I am happy to see the return of fall weather - the natural air conditioning is working again and the rains soon will turn the hills back to green.  This is a great time to get your exercise program going before those rains challenge your resolve.  This newsletter completes my health screening article.   Please read it through and think about what you might need to do.  In part because I usually forget to remind you, a number of you have not looked at my website .  Please take a look as there is a great deal of information posted and the feedback has been very positive.

Finally, every day I spend too much time tossing aside marketing emails.  I dread that some of you might feel the same way about this newsletter.  If you do PLEASE write me an email and I will take you off the list immediately.

To the rest of you - thanks for your many appreciative emails.

Best Michael Carlston, M.D.
www.carlstonmd.com

• INHALED STEROIDS AND CATARACT
• FRUIT AND VEGGIES REDUCE STROKE RISK
• GARLIC IS GOOD
• WHY PHYSICIANS NEGLECT HEALTH PROMOTION/PREVENTIVE SERVICES
• HEALTH SCREENING, WELLNESS AND DISEASE PREVENTION - PART II

Clinical efforts to control the inflammatory side of asthma have focused on the use of steroids.  As systemic steroids have systemically ill effects (osteoporosis, immune suppression, elevating blood pressure, skin atrophy, growth suppression in children, adrenal problems and possibly cancer) clinicians initially believed that inhaled steroids would not create those ill effects. 

Unfortunately, as time passes, research has partially deflated this optimism. Even inhaled steroids do cause widespread adverse effects.  The most recent data come from a survey of asthmatic patients in England.  The study found that those who used inhaled steroids increased their risk of developing cataracts in direct proportion to the steroid dosage.  Overall the risk of cataract was 50% higher among those using steroid inhalers. 

The study authors wrote "Cataract is the main cause of low vision and blindness in the world, any common exposure that increases the risk of cataract is thus of great public health importance." 

Certainly steroid inhalers benefit asthmatic patients and are better than systemic steroids.  However, these data are a reminder that it is best to try to help asthma in other ways whenever possible.

The study was part of the ongoing observation of those living in the Hiroshima and Nagasaki areas.

On to Adulthood

Standard medical care starts out pretty well by uncharacteristically focusing on prevention, but then loses the plot neglecting labor-intensive health promotion counseling. This has always seemed odd to me because health care is largely about education, not just writing prescriptions hand-over-fist.

Once again, a thorough periodic examination of your diet, supplement usage, exercise patterns and other lifestyle elements is a great way to prevent disease while improving the quality of your life. Obesity is becoming epidemic in our high carbohydrate, low activity society. The health consequences are enormous and it is certainly easier to reign in on the problem when you discover your weight has just started to go up, than it is to drop serious poundage later on.

High blood pressure is often a consequence of excessive weight gain, although in many cases it appears in people whose weight is not markedly abnormal. Unlike the visibility of weight gain, most people have no idea that their blood pressure is elevated. People with hypertension don't feel any different until years of increased blood pressure have made their mark with heart disease or stroke or some other nasty problem. Checking your blood pressure annually is a good idea.

I should mention the growing discussion in the medical literature about when or if doctors should check patients1 blood pressures. Because there are a significant number of people whose blood pressures are fine everywhere except the physician1s office, too many people are incorrectly diagnosed with hypertension. Most of them are then placed on prescription medications that they do not need, and from which they suffer adverse effects. I usually check my patient1s blood pressures periodically and, if elevated, I urge them to check it again themselves every morning for a week or two. There is a new generation of highly accurate, easy and maybe even fun-to-use blood pressure monitors, so checking it yourself is not a big deal.

Periodic blood screening for diabetes and lipid abnormalities (elevated cholesterol, serum c-reactive protein) is anything from a good idea to crucially important, depending upon your family history, weight and lifestyle habits.

Mens Health

Unfortunately, men tend to be relatively oblivious to preventive health care. That may explain why we tend to live a couple of years less than women. Just as women are more vulnerable to certain health problems, men have our own weaknesses.

Testicular cancer is the most common form of cancer in 15-34 year old males, and the second most common in 35-39 year old men. This cancer can be diagnosed easily. All it takes is a physical examination, and young men should learn to do this for themselves.

Annual digital prostate exams are a good idea after age 50, or even much younger if symptoms warrant. Blood testing using the PSA (Prostate Specific Antigen) test has its uses, but unfortunately, it is very prone to false positives. As a result, many men have undergone needless procedures, some of which have often led to serious long-term ill effects. As the years go by, the test is getting refined, which increases the accuracy and decreases the false positive rate.

Womens Health

Young women need to be concerned about cervical cancer screening. This preventable cancer is most common in young sexually active women. Regular PAP smears should start within 3 years of first intercourse. Bimanual pelvic exam is also important because it can help us diagnose ovarian cysts, ovarian cancer, uterine fibroids and a number of other problems. Examinations should be repeated annually until 30 or 35, and then every 3 years until age 65. Women who are at higher risk (DES daughters or granddaughters, multiple sexual partners, immunosuppression) should be screened annually. Women who have had a hysterectomy do not need PAP smears.

Mammograms are a controversial and confusing topic these days. Mammograms can detect breast cancers 1-3 years before they can be felt. But, there are many falsely abnormal mammograms, particularly in women under age 50. Maybe breast exams can help, especially if performed well. Then again, further adding to the confusion, one recent massive study in China found no benefit of breast self-exam, even when women had received instruction in proper examination techniques. How can that be when most breast cancers are still discovered by women examining their breasts intentionally or unintentionally?

So my recommendations are: First--stay tuned. New technologies are in development that promise more reliable information, everything from breast MRI to electrical impedance to ductal lavage with microfiberoptic equipment. Second--consider your family history and other risks for breast cancer (early onset of menses, no breast feeding, use of hormones, alcohol consumption, weight gain after menopause). Third--I think there is a role for breast self examination, but we just don1t know what it is. The same can be said of professional clinical breast exams. You should consider mammograms every other year, especially if you are between the ages of 50 and 70, have a close family history of breast cancer or have a number of risk factors for the disease. One other note is that I do not think that breast thermography is a useful tool. It is just doesn1t give enough consistent or meaningful information.

Ovarian cancer screening is another area of evolving controversy. At this time, the most useful predictive factor is family history. An American woman with no family history of ovarian cancer has a 1.2% lifetime risk of developing the disease. If one relative has had ovarian cancer, her risk goes up to 5%, and 7% if two relatives have had the disease. There is also a rare genetically inherited syndrome that increases the risk drastically - 40% lifetime risk.

The CA-125 blood test has gotten a great deal of attention as a screening test. The numbers from a large (22,000 women) study in the United Kingdom highlight the limitations of this blood test. Of the 11,000 women receiving the CA-125 test annually, 16 developed ovarian cancer. However, the blood test was not very good at finding them. Of the 468 women who tested positive, only 6 had ovarian cancer. The other 10 women with ovarian cancer had tested negative.

Another blood test of a tumor marker, lysophosphatidic acid, looks like it may be better, but it needs to be evaluated in screening studies to learn if it is adequately sensitive to use for screening.

Women who are at very high risk for ovarian cancer (family history, Northern European descent and never pregnant) might consider taking oral contraceptives, as they appear to significantly reduce the risk of ovarian cancer.

Osteoporosis screening is recommended for women at age 65, but I think it is a big mistake to wait until then. As bone density declines sharply following menopause, I recommend a DEXA bone density at the onset of menopause. That way you can take action to prevent osteoporosis, instead of getting backed into a corner having to consider prescription medication.

As We Age

As the time we have left gets shorter, the likelihood of significant health problems inevitably increases. Colon cancer is one of the best examples of a health screening success story. This is a very common cancer with good evidence that early treatment saves lives.

After age 50 every one should have an annual stool blood test (guaiac), looking for invisible blood in the stool. Also, either a sigmoidoscopy every 5 years, double contrast barium enema every 5 years or a colonoscopy every 10 years looks to be a good idea. A sigmoidoscopy is easier and cheaper, but it only looks at the last 30% of the colon. In my opinion, patients with a family history of colon cancer, especially in relatives under age 50, should start colon cancer screening even younger.

So called "virtual colonoscopy" is a fancy X Ray test (CT scan) of the colon. While this test identifies polyps like colonoscopy, the patient must then undergo regular colonoscopy to biopsy the polyps. In traditional colonoscopy, any polyp can be easily biopsied, and often the simple removal of the polyp is therapeutic, as the polyps then cannot follow their common natural history and become cancerous. I do not like the radiation exposure virtual colonoscopy requires.

I am skeptical about the new wave of body scans. They are marketed to the public as an accurate means of disease screening, but there are drawbacks. The radiation exposure is considerably less than years ago, but still considerable. We all have a variety of "defects", and you have to ask what good it does to find more of them. Sometimes even finding a cancer early only leads to interventions which make the patient suffer without leading to a longer or more enjoyable life. In some rare circumstances these scans might save a life, but what about the worry over something which might never have caused you symptoms, the risk of the radiation, your potential uninsurability after something is discovered, the cost .? I think this is more of an individual decision based upon your intuition, than it is a clear cut medical decision.

Years of exposure to the sun and environmental toxins can lead to skin cancer. I recommend an annual skin exam after age 40. In addition to the clinical features that tell us that a skin lesion is likely to be malignant, a new technology, well established for years in Europe, helps distinguish cancers from "funny looking" moles. This simple hand held device is a polarized light. I have found it helpful and very easy to use.

There are a few other tests that I think have a role in health screening.

Many patients experience low energy or immune dysfunction from low levels of iron without knowing it, because most physicians do not know to test the body's store of iron. It is very well established that physical abilities are hampered and patients have symptoms because of low iron, even when they are not anemic. The simplest blood test for body iron stores is ferritin. Among my patients, 20-25% of females in their 40's have low iron stores.

Thyroid deficiency is also very common. As laboratory technology has improved dramatically at measuring low levels of hormones, we can screen for low thyroid with a simple blood test. I do not agree with those who contend that morning body temperature is an accurate gauge of thyroid function.

When I worked as an emergency room physician years ago, I would often see patients with chest pain for which it was difficult to determine the cause. In the past few years, some rapid blood tests have appeared, improving diagnostic accuracy, but I still think it is a good idea for any adult who has had an EKG to carry a copy of it in his/her wallet. That way an ER doc can compare it to a new EKG if you have chest pain.

I believe that periodic eye examinations, including glaucoma screening, are a good idea.

The future promises many new blood tests for cancer markers, and a variety of health assessment tools using light to examine body tissues. We have a long way to go before we advance to the "Star Trek" physical, but as tools become finer they can tell us more while being less intrusive.

Finally

The subtlest instrument in our possession continues to be the power of human perception and intelligence. For this reason it is vital to consider your own unique family history, tendencies, strengths and weaknesses. Just so, it is important to seek the advice of someone who knows about health and has the experience to understand your qualities.

Mark Twain wrote that a man who has no vices may not live longer, but it will surely seem that way. I like the humor, but in my experience living in the right way is the best guarantee of living your life to the fullest in every sense of the word.