Tuesday, August 19, 2014

MIM MEETING LAST WEEKEND, 16-17th AUGUST 2014

It has been a busy weekend. I had to tutor UTAR 5th yr medic and then run to UM, Faculty of medicine to take part in MIM ( Medicine in Malaysia ) weekend seminar. They had invited me to go take part in their seminar. To judge their poster competition and also deliver a talk on Cardiology in Malaysia.
I was very impressed with what I saw over the weekend.
Lets take a step back.
This MIM series of meeting through the country, is run by a group of undergraduates from Overseas ( mainly UK ), together with their Malaysian counterparts ( undergraduates ) from UMMC and IMU. It is funded by Talent Corp, who obviously wanted to get to this group of Malaysians studying overseas, to get them to return.
The meeting was well attended ( guestimate ), about 300 in the Dewan TJ Danaraj, UMMC. The poster competition featured some simple research ( some done overseae and some from local Us like UMMC and Hospital Pinang ). It was quite obvious that the work done overseas were better thought about and executed. I was particularly impressed by a piece of work from UK where they tried to identify markers of drug non responsiveness in patients given come chemotherapy for Glioblastoma Multiforme. I thought that that held much clinical promise.
I spoke on Cardiology in Malaysia, outlining our journey through the last 2 decades, from the time of clinical cardiology till present day PCI. I also dwell a bit of current day private practice in Malaysia and the plethora of laws governing us from Medical Act '71 to PHCFS Act, Local council laws, to  PDPA, to Medical Act 71 amendment ( NSR ) to GST, and yet we are being squeeze by MCOs where there is no law to govern them. Life as a private doctor is tough.
I sat through some of the sessions hearing big chiefs from MOH telling the young ones, how good is the Healthcare service in Malaysia. Gosh, it made me want to pewed.
Anyway, that was my weekend. Life is almost back to normal.
This weekend we start to finalise preparation for ICF 2014, at year end.

Sunday, August 10, 2014

WEEKEND SEMINAR IN CARDIOLOGY AND DIABETES FOR GPs 2014;

This event went very well. The program was smoothly carried out. All in good time. One session in the breakout room ( ECG tutorial ) started late as both tutors came late. I nearly had to take over.
We registered 900+ attendees ( preliminary ). 850 before Friday and 123 on site. On Saturday afternoon, we had about 500 in the ballroom, and on Sunday morning we had 400 in the ballroom. The Saturday lunch had no sitting seats although NovoNordisk ( sponsors for lunch ) had book 400 shares. We nearly had to send people to coffee house for lunch.
This year, we altered the program significantly. Only 2 hours of monolog lecturers for all the whole weekend and 8 hors of case discussion in 3 rooms concurrently.
Pullman Hotel catering is good. The food quality was good. BUT the management is not so well organise to cater for a large meeting. They did quite a few things wrong. I went to Pullman using the LRT. It is off the Kg Kerinchi station.
The ballroom at 3.30pm on Saturday. We had placed 400 seats and added 50 seats and some were standing.
All in all it was a good meeting. These were the comments from the attendees. They like the venue, although I do not. They love the case discussions and use of the interactive pads.
The whole ballroom ( ballroom 1 ) was crowded during tea break with hardly any place to stand or walk.
I must thank the lecturers and tutors who worked hard to complete their case discussions and learning objectives.
It was a tiring but very rewarding weekend.
Thanks to all attendees for making this event a success. Thanks to the sponsors and the secretariat ( MSD ).
See you all again next year.

Saturday, August 02, 2014

WEEKEND SEMINAR IN CARDIOLOGY AND DIABETES FOR GPs 2014

JUST A REMINDER.

This event is on next weekend. There is very experience and expert faculty to discuss clinical cases and how to manage. All sessions will be interactive with use of interactive pads to poll the audience. Lunch and dinner provided.
WEEKEND SEMINAR IN CARDIOLOGY FOR GPs 2014                                                             PROGRAM
Saturday
9th August 2014


12.45-13.50 pm
 LUNCH SYMPOSIUM
1400-1415

Opening of Weekend seminar.
1415-14.45 pm
Management of Diabetes in the Clinic – State of Art
                     Goal of therapy and how to achieve the goal    Dr Hew FL

14.50 – 15.50 pm
Case study on Diabetes – Problem solving
                               MH       :  Dr Hew FL
                               RM 1    :  Dr Vijayan    RM 2 : Dr Wong Ming
1550-1620
TEA BREAK
16.30-18.00 pm

ECG tutorial  -  Self assessment
                              MH   : Dr P Kannan
                              RM 1 :  Dr Yee KM                 RM 2  :  Dr Ed Mah
18.10  18.40 pm
Managing chest pains in the clinic – State of art
      How to recognize the problems and what to do?  Prof Wan Azman
1840
DINNER SYMPOSIUM  


Sunday
10th August 2014
0800-08.30 am
Hypertension – State of Art
             Life style modification, drugs and intervention?
             Which and When?                                  Prof Chia YC
08.40 – 10.00 am
Case study on hypertension - Problem solving
                                                     MH  :  TBC
                                                    RM 1 :  Dr Wong TW    RM 2 : Dr  CK Yeo
10.00-10.30am
TEA BREAK
10.40-12.00 noon
Case study on CCF and Dyslipidemia
                                       MH    :   Dr L Chan
                                       RM 1 :  Dr Dewi  Ramasamy      RM 2 : Dr Ernest Ng
12. 10 – 12.40 pm
Management of ambulatory Heart Failure – State of Art
                          Life style, Drugs or devices   
                                                                   Dr Tamil Selvan
12.40- 12.50 pm
                                             CLOSE            
13.00-14.00 pm
Lunch Symposium.

 It is free. We have registered 700 attendees. CME points and Certificate of Attendance will be awarded.

If you wish to join us at the seminar, please call your favourate pharma and they will register you or call 012-2122468 ( Ivan Lee ). Hurry

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.