Empowered Patients

I know that Dr. Quick is being polite in his discussion of the 1213 ADA guidelines when he makes this point, “And there’s one concept that the ADA doesn’t fully discuss: empowering the diabetes patient to become an active partner in their own diabetes care (self-management). In fact, the only mention of the word “empower” this year is in the discussion of pregnancy planning: “The goals of preconception care are to... involve and empower the patient in the management of her diabetes...” Oh well. Maybe next year?”

From my perspective as a patient, I feel that many doctors are not ready to deal with empowered patients. After talking with a couple of medical students, they said their school was not teaching new doctors to deal with them where they were in school. One student did say she knew better and that she would work with empowered patients and proactive patients. She was very discouraged by the teachings in this area as she was reading more about doctors working with e-patients on the internet than she was getting in the classroom. She also commented that is was mostly male teachers not talking about empowered patients, but that one of the female instructors was mentioning it.

This needs to be part of the discussion by patients with diabetes (and other patients with chronic diseases) to encourage the national organizations to make this part of the professional guidelines. If this were to happen, then the medical schools could not continue to ignore the topic.

Thimerosal for Vaccines - AAP Endorses WHO Statement

Some people seem to like controversies. This is one controversy that I wish our medical researchers could eliminate. For the present, many people will need to continue to be exposed to (admittedly extremely low) low levels of mercury poisoning, especially the children of the world. At the center of this controversy is thimerosal, a preservative used to prevent contamination in multidose vaccine vials. Why science or our researchers refuse to find an alternative preservative that is mercury free is indeed a puzzle.

The World Health Organization's (WHO's) Strategic Advisory Committee (SAGE) wants thimerosal exempted from a pending international treaty aimed at reducing global health hazards by limiting exposure to mercury. The American Academy of Pediatrics and many other medical professional organizations have now supported the position of SAGE. Why, you may ask? Because banning thimerosal would make our flu vaccines, cost nearly triple what they do presently by using thimerosal. The cost of manufacturing vials for single-use shots of vaccines (including the flu) would make the cost go up.

Thimerosal contains ethyl mercury, which supposedly has not been linked with any of the toxic effects associated with its relative compound, methyl mercury. Methyl mercury is a known neurotoxin. Since the late 1990s, studies have found no evidence of harm by using thimerosal in vaccines, and the WHO endorsed the use of thimerosal in vaccines in 2008.

The American Academy of Pediatrics in 1999, issued a joint statement with the US Public Health Service, advocating for the elimination of mercury in vaccines. Then in 2002, they pulled the statement.

Currently the United Nations Environmental Program is developing an international treaty that would call for the elimination of any controllable mercury pollution and exposure around the world. The treaty under consideration would remove mercury from thermometers and other medical devices and would remove thimerosal from vaccines.

The principal reason for resistance to removal of thimerosal is cost, cost, and cost. The cost of manufacturing in switching from multidose to single dose will vary greatly from country to country. This cost increase will range from 200% to greater than 500%. Then add the costs of adding additional manufacturing space since current manufacturing space would be limited. The costs of transportation and storage space would also increase for single dose vials by three times. Last, consider the policy and vaccine program changes necessary to accommodate the single dose use.

Now consider this, thimerosal is not generally used in the United States, where vaccines are now single-dose. However, and this is a biggie, our seasonal influenza vaccines still use thimerosal. Yes, our flu shots are available without thimerosal, but the cost is almost triple. Most doctors will not keep a supply of the thimerosal free flu vaccine on hand because of this cost and most insurance will not cover this.

Sulfonylureas May Increase Cardiovascular Events

Sulfonylureas seem to be coming under more scrutiny lately. This is apparently justified on several fronts because of changes that have alerted researchers of some very real problems. Many of these problems were not part of the requirements or perceived requirements when the drugs were originally approved by the Food and Drug Administration.

Gretchen Becker wrote about this class of drugs causing pancreas fatigue and decline of the functionality of these drugs when used for extended periods. While I am a believer of this, this discussion is still controversial and more research is needed to prove this beyond argument. I am one of the fortunate people because of my allergy so this is not something I need to concern myself with in my lifetime. This was also the reason that I suspect my doctor was so willing to move me to insulin when the oral medications were not helping manage my blood glucose levels.

Recently, another concern has been brought to the front. The American Diabetes Association stated that sulfonylurea drugs are insulin-production stimulants that have been in use since the 1950s. Metformin, also dating to the 1950s, works by lowering blood glucose levels by reducing the quantity of glucose entering the blood. A recent multi-year study published in the Nov. 6 issue of the journal Annals of Internal Medicine found that sulfonylurea use was associated with a 21 percent increased risk of acute myocardial infarction, stroke, or death.

For comparison purposes to determine the impact of the two drugs on cardiovascular results, a pool of more than 250,000 veterans over the age of 18 was used. No average age of the study is given and none of the participants had any serious medical complications other than diabetes at the start. Almost 100,000 were placed on a standard regimen of sulfonylurea therapy, while slightly over 155,000 took metformin.

The authors stated that their observations were consistent with previous indications that metformin is associated with fewer serious heart issues than sulfonylureas. Even with this, the researchers stated that the findings suggest metformin should be the oral treatment of choice. They did stress more testing is needed to determine if their findings would apply to women or other racial and ethnic groups since 97 percent of their study participants were men and 75 percent were white.

While the findings pointing to this situation have probably been there for several decades the U.S. Food and Drug Administration did not require testing for cardiovascular outcomes when looking at diabetes drugs until very recently.

The drugs used for the study include for metformin, the brand names of Glucophage and Fortamet (or Glucophage XR). The drugs used for sulfonylureas include glyburide (brand name - DiaBeta) and glipizide (brand name - Glucotrol). No other sulfonylureas were mentioned, therefore, we cannot know if the others are more or less likely to cause cardiovascular problems.

Wearable Technology Can Monitor Rehabilitation

This technology is happening and will be second nature to many of us in the near future – if the Food and Drug Administration does not get in the way. I will admit when I first read the short article, I had to laugh at the way it looks on a person, but manufacturers may change this as they perfect the fit and work on the design.

I can envision many other types of outfits that could be designed for recording information from the human body and some of them could be fashioned for undergarments. Until TSA is mandated or given an order to take a doctor's written notice, I can imagine their strip searching patients wearing anything like this when traveling.

Neurorehabilitation researchers from Italy have developed a low cost, wearable system, consisting of strain sensors made of conductive elastomers printed onto fabric. (Credit: Paolo Tormene)

A low voltage battery powers the sensors. This enables sending data to a computer via a Bluetooth device. The device was tested in a healthy person and used to collect a comprehensive set of over 600 movements, at varying speeds and number of repetitions, over a range of movements. In the study, a wireless inertial sensor (MEMS) using triaxial accelerometers and magnetometers confirmed the accuracy of the results and were accurately able to measure movement.

It is understandable that the system is not designed for high precision, but for ease of use, to be inexpensive, and an aid in the development of portable, remote monitoring of rehabilitation. Now it will be very interesting to see what is developed next for monitoring other health problems and if this is usable for monitoring some chronic diseases.

What Is Happening to Type 2 Bloggers?

Making my review of type 2 bloggers in the last two weeks, I was very surprised at the number that have deleted their blogs entirely. What happened?

I know that a few have exited to Facebook and they are active there, but the rest I have not found on Facebook either.   It is discouraging to have to remove twelve bloggers from my list.  If you read this, please let me know what happened.  A couple had been very active up until suddenly their blog was gone.

I am sorry to see many of them not blogging.