Calcium Scans Help Predict Coronary Risk

(HealthDay News) -- Scanning the heart arteries for calcium deposits can help predict future cardiac problems, a new study shows, but experts aren't sure that adding such scans to routine checkups would be worth the cost.

"It has been shown to be predictive" of potential heart trouble, said Dr. Diane Bild, deputy director of the division of prevention and population sciences at the U.S. National Heart, Lung, and Blood Institute, which funded the study. "Whether it is actually beneficial to the people who are screened has not been shown."

A calcium scan using computed tomography (CT) costs $300 to $600. These scans look for calcification -- hardening of the arteries caused by high blood fats and calcium deposits that can eventually cause blood vessel blockage. The scan is a potential competitor for much less expensive tests for coronary risk, such as blood cholesterol and blood pressure readings.

The new study involved more than 6,700 American men and women across a number of racial and ethnic groups -- white, black, Chinese, Hispanic -- who were followed for an average of 3.8 years. It found that the risk of a coronary event was nearly 10 times higher for those with the highest calcium deposit scores than for those with the lowest.

"This study was launched in 1999, a time when there was a lot of interest in whether this new test could predict coronary artery disease," Bild said. "A lot of studies have been done in predominantly white populations. This was one of our efforts to include minority groups."

The study does show that calcium scanning "modestly improves predictions over traditional risk factors," she said. "Several pieces of information are needed in order to understand whether this is clinically useful."

The findings are published in the March 27 issue of the New England Journal of Medicine.

The cost of such scans could be reduced, according to a statement from study lead author Dr. Robert Detrano, professor of radiological sciences at the University of California, Irvine, who is traveling in China. Scans have been done for just $30 in China, Detrano noted.

"It is mostly an issue of cost," said Dr. William S. Weintraub, chief of cardiology at the Christiana Health Care System, the largest health-care system in Delaware, who wrote an accompanying editorial in the journal. "It does add to our discrimination, but it costs a couple of hundred dollars and we're not sure how you use it."

Reducing the cost would make the test more usable, and "more epidemiological studies showing its value in risk prediction would be of great value," Weintraub said.

"But I'd be uncomfortable now with the idea of recommending this for everybody, or even defining a middle ground where we are unsure how we treat people so they get this first," he said.

A calcium scan also carries some risk, since it exposes a person to radiation, Bild noted. "It would be worth it if the benefit outweighed that risk," she said. "We don't clearly have both sides of that equation established."

More information
For more on coronary calcium scans, visit the U.S. Heart, Lung, and Blood Institute.

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Even in Middle Age, Starting to Drink May Lower Heart Risks

(HealthDay News) -- If you start drinking moderate amounts of alcohol in middle age, particularly wine, you can lower your risk of heart attack by up to 68 percent, compared to nondrinkers, a new study finds.

While previous research had suggested that moderate alcohol consumption was good for the heart, it hadn't been clear whether starting drinking later in life confers a benefit.

"Among middle-aged people who began to drink alcohol in the middle age, we found considerable cardiovascular benefit," said lead researcher Dr. Dana E. King, a professor at the Medical University of South Carolina's Department of Family Medicine.

Current American Heart Association guidelines suggest that moderate drinking may be good for you, King noted. "But if you don't currently drink, you shouldn't start, because of the possible negative consequences of alcohol," he said, summarizing the guidelines.

But this new study will challenge that policy, King said. "The study shows, in a natural experiment, what did happen when people started to drink in middle age," he said. "Indeed, there was a considerable cardiovascular health benefit without paying the penalty in mortality or in higher blood pressure. In fact, it improved the cholesterol profile."

The findings are published in the March issue of The American Journal of Medicine.
For the new research, King and his colleagues collected data on 7,697 people taking part in the Atherosclerosis Risk in Communities study. All were between 45 and 64 years old and non-drinkers at the start of the trial.

During the study, 6 percent of the participants began moderate drinking, which was defined as one drink a day or less for women and two drinks a day or less for men.

After four years, those men and women who became moderate drinkers reduced their risk of developing cardiovascular disease or having a heart attack by 38 percent, compared to the non-drinkers.

However, the type of alcohol did matter, King said. "Wine-only drinkers had 68 percent fewer cardiovascular events, whereas the drinkers of beer, liquor and mixed drinks had only a 21 percent benefit, and that was not [statistically] significant," he said.

"A sip of wine with dinner is part of a healthy lifestyle, even if you haven't been doing it previously," he added.

King cautioned that starting to drink isn't a wise choice for everyone. "There's a small percentage of people who, when they start to drink, will drink too much," he said. "People should discuss this with their physician if they have liver disease or a family history of alcoholism or other medical problems."

But Dr. Gregg C. Fonarow, a professor of cardiology at the University of California, Los Angeles, is one heart expert who doesn't think that studies have conclusively proven that alcohol reduces your cardiovascular risk.

People should stick to controlling known risk factors for heart disease -- such as cholesterol and blood pressure levels -- before taking up drinking, he advised.

"A number of observational studies have suggested moderate alcohol consumption is associated with lower risk of cardiovascular" problems, Fonarow said. "However, it has not been established whether it is the alcohol consumption itself or other factors that distinguish those with moderate alcohol consumption from non-drinkers which account for the lower cardiovascular risk."

The new study offered evidence that moderate alcohol consumption was linked to lower heart risks, but there was no difference in overall mortality between drinkers and non-drinkers, he noted.

"The findings suggest that for non-drinkers, adopting mild alcohol consumption may have cardiovascular benefits," Fonarow said. "However, until the potential cardiovascular benefits of moderate alcohol consumption are tested in a prospective randomized trial, there will continue to be debate as to whether this is advisable or not.

"Individuals wishing to lower their cardiovascular risk should stick to what is proven and recommended by the American Heart Association, including maintaining a healthy blood pressure, weight, and cholesterol levels, exercising, and avoid smoking," he advised.

More information
For more on the benefits of alcohol, visit the American Heart Association.

Health Tip: Risk Factors for Type 2 Diabetes

(HealthDay News) - Type 2 diabetes is a disease in which the body doesn't properly process the hormone insulin, which regulates blood sugar. This form of diabetes is controlled with medication, proper diet and exercise, and maintaining a healthy body weight, and normal blood pressure and cholesterol levels.

The National Diabetes Information Clearinghouse lists common risk factors for type 2 diabetes:

• Being overweight.
• Being over age 45.
• Having a family history of type 2 diabetes.
• Giving birth to a large baby (more than 9 pounds).
• Having high blood pressure or high cholesterol.
• Having a history of heart disease.
• Maintaining a sedentary lifestyle and getting little or no exercise.

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No Clear Evidence Meditation Can Boost Health: Study

(HealthDay News) -- There's no definitive evidence that meditation eases health problems, according to an exhaustive review of the accumulated data by Canadian researchers.

"There is an enormous amount of interest in using meditation as a form of therapy to cope with a variety of modern-day health problems, especially hypertension, stress and chronic pain, but the majority of evidence that seems to support this notion is anecdotal, or it comes from poor quality studies," concluded researchers Maria Ospina and Kenneth Bond of the University of Alberta/Capital Health Evidence-based Practice Centre, in Edmonton.

They analyzed 813 studies focused on the impact of meditation on various conditions, including high blood pressure, cardiovascular disease and substance abuse.

Released Monday, the report looked at studies on five types of meditation practices: mantra meditation; mindfulness meditation; yoga, Tai Chi and Qi Gong.

Some of the studies suggested that certain types of meditation could help reduce blood pressure and stress and that yoga and other practices increased verbal creativity and reduced heart rate, blood pressure and cholesterol in healthy people.

However, the report authors said it isn't possible to draw any firm conclusions about the effects of meditation on health, because the existing studies are characterized by poor methodologies and other problems.

"Future research on meditation practices must be more rigorous in the design and execution of studies and in the analysis and reporting of results," Ospina said in a prepared statement.

Bond added that the new report doesn't prove that meditation has no therapeutic value, but it can inform medical practitioners that the "evidence is inconclusive regarding its effectiveness."

For the general public, the report "highlights that choosing to practice a particular meditation technique continues to rely solely on individual experiences and personal preferences, until more conclusive scientific evidence is produced," Ospina said.

The study was funded by the U.S. National Center for Complementary and Alternative Medicine in Bethesda, Md., part of the National Institutes of Health.

More information
The U.S. National Center for Complementary and Alternative Medicine has more about meditation for health purposes.

PSA Test Still Important to Detect Prostate Cancer, Studies Find

(HealthDay News) -- Despite questions as to whether early screening for prostate cancer is accurate, new research suggests it continues to be important.

And even more encouraging news indicates that statins, drugs designed to lower cholesterol, might also reduce the risk of developing prostate cancer. Both sets of findings were presented Sunday at the American Urological Association's annual meeting, in Anaheim, Calif.

Screening for prostate cancer has become controversial, particularly the issue of whether a prostate-specific antigen (PSA) blood test is useful as an early detector of malignancy. Two studies presented at the conference indicate it is still worthwhile to have such a test.

In one study, Dr. Hans Lilja, from Memorial Sloan-Kettering Cancer Center in New York City, and colleagues found that PSA testing of men in their 40s was predictive of developing prostate cancer later. In fact, the higher the initial PSA, the greater was the probability that the cancer would be aggressive, the research showed.

As recently as last month, a study published in the Journal of the National Cancer Institute found that PSA tests "perform poorly in distinguishing between those who develop a lethal prostate cancer from those at low or no risk of disease progression."

But among the patients in the Sloan-Kettering study, risk for prostate cancer was concentrated, with 89 percent of advanced cancers occurring in men with the top 10 percent of PSA levels, the researchers found.

Lilij thinks that men should have an initial PSA test when they are in their 40s rather than waiting. "It is surprising that this marker can predict cancer 20 years later," he said. "We should focus our efforts on those men who are on the highest risk for cancer."

Another study found that among patients who had a radical prostatectomy (removal of the prostate and some of the tissue surrounding it), those who had been screened for prostate cancer were more likely to have malignancy confined to the prostate, compared with men who had not been screened.

"Patients should be screened," said lead researcher Dr. Alexandre E. Pelzer, from the Medical University Innsbruck, Austria. "Screening reduces mortality from prostate cancer by 50 percent in our part of Austria, where screening is done, compared with other parts of the country where it isn't," he said.

Another debate in prostate cancer care is whether patients diagnosed with the disease should be treated immediately or whether watchful waiting is best.

In one study, Dr. Marc A. Dall'Era, and colleagues from the University of California, San Francisco, found that it was not possible to predict how fast the cancer would progress among the study subjects who had what was termed low-risk prostate cancer.

In the study, more than 400 men had their cancer watched monthly. "Among the men on active surveillance, about 28 percent progressed," Dall'Era said. "Over five years, none of the men died from prostate cancer," he added.

Men who opted for treatment were those who had the highest grade tumors, Dall'Era added.
In another study, Dr. Bradley A. Erickson, from Northwestern University, and colleagues collected data on 347 older men who selected watchful waiting. Among these men, 36 percent showed progression and/or underwent secondary treatment. Overall mortality was 30 percent, with 8 percent dying from prostate cancer.

"Men who were more likely to die were those with higher PSA and those whose cancer progressed," Erickson said. "This is the first study to that gives us a natural history of PSA screening."

In a second group of studies, researchers presented evidence that statins might reduce prostate cancer risk.

In the first report, Dr. Janet Colli, and colleagues from the University of Alabama, Birmingham, were able to make an association between declining prostate cancer rates in the United States and statin use.

The researchers said they found the declining death rates were most noticeable among white men who used statins. "There was a very strong correlation between declining prostate cancer mortality rates and declining high cholesterol levels in white males," Colli said.

Colli thinks statin use may be one reason for this decline in prostate cancer mortality. "Future studies are needed to determine the effect of statins on prostate cancer," she said.

In a second study, a research team led by Dr. Robert J. Hamilton, from Duke University Medical Center, found statins lower PSA levels. "In 1,200 men, we found an average 4.1 percent decline in PSA after starting their statin," Hamilton said. "The PSA dropped more if the patient was on a higher dose of a statin."

Moreover, men whose PSA was highest saw the greatest drop in PSA levels after starting statins, Hamilton said. "These men had an average of a 15 percent drop in their PSA," he noted.
Hamilton said studies need to be done to see if statins actually protect against prostate cancer.

He added the concern that statins may not prevent cancer, but rather mask the malignancy through the decline in PSA levels, so some prostate cancers may go undiagnosed.

In a third study, a group headed by Dr. Teemu J. Murtola from the University of Tampere, Finland, collected data on 78,484 Finnish men between the ages of 55 and 67.

They found that there were fewer cases of prostate cancer among men who used statins. "There was a dose-dependent reduction in prostate cancer among users of statins, but not among users of other cholesterol drugs," Murtola said. "The overall risk of prostate cancer was around half of that of non-statin users."

In addition, Murtola's team found that PSA levels were also lower among study subjects without cancer who used statins.

"The association of statins with the reduced risk of prostate cancer should be made known to men taking statins," Murtola said.

More information
For more information on prostate cancer, visit the U.S. National Cancer Institute.

New Cholesterol Check Gauges Kids' Heart Risk

(HealthDay News) -- Whether America's fast-food-and-video-game culture, or some other confluence of factors is to blame, there's no denying that adolescents' health is at risk.

Little wonder, then, that one group of researchers has begun to take a serious look at the long-term health consequences of kids' inactivity. And they are using cholesterol levels as a window into these youngsters' futures.

Obesity, inactivity and cholesterol are closely linked, and data from the latest U.S. National Health and Nutrition Examination Survey (NHANES) finds that 17 percent of U.S. teens are overweight. Just one in four high school students packs enough physical activity into their day, and 12 percent get little or no daily exercise, reports the U.S. Centers for Disease Control and Prevention.

So, measuring kids' cholesterol in a really detailed way may make sense.
"There is growing scientific evidence indicating that cholesterol levels in childhood and adolescence have an effect on the development of plaque in the arteries, which is a clear indication of cardiovascular disease risk," explained study leader Ian Janssen, an assistant professor in the School of Kinesiology and Health Studies at Queens University in Ontario, Canada.

"There is also strong evidence indicating that children and youth with high cholesterol will continue to have high cholesterol in adulthood," he added. "Thus, it is important to start treatment and prevention efforts early."

Using data from the NHANES on more than 6,000 kids aged 12 to 20, Janssen and his colleagues developed age- and gender-specific reference points for total cholesterol, LDL ("bad") cholesterol, HDL ("good) cholesterol and triglyceride fat levels. The new tables, published last year in the journal Circulation, take into account fluctuations in cholesterol and fat that occur as a child matures.

The new reference data are meant to improve upon current guidelines, published by the U.S. National Cholesterol Education Program, which do not account for age-related fluctuations.
Still, Janssen admits that the guidelines have not yet been routinely adapted into clinical care settings in the United States. "These sorts of changes to clinical practice typically take years to manifest," he said.

Dr. Marc S. Jacobson, director of the Center for AtherosclerosisAtherosclerosis Prevention at Schneider Children's Hospital in New Hyde Park, N.Y., said it's unclear how the new tables will be received in the United States.

"It complicates lives of people like me who treat adolescents with lipid problems because instead of just having one number, you have to have four graphs and plot them out by age," he said.
"Instead of having one cut point," he continued, "you have a graph that you have to plot out a percentile. With each lipid profile, you have to decide which percentile this is for that individual's age. And when it goes up and when it goes down, did it go down because of treatment? Or did it go down because of advancing puberty?"

The challenge, then, is to make sense of that information, he explained. "It argues that you almost have to take it into account because you could say if the LDL changes, is it the treatment or is it a change in puberty?"

Currently, the federal government recommends cholesterol screening for children and teens with at least one parent with high cholesterol or a family history of early heart disease.
"Typically high-risk adolescents should be screened, and probably every year or two," Janssen said. "A high-risk adolescent would be one who's had a parent or grandparent with premature cardiovascular disease or high cholesterol, or a teen with other risk factors, such as obesity and high blood pressure."

Other risk factors, such as high blood pressure, obesity, diabetes or smoking, also would trigger cholesterol testing in doctors' offices, "and that covers a lot of kids now," Jacobson noted.
The issue is destined to garner greater attention when a U.S. National Heart, Lung, and Blood Institute (NHLBI) panel updates guidelines on cholesterol screening in children and teens. The new guidance is scheduled for release in April 2008, said Dr. Rae-Ellen Kavey, senior medical officer with the Pediatric Cardiovascular Risk Reduction Program in NHLBI's Office of Prevention, Education, and Control.

"Stay tuned," Kavey said, "because there really is going to be new information."

More information
Find out more about cholesterol at the U.S. National Heart, Lung, and Blood Institute.

The Cardiovascular Cure

The Cardiovascular Cure

Written by John P. Cooke, M.D., Ph.D. and Judith Zimmer
Category: Medical - Diet Therapy
Publisher: BroadwayFormat: Trade Paperback, 336 pagesPub Date: August 2003
Price: $15.95
ISBN: 978-0-7679-0882-5 (0-7679-0882-1)

ABOUT THIS BOOK
The Cardiovascular Cure offers a groundbreaking approach to preventing heart attack and stroke by enhancing your body’s own natural defenses. Dr. John Cooke, head of Stanford Medical School’s vascular unit, has devised a powerful new method for fighting cardiovascular disease without bypass surgery or angioplasty.

Drawing on his own investigations, as well as Nobel Prize-winning research from a team of American scientists, Dr. Cooke provides heart patients with a diet, supplement, and exercise program that will help them feel better in as little as two weeks.

His program also works to prevent heart disease in those at risk.

In 1998, the Nobel Prize in Physiology or Medicine was awarded for the discovery of EDRF (endothelium-derived relaxing factor), a chemical produced in the lining of the blood vessels, which keeps them free of plaque. Dr. Cooke and other investigators have found that specific nutrients can enhance EDRF production and improve blood flow in people with high cholesterol, high blood pressure, diabetes, or other risk factors for heart disease.

This potentially life-saving book shows how anyone can achieve healthier blood vessels (the key to preventing heart disease). A two-week menu plan contains recipes that emphasize EDRF-enhancing foods, and there is detailed information on supplemental nutrients and vitamins that are useful in strengthening the cardiovascular system. Recipes from breakfast (Banana Date-Nut Bread; Blueberry Oat Pancakes; Pineapple Ginger or Tropical Smoothies; Pumpkin Muffins) to dinner (Moroccan Red Snapper; Chicken Wrap with Refried Beans; Soy-Glazed Salmon; Turkey Meatloaf) feature healthy fats found in fish, nuts, and olive oil.

There is also welcome news that red wine and chocolate can be good for you (there are recipes for Double Chocolate Cake and Chocolate Raspberry Surprise). The exercise program consists of the same therapeutic plans Dr. Cooke has prescribed for even his most severely ill patients, many of whom begin to walk and even exercise more vigorously without pain after two weeks. In addition, there are aerobic workouts designed for more active patients.

Dr. Cooke also provides state-of-the-art information (pro and con) on conventional drugs–from aspirin to beta blockers–and medical tests and procedures to further combat cardiovascular disease. With an introduction by Sir John Vane, a Nobel Prize-winning cardiovascular scientist, this book will provide anyone concerned about his or her cardiovascular health with new hope for a pain-free, disease-free life.

From the Hardcover edition.PRAISE“In The Cardiovascular Cure, Dr. Cooke has translated the research of our field into life-saving information that we can all use. If you really care about your cardiovascular health, you must read this book!”--Louis J. Ignarro, Ph.D., 1998 Nobel Laureate in Physiology or Medicine for the discovery of Nitric Oxide“This authoritative book appropriately points out why everyone should worry about the health of their endothelium and, better still, do something to protect it if it shows signs of damage.

Early identification and treatment of reduced nitric oxide release should be the preventive agenda for the new millenium.”--Jay N. Cohn, M.D., Professor of Medicine, University of Minnesota Medical School“This book should be read by all patients with heart disease as well as anyone at increased risk for a heart attack or stroke.

The comprehensive risk reduction program recommended by Dr. Cooke uses the most advanced research to help everyone improve the health of their blood vessels.” --William L. Haskell, Ph.D., Stanford Center for Research in Disease Prevention“The Cardiovascular Cure is a lucidly written description of EDRF and endothelial dysfunction.

Treatment with exercise and a diet rich in arginine, vitamins, and anti-oxidants is important to the many patients prone to develop heart attacks or stroke.”--Dr. Ferid Murad, M.D., Ph.D., Director of the Institute of Molecular Medicine at the University of Texas, 1998 Nobel Laureate in Physiology or Medicine“Helping yourself prevent a heart attack means knowing more than your ‘cholesterol count.’

In this clearly written book, Dr. Cooke introduces you to the important role played by the endothelium (the lining of your blood vessels) in this process, and what you can do to keep this vital organ as healthy as possible.”--Gerald Reaven, Professor of Medicine, Stanford University School of MedicineFrom the Hardcover edition.

ABOUT THIS AUTHORJOHN P. COOKE, M.D., Ph.D., is Associate Professor of Medicine and Director of the Section of Vascular Medicine at Stanford University’s Medical School. He trained at the Mayo Clinic, earning a Ph.D. in physiology there, and he was on the faculty of Harvard Medical School before he was recruited to Stanford to spearhead the program in Vascular Biology and Medicine.

He is a sought-after consultant and has served on numerous national and international committees dealing with cardiovascular diseases, including those of the American Heart Association and the National Heart, Lung and Blood Institute. JUDITH ZIMMER has been a medical journalist for more than fifteen years.

She has contributed to such publications as the New York Times, and Self and Fitness magazines, and she currently writes for academic medical centers in New York City.
From the Hardcover edition.

Calculator Helps Users Gauge Heart Attack Risk

(HealthDay News) -- A new online heart disease risk calculator that can help you understand and gauge your heart attack risk is available from the Mayo Clinic.

The risk calculator on MayoClinic.com asks several questions about your lifestyle and health and then determines your 10-year risk of a heart attack. The risk score is based on a number of factors, such as age, gender, tobacco use, cholesterol levels, and blood pressure.

You can find the risk calculator by heading to MayoClinic.com and looking under "Heart Disease Risk Factors," in the Web site's Heart Disease Center.

About one in 10 people with a risk level of 12 percent will have a heart attack or die of heart disease within the next 10 years, experts say.

Here are five heart disease prevention tips:

• Don't smoke or use tobacco products.
• Get exercise. Regular, moderately vigorous physical activity can reduce the risk of fatal heart disease by 25 percent. Combining physical activity with other positive lifestyle habits, such as maintaining a health weight, can provide even more heart health benefits.
• Eat a heart-healthy diet that includes plenty of fruits, vegetables, whole grains, and low-fat dairy products. Legumes, low-fat sources of protein and certain types of fish may also help reduce heart disease risk.
• Limit intake of saturated fats and trans fat.
• Watch your weight.
• Excess pounds can lead to conditions -- high blood pressure, high cholesterol and diabetes -- that increase the risk of heart disease.
• Get regular blood pressure and cholesterol screenings.
• High blood pressure and high cholesterol can damage your cardiovascular system, including your heart.

More information
There's more on reducing heart disease risk factors at the American Heart Association.

Researching Alternatives: A Talk With Donald Abrams

By Bob Huff
June 2003
You have a reputation as being a rigorous clinical researcher and tough advocate for making evidence-based treatment decisions.

Yet you've also been very open to studying a number of alternative and complementary therapies that have been used in the HIV patient community. How did all these concerns come together and what are you involved with these days?

I was training in oncology at UC San Francisco just as the first AIDS cases were reported. I helped found the AIDS program there and I've been participating in academic clinical research for over 20 years. More recently I've become an associate fellow of the Program in Integrative Medicine at the University of Arizona that was founded by Andrew Weil.

This is a two-year program, mostly online, that is increasing my training and background in integrative medicine, including things like botanical medicine, manual medicine, and spirituality. It's been a stimulating experience so far and I'm really enjoying it.

I've been interested in complementary medicine since the very beginning of my career, so one of the reasons I'm doing the fellowship is to learn more that I can integrate into my own healthcare discussions with my patients. Of course another impetus is to see what other things we might want to do clinical research on.

My intention is to continue to investigate the complementary and alternative approaches that our patients are using. We want to determine whether or not they may be beneficial, but also determine whether or not they may be harmful, particularly in how they interact with the conventional medications that patients are taking.

In the earliest days of AIDS we didn't have any treatment for this new disease; people were dying and everybody was frightened. Being here in San Francisco, we were near the Linus Pauling Research Institute in Palo Alto, so there were a number of people in the city who were proponents of high doses of Vitamin C.

One of the first responses we saw in the early '80s were storefront clinics opening up where people went to receive intravenous injections of very high doses of Vitamin C.

At that point in time we didn't even know that it was a virus causing the disease. So I used to go around on the lecture circuit with someone who would talk to audiences of concerned people who listened to him while hooked up to intravenous infusions of Vitamin C.

Then I would speak as the academician who cautioned people that we really don't know if this is beneficial and there may be some dangers to being hooked up to intravenous vitamin C, and so on. Ultimately, this led to me to write a grant proposal in collaboration with the Linus Pauling Institute.

It was right about the time we learned that HIV was the cause of AIDS so we wrote a proposal to the NIH to study the in vitro effects of Vitamin C on HIV. That grant didn't get funded.

In San Francisco at that time there were also a number of DNCB proponents. DNCB, dinitroclorobenzene, is actually a photographic chemical used for developing pictures, but it is also a skin sensitizer that had been used to test for delayed hypersensitivity reactions.

There were people who believed that somehow it might be useful in restoring some of the T-cell immunity that patients with this new disease were lacking. So there were people who would paint themselves weekly or so with DNCB until they developed these skin reactions, thinking that the skin reaction was some sort of improved T-cell immune response that would help combat the virus.

And again, seeing that people were using this and seeing that we really didn't have much else happening, I worked with some of the DNCB proponents, as well as some experts from the University of California -- I remember Jay Levy was involved, as was Marcus Conant and others -- and we wrote a protocol that we submitted to the FDA for funding. That also was rejected.

Around the time that AZT first became available in 1986, I went to a conference in Japan where I was introduced to some investigators from the Ueno Fine Chemicals company who told me that they had the cure for this disease. They said it was something that was very commonly used in Japan but they couldn't tell me about it until I signed a confidentiality agreement.

That turned out to be dextran sulfate. Not long after I was going through the process of filing the paperwork to get approval from the FDA to do a phase I study of dextran sulfate in the United States when evidently some people heard about it.

They realized that it was a product that was widely available in Japan -- I believe it was used for lowering cholesterol -- so they started an importation scheme similar to what had happened in earlier days with isoprinosine and ribavirin, which were brought across the Mexican border.

But people had now become more sophisticated in their methods and began to import dextran sulfate from Japan to sell in the underground AIDS therapy market.

I remember that activists stormed the offices of a Japanese drug distributor in New York for refusing to make dextran sulfate more widely available. Ultimately it became such a political issue that, even though my clinical trial here in San Francisco didn't show much benefit, Congress got involved and the AIDS Clinical Trial Group (ACTG) was asked to do a study of dextran sulfate through the NIH-funded mechanism. It turned out the drug was not even absorbed into the blood.

Another Japanese product I worked with was lentinin, which was an intravenously administered extract of shiitake mushroom. In Japan it was felt to be an immune booster for patients with cancer. Although it was being used by mainstream doctors in Japan, it was an alternative therapy here because it was not something that we had ever learned about or used in hospitals in the U.S. That's David Eisenberg's description of what an alternative therapy is -- that it's not taught about in medical schools or widely available in U.S. hospitals -- and certainly shiitake mushroom extracts qualified. Again, that's another study we did that had negative findings;

there was no benefit to the intravenous infusions of lentinin. Since I've learned more about botanicals, it would seem to me that if there were immune enhancing benefits to shiitake mushrooms then they are more likely to be obtained by eating them rather than by injecting an extract intravenously.

During that time I was also involved with studies of conventional therapies. Even in the days of early AZT monotherapy, which I was not a big supporter of, I was involved in trying to put some evidence behind the claims of the proponents for these various agents. And since that time, I've had a constant history of investigating conventional therapies through the federally-funded CPCRA (Community Programs for Clinical Research on AIDS), and more recently through the ESPRIT study of interleukin 2, as well as in other, sometimes pharmaceutical industry-sponsored trials. But always ongoing with those studies, I've been involved with clinical trials of complementary and alternative interventions.

When we first became aware of immune thrombocytopenic purpora (ITP) in AIDS, I worked with a nurse who was very interested in therapeutic touch and we studied men with low platelet counts to see if therapeutic touch could decrease their stress and increase their platelet counts. That was another study that turned out to be fairly negative.

I then became interested in traditional Chinese medicine (TCM) and, in fact, one of the colleges of TCM here in San Francisco sent me to China in 1989 just to learn about Qigong (Chi Kung) -- that exercise that's felt to improve the immune system -- to see if it was something that I wanted to study here. Although I never studied Qigong I collaborated with Misha Cohen from the Quan Yin Healing Arts Center here in San Francisco. We did three studies of traditional Chinese herbal interventions for, first, symptomatic HIV, then for patients with diarrhea without a pathogenic source, and then another study for patients with anemia.

The last two were hindered by the fact of being initiated about the time that HAART became available, so patients with diarrhea as well as anemia became scarce. There were also a lot of pills that needed to be taken in these Chinese herbal investigations and patients at that time were taking huge amounts of pills with their antiretroviral regimens, so the studies weren't very attractive. None of these studies had spectacular results and the anemia study was terminated for poor enrollment.

Have "soft endpoints" such as life satisfaction created a problem for designing and conducting credible studies?

The TCM herbal study that we published in 1996 investigated herbs versus placebo in symptomatic HIV infection. At the time of the study in 1993, we had patients with about 14 symptoms on average and we found that there was a significant decrease of symptoms in the herb-treated group -- they decreased from 14 to 12 -- whereas the other group still had 14 symptoms. We also found that they had improved "life satisfaction" which improved by a factor of +0.86 or thereabouts.

Yet, if you look at the rest of the results, the Chinese herbal patients actually lost weight over 12 weeks compared to the placebo group, and their CD4 counts also dropped -- not statistically significant, but it was a trend. So that was an example of where their symptoms improved and their life satisfaction increased, but the parameters that we would normally look at to see if a patient is doing well (i.e., weight and CD4 count) went in the wrong direction. So, although I was also first author on a study that showed that epoetin alfa improves quality of life in HIV patients who are anemic, I'd have to say that a study whose main endpoint is quality of life is something I would find difficult to interpret.

The CPCRA actually did a large study of acupuncture for patients with HIV-related peripheral neuropathy that was published in JAMA. That was a landmark, having the NIH support an acupuncture study, although, again, it turned out to have negative results; acupuncture didn't appear to be effective in treating peripheral neuropathy.

About this time I began trying to study another botanical, which has consumed my efforts for the past decade, and that would be cannabis, or marijuana. Starting in 1992 I began proposing and developing clinical trials to investigate first the effectiveness -- but then I realized that that wasn't going to happen -- so subsequently, the safety of smoked marijuana in patients with HIV.

We finally completed a study in the year 2000, that we hope will soon be published, that looked at the safety of marijuana in patients taking protease inhibitor regimens. And since that time we have obtained funding from the State of California that allows us now to conduct clinical trials to look at the potential effectiveness of smoked marijuana in patients with various syndromes. We have also just completed a pilot study in patients with HIV peripheral neuropathy, which allowed us to ascertain that there was some effectiveness of marijuana. But an open-label pilot study is not going to prove that, so we're now in the process of continuing on with a randomized, placebo controlled, double-blind trial in patients with HIV-related peripheral neuropathy. We're also doing marijuana studies in patients with cancer who have pain who are on opioid analgesics, and another study to look at the effect of smoked marijuana in patients who have delayed nausea and vomiting from breast cancer chemotherapy.

It was working with marijuana and all the problems that are inherent in studying a plant as a therapy that has led me to a broader interest in botanicals and the use of substances that come from nature as medicinal agents. Certainly, for thousands of years, people have depended primarily on these things. Whether or not they worked is unclear, but as an oncologist I know that many of my most potent chemotherapeutic agents were derived from plants. So right now we are waiting to hear if a protocol we submitted to the National Center for Complementary and Alternative Medicine (NCCAM) to investigate the lipid lowering effects of oyster mushrooms in patients on Kaletra is being funded. There's good evidence that mushrooms, including oyster mushrooms in particular, have some activity for lowering blood lipids and cholesterol.

We're also just finishing a three-year NCCAM grant studying the effects of DHEA, dehydroepiandrosterone, which is an over-the-counter adrenal steroid that people are taking for many reasons. We received a grant to investigate it as an antiviral and to see what impact it has on the immune system. Hopefully that data will be available by the end of the year and we will know if DHEA had any impact, positively or negatively, in our patients.

The goal, ultimately, would be to submit a center grant to the NCCAM, to allow us to establish a center here for the study of botanicals in HIV because there are still a number of herbal preparations and mushroom extracts that warrant further investigation for their potential benefit -- and to make sure that they're not harmful in our patients.

Safety keeps coming up again and again as one of the inarguable justifications for doing this research.

There's not a huge amount that we know about some of these botanical products and how they're metabolized, but there's probably more than people think. There are a number of textbooks available that talk about herb-drug interactions. That was the question in our marijuana study: is there an interaction between cannabinoids and protease inhibitors, which are both metabolized by cytochrome P450 enzymes in the liver, that may alter the activity of the protease inhibitors such that patients lose their viral suppression when they mix cannabis with their treatments?

And in fact, in our article that was already published in AIDS, we saw no such effect. We've all heard about garlic and St. John's Wort and their interactions, and I think there are many other agents that we would like to study to make sure that they are not having significant interactions with protease inhibitors. We don't want people to either lose control of their viremia (through underdosing) or experience toxicity (through overdosing) because of antiretroviral concentrations that have been affected by herb-drug interactions.

You had to be enormously persistent to accomplish your marijuana study. In the current political climate, is it going to be more difficult to do marijuana studies?

I think we're blessed to live in the State of California, which is somewhat of a freestanding republic in and of itself. In 1996, the people of California voted to allow physicians to talk to their patients about the medicinal use of cannabis. Then, through the work of Senator John Vasconcellos, one of our state senators, appropriations were made to the University of California that established the Center for Medicinal Cannabis Research (http://www.cmcr.ucsd.edu/). And that Center has had funds for the past three years that allows it to support clinical trials to investigate the use of marijuana for medicinal purposes.

Whereas the NIH and NIDA, via their congressional mandate, could only give marijuana to clinical trials that show that it was harmful (they are the National Institute on Drug Abuse, not for Drug Abuse, as NIDA's director Alan Leshner always reminded me), they were not really able to provide us with marijuana to study the benefits. But now, they have modified their system so they can provide marijuana for peer reviewed clinical trials that will look at its effectiveness as a therapeutic agent -- as long as they are not funding it. So they have now created this ability for us to obtain government marijuana.

Is there a need to increase provider knowledge about these issues?

I think a part of the problem is a lack of communication from both sides. Patients don't really perceive that these substances are something that they need to tell their doctor about -- in fact many studies show they don't want to tell their doctor because they're afraid they're going to be reprimanded or told that they're wasting their money. And many physicians never even think about asking about these things as potential confounders or as things that are causing clinical symptoms.

There also may be a variable of where in the country you are. I know many surveys show that we in the West have the highest percentage of people in the population who are using complementary and alternative interventions. So many of my colleagues here might be more familiar with how to ask the question and what to be looking for.

I remember once seeing a patient at our drop-in clinic who clearly had a drug rash. I looked through his chart -- this was when we had paper charts -- and he had a high CD4 count and a low viral load but he wasn't taking any medications.

So I said to the guy, "You're not taking any medications, huh?" And he said, "No."
"Are you taking any vitamins?" And he said, "Yeah."

So I asked him what he took and he listed about four or five vitamin preparations. Then I asked, "Do you take any herbs?" And he said, "Sure."

And so I listed the three or four herbal substances th
at he took.
"Do you take any minerals?" And he said, "Yeah."
By the time I finished I had a list of 12 different things he was taking.
So I asked, "Well, how come everybody else wrote down that you don't take anything?" And he said, "Well, nobody ever asked me before."


more info at:
http://www.dreddyclinic.com/integrated_med/integrated_med.htm

The biggest threat to the health of most Americans is the health-care system itself.

The biggest threat to the health of most Americans is the health-care system itself. More and more people are being drawn into treatment as a result of an astonishing increase in diagnoses, and ever-expanding definitions of what constitutes a disease.

This actually places these "patients" in greater danger than if they were simply left alone.
One problem is the medicalization of everyday life; everyday experiences such as insomnia, sadness, or twitchy legs are now being diagnosed as sleep disorder, depression, or restless leg syndrome. Especially troublesome is the medicalization of childhood, where trouble reading becomes dyslexia and unhappiness is deemed depression.

Another problem is the drive to diagnose disease early. Illnesses are now being identified in those with no symptoms, but who are merely "at risk." However, advanced technologies such as CT scans, ultrasounds, MRI and PET scans can detect subtle flaws that make practically everyone "at risk."

Meanwhile, at the same time, the definitions or diseases are expanding, as experts drop the thresholds for diagnosing diabetes, hypertension, osteoporosis and obesity. The level of cholesterol deemed "normal" has dropped several times. Merely because of these changes, more than half the population is now "diseased."

This epidemic of diagnoses has in turn led to an epidemic of treatments. And while not all treatments have benefits, almost all of them have harms. While the harms may outweigh the benefits for the severely ill, they can be far worse than the "disease" for those with only mild symptoms.

more informations at: dreddyclinic.com/

References:
New York Times January 2, 2007
Deseret News.com January 2, 2006

Do You Need These Tests?

Q: Do You Need These Tests?
Can you tell me what tests we all should have as we get older? Which ones do you recommend?

A: As we get older, a variety of medical tests can warn of impending problems, with hearts, bones and other chronic disorders. As long as you're in good health and have no unusual symptoms, I don't necessarily recommend an annual physical exam. But here's a list of the tests I do think everyone should have periodically as they age:

Cholesterol: This simple blood test can give you an idea of your heart disease risk. Have your cholesterol tested every five years beginning at age 20 and have your HDL ("good") cholesterol and LDL ("bad" cholesterol) checked if your total cholesterol is over 200. You should also request measurement of serum homocysteine and C-reactive protein, other indicators of heart disease risk.

Bone density: Any woman at high risk of osteoporosis (because her mother had it or because she is light boned and fair-skinned) should have this DEXA scan to determine her bone mineral density and keep track of how it is declining over time.

All women age 65 and older should have at least one DEXA scan to gauge the condition of their bones. We have good drugs to halt and reverse osteoporosis and reduce risk of hip fractures in old age. You should know, however, that DEXA tests also identify bone weakness (osteopenia) that is nowhere near the range of osteoporosis.

As a result of these findings, women may be put on the same strong drugs used to treat osteoporosis - not a wise move, in my judgment.

PSA: This test for prostate specific antigen, a protein produced by prostate cells, can warn men of prostate cancer.

However, false positives are common, and even when the test does detect cancer, it provides no information about how aggressive it is or how likely it is to spread. Until we have a reliable follow-up test to show whether or not a tumor is aggressive, I doubt the wisdom of using PSA as a screening tool, except for men at high risk of prostate cancer on the basis of family history or lifestyle. A newer test, the pro-PSA, may do better.

Discuss prostate screening with your physician.

Mammogram: Every one to two years for all women over 40 to detect early (and curable) breast cancer. Women with a positive family history of breast cancer may want to start screening earlier.

Colonoscopy: A test for early signs of colon cancer; every 10 years starting at age 50, earlier if there is a positive family history.

Blood pressure: Every two years after the age of 18 as long as your blood pressure is normal.
Eye exams: Every two to four years between ages 40 and 65; every one to two years after age 65. If you wear glasses or contacts, you should have your eyes checked annually, regardless of age.

Dental exams: Everyone, regardless of age, should have a dental check-up once or twice a year.
Full body skin exams: Check yourself monthly for moles; an annual skin exam by a physician regardless of age; follow your doctor's recommendations for more frequent exams if you've had any type of skin cancer.

Thyroid tests: All adults, particularly women, should be screened for thyroid disorders at the age of 35 and every five years thereafter.

Pap smears: Women need Pap smears to detect abnormalities that may precede cervical cancer every one to three years.

Diabetes screening: Fasting blood sugar and insulin levels should be checked if you are overweight or have a positive family history.


Weil, M.D.

Regular Exercise Helps Obese Teens' Hearts

(HealthDay News) -- Obese teens who start a regular exercise program can reverse or reduce early signs of heart disease, new research shows.

The finding suggests that continued exercise could decrease their risk of developing hardening of the arteries, heart attacks and strokes, said Dr. Andreas Alexander Meyer, of the University of Rostock in Germany.

"Obese young adults who were already obese in childhood have a high risk of developing serious cardiovascular events," Meyer said. "First events can occur between the age of 20 and 30 years."

Meyer's team studied 67 obese German teens with early signs of hardening of the arteries: decreased flexibility of their arteries and increased thickness in the linings of the carotid arteries of the neck.

"It was in the range we usually see in adults between the ages of 30 and 40," Meyer said. "This is clear evidence of vascular changes in obese children."

During the study, the researchers randomly assigned the teens, who averaged 15 years of age, to either a six-month exercise program or no change in their usual routine.

The exercise regimen included 60 minutes of swimming and water aerobics on Mondays, 90 minutes of team sports on Wednesdays and 60 minutes of walking on Fridays.

In the exercise group, the researchers saw an almost complete restoration of the arteries' flexibility, which resulted in improved blood flow. They also observed a significant reduction in the thickness of the linings of the youths' carotid arteries.

Because exercise also led to improvements in body-mass index (BMI), blood pressure, and cholesterol and triglyceride levels, the researchers concluded that it could significantly reduce the teens' risk of developing heart disease. "Even children who did not lose weight showed improvements in vascular status and obesity-related risk factors," Meyer said.

The study results are published in the Nov. 7 issue of the Journal of the American College of Cardiology.

Meyer cautioned that these benefits would quickly vanish if the teens did not maintain their healthy new lifestyle and strive to become even more physically active. "Generally, in children, we recommend moderate exercise of 45-90 minutes per day to keep cardiovascular risk low," he said.

Parental support is essential, Meyer said, but it can be difficult to convince parents -- who may themselves be obese and sedentary -- that their children's lives depend on eating right and exercising regularly.

"Most obese children don't get sufficient support in their efforts to reduce weight," Meyer said. "We have intensive talks with the parents about their children's medical and vascular status. We try to make clear that the whole family needs to change its risky behavior."

In recent years, childhood obesity has become a worldwide epidemic, affecting an estimated 22 million children under age 5. In the United States, one-third of children are either obese or at risk of becoming obese, according to a 2006 federal report, Progress in Preventing Childhood Obesity: How Do We Measure Up?.

Between 2002 and 2004, the obesity rate for American children and teens increased from 16 percent to 17.1 percent and is expected to reach 20 percent by 2010, according to the report.
"All children and adolescents should engage in at least 60 minutes of physical activity on most, preferably all, days of the week," said Karen A. Donato, coordinator of the National Heart, Lung and Blood Institute's Obesity Education Initiative. She was not part of the study.

"According to the U.S. dietary guidelines for Americans, regular physical activity has been shown to reduce the risk of certain chronic diseases, including high blood pressure, stroke, coronary artery disease and type 2 diabetes," Donato said. "The National Institutes of Health has begun a national education program entitled We Can! (Ways to Enhance Children's Activity and Nutrition) to provide parents and primary caregivers of children with important information and tips on ways to increase physical activity in children and youth, as well as to decrease screen time, and eat a nutritious diet."

More information
For more on childhood obesity, head to the U.S. Centers for Disease Control and Prevention.

Do you know any substances that May Lower Cholesterol

Interest in the heart-health benefits of fish oil dates back about two decades, beginning with a 1980 study showing that Eskimos in Greenland — who eat nearly a pound of fish a day — have low rates of death from heart disease.

In subsequent years, there has been substantial research on the effects of fish oil on the heart and arteries. Laboratory studies have shown that fish oil, which contains what are known as n-3 or omega-3 fatty acids, makes blood platelets less sticky, helps protect the linings of arteries, and may also lower blood pressure. Population studies from several countries have shown lower rates of heart disease in people who eat fish regularly. In 1998, data from the Physicians’ Health Study showed that eating fish once a week versus less than once monthly halved the likelihood of dying suddenly from a heart attack.

Total heart attack rates were not affected by fish consumption or the amount of omega-3 fatty acids ingested. One year later, a report in Lancet described a randomized trial in which men who’d had a heart attack received either a fish oil supplement, 300 mg of vitamin E, both, or neither. The groups who received the fish oil supplement had significantly lower rates of heart attack, stroke, and death during the next three and a half years.

Rates of sudden death dropped by 45%. Additional support for fish oils comes from a report on nearly 80,000 women in the Nurses’ Health Study. Published in 2001 in the Journal of the American Medical Association, this 14-year study found that eating fish at least twice a week versus less than once a month cut in half the risk of strokes caused by clots blocking an artery to the brain.

The Nurses’ Health Study also found that eating one to three servings of fish per month cut the risk of heart disease by 20%, while eating at least five servings a week lowered risk by 40%. Anyone hoping to benefit from fish oil would probably be better off sticking with dietary sources, primarily from cold-water fish such as salmon, trout, mackerel, sardines, and herring. Forgoing meat for cold-water fish, or any fish for that matter, may lower cholesterol and heart disease risk simply by reducing the amount of saturated fat in your diet.

Three groups of people may benefit from fish oil supplements. One group includes people with arrhythmias, or disordered heart rhythms. The omega-3 fatty acids in fish oil can stabilize wayward electrical activity in the heart and calm arrhythmias. The second group includes people with high levels of triglycerides, especially those who can’t control the problem through diet and exercise, because fish oil supplements have been shown to help lower triglycerides.

The third group includes people with coronary heart disease. The American Heart Association recommends that these people eat one serving of fatty fish a day; recognizing that this may be more fish than most people will eat, the association notes that a supplement can be substituted.

Mexican-Americans at Higher Risk for Second Stroke

(HealthDay News) -- Mexican-Americans who've suffered a stroke are 57 percent more likely than non-Hispanic whites to suffer a second stroke, researchers report.

The finding adds to the results of a 1998 study that found that Puerto-Rican American stroke patients face three times the risk of a second stroke as white stroke patients do.

"We found that Mexican-Americans have a higher stroke recurrence risk, but we still don't exactly know why that is," said study author Lynda D. Lisabeth, an assistant professor in the department of epidemiology at the University of Michigan School of Public Health in Ann Arbor.
Lisabeth and her colleagues noted that, compared with a single stroke, recurrent strokes were associated with poorer patient outcomes and an increased risk of death.
Reporting in the September issue of the Annals of Neurology, the authors remarked that 700,000 Americans experience a stroke each year, and for 200,000 of them it's a recurrent event.
Prior estimates had put the average risk for experiencing a second stroke within 30 days of a first incident at between two percent and four percent. That risk rose to between seven percent and 13 percent over the course of a year.
In their four-year study, Lisabeth and her team identified all cases of ischemic stroke occurring among adults over the age of 45 in an urban county of more than 310,000 people located in southeast Texas. Mexican-Americans made up more than half the county's population.
Ischemic strokes, which comprise about 90 percent of strokes, are caused by a blockage in an artery.
Of a total of 1,345 stroke cases tallied, 118 patients went on to suffer a second ischemic stroke. Mexican-Americans accounted for 76 of those recurrences, and had a 57 percent higher risk for stroke recurrence compared to non-Hispanic whites, adjusting for other risk factors.

Having a second stroke nearly tripled the risk of death, compared to patients who experienced just one stroke, the researchers found. This added risk did not differ by ethnicity, however.
In fact, Mexican-American stroke patients appeared to have somewhat better survival rate than non-Hispanic whites, regardless of how many strokes they suffered.

"There are interesting differences, and we need to better understand them," said Lisabeth. "So, now we're exploring some of the social determinants of health to see if they have an influence -- things like religion, and beliefs about fatalism, depression, spirituality."
Other potential factors include "the patient's underlying disease pathology, the medications used, and compliance with prescriptions for conditions like high blood pressure and high cholesterol, as well as genetic factors," Lisabeth said. "All of these can perhaps play a role. But at this point, it's all speculation."

But another expert offered up a different reason.
"Secondary strokes are almost always related to the persistence of high blood pressure and the persistence of diabetes, and half of the Mexican-Americans in the study had diabetes, while only 22 percent of the non-Hispanics had diabetes," noted Dr. Norman M. Kaplan, a clinical professor in the division of hypertension at the University of Texas Southwestern Medical Center at Dallas.
"This fact clearly puts the Mexican-American patients at a much higher degree of risk for any vascular trouble," he said.
Other factors may play a role, Kaplan said.
"These results are not unexpected, because I work in a largely Hispanic area, and I know that Mexican-Americans do not get the medical care that other population groups do," Kaplan added. "In part, it may be cultural: A lot of people in Mexico believe in healers, and there's a lot of folk medicine which doesn't work as far as controlling blood pressure. But an even bigger part of it is certainly poverty, because if you look at any poor population, they're going to get less medical attention. So, we have to look at a wide range of things."

More information
For more on stroke risk, visit the American Stroke Association.

Accutane Shows Strong Link to Higher Cholesterol

(HealthDay News) -- About a third of patients who took the anti-acne drug Accutane developed elevated cholesterol levels, and over 40 percent showed raised levels of blood fats called triglycerides, a new report warns.

These side effects were known to doctors, but prior reports had suggested a much smaller number of users might be affected.

"This is a side effect that we have known about all along. We've been monitoring patients since the day the drug came on the market," said Dr. Stephen Stone, president of the American Academy of Dermatology and professor of clinical medicine at Southern Illinois University School of Medicine in Springfield. "The only thing that is different is the number of patients who have elevated cholesterol or triglyceride levels is greater than the number stated in the original package insert."

Stone was not involved in the study, which was published in the August Archives of Dermatology.

Researchers also found that about one in 10 Accutane users develop higher than normal levels of specific liver enzymes.
The risks should not be overstated, however, said lead author Dr. Lee T. Zane, assistant professor of clinical dermatology at the University of California, San Francisco.

"Having abnormal tests results does not necessarily signal a bad medical outcome. It's just lab tests, not heart attacks," Zane said. "Isotretinoin is undeniably the most effective medication we have for treating severe acne. It can truly be life-changing. We can't lose sight of the fact that isotretinoin is the most important revolution in medical dermatology in the last 30 years."
Accutane (generic name isotretinoin) is the most effective acne medication on the market, resolving some 89 percent of cases. But the drug has potential side effects, the most severe of which is birth defects in the babies of moms who are take the medication while they are pregnant. This risk prompted the U.S. Food and Drug Administration to launch a mandatory registry to track all isotretinoin prescriptions.

The drug package insert currently notes that about one-quarter of patients may experience elevated triglycerides and 15 percent elevated liver enzymes. Other studies have found elevated triglycerides in 5 percent to 18 percent of people taking isotretinoin and elevated total cholesterol in 6 percent to 32 percent of patients.

Previous studies had involved much smaller sample sizes than the new trial, however.
For this study, the UCSF team looked at the frequency of abnormal lab tests among nearly 14,000 patients, aged 13 to 50, who took Accutane for acne between 1995 and 2002.
Among individuals whose pre-treatment lab results were normal, 44 percent developed high triglycerides, 31 percent high cholesterol and 11 percent high liver enzymes while taking the drug. These changes were "generally transient and reversible," the authors noted, meaning that blood test results usually returned to pre-treatment levels once patients stopped taking Accutane.

Ninety-two percent of participants with liver enzyme abnormalities returned to normal after stopping the drug, 80 percent of those with high triglyceride levels and 79 percent of those with high cholesterol levels.

However, the elevations could put people at risk for what doctors call the "metabolic syndrome," the researchers warned.
Metabolic syndrome refers to a collection of unhealthy factors, including hypertension, cholesterol abnormalities, a waist circumference greater than 40 inches in men and 35 inches in women, and hyperglycemia. Studies have shown that people with metabolic syndrome have a 1.5 times increased risk for coronary heart disease.

All of this points to an "added message to do the blood tests," Stone said.
When a patient does have abnormal lab tests, doctors often keep them on the drug but try to manage the cholesterol and triglyceride levels with diet and exercise and, possibly, also with cholesterol-lowering statin drugs.

What's still unclear is whether kids who take Accutane and experience elevations in their cholesterol and triglyceride levels are at greater risk for cardiovascular disease later on in life. "This could be a marker," Stone said.

For now, however, doctors and patients just need to follow known precautions, he said.
"I don't think this changes our appreciation of the overall safety of the drug," Stone said.
More information
For more on Accutane, head to the U.S. Food and Drug Administration.

Dr. Andrew Weil: Living longer, better

Friday, January 13, 2006; Posted: 10:52 a.m. EST (15:52 GMT)
Programming note: CNN's Heidi Collins profiles health expert Dr. Andrew Weil on "Anderson Cooper 360°," 10 p.m. ET Friday.

(CNN) -- Dr. Andrew Weil is arguably America's foremost practitioner of alternative medicine, or as he likes to call it, integrative medicine.
CNN correspondent Heidi Collins sat down with Dr. Weil recently to discuss his new book, "Healthy Aging."
Here is an edited version of their discussion.

COLLINS: Can you make me live longer?
WEIL: I don't know. Possibly by reducing your risks of the age-related diseases, especially cardiovascular disease. But, my emphasis is not on life extension. It's on healthy aging. So, I'm trying to keep you healthy as long as possible.

COLLINS: So, what is the key to longevity?
WEIL: I think the key to longevity is delaying the onset and reducing the risk of age-related disease. Age-related disease are these big categories of illness that become more common after age 60 and that account for a great deal of premature death and disability. So, the big ones are cardiovascular disease, cancer, Alzheimer's disease and its relative. So, I think the emphasis is on preventing those, showing you how to reduce the risk or delay the onset. And if you came to me as a patient, I would look at your family history, personal history to see where your greatest risks were. And then I would concentrate the preventive efforts in those areas.

COLLINS: So, I mean, this isn't all that complicated?
WEIL: I don't think it's all that complicated. It just means doing some work, though. It means doing some homework and then learning the information that you need then applying it. And it's applying it really in all areas of your lifestyle. It means looking at how you eat, how you use dietary supplements, how you exercise, how you handle stress, how you sleep, how you rest, how you deal with your mind. You know, you really need to work in all those areas to ensure healthy aging.

COLLINS: So, if I breathe, if I put flowers in my house, if I get massaged by love, if I have spiritual health, if I walk, dance, golf, and couple other things, I am going to feel better longer?
WEIL: Yes, probably. But, if you ...

COLLINS: I forgot eat fruits and vegetables.
WEIL: Correct. But, if you are smoking also, I probably can't do much for you. And if you're not paying attention to weight and not paying attention to your cholesterol and not paying attention to other medical risks that you may have, you know, you can put all the flowers you want in your house and it's not gonna help. So, you know, we have to attend to that part of you as well.

COLLINS: What's the bottom line with stress? How do we learn to maintain nonstress?
WEIL: There's lots of ways of doing that. Everything from doing yoga to listening to relaxing music to getting massaged. My favorite techniques are breathing methods because they're so cost efficient and time efficient. And these mostly come from the yoga tradition. But, they're simple. I mean, there's a relaxing breath that I teach that takes all of two minutes a day to practice that has a remarkable effects if you do it regularly over time.

COLLINS: How much of being healthy and living longer is really up to the individual?
WEIL: Well, I think most of it's up to the individual. You know, a lot of people ask me how much is genetics and how much is environment and lifestyle? I think it's always both. My way of thinking of this is that we're all dealt a certain hand of genetic cards, some good, some bad. But, it's up to us how we play them.

COLLINS: Okay. So, we'll keep this one simple. But if you were to give me the sort of outline to walk away with today, diet-wise.
WEIL: Eat fewer foods of animal origin; more fruits and vegetables; more plant-based protein from soy foods, for example. Make sure you've got omega-3 fatty acids in your diet, either from oily fish, or fish oil supplements. Try to reduce consumption of quick-digesting carbohydrate foods, which are the ones made from any kind of flour, sugar, high fructose corn syrup.
And try to eat more of the slower-digesting carbohydrate foods, which are beans, whole grains, packed grains, winter squashes, sweet potatoes. Really learn the differences between good fats and bad fats. Use olive oil as a main cooking oil. Include nuts, seeds, avocados, in your diet.
Take a good multivitamin, multimineral supplement. Add things to the diet, like green tea and dark chocolate and red wine, in moderation, if you want their antioxidant effects.

COLLINS: Should we have dogs?
WEIL: I can't imagine life without dogs. It doesn't have to be dogs. There's very interesting medical research showing that people who have pets recover faster from illness. They get out of the hospital faster if they have surgery. So I think there's a lot of benefits to being involved with, you know, other things than yourself.

COLLINS: Anything else?
WEIL: Well, I think aside from eating right, you want to maintain physical activity throughout life. And that doesn't mean you have to run marathons, or go to aerobics classes. Walking is a perfectly good physical activity if you do enough of it regularly enough. You want to learn some method of stress management. You know, as I said, I like breathing exercises. But, you know, anything you can do. You want to really try to identify negative thought patterns that lead to negative behavior, and see how you can change them.
I think you want to keep your mind active, whether that's by learning another language, or changing your computer operating system frequently. You want to stay connected and involved with life. I think you really want to try to focus on the positive attributes that come with aging, as well as the negative ones.

Andrew Weil, M.D.

–Author of:
Eight Weeks to Optimum Health
Spontaneous Healing
The Natural Mind
The Marriage of the Sun and Moon
Health and Healing
Natural Health, Natural Medicine
From Chocolate to Morphine (with Winifred Rosen)

Timing May Be Key to Hormone Therapy

(HealthDay News) -- While controversy on the safety of hormone replacement therapy (HRT) continues, a new study suggests that when a woman begins the therapy may be key to whether or not it will protect her from heart disease.

According to the new report, women who start HRT when they are younger, near the onset of menopause, have about a 30 percent lower risk of coronary heart disease compared with women who never use hormones. However, women who start HRT 10 years or more after menopause, or after the age of 60, gain no cardiovascular benefit from the therapy.

"The timing of hormone therapy in relation to age and time since menopause may be a key factor in whether these hormones protect the heart or increase risk of heart disease," said researcher Dr. JoAnn E. Manson, the chief of the division of preventive medicine at Brigham and Women's Hospital, in Boston.

These findings may help to address the discrepancies in results from earlier studies, Manson said.

The report appears in the January/February issue of the Journal of Women's Health.
In their study, Manson and her colleagues looked at the association between heart disease and HRT as they relate to age. The women in the study had all participated in the Nurses' Health Study from 1976 to 2000.

The team found that women who started HRT near menopause had a significantly reduced risk of heart disease compared with women who didn't start HRT. In contrast, women who started HRT after age 60 or 10 or more years after menopause gained no protective effect from hormone replacement.

"What we need is a way to identify women who are good candidates for HRT versus women who are poor candidates for HRT," Manson said. "The findings that age and time since menopause may be key factors is an important first step."

A lot of women who are good candidates for HRT may have been scared away by findings suggesting no heart benefit or that the risk of heart disease might outweigh the benefits, Manson said. "The risk of heart disease and stroke are lower in the younger, recently menopausal women," she said.

But in older women, existing damage to vessels may be the reason HRT does not protect them from heart disease. "If a blood vessel already has advanced atherosclerosis, hormone therapy may be more likely to cause a clot," Manson speculated.

"However, if the blood vessel is open, the increase in clotting risk usually will not translate into a heart event, and some of the benefits may predominate as improvement in cholesterol, improvement in insulin sensitivity and antioxidant effects. Estrogen may actually delay the development of artherosclerosis in those women," she added.

One expert doesn't think the findings should change current recommendations.

"This is an important question," said Dr. Nieca Goldberg, the chief of women's cardiac care at Lenox Hill Hospital, in New York City. "However, we would need a randomized trial. The results of this study are not going to change the current guidelines on the prescription of hormone therapy," she said.

Goldberg believes that women who want to lower their risk of heart disease should stick to reducing the known risk factors.

"Women should continue to use proven therapy," she said, noting that lifestyle changes, such healthy diets and exercise, "clearly have been proven to reduce risk." Of course, "that may not be as easy as taking a pill," Goldberg added.

In addition, women who need treatment for risk factors like high blood pressure and high cholesterol should be taking medications that have been documented to reduce the risk of heart attack and stroke in women, Goldberg said. "We still do not prescribe HRT for heart disease prevention."

Concerns about HRT were initially raised by the Women's Health Initiative, a landmark study involving 27,000 participants that caused many women to discontinue their use of hormone therapy.

Researchers halted the WHI study in 2002 after they found the regimen entailed more health risks -- most notably an increased risk for breast cancer and stroke -- than benefits.

Several subsequent studies have also questioned the WHI findings. One study noted some women in the WHI project were in their 60s and 70s who hadn't been on hormones before. Because these women were older, they were already at greater risk of cardiovascular problems, researchers reasoned.

More information
For more on HRT, head to the National Institutes of Health.

Be Skeptical About Alternative Therapies

A number of natural therapies are promoted as treatments for heart disease, but few have lived up to the marketing hype when put to the test in scientific studies. And because herbs and other nutritional supplements are not reviewed for purity or effectiveness by the FDA, you can’t be sure that what you’re buying is effective, or even that the bottle contains the substance on the label. If you take any herbal remedies, be sure to tell your doctor.

These preparations may hinder or exaggerate the effects of prescription drugs used to manage coronary artery disease. Indeed, people with heart disease are more vulnerable than most others to adverse drug interactions.

Antioxidant supplements Some people believe that antioxidant pills provide a way to counter the biological oxidation that activates unhealthy LDL and initiates atherosclerosis. But the research hasn’t panned out.

The American Heart Association in 2004 published an analysis of 15 large trials involving thousands of volunteers who didn’t know whether they were taking an antioxidant pill (either vitamin E or beta carotene) or a placebo. The result?

For the most part, there was no evidence that antioxidant therapies lessen the risk of developing or dying from coronary artery disease. Two studies even suggest that antioxidants might make matters worse. A 2001 study of people who had undergone angiography and had a stent inserted found that those who took antioxidant supplements were more likely to experience restenosis than those who did not — even though both groups were taking statins and niacin to prevent just this occurrence.

A 2002 study found that postmenopausal women on hormone replacement therapy who also took antioxidants were more likely to die than women taking only hormones. The research into antioxidants is continuing, but for the time being the best bet is to obtain these vitamins by eating a variety of fruits and vegetables.

Carnitine This amino acid is found in many foods, especially meat, poultry, fish, and dairy products. Carnitine works with several enzymes as a sort of cellular escort service, ferrying fats into the cell to generate energy and then hauling harmful by-products out for disposal.

Proponents of carnitine believe it can help the heart to generate energy more efficiently.

A handful of clinical trials suggest that taking carnitine supplements might have a modest benefit in treating angina, heart attack, and heart failure. At this point, carnitine is in the "promising but unproven" category. If standard treatments aren’t working to keep your chest pain, leg pain, or heart failure in check, talk to your doctor about adding this supplement to your current therapy.

Chelation therapy (chelation & detoxification) uses infusions, or slow injections, of a chemical known as EDTA. This process is sometimes used to remove toxic levels of lead, iron, or other metals from the body. (The chelated metals exit the body via the urine.) Chelation therapy has also been promoted as a way to cleanse the coronary arteries.

Proponents say a series of 30 or so intravenous infusions will dissolve cholesterol-filled plaque and offer a natural way to ease angina or avoid heart surgery. But so far the research hasn’t substantiated these claims. An analysis of 22 studies found that chelation improved neither objective measures like capacity for exercise nor more subjective outcomes like symptom relief and quality of life. Chelation can also have serious side effects, such as kidney failure, dangerous heart rhythms, and convulsions.

Many experts believe chelation therapy is worthless. Yet thousands of people are paying thousands of dollars each year to receive this treatment. The last word on the subject may arrive in 2007, when the results of a randomized study, involving 100 medical centers and sponsored by the National Center for Complementary and Alternative Medicine, is completed.

Coenzyme Q10 This vitamin-like substance is found in almost every cell in the body, but it is most prevalent in tissues with high energy demands, such as the muscles or the heart. Many advocates of alternative medicine believe that it can strengthen the heartbeat by increasing the cellular fuel available to the heart muscle. And some small studies have suggested that it might help people with angina, heart failure, or other cardiovascular problems.

Other studies, however, report that coenzyme Q10 is of little benefit in these situations. For now, it appears that this supplement is safe, but there is no good evidence that it improves heart health.

Policosanol This product is marketed as a cholesterol fighter. Some small, short-term studies indicate that it lowers harmful LDL and raises helpful HDL levels about as well as a low-dose statin. It also appears to make blood platelets less sticky, thereby reducing the risk for blood clots.

However, almost all studies done on policosanol were carried out by a single research team in Cuba. And no one knows if taking this product will result in fewer heart attacks and strokes. Finally, some policosanol sold in the United States is made from beeswax, which may or may not have the same effects on cholesterol as the product used in the Cuban studies, which was derived from sugarcane wax. At this point, the better bet to control cholesterol is to eat a healthy diet, exercise regularly, and take a statin if necessary.

From the Harvard Health Publications Special Health Report,

The Healthy Heart: Preventing, Detecting, and Treating Coronary Artery Disease.

Copyright 2005 by the President and Fellows of Harvard College. I

llustrations by Harriet Greenfield, M.A., Scott Leighton, Michael Linkinhoker, and Ed Wiederer. All rights reserved. Written permission is required to reproduce, in any manner, in whole or in part, the material contained herein. To make a reprint request, contact Harvard Health Publications.

Used with permission of StayWell.