Jeff Narvid, Vice President of Product Development

Since last month’s article, many people have asked for an update on the condition of the patient who received my bone marrow donation. I have indeed received an update, and it’s good news! The National Marrow Donor Program (NMDP) has informed me that the transplant was successful and that the recipient’s condition has improved enough for her to return home from the hospital! Although this is only the beginning of her recovery, the outcome at this stage couldn’t be better.

It is quite possible, however, that despite this hopeful beginning, the recipient could suffer a future setback that requires a second donation. According to the NMDP, “nine percent of marrow and PBSC donors have given one or more additional blood donations for the same patient.” I’ve informed the NMDP that if this happens, I would be willing to donate again in the future. For the patient’s sake, however, I hope that it isn’t necessary.

I expect the NMDP to contact me again within the next few months with more information on the status of the patient, as well as with any possible requests for additional donations. I’ll write more when I know more!

–by Jeff Narvid, Vice President of Product Development

Each month, the GeneEd newsletter features a Job of the Month that correlates with our featured Course of the Month.  Relevant e-Learning courses from the GeneEd catalog are linked to the monthly job description, providing a handy resource for people who wish to enhance their qualifications for that career

Ophthalmologists are physicians who diagnose and treat diseases of the eye, including glaucoma and cataracts; vision problems such as nearsightedness; and eye injuries. Optometrists (who test vision and prescribe corrective lenses) and family doctors often refer patients with serious eye conditions to ophthalmologists. Because of their extensive training, ophthalmologists can often link eye problems to other disorders. For example, they are sometimes the first to detect brain tumors, diabetes, or multiple sclerosis.

Ophthalmologists undergo extensive training after high school: four years of college, four years of medical school, one year of internship, and three years of training as hospital residents in ophthalmology. After their internships, students take a series of exams to become licensed to practice general medicine. After their residencies, ophthalmologists must pass exams and other requirements for certification in their specialty.

GeneEd e-Learning courses can help you or someone you know become familiar with the subject matter of ophthalmology. View the GeneEd courses about ophthalmology by clicking here.

By Rachel K. Sobel, MD

As an ophthalmologist-in-training, I often receive questions from family and friends about LASIK. Should I have LASIK surgery? Would you? At these times, I often think about an insight from one of my professors. “In my whole practice,” he told us at a conference, “my happiest patients are LASIK patients, and my unhappiest patients are LASIK patients.”

On the happy side of the spectrum are patients like Brian Sitongia, 30, a Wills Eye records manager from South Philadelphia who was frustrated with contact lenses. His eyes burned when he became tired. If he fell asleep, the lenses stuck to his eyes, putting him at risk for infection. He had LASIK four years ago, and he is thrilled with the results. “The next day, I drove to the Shore without glasses. I was amazed and in awe,” Sitongia says. “It’s the best money I’ve ever spent.” He has had no complications and continues to enjoy watching TV and driving without glasses.

LASIK is a short outpatient procedure in which a flap is cut into the cornea and lifted up, allowing tissue to be reshaped by a laser. This remodeling, which changes the refractive qualities of the eye, frees the patient of the need to wear glasses or contact lenses. Insurance rarely covers the procedure, which costs $1,500 to $3,000 per eye.

About 700,000 Americans get LASIK every year, and the vast majority do well. There is something about LASIK that can make patients remarkably happy. Being relieved of the burden of glasses and contacts, although seemingly mundane, can be deeply satisfying. Another professor says that his LASIK patients even seem happier than his corneal transplant patients, who can go from being blind to seeing the world.

Still, some patients are not satisfied. Although only 140 people filed complaints with the Food and Drug Administration between 2006 and 1998, when the laser device was approved, many more patients are unhappy with their results. The precise number is not yet known, but studies are under way to find out.

So how do you avoid becoming one of the many who regret their decision to have LASIK? The best way to avert problems is to ascertain whether you are a good candidate before deciding to undergo the surgery. A preoperative evaluation that assesses both physical and personality factors may be more important than the actual surgery. It is the job of the LASIK surgeon, along with the patient, to decide if it makes sense to go forward.

The most significant side effects range from debilitating dry eye to bothersome visual effects such as halos, glare, or starbursts. Patients may also get ghost images (double vision), poor night vision, and even poor daytime vision. To help prevent such complications, surgeons screen out patients with dry eyes, large pupils, or irregularly shaped corneas. Some of these patients may be better candidates for surface ablation, a procedure similar to LASIK, but one in which no flap is created. Although the end result of surface ablation is the same as LASIK, there is more postoperative discomfort and vision takes longer to recover.

Another part of the preoperative screening focuses on personality. A successful patient needs to be a risk-taker, for one thing. But the most important personality screening may be for depression. A study of 370 active-duty naval patients who completed a preoperative depression scale revealed that although 89 percent of them achieved 20/20 vision following LASIK, those with higher levels of depressive symptoms were three times as likely to be less satisfied than those with low levels of depressive symptoms.

The FDA has made it easier for patients and physicians to report LASIK-related problems and has updated Web resources for prospective patients. In addition, websites such as “LifeAfterLasik.com” can provide a supportive outlet for unhappy patients. One patient who posted on the site reported that since his surgery eight weeks ago, he has experienced constant eye pain that interferes with his work and, even worse, disrupts his sleep. “I now realize it was the most reckless decision I’ve made in my life,” he wrote.

So, would I ever get LASIK? After discussing the pros and cons with an attending physician, I was nearly persuaded to go through with it. After all, contact lenses pose their own set of dangers, along with the risk of infection. Undergoing LASIK might simply be trading one risk for another. But for me, that reasoning was ultimately unconvincing. As an ophthalmologist, blurry vision would handicap me. Furthermore, I do have dry eyes, which could get worse. The risk is too weighty for me, and I’m not a risk-taker. I think I’ll stick to my glasses and contacts for now.

About the Author

Dr. Rachel K. Sobel is a second-year resident of the Wills Eye Residency Program at Thomas Jefferson University.

by Nyssa Hoch, PhD

Age-related macular degeneration (AMD) is an eye disease that gradually destroys vision in the center of the visual field, resulting in the inability to see objects clearly, to read, and to recognize faces. It is a major cause of blindness in the US in those over 60 years old. Approximately 10 percent of patients from the ages of 66 to 74 years have findings of macular degeneration. The prevalence increases to 30 percent in patients from 75 to 85 years of age.

AMD affects the macula, the part of the eye located in the center of the retina. The retina, composed of light-sensitive tissue at the back of the eye, contains nerves that instantly convert light, or an image, into electrical impulses. It then sends these impulses, or nerve signals, to the brain. Behind the retina is the choroid, a thin layer of connective tissue and blood vessels that supplies oxygen and nutrients to the outer layers of the retina.

AMD occurs in two forms: wet and dry. In the dry form, yellow deposits of cellular debris called drusen accumulate between the retina and the choroid, and the light-sensitive cells in the macula slowly break down. The dry form has three stages, beginning with a lack of symptoms and progressing to cellular damage and retinal detachment that cause a blurred spot in the central field of vision.

Wet AMD, also known as advanced AMD, does not have stages. In this form, which is more severe than dry AMD, abnormal blood vessels grow from the choroid behind the macula. These new, fragile blood vessels often leak blood and fluid that raise the macula from its normal place at the back of the eye, causing rapid damage to the retina.

Dry AMD is much more common than wet AMD. About 90 percent of all people with intermediate and advanced AMD combined have the dry form. If only advanced AMD is considered, however, about two-thirds of patients have the wet form. Because almost all vision loss comes from advanced AMD, the wet form leads to significantly more vision loss than the dry form.

All people who have the wet form had the dry form first, but dry AMD can advance and cause vision loss without turning into the wet form. The dry form can also suddenly turn into the wet form, even during early stage AMD. There is no way to tell if or when dry AMD will turn into wet AMD.

Symptoms of AMD depend on the form of the disease, although neither form causes pain. The most common symptoms of dry AMD are the presence of drusen, slightly blurred vision, difficulty recognizing faces, and the requirement for more light for reading and other tasks. Dry AMD generally affects both eyes, but vision may be lost in one eye while the other eye seems unaffected.

An early symptom of wet AMD is that straight lines appear wavy. With wet AMD, loss of central vision can occur quickly. In some cases, AMD advances so slowly that people notice little change in their vision. In others, the disease progresses faster and may lead to a loss of vision in both eyes.

AMD is diagnosed by means of a comprehensive eye exam that includes a visual acuity test, dilated eye exam, tonometry (which measures the pressure inside the eye), and the Amsler Grid Test (which reveals whether a patient sees a grid of straight lines as wavy or missing lines). If AMD is suspected, further diagnostic exams may include a fluorescein angiogram, which uses dye to detect vascular changes in the eye, or optical coherence tomography, which obtains high resolution images of the retina.

Wet AMD can be treated with laser surgery, photodynamic therapy, or medications injected directly into the eye. These treatments are able to stop or reverse the growth of blood vessels in the eye.

There is currently no treatment that can prevent vision loss once dry AMD reaches the advanced stage. However, the National Eye Institute’s Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants and zinc significantly reduces the risk of advanced AMD and its associated vision loss. Slowing AMD’s progression from the intermediate stage to the advanced stage could save the vision of many people.

A hopeful option for the treatment of AMD-related vision loss is the generation of an artificial retina. To develop this new technology, an ongoing project is being conducted by the US Department of Energy (DOE). The research team, which includes six DOE national laboratories, four universities, and private industry, is working on a device that will restore sight to people blinded by retinal diseases, such as AMD and retinitis pigmentosa, by bypassing the damaged eye structure. Clinical testing of the device is supported by the National Eye Institute of the National Institutes of Health and others. The project has already made significant advances by enabling direct communication between an implanted device and neural cells that carry visual information to the brain.

The device is complex in operation and involves several combined technologies. According to the project’s website[1], “a miniature camera mounted in the patient’s eyeglasses captures images and wirelessly sends the information to a microprocessor (worn on a belt) that converts the data to an electronic signal and transmits it to a receiver on the eye. The receiver sends the signals through a tiny, thin cable to the microelectrode array, stimulating it to emit pulses. The artificial retina device thus bypasses defunct photoreceptor cells and transmits electrical signals directly to the retina’s remaining viable cells. The pulses travel to the optic nerve and, ultimately, to the brain, which perceives patterns of light and dark spots corresponding to the electrodes stimulated. Patients learn to interpret these visual patterns.”

Because more electrodes in the device provide greater visual resolution, the ultimate goal is to design a device with hundreds to over a thousand microelectrodes. This resolution will help restore limited vision that enables reading, unaided mobility, and facial recognition.

In 2002, a breakthrough operation was performed by the research team at the Doheny Eye Institute of the University of Southern California in which they successfully implanted the first device of its kind—an array containing 16 microelectrodes—into the eye of a patient who had been blind for more than 50 years.

Three models are now in development or testing. Model 1, containing 16 electrodes, has been implanted in six patients. As of mid-July 2009, a second model with a 60-electrode array has been implanted in 30 human subjects in the US and other countries. These devices enable patients to distinguish light from dark and to localize large objects. A third model, an array with a higher electrode count, is currently under development.

The first study[1] showed for the first time in primates that a calorie restricted diet, one that has 30% fewer calories compared to a “normal” diet for primates, prevents age-related diseases such as cancer, cardiovascular disease, and brain atrophy and extends lifespan.  Researchers also noted that the calorie-restricted animals looked younger compared to their “normal” diet counterparts.  These effects have been previously demonstrated in rodents, but not in primates, which have a high similarity to humans.

The other study[2] demonstrated that the immunosuppressant drug rapamycin increased the lifespan of already-aged mice by delaying onset of cancer and/or slowing the aging process.  Similar effects had been previously shown in invertebrates, but this was the first study to show rapamycin’s effects in mammals, and it further emphasized the role of mammalian target of rapamycin (mTOR) signaling in the aging process.  This study was especially interesting because researchers began treatment in mice that were already the equivalent of 60 human-years old. So the results suggest that it is possible to delay aging and age-related disease even later in life.

Naturally, both of these studies have raised the question of whether an anti-aging drug may soon be developed for humans. This “fountain of youth” in pill-form is still a ways off, especially since the effects observed in these studies remains to be demonstrated in humans.  Nonetheless, these studies add valuable information to the growing body of knowledge about aging and will help eventually unlock the mysteries of growing old.

- Nyssa Hoch, Ph.D., Senior Content Scientist, GeneEd, Inc.

[2] Harrison DE, et al “Rapamycin fed late in life extends lifespan in genetically heterogeneous mice” Nature 2009; DOI: 10.1038/nature08221.

In this edition, our feature story is an overview of endometrial cancer, otherwise known as uterine cancer. Our special feature this month describes the experience of donating bone marrow. Our Job of the Month feature covers the requirements and prerequisites for a career as an oncology registered nurse. Relevant e-Learning courses from the GeneEd catalog are linked to this job description, providing a handy resource for career seekers wishing to enhance their qualifications.

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In this edition, our feature story is an overview of endometrial cancer, otherwise known as uterine cancer. Our special feature this month describes the experience of donating bone marrow. Our Job of the Month feature covers the requirements and prerequisites for a career as an oncology registered nurse. Relevant e-Learning courses from the GeneEd catalog are linked to this job description, providing a handy resource for career seekers wishing to enhance their qualifications.

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A few months ago, I was contacted by the National Marrow Donor Association (NMDP), informing me that I’d been identified as a possible donor for a female patient in need of a bone marrow transplant. Having all but forgotten that I had indeed joined the NMDP Registry a few years back, my first honest reaction was one of fear – fear of a giant steel needle being painfully plunged into my hip bone to extract the marrow. However, even with this gruesome image in mind (which turned out to be false), it’s difficult to turn down the opportunity to save a life, so I agreed to learn more about the donation process and begin the steps leading to donation.

Marrow donation requires a series of commitments on the part of the donor that aren’t particularly difficult, but at the same time couldn’t be more serious. The NMDP is very straightforward about the fact that while you have the right to abandon the process at any time, doing so will likely result in the death of the patient. With that in mind, I took the commitments very seriously.

First, there was the time commitment. This involved reading the NMDP literature on the donation process, extensively discussing the process on the phone with an NMDP representative, making multiple trips to the donor center for pre- and post- donation physical exams, and the donation procedure itself. Luckily, I live 11 blocks from a donation center, so the travel time was minimal. Still, the time commitment is significant, especially taking into consideration work and family responsibilities. Because the NMDP takes care of all expenses, there is no financial commitment beyond the time away from work. In my case, GeneEd generously supported my time commitments throughout the donation process.

Next was the physical commitment. While the pre- and post- donation physical exams involved nothing worse than a blood draw, the donation process itself was physically draining, though not nearly as frightening as I had initially imagined. Rather than donating marrow via a surgical procedure in which marrow is extracted from the pelvic bone with a hollow needle, I donated peripheral blood stem cells (PBSC) via an outpatient process called apheresis. A clinical research study is currently being conducted to determine which procedure results in a more positive outcome for the patient, but the PBSC donation process is clearly easier on the donor.

PBSC are the same blood-forming cells found in the marrow, but they actually circulate in the blood in small quantities. In order to be able to donate enough of these cells for a transplant, however, a drug called filgrastim must be taken prior to donation to move PBSC out of the bone marrow and into the bloodstream. In my case, I was given an injection of filgrastim on each of the five days leading up to the donation, the first and last injections at the donor center and the others by a terrific nurse who came to my home.

The filgrastim basically puts your bone marrow into overdrive, expanding within the bone to produce significantly more PBSC than normal. Typical side effects are bone pain and flu-like symptoms such as fever, headaches, fatigue, and nausea. Luckily, I only experienced minor pain in my lower back, a few headaches, and a bit of fatigue.

The fifth day was the donation day, and I showed up at the donor center at 6:30 a.m. for my final filgrastim injection and the rather lengthy apheresis procedure. During the procedure, a needle was placed into each arm, and blood, which was now full of PBSC, was removed from the vein in one arm, passed into a blood separator machine, and returned to my body through the other arm. For six hours, I drifted in and out of sleep, watching a bag next to my bed very slowly fill with PBSC extracted from my blood. It wasn’t a particularly painful procedure, but I was both literally and figuratively “drained” by the end. I did, however, manage to walk the 11 blocks home, feeling tired but hopeful that a mere six hours of my time might make a life-changing impact on the patient and her family. Since then, I’ve experienced very few side effects beyond some bruising where the needles were in my arms, some lingering back pain, and minor fatigue.

As you might imagine, there is an emotional commitment to the process in addition to the physical commitment. Personally, I did not feel particularly nervous before the procedure, especially once I learned that I was going to be donating PBSC and not having surgery. Ultimately, I felt honored to be a part of it.

It’s been two weeks since my donation and I’m fully recovered. I’ve been in constant communication with a representative from the NMDP, who checked on my condition daily the week after donation and once this week. From here, I expect to receive a call from the NMDP one month, six months, and one year after the donation to assess my health. As for the patient who received my donation, I’m looking forward to the possibility of hearing about her (hopefully) improved condition. However, there are a number of confidentiality issues surrounding the contact between donors and recipients, so I’m still not sure if I’ll get an update on the success of the transplant. If both of us agree, we are allowed to contact each other one year after the donation. I have informed the NMDP that I’m very willing to be contacted but understand if the patient would like to remain anonymous.

I may never learn the identity of the patient who received my donation or whether the transplant was successful. I hope it was. Donating marrow is, quite simply, a selfless act of kindness with no material reward. If you ever have the opportunity, I think you’ll find it to be a very worthwhile experience.

–Jeff Narvid, Vice President of Product Development

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