This newsletter is about new, new information and two new technologies.  The topics are women's health, sports medicine and skin cancer.  The latter two introduce two exciting new services I have started to use in my practice.

Next time (I hope) the promised article on health screening.

Best,

www.carlstonmd.com

• Hormone Replacement Therapy
• Concussion Evaluation/ Safe Return To Play
• Polarized Light Examination For Skin Cancer 

Unless you have been living entirely without media contact for the past year, you know that the standard of care and opinion of postmenopausal hormone therapy went down in flames.  Early in 2002 nearly every conventional medical doctor in this country would have told you that taking HRT reduces the risk of heart disease, osteoporosis and many forms of cancer.  A great number of women (and a few of us in the medical profession) felt that this was wrong.  How could a normal process of aging become a disease?  Over 1/3 of women who started HRT dropped it within 3-6 months. Since then the research evidence has been piling higher and higher that intuition and common sense should be honored.

Two important studies have been published in the past week.  The first showed that women using HRT doubled their risk of having a heart attack within the first year of starting the therapy.  The second study was a massive one (more than 25% of ALL British women) and it found that postmenopausal women who used any form of estrogen with or without progesterone were more likely to develop breast cancer.  The risk of taking estrogen alone was lower than taking it with progesterone (30% vs 50% increased risk).  The longer women took the hormones the higher the risk.  This translates into 100,000 HRT induced cases of breast cancer over a ten year period in the United States.

Why was the conventional opinion so wrong?  Well for decades I've held opinions that deviated from the norm and year by year it turns out that I've usually been right all along.  I think I can answer this question pretty easily then.  First, doctors tend not to ask enough questions.  As a profession we tend to accept the "truth" as it is spoon feed to us in training.  Second, the minority who actually read the old research were misled because the study results were confused by the fact that healthy active women are more likely to do all they can to take of themselves, including taking HRT recommended by their physicians.  These women were less likely to develop many problems and researchers falsely attributed that improvement to HRT.

Concussions are a very big problem in sports especially contact sports.  They are the most common serious injury resulting from sports participation.  The high rate of concussion in some sports, such as cheerleading, and among track and field athletes is surprising.

Clinical assessment has always been extremely crude and all other available testing (MRI, CT etc) is too insensitive to be useful in 99% of cases.  In addition, the response to these injuries in both the short and long term is unpredictable because of marked individual variation.  Some evidence suggests that susceptibility might be largely genetically determined.  There is concern that the brain may be extraordinarily vulnerable to another head injury occurring shortly after the first.  Some believe this "second impact syndrome" is a major cause of head injury deaths.

Obviously, prevention of such tragedies and prevention of persistent thinking deficits or other symptoms (most commonly dizziness, headache, visual problems) is an important goal.

One of the most important developments in sports medicine in recent years is the use of computerized neuropsychiatric testing to evaluate players.  Ideally the testing is conducted annually to determine the baseline functioning and then again after injuries to assess the impact of the injury.

Reviewing the medical literature, in my opinion the Cogsport system is the best.  It was developed by Dr. Paul McCrory who is Editor of the British Journal of Sports Medicine and a consultant to the Australian Rules Football League.  Fortunately for the rest of us the very high rate of head injury among ARF players (picture football without helmets) has given McCrory's group a great deal of data and experience refining their computerized testing process.

I recommend that all who participate in certain sports (football, boxing, hockey, soccer, gymnastics, home trampolining, cheerleading, skiing) especially children, should have annual screening for baseline cognitive testing.  Then those who are unfortunate enough to have a head injury should be retested to determine when it is safe to return to play.

The use of this test is spreading rapidly with Stanford and UCLA among the institutions who have begun using it recently with their athletes.  We now have it available in the office.

As the rate of skin cancer rises there are new diagnostic technologies appearing to help.  Epiluminescence (literally skin lighting) has been used in Europe for a number of years.  With growing evidence of the utility of this method you will be seeing it applied here.  I recently purchased a cross polarizing light from the leading company in this technology.  If I use a strange looking lighted magnifying glass to evaluate something growing on your skin you will now know what it is and why.