Sleep is important!

Especially to teeagers. Especially when a teenager has diabetes.
from this article:

• Teens with type 1 diabetes who are not adherent to their sleep schedules can experience a myriad of behavioral and psychosocial problems.
• Health care providers need to provide proper sleep therapy counseling for teens with diabetes.
• With proper counseling on sleep, teens begin to have a better quality of sleep, longer duration of sleep, and improved average HbA1C levels.

I'm looking for a receptionist/MA

Lauren is going to medical school! And I'm looking for her replacement. Here is the job description:

Solo practice, busy front desk position. You are the face and voice of this practice! Cheerfulness and enthusiasm are a plus.

This job will include: checking in patients, answering the phone, downloading faxes, scheduling patients, answering emails, voicemails and text messages, and preparing materials for billing. Medical assistant services includes prescription and prior authorization preparation, updating patient medical and medication history, vital signs, and teaching patients how to use glucose meters and sensors.You will communicate closely with the doctor, billing service and business manager. There may be more. A detailed training manual is included at the start.

The work week is Mon-Thu, 8:30 to 6:30. Some days are shorter and the hours are made up one Friday morning a month.

Medical office experience or career college certificate is required. Experience with electronic medical records (EMR) is a huge benefit. You can check out the EMR this practice uses at
https://help.practicefusion.com/s/tutorials

Drug test and background check are both required.
Please send your resume with references.

insulin research trial in Reno: are you interested?

If you are an adult between ages 18 and 65 living with type 1 diabetes you may be eligible to take part in the GAZELLE clinical research trial. This trial will look at an investigational fast-acting insulin to see if it works as effectively as an existing fast-acting insulin already being used to treat diabetes. Trial-related medications, procedures, equipment, and supplies will be provided at no cost; health insurance is not required to participate. Ready to learn more? Please read on.

The GAZELLE trial aims to understand if an investigational medication is as clinically effective as a currently-approved fast-acting insulin replacement, with the hope of improving patient access with more options for treating type 1 diabetes.

We are looking for people ages 18 to 65 who, among other things:

  Have been diagnosed with type 1 diabetes for at least six months   Are on a stable once daily dose of basal Lantus or Toujeo injections and multiple daily bolus NovoLog injections for at least 3 months prior to screening

  Have not used insulin pump therapy or any anti-diabetic medications other than trial-approved insulins within the last 3 months

  Have not used animal insulin (such as from a cow or pig) within the last 2 years

  Have not used a regular immunomodulator therapy within the last year

  Are able and willing to self-monitor blood glucose, including up to 7 times per day on selected days

Please contact me if you are interested in learning more about this clinical trial.

Eat for your gut type

I love this name. I have to give credit to Soraya Petroff, specialty sales representative with Eli Lilly.
This concept refers to research showing that it is the bacteria in your gut, not your blood type or personal genetics, that has the greatest influence on how different foods effect you.
You can find out what foods are more likely to work well with you or fight with you by having your gut biome DNA tested. The results will reveal the foods optimal to your health.
If you want to get this done, got to www.daytwo.com   I hope to have a discount code soon for you so you don't have to pay full price.
I am fascinated with my analysis.  Fat content, protein content a portion size play a big role in the score of a food. the food is scored 1 to 10 with 10 being the best on my blood sugar, meaning it will raise my blood sugar the least. A 1 score is the worst, meaning it will raise my blood sugar the most. fore example, both brown and white rice served plain are 1.5 and 1.4 respectively. So much for the brown rice theory being good for me. But if I prepare the brown rice as risotto with mushrooms, this recipe adds cream and cheese which adds fat and protein. Now the score goes up to 7.6.  The calories go up so I have to watch the portion size. This needs to be kept as a side dish, not an entree. a 4 oz serving is recommended. Another example, I was looking at spaghetti carbonara. Scores ranged from 3 to 7. Why such a wide range? The one with 3 was a 12 oz serving, the one with 7 was a 3.5 oz serving. Simple math. Keep it a side dish, not an entree.

New year and the office changes

New face at the front desk: Lauren Bony, who you may know as my medical assistant, is filling in at the front desk for an indefinite time. She did this for a brief bit a couple years ago and it's taking her a moment to get used to it again. Please be patient as we get back up to speed. Since I don't have her as my MA I now have to do more myself and it's taking a little longer for everything to get done, but it is getting done.
Please pass this on to any of my patients so they all know what's going on.

More bad news about pot and T1 diabetes

Study finds higher risk of diabetic ketoacidosis in pot users.

I love my daily diabetes updates- look what I found!

Study shows efficacy of mDiabetes app in reducing A1C levels

A study in Diabetes Care showed that type 2 diabetes patients who used mDiabetes, a smartphone-based app with an individualized diabetes management algorithm, significantly improved their A1C levels and had more significant A1C reductions below the 7.0% threshold after 24 weeks, compared with those who used a paper logbook. South Korean researchers recruited 172 patients, ages 19 to 80, and found that 31.1% of those in the mDiabetes group experienced a drop in A1C levels below 7.0% without experiencing hypoglycemia, compared with 17.1% among those in the logbook group.

What to do about your basal insulin

You've tried them all; Lantus, Basaglar, Levemir, Tresiba, Toujeo. Either they don't meet your needs or they cause side effects. What is next? An insulin pump! this is by far the most predictable delivery of basal insulin. You get a fine trickle of short acting insulin for 24 hours. The new pumps by Medtronic and Tandem are very high tech. If you want to get in to that I am more than happy to support you. If you want simple insulin delivery then go with the Omnipod. Few buttons to push, no tubing and if you order now you will get the DASH upgrade free when it ships next year.
Diabetes only gets more difficult with age. Modern technology makes it easier.

Is stress shortening your life?

Everybody experiences stressors. How this affects you health and longevity depends on how you respond to stress.  Do a Google search on "does stress shorten your lifespan" and you find an abundance of articles and research demonstrating the relationship between stress response and lifespan.

There is an abundance of resources to help you better respond to stress.  Many are free ans simple to do. But, similar to eating healthy and exercising, they are often forgotten or dismissed.  How you prioritize your health is reflected in what you do to stay healthy.

There is a more thorough approach to stress management called resilience training.  Resilience is the concept of dealing with stress in a positive and healthy way that allows you to bounce back better than you were before the stressor.  You know that muscles get stronger by using them to their maximum. In the same way you can get mentally and emotionally stronger by using stress as mental weight lifting. The challenge is to engage these mental exercises regularly, just as you should be doing with physical exercise.

The methods utilized in resilience training are quick, simple and have been shown to be clinically effective. Pick up a training book on Amazon, find a few exercises that fit with your schedule and personality, and DO IT.

I am planning to offer a resilience training workshop in February 2019. My current plan is to have a 60-90 minute session once weekly for 4 weeks. Start time would be 5:15 pm.  Attendees are expected to purchase the workbook and read the introductory chapter prior to the first class.  I haven't determined the fee yet, or if it will be billable to insurance. I will keep you posted via this blog and my office Facebook page.

Give me the placebo!

But don't tell me I'm getting it. If I know then it won't work.
I was looking at data on a recently-approved medication for migraine prevention. For $600 a month I can reduce my average migraine from 8 per month to 4 per month. The cost-free, side-effect free placebo reduced migraine days from 8 per month to 6 per month. If the placebo doesn't' work I can always switch to the real medication.
The power of placebo is real. Clinical trials routinely include a placebo group. The response rate to the placebo varies depending on what condition is being treated. The 'side effects' on placebo are also interesting, further demonstrating what the power of the mind can do.
I think that the power of placebo frightens off a lot of 'alternative practices' from doing any science to demonstrate safety and efficacy. What if they discover that the recent fad of (insert name of fad) is no more beneficial than placebo?  On the other hand, if I don't know that it's a placebo it might work for me!
Dr. George Lundberg has some excellent articles  that discuss the placebo effect. In 1998 he and Dr. Phil Fontanarosa wrote:
There is no "alternative medicine." There is only medicine:
Medicine that has been tested and found to be safe and effective. Use it; pay for it.
And, medicine that has been tested and found to be unsafe or ineffective. Don't use it; don't pay for it.
And, medicine for which there is some plausible reason to believe that it might be safe and effective. Test it and then place it into one of the other two categories.
This approach sounds simple. It also can be threatening to the multi-billion dollar industry of nutritional supplements. Try it and see if it works? Look back on the comment 'there is some plausible reason...". If it's cheap and harmless it might be worth a try. The likelihood of success depends on your susceptibility to he placebo effect.
There are plenty of trials for a variety of nonprescription therapies showing various benefits and failures. It's not always easy to find these reports. You need to know how to navigate PubMed and Google Scholar and know how to stratify the validity of the studies. As examples, there have been clinical trials for migraine headache using coenzyme Q10, riboflavin and melatonin. The studies weren't sufficiently large enough to garner the attention of the American Headache Society but the data supports at least giving it a try. On the other hand, herbal treatments purported to be useful for headache, including ginger, wood betony, feverfew and vervain, have no actual data. They have the support of history and urban legend. I have no idea what the effectiveness is above placebo.
I recommend the following articles by Dr. Lundberg to round out the discussion:
Accidental genius of homeopathy
Therapeutic (non) touch.

Advanced diabetes management webinar with Medtronic

FREE Diabetes Education for Patients Taking Multiple Shots Daily

FREE Diabetes Education for Patients Taking Multiple Shots Daily.
DATES: First Monday of each month
Location:  Dr. Caruso’s office
Educator:  Lynea Albers MEd, RD, CDE (916) 396-7678 (Omnipod employee)
Call or text to schedule appointment.

Medicare pays for continuous glucose sensors

But...there are a lot of rules. If you want a Dexcom you will order from Dexcom. If you want a Freestyle Libre you need to order through one of their partners.
Here are the rules:

• The beneficiary requires a therapeutic CGM. The beneficiary has diabetes mellitus; and,
• The beneficiary has been using a home blood glucose monitor (BGM) and performing frequent (four or more times a day) BGM testing and records are kept or meter is downloaded for 30 days; and,
• The beneficiary is insulin-treated with 3 or more daily injections (MDI) of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and,
• The beneficiary's insulin treatment regimen requires frequent adjustments by the beneficiary on the basis of therapeutic CGM testing results.
• Within six (6) months prior to ordering the CGM, the beneficiary had an in-person visit with the treating practitioner to evaluate their diabetes control and determine that the above criteria are met; and,
• Every six (6) months following the initial prescription of the CGM, the beneficiary has an in-person visit with the treating practitioner to assess adherence to their CGM regimen and diabetes treatment plan.

Happy to pass this along

Coming Soon! Adult Education Workshop

The Nevada Diabetes Association will be offering an Adult Diabetes Education Workshop in Reno this spring. This workshop will be field trip based one day, every 2 weeks, from February 15th, 2018 to April 26th, 2018.   Please take this anonymous survey so we may provide the best possible workshop for you.  Your feedback will be very helpful in the planning process.     Take this survey

 I am now providing a non-drug treatment for neuropathy, insomnia, anxiety and depression. It is called Alpha Stim. Treatment takes 20-30'. I will have you fill out a neuropathy pain score before and after treatment. These treatments will be $30 per session. I do not bill insurance for treatments alone. If you have a treatment done the same time as your appointment the fee will be included in your office charge. Please call for an appointment. My medical assistant will be providing this service on Tuesdays and Thursdays.
If you want to order one for yourself I will be happy to provide a prescription for established patients only.
http://www.alpha-stim.com/

Live on-line support for T2 diabetes

The American Diabetes Association has a series of live webcasts for T2 diabetes. They are also available as podcasts if you don't have time for the live session. Past sessions are also recorded.
REGISTER TODAY! Visit diabetes.org/experts. Text EXPERTS to 828282 to register for the series.
QUESTIONS? Contact the ADA at 1-855-565-0595 or via email at askada@diabetes.org

Take care of your brain

There are ways to make your brain 'stronger'. This research in 2011 demonstrated visible improvements (on MRI) in brain structure after only 8 weeks of "Mindfulness-Based Stress Reduction".

Mindfulness is a concept that started in the 1970's and has grown steadily since then. It is the opposite of multitasking. you focus your mind on a single thing and actively exclude all other thoughts. In practice it is a form of meditation.

You can do the same thing! What makes it easy is the Muse brainwave sensing headband. This device gives you feedback on your thoughts. When you are focused on a single thing, your breath, you hear gentle sounds and even chirping birds. When you are distracted the wind, waves or rain will get louder as a reminder to focus your thought. 

When you buy this device direct from the developer you get a 60 day money back guarantee. You will need a smartphone or Ipad or Android tablet to run the app for the headband. Check to make sure your tablet or phone has the operating system necessary to run the app.

Too busy to blog

A lot has happened in the last 2 years. Here's a summary.

1. Ariana is in law school. My front desk person is Tammy Manke as of Aug 2017.

2. I have a Certified Diabetes Educator, Josh Quinn, 'on loan' from Medtronic. He is here on the 2nd and 4th Thursday of the month to co-manage people on Medronic/Minimed pumps and those wanting to start on the pump.

3. I have a medical assistant, Kaitlin Shonnard, here each Tuesday and Thursday to get your vital signs, update your medication list and upload your glucose meter or pump. Be sure to bring your meter. She has the app for uploading 26 different meters. 

4. If you need a coach for stress management, see Toni Caruso. The visit will be included with your appointment with me. I also have a device, a Muse headband, that facilitates stress management. You can demo the unit at the office any day I'm open. Bring your smartphone to run the app.

5. I have guest wifi available. Just ask when you're here.

6. I love my Medtronic 670G hybrid closed loop pump. It's reduced my hypoglycemia by 80-90%. Instead of averaging 1-2 h/day under 70 I'm down to 10-15' on the average. I can go days without a low.
7. I have a Facebook page for my office to announce when I'm out of the office, etc. Search For Dan Caruso MD on Facebook to stay up-to-date. Please don't use Facebook to communicate with me about your health care.
8. I also have a Yelp page. I'm not as attentive to it as I am Facebook.

Merry Christmas!

Moana Lane will be my only location for office visits starting Jan 1, 2016

Starting January 1, 2016, I will no longer be a provider at the Renown Diabetes Center. This means changes for my patients at both locations:

      

For my Moana Lane patients: A letter has gone out explaining my new office days and what insurances I will be contracted with starting in 2016. If you have any questions or need to reschedule an appointment, please call the office.

For my Renown patients: My private practice is very small and a major change from the Renown practice. I only have a small refrigerator so I will, unfortunately, not have the room to keep samples as I have been at Renown. This means that I will not be able to provide enough samples to get people through their deductible or doughnut hole.

I do not do the hemoglobin A1c test in the office. I don't have the space or staff to maintain, operate, run quality control and manage inventory for it.  Please go to the lab before your appointment to get it done. You can also go to a health fair lab and order your own A1c if you don't have a lab order. 

I do not have a nurse or an educator or a medical assistant at this office. I am going to miss them dearly.  Unfortunately, this means your refill request may need to wait until the end of the day or if I am out of the office for an extended period of time, it may have to wait until I get back. This is a very important reason to have a primary care provider- to help you get your prescriptions ordered if I am not available. Education will still be available at the Renown Diabetes Center and is also available through Karen Fisher at Nutrition Connection.

Another important service I am outsourcing is influenza vaccine.  Your primary care provider or local pharmacy can help you with your vaccines.

My office policies will stay as they are for the foreseeable future. I understand these are significant differences from the Diabetes Center so please be sure to take all of it into consideration. If these changes are not to the level of care you would like from your endocrinologist, there are several other doctors in Reno who could provide you with the care you need. Please check with your primary care physician or check your insurance provider list.

For ALL my patients: I have officially opened up my 2016 schedule for my Monday through Thursday schedule. If you have any questions regarding scheduling and/or on any of our office changes, please call the office and we can help you. However, also please remember that I am only in the office on Thursday and Friday (excluding Holidays) until the end of the year. Also remember that I only have one receptionist in charge of scheduling. She is getting a high number of calls so if you call during office hours and don’t speak with her, leave a message. It will take her some time to get back to you, but she will return all messages as soon as she can.

you can email me at caruso.patient@gmail.com. Keep in mind this email account is not HIPPA compliant.

Thank you for your understanding and for continuing to utilize me for your health care needs.

change in practice schedule

Beginning August 2015 my office schedule will change and I will be open at Moana Lane on Thursday and Friday.  I will no longer see patients at Moana Lane on Tuesdays starting in August.

I will be working at the Renown Diabetes Center on Monday, Tuesday and Wednesday.  Dr Claude Lardinois works at the Diabetes Center on Thursday.  There is full-time staff including certified diabetes educator nurses and dieticians at Renown.  Phone messages are checked regularly at the Diabetes Center.  You are more than welcome to see me at Renown for your diabetes.

If you do not have diabetes and my new schedule does not meet with your needs I will forward your records to another endocrinologist of your choosing.  Your primary care provider may also be able to treat your endocrine condition. Consider discussing this with your PCP.

Thank you for your understanding.