Thursday, November 29, 2012

Vitamin D Facts

1.     In building bone, calcium has an indispensable assistant: vitamin D.
2.     Vitamin D helps the body absorb calcium,
3.     Increasing vitamin D can help prevent osteoporosis.
4.      A small amount of sun exposure can help the body manufacture its own vitamin D
5.     Five to 30 minutes of sunlight between 10 a.m. and 3 p.m. twice a week to your face, arms, legs, or back without sunscreen will enable you to make enough of the vitamin.
6.     People with fair skin that burns easily should protect themselves from skin cancer by limiting sun exposure to 10 minutes or less.
7.      Food and sun exposure should suffice, but if not, get 2,000 IU of vitamin D daily from a supplement.
Commentary: There is a lot of "pharma interest" in Vit D, and we have had a large number of preparations (drops, tablets, powders etc.) in multiple strengths being marketed for preventing and treating Vit D Deficiency. While conventional wisdom was that due to sunlight tropical countries are unlikely to suffer from serious Vit D Deficiencies, the reality has turned out to be different. Due to many factors, including pollution, dark skin, our aversion to sunlight exposure, lifestyle changes etc. there is an apparent epidemic of Vit D deficiency. Even though experts are still debating about the normal values of Vit D for Indian population, the large number of people with Osteoporosis (weak bones) and fractures occurring in even youngsters points to a definite problem related to poor calcium absorption that occurs in the absence / deficiency of Vit D.
The above mentioned tips are important for preventing & treating Vit D deficiency, it is probably more practicable to take supplements of Vit D (not the usual Calcium pill) after consulting your doctor. A weekly course of Vit D packets (costing 20-25 rupees each) for 8-12 weeks is helpful for most people, and then they may need to take this monthly for an even longer period of time. However, this & any other treatment should ONLY be started after talking to your doctor.

Preventing preterm births - Lancet 2012

Preventing preterm births

Wider implementation of evidence-based interventions could reduce preterm birth rates by 5% by 2015, say researchers.
Every year, 1·1 million babies die from prematurity, and many survivors are disabled. Worldwide, 15 million babies are born preterm (<37 a="a" all="all" almost="almost" analysis="analysis" and="and" benefit="benefit" births="births" born="born" countries="countries" data.="data." decades="decades" development="development" drivers="drivers" estimate="estimate" evidence-based="evidence-based" examined="examined" font="font" for="for" gestation="gestation" high="high" human="human" if="if" implemented.="implemented." in="in" increasing="increasing" index="index" inform="inform" interventions="interventions" is="is" of="of" poor.="poor." potential="potential" present="present" preterm="preterm" preventive="preventive" rate="rate" rates="rates" reduction="reduction" reliable="reliable" soon.="soon." target="target" the="the" this="this" to="to" too="too" trends="trends" two="two" understanding="understanding" very="very" we="we" weeks="weeks" were="were" widely="widely" with="with">

Countries were assessed for inclusion based on availability and quality of preterm prevalence data (2000—10), and trend analyses with projections undertaken. We analysed drivers of rate increases in the USA, 1989—2004. For 39 countries with VHHDI with more than 10 000 births, we did country-by-country analyses based on target population, incremental coverage increase, and intervention efficacy. We estimated cost savings on the basis of reported costs for preterm care in the USA adjusted using World Bank purchasing power parity.

From 2010, even if all countries with VHHDI achieved annual preterm birth rate reductions of the best performers for 1990—2010 (Estonia and Croatia), 2000—10 (Sweden and Netherlands), or 2005—10 (Lithuania, Estonia), rates would experience a relative reduction of less than 5% by 2015 on average across the 39 countries. Our analysis of preterm birth rise 1989—2004 in USA suggests half the change is unexplained, but important drivers include non-medically indicated labour induction and caesarean delivery and assisted reproductive technologies. 
For all 39 countries with VHHDI, five interventions modelling at high coverage predicted a 5% relative reduction of preterm birth rate from 9·59% to 9·07% of live births: 
smoking cessation (0·01 rate reduction), 
decreasing multiple embryo transfers during assisted reproductive technologies (0·06), 
cervical cerclage (0·15),
progesterone supplementation (0·01), 
and reduction of non-medically indicated labour induction or caesarean delivery (0·29).
These findings translate to roughly 58,000 preterm births averted and total annual economic cost savings of about US$3 billion.

We recommend a conservative target of a relative reduction in preterm birth rates of 5% by 2015. Our findings highlight the urgent need for research into underlying mechanisms of preterm births, and development of innovative interventions. Furthermore, the highest preterm birth rates occur in low-income settings where the causes of prematurity might differ and have simpler solutions such as birth spacing and treatment of infections in pregnancy than in high-income countries. Urgent focus on these settings is also crucial to reduce preterm births worldwide.
Chang HH, Larson J, Blencowe H, et al. Preventing preterm births: analysis of trends and potential reductions with interventions in 39 countries with very high human development index. The Lancet. 2012;doi:10.1016/S0140-6736(12)61856-X.

Obstetricians' Attitudes on Maternal and Infant Immunization - A survey in USA

Missed Opportunities


The recent reoccurrence of several vaccine-preventable diseases demonstrates the need for new techniques to promote childhood vaccination. Many mothers make decisions regarding vaccination of their children during pregnancy. As a result, obstetricians have a unique opportunity to influence maternal decisions on this crucial component of child health. Our objective was to understand OB/GYNs' attitudes, beliefs, and current practices toward providing vaccinations to pregnant patients and providing information about routine childhood immunizations during standard prenatal care. We surveyed OB/GYNs in the United States about their vaccination practices and perceptions during the 2009 H1N1 outbreak. Most (84%) respondents indicated their practice would be administering H1N1 vaccines to pregnant patients. While a majority (98%) of responding providers felt childhood vaccination is important, relatively few (47%) felt that they could influence mothers' vaccination choices for their children. Discussion of routine childhood immunization between obstetricians and their patients is an area for future improvements in childhood vaccination.
Read the entire article at Medscape
Comments: What I find fascinating is the interplay between Ob/gyn and the Pediatrician that is being increasingly realized in the West. While problems exist, they are taking steps to try to come together in the best interests of the patients. Here in India though, the situation is unfortunately quite different. There is hardly any professional interaction between Pediatricians & Ob/gyn. There are many reasons for this, including problems related to fees sharing (many Ob/gyn still deliver without pediatric support, and only call the pediatrician when the child is born distressed after birth). Other problems include lack of updated knowledge regarding newer recommendations for vaccines like Influenza in pregnancy, or cervical cancer vaccination. Finally, in smaller towns, many Ob/gyn also do the pediatric vaccination & OPD consultations themselves, thus creating further conflict of interest. Of course, I am speaking predominantly from a pediatrician perspective, but I am sure most doctors would agree that further cooperation would be in the best interest of the patients. Perhaps our professional bodies, FOGSI & IAP in India, can take further steps in this regard.

Thursday, November 22, 2012

Breast cancer screening evaluated: the verdict - Lancet

Whether breast cancer screening does more harm than good has been debated extensively. The main questions are how large the benefit of screening is in terms of reduced breast cancer mortality and how substantial the harm is in terms of overdiagnosis, which is defined as cancers detected at screening that would not have otherwise become clinically apparent in the woman's lifetime. An independent Panel was convened to reach conclusions about the benefits and harms of breast screening on the basis of a review of published work and oral and written evidence presented by experts in the subject. To provide estimates of the level of benefits and harms, the Panel relied mainly on findings from randomised trials of breast cancer screening that compared women invited to screening with controls not invited, but also reviewed evidence from observational studies. The Panel focused on the UK setting, where women aged 50—70 years are invited to screening every 3 years. In this Review, we provide a summary of the full report on the Panel's findings and conclusions. In a meta-analysis of 11 randomised trials, the relative risk of breast cancer mortality for women invited to screening compared with controls was 0·80 (95% CI 0·73—0·89), which is a relative risk reduction of 20%. The Panel considered the internal biases in the trials and whether these trials, which were done a long time ago, were still relevant; they concluded that 20% was still a reasonable estimate of the relative risk reduction. The more reliable and recent observational studies generally produced larger estimates of benefit, but these studies might be biased. The best estimates of overdiagnosis are from three trials in which women in the control group were not invited to be screened at the end of the active trial period. In a meta-analysis, estimates of the excess incidence were 11% (95% CI 9—12) when expressed as a proportion of cancers diagnosed in the invited group in the long term, and 19% (15—23) when expressed as a proportion of the cancers diagnosed during the active screening period. Results from observational studies support the occurrence of overdiagnosis, but estimates of its magnitude are unreliable. 
The Panel concludes that screening reduces breast cancer mortality but that some overdiagnosis occurs. Since the estimates provided are from studies with many limitations and whose relevance to present-day screening programmes can be questioned, they have substantial uncertainty and should be regarded only as an approximate guide. If these figures are used directly, for every 10 000 UK women aged 50 years invited to screening for the next 20 years, 43 deaths from breast cancer would be prevented and 129 cases of breast cancer, invasive and non-invasive, would be overdiagnosed; that is one breast cancer death prevented for about every three overdiagnosed cases identified and treated. Of the roughly 307 000 women aged 50—52 years who are invited to begin screening every year, just over 1% would have an overdiagnosed cancer in the next 20 years
Evidence from a focus group organised by Cancer Research UK and attended by some members of the Panel showed that many women feel that accepting the offer of breast screening is worthwhile, which agrees with the results of previous similar studies. Information should be made available in a transparent and objective way to women invited to screening so that they can make informed decisions.

Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. The Lancet. 2012;380:1778-86.

Tuesday, November 06, 2012

Cocooning Protects Babies

Everyone in a baby’s life needs to get vaccinated against whooping cough and flu!
What is cocooning?
Babies younger than 6 months old are more likely to develop certain infectious diseases than older children are. Cocooning is a way to protect babies from catching diseases from the people around them – people like their parents, siblings, grandparents, friends, child-care providers,  babysitters, and healthcare providers. Once these people  are vaccinated, they are less likely to spread these contagious diseases to the baby. They surround the baby with a  cocoon of protection against disease until he or she is old enough to get all the doses of vaccine needed to be fully  protected.

Why is cocooning important?
Babies less than 6 months old are too young to have  received all the doses of vaccine that are needed to protect  them from whooping cough (pertussis), flu (influenza),  and other dangerous diseases. To be fully protected, babies need to get all the vaccine doses in a series – not just  the first dose.
Unvaccinated adults and family members, including parents, are often the ones who unknowingly spread dangerous  diseases to babies.
How can we protect babies?
Everyone has the opportunity to protect babies by getting  vaccinated themselves. Cocooning is an easy and effective  way that people can work together to prevent the spread  of whooping cough and flu to babies.
How can we protect babies against  whooping cough?
        All children should be vaccinated on schedule with  DTaP (the childhood whooping cough vaccine).
        All teenagers and adults need a one-time dose of Tdap  vaccine (the teen and adult whooping cough vaccine).
        Unvaccinated women who might become pregnant  should receive a Tdap vaccination.
        Pregnant women who haven’t been vaccinated with  Tdap should receive a dose in the 2nd or 3rd trimester  of pregnancy. This will protect the pregnant woman as well as her baby!
How can we protect babies against flu?
Everyone age 6 months and older needs to receive flu  vaccine every year.
Commentary: In India, where even routine vaccinations are not completed for many babies, cocooning may seem like an exotic concept! However, there needs to be an awareness regarding this concept among pediatricians, since there are increasing number of parents coming to private practitioners who want to protect their babies from "all" infectious illnesses by vaccinations. In this situation the concept of cocooning should be explained to them in relation to grandparents, the parents & other close care-providers. Given the abysmal lack of adult vaccination, this would end up benefiting the adults too ! As stated above, Pertussis & Flu (influenza) are the two vaccinations which the adults maybe offered to prevent the newborn baby from getting these serious diseases.