Archive for February, 2006

Interesting Article About Buttonhole Technique

As some of you know, buttonhole, or “constant site” cannulation is nothing new. Some of you are probably using buttonhole technique, and still others have probably read about it here, as I have described my experience with it.
Well today I found an interesting article about reducing the time it takes to establish buttonhole sites.
You can read the article here.

One thing I find interesting, is that the article starts off by stating that it typically takes 2-3 months to establish buttonhole sites. Has this been the case with any of you? From everything I’ve read the “normal” time is 6-9 cannulations, that’s 2-3 weeks. Certainly it must take longer sometimes, but is 2-3 months really the norm?
I bring this up, because the article then proceeds to explain a technique wherein a “peg” is placed in your arm after the needles are pulled after your treatment, and this peg is left in until your next treatment. Obviously this gives something for your track to graft around, so it seems to make sense (in theory anyway). What perplexes me, is that their results are viewed as a success, because the time to create the sites is shortened to 2-3 weeks.
If it takes most of us 2-3 weeks anyway, why would this study be seen as a success?
Also, is there increased risk of infection? The study indicates that nobody had serious problems with infection, but with a sample size of 37 patients is that really telling us anything?
It is an interesting idea, but I would think a slightly more scientific study would be needed to conclusively say this was a safe way to rapidly establish buttonhole sites.
What do you think?

Medicare Part D – Selecting the Right Plan

I’ve been looking at these plans for months. I keep wondering to myself, how many other twenty-somethings are sitting at home right now looking at medicare prescription coverage plans?
Here’s the deal for those of you not familiar:
Medicare is now going to start “helping” us with prescription drug coverage. The “approved” plans will be offered by private companies, and can vary quite a bit in coverage, and what medications they allow. The rules are fairly simple, an approved plan will cover your drugs at x% until you reach an out-of-pocket total of $2500. Here’s where it gets tricky though. The plans then cover nothing between $2500 and $3600, at which point the plan picks back up, and covers the drugs at a different rate.
That’s right, those of you with high prescription drug costs are still going to pay a lot out of pocket (what a surprise).
So let’s say you’re taking some fairly useless cholesterol medication (you know, the kind that lowers your numbers but doesn’t improve your health). Let’s say you pick up that prescription for $50.00 a month. With your shiny new Medicare Part D plan, you will pay a monthly premium between roughly $25 and $50 (depending on the provider). Assuming your drug is “Tier 1″ drug, you might have a copay of $0, or $5, or whatever the plan decides. Well that’s a pretty good deal if you have a low monthly premium, you might save $20 or $30 a month. It’s even better if you are on several medications, and find a plan that includes all of them, and considers them all “Tier 1″.
But what happens when you have a lot of expensive medication, and can’t find a plan that considers them all “Tier 1?” What happens if you absolutely need a medication, and it is Tier 4?
I received the documentation for the plan from my Medicare Supplemental Provider (Anthem) several weeks ago. Unfortunately, after looking through their formulary only 3 of my 5 medications were listed, and only two of those were Tier 1 ($5 a fill). So the plan costs ~$38 a month, and will give me my two cheapest medications for $5 a fill. Really though, I’m only saving about $25 on those two fills, which hardly makes up for the monthly premium – not to mention I still have the two more expensive medications which are going to add up to about ~$190/month.
Well that doesn’t sound very awesome.
So why are the fatcats in Washington patting themselves on the back for getting this passed?

To further confuse things, there are literally hundreds of plans available, all with different formularies (what they will cover and at what %), different preferred pharmacies, and different territories. If you have the patience to sift through it all, you might find a decent plan somewhere else in the U.S., that happens to be offered in your State and County, that covers all or most of your meds, and considers them all Tier 1.
I think I finally found this plan last night.
No I didn’t have the patience to go through all of it, but thankfully the Medicare web site has a pretty useful utility to help you find the best plan (awwww, finally the meat of this loquacious rant).
Just head on over to the Medicare site, and you will find a link right on the first page where you can go to begin comparing plans. It will ask for some of your medicare information, so have your card handy.
Next it will ask you what medications you’re currently on, and what dosages. After you put in all of this information it will show you a list of plans offered in your area that cover all, or some of your listed meds. It will then sort them by price, and will give you estimated annual and monthly costs, as well as cost analysis of preferred pharmacy vs. mail order pharmacy.

The plan I found has no annual deductible, and a low monthly premium (under $30 if I remember correctly). It covers four of my five drugs at the Tier 1 level (which means I have a $0 copay), and the fifth at a Tier 4, which is only slightly discounted. Still though, I will get away monthly at around $100 instead of ~$250.
“Wow, that sounds great Jonathan!”
Yeah … for now perhaps. But these providers can drop their with little notice. Hopefully though this will cut down on drug costs for me for awhile. The “killer” right now is phoslo, which paying out-of-pocket costs me $130/month. When my phosphorous is high that cost goes up as I take more of it.
“Why don’t you take Renagel?”
Because Renagel would cost me ~$600/month. They used to have a program to help people like me without prescription coverage, but recently have put a stop to it, most likely because of the new Medicare Part D plans that will cover the drug. I did find some plans that had Renagel as a Tier 1 drug, and I contemplated switching to Renagel to get one of these plans – but after enough searching I finally found one that covered almost everything I was on, which in the end is cheaper, and therefore beneficial.
If I can scrape enough together to purchase three months at a time I will save even more, and will hopefully never again have the problem I have this month: picking and choosing which drugs I can go without or take less of due to financial constraints.

Tomorrow: Part Two
How Medicare Part D coverage affects locally owned independent pharmacies.

Buttonhole Update

We tried Wednesday to do both buttonhole sites with blunt needles … … again.

To our dismay, the same thing happened that happened before, the arterial needle seemed to be “glancing” off the side of the fistula, causing it to push over. And once again, a sharp slid in easy as pie.
So I spoke with two of the buttonhole “gurus” who happened to be visiting our clinic doing the quarterly transonic testing. They both told me that this was fairly normal, and that it was also fairly normal to have one site establish much quicker than the other.
I was told that I most likely had the tunnel established, evidenced by how easily the sharp was sliding in.
Their recommendation was simple: “push harder”.
It seems that it is normal to encounter some resistance with the blunt needles, and theoretically you can’t hurt the fistula with one since it is dull (I’m not going to test this theory however).
So I was simply told to push harder, and “twist”. The thinking is that the needle is entering the track, and then hitting resistance at the vessel wall. Since I’m so careful (after sticking with sharps), I’m probably not exerting enough pressure on the needle to break through this last “flap” of resistance.
Here’s the plan folks, tomorrow I will attempt blunt needles again (the venous site is doing fine with the blunts by the way), and will not be such a pansy with my arterial stick. I’ve been told it is safe to apply three times more pressure than usual with these needles.
3 X !
I’ll let you know how it goes.
It is true by the way that constant site cannulation hurts a lot less. I noticed the very first day that I started developing the sites, that the sharps slid in easier, and hurt much less.
Just sticking yourself hurts a lot less (seriously), so give it some thought.

Synthetic Heparin

Interesting story I found on the dialysis_support list:

Heparin prepared synthetically could replace animal-derived drug

Researchers at Rensselaer Polytechnic Institute and University of North Carolina at Chapel Hill have discovered an alternative way to produce heparin, a drug commonly used to stop or prevent blood from clotting. The findings could enable the current supply of the drug – now extracted from animal tissue – to be replaced or supplemented by the synthetic version. The new process also can be applied as a tool for drug discovery, according to the researchers. Heparin is a complex carbohydrate used to stop or prevent blood from clotting during medical procedures and treatments such as kidney dialysis, heart bypass surgery, stent implantation, indwelling catheters, knee and hip replacements, and deep vein thrombosis. The annual worldwide sales of heparin are estimated at $3 billion. “We have synthetically prepared heparin in quantities large enough for use in human medical treatments by engineering recently discovered
heparin biosynthetic enzymes,” says Robert Linhardt, the Ann and John H. Broadbent Jr. ’59 Senior Constellation Professor of Biocatalysis and Metabolic Engineering at Rensselaer Polytechnic Institute. “These discoveries will enable us to effectively replace a variable raw material – heparin derived from processed animal organs – with a synthetic material – synthetic heparin – and have the same therapeutic result.” Research in Linhardt’s group at the Center for Biotechnology and Interdisciplinary Studies at Rensselaer focuses on complex carbohydrates such as heparin. After determining the structure of these molecules, researchers study their biological activities to establish a structure-activity relationship that may reveal lead compounds for new drug development. Researchers at MIT first prepared a synthetic heparin, but, in amounts of less than 1 microgram, it was insufficient to treat humans, says Linhardt. One human dose of heparin is approximately 100 milligrams.
Rensselaer and UNC-Chapel Hill researchers successfully synthesized hundreds of milligrams of heparin by developing a large-scale process involving engineered enzymes and co-factor recycling. The new, scaleable process can be applied to synthesize other heparin-based structures that regulate cell growth and may have applications in wound healing or cancer treatment, according to the researchers. The findings were reported Dec. 30, 2005, in the Journal of Biological Chemistry in a paper titled “Enzymatic redesigning of biological active heparan sulfate.” The process also can be applied in solid phase synthesis as a tool for screening lead compounds with heparin-like structures for drug discovery, according to the researchers. The findings were published Jan. 13, 2006, in Biochemical and Biophysical Research Communication in a paper titled “Enzymatic synthesis of heparin related polysaccharides on sensor chips: Rapid screening of heparin-protein interactions.”
Linhardt collaborated on the interdisciplinary project with Jian Liu, assistant professor of medicinal chemistry at University of North Carolina at Chapel Hill. Graduate and post-doctoral students involved in the work include: Jinghua Chen (UNC-Chapel Hill), Eva Munoz (Rensselaer), Fikri Avci (Rensselaer), Ding Xu (UNC-Chapel Hill), Melissa Kemp (Rensselaer), and Miao Chen (UNC-Chapel Hill). The work was supported by the National Institutes of Health and the American Heart Association. Rensselaer and UNC-Chapel Hill have jointly filed a provisional patent on the process. Linhardt said additional research will seek to scale the process another million-fold to make it commercially viable.

Biotechnology and Interdisciplinary Studies at Rensselaer:
At Rensselaer, faculty and students in diverse academic and research disciplines are collaborating at the intersection of the life sciences and engineering to encourage discovery and innovation. Rensselaer’s four biotechnology research constellations – biocatalysis and metabolic engineering, functional tissue engineering and regenerative medicine, biocomputation and bioinformatics, and integrative systems biology – engage a multidisciplinary mix of faculty and students focused on the application of engineering and physical and information sciences to the life sciences. Ranked among the world’s most advanced research facilities, the Center for Biotechnology and Interdisciplinary Studies at Rensselaer provides a state-of-the-art platform for collaborative research and world-class programs and symposia.

About Rensselaer :
Rensselaer Polytechnic Institute, founded in 1824, is the nation’s oldest technological university. The university offers bachelor’s, master’s, and doctoral degrees in engineering, the sciences, information technology, architecture, management, and the humanities and social sciences. Institute programs serve undergraduates, graduate students, and working professionals around the world. Rensselaer faculty are known for pre-eminence in research conducted in a wide range of fields, with particular emphasis in biotechnology, nanotechnology, information technology, and the media arts and technology. The Institute is well known for its success in the transfer of technology from the laboratory to the marketplace so that new discoveries and inventions benefit human life, protect the environment, and strengthen economic development.

George Lopez Show – ESRD Awareness

thanks to Bill Peckham for this:

This is a message from WeKan Kidney Advocacy Network
http://www.renalnetwork.org/wekan/

Tune in to the George Lopez Show on ABC TV tomorrow night, February 8
@ 8 pm Eastern/7 pm Central and watch a chronic kidney disease
storyline unfold (story details attached). Kudos go to NKF National
Spokesperson George Lopez who wrote this episode into his show and
coordinated with NKF on a post-show informational announcement.
Special thanks also to NKF Chancellor Ken Howard, kidney transplant
recipient, for participating in the effort to generate public
awareness of kidney disease by playing the doctor on this episode.

At the end of the episode, ABC will air a 15 second announcement,
narrated by Lopez, that will provide NKF's toll-free number and
website for callers seeking more information on kidney disease.

We encourage everyone to write in to ABC expressing our support and
appreciation and have included below a sample letter with contact
information for ABC corporate communications.