richardulrich.com

Almost all of us know some older person who has had the “wet” (bleeding or oozing) type of age-related macular degeneration.   Generally, the treatment that restores some vision best, is by injecting various medicines into the eye.  Typically,  this would be (trade-marked)  Lucentis or Avastin shots directly into the eye with a small needle.    One scheme of treatments is to give three shots a month apart and then more as needed to stabilize or improve the vision.  This reduces the monthly shots for one to two years which is very taxing for all involved.   One study from Philadelphia at Wills Eye Institute concluded that average vision would improve from about 20/200 to 20/100 after seven shots in twelve months at a direct cost of about $6,000*.  (This  20/100 vision is not good enough for a driver’s license if it’s the better eye.)

Often, the worst eye is being treated first, so the other eye is still functional for several years.  Reportedly, there is about a 10% chance per year of the second eye being involved the same way.  Since 20/100 is still not good enough to drive or read very well with the affected eye, one option is to spend about $2500  on an electronic reader once the second eye is beyond reasonable help,  skip the shots, and stay home.  I have a number of patients who choose this rather than undertaking the burden of frequent trips, frequent shots,  expenses and anxieties associated with them.

Of course,  when the second eye is newly involved, or if someone has vision that can improve from “no-driving” to “driving-permitted,” the treatment and shots are worth considering. This would be the case where the affected eye still  had vision in the 20/100 range (rather than 20/200).  Of course, there are great individual, unpredictable variations.

Years ago,  I had a family member who thought that the best electronic reader was made by Optelec (www.optelec.com), so that’s the brand I keep in the office to show patients.  It would seem in this age of electronics there would be a less expensive option, but I demonstrate what worked.  Hand held illuminated devices  help with prices in stores, the thermostat, etc. but are laborious for much reading.  [I had one patient recommend the PowerMag 6.5x/ 22 diopter unit.]   In my experience, other low-vision magnifiers just don’t work out very well.    Generally, insurance does not cover magnifying aids.

There are many resources dealing with macular degeneration, and it’s worth-while getting some perspective from them.  Generally, dry forms of the disease don’t respond to anything available just yet.  Great research efforts are underway to change that.  Also, it seems that there is about a 10% familial risk so that if a parent has macular degeneration, there is about a 10% risk of biological children getting the disease in their old-age.

While treatment may not help as much as we like, as far as I know,  there isn’t any risk that trying to use the eyes makes the disease worse (like reading or straining or dim light).   Oddly enough, most folks with macular degeneration are very light sensitive, though they need plenty of light to see.   It’s a good idea to use ultra-violet blocking sunglasses in direct sunlight, but it would probably take a year or two of exposure to make any difference.  I think smoking increases the risk of getting or making  macular degeneration worse.

Again, this advice is not to replace professional examination and advice (like you would get in my office or elsewhere).  It is aimed at giving you some perspective, to be considered at your own risk and for your own benefit.    R A Ulrich, MD  (ophthalmologist)

*From the Annual Meeting Report of ARVO (The Association for Research in Vision and Ophthalmology, Inc) cited in Review Of Ophthalmology, May 2010, p 38.

From the Journal of American Medical Association (April 28, 2010 — p 1603),  extra folic acid (2.5 mg), Vitamin B6 (pyridoxine 25/mg), and vitamin B12 (1 mg or 1000 micrograms) per day for diabetic neuropathy doubled the combined risk of heart attacks, strokes, need for coronary surgery, and death. It caused kidney and circulatory damage.  This was a 3 year study. It did  lower the plasma level of homocysteine — but that didn’t have the expected outcome.

So, if you are a fan of Vitamin B — recheck your thinking.     R A Ulrich, MD

Now that Mr. Obama has signed the Health Care bill of 2010, how does that settle into our minds?

My sense is that  reality is a tough parent, and not necessarily a loving one.  I think there will be enough money-lovers to water this down.  The insurance companies that suddenly have to cover dependents to age 26 are going to be sending some premium hikes to a lot of taxpayers.  Some companies and medical facilities are likely to shut down.  Today’s Macon Telegraph featured an interview with the director of the Macon Volunteer  (Medical) Clinic.** The director agreed it would be nice if everyone could be cared for, but didn’t offer an opinion that it would work out that way.   I told Angelia that there is a big difference between the ideal and reality.  I remember my brother,  Wes’,  20-year experience in Jordan where there is “free care,” but lots of folks still came to the Mafraq clinic (presumably because the folks there cared for them more than just another patient).   We’ll see.

Here’s what the WSJ* says about prospects for repeal:

“Many Republicans are already calling for ‘repeal’ of ObamaCare, and that’s fine with us, though they should also be honest with voters about the prospects. The GOP can’t repeal anything as long as Mr. Obama is President, even if they take back Congress in November. That will take two large electoral victories in a row. What they can do now is take credit for fighting on principle, hold Democrats accountable for their votes and the consequences, and pledge if elected in November to stop cold Mr. Obama’s march to ever-larger government.”

* http://online.wsj.com/article/SB10001424052748704117304575138071192342664.html

**http://www.macon.com/2010/03/23/1069239/midstate-in-wait-and-see-mode.html

Over the years, my brother,  Dr. Wesley D. Ulrich, MD,   has received some rave reports with regard to this migraine treatment.  Some cases of chronic  migraines plaguing patients for over 20 years have been resolved in this manner.  In a study he conducted years ago, 80% of all comers (who were told by their doctor they vascular headaches) got 50% relief.  He found that 5% were non-responders, and there were no known adverse effects. It is advisable to monitor blood pressure if one feels uncomfortable.

A 2006 Audio-Digest Internal Medicine reminds us that  migraine sufferers often do better with regular meals since a delayed meal may lead to a drop in blood sugar which triggers the migraine center.

Again,  this advice is to be used at your own discretion, for your own benefit, and at your own risk.

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INFORMATION FOR PATIENTS WITH MIGRAINE HEADACHES

Patients with vascular headaches in general and migraine headaches in particular often are made worse by heat exposure especially on their backs. The phenomenon was noted by Frederick Erdman early in the 1900’s. He found that the majority of men and women who suffer from migraine can be helped by gently and intermittently cooling the paraspinal area until the pulses in the wrists improved appropriately. Even though the proper technique of pulse analysis is difficult to learn and its significance is not yet understood many patients can still benefit from a judicious change in life style and by gentle therapeutic cooling of the back. Apparently this cooling stimulates a redistribution of blood throughout the body so that blood stagnating in the abdominal (splanchnic) circulation is free to circulate in the peripheries and particularly to the brain. This improvement in flow may prevent the arterial spasm in the vessels of the neck which trigger migraine headaches.

GENERAL INTRUCTIONS

Avoid getting your back over heated. This does not mean that you expose it to excessive cold either. Dress comfortably but also:

1)  avoid hot showers and baths; use warm, not hot, water.

2)  avoid long hot car drives; use an air cushion for your back. And,    if necessary double up the air cushion and put a small freezer pack between the two layers about the level of the belt line to keep the middle of your back cool.

3)  sleep on your side; avoid hot covers. A hot water bottle for your feet is acceptable but not on your back. Heating pads are notorious for over heating ones back while asleep.

4)  avoid vinyl covered chairs or sit sideways on them since they prevent the natural cooling.

5)  develop an awareness of overheating your back and simply do what is necessary to avoid it.

SPECIFIC INSTRUCTIONS

Remember that headaches are sometimes a serious medical sign. Anyone with a new or severe headache especially one associated with numbness or paralysis of any kind should promptly seek medical attention, Help-yourself remedies should not be applied to -these headaches.

Witch hazel is used as a cooling agent because it provides a greater cooling stimulus than water; it evaporates faster, is not irritating usually even when used a lot; and it is not as cold as ice which is too severe a stimulus for most persons.

Apply as directed from base of neck to the crease between your hips directly over the spinal column:

• 10 times (with about one minute between applications to allow for evaporation) morning, noon, and evening. Or, 15 times morning and evening for the first week, then . . . .
• 10 times morning and evening during the second week, then ,..
• 10 times morning OR evening for the third week, then evaluate progress.

If you are tolerating the cold and continuing to get better continue using 10 or 15 applications a day until reaching a plateau and then use 2 or 3 daily as necessary just to keep “in tune.” Many people need nothing more at that point unless some stress occurs at which point they may need to re-initiate the program.

A few persons will only need a few cold applications to obtain relief; most, however, will need two or three hundred applications; a few will need even more.

IF YOUR BLOOD PRESSURE RISES EXCESSIVELY (to more than 160/100) OR IF THE TREATMENT PRECIPITATES A HEADACHE DO NOT CONTINUE USING COLD.

-       Revised instructions from 1988 as adapted by Dr. Wesley D. Ulrich, MD : for use at your own risk,  and for your own benefit.      [Richard A. Ulrich, MD   Mar 2010]

[These are my private medical opinions  based on the literature I am familiar with (to be followed at your own risk, and for your own benefit)]

R A Ulrich, MD

This week,  former President Clinton had chest pain, followed by angioplasty and two coronary artery stent placements.  What are the chances that he will live longer for it?  In my opinion, his life expectancy won’t change much.   (With pain at rest, it most likely is the unstable anginal variant listed below.)

Here are some articles which indicate that the likelihood of prolonging life with such procedures is something like one in a hundred for stable chest pain with exertion.  It is about one in fifty for pain that occurs in an unpredictable manner (unstable angina).  And for patients in more critical condition, with three-vessel disease or reduced cardiac efficiency, there was little difference.  On top of this, the dye studies may cause acute kidney injury; and placement of a stent requires blood thinning with Plavix that may greatly complicate other surgery later.

Basically, surgery is for symptoms — it often reduces symptoms of breathlessness or chest pain.  Many patients feel better, but many do not.  Nonetheless, if you think it will give you a few years more life, think again.  You shouldn’t have to feel guilty for sticking with medicines.  This same conclusion is repeated in the August 2009 issue of Mayo Clinical Proceedings (2009; 84, 741-757). Incidentally,  this article says that  vitamin D and omega-3s do help prevent cardiovascular disease.  And, you might be wise to be sure your kidney function is up to par before having angiography (cardiac catheterization).

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In the New England Journal of Medicine,   Mar 26, 2007,  citing the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE, NCT00007657 [ClinicalTrials.gov] ) trial, is a report that for a large population with stable coronary artery disease, the 4.6-year cumulative rates of myocardial infarction and death were 19.0% in patients who underwent PCI (percutaneous coronary intervention) in addition to receiving optimal medical therapy (PCI group) and 18.5% in those who received medical therapy alone (medical-therapy group); the rates of death were approximately 8% in both study groups.

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Revascularization for patients with unstable angina using an invasive versus a conservative approach  during instability in coronary artery disease [FRISC II]).

The cost-benefit ratio of an initial invasive approach based on the FRISC II trial has been estimated. At the cost of 15 extra coronary artery bypass graft and 21 percutaneous coronary intervention procedures, the benefit per 100 patients per year is as follows:

• 1.7 lives saved
• 2 myocardial infarctions prevented
• 20 readmissions prevented
• Earlier and better symptom relief

[http://emedicine.medscape.com/article/159383-treatment]

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Unstable angina: by-pass surgery for three vessel disease or moderate ejection fraction reduced mortality.

No more patients with unstable angina who had bypass surgery compared with medical therapy, lived longer or had fewer hospital admissions. The effect on non-fatal MI [heart attack] was unclear.

1. Fewer high risk patients (three vessel disease or ejection fraction <58%) died with surgery (NNT = 9 at 8 years) .
2. More low risk patients (one or two vessel disease or ejection fraction 58% or more) died with surgery (NNH = 6 at 8 years) .

From    http://www.eboncall.org/CATs/2172.htm