Doctor My Eyes

Some states could lose millions in education funds

2012-01-10T07:25:00.000-08:00

Some states could lose millions in education funds

Duane's Syndrome

2012-01-09T17:21:00.000-08:00

This link will take you to an hour long discussion of surgery for Duane's syndrome. This is an extraocular muscle movement promblem or a special type of strabismus with newly found genetic links. http://orlive.com/childrenshospitalboston/videos/aligning-the-eyes?view=displayPageNLM

In general pediatric ophthalmologists want to correct eye muscle deviations as soon as possible so that the eye doesn't stay deviated for a long time. The length of time deviated seems to have effects on the development of visual reflexes and even acuity.

National Defense Authorization Act Politics

2011-12-13T12:22:00.000-08:00

There are many real concerns about civil rights under this proposed reiteration of this law. Obama has threatened a veto and the congress is spit as usual along party lines. How many rights do we have to give away to be safe? Are you ever really safe anyway? I would like to see a veto of this flawed legislation but I don't know if the president has the guts to do it. A better solution must be found unless we are willing to take another step towards totalitarian rule by an imperial elite. An elite that seems untouchable even though their bankers brought the world to a precipice from which you could see the real death of American democracy.

This is a link to a discussion of some of the issues at stake. http://www.huffingtonpost.com/2011/12/13/indefinite-military-detention-defense-bill-citizens_n_1146181.html

There should be more people in the streets standing up for more democratic solutions.

POGO Oversight for the One Percent

2011-11-30T09:02:00.000-08:00

Ostensibly watching the congress,judiciary, government agencies and their lobbies...this organization is invaluable to the continuation of any semblance of democracy in the USA. As we slide into a kleptocratic corpocracy we must keep our eyes on our elected officials. Who owns them? How many favors do they owe to lobbies? Why we can't get the money out of politics is the crux of the matter. Here is a link to pogo on enforcement efforts for financial issues.
http://www.typepad.com/services/trackback/6a00d8341c68bf53ef0162fd1715bb970d

As you can see there is precious little enforcement going on. Madoff must have been emboldened by this atmosphere... the prelikewise for the predatory lenders and greedy bankers.

Read these books for more info: The Big Short by Michael Lewis....Griftopia by Matt Taibbi.

Class Warfare Your Cup of Tea?

2011-10-16T14:21:00.000-07:00

Apologists for the big banks and Wall St robber barons are quick to use the term "class warfare" in a peculiar way. It is the upper 1% that control this country and are maximizing their death grip on power daily. The supreme court is a joke and has rubber stamped this march to kleptocracy. How the media let these politicians and made men of the congress pervert the debate is shameful. This article posted in Matt Taibbi's blogroll is to the point:
Sun Oct 16, 2011 at 11:15 AM PDT
Who is waging class warfare?

by Laurence Lewis
Halte de chasse
Van Loo: Halte de chasse (Wikimedia Commons)
President Obama wants to raise taxes on those making a million or more a year, and the Republicans and their media stooges whine about "class warfare." The Republicans kill President Obama's jobs program, but that's not class warfare. And the framing is standard operating procedure. It's standard operating procedure for Republicans to respond to calls for fair taxes by whining about supposed class warfare. It's standard operating procedure for Republicans to do all they can to concentrate more and more wealth and power in the hands of fewer and fewer without anyone calling it what it is. But for a little perspective on the supposed class warfare from the left, we can refer to future Sen. Al Franken's 2003 best-seller Lies And the Lying Liars Who Tell Them:

In her book A Distant Mirror: The Calamitous Fourteenth Century, Barbara Tuchman writes about a peasant revolt in 1358 that began in the village of St. Leu and spread throughout the Oise Valley. At one estate, the serfs sacked the manor house, killed the knight, and roasted him on a spit in front of his wife and kids. Then, after ten or twelve peasants violated the lady, with the children still watching, they forced her to eat the roasted flesh of he husband and then killed her.

That is class warfare.

Arguing over the optimum marginal tax rate for the top one percent is not.

Of course, it's not only an outrageous smear for Republicans to accuse those seeking some measure of economic justice as waging class warfare; it's also the very definition of hypocritical. Because in the Post-Industrial Era, it's the Republicans who have been attempting a systematic dismantling of all government protections and services that help the less economically advantaged, while at the same time opposing any similar cuts that might affect the wealthiest, while at the same time continuing to promote government spending that further enriches the wealthiest. But that's not class warfare. Calling for a return to the tax rates of 1950s and 1960s—which saw the blossoming of the middle class, the construction of the national highway system, the expansion of Social Security and the creation of Medicare and Medicaid—is class warfare.

Republicans love to blither about moral values. To Republicans, moral values seem solely and obsessively to be about repressing people's sex drives. To Republicans, moral values don't seem to have anything to do with protecting such other drives as the need to eat and have shelter, much less such extreme luxuries as health care, an education and economic opportunity. To Republicans, moral values don't seem to include social and economic fairness and justice. To Republicans, moral values don't seem to have anything to do with being our neighbors' keepers. Child poverty is nearing an astonishing 25 percent, but to Republicans, that's probably the fault of the children themselves, who apparently didn't choose the right families into which to be born.

It's bad enough that the Republicans deliberately pursue an agenda that hurts people, voting against jobs programs, trying to deny expanded health care, waging war on the unions that were responsible for forcing the creation of the forty hour work week, mandated time off, worker safety laws, and an end to child labor. But they also blatantly lie about the dire conditions in which increasing millions of people live. They blatantly lie about the causes of economic duress. They blatantly lie about their own economic agenda, the promotion of which is almost entirely constructed of lies. They know that they can't convince people deliberately to vote against their own self-interests, and their economic agenda is hostile to most people's self-interests—their economic agenda is hostile to most people—so they have no choice but to lie. And the more successful they have been, the more difficult and desperate life has become for most people.

The poverty rate last year hit a 52-year high while the wealthiest continued to grow wealthier. And that was but the continuation of the expansion of the greatest income gap ever recorded in this country. But to what purpose? How rich is rich enough? How many future generations need to be ensured of having more money than they will ever be able to spend? What is the need for such extreme greed, such mendacity and such cruelty? Real people are hurting. According to the United States Department of Agriculture, 48,800,000 Americans lived in food-insecure households in 2010, and 16,200,000 of them were children. And none of it is accidental.

What kind of people would willingly inflict so much suffering on so many people? On millions of children? What kind of people would block every attempt to help so many people who are suffering, and then label attempts to help them "class warfare"? This is the real question, both about next year's elections and about the past 30 years of right wing economic policy. Which century do these people most want to emulate? The Gilded Age of the 19th century? The Rococo era of the European royals?

Those striving for some measure of social and economic justice mean to hurt no one. Creating some balance in the income gap and the distribution of wealth will not cause anyone to go hungry or homeless or to lack adequate health care. Those using every possible means to deny some measure of social and economic justice are hurting people. They are deliberately and unconscionably perpetuating the causes of immeasurable unnecessary suffering. So who is waging class warfare?

Who are these people?

Yersinia Pestis (cause of the Black Death) genome determined

2011-10-15T17:41:00.000-07:00

Human Genome Sequence Editing the arrangement of a sequence of these letters corrected a genetic mutation in stem cells, a breakthrough combination of stem cell therapy and genetic modification. Wikimedia Commons

For the first time, scientists using a combination of gene-editing technologies have corrected mutations in a patient’s own induced stem cells. The breakthrough could pave the way toward reprogramming a person’s own cells to cure genetic diseases, rather than using transplanted organs and drug therapies.

Researchers led by two institutions in the UK corrected a mutation in cells derived from a patient with a metabolic liver disease.

Related Articles
First Successful Use of Genome Editing In Living Animals Cures Hemophilia In Mice
New Genome Editing Method Helps Scientists Rewrite Whole Sections of the Code of Life
Seeking Advanced Stem Cell Treatment, Peyton Manning Flies to Europe
Tags
Science, Rebecca Boyle, chromosomes, editing, gene expression, genetic mutation, GENOME, genomics, health, iPS cells, stem cells
Stem cells — embryonic ones and induced pluripotent ones — can turn into any type of cell, so they hold promise for treating a host of disorders. They can come with unwanted mutations, however. For one thing, induced pluripotent stem cells (iPS cells) would contain the same genetic defects as the rest of a patient’s body, so you’d have to remove those defects before you could treat a person with his or her own cells. But this removal can be imprecise; current editing methods can cause misplaced alleles or residual genetic sequences, which can lead to formation of cancer or other unwanted side effects. And recent breakthroughs in gene editing methods have not involved stem cells.

To work on stem cells, you would need a very careful editing method to snip out incorrect gene sequences in the stem cells and replace them with the correct kind. And that’s what these researchers have done.

Scientists at the Wellcome Trust Sanger Institute and the University of Cambridge worked with a mutation in a gene responsible for coding a specific protein in the liver. It’s a common mutation, found in about 1 of every 2,000 people of European descent, and it’s also a fairly simple mutation, with just one transposition of letters.

The team took skin cells from a patient and turned them into iPS cells. Then they used genetic scissors, zinc-finger nucleases, to snip the genetic sequence at the site of the mutation. They also used a piggyBAC transposon, which cuts and pastes genetic information. In this way, they were able to correct both alleles involved in the mutation of this liver gene.

Once the stem cells were corrected, the team induced them to become liver cells. These were transplanted in mice with the liver disorder. The cells restored the liver’s proper function, and were still working properly after six weeks, the researchers said.

This was an incredibly difficult maneuver, and it’s the first time anyone has been able to pull it off, the researchers say. Researcher David Lomas told the BBC it was “ridiculously hard.”

But it’s proof, at least in principle, that well-edited genetic sequences in induced human stem cells can provide new cells for a variety of clinical treatments. The paper was published in today’s issue of Nature.

Scientists have also dug up Alaskan victims of the 1918 flu pandemic to explore the genetics of the h5n1 variety of the flu virus that killed close to 40 million people worldwide. These plagues still roam the earth and dedicated scientists try to take steps to eliminate these deadly threats to humankind. Smallpox and polio have been all but eliminated from the western world. Pockets of polio still remain. There is an interesting talk on TED by Larry Brilliant one of the scientists working on smallpox eradication in India. If this interests you I would recommend a book called Deadly Feasts that explores the "mad-cow" phenomenon....also The Hot Zone which is about Ebola virus outbreaks. A book concerning aids that has been very controversial is Hooper's book The River. It explores a theory of the origin of aids....the polio vaccine theory. Polio researchers roamed Africa using live and attenuated polio virus vaccines on native populations. The evidence for the theory is all circumstantial but it is very well researched. Dr Koprowski of the Wistar Institute denies any culpability as do most researchers but the case may not be laid to rest yet.

Part of Healthcare Plan Dismantled

2011-10-15T03:23:00.000-07:00

CLASS was a section of the Obama plan to give long term care to seniors. Apparently Washington can't find money to fund it and it is doubtful that subscription to the plan would support it. This was posted on the Huffington Post 10-15-11:

Obama Administration Cuts Major Part Of Health Care Reform Law: CLASS Long-Term Insurance Program Canceled
Barack Obama Health Care Reform

RICARDO ALONSO-ZALDIVAR 10/14/11 11:40 PM ET AP

WASHINGTON — The Obama administration Friday pulled the plug on a major program in the president's signature health overhaul law – a long-term care insurance plan dogged from the beginning by doubts over its financial solvency.

Targeted by congressional Republicans for repeal, the program became the first casualty in the political and policy wars over the health care law. It had been expected to launch in 2013.

"This is a victory for the American taxpayer and future generations," said Sen. John Thune, R-S.D., spearheading opposition in the Senate. "The administration is finally admitting (the long-term care plan) is unsustainable and cannot be implemented."

Proponents, including many groups that fought to pass the health care law, have vowed a vigorous effort to rescue the program, insisting that Congress gave the administration broad authority to make changes. Long-term care includes not only nursing homes, but such services as home health aides for disabled people.

Known as CLASS, the Community Living Assistance Services and Supports program was a long-standing priority of the late Massachusetts Democratic Sen. Edward M. Kennedy.

Although sponsored by the government, it was supposed to function as a self-sustaining voluntary insurance plan, open to working adults regardless of age or health. Workers would pay an affordable monthly premium during their careers and could collect a modest daily cash benefit of at least $50 if they became disabled later in life. The money could go for services at home or to help with nursing home bills.

But a central design flaw dogged CLASS. Unless large numbers of healthy people willingly sign up during their working years, soaring premiums driven by the needs of disabled beneficiaries would destabilize it, eventually requiring a taxpayer bailout.

After months insisting that could be fixed, Health and Human Services Secretary Kathleen Sebelius finally acknowledged Friday she doesn't see how.

"Despite our best analytical efforts, I do not see a viable path forward for CLASS implementation at this time," Sebelius said in a letter to congressional leaders.

The law required the administration to certify that CLASS would remain financially solvent for 75 years before it could be put into place.

But officials said they discovered they could not make CLASS both affordable and financially solvent while keeping it a voluntary program open to virtually all workers, as the law also required.

Monthly premiums would have ranged from $235 to $391, even as high as $3,000 under some scenarios, the administration said. At those prices, healthy people were unlikely to sign up. Suggested changes aimed at discouraging enrollment by people in poor health could have opened the program to court challenges, officials said.

"If healthy purchasers are not attracted ... then premiums will increase, which will make it even more unattractive to purchasers who could also obtain policies in the private market," Kathy Greenlee, the lead official on CLASS, said in a memo to Sebelius. That "would cause the program to quickly collapse."

That's the same conclusion a top government expert reached in 2009. Nearly a year before the health care law passed, Richard Foster, head of long-range economic forecasts for Medicare warned administration and congressional officials that CLASS would be unworkable. His warnings were disregarded, as Obama declared his support for adding the long-term care plan to his health care bill.

The demise of CLASS immediately touched off speculation about its impact on the federal budget. Although no premiums are likely to be collected, the program still counts as reducing the federal deficit by about $80 billion over the next 10 years. That's because of a rule that would have required workers to pay in for at least five years before they could collect any benefits.

"The CLASS Act was a budget gimmick that might enhance the numbers on a Washington bureaucrat's spreadsheet but was destined to fail in the real world," said Senate Republican leader Mitch McConnell of Kentucky.

Administration officials said Obama's next budget would reflect the decision not to go forward. Even without CLASS premiums, they said the health care law will still reduce the deficit by more than $120 billion over 10 years.

Kennedy's original idea was to give families some financial breathing room. Most families cannot afford to hire a home health aide for a frail elder, let alone pay nursing home bills. Care is usually provided by family members, often a spouse who may also have health problems.

"We're disappointed that (Sebelius) has prematurely stated she does not see a path forward," AARP, the seniors lobby, said in a statement. "The need for long-term care will only continue to grow."

Sebelius said the administration wants to work with Congress and supporters of the program to find a solution. But in a polarized political climate, it appears unlikely that CLASS can be salvaged. Congressional Republicans remain committed to its repeal.
This underscores what our priorities are in this country. It would be nice if we could find the way to save 2 patients in this country for the same price as we spend to kill one terrorist in the middle east.

Glaucoma Stats

2011-10-14T19:03:00.000-07:00

Almost half of those with glaucoma don't know they have a pressure problem or a sight threatening optic neuropathy.....glaucoma incidence varies with age...varies with family history...varies with ethnic background and race...varies with type of refractive error....glaucoma may have no or very little pain in early stages... field testing/peripheral vision tests may not pick up early glaucoma (40% of retinal ganglion cells may die before field defect becomes apparent)...incidence at age 40~1%...incidence at 70 ~4%....Afro American population has 5 times the number of glaucoma patients with 6 times the number of blind patients... one in 10,000 children in the US are born with glaucoma...
More info is available at the CDC website or through MMWR.....also AHRQ website and glaucoma.org website.

The randomized multicenter clinical trials are a nation-wide effort to move doctors to practice evidence based medicine. The National Eye Institute has done several trials that have changed the treatment of glaucoma and helped understand the best approaches to several other eye diseases.

Obama’s Ozone Capitulation: Celebrated by Conservatives and Denounced by Liberals

2011-10-11T18:42:00.000-07:00

Obama’s Ozone Capitulation: Celebrated by Conservatives and Denounced by Liberals

If you believe in stewardship of the planet and want your children to breathe clean air you may already be tuned into this great debate. A debate that the current administration may have just decided not to engage in. This is not what many supporters of Obama expected.

Vast New Oil Source Discovered in the Gulf

2011-10-11T18:22:00.000-07:00

Vast New Oil Source Discovered in the Gulf
This was posted at Daily Kos blog on 10-11-11. The article exposes the games that oil arbitrage guys play with the life blood of the economy. What could possibly be done to give these guys oversight? They operate outside the country in shady cartels and really have only one guiding principle: maximize their profit though the world might grind to a halt.

Contact Lens and Solution Compatibility

2011-06-11T19:24:00.000-07:00

Only recently has the contact industry had a close look at this subject. The silicone hydrogel high oxygen lenses had a tendency to coat with protein and the showed some incompatibilities with certain solutions. This was a cause of concern to doctors who wanted safer lenses but saw an increase in complaints of discomfort and reduced tolerance. The current rundown is at this web-site: http://staininggrid.com/faq.aspx This helps us troubleshoot contact lens problems and might help avoid comfort issues (staining is uncomfortable). The Pure Vision lens is a good lens when used with the right solutions, but can be unsuccessful if used with the wrong solution .

J Craig Venter Genetic Pioneer

2011-03-23T13:38:00.000-07:00

A good read for biology or health nuts is the book "A Life Decoded" by Venter. It details his struggles in starting and running several genetic ventures involved in decoding the human genome. It also shows how petty and competitive the business of science can get. His rivalry with Frances Collins is well documented and the competition between rival efforts to sequence the genome are legend. Essentially, Venter's program promised to do the genetic work in a shorter time than the government sponsored effort headed by Collins. A lot of professional egos were bruised and wall street fortunes were bet and lost trying to second guess the direction of genetic progress and patents. here is the link to a short lecture by Venter.

Science Video Winners

2011-02-13T04:52:00.001-08:00

http://bcove.me/mkc0yaji This link takes you to a nice explanation of how streptomycin works at the level of the ribosome. Pharmaceutical companies are always looking for various targets for antibiotic action and this is just one such target.

http://bcove.me/8nclmb1y This link is to a discussion of the 4th dimension.

http://bcove.me/rcq0dgdl This link is to an overview of the large hadron collider.

http://bcove.me/s7llr2xk This link discusses quantum entanglement, a concept that tangles most of our minds....one of the wierdest concepts physics has come up with.

These short videos are winners in a contest sponsored by Ars Technica. If you don't currently surf to their website please go there and sample their excellent content...from computers to basic science.

This is the search cloud from the NIH and MedlinePlus

Content on this page requires a newer version of Adobe Flash Player.

If you decide not to install Flash player at this time, click Search Cloud to see MedlinePlus top searches

Search Box Widgets

Where Was This Mind Numbing Video During the Election?

2011-01-05T03:59:00.000-08:00

Is it any wonder that we have gridlock in government? How exactly is Scott going to make anything better for Florida? If this video had seen more exposure he wouldn't be our governor....Scott evidently intends to ask business concerns to write the rules for Florida....he will aid and abet them in giving away any advantage and stopping any oversight that hinders them in any way. This is how we got the BP oil spill ie no effective regulation. Floridians will have buyers remorse with this guy who is already in violation of sunshine laws in his first week. As one pundit on npr said "maybe the new attorney general can investigate the new governor?!" IN THEIR FIRST WEEK!! Moving into the end of 2011 we find Scott hesitating to pick sides in the Republican primary...is it Perry or is it Romney? This snippet from Politifact as posted in Huffington Post is illustrative of Scott's convenient memory and political side stepping of issues:
Before Herman Cain got America excited about numeric repetition with his storied (and secret!) 9-9-9 plan, Florida Governor Rick Scott was selling the state of Florida on his own triple-integer gem. As a candidate for office, Scott announced that he was going to pursue what he called the "7-7-7 plan." And no, it didn't involve decapitating Gweneth Paltrow. Here's the St. Petersburg Times, back in July of 2010:

GOP front-runner Rick Scott unveiled his jobs plan Wednesday, his first major policy proposal in the race for the governor's mansion. The plan promises 700,000 jobs in seven years. (And it's seven steps, so it's called the 7-7-7 plan.)

“As governor, I’ll be Florida’s Job Creator-in-chief. I’ll be focused on putting Floridians back to work, not securing my next political job, and I’ll be accountable to taxpayers not beholden to special interest,” said Scott. “My 7-7-7 Economic plan will grow the economy, create jobs and increase wages.”

The seven tenets: Accountability Budgeting; Reduce Government Spending; Regulatory Reform; Focus on Job Growth and Retention; World Class Universities; Reduce Property Taxes; Eliminate Florida’s Corporate Income Tax.

Now, here's a critical detail about Scott's ambitious promise. The 700,000 jobs he promised to create would be his own doing. These would be 700,000 jobs generated on top of whatever growth was projected to occur without instituting any changes. Politifact Florida remembers this well:

Let's rewind to July 2010. State economists had already estimated Florida's recession rebound — no matter who the new governor might be — would add more than 1 million jobs by 2017.

[...]

Reporters wanted to know: If the state's expected growth alone was projected to restore 1 million jobs, did that mean Scott's structural changes to spending, regulation and the tax code would add 700,000 more?

"Are those jobs that are in addition to the number of jobs that are going to be created automatically, just without any change in tax policy over the next five or 10 years?" a reporter asked Scott while traveling on his campaign bus. (We know, because we have the video.)

Scott answered yes, then pointed out that jobs aren't created automatically. The reporter then corrected himself.

"Well, projected. The job creation that is projected over the next five years," he said.

"It's what's projected, yeah. It's what's projected, yeah," Scott said, nodding. "It's on top of that. If you do these things we're going to grow 700,000 more jobs."

But as we've been telling you, that Rick Scott is a bit of a trickster! And he soon decided to start giving himself the credit for the job growth already in motion. As you'd imagine, the promises of old have changed. Let's toss this back to Politifact:

In June, Scott spokesman Brian Burgess touted news that Florida had added 50,000 jobs since January, saying that Scott was going to count every one toward keeping his promise.

In the same few days, another Scott spokesman, Lane Wright, brushed off a question about Scott's original promise to create 700,000 jobs "on top of what normal growth would be."

"Gov. Scott committed to creating 700,000 jobs in seven years, and we are on track to meet that goal," Wright said.

In August, the governor himself weighed in. An Associated Press reporter reminded Scott that his jobs plan was designed to generate 700,000 jobs on top of those restored by the state's expected growth.

"No, that's not true," Scott said.

So, the reporter pushed, statements by his campaign were totally wrong?

"I don't know who said that," Scott said. "I have no idea."

(Here's a hint: It was "Rick Scott.") Politifact rates this a "full flip flop."
...and so should the residents of Florida.

While we are on the subject of stunningly bad behavior by politicians how about ol John Ensign? A C-Street Family associate :

On December 7th 2011 this from Huffington Post:
For Rick Scott, every day's a new record -- and each one seems worse than before. New numbers from Public Policy Polling show the Florida Governor's approval ratings have hit a new low at 26 percent, a 7 percent slide from a previous personal worst this past June.

In fact, PPP says, the latest poll makes Scott the least-liked governor in the entire United States.

Maybe for Christmas I will ask Santa for a new Governor!

Amber Alert

2010-12-16T17:25:00.000-08:00

Cataract Surgery

2010-12-11T04:26:00.000-08:00

Cataract surgery is one of the most frequent surgeries paid for by Medicare. Almost all of us will sooner or later need to address the poor vision caused by natural aging processes that lead to cataract. When your vision becomes worse than 20/40 or your ability to work is hampered by cataract changes insurance companies begin to pay for the procedure. This surgery is one of the most successful surgeries done and usually leads to very few complications. Each case is different and your surgeon cannot give ironclad guarantees. This short video from youtube gives an overview. Small incision surgery (no stitch or one stitch) is most prevalent today, although certain cases may require different approaches.

There are choices to be made concerning newer types of implants....bifocal or accommodating implants. Your surgeon can be of help in detailing the advantages. These lenses will of course cost more and insurances may not pay for the extras. Be sure you are clear on this. Vision may actually be clearer with the standard lenses so be careful if you are an accountant or a person that does detailed work. A standard lens with a reading glass over the top may be better for some.

Pro Publica Story on Pharmaceutical Companies

2010-11-20T09:06:00.000-08:00

For Years, Drug Company Paid Top Athletes to Attract Doctors

by Marian Wang
ProPublica, Nov. 19, 2010,

If you’ve checked out our Dollars for Docs coverage [1], you’ll know that drug companies often pay doctors to consult and give speeches about their products to other doctors. Since 2009, as we’ve noted, seven major pharmaceutical companies have paid $282 million in such payments to health professionals.

But doctors aren’t the only ones who got paid to speak at company events, according to the Washington Times.

From 2006 to 2009, one company, Novartis, took a creative approach to boost doctor attendance and spent $3.6 million paying 150 top athletes and coaches [2] to make appearances, give speeches, answer questions about their careers, and pose for photos with attendees. The payments ranged from $8,000 to $35,000 per appearance, according to the Times:

"Over the years, it got harder and harder to get physicians to come to the informational dinners," said Rooney Nelson, whose company, the Nelson Group, was hired by Novartis in 2006 to put together the dinners with athletes. In a three-year period, the company put on more than 250 events, ending in 2009.

He said his firm provided the athletes and physician speakers and arranged for the restaurants, some of which were high-end. He said his firm would pay the expenses and then be reimbursed by Novartis.

Mr. Nelson, who is suing Novartis over $538,000 in bills he said were unpaid, recalled that the number of doctors attending the events went from a handful to more than 70 once the athletes were involved.

Novartis declined to comment to the Times about the specifics of its athlete-speaker program, but a spokesman said the company is “committed to promoting its products in an ethical and compliant manner and has developed corporate guidelines and procedures to help ensure that all promotional activities and programs meet the applicable requirements by the FDA and other regulatory agencies.” (We’ve called Novartis, but have not yet heard back.)

In an agreement reached last month with the Justice Department, Novartis agreed to pay more than $420 million [3] to settle allegations that it paid kickbacks to doctors to prescribe six drugs and promoted a drug for uses unapproved by the Food and Drug Administration.

According to the Times, three of the drugs named in the kickback portion of the settlement were products that were pitched to doctors at events with athletes.

Novartis payments to physicians are not currently in our Dollars for Docs database because the company won’t begin disclosing these payments until March 2011 [4], when it is required to as part of its settlement with the Justice Department. Seven other drug companies have already been disclosing their payments to doctors, and you can see if your doctor is among them [1].
The December online issue of New England Journal Of Medicine has a copy of the Shattuck lecture on healthcare policy and a good history and argument for strong regulation by the FDA. http://www.nejm.org/doi/pdf/10.1056/NEJMsa1007467?ssource=hcrc
A very good history lesson for all involved in healthcare. Recent hiccups by the FDA may be due to underfunding and lobbies against strong regulation by big pharma.

Gentlemen Start Your Political Machines

2010-08-06T17:40:00.000-07:00

So we may have passed some healthcare reform measures, but now comes the aftermath. Already several states are challenging the foundation of the reforms passed and challenge its constitutionality. Everyone is second guessing the needed changes these days. One real need is to graduate more generalists from medical schools. There have been too many specialists in the field for many years. This is an excerpt from the pre-publication electronic issue of the New England Journal of Medicine concerning just that problem.

underscoring the concern over the scarcity of primary care providers and the income gap between generalists and specialists,9 the law awards a 10% bonus for 5 years under the Medicare fee schedule, beginning in 2011, to family doctors, internists, geriatricians, nurse practitioners, and physician assistants who provide 60% of services in qualifying evaluation and management codes. The adjustment will not change the fees that Medicare pays to specialists. The law also requires states to increase Medicaid payment rates to Medicare levels in 2013 and 2014 for providers who deliver certain primary care services.

Other forms of support for primary care have emerged as well. A draft report prepared by the Council on Graduate Medical Education that has been approved but not yet officially released by the Department of Health and Human Services emphasizes that a shortage of primary care physicians overshadows deficits in all other specialties. The report’s major recommendation is that GME policies should be designed so that the number of primary care physicians among all doctors would increase from the current estimate of 32% to at least 40%. Other signs of support for primary care are coming from a multisector coalition known as the Patient-Centered Primary Care Collaborative,10 a report produced by a group of medical leaders,11 and a leading policy journal that devoted an entire issue to the subject.12

By comparison, when it comes to graduating medical students who are actually opting for careers in primary care, as measured by the residency training positions they secure, interest falls precipitously and has for a decade or more.13 The upcoming report of the Council on Graduate Medical Education estimates that among 24,378 medical students who were matched to residency training positions in 2010, between 3891 and 4385 plan careers as primary care physicians.14 Thus, only 16 to 18% of medical students who obtained positions through the National Resident Matching Program in 2010 are likely to practice primary care (Robertson R: personal communication) (Table 1).15,16,17,18 The 2010 match results are “not encouraging for adults needing primary care,” according to a March 18 statement by the American College of Physicians.19 The group estimated that 20 to 25% of internal medicine residents are now specializing in general internal medicine, as compared with 54% in 1998. The remaining residents are pursuing a subspecialty of internal medicine, such as cardiology or gastroenterology.

Obviously we need both types of docs but the balance is a real hot potato for medical educators. We have only begun to explore the ramifications of healthcare reform. Why didn't we listen to Wendell Potter?

A Pensacola judge recently ruled that parts of the Obamacare plan are unconstitutional. Here is an except from Huffington Post:
Congress could require that people buy and consume broccoli at regular intervals," he wrote, "Not only because the required purchases will positively impact interstate commerce, but also because people who eat healthier tend to be healthier and are thus more productive and put less of a strain on the health care system."

Defenders of the law said that analogy was flawed. Insurance can't work if people are allowed to opt out until they need medical attention. Premiums collected from many who are healthy pay the cost of care for those who get sick. Since the uninsured can get treated in the emergency room, deciding not to get coverage has consequences for other people who act prudently do buy coverage.

"The judge's decision contradicts decades of Supreme Court precedent that support the considered judgment of the democratically elected branches of government that the act's individual responsibility provision is necessary to prevent billions of dollars of cost-shifting every year by individuals without insurance who cannot pay for the health care they obtain," White House adviser Stephanie Cutter wrote in an Internet posting.

Vinson, who was appointed to the federal bench by President Ronald Reagan in 1983, said in his 78-page ruling that requiring people to buy health insurance marks a break with the nation's founding principles.

"It is difficult to imagine that a nation which began, at least in part, as the result of opposition to a British mandate giving the East India Company a monopoly and imposing a nominal tax on all tea sold in America would have set out to create a government with the power to force people to buy tea in the first place," the judge wrote. "If Congress can penalize a passive individual for failing to engage in commerce, the enumeration of powers in the Constitution would have been in vain."

It would be difficult to recognize any limits on federal power, he added. Defenders of the law said the founders couldn't have envisioned Medicare or Social Security either.

Vinson did side with the administration on another major issue in the case, the expansion of Medicaid to cover more low-income people. About half of the more than 30 million Americans who would gain insurance through the law would be enrolled in Medicaid. However, striking down the law would also invalidate the Medicaid expansion.

Opponents of the health overhaul praised the decision. House Speaker John Boehner said it shows Senate Democrats should follow a House vote to repeal the law.

"Today's decision affirms the view, held by most of the states and a majority of the American people, that the federal government should not be in the business of forcing you to buy health insurance and punishing you if you don't," he said.

Democrats just as quickly slammed the ruling.

"This lawsuit is nothing more than an attempt by those who want to raise taxes on small businesses, increase prescription prices for seniors and allow insurance companies to once again deny sick children medical care," said Senate Majority Leader Harry Reid, D-Nev.

Former Florida Republican Attorney General Bill McCollum filed the lawsuit just minutes after Obama signed the 10-year, $938 billion health care bill into law in March. He chose a court in Pensacola, one of Florida's most conservative cities. The nation's most influential small business lobby, the National Federation of Independent Business, also joined.

Officials in the states that sued lauded Vinson's decision.

"In making his ruling, the judge has confirmed what many of us knew from the start: Obamacare is an unprecedented and unconstitutional infringement on the liberty of the American people," Florida Gov. Rick Scott said.

Other states that joined the lawsuit were: Alabama, Alaska, Arizona, Colorado, Georgia, Indiana, Idaho, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Ohio, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Washington, Wisconsin and Wyoming.

John Cohn of NPR says this: elsewhere, Vinson asserts that the decision not to carry health insurance has "zero" economic impact. But then, literally a paragraph later, he acknowledges that uncompensated care for the uninsured transfers $43 billion in costs to the rest of society. Later, he goes so far as to recognize that requiring people to get insurance is "necessary" for carrying out the universal coverage scheme Congress determined it wanted.

So if Vinson admits all of these things, why did he bother first to assert that forgoing coverage has "zero" impact? He's drawing a distinction between present and future commercial activity that doesn't make a ton of sense to me. (I'm going to write a separate post on that later.) My guess, honestly, is that Vinson is desperate to play down the link between decisions to forgo insurance and the impact on other people's premiums — a link that history and scholarship have established firmly. And that's because the link, if real, would place it within most contemporary understandings of the Commerce Clause's reach.

Can we expect more such creative reasoning as the case moves forward? The justices of the Supreme Court have certainly imposed their own will before. If they hadn't, George W. Bush might never have become president. (Ezra Klein is not the only one who sees echoes of Bush v. Gore in this litigation.)

Still, there is one other check on the courts' discretion: Public perception. Judges can defy public values up to a point, but only up to a point. And while the public remains divided on the Affordable Care Act, it has expressed a clear and unambiguous preference for health insurance that is affordable and available to all — while preferring, for better or for worse, to keep the existing system of private insurance in place. Is the Supreme Court really ready to reject that preference?

So Washington will spend months on this argument while many sick people suffer and maybe die from lack of care. You have to ask yourself how civilized is this society...that we can't come up the the standards of Canada and Europe?

The pols in Washington will bemoan the budget while ignoring the 2 wars and the great waste of money, treasure and life that has come about. The commission on military contracting for the congress has issued several interim reports here is an excerpt from an introduction to one of their latest reports:
Executive Summary
Federal reliance on contractors to support defense, diplomatic, and development
missions during contingency operations stands at unprecedented levels. Over the
course of the past nine years, contractors have at times exceeded the number of
military personnel in Iraq and Afghanistan.
Total spending through contracts is correspondingly large. While there is no central
federal source for definitive data on contracts and grants regarding contingency
operations, the Commission’s conservative estimate is that since October 2001,
at least $177 billion has been obligated on contracts and grants to support U.S.
operations in Iraq and Afghanistan.
Given the magnitude of mission and money at risk, losses from waste, fraud, and
abuse represent a significant cost. While the impact on mission cannot be readily
quantified, misspent dollars run into the tens of billions.
▪▪ The Special Inspector General for Afghanistan Reconstruction (SIGAR)
warned at the Commission’s January 2011 hearing that the entire $11.4
billion for contracts to build nearly 900 facilities for the Afghan National
Security Forces is at risk due to inadequate planning. This estimate does
not include the waste that has resulted from the host country’s inability to
sustain projects.
▪▪ The Association of Certified Fraud Examiners has reported a survey-based
estimate that 7 percent of revenue is lost to fraud. Applying this metric to
the $177 billion in contingency contracts and grants suggests the cost of
federal failure to control the acquisition process could be as high as $12
billion for fraud, not including contract waste.
Congress instructed the Commission to make recommendations to avoid such
results in future contingencies. These recommendations must meet two primary
criteria: they must address the underlying causes of the poor outcomes of
contracting, and they must institutionalize changes so as to have lasting effects.
In At what risk? Correcting over-reliance on contractors in contingency operations,
our second interim report to Congress, we are making recommendations that we
believe do both. Finally, these recommendations require an investment that the
U.S. government must make as it continues to rely on contractors as part of the
total force in contingency operations.

It seems to me that we must make a choice ....guns or butter, guns or health, hegemony or civil society. We had Bin Laden at Tora Bora and let him get away because Gen. Franks never got or gave the order to close the border into Pakistan. This is all detailed in the book "Jawbreaker" by the CIA agent in charge of the hunt for OBL. So Bush got his rationale to go into Iraq (was it really oil? read the "Plan for a New American Century" by the neocons who later influenced the buildup to war) and dragged us all into another costly war with inadequate planning and inadequate forces and no coherent plan. So we may be broke soon. OBL may win after all since this was his goal ie to bankrupt the USA.

The best guitar player you haven't heard of.....

2010-08-05T10:47:00.000-07:00

An eye doc in Georgia has produced a dvd of Scotty Anderson playing jazz with several well known players from around the south...all pros and all worth a listen if you like jazz or just guitar playing. As a semi-retired musician myself I am amazed at the quality of playing on this cd and I hope you will be too. I also hope you buy the dvd. Just a little plug for a deserving player.

Factors in Progression of Diabetic Retinopathy

2010-06-30T08:47:00.000-07:00

The latest issue of New England Journal of Medicine contains this comment/summary of recent findings from the ACCORD Study. This study investigated the progression of retinal complications in diabetes. These large studies are moving the science of management forward and the A1c hemoglobin test has made a difference in the ability to follow blood sugar over time. Recent actions by the FDA have clarified some risks associated with some of the oral diabetes drugs. Both Avandia and Actos have been suspected of causing macular edema (another diabetic complication that can cause vision loss) Some have questioned the ability of the FDA to police the pharmaceutical industry and their new drugs. Often the FDA can only take the drug company's studies and look for flaws in methodology or sampling since the FDA itself has not got the budget to run labs capable of doing the science needed to assure us of safety. We may not have a way to check up on the drug companies except after the fact...after the drug has been on the market side effects and complications will surface. For example the flouroquinolone antibiotics are good at killing bacteria, but may also damage tendons in some patients and cause heart rhythm problems in others. The cox2 inhibitors were supposed to protect our stomachs when we took pain pills, but they increased heart attack risk. The diabetes drug Avandia is now found to be increasing heart risks and is not as safe as other drugs on the market. There may be an issue of failure to divulge this risk to the public and Glaxo-Smith Kline will certainly have more lawsuits on this problem. Will the FDA remove it from the market or just issue a caution to the medical profession? It is expected that new prescriptions for this drug will cease to be written while those doing well on it will have to be watched carefully or switched to a safer drug. As an eye doc I am always amazed at the number of diabetics that postpone eye exams and dilation. A dilated eye exam is a must if you have blood sugar problems. This should be done every year and becomes critical after the patient is diabetic for 10 years or longer. The incidence of problems goes up every year. The following is excerpted from the Accord study:

Published at www.nejm.org June 29, 2010 (10.1056/NEJMe1005667)

Reduction in Risk of Progression of Diabetic Retinopathy
Barbara E.K. Klein, M.D., M.P.H.

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial (ClinicalTrials.gov number, NCT00000620 [ClinicalTrials.gov] ) was designed primarily to study the effects of intensive glycemic control on cardiovascular events in persons with type 2 diabetes. The ACCORD Eye study (NCT00542178 [ClinicalTrials.gov] ), described by the ACCORD Study Group and ACCORD Eye Study Group in this issue of the Journal,1 is a subgroup study of the larger ACCORD trial, designed to examine effects of several medical interventions on the progression of diabetic retinopathy. A sample of 4065 of the 10,251 participants in ACCORD was targeted for the eye study; complete data were obtained for 2856 subjects.

The authors assert that limiting the progression of diabetic retinopathy is important because doing so would limit the occurrence of proliferative retinopathy (the most severe form of retinopathy), a severe threat to vision. Perhaps more critical, in my view, is that retinopathy is a concomitant or precursor of systemic microvascular complications, such as renal disease, as well as of neuropathy and macrovascular complications. For these reasons, the report of the ACCORD Eye study has great importance, particularly because of the increasing prevalence of diabetes related to aging of the population and also the increasing prevalence at younger ages, which is likely to be related to obesity.

In the ACCORD Eye analysis, intensive glycemic control resulted in a 33% reduction in the relative risk of progression of diabetic retinopathy in a relatively short period (4 years). In contrast, the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) study (NCT00145925 [ClinicalTrials.gov] ),2 another study of patients with type 2 diabetes, showed no significant effect of glycemic control on severe diabetes related to ocular end points. The sample size was smaller in the ADVANCE trial (with 791 participants in the intensive-therapy group and 811 in the standard-therapy group) than in the ACCORD Eye trial (with 1429 and 1427 participants, respectively), and the odds ratio for severe diabetes related to ocular end points with the use of tighter glycemic control was in a protective direction in ADVANCE. A previous trial in persons with type 2 diabetes3 found beneficial effects of tight glycemic control on retinopathy, although the effect took longer to become significant. In addition, in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study, which was performed in persons with type 1 diabetes, the results were substantially the same. The specific effects of intense glycemic control on the odds of proliferative retinopathy in the DCCT/EDIC study are of interest. However, the effects on proliferative disease were not discussed directly, possibly because of the limited number of cases.

An exciting finding is the 40% reduction in the odds of having progression of retinopathy that is conveyed by fenofibrate (taken along with simvastatin) in the ACCORD Eye study over a 4-year period. This occurred in concert with a decrease in the serum triglyceride level by roughly 20 mg per deciliter (22.6 mmol per liter) in the fenofibrate group, as compared with the placebo group, occurring over the first year of treatment and maintained through the end of the study. The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study (Current Controlled Trials number, ISRCTN64783481 [controlled-trials.com] ) previously reported a protective effect of fenofibrate on laser treatment for proliferative diabetic retinopathy, but there was no evidence of a concomitant decrease in serum triglyceride levels.4 In the ACCORD Eye trial, the effect of fenofibrate was independent of glycemia. Whether an enhanced effect of fenofibrate in the ACCORD Eye study is the result of an interaction with simvastatin will be an interesting topic for further research.

Some may find the lack of an apparent beneficial effect of intensive blood-pressure control on progression of retinopathy in the ACCORD Eye study surprising. However, blood pressure has not been a significant factor for the incidence or progression of retinopathy in patients with type 2 diabetes in observational studies.5,6 Higher blood pressure has been found to be associated with the incidence or progression of retinopathy in patients with type 1 diabetes and those with type 2 diabetes in the United Kingdom Prospective Diabetes Study (UKPDS; ISRCTN75451837 [controlled-trials.com] ). The range of blood pressures in the ACCORD Eye trial was relatively small, and the duration of lowered pressure was relatively short. It may be that a longer follow-up period would be needed to show either a protective effect of blood-pressure lowering at the levels achieved in the ACCORD study or an increase to significance of the nonsignificant deleterious effect of intensive blood-pressure control that was found in the study. It is also possible that there is little effect of blood-pressure control in persons of the age and with the risk factors of the ACCORD Eye participants.

Although change in visual acuity was not a primary outcome of the ACCORD Eye study, data on this important functional result are provided. No significant beneficial effect on moderate vision loss was shown for any of the interventions.

There are many differences among studies of risk factors for the progression of retinopathy that might lead to the observed variation in their results. The means of ascertainment of retinopathy severity has not been uniform across studies. Even when photographs are taken, the protocols for photography may vary, as may the grading techniques and severity scales used. In addition, comparing findings between patients with type 1 diabetes and those with type 2 diabetes is not always appropriate. Finally, the inadequacy of some sample sizes and the use of repeated testing may also color our interpretation of study findings.

Overall, the ACCORD Eye trial has added substantially to our knowledge and confidence about the importance of glycemic control in the progression of diabetic retinopathy. The findings also strongly suggest the need for further evaluation of the potential importance of fenofibrate in our armamentarium of treatments for this condition.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Source Information

From the Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin, Madison.

This article (10.1056/NEJMe1005667) was published on June 29, 2010, at NEJM.org.

References

1. The ACCORD Study Group and ACCORD Eye Study Group. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med 2010. DOI: 10.1056/NEJMoa1001288.
2. Beulens JW, Patel A, Vingerling JR, et al. Effects of blood pressure lowering and intensive glucose control on the incidence and progression of retinopathy in patients with type 2 diabetes mellitus: a randomised controlled trial. Diabetologia 2009;52:2027-2036. [CrossRef][Web of Science][Medline]
3. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-853. [Erratum, Lancet 1999;354:602.] [CrossRef][Web of Science][Medline]
4. Sacks FM. After the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study: implications for fenofibrate. Am J Cardiol 2008;102:34L-40L. [CrossRef][Web of Science][Medline]
5. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. Is blood pressure a predictor of the incidence or progression of diabetic retinopathy? Arch Intern Med 1989;149:2427-2432. [Free Full Text]
6. Yanko L, Goldbourt U, Michaelson IC, Shapiro A, Yaari S. Prevalence and 15-year incidence of retinopathy and associated characteristics in middle-aged and elderly diabetic men. Br J Ophthalmol 1983;67:759-765. [Free Full Text]

This is the discussion section of the actual study:
The ACCORD trial consisted of three randomized comparisons evaluating the effect of intensive glycemia therapy versus standard glycemia therapy, simvastatin plus fenofibrate versus simvastatin plus placebo for lipid control, and intensive antihypertensive therapy versus standard antihypertensive therapy on cardiovascular events. Our ACCORD Eye study evaluated the effect of these same three comparisons on the progression of diabetic retinopathy.

Intensive glycemia therapy significantly reduced the risk of progression of diabetic retinopathy, defined as an increase of three or more steps on the ETDRS Severity Scale for Persons or the performance of laser photocoagulation or vitrectomy for diabetic retinopathy at 4 years (7.3% vs. 10.4% with standard therapy, P=0.003). Two recent, smaller trials in similar patients reported nonsignificant results in the direction of a benefit with glycemic control.24,25,26 Similar to previous studies, our study did not show that intensive glycemic control reduces the risk of moderate vision loss. As reported elsewhere, however, there was a significant reduction in the rate of moderate vision loss in the entire ACCORD population with intensive glycemia treatment (19.1%, vs. 20.7% with standard therapy; hazard ratio, 0.91; 95% CI, 0.83 to 1.00; P=0.047).27

As in other studies, the ACCORD trial19 showed a significantly increased risk of having a hypoglycemic event that necessitated either any assistance or medical assistance in the group receiving intensive glycemia therapy (targeting glycated hemoglobin levels <6.0%) as compared with the group receiving standard therapy (targeting glycated hemoglobin levels of 7.0 to 7.9%) (10.5% vs. 3.5%, P=0.001). The intensive-therapy strategy was also associated with an increased rate of death from any cause after a mean of 3.5 years of follow-up, as compared with the standard strategy (5.0% vs. 4.0%). The glycemia trial was thus stopped early, potentially underestimating the reported effect of glycemia treatment on diabetic retinopathy.

We also found a beneficial effect of fenofibrate therapy on the progression of diabetic retinopathy at 4 years in participants with type 2 diabetes who were also receiving simvastatin (6.5%, vs. 10.2% with placebo; P=0.006). The FIELD study,15 a randomized trial of monotherapy with fenofibrate (200 mg per day), showed a significant reduction in the need for laser therapy for either macular edema or proliferative retinopathy in the fenofibrate group as compared with the placebo group (3.4% vs. 4.9%, P<0.001). Our results provide further evidence that fenofibrate slows the progression of diabetic retinopathy.

We did not demonstrate a significant effect of intensive versus standard blood-pressure control on the progression of diabetic retinopathy at 4 years (10.4% vs. 8.8%, P=0.29), nor was there a significant effect in any of the prespecified subgroups (Figure 3). In contrast, the United Kingdom Prospective Diabetes Study (ISRCTN75451837 [controlled-trials.com] ),6 a nested trial of antihypertensive medications, showed that intensive blood pressure control (targeting a systolic blood pressure <150 mm Hg, vs. <180 mm Hg with standard control) achieved a significant reduction in the progression of diabetic retinopathy (34.0% vs. 51.3%, P=0.004) and a significant reduction in moderate vision loss (10.2% vs. 19.4%, P=0.004) after 7.5 years. The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) study (NCT00145925 [ClinicalTrials.gov] )24,25 also did not show a beneficial effect of intensive blood pressure control on progression of diabetic retinopathy. However, the difference in systolic blood pressure between the treatment groups was only 5.6 mm Hg, which may account for the lack of benefit seen in the ADVANCE trial.

One limitation of our study is the collection of data on retinopathy outcomes from fundus photographs at only two time points. Another limitation is the sizable proportion of the original ACCORD Eye study population whose retinopathy status could not be assessed at 4 years. As compared with those whose retinopathy status could be assessed, these subjects were more likely at baseline to have elevated LDL levels, higher urinary albumin:creatinine ratios, and lower visual acuity scores. However, there was no evidence of significant differences regarding the amount of missing data, and the results of sensitivity analyses supported those of the primary analyses.

In summary, our study provides evidence that the beneficial effect of intensive glycemia therapy on retinopathy progression, previously shown in participants with type 1 diabetes2,3 and those with type 2 diabetes that was newly diagnosed5 or not yet accompanied by hypertension, lipid abnormalities, or established cardiovascular disease,4 applies also to patients with type 2 diabetes like those enrolled in the ACCORD trial, who were older and at greater cardiovascular risk. We also demonstrated that fenofibrate, when added to statin therapy, slows the progression of diabetic retinopathy in patients with type 2 diabetes. We did not find a significant difference in the progression of diabetic retinopathy between patients receiving standard antihypertensive therapy and those receiving intensive antihypertensive therapy according to our treatment protocols.

Paying for Healthcare and the Individual Mandate

2010-06-29T08:43:00.000-07:00

This is an article from the New England Journal of Medicine that does a good job of explaining the complexity of the decisions involved in the individual mandate. It seems to me that we are in trouble if this doesn't pass. Unreimbursed care is tearing our healthcare system apart.

Buying Health Care, the Individual Mandate, and the Constitution
Posted by NEJM • June 23rd, 2010 • Printer-friendly

Sara Rosenbaum, J.D., and Jonathan Gruber, Ph.D.

In Rashomon, a classic film that explores the concept of truth, director Akira Kurosawa presents a story about a single incident retold by four narrators, leaving the audience to figure out what is real. Litigation has a Rashomon-like quality to it: two sides meet in a courtroom and each presents its case, arguing not only that abstract legal principles favor its cause, but equally important, that its version of the event that gave rise to the dispute should be the filter through which the court decides the matter.

Three separate cases raising constitutional challenges to the Affordable Care Act (ACA) are now under way,1,2,3 and together they present issues of great legal complexity.4 Yet although difficult legal questions must be resolved, a pivotal issue is whose version of events will serve as the judicial analytic filter. For reasons related to the very basis of Congress’s constitutional power to enact health care reform, the fight is over whether the individual mandate to purchase health insurance (or pay a tax) is about regulating individuals’ economic conduct or regulating their noneconomic status. Depending on which characterization of the facts prevails, the individual mandate either falls within or lies outside Congress’s power to act.

The Supreme Court precedents indicate that the framers of the U.S. Constitution vested Congress with enormous powers to regulate individual economic conduct, even as they limited congressional authority over noneconomic activity. The source of this power to regulate economic activity down to the individual level is found in the Constitution’s Commerce Clause (article 1, section 8, clause 3), on whose reach the legal resolution of these cases ultimately depends. This clause explicitly grants Congress the authority to regulate interstate commerce.

In Gonzalez v. Raich, a 2005 decision involving federal regulation of home-grown marijuana, the U.S. Supreme Court concluded that growing marijuana amounted to economic activity and interpreted the Commerce Clause as permitting Congress to reach the “consumption of commodities for which there is an established and lucrative interstate market.” In other cases involving the constitutionality of federal laws sanctioning individual conduct — gun possession on school grounds (in United States v. Lopez, 1995) and domestic violence (in United States v. Morrison, 2000) — the Court concluded that the specified activities did not amount to economic conduct within the definition of the Commerce Clause. To be sure, both gun possession and violence against women have economic consequences, but an indirect economic effect is insufficient to warrant congressional regulation. As a result, only states, using their police powers, can directly regulate such activity, which lies beyond the limits of Commerce Clause control.

Thus, the outcome of the battle over the individual mandate turns on whether the courts understand the ACA as a law that regulates economic conduct. Complaints recently filed by the state of Virginia and by multiple state claimants in Florida represent a direct challenge to the proposition that economic conduct is involved. In their complaint, the multistate plaintiffs argue that the law should be viewed as an attempt “to regulate and penalize Americans for choosing not to engage in economic activity.” Similarly, in his June 2010 brief, the Virginia attorney general argues that the ACA must be understood as an attempt to compel individuals to undertake economic conduct by forcing them to buy health insurance. In other words, highly cognizant of the distinction drawn in Raich between economic and noneconomic conduct, the plaintiffs argue that health care reform is a blatant attempt to force an economic undertaking; they frame the ACA as a law about status (being uninsured) rather than about economic activity.

The U.S. government, on the other hand, frames the law as precisely about Americans’ buying practices in relation to a commodity “for which there is an established and lucrative interstate market.” In its briefs in the Florida and Virginia cases, the U.S. Department of Justice argues that the ACA is a quintessential economic regulatory effort because it addresses the when and how of paying for health care (a market commodity that almost all Americans will purchase at some point, either because they plan to or because of an unforeseen event). In its argument, the Justice Department lays out the congressional findings that undergird the ACA, which highlight the economic imperative of health care reform in order to save a health care system that is fundamentally failing the tens of millions of Americans who are either uninsured or faced with purchasing insurance in a dysfunctional insurance market.

From an economics standpoint, the conclusion is clear: the purpose of the ACA is to regulate how Americans buy health care, which is clearly economic conduct. Above all, the ACA’s fundamental goal is to stabilize the vast U.S. market for health care services — which accounts for 17.5% of the gross domestic product, according to Congress — along with the health insurance system on which nonelderly Americans rely as a principal means for financing their health care. The law’s goal is revealed through extensive legislative findings that are set forth in the ACA. The goal also can be seen in the act’s provisions that collectively are aimed at making the insurance market work for millions of Americans who, because of their income, health status, or both, have been locked out of affordable, accessible, and stable coverage and must therefore try to pay for care at the point of service.

The existing system has broad economic implications for both the insured and the uninsured. Far from being passive and noneconomic, the uninsured consume more than $50 billion in uncompensated care, the costs of which are passed through health care institutions to insured Americans. Moreover, medical expenses not covered by insurance are one of the leading causes of bankruptcy in the United States, and the costs of resolving those bankruptcies are borne throughout the U.S. economy. In addition, the lack of health insurance leads to poorer health, which can, in turn, reduce workplace productivity. Even the possibility of losing health insurance makes many workers afraid to leave their jobs for more productive positions elsewhere, so the current system reduces the overall productivity of the U.S. labor force.

The changes made by the ACA to stabilize the insurance market are fundamentally economic. The legislation’s core is its mandate to end pervasive discriminatory insurance practices while making care affordable. But such change is not possible without an individual mandate. If people who are in better health can opt out of the market and effectively gamble that they can pay for whatever health care they need at the point of service, prices rise for those who are in poorer health, leading to an “adverse selection” spiral that raises insurance prices for all. This is not an idle conjecture. Five states have tried to undertake reforms of the nongroup insurance market like those in the ACA without enacting an individual mandate; those five states are now among the eight states with the most expensive nongroup health insurance.

In the end, the ACA is all about altering individual economic conduct, and its importance lies in the way it changes the when and how of health care purchasing. By ensuring access to affordable coverage for most Americans, the law seeks to rationalize our economic behavior while providing the regulatory and subsidization tools to make this rationalization possible. To characterize the ACA as a law aimed at anything other than individual economic conduct is to fundamentally miss the point of the legislation.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Source Information

From the Department of Health Policy, School of Public Health and Health Services, George Washington University Medical Center, Washington, DC (S.R.); and the Massachusetts Institute of Technology, Cambridge (J.G.).

This article (10.1056/NEJMp1005897) was published on June 23, 2010, at NEJM.org.

References

1. Thomas More Law Center v. Barack Hussein Obama, Case no. 2:10-cv-11156 (E.D. Mich., 2010).
2. Commonwealth of Virginia v. Sebelius, Civil action no. 3:10cv188 (E.D. Va., 2010).
3. State of Florida v. U.S. Department of Health and Human Services, Case no.: 3:10-cv-91-RV/EMT (N.D. Fla., 2010).
4. Balkin JM. The constitutionality of the individual mandate for health insurance. N Engl J Med 2010;362:482-483. [Free Full Text]

BP and the Gulf Spill

2010-05-05T11:16:00.000-07:00

The whole Gulf of Mexico and the shorelines of Texas,Louisiana,Mississippi, Alabama and Florida are waiting for the landfall of the massive oil spill floating towards our estuaries and beaches. The only good that can come of this is that government gets real and puts energy and money behind alternative fuels. This can't happen soon enough. All the regulatory failures of past administrations must be corrected and even then, the safety of deep water drilling is in question. There are many green sites on the web and I would advise everyone to tune in to these sites to become more educated concerning the problem and possible solutions. Here are several sources of info: http://www.theoildrum.com/special/mission
www.treehugger.com
http://www.bestgreenblogs.com/greenblogs/
and especially: http://www.healthygulf.org/
The oil industry will certainly flex their considerable muscle to influence Washington policy makers and regulators. We will probably always need some fossil fuel, but we must decrease our dependence for national security reasons and for ecological reasons. The revolving door between government and lobbys is hopefully not going to be a factor (like it has been in the Wall Street mess). Everyone in congress should be strapped into a seat and made to listen to Bob Dylan's old song"The Times They Are A'Changing...and if they don't listen waterboard them?!!
An update 05-19-2010:the oil spill has reached the loop current and may be headed to the rest of Florida and the Keys and the Gulf Stream??? http://news.bbc.co.uk/2/hi/world/us_and_canada/10127904.stm

update: 05-20-2010 By Juliet Eilperin
Washington Post Staff Writer
Thursday, May 20, 2010; 10:13 AM

The Environmental Protection Agency informed BP officials late Wednesday that the company has 24 hours to choose a less toxic form of chemical dispersants to break up its oil spill in the Gulf of Mexico, according to government sources familiar with the decision, and must apply the new form of dispersants within 72 hours of submitting the list of alternatives.

The move is significant, because it suggests federal officials are now concerned that the unprecedented use of chemical dispersants could pose a significant threat to the Gulf of Mexico's marine life. BP has been using two forms of dispersants, Corexit 9500A and Corexit 9527A, and so far has applied 600,000 gallons on the surface and 55,000 underwater...So it seems that the only answer they have is pour in more chemicals to put the topping on this toxic mess.

Factor in this information about the general health of the global fisheries: More than 20 million people employed in the fishing industry may need to be taken out of service and retrained for other work over the next 40 years if the final collapse of fish stocks in oceans around the globe is to be avoided, the UN warned today.

The UN's environment branch, UNEP, gave a sneak preview of its green economy report that will be published in October. It said that if the world remained on its current path of over-fishing, by 2050 all fish stocks could have become uneconomic to exploit or actually extinct.

Pavan Sukhdev, who heads UNEP's green economy initiative, said: "That is not as absurd as it sounds, as already 30 per cent of the ocean fisheries have collapsed and are producing less than 10 per cent of their original ability." What effect will giant oil spills have on fisheries? It can't be good. Where are we headed if we can't quit polluting and overfishing? Breaking the oil habit would seem to be a giant first step that we need to accomplish as soon as possible. Any politicians listening?

Update 06/24/2010: Tarballs and emulsified oil (can't be burned) are washing up as far East as Panama City. Scientists say the methane concentration close to the spill is 1 million times the normal concentration. This certainly raises the probability of increasing the dead zones in the northern gulf. The costs of this spill will only gradually become apparent. Meanwhile Petrobras Brazil's oil consortium plans the expansion of their deep water drilling. Pres. Obama and the justice dept. overturned a New Orleans judges stay on the halting of deepwater drilling for 6 months. It became apparent that the judge had significant holdings in BP stocks and subsidiaries of BP as well. This halt of drilling is only for the deepest wells and represents less than 1% of the drilling ongoing. I think we should be safe and inspect all the wells for evidence of criminal neglect before we go blindly ahead. Meanwhile Jimmy Buffet opens a new Gulf Beach Hotel and gives a free concert to promote tourism to the area. Thanks Jimmy...let's try to be positive. There is now some speculation that a hurricane would actually be good for the reefs in that the temperature would be lowered and the reef may be somewhat cleaned by wave action. Basically this sounds like guesswork and I would like to see BP have uninterrupted time to finish their drilling. Our ecosystem and the livelihood of many on the coast depend on the events of the next month. It was disclosed that there are 3600 producing wells and 27000 old or abandoned sites. No one seems to have the responsibility to check the old sites for integrity or leaks. NO ONE!!

On Wednesday July 15th the flow of oil was stopped by a capping device. This is a temporary stop while pressures are evaluated to ascertain if there are leaks below the well head. If pressures maintain a high level this would indicate that the subsurface structure is intact and should withstand further manipulation.
07/30/10 Everyone is amazed that the oil slicks seem to have disappeared fairly quickly. Boom has been taken out of many areas and aerial views don't see much oil on the surface...where did the oil go? Dispersant use may explain this. check out this excerpt from Huffington post:

Scientists have found signs of an oil-and-dispersant mix under the shells of tiny blue crab larvae in the Gulf of Mexico, the first clear indication that the unprecedented use of dispersants in the BP oil spill has broken up the oil into toxic droplets so tiny that they can easily enter the foodchain.

Marine biologists started finding orange blobs under the translucent shells of crab larvae in May, and have continued to find them "in almost all" of the larvae they collect, all the way from Grand Isle, Louisiana, to Pensacola, Fla. -- more than 300 miles of coastline -- said Harriet Perry, a biologist with the University of Southern Mississippi's Gulf Coast Research Laboratory.

And now, a team of researchers from Tulane University using infrared spectrometry to determine the chemical makeup of the blobs has detected the signature for Corexit, the dispersant BP used so widely in the Deepwater Horizon

"It does appear that there is a Corexit sort of fingerprint in the blob samples that we ran," Erin Gray, a Tulane biologist, told the Huffington Post Thursday. Two independent tests are being run to confirm those findings, "so don't say that we're 100 percent sure yet," Gray said.

"The chemistry test is still not completely conclusive," said Tulane biology professor Caz Taylor, the team's leader. "But that seems the most likely thing."

With BP's well possibly capped for good, and the surface slick shrinking, some observers of the Gulf disaster are starting to let down their guard, with some journalists even asking: Where is the oil?

Hindsight may indicate that it was better to have the oil on the surface than to coat the bottom of the sea and disperse oil through the water column. Corexit was banned in Europe...why not here?
Ongoing speculation about subsurface plumes of oil have darkened the prospect for a quick ending to the spill cleanup phase. This is from Newsweek commenting on a journal article from Science magazine:
continuous, unbroken plume of hydrocarbons about 3,300 feet down, stretching southwest from the well for some 22 miles. The scientists suspect it is even longer, but they had to stop sampling when Hurricane Alex blew in. Still, said Camilli, “we’ve shown conclusively not only that a plume exists, but also defined its origin and ... structure. Until now, these have been treated as a theoretical matter”—especially by BP and even the government, which for weeks denied the existence of the plumes. (In late June and again in late July, however, the National Ocean and Atmospheric Administration released results of subsurface monitoring by several of its research vessels, finding a “cloud of diffuse oil at depths of 3,300 to 4,600 feet near the wellhead.”) Now in August we have scientists from Florida and Woods Hole Oceanographic Institute agreeing on the persistence of the subsurface plume:
The oil plume's stability is "a little unexpected," study leader Richard Camilli, of WHOI's Applied Ocean Physics and Engineering Department, said at a Thursday press briefing in Washington, D.C.

"We don't have any clear indication as to why it set up at that depth."

It's unclear why the Gulf's microbes aren't eating the oil plume, but the organisms are infamous for being unpredictable, said study co-author Christopher Reddy, a marine chemist at WHOI.

Counting on microbes to quickly clean up an oil spill is "like asking a teenager to do a chore. You tell them to do it on a Friday, to do it when it's most advantageous, and they do it on a Saturday," Reddy told National Geographic News earlier this month.

Further studies are needed to figure out why the plume isn't degrading, Reddy said during the press briefing: "We don't live in the world of the TV show CSI. ... Patience is a virtue."

Hard Evidence for Gulf Oil Plume

During a ten-day research cruise in June, the WHOI team used autonomous underwater vehicles (AUVs), free-swimming probes that are the "next generation" of remotely operated vehicles, Camilli said during the briefing.

The team's AUVs were equipped with mass spectrometers—devices that measure the masses of molecules. The spectrometers collected thousands of samples in various regions near the spill site.

Most of these samples detected hydrocarbons—ingredients of oil—at concentrations of 50 micrograms a liter.

Using this data, the scientists were able to piece together the shapes and sizes of two oil plumes: the large, deep plume and a more diffuse plume spread out between depths of 160 and 1,600 feet (50 and 500 meters).

University of South Florida (USF) chemical oceanographer David Hollander said the discovery of stubborn oil in the deep sea "falls right into line" with his recent findings.

"These hydrocarbons are plentiful, and will be around for a long time," Hollander said by email.

Sadly, BP and the government are silent about this and any possible remedies.

New York Times Green Blog states this on 1106-10:
“I have seen many individual dead coral colonies over the years, but I’ve never seen a site full of dead and dying coral colonies,” he said.

Roughly 90 percent of corals at one site he surveyed were dead or dying and covered in a brown substance that he suspects was not oil but “gooey, rotting coral tissue.”

Further testing is necessary to determine exactly what killed the coral, but Dr. Fisher said the circumstantial evidence linking the die-off to the oil spill was overwhelming and represented “a smoking gun.”

“The proximity of the site to the disaster, the depth of the site, the clear evidence of recent impact and the uniqueness of the observations all suggest that the impact we have found is linked to the exposure of this community to either oil, dispersant, extremely depleted oxygen, or some combination of these or other water-borne effects resulting from the spill,” Dr. Fisher wrote in a statement released Friday afternoon by Penn State.

Whether more damaged coral exists near BP’s now-capped well remains to be seen. According to Dr. Fisher, he and a fellow scientist have identified a series of 25 sites within 15 miles of the wellhead that may host undiscovered coral communities. The site of the coral die-off discovered this week was the first of the 25 sites surveyed.

Sadly this damage is hidden and will only show its impact in reducing the health of the gulf in general. Perhaps the best analysis of the BP problem is found on ProPublica http://www.propublica.org/article/bp-accidents-past-and-present This article details BP's corporate history of regulatory problems and safety infractions. It is a history of oversight that wasn't working.
On a positive note Ken Salazar's quote from Huffington Post on Dec 1 2010:"In the Gulf and the Atlantic we are adjusting our strategy," Salazar said. "We believe the most appropriate course of action is to focus development on areas with existing leases and not expand to new areas at this time."

Under the revised plan, the Interior Department will not propose any new oil drilling in waters in the Atlantic Ocean and eastern Gulf for at least the next seven years. Already planned lease sales in the Gulf of Mexico, expected in March and August, will be delayed until late 2011 or early 2012, Salazar said.

The administration's previous plan – announced last March, three weeks before the April BP spill – would have authorized officials to explore the potential for drilling from Delaware to central Florida, plus the northern waters of Alaska. The new plan allows potential drilling in Alaska, but officials said they will move cautiously before approving any leases.
The saga continues: Oil spill commission's missing document adds insight to Gulf investigation
by: jerimee
Thu Dec 02, 2010 at 11:32:09 AM EST
Cross-posted from Facing South, article by Ryan Knutson, ProPublica

A new document uncovered last week might help to clear up some confusion over comments made by the President's Oil Spill Commission earlier this month when its chief counsel, Fred Bartlit Jr., said, "To date we have not seen a single instance where a human being made a conscious decision to favor dollars over safety."

Bartlit's comments made a big splash because they appeared to indicate that the commission was exonerating BP of the allegation that it cut corners on safety in favor of saving money -- seeming to fly in the face of what the press and other investigatory bodies had lately uncovered. Even the Wall Street Journal blogged that Bartlit "all but acquitted BP of the gravest charge."

Bartlit and the commission later backtracked, saying the media reached "overarching conclusions" about his presentation, but that wasn't enough to prevent a group of 60 scientists from publicly challenging the statement.

A new document, however, shows that the commission has in fact been considering harsher conclusions. The report, obtained by Greenwire, highlights 11 potentially time-saving (and ultimately cost-saving) decisions made by BP, Transocean and Halliburton that increased the overall risk of the operation.

The document was mistakenly posted to the commission's website last month and quickly taken down, which has led to claims that the commission might be trying to stifle the cost-cutting claim within its own ranks.

But the commission says that's not the case and that the document actually does align with the commission's findings, which are more critical of the companies than has been reported. The only reason the document was removed was that it hadn't yet been viewed by all seven members of the panel, commission spokesman Dave Cohen told ProPublica.

"We stand behind the document 100 percent," he said, adding that it will likely be presented formally at the commission's meetings this week. Cohen said Bartlit felt "extremely misunderstood" after his earlier comments and that he was only trying to avoid blaming the 11 workers who died on the Deepwater Horizon.

"He was trying to be extremely respectful to the men who lost their lives and the fact that they could not speak for themselves," Cohen said. "And in his view, everything he saw was that they were doing their jobs well, and it wasn't their fault."

Here's more of Bartlit's statement (you can view an archive video here), which he made as part of a two-day presentation on Nov. 8 and 9.

"It won't surprise you to learn that the out-of-pocket, all-in cost to somebody like BP of running one of these rigs is about $1.5 million a day, and of course if you're taking four or five days running drill strings up and down to do work, that's a cost. Now I'm going to say something now, I'll say it again at the end: To date, we have not seen a single instance, where a human being made a conscious decision to favor dollars over safety. I'll talk more about that later but it's important you keep that in your mind as we go. There's been a lot said about it. ... We have not found a situation where we could say a man had a choice between safety and dollars and put his money on dollars, we haven't seen it. And if anybody has anything like that, we of course welcome it."

The point was also highlighted in the panel's preliminary findings: "No evidence at this time to suggest that there was a conscious decision to sacrifice safety concerns to save money," reads the preliminary report.

The new document, though, explicitly lists decisions -- such as "not waiting for more centralizers" -- as risky, unnecessary and less time consuming.

Bartlit, 78, has been criticized by environmental groups because his firm, Bartlit Beck Herman Palenchar & Scott, has represented Halliburton in past litigation. He also represented George W. Bush in Florida in the 2000 election dispute versus Al Gore.

Cohen defended Bartlit, noting that even though the panel lacks subpoena power, Bartlit was able to persuade Halliburton to provide documents showing the company knew the cement used in the Macondo well had problems. Bartlit has other experience in offshore investigations; he played a major role in the investigation of the 1989 Piper Alpha disaster in the North Sea, where 167 people were killed.

Cohen insists the panel is not trying to exonerate any of the companies involved in the Deepwater Horizon disaster.

"We only ask that people judge us by the final report that is due out January 11," Cohen said. "The fact of the matter is that this commission has serious doubts about some of the decisions made by all three of the companies that were involved in the Macondo well."
It is amazing to see the efforts to cover tracks and culpability that have been undertaken by BP. These guys had twice the number of safety violations over the last decade as their nearest competitor. Lax regulators no doubt!
This is a time lapse photo sequence from NASA :

The guardian.uk website has posted some information from Wikileaks cables that detail a similar leak that BP successfully covered up or at least kept out of the press:
Striking resemblances between BP's Gulf of Mexico disaster and a little-reported giant gas leak in Azerbaijan experienced by the UK firm 18 months beforehand have emerged from leaked US embassy cables.

The cables reveal that some of BP's partners in the gas field were upset that the company was so secretive about the incident that it even allegedly withheld information from them. They also say that BP was lucky that it was able to evacuate its 212 workers safely after the incident, which resulted in two fields being shut and output being cut by at least 500,000 barrels a day with production disrupted for months.

Other cables leaked tonight claim that the president of Azerbaijan accused BP of stealing $10bn of oil from his country and using "mild blackmail" to secure the rights to develop vast gas reserves in the Caspian Sea region.

WikiLeaks also released cables claiming that:

• Senior figures in Thailand are concerned about the suitability of the crown prince to become king, citing rumours that he has lovers in several European capitals in addition to his wife and son in Thailand.

• American energy firm Chevron was in discussions with Tehran about developing an Iraq-Iran cross-border oilfield, despite US sanctions against Iran.

The leaks came as the whistleblower site's founder Julian Assange prepared for another night in jail ahead of tomorrow's high court challenge to the decision to grant him £200,000 bail. Swedish authorities, who want to question Assange on allegations of sexual assault, believe he should remain in custody as he is a flight risk.

On the Azerbaijan gas leak, acable reports for the first time that BP suffered a blowout in September 2008, as it did in the Gulf with devastating consequences in April, as well as the gas leak that the firm acknowledged at the time.

"Due to the blowout of a gas-injection well there was 'a lot of mud' on the platform, which BP would analyze to help find the cause of the blowout and gas leak," the cable said.

Written a few weeks after the incident, the cable said Bill Schrader, BP's then head of Azerbaijan, admitted it was possible the company "would never know" the cause although it "is continuing to methodically investigate possible theories".

According to another cable, in January 2009 BP thought that a "bad cement job" was to blame for the gas leak in Azerbaijan. More recently, BP's former chief executive Tony Hayward also partly blamed a "bad cement job" by contractor Halliburton for the Deepwater Horizon disaster in the Gulf of Mexico. The blowout in the Gulf led to the deaths of 11 workers and the biggest accidental offshore oil spill in history.

BP was also criticised for not initially sharing all its information with the US authorities about the scale of the Gulf spill. The gas field in the Caspian Sea was in production when the leak and blow out occured, unlike the well in the Gulf which was being drilled to explore for oil.

BP declined to answer questions put by the Guardian about the cause of the Azerbaijan gas leak and who carried out the cement job, pointing to a general statement it had made about the cables.

The cable reveals that the company had a narrow escape. "Given the explosive potential, BP was quite fortunate to have been able to evacuate everyone safely and to prevent any gas ignition. Schrader said although the story hadn't caught the press's attention, it had the full focus of the [government of Azerbaijan], which was losing '$40-50m each day'."

The leak happened at the Azeri-Chirag-Guneshi (ACG) field, Azerbaijan's largest producing oil field in the Caspian where vast undeveloped gas reserves also lie. BP is the operator and largest shareholder in the consortium, which includes US companies Chevron, ExxonMobil and Hess (formerly Amerada Hess), as well as Norwegian firm Statoil and Azerbaijani state owned oil company Socar.

What is the lesson in all this for the US? It is that the regulation of our natural resources is of paramount importance and cannot be subverted by greedy corporate interests. If we allow this to continue coming generations will look back and rightly blame us for poor stewardship.

In the latest developments BP has reached agreements with a Russian oil company to develop arctic oil fields. Look out polar bears! Recent blood testing of people on the gulf have shown high levels of volatile organic chemicals in the blood. This is an excerpt from Huffington Post 01-17-2011:

Ada McMahon works with Bridge the Gulf Project, a citizen journalism website that highlights stories from Gulf Coast communities about justice and sustainability. She told IPS that "the unmet health issues are the biggest issue, along with residents turned advocates going to meetings of the commission or with [BP oil spill fund administrator Kenneth] Feinberg to tell people about their health problems."

"People who can afford the 300-dollar blood tests have found alarming rates of chemicals in their bodies, and these people are concerned and doing what they can to speak out," she said. "But they feel they can't wait for Congress or Obama to address this, because they need doctors and support now in the communities."

LaTosha Brown, director of the Gulf Coast Fund for Community Renewal and Ecological Health, which works with 250 community groups, agreed that "the key concern expressed by the community in response to the report is the overwhelming need for access to health care."

"Over and over, people exposed to crude and dispersants from the drilling disaster told stories of serious health issues - from high levels of ethylbenzyne in their blood, to respiratory ailments and internal bleeding - and expressed an urgent need for access to doctors who have experience treating chemical exposure," she said.

Stephen Bradberry, executive director of the Alliance Institute, a non-profit that provides community organising support in the Gulf South, worries that the Gulf Coast Claims Facility is not accepting health claims, thus leaving sick residents unable to work and without any income to pay their medical bills.

"There is bruising and skin lesions, not just with clean-up workers, these are residents not involved in the clean-up," Bradberry told IPS. "Just yesterday I learned of five people on Grand Isle who passed away…people who did not have health problems prior to this. Nevertheless, there has not been any talk of monitoring of these communities."

Bradberry, who also attended the forum on Wednesday, also said, "We need a separate health task force that can focus solely on testing, monitoring, and studying the long-term health issues from exposure to crude and dispersants. And this needs to happen now."

Closer to Pensacola there seems to be a submerged oil plume off of Orange Beach, Alabama. The Pensacola News Journal detailed some work being done by the dept. of bioremediation at West Florida University. Small clams are being examined for oil content and being matched with chemical signatures for oil from the BP spill. It is now Feb. 24th 2011 and we still don't know the extent of the damage. NPR reports that 150,000 area residents in 4 gulf states will be followed for health effects from working with and around the spill. Univ. of West Florida will share in research monies with other gulf area oceanography and bioremediation departments. The figure reported as UWF's share was 600,000 dollars.

Meanwhile it's spring and this observation from Huffington Post:
Along the Gulf Coast, the marketing blitz for spring break is rolling out as the oil from the BP blowout 11 months ago continues to roll in along with increasing numbers of dead infant dolphins, in numbers completely without precedent. The beaches remain polluted with toxic oil and dispersant even as local politicians and government officials insist everything is fine and the oil miraculously gone. Thousands of pounds are collected each day from the few areas that remain under scrutiny, all of those being in highly visible resort areas. In one zone on Ft. Morgan beach in Alabama, a record 17,000 lbs was collected in one day after a winter storm rolled through. Along the beaches of Alabama in areas not frequented by media or guests, dead infant dolphins are left uncollected in the sand. Current plans by mayors of resort communities along the Gulf Coast will have thousands of vacationers, including at-risk populations, once again making sandcastles and sunbathing on toxic, polluted beaches.

As long as we are talking about water quality you must go to this web site whttp://www.wri.org/project/eutrophication/map This is a mind blowing picture of how we are polluting the oceans. The gulf doesn't look too good. In early April the years total of dead dolphins topped 400 most of them immature animals that washed up on the beaches. Also Ridley Turtles have been found in larger numbers than usual. Autopsies of a small number of these animals points to the BP spill as the cause. More tests are being done.
Now in June 2011 Governor Barbour of Mississippi is criticizing the Obama administration's response to the oil spill and the drilling ban. This is an excerpt from Huffington post: While we and many others will continue to monitor and analyze events and readings from the Gulf to learn if some currently unrecognized or future development changes the situation, it appears the Gulf has essentially digested the oil and other chemicals thus far," Barbour said in a statement Thursday. "Further, in our state, on-shore impacts were quickly remediated, and there is no apparent residual environmental damage."

Barbour said there have been more than 31,000 oil wells drilled in the Gulf of Mexico in the last 50 years and that nothing like the last year's spill, which killed 11 rig workers and dumped almost five million barrels of oil into the Gulf, has ever happened before.

"The president's commission says that that's not so," countered Bromwich, noting there have been dozens of similar incidents in the past 15 years.

“They cite 79 incidents of loss of well control ... between 1996 and 2009," Bromwich said. "So another way to describe that is 79 near-misses, 79 almost-Deepwater Horizons. So without going into the details of each one, that's what the president's commission found. So to say that the risk is one in a million, or one in 'x'-thousand of deepwater wells drilled is not accurate."

"We will never be able to reduce the risk to zero," Bromwich continued. "We know that and you know that. But we have to work constructively to try to diminish those risks in a balanced way so that we don't impose inappropriately high costs on industry and yet we do raise the bar on safety."

Meanwhile, 25% of female croakers caught in the Gulf of Mexico over the last several years from the waters termed the "dead zone"....have testicles!! The Gulf may wind up being an evil chemical brew of hormone modulating chemicals and hypoxia.

On Dec 06,2011 the news surfaced in the BBC that BP is accusing Halliburton of destroying evidence...of course this is an effort to gain pretrial advantage and I am sure accusations will fly both ways.

(from the BBC) BP and Halliburton are locked in a legal battle ahead of a trial on damages early next year.

Through their lawyers, the former partners in the venture are seeking maximum pre-trial advantage, the BBC's Steve Kingstone in Washington reports.
Trading allegations

BP made its accusations in a court filing on Monday.

It said that after reviewing the test results, Halliburton "destroyed records of the testing as well as the physical cement samples used in the testing".

The company also said that Halliburton had failed to produce computer modelling evidence, which showed how the cement performed.

In its motion, BP asked for sanctions against Halliburton, claiming that the company's cement slurry was "unstable".

A Followup to Healthcare Reform

2010-05-05T08:34:00.000-07:00

Now we are in a brave new world of reform: a much needed fix to decades of insurance and medical industry abuses. The big pharma concerns seem to have largely escaped from the cost cutting at this time, but I hope there will be changes.
There is no reason for industry reps to be on the road in company cars distributing party favors to doctor's offices. There is no need to advertise Viagra on tv ...on 6 different channels...especially when those in need of orphan or experimental drugs for fatal diseases go begging. Sure I have some free ballpoint pens and some sample drugs, but anything beyond that is really overkill...and morally repugnant. Some states are now setting up their own high risk pools...others are accepting federal dollars to cover uninsurables in their state. I am not sure that these politicians have a conscience. Do they think beyond their own needs for re-election campaign donations? Do they stick to party lines and talking points? Honestly the republicans have become predictably obstructionist and the Tea Party folks are laughable. Michelle Bachmann rants about big government, but her family accepted 250,000 bush bucks for the family farm operation!! She and Palin are simply divorced from reality. Palin rants about reform and the dysfunctional Canadian system but she admits taking her children to Canada for healthcare!! But perhaps the champion of surreal talking heads is to be found on Fox network: Glen Beck...or perhaps O'Reilly....or perhaps Limbaugh on a good night. Is the public as stupid and ill informed as they seem to think? I hope not. Time magazine lists 5 immediate good effects of the reform bill that passed. If Republican and other obstructionist factions resist this implementation too much the Feds can actually take over for them. I am sure that is not what they want as a group. This backfired on them when they shut down the government a few years ago. Honestly, how do these guys get elected? The short answer is lobbyists and money of course. Maybe P.J. O'Rourke was right in his book title "Parliament of Whores". In late Nov. 2010 the Supreme Court in a rare fit of rationality refused to hear the state attorney generals' bid to deem healthcare reform unconstitutional.
The Dec 1, 2010 online issue of The New England Journal of Medicine had an article by V.R. Fuchs concerning US healthcare financing vs other nations. Our trend is for the government to pay for more healthcare regardless of recent reforms. In Europe of course almost all healthcare is paid by governments. The contrasts are many as noted by Fuchs: "The most obvious, easily quantifiable difference between the United States and countries that have national health insurance is that those countries spend much less on health care, whether measured per capita or as a share of the gross domestic product. Not only is the United States the highest spender, but the gap between it and the other countries is unnaturally large — we spend 50% more than the next-highest spender and twice as much as the average country in the Organization for Economic Cooperation and Development. One explanation that is frequently offered is the role of “special interests” in the United States. There is little doubt that the suppliers of health care goods and services — manufacturers of drugs, devices, and equipment, as well as physicians and hospitals — prefer higher expenditures to lower ones. But isn’t that true in every country? The difficult question is why the special interests have more influence over health policy in the United States than they do elsewhere. The answer probably lies in part in the structure of the U.S. political system, including the role of primary elections, long and expensive election campaigns, the separation of powers, the numerous congressional committees and subcommittees with overlapping authority, and the need for super-majorities in the Senate in order to pass meaningful legislation. But the quirks of the political system can’t be the whole answer. If the U.S. public wanted a different outcome, over time they could move policy in that direction.

It should be noted that the higher expenditures in the United States do confer some benefits. There is less likelihood of having to wait for a diagnostic or therapeutic procedure or to travel far to obtain it. Also, the amenities in hospitals, clinics, and physicians’ offices are usually superior to those in other countries that have a per capita income close to that of the United States. It would be of interest to determine how these benefits are distributed and how they are valued by people at different income levels.

A second large difference between health care in the United States and in countries with national health insurance is the more important role of redistribution in the latter countries. Such redistribution is evident in the greater equality of access to care and in the sharing of costs through taxes on income or payroll, value-added tax or sales tax, or other forms of taxation that are either proportional or progressive with respect to income. Of course, all insurance is redistributive after the fact. The large amount of care utilized by a small proportion of policy holders is paid from the premiums of others who use little care. The important distinction is that under a national health insurance system, the redistribution occurs before the event, since it is clear that some individuals will pay much less tax than the value of their insurance and some will pay much more.

Since redistribution plays a greater role in the health care systems of other countries than it does in the United States, there is an implication that a more egalitarian ethos holds sway in Europe, Canada, Australia, and New Zealand. From de Tocqueville to the present, many observers have commented on the stronger role of individualism in the United States than elsewhere, but there is no consensus regarding its explanation. Possible contributors to the phenomenon include the heterogeneity of the population, the revolutionary origins of the country with its dedication to “life, liberty, and the pursuit of happiness,” and the absence of many centuries of a common language, history, and culture. In speculating about the possible rise of despotism in a democracy, de Tocqueville painted a grim picture of individualism taken to the extreme. He wrote, “Each . . . living apart, was a stranger to all the rest — his children and private friends constitute to him the whole of mankind; as for the rest of his fellow citizens, he is close to them, but he sees them not; he exists but in himself and for himself alone.”3

The lower spending and the greater redistribution in countries that have national health insurance are not independent phenomena. If spending in these countries were at U.S. levels, the taxation required to accomplish their redistribution goals would probably wreck the economy. Given the social or political desire to redistribute health care resources, constraints on spending become a necessity. These constraints take various forms, such as controls over the number and specialty mix of physicians, limits on facilities and acquisition of expensive technologies, hard bargaining over prices charged by drug companies and other suppliers, and restraints on physicians’ fees and incomes, among others.

Because the governments in these countries pay for most medical care — usually 70 to 90% of total expenditures — they are in a good position to apply these cost-restraining measures. They have what economists call “monopsony power.” The U.S. government, although it pays for almost 50% of health care, makes very little use of its power to restrain costs. Thus, in one sense, Americans wind up in the worst of all worlds, with government bearing a big part of the burden of paying for health care, with the concomitant large burden of taxes, but exercising very little control over the cost of care. As an indication of how absurd the situation is in the United States, government currently spends more per capita for health care than eight European countries spend from all sources on health care. Though life expectancy is far from a perfect measure of the quality of care, it is not without interest to note that life expectancy at birth in every one of these eight countries is higher than that in the United States."
Now ask yourself why this is so hard to comprehend? Is disinformation in our lobbied to death congress causing the lack of clarity or do we just not care anymore?
Senator Ryan's voucherization of Medicare is the biggest bone of contention in June 2011. 2012's election will revisit this often. current polls universally show that it is very unpopular among seniors and those who follow this issue. Spin machines are going full tilt and the GOP is having a hard time justifying their backing of this nightmare plan.

global warming science

2010-04-02T16:20:00.000-07:00

Moving beyond opinion to reasoned scientific approach is necessary if we are to understand what may be happening. Hopefully it won't be too late. Freeman Dyson is a scientific voice that we may do well to listen to.

part 2

The generally accepted view: that climate change is cyclical, but that human caused changes are accelerating warming.

A further discussion of atmospheric studies and skeptical science can be found at this blog:
http://www.skepticalscience.com/tropospheric-hot-spot.htm

The following is a quote from the excellent green blog "climateprogress.org"
This post is an update of my April 2008 analysis [5]. A 2008 report by the International Energy Agency came to almost exactly the same conclusion as I did, and has relatively similar wedges [6], so I view that report largely as a vindication of my overall analysis.

The reason that we need twice as many wedges as Princeton’s Pacala and Socolow have said we need was explained in Part 1. That my analysis is largely correct can be seen here: “IEA report, Part 2: Climate Progress has the 450-ppm solution about right [6].”

I agree with the IPCC’s detailed review of the technical literature, which concluded in 2007 that “The range of stabilization levels assessed can be achieved by deployment of a portfolio of technologies that are currently available and those that are expected to be commercialised in coming decades [7].” The technologies they say can beat 450 ppm are here [7]. Technology Review, one of the nation’s leading technology magazines, also argued in a cover story two years ago, “It’s Not Too Late [8],” that “Catastrophic climate change is not inevitable. We possess the technologies that could forestall global warming.”

I also agree with McKinsey Global Institute’s 2008 Research in Review: Stabilizing at 450 ppm has a net cost near zero. [9]

I do believe only “one” solution exists in this sense — We must deploy every conceivable energy-efficient and low carbon technology that we have today as fast as we can. Princeton’s Pacala and Socolow proposed that this could be done over 50 years, but that is almost certainly too slow.

We’re at about 30 billion tons of carbon dioxide emissions a year — and notwithstanding the global economic slowdown, probably poised to rise 2% per year (the exact future growth rate is quite hard to project because it depends so much on what China does and how quickly peak oil kicks in). We have to average below 18 billion tons (below 5 GtC) a year for the entire century if we’re going to stabilize at 450 ppm (see “Nature publishes my climate analysis and solution [10]“). We need to peak around 2015 to 2020 at the latest, then drop at least 60% by 2050 to at most 15 billion tons (4 billion tons of carbon), and then go to near zero net carbon emissions by 2100.

That’s why a sober guy like IPCC head Rajendra Pachauri, said in November 2007 [11]: “If there’s no action before 2012, that’s too late. What we do in the next two to three years will determine our future. This is the defining moment.” Or as I told Technology Review, “The point is, whatever technology we’ve got now — that’s what we are stuck with to avoid catastrophic warming [12].”

California seems to be taking the lead in encouraging green tech...say what you want,but the "gubinator" has been instrumental in this positive move. Governmental spurs to development must be used and used quickly. Meanwhile fishermen off of California's coast have seen large influx of Humboldt squid...a species that usually ranges from Mexico south. Is this due to expansion of the squid's favorite habitat? probably. In fact the squid may be uniquely suited to a global warming scenario since it thrives in oxygen depleted waters at great depths. This is a voracious species that potentially could deplete some of California's favorite fisheries. Maybe we can all cultivate a taste for squid. The sooner,the better. This is a link to a youtube video from WQED. http://www.youtube.com/watch?v=AQKs1-fwTgU&feature=related

Brain, Mind and Society

2010-01-12T11:31:00.000-08:00

FDA Contact Lens Site

2009-11-17T12:15:00.000-08:00

http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/ContactLenses/ucm062589.htm This site is intended to be helpful to patients and doctors in reinforcing correct safe and approved methodology for cleaning and wearing today's contacts. There is no doubt that we have a clearer picture of what is and is not prudent with respect to extended wear schedules. These views may change over time. I will try to keep this blog up to date and if you have questions please call me at the office. In a large retrospective study of microbial keratitis (bacterial infection of the cornea) about 1/3 of the reported cases lost 2 lines of vision. There was probably sampling error in these studies since only the most severe cases were reported to larger centers of care. Daily wear schedules are far more safe than extended wear schedules. Again I must emphasize that if you sleep in your lenses you must return to our office on a 6 month basis. This is in accord with current practice guidelines from contact companies and the FDA. This has changed over the years and will change again in the future as we learn more about the eye and contacts.

More on Acanthamoeba Keratitis

2009-09-25T11:30:00.000-07:00

The recent spike of acanthamoeba corneal infections in contact wearers has been reviewed in some depth and more factors are emerging. Between 2003 and 2006 the incidence of this dangerous problem went up. Soft contact wearers who used Complete Moisture Plus by AMO had a significant increase in risk (7 times greater than those not using this solution). The 40% of cases not using Moisture Plus had other factors that influenced their coming down with this condition: re-using solution (topping off the solution in the case)...not rubbing the lens when cleaning them (despite "no-rub" indication from the product label)...showering with the lenses on (microbes in the mist). The EPA is reviewing the allowable microbial load in tap water and reviewing chlorination policies of urban water supplies. This follows the discontinuation of B&L's ReNu with MoistureLock because of Fusarium fungal keratitis outbreaks and the recent announcement that many cultures for mycobacterium avium in shower heads are positive. There are more and more cautions to be aware of. Ninety percent of these amoeba infections occur in contact lens wearers at a rate of about 10 cases per million wearers. Let me be clear about one thing: the safest soft lenses are no doubt the daily wear disposables worn on a daily basis ie not extended wear. One should never let tap water come into contact with the contacts. The case should be air dried while the lenses are in use (if you wear standard weekly or monthly lenses)and the case should be replaced frequently. We don't really advise swimming in contacts at this time. Extended wear patients must be seen every 6 months. We are currently withdrawing the advice to wear lenses on these extreme schedules. If everyone wore daily disposables, we would not have allergy to solutions, no build up of proteins on the lens, and fewer comfort problems due to long term allergic problems (GPC). Also there would be less need to purchase expensive disinfectants. We will be more than glad to switch anyone over to daily wear lenses because we know there is less possibility of infection and greater overall comfort.

Medical Need in Africa=political malfeasance in Africa

2009-08-15T10:21:00.000-07:00

Is it this simple? Obviously civil wars and ineffective governance along with corruption hamper any efforts to make a difference in some spots around the globe. First a story from IPS excerpted from Huffington Post:

"South Sudan looks to be the worst. Maybe two percent of the population is blind," Mulugeta, who works with the Christian Blind Mission, said. This estimate is an extrapolation of numbers from neighbouring Ethiopia where 1.6 percent of the population is visually impaired but where there are far more public health services and infrastructure.

The Director of Eye Health at South Sudan's health ministry, Ali Yousif Ngor, oversees the South Sudan part of an Africa-wide attempt to combat river blindness, also known as onchocerciasis (O.V). It is a disease spread by the black fly that carries larval forms of a worm parasite. These worms grow and breed, releasing thousands of larvae that move all over the body causing intense itching and blindness.

River blindness is prevented by widely dosing communities in affected areas with a drug called ivermectin. For the last two decades ivermectin has been provided free of charge by a U.S. pharmaceutical company in an attempt to eradicate the disease in endemic countries, mostly in Africa.
Story continues below

It was only at the end of the 22-year civil war in Sudan in 2005 that international health organisations and government officials were given a chance to reach many rural communities. "It is so hard to get everyone to take the drug at the same time, twice a year. That would really hit the transmission of the disease," Ngor said.

Part of the problem is that officials like Ngor simply do not know how widespread the disease is. Ngor said that the government does not even know if O.V is more or less common than trachoma, another major cause of blindness in the South. Trachoma occurs when untreated, repeated infections of the eye by bacteria eventually causes scarring so extensive the eyelid partially turns in on itself. The lashes scratch the cornea causing intense pain and often first reversible and then irreversible blindness.

Ngor described one small village where the arrival of a mobile ophthalmologic team prompted 400 blind or partially sighted people to turn up in the hope of treatment. "But it was too late for many of them," he said.

Even within Juba city, lack of knowledge about diseases mean patients often do not go to the clinic early enough to save their sight. But outside the city the situation is far worse; there are no ophthalmologists or even an optometrist to fix disabling short or long sight with a pair of spectacles. Glasses were desperately rare even in the capital until last year. During the 22 years of Sudan's bloody north-south war the only way to get glasses was to travel to Khartoum, North Sudan, or to the neighbouring countries of Kenya or Uganda.

Levi Sunday is thin, smartly dressed and blind. As his stick tip-taps the ground uneven with tree roots and rain gullies, he moves faster than the average Juba citizen in the hot and small town.

He is Chair of the Equatorian Union of the Blind that has some 800 members. It is a comparatively large organisation by the South's standards but Sunday said they are finding it hard to draw attention to the problems the blind and partially-sighted experience, including issues of poverty and stigmatisation.

"The union was formed in 1984 ... to combat begging, train the blind in handcrafts like basket weaving so they can depend on themselves," Sunday explained. Classes in other income-generating skills have also been put in place but in reality, Sunday said, many blind are begging.

The union also organises classes to help the blind learn to use a stick and has close connections to the blind school where Braille is taught. "Many of the blind are not educated because of the poor quality of education in the South, there is nothing for the blind - except here in Juba. Now we have Braille machines here so they can type their notes in Braille and read books in it," Levi said.

Five former students are now enrolled at Juba University, a cause of some pride. The union is also responsible for dozens of marriages between Juba's blind. Macho South Sudanese society is still too narrow-minded for blind men to easily marry girls with sight, Sunday said.

"There is great ignorance in the south. People do not consider the blind as human. They are seen as powerless. Sometimes they are not helped, even with food. The blind in the south can die because of a lack of support. Blind children are undermined," Sunday said.

His chairmanship got off to a rough start earlier this year. The union spilt into those supporting Sunday and those supporting his predecessor (who established the union in 1984) over differences over the constitution and personal politics. Feelings ran so high a policeman was put outside the run down union building after someone punctured the wheels of the body's ancient Suzuki (they have a volunteer part-time sighted driver).

Too much politics everywhere seems like a curse of the South. Even in peacetime life in the region is fraught for many. Southerners are still holding their breath for a 2011 referendum promised under the peace deal that will give them a long-awaited chance to vote for separation from north Sudan. But many worry that tense North-South Sudan relations will worsen in the run up to elections next year and the referendum vote. In the meantime tribal violence has intensified this year, with hundreds killed including women and children.

With these problems perhaps it is not surprising that the blind are side-lined. The four-year-old government has not yet met the poor standards of garrison times when the blind were provided free transport and educational support. Experienced blind teachers were recently threatened with dismissal, because they were deemed unfit to teach, a deep blow to the union's confidence, although the threat was later retracted.

"Since the peace, I myself have not seen a change in the lives of the blind. People now (in power) are not cooperating with blind people... before the peace when Juba was under Khartoum at least we had free transport cards. Now there is nothing like that," Sunday said.

For experts in the sector the problem is extremely worrying. The Carter Centre, an American non-profit that has trained surgeons to do trachoma surgery in rural areas, says that in Sudan some 5 million people could be at risk from river blindness.

"Early blindness is early mortality in South Sudan," Dante Vasquez from the Carter Centre said. The blind tend to have poorer nutrition and are isolated so they die younger.

The Carter Centre has performed well over 4,000 trachoma surgeries, a procedure which involves cutting and re-sewing the eyelid in a way that turns the eyelashes back outwards, in the South and has treated hundreds of thousands of earlier-stage cases with antibiotics. Though Vasquez believes the true scope of the disease is unknown; and the centre could be just scratching the surface. In Ayod county the Carter Centre found 15 percent of the population affected, and three percent of children. Trachoma infection in more than one percent of the population is usually considered a serious health risk.

Children with the disease are stigmatised, not least by the pain that renders them unable to perform everyday duties. They also become a burden; as Ngor pointed out. He explained that every blind person also needs another to help them, thus creating a drain on family resources.

Children blinded by the disease are especially worrying as loss of sight follows repeated infection, normally only occurring by the time they are adults. "We're seeing it in younger and younger populations. This is an indicator of how acute the problem is," Vasquez said.

Read more at Inter Press Service.

In this country we depend on charitable organizations to pick up those that fall through the large gaps in our medical safety net. Why this country can't seem to get a consensus about what is needed completely baffles me. Why do drugs cost more here than in Canada? Why can't Medicare and Medicaid barter with big pharma to keep costs down? Bravo to Indian drug companies who said to hell with the patents... we have people dying because the third world can't afford your expensive drugs...we will make our own thank you very much. Why is imaging so costly in the U.S. and cheap as dirt in Japan (on the same equipment)? So while I look at the article quoted above and feel that backward political turmoil is at fault...I look at our system and feel the exact same feeling. The senate and congress must begin to be responsive to something other than the balance of their re-election campaign fund. I believe that the comedian who suggested that politicos should wear patches on their arms to signify whose money they had accepted and whose agenda they were pushing....just like sports figures do. Our politicians are held hostage to special interests and lobbies who have only their own bottom line to consider. All this is not new...so why isn't someone trying to fix it?? End of rant. Please support charitable organiztions doing work in your community. If the feds can't help, then help yourselves.

Preventable Blindness in the Third World

2009-08-15T09:12:00.000-07:00

Preventable blindness...we should all be on board with whatever agencies are working to eradicate this problem. In this country we depend on local organizations and societies such as the Lion's Club, Prevent Blindness and other charitable groups to take care of those who fall through the rather large uninsured cracks in our system. Most doctors encounter needy patients that can be greatly helped by the intervention of these groups whether by supply of glasses or medicine or cataract surgery. In countries that have universal health care this is not so much of a problem. On the world stage the Gates Foundation among others has been on the forefront of the fight to eliminate river blindness in Africa. Intervening problems such as civil wars poor or ineffective governance and shortages of health care workers and doctors make this task more difficult of course. This is an excerpt from an online article detailing the problems in Sudan and generally the rest of the developing world:

South Sudan looks to be the worst. Maybe two percent of the population is blind," Mulugeta, who works with the Christian Blind Mission, said. This estimate is an extrapolation of numbers from neighbouring Ethiopia where 1.6 percent of the population is visually impaired but where there are far more public health services and infrastructure.

The Director of Eye Health at South Sudan's health ministry, Ali Yousif Ngor, oversees the South Sudan part of an Africa-wide attempt to combat river blindness, also known as onchocerciasis (O.V). It is a disease spread by the black fly that carries larval forms of a worm parasite. These worms grow and breed, releasing thousands of larvae that move all over the body causing intense itching and blindness.

River blindness is prevented by widely dosing communities in affected areas with a drug called ivermectin. For the last two decades ivermectin has been provided free of charge by a U.S. pharmaceutical company in an attempt to eradicate the disease in endemic countries, mostly in Africa.
Story continues below

It was only at the end of the 22-year civil war in Sudan in 2005 that international health organisations and government officials were given a chance to reach many rural communities. "It is so hard to get everyone to take the drug at the same time, twice a year. That would really hit the transmission of the disease," Ngor said.

Part of the problem is that officials like Ngor simply do not know how widespread the disease is. Ngor said that the government does not even know if O.V is more or less common than trachoma, another major cause of blindness in the South. Trachoma occurs when untreated, repeated infections of the eye by bacteria eventually causes scarring so extensive the eyelid partially turns in on itself. The lashes scratch the cornea causing intense pain and often first reversible and then irreversible blindness.

Ngor described one small village where the arrival of a mobile ophthalmologic team prompted 400 blind or partially sighted people to turn up in the hope of treatment. "But it was too late for many of them," he said.

Even within Juba city, lack of knowledge about diseases mean patients often do not go to the clinic early enough to save their sight. But outside the city the situation is far worse; there are no ophthalmologists or even an optometrist to fix disabling short or long sight with a pair of spectacles. Glasses were desperately rare even in the capital until last year. During the 22 years of Sudan's bloody north-south war the only way to get glasses was to travel to Khartoum, North Sudan, or to the neighbouring countries of Kenya or Uganda.

Levi Sunday is thin, smartly dressed and blind. As his stick tip-taps the ground uneven with tree roots and rain gullies, he moves faster than the average Juba citizen in the hot and small town.

He is Chair of the Equatorian Union of the Blind that has some 800 members. It is a comparatively large organisation by the South's standards but Sunday said they are finding it hard to draw attention to the problems the blind and partially-sighted experience, including issues of poverty and stigmatisation.

"The union was formed in 1984 ... to combat begging, train the blind in handcrafts like basket weaving so they can depend on themselves," Sunday explained. Classes in other income-generating skills have also been put in place but in reality, Sunday said, many blind are begging.

The union also organises classes to help the blind learn to use a stick and has close connections to the blind school where Braille is taught. "Many of the blind are not educated because of the poor quality of education in the South, there is nothing for the blind - except here in Juba. Now we have Braille machines here so they can type their notes in Braille and read books in it," Levi said.

Five former students are now enrolled at Juba University, a cause of some pride. The union is also responsible for dozens of marriages between Juba's blind. Macho South Sudanese society is still too narrow-minded for blind men to easily marry girls with sight, Sunday said.

"There is great ignorance in the south. People do not consider the blind as human. They are seen as powerless. Sometimes they are not helped, even with food. The blind in the south can die because of a lack of support. Blind children are undermined," Sunday said.

His chairmanship got off to a rough start earlier this year. The union spilt into those supporting Sunday and those supporting his predecessor (who established the union in 1984) over differences over the constitution and personal politics. Feelings ran so high a policeman was put outside the run down union building after someone punctured the wheels of the body's ancient Suzuki (they have a volunteer part-time sighted driver).

Too much politics everywhere seems like a curse of the South. Even in peacetime life in the region is fraught for many. Southerners are still holding their breath for a 2011 referendum promised under the peace deal that will give them a long-awaited chance to vote for separation from north Sudan. But many worry that tense North-South Sudan relations will worsen in the run up to elections next year and the referendum vote. In the meantime tribal violence has intensified this year, with hundreds killed including women and children.

With these problems perhaps it is not surprising that the blind are side-lined. The four-year-old government has not yet met the poor standards of garrison times when the blind were provided free transport and educational support. Experienced blind teachers were recently threatened with dismissal, because they were deemed unfit to teach, a deep blow to the union's confidence, although the threat was later retracted.

"Since the peace, I myself have not seen a change in the lives of the blind. People now (in power) are not cooperating with blind people... before the peace when Juba was under Khartoum at least we had free transport cards. Now there is nothing like that," Sunday said.

For experts in the sector the problem is extremely worrying. The Carter Centre, an American non-profit that has trained surgeons to do trachoma surgery in rural areas, says that in Sudan some 5 million people could be at risk from river blindness.

FDA Lasik Information

2009-07-15T13:18:00.000-07:00

The following information is from the FDA website:

LASIK - FAQs (Frequently Asked Questions)

* Can you refer me to a good LASIK surgeon in my area?
* How do I report a bad experience or who do I notify about a 'bad' doctor?
* How much does LASIK cost?
* How can I find out if a particular laser has been approved to treat my refractive error (nearsightedness, farsightedness and/or astigmastism)?
* If the laser I am interested in has not yet been approved for a particular indication, how can I find out when it will be approved?
* Which laser is the best for treating my refractive error?
* How does wavefront LASIK compare to conventional LASIK?
* What percentage of patients attain 20/20 vision or better without glasses or contacts?
* What is “All-Laser LASIK” and how does it compare to traditional LASIK surgery?
* Can I use information from the FDA LASIK website?

Q: Can you refer me to a good LASIK surgeon in my area?
A: Refer to the Other Resources section of this site. You may want to contact the organizations listed there for additional information. While FDA regulates medical devices and drugs, FDA does not regulate the practice of medicine and does not have a registry of doctors. FDA does not know of any government agency that can provide a referral for any medical procedure. You may want to go to your library and see if there is a local community services magazine that may provide comparison information of services for doctors in your area.

Q: How do I report a bad experience or who do I notify about a 'bad' doctor?
A: If you had a bad experience or sustained an injury, you should file a voluntary MedWatch report (1-800-FDA-1088) to the FDA. Also, you could contact your state medical licensing board and file a complaint with them. In addition, you could contact your state health department or consumer complaint organization (e.g., Better Business Bureau).

Q: How much does LASIK cost?
A: The FDA regulates the safety and effectiveness of medical devices for their intended use. The FDA does not regulate the marketing of or any fees associated with the use of that product. Again, you may want to go to your library and see if there is a local community services magazine that may provide comparison information of services for doctors in your area.

Q: How can I find out if a particular laser has been approved to treat my refractive error (nearsightedness, farsightedness and/or astigmastism)?
A: You can find approved devices, their approval date, and a synopsis of the approved indications on the FDA-Approved Lasers page.

Q: If the laser I am interested in has not yet been approved for a particular indication, how can I find out when it will be approved?
A: Confidentiality restrictions prohibit FDA from commenting on the status of a device under regulatory review, but you can try asking the laser company for this information.

Q: Which laser is the best for treating my refractive error?
A: FDA does not provide comparisons between refractive lasers. FDA approves the safety and effectiveness of a device independent of any other product. However, you are encouraged to review the approval documents to assess the capabilities of specific laser systems and make your own comparisons. The approval number for each laser on the FDA-Approved Lasers page is linked to these documents, which provide additional, detailed information about the clinical trial results and indications for use. Discuss any concerns you may have with your doctor.

Q: How does wavefront LASIK compare to conventional LASIK?
A: Wavefront adds an automatic measurement of more subtle distortions (called higher order aberrations) than just nearsightedness, farsightedness, and astigmatism corrected by conventional LASIK. However, these “higher order aberrations” account for only a small amount (probably no more than 10%) of the total refractive error of the average person’s eye. Conventional LASIK increases higher order aberrations. Although wavefront-guided treatments attempt to eliminate higher order aberrations, results from the clinical studies have shown that the average aberrations still increase, but less than they do after conventional LASIK. In a few studies comparing wavefront-guided LASIK to conventional LASIK, a slightly larger percentage of subjects treated with wavefront LASIK achieved 20/20 vision without glasses or contact lenses compared to subjects treated with conventional LASIK. Patient selection (“When is LASIK not for me?”) and the experience and competence of the surgeon are still the most important considerations.

Q: What is “All-Laser LASIK” and how does it compare to traditional LASIK surgery?
A: The difference between traditional LASIK and “All-Laser LASIK” (also known as “Bladeless LASIK”) is the method by which the LASIK flap is created. In “All-Laser LASIK”, a laser device called a laser keratome, is used to cut a corneal flap for LASIK surgery. This is a newer method to create a corneal flap than the traditional method of using a microkeratome, a mechanical device with a blade. There is no absolute agreement among eye surgeons on the better choice for flap creation. Some of the factors a surgeon considers when choosing a preferred method of flap creation during LASIK are as follows:

* Quality of vision
* Rate of complications
* Pain during and after surgery
* Precision of flap size and thickness
* Time to recovery of vision
* Expense

Discuss with your doctor any questions and concerns you have about how they chose their preferred method of flap creation.

Q: What percentage of patients attain 20/20 vision or better without glasses or contacts?
A: Data in the Approval Orders and related documents summarizes the outcomes from the clinical trials submitted to the FDA for each approved device. Links to these documents are included on the FDA-Approved Lasers page.

Q: Can I use information from the FDA LASIK website?
A: Yes. Information on this website can be used freely by the public. Any use on other websites or in publications should be properly cited.

The Importance of Vision

2009-07-08T12:14:00.001-07:00

Did you know that approximately 75% of all neurons in your brain have to do with vision or processing visual input? The eyes help answer certain questions about the environment: who? what? where? howbig? is there movement? how fast? relative position? The following TED talk has an overview of vision in knowledge formation.

Cataract Surgery and New Tech Lens Implants

2008-08-10T14:36:00.000-07:00

Newer high tech lenses are starting to be available for use in restoring vision after cataract surgery. Previous models were all monofocal, giving clear vision only at one distance. There are now several bifocal lenses approved for implantation. Rezoom, Restore, and Crystal lenses are all available to the patient, but because Medicare won't pay for the new lenses the patient will have to pay several hundred dollars more for these lenses. Why is this important? Some seniors in the 7th decade and up are forever losing their reading glasses and bifocal lenses would lessen their need for a reading glass. There are also astigmatic lenses which will compensate for corneal toricity that causes defocus of the retinal image. Wavefront technology is being used to optimize focus in some new lenses and the bar is gradually being raised with respect to the best choice for your cataract surgery . There are some tough choices to be made and you must be counseled by your surgeon on the best path to take. Post op follow up may be done by your surgeon or the referring optometrist as the insurance companies direct. This is one of the most successful surgeries ever and there are very few instances in which waiting til the last minute is a good idea. In fact, waiting to let the human lens become extremely mature may complicate your surgery. We are glad to answer questions you may have and look forward to providing you with better vision.

Regenerative Medicine

2008-03-18T08:51:00.000-07:00

I frequently get questions from visually disabled patients or their families about regrowing functional units or whole body parts and when will this be possible? The following talk on ted.com is very interesting and points the way to a future technology that we all have wondered about. The Japanese have alocated large amounts of money to pursue this technology. The human foetus below a certain aqe has the ability to regenerate a limb...this power is lost at time goes on. Dr Russell shows a film in which a 78 year old man regenerates his fingertip! Stem cells are the key to this and sadly have been neglected by the NIH and the Bush administration. As healthcare becomes more expensive it seems that it may be more cost effective to regenerate function rather than amputate dysfunctional parts and deal with the consequences. New directions are clearly needed, but this requires leadership with a vision for the future. Ted.com has many interesting talks , but I found this one by Dr Russell to be most interesting and I hope you do too.

Ray Kurzweil is also a tech guru who foresees great changes in the next decade...."The Singularity Is Near" is the title of his book about the exponential growth of biotechnology and the re-engineering of the human condition.

In June of 2010 an article appeared in the New England Journal of Medicine that summed up work being done in corneal rehabilitation with stem cell products. I am posting the discussion section of this article:
Discussion

Autologous cultures of limbal cells provide an adequate long-term source of transplant tissue for the treatment of corneal damage due to burns. We observed that a minimum of approximately 3000 stem cells, detected as p63-bright holoclone-forming cells, was required to achieve clinical success. (A limbal culture contains a minimum of 3x105 cells,20 about 30% of which are clonogenic; thus, about 3% of these clonogenic cells should be holoclones.) Analysis of our findings suggested that outcomes differ significantly depending on whether the transplanted cultures contain more than 3% p63-bright holoclone-forming stem cells or 3% or less — the success rates were 78% with the larger number of stem cells and 11% with the smaller number. On the basis of this observation, we speculate that corneal regeneration cannot be ascribed to a nonspecific stimulatory effect of epithelial cultures, fibrin, or surgical manipulation on spared residual limbal cells (if such cells are even present).

Preservation of holoclones requires culture with selected 3T3 feeder cells and fetal-calf serum,6,22,23 and this culture method has been used worldwide since the 1980s6,7 to treat patients with massive full-thickness burns.18,19,24 During the past 30 years, no adverse effects have been reported, and this method has been approved for use in the United States, Japan, Italy, and South Korea.6,7 Retention of holoclones also requires appropriate substrates for the cultivation of cells; both fibrin and plastic have been shown to preserve holoclone-forming cells.18,19,20 Alternative methods involving other reagents have been proposed that obviate the use of feeder cells, serum, or both,6,17 since some investigators consider these reagents to be potentially harmful.25 The retention of stem cells when these alternative methods are used has not been investigated.

Allogeneic and buccal keratinocytes have been used as sources of grafts in previous clinical experimental studies to treat limbal stem-cell deficiency.6,17 Allogeneic keratinocytes — even when frozen or lyophilized — improve healing of partial-thickness or small skin wounds by stimulating resident cells.26,27 However, engraftment of these allogeneic cells is not permanent,26 and it seems unlikely that the presence of stem cells is required for their clinical effect. Donor epithelial cells have not been recovered from the ocular surface in studies that looked at long-term outcomes,28,29 and it seems unlikely that these cells would regenerate functional epithelium in patients with total limbal stem-cell deficiency, nor is there evidence that buccal keratinocytes can generate bona fide corneal epithelium.30 If limbal stem-cell deficiency is only partial, allogeneic or oral keratinocytes may be sufficient to stimulate resident limbal cells to regenerate corneal epithelium. Additional studies to test this hypothesis are warranted. The same argument might hold true for the effect of autologous cultures on corneal regeneration. Nevertheless, the association that we observed — between the percentage of p63-bright cells and clinical success — was never related to a nonspecific stimulatory effect of the transplanted culture on resident stem cells.

In conclusion, our study shows that in patients with limbal stem-cell deficiency who received cultured limbal stem-cell grafts for corneal transplantation, the clinical results were successful at up to 10 years (at a median of 2 years) in more than 75% of the patients treated. Cultures of limbal stem cells thus represent a source of cells for transplantation in the treatment of burn-induced destruction of the human cornea.

Published pictures of these treated corneas are wonderful and give hope to many with visual problems. This technology has great promise and I hope our cornea specialists will have availability of proper stem cell lines to use.

This was excerpted from PopSci website and was posted by Rebecca Boyle...
A pioneering study published Online First in the Lancet has shown that failing joints can be replaced with a joint grown naturally using the host's own stem cells. The work paves the way for a future of naturally grown joints that would last longer than currently used artificial joints. The work was carried out by Professor Jeremy J Mao, and his team at Columbia University Medical Center, New York, USA, and colleagues from University of Missouri and Clemson University.

Patients having joints replaced almost always want to know how long their artificial joint will last. But with ageing populations, and an increasing number of patients under 65 requiring replacement joints, there is a real danger many patients will outlive their replacement joint. These patients would then need another gruelling operation, at an advanced age, and yet without much bone left to support another metallic joint.

In this proof-of-concept study, Professor Mao and colleagues removed the forelimb thigh joint of 10 rabbits, and then implanted three dimensional biomaterial scaffolds infused with growth factor. The rabbits' own stem cells were 'homed' by the growth factor to go to the location of the missing joint, and regenerated cartilage and bone in two separate layers. Just four weeks later, the rabbits were able to resume normal movements, similar to rabbits with normal functional joints. These rabbits had grown their own joint using their own stem cells, instead of stem cells harvested apart or outside of the host.

Prior to the work reported in this Lancet paper, no one has been able to regenerate a limb joint with either stem cells harvested or the host's endogenous stem cells. Thus there are two new aspects to this work: 1) a limb joint regenerated for the first time with the animals involved resuming functions on the new joint; and 2) the regenerated limb joint being created from host's own endogenous stem cells, not stem cells that are harvested and manipulated outside the host's body.

Professor Mao says*: "This is the first time an entire joint surface was regenerated with return of functions including weight bearing and locomotion. Regeneration of cartilage and bone both from the host's own stem cells, rather than taking stem cells out of the body, may ultimately lead to clinical applications. In patients who need the knee, shoulder, hip or finger joints regenerated, the rabbit model provides a proof of principle. Several scientific and regulatory issues must be dealt with prior to patientapplications." Other reports are surfacing that experiments have allowed rats to regrow teeth when treated with stem cells. In ocular pathology marvelous results have been achieved with stem cell treatment of opaque corneas.

This link is to a story from Ted and the printing of tissue by innovators in tissue science. Amazing stuff!

ACANTHAMOEBA KERATITIS (YOU DON'T WANT IT!)

2008-03-03T09:39:00.000-08:00

A recent issue of Review of Optometry gave a rundown of the latest thinking on this devastating corneal infection. Thankfully we don't see many of these problems, but the CDC has in the past alerted the medical professions to peaks of incidence. You no doubt heard about this in the press and it seems that in late May of 2007 the FDA notified another contact lens solution manufacturer (AMO) that there had been in increase in incidence in patients using Moisture Plus multi purpose contact solution. Acanthamoeba is a ubiquitous organism, but reports were not seen in the literature until the 70's and then a peak of cases in contact wearers in the mid 80's. Treatment was very unsuccessful at first and remains difficult today. There didn't seem to be a magic bullet for this critter. It can get under the contact lens and feeds on whatever it finds...including your cornea. It can encyst and remain dormant for a time and then come back to cause problems. This is why doctors preach "no tap water" on your lenses and" discard your case frequently....follow cleaning directions and use fresh solution each night. "

With the Moisture Plus recall there may be an issue with propylene glycol an ingredient used to soothe and wet the eye. This is also used in tear solutions sold over the counter and may be sold for use on contacts. It is currently our advice for extended wear contact wearers not to use a solution that contains propylene glycol. This chemical seems to encourage encystation of the amoeba. Encysted forms are very resistant to treatment. Tap water is a big source of both fusarium fungal infections (~80% of the fusarium outbreak used tap water on their lens) and amoeba infections also. The FDA has not finished it's investigation and has not issued any guidance on lens materials as of March,2008. The best protection is follow instructions to the letter. Extended wear is of course more of a general risk for eye infections. Forget the labeling that stated "no-rub"....rubbing and rinsing is now viewed as critical to getting your lens clean.

CONTROVERSIAL NEW APPROACH TO DIABETES

2008-01-23T05:19:00.000-08:00

The following is an abstract from a journal article that is sure to stir some controversy in diabetes treatment. For years docs have been telling patients to lose weight and get exercise to help control diabetes and of course this is easier said than done for some patients. It will be interesting to see if this approach is useful:

Physician's First Watch for January 23, 2008David G. Fairchild, MD, MPH, Editor-in-Chief
Gastric Banding Brings Remission in Type 2 Diabetes

Gastric Banding Brings Remission in Type 2 Diabetes
Gastric banding far outperforms conventional therapy in achieving remission of type 2 diabetes, according to an industry-sponsored, preliminary study in JAMA.
Australian researchers randomized 60 obese patients (BMIs between 30 and 40) with type 2 diabetes to laparoscopic adjustable gastric banding or "best practice" conventional therapy. When assessed 2 years later, 73% of the surgical group had achieved remission versus 13% of the conventional-therapy group. Likewise, weight loss averaged 20% of baseline with surgery and 1.4% with conventional therapy.
Editorialists, citing the Australian surgical team's high level of experience, say "their excellent results may not be ... reproducible elsewhere." And they acknowledge that the "general applicability of these findings remains to be determined." Nonetheless, they observe that guidelines for diabetes care "do not mention surgery at all, even for severely obese patients." They urge professional societies and clinicians to "reconsider the role of surgery to treat diabetes."
JAMA article (Free abstract; full text requires subscription)

CONTACT LENS PROBLEMS? MOST CAN BE RESOLVED

2008-01-10T05:18:00.000-08:00

The last several years has been interesting for those of us in contact lens practice. There have been a few recalls of contact lens solutions and lens recalls as well. B&L's problems with Renu were well publicized, but other companies also had recalls. The following is an excerpt from a contact lens journal article : Patient compliance has been suggested as a factor in the recent outbreaks of Fusarium and Acanthamoeba infections. We compared the data generated on compliance by Collins and Carney1 in 1986 in Australia to a study reported at BCLA in 20072. When we look at these two studies we find some very interesting comparisons. First, washing hands, while an important step in hygiene, does not remove all organisms and is not performed by all patients. Collins and Carney reported that this behavior was correlated with the observation of corneal staining. The 2007 study indicated that 35% of patients surveyed admitted to irregular hand washing before lens handling. The 1986 study indicated that about 18% of patients irregularly changed their solution which leads to corneal staining and increased deposits. The 2007 study similarly reported 15%. A new survey by the Contact Lens Council3 indicates that as many as 44% of patients occasionally “top off” solutions. Lens case care continues to be equally dismal. Collins and Carney reported about 28% did not clean lens cases, which significantly correlated with corneal staining. The 2007 BCLA poster reported that 38.7% of patients clean lens cases less than once a week. In the BCLA poster, 58% of patients use tap water to clean their case, probably a primary source of Pseudomonas bacteria and other organisms. The recent Contact Lens Council survey reports 54% of patients don’t clean lens cases after every use.Poor compliance in lens handling, lens case hygiene, and “topping off” have not improved since the 1980’s leading to the question of what are we doing as medical professionals to educate patients. These major sources of non compliance affect our patients’ exposure to microorganisms. As reported at BCLA, we are spending only 1-3 minutes with patients to reinforce lens care and only when the patient shows some behavior that indicates non-compliance.
If we are to improve compliance, we need to start with teaching and reinforcing correct lens care to our patients.References:1. M.J. Collins L.G. Carney, Compliance with care and maintenance procedures amongst contact lens wearers, Clinical and Experimental Optometry 69(5): 174-177; 1986.2. R.P.Stone, The Importance of Compliance: Focusing on the Key Steps, Poster at BCLA Annual Meeting 2007.3. Contact Lens Council Survey as reported in Contact Lens Today August 19, 2007

There have also been hints that showering in contacts can be a factor especially in light of the fact that some municipal water suppliers have changed the way they purify water. Last year it was also found that Legionaires disease bacteria (legionella) can be found in water coming from your tap. Contact lens wearers should never put tap water on their lenses or in their cases....cases should be discarded frequently (every month or 2 is good)...don't buy solutions in huge containers that will sit opened for months at a time....it is better to buy smaller units and use them before the preservatives go flat. It is important to let your case air dry without the cap on during the day while the lens is being worn. This helps keep down case contamination.

I still feel that the majority of contact lens intolerance cases I see are allergy related. Giant papillary conjunctivitis is an allergic lid phenomenon that can exist without the conventional allergic symptoms of sneezing or sinus congestion...just itching, foreign body sensation and contact lens intolerance. Some wearers need to use oral and topical drugs to make it through the allergy season and maintain a good level of comfort. Sometimes a break in wear is necessary, but we can usually get you back in lenses within a month or two. It is our job to advise you on contact lens safety and how you can avoid these complications. Please check this website frequently for any news on contact lens recalls or new products that might be of interest. One of the latest contacts to come out is a toric bifocal lens from Cooper. I have seen some success with this new lens and look forward to using it . We have been waiting for advances in this product category for some time. The outlook for 2008 is much better for the contact lens marketplace. The recalls of the past years have refocused us on safety and better communications to new wearers. The wearer has a lot of control and responsibility to follow instructions for safe wear. We take our responsibilities to you, the wearer, seriously. All extended wear patients should come back for followup on a regular basis...this is a mandated schedule of followup. If patients disregard this regularly we may have to withdraw our OK for continued wear. This is usually for limbal neovascularization and or stem cell depletion and loss of clarity in a normally clear tissue. It is possible to physically damage your cornea and your vision by neglectful habits and poor followup. The good news is that the newer silicone hydrogel lenses provide 4-5 times the oxygen supply to your cornea as compared to the older style lenses. In our view, if you are sleeping in lenses you should be in a silicone hydrogel.

Choosing Eyewear

2008-01-08T18:16:00.000-08:00

Choosing eyewear can be a frustrating and challenging job. This is often made more difficult if the eyecare staff is inexperienced or even worse if they are on commision to sell expensive extras. Then you may not be able to trust the advice you get. Let's face it! Some people are more difficult to fit than others. The final cosmetic result you achieve with your choices will be with you daily for the next year or so. All the more reason to seek out reputable sources who have the experience to make helpful suggestions and share their product knowledge. Today's optical goods are thinner, lighter and better looking than what we had previously. High index lenses help us fashion a thinner lighter pair of lenses so that even those with high prescriptions can enjoy a reasonable and fashionable result. Anti-reflective coatings help pass more light through the lenses and help hide the annoying reflections that hide your eyes from observers. Does everyone need A-R coatings?...no! Even though these coatings are now tougher than they have ever been I would not advise people who work in dusty or challenging environments to wear them. Maybe they should be used only on dress glasses for those working under less than ideal conditions. If you are a person who does a lot of night driving these coatings are great and can significantly improve your night vision. For people who are rough on frames or have corrosion problems with their eyewear, the obvious choice is a titanium frame or perhaps a zyl or composite frame. There are a dizzying array of choices to be made and we will try to help you with making the best choice for you and your lifestyle. In general frames have tended to be smaller and metal frames have been more popular. Fashion is cyclical and now we may see some designers going for more color and effects only achieved with plastics.

FDA Lasik Data

2007-04-04T14:35:00.000-07:00

The web is a wonderful source of information and misinformation. When considering something as serious as lasik patients should make every attempt to check and cross check the facts concerning their vision and their proposed procedure. The FDA has made available a lot of data on the individual lasers and the data used to make the decisions on approval for marketing in this country. The following is an excerpt from their website meant to help patients in their decision.
When is LASIK not for me?

You are probably NOT a good candidate for refractive surgery if:

You are not a risk taker. Certain complications are unavoidable in a percentage of patients, and there are no long-term data available for current procedures.

It will jeopardize your career. Some jobs prohibit certain refractive procedures. Be sure to check with your employer/professional society/military service before undergoing any procedure.

Cost is an issue. Most medical insurance will not pay for refractive surgery. Although the cost is coming down, it is still significant.

You required a change in your contact lens or glasses prescription in the past year. This is called refractive instability. Patients who are:

In their early 20s or younger,
Whose hormones are fluctuating due to disease such as diabetes,
Who are pregnant or breastfeeding, or
Who are taking medications that may cause fluctuations in vision,

are more likely to have refractive instability and should discuss the possible additional risks with their doctor.

You have a disease or are on medications that may affect wound healing. Certain conditions, such as autoimmune diseases (e.g., lupus, rheumatoid arthritis), immunodeficiency states (e.g., HIV) and diabetes, and some medications (e.g., retinoic acid and steroids) may prevent proper healing after a refractive procedure.

You actively participate in contact sports. You participate in boxing, wrestling, martial arts or other activities in which blows to the face and eyes are a normal occurrence.

You are not an adult. Currently, no lasers are approved for LASIK on persons under the age of 18.

Precautions
The safety and effectiveness of refractive procedures has not been determined in patients with some diseases. Discuss with your doctor if you have a history of any of the following:

Herpes simplex or Herpes zoster (shingles) involving the eye area.

Glaucoma, glaucoma suspect, or ocular hypertension.

Eye diseases, such as uveitis/iritis (inflammations of the eye)

Eye injuries or previous eye surgeries.

Keratoconus

Other Risk Factors
Your doctor should screen you for the following conditions or indicators of risk:

Blepharitis. Inflammation of the eyelids with crusting of the eyelashes, that may increase the risk of infection or inflammation of the cornea after LASIK.
Large pupils. Make sure this evaluation is done in a dark room. Younger patients and patients on certain medications may be prone to having large pupils under dim lighting conditions. This can cause symptoms such as glare, halos, starbursts, and ghost images (double vision) after surgery. In some patients these symptoms may be debilitating. For example, a patient may no longer be able to drive a car at night or in certain weather conditions, such as fog.

Thin Corneas. The cornea is the thin clear covering of the eye that is over the iris, the colored part of the eye. Most refractive procedures change the eye’s focusing power by reshaping the cornea (for example, by removing tissue). Performing a refractive procedure on a cornea that is too thin may result in blinding complications.

Previous refractive surgery (e.g., RK, PRK, LASIK). Additional refractive surgery may not be recommended. The decision to have additional refractive surgery must be made in consultation with your doctor after careful consideration of your unique situation.

Dry Eyes. LASIK surgery tends to aggravate this condition.

It is helpful for you to know how long the healing period should last and what to expect. With larger corrections the healing will be slower. Your doctor is the best source of this information.

Reversing Coral Reef Damage

2007-03-03T05:09:00.000-08:00

The February 2007 issue of Biophontonics International has an interesting article about Australian researchers and the role that several fish species can play in reversing coral reef damage. It seems that the dusky batfish and the orbiculate batfish are the greatest consumers of microalgal blooms that can slowly choke coral reefs to death. They can function as cleaners of the reef ecosystem. In the Dec 19th issue of Current Biology, Bellwood et al describe these fish as assuming this alternate role under exceptional circumstances and point out that this species has no protection status and faces increased human encroachment. The dugong and the green turtle are also consumers of algae that have been under great pressure from humankind. Researchers are rushing to find out what factors help to heal the reef and hopefully aid in protecting this delicate balance. Offshore in Pensacola we have the Oriskany naval vessel that was sunk as an artificial reef. Programs of this kind are great for the local economy: fishing, diving and tourism in general. What doesn't work well seems to be the old idea of sinking old auto tires as reefs. Where this has been tried, the tires seem to work loose and wash up on beaches after leaking toxins into the water. So we learn from mistakes. Florida has been slow in permitting reefs compared to Alabama despite the efforts of sportfisherman and other interested parties. In the vein of the maxim "think globally and act locally" I would direct anyone interested in preserving Gulf of Mexico waters estuaries and rivers to this website www.healthygulf.org.
There are many topics to discuss from wetlands to Corps of Engineers projects to natural gas projects in the gulf and how to best avoid further habitat destruction.

Deal or no Deal? Optical Choices

2007-01-23T12:42:00.000-08:00

Yeah Doc, I got my frames 2 years ago at "Adequate optical" down the street, but the lenses scratched so I went to "Three Weeks Later" optical and had new lenses put in but they don't seem right to me. I need a new frame by now since the earpieces are corroded. "Brown Bananna " optical had some closeouts and discontinued merchandise for very reasonable prices, but they were not too fashionable...know what I mean? Just some stale inventory I guess. What can I do?
In desperation I tried "Not Licensed In My State" optical over the internet and found the frames I wanted but they rub my nose and fall off my face everytime I bend over. Also the coatings are scratching off the surface of the lens. I called about it but they said I had no warrantee. What can I do?
In our industry we hear a never- ending litany of complaints such as these. Quality comes at a price as does service. Value has to be judged on a balance of price, quality and service. If you leave one of these factors out in your decision making you will likely be disappointed. Lots of folks buy discontinued frames thinking they are a bargain, but then discover that they can't get replacement parts or replacement frames to match their lenses. Obviously they didn't understand this when they got that "great deal". Caveat emptor....

Demographics of Aging Vision

2006-12-23T06:55:00.000-08:00

Sobering statistics about vison loss in the over 40 age group give us plenty of cause to take precautions and have routine exams on a frequent basis. A recent article ( Arch Ophthalmol. 2006;124:1754-1760) estimates the cost to the US for vision conditions in this age group could approach 35.4 billion dollars per year in direct and indirect costs. This counts lost productivity and underemployment figures. Direct cost from visual conditions is 16.2 billion in medical costs per year. Much of this is preventable. If a diabetic puts off seeing the eye doc for years and neglects his sugar control, this is a recipe for eventual disability. Uncontrolled hypertension and thyroid problems can also lead to severe visual deficits. As in so many other areas an ounce of prevention is worth a pound of cure and you are in control of this. Only you can pick up the phone and make the appointment. National Eye Institute figures indicate that at 40 there are 0.3% of the population with visual impairment . This figure climbs to 23.7% at age 80. In the fourth decade 2.5% of us will have cataracts and in the eighth, 68.3%. Severe age related macular degeneration ranges from 0.1% at 40 to 11.8% at 80. Intermediate or less severe ARMD starts with 2% at 40 and goes to 23.6% at 80. So you see that few of us will escape having some sort of visual complication in our lives. A full set of statistics is available at the NEI website: http://www.nei.nih.gov/
From the American Journal of Ophthalmology comes the study indicating that for every dollar spent on prevention and close followup, five dollars of value is returned to society. Said differently, the burden of blindness upon society is lessened greatly if we maximize our efforts at prevention and frequent exams.

I See 20/20 So Nothing's Wrong!

2006-12-14T11:41:00.000-08:00

This is the number one mistake not to make. Don't assume that because your central vision seems sharp and crisp that you couldn't have hidden problems. Many retinal problems go undetected for years before they become apparent to the patient. For instance in the picture you can see that this patient has had serious retinal complications in his superior retina...but not in the macula (darker area to the right of the optic nerve). His superior retina is involved so we would expect an inferior field defect. Because the macula is not involved his vision straight ahead is still good. Perhaps the number two mistake that older folks make is that their vision seems to be getting better so they gladly put off coming in to the eyedoc's office. This is sometimes termed "second sight". Diabetes or cataracts or corneal swelling could be responsible for the changes that they are noticing. Big changes in the over 50 crowd are not a good sign. There is no pain in the retina or optic nerve so any pathology can cause painless progressive blindness. There is no substitute for regular comprehensive eye exams.
The following is excerpted from the preventblindnessamerica.org website:
Even if you have no signs, regular eye exams are recommended—especially for those with some chronic health conditions such as diabetes and high blood pressure. Early detection and treatment can be the key to preventing sight loss.

Any changes in the appearance of your eyes or vision should be investigated further. Some examples include: ▼

Unusual trouble adjusting to dark rooms;

Difficulty focusing on near or distant objects;

Squinting or blinking due to unusual sensitivity to light or glare;

Change in color of iris;

Red-rimmed, encrusted or swollen lids;

Recurrent pain in or around eyes;

Double vision;

Dark spot at the center of viewing;

Lines and edges appear distorted or wavy;

Excess tearing or "watery eyes";

Dry eyes with itching or burning; and

Seeing spots, ghost-like ../images.

The following may be indications of potentially serious problems that might require emergency medical attention: ▼

Sudden loss of vision in one eye;

Sudden hazy or blurred vision;

Flashes of light or black spots;

Halos or rainbows around light;

Curtain-like blotting out of vision; and

Loss of peripheral (side) vision.

If you notice any of these signs or symptoms timeliness is important. Many patients would have happier outcomes if they had come in a day earlier.

Will the Real Harry Potter Please Stand Up?

2006-12-07T05:30:00.000-08:00

http://www.physics.usyd.edu.au/cudos/research/plasmon.html
Just as Jules Verne's fiction predicted space and undersea travel and was realized by scientific and technological advances, today's scientists are stretching to achieve new capabilities that will match or exceed recent fiction. Writers have proposed cloaking devices and invisibility as a tactic for many years...remember the Klingons? Now if you think optics is a boring subject you must read about these developments. Check out the latest in superlenses...cloaking devices may be right around the corner. Nanotechnology may make it possible to bend visible light to create new optical effects. Super sharp pictures, increased resolution beyond presently accepted limits and the ability to see through or around obstacles may all be achievable. In addition to the group at Sydney, Duke University researchers are also experimenting with metamaterials and are working in the microwave spectrum and ultimately the visible spectrum as well. The ability to hide obstructions that block line of sight microwave transmissions may be the first real application to evolve. Needless to say the military is very interested and funding for this research should not be hard to come by. The Milton-Nicorovici hypothesis is the mathematical underpinning of work on the superlens. Essentially a thin film of silver can have a negative index of refraction that will bend light in an unnatural way...negative indices of refraction have only recently been achieved. I am sure there will be many surprising outcomes from this research. Other optical/laser researchers are working on novel propulsion systems at White Sands New Mexico. The lightcraft runs on nothing but laser light and air which is combustable at high temperatures. http://www.cnn.com/SPECIALS/cold.war/experience/the.bomb/route/04.white.sands/

Real Advances in Retinal Treatments

2006-12-05T06:39:00.000-08:00

Age related macular degeneration(abbreviated ARMD or sometimes AMD) is a slowly progressive condition that is the most common cause of blindness in the 65 and over population. In the fifth decade there is a 2% chance of having signs of macular degeneration. In the ages 65-75 there is a 10% chance and for 75-85 we expect 30% incidence. For patients in families with a history there is a 50% lifetime risk vs. roughly 12% risk for those without a positive family history. There are two forms, wet and dry. Dry is slowly progressive with the hallmark drusen spots in the center of the macula (where all detail seeing is focused). Drusen are defects at the boundary of the retina and the underlying vascular area the choroid. Small drusen can be watched safely in the early stages without any intervention. They are visible as white specs when your doctor looks inside the eye. Confluent drusen signal a later stage of ARMD. A small percentage of the these dry ARMD patients will progress to a wet form when blood vessels grow through Bruch's membrane from the choroid into the retina causing edema and disruption of normal vision. What causes this to happen? There are risk factors: high cholesterol, heredity(complement factor H polymorphism), lifetime of exposure to UV radiation, blue eyes, cardiovascular risk factors, smoking, and dietary influences. Prevention should be uppermost in the minds of those with a family history of ARMD. The AREDS study demonstrated the value of antioxidant formulations and is widely available now. AREDS II will be a study that further explores the need for dietary supplementation. Increasingly it is becoming clear that DNA is not destiny...i.e. the new science of epigenetics is giving insight into how genes can be switched on and off and the role that our diet can play. The trigger to the neovascularization that occurs is first the disruption of Bruch's membrane and the influence of VEGF or vascular endothelial growth factor. This growth factor is also responsible for vessel growth in tumors. Avastin is a drug that has been used and approved for colon cancer patients. It is now beginning to be used for wet macular degeneration. There are several other VEGF blocking drugs that are under investigation and there are other approaches such as VEGF trap and interfering RNA to either compete with VEGF function or to block it from being genetically expressed in the eye. PDT or photodynamic therapy has been used for some time now, but has not proved to be a magic bullet. A photoactive dye in combination with an exciting laser causes the death of ingrowing vessels. The treatment has to be repeated however. Combination treatments of PDT and Avastin plus intravitreal anti-inflammatories (Retaane or triamcinolone) should prove to be more effective than any one treatment alone. These studies are now ongoing. http://www.medpagetoday.com/Ophthalmology/GeneralOphthalmology/tb/4239 On the diagnostic side, optical coherence tomography has made evaluation of macular problems much quicker and easier on the patient. Newer versions of the OCT (spectral OCT recently FDA approved) will lessen the need for invasive studies such as flourescein angiography (the dye in the arm test). http://en.wikipedia.org/wiki/Optical_coherence_tomography New techniques and new drug use may in fact lessen the need for many of the surgeries done today. There is much more to be done, but there is real optimism in the the retina field today.

Doctor My Eyes Have Spots

2006-11-30T13:28:00.000-08:00

It is not uncommon to see eyes with iris freckles like this. They can be normal variants or they can be a part of a syndrome called Iris Nevus-Cogan Reese Syndrome. Iris nevi usually do not grow but these patients can be at risk for corneal thickening, iris degeneration and possible glaucoma. Iris Nevus Syndrome is a subset of what is known as ICE or iridocorneal endothelial syndromes (Chandler's Syndrome and essential iris atrophy) that give rise to a spectrum of anterior segment changes. More serious causes of melanotic change in the iris would be melanoma which can be diffuse or localized. Melanomas are usually unilateral, usually elevated and may have feeder vessels or show other distortion of iris structure. Inflammatory granulomas may also appear on the iris surface and can be caused by Sarcoid or Tuberculosis. In addition syphilis, mongolism and neurofibromatosis patients can show iris changes. Chances are the eye in this picture is perfectly normal. Pigment is just out of place. If you have a friend or relative with similar eye changes it would be good advice to have a doc take a close look to verify that all is well. Close observation is usually all that is needed. Normal pigment can also be out of place on the whites of the eyes or sclera. Close inspection with a slit lamp biomicroscope is the only way to inspect these changes. There are certain fringe alternative "medicine" people who claim to be able to diagnose all manner of illnesses from the morphology of the iris. Iridology has no sound basis in or place in modern medicine.

Doctor I Have Pain in My Eyes

2006-11-30T13:27:00.000-08:00

Your complaint will have to be carefully investigated. Before you go in for your visit try to think about the onset of symptoms, the location, the severity. Is the pain episodic or steady. On a scale of 1 to 10 how would you rate the severity? Is it surface pain like a foreign body or is is deep inside the eye? Also think about what makes the pain worse or better. Is it only when you read? Is it worse in the morning or afternoon? Have you had a significant sinus, ear or dental problem lately? Have you had an upper respiratory problem in the last week? Have you had any cold sores or herpetic mouth ulcers lately? Do you have vascular or migraine headaches? Is your vision affected before, during or after the pain? Is the globe itself tender? Are you photophobic? Are you a contact lens wearer who overwears lenses? These are a few of the points that you should be able to discuss with your doctor. Doctors often consider themselves lucky if they can elicit a good detailed history...but it is really essential to good care. Your symptoms must be evaluated in a context which gives further clues.

Disclaimer

2006-11-27T11:06:00.000-08:00

It is hoped that the materials presented here are educational in nature. These articles do not in any way constitute specific medical advice concerning an ongoing pathology or illness. To get diagnostic and treatment advice you must visit your doctor. The internet is not the place to get specific medical help. It can function to give background and educate and I think this is a valuable tool for us all. I do not have editorial control over the websites that are linked to but seek to share the information contained there. I disclaim any liability for injury or damages resulting from review of this blog or the web pages linked to. It is my hope that you will be more informed and able to make decisions concerning your healthcare. The internet has many websites with questionable information. Notably the Bates method keeps cropping up. The Irlen" scotopic sensitivity syndrome" people....the pinhole glasses for everyone people etc. etc. The American Optometric Assoc and the American Academy of Ophthalmology issue position papers on certain subjects that are valuable in steering patients to more acceptable paths. www.quackwatch.com is also somewhat helpful, but a little severe in some pronouncements. One day I heard a commercial on tv that touted pinhole glasses to older drivers having difficulty with vision. I called the station manager and asked him what his liability was if an elder citizen donned pinhole glasses and then had a motor vehicle accident. His answer was that "If you have enough money you can advertise anything you want. We have no liability" . Prior to this I had seen a 79 year old man who had been sentenced to 15 years in the state penitentiary for running over 4 children at a bus stop and killing them....and driving away. He thought he had "hit some garbage cans or something". His remark to me was that he hoped I could give him stronger glasses. It was obvious that he had been blind for some time and that a state required exam should have kept him off the street. He was renewing by mail to another state up north. Do I think that he would have tried pinhole glasses for driving? ...unfortunately, yes. Losing one's privilege to drive is a life altering thing and the temptation is for some elder drivers to continue longer than they should. Florida's new elder driver rule let's us prove our visual competence every year after the age of 80. I personally think it should start at 75.

Healthcare Reform

2006-11-24T15:27:00.000-08:00

In 1950 the country spent less than 100 dollars per year on each citizen for healthcare. That would be $500 in todays dollars. Eye exams ranged up to $18 on the high end. The current rate of spending for healthcare is $6000 per patient. If eye exams kept pace, that would be over $1000 for an eye exam...without glasses or contacts. Vision is a small part of the healthcare puzzle. The biggest social debate of the decade continues. Why have we stalled at this point? Political cowardice...apathetic voters....lack of news coverage...no view of how this affects ME? These web sites give a small taste of the viewpoints you will encounter. The twin plagues of HIV and Alzheimers continue to sap resources from an already overtaxed system. The worldwide HIV picture can be seen at this website http://www.who.int/hiv/countries/en/ There seems to be no end in sight. Short sighted politicians have hampered stem cell research and seem to suffer no consequences at the ballot box. An uninformed polity allows these missteps to happen. If there were real political pressure I think we might choose a wiser course. The following web sites are a little taste of what the opinion makers are pushing.

Alliance for Health Reform - Balanced information about the uninsured,
health care coverage and many other health policy issues.
and http://americanhealthcarereform.org/
and then follow this link to an excellent healthcare blog.
http://www.thehealthcareblog.com/the_health_care_blog/
the_industry/index.htm l

These web sites should give you insight into the vast and difficult task that reforming healthcare will be. We must begin somewhere. Our industries are crippled competitively for several reasons not the least of which is healthcare costs for their employees. Why in our current system should a worker fear to change jobs because he might lose coverage? What is the shameful political pandering coming out of Washington lately? The insurance companies have waited till the last step to wield their considerable clout with the politicians they have "bought". Talking heads such as Limbaugh and Beck have inflamed the discussion and taken it to a new low in terms of misrepresentation. The gang of six in Washington will force delays and extreme compromises that most likely will gut any real chance of healthcare reform. We may however be able to achieve health insurance reform to some degree. Portability, universality and affordability is what everyone deserves. No big changes to Medicare or military medicine....contrary to the rumors on the Fox channel. What was one of the biggest factors in General Motors decline and fall? ....healthcare benefits for retirees and workers. If they couldn't afford healthcare what makes any of us think that we can as individuals find affordable plans? Small business certainly can't find it either.
Forty six million without health care coverage in the USA. This is an astounding statistic. We all wonder why it takes all night to get seen by the emergency room staff but the uninsured and underinsured are clogging up the nation's emergency departments with situations and conditions that could be handled elsewhere if only they had adequate coverage. The self employed or the small businessman can barely afford to buy insurance for themselves much less employees. Where do we go from here folks? This system is badly broken. I am not sure that I agree with everything or even the majority of things on these websites, but we need to be talking about this and seriously moving toward some kind of consensus. The Clintons bit off more than they could chew but I respect them for trying. Fighting big medicine and big insurance and big pharmaceuticals all at once is tough unless popular opinion is solidly behind you. I thought Dr. Frist lost all credibility when he voiced an opinion on Terry Schiavo, a patient he had only seen a tape of. This was justified in his political thinking at the time I guess. Since his brother is a hospital executive with a national chain of hospitals I tend to look closely at any pronouncements he makes. He seems to me to be playing politics with the nation' s health. Pharmacy benefits managers and risk managers seem to be exerting undue influence on medical decisions as well. The book Enemies Of Patients by Ruth Macklin is an excellent analysis of some of the ethical problems involved in today's critical care. In closing, we spend 1.69 billion per year just to regulate healthcare! See this website for some proposed legislation: http://www.heritage.org/Research/HealthCare/wm803.cfm
If you add the amount we spend on healthcare worldwide and compare it to the amount spent on illegal drugs, alcohol and cigarrettes what do you get? The impression that we really don't take our own heath seriously. Check the stats http://www.worldometers.info/

Eyes and Aviation

2006-11-24T06:43:00.000-08:00

There was a famous airliner incident in 1987 where a pilot wearing contacts belly flopped a 747 on landing because he had impaired depth perception. The investigation found that he was wearing contacts fit for one focal distance per eye i.e. mono-fit contacts. He saw distance with one eye and near with the other, but couldn't use the eyes together to achieve good depth perception. This was frequently done in the civilian population due to our lack of good bifocal contact lenses. All pilots should know that this type of fitting is not advised for flying. In general, today we have better options and several bifocal designs to choose from. Older pilots all have to contend with the bifocal problem eventually. For civilian aviation we can generally find a workable option that won't impair the visual judgements necessary to be safe. Anti reflective coatings for night flying are an advantage to eyeglass wearers since they get more light transmission through the lenses. UV blocking should be standard for anyone in the cockpit since exposure is greater at altitude. This is often a property of the lens material or can be added to traditional lens materials. This link is to a paper on glare and aviation accidents. http://www.hf.faa.gov/docs/508/docs/cami/0306.pdf
The DOT/FAA do not advise the use of polarized lenses.

Refractive Surgery Gets Better

2006-11-23T10:57:00.000-08:00

One complication that all lasik docs dread is flap problems either from malpositioning and slippage or inflammation under the flap. This has been such an issue that some have gone back to prk instead of lasik claiming better results (no flap involved).
Some studies have indicated that prk can give better vision than lasik. Military pilots are usually limited to PRK for this reason and concern over flap stability. The healing and pain issues with prk are controlled much better with newer medications. One of the latest lasik advances, Intralase, makes a cleaner flap interface without using a blade and probably removes less or the same amount of tissue as compared to conventional lasik. The ability of the older keratome blade to slice a flap of consistant thickness was always suspect. If your corneas are thick this may not be a problem in terms of your proposed correction. Intralase makes progress in lasik accuracy and safety due to better control of the flap making procedure. A very fast femtosecond laser makes the flap cut with no blade involvement. The laser cycles and fires in an extremely fast manner measured in femtoseconds. A femtosecond is a billionth of a millionth of a second. Wavefront analysis or aberrometry is also guiding lasik into an era of more predictable results. The ability to treat higher prescriptions is also making strides. The Star S4 in now able to treat from -14 myopia to +5 hyperopia and 5 diopters of astigmatism. This may vary with the proposed procedure i.e. lasik vs prk. The incidence of post lasik farsightedness in nearsighted corrections has been reduced due to better algorithms and better understanding of the cornea. Results with hyperopic patients tend to be a little less stable than myopic corrections. Your doctor will go over the risks and discuss any concerns you may have. Your cornea will be mapped and the thickness checked. Pupil size is also a concern with larger pupils more at risk for glare and halos. Old records should be reviewed to see if you have stable corneas and stable refraction. If you have developed several diopters of astigmatism over the last several years this may be enough change to be a contraindication to surgery. Until a records review is done it is premature to proceed with surgery. The FDA has as website that is very helpful in giving an overview of the technology and concerns that need to be addressed when making the decision to pursue refractive surgery. http://www.fda.gov/cdrh/lasik/
Perhaps the best website available for this purpose is http://www.refractivesource.com

I Have Eyes for You

2006-11-23T09:01:00.000-08:00

The Anableps fish has eyes that allow him to see above and below the waterline...simultaneously. His eyes have 2 foveal areas that allow clear focusing when he cruises with the waterline splitting the pupil. This allows him to have both worlds in focus at the same time. Here he is in shallow water and intent on an above water target. There are several species of these fish. Archer fish are a common aquarium pet and also have the ability to see and hunt in water and in air. Their ability to spit water at a target to bring it down into the water gives them their name. A recently discovered fact is that sea urchins have photo sensing capability in their feet. As their genome has been unraveled it is clear that this rudimentary "vision" exists. Previously no one had suspected that urchins could really sense anything close to vision. Raptors, birds of prey, have also evolved a second fovea and have stereo vision or depth perception for rapid localization as they dive at tremendous speed. The Limulus polyphemus or horseshoe crab is also notable for the size of its optic nerves. These are used in research simply because the size makes it easier to work with. Research may one day allow us to regenerate optic nerve tissue and restore human vision to those who have had damage. As our population ages there are more and more of us that will one day benefit from knowledge gained by studying the comparative biology of vision and eyes. There is a recently discovered oddity in Madagascar...a moth that feeds of the tears of sleeping birds. There are plenty of insects that attack eyes but this one has a forked and barbed proboscis that helps penetrate the birds closed eyelid to gain access to fluid.http://www.newscientist.com/article.ns?id=dn10826
Obviously there are many wonderful and sometimes terrifying adaptations and designs that mother nature has in store.

OSHA, safety glasses and you

2006-11-21T17:24:00.000-08:00

Probably an unpopular topic but a very very important one: safety glasses and why they are necessary. Today I saw a young man for the second time this month with a nail gun injury to his eyes. He was lucky last time and only had an embedded piece of metal which was extracted with some difficulty. It did leave a scar but luckily it was not in the pupillary area. If it had been, he would have lost at least 2 or 3 lines of acuity i.e. from 20/20 to 20/40. Today he was not lucky and came in with an injury to the other eye. He had been wearing some cheap sunglasses which were shattered. It is hard to say that OSHA approved lenses would have helped him avoid any injury, but chances are good that it would have mitigated the trauma to his eye. As it is, he was 20/200 and in great pain. There was bleeding in the eye and a probable retinal detachment. He was turned away at 4 o'clock by one of the local hospitials but they said that he needed to be seen" right away by an eyedoc". Maybe they dropped the ball here, but after a visit to my office and a long talk about safety,the retinal specialist saw him right away. It will be several weeks before we know how this turns out. The optic nerve could also be damaged. I am sure that this young man now understands the necessity of good quality safety eyewear. Typically safety glasses are made of polycarbonate or perhaps newer more impact resistant plastics. If your safety officer at work can't help you with a safety eyewear program please contact your doctor's office for advice. You can't always count on being lucky with these injuries. To be compliant with OSHA the frame and the lenses must be of approved type and should not be reglazed with replacement lenses. Your eyewear professionals know the rules. Please take advantage of their knowledge. This website has the lowdown on all ANSI standards. Z87.3 is the safety eyewear standard. There are other standards for sports goggles and face shields etc. http://webstore.ansi.org/ansidocstore/default.asp?source
=google&adgroup=ANSI&keyword=
ansi&gclid=CIaujc7I2ogCFSAnSgode0pNtw

Concerning the eye accident mentioned above: initial evaluation by retinologist said he was ok but he subsequently detached 2 days later. This was repaired and vision should be relatively good because of quick response to the problem. This illustrates the problem of delayed detachment. Sometimes retinas can detach months after an injury that was initially thought to be minor. Any sudden onset or change in floaters or flashes of light or "smoke" or "water running in the eye"...should be addressed quickly. Remember small areas of damage can evolve over time to become sight threatening tears, rips, detachments, etc.

Twenty First Century Eyecare

2006-11-13T13:59:00.000-08:00

Post cataract implants that actually focus like your original lens, oxygen permeable contacts, contacts that release medication into the tear film, contacts that can sense blood sugar level, the ability to switch on or off some genes that may affect vision, new antibiotics to treat infections, new rehabilitative approaches to dyslexia, low vision and of course new surgical approaches to the remediation of dysfunctional and diseased eyes...these medical advances are all close to being realized. ReZoom and Restore intraocular lenses are now being implanted and I am sure there will be better designs to come. They cost a little more than what Medicare or most insurances will allow, but promise better function. Newer approaches to refractive surgery may finally take some of the risk out of the procedures. The new genetic understanding realized by the genome project has already shown us the way to new targets for medical therapies. We are now able to test glaucoma family members to see if they are genetically predisposed to developing the condition. These tests will be refined in the next decades to give us earlier warning. The ability to switch a gene on or off will be a very powerful tool for all of medicine. The field of muscular dystrophy is benefiting from recent discoveries of proteins that encourage muscle growth. The biggest problem we will have is to find a way to pay for the newer technologies. There is something wrong with the governmental- medical interface. It is sad when our citizens have to resort to internet drug sales or crossing the border to get affordable medicines. Politicians simply don't have the guts to fix this problem. The Medicare donut hole and Medicare D in general is a flawed program. The drug companies must be brought to the bargaining table if this is to be fixed. As much as organized medicine dislikes it, we may have to go to a single payer system. Can you hear the insurance companies protesting? Accountability will have to be brought to the whole field. HMO's are notorious for rationing health care largely by patient confusion. Canada may not have a great system , but at least they don't spend 25 cents of every health care dollar on paperwork like we did in the last decade. I recently moved my office from one end of Palafox St to the other end....63 days later, I still don't have the government/FCSO/PGBA required paperwork straightened out so that I can see Medicare and Medicaid patients and bill for their visits. Paperwork just adds inertia to the whole system and creates paper- shuffling jobs that up your health care costs. This is where political pressure must be placed. And as a doctor, I don't care if I ever see another drug detail person or sales rep. It's just another trapping of a system gone overboard and allowed to run rampant by drug company patronage to regulators and officials at all levels and political lack of will to fix the problems. The FDA's performance over the last decade is a case in point. It will take real leadership to even begin the process of reform, but it must be done. George Bernard Shaw acerbicly observed that "the professions are a conspiracy against the laity". It seems to me that the beaurocrats and paper pushers conspire against both the professions and the laity and allowing the current state of affairs to continue is a travesty.

Whoo does your eyes?

2006-11-13T11:33:00.000-08:00

In the animal kingdom eyes take many shapes and sizes. The largest known eyes are the eyes of architoothus the giant squid or his realative the colossal squid. These eyes may approach the size of a dinner plate. This size is necessary to allow gathering of all available light in the deep undersea environment. Weird compound eyes of the insect kingdom or perhaps the blue eye spots of the scallop seem very curious to us, but when the environment they live in is considered it makes more sense. Take your average housecat on the prowl for whatever it can pounce on or play with. Under her retina is a layer called a tapetum which gives a double bounce effect to the light rays entering the eye. It effectively helps in the motion sensing function for this efficient predator. Humans don't have this layer but we do have a subset of retinal ganglion cells (magnocellular cells) that are used in the location and motion sensing system. This function was evidently very important for both prey and predator. A very interesting web site for further information is http://ebiomedia.com/gall/eyes/eye1.html
Another fascinating site gives an overview of primitive compound eyes in trilobites.www.trilobites.info/eyes.html and another paleobiology site: http://www.lifethroughtime.com/

Psssst!

2006-11-13T07:50:00.000-08:00

Psst! Over here! If you are a senior or have medicare aged parents or family members you need to be aware of the website that helps seniors with choosing a Medicare plan D provider for drugs. This is way overcomplicated don't you think? Anyway try this website and then vote out everyone that signed on to this plan. How much simpler to just negotiate better pricing from the drug manufacturers....it boggles the mind how many ways we can mess up medicare. All providers listed are approved by Medicare, but some may not be in your area. This tool allows you to check it out. Good luck! http://www.medicare.gov/MPDPF/Public/Include/DataSection/Questions/SearchOptions.asp

What is wrong with this picture?

2006-11-12T12:46:00.000-08:00

What's wrong with this? They were cheap and I see fine. Well, let's start with the size. They seem a little big and may in fact rest on your cheeks a bit. So you can expect the metal to corrode inferiorly and on the temples...depending on how cheap they were. If you have had problems with corrosion in the past, I would advise a titanium frame. If you are allergic to metals I would advise titanium also. They will be more expensive but they will last twice or three times as long as your typical cheap frame.
And what about those reflections? You lose about 4% of the light coming to you at each surface...so about 8% is lost here. If you already have night vision problems , 8% is too much to sacrifice. This one option does make glasses significantly more expensive, but gives better vision under difficult driving conditions. If you have a large prescription, then the shape is alright, but the size is definitely on the large side and will cause the edges to be thicker than in a small frame. Aspheric and atoric lenses are now on the market and will mask the thick edges that are a giveaway that you have a large refractive error. The average price of a pair of glasses sold in the US ranged up to $175 in the late 90's. Now it is more, but people are much more satified with their correction and I believe they see better as well. Granny's glasses with the lines are not an inevitable end point for the 40 and above crowd. If you tried progressives in the past and were not successful, take heart...the new progressives are much better. We still have some adaptation problems but they are usually with more complicated prescriptions. Be sure to ask what the performance warranty is on the lenses you buy. If you have a simple light prescription you may be successful in ordering glasses on the internet, but sooner or later as your prescription gets more complicated, you will have to come up to quality. There is no way to do today's precision eyewear at bargain basement prices and supply quality goods and warranties. Make no mistake, there is a degree of precision needed to do your eyes justice.

Refractive Surgery Caveats

2006-11-12T12:36:00.000-08:00

Lasik effects on glaucoma testing can be unpredictable. I am aware of several patients in my area that had undiagnosed glaucoma due to the masking effects of a thinner cornea. Now that we know how to compensate readings, there is much less of a risk. Be aware that not all offices will have the correct equipment (a pachymeter) to help gauge pressure effects. New tonometers that are independent of thickness are becoming the standard of care. Make sure that when you have followup on your laser procedure that the pressure is being correctly measured. here are some references on the subject:

Munger R, Hodge WG, Mintsioulis G, et al. Correction of intraocular pressure for changes in central corneal thickness following photorefractive keratectomy. Can J Ophthalmol 1998 Apr;33(3):159-65.

Chatterjee A, Shah S, Bessant DA, et al. Reduction in intraocular pressure after excimer laser photorefractive keratectomy. Correlation with pretreatment myopia. Ophthalmology 1997 Mar;104(3):355-9.

Kaufmann C, Bachmann LM, Thiel MA. Intraocular pressure measurements using dynamic contour tonometry after laser in situ keratomileusis. Invest Ophthalmol Vis Sci 2003 Sep;44(9):3790-4.

Siganos DS, Papastergiou GI, Moedas C. Assessment of the Pascal dynamic contour tonometer in monitoring intraocular pressure in unoperated eyes and eyes after LASIK. J Cataract Refract Surg 2004 Apr;30(4):746-51.

Complication rates and the handling of suboptimal results depend on the definition of success. There will be noone who can guarantee you a certain endpoint (20/20, 20/25/, 20/"happy"). Wavefront seems to help avoid some of the postop surprises that used to occur and statistically the results are better than those of 5 years ago. Some surgeons who use both wavefront and standard laser treatments will tell you that patients don't always require the wavefront guided treatment. Wavefront will cost slightly more. Always understand the doctor's policy on second surgeries...or refinements. Have them demonstrate what 20/40 looks like since this seems to be the level at which some clinics deem you eligible for a redo. If everyone had a clear understanding of the disclosures before surgery it would be much better for patient and doctor. In the early days of lasik, people used to go to Canada and Mexico and even Columbia for the latest laser treatments. Our FDA approval process made us lag a bit behind the Europeans as well. Currently I can think of no reason to leave the country to get lasik. Unfortunately, I saw a patient who had gone to Canada for a cheapo laser treatment and had terrible results. It was because she had a corneal condition that should have ruled out laser treatment. She had a very good legal case, but the cheapo place had gone out of business and she would have had to pay lawyers on both sides of the border. She got a cheap price for the procedure without any provision for followup. Be sure you know what provisions are made for follow-up and any complications. This is surgery and there can be unforeseen outcomes. Thankfully, they are fewer and fewer as the technology matures. Aberrometry may move from Zernike polynomial analysis to Fourier analysis in the future. Clinically it may not matter that Fourier is more detailed, but the mathematical treatment of aberrations may change. Astronomers have been using this type of analysis of optics for quite some time now. This site is for the mathematicians among us. http://www.iovs.org/cgi/content/full/46/6/1915
Many "complications" can be avoided if the patient is well informed before the procedure and understands the healing process. Knowing what to expect is crucial to your final satisfaction with the procedure. This is an FDA site that helps in decision making: http://www.fda.gov/cdrh/LASIK/reduce.htm

Twenty First Century Eyecare

2006-11-12T06:36:00.000-08:00

Eyecare Progress

In the 25 years since I graduated from optometry college, eyecare has made great strides in providing better quality goods and services. Computerization has largely made our accuracy better and our ability to work efficiently has been enhanced greatly. Old turf wars flare up sometimes when the three O's can't seem to agree (opticians, optometrists, ophthalmologists). Just to put an old feud to rest, the latest research by OD's and ophthalmologists indicates that judicious use of bifocals may slow myopia progression. This has been a bone of contention between OD's and MD's for many years now. Early optometric practices in this regard now seem justified. On other fronts federal laws now mandate prescription release for both professions and better cooperation can be seen in many areas. Lasik is one area where comanagement does seem to work. I would encourage all who contemplate lasik, lasek, prk, refractive implants and corneal moulding or the new orthokeratology to do a lot of homework and surf the web for all sides to a complex decision. Understand that glasses may continue to be a part of your visual correction even after the proposed treatments. Word of mouth is perhaps a good metric. You will see many many ads with docs all claiming to be the best, most experienced and best equipped. It is hard for the patient to filter out the puffery. There have been some missteps along the way and you will see these chronicled on the web. Some laser "chains" have been fined large amounts for their handling of disclosures and pre-op fees. As with any surgery, there can be mishaps and or a mismatch between expectation and final results. So, start with an eye exam to judge your suitability and motivation to proceed. If you have a good rapport with your current doctor then start there. A good website : refractivesource.com

2006-11-12T06:28:00.000-08:00

Doctor My Eyes Need Treatment But I Can't Afford It

2006-11-12T05:49:00.000-08:00

I know several eyedocs that have made it a point to join in efforts to supply much needed eyecare to developing (or not developing) nations in the third world. Their efforts are largely self funded. Students organizations at schools of optometry known as SVOSH are involved in programs such as this. If you get the opportunity please support these efforts by donating old glasses to them for redistribution to very needy folks who don't have many options. Of course the local Lions Club in your area does the same thing here in the US. If you know of people who fall through the cracks and don't have the resources, then vocational rehab organizations may be of help. Prevent Blindness also does charitable work. Many drug companies now have programs for indigent patients needing medications. It is always sad to see a patient who couldn't afford glaucoma medication who then subsequently goes blind needlessly. Your local eyedoc should have the ability to point these people in the right direction. This link is to a view of world poverty that makes many valid points. I would add that the US is not immune from this same analysis and that global politics has a great part to play. http://www.reason.com/news/show/33258.html?id=05dr3

Doctor My Kid's Eyes Are Bad

2006-11-10T05:49:00.000-08:00

Doctor My Childrens Eyes
I would like to direct you to the Vision Council of America's web sites....www.visionsite.org and www.checkyearly.com/ In vision care as in other walks of life there are controversies and strong opinions...some based in science and some based in prejudice rooted in economic interest. I am reminded that the organized religion that persecuted Galileo took 319 years to admit that they were wrong and had reconsidered the evidence. Turf wars abound in visual subject areas. For example, take dyslexia. Psychologists, educators, ophthalmologists, optometrists, and orthoptists have all written profoundly on the subject. They frequently pontificate that their answer is the only way. Reading problems do not have a monolithic cause and have a mixture of aetiologies. Certainly if a vision problem overlaps a processing problem, then it may impede any progress in remediation. After 100 years we are still only beginning to unravel some of the causes. I would basically disregard most if not all of the old literature on the subject and concentrate on research within the last 10 years. I can recommend a book by Sally Shaywitz MD called Overcoming Dyslexia. Future reasearch will uncover many other avenues to pursue.
Juha Kere and her colleagues at University of Helsinki in Finland and the Karolinska Institute in Sweden have discovered that a flaw in a gene called DYXC1 may cause dyslexia.

They suggested [DYXC1] may be involved in helping cells cope with stress but they acknowledged that much more study is needed. They added that faults in other genes may also cause dyslexia.
But writing in the PNAS, they said: "We conclude that DYXC1 should be regarded as a candidate gene for developmental dyslexia."
They added: "There is overwhelming evidence that dyslexia is a genetically complex condition."

What is our responsibility to the kids? Do screenings at school do a good enough job? The answer is that there is no substitue for a good eye exam done in the doctor's office. There are simply too many distractions at school and not enough manpower. The pediatric doc is probably not well enough equipped to detect things such as latent hyperopia or small angle squints that can affect reading performance. And folks , most of the time they will not grow out of it! A recent study found severe shortcomings in school screenings as currently done. Paradoxically, some powerful ophthalmologists are on record as opposing mandatory school screenings...whose side are they on anyway? They are certainly not serving as advocates for the kids in my view. The Vision Council of America has more data on the state by state efforts to pass laws that help us discover visual problems before they become more severe perhaps lifelong problems. Here the turf wars become very intense and hotly contested. My advice: if your kid has reading problems, start with a vision exam. Psychologists are fond of saying that reading problems (the monolithic dyslexia) are not caused by eye related difficulty. My response is that while there are pure processing problems there are a subset that may have visual factors of poor reading efficiency. I guess you could say that if you really believe that eyes don't impact reading, close both eyes and read the rest of this blog. ;-)

Doctor My Eyes

2006-11-10T05:10:00.000-08:00

Doctor My Aging Eyes
An all to common form of retinal degeneration centered in the macula has been found to be linked to genetic variants (polymorphisms) that can explain a large number of cases of age related macular degeneration. This is just one of the newly discovered polymorphisms that can contribute to risk of blindness.

Originally published in Science Express on 10 March 2005
Science 15 April 2005:
Vol. 308. no. 5720, pp. 419 - 421
DOI: 10.1126/science.1110359

here is the abstract of this article:

Reports

Complement Factor H Variant Increases the Risk of Age-Related Macular Degeneration

Jonathan L. Haines,¹ Michael A. Hauser,² Silke Schmidt,² William K. Scott,² Lana M. Olson,¹ Paul Gallins,² Kylee L. Spencer,¹ Shu Ying Kwan,² Maher Noureddine,² John R. Gilbert,² Nathalie Schnetz-Boutaud,¹ Anita Agarwal,³ Eric A. Postel,⁴ Margaret A. Pericak-Vance²^*

Age-related macular degeneration (AMD) is a leading cause ofvisual impairment and blindness in the elderly whose etiologyremains largely unknown. Previous studies identified chromosome1q32 as harboring a susceptibility locus for AMD. We used single-nucleotidepolymorphisms to interrogate this region and identified a stronglyassociated haplotype in two independent data sets. DNA resequencingof the complement factor H gene within this haplotype revealeda common coding variant, Y402H, that significantly increasesthe risk for AMD with odds ratios between 2.45 and 5.57. Thiscommon variant likely explains 43% of AMD in older adults.

¹ Center for Human Genetics Research, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
² Center for Human Genetics and Department of Medicine, Duke University Medical Center, DUMC Box 3445, 595 LaSalle Street, Durham, NC 27710, USA.
³ Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
⁴ Duke University Eye Center and Department of Ophthalmology, Duke University Medical Center, Durham, NC 27710, USA.

In more detail the combination of genetic markers may predict 74% of ARMD ! click this link:

http://www.rxpgnews.com/research/ophthalmology/retina/ARMD/article_3599.shtml

Prevention may be our best approach to this condition regardless of the genetics:

Antioxidants reduce risk of age-related macular degeneration
Dec 28, 2005, 18:23, Reviewed by: Dr. Priya Saxena

"This study suggests that the risk of AMD can be modified by diet; in particular, by dietary vitamin E and zinc. A higher intake of vitamin E can be achieved by consumption of whole grains, vegetable oil, eggs, and nuts. High concentrations of zinc can be found in meat, poultry, fish, whole grains, and dairy products. Carrots, kale, and spinach are the main suppliers of beta carotene, while vitamin C is found in citrus fruits and juices, green peppers, broccoli, and potatoes. Based on this study, foods high in these nutrients appear to be more important than nutritional supplements. Until more definitive data are available, this information may be useful to persons with signs of early AMD or to those with a strong family history of AMD. Although in need of confirmation, our observational data suggest that a high intake of specific antioxidants from a regular diet may delay the development of AMD"

By JAMA, A diet with a high intake of beta carotene, vitamins C and E, and zinc is associated with a substantially reduced risk of age-related macular degeneration in elderly persons, according to a study in the December 28 issue of JAMA.

Age-related macular degeneration (AMD) is a degenerative disorder of the macula, the central part of the retina, and is the most common cause of irreversible blindness in developed countries, according to background information in the article. Late-stage AMD results in an inability to read, recognize faces, drive, or move freely. The prevalence of late AMD steeply increases with age, affecting 11.5 percent of white persons older than 80 years. In the absence of effective treatment for AMD, the number of patients severely disabled by late-stage AMD is expected to increase in the next 20 years by more than 50 percent to 3 million in the United States alone. Epidemiological studies evaluating both dietary intake and serum levels of antioxidant vitamins and AMD have provided conflicting results. One study (called AREDS) showed that supplements containing 5 to 13 times the recommended daily allowance of beta carotene, vitamins C and E, and zinc given to participants with early or single eye late AMD resulted in a 25 percent reduction in the 5-year progression to late AMD.

Redmer van Leeuwen, M.D., Ph.D., of Erasmus Medical Centre, Rotterdam, the Netherlands, and colleagues investigated whether antioxidants, as present in normal daily foods, play a role in the primary prevention of AMD. Dietary intake was assessed at baseline in the Rotterdam Study (1990-1993) using a semiquantitative food frequency questionnaire. Follow-up continued through 2004. The Rotterdam Study included inhabitants aged 55 years or older from a middle-class suburb of Rotterdam, the Netherlands. Of 5,836 persons at risk of AMD at baseline, 4,765 had reliable dietary data and 4,170 participated in the follow-up.

Average follow-up of participants was 8.0 years. During this period, 560 persons (13.4 percent) were diagnosed as having new AMD, the majority of whom had early-stage AMD. A significant inverse association was observed for intake of vitamin E, iron, and zinc. After adjustment, a 1-standard deviation increase in intake was associated with a reduced risk of AMD of 8 percent for vitamin E and 9 percent for zinc. An above-median (midpoint) intake of beta carotene, vitamins C and E, and zinc, compared with a below-median intake of at least 1 of these nutrients, was associated with a 35 percent reduced risk of AMD, adjusted for all potential confounders. In persons with a below-median intake of all 4 nutrients, the risk of AMD was increased by 20 percent. Adding nutritional supplement users to the highest quartile of dietary intake did not change the results.

"This study suggests that the risk of AMD can be modified by diet; in particular, by dietary vitamin E and zinc. A higher intake of vitamin E can be achieved by consumption of whole grains, vegetable oil, eggs, and nuts. High concentrations of zinc can be found in meat, poultry, fish, whole grains, and dairy products. Carrots, kale, and spinach are the main suppliers of beta carotene, while vitamin C is found in citrus fruits and juices, green peppers, broccoli, and potatoes. Based on this study, foods high in these nutrients appear to be more important than nutritional supplements. Until more definitive data are available, this information may be useful to persons with signs of early AMD or to those with a strong family history of AMD. Although in need of confirmation, our observational data suggest that a high intake of specific antioxidants from a regular diet may delay the development of AMD," the authors conclude.

- December 28 issue of JAMA

JAMA . 2005;294:3101-3107

Doctor My Eyes

2006-11-10T04:56:00.000-08:00

The gulfcoast has had a terrible blow from the last 2 hurricane seasons. I thought it might be good to focus on some positive news in relation to our situation. As a personal note, my cousin loaded 3 flatbed trucks with generators, water and gasoline and drove from Ohio to New Orleans...before the national guard ever got to New Orleans...I hope we have all learned some lessons from this catastrophe.

DIRECT RELIEF ISSUES ONE-YEAR REPORT ON KATRINA EFFORTS

Direct Relief Intenational has done a good job of helping to rebuild medical infrastructure in the affected areas. It will take several hundred million dollars to do justice to the enormity of the catastrophe. This will begin to rebuild the medical infrastructure needed to respond to emergencies of this magnitude. The hardening of cell phone towers would be a good place to start with mandated generators for gas stations so that mobility isn't hampered so much. I know these things are being worked on, but why did it take so long to realize this was needed? I guess the governmental studies that were done were just swept under the rug. A friend of the family spent about 14 days and nights in a New Orleans hospital where she was physicians assistant...most of this time without water, electricity or adequate food. Government at all levels failed to mandate precautions and procedures to lessen the hardships. 2004 and 2005 were a 1-2 punch for the gulfcoast but we are beginning to recover.

Doctor My Eyes Are Red

2006-11-09T19:26:00.000-08:00

Redness is caused by many conditions. The most common being bacterial, viral and allergic conjunctivitis. Other more serious causes include iritis, scleritis, internal eye infections, glaucoma, pre and post septal cellulitis (associated with severe sinus infections) , toxoplasmosis and histoplasmosis. Pterygium is a superficial degenerative condition taking place in the area exposed to sunlight and is thought to be accelerated by dryness and uv exposure over a lifetime. Lymphomas and certain cancers can occur superficially or internally and are occasionally the cause of a red eye. It never ceases to amaze doctors when patients come in with a condition that was first noticed months ago but procrastination has allowed an otherwise treatable problem to become sight threatening. This is the case with contact lens wearers who overwear and don't follow their prescribed cleaning regimen. Corneal infiltrates and corneal ulcers can result from this neglect and may cause a decrease in vision even when healed if scarring is in the pupillary area. The message is to be proactive and do not procrastinate!

Doctor My Eyes Are Getting Dry

2006-11-09T14:11:00.000-08:00

Post lasik dry eyes are sometimes a worsening of a preexisting condition, making a dry eye even drier. Most of the time the dryness is a temporary post surgery phenomenon which will improve over several months with some help from wetting drops, punctal plugs or dietary supplements and medicines targeted to improve tear quality and quantity. Certain health conditions (Sjogrens Syndrome and other assorted connective tissue diseases) will have dryness of mucous membranes as an element of the condition. Women with low estrogen levels will show a drying of the mucous membranes throughout the body. There are certain health conditions that contraindicate lasik and other refractive surgeries. The doctor who does your preop exam will weed out possible complicating conditions and contraindications. Severe dry eye would be a contraindication to lasik. With contact lens wearers it is sometimes difficult for the patient to tell the difference between a dry eye and an allergic eye giving rise to discomfort similar to "dryness". Treatment with drugs such as Patanol is sometimes all that is needed to give relief. This can save a borderline contact lens fit in many instances. Dry eye with musculoskeletal symptoms may warrent a consult or rheumatology workup. The dry eye may be a small part of a systemic problem. Occasionally a cornea with a stem cell deficiency will present as a red eye...sometimes with a contact wearer. In this case the patient should probably be taken out of contacts.

Doctor my eyes

2006-11-09T06:56:00.000-08:00

Most visits to my office start this way: a list of ocular or visual complaints or perhaps a complaint concerning optical goods. Patients with fuzzy vision, variable vision, double vision, headaches of all types (sometimes with contributary health problems), poor school performance and inability to do visually related tasks at work all present to the eye doctor's office. First our task in eyecare is to listen carefully to patient complaints. It helps if you as a patient know how to relay information necessary for a complete evaluation of your symptoms. We will want to know how long the symptom has been noticed, if it was of sudden or gradual onset, the location and character of any pain, the duration of any episodic problems, what relieves and what makes the symptoms worse.

A family history and a general history of your physical health gives us context in which to evaluate complaints. It's not that we are really nosey...just looking for facts. Some patients that come in seem shocked that we ask so many questions....This is probably an indictment of the care they have received before. If their previous doc never asked questions what kind of care were they really receiving? A word of caution here: bargain eyecare is perhaps a bargain that you should pass up. It is frequently cursory and may miss important health issues.