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ACNP AG - Acute Care Nurse Practitioner

The Adult-Gerontology Acute Care Nurse Practitioner (AG-ACNP) Post-Professional Certificate is designed for graduate prepared Nurse Practitioners (NP) or Clinical Nurse Specialists (CNS) who are seeking to expand their roles via nurse practitioner certification in Adult-Gerontology Acute Care. The curriculum prepares nurse practitioners to function as generalist, principal providers of care for adults and older adults with acute, critical and complex chronic health problems across the continuum of acute care services.

AG-ACNP students may choose a clinical emphasis in cardiopulmonary, critical care, oncology, trauma emergency preparedness or directed study. The directed study allows students to design clinical experiences around a particular area of interest (i.e. internal medicine, general surgery). The curriculum consists of NP and AG-ACNP specialty courses and clinical practice hours.

Graduates of the AG-ACNP Post-Professional Certificate are eligible to sit for the national certification examination in Adult-Gerontology Acute Care offered by the American Nurses Credentialing Center or American Association of Critical Care Nurses. Successful passing of the national certification examination entitles the graduate to apply for certification as a Certified Registered Nurse Practitioner (CRNP) in Adult-Gerontology Acute Care by the State Board of Nurse Examiners of the Commonwealth of Pennsylvania.

Course work may be completed in 3 terms

540 clinical hours

Online or onsite

Students are required to attend 2 onsite laboratory intensives - 2 days in the Summer term and 1 day in the Fall term. Each student will be responsible for the room and board cost during the lab intensives.

Online students will need to arrange for clinical placements and appropriate physician or nurse practitioner preceptors. An Affiliation Agreement between the University and the clinical site is required before clinical hours can begin.

Graduates of the AG-ACNP Post-Professional Certificate are prepared to accomplish the following:

Assume responsibility for promoting, maintaining and restoring health to acutely/critically or complex chronically ill adults and older adults

Identify health risks, promote wellness, and diagnosis and manage acute and chronic illness

Participate in multi-disciplinary research and provide leadership in mobilizing health services
AG - Acute Care Nurse Practitioner
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Acute Care Nurse Practitioner
Question: 61
Which patient is at the greatest risk for septic shock?
A. An 84 year old woman with a long term foley catheter, a stage four pressure
ulcer on her coccyx and insulin dependent diabetes.
B. A 55 year old woman with pneumonia.
C. A 38 year old woman with asthma and status post day 2 appendectomy.
D. A 63 year old man who had bypass surgery two weeks ago.
Answer: A
The patient at the greatest risk for septic shock would be the 84 year old woman.
She has multiple areas of entrance for bacteria.
Question: 62
Which cranial nerve is tested to assess the gag reflex?
A. Trochlear nerve
B. Trigeminal Nerve
C. Vagus Nerve
D. Glossopharyngeal Nerve
Answer: D
The cranial nerve that is tested to assess the gag reflex in a person is the
Glossopharyngeal nerve. Assessment of the vagus nerve identifies the symmetry
of the arch of the tongue (the ahh test). One would test the trigeminal nerve to
assess the ability to swallow and bilateral facial sensation. Testing the trochlear
nerve identifies the ability of the patient to move their eyes.
Question: 63
Mrs. C has been admitted to the hospital for exacerbation of heart failure three
times in the last 14 months. What nursing action might decrease the likelihood of
being readmitted so quickly?
A. Ask the patient to see their doctor more often
B. Allow the patient to stay in the hospital an extra 36 hours as an inpatient.
C. Increase the diuretic dose on discharge
D. Provide adequate patient education information about the disease and
management principles and follow up with the patient within one week
Answer: D
The nursing action that might decrease the likelihood of Mrs. C being readmitted
so quickly is adequate discharge information and follow-up care. Discharge care
begins at admission so the more information and understanding Mrs. C has about
her disease and the management of it, the more likely she will be able to
appropriately take care of herself and identify the warning signs when she needs
to call her doctor.
Question: 64
Which of the following scenarios reflects the greatest need for mechanical
A. A patient with a respiratory rate of 26 and an oxygen saturation of 89% on 1
Liter of oxygen.
B. A patient who is visiting with visitors with an oxygen saturation level of 87%.
C. An alert and oriented patient who is slightly diaphoretic and is having
difficulty breathing.
D. A patient who has a history of sleep apnea and continues to wake up because
of missed breaths.
Answer: C
The scenario that reflects the greatest need for mechanical ventilation is the
patient who is having difficulty breathing. Mechanical ventilation is appropriate
when the patient"s ability to oxygenate and exchange carbon dioxide is impaired.
Question: 65
Which part of the heart usually shows the signs of deterioration in heart failure?
A. Mitral valve
B. Left ventricular function
C. Right ventricular function
D. Aortic valve
Answer: B
The part of the heart that typically shows the deterioration is the left ventricular
function. Heart failure is disease of the ventricles of the heart, usually affecting
the left ventricle before the right ventricle.
Question: 66
A patient is admitted to the intensive care unit with a diagnosis of exacerbation of
heart failure. Her heart rate is 145/minute and she is breathing rapidly; her oxygen
saturation is 90% on 2 L of oxygen. She has been taking beta blockers at home for
her heart failure. Which medication would be the drug of choice to increase the
contractility of her heart?
A. Primacor
B. Dopamine
C. Digoxin
D. Metroprolol
Answer: A
The medication that would be the drug of choice to increase the contractility of
the heart when beta blockers are being used for mainstay management would be
Primacor. Dopamine will not work if beta blockers are being used at home
because the needed receptor sites are being used.
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Medical Practitioner Exam Questions - BingNews Search results Medical Practitioner Exam Questions - BingNews Referring medical practitioners

Radiological imaging is a major and increasing source of radiation exposure worldwide. Computed tomography (CT) is the largest contributor to medical radiation dose patients receive. Typically, CT scans impart doses to organs that are 100 times higher than doses imparted by other lower dose modalities such as chest X-rays. In general, CT examinations may involve doses (typically an average of 8 mSv) which may be equal to the dose received by several hundreds of chest X-rays (about 0.02 mSv/chest X-ray).

During an IAEA consultation on justification in 2007, it was estimated that up to 50% of examinations may not be necessary. It should be anticipated that part of the increase in global annual mean dose that has been observed recently is due to unjustified radiological procedures. Direct epidemiological data suggest that medical exposure to low doses of radiation even as low as 10-50 mSv might be associated with a small risk of cancer induction in the long term. The fact that a considerable percentage of people may undergo repeated high dose examinations , such as CT (sometimes exceeding 10 mSv per examination) dictates that caution should be used when referring a patient for radiological procedures. Health professionals need to make sure the patient benefits from the procedure and risk is kept minimal. 

However, ensuring maximum benefit to risk ratio for the patient is not a trivial task. Referring medical practitioners, in a large part of the world, lack training in radiation protection and in risk estimation. 97% of practitioners who participated in a study underestimated the dose the patient would receive from diagnostic procedures. The average mean dose was about 6 times higher  than the physicians had estimated. The fundamental principles of radiation protection in medicine are justification and optimization of radiological protection. Referring medical practitioners have a major role in justification. They are responsible in terms of weighing the benefit versus the risk of a given radiological procedure.

» What is justification and what is the framework?

Justification requires that the expected net benefit be positive. According to principles established by the International Commission on Radiological Protection (ICRP) and accepted by major international organizations, the principle of justification applies at three levels in the use of radiation in medicine.

» Is the referring medical practitioner responsible for justification of radiological procedures?

Yes, jointly with the radiological practitioner. As stated above, justification at the third level is the responsibility of the referring medical practitioner, as is the awareness about appropriateness criteria for justification at level 2. According to the BSS, the radiological exposure has to be justified through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate, or be part of an approved health screening programme.

Since referring medical practitioners usually have the most complete picture of the patient’s health, they should be responsible for the guidance of the patient in undergoing only necessary procedures and benefitting from them. Particularly, this responsibility weighs more on generalists such as primary care providers. In order to facilitate justification in the case of radiological procedures, it is desirable that referring medical practitioners are knowledgeable about radiation effects in regard to the various dose ranges. The referring medical practitioners are responsible for keeping their knowledge about radiation up to date. In support of this, they should be provided education in radiation protection during their medical studies.

» How should justification be practiced and what knowledge is required for proper justification of a radiological procedure?

According to the BSS, the justification of medical exposure for an individual patient shall be carried out through consultation between the radiological medical practitioner and the referring medical practitioner, as appropriate, with account taken, in particular for patients who are pregnant or breast-feeding or paediatric, of:

  • The appropriateness of the request; 
  • The urgency of the procedure; 
  • The characteristics of the medical exposure; 
  • The characteristics of the individual patient; 
  • Relevant information from the patient’s previous radiological procedures. 

Justification should be patient specific. The referring medical practitioner should take into account all clinical aspects regarding the management of every patient separately. Other possible procedures with lower or no exposure, such as ultrasound or magnetic resonance imaging, should be considered, if and when appropriate, before proceeding to radiological procedures.

» Is the acquisition of patients’ consent important?

According to the BSS, in order for a symptomatic or asymptomatic patient to undergo a medical procedure that involves ionizing radiation, the patient or the patient’s legally authorized representative should be informed in a timely and clear fashion, of the expected diagnostic or therapeutic benefits of the radiological procedure as well as the radiation risks. Thus, the emphasis is on provision of information.

» When is an investigation useful and what are the reasons that cause unnecessary use of radiation?

According to the guidelines published by the Royal College of Radiologists (RCR),  a useful investigation is one in which the result, either positive or negative, will alter a patient’s management or add confidence to the clinician’s diagnosis. According to the RCR guidelines, there are some reasons that lead to wasteful use of radiation. With emphasis on avoiding unjustified irradiation of patients, the RCR report has provided a check list for physicians referring patients for diagnostic radiological procedures:

  • HAS IT BEEN DONE ALREADY? It is important to avoid repeating investigations which have already been performed relatively recently. Sometimes it is not possible to accurately track the procedures history of patients. Furthermore, patients may not be able to inform the practitioner that they had a similar procedure recently. It is important to attempt retrieving previous patient procedures and reports, or at least procedure history when possible. Digital data stored in electronic databases may help in that direction; 
  • To help in avoiding repeating investigations, it is necessary to establish a tracking system for radiological examinations and patient dose. The IAEA has taken steps towards that direction by setting up the “IAEA Smart-Card” project;
  • DO I NEED IT? Performing investigations that are unlikely to produce useful results should be avoided, i.e. request procedures only if they will change patients’ management. It is important for the practitioner to be sure that the finding that the investigation yields is relevant to the case under study;
  • DO I NEED IT NOW? Investigating too quickly should be avoided. The referring medical practitioner should allow enough time to pass so that the disorder or impact of management of the disorder may be sufficiently evident; 
  • IS THIS THE BEST EXAMINATION? Doing the examination without taking into consideration the optimal contributions of safety, resource utilization and diagnostic outcome should be prevented. Discussion with an imaging specialist may help referring medical practitioners decide on proper modality and technique; 
  • HAVE I EXPLAINED THE PROBLEM? Failure to provide appropriate clinical information and address questions that the imaging investigation should answer should be avoided. Deficiencies here may lead to the wrong technique being used (e.g. the omission of an essential view); 
  • ARE TOO MANY INVESTIGATIONS BEING PERFORMED? Over-investigating. Some clinicians tend to rely on investigations more than others. Some patients take comfort in being investigated. 

» What are the reasons for over-investigating?

There are various reasons that may lead medical practitioners to refer patients for more procedures than needed. Practitioners should be aware of that and take action to avoid such situations. Some of the reasons that lead to over-investigation are the following:

  • Patient wishes. Patients feel more reassured when they are sure that their practitioner has thoroughly investigated their health condition. Some of them connect the quality of care with the number of procedures they undergo and ask their practitioner to subject them to more procedures. There must be a careful balance between informing patients of risks and benefits and the importance of considering patient desires and needs in the decision making process;
  • Financial. Some organizations or doctors get a direct financial benefit related to conflict of interest (also known as self-referral) from subjecting the patients to various procedures mainly because the services in question are provided by these health care professionals. Such practices are unethical and should not be accepted. Financial reasons may also influence a referring medical practitioner’s equity and also equal access to health services; 
  • Defensive medicine. Some professionals rely far more heavily on investigations including radiological procedures than others, possibly to avoid litigation. In the case of radiological procedures, the risk should also be taken into account and exposure limited to the minimum required for a correct diagnosis;
  • Role of media. The opinion of the public on a subject is shaped by many parameters in a society. Media is one of them. For instance, exaggerated publicity in reporting a medical mistake may lead to increased public sensitivity about the subject. Publicity and increased sensitivity are good things and should be encouraged, but when reporting is not scientific but emotion-driven for audience reasons, as is often the case in mainstream media; this may lead to practitioners practicing defensive medicine and patients refusing indicated procedures; both of these scenarios undermine the appropriate practice of medicine; 
  • Role of industry. The medical industry comprises large corporations that compete with each other for market-share. However, one large problem is that time is needed for new or improved technology, and this must be understood and assessed by the scientific community with regard to the cost-benefit ratio. Studies have to be done and sometimes results take time to come. This creates a window of time when misuse of equipment due to knowledge deficiency is possible;
  • Convenience. Sometimes a practitioner may subject a patient to a procedure that the patient has already undergone when imaging films or discs are unavailable, in order to save personal time, instead of checking the patient’s record. This is not relevant with the specific patient’s well-being, and similar convenience driven prescriptions should be avoided. Such practices are also unethical. 

» Is there any guidance available?

During the last 20 years international and national organizations published guidelines for proper justification of radiological procedures. The UK Royal College of Radiologists (RCR) publication "Making the best use of clinical radiology services " has been in print since 1989. The American College of Radiology (ACR) published its guidelines as Appropriateness Criteria. Similar efforts have been undertaken by the Department of Health of Western Australia in Diagnostic Imaging Pathways. 

For references of publications from national societies in Europe, Oceania, and other regions please see publication from Remedios. These publications constitute guidelines and aim to guide referring medical practitioners in the selection of the optimum procedure for a certain clinical problem. In case there are alternative procedures that do not utilize radiation but yield results of similar clinical value, these guidelines encourage the avoidance of radiological procedures.
The cited publications give very specific guidance to help practitioners perform justification properly. 

» What if the patient whom I refer for a radiological procedure is pregnant?

The responsibility to identify patients that might be pregnant and are unaware of it is shared by the patient, referring medical practitioner and the imaging service providers. Safeguards to avoid inadvertent exposures of the foetus should be observed at all times. 
The “ten day rule” was postulated by ICRP for women of reproductive age. The more recent “28-day rule” allows radiological procedures throughout the complete menstrual cycle unless there is a missed period. When a woman has a missed period, she is considered pregnant unless proven otherwise. 

Even if safeguards are observed, sometimes a pregnant patient may be exposed to radiation. Depending on the radiation dose and the gestation age of the foetus, radiation effects may differ. Radiation risks are most significant during organogenesis in the early foetal period, somewhat less in the second trimester, and least in the third trimester. 

As a rule of thumb one can assume that properly carried out diagnostic radiological  procedures to any part of the body other than the pelvic region or when the primary X-ray beam is not passing through the foetus can be performed throughout pregnancy without significant foetal risk, if clinically necessary and justified. For radiological procedures where the primary beam intercepts the foetus, advice from the medical physicist should be obtained, who will calculate radiation dose to the foetus and, based on that, the practitioner and patient should make a decision. However, doses associated with radiotherapy procedures and interventional procedures are high and they require the attention of experts (including medical or health physicists, practitioners, and sometimes engineers and epidemiologists). In the case when a practitioner is responsible for a patient who has undergone a radiological procedure inadvertently and has subsequently been found to be pregnant, advice from the individuals listed above is needed. For more information, please click here where comprehensive information is provided not only for diagnostic radiology but also for nuclear medicine and radiotherapy.

Read more:

  • Report of a consultation on justification of patient exposures in medical imaging. Rad. Prot. Dosimetry 135 (2009) 137–144. 
  • Brenner, J.D., Doll, R., Goodhead, D.T., Hall, E.J., et al., Cancer risks attributable to low doses of ionizing radiation: Assessing what we really know. P Natl Acad Sci USA 100 (24) (2003) 13761-13766. 
  • Mettler, F.A., Huda, W., Yoshizumi, T.T., Mahadevappa, M., Effective doses in radiology and diagnostic nuclear medicine: A catalog. Radiology 248 (2008) 254-263. 
  • Shiralkar, S., Rennie, A., Snow, M., Galland, R.B., Lewis, M.H., Gower-Thomas, K., Doctors’ knowledge of radiation exposure: questionnaire study. BMJ 327 (2003) 371–372. 
  • INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, 2007. Recommendations of the ICRP, Publication 103, Pergamon Press, Oxford (2007). 
  • INTERNATIONAL ATOMIC ENERGY AGENCY. International Basic Safety Standards for protecting people and the environment. Radiation Protection and Safety of Radiation Sources: International Basic Safety Standards. General Safety Requirements Part 3. No. GSR Part3 (Interim), IAEA, Vienna (2011). 
  • Royal College of Radiologists. Making the best use of clinical radiology services. Referral guidelines. Sixth edition, London 2007. 
  • Remedios, D., Justification: how to get referring physicians involved. Rad. Prot. Dosimetry (2011) Epub ahead of print, accessed 21 July 2011. 
Tue, 21 Feb 2012 23:54:00 -0600 en text/html
My Unraveling

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Let’s begin with an action scene: I was in midair, tumbling sideways, heading for the floor of the Columbus Circle subway station. Not a place I wanted to be. Where I wanted to be was on the downtown 1, five or ten yards away, doors standing open. I’d made this connection more than a thousand times, though usually getting off the 1, not on it.

This time, I was out of practice and I got it wrong. After stepping off the downtown B or C, I took the wrong stairway and had to double back to get over to the right side of the 1. When I climbed up the correct stairs, the stairs I used to fly down every morning, straight from the optimal train door on my precisely plotted commute, I saw the 1 arriving.

And then — well, if I knew exactly what happened, it wouldn’t have happened, would it? What I registered went like this: I sped up, or I meant to speed up. Someone cut across my path. I tried to steer around them and my legs … my legs did something else. Or did nothing. The extra walking and climbing had taken too much effort, and my intentions lost contact with my legs. I reached out and tried to brace myself on someone’s shoulder; they were wearing a black-on-white shirt; I was so undone I was trying to make physical contact with a total stranger on the subway platform. I missed. All that was left was to hit the station floor, so I did.

I rolled to my knees and discovered that was as far as I could make it. My legs couldn’t get me upright again. One guy streaming by broke stride, asked if I was okay, and hauled me to my feet. I checked myself: no torn clothes, no blood. Another 1 was pulling in, one minute behind the train I’d missed. I got on and went where I’d been going. I had just had a fall.

Old people have falls. I had only just turned 52 one week before the September evening I collapsed. But the year from 51 to 52 had been a remarkably bad one. I gambled on a job I wanted, as the editor-in-chief of a small magazine, and it ran out of funding. I sent applications to other publications and got thoughtful rejections. I sent more applications, and they went unanswered. I made an appeal for paid subscriptions at a newsletter I’d been writing. Its revenue flattened out at about 20 percent of my share of our living expenses. The household finances began to drain.

I picked up an adjunct gig, teaching a writing class on Zoom, three straight hours a shot, and the anxiety of filling the time — of giving the students what they were paying for — gathered into a lump in my upper torso until I couldn’t stand the taste of the herbal tea that was supposed to relax me and give me something to do with my hands on-camera. My shoulder locked up. I got pins and needles in my arm.

What was happening to me? I don’t go looking for medical-mystery articles in the newspaper, but when I see one, I read it end to end. The strangest things happen to other people’s bodies! Someone, if I remember right, fought a lingering cough for years because they accidentally inhaled a pea and forgot about it. The medical-mystery column has a beginning and a conclusion. In between is a fumble for clues, moving toward a flash of insight. Some doctor finally runs the right test, recollects the right journal article. The shapeless misery takes shape.

I went to see a shoulder specialist. He knew exactly what was wrong. I had trigger points, little knots in the muscle under the shoulder blade. He gave me some exercises — pin a tennis ball between the shoulder and the wall, lean back, and roll around on it — and a prescription for an anti-inflammatory. A few days later, I noticed my shoes were laced too tight when I tried to put them on. Another day and I made the connection: No, my feet were too big for my shoes. Google said that anti-inflammatories can cause swelling in the extremities, so I stopped taking the pills.

My feet kept swelling, day by day, until my pink ankles looked like deli hams and I started using a butter knife as a shoehorn. I’d reluctantly spent some money to order a new pair of canvas sneakers, off-white, for the spring and summer, and I left them in the box, unable to face the thought of jamming my distended feet into them. The pins and needles spread to both arms, like I’d slept on them funny, except the sensation lasted all day.

I could still type through the numbness, though, publishing what I could for what money I could get. I stopped buying myself things that seemed discretionary — the good oolong tea leaves, crushproof imported pocket notebooks, a new pair of jeans — but some spending had its own momentum. My wife’s family had booked an Airbnb in Italy for April. It would be our first vacation since before the pandemic, our middle-schooler’s first trip abroad since he was in an infant seat. It would have been absurd to cancel just because I was between jobs. My ankle ached on the clutch pedal of the rented Fiat. I brought along a folder of unfinished tax paperwork. The amount I owed the IRS would match, almost exactly, a big freelance check I was waiting on. The deposit went into and out of my account on the same day.

I went to my regular doctor, whom I’d bypassed on the shoulder thing. He was baffled at the symptoms and frank about his bafflement. Swollen feet can mean congestive heart failure, so he referred me to a cardiologist. She instructed me to walk and then run on an inclined treadmill, hopping on and off for ultrasound imaging of my heart. I have — had — always been extremely healthy without being physically fit, so while I didn’t enjoy the test, I still passed handily. My heart was strong and well.

Sometimes this kind of swelling just happens and then goes away, the cardiologist said. Whatever it is, you won’t die of it.

I’ve told the story over and over, to various doctors, till it almost sounds like a coherent narrative. When I drafted this passage, in the dark, by thumb, on a phone plugged into the USB socket of a hospital bed, I’d been telling it to several people a day: general practitioners, neurologists, rheumatologists, radiologists, nurses, physical therapists, medical aides, a dietitian, a surgeon. The story, I told them, happened in two parts. In the spring and summer, part one, I chased the swelling and numbness and other symptoms — stiff fingers, shortness of breath, tightness in the chest — in slow motion from doctor to doctor. Mostly, this was shepherded by the cardiologist, who seemed to feel as if, by ruling the problem not to be her business, she had made it her duty to discover whose business it might in fact be.

I saw a neurologist, who talked me into spending $700 from our high-deductible health plan on getting my muscles zapped with a little Taser and told me the results said I had carpal tunnel. I did have carpal tunnel, but not really, not because my terrible ergonomic habits had caught up with me. The swelling had simply gotten into my carpal tunnels for a while. I ignored his suggestions for exercises and supplements, and months later, in the hospital, I got an email telling me his practice was going out of business.

I saw a rheumatologist. He ordered a bunch of blood tests and suggested I take prednisone and something else. When I opened the paper bag from the pharmacy, I realized the something else was hydroxychloroquine, the malaria drug that had a moment in the news as a spurious COVID treatment. I took only the prednisone. My ankles stayed puffy. You could jab a finger into one and leave a dent that lingered.

Before this, my hands had been loose-skinned and a bit wrinkly, the one part of me going more visibly on ahead through middle age than the rest. My hands looked like my mom’s hands, and I would catch myself gazing at them sometimes and congratulate myself on my resignation to the realities of aging, the mortality of all flesh. Now my fingers resembled Italian sausage links, tight and shiny, with no reassuring philosophical overtones at all.

One symptom would fade and a new one would assert itself. My ankles deflated and I started wearing the new sneakers, but my breathing and stamina steadily worsened. A wheeze or cough would interrupt my talking. On the mile-long walk back from school with my younger son, the route we’d been taking for two years, I lagged behind, guiltily asking him to slow down. I started buying five-pound bags of rice from H Mart instead of ten-pound ones. Then I just started getting rice delivered.

Nobody cracked the puzzle. The folder of referrals and results I carried to appointments got thicker. My blood tested positive for signs of general inflammation and negative for the constellations of markers that would point to any particular inflammatory condition. I had not been bitten by any ticks; I had never gotten the Lyme rash or any other diagnostically meaningful rash. My fingers did not exhibit a telltale sign of turning stark white when they got cold. My chest X-ray and CT scan were clean. The closest thing to a breakthrough was basically an accident: During a routine vitals check, a nurse asked if I was holding my breath. I was sitting still, and my pulse-oximeter reading was refusing to go over 95 percent.

Normal is 95 and above. Below 90 is an emergency. I self-tested at home with a device on my finger. Light activity, like bustling around the kitchen, would knock my level down to 91. Walking a bag of groceries home and up the stairs dropped me to 87. At a medical center, I did breathing exercises with a mouthpiece in a sealed booth. I passed that test. I went to a pulmonologist and passed every test there, too. If you ignored the pulse-ox readings, my lungs and heart were, officially, fine.

There was zero explanation; there was, maybe, the absolutely obvious explanation: that I was stressing myself into this over money. We’d been absorbing plenty of strain in the household before I lost my job — some normal midlife stuff, some normal parent stuff, some abnormal and menacing stuff that I truly can’t even get into. Our black cat gnawed our potted prosperity bamboo to shreds. Trying to save it, we overwatered it until it rotted from the inside out.

It had not been the wisest time to choose an unstable job in a beyond-unstable field. If my time as an editor-in-chief had even been a job: I applied for unemployment, got rejected, and after months of appeal, the State of New York ruled that my past two full-time situations had been contract gigs, uncovered. I considered whether my illness could be a conversion disorder flowing from my misguided career choices. On some level, I believed the swelling would go down and the oxygen would go up as soon as I collected a few consecutive pay stubs from a normal, salaried job.

Back in the winter, I’d met up with a friendly fellow writer who happened to have just secured, through a different line of work, an amount of money that meant financial security forever. In theory, we were talking about ways to fund the job of mine that was about to run out of money, but we both knew that wouldn’t happen. “You’ve got a good reputation,” he said. “Someone will want you to work for them.”

This had been true enough before. I’d made myself a useful editor and a reasonably well-known writer over the years. I moved between jobs without much trouble, tending to get hired the way murderers in movies get hired: a message or phone call from someone who needed something done and who thought I could do it. Abruptly, all that my connections could offer were gigs. Someone needed a manuscript edited before they gave it to their book editor. A magazine wanted a book review. Work, but no jobs.

I kept applying for something stable. A notoriously lavish start-up loved my proposal for a mini-section within its soon-to-be-launched vertical until the sponsorship for the vertical failed to come through. A major media company advertised for a position that exactly fit my history, then withdrew the listing in the middle of an executive meltdown. A friend of a friend let me know that another major media company was ignoring my application because it wanted someone less opinionated. I started calling in favors, nagging people with whom my friendships had previously been non-transactional. It broke up the dead silence, at least.

My wife and I considered disaster scenarios in which the “disaster” was simply that things kept going the way they were going. We did the math on vacating our condo, finding tenants, and living in a cheaper rental. Maybe it was time to leave New York. But it wasn’t clear if we had enough savings to cover such a move. It wasn’t even clear if I had the physical energy to pack boxes. On the online job forms, there was usually a question about whether I, the applicant, identified as disabled. I paused longer and longer each time. Disabled? I was … less able. To do things. Than I’d been. For now? I clicked “no,” uncertainly.

Part two of the story is I got COVID. I’d avoided it for three years, but everyone is going to contract the virus sooner or later. It’s not worth the trouble, officially, to even politely suggest people should wear masks or to keep the public up to date on the rate of new cases. The pandemic is over, people keep on saying. You are free to make your own decisions about what risks to take individually without any useful information about the overall risk picture.

I’d been furious about this already on other people’s behalf. Most Americans, the Biden administration said, would be fine if they were vaccinated. This elided the people who wouldn’t be: the immunocompromised, for example, and those with certain respiratory conditions. The political and journalistic consensus had set the value of these people’s safety at zero, not even granting them the benefit of mask advisories or ventilation standards.

When I started hearing about the late-summer COVID wave, it occurred to me that now I was one of those people myself. This is what disability advocates have said all along, not that it usually sinks in: The able and the disabled aren’t two different kinds of people but the same people at different times. Last year, I was healthy; this year, I had a breathing ailment, even if nobody could say exactly what that ailment was.

I got Paxlovid delivered and sank into fever. The back of my throat was so raw I would wake up snorting for air. Rolling around in my bed, I felt, for the first time, that this body of mine truly was going to die someday. Not the abstract knowledge that death awaits all of us but the shocking awareness that eventually this system of veins and nerves and organs would lose its familiar stubborn equilibrium, cease functioning, and fail. I fixated on whales. They’re right out in New York Harbor. What if I used up my allotted time on the planet without ever laying eyes on a whale? I booked a whale-watching cruise for the family. Later, when the day came, it got canceled by a hurricane.

In August, when the acute COVID infection ran its course, I got out of bed and back on my feet. But after a week or two on the upswing, a whole new set of malfunctions took over. Routine movements burned as if I were doing deep stretching. I couldn’t get through a meal without a coughing fit from a lump of food getting stuck or a drink of water splashing the wrong way. Saliva accumulated in my mouth till I had to go to the sink and spit. I ate more slowly and stopped getting seconds, feeling like I was in one of those testimonials about the new anti-obesity drugs, in which people tell how their motivation to keep eating has disappeared. I was far past needing or wanting any weight loss. My sedentary midlife flab had long since ebbed away, and now I was losing something else, down ten pounds in a month. Maybe, the cardiologist said, eyeing my scrawny limbs and loose clothes, I should consider checking into a hospital. Just so I could get all my testing coordinated in one place.

It was only a thought, one that dissipated as I sought out second opinions. The medical-mystery column doesn’t usually dwell on how slowly the inquiry goes in our fractured health-care system. How the highly recommended pulmonologist doesn’t return the first phone call and only has an opening five months away, and how the major-medical center does have an appointment but isn’t in network with the major-medical insurer. How the chest X-ray is over by the East River and the breathing booth is in the West 160s and the phlebotomist is by Columbia, and how each one has its own online portal for billing and results.

Every day, my legs were harder to move. Climbing in the door of an SUV, I couldn’t lift my rear foot over the threshold until I reached down with my hands and pulled it in. Then the grab-and-lift maneuver became necessary to step into my pants. I had to ask the kids to pull pots and cutting boards out of the bottom kitchen cabinets for me. I gave up bedtime-story duty, crawling into bed each night before anyone else, half-hearing my wife’s voice reading in the next room, feeling myself fading out of my own life. I imagined living in a world and a class where a person could retreat to a sanatorium and shut everything down until the problem was figured out.

I stopped leaving the apartment. The project of washing left me needing to lie down. One morning, or possibly afternoon, it took me four or five tries to shrug my way into my bathrobe, nearly overcome by the weight and friction. I gave up on shaving, and the rattiest stubble of my life took over my chin. The kids were put in charge of the cat box because I couldn’t reach that corner of the bathroom anymore, but one night I got down on the floor to help and when we were done I couldn’t stand up. I didn’t even know how to start to try. Eventually, my wife grabbed me under the armpits from behind and hauled me most of the way upright while I gabbled warnings about my legs giving way.

Two different realities or images stood superimposed in my mind. There was the body I’d occupied two months ago — my body, as I understood it — walking over to Broadway for pizza, taking the younger boy to the basketball courts, ducking into Central Park to climb the Great Hill. And then there was Andrew Wyeth’s Christina’s World, a gaunt figure dragging her useless legs along the ground. If this was histrionic or self-pitying, it seemed less so on the days when I couldn’t raise my hips up off the floor. The only thing that still felt more or less normal was sitting at a desk, doing the work I was trying to get someone to pay me to do.

Meanwhile, in the span of time that it took a newspaper to move one step down its hiring checklist from a Zoom interview to an edit test, a law school in a small southern town progressed from sending my wife a preliminary inquiry to making her a tenured job offer with a part-time teaching slot for me thrown in. We booked a visit for the family to see if we could really live there. As the trip came closer, we realized there was simply no way I could walk through an airport. The rest of the family would have to scout out our possible future while I stayed home.

As they prepared to go, my GP called with the results of my latest bloodwork. A normal range for creatine kinase, a marker of muscle breakdown, might be between 30 and 200 units per liter. A new test said my level was 8,000. The reason my muscles felt so weak was that they were actively dissolving into my bloodstream.

I wrapped up a job-recruiting call, threw my glasses and contact-lens case into a shoulder bag, and booked an Uber to the emergency room. My wife took my sons to see about the job. It was unclear which of us was going to the place that would offer a solution.

In the hospital, the medical mystery falls into an awkward, indeterminate zone. Between the fall and the choking and the creatine kinase, my story qualified me as a definite emergency when I shuffled up to the admission desk. But it was a conundrum to be solved, not as straightforward and urgent as a stroke or broken hip. The staff put me in a wheelchair and parked me in a walkway lined with other people in wheelchairs. The hospital was beyond full. There were genuinely not any open beds, not only as an administrative category but as literal objects to lie down on. I spent my first night on a gurney in the ER observation section, fully dressed and still in my shoes. To avoid catching anything else, I kept a mask on, the elastic digging into my ears.

On the second day, I got a bed and changed into two layers of hospital gowns. My clothes and my new sneakers went into a pair of plastic patient-possession bags. Doctors came by, individually and in teams, with blue gloves on, to test my muscles. Squeeze my fingers. Push up against my hand with your knee. Stick out your elbows and don’t let me push them down. The closer the blue gloves came to the middle of my body, the worse I did.

The doctors had questions. Had I been hiking at all back in the spring, when my troubles started? No? Was I sure? Not even in Central Park? This was about Lyme disease again, of course. I knew about Lyme, and the ever-growing literature of people’s struggles with Lyme, and the whole elusive post-Lyme complex. But I also still knew, as solidly as I could know any fact about my health, that I had not been bitten by any ticks. One doctor after another asked me to blink my eyes, harder, over and over, watching for the lids to droop from fatigue, which might mean myasthenia gravis. My lids did not droop.

ER time took over, with “day” and “night” merely more or less busy spells in an unbroken atmosphere of fluorescent lights and beeping. A 24-hour flight in coach, a 48-hour flight in coach, a 72-hour flight in coach. The patient behind the curtain to my right kept his TV blaring all night, cycling episodes of the same forensic true-crime show: some ghastly rape or murder, the bafflement of investigators, the infallibility of scientific evidence coming to the rescue. The Kars-4-Kids jingle playing in between.

My obvious risks — choking, falling — had standard countermeasures: puréed meals and caution-yellow nonslip socks with a matching wristband that read FALL RISK. For treatment, there was nothing but big bags of IV fluids to flush out the creatine kinase while keeping my underlying symptoms untouched, the better for accurate testing and observation. The creatine kinase went down to 5,000, back up to 6,000, down again. The staff rolled me away to a chest X-ray, a thyroid ultrasound, a contrast CT scan, an MRI. Wheeling down the hall toward an echocardiogram, I passed the neurology team going the other way, misconnecting on a planned meeting. I never talked to them again.

A real hospital room, outside the ER, opened up in the late afternoon on the fourth day, a Saturday. It was on the tenth floor with a window looking uptown over the top of Central Park. I could see the boathouse by the Harlem Meer, but not the water itself, because the trees were so thick and green. I wondered, tempting fate, what it might look like when the colors turned.

My new roommate, a friendly, stooped figure, was in agony for non-mysterious reasons — a manageable condition that had gone unmanaged because the treatments cost too much money. The problem-solving sessions on his side of our shared curtain, with the doctors and social workers, were about which programs or policies might help him if he and his family could sort them out.

For me, evidence and theories kept trickling in. Doctors would come by and mention some finding, or my phone would give an automated notice that a new lab result had arrived and I would Google as best I could. Open tabs accumulated on my phone: RNP antibodies, rheumatoid arthritis, polymyositis, mixed connective tissue disease. (“The overall ten-year survival rate is about 80 percent.”) I was negative for hepatitises B and C, negative for Sjögren’s-syndrome antibodies, negative for syphilis, negative for Lyme (told you) — negative for most things, as I’d been all along. The speed with which my muscles were falling apart seemed to be, in some sense, good news, meaning that I probably wasn’t going through one of the more gradual neurological degenerations like ALS.

Down in radiology, I took a swallowing test, a three-course flight of barium snacks: a thick barium drink, spoonfuls of barium marshmallow fluff, then bites of the barium fluff on a graham cracker, consumed one after another on live X-ray video. There was my jaw, my tongue, my hyoid bone, and there were clots of barium-tinged food getting visibly hung up short of the esophagus, behind the tongue, in little pockets of underperforming pharyngeal muscle. None of the food, however, was obstructing my windpipe. It meant I was eligible to trade in puréed green beans for individual green beans, French-toast paste for ordinary French toast.

A provisional unifying idea took shape. More and more, the conversations circled back to one form or another of myositis: an autoimmune attack on my proximal muscles. If the muscles were the essence of the problem, then my oxygen troubles could have been a muscle problem all along too, a creeping weakness in the diaphragm. The swallowing trouble would be the muscle problem appearing in the pharynx. The swollen ankles and knuckles — well, those weren’t quite muscle problems, but they also were no longer a pressing concern. What I needed, urgently, was a muscle biopsy, one that might tell the doctors exactly how that part of me was going wrong.

It was my bad luck, the attending doctor said at my bedside, to be an interesting case. Our meetings had a tone of rueful amusement. Yes, I was in pain and reeking from infrequent showering, but we could talk about the unresolved mystery and its submysteries with a certain detachment. My oxygen levels were behaving themselves. No one knew where that problem had gone, nor why my voice had suddenly gone faint and reedy.

My wife was back from the job-scouting trip, but she’d picked up a foot infection and was stuck in the apartment, taking antibiotics. The boys trooped across the park to bring me my laptop. They were visibly alarmed by how gaunt and shaky I was. I took them on a shuffling tour to a long back hallway lined with sleek, derelict equipment, with a window facing out on a black monolith of a building, to show them how much it looked like Andor. We shared the crunchy, startlingly good French fries on my dinner tray. I couldn’t have swallowed that many on my own.

Now that I had the computer, I rummaged through test results and image scans on the hospital information portal. I could navigate this way and that through the inside of my own body on the CT or MRI files, moving the cutaway to watch the stark white rib cage flow into the spine. My thoracic aorta was “normal in caliber and course.” My right iliac bone had a “tiny sclerotic focus” that was probably a “bone island.” My muscles were all fucked up:

Diffuse STIR hyperintense signal throughout the visualized musculature of the pelvis and thighs as well as partially visualized portions of the paraspinal muscles of the lower back, including the quadriceps muscle (vastus lateralis, medialis, intermedius), hamstrings, iliacus, psoas major, gluteus medius and minimus, pubococcygeal muscles, adductor muscles, highly suggestive of systemic myositis in the appropriate clinical setting.

I knew this, implicitly. It was apparent every time a nurse or technician asked me to scoot a little in my bed and my psoas major or adductor or the rest simply wouldn’t do the scooting. The most minimal movements were the most impossible. It was easier to clamber out of bed, take a six-inch step, and clamber back in at the new spot than to shift my body. If my pillow slipped down to the small of my back, there was no retrieving it.

A perverse rule of medical technology is the more you scan, the more you discover, whether those discoveries matter or not. The imaging reports noted a “small hiatal hernia”: Google said a weakened diaphragm could cause that. I had an “underdistended stomach,” as would anyone who was expected to eat French-toast paste. My liver was “prominent in size,” which qualified as “hepatomegaly.” My lower lungs had “minimal mild reticular opacities.”

One discovery was notable, or might have been. A night-shift doctor brought it up offhandedly, as if someone else must have already mentioned it: The ultrasound had picked up a nodule on my thyroid. Could it be squeezing my trachea? Could it be cancer? Could it be nothing? Sure. A little more inspection and the nodule became nodules, plural, the largest being a nearly inch-long sausage on the thyroid isthmus, salient and crying out for analysis. The thyroid-biopsy team swooped in during lunchtime, chatty and armed with portable gear for working at my bedside. One person tracked down the sausage with an ultrasound wand against my neck while another jackhammered away at it with a tiny needle. They prepared the samples in little vessels of brightly colored liquids laid out in the sun on the windowsill. The technicians eyeballed the cells on a microscope set up in the hallway and declared that nothing looked obviously malignant. My thyroid itself, they said, showed “lymphocytic thyroiditis.” Also known as Hashimoto’s disease, although who could say, here, whether it was a disease unto itself or a manifestation of some greater disease. The question was bigger than the thyroid.

Now there was almost nothing left to do but the muscle biopsy. Ten stories up turned out to be cruising altitude for hawks, wheeling by the window in the sunlight, borne along on the fresh autumn breezes. I gave my daily samples of blood. I sent some follow-up emails about jobs. The procedure was scheduled for Thursday, my ninth day in the hospital, in the last slot of the afternoon.

As the time came closer, I began to apprehend an uncomfortable truth. The actual medical mystery wasn’t about anything inside me. It was whether the tests were going to point to some far side of this where I got my life back. Was there a future where I could walk out the door on Sunday morning in decent shoes and make it to church? Where I could pick up heavy groceries to put a three-course meal on the family dinner table? Where we could rent a rowboat? Where I was a helpful and economically viable member of the household?

The operating team drew a mark on my right thigh and put me under sedation. When I came around, I was still in the operating room. My wound was neatly sewn up but the team was on the phone with the pathologists, who wanted to discuss whether they’d taken a big enough chunk of my leg. Pleasantly high and feeling fantastic, I assured everyone it was fine if they wanted to go back and get more. You know — While we’re here, happy to oblige. They decided against it, and off I went to recovery. It was the nicest feeling I’d had in weeks. I looked at my hands and I could believe the old familiar wrinkles were coming back.

Later on, it felt as if someone had sliced open my thigh, since they had — an additional stabbing pain tucked inside the usual burning pain when I used my quadriceps. But that was tolerable. I was finished with being a test subject. All the possible diagnoses pointed to the same treatment, anyway, so the next morning, I got a syringe of steroids pushed into my IV, chased with a cold squirt of saline to make sure every drop went through. I was a patient, trying to get well. Within hours, maybe, my thigh muscles seemed a little less dead than before. That afternoon, I limped off to the bathroom, pulled the shower chair out of the shower, and sat down to make a job interview call, away from any beeping machines or doctor visits. At least it wasn’t a Zoom.

Out the window, I could see magenta and gold in the tree canopy of Central Park. It was deep enough into October for that now. My creatine kinase dropped from 6,200 to 4,500 overnight, then headed for the 3,000s, a level a person could go home with. Whatever had made my immune system start tearing up my muscles, the steroids seemed to be making it slow down. That’s what they were: immunosuppressive drugs, to be followed over time by other, different immunosuppressives. If all went well, I would trade being an actively sick person for being an immunocompromised one.

The blue-gloved muscle checks resumed. Oh, yes: Much stronger in the legs. I took a lap around the ward. I spent less time in bed and more in a chair. I booked another job call with maybe some steroids-laced overconfidence. My wife, with a counteroffer from her current employer in hand, turned down the southern school.

Normal life, or whatever would stand in for normal, was calling. On my 15th day, with the pathology report on my leg sample still a work in progress, the last sparkling dregs of a fat bottle of immunoglobulin filtered into my veins. The two-day infusion was the final piece of treatment that had required hospital care. I was free to go. When the IV came out of my arm, I dug out my things from the closet and got dressed. Clean pants and a clean T-shirt over my poorly cleaned body. My eyes in the mirror were sunken, my neck withered. Nonstop mask wearing had scraped the bridge of my nose raw, and my ratty stubble was now a full ratty Vandyke, the chin shot through with gray. I peeled off my last pair of grimy yellow nonslip socks and wrestled my way into my own regular socks.

Now the shoes. I’d been imagining how this would feel for days. I reached into the hospital bag for my canvas sneakers and pulled them out. They were mashed out of shape and … damp to the touch? Damp to the touch. Had something spilled into the bag, somehow, or was it just residual sweat? Either way, they had been sealed in plastic with it for two weeks. Flecks of mold had sprung up on the otherwise new-looking insoles.

There was nothing to do but wear them. I would be taking myself home. The hospital had sent my prescriptions to the nearest pharmacy for me to pick up on my way out. A string of robocalls and human calls then informed me that the branch did not, in fact, have all the meds I needed, specifically the steroids. My wife headed across town to another location, where the computer indicated there were enough steroid pills to last me three days.

The nurse who’d unplugged me reappeared with a sheaf of papers: I was discharged. No final consultation with any of the doctors. The nurse asked if I wanted a wheelchair. I figured I might as well start walking.

By the time I reached the ground floor of the hospital with my bags, I understood that had been a mistake. My room had been on the west side of the building; the pharmacy was on the east, an entire avenue over. I walked a few yards down the vast hallway, paused for a stricken moment, then walked a few more. I couldn’t wipe out again. Stopping and going, I made it to the east side of the building, down a short flight of steps, and out. Numbly, I trudged up the sidewalk in the quickly fading twilight, clutching my papers. It dawned on me that I still didn’t have a diagnosis.

I despise those stories where a writer tells you all about some mystery for thousands of words and then fails to deliver the solution. Usually with some metaphysical vamping about the unknowability of all things. What are you even telling anyone about it for? But I didn’t have an answer, and I still don’t. It would be more than another week before the pathology report came back. My muscles, it said, showed “myopathy with scattered necrotic myofibers in the absence of significant lymphocytic inflammatory infiltrates.” I couldn’t raise a doctor on the phone to talk about it. Whoever wrote the report had floated a whole new possibility, “antisynthetase syndrome,” to go with the other possibilities still bobbing around. The hospital rheumatologists, weeks later, would stick with polymyositis; a different myositis expert would propose “immune-mediated necrotizing myopathy.” A neurologist would suggest “lupus-myositis overlap syndrome.”

Medicine hasn’t really solved for the body attacking itself. Since the inflammation first brought me to the rheumatologist months before, I’d been quietly bracing for an answer that wouldn’t feel like an answer. An authoritative-sounding name like scleroderma would come up, and Googling would fill in non-detail details like “no cure” and “symptoms vary” and “don’t know exactly what causes this process to begin.” The thing that had taken me apart was something rare and diffuse, its effects almost certainly melded with those of the coronavirus. I was on my own with it. I was three weeks behind on a freelance editing gig, and November’s bills were cycling into view. In January, an endocrinologist had an opening to see about my thyroid.

The pharmacy window was, as pharmacy windows are, all the way at the back of the store. An incredible distance. A terrifying distance, alone on my shaky legs. I put out a hand to steady myself against the shelves along the way, and waiting in line I just grabbed on. I said my name to the pharmacist as clearly as my cracked voice could muster, got the pills, and retraced the long path to the door.

It was fully night now. As I stepped outside the pharmacy vestibule, I saw an empty taxi coming up the block, preparing to turn the corner. Memory and instinct said it was mine: Two or three long, quick strides to the curb and a sharply upthrust hand would catch the driver’s eye. My body knew otherwise. I ventured a short step, not even to the middle of the sidewalk, and the taxi went on by my half-raised arm.

Mon, 01 Jan 2024 19:00:00 -0600 Tom Scocca en text/html Ask A Doctor: Diet And Exercise Aren’T Working For Me. What Else Can I Do To Treat Obesity? No result found, try new keyword!Expert opinion from Ilya Aleksandrovskiy M.D., MBA · 5 years of experience · USA In such cases, you should visit a medical practitioner who will give you certain medications that might inspect the ... Thu, 28 Dec 2023 07:28:38 -0600 en-us text/html Babylon claims its chatbot beats GPs at medical exam

By Jen CopestakeBBC Click

The artificial intelligence software provides what it determines to be the most likely diagnoses

Claims that a chatbot can diagnose medical conditions as accurately as a GP have sparked a row between the software's creators and UK doctors.

Babylon, the company behind the NHS GP at Hand app, says its follow-up software achieves medical exam scores that are on-par with human doctors.

It revealed the artificial intelligence bot at an event held at the Royal College of Physicians.

But another medical professional body said it doubted the AI's abilities.

"No app or algorithm will be able to do what a GP does," said the Royal College of General Practitioners.

"An app might be able to pass an automated clinical knowledge test - but the answer to a clinical scenario isn't always cut and dried.

"There are many factors to take into account, a great deal of risk to manage, and the emotional impact a diagnosis might have on a patient to consider."

The chatbot was unveiled at an event in London

But NHS England chairman Sir Malcolm Grant - who attended the unveil - appeared to be more receptive.

"It is difficult to imagine the historical model of a general practitioner, which is after all the foundation stone of the NHS and medicine, not evolving," he said.

"We are at a tipping point of how we provide care.

"This is why we are paying very close attention to what you've been doing and what other companies are doing."

Higher score

The chatbot AI has been tested on what Babylon said was a representative set of questions from the Membership of the Royal College of General Practitioners exam.

The MRCGP is the final test set for trainee GPs to be accredited by the organisation.

Babylon said that the first time its AI sat the exam, it achieved a score of 81%.

It added that the average mark for human doctors was 72%, based on results logged between 2012 and 2017.

But the RCGP said it had not provided Babylon with the test's questions and had no way to verify the claim.

"The college examination questions that we actually use aren't available in the public domain," added Prof Martin Marshall, one of the RCGP's vice-chairs.

Babylon said it had used example questions published directly by the college and that some had indeed been made publicly available.

"We would be delighted if they could formally share with us their examination papers so I could replicate the exam exactly. That would be great," Babylon chief executive Ali Parsa told the BBC.

To further test the AI, Babylon partnered with doctors at two US organisations - Stanford Primary Care and Yale New Haven Health - as well as doctors from the Royal College of Physicians.

It said they had developed 100 real-life scenarios to test the AI.

The company added that it expected its chatbot's diagnostic skills would further improve as a consequence.

Probable causes

Babylon has demonstrated its chatbot being used as a voice-controlled "skill" on Amazon's Alexa platform.

While Babylon's existing GP at Hand service refers users to a human doctor if the app suspects a medical problem, the new chatbot makes a diagnosis itself - offering several possible scenarios along with a percentage-based estimate of each one being correct.

The GP at Hand app launched in late-2017

"The suggestion that this can replace doctors is the key issue for us,' said Prof Marshall.

But Mr Parsa disputed the idea that doctors would be left out in the cold, explaining that the intention was still for a medic to follow up the AI's diagnoses.

"We are fully aware that an artificial intelligence on its own cannot look after a patient. And that is why we complement it with physicians," he said.

"It is never going to replace a doctor, but just to help."

Babylon envisages that a human doctor would make use of its chatbot's diagnosis within a follow-up video chat

Rwandan connection

Babylon's stated ambition is to deliver affordable health care to people all over the world.

Since 2016, it has been working in partnership with the government of Rwanda.

The country's health care service was decimated after the genocide in 1994, in which more than 800,000 people were killed.

Babylon has two million registered users in Rwanda and has conducted tens of thousands of consultations.

Nurses in Rwanda have helped train Babylon's software by using it to diagnose people in the country

Since smartphone use is not widespread in the country, people currently call nurses who follow symptom-checking prompts that appear to them via computer screens.

Information gathered as a result has been used to improve the chatbot.

BBC Click will have more on Babylon's work in Rwanda on this weekend's television show. Find out more at and @BBCClick.

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Wed, 27 Jun 2018 06:15:00 -0500 text/html Virginia Cannabis Control Authority to take over medical marijuana program in 2024 No result found, try new keyword!B eginning January 1, 2024, the Virginia Cannabis Control Authority (CCA) will take over regulatory oversight of Virginia’s medical cannabis program. The CCA is working with the Board of Pharmacy, the ... Thu, 28 Dec 2023 13:30:30 -0600 en-us text/html Litigators of the Week: Zuckerman Spaeder Gets a Post-Trial Acquittal for Doctor Accused of Fraudulent Billing for COVID Tests

Last year federal prosecutors in Maryland secured the conviction of Dr. Ron Elfenbein, an emergency room doctor and part owner of an urgent care clinic and COVID testing sites, on charges that his clinics overbilled Medicare and insurance companies for testing services. With the government alleging there were more than $15 million in false and fraudulent claims, Elfenbein faced the prospect of significant prison time.

But just before Christmas, Elfenbein’s defense lawyers—Gregg Bernstein, Marty Himeles and Samantha Miller of Zuckerman Spaeder—won their bid for a post-trial acquittal. Chief Judge James Bredar found that the government hadn’t proven the way Elfenbein’s testing locations coded their services was false beyond a reasonable doubt—especially in light of the shifting and ambiguous coding guidance issued during the pandemic. “The ‘common sense’ conclusions the government asks the jury (and now the court) to draw amount to speculation, and the court cannot allow a verdict to stand when it is based on speculation masked as common sense,” he wrote.

Thu, 04 Jan 2024 22:43:00 -0600 en text/html
The Paradox of How We Treat Diabetes

Understanding diabetes today requires holding two conflicting realities in your head simultaneously.

First, diabetes therapy has been revolutionized by a world of new drugs that have become available since the turn of the century—most notably, drugs of the same class as Wegovy and Ozempic that began their existence as diabetes medications and are now hailed as wonder drugs for treating obesity. These drugs do the best job yet of controlling blood sugar and, of course, body weight, which is critical for those Type 2 diabetes, the common form of the disease that constitutes over 90 percent of cases and is associated with age and obesity. For type 1 diabetes, the acute condition that typically strikes in childhood and adolescence, new devices—continuous blood sugar monitors and automated insulin delivery systems—make blood sugar control easier than ever. Still more advanced devices and better drugs are in the pipeline.

But then there’s the flip-side. It’s why the pharmaceutical industry has invested so heavily in new therapies: Once a relatively rare condition, diabetes is now so common that drugstores dedicate entire aisles to it and television commercials for diabetic medications are common fare. In 1960, when the first concerted federal surveys were quantifying prevalence, two million Americans were living with a diabetes diagnosis. Today that number is 30 million; almost nine million more have diabetes but don’t yet know it. Each year, 1.4 million new cases are diagnosed and at ever younger ages.  

Diabetes puts all of these individuals at increased risk of heart disease, strokes, cancer, blindness, kidney failure, nerve damage, gangrene, and lower limb amputation. It increases cognitive impairment and dementia risk as patients age. Living with diabetes still comes with a decrease in life expectancy of six years.

For those with Type 1 diabetes, despite the remarkable new drugs and devices, blood sugar control is seemingly getting worse, on average, not better. As of 2018, fewer than one in five individuals diagnosed with Type 1 diabetes were achieving even the relatively generous blood-sugar goals set by the American Diabetes Association (ADA); this was a smaller proportion than a decade earlier.

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Despite the remarkable advances in therapy, both Type 1 and Type 2 diabetes are still considered progressive chronic diseases, meaning the patient’s condition is expected inevitably to deteriorate as they live with the disease. The greatest challenge to better therapy, as one recent analysis suggested, is the hesitation of physicians to continue prescribing more or newer drugs and increasing dosages as the diseases progress.

All of this comes with a staggering financial burden. In November, the ADA estimated that the total annual cost of diabetes in the U.S. is over $400 billion; over $300 billion is direct medical costs. This was up $80 billion from 2017 when an editorial commenting on a similar accounting characterized these costs as the “elephant in the room” of the diabetes epidemic. Patients with diabetes are likely to spend over $12,000 a year just for medical care, almost three times that of healthy individuals of equivalent age. It does not help that the drugs themselves—whether insulin or Ozempic and its ilk —are expensive, costing many thousands of dollars a year. One in every four health care dollars spent in America goes to treating diabetic patients.

And the U.S. is by no means unique. The World Health Organization estimates that diabetes prevalence worldwide increased four-fold between 1980 and 2014, from 108 million to over 400 million, with the greatest rise coming, paradoxically, in the poorest countries. In 2016, Margaret Chan, then WHO director general, described the situation as a “slow-motion disaster” and predicted with near absolute certainty that these numbers would only get worse. They have.  

So how do we reconcile these conflicting realities: Unprecedented advances in medical therapies for an out-of-control disease epidemic in which patients, at least in general, are doing poorly and can expect to do worse as time goes on? Confronted with such a dismal state of affairs shouldn’t we be asking how we got to this point? Were mistakes made in how we think about this disease? Were questionable assumptions treated as facts, and could those assumptions be wrong?

Asking the Right Questions

These are the kinds of questions you would hope health organizations worldwide would be asking, but surprisingly they have no mechanisms or protocols to do so. Diabetes associations like the ADA will regularly convene expert panels to address revisions in the latest standard of care guidelines to accommodate the latest research, but not whether the guiding principles underlying those guidelines should be rethought entirely. Independent investigators are not recruited to analyze and to provide an unbiased assessment of where progress might have gone off the rails. That job instead has been left to physicians in their clinics, those confronted with ever more diabetic patients and willing to take the risk of thinking independently, and to investigative journalists like myself, whose obligation when confronted with such conflicting realities is to ask just these kinds of questions.

Among the revolutions that changed medical practice over the past half century, one in particular is very relevant here. Beginning in the 1970s, health-care analysts began to confront quite how little physicians really knew about the risks and benefits of what they were doing for their patients. Not only had clinical trials demonstrated that some standard medical practices resulted in far more harm than good—the surgical procedure known as a radical mastectomy, most infamously, for breast cancer—but researchers were documenting wide variations in medical practices from physician to physician, hospital to hospital and state to state. This, in turn, resulted in a wide variation of benefits, harms and costs to the patients, depending on which physicians they might visit, and so which treatments they might get.

Read More: Should We End Obesity?

The revolution that followed became known as the Evidence-Based Medicine (EBM) movement, founded on the principle that medical interventions should be rigorously tested in clinical trials— double-blind, randomized, placebo-controlled—before they be used or prescribed. This would be necessary whenever physicians were faced with a choice between multiple options, and whenever the harms of an intervention might outweigh the benefits. David Sackett of McMaster University, a founder of the movement, would describe the EBM process as beginning with the fact that half of what aspiring doctors learn in medical school is “dead wrong,” and then trying to establish thoughtfully and critically which half that is. David Eddy of Duke University, another EBM pioneer, later described his motivation and that of his colleagues as the revelation that “medical decision making was not built on a bedrock of evidence or formal analysis, but was standing on Jell-O.”

It would be nice to think that this situation has been widely resolved by evidence-based guidelines, but that’s not the case. Journalists or physicians looking for the evidence base in decision making about diabetes therapies, will likely find themselves, as I did, with the same revelation. Clearly it, too, was standing on Jello-O in the 1970s, but the problem neither began nor ended there. A remarkable history emerges, with three clear observations.

Ozempic Photo Illustrations
Ozempic manufactured by Novo Nordisk packaging is seen in this illustration photo taken in a pharmacy in Krakow, Poland on December 7, 2023. Jakub Porzycki-NurPhoto/Getty Images

First, we’ve been here before. We have had miracle drugs for diabetes. Most notably, the hormone insulin itself, when University of Toronto researchers led by Frederick Banting and Charles Best purified it and put it to use in 1922 treating patients with severe cases of diabetes. We then had better insulins, slower-acting and longer-lasting, and then, in the post-World War 2 years, drugs (oral hypoglycemic agents) that could lower blood sugar without having to be injected, as insulin did. We have had revolutionary advances in diabetes technology, beginning in the 1970s with devices that allowed patients to monitor their own blood sugar, and then insulin pumps that automated the process of insulin therapy. All contributed to easing the day-to-day burden of diabetes. None had any influence in controlling the epidemic, nor did they eradicate or meaningfully reduce the long-term complications of the disease. Put simply: diabetes plus drug therapy and devices, even the best drug therapy and devices, does not equate to health.

Secondly, diabetes researchers have not been averse to testing their fundamental assumptions. They‘ve done so in ever more ambitious clinical trials. But a disconcerting proportion of those trials failed to confirm the assumptions, despite the fact that it was these assumptions that constituted the rationale for therapeutic approaches. The $200 million Look AHEAD Trial, for example, tested a foundational belief in the field: that weight loss in those with Type 2 diabetes would lengthen lives. The trial was ended for “futility” in 2012. ”We have to have an adult conversation about this,” as David Nathan, a Harvard diabetes specialist, said to The New York Times. The 10,000-patient ACCORD trial had also been ended prematurely just four years earlier. “Halted After Deaths,” in the words of The New York Times headline. “Medical experts were stunned,” the 2008 article said. ACCORD was one of three trials testing the assumption that intensive blood sugar control by medications would reduce the macrovascular complications of Type 2 diabetes—particularly heart disease—and premature death. All three trials failed to confirm it.

Third, the remarkable aspect of all these trials is that they all assumed an approach to dietary therapy that itself had never been tested. This is the “standing on Jell-O” problem. For well over a century, diabetes textbooks and chapters in medical texts invariably included some variation on the statement that diet is the cornerstone of treatment. The most recent guidelines from the ADA refer to dieting as “medical nutrition therapy” (MNT) and say MNT is “integral” to therapy.

But what constitutes MNT—the dietary advice given—has been determined not by any meaningful research comparing different dietary approaches. Rather it has been assumed that individuals with diabetes should eat the same “healthful eating pattern” that health organizations recommend for all of us—“non-starchy vegetables, fruits, legumes, dairy, lean sources of protein… nuts, seeds, and whole grains”—albeit with the expectation, if weight control is necessary, that they should eat fewer calories.

Read More: Are Weight Loss Drugs From Compounding Pharmacies Safe?

Controlling the symptoms and complications of the disease is left to insulin and the pharmacopeia of drugs that work to maintain blood sugar levels near enough normal that the specter of diabetic complications may be reduced as well. Diabetes associations have assumed that this approach is easiest on the patients, allowing them to balance the burden of insulin injections or multi-drug therapy, against the joy of eating as their non-diabetic friends and family do. But this assumption has never been tested to see if it is true, nor whether a better approach exists that might truly minimize the disease burden of diabetes, extend lives and make the trade-off of restrictive eating vs. health worthwhile.

History of Diet and Diabetes

This is where understanding the history of the diet-diabetes relationship can be vitally important. What has been known for certain about diabetes since the 19th century is that it is characterized by the inability to safely metabolize the carbohydrates in our diet. This observation led to two divergent approaches/philosophies to dietary therapy. Beginning in 1797, when a British physician named John Rollo wrote about curing a diabetic patient using a diet of fatty (rancid) meat and green vegetables, through the early 1900s, diabetes therapy was based on the assumption that since individuals with diabetes could not safely metabolize the sugary and starchy foods in their diet, they should abstain from eating them. In this pre-insulin era, the only meaningful advice physicians could give their patients was dietary, variations on Rollo’s approach: sugars, grains, starches, even legumes were prohibited because they are carbohydrate-rich: meats, ideally as fatty as possible, butter and eggs, along with green leafy vegetables (boiled three times to remove the digestible carbohydrates) could be eaten to satiety.

Throughout Europe and America, this was known was “the animal diet,” endorsed by virtually every major diabetes specialist of the 19th Century. Physicians believed that the more calories their diabetic patients consumed, and ideally the more fat (because protein is composed of amino acids, some of which the liver converts to carbohydrates), the healthier they would be.  “Patients were always urged to take more fat,” is how this was described in 1930 by the Harvard physician Elliot Joslin, who was then, far and away, the most influential diabetes authority worldwide. “At one time my patients put fat in their soup, their coffee and matched their eggs with portions of fat of equal size. The carbohydrate was kept extraordinarily low….”

This thinking only changed in the years before World War I, when Joslin embraced and disseminated the idea promoted by a Harvard colleague, Frederick Allen, that diabetic patients, still without insulin, were best served if they were semi-starved—avoiding carbohydrates and fat. In short, patients suffering from a disease in which one characteristic symptom is ravenous hunger would be treated by making them go even hungrier than otherwise. The approach was unsurprisingly controversial. Joslin and others, though, came to believe they could keep their young Type 1 patients alive longer with Allen’s starvation therapy, even while the high fat, animal-based diet seemed more than adequate for their older Type 2 patients. Allen’s starvation therapy was in turn challenged between 1920 and 1923, when University of Michigan physicians Louis Newburgh and Robert Marsh reported in a series of articles that it was simply unnecessary, that even young patients with severe diabetes could thrive on the high-fat, carbohydrate-abstention approach if properly administered. By then, though, it was too late.

Insulin therapy had arrived in the winter of 1922. It launched what medical historians would call a “therapeutic revolution,” as close as medicine had ever come, and maybe ever has, to a miracle. Patients, often children, on the brink of death, horribly emaciated by the disease and the starvation therapy, would recover their health in weeks, if not days on insulin therapy. They were resurrected, to use the biblical terminology, which physicians of the era often did.

Diabetes specialists realized that insulin therapy was not a cure of the disease, but it allowed their patients to metabolize carbohydrates and held the promise of allowing them to eat whatever and however they wanted. “Were I a diabetic patient,” wrote Frederick Banting in 1930, by then a Nobel Laureate. “I would go to the doctor and tell him what I was going to eat and relieve myself of the worry by demanding of him a proper dose of insulin.”

That thinking, for better or worse, has governed diabetes therapy ever since.

While diabetes specialists still had no conception of the long-term complications of living with diabetes—the damage to large and small blood vessels that results in heart disease, strokes, kidney disease, neuropathy, amputations, blindness, dementia—they would advocate for ever more liberal carbohydrate diets and ever higher insulin doses to cover them. Patients would be taught to count the carbohydrate content of each meal, but only so they could properly dose their insulin. Diets would be prescribed, and still are, to allow for the drugs to be used freely, not to minimize their use. Patients, in turn, were allowed to eat anything, which physicians assumed they would do anyway.

Close-up looking over shoulder of woman checking her diabetes management app on her smartphone.
A woman taps the screen of her diabetes management app as she views her blood glucose levels. Matt Harbicht/Getty Images

Whether the patients lived longer, healthier lives because of it, would never be tested.  As diabetes specialists began to understand the burden of the disease they were treating, the wave of microvascular and macrovascular complications that set in after 10 or 20 years, they would rarely, if ever, ask the question, whether these complications were mitigated by their dietary approach or perhaps exacerbated by it. They would only test drug therapy.

In 1971, the American Diabetes Association institutionalized this philosophy with dietary guidelines that would commit the organization to this approach ever after: diabetic patients would be told to restrict dietary fat—by then thought to cause heart disease—rather than carbohydrates, the one macronutrient they could not metabolize safely without pharmaceutical help. “Medical Group, in a Major Change, Urges a Normal Carbohydrate Diet for Diabetics,” was the headline in The New York Times. By taking the ADA’s advice, diabetic patients would trade off blood sugar control for cholesterol, assuming this would prevent heart disease and lengthen their lives. While the guidelines explicitly acknowledged that the ADA authorities had no idea if this was the right thing to do, the advice would be given anyway.

Read More: Why You're Not Losing Weight

By 1986, the ADA was recommending diabetic patients get “ideally up to 55-60% of total calories” from carbohydrates, while researchers led by the Stanford endocrinologist Gerald Reaven had established that such a diet was almost assuredly doing more harm than good. That same year, the NIH held a “consensus conference” on diet and exercise in Type 2 diabetes. The assembled authorities concluded that, at best, the nature of a healthy diet for diabetes remained unknown. The conference chairman, Robert Silverman of the NIH, summed the state of affairs up this way: “High protein levels can be bad for the kidneys. High fat is bad for your heart. Now Reaven is saying not to eat high carbohydrates. We have to eat something.” And then he added, “Sometimes we wish it would go away, because nobody knows how to deal with it.”

The modern era of the diabetes-diet relationship began 25 years ago, with the awareness that the nation was in the midst of an obesity epidemic. Physicians, confronted with ever more obese and diabetic patients and the apparent failure of conventional advice—eat less, exercise more—suggested instead the only obvious options, the approaches suggested by popular diet books. Many of these—Dr. Atkins’ Diet Revolution, Protein Power, Sugar Busters—were touting modern incarnations of Rollo’s animal diet.

The Diet Trials

The result was a series of small, independent clinical trials, comparing, for the first time, the conflicting dietary philosophies of a century before. Is it better for patients with Type 2 diabetes, specifically, to avoid dietary fat and, if they’re gaining weight, restrict total calories (both carbohydrates and fat), or will they do better by avoiding carbohydrate-rich foods alone and perhaps entirely? The earliest trials focused on treating obesity, but many of the participants also struggled with Type 2 diabetes. In 2003, physicians at the Philadelphia VA Medical Center published the results from the first of such trials in the New England Journal of Medicine: patients with both obesity and diabetes counseled to eat as much food as they desired but to avoid carbohydrates, became both leaner and healthier than patients counseled to eat the low-fat, carbohydrate-rich, calorie-restricted diet prescribed by both the American Heart Association and ADA. The numerous trials since then have concluded much the same.

Among the profound assumptions about Type 2 diabetes that these trials have now challenged is that it is, indeed, a progressive, degenerative disorder. This may only be true in the context of the carbohydrate-rich diets that the ADA has recommended. In 2019, researchers led by the late Sarah Hallberg of the University of Indiana, working with a healthcare start-up called Virta Health, reported that more than half of the participants in their clinical trial were able to reverse their type 2 diabetes by eating what amounts to a 21st century version of Rollo’s animal diet or the Newburgh and Marsh approach. They were able to discontinue their insulin therapy and all but the most benign of their diabetes medications (known as metformin) while achieving healthy blood sugar control. A third of these patients remained in remission, with no sign of their disease, for the five years, so far, that their progress has been tracked.

As for Type 1 diabetes, in 2018, a collaboration led by the Harvard endocrinologists Belinda Lennerz and David Ludwig reported on a survey of members of a Facebook Group called TypeOneGrit dedicated to using the dietary therapy promoted by Dr. Richard Bernstein in his book Dr. Bernstein’s Diabetes Solution. Bernstein’s approach requires patients to self-experiment until they find the diet that provides stable healthy levels of blood sugar with the smallest doses of insulin. Such a diet, invariably, is very low in carbohydrates with more fat than either the ADA or AHA would deem healthy. Both youth and adults in the Harvard survey maintained near-normal blood sugar with surprisingly few signs of the kind of complications—including very low blood sugar, known as hypoglycemia—that make the life of a patient with Type 1 diabetes so burdensome. The TypeOneGrit survey, Lennerz said, revealed “a finding that was thought to not exist. No one thought it possible that people with type one diabetes could have [blood sugar levels] in the healthy range.” This does not mean that such diets are benign. They may still have the potential to cause significant harm, as Lennerz and Ludwig and their colleagues made clear. That, again, has never been tested.

One consequence of the diabetes associations embracing and prescribing a dietary philosophy in 1971 that has only recently been tested is that we’re back to the kind of situation that led to the evidence based medicine movement to begin with: enormous variation in therapeutic options from physician to physician and clinic to clinic with potentially enormous variations in benefits, harms and costs.

Even the ADA advice itself varies from document to document and expert panel to expert panel. In 2019, for instance, the ADA published two consensus reports on lifestyle therapy for diabetes. The first was the association’s consensus report on the standard of care for patients with diabetes. The authors were physicians; their report repeated the conventional dietary wisdom about eating “vegetables, fruits, legumes, whole grains….” It emphasized “healthful eating patterns”, with “less focus on specific nutrients,” and singled out Mediterranean diets, Dietary Approaches to Stop Hypertension (known as the DASH diet) and plant-based diets as examples that could be offered to patients. This ADA report still argued for the benefits of low-fat and so carbohydrate-rich diets, while suggesting that the “challenges with long-term sustainability” of carbohydrate-restricted eating plans made them of limited use.

Three months later, the ADA released a five-year update on nutrition therapy. This was authored by a 14-member committee of physicians, dietitians and nutritionists. Among the conclusions was that the diets recommended as examples of healthful eating patterns in the lifestyle management report—low-fat diets, Mediterranean diets, plant-based diets and the DASH diet—were supported by surprisingly little evidence. In the few short-term clinical trials that had been done, the results had been inconsistent. As for carbohydrate-restricted high fat eating patterns, they were now “among the most studied eating patterns for Type 2 diabetes,” and the only diets for which the results had been consistent. “Reducing overall carbohydrate intake for individuals with diabetes,” this ADA report stated, “has demonstrated the most evidence for improving glycemia [high blood sugar] and may be applied in a variety of eating patterns that meet individual needs and preferences.”

Physician awarenessof the potential benefits of carbohydrate-restriction for Type 2 diabetes, meanwhile, still often comes from their patients, not their professional organizations. In the United Kingdom, for instance, David Unwin, a senior partner in a medium-sized practice began suggesting carbohydrate-restricted high fat diets to his patients in 2011, after seeing the results in one such patient who chose to do it on her own and lost 50 pounds. When results of her blood tests came back, says Unwin, they both realized that she was no longer suffering from diabetes. Both the weight loss and the reversal of diabetes were unique in Unwin’s experience. After reading up on the burgeoning literature on carbohydrate restriction, Unwin began counseling his diabetic patients to follow a very-low-carbohydrate, high-fat eating pattern. In 2017, the UK’s National Health Service awarded Unwin its “innovator of the year” award for applying a 200-year-old approach to diabetes therapy, as Unwin says, that “was routine until 1923.” Unwin has now published two papers documenting the experience in his medical practice. As of last year, 20 percent of the clinic’s diabetic patients—94 in total—had chosen to follow this restricted dietary approach and put their Type 2 diabetes into remission.

If the diabetes community is to solve the formidable problems confronting it, even as drug therapies get ever more sophisticated, it will have to accept that some of its fundamental preconceptions about diabetes and diet may indeed be wrong. As it does so, it will have to provide support for those living with diabetes who decide that what theyhave been doing is not working. Some patients, when confronted with the choice between following a restricted eating pattern that seemingly maximizes their health and wellbeing or eating whatever they want and treating the symptoms and complications with drug therapy, will prefer the former. For those who do, the informed guidance of their physicians and diabetes educators will be  invaluable.

When I interviewed individuals living with Type 1 diabetes, among the most poignant comments I heard was from a nutrition consultant diagnosed in 1977 when she was eight years old. She told me that she finally had faith she could manage her blood sugar and live with her disease when she met a physician who said to her “What can I do to help you?” That’s what changed her life, as much as any technology or medical intervention. In the context of the dietary therapies we’re discussing, that requires practitioners who are themselves open-minded and willing to spend the necessary time and effort to truly understand an approach to controlling diabetes that is, by definition, unconventional and, in Type 1 diabetes, still lacking clinical trials that test (or testify to) its safety and efficacy. Easy as it is for physicians to continue believing that what they should be doing is what they have been doing, they do not serve their patients best by doing so.

Adapted from Gary Taubes' new book Rethinking Diabetes: What Science Reveals About Diet, Insulin and Successful Treatments

Tue, 02 Jan 2024 22:00:00 -0600 en text/html
Dr. Vijay Naik, Owner Of Survivors Exam Preps, Reviews The Best Ways To Study For The USMLE Exam

(MENAFN- EIN Presswire) Dr. Vijay Naik, Owner of Survivors Exam Preps, Reviews the Best Ways to Study for the USMLE Exam

BOSTON, MA, UNITED STATES, January 4, 2024 /EINPresswire / -- Dr. Vijay Naik, founder of Survivors Exam Prep, is a medical professional who has made it his mission to prepare and support aspiring doctors and physicians. With a deep understanding of the rigorous journey that lies ahead for these students, Dr. Naik founded Survivors Exam Prep to offer personalized guidance and mentorship. His program has been developed based on reviews and feedback from current and previous students, ensuring that the curriculum is tailored to their needs. Dr. Naik's dedication to helping students successfully pass their USMLE exam is backed by his own experiences and the challenges he faced on his path to becoming a doctor. With Survivors Exam Prep, students can feel confident that they will have the support and resources they need to thrive in their medical careers.

Dr. Vijay Naik has reviewed his previous students' success and compiled three essential tips to help them pass the exam with flying colors.

Understand the fundamental reasoning behind all medical information. Dr. Naik advises that by comprehending where terms come from and their function that serves a bigger purpose, students can apply the knowledge in a more effective and memorable way.
Pay attention to current medical information as medicine is an ever-evolving field, and it's crucial to stay updated.
Invest in joining a study program such as Survivors Exam Prep. This program offers access to the exact course material, one-on-one help, and access to all the questions students may have.

Dr. Vijay Naik's tips may make the difference between success and failure for USMLE Exam takers.

In a recent review a previous student said,

“Dr. Naik does a great job at explaining and teaching the toughest and biggest concepts in medicine. He drills you throughout the course to ensure you retain these high-yield concepts. He is a wizard when it comes to breaking down questions, and a large part of why this course is so special is the test-taking skills and principles of management that he drills into you during the course. The combination of understanding the big concepts in GI, NEURO, CARDIO, RESP, and OBGYN to name a few, coupled with the test-taking skills is what helped to boost my exam score by over 20 points.”

Developing a deep and thorough understanding of medical terminology is essential for anyone pursuing a career in the healthcare industry. Fortunately, Dr. Vijay Naik offers some valuable tips for students, including the importance of consistent quizzing and testing. It's not enough to simply memorize medical terms; students must also understand how to apply them in real-life situations. By taking the time to quiz themselves and ask questions, they can develop a deep knowledge of the subject matter. Additionally, Dr. Naik also teaches test-taking skills that can help reduce stress and ensure proper time management during rigorous exams like the USMLE. With these tips in mind, students can feel confident and well-prepared as they move forward in their healthcare careers.

Dr. Naik is a committed and dedicated medical professional who has made it his mission to support aspiring students in their journey to becoming successful medical practitioners. With access to a wealth of high-quality resources and up-to-date information, Dr. Naik utilizes a personalized approach to ensure that students have the tools and skills they need to succeed. His Survivors Exam Prep program focuses on the unique needs of each candidate, providing essential practice materials and personalized study plans. What's more, Dr. Naik's commitment to staying up-to-date with the latest medical industry trends through updated lessons and a supportive community makes his program a trustworthy choice for anyone preparing to take the USMLE. His dedication, perseverance, and unerring belief in his students' potential make him an exemplary leader and mentor to aspiring medical professionals.

Jon Smith
News Live
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Wed, 03 Jan 2024 18:22:00 -0600 Date text/html
Even Good Health Insurance Is Bad, Or: How I Got Top Surgery With A Family History Of Breast Cancer

At the beginning of this year, I started the logistical process of getting top surgery. I'd been mulling it over since 2016 but put off the decision to pursue other more pressing things, like gaining full-time employment, starting therapy, and buying vintage animal tees on eBay. As the years passed and the animal tees became increasingly oversized, top surgery felt increasingly like an inevitability, but I never felt stable enough to start the months-long process of convincing Big Healthcare to go splitsies with me on lopping off my knockers.

Like many other media workers, my history of health insurance is chaotic and disjointed, due to the fact that I've never had a job for longer than two years. My internships offered me no health insurance, nor did my six-month fellowship. When I was laid off during the pandemic, I lost health insurance and had to pay an exorbitant fee for COBRA coverage that swallowed most of my unemployment. It was exhausting to constantly find new doctors each time I switched jobs and insurances, and many of these new doctors kind of sucked. My healthcare dread only increased as I started medically transitioning; I stopped going to some doctors altogether until I found explicitly trans-friendly providers in my network. I didn't go to the gynecologist for three years because I simply couldn't find one. But then by some act of divine intervention, I became a blogger, recovered from burnout, and realized I couldn't put it off any longer. And, thanks to my comrades, I had health insurance that was good!

My actual top surgery experience was largely great for what is almost universally a protracted bureaucratic process, in part due to my privileges. I have health insurance and live in a big city with lots of surgeons and some healthcare providers who respect trans people. I have a partner who took amazing care of me as I recovered. And the surgery I got happens to be the most common gender-affirming surgery, which meant there were many helpful guides out there that explained how to get it and how to recover. But these guides are often too broad to capture the individual, often extremely annoying experience of what can feel like threatening your healthcare at knife-point to actually do what it is supposed to do. The hardest part of my experience was navigating a slew of extra hurdles necessitated by my family's strong history of breast cancer and I found nary a guide that helped me understand that process. So I decided to write one, and here we are!

March: Even though I was still racked with anxiety about whether I really wanted top surgery, I had already chosen a dream quasi-celebrity surgeon and ideal recovery season (spoiler: people who don't want top surgery don't do these things). I called the office of the famous surgeon and made an appointment for the earliest consultation they had, which was more than a year away. And that was just for the initial appointment, not the actual surgery! Still, I was so set on this famous surgeon I figured I wouldn't mind waiting, especially as I figured out if I really wanted surgery.

May: There's nothing like setting a date to make you realize not only do you want it, you want it right now. I'd heard through the trans grapevine that if you called the famous surgeon's office every few weeks, you could get moved up on the waitlist, so I tried doing this once and was told, nicely, to stop. They also told me this surgeon did not take my insurance plan, which bummed me out more than it should, and I took a month off from the process to be sad.

June: I finally looked at the list my insurance provided me of surgeons in the area who were in network for me, and I recognized one of the names on the list: Keith Blechman. His practice had a website that used a lot of ™s and that spooked me, because I figured I'd want the standard top surgery, nothing too unique or innovative. I didn't even think he'd be in-network because he is bicoastal and runs a private practice, which altogether seemed too fancy for my good insurance. But now, those ™s appeared increasingly attractive. Why shouldn't I have the fanciest surgeon insurance can buy? On June 30, I had a call with a patient coordinator, and she scheduled me for an in-person consultation with bicoastal Dr. Blechman on July 27.

July: My consultation was great and normal, and Dr. Blechman was not only nice, but also wearing beautiful jeweled-color loafers. At one point in our meeting, as we were discussing the eventual placement of my nipples, he pointed to his own nipples under his shirt without even looking down. He'd found them on the first try! Later that day I'd try to find my own nipples without looking, and I was way off. Here was a man who really got nipples, which felt like an auspicious sign.

At the end of the consultation, when he asked if I had any questions, I asked a slew of small ones and then the big one I was dreading. I had a family history of breast cancer, and asked if the surgery would still be advisable. He asked who, and how old, and I realized I had no idea. I just knew my grandma was diagnosed, had a mastectomy, and went into remission. I took a blind stab at her age. "In her fifties or sixties?" I said, realizing I should have checked this before the appointment. He asked if any other relatives had been diagnosed—what about my mother? "Not that I know of," I said, and he told me not to worry. Breast cancer was common cancer, he said. I should only worry if multiple relatives had been diagnosed, or one at a young age. He told me I could always get tested to see if I had a genetic risk for the disease, and if I were positive, he'd refer me to a cancer surgeon.

I left the appointment and called my mom. I hadn't planned on telling my parents about top surgery until after it happened, but I figured I'd ask in a general way. She told me she'd never wanted genetic testing, because she didn't want to know if she had either of the two main breast cancer genes and the dread that might come with that knowledge. I told her my doctor said I probably didn't need the test, given that Grandma was the only one in our family who was diagnosed.

"That's not true," she said. She followed up with a breast cancer age timeline. My grandma: 41. My grandma's sister: 43. My grandma's mom: 56. My heart sank. I texted my surgeon's office and they referred me a nurse at the breast surgery center. My appointment for genetic testing was in two weeks.

Early August: About 10 percent of breast cancers are hereditary, passed down through mutations in certain genes. People of all genders who carry mutations in the tumor-suppressing genes BRCA1 or BRCA2 face a higher risk of cancer. In people assigned female at birth, this risk increases the chance of breast and ovarian cancer, as well as several additional cancers. In people assigned male at birth, these genes increase the risk of breast cancer and prostate cancer. The guidelines for who should get tested have changed over time, but if you are over 18 and have any close relatives who were diagnosed with breast cancer at a young age, check them out. This is all stuff I had learned in advance of my appointment, but, of course, all of the "what ifs" gave me no more insight into my own personal risk.

When I arrived at the medical complex for my appointment, I said that I was here for the breast imaging center and the security guard directed me to orthopedics, presumably because I did not appear to be someone who had breasts. Tricked 'em! I thought as I wandered aimlessly around various floors before I found the breast imaging center. The waiting room was casually serene, with a soundtrack of Debussy-esque piano and a large television playing Diners, Drive-Ins and Dives in hushed tones.

Although my surgeon had recommended the specialist I was about to meet, I was nervous because I had been "ma'am"ed on the phone and at the front desk of the breast imaging center (and would later be "ma'am"ed by the person who drew my blood). But my practitioner Jenna proceeded to give me perhaps the single best medical experience of my life. She made a conversation that would seem inherently discomfiting—talking to a transmasculine person about their risk of breast cancer and physically examining their chest—effortlessly affirming. She told me her team would take either blood or saliva to send out for genetic testing today, and I chose blood, as I'd just downed a Dunkin' iced latte, a beverage that seemed powerful and burnt enough to sabotage my DNA.

You might be thinking—masculinizing top surgery takes out the breast tissue, so wouldn't that mean no more risk of breast cancer? It appears to reduce risk, but not every top surgery is a mastectomy, a procedure where all breast tissue is removed—from the armpit to the clavicle. A mastectomy often has the effect of a concave chest and often also removes the nipple. A top surgery that does not involve a full mastectomy will leave some breast tissue for aesthetic reasons, meaning it is still possible to develop breast cancer in the tissue left behind.

Jenna also gave me a physical exam and noted my breast tissue is "extremely dense," which both increases cancer risk and makes it harder for physical exams and mammograms to detect breast cancer. This, combined with my family history, meant that Jenna recommended I get a mammogram, an ultrasound, and an MRI to make sure I was cancer-free before surgery, regardless of the results of my genetic test. If all went well, I would start seeing her every year for a physical exam to check my new chest for anything suspicious. I am 29, and Jenna told me people with my risk of breast cancer are recommended to start screening with yearly MRI and mammograms when they turned 30. I realized I wouldn't have known my risk or when and how to start these preventative screenings had I not been planning to yeet the teat. Transexuality: It can help save your life!

Late August: I am an anxious person, and my days were now clouded by the fear not just of my impending genetic results but also of entering the Tube of Fear, or what others call an MRI. How I dreaded the tube! I have claustrophobia, so Jenna prescribed me two of the tiniest pills I've ever seen for anxiety. I did a test-run of the pill and a mindfulness exercise I practiced with my therapist to prepare for my MRI on Aug. 17. But a few days before I was to enter the tube, Jenna called me to let me know my insurance had denied the MRI on the grounds that it was not medically necessary. I freaked out! But Jenna was calm and told me she would appeal the decision, and I should reschedule the MRI for two weeks from now.

Sometime in the next week, Jenna called me back with my results of my genetic testing—negative for both BRCA1 and BRCA2!—I was flooded with relief and gratitude. But the Tube still waited for me.

September: This was a month of continued healthcare dread. Jenna called to let me know United Healthcare told her they did not receive my practitioner's appeal letter, so they made her resubmit one, delaying the process. When they finally did receive it, they denied it again, this time through a third party company named eviCore—non-coincidentally a single letter away from EVILCore—whose entire purpose seems to be denying patients care. EviCore sent me a letter explaining why I, greedy beggar, far too healthy for my own good, did not deserve something as wanton and frivolous as an MRI. Luckily, this drawn-out process had essentially cured my fear of MRIs. Now, I daydreamed about the idea of the tube, cramped and sterile and full of magnets. Put me in, coach, please!

Jenna told me she would try a peer-to-peer review, a conversation between her and a physician from my insurance in which she would plead my case with fire and fury and ample medical evidence. Another week passed, and then ... success! Jenna had wrangled approval. One Friday morning I took my anti-anxiety pills, got my chest pulled and squeezed by the acrylic panini press that gives out mammograms and then went inside the Tube of Fear, which clanged so much it felt like being inside a Kraftwerk song. To celebrate the MRI, my partner and I went to Dave & Buster's and rode fake motorcycles in a racetrack called "Nepal Extreme" that I believe was designed by the same person who made the Panera death lemonade.

October: The results started rolling in. My extremely dense chest remained extremely dense but was thankfully looking normal, and Jenna called to clear me for top surgery. Nice!

November: I got top surgery. Nice!

December: When you get top surgery, the tissue they remove, such as skin, fat, and tissue, is sent to pathology to check for cancer, and my surgeon's office confirmed my samples were benign. Nice!

My next appointment with Jenna is in February, where she'll examine my new chest to establish a baseline of what it feels like when everything is normal, and I'll do this every year to stay on top of my risk. Just as in many aspects of trans healthcare, researchers are still figuring out best breast cancer screening practices for people who have gotten masculinizing top surgery or are on testosterone hormone therapy. And trans women who have been on hormone therapy are at higher risk of developing breast cancer. So many trans people are left to investigate their own risk and navigate the twisted system of American healthcare on their own. My story is very specific, but I hope that the more stories that are out there help people become stronger advocates for their own health, because if I've learned anything from having and not having health insurance, it's that sometimes no one is looking out for you but you. And if any healthcare professionals are reading this, Diners, Drive-Ins and Dives is genuinely the most calming video one could play in a room full of people awaiting the Tube of Fear.

Tue, 02 Jan 2024 04:01:00 -0600 en text/html
Matthew Perry’s ketamine OD prompts questions about its use for mental illness

The death of actor Matthew Perry in October from ketamine has prompted new concerns and scrutiny focused on unapproved uses of the drug.

Ketamine is used as an anesthetic in hospitals, where it has a long history of safe usage. It also has been abused as a recreational drug. Most recently, it has shown promise as an alternative treatment for unusually difficult cases of mental illnesses, including depression, anxiety, post-traumatic stress disorder and obsessive-compulsive disorder.

Although it’s not FDA-approved for psychiatric illnesses, doctors can legally prescribe it as an off-label treatment.

Meanwhile, a pandemic-era waiver allows doctors to prescribe ketamine via telemedicine without an in-person exam. Some patients receive ketamine at clinics or at home in the presence of a therapist, and some use it unsupervised at home.

Perry battled alcohol and drug addiction for all of his adult life. He was open about his struggles, detailing his dozens of treatment stays and the profound toll of addiction on his health.

Perry, 54, had been getting ketamine infusions legally from a clinic to treat depression. However, an autopsy determined the ketamine found in his body after his death on Oct. 28 couldn’t have been from his most recent known treatment, because too much time had passed, according to The New York Times, which reviewed the autopsy report.

While the Los Angeles medical examiner ruled that ketamine was the primary cause of his accidental drowning in a hot tub, other contributors included heart disease and buprenorphine, which is commonly used to treat opioid addiction and sometimes as a painkiller. The ketamine would have accelerated his heart rate while slowing his breathing, according to the medical examiner.

In October — several weeks before Perry’s death — the FDA published a warning about ketamine, citing risks including abuse, increased blood pressure and bladder problems, and risks of using it at home without a health care provider being present.

The U.S. Drug Enforcement Administration was already working on new rules that would limit use of telemedicine to prescribe drugs including ketamine.

Deaths such as Perry’s are considered rare. Still, it has prompted new discussion and concern. The American Society of Ketamine Physicians, Psychotherapists and Practitioners called the star’s death “a wake-up call for ketamine practitioners and the wider medical community to put clear and unified guardrails in place guided by real-world data and medicine,” the Washington Post reported. The non-profit group said it would devise guidelines for using ketamine at home.

According to MedPage Today, psychiatrist Drew Ramsey of Spruce Mental Health in Jackson, Wyoming, wrote on social media: “In clinical settings, ketamine is known for its safety profile. That doesn’t mean it is safe.” Ramsey also “cited celebrity, substance use disorders, character pathology, psychedelic medicine, and concierge medicine” as possible factors in Perry’s death.

Adam Kaplin, chief scientific officer for Mira Pharmaceuticals, cited by The Washington Post, believes ketamine has great potential to help people with psychiatric illnesses said Perry’s death shows “it is a very potentially dangerous practice to give patients access to this at home.”

At the same time, assorted start-ups are working to increase access to ketamine for people with hard-to-treat depression and other mental illnesses.

One point of contention centers on those who believe the drug should be used only in the presence of a trained therapist, and others who say the treatment will be unaffordable for many patients if they aren’t allowed to use it at home, according to the Post.

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Thu, 28 Dec 2023 08:55:00 -0600 en text/html

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