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Omega-3s May Raise Prostate Cancer Risk

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Independent & Assisted Living
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on Tuesday, 15 April 2014
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Omega-3 fatty acids have been shown to have many health benefits. But they may have risks as well, including an increased risk for prostate cancer.

In a nine-year prospective study, scientists at the Fred Hutchinson Cancer Research Center in Seattle took annual blood samples from 834 men diagnosed with prostate cancer and 1,393 men who were cancer free. The study, published online in The Journal of the National Cancer Institute, controlled for more than a dozen cancer risk factors.

Compared with men in the lowest one-quarter for omega-3 levels, those in the highest one-quarter had a 44 percent increased risk for low-grade prostate cancer and a 71 percent increased risk for high-grade cancer. They found the association with three different omega-3’s — eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and docosapentaenoic acid (DPA), which are all found in fish and fish oil supplements — but not with alpha-linolenic acid, which comes from flax seed.

The findings are an association and do not imply causation. But according to the lead author, Theodore M. Brasky, now at The Ohio State University, omega-3’s can affect gene expression and, in high doses, be pro-oxidative or suppress immunity, all of which could promote cancer.

Still, he added, the possible “increase in prostate cancer risk doesn’t preclude a beneficial effect for other diseases.”

Tags: cancer, Omega-3
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At Too Many Hospitals, a Revolving Door

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Jessie Gruman can’t remember the number of times she’s been hospitalized for cancer. The list of the conditions she’s had over almost 40 years is daunting: from Hodgkin’s lymphoma to cancers of the cervix and lung.

But Ms. Gruman, 59, can’t forget her experience three years ago, when it was time to leave the hospital after having her stomach removed, a consequence of gastric cancer.

Ms. Gruman was alone; her husband was on his way to this hospital but hadn’t yet arrived. This is all she remembers a nurse saying before she was shown the door.

Here is a prescription for pain medication. Don’t drive if you take it. Call your surgeon if you have a temperature or are worried about anything. Go see your doctor in two weeks. Do you want a flu shot? I can give you one before you leave. If you need a wheel chair to take you to the door, I’ll call for one. If not, you can go home. Take care of yourself. You are going to do great!

What wasn’t communicated to Ms. Gruman: Here’s a number to call if you have any questions. Here’s the medical expert who’s in charge of your follow-up care and how to reach him or her. Here’s the plan for your care over the next month, and here’s the plan for the next six months.

Or this: You’re going to experience a lot of challenges when you get home. Here are the three or four concerns that should be your priorities. Here’s what your caregiver needs to know to help you most effectively. Here are resources in the community that might be of assistance.

Given the inadequacies in care for discharged patients — a well-documented and common problem — is it any wonder that so many bounce back to hospitals after they’re sent home?

Medicare, the government’s health care program for seniors, has trained its sights on the issue and is focused on trying to reduce the number of seniors readmitted to hospitals shortly after being sent home. Nearly one in five older adults discharged from a hospital returns within 30 days, at an annual cost of $17.4 billion, according to a recent study in The New England Journal of Medicine.

Not all readmissions are avoidable — sometimes a patient’s condition will worsen no matter what anyone does. But experts are convinced a substantial proportion of readmissions could be prevented if hospitals did more to educate patients, ensure they’re able to care for themselves, and coordinate their care with other medical providers.

The Obama administration hopes to trim Medicare readmissions by 20 percent and, under the Affordable Care Act, has started penalizing more than 2,200 hospitals that have higher-than-expected readmissions rates for seniors with heart failure, heart attacks and pneumonia. Medical centers risk losing up 1 percent of their annual Medicare reimbursement; that financial penalty will rise to 3 percent by October 2015. More medical conditions will be added to the list over time.

What does this mean to older adults and their caregivers? What can they expect as hospitals put into place programs to address readmissions and what can they do to prevent return trips to the hospital?

Ms. Gruman’s problems began in the hospital, when a day after surgery a nutritionist came to visit and tell her how to manage life without a stomach. “It was misguided to see me so soon after surgery, when I was loopy and could barely remember my name,” said Ms. Gruman, now a patient advocate and president of the Center for Advancing Health in Washington.

“When you’re in the hospital, you’re not operating on all cylinders,” she added. “You don’t really know until you’re home for a while and reality sets in what questions are going to be important, anyway.”

Here’s what she learned from the experience.

Lesson No. 1: If a patient isn’t ready to hear what a medical provider wants to say, meaningful communication becomes impossible. Ms. Gruman said she probably should have told the nutritionist, “I can’t possibly concentrate on what you’re telling me right now; it’s not a good time.” Speak up when you find yourself in a similar situation, feeling muddled or unable to concentrate.

The morning of her discharge from the hospital, the nurse responsible for her discharge didn’t help Ms. Gruman see the big picture: “No one said this is going to be a really big deal, adjusting to this change in your body, and you’ll have a lot of adjustment to go through.” What was missing, she said, was “any recognition of the magnitude of the time and attention my husband and I would have to spend attending to my recovery.”

Lesson No. 2: Handing someone a sheaf of papers and going over a set of instructions won’t guarantee a successful transition from the hospital to home. People need more. They need a human touch, emotional recognition, and a sense that they’re not going to be left on their own as they try to recover from the setback that brought them to the hospital.

Feel free to stop the person handling your discharge and say, “Wait, slow down, I don’t really understand how I’m going to get along day to day and how all this is going to work.” Don’t leave until you feel more comfortable.

At home, Ms. Gruman wasn’t sure about her health priorities. “I had a whole new digestive system, and I wasn’t sure how it functioned,” she said. “I wish I’d known more about eating, what to expect in terms of my energy level, how much I should try to exercise, if there was anything I needed to be monitoring.”

Lesson No. 3: Some people may be able to assimilate information in the hospital or upon discharge, but many cannot. It may take several days or even longer at home for people to understand what challenges in their recovery are most important.

Staffers also need to teach caregivers the skills they will need while the patient is still in the hospital. That’s the time to learn how to turn someone in bed, help with mobility, assist them in taking a bath, or assess their breathing or level of pain. Be willing to ask a nurse “show me how you do that” several times if necessary so you are not left in the lurch when you get home, Ms. Gruman said.

Many of you have undoubtedly had experiences with this issue; we’d be glad to hear about those in the comments. Later this week we’ll post some advice from experts.

Tags: cancer, Hospitals
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A Novel Way to Document End-of-Life Preferences

Posted by Breakers Team
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Maybe we’ve been going about this all wrong.

In the continuing campaign to get people, particularly the old and sick, to discuss their preferences for end-of-life care, we’ve been pushing for them to have intimate conversations with family members.

Web sites like The Conversation Project and PREPARE, campaigns like National Healthcare Decisions Day in April, my own posts here — all reflect the idea that Americans can overcome their apparent aversion to acknowledging mortality if their children will just talk to them.

Progress on this front has been slow, however. Pew Research surveys found in 1990 that 12 percent of Americans had a “living will,” a figure that rose to just 29 percent by 2005. So on a nearly daily basis, the palliative care specialist Dr. Joshua Lakin told me in an interview, “I’d see someone who’d had lung cancer for several years, who’d been in and out of the hospital, had seen 20 doctors, and still hadn’t thought about the future and his priorities. It kind of blindsided me.”

So Dr. Lakin, who just completed a fellowship at the University of California, San Francisco, and some colleagues took an entirely different approach to what is called advance care planning. They experimented with brib . . . er, incentivizing doctors. And whaddya know, it worked.

 

As the team reported in JAMA Internal Medicine last week, the UCSF Medical Center has an incentive program to improve quality; each year its doctors-in-training pick one area to focus on. For the 2011-2012 academic year, the internal medicine department decided to concentrate on documenting patients’ advance care decisions.

The researchers came up with a standard form, which was inserted in patients’ electronic health records. It asked just a few questions: Does the patient have any “expressed wishes” about how much care he wants or doesn’t? Where are those preferences recorded — in a living will, a durable power of attorney, a P.O.L.S.T. form (which would be scanned into the record). Or are they expressed orally?

The researchers’ form requests a brief summary: He doesn’t want to be resuscitated or intubated? She wants a feeding tube but not a ventilator? Or she wants “all available care?” Does he have a designated decision maker? What is that person’s name and phone number, and what language does he or she speak?

If residents recorded this information for at least 75 percent of discharged patients, for three of the four quarters in the academic year, they each got a $400 bonus. If not, they didn’t.

The hospital, not the researchers, established that sum, but “it was enough to get people motivated,” Dr. Lakin noted. Residents around the country earn between $40,000 and $50,000 a year, plus housing stipends. An additional 400 dollars isn’t life-changing, but it’s not pin money, either. And the researchers sent out bar graphs via e-mail to point out if teams were hitting the goal or endangering everyone’s bonus. (“Marketing 101,” Dr. Lakin called it.)

The experiment followed nearly 1,500 patients, more than half the adults (of all ages) seen by the hospital’s medical department that year.

In July, the first month, only about 22 percent had their preferences documented, roughly the same proportion as before the incentives began. So “the template itself wasn’t enough,” Dr. Lakin said.

But by October, following Marketing 101, the proportion of patients with documented preferences hit 90 percent and stayed there. By contrast, a separate team of attending physicians who didn’t participate in the incentive program averaged less than 12 percent for the year.

So maybe we don’t have to keep nudzhing our parents, bracing for uncomfortable discussions. Maybe a doctor, at a hospital or not, can do this in 10 minutes without angst.

Of course, the study doesn’t answer some major questions. We don’t know how much of an incentive, if any, would motivate practicing physicians, who are paid more than residents. We also don’t know whether simply having a standard form in your medical records means that you will actually have your wishes respected — that you’ll be put on a ventilator if you said you’d want that, but not if you said you didn’t.

But we do have some idea of the scenario that ensues when people have never discussed their wishes. The medical conveyor belt cranks up. “There’s a set of default choices in the hospital system, which does things unless told not to,” Dr. Lakin said.

I’d still rather have the family conversation. But so often, it never takes place. Stricken families, sometimes bitterly at odds, wonder what Mom would want if she could speak. Maybe nobody really knows. Maybe, for a paltry sum compared with the cost of a single day in intensive care, her doctor could have found out.

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Scientists Seek to Rein In Diagnoses of Cancer

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The panel said that some premalignant conditions found in mammograms should not be identified as “carcinoma.”

 

A group of experts advising the nation’s premier cancer research institution has recommended changing the definition of cancer and eliminating the word from some common diagnoses as part of sweeping changes in the nation’s approach to cancer detection and treatment.

The recommendations, from a working group of the National Cancer Institute, were published on Monday in The Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.

The group, which includes some of the top scientists in cancer research, also suggested that many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should instead be reclassified as IDLE conditions, which stands for “indolent lesions of epithelial origin.”

While it is clear that some or all of the changes may not happen for years, if it all, and that some cancer experts will profoundly disagree with the group’s views, the report from such a prominent group of scientists who have the backing of the National Cancer Institute brings the discussion to a higher level and will most likely change the national conversation about cancer, its definition, its treatment and future research.

“We need a 21st-century definition of cancer instead of a 19th-century definition of cancer, which is what we’ve been using,” said Dr. Otis W. Brawley, the chief medical officer for the American Cancer Society, who was not directly involved in the report.

The impetus behind the call for change is a growing concern among doctors, scientists and patient advocates that hundreds of thousands of men and women are undergoing needless and sometimes disfiguring and harmful treatments for premalignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.

The advent of highly sensitive screening technology in recent years has increased the likelihood of finding these so-called incidentalomas — the name given to incidental findings detected during medical scans that most likely would never cause a problem. However, once doctors and patients are aware a lesion exists, they typically feel compelled to biopsy, treat and remove it, often at great physical and psychological pain and risk to the patient. The issue is often referred to as overdiagnosis, and the resulting unnecessary procedures to which patients are subjected are called overtreatment.

Cancer researchers warned about the risk of overdiagnosis and overtreatment as a result of new recommendations from a government panel that heavy smokers be given an annual CT scan. While the policy change, announced on Monday but not yet made final, has the potential to save 20,000 lives a year, some doctors warned about the cumulative radiation risk of repeat scans as well as worries that broader use of the scans will lead to more risky and invasive medical procedures.

Officials at the National Cancer Institute say overdiagnosis is a major public health concern and a priority of the agency. “We’re still having trouble convincing people that the things that get found as a consequence of mammography and P.S.A. testing and other screening devices are not always malignancies in the classical sense that will kill you,” said Dr. Harold E. Varmus, the Nobel Prize-winning director of the National Cancer Institute. “Just as the general public is catching up to this idea, there are scientists who are catching up, too.”

An expert panel says lesions found in some cancer screenings should not be called cancer but should instead be reclassified.
Joe Raedle/Getty ImagesAn expert panel says lesions found in some cancer screenings should not be called cancer but should instead be reclassified.

One way to address the issue is to change the language used to describe lesions found through screening, said Dr. Laura J. Esserman, the lead author of the report in The Journal of the American Medical Association and the director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco. In the report, Dr. Esserman and her colleagues said they would like to see a multidisciplinary panel convened to address the issue, led by pathologists, with input from surgeons, oncologists and radiologists, among others.

“Ductal carcinoma in situ is not cancer, so why are we calling it cancer?” said Dr. Esserman, who is a professor of surgery and radiology at the University of California, San Francisco.

Such proposals will not be universally embraced. Dr. Larry Norton, the medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering Cancer Center, said the larger problem is that doctors cannot tell patients with certainty which cancers will not progress and which cancers will kill them, and changing terminology does not solve that problem.

“Which cases of D.C.I.S. will turn into an aggressive cancer and which ones won’t?” he said, referring to ductal carcinoma in situ. “I wish we knew that. We don’t have very accurate ways of looking at tissue and looking at tumors under the microscope and knowing with great certainty that it is a slow-growing cancer.”

Dr. Norton, who was not part of the report, agreed that doctors do need to focus on better communication with patients about precancerous and cancerous conditions. He said he often tells patients that even though ductal carcinoma in situ may look like cancer, it will not necessarily act like cancer — just as someone who is “dressed like a criminal” is not actually a criminal until that person breaks the law.

“The terminology is just a descriptive term, and there’s no question that has to be explained,” Dr. Norton said. “But you can’t go back and change hundreds of years of literature by suddenly changing terminology.”

But proponents of downgrading cancerous conditions with a simple name change say there is precedent for doing so. The report’s authors note that in 1998, the World Health Organization changed the name of an early-stage urinary tract tumor, removing the word “carcinoma” and calling it “papillary urothelial neoplasia of low malignant potential.” When a common Pap smear finding called “cervical intraepithelial neoplasia” was reclassified as a low-grade lesion rather than a malignancy, women were more willing to submit to observation rather than demanding treatment, Dr. Esserman said.

“Changing the language we use to diagnose various lesions is essential to give patients confidence that they don’t have to aggressively treat every finding in a scan,” she said. “The problem for the public is you hear the word cancer, and you think you will die unless you get treated. We should reserve this term, ‘cancer,’ for those things that are highly likely to cause a problem.”

The concern, however, is that since doctors do not yet have a clear way to tell the difference between benign or slow-growing tumors and aggressive diseases with many of these conditions, they treat everything as if it might become aggressive. As a result, doctors are finding and treating scores of seemingly precancerous lesions and early-stage cancers — like ductal carcinoma in situ, a condition called Barrett’s esophagus, small thyroid tumors and early prostate cancer.

But even after years of aggressively treating those conditions, there has not been a commensurate reduction in invasive cancer, suggesting that overdiagnosis and overtreatment are occurring on a large scale.

The National Cancer Institute working group also called for a greater focus on research to identify both benign and slow-growing tumors and aggressive diseases, including the creation of patient registries to learn more about lesions that appear unlikely to become cancer.

Some of that research is already under way at the National Cancer Institute. Since becoming director of the institute three years ago, Dr. Varmus has set up a list of “provocative questions” aimed at encouraging scientists to focus on critical areas, including the issue of overdiagnosis and molecular tests to distinguish between slow-growing and aggressive tumors.

Another National Cancer Institute program, the Barrett’s Esophagus Translational Research Network, or Betrnet, is focused on changes in the esophageal lining that for years have been viewed as a precursor to esophageal cancer. Although patients with Barrett’s are regularly screened and sometimes treated by burning off the esophageal lining, data now increasingly suggest that most of the time, Barrett’s is benign and probably does not need to be treated at all. Researchers from various academic centers are now working together and pooling tissue samples to spur research that will determine when Barrett’s is most likely to become cancerous.

“Our investigators are not just looking for ways to detect cancer early, they are thinking about this question of when you find a cancer, what are the factors that might determine how aggressively it will behave,” Dr. Varmus said. “This is a long way from the thinking 20 years ago, when you found a cancer cell and felt you had a tremendous risk of dying.”

Tags: cancer, treatment
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Concerns About Dementia Screening

Posted by Breakers Team
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Marie Theriault, with husband, Paul, started dropping things three years ago, and was given a diagnosis of a rare form of Alzheimer’s.

Marie Theriault started having trouble with her hands more than three years ago. She was the director of a day care center, but suddenly she couldn’t change diapers or tie shoelaces. She started dropping things.

“People would say to me, ‘Look, you dropped your folder,’ ” Mrs. Theriault, 59, said. “I wasn’t aware I had dropped it.”

Though she did not have any problems with memory, Mrs. Theriault eventually found out that she has a rare form of Alzheimer’s disease. The diagnosis enabled her family to plan ahead: Her husband took early retirement and found a clinical trial for her to enroll in, and the two went on a safari that had been a dream for years.

“We’re front-loading a bit, enjoying life as much as we can, now that the disease is manageable,” said Paul Theriault, 57. “It can get pretty ugly.”

For the Theriaults, getting an accurate diagnosis of Alzheimer’s disease brought a measure of relief, even though the future might be grim. Indeed, there is a growing interest in the early detection of dementia, not only in patients like Mrs. Theriault but also in people with normal age-related memory changes or even no symptoms at all.

The idea is that treatments for Alzheimer’s disease and other dementias have been largely ineffective because the conditions aren’t caught early enough. Now researchers are starting clinical trials that focus on people in the “pre-symptomatic phase” of Alzheimer’s disease. Medicare is paying for wellness visits that include cognitive assessments and screening.

But the push for ever-earlier dementia screening raises troubling questions for patients and their families. When the diagnosis is early Alzheimer’s disease, the medical profession has little treatment to offer. This month, researchers at an Alzheimer’s Association conference in Boston urged policy makers to think hard before recommending wider dementia screening, saying studies have found no evidence that early detection improves outcomes.

And the experts said that little, if anything, is known about the potential risks of early detection. The diagnosis may cause stress, anxiety, depression and even suicide in patients, and can have implications for employment, purchasing life and long-term care insurance, and one’s overall quality of life, sense of autonomy and self-image.

“It colors how people see you and how you see yourself,” said Dr. Daniel J. Brauner, a geriatrician and ethicist at the University of Chicago. “Everyone forgets things, but if you have the diagnosis, whenever you forget something you’ll think, ‘It’s because I’m sick.’ It pathologizes everything.”

The amyloid plaque that is characteristic of Alzheimer’s disease starts to accumulate years, even decades, before symptoms become apparent, and some researchers are convinced that in order to prevent or postpone cognitive impairment, these plaques must be attacked earlier.

Laurie Ryan, director of the Alzheimer’s Disease Clinical Trials Office at the National Institute on Aging, said new trials of a monoclonal antibody that binds to amyloid will specifically recruit subjects who do not show any symptoms of Alzheimer’s disease but already have evidence of amyloid plaque buildup.

Healthy subjects will have to volunteer to undergo PET scans that detect amyloid plaque in the brain. They may be recruited from among the many “worried well” who are seeking reassurance and clear answers about the future.

“This trial will require participants to have an amyloid burden that is consistent with risk for Alzheimer’s disease, so you essentially will know your status, which is uncharted territory,” Dr. Ryan said. “This type of trial has not been done before.”

There are already 450 medical centers that have PET scanners that use an imaging agent called amyvid approved by the Food and Drug Administration to detect amyloid plaque in the brain. Yet this month the federal Centers for Medicare and Medicaid Services, in a draft proposal, indicated that the agency would not pay for these brains scans as diagnostic tools because they just don’t help much.

Even when a brain scan helps confirm the diagnosis of early Alzheimer’s disease, available treatments only delay symptoms for a relatively short period of time. And there is the potential for misdiagnosis, since plenty of people have amyloid plaque in their brains without developing symptoms of Alzheimer’s disease or other dementias.

The rush to find early Alzheimer’s disease worries some physicians and ethicists.

“You are telling someone they have a disease that they’re not experiencing in any way that they can see, and you’re telling them it’s an incurable disease. That’s kind of tough,” said Nancy Berlinger, the lead author of “The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life.”

“We don’t know yet what it’s like to live with the experience of asymptomatic Alzheimer’s,” she added. “It’s hard to even conceive of.”

Still, many scientists use heart disease as an example in describing how Alzheimer’s disease may develop. It takes decades for the underlying biological changes, including plaque accumulation, to damage the brain, just as high cholesterol and hypertension, left uncontrolled, may ultimately lead to a heart attack.

“The plaque is kind of like cholesterol,” Dr. Ryan said. “Not everyone who has high cholesterol goes on to have a heart attack, but it puts you at higher risk.”

It makes sense, she said, to treat this risk factor as early as possible, even if not everyone with plaques will develop Alzheimer’s. Still, that is just a hypothesis, said Dr. Malaz Boustani, an associate director of the Indiana University Center for Aging Research and the medical director of the Healthy Aging Brain Center at Wishard Health Services.

“It’s a beautiful hypothesis and it’s what I do my research on, but it’s still a hypothesis, and we need data,” Dr. Boustani said.

Both he and Dr. Brauner urge patients who notice cognition or memory problems — or whose family members notice changes — to get a complete evaluation. The physician should take a history, do a thorough exam, and rule out a number of potential causes of mental impairment: depression; thyroid, kidney and liver function; vitamin B12 levels; infections; and dehydration and electrolyte disturbances.

Sometimes an M.R.I. or CT brain scan may also be done to assist in diagnosis. These are different from the PET scans that detect amyloid plaque, and proponents argue that they can help clarify a diagnosis under certain circumstances.

The physician should also do a careful review of medications, since many drugs can have adverse effects on cognition. “You cannot believe the number of people who come to our clinic with memory symptoms and we find it was driven by their exposure to medications, like taking Benadryl to sleep or bladder medications,” Dr. Boustani said.

Reassuringly, many people who experience mild cognitive impairment do not progress to dementia, and many even return to normal, some studies suggest. A study of primary care patients seen at Wishard Health Services identified 130 patients with mild cognitive impairment. A year later, most were stable, and nearly one-third had reverted to normal.

Tags: dementia
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