Tiny Sensors to Monitor Medicine Intake Internally

Ingestible SensorsProteus Digital Health is in the process of fine tuning small BB size sensors that you swallow. They are called ingestibles and are activated when they come in contact with saliva or gastric digestive juices. They send signals to monitors, the size of band aids, worn on your chest. From there the data is sent via your smartphone or computer to those health care professionals you designate to receive the data.

The data can include whether you actually took the medicine or not and have developed appropriate blood serum levels, while also monitoring blood sugar levels, blood chemistries and other vital signs. These devices are designed to assist our growing senior citizen population and their care givers up to date on whether you are actually following the prescribed therapies and are they effectively working.

Ingestible chips are now being fine-tuned and integrated with the British National Health Service and are not yet commercially available here in the USA. In development are tinier chips that will actually be in medication pills and send messages to us via our smart phones that it is time to take your pill. Once the pill has been taken it will record that data and serum levels. If you forget you have taken your medication and go to take a second dosage, it will alert you to the fact that you already have taken the medication. If you forget to take your medication a message will be sent to your cell phone or computer and or health care provider.

Some individuals wonder whether all this data is one more “big brother” invasion of personal privacy. With 10,000 baby boomers turning 65 every day and 90% suffering from at least one chronic illness requiring several medications, we will need to balance the benefits versus the risks in deciding if we wish to participate in these monitoring programs.

What Is In Those Supplements?

VitaminsThe Attorney General of the State of New York charged four national retailers on Monday, February 2nd  of selling dietary supplements that were “ fraudulent and in many cases contaminated with unlisted ingredients.” His office said they had run tests on popular store brands of herbal supplements at the retailers – Walgreens, Walmart, Target and GNC and found that out of five products tested, four contained none of supplements listed on the label. At GNC they found that five of six samples from its “Herbal Plus “brand were either “unrecognizable or a substance other than what they claimed to be.” They analyzed Ginkgo Biloba, St. John’s Wort, Ginseng, Echinacea, Saw Palmetto, Garlic and Valerian Root.

For many years now health care advocates have encouraged the Federal government to establish a safety monitoring system for the multibillion dollar vitamin, mineral, herb and supplement product market. Many health care providers question the safety and efficacy of these products to begin with since there are few if any well designed double blinded controlled studies which look at their overall risks and benefits. To now find out that the bottles do not even contain product raises further questions about their efficacy and safety. The American College of Nephrology has been trying to educate the public to the harmful contaminants they have found in many over the counter supplements leading to renal failure and problems in children. Most of these poisons and heavy metal contaminants however, came from products produced overseas.

The time to set up a Federal watchdog on these products is long overdue. The National Institute of Health Division of Alternative and Complimentary Medicine has always taken the position that if products results are positive and reproducible in legitimate studies then the product is not an alternative treatment. That feeling is still shared by me but it does require the product to be in the container you purchase free of harmful contaminants.

Dying Should Not Be So Brutal

End of LifeIn an Op-Ed article in the NY Times, Ira Byock, MD, correctly details how brutal dying from a terminal disease is in this country. He cites the tragic case of a friend who fails to respond to conventional therapy for oncologic disease at a well-known Center of Excellence and the suffering he is going through. With conventional therapy failing he is offered a chance to enter a clinical trial or experiment to save his life. The author recommends Hospice care instead but if the patient chooses Hospice care he will be forced to forsake entering the clinical trial and turn his care over to the Hospice team. The author believes this is wrong and the patient should be able to receive comfort care and palliative care while still treating his disease. He goes on to make a list of sane recommendations regarding the future training of doctors and nurses so that patients and their loved ones will have the opportunity to be better informed about end of life issues.

I became exposed to Hospice in the late 1970’s early 1980’s when the Hospice movement consisted of caring angels of mercy , who at no cost to the patient or family provided comfort measures to the patient and support and counseling to the family. Hospice of Boca Raton met in a store front on Spanish River Boulevard off Federal Highway. It was staffed by volunteers from local churches, off duty paramedics, nurses, and community volunteers. They needed a medical director so I was asked to participate as part of a rotating group of physicians who donated our time to this worthy cause. Volunteers took a training course and devoted countless hours to providing bedside care and comfort to the sick and dying.

As one of the volunteer medical directors I attended care team meetings, reviewed care plans and signed for the prescription medications and narcotics needed to care for our patients. My time commitment was very structured and limited compared to the long hours the volunteer staff invested in providing comfort measures. We were paid nothing, expected nothing and worked with the patient, their loved ones and their doctors tailoring a care plan that fit each individual’s needs. We did not make them stop their treatments. We did not make them transfer their care to Hospice and away from their long time care team. In those days patients actually had a personal physician who knew them for years.

We were thanked and loved for our limited time investment far in excess to our contribution especially compared to those wonderful volunteers who performed the daily bedside and household care. This all changed when insurance and Medicare agreed to finance Hospice. At first we all thought the extra funding would now make it possible to provide service to many more individuals and pay for badly needed supplies and medications.

The first thing that happened is that many of the volunteers were dismissed and replaced with full time help. That included the volunteer physician medical directors. Medicare wanted full time people. Hospice became a business run by profit making corporations, hiring per diem help to go into homes instead of full time well trained Hospice staff. To be a patient in Hospice you were asked to relinquish your current doctor and medical care and transfer your care completely to the paid full time Hospice teams. In many cases patients were taken off their routine medications and over-medicated with narcotics producing a legal “Kevorkian-like” result even if the conditions did not dictate this approach. It became a big business, not a center for comfort and caring.

Dr. Byock’s article in the NY Times should be required reading for all families and persons over age 50. His suggestions should be discussed in our places of worship, places of education and especially in our medical school and nursing school curriculums. Dying from a painful incurable disease in America should not be this hard and brutal.

Medical Costs Rise as Retirees Winter in Florida

Healthcare CostsIn the January 31, 2015 edition of the NY Times, Elisabeth Rosenthal writes about the high numbers of tests performed on seasonal visitors to the state of Florida in the winter (as if seasonal visitors to Florida requiring health care are a new phenomenon). She cites a NY Times analysis of Medicare data released for 2012 showing twice the number of nuclear stress tests, echocardiograms and vascular ultrasounds for Medicare beneficiaries in Florida than in Massachusetts. She blames it on Florida cardiologists purchasing medical testing equipment for their offices and doing a large volume of tests to recover much of the income lost to a drop in reimbursement rates by Medicare to doctors for actually seeing patients, examining them and providing care. The article then goes on to discuss the increased number of tests in Florida in the last two years of a patient’s life compared to other areas of the country. She does admit that senior citizen rich population centers in NY, California, Arizona, South Texas and South Nevada have similar data showing high rates of testing than the rest of the country, but this is passed off as an afterthought. There are then a slew of anecdotal stories about individuals advised to undergo a procedure or test who declined and recovered nicely without it being done.

I have a suggestion for the NY Times, New York magazine and all the online purveyors of pearls of wisdom on health care. Suggest that your readers vacationing in Florida for the winter find a primary care physician (PCP). Find one who is willing to review the patients’ medical records from their northern physician and share clinical decision making on important issues with the physician(s) who know them longest and best.

For many years these prestigious periodicals have been suggesting that the patients’ only see a specialist. If the patients do not self-refer themselves to a specialist, their children often self-refer them to a specialist. Most specialty physicians are ethical, moral practitioners not churning out tests for self-profit. You can avoid the ones over utilizing at your expense by finding a well-trained internist or family practitioner who has no x-ray suite in the office, no nuclear stress testing equipment, no echocardiogram machines and no extensive in house laboratory. You probably won’t find that type of doctor if your physician is an employee of a hospital based health care system or Accountable Care Organization where the facility fee and incentives to over utilize are very strong. You won’t find that if you use the Emergency Room or a walk in center as your primary care physician because the same incentives exist.

You can find this dying breed of physician (dying because Medicare reimbursement for their services and influential periodicals have driven them out of existence) by calling the local county medical society or the local hospital medical staff offices and asking for a board certified internist or family practitioner who is not employed by the hospital or one of its large health care systems.

Consider a concierge or direct pay practice as well. The customer services in those practices, and additional patient time the doctors have, allows them to get the full story and communicate with those doctors who know you best rather than just shuffle you off for tests.  After all, time is the essence of quality, especially when it comes to healthcare.

Irritable Bowel Syndrome Responds To Rifaximin

Abdomin v2In a study presented at annual meeting of The American College of Gastroenterology, Anthony Lembo, MD, of the Harvard Medical School and Beth Israel Deaconess Medical Center, presented data that showed that the non-absorbable antibiotic Rifaximin helps control cramping and diarrhea related Irritable Bowel Syndrome (IBS). Irritable bowel cripples individuals by causing abdominal cramping and multiple loose or watery stools per day. These patients have been screened by colonoscopy and imaging studies for more serious diseases such as Crohn’s Disease and ulcerative colitis with testing ruling these entities out. They are left with severe symptoms but no objective findings on available tests.

The study was comprised of 2,579 patients who received either Rifaximin or placebo three times per week. The decision to try an antibiotic was based on the theory that some IBS patients have excessive bacteria in the gut causing the problem. The treatment was successful in a significant number of participants compared to placebo based on a reduction of pain and frequency and number of stools. The patients were then observed for four weeks during which time some patients relapsed. If these patients were treated for another two weeks they showed significant improvement.

Irritable bowel incapacitates millions of individuals. While this data is extremely preliminary, it gives us hope of another treatment regimen, becoming available soon, that is effective and safe.

FDA Approves Coronary Artery Disease Screening Test

FDA - Steven Reznick, MDMedPage Today, the online medical journal of the University of Pennsylvania School of Medicine, announced that the FDA has ” cleared a blood test ” to screen for heart disease known as Lp-PLA2 or lipoprotein associated phospholipase A2. This test is an individual marker of vascular inflammation produced within atherosclerotic plaques. Its use was cleared for screening in all adults with no history of coronary artery disease.

In a National Institute of Health study, known as Reasons for Geographic and Racial Differences in Stroke, it was shown in a review of 4,598 people, aged 45 – 92, that individuals above the threshold level for Lp-PLA2 were more than twice as likely as others to have an event, heart attack or stroke, 7% versus 3.3 %. The study was particularly helpful when looking at black women as a group. An Lp-PLA2 level > 225nmol/min/mL is considered elevated.

This test has been available to patients in our practice through the Cleveland Heart Labs screening panel. It plus the myeloperoxidase level, CRP and other markers have been felt by the Cleveland Clinic cardiology division to have predictive value. These tests are currently available but in many cases require private pay because Medicare and private insurers do not yet cover them all.

Ambulatory Blood Pressure Monitoring Proposed As Gold Standard

Bllod Pressure - OmronThe US Preventive Services Task Force (USPSTF) recommended that physicians use ambulatory blood pressure monitoring to confirm the existence of hypertension in newly suspected cases before instituting therapy. The USPTF has been making recommendations on appropriate health screening for years now. Their new positions now says that patients 40 years of age or older with an initial BP of 130/85 or higher should be screened for hypertension annually instead of every 3-5 years as previously suggested. The recommendation includes annual blood pressure screening for all adult African Americans. Included in the recommendation is a call for the use of ambulatory blood pressure monitoring. It is felt that blood pressure readings in the doctor’s office may be influenced and higher due to anxiety or “white coat hypertension.” Ambulatory Blood Pressure Monitoring providing multiple readings will give you a true average systolic and diastolic reading which permits you to separate hypertensive patients requiring treatment from anxious individuals.

When evaluating a patient for hypertension we have used the 24 hour ambulatory monitor in my office practice for years. It is a traditional blood pressure cuff designed to inflate six times an hour during daytime hours and four times per hour when you go to bed. Patients are asked to shower or bathe prior to coming to the office and to limit their activities to their normal activities of daily living. The patient drops the device off 24 hours later and we connect it to our computer and print out the readings. The device produces hourly readings plus average readings. The major side effects are the inconvenience of wearing a device which inflates six times per hour. Cost has been a factor since most insurance companies have not seen the wisdom of paying for this. In my experience it allows us to classify someone as normal or normotensive and not institute treatment most of the time. Without this type of device we were dependent on looking for complications of hypertension such as changes in the arteries and veins in the eyes using the ophthalmoscope or changes on your EKG to confirm the diagnosis of hypertension. With the development of vital sign monitoring devices associated with cellphones and computer tablets it will only get easier to accurately monitor ambulatory blood pressures in the future. These devices will additionally allow us to check on whether or not our treatment is actually keeping your BP within the limits it should.

We have one monitor in the office at the current time and ask that you make an appointment to have it placed on you if you wish to be checked.

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