Thursday, May 30, 2013

Vaccination for your parents / grand parents !

The best gift to your grandparents is to get them vaccinated if they have not been vaccinated earlier.

  • Annual influenza or flu vaccine is recommended for all persons aged 6 months and older.
  • Pneumonia vaccine should be given to all adults aged 65 years and older.
  • Tetanus Toxoid should be given to all irrespective of age after every 10 years.
  • A single dose of herpes zoster vaccine is recommended for adults aged 60 years and older regardless whether they have had a previous episode of herpes zoster. The vaccination begins at 60 years of age.
  • Hepatitis B vaccine should be given to all if they have not been vaccinated earlier.
  • All diabetics aged 60 years or older should be vaccinated for hepatitis B. This recommendation is based on increased need for associated blood glucose monitoring in long term care facilities.
  • All patients with chronic liver diseases should also be given the Hepatitis B vaccine.

Therapeutic Index (TIX) for intranasal corticosteroids in the treatment of allergic rhinitis

 2011 Aug;49(3):272-80. doi: 10.4193/Rhin.

Therapeutic Index (TIX) for intranasal corticosteroids in the treatment of allergic rhinitis.


Practice for Dermatology and Allergy, Immenstadt, Germany.



Intranasal corticosteroids (INS) are the first line treatment for allergic rhinitis (AR). To guide clinical decision-making, we created a therapeutic index (TIX) for INS reflecting efficacy and safety.


A Medline search (1966 to June 2009) was carried out to identify all placebo-controlled randomized trials, and observational reports for safety issues, with Dexamethasone, Budesonide (BUD), Fluticasone propionate (FP), Fluticasone furoate (FF), Flunisolide, Mometasone furoate (MF), Triamcinolone (TRIAM), and Beclomethasone dipropionate (BDP) as treatment for AR. Data on three efficacy (nasal symptoms, ocular symptoms, global assessment) and three safety outcomes (epistaxis, growth, systemic ocular effects) were extracted. Meta analyses were performed for each INS and outcome and results were categorised into scores by quartiles. Scores of the three efficacy and safety outcomes were summed up to create summation scores for efficacy (ES) and side effects (AES), respectively with a maximum of 9 points. The TIX was then defined as the ratio of ES and AES.


Data of 84 studies were extracted. Based on availability of data, a TIX was calculated for 6 substances. BUD showed the highest efficacy score followed by MF and TRIAM. The lowest scores for side effects were achieved by MF and TRIAM followed by FP. These findings resulted in TIX scores of 7 and 5 for MF and TRIAM, respectively, indicating a high efficacy and low potential of adverse events. Medium scores were reached by BUD and FP and lower scores by BDP and FF.


Although safety and efficacy is proven for all available INS by multiple studies, the systematic aggregation and analysis of data allows for a differentiated summary on clinically important features.
Comment: We had published an earlier post about safety of Intranasal steroids in Allergic Rhinitis in kids (link )
This study suggests that while both Mometasone & Fluticasone Furoate may be safe in children above 2 years, MF is more likely to be effective given its higher therapeutic index. 

Wednesday, May 29, 2013

Best practices for children (& adults) wearing Contact Lens

What are some rules for safe contact lens wear? First, contact lenses should only be used to correct the patient's vision and not as a costume or for a decoration. They need to be fitted by a professional -- an optometrist, ophthalmologist, or optician -- who is skilled and licensed in the fitting of contact lenses. The lens should be one that has been approved by the FDA for use in humans. The lenses need to be fitted properly and the patient needs to be instructed on the proper technique for insertion, wearing, sterilization, and cleansing of the lens and storage case. Finally, those rules have to be followed carefully.
Lenses should never be worn overnight. Other high-risk use of lenses would be wearing lenses for swimming or other activities in which water or contamination would be splashed into the eyes. If a child or an adult has a red eye or a painful episode related to contact lens use, the lens should be removed immediately and the patient, along with the lens, should be sent immediately to an emergency room or, on the same day, to an eye professional to be evaluated for possible infection and started on treatment.
Those are some of the rules for safe contact lens use, but I would strongly advise that no decorative or purely cosmetic, costume contact lenses ever be used or be considered safe unless they are fitted by a professional.

Tuesday, May 28, 2013

Insufficient Hepatitis B vaccine coverage in Indian Children

For the last 30 years, the Hepatitis B vaccine has been successfully introduced in a number of countries across the globe where it has helped reduce the incidence of these infections. There are an estimated 40 million chronic Hepatitis B virus (HBV) carriers in India which constitute about 11% of the global burden of this infection. Since 2007-08, the Hepatitis B vaccination program has becomes an integral part of the Universal Immunization Program across 10 states in India. The Indian national policy recommends that children receive this vaccine along with the DPT and the trivalent polio vaccine at 6, 10 and 14 weeks in addition to a birth dose.
However, the low coverage of the HBV vaccine, compared to the similarly timed DPT, prompted the World Health Organization - India's National Polio Surveillance Project (NPSP) to assess the possible reasons behind this scenario. The assessment was carried out between August and December 2009 in selected districts in Punjab, Madhya Pradesh, West Bengal, Karnataka and Tamil Nadu.
The study assessed that some of the reasons for the poor coverage included poor stock management, incomplete recording and reporting, the perceived high cost of the vaccine, the fear of wastage of vaccine because of the 10-dose vial, and incomplete knowledge amongst health professionals about the vaccine schedule. Clear, precise instructions along with improved management of vaccine stocks could help improve the coverage for this – and other new vaccines.

Source: Lahariya C et al. An assessment of hepatitis B vaccine introduction in India: Lessons for roll out and scale up of new vaccines in immunization programs. Indian J Public Health 2013;57:8-14

Friday, May 17, 2013

Doctors - Beware of pharma pushed news in your name in the newspapers !

Many pharmaceutical companies are hiring PR agencies to push disease management or prevention health stories in newspapers at national level.
The story on behalf of the pharmaceutical company is created by the PR agency who then approaches key opinion leaders as suggested by the pharma and publish the same story under the name of KOL in the city.
Any story where we lend our name and photograph may land us into problem under the MCI Act.
Also it is possible that the PR agency may send same story to their state counter parts and get exactly the same story published in various state newspapers under the name of different doctors.
You may end up verbatim same story appearing under the name of different doctors with their photographs in various states.
Sometimes doctors may not even know that a pharma company is behind these stories as they may be approached by a PR agency that will send doctors an article and ask to give their name and photograph against that article and doctor may not be aware that the same article also has been sent to another doctor in another state.
It may also so happen that the PR department of your own hospital may approach you for a story to take your name and photograph. The doctor might be thinking that the story has been developed by their PR department and they may not be even away that the story has come through another PR agency to their hospital PR department. The hospital PR department is always under pressure to give the target to their management.
The same story being published under different names in any way is unethical and illegal.
I came across recently where a pharma company pushed an exactly same vitamin D article in different states with their photos.

Thursday, May 16, 2013

India unveils rota virus vaccine

Indian scientists unveiled an affordable vaccine ( a dollar a vaccine) against a deadly diarrhoea-causing virus, Rota virus, that kills some 100,000 children in India every year. Rotavirus, is globally responsible for some 453,000 deaths annually. Rotavirus is blamed for causing up to 884,000 hospitalisations in India a year, at a cost to the country of 3.4 billion rupees.
K Vijaraghavan, Secretary of India’s Department of Biotechnology said it was a product of international cooperation. For the first time Indian scientists have taken a vaccine from the earliest discovery to every stage of development.
The vaccine named Rotavac will be manufactured by Hyderabad-based Bharat Biotech. Each vaccination consists of three doses.
Each dose of licenced vaccines from GlaxoSmithKline and Merc cost around 1,000 rupees.
Dr M K Bhan pioneered the project after local scientists discovered a localised rotavirus 23 years ago in a New Delhi hospital.
25 percent of all diarrhoeal admissions would be prevented by this. More than 300,000 babies die within 24 hours of being born in India each year from infections and other preventable causes.

NIH has also congratulated the Program for Appropriate Technology in Health (PATH), Bharat Biotech International, Ltd., and the scientists, government and people of India on the important results from the ROTAVAC rotavirus vaccine study.
An oral vaccine, Rotavac will be administered to infants in three dose course at the age of  6, 10 and 14 weeks. It will be given along with routine immunizations recommended at these ages.
Comments: This is wonderful news. Not only do we have an indigenous vaccine with Indian strains, and studies from AIIMS, but the cost of the vaccine is mindbogglingly amazing. In this era of MNCs vaccines where in all vaccines appear to cost more than INR 1000 at least, including currently available Rotavirus vaccines, this price point of INR 54 is going to help prevent Rotavirus disease in millions of kids and prevent lakhs of children from dying. Well done India !

Wednesday, May 08, 2013

The Association Between Acetaminophen (PCM / Crocin) and Asthma .... Should Its Pediatric Use Be Banned?

Expert Review of Respiratory Medicine
Expert Rev Resp Med. 2013;7(2):113-122. 


During the last few decades, a huge epidemiological effort has been made all over the world in order to cast some light on the origin of asthma (or 'wheezing disorders' as a general term) and its recent increase in prevalence. The focus on genetic factors has failed to show any genetic signal strong enough to be seriously considered, and the tiny genetic signals found have never been appropriately replicated. The focus on environmental factors has provided some variable signals on the role of infections, allergens and bacterial substances, the direction of which have curiously varied from protecting to inducing asthma. The only environmental factor that has launched a large and consistent epidemiological signal, found in almost every epidemiological study addressing the issue, is previous acetaminophen exposure, which consistently increases the prevalence and clinical manifestations of every wheezing disorder under study. Is acetaminophen a real asthma promoter or an innocent bystander?


Too liberal use of acetaminophen in children should no longer be recommended. In the general pediatric population there is a good deal of epidemiological evidence suggesting that acetaminophen exposure increases wheezing disorders prevalence, and while awaiting the results of appropriate randomized clinical trials evaluating this intervention, yet to be designed and carried out, it seems reasonable to limit acetaminophen exposure to clinical settings where no alternatives exist, that is, when ibuprofen is not appropriate. In wheezing children, this recommendation is more strongly evidence based: this intervention (avoiding acetaminophen by using ibuprofen) has proved to decrease wheezing morbidity in this population in a large and well-designed clinical trial.
However, acetaminophen banning in the general pediatric population does not seem appropriate yet, because this intervention has not been properly evaluated to date and there are clinical situations in which children and pediatricians are devoid of an appropriate alternative antipyretic and analgesic drug. Moreover, banning or drug withdrawal is a regulatory issue and only regulatory agencies, with their wide access to safety databases, can accomplish this complex task. The time has come for them to do their part.
We cannot avoid the already classic ending: we are in urgent need for well-designed clinical trials evaluating the effect of avoiding acetaminophen exposure in children on wheezing disorders prevalence and morbidity. Pediatric community: please, move on!
Comment: It is time for pediatricians to at least start using plain Ibuprofen (without PCM) in children who have wheeze.

Wednesday, May 01, 2013

Infant Botulism case in the USA

Published Date: 2013-04-28 21:21:03
Subject: PRO/EDR> Infant botulism - USA (02): (KS) 
Archive Number: 20130428.1678643
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Wed 24 Apr 2013
Source: Topeka (KS) Capital-Journal [edited]

A mother took her 5-month-old son to Stormont-Vail Regional Health Center's breast-feeding clinic 12 Apr 2013 because he wasn't eating well, was unusually fussy and just wasn't acting like himself. Within 24 hours, the infant was in Stormont's pediatric intensive care unit, limp and weak, and finally needing a ventilator to help him breathe. As doctors filed in and out, eliminating possible causes of The rapid deterioration, both parents began to fear the worst.

Although it took more than a week for laboratory tests to confirm the finding, Muthukumar Vellaichamy, a Stormont-Vail pediatric critical care physician, and Daniel Katz, a Cotton O'Neil Clinic pediatric neurologist, were sure enough of their conclusion that they ordered the BabyBIG botulism antitoxin delivered from California to combat infant's illness.

Infant botulism is caused when spores of _Clostridium botulinum_ are ingested by an infant, and germinate in the large intestine into the vegetative bacteria and produce botulin neurotoxin, according to a California Department of Health website. 

The antitoxin had a hefty price tag of $60 000, the mother said. The California Department of Health had to have a guarantee of payment before it could ship, and thankfully, she said, insurance covered $45 000 and the rest was written off. 

Vellaichamy said he saw a case of infant botulism when working in Wichita 2 years ago, and along with Katz, decided that was the most likely cause of the illness.

This case is just the 5th case of infant botulism reported to the Kansas Department of Health and Environment in Kansas since 2002.

Vellaichamy said he expects the infant to have a full recovery, since infant botulism rarely causes long-term effects.

[Byline: Morgan Chilson]
Comment: I am not sure why we in India do not see cases of Infant Botulism, is it being misdiagnosed as sepsis?
Also the price tag of medicines in USA appears to be highly inflated, USD 60,000 for BabyBIG (Infant botulism anti-toxin) translates to more than INR 30 lakh !

A simple two question tool to reliably indicate Post Partum Depression

Postpartum Depression (PPD) (also known as postnatal depression) is a largely overlooked health problem in India, due to lack of awareness and to a stigma of mental illness. In a recent mdCurrent-India survey, 70% of doctors delivering 5 or more babies a week did not always screen for post-partum depression. PPD is a health condition that should not be ignored, as it affects not only the mother, but also the short- and long-term growth and health of the child. Depressed mothers are less able to take care of themselves and provide proper care or nourishment for their infant, which can even lead to increased maternal and infant mortality. The number of deaths and adverse effects on families in India can be reduced by early intervention and prevention by obstetricians and primary care physicians (PCP). The PCP is usually the first doctor to see the mother and infant after birth, and has the advantage of continuity and building a long-term doctor-patient relationship with the patient and family.

PPD diagnostic tools
A well-established screening tool for PPD in India is the Edinburgh Postnatal Depression Scale (EPDS) or a Hindi-translated version of the structured questionnaire. The Kessler-10 item scale is also an established questionnaire for detecting common mental illness in a community setting, and has been used in India and World Mental Health Surveys. The Two-Question Test on depressed mood is a short screening tool with a high sensitivity that may be an effective screening tool for doctors who have time constraints . The following questions are asked in the Two-Question Test:
  1. “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
  2. “During the past month, have you often been bothered by little interest or pleasure in doing things?”
If the patient answers “no” to both questions, then depression is highly unlikely. If a patient answers “yes” to either question, then other symptoms of depression should be detected before confirming the diagnosis of postpartum depression.
For a formal assessment you can look at these resources...
Physician resources – screening tools:

Edinburgh Postnatal Depression Scale (EPDS) with scoring instructions (
Kessler Psychological Distress Scale (K10)
  Self-administered questionnaire (
  Interviewer-administered questionnaire (
Comment: Even though I am a pediatrician, I do see many mothers who appear to be having at least some symptoms of PPD. These two questions should help me at do a basic screen to help identify those at risk for this problem which may adversely affect the development of the child too.