Biopsy scheduled

 Dr. Ronald Benoit, a UPMC urologist, advised me yesterday during my "emergency" appointment that he was confident my most recent Prostate-specific antigen test or PSA does not indicate prostate cancer. Music to my ears. PSA levels, he said, can fluctuate dramatically, and he's confident that it was one such inexplicable fluctuation that sent my PSA from a September reading of 2.6 -- well within the normal range ---  to 5.9 in October, which is almost two points higher than the 4.0 level that represents a level of concern.

He noted my previous trend of declining PSA from 3.9, then 3.2 last April, to 2.6, with no signs of cancer.

But the critical point is this: Only a biopsy of the rostate gland will convince the team at the Thomas E. Starzl Transplantation Center that I have no cancer. Understand that prostate cancer would prevent me from qualifying for a kidney-pancreas transplant due to the fact that immunosuppressants drugs, necessary to prevent organ rejection, would allow any cancer to thrive and jeopardize my health, my life.

That's to say there will be no transplant if cancer is present.

So I asked him to put me on the prostate biopsy fast-track. I'm scheduled to have the biopsy on Monday. It's an outpatient procedure but I'll be able to return to work on Tuesday. I will need to take antibiotics on Sunday through Tuesday to prevent infection.

So let the drilling begin. 

Now the good news:

Nephrologist Dr. Cynthia West reported what I already knew, that my kidney numbers were "excellent." Her word.

 I blushed and smiled.

They actually show a decline in my creatnine levels which means my kidneys might be functioning slightly more efficiently than perhaps doctors previous thought. While that number is positive, it's nothing to take to the bank.  It's but one test. My kidneys just might have been having a splendid kidney day when I got the blood work done.. 

Dr. West also has taken me off my prescription of Zemplar -- an active vitamin D medication necessary to help bring my parathyroid levels, which can be adversely affected by kidney function, back into the normal range.. Apparently my use of over-the-counter levels of vitamin D at 5,000 IUs per day has brought my parathyroid numbers well within the normal range, making the Zemplar unnecessary.

I got a second star on my forehead for that result.

She also said my efforts to control my diet have succeeded in lowering my potassium and phosphorous levels into the normal range.

Don't tell my boss, but my numbers, save for the creatinine level, are all normal.

"Excellent," Dr. West said. "I couldn't be more pleased."

So two more stars on the forehead. Four big stars. I could hardly see to drive.

So the sole test necessary to determine my eligibility for a kidney-pancreas transplant remains the prostate biopsy. I should have results on that next week. That alone will determine my eligibility.

Stay tuned..

Pondering dead limbs

On Sunday, Suellen and I went for a brisk walk, which ended up with an even brisker chase of our dog Nutmeg, who decided to go on an impromptu visit to the neighbor's house. They have dogs. Over the hilltop then into the valley we chased her until the neighbor had her by the collar and delivered her to us.

But before we went a-chasing "Nutmeg-nificent" through the woods and fields, we did have a grand moment to enjoy the expansive view of the homestead from our farm's high point. To the left is a photo from near the top of the property.

And it's funny how pending health problems can alter life's focus -- if you let it. Looking at the beautiful autumnal fields, with eyes darting across the expanses, I focused attention on the heartfelt beauty of farm and nature as my subconsious took its own detour to contemplate nature's cycle. The once green fields full of foliage and verdant colors now has faded into sepia tones. As Keats noted in "Ode to Autumn, "Where are the songs of spring?" Or, as he ultimately concluded, autumn certainly has its own songs that are equally compelling, if you listen. 

And my mind, contemplating diabetes as something of a metaphor for fall, honed in on dead limbs and lessons these dead limbs can teach those of us with diabetes.  Certainly people who do not manage their diabetes face a high chance of circulation problems that can lead to numbness, wounds and ulcers that often do not heal and create a series of problems including gangrene and sometimes amputations.  Dead limbs, indeed.  Diabetes is a major cause of limb amputations.  So I took note of all the dead limbs, with the mental note to mention them in this blog.

Then I noted that the spring running down the middle of the flarm did not have much flow as it does during times of normal rain. Reminded me of, yes, my lowly kidneys that are working overtime at about 16-20 percent function to keep my pipes drained and blood detoxified.

And while it does not relate directly to diabetes, the falling leaves can remind one of the thinning hair, with the gray sky also suggesting what color takes hold as the year -- and the hair -- ages.  And as with those aforementioned dead branches, I too have some knots in my limbs I didn't have a few years ago, although said limbs remain functional and still attached to the trunk.

I want to keep it that way.

The farm in autumn stresses the point that limbs from unhealthy trees do fall.

Despite sepia tones and gray skies, autumn always has been an inspirational and soulful time for me. It is a time to assess the state of health and confirm that aging is harmonious with nature. T.S. Eliot suggested that April is the cruelest month because it shows nature regenerating itself while people are condemned to getting older. That would suggests then that November is the kindest month. Thus the joy I experienced in beholding all the sepia tones and gray skies.

That said, I have two important doctors' appointments today, one that seems destined to go well and another that remains problematic.

The one I'm anticipating to go smoothly is the periodic go-around with my nephrologist Dr. Cynthia West. I've already seen my lab results and my phosphorous and potassium levels have fallen into the normal range. Both can go out of balance and rise in the blood due to poor kidney function. But I quit drinking pop (mostly diet colas) to reduce my phosophorous intake and also to allay bone problems. Carbonated water depletes the bones of calcium and has left me on the verge of osteoporosis -- low bone density. I should have quit drinking pop years ago, but I never realized how unhealthy pop is. Through dietary measures, I've also succeeded in reducing potassium levels in the my blood to the normal range.  High potassium levels can produce heart problems.

So I should get good grades from my nephrologist. 

But the problem appointment will be the one with urologist Dr. Ronald Benoit of UPMC. He again will test me for prostrate cancer due to an elevated PSA level detected during my evaluation last month at the Thomas E. Starzl Transplantation Center at UPMC Montefiore. That high reading was unexpected, given my PSA -- postate-specific antigen test --- one month earlier that fell well within the normal level.

I should have more insights by day's end.

So, within days, once my PSA test results come back, I should have a better assessment of whether or not I willl qualify for a kidney-pancreas transplant. I'm calm and collected but certainly anxious to see those PSA results. The kidneys, as with those branches and leaves, face the impact of life in autumn. It's known as fall for a reason. And if I fail to get on the transplant, then we're talking about a winter of discontent.

Ruminations about diabetes

I’ve always considered diabetes to be a solitary disease. Perhaps that’s my attitude because I’m a private person. You might not believe that, considering this blog. But, indeed, I’m just a shy Washington County guy.

My family, especially wife and daughters, keep alert to my sugar levels when they are around me. They observe my behavior and take action whenever I do something weird, become awkward or look or act crazy in a way that demands attention. That is when they give me a ready belt of sugar.

Wife Suellen often will ask whether my sugar is low when I’m acting strange, which is pretty much all the time, but not always due to low blood sugar. "So you need some sugar?" she will ask with her crinkled-lip scowl and serious stare-down.

And at work, coworkers unfortunate enough to have to sit near me are aware of my diabetes and readily l ask me if I’m OK when I don’t respond in a manner they are used to.

They, too, know when to retrieve some sugar. Sometimes they even offer me sugar when they think I’m getting shaky, when in fact I’m simply being my own version of normal.

Still, the daily routine of handling diabetes is an individual thing that requires one to stay attentive to sugar levels, alert to the time of day, ready to take action if the sugar climbs too high or dips too low, with plans to eat well ahead of the time when sugar levels become a crisis. A regular schedule is the best way to prevent sugar levels from plummeting unexpectedly.

Linda Siminerio, executive director of the University of Pittsburgh Diabetes Institute, has been preaching the concept of team management for years, and it’s a grand concept. People with diabetes need family, friends, doctors, diabetes educators, pharmacists and a host of others familiar with diabetes to help keep things under control.

The team approach represents the new paradigm of management, and Dr. Siminerio has led that charge successfully. The world is following her lead. It works to the extent that one reacts more fervently, perhaps psychologically, when others are watching and taking note of your success of failures. Who wants to let down the team or disappoint those who care? The team concept does work, especially for those who have had trouble with control.

That said, I remain something of a diabetes loner and recluse. I enjoy discussing diabetes with others and gaining new insights. But most of what I’ve learned has come the hard way, through experience. I don’t advocate doing it alone. I do have help when needed. I do seek help when necessary. But 99 percent of the time, I take care of my diabetes on my own.

And, even with a team involved, diabetes mostly is a solitary gig. One has to take stock of one’s own health and know how best to manage it. Mistakes will be made. But when management is tight, and the person is dutiful and responsible, mistakes are few.

I think what Linda Siminerio and her crew do is amazing and necessary. They have taken great strides in developing a means whereby most people can find success in managing a difficult disease. Anybody who has even mild problems with control should follow the management approach. Improvements will follow. You can almost guarantee it.

And the team will be proud.

But just realize that no one will ever care as much about your health as you do.

For that reason, you must be responsible for your own health and diabetes. If you, as I, have chosen to live as long and healthy a life as possible, you must have discipline. You must exercise. You must eat a healthy diet. You must take your medications. You must test your blood sugar. Then, and this is the key, you must react to any test that is not in the healthy range by taking medications or insulin, exercising or, if the sugar is too low, consuming some carbohydrates immediately.

Medicine, and I don’t mean to sound harsh, ultimately cannot save you from diabetes complications. There are treatments to assist you with heart problems, amputations, blindness and kidney failure. But there never will be a way to fully undo the harm uncontrolled diabetes does to your body.

Don’t think doctors and medicine can correct a lifetime of mistakes. Doctors certainly will try, but life is fragile.

And when the years pass and you have experienced relative success in controlling your diabetes, you will have no regrets, or perhaps fewer regrets. Happiness is good health.

Those who ignore their diabetes and figure they will beat the odds, won’t. It’s that simple. Look in the mirror and say it. What likely will occur instead are horrid complications. When the complications happen, it’s not too late to take action to improve your diminished health, but it could be too late to restore it to normal. And it could be too late to prevent a domino effect of health consequences.

With my declining kidney function, I do regret my earlier years when I did not care for myself as closely as necessary or heed doctors’ advice soon enough to prevent further problems. I’m glad I eventually did get things under control. But I do wish I’d been more serious about my diabetes at an earlier age.

In truth, diabetes treats you as you treat yourself. If you mistreat your body, it will take advantage of your vulnerability and do you double harm. Diabetes does to bodies what demolish derbies do to jalopies.

But if you take care of your body, diabetes will take heed and be kind you, as well. In this dance of life, diabetes follows your lead.

Any questions before the quiz?

Blood flow

A bit of good news from the Thomas E. Starzl Transplantation Center .  Amy Singh, my UPMC liaison, reported that I do have blood flowing through my carotid arteries.

She received the results of the carotid doppler exam I underwent last week, and they show that I actually have normal blood flow in the carotids. Now, in my humble opinion, this is excellent news. However, this news is subject to debate in my household. Wife Suellen has long claimed I have no blood flowing to the brain. But, hey, I now have confirmation from Washington Hospital who did the test and UPMC that received the results. My carotid is a veritable gusher.

I even heard the swooshing sounds during the test. The lady who did the testing told me if I didn't hear swooshing sounds, I would not be getting up from the table.

Now my only hurdle is the examination with the urologist to determine whether my high prostate reading, about a month after I had normal PSA numbers, indicates prostate cancer. If it does, it must be early in the process, since I had good results one month ago.

But I've always tried to beat the odds with some of my own self medications.

I take 5,000 IUs per day of vitamin D, which has anticancer properties and also helps the heart and bones, among many other benefits. I think I've experienced good results from my vitamin D regimen. When Suellen came home from work with H1N1 11 days ago and was in bed for a few days, I decided that first night not to share the same bed with flu-ridden Sue. But I made her chicken noodle soup, and poured her Ginger Ale, and made her toast and other food. After that first night, I proceeded to hang out with her in the house for the entire weekend, and we shared a bed after that first night apart. I actually did not sleep well in the bed in the other room, so I said I'll take my chances.

And, you guessed it, I never got the highly contagious H1N1 flu. I still plan to get the vaccine when it's available.

There's no way to confirm that my good results with H1N1 were due to vitamin D. But something had to be working to prevent me from contracting the infection.  A study came out several weeks ago saying that vitamin D helped to prevent H1N1. Based on that alone, I attribute my good results to my vitamin D intake.

We'll soon see if it, and other supplements that I'll discuss sometime later, have helped with my PSA.

Cow Graduation

The cows are gone. All eight heifers went back to the home farm of Shilling Hill. Our field is empty. Quiet. Our dog Nutmeg no longer has fresh Cow-logne to roll in. And I miss seeing them grazing and frolicking across the pasture.

But the moment won't pass without a video of their departure. See below.

When their owner, Bill Paxton, my esteemed brother-in-law and a dairyman whose farm is five miles away, came by with the trailer to pick them up, I decided to video the action. It typically is a pretty interesting ordeal. The cows felt at home in their private little field and had no interest in leaving it. Why should they? There is grass, a beautiful view, plenty of tree cover and, best of all, free food. Everyday is a cow buffet, including all the lush green grass you can eat, big round bales of hay and two buckets of delicious molasses feed every day.

Cow paradise. 

This year, five of the cows got herded onto the trailer without too many commotion. There was hay inside, so that was the attraction. But two real troublemakers, Marble and Eyebrow -- both destined to be cow criminals -- decided to rebel. They weren't going anywhere near that trailer, although they ultimately were attracted to a trough full of feed immediately outside the trailer door.

But the real killjoy? You guessed it, my favorite Woolly Mammoth -- the smallest and youngest cow. She had to be wrestled into halter then dragged and pushed and encouraged and encouraged yet some more, especially with a couple guys finally getting their shoulder's against her back lags and lifting to get the half-ton cow into the trailer.

I'm sure they were confused as to where they were headed next. Bill hauled seven of them to yet another farm, where they proceeded to break through an electric fence. Six of the seven ended up at yet another dairy farm. But Eyebrow could not be found.

Bill searched high and low and finally spotted her in a valley. Knowing he couldn't catch her there, because she had been spooked and was letting no one near her, he left with plans to return later to try to corral her. But Eyebrow had plans. Always interested in free food, she made her way to the barn of yet another local dairy farm, where the farmer was able to secure her into a stall.

And so another Year of the Cow comes to an end.

I did not do a whole lot to get the cows on the trailer. I was filming the action and did some chasing of the cows in the field. All the excitement and activity caused my blood sugar to dip to 52 mg/dL, which is pretty low. I had to retrieve a thermos full of grape juice before filling buckets with feed to be used to attract the cows.

So the field is empty, as is the heart, when the cows aren't there.

Hoof note: If I do succeed in getting a kidney transplant, I might have to avoid the cows for months or longer. My UPMC liaison Amy Singh said she saw the blog where I noted that I raise heifers each summer. She said I will have to stay completely clear of animal droppings once I have the transplant and am taking immunosuppressant drugs. Any exposure to what comes out of the south end of a northbound animal could cause infection.

As much as I enjoy cow-sitting each year, I told Amy that when it came to cows vs. a kidney, the choice was pretty easy.

Kidney wins.

Surprise letter

Yesterday, after a long and arduous day at work, I arrived home to have wife Suellen scold me for missing an important appointment at the Thomas E. Starzl Transplantation Center.

"Who, me? You're saying I missed an appointment at the transplantation center? No way!"

"Way."

I was stunned at the news, and the scolding, as I always am, or pretend to be, when Suellen scolds me with her skilled look and dour expression and searing words that penetrate my usually guilty soul like a steak knife (with serrated blade). Here I was, being called on the carpet, especially that dreaded Suellen carpet. I've been called on her carpet so many times there is a hole where I stand. Suellen is skilled in marital argumentation, and I cannot compete with her oratorial skills. So I should learn to shut up, even though I have not yet managed to shut up for 31 years of happy marriage.

 She restated her grand pronouncement and indicated that the proof was the letter on the table.

"This letter is to advise you that you missed your clinic appointment on 10/27/2009. Return appointments are important to insure proper medical care . . ."

 What? I had to think. The date, indeed, was the same day I spent about seven hours at the transplantation institute, where I met with about as many people as I have fingers and surrendered 16 vials of blood, all in the name of better health. I took a tuberculosis test, underwent three hands-on, groin-poking physical examinations, while listening to more lectures, and storing away more information into my brain files and learning more in those hours than I had since college. So much happened at the transplantation institute that my blood sugar had become almost dangerously low by the time I left the place.

Then the next day after the evaluation, I received an e-mail proclaiming my PSA test (test of antigens that could indicate prostate caner) was too high, requiring a retest to see if I have prostate problems. Just one month previous my PSA level had been well within the normal range. The institute also added another test to the 15 I'd already taken, this time an doppler carotid ultrasound. I had that test taken on Wednesday and await results. The test was required because I have had type 1 diabetes for 40 years, and they want to make sure my veins are clear enough to handle a transplant. They want both lanes of my arterial highways to be open, rather than be PennDOT-like with one lane or even a makeshift berm open with backed-up traffic and orange cones everywhere.

Or at least that's my interpretation.

In fact they were volleying around the idea of having me get an ultrasound of that much-poked groin artery, but they decided against it after all three certified pokers detected a reasonably healthy pulse.

This is a long way of saying, I DID NOT MISS MY APPOINTMENT, TRANSPLANTATION INSTITUTE. I was the warm-blooded mammal slumped in the chair all morning -- you know, the one with the orange hair, round goofy face and too-happy expression I employed try convincing everyone that I was transplant worthy.

How'd they miss my presence last week?

So I called the transplantation institute this morning. I had an edge to my voice. The person on phone took my social security number. I waited. She checked. Seconds ticked. And, yes, ultimately she apologized.

"Were you the warm-blooded mammal slumped in the chair with clown-colored hair, the pie face and obviously false smile ... ?"

"Yes, yes, that was I."

OK, I kid the lady.

She didn't use the phrase "obviously false."

Actually, she was very nice, kind and apologetic. Indeed, she admitted the letter was one gigantic mistake. Don't tell the transplant people, but I even heard a bit of a snicker in her voice when she said someone there at the institute had made a mistake.

Never mind that letter, she said.

And I can't wait to tell Suellen. I won't be on the carpet tonight, at least not for that.  

I certainly understand that mistakes do happen.

I'm hoping there were other mistakes that occurred the day of my transplant evaluation, including the high PSA reading they found with my blood tests.  I would roundly welcome that mistake, especially if the reading turns out to be in the normal range when I have the test taken yet again on my return visit to my urologist, Dr. Ronald Benoit. If not, I hope he can explain how my PSA test more than doubled in just one month.

I offer yet another update, this time concerning the fact that my blood-sugar levels stabilized once I began using a new Novolog insulin pen earlier this week. A blog reader suggested doing what she does with her child's insulin pens: She marks the date of first use on the label of each new pen, and that method works for her, so she knows when 30 days has expired and the insulin has grown stale.

That likely explains why I could not lower my sugar levels that particular day despite taking shot after shot. (See previous blog concerning that fun day.) Perhaps I'll adopt the reader's suggestion. 

And that insulin pen is destined for the insulin Penitentiary.  

Bad blood-sugar day

 It sometimes amazes me why my sugar levels can run so erratically, despite the fact that I follow a similar routine each workday, with a diet that does not vary to any great degree. It's not as though I eat Mexican one day then Thai the next, then opt to try Ethiopian. I enjoy all of those cuisines but my diet typically involves whole-grain bread with peanut butter in the morning, occasionally with a bowl of whol-grain cereal such as Kashi with soy, rice or almond milk, and an apple or some sort of fruit.

Lunch typically includes a salad or vegetarian sandwhich. Working in Washington County this week, I've been frequenting Jersey Mikes and relishing the vegetarian sandwich on whole-wheat bun. It does raise my sugar about 20 points higher than I would like, so I usually test and take a shot once back at the office. 

Supper is a little more catch-as-catch-can. But it typically includes a salad of some sort, often including broccoli, along with a relatively humble helping of fish, chicken, and on rarer occasion, beef. My big supper sin is heated white bread with butter. If Suellen makes it, I can't not eat it. And it does raise the sugar level.

I usually don't snack between meals or before bedtime.

So yesterday the question arose, "What gives?"

Yesterday my sugar levels ballooned various times over 200. I took three different shots, but by the end of the afternoon, when I had exhausted my insulin pen, my sugar still was topping 200. With no insulin left, I headed home late (about 7 p.m.), where I tested again to find my sugar at 160. I retrieved a new insulin pen and quickly took a shot -- enough, so I figured, to get me down below 100 so that my Chinese supper including steamed rice and broccoli would not send my blood sugar through the roof once again.

Well, by about 8:30, as I was attempting to write at my computer, I couldn' focus and what appeared in front of me didn't make sense. I figured my sugar now was low. I tested, and it had dipped to 50 mg/dL. So I drank grape juice and ate some candy. I tested before I went to bed and my sugar was in the 100 range.

But in the middle of the night, when I awoke and tested, it again was over 200. I took a huge shot and when I tested a few hours later (my poor kidney function requires me to empty my bladder about every three hours) I still was at 130 mg/dL. Two more units of insulin. When I awakened I was in the normal range.

So what gives?

Most days are variable for me in terms of blood-sugar readings. Some days are low-sugar days and some are high. Occasionally there are extremes, as I experienced yesterday.

But thinking it through, here is my assessment of what went wrong:

Obviously I was having a high sugar day. But my insulin pen of Novolog might have exceeded the 30-day limit. Insulin pens are not supposed to be refrigerated after they are opened and used. So I keep mine in my bag with my test kit. I'm thinking that insulin pen grew stale and failed to work as readily as usually.

So a person like me, who doesn't use a standard dose of Novolog each day and instead uses it as needed, might want to designate the date it is opened. When the one-month deadline approaches, it would be a good idea to note how well the insulin is working. (One unit drops my readings by 30 mg/dL.) If there is a deterioration of impact, such as I experienced yesterday, toss the insulin away and get a new pen.

This morning, my insulin is fine once again. Right now it is 99.

I have my grape juice ready in case it dips lower. I just ate an apple and a Kashi whole-grain cookie, which is my idea of a big dessert. It looks as though today will be more routine than yesterday. My usual goal is nothing over 150 and nothing much under 80. 

We'll see what the day brings.

,  

Detecting hypoglycemia

The mother of a 12-year-old boy with type 1 diabetes asked about whether the symptoms for hypoglycemia, including shaky hands, perspiration and weakness wear out as the person matures. Here is how I replied.

For years, I was able to detect the approach of low blood sugar. Usual symptoms for me included weakness, shaky hands and perspiration.

But as the years go by, the body's ability to signal low blood sugar wears out and disappears. That's the reason why so many people with diabetes end up facing problems including unconsciousness.

The wear-out factor began occurring for me 15 or 20 years after diagnosis, but I'm guessing here. Of course at that time I was not well-controlled because there still was no easy way to test blood sugar. I don't know if lack of control contributed to the decline of the signaling system. For the next 15 years I had no clue how to prevent low blood sugar, save for rather aggressive testing of the blood sugar once that method became available in the mid-1980s. Low blood sugar would overcome me without any signal. I didn't even feel weak before the low-sugar episode.

I can recall jogging on one notable occasion and having my knees buckle, causing me to go wobbly amd flipflop like some drunken ostrich right in the middle of the road.  Luckily for me, my wife Suellen was with me at the time. She got me off the road then headed home for sugar.  I had no warning.  When the knees buckle that means the musculature does not have enough sugar to sustain function.  Another time I was walking the dog and my knees buckled. Chaos ensued. The dog started pulling and I kept bobbing up and down trying to keep up with her. I strived to remain upright but ended up going flat on the roadway with broken glasses and scraps on my face and hands. Luckily, once again, someone passed by, inquired about my condition and got me some pop from a nearby machine. The pop brought me back to my senses.  Again, no warning.

Nowadays I do feel a weakness settle over me that typically signals low blood sugar. I'm thankful for that. Only when I'm experiencing severe hypoglycemia do I perspire profusely. When I come back to consciousness in the hospital, or when someone in my family provides sugar that brings me back, I usually find myself to be soaked from sweat, requiring that I change all my clothes and take a bath or shower.

So detecting hypoglycemia does become a greater challenge as the years pass by. Hopefully they will develop methods -- bracelets or detectors -- that will signal when the blood sugar falls below a certain threshhold and perspiration or some other bodily effect begins to takes place. That's been my hope. That's one reason why I applied for a hypoglycemia-detecting dog. But control on most days is not as difficult as it might sound. In fact, below, you can see the primary tools I use to control blood sugar, including my insulin pen, my One Touch test kit and some glucose tablets that can be purchased in any drug store.

Detecting low blood sugar is one area of diabetes technology that has been lagging, in my opinion. A continuous glucose monitoring system will help, but who wants to wear all that hardware 24 hours a day, especially if the person also has an insulin pump? Some pump makers are attempting to combine the two into one system and such a system might already exist. But insurance has been reluctant to pay for continuous glucose monitors, which can cost thousands.

Also, as noted in one of the blog entries, the CGMS tests fluid under the skin, known as interstitial fluid. So the readings don't reflect current blood-sugar levels, although they can alert to trends that you can learn to interpret and use to predict blood-sugar levels. Some experts think that someday we will test interstitial fluid rather than blood and adapt our numbers and readings to a system that reliably can predict actual blood sugar.

I'm just guessing at this, but if you see the continuous glucose meter going below 100, you might need to react quickly because blood sugar might actually be 70 or 80 or even lower. We'll have to see how the science progresses with this.

For now, if a person can detect his lows, then all the better. But as the years pass, he might have to rely on test blood sugar to prevent hypoglycemia, or low blood sugar.

Hopefully in coming years a new system will emerge to detection low blood sugar. If one does become available, I'll be the first one in line. 

Answering Jgirl's question

Jgirl has asked this question: Do you have a CGMS (Continuous Glucose Monitoring System) or an insulin pump? I’m curious about how you maintain such great control while farming and being a reporter -- and if you use any tools to make it marginally easier.

Dear Jgirl:

Actually, I grew up with syringes and eventually adopted finger-pricking glucose machines to test sugar and I continue to be comfortable with those methods. Insulin pumps and CGMS are the salvation for many, but I’ve learned to manage well without them. I would recommend them, however, to anyone who needs to maintain better control. They are valuable in preventing as much hands-on maintenance of the disease as insulin pens or syringes and regular glucose-testing meters demand.

Using insulin pens, I take about 70 units of Levemir (I know, that’s a lot) in the morning to provide a strong base of insulin for the day. Then I use Novolog insulin pens to provide booster shots as needed. Sometimes I need several booster shots or boluses each day, while other days I don’t need any.

When my sugar rises above 100, and depending on the trend -- whether it is on the rise or lowering -- I decide whether to take a shot of Novolog or not. If it remains at 130 for an hour without movement, for example, I will take one unit to bring it down to 100. If it is 150, I’ll take two units.

For me, one unit of Novolog will drop my sugar levels by about 30 mg/dL. So if my sugar were to climb to 200, for example, I might take three or four units.

But that doesn’t mean going about my day without worry. I take note of the time I took the shot, then one hour later or so, I will retest to see if the insulin did its job. Usually by then I will be down to 100. If I dip below 100, I will take a bit of grape juice (or some other sugar or carb, although I think grape juice is healthiest), then test my sugar periodically to make sure that the Novolog, which always has a tail and continues working for several hours, does not edge me ever lower to the danger zone of hypoglycemia (dangerously low blood sugar).

In short, the key to good control is testing, then reacting to the test. When the test shows high blood sugar, go out and exercise or take a corrective dose of insulin. If the sugar level is too low, then consume some fast-acting calories.

This is my daily routine.

At night it’s a bit trickier, so you need to understand your body and sugar levels so you don’t take a shot then go low while asleep. This is the toughest time of day for me, and the one that causes me the most trouble.

I try to keep my sugar levels about 100 throughout the day. Some doctors think that’s too low, and perhaps rightfully so. They know that most people will not test as often as I do, so trying to keep it in the normal range can be a road to disaster. That’s because the sugar level often will fall too low without warning, and if the person isn’t timely in testing, he or she will slip into insulin shock or hypoglycemia, which can be deadly if someone is not nearby to provide sugar or to call for help.

That’s to say, everyone has to develop a strategy to maximize health and safety. You must strive to maintain a level as close to normal as feasible while avoiding danger.

For that reason, it becomes necessary for the patient to discuss any strategy with doctors, diabetes educators and family members and become proficient in that agreed-upon strategy to assure good health, comfort and safety.

Doctors will warn against my method. I have heard many words of warning from physicians whom I trust and respect. The four times I’ve ended up in emergency rooms due to low blood sugar are testaments to their concerns with my strategy.

But I also attribute my ability to maintain my kidney function at near stable levels for 15 years to the strategy of tight control and frequent testing, along with a generally healthy diet and exercise regimen. If you control your diabetes and live a healthy life you will find success with diabetes management.

If you want to discuss this further, send a reply to the blog or e-mail me at dtempleton@post-gazette.com. There are multiple strategies that can be successful. Again, discuss this with physicians, educators and family. Diabetes requires a team approach. Adoption of a sound strategy is absolutely key to good health and diabetes management.

For most people, striving for an A1C of 6 is sufficient to ward off problems. My 4.8 - 5.3 is obsessive, but a level I’m comfortable with and reluctant to change.

A method such as mine can be one’s salvation or one’s undoing. Caution is key.

Cowfume

Talking of transplants, our dog — Nutmeg — a transplant on our farm, helps to keep me energized. The transplant center should make sure every transplant patient has a Nutmeg as a means of getting adequate exercise.

She was a gift, of sorts, and now we know why the previous owner was so generous. For one thing, she’s a canine nut-case. But we also discovered that Nutmeg has a particular talent and penchant for rolling in cow manure. We call it Cowfume -- FurFume -- Eau De Bovine. We’ve been trying to come up with names for it.

Cow-nel No. 5.

Break-Windsong.

Beeph-oria.

Of course, Nutty, pictured to the left, thinks it’s fashionable to have brown highlights in her blond locks and absolutely loves advertising her fashionable new fragrance.

Mischief is her daily goal. She’s tall enough to stand on hind legs and eat anything left on the stove or kitchen counter. I was brushing my teeth last week when she brought my plastic lunch bag containing my peanut butter toast and apple upstairs to snack while I spit toothpaste and screamed at a level audible in the next two zip codes.

NUT-MEG!

And she’s not completely housebroken, but refuses to go outside when it’s dark or raining. Absolutely no knowledge of household etiquette. She thinks she belongs on the couch, especially after donning her favorite fragrance. And she thinks every face is a lollipop.

Anything organic — and a whole lot that isn’t — is a very likely candidate to end up in the pit of her stomach.

What got me thinking about Nutmeg -- the dog not the spice -- is what occurred after my last episode of low blood sugar last April. I described it in an earlier blog.

I searched the Internet for a better way to detect low blood sugar before the critical point, and I found one.

It’s possible nowadays to teach dogs how to detect low blood sugar in their owners. When they do they scratch at you or even lick you before the level gets too low. And they continue with this behavior until the person with diabetes consumes some quick-acting carbohydrates and the blood sugar rises.

I applied online for such a dog, but I’m sure I’m low on the list. But just as there is great competition for kidneys and pancreases for transplantation, the demand for hypoglycemic-detecting hounds likewise exceeds supply.

Such dogs have the same rights as seeing-eye dogs. You take them to work, inside stores, and anywhere else you care to adventure. I could see a dog sitting next to me in the newsroom occasionally sniffing me.

That point became even more poignant when Dr. Amit Basu, the transplant surgeon at the Thomas E. Starzl Transplantation Institute who was part of my evaluation team stressed that low blood sugar, especially for a brittle diabetic, as I am, can lead to a quick death if control or circumstances go awry. I’ve known that for 43 years, but last April’s episode of being alone and unconscious for four hours makes it all the more pertinent to the discussion

So I’ve been thinking. What are the prospects of Nutmeg learning how to detect low blood sugar? Maybe I could teach her.

(To the left is proof that she has a good nose. Kernel, our 15-year-old Papillon, remains in charge and is making sure Nutmeg does not violate too many house rules.)

Having a hypoglycemia-detecting pooch is an interesting consideration, but the prospects are unlikely I can teach her how to detect low blood sugar. She already scratches at me and licks me. How would I ever know that she actually meant business.

And with her penchant for wearing Cow-logne, Nutmeg never would be able to detect the faint, gentle scent of hypoglycemia.