12/24/02	NEWSLETTER	carlstonmd.com
Hello Patients		HOME
I have been working on this newsletter, not quite getting it finished for far too long. As a result, it is that – Far Too Long. I guess reading it can give you something to do in between trying to find some way to recharge your cell phone, to call PG&E; about your lack of power, holiday parties, chasing your trash (or is that your neighbor's) blowing down the street, seeing LOTR again and again, calling PG&E;, visiting family, calling PG&E;, etc etc. My apologies. I hope the information herein justifies your neglecting other tasks. Seriously, I hope you all have a peace filled holiday season with good health and lots of love. Many of you learned that my youngest was pretty sick for much of the fall. She seems to like the winter much better. We avoided surgery and she seems to have fought off whatever it was. Thank you very much for your concern and support during what was an extremely difficult time for us. While I am much more comfortable on the other side of the equation, it was wonderful to feel the support of our community. Best, Michael Carlston
In This Issue:		INDEX
HIGH FAT/HIGH PROTEIN DIETS AND CHOLESTEROL KAVA EXERCISE LOWERS RISK OF HEART ATTACK INDEPENDENTLY OF CHOLESTEROL PAP SMEAR GUIDELINES ANTIBIOTIC OVERUSE IS LESSENING CHOLESTEROL IS NOT ALL IT IS CRACKED UP TO BE VACCINATIONS
HIGH FAT/HIGH PROTEIN DIETS AND CHOLESTEROL		TOP
On a seasonally appropriate note – a low carbohydrate diet might take off more weight that a low fat diet but, surprising many, this type of diet may lower your weight without wrecking havoc on your cholesterol. Several good recent studies support this belief. One new independent study comparing the Atkins dietary regimen to the American Heart Association (AHA) diet discovered a number of positive findings favoring the Atkins approach. Dr. Eric Westman of Duke University studied 120 overweight volunteers, who were randomly assigned to the Atkins diet (very low carbohydrates with 60% calories from fat) or the AHA Step 1 diet (low fat) for 6 months. The people on the Atkins diet on average lost 31 pounds, compared with 20 pounds for those on the AHA diet. As for the lipids: Total cholesterol - fell slightly in both groups HDL (good cholesterol) rose 11% in the Atkins group No change in the AHA diet group LDL (bad cholesterol) no significant change in either group but in both it changed to a less damaging form Triglycerides dropped 22% in the AHA group – no significant change with Atkins
KAVA		TOP
Many of you have heard my comments about the controversy surrounding kava kava. I said that the reports of liver damage out of Europe appeared to be due to the extracts used there. This seemed to be the explanation because, despite hundreds of years of wide spread use in the South Pacific, this problem was previously unknown. Now Swiss researchers have linked the kava liver toxicity to the process of extraction used in Germany and Switzerland. The highly toxic chemical acetone was used to extract what they determined were the active components of the kava. I wrote an article on reading herb labels but it has not been posted to the website yet. I just discovered this preparing this newsletter. The reason seems to be that the file was damaged. I will get it fixed and then posted as time allows. Look it over when it appears, as it will help you understand the issues surrounding herbal quality.
EXERCISE LOWERS RISK OF HEART ATTACK INDEPENDENTLY OF CHOLESTEROL		TOP
Everyone knows that exercise is good for you but we still have a lot to learn about how it helps and the many ways it does so. Vigorous exercise is better but more is also better in a recent study of lipids (cholesterol). Blood lipids changed more with long spells of mild exertion than with short bouts of more intense exercise. Also we have learned that exercise reduces the risk of heart attack even when it does not change the lipid levels. That of course makes a great deal of sense. Cholesterol is not the be all and end all some make it out to be. Exercise changes the stickiness of the blood, increases blood flow to all areas of the body and helps eliminate stress hormones which cause the heart irregularities that kill most heart attack victims. Exercise is just plain good for you as long as you don't go overboard building it up too quickly or ignoring your bodies pleas for mercy.
PAP SMEAR GUIDELINES		TOP
Deaths from cervical cancer have dropped by 70% over the last 50 years. That's largely due to annual Pap tests. Now a better understanding of the natural history of cervical cancer means fewer women need the tests as often, and many don't need them at all, according to the American Cancer Society. A young women should start getting Pap tests approximately three years after she starts having vaginal intercourse, or at age 21. (Old guidelines had women start testing at age 18). * Regular Pap tests should be done every year. However, newer liquid-based Pap tests need be done only once every two years (because they are more sensitive). * At or after age 30, a woman who has had three normal test results in a row needs screening only once every two or three years. That is unless the woman has certain other conditions that raise her risk of cervical cancer (maternal DES exposure, history of vaginal warts, unusually high number of sexual partners) * Women age 70 or older who have had three normal Pap tests in the last 10 years do not need anymore Pap tests. Most women who have had a total hysterectomy -- including removal of the cervix -- do not need Pap testing. The most important exception is if the hysterectomy was performed to treat cervical cancer or a precancerous condition.
ANTIBIOTIC OVERUSE IS LESSENING		TOP
Antibiotic is an ongoing problem in America. Overuse leads to lots of needless adverse effect, bacterial resistance and ineffectiveness when they are really needed. Probably the most common circumstance of antibiotic overuse in humans is in the treatment of colds, bronchitis, ear infections and other upper respiratory tract infections (URTIs) particularly in children. The government and many medical groups have been teaching docs to break this nasty habit. To determine whether these efforts have changed antibiotic prescribing patterns in the U.S., researchers examined data from a large national survey of office-based physicians. They looked at data from child office visits in the years 1995-1998 to pediatricians and family/general practice physicians. In 1998, the first year of intensive educational efforts to curtail inappropriate antibiotic use, children with URTIs or bronchitis were 31% less likely to receive antibiotics than they were in 1995. That is the good news. The bad news is that almost half of the children with URTIs or bronchitis received antibiotics for their viral infections during the 4 years of the study. The message seems to be getting through better with sinusitis which showed a 70% drop in antibiotic prescription rates.
Another "I told you so" - CHOLESTEROL IS NOT ALL IT IS CRACKED UP TO BE		TOP
CRP vs. LDL for Predicting Cardiovascular Risk There is persuasive evidence that C-reactive protein (CRP), a marker of inflammation, is associated with cardiovascular disease. In a recent study, researchers compared the value of CRP levels and LDL-cholesterol (the "bad cholesterol") levels for predicting cardiovascular risk.
LDL-cholesterol and CRP were measured in 28,000 healthy middle-aged women (mean age, 55). Over an average 8-year follow-up, the CRP level predicted a first cardiovascular event better than the LDL level did. Women with the highest levels of CRP were 2.3 times as like to have their first heart attack than women with the lowest levels (after adjusting for other known risk factors). LDL and CRP measure different risks. The women who had both a low LDL and a low CRP were almost certain ( a 99% likelihood) not to have a heart attack during the study.
While many "experts" advise against relying on CRP, I strongly disagree. Certainly as a 48 yo whose father died of a heart attack at 47 I can relate to the desires of patients who don't want to wait for research perfection to take action. What we need at this point is to look at the effects of omega-3 oils/dietary fish consumption, aspirin and folic acid on CRP. As these factors all reduce cardiac mortality, can we measure that effect through CRP and so use it as a reliable gauge of the success of our efforts? The best cholesterol lowering prescription drugs, the statins, are powerful anti-inflammatories and seem to reduce CRP. Some (like me), think that that is their chief means of action.
VACCINATIONS		TOP
Finally, many of you have been asking me about smallpox vaccinations. You can glean my thoughts from the following letter I wrote to the local paper in response to an editorial about misguided parents refusing to immunize their children. It has not been published and I do not expect that it will be – it is longer than the paper's 200 word limit and they are notoriously conservative in their medical attitudes. So I will share with you
SANTA ROSA PRESS DEMOCRAT To The Editor: (My apologies for the length but this column touches on several important and timely issues deserving a thoughtful response) In her recent editorial column, Ann DuBay railed against the fearful and uninformed parents who question the wisdom of vaccination. Before pooh-poohing the opinions of a large group of well-educated people (typically college graduates) who often have spent a good deal of time researching the issue, I encourage critics, such as Ms. DuBay, to do the same. Over the past 30 years in medicine I have seen the good and the bad of conventional medical practices including immunization. Many accepted practices have fallen into disfavor, often to reappear years down the road as the latest best thing. Our only dogmas should be critical examination of all points of view, and sincere, open-minded dedication to relieving suffering. Maybe the greatest lesson has been that humility about the limitations of our knowledge is an essential component of responsible medical practice. In addition to the apparent benefits of immunizations, there are considerable data from impeccable sources that support a healthy skepticism. The old childhood meningitis vaccine we used 15-25 years ago was associated with an increased risk of the disease. This was first documented in a study conducted by the director of the Minnesota Department of Public Health. The DPT vaccine mentioned in the article was withdrawn because it was relatively ineffective as well as the cause of severe adverse effects, an unfortunate combination. The diarrhea vaccine was withdrawn in 1999 after less than one year of use because it was associated with a four-fold increase rate of a severe bowel problem (intussusception) requiring surgical correction. Finally, the last time the US government got into the vaccination business nearly 700 Americans died of Guillon-Barré following swine flu immunization. Mysteriously, the rate of asthma has climbed nearly 300% in American children in the past two decades. Some recent studies conducted by public health officials have linked this to vaccinations or not getting sick with one of the childhood diseases (rubella). Other studies have contradicted the apparent linkage. While there are too few studies on this topic to draw definitive conclusions, the prevailing opinion is that some childhood illnesses appear to make us healthier and vaccinations might hurt or help. What does account for the unexplained rise in autism, asthma and other chronic diseases in our children? The explanation may not be vaccination but we simply do not know at this time. Overplaying the fear card, Ms. DuBay conjures the specter of bioterrorism ala smallpox. Tarnishing her own argument, this example highlights the necessity for careful study to avoid uninformed decisions or certainly before making uniformed pronouncements. Pox viruses generally are easily bioengineered. That is why many of them (chickenpox, mousepox, etc) are used in labs all over the world. It is also why the smallpox used by terrorists would most likely be an altered strain probably making vaccinations ineffective. Ignoring that fact, the CDCs Advisory Committee on Immunization Practices recently issued guidelines stating that the smallpox vaccine is contraindicated in 20-30% of the US populace. Why is it wrong to ask questions? Should any parent simply turn over their responsibility to consider what is best for their child to me or any other authority figure? I often tell my patients that I respect everyone's opinion but I deeply mistrust those who feel they know all the answers. Choosing not to ask questions is the only foolish choice. Sincerely, Michael Carlston, MD
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