Work and figuring out our workshops

Posted on by

Buenos Noches Well I was wrong about today. Yesterday we worked very hard digging out the hole mixing cement and moving loads of stuff. I then went to the gym please see pictures attached its like rocky 2. One of the girls made the silo wall collapse so I went in and sorted it out and finalised the depth and breathe of it its really pained me to do so. Rewarding none the less. We laid some

An English Man in New York

Posted on by

DAY 433Firstly everyone many apologies for the picture on our last blog sometimes we have a busy interesting day and do not take any photographs which happened on this day so when time came to upload the blog we had a situation of a photo less entry and in this case Caroline decided to take a picture of Misha the little dog and Rocky the Kelpie.Today was an important day for us we both have

Las Vegas Business Mastery Day 2 3

Posted on by

Toujours aussi intense on est en pause linder lunchdiner du 3e jour c'est tres interessant et SynHeme va beaucoup changer au cours de l'anne a venir. Hier on a eu The human calculator un gars qui calcule mentalement plus vite qu'une calculatrice tres interessant et passionne.Je n'ai pas le temps d'entrer dans les details alors je vous quitte la dessus.J.P.

Is breech vaginal delivery safe?

Posted on by

Between 3-4% of babies begin labor in the breech (bottom first) position, increasing the risk of neonatal morbidity and mortality. Pre-emptive C-section has become the preferred method of delivery for breech babies, but now some are questioning this recommendation. The controversy is fueled by differing appraisals of the danger and by differing assessments of the whether any risk of neonatal death can be justified in the age of the safe Cesarean.

The best conducted and most important study comparing breech vaginal delivery with elective C-section is the Term Breech Trial (TBT) conducted by Mary Hannah and colleagues. It is the only randomized control trial of its kind.

… [W]e found that the fetuses of women allocated planned caesarean section were significantly less likely to die or to experience poor outcomes in the immediate neonatal period than the fetuses of women allocated planned vaginal birth. Although some of the deaths in the planned vaginal birth group were related to difficulty with vaginal breech delivery, others were clearly associated with problems during labour. Thus the avoidance of labour and vaginal breech delivery could have contributed to better outcomes with planned caesarean section…

A more recent trial, the PREMODA (PREsentation et MODe d’Accouchement: presentation and mode of delivery) study produced different findings and as a result, some obstetricians have been calling for a re-evaluation of the standard recommendation for C-section delivery of a breech baby.

The groups [planned vaginal delivery vs. planned C-section] did not differ significantly for the combined outcome of fetal or neonatal mortality or serious morbidity (odds ratio [OR] = 1.10, 95% CI [0.75-1.61]. Of the criteria included in this combined variable, only a 5-minute Apgar score less than 4 was significantly more frequent in the planned vaginal group (n = 4 vs n = 1, OR = 8.9, 95% CI [1.00-79.8]). Of the other individual outcomes, the following were significantly more frequent in the planned vaginal than in the planned cesarean group: 5-minute Apgar score less than 7 (OR = 3.2, 95% CI [1.9-5.3]), total injuries (OR = 3.9, 95% CI [2.4-6.3]), and intubation (OR = 1.8, 95% CI [1.08-3.1]).

The authors of the PREMODA study acknowledge that their trial was not randomized and that the results must applied with caution. Nonetheless, the authors concluded:

In centers where planned vaginal delivery remains a widespread practice and in complying with rigorous conditions before and during labor, we did not find a significant excess risk associated with planned vaginal delivery compared with planned cesarean for women with a singleton fetus in breech presentation at term. There may be a slightly higher neonatal risk associated with planned vaginal delivery but it is very different from that reported in the only published large randomized trial….

In light of the PREMODA study, some obstetricians have been calling for a return to breech vaginal delivery. The NNT to prevent neonatal death from breech is 111. That translates to 110 unnecessary (in retrospect) C-sections for every baby saved. What are the risks of those C-sections? They include hemorrhage, transfusion and possible hysterectomy. Maternal mortality after elective C-section is so rare that many contemporary studies of C-section focus exclusively on morbidity.

So why not simply explain the controversy to patients, as well as the differing findings and let them choose? Putting aside the issue of the magnitude of the risk, are patients capable of giving informed consent to a procedure that will, if widely offered, lead to preventable neonatal deaths? Obviously consent ultimately rests with the patient, but can it be truly informed consent?

Let’s assume for the moment that The Term Breech Trial is correct and the excess risk of neonatal mortality in breech vaginal delivery is 9/1000. That sounds like a small number and many women will reason that the number is so small that they need not worry that their babies will die.

However, 9/1000 means that approximately 9 babies per 1000 WILL die. In the US approximately 140,000 babies each year present as breech at the onset of labor. Not all will meet the eligibility criteria for vaginal delivery (approximately 35% of breech babies are in an unfavorable position for vaginal delivery, and others will exceed the weight criteria or have other contraindications), but even if only half were eligible, that would mean 70,000 attempted breech vaginal deliveries. At an excess rate of neonatal mortality of 9/1000, we could expect that 630 babies would die from preventable neonatal deaths each year.

This is a relatively small number. Indeed, it would barely impact overall neonatal mortality figures (approximately 18,000 neonatal deaths per year), since the bulk of neonatal mortality is due to prematurity and congenital anomalies. On the other hand, that is quadruple the number of deaths we would expect in an otherwise low risk group. Most importantly, that number represents 630 sets of bereaved parents who would have had a healthy baby had they opted for elective C-section. Would those parents accept a preventable death philosophically, or would they be shocked and bewildered that the baby actually died? Would they simply try again or will they look for someone to blame?

Can the excess risk of neonatal mortality can be reduced somewhat by making the eligibility criteria more strict as the authors of the PREMODA study suggest? Only a randomized trial can provide that information, and unless the excess neonatal mortality rate could be reduced dramatically, we would still anticipate the preventable death of hundreds of babies per year.

C-section is not a trivial procedure, but it is an extremely safe surgery, reducing risk to the baby and only slightly elevating risk to the mother. Even though the risk of breech vaginal delivery is small, the outcome can be catastrophic. A lot of unnecessary (in retrospect) C-sections are being done. Do we think that is too high a price to pay to save several hundred babies each year?


[Slashdot]
[Digg]
[Reddit]
[del.icio.us]
[Facebook]
[Technorati]
[Google]
[StumbleUpon]

The War on Salt

Posted on by

The problem with the Western diet is not one of deficiency, but one of excess. We get too much of a good thing – too many calories, too much of the wrong kind of fat, and too much salt. As a result obesity, diabetes, and hypertension are growing health problems.

There also does not appear to be an easy solution – voluntary diets founded primarily on will power are notoriously ineffective in the long term. Add to that is the marketplace of misinformation that makes it challenging for the average person to even know where to apply their (largely ineffective) will power.

It can be argued that this is partly a failure, or an unintended consequence, of market forces. Food products that provide cheap calories and are tasty (sweet, fatty, or salty) sell well and provide market incentives to sell such products. Consumers then get spoiled by the cheap abundance of tempting foods, even to the point that our perspective on appropriate portion sizes have been super-sized.

It may be counter argued that there is a market for healthful foods, but it seems that this creates the incentive to claim that food is healthful with marketing gimmicks rather than to make food for which there is good scientific evidence that they improve health.

And so the public is faced with claims that products are “all natural” when this term is not regulated and there is no evidence to support this notion that “natural” by any definition is necessarily healthful. Low fat foods are made palatable by adding sugars, and low sugar foods are kept tasty by adding fat.

All of this has led to the conclusion that systemic fixes are necessary to address what is becoming and increasing public health problem of diet-related diseases. The first round of regulations dealt with transparency – providing the consumer with accurate and complete information on food labels so that they cna make informed choices. If we gauge success by public health outcomes, this strategy has not succeeded.

So governments, who are also increasingly conscious of the cost of health care, are experimenting with other options. New York City has famously declared War on Fat and has passed laws to limit the use of trans fat. Now the Big Apple has added salt to their 10 most wanted list.

According to the New York City Department of Health:

The New York City Health Department is coordinating a nationwide effort to prevent heart attacks and strokes by reducing the amount of salt in packaged and restaurant foods. Americans consume roughly twice the recommended limit of salt each day – causing widespread high blood pressure and placing millions at risk of heart attack and stroke. This is not a matter of choice. Only 11% of the sodium in our diets comes from our own saltshakers; nearly 80% is added to foods before they are sold.

How do these claims hold up to the evidence. I found a reference that states that over 75% of salt intake is from processes food and restaurants – which is close to the 80% figure quoted above.

Do Americans really get twice the recommended salt intake? Here is a comprehensive review of salt intake around the world, suggesting that Americans get close to three times the daily recommended about (which is about 65 mmol/day or 1.5 grams – Americans get about 165 mmol per day).

What about the core claim – that salt intake causes increased risk of hypertension, cardiovascular disease, and stroke? Well, this is a trickier question – as are all epidemiological questions. My review of reviews suggests that there is a growing consensus that increased salt intake does correlate with an increased risk of vascular disease. However, increased salt intake also correlates with obesity, which may be at least partly responsible for this increase.

The more important question, however, is this – does reducing salt intake reduce high blood pressure and/or the risk of vascular disease? Here the answer seems to be a qualified yes. Salt reduction reduces blood pressure, but only a little. However, most of these studies are short term. Longer term studies are still needed. Some reviews claims that salt reduction – with or without a reduction in blood pressure, in hypertensive and normotensive people – reduces cardiovascular risk. Meanwhile, other reviews claim the evidence is inconclusive on long term effects.

Conclusion

As usual, the medical and regulatory communities are tasked with making sense out of chaos – with implementing bottom-line recommendations in the face of inconclusive evidence. While there remains legitimate dissent on the role of salt in vascular health, the current consensus is something like this:

- Most of the world, including Americans and those in industrialized nations, consume more salt than appears to be necessary.

- In the US most of that salt comes from processed or restaurant food (while in other countries, like Japan, most salt intake is added while cooking).

- There is a plausible connection between excess salt intake, hypertension, strokes and heart attacks.

- There is evidence to suggest that reducing overall salt intake will reduce the incidence of these health problems, but the evidence is not yet conclusive and longer term and sub-population data is needed.

Given all this it seems reasonable (from a scientific point of view – and ignoring the role of political ideology) to take steps to reduce the amount of salt in processed and restaurant food, while continuing to study the impact of such measures. But we also have to consider unintended consequences. Part of the reason salt is added to processed food is because it helps preserve it – give it a longer shelf life. People also develop a taste for salty food, and a sudden decrease in salt content may be unsatisfying, leading people to seek out higher salt foods. But these are technical problems that can be addressed.

It should also be noted that salt requirements and tolerance may vary considerably from individual to individual – based upon genetics, and certainly underlying diseases. Therefore recommendations from one’s doctor should supercede any general recommendations for the population.

In any case it seems that the War on Salt has begun. I only hope this is a war we choose to fight with science.



[Slashdot]
[Digg]
[Reddit]
[del.icio.us]
[Facebook]
[Technorati]
[Google]
[StumbleUpon]

The CoRoT target HD 49933*

Posted on by

Authors: R. Samadi, H.-G. Ludwig, K. Belkacem, M. J. Goupil, O. Benomar, B. Mosser, M.-A. Dupret, F. Baudin, T. Appourchaux and E. Michel.<br />Astronomy and Astrophysics Vol. 509 , page A16<br />Published online: 12/01/2010<br />
Keywords:
convection ; turbulence ; stars: oscillations ; Sun: helioseismology ; stars: individual: HD 49933 .