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on Jan 13, 2012 Tagged in: Treatment , PD Rehabilitation
Symptoms of Parkinson's Disease (PD) may interfere with people's ability to function effectively on a daily basis. Occupational Therapy, Physical Therapy, and Speech and Language Pathology are health disciplines that help people to prevent problems from occurring and to treat difficulties people are having. They can offer you strategies to improve your function or adapt to changes that are imposed by Parkinson's symptoms. Family members can also be involved in learning techniques to make life easier. Typically, a referral by a physician is needed in order to have these services covered by health insurance. It is also necessary to see under what circumstances your health plan provides coverage.
Speech, language, voice and swallowing disorders are common problems in patient's with moderate to significant PD. Very often the first sign of significant PD is reduced voice power and increased rate of utterance. As the duration of PD increases communication impairment also becomes more complex. Additional communication problems may include poor precision and strength of speech sound pronunciation and reductions in expressive language complexity. Further some patients will experience slowing of mental functioning and memory loss that will also impact language formulation and expression. If these communication impairments become dominant in everyday activities then the patient will begin to withdraw from necessary daily communication activities . Patients may decide to refrain from answering the phone or initiating telephone calls or maintaining conversations. This communication disability can seriously isolate patients and make it difficult for them to function in their families and with caregivers.
The speech and voice communication impairment symptoms in PD are identified by speech-language pathologists as a stereotypic cluster identified as "hypokinetic dysarthria". In general, PD patients will eventually exhibit:
These symptoms of communication impairment can be treated by speech-language pathologists to provide exercises that will allow the patient to reduce the negative effects on overall speech intelligibility. PD patients can improve their communication with treatment, practice and a willingness to work hard to compensate for the neuromuscular impairment in PD.
Swallowing disorders in PD can be significant and should also be evaluated and treated by speech-language pathologists. Because the neuromuscular deficits in PD also affect the muscles of swallowing, patient precautions, x-ray evaluation procedures and treatment may be necessary. Patients may experience difficulty in chewing certain foods sufficiently, choking on liquids or poor passage of food into the esophagus. These swallowing difficulties can also be remedied with exercises and diet recommendations provided by the speech-language pathologist.
Finally, the possible reduction in mental functioning in PD patients has become an increasing concern. These cognitive difficulties include slowing of mental response, short-term memory limitations, slowing word retrieval, time and space disorientation, reductions in expressive language complexity and length, and diminished emotional affect. These problems should also be addressed by the speech-language pathologist in concert with social workers and caregivers.
Evaluating and treating the communication impairment of PD patients while complex, it is rewarding, because improved functioning is possible with speech-voice-language and cognitive rehabilitation.
Contributed by Richard Merson, Ph.D., Speech and Language Pathologist, Beaumont Hospital, Royal Oak MichiganChairman, MPF Professional Advisory Board, Member MPF Board of Directors
Occupational therapists (OT) - Occupational therapy is a health care/rehabilitation profession. OT's work with people of all ages, who are experiencing difficulties with leading independent, productive, and satisfying lives. The goal of an occupational therapist is to assist individuals with performing their activities of daily living. People with Parkinson's Disease may need the help of an occupational therapist for many different reasons. While one person may need help learning various strategies to manage their tremors, another may need help with feeding skills, and yet another may need to learn various coordination exercises to maintain functional use of their hands, and someone else may need a home evaluation so the therapist can make recommendations on equipment needs and home safety, the list is endless. The treatment is individualized to your needs which is based on your goals for therapy as well as the therapists evaluation. If you have lost some independence due to your Parkinson's Disease consult your physician regarding occupational therapy.
Contributed by:Sue Vergilio, O.T.R., St. John Macomb HospitalPast Member, MPF Professional Advisory Board
Some symptoms of Parkinson's disease may include tremors, rigidity or muscular stiffness, and bradykinesia or slowness of movement. These symptoms can cause you pain, a decrease in range of motion in your joints, neck and back, a change in your posture and difficulty moving.
When you experience these problems, your balance and mobility may be affected. You may have difficulty walking and may even start to fall. If any of these occur, you may benefit from visiting a physical therapist. First you need to see your physician for a referral.
When you see a physical therapist, you will have a thorough evaluation. The P.T. will examine your range of motion, strength, coordination, balance, posture, functional mobility skills and your gait, or ability to walk.
One the evaluation is completed, recommendations may include assistive devices such as a cane or walker and a comprehensive exercise program designed especially for your needs. You will also be instructed on the importance of daily exercise or activity to help maintain or improve your quality of life.
Contributed by: Stacey Turner, R.P.T., St. John Macomb Hospital, Warren, MIPast Member, MPF Professional Advisory Board
The recognition and management of mental health issues is an important part of maintaining a high quality of life for all people. Common issues experience by people with Parkinson's and their families include depression, anxiety, acute confusional states, and dementia. Depression may cause sadness, loss of interest, guilt, lack of energy, insomnia and the inability to experience pleasure. Anxiety may be due to medical problems, pain, or be an understandable reaction to life's circumstances. Medical illness and medications are common causes of acute confusion. Finally, chronic confusion (or dementia) can be seen in some people with later stage Parkinson's Disease. Proper diagnosis of each of these conditions is important because treatment will improve the quality of life.
If you are experiencing any difficulties such as a change in mood or thinking, or anxiety, please discuss this with your physician. It is possible that medications prescribed for P.D. or other illnesses can cause some of these symptoms. You may need to have your medications adjusted. After exploring if there are any physical issues or medications that contribute to your mental health changes, you may receive a referral for further consultation.
Contributed by:
Mark Ensberg, M.D., Michigan State University School of Human Medicine, East Lansing, MIMember, MPF Professional Advisory Board
on Jan 13, 2012 Tagged in: Treatment
The United States Food and Drug Administration approved the use of deep brain stimulation (DBS) in the subthalamic nucleus (STN) and globus pallidum (Gpi) in March of 2002 for the treatment of medically refractory Parkinson's disease (PD). In contrast to the thalamic DBS, which controls only the tremor of PD, both STN and Gpi DBS stimulation are able to ameliorate all cardinal symptoms (tremor, bradykinesia, and rigidity) of PD. There is an impression that the STN stimulation appears to be superior to the Gpi stimulation, but thus far, no prospective randomized data exist for comparison of the two sites.
Not all people with P.D. require surgery. In fact, the vast majority do not require surgical intervention. Prospective candidates must have a diagnosis of P.D., have undergone optimization of medication regimen or who are intolerant to medications due to side effects, not experience significant disability or who have moderate to severe dementia..
Improvements are seen in disabilities related to either "off" period symptoms (tremor, rigidity, bradykinesia, muscle cramps associated with off-dystonia etc) that are responsive to Sinemet, or "on" period symptoms (e.g., dyskinesia) that are induced by dopaminergic drugs. When such symptoms threaten one's independence or livelihood, the risks associated with surgical interventions are often justified.
DBS surgery is a time consuming and tedious procedure that requires extensive cooperation from an awake patient during the surgery. Often the benefits of surgery are delayed and require more frequent postoperative visits for stimulator adjustments. Thus, prospective patients should be in good medical, physical, and mental condition to tolerate the surgery and postoperative care.. Optimal outcome requires significant effort from the patients. Therefore those patients with untreated or under-treated mental illnesses (e.g., depression, schizophrenia, etc.) are excluded from the surgery.
STN DBS surgery is often performed bilaterally. Both sides are usually implanted at the same time. In somewhat frail patients, each side is performed separately often months apart for recovery from the initial surgery.
On the day of surgery, a stereotactic frame is placed on the patient's head under local anesthesia. The patient then undergoes MRI and CT examination of the head with the frame in place. The surgeon will use the information obtained from the imaging studies to plan a surgical target. This imaging step takes approximately 1 hour (it may be variable depending on the surgeon). Following the studies, the patient will be moved to the operating room. The patient will be placed in lounge chair position in the operating room. Hair will be shaved and under a heavy sedation, two small burr holes will be placed on the skull. Microrecording system will be mounted to the head frame and the surgeon will perform mapping of the brain to accurately localize the brain target. This process may take 2 to 3 hours. During this part, patient is awake and will be asked to report various sensations and movements. Once the localization is completed, then permanent electrodes are placed into the brain targets. The electrodes are then anchored to the skull and the wounds are closed. The frame is then removed and the patient discharged from the operating room. The patient usually spends 1 or 2 days in hospital for test stimulation and postoperative MRI imaging. The patient is readmitted after 1 week and under general anesthesia, battery packs will be placed under the collarbones. After an overnight stay, the patient will be discharged for convalescence. Programming of the DBS will begin 1 month after the surgery. Adjustments of electrical stimulation and medications are usually made on a monthly basis until optimum setting is achieved. The implanted batteries usually last 5 years depending on stimulation parameters.
The surgery has been shown to be effective for all of the "off" symptoms of PD that were responsive to preoperative Sinemet. Rigidity, bradykinesia, tremor and gait difficulties improve by 40 -60 % in many studies. There is often a marked decline in "on/off" fluctuations, total duration of "off" periods, and "off" dystonia or painful leg spasms. The surgery also decreases the severity of "on" dyskinesia. Most patients experience approximately 50% reduction in PD medication intake. It is generally ineffective in improving "on" state function (i.e., If a patient was wheelchair bound before the surgery even at the best of times, then one would not be walking independently after a successful surgery).
The benefits of the surgery are similar to those of STN DBS. The degree of improvement appears to be somewhat less than that of STN. The "off" symptoms have been shown to decrease from 20 - 45%. Improvement in "on" dyskinesia appears to be greater with Gpi than STN DBS. Patients generally require the same amount of medications after the surgery as before the surgery. Also the battery use appears somewhat greater with Gpi stimulation than STN. The only real advantage of Gpi stimulation over STN DBS appears to be in the postoperative DBS programming, which is less problematic with Gpi than STN.
Most DBS procedures are associated with a 1 - 2% chance of devastating intracranial hemorrhages. These hemorrhages are usually lethal or, if one survives, lead to permanent severe neurological deficit including coma, hemiplegia and language impairment. The surgeries are also associated with a 5 - 10% rate of less severe complications including those related to hardware (e.g., infections and breakage). One of the most common transient side effects of surgery is postoperative confusion. This is present in up to 40% of the patients in the immediate postoperative period. It is frightening to unprepared family members, because the patient can be quite agitated, confused and hallucinating. This is short-lived usually lasting 2- 3 days but can last up to weeks. Most patients experience some degree of tingling, numbness, muscle contractions, visual blurring, or lightheadedness associated with stimulation. These stimulation-induced side effects are usually well controlled by adjustments in stimulation parameters. Rarely, a patient will show severe sensitivity to stimulation manifested by violent involuntary movements of extremities, similar to dopa-induced dyskinesia but more severe (hemiballism). Again, this side effect is usually stimulation-induced and can be controlled with alteration in stimulation parameters. These patients will require a slower increase in stimulation parameters than the usual PD patients.
Rarely, DBS stimulation has been shown to worsen existing depression - it is usually associated with stimulation of the electrode in the deeper brain structure and corrected by using an alternate electrode. Permanent cognitive decline is rare except in those with existing dementia or in the most elderly patients. Temporary blunting of affect and a slightly withdrawn personality are often seen in the first 3 months of surgery but permanent changes are rare.
For the most successful surgical outcome, a strong and committed family and social support is mandatory. Patients are often elderly and frail and require close supervision and assistance postoperatively. Temporary rehabilitation or nursing home facilities may be necessary. Also in contrast to other surgeries, the beneficial effects of surgery are obtained with resumption of electrical stimulation. Optimization of electrical stimulation of DBS requires multiple monthly visits to the physician's office for programming sessions. These sessions are usually very short visits where various electrical stimulation parameters are adjusted but can last several hours especially the very first programming. Medication adjustments are usually made at each programming session. Since the patients are usually debilitated, extensive family or social support are needed to realize the postoperative care.
STN and Gpi DBS procedures are approved by the FDA and covered by Medicare and thus by other US insurers. Due to the significant costs associated with the medical devices implanted, in excess of $30,000.00, the insurance co-payments can be significant and should be investigated before the surgery. Also expenses associated with frequent trips to the physician's office associated with programming should be considered before the surgery.
The most important consideration is the patient's expectation of the surgical benefit. It is important to have a realistic expectation of the surgery to avoid postoperative disappointments despite a successful surgery. It is important to recognize that no two patients are the same and therefore postoperative benefits are not the same. Equally important is recognizing the risk associated with surgery. Too often patients are only concerned with the anticipated benefits and ignore the risks. For this reason and others, a frank discussion of surgical benefit and risks should take place with the medical team and the patient and his or her family.
Taken from MPF The Messenger Newsletter, June 2002Frederick Junn, M.D., Neurosurgeon, Oakwood Hospital - Dearborn, MIMember, MPF Professional Advisory Board
Contributed by: Michigan Parkinson Foundation and MPF Professional Advisory Board
Since the 1960s, much research and study has contributed to the development of new treatments for Parkinson's disease. Although there is no cure, a variety of medications are available to control symptoms. Rehabilitation therapies are frequently used to improve function. Mental health consultation may additionally be called into use. For some, if medication management is no longer effective, surgical options are a possibility. Some people opt to enter research studies.
As the symptoms of Parkinson's disease vary from individual to individual, so does the treatment. What works for one individual, may not work for the next. The one constant is that treatment changes over time. Each person with P.D. needs to be individually evaluated with a regimen developed specifically to meet his or her needs. Family involvement is very helpful. Recommendations will change over time, as P.D. is a progressive disorder, and treatment will depend upon the person's symptoms. Finding a physician who is knowledgeable about the treatment of P.D. and with whom you can communicate is essential in effectively managing your Parkinson's disease. Learning how to monitor your responses to medication and other therapies is an important role the person with P.D. and family needs to learn. Dealing with Parkinson's disease requires patience and a good working relationship with the health care team.
Your overall health is important in maintaining optimum wellness. A healthy lifestyle contributes to your sense of well-being and is your first line of defense against illness. Managing the symptoms of Parkinson's disease can be a "career" in itself and you may overlook general health concerns. Care partners may also neglect their own health needs when a family member has care needs.
Have routine health check-ups.
Exercise regularly.
Be on the alert for signs of stress and learn ways to manage them before distress takes over.
Eat a well-balanced diet.
Get adequate sleep and relaxation.
Maintain connections with others and the world around you.
Stay as active and involved as you can.
Be the "captain of your ship," by finding a competent physician with whom you can relate.
Learn to ask for help from others.
Educate yourself on your condition - knowledge is power.
Keep a sense of humor.
on Jan 13, 2012 Tagged in: PD Glossary , General PD Information
Akinetic-rigid syndrome: A syndrome, or collection of systems, consisting of lack of movement (akinesia) or reduced movements (hypokinesia), slow movements (bradykinesia), and stiffness or rigidity (involuntary resistance to movement). The rigidity is of a type called cogwheel rigidity.
Basal ganglia: A group of nuclei, or clusters of nerve cells, near the base of the brain that is important in regulating both movements and emotions.
Bradykinesia, hypokinesia & akinesia: Bradykinesia means slow movements. Hypokinesia means reduced movements and generally refers to making smaller movements than intended, such as the small steps seen when a Parkinsons patient walks, or the small size of a Parkinsons patient's handwriting (called micrographia). Akinesia means lack of movement.
Cogwheel rigidity: " A type of rigidity in which, when a patient's limb is moved by the examiner, it resists and gives way in small, step-like movements as if it was being controlled by a cog-wheel.
Dopamine: One of a number of chemicals used by nerve cells as neurotranmitters. Messages are carried electrically along individual nerve cells but signalling from one nerve cell to another is usually accomplished by releasing a neurotransmitter chemical. Dopamine is the main neurotransmitter of the nerve cells which die off in Parkinson's disease.
Dysarthria: soft voice or inarticulate speech.
Dyskinesia: Abnormal writhing movement of voluntary muscles.
Dystonia: Involuntary spasms of muscle contraction that cause abnormal movement and posture.
Epidemiological studies: Statistical studies of the occurence of diseases in populations and environments.
Familial Parkinsons: Some unusual forms of Parkinson's disease run in a few families. Abnormal genes have been identified in some of these families, but abnormalities in these genes are NOT found in most patients with Parkinson's disease. Alpha-synuclein and parkin are the proteins coded for by genes identified as being abnormal in some familial forms of atypical Parkinson's disease. Normal alpha-synuclein is also the major protein in Lewy bodies, the pathologic inclusions found in typical Parkinson's disease. The normal functions of alpha-synuclein and parkin are not yet clearly established.
Freezing: Temporary inability to move.
Levodopa: Levodopa was the first major breakthrough in the treatment of Parkinson's disease. Levodopa is used by the brain to produce the chemical dopamine, which is deficient in persons with PD. The neurotransmitter is converted by the neurons in the brain into dopamine, which is stored within the cells until needed by the body.
Neurodegenerative Disease: A disease in which nerve cells in the brain or spinal cord (central nervous system, CNS) progressively die or degenerate.
Neuron: a cell that generates or conducts electrical impulses to carry information from one part of the brain to another.
On-off phenomena: sudden, unpredictable changes in motor performance by people on levodopa therapy.
Parkinson's Plus diseases: These are neurodegenerative diseases which cause the akinetic-rigid syndrome or parkinsonism PLUS additional symptoms not usually seen in Parkinson's disease. These diseases are progressive supranuclear palsy or PSP, corticobasilar ganglionic degeneration or CBGD, and multiple system atrophy or MSA, which includes Shy-Drager Syndrome, olivopontocerebellar atrophy or OPCA, and striato-nigral degeneration.
Pathology of Parkinson's disease: Examination of brain tissue from Parkinson's disease patients under the microscope shows loss of the dark-colored dopamine-producing nerve cells in the substantia nigra pars compacta and appearance of Lewy bodies, abnormal small round clumps of protein and other materials which are rarely seen except in Parkinson's disease.
Postural reflexes: Postural reflexes are the involuntary movements people automatically make to maintain their balance when standing and walking. Impairment of the postural reflexes causes poor balance and a tendency to fall.
Resting tremor: Tremor is a rythmic movement or shaking of any part of the body. The tremor of Parkinson's disease is called a "resting tremor" because it is present when a limb is at rest and may be reduced or go away when the limb is held up or otherwise used by the patient. Most other types of tremor are reduced or absent when the limb is at rest and relaxed.
Striatum: A region of the brain made up of two nuclei, or clusters of nerve cells, the globus pallidus (which means "white ball") and caudate (which means "tailed"). These two nuclei are part of a group of nuclei called the basal ganglia, which is important in regulating both movements and emotions.
Substantia nigra: This literally means "the black substance" and is a region in the brainstem (where the spinal cord joins the brain) where there is a group of dopamine-producing nerve cells, which appear darker than the surrounding tissue. The dopamine-producing nerve cells are in the pars compacta (meaning "compact or dense part"). There is another part called the pars reticulata ("speckled part").
Edwin B. George, MD, PhD., Wayne State University School of Medicine, 2003
on Jan 12, 2012 Tagged in: Neuro Exam , General PD Information
When you visit your neurologist, there are several things that regularly occur: forms to fill out, lots of questions and, usually, a neurologic examination.
Do you ever wonder what neurologists are really doing to you during your physical exams and what they are looking for?
In general, the neurologic exam concentrates on several specific areas: mental status, cranial nerves, motor function, sensation and reflexes.
Depending on whether it is your first visit or a routine follow-up visit, the exam's length and complexity may vary. It actually begins before you realize it!! The neurologist checks the forms you filled out to see if the handwriting is small or shaky, then closely observes you during the initial interview - is there a lack of facial expression, a lack of movement of one arm or leg, a tremor and is the voice loud or indistinct? Often the diagnosis of Parkinson's disease is reached within the first minute or two the neurologist is in the room.
Then the neurologic examination begins. Although the exams performed by different neurologists vary widely, and also from one visit to the next, there are certain things a neurologist checks to determine the diagnosis (is it Parkinson's disease?) or to see how well you are responding to medication.
Mental Status: During the interview, and often with additional questioning, us¬ing standardized tests of cognitive function, the neurologist assesses your memory, concentration skills, language skills and orientation.
Gait: Usually you are asked to walk back and forth, on your toes and heels, then in a straight line. Observing whether you swing your arms normally or not may provide an early tip-off to the diagnosis of Parkinson's disease. You may be pushed or pulled to see how well you can maintain your balance (postural stability). You also watched to see if you have trouble rising from a chair and whether you stand straight or stooped.
Cranial Nerves: The cranial nerves are those that supply the eyes, face, ears, mouth/tongue and neck. A lack of facial expression (masked facies) may be noted, but there can be certain abnormalities that indicate a diagnosis of something other than typical Parkinson's disease (an inability to normally move the eyes, for example).
Motor Function: During this portion of the examination, your doctor checks your strength, pulling or pushing your arms and legs, comparing one side of the body to the other, and seeing if there is a difference between the upper and lower limbs. Your doctor will also move your arms and legs while you relax, to decide if there is increased tone or stiffness. (In Parkinson's disease we are looking for "cogwheeling," which is a type of stiffness with a "ratchety" feeling.) The speed of your movements is also examined: you are often asked to hold your arms in front of you and rapidly move them from "palm up" to "palm down," something called "rapid alternating movements." Additional maneuvers may be performed, such as finger tapping and repetitive "hand opening-closing," looking for bradykinesia (slowness of movement). The speed of these rapid movements often helps in making the diagnosis. It is important to note whether the abnormalities are worse on one side or the other.
The search for tremor actually continues throughout the entire time with your doctor. A tremor observed while a person is sitting quietly is known as a resting trem¬or and is the most typical type seen in PD. Often, this tremor is visible while you are walking, and is also called a "pill-rolling" tremor, named after the movement that an old-time pharmacist would make as he created a pill between his fingers. Tremor can also be seen with certain activities (holding objects, writing, etc.), and may or may not be seen in PD. Often you are asked to hold your arms outstretched, or to touch your finger to your nose.
Sensation: The sensory exam consists of being poked with a pin, lightly brushed with cotton/tissue, or asked whether you feel a vibrating tuning fork, or if a finger or toe is moved upward or downward. Again, the physician wants to know whether you feel these sensations equally on both sides of the body and whether it differs between how it feels in your feet/hands (distal sensation) or closer portions of the limbs (proximal sensation). This portion of the exam is probably the least important in the diagnosis of PD. However, certain abnormalities might be clues to a different neurologic disorder.
Reflexes: Here the doctor observes how your limbs react to being tapped with a reflex hammer (deep tendon reflexes). In particular, are the responses equal on both sides and are they increased or decreased in a particular pattern? Another very important reflex commonly tested is the plantar reflex, when the bottom of your foot is stroked unpleasantly to see what direction your toes move. This is one of the most important tests in neurology. If the toes move upward in a specific way, it is known as a "Babinski sign." This is not usually seen with PD, but may indicate another disorder.
The neurologic examination remains the most accurate way to diagnose Parkinson's disease, coupled with the history that you give. Testing is generally not required to make a diagnosis, but is occasionally ordered to rule out a different diagnosis, if there are unusual features noted during the exam. Remember: the length of the neurologoc exam may vary from visit to visit, with the initial consultation generally being the most extensive examination, and follow-up visits being shorter. When it is only a brief office visit, only a few things may be tested to decide if medication is helping, or if changes are required. While the examination is very informative and can usually result in a definite "yes" or "no" to the question of whether you have PD, some of you may have experienced exams where the neurologist is not certain and asks you to return in a few months or a year to see if your physical exam changes.
Despite all the advances that have been made in the field of neurology, the examination remains essential.
Neurologist Dr. Glen Ackerman, M.D., is a past Chairman of the Michigan Parkinson Foundation Professional Advisory Board and is a cur¬rent Member. He is Assistant Professor of Neurology, Michigan State University School of Human Medicine and School of Osteopathic Medicine, and is Head of its Movement Disorders Clinic.
on Aug 19, 2011 Tagged in: Young Onset
Source: J.B. Bieske firstname.lastname@example.com or Firm: J.B.Bieske and Associates Address: Box 1007 Warren, MI 48090 Phone: (586) 977-8100 Description: FAQs regarding SSI Disability Claims Category: Text DATE STAMP: 08-Mar-04 Source Event: Attorneys Forum (08-Mar-04)
A person with a physical for mental condition which prevents him/her from working on a full-time basis A person need not be physically confined to a bed or wheelchair to receive benefits.
A retired person on a pension from a Company, which has paid into a Social security program, may apply for Social Security Disability benefits.
A person receiving Workman's Compensation is eligible to apply.
A person receiving disability from a private insurance company is eligible to apply.
Go to any Social Security office or call (800) 772-1213 for request an information packet and to schedule an interview. Review the information packet and bring the requested information to the interview.
During the interview, your work and health history will be presented and reviewed. At he conclusion of the interview, if you choose to do so, a disability claim will be initiated on your behalf.
Over the next few months, the Social Security Administration will evaluate the information you provided, along with additional information solicited from your physicians, clinics and/or hospitals.
During that period, you and/or your physician(s) may be asked for additional information. You may also be required to undergo a physical exam by a Social Security Administration-certified physician.
A decision will be made, usually within 120 days, to approve or reject your claim. You will receive a written notice of the decision.
If your initial claim is rejected, you should contact an attorney to assist in fling an appeal. Usually this requires a submission of a legal brief and a judicial review.
It is possible to win a legal appeal on a disability claim many years after a person has stopped working. Disability benefits are received by persons who are also receiving:
Most attorneys in this area are compensated with a portion of the past due (lump sum) benefits, which is not paid until the case is won (contingency).
Usually, attorney's fees are a percentage of the past due (lump sum) benefits, and only if the appeal is successful. Expenses are generally low in cases of this type. Confirm payment terms with the attorney in your initial discussion.
on Aug 09, 2011 Tagged in: Managing PD , Advancing PD
PD is a disorder of some parts of the brain that control movement. One major area of involvement is the substantia nigra, in the rear part of the brain (midbrain). It is there that, for reasons we are still trying to discover, nerve cells in PD stop functioning normally and some cells die prematurely. Because of the usual slow worsening of PD, there are still enough working nerve cells to be able to respond to medications and surgical treatment for a long while.
We'd all like to prevent continued loss of nigral and other nerve cells in PD with "neuroprotective" medication treatment, and several groups in Michigan are involved in a long-term NIH study of such potentially useful drugs. However, results of such studies will take several years to be known, and our concern here is to address the practical, symptomatic treatment of PD for patients whose illness has interfered with work- and/or home-related activities most of the time. This covers the spectrum of disability we'd call moderate-advanced.
This is a general review of current concepts and practices regarding PD evaluation and treatment. Inevitably, statements made will reflect personal opinions and approaches, not buttressed here by citations from the medical literature. The statements must not be taken as reflecting what is happening to any particular person medically, or what's best for a particular person's treatment, now or in the future. The offering of this guide is not "practicing medicine" via informational exchange by website. The practice of medicine occurs when an individual consults a physician to obtain a diagnosis and treatment plan specifically for him or her. That's not what this guide can or should do, and it is no substitute for an individual consultation or an ongoing medical relationship between a doctor and a patient.
Medication doses or dose ranges are best dealt with at the individual doctor-patient level, addressing the need presented by particular clinical situations. The effects of treatment can vary enormously, and much telephone and clinic time is spent sorting out risks, benefits, side effect possibilities, alternate treatments, etc. This is the art of medicine. The desire to help people drives the passion.
The best model for care of any chronic medical disorder is to have a trusting, working relationship between patients, caregivers, doctors, nurses and other health professionals. Practically, this means having patients benefit from the expertise of the medical team and having the medical team benefit from the experience of patients as they try to create an effective treatment plan together. It means having as frequent contact between these individuals as is really needed to optimize care. This may be by phone calls, clinic visits and, in some instances, by e-mail or letters. It will vary, depending on the needs of patients and the needed availability of the medical team. The following points, through many years of experience, are most important:
What is the goal of treatment in PD? It is the individualized crafting of a plan of care that allows each patient to get and maintain the best function that he/she can with few or no side effects of therapy. Because each plan is individualized, the ultimate functional outcome will vary, depending on the severity of the illness, as well as patients' ability to benefit from, and to tolerate, adequate doses of medications, DBS (if appropriate), as well as physical, occupational and speech therapy. We need to be realistic about what is achievable, and this may have to be revised as time goes on. Generally, we offer as few drugs, and as little of them, as patients need to be as functional as possible. Whenever possible, new drugs are introduced at low doses, and at a suitable, individualized pace, in order not to give more than is needed, as well as to limit potential side effects.
Not every symptom can, or needs to be, treated. Some symptoms are relatively minor, particularly when considering whether an otherwise effective treatment plan would have to be overhauled, complicating daily life unduly for unclear potential benefits. This is an important part of the cooperative realism that patient and doctor must discuss.
These drugs include Artane® (trihexyphenidyl) and Cogentin® (benztropine). They are useful for treatment of tremor of a hand or foot at rest, i.e., when supported, not when raised up or during action. They give little or no benefit for bradykinesia (slow movement), muscular rigidity (stiffness), or gait imbalance.
Neither drug should be used in those with dementia (loss of memory, other cognitive function), or in those with glaucoma, prostate enlargement, visual blurring, rapid heartbeat, or excessive constipation.
If a patient develops mental confusion, with or without visual hallucinations (seeing visions), while on them, they may need to be discontinued.
The drug is used either as a mild agent to help tremor, bradykinesia and rigidity, or to decrease choreic (jerky) limb dyskinesias (involuntary movements) due to excessive dopaminergic (dopamine-promoting) medications. Amantadine is usually well-tolerated, though it can cause foot or leg edema (swelling) and a leg rash that looks like a red roadmap, called livedo reticularis. Among demented individuals, it alone can be responsible for mental confusion, and/or hallucinations.
Recent data suggest that dopamine agonists (dopamine-mimicking drugs), may be used before Sinemet® (levodopa-carbidopa) to get adequate motor benefit, and that such benefit can persist in many patients for years. Moreover, unlike with Sinemet®, drug-induced motor fluctuations ("wearing-off" or "on-off" impairment of mobility between doses) are less likely with the agonists. For this reason, if a patient's condition permits it, an agonist may be a better initial choice than Sinemet®. However, more severely disabled patients may need Sinemet® from the start. Most patients with advanced PD will need both an agonist and Sinemet® (see below).
There are data that suggest that there may be a neuroprotective action of Requip® and Mirapex®, but this is an area of controversy. Further research is needed.
These drugs act on nerve cells in the brain that respond to dopamine, the major signaling chemical (neurotransmitter) that is low in PD. By stimulating the dopamine receptor (signal receiver), dopamine agonists act as though they were dopamine, and they activate the nerve cells they stimulate. In so doing, they improve motor function. However, they are not as powerful as Sinemet®.
The agonists were developed over many years, with Parlodel® and Permax® introduced earlier, and Requip® and Mirapex® becoming available more recently. All are potentially effective drugs, depending on whether a particular patient can tolerate enough medication to improve mobility adequately. The agonists have not often been tested directly against one another in clinical trials, but have either been tested against placebo (no effective drug) alone, or as additions to a Sinemet® regimen. One has a general impression of rough equality of efficacy among the agonists, if adequate doses of drug can be given, but it is possible that some patients may benefit from one or another to a greater extent. Only individual trials of medications with patients can establish that, however, and if a particular agonist is effective enough, it is unwise to try another. If sufficient side effects appear, though, a trial of a different agonist may be warranted. Any of the agonists may produce side effects, often having a similar dopamine-mediated motor and mental character (see 6, below).
This drug is accepted as the gold standard for symptomatic PD treatment, i.e., the most powerful one against which clinical effectiveness can be measured. Its introduction by the late Dr. George Cotzias and colleagues in 1967 was a watershed event in neurology, and one which brought great hope and functional benefit to patients with PD everywhere.
It used to be that nearly every patient with PD was begun on Sinemet® as soon as the diagnosis was made. However, many movement disorders neurologists today reserve that treatment for patients whose mobility, dexterity and tremor we judge will not be sufficiently responsive to either an anticholinergic, amantadine or an agonist, either by mental comparison of our experience with that of other patients, or after a trial of these other drugs sequentially. This is because many patients may benefit adequately from either an anticholinergic, amantadine or an agonist for several years, without the risk of motor fluctuations ("wearing off" or "on-off" effects, between Sinemet® doses) that levodopa treatment typically produces after several years of treatment.
In practice, as PD advances, most patients will need Sinemet® at some dose to function well. It will often be gratifying to them and to caregivers to see significant improvement, allowing more activities and independence to occur.
Following patients on Sinemet® or agonists involves balancing the doses needed for adequate mobility against the possibility of inducing dopamine-mediated side effects. Such effects may include:
During the early stages of PD, patients don't notice a difference in motor function between medication (usually Sinemet®) doses. However, in moderate-advanced PD, an increasing number of patients will. They may become slower, stiffer and less coordinated, more tremulous, and have more gait imbalance before the next dose is due. If such disabilities are marked, they may not be able to get out of a chair, get dressed, bathe, or do other activities of daily living without help. Falling may be more likely at such times. This is distressing and potentially dangerous and needs to be dealt with.
Several choices are available. Though it is possible to increase each Sinemet® immediate release dose (i.e., 10/100, 25/100, 25/250) and/or to decrease the interval between doses, that is not what is preferred. This is because we wish to decrease the likelihood of Sinemet®-related side effects (see above), and to reduce later motor fluctuations. It is possible to add controlled-release Sinemet® (i.e., 25/100CR, 50/200) to the existing immediate-release Sinemet® regimen, but, again, it is desirable to limit total daily levodopa, if possible. This may not be possible in individual cases, however, and the giving of both immediate- and controlled-release Sinemet® is certainly a viable and valuable option for many patients.
With these issues in mind, it's often best to consider the use of a COMT inhibitor (Comtan® [entacapone], Tasmar® [tolcapone]), or an agonist. COMT inhibitors extend the duration of levodopa (but not agonist) action by preventing breakdown of brain dopamine. Comtan® is easy to use as individual 200 mg tablets, given at the same time as Sinemet® doses, matching the times of the day when wearing-off occurs. The recent incorporation of Comtan® into one pill with Sinemet® (Stalevo®) is suitable for those patients with wearing-off of all Sinemet® doses, but doesn't allow dose-by-dose individuation that using Comtan® alone permits.
Tasmar® is a highly effective COMT inhibitor, but came under special FDA guidelines when several patients died as a result of unmonitored liver injury. For this reason, Tasmar® may be used only when other medications have been found to be ineffective or not tolerated. If used, blood studies of liver enzymes (SGPT) must be done every two weeks, and even values just above normal must be taken as grounds for discontinuing the drug. There is no such issue with Comtan®.
The agonists are often helpful in treating wearing-off effects because their duration of action is relatively long (4-6 hours, depending on the drug).
Freezing is the sudden loss of the ability to walk forward. It may occur during a wearing-off episode (more commonly) or not, and may or may not be associated with a greater likelihood of falling. At such times, patients may recover if they either focus mental attention on walking, try marching in place or to either side, or get verbal or physical support to walk from someone else.
Falling is to be feared and avoided, if possible. Hips, arms, pelvises, necks, etc. can be broken and may not be repairable to restore adequate function. Heads can be injured, producing blood clots in or over the brain, requiring surgery.
Staying mobile, however, is essential. Whenever possible, patients should walk, within their own limitations. Others who can do more, physically, should.
Certainly, safe mobility must be maintained, whether that is achievable with some combination of medical, physical, occupational or surgical treatment. If these treatment modes alone cannot fully succeed, some form of physical support [i.e., cane, walker, scooter, or holding onto someone or some immovable object(s)] has to be used.
These issues are dealt with in detail elsewhere, but several general points are worth making. Communication with others is so important that it may be best to consult with a speech pathologist working with your doctor to optimize your individual function if you cannot be understood. Similarly, swallowing function needs to be evaluated in those patients who are choking on liquids or solids.
This important area of expertise is offered to patients who need special help to do activities of daily living, including standing, balancing, gait training, bathing and other bathroom activities, feeding, and others. Occupational therapists work well with others in the medical team to optimize function, offering individualized treatment programs.
This is very common, especially among those with moderate-advanced PD. It is because of an illness-related abnormality in the nerves supplying the bowel. It can be made worse by the use of anticholinergic drugs, and these may need to be discontinued if constipation poses a serious problem.
Patients often benefit from a high fiber diet, increased liquid intake, exercise, and the use of over-the-counter stool softeners. Frequent laxatives or enemas should be avoided, if possible, but these measures need to be discussed with a treating physician.
Patients will often notice an increased urgency to urinate, as well as an increased urinary frequency. In men, this may exaggerate ongoing symptoms of prostate enlargement, and such issues need to be clarified with urological consultation. Generally, it is useful to limit fluid intake after supper, and the use of either Ditropan® (oxybutynin) or Detrol® (tolterodine) may be considered.
Impotence (impaired erection) in men may occur in PD, as it does in nearly all cases of multiple system atrophy (MSA). One needs to consider the potential role of medications (e.g., beta-blockers, anti-anxiety drugs, anti-depressants, others), and of depression itself, when impotence occurs. Both men and women may experience a decrease in libido, independent of depression.
Depression is common among those with advancing PD, affecting as many as 30-50% over the course of the illness. There is often a loss of pleasure in usual activities, decreased desire to socialize, a loss of interest in sexual activity, insomnia, weight loss or gain, increased irritability, and, sometimes, a lesser ability to concentrate and perform other usual mental functions. Think about the possible presence of depression when these symptoms appear and go on for weeks or months. They rob people of the joy in life they otherwise might have and appear to make the motor portion of PD worse.
It is a common clinical experience that, unless depression is adequately treated with medication at least, and often also with some form of counseling, full responses of PD patients to their medications will not occur. So, not only should depression be treated on humanitarian grounds, but also to help the PD itself. Many experienced non-psychiatrists manage depression well, but some instances are best co-managed with a psychiatrist.
Some PD patients will have vivid dreams and/or insomnia because of one or more of their anti-PD medications. Such sleep disruptions may not only awaken the patient and his/her partner, but can also make it impossible to get all the rest that's needed to recuperate enough to do the next day's activities well or at all. In such circumstances, consider with your doctor reducing or eliminating late evening anti-PD medication dose(s).
We need to realize that some patients will require nighttime doses of anti-PD medication(s) to get out of bed to go to the bathroom, or simply to turn comfortably in bed to rest well. Obviously, this is another individual clinical decision to make, and one that may need revision over time.
Several years ago, it was reported that some patients may have "sleep attacks" (unheralded, sudden, irresistible sleep episodes) when taking agonist drugs. This remains an area of controversy since it isn't clear that such "attacks" haven't occurred because of another ongoing sleep disorder (e.g., due to excessive daytime sleepiness, depression, other medication effects, etc.). However, although there may be variable explanations for "attacks", the potential occurrence of dangerous sleep episodes (e.g., when driving a vehicle) makes it important to be aware of such a possibility. In my view, a physician should not hesitate to prescribe an otherwise potentially beneficial agonist or other anti-PD drug, and both doctor and patient should be vigilant about this uncommon, possible issue. As with many other therapeutic issues in PD, this needs thorough, individualized attention in a medical setting.
Dementia (loss of acquired cognitive function, including memory) can occur in about 30% of PD patients over the course of the illness. It is not inevitable.
When dementia occurs, it is important to try to identify the cause, as some 5-10% are potentially reversible, partly or fully. The list of potentially reversible causes includes hypothyroidism (low thyroid), vitamin B12 or folate deficiency, syphilis, subdural hematoma (blood clot over the brain), communicating hydrocephalus (impaired circulation of spinal fluid), and others. Studies to identify these disorders include blood tests (for thyroid [TSH and perhaps others], B12, folate, RPR or VDRL [syphilis], MRI or CT scan of the brain) and, perhaps, a spinal fluid examination for those whose dementia is rapidly advancing or otherwise atypical. Correcting the abnormalities, medically or surgically, will follow.
The same diagnostic studies, and perhaps others, may be needed to establish the cause of other forms of dementia. Some causes cannot be reversed, including:
Whatever the cause of dementia, its management should include having the patient live in a caring, safe, clean and comfortable environment. If possible, living at home is most desirable and least disruptive. Ideally, family, friends or paid help may share the burden of care. If this is not possible, moving a patient, with or without his/her spouse, to an assisted care facility should be considered. If this is unrealistic, a patient may be placed in a nursing home that family members determine provides good care. Often, an experienced social worker will be immensely helpful in reviewing realistic care options and in helping to implement them; most often, these professionals are associated with larger healthcare organizations. Moreover, the Michigan Parkinson Foundation (1.800.852.9781) and the Alzheimer's Diesease and Related Disorders Association (1.800.337.3827) are invaluable resources for caregivers of PD patients who face these difficult challenges.
The advent of functional surgery for PD, especially deep brain stimulation (DBS) of the subthalamic nucleus, has been a major advance in treatment for the right patients in the right medical setting. The subject is covered at length elsewhere, but several points are worth emphasizing:
Jay M. Gorell, MD, FAAN President and Former Chairman, MPF Professor in Neurology, Wayne State University School of Medicine
William T. Gossett Chair in NeurologyHead, Division of Movement DisordersDepartment of NeurologyHenry Ford Health SystemFormer Chairman, Board of DirectorsMichigan Parkinson Foundation
on Jul 12, 2011 Tagged in: Medications
Medication management is the cornerstone of treatment for Parkinson's disease. One thing to keep in mind is that medications work best with all other aspects of treatment. It is a supportive therapy, not a cure. You need a treatment plan that takes into consideration a number of factors that work to overcome Parkinson's symptoms. Medications work best when used in combination with rehabilitation therapies and general health measures, such as proper diet, stress management, exercise, and so on..
Slow progression of the disease. Currently the dopamine agonists have been shown to have some effect in this area.
Restore the lost nerve cells. This is a research focus at present, but no agent has been found to be effective to accomplish this task.
Treat active Parkinson's symptoms:
agents that are dopamine replenishing (Sinemet®)
Dopamine releasing (Amantdine®)
Dopamine enhancing (dopamine agonists)
Increase dopamine absorption
Advancing Parkinson's
When one should start taking medications depends upon the individual: how much the symptoms interfere with lifestyle.
It is currently agreed that Sinemet® should be avoided initially. Other medications, such as the agonists, are preferred first. This depends, however, on what your initial symptoms and disabilities are, and how old you are. For example, younger people with Parkinson's may be treated initially with the anticholinergics, such as Artane or Cogentin for tremor. Older people may be started initially on the agonists.
Similar to the treatment of most disease states, the optimal drug therapy for Parkinson's disease is both individualized and based on numerous factors. The choice of medication takes into consideration patient response, short and long-term side effects, possible drug interactions, presence of other medical and psychiatric conditions, as well as prescription insurance coverage.
Get all the information you can about medications that are prescribed from your doctor, pharmacist or health care professional.
Make sure that you doctor is aware of ALL the medications you take, including over the counter medication, herbals, vitamins, etc.
Ask questions, as given below, about your medications and how to take them - and keep notes.
What is the name of the medication, the dose, and when do you take it.
How do you take your medication, such as the time of day, with or without meals.
What can you expect from your medication? What kind of symptom relief is to be expected and when? In one day; in two days? How long do you wait before you call you doctor to know if your medication is working as expected? When you start some medications, it may take a while to build up to a "therapeutic dose." You may be started on a low dose and gradually build up to the level you need in order to manage your symptoms adequately.
What happens if you miss a dose, or forget to take it at the allotted time? This greatly depends on the medication - so don't assume from one medication to the next.
Anticipate situations that may happen to you and ask the doctor how to handle that situation.
What side effects are usual for each medication? If you have the side effect, what do you do? When do you call the doctor?
You need to recognize side effects. What will the side effect look like?
Learn the terms used to describe the side effect, such as dystonia (involuntary movement resulting in a sustained posture of the affected limb, often associated with painful muscle spasms), dyskinesia (abnormal involuntary writhing movement) nausea, vomiting, headaches, ataxia (loss of balance), on-off, discolored urine.
What do you do if you experience a side effect?
Is there anything you can do to avoid having a side effect?
Several medications should not be taken when you are on Parkinson's medications. You need to inform health professionals about this, particularly when hospitalized, in a nursing home, or in an emergency room. Some medications frequently used in these settings could create problems for you. Here is a listing that you can print off - put a copy in your wallet. need to post list of medications
It is not unusual that you may be having symptoms at home and when you have your office appointment, the symptoms are not readily apparent. Your health care provider may not actually see the difficulties you experience. It is a good idea for you to keep a diary for 3 days prior to your office visit, or at times you are experiencing difficulty.
What are your symptoms?
When your symptoms start?
How long your symptoms last?
When do you take your medications (with or without meals)?
Are you experiencing any stress or anxiety, or are you sick (any special situations you notice)
Write down the symptoms you have to keep track of them, including tremor, falls, dyskinesia, and ESPECIALLY when you take which medication, when you sleep (how long), when you eat, and what foods are you eating?
Click here for a form you can use to monitor your response to medication and symptoms.
There are several tips that people use to remember to take their medications at the correct time. Here are a few:
use medication boxes (you can purchase them at your pharmacy or ask your doctor)
use a timer or alarm
leave cues in the house, such as notes, or leave the medicine bottle near your phone
keep a calendar
associate taking your medication dose with your normal daily activities
You want to develop a regular schedule and stick as close to it as you can.
If you're feeling good, don't take less.
Look at what your medication is designed to do - you're not always trying to treat the acute problem. Keep a routine of when you are taking your dose, realizing that you will have ups and downs. Taking more is not always better. Symptoms may fluctuate and your response to medications may fluctuate over the course of the day and from day to day.
One of the biggest problems is not being able to count on your medication working to control symptoms all of the time.
You need to "get tough" - try not to let changes affect you. Continue to function in a manner you're accustomed to. DON'T GIVE UP.
There may be challenges when you are initially started on a medication, when your medications are adjusted or when a medication is to be discontinued.
Make sure you take the entire dose of your medication. Drink a full glass of water with each dose.
When you go out, take a dose of medication with you so you will not be caught without it if you are away from home longer than expected.
Store your medication in a clean, dry place that is not too warm or too cold. Don't leave your medication in a glove box during the summer.
Other information on medications:
For information on research trials: http://clinical trials.gov
For information on cost of medications: www.costco.com (go to pharmacy)
www.needymeds.com (information about qualifying for assistance programs)
www.Pparx.org (partnership for perscription assistance)
www.Rxassist.org (patient assistance program center)
Contact MPF
Contributed by:
Richard Berchou, PharmD, Wayne State University School of MedicineMember MPF Professional Advisory BoardandDebby Orloff, MPH, BSN, RNChief Executive Officer, Michigan Parkinson Foundation


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Center will be the first in the world to integrate research on both in vivo and in vitro diagnostics to deliver blood and complementary imaging tests for solid tumor cancers
PALO ALTO, Calif., June 9 /PRNewswire-USNewswire/ -- Canary Foundation, a nonprofit organization that funds research in early cancer detection, and
The new center will include a first-of-its-kind facility that combines in vitro and in vivo strategies to enhance future cancer detection and patient management. The center will include cancer proteomic research for early blood/body fluid markers (in vitro diagnostics) and molecular imaging (in vivo) to verify the presence and location of tumors. Currently, there is a lack of clinical tools that reliably detect signs of early tumors. If these tools were made available, the hope is that physicians would have a much better chance of treating and even curing cancer.
Canary Foundation is pledging $15 million toward the center, doubling its earlier commitment to support early detection research at the university. The medical school, together with the school's Department of Radiology, is committing $5 million through faculty recruitments, research facilities, and other infrastructure. The center will be led by Sanjiv Sam Gambhir, MD, Ph.D., professor of radiology and by courtesy bioengineering, director of the Molecular Imaging Program at
|SOURCE Canary Foundation
Copyright©2009 PR Newswire.
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Poached Pears With Cranberry Cardamom Sauce
26 Sep 2009
|Dry white wine
|2 Cup (32 tbs)
|1 Cup (16 tbs)
|1 Cup (16 tbs)
|1⁄2 Cup (8 tbs)
|Whole cloves
|Orange peel strips
|2 (2 Inch)
|Ground cardamom
|1⁄2 Teaspoon
|2 (Peeled)
|Vanilla frozen yogurt
|1 Cup (16 tbs)
|Almond cookies
|1 Cup (16 tbs)
Combine first 7 ingredients in heavy medium saucepan.
Bring to boil, stirring to dissolve sugar.
Add pears, reduce heat, cover and simmer until tender when pierced with knife, turning once, about 20 minutes.
Transfer pears to bowl using slotted spoon.
Cover and refrigerate until well chilled.
Boil poaching liquid until reduced to 1 cup plus 2 tablespoons, stirring occasionally, about 15 minutes.
Strain into bowl, pressing on solids. (Can be prepared 1 day ahead. Refrigerate pears and sauce separately.)
Rewarm sauce over medium low heat.
Stand pears on plates.
Place scoop of frozen yogurt next to each pear.
Drizzle sauce over pears and yogurt.
Serve with cookies.
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Poached Pears With Cranberry Cardamom Sauce Recipe


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Five More Semifinalists Advance to Top 20 on AMERICAN IDOL
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Tonight from Las Vegas, the first group of guy semifinalists performed on the stage of Cirque du Soleil's Beatles LOVE Theatre at The Mirage. After another dramatic round of deliberations, judges Mariah Carey, Randy Jackson, Nicki Minaj and Keith Urban announced the first five guys who will join the five Girls announced last night in this season's Top 20. The five guy semifinalists are Charlie Askew, 18, from Little Rock, AR; Curtis Finch Jr., 24, from St. Louis, MO; Paul Jolley, 22, from Palmersville, TN; Elijah Liu, 18, from Rowland Heights, CA; and Devin Velez, 18, from Chicago, IL.
Tune in next week on Wednesday, Feb. 27 (8:00-10:00 PM ET/PT) as the Sudden Death Rounds continue when the second group of Girls - Melinda Ademi, Janelle Arthur, Juliana Chahayed, Cristabel Clack, Aubrey Cleland, Candice Glover, Rachel Hale, Jett Hermano, Zoanette Johnson and Breanna Steer - perform and the judges decide which five will join the Top 20.
Don't miss the dramatic conclusion from Las Vegas on Thursday, Feb. 28 (8:00-10:00 PM ET/PT), as the final group of guys - Lazaro Arbos, Nick Boddington, Josh Holiday, Vincent Powell, Cortez Shaw, Gurpreet Singh Sarin, Bryant Tadeo, BurNell Taylor, Mathenee Treco and David Willis - perform with the hope of claiming one of the five remaining spots.
AMERICAN IDOL is produced by 19 Entertainment, a division of Core Media Group, and FremantleMedia North America. The series is created and executive-produced by Simon Fuller, CEO, XIX Entertainment. Cecile Frot-Coutaz, FremantleMedia, Trish Kinane, FremantleMedia North America; Ken Warwick, FremantleMedia North America; and Nigel Lythgoe, CEO, Nigel Lythgoe Productions also serve as executive producers.
Photo courtesy of FOX
About Author
- CNBC to Air THE MAKING OF DIG, the USA Network Event Series, 3/1
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- Discovery Family to Premiere New Episodes of TRANSFORMERS RESCUE BOTS, Today
- Telemundo to Present FUTBOL ESTELAR: LEON VS SANTOS, Today
- Telemundo to Give Viewers Sneak Peek at Upcoming Programming on LO NUEVO, Today


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Monte Burt Cady Sr., 74, passed away Wednesday, March 27, 2013, at his home in Rathdrum, Idaho.
He was born to Virgil Monte and Grace Burt Cady on June 24, 1938, in Missoula, Mont. Monte grew up in Fairbanks, Alaska, and graduated from Lathrop High School in 1956. He attended the University of Alaska-Fairbanks (UAF) where he met and married Barbara Ann Sawey Cady on April 7, 1960. They had 10 children.
While attending the UAF, Monte was a member of the ROTC, which led to a commission, and later retired as an infantry captain. Monte graduated from UAF in 1960 with a bachelor's degree in business administration. He went on to work in the banking and mortgage industry in Vermont, Alaska, Washington and Idaho.
Monte was an avid writer and genealogist. For fun, he and his wife would write and host murder mystery parties for friends and neighbors. He combined his love of family history and writing. Within his family, Monte was well known for writing and sharing short memoirs and stories of his life growing up and living in Alaska.
Monte was a faithful member of the Church of Jesus Christ of Latter-day Saints. He was preceded in death by his wife, parents and one grandson. He is survived by his brother, Douglas A. Cady; sister, Mary Lou Cady; 10 children; 27 grandchildren; and four great-grandchildren.
Services will be held Friday, April 5, 2013, at 2:30 p.m. at the Church of Jesus Christ of Latter-day Saints, 1700 Brick Road, Ellensburg, Washington.
Arrangements are under the direction of Steward & Williams Tribute Center, and condolences can be left for the family at www.steward-williams.com.
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In with the Devil
A Fallen Hero, a Serial Killer, and a Dangerous Bargain for Redemption
By James Keene; Hillel Levin
(St. Martin's Press, Hardcover, 9780312551032, 272pp.)
Publication Date: September 28, 2010
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Featured on Dateline and CNN, the true story of a young man destined for greatness on the football field—until a few wrong turns led him to a ten-year prison sentence. He was offered an impossible mission: Coax a confession out of a fellow inmate, a serial killer, and walk free.
Jimmy Keene grew up outside of Chicago. Although he was the son of a policeman and rubbed shoulders with the city's elite, he ended up on the wrong side of the law and was sentenced to ten years with no chance of parole.
Just a few months into his sentence, Keene was approached by the prosecutor who put him behind bars. He had convicted a man named Larry Hall for abducting and killing a fifteen-year-old. Although Hall was suspected of killing nineteen other young women, there was a chance he could still be released on appeal. If Keene could get him to confess to two murders, there would be no doubt about Hall's guilt. In return, Keene would get an unconditional release from prison. But he could also get killed.
A story that gained national notoriety, this is Keene's powerful tale of peril, violence, and redemption.
James Keene was the son of a former police officer who went from high-school football star to convict. Besides working on a book and movie about his life, he is also involved in producing, writing, and consulting for other film and book projects. Hillel Levin has been an investigative reporter for The Nation, New York magazine, Metropolitan Detroit, Playboy, and editor for Chicago magazine. He is the author of Grand Delusions and coauthor of When Corruption Was King.


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I draw a polyline to a google maps, and put markers to every point of it. I want to hide these markers higher zoom levels, therefore I use the Marker Manager. It's works well.
After draw everything, the map zoom to the bound of the polyline with the google.map.fitBound command. But if it zoom to far, where the markers would be hided, they don't. They still visible. If I drag or zoom again, they are hiding.
I use the markermanager in the simple way:
var aMarkers [...array of markers...],
markerMgr = new MarkerManager(map);
google.maps.event.addListener(markerMgr, 'loaded', function() {
markerMgr.addMarkers(aMarkers[0], 15, 0);
markerMgr.addMarkers(aMarkers[1], 12, 0);
markerMgr.addMarkers(aMarkers[2], 10, 0);
Is anybody met this problem before? Thank is advance!


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Select Local Merchants
Active FitnessRead MoreActive Fitness prides itself on its friendly, welcoming atmosphere, and for the last 20 years, patrons have noticed. A team of certified personal trainers stands at the ready throughout the spacious fitness center, helping guests buff up on the weight-training equipment or burn calories on the rows of more than 50 cardio machines. Their goal is to make each guest feel like they're part of a team, rather than just another membership number, which they stress in their small-group classes. Their classes include VastForce, an intense circuit-training class that combines elements of rock climbing, suspension training, and rowing, in which they coach each exerciser to complete the routines at their individual fitness levels. They also helm personal-training sessions, in which they push patrons toward their fitness goals—from running a marathon to losing a few pounds to flying 2 feet—with tailored routines and nutrition counseling.309 Fries Mill Rd.Sewell, NJ US
Okinawa Kenpo Karate AcademyRead MoreOkinawa Kenpo Karate Academy teaches children so much more than self-defense. For more than 20 years, instructors armed with at least a bachelor's degree have combined classic fighting techniques with important character-building lessons centered on concepts such as kindness, confidence, personal safety, and the discipline to face opponents armed with cool trading cards. Adult classes instill the same skills, exploring basic martial arts techniques and granting a full-body workout without requiring any previous experience. Beyond their standard karate lessons, the experts also teach other martial arts?such as the self-defense techniques of krav maga, the slow, energetic movements of tai chi, and the somersaults and takedowns of capoeira?and teach general fitness classes, including Pilates.72 E Holly AvePitman, NJ US
Yoga InspiredRead MoreNestled in a refurbished loft of a former bank building, Yoga Inspired offers a uniquely soothing space for connecting body to breath. Visitors walk under the building's imposing entrance and white columns before making their way to an airy loft space painted in an aqua marine color that helps calm pet seals. The carpeted floor adds extra cushioning to yoga mats as natural light filters in through large windows. The studio's classes include classic Hatha and Vinyasa Flow and are clearly coded as challenging, beginner-friendly, or gentle. Yoga Inspired's team of certified instructors leads sessions seven days a week, and in the spring, the studio offers outdoor classes on a 20-acre horse farm in Mullica Hill, New Jersey.51 S BroadwayPitman, NJ US


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Do these MM-1 speakers work with the Mac Pro?
- Asked by Ronald P from New York
- Flag as inappropriate (Do these MM-1 speakers work with the Mac Pro?)
2 Answers from the Community
They most certainly do work with a Mac Pro. I have had these speakers for over a year, and the sound experience has been great! I also use them with my kitchen TV--it is like having a theater in your kitchen. I also play my iPod off them.
- Answered by Marlene S. J from Grants
- Flag as inappropriate Answer 1
listening to them now on a Mac Pro and using Audirvana plus music software player (itunes still manages the music ) and this is giving me the best sound i have got from them yet.Have tried many other players.
If possible get some higher res files load them into iTunes and then play them through Audirvana, the sound is incredible, hard to believe that the 2 small boxes make all that sound. i have never been a fan of over bassed speakers and i find the balance of bass but not to extreme perfect for me.
- Answered by Andrew H
- Flag as inappropriate Answer 2
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While some builders welcomed NGT's guidelines, others felt that halting construction with immediate effect was no solution to curb air pollution.
Caught up in uncertainty as a result of the legal action by farmers, construction work had all but stopped in these areas since 2011.
Apartment buyers are asking for it and developers are offering it as an amenity. And considering its benefits no one is complaining about the one time investment.
The areas identified are two-km stretch from NH-24 to Char Murti Chowk in Noida Extension and Golf Course, Gurgaon, on either side of the road.
As the Empire Builder snakes along 2,230 miles on a 46-hour journey, it offers insights into the financial problems plaguing America's passenger railroad.
Ballast Nedam said that it is in exploratory talks with several foreign companies about a merger or acquisition of the firm.
The international community regards all Israeli construction on Palestinian land seized during the 1967 Six-Day War as illegal.
The Broad Sustainable Building Co. built the 57-storey skyscraper in 19 days by using a modular method, constructing three floors each day.
Real estate developer Antriksh Group has bagged the 'Best Builder of the year 2015' award in the recently-concluded 29th Builder Council of India – Real Estate Excellence Award 2015 in New Delhi.
"Uddhav Thackeray must not be aware of the full form of the DP, but only about the economics involved in it. He is hand in glove with builders," Rane alleged.


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My 13-year-old daughter's doctor said she should learn to give herself breast exams. Is breast cancer really a threat for a teenager?
- Dixie
Although breast cancer in teens is extremely rare, it's a good idea for girls to learn how to perform a breast self-examination (BSE) so they can get used to how their bodies feel normally. After learning what is normal for them, teens can then recognize changes in their breasts.
Doctors recommend doing a monthly BSE at the same time each month (like a few days after a girl's period ends, when breasts are less tender). Some kinds of lumps that teenage girls may feel are normal, but a doctor should check out any lump to be sure.
If your daughter notices any changes or has any questions, she should talk to her doctor.
Reviewed by: Mary L. Gavin. MD
Date reviewed: April 2012
Note: All information is for educational purposes only. For specific medical advice, diagnoses and treatment, consult your doctor.
© 1995–2014 The Nemours Foundation/KidsHealth. All rights reserved.
Find out by selecting your child's symptom or health condition in the list below:
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Enjoy heartwarming stories about mothers and patients and learn more about the amazing work done by the doctors and nurses at Seattle Children's. Consider making a donation in honor of a woman you know, love or admire at www.seattlechildrens.org/mothersday.
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Protect your kids from certain cancers and other diseases caused by human papillomavirus, or HPV. Get your girls and boys vaccinated when they are 11 or 12, or as soon as possible if they're already 13 or older. The vaccine is a series of three doses. Be sure your child completes the whole series for the best protection. If you have questions...
Vaccine is the best way to prevent seasonal flu. Everyone 6 months of age and older should get the flu vaccine each year, whether it's as a shot or as a nasal spray. Your healthcare provider can help you choose the right form. Get the vaccine for your family as soon as you are able, and be sure to ask anyone who takes care of your child to get the...


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Google is making its Dart system open source. This is very important, not just for open source. Dart is a structured language for web programming. That means you can actually build a website as you would write a little Javascript. In fact, Dart can be run on a Java Virtual Machine, or compiled... Read more
In our experience, every marketing team is different--but increasingly they have a few things in common. For a start, it's rare to find the whole team in any single place on any given day. More often, we find teams distributed across cities, countries, and fairly frequently, continents. The members... Read more
Americans, by nature, are not inclined to share. We have a culture of ownership—we want our own homes, yards, and even public schools. But if music television, radio commercials, and Bruce Springsteen are good indicators, what we want most of all is our own cars.
Open source has always had an on-again, off-again relationship with profit. Richard Stallman's FOSS idea was anti-capitalist. Eric Raymond's open source attitude is profoundly pro-capitalist. Yet the first open source companies to emerge in the early part of the last decade used FOSS licenses, not... Read more
Almost every time I've turned on the television in the past week, I've seen an ad for Google Chrome. What started earlier this year as a sprinkling of ads here in the United States has become a torrential downpour. For me, Google has long been one of the poster children for a new breed of company... Read more
Open source software has been referred to as a "gift economy," one where valuable goods and services are exchanged without the expectation of payment. That's fine, so far as it goes, but when it comes to businesses involved with open source software, I think the term "reputation economy" is more... Read more
In October 1969, when experts at the US Department of Defense Advanced Research Projects Agency (DARPA) connected the first two nodes of what has now become the Internet, they probably weren't considering the ramifications of their actions on future organizational cultures. But while these DARPA... Read more
Employee engagement is, as they say, a no-brainer. There are stacks of literature showing that companies with committed employees who feel strongly about their organization do better financially than those with indifferent employees. In many cases, too, improvement is actually quite easy to... Read more
Generation Z is beginning to join the workforce. This age group--born between the early 1990s and early 2000s--has never really existed in a world without the web or lacking the widespread use of cell phones, laptops, and freely available wireless networks and digital media. The combination of... Read more
My theme this week is organizational openness and transparency and today I'd like to highlight a fantastic example of an organization that has built a culture with openness at its core: Mozilla. Most of you probably know Mozilla as the organization famous for its open source Firefox web browser.... Read more


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Not blogged for a while so thought it was high time I wrote one.
Had to walk down 15 flights of stairs this morning as the lifts were out...AGAIN and then had to walk up all 210 steps when I came back. Great workout I highly recommend it #sarcasm...
So whats been going on well I left the mighty Flea production company that I was a part of, a lot of things happened and people are asking me for the truth. Professionally I've given the normal I want to do other things excuse but personally the the truth is very different. I may speak about it at some time but right now I want to focus on the positives, there are many great games coming out soon and with E3 just round the corner well it's a great time to be a gamer.
Anything in particular you guys are looking forward to with E3? Any games or announcements?
I can't wait to see what the PS4 finally looks like, couldn't be much worse than the Xbox One that's for sure.
Then there is the whole Killer Instinct news, Rare's website now has a section for the fighting game but it's blank. My reasoning is we are going to get the original games on XBLA which I wouldn't mind at all to be honest. However I better not see Killer Instinct Kinect or Killer Instinct workout fantasia I may just put salt in Bill Gates coffee if that happens.
I'm loving those Rockstar energy drinks too at the moment, I know they are bad for me but I don't care when they taste so good. Why is it that the things that taste so good are so bad for your health?
That's all I can think of right now to talk about, hoping your all good and life is treating you all well :)


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We have rich conversations with our clients every day, and increasingly these conversations are happening online. We encourage you to ask questions, share your views, and connect with like-minded professionals.
The International Annual Review demonstrates our achievements and reflects the insights and expertise professionals bring to client relationships.
KPMG's Global IFRS Institute provides information and resources to help Board and Audit Committee Members, Executives, Management, Stakeholders and Government Representatives gain insight on the evolving global financial reporting framework.
KPMG's global network of climate change and sustainability practices helps you build long-term value in a rapidly changing world.
Mining organizations need to adapt across the mining asset lifecycle, from expansion to closure, as changing economic, political and regulatory environment demand greater flexibility.
The Chemical industry's landscape is changing fast - global companies are developing or launching new products and services – and appear optimistic - setting sights on geographic expansion.
Over the last two decades many industries have changed their value proposition by developing their customers' capacity to create value.
KPMG Global Manufacturing Outlook 2014 surveyed 460 executives worldwide, and offers practical and provocative insights to help organizations evaluate future strategies.
The global job search tool allows you to search available career opportunities within many of our 150 member firms worldwide.
KPMG's International Case Competition (KICC) is a chance for students to challenge yourself to solve a real business issue and an opportunity to meet new people across the globe.
At the core of our argument is changing the way in which healthcare works with patients in order to ensure they are more active in their own healthcare. We believe that the economic argument for this is clear. Here we outline four next steps to take in realizing the extra value that patients can contribute.
Since we want to increase patient activation make every interaction with patients countHealthcare spends most of its resource in developing its interaction with patients. If we want to increase patients' activity we need to review all of these interactions to ensure that each of them increases the capacity of patients to be more active in their own healthcare. At the end of a consultation, does the patient always leave with greater skills to self-manage than they had at the beginning of that consultation? Does every letter, email or phone call leave them with greater capacity to know what they have to do next? Are you checking up that these attempts at improving patient capacity actually work with the patients and are not just empty instructions from medical professionals that have no impact on behavior?
If you want to allow patients to add value to their own healthcare make sure the healthcare is designed with them in mindSuccessful industries that encourage consumers to create value design their products with those that consume them. Healthcare needs to fully involve patients their carers and communities in all healthcare redesign. Our research shows that few patient organizations think that happens at the moment.
Develop your workforce to search for and realize assets in patients their carers and their communitiesThe practice of most medical professionals is based upon seeing patients as a set of deficits. For medical professionals to recognize the possibilities of self-management and to see patients, their families and their communities as a set of assets is a departure from the deficit model. One of the best ways of developing the workforce in this direction is to use individual or groups of expert patients to carry out that development. The workforce will also need new technical skills to work with, a number of tools such as decision aids, telehealth and other self-care technology and with real-time information about patient experience. All of the components need to be built into recruitment, induction, appraisal and reward strategies.
Payment systems will need to be reorganized to recognize the value creating possibilities of patients, their carers and the communitiesCompared to most medical interventions, the investment in better patient self-management is not expensive. But it still calls for some resource. If the payment system is organized in such a way as to see self-management as just another form of episodic cost, then it is difficult to see where the return on this investment comes from. If however, the payment system is organized to cover an entire patient pathway or population, the return on the investment in better patient self-management is potentially significant.
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