Interesting Medical Articles by
Albert M. Balesh, M.D.
 For Your Enjoyment
All Rights Reserved.
Contact the author at MadDoctorB@aol.com 

Ornery Coronary 6-06

      Whether you ride it or it rides you, that ornery, cantankerous coronary makes for bumpy going. It can turn an ordinary day into the likes of the O.K. Corral, with its sudden compromise of blood flow to the heart, commonly known as acute coronary syndrome (ACS). A chameleon by day, it takes many forms, none of them pleasant, ranging from unstable angina and myocardial infarction to sudden cardiac death and acute onset heart failure or pulmonary edema. Lungs fill with fluid, causing shortness of breath and a drowning sensation, and a pain in the chest becomes so intense and unbearable that even Wyatt Earp would whimper. All this because of a small thrombus of blood clotting cells called platelets, with a pinch of fibrin, coming to rest on a stump or plaque of atherosclerosis in a coronary artery.

      Being fast at the draw means very little when the gunslinger is elderly, diabetic, afflicted with poor circulation, or subject to bouts of high nitrogen and cardiac enzymes in the blood, or wobbly and unstable electrocardiographic signs. A good saloon and a dancehall girl are no match for a stacked cardiac deck, and a posse of health professionals must intervene early and aggressively, if a tombstone over a lonely prairie plot is to be avoided.

      Diagnosis of acute coronary syndrome in its various disguises is actually quite simple and straightforward, regardless of whether bandanas have been pulled high to mask symptomatology and impending cardiac holdup. Chest pain, electrocardiographic findings, two or more episodes of angina within the preceding 24 hours, and elevated serum, cardiac biomarkers and enzymes specifically point to its likelihood, like smoke signals billowing from a high mountain pass, Kemosabe.

      When acute coronary syndrome is suggested, patient care should not be left to chance or a roll of the dice or tumbleweed. An antithrombotic and anti-ischemic regimen should be instituted immediately in order to tame the raging thrombosis, reduce the constriction of coronary arteries, and help cardiac muscle make more efficient use of the limited oxygen supply available. Aspirin and heparin therapy should be initiated to prevent clotting, and nitroglycerin and beta-blockers to increase blood flow and reduce ischemic episodes.

      With a new sheriff in town, law, order, and risk factor management can be maintained, and the shadier elements of the underlying atherosclerosis held in check by judicious use of weight management protocols, diet, statin drugs, smoking cessation advice and counseling, and increased physical activity, not to mention blood pressure control and diabetes management, when necessary.

      And if six-guns start blazing and the cavalry is called for, diagnostic coronary angiography and angiographically directed revascularization can lead the charge, to the sound of a bugle call, within 48 hours of symptom onset.

      The day is done, our hero rides slowly off into the sunset of a human cardiovascular system, and, while he didn't get the girl, he made sure as hell that the girl (or boy) would live to see another dawn, or perhaps many more.

© 2006, Albert M. Balesh, M.D. All rights reserved.

 

Face to Place 4-06

      Does Frankenstein live? Bits and pieces and Humpty Dumpty are all well and good in bedtime stories, but when confronted face to face with a face newly placed, wonder may cede the field to nightmare. We saw it coming, however. Test tube babies, cloned sheep, and bionic limbs just wet our appetites, in anticipation of the pièce de résistance, the “face-off.” As mankind continues to sashay the so-called high ground, the noble cause received a jumpstart in Lyon, France at the bite of a dog. Dirty work was done to a face, and the men in white tried to “one-up” all the king’s horses and all the king’s men. The lower part of the nose, the lips, and the chin of a torn visage were transplanted, as the world watched in awe. Now China and the U.S. want to hop on the bandwagon, and their target is the entire face. But are we ready for this? Is the technology up to speed for such a complex endeavor? Does the end, indeed, justify the extremely exorbitant means? You be the judge. It becomes much easier for me to present the simple facts.

      A complete facial transplant would require ten or more surgeons, take 14-20 hours to complete, mandate a donor with a compatible blood group and matching sex, race, and age, and necessitate sufficiently large areas (1200 cm²) of skin, via autologous skin grafts from the same patient, to cover the entire face, scalp, front of the neck, and ears, should the transplant fail or be rejected. Add an additional $12,000-$24,000 price tag for immunosuppressive drugs to follow an already expensive procedure and prevent rejection, and the almighty healthcare dollar might be stretched to limits paralleling those reached by the rack in a medieval torture chamber. With so many pros and cons at issue, calmer minds must prevail, and we, the public, must weigh and pronounce, with a foot to the gas while finger rides ignition.

      To start out with, the operation itself is very difficult technically, not to mention the fact that nerves grow and heal slowly, limiting assessment of sensory and motor function of the transplant to nine months or longer post- procedure. Furthermore, rejection is always an unwelcome visitor lurking in the wings, more than willing to come a knocking at a moment’s notice. Enter the necessity for frequent medical monitoring and immunosuppressants for life, which would hardly curb the estimated 10 percent rejection rate in the first year and 30-50 percent rate during the first two to five years.

      So, is it all worth it? Skin and subcutaneous tissue, though not underlying muscle, would be transplanted, and major blood vessels in the neck would be called upon to connect the recipient’s circulation to the newly placed graft. The recipient’s own facial muscles would be enlisted to animate the transplant, restore facial mobility, and allow _expression. That’s it in a nutshell, and in theory.

      While cosmetic lips and ears, in the absence of facial function, are fine for a Halloween gathering or in the recesses of subterranean Paris, they would hardly constitute success in the light of day. With bugs to iron out and questions lingering, all bets are off right now. Doubts remain regarding adequate blood supply to the graft and connection of the patient’s facial muscles to the transplanted face. If a mask is all you are to end up with, then why go it at all. Even the limited French procedure, while quite impressive in the short term, has yielded deluding results in the weeks thereafter, with marked drooping and paralysis of the patient’s lower lip.

      The eventual transplant recipient and family will have to get used to a new hybrid face, combining aspects of both the donor and the recipient. All the exhaustive, preoperative, psychological testing in the world will not prepare for those first few seconds, when the bandages are cut and a new being is hatched. The only thing more traumatic for patient and family might be abortion of the procedure. Once the medical risks, uncertainty of success, and media scrutiny have been digested by the immediately involved, hinging all hopes on an evanescent and uncertain, brain-dead donor, free of cancer and various infections, hooked up to a ventilator, and meeting other stringent requirements, might be hard to stomach and, excuse the pun, to face. The pool of potential donors is small, and one can only imagine the difficulties inherent in obtaining consent for a facial transplant.

` Perhaps the final decisions regarding these new and provocative, surgical procedures should be left to the severely disfigured, for they are the ones who stand the most to gain or lose. You will not see them in a neighborhood mall or in a local grocery store. Their legions populate the corridors where The Phantom lives!

© 2006, Albert M. Balesh, M.D. All rights reserved.

Placebo Domingo 3-25-06

      Can a glass of water cure? Can the power of suggestion be used to stop the human body’s inner demons dead in their tracks? Pondering these matters on a peaceful Sunday afternoon makes for an uncomfortable work week to follow. Yet we had better hope that researchers are every bit as curious as ourselves, for their answers may one day provide the key to a defensive arsenal that we never dreamed each and every one of us possesses.

      Placebo therapy, unlike an aging tenor’s vocal cords, is just not going away. Its original praises were first sung back in 1955, when a groundbreaking scientific paper reported a 32% response rate of patients to placebos. Nothing has changed in the last half century, with clearly one-third of patients responding positively to therapeutic measures geared more toward their expectations than to proven physical alterations.

      Thoughts and beliefs are extremely powerful healers. They not only affect our psychological states, but also cause our bodies to undergo actual biological changes. VIVA the placebos! They have been employed with some success in medical conditions ranging from arthritis and enlarged prostates to multiple sclerosis and psychiatric disease. Placebo controls and sham surgeries have been performed in an attempt to gauge the effectiveness of experimental surgical procedures for Parkinson’s disease. In those studies, the efficacy of implanted fetal pig cells for Parkinson’s was compared to simple burr holes drilled into patients’ skulls in the absence of subsequent cell implantation.

      Like a heavy downpour on a Sunday holiday, however, placebos and placebo-controlled studies can reveal themselves to be much more than an inconvenience for a number of reasons. Before the sky clears, side effects, commonly known as the “nocebo” effect, may strike. Furthermore, in oncology, placebo-controlled studies, in which one group is administered an experimental anticancer drug and the other a placebo, are constantly debated and often unacceptable because of the risk they pose to the latter group by treatment delays. How would you like to be the one running those risks!

      Opposition to the use of placebo pills in medical practice, while in a constant state of flux, has a hardcore base. There are those who decry the deceit, inherent in the use of placebos, and the undermining of the sacrosanct trust between patient and physician. Others take a more legalistic approach, asking where it is all going to end. If placebos were to become the status quo in many cases, then how would we discourage and prevent vineyards from bottling “placebo” vintages, museum curators from displaying masterpiece look-alikes, journalists from sanitizing the news, and congressmen from enacting extralegal activist bills? The slippery slope to chaos would gain momentum on soles made of placebo.

      Now, while there are circumstances in which benevolent deception may be warranted, for example, in cases involving patient insistence on medications that are unnecessary and risky, as often occurs on oncology wards, those same patients feel betrayed upon hearing that they were given a placebo. So, it appears that while we cannot live with placebos, we can certainly live without them.

      The essential questions still remain. Do placebos really work, and, if so, how so? Though definitive answers are not yet forthcoming, shades of gray are slowly but surely veering toward the opposite end of the color spectrum. We know that an inherent human potential to react positively to a healer exists, and that a patient’s stress can be reduced by doing something which might not be medically effective. That, coupled with the knowledge that stress can often trigger negative physiological reactions, has led many a “closet Einstein” to the simple placebic conclusion: cure the mind, cure the body. The proof is in your Sunday porridge. The symptoms of an enlarged prostate, for example, can be relieved by placebo tablets which, via a patient’s positive expectations of their benefits, can relax smooth muscle and subsequently increase urine flow by decreasing nerve activity affecting the bladder, prostate, and urethra.

      As aging opera divas grow hoarse and our placid day of rest comes to a halt, perhaps we can count on an inert elixir to stretch vocal cords and erase those Monday blues.

© 2006, Albert M. Balesh, M.D. All rights reserved

The Natural First Aid Kit

Terminator versus Defibrillator 1-29-05

      There is a battle being waged against an enemy whose ranks continue to swell. He has been with us for quite some time, and, although we fully expected to see a retreat due to our vast arms’ superiority, his legions continue to muster on the horizon. His all-volunteer army targets “everyday Joe’s and Joanne’s,” whose body armor will not protect a corps ravaged by obesity, high cholesterol, elevated low-density lipoproteins (LDL), essential hypertension, diabetes, atherosclerosis, and coronary artery disease.

      Our last stand is imminent, and no prisoners will be taken in the ultimate sacrifice to our vanity and disbelief. We were warned of the “Terminator’s” coming, and, yet, we chose to live the “good life” and forget that the inevitable was already on hand.

      Now, only one thing stands in the way of our immediate demise. A secret weapon! Research and development has provided us with a fully affordable system that can even the score, and reduce the commissions of real estate agents dealing in cemetery properties. The “Defibrillator” is here, and perhaps we have a chance, after all.

      Heart failure, our worthy but utterly ruthless foe, represents a major public health problem in all industrialized nations. Dress a developing world’s population in the trappings and vestments of the modern world, and it, too, will find itself naked to the onslaught. Each year in the United States alone, heart failure infiltrates our unsuspecting, elderly troops, to the tune of almost 1 million hospital admissions and 50,000 deaths. Its incidence and prevalence is on the rise, and they are likely to increase still further as our population ages. So, let the “baby boomers” beware! No solace can be taken in a contemporary “Lili Marlene,” “Radio Free Europe,” or “Radio Saigon.”

      The current battle plan and medical logistics are particularly important to me, as my father was a victim of the “Terminator” on March 30, 2004. As he lay in my arms at home, and I observed first hand his rapid breathing and heart rate, wheezing and gagging, pale color of his skin, and, finally, dilated pupils and respiratory and cardiac arrest, all in a matter of minutes, I knew I was in trouble. Years of medical experience vanished at that sight, and I felt totally impotent at that moment. They say that hearing and touch are the last things to go, when someone dies. As his muscles became flaccid, I jumped into action. It was a losing battle, however, as I had neither the drugs nor instrumentation for advanced life support, as my basic life support (CPR) technique was rusty, as I knew that it would take more than six minutes for the paramedics to arrive, and as I was fully aware of the fact that even if I succeeded in resuscitating my father at home, the current medical literature suggested that there was a 75% chance that he would not make it anyway. If I had only possessed an automatic external defibrillator (AED) yesterday, I might not feel so much guilt today. “Defibrillator” might not have evened the score, but it would have leveled the playing field.

      Sudden cardiac arrest kills an average of 930 people every day, and, while CPR (two lung inflations for every 15 chest compressions, and a rate of 100 compressions per minute) is an essential stopgap measure until the paramedics arrive, it usually takes longer than we would hope and pray. Severe cardiac arrhythmia or arrest without CPR within the first 4 to 6 minutes has a poor outcome even if defibrillation is later successful. The “Terminator” will inevitably triumph, when life support is not instituted within the first 8 minutes of arrest or ventricular fibrillation. Once anoxic encephalopathy (brain damage from lack of oxygen, or hypoxia) sets in, the point is mute. The patient will never be the same, and the “Good Samaritan” or family member will curse both the day he or she was born and the so-called “successful” resuscitative effort.

      On September 16, 2004, the U.S. Food and Drug Administration (FDA) agreed for the first time to allow consumers to purchase AEDs, like the Philips HeartStart Home Defibrillator for $1,495, online at amazon.com, for example. It does not take a lot of know-how to use a home defibrillator, but speed and easy access to it are of the essence. “Defibrillator” must act within 5 minutes of the skirmish, in order to vanquish the “Terminator.” Shocking the heart back to some semblance of normality within that limited and precise timeframe can quadruple the chances of survival. Had “Defibrillator” been available to me on March 30, 2004, I would not feel so much guilt right now. The memories of my poor father’s demise and his ghost will haunt me forever, but the brand new portable AED in the trunk of my car will stop the “Terminator” in his tracks the next time he decides to pay a friend, family member, or innocent pedestrian a visit. That will be my “shock and awe!”

© 2005, Albert M. Balesh, M.D. All rights reserved.

In memoriam, Chiffie J. Balesh, July 18, 1911 – March 30, 2004. 

Hocus-pocus Meningococcus 1-1-05

      Life is beautiful for young people in their primes, with everything to live for. Then, “hocus-pocus,” sudden headaches, fever, malaise, confusion, eye discomfort to light, and a literal pain in the neck, and all that changes. Hearing loss, neurologic deficits, and the ultimate “disappearing act” leave no doubt that this was black magic.

      From schoolyards to college campuses, masters of deception levitate in the air, infiltrate large groups of people, and finally decimate central nervous systems with sleight of hand. Bacteria, mycobacteria, fungi, spirochetes, protozoa, helminths, and viruses are their names, but on their marquees is emblazoned a simple, “MENINGITIS.” As beguiling as Houdini, they often seek instant gratification, presenting acutely to a virtually limitless audience within hours to 1-2 days after the appearance of nonspecific cold or flu symptoms. On a whim, they may prolong their tours, performing less frequently, with hiatuses of weeks to months of general symptoms. Let there be no mistake, however, what they are selling is not pure entertainment, but medical emergency.

      Their youngest fans are 3 months old and lie in cribs. Their oldest lie in nursing homes, and no one inbetween is immune to their charms. With enigma as a tool of their trade, they often go undiagnosed until the final act. One-third of meningitis cases, in fact, go undetected despite careful laboratory evaluation.

      In order to banish our infectious friends in a “puff of smoke,” we must first understand what we are up against. It is common knowledge that meningitis is an infection and inflammation of the membranes, which are called meninges, and cerebrospinal fluid (CSF) surrounding the brain and spinal cord. With the advent of current vaccines, there has been a shift in preferred “live targets,” from children younger than 5 years old to the 15-24-year-old age group and older adults. Audiences, too, have indeed become “captive,” with 700 Americans dying of meningitis each year.

      Viral meningitis, also called aseptic meningitis, usually results from the spread of enteroviruses through direct contact with respiratory secretions (e.g., saliva, sputum, or nasal mucus) of an infected person. It causes signs and symptoms for 10 days, followed by resolution on its own. Supportive intervention is all that is needed, and the cause may never actually be found. Have you ever asked a magician where the rabbit he has pulled out of his hat comes from?

      Bacterial meningitis, on the other hand, is the stuff of sorcerers, Wiccans, and wizards. It is much more serious than viral meningitis, and the curtain goes up when infection in another area of the body threads blood vessels and a path to the meninges. Signs and symptoms are varied, but, with over 50,000 hospitalizations in the U.S. each year due to some form of meningitis and its nefarious bag of tricks, it pays to be vigilant. In addition to the common manifestations of the malady listed above, others include neck stiffness, vomiting, seizures, lethargy, delirium, and focal neurologic signs, the latter particularly alarming and requiring a computed tomography (CT) scan to rule out cerebral edema.

      Timely diagnosis relies on the thrust of a magic wand, commonly known as a lumbar puncture needle, between lumbar vertebrae L₄ and L₅ for collection of cerebrospinal fluid (CSF). Analysis of the opening pressure, color, culture, number of red and white blood cells, glucose, and proteins of that ethereal nectar is confirmatory to both the diagnosis of the disease itself and its etiologic agent.

      That leaves only the esoteric pièce de résistance to put an end to the harbingers of meningitis before they put an end to us. If meningitis is not eliminated immediately, presto chango, permanent neurologic sequelae, hearing loss among others, will inevitably result. Antibiotic therapy, for a minimum of 7 days and a maximum 3-4 weeks, depending on the bacterial agent involved, is the name of the game. With a clear and proactive focus, there is no need for hocus-pocus.

© 2005, Albert M. Balesh, M.D. All rights reserved. 

AVERAGE AGES AT WHICH DEVELOPMENTAL MILESTONES ARE ACHIEVED

1. While prone, lifts head up 90°    3-4 mo
2. Rolls front to back      4-5 mo
3. Sits with no support      7 mo
4. Voluntary grasp (no release)     5 mo
5. Voluntary grasp with voluntary release   10 mo
6. Plays pat-a-cake       9-10 mo
7. Can build a tower of 2 cubes     13-15 mo
8. Can build a tower of 6 cubes     2 yr
9. Good use of cup and spoon     15-18 mo
10. Understands 1-step commands (no gesture)  15 mo
11. Separation anxiety      12-15 mo
12. First words       9-12 mo
13. Imitates others’ sounds     9-12 mo
14. Cooing        2-4 mo
15. Ties shoelaces       5 yr
16. Waves “bye-bye”      10 mo
17. Social smile       1-2 mo
18. Runs well       2 yr
19. Walks without help      13 mo
20. Pulls to stand       9 mo
21. Stranger anxiety      6-9 mo

Reduce the age of premature infants in the first 2 years for assessing development. For example, for children born after 6 months’ gestation, subtract 3 months from their chronologic age. Therefore, they should be expected to perform only at the 6-month-old level when they are 9 months old.

Supercalafragilistichemochromatosis

      “. . . . . . . Even though the sound of it is something quite atrocious, occurring in the virile sex it is more precocious, supercalafragilistichemochromatosis.” In this, the Hemochromatosis Screening Awareness Month, that little ditty seems all the more apropos. I can assure you, however, that for 0.5 percent, or one million plus, of the U.S. population, it is no laughing matter. Even the treatment of hemochromatosis would make Bram Stoker’s Count Dracula proud, as phlebotomy (bloodletting), to reduce and maintain body iron at normal or near-normal levels, is the treatment of choice.

      But let’s not put the cart before the horse. Hemochromatosis, like any other hematologic disorder, must be affronted in an orderly, systematic manner. It is currently the most common cause of iron overload in the United States, with as much as 10 percent of the population heterozygous for this condition, and subject to a 25 percent risk of developing minor, apparently harmless increases in body iron stores. For the 0.5 percent of the population homozygous for hemochromatosis, the genetic defect results in an abnormality in the control of iron absorption that causes an inappropriate increase in iron uptake and a progressive buildup of body iron.

      And if that were not bad enough . . . . . . ., the iron accumulates as hemosiderin in liver prenchymal cells (hepatocytes), and subsequently in the pancreas, heart, adrenal glands, testes, pituitary gland, and kidneys, leading eventually to hepatic, pancreatic, and cardiac dysfunction and insufficiency and hypogonadism. Women, take heart, however (and please excuse the pun), as the disease usually occurs in males and is rarely recognized before the fifth decade. Ten to twenty years postmenopause is the time-frame for targeted women.

      Now, let’s get down to the nitty-gritty, and some of the “gorier” aspects of hemochromatosis. The classic tetrad of clinical signs is hepatomegaly and liver disease, diabetes mellitus, skin pigmentation (combination of slate gray due to iron and brown due to melanin, sometimes resulting in bronze color), and gonadal failure (impotence). Cardiac failure develops in about 10 to 15 percent of untreated patients, with arthropathy and bleeding esophageal varices bringing up the rear. Furthermore, in patients who develop cirrhosis due to hemochromatosis, there is a 15 to 20 percent incidence of hepatocellular carcinoma. So, the picture isn’t pretty!

      Body iron stores have usually increased from the normal amount of 1 gram or less to 15 to 20 grams or more by the time symptoms of organ damage appear. Environmental factors, including dietary iron content and alcohol use, as well as the coexistence of other hereditary hematologic disorders, may also greatly influence the rate and severity of organ damage.

      So, how do we screen for this polymorphic intruder, who bides its time and lies in wait at our very doorsteps, ready to spring when the genetic equinox is favorable? Screening, after all, is the point of this article.

      Needless to say, a high degree of clinical suspicion must be maintained in patients with a family history of hemochromatosis or otherwise unexplained mild liver test abnormalities. For screening purposes, liver function tests (including enzyme assays) and measurements of the plasma iron, transferrin (iron-carrier protein) saturation, and plasma ferritin (storage form of iron) provide the best indirect means of screening. If any of these measurements is abnormal, further evaluation is indicated. Computed tomography (CT) and magnetic resonance imaging (MRI), however, are not sensitive enough for screening asymptomatic persons. Liver biopsy, on the other hand, which characteristically shows extensive iron deposition in hepatocytes and usually in bile ducts, vessel walls, and supporting structures, permits a definitive diagnosis. Further confirmation derives from determination of the hepatic iron index on a liver biopsy specimen (hepatic iron content per gram of liver converted to micromoles and divided by the patient’s age). A hepatic iron index greater than 1.9 suggests hemochromatosis.

      However the diagnosis of hemochromatosis is established, screening of family members at risk for the disease is obligatory. Screening should include not only siblings, but also parents and children because of the possibility of homozygous-heterozygous matings.

      Which brings us now to the matter of treatment, both in the cirrhotic patient and, more importantly, in the precirrhotic phase of hemochromatosis. Weekly phlebotomies of 500 milliliters of blood (about 250 milligrams of iron), continued for up to 2 to 3 years, achieve depletion of iron stores. When that is achieved, maintenance phlebotomies (every 2 to 4 months) are continued. Now, although the chelating (binding) agent, deferoxamine, administered intramuscularly, has been shown to produce urinary excretion of 5 to 18 grams of iron per year (comparing favorably with the rate of 10 to 20 grams of iron removed annually by weekly or biweekly phlebotomies), the treatment is painful and requires a constant infusion pump. Furthermore, active treatment of the complications of hemochromatosis - arthropathy, diabetes mellitus, heart disease, portal hypertension, and hypopituitarism - may be necessary. A multifaceted approach is the name of the game. 

      So, what is the “silver lining,” if, indeed, there is one? In precirrhotic patients, phlebotomy therapy can prevent the onset of cirrhosis, while at the same time reducing cardiac conduction defects and lowering insulin requirements. In patients with cirrhosis, bleeding esophageal varices may be reversed, but, unfortunately, the risk of hepatocellular carcinoma still lurks in the shadows.

      Vigilance and aggressive therapy are the only options available to turn down the volume on our “Supercalafragilistichemochromatosis.”

© 2003, Albert M. Balesh, M.D. All rights reserved. 

 Eye-atollah

      Like a desert sheik stealing through the night in search of a fertile bed, a welcome crumb, and a drop to quench his thirst, cataracts stealthily infiltrate the tranquility of our aging population. But where do they come from, and what is their grand design?

      Simply put, a cataract is nothing more than a painless, cloudy area in the lens of the eye, which blocks the passage of light from the lens to the nerve layer of the retina. Unlike a sultan’s harem, which at the least has vigilant, muscularly well-endowed eunuchs to halt the march of an unholy infidel, the retina is defenseless to the onslaught. In fact, some cataracts grow larger or denser over time, causing severe vision changes leading to blindness, glaucoma, or a loss of independence in older adults.

      While aging, ultraviolet radiation from sunlight, eye injury, poorly controlled diabetes mellitus, glaucoma, steroid medications, and frequent radiation treatments of the head all contribute to the clouding effect of cataracts, some degree of lens opacity is expected in everyone over the age of 70.

      Risk factors for cataracts are as multivariegated as the colors of a Persian rug, and some of them can literally represent straws to break a camel’s back. There are those, for example, that one cannot change, such as age 65-74, Native American and African American race, female sex, and family history. Others, like life-long, chronic diseases (diabetes, glaucoma, and high blood pressure), when kept in check, can be temporarily thwarted in the inexorable march toward cataract. Still other risk factors, for example chickenpox during pregnancy, smoking, exposure to ultraviolet light, long-term use of steroid medications, and even alcohol, should not be underestimated.

      So, when does cataract warrant the same concern demonstrated by the head of a clan, unable to find a suitable husband for the eldest of his eight daughters? Severe eye pain, sudden change in vision or eyeglass prescription, and blurred or double vision all mandate recourse to the healing arts. Surgery becomes necessary when vision loss caused by a cataract affects the patient’s quality of life. Until then, not smoking, wearing sunglasses in the sun, eating a diet rich in vitamins C and E, limiting alcohol intake, avoiding steroid medications, keeping high blood pressure and diabetes under control, taking estrogen for menopause, and using mydriatic eyedrops to dilate the pupil do as much to prevent or postpone surgery, as a “toke” on a water pipe and a good cup of Turkish coffee do to make a reluctant suitor more malleable to the manipulative whims of a prospective father-in-law.

      When standard extracapsular surgery, in which the lens and its anterior membrane are removed, or extracapsular surgery using phacoemulsification, in which sound waves are used to break the lens up into small pieces, becomes necessary, subsequent placement in the eye of a new intraocular lens will usually guarantee most adults 20/40 vision or better within 3 weeks to 2 months after surgery.

      It therefore goes without saying that, dollar for dollar, an ounce of prevention and informed consent do far more than smart bombs and cruise missiles to halt unwanted incursions of the “Eye-atollah.” Remember, cataracts are no fun, and belly dances are performed at night!

© 2003, Albert M. Balesh, M.D. All rights reserved.

Elder-bury Whine

      “Crabbing,” complaining, aches, pains, groans! All constant companions of a dear friend called “Old Age.” When you’re up, he brings you down. Our bodies are both friends and traitors, to be taken for granted in health and then turning their backs on us when we need them most. Can we do something about this, or should we drown ourselves in Tylenol, Celebrex, Kaopectate, and stool softeners?

      Over the next 3 decades, the number of individuals over 65 years old will almost double, going from 29 million to over 51 million in the year 2020. This group will represent 17% of the total population. Currently, over 21% of all first admissions to state and county mental health facilities in the U.S. are over 65 years old. Furthermore, depression is particularly prominent in the geriatric population, with those over 65 committing suicide at a rate higher than any other group in the U.S.

      Medicine cabinets crammed full of a vast assortment of multicolored elixirs and “bonbons,” upon which we rest our hopes for the future, are the envy of every “kid in the candy store.” Exercise and healthy diet, too, have ceded the sidewalk to “pushers” in three-piece suits, who hawk their wares to the tune of b