Judy Foreman

Nationally Sindicated Fitness, Health, and Medicine Columnist

Who should be screened for lung cancer with the new, low-dose CT scans?

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It’s a tough call because doctors disagree and insurance doesn’t pay for the test, so if you do opt for it, you’ll be paying out of pocket — around $300.

In October, The New England Journal of Medicine published a massive study of more than 30,000 current and former smokers and came to a provocative conclusion: The noninvasive screening, which can catch lung cancers very early, was linked to a projected 88 percent 10-year survival rate if patients are treated promptly with surgery — dramatically better than the usual survival rate because lung cancers are rarely caught that early.

At first glance the implication of the new study, done by Dr. Claudia Henschke, a radiology professor at Weill Cornell Medical College in New York, seems like a no-brainer: Get screened if you’re at high risk for lung cancer, meaning you’re a current or former smoker who smoked at least half a pack a day for years and years.

But it’s not quite that simple. In part because it had no control group, the Henschke study “cannot answer the question of whether screening reduces deaths from lung cancer,” said Dr. Phillip Boiselle of Beth Israel Deaconess Medical Center.

A different, ongoing study, the National Lung Screening Trial, should be able to answer the question of whether CT screening truly saves lives, but those results won’t be available until 2009 at the earliest.

There are also risks to CT screening, said Dr. Michael Thun , who heads epidemiological research for the American Cancer Society. Among other things, the test is so sensitive that it can pick up small nodules that might not turn out to be life-threatening cancer but could result in unnecessary biopsy, surgery, and the attendant risks from bleeding, infection, and anesthesia.

So here’s my take: If I were a policymaker or an insurance company executive, I’d say CT screening is not ready for prime time. But if I were a smoker, first I’d work harder to quit. Then I’d talk to my doctor about getting tested. The Henschke study, though not perfect, is too important to ignore.

I know you can’t catch AIDS from a toilet seat. What CAN you catch?

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Not much. You stand a much better chance of catching something nasty from the germs living in your kitchen sponges than from anything on your toilet seat, said Dr. Iain Fraser, a pediatric infectious disease specialist at Massachusetts General Hospital.

The image of the toilet seat as a carrier of noxious material “is more an esthetic problem than a health problem,” said Dr. John Bartlett, an infectious disease specialist at the Johns Hopkins University School of Medicine. To be sure, if there is fecal material on the toilet seat and you touch the seat with your hands and then put your hands in your mouth, you may catch an intestinal bug such as salmonella or E. coli. Urine on the seat is probably harmless because urine is usually sterile.

If you have open cuts on your buttocks or thighs, bacteria on the seat could get into your body through the skin, “but this would be a very unusual way of transmission,” said Fraser. In theory, you could catch a cold from a toilet seat, but someone would have had to sneeze on the seat, then you’d have to touch the seat with your hands and then rub your mouth, nose or eyes.

On top of that, toilet seats and other hard surfaces are not good carriers of germs. “That’s not an area where bacteria can live long or well,” said Bartlett. “Skin to skin is a much better transmitter of bugs than windshields or walls or toilet seats.

In other words, to reduce the chances of getting sick, change kitchen sponges often, wash your hands after you touch surfaces that people with colds also touch (phones, doorknobs, subway grab bars), and wash your hands after you use the bathroom for basic hygiene. But don’t worry about catching things from just sitting on the toilet seat.

Are there homeopathic or herbal alternatives to the flu vaccine?

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No, at least when it comes to genuine prevention, which is what the flu vaccine does.

Some people shy away from getting the flu vaccine because they think it will make them sick (it won’t) or because of unfounded fears about a mercury-containing preservative called thimerosal found in some vaccines. Numerous studies have failed to find any basis for the concern that thimerosal is linked to autism or learning disorders. For parents who worry nonetheless, there are now thimerosal-free vaccines available for kids.

The concern that getting a flu shot will give you the flu is “absolutely ridiculous, ridiculous,” said Dr. Alfred De Maria, chief medical officer at the Massachusetts Department of Public Health. “There is no way you can get the flu from a flu shot.”

When it comes to treating the flu, a number of homeopathic or plant-based remedies are on the market, but how safe and effective they are is difficult to say.

Some people who sell these products, like Steve Bernardi, a co-owner of Johnson Drug in Waltham, MA, which he described as “a conventional pharmacy with a slant toward complementary medicine,” swear by products like Boiron’s Oscillococcinum to reduce the severity and duration of the flu. It’s made from duck liver, but data on the product are scanty. (Besides, wouldn’t you rather have your foie gras with a nice glass of pinot noir?)

Bernardi also touts several products made from mushrooms, including LifeShield Throat Defense and Host Defense, both made by New Chapter. Again, it’s impossible to evaluate the claims that these products reduce the severity or duration of colds or flu.

Mark Blumenthal, founder and executive director of the American Botanical Council, a nonprofit organization that distributes information on herbal products, advised combining mainstream and alternative medicine on this one: Get a flu shot AND take the dietary supplements if you like.

My take is more mainstream: Get a flu shot, which is 70 to 90 percent effective, according to the Centers for Disease Control and Prevention. If you do get the flu, see your doctor and take one of the four FDA-approved drugs for influenza: amantadine, rimantadine, zanamavir or oseltamivir. The mushroom remedies sound intriguing, but for now, I’ll save my mushrooms for omelettes after the foie gras.

Why is it important for people with diabetes to check their feet regularly?

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Diabetes can impair both blood flow to and nerve sensitivity in the feet. Poor circulation means that tiny cuts, ulcerations, cracks in the skin or other minor injuries can become infected, and, because of poor nerve functioning, a person with diabetes may not notice.

Untreated infections can progress so quickly that the foot or lower leg may have to be amputated. There were nearly 82,000 such amputations among diabetics in 2002 alone, according to the National Diabetes Education Program, part of the National Institutes of Health.

More than 40,000 of these could be avoided if people with diabetes checked their feet daily, primary care providers examined patients’ feet at every visit, and people with poor circulation and poor nerve function (neuropathy) saw a podiatrist regularly, said Dr. Martin Abrahamson, medical director of the Joslin Diabetes Center in Boston. “Care of the feet is a high priority for people with diabetes,” he said. When a person gets a foot infection and can’t feel it, “the next thing you know, it can get rip-roaring — it can get exponentially much worse.”

Dr. Joseph Caporusso, a podiatrist in McAllen, TX and a trustee of the American Podiatric Medical Association, said that reducing amputations is the goal of an awareness campaign called “KnockYour Socks Off,” supported by the podiatric group and other medical organizations.

If you have diabetes, the podiatric group says, you should inspect your feet daily, wash and dry them (including between the toes), cut toenails straight across, keep feet warm and dry, use moisturizer to keep feet from cracking and wear comfortable, well-fitting shoes. You should also never go barefoot, cut or burn corns or calluses off yourself, or wear shoes that irritate the feet, such as flip-flops.

Is liposuction safe?

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In general, yes, but safety depends on the health of the patient, the amount of fat being suctioned out, and on the circumstances under which the operation is performed. Liposuction, which is not covered by insurance and can cost thousands of dollars, should be done only by a doctor trained in the technique who works in a facility with adequate post-operative monitoring.

In liposuction, a doctor inserts a hollow tube called a cannula through tiny incisions to suction out fat and fluid. It is done under general anesthesia or sedation. Although the surgeon can’t see the tip of the cannula, he or she is guided by experience and training.

Liposuction is still the nation’s most popular form of cosmetic surgery — 324,891 men and women had it last year, according to the American Society of Plastic Surgeons. But its popularity has declined in recent years, with 9 percent fewer surgeries now than in 2000.

Make sure there is adequate monitoring of a patient after surgery, especially if more than 10 pounds of tissue is removed, said Dr. Rod J. Rohrich , past president of the plastic surgeons’ group and chairman of plastic surgery at the University of Texas Southwestern Medical Center in Dallas. If a doctor removes more than this, serious “fluid shifts” can occur, triggering drops in blood pressure and stresses on the heart.

Plasma, the liquid part of blood, seeps into the hole created by suctioning out fat, potentially depriving organs of the plasma they need, said Dr. James W. May Jr. , chairman of plastic surgery at Massachusetts General Hospital. “There are more fluid shifts with liposuction than, say, with an appendectomy.”

Liposuction is not a treatment for obesity, because doctors can’t safely remove enough fat. If you are considering liposuction, ask about your doctor’s training and how many procedures he or she does per year (a busy specialist should do at least 50 to 100). Ask how you will be monitored afterward and talk to previous patients.

What is toenail fungus and what’s the best way to get rid of it?

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Toenail fungus, or onychomycosis, is common, affecting three to five percent of Americans. It can start with simple athlete’s foot, a fungal infection that, if untreated, can lead to infection deep into the nail matrix, from which the nail grows.

The microorganism that causes toenail fungus is a dermatophyte, which lives on keratin, the protein that nails are made of, and thrives in the dark, moist, warm environment of sweaty feet. (Fingernails are much less susceptible to fungal attack because they are usually cleaner and dryer.)

As toenail fungi grow, the nails become thicker and may smell foul. The thickened nails can then press into the nail bed, causing pain, especially in tight shoes.

Topical prescription solutions such as Loprox, Loceryl, Keralac and Penlac may help, said Dr. Peter Paicos, Jr., immediate past president of the Massachusetts Podiatric Medical Society and associate medical director of the wound healing center at Winchester Hospital. There are also some non-prescription topical solutions available, including Mycocide NS.

If topical treatments don’t work, you can try oral medications such as Lamisil or Sporanox, which are usually taken daily for 12 weeks. But the oral medications can, in rare cases, cause liver damage. For that reason, you should get a liver function test before starting these medications and then during the course of treatment as well, said Dr. Joseph Caporusso, a McAllen, TX podiatrist and trustee of the American Podiatric Medical Association.

In really stubborn cases, the permanent solution is to surgically remove the infected nail and nail root. Cosmetically, the result is “mostly acceptable,” said Caporusso, and women often paint the area with nail polish as they would a normal nail.

To prevent toenail fungus in the first place, wear comfortable shoes that allow your feet some breathing room, wear sandals in public locker rooms, wash your feet every day, wear clean socks or stockings every day, according to the Harvard Medical School website.

Should high school and college athletes be screened for heart problems?

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Yes, by having a doctor listen to the heart and take a history of heart problems, not with the more extensive testing.

The debate over cardiac screening for young athletes heated up earlier this month when an impressive 26-year Italian study was published in the Journal of the American Medical Association. It showed that a nationwide screening program lowered the incidence of sudden deaths from a heart problem by 89 percent. In Italy, young athletes are screened with electrocardiograms (EKGs), which can detect potentially fatal disturbances in heart rhythms.

“This is a very good study, but it doesn’t prove everybody needs an EKG,” said Dr. Paul Thompson [cq] a cardiologist at Hartford Hospital in Connecticut who is advising the American Heart Association on the problem.

For one thing, the sudden cardiac death rate among Italian athletes despite the screening was about one in 250,000, “the same as we have in the US without such an elaborate system,” he said.

“It’s hard for people to understand that screening can make more problems,” he said. But any abnormality on an EKG can trigger further testing that can end up keeping young people out of sports for “funky little things” that might never cause serious problems. said.

Granted, just listening to the heart and taking a history “”may not do enough” to detect potentially fatal problems such as thickening of the pumping chamber of the heart, said Dr. Barry Maron [cq], of the Minneapolis Heart Institute Foundation.

But even if we had all the money in the world,” said Maron, more extensive screening “would still be a resource issue. With 10 million young people playing sports, it could cost $1 billion per year to screen them as the Italians do.” Worried parents can always pay for EKGs or echocardiograms out of pocket if they choose to. And all parents of athletes can pay attention to warning signs such as a fainting spell that could indicate heart problems.

What are varicose veins and how can you prevent them?

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Varicose veins, those bumpy, enlarged blood vessels, usually in the legs, occur when the valves inside the veins fail. The valves are there to keep blood from flowing backward, so when they fail, blood pools lower and lower in the leg, causing the vein to “pop” up toward the surface of the skin. Each time one valve fails, that puts more pressure on the valve below it.

“It’s like a domino effect,” said Dr. Robert Weiss, a dermatologist and director of the Maryland Laser, Skin, and Vein Institute in Baltimore. The result of the pooling blood is a less-than-optimal cosmetic appearance and an achy, fatigue-like feeling in the legs, especially in people who stand for long periods of time.

In some cases, varicose veins can also be caused by blood clots, so if you have large, painful veins, you should have an ultrasound exam to rule out clots, said Dr. Michael Jaff, director of vascular medicine at Massachusetts General Hospital.

In one sense, there’s not much you can do to prevent varicose veins. The tendency to get them run in families, and women, perhaps because of the pressure of pregnancy on leg veins, get them more than men.

But aerobic exercise like running, swimming or cycling can help, in part by building strong calf muscles help squeeze blood back up toward the heart. Weight lifting is a no-no because the increased pressure with all that straining can make varicose veins worse.

If your varicose vein problems are mild, compression stockings – the over-the-counter kind or thicker, stronger ones available by prescription – can help keep blood from pooling at the ankles.

Historically, doctors used to recommend surgery to “strip” or remove the veins in severe cases. Now, the preferred treatment is endovascular laser therapy, in which a laser is used to burn the inside of veins, causing the sides to stick together; an even newer approach, using radio frequency, is also in the works. Over time, the body absorbs the vein and other blood vessels take over the circulatory function.

Smaller varicose veins called spider veins can be treated with sclerotherapy – the injection of a medication – into the vein to make it collapse and disappear.

Now that it’s harder to get decongestants containing pseudoephedrine, will cold and allergy sufferers have to make do with weake

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That depends. As of September 30, the effective date of an amendment to the US Patriot Act, nasal products containing pseudoephedrine must be sold “behind the counter,” which means the purchaser has to show a photo ID and sign a log book to get them. The idea is to make it harder for illegal drug suppliers to make methamphetamine from pseudoephedrine, though whether the new law will actually do so is an open question.

For those of us who want pseudoephedrine-type drugs, there are now two choices. Go through the hassle of signing the log book to get pseudoephedrine, or switch to decongestants such as Sudafed-PE containing a similar, but less powerful ingredient, phenylephrine.

According to Dr. Leslie Hendeles, a professor of pharmacy and pediatrics at the University of Florida who co-authored a recent peer-reviewed letter in the Journal of Allergy and Clinical Immunology, phenylephrine at the approved 10 milligram dose is “unlikely to be effective in relieving a stuffy nose because it is inactivated by [digestive] enzymes” before it enters the bloodstream. You could take a higher dose – two and a half phenylephrine tablets, to get 25 milligrams, which some studies show to be safe and effective, but this dose has not been approved by the US Food and Drug.

There are also other alternatives.

“For those with allergic symptoms, antihistamines alone suffice. They are, however, not very effective for colds,” said Dr. Frank Twarog, an allergy specialist and clinical professor at Harvard Medical School. There are also good steroid nasal sprays such as Flonase, Nasonex and Rhinocort, all available by prescription. Non-steroid nasal sprays such as Afrin can also help, but they tend to cause rebound congestion if used for more than a few days.

What’s the best treatment for macular degeneration?

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The short answer is a new drug called Lucentis, approved by the US Food and Drug Administration in June, though the drug has side effects, is extremely expensive, and is useful for only the rarer form of the disease. Macular degeneration and its new treatments were the focus of five separate articles in last week’s New England Journal of Medicine.

There are two kinds of macular degeneration — a disease of the retina that affects more than 9 million Americans and is a leading cause of blindness in people over 55.

In the “dry” form, which 90 percent of patients have, there is a loss of the light-sensing cells in the retina and the cells that nourish them. Vision is often disturbed but not destroyed altogether, said Dr. N.A. Adams, of the Wilmer Eye Institute cq at Johns Hopkins Hospital.

There is no treatment for this form of the disease, said Pat D’Amore, a senior scientist at the Schepens Eye Research Institute.

“Wet” macular degeneration is rarer, but far more devastating. Abnormal blood vessels grow into the macula — the central part of the retina — where they bleed, leak and cause swelling, often leading to irreversible blindness.

Three relatively new drugs — Lucentis, Macugen and Avastin — all attack VEGF, the growth factor that stimulates vessel growth. All must be injected directly into the eye. Lucentis “actually improves vision in 30 to 40 percent of patients,” said Dr. Emily Chew, of the National Eye Institute.

Lucentis costs $1,950 per dose, but a very similar drug, Avastin — which is approved for treating colon cancer and can be used “off-label” to treat macular degeneration — costs only $17 to $50 per dose. A head-to-head comparison of the two drugs, both made by Genentech, has just been approved.

Macugen was approved for the wet disease two years ago, but appears to be less effective.

Anyone with the wet form of the disease should ask his or her doctor about starting one of these drugs, Adams said. But be cautious: Some of the drugs can have rare but serious side effects, including glaucoma, cataracts, inflammation and infection. And these risks are incurred repeatedly because patients must have injections every four to six weeks.