Monday, September 22, 2014

IVABRADINE DID NOT DO WELL IN SIGNIFY.

I must say that nowadays, at clinical meeting, we are hearing reported, more negative trials.
In the recently concluded European Society of Cardiology Annual Scientific Congress,, one such trial reported was the SIGNIFY trial. This trial was to a randomised, double blinded, placebo control trial to test the benefits of Ivabradine against the placebo in patients with stable angina pectoris, without heart failure and worse heart rate was greater than 70 beats per minute. Ivabradine was a heart rate slowing drug working through the If  channel n the SA node. I suppose the investigators were hoping to show that by slowing the heart rate from 70 to 60 per minute, it would make a better outcome. The PI was Dr Kim Fox of London. The paper was also published simultaneously in the New England Journal of Medicine 371:1091, 2014. They managed to enrol 19,102 patients who had stable coronary disease without heart failure and whose heart rate was more than 70 / min. It is important to note that of the 19,000 or so patients, 12,000 or so had class 2 angina or more ( Canadian classification ). The primary endpoint was CVS mortality and non fatal MI. Half the patients were given Ivabradine and the other half, a placebo.


After 27 months of follow-up. it was true that the Heart Rate was lower in the treated arm. There was however no significant difference in the primary endpoint. But in the 12,000 patients with Canadian class 2 or more angina, there were more deaths and non fatal MI. There also seemed to be a higher incidence of atrial fibrillation in the treated arm.

Now, this last two points have given rise to some concern. We now know ( 19,000 is a large number ) that there is no point using ivabradine in patients with stable angina pectoris without heart failure. Secondly, we have to be careful in those with Class 2 or more angina, as it may do harm. Why? we are not certain.

IMPROVING PATIENT SAFETY - REPLY.

I wrote this reply to A Prof Azmi article in Saturday's Star, on "Improving patient safety".

Having read the interesting article by Assoc. Prof Mohammed Azmi, it is important to emphasize a few crucial points. What ails Malaysian Healthcare is basically a lack of funding. With 4.6% of GDP, we have done remarkably well. Healthcare transformation with greater public – private integration of course is greatly welcomed. However, retaining a two tier system of public-private healthcare is crucial to a successful healthcare system. It provides for a check and balance. This promotes healthy competition and no one is left out without the care that he or she needs. Having just a one tier system ( like NHS-UK ) would be a step backwards, as the public has less choice, greater taxation and when that one system fails ( as evident in UK now ), many now buy their own private insurance. Alas, our wish would be that with a greater Healthcare expenditure budget the public sector may be transformed to be on par with the private sector.

We all agree that improving patient safety is very important. We differ that setting up another body is the answer. Medical care has now progress from just curative medicine to preventive medicine and in the area of curative medicine, from just diagnosing and treating a condition to diagnosing, treating and also counselling. It is in this area of counselling that much can be done to improve patient care especially patient safety. Doctors are spending more time to counsel patients on their illness, and their treatment regimes. And if drugs are involved,  their effects and side effects. In this y age of information and the internet, even if the doctor fail  to mention, the more knowledgeable patient will ask. This is the best way to improve patient safety. Patients talking to their doctors, and doctors empowering their patients. That is also why we are concern about this talk every now and then to restrict dispensing to pharmacy alone. Should the government be so silly as to do that, it invites trouble. Asking a family to go searching for a pharmacy at 2 am in the morning, when a crying, wailing child has fever is ridiculous, bordering on irresponsibility, when his doctor is sitting just in front of him and can explain the medications, the effects and side effects. Yes, the pharmacist has the theoretical knowledge of the effect and  side effects of drugs. but which drug and dose is  suitable for his illness and his body, only his caring doctor knows, unless the government is of the view that all patients are the same and all illnesses are the same and one size fits all. The current system of prescribing dispensing allows for choice.  No exclusiveness, allow free choice. We are certain that this is what the patient wants, although it may not be what the pharmacists want. 

This reply was send to the Star editor on Saturday evening.

Wednesday, September 17, 2014

KEMBALI NEGARA-KU

This morning I join the Kembali Negara-Ku Piknik at Taman Jaya. I reached the site at 8.20 am and found the action point, sat down and had breakfast with y friend Dr KB Ng.

The crowd started to build up at about 8.45 -9 am. By the time the speeches started, I think (guesstimate ) there were about 200 people, who had come fairly prepared. Some chit chat, like us. Some played badminton ( father and son ), and most just sat down and ate mostly nasi lemak.
Of course the VIP was Zaid, Samad, aand Ambiga. I also shock the hands of Maria Chin ( Bersih ) and Haris Ibrahim ( ABU ). maybe there were others there that I did not recognise. I believe there were no politicians there.
After some chit chat fellowship, the speeches started at about 9.45 am with Zaid ( chairman ) speaking first, then the poem by Samad, and a short encouragement by Ambiga.
Their speeches were all short. Samad seemed rather weak. I could hardly hear him reciting his poem. To conclude the morning of fellowship, Kembali Negara-Ku Piknik, we sand Negara-Ku with some gusto and also Rasa Sayang.
We dismissed at about 10 am.
It was a simple memorable morning.
Well we are 52 years old ( half a century ), and we are still as divided as ever. This racist UMNO must be held responsible for most of this.

Monday, September 15, 2014

THE ABSORB STENT. WILL IT LIVE UP TO EXPECTATION?

In the field of interventional cardiology ( which is plateauing ), obviously the latest stent impacting us is the Absorb bioresorbable vascular scaffolding, which reach our Malaysian shores about 4-5 years ago. Of course the initial results were excellent, Absorb cohort A, Absorb cohort B, ABSORB I trial ( we are awaiting the 5 year follow-up results ) and the ABSORB II study, the prelim 1 year FU data was just released by Patrick Serruys at TCT. From the CV, looks like Patrick, the cornerstone of ThoraxCenter, Rotterdam, for so many years, have now moved to Imperial College, London ( need to check this out ). Well, Patrick released the Absorb II interim analysis and showed that the Absorb was as good as the good "old" Xience V ( good DES ), except for some less acute lumen gain. That is a minor point according to Patrick but I think that that point cannot be simply dismissed.
Anyway, between Absorb I and Absorb II, investigators ( not from the Patrick group ), the other European investigators have published the GHOST-EU registry at Eurointervention 2014. Led by Dr Capodanno, these investigators publish their registry of 1,189 patients, across 10 European Centers,  who had the Absorb bio-resorbable vascular scaffolding implanted between Nov 2011 - January 2014 ), and followed up. This seemed more real world, when compared to the "mastery" skills of Patrick and team. They found that there were significant problems. Over follow up of 6 months, there were 2.1% stent thrombosis, death rate 1.0%, target lesion MI of 2.0% and TLR of 2.5%. TVR was 4.0%. These are not small numbers. And it is only 6 months.
Of course, I have always shy away from using Absorb because Abbott Vascular's Xience Prime was working excellent in my hands and not to forget, the Xience Prime DES was much cheaper, making it more cost effective ( value for money ), except that this Xience Prime cannot disappear.
Looks like Absorb is a good stent but there are still issues to be resolved. Xience Prime is a very good stent and is much cheaper.
I hear that there is a company call Elixir, who also has a bio-resorbable vascular scaffolding. The drug is different,another -limus, called novolimus. So competition is on the way. Looks like prices will becoming down.

HAPPY MALAYSIA DAY, MALAYSIA

Tomorrow is Malaysia Day. This should be our National Day. It was the day our Sarawak and Sabah brothers and sisters join us to form the Federation of Malaysia, 16th September 1963.

Just to remind us all.
                 After 51 years of Malaysia.
                 Borrowing a line from Charles Dickens -
                                         It is the best of times, we have seen tremendous progress of iconic buildings and disconnected monorails / LRT services, a so called "booming economy" propped up by great household debt. A government trumpeting economic numbers that many have trouble trying to understand as things on the ground is a far cry from things declared in Putrajaya.
                                          It is the worse of times , as we become a laughing stock to the world, with one country, two Allahs, laws meant for prosecution are used selectively to become laws for persecution. The constitution challenged with impunity with government tacit support. It is the worse of times, when clicking "like" in a facebook page can be deemed as seditious. When we have many "hot crimes" without criminals.
We must all come together and remember the Philosophy of Malaysia as stated in our Rukun Negara.
We must believe in God. Please call it whatever name you wish, but believe in God. I will respect your Allah, and you please respect mine too. I will be loyal to the king and our country and I hope that the Kings will also be loyal to king and country. The Constitution is SUPREME and so also the RULE OF LAW ( not rule by law ). We must have mutual respect for each other as fellow Malaysians and have good social behaviour.
We are all Malaysians first and only Malaysians. Let not the racist politicians divide us.


We are all one, a Malaysian 


I was born here and I will die here. I hope that I do not have to die saving my country from pseudo-Malaysians who are out to divide us. 
Please come and join us for a morning picnic.
16h September 2014
8.30 am - 10 am
Taman Jaya, PJ

Thursday, September 11, 2014

#MansuhAktaHasutan. STUDENT MINI DEMO IN UM

I was at UM campus yesterday to be with the students at their mini demo next to the UM bus station.

Also there with the students ( at least those that I could recognise ) were Nurul Izzah ( looks like crowd favourate posing fo pics all the time ), Rafizi, Ong Kian Meng and Haris Ibrahim. There may be other YBs that I may not have notice. We small people stand at a corner.
The crowd must be about 300-400 mainly students. Looks like there were some outsiders.
We all left after singing the Negara-Ku.
When you are there, it is heart warming to see these young ones speaking, walking and taking up the challenge against a corrupt and abusive government. I only hope that they were persevere and persist in their strive to build a new Malaysia.
They made a severe mistake detaining so many under the Sedition Act. And an even bigger mistake, charging a law lecturer, who teaches the young minds. That is a severe mistake which I am sure thay will regret.
#MansuhAktaHasutan

Wednesday, September 10, 2014

#MansuhAktaHasutan



See you all at the UM camps at 1pm.

We need to repeal the Sedition Act. It has been grossly abused.

Friday, September 05, 2014

Negara-Ku to picnic on September 16 to reclaim Malaysia.

This is the tagline civil society movement Negara-Ku is using as it seeks to battle the wide use of the Sedition Act against political opponents and the stifling of dissent among academicians and the media.
Organising chairman Zaid Kamaruddin said in line with its “Kembalikan negara-ku” effort, the movement's steering committee will hold a “Piknik Rakyat” on Malaysia Day, September 16 at Taman Jaya in Petaling Jaya from 8.30am until 10am.

Please come and join us for a morning picnic.
16h September 2014
8.30 am - 10 am
Taman Jaya, PJ


#Mansuh Akta Hasutan

The Sedition Act must go.
These last seven days have been very upsetting for Malaysians who voice opinions from the goodness of their hearts, for a better Malaysia. A Prof Azmi clearly was doing what his job requires him to do, and what the government of the day wants our students to learn. The ability to analyse facts and form opinions.  Not to be spoon fed. So A Prof Azmi gave his opinion and he was arrested and investigated for sedition. Reporter Susan was doing her job, reporting on an event that happened in Penang. She is a journalist. That is her job. She too was arrested for sedition, questioned for 9 hours and released on bail.  For doing her job. Can some great legal mind please explain to me and all right thinking Malaysians, what is “sedition” and can that law be applied like this? I do not know either of them. But I sympathise with them and their family. They were just doing their job. They have done no wrong.
Can I be charged for sedition, if I were   treating a patient ( who happens to be an opposition politician ) and on interview found that his heart attack was a result of intense interrogation and sleep deprivation by the Police, and I  document that in the case notes?
Are we living in a nation, where we are fearful to speak and give opinions?
No, no, no. This is not the Malaysia that we know. This is ridiculous. The Sedition Act must go.


This piece was send to the STAR today. Lets see if they will publish.

There are so many NGO coalition now, all spring up overnight. How I wish that they will combine and form a giant one to repeal this draconian Act.

Please support # Mansuh Akta Hasutan.   

Monday, September 01, 2014

Help

I tried to post the PARADIGM-HF study this morning. As you can see, the middle paragraph came out gibblish. I do not understand why and I could not correct it.
Can anyone teach me how? Am I corrupted by virus? or is this manmade?

HELP

I tried this morning to re-write the article again. The same thing happened.