9, 2017

Metformin May Prevent Colorectal Cancer

Metformin has been promoted for preventing other cancers, so it is not a surprise that colorectal cancer is prevented to some degree by metformin.

Meta-analysis found metformin therapy was associated with decreased risk for colorectal adenomas and colorectal cancer among type 2 patients.

Studies have suggested that patients with type 2 diabetes may be at an increased risk for developing colorectal cancer (CRC); hyperinsulinemia, hyperglycemia, and chronic inflammation are thought to all contribute to carcinogenesis. Metformin, a biguanide, exerts its antihyperglycemic effects by decreasing hepatic glucose production, decreasing intestinal absorption of glucose, and improving insulin sensitivity by increasing peripheral glucose uptake and utilization.

Since metformin is the most commonly prescribed medication for the treatment of type 2 diabetes, researchers sought to assess whether metformin use has an effect on the incidence of CRC in this patient population. A total of 8,046 study participants were included in the analysis (2,682 in the case group [diabetes patients with incident diagnosis of CRC]; 5364 individuals in the control group [diabetic patients without CRC diagnosis]); each group was 60% male, 40% female. In the case group, 36.6% of patients had metformin exposure, while 38.4% had metformin exposure in the control group. In this study, any metformin use led to a 15% reduction in the odds of CRC; after accounting for healthcare use, the effect was reduced to 12%. Reduction of risk was not significantly associated with metformin dose, duration or total exposure.

Metformin therapy was associated with decreased incidence of colorectal adenomas (P equal to .0002). On adjusted analysis, the summary estimate decreased further to a 25% reduction in colorectal adenoma risk (P equal to .03). Colorectal cancer risk was also significantly reduced among metformin users vs metformin non-users or other treatment users (P equal to .0002).  Adjusted analysis revealed a 22% reduction in colorectal cancer risk for metformin users (P less than .00001).

Recent evidence indicates that metformin therapy may be associated with a decreased colorectal adenoma/colorectal cancer risk in type 2 diabetes patients. However, results are not consistent. So a systematic review and meta-analysis to assess the association between metformin therapy and risk of colorectal adenomas/colorectal cancer in type 2 diabetes mellitus patients was done. They searched the literature published before Aug. 31, 2016 in four databases: PubMed, Embase database, CNKI and VIP Library of Chinese Journal. Summary risk estimates with their 95% confidence interval (95% CI) were obtained using a random effects model.

Twenty studies (including 12 cohort studies, 7 case-control studies and 1 randomized controlled trial study) were selected in terms of data of colorectal adenomas or colorectal cancer incidence. Metformin therapy was found to be associated with a decreased incidence of colorectal adenomas (P equal to 0.0002). When the adjusted data were analyzed, the summary estimate decreased to 25% reduction in colorectal adenomas risk (P equal to 0.03). Besides, a significant reduction of colorectal cancer risk was also observed (P equal to 0.0002). And when the adjusted data were analyzed, colorectal cancer risk for metformin users was decreased with a reduction of 22%, compared with non-metformin users and other treatment users  (P less than 0.00001).

In another study published in Cancer in 2014, it was also concluded that metformin use appears to be associated with a reduced risk of developing CRC among diabetes patients in the United States by 12%. The mean age of the study participants was 55 years and 57 years, respectively, in the control and case groups (P = 1.0). Approximately 60% of the study participants were male and 40% were female in each group. In the multivariable model, any metformin use was associated with a 15% reduction in the odds of CRC. The dose-response analyses demonstrated no significant association with metformin dose, duration, or total exposure.

From the results of multiple studies, it was concluded that the meta-analysis suggested that metformin therapy may be associated with a decreased risk of colorectal adenomas and colorectal cancer in type 2 diabetes mellitus patients.

February 8, 2017

Low Accuracy for Prediabetes Screening Tests

This study surprised me a bit, but after reading some of my previous blogs, I realized that the study does have value and is probably correct.

The accuracy of the tests used to detect prediabetes in screening programs is low. The diagnostic accuracy of the current tests used to detect prediabetes in screening programs is low, according to a study published in BMJ. The results showed that the fasting glucose screening test is specific but not sensitive, and the HbA1c test is neither sensitive nor specific.

Eleanor Barry, MBBS, BSc, MRCP, MRCGP, from the Nuffield Department of Primary Care Health Sciences at the University of Oxford, and colleagues assessed the diagnostic accuracy of screening tests for prediabetes and the efficacy of lifestyle or metformin interventions in preventing the onset of type 2 diabetes.

The researchers performed one meta-analysis to summarize the accuracy of screening tests for identification of prediabetes, with the oral glucose tolerance test as the standard, and they conducted an additional meta-analysis that assessed relative risk of progression to type 2 diabetes after lifestyle intervention or treatment with metformin.

The investigators included 49 studies of screening tests and 50 intervention trials in their final analysis. They examined empirical studies examining the accuracy of tests for the identification of prediabetes, randomized trials, and interventional studies.

As the prevalence of type 2 diabetes rises inexorably in high, middle, and low income countries alike, controversy continues to surround the questions of who is ‘at risk' and what preventive interventions to offer them,” the study authors wrote. “A screen and treat policy will be effective only if a test exists that correctly identifies those at high risk (sensitivity) while also excluding those at low risk (specificity); and an intervention exists that is acceptable to, and also efficacious in, those at high risk.”

The HbA1c screening test had a mean sensitivity of 0.49 and specificity of 0.79 for the identification of prediabetes, although different studies used different cut-off values. In addition, fasting plasma glucose had a mean sensitivity of 0.25 and a specificity of 0.94.

Lifestyle interventions were associated with a 36% reduction in relative risk of type 2 diabetes during the course of 6 months to 6 years, which attenuated to 20% at follow-up in the period after the trials.

The authors note that future studies should focus on the pragmatic real world effectiveness and cost effectiveness of interventions for prediabetes that have already shown to be efficacious in trials. Further research should also be conducted to evaluate population level or health system interventions.

February 7, 2017

Low 'LDL' Puts You At Risk For Cataract

According to a study in the Journal of the American College of Cardiology, very low levels of LDL, or bad cholesterol, puts you at a greater risk for cataract. The researchers studied patients with heart disease taking LDL inhibitors to achieve unusually low cholesterol level. There were no adverse effects noted from the inhibitors except for an increased risk of cataracts.

This is news and not good news. I have had cataracts and the operation to correct my vision, but I have not used a PCSK9 inhibitor.

The cholesterol-lowering drug, or statins, used in the study were specifically PCSK9 inhibitor, and no reports of side affects have surfaced, including memory impairment or nervous system disorders. However, the study showed that the risk for cataract is increased among statin users as compared with nonusers. According to the researchers, to glean the maximum amount of benefits and avoid risks, statin use specifically for primary prevention, should be carefully weighed.

According to the EurekAlert, statins are largely used to lower LDL cholesterol, or bad cholesterol. They are prescribed in hopes to lower risks of a heart attack or stroke. However, some high risk patients need to reduce their LDL level even further.

PCSK9 inhibitors can help them do that, but concerns on very low levels of LDL cholesterol effects on the body functions have risen. An analysis did show an increased incidence of cataracts in patients with LDL less than 25 compared to those greater than 25. This finding could be because reducing cholesterol accelerates underlying aging-related changes resulting to the development of cataracts.

According to The Jama Network, cataract development may be induced by oxidative stress, including a possible mitochondrial effect, which can potentially increase risk for cataract. Previous studies have seen increased rates of cataract among animals and humans with hereditary cholesterol deficiency. The recent studies on the effects of very low bad cholesterol have yielded an unexpected finding, putting patients who take statins in a precarious condition.

Please read this blog as it does add the side effect of type 2 diabetes, which is not recognized by this study.

February 6, 2017

Is Your Hospital Safe?

This is a very alarming article and some of the information I was not aware of, especially how often hospitals avoid reporting information. It appears that I need to work with my federal and state legislators to develop laws mandating reporting adverse events and assessing fines when they don't report them.

I would say that the hospital actions are in the criminal level. It is a shame that we have to rely on a newspaper originating outside the United States for information like this. Yes, a recent report by Reuters details how hospitals around the country are negligent when it comes to reporting outbreaks of antibiotic-resistant infections, and it's costing lives.

Between 2008 and 2011, twenty-one patients were infected with a deadly, drug-resistant bug at St. Anthony’s Medical Center in St. Louis, Missouri. The hospital didn’t think the number of cases warranted reporting to state health authorities. In 2009, a patient named Richard Armbruster, who was in St. Anthony’s for a hip replacement, died two days after contracting the infection. His daughter told Reuters, “Had [the outbreak] been reported to the authorities and the story picked up by the media, there is NO WAY we would’ve allowed by Dad to have his surgery there.”

Twenty-two patients were infected with a drug-resistant “superbug” in Ohio, causing seven deaths. The outbreak was able to spread through a hospital and seven long-term care facilities because they did not warn each other when infected patients were transferred.

Generally, states require hospitals to report an outbreak within twenty-four hours, but hospitals are given lots of leeway in determining what constitutes an “outbreak.” This leaves room for hospital administrators to downplay the seriousness of an outbreak to keep the patients—and the dollars—rolling in.

Hospitals are rarely held accountable, and when they are, states rarely dole out any punishment. Reuters reports that thirty-six states are able to impose civil or criminal penalties—yet none of those states did so in the last five years. When states release reports on outbreaks, they lack basic information: in sixteen states, the name of the facility must be removed.

Meanwhile, Medicare favoritism toward hospitals (the government pays far more for the same procedure if the doctor works for a hospital) has driven most private practices out of business. They have been forced to sell out to —who else? —hospitals!

This is our crony medical system: a system that cares about and looks after hospitals (and pharmaceutical companies) rather than patients.

Yes, I will be attaching a copy of this article and sending an accompanying letter to my federal and state legislators recommending investigation and action to reign this from happening more often and if necessary imposing penalties for violations. Because hospitals are needed, I would recommend the penalties be imposed on the hospital administrators.

February 5, 2017

Some Problems the Elderly Have for Sleep

A doctor writes the article I am using for this blog and she chooses to label it, ”5 Top Causes of Sleep Problems in Seniors.” I am certain that Dr. Leslie Kernisan understands this topic far better than I do, but I do feel she left much out of the discussion on sleep apnea.

There are several warnings that should be issued. First, even though mortality is mentioned, there should be a clear warning about obstructive sleep apnea causing death and/or heart attacks. Even central sleep apnea can cause serious health problems.

I have had sleep apnea since 1999 and have had treatment since 2001. I use a CPAP mask every night. I have progressed from the original CPAP to a machine known as a Bi-PAP machine, which is much quieter and more efficient. I am not like many people that have problems and either won't wear the mask or only use it part of the night. Two friends have moved to an oral device and say they like the device better than the mask. Two other friends like using the mask and are using their machine every night, like I do.

Doctors use a language seldom used by patients. Sleep apnea is no different. They use sleep-related breathing disorders (SRBD) and it is sometimes referred to as sleep-disordered breathing (SDB). The SDB is an umbrella term covering a spectrum of problems related to how people breathe while asleep.

Sleep apnea (as most patients know it) is a common condition, which is important to have diagnosed since it has been associated with many other health problems, especially in adults of middle age. In sleep apnea, a person has frequent pauses in their breathing during sleep. The most common form is obstructive sleep apnea (OSA), in which the breathing pauses are due to obstructions in the breathing passages. OSA is often associated with snoring. A less common form is central sleep apnea, in which the breathing pauses are related to changes in the brain.

The likelihood of having sleep-disordered breathing disorders goes up with age. It’s also more common in men, and in people who are overweight. In one study of 827 healthy older adults aged 68, 53% were found to have signs of SRBD, with 37% meeting criteria for significant sleep apnea. Interestingly, most participants did not complain of excess sleepiness.

Studies have found that untreated OSA is associated with poor health outcomes including increased mortality, stroke, coronary artery disease, and heart failure. However, studies also suggest that these associations are strongest in people aged 40-70, and weaker in older adults. For older adults with symptomatic OSA, treatment can reduce daytime sleepiness and improve quality of life.

Helpguide.org’s page on sleep apnea has a useful 7-item questionnaire, to help you determine how likely it is that symptoms are sleep apnea. It also has a discussion on sleep apnea. You can also ask the doctor about further evaluation if you’ve noticed a lot of daytime sleepiness. To be diagnosed, you’ll need to pursue polysomnography (objective sleep testing) either in a sleep lab or with a home sleep testing kit.

Whether or not you pursue an official diagnosis for SRBD, avoiding alcohol (and probably other sedatives) is likely to help.

Other problems listed by Dr. Kernisan in addition to the above:

#1. Sleep problems due to an underlying medical problem.

#3. Restless leg syndrome (RLS).

#4. Periodic Limb Movements of Sleep (PLMS).

#5. Insomnia.

In my research, I found an article in Newswise that covers the problems with oral devices for obstructive sleep apnea. You may read about it here. It does discuss a French study with this opening statement: In patients with severe obstructive sleep apnea (OSA), oral appliances that treat the condition by moving the lower jaw forward appear to improve sleep but not reduce key risk factors for developing heart and other cardiovascular disease, according to new research published online, ahead of print in the American Thoracic Society’s American Journal of Respiratory and Critical Care Medicine.