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New MRI Technique Can Detect Diabetes
MonkeyBoy writes "Researchers at Joslin Diabetes Center and Massachusetts General Hospital have unveiled a new magnetic nanoparticle based magnetic resonance imaging technique that can detect diabetes even before clinical symptoms. In mice they were able to take non-invasive images of pancreatic inflammation and its reversal for type 1 diabetes. Full article is available as a PDF from Pubmedcentral. Will we see rapid translation of these pre-clinical observations to prediction and/or stratification of type 1 diabetes and treatment of individuals with the disease? This would provide a crucially needed early predictor of response to therapy. As an added bonus it looks like the analysis was done on a Linux box too."
Sweet!
Sure.. MRI should be able to scare away diabetes with the ridiculous sounds it makes..Gosh why did no one think of this before?
Explore your creative side
Yay! Now they can detect my Mountain Dew drinking habits and force me to go cold turkey even when I'm still in denial!
As an added bonus it looks like the analysis was done on a Linux box too.
Now as I understand it, the emphasis on Linux is because it is secure, and free. Therefore, wow, nobody will know you have diabetes, and wow, the doctors will make a larger profit.
This once again proves that the OS is unimportant, and only the application matters. Who cares what OS was used to run the program that allowed this development? Certainly not the patients that benefit from it.
http://www.residentcynic.net/
That's fantastic, but it's going to take a lot of persuasion to get me to go near an MRI willingly after seeing its effect on nearby hospital equipment. You're only as safe as the stupidest person in the room.
Just reading the summary, it says the box might run on Linux?
This is a good thing, now if only the pharmaceutical companies would make alot of their stuff open to the public, maybe we'd all not suffer nearly as badly due to our wallets not being fat enough.
Still waiting on Serviscope_minor to wake up to fucking reality and realize that Jessica Price isn't going to fuck him.
This doesn't belong on Slashdot.
Of course it does. Given the sedentary lifestyle of many Slashdotters, it concerns them most directly.
"A door is what a dog is perpetually on the wrong side of" - Ogden Nash
I was just at a meeting at a meeting at a major healthcare company, and number two on the list of priorities for the next 3 years was diabetes detection/prevention. The budget was in the billions.
These guys will be making a LOT of money.
This is an interesting application of magneto-immunoassay - using the change in magnetic properties to determine if there has been a reaction.
Erm, they're talking about detecting TYPE I diabetes. Not caused by a sedentary lifestyle, but an autoimmune disease.
Don't be a Darwin awardee, do something smart, and cheap, to save yourself lots of misery, and save us (taxpayers) lots of unnecessary bills for misdirected medicine. Check these sites, how to prevent and reverse it: http://doctoryourself.com/diabetes.html http://www.mercola.com/2002/apr/10/diabetes.htm Cheap blood glucose tests at the discount stores, say $10-15 for the digital meter, $20-40 for the strips. MRI for diabetes - a gold hammer for slicing the fat out of milk... no wonder we are going broke.
I am posting instead of replying b/c there are already several separate posts that have it wrong. Gasp and shock, I know.
Type I diabetes is NOT associated with diet.
This article refers to an autoimmune disease, not a lifestyle induced one.
Ignorance is not a crime; neither should it be a way of life
Congress control $ = inmates run the asylum
Type II isn't caused by a sedintary lifestyle either. I was living an active life, getting lots of exercise when I developed it. I would regularly go out to a mall to walk, not caring that I didn't buy anything, just for the exercise, and I kept that up for the first several years after I was diagnosed. I'm not as active now, but that's because my health isn't good enough right now, and I miss the exercise.
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Anyone who has been cramed into one of those MRI "tubes" know that the size and amount of time you need to stay in it, are what needs to be worked on. I've been in two MRI machines and it is a horrible feeling!
J Clin Invest. 2005 Aug 18; [Epub ahead of print] Related Articles, Links
Noninvasive imaging of pancreatic inflammation and its reversal in type 1 diabetes.
Turvey SE, Swart E, Denis MC, Mahmood U, Benoist C, Weissleder R, Mathis D.
Section on Immunology and Immunogenetics, Joslin Diabetes Center, and Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
A major stumbling block for research on and treatment of type 1 diabetes is the inability to directly, but noninvasively, visualize the lymphocytic/inflammatory lesions in the pancreatic islets. One potential approach to surmounting this impediment is to exploit MRI of magnetic nanoparticles (MNP) to visualize changes in the microvasculature that invariably accompany inflammation. MNP-MRI did indeed detect vascular leakage in association with insulitis in murine models of type 1 diabetes, permitting noninvasive visualization of the inflammatory lesions in vivo in real time. We demonstrate, in proof-of-principle experiments, that this strategy allows one to predict, within 3 days of completing treatment with an anti-CD3 monoclonal antibody, which NOD mice with recent-onset diabetes are responding to therapy and may eventually be cured. Importantly, an essentially identical MNP-MRI strategy has previously been used with great success to image lymph node metastases in prostate cancer patients. This success strongly argues for rapid translation of these preclinical observations to prediction and/or stratification of type 1 diabetes and treatment of individuals with the disease; this would provide a crucially needed early predictor of response to therapy.
To-do List: Receive telemarketing call during a tornado warning. Check.
I have heard from several people that have had an MRI that (a) it is almost impossible to get scheduled in any reasonable timeframe for one and (b) they are 'incredibly expensive'.
:)
For something like diabetes that can be diagnosed in other ways, I don't see a normal doctor or health insurance company prescribing an MRI. Health care is one of the areas where capitalism is really the wrong motivation (because our long term health is not their concern - just short term costs).
I guess I'm just cynical, but I see some of these great advances being almost useless to the majority of people because they simply can't afford it or don't even have healthcare.
I keep hoping for things to change though
This is quite the breakthrough, and these things seem to happen out of technology we already have but just haven't used it in the right way. Personally, I'd settle for a cure for cancer being found on a Windows box if it meant saving lives. :(
Perhaps this wonderful new technology will be used by insurance companies to deny your child insurance before the diabetes could possibly cut into their profit margins?
Sorry. There should be a "cynic" moderation.
fifth sigma, inc.
The way I do it, it does. I go around every level, not stopping to rest if I can help it, and quickly. Also, at that time I was working up two flights. At fifty, I'd go up and down the stairs and watch kids half my age take the elevator and not get there any quicker. As far as the ad homenem comments at the end, they reflect more on you than on me, and show why you're posting as AC. Never did the word "coward" fit so well.
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Is impossible to get independently. But there are laws (at least in the US) that say that you cannot be turned down for a group plan (ie, your employer's) because of your illness. It's pretty much the only way a diabetic can have insurance.
I know I shouldn't feed the troll, but I will say that my doctor considered me to be in good health and getting enough exercise. That's because the mall-walking was only one aspect. I love to walk and never drive anyplace if it's within my walking distance. For me, if it's less than about two miles one way, it's close enough to walk. How far are you willing to walk? Fifty feet?
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Actually the treatment described in the paper (the use of non-mitogenic anti-CD3) is showing some remarkable results in clinical trials. There was even a recent report in the New England Journal of Medicine. Although it isn't a cure for everyone, it is a start. I think that was the point of this article about the MRI technique. It lets them actually see the inflammation so that it will be easier to test new therapies.
Back in college I had an Amiga 500 that I loved hacking on (dating myself here), but a guy I knew was not only really into the Amiga, he had to work it into practically every sentence. He'd raise his hand in Compsci classes and brag about how "My Amiga can do that better" and "That's so much easier on My Amiga". Even I grew sick of hearing the word "Amiga". He earned the derisive nickname "Amiga Man".
Apparently he's now "Linux Man"and works for Slashdot.
We apologize for the inconvenience.
Anyone know whether the magnetic nanoparticles mentioned in the article are a more general replacement for MRI contrast agents like gadolinium? Iron (even in nanoparticulate form) is probably going to be less toxic than obscure rare earth elements...
As a doctor, I had a few observations about this
... how often would
stusdy. These researchers demonstrated that an
MRI can find evidence of diabetes in mice before
the development of clinical symptoms. How does
this relate to people?
1. Practical: Type I diabetes typically develops in
children, who usually must be sedated and
observed for an MRI. This could double the cost
of the MRI (typically $1-2k in US). Also, we
don't know how long these findings are present
before diabetes develops
this need to be done?
2. The Incidence of type I diabetes is about
0.4% among people without relatives with
type I. First degree relatives have a 5-30%
risk... Certain genes predispose to type I
diabetes.... maybe this could be used in certain
people.
3. Since there is no such early diagnosis, we
don't really know who we might treat this
pre-type I state. Certainly we could make a
few reasonable guesses, but any benefit is
still in doubt until there are human trials.
I think this will definitely be more handy when
tricorders are perfected!
Building a healthy future; Connecting communities
Lots of cool marker based diagnostic methods are possible. These methods basically take a non invasive assay and use it to predict whether you have a specific disease/phenotype. Microarrays, proteomics, and analysis of bodily fluids (urine, blood, saliva, etc) all have potential to create noninvasive diagnostics.
Both islet cell and pancreas transplants work to cure type 1 diabetes. They aren't viable for type 1s in general at present because of the great imbalance between the numbers of diabetics and donors but they are effective treatments. They may never be viable for most - certainly pancreas transplants won't be.
One of the many Open MRI systems.
Can you be Even More Awesome?!
(Disclaimer: I'm a primary care doctor in the USA. I have a few type I diabetics, and many type IIs.)
First, I think it's great that the researchers have demonstrated a potential way to identify pre-clinical type I diabetes. If these patients could be easily identified and the pathologic process halted or reversed, this would be one of the greatest feats ever accomplished in medicine.
However, this approach has several problems. Another poster has already mentioned that health insurance companies could start denying coverage to kids(and adults) who don't have diabetes, but might get it. If you're a health plan administrator, diabetes is a very, very expensive disease and you want to avoid these patients.
(Whether health insurance companies should even be in the business to make a profit is a topic for another debate. Short answer: It's absolutely wrong.)
More importantly, who do you screen with MRI? Do you screen every child at age 5 (or another pre-defined age)? Do you only screen them once? It's true that most type I patients are diagnosed by the early teens, but a significant portion develop the disease in their later teens or twenties. I have a 20 year old patient who was just diagnosed with type I after the birth of her first child. I also had a medical school classmate who was diagnosed while in his residency.
Once you've decided who you'll screen and at what age and interval, how do you pay for it? This cannot be ignored. An abdominal MRI can cost $1-3,000, and you often need to sedate patients because it's quite claustrophobic. If you were to screen every child only once, the cost would skyrocket into billions of dollars almost immediately.
diabetes as been cured in mice? Detected in mice, etc?
....
They are REALLY good at inducing diabetes in mice and almost as good at reversing it.
However, they really haven't figure out how it happens in humans.
Well, they can induce
Maybe if Cmdr Taco were under constant MRI, a script could detect when he was about to post a dupe.
Now in general, I favor small government, but regulation is necessary sometimes (especially with regard to the physical health of the citizens). Frankly, medical care is too expensive. And I'm not just trolling, it really is. It's a scam that starts at the med schools and continues on to the hospitals and the medical equipment producers.
Now, there is need for reliable medical equipment, properly maintained hospitals, and skilled doctors, but that expense has been greatly exaggerated and we're paying too much for it.
And as someone who's worked repairing ambulances and medical equipment, I can't say they're particularly reliable or well maintained. Operating costs were constantly slashed, yet the administrators pay was ever increasing. Of course the cost to visit said hospital never decreased.
My father teaches at a medical university, so I've visited the place occasionally. (I have no interest in being a doctor, but it's fun to sit in on classes. My major was Chemistry, so it is pretty interesting.) It's a nice school, but I fail to see why it carries a $200k price tag. I suppose it's only because you'll graduate to make big money. (Don't even get me into some of the people who go to these schools. They make it quite clear that a passion for medicine or helping people is not their driving interest!)
Anyway, I'll bring this rambling rant to an end: Medicine is about the cash first. If people happen to get helped along the way, then great. Government regulation reining in medical costs to more reasonable levels would solve a great deal of these problems.
If you want a vision of the future, imagine a youtube comments section scrolling - forever.
The subject of this thread is not correct for the Slashdot audience. A more appropriate subject would be "Linux cures diabetes."
Type 2 diabetes is/will be a huge issue in health care for the foreseeable future. Type 2 is also known as Adult onset diabetes and is the one related to obesity and all. It is almost 20 times more prevalent than Type 1 diabetes. But this test only works with Type 1 diabetes(where basically, the body's immune system decides the pancreas is a foreign object and doesn't belong, so attacks it, destroying the insulin producing cells), detecting the early signs of trouble in the pancreas. I'm really not sure there's much money at all for these folks because I can't see them screening every child in the US every few years just on the off chance they might become diabetic. And for those patients who start showing some of the symptoms, a simple fasting blood sugar check is easier and cheaper to do.
The reviewer and posters are sort of missing the point, here, which is that if you inject about *2 grams equivalent for a human* i.e. 20 mg/kg of starch coated rust (dextran coated iron oxide) intravenously into a mouse, or presumably a person, you can see where it preferentially leaks out of microscopic blood vessels in areas of inflammation (here inflammation in the pancreatic islets due to autoimmune diabetes) by MRI (changes in the spin relaxation time).
Now that's a hack, to my mind way better than many others.
The entire pdf of the original article is available free on Biomed Central. Incidentally, resolution is not too important here, so this should work for "low field MRI", which uses ordinary magnets (.01-.1 Tesla), and costs about 10% of ordinary MRI (exclusive of technician and radiologist fees), i.e. a real currently existing "tricorder"
Troll aside, you're incorrectly generalizing your case to the rest of the population, and thus misinforming other people. Obesity does indeed strongly predispose one towards developing Type II diabetes, though it is neither always sufficient nor mandatory. If you are obese, you are at considerably greater risk of developing diabetes than if you were not. Just because you felt like you were getting enough exercise when you developed diabetes doesn't mean that sendentary habits can't cause diabetes in others. Also you never commented on whether you were obese at the time you developed diabetes.
Also, if you're going to accuse someone of attacking you, at least spell the latin correctly.
"No, no, no. Don't tug on that. You never know what it might be attached to."
Yes.
I love these questions! They do the same thing on NPR. "Mr. So-and-So, do you think that this Gaza strip pullout will mean that peace negotiations can continue, thereby creating a harmonious world balance where children hold hands and laugh gaily, frolicing through streets lined with happy merchants selling kumquats at a mere 15 cents for a dozen? Yes or no?"
If aspiration is a virtue, achievement cannot be a vice.
I'm the first to admit I'm not the typical Type II, but as you said, obesity is not a sufficient cause, nor is a sedantary lifestyle. If it were, most slashdotters would be Type II.
As far as trolling, if I did, it wasn't my intention. There's a lot of misinformation and misunderstanding about both types, and I wanted to point out that exercise by itself isn't enough to prevent it any more than lack of it will always cause it.
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This new technique is neat because it works at smaller applied magnetic fields, of order a few Gauss (Earth's field is ~1/3 - 1/2 Gauss). This means you don't need big bulky claustrophobic expensive helium-cooled superconducting electromagnets, but can use simpler, cheaper coils.
Basically, you get injected with a bunch of small particles of magnetite, which magnetically saturate at low fields. If you hit an unsaturated particle with a varying magnetic field, its magnetization varies and it gives a signal that can be detected by a readout coil. When the particle is saturated by a few Gauss field, then additional field variation doesn't change the magnetization, and so there isn't much signal out.
By scanning an applied semi-static few-Gauss field, with a gradient so that the field is zero in some region, you can differentially look for signal in the zero region. By scanning this zero region around the body, you can cover the entire body region by region and so build up a 3-D image of where the magnetite particles are.
(This is assuming that this is the same technique as was reported in Nature a few weeks ago.)
It may not be worth spotting early if it turns out to be curable after the fact, which it might ultimately be. Though I would imagine that if swelling of the pancreas can be spotted on an MRI, so can a lot of other things they haven't yet thought to look for. This might end up being a broad, multi-purpose diagnostic that is cost-justified because it eliminates so many other procedures.
:/
I can see it going either way.
Mal-2
How is the Riemann zeta function like Trump rallies? Both have an endless number of trivial zeros.
I wasn't talking about you, but about the guy who was baiting you on this thread.
"No, no, no. Don't tug on that. You never know what it might be attached to."
For your information, as time and weather allows, I rely largely on walking and biking to get around the city. I bike long distances in my spare time, visit the gym weekly, and have a daily exercise regimen I try my best to adhere to. I don't consider myself to be in the best of shape, but I try.
Although I suppose I should scrap all that, and take to aimlessly wandering the mall instead? It's clearly superior to my efforts.
What about cure for diabetes? Is there any progress to stop this pervert disease to affect millions of people? As not many knows, diabetes is a very pervert disease, because it affects many other organs like kidneys, heart or eyes.
I glanced through the article, but I wasn't able to find the reference to a Linux machine being used. How did you figure out that the analysis was probably done on a Linux box? (I'm not saying that it wasn't, just that I'm not able to find where it says so).
---
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Karma: I don't care too much, but it's 0.0% (mostly due to lack of interest)
- Most diabetics are "type 2", which usually dont have anything to do with pancreatic inflamation.
- Even for "type 1's" or peole at risk of type 1, what are they supposed to do, get a MRI every day, at $800 per scan?
- Even so, even if an inflammation is found, what can be done? Be on immuno-surpressors for a long long time?
This sounds like a technique more usueful for ivory-tower research on the progression of inflamation, not terribly useful to the end sufferer.I'm glad it runs Linux because everyone knows that MRIs cost so much and are so complicated only because they run Windows. I bet now that they are running Linux, a MRI will only cost about $20 and any 10th grader will be able to operate it.
Another added benefit will be its superior security. I'd hate all those MRI machines connected straight to the internet to be vulnerable to hacking. Someone could take control and give a patient a superdose and inadvertantly give them superpowers!
Ninjas don't carry tic tacs
I wonder where the poster is getting their information that they use Linux. Neither the Science Digest nor the original PDF paper appear to mention it. -- IV
http://www.LinuxMedNews.com Revolutionizing Medical Education and Practice.
No, what you're doing is great. Howevr, I don't have the time for that much, and getting around Los Angeles by bike isn't practical, especially when it's a fifteen to twenty mile commute to work. Equally, you're probably less than half my age, so the amount of exercise you need is greater than mine. That's not meant as a put down, either. When I was in my twenties, I was more active too.
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Most people in this country have insurance. The number of people who could "afford" bypasses if everyone had insurance would less than double with universal insurance.
What makes it so there are no lines in the US is the ridiculous amount of money to be made, since we don't have a single payer system. There are plenty of heart doctors because heart doctoring pays big bucks.
So, if we went to a socialized medicine system, then perhaps there would be lines. With no real money as the scarce resource to decide what you get, time becomes the currency. Just like in Canada, or the USSR. Get in line for your "free" stuff.
I'm not saying socialized medicine doesn't have its merits, even perhaps is better than our current system. But it has its downsides too.
http://lkml.org/lkml/2005/8/20/95
As a Multiple Sclerosis patient I had a look at the links to see if there were any suggestions regarding my condition. There were and I read them with interest. However none of the proposed treatments showed full results of any kind of clinical trials. Claims such as the ones made in the various articles linked on "doctoryourself" would carry far more weight if backed by clinical trials rather than anecdotal evidence. After all, what about those who underwent these treatments who did not respond or even deteriorated?
As for the claims that drug companies are out to swindle the public, it's worth noting that at the doses required, the costs of these vitamin treatments would be similar to the two current approved treatments (interferon and glatiramer acetate).
I'm not saying that the articles are wrong. I'm merely saying that if what they are saying is right it needs to be proven beyond all doubt and any safety fears need to be measured against benefits. This is something articles such as this fail to do as far as I can tell.
Let's imagine that you can treat MS with mega-doses of vitamins. Let's also imagine that the deficiency of these vitamins in the diet is at least a contributory factor in causing MS.
Most of us don't take the vast quantities of vitamins suggested in these documents. Yet only 1 in 800 of people have MS. Logic dictates that vitamin defficiency is not the cause of MS.
Also there are several types of MS - not in terms of progression which is well documented but in terms of which bits of immune system are causing the damage.
Here is an article scanned from The Lancet from Aug 13th 2005 discussing multiple sclerosis in terms of the immune system:
Immunohistopathology to guide multiple sclerosis treatment.
See Research Letters page 579
Immunologists have often been accused of overly complicating medicine with details of molecules, cellular differentiation patterns, and insights with disputable usefulness. By contrast, the recognition that one subtle fact of medical history or clinical sign is the key to distinguishing between diagnoses, often with the implication of a completely different therapy, is a cornerstone of good medical practice. In today's Lancet, Mark Keegan and colleagues(1) show that immunopathological differentiation might lead to better therapies for complex disorders, such as multiple sclerosis.
Multiple sclerosis is a multifactorial disease, with interactions between genetic and environmental factors via the immune system. MHC molecules, which present foreign antigens and self-antigens to T lymphocytes, are encoded by the highly polymorphic locus of the human leucocyte antigen on chromosome 6. Specific haplotypes of this susceptibility locus, in interaction with other genetic factors and environmental influences, might contribute to the various phenotypes of the neurological deficits (eg, relapsing-remitting versus primary-progressive, severity, course). Although no factor has been proven as the cause of multiple sclerosis, the pathological changes involve inflammatory processes that lead to the production of cytokines, chemokines, gelatinase-B/matrix-metalloproteinase-9, autoantibody-producing B lymphocytes, and autopeptide-recognising T cells, hence its classification as an autoimmune disease(2-5).
Current therapies for multiple sclerosis are disease-modifying, rather than real cures, and have been given to rather broad groups of patients with multiple sclerosis and solely on the basis of a clinical diagnosis. The cytokine interferon B, and the co-polymer glatiramer acetate, delay progression, but are both fraught with side-effects and high costs.(6,7) These elements constitute enough grounds to search for better, more efficient, and less expensive therapies. One way to achieve such therapies is to detail the subtle diagnostic differences, subcategorise patients who might respond better to a particular therapy, and assess the benefits.
Combinations of attacks, clinical evidence and paraclinical signs, including neuroimaging, evoked potentials, and laboratory findings of oligoclonal bands in the spinal fluid, or intrathecal immunoglobulin production, are used in the classical Poser criteria for diagnosis of multiple sclerosis(8). The IgG index - ie. the ratio of spinal fluid immunoglobulin to serum levels - is a marker that suggests the involvement of B lymphocytes and antibodies. The index correlates with the ratio of gelatinase B to A, a marker of innate immunity.(9)
The study by Keegan and colleagues is based on the combination of two studies: the clinical finding that total plasma-exchange might help in demyelination diseases,(10) and the refinement of the differential diagnosis of multiple sclerosis on the basis of careful histopathology of brain sections.(11) Similar to other frequent autoimmune diseases, such as rheumatoid arthritis and diabetes, multiple sclerosis is not just one disease. Instead, it forms a heterogeneous group of clinical and histopathological entities. For instance, T lymphocytes predominate in some forms of multi
And here I thought they called that "water" ...
Well, I guess it's a bit more like "radioactively glowing, green-colored chemical water" but still...
You might consider comprehensive digestive test analyses more than just "vitamin" testing. If the digestive system has broken down, you will presumptively suffer general malabsorbtion, requiring special nutrition for genuine repair and adequate intake.
Some of the B vitamins are directly involved in nerve cell repair of conductors and insulators and will be required at high levels.
I can not emphasize enough independent reading, research, thought and action. Those previous links are mere starting points. You might consider them as potential augmentation or therapy under knowledgeable professional supervision. Doctoryourself.com and LEF both give lots of references too.
Other technical fields categorically reject "vendor science" results as the last word as insisted in priestly pharma/medicine. (Perhaps if one adds "tobacco company" to "medical" or "pharmaceutical studies" the point is made) Individuals need to assess the situation, and make careful choices to prosper.
The various theories, evidence and remedial logic are lengthy but definitely not a waste of time. Here in the US the supplements may be somewhat less expensive. I am very thankful for the "alternative/ orthomolecular" medicine and consider them far more coherent therapeutic models in these areas.
The hopes you have for stem cells and genetic engineering may actually well be within your reach with proper biochemistry starting in your kitchen and aided by various supplements. Good reading.
Yes, you are missing something. The technique is for type 1 diabetes, not type 2. There are about 1 million type 1 diabetics in the US alone and a number of type 2 diabetics are really type 1 diabetics (LADA or latent autoimmune diabetes of the adult) or may have a component of inflammation in addition to insulin resistance. From reading the abstract it sounds like this technique is designed as a research tool to develop new treatments for diabetes. That is the real power of the technique, it identifies those individuals at the highest risk (since any treatment will have its own risk). It will also allow monitoring of treatment so that clinical trials can be shortened. Sounds like a big advance to me.
A bit of advice - HMO's are cheap, and you get what you pay for. If you can get a PPO do it, you will not regret it if you have a problem. EVERY pt I see with an HMO regrets not getting the PPO insurance option.
..........FULL STOP.