The Value of the Patient-Centered Medical Home

The Patient-Centered Medical Home (PCMH) is an approach to healthcare that is widely seen as a first step toward healthcare reform. The PCMH is usually a primary care office - family medicine, internal medicine, pediatrics or geriatrics - that serves as the hub for all a patient's medical needs. Focusing on the whole person, it provides continuous, comprehensive, coordinated care, establishing a partnership between patients and their personal healthcare team as part of an integrated medical neighborhood.

The PCMH emphasizes:

• Enhanced access, making it easier for patients to contact their personal healthcare team;
• Prevention and proactive management of chronic conditions, improving clinical quality and safety;
• Education to engage patients in their care to attain optimum health;
• A team approach to care; and
• Technology, such as electronic health record and patient registries, to facilitate information exchange, storage and retrieval.

According to the Patient-Centered Primary Care Collaborative, "Clinicians practicing in the highest level medical home will:

• "Take personal responsibility and accountability for the ongoing care of patients;
• Be accessible to their patients on short notice for expanded hours and open scheduling;
• Be able to conduct consultations through email and telephone;
• Utilize the latest health information technology and evidence-based medical approaches, as well as maintain updated electronic personal health records;
• Conduct regular check-ups with patients to identify looming health crises, and initiate treatment/prevention measures before costly, last-minute emergency procedures are required;
• Advise patients on preventative care based on environmental and genetic risk factors they face;
• Help patients make healthy lifestyle decisions; and
• Coordinate care, when needed, making sure procedures are relevant, necessary and performed efficiently."1

To enable medical practices to adopt these priorities and build the appropriate infrastructure, the PCMH model realigns payment to blend standard fee-for-service reimbursement, a monthly care-management fee and a bonus for meeting or exceeding quality outcomes. Theoretically, this compensation model will shift the focus of care away from acute, episodic care toward more comprehensive, holistic care. It will incorporate both lower costs and better outcomes for patients.

Few practices can achieve the transformation to the PCMH on their own. Most lack the time, expertise and resources to transform their care delivery methods. On-site coaching by quality-improvement experts shows them how to adopt new work flows, realign staffing, acquire and use new technology to its fullest extent, and make the culture change to a quality-driven mindset. Once attained, the new framework allows a practice to improve operations, incorporate quality approaches and increase patients' and care-givers' satisfaction with the healthcare experience.

The PCMH narrows the gap between today's fragmented healthcare system and tomorrow's integrated approach.

1. Patient-Centered Primary Care Collaborative., accessed Aug. 15, 2011.

Lisa H. Schneck, MSJ, is staff writer for HealthTeamWorks, a nonprofit medical-practice transformation company in Lakewood, Colo

White Blood Cells in Urine

Finding white blood cells in urine is not common and is usually a sign that something is wrong with the body. Should this occur, individuals would be exposed to a battery of tests to find out exactly why white blood cells are present in the urine that is usually sterile.

Detection of white blood cells in urine can be done through two different methods. The first one is by peeking through the microscope and the other is by using an indicator strip. Either way, both are done in laboratories and are very accurate indicators of the presence of white bcs in a person's urine.

How they get there, however, is another matter. Following are some of the known causes for the presence of white blood cells in the urine.

Urinary Tract Infection
This is actually the most common and also the easiest to treat. The urinary tract encompasses three organs - the bladder, the kidneys and the urethra. As most people know, some of the sign of a UTI include fever, vomiting and painful yet frequent urination. Usually, it is easy to diagnose the presence of UTI because the urine not only contains WBC but also nitrites. This kind of infection usually occurs if bacteria enter the urethra, which could happen during sexual intercourse.

Kidney Disease
A kidney disease is also a big possibility when the white blood cell is present in the urine. At the same time, red bcs and protein would also be present in the liquid. The presence of kidney stones is also a known culprit as these stones block the pathway of the urine. In some cases, the blockage is not made by kidney stones but a tumor in the said organs.

A kidney problem leading to WBC in the urine is not usually felt by the person having it unless the problem is already advanced. Hence, the urinalysis is actually a good indicator of a kidney problem so that people can resolve the disease before it becomes worse.

Bladder Infection
Aside from the presence of WBC in the urine, people with a bladder infection will notice that their urine is very cloudy. This usually happens if a person has any blockage in their bladder, causing the WBC to accumulate in the organ. Pregnant women are also prone to infections that may lead to the presence of white blood cells in their urine.

Of course, there are some cases when white blood cells in urine do not pose a large threat to a person's health. The urine could have been contaminated by WBC from the vagina, in which case obstructions or kidney diseases are not to be blamed.

The presence of white bcs in urine is more of a symptom than the actual cause of the problem. This is why submitting to a routine urinalysis is a good way to prevent problems even before they become too serious. Of course, the amount of white blood cells as well as how often they appear in the urine could also be indicators of an underlying problem.

Incretins in Diabetes

Incretins are hormones that are released in the gut in response to a meal. The incretins promote insulin secretion, inhibit glucagon, and slow emptying of the stomach. The result of these effects is to lower sugar levels in the morning and after eating a meal. Incretins also appear to promote the growth and survival of beta cells (the cells that release insulin).

The insulin-secreting effects of the incretins depend on blood sugar levels. They have their greatest effects at high sugar levels, when increased insulin secretion is needed. When sugar levels are normal, they have minimal effects, thus avoiding hypoglycemia (low sugar). This is a significant advantage when these hormones are used for treatment.

Although these benefits were first noted over 50 years ago, incretins were not previously available as therapy since the hormones lasted less than 10 minutes in your circulation. Researchers however recently identified technologies that allowed the incretins to last for longer periods of time. This has allowed physicians to use the incretins to treat people with Type 2 Diabetes, in whom incretin related actions are typically reduced.

The first class of incretin related drugs developed were the "incretin mimetics". Currently available drugs in this class are Byetta and Victoza. Both are delivered by injection. Byetta is a synthetic formulation of exendin 4, a hormone found in the Gila monster. It is very similar to the human incretin (53% homology), but much more resistant to breakdown. It thus lasts for more than 2 hours (compared to 10 minutes).

The formulation which is currently available requires two injections per day. Victoza has been chemically modified to resist breakdown. It lasts for 11-13 hours, and is injected once per day.

Bydureon, a once weekly version of Byetta, was approved by the FDA in January 2012.

On average, Byetta and Victoza reduce HA1C levels by 1-2%, lower after meal sugars by ~50 mg/dl, and lower fasting sugars by ~25 mg/dl. Both drugs are associated with reduced appetite and an average weight loss of 2-6 pounds after 7 months. At one year, the average weight loss is 10 pounds.

Victoza appears to be more effective in HA1c reduction, with the greatest benefits in people with the highest sugar levels.

The weight-loss benefits associated with this class of drugs are typically described as an early sense of "fullness" while eating a meal. Byetta and Victoza have also been associated with small reductions in blood pressure. New retrospective data suggests a potential role for incretins in the reduction of heart-related risk.

Prospective clinical trials regarding heart disease reduction are now underway. Incretin related side effects include nausea, and rarely, vomiting. Gastrointestinal complaints are typically dose-related, and lessen with time (typically within 6-8 weeks).

Nausea appears to be more common with Byetta.

A gradual increase in dose reduces the frequency and duration of nausea in many patients.

Recently, cases of acute pancreatitis have been described in people treated with Byetta and Victoza. A causal relationship has not been definitively identified.

Risk assessment is complicated since pancreatitis risk is already increased in people who are obese and who have Type 2 Diabetes.

Until further information is available, you should not use these medications if you have a history of pancreatitis, or are judged to be at high risk for this disease.

Thyroid tumors were seen in mice and rats treated with Victoza in pre-clinical trials. These findings were not observed in monkeys. There were no reported cases of medullary thyroid cancer in human clinical trials.

Nonetheless, Victoza should not be used if you have a history of medullary thyroid cancer, or if anybody in your family has medullary thyroid cancer.

The second class of incretin related drugs are the "DPP-4 inhibitors".

The DPP-4 inhibitors inhibit the breakdown of the incretins, thereby increasing circulating levels of these hormones. Currently available drugs in this class include Januvia, Onglyza and Tradjenta. All are once daily oral medications.

The DPP-4 inhibitors reduce HA1C levels by 0.8% on average. Fasting and after-meal blood sugar levels are also reduced. They are "weight-neutral" without an effect on appetite. The DPP-4 inhibitors are very well tolerated due to simple once daily dosing and rare side effects.

These drugs are an interesting addition to the treatment options available to people with Diabetes.

Before you begin therapy, remember to discuss all potential risks with your physician.

Michael A. Dempsey, M.D.

Diabetes Symptoms and Treatment

One of the most common metabolic disorders in today's world is diabetes. Malfunctioning of the pancreas in - producing too little insulin, resistance to insulin, or both and this causes diabetes. Insulin is a hormone secreted by the pancreas to help in converting sugar, starches, and other foods into energy. A person who has regular high levels of blood glucose is diagnosed to suffer from diabetes. There are three types of diabetes - Type I, Type II, and Gestational diabetes.

Polydipsia or increased thirst causing to drink fluids more often, Polyphagia or increased appetite, Polyuria or frequent passing of urine, Blurred eye vision, Lack of energy and fatigue, Unusual and sudden weight loss, Dry itchy skin, Slow healing sores, Losing sensation or tingling and numbness in feet are all diabetes symptoms.

The different allopathic diabetes medicines are - Meglitinide Drugs, Alpha-glucosidase Inhibitors, Thiazolidinedione Drugs, DPP-4 Inhibitors, Sulfonylureas Drugs, Biguanide Drugs, Dopamine Receptor Agonists, Bile Acid Sequestrants, and Combination Drugs.

In Ayurveda, diabetes is also known as Madhumeha and according to them, there are 20 types of diabetes - four types are due to Vata, six types from Pitta, and Kapha causes the remaining ten. Ayurveda for Diabetes helps to maintain blood sugar and keep kidneys, liver, eyes, and heart safe as these organs are affected by long drawn diabetes. Some diabetes herbal medications are listed here - Gymnema Sylvestre, Salacia oblonga, Bitter Melon, Cinnamon, Fenugreek, Ginseng, Aloe vera, and Chandraprabha. Some specified herbs for diabetes are - Savory to alleviate thirst, Broccoli, Ginseng, Green Tea, Lantana, Plantain, Sage to lower blood sugar, Evening Primrose for blood circulation, and Aloe Vera, Beans, Ginseng, Green Tea, Plantain to normalize blood sugar.

In Ayurvedic medication since ages, cow urine is used to prepare diabetes medicines. A recent scientific study by Dr. Jayakumar and his team in their research have found that the cow urine has anti-diabetic properties and has raised hope for millions of diabetic patients in India and abroad. The project funded by the State Government will be over five years.

Natural medicines for diabetes do not cause any side effects and help in stimulating pancreas to function normally. Any form of regular exercise, stopping smoking and alcohol, and taking a balanced diet along with few life-style changes can help in controlling diabetes. Some yoga exercises that are beneficial for diabetes are Sarvangasana, Halasana, the Child pose, Paschimotasana, and Ardha Matsyendrasana. Diabetes yoga helps to manage diabetes by activating glandular system responsible for this illness.

Cow Urine Therapy is an ancient therapy part of Ayurveda which has been re-established by study and research. Cow's urine is very much capable of diabetes treatment. For more information on Ayurveda for diabetes visit our website at

Diabetes Is Preventable

Diabetes and the Consequences

It is no laughing matter when one contracts this horrible disease. Early symptoms might include headaches, dizziness, thirst, hunger and a few other mild out of sort's conditions. It's when the other more serious symptoms start that one generally becomes very anxious.

The feet may lose feeling, the centre of the brain feels numb, the eyes are not what they used to be and balance is fading. You head to the doctor's and a sucrose tolerance test is ordered. You suspect high blood sugar because you have a sweet tooth and a great love of chocolate and ice cream. So will that explain why you are so thirsty, particularly when you wake up in the morning? What about that funny feeling in your tongue?

Some of these symptoms go with high cholesterol and high blood pressure and these too are warning signs for diabetes.

During my lifetime there have come and gone many with the disease and the thing noticed most about them is the smell of their breath. It is a somewhat sickly artificial smell that might be explained by the intake of insulin. My grandmother had diabetes and that smell was prominent on her breath and would see me avoiding coming too close to her face, although her affection was much sought after.

Lately some diabetics have come to my attention in hospitals where they were having lower limbs removed. In the eye hospital some were being treated for blindness and other things.

This is a preventable disease although if you have the diabetic gene it only takes careless abuse of your body to get it. Obesity is one of the primary causes and here blood pressure and cholesterol are always present. People with the latter can contract heart disease, suffer strokes and die suddenly.

These are all reasons to avoid sugar at all costs and yet parents feed masses of it to their children. Soft drinks or sodas are full of it, some worse than others. Chocolate bars and candies are quite potent poisons and ice cream loaded with sugar is also full of fat.

If we can prevent diabetes why would we not want to. The information here may help with that task and make potential victims more aware.