Dr. Noorali Bharwani

February 19, 2013

Circumcision: The Controversy Continues

“What advice should a physician give to parents considering whether or not to have their baby circumcised?” asks Dr. Jeff Blackmer. Dr. Blackmer is a Director of Ethics at the Canadian Medical Association (CMA). His column appears in the Bulletin of the CMA which is part of the Canadian Medical Association Journal (CMAJ February 5, 2013).

The Canadian Paediatric Society (CPS) evaluates scientific evidence and sets guidelines in matters affecting children’s health. Since 1996, CPS has advised physicians that circumcision of newborn should not be routinely performed as there was no medical benefit. This, of course, has not changed the practice. Some parents request circumcision for their sons for religious reasons or family tradition.

In August, 2012 the American Academy of Pediatrics (AAP) updated its 1999 policy on circumcision to say that there are some medical benefits to having the procedure. Circumcision lowers risk of urinary tract infection, cancer of the penis, and sexually transmitted infection. Blackmer says that CPS is reviewing the evidence and may release an updated statement.

In 2011, Dr. Noni MacDonald, Section Editor of CMAJ wrote an article in the CMAJ under the title, “Male circumcision: get the timing right.” (CMAJ April 19, 2011). Dr. Noni MacDonald is a Professor of Paediatrics and of Computer Science at Dalhousie University with a clinical appointment in Paediatric Infectious Diseases at the IWK Health Centre in Halifax Canada. She is the former Dean of Medicine at Dalhousie University.

“The most commonly performed surgical procedure in the world – male circumcision – is done for therapeutic, prophylactic, religious, cultural and social reasons. Discussions of male infant circumcision for health reasons are always split,” says MacDonald in her article.

Those who support circumcision say that there are significant potential health benefits including a decreased risk for some sexually transmitted infections, a decrease in HPV-related penile cancer and reduced phimosis and paraphimosis (tightness of the foreskin).

Those who oppose circumcision say that the procedure is not without likely complications – about 1.5 per cent – and it is a painful procedure for the newborn.
Medical organizations in western countries have discouraged infant circumcision for many years. MacDonald asks, “The question now is whether the findings from the randomized trials of adult male circumcision in sub-Saharan Africa that show circumcision halves the risk of acquiring HIV and decreases risk for HSV-2 (a herpes simplex virus that can cause genital herpes) and high-risk HPV in heterosexual African adult men push these organizations to change their positions on routine infant circumcision.”

MacDonald adds, “… none of the sub-Saharan African studies examined infant circumcision; all involved adult male circumcision. There is no new evidence that infant circumcision provides any added benefit to the neonate, infant or young child with respect to HIV and HPV protection. The potential benefit from circumcision only begins to accrue when the male becomes sexually active.”

The dilemma is: if the infant is not going to benefit from circumcision until he is sexually active then should we offer circumcision during peripubertal time? Would the male adolescent be willing to go through the procedure? Currently, infants have no choice. The choice for them is made by their parents.

The World Health Organization agrees there is evidence that male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should not replace other interventions to prevent transmission of HIV.

Well, what is the conclusion? I will quote Dr. Blackmer from his ethics corner column mentioned earlier. It says, “Some parents will always choose circumcision, some will always reject it, and some will decide based solely on the evidence.” The only thing a physician can do is present the evidence and let the parents make the decision.

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February 5, 2013

Preventing Cervical Cancer – New Guidelines Published in 2013

Pap smear micrograph showing a high-grade squamous intraepithelial lesion (HSIL). (Copyright 2010 Nephron. Permission is granted to copy, distribute and/or modify this image under the terms of the GNU Free Documentation License Version 1.2 or any later version published by the Free Software Foundation.)

Every woman should know it is important to have regular Pap smear test. Since World War II, the test has been the most widely used and successful cancer screening technique in history. It is named after the Greek doctor who invented it – Dr. George Nicholas Papanicolaou.

An article in the Canadian Medical Association Journal (CMAJ January 8, 2013) says, “The incidence of and mortality due to cervical cancer in Canada have decreased substantially in the past 50 years, and long-term survival rates after treatment are high. Lifetime incidence was 1.5 per cent in 1972, and is now 0.7 per cent; risk of death from cervical cancer is now 0.2 per cent. Most advanced cervical cancer (and associated mortality) occurs among women who have never undergone screening or who have had a long interval between Papanicolaou (Pap) tests.”

For example, in 2011, an estimated 1300 new cases of cervical cancer were diagnosed in Canada, with about 350 deaths. The risk increases after age 25 years and older, peaking during the fifth decade of life.

Pap smear test helps pick early lesions before they become cancerous. This means less invasive treatment is required and the prognosis is better. In the same issue of the CMAJ, the Canadian Task Force on Preventive Health Care has published new guidelines for Pap smear test. These guidelines, which are based on the current scientific evidence, are as follows:

-For women aged less than 20 years, no routine screening for cervical cancer. (Strong recommendation; high-quality evidence)

-For women aged 20-24 years, no routine screening for cervical cancer. (Weak recommendation; moderate-quality evidence)

-For women aged 25-29 years, routine screening for cervical cancer every three years. (Weak recommendation; moderate-quality evidence)

-For women aged 30-69 years, routine screening for cervical cancer every three years. (Strong recommendation; high-quality evidence)

-For women 70 years of age or older who have undergone adequate screening (i.e., three successive negative Pap test results in the last 10 yr), routine screening may stop. For all other women 70 years of age or older, should continue screening until three negative test results have been obtained. (Weak recommendation; low-quality evidence)

Where the recommendations are weak, the decision to undergo Pap smear test depends if the health care provider and the patient think that there is an indication to do one. If the woman is sexually active, she has multiple partners or she has sexually transmitted infection then there would be an indication to do one. One drawback with these updated recommendations is they do not address screening with tests for human papilloma virus (HPV), because there is not yet sufficient data on its effect on mortality and incidence of invasive cancer, says the article.

In a commentary related to the guidelines, Dr. Janet Dollin says, “When Dr. Georgios Papanicolaou developed his famous test in the 1940s, we did not know that cervical cancer is a preventable sexually transmitted infection.” The role of cancer causing virus like HPV was not known. We now know infection with specific strains of HPV is a necessary precursor to cervical cancer. Some of these viruses cause genital warts – another sexually transmitted infection.

Dr. Dollin says, “Indeed, improving uptake and access to HPV vaccination and cervical screening would do more to lower the rates of cervical cancer than deciding at what age to start Pap testing and how frequently it should be done.” The National Advisory Committee on Immunization (NACI) recommends the vaccination of boys and girls to prevent the burden of HPV disease.

Dr. Dollin says that the US Preventive Services Task Force recommends screening for women aged 21-65 years with a Pap every three years or, for women aged 30-65 years who want to lengthen the screening interval, a combination of Pap and HPV testing every five years.

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January 22, 2013

The Importance of Vitamins in Our Diet

In general, most people know the importance of vitamins in our diet. But many people do not know which vitamins are really important in maintaining good health.

I would like to revisit an article I had discussed about ten years ago on this topic. Not much has changed since. The topic was also discussed in a Clinical Practice article in the New England Journal of Medicine (NEJM) titled, “What vitamins should I be taking, doctor?”

Medical teaching says that a healthy individual, who eats a good diet, does not require vitamin supplements. He should be able to meet his vitamin needs from his healthy diet. But the public interest in vitamin supplements is enormous – sometimes due to misguided reasons. Almost 30 percent of our population takes vitamin supplements. And there is no control over it.

Because the food we eat contains too many nutrients, it would be almost impossible to conduct double blind trials to see if vitamins do have improved clinical outcomes. Also the users of vitamin supplements may have healthier lifestyles or behaviours than nonusers. This would distort any clinical trial results.

The good thing about vitamin supplements is that there is greater likelihood of good than harm and cost of supplements is not that high so the authors of the article in the NEJM recommend the following vitamin supplements for healthy individuals. There is substantial evidence that higher intake of:
1. folic acid (400 ug/day),
2. vitamin B6 (2 mg/day),
3. vitamin B12 (6 ug/day), and
4. vitamin D (400 IU/day) will benefit many people, and a
5. a multivitamin will ensure an adequate intake of other vitamins for which the evidence of benefit is indirect.

The authors say a multivitamin is especially important:
-for women who might become pregnant
-for persons who regularly consume one or two alcoholic drinks per day
-for the elderly, who tend to absorb vitamin B12 poorly and are often deficient in vitamin D
-for vegetarians, who require supplemental vitamin B12 and
-for poor urban residents, who may be unable to afford adequate intakes of fruits and vegetables.

It should be noted that recent recommendation for vitamin D suggests all adults should take 1,000 to 2,000 IU daily. The upper level for safe vitamin D intake has not been well defined but is probably as high as 250 μg (10,000 IU) daily but in clinical practice, supplementation with this dose of vitamin D is rarely required.

Physicians who encourage their patients to take vitamin supplements should also educate their patients regarding healthy lifestyle and about healthy nutritious diet. Foods contain many additional important components, such as fiber and essential fatty acids and vitamin pills cannot be a substitute. Vitamin pills do not compensate for the massive risks associated with smoking, obesity, or inactivity, say the authors of the NEJM.

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January 8, 2013

Genetically Engineered Frankenfish is Considered Safe

A fish jumping out of the water. (Hemera/Thinkstock)

Have you heard of “frankenfish”? It is a Frankenstein fish. Yuck, right? Well, have no fears. A media report including one in the Washington Post (December 21/2012) says, “Federal health regulators say a genetically modified salmon that grows twice as fast as normal is unlikely to harm the environment, clearing the way for the first approval of a scientifically engineered animal for human consumption.”

The Canadian Press reported on January 4, 2013, “Canadian ‘frankenfish’ moves closer to FDA approval for human consumption.”

In the U.S., the Food and Drug Administration (FDA) said the fish is unlikely to harm populations of natural salmon, a key concern for environmental activists. The AquaAdvantage salmon has been called by the critics as frankenfish. They see the development of frankenfish unethical and worry it could cause human allergies and eventually destroy the natural salmon population if it escapes and breeds in the wild.

FDA has said in the past that animals that are cloned are safe to eat. But frankenfish is not a clone. The DNA has been changed to produce a desirable effect. There is added growth hormone from the Pacific Chinook salmon that allows the fish to produce growth hormone all year long. Typical Atlantic salmon produce the growth hormone for only part of the year. The company says frankenfish will have the same flavour, texture, colour and odour as the conventional fish.

This is only one example of genetically altered food. There are many other foods which have been genetically changed. The Health Canada website (http://www.hc-sc.gc.ca/) says, “Health Canada conducts a thorough safety assessment of all biotechnology-derived foods to demonstrate that a novel food is as safe and nutritious as foods already on the Canadian marketplace.” Internationally, more than 10 species specific consensus documents have been developed, including for corn, soybean, wheat, rice, canola and sugar beet to ensure safety of these foods for human consumption.

As of 2012, Health Canada has approved over 81 genetically modified foods for sale in Canada. No applications have been turned down as long as they meet Health Canada’s strict guidelines. According to Wikipedia, commercial sale of genetically modified foods began in 1994, when Calgene Inc. first marketed its Flavr Savr delayed ripening tomato. Since then the technology has been used in different areas. There are organisms which have been genetically engineered and there are crops which have undergone genetic changes.

Some fruits and vegetables have been genetically changed to prevent disease in the crops. For example, Papaya has been genetically modified to resist the ringspot virus. Today, 80 per cent of Hawaiian papaya is genetically engineered. As of 2005, about 13 per cent of the zucchini grown in the US was genetically modified to resist some viruses. Most vegetable oil used in the US is produced from genetically modified crops. We can go on. There are many such examples. No reports of ill effects have been documented in the human population from genetically modified food.

Looks like genetically modified food is here to stay. And we are eating it every day.

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