February 8, 2014

Gastroparesis – The Good and Bad – Part 3

Fortunately, there are prescription medications to treat gastroparesis. Often a combination of medications are used to determine the most effective treatment. The list of medications is short and includes:
#1. Metoclopramide (Reglan). This medication stimulates stomach muscle contractions to help with gastric emptying. Metoclopramide also helps reduce nausea and vomiting. The medication is taken 20 to 30 minutes before meals and at bedtime. Possible side effects of metoclopramide include fatigue, sleepiness, and depression. Currently, this is the only medication approved by the FDA for treatment of gastroparesis. The FDA has placed a black box warning on this medication because of rare reports of it causing an irreversible neurologic side effect called tardive dyskinesia, which is a disorder that affects movement.
#2. Erythromycin. This antibiotic, prescribed at low doses, may improve gastric emptying. Like metoclopramide, erythromycin works by increasing the contractions that move food through the stomach. Possible side effects of erythromycin include nausea, vomiting, and abdominal cramps.
#3. Other medications. Other medications may be used to treat symptoms and problems related to gastroparesis. For example, medications known as antiemetics are used to help control nausea and vomiting.
#4. This is not a medication and care should be used if you allow this. Botulinum toxin is a nerve-blocking agent also known as Botox. After passing an endoscope into the stomach, a doctor injects the Botox into the pylorus, the opening from the stomach into the duodenum. Botox is supposed to help keep the pylorus open for longer periods of time and improve symptoms of gastroparesis. Although some initial research trials showed modest improvement in gastroparesis symptoms and the rate of gastric emptying following the injections, other studies have failed to show the same degree of effectiveness of the Botox injections.

There are procedures that are also used and have varying degrees of success. The following are the ones used currently:
#1. Gastric Electrical Stimulation This treatment alternative may be effective for some people whose nausea and vomiting do not improve with dietary changes or medications. A gastric neurostimulator is a surgically implanted battery-operated device that sends mild electrical pulses to the stomach muscles to help control nausea and vomiting. The procedure may be performed at a hospital or outpatient center by a gastroenterologist. General anesthesia may be required. The gastroenterologist makes several tiny incisions in the abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached. The camera sends a magnified image from inside the stomach to a video monitor, giving the gastroenterologist a close-up view of the tissues. Once implanted, the settings on the battery-operated device can be adjusted to determine the settings that best control symptoms.
#2. Jejunostomy If medications and dietary changes don’t work, and the person is losing weight or requires frequent hospitalization for dehydration, a health care provider may recommend surgically placing a feeding tube through the abdominal wall directly into a part of the small intestine called the jejunum. The surgical procedure is known as a jejunostomy. The procedure is performed by a surgeon at a hospital or outpatient center. Anesthesia is needed. The feeding tube bypasses the stomach and delivers a special liquid food with nutrients directly into the jejunum. The jejunostomy is used only when gastroparesis is extremely severe.
#3. Parenteral Nutrition When gastroparesis is so severe that dietary measures and other treatments are not helping, a health care provider may recommend parenteral nutrition—an IV liquid food mixture supplied through a special tube in the chest. The procedure is performed by a surgeon at a hospital or outpatient center; anesthesia is needed. The surgeon inserts a thin, flexible tube called a catheter into a chest vein, with the catheter opening outside the skin. A bag containing liquid nutrients is attached to the catheter, and the nutrients are transported through the catheter into the chest vein and into the bloodstream. This approach is a less preferable alternative to a jejunostomy and is usually a temporary treatment to get through a difficult period of gastroparesis.

My friend and member of our support group, Allen, says that one of his friends had the last procedure and had to remain in the hospital to fight a resulting infection and does not recommend the last procedure above.

For a comparisons of information please read this.  Or you can also enter gastroparesis in your search engine and do your own search.

February 7, 2014

Gastroparesis – The Good and Bad – Part 2

Part 2 of 3 parts

Treating gastroparesis is important if you have diabetes and often your diabetes medications will need to be changed. Gastroparesis can occur when the vagus nerve is damaged by illness or injury and the stomach muscles stop working normally. Food then moves slowly from the stomach to the small intestine or stops moving altogether.
It is known that elevated blood glucose levels directly interferes with normal stomach emptying. Excellent blood glucose management is needed to prevent gastroparesis and help food move through the stomach.

Gastric emptying is unpredictable with gastroparesis. It causes a person’s blood glucose levels to be erratic and difficult to control. “The primary treatment goals for gastroparesis related to diabetes are to improve gastric emptying and regain control of blood glucose levels. In addition to the dietary changes and treatments already described, a health care provider will likely adjust the person’s insulin regimen.

To better control blood glucose, people with diabetes and gastroparesis may need to
  • take insulin more often or change the type of insulin they take
  • take insulin after meals, instead of before
  • check blood glucose levels frequently after eating and administer insulin when necessary”

Your doctor should give you specific instructions for taking insulin based on the needs of the individual and the severity of gastroparesis. It is often suggested that you eat several liquid or pureed meals per day until gastroparesis symptoms improve and your blood glucose levels are more stable.

The problems of gastroparesis can include
  • severe dehydration due to persistent vomiting
  • gastroesophageal reflux disease (GERD), which is GER that occurs more than twice a week for a few weeks; GERD can lead to esophagitis— irritation of the esophagus
  • bezoars, which can cause nausea, vomiting, obstruction, or interfere with absorption of some medications in pill form
  • difficulty managing blood glucose levels in people with diabetes
  • malnutrition due to poor absorption of nutrients or a low calorie intake
  • decreased quality of life, including work absences due to severe symptoms”

Bezoars is a hard indigestible mass of material, such as vegetable fibers, or the seeds and skins of fruits, formed in the alimentary canal.

Important points to keep in mind:
#1. Gastroparesis is a disorder that slows or stops the movement of food from the stomach to the small intestine.
#2. Gastroparesis normally occurs when the vagus nerve is damaged by illness or injury and the stomach muscles stop working normally.
#3. Idiopathic gastroparesis is often the diagnosis because the doctors cannot identify the cause, even with medical tests.
#4. Diabetes is the most common cause of gastroparesis. Over time, the people with unmanaged diabetes and have consistent high blood glucose levels cause damage to the vagus nerve.
#5. The most common symptoms of gastroparesis are nausea, a feeling of fullness after eating a small amount of food, and vomiting undigested food (this can occur several hours after a meal. Other symptoms include gastroesophageal reflux, pain in the stomach area, abdominal bloating, and lack of appetite.
#6. Gastroparesis is diagnosed through a physical exam, medical history, blood tests, tests to rule out blockage or structural problems in the gastrointestinal (GI) tract, and gastric emptying tests.
#7. Changing eating habits can sometimes help control the severity of gastroparesis symptoms. A health care provider may suggest eating six small meals a day instead of three large ones. When a person has severe symptoms, a liquid or puréed diet may be prescribed.
#8. Treatment of gastroparesis may include medications, botulinum toxin, gastric electrical stimulation, jejunostomy, and parenteral nutrition.
#9. For people with gastroparesis and diabetes, a health care provider will likely adjust the person’s insulin regimen.

Jejunostomy is an artificial opening from the jejunum through the abdominal wall, created for the drainage of jejunal contents or for feeding.

Jejunum is the middle portion of the small intestine, between the duodenum and the ileum.

February 6, 2014

Gastroparesis – The Good and Bad – Part 1

Part 1 of 3 parts

Gastroparesis is something that has two sides to the issue. Most people do not want this, but others take medications that mimic this. Gastroparesis, also called delayed gastric emptying, is a disorder that slows or stops the movement of food from the stomach to the small intestine.

David Mendosa covers the medication that slows the emptying of the stomach – Byetta. Read his blog here from 2006. Bydureon has the same effect. Some people are wanting the slowing of food passing through the stomach, as it is great for prevention of blood glucose spikes.

If you are like me, then gastroparesis is not what you want. Over time, high blood glucose levels can damage the vagus nerve. Other identifiable causes of gastroparesis include intestinal surgery. The most common symptom of gastroparesis is nausea. Other symptoms include:
  1. A feeling of fullness after eating a small amount of food
  2. Vomiting undigested food – often several hours after eating
  3. Pain in the stomach area
  4. Abdominal or stomach bloating
  5. Gastroesophageal reflux (GER), which is also called acid reflux or acid regurgitation and you can add gastroesophageal reflux disease (GERD). These all represent a condition in which the stomach contents flow back into the esophagus.
  6. Lack of appetite

What surprises me is the symptoms that can aggravated by consuming greasy or rich foods, large quantities of foods with fiber, such as raw fruits and vegetables. I am not surprised that drinking beverages high in fat or carbonation and I have been forced to eliminate most of these. Because symptoms vary in intensity over time and may be mild to severe, this often make gastroparesis difficult to diagnose.

I will quote the following, as I want to be sure I get it all. “Gastroparesis is diagnosed through a physical exam, medical history, blood tests, tests to rule out blockage or structural problems in the GI tract, and gastric emptying tests. Tests may also identify a nutritional disorder or underlying disease. To rule out any blockage or other structural problems, the health care provider may perform one or more of the following tests:
  • Upper gastrointestinal (GI) endoscopy. This procedure involves using an endoscope—a small, flexible tube with a light—to see the upper GI tract, which includes the esophagus, stomach, and duodenum—the first part of the small intestine. The test is performed at a hospital or outpatient center by a gastroenterologist—a doctor who specializes in digestive diseases. The endoscope is carefully fed down the esophagus and into the stomach and duodenum. A small camera mounted on the endoscope transmits a video image to a monitor, allowing close examination of the intestinal lining. A person may receive a liquid anesthetic that is gargled or sprayed on the back of the throat. An intravenous (IV) needle is placed in a vein in the arm if general anesthesia is given. The test may show blockage or large bezoars—solid collections of food, mucus, vegetable fiber, hair, or other material that cannot be digested in the stomach—that are sometimes softened, dissolved, or broken up during an upper GI endoscopy.
  • Upper GI series. An upper GI series may be done to look at the small intestine. The test is performed at a hospital or outpatient center by an x-ray technician, and the images are interpreted by a radiologist—a doctor who specializes in medical imaging. Anesthesia is not needed. No eating or drinking is allowed for 8 hours before the procedure, if possible. If the person has diabetes, a health care provider may give different instructions about fasting before the test. During the procedure, the person will stand or sit in front of an x-ray machine and drink barium, a chalky liquid. Barium coats the small intestine, making signs of gastroparesis show up more clearly on x rays. Gastroparesis is likely if the x-ray shows food in the stomach after fasting. A person may experience bloating and nausea for a short time after the test. For several days afterward, barium liquid in the GI tract causes stools to be white or light colored. A health care provider will give the person specific instructions about eating and drinking after the test.
  • Ultrasound. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The procedure is performed in a health care provider’s office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. The images can show whether gallbladder disease and pancreatitis could be the cause of a person’s digestive symptoms, rather than gastroparesis.
  • Gastric emptying scintigraphy. The test involves eating a bland meal—such as eggs or an egg substitute—that contains a small amount of radioactive material. The test is performed in a radiology center or hospital by a specially trained technician and interpreted by a radiologist; anesthesia is not needed. An external camera scans the abdomen to show where the radioactive material is located. The radiologist is then able to measure the rate of gastric emptying at 1, 2, 3, and 4 hours after the meal. If more than 10 percent of the meal is still in the stomach at 4 hours, the diagnosis of gastroparesis is confirmed.
  • SmartPill. The SmartPill is a small electronic device in capsule form. The SmartPill test is available at specialized outpatient centers. The images are interpreted by a radiologist. The device is swallowed and moves through the entire digestive tract, sending information to a cell-phone-sized receiver worn around the person’s waist or neck. The recorded information provides a detailed record of how quickly food travels through each part of the digestive tract.
  • Breath test. With this test, the person eats a meal containing a small amount of radioactive material; then breath samples are taken over a period of several hours to measure the amount of radioactive material in the exhaled breath. The results allow the health care provider to calculate how fast the stomach is emptying.

Treatment of gastroparesis depends on the severity of the person’s symptoms. In most cases, treatment does not cure gastroparesis, which is usually a chronic, or long-lasting, condition. Gastroparesis is also a relapsing condition—the symptoms can come and go for periods of time. Treatment helps people manage the condition so they can be as comfortable and active as possible.”

I have been tested using the first three above and even they are not fun. I felt after the doctor and I discussed the tests, that the tests were beneficial. The doctor could not rule out gastroparesis, but did discover that I had gastroesophageal reflux disease (GERD).

Continued in part 2 of 3 parts.

February 5, 2014

Most Guidelines Done by People with Conflicts

When I wrote this blog, I felt that this was important and that Dr. Kendrick was correct, but I did not realize that I would see something so quickly from a United States authority. The Mayo Clinic in Rochester, Minnesota published a study in the January issue of Mayo Clinic Proceedings showing that most clinical practice guidelines are based on lower-quality medical evidence and a failure to disclose authors' conflicts of interest.

Then I had to realize that in early 2013 the American Association of Clinical Endocrinologists led by the nefarious Dr. Garber was attempting to have universal acceptance of the diabetes algorithms without disclosure of the authors' conflicts of interest. Fortunately, for patients, a couple of articles made it necessary for them to publish a consensus statement, which also listed the conflicts of interest of which Dr. Garber had plenty.

This is important enough to quote, ““Guidelines are meant to create a succinct roadmap for the diagnosis and treatment of medical conditions by analyzing and summarizing the increasingly abundant medical research,” write Joseph Feuerstein, MD, and colleagues from Beth Israel Deaconess Medical Center. “Guidelines are used as a means to establish a standard of care … However, a guideline’s validity is rooted in its development process.””

Most of the current practice guidelines in publication do not satisfy criteria that represent trustworthiness as defined by the Institute of Medicine. This definitely means that more attention needs to be paid to potential conflicts of interest among guideline authors and guideline development panels.

How much longer will the medical and other groups let the literature continue to grow that documents the existence of potential conflicts of interest reported for authors or members of guideline development panels? I may be wrong, but it seems that they are staying quiet to earn their place on one of these panels or to keep the side income flowing that they are currently receiving.

As a result, the influence of external activities such as consulting or speaking fees, research grant funding and stock ownership has the potential to create significant bias and uncertainty for issued recommendations.” Who pays the price for these greedy doctors and panel members. If you don't think that we as patients will suffer for the guidelines that overreach and promote more medications that have not been clinically proven to be beneficial, then go ahead and take the higher dosage and the extra medication the guidelines insist that we need.

February 4, 2014

2014 Third-Party Reimbursement for Diabetes Supplies

I do not understand the American Diabetes Association (ADA). This article on the Diabetes Care section, covers many of the points that should have been covered, but I am in doubt about the enthusiasm and sincerity even being part of the 2014 Guidelines.

The point of self-management education (inpatient and/or outpatient) is delivered by an interdisciplinary team and this will help people with diabetes adjust their daily regimen to improve glycemic management. Diabetes self-management education teaches individuals with diabetes to assess the interplay among medical nutrition therapy, physical activity, emotional/physical stress, and medications.

Today, self-management education is understood to be such a critical part of diabetes care that medical treatment of diabetes without systematic self-management education is regarded as inadequate. The weakness of today is doctors that will not support education, support needed testing supplies, and the lack of certified diabetes educators to assist in education.

The following is quoted, “Numerous studies have demonstrated that self-management education leads to reductions in the costs associated with all types of diabetes. Participants in self-management education programs have been found to have decreased lower-extremity amputation rates, reduced medication costs, and fewer emergency room visits and hospitalizations.”

To achieve optimal glycemic control, thus achieving long-term reduction in health care costs, individuals with diabetes must have access to the integral components of diabetes care, such as health care visits, diabetes supplies, self-management education, and diabetes medications. As such, insurers must reimburse for diabetes-related medical treatment as well as for self-management education programs that have met accepted standards, such as the American Diabetes Association's National Standards for Diabetes Self-Management Education and Support. Furthermore, third-party payers must also reimburse for medications and supplies related to the daily care of diabetes. These same standards should also apply to organizations that purchase health care benefits for their members or employees, as well as managed care organizations that provide services to participants.”

It is recognized that the use of formularies, prior authorization, competitive bidding, and related provisions can manage provider practices and costs to the potential benefit of payors and patients. Social Security Act Title XIX, section 1927, states that excluded medications should not have “a significant clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical outcomes of such treatment of such population.” A variety of laws, regulations, and executive orders also provide guidance on the use of such controls to oversee the purchase and use of durable medical equipment and single-use medical supplies associated with the management of diabetes.”

The last paragraph has me wondering if they are telling payors (insurance providers) to do what they want when it comes to diabetes. I know many of the current people on Medicare are attempting to opt out of the mail order supply sources and returning to local pharmacies for their diabetes supplies. This has meant an increase in costs the patient is required to shoulder, but some patients are unwilling to accept the second rate and unreliable testing supplies they were required to use under the mail order business.

The following is quoted because Medicare is totally ignoring this and could care less about what the Medicare patient is doing to manage their diabetes. “Though it can seem appropriate for controls to restrict certain items in chronic disease management, particularly with a complex disorder such as diabetes, it should be recognized that adherence is a major barrier to achieving targets. Any controls should take into account the huge mental and physical burden that intensive disease management exerts upon patients with diabetes. Protections should ensure that patients with diabetes can readily comply with therapy in the widely variable circumstances encountered in daily life. These protections should guarantee access to an acceptable range and all classes of antidiabetic medications, equipment, and supplies. Furthermore, fair and reasonable appeals processes should ensure that diabetic patients and their medical care practitioners can obtain medications, equipment, and supplies that are not contained within existent controls.”

February 3, 2014

Can The Medical Community Re-engineer Health Care?

Health care technology of today lacks common sense. The needed ability for different pieces of equipment to work and communicate with other equipment is absent and manufacturers will not work with other manufacturers. This proprietary attitude is doing harm to patients. This blog by Peter Pronovost of the Armstrong Institute division of Johns Hopkins in Baltimore covers what is starting to happen at a few hospitals across the nation.

Changing this will require unprecedented collaboration between health care’s many stakeholders. Will this work to end the problems presently built into the medical equipment? Only time will tell if the hospitals will work together to make this happen. Johns Hopkins has a project in place at the Johns Hopkins Baltimore hospital. The project, 'Project Emerge' is supported by a 9.4 million grant from the Gordon and Betty Moore Foundation.

Combining the wisdom of engineers, nurses, doctors, bioethicists, and patients and family members, or 18 disciplines from across Johns Hopkins University to design safer care in intensive care units (ICUs). This is desperately needed because patients treated in ICUs often need up to 200 therapies a day, and there is not a system that has automated this list of therapies. It is expected that by integrating medical devices that this would eliminate human error and save $8 billion annually.

For this to become a reality, device manufacturers must be willing to their systems and share their data. Providers need to say they will no longer purchase equipment from vendors that won't agree to that standard and policy makers need to revise pre-EHR regulations to allow electronic double checks.

To accomplish this, hospital systems will need to work together to help integrate health care information technology systems to optimize them for helping health care providers to work more efficiently. This could solve healthcare's cost problem once we are past the cost of integrating all the pieces. This would reduce waste, but also reduce preventable patient harm. We could then improve patient outcome and experiences.

Now for a piece of news on the diabetes front and what a help this will be for those using a certain insulin pump. Finally, some integration in diabetes equipment and this is welcome news. You can read about it here on the DiabetesMine blog.

Now for the last piece of interesting information on electronic health records and this is alarming. Michael Chen, MD is exposing a giant flaw in many EHRs. He is a practicing physician and well as a software coder. Dr. Chen declares that health care IT is still in its infancy despite the number of years computers have been around and the legislation behind the use of computers in healthcare. He is concerned about the poor user interfaces that affect not just workflow and user happiness, but patient safety.

One patient safety design element he points out in the EHR he is working with and can greatly affect patient safety is the medication list. Dr. Chen says that this on one problem most physicians may not be able to identify until safety problems become known. He states that as a physician, you would assume the current medication list is current and up to date. He continues that with the EHR system he is using, this is not the case and medication lists are often not current because the EHR automatically removes a medication from the list when it is determined to be expired.

Patient safety is therefore compromised because not all patients take their medications regularly and no physician assumes this to be true. Programmers failed to take this into account and therefore the EHR makes an unverified assumption. Also troublesome is treatments sometimes are to be taken only as needed. The EHR cannot even account for this variance.

I urge everyone to read his blog. Then always keep your own medication list up to date and if when you are allowed a patient portal to the EHR, check your medication list. I have found several mistakes on mine and I am having trouble getting corrections done by the people that work in the doctor's office. So far, they make one correction and another error shows up. This is why when I was admitted to the hospital, a couple of my medications were not given to me. If I had not taken my own medications, I would have missed taking two of them, plus the supplements.

So do not rely on the medication list in your EHR being correct at anytime.

February 2, 2014

A New CDE Organization – Good or Bad?

A new CDE organization announcing its formation raises all types of issues and makes one wonder what is happening. I'll admit I was perplexed when I read the blog on Diabetes Mine on January 30. I do think changes need to be made in the American Association of Diabetes Educators. However, I question a new organization which will take a few years of get firmly established and provide the services needed to keep up with the epidemic of new diabetes cases.

The new organization is named the Academy of Certified Diabetes Educators (ACDE) and it officially announced its coming on January 1, 2014. Whether this means more or less actual workers to help those of us with diabetes – this is the question to be answered over the next several years. And, will they be better trained, more empathetic, or will there be just more of the same old mantras, mandates, and dogma we have had to deal with from members of the AADE.

There are several issues that need to be put on the table for discussion. The first issue is what prompted my ire in the beginning. The leaders of the American Association of Diabetes Educators (AADE) sat in their ivory towers and lost track of what the educators in the field were doing. As a result, more doctors were disappointed and unhappy with the education not being done.

The second issue is what will one CDE organization do to combat the effects of the other organization. We don't need the tactics employed by the Academy of Nutrition and Dietetics where they have pushed licensure through some state legislatures to make them the only organization able to preach faulty nutrition. Then in some states they have been successful to criminalizing other nutrition professionals. With the shortage of certified diabetes educators, we as patients don't need this happening.

The third issue is conflicts of interest. The ACDE is too young to have conflicts of interest (COI) yet, but the AADE does have COIs. We don't need either organization having these and making their education less effective and transparent.

The last issue is peer mentors and peer workers. The new ACDE organization is promoting only members that have passed the test administered by the National Certification Board for Diabetes Educators (NCBDE). If they are intending to be so exclusive in their education that they limit new members, then they may not meet the needs of people with diabetes.

I like the statement Mike Hoskins ended his blog with and I will quote it, “Whatever the focus, hopefully one thing is clear to anyone working in this field, whether you’re “certified” or part of this or that organization: the key is to do less talking, and more listening to the real-world concerns of patients. In the end, you can have all the certification and titles in the world, but if you’re not effectively connecting with us PWDs, then all is lost.”

I would also encourage you to read the comment by Sheryl Traficano, CEO of NCBDE, about the qualifications to set for the test. These are almost impossible for lay people to achieve even if they have the education in related fields.

I am just thankful that more doctors are realizing they don't have the time for the necessary education and are working with peer mentors and peer workers to fill the gap left unfilled by CDEs. This is important in many rural areas. Thank goodness telemedicine is also coming of age and being accepted.