Thursday, January 05, 2023

Let us talk about the sick Malaysian Healthcare. The sickness is the system? – Facts and figures

 

Recently there has been many write ups on what ails the Malaysian Healthcare system. There was much focus on the problems of junior house officers  and the toxic eco-system that junior doctors are working under. Politicians and NGOs were also concern about the “brain drain” of bright young Malaysian doctors who have migrated overseas, or some just over the causeway.

I have been watching the Malaysian Healthcare scene for the last 40 years, having work in the public sector, then the private sector, having taught in the public sector then the private sector and also having contributed to the some of the treatment methods currently in use in hospitals ( both public and private ). I would like to highlight the issues that I see as an outsider ( not in the Putrajaya eco-system ), and hopefully suggest some remedy.

“ Is the present Malaysian Healthcare sick”?

The answer is a big YES.

In the 90’s the Malaysian healthcare system was greatly admired by our peers. We were spending about 3.6% GDP on our healthcare and were achieving good healthcare outcome. We first started with one medical school ( UM 1962 ), then two medical school ( UKM 1972 ), then three medical school ( USM 1979 ).  3 medical schools in 17 years. Many of the junior doctors then were from local universities and the teachers were either expats from overseas or graduates from University of Malaya In Singapore.  Toxic culture among the juniors were unheard off and they were keen to learn with good attitude. The seniors were keen to teach. Hos/Mos and specialist got along well.

However since the 1990s, many radical changes took place. Under the PM 4 ( Prime Minister 4 ) administration, the sickness began, slowly but surely. I mean the deterioration of our healthcare system both in delivery of healthcare and also the outcome of healthcare delivery.

Since the beginning of 1990 till 2014 ( moratorium on medical schools ) we had an additional 33 medical schools of various sizes, most without their own teaching  hospitals ( sharing hospital patients with public hospitals ).

PM 4, having started the production of our national car, and decided that Malaysia was now an industrialised nation and should have the health standard of an industrialised nation. Political leaders began talking about having a national patient to doctor ratio of 1:600. Looks like this triggered the tsunami of medical schools and medical graduates. There was no concern about medical standards and quality. Only great concern about medical quantity. Not to forget that it was also a lucrative business to start medical schools ( remember PTPTN loans for students ). Ex-DGs of MOH upon retirement became Pro-Chancellor of medical school, one almost the next day after retirement as DG.

Sooner or later the poor quality was bound to show, and symptoms showed. When the symptoms became serious, there was public outcry and the first knee jerk response was a moratorium on medical schools effective 2014 telling us that they then realise there was a problem.

Symptoms of this ailing system.

The symptoms first began to show itself at the turn of the millennium when reports began to appear of poor standard of care in public hospitals. These were initially treated as isolated instances and dismissed.

Then things got worse and too serious to cover up.

Malpractice suits began to appear. We all the baby who ( born at Selayang Hospital ) suffered brain damage in 2005. The parents filed a law suit and won. Then there was the case of baby Yok Shan ( 2007 )  who lost her arm, when a doctor in Klang Hospital inserted an intravenous cannula into her arm muscle instead of her arm vein, causing her to lose her arm. The parents again went to court and won. These cases are mentioned as examples.  The Deputy Minister MOH told the press ( 2017 )  that annually, MOH received about 7,000 complaints annually and paid out about RM 20 million. The MOH 2020 annual report showed that in 2019 MOH paid out about RM 23 million in legal suits against MOH. ( Remember only those with money can afford to sue ).

The other troubling symptom is of course housemen bullying ( toxic work environment for junior doctors ). Absenteeism from work, downing tools at 5pm sharp became common. Junior doctors clocking out without reviewing their patients and without passing over ill patients to the on-call to care. Housemen  ( and even specialists ) bought clock-in  machines from on-line shops and were clocking in and out at will at home. There was even a case report of a housemen who was suppose to take blood from ward patients for investigation, who decided that he will take 20 cc blood from one patient and put them into multiple bottles labeled for other patients. And as a result of that houseman who committed suicide in Penang, and measures were taken by MOH to chastise medical officers and specialist who then became defensive. The pendulum swung the other way. Housemen have now become the “untouchables”, beyond discipline, even when they are clearly not doing their job, as the MOH has now given the right for housemen to complaint against their seniors. How then can the housemen learn and get trained when an advice and correction can be taken as “scolding”? Yes, there is a lot of training and corrections going on in the ward. Some seniors do abuse their position, but not the majority. Taking action that stops training and correction of junior doctors is counter productive and will show itself in badly trained junior doctors, which will translate to poorly trained medical officers and specialist and consultants. It takes time, but will eventually spoil the whole system. When you have poorly trained, incapable MO’s in peripheral hospitals, more cases get referred back to overcrowded district hospitals and state hospitals.

Of course the other symptom is the “brain drain”. Seeing the poor state of affairs in the public hospitals many young doctors seeing a poor career prospect, have chosen to vote with their feet, mostly to the English speaking countries and across the causeway. Many rose to prominent position  receiving outstanding awards and peer recognition. Their new country benefitted from our loss. There is shortage of data on medical brain drain. The Sun Daily reported recently that about 0.5 million skilled Malaysian ( all categories ) leave the country yearly for jobs overseas. Professor of Medicine of University of Malaya, tweeted recently that UM loses about 30 doctors yearly to Singapore. In fact Malaysians fill many of the top medical jobs in Singapore. This is also true for other professions and disciplines as well. 

Signs of this ailing system

I will use hard facts as the signs of an ailing healthcare system. These are hard facts on record, and not a personal opinion. I am talking about national clinical outcomes of our system, comparing our outcomes in 1990 and what they in 2019 ( before the onset of the pandemic ).The source of the data is also provided for all to check.


This is how we compare with our peers in the region. How they have improved compared to how we have improved. For Infant Mortality, our ASEAN  neighbours improve by double digits, we improve by low single digits. For life expectancy we improve at halve their rate. I could also use other indices which will show the same trend.

Then there is the index of medical litigation which reflects medical management standards not in keeping with community standards.  The Malaysian Medical Council ( medical professional governing body ) receives complaints and only investigate those complaints that have an ethical element, or an element of professional misconduct. They ask all who feel aggrieved by medical malpractice to seek redress through the civil court process. This cost money and the average B40 after losing their bread winner surely cannot get justice. How does the DG separate professional misconduct and professional negligence is surely a mood point? Anyway, I tried to get figures of professional misconduct, but such figures are not available. The MMC takes a long time to investigate a complaint ( may take years ) and very few doctors are found guilty by MMC, resulting in one reporter calling the MMC a protector of doctors, not of the people.  

Anyway, I did manage to find some statistics from the Annual MOH report 2020. ( shown below ). I was unable to find any record of litigation in the 90’s for comparison.



As we can see, we are paying out RM18 to RM 20 million annually for malpractice suits. Another sign of an ailing Healthcare?

Conclusion.

As can be seen from the symptoms and signs shown by our healthcare system, the system is sick and needs radical treatment, the sooner the better before it becomes malignant.

 The sickness is the system.  















Happy New Year 2023. A new beginning.

 




Sunday, August 28, 2022

 21st Century Paradigm shift in medical education.

I spend Friday and Saturday, examining final year medical students in their final professional exam. It went well, but the mark sheet presented to me to assess them ( give them marks ) really surprised me. 

They still insist on how they do the "heel shin test", how they, stroke the toes, how they feel for thrills and listen to murmurs, in this era of ubiquitous use of imaging techniques. The mark sheet does not give enough marks for the students ability to synthesize facts and arrive at a diagnosis and work out what could be wrong. I have mention this to the "bosses" repeatedly, but apparently this is what thw examination board wants?

I am sure, that anyone who hears a murmur ( be it diastolic or systolic ) will instantly order an cardiac ultrasound and doppler and they can see the valves the dysfunctional blood flow and arrive at the diagnosis. It is much more important, to have them know the pathology, how to integrate the gross clinical signs pick up ( enough to know which system is disordered ) and investigate accordingly and probably more actually and spend time discussing management. 

Investigations, especially imaging techniques are so common and so good nowadays, that it has become an vital tool for good management. I suppose if I am stuck in the deep jungles of Sabah and Sarawak, I may have to rely solely on percussion, auscultation and scratching the toes and rubbing the shins. But then my misdiagnosis rates will be higher and clinical outcome poorer.

Previously, a 5 year program for medical education will be sufficient, but in the 21st century is 5 years sufficient? We are seeing more types of diseases, with more complications, more treatment modalities with more treatment side effects and complications, even organs have been found to have new functions we never realise before. 

We have open up a whole new field of gene therapy and immunology. Is 5 years sufficient? Even if the answer for some is yes, should those 5 years be spend on teaching detail techniques of examination at the risk of losing out in anatomy of imaging modalities and how to better understand human organ function and inter system interaction to better treat the patient.

Medical education must make a paradigm shift and not do the same thing the same way, since the time of Sir William Harvey. It is nice to know the Wallenburg Syndrome, but an MRI of the brain will surely give me a more accurate assessment and aid my management better.

In the next posting  we shall address the Paradigm shift on "What is the truth?"

Saturday, August 20, 2022

 THE PARADIGM SHIFT IN THE 21ST CENTURY -The end of American exceptionalism.

Introduction, 

When I was a kid going to school, I thought so highly of the USA. After the 2 world wars, the USA became the dominant force and country in this world. They really know how to convince the whole world that they are a force for good and will save the world from all catastrophes.  Their marketing and promotion of their country was superb. Whenever cowboys appear to kill the red Indians, we cheer almost as if good has overcome evil. Little did I realise that the Red Indians were the original people who own the land and the Americans from England were the transgressors who were the Imperialist who came to take over by force, the land of the Red Indians. It sure looks like the Americans were a very aggressive race, who likes to fight, conquer and take by force whatever they wish.

This trait was quite obvious in the 21st century as every American President since the 21st century has started a war against often innocent nations, just because they wanted, their oil, their minerals, or who did not agree with them. 

The problem of American Exceptionalism

American exceptionalism is the problem. The Americans seem to think that they are God's special chosen people. They think of themselves as the light upon the hill. A nation called by God to police and save the world. In the 20th century, they use their soft power to try and win over the world. They had their "Peace Corp", they established good educational Universities with seductive names like "Ivy Leagues' and use their military budget to make inventions like the internet and digital world. Once they have the whole world "hooked" on them, they show their true colours in the 21st century. They became very arrogant. Because of their military might, their Naval fleets sail the oceans exerting their will. If you are not with me, you are against me and I have God's given right to punish you, either by way of sanctions, or even worse attack and bomb you to smithereens. You can see all the evidence around you. And if they do not like your government they send in their dirty tricks department ( usually that CIA band under the NGO of the National Endowment for Democracy ) to cause trouble, instigate the local opposition always waiting for the chance to stage a coup and regime change. They have done that all over the world. The best example maybe Ukraine.  They have also change the government of Imran Khan in Pakistan, and they are working hard to change the government in Thailand.  And they are continuing to do so in Taiwan, of which President Tsai looks like a CIA agent acting on behalf of USA. We can now easily see the ugly side of USA by :

1. Fake NEWS: BUT lately, we have seen their ugly side. The Covid pandemic showed us that their control of the mass media and spread of fake news has caused the world to have vaccine mandates, using injections which they falsely call vaccine ( when in fact it is gene therapy ), with almost no data of effectiveness or safety. Now after 18 months it is so clear that those gene shots did not prevent the spread of covid, did not prevent those getting those gene shots from getting covid. They claim that it made covid milder, but virology 101 will tell you that when viruses pass from human host to human host, it either kills them ( those lethal viruses ) or the virus loses its virulence and survive by getting attenuated  losing some virulence ( milder ) so that it spreads more. They do this by mutating and so we now see more and more variants and sub-variants.

2. De-platform those who tell the truth. Although USA confesses to freedom of information, and transparency, in the 21st century, they have become dictatorial. They silence people who tell the truth ( remember Chelsea Manning and Julian Assange ) , they deplatform ( remove from alternative media and main media, those who try to speak the truth. Even small fry me, was deplatform 3x by facebook, and twice by MKini and oncc by Star, because I wrote things that did not conform with the official narrative.  Looks like George Orwell 1984 is here. 

3. They have lost all their values and sense of fairness and fair play. They kill Red Indians to steal their land, in the 18th century. Now they give arms by the billions to Ukraine so that Ukrainians can fight Russia to weaken Russia, using the lives of Ukrainians. When the whole world is asking for negotiations to end the war and save lives, the US is sending billions of sophisticated weapons to fight a war and get Ukrainians killed, till the last drop of Ukrainian blood. How wicked can you get.

And sadly, the Taiwanese cannot see it. They are instigating to fight till the last drop of Taiwanese blood, promising arms BUT not American lives. These actions are evil.

USA is a country with a 300 year history and they are trying to teach China ( a country with a 3,000 year history civilisation ) "rules based order"? How arrogant can you get? I really hope that China will teach them a big lesson.

4. Can we trust medical journals ( even reputable ones ) after how they have published lies, remove articles of well studied work, in this covid pandemic. It is so obvious that big Pharma did not tell the whole truth with their gene shots and drugs, yet they faithfully publish their half baked findings and refuse to publish good scientific studies tell tell an alternative narrative.

Looking back, they also tricked us about understanding and treatment of hypertension, and understanding and treatment of hypercholesterolemia. Can we trust evidence based medicine as a whole, knowing that the world capitalist world is corrupted by the greed for money.

4. It is all about money.

   How do you trust a country when their system of election is based on raising money from the Military Industrial Congress Complex MICC ). To get elected cost millions of dollars. The industry, especially the the MICC and the big pharmas donate millions towards their election funds. After they win, of course those who have donated millions to them will come calling to ask for favours, to get back their return on investment. This is CORRUPTION, straight and simple, but it is all legal. This results in USA becoming a plutocracy. The ordinary man in the street gets to put a ballot into the box, once every 4 years. BUT the people have no say. The rich donors ( MICC and Pharmas ) control congress and the president. When war becomes profit making, you can only expect more wars and more lives lost, because it is a business.  As long as lives lost is not in your country. That surely cannot be right. Kill more Ukrainians, I make more money. Kill more Taiwanese, as long as I make more money. How does that sound to you? 

This paradigm shift will surely destroy the world. It is so sad. Yet, we in small Malaysia cannot do anything about it. I suppose except pray for divine intervention.  With so much high tech very powerful missiles flying around, it does take just a small miscalculation, to destroy the whole world.


That is the world that we find ourselves in, in the 21sst century. Sad but true.

I was born in the 20th century and this 21st century is surely a severe and deadly paradigm shift bringing the whole world to the edge of destruction. 

WE MUST END AMERICAN EXCEPTIONALISM, OTHERWISE CALLED AMERICAN BULLYING, AS SOON AS POSSIBLE.

After 

Saturday, August 13, 2022

THE PARADIGM SHIFT IN THE 21st CENTURY.

1. How doctors failed the world.

Ever since the start the start of the covid pandemic, I have been very ashame of being a doctor, although I wrote and got myself de-platformed by our local mass media, and also facebook.

How did good doctors allow 1. The repeated lockdowns which severely damaged the economy of all countries in an attempt to eradicate and control a single stranded RNA virus ( which after 30 months ) we know will give us a mild cough and will kill <1% of those infected. In fact if you follow the projection of one expert epidemiologist, the ultimate mortality rate from covid 19 will be 0.2%. 

Even if we accept that covid 19 ultimate mortality is somewhere between 0.2-1%, the damage that we did to the economies  of all countries with our lockdowns  is incalculable. The poor have become much much poorer while the superrich has become super superrich. In fact those countries with minimal lockdowns had their economies minimally affected. Why did not doctors speak out louder against lockdowns? Yes, I signed the GBD ( Great Barrington Declaration ) but we also have another group of doctors who wrote against GBD.

How did we allow 2. The world to embark on a mass MANDATORY gene therapy against covid 19, with  novel gene shorts, with very very minimal safety data, not proven effective, did not control the spread of the infection, did not stop you getting the infection, and yet we allowed them to called those novel gene shots "vaccines"? If those gene shorts only make the infections milder, we all know from virology 101, that all viruses through passage across human host will either kill ( thereby stopping further spread ) or get milder. It was just a matter of time. GBD seeks rightly to promote focal protection ( which I believe is correct ) and the Swedes seek to allow minimal intervention and allow the virus to run its natural course. Well after 30 months, it sure looks like Sweden is correct.

Now we are hearing more and more reports of the harms from those gene shots. In fact there were reports that in some countries, those gene shots were killing more, than Omicron BA.5? We now also have to worry where those gene shit nanoparticles may end up? Will we be seeing a surge in Malignancies in the next 5-10 years ( in fact there seemed to be an increase in malignancies recently. What about kids 5 yr old now with those nano particles in the blood stream, bone marrow, testicles, ovaries, livr, cardiac sarcomeres, brain cells, and God knows where else. What evil have we done to them, and we had Malaysian doctors arguing with me over the safety of those gene shots. I supposed, they are sincerely ignorant or just medically naïve because they did get their own child get those harmful gene shots. Now that we have seen the Pfizer records released by FDA, we know that those gene shots are harmful, AND PFIZER KNEW IT. Some doctors appear on TV and talk shows actively promoting a harmful therapy. I am ashamed, even if these colleagues of mine were sincerely wrong. 

How did doctors allow 3. Them to ban the use of Ivermectin to prevent and treat covid 19?

Of course, those big pharmas want to make big bucks from patented drugs and want to ban cheap generics, when cheap generics were safer and  more effective in the prevention and early treatment of covid. I have been on it for 15 months now ( 2 tabs weekly ) and thank God, so far I am covid 19 naive. I can only guess how many thousands of lives Ivermectin would have saved. That cheap and effective drug that was so good against Loa Loa in Sub-Saharan Africa is also so good and so safe against SARS COV 2. 

How did doctors allow 4. Reputable medical journals to print articles written by pharmas using pseudo-doctors?  Through out this pandemic, we have seen the death of evidence based medicine. Clinical studies were manipulated to show whatever the "pharmas" want to show, using "Pharmas friendly" doctors. As the saying goes, there are always doctors who can be bought. It is a matter of the price, so doctors are no better than prostitutes, just a different trade. The medical world will never trust medical evidence again knowing that many are fake. That raises a new problem of fact checking to see which is true and which is fake.

Throughout this pandemic, I had a very hard time trying to reconcile data with basic medical science, to try and arrive at the truth. It was tough analysing data and basic medical science. But that is the oath that I have chosen. 

Drs Anthony Fauci and Francis Collins are no world renown virologist to tell the world how to treat and control Covid 19. They are probably the two most hated medical doctors who let the world down. They betray their calling.  They are traitors to our fraternity. But alas, they are very rich for doing that.

In subsequent articles I will try and see the next 21st Century paradigm shift. THE FALL OF THE GREAT USA. AMERICAN EXCEPTIONALISM IS OVER. 

Monday, August 08, 2022

 I AM BACK.


I was working hard doing, professional and social work, so did not find time to blog. I replaced this blog with daily posting on Covid in Malaysia through the medical doctors' facebook. 

Now that I am semi-retired, I thought that I will again blog and share my experience in medical and also social issues.

I hope that I will have enough energy ( by the grace of God ), to continue till my last breathe,



Monday, September 07, 2015

ESC. PLATFORM ( PROSPECTIVE LONGITUDINAL TRIAL OF FFRct ; OUTCOME AND RESOURCE IMPACT ) STUDY

Taking the cue from Dr Alan Teh, I thought that I better read up on what happened at the just concluded ESC ( European Society of Cardiology), Annual Congress 2015, London . I found a very interesting presentation, which to me, had a very important and practical message for Malaysian Cardiology and Cardiac investigation scene.
Dr Pamela Douglas ( that sharp lady ), from Dukes Clinical Research Institute, Durham, N Carolina, presented the results of the PLATFORM ( Prospective Longitudinal Trial of FFRct : Outcome and Resource Impact ) study. Basically, this study looked into the usefulness and impact of a plain CTA, against a CTA with FFR analysis with the Heartflow software, done offline. PLATFORM has 2 different arms and I will describe that arm that has to do with comparing CTA without FFR and CTA with FFR or FFRct. ( these are non invasive FFR ).
Dr Douglas and colleagues studied 380 patients, who had CTA, who were all scheduled for coronary angiogram, She divided them into 2 groups. One group when straight for coronary angiogram ( 187 patients ), Gp A and the other group ( 193 pts ) had FFRct before Coronary angiogram, Gp B.
They found that in Gp A, 73% of patients had NO significant coronary artery disease and after 3 months followup, non had any coronary events. While in Gp b, following FFRct, they were confident to cancel 61% of the coronary angiogram, without any follow-up incidences, and in the remaining 39% who had coronary angiogram done, 12% had no significant coronary disease.
Take awhile to have the message sink in. After all these years, if PLATFORM is to be believed, we have a 73% coronary angiograms where no significant disease is found. And in 61%, the coronary angiogram could be safely excluded.
Just imagine the abuse all these years and which will probably will be carried on by the CTA-philes for many more years to come. I suppose it would be too drastic to say that  these people are  "CTA for bread".

When I saw these figures, I was appalled. Thanks Dr Douglas for enlightening us. I hope that many more centers, especially local ones will repeat this study and see where we stand. I firmly believe that FFRct is the way to go.
We have been advocating a clinical approach to investigation of CAD,, instead of a factory, everyone get CTA approach, as often done in many medical centers on the rational that what you see is real. Well I hope that cardiologist will wake up and realise that what you see may not be real and adding a functional component would greatly assist in the accuracy and patient care management aspect of diagnosis of CAD. I of course assume that we are clinicians and not businessmen.

Saturday, September 05, 2015

POST BERSIH 4.0. REPORT. MY TAKE


Bersih 4.0 has come and gone. We each have our take on it. The pro-Bersih have their slant. The anti-Bersih have their views too. I thought that as a witness to all 34 hours of the event, I shall also pt on record, my take. I will try to state the facts, although I would confess that I am a Bersih 4.0 supporter. I will try and state the facts. Please read and if you do not agree, please tell me. If you agree, please tell all your friends. We must pass on the real message.

Fact 1. It cannot be denied that the crowd was big. On day 1 ( 29th Aug ), Jln Tun Perak / Pasar Seni probably had the biggest crowd. We were full up all the way to Kota Raya bus station. The Sogo area had the next largest, the Brickfields next and the smallest crowd was from Masjid Negara ( I was told, a crowd of about 5,000 ). All in all, I eyeball estimate about 150-200,000.
Besides the crowd, the next obvious thing was the racial composition. Having been to 5 mass street rally, it was quite obvious that the crowd was mainly Chinese, and Indians. The number of Malays was small. ( I apologise for being racist here. I don't like to but it looks like in Malaysia '15 we all seem to be abit ).
On Day 2, the crowd as bigger. Easily 2-300,000 at the peak. What was more heartening was the racial composition. We saw more Malays appearing, young and old. That was heartening.

Whether the larger crowd and more Malays attending, is due to the wily old fox appearance, is a mood point. I personally feel that he is the cause of all our problems, so he is certainly no hero of mind.

Fact 2. One of the sights that will leave a big impression on me, is the 1am 29th Aug seen on Jln TAR and Jln Tun Perak.

I saw young ( mainly ) and some old, sleeping on the streets, on the pavements, and on the road divider. On sleeping bags, on simple mats, on cardboards, on papers, with their water bottle and bags beside them. Some even had their helmet next to them. This was a sight to behold.

Fact 3. After 1am on 29th Aug, I could see many walk pass me at my Pasar Seni base to go home to sleep. Mainly the senior citizens. They would wave to us at the medic base, and say thank you or good night, as they stroll pass to go home.
        The next morning, I woke up at 6.15 am to go wash up. I could see the seniors walking back in the direction of Jln Tun Perak, to join the rally again. This was heart warming. Why would seniors, who had already attended the Rally on 29th Aug, come back again on Sunday. Have they nothing better to do, or are they so angry, that day of rest also must come.


That really make me think how committed they are to the cause.
Mind you, I know for certain that non in the crowd was paid to attend. As a medic team leader, I lost money, making "medical vest", buying food, medication, and the little nitty gritties. My team had to buy first aid kits, donate masks and googles, etc etc etc. These people gave up their sunday rest to send the government a clear message.

Fact 4. Why do I bother to go attend this historical rally, called Bersih 4.0. I will sum it up in two pics which I think summaries well why I took part, besides the fact that it is my calling to help people who may be injured or sick who needed my help.
I only hope that this government will listen to the people. Will give us back our voice. We are out there because we have no choice. We try talking to the government politely, strongly, even more strongly. But they sack, they ban, the declare illegal, they transfer out, they "promote", they shut down, the withdraw licence, they do all manners of evil to deny us information and accountability.
Bersih 4.0 is because the people have lost their voice, and they want it back.

Thanks to Mdm Maria Chin and committee for a job well done.
Thanks to brave Malaysians, THANKS FOR STANDING UP.

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.