Columns Archive - Page 32 of 32

In medical laboratories, garlic is coming up roses

February 19, 1996 by Judy Foreman

Garlic, the “stinking rose” beloved by gourmets and health gurus for nearly 4,000 years now, is finally getting respect from the mainstream medical establishment.

First mentioned in 1550 B.C. in an Egyptian medical papyrus, then given a whiff of credibility in 1858, when Louis Pasteur discovered that its juice kills bacteria, garlic is now one of the hottest phytochemicals – plant compounds – in medical research.

In cancer centers, government labs and dietary supplement factories, garlic in all its many forms – raw and raunchy, stewed and sweet, deodorized and dandified – is being hungrily studied, not to mention munched, by eager scientists.

But the more they tease apart the 60-to-100 compounds in garlic’s crescent-shaped cloves, the more complicated its chemistry turns out to be.

In fact, the chemistry is so ridiculously complicated – you definitely don’t want the details – that garlic supplement manufacturers could almost, but not quite, be forgiven for all their glaring omissions, spurious claims and misleading ads.

Such sins aside – for the moment – there’s no question that garlic research has become mainstream and that scientists are starting to understand how garlic may help fight cancer, heart disease and other ills, just as old wives’ tales have long said. Several months ago, for instance, the National Cancer Institute, long interested in the potential of some foods and herbs to prevent or treat cancer, threw its weight behind a study of 3,600 people in Shandong province in China. In 1988 and 1989, epidemiological studies of thousands of people in Shandong had shown that the risk of stomach cancer was lowest among people who ate the most garlic.

To find out if garlic can actually prevent cancer in high-risk people, NCI epidemiologist Linda Morris Brown and others have begun a randomized clinical trial in which Shandong residents will get supplements of aged garlic extract and others, a look-alike placebo.

While it might have been better in some ways to let some people simply eat more garlic than others, says Brown, supplements were necessary to ensure that the trial subjects didn’t know who was getting the extra garlic and who was not, lest those expectations – the placebo effect – influence the results.

And that’s just one sliver of a growing body of research, some of it paid for by supplement manufacturers, on garlic’s medicinal potential.

Several months ago, Pennsylvania State University researchers found in a randomized, double-blind study of men with high cholesterol that aged garlic extract has a “mild cholesterol-lowering effect.”

Brown University researchers found much the same thing in 1994. Nine 700-mg capsules of aged garlic extract a day lowers cholesterol by a modest 8 percent, says Robert I-San Lin, a co-author of the study. Lin is also director of nutrition at the Nutrition International Co. in Irvine, Calif., which sells vitamins and meal supplements and helped support the study.

At a garlic conference in Berlin last fall, British and Australian researchers pooled data from 16 studies on cholesterol and found that garlic has a small beneficial effect.

In similar work involving eight pooled studies on blood pressure, they found that garlic lowered systolic blood pressure (the top number) by about eight points and diastolic pressure (the bottom number), by 5 points.

Garlic may also fight cardiovascular disease in yet another way – by reducing the tendency of platelets in the blood to clot and stick to artery walls.

And emerging data suggest garlic can fight cancer as well.

Dr. Manfred Steiner, a hematologist at East Carolina Medical School in Greenville, N.C., has found that SAMC (S-allyl mercaptocysteine, a consituent of aged garlic extract) can stop the process by which cells divide and grow in both normal and cancerous cells, at least in the test tube.

“You add these compounds and you can watch what happens,” he says. “Cell growth slows and cells die off.”

Like Steiner, John Pinto, a biochemist at Memorial Sloan-Kettering Cancer Center in New York, has documented the ability of garlic to slow cell growth and says it may help fight cancer in other ways as well.

SAMC, for instance, may keep cancer from getting started by protecting the genetic molecule DNA against damage from free radicals, the destructive forms of oxygen that are formed as food is burned. In test tube experiments, Pinto has found that SAMC protects against this damage by boosting glutathione, a natural free radical fighter.

SAMC and its chemical cousins may also act as chemical pumps, Pinto adds, pushing into overdrive a complex family of enzymes that detoxifies carcinogens and drugs, the so-called cytochrome P-450 system.

By activing these enzymes, garlic seems to help keep carcinogens away from DNA and then, using other molecules, to escort the carcinogens out of cells, Pinto says.

Microbiologist Michael Wargovich at the M.D. Anderson Cancer Center in Houston, who is also studying garlic’s effects on the P-450 system, agrees. In fact, his latest project, presumably awaited with bated breath by backyard chefs, is to find out whether garlic can detoxify the carcinogens created when hamburgers are burned.

And other recent studies, including two supported in part by Wakunaga of America Co., the world’s leading manufacturer of garlic supplements, have shown that garlic constituents may retard bladder and breast cancers in rodents.

All of which, of course, is music to manufacturers’ ears.

The public is so ga-ga about garlic, in fact, that the world market for supplements is now $ 250 million a year, says William Sterling, director of sales and marketing for Wakunaga, which has the lion’s share, $ 200 million a year.

But the mere fact that sales are booming does not mean that supplements are any better than natural garlic. And you certainly won’t find much enlightenment on the labels.

Many labels don’t even say which compounds are in the product, much less how they may help or harm you, because supplements are not tightly regulated by the US Food and Drug Administration, as drugs are.

And labels often make little sense, like some touting a garlic component called allicin. Some products may not even contain active allicin because allicin breaks down so easily, says biophysicist Lin of California.

And even those with allicin “potential,” which are supposed to creat allicin in the body when mixed with water, may not do so because stomach acids block allicin formation, he adds.

Besides, even if you could get lots of allicin into your system, it might not be a good idea because allicin can irritate the digestive tract, just as raw garlic can. In fact, the nutritionists who run the Garlic Information Center in New York say supplements without allicin may be safer than raw garlic.

The real problem, though, is not that supplement makers are making a bundle on our garlic gullibility, but that researchers, despite recent progress, still don’t have the answers.

“We still don’t know precisely which constituents of garlic work best or whether it’s better to eat real garlic or take supplements,” says Dr. Richard Rivlin, program director of the clinical nutrition research unit at Sloan-Kettering.

Nor does anybody know how much garlic we should consume, though Lin of California, is willing to offer his best guess.

He recommends a daily dose of 10 grams (or three cloves) of natural garlic, which is equivalent to 4 grams of garlic powder or 40 milligrams of garlic oil, though cloves, powders and oils all have different constituent chemicals.

(There’s no way to translate natural garlic into aged extract equivalents because some compounds in the extracts are not in raw garlic.)

However you take it, the bottom line, as Pinto of Sloan-Kettering puts it, is that “some garlic is better than none.”

A garlic chemistry primer

The main component in raw garlic is alliin. But as soon as you crush or cut a clove of garlic, an enzyme called alliinase is released, converting alliin into allicin.

Allicin, which gives garlic its odor, is a strong oxidant, that is, a chemical that creates free radicals, which in excess, can be dangerous. Allicin can cause stomach irritation and, in rare cases, hemolytic anemia, destruction of red blood cells. If if placed directly on the skin, allicin can cause blistering. During cooking, allicin produces ajoene, DADS (diallyl disulfide) and other compounds that may help keep blood from clotting.

During aging, alliin and allicin are converted to water-soluble compounds such as S-allyl cysteine and S-allyl mercaptocystine, which have little odor, are stable and survive cooking. These are among the ingredients in “aged garlic extract” supplements and may help combat cancer and protect against heart disease.

Garlic also contains oil-soluble compounds like DAS (diallyl sulfide) and DADS which may have beneficial effects on blood pressure, lipids and clotting and may help prevent cancer.

Where to call

For more information on garlic, you may call:

The Garlic Information Center hotline, 1-800-330-5922, The line was set up last year by researchers at Cornell University Medical College.

Fear of aids is no reason to avoid dentist

February 12, 1996 by Judy Foreman

At 2:30 on a Monday afternoon in the summer of 1989, James Sharpe, a convenience store owner from Northampton, settled back in the dentist’s chair to have three teeth extracted.

AIDS was, presumably, the last thing on his mind, and he certainly had no risk factors for the disease.His dentist, Dr. Anthony E. Breglio, was not infected with the AIDS virus, quite unlike Dr. David Acer, the Florida dentist who was infected and passed the virus to six patients.

Furthermore, no other patients Breglio had treated earlier that day are known to have had AIDS.

Breglio practiced the type of infection control that most dentists used at the time – soaking his drills and other similar tools in chemicals, says Dr. Alfred De Maria, director of communicable disease control for Massachusetts, who looked into the case in 1991.

Today, Sharpe has AIDS, and he blames it on poor sterilization of dental equipment by Breglio, whom he is suing in Hampshire County Superior Court. Seven weeks after his dental visit, Sharpe developed flu-like symptoms; when other tests came back negative, he had an AIDS test. It was positive.

Whatever the outcome of the Sharpe case, which is expected to go to the jury this week, it has revived one of the nagging fears of the AIDS epidemic: that you can catch it just by going to the dentist.

How realistic are those fears?

Not very, say many infection-control specialists. And whatever the odds were in 1989, they are even tinier today.

In fact, if you’re looking for an excuse to avoid the dentist, you’d be better off with the old “My dog ate the appointment card” line.

But fear is a notoriously stubborn thing, and in the case of invasive medical procedures, not irrational. So like a diligent dentist picking around with that nasty little “explorer” tool, let’s take a close at the evidence.

With the Sharpe case still unresolved, there has been not one documented case in which a person has caught AIDS from dental equipment, even though Americans make nearly 500 million dental visits a year. If you want to calculate the risk ratio since the AIDS epidemic began in 1981, that’s zero cases over a denominator in the billions.

In fact, even if all 32,381 AIDS cases in which the mode of infection is unknown were actually caused by dental equipment – which is unlikely – the risk would still be vanishingly small.

Furthermore, Acer’s six patients are the only documented cases of AIDS transmission from a dentist infected with HIV. Federal health officials have never been able to pinpoint whether Acer cut himself and then accidentally exposed patients to his blood, failed to sterilize his equipment properly or infected his patients intentionally.

“There were some problems with his infection-control methods,” acknowledges Dr. Harold Jaffe, associate director for the HIV-AIDS National Center for Infectious Diseases at the federal Centers for Disease Control in Atlanta. “But we didn’t prove the route of transmission.”

The Acer case aside, there have been zero – count ’em, zero – documented cases of HIV transmission from infected health care workers to patients. And this holds true even after “look-back” studies involving 22,000 patients, though critics note that there were some methodological flaws in these studies.

By contrast, at least 40 health care workers have been infected by patients.

Still, there’s no question that, under pressure from nervous patients, dentistry been getting safer.

In 1989, when Sharpe believes he was infected, American Dental Association guidelines recommended sterilization by autoclave (which uses intense heat and steam under pressure), but said disinfection with chemicals, a less surefire germ-killing method, was also adequate, says Dr. Richard Price, a Newton dentist and ADA spokesman.

In 1992, the ADA toughened its stance, recommending that all metal instruments, including drills, be heat-sterilized after each use by autoclave, dry heat or chemical vapors. It also said chemical disinfection was no longer adequate.

This proved difficult, however, because many handpieces had to be taken apart to be sterilized or could not withstand heat, prompting some dentists to continue using chemical disinfectants instead.

Even today, some dentists don’t heat-sterilize as they should. The ADA’s own survey last year found that 92.5 percent of dentists heat-sterilize handpieces before each use – up from 25 percent in 1990 – but that still leaves 12,000 who don’t.

And some specialists, like David Lewis, a microbial ecologist at the University of Georgia, contend that only 50 to 80 percent of dentists heat-sterilize tools after each patient.

The technology has improved so much that dentists “can sterilize handpieces in toto now, without taking them apart, because manufacturers have made all the components heat-resistant,” says Price.

In 1993, the CDC issued its own infection-control guidelines, which don’t carry the force of law but are generally followed. These call for sterilizing with an autoclave, dry heat or chemical vapor all instruments that penetrate soft tissue or bone, like the burs used for drilling, as well as instruments that contact oral tissues, like mirrors.

Because the internal surfaces of high-speed handpieces and other devices can become contaminated, the CDC concluded that “soaking in liquid chemical germicides” is not acceptable infection control.

In practice, though, some dentists still use chemicals to sterilize equipment that is not heat-resistant, like the tabs that hold X-ray films.

“Cold sterilization with chemicals obviously only works for surfaces that the chemicals can reach – not for instruments with tiny nooks and crannies or hollow tubes – but it does work well for these solid surfaces,” insists Price of Newton.

“But things are evolving even as we speak, and as of this week, because of questions remaining in patients’ minds, I am doing away with cold sterilization myself.”

Increasingly, he adds, dentists are turning to materials they can use once and throw away, like devices used to polish teeth and the tubes that suck saliva out of the mouth.

So does this mean all risk of AIDS in dentistry is gone?

Not quite. A small risk will remain as long as there is any dentist out there who does not heat-sterilize or throw away after use everything that goes in your mouth.

That’s because, as Lewis showed in studies published in 1992 in the journal Lancet and last year in Nature Medicine, the AIDS virus can get into dental equipment and survive “up to several days” in the lubricating fluids inside the instruments.

Lewis, who testified last week for Sharpe, took blood from AIDS patients and mixed it with lubricants, then immersed the lubricants in a 2-percent solution of glutaraldehyde, a disinfectant. The virus survived.

“And if glutaraldehyde couldn’t kill the AIDS virus, then no chemical disinfectant used would be effective. Only heat effectively kills the AIDS virus in dental devices,” he said in a telephone interview. “But if the equipment is properly sterlized, there should be no concern.”

Dr. Sanford F. Kuvin, who also testified for Sharpe last week, charging that “dirty dentistry” was involved, agrees “there is no risk if the dentist or other invasive dental health care worker is HIV-negative and if sterilization is proper.” If not, he said, “there is a risk that’s somewhere between infinitessimal and small.”

So how can you tell if your dentist is doing the right thing?

“Ask questions and don’t stop until you’re satisfied,” advises Price, though for many patients, that’s easier said than done, especially with a mouth full of dental hardware.

Still, you could start by asking how much your dentist has spent to meet infection-control guidelines, including guidelines to protect dental employees. Many dentists have spent $ 24,000 a year to comply and may be quite happy to tell you so.

Ask if your dentist uses an autoclave, and if you’re in doubt, ask to see it. Then ask how often your dentist checks to be sure it’s working.

After that, you might as well relax because, as Price puts it, “There’s got to be some trust.”

Dr. Martin Hirsch, director of clinical AIDS research at Massachusetts General Hospital, agrees.

“I hate going to dentists,” says Hirsch, “but I think the risk of spread of HIV is infinitessimally low in that setting and people shouldn’t avoid dentists for that reason.”

Look and ask questions

Things to look for and ask about at the dentist’s office:

Is the room clean and orderly, and do surfaces and equipment appear clean?
Is the staff willing to answer your questions?
Do the dentist and other dental workers practice “universal precautions,” including wearing gloves and other protective gear during your treatment?
Are needles and other sharp items disposed of in special puncture-resistant containers?
Is everything that goes in your mouth heat-sterilized or disposable? (If you’re worried about non-heat-resistant items like the gadgets that hold X-rays, ask. American Dental Association guidelines say it’s acceptable, though not preferred, to use chemicals to sterilize these.)
How often is the autoclave machine checked? (Federal guidelines say it should be checked at least weekly.)

If you’re still worried, call the state Board of Registration in Dentistry (617-727-7368 begin_of_the_skype_highlighting 617-727-7368 end_of_the_skype_highlighting).

The agony of the feet

January 29, 1996 by Judy Foreman

Catherine Wright, 61, a retired telephone operator from Quincy who cheerfully admits she wore “fancy high heels” for years, sat propped up, admiring her podiatrist’s handiwork.

On her right foot, where a mish-mash of hammertoes and a nasty bunion had been, Wright had a long incision and a string of neat, black stitches from her big toe halfway along the top of her foot. Her other newly-straightened toes sported smaller incisions — and steel pins to keep them aligned as they healed.

“I don’t think it’ll ever be beautiful,” she said, as her husband Scotty looked the other way, “but I’ll paint up the toenails and be able to walk without pain.”

In the examining room next door, Irene Pozzi, 72, a retired clerical workerfrom Dorchester, gazed at her right foot, a monument to her ongoing battle with rheumatoid arthritis.

Her index toe lay at a right angle to her leg, crunched under her other toes. “I ignore it,” she said matter-of-factly, more interested in her glowing pink, freshly-scraped calluses.

In the waiting room, every seat was taken. A 62-year-old Roslindale man wondered why his foot swelled when he walked. A 57-year-old Dorchester woman wanted her excessively thick toenails cut. A 69-year-old Hingham woman had corns that needed some TLC.

But the crowd this recent January morning was actually nothing special. Business is always booming in the homey South Boston offices of podiatrist Edward Hurwitz, as it is for foot specialists nationwide, because most of us, as we age, either can’t or won’t take good care of our feet ourselves.

Every year, 5.4 million people with sore feet hobble to medical doctors, according to the National Center for Health Statistics.

And that doesn’t include the 68 million of us who take our aching bunions, heels spurs and ingrown toenails to podiatrists, who are not M.D.’s but have four years of post-college training in one of the nation’s seven schools of podiatric medicine.

Indeed, as we walk, run or stumble through life, 75 to 80 percent of us get foot problems of some sort, and the risk goes up sharply with age, says Glenn Gastwirth, deputy executive director of the American Podiatric Medical Association.

Usually, the problems are pedestrian — like hammertoes, a claw-like condition that is triggered by muscle problems and exacerbated by shoes that crunch up the toes; or bunions, which are caused by an inherited tendency toward misaligned big toes and are made worse by bad shoes.

But sometimes, foot problems can be deadly serious, especially for America’s 16 million diagnosed diabetics and another 8 million who have diabetes but don’t know it.

One in four people with diabetes develops foot problems, says podiatrist Pamela Colman of the 10,000-member podiatric association, and for many those problems are tragic.

Every year, government figures show, people with diabetes have more than 50,000 leg amputations above or below the knee, and 34,000 have foot or toe amputations. About half of these surgeries could be avoided with proper foot care.

The problem in diabetes, specialists say, is that excess sugar in the blood triggers a process called glycosylation, in which glucose molecules and their breakdown products infiltrate and stiffen bodily tissues. When this happens in peripheral nerves — like those in the arms, legs and feet — the ability of the nerves to function properly declines markedly.

And without good nerve function, people with diabetes simply don’t feel the pain that tells other people when blisters, calluses or ingrown toenails are becoming infected.

Because diabetes also causes circulatory problems, many people with diabetes also have decreased blood flow to the feet, which means immune cells can’t keep up with otherwise routine infections in the feet, says Geoffrey Habershaw, chief of podiatry at Deaconess Hospital and the Joslin Diabetes Center.

In that joint program and at one other center — the University of Texas Health Science Center in San Antonio — doctors are finding that good foot care reduces amputations.

At the Boston center, many people’s feet are saved by antibiotics — often a combination of several kinds to combat the mixed bag of germs in most foot infections — plus reconstructive surgery and bypass surgery to restore circulation.

The payoff has been dramatic. Fifteen years ago, nearly a third of diabetics with foot infections wound up with an amputation. Today, though the amputation rate is not falling nationwide, it is just 4 percent in the Deaconess-Joslin program.

Specialists are hoping that a two-year-old program called LEAP — Lower Extremity Amputation Prevention program — may bring similar benefits to more people.

Through the government’s LEAP program, health care providers learn to assess nerve function with a simple instrument called the Semmes-Weinstein monofilament, essentially a piece of fishing line that pops out of a plastic handle with 10 grams of force. If the individual cannot feel the tiny pricking sensation, it is a sign of faulty nerve function in the feet.

For most people, though, it’s not the dramatic complications of diabetes but the humdrum effects of aging that cause the most foot problems.

“As people age, ligaments lose elasticity,” especially in those who gain weight,” says Hurwitz of South Boston. “You don’t get bunions because you wore Mary Janes when you were 12, but from bad genes, bad shoes and wear and tear, as ligaments and tendons get loose.”

In fact, years of wearing attractive but orthopedically-disastrous footwear — including shoes that are too narrow and shoes with more than a one-inch heel — are the main reason women have four times the foot problems of men.

So if you’re among the millions who think it’s normal to kick off your shoes at night and moan, “My feet are killing me!” there’s a simple message: Think again.

Feet are not supposed to hurt. If yours do, it’s time to get help, from a podiatrist or an M.D. trained in orthopedics, like the 14,000 members of the American Orthopedic Foot and Ankle Society, who have four years of medical school plus four to six years of residency training.

For most things, like bunions, corns, heel pain and the like, it probably doesn’t matter which type of specialist you see, as long as he or she is licensed. But podiatrists vary widely in surgical training and experience, so be sure to ask.

For problems above the foot — notably the ankle — it may best to see an orthopedic surgeon.

“If I were a patient with an ankle problem,” says Dr. Mark Myerson, director of foot and ankle services at Union Memorial Hospital in Baltimore, ”I would not go to a podiatrist because podiatrists, across the board, are not generally trained in ankle problems but in problems of the feet.”

The same goes, in his view, for bone fractures and deformities of the feet, including arthritis.

But many podiatrists, among them Habershaw of the Deaconess, disagree, noting that many podiatrists take advanced residency training after podiatry school.

Whomever you consult, what counts is getting help before minor problems become major.

Take it from Catherine Wright, who should know: “I just kept putting things off.”

SIDEBAR 1THE MOST COMMON FOOT PROBLEMS

– Blisters, caused by skin friction. Don’t pop them. Apply moleskin or a Band-Aid and leave in place until it falls off naturally in bath or shower. Keep feet dry and wear socks to cushion feet. Seek help if blisters become inflamed or painful.

– Bunions, misaligned big toe joints that can become swollen and tender. Bunions tend to run in families, but the tendency is aggravated by shoes that are too narrow in the toe. Surgery is recommended if the bunion affects your lifestyle.

– Corns and calluses, protective layers of dead skin caused by friction of bones against skin. Corns may be caused by too-tight shoes and crooked toes. Calluses are caused by friction from faulty foot mechanics, often from arches that are too high or too low. You should file calluses and corns with a pumice stone, but never cut them with sharp instruments. And don’t try to burn them off with acids.

– Hammertoes, a condition in which the toes are bent in a claw-like position. Usually caused by muscle imbalance, but can be aggravated by bad shoes. Buy shoes with ample toe room and soft uppers, the part of the shoe above the sole. If hammertoes affect lifestyle, surgery may be needed.

– Heel pain or heel spurs, caused by plantar fasciitis, an inflammation of the connective tissue on the bottom of feet. They’re caused by faulty foot structure that puts stress on the heel bones. Try over-the-counter anti- inflammatory drugs and ice. Orthotic devices may help redistribute weight.

– Ingrown nails, which dig into the skin because of improper trimming, shoepressure, injury, fungal infection, heredity or poor foot structure. Nails should be clipped straight across, slightly longer than the end of the toe.

– Neuromas, enlarged, benign growths of nerves, usually between the third and fourth toes, caused by bones rubbing against nerves. Orthotic devices and/ or cortisone injections may help, but surgery may be needed if neuromas affect lifestyle.

– Warts, caused by a virus that enters the skin through small cuts. Warts usually go away without treatment. Over-the-counter medication may help, but don’t use these acids on calluses. Warts can also be treated with minor surgery.

SIDEBAR 2A CHECKLIST FOR FOOT CARE

– Check your feet daily for cuts, sores, bumps and red spots, especially if you have diabetes. If you think an infection is brewing, see a foot specialist immediately.

– Have your doctor check your feet at every visit.

– Wash your feet in warm, not hot, water, every day. Do not soak feetbecause this can dry your skin. Dry well between the toes, then put on moisturizing cream to reduce skin cracks.

– Cut toenails straight across. Use an emery board to smooth sharp edges that could cut an adjacent toe.

And when you’re buying shoes:

– Have feet measured while you are standing.

– Try on both shoes and walk around.

– Don’t buy shoes that need “breaking in.” Shoes should feel reasonably comfortable as soon as you buy them.

– Don’t rely on remembering what your size is. Feet get bigger and brands vary.

– Shop for shoes late in the day, because feet swell.

– Get shoes that fit in front, back and sides and distribute your weight well.

– Select shoes with leather uppers, a stiff cup around the heel, appropriate cushioning and flexibility at the ball of the foot.

– If you’re going to wear socks, have them on when you try on shoes.

Specialists offer these tips on foot care:

– Athlete’s foot, a fungal skin disease that starts between the toes or on the bottom of the feet. Symptoms are scaly skin, itching, inflammation and blisters. You can help prevent infection by washing feet daily with soap and warm water, drying thoroughly, and changing shoes and hose often.

Fine-tuning the Pap Smear with Technology

January 22, 1996 by Judy Foreman

The humble Pap test, a screening test so good that American women now die of cervical cancer at only one-fifth the rate of 50 years ago, is one of the best tools in modern medicine.

Unlike mammograms, which detect breast cancers at an early stage, Pap tests spot abnormalities in cervical cells even before they become cancer.

In fact, if all women got Pap tests regularly, the incidence of cervical cancer — still the chief cause of cancer death in developing countries — could approach zero, specialists say.

Ironically, though, just as improvements are becoming available to make the Pap smear even better — by reducing the rate of both missed cancers and false alarms — cost-conscious health planners are wondering whether we can afford the new tests and even how often women should get Pap smears.

Cervical cancer is a sexually transmitted disease caused in virtually all cases by any one of four common papilloma viruses, which are spread primarily by genital skin contact. The major risks are having sex before age 20, having three or more sexual partners or having a history of abnormal Pap smears or genital warts. Smoking adds significantly to the risk because tobacco smoke bathes delicate cervical tissues in tar and nicotine.

Since the 1940s, when Dr. Georges Papanicolaou developed his now-famous method of scraping cells from the cervix, spreading them on a glass slide and examining them under a microsocope, the death rate from cervical cancer has plummeted, though it now seems to be rising again slightly in younger women. This year, it is expected to hit nearly 16,000 American women and kill nearly 5,000.

But those figures only begin to tell the story of what has become a $6 billion-a-year industry. Every year, American women have 55 million Pap smears — at $7 to $15 each — and four to five million of these are abnormal.

In most cases, the abnormal tests turn out to be nothing serious, says Dr. Ellen Sheets, director of the Pap smear evaluation center at Brigham and Women’s Hospital.

But in order to be sure, many women are sent into what doctors call secondary triage — more testing, usually with a $150 exam called colposcopy in which doctors use a high-powered microscope to look at the cervix. This is often followed by freezing, burning or using electrical wires to removesuspect tissue, at another $500 or more per patient.

All this is worth it, of course, if a woman leaves the doctor’s office 100 percent cured, as is usually the case when cervical abnormalities consist of mere dysplasia, the presence of abnormal cells, or carcinoma in situ, a noninvasive cancer.

But it can also be too much of a good thing.

Often, women whose Pap tests are only mildly abnormal “end up with a $500 procedure for a lesion that didn’t need to be treated in the first place,” says Dr. Michael Policar, former vice president of the PlannedParenthood Federation of America and now medical director of the Solano Partnership Health Plan, an HMO in Fairfield, Calif.

The problem, gynecologists say, is that Pap tests are nowhere near as accurate as women assume — or doctors would like.

Granted, things have improved since 1988, when Congress passed a law tightening lab practices following scandals over inaccurate tests read by overworked, underpaid technicians.

But even in good labs, human eyes still miss 20 percent or more of abnormal smears and, somewhat less frequently, tend to see abnormalities where none exist.

Because of this, researchers have been scrambling to fine-tune Pap testing with add-on technology, and a number of devices are now working their way through the US Food and Drug Administration approval process.

Several months ago, the FDA approved a system called PAPNET, which uses computers to re-read normal Pap smears already examined by human technicians. It’s not clear yet whether re-reading by computer “will be more helpful than human re-reading,” says Sheets of the Brigham.

Earlier this month, the FDA also approved for cervical screening a device developed by the Trylon Corp. in California, to be marketed soon by Pharmacia & Upjohn, Inc. in Michigan.

Called Pap Plus Speculosocopy, the device is a tiny light that is taped to a speculum, the standard device used to examine the cervix. After a Pap smear is done, the doctor simply swabs vinegar on the cervix and shines the blue- white light on it. Abnormal cells appear white, normal cells, dark.

The extra test adds $25 and five minutes to a Pap exam, but it can cut the rate of missed abnormalities to about 5 percent, says Dr. Steven Vasilev, director of gynecologic oncology at the City of Hope Medical Center in Duarte, Calif.

Vasilev, who has tested the device in hundreds of women, says “the returns are great, because you are decreasing the chance a patient will come back in two or three years” with cancer.

But many specialists are unconvinced the device will save enough lives to justify the cost. Dr. Diane Solomon, chief of the cytopathology section at the National Cancer Institute says, “I’m not convinced by the data I’ve seen so far.”

Neither is HMO medical director Policar, who says speculoscopy could be “a big deal” as a way to tell which women with abnormal Pap tests need expensive colposcopy. But as “the person who decides which tests to pay for and which not” in an HMO of 45,000 patients, he says he is not sure the test will prevent enough cases of cervical cancer to justify the extra cost.

Dr. Michele Follen Mitchell, director of colposcopy at M.D. Anderson Cancer Center in Houston, is also wary, though she has hopes for her own test, called fluorescence spectroscopy.

Down the line, other refinements may also help make Pap smears more accurate, including a machine to spread cells more uniformly on microscope slides and using infrared light and antibodies to spot abnormalities.

Even before such improvements become available, though, women should not hesitate to get Pap tests. Among all cancer detection tests, the standard Pap test is “probably the only true screening tool that has impacted the death rate,” says Sheets.

Even if doctors don’t know how often women should have it.

For years, the rule of thumb was a Pap test every year, and the AmericanCollege of Obstetricians and Gynecologists still recommends that for sexually active women.

If a woman doesn’t have a yearly Pap test, says Dr. Henry Klapholz, vice chairman of the obstetrics and gynecology department at Beth Israel Hospital, she may skip her annual pelvic exam, the main way of detecting ovarian cancer, as well.

But in 1988, a coalition of medical organizations changed Pap test guidelines. The guidelines say that “all women who are or have been sexually active, or who have reached age 18, should have an annual Pap smear and pelvic exam. After a woman has had three or more consecutive, satisfactory normal annual examinations, the procedure may be performed less frequently at the discretion of the woman and her doctor.”

Concerned about rising costs, “many insurers are pushing” for a three- year interval, says Sheets. In Europe, she adds, women get Pap smears every two or three years, yet have cervical cancer rates similar to those of American women, probably because they are less likely than Americans to skip scheduled exams.

“The real key,” says Cindy Pearson, program director for the National Women’s Health Network, is “to get tested regularly, at the very least every three years. This is the most preventable cancer we’ve got going

High-fat diet helping many with Epilepsy

January 15, 1996 by Judy Foreman

Jason Simon, now 15 and an 8th grader in Sandwich, was only 9 on the day when, as he recalls, he “woke up one morning with a bunch of men standing around to take me to the hospital.”

He had no idea what was going on, but his family was terrified. During the night, his sister had heard him making “gurgling noises,” the first sign Jason was having seizures.

At first, like many of the other 400,000 children with epilepsy — a condition in which people have recurrent seizures — Jason was treated with drugs. They worked, for a while.

But soon, like 30 percent of children on medications, Jason found that no matter which drugs he tried, he still had seizures — and the brain-numbing side effects of the drugs as well.

In 6th grade, he had so many dizzy spells and seizures that he missed 77 days of school. In 7th grade, he was taking 16 pills a day — but still missed 108 days of school.

Reluctantly, his parents agreed to surgery to remove the right temporal lobe of his brain, where his seizures — caused by abnormal discharges of electrical energy from brain cells — began.

Surgery did have one benefit. The courage it took to get through it left Jason “not scared of much anymore,” he says.

But though surgery helps some kids, it did nothing for his seizures. They soon came back, two or three times a day, each one causing him to stare and be unresponsive for a few seconds to several minutes.

Today, however, Jason is nearly seizure-free, thanks to a special diet that is 80 percent fat and has been sweeping the often-desperate world of epilepsy like a January blizzard.

No one is sure why it works, but the high fat/low protein/low carbohydrate diet seems to push the body into a starvation-like state called ketosis, says Dr. Gregory Holmes, director of the epilepsy program at Children’s Hospital in Boston.

Patients are first starved for several days to deplete the body’s stored sugar, then put on the diet, which contains almost no carbohydrates. Soon,
because the body has no glucose for fuel, cells begin burning fat from the diet instead, which slows the frantic firing of brain cells.

Burning fats in the absence of glucose leads to the production of fatty molecules called ketone bodies. Some scientists think ketone bodies may change the lipid membrane of brain cells to produce a lower firing rate. Others think the diet changes the rate at which charged particles called ions cross the lipid membranes of nerve cells. But the truth is, nobody knows.

So far, the diet is being studied only in kids, but there is “no theoretical reason” why it couldn’t help some of the 2 million adults with epilepsy as well, says Dr. Patricia Crumrine, director of the pediatric epilepsy program at Children’s Hospital in Pittsburgh.

In the approximately 200 children studied to date in a handful of medical centers, initial results suggest that 20-30 percent become “seizure-free, usually in a month to six weeks,” and about half have a 50-percent reduction in seizures, says Dr. John Freeman, director of pediatric neurology at Johns Hopkins Medical Institutions and the leading proponent of the ketogenic diet.

Most children stay on the diet for two years, he says. When it works right, seizures rarely return, even after normal diet is resumed. So far, there is no evidence that the high fat diet raises the risk of atherosclerosis, heart disease or stroke.

“Even if there were a slight increase,” says Freeman, “after two years, the children come off the diet” and any buildup of fatty plaques in arteries should disappear. “And even if you shortened the lives of these children by a year or two or five, you would have dramatically improved their quality of life.”

But there are caveats.

The diet is very stringent, even more so than diets for diabetes, and is appropriate only for children whose seizures are difficult to control by drugs. The slightest error — too much liquid, eating seven nuts instead of three or changing brands of sausage — can bring back the seizures.

Also, the diet “should only be done under medical supervision,” adds Freeman, noting that unconfirmed reports suggest at least three children have died after parents tried it on their own.

And while the diet may sound like a picnic, it isn’t.

Jason has lived on sausages and eggs, choked down heavy cream at every meal and, despite teenage temptation, has had little non-fatty food other than bouillon and lettuce since he started five months ago.

His parents are “always in the kitchen,” says his father, Steve, 42, a certified public accountant. “One of us is always cutting, cleaning, weighing” everything that goes into Jason’s mouth.

“You have to be totally committed — it’s an entire family commitment,” adds Jason’s mother, Lori, 39. “We never go out to eat anymore or have pizza at home. It’s absolutely amazing that Jason has the willpower to do this. I know I never could.”

Jason’s sister Julie, 12, says she has to eat any tempting foods she has out of his sight, be a good sport at holidays like Thanksgiving — when the whole family ate eggs — and put up with the fact that her parents “spend so much time on his meals.”

But the diet is toughest on Jason. Though he consumes 2,000 calories a day, he says, “It’s not enough. I’m always hungry.”

Which is precisely the point.

Ever since 400 B.C., people have observed that under conditions of starvation, seizures decline, says Dr. Ed Dodson, president of the Epilepsy Foundation of American.

Earlier this century, in fact, that knowledge led a few American doctors to deliberately starve their epilepsy patients. It often worked to reduce seizures, but the achievement — and interest in the diet — dropped from sight in the late 1930s when Dilantin, the first anti-epileptic drug, was developed.

But even as new drugs trickled onto the market, interest in the ketogenic diet never completely waned at Johns Hopkins, says researcher Freeman. Until recently, though, he used the diet with only eight to 12 children a year.

All that changed in October 1994, when Dateline NBC aired a program on the ketogenic diet, spurred by California movie-maker Jim (“Airplane” and ”Naked Gun”) Abrahams, whose 18-month-old son Charlie had become seizure- free on the diet.

Like Jason, Charlie had been given numerous drugs and had had brain surgery, his father says, yet still had dozens of seizures a day. Eventually, Abrahams quit work to pore over the medical literature, including Freeman’s book on the diet.

Abrahams, who founded the Charlie Foundation to publicize the diet, is thrilled that his son, now 3 1/2, is well, if a bit skinny. But he’s angry that all the doctors he had consulted for years knew nothing, or told him nothing, about it.

“We would not have drugged Charlie into oblivion if we had known about the diet,” Abrahams says. “And we certainly would never have let them carve into his brain.”

To some, the failure to take the ketogenic diet seriously smacks of the old days, when epilepsy carried so much stigma that patients were housed in ”colonies” for treatment so that other people would not have to see their jerking, twitching and other uncontrollable behaviors.

Some states laws forbade people with epilepsy to marry or have children, and some permitted involuntary sterilization of epileptics, says Dr. Orrin
Devinsky, director of the epilepsy program at New York University Medical Center.

But for kids like Jason Simon, the focus is not on past mistakes, but on the future. Thanks to the diet, he’s down to two seizures a month and four pills a day.

He hates the hunger, but he rarely complains, he says, “because complaining is not going to do anything. I figure why waste my breath. I’m just going to annoy myself and everybody else.”

Besides, he’s got his eye on more important things.

“I really want to drive when I’m older,” he says, “and I won’t be able to drive if I’m having seizures.”

SIDEBAR:

MEDICATIONS WORK FOR MOST

While the ketogenic diet can be useful for children whose epilepsy does not respond to medication, most people with epilepsy — adults and children alike — are helped by the growing array of available drugs, including newer ones like Lamictal and Neurontin.

If you are not sure whether you or your child is having seizures, ask your doctor — some seizures can be subtle and difficult to detect.

Often, doctors cannot tell what triggers seizures, though common causes are head trauma, infections, genetic defects and problems that occur as a child’s brain develops.

In general, seizures fall into two classes: partial seizures, in which the abnormal firing of nerve cells begins in just one part of the brain and then may spread; and generalized seizures, which begin in both sides of the brain at once.

Some partial seizures are so mild the patient merely twitches or feels odd but does not lose consciousness, though patients with complex partial seizures may lose consciousness.

Even in generalized seizures, some patients merely stare into space for 10 to 15 seconds, particularly with a type once called “petit mal” but now called “absence” (prounounced the French way). A child with an “absence” seizure may simply stop talking and stare, blink his eyes, then return to normal.

Other generalized seizures, particularly the tonic-clonic type once called ”grand mal,” are more severe. During these attacks, the body stiffens and jerks rhythmically, sometimes for up to three to five minutes.

Lay people often worry that a person having a seizure may swallow his tongue. This does not literally happen, though the base of the tongue may slip toward the back of the throat.

Contrary to a popular misconception, you should never put anything in the mouth of a person during a seizure. Instead, roll the patient onto his side and make sure the head is turned toward the ground to help clear the airway.

For more information, call:

The Epilepsy Foundation of America, 1-800-EFA-1000 (or 1-800-332-1000)

The Charlie Foundation to Help Cure Pediatric Epilepsy, 1-800-FOR-KETO (or 1-800-367-5386).

Drink up – or not? Studies in women are at odds on alcohol’s risks and benefits

January 8, 1996 by Judy Foreman

Last May, a huge Harvard study of more than 85,000 women showed that moderate drinking — about one drink a day — lowers the overall risk of death, without apparently raising the odds of dying from breast cancer.

Six weeks later, another big study — of more than 16,000 women — came to a more sobering conclusion: Over a lifetime, even one drink a day may slightly raise breast cancer risk.

Given that women are roughly six times more likely to die of heart disease than breast cancer, and that alcohol protects against heart disease in both men and women, perhaps women shouldn’t worry about a small increase in breast cancer risk from drinking.

But many do.

Which is precisely why the new data on women and drinking is so frustrating. Taken together, the data suggest that drinking decisions for women may be even more complex than for men because risks and benefits are more closely balanced.On top of that, evidence is piling up that women’s bodies are far more vulnerable than men’s to the toxic effects of booze.

All of which suggests that before you pour the next drink, ladies, you might want to ponder the research — on both sides.

Medically, the main argument for drinking is that it protects against heart disease, the leading killer of both men and women.

Alcohol can change the balance of lipoproteins in the blood, boosting ”good” cholesterol (HDL) and lowering “bad” (LDL), notes Dr. Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism.

It can also reduce, at least temporarily, the ability of platelets in the blood to form clots that can block coronary arteries.

And at least some types of alcohol, notably red wine, contain anti-oxidants that may keep LDL from oxidizing. In oxidized form, LDL leads to fatty plaques that clog vessels.

Primarily because of the cardiovascular effects, the Nurses’ Health Study of 85,709 women showed that moderate drinkers (women who had between one-half and one drink a day) had a 12 percent lower risk of death from all causes than women who drank nothing and a 26 percent lower risk those who drank heavily.

A drink was defined as a 4-ounce glass of wine, a 12-ounce can or bottle of beer and a half-ounce of spirits.

But not all women benefit from moderate drinking. In fact, the Nurses’ study showed that if a woman is at low risk of heart disease to begin with, either because she is under 50 or has no coronary risk factors, moderate drinking doesn’t carry any health benefit, though it won’t hurt either.

The women who do benefit are those at higher-than-normal risk of heart disease, notes Dr. Walter Willett , one of the authors and a professor of epidemiology and nutrition at the Harvard School of Public Heath.

Factors that raise heart disease risk include high blood pressure, high cholesterol, diabetes, obesity, a sedentary lifestyle and having a parent who had a heart attack before age 60.

And there’s other evidence that a drink or two may do more than just keep the heart doctor away.

One study of nearly 10,000 women over 65, published last year in the Journal of the American Medical Association, showed that women who drank moderately did better than nondrinkers on physical function tests, perhapsbecause alcohol was a sign that the drinkers had a more active lifestyle.

Another study, published in 1994 in the American Journal of Public Health, showed that women — and men — who drank moderately got less depressed under stress than teetotallers or heavy drinkers, again perhaps because moderate drinking was a marker for other healthful habits that offset stress.

But drinking clearly has a dark side for women, too, quite apart from the obvious — alcoholism and fetal alcohol syndrome.

At one and a half to two drinks a day, the Nurses’ study showed, the risk of dying from breast cancer — a risk that was invisible at lower levels — increases, perhaps because alcohol raises levels of the hormone estrogen, which promotes some breast cancers. At more than two and a half drinks a day, overall mortality begins to rise, too.

And the risk of breast cancer may increase with as little as one drink a day, says Matthew Longnecker, an epidemiologist at the National Institute of Environmental Health Sciences whose report on more than 16,000 women was published in June.

In contrast to the Nurses’ study, which focused on death rates, Longnecker studied the risk of getting breast cancer and found a daily drink was linked to a 40 percent increase in risk, suggesting that 5 to 10 of the 184,300 cases of breast cancer expected this year might be attributed to alcohol consumption.

“That is a stronger association than what had been found in previous studies,” he says, perhaps because he studied lifetime consumption, not recent drinking.

On the other hand, Dimitrios Trichopoulos, an epidemiologist at the Harvard School of Public Health, found in a smaller study of 2,400 women last year that it takes three drinks a day to increase breast cancer risk at all.

To some, like epidemiologist Lynn Rosenberg of Boston University, all this simply means that any causal link between alcohol and breast cancer is farfrom established. But she adds that since “we don’t know how to reduce the risk of breast cancer, even the hint of an increased risk may be enough to persuade some women, particularly younger women at low risk of heart disease, not to drink.”

Others, notably the Wine Institute, a California-based industry association, put a cheerier spin on ambiguous findings, especially the hint — from Longnecker’s study — that the kind of alcohol a woman drinks may affect breast cancer risk.

Longnecker acknowledges that he found wine “was not related to risk of breast cancer,” while beer and liquor were. Beer drinkers had a 25 percent increase in breast cancer risk and liquor drinkers, an 18 percent increase. If wine has an advantage, it might be because it contains so-called “phenolic compounds” that may be protective, he and his team wrote, while beer and liquor “may contain substances that have estrogenic activity.”

But he and other epidemiologists stress that other studies, including somefrom Italy and France, found an increased breast cancer risk even among wine drinkers, which means the issue is far from settled.

And there is growing evidence that women’s bodies are more vulnerable than men’s to alcohol, says Dr. Charles S. Lieber , director of the alcoholism research and treatment center at the Bronx Veterans Affairs Medical Center and professor of medicine at the Mt. Sinai School of Medicine in New York.

In men and women of equal size who consume equal amounts of alcohol, he says, blood levels of alcohol are higher in women, partly because women’s bodies contain less water and more fat, which means alcohol is less diluted in their blood. But women also make less of a stomach enzyme called alcohol dehydrogenase, which helps digest alcohol.

Lieber, whose team recently cloned the gene for this enzyme, says that unlike male alcoholics, who still make some alcohol dehydrogense, female alcoholics make virtually none. And for some women, the ulcer drug Tagamet also exacerbates the problem, making alcohol dehydrogenase even less active.

Women’s livers are particularly vulnerable to alcohol, too, he adds. French studies show men must have about five drinks a day to cause cirrhosis, or heavy scarring, of the liver, while women can get cirrhosis drinking only a glass and a half to two and a half glasses of wine a day.

The bottom line, he says, is that “one drink in a woman of average size is equivalent to two drinks for a man.”

And that is precisely what the revised US government dietary guidelines, issued last week, recommend for those trying to get the health benefits but not the risks of alcohol:

No more than one drink a day for women, two for men.

At this level of consumption, says Willett, alcohol “won’t have overall harmful effects and might even help some women.”

SIDEBAR

EARLY ABUSE IS OFTEN A FACTOR IN ALCOHOLISM

Though male alcoholics outnumber female alcoholics 3 to 1, women seem to suffer medical complications from drinking at far lower levels of alcohol consumption than men. And different factors seem to predispose women to problems with alcohol.

As with men, a family history of alcoholism raises women’s risk of alcoholism, perhaps even more so than for men.

But women, to a greater degree than men, tend to start abusing alcohol during periods of transition like divorce, or when they are in relationships with heavy drinkers, says Norma Finkelstein, director of the Coalition on Addiction, Pregnancy and Parenting in Cambridge.

But perhaps the most telling factor is that many of the 4 million American women who abuse alcohol or are alcoholics were physically or sexually abused as children, says the National Council on Alcoholism and Drug Depencence, Inc., in New York.

But socioeconomic factors also play a part. Alcohol use is most prevalent among white women, according to the Commonwealth Fund Commission on Women’s Health. Seventeen percent of white women report moderate to heavy drinking, compared with 11 percent of African American women, 9 percent of Latinas and 6 percent of Asian women.

Alcohol use also increases with income and education, the Commonwealth Fund found. Roughly 8 percent of women without a high school education are moderate to heavy drinkers, versus 20 percent of those with at least some college. Heavy drinking was defined in this study as having more than two drinks a day.

Some states, Massachusetts foremost among them, have made a special effort to create women-only alcohol treatment programs. Research suggests that when men and women are treated together, “the men do better and the women do worse” because women “pay attention to what men need, not what they need,” says Finkelstein.

Co-ed treatment groups can make it more difficult for women to talk about sex abuse, incest, violence and feelings of guilt and shame about raising children while drinking or having drunk alcohol during pregnancy, which can lead to fetal alcohol syndrome, adds Alan Milner, director of the Massachusetts Drug and Alcohol Hotline.

Women drinkers also face more scorn from society than men, adds Dr. Roger Weiss, clinical director of the alcohol and drug abuse program at McLean Hospital in Belmont.

Once in treatment, though, women who are both depressed and alcoholic do better than women who are not depressed, he says, though this is not true for men. Perhaps, he says, depression makes women “more ready for treatment.”

SIDEBAR:

If you need information or help with an alcohol problem, you may call:

The Coalition on Addiction, Pregnancy and Parenting, 617-661-3991.

The Alcohol and Drug Abuse Hotline, 617-445-1500 or 1-800-327-5050. For the deaf, the TTY number is 617-354-0997.

Alcoholics Anonymous, 617-426-9444.

Drink up – or not?

January 8, 1996 by Judy Foreman

Studies in women are at odds on alcohol’s risks and benefits