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.

Wednesday, May 20, 2015

IN SCHIZOPHRENIA, TO LOWER OR NOT TO LOWER HYPERLIPIDEMIA?

If a 40 year old male suffering from chronic schizophrenia, is found to have a raised serum cholesterol and serum triglyceride. Should his treating physician lower his serum cholesterol?
What do you think?
Well, at the ( now on ) annual American Psychiatric Association meeting in Toronto, Dr Henry Nasrallah of the St Louis University School of Medicine in Missouri, presented the findings of CATIE ( Clinical Anti-Psychotic Trial of Intervention Effectiveness ). They studied the lipid profile of 1,460 schizophrenics  with an average of 40 years. They found that those with raised serum cholesterol and triglyceride had significantly better neurocognitive scores. These neurocognitive scores measures various aspect of neurocognitive functions, memory functions and also executive functions. Those with lower cholesterol and triglycerides, had poorer scores. These findings were in schizophrenics. It is important to note that 85% of the brain is lipids.
Interesting.
However, it is important to note that the study did not show that lowering the serum lipids, worsened the  neurocognitive scores. So it is not bidirectional.
However, I find this association interesting?
Should we allow schizophrenics to have raised serum cholesterol and triglycerides, so that we help the brain, but which may harm the heart? What then is the best for this patient?

Monday, May 18, 2015

PRICE HIKE IN APC FEES. FROM RM 50 TO RM 300 ANNUALLY.

MMC Meeting with Doctors Associations on May 13th , 2015, held at the MMC Office in Jalan Chenderasari , Kuala Lumpur at 230 pm
The meeting was chaired by the Head of the Sub Committee for Fee Schedule Revision, Datuk Seri Dr Abu Hassan Asaari Abdullah . Also present was the member of the sub committee, Dr Milton Lum, and MMC Secretary Datuk Dr Azmi Shapie from the MMC side.
Medical Associations were represented by
1. Malaysian Medical Association
2. Medical Practitioners Coalition Association of Malaysia
3. Federation of Private Practitioners Association of Malaysia
4. Pertubuhan Doktor Islam Malaysia
5. Academy of Family Physicians of Malaysia [ College of GPs ]
6. Association of Private Hospitals of Malaysia
7. Academy of Medicine
8. College of Paediatrics
9. College of Surgeons
10 College of Anaesthesia
The Chairman called the meeting to order at 235 pm and introduced himself and the 2 members from the MMC. He then proceeded to stress that he understands the feeling of the doctors on this hike, but he would like us to view a presentation from the MMC side, to see their point of view.
A slide presentation then ensued where APC fees of other countries was compared. The reasons for the corporatisation of MMC was given. Among the reasons given, the main reason was that the MMC wants to be a independent body free from Government dictates. This is so that MMC can make decisions free for the improvement of the Medical fraternity. The National Specialist Register [NSR ] will also be then taken over by the MMC. Once independant MMC will most probably have to pay rental for its office or probably asked to get its own office to function. The staff salary and any litigation brought upon the MMC will then be solely borne by the MMC, without any financial assistance from the Govt.
It was also noted that there were 118 feedback from the ? 2 mths feedback done by MMC on this issue. Datuk Abu Hassan said that nearly ALL were against the feedback.
However Datuk Abu Hassan said he would be grateful if we could reach a compromise on this issue as he could then take this issue back for discussion with the Minister, Director General and MMC Councillors.
After the presentation the floor was then open for discussion
1. MMA President Krishna Kumar said that the doctors rejected this increase as it was too sudden and too steep at this current time, when the economy of everyone was difficult. Citing GST and PDPA amongst other recent fees incurred by doctors. MMA also disagreed with the comparison of the fee structure of other countries, as we should take into consideration , the conditions and consultation fees charged by our doctors here in Malaysia.
2. Doctors Fees have not increased in many years however we see increase and introduction of new fees for doctors [MMA ] . For this the MMC suggested that the fee structure included in the PHFSA be removed from the PHFSA.
3. Fee increase is too steep too sudden and too much – this was raised by all associations at the meeting . It was suggested that the increase should be gradual over the years. Datuk Abu Hassan agreed that the increase should be gradual so as to be more palatable to everyone. However we have not given our suggestions as to how much should be increased over how long [ period ]. No association objected to the fee increase after the presentation
4. Datuk Jacob [ APHM ] suggested that MMC look at other sources of income and ways how members could benefit from this increase . This could be studied from the models from other medical councils from other countries.
5. PERDIM highlighted that the feedback from doctors was conducted over a period of 2 weeks and not 2 months as noted and there were about 500 respondents to the survey. MMC said they will look into this.
6. MPCAM highlighted that in the event of litigation, MMC does not do the payment from its coffers, as the insurers of the MMC will do the payout. If ever , the insurance premium for the MMC will increase the following year. Hence examples of amounts of money being payed out [ RM 6.8 million in a recent O&G case ], cannot be included as an expense for the MMC should it be corporotised.
7. PERDIM questioned the reason why the Director General of Health remains as the President of MMC as this defeats the purposes of the main objective that MMC be free from Govt interference, as the post of the DG is a Govt post, hence a Govt appointment. This was agreed also by the MMC members present at this meeting and they promised that the will bring up this matter with the Minister as all associations present at the meeting agreed that the post of President should be an elected post and not an appointed post. The MMC stressed that the Govt, though agreeing that the MMC be corporatised, wanted its appointee as the President.
8. MPCAM question the election process of the MMC . It was highlighted that many did not get their ballot papers in the 2013 elections. Datuk Abu Hassan said the MMC had formed a election committee and the committee was looking into the suggestion to change the regulations [ which needs approval from the Govt ] for the voting to be more transparent and conducted online.
9. AFPM asked if the APC fees could be charged according to the risk of survice given. MMC will look into this suggestion
10 Academy of Medicine suggested that the fee for senior doctors be exempt as most of them are working either for charity or for survival. Datuk Abu Hassan said he will bring up this issue with the MMC Council and relevant authorities as well.
11. MMA suggested that the GPs be charged lesser for the APC as our revenue was not as high as other doctors. Datuk Abu Hassan said he will bring up this issue with the MMC Council and relevant authorities as well.
There being no further issues Datuk Abu Hassan called the meeting to an end with a vote of thanks to the Chair at 4:20 pm.
Datuk also said the doors for more suggestion is welcome and all suggestions will be read and taken into account. He welcome more suggestions to be emailed to the Secretary of MMC at drazmis@gmail.com .
Datuk Abu Hassan promised that no decision will be made unilaterally by MMC, and another meeting will be called for further deliberation on this issue, this time with an earlier notification.
The MPCAM team met Datuk Seri Dr Abu Hassan after the meeting and thanked him for his openess and professionalism in the way the meeting was conducted.
Prepared by Dr Peter Chan Teck Hock and Dr Raj Kumar Maharajah for MPCAM



My response.

The issue of Exorbitant increase in APC fees.
1. Obviously the fees suggested is too high. The reason given ( that we are independent and not answerable to the government) sounds good but NOT POSSIBLE. WE ARE NEVER INDEPENDENT. MMC can never be for the medical fraternity as the other stakeholders are the government and also the patients. Medical Act 1971 is about administration by doctors of medical care to the patients. So the Public are also stakeholders and also the government has a responsibility as they run the public service and also regulates the private medical facilities. They are all inter-related. They just want to make it sound good ( That MMC is independent ).
2. If MMC is truly independent and for doctors only, then the first thing to insist is for free and fair election of the whole board without quotas. Everyone gets elected for a term including the President of MMC. How can you keep reserving places for your lackeys and also say that you are independent. ALL MUST BE ELECTED IN FREE AND FAIR ELECTIONS REGULATED BY LAW AND CAN BE CHALLENGE IN COURT. The only exception perhaps would be for our East Malaysian colleagues as some of the issues faced by them may differ from Peninsular Malaysia. Otherwise it is independent in name but not in practise.
3. All doctors must pay one fee ( I suggest RM 100 per year ) for the APC. We must not allow them to divide using APC eligibility. It is not an issue of affordability. It is an issue that we are all equal as doctors.
4. If MMC wants to indemnify themselves, they may have to buy medical insurance. It is naive to think that members money can ever be enough for insurance payout. That is a separate issue and cannot be used as an argument to increase APC fees.
5. MMC if truly independent, must employ their own staff so that their staff will not be getting orders from the Chief Secretary of the government. The very fact that they mention that means that they DO NOT intend that the new MMC be truly independent. They just want you to pay more fees while everything remains status quo.
6. Insist that 2 weeks notice at least be given for the next meeting, so that we can band the doctors together in one effective vice. This is an attempt to catch us by surprise so as to divide us ( prevent a unified response ).
7. What began as a meeting on APC fees has wide ranging implications including the workings of the new MMC under Medical Act 1971 Amendments. DOCTORS BEWARE.
8. All like minded Medical Associations should consider drafting a memorandum to be forwarded to the Minister. I am not sure if the Chairman will “remember” to pass on all the sentiments.
No No No. It is not just an issue of super-rising fees. There is more to it then meets the eyes.



Saturday, May 16, 2015

WARNING ON USE OF SGLT2 INHIBITORS



The US FDA yesterday issued a warning on the use of SGLT2 inhibitors in the management of T2DM. From March 2013 - June 2014, 20 cases of Diabetic ketoacidosis requiring hospital admissions were reported. The SGLT2 inhibitors involved included -Canagliflozin, Dapagliflozin and Empagliflozin. Some were use singularly and others in combination with Metformin and in a few cases with linagliptin. These were patients with T2DM and the average blood sugars were > 200 mMols/L. ( relatively low compared to DKA in T1DM. There also seemed to be a large anion gap in these patients. Half of these patients had triggering factors like sepsis and infections. The other half did not have any obvious triggering factors.
This warning is timely as we see physicians attempts to better control T2DM to target and the use of double or triple therapy with the avoidance of secretogogues. The new kid on the blocks may be effective but we have to keep monitoring them to see what other hidden side effects there maybe even as we embrace their use.

This FDA warning is timely.
We in Malaysia should also monitor our drugs for adverse drug reaction.

Friday, May 15, 2015

FIRST BATCH OF UTAR MEDICAL SCHOOL GRADUATES

             Group photo at "CONGRATS" dinner of the 19 students who turned up for dinner.
On 25th April, we held the clinical examination for the final year medical student of University Tungku Abdul Rahman. Out of a group of 36 students, 30 pass and 6 did not make it ( 16% failure rate ). There were no President Scholar, but 4 students did pass with merit. This results was endorsed by the UTAR Senate on 12th May 2015, and so the results became official.
Congratulations to those who pass. Those who did not make it will have to resit in 6 months.
On the 13th May 2015, I took those who pass for a "CONGRATS" dinner, at Restaurant Extra Supertanker.
I was very keen that the first batch must pass well as they set a benchmark for the rest who are following, almost like what we noted with the first bath from UM back in the 60s.
I was told that with this exam, UTAR medical school was given a preliminary 3 year accreditation.

SYABAS UTAR Medical School.

Tuesday, May 05, 2015

OBAMA HAS SOLD AMERICA AND THE WORLD TO BIG CORPORATIONS

Last month on 15th April, the FDA, did something unprecedented. The chairman 0f the FDA Division of Cardiovascular and Renal products, Dr Norman Stockbridge, announced FDA approval for the use of Ivabradine ( Coralan ), in the management of heart failure following the publication of the SHIFT data which showed an 18% reduction in heart failure hospitalisation when patients were given Ivabradine. It was unprecedented as usually, dug approvals have to be studied and debated at the FDA Cardiovascular and Renal Drugs Advisory Committee first, voted on and if successful,  before approval was given. This time, this drug by Servier, did not follow this safeguard. Whether Ivabradine will help or harm is an open question. Some like me, feels that there is a potential for real harm. Remember the SIGNIFY study upon which Ivabradine was approved for stable angina and then was subsequently shown to have more combined death and non fatal MI. Ivabradine ( for those who are not so familiar ) is blocks the If current in the SA node, and therefore slows heart rate. As I argued with Servier expert, Dr Ferari in Bangkok when he came to launch the drug about 10 years ago, sinus tachycardia is a compensation for a falling cardiac output in Heart Failure. Blocking the sympathetic compensation without improving cardiac output and also reversing the cause of CCF is potentially harmful.  Anyway, what is the hurry for quick fasttrack approval, "out of the blues"? There are many many drugs for use in heart failure. Why not let the CVS advisory committee study it and vote on it, as was with other cardiac drugs. I smell a rat. Is US FDA sleeping with big pharma?
So the Malaysian government is not the only one. Looks like USA has the same culture too.

     Over the long weekend, I was also studying and reading / listening on the TPPA that President Obama is trying to push through before his term ends. Gosh, this TPPA breaks all rule on fairness and transparency. Obviously engineered by big Corporations in America, they are now leaning on the President and Congress to pass TPPA. I think it is payback time for their funds support in Obama's last presidential campaign. So sad, we are all sold by corrupt Obama. In Obama land, these forms of corruption ( buying politicians at the highest level ) is legal, because of their right of free speech, and yet with TPPA, there is no freedom. All stakeholders affected by TPPA does not have access to the draft of TPPA ( sound like what MOH is doing with the DS law ). To be honest, this TPPA is a monster and although I have been doing some research on it, it is still very woolly in my mind. How can corporations tell the President what to do? How can corporations be allowed to sue the government when they feel like doing so. All of you please take some time to look into this TPPA issue, which will also affect Malaysia as we are one of the 12 signatories. You can find some insight if you care to listen to this you tube, attached below. There are also many more you tubes if ytou care to listen.

https://youtu.be/FYXndJVJbm8

The world has gone mad. The President of USA has sold American and by extension, the whole world, to large corporations.
We need an alternate system

So sad.

REMEMBERING May 5th 2013.

Remember how on 5th May 2013, we went to vote in GE 13. Then we went to catch illegal voters ( the banglas ). I was in Pantai Dalam. In the evening we ate our dinner quickly and watch the GE 13 results.
From 9pm - 12 midnight, we were thrilled as we were well on the way to an upset victory, as the results came in. Bentong we were in the lead ( slim ) and in Segamat we were also in the lead ( clim ). As the night went on, we knew that sinister forces were at work. In Lembah Pantai the Proton car with extra ballot boxes ( look alike )  were seized by supporters of YB Nurul. Then the story about the re-counts in Teluk Intan and how Police had escorted the opposition candidates out while the recounts were being made, resulting in a BN victory.
All over the country, early gains were being reversed under "suspicious" circumstances. That resulted in a BN victory by seats and a PR victory by popular votes.
REMEMBER.
If you remember and still feel anger at how we were cheated in GE 13, please wear BLACK today, in protest. This is BLACK 505.

Saturday, May 02, 2015

1st MAY ANTI- GST RALLY

I was out in Masjid Jamek again to provide medical cover for the May 1st Labour Day Rally.
I arrived at my meeting point with my team, at about 1.40pm. I choose  the entrance of OCBC Bank at the Masjid Jamek LRT station because it was easy to find and also near my area of responsibility, which was Dataran Maybank.
When I first reach my meeting point, there was almost no one ( except for the usual people ). However, soon, by 2pm, the crowd had increased. St 2pm I went in search of Dataran Maybank, as it was quite confusing to me with Menara Maybank and Dataran Maybank. I did reach Dataran Maybank and found virtually no protesters, but quite a few Nepalis. Along the way back to Majid, I was handed my walkie talkie for effective communication.
By the time I reach back to Masjid Jamek, the crowd at OCBC Bank was large. I guess about
 2-3,000. As the crowd grew, we were getting worried and looking out for the FRU. From Bersih 3.0, were learned that large crowd will bring out the water cannon and tear gas. Small crowd, they will not bother.


I waited there for instructions. And soon, a large crowd joined us from the Tung Shin end. This was the DAP crowd. On the head lorry, I could recognise YB Antony Loke and also saudara Wong Tack.

After some wait, we walked towards Dataran Merdeka, following the crowd. At the Dataran Merdeka, we waited quite long. I believe the leaders of the protest group was negotiating with the Police to gather in Dataran Merdeka. I believe that permission was denied. I was told that we were walking to KLCC. It was during this time, that a diabetic man fainted and had a fit. He was hypoglycemic and was revived with some ice cream.
Even as we started to walk towards KLCC ( in fact one group had already reached KLCC ), we saw a large group from Sogo, walking back to Dataran Merdeka, being led by a lorry with flags and singing. They were heading to Dataran Merdeka. So I waited. A small medic team had in fact followed the first group to KLCC.
I waited to follow the end of these people who were still mingling around in Dataran Merdeka. Finally, I was informed that we were all to walk to KLCC. It was during this time of waiting that I saw some smoke bomb ( orange color ) going off. I did not like it as it dirtied the atmosphere.

Finally we walk to KLCC, arriving there at about 5pm.
After some speeches, and with a parting prayer, we dismissed, probably at about 5.30pm.
                                             The Medic Team for May 1st, anti-GST Rally.
As far as I could see, there was no untoward incident. My medical team was actually getting quite bored. No action.
When we were dismissed, I returned my walkie talkie, when for a drink with my team, and then headed home.
Tiring but another job done.
I hear when I reached home, that many at the Rally was arrested and there were allegations that we were violent and vandalised public property. I did not witness any of that except the harmless smoke bombs going off at Dataran Merdeka area.
The Police should have just arrested those damaging public property, there and then. Otherwise, one wonders whether these were staged incidents to justify the post Rally arrest and detentions.

Tuesday, April 28, 2015

CALLING HELPERS FOR #BATAL GST

Calling all those who love Malaysia, to come out and support #BatalGST this Friday, 1st May 2015.
I am in particular, looking for medical doctors and also paramedicals, to provide medical cover and support for this event. As usual, we are concerned when a large group of people of all ages are walking or running under the sun and rain, they may need medical help. So do come and join us. If you wish to help, please leave me a message at the comments column and I will contact you. Or contact me at ,drngsc@gmail.com>.
Let us do our part for the people of Malaysia.

REMEMBERING BERSIH 3.0

It has been 3 years since we faced the water cannons and tear gas on 28th April 2012. I remember that I was maintaining the medical team at Jalan Sultan and we walked to Dataran Merdeka. All was well and peaceful until 3pm. Just after 3 pm, all hell broke loose. Our cell phone could not communicate. I never even saw the Dataran. I was on the outskirts near Dataran Maybank. But run we did. We had to run and hide from tear gas stink and also direct hit from the tear gas guns. They were shooting at shoulder height, obviously to injure us. People in yellow were removed from restaurants and beaten, just for wearing yellow, I think. We had to treat many cases. Bersih 3.0 had the most casualties. Bersih 3.0 arguably had the biggest crowd and we also suffered the most casualties.
The sad thing is that we made an impact, but failed to change the government at GE 13. They stole it from us. We only manage to win popular vote, 52%. It showed the effectiveness of their gerry meandering, and the electoral power of East Malaysia.

That is why we are spending a lot of time and money to work amongst the locals in Sarawak, to try and win their hearts and mind.

I hope that we will have another BERSIH 4.0 before GE 14.

Well, I just wanted not to forget BERSIH 3.0.