Financing and recruitment/retention will remain important considerations. While RBHAs are projecting costs incurred by requiring Master’s level credentialed professionals to perform initial assessment, there is also the related concern that, even if cost is of no concern, it remains questionable, given overall recruitment and retention problems, that enough personnel are available in Arizona to meet such a requirement. Again, this raises the fundamental question: Is it really necessary, to use credentialed professionals in all screening and initial assessment activities?

Adequate training and supervision by credentialed professionals ought to be able to provide sufficient assurance of quality. Obviously there will be attendant cost associated with this training. Arizona officials might want to consider conducting comparative studies to determine if the added training is cost effective when compared to meeting state credentialing requirements.

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In recent months the issue of behavioral health credentialing has received considerable public attention in Arizona. DBHS has stipulated that by 2003, a Master’s level and certification as a Primary Behavioral Health Professional (PBHP), or licensure as a PBHP, is required for those carrying out initial behavioral health assessments.11 The added cost to the system in recruiting and retaining qualified personnel to meet this requirement, especially in rural regions of the state, has raised concerns in some quarters.

Currently Arizona has several boards overseeing certification of behavioral health professionals. The Board of Medical Examiners licenses allopathic physicians, and the Board of Osteopathy licenses osteopathic physicians. Allopathic and osteopathic physicians can then become certified by the National Board of Psychiatry and Neurology as psychiatrists, or are considered “Board Eligible” if they have completed an accredited psychiatric residency. Registered nurses and nurse practitioners are licensed by the Board of Nursing (and physician assistants by another board). They can be considered behavioral health professionals if they have two years of experience with psychiatric patients. The Association of Psychologists licenses psychologists. The Board of Behavioral Health Examiners provides certification for social workers, substance abuse counselors, marriage and family therapists, and other counselors. While certification of behavioral health professionals other than psychiatrists and psychologists is voluntary at present, there is some pressure – as well as incentive – for all such certification to become mandatory, as DBHS moves to implement its credentialing requirements by 2003.

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Women may also get these infections if they use a diaphragm for contraception because it can irritate the urethra.

People with diabetes and weakened immune systems are also at increased risk of infection, as are those with kidney stones and other urinary blockages, or people who must use catheters.

The likelihood of your developing urinary tract infections increases as you grow older. Though they are painful and bothersome, they usually can be treated successfully with antibiotics.

“This is the first report to demonstrate… that grafts of fetal human midbrain tissue not only store dopamine but can release it in a (normal) manner,” and continue to relieve Parkinson’s disease symptoms, Dr. Paola Piccini of the Imperial College School of Medicine in London, UK, told Reuters Health.

Parkinson’s disease is a brain disorder characterized by slowness of movement, rigidity, and tremors. A type of brain cell, the neuron that produces dopamine, is lost in an area of the brain called the basal ganglia, which controls voluntary movements. Drugs that replace dopamine can be used to treat the disease, but they eventually fail and also produce debilitating side effects.

In the December issue of Nature Neuroscience, Piccini and colleagues in the UK and Sweden describe how they used an imaging technique to measure dopamine release from the transplanted neurons.

The Parkinson’s patient who was studied had responded well to the transplanted cells that were implanted only into the right side of the brain. Therefore, the researchers were able to compare the function of the transplanted and nontransplanted sides of the brain. Five healthy people were studied for comparison.

The investigators found that the ability of the patient’s brain cells to store dopamine on the transplanted side of the brain was restored to the same levels observed in the healthy volunteers. In contrast, the nontransplanted side stored dopamine at only 12% of normal levels.

Piccini’s group also found evidence that the transplanted neurons were releasing dopamine. Peak dopamine levels were increased by 2- to 10-fold, according to the report.

There were no signs of transplant rejection, even though the patient had not received any immune system therapy for over 4 years.

“Our intention is now to explore other sources of (dopamine-releasing) tissue,” Piccini said in the interview with Reuters Health.

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Treatment of an underactive thyroid involves just a single natural thyroid hormone supplement pill once a day for life, and the dose can easily be adjusted to keep your blood levels and your metabolism normal. In contrast, treatment of an overactive thyroid involves taking several pills each day containing medications that on occasion may cause side effects and that require frequent check-ups.

Surgery
Surgical removal of the thyroid gland (an operation called a thyroidectomy — ectomy meaning removal) is very effective in the treatment of Graves’ disease. It has the advantage of being the quickest way to deal with the problem.

As with taking a radioactive iodine treatment, surgery usually leaves the patient with an underactive thyroid gland that requires life-long therapy with a single natural thyroid hormone supplement pill each day.

A skilled surgeon who does this type of surgery frequently best performs thyroidectomy. Ear, nose, and throat surgeons and some general surgeons perform this operation. It usually requires only a single overnight stay in the hospital, and the recovery time requires about 2 weeks, though the patient is usually instructed to avoid heavy lifting for about a month.

The surgeon must take care to avoid damaging the nerves to the vocal cords which run along the windpipe beneath the thyroid. Damage to these can result in temporary or permanent hoarseness. In addition, four small pea-sized glands called the parathyroid glands (para means next to) lie next to the thyroid and must be left undamaged and in place.

These glands control the calcium level in the blood and if they are damaged the patient will have a low calcium level that will require treatment with extra calcium and vitamin D pills each day. In the hands of a skilled surgeon, these complications should occur to only about one in every 100 patients undergoing surgery.

In spite of this low incidence of complications, thyroidectomy is used only infrequently to treat Graves’ disease because most patients would prefer to avoid surgery if possible. Perhaps the only strong indication for surgery is in a pregnant patient who has severe Graves’ disease that is not being controlled with antithyroid medications.

If a patient decides to have a radioactive iodine treatment, she of he will likely be referred to a specialist who is trained in the use of radiation. These include radiologists, radiation therapists, and some endocrinologists. Before the treatment, the patient will be asked to have a radioactive iodine uptake test.

This is an easy test that involves swallowing a pill containing a very tiny dose of radioactive iodine. The next day the specialist puts a counter over the lower part of the neck of the patient to determine how much radiation has stuck in the thyroid gland. The physician may tell that patient that the uptake is 60 percent at 24 hours. This means that 60 percent of the radiation in the test pill went into the thyroid during a 24-hour period.

Normally, the thyroid takes up only about 20 percent of a test dose of radioactive iodine, but in Graves’ disease the value is usually much higher because the gland is so overactive. Based on this uptake test number and the size of the patient’s thyroid gland as determined by palpation, the specialist will decide on the treatment dose of radioactive iodine.

In general, the bigger the thyroid gland and the lower the uptake measurement, the larger the dose of radioactive iodine that will be need. Usually doses of radiation between 5 to 20 millicuries are used. If the patient has been taking PTU or methimazole, these must be stopped for about one week while the treatment is given. Beta-blockers, however, can be continued right through the treatment.

Since a radioactive iodine treatment can not be given to a pregnant woman, it is important that all women in their reproductive years have a pregnancy test before they are treated. Female patients are usually asked to do this even if they are taking birth control pills or using some other form of contraception.

At the time of the treatment, the radiation specialist explains to the patient certain precautions that need to take at home for about three days after the treatment. These are necessary because small amounts of radiation will be present in the saliva and urine for a period of time. So it is best to be sure that family members do not use the patient’s eating utensils if they have not been washed and that the patient take care while using the bathroom.

In addition, patients are asked to avoid close contact for extended periods of time with family members. For patients with young children this can sometimes be difficult. Although these instructions sound alarming, they are really just common-sense precautions, and with a minimal amount of care, a radioactive iodine treatment does not present any health risks to the patient, or her or his family.

Although radioactive iodine is a very good treatment for Graves’ disease, there are some disadvantages. First of all, it usually takes three to four months before the hyperthyroidism is controlled. So if the patient is not also taking antithyroid drugs, it will be some time before the thyroid comes under control. The use of beta-blockers can help with the symptoms during this period of time.

Secondly, the radioactive iodine treatment usually leaves the patient with an underactive thyroid gland. This is because it is difficult for the specialist to judge exactly how much radioactive iodine will be needed to bring the activity of the gland exactly back to normal. If too low a dose of radioactivity is given, then the treatment will not be effective and the patient will continue to be hyperthyroid. Most specialists therefore choose a dose of radioactive iodine that they are confident will be effective so as to avoid the inconvenience of making the patient go through a second treatment.

An important aspect of a radioactive iodine treatment is the checkups that are required after therapy. Patients should generally have checkup at monthly intervals for the first 5-6 months to measure their blood levels of T4 and T3, and later of TSH.

If the patient is on antithyroid medications, these need to be adjusted and then stopped when the radioactive iodine treatment becomes effective.

In addition, it is very important to determine when the patient’s thyroid gland becomes underactive so that a thyroid hormone supplement can be started. This will usually need to be continued for the rest of the patient’s life.

This condition develops in only three of every 1,000 patients that takes one of these drugs. Signs that this may be occurring include the development of fever, sore throat or a sore mouth. Patients should stop the PTU or methimazole immediately if these develop and call their physician, who will probably order a blood count to check for the number of granulocytes.

If agranulocytosis is present, the condition will reverse itself with a few days of stopping the medication. However, if the medication is continued, severe and even life-threatening infections may occur.

One other uncommon side effect of these drugs is damage to the liver. Symptoms of this include severe fatigue or the presence of a yellowish discoloration of the white parts of the eye, a condition called jaundice. Liver problems are also reversible once the medication is stopped. If a patient develops agranulocytosis or liver damage from either PTU or methimazole, they should not take either of these drugs ever again.

There is a second group of medications, called beta-blockers, which are also very useful in the treatment of Graves’ disease and other forms of hyperthyroidism. These medications are often used in combination with PTU or methimazole since they work in a different way.

Instead of slowing the production of hormone in the thyroid gland, these medications block the effects of the high hormone levels on the heart, brain, and other tissues. Because they work very rapidly, beta-blockers can help to almost immediately relieve some of the symptoms of hyperthyroidism, particularly the rapid heart beat and tremor.

However, their effects are not complete, and if used alone, some troublesome symptoms of hyperthyroidism may persist. Most commonly, beta-blockers are used at the beginning of treatment along with PTU or methimazole, and are then stopped when the thyroid hormone levels in the blood are back to normal. Many different beta-blockers are now available.

Propranolol, which is the original beta-blocker first developed several years ago, is still as effective as the newer medications in treating the symptoms of hyperthyroidism. Typically a dose of 20 to 40 mg of this medication taken three to four times a day will be prescribed. Long-acting preparations that can be taken only once or twice a day are also available, but are more expensive. Beta-blockers should be used with caution for patients with a history of asthma, as they may aggravate this condition.

Radioactive Iodine Treatment
Radioactive iodine has been used in the treatment of hyperthyroidism and other thyroid disorders for over 50 years. Millions of individuals have been treated worldwide with this agent. It has an excellent safety record and is extremely effective in slowing down the thyroid.

Additional advantages are that it is easy to administer without the need for hospitalization, is almost always a painless form of treatment, and the chance that the hyperthyroidism will return after a successful treatment are extremely low. Thus, a major advantage of a radioactive iodine treatment over antithyroid medications is that it results in a permanent cure of the condition in most patients.

Although some patients are understandably concerned about swallowing a radioactive pill, large studies with tens of thousands of patients have demonstrated that it is very safe with no side effects. These studies have shown that after having radioactive iodine treatment there is no increased risk of developing cancer or leukemia.

In addition, women who take the treatment do not have an increased incidence of miscarriages, fertility problems, or having children with birth defects. Thus, many physicians view radioactive iodine as the treatment of choice for most patients with Graves’ disease.

Taking a radioactive iodine treatment involves simply swallowing a pill or a small drink that contains radioactive iodine. Because the thyroid gland actively takes up iodine to make its hormones, most of the radioactive material is taken up and sticks in the gland.

Over the next several weeks, the gland becomes damaged by the radiation and the amount of hormone produced is greatly decreased. Radiation that didn’t go into the thyroid gland gets excreted in the urine for a couple of days. It usually takes about two months for a radioactive iodine treatment to start to have effects, and about four months for the full effects to be seen.

Medications
Medications used to treat Graves’ disease include propylthiouracil (abbreviated PTU) and methimazole (TapazoleT). In Europe and other regions, a third drug called carbimazole is also available.

These drugs all have similar chemical properties and are frequently called anti-thyroid drugs. They work by slowing down the production of thyroid hormone in the gland. They do this by interfering with the thyroid’s handling of iodine.

As a result, the thyroid makes and secretes less T4 and T3 causing the hormone levels drop in the blood, the patient’s metabolism returns to normal, and the symptoms improve. Usually, it takes about two to three weeks for patients to start to feel better after beginning an antithyroid drug, and four to six weeks for the thyroid levels to get back to normal.

Most physicians will start out prescribing a relatively high dose of PTU or methimazole to be sure that the hyperthyroidism is brought under control as quickly as possible. The dose can then often be decreased as the thyroid hormone levels return to normal.

Such adjustments in the dose are based on checking the levels of T4 and T3 in the blood. This is an important part of the therapy, as it is possible to make the thyroid gland underactive if too high a dose of PTU or methimazole is continued. To make these adjustments, the physician usually sees the patient back in her or his office about every four to six weeks during the first few months of therapy.

A usual starting dose of PTU is two tablets (50 mg each) taken three times daily. Because methimazole is more potent and lasts longer in the body, it can be taken just once a day. A typical starting dose of this drug would be two or three tablets (10 mg each) in the morning. The actual dose prescribed may be higher or lower depending on the severity of the hyperthyroidism.

Some physicians take a somewhat different approach to adjusting these medications. If the thyroid levels drop below normal, they will instruct the patient to continue the antithyroid drug at the same dose and, in addition, take a thyroid supplement containing pure T4 each day. Several generic and brand name (SynthroidT, LevothroidT or LevoxylT) preparations of T4 are available by prescription.

If used properly, PTU or methimazole are very effective in treating even severe cases of hyperthyroidism. Other advantages are that they work relatively quickly, they usually do not cause side effects, and they avoid the need for a radioactive iodine treatment or for surgery.

The major disadvantage is that most patients (about 60-70 percent) will have a return (relapse) of their overactive thyroid if the medication is stopped, even after months of treatment. There are some patients, however, who stand a better chance of being able to eventually stop PTU or methimazole. In general these are female patients with mild degrees of hyperthyroidism and thyroid glands that are not very enlarged.

In such cases, treatment with medications may allow the immune system to calm down and the Graves’ disease to disappear. When that occurs, physicians say the patient’s Graves’ disease is in remission. Unfortunately, some patient’s in remission will relapse after a few months.

Because of this strong tendency in most patients for the Graves’ disease to relapse, many patients will choose to start their treatment with one of these medications, and then, after their symptoms have improved, undergo a radioactive iodine treatment as a way of permanently dealing with the disease.

Although most patients do well while taking PTU or methimazole, side effects do occur. The most common one is a rash accompanied by itching. In cases of a mild rash, this will often disappear even if the medication is continued. But if the rash is severe, the medication should be stopped. In some cases a patient with a rash can be switched to the other medication and will do well.

You might ask “What would you want in my position?”, “If this were your spouse, what would you do?”, or “If this were your child, what would you want?”

You can also ask about other sources of information, or about getting a second opinion.

Once you are fully informed, you and your doctor can work together to pick the best course of treatment. Before deciding, though, give yourself time to think about these important issues:

How much pain am I willing to endure?

How much risk am I willing to take?

How much cost am I willing to bear?

Bring along your ideas, as well. If you read or hear about a treatment or medication you would like to try, bring the information with you.

Ask your doctor if it could work for you. That way, you can make informed decisions about your own care.

There are a number of lactose-free nutritional supplements designed specifically for the elderly. Some names are: Ensure, Sustacal and Resource. The nursing home is required to have a plan of action regarding your aunt’s food intake. She may not be able to chew or swallow what is offered, she may need help being fed, or may need a detailed diet history taken of food likes and dislikes. Her tray may need to be altered accordingly.

She could be offered high-calorie snacks and drinks. Many nursing homes routinely offer the high calorie lactose-free drinks. Your aunt’s doctor can order special nutrition intervention for her.

It may be that all of these things have been done, and she still will not eat because of changes in her taste buds or digestion, her underlying illness, or depression. Family can request a patient care conference with the nursing home to evaluate the situation. Ask for their help, and follow-up regularly.

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