"Doctor, can I take 'Abcdxyz' for control of my Diabetes?"
The patient in front of me was asking about one of those numerous alternative 'medicines' for Diabetes advertised all over the media.
Iam asked such questions very often and my standard reply was I am a practioner of Modern Medicine and had little or no knowledge of other Medicinal Systems.
"Is there any harm in taking such medicines?" will be the next question and I will reply that I do not know.
Do I really do not know anything about such alternative medicines? If so why? Should I have been able to guide my patients better about the usage of alternative medicines?
Modern medicine is the science that tries to use all the new knowledge and technology available for mankind to improve the health of human beings. Being a practitioner of Modern Medicine and a keen follower of all research that is taking place in this field I should be able to tell whether a therapeutic method is superior, inferior or useless in comparison to currently accepted treatment method.
So how can I research the data regarding these so called ‘wonder alternative medicines’ for Diabetes? Is there any research ever done for these drugs?
The truth is no good quality research takes place before such products come into market. The Company that produces and markets such drugs never provides any research data. Just plain logic should make all of us realise that these medicines are ineffective because a medicine that can be proven to reduce blood sugar even by few milligrams can make billions if it was scientifically approved. The mere fact that no effort is made to get scientific approval for such products by conducting scientific studies tells us that these products are just placebos sold to unsuspecting public with massive advertisement budgets.
Should we stop such Fake therapies?
Many will say that even though such therapies are ineffective they can do no harm, so why one should try to stop them.
The Companies are fooling unsuspecting people using the name of ancient Indian science Ayurveda. People are wasting their hard earned money by buying and consuming useless products. They could have used this money for a much more useful purpose in bettering their lives.
Also how can one surely say that there are no harmful effects for such products without any proper studies? So stopping of such fake therapies is important for society's health.
How can we stop such Fake therapies?
Most important step should come from the Government. All such alternative medicines and supplements should undergo rigorous scientific testing before they are sold in the market. Advertisements with exaggerated or false claims should be severely curbed.
As a practising doctor I should strongly discourage patients from taking such unproven therapies. I should explain to them that their money will be wasted and no one has any idea of the side effects that it can produce.
With increasing awareness among Indian consumers I feel that people of our country cannot be taken for granted any more. Useless [and maybe harmful] products minting money for unscrupulous Companies should be stopped.
Sunday, December 19, 2010
Wednesday, October 27, 2010
UK Govt continues support for Homeopathy despite lack of evidence of efficacy
United Kingdom Parliamentary Committee on Science and Technology was asked to review the efficacy and the policy of Govt funding for Homeopathy last year. On February 22,2010, the committee submitted a report to the Government. The report,one of the most comprehensive evaluation of Homeopathy by a Government Body recommended discontinuation of State funding for Homeopathy.
Here are some excerpts from the report:
...We conclude that the principle of like-cures-like is theoretically weak. It fails to provide a credible physiological mode of action for homeopathic products. We note that this is the settled view of medical science....
....We consider the notion that ultra-dilutions can maintain an imprint of substances previously dissolved in them to be scientifically implausible.....
....In our view, the systematic reviews and meta-analyses conclusively demonstrate that homeopathic products perform no better than placebos.....
...There has been enough testing of homeopathy and plenty of evidence showing that it is not efficacious. Competition for research funding is fierce and we cannot see how further research on the efficacy of homeopathy is justified in the face of competing priorities.
It is also unethical to enter patients into trials to answer questions that have been settled already.
...We do not doubt that homeopathy makes some patients feel better. However, patient satisfaction can occur through a placebo effect alone and therefore does not prove the efficacy of homeopathic interventions...
..For patient choice to be real choice, patients must be adequately informed to understand the implications of treatments.
For homeopathy this would certainly require an explanation that homeopathy is a placebo. When this is not done, patient choice is meaningless. When it is done, the effectiveness of the placebo—that is, homeopathy—may be diminished. We argue that the provision of homeopathy on the NHS, in effect, diminishes, not increases, informed patient choice.
...The Government should stop allowing the funding of homeopathy on the NHS.
We conclude that placebos should not be routinely prescribed on the NHS. The funding of homeopathic hospitals—hospitals that specialise in the administration of placebos—should not continue, and NHS doctors should not refer patients to homeopaths.
Govt Response
Even though the UK Government agreed to most of the points raised by the Committee report,it did not agree to stop NHS funding for homeopathy.Instead the Government is trying to put the ball in the local hospital/clinician's court.
The Govt response said:
In its response to the report, the Government also said that it will keep the position on NHS funding under review.
"However, we believe that providing appropriate information for patients should ensure that they form their own views regarding homeopathy as an evidence-based treatment," it said.
Scientists point out, however, that if patients are told clearly that there is no credible evidence to support homeopathic treatments, this may undermine the only benefit that homeopathy is likely to provide, namely the well-established "placebo effect" where someone feels and gets better because they believe a treatment is working.
My view
I fully agree that Homeopathy is just a glorified placebo. At the same time it has an important role to play in the society as a pseudo scientific placebo [some may compare it with the good effects of God/religion in society]
In Indian situation it is more relevant. With Modern medicine practise as un-regulated as in India misuse of antibiotics is very wide spread. Many self limiting viral infections when presented to a modern medicine practitioner receives an antibiotic prescription.If all such mild illnesses gets treated by a homeopathic placebo,the emergence of antibiotic resistance could be delayed.
Moreover for many mild illnesses modern medicines with varying toxicity profiles are prescribed instead of reassurance. Here a homeopathic consultation will provide reassurance in the form of harmless homeopathic drugs.
My conclusion is that what ever be its lack of efficacy homeopathy should continue as a harmless placebo.
Links
Parliament Committee report
Govt Response
Here are some excerpts from the report:
...We conclude that the principle of like-cures-like is theoretically weak. It fails to provide a credible physiological mode of action for homeopathic products. We note that this is the settled view of medical science....
....We consider the notion that ultra-dilutions can maintain an imprint of substances previously dissolved in them to be scientifically implausible.....
....In our view, the systematic reviews and meta-analyses conclusively demonstrate that homeopathic products perform no better than placebos.....
...There has been enough testing of homeopathy and plenty of evidence showing that it is not efficacious. Competition for research funding is fierce and we cannot see how further research on the efficacy of homeopathy is justified in the face of competing priorities.
It is also unethical to enter patients into trials to answer questions that have been settled already.
...We do not doubt that homeopathy makes some patients feel better. However, patient satisfaction can occur through a placebo effect alone and therefore does not prove the efficacy of homeopathic interventions...
..For patient choice to be real choice, patients must be adequately informed to understand the implications of treatments.
For homeopathy this would certainly require an explanation that homeopathy is a placebo. When this is not done, patient choice is meaningless. When it is done, the effectiveness of the placebo—that is, homeopathy—may be diminished. We argue that the provision of homeopathy on the NHS, in effect, diminishes, not increases, informed patient choice.
...The Government should stop allowing the funding of homeopathy on the NHS.
We conclude that placebos should not be routinely prescribed on the NHS. The funding of homeopathic hospitals—hospitals that specialise in the administration of placebos—should not continue, and NHS doctors should not refer patients to homeopaths.
Govt Response
Even though the UK Government agreed to most of the points raised by the Committee report,it did not agree to stop NHS funding for homeopathy.Instead the Government is trying to put the ball in the local hospital/clinician's court.
The Govt response said:
We agree with many of the Committee’s conclusions and recommendations. However, our continued position on the use of homeopathy within the NHS is that the local NHS and clinicians, rather than Whitehall, are best placed to make decisions on what treatment is appropriate for their patients - including complementary or alternative treatments such as homeopathy - and provide accordingly for those treatments.
In its response to the report, the Government also said that it will keep the position on NHS funding under review.
"However, we believe that providing appropriate information for patients should ensure that they form their own views regarding homeopathy as an evidence-based treatment," it said.
Scientists point out, however, that if patients are told clearly that there is no credible evidence to support homeopathic treatments, this may undermine the only benefit that homeopathy is likely to provide, namely the well-established "placebo effect" where someone feels and gets better because they believe a treatment is working.
My view
I fully agree that Homeopathy is just a glorified placebo. At the same time it has an important role to play in the society as a pseudo scientific placebo [some may compare it with the good effects of God/religion in society]
In Indian situation it is more relevant. With Modern medicine practise as un-regulated as in India misuse of antibiotics is very wide spread. Many self limiting viral infections when presented to a modern medicine practitioner receives an antibiotic prescription.If all such mild illnesses gets treated by a homeopathic placebo,the emergence of antibiotic resistance could be delayed.
Moreover for many mild illnesses modern medicines with varying toxicity profiles are prescribed instead of reassurance. Here a homeopathic consultation will provide reassurance in the form of harmless homeopathic drugs.
My conclusion is that what ever be its lack of efficacy homeopathy should continue as a harmless placebo.
Links
Parliament Committee report
Govt Response
Tuesday, August 31, 2010
Tips for prevention of breeding of Aedes mosquito in your urban neighbourhood
Dengue fever is an acute febrile illness which can be life threatening.The WHO says some 2.5 billion people, two fifths of the world's population, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year.
Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A. albopictus.So it is very important for us to know about these mosquitos and to learn how to prevent its breeding in our neighbourhood.
Dengue Virus Transmission
Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes. The mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to ten days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. There is no way to tell if a mosquito is carrying the dengue virus. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined.
Aedes aegypti goes through a complete metamorphosis with an egg, larvae, pupae, and adult stage. The adult life span can range from two weeks to a month depending on environmental conditions. The life cycle of Aedes aegypti can be completed within one-and-a-half to three weeks
After taking a blood meal, female Aedes aegypti mosquitos produce on average 100 to 200 eggs per batch. The females can produce up to five batches of eggs during a lifetime. The number of eggs is dependent on the size of the bloodmeal. Eggs are laid on damp surfaces in areas likely to temporarily flood, such as tree holes and man-made containers like barrels, drums, jars, pots, buckets, flower vases, plant saucers, tanks, discarded bottles, tins, tyres, water cooler, etc. and a lot more places where rain-water collects or is stored. The female Aedes aegypti lays her eggs separately unlike most species. Not all eggs are laid at once, but they can be spread out over hours or days, depending on the availability of suitable substrates. Eggs will most often be placed at varying distances above the water line. The female mosquito will not lay the entire clutch at a single site, but rather spread out the eggs over several sites.
The eggs of Aedes aegypti are smooth, long, ovoid shaped, and roughly one millimeter long. When first laid, eggs appear white but within minutes turn a shiny black. In warm climates eggs may develop in as little as two days, whereas in cooler temperate climates, development can take up to a week. Laid eggs can survive for very long periods in a dry state, often for more than a year. However, they hatch immediately once submerged in water. This makes the control of the mosquito very difficult.
Prevention of breeding of Aedes mosquito
Aedes mosquito lay their eggs in clear,clean water and not in contaminated water.As they fly only a few metres their breeding place is usually in our house itself.
Most common breediing places and tips to prevent breeding
Water storage tank/cistern ---should have mosquito proof lids
water coolers/collection pans in Fridge/ACs ------ water should be drained out periodically
Drum ------tight lids
Flower vase with water [least in brass vase]----------change water frequently,use sand
Potted plants with saucers ------- change water frequently
Ornamental pool/fountain ---------water changed once a week
Roof gutter/sun shades------------check frequently for drain block
Animal water container----------- empty and clean periodically
Ant trap--------------------------use oil/salt
Used tyres-----------------------keep it under roof
Discarded large appliances-------bury or keep it under roof
Discarded buckets,plastic cups,tin cans etc-----bury
Whenever piped water supply is inadequate and available only at restricted hours or at low pressure, the storage of water in varied types of containers is encouraged, thus leading to increased Aedes breeding.It is essential that potable water supplies be delivered in sufficient quantity, quality and consistency to reduce the necessity and use of water storage containers that serve as the most productive larval habitats.
Chemical and biological agents can also be used for prevention of breeding of Aedes mosquito.
from
Denguevirusnet
WHO
Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A. albopictus.So it is very important for us to know about these mosquitos and to learn how to prevent its breeding in our neighbourhood.
Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes. The mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to ten days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. There is no way to tell if a mosquito is carrying the dengue virus. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined.
After taking a blood meal, female Aedes aegypti mosquitos produce on average 100 to 200 eggs per batch. The females can produce up to five batches of eggs during a lifetime. The number of eggs is dependent on the size of the bloodmeal. Eggs are laid on damp surfaces in areas likely to temporarily flood, such as tree holes and man-made containers like barrels, drums, jars, pots, buckets, flower vases, plant saucers, tanks, discarded bottles, tins, tyres, water cooler, etc. and a lot more places where rain-water collects or is stored. The female Aedes aegypti lays her eggs separately unlike most species. Not all eggs are laid at once, but they can be spread out over hours or days, depending on the availability of suitable substrates. Eggs will most often be placed at varying distances above the water line. The female mosquito will not lay the entire clutch at a single site, but rather spread out the eggs over several sites.
The eggs of Aedes aegypti are smooth, long, ovoid shaped, and roughly one millimeter long. When first laid, eggs appear white but within minutes turn a shiny black. In warm climates eggs may develop in as little as two days, whereas in cooler temperate climates, development can take up to a week. Laid eggs can survive for very long periods in a dry state, often for more than a year. However, they hatch immediately once submerged in water. This makes the control of the mosquito very difficult.
Prevention of breeding of Aedes mosquito
Aedes mosquito lay their eggs in clear,clean water and not in contaminated water.As they fly only a few metres their breeding place is usually in our house itself.
Most common breediing places and tips to prevent breeding
Water storage tank/cistern ---should have mosquito proof lids
water coolers/collection pans in Fridge/ACs ------ water should be drained out periodically
Drum ------tight lids
Flower vase with water [least in brass vase]----------change water frequently,use sand
Potted plants with saucers ------- change water frequently
Ornamental pool/fountain ---------water changed once a week
Roof gutter/sun shades------------check frequently for drain block
Animal water container----------- empty and clean periodically
Ant trap--------------------------use oil/salt
Used tyres-----------------------keep it under roof
Discarded large appliances-------bury or keep it under roof
Discarded buckets,plastic cups,tin cans etc-----bury
Whenever piped water supply is inadequate and available only at restricted hours or at low pressure, the storage of water in varied types of containers is encouraged, thus leading to increased Aedes breeding.It is essential that potable water supplies be delivered in sufficient quantity, quality and consistency to reduce the necessity and use of water storage containers that serve as the most productive larval habitats.
Chemical and biological agents can also be used for prevention of breeding of Aedes mosquito.
from
Denguevirusnet
WHO
Saturday, August 14, 2010
'Superbug' scare. Myths and facts
A scientific article in the Lancet has created big commotion in the media both in India and outside.It is being said that a bacteria which is resistant to all known antibiotics is wide spread in India and Pakistan and is being spread to other countries including U.K through medical tourism.This bacteria termed the 'superbug' is supposed to bring an end to the antibiotic era. Indian Government has come out with a clarification saying the media scare in UK is unwarranted.
Let me try to separate facts from myths in this issue.
Fact 1
WHO has identified antibiotic resistance as one of the greatest threats to human health. In the European Union (EU), about 25 000 patients die every year from infection with multidrug-resistant bacteria, and such infections result in health-care costs and lost productivity totalling at least €1·5 billion per year. Methicillin-resistant Staphylococcus aureus alone infects more than 94 000 people and kills nearly 19 000 in the US every year, more deaths than are caused by HIV/AIDS, Parkinson's disease, emphysema, and homicide combined.
Fact 2
Bacteria with Carbapenemase activity is a fast emerging threat in the field of antibiotic resistance all over the World as you can see from this article. India is actually a late entrant in this field.
Fact 3
There are 4 classes of Carbapenemase A,B,C and D.Each have different sub groups.So there are a large number of such bacteria producing different Carbapenemase isolated from all over the World.
Fact 4
New Delhi metallo-beta-lactamases[ NDM-1] belonging to B sub group of Carbapenemase was first detected in a Klebsiella pneumoniae isolate from a Swedish patient of Indian origin in 2008.It was given such a name assuming that the patient got it while hospitalized in New Delhi.
Fact 5
Further study in India indicated that NDM 1 enzyme producing bacteria are fairly common in a tertiary hospital in Mumbai.
Fact 6
In short NDM1 enzyme is the major cause for antibiotic resistance in Ecoli and Klebsiella species in India.In other countries enzymes are different and are named differently like VIM-1 (for “Verona integron-encoded metallo-β-lactamase” first isolated in Verona, Italy,) SPM-1 (for “Sao Paulo metallo-β-lactamase”), GIM-1 (for “German imipenemase”) SIM 1 (for Seoul imipenemase) etc.
Fact 7
The Lancet article in question is only about NDM 1 producing bacteria. It is a good attempt to find out the extend of spread of antibiotic resistance in bacteria in India.
Fact 8
It showed NDM in UK not only in those who had surgical procedures in India but also in many who have never visited India..Out of the 37 samples with NDM1 collected in UK, only 17 samples had history of travel to India or Pakistan.
Myth
The article in Lancet says
'It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals'.
This is an unscientific comment not based on any data.The authors have not proved that NDM 1 enzyme producing bacteria in UK was imported from India. More than 50% of patients in UK detected to have NDM 1 has never traveled to South Asia.Also the comment is not taking into consideration other groups and sub groups of Carbapenemase enzyme producing bacteria which are more prevalent in UK than in India.
It is true that Indian health system abuses antibiotics like most other 3 rd World countries.While protesting the unfair conclusion of the author of the article let us hope that the concerned authorities will open their eyes to the lack of antibiotic policies in most health care centers of India and implement strict regulations so that patients both native and foreign are protected from emergence of resistant bacteria.
Let me try to separate facts from myths in this issue.
Fact 1
WHO has identified antibiotic resistance as one of the greatest threats to human health. In the European Union (EU), about 25 000 patients die every year from infection with multidrug-resistant bacteria, and such infections result in health-care costs and lost productivity totalling at least €1·5 billion per year. Methicillin-resistant Staphylococcus aureus alone infects more than 94 000 people and kills nearly 19 000 in the US every year, more deaths than are caused by HIV/AIDS, Parkinson's disease, emphysema, and homicide combined.
Fact 2
Bacteria with Carbapenemase activity is a fast emerging threat in the field of antibiotic resistance all over the World as you can see from this article. India is actually a late entrant in this field.
Fact 3
There are 4 classes of Carbapenemase A,B,C and D.Each have different sub groups.So there are a large number of such bacteria producing different Carbapenemase isolated from all over the World.
Fact 4
New Delhi metallo-beta-lactamases[ NDM-1] belonging to B sub group of Carbapenemase was first detected in a Klebsiella pneumoniae isolate from a Swedish patient of Indian origin in 2008.It was given such a name assuming that the patient got it while hospitalized in New Delhi.
Fact 5
Further study in India indicated that NDM 1 enzyme producing bacteria are fairly common in a tertiary hospital in Mumbai.
Fact 6
In short NDM1 enzyme is the major cause for antibiotic resistance in Ecoli and Klebsiella species in India.In other countries enzymes are different and are named differently like VIM-1 (for “Verona integron-encoded metallo-β-lactamase” first isolated in Verona, Italy,) SPM-1 (for “Sao Paulo metallo-β-lactamase”), GIM-1 (for “German imipenemase”) SIM 1 (for Seoul imipenemase) etc.
Fact 7
The Lancet article in question is only about NDM 1 producing bacteria. It is a good attempt to find out the extend of spread of antibiotic resistance in bacteria in India.
Fact 8
It showed NDM in UK not only in those who had surgical procedures in India but also in many who have never visited India..Out of the 37 samples with NDM1 collected in UK, only 17 samples had history of travel to India or Pakistan.
Myth
The article in Lancet says
'It is disturbing, in context, to read calls in the popular press for UK patients to opt for corrective surgery in India with the aim of saving the NHS money. As our data show, such a proposal might ultimately cost the NHS substantially more than the short-term saving and we would strongly advise against such proposals'.
This is an unscientific comment not based on any data.The authors have not proved that NDM 1 enzyme producing bacteria in UK was imported from India. More than 50% of patients in UK detected to have NDM 1 has never traveled to South Asia.Also the comment is not taking into consideration other groups and sub groups of Carbapenemase enzyme producing bacteria which are more prevalent in UK than in India.
The author of the article in Lancet seems to show undue haste in blaming medical tourism for antibiotic resistance in UK.
It is true that Indian health system abuses antibiotics like most other 3 rd World countries.While protesting the unfair conclusion of the author of the article let us hope that the concerned authorities will open their eyes to the lack of antibiotic policies in most health care centers of India and implement strict regulations so that patients both native and foreign are protected from emergence of resistant bacteria.
Thursday, July 29, 2010
Two births that made me happy
Last week two births made me very happy.
I had blogged about one of the mother before. She was a type 1 Diabetic dependent on Insulin for more than 12 years now. I had blogged about my interview with her to-be-husband in 'Strange Interview' . Also I had posted about the first time she became pregnant in 'Happy News' and about her abortion in 'Sad News'. Now she has delivered a healthy baby. She recently came to me with her husband and the new born and we were all smiling.
Many type 1 Diabetics deliver normal healthy babies but still it is a difficult task. Perinatal mortality and still birth rates are 4 to 5 times of normal pregnancies. That is why we were smiling.
The other birth was the planned conception and delivery of a baby for an HIV positive couple.The couple were my patients for last 5 years.They had asked me the possibility of parenting a child before .Initially I did not encourage them because I did not knew how compliant they will be with the treatment.schedule. They were regular in their follow up and very compliant in taking medicines in time. When they asked me again after 3 years of Anti retro viral therapy I was more positive.I directed them to a suitable center for guidance. After a lot of counseling they were ready to accept the risks involved. They did everything as told and the mother delivered by cesarian section a healthy baby recently.
This proved that nothing is impossible for a 'positive' couple.
Read more about HIV and Pregnancy here
I had blogged about one of the mother before. She was a type 1 Diabetic dependent on Insulin for more than 12 years now. I had blogged about my interview with her to-be-husband in 'Strange Interview' . Also I had posted about the first time she became pregnant in 'Happy News' and about her abortion in 'Sad News'. Now she has delivered a healthy baby. She recently came to me with her husband and the new born and we were all smiling.
Many type 1 Diabetics deliver normal healthy babies but still it is a difficult task. Perinatal mortality and still birth rates are 4 to 5 times of normal pregnancies. That is why we were smiling.
The other birth was the planned conception and delivery of a baby for an HIV positive couple.The couple were my patients for last 5 years.They had asked me the possibility of parenting a child before .Initially I did not encourage them because I did not knew how compliant they will be with the treatment.schedule. They were regular in their follow up and very compliant in taking medicines in time. When they asked me again after 3 years of Anti retro viral therapy I was more positive.I directed them to a suitable center for guidance. After a lot of counseling they were ready to accept the risks involved. They did everything as told and the mother delivered by cesarian section a healthy baby recently.
This proved that nothing is impossible for a 'positive' couple.
Read more about HIV and Pregnancy here
Saturday, March 27, 2010
Is alcohol good or bad for the Heart?
Is alcohol good or bad for the heart?
I am asked this question many a time in my practice. I usually answer without committing myself. I will reply that in very small amounts it may not be harmful.
I am aware that many studies from the West have shown that mild to moderate intake of alcohol,especially Red wines are somewhat protective to the heart. At the same time I know that many who ask this question are alcoholics who just want a positive response from the doctor to continue to indulge in spirits.
A recent study in Indian males disapproves the theory that alcohol in mild to moderate doses has a protective effect on Heart. In a large retrospective survey based study [being the first of it kind in India looking at this question] conducted in 10 centers showed that alcohol consumption even in low amounts increased coronary artery disease risk. Heart attacks were more seen in those who are regular drinkers, occassional drinkers and even ex-drinkers when compared to life long abstainers.
Why Indian male drinkers are more prone to heart disease than Western drinking population?
The reasons are not clear and even lack of protective effect has to be proved with large prospective randomised controlled studies. But some theories are postulated.
1. Indians are more prone to binge drinking than Caucasian population.Binge drinking can cause Heart attack. In the above study around 55% were binge drinkers.
2. Indians tend to drink more stronger spirits that Caucasians. We drink more whiskey and Rum than wine and beer.
3. There may be genetic/racial difference in effect of alcohol on human body. African American drinkers also do not have that much protective effect on Heart as Caucasians.
So in conclusion let me state that the so called protective effect of alcohol on Heart is under a big question mark especially for Indians.
So please do not drink to live.
I am asked this question many a time in my practice. I usually answer without committing myself. I will reply that in very small amounts it may not be harmful.
I am aware that many studies from the West have shown that mild to moderate intake of alcohol,especially Red wines are somewhat protective to the heart. At the same time I know that many who ask this question are alcoholics who just want a positive response from the doctor to continue to indulge in spirits.
A recent study in Indian males disapproves the theory that alcohol in mild to moderate doses has a protective effect on Heart. In a large retrospective survey based study [being the first of it kind in India looking at this question] conducted in 10 centers showed that alcohol consumption even in low amounts increased coronary artery disease risk. Heart attacks were more seen in those who are regular drinkers, occassional drinkers and even ex-drinkers when compared to life long abstainers.
Why Indian male drinkers are more prone to heart disease than Western drinking population?
The reasons are not clear and even lack of protective effect has to be proved with large prospective randomised controlled studies. But some theories are postulated.
1. Indians are more prone to binge drinking than Caucasian population.Binge drinking can cause Heart attack. In the above study around 55% were binge drinkers.
2. Indians tend to drink more stronger spirits that Caucasians. We drink more whiskey and Rum than wine and beer.
3. There may be genetic/racial difference in effect of alcohol on human body. African American drinkers also do not have that much protective effect on Heart as Caucasians.
So in conclusion let me state that the so called protective effect of alcohol on Heart is under a big question mark especially for Indians.
So please do not drink to live.
Monday, February 8, 2010
Pregnant but HIV positive
The other day I received a call from a Gynaecologist of a nearby Hospital.
'I have an ante-natal [pregnancy] patient who is HIV positive. Should I send her to you now or after delivery?'
The doctor was asking me.
I was happy that she called to inform me, but was disappointed with her question. I had spend some effort as an HIV/AIDS trainer to make doctors aware that pregnant women need anti-HIV treatment to prevent the birth of a 'positive' child. I am not sure whether the above-mentioned doctor attended the training, but I expected her to know the importance of ART [anti HIV treatment] in pregnancy.
'You should send her to me immediately. She needs treatment to prevent the birth of a 'positive' child.' I replied.
The next day the patient came with her husband. I explained the situation to them in detail and asked them to attend the Govt ART center as early as possible. I telephoned the ART Medical Officer about this patient and fixed a suitable time for the patient to reach the center.
That lady will get the treatment, which will greatly reduce the chance of the birth of a 'positive' child from about 40% to less than 5%.
All pregnant females should be tested for HIV and if found positive should immediately receive treatment so that we can eliminate the chance of birth an HIV positive child
'I have an ante-natal [pregnancy] patient who is HIV positive. Should I send her to you now or after delivery?'
The doctor was asking me.
I was happy that she called to inform me, but was disappointed with her question. I had spend some effort as an HIV/AIDS trainer to make doctors aware that pregnant women need anti-HIV treatment to prevent the birth of a 'positive' child. I am not sure whether the above-mentioned doctor attended the training, but I expected her to know the importance of ART [anti HIV treatment] in pregnancy.
'You should send her to me immediately. She needs treatment to prevent the birth of a 'positive' child.' I replied.
The next day the patient came with her husband. I explained the situation to them in detail and asked them to attend the Govt ART center as early as possible. I telephoned the ART Medical Officer about this patient and fixed a suitable time for the patient to reach the center.
That lady will get the treatment, which will greatly reduce the chance of the birth of a 'positive' child from about 40% to less than 5%.
All pregnant females should be tested for HIV and if found positive should immediately receive treatment so that we can eliminate the chance of birth an HIV positive child
Tuesday, January 19, 2010
Should I give the cervical cancer vaccine to my daughter?
A mother of a 12-year-old girl was asking me this question the other day.
"Should I give my daughter cervical cancer vaccine?"
I was not prepared for the question. Though I know such a vaccine is available I have not studied it in detail. So my answer was little bit evasive.
' It is a new vaccine. Needs to be studied more .........."
I was curious why she asked the question.
"My sister who lives in USA gave her daughter the vaccine. I was wondering whether I should give it to my daughter too."
I realized that I would be asked similar questions again and again as the vaccine has been launched in India. More over I may have to take a decision about it personally since I have a daughter of about same age.
This post is an attempt by me to answer the question raised by that mother after considering all the facts available at present.
What is cervical cancer?
The cervix is another name for the neck of the womb. It is the opening to the womb from the vagina. It is really a strong muscle. Normally it is quite tightly shut, but during labour it opens up to let the baby out.
The cervix has a layer of skin-like cells on its outer surface. When these cells become cancerous it is called squamous cell cervical cancer.
There are glandular cells lining the inside of the cervix. The glandular cells produce mucus. Cancer of these cells is called adenocarcinoma of the cervix.
The area where cervical cells are most likely to become cancerous is called the transformation zone. It is the area around the opening of the cervix that leads on to the narrow passageway running up into the womb.
What causes cervical cancer?
HPV infection
Human papilloma virus or HPV is the major cause of cervical cancer. There are many different types of HPV. It is sometimes called the genital wart virus as some types of HPV cause genital warts. In fact, the types that cause warts are not the types that cause cervical cancer. But there are other types of HPV that are considered 'high risk' for cancer of the cervix. HPV is passed on from person to another through sexual contact.
Women who get cervical cancer have had past infections with HPV. High risk types of HPV can cause changes in the cells covering the cervix that make them more likely to become cancerous in time. It is said that around 50 to 80 % of women get infected with HPV some time in their lifetime.
Most people with HPV do not develop symptoms or health problems from it. In 90% of cases, the body’s immune system clears HPV naturally within two years.
But most women infected with these viruses do NOT develop cervical cancer. So other factors must also be needed for someone with HPV infection to develop cervical cancer.
HPV is passed on through genital contact, most often during vaginal and anal sex. HPV may also be passed on during oral sex and genital-to-genital contact. HPV can be passed on between straight and same-sex partners—even when the infected partner has no signs or symptoms.
A person can have HPV even if years have passed since he or she had sexual contact with an infected person. Most infected persons do not realize they are infected or that they are passing the virus on to a sex partner. It is also possible to get more than one type of HPV.
HPV can cause normal cells on infected skin to turn abnormal. Most of the time, you cannot see or feel these cell changes. In most cases, the body fights off HPV naturally and the infected cells then go back to normal. But in cases when the body does not fight off HPV, HPV can cause visible changes in the form of genital warts or cancer. Warts can appear within weeks or months after getting HPV. Cancer often takes years to develop after getting HPV.
Other risk factors for Cervical Cancer
Women who smoke are more likely to get cervical cancer than those who do not. Taking the birth control pill could increase a woman’s risk of cervical cancer. It is not clear why this is. Women with a weakened immune system are also more likely to get cervical cancer, as are those who have had a large number of children.
Preventive measures against HPV infection
For those who choose to be sexually active, condoms may lower the risk of HPV. To be most effective, they should be used with every sex act, from start to finish. Condoms may also lower the risk of developing HPV-related diseases, such as genital warts and cervical cancer. But HPV can infect areas that are not covered by a condom - so condoms may not fully protect against HPV.
People can also lower their chances of getting HPV by starting sexual activity at a later age, being in a faithful relationship with one partner; limiting their number of sex partners; and choosing a partner who has had no or few prior sex partners. But even people with only one lifetime sex partner can get HPV. And it may not be possible to determine if a partner who has been sexually active in the past is currently infected. That's why the only sure way to prevent HPV is to avoid all sexual activity.
Preventive measures against Cervical Cancer
Screening/PAP smear
Cervical screening is very important because we can stop cervical cancer from developing in the first place. This is one of the few cancers that are preventable because pre-cancerous cell changes can be picked up before they have a chance to develop into a full-blown cancer.
The screening test is often called a cervical smear. A nurse or doctor takes a small sample of cells from the surface of your cervix and spread straight onto a glass slide or put into a liquid. When it reaches the lab, your sample is put under a microscope. The cells are examined and any abnormal ones reported.
The smear test picks up pre-cancerous changes. If you have an abnormal result, it does NOT mean you have cervical cancer. But you may need further tests or treatment for an abnormal smear.
You have to be screened like this every 3 to 5 years from 25 years of age.
Vaccine against HPV
Now I come to the topic I wanted to discuss.
How good are these vaccines in preventing Cervical Cancer?
Are there any risks in taking this vaccine?
Though they are marketed as cervical cancer vaccines, they only prevent the infection of few types of HPV that are responsible for about 70% of cervical cancers. The studies that were conducted were for a period of about 2 to 3 years only. No long-term study results are available yet. Also no studies were conducted in girls less than 16 years of age. The studies had shown that the Vaccine can prevent abnormal cell changes for 2 to 3 years, but long-term effectiveness is not known.
Cervical intra epithelial neoplasia (abnormal cell growth) is graded from 1 to 3. Grade 1 indicates active HPV infection and is not considered to be pre-cancerous; current guidelines discourage treatment of this condition. Grade 2 is treated in most women but is not considered as true marker of developing cancer, as up to 40 percent of such lesions regress spontaneously; current guidelines suggest that some young women with such lesions do not need treatment. Grade 3 cervical neoplasia has the lowest likelihood of regression and the strongest potential to become cancerous.
In the HPV vaccine trials not much efficacy was reported in Grade 3 disease. This was attributed to other types of HPV, [against which we do not have vaccines] taking over and producing Cancer.
Though 3 doses are currently recommended whether there is a need for booster dose is not known
In conclusion the overall efficacy is only about 17 to 20 %.
Even after taking the vaccine the Women should undergo routine screening and safe sex practices to get maximum benefits.
Although it was licensed for use in the United States in June 2006, the first phase 3 trials of the HPV vaccine with clinically relevant end points — cervical intraepithelial neoplasia grades 2 and 3 (CIN 2/3) — were not reported until May 2007,
Why the US FDA and CDC was in such a hurry to give approval to this vaccine?
The editorial in the New England Journal of Medicine [NEJM] said:
The vaccine was highly successful in reducing the incidence of precancerous cervical lesions caused by HPV-16 and HPV-18, but a number of critical questions remained unanswered.
For instance, will the vaccine ultimately prevent not only cervical lesions, but also cervical cancer and death?
How long will protection conferred by the vaccine last?
Since most HPV infections are easily cleared by the immune system, how will vaccination affect natural immunity against HPV, and with what implications?
How will the vaccine affect preadolescent girls, given that the only trials conducted in this cohort have been on the immune response? ......
.....In the meantime, there has been pressure on policymakers worldwide to introduce the HPV vaccine in national or statewide vaccination programs. How can policymakers make rational choices about the introduction of medical interventions that might do good in the future, but for which evidence is insufficient, especially since we will not know for many years whether the intervention will work or — in the worst case — do harm?
....... serious questions regarding the overall effectiveness of the vaccine in the protection against cervical cancer remained to be answered, and more long-term studies were called for before large-scale vaccination programs could be recommended.
Is the vaccine safe?
.Even though most of the reported adverse events were not serious, there were some reports of hypersensitivity reactions including anaphylaxis, Guillain-Barré syndrome, transverse myelitis, pancreatitis, and venous thromboembolic events. The editorial in the JAMA [Journal of American Medical Association] says, "it is also difficult to conclude that a serious event is not caused by the vaccine". That means the safety is not fully assured.
Should I recommend the HPV Vaccine?
The JAMA editorial says:
When do physicians know enough about the beneficial effects of a new medical intervention to start recommending or using it? When is the available information about harmful adverse effects sufficient to conclude that the risks outweigh the potential benefits? If in doubt, should physicians err on the side of caution or on the side of hope? These questions are at the core of all medical decision making. It is a complicated process because medical knowledge is typically incomplete and ambiguous. It is especially complex to make decisions about whether to use drugs that may prevent disease in the future, particularly when these drugs are given to otherwise healthy individuals. Vaccines are examples of such drugs, and the human papillomavirus (HPV) vaccine is a case in point.
........Whether a risk is worth taking depends not only on the absolute risk, but on the relationship between the potential risk and the potential benefit. If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to a woman is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened. So rationally she should be willing to accept only a small risk of harmful effects from the vaccine.
When weighing evidence about risks and benefits, it is also appropriate to ask who takes the risk, and who gets the benefit. Patients and the public logically expect that only medical and scientific evidence is put on the balance. If other matters weigh in, such as profit for a company or financial or professional gains for physicians or groups of physicians, the balance is easily skewed. The balance will also tilt if the adverse events are not calculated correctly.
My conclusion is like this.
I will not recommend HPV Vaccine with the present available scientific evidence due to the fact that the efficacy in preventing invasive cervical cancer is not much and there is a small but considerable risk of adverse events.
Even though India reports more than 70000 deaths yearly due to cervical cancer,this coslty vaccine [around 10000 Rs for 3 shots] is highly unlikely to make any change in incidence of Cervical cancer in India due low efficacy and prohibitive cost.
Links and references
NEJM editorial
JAMA editorial
Controversy on cancer vaccine
more on cervical cancer
"Should I give my daughter cervical cancer vaccine?"
I was not prepared for the question. Though I know such a vaccine is available I have not studied it in detail. So my answer was little bit evasive.
' It is a new vaccine. Needs to be studied more .........."
I was curious why she asked the question.
"My sister who lives in USA gave her daughter the vaccine. I was wondering whether I should give it to my daughter too."
I realized that I would be asked similar questions again and again as the vaccine has been launched in India. More over I may have to take a decision about it personally since I have a daughter of about same age.
This post is an attempt by me to answer the question raised by that mother after considering all the facts available at present.
What is cervical cancer?
The cervix is another name for the neck of the womb. It is the opening to the womb from the vagina. It is really a strong muscle. Normally it is quite tightly shut, but during labour it opens up to let the baby out.
The cervix has a layer of skin-like cells on its outer surface. When these cells become cancerous it is called squamous cell cervical cancer.
There are glandular cells lining the inside of the cervix. The glandular cells produce mucus. Cancer of these cells is called adenocarcinoma of the cervix.
The area where cervical cells are most likely to become cancerous is called the transformation zone. It is the area around the opening of the cervix that leads on to the narrow passageway running up into the womb.
What causes cervical cancer?
HPV infection
Human papilloma virus or HPV is the major cause of cervical cancer. There are many different types of HPV. It is sometimes called the genital wart virus as some types of HPV cause genital warts. In fact, the types that cause warts are not the types that cause cervical cancer. But there are other types of HPV that are considered 'high risk' for cancer of the cervix. HPV is passed on from person to another through sexual contact.
Women who get cervical cancer have had past infections with HPV. High risk types of HPV can cause changes in the cells covering the cervix that make them more likely to become cancerous in time. It is said that around 50 to 80 % of women get infected with HPV some time in their lifetime.
Most people with HPV do not develop symptoms or health problems from it. In 90% of cases, the body’s immune system clears HPV naturally within two years.
But most women infected with these viruses do NOT develop cervical cancer. So other factors must also be needed for someone with HPV infection to develop cervical cancer.
HPV is passed on through genital contact, most often during vaginal and anal sex. HPV may also be passed on during oral sex and genital-to-genital contact. HPV can be passed on between straight and same-sex partners—even when the infected partner has no signs or symptoms.
A person can have HPV even if years have passed since he or she had sexual contact with an infected person. Most infected persons do not realize they are infected or that they are passing the virus on to a sex partner. It is also possible to get more than one type of HPV.
HPV can cause normal cells on infected skin to turn abnormal. Most of the time, you cannot see or feel these cell changes. In most cases, the body fights off HPV naturally and the infected cells then go back to normal. But in cases when the body does not fight off HPV, HPV can cause visible changes in the form of genital warts or cancer. Warts can appear within weeks or months after getting HPV. Cancer often takes years to develop after getting HPV.
Other risk factors for Cervical Cancer
Women who smoke are more likely to get cervical cancer than those who do not. Taking the birth control pill could increase a woman’s risk of cervical cancer. It is not clear why this is. Women with a weakened immune system are also more likely to get cervical cancer, as are those who have had a large number of children.
Preventive measures against HPV infection
For those who choose to be sexually active, condoms may lower the risk of HPV. To be most effective, they should be used with every sex act, from start to finish. Condoms may also lower the risk of developing HPV-related diseases, such as genital warts and cervical cancer. But HPV can infect areas that are not covered by a condom - so condoms may not fully protect against HPV.
People can also lower their chances of getting HPV by starting sexual activity at a later age, being in a faithful relationship with one partner; limiting their number of sex partners; and choosing a partner who has had no or few prior sex partners. But even people with only one lifetime sex partner can get HPV. And it may not be possible to determine if a partner who has been sexually active in the past is currently infected. That's why the only sure way to prevent HPV is to avoid all sexual activity.
Preventive measures against Cervical Cancer
Screening/PAP smear
Cervical screening is very important because we can stop cervical cancer from developing in the first place. This is one of the few cancers that are preventable because pre-cancerous cell changes can be picked up before they have a chance to develop into a full-blown cancer.
The screening test is often called a cervical smear. A nurse or doctor takes a small sample of cells from the surface of your cervix and spread straight onto a glass slide or put into a liquid. When it reaches the lab, your sample is put under a microscope. The cells are examined and any abnormal ones reported.
The smear test picks up pre-cancerous changes. If you have an abnormal result, it does NOT mean you have cervical cancer. But you may need further tests or treatment for an abnormal smear.
You have to be screened like this every 3 to 5 years from 25 years of age.
Vaccine against HPV
Now I come to the topic I wanted to discuss.
How good are these vaccines in preventing Cervical Cancer?
Are there any risks in taking this vaccine?
Though they are marketed as cervical cancer vaccines, they only prevent the infection of few types of HPV that are responsible for about 70% of cervical cancers. The studies that were conducted were for a period of about 2 to 3 years only. No long-term study results are available yet. Also no studies were conducted in girls less than 16 years of age. The studies had shown that the Vaccine can prevent abnormal cell changes for 2 to 3 years, but long-term effectiveness is not known.
Cervical intra epithelial neoplasia (abnormal cell growth) is graded from 1 to 3. Grade 1 indicates active HPV infection and is not considered to be pre-cancerous; current guidelines discourage treatment of this condition. Grade 2 is treated in most women but is not considered as true marker of developing cancer, as up to 40 percent of such lesions regress spontaneously; current guidelines suggest that some young women with such lesions do not need treatment. Grade 3 cervical neoplasia has the lowest likelihood of regression and the strongest potential to become cancerous.
In the HPV vaccine trials not much efficacy was reported in Grade 3 disease. This was attributed to other types of HPV, [against which we do not have vaccines] taking over and producing Cancer.
Though 3 doses are currently recommended whether there is a need for booster dose is not known
In conclusion the overall efficacy is only about 17 to 20 %.
Even after taking the vaccine the Women should undergo routine screening and safe sex practices to get maximum benefits.
Although it was licensed for use in the United States in June 2006, the first phase 3 trials of the HPV vaccine with clinically relevant end points — cervical intraepithelial neoplasia grades 2 and 3 (CIN 2/3) — were not reported until May 2007,
Why the US FDA and CDC was in such a hurry to give approval to this vaccine?
The editorial in the New England Journal of Medicine [NEJM] said:
The vaccine was highly successful in reducing the incidence of precancerous cervical lesions caused by HPV-16 and HPV-18, but a number of critical questions remained unanswered.
For instance, will the vaccine ultimately prevent not only cervical lesions, but also cervical cancer and death?
How long will protection conferred by the vaccine last?
Since most HPV infections are easily cleared by the immune system, how will vaccination affect natural immunity against HPV, and with what implications?
How will the vaccine affect preadolescent girls, given that the only trials conducted in this cohort have been on the immune response? ......
.....In the meantime, there has been pressure on policymakers worldwide to introduce the HPV vaccine in national or statewide vaccination programs. How can policymakers make rational choices about the introduction of medical interventions that might do good in the future, but for which evidence is insufficient, especially since we will not know for many years whether the intervention will work or — in the worst case — do harm?
....... serious questions regarding the overall effectiveness of the vaccine in the protection against cervical cancer remained to be answered, and more long-term studies were called for before large-scale vaccination programs could be recommended.
Is the vaccine safe?
.Even though most of the reported adverse events were not serious, there were some reports of hypersensitivity reactions including anaphylaxis, Guillain-Barré syndrome, transverse myelitis, pancreatitis, and venous thromboembolic events. The editorial in the JAMA [Journal of American Medical Association] says, "it is also difficult to conclude that a serious event is not caused by the vaccine". That means the safety is not fully assured.
Should I recommend the HPV Vaccine?
The JAMA editorial says:
When do physicians know enough about the beneficial effects of a new medical intervention to start recommending or using it? When is the available information about harmful adverse effects sufficient to conclude that the risks outweigh the potential benefits? If in doubt, should physicians err on the side of caution or on the side of hope? These questions are at the core of all medical decision making. It is a complicated process because medical knowledge is typically incomplete and ambiguous. It is especially complex to make decisions about whether to use drugs that may prevent disease in the future, particularly when these drugs are given to otherwise healthy individuals. Vaccines are examples of such drugs, and the human papillomavirus (HPV) vaccine is a case in point.
........Whether a risk is worth taking depends not only on the absolute risk, but on the relationship between the potential risk and the potential benefit. If the potential benefits are substantial, most individuals would be willing to accept the risks. But the net benefit of the HPV vaccine to a woman is uncertain. Even if persistently infected with HPV, a woman most likely will not develop cancer if she is regularly screened. So rationally she should be willing to accept only a small risk of harmful effects from the vaccine.
When weighing evidence about risks and benefits, it is also appropriate to ask who takes the risk, and who gets the benefit. Patients and the public logically expect that only medical and scientific evidence is put on the balance. If other matters weigh in, such as profit for a company or financial or professional gains for physicians or groups of physicians, the balance is easily skewed. The balance will also tilt if the adverse events are not calculated correctly.
My conclusion is like this.
I will not recommend HPV Vaccine with the present available scientific evidence due to the fact that the efficacy in preventing invasive cervical cancer is not much and there is a small but considerable risk of adverse events.
Even though India reports more than 70000 deaths yearly due to cervical cancer,this coslty vaccine [around 10000 Rs for 3 shots] is highly unlikely to make any change in incidence of Cervical cancer in India due low efficacy and prohibitive cost.
Links and references
NEJM editorial
JAMA editorial
Controversy on cancer vaccine
more on cervical cancer
Sunday, January 3, 2010
Life style changes in the New Year
I do not practice what I preach.
I preach to my patients about
'the importance of regular exercise in maintaining good health'.
I preach about
'importance of eating less fatty food'
I preach about
'reducing weight to reach an ideal BMI'
I preach about
'eating plenty of fruits and vegetables'
I preach about
'cutting down on snacks'.
I do not practice what I preach.
I never do regular exercise. Never cut down on fatty foods. Eat fruits rarely but snacks frequently.
May be it is time for me to practice what I preach starting from this year.I aim to achieve a BMI of 25 by the end of this year. Currently it is 28.4.
Let me try my best.
To calculate your BMI and to know more about a healthy BMI click the link below.
http://www.nhlbisupport.com/bmi/bmi-m.htm
I preach to my patients about
'the importance of regular exercise in maintaining good health'.
I preach about
'importance of eating less fatty food'
I preach about
'reducing weight to reach an ideal BMI'
I preach about
'eating plenty of fruits and vegetables'
I preach about
'cutting down on snacks'.
I do not practice what I preach.
I never do regular exercise. Never cut down on fatty foods. Eat fruits rarely but snacks frequently.
May be it is time for me to practice what I preach starting from this year.I aim to achieve a BMI of 25 by the end of this year. Currently it is 28.4.
Let me try my best.
To calculate your BMI and to know more about a healthy BMI click the link below.
http://www.nhlbisupport.com/bmi/bmi-m.htm
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