Vitamin D and Breast Cancer, CDC Recommends Shingles Vaccine, Autism Test May Lead to Earlier Detection

From Washington - Low levels of vitamin D in women diagnosed with breast cancer may increase the risk of death. In a study of over 500 women, those found to have a vitamin D deficiency were 94% more likely to have their cancer spread, and 73% more likely to die than those with sufficient vitamin D levels. However, the researchers caution that taking too much vitamin D can be toxic.

From Atlanta - The CDC is recommending that those over the age of 60 receive Zostavax, the only vaccine available that protects against shingles. Research has shown that the vaccine can reduce the occurrence of shingles by 50% in those over 60. Shingles is a viral disease that causes painful rashes and blisters, and affects about a third of all people in the U.S.

And finally, from Hamilton - Researchers have developed a test to screen for autism in babies as young as 9 months. The test is performed by placing a child in a car seat, and using an eye tracker to observe their interest in objects displayed on a computer screen. The study examined two groups of babies: those at high risk for autism, and those at low risk. The researchers found that, starting at 9 months, they were able to see distinctions between the two groups, a finding which could lead to earlier detection of this disorder.

Errr somebody got featured in the Malay Mail Blogspot Column

Breastfeeding May Prevent Arthritis, Antifibrinolytic Agents Increase Death Risk, Education Level Related to Death Rate

From Sweden - According to research in the Annals of the Rheumatic Diseases, women who breastfeed for extended periods of time are less likely to develop rheumatoid arthritis. Over 130 women with rheumatoid arthritis were compared to over 500 controls, and those who breastfed for one year following birth were half as likely to develop arthritis. Even breastfeeding for as little as a month lowered the risk.

From Ottawa - According to research in the New England Journal of Medicine, a medicine routinely used to prevent blood loss during heart surgery is associated with a 50% increased risk of death. In a randomized clinical trial comparing three different antifibrinolytic agents, about 6% of patients who received aprotinin died within 30 days of surgery compared to 4% of patients who received tranexamic acid or aminocaproic acid.

And finally, from Atlanta - The difference in death rates between highly educated and poorly educated people in the U.S. is widening. Researchers examined data on over 3.5 million deaths between 1993 and 2001 and found that, while the death rate for the most educated citizens decreased, the rate for those with less than a high school education increased. For example, white males who dropped out of high school were 4.4 times more likely to die prematurely than their college educated counterparts.

Medscape features an article on the Trial to Assess Chelation Therapy (TACT) and why it should be abandoned:

The National Institutes of Health (NIH) Trial to Assess Chelation Therapy (TACT) was begun in 2003 and is expected to be completed in 2009. It is a trial of office-based, intravenous disodium ethylene-diamine-tetra-acetic acid (Na2EDTA) as a treatment for coronary artery disease (CAD). A few case series in the 1950s and early 1960s had found Na2EDTA to be ineffective for CAD or peripheral vascular disease (PVD). Nevertheless, a few hundred physicians, almost all of whom advocate other dubious treatments, continued to peddle chelation as an office treatment. They claim that chelation dramatically improves symptoms and prolongs life in 80% to 90% of patients. In response, academics performed 4 controlled trials during the 1990s. None favored chelation, but chelationists repudiated those findings.
We have investigated the method and the trial. We present our findings in 4 parts: history, origin and nature of the TACT, state of the evidence, and risks. We present evidence that chelationists and their organization, the American College for Advancement in Medicine, used political connections to pressure the NIH to fund the TACT. The TACT protocols justified the trial by misrepresenting case series and by ignoring evidence of risks. The trial employs nearly 100 unfit co-investigators. It conflates disodium EDTA and another, somewhat safer drug. It lacks precautions necessary to minimize risks. The consent form reflects those shortcomings and fails to disclose apparent proprietary interests. The trial’s outcome will be unreliable and almost certainly equivocal, thus defeating its stated purpose.
We conclude that the TACT is unethical, dangerous, pointless, and wasteful. It should be abandoned.

Here are some responses in medical blogs:
They don’t call it “cheat-lation” for nothing (Respectful Insolence)
Medscape article blows the lid off of NCCAM’s chelation study (Notes from Dr. RW)

I feel sorry for the American public. That’s US Tax dollars at work!

Related MMR posts on Chelation

You may be interested to read the updated Recommendations of the Advisory Committee on Immunization Practices (ACIP) on the Prevention of Herpes Zoster, particularly the recommendations for the use of Zoster Vaccination.
The CDC is now recommending Routine Vaccination of Persons Aged >60 Years

ACIP recommends routine vaccination of all persons aged >60 years with 1 dose of zoster vaccine. Persons who report a previous episode of zoster and persons with chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease) can be vaccinated unless those conditions are contraindications or precautions. Zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing PHN, or to treat ongoing PHN. Before routine administration of zoster vaccine, it is not necessary to ask patients about their history of varicella (chickenpox) or to conduct serologic testing for varicella immunity.

The zoster vaccine, ZOSTAVAX®, is a live, attenuated vaccine containing Oka/Merck strain VZV. The vaccine is similar to the varicella vaccine, VARIVAX®, except the minimum PFU-content of the ZOSTAVAX® is at least 14-fold higher than the minimum PFU-content of VARIVAX®.
I don’t believe it’s available in Malaysia at the moment.

More info:
Herpes zoster (Wikipedia)

We read in the news that the Health Minister continues with what his predecessor set out to do: cut down waiting time in public hospitals.

Health Minister Datuk Liow Tiong Lai said yesterday that patients currently waited an average of 90 minutes before being attended to by specialists.
“I have already set a target waiting time for general outpatient treatment. Now, we will study what should be the ideal time for specialist treatment,” he said after a working visit to the Kajang Hospital.
Liow said the targeted waiting time for specialist treatment would not be 30 minutes that he set for outpatient treatment.
“One must understand a specialist takes more time to examine patients,” he said.

Doesn’t the Health Minister realize the irony of his statement in the last line? The reality of it all, is that after waiting for “specialist treatment”, the patient is in fact more likely to encounter a medical officer rather than a specialist in the “specialist clinic”.

I’d like to repeat once again the wise saying of Bushido@Dobbs (indeed I’ve incorporated this into one of the MMR Quotes which you see randomly displayed in the upper right hand corner of the page):

The practice of medicine is not like instant mee - it’s not how long you wait but what you get at the end which matters

Precisely, dear Health Minister. I think you should forget about waiting times. Concentrate on Quality. There are issues which are far more important to the doctors running the clinic which could improve efficiency. Lousy records management resulting in 404 situations (that’s Internet-speak for “file not found”). Missing or untraceable lab results. Computer system going down. Actual specialist not around - too busy attending some mesyuarat somewhere.

In any case, this pursuit of “shorter waiting time” is an exercise in futility. Why? That’s because many patients don’t keep their appointments anyway! They either don’t come on time or sometimes don’t show up at all. That’s the Malaysian style lah. You know, Malaysian time!

What I suggest is that the MOH (or any hospital for that matter) could put up a Doctor and Patients’ Charter which reads something like that:

We Guarantee Patients a Clinic Waiting Time of Not More Than 30 Minutes
** Terms and Conditions Apply

And in the small print, the T&C are:
1) If any patients don’t turn up on time or are late for their appointment, then the guarantee for the day does not apply as this messes up the appointment system.
2) Turning up earlier than scheduled does not necessarily mean you will be seen earlier, duh.
3) Turning up on the wrong day means we are likely to reschedule you to another day. There is no guarantee of being seen on a non-appointment day.
4) Don’t expect the specialists clinic to see you quickly just because you feel your problems are “urgent”. We have the ER for that.
5) Patients in the wards should be considerate enough not to suddenly become ill or arrest during clinic times as the doctors will have to leave or be late for the clinic to attend to them. If any of them do, then the clinic waiting time guarantee will not apply.

Any doctor working in a Government clinic will tell you that practically everyday, you’ll see 1, 2 or 3. So hey, it’s impossible to guarantee you short waiting times, dear patients, simply because some of you don’t know how to keep appointments! It works both ways!

Related MMR posts:
Ministry of Hell
10 things a new Health Minister needs to address

Mammography Plus Ultrasound Improves Breast Cancer Detection, Raises False Positive Rate

Adding ultrasound to mammography increases the rate of detection of breast cancer among high risk women, but at the expense of higher false positive rates, according to research published in the Journal of the American Medical Association.

Here are some recommendations for screening for breast cancer from the American College of Obstetricians and Gynecologists:

• Women aged 40 to 49 years should have screening mammography every 1 to 2 years.
• Women aged 50 years and older should have annual screening mammography.
• Despite a lack of definitive data for or against breast self-examination, breast self-examination has the potential to detect palpable breast cancer and can be recommended.

Researchers from American Radiology Services, Inc., Johns Hopkins at Green Spring in Lutherville randomized over 2,800 women who were at high risk for breast cancer and who had dense breast tissue to undergo mammography or mammography plus ultrasound.

Overall, 40 participants were diagnosed with cancer. The diagnostic yield for mammography was 7.6 cancers/ 1,000 women screened, compared with 11.8 for mammography plus ultrasound. The diagnostic accuracy was 0.78 for mammography and 0.91 for both modalities combined. The positive predictive value for a biopsy recommendation following a full diagnostic workup dropped from 22.6% for mammography to 11.2% for the combined modalities, and the false-positive rate rose from 4.4% with mammography alone to 10.4% with mammography plus ultrasound.

Today’s research calls into question the use of mammography as the gold standard screening tool for early breast cancer detection. Adding ultrasound improves detection rates, albeit at the expense of a higher false positive rate. MRI also remains a potential superior screening modality.

Patient: Doc, I’ve got a pain in my cat’s ass
Doc: Say what?
Patient, lifting up shirt : Right here….

(Spotted in The Happy Hospitalist, via Kevin MD)

Related MMR posts:
Medical body art
Tattoos - Decoration or Dangerous Fad?

Today I’d like to highlight a post at LKS’s blog on Bangalore heart trip - self-inflicted malady of Malaysian healthcare which makes interesting reading. The writer is obviously quite knowledgeable about the cardiac surgery setup in Malaysia and gives a brief wrtie-up on the history and development of heart surgery in Malaysia as well.

He does ask pertinent questions.

Why is it that after all these years we are still very short of heart surgeons in the public sector?

I think there is no answer to this until there is a total overhaul of the Malaysian healthcare system including a National Health Financing Scheme, an independent Medical services commission replacing the JPA in determining the salary and promotions of health care professionals, and the practice of true meritocracy in the MOH and the Universities. In other words, not until the cows come home.

Why do we have to “outsource” heart surgery to India when there are other solutions?

The author does have some good ideas:

1. Outsource non-blue baby and palliative surgery for blue babies to local private hospitals at a competitive price as this will be logistically more suitable for the family. Blue babies that will require complex staged surgery could perhaps be flown to Bangalore although there will be risks involved for the 3 hour flight and that perilous road journey to the Narayana itself.

5. And importantly, the Universities and the MOH have to revise their training programs to ensure that Malaysia’s expertise in this area rises to match the number of patients in this country.

Related links:
Health Minister’s Decision To Send Patients To India For Heart Surgery - Medical Outsourcing?

meyli wrote (as a comment but really this should be posted as feedback)

hi im meyli a malaysia doctor completed 1 year of housemanship here and currently 6 months away to complete my compulsory service , my husband is overseas and i am planning to resign the job here and come and join back later as contract doctor . Im so confused do i have to star back as contract doctor being a houseman again just that i missed 6 months of compulsory service .. can someone explain of the consequnces of not completing complulsory service .. and can i work overseas time being

Compulsory government service is 3 years. What you mean is the housemanship which you have not completed. I think you’ll have to check with the MMC/MOH to see if they’ll allow you to leave before completing housemanship and whether the 1 year you have done is “recognised” so you don’t have to repeat it. My advice is to talk to your hospital administrators.

The Daily Express

Come next year, it will be compulsory for nurses to achieve the relevant points by attending continuous professional development (CPD) courses to obtain a nursing practice certificate.
Health Minister Datuk Liow Tiong Lai said the requirement was important to ensure they upgraded their nursing knowledge and skills.
“As nurses, they get on-the-job training and promote themselves in many other skills. So, this (CPD) is compulsory now,” he told a press conference after launching the International Nurses Day at Sunway Pyramid Convention Centre, here, Monday.

Next up, Doctors!

If I Knew Then - Dr. Alan Yeung, MD, Discusses the Different Career Options that Can Stem From Medicine

A degree in medicine is just a starting point which can branch out into many, many pathways to a long a fruitful career. You could end up as a politician, businessman, IT specialist - not just GPs or a specialist in some clinical discipline!
Dr Alan Yeung, a cardiologist emphasises this in an Insidermedicine “If I Knew Then” video

Related MMR posts:
Medical Specialist Aptitude Test
Considering your Specialty Career in Medicine (funny flowchart)