Monday, November 24, 2014

MKINI OPEN HOUSE. AFTER 15 YEARS




I was at the Mkini Open House on 22nd Nov 2014, amidst a pouring rain. It was a small struggle getting there because of the rain and I also had some difficulty finding the place as Jln Tandung was not my usual haunt. Anyway find it I did after a couple of U turns. Arrived there at about 5 pm.


Nice place. Big multi storey building. I have never been to  a press center before, but they look fairly well equipped. Plenty of laptops al over the pace a some staff was working. Some visitors were going "on air" in one of the staged room. The crowd, well at 5pm was sparse, and the rain was a dampener. I am sure that it was larger once the dragon dance can and the entertainment began.


After finding my "brick" and those of a couple of my friends, and after a self tour of the whole building, I decided to leave. Took a drink and then left at about 6pm into a severe traffic jam along Fed Hwy. It took me a hour to get from the Jln Templer traffic light to Subang. When I reach the Subang entrance, I discovered that the whole Fed Hwy was closed at the Subang exit. Now I know, it was because of a new landmark in Subang, called " the leaning LRT beam of Subang". What kind of contractors do we have in Malaysia. After so many deaths and accidents, ( with instant promises of no repeats after each incident ), we now have the leaning LRT beam of Subang. When will we ever learn.

I could get home with the relatively minor detour, to USJ, but I pity the Klang folks who were not so conversant with the detour routes. The crude signage just say ( arrow pointed left ). So the Klang foks have to find their way to Klang either through Subang ( free tour of Subang ) or through the old airport road. There was no signage to help them.
This is Malaysia. Malaysia Boleh.



Thursday, November 20, 2014

HEALTHCARE COST SURELY TO RISE FROM NOW TILL APRIL FOOL’S DAY 2015

This statement was send to Star yesterday, as letter to the editor. Let's see if they will print. I am very concerned that the Custom's Dept have no clue as to the workings of the private doctors. While public hospital supplies and services are all zero rated, 1-2% of private healthcare supplies and services are zero rated, and the bulk ( 98% approximately ) are standard rated. The PM's call for Healthcare to be exempted ( in a very broad term ) we know now to be a farce and simply untrue.

The YB MOH announced last week  that not all drugs will be zero rated. In fact, a quick calculation revealed that probably less than 10% of commonly used drugs will be zero rated. Following  the numerous briefings , seminars,  Q&As, notes, documents and meetings with Customs Department, a few things are very obvious in this GST for Healthcare due for implementation about 6 months for now. Firstly, that Customs Department did not realize how many types of disciplines and categories there are in Healthcare. They must have thought that there is a doctor who sees patients and  who charges patients. Little did they realize that there are GPs, family physicians, specialists in solo practice, specialists in private hospital practice, etc  etc  etc. Secondly, it is also fairly obvious   that Healthcare is GST exempt means that only the doctors consultation fees is GST exempt. Not his fees for surgery and procedures, not 90% of his medications, not his professional indemnity fees, not if hospital collects the fees for the consultant ( which is the majority of the private hospitals ). Since that is what the government wishes, and since doctors have family and responsibilities he will have to increase his fees to cover whatever GST will take away. I am sure that the private hospitals will do the same.
The sum total being, healthcare cost will surely rise. It is only the quantum of rise that is yet unknown.

In order to avoid this, we call upon the government of Malaysia, to make Healthcare GST zero rated all along the supply and service chain. If that is not possible, then be prepared to face a severe rise in Healthcare Cost for the patients come 1st April 2015. It may be best to shelve this GST all together, until proper studies are done and the customs understand the working of private healthcare system.

The public must wake up. and take the government to account.

Tuesday, November 18, 2014

1MDB : WHAT THE GOVERNMENT DOES NOT WANT YOU TO KNOW.



Please come and attend this 1MDB public forum. See what Rafizi and Tony Pua have discovered.. I understand that Dr Mahathir is speaking too.
Tomorrow night at THE CLUB, Bandar Utama

Monday, November 10, 2014

HELP. HELP HELP FOR CLEAN FREE AND FAIR ELECTIONS




The Election commission has announced that they intend to table in Parliament the new electoral boundaries for GE 14  However, they would not allow Tindak Malaysia or Bersih to have copies of the new electoral boundaries, even if they wish to pay for it. Just to make it difficult, these new maps will be presented to Parliament and placed in the various constituencies where they can be viewed. There is no soft copy.
So both Tindak Malaysia and Bersih have launch a campaign to look for volunteers to form groups of 3-4 people, to visit all the electoral constituencies and physically take pictures of all the new maps and bring them back to HQ, where they can be studied to see where the Gerry Meandering is so that we can go to court to dispute the new boundaries. All these work within 30 days.
This is all in line with the Federal Constitution.
We must uphold the Federal Constitution, especially 13th Schedule.
We need volunteers who can spare 3 days to help do this work. It helps if you have a driving licence and is good at photography.

If you are interested, please contact me at

Thank you. In any democracy, we must have clean, free and fair elections.

Thursday, November 06, 2014

GE13: Clean and Fair? The verdict of the People’s Tribunal

I spend last night at the Bersih forum on " Verdict of the Peopl's Tribunal"  on GE 13. I also bought a hard copy of their report.


The Tribunal's report is published and the findings I am told is posted in the Bersih website ( www.bersih.org ) and you can also buy a copy. The conclusion ( or verdict as they called it is obvious. There was widespread fraud, almost at every level. The only level left unhindered was that you could go, and cast your vote, fairly freely. All other stages of the electoral process was flawed and there was good evidence. Non of the court cases challenging ever got to open court. They were all thrown out at the preliminary stages through some technicality and excuse.

The following in the final verdict, found in pg 65 of the Report.
                 OVERALL, TAKING INTO ACCOUNT THE 'MACRO-LEVEL' OF APPORTIONMENT-THERE IS REASON TO BELIEVE THAT THE 'WRONG PARTY' WAS DECLARED TO HAVE WON THE 2013 ELECTIONS.

So what can be done. GE 13 was stolen from the people.

Of course most of the discussion last night at the forum was, What then shall we do? Especially with GE 14 facing us, and the electoral delineation exercise about to take place before the end of 2014.

Some were focusing on how to garner people's support to object to the proposed delineation ( DART program ), noting that ALL previous delineation have always resulted in boundaries favouring the ruling party, and thus resulting in landslide victory for the ruling party at the next GE. Some were in favour of greater publicity for electoral boundaries that were free and fair ( Tindak Malaysia ). Some were in favour of asking opposition MPs to be more vigilant in Parliament, as delineation with increase in seats would require the support of 2/3 in Parliament ( meaning support of the opposition ). I was in support of getting the people's support through peaceful street demonstration ( people's power ), to get the ruling party to listen and not mess around with the delineation.

Whatever it is, we have to uphold the Federal Constitution, 13th Schedule.

Whatever it is, we should all return to the Rukun Negara and uphold it, together with the Federal Constitution.










Tuesday, November 04, 2014

DAP Fund Raising Dinner. 3rd NOV 2014.

I spend last night attending the DAP fund raising dinner. A very big affair boosting 110 tables booked for the evening at PJ Civic Center. Thank God there was no rain, so trafficwas smooth. I carpooled and we reached at 7.15pm and there was no longer any parking space at the Civic Center and we had to park by the houses on top of the hill. I had organised to fill 2 "Gold" tables, with my medic colleagues and some business people.

It was speeches after speeches. Saudara LGE spoke well, highlighting the "Bible Burning Issue" an of course the new MB of Selangor Azmin Ali spoke and he outlined his plan for Selangor during his term. All in the poster spoke, so the meeting lasted till 11.30pm. Tong Pua ( organising chairman for this dinner ) spoke last, outline the 1MDB issue. Gosh, how did a responsible PM and Chairman of IMDB advisory board, allowed 1MDB to accumulate so much debt. If Tony is correct, we will be paying this debt till the next generation. Some more no accounts for the last 2 years. A company holding debts of billions with no accounts shown. How can this be? ROC where are you? Nowadays, we hear of borrowing by the billions, and eating by the billions. Some more money park in Cayman Island where are the darling company accounts cannot be scrutinised. Sounding more and more like a scam, except that the Government of Malaysia stands guarantor ( thru some legal papers ). I am really worried for 1MDB.

Anyway, it looks like DAP is trying to groom up a new set of younger leaders. Still very raw, I must say. Last night was a good effort. I hope that DAP managed to raise a lot of money. I must say that the floor collection was ( to me ) disappointing. About RM 20+K only.

I expect that from now till GE 14, there will be about 5-6 more fund raising. It gets more challenging as the economy gets slower and times get harder for the man in the street.

All in all it was a good time. I learn many new things, prime of which is " How can a responsible government allow one of its crony companies to accumulate so much debt? I thing I am right to say that they have not shown an profits yet, after 4 years in operations. They sure have shown plenty of debt.

Monday, November 03, 2014

CAUTION. BEWARE THAT ANTIBIOTICS IN COMBINATION WITH CERTAIN ANTI-HYPERTENSIVES MAY KILL

Hypertension is a growing problem amongst the Malaysian population. ACEI and ARBs are commonly used as they are proven to be very effective in the treatment of hypertension and also confers additional benefits with respect to renal protection.
"Flu", cough and cold is also a very common ailment afflicting us Malaysians. Co-trimoxazole ( commonly called Bactrim ) is also a commonly used antibiotic for treatment of common infective disorders.
There were some reported deaths in people taking Bactrium, who were also hypertensives on ACE-I. So the Canadian Researches looked into this issue. This resulted in a paper published in the BMJ 30th Oct issue. The paper is entitled, " Co-trimoxazole and sudden cardiac deaths in patients taking inhibitors of Renin Angiotensin system.". The study was led by Dr Michael Fralich From the Canadian Drug Safety and Effectiveness Research Center. They review the hospitalisation data and discharged data of the Ontario Health District from 1st April 1994 till 1st Jan 2012. There were all together 39,879 sudden cardiac deaths. They analysed those who had received ACEI / ARB  and also antibiotics Co-trimoxazole and also ciprofloxacin and two other antibiotics. These SCD were matched against 3,733 patients of the same age and sex group and who also have the same co-morbid factors of T2DM and kidney disease. These were used as matched controls.

Table 3 
 Antibiotic use and risk of sudden death within 14 days
Antibiotic useNo (%) casesNo (%) controlsOdds ratio (95% CI)Adjusted odds ratio (95% CI)*
Amoxicillin (reference)418 (22.9)2021 (29.8)1.0 (reference)1.0 (reference)
Co-trimoxazole474 (25.9)1262 (18.6)1.80 (1.54 to 2.09)1.54 (1.29 to 1.84)
Ciprofloxacin603 (33.0)1888 (27.9)1.50 (1.30 to 1.72)1.18 (1.00 to 1.39)
Norfloxacin158 (8.6)832 (12.3)0.89 (0.73 to 1.09)0.83 (0.65 to 1.05)
Nitrofurantoin174 (9.5)768 (11.3)1.08 (0.88 to 1.32)1.03 (0.81 to 1.30)
*Analysis adjusted for disease risk index.

They found that those taking Co-trimoxazole and also an ACEI / ARB had a significantly higher SCD rate than match controls, especially if used till 14 days.  Ciprofloxacin also carries a slightly increase SCD rate, though not as high as Co-trimoxazole.
The reason for this may be the effect of Co-trimoxazole to increase serum potassium is some people.
There were earlier evidence that the use of ciprofloxacin was associated with a risk of SCD.

I suppose the message should be that when we use ACE-I / ARB, we should beware of the problem of hyper-kalemia and we should also be careful of antibiotics used. Co-trimoxazole use should be restricted to patients not taking ACE-I / ARB.






Thursday, October 23, 2014

IS VIAGRA GOOD FOR THE HEART?


Viagra is a popular drug, frequently used in Malaysia as treatment for erectile dysfunction. That is the medical indication. However, many young men are using it as a tonic for sexual enhancement.
Now, they are asking , if I should take Viagra often ( chronically for some ) will it harm my heart.
Well, a recent study by the Italian group seemed to suggest that it surely does not harm the heart but in fact may help the heart. It that true?
This issue was highlighted in the lay press recently showing that it is of public interest. So I thought that I should have a look at it.
The study is an Italian one, published in the BMC Medical, 19th Oct 2014. The Article is entitled " Is chronic inhibition of Phosphodiaesterase Type 5 cardioprotective and safe? A meta-analysis. This Italian group from the Sapienza University of Rome, went into the medical data base of Medline and Embase to look over 24 RCT involving PE 5 inhibitors usage from 4 weeks to 1 year, where cardiac indices were also measured. There were 1,622 patients deemed suitable. 954 were on PD 5 inhibitors and 772 were on placebo. They were enrolled from March 2012 till Dec 2013.The indications for PD 5 usage was not clear. They researchers only wanted all patients to have placebo control and also to have taken PD 5 inhibitors chronically. Most of the patients were taking sildenafil citrate ( viagra ). Fewer were taking Levitra and Cialis.
They concluded from their meta-analysis ( which had a lot of statistics ), that PD 5 was safe to use chronically. That there was some improvement in LV function indices, that it helped the heart with LVH to remodel better, that with usage in patients with heart failure, the pro-BNP estimation improved, and there was also better peripheral vasodilation.

So I had a look at the paper. It must have been a big ask to take so many diverse study and try and match them together. There were many variables. I did not know how the investigators were able to analyse the data coherently. Yes, there was improvement in LVEF but it was in the region of 3-4%, and they were using echocardiogram as a means of determining the LV function. Surely, 3-4 % may not be significant. The methodology to measure vaso-motion was not detailed.
All in all, in my opinion, a rather weak study, using statistics to mesmerise us. Drawing big poster concusions based on rather flimsy data.

I am quite sure that it is safe to consume PD 5 inhibitor chronically but remember NOT to use it together with GTN. If used chronically, it may reduced Pulmonary artery resistance and improve RV function somewhat. As for improvement in LV function, we should take that with a large pinch of salt.

To be certain, we will have to wait for more data, and more evidence.

Friday, October 17, 2014

LAWYERS WALK FOR PEACE

Yes, I was out there yesterday to join and also assist in the Bar Council organised, "Lawyer's Walk for Peace ". We were there as supporters as well as to provide Medical cover as a Medical team on duty. I manage to enrol about 4 others. There were five of us. I had also got the assistance of Mr Genta ( SJA ), so there was also an ambulance on standby.

I when down to Masjid Jermak by LRT, and walked to Padang Merbok. Somehow managed to take the wrong road up the hill and so was lost for a while. So it tok me longer than anticipated to reach Pdg Merbok. I managed to reach there at about 11am just before Mr Christopher Leong started his address. It was a bit hot, and I had forgotten my golf cap ( stupid me ).

At the peak of the gathering, I think there were about 1,000 mainly lawyers with some people in civilian clothes. The lawyers' response was indeed heartening. Some were from Pahang and Johore Baru. Even before we started to walk to Parliament, there was a medical alert for a "collapsed" patient. I went to have a look. The most senior member of my medic team had felt dizzy like near faint. He had no breakfast and so we got him some sweets and fluids and that took care of that.
We started to walk at around 12 noon, I think. Up the hill to Parliament house to hand a memorandum to the PM. I understand that the President and 9 members of his council met with Datuk Mah and handed the memorandum to Datuk Mah for PM. The delegation of 10 returned at around 1pm.
By that time, there were 2 more near faints.

We dismissed at about 1.10pm and I returned to LRT and train back to Subang Jaya. Wonderful but tiring morning.
#MANSUHAKTAHASUTAN

Wednesday, October 08, 2014

THE FPMPAM HEALTHCARE WISHLIST - BUDGET 2015

THE FPMPAM HEALTHCARE WISHLIST - BUDGET 2015
Kuala Lumpur, 8 October 2014 - In view of the upcoming announcement by the
government on the 2015 Budget, the Federation of Private Medical Practitioners’
Associations Malaysia (FPMPAM) has circulated its wish list for healthcare for 2015. These
are as follows:
1. Put more money in Rakyat’s healthcare
We urge the Government to increase the Healthcare allocation in the budget to 6% -
7% GDP.
With the increased allocation, the Government should strengthen the primary care
system by increasing the level of Private / Public integration via outsourcing care of
out-patients with chronic illness from the public hospital outpatient clinics to the
private primary care clinics (in the same vicinity) for follow-up treatment. All private
primary care, GPs and family practitioner clinics should be invited to take part in this
program. The present one-stop prescription and dispensing system in private clinics
should be continued as it is patient-friendly and cost-effective.
Likewise, for patients requiring surgery and procedures, if the wait list in the public
hospitals is too long, these patients should be referred to local private healthcare
facilities instead of being sent overseas.
Rationale: This will allow a shorter waiting list for public out-patient clinics. Shorter
waiting time is patient-friendly, allows better patient-doctor interaction and translates
as improved productivity for both the patient and the healthcare system. Referring
patients to local private facilities will save time and cost and strengthen local
expertise.
2. Designate healthcare services as GST zero rated.
Rationale: Healthcare is a right of the rakyat. The sick is already suffering from the
ravages of ill-health and should not be taxed.
3. Do not privatise public hospitals and public healthcare clinics
With the current escalating cost of living, we urge the Government to abide by its
promise made two elections ago, not to privatise the public hospitals and public
healthcare facilities. Privatisation of public healthcare facilities will only further worsen
the situation and gravely affect the safety net for healthcare for the lower income
groups and those not who are not insured.
Rationale: The provision of this safety net allows for affordable and universal
accessibility of our healthcare system for this sector of the population and should
remain as the responsibility of the Government.
4. Control Healthcare Cost by implementing the following:
i) Implement immediately a schedule for hospital fees
Escalating hospital fees are a major cost in increasing healthcare cost. There is at
present no laws to regulate the hospital fees and the fees of commercialised
healthcare services. It is escalating by leaps and bounds since 2000. We urge the
immediate implementation of regulations to require all private hospitals to declare
their fees for their index 50 hospital procedures.
Rationale: This will allow initiation of some form of containment of private hospital
fees with the eventual target of a schedule for hospital fees. This hospital fee
schedule is vital for the long-term viability of the system.
ii) Enforce Pathology Laboratory Act 2012 to control unregulated
health screening and medical tests
We urge the Government to immediately enforce the Pathology Laboratory Act.
Unnecessary blood tests and health screening, random wellness checks by
business-driven private laboratories and business entities must be regulated. All
these must be compliant with the Pathology Laboratory Act, the Private Healthcare
Facilities and Services Act (PHFSA) and all other laws to stop the current trend of
unnecessary tests.
Rationale: Unnecessary medical tests and health screening is a big business.
Unfortunately it is a health and moral hazard. An independent registered medical
practitioner assessment, preferably by the family doctor, must be required before any
test is allowed to be done. All such tests should only be ordered by a registered
medical practitioner based on patient’s health needs and the doctor must have no
vested interest in the investigating facility.
iii) Regulate the middle-men in healthcare
We urge the Government to immediately implement and enforce regulations in the
PHFSA 1998 to regulate this business of medicine. No such regulations exist to date.
Rationale: Middleman services are draining away patient’s healthcare money at
source. This affects simple taken-for-granted items like medical examination, seeing
a doctor when one is sick and now, even the dispensing of medicines. Eventually the
terms and conditions of the middleman and not the doctor will end up determining the
care of the patient.
This business is unregulated and many such entities have come and gone leaving
patients and doctors with millions of ringgit of unpaid bills. If this is allowed to
continue, the private healthcare system will eventually be broken beyond repair.
iv) Enforce the Medical Devices Act 2012
The use of medical devices should be in the hands of properly trained registered
medical practitioners and in a medical setting. The Act has been passed in
Parliament but yet to be enforced. To avoid a conflict of interest, doctors teaming with
entrepreneurs to own high end equipment must also declare their interest.
Rationale: These devices are capable of inflicting damage and injury when used by
unauthorised individuals and is a danger to the sick and the suffering
v) Implement Alternative Dispute Resolution for Medical Mishaps
We urge the Government to urgently implement the Alternative Dispute Resolution
for medical mishaps.
Rationale: The current system of resolving medical mishaps occurring for whatever
reason takes too long and is not fair to the patients. The system is already backlogged
by many existing cases. The increase in new cases both in the private and
the public sector is expected to worsen the situation. At the end of the day the overall
cost of healthcare escalates as reflected by increasing medical indemnity fees,
increased defensive medicine and increased absolute cost of provision of care.
ADR for medical mishaps is a proven system worldwide which lessens the need for
expensive long-drawn court proceedings.
5. Set up Multi-Agency Dengue Task Force in every State Health Department
We urge the Government to set a target to control Dengue Fever incidence by 50%
in year 1, 60% in Year 2, 70% in year 3, 80% in Year 4 and 90% in year 5. Target
reduction in Dengue mortality by 75% in year 1, 80% in year 2, 90% in Year 3, 95%
in year 4 and 99% in year 5
Rationale: The Dengue epidemic has gone on for too long. It is a major disease
burden and is taking away too many lives. It must be controlled and we must be more
focussed. The Dengue Task Force must be empowered to inspect all sites posing a
Dengue hazard and empowered to take all necessary measures until a particular
Dengue hazard is rectified. It is clear that present enforcement measures are not
effective in construction sites and areas under the jurisdiction of local authorities.
Dr Steven K W Chow
President
Federation of Private Medical Practitioners’ Associations, Malaysia