Wednesday, July 23, 2014

GST : POTENTIAL EFFECTS ON HEALTHCARE IN MALAYSIA.

I was asked to do some reading up and write an article on GST and its potential effects on Healthcare in Malaysia.
As we all know, GST is coming next year.

You can read this article at 
http://www.fpmpam.org/files/GST_July2014.pdf

Thanks.

Monday, July 21, 2014

STABLE ANGINA PECTORIS. SHOULD WE OR SHOULD WE NOT, REVASCULARISE? NEW DATA POST COURAGE



The interventional world was noticeably shaken in 2007 with the release of the COURAGE trial ( Dr William Bolden ) that optimal medical therapy was as good as PCI in the management of stable angina pectoris. That paper caused many interventional cardiologist to rethink their strategy. Of course the noise level came up that optimal medical therapy was very intensive an "optimal" ( more "optimal" than was practised by many institution at that time ) and PCI was done with mainly bare-metal stents ( this was 2007 ), or just plain old balloon angioplasty. Those were the days.
Of course since then stents have improved in design and also technology from bare metal to 1st generation drug eluting and now 2nd generation drug eluting, and today even 3rd generation drug eluting stents and even bioabsorbable vascular scaffolding. Things have gotten along and clinical trials are always behind the curve.

Well these advances prompted Dr Stephen Windecker and colleagues to re-visit this question with a meta-analysis of data from 1998-2013 of 100 randomised trial of medical therapy Vs PCI with second generation DES. It included all RT ( randomised trials ) with an enrolment of at least 100 patients in each arm ( medical therapy Vs PCI )  and which had a t least 6 months follow up.This paper was published in the June 23rd BMJ. There were 93, 553 patients in total, in the 100 RT analysed.

Rate Ratio (95% CI) for Outcomes by Revascularization Method vs Med-Based Strategy for Stable CAD in Meta-Analysis
Revascularization methodEnd points
All-cause mortality, 95 trials (n=93 553)MI, 92 trials (n=90 472)Revascularization, 94 trials (n=90 282)
CABG0.80 (0.70–0.91)0.79 (0.63–0.99)0.16 (0.13–0.20)
Balloon angioplasty0.85 (0.68–1.04)0.88 (0.70-1.11)0.97 (0.82–1.16)
Bare-metal stent0.92 (0.79–1.05)1.04 (0.84–1.27)0.44 (0.59–0.82)
"New-generation" DES
Everolimus0.75 (0.59–0.96)0.75 (0.55–1.01)0.27 (0.21–0.35)
Zotarolimus (Resolute)0.65 (0.42–1.00)0.82 (0.52–1.26)0.26 (0.17–0.40)
"Early-generation" DES
Paclitaxel0.92 (0.75–1.12)1.18 (0.88–1.54)0.44 (0.35–0.55)
Sirolimus0.91 (0.75–1.10)0.94 (0.71–1.22)0.29 (0.24–0.36)
Zotarolimus (Endeavor)0.88 (0.69–1.10)0.80 (0.56–1.10)0.38 (0.29–0.51)

Basically, the results showed that PCI with 2nd generation DES came out better for patients with chest pains and also asymptomatic CAD.
This paper showed me that the pendulum is still swinging and the definitive answer is still unknown. This is obviously because stents are getting better and that is the way it should be. The second lesson that I learn from this paper is that not all stents are the same. There are significant differences between the bare metal, 1st generation and 2nd generation DES. The difference between the 2nd and 3rd generation, in my opinion is minimal. When we talk about the second generation DES, we are talking about the everolimus eluting Xience V and the Zotarolimus eluting Endeavor Resolute. I suppose by extension also the Promus Element, although the data is scarce here.
I am very concern that all over town and this country, generic stents are being implanted left right and center, on unsuspecting patients who were being told that all stents are the same. This I believe is also being done in Public Hospitals where cost is a constrain, so cheap DES ( non FDA approved ) are being used in significant number on the assumption that all stents are the same and patients don't know better.This is simply not fair.

Well, maybe this blog posting will serve to further inform the public, though limited in its outreach.




Thursday, July 17, 2014

THE DENGUE VACCINE - EARLY EXPERIENCE



Yes, I am a cardiologist, but being a civil society activist, I have great interest in this dengue scourge that is upon us, in my opinion, in epidermic proportions. When tens of Malaysians  are dying every month, one has to sit up and take notice and scratch our heads to find a solution.
So when news broke last week that Sanofi has been studying a vaccine and that the first publication is out, I looked around for a copy. My friend found me a copy and so I took a look at it.

The latest issue of Lancet carries the full article.
This study was led by Dr Maria Capeding of the Research Institute for Tropical Medicine in the Philippines and funded by Sanofi. I am only glad to note that two of our paeds Institute ( the Penang Hospital Paeds institute and the HKL paeds institute took part in the study.
Dr Maria and team carried out an observer masked, randomised controlled, multicenter, phase 3 trial in 5 countries in the Asian Pacific Region between June 3 and Dec 1 of 2011. Their aim was to assess the efficacy of the CYD dengue vaccine against symptomatic, virologically confirmed dengue in otherwise healthy children.
They vaccinated 10,275 healthy children ( age 2-14 years ), assigned to receive either vaccine or placebo of which about 10,000 were included in the primary analysis. Those assigned to the treatment arm received 3 injections of recombinant, live attenuated, tetravalent dengue vaccine at 0, 6, 12 months. The cohort was followed up for 25 months.The primary endpoint was the vaccine efficacy against symptomatic virologically confirmed dengue, that took place more than 28 days after the third injection.
From the 10,000 children in the study, about 250 cases ( 2.5% ) of dengue took place 28 days or more after the third injection ( 117 cases in the treatment arm and 133 cases in the placebo arm ). The primary end point was achieved with 56.5% efficacy.
However, the side effects were significant. They recorded 647 serious adverse events ( 402 in treatment arm and 245 in the placebo arm ), some within 28 days of the vaccination. This is not minor. There was one case of acute disseminated encephalomyelitis. There were 4 deaths in the treatment arm and non in the control arm. 3 of the deaths were classify as accident? one of tracheal injury. The numbers all round were small, so may give a skewed picture. Need more numbers to have a fairer picture. Certainly the side effects are not insignificant.

All in all, although we greatly need a vaccine to combat this dengue epidermic that has befallen us, this first attempt leaves much to be desired. A small sample ( 2.5% ) infection in a region infested by the Aedes mosquito must raise a few questions. Why did we not get more cases? A 5.6% protection rate against a serious side effect rate of 6% must also raise an issue?

Looks like this first vaccine is NOT yet ready for primetime. Let us call it an early experience.
I hope that the government is smart enough to see that.


Wednesday, July 02, 2014

“NEGARA - KU” TO RECLAIM OUR NATION

A group of NGOs and NGIs led by Pak Samad and Dato Ambiga Sreenevasan has decided to launch a People’s Movement “Negara-Ku” to Reclaim Our Nation.

        “NEGARA-KU”: A PEOPLE’S MOVEMENT TO RECLAIM OUR NATION
2 July, 2014
WHY?
On a daily basis, we are confronted with serious challenges that have begun to undermine the very foundations of our Nation. The peace and harmony of our multi-ethnic, multi-faith and multicultural society are under threat.
Ethnocentric and race-based politics and communally-minded politicians continue to derail the process of inclusive nation building and the formation of a Bangsa Malaysia national identity. Importantly, religion is now increasingly used as a main marker of identity, and as a boundary maintenance mechanism to polarise the people.
There are political parties and their affiliates that are not focused on nation building, rather on building their respective power bases. These parties on both sides of the divide pursue their agenda that are transactional and short-term, not transformational and long-term.
The mobilisation and manipulation of race, ethnicity and religion have resulted in increasing intolerance, bigotry and extremism. There is also an emerging sub-culture of political violence. These are symptomatic of dangerous under-currents in our society.
The State, by default or design, has failed to address these pernicious developments. The State has also failed to play the role of an honest broker in managing conflicts in our society.
WHAT?
We believe the majority of the People want to end this brand of divisive ethno-religious politics.
We want to take ownership, fully cognisant, that Malaysia is a nation where her people are inextricably bound by a shared history, commonweal and destiny.
We have to act before our society descends into the abyss of instability.
2
The “NEGARA-KU” Coalition aspires to mobilize and empower the People: -
 To resist all forms of intolerance, bigotry, hatred, extremism, and violence;
 To oppose all forms of discrimination, oppression, persecution and injustice;
 To strive for a socially inclusive society;
 To exhort the State and its Institutions to respect, adhere and uphold the Rule of Law; and
 To demand adherence to the principles of stewardship, integrity, accountability and transparency in all aspects of governance.
We will strive to do this by returning to the basics:-
 The Federal Constitution as the Supreme Law of the Land;
 The Malaysia Agreement; and
 The Rukunegara as the guide for national objectives and values.

By this process of engagement and empowerment we endeavour to “HEAL THE NATION” and “RESTORE HOPE” in our future.


NEGARAKU-COALITION 
c/o GBM Secretariat, No. 1, Jln Maharajalela, 50150 Kuala Lumpur. 
Tel: 03- 2272 3594 / 017 3985 606 EAdd: infogpoam@gmail.com 

2 July, 2014 


Dear Friends, 

Our beloved Nation is in distress! 
Known and unknown forces are beginning to overtly and covertly shred the fabric of our society. 
The very foundations of our multi-ethnic, multi-faith, multi-cultural nation are being undermined. 
The time has come for the silent majority to stand up and reclaim ownership of our Nation. 
Silence is not an option! 
A group of NGOs and NGIs led by Pak Samad and Dato Ambiga Sreenevasan has decided to launch a 
People’s Movement “Negara-Ku” to Reclaim Our Nation. [Please see attached Charter] 
We earnestly need your whole-hearted commitment to this cause to “Heal the Nation and Restore 
Hope” for our shared common future. 
A series of road shows, forums, and dialogue sessions including multimedia presentations are being 
planned to engage and empower our People to take ownership of our Nation. 
In this regard we call upon you and your organization to:- 
1. Endorse the “Negara-Ku” Charter; 
2. Attend in solidarity the Media Conference to launch “Negara-Ku” on 10th
 July 2014 (Thursday), 
11.00 am @ KLSCAH; 
3. Participate in the Civil Society Discussion on the Way Forward for “Negara-Ku” on 17
th
 July 
(Thursday), 2014 (Wednesday), 6.00pm @ KLSCAH; 
Kindly email endorsement and confirm attendance for events (2) and (3) above by latest 8
th
 July 2014 
(Tuesday) to the Coordinating Secretariat, Gabungan Bertindak Malaysia (GBM), 
infogpoam@gmail.com. Tel: 03 2272 3594. 
We look forward to your invaluable support and contribution to this initiative to save the Nation. 

Thank You! 
For and on behalf of Negara-Ku Coalition 

Zaid Kamaruddin 


I THINK THIS CALL IS TIMELY.
THINGS ARE GETTING OUT OF CONTROL
WE NEED TO SAVE MALAYSIA.
LETS JOIN HANDS TOGETHER AND DO IT.


Monday, June 30, 2014

ANTIDOTE FOR DABIGATRAN. IDARUCIZUMAD.

Boehringer Ingelheim has just announced that the US FDA has granted breakthrough therapy designation to its new investigational drug, Idarucizumad, an antidote for Dabigatran ( Pradaxa ). They have began enrolment for their phase 3 clinical trial, Re-Verse-AD, to study the safety of this new humanised antibody fragment.

Dabigatran suffers from the fact that dosing is difficult and for patients who need unscheduled surgery, bleeding has become a major issue. In fact, 5,000 over law suits have been filed for bleeding and BI is in the midst of settling many of them. 
With this breakthrough therapy status, BI can fast forward their trials and apply quickly for approval pending the results.
All this also means that BI recognises that bleeding is a major concern with Dabigatran as it is with warfarin. With warfarin, we have the option to reverse with Vitamin K.

Lets see what comes out from Re-verse-AD?

Sunday, June 29, 2014

BERSIH 2.0 FUND RAISING DINNER

Dear friends, 

I am sending this on behalf of BERSIH 2.0's fund raising campaign. Bersih plans to raise RM800,000 annually to execute programmes that are critical to our fight for a democratic Malaysia. The time is now especially in the face of a declining state of affairs in our country, Malaysia.

There is now an urgency for us to reach this target as we only have about RM60k in our coffers. We are scrambling to raise this amount for both the activities, which includes public awareness, delineation campaign,mounting legal challenges and public protests. In addition, we have to also support our staff who have been doing sterling work to keep BERSIH alive. Your contribution will keep our work going.

You can help BERSIH by:
1.  BUY A TABLE
BERSIH is calling on supporters to support its fundraising campaign by buying a table (10 seats) at RM2,000, RM5,000, or RM10,000.
The DINNER details:
Date: 8 August 2014
Time: 7.30pm
Venue: PJ Civic hall, Jalan Yong Shook Lin, PJ.

2. Or just donate - RM50, RM100, RM100 - whatever amount 
3. Or pass this message to 10 friends, relatives, employees, etc. and get them to donate. In turn they too can help by each getting another 10 friends to donate and the chain goes on.

You can bank in your donations to: PERSATUAN KESEDARAN KOMUNITI SELANGOR. Account No.: 03000064902 (Hong Leong Bank). Swift code: HLBBMYKL
Please forward your bank in slip to <donation@bersih.org> or fax to +603-77844978 for our records. Please avoid handing money to unauthorised persons. Do call us @ +603-77844977 if in doubt.

We cannot afford to stop. Not until we are all champions. 
When elections are clean, the Rakyat wins.

Check out our website:
BERSIH website: https://www.bersih.org/champion/

Warm regards,
Maria Chin Abdullah
Chair, BERSIH 2.0

Monday, June 16, 2014

ARE PROCESSED MEAT HARMLESS? THE DANGERS OF PROCESS MEAT



When I was on holiday last week, I observed one of my friends having a handsome portion of processed meat for breakfast. He was obviously enjoying the breakfast, down with a cuppa.
Later as we were travelling, I casually mentioned that that was not a healthy breakfast and he was surprised. Why?

Well. last year, the European Prospective Investigation into Cancer and Nutrition, had already published their study to show that ingestion of process meat was associated with an 18 % increase in all cause mortality, a >70% increase in CV deaths and a 43% increase in cancers. It is a wonder that process meat have NOT been banned.

Well, in the latest issue of Circulation : Heart Failure, Dr Joanna Kaluza of Warsaw University of Life Sciences published her study on the Cohort of Swedish Men and their consumption of processed meat, after a 11.8yr follow-up. These were apparently healthy males between the ages of 45-79yrs, with no previous history of heart disease or heart failure

Hazard Ratios* (HR, 95% CIs) for Heart Failure Incidence and HF Mortality Over a Mean 12 Years by Processed-Red-Meat-Consumption Levels in the Cohort of Swedish Men Study 

End points                 25–49.9 g/d                  50–74.9 g/d                           > 75 g/d                     p for trend
Incident HF         1.09 (1.00–1.19)                1.09 (0.97–1.23)                1.28 (1.10–1.48)                0.01
HF mortality       1.22 (0.91–1.63)                1.42 (0.97–2.07)                2.43 (1.52–3.88)                <0 .001="" o:p="">


*Adjusted for age, education, smoking, body-mass index, total physical activity, aspirin use, supplement use, family history of MI at aged <60 alcohol="" and="" consumption="" daily="" fish="" for="" fruit="" intake="" kcal="" levels="" o:p="" products="" vegetables="" whole-grain="" years="">
They found that for every 50gm increase in processed meat consumption, there was an 8% increase in incident heart failure and a 38% increase in heart failure mortality.
Is that not worrisome?

This same group had also earlier published ( Yr 2011 ), that processed meat consumption was associated with a 23% increase in strokes after 10 years followup.

Of course the important question, is why? Is it the salt used to preserve, is it the chemicals including nitrates used, or other chemicals? We are not too sure. But the observation is true. Eating processed meat is a hazard to good health. A simple breakfast may be better.

Friday, June 06, 2014

UNDERSTANDING ATRIAL FIBRILLATION IN 2014

Atrial Fibrillation is the arrhythmia of the decade. In the 70s the focus was on ventricular arrhythmias and much work was done in terms of early monitoring and control. After much research, we concluded that apart from electrical cardioversion or defibrillation, when the malignant rhythm occurs, nothing more can be done. Life style modification was advocated in an attempt to lessen the athrosclerotic burden and so reduce the incidence of ventricular arrhythmias and prevent sudden cardiac death. We also embarked on a program to teach the lay population the art of by-stander basic life support techniques to help salvage those unfortunate ones who may have sudden arrhythmias in public places. Drugs in the control of ventricular arrhythmias proved disappointing as it produce the very arrhythmias that is was suppose to prevent.
In the 21st century, attention was re-directed to less malignant arrhythmias like atrial fibrillation, the atrial equivalent of their ventricular counterpart. However the issue here was not so much sudden cardiac death as sudden brain death, ie strokes. We now have a much better understanding of A.Fib.. However, the initial focus on drug therapy for control only yielded limited success. Anti-arrhythmics to correct A.Fib was disappointing as they all seem to exhibit some pro-arrhythmic effects. Anti-coagulation to reduce the risk of stroke and rate control worked well except that it was fussy and had the side effects of bleeding. However, industry went ahead, and although VKA ( Vit K antagonist ) worked well ( effective ), cheap but fussy, the pharmas are trying to have us all shift to NOAC which are effective, expensive and still have the bleeding risk. The only advantage seem to be less hassle for 3 monthly blood ( PT-INR ) monitoring.
Then came along the Americans with their complex anti-A,Fib maze surgery, slicing up the atrial wall in an attempt to cut off all the routes propagating A.Fib.. This did not sound very sound. Then came along the French who pioneered the initial percutaneous transvenous R.F ablation, which worked quite well, which I have blogged earlier. This is still popular and more and more EP cardiologist are embarking on the program.

However, I believe the answer lies with the Australians. The group from Adelaide, led by Dr Prashanthan Sanders have published two interesting papers on the reduction of A.Fib burden by life style modification. They believe that A.Fib may be related to the traditional coronary risk factors, especially obesity. They first showed that if you make sheep reduce their weight ( BMI ), they have smaller atrial size and smaller risk for A.Fib.  Then they did the same on Humans with A.Fib but were obese and found that when these people lose weight through life style modification, their . Fib load came down. That paper was published in 2013.

Now at the recently concluded Heart Rhythm Socety Annual Scientific Meeting, The Adelaide boys presented their latest paper on this subject. Dr Rajeer Patnak from Dr Sander's unit presented a paper on this subject. They studied 281 patients with A.Fib who were scheduled for A.Fib ablation. 149 of them had BMI > 27 ( obese ). Of these 149 patients, 61 agreed to undergo intensive life style modification under a supervising physician ( Gp1 ), before the ablation. 88 did not agree ( Gp 2 ) and so acted as control. They all underwent successful ablation. After 3 months, 62% of Gp 1 were free from A.Fib recurrence compared to 26% in Gp 2.  After 42 months, following multiple ablations, 87% in Gp1 and 48% in Gp 2 were free of A. Fib after multiple ablations.

Seeing things overall, looks like we do have many choices in the management of  atrial fibrillation. Firstly, in paroxysmal AFib, we could have them on a life style modification, weight reducing diet, hoping that by reducing the size of the LA and the amount of fibrosis in LA, we can reduce the frequency of A.Fib.
In established A Fib, we can rate control them and anticoagulate them noting the benefits according to the CHAD and Modified CHAD score, and also the risk of anticoagulation. I still prefer warfarin although many of my colleagues have gone on to NOAC. My patients do well with warfarin. For established chronic A Fib we can also offer RF ablation, warning them that they may need 2 ablations in 5 years because of the significant risk of recurrence.
Whatever strategy we chose, life style modification can only help ( according to the Australians ) as shown in their work above.

Friday, May 30, 2014

GLOBAL BURDEN OF DISEASE STUDY ON OBESITY




In the 28th May online issue of Lancet,  Dr Marie Ng and colleagues from the Institute of Health Metrics and Evaluation, University of Washington, published their research on the Global Burden of Disease. This was a Global survey carried out to estimate the scale of chronic lifestyle disease across the globe, including 188 countries across 21 regions. The survey included data from 1980 - 2013.
They found that from 1980 - 2013, there was a 27.5% increase in obesity amongst adults and 47.1% increase incidence amongst children. Over these 30 + yrs, no country has registered any drop in incidence of obesity. Every conry, developed and developing and undeveloped, have seen the incidence of obesity rise. There seem to be slome slowing down in the rise of obesity amongst developed country. While developed country have seen a higher incidence of obesity amongst males, in developing countries, females had a higher incidence of obesity.

Global Burden of Disease Study

       1980
2013
Overall
  857 Million
2.1 Billion
      Males
   28.8%
  36.9%
     Females
   29.8%
  38.0%
     Boys
   16.9%
  23.8%
     Girls
   16.2%
  22.6%


The fact that on obesity in on the rise is not in doubt. What is more challenging is, what can we do about it? Obesity will give rise to higher incidence of hypertension and diabetes and these 3 sisters will increase cardiovascular morbidity and mortality. This will obviously impact on a country's healthcare budget, which in many developed countries have become a serious issue, causing severe budget deficits.
 What then shall we do?.

Of course, the data and research on preventing obesity is well established. Obviously controlling the advertisement and sales of fast food and carbonated drinks to kids, is one of the main causes of obesity amongst children.


Nowadays, ads are directed at children, so that mum and dad is put under tremendous pressure to control.
Which country will take the first step to control the ads and also the sale of fast food and carbonated soft drinks, because these are the killers.

Of course, drinks go with food and fast food is a favourate in our fast track society of the 21st century. We are in the "instant" age. Remote control for instant gratification, is a must and looks like life cannot do without. Fast food is one manifestation, and of course the instant culture promotes a sedentary lifestyle.
The McDonald culture must in some measure be to blame for the epidermic of obesity that we see around us. As McDonald's influence spread across the globe, so also obesity. It looks like they are both in tandem.
In Malaysia, besides battling the McDs, parents also have to battle the mamak stalls with their kurang manis ( even that it is still sweet++) teh tariks. and the so unhealthy roti canais. Nasi lemak, which our government advertises as popular Malaysian food also contributes to obesity and dyslipidemia. Controlling these food, may prove politically unacceptable.
To be fair, there is also a proliferation of gyms and exercise joint for you to jog, do yoga, do line dancing etc etc, this are all good and helpful. But unfortunately, the number of McD joints far outweigh the number of gyms and exercise joints.


If only we can convince some governments that it pays to close down  fast food joints and control adverts of these fast food joints to children. Maybe it is time to label carbonated drinks as "sin beverages" and raise taxes on them. Calorie labelling has started but has had limited effectiveness.
Another worth while measure that was raised before was to reward people who lose weight, either in terms of reduction in health insurance premium ( almost like a lose weight claims ). Rewarding success maybe a better way, than punishing people who sell offending foods.
Basically we know what needs to be done. Food ( calorie ) control, more exercises for individuals, less sedentary lifestyle. These measures will be a good start. But it is easier said than done as some of these measures may be politically unacceptable. Politicians would rather hold a highly publicised "we exercise together" campaign once in awhile,  paying lip service to the importance of lifestyle modification in the fight against chronic non-communicable diseases control.