Carry That Weight

Being too heavy can carry so many health risks.  ThePassionatePharmacist takes a look at being overweight, with a wink of the eye to Madison Avenue.

by Joe Goldstein, R.Ph.

The U.S. National Heart, Lung and Blood Institute (NHLBI) informs us that a normal Body Mass Index (BMI) for adult men and women is between 18.5 and 24.9.  The BMI is a ratio that is calculated using you weight and your height.  If you have a BMI less than 18.5, you are underweight.  A BMI between 25.0 and 29.9 is considered overweight.  People with a BMI of 30 or more are classified as obese.

You can calculate your BMI using a little math.  BMI equals your weight, in pounds, multiplied by 703, divided by your height, in inches, squared.

When I last weighed myself, I tipped the scale at 220 pounds.  I stand 5 feet and 9 inches tall, meaning I shrunk one and three-fourths inches in the past few years.

For me, the formula looks like this:

                   220 x 703 /69 x 69,  or   154,660 / 4761,  or 32.48.  

You may find the BMI Table at the end of this post easier to use.  My BMI is 32.5 (actually 32.48). BMI is further classified as class I, II or III.  Body Mass Index is not the only measure we look at when determining our health risks in relation to body size.  BMI may not be an accurate measure for body-builders; for the elderly and frail; and not for children who are still growing.  We also look at waist circumference.  If your waist circumference (above your hips) is over 40 inches for men, or over 35 inches for women, your risk of diseases increases.  These diseases include diabetes, heart attack, stroke, other cardiovascular disease (CVD), and hypertension (high blood pressure).  Extra weight also puts strain on your muscles, bones and joints.  It can interfere with your sleep.  The chart below shows your risk relative to your BMI and waist circumference.  By reducing your BMI and/or your waist size, you can reduce your disease risk.  Simple?  Yes.  Easy?  HaHaHa!

Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risks

			Disease Risk* Relative to Normal Weight and Waist Circumference
	BMI (kg/m2)	Obesity Class	Men 102 cm (40 in) or less Women 88 cm (35 in) or less	Men > 102 cm (40 in) Women > 88 cm (35 in)
Underweight	< 18.5		–	–
Normal	18.5–24.9		–	–
Overweight	25.0–29.9		Increased	High
Obesity	30.0–34.9	I	High	Very High
	35.0–39.9	II	Very High	Very High
Extreme Obesity	40.0 +	III	Extremely High	Extremely High

* Disease risk for type 2 diabetes, hypertension, and CVD.
+ Increased waist circumference also can be a marker for increased risk, even in persons of normal weight.

 

Losing weight is not easy.  One  would think it shouldn’t be too difficult.  Reduce the amount of food you eat, and watch the types of food.  And exercise.  After all, weight loss should be a simple mathematical formula: calories in greater than calories out equals weight gain.  Conversely, if you burn more calories than you take in, then you should lose weight.  For some bizarre reason, this logic doesn’t always work!

Weight loss is a complex process, with many factors involved.  First, why are overweight people carrying those extra pounds to begin with?  I have been “husky” since I can remember.  In the second grade I weighed 69 pounds, the heaviest child in my class.  It’s likely that I was too heavy because my mother had no sense of proper nutrition.  While she made sure our meals were balanced with protein, carbohydrates, and vegetables, there was no sense of portion control. There was no disciplined eating.  Saturated fats abounded.  Cakes, cookies, ice cream and candies were the desserts.  Sugar-laden drinks were always on the table.  Eating fruits was encouraged, but again without portion control.  As a kid, I easily drank one to two quarts of whole milk every day, and had frequent second helpings of dinner, usually consisting of meat and potatoes.

Ethnic cooking, I believe, also contributed to my unhealthy diet.  Foods were cooked and baked at home, rarely store-bought, and the ingredients always included fats or sugar or both.  Those two ingredients are what make foods taste good.  Even today, prepared foods usually contain sugar or fat to enhance their flavor.

When I married in 1976, I weighed just over 200 pounds.  Keeping my weight relatively stable was a constant challenge.  I was a smoker, and that helped with my weight control.  When I stopped smoking in 1992, my weight shot up, eventually peaking at 262 pounds.  I have no regrets that I stopped smoking, and have been smoke-free since then.  I gained so much weight because I needed something to do with my mouth and my hands.  Shortly after I stopped smoking, food began to taste better, as my taste buds came back to life.  It took a long time for me to change my eating habits, and it’s a work in progress.  A year ago my weight dipped below 200, but several months of inactivity, all my fault, have seen it creep back up.

I mentioned Madison Avenue, because we are all inundated by ads in print, on TV, on the Internet.  Many of these ads that promote a weight loss program  talk of the huge weight loss enjoyed by some of their clients, including celebrities.  They claim to have lost up to 100 pounds by following these programs.  What you may not see is the disclaimer, in fine print, that informs you that these results are not typical, and that your results may vary.  The actress Goldie Hawn observed, in the movie Protocol (1984), that if someone sells you a diamond for ten cents, you’re probably getting something that’s not worth even a dime.  That’s not to say every weight-loss program is worthless.  You just need to be cautious, and know what you’re getting.  Advertisements are designed to get your attention, and some imply that you will have huge successes.  And you might, but dramatic results are not usual.  Are you getting the services of a physician? A nutritionist?  A dietician? A psychologist?  A nurse?  An exercise physiologist? Are you being sold a meal plan? What support are you getting?  The buyer must beware!  I’m not telling you to avoid these groups and companies.  I’m telling you to be cautious and selective, and read the fine print.

Americans want everything as quickly as we can get it.  We want instant gratification.  We do not want to wait.  We want our pounds to fall off.  We want to be slimmer in just days.  Well, it doesn’t work that way.  Weight goes on much easier than it comes off.  Crash diets, starvation, food and water deprivation are all too unhealthy, and can be dangerous.  And “diet pills”, whether by prescription or over the counter, are never the right answer.  A proper combination of healthy diet change, appropriate exercise, professional behavior modification, and lots of support are key in helping to take weight off and keep it off.  And let’s not forget patience.

Proper nutrition is essential.  The U.S. Department of Agriculture (USDA) has developed a nutrition “plate” to help people understand and satisfy their nutritional needs.

ChooseMyPlate.gov is a web site sponsored by the USDA to help steer people toward proper nutrition.  The information is excellent, and filled with very useful information.  But no matter how good or how thorough this, or any web site is, do not begin a weight loss program before consulting with your physician.  This is necessary to make sure your body is ready for changes brought on by diet and exercise.  Follow his or her advice.

Exercise does not have to be rigorous.  Gentle exercises are sufficient, especially when starting out.  It’s generally accepted that in order to realize a cardiovascular benefit, exercise, needs to be sustained for at least 20 minutes.  Well, 20 minutes is a goal you can aspire to after you build your strength and endurance, and lose some more weight.  And just a 5-10% weight loss will significantly improve your cardiovascular health.  Progress is often made in baby steps.  Do too much too soon, and you are sure to fail.

What if you can’t exercise in a traditional sense?  What if you’re wheelchair bound?  Any additional movement or use of your muscles will use up extra calories, and the effect is cumulative.  That means however many calories you use continue to add up.  If you’re limited in what you can do, try, with your doctor’s permission, sitting in a chair and lifting your legs.  Or your arms.  Lift a hardcover book.  Do each for a few repetitions, then stop.  Do it again tomorrow, but increase by one repetition.  After a few weeks you’ll gain strength, and maybe lose some weight.

Ask your doctor about changing your eating habits, and about how you cope with stressful situations.  Resist the temptation to take medication for stress or anxiety.  Try breathing exercises.  Try to visualize something pleasant (your “happy place).  Get a puppy!  Ask for the support of your family, friends, coworkers.  That doesn’t mean they should harass you, or tease you, or shame you.  Guilt is a powerful motivator, but I don’t recommend it.

Don’t worry if you don’t meet your goals, or if you slip up, or go off diet for a day or two.  You’re only human, and you are allowed an occasional mistake.  Having an ice cream cone is okay, as long as it is the exception and not the rule.  Snack on carrots, or celery, two of my favorite snacks.  Mix it up a little, and dip them in hummus, or plain Greek yogurt.  Air-popped popcorn is a good snack, if your doctor clears it (no butter, oil or salt).  And make sure you are drinking enough water.  Not soda, or coffee, or tea.  Just have 8-10 glasses of water every day (check with your doctor).  The other beverages are fine, but they are not a substitute for out-of-the-bottle or from-the-tap clear water.  It fills you, and helps rid the body of toxins wastes, including fats.

Measure your progress regularly, but don’t make any decisions based on what your scale tells you.  Scales can vary, and so can your weight through the day (diurnal changes).  A better indicator is the way your clothes fit.

More than two-thirds of American men and women age 20 and older are overweight or obese.  We are also raising a generation of obese children. The causes include some of the nutritional factors and eating habits already discussed.  Also included are inactivity, use of computers, phones and online games, and television use.  Both adults and children may have diseases that lead to obesity.  Genetics often play a role.  And some medications can cause weight gain in some people.  The first step in losing weight is to admit that a problem exists, and be determined to do what is necessary to try to correct it.  The second step is to see your physician to rule out and underlying medical causes, and identify restrictions.  With your doctor’s help, you can healthily and successfully shed the weight.

 

Body Mass Index Table

To use the table, find the appropriate height in the left-hand column labeled Height. Move across to a given weight (in pounds). The number at the top of the column is the BMI at that height and weight.
Pounds have been rounded off. 

BMI	19	20	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35
Height (inches)	Body Weight (pounds)
58	91	96	100	105	110	115	119	124	129	134	138	143	148	153	158	162	167
59	94	99	104	109	114	119	124	128	133	138	143	148	153	158	163	168	173
60	97	102	107	112	118	123	128	133	138	143	148	153	158	163	168	174	179
61	100	106	111	116	122	127	132	137	143	148	153	158	164	169	174	180	185
62	104	109	115	120	126	131	136	142	147	153	158	164	169	175	180	186	191
63	107	113	118	124	130	135	141	146	152	158	163	169	175	180	186	191	197
64	110	116	122	128	134	140	145	151	157	163	169	174	180	186	192	197	204
65	114	120	126	132	138	144	150	156	162	168	174	180	186	192	198	204	210
66	118	124	130	136	142	148	155	161	167	173	179	186	192	198	204	210	216
67	121	127	134	140	146	153	159	166	172	178	185	191	198	204	211	217	223
68	125	131	138	144	151	158	164	171	177	184	190	197	203	210	216	223	230
69	128	135	142	149	155	162	169	176	182	189	196	203	209	216	223	230	236
70	132	139	146	153	160	167	174	181	188	195	202	209	216	222	229	236	243
71	136	143	150	157	165	172	179	186	193	200	208	215	222	229	236	243	250
72	140	147	154	162	169	177	184	191	199	206	213	221	228	235	242	250	258
73	144	151	159	166	174	182	189	197	204	212	219	227	235	242	250	257	265
74	148	155	163	171	179	186	194	202	210	218	225	233	241	249	256	264	272
75	152	160	168	176	184	192	200	208	216	224	232	240	248	256	264	272	279
76	156	164	172	180	189	197	205	213	221	230	238	246	254	263	271	279	287

Give it Up

Saturday, April 28, is National Drug Take Back Day. A short public service announcement.

by Joe Goldstein, R.Ph.

A couple of times a year the U.S. Drug Enforcement Administration (DEA), a division of the Department of Justice, sponsors a day when anyone can dispose of unwanted, unused, outdated prescription and non-prescription medicine.  No questions asked!  You can find out where the drop-off centers are, usually police and other law enforcement offices in your community, at http://www.dea.gov.  Get rid of your old drugs, especially old pain relievers.  Be part of the solution.

Tell It Like It Is

• 

A letter to a hospital CEO prompts a couple of responses.

by Joe Goldstein, R.Ph.

Reprinted below is a letter I sent to the CEO of an area hospital, with excerpts of the replies I have received.  Neither of the two response letters were from the CEO, but were from a direct report. 

March 14, 2018

 

Dear Mr.

I received a survey this week from —-, and that’s what has prompted this letter, which I’ve wanted to send for quite some time.  I have much to say about the hospital and its people.

First, I have made several trips to — and have spent many days and nights there.  Twenty-eight years ago my youngest child was born there.  I’m no stranger to the hospital.  That being said, let’s share some observations.

Most of the people who work there genuinely care about the patients. I can overlook an occasional request being delayed, or put on the back burner.  The staff is not there to satisfy my whims.  They are there to take care of my needs.  They do that well.  I’m usually very critical of the care I receive.  I have been a registered pharmacist for 42 years, and spent most of that in direct patient care in the community.  I’ve published two books; a third is being formatted, and I’m writing a fourth.  I also manage a healthcare blog.

The people at —- occasionally make mistakes.  They are human.  Incorrect drugs and doses are sometimes passed.  The food service is not always efficient.  But the care is usually more than adequate. — suffers from the same syndrome that plagues all health care: everything is at the will and pleasure of the physician.

You can have the most efficient staff, but a physician arriving late sets the tone for the patient, who believes the clinician is never at fault. I have personally been involved in an hour-long surgical delay because an Irresistible Force met an Immovable Object.  And to be fair, the physician has to care for multiple patients.  As I used to tell my pharmacy patients who wanted their orders NOW: someone is first, and someone is last, and the rest of us are somewhere in the middle.

Are my procedures begun when scheduled? That’s unlikely.  Am I given my meds exactly every six hours?  It would surprise me if it were so.  It’s impossible to anticipate how unexpected circumstances will affect routines and schedules.  Sudden erratic heart rhythms ruin schedules.  Unexpected vomiting can spoil your day, as can incontinence. 

So let me bottom-line it for you. In all these years I have had one major personnel complaint.  I had a radiology technician fail to offer me a lead shield for a couple of x-rays.  I didn’t say anything to the technician, but I did tell my nurse.  I assume this technician was re-educated.

I do have a criticism of the physical plant. Your parking situation is appalling, especially at the Emergency Department.  I have made several trips to the ED for issues with my foot, both acute and chronic.  I have had to park at the bottom of the hill and walk up and down it, in all weather conditions.  I once asked the transport department to bring me to my car at the bottom of the hill, and was refused.  The reason given was that she was not allowed to leave the hospital. 

The triage and treatment rooms in the ED are in sad shape. Look at the floors.  Some have cracked flooring, which is a breeding ground for bacteria.  Treatment rooms may have debris and fluids from previous patients on the floor.  I have found the conditions to be unsightly, unsanitary, and unsafe.

Lastly, I want to comment about the amount of paper generated. Each time I have had any treatment in the ED, I have had papers generated explaining the drugs I have been given—and the drugs I have not been given!  Imagine my horror when I began to read these generic explanations of several drugs that are used in emergency medicine, and knew I had been given one drug listed on the three pages I was handed.  Grab a copy of these pages and read the first couple of paragraphs.  It sounds like the patient received all the drugs listed.  I understand that this is given for compliance purposes, but it should be either better tailored, or have a strong disclaimer.  At the very least, the nurse should give a better explanation on discharge.

But the big issue in hospitals also is at —-: staffing.  Staffing is inadequate.  We all know it.  The vomiting child, or incontinent elder, or the middle-aged man who develops atrial fibrillation are all patients who need extra care, who take nurses and support staff away from other patients who also need care.  There are only so many hours in an 8-hour shift, and the work needs to get done.  Nurses and other staff who are dedicated professionals may seem brusque or uncaring, because they have tasks to perform and deadlines that must be met.  They also would like to have, and deserve, lives outside the hospital.  Staffing, patient ratios—we’ve heard it all.  Everybody talks about the weather, but nobody does anything about it.

I’ve really only scratched the surface here. The hospital faces many challenges, including an indigent population, a multi-cultural population, corporate mandates, and the need for efficiency and profit.  It hasn’t yet reached the point where it impacts patient care—my care.  Please don’t let it.  And I will let you know if it does.  Thanks.

Sincerely,

The first response came just two weeks later, and was essentially an acknowledgement of my letter.  The important part of the one-page response was:

“Please be assured that the comments expressed in your letter are currently being reviewed by the appropriate department directors.  You will receive a written response with the outcome of this investigation and any improvements to be made within 30 days of our receipt of your correspondence.”  It was signed by the Patient Relations Manager of the Quality and Patient Safety Department.  And to her credit, she included full contact information and invited me to share any additional concerns or information with her.

The next letter was dated just a few days later.  This one was a page and a half, from the same representative.  She began by thanking me for my original letter, and said she had shared my positive observations and comments with the department leadership team to remind them that good care is meaningful to patients and their families.  She went on to say that my concerns were shared with various department heads.  The parking situation was brought to the attention of the Senior Director of Facilities and Support Services, as well as the Security Department.  Mine was apparently not a lone voice in the wilderness.  She assured me that Security personnel were now making daily rounds to assure available parking for patients.  This has been an ongoing issue there.

The Director of Facilities and the Nursing Director of Emergency Services are now working to “…schedule more frequent, deep cleanings of the Emergency Department exam rooms.”  Cleanliness is a top priority, she said, and has been somewhat challenging due to high patient volume.  The Nursing Director will be educating her staff on providing a better explanation of the paperwork each patient receives upon discharge, and the documentation will be reviewed to see if the amount of paper can be decreased, and made easier for patients to understand.  I will suggest including a pharmacy team member on that review committee.

I do intend to follow-up these letters with a personal phone call, and perhaps a visit or two to help point things out.  My concerns about the food service were not mentioned, and I will address those soon.  Those issues could have serious negative effects on health.

It’s important to give feedback to healthcare facilities that serve your needs.  This goes for all businesses in which you find genuine opportunities for improvement, or glaring deficiencies.  Please be sure to also tell them about the good things you have seen there.  People who do their jobs well, and who go beyond their basic requirements, deserve to get a pat on the back.  Also, it shows you’re not just a whiner and complainer. 

Don’t be intimidated because these offices and hospitals dispense healthcare.  Cracked floors and unclean surfaces are unacceptable and unsafe in any environment.  Whether they are serving hamburgers or monitoring your heart rate, they should be happy to answer your questions and listen to your observations.  If they don’t, take it the next level, which is to the local municipal, state, or federal governing authorities.  You have to be willing to advocate for yourself.  Unless you’re unable, don’t expect others to do it for you.  If you have difficulty expressing yourself, or are physically incapable of doing so, get someone to help you.  Make your voice heard.  We all deserve, and should demand, medical offices and facilities that are clean; uncompromising, patient-focused care and service; and information that is given clearly, and is understood and explained to our satisfaction.  We should accept nothing less.

 

 

 

 

 

Tell Me, Tell Me, Tell Me.

ThePassionatePharmacist would like to hear from you.

by Joe Goldstein, R.Ph.

For the past seven months I have enjoyed bringing you hard facts, anecdotes, stories, first hand accounts, personal opinions, professional recommendations, and different views of many healthcare topics.  But I am writing what I think you want to read.  I want to make ThePassionatePharmacist better.  I want it to be more educational, more informative, and more entertaining.  But what do you want?  Do you want more statistics?  Do you want it to be less “folksy” (someone described it that way)?  Do you want more or less graphics?  Should I change the font?  Should I use more colors?  Are there topics you would like to see discussed here?  Your input and feedback can help make ThePassionatePharmacist even better.

So tell me what you think.  Leave your comments, criticisms and suggestions.  Shy writing in public?  Send me an email to ThePassionatePharmacist@gmail.com.  I won’t reprint anything without your permission.  I won’t identify you.

If you like ThePassionatePharmacist as is, please tell me. Like me, Follow me, repost and re-Tweet some or all of my posts.  Share them.  Help get the word out to the world.  By the way, ThePassionatePharmacist is now viewed by readers in half the states in the U.S., and in 25 countries on almost every continent.

To my long-term readers: thanks for your loyalty and your enthusiasm, and I really look forward to reading your comments and your suggestions.  For now, I’ll continue to bring you what I feel is the highest quality, accurate, and useful healthcare information. To my newest readers: welcome to ThePassionatePharmacist family.  Relax, take off your shoes, lie back, and enjoy the journey.

It’s the Time of the Season

The first robin, the first crocus, and the first pitch thrown on opening day are all sure signs of approaching Spring, heralding the arrival, for many, of nasal and sinus congestion.

by Joe Goldstein, R.Ph.

Last night I received a phone call from a friend, and made plans to meet with him next week.  In the course of our conversation he mentioned he was suffering from “sinusitis”.  Sinusitis is a generic term that means the spaces in the bones around the nose are inflamed.  The “itis” suffix on the word indicates inflammation.  Don’t confuse this with the ending “itus”, which indicates a condition.  Pruritus, for example, means itching.

My friend Mark told me his sinusitis would soon be gone, when the weather here stabilizes.  Sinusitis may be acute or chronic, and may be confused with a cold, which is a viral infection caused by a rhinovirus (“rhino” means nose).  It may also be a bacterial infection, or a seasonal or other allergy, or a reaction to an environmental irritant, such as smoke.  Most of the time it’s okay to self-diagnose and self-treat sinusitis, but always remember thePassionatePharmacist’s mantra: if it’s not significantly better after three days of self-treatment, then it’s time to seek medical attention.  While sinusitis is usually not serious, sometimes it may need medical, or even surgical, intervention.  Sadly, sometimes the treatment can be worse.

Mark told me he was using Afrin nasal spray.  Afrin was the first and best known brand of a drug called oxymetazoline, a medication that dilates, or expands, the sinus and nasal passages.  This allows mucus and pus to pass more feely.  This drug is very efficient, and very useful.  Another similar drug, phenylephrine, is also effective.  It’s more commonly known as Neo-Synephrine.  Both are easy to use, and safe if used according to directions.

These products should not be used by people who have high blood pressure, heart disease, stroke, diabetes, glaucoma, or thyroid disease unless their use has been okayed by a physician, and under a doctor’s supervision.  These medicines can cause worsening of these diseases.  These precautions are clearly stated on the packages.  The labels also offer the following caveat: do not use more often than twice a day, and for not more than three consecutive days.  Overuse of these sprays or drops can lead to a condition called rebound congestion.  The nasal and sinus passages become more inflamed and narrowed.  Breathing becomes more difficult, so people use them more than twice daily, because they can’t breathe without it.  It’s really developing a drug tolerance.  The more you use it, the more you need to use to get the same effect.  People need to be withdrawn from these drugs, which is a slow and uncomfortable process.

What else can be done to relieve and treat sinusitis?  Since it is an inflammation, can oral anti-inflammatory drugs such as ibuprofen and naproxen help?  The answer is a qualified “maybe, but not likely”.  While these drugs do relieve inflammation and pain, they would need to be taken in doses that might be harmful, so the risk of using them would outweigh their benefits.  So what else is there?

Sinus infections need to be properly diagnosed.  If you have a bacterial infection, it is likely you will need an antibiotic.  Take the one your doctor prescribes today.  Don’t use the one that you took for a few days when you had an infected fingernail, and then saved the rest for when you might need them.  Taking the wrong antibiotic could delay proper treatment and cause complications, in addition to making your infections resistant to future therapy.

If you are reacting to smoke, perfumes, or other environmental stimulants, removing yourself from that environment can often relieve your symptoms.  Steroid nasal sprays are helpful in treating this, as well as other types of sinusitis.  As always, follow package instructions.  Over-the-counter (OTC) steroid nasal sprays can be accidentally sprayed into the eyes.  Be careful!  Steroid nasal sprays can increase blood sugar in diabetics, and increase your eye pressure.  Report any changes in vision, or elevated blood sugars to your doctor.

ThePassionatePharmacist likes to start with something very simple: saline (salt water) nasal spray.  It really is a moisturizer for your nasal passages, but does a very good job of relieving congestion.  I first gently blow my nose to initially clear the passages.  I do that before using any nasal spray.  I also buy commercially prepared spray.  There are many formulas online for preparing your own saline solution, but I think the ready-made sprays are well worth the minor cost.  The original saline nasal spray was called Ocean (clever, right?), but most other brands (e.g. Ayr) and generics will work as well.  I keep my head upright and sniff up as I spray once into each nostril to get the spray as high up into the passages as possible.  I then wait a minute and repeat the process: blow, spray, sniff.  I feel comfortable doing this whenever I get stuffy, whether it’s every three hours or every 12 hours.  Nasal saline is safe.

Sinusitis from environmental irritants and from seasonal or other allergies can often benefit from the use of antihistamines.  I take a non-sedating antihistamine tablet every day, and I believe it minimizes any symptoms I may have.  I have been tested and found to be allergic to Timothy, a common lawn grass.  While taking an antihistamine I can walk across a freshly-mowed lawn without any suffering.  I rarely have allergy symptoms, even during the days of the highest pollen counts in the air.  Check with your doctor or pharmacist to know which antihistamine would be the best for you.  Antihistamines are not without their precautions.  They are very drying, and could be a concern in men with prostate problems, or people who have difficulty urinating or fully emptying their bladders.  Some antihistamines can adversely affect patients with glaucoma.  They may cause drowsiness, blurred vision, and difficulty driving or operating machinery.  All this should be discussed with your healthcare practitioners.

So welcome the Spring and summer, and enjoy the good weather when you first see that crocus, or hear the crack of the bat and cheers of the crowd, or see your first rockin’ robin.  Don’t let sinusitis get in your way.  Go sox!

 

 

 

 

 

My Head is Spinning

Keeping your balance can sometimes be a challenge.  ThePassionatePharmacist puts a personal spin on maintaining your equilibrium.

by Joe Goldstein, R.Ph.

We often talk of balance in our personal and professional worlds.  Employers claim to care about our work-life balance (while they issue us laptops and iPads to make us more productive at home).  We see the scales of justice depicted as in balance (equipoise).  Pharmacists of yore used a balance to weigh out powders, creams, and even herbs.  Some compounding pharmacists still do that today.  The concept of balance is not uncommon, or difficult.

We take for granted our own ability as humans to keep our balance on just two legs.  That’s one trait that distinguishes us from other animals.  When our ability to maintain that balance is compromised, it can be a temporary self-inflicted state, or it can be a sign of a more sinister pathology.  Getting to the doctor, and receiving a proper  diagnosis, is essential to finding the best treatment.

Raise your right hand if you have ever had too much alcohol to drink.  Raise both hands if you have ever had the room spin around when you lay down and closed your eyes after too much alcohol.  Often called “the spins”, or vertigo, this happens when alcohol in your blood stream disrupts the normal fluid properties in a part of your inner ear called the semicircular canals.

The fluid stimulates tiny hairs that line the inside of these canals, and minor changes to the fluid, as with alcohol intake, cause your brain to think you are not in a stable position, but you really are.  Keeping your eyes open may help a bit, as you then have point of reference around you.  You can sometimes prevent this and other unpleasant effects of alcohol intoxication by drinking a lot of water with the alcohol, as well as after.  Or just don’t overindulge!  The parts of your inner ear and your brain that control your balance and your eye movements are known as the vestibular system.  This delicate system can be disrupted by disease, inflammation, and trauma to the ear, eye(s) or brain, and can lead to vertigo, dizziness, nausea, and loss of hearing and balance.

Vertigo can be a part of a more complex process called dizziness.  Dizziness may have multiple facets.  It is a condition of being light-headed, and losing your equilibrium, or balance.  You may feel disoriented.  You may or may not have vertigo.  Rapidly spinning around, or moving your head from side to side, can cause vertigo and dizziness.  Both may be accompanied by nausea.  Dizziness can also afflict people with low blood pressure (hypotension), low blood sugar (hypoglycemia), low levels of thyroid hormones (hypothyroidism), and other medical issues such as inner ear infection or inflammation (labyrinthitis).  The inner ear is called the labyrinth, because its shape and structure is very complex.  The semicircular canals are part of the labyrinth.

Some drugs can cause dizziness.  They include drugs to treat high blood pressure (hypertension), depression or insomnia.  Muscle relaxers can cause both dizziness and drowsiness, as can some drugs used to treat seizures, anxiety, and some heart disorders.  Some drugs can cause damage to your ear and to your balance if taken at high doses, or for prolonged periods of time (ototoxic).

Standing up quickly when you first wake up can make you very dizzy, because your blood pressure, already low from sleeping and from lying down, drops further when you stand up.  Sit at the side of your bed for a minute or two when you first awaken, and then slowly stand.  You’ll be less likely to get dizzy and fall, joining the more than 30 million Americans who do so each year, according to the U.S. Centers for Disease Control and Prevention (CDC).  Balance issues can be the result of anatomical problems with your feet, and also visual disturbances. Other possible causes of dizziness include not eating enough food, or not drinking enough water.  Heights also make some people dizzy.

How do you treat dizziness and vertigo?  The several different types of treatments include head and neck exercises, breathing exercises, and treating any underlying pathologies.   Drugs treatments that are used are most often types of antihistamines.  Meclizine is the most common.  Sold as the common brand names Antivert and Bonine, these drugs are thought to reduce the signals the brain receives from the inner ear.   Antihistamines may also act as mild anesthetics, or may be useful for their ability to depress the central nervous system.  Promethazine is another antihistamine used for this purpose, although it is more commonly used as a cough suppressant.  If meclizine is prescribed for you, you may purchase it over the counter (OTC) in either of its common strengths (12.5 mg tablets and 25 mg tablets).  You will likely have to ask for it at the pharmacy counter, and it may need to be ordered.  Here’s my financial tip of the day: Buying meclizine OTC can save you substantial money.  Buy it in bottles of 100 tablets for the best price.  The last time I purchased meclizine  (in 2017) I paid lass than $5.00 for a bottle.

Nausea often accompanies dizziness and vertigo, and any number of anti-nausea medications may be used, including bismuth subsalicylate (Pepto Bismol).  Don’t take Pepto Bismol if you are allergic to aspirin, or are taking an oral anticoagulant.  Emetrol, a solution of dextrose and fructose (two sugars) in combination with phosphoric acid, has been an OTC remedy for nausea for nearly 70 years, and is claimed to treat as well as prevent nausea.  Always check with your doctor or pharmacist before starting any new medication, including those sold OTC.  If these don’t help, your doctor may prescribe promethazine or ondansetron.  Sometimes ginger, or saltine crackers, are helpful.

My own experience with dizziness and vertigo has been educational, and frightening (see the previous posts “The Sound of a Dropping Pin” and “Pet Sounds” in this blog).  I arose one morning, stood up from bed, and found myself on my butt in the opposite corner of the room.  The room didn’t spin—I did.  I tried to get up again, and was able to do so only by grabbing onto a chair, hauling myself up, and sitting down until the  spinning stopped.  I knew I was having minor balance and hearing problems, having been  recently diagnosed with a large benign cyst in my right ear canal.  What I didn’t know at that time was that the cyst (tumor) had destroyed two of the three bones in my middle ear, all of my inner ear, and was advancing into my brain cavity.  I was also learning to balance myself after having three partial toe amputations on my left foot.  And I was still getting used to having only partial sight in my left eye, the result of multiple strokes I had suffered the year before.  Balance was eluding me on multiple levels.

I got an appointment with the otolaryngologist (ear, nose & throat specialist—ENT) who had originally seen my MRI films the year before, and had diagnosed the cyst, called a cholesteoma.  He prescribed meclizine, which I found very helpful, especially at higher doses.  Now, nearly a year after surgery to remove the cyst, I have no hearing in the right ear, and continuous severe tinnitus, or “ringing’ in the ear.  I no longer have vertigo, but occasional dizziness and disorientation.  Sometimes I get more disoriented on bright, sunny days.  I have a constant noise in my right ear,  which also causes some balance issues.  Sometimes the noise is mild, like it is right now.  Sometimes it’s a loud roar, like a freight train going by, or a jet airliner on take-off.  This has all made me more appreciative of the concept of balance.  Balance in my gait; balance in my diet; balance in my hearing; balance in our lives.  That balance keeps us grounded while we see the world spinning ’round.

 

Listen, People

Titles are not as important as what people actually do, and titles can be confusing.

by Joe Goldstein, R.Ph.

Before I start, I want it to be understood that it is not my intention to demean or belittle any individual or group, and I hope it does not come across that way.  I am simply trying to help us all to muddle through the fog.

In the seventy or so posts that have appeared in this blog, I have tried to judiciously use the term “doctor”.  I usually use it as part of a title (e.g. Dr. Seuss), or in reference to a particular person (e.g. your primary care doctor).  I am more likely to use the term “physician” to identify a learned individual who has earned that title.  In a hospital, one may encounter any number of people who greet you with, “Hello, I’m Dr. So-and-so”.  While it’s likely that person will be a physician, it may not necessarily be so. Their title does not tell you what level of education, training, or experience they have attained.

When I managed a medical office, the confusion about titles became clearer to me.  The primary doctor in the practice was an ophthalmologist, a medical doctor (M.D.).  He was a physician, and you will see me use that term more frequently in my posts.  He employed another ophthalmologist, also an M.D.  These individuals completed an undergraduate program, went to medical school, completed an internship, and then specialized during a residency program.  They also went through further training in a Fellowship program.  They could diagnose and treat diseases, perform surgery, and admit patients to hospitals where they had privileges to do so.  They were medical doctors—physicians.

The practice also employed optometrists.  They are doctors of optometry.  At the time of this practice, optometrists were primarily focused (no pun intended) on addressing the correction of vision issues using lenses, prisms, other devices, as well as eye muscle exercises.  Today’s doctor of optometry (O.D.) is trained and skilled in the diagnosis and treatment of eye diseases, including the use of prescription drugs to diagnose and treat many eye pathologies.  All this is done within the scope of their state’s laws.

I also learned, at that time, proper decorum in addressing doctors.  I always addressed the lead physician by his proper title—doctor—no matter what the setting was.  He was my employer, and had not invited me to address him by his first name.  I addressed his employee doctors, whether, ophthalmologist or optometrist, as “doctor” whenever in front of patients, or at a conference, or in any public setting.  When together socially, or privately, I used their first names.  This was not because of any “pecking order”, or because they had requested it.  It was simply a way for me to express my respect for their positions.

Back in the hospital, the doctor who visits you may not be a physician.  She may be a nurse, more likely a nurse manager or director.  Nurses are earning advanced degrees more frequently today than ever.  Yesterday’s nurses were trained in hospital-based programs, and were referred to as diplomate nurses.  Colleges and universities began to offer nursing programs leading to an Associate’s degree in nursing.  Further study and experience could earn a Bachelor or Nursing, or a Bachelor of Science degree.  Nurses may continue their formal education with a Master’s degree in Nursing, or even a Doctor of Nursing degree.

The doctor may hold a traditional M.D. degree (allopathic physician).  She may have a D.O. degree (osteopathic physician).  Or he may have a degree as a naturopathic physician (N.D.).  Any of these practitioners may hold additional training and credentials in other types of medicine, including holistic or Ayurvedic (traditional Indian) medicine.  Let’s not forget the doctors of podiatric medicine (podiatrists) who have earned a D.P.M.

Until the mid-1970’s, pharmacists who attended a school of pharmacy graduated from  school with a Bachelor of Science in Pharmacy degree (B.S.).  Not all pharmacists had to do this.  Many states “grandfathered” the pharmacists who were already practicing, and either made no changes to their titles, or gave them a new title, such as Qualified Assistant in Pharmacy.  Some states differentiated between a pharmacist and a Registered Pharmacist.  Organized pharmacy, through a tremendous effort, designed educational programs that led to a Doctor of Pharmacy (PharmD) degree, the entry level degree today.  The doctor who visits you in your hospital bed may be a pharmacist.   Several years ago there was talk of the State of Maine grandfathering pharmacists with a B.S. degree in Pharmacy to take a new title: P.D. (Pharmacy Doctor).  I declined, as I believe a doctorate degree should indicate advanced knowledge and education, gained through didactics and training, not just through experience.

Other doctors who visit you may have advanced academic credentials in their specialty.  These may include your respiratory therapist, physical therapist, or occupational therapist.  The social worker who helps with your discharge planning may have a doctorate degree in social work, or in psychology.  Any of the people who visit you may also have a degree in English, Business Administration, Sociology, Public Health, or any other discipline that awards a doctorate degree.  You may be visited by a member of the clergy, and he or she may hold the title of Doctor of Divinity.  It is therefore important to know who your visitor is, and what credentials they hold.  I don’t know if it’s likely, but you could see a Doctor of Nutrition who manages the food service.  How often might you be visited by a Doctor of Facilities Management?  So, as you can see, it’s important to know who the doctor is, whether at your bedside, or anywhere else.  And don’t wait to be told.  You need to ask.

You want your Doctor to be the best at what she does.  You want her to have a few years under her belt.  You want her to know how to communicate with you, her patient.  And communication involves both speaking and hearing.  Good communication is a mixture of watching, and feeling, and understanding, and listening.  The study of medicine and all the other healing disciplines are very difficult, and involve long hours of hard work.  And they should all put more emphasis on good communication.

When my oldest child was a patient at Boston’s Children’s Hospital, at the ripe old age of two months (she is now in her 30’s), I was given advice by the physician I worked for at the time.  He said to make sure that someone on my daughter’s medical team had grey hair.   He was right.  While her young doctors had the knowledge and skill and intuitiveness to interpret all her tests, symptoms and physical signs, they did not yet possess the patience or training or wisdom to properly communicate with her parents, and listen to and evaluate our observations and feelings.

She had been in the hospital for a couple of weeks, after some projectile vomiting, and subsequent vomiting of blood.  By that time, I had alienated much of the hospital’s professional staff.  I was incensed that I had to meet with an on-call senior resident in the children’s playroom to discuss my daughter’s care, sitting on miniature chairs.  And when I questioned some lab results, she admitted she was not familiar with my daughter’s case, and had not looked at her chart.  I reacted very negatively.  I was infuriated with the hospital’s patient advocate, who didn’t want to meet with me on a Saturday night because she was at a party.  I threatened to report her to the hospital administrator.  I was livid when, one Sunday, the medical team met with us in front of the nurses’ station, and the senior resident told us they had looked at the obvious causes for her ills, and was now going to look at the esoteric, such as rare parasitic intestinal  infections, and inborn errors of metabolism.  That was when my meltdown came, and I lectured them all.

I told them all, all the doctors, from the youngest intern, to the residents, to the senior resident, to the GI fellow; to the medical students and nurses on the floor and all the other parents watching.   All the M.D.s, D.O.s, and Ph.D.s.  Only the attending physician was missing.  I was no longer a complacent pharmacist.  I was a distraught first-time father, exploding with anger and frustration, and the fear my wife and I shared.  And I was ready to call in my own doctor: a Doctor of Jurisprudence.  I told them the GI (gastrointestinal) tract was essentially a hollow tube, and that what went in the top was supposed to come out the bottom.  If it didn’t, and came back up to the top, there was a blockage somewhere.  The chief resident told me I was over-simplifying it, and I replied that I apparently had to make it simple in order for them all to understand.  We parted, all of us angry.  But one first-year intern heard the message, and listened, and ordered an ultrasound exam for the next morning.  Something told him it was the right thing to do.  The next day, after a brief surgery, all was fine.  I learned a great lesson that day.  The doctors had all heard our words.  All they had to do was listen.

Act Naturally

The pharmaceutical industry is producing life-changing and life-saving medicines.  But let’s take a look at what Mother Nature has given us.

by Joe Goldstein, R.Ph.

It’s often been said that there is nothing new under the sun.  Big Pharma is constantly looking for new compounds and creating new chemical entities to fight disease.  I can’t help but think that if we look hard enough, we will find some or all of these chemicals in God’s green earth.  Nature has given us many medicines through the centuries.  I talk about a few in my book Recipe for Health (amazon.com/dp/1622494318), along with the field of pharmacognosy, which is the study of plants and other natural sources of drugs.  Some medicines owe their effectiveness to rocks, minerals and metals, such as sulfur, silver, and even gold.  That may be for another post, but this is all about plants and animals.  They are in no particular order.

One of the best known medicinal chemicals comes from white willow bark, and from the meadowsweet plant.  For more than 2,000 years these have been used to reduce fever and relieve pain and inflammation.  Both were found to contain a chemical called salicin.  Salicylic acid, a chemical that comes from salicin, is where we get acetylsalicylic acid (ASA), or aspirin.  Today we hear of aspirin used mostly to prevent stroke in certain patients, and at low doses of 81 milligrams or less.  When I was growing up, it was commonplace to be given, as children, aspirin for headaches, other pains, and fever, at doses of 650 milligrams.  We no longer give aspirin to children under age 18 years, as it was found to cause Reye’s syndrome in children who have had a recent viral infection.  Reye’s syndrome can be fatal.  Aspirin is still used today by people who suffer from arthritis, and is an effective and very useful medication when used properly under medical supervision.

Foxglove is a beautiful plant that flowers every two years.  In the 18th century it was given to people who had “dropsy”, now known to be congestive heart failure (CHF).  Digitalis purpurea is the scientific name for foxglove, which gave us the class of drugs called digitalis glycosides.  The best known, digoxin, is a potent drug used today to treat CHF, atrial fibrillation (Afib) and other cardiac ailments.

Chinese medicine still uses plants, animals and insects to make traditional remedies, just as it has for hundreds of years.  Fermenting a particular yeast, and mixing it with red rice, gives red yeast rice, a food eaten in China.  It has also been used as a medicine to improve cardiovascular health.  Red yeast rice has been found to contain important nutrients, and a statin-like substance that has been shown to substantially lower LDL-cholesterol and triglycerides.

Some people remember growing up and having a tablespoonful of cod liver oil administered to them every morning.  It is a great source of vitamins A and D, and may help ward off some common ailments.  It is also rich in omega-3 fatty acids, known today to help protect from triglycerides.  The omega-3 fatty acids also may help ease joint pain in some people with arthritis and other musculoskeletal problems.  I personally recommend cooking fresh cod.  White fish often have little flavor, but a little creative seasoning will give you a hearty, healthy, and flavorful alternative to that oily spoonful.  Salmon and mackerel are other options from our bountiful seas, to help your healthy heart stay healthy.

Cinchona is a group of plants native to South America.  In the mid-17th century an extract of its bark was found to relieve the symptoms of malaria.  That extract, quinine, is still used today.  Small amounts of quinine are added to tonic water as a flavoring agent.  In the early 1900’s another cinchona compound, quinidine, was found to treat some types of irregular heart rhythms (arrhythmia), and is still used today.

Paclitaxel is a chemical that comes from the bark of the Pacific Yew.  It was originally used to treat women with ovarian cancer, and is now used in some patients with certain types of breast cancer, and is also used to treat Kaposi’s sarcoma, a cancer found in some people who have AIDS.

Ma huang is a chemical found in the ephedra plant, and has been used in Chinese medicine for thousands of years.  The true chemical name is ephedrine, and has been used to treat asthma and other respiratory diseases.  Ephedrine and its chemical derivatives are not available legally in the United States as a result of passage of the Combat Methamphetamine Act of 2005.  Ephedrine, as well as pseudoephedrine (available in limited quantities behind pharmacy counters), are necessary chemicals in the production of methamphetamine.

Cows eat grass, and also clover, including common sweet clover.  If sweet clover gets moldy, and is allowed to spoil, it produces a chemical called coumarin.  In the 1930’s, a Wisconsin farmer wanted to know why his cows were dying.  Cows that ate spoiled sweet clover were found to hemorrhage, and die.  Coumarin was the culprit.  The spoiling process turned it into dicumarol, which interfered with the cows’ blood-clotting, so they bled to death.  Scientists produced several synthetic chemicals from coumarin and dicumarol.  One, warfarin, was very potent, and was sold as a rat poison.  Warfarin eventually was approved for use in humans, and is taken today by millions of people in the U.S.  How did warfarin gets its name?  It is a derivative of coumarin from the Wisconsin Animal Research Foundation.

There are many other medicines, both old and new, that have their origins in nature.  Watch for future posts.

Shakin’ All Over

Uncontrollable shaking of parts of the upper body may be benign, but should be evaluated by a doctor.

by Joe Goldstein, R.Ph.

Essential tremor is the most common movement disorder, and affects some 10 million American adults.  It is an involuntary, and often rhythmic, shaking of one or more body parts, most often above the waist (hands, lips, chin), but may include a side-to-side rocking and foot shuffling.  It is usually not harmful of itself, and is sometimes confused with Parkinson’s disease, multiple sclerosis, or other neurological or neuromuscular disorder.  It may also be mistaken for sudden alcohol withdrawal.  Because it must be differentiated from other pathologies, it is very important that it be evaluated by a physician.

One of my neighbors has essential tremor.  He and his family call it “the shakes”.  It was noticeable 30 years ago, and it is much more so now.  He used to have fine tremors in his hands, which have greatly increased over the years.  As is typical with essential tremors, one hand is more affected than the other.  In the three decades I have known him, he has rocked from side-to-side when he stands and talks with us.  He was a blue-collar worker all his life, working in the public sector in the transportation industry.  He is now 75 years old.  He’s not helpless.  He uses a snow blower when necessary, rides a bicycle every day, works out with free weights, mows his lawn in the warmer months, and is very sociable.  However, he has difficulty holding a glass, or a fork, and fine work is very difficult, or even impossible.  He used to perform all the mechanical work on his cars, but is now unable to because of his hand tremors.  More recently, his chin has begun to show signs of tremor.

What causes essential tremor?  Nobody really knows.  The term “essential” indicates it is not caused by another disorder.  There is a type of essential tremor called familial essential tremor, which is believed to be inherited.  The specific gene associated with this has not yet been identified.  Maybe we can compare essential tremors to an automobile engine.  Sometimes the engine misfires, and the car shakes.  With essential tremors, it’s possible that the nervous system “misfires”, sending signals to the body parts that cause the surrounding muscles to “twitch”.  This rapid twitching turns into tremors.  The severity of the tremors often increases with age.  Older people tend to have more musculoskeletal issues anyway, so essential tremor may be more difficult to diagnose.

Medication may be prescribed to try to treat essential tremor, but there is no known cure.  The first line of medication is a class of drugs called beta-blockers, which interfere with certain nerve impulse transmission.  Beta-blockers are used to treat high blood pressure (hypertension), but are also used for other disorders, including some types of headaches.  Actors and other performers sometimes take the beta-blocker propranolol (INDERAL) to relieve performance anxiety before they go on stage.  Like every other medication, beta-blockers have side effects that include drowsiness, lowered pulse (heart rate), decreased blood pressure, and erectile dysfunction, and more.  Beta-blockers should be used with caution in people with asthma and other respiratory disorders.

Another commonly used drug to treat essential tremor is primidone, an anti-seizure drug often used to treat epilepsy.  Primidone (MYSOLINE) also has side effects, including drowsiness, dizziness and nausea.  Both primidone and the beta-blockers should be taken with caution by people who drink alcohol.

Alcohol is actually another treatment for essential tremor, and people who are afflicted can sometimes mask their symptoms in social settings by having a drink or two.  Alcohol is not an ideal treatment, as it causes impairment, and may also result in tolerance, requiring increasing amounts of alcohol to be effective.

Topiramate (TOPAMAX) and gabapentin (NEURONTIN) are two other drugs that may be prescribed to treat essential tremor, although they are indicated for other disorders.  They may cause drowsiness.  They should be used when other treatments fail, or are contraindicated.

Onabotulinum toxin (BOTOX) may be of some use in patients with essential tremor.  Onabotulinum is injected every three months, and is thought to reduce tremors by weakening surrounding muscles.  Onabotulinum may not be covered by some insurance plans, and costs hundreds to thousands of dollars for treatments.

In some cases, surgical intervention is indicated.  Deep brain stimulation is the insertion of a long, thin probe into the thalamus, the part of the brain thought to be involved in the tremors.  A device implanted in your chest sends impulses to the thalamus, and blocks the signals causing the tremor activity.  Deep brain stimulation comes with its own side effects and risks, and should be carefully discussed with your doctor.

As stated before, essential tremor itself is usually not harmful, but it can interfere with some of the activities of daily living.  Patients may not be able to tie their own shoelaces.  It is difficult to drink fluids while holding a cup or glass.  Using a fork may be difficult, especially if using it to hold down food while trying to cut it with a knife.  Some people find it easier to use oversized utensils, or ones that are weighted down (especially cups).  Writing may be especially difficult.  Some people with essential tremor may become withdrawn, and depressed.

What can someone who has essential tremor do to make things better?  Sometimes avoiding caffeine can make the tremors less pronounced, or less frequent.  Although drinking alcohol can be a treatment, it is best to keep alcohol use minimal, as tremors, if they go away for a while, often come back stronger.

Try to avoid or reduce stress, which seems to bring on stronger and more frequent tremors.  Learning and employing relaxation techniques, even controlling your breathing, can often help to reduce the severity of tremors, and decrease their frequency.  Try to adapt to your situation.  If your right hand shakes more, then learn to use your left hand for some tasks.  Use the speaker on your home and cellular phones, instead of holding them to your ear.  Avoid writing when you can, including paying bills with checks.  Use on-line banking and shopping if you feel comfortable doing so.

Essential tremor is more common than most people realize, and can have similar symptoms to other disorders.  Only by consulting with a physician can a correct diagnosis be made, and proper treatment begun. Shaking hands should be something you’re happy to do, not something you can’t undo.  Give yourself a fair shake.

 

 

 

I Can See Clearly Now

Sudden, unexpected pathology to your eye can be life-changing.

by Joe Goldstein, R.Ph.

My friend Keith had surgery last week to repair a hole in the retina of one eye.  The retina is a thin tissue at the back of your eye that has been compared to the film in a camera, or the sensors of a digital camera.  Normally, light enters at the front of the eye through the cornea, the clear, domed part that covers the pupil.  The rounded cornea slightly bends the light, which passes through the pupil and enters the lens of the eye, which bends it more.  The light passes through a jelly-like substance that fills the eye, called the vitreous humor.  Ultimately, the light falls on the retina, which is really the part of the eye that sends electrical signals to the brain, which translates the light into images.  That’s how we see.  What caused the hole in Keith’s retina?  Most likely the vitreous humor at that area separated from the retina, causing the hole.  Some diseases, such as diabetes, make people more likely to have this happen.

Each part of the eye is marvelously designed to function together with other parts to provide the best possible vision we can have.  Sometimes, things go wrong, even at birth, and people are born without sight, or with diminished vision.  Visual problems can range from any issues within the eye itself, to problems with tears (see “96 Tears” in this blog), to eyelid diseases, to eye muscle disorders.  Other disorders of the body may affect the eye and vision (diabetes, multiple sclerosis, and more).  Fear of blindness is one of our greatest fears.  The eye is designed to protect itself, and God, in His wisdom, gave us two of them, in case one failed.

I want to give you a sense of the simplicity, and the complexity, of the eye.  Much of what I write here is fact.  Some of it is theory.  I’ll let you know which is which.  I would color-code it, but some of my readers may have some form or degree of color blindness.  Color blindness is often an inherited trait.  As many as 8% of men are color blind, but only 0.5% of women are genetically affected.  Chemical or other traumatic injury to the optic nerve can also cause some color blindness.  As we age, our color vision is often altered by the development of cataracts in the lens of our eye.  When (if) the cataract is removed, by surgically removing the entire lens, color vision is most often fully restored, and can be quite a dramatic change for a person.  Compare it to the movie “The Wizard of Oz”.  The first part of the movie, taking place in Kansas, is in black & white.  When Dorothy opens the door of her house after it lands in Oz, she sees everything in vibrant colors.  Cataracts can dull color vision substantially.  By the way, cataract extraction is the most common surgery performed in the U.S. according to the National Institutes of Health.  The American Academy of Ophthalmology informs us that nearly 25 million Americans have some form of cataracts, and 2 million cataract operations are performed each year.

The usual process is that light enters the cornea in a straight line.  The cornea bends the light as it comes in, and directs it onto the lens.  The pupil is the black hole in the center of the eye.  It can be constricted (very small) or dilated (wide open), or anywhere in between.  The size of the pupil is governed by the iris, the colored part of your eye.  Iris color is determined by your genes, and also by some disease states.  Behind the iris is a space in which a clear liquid flows, called the aqueous humor.  It’s function is to provide the front part of the eye with nourishment, and remove any waste materials.  The rest of the body is provided for by circulating blood, but since the front of the eye must remain clear, blood vessels can’t be there, or they would interfere with our sight.

Next, we find the lens of the eye, often called the crystalline lens.  This organ changes size and shape with the changing needs of your vision.  Light focused on the lens is re-bent and directed to the retina, at the back of the eye.  But let’s spend a few minutes talking about the lens, since it composes a major part of our visual pathway.

The lens should be clear and flexible.  Some diseases make it more rigid, and make it lose its clarity.  Age also does the same thing.  Typically, the lens loses the ability to change its focusing power, and when we reach our 40’s and 50’s, it becomes fixed in a focus that is usually just beyond out outstretched hand.  This is called presbyopia (“old-sightedness”), and it affects almost everyone.  Some people who are nearsighted (myopia) aren’t as affected as the rest, and those of us who are farsighted (hyperopia) tend to need reading glasses sooner.

The lens may become cloudy, or have areas that are opaque.  These are called nuclear cataracts, meaning they are in the central part of the lens, called the nucleus.  They interfere with light getting to the retina.  They can range from yellow to brown in color. What causes them?  Great question.  Diabetics and smokers have a higher incidence of cataracts, as do people who live near the equator.  Here is where my theory comes in. Grab a hold of your seat, because it can get a little convoluted.  And some of it may be contrary to what other sources claim.  Another type of cataract, called a posterior subcapsular cataract (PSC), is in a different field of vision, and usually causes some glare, most often at night.

Ultraviolet (UV) light, which comes from the sun, is the light that enters our eyes.  Ultraviolet light can damage human tissue.  It is what causes sunburns.  It also helps us to stay healthy, and alive.  But it doesn’t belong directly in our retinas.  I believe our eyes use a very potent, naturally occurring chemical to protect our retinas from UV light: vitamin C.  Aqueous humor has one of the highest concentrations of vitamin C in our bodies.  Aqueous humor normally is circulating.  It is not like standing water.  I believe that a sufficiently high level of vitamin C protects the rest of the eye from UV damage, a process that takes many, many years.  A long-standing debate is why there is a higher incidence of cataracts in the southern United States than in the north.  Is it because people there live closer to the equator, and are exposed to more sunlight?  Or do more older citizens move down South, and the higher incidence is age-related?  Let the epidemiologists work on that.   When the level of vitamin C in the aqueous humor drops, I believe the vitamin C begins to accumulate in the lens.  Throughout our lives, our levels of vitamin C, as well as other essential nutrients, fluctuates.  Stress depletes vitamin C.  Smoking depletes it.  Sickness lowers it, as does surgery, trauma, emotional distress, etc.  Diabetes causes several changes to our body that deplete vitamin C.  Our parents and grandparents showed great wisdom in having us drink orange juice, a good source of vitamin C.  I believe that these episodes of stress, strewn over six or seven decades of life, cause vitamin c to accumulate in our lens, which is the body’s way of clouding our vision, thus protecting our retina.  In an experiment many years ago, I obtained lenses that had been surgically removed, and placed them in both clear and amber bottles.  I also placed them in different solutions: tap water; tap water with vitamin C; vitamin E oil; and even vodka!  I thought the results were interesting.  One lens turned brown: the lens in vitamin C solution in a clear bottle.  You can draw your own conclusions from that.

The light that has passed through the cornea and lens now is focused on the retina, after passing through the vitreous humor.  The millions of sensors in the retina change the light into electrical impulses that are transmitted to our brain via the optic nerve.  The brain translates it all into images.  By the way, each of our eyes has a blind spot, called the physiologic blind spot.  It’s where our optic nerve comes into our retina.  There are no sensors there.  Getting back to Keith, a retinal hole is usually in a part of the retina called the macula, which is responsible for detailed vision, including reading and writing.  It is what is affected in the condition called senile macular degeneration (SMD), also called age-related macular degeneration (ARMD).  People with ARMD often can’t see well enough to read, or write, or sign their names.  They usually don’t walk into things, but may have trouble getting around.  They surely should not drive.

Keith did well through his surgery, which included removing some of the vitreous humor from his eye, and injecting a gas bubble to replace it.  The gas bubble has to stay in place for one to two weeks so the area can seal.  The bubble eventually dissolves, and vitreous humor, or any replacement that the surgeon may have introduced, keeps the seal in place.  Patients must stay in a face-down position.  Specialty medical companies rent and sell face-down chairs for patients who have had this type of surgery.  They come with options and accessories to enable people to eat, sleep, watch television, and perform daily routine activities.  In a car, Keith sits with his chin to his chest.

Keith will probably be back to work in a few days.  The irony is that Keith works in the optical industry.  He told me that being monocular (vision in one eye) was disturbing, a sentiment I can appreciate, as I have been monocular since I lost most of the vision in my left eye in mid-2016, due to a stroke that affected my optic nerve.  Keith also does not like having no depth perception.  He’ll get over it.  His blurred vision is fading, and he is making great strides toward again having clear, binocular vision.  He wore a plastic or metal shield over his operative eye the first day or two, and wears it at night so he can’t rub his eye, or poke the corner of a pillowcase in it.

Keith will lead a normal life, but will need to control his activity and his diet.  He will need to be a little more aware of what’s going on around him, a little more wary of potential traumas.  He will need to avoid stress.  He has learned what it’s like to be up tight, and out of sight.