Friday, December 21, 2012

Articles worth keeping - Child Presenting With Recurrent Cutaneous Abscesses

What is the most specific and practical work-up for a child (12 years old) who has recurrent cutaneous abscesses? The last one cultured out methicillin-resistant Staphylococcus aureus (MRSA). 
Recurrent cutaneous abscesses can be caused by particularly virulent pathogens, immune deficiencies, or primary dermatologic conditions. If MRSA has been cultured from the abscess, it suggests that the former may be the most likely explanation. This type of organism is, by definition, resistant to treatment with many of the standard antibiotics, and sensitivities should be performed to direct therapy. Especially in a child, it is important to treat until multiple cultures are negative to establish that the infection has indeed resolved. It is also important to search for a reservoir where the bacteria may be "hiding" between infections. The nasopharynx is the most common reservoir (and this area should be cultured), although occasionally a pet or another family member or playmate can carry the bacteria.
Immune deficiency should also be considered, since neutrophil-killing disorders such as chronic granulomatous disease (CGD) are typically associated with recurrent abscesses of the skin. Clues for an immune deficiency would be a history of abscesses in other closed spaces (lung, sinuses, etc), or periodontal disease. If CGD is suspected, a complete blood count should be obtained, along with a differential to calculate the absolute neutrophil count. The bloodsmear should be evaluated to assess neutrophil morphology, which is abnormal with some immune deficiencies. Finally, superoxide production, which is an important tool for killing bacteria and fungi, can be screened with the nitroblue tetrazolium (NBT) test. This test involves incubating fresh peripheral blood cells with a colorless dye (formazan), which turns blue when cells are activated in the test tube.
Dermatologic diseases can also present with either abscesses or pustules that closely resemble abscesses. In addition, some dermatologic diseases, such as atopic dermatitis, are associated with an enhanced susceptibility to infections, particularly with Staphylococcus and Streptococcus. Finally, hidradenitis suppurativa can be recognized by a typical distribution of cutaneous abscesses corresponding with apocrine sweat glands. It is uncommon before puberty, and is sometimes associated with inflammatory bowel disease.
Comments: A common problem seen in OPD practice. Now all I need is a lab in Chandigarh (in the private sector) that can do an NBT test with accuracy.

Thursday, December 13, 2012

Bouncy-House Injuries Skyrocket !

Yael Waknine
  Nov 27, 2012
The number of bouncy-house injuries has skyrocketed in the last 10 years, reaching the point where an American child is injured every 46 minutes, according to research published online November 26 in Pediatrics.
Meghan C. Thompson, BA, from the Center for Injury Research and Policy, Research Institute at Nationwide Children's Hospital, Columbus, Ohio, and colleagues analyzed injury records for almost 65,000 children, finding that the rate and number of bouncy-house-related injuries increased 15-fold from 1990 to 2010, more than doubling in the last 2 years alone.
"Bouncer-related injury patterns identified in this study were similar to those described for trampolines," the authors write. For both trampolines and inflatable bouncers, with increasing age the frequency of upper-extremity injuries and fractures decreased and lower-extremity injuries increased.
Children aged 6 to 12 years were most often hurt compared with those aged 0 to 5 years and 13 to 17 years (54.0% vs 35.8% and 10.2%, respectively).
Boys were more likely to sustain injuries than girls (54.6% vs 45.4%), including concussions/closed head injuries and lacerations (relative risk [RR], 2.49 [95% confidence interval (CI), 1.46 - 4.25] and 2.41 [95% CI, 1.55 - 3.73], respectively), or injure their head/neck or face (RR, 1.37 [95% CI, 1.09 - 1.73] and 1.76 [95% CI, 1.35 - 2.30], respectively). In contrast, girls were more likely than boys to sustain lower-extremity injury (RR, 1.39; 95% CI, 1.17 - 1.64).
Of the 65.2% of cases for which a venue was reported, 43.7% of injuries occurred at a sports or recreational facility and 37.5% occurred at home.
The vast majority of children treated in the emergency were released or left against medical advice (96.6%); only 3.4% of injuries required hospitalization or 24-hour observation, primarily for fractures (81.7%).
"Policy makers must consider whether the similarities observed in bouncer-related injuries warrant a similar response" to the recommendations given for trampolines, the authors write, noting that although pediatric bouncer-related injury rates are currently lower than trampoline-related rates (5.28 vs 31.9 per 100,000 in 2009), they are rising rapidly. "[P]olicy makers should, at minimum, formulate recommendations for safer bouncer usage and design," they emphasize.
65,000 Injuries Over the Course of 20 Years
For the study, researchers analyzed the National Electronic Injury Surveillance System records for an estimated 64,657 children younger than 18 years who had been treated in US emergency departments for inflatable bouncer-related injuries from 1990 to 2010.
Results revealed that the rate and number of bouncy-house related injuries increased 15-fold during the period from 1995 to 2010, from 1.01 per 100,000 children (95% confidence interval [CI], 0.70 - 1.32 injuries/100,000 children) in 1995 to 15.2 per 100,000 children (95% CI, 9.93 - 20.56 injuries/100,000 children) in 2010. There were 702 (95% CI, 284 - 1120) injuries in 1995 compared with 11,311 (95% CI, 7115 - 15,506) injuries in 2010. ( P < .001 for both). In 2010 the average number of injuries in the United States was 31 per day, corresponding to an injury report every 46 minutes.
Fractures were the most common type of injury (27.5%) and most frequently occurred in children aged 5 years and younger (relative risk [RR], 1.31; 95% CI, 1.12 - 1.54); strains and sprains were also common (27.3%) and were reported most frequently among teenagers aged 13 to 17 years (RR, 1.45; 95% CI, 1.12 - 1.88). Teenagers were also more likely to experience lower-extremity injuries (RR, 1.37; 95% CI, 1.13 - 1.66).
As with trampoline-related accidents, the majority of injuries occurred to the extremities (lower, 32.9%; upper, 29.7%). An additional 18.5% of injuries involved the head and neck, 9.3% affected the face, and 9.0% were trunk injuries.
Lacerations were 14.3 times (95% CI, 10.46 - 19.53 times) more likely to occur in the face than any other body region, and fractures were 3.31 times (95% CI, 2.58 - 4.24 times) more likely to occur in the upper extremity than any other body region, particularly among children aged 12 years and younger (RR, 1.89; 95% CI, 1.05 - 3.41).
Stunts and Collisions
As with trampoline-related accidents, falling was the major source of injury, accounting for 43.3% of cases. More children were injured falling in or on the bouncer than getting on or off (26.1% vs 17.2%), which may be a matter of design, the authors note.
Other sources of injury included other children (16.2%), with 9.9% of cases attributable to colliding with or being pushed/pulled by another person and 6.3% the result of another child's fall.
"Stunts and collisions were common injury mechanisms in this study and in previous bouncer and trampoline studies," the authors write, noting that as with trampolines, the presence of several children on a single bouncer is a risk factor for injury.
According to the authors, the similar nature and mechanism of trampoline- and bouncer-associated injuries suggests that prevention methods for one may be extrapolated to the other, but this concept has not been adequately explored.
As previously reported by Medscape Medical News, recommendations from the American Academy of Pediatrics in 2012 addressed trampolines and recommended their use only as part of a structured training program that includes appropriate safety measures. These recommendations made no mention of bouncy houses because they do not fall into the training category. Other organizations such as ASTM International and the US Consumer Product Safety Commission have attempted to address bouncer safety issues. In the end, the standards are set by individual manufacturers, the authors write.
"To date, the medical and public health community has not provided safety recommendations regarding pediatric use of inflatable bouncers," the authors assert, noting that the recent increase in injuries also underscores the need for guidelines to improve bouncer use and design.
The authors have disclosed no relevant financial relationships.
Pediatrics. Published online November 26, 2012. Full text
Comments:  We have an increasing number of bouncy houses that are now available in various play areas and fairs in India. A large number of children are invariable found in these at any given point of time. Given the fact that most injuries seem to occur to children while they are on the bouncy house and due to collisions./ stunts I am fairly certain that we too need to be careful to prevent such injuries in our children. My daughter loves playing on these bouncy houses, and I for one, would now approach these with more care

Monday, December 03, 2012

A beautiful infographic regarding baby developmental milestones

For many parents, regularly worrying about their baby's development is the norm.
The following lovingly created infographic tells about the common milestones for children from 0-24 months (2 years) old. Please remember to ask your pediatrician if you have persistent concerns regarding your child's development though !

Click to Enlarge Image

The FamilyCord Baby Milestones Guide - Brought To You By FamilyCord

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.

Wednesday, October 31, 2012

A wonderful article on "Wildly successful medical practices" on Medscape

Why Some Practices Are Wildly Successful?

Here are some helpful tips from a fascinating article, the link to the entire article is provided at the end.


Some practices struggle. Some bring in a reasonable income for the partners. And some --even in the current economic climate -- soar. They attract new patients and add new providers, and their revenues outpace those of their peers.
What's their secret? External factors can certainly contribute to a practice's success, and clinical excellence is a must-have foundation. But one of the keys to cultivating a wildly successful practice lies in understanding, accepting, and embracing the fact that a medical office, at its core, is a business.
We asked experts to describe what differentiates wildly successful practices from their peers. Here's their list of must-have qualities:

No Substitute for an Entrepreneurial Spirit

While some physicians focus on the uncertainties of healthcare reform, successful physicians look for opportunities.
"Successful physicians are often impatient," says David Zahaluk, MD, a Dallas, Texas-based family practice physician and author of The Ultimate Practice Building Book (Trafford Publishing, 2007). "They don't want to wait for organic growth, and they're positive."

Have a Strategy and a Plan

For too many practices, the plan for growth consists of little more than "doing the same thing over and over again and hoping to do more of it," says Dr. Zahaluk. "That won't achieve your ends. Seeing one more patient a day just means more energy, more man-hours."
Successful practices plan for long-term growth and have immediate and mid-range action plans that advance their longer-term objectives.

Visibility Is Imperative

Wildly successful practices know how to attract attention.
Some practices tout the expertise or specialized skills of individual physicians, who have name-recognition in their community. Others tap their social and professional networks to attract new patients. Still others differentiate themselves through effective advertising that highlights their unique offerings.

A World of Potential in Reliable Data

Rock-solid practices don't waste their time on guesswork. They depend on data.
They know when diabetic patients need to have their A1c checked. They know their charge volume and payer mix and how long it takes to get paid by a particular payer for a specific procedure. Success depends on "having the right data at the right time and trying to make the right decisions with it," says Scott Andrews. "If you don't, you can't and you won't."
A Patient-Centered Culture Makes a Difference
Of course, few tactics will work effectively if the practice doesn't keep patients happy. Word of mouth is still the strongest weapon in any marketing arsenal. That type of culture doesn't just happen; it's cultivated. Physicians hire with an eye for fit, ensuring that new doctors and staff share their goals and work ethic. 

Strong Leaders and an Outstanding Staff

Great practices have great leaders who set the direction for the practice, says Capko. That said, excellent leaders surround themselves with the right staff. A physician leader needs to have the office manager, support staff, and technological tools in place to effectively handle the day-to-day demands of running the business so that he or she can focus on clinical issues and the overall direction of the practice. Great physicians don't micromanage, because they know they've hired capable staff members and provided them with the training and education they need to help the practice excel. In a perfect scenario, a doctor is spending 95% of his time seeing patients, and the 5% of his time he spends on business is just monitoring and checking the state of the business. 

Willingness to Create Helpful Partners

Successful practices seek expert advice when they need it. 
Efficiency, Productivity, and Discipline
"Top-tier doctors know how to be efficient with their time," says Randy Bauman. "It's not that they're giving patients 2 minutes; it's that they're conscious of their time. They're doing simple things, such as not going in and out of the examination room more than once."
Effective practice management tools are essential to boosting efficiency, Dr. Wilhelm says, and the payoff extends beyond productivity. Because physicians and staff are using their time more efficiently, improved workflow creates a more professional, calm environment, which benefits staff and patients alike.
For the entire article I would recommend logging in to Medscape (free registration) & reading it here

Tuesday, October 30, 2012

Doctors Admit to Unprofessional Behavior in Study at 3 Chicago Hospitals

Working in a real hospital isn’t usually as dramatic as is portrayed in TV shows like Grey’s Anatomy orHouse, MD, but a new study has identified unprofessional behaviors to which hospital-based doctors most frequently admit, including badmouthing fellow doctors and finding medical excuses to get out of having to care for patients.
Two-thirds of doctors surveyed at three Chicago hospitals copped to having personal conversations, such as discussing evening plans, in earshot of patients, and 62 percent said they had mischaracterized a routine test as “urgent” to get it done faster. Four out of 10 said they mocked another physician to colleagues. The same number said they bad-mouthed emergency room doctors for missing part of a patient’s medical problems.
Three out of 10 said they made disparaging comments about a patient on rounds. Twenty-nine percent said they had attended a dinner or social event sponsored by a drug or medical device manufacturer or other business that stood to gain by a doctor’s decision.
The study, published in the Journal of Hospital Medicine, was based on the responses of 77 hospital-based doctors–known as hospitalists–from the University of Chicago Pritzker School of Medicine,Northwestern University Feinberg School of Medicine and NorthShore University HealthSystem.
Some of the unprofessional behaviors involved dumping work on someone else.  According to the study, 9  percent admitted that they had transferred a patient they could have taken care of to another in order to reduce their patient load. This practice is known as turfing, and 12 percent of physicians admitted they had “celebrated” a successful turf. Eight percent of doctors said they had blocked a patient, which means they refused to accept the patient into their unit by claiming the patient should be cared for in another part of the hospital. Twenty-one percent acknowledged celebrating a blocked admission.
The study noted that “participation in egregious behaviors, such as falsifying patient records (6.49%) and performing medical or surgical procedures on a patient beyond self-perceived level of skill (2.60%), was very low.” But more hospitalists reported seeing another doctor act unprofessionally than admitted they did so themselves. For instance, 68 percent said they had witnessed another doctor “blocking” a patient–eight times as many who admitted doing the blocking. And almost 20 percent of doctors said they had observed a patient being discharged before they were ready to go home, while only 2.6 percent admitted to doing that.
Dr.Vineet Arora, one of the authors of the study, said observations of unprofessional behavior can be wrong because doctors don’t “know the full context of the story” or because more than one doctor can report seeing the same incident, inflating the number. She said the study focused on rates of unprofessional actions that doctors admitted participating in, because those are more persuasive to the officials who put together trainings on professionalism for doctors and residents.
“The goal is to figure out what types of behaviors people are not in touch with, that come across as unprofessional,” she said. She said that since doctors may not admit to bad actions even in an anonymous survey, the real rates of some of the unprofessional actions may be somewhere between the number doctors admitted to doing and the number they claim they observed.
Commentary: I found this study fascinating in its definitions of possible "unethical behavior". It showed that most of us doctors are human too, and have our frailties and weaknesses. It also suggests that many a times we may be aware of the 'unethical' nature of our conduct, but may carry on regardless.
Looking at myself, I feel that I have probably done most of the above mentioned stuff at some point of my career, and continue doing some of this, specifically "attended a dinner or social event sponsored by a drug or medical device manufacturer or other business that stood to gain by a doctor’s decision" even now, along with most other private practitioners of our fraternity." I am not sure that I completely agree with this being unethical behavior though, since this is one of the more important ways to learn about new stuff in medicine, especially for doctors from non-academic background in India, and helps us network with other doctors too.

Friday, October 26, 2012

CDC - Prevnar13* and Pneumovax* (PSSV23) Recommendations Update

This message serves to inform you about the new ACIP recommendations to give PCV13 (Prevnar 13) to high-risk adults and includes reviews on existing PPSV23 (Pneumovax) recommendations for adults.
This overview is a must-see for every doctor, nurse, and health care provider who provides medical care to adults.
Healthcare providers should follow these overarching recommendations:
  • Adults 19 years of age or older with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants, and who have not previously received PCV13 or PPSV23, should receive a dose of PCV13 first followed by a dose of PPSV23 at least 8 weeks later. Subsequent doses of PPSV23 should follow current PPSV23 recommendations for high risk adults.
  • Adults 19 years of age or older with the aforementioned conditions (functional or anatomic asplenia, immunocompromising conditions, or those with CSF leaks or cochlear implants) who have previously received one or more doses of PPSV23 should be given a dose of PCV13 one or more years after the last PPSV23 dose was received. For those who require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years since the most recent dose of PPSV23.
  • Those who received one or more doses of PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or older if at least 5 years have elapsed since their previous PPSV23 dose. If a dose of PPSV23 was received at age 65 years or later, no additional doses of PPSV23 are recommended.
  • PPSV23 recommendations remain the same for those 65 years and older and those who are immunocompetent with chronic medical conditions, such as diabetes or heart disease.
To learn more about pneumococcal disease and vaccines, visit the resources listed below.
Web Sites

Monday, October 22, 2012

Parenting Common Questions - Breastfeeding during abortion using Misoprostol

Q: I conceived accidentally while my baby is 6 months and being breastfed. I have been advised Misoprostol for abortion. Should I stop Breastfeeding, and for how long?
Ans. Mispoprostol is a prostaglandin E1 analogue. Prostaglandin E1 and other prostaglandins appear normally in colostrum and milk. Misoprostol is rapidly metabolized in the mother to misoprostol acid which is biologically active and is excreted in human breast milk in small quantities. There are no published reports of adverse effects of misoprostol in breast-feeding infants of mothers taking misoprostol. Pharmacokinetic studies reveal that misoprostol is excreted into breast milk with drug levels that rise and fall very quickly. Levels become undetectable within 5 hours of maternal ingestion. However, breastfeeding women should be advised that misoprostol may cause infant diarrhea. The manufacturer recommends that caution should be exercised when misoprostol is administered to a nursing woman. 
However, because of the low levels of misoprostol in breastmilk, amounts ingested by the infant are small and would not be expected to cause any adverse effects in breastfed infants. No special precautions are required.
Given these facts, my recommendation would be to avoid BF for not more than a day after taking Misoprostol, you may give formula milk during this period.

Common Parenting FAQs - Can I breastfeed my baby during the time I have Viral Fever?

Dr. Can i breastfeed my during viral fever i m very scared to feed him?
Yes you can, 
It's actually good for the baby, since the antibodies that protect the child can travel through the Breast milk and help ward off infections,
Warm regards
Dr Gaurav Gupta

Saturday, October 20, 2012

'Mother's Kiss' May Dislodge Objects Stuck in Child's Nose

October 15, 2012 — The "mother's kiss" technique helped dislodge foreign objects from children's noses in 60% of reported cases, according to a literature analysis published online October 15 in theCanadian Medical Association Journal.
"The mother's kiss appears to be a safe and effective technique for first-line treatment in the removal of a foreign body from the nasal cavity," Stephanie Cook, BM BCh, from Buxted Medical Centre in the United Kingdom, and colleagues write. "In addition, it may prevent the need for general anesthesia in some cases."
The positive pressure technique involves a trusted caregiver sealing his or her mouth over the child's mouth and rapidly exhaling while occluding the unaffected nostril. Closure of the glottis limits the risk for barotrauma, and the low pressure generated is comparable to that of a sneeze (60 mm Hg).
To determine whether "mother's kiss" was effective, researchers from the United Kingdom and Australia performed a systematic search of current literature, identifying 6 relevant case series and 2 case reports involving children aged 1 to 8 years. Fourteen articles were excluded, including 4 review articles, 7 articles not written as case series, and 3 articles that consisted of a technique description only.
Data analysis revealed that mother's kiss was effective 59.9% of the time (95% confidence interval [CI], 52% - 67%), a success rate found to be independent of object type (smooth, 73% [95% CI, 56% - 86%] vs irregular, 77% [95% CI, 62% - 87%]).
Most foreign objects (87%, 27/31) documented in the studies were visible before removal attempts. Two studies concluded that fully obstructing objects were much more likely to be propelled out of the nose than those allowing air to pass, and that irregularly shaped objects tended to be easier to grasp.
The authors also found that implementation of the technique may prevent the need for general anesthesia in some cases. Of the 2 studies that included relevant information, one reported a 90% decrease in anesthesia use during 6-month periods before and after implementation of the technique (from 32.5% to 3.2%), and the other reported a lower rate of general anesthesia when the technique was attempted first (11.9% vs 18.8%; P = .34).
No adverse events were reported despite theoretical risks for epistaxis, ruptured tympanic membrane, or pneumothorax.
Insufficient data were provided in the studies with respect to determining technique success relative to the length of obstruction time, object visibility, or prior attempts at removal.
"Further studies are needed to compare different positive-pressure techniques, and to test their efficacy in specific situations addressing how long the foreign body has been lodged and its location in the nasal cavity," the authors write. They also note that future research should involve preregistered, large, consecutive, prospective case series to reduce the effect of selective reporting.
CMAJ. Published online October 15, 2012. Abstract
Commentary: A fascinating study regarding a unique way in which parents can actually treat their child effectively while potentially avoiding need for traumatic medical intervention.

Tuesday, October 09, 2012

Trial Suggests Prevnar May Also Protect Ages 18 to 49

(Reuters) Oct 05 - Pfizer Inc said a late-stage trial of its vaccine to protect against pneumococcal pneumonia suggested it would also work in adults aged 18-49, thereby possibly expanding its sales.
The vaccine, Prevnar 13, which already has $3.5 billion in annual sales from its use in adults over age 50 and children under age five, is designed to protect against pneumonia, meningitis and other infections caused by 13 strains of Streptococcus pneumoniae.
Pfizer said Prevnar 13 met the main goal of the late-stage study by showing that the immune response to the vaccine in the 18- to 49-year-old age group was not inferior when compared with the response in the 60-to 64-year-old group.
Pfizer said on Thursday that the favorable results from the study will support both its recent European Union application to market the product for the 18-49 age group, as well as applications it plans to make in other countries.
A competing vaccine from GlaxoSmithKline, Synflorix, protects against 10 strains of S. pneumoniae.
Commentary: It's always good to know about the clinical effectiveness of a vaccine in a defined age-group. However, two notes of caution are warranted....
1) It is very important to know the disease burden in the defined age group, more so in case of an expensive vaccine like Prevenar, since that would help decide the cost-effectiveness. How commonly do these problems occur in 18-49 year old people? Not very often, in my opinion.
2) The study talks about immune response only, which is NOT the same thing as clinical effectiveness. This means that the antibody responses that are measured do not necessarily result in people being actually protected against these illnesses.
Overall, given that the illnesses that are being protected against (pneumonia, meningitis, sepsis) do not occur frequently in the age group of 18-49 years, and the vaccine is prohibitively expensive, I do not think this study  would have a major impact in developing countries including India.


Monday, October 08, 2012

Nephrotic Syndrome - Parent Information Sheet

From the University of Alberta, Canada

This fact sheet has been written to tell you some facts about a kidney disease called the nephrotic syndrome. This illness also is called nephrosis or minimal change disease. The brochure will give you and your family information about your child's illness. It will tell you what will happen with this illness. You also should talk to your doctor. The more you know, the more you can help your child.
What do the kidneys do?
The kidneys are two fist-sized organs found in the lower back. When they are working well, they clean the blood, and get rid of waste products, excess salt and water. When diseased, the kidneys may get rid of things that the body needs to keep, such as blood cells and protein.
What is the nephrotic syndrome?
This is an illness where the kidney loses protein in the urine. This causes protein in the blood to drop, and water moves into body tissues, causing swelling (edema). You will see the swelling around the child's eyes, in the belly, or in the legs. Your child will not go to the bathroom as often as usual and will gain weight with the swelling.
Do other kidney diseases cause edema and protein in the urine?
Yes. Edema and protein in the urine are common in other types of kidney disease, especially a disease called glomerulonephritis.
What causes the nephrotic syndrome?
In the majority or cases, the cause is not known. The National Kidney Foundation has active research programs into causes and treatments of the nephrotic syndrome.
Who gets it?
Usually, young children between the ages of 1 1/2 and 5. It happens twice as often in boys as girls. However, children of all ages and adults also can get it.
How can you tell if your child has it?
You may see that your child has swelling around the eyes in the morning. You may think that your child has an allergy. Later, the swelling may last all day, and you may see swelling in your child's ankles, feet and belly. Also, your child may be:
• more tired & more irritable
• eating less
• pale looking
The child may have trouble putting on shoes or buttoning clothes because of swelling.
How is the nephrotic syndrome treated?
The treatment will try to stop the loss of protein in the urine, and increase the amount of urine. Usually, the doctor will start your child on a drug called prednisone. Most children get better with this drug.
What does prednisone do?
Prednisone is used to stop the loss of protein from the blood into the urine. After one to four weeks of treatment, your child should begin going to the bathroom more often. As your child makes more urine, the swelling will go away.
When there is no protein in the urine, the doctor will begin to reduce the amount of prednisone over several weeks. The doctor will tell you exactly how much prednisone to give your child each day. Never stop prednisone, unless the doctor tells you to do so. If you stop this drug or give your child too much or too little, he or she may get very ill.
Sometimes, your child will stay healthy after treatment. Your child may relapse (get sick again) at any time, even after a long time with good health. Getting sick may happen after a viral infection, such as a cold or the flu.
What problems call occur with prednisone?
Prednisone can be a very good drug, but it has a number of side effects. Some of these side effects are:
• being hungry
• gaining weight
• acne (pimples)
• mood changes (very happy, then very sad)
• being overactive
* more chance of infection
• slowing of growth rate
Side effects are more common with larger doses and if it is used for a long time; once prednisone is stopped, most of these side effects go away.
What if prednisone does not work?
If prednisone does not work for your child or if your child has serious side effects, the doctor may order another kind of medicine, called an immunosuppressive drug. These drugs decrease the activity of the body's immune system. They are effective in most, but not all, children. Your doctor will discuss in detail with you the good and bad things about the drug. The side effects of these drugs include: increased susceptibility to infections, hair loss and increased blood cell production.
Parents also should be aware that children taking immunosuppressive drugs may become ill if they develop chicken pox. Therefore, you should notify your doctor any time that your child is exposed to chicken pox while on these medications.
Your child also may be given diuretics (water pills). These drugs help the kidney get rid of salt arid water. The most common water pill used in children is called furosemide. If your child starts to have a problem with vomiting or diarrhea, you should call your doctor as the child can lose too much fluid and become even sicker. Once protein disappears from the urine, diuretics should  stopped.
What other problems happen with the nephrotic syndrome?
Most children will have problems only with swelling. However, a child with nephrotic syndrome can develop a serious infection in the belly. If your child has a fever or starts complaining of severe pain in the belly, you should call your doctor at once.
Sometimes, children with nephrotic syndrome get blood clots in their legs. If this happens, your child will complain of:'
• severe pain in arm or leg
• swelling of arm or leg
• changes in color or  temperature of arm or leg
If any of these things happens, you should call your doctor right away.
What can parents do?
Much of your child's care will be given by you. Pay attention to your child's health, but do not overprotect the child. If your child is ill or taking prednisone, the doctor will recommend a low salt diet. This type of diet will make your child more comfortable by keeping the swelling down. Try to give your child foods that he or she likes, but that are low in salt. Ask the dietitian for suggestions.
Usually, the child will be allowed to drink as much as he or she wants. A child's natural thirst is the best guide as to how much to drink. You should also weigh your child and keep a record of weight to spot a change in the disease.
The first sign that your child is getting sick again is the return of protein in the urine. Because of this, many doctors ask you to check your child's urine regularly. To do this, a special plastic strip with a small piece of paper on the end is dipped into the urine. The paper will change color when protein is in the urine. This test can be done easily at home and it can detect a relapse before any swelling is seen. Check with your doctor to learn how to do the test and how often to do it.
When there is swelling, check that your child's clothing is not too tight because the clothing can rub the child's skin over the swollen areas. This can make the skin raw, and it may get infected.
Your child will probably have this disease several years. It is very important to treat your child as normally as possible. Your child needs to continue his or her usual activities, such as going to school and seeing friends. Your child should be treated just like other children in the family in terms of discipline. Occasionally, your child may not go to school for a time. Your doctor will let you know if this is necessary. Keeping your child out of school or not letting him or her see friends will not change the illness.
Does the disease ever go away?
Sometimes. Even though the nephrotic syndrome does not have a specific cure, the majority of children "outgrow" this disease in their late teens or early adulthood. Some children will have only one attack of the nephrotic syndrome. If your child does not have another attack for three years after the first one, the chances are quite good that he or she will not get sick again.
Still, most children will have two or more attacks, The attacks are more frequent in the first one to two years after the nephrotic syndrome begins. After ten years, less than one child in five is still having attacks. Even if a child has a number of attacks, most will not develop permanent kidney damage. The major problem is to control their accumulation of fluid using prednisone and diuretics. Children with this disease have an excellent long-term outlook.
What else should I know?
1. Most children with the nephrotic syndrome respond to treatment.
2. Most children with the nephrotic syndrome have an excellent long-term outcome.
3. You should feel free to ask your child's doctor any questions.
What if I have more questions?
If you have more questions, you should speak to your doctor. You also can get additional information by contacting your local National Kidney Foundation Affiliate.
What is The National Kidney Foundation and how does it help?
Twenty million Americans have some form of kidney or urologic disease. Millions more are at risk. The National Kidney Foundation, Inc., a major voluntary health organization, is working to find the answers through prevention, treatment and cure. Through its 50 Affiliates nationwide, the Foundation conducts programs in research, professional education, patient and community services, public education and organ donation. The work of The National Kidney Foundation is funded entirely by public donations.