Photo by Karl Norling.

Summer is upon us, when Manhattanites flee the sweltering heat of the city for the beautiful beaches of Long Island and Fire Island, where woodland creatures, deer, raccoon, mice and opossums wander amidst densely wooded areas, spreading the threat of Lyme disease.
July is peak season for Lyme disease because it’s the time when ticks are most active. Last year, there were more than 5,800 confirmed cases of Lyme disease in New York State. The disease is a serious bacterial infection caused by the bite of the blacklegged deer tick, no larger than a poppy seed. If the bite is left untreated it can lead to memory loss, joint pain, paralysis and, in some cases, heart block. Pregnant women with Lyme disease can miscarry.

Ticks will attach themselves anywhere but tend to seek out the area where the blood supply is the greatest, such as the scalp, armpit or groin. A tick must be attached for 36-48 hours before Lyme disease can be transmitted. Once the tick has fed, the body becomes engorged and the tick falls off. Since the bite is painless, people are often unaware they have been bitten, so it is essential to always check for ticks, especially if you are camping or at the beach.

Lyme disease symptoms fall into three stages: early, middle and late. The early stage occurs three days to one month after being bitten. The person will experience flulike symptoms, including fever, chills, stiff neck, headache, muscle aches and joint pain. The classic bull’s-eye rash can be seen during this time, but not always.

The middle stage occurs one to four months after the bite, with painful and swollen joints as the most common symptom. People experience arthritis-type symptoms that migrate, though the knees are the most affected. An inability to concentrate and facial paralysis can also occur at this stage.

Tommy Hilfiger’s daughter, Ali Hilfiger, herself a designer, was bitten by a tick as a child in Bridgehampton. She spoke last year at a seminar in Sag Harbor about how she suffered for years with leg pains and difficulty concentrating; it wasn’t until she saw a psychiatrist that she made the startling discovery that she had second-stage Lyme disease. Hilfiger now speaks often for A Time for Lyme to bring awareness of how serious this disease is, especially if left untreated.

The late stage of Lyme disease can cause the heart to slow down, causing dizziness, shortness of breath and at times even the need for a pacemaker.

Lyme disease is treatable with antibiotics when recognized and diagnosed early.

When you go outside this summer, here are some safety tips:

• Stay off dunes and away from high grassy areas and wooded areas where ticks breed.

• Wear light-colored clothes and long sleeves and slacks if you are in a wooded area so you can see the ticks.

• Keep you hair pulled back and wear a hat.

• Use insect repellent with 20-30 percent DEET on exposed skin and clothing—10 percent DEET for children—to prevent bites.

• Treat your clothes, especially pants, socks and shoes, with Permethrin, which kills ticks on contact. NEVER use this on your skin.

• Treat your pets with tick solution and check them carefully for ticks before they enter your house.

• Check yourself and children daily for ticks and shower daily to eliminate any loose ticks.

• If you find a tick, use fine tweezers, grasp the head and pull the tick upward, never crushing the body, which will introduce bacteria into your bloodstream. Clean the area with an antiseptic and see your doctor. Try to save the tick for identification.

Now go out and enjoy the beautiful beaches, but be careful.

Dr. Jamie Grifo said because "IVF is more involved, more invasive and more expensive," he usually recommends that infertile couples try intrauterine insemination (IUI) first.

by Laura Shin

Trying to conceive a baby can be a challenging time for some couples, and when it comes to understanding the different fertility treatments that are available, it can be even more stressful.

In vitro fertilization (IVF) is an effective and well-known procedure. It involves removing eggs from the woman’s body, fertilizing the egg or eggs outside of the body and then placing the embryo in the uterus to establish pregnancy.

Though IVF has become much more common since it was first done in the late 1970s, it is still costly and invasive. Because of this, most patients begin with intrauterine insemination (IUI), also known as artificial insemination, said Dr. Jamie Grifo, director of the Division of Reproductive Endocrinology at NYU Langone Medical Center.

IUI is a simple, less expensive procedure that involves injecting sperm into the uterus with a catheter. Grifo explained the benefits and risks of both procedures.

In what situations are intrauterine insemination and in vitro fertilization used?

It’s highly individualized and it depends on a lot of things, including patient age and diagnosis. In general, for patients who have unexplained infertility, IVF is a last resort option, not a first resort option. Depending on the kind of male factor infertility—how low the sperm count, how low the mobility—we offer IUI before IVF.

In general, IUI is done in addition to fertility medicine to improve the odds. The first round of IUI therapy usually involves Clomid, which is a fertility medicine that stimulates ovaries. We usually do Clomid with IUI three to six tries before moving on to IVF.

What is the risk of multiple births with IUI and IVF?

The risk of multiple births comes from the stimulation you use for the ovaries. Clomid, the oral medication used with initial IUI attempts, has a very low multiple pregnancy rate—it has an 8 percent multiple pregnancy rate, and the majority are twins.

Most of the high order multiple pregnancies these days don’t come from IVF, they come from the injectable medications—the stronger fertility medicines—that we use for IVF and with IUI. In those cases, patients make multiple follicles, multiple eggs, and are more at risk.
There was a study done to see what was more cost-effective after three failed Clomid IUI cycles. The question is, do you go right to IVF or to injectable IUI? The conclusion was that it was cheaper and safer, with less risk of multiples, if you went to IVF. Even though IVF is more involved, more invasive and more expensive, the actual cost was lower, and part of the reason was that the multiple pregnancies that occur from injectable IUI eat up a lot of health care dollars, taking care of triplets and quadruplets and beyond. You don’t get those with IVF because you can manage which embryos you put back. I think multiple births will be less and less of a problem as we shift away from injectable IUI cycles and go straight to IVF.

Does insurance typically cover both IUI and IVF?

It depends on the policy. It varies so much, and it often influences patients’ decisions about what to do. A lot of policies cover IUI but don’t cover IVF. Some cover none of it and some cover all of it. But those that cover all of it often require three to six cycles of IUI before covering IVF.

What are the success rates for these procedures?

All of it is age dependent. But in general, if X is the at-home, in-bed pregnancy rate, Clomid IUI is 2X [twice as likely], injectable IUI is 2.1X and IVF is 5X.

Are there any negative effects of trying IUI multiple times?

No. IUI is really simple. It’s like a pap smear in terms of what you experience as a patient. You may feel more cramps when you push the sperm into the uterus, but basically you use a speculum, put a little plastic tube in the cervix and inject the sperm. Injection implies needle, but there’s no needle, just a small tube that goes in the natural opening of the cervix and the sperm is then inserted. It usually takes a few minutes and you’re done.

In what situations might a patient skip IUI altogether and go to IVF?

I think most patients don’t skip IUI. A patient over 40 might, but still, a few months of IUI is usually done because a few months wouldn’t change the outcome. Patients don’t choose IVF right away. If they did, people would get pregnant a lot faster, but there’s always the cost barrier. IVF is much more expensive, usually around $10,000, whereas IUI might be around $2,000, so it’s five times less, but it’s also two and half times less efficient. It’s highly individual. It depends on the patients; that’s why you really need to have a good dialogue with your doctor and talk about the pros and cons of the different options.

Infertility is a disease or condition of the reproductive system and can be present in the woman, the man or both. Certain health conditions and factors, such as age, can affect a woman’s ability to conceive. A healthy 30-year-old woman has about a 20 percent chance of getting pregnant every month, but that percentage drops by age 40, when her chances are about 5 percent each month. Infertility can affect women regardless of age and background.

When you look at the process of conception, it is remarkable that pregnancy happens at all. When a man ejaculates, 200 million sperm are mixed with semen. In most men, only 15 to 45 million of those sperm will be healthy enough to fertilize an egg, and only 400 of those will survive after a man ejaculates. Traveling up the vagina, which is hostile to sperm as well as the toxic environment of the semen, only around 40 of the 400 will reach the vicinity of the egg. Then, only one sperm will be able to drill through the tough layer of the egg to fertilize it, and voilà, a baby is on the way—well, maybe. There are other circumstances that can end the pregnancy.

For sperm to make it to the end goal, three factors come into play: quantity, quality and movement. Conception is a numbers game, so the more semen discharged in an ejaculation, the better. The quality of the sperm—with an oval head and long tail—is important, as is the ability to move quickly through a hostile environment.

Certain factors can create problems for sperm, with the No. 1 problem being temperature. Increased scrotal temperature can interfere with sperm production. If you are trying for a family, avoid hot tubs, saunas and steam baths. Even though exercise is important, bike riding or remaining seated for long periods at a time can interfere with sperm production. Tight-fitting clothes such as briefs or athletic shorts will increase your body temperature, so switch to boxers.

Sperm movement and shape can be altered by smoking and marijuana, cocaine and heroin use. Excessive alcohol consumption can reduce the quantity and quality of the sperm produced. Lubricants, such as KY and skin lotions, will slow down the movement of sperm so they never reach the egg. Certain medications can also contribute to infertility issues, such as calcium channel blockers, tricyclic antidepressants, steroids, chemotherapy and radiation treatment.

For women, infertility issues are more likely structural or age-related problems. Damage or blockage in the fallopian tube caused by inflammation can prevent the egg from moving down to the uterus. The most common cause of this is chlamydia, a sexually transmitted infection that can affect both men and women. Uterine fibroids, tumors in the uterus, and endometriosis, uterine tissue implants growing outside of the uterus, can affect the function of the egg, ovaries, uterus and fallopian tubes.

Another cause of infertility is polycystic ovarian syndrome, in which the body produces too much androgen, a hormone that in turn causes ovulation problems. Pelvic adhesions secondary to pelvic infections, appendicitis, pelvic and abdominal surgery can also impair fertility.

Medications, thyroid problems and cancer treatments can also affect fertility.

Fertility for women starts to decline after age 30, whereas men can maintain their fertility well past 40. For both sexes, it is important to maintain a healthy body. Stop smoking and use alcohol in moderation. A healthy weight is important, but too much exercise can be associated with ovulation problems. A sedentary lifestyle, which can contribute to obesity, can also be a contributing factor to infertility.
For those couples who are infertile, there is still hope. Through in vitro fertilization (IVF), many couples have gone on to have successful pregnancies. Another option that may help that many specialists now recognize is acupuncture.

Mary Sabo, one of the clinical directors at the Yinova Center on 11th Street and Broadway, uses acupuncture to support IVF. “When couples come in to us, we look at their entire bodies and see how they are functioning,” she said. “If they have a diagnosis from their gynecologist or endocrinologist, we can help. If the uterine lining is too thin or if the blood flow to the uterus or ovaries is not ideal, we can increase the blood flow, relax the uterus before transfer in an IVF and help balance the hormones to improve fertility. The leading reproductive endocrinologists in the city are now recognizing the importance of acupuncture.”

If you are experiencing problems with infertility, don’t despair: Reproductive medicine has advanced over the years and it is still possible for you to have a child or, sometimes with fertility clinics, multiple children. Then you can buy one of those double-wide buggies and get a nice house in Brooklyn.

By Dr. Cynthia Paulis

Erectile dysfunction or impotence occurs when a man can no longer get or keep an erection firm enough for sexual intercourse. If this is an ongoing problem, it can be a sign of a serious health condition that needs evaluation, such as heart disease or poorly controlled diabetes. Oftentimes treating the underlying problem can reverse erectile dysfunction, but if it still occurs there are alternative treatments.

Dr. Aaron Katz, chairman of the department of urology at Winthrop University Medical Center, said, “The goal of oral medications is to restore or enhance blood flow to the penis.”

He said Viagra, which comes in three dose levels, works for about four hours.

“It can be very helpful for men recovering from prostate cancer surgery, where the nerves and the blood supply to the penis may have been damaged during the surgical removal of the prostate,” he said. “We typically would use this medication much earlier after the surgery than we had in the past.

“In the past, we had the philosophy of just watch and wait and maybe the blood flow and the nerves will be restored. But some of the more recent studies have shown that if you use these drugs early on…the long-lasting effects can be much greater,” he said.

“Viagra can be used as a bridge and hopefully it will restart, almost like a battery, and then maybe—hopefully—Viagra will not be used for long-term use.”

One of the other well-known drugs on the market is Cialis (tadalafil), which has a much longer-acting component but works in a similar way to Viagra.

What makes this drug unique is that it can work for 36 hours. “It does give you much more spontaneity than Viagra does,” Katz said. “Cialis is known in Europe as the ‘weekender.’ You can take it on a Friday and have sex for the entire weekend.”

Cialis comes in a 20-mg dose, but the company has now come out with 2.5-, 5- and 10-mg doses that can be taken daily.
Both Viagra and Cialis take effect within an hour of taking them. Side effects of both drugs are minimal; some men can develop back pain after taking Cialis, and both medications can cause flushing and headaches. However, they are fairly safe drugs as long as you are not taking them with nitrates, drugs commonly prescribed for chest pain such as nitroglycerin, Nitro-Bid, Nitrostat, Imdur, Monoket, Dilatrate and Isordil.

Other medications that can cause problems with erectile dysfunction meds are blood thinners, alpha blockers for benign prostatic hyperplasia and high blood pressure medication.

A third oral medication is Levitra, which works similarly to Viagra and has a four-hour window.

A recent call to a pharmacist broke down the prices as following. Their best-seller was Viagra, with a six-pill pack costing roughly $135; Levitra was the least expensive, at $10 a pill; and Cialis ranged in price from $134 for the 20-mg pill to $147 for the lower dose of 5 mg, which is taken daily.

Most of these are covered by insurance but according to the pharmacist, Viagra seems to be the one favored by insurance companies.

There are two other, non-oral medications used to treat erectile dysfunction. The alprostadil penis suppository is a small suppository that goes into the opening of the penis and delivers blood flow there. Erections usually begin within 10 minutes and last 30 to 60 minutes. It is not used often because it can cause pain and bleeding in the urethra, along with the formation of fibrous tissue.

Another method is alprostadil self-injection (brand names Caverject, Edex), wherein a fine needle is used to inject alprostadil into the base or side of the penis. The injection will produce an erection that occurs within a few minutes and lasts an hour. Side effects from this method include bleeding, prolonged erection and formation of fibrous tissue at the injection site.

Katz said, “More than 50 percent of [male] diabetics have erectile dysfunction, so this may be very helpful for those patients.”

Testosterone replacement for men with low levels of testosterone have helped some men who are menopausal and experiencing erectile dysfunction.

If medications fail, the patient may have to seek alternative treatments such as a penis pump, a penile implant or blood vessel surgery.

Katz said he has patients in their eighties with very active sex lives. One thing he emphasizes is that “you need to take care of your body. It’s all about flow and cholesterol and preventing arterial plaque that builds up in the heart and the small arteries to the penis. Men who are overweight and want to have sex, they want to take the quick fix, they want to take the Viagra—well, that’s not the answer.

“The answer is to get in shape, work out, do yoga, meditate, be mindful of what we take into our bodies,” he explained. “Eat less fat, less red meat, eat more vegetables and practice more healthy living, do more aerobic exercise—running, jogging, swimming, biking—then you will have a better sex life and you won’t need the Viagra.”

By Joseph Alexiou

Eight years ago Norma Loeb, now 57, was regularly taking her mother, Lillian, to a geriatrician after the 80-year-old Bronx native began experiencing memory loss. The doctor hesitated to diagnose Lillian with Alzheimer’s disease due to her alertness and cognitive abilities. Then he noticed the elder woman’s shuffling and head movements, which were not unlike Parkinson’s—behaviors Norma had noticed for years. More visits to neurologists at Mount Sinai and Columbia Presbyterian caused only confusion until one doctor mentioned the possibility of a disease called Lewy Body Dementia. Norma did the research herself online. “I could not believe that she had every symptom,” she said during a recent phone interview.

Lewy Body Dementia (also known as LBD) is a neural disease characterized by a loss of cognitive abilities and motor control, and is closely related to Parkinson’s disease. The ailment has distinct symptoms—including motor disorders, hallucinations and REM sleep disturbances—however, some of the drugs used to treat symptoms in similar disorders such as Alzheimer’s and Parkinson’s can be dangerous for those with LBD. According to Dr. James E. Galvin, director of the Lewy Body Dementia Center at NYU’s Langone Medical Center, a typical antipsychotic medicine like haloperidol, normally used to treat mental disorders, can exacerbate various cognitive symptoms in patients with LBD and can also cause physical problems to the point of being fatal.

The Lewy Body Dementia Center is the first of its kind to treat LBD in the New York area, having opened in late September of this year. It works closely with the Lewy Body Dementia Association, a national group created to spread awareness and provide information for caregivers. The center provides the most up-to-date testing, analysis and palliative care guidance for those ill with LBD, which currently has no cure.

Over 1.3 million people in the United States are thought to suffer from LBD, yet few have ever heard of the affliction—including doctors. Compare that with an estimated 400,000 people suffering from multiple sclerosis, according to the National Multiple Sclerosis Society, and the approximately one million people in the United States infected with HIV, according to the Center for Disease Control, and it becomes apparent that more efforts need to be made to make people aware of LBD. According to Galvin, who is aided with the data analysis in “Caregiver Burden in Lewy Body Dementias”—a medical study published in several medical journals this past spring and summer (designed by Dr. Steven H. Zarit of Penn State University)—80 percent of LBD patients are misdiagnosed as having other diseases before receiving the proper diagnosis, going through an average of three different doctors.

“On average, it takes a caregiver at least 18 to 24 months before the proper diagnosis is achieved,” Galvin explained. “Before then, nobody knows what’s going on and the caregiver feels burdened, isolated and alone.”

Nowadays, Lillian Loeb lives in her daughter’s Long Island home, and Norma is her primary caregiver. The ride has not been an easy  one—the needs of an LBD patient often change from week-to-week, with caregiving, as Norma describes it, like a full-time job. According to Norma, while she was first learning how to take care of her mother as the illness progressed, she learned more from the website of the Lewy Body Dementia Association (www.lbda.org, formed in 2004) than any doctor.

“They are the only organization that had any information,” Norma said. “They also had an online support group that was very helpful to me.”

After participating in discussions, a woman from the organization’s website asked Norma if she would help to create a monthly support group for caregivers, since there was no support system beyond the website in the tri-state area, or even as far away as Boston. Since 2007, Norma has started two monthly groups, one in Manhattan and one in Long Island. Both groups draw caregivers seeking support from the local population as well as from Westchester County and New Jersey.

“There’s not a person [involved in the groups] who hasn’t been thankful to hear from everybody that they’re not alone, to learn helpful things about their daily caregiving,” Norma said. “It’s so widely undiagnosed, there’s no awareness of it at all. Even GPs don’t know about it.”

Despite the difficulties associated with taking care of a loved one, especially a parent and the role-reversal of parents and children, Norma Loeb has no regrets, calling her choice the “best decision I ever made.” She cherishes the moments when she connects with her mother and the surroundings that allow her to live with a loved one instead of in a nursing home. Norma Loeb tells the members of her support groups to focus on the positive moments of communication—those are the moments they’ll remember.

By Deb Sperling

Sheila Warnock and co-author Cappy Capossela first published Share the Care in 1995 after a group of 12 friends, including the authors, took care of a working divorced mother who was diagnosed with cancer while also raising two teenagers. “We took care of her for three-and-a-half years and figured out a way to do it so that no one had to carry the entire load,” Warnock explains. They later taught other groups how to do what they did. “We really understood the importance of what we had done, because we felt major transformation in the person, a sense of, ‘We can do this.’”

Later, Capossela herself was diagnosed with a terminal brain tumor, as was her father. Warnock organized a Share the Care group to help her, and she and 33 friends took care of her for the next 10 months until she passed away. “It was a pretty trying experience because she, during this course of 10 months, lost her ability to speak, to write, to talk or even move without help,” Warnock says. “That is what prompted me to create our nonprofit organization ShareTheCaregiving. I built the website, and updated the book—the second edition was published in 2004.” An e-book version of Share the Care will be released Dec. 21.

Since the time Warnock created the ShareTheCaregiving organization, she also developed a full-day training workshop for health professionals and clergy, which is accredited by the New York State Nurses Association. “The reason for wanting them to know and understand Share the Care was to reach the most caregivers, because caregivers are so busy, so overwhelmed, so exhausted, they don’t even think about looking for help.”

Q: Are there any particular problems with sharing caregiver responsibilities in New York City?

Sheila Warnock: It’s tough in New York because New York is like 100 cities or towns. But the whole idea, the whole model, was born here in New York City, so it came out of total necessity.

I have done a number of trainings in the city, but it takes time to get it really launched here. It’s a grassroots kind of thing, and once people have been in a Share the Care group, once people have been touched by this and participate in a group, they go on and help other people who need help. They’ll recommend Share the Care; they’ll send the book to somebody. It’s been a lot of word of mouth. Still, the professionals and clergy are important because they see people and families struggling to hold it together just about every day. So it’s about introducing it to them. It takes a bit for the family and the care recipient to accept help. That’s the biggest stumbling block: to realize that the quality of life can be so much better if they are not doing every single errand, job, meal themselves.

So the idea of a Share The Care group is people who know you, helping you, because they know and care about you, so they’re gonna go really far to do everything they can. The other idea is that your group of friends will take care of the whole family.

New York is a challenge, because there’s so much here. But New Yorkers have great hearts, so this is where it was born, and I’m sure it’s gonna stay.

What sort of groups have been formed for what sort of issues?

Share the Care has been used for every known illness, disability, terminal, temporary situations—even for multiple births. We had people in Texas taking care of quadruplets. It could also be used to help older people who are in pretty good shape to stay in their homes, if they had some assistance. Because the population is rapidly growing, the amount of value that caregivers provide… they are holding a long-term care system in place because they’re doing all this work for free.

What is the additional value of Share the Care given the situation in our country with health care and insurance issues?

It empowers the caregivers to take charge. If you wait around for somebody else to figure out how to take care of your loved one, forget about it. There are so many wonderful programs that are being cut because of lack of funding or cutbacks in staff. There aren’t enough professionals to do everything.

Because we’re all separated by technology—we’re separated because of fractures in the family, people are divorced; they move away; they retire; they move to another place—we really have to get back to helping each other, as a way of life.

On the website, sharethecare.org, there is a form where people can submit stories about their group. What has been the response to that?

I used to get a lot of feedback on that, but I don’t so much these days right now. The way I learn now about some groups is when they download our forms, and they register. So I know what kind of illness they’re dealing with and what state or country they’re located in and the size of groups can vary—eight people to over 100.

Older adults don’t want to have tons of people, they only want certain people around them, but there are still ways for those inner circle people to be supported by outer circle people. It works for just about everything: It’s a skeleton and you build it to work for your situation, and there’s lots of ideas or suggestions that came from groups around the country.

We’re also building a way for groups to work online. That’s in the works, and should be up next year. It’s going to be a way for groups to communicate, schedule and use our forms and systems online. There are already tools on the web that people can use to do schedules, but we operate a little differently. That’s why it’s important for us to have our own management tool. Those other systems don’t offer any guidance for how to get started, how to stay motivated or what to do when problems arise. Share the Care offers a full lifecycle for the group. It’s really written to the group because people are also going through their own emotions, and looking at their own lives when they’re taking care of someone as a friend.

By Joseph Alexiou

This past July, the New England Journal of Medicine released a study showing that people with Type 1 diabetes—the metabolic disease with high levels of blood sugar caused by the body’s inability to produce insulin—were able to more effectively reduce their levels of blood sugar using insulin pumps than the traditional self-injection method.

According to the report, authored by Richard M. Bergdenstal, William V. Tamborlane, Andrew Ahmann and others, the level of glycated hemoglobin—the scientific name of the blood sugar test often called the A1C by most diabetics and endocrinologists—in
485 patients aged 7 to 70 was reduced on average from 8.3 percent to 7.5, a much more acceptable level. Twenty-seven percent of pump-therapy patients were able to reduce their A1C to under 7 percent, which is essentially the Holy Grail of acceptable sugar levels for Type 1 patients. Only 10 percent of self-injecting patients could achieve this.

So why is it, with 700,000 New Yorkers affected by diabetes, we don’t hear more about the use of insulin pumps versus traditional injection methods? Are the pumps not as effective as studies claim, or are we only now starting to benefit from the efficacy of these marvels of modern medical technology? “The technology, in general for patients with diabetes, has improved dramatically in the last 10 years,” said Dr. Joel Zonszein, a director of the Clinical Diabetes Center at the Albert Einstein College of Medicine—a division of
Montefiore Medical Center in the Bronx. “But I always say that the pump will be only as good as the person who’s using it. Patients think, ‘OK I get a pump, an automatic pilot.’ But really, they are very labor intensive.”

Insulin pumps are small electronic devices made up of a syringe and a motor-driven screwdriver. The patient attaches the pump to a catheter, which he or she has inserted into his or her skin using a needle, allowing a continuous delivery of fast-acting insulin. This plastic tubing must be changed every three days, but the constant stream of insulin allows for patients to easily adjust their level of intake for meal portions, exercise and other factors that longer-term self-injection insulin make more complicated. And the amount of needle sticks, which is usually three to five injections daily by patients who use the traditional method, are much reduced.

While diabetes experts like Dr. Zonszein and Dr. Daniel Lorber, an associate professor at the Weill-Cornell Medical and an instructor at the New York Hospital in Flushing, Queens, agree that there are advantages to using the insulin pumps, “There’s no such thing
as treatment without negatives,” said Dr. Lorber in a recent phone interview. “Pumps take work, they require logic and brain power—you can be stupid and be OK on a pump, but it’s better if you’re smart.”

According to Dr. Lorber, using the pump also requires patient training, which has more of a learning curve and can take at least a full day of training from a practice educator in the most sophisticated of diabetes medical practices. Beyond the training, there are two serious negatives for pump use: the risk of infection from improperly sanitized catheters; and mechanical pump failure—a patient who stops receiving the constant stream of fast-acting insulin can quickly develop complications of diabetic ketoacidosis, an affliction of diabetics with symptoms including falling into a coma.

Other cons of pumps include the cost—an extra $10,000 a year, which is often covered by insurance, but also the emotional and psychological weight of being attached to a machine. The size of pumps has certainly been reduced since they were introduced in the early 1990s, but “there’s an emotional response and resistance on being machine dependent,” said Dr. Lorber, who, in the face of all the negatives, sees them as minimal risks. “If I had Type 1 diabetes I’d be on a pump in a hot minute.”

Dr. Zonszein is more cautious in his view of the pump, and believes that the effectiveness of the treatment is mostly a result of the patient’s efforts, and less the technology. He sees the extra cost, no small number, to be a lot to pay for what he believes is “not such a big increase in efficiency.” Unlike the findings in the study cited above, Dr. Zonszein’s patients—80 percent of whom use a pump—are rarely able to reduce their A1C below 7 percent, regardless of the method they use for insulin delivery.

Ultimately, according to Dr. Zonszein, the best way to treat diabetes is to mimic the deficient human system as best as possible: a mechanical pancreas implanted in the pelvic region, secreting insulin directly into the central venal system. This kind of technology has been under development as long as insulin pumps, but an effective version is years away from completion.

By Mariah Summers

Treatment methods for Type 2 diabetes are rapidly changing with the development of new drugs and the erosion of the stigma around insulin use.

The disease, also referred to as adult onset diabetes, is usually diagnosed in adulthood and carries a number of misconceptions, the most common being that Type 2 diabetes is the disease of people who don’t take care of themselves.

“A lot of people think it is a disease of self-neglect, and patients may feel self-conscious,” says Dr. Ronald Tamler, assistant professor in the Division of Endocrinology and clinical trials leader of the Diabetes Program at Mt. Sinai School of
Medicine, “but it has a strong familial component.”

According to Dr. Tamler, the stigma of using insulin is born in this misconception that Type 2 diabetes is somewhat of a self-inflicted disease. Still, physicians are trying to break down the stereotypes of using insulin, including that it is a treatment of last resort, as it was once thought to be.

“People are often afraid to use insulin because it makes them think they have failed in their diet,” says Dr. Stuart Weiss, clinical assistant professor in the Department of Medicine and New York University’s Langone Medical Center. “It used to be a treatment of last resort. Now if people don’t use it, that can lead to poor blood sugar control.”

In addition to patients’ reluctance to use insulin, physicians are also unwilling at times to prescribe the drug, due to the time and emotional investment such a prescription requires.

“There is a resistance among physicians to prescribe insulin when it is needed because it takes time and an emotional toll on preparing the patient for insulin use,” Dr. Tamler says. “Insulin can be very good if needed, and there are ways to overcome the stigma on both the part of the physician and the patient.”

Among these solutions, Dr. Tamler listed insulin pens, pumps, superfine needles and pills that can be taken to supplement insulin injections throughout the day.

“One device, insulin pens, can be carried around in a pocket and can be used anywhere,” Dr. Tamler says. “You can use them and no one would know you’re taking insulin.”

As patients progress through the disease, the schedule of administering insulin could become more challenging, but such alternatives to a typical shot can help ease the psychological and physical impact of the treatment.

While the stigma attached to insulin injections continues to crumble, doctors say there are currently new forms of Type 2 diabetes treatments in development.

“The big developments in the industry have not really been in the world of insulin, but rather in the world of oral medications, which are typically given earlier in the course of diabetes,” says Dr. Tamler. “A big push is currently being made in the following category of medications for T2DM: DPP4 inhibitors, like Januvia, and GLP-1 agonists, like Byetta.”

A benefit of these new treatments is that they promote weight loss, making it easier for patients to accept them, even though they are injections.

“These new products not only help the body work to improve insulin, but also help to better control glucose and weight loss,” NYU’s Dr. Weiss says of the new injection treatments. “Most medications contribute to weight gain, and this does not. These products lead to a more significant weight loss and blood sugar does not get too low.”

Other treatment developments for Type 2 diabetes include new oral medications that will be available to patients in the near future. Two of these oral medications are SGT-2 inhibitors and Glucokinase agonists, both of which are not yet on the market.

Even with these forthcoming treatments, physicians warn that diabetes patients must always consider their diet in addition to any medication they are taking.

“Another way to reduce insulin injections is to have a non-carb meal,” Dr. Tamler says. “Determining certain meal choices if possible, with limited carbohydrates, can help with treatment.”

“The bottom line is there is no treatment that can’t be overwhelmed by a bad diet,” Dr. Weiss says. “That is the cornerstone of treatment. The future is going to be based on more people eating properly. All the medications in the world will not beat that. Aside from the social issues, the science is moving ahead.”

By Deb Sperling

When Yael Cohen’s mom got cancer, she was pissed. So pissed that she made a T-shirt that expressed how she felt: “F*** Cancer.”

“It was meant to be something she wore privately at home while she was recovering,” Cohen explains. “But my mother is absolutely fearless. She wore it everywhere. She wore it through her treatment; she wore it to get coffee; she wore it to whatever she was doing.”

Yael Cohen (right) and her mother in the “censored’ version of the T-shirts.

F*** Cancer is a message of defiance against politeness, a powerful statement that silence can be deadly. It’s also meant as a message to its followers that cancer can do a hell of a lot more damage than some four-letter word.

The T-shirt evolved into a movement that, in turn, became a registered nonprofit, foundation and charity known as F*** Cancer, which is celebrating its one-year anniversary this month. F*** Cancer’s proceeds—from the sale of T-shirts and other merchandise, available in censored and uncensored versions at www.letsfcancer.com—go toward prevention, early detection and education about different types of cancer and possible symptoms. It may be the best option for those who aren’t really interested in being a part of the pink brigade and have a more forthright way of expressing themselves.

Speaking with Cohen, who is based in Vancouver, even the most hardened, chain-smoking New York cynic would find it hard not to be moved to tears. Her tiny voice swells with an almost overwhelming passion when she speaks. This emotion is the heart of her movement.

“My mother is strong and beautiful and radiant and all of a sudden people would tilt their heads and actually pat her on the head,” Cohen says. “You’re fighting the fight of your life, and people are treating you like you’re a child. Everybody wants you to be happy. Everybody wants you to pretend that there’s some good reason you got cancer: It’s made you realize how good your life was or what you could be, and maybe that’s true, but at the same time it fucking sucks. It’s hard, and it’s painful and it’s embarrassing and it’s a lot of other really bad things too, and it’s OK to say that. But, as a society we don’t often want to hear that, because it makes it so much harder for us, to see what somebody’s going through.”

For Cohen, the most important defense available—the best “Fuck You!” to cancer—is early detection. “Ninety percent of cancers are curable in stage one,” Cohen explains. “We spend billions of dollars and over 40 years searching for a cure, and we’re not really that close. So why aren’t we teaching people the only cure we have now? Early detection is one shitty year, versus the rest of your life.”

To that end, F*** Cancer uses its proceeds to educate Generation Y to start “looking for cancer, instead of just finding it.” In particular, Cohen aims to motivate the younger generation to reach out to their elders, to encourage them to be more aware of risks and warning signs, to help them make positive lifestyle changes, and nag them to seek appropriate testing and treatment. “We’re teaching our parents how to use a Blackberry or TiVO or whatever it may be,” says Cohen, “so we might as well teach them something that can save their lives.”

F*** Cancer is partners with Fran Drescher’s organization, Cancer Schmancer, which targets an older generation with a similar education based mission. Cancer Schmancer also operates “Fran Vans,” which offer cancer screening and diagnosis to un- and under-insured individuals in the United States.

Based in Vancouver, F*** Cancer also has an office in New York where U.S. donors can make a donation if they wish. Cohen believes it is of particular importance to serve patients in the United States because of the lack of universal health care. “And all of our programs are don’t ask, don’t tell for illegal immigrants as well,” Cohen says. “There’s care all the way through. Why would you come in and get tested to find out you have cancer if you can’t get care? Or when you know you may be sent home when they ask for your papers in the Emergency Room?”

Cohen’s organization spreads its message primarily through the use of social media, with informational cue cards available on Facebook, and an interactive online game, which Cohen refers to as a sort of “Farmville for cancer,” is also in the works. The cue cards, in particular, help readers pinpoint potential signs and symptoms, and provide guidelines on how to talk to doctors.

“A lot of the time symptoms are seemingly benign and highly embarrassing. If you go to the doctor and get told you have IBS, you walk away embarrassed,” Cohen says. “You don’t really ask questions. You’re told, stop eating whatever foods and you’ll be fine. And by the time you go back because something is so wrong that you feel like you need to go back, it’s often much farther advanced.”

Beyond prevention, early detection and education, F*** Cancer provides a safe space for “Cancer F***ers”—people fighting cancer, plus friends, families and other supporters—to express their thoughts, feelings and stories about cancer. Users post their personal stories to a cloud on the website, where other viewers can read them at random.

“This is a place where you can say how much it f***ing sucks that you’ve lost your hair or that you can’t keep food down because of your chemo or that you miss your dad so much,” says Cohen. “It’s OK to be emotional, and it’s OK to laugh and say that you decided to shave a mohawk because you were gonna have to lose your hair anyway. You can be happy, you can be sad, you can be what you actually feel. It’s OK to have a valid emotion around us, we don’t need to be daffodils and rainbows all the time.”

By Francine G. Burke

“We saw something in your films.” These are the most-dreaded words after your tits have gone through Pancakeville. It was finally explained to me that breasts, cysts, fibrous tissue and the like will flatten under the X-ray machine and cancer doesn’t. Good old big “C” is so strong it can withstand the scrunch like a cockroach. The Sharpie mark on my breast is where the machine is going to drill.

Approximately 12.7 percent of women born today will be diagnosed with breast cancer at some point in their lives: that’s about 1 in 8 women. And all you dudes better man up and get in touch with yourselves! As on a recent episode of CSI, the coroner couldn’t identify some sticky plastic with a metal dot. It was a not-so subliminal television message that guys are clueless about the mammography. The metal ball is a nipple marker, a little Band-Aid with a metal tip. The metal shows up in the X-ray so technicians can see where and what they are looking for. Pulling them off after the test just may be the worst part of the annual ordeal… that is, when the test is negative. When even my hero Peter Criss, the former drummer of KISS, can get boob cancer, you know that it can happen to anyone.

The radiologist poked at the white dots on my X-ray with his pointer. They’re not concerned about the little calcium deposits that are scattered on the fi lms of my fibrocystic breasts, but this is a cluster and it’s necessary to have a biopsy. My mind ran in a hundred directions and my eyes watered, so I fought the tears with a stream of intellectualizing. I badgered the doctor with questions: “What’s the difference between calcium dots and a cluster? And why is one dangerous but not the other? So if it is early detection, it can be isolated right? A little radiation, keep my hair and good to go, ’cause I haven’t met my second husband yet and need my tits and my hair. They are my best features!”

I think the doctor wanted to slap me silent, but, instead, asked me quietly to stop getting ahead of myself. I was given an appointment and a list of stuff to stay away from (like anything that interfered with blood clotting) and didn’t realize just how much I missed my aspirin!

The procedure, called a Stereotactic Breast Biopsy, was scheduled a week later. I am again a part of the bland, scratchy robe-wearing procession of women. But this time, as they are getting routine annual check-ups, I keep my mind distracted by reading crappy, outdated Golf, Parents and Elle magazines, and make a note to self not to pay too much attention to the 2005 fashions until Shivka, a lovely, prematurely gray-haired woman with kind eyes and fi rm voice, calls me to the special room.

The table has a hole in the middle; it rises up so they can work on the spot at eye level. My left tit is milked, prodded, poked and, yes, fl attened again. The room and plastic table are freezing. I whine and Shivka covers me with several blankets. She continues to yank and squish and shoots more films but cannot get a clear shot of where they have to get the biopsy sample.

Dr. Shack arrives, walking around the table, and he looks so short, stern and emotionless that it’s pretty darn disconcerting. They lower the table and tell me it’s an older machine, and they want me to go to another lab a few blocks away that is equipped with a newer, state-of-the art machine. When the table is lowered, I’m surprised to see the “short” doctor is over 6 feet tall.

The nurse and doctor gather all the supplies they could possibly need—not knowing what would be available to them at the new place—and the doctor never changes his expression, instructing Shivka to take the walk with me to the lab. She seems insecure, not knowing the new machine, but is happy to get out of the lab in the warm sunshine.

Armed with manila envelopes filled with anesthesia, alcohol, ice packs, needles, bandages and more, I feel special, having a medical entourage escorting me from West 59th Street and Columbus Avenue to 58th Street and Broadway. While we trundle over, I listen to Shivka tell me about her husband and three sons. Arriving at the new lab, we are welcomed and the magazines are current. The table is prewarmed.

I have four additional women leading, prepping, poking and prodding me, and the lab technicians compare notes and teach each other their “way” with much respect. I am the benefi ciary of all of their great experience. With a total of five women and the doctor taking care of my needs, there’s probably over 100 years of know-how in the room.

When they’re confident that all is ready, they mark the spot, the table is raised again and I’m locked into place by my left udder, er, breast, and I try to ignore the metal squeezing against my breast bone and ribs.

“You’ll hear a clap that will indicate the pinch of the needle is coming for the anesthesia,” the doctor says. And I hear what sounds like two plastic pieces on a tight spring slapping together. I am warned that I will then hear a “whirring” sound when the tool starts excavating.

Unfortunately, the doc didn’t shoot me up with enough anesthesia and there’s a “whirrrr” and PAIN! I scream and nearly jump out of the confi nes of their grip and off the table. “Whirrr!” Pain again! I cry for them to stop and with all of the tension and anxiety that has built up from the time I heard I needed the biopsy, I start sobbing like a baby.

Shivka gripped my leg and sternly told me to hold still while another nurse, Michelle, walks around the table and dabs the tears from my eyes. It’s the lab assistant version of good cop/bad cop, I figure. I’m so afraid to hear the whirr again and cry out: “Please no, please no, stop stop stop!” They shoot me with a large dose of additional anesthesia, and it kicks in and the doctor, confident and pleased, informs me he’s gotten the sample he needed. “It went very well.”

All the women stand around me, instructing me on post-procedural care while I dress. Michelle absently-mindedly evens-out the string in my hoodie, telling me how great I did. Dr. Stack, still emotionless, pushes his card into my hand and says, “Call me tomorrow, so I can tell you it’s benign.”

Dr. Stack’s confident diagnosis held true, and I’m happy to say that I did, indeed, get the benign good news. Just days later, I found out a good friend was not so fortunate and scheduled the next step, a Ductal Carcinoma in. But I’m glad both of us got our checkup, and I continue to spread the word: with early detection, non-invasive procedures can lead to full recovery.