HemoDoc, From Doctor to Patient

NBC Report on Dialysis Reveals Continued Media and Nephrology Bias

By Peter Laird, MD

NBC did several background videos on dialysis to accompany their  recent ProPublica feature report which  in my opinion continues the false impression that dialysis is a horrible treatment and renal transplant is our only hope. They correctly pointed out the need for a fistula to avoid complications of catheters, patients fear of needles, risks of infection and reduced clearances, but the primary focus was that of renal transplant implying that renal transplant is the only true hope.  This report based on the ProPublica series returns to the sad bias, in my opinion, now also by NBC of the only hope for patients with CKD-5 is to avoid dialysis and get on the transplant list early.

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Visit msnbc.com for breaking news, world news, and news about the economy

I would hope that one day, a true and unbiased report on all renal replacement options, including optimal dialysis strategies would be headline news on a national network. Unfortunately, even noting the ProPublica report as the first part of the NBC nightly news that accompanies these videos gives the very biased viewpoint that dialysis is dangerous and that the only hope is renal transplant. Yet, for those that are not part of the 15,000 or so that get a renal transplant in the US each year, we must continue with dialysis as our mainline treatment option.  Yes, for many, renal transplant transforms their life, but so likewise does daily, nocturnal dialysis which is equal in survival to cadaveric transplant, and you don't have to wait to survive 5-8 years to get that survival benefit.  

While I applaud the attention that NBC focused on the ProPublica Dialysis series, it did so in my opinion, by continuing the myth of the gift of life only from renal transplant.  In such, their report will only bring continued death and destruction to hundreds of thousands of dialysis patients because NBC chose to completely ignore optimal dialysis in these 4 segments.  What a failed opportunity.

The dialysis  industry spin continues and people continue to die needlessly because home dialysis options are overlooked at the hands of our nephrologists who fail to inform.  Dr. Barbara Murphy of Mount Sinai Medical Center, in my opinion, is simply the latest biased nephrologist failing American dialysis patients by lack of informed consent of all renal replacement options, even more so on a national news program.  Perhaps she did speak of optimal dialysis, and NBC chose to exclude that discussion in her three segments, I will give her the benefit of the doubt on that issue, but certainly NBC could have chosen to truly educate but did not do so in 4 separate dialysis segments.

You may wish to contact Dr. Murphy at the link above and inform her of your opinion on optimal dialysis issues as I plan to do myself since she failed to make mention of anything outside of in-center dialysis other than renal transplant in three news segments focussed on dialysis especially in light of the recent FHN results.  I will be more than willing to run a full rebuttal by NBC or Dr. Murphy on my blog as well, should they choose to do so.

Not surprisingly, Dr. Barbara Murphy's specialty is renal transplant medicine.  Why would NBC choose a transplant specialist to tell us about dialysis?  Why not a dialysis specialist such as Dr. Chris Blagg, Dr. Robert Lockridge or Dr. John Agar? I can only state that the bias against optimal dialysis appears to run deep in my opinion, even at NBC nightly news. After all, these 4 segments were featuring dialysis, not renal transplant.  Shall the truth ever be told? This is simply my own opinion and my own personal impression of the 4 NBC nightly news segments on Dialysis.

ProPublica Dialysis Facility Tracker Featured on NBC Nightly News

By Peter Laird MD

The recent ProPublica article on dialysis facility reports is featured on a  Brian Williams NBC nightly news special report showing how the lack of information may have contributed to the death of one patient at Dutchess Dialysis Center in Poughkeepsie, NY in 2006.  This is a center that had a much higher than expected rate of death but was listed by CMS as "expected" death rate on its Dialysis Facility compare.

The NBC clip highlights the difficulty that dialysis patients have had obtaining needed information until ProPublica made available the dialysis facility tracker. It further highlights the entire issue of lack of informed consent for dialysis patients to hear of all renal replacement options at the onset of the need for such treatment. Not only do patients rarely hear of home hemodialysis from their health care team, even worse, they previously could not tell which units were better than others to make an informed choice since CMS released only partial data on these facilities and worse yet, hid the true death rates by terms of expected death rate even many times the facility in question had much higher than average death rates.  In such, the ProPublica Dialysis series has entered a new arena of not only investigative reporting, but actual consumer choice by making available this data for the very first time.

A Tale of Two Cities: The Story of Dialysis in America

By Peter Laird MD,

The influences of two cities in America during the last fifty years is the tale of two cities taking the technology of dialysis in two different directions. Truly, "It was the best of times, it was the worst of times..." Dr. Scribner in Seattle started the entire field of chronic hemodialysis by his inspiration in the middle of the night for the Scribner Shunt.

Belding Scribner: The Inventor of Shunt Dialysis 

Scribner came upon his idea in 1960 after he saw a young man recover briefly following dialysis, only to die a few weeks later. At the time, haemodialysis could only be performed for a few cycles. In a painful procedure, glass tubes were inserted into a patient’s blood vessels, permanently destroying them for further access.

The patient weighed on Scribner’s mind until one night when he suddenly awoke with an idea of how to save patients with end stage kidney disease. He would fashion a loop between an artery and vein, allowing the device—rather than the patient’s own vessels—to be opened and closed with each cycle of dialysis. that it was just like turning on the light from the darkness.” 

Dr. Scribner, a patient in his own right from chronic eye problems, immediately freely gave his invention to the medical world for one sole purpose, to save lives, profiteering never entered his mind.  This gift followed the example of Wilhelm Kolff, the inventor of the first workable dialysis machine who freely gave his invention to the medical world to save lives as well.

Kolff’s machine is considered the first modern drum dialyzer, and it remained the standard for the next decade. At the time of its creation, Kolff’s goal was to help kidneys recover. The brave doctor had no way of knowing that his invention was one of the foremost life-saving developments in the history of modern medicine.

After World War II ended, Kolff donated the five artificial kidneys he’d made to hospitals around the world, including Mt. Sinai Hospital in New York. Because of this unselfish act, doctors in many countries were able to learn about the practice of dialysis.

Wilhelm Kolff gave the blueprints of his machines to Dr. Thorn at Peter Bent Brigham Hospital in Boston.  They shipped 22 of these machines updated at Brigham hospital around the world between 1954 and 1962.  Yet, it was not until Dr. Scribner invented his shunt that chronic hemodialysis beyond one or two treatments became a reality. Dr. Scribner immediately set out on his most important mission, to make this new technology widely available and he was the driving force behind the 1973 Medicare legislation initiating the ESRD Medicare program. The Seattle experience brought forth the new field of bioethics and the first dialysis unit opened which still operates now as the Northwest Kidney Center in Seattle, a non-profit organization that is still a leader in dialysis innovation today.

However, in Boston, a new corporation sprang forth from among the Peter Bent Brigham  Hospital doctors called National Medical Care, Inc.  After two years, in 1970, it became the first for-profit dialysis company. The era of altruistic innovations gave way to the era of grand profiteering on a monumental scale. Despite its initial humble beginnings with the Kolff-Brigham machine, Boston would become the most influential center of dialysis making the goals of for-profit dialysis as the standard of care in America. 

Dr. Edmund G. Lowrie, in a 1978 Medicare hearing changed the face of dialysis in America from predominantly a home based therapy given three nights a week for a total of 27 hours, into the current ultra-short hemodialysis of 3-4 hours sessions, thrice weekly.

The politics of health cost containment: end-stage renal disease

R.A. Rettig (pages 132-133)

Dr. Edmund Lowrie of Peter Brent Brigham Hospital attacked the Seattle experience directly on two points: "our analysis indicates that the cost of self-care dialysis is not significatly less than limited care dialysis, and that the the indiscriminate use of home dialysis may lead to unacceptable patient mortality." . . . "After careful analysis," Lowrie claimed, "the only obvious reason for this inferior patient survival that we can think of is the indiscriminate use of home dialysis therapy." Lowrie's testimony created the impression that three-year survival ofhome patients in Seattle was unacceptably low. But as Blagg later pointed out, the 58% applied to all Seattle patients, center and home, and inclued elderly and diabetics insignificant numbers.⁵⁰ "When we look at patient survival on home dialysis ," Blagg wrote, "and exlude the center dialysis patients, the 3-year survival in our program is 74 percent including diabetics; if we exlude diabetics, the 3-year survival rate in pateints aged 55 of less is 81 percent on home dialysis. . .

But the political damage had been done. 

The cast was set once again by Edmund Lowrie, et al after the Boston based NCDS ( NCDS: Revisited Three Decades Later) pronounced Kt/V as the best measure of dialysis "adequacy" and for the next thirty years, outcomes in America plummeted to the lowest of all developed nations while at the same time, the predominantly home based American therapy given to us from the Seattle model of care passed over to the Boston model of care in for-profit centers giving short, thrice weekly treatments.  At the time of the hearings in 1978 on the future of dialysis in America, where the best model we know today of home based, long nocturnal therapies, fell at the hand of what we now know is the incorrect testimony by Edmund Lowrie that in-center care was better, Dr. Lowrie was a high ranking corporate officer in the for-profit dialysis chain, National Medical Care, Inc. Indeed, he later became the president of this corporation. In response to the 1995 Kurt Eichenwald NY Times article, Death and Deficiency in Kidney Treatment, the dialysis industry responded in a letter to the editor: "There is no evidence that an adequate Kt/V delivered in 2.5 hours in[sic] inferior to the same dose delivered inefficiently in 4 or 5 hours. We believe it is to everyone's advantage - patient, provider and payor - to deliver high quality dialysis efficiently at a time of limited resources." 

The story of National Medical Care, Inc. in my opinion, is one of obscene profits soon after the ESRD Medicare program began paying for all dialysis care in America .  Even Jack Anderson, the prototypical investigative reporter of decades past took notice of the "padding" of dialysis costs by National Medical Care, Inc: Clinics Pad Kidney Dialysis Costs.  

The story of dialysis in America truly follows the tale of two cities, that of Seattle giving us chronic hemodialysis, thrice weekly overnight at home for 27 hours weekly, it gave us the first non-profit dialysis center, started the field of bioethics, and has continuously fought against those that have instead turned dialysis into one of the most outlandish profiteering medical schemes in history. Boston, on the other hand ultimately gave us National Medical Care, Inc., the NCDS and those that reduced a life saving technology done best at home into one, in my opinion, of death, despair and disability that we now own today as our American legacy of dialysis for the simple reason, in my opinion, of turning the highest profits. Improving dialysis care in America today can best be accomplished by simply turning time back to the Seattle model of care.  

The Boston experiment of dialysis care in America is a failed trial of medical care at best founded on the for-profit industry standards.  We can do better here in America, and it is my hope that we shall.

 

Exercise Risks at the Health Club

By Peter Laird, MD

Exercise is an important activity to prevent and in some cases treat chronic health problems such as HTN, diabetes and chronic kidney disease with studies showing improved survival in all of these risk groups.  However, taking your exercise regimen to the local gym might endanger patients unduly, especially for people who are already at high risk of developing infections from these chronic medical conditions.  MRSA is a resistant bacteria previously seen in hospitalized patients, but now there is a subset of patients who develop a community based strain of MRSA.  Health clubs are one of the most common sites where MRSA is spread from person to person.

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Exercise remains an important adjunct to dealing with chronic medical conditions, but where you choose to exercise is important. Prevention of acquired infections should be one consideration when deciding on an exercise program. Fortunately, there are many options that do not place people at increased risk. Grab the running shoes and beware of communal spread of infectious agents.

 

Is Dialysis a "Horrible Treatment"?

By Peter Laird, MD

A recent link in I Hate Dialysis about a young mother who skipped dialysis treatments and died regrettably at the age of 38 leaving behind young children further brought to light the negative attitude that patients and doctors have towards this remarkable gift of life.  Sadly, those that miss treatments are some of the highest risk dialysis patients for adverse events, especially sudden death.

For patients, dialysis as practiced in many units is difficult to tolerate with their tendency to high ultrafiltration rates leading to cramping, nausea, vomiting, hypotension and at times patients actually faint. No doubt, dialysis needs not to be such an event.  Longer treatment times, more frequent and gentler approaches to dialysis render sessions well tolerated. Nevertheless, many who dialyze and their physicians view this life saving treatment in negative terms:

Young mum died after missing dialysis

Consultant Nephrologist, Dr Peter McClelland, from the Countess of Chester said: “Dialysis is a horrible treatment. I wouldn’t wish it on anybody.

“But those people who embark on it usually see it has an end point, to make it worthwhile entering those treatments. Most people recognise it is a means to an end.”

I take issue with Dr. McClellands dire pronouncement of dialysis as a horrible treatment. I am currently hooked up to my machine in the comfort of my own home.  My wife provided me with my favorite meal, and under my shroud of blankets, I am not in the least suffering. I was able to speak to Rich Berkowitz of NxStageUsers  while dialyzing and write two posts for my blog.  Dialysis practiced in an optimal manner is anything but horrible.  I feel sorrowful not only for patients who do not have access to optimal dialysis, but also for nephrologists who fail to realize the true potential of this noble experiment as Dr. Scribner called dialysis.  Dialysis is not horrible at all in the hands of those that use it wisely and humanely.

ProPublica Introduces Dialysis Facility Tracker

By Peter Laird, MD

Robin Fields of ProPublica introduced the Dialysis Facility Tracker, a website where patients can obtain previously confidential information about their individual dialysis centers.  This will be the best way for patients to be able to compare regional dialysis units to be able to choose the center that has the best outcomes.  CMS has collected this data for years, but has never before made it available.

For years, the government has collected a rich store of data about the performance of individual dialysis facilities. But it has kept nearly all the information secret from those it might benefit most: Patients.

Now ProPublica has obtained this data under the Freedom of Information Act. We are making a comprehensive set of clinic records publicly available for the first time on our website.

Patients and others can search for a clinic and see how it compares on 15 key measures, ranging from mortality and hospitalization to transplant rates and infection control. Also on the site are historical reports dating to 2002.

Patients are already responding and questioning their providers on infection control issues and other parameters now open to the public for the first time ever.  I applaud the efforts by Robin Fields and ProPublica in publicizing the plight of American dialysis patients.  Even congress has taken notice with a letter by Senator Grassley to CMS to answer the issues raised in Robin Field's first article, In Dialysis, Life-Saving Care at Great Risk and Cost.  Dialysis in America is at a cross road and we need to go in the right direction this time.  

NCDS: Revisited Three Decades Later

By Peter Laird, MD

The debate over length of chronic dialysis sessions began nearly as soon as Dr. Scribner solved the access issues with the Scribner shunt in 1960.  Fifty years later, it is still a topic of debate. Dr. Chertow, et al, recently published an observational study based on the USRDS data base looking at mortality and treatment length per session:

Shorter dialysis times are associated with higher mortality among incident hemodialysis patients

On primary marginal structural analysis, session lengths <4 h were associated with a 42% increase in mortality. Sensitivity analyses showed a dose–response relationship between session duration and mortality, and a consistency of findings across prespecified subgroups. Our study suggests that shorter hemodialysis sessions are associated with higher mortality when marginal structural analysis was used to adjust for time-dependent confounding. Further studies are needed to confirm these findings and determine causality.

Glenn Chertow will report on these findings further at the Annual Dialysis Conference in Phoenix as the key note speaker.  Certainly, this is an important study in its conclusions, yet why has it taken 50 years to resolve this rather simple concept in dialysis outcomes? Sadly, The National Cooperative Dialysis  Study (NCDS) from 1981 should have already lead to accepting longer treatment times and to avoid shorter dialysis sessions than 4 hours.  

The NCDS was the first dialysis RCT with four treatment arms: Group I) high BUN clearance and time of 4.5-5 hours, Group II) low BUN clearance and time 4.5 - 5 hours, Group III) high BUN clearance but short time of 3-3.5 hours, Group IV) low BUN clearance and short time of 3-3.5 hours.  The study was stopped prior to the targeted completion date because of significant adverse outcomes in Group II and Group IV which were the lowest BUN clearance groups.

The best outcome in the NCDS was high BUN clearance and long treatment sessions of 4.5-5 hour length seen in Group I. Despite this, the dialysis industry gravitated to shorter and shorter dialysis sessions justifying their use by "adequate" Kt/V clearances derived from a post hoc analysis of the NCDS.  The authors of the NCDS did discuss briefly the element of time as a factor in improving dialysis outcomes, yet continued the main focus of the article on urea kinetics, as did the dialysis industry in general for the next three decades.

Treatment duration appeared to contribute somewhat to morbidity, since Group II had more hospitalization then Group I, and Group IV had more than Group II. Fluid removal is limited by the duration of dialysis treatment. Although there are marginal effects suggesting that short-duration therapy may be inferior to longer-duration therapy, these effects are minor when compared with the effects of TAC_urea. Interpreting the contribution of dialysis TIME to morbidity, however, is made more difficult by the observation that TAC_urea was slightly higher in the two short-TIME groups than it was in the two longer-TIME groups. Furthermore, we cannot make inferences about the effect of treatment times that exceed the limits of those employed in this study (six hours or two hours).

I am taken aback by the NCDS authors discussion on duration of dialysis sessions especially in light of the nearly 30 years of adverse dialysis outcomes in America by adhering to the Kt/V as the single best determinant of "adequate" dialysis.  Clearly, the NCDS showed a profound impact of duration of dialysis sessions on outcomes in this relatively small and short duration RCT when viewed by the hospitalization rates analysis.

Time was clearly an independent factor of improved outcomes. Yet the authors chose to focus mainly on the biochemical clearance which no doubt is also an independent variable in patient outcomes, but not alone. Both improved urea clearance and time are important factors and neither should be ignored, yet history records that those that promoted longer and more frequent sessions continued to be maligned for decades despite many studies showing its benefit even before the NCDS was published.

I take issue with the authors of the NCDS who, in my opinion, belittled and essentially ignored the effect that time and total duration of each session had on the outcomes. At the same time, they elevated biochemical measures, specifically urea clearance as the most important factor alone. This allowed the dialysis industry to justify what had been termed ultra short dialysis to become the new standard of care as long as the Kt/V met minimum goals.  In addition, the dialysis industry did not conduct any further RCTs looking at the independent factor of time or frequency of dialysis until the Toronto group published a small RCT on nocturnal dialysis in 2007 and 2010 when the Frequent Hemodialysis Network Trial Group study was published.  

While Dr. Chertow, et al present a very welcome analysis of dialysis outcomes based on duration of dialysis sessions more than 4 hours, in my opinion, it is nearly 30 years too late for the hundreds of thousands, perhaps millions of patients who suffered in the American dialysis industry while their nephrologists calmly assured them that their dialysis was adequate based on Kt/V. We cannot go back in time, but assuredly we can stop the future debate on dialysis session length. What more do we need to know than the established fact that more frequent and longer duration dialysis saves lives.  Isn't that what Dr. Scribner told us back in the 1960's?

Ultrasound Improves Fistula Patency

By Peter Laird, MD

Fistula First, the initiative to improve placement of arteriovenous fistulas for dialysis access reached 57.1% in October of 2010, yet this still falls short of nations such as Japan with over 90% of patients utilizing fistulas for dialysis access.  A recent randomized study on the use of preoperative vascular ultrasound may improve the success rate of fistula placement:

Routine Preoperative Vascular Ultrasound Improves Patency and Use of Arteriovenous Fistulas for Hemodialysis: A Randomized Trial

Results: AVFs were made in 208 of 218 randomized patients. Clinical and ultrasound groups were similar in terms of patient characteristics, allocation to individual surgeons, and proportion of forearm AVFs. The ultrasound group had a significantly lower rate of immediate failure (4% versus 11%, P = 0.028) and, among failed AVFs, less thrombosis (38% versus 67%, P = 0.029). Primary AVF survival at 1 year was not statistically different (ultrasound = 65%, clinical = 56%,P = 0.081). Assisted primary AVF survival at 1 year was significantly better for the ultrasound group (80% versus 65%, P = 0.012). The number of patients requiring preoperative ultrasound to prevent one AVF failure was 12.

Conclusions: Routine preoperative vascular ultrasound in addition to clinical assessment improves AVF outcomes in terms of patency and use for dialysis. National Research Register, United Kingdom, trial number N0046131432.

Previous studies also show that the number of fistulas placed in training by vascular surgeons corresponds to better rates of success as well.  For those that perfom less than 25 fistula procedures in training, they have poor rates of patency.

Enhanced Training in Vascular Access Creation Predicts Arteriovenous Fistula Placement and Patency in Hemodialysis Patients: Results From the Dialysis Outcomes and Practice Patterns Study. 

Significant predictors of fistula versus graft placement in hemodialysis patients included number of fistulae placed during training (adjusted odds ratio [AOR] = 2.2 for fistula placement, per 2 times greater number of fistulae placed during training, P < 0.0001) and degree of emphasis on vascular access creation during training (AOR = 2.4 for fistula placement, for much-to-extreme emphasis vs. no emphasis, P = 0.0008). Risk of primary fistula failure was 34% lower (relative risk = 0.66, P = 0.002) when placed by surgeons who created >/=25 (vs. <25) fistulae during training.

CONCLUSIONS: Surgical training is key to both fistula placement and survival, yet US surgical programs seem to place less emphasis on fistula creation than those in other countries. Enhancing surgical training in fistula creation would help meet targets of the Fistula First Initiative.

Microscopic surgical techniques more widely used in pediatric cases is also a promising adjunct to increased cases in training and vascular ultrasound.  Perhaps the best indicator of success with fistula placement is the size and condition of the veins in the arm.  All patients with CKD who may be at risk of developing the need for renal replacement therapy need to preserve these veins by avoiding blood draws and BP checks.  Using the distal veins in the hands is the preferred site for blood draws.  Exercises to improve circulation in the arms is highly recommend as well.  A concerted effort to improve dialysis access is a proven method of reducing dialysis related complications.  Use of the vascular ultrasound is a step in the right direction.

NxStage Celebrates Seven Years of Continuous Home Dialysis

By Peter Laird, MD

NxStage announced the seven year anniversary of its first patients to go home on the NxStage System One, the only FDA approved home dialysis system in America.  These patients came from the original studies on the NxStage System One and they have simply continued without going back to the usual in-center care:

Everette had been undergoing in-center dialysis treatments when he learned about daily home hemodialysis with NxStage. "For the past seven years, the NxStage System One has given me the freedom to live my life closer to the way I want to live it and allowed me to dedicate more time to my hobbies and business dreams," he said.  "Thanks in part to NxStage and dialyzing more frequently, I feel more healthy and active. I've come off several blood pressure medications and play basketball twice a week while spearheading my online clothing store."

"This is a tremendous milestone not only for these patients, but also for all of our patients, prescribing nephrologists, partners and employees," stated Jeffrey H. Burbank, founder and CEO of NxStage Medical, Inc. "We are extremely gratified to see these patients thriving and are excited to expand access to the life changing benefits possible with more frequent home hemodialysis using the System One to a growing number of patients worldwide."  

Congratulations to NxStage with not only their success in the clinical arena of home dialysis, but also in the fact that they are the first financial sustainable home dialysis corporation which is opening up the doors to further improvements and competition among other dialysis providers.  I am personally thankful for this extraordinary little machine that has given me the freedom and the oppportunity to obtain daily dialysis, the only proven dialysis strategy that improves the burden of disease for dialysis patients as shown in the recent FHN.

Eating Almonds to Avoid Diabetes

By Peter Laird, MD

Dietary modification is a long recognized intervention for patients at risk of developing diabetes, but many of those modifications come at the price of convenience and taste. An interesting article recently published shows that eating almonds reduces LDL cholesterol as well as improving insulin sensitivity.

Almond Consumption and Cardiovascular Risk Factors in Adults with Prediabetes

Results: The almond-enriched intervention group exhibited greater reductions in insulin (–1.78 µU/ml vs. +1.47 µU/ml,= 0.002), homeostasis model analysis for insulin resistance (–0.48 vs. +0.30,= 0.007), and homeostasis model analysis for beta-cell function (–13.2 vs.+22.3, p = 0.001) compared with the nut-free control group. Clinically significant declines in LDL-C were found in the almond-enriched intervention group (–12.4 mg/dl vs. –0.4 mg/dl) as compared with the nut-free control group. No changes were observed in BMI (–0.4 vs. –0.7 kg/m² 0.191), systolic blood pressure (–4.4 mm Hg vs. –3.5 mm Hg, = 0.773), or for the other measured cardiovascular risk factors.

Conclusions: An ADA diet consiting of 20% of claories as almonds over a 16-week period is effective in improving markers of insulin sensitivity and yields clinically significant improvement in LDL-C in adults with prediabetes.

Overcoming some of the restrictions of the American Diabetes Diet by adding what many people consider a delectable item to an otherwise restrictive diet with these sort of dramatic results is good news for patients concerned about avoiding diabetes.  Previous studies have shown the benefit with LDL-C reduction from a diet with 20% of carbohydrates from almonds, but the connection to improved insulin sensitivity, a key component of Type II diabetes is an interesting new observation.

Taken in perspective with weight loss and exercise, modification of the diet to include more nuts such as almonds is an elegant adjunct in its simplicity for the primary care physician caring for the prediabetic patient.  The impending epidemic of diabetes in America and around the globe will have serious and long lasting consequences for individuals as well as society in general by its impact not only on the health care system, but in lost productivity as well.  A handful of almonds a day may just keep the doctor away.