Writing in the journal Nature, the Stanford University team said they used just three genes to transform ordinary mouse skin cells directly into nerve cells called [...]]]>

Researchers said they had transformed ordinary skin cells directly into neurons, bypassing the need for stem cells or even stemlike cells and greatly speeding up the field of regenerative medicine.

Writing in the journal Nature, the Stanford University team said they used just three genes to transform ordinary mouse skin cells directly into nerve cells called neurons.

Share/Save

Continuing Education Units

1.5 CEU credits from the University of Missouri are available for taking this case and successfully completing a 12-question examination. The cost is $22.50. Register at our [...]]]>

This case presents the story of Alvin Floyd, a 53-year-old African American who presented with symptoms of uncontrolled diabetes mellitus, and traces the 9 months following diagnosis.

Continuing Education Units

1.5 CEU credits from the University of Missouri are available for taking this case and successfully completing a 12-question examination. The cost is $22.50. Register at our secure server; you will need your credit card.

History of Present Illness

He had been in good health until about two months ago when he started to feel weak and tired more rapidly than usual. On questioning, he admitted to getting up two or three times a night to urinate. He also is often thirsty at those times and drinks a glass of water each time.

His weight had been average through high school, where he had been on the football team. After leaving school, he had gradually gained weight over the years. His appetite remained excellent but he now was losing weight and becoming weak.

The pain in his feet was worse at night and sometimes kept him awake. It was burning in character and sometimes his toes felt numb. The tingling and numbness in his fingers was causing him problems at his work as an auto mechanic because he frequently drops small parts or has difficulty making fine manual adjustments to engines.

His vision was blurry at times, especially in the afternoon.

All other symptoms were negative.

Physical Examination

Wt. 217 lbs., ht. 5′ 11″ (BMI 30), P 76, regular, BP 142/78
Obese.
Head and neck-mild bleeding of gums reported with tooth brushing.
Chest, abdomen and genital examination normal.
Feet: skin dry with calluses on the medial side of the big toes.
Nails normal.
Pulses strong and equal.
Sensation: normal to 10g monofilament.
Laboratory Tests

Urinalysis: 4+ glucose, negative for ketones and protein.
Random blood glucose: 456 mg/dL.
Glycohemoglobin (HbA1c) 16.4%.
Total cholesterol 243 mg/dL, HDL 20 mg/dL, triglycerides 416 mg/dL.

Primary Care Physician

Dr. Emmett told Alvin that he had diabetes based on his elevated random glucose and the presence of symptoms. The American Diabetes Association standard for diagnosing diabetes is a fasting blood glucose above 125 mg/dL or a random blood glucose of 200 mg/dL or above with symptoms of diabetes, either criteria repeated on a second day. The elevated HbA1c result indicated that Alvin’s average blood glucose for the prior two to three months was in excess of 400 mg/dL. This level of blood glucose accounted for the increase in urination and the weight loss that Alvin had experienced. The four classic symptoms of diabetes are:

* polyuria (excessive urination),
* polyphagia (excessive hunger),
* polydipsia (excessive thirst) and
* unexplained weight loss.

Common symptoms are fatigue, blurred vision, frequent infections, poor wound healing, dry, itchy skin and numbness and tingling in hands, legs and feet. Of the common symptoms, Alvin had the numbness in his fingertips, a burning sensation in his feet and blurred vision. His blurred vision was often worse after lunch on workdays, caused by his drinking a “Big Gulp” regular soda with his lunch, and thus increasing his glucose load in the afternoons.

Dr. Emmett gave Alvin a referral for a dilated eye exam in his health plan’s eye care center. He also suggested that Alvin make an appointment with a dentist to be assessed for periodontal disease, another common problem for patients with diabetes.

Dr. Emmett performed a Carville foot exam on Alvin, checking for both microvascular and neuropathic problems. The exam was normal, except for calluses on his big toes. Dr. Emmett advised to wear shoes with larger toe boxes. Alvin did discuss his fears with Dr. Emmett about diabetes leading to amputations, since this had been a major problem in his mother’s condition.

Dr. Emmett used the opportunity to discuss blood glucose management through monitoring, medical nutrition therapy, and medication. He instructed Alvin to contact the Diabetes Center to sign up for classes on diabetes self-management, which were a benefit of Alvin’s health plan. In addition, he gave Alvin two prescriptions: one for a blood glucose meter, instructing Alvin to check his blood sugar before meals, and one for an oral diabetes agent.

In Alvin’s case, Dr. Emmett prescribed Amaryl® (glimepiride), 4 mg. a day. Amaryl® is in the class of drugs called sulfonureas, which stimulate the islet cells in the pancreas to produce more insulin. Other classes of oral diabetes agents are:

* Biguanides:  decrease the release of glucose by the liver, and makes other cells more sensitive to insulin.
* Thiazolidinediones (TZDs):  increase cellular sensitivity to insulin and decreases the release of glucose by the liver.
* Meglitinides:  stimulate the pancreas to release insulin over a shorter period of time (after meals).
* Alpha glucosidase inhibitors:  slow the absorption of carbohydrates in the intestine.

These oral diabetes agents can be given singly or in combinations.

Dr. Emmett scheduled Alvin back for a visit in one month.

Progress and Monitoring

When Alvin and his wife returned for their second class in two weeks, Alvin reviewed his blood sugar testing records with Nurse Ireland. His records showed that he had been testing 3 — 4 times daily and that greater than 75% of the results were in target range. At class, Alvin’s test result was 93 mg/dl, and his technique was good.

Since the first class, Alvin had had an appointment with Dr. Emmett. Based on his blood sugar records, Dr. Emmett had decreased the dose of Amaryl® from 4 mg. to 2 mg. daily. Alvin had also noticed that the burning in his feet was gone and the numbness and tingling in his fingers was much better. He stated that Dr. Emmett had said this was because his diabetes was better. Nurse Ireland praised Alvin for his success and encouraged him to keep up the good work. She also pointed out that his weight had stabilized another sign that his diabetes was better controlled. His wife smiled broadly.

The class learned about low blood sugar and high blood sugar, the causes of both and what actions to take if either occurred. Alvin learned that he should carry some form of fast-acting carbohydrate on him at all times, to treat a low blood sugar, and should wear some type of medical identification.

The class reviewed their food and activity records with Ms. May. They asked questions about various foods and the effects that they noticed on blood sugars. Alvin was surprised to learn that the sugar-free cookies he had at lunch one day still contained a significant amount of carbohydrate, and were the reason his blood sugar was high before dinner. Ms. May reviewed food label reading, and told the class to be especially watchful on foods labeled low-fat or sugar-free, since these foods may still contain carbohydrates.

She then moved on to discuss other nutrition issues, such as the recommendation to eat 6 oz. protein daily, and to try to limit fat intake to 30% or less of total daily calories.

Ms. May also discussed alcohol consumption in diabetes. She told the class that persons with controlled diabetes could drink alcohol, but men should limit themselves to two drinks per day, and women to one. Persons with diabetes should never drink on an empty stomach, since alcohol can lower blood sugar levels, leading to hypoglycemia. She also reminded the class to be sure and “count” any carbohydrate in the drink itself (like beer), or in the mixer, such as fruit juice or milk.

Ms. May and Nurse Ireland talked with the class about setting personal goals for their own management of their diabetes. Alvin was happy to report that he and his wife had taken a walk after dinner several times in the past week, and that he had enjoyed the time to talk. He set a goal to walk at least 5 times per week, and to purchase a medical identification medallion.

The class was instructed to continue their blood glucose testing schedule, and to bring their record books to the next class in 2.5 months.

By the time Alvin returned for his 3 month class, 100% of his tests were in target range, and his average blood sugar, calculated by his glucose monitor, was 111. He had lost 4.4 lbs. He had seen Dr. Emmett again, who again cut his dose of Amaryl®, down to 0.5 mg qd.

He had also seen the eye doctor. His blurry vision was resolved, and his eye exam was normal.

Alvin was most proud to report that his HbA1c was down to 8.3%. At the third class, he and his wife learned about the necessity for maintaining normal blood pressure, what to do on sick days, and how to check and care for his feet.

They also learned how to estimate portion sizes, like a piece of meat the size of a deck of cards is about 3 oz. and a serving of potatoes about the size of a tennis ball is one carbohydrate choice or 15 grams. The class discussed strategies for dining out and reviewed how they were doing on their goals.

The fourth and final class was six months after Alvin started at the Diabetes Center. His weight had stabilized at 199 lbs. And he had taken in his belt by an inch. He was no longer taking Amaryl®, and his blood glucose tests remained 100% in range. He was walking/jogging 5 — 6 times per week for at least 30 minutes. Most impressively, his HbA1c was down to 6.8%.

In class, pattern control of blood glucose readings was discussed, and what to do if more than 50% of tests were out of target range. The role of stress and stress management were emphasized. The natural progression of diabetes was discussed, along with the need to maintain blood glucose testing for a lifetime.

Necessary routine medical care such as frequent blood pressure checks, an annual eye exam, an annual foot exam, periodic laboratory tests, and an annual flu shot were outlined. The session included a review of the food pyramid and healthy eating habits. Goal setting and community resources for ongoing education and support topped off the class.

A complete report of Alvin’s progress in class was sent to Dr. Emmett. A few months later, Dr. Emmett shared back with the Diabetes Center that Alvin’s nine-month HbA1c was 6.9% and his weight remained stable. He continued off of medication, and his glucose control was excellent.

Medical Nutrition Therapy & Activity

“Diets” are temporary. The goal of “medical nutrition therapy” is to promote healthy eating habits and to decrease obesity. There is no specific “diabetic diet;” it is the same as the “prudent diet” promoted for cardiac health.
Calories

Caloric control is the keystone. A negative caloric balance will reduce blood glucose levels before any reduction in weight is seen. It is unnecessary and impractical to aim for an “ideal body weight.” A reduction of 5–10% of body weight often is sufficient to reduce blood glucose levels into the normal range. Note that the goal is not to lose weight but to lose fat. Improved glucose control and increased activity can increase muscle weight and results may only be evident in a smaller waist. An extreme reduction in calories can not be maintained. A modest decrease in calories can and, if continued, will have a better long-term effect.
Fat

People with diabetes mellitus are at high risk for cardiovascular disease. They often have hyperlipidemia. Their meal plan should aim for 30% or less of calories derived from fat and 10% or less saturated fats. Monounsaturated fats, like those found in olive oil, are best.
Exercise

It is not necessary to join a gymnasium or a high-impact aerobics class. Any increase in activity will improve insulin sensitivity of the muscles. Aerobic activities also will improve cardiovascular fitness and walking further on a regular basis is an excellent choice. Long sessions are not required; three ten-minute sessions are as effective as one thirty-minute period.

Exercise improves the body’s response to insulin, lowers the risk of heart and blood vessel disease, burns calories, and reduces stress and tension.

Standards of Care

Early detection of complications is extremely important because appropriate therapy can prevent progression.

Eyes: A dilated eye examination every year.

Feet: Check for lesions, vascular status and neurologic integrity at least annually if normal. For any abnormality, check at each visit.

Kidneys: Urinalysis for microalbuminuria every year.

Lipids: Fasting lipid profile every year if not yet on therapy.

Choice of Initial Therapy

This depends upon the severity of symptoms and associated clinical factors.

If the patient is asymptomatic, a trial of just a meal plan and increased activity is appropriate. With a negative caloric balance, glucose levels come down before any change in weight is seen. In a very obese person, metformin may be useful because it is the only antidiabetic medication that does not cause weight gain.

In a symptomatic patient, relative insulin deficiency predominates and either a sulfonylurea or insulin should be used. Metformin can be added. Initial therapy with metformin or a thiazolidinedione alone can take several weeks to develop a full effect.

Share/Save

A medical vocabulary, cachexia, dysphagia, gastroesophageal reflux disease (GERD), loss/depression, nutritional needs, oral care. The user should also be able to classify obese patients and tobacco users.

This case helps the user appreciate the complexity of needs that a tumor in the esophagus creates, and appreciate the need for multidisciplinary team approach. Objectives

* Describe the risk [...]]]>

Prerequisite Concepts

A medical vocabulary, cachexia, dysphagia, gastroesophageal reflux disease (GERD), loss/depression, nutritional needs, oral care. The user should also be able to classify obese patients and tobacco users.

This case helps the user appreciate the complexity of needs that a tumor in the esophagus creates, and appreciate the need for multidisciplinary team approach.
Objectives

* Describe the risk factors for esophageal cancer.
* Select and use a nutritional assessment tool.
* Recognize the need for speech therapy and respiratory therapy input with esophageal malignancy.
* Recognize need for support with anticipatory grief.
* Recognize needs of caregivers in family units.

Concepts Discussed in the Case

Anticipatory grief, cachexia, esophageal cancer, invasive tumors, malnutrition, metastasis, nutritional support, quality of life, staging of malignant disease, supportive care, and treatment for cancer.

Patient Presents

Arden is a 37-year-old white male who presents to his family doctor and is referred to the radiation oncology department for consultation.

Chief complaint: Heartburn for “a long time” and difficulty swallowing during the past 4 or 5 months. Occasionally food seems to “hang up” in his throat. He points to the upper portion of his neck, directly beneath his chin. Pain immediately below the sternum that feels like “a gnawing or burning.”

Other complaints: Weight loss of 33 pounds in the past 6 or 7 months, weakness, coughing at night. (Usual weight: 230 pounds).

Other information: Does not use tobacco; alcohol intake does not exceed 2 cans of beer per week. Has treated stomach pain with otc (over the counter) medications for acid stomach.

Students should identify: dysphagia, gastric reflux, cachexia, respiratory component, habits.

Physical Examination

Appearance: Pale, malnourished, distressed
Vital signs: 132/92; 88
Temperature: 98.4°
Respirations: 14
Height: 6 feet (183 cm)
Weight: 62 kg

Joints appear prominent with evidence of some muscle wasting
Epigastric tenderness on palpation

What Tests Should Be Ordered?

1. Chest x-ray.
2. Barium esophagram can show mucosal irregularities, displacement, narrowing, and strictures. (If cancer is diagnosed, a CT scan will be useful for staging because it will show node involvement and invasion of adjacent structures.)
3. Endoscopy and biopsy. Bronchoscopy will be indicated to rule out involvement of the left main stem bronchus if a tumor is found in the middle third of the esophagus. CT scan of the liver and bone may be recommended depending on metastasis.

Staging a cancer is important for determining appropriate treatment and prognosis. If the disease is limited to the area of origin (primary site) it is considered an earlier stage disease than one that has spread to lymph nodes and adjacent viscera.

Blood tests are not useful for identifying the disease because there are no known “tumor markers” for esophageal cancer. Tumor markers are chemicals characteristic of specific tissues; when they are elevated, disease is suspected and further tests are indicated. For example, the PSA (prostate specific antigen) is specific for prostate cancer, and although not diagnostic of prostate cancer, is a useful indicator of prostate health.

Treatment

What are the most important concepts to understand about the management plan:

1. Staging of the disease.
2. Performance status:

Karnofsky scores
ECOG score
3. Nutritional status: He needed nutritional support prior to beginning intensive therapy so he increased his intake, particularly protein, by using high calorie protein liquid supplements.
4. Preoperative radiation therapy to reduce the size of the tumor, aid in swallowing.
5. Esophagectomy by either left thoracoabdominal approach for a esophagogastrectomy or transhiatal esophagectomy.
6. Chemotherapy for systemic disease.

How is performance status related to treatment for cancer?

What assessments related to nutritional status need to be made? What is his nutritional risk?

What is the relationship of weight loss and prognosis in cancer patients?

What are some issues for caregivers?

What are the issues of anticipatory grief?

Discuss any alternatives: Macrobiotic diet, an alternative therapy, does not cure the disease. This diet may be used as complimentary to medical treatment and provide some patient satisfaction because of patient involvement in self care; however, the diet is fairly stringent and unfamiliar to most Americans.

Conclusion

Arden’s disease recurred after treatment with radiation therapy, surgery and chemotherapy. Early in the treatment course, his wife became pregnant, and he died 2 weeks after the birth of his little girl. His widow is employed as a waitress.

Arden presented after months of symptoms with invasive disease that had spread microscopically. In the remaining 13 months of his life, he had periods of good quality of life (by his own definition), as well as periods of distress from pain and fatigue.

Share/Save

Jody has been seeing a rheumatologist; below is a summary of a recent visit.

Chief complaints: pain, swelling, and stiffness.

Other complaints: myalgias, malar rash, photosensitivity, dryness of eyes and throat, cold intolerance, epigastric and gastrointestinal discomfort, difficulty sleeping, and depression.

Appearance: The patient is a 50-year-old woman weighing 188.5 lbs.

Vital signs: pulse: 68 bpm, blood pressure: [...]]]>

Patient Presents

Jody has been seeing a rheumatologist; below is a summary of a recent visit.

Chief complaints: pain, swelling, and stiffness.

Other complaints: myalgias, malar rash, photosensitivity, dryness of eyes and throat, cold intolerance, epigastric and gastrointestinal discomfort, difficulty sleeping, and depression.

Appearance: The patient is a 50-year-old woman weighing 188.5 lbs.

Vital signs: pulse: 68 bpm, blood pressure: 122/76.

She exhibited symptoms consistent with rheumatoid arthritis (RA), systemic lupus erythematosus, mixed connective tissue disease, and fibromyalgia. The rheumatologist ordered x-rays which showed mild osteoarthritic changes in several joints and laboratory tests which came back negative for FANA and rheumatoid factor.

It took approximately 5 years for a rheumatologist to make a definitive diagnosis which is not unusual.

At this time the patient’s diagnosis is seronegative rheumatoid arthritis and fibromyalgia.

Physical Exam and History

Some physical findings of particular interest due to the diagnosis include:

* morning stiffness lasting from ten minutes to over an hour
* general strength of 4/5 (80% of normal)
* metatarsalgia
* deformity of toes of both feet
* swan-necking and ulnar deviation of the fingers of both hands
* swelling of various joints

Through the course of her disease, Jody has been on many different medications, including:

* A variety of NSAIDS (non-steroidal anti-inflammatory drugs)
* DMARDs (disease modifying anti-rheumatic disease) e.g. plaquinel, oral gold
* Medications for gastrointestinal problems: Cytotec®, Zantac®
* Pharmaceuticals for fibromyalgia: Elavil®, amitryptyline
* Prednisone for inflammatory flares

Due to muscular weakness, joint stiffness, fatigue, decreased endurance, disturbed sleep, and depression, the doctor also ordered exercise.

Jody consulted a physical therapist and she began to participate in an exercise research project and then in a community-based exercise program.

Think about the special benefits of exercise for people with arthritis:

* Stronger muscles protect joints from injuries, reduce pain, and improve function. (Exercises slideshow.)
* Better flexibility decreases pain and risk of injuries during activity.
* Stronger bones reduce the risks of osteoporosis and fractures.
* Better coordination reduces the risk of falls and increases efficiency.
* Increased endurance improves energy levels and reduces fatigue.
* Regular motion and weight-bearing nourishes and strengthens joints, including cartilage and bone.
* Being physically active improves sleep and mood and lessens depression and anxiety.

In addition, people with arthritis who exercise regularly also report:

* Less joint pain and swelling.
* Less morning stiffness.
* Increased participation in physical activity.
* Involvement in more social activities.
* Improved self-efficacy for managing pain and other symptoms.
* Less fear of pain.
* They regained control over their lives and their arthritis.

Comprehensive Exercise Program

A comprehensive exercise program the three kinds of exercise: strength, flexibility, and cardiovascular fitness/endurance.

* Strengthening can be done using weights, machines, body weight, rubber bands or whatever is available to you that you enjoy using for resistance.
* Flexibility involves stretching that can be done in a class or on your own or however you prefer.
* Cardiovascular fitness/endurance can be achieved by activities such as walking or swimming.

Physical Therapist’s Viewpoint

As a physical therapist for over 30 years, I have seen our treatment of arthritis and expectations of treatment change dramatically. Probably the greatest impact in the last 15 years has come from the positive results from research on exercise and arthritis and the advances in drugs used to treat a number of rheumatic diseases. As we have learned more about the feasibility and benefits of conditioning exercise for people with many different types of arthritis, we also have developed safe and effective drugs to stop inflammation and slow or stop the progression of disease. We can’t cure arthritis, yet, but good medical care combined with exercise and education for self-management go along way toward decreasing the loss of function and disability we used to think was inevitable.

When I started as a PT, we barely knew the pathogenesis of rheumatoid arthritis and didn’t even think that osteoarthritis could be managed. The most we had for treatment were range of motion exercises and thermal modalities. It was disheartening to have so little to offer. Now there is so much that can be done. Our challenge today is to encourage people to seek good professional care early and to start effective disease management without delay.

We now know that people with arthritis can improve flexibility, endurance, strength and cardiovascular fitness with regular exercise. Their arthritis does not get worse with increased activity. In fact, regular exercise appears to have a positive effect on disease-related problems such as joint swelling, morning stiffness, pain, depression and lost function. Appropriate exercise and maintenance of adequate levels of physical activity are important components of improved outcomes and are well within the scope of self-management. All people with arthritis should be told about the importance of exercise, and provided appropriate information and ongoing support to become successful exercise self-managers. We know too much about the safety and benefits of exercise to not make it a part of everyone’s comprehensive care.

Share/Save

History of Present Illness

Mr. X is a 53-year-old male who presents to you with memory loss and blackouts. His wife thinks he has Alzheimer’s disease. She states that over the last year, Mr. X has become more and more forgetful. He used to take care of the family finances and run his own business [...]]]>

Patient Presents

History of Present Illness

Mr. X is a 53-year-old male who presents to you with memory loss and blackouts. His wife thinks he has Alzheimer’s disease. She states that over the last year, Mr. X has become more and more forgetful. He used to take care of the family finances and run his own business out of his home until his memory loss forced him to turn the finances over to his wife and quit his business. Mrs. X also states that he forgets appointments and phone calls, sometimes just after he hangs up the phone.

His wife states that last week he blacked out while driving home from the grocery store, ran a stop sign and hit a parked car. No one was injured, but the episode scared them both.

Mrs. X states that over the last year, her husband has had problems walking. Although he was never very active prior to this, he has become more sedentary and prefers to sit in his recliner all day. Over the last 6 months, he has used a walker to get around the house.

He also reports urinary incontinence over the last 6 months. Mr. X describes it as “not being able to control it.”
Past Medical History

Unremarkable except for the report of a prior head injury with no loss of consciousness occurring last year.

Social History

He reports a 60 pack year smoking history, starting when he was 23. His alcohol consumption consists of about a case of beer a week.
Family History

Mr. X’s father died at the age of 49 from a heart attack. His mother is still alive and is in a nursing home. She moved there after having a stroke 3 years ago. His brother and sister are in good health.

Physical Examination

Temp: 98°F
BP: 170/110
Pulse: 95
Resp: 19/min
Height: 5’11″ Weight 293
HEENT: Within normal limits
Motor:

Biceps: 5/5 bilaterally
Triceps: 5/5 bilaterally
Quadriceps: 3/5 bilaterally
Hamstrings: 3/5 bilaterally
Sensory:

Pin-prick and temperature sensation and simple touch are intact. Vibration is normal in upper extremities, but diminished in lower extremities bilaterally.
Neurological
Reflexes:

Biceps: 2+ bilaterally
Brachioradial: 2+ bilaterally
Patellar: 3+ bilaterally
Ankle: 4+ bilaterally
Plantar Response: Extensor bilaterally
Proprioception and Cerebellar Function:

Finger to finger: normal
Heel to shin: normal
Rapid alternating movements: normal
Romberg: negative
Joint position: normal
Gait:

Mr. X’s gait is abnormal, walking in a shuffling manner. He is mildly ataxic.
Cranial Nerves:

II-XII are intact.

Mental Status:

Patient seems confused. He is oriented to person, but not place or time. He exhibits dyscalculia. Remote memory is intact, yet immediate recall is impaired. When asked to act out combing his hair or shaving, the patient could not do so. Complex commands were difficult for the patient to follow. Judgment was impaired as was the ability to describe simple analogies.

What is your Differential Diagnosis?

Reflect on the information you have gathered thus far.

* Chief complaint: memory loss and black outs
* Other major symptoms: urinary incontinence, trouble walking
* Items noted from history: 60 pack-year smoking history, alcohol abuse issues, head injury within the last year
* Abnormalities noted from the physical and neurological exam:

• decreased strength bilaterally in lower extremities,
• diminished vibratory sensation bilaterally in lower extremities,
• increased reflexes bilaterally on patellar and ankle reflexes,
• plantar reflex was extensor bilaterally,
• mild ataxia,
• shuffling gait,
• patient is confused and not oriented to place or time,
• dyscalculia,
• impaired immediate recall,
• task apraxia,
• impaired judgment,
• could not follow simple commands.

Treatment

Once the diagnosis of NPH was made, a neurosurgical consult was obtained and placement of a shunt was recommended. After discussing the risks and benefits with Mr. X and his wife, they agreed to the placement of a ventriculoperitoneal shunt.
Two Weeks Later

Mr. X returns 2 weeks after surgery during a follow-up appointment. He reports that his walking has become much easier since the his operation. This is evident on observation of the patient’s gait. He also notes that his incontinence has resolved. Mrs. X states that his memory is a little better but not back to normal.

Share/Save

In a study of [...]]]>

Obesity is defined as an excess accumulation of body fat. This excess accumulation is the result of a positive energy balance where caloric intake exceeds caloric expenditure. Recent evidence suggests that American adult men and women today consume, respectively, 116 and 112 more calories per day than in the mid 1970′s. [1]

In a study of temporal trends in energy intake in the United States between 1970 and 1998, Harnack et al. concluded that consistent with trends in overweight, most ecologic data suggests that energy intake has increased and is a likely contributor to the observed increases in average bodyweight. [2] Since the caloric value of fat is known (~3,500 calories), this translates into a potential weight gain of one pound approximately every 31 days or 11–12 lbs per year. Obviously, the “fattening of America” hasn’t occurred at this astounding rate, suggesting that energy outputs are also slightly greater due to larger body mass or an increase in physical activity and thus energy expenditure. Since physical activity rates over the past three decades are essentially unchanged or lower, it would seem that increased body mass has limited the weight gain due to increased energy output. [3]

Thus, overweight and obesity have increased dramatically, particularly since the 1980′s, throughout the world. This trend prompted the World Health Organization (WHO) in 1998 to recognize a “global epidemic of obesity.” [4]

In 1998, the National Institutes of Health (NIH) published guidelines for the identification, evaluation, and treatment of overweight and obesity in adults. [5] Body mass index (BMI), expressed as a weight/height ratio (kg/m 2 ), is recommended to distinguish between overweight (BMI is between 25 and 29.9) and obesity (BMI greater than or equal to 30). Obesity is further subdivided into three categories based on increasing disease risk as described below. [5]
Three classes of obesity Obesity Class     BMI (kg / m[2])
1     30-34.9
2     35-39.9
3     40+

It also is important to consider the distribution of body fat. Excess body fat in the abdomen is an independent predictor of the presence of risk factors such as diabetes mellitus (DM), high blood pressure, and abnormal blood lipids. [6] The NIH document recognized that, particularly in men and women with BMI’s between 25–34.9, a waist circumference of > 40 and > 35 inches in men and women, respectively, further increases the risk of morbidity and mortality. Finally, studies support the importance of considering percentage of body fat or the ratio of fat to lean body mass, particularly in relationship to risk of obesity-related diseases. [7]
Continuing Education Units

2.0 CEU credits from the University of Missouri are available for taking this case and successfully completing a 10-question examination. The cost is $30.00. Register at our secure server; you will need your credit card.

Epidemiology

According to the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS), self-reported prevalence of obesity among US adults increased from 12% in 1991 to 18% in 1998. [8] Data from the 1988 to 1994 National Health and Nutrition Examination Survey (NHANES) suggested that 63% of men and 55% of women were overweight. [9] More recent (1999) data from NHANES IV found that obesity rates among adult Americans increased from 15% in 1980 to 27% in 1999. [10]

America regrettably is a world leader in the epidemic of overweight and obesity, but it does not stand alone. Surveys in Europe and the Far East show that over the last 10-20 years, rates of overweight and obesity have increased by 1.5 to 2.0 fold in many countries. [11] Recent reports from Hong Kong and the Republic of China suggest an emerging epidemic of obesity which is directly related to the increasing dietary fat and calories.

The magnitude of the increased prevalence of obesity in the US between 1991 and 1998 varies by region. It ranges from 31.9% in the mid-Atlantic to 67.2% in the south Atlantic regions. [8] The increased prevalence also varies considerably by state ranging from 11.3% in Delaware to 101.8% for Georgia. [8] In another survey, Missouri ranked 2nd in overweight. [11] The magnitude of the increase is greatest in 18 to 29 year olds (7.1% to 12.1%), those with some college education (10.6% to 17.8%), and those of Hispanic ethnicity (11.6% to 20.8%). [8]

Although attempts to lose weight are common in the United States (36.2% of the population in the 1998 BRFSS were trying to lose weight), the prevalence of overweight and obesity continues to increase. [12] An additional 55.6% of respondents in the 1998 BRFSS indicated they were trying to maintain their current bodyweight. One third of the respondents indicated they were consuming fewer calories and fat, and 60% indicated they were using exercise to assist with weight control. However, other studies indicate that most persons attempting to lose weight through exercise and diet are neither doing enough exercise nor are they using sound dietary principles. [13]

The annual economic costs of obesity are estimated to be > 70 billion dollars. [14] In spite of the health and economic burden of obesity, studies show that health professionals do not consistently advise overweight and obese patients that they should lose weight. [12] [15] In fact, the 200 BRFSS revealed that only 14.5% of patients were counseled about weight whether it was to lose, gain, or maintain bodyweight. [15]

Thus, there is clearly a global epidemic of overweight and obesity. It can be estimated that, at the present rate of increasing prevalence of obesity, by the year 2030, 90% of US adults will be obese! We think it’s time to seriously address this issue and establish a nationwide campaign to help American adults achieve and maintain healthy body weights.

Health Risks of Obesity

Overweight and obesity are risk factors for numerous chronic diseases. After statistically accounting for tobacco use, an estimated 325,000 deaths each year are attributable to obesity (body mass index [BMI] > 30.0). [16] Several studies confirm a strong relationship between BMI and mortality in US adult men and women. [17] [18] [19] [20]

Calle et al. reported that the lowest risk for mortality in a 14 year follow-up of a large cohort of 457,785 men and 588,369 women was at a BMI of 23.5 to 24.9 in men and 22.0 to 23.4 in women. [17] The relative risk for mortality in the heaviest BMI group ( > 40) was 2.58 in men and 2.0 for women compared to those in the group between 23.5 and 24.9 in men and 22.0 and 23.4 in women. A high body mass index was most predictive of death from coronary vascular disease (CVD), especially in men (relative risk = 2.90). The CVD risk of overweight and obesity was greater in Caucasians than African-Americans.

Similar findings in large cohorts were reported previously by Manson et al. (women) and Stevens et al. (men and women) although the nadir of their curves was somewhat lower at between 19 and 22 BMI. [18] [19] In the study by Manson et al., the lowest mortality over 16 years was observed among women who weighed at least 15% less than the U.S. average for women of similar age and among those whose weight had remained stable since early adulthood. [18]

In a 26-year study of 26,000 white Seventh Day Adventist women who never smoked and were healthy at baseline, the relative risk of death was lowest for 30-54 year old women at a BMI between 21.3 to 22.9. [15] [20] For women between 55 and 74 years of age, the lowest relative risk was found at a BMI between 23.0 to 24.8.

A recent ten-year follow-up report of middle aged women (Harvard Nurses’ Health Study) and men (Health Professionals Follow-up Study) looked at the impact of overweight on the risk of developing common chronic diseases during a 10-year period. [21] The most significant and startling finding from this study was that men and women with a BMI over 35 were approximately 20 times more likely to develop diabetes mellitus (DM) than their same-sex peers with a BMI between 18.5 and 24.9. Additionally, women and men who were not obese, but were overweight (BMI’s between 25 and 29.9) were at 1.5 to 2.0 fold greater risk of developing gallstones, hypertension, high cholesterol, colon cancer, heart disease, or stroke. The results of another study also found that persons with coronary artery disease (CAD) and a BMI greater than 35 had a seven-fold increased risk for mortality compared to persons with CAD and a BMI less than 25. [22]

Chronic diseases are the leading causes of mortality and morbidity in the United States and they pose a tremendous public health challenge. Clearly, one of the most well-established risk factors for chronic diseases is overweight and obesity. In fact, a recent report from the RAND Corporation found that after controlling for demographics, obesity was associated with more chronic conditions and worse physical health-related quality of life than tobacco use or poverty. [23]

Health Benefits of Intentional Weight Loss

Prospective epidemiological studies have shown that weight loss, weight gain, and weight cycling (frequent episodes of weight loss and regain) are all related to increased mortality compared with a stable weight. [24] Since unintentional weight loss is often associated with symptomatic disease, it is apparent why mortality might be increased. Weight gain clearly increases the prevalence of several risk factors for chronic disease and, thereby, would be expected to increase morbidity and mortality. Recent studies also have demonstrated that weight cycling is associated with increased health risks. [25] [26] [27] Many epidemiological studies of weight loss have not adequately addressed these issues creating confusion among the public. It is the author’s perspective that the evidence regarding sustained weight loss in adulthood clearly supports the health benefits of intentional weight loss and maintenance.

Numerous studies show that weight loss, even if only 5-10%, significantly improves lipoproteins, [28] [29] hypertension, [30] DM and insulin resistance, [31] risk for osteoarthritis and it’s symptoms, [32] risk for selected cancers, [33] and other risk factors for chronic diseases. [34]

A recent study from Finland of nearly 500 men and women at risk for type 2 DM who were randomized to intensive lifestyle modifications or standard care found a 58% reduction in new cases of DM over three years. [35] None of the subjects who achieved all five study goals (weight loss of 5-10%, 30-45 minutes of physical activity, 4-5 days per week, < 30% fat calorie intake, < 10% saturated fat calorie intake, and 15 grams of fiber per 1000 calories) developed DM. This study was a multifactorial design, but included common lifestyle changes (i.e., increased physical activity and a 30% or less fat diet with increased fiber) aimed at weight loss. Clearly even small amounts of weight loss can significantly improve risk factors for CVD and other chronic diseases. However, it is not clear whether the benefits of moderate weight loss are sustained long term. One basic problem has been the inability to successfully maintain significant long-term weight loss. The Finnish study which was the first published randomized clinical trial of diabetes prevention through lifestyle changes suggests that sustained modest weight losses of 5% of bodyweight can indeed reduce the risk of developing a chronic disease. [35]

Several recent large prospective studies suggest that intentional weight loss is associated with decreased mortality. [33] [36] [37] One study of 43,457 women found that any amount of intentional weight loss resulted in health benefits. [33] In this study, women who intentionally lost weight had a 40-50% decrease in deaths from obesity-related cancers and a 30-40% decrease in death from type 2 DM. Another study of 49,337 men reported a 32-36% decline in death from DM among men with health problems who intentionally lost weight. [37]

It is beyond the scope of this case to thoroughly review and discuss the benefits of intentional weight loss. However, it seems clear that numerous health benefits are potentially derived from weight loss, particularly when it is intentional and sustained over the long term. Throughout the management plan for the case study presented in this paper, additional evidence will be provided for the health benefits associated with intentional weight loss.

Share/Save

Prerequisite Concepts

A medical vocabulary, cachexia, dysphagia, gastroesophageal reflux disease (GERD), loss/depression, nutritional needs, oral care. The user should also be able to classify obese patients and tobacco users.

This case helps the user appreciate the complexity of needs that a [...]]]>

This case is of interest to dietitians, chaplains, social workers, radiation therapists, speech therapists, and respiratory therapists.

Prerequisite Concepts

A medical vocabulary, cachexia, dysphagia, gastroesophageal reflux disease (GERD), loss/depression, nutritional needs, oral care. The user should also be able to classify obese patients and tobacco users.

This case helps the user appreciate the complexity of needs that a tumor in the esophagus creates, and appreciate the need for multidisciplinary team approach.
Objectives

* Describe the risk factors for esophageal cancer.
* Select and use a nutritional assessment tool.
* Recognize the need for speech therapy and respiratory therapy input with esophageal malignancy.
* Recognize need for support with anticipatory grief.
* Recognize needs of caregivers in family units.

Concepts Discussed in the Case

Anticipatory grief, cachexia, esophageal cancer, invasive tumors, malnutrition, metastasis, nutritional support, quality of life, staging of malignant disease, supportive care, and treatment for cancer.

Arden is a 37-year-old white male who presents to his family doctor and is referred to the radiation oncology department for consultation.

Chief complaint: Heartburn for “a long time” and difficulty swallowing during the past 4 or 5 months. Occasionally food seems to “hang up” in his throat. He points to the upper portion of his neck, directly beneath his chin. Pain immediately below the sternum that feels like “a gnawing or burning.”

Other complaints: Weight loss of 33 pounds in the past 6 or 7 months, weakness, coughing at night. (Usual weight: 230 pounds).

Other information: Does not use tobacco; alcohol intake does not exceed 2 cans of beer per week. Has treated stomach pain with otc (over the counter) medications for acid stomach.

Students should identify: dysphagia, gastric reflux, cachexia, respiratory component, habits.

Define and describe GERD.

Identify structures surrounding or in close proximity to the distal esophagus that could be involved in this disease.

What is the relationship of weight loss to prognosis in malignant diseases?

What are acceptable hypotheses?

Patient History

* Fractured left leg age 14
* Usual childhood illnesses, immunization status unknown
* Wears glasses for myopia

Family History

* Negative heart disease, diabetes, mental illness
* Mother died of liver cancer at age 59
* father is alive and well

Social History

He is married and is employed as a carpenter.

Arden is self employed in the building industry. He does not have health insurance, but has $10,000 in life insurance. He married at age 36 and does not have a large support group because he was emancipated from his family of origin for a long time and developmentally is late in establishing a family.

Self care measures did not include consulting a physician until he is highly morbid.

What are the key points made so far?

* Family history of cancer
* He will likely need familial support

Appearance: Pale, malnourished, distressed
Vital signs: 132/92; 88
Temperature: 98.4°
Respirations: 14
Height: 6 feet (183 cm)
Weight: 62 kg

Joints appear prominent with evidence of some muscle wasting Epigastric tenderness on palpation

What are your differential diagnoses?

What global nutritional assessments can Arden take?

What Tests Should Be Ordered?

1. Chest x-ray.
2. Barium esophagram can show mucosal irregularities, displacement, narrowing, and strictures. (If cancer is diagnosed, a CT scan will be useful for staging because it will show node involvement and invasion of adjacent structures.)
3. Endoscopy and biopsy. Bronchoscopy will be indicated to rule out involvement of the left main stem bronchus if a tumor is found in the middle third of the esophagus. CT scan of the liver and bone may be recommended depending on metastasis.

Staging a cancer is important for determining appropriate treatment and prognosis. If the disease is limited to the area of origin (primary site) it is considered an earlier stage disease than one that has spread to lymph nodes and adjacent viscera.

Blood tests are not useful for identifying the disease because there are no known “tumor markers” for esophageal cancer. Tumor markers are chemicals characteristic of specific tissues; when they are elevated, disease is suspected and further tests are indicated. For example, the PSA (prostate specific antigen) is specific for prostate cancer, and although not diagnostic of prostate cancer, is a useful indicator of prostate health.

What preparation does Arden need for barium esophagram and endoscopy studies?

Diagnosis

From findings during endoscopy, pathology report on the biopsy, and the results of a barium swallow, Arden was found to have cancer of the gastroesophageal junction or GE junction.

What information rules out other diagnoses?

Treatment

What are the most important concepts to understand about the management plan:

1. Staging of the disease.
2. Performance status:

Karnofsky scores

ECOG score
3. Nutritional status: He needed nutritional support prior to beginning intensive therapy so he increased his intake, particularly protein, by using high calorie protein liquid supplements.
4. Preoperative radiation therapy to reduce the size of the tumor, aid in swallowing.
5. Esophagectomy by either left thoracoabdominal approach for a esophagogastrectomy or transhiatal esophagectomy.
6. Chemotherapy for systemic disease.

How is performance status related to treatment for cancer?

What assessments related to nutritional status need to be made? What is his nutritional risk?

What is the relationship of weight loss and prognosis in cancer patients?

What are some issues for caregivers?

What are the issues of anticipatory grief?

Discuss any alternatives: Macrobiotic diet, an alternative therapy, does not cure the disease. This diet may be used as complimentary to medical treatment and provide some patient satisfaction because of patient involvement in self care; however, the diet is fairly stringent and unfamiliar to most Americans.

Conclusion

Arden’s disease recurred after treatment with radiation therapy, surgery and chemotherapy. Early in the treatment course, his wife became pregnant, and he died 2 weeks after the birth of his little girl. His widow is employed as a waitress.

Arden presented after months of symptoms with invasive disease that had spread microscopically. In the remaining 13 months of his life, he had periods of good quality of life (by his own definition), as well as periods of distress from pain and fatigue.

Share/Save

Susan said “Yes, I’ll take a student” and added, “she can stay with us on the farm since we’ll be starting early in the morning for my first [...]]]>

Recently, a faculty member at the School of Health Professions called Susan Roberts, an occupational therapist in southern Missouri, and asked if she could mentor an OT student.

Susan said “Yes, I’ll take a student” and added, “she can stay with us on the farm since we’ll be starting early in the morning for my first school.”

Susan is one of several rural therapists who serve as mentors and clinical supervisors to OT and PT students.

Susan mentored Joyce, a junior OT student from St. Louis. Joyce worked as a student assistant at Rusk Rehabilitation Center and formerly worked with developing the vocational skills of adults who were disabled.

Joyce had never seen rural and pediatric practice. With Susan she saw both. She also saw how Susan lived with the effects of post-polio syndrome.

Student: Transporting testing and therapy equipment is a challenge for anyone providing OT services in rural settings! How does Susan manage time, energy and resources to treat children during the week and accommodate guests on weekends?

Client Client: I have been able to achieve many dreams because of my disability as well as in spite of it. My ability to adapt and problem solve has been sharpened by necessity and by the profession I chose after having polio at age 17. I may take a different perspective and approach at times but I’ve also had experiences that make me empathetic, resourceful, and creative in my approach to others and to living.

Physical therapist Physical Therapist: Some of the mobility aids that work in urban areas don’t work in the country. What kind of wheelchair, cart, or small vehicle is most useful?

Occupational therapist Occupational Therapist: What lifestyle changes will make Susan’s retirement dreams more reachable? What adaptations to a modular home and a 19th century farm house are practical and esthetically pleasing? What tools and adaptations make gardening, cooking, and leisure activities on a farmstead easy and fun to perform?

Orthotist Orthotist: During Susan’s acute polio period in the 1950′s, the mark of successful rehabilitation was to throw away orthotics and assistive devices. Now many persons with post-polio syndrome (PPS) have to reassess. Their previous reliance on compensatory movement may now be taking a toll in terms of energy, pain, and fatigue. For Susan, genu recurvatum, or ‘back-kneeing,’ has been her compensatory movement for walking. Now it is causing transient back pain and instability for which a brace has been prescribed. Custom-made orthotics for the shoes help other people relieve back pain and fatigue. An ankle-foot orthosis can help correct foot drop and prevent the need to lean forward to watch the floor when walking.

Social worker Social Worker: Susan is fortunate to have a profession and retirement plans that allow her financial stability. Many adaptive devices are expensive and require outside funding such as the state division of vocational rehabilitation, private insurance, and supplemental security income or small grant and non-profit organizations.

Sometimes the greatest adjustments for people with post-polio are not just the physical losses. The financial, psychological, and self-esteem issues are often tied to reduced or lost employment and the hardships of being on disability. I could help Susan address some of these issues and also support her in her active participation in the International Polio Network.

Susan has been a strong advocate for persons with disabilities, and knows first hand the struggle to be a productive working taxpayer. My job is to help her find the resources to continue her personal and social quest which benefits our community and strengthens the quality of life for all of us.

Armed with cameras and curiosity, three students visited the Roberts’. They wanted to capture first-hand the flavor of this therapist’s lifestyle (not to mention her homemade scones and pear preserves).

The students were greeted by Susan standing on the ramp outside the Roberts’ temporary modular home. Inside the front door, Susan props her wooden “country” cane on the back of an antique chair. A plexiglass “city” cane hangs from a shelf of cookbooks in the kitchen. Susan tells how little children often ask if her cane is made of glass. She tells them, with a twinkle in her eye, that she fills it with water and keeps her goldfish in it.

Susan uses a Swedish-made wheeled walker in her kitchen for multiple purposes. Her balance and endurance have declined due to post-polio syndrome. The walker, with a built in basket, tray and bench allows her to carry garden squash, roast pork tenderloin, and fresh baked bread to the table. She sits on the walker’s built-in bench to save energy for two of her passions: gardening and cooking.

Two overflowing bags that look like something Santa Claus might carry, sit just inside the door of her home. They hold inflatable splints, bolsters, balloons and bubbles. Toys to her clients, these are the carefully chosen tools of her trade. As a rural pediatric therapist, Susan is a modern day circuit rider.

During Joyce’s fieldwork, she and Susan would pick up the bags and head out the door at 7:30 a.m. First they drove to a rural school where Susan gave six children therapy.

Two hours later, they drove to a home 90 miles away to treat a 6 month-old infant with spina bifida. The floor is littered with bits of peanuts, pretzels and crackers. Susan spreads a blanket on the floor and hands Joyce a toy to use in checking the infant’s visual tracking skills. Susan picks up tiny Theresa and begins to gently roll and relax her over a ball. Meanwhile three brothers, all under the age of seven, enjoy going through Susan’s toy bag. She massages the baby’s feet to increase circulation while keeping an easy dialog going with the baby’s mother.

Mom expresses her frustration with the two-hour drives to the doctor appointments in St. Louis. Susan offers to leave the therapy ball and printed instructions so that mom can work with her baby between visits. The father declines stating that the ball might be ruined. Susan leaves the family a bag of clean baby clothes she had purchased at a garage sale and sets the next appointment for a month from now. Lack of transportation and low or unstable incomes are a reality for some of Susan’s rural clients.

Back on the road, Susan questions Joyce about the case, not to test her for right answers, but to generate ideas. She stresses that problem solving is an important strength for therapists. Rarely will a child mirror the situations found in textbooks.

Back at the farm that evening, Susan explains how she does her billing. She is reimbursed by the Department of Mental Health, a not-for-profit Home Health Care Agency, local school districts, the Bureau of Special Health Care Needs, and Medicaid. Each has their own policies and paperwork.

Susan uses a photocopier, a computer with fax and CD-ROM in her home to keep up. The computer allows her to take advantage of a Managed Care Course offered on line from her professional organization. Joyce sees first hand how a rural therapist stays up-to-date through journals, conferences, and technology with the wider professional community.

Joyce returned to the Roberts’ farm on another visit, along with Joan Crosby who will be doing a clinical in the area soon. On this trip, they learn how Susan is adapting her home and lifestyle to adjust to the physical changes caused by post-polio syndrome.

John Deere cartSusan shows them the “green machine,” a John Deere 5-wheeler, that allows her to travel around the 57-acre farm to her garden and up the hill to the old 1850′s farm house they restored.

HouseThe original log beams and inner stone walls with grass growing in the cracks still show but so does Susan’s knowledge of accessibility. Ramps, levers on door handles, and safety features in the bathroom will make life easier for Susan and her guests. Stair chairs carry her to the second floor guest rooms and down to the basement where she weaves on a floor loom.

Her husband, David, takes her ideas and finds a way to construct them. Some simple things, like the hot-dog roasting stick reacher her son made for the fireplace, have dual functions. Susan uses it to retrieve baskets from where they hang in the kitchen. A basket and a shoulder bag allow her to carry objects using her trunk and arm while keeping one had free to use her cane.

“It is evident that Susan is dedicated to the welfare of children and the field of occupational therapy,” Joyce observes. Susan’s own experience of living with disability from a young age has heightened her sensitivity towards the needs of others with disabilities. She has just returned from three days at the Governor’s 2nd Annual Missouri Conference on Disability Rights and is wearing a button that says: “I have a disability and I vote.”

She is not shy about questioning the student’s use of the term “confined to a wheelchair.” “Do you know anyone who has to sleep in her wheelchair?” she asks playfully. She explains how her wheeled scooter saves her energy and frees her rather than confines her.

Conclusion

Susan has lived with her disability for 43 years. She is comfortable letting students assess her muscle strength, analyze her gait, observe her activities of daily living and her adaptations.

She advocates a transdisciplinary team approach to assessment. She uses a transdisciplinary model in her early intervention cases and says it could be used with adults as well. There is no need to ask a person to repeat the same medical history to the physician, social worker, and therapists, according to Susan. She also suggests that new therapists who were not alive at the time of the original polio epidemic listen to the wisdom of their patients before giving advice.

Share/Save