New recommendations on the bariatric surgery and diabetes

New recommendations out of a recent conference in Austria as reported by the Heart.org.  This comes on the heels of the most recent changes in BMI recommendations, as we reported last month.

As reported by Steve Stiles over at the Heart.org,  in”Case made for metabolic bariatric-surgery eligibility criteria,”  new evidence and recommendations suggest that surgery should be done earlier in the course of the disease process (diabetes) in patients with lower BMIs.  Currently the BMI restriction criteria enforced in North America and Europe prevent the majority of diabetic patients from receiving gastric bypass surgery, which is the only proven ‘cure’ for diabetes.  That’s because the majority of type II diabetic patients are  overweight but not morbidly obese.

As reported previously on this site, Latin American bariatric surgeons have been at the forefront of the surgical treatment of diabetes.  Many of the surgeons previously interviewed for numerous projects here at Cartagena Surgery were involved in several early studies on the effects of surgery in moderate overweight patients with diabetes.

More interestingly, researchers at the conference are also suggesting possible gastric bypass procedures for patients with ‘pre-diabetes’ or patients with an hemoglobin A1c greater than 5.7 % but less than 6.5% (6.5% is the cut off for diagnosis of diabetes.)

This is wonderful news – it means committees and such are finally getting around to following all of the research that has been published and presented over the last ten years..  But then it just one more important step…

Call it by its name

So I have my own suggestion to doctors and researchers – and it’s one that I’ve made been – a nomenclature change.  We need to stop calling it “pre-diabetes”, because the name is a falsehood – and leads everyone (patients, nurses and doctors astray.)

- Greater than 95% of patients with ‘pre-diabetes’ will develop diabetes – so without a drastic intervention (far beyond diet and exercise)  it’s pretty much a certainty.

- Many of the devastating complications of diabetes develop during this so-called pre-diabetic period.

- Doctors are now recommending surgical treatment to cure this “pre” disease state.

So….  

if almost everyone who has ‘pre-diabetes’ gets diabetes, and it’s already causing damage PLUS we now recommend a pretty radical lifestyle change (surgical removal of most of the stomach) —> that sounds like a disease to me.  Call it early diabetes, call it diabetes with minimal elevation of lab values, but call it what it is….Diabetes..

This is critical because without this firm diagnosis:

- insurance won’t pay for glucometers, medications, diabetic education, dietary counseling (or surgery for that matter).  That’s a lot of out-of-pocket expenses for our patients to bear, for something that is treated like a ‘maybe’.

- patients (and healthcare providers) alike won’t take it seriously..  Patients won’t understand how crucial it is to take firm control of glucose management, patients won’t be started on preventative regimens to prevent the related complications like renal failure, heart disease and limb ischemia.

- Patients may not receive important screening to prevent these complications – and we already know that at the time for formal diagnosis (usually SEVEN years after initial glucose derangements are seen) – these patients will already have proteinuria (a sign of kidney disease), retinopathies, vasculopathies and neuropathies..

I work with providers every day, and the sad fact is that too many of them (us) shrug their shoulders and say – yeah – he /she should eat better, get more exercise, shrug.. But they don’t treat the disease – they don’t start checking the glucose more often, they don’t start statin drugs, the don’t screen for heart disease and they don’t consult the specialists – the diabetic educators, the nutritionists, the endocrinologists – and yes, the bariatric surgeons…

Chances are if your doctors and your nurses don’t take it seriously; and don’t make a big deal out of it – and don’t talk to you, at length about what “pre-diabetes” IS and what it really means for your life and your health -

then neither will you.

For related content:  see the Diabetes & Bariatric tab

the Weight of a Nation: the obesity epidemic

Bariatric surgery and non-alcoholic fatty liver disease

The Pros & Cons of Bariatric Surgery

Gastric bypass to ‘cure’ diabetes goes mainstream

The lost of Las Vegas

Desert Oasis or Roadside Toilet?

Gleaming neon, dazzling lights; glamorous yet slightly seedy, Las Vegas is the glittering rest stop on the otherwise lonely desert highway west.

all that glitters

Like it’s upscale and more mature big sister, Hollywood; Las Vegas attracts millions of visitors each year.  Many of these visitors come seeking fame and fortune.   Unlike the more illustrious fantasies of super-stardom on the silver screen and streets paved with gold, even the “Las Vegas dream” has a harder edge.

‘Easy money’ is the lure of the city; but instead of striking it big, many of the fame seekers find themselves in the shady world of drugs, prostitution, porn or living on the streets..

Peg Entwistle  & John O’Brien

While Hollywood may be the birthplace of such romanticized tales of stripping and prostitution, ala “Striptease,” “Indecent Proposal” and “Pretty Woman” in real-life there are few happy endings for all the runaway erstwhile Julia Roberts.

As illustrated in the 1990′s novel (and film), “Leaving Las Vegas” even survival in Sin City is a mark of success.

Like Hollywood, the side streets and alleyways serve as a cautionary tale to wayward youth.  Homeless youths clutter the sidewalks of the Strip, sleeping in doorways or holding signs asking for help.

The Lost

Panhandling in downtown Las Vegas

Broken promises, forgotten youth

They are running from something; abusive or neglectful homes, impoverished or alcoholic families or perhaps something even darker, but today I am too disheartened to ask the specifics.

The four young adults are outside a casino, quiet, friendly and polite when I approach.  But their youth is almost an accusation against this modern world that has no place for them, outside of the gutters and the trash of our glaringly tacky, frantic shopping spree, free-for-all that has become the American economy.

Andrian Wack, Angelica Gaskin,  Robert Gaskin and Ritchie Cunningham fight to survive on the streets of Las Vegas

Angelica Gaskins, 20 wears a Pikachu cap and a brown hoodie.  Originally from Anaheim, California, she and her husband, Robert along with the remaining members of the group narrowly avoid homelessness by panhandling  during the day and sharing a tiny room in a cheap hotel.  She explains their signs by saying, “We used to earn money by entertaining people with our signs, but now we aren’t allowed.”  New ordinances aimed at controlling the increasing number of homeless in Las Vegas have Angelica upset.

Andrian Wack, a twenty year old girl from northeast Ohio, whose pixie-ish freckles and fair complexion are marred by multiple facial piercings, fang-shaped incisors and skateboarder style shares this sentiment.

Robert Gaskins, 23 from upstate New York is pleasant but more subdued; only speaking up when introduced by his wife, whose face is shining with pride.    He stands close to her; giving support and protection from the unnamed demons she is running from.

At first glance, they seem an unlikely pairing but after a moment’s reflection – a good match, supporting each other.  It’s hard not to look at them, with a bit of painful cynicism brought on by maturity and experience.  What chance do they have to stay together, with all the obstacles they face?  One can only hope, for their sake, that “love is enough” since they don’t have much else.

Ritchie Cunningham, 23, “Yes, I swear that’s my name,” is an engaging young man with a shy smile, in a camouflage jacket.  He catches sight of my camera and readily recruits his friends; posing kneeling near the ground.    Unlike the others, he offers little information about his past, instead focusing the conversation on the future saying, “I want to get my GED soon.”

Walking away from this foursome, I can’t help but think about these damaged children.

The American Dream vs. “The Running Man”

It’ s no longer the ‘American dream’, it has degenerated into a winner-takes-all, survival-of-the-fittest endurance contest just to survive.   Now our younger generation has inherited our financial messes, our love of excess and fierce competitiveness and too many of them are just like Angelica, Andrian, Robert and Ritchie: shunted to the sidelines and pushed out of the game.

No job, no education, no future 

In my own immediate family, my mother was the first to go to college.  Her father was a successful business man from the “School of Hard Knocks” and their family was solidly middle class, if at the lower end.

While my father-in-law had limited education, and the family (of six) often struggled to make ends meet – there was always hot food on the table, clothes on their backs and a roof over their head.  But that was in the aftermath of the second world war, and as an honorably discharged veteran, and skilled craftsman, there were always employers looking for someone willing to work hard.

It might have been the same for my husband, who was a modern-day version of the Loretta Lynn story.  After leaving high school at the age of 16 to work full-time in the local gold mine, he could have easily become an educational footnote – but still, the jobs were there; with decent wages and benefits for hard-working men with GEDs in hand**.   Luckily, he used his GED and the gold mine as part of his stepping stone to community college, university and eventually, a master’s degree..

But what about the legions of high school dropouts within an era of grade inflation (and degree inflation)?

Unable to compete

In a generation of lowered expectations and easy A’ s which make a post-secondary education more obtainable (but even more expensive), and where even 10 dollar an hour jobs often require college educations – what will happen to people like Angelina and Andrian?

When “Do you want fries with that?” is no longer an option

What will happen to all of those who have been marginalized by their families and society for their entire lives?  Now that even the fast food industry is shunning them, it seems that the ‘working class’ / blue-collar life is out of reach.

Whatever the answer is – it’s not on a cardboard sign..  Good luck kids.. and good luck to everyone else out there..

** Of course, this all changed in the late 80′s and early 90′s as the mines closed, along with factories and plants across the United States as companies moved their workforces overseas, setting the foundation for today’s employment landscape.

Additional Information

Resources for homeless youth

Home sweet blog..

Readers -

My current assignment in Texas is coming to an end – so the blog content will be shifting back; less photography and more medical news.  I’d like to thank all my loyal readers for staying with me as I indulged my creative side for the last few months, and drifted away from our original foci.

But I hope, that for your part – it hasn’t all been eye-rolling, deep sighing, shoulder shrugging ‘tolerance’.  I hope that you have enjoyed the chance to connect on a more personal and less formal level.

That’s how I feel when I read other bloggers pages about photography, travel, sewing, art or any of the other interests that define me outside of nursing and health care.  I hope that you get that same sense of familiarity, of enjoyment when each of my blogs is posted.

If I can recreate that same, “I wonder what she has today?” anticipation that I feel when reading the Mexfiles, seeing the latest creations at the Renegade Seamstress or vicariously enjoying the tasty travels of Bunny and Pork  Belly; well, that’s success in its own right.

My blog certainly isn’t up to the caliber as the others I’ve enjoyed – but I think if I can get each of my subset of readers (photography fans and medical / health readers) to remain interested and engaged, even when I stray off topic..

with fellow Nurse practitioners in Texas

These last few months, since returning from Colombia have been fun.  Figuring out photography and trying to get past point-and-shoot has been frustrating, frustrating, jaw clenching, foot stamping frustrating at times..

But – it’s good photography practice for my future writings, and it’s also a bit less strenuous.  Writing and posting research based articles (with relevant citations) can be a bit onerous after a long day in the hospital.. Tired eyes tend to make for more spelling errors..  I could just post less often when on assignment, I suppose..

Yet – I am always hesitant to leave the blog for too long because it has come to be a place for me to indulge my ‘nerdy’ side with a friendly audience.

The blog lets me address and talk about the issues in medicine and patient care, explore relevant medical discoveries and emerging research as well as passing on some of the information (and patient education) that I have gained as part of my years of taking care of people.  It lets me talk about all the nerd stuff that people at work don’t really sit around and talk about -

Like everyone else, they talk about families, finances, home life. Taking kids to soccer, going to church, socializing with friends, landscaping the lawn..   All good things, great community and friendly folks.. But it doesn’t fill that ‘Dora the Explorer’ inside me; or the inner Florence Nightingale.

It also doesn’t mesh with my family; the vagabond roving band of travelers that we are, so it is sometimes hard to relate.  I mean, right now, I live in a hotel, my ‘home base’ is a storage shed in another state – where we stop in and swap out clothes.. My husband and I are sometimes working in different states (or countries) for weeks or months at a time – so we aren’t the best candidates to join leagues or make long-term commitments.  All of it sounds wonderful but it sometimes makes us feel like outsiders looking in.

So I come here to wordpress; to enjoy Serapa, Nicephore’s diary, and the return of Miss Christina and all the other people I will never meet – but sure enjoying knowing about a little corner of their lives..  I hope it is the same for all of you.

Downtown Shreveport and the Strand

Bridge crossing the Red River from Shreveport to Bossier City

On a recent trip to Shreveport, we headed downtown to indulge in two of my favorite hobbies; photography and looking at architecture..

While much of downtown Shreveport is like downtown segments of many cities across the United States, with some run-down areas; there are several lovely buildings from by-gone areas.

Downtown Shreveport (and other images of Shreveport)

This slideshow requires JavaScript.

The Strand

Most notably among these buildings is the Strand theater.  Originally built in 1925, (according to a local press clipping from the time), the Strand was originally conceived almost 18 years earlier.  It cost one million dollars to complete and opened its doors to the public for its first performance on July 3, 1925.  The first show at the Strand was “The Chocolate Soldier,” a comedic operetta first written in 1860, and popularized on Broadway in 1909.

This slideshow requires JavaScript.

Despite it’s illustrious opening, by the 1970′s the Strand had closed and fallen into disrepair.  It wasn’t until 1984 that the Strand re-opened, after several years of painstaking and meticulous restoration.

This slideshow requires JavaScript.

While we were wandering downtown and taking pictures – we noticed that the marquee was advertising a show that evening – for a Queen tribute band, “One Night of Queen”.  Who could pass that up??  so off we went..

A Night of Queen with Gary Mullen

Low light, and constantly changing light conditions, using my long lens (200mm), no flash, subjects with rapid movement.. Some of the pictures are terrible – but it sure was fun!  As you can see – the photos are a riot of color and noise, but it was great practice while rocking out to some great music..

This slideshow requires JavaScript.

Thank you to everyone at the Strand for allowing us to take pictures.  (They usually restrict photography, but immediately before the show, several ushers stated that photography would be permitted.)

The Riverwalk -

The River Boardwalk is a modern creation, devised to attract tourists to the areas surrounding the waterfront casinos.  On one side of the river lies a park and trails, along with a small string of businesses (that were almost all closed when we strolled by) and on the other side of the river, a huge shopping complex (and more casinos.)

We strolled down to the River Boardwalk after walking around downtown.  While most of it is pretty typical and kind of generic looking, I did enjoy some of the art designed to highlight Shreveport and its history.

panel from the past – tools and instruments from early Shreveport

The panel above is my favorite – in a string of decorated panels on the underside of the Neon Bridge.  There is a performance stage, several preserved handprints as well as a lonely little Mexican restaurant.  (All the other storefronts were vacant.)

Under the neon bridge

celebrating the native inhabitants of the area

in it’s proper perspective

More Shreveport: 

While I always fall in love with the big things; bridges, skyscrapers and massive landscapes – along with their rich details, there is so much more to Shreveport.

While looking for more information about Shreveport architecture, I found another great photography blog called Southern Lagniappe.  If you want to better know Shreveport, and architecture, this is a good place to start.

Now, if you love home architecture, especially the ‘Painted Ladies’ – Gerald Massey has written a nice article about some of the Victorian homes in the city. (As the proud owner of my own historic home, in my native Virginia, these homes always make me just a tad wistful.)

Low Light photography, Shreveport and the Strand

Since I had a few days off, we decided to take a road trip.  My assignment here is almost complete, so we are trying to squeeze in as many adventures and outings as possible before we leave for our next location.

Since I am a little camera-crazy – we usually plan trips that give me the opportunity to practice a little photography.  It’s funny how I can always manage to cram in a bit of ‘homework’ where ever we are – I guess that is what makes photography such an addictive hobby.

As many of my readers know, I never meant to do more than the usual touristy snaps – but necessity forced me to become more and more adept, to illustrate my writing, and visually document my  interviews and observations.  As I’ve progressed from project to project – my writing style has evolved, my detailing has become more precise – and I’ve refined my picture-taking.

In the most recent months, as I begin researching the next project, I’ve started practicing by trying to expand my range, beyond the casual snapshot – to fast-motion, low-light and a variety of other conditions.

So we headed off to Shreveport, for some new scenery and more practice.

Low-light, No flash with a tripod 

captioned, postcard style

I have always lacked confidence in my photo-taking, so I’ve resisted using a tripod for a long time (and missed a lot of great photos because if it).  But, I finally had to face it; it’s just impossible to keep still enough during the SLOW shutter speeds necessary to capture low-light situations..

Even so – the photo still has a lot of noise, or fuzziness..

During our trip, we attended a concert at the Strand theater..  Surprisingly, both the theater staff, and the performers explicitly lifted the usual rules to permit photography – which was just fantastic, even if only to get photos of the restored theater.. But it was even nicer that the performers invited us to take pictures.

(More about the beautiful and historic Strand theater in my next post.)

The freehand photos from the concert stage demonstrate this lack of definition (and noise) even more acutely.

If you don’t take a lot of photos, than this post is probably boring beyond belief – but you also don’t know the frustration of seeing an image in your mind’s eye, and then struggling to capture that image with your lens.

But then too – comes that satisfaction when the shutter clicks and the image is immortalized – in your mind, and on file, forever.  (or at least until I crash the hard drive.)

With the help of several friends, amateur and professional photographers – I’ve learned a lot, in my efforts to move the image from my eye to the camera.  I’m not always successful, but I seem to be getting better and better..  But there are other issues in photography.

For me, that struggle is two-fold; it’s both accuracy and providing perspective. Accuracy seems like an oxymoron for photography – but it’s not.  The next photo is a good example of what I mean..

a country lane?

Accuracy in photography to me means depicting a person, place or circumstances as honestly and straightforwardly as possible.  Now, in a movie, I recently watched – “The Best Exotic Marigold Hotel“, a group of English citizens decided to retire to a residential hotel in India based on a brochure, and the photos of the hotel in the brochure..

this ‘romantic’ backdrop for my lovely model is actually the corner of a somewhat dirty, beat-up parking lot in downtown Shreveport.

(I bet you can see where this is going.)  Of course, when they arrive in India – the group quickly finds out life in India (and their hotel) isn’t quite as cute, contained and photographic as the brochure led them to believe.

This isn’t a great photo – but it does show the size and scale of some great art.  This mural, 14 stories tall, is so detailed you can visualize the fabric of her dress.. (Note the size of the reference man walking on the sidewalk). It’s not crazy to want to be able to accurate capture that image just as it is.

With my style and type of writing, equally accurate photography is essential.

I also want to give perspective – whether that perspective is from peeking over the shoulder of a surgeon hard at work, the view from outside the operating room theater or even just the view from down the street.. (or even from really, really far away..)

washing a fire truck

That doesn’t mean that I don’t enjoy the sweet, or romantic photos – like these pictures from the sidelines of a recent parade.   (I was across the street – quite a distance away – but just watching from behind a camera – really did seem to tell a story.)

another photo from the same St. Patrick’s Day parade

little Evel Knievel jumping his bike while waiting for the parade

I’ll post some more photos of Shreveport in my next post..

Cottonwood Trail

You may have guessed from some of my posts – and my eternal fascination at some of modern metropolis lifestyles that I am, at heart, a small town girl.

Of course, that just makes the big cities all the more wonderful and wonderous to me.  All of the essentials of big city life that are a big yawn for long-term residents still seem a bit magical to me.   I really do feel a bit like Dorothy at the gates to the Emerald City.

I don’t think we are in Kansas anymore…

I guess, even with all of my travelling, the rural redneck remains..

Never has this been more obvious than during my current stay in Texas..  Despite living in the shadow of the mega-freeways, I remain fascinated, and awed by their sheer size and scope.  The challenge has been trying to bring this to life with my camera..  I’ve tried on multiple occasions, and on every road trip since we’ve been here – but the results have been well, rather uninspiring..

How can something that is so captivating to me, (yet so pedestrian to the  local citizenry) be so difficult to capture?

But I have included a gallery of my most recent attempts – in a mix of color and black and white..  The photos below come from the Cottonwood Trail.

This slideshow requires JavaScript.

The Cottonwood (Creek) Trail

Just a few days ago – we wandered off our usual trail for our walk.. We took the path, that is (literally) less travelled – and headed down the Cottonwood Trail.   (I wouldn’t recommend it for solo journeys – we didn’t pass a single other person for much of the walk – in some pretty desolate areas.. Then, as we passed through some sketchy areas; there were large groups of homeless men gathered at the side of the trail.)

The desolation, the sense of aloneness is overwhelming, and bewildering since the trail winds thorough the heart of the maze of freeways that make up the cosmopolitan city.  Yet – alone we were on trails the snaked beneath the very freeways that rumbled and trembled above us, reducing the sky to just a sliver of blue.  At times, the roar of traffic was so loud as to be deafening, with the bombardment of noise coming from all directions – ricocheting off the acres of concrete, in the valleys beneath the elevated roadways.

on the path underneath the freeways of Dallas

Maps of Trails in Dallas

Much of the trail (along with much of Dallas) is under construction, so we took a couple of detours during our outing – including a trip past Mount Calvary Cemetery.

This slideshow requires JavaScript.

Is your ‘cosmetic surgeon’ really even a surgeon?

The answer is “NO” for several disfigured patients in Australia, who later found out that a loophole in Australian licensing laws allowed Dentists and other medical (nonsurgeons) professionals to claim use of the title of ‘cosmetic surgeon’ without any formalized training or certification in plastic and reconstructive surgery (or even any surgery specialty at all).

In this article from the Sydney Morning Herald, Melissa Davey explains how dentists and other nonsurgical personnel skirted around laws designed to protect patients from exactly this sort of deceptive practice, and how this resulted in harm to several patients.

As readers will recall – we previously discussed several high-profile cases of similar instances in the United States, including a doctor charged in the deaths of several patients from his medical negligence.  In that case, a ‘homeopathic’  and “self-proclaimed” plastic surgeon, Peter Normann was criminally indicted in the intra-operative deaths of several of his patients.  The patients died while he was performing liposuction due to improper intubation techniques.

But at least, in both of the cases above – the people performing the procedures, presumably, had at a minimum, some training in a medical/ quasi-medical field..

Surgeon or a handyman

More frightening, is the ‘handyman’ cases that have plagued Las Vegas and several other American cities – where untrained smooth operators have preyed primarily on the Latino community - injecting cement, construction grade materials and even floor wax into their victims.

How to protect yourself from shady characters?  In our post, “Liposuction in a Myrtle Beach Apartment” we discuss some of the ways to verify a surgeon’s credentials.  We also talk about how not to be fooled by fancy internet ads and the like.  (Even savvy consumers can be fooled by circular advertisements designed to look like legitimate research articles as well as bogus credentials/ or ‘for-hire’ credentials*. )

*We will talk about some of the sketchy credentials in another post – but the field is growing, by leaps and bounds..More and more fly-by-night agencies are offering ‘credentials’ for a hefty fee (and not much else.)