Monday, August 17, 2015

THE DILEMMA OF A RAISED TROPONIN T IN DIABETICS WITH STABLE CAD

Many of us use Troponin T as an enzymatic marker for unstable coronary artery disease, thinking that these trop T elevation is due to enzymatic leakages from death of myocardial cells. In fact, this is one of the WHO criteria for diagnosis of AMI. Now, is this true all the time?



In an article published in the 13th August issue of New England Journal of Medicine, Dr Brendan Everett and investigators looked into the BARI-2D data, and found that in 2,285 patients with diabetes mellitus and stable coronary artery disease, 40% had elevation of Troponin T without chest pains. Trop T levels > 14ng/L was the cut off. 27.1% of those with Trop T had a clinical event, defined as CV death, MI or strokes in 5 years. While 12.9% of those with normal Trop T had any clinical events in 5 years.. This was statistically significant at
Those with Trop T elevation also had a 19.6% risk of dying at 5 years compared to 7.1% who had no Trop T elevation. This was also highly significant. ( < P=0.001).
The other surprising thing is that, those with Trop T elevation who were revascularised, did not normalise their Trop T, neither did it improve the outcome. Now this is puzzling.
It then bags the question, where is this Trop T coming from, and what is the cause of its elevation?
What then shall we do wit diabetics who present to ER with chest pains that are like that of acute myocardial infarction? Shall we treat them all as AMI? knowing that it may not alter prognosis? or shall we repeat serial Trop T in an attempt to better define this group.
Is Trop T a reliable indicator of myocardial necrosis? Or are there other reasons for Trop T elevation like poor glucose control? presence of metabolic syndrome and high TG levels?, Or is it hypertension with myocardial over-stretch?
I suppose as always, there is so much that we do not yet know. Obviously more studies need be done, to look nto this.

BERSIH 4.0 LOCAL AND GLOBAL

Yes, I have not been posting for almost 1 month now, due to a combination of factors. Have been rather busy with my many social duties, ranging from organising medical meetings, medical camps, fund raising, teaching and the latest is organising a medical team for the coming Bersih 4.0. I am told that the Bersih organisers are trying to get 400,000 to walk in the streets of KL on the 29th August and also to sleep over at Dataran Merdeka on 29th night.
Yes, we are local and global too.



We expect that with hundreds of thousands of Malaysians from all walks of life in the streets walking, there may be some who may need medical attention, being Police officers with faints, or citizens with asthmatic attacks. My task is to help raise a medical team, so that those who have medical needs on that day, can receive medical attention. We have already readied ambulances on standby, and AEDs ( just in case ), of course together with our first aid kits, and also our survival gears against tear gas and water cannon. This time, I have also advised members to bring along a sleeping bag, should they wish to sleep over at Dataran Merdeka.


Of course, I feel that this Bersih 4.0 rally is justifiable, because, our minority, elected ( on 47% popular vote ) government  no longer wish to listen to the people when we talk to them.
What then do you do, when the people who represent you, hide from you, give vague answers to simple questions, ban, sack, detain, and transfer government officers whom they do not like for speaking up. This is a gross abuse of power. You represent us ( so you say ), take our tax money, impose GST on us, and give us hardship, then do not respond to us in a reasonable manner, when we ask you for answers. This is unreasonable.
So we have no choice but to walk our talk. We want answers. The economy is failing. Soon, our money will be almost like "banana notes" during the Japanese occupation.


Please come out on the 29th August in large numbers. I hope that God will give us good weather and protect us from harm. It starts at 2 pm. There are 5 staging points for us to assemble. I expect that my stations will be Pasar Seni and Dataran Maybank.
Can you imagine Kuala Lumpur in a sea of yellow? Please come and make Kuala Lumpur a sea of yellow on 29th August. Let the 47% PM get a clear message that the rakyat wish to be heard, and we are important. In a democracy, the state may think that they have the power, but the real power is with the people. Afterall, it is a government, for the people, of the people and by the people, is it not.

PLEASE COME ONE COME ALL. COME AND BE HEARD. MAKE KUALA LUMPUR A SEA OF YELLOW ON 29th August.


Thursday, July 23, 2015

US NEWS AND WORLD REPORT BEST HOSPITAL RANKING. 2014

US News and World Report's "Best Hospitals" listing 2014
Top 10 Ranked Hospitals for Cardiology and Heart Surgery
  1. Cleveland Clinic, OH
  2. Mayo Clinic, Rochester, MN
  3. New York-Presbyterian University Hospital of Columbia and Cornell, NY
  4. Duke University Hospital, Durham, NC
  5. Brigham and Women's Hospital, Boston, MA
  6. Massachusetts General Hospital, Boston
  7. Hospitals of the University of Pennsylvania-Penn Presbyterian, Philadelphia
  8. Cedars-Sinai Medical Center, Los Angeles, CA
  9. St Francis Hospital, Roslyn, New York, NY
  10. Mount Sinai Hospital, New York, NY
The 2014 "Honor Roll" for Top Hospitals (Overall)
  1. Mayo Clinic, Rochester, Minnesota
  2. Massachusetts General Hospital, Boston
  3. Johns Hopkins Hospital, Baltimore, MD
  4. Cleveland Clinic, OH
  5. University of California, Los Angeles Medical Center
  6. New York-Presbyterian University Hospital of Columbia and Cornell, NY
  7. Hospitals of the University of Pennsylvania-Penn Presbyterian, Philadelphia
  8. University of California, San Francisco Medical Center
  9. Brigham and Women's Hospital, Boston, MA
  10. Northwestern Memorial Hospital, Chicago, IL

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.