STRETCHING THE HEALTHCARE DOLLAR ; RATIONING CARE ( 2 )?

I can see from the readership to the last article on rationing in healthcare that it is a very popular issue. There were many who read the article. I thought that I should write a few more ideas that all healthcare planners are grabbling with, be it President Obama, or NHS-UK, or the Australian Health Authorities, or our Ministry of Health.

How do we provide the best of care to all our citizens, with a fix amount of money. Afterall, a country's health resources can never be unlimited. If and when we overspend, that we go into a current accounts deficit ( like what may happen in USA if President Obama is not careful with his healthcare reform ). We have a fix amount of money, but we have to deal with either a growing population, or an aging population, a growing number of disease conditions, with an ever growing number of ways to treat those growing number of disease conditions. And sometimes these growing number of ways of treatment is not aimed at the basic of prolonging life, but is also aim at reducing discomfort ( improving quality of life ). As a healthcare planner, how do you balance all these issues. And also, I forgot, no one must be left out. All citizens ( and someimes non-citizens too, what with health tourism ), must have equitable healthcare, as healthcare is deemed as a basic human right.

How do we juggle all these and come out with a good healthcare system? I suppose to solve the last point ( equitable healthcare ) there must be a public option. That is why, I am very keen that the government must continue to be the main provider of basic healthcare. That will make sure, that everyone ( rich or poor or tourist ) will always be provided with healthcare at almost no cost. Obviously the public option cannot provide all forms of healthcare. There need to be some rationing. In our language, we call it " the healthcare that we must have ". I suppose this will be made up of basic healthcare, first aid, and emergencies and perhps infectious diseases, so that they do not affect the economy of the country. It must also include some palliative medicine and basic care for the terminally ill. If money allows, the public option may also include " healthcare for conditions that is good to have ". I suppose included in this would be investigative techniques to diagnose life threatening disease conditions, treatment and followup of chronic disease conditions, basic cardiac care including bypass-surgery and angioplasty using bare-metal stents. Of course the last option for public health service is " those healthcare that is nice to have ", by which I will include things like oncology treatment that will prolong life by 6-8 months, treatment for exotic conditions, complex angioplasty where CABG is an alternative, and of course all the cosmetic surgeries. As you can see, this strategy is one form of rationing.
However, being a free market economy, those pro-rich, will want better care. I believe that if they are paying out of their own pockets, or through their own health insurance with high premiums, then no one should begrudge them. Private insurance is one way of paying for healthcare, and they are getting more popular. Either the subject buys their own health insurance or many companies are also insuring their employees. Then, the level of care is in some way dictated by the insurance policy that you buy. Invarably, insurance will have their own way of rationing, sometimes rather arbitrarily I must add. We have always advocated that health insurance firms to survive and profit, must enroll more of the healthy who will not claim and less of the sick, who are likely to claim. We also advice them to go on well publicise drives to launch preventive disease programs, especially with lifestyle diseases and even better to reward those who do not claim ( a form of no claim bonus ), so as to encourage a more healthy populace. This is a win-win strategy.
In UK, there is a body called NICE ( National Institute for Health and Clinical Excellence ) who have decided that it is not cost effective to spend more than US$ 45,000 for a one year life extension. They calculated " Quality adjusted life year ", for all conditions and found that anything more than US$ 45K per year is not worthit. This approach has also been heavily criticised.
Looks like rationing healthcare is a rather emotional subject too, especially when your love ones is the subject. Politicians find it very difficult to draw the line. Yet we all know that the budget is finite. If you use up too much for one patient, you are actually depriving someone else, who may be more deserving.
I really do not know what the answer is. It is never nice or humane to deny someone some therapy which may help, but then sometimes we have no choice.
That choice is always a tough one. Rationing healthcare??

STRETCHING THE HEALTHCARE DOLLAR ; PREVENT DIABETES AND OBESITY

We sometimes use a recently coined term to describe these two disease condition which takes up ( in some country ) up to a third of the healthcare dollar. The term is diabesity ( diabetes with obesity ). It is true to say that at the root of cardiovascular disease is diabetes and obesity, maybe it begins with only obesity with contributes to diabetes and then the rest. We know that our fast western culture, allows us a short time to grab a meal ( everything is instant ), and we rely on fast food to fill over tummies before the next appointment or task. Invariably, all the fast foods around us ( McDonald and the like ) contain too much carbo and too much trans-fat, and have often been blame for the rising level of obesity that we see growing around us. Of course, the fact the we are always stressed and on the move with no time to exercise, does not help.
Recently, the reknown British medical journal Lancet, published a study by the US led Diabetes Prevention Progamme Research group. It is an interesting study, which enrolled 3,000 patients who were overweight and followed them for 3 years of the study and further on to another 7 years ( essentially a 10 year study ). Group one consist of patients who were aught to lose 7% of their weight over 3 years, thru' dieting and exercising half hour a day for 5 days a week. The second group received just normal lifestyle changes counselling and the drug metformin, and the third group were the control placebo, who received only life-style counselling. After 3 years, the group with the intensive diet, lowering weight by 7% and who were regularly exercising, had a 58% lower incidence of diabetes, and this was continued for the next 7 years too, if they continued to lose weight. Group 2 had only a 30% reduction in incidence of diabetes, bothe when compared to the placebo group which act as a control. All the impprovements continued out to the 10 years of followup.
I must say that this is probably one of the best way to stretch the healthcare dollar, except that there is a snag! It requires the patient / subject to take good care of his / her own health, and that proves to be a problem, even as we all grumble that we are spending too much on healthcare. You cannot win them all.

STRETCHING THE HEALTHCARE DOLLAR : RATIONING CARE?

In passsing, just let me say that after my last posting, President Obama has declared a state of national emergency in USA resulting from A H1N1 infections in epidemic proportions in USA. I am made to understand that it is a bureaucratic manuever to allow the heathcare providers to bypass certain bureaucratic requirements, in trying to provide urgent heathcare to suspected A H1N1 patients. Nonetheless, it also means that there are more then the usual number of ILI cases in USA for this season.
Anyway, lets come to the issue in this blog. I wanted to discuss the issue of whether we can provide equitable, equivalent healthcare to all? Is that a realistic aim?
I think that we should always strive to provide equitable heathcare for all. Everybody, should have access to healthcare. I am very proud of our present healthcare system because it does provide equitable healthcare. I have always appreciated the fact that should I happen to need medical help, even if I am in the deepest jungle in West Malaysia ( probably a bit more delayed in the jungles of East Malaysia ), I can approach a health clinic who will take care of me, and if necessary, transport me out to a district or general hospital, for almost no cost.
Equivalent healthcare for all is a different matter. I would like to approach standard of care from the point of universally accepted criteria of healthcare like the infant mortality rates, the maternal mortality rates, quality of life expectancy rates, etc. Malaysia, being a free market economy, allows people with different financial background and affordability, to buy themselves different health therapies. In 2008, 45% of patients pay for their healthcare, out of pockets. Health insurance is still not very popular,and accounts for 10-20%, although it is getting more popular. For out of pocket payments you pay for what you wish or can afford. For example, some patients wish for hospitalisation with comfort, and all the frills of therapy, because they can afford it, while others do not mind sharing a double room, and not having the extra scan, if it is not absolutely necessary. Comforts are but one example of how healthcare may not be equivalent.
The more difficult ( ethically speaking ), is the rationing of care to those who cannot afford it or who are paid for by health insurance. A few examples may highlight the point. Rich patients with severe headache may get a CT scan of the brain done much earlier, then those who cannot afford it, although CT scan of the brain is not required as the initial investigation in headaches. That is an easy and safe analogy. How about treatment for terminal cancers with very expensive chemotherapy which may only serve to prolong life for 6-8months. Should we give chemotherapy to patients with terminal cancers to prolong life for 6-8 months. I am sure, some will say yes, because life is precious and must not have a price tag. However, in the real world where healthcare has a cost and especially if you are covered by insurance, the insurance company may assess that prolonging life of a terminally ill cancer patient at the cost of RM 100K per cost may not be worth it and so they will ration. Is that wrong? Must we give equivalent care to all who are sick. It is a nice uthopian idea, but certainly difficlut to implement in the real world. For if we do, we will help some ( probably the minority ) and leave many deserving cases untreated, as there is a physical limit as o how much money you have to spend on healthcare.
I wanted to highlight the fact that at the moment, Malaysia have a good healthcare system, and although healthcare cost is rising, as people are living longer and better. That whatever system we reform to, we must always work towards equitible healthcare for all, but not necesarily equivalent healthcare for all. At some point, there will need to be some rationing. Those things that are " nice to have " may have to be curtail, only for those who can pay out of their own pockets. I think that President Obama will soon find that out too.

THE LATEST ON A H1N1 INFLUENZA 2009.

I have always had an interest since they started to include us ( FPMPAM ) in the advisory committee on this "swine flu " pandemic that swept us in May 2009 ( about 1 month after the Mexican case reports ). Well we have seen that the initial wave seemed to have quietened down. There are still sporadic cases reported but the fatality in Malaysia has remained at 77 ( no new deaths since september 2009 ). The ICU admissions also seemed to have reduced. Thank God for our good fortune.
At the moment, the cases in the southern hemisphere ( now they are in autumn going to summer ) seem to have lessened. The reports from New Zealand suggest that there are still sporadic cases and no deaths. As for the northern hemisphere, the USA has reported more cases of ILI ( influenza like illness ) and also fatality. The CDC estimates that they expect that about half of the US population will be infected at some point or other, with about 1.5 million hospitalisation, and about 30,000-90,000 deaths, working out to a fatality rate of 0.06% ( not as high as the death rate of SARS or bird flu or the dreaded Spanish flu ). So far, they have noted that the ILI seem to infect the younger age group ( 5-15 years ) and most of the deaths are also in the younger age group. A significant number still involved those with co-morbidities. There is also an increase rate of secondary pneumonias. It appears that the A H1N1 now seem to predispose the lower respiratory tract to secondary bacterial infections, like pneumococus, and streptococcus. The US has began to vaccinate their school children, and front liners and found that they do not have enough vaccines, since some of the promised vaccines, are still undergoing testing, suggesting that they may not be as safe as initially touted. It is never a good idea to rush out a poorly tested vaccines.
In the northern hemisphere, as it Europe, there are most reported cases of ILI, almost like the US situation but with less deaths. The UK and France have began to ask their front-liners to be vaccinated. I understand that the front-liners have a choice and some are finding it difficult to choose. There is no increase deaths as compared to a severe seasonal flu.
In summary, after 6 months from the initial Mexico report, the A H1N1 is still very much amongst us and seem to be very active in the northern hemisphere, winter countries. So far there seem to be no sign of any severe mutation, except that the A H1n1 virus now seem to predispose the lower respiratory tract to secondary bacterial infections causing some of the severe pneumonia. The vaccines are being rushed out and some are obviously not ready for widespread use. It looks like personal vigilance and personal hygiene remains the best way to try and prevent infection and contain the infection. Things at the moment, are not as bad as we had feared. But the A H1N1 is still very much alive and kicking.
But always remember, this virus is ever changing and nothing is firm and clear at the moment. we will have to keep monitoring and keeping all of you informed.
Please take care.

INTERESTING IDEA : CALCULATE YOUR HEART AGE

I discovered this simple example of trying to assess your cardiac risk / age. I tested OK. Why dont you try and see if your heart is healthy.

https://www.heartagecalculator.com/HeartHealth/HeartAgeCalculator.aspx?hostID=1503

Thanks for trying. At best it is true. At worse it teaches us about cardiac risk factors.

HEART FAILURE ; THE OLD IS NEW, FISH OILS ( CHEAP AND GOOD )

Heart failure is a clinical situation where the heart is unable to pump out enough blood to sustain an adequate circulation to maintain life. This is usually due to failure of the heart as a muscular pump. Damage to heart muscle, as a result of heart attacks and heart artery blockages, are amongst the most common causes. Heart muscle failure due to infections by viruses, and also toxins like alcohol are also other common causes.
Whatever the causes, once the heart muscle cannot pump, we have diagnose heart failure. Medical science has been working very hard to find ways and means of improving heart muscle function to help heart failure. Reducing circulatory volume is another way. Improving the efficiency of the circulation is yet another approach. Some of these approaches improve quality of life. Others are able to also improve quantity of life. With these approaches, we have drugs like ACE-I, ARBs, beta-blockers, diuretics, vaso-dilators, etc., etc..
It is fair to say that over the last two years, there have been almost no advances in the use of drugs to improve heart failure. In fact over the last two years, interventionist have moved on with the use of special pacemakers to treat certain sub-groups of patients with heart failure. This came across quite loudly at the last annual scientific meeting of the Heart Failure Society of America 2009, when some experts sat in at a special session to represent the results of some studies done earlier and presented in 2008, of an important paper by the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico Heart Failure (GISSI-HF) trial. Dr Mihai Gheorghaide of the North Western University, Feinberg School of Medicine, Chicago, and his colleagues, rehashed the results of GISSI-HF. This was a 4 year followup study by the Italian GISSI group. They studied 7,00 patients with class 2-4 heart failure who were on standard, maximal heart failure therapy ( including beta-blockers, ACE-I, vasodilators, diuretics and spironolactone ). One arm was given placebo and the other arm was given omega-3 PUFA ( fish oils )1 gm daily. The authors showed that the patients given the omega-3 PUFA ( fish oils ) had a 9% reduction in all cause mortality and an 8% reduction in the composite endpoint of cardiovascular mortality and cardiovascular hospitalisation. It was important to note that these improvements came on top of maximal standard heart failure therapy. This is very significant.
I am rather impressed with the findings, as fish oils is much cheaper then the pharmacotherapy and is relatively free of side effects ( baring the mercury in some of the fish oil tablets ). Fish is something that all of us ingest regularly in varying amounts.
On closer inspection, it appears that fish oils have profound CVS effects. It was found to reduce heart rates, vasodilates, anti-apototic, neurohormonal modulation, reduce O2 consumption, anti-fibrosis, anti-arrhythmic, amongst other effects. Whether all of these are clinically significant is left to be proven. But what is ceratin is that less people die from arrhythmic deaths and all cause mortality, when they are on fish oils.
It is good to know, every now and then that something cheap and natural, could be good and effective. There is still an increase role of fish oils and omega-3 polyunsaturated fatty acids. I certainly think that fish oils should be used in management of heart failure, in order to improve outcomes.

UNPROTECTED LEFT MAIN STEM CAD MANAGEMENT : SURGERY OR PCI?

When I was in medical school, CAD was treated by medical therapy, and any attempt at intervening or instrumenting the coronary artery was deem heresy and punishable as professional negligience. Well sometime in 1965, while trying to inject dye into the aortic root in a patient with aortic valve disease, the catheter that Dr Mason Sones placed in the root of the aorta accidentally fell into the right coronary artery and besides an aortogram, he also did a right coronary angiogram. He watched in horror as the patient's heart rate fall and BP fall, and then slowly stabilised. The patient survived the RCA angiogram. Dr Sones then realised that you could safely take angiogram pictures of coronary arteries with selective coronary artery cannulation. Of course, Dr sones was working in the Cleveland Clinic and his surgical colleague there was pioneering a procedure called coronary artery bypass graft surgery, where selective coronary angiogram would prove invaluable both for diagnosis and also to assist the planning of CABG. Of course Dr Sones colleague was the famous pioneer cardiac surgeon called Dr Rene Favaloro of Argentina.
Then we fast forward till September 15th 1977, when Dr A Greuntzig successfully dilated an LAD stenosis in a Swiss dentist. This further proved that the goal post has moved again. That it was safe ( with all the appropriate training and precautions ) to safely work within coronary arteries. This began the journey of "percutaneous coronary interventions ". One by one, the goal post moved. Initially, Dr Greuntzig only advocated angioplasty ( as the new procedure was initially called ) for single lesion CAD. Then with better equipment and devices we began to do two vessels and then three vessels disease, much to the chargrin of our cardiac surgeons. The goal post was moving and still is. Coronary interventionist, ably led by the Korean Dr SJ Park and the French, Dr Jean Marco and Fajadet, began to take on left main stem disease, initially in the protected left main ( left main disease with a good functioning bypass graft ), and later in unprotected left main stem disease ( isolated ) and gradually to left main stem in the context of other vessel disease. Left main stem disease post a significan challenge because of the severe myocardium at risk. Surfice to say that in any given individual, the left main stem controls the blood supply to the whole of the left ventricle and in many cases even some myocardium of the right ventricle. Therefore, should there be any mishaps, cardiac death was inevitable. In other words, the margin for error was minimal. When the work was being done by Dr Park and Dr Fajadet, there was much surgical protest. They felt that we were killing our patients and that surgery ( CABG ) was the only option in left main stem ( LMS ) disease. However, Dr Park. Fajadet and Marco, was able to show that they they could do LMS PCI safely and with good short and medium term results apart from repeat revascularisation from restenosis. Then came along the Drug Eluting Stents that would reduced restenosis. With that, large clinical trials were done to compare CABG and PCI in left main stem disease. Sme of these trails were done with the cooperation of cardiac surgeons who also wanted to know how their technique compared. The results with PCI proved almost comparable. The goal post is moving again.
This blog is written partly in response to the paper in the Oct 20th issue of the Journal of the American College of Cardiology, by a group of expert interventionist, calling for a review of the PCI guidelines in America. They argued that there was enough evidence now accumulated to justify making LMS PCI a class 2 a or class 2 b indication. This paper's lead author is Dr David Kandzari of Scripps Clinic, La Jolla California.
A word about the guidelines.
A class 3 indication for a treatment procedure means that the treatment procedure have not been shown to be of benefit and may be of some harm. A Class 2 indication means that the treatment procedure maybe of benefit. Class 2 b means that this statement is attested to be the opinion of kep opinion leaders and class 2 a means that there is good clinical evidence, besides that of key opinion leaders. Of course a class 1 indication means that that treatment method is obviously of benefit for that condition and that that should be the treatment of choice.
At the moment, the USA guidelines has put LMS PCI as a class 3 indications, and that it should be undertaken only if the patient is not fit for CABG or refuses CABG. However across the big pond, the European Cardiac Society had LMS PCI as a class 2b indication. Now Dr Kandzari and colleagues felt that it is time ( in the face of the body of evidence ) to review the USA guidelines ( call it shift the goal post ) too include LMS PCI as a class 2 b indication, and for those with just isolated LMS disease without concomitant other vessel disease, a class 2a indication. Afterall, we have recently seen the published results of the all important SYNTAX trial, the ISAR Left Main trial, and the MAIN COMPARE trial. There is another large Asian trial, the COMBAT, whose results is yet to be published.
In my opinion the call by Dr Kandzari and colleagues is not unreasonable. As usual, there are no perfect guidelines. Guidelines are only as good as those who use them. The practitioner / interventionist, is very important. LMS PCI is a very complex and delicate angioplasty technigue and there are many judgement calls along the way, to keep out of trouble. As we said initially, the margin for error is small, and I have seen beautifully done LMS PCI that turned sour within hours in the ward. A certain degree of competence is required. I have no problem with Dr SJ Park, Dr Fajadet and Marco do LMS PCI. I am just not sure if the avaerage Malaysian interventionist can. Therein lies the danger. I attend many live demo and PCI courses and have seen many LMS PCI cases presented. I sometimes shatter at the cases some junior interventionist take on. Afterall, one must not forget that there are some interventionist out there who would dilate for bread. And I am very worried for that. Anyway, I do not wish to be judge and jury. I am writing to highlight that the Oct 20th JACC call, means that the goal post may be moving again.
Soon there will be much less indication for CABG. What shall the cardiac surgeons do? In USA trhe number of doctors undergoing cardiac surgical training has dropped. The goal post is indeed moving and the cardiac scene is changing.

IN CONTROL OF DIABETES, IS LOWER Hb A1c BETTER : UPDATES

The European Association for the Study of Diabetes ( EASD ) at their Annual Scientific meeting in Vienna this October debated the HbA1c target for good control of diabetes. The scientific committee organised a debate to a packed audience of the "Lower HbA1c is better ". They took note of the criteria set by the ESAD and ADA ( American Diabetes Association ) of HbA1c level of <7%, as opposed to the American Association of Clinical Endocrinologist ( AACE ) and the Iternational Diabetes Federation ( IDF ) which set the level of <6.5%. Is the EASD/ADA being too conservative or is the AACE/IDF being too aggressive. Where does the evidence point too? I had infact talked about this in a posting about a year ago. This is an update.
Unfortunately, a latest review of the literature is still confusing. The landmark UKPDS study ( we have relied on this for a longtime ) seem to point to the fact the lower is better. However, more recent studies using never agents seemed to point to the fact the sometimes lower can cause harm, as in the ACCORD ( Action to control CVS risk in diabetes ), where lower HbA1c levels seemed to be associated with higher mortality. This fact in fact cause the study to be prematurely terminated. Other studies with the same objective, including the VADT ( Veteran Affairs Diabetes Trial ), the ADVANCE ( Action in Diabetes and vascular disease ) seemed also not to be decisive. Some studies seem to suggest that there was an improvement in urine albuminuria ( ADVANCE ) with lower HbA1c without an improvement in mortality.
Basically, we are all still very confusing.
I have been keeping a lookout for any progress, but I do take a few important message from the lack of concensus. I take it there the reasons for lowering mortality is not just from lowering HbA1c alone. It may have to be taken together with lowering hypertension to target and also the serum cholesterol, afterall diabetics die from vascular disease and serum cholesterol and hypertension may impact on the outcome. I also take note that diabetologist is beginning to note that gluco-centrism alone is not complete. Glucose level control must be seen in the light of outcomes. Therapy of diabetics must be patient-centric.
All in all, looking at all the data, I still follow the principle that in the elderly diabetics, fair control ( dont be so aggressive ) is reasonable. In this group, hypoglycemia from aggressive gluco-centrism may be bad for the patient. In the adults with established end-organ damage a conservative control, as proposed by the EASD/ADA may be reasonable. However in the younger adults or in adults with no evidence of target end-organ damage ( those with just diabetes mellitus ), then aggressive control ( in my opinion ) is justified. I will push fo HbA1c of <6.5% or even <6% especially in those who are obese and who are educated and compliant.
Looks like the issue of "lower HbA1c is better " cannot be answered in one word. We will more then ever here, to individualised patient care. The act of medicine is still very important.

DES ( DRUG ELUTING STENT ) FOR ERECTILE DYSFUNCTION ( ED )

Towards the conclusion of the recently concluded TCT 2009 at San Francisco, Dr Jason H Rogers ( UC Davis Medical Center, Sacramento ) rose up to announce the launch and recruitment of patients for a new study called the ZEN trial. This is a trail to show that implanting a zotarolimus eluting stent in the internal pudendal artery, could help patients with erectile dysfunction. What will we think of next. This study will be sponsored by Metronic International, the maker of the zotarolimus eluding stent. In fact the imvestigators had done an earlier pilot study, the PANPI ( Pelvic angiography in non-responders to PD-5 inhibitors ) study.
What was revealed in PANPI was very interesting 70 % of patients with CAD suffers from ED ( erectile dysfunction ). When they did angiography on their sample patients with ED, there was a 100% correlation with CAD ( meaning that all those who had arterial blockage of their internal pudendal artery also had CAD ). And ED predates CAD by about 36 months. It would appear that the authors concluded that ED that does not respond to phosphodiesterase-5 inhibitors ( drugs like viagra ) are liely to be due to arteriosclerosis of their internal pudendal artery.
A point of clarification. The penis ( without going into a lot of jargon ) is supplied by the left and right internal pudendal arteries, which are branches of the left and right internal iliac arteries. Just as cholesterol can accumulate in the walls of heart arteries ( coronary arteries ), it can also accumulate in the internal pudendal arteries. Apparently the risk factors of pudendal artery arteriosclerosis is the same as that of coronary arteries. Looks like taking care of your cardiac health is also taking care of your sexual health. Maybe making this fact known will help to cut down cigarette smoking.
What was also interesting from the PANPI study was that the authors noted that when patients were told that they have both CAD and arteriosclerosis of their internal pudendal arteries, they wanted to have stenting done to help their ED first. Looks like for some, sex is more important than life.
Perhaps the other lesson that we should learn is that, cardiologist and family physicians should ask more often about sexual habits in an attempt to diagnose CAD, since they have a 100% correlation especially in those with phospho diesterase-5 inhibitors resisitance.

SUDDEN CARDIAC DEATH ; PREVENTABLE CAUSES

At the last blog, I talked about the most common type of sudden cardiac death, those that we could not predict and so often cannot help. It is also important to note that there are some sudden cardiac death causes that can be treated if detected early. Some of them are due to heart muscle abnormalities like cardiomyopathies, some are due to electrical instability of the heart, and of course those that happen in patients with severe heart failure.
Every now and then we hear of athletes, lately some footballers who collapsed while playing professional soccer and also some American footballers. In those who had autopsy done, many of these sportsmen had hypertrophic cardiomyopathy as their cardiac disease causing sudden cardiac death. Hypertrophic cardiomyopathy is a condition whereby the heart muscle have become abnormally thickened, especially in the area around the outlet of the left ventricle. This will cause the blood flow out of the heart to be compromised, resulting in failure of the whole cardiovascular circulation and collapse. These patients are also associated with a higher possibility of electrical instability of the heart. Its so sad, because a good cardiac assessement before they are allowed to play would have detected the ondition, which is treatable. It is known in USA that some footballers are only assessed by GPs before they are signed on s professionals.
In the cardiac electrical instability group three varieties should be mentioned obviously because they are the most common of these uncommon causes. Some children ( sometimes they live to adulthood ) are grown with some abnormal conduction system, which makes the heart unstable and susceptible to VF. They are afew of these arrhythmias which the patients are born with. Some technical names include the "the long QT syndrome " and the "Brugada syndrome ". The first ( long QT syndrome ), maybe congenital, but can also be induced by drugs and also metabolic upsets. The second ( Brugada Syndrome ) is important to us because although it was first discovered in Spain, many sudden cardiac deaths among foreign workers in Singapore and the Philippines, may be due to the Brugada syndrome. There are obvious ECG signs and can be spotted. In that case, it can be treated and so sudden cardiac death avoided. We hav also seen sudden cardiac death in people who went on extreme fasting, which we think is dued to severe electrolyte imbalance and a hidden long QT syndrome. Most of these arrhythmic sudden cardiac deaths sometimes require them to survive the first episode, so that we can then treat them. Some of these patients with electrical instability can be treated with drugs and sometimes with implantable defibrilators.
The last group of people who collapse and die suddenly are patients with poor heart function and heart failure. It is now well known that the most common cause of death in patients with severe heart failure ( more specifically systolic heart failure ) is VF ( ventricular fibrillation ). When they are in mild or moderate heart failure, treatment of heart failure with drugs will greatly improve their quality of life, and some drugs would also improve their quantity of life ( not all drugs do this ). However, it is becoming more and more abvious to us that very often, our heart failure patients just collapse and die ( suden cardiac death ). In fact, the Americans are advocating that patients with severe heart pump failure should also get an automatic implantable cardiac defibrillator ( AICD ). This may prolong the quantity of life. This is however a very expensive therapy and is also slightly invasive and so not gain much popularity.
The automatic implantable cardiac defibrillator ( AICD ) is a defibrillator that is now condensed into a small implantable unit. It can be implanted through a small chest incision and is considered a relatively minor surgical procedure. It can automatically detect the VF when it comes on and then delivers a programmed shock that will convert the heart rhythm back to normal. It works like the external defibrillator that we and the St John Ambulance are advocating to be placed in popular public places for citizens to help defibrillate anyone who may suffer a sudden cardiac arrest in public. Because of the many functions that the AICD must do ( so that it does not shock wrongly ) the battery does not last so long and may have to be changed as often as 3-5 years, depending on how many times it is called to function.
I suppose the message that I wish to put across is that, there are many unfortunate people who may collapse in public, that we cannot help. But it is important to know that there are also some ( maybe the minority ) that we can, and we should. Regular checkups who those at risk of CAD would be a very good strategy to try and prevent the unfortunate sudden cardiac death.

SUDDEN CARDIAC DEATH ; WHAT IS IT? HOW TO AVOID IT?

This last two weeks, I have received news of two friends ( in their 50-60yrs ) who have just suddenly collapsed for no obvious reason and died. One was found in a bathroom dead. He was apparent hale and hearty ( in fact a health freak ), and the other an active bus-driver, with no known previous disease.
Sudden collapses resulting in death within 24 hours of collapse, is term sudden cardiac death ( of course I am excluding foul play or criminal assault ). 90-95% of sudden cardiac death is due to undetected coronary artery disease. The terminal event at the fatal moment is invariably primary ventricular fibrillation ( the heart just suddenly beating fast and so irregular that it cannot pump forcefully, for no apparent reason ). This primary VF ( short for ventricular fibrillation ) may or may not be due to a heart attack. Sometimes the heart just fibrillates without a heart attack.
Of course, of concern to us ( both from the point of understanding the disease and also from the point of prevention ) is why it happens. Much research has been done in this area. In fact, one of the early pioneer workers in this area of cardiology was one of our own Malaysian ( I remember ) called Dr Regius de Silva, who was working in USA, who was studying the effects of severe fear resulting in VF. He discovered that certain forms of culture bound behaviours like voodoo, works through this mechanism of VF. Severe fears induced, resulting in VF and sudden death. But sad to say, the research, till this day, did not lead to any meaningful application and we are still waiting to understand what triggers VF? Is it just bad luck? Is it severe stress at that point in time ( like in voodoo ), or a minor plague rupture causing an electrical heart attack, not necessarily with a physical heart attack? We just do not know.
Of course the next question must be, how then do we prevent this sad event from happening. A fatality at the prime of their life, with a family to support is a very sad, catastrophic event.
We always evocate that all males above 40 yrs and all females above 50 yrs, should go for a routine medical checkup, to make sure that they do not have coronary artery disease. 70% of coronary artery disease is silent, and so many just do not know. Of course, once they know then the cardiologist takes over and they will be under scrutiny and therapy will be given, to prevent VF. There are some drugs that have been shown to prevent sudden cardiac death, like beta blockers ( especially the older generation ones ) and fish oils. One of the benefits of fish oil that is well established is the prevention of sudden cardiac death.
Of course the third line of approach that we have suggested to the government and am waiting for implementation is the stationing of automated external cardiac defibrillators ( AECD ) in public places, so that should someone collapse next to me, I get then use the defibrillator to shock him back to life. Afterall, the treatment of VF is to defibrillate within 4 mins of the collapse, and 95% will survive. However, stationing AECD in public places does carry two other responsiubilities. Firstly the public or some of the public must be trained to use it. In this regards, I must appreciate the work of the St John Ambulance, to go around conducting basic life support classes for the public, so teach them the bacics of resuscitation and also how to use the AECD. I have been with them to lecture on the basics of VF and have seen their largely unapprecaited efforts. I think they are often aided by members of the Federation of Private Medical Practitioners Association of Malaysia, who have a program called the CARE program, to help teach resuscitation to the public. Secondly, to allow public to help public, the government may have to pass through Parliament, an Act called the " Good Samaritan Act ", so that no one who goes out of his way to help another, can be caught up in legal entanglements. No body wishes to be suit, when he is trying to help resuscitate and defibrillate? Such an Act will protect those who wish to help. Alas, although we have suggested to the Ministry of Health, it is yet to come.
For the moment, we are left to ourselves. Please all males above 40yrs and all females above 50yrs, go for a medical checkup. And by the way, I do not mean a MSCT scan ( it is largely useless for this purpose and the radiation harm, may outweigh their so called benefit ). Just a simple clinic consult and a stress ECG usually surfices. Eat plenty of fishes if you wish and take care of yourselves.
Sudden Cardiac Death is a major catastrophe and we must do our best to avoid it if possible. It is obvious that we have much more to learn, especially the triggers for sudden cardiac death.

IN APPRECIATION ; NOBEL PRIZE FOR MEDICINE 2009

On monday 5th Oct 2009, the Nobel assembly of the Swedish Karolinksi Institute, announced the recipients of this years nobel prize for medicine. The prize goes to Dr Elizabeth Blackburn of University of California at San Francisco, Dr Carol Greider of John Hopkin's and Dr Jack Szostak of Harvard Medical School. The three will share the prize money. I watch the Nobel prize from two points of view. First, with some envy and wonder when we will see a Malaysian win a Nobel Prize ( even if it is to share ), and secondly, to see how the Swedish Karolinski Institute see what is important in medical advance.
This year, the Swedish Institute chose to emphasize cellular growth, the good and the bad. Too little cell growth will mean aging as cells are not replaced when they aged and die. Too much cell growth ( or growth out of control ) would mean cancers and their growth. Cancer afterall is uncontrolled cell growth. It is not exactly the opposite of aging, although they control system is about the same. The three Nobel Prize winners were working on the control mechanism for cellular growth. From what I read of their work, it appears that they have increase our understanding of how cells multiply and duplicate their genetic code. These of course all occurs at the chromosomal level.
I suppose all of us understand that the 46 chromosomes in our cells carry our genetic material, that says who we are. Their dependable duplication and replication of the chromosomes allow cells to divide and make exact copies. As we age, the chromosomes shorten, and the end of the chromosome is a segment labeled "telomeres ". The enzyme that controls the splitting off of the telomeres is called "telomerase". It would appear that the three Nobel Prize winners are masters in the understanding of the work of the telomerase enzyme.
I can understand that if the telomerase enzymes were too active, cells will age very quickly. The reverse is also troublesome. That if the telomerase enzymes are inactivated, then cells will just keep multiplying and promoted cancer formation. The cells will have no programmed aging. I can see the obvious application. Cancer has become a real medical problem, probably the commonest cause of death in the western world, now that cardiovascular death is coming under control. A very simple understanding would be that if we know more of the telomerase enzymes we can produce them in the laboratory and be able to cause cells to die, and so limiting cancers. Of course this is too simple, as that will almost certainly cause prematured aging. ( No wonder I did not win the Nobel Prize ). It gives us a way to approach the therapy for cancers.
Be that as it may, congratulations to Drs Blackburn, Greider, and Szostak. They have help us understand our body better and maybe their work will help us end the dreaded Cancer.

MY PERSONAL EXPERIENCE ; TOTAL HIP REPLACEMENT

One day about 5 years ago, while playing golf, I experienced severe left hip pain. I immediately abandoned the game and returned to hospital, where an X- ray showed that I had developed severe osteoarthritis probably from avascular necrosis of the head of my left femur. Initially the pain was easily bearable. I decided to bear with the pain and continue my work, while waiting for the technology to improve and also planning to have the prosthesis ( it is essentially spare parts replacement ) to outlast me. I suspected that the left head of femur avascular necrosis is probably the result of radiation from my wrk as an interventional cardiologist. I remember in the good old days of 1990s the interventional devices and accessories were bulky ( nothing compared to present day ) and procedures were long, as we struggled sometimes for hours doing three vessel diseases. Flouo times were often in the hours. The hip is in that position where there is a slit in our lead apron, and some radiation may have escaped in.
Anyway, about the beginning of this year, the pain was getting unbearable and I had difficulty performing my duties in my teaching programs and patientcare. I decided that it was time to get my left hip replaced. The titanium metal-metal hip prosthesis should last me 15-20 years at least and that should bring me to 73-78yrs old ( God willing ). I have always been in consultation and supervision of Dr Teo Wee Sin, consultant orthopedic surgeon at Sunway Medical Center. In late August, we planned to have the surgery on the 30th Sept 2009 ( his operations day in Sunway ). Dr Teo chose Dr Tan Yit, as the anaethesist. Dr Teo is my classmate. ( Weare both from MU, the medical class of 1970-75 ).
I checked my self into Sunway Medical Center on the afternoon of the 29th Sept 2009, having done my pre-admission procedure, especially insurance clearance on the 23rd Sept 2009. The surgery on the 30th Sept went well. It was practically painless. The night before, I had some sedation. On the morning of, I had skin preparations at about 6.30am and was wheeled into OT ( operations theatre ) at about 7.45am. I felt a smal needle prick in my left hand and thereafter, I slept through the whole surgery and was awoken in CCU at about 2pm, having been brought back from OT at about 11am. Well of course I cannot say that it was a pleasant experience ( afterall it is major surgery ), but it is fair to say that it was not too unpleasant. I had thoughts of pains and scary experiences pre-op. The whole surgery was done under Epidural anaesthesia with heavy sedation. I still had an epidural cathether when I returned to CCU and the wards. From the op onwards, it was just boredom and inconveniece as I recover. I could not get out of bed till third post-op day, which means that I could not wash up, pass motion ( not use to doing on bedpan ), or walk around. It was just boring. On the second post-op day, I had my first physio ( passive exercises in bed ). On the third post-op day, the epidural catheter and the drains came off, and also the urinary cathether. That evening, the physio allowed me to get out of bed to walk with a walking frame. I was also taught how to get up and down the staircase with a walking clutch. ( my bedoom at home was upstairs ). I was discharged on the fourth post-op day. It took me 2 hours to await insurance clearance before I was allowed to leave the hospital. This was despite my having obtained insurance clearance before my surgey and also having my insurance agent ( a personal friend ) involved tp make sure things are according to insurance procedures.
Throughout this whole adventure, I learned a few lessons to share with you all :-
1. That anaesthesia and orthopedic surgery have come along way, and you could have major surgery done under regional anaesthesia, with minimal pain. The team was good
2. That the biggest challenge post-op was lack of freedom, to do the things that you wish. All your usual routines are upset, and you have to accomodate and get use to new way of doing things. Staring at the ceiling, repeatedly being interrupted with nursing procedures, watching the TV showing reruns, is a real challenge. Visitors break the monotony every now and then.
3. Insurance can be a pain. Up till now, I have not seen my hospital bill. Taking hours to clear me, despite all the pre-admission documentations, is not reasonable. With the attending physician's statement preop, and with his postop report, the bills should have no problem being cleared. My advice to all of you, is to have a good friendly relationship with your agent, who can help much to expedite the whole billing process. Without her help, I do not know who long more it would have taken. The medical insurance claims procedure surely needs a revamp.

I need much more physio before I can walk normally and know how successful the operation have been. I hope that the rest of the recovery will be as smooth, as the operations.
Well at least now you know why I did not blog on Friday.

A WORD OF CAUTION ON THE USE OF VACCINES. PUBLISHED IN THE SUN AND ALL MAJOR NEWSPAPERS ON 1st OCT 2009

Use vaccines with caution

By: (Thu, 01 Oct 2009)

RECENTLY, there has been some urgency by the Health Ministry to buy vaccines for the influenza A H1N1 pandemic, in view of the threat of a second phase.

While this move is with good intentions, it may be wise for the ministry to proceed with caution as this Influenza A H1N1 vaccine is not entirely harmless.

The treatment must not be worse than the disease itself. If the flu virus A H1N1 remains as such, is there a need to mass vaccinate? Is it not better to maintain good health and personal hygiene.

Furthermore, vaccines prepared in a hurry may not have been well tested to make sure that it is safe enough. There is also the issue of the target virus, which at the moment is still not obvious, so that at the end of the day, the vaccines may not protect against the offending virus and may in fact give a false sense of security.

So far, there are more than 20 reported cases of resistance to H1N1 vaccines and this number is rising, especially in Australia, Denmark, Canada, United States, China and even across our shores in Singapore.

Most of the cases have occurred in people who were given the drug either to prevent infection after exposure to the virus or as treatment.

There are also many documented accounts of side effects from flu vaccines. In 1976, Washington rushed in a mass immunisation programme against a similar swine flu outbreak that was confined to a military base.

Several hundred cases of a rare, lethal, paralysing neurological disease called Guillain-Barré syndrome (GBS) were reported afterwards from previous experience of mass vaccination as well as the Gulf War Syndrome.

Although the H1N1 vaccine now close to completion is different from the one used in 1976, the British Government’s Health Protection Agency said the earlier incident nevertheless highlighted a possible area of concern.

Similarly with the vaccine for cervical cancer. Though initial results with this vaccine are impressive in the reduction of pre-cancerous cervical lesions after three years of clinical trial, its long-term side effects are yet unknown. One has to only Google HPV vaccine deaths to know of the short-term risks present with mass immunisation programmes.

At the same time, vaccinating 13-year-olds in the prevention of a sexually transmitted disease has its social implications, not excluding promiscuity and a false sense of security, therefore indulging in more sex?

Is there a need to vaccinate 13-year-olds against pre-cervical cancer? Is it not better to improve cancer awareness and educate the females in the risk group to undergo the time-tried pap smear in the prevention of cancer of the cervix.

In any case, at the end of the day, it should the patient’s choice of how they wish to be treated or protected but as physicians, we must always remember, first do no harm.

Dr Ng Swee Choon
Medical Affairs Committee
Federation of Private Medical
Practitioners Associations of Malaysia