Thursday, June 25, 2015

A TIMELY REMINDER. SMART PHONE AND PACEMAKERS









The European Heart Rhythm Association, Cardiostim is currently meeting in Milan. One of the papers presented deals with the effect of smartphone ( which we all have one or two nowadays ) and their effect on pacemakers and other implantable cardiac devices like AICD and CRT pacers. These cardiac implantable devices are basically triggered by EMW ( electromagnetic waves ) and the smartphones emit EMW. What may happen is that the smartphone may emit EMW and the cardiac device may pick up the signal and stop firing causing bradycardia and syncope, or the ICD may fire and cause an unnecessary painful shock.



Dr Carsten Lennerz and colleague from the German Heart Center studied 308 patients who had implantable cardiac devices like pacemakers, AICDs and also CRT ( Cardiac resynchronisation therapy ). They tested 3 types of smartphones in near proximity to these implantable devices. The smartphone tested were the Nokia Luminia, Samsung Galaxy S III, and the HTC one XL. They administered 3,400 stimulations on the 308 devices ( 147 pacemakers, 96 ICDs and 65 CRT ). They found that of the 3,400 stimulation tests, only one test found interfernece, meaning that the chance of interference is low.
However the authors did not see it fit to alter the standard FDA advise on implantable cardiac devices and smartphone, which is to hold the smartphone about 15-20 cm away from the implantable cardiac devices. For example, to hold the smartphone to the opposite ear from the implantable device. And of course never to store the smartphone in the pocket on the same side as the implantable cardiac device.
This is to serve as a reminder since we have more and more smartphone users and also more and more patients having implantable cardiac devices.

Sunday, June 21, 2015

CALLING ALL PRMARY CARE PROVIDERS - GP N SOLO SPECIALISTS

For those who have yet to join / pledge to 1000 PCPs (Primary care Providers) please do so. This is the brainchild of the TASK FORCE.
We are gathering 1000 GPs /PCPs to pledge to meet PM and VVIPs and a lot more are in store for us should this 1000 gathering become a reality.
OBJECTIVE
TO UNITE THE PRIMARY CARE PROVIDERS
FOR ALL GENERAL PRACTIONERS AND SOLO SPECIALIST
TO DISCUSS CHALLENGES FACED
TOWARDS A HEALTHCARE TRANSFORMATION
Date & venue ...to be announced and it is soon.......
We need the numbers for us to see this become a reality ..we will see this thru ..together.
For those who are yet to join / pledge...pls list your name , hp no and place of practice for us to add you into the respective whatsapp groups for daily updates.



iF YOU WISH TO JOIN, PLEASE GO TO -

Thank you. Please join, and let all of us stand together,

Friday, June 19, 2015

EAT MORE CHOCOLATES TO AVOID CARDIOVASCULAR DISEASE

 Interesting. The issue of " Is chocolates good for you?", has come back again, in view of athe releas of an article in the Heart, online edition June 15 2015.
Dr Kwok Chun Shing and colleagues from the University of Aberdeen, Scotland, published their findings on Habitual chocolate eating and cardiovascular disease. They used the data from the UK's EPIC-Norfolk Study. This study involved about 21,000 UK citizens, who had 12 years follow up. There was a questionaire, including the amount of chocolates that each subject consumed. The researchers found that those who consume chocolate, after 12 years had a 11% reduction in risk of coronary heart disease, 25% reduction of CV death and most importantly 23% reduction of strokes. What is even more interesting was the finding that it did not really matter whether it was dark bitter cocoa full chocolates or white chocolates.

There was another study released almost the same time of 155,000 subjects, in USA which showed basically the same findings.
Neither of the studies, studied the reason why. So it is essentially a correlation.

It sure looks like we should all eat more chocolates.
So now we have nuts and chocolates are good for your heart. Will we eat Cardiologists out of a job?

Friday, June 12, 2015

NUTS ARE GOOD FOR YOUR HEART AND ALSO REDUCE PREMATURE DEATH




I miss this study until I heard it discussed on BBC last night. This is a simple study, prospective cohort study, published in the latest edition of International Journal of Epidemiology.
Prof Piet Van den Brandt from the University of Mastricht looked into the daily consumption of nuts  of various types, and followed the subjects for 10 years to see the outcome after 10 years. They studied 120,000 subjects aged 55-69 years starting in 1986. They reviewed these same individuals after 10 years and see their condition. They found that after 10 years, those who consumed 15 gms of nuts daily had a 23% reduced risk of dying. There was also a 45% reduction in neurodegenerative disease, 39% reduction in respiratory diseases, and 30% reduction in incidence of diabetes.
Interesting.
This is the second large study to show this. If you remember, back in Nov 2013, the NEJM also published another large study done by the researchers in Harvard which showed essentially the same.
The fact that eating nuts ( part of the DASH diet ), reduces CAD is not in doubt.
Looks lie eating nuts is good for us. 15 gms is not much, probably a handful only, and yet over 10 years can have such a major impact. Note that this does not apply to peanut butter as that contains too much salt and transfat ( thats what they thing ).
Lets go for it.

Thursday, June 11, 2015

FPMPAM SARAWAK MEDICAL CAMP 2. IN PICTURES.

Having written about the facts of the Medical Camp, I thought that I should also show the Medical Camp in Pictures,
It took me a few days to figure out how to link them to slideshare. This is as far as I could manage. Please advise if you can improve on this.


http://www.slideshare.net/JohnNg4/fpmpam-sarawak-medical-camp-21-day-1-kg-bogag

http://www.slideshare.net/JohnNg4/fpmpam-sarawak-medical-camp-22-day-2-kg-rantau-panjang

http://www.slideshare.net/JohnNg4/fpmpam-sarawak-medical-camp-23

http://www.slideshare.net/JohnNg4/fpmpam-sarawak-medical-camp-24

http://www.slideshare.net/JohnNg4/fpmpam-sarawak-medical-camp-25


Please enjoy the pics. If you feel inclined to join us, please do let me know

Thursday, June 04, 2015

FPMPAM SARAWAK MEDICAL CAMP 2

I was back in Sarawak last week ( 26th May - 2 nd June 2015 ) to rn a medical camp in the interior of Sarawak, around the Kuching to Kalimantan border area. This time, I was able to master a team of about 20 with 10 professionals ( 3 GPs, 2 physicians, 1 surgeon, 1 EYE, 1 ENT and 2 dentist ), and 10 paramedic including a dispenser and 4 nurses and 5 medical students ). Our logistic partner was again Impian Sarawak ( DAP ).


On 27th May, we were at the Kg Bogag area. The Camp site chosen for us, was really very challenging. It was basically two verandahs separated by a small wall. It also rained for awhile when camp started. In the 1pm-5pm, 7pm-10pm sessions ( advised by Impian Sarawak ), we managed to see about 146 patients and this time extracted 10 teeth. ( Looks like dental hygiene here is better ).

We stayed the night at the Kg Duyoh homestay. The conditions here was also challenging. I had to bath cold water in a semi squat position as I have a left total hip replacement. I also had to sleep on the sitting room table top, for lack of space. Hahahahahaa.
On the 28th May, we held camp at Kg Serikin. The Camp site was a very spacious multi-purpose hall. We now have a problem of a huge hall. I had to site the dental clinic on the stage and fence them off for privacy. Nice. Here we saw 176 patients and extracted 21 teeth. I was told that Kg Serikin was next to the Indonesian border ( waling distance ).
We again spend a second night at the Kg Duyoh homestay.
Early 29th morning ( 6.30am to be precise ), we left te Kg Duyoh homestay to start Camp at Kg Rantau Panjang ( in Batu Kawa ). Clinic was to start at 8am and Kg Rantau Panjang was about 80 mins from Kg Duyoh. Well, we managed to start on time. We saw 181 patients and extracted 21 teeth. Clinic hours here at Batu Kawa was 8-12 noon and 3-7 pm. We had a nice seafood dinner at Kuching.

From Kg Rantau Panjang, we return to stay at 56 Hotel and enjoy the comfort of a warm shower and good mattresses.
The last Camp was at Kg Kitang ( Batu Kawa ). This was about 40 mins from the Hotel and so we could sleep a bit later and left to set Camp at 6.45 am for Clinic start at 8 am. At Kitang, we saw 197 patients and extracted 13 teeth.
Camp was over at about 5pm on 30th May. We rested on 31st May. Some members of the team returned, while 12 remained to celebrate Gawai with the locals. " GAYU GURU GERAI NYAMAI" It was nice. On 1st June, the DAP staff took us visiting the various homes at the Mas Gading area, drank a fair amount of Tuak and ate much local delicacies.
We all return on the late morning flight out of Kuching.
It was a great experience.
We did help about 700 + patients. There were many interesting cases with good clinical signs. The medical students must have seen more clinical material in 4 days then perhaps an 8 week posting in General Hospital. I suppose, the total laryngectomy with artificial voice box, and visceral larva migrant must top the list. They also saw a late stage Ca Breast, besides murmurs and Atrial fibrillation. The medic students really had a educational trip.
I learn a lot too, about people who would prefer to sleep late boozing, and say that they cannot attend to an early clinic. As usual, there is always the complaining lot. What to do, we are all different. Discipline seem to be severely lacking, especially with prima donnas. Dealing with the non-prima donnas was obviously easier. They sleep early and even volunteered for early "recce" team.
A word of thanks to my whole team who performed very well, under very trying conditions. Terima Kaseh, beribu ribu Terima Kaseh.
And our logistic partner again performed admirably. We were working under very trying conditions, hot sun and then rain. Can you imagine, heavy rain when we were parked in a verandah, or hot sun in a stuffy 800-1,000 sq ft room with 30 human bodies inside? The Impian team managed to get us fans to cool us down and the next moment patch leaks in the roof so that our drugs would not be contaminated.  Words cannot adequately express my gratitude to the Impian Team led by Melisa and Billy. You all were great and I truly thank you, from the bottom of my heart.
All in all, it was a great experience and I am sure we help many in the Mas Gading and Batu Kawa area. Many locals ( who do not know me ), came to shake my hands and ask when we will be returning again. A question I have great difficulty in answering honestly.

I apologise for the lack of pictures this time, as my professional photographer could not make it, and so poor me have to try and take pics, whenever free, with my Xaiomi Note camera. Not so good lah.

"Gayu Guru Gerai Nyamai".

Thursday, May 21, 2015

FINALLY A CTA WITH FFR THAT WE CAN RELY ON.

If you note that many senior cardiologist ( except some old ones ) are missing from town, please know that EuroPCR is o in Paris from 19th-22nd May. So there are quite a few Malaysian Cardiologist wandering around Paris now. I hope that they learn alot and enjoy their brief stay in Paris.
Amongst one of the important papers presented in EuroPCR is the FFRctRIPCORD. This is actually a followup of the earlier RIPCORD study which proved the usefulness in invasive FFR in angiographic assessment of a coronary stenotic lesion. ( Actually a follow-up to FAME ).

In FFRctRIPCORD, ( Led by Dr N Curzen of University Hospital Southampton ), 200 patients with stable cheat pains of uncertain etiology, were subjected to conventional CTA. These CTA were interpreted by 3 independent cardiologist and these patients were advised to undergo management under 4 categories. 1, OMT ( optimal medical therapy ), 2, PCI + OMT, 3. CABG + OMT and 4, MIR ( more information required ). These patients CTA films were then send for assessment using a Heart Flow ( patented ) FFR software, which was approved by FDA in Nov 2014. Reassessment of the same CTA using the Heart Flow FFR software, cause the cardiologist to re-categorise the patients.
The results are shown below.

 Change in Management Recommendations Based on CT Angiography Alone and After Disclosure of FFR-CT Data in 200 Patients

End pointsCT angiography alone (% of cohort)CT angiography plus FFR-CT (% of cohort)*Change
More data needed19.00 
OMT33.556.5+23
PCI+OMT43.539.0-5
CABG+OMT4.04.5+0.5
OMT=optimal medical therapy
FFR-CT=fractional flow reserve at computed tomography
*reallocation P<0 .001="" span="">  

Looks like adding the Heart Flow FFR software improves the clinical accuracy of the CTA and so helps patient management, reducing the need for normal angiograms and increasing the accuracy of the CTA.
This is something that all cardiac scan centers should seriously consider acquiring.

Wednesday, May 20, 2015

IN SCHIZOPHRENIA, TO LOWER OR NOT TO LOWER HYPERLIPIDEMIA?

If a 40 year old male suffering from chronic schizophrenia, is found to have a raised serum cholesterol and serum triglyceride. Should his treating physician lower his serum cholesterol?
What do you think?
Well, at the ( now on ) annual American Psychiatric Association meeting in Toronto, Dr Henry Nasrallah of the St Louis University School of Medicine in Missouri, presented the findings of CATIE ( Clinical Anti-Psychotic Trial of Intervention Effectiveness ). They studied the lipid profile of 1,460 schizophrenics  with an average of 40 years. They found that those with raised serum cholesterol and triglyceride had significantly better neurocognitive scores. These neurocognitive scores measures various aspect of neurocognitive functions, memory functions and also executive functions. Those with lower cholesterol and triglycerides, had poorer scores. These findings were in schizophrenics. It is important to note that 85% of the brain is lipids.
Interesting.
However, it is important to note that the study did not show that lowering the serum lipids, worsened the  neurocognitive scores. So it is not bidirectional.
However, I find this association interesting?
Should we allow schizophrenics to have raised serum cholesterol and triglycerides, so that we help the brain, but which may harm the heart? What then is the best for this patient?

Monday, May 18, 2015

PRICE HIKE IN APC FEES. FROM RM 50 TO RM 300 ANNUALLY.

MMC Meeting with Doctors Associations on May 13th , 2015, held at the MMC Office in Jalan Chenderasari , Kuala Lumpur at 230 pm
The meeting was chaired by the Head of the Sub Committee for Fee Schedule Revision, Datuk Seri Dr Abu Hassan Asaari Abdullah . Also present was the member of the sub committee, Dr Milton Lum, and MMC Secretary Datuk Dr Azmi Shapie from the MMC side.
Medical Associations were represented by
1. Malaysian Medical Association
2. Medical Practitioners Coalition Association of Malaysia
3. Federation of Private Practitioners Association of Malaysia
4. Pertubuhan Doktor Islam Malaysia
5. Academy of Family Physicians of Malaysia [ College of GPs ]
6. Association of Private Hospitals of Malaysia
7. Academy of Medicine
8. College of Paediatrics
9. College of Surgeons
10 College of Anaesthesia
The Chairman called the meeting to order at 235 pm and introduced himself and the 2 members from the MMC. He then proceeded to stress that he understands the feeling of the doctors on this hike, but he would like us to view a presentation from the MMC side, to see their point of view.
A slide presentation then ensued where APC fees of other countries was compared. The reasons for the corporatisation of MMC was given. Among the reasons given, the main reason was that the MMC wants to be a independent body free from Government dictates. This is so that MMC can make decisions free for the improvement of the Medical fraternity. The National Specialist Register [NSR ] will also be then taken over by the MMC. Once independant MMC will most probably have to pay rental for its office or probably asked to get its own office to function. The staff salary and any litigation brought upon the MMC will then be solely borne by the MMC, without any financial assistance from the Govt.
It was also noted that there were 118 feedback from the ? 2 mths feedback done by MMC on this issue. Datuk Abu Hassan said that nearly ALL were against the feedback.
However Datuk Abu Hassan said he would be grateful if we could reach a compromise on this issue as he could then take this issue back for discussion with the Minister, Director General and MMC Councillors.
After the presentation the floor was then open for discussion
1. MMA President Krishna Kumar said that the doctors rejected this increase as it was too sudden and too steep at this current time, when the economy of everyone was difficult. Citing GST and PDPA amongst other recent fees incurred by doctors. MMA also disagreed with the comparison of the fee structure of other countries, as we should take into consideration , the conditions and consultation fees charged by our doctors here in Malaysia.
2. Doctors Fees have not increased in many years however we see increase and introduction of new fees for doctors [MMA ] . For this the MMC suggested that the fee structure included in the PHFSA be removed from the PHFSA.
3. Fee increase is too steep too sudden and too much – this was raised by all associations at the meeting . It was suggested that the increase should be gradual over the years. Datuk Abu Hassan agreed that the increase should be gradual so as to be more palatable to everyone. However we have not given our suggestions as to how much should be increased over how long [ period ]. No association objected to the fee increase after the presentation
4. Datuk Jacob [ APHM ] suggested that MMC look at other sources of income and ways how members could benefit from this increase . This could be studied from the models from other medical councils from other countries.
5. PERDIM highlighted that the feedback from doctors was conducted over a period of 2 weeks and not 2 months as noted and there were about 500 respondents to the survey. MMC said they will look into this.
6. MPCAM highlighted that in the event of litigation, MMC does not do the payment from its coffers, as the insurers of the MMC will do the payout. If ever , the insurance premium for the MMC will increase the following year. Hence examples of amounts of money being payed out [ RM 6.8 million in a recent O&G case ], cannot be included as an expense for the MMC should it be corporotised.
7. PERDIM questioned the reason why the Director General of Health remains as the President of MMC as this defeats the purposes of the main objective that MMC be free from Govt interference, as the post of the DG is a Govt post, hence a Govt appointment. This was agreed also by the MMC members present at this meeting and they promised that the will bring up this matter with the Minister as all associations present at the meeting agreed that the post of President should be an elected post and not an appointed post. The MMC stressed that the Govt, though agreeing that the MMC be corporatised, wanted its appointee as the President.
8. MPCAM question the election process of the MMC . It was highlighted that many did not get their ballot papers in the 2013 elections. Datuk Abu Hassan said the MMC had formed a election committee and the committee was looking into the suggestion to change the regulations [ which needs approval from the Govt ] for the voting to be more transparent and conducted online.
9. AFPM asked if the APC fees could be charged according to the risk of survice given. MMC will look into this suggestion
10 Academy of Medicine suggested that the fee for senior doctors be exempt as most of them are working either for charity or for survival. Datuk Abu Hassan said he will bring up this issue with the MMC Council and relevant authorities as well.
11. MMA suggested that the GPs be charged lesser for the APC as our revenue was not as high as other doctors. Datuk Abu Hassan said he will bring up this issue with the MMC Council and relevant authorities as well.
There being no further issues Datuk Abu Hassan called the meeting to an end with a vote of thanks to the Chair at 4:20 pm.
Datuk also said the doors for more suggestion is welcome and all suggestions will be read and taken into account. He welcome more suggestions to be emailed to the Secretary of MMC at drazmis@gmail.com .
Datuk Abu Hassan promised that no decision will be made unilaterally by MMC, and another meeting will be called for further deliberation on this issue, this time with an earlier notification.
The MPCAM team met Datuk Seri Dr Abu Hassan after the meeting and thanked him for his openess and professionalism in the way the meeting was conducted.
Prepared by Dr Peter Chan Teck Hock and Dr Raj Kumar Maharajah for MPCAM



My response.

The issue of Exorbitant increase in APC fees.
1. Obviously the fees suggested is too high. The reason given ( that we are independent and not answerable to the government) sounds good but NOT POSSIBLE. WE ARE NEVER INDEPENDENT. MMC can never be for the medical fraternity as the other stakeholders are the government and also the patients. Medical Act 1971 is about administration by doctors of medical care to the patients. So the Public are also stakeholders and also the government has a responsibility as they run the public service and also regulates the private medical facilities. They are all inter-related. They just want to make it sound good ( That MMC is independent ).
2. If MMC is truly independent and for doctors only, then the first thing to insist is for free and fair election of the whole board without quotas. Everyone gets elected for a term including the President of MMC. How can you keep reserving places for your lackeys and also say that you are independent. ALL MUST BE ELECTED IN FREE AND FAIR ELECTIONS REGULATED BY LAW AND CAN BE CHALLENGE IN COURT. The only exception perhaps would be for our East Malaysian colleagues as some of the issues faced by them may differ from Peninsular Malaysia. Otherwise it is independent in name but not in practise.
3. All doctors must pay one fee ( I suggest RM 100 per year ) for the APC. We must not allow them to divide using APC eligibility. It is not an issue of affordability. It is an issue that we are all equal as doctors.
4. If MMC wants to indemnify themselves, they may have to buy medical insurance. It is naive to think that members money can ever be enough for insurance payout. That is a separate issue and cannot be used as an argument to increase APC fees.
5. MMC if truly independent, must employ their own staff so that their staff will not be getting orders from the Chief Secretary of the government. The very fact that they mention that means that they DO NOT intend that the new MMC be truly independent. They just want you to pay more fees while everything remains status quo.
6. Insist that 2 weeks notice at least be given for the next meeting, so that we can band the doctors together in one effective vice. This is an attempt to catch us by surprise so as to divide us ( prevent a unified response ).
7. What began as a meeting on APC fees has wide ranging implications including the workings of the new MMC under Medical Act 1971 Amendments. DOCTORS BEWARE.
8. All like minded Medical Associations should consider drafting a memorandum to be forwarded to the Minister. I am not sure if the Chairman will “remember” to pass on all the sentiments.
No No No. It is not just an issue of super-rising fees. There is more to it then meets the eyes.



Saturday, May 16, 2015

WARNING ON USE OF SGLT2 INHIBITORS



The US FDA yesterday issued a warning on the use of SGLT2 inhibitors in the management of T2DM. From March 2013 - June 2014, 20 cases of Diabetic ketoacidosis requiring hospital admissions were reported. The SGLT2 inhibitors involved included -Canagliflozin, Dapagliflozin and Empagliflozin. Some were use singularly and others in combination with Metformin and in a few cases with linagliptin. These were patients with T2DM and the average blood sugars were > 200 mMols/L. ( relatively low compared to DKA in T1DM. There also seemed to be a large anion gap in these patients. Half of these patients had triggering factors like sepsis and infections. The other half did not have any obvious triggering factors.
This warning is timely as we see physicians attempts to better control T2DM to target and the use of double or triple therapy with the avoidance of secretogogues. The new kid on the blocks may be effective but we have to keep monitoring them to see what other hidden side effects there maybe even as we embrace their use.

This FDA warning is timely.
We in Malaysia should also monitor our drugs for adverse drug reaction.