DIET, WEIGHT LOSS AND HYPERTENSION

It looks like the doctors at Duke University, Durham must be very keen on diet, weight loss and hypertension. They have two papers published in the Archives of Internal Medicine this month on life style modification and blood pressure lowering. Dr James Blumenthal and colleagues published the followup on ENCORE in the Jan 5th issue of the Arch., and Dr William Yancy and colleagues published their study on carb. restriction with weight loss as compared with low fat diet and orlistat and blood pressure in the 25th January issue of the Archives of Internal medicine.
Of course both the studies point to the fact that if one is prepared to go on the DASH diet ( a diet low in salt and rich in greens and fruits ), with weight loss, the BP will come down significantly and if one is prepared to go on a low carb. diet, with weight loss the BP will come down. The slight surprise is that if one goes on a low fat diet, and use of orlistat ( a fat reducing, weight reducing agent by Roche ), your weight will come down, but the BP does not come down as much as those on low carb. diet and weight loss.
I suppose the message that I got was that diet and weight loss lowers BP and should always be advocated by physicians as a important component in our fight against hypertension. In my opinion, drugs must always be used with life style modification and, never alone. Sometimes in pre-hypertension, life style modification with weight loss ( especially in those obesed ) is enough to control BP. I do this all the time in my clinic. It is indeed very gratifying to see an obesed patient with pre-hypertension, lose weight and lose high BP. He feels happier and fitter and you feel that you have help someone in a very basic way. Maybe most of us should start a life-style counselling service and provide this service as a means to tackle this problem of hypertension.
Incidentally, this weekend ( I am told ), is the Annual Scientific meeting of the Malaysian Society of Hypertension. Lets see what new things come out of this meeting.
Remmember, lose your weight and lose your hypertension.

ASIA PCR SINGLIVE 2010

I spend the last few days of last week in Singapore at the Asia PCR Singlive 2010. SingLive began in the early 90s ( wow, I have been invited there yearly for the last 15 years ) as the Singapore GH Live demo congress. Initially it was held in Singapore General hospital-Outram road ( I remember staying at Apollo hotel ). Then it was a Singapore Heart Center show.
Similarly, the EuroPCR began as a live demo course in Interventional cardiology, organised by the cardiologist at Clinic Pasteur Toulouse, France. It grew, and grew and the Toulouse cardiologist worked along with the Paris cardiologist, and soon the European cardiologist, to form EuroPCR, held every year in May. This EuroPCR meeting is probably the second largest Live demo course in Interventional cardiology in the worl ( after the TCT-Washington ).
Now, the Europeans have agreed to joint host the SingLive course in Singapore in March. They called it the AsiaPCR SingLive. This allowed the Singaporeans to tap into the resources of EuroPCR, including their branding and also their very experienced teaching faculty.
I made a few observations at this year's meeting. I think, the attendance is down abit and also sponsorship money, so the meeting is on a less grand scale. There is no gala night ( not that we miss it ), and also less " big guns " walking around. Even the operators doing cases are mainly local ( Singapore Heart Center ) cardiologist ( and they do have quite a strong team there ),with a springling of foreigners, like Koreans and Japanese. There were the usual oversease transmission from Australia ( Melbourne ) and India. I particularly like the session conducted by Dr Jean Fajadet ( Toulouse ) on Friday afternoon, when he tried to be very practical to teach ( almost step by step )the way of doing bifurcation stenting, inviting alot of discussions and explanation.
Throughout the whole meeting ( from Thursday to Saturday ), when I sat through the meetings and seeing what's going on, I kept wondering ( as usual ) how do live demo courses end. Having sat through, literally, about 50 such courses in my career, I have seen the importance of it, at the beginning and then how it seem to just flow on, almost aimlessly. Do live demo courses ever end? When Andreas Greuntzig first started doing angioplasties, there were so many new things to talk about and teach, to all of us, who did even know the basics then. This was back in the 70s and 80s. There were then so many new devices ( many never made it to primetime ), and we had to know, which to use and when and which was good for the patient and which were harmful ( like the lasers ), to the patient. There was then a need for discussions and teaching ( live demos ), to share experience. Junior as I was, in the 80s and early 90s, we did get a bit involved. Now in 2010, when there are literally hundreds of thousands of interventionist worldwide, and when the procedure itself have matured, with no new breakthrough devices to discuss, is there still a need for a routine annual live demo course, and I am not refering to the AsiaPCR SingLive, in particular, but to live demo courses in general. I am concern because, all these money spend at all these courses by the sponsoring companies, must evetually go back to the company's A&P budget and to the cost of product.
Well, I know the question and have asked it many times, at the proper forum, but unfortunately, I do not have the answers.
We are still demonstrating. But is it a new technique, a new device, a new discovery to benefit our patients, or just demonstrating ourselves. This we must ask all the time, and come out with our own answers to settle our own conscience.
I did send a congratulations message to Prof Koh Tian Hai, who must have worked his socks out, to pull off this AsiaPCR Singlive demo. Syabas to Prof Koh and his team.

CHEST PAINS IN THE RISK GROUP-GENDER DIFFERENCES IN PRESENTATION AT PRIMARY CARE

We have always struggled with chest pains in females in the risk groups because they are often atypical. We have always attributed it to the fact that females are smaller in size and so their arteries are also smaller. This maybe true to a certain extend. Coronary flow restriction becomes more obvious by lesser narrowing and by fixed ( atherosclerotic plaque ) narrowing and also by some degree of coronary spasm, on top of the fixed narrowing.
I happen to browse over in medscape, an article published in the Dec 14th 2009, online edition of BMC family practice ( BioMed Central family practice , an article published on-line by a German team, Dr Haassenritter et al from University of Marsburg, a study that they carried out on coronary chest presentation, amongst German females presented to 74 pprimary care clinics. A total of 1212 patients were studied.
The authors found that there seemed not much difference in presentation between the sexes, except that females tend to have more associated psychogenic disorders, and that their chest pains seem to last longer. Males with cardiogenic chest pains tend to have pains which last about 30 mins or less then 1 hour, whereas females tend to have chest pains which last 1 - 12 hours typically. Females tend to have chest pains brought on by emotional upsets, more often. Also, females are less often smokers, although I suspect that this may change, with the increasing number of females who take up smoking in this country.
I suppose, these findings go well with our initial understanding that females with smaller arteries and a higher spasm component, tend to have longer lasting chest pains and emotion plays a greater part.
I must say that this is also what I notice here. Females still have exertional angina, but there is usually a higher emotional component, and they tended to last longer, although for me, 12 hours is way too long. I have seen coronary angiograms of females with chest pains where the artery wall have minimal atherosclerosis, but had a very high incidence of spasm, documented angiographically. In fact, one patient had total occlusion of her right coronary artery due to spasm, which was relieved by IV nitroglycerin.
There are gender differences and we need to be more aware. The fact the more females are having diabetes, and their presentation can be even less typical.

THE CINOIDS, THE PERFECT ANALGESIC?

Chronic arthritis is a very common problem, that affects many and many more of us as we age. Osteoarthritis is almost synonymous with aging. Of course, some are affected earlier, while others have more severe forms of arthritis, including rheumatoid arthritis. When we suffer all these pains, we wish we had a perfect analgesic.
From centuries ago, we found aspirin, which help many and was good while it lasted. But alas, it had the habit of causing gastric upsets, gastritis and worse still, gastric bleeding. Some of these side effects were dose related. If only we had something stronger? But aspirin was cardiac friendly. It protects the heart against heart attacks. From aspirin, we moved on to the non-steroidal anti-inflammatory drugs ( commonly called NSAID ). Well these drugs were a significant improvement on aspirin. They were more potent. But they too suffered from gastro-toxicity and they may also be cardiac unfriendly, being associated with a higher then usual incidence of heart attacks. Mainly because of the gastrotoxicity of aspirin and the NSAIDs, researchers were looking for potent analgesics without gastrotoxicity and if possible, cardiac friendly.
After much research, they found that drugs which inhibited the COX2 receptors may do some of these. The COX2 came on the scene. They were good analgesics, with only minimal gastrotoxicity ( so were well tolerated ), but the first agent approved ( rofecoxib ) when used widely, was found to be associated with an increase incidence of heart attacks. we now know that COX2 inhibitors were good for analgesia, well tolerated, but may affect your heart, some more then others.
The search continues. Over the weekend, I came across this paper describing a new group of analgesics codenamed the " CINODS ". These are a group of agents derived from the NSAIDs which were nitic oxide releasing ( NO derivatives of NSAIDs ). They were suppose to have the analgesic effects of NSAID, without gastric-toxicity, and lowers blood pressure, thereby lowering cardiac side effects. The first paper was published in the American Journal of Cardiology by Dr White WB et al. The paper is entitled, "Effects of the cyclooxygenase inhibiting nitric oxide donator naproxcinod versus naproxen on systemic blood pressure in patients with osteoarthritis. Am J Cardiol. 2009;104:840-845".This is an interesting groud breaking paper on a new class of drugs which could help patients with chronic pains. Of course we have heard much about the Nobel prize winning molecule, nitric oxide. How it helps the body do almost all good things since it have anti-oxidant properties. Looks like in this context, the analgesic part is the NSAID and the gastro, and cardiacfriendly part is the NO derivative.
I look forward to reading more about the CINODS. I just thought that I should introduce this new group of drugs to you all. If it works out as it is touted in this article, then perhaps we are nearer the perfect analgesic. Only time can tell.

PUBLIC FORUM IN PENANG ON "DANGERS OF SELF MEDICATION"

On Sunday morning, I was in Penang to speak at a public forum on " The Dangers of Self Medication ". I was on of 5 speakers. This event was organised by the Private Medical Practitioners Society of Penang, CAP and also the Malaysian Pharmaceutical society. Interesting meeting. I thought that I will share the lecture with you in the form of the slides. Looks like I can't. The powerpoint slides just cannot be uploaded into this blog.
Anyway, we all know that there are dangers with self medication, but yet many of us do in. In a survey in Sri Lanka ( WHO ), in 1997, 37% of Sri Lankans, self medicate. I think Malaysia is about the same or maybe more if you include traditional and herbal medicines. I spoke of the dangeres of wrong dosing and side-effects, and adverse reactions. Sometimes, self medication masks the underlying disease and so when the patient ultimately sees a medical practitioner, the diagnosis is delayed, or even missed. There is always the danger of drug drug interaction and food-drug interaction that the lay public does not realise. Of course we know that one of the main reasons for self-medication is the cost of seeing doctors, and maybe the fear of knowing the diagnosis.
Some of the other topics discussed included " The role of the Pharmacist in Healthcare Delivery ", " Antibiotics and elf medication ". A very interesting morning.
The Penang folks ( and I am talking about the public), came in good numbers. About 60-70 in the room at Dewan Sri Pinang. Question time was very lively, with arguments about drug labelling, expiry dates, legal rights, generic drugs and branded drugs and the like. The Forum, scheduled to last till 12noon, lasted till about 1.30pm, mainly because of a very lively question time. Penang people are quite well informed and dare to speak up.
I thought that we had a good time sharing views on self medication and patient's right. We could do with more of such forums, so that our public will be better empowered to know more about how to take care of themselves in health and disease.
( If I can, I will try and learn how to upload my slides, so that you can have a flavour of the talk).

BLACKS AND CARDIOVASCULAR MORTALITY ; RELATIONSHIP AND POSSIBLE EXPLANATION

Black Americans have always had a higher CVS mortality than white Americans. This association has been known for a longtime and it was often put down to poor socio-economic status and obesity, hypertension and diabetes. All this seem to be true.
In the latest issue of the Annals of Family Medicine, Jan 2010, Dr K Fiscella and colleagues studied firstly, the association of Black Americans and CVS mortality and also the serum vitamin D levels and CVS mortality, USA. They actually did a retrospective cohort Study going back into records of the National Health and Nutrition examination Survey ( NHANES III ) from 1988-1994, an also the records of the " cause specific mortality or National Death Index 2001. They were hoping to answer 1. that Blacks had higher CVS mortality, and 2. that this increase mortality could be due to a lower Vit D level, due to the fact that darker skin manufactured less Vit D from the sun. Well, the authors were able to prove the first. That Black Americans had a higher CVS mortality than whites. But when they added the confounding factor of serum Vit D, that correlation was lost. Suggesting that the higher CVS mortality in blacks was not related to serum Vit D levels. That it may be due to poverty or other diseases associated with the lower socio-economic status.
I took out this piece because I was trying to correlate the higher CVS mortality in Indians in South East Asia, and whether or not Vit D was a factor, as this can be easily corrected with Vit D supplements. Alas, this is not to be so. It looks like dark skin maybe a minor risk factor for heart disease and mortality, and Vit D may not be the reason. The usual risk factors of cigarette smoking, obesity, hypertension, diabetes, and dyslipidemia, maybe the main factors. Certainly the stress of life on the darker skin individual, and the diet that they can afford, the lack of exercise, cigarettes or cigars, may also be important in this group.
Be that as it may, it is true that darker skin individuals have a higher CVS mortality when compared to fairer skin and that it is not due to low Vit D levels, although there is much evidence that low Vit D levels may be associated with heart disease. Looks like not in this case here.

MUCH ADO ABOUT NOTHING : THE 1MALAYSIA CLINIC

The last week, over the internet and also on my handphone sms, there has been much cyberspace traffic about the setting up of the 1Malaysia clinic, which will be launch by the Prime Minister on the 7th Jan 2010. When these clinics were first announced under the budget speech by the Finance Minister, I wrote a protest note to the STAR newspaper, pointing out that these clinics were running afoul of the Private Healthcare Facilities and Services Act 1998.
In fact, one of my colleagues pointed out to me that, they were not. You see when we were negotiating the amendments to the PHCFS Regulations 2006, the then Minister and DG agreed with us that the Act was wrongly named. It should have been called the " Malaysian Healthcare Facilities and Services Act. Alas, the last Minister was replaced and all our agreements and negotiations seemed to have gone to not. As it stands, the 1Malaysia Clinic is not exactly illegal.
Over the last week, the MMA president have been soliciting opinions as to what to do, to show their disgust at launching of the 1Malaysia clinic. The suggestions varied from seeking a dialogue with the PM and Minister of Health, sending a petition to the MOH, holding placards and demonstrating in front of Putrajaya. I suppose the first two suggestions have some merit. To show our disgust and try and protect our GPs who felt that their " rice-bowl " will be affected. The last suggestion must be a joke. " Doctors demonstrating, in Malaysia "? Firstly, my experience tells me that no one will show up ( the apathy is so strong ), and secondly, we will be the laughing stock of the public. What will the public think about us, demonstrating like " orang kurang ajar " in public over a government clinic, which may have some merit.
If you see the " Private Healthcare Facilities and Services Act 1998 " as solely for the private sector, then what the government is doing is proper and maybe good.
Firstly, it is true that in some western countries, nurse-techs and paramedics are running healthclinics in urban areas through Walmart and the like, to renew prescriptions, vaccinate, check blood sugars, and also do simple medical procedures, in an attempt to cut down healthcare cost. Some technologists are even taught to do endoscopies and echocardiograms. The danger here is that with the 1Malaysia clinic, the hospital assistants and nurses, may not have sufficient training and skills to be safe. And of course, there is the temptation to do and take more responsibilities than they should. We would certainly like to see the terms of reference and terms of conduct of these clinics ( what they can and cannot do ).
Initially, I wrote in my short piece, that if the government wishes to help the rakyat, these clinics should be in the rural areas. I thought that there should be greater need for these in the rural areas. Again, I was corrected by my colleagues there in the rural areas, there is a government day-care center within easy reach, in every community ( I suppose except Sabah and Sarawak ). There is greater need amongst the urban poor, like the inner cities in the US.
I have also begin to realise more and more that the the medical scene is changing and that doctors cannot be protected forever. They must be prepared for competition ( and I hope that it is fair competition ), and that the public must be served, as best as we can, as an individual and as a country. The " subsidy mentality " and "the government will protect me mentality", must go, sooner rather than later. If there are three new clinics in my housing estate, I must work harder, treat patients better, provide better service, so that I can compete, and not just cry and shout blue murder and hope that everyone else will help you out and protect your rice bowl. There is a need, and the government, for their own reasons, have come to fill up that need. Of course, they have their political agenda.
Whatever it is, and whatever we say and do, protest notes, petitions, meeting with PM / MOH, placards and demonstrations ( I hope not ), on the 7th Jan 2010, the Prime Minister will be launching their 1Malaysia clinic, and we have to live with that. GPs arise, and compete. Your hallowed ground is being invaded, somewhat. This is the practice trends of the 21st century.

THE MOST DEADLY INFECTIOUS DISEASE IN MALAYSIA. : DENGUE FEVER

It has always amaze me, since the start of the so called A H1N1 pandemic, how the MOH could spend so much money, time and effort on A H1N1 and yet ignore the deadly Dengue Fever. Why? The DG of Health reported yesterday that in the month of December 2009, there were 84 deaths in Malaysia, the last victim was a lady in Sarawak.
I remember clearly, when I was in medical school, and when the present DG of Health was in medical school ( we are classmates ), the University of Malaysia medical school, brought an expert from Thailand to lecture us about dengue fever. This was in 1971 ( 38 years ago ). He taught us about the dengue virus ( virus 1,2,3,4 ), the mosquito vector ( aedes eguipti ), the disease presentation and the therapy. At that time, we already understood a fair amount. Yet 30 years later, it is still killing 84 people a month ( about 1,000 a year ). We rush to do all kinds of publicity and panic with A H1N1 which killed 70 odd people in 6 months or 140 people per year. Of course there was great financial gain for some parties from pharmas, and detergents makers and masks maker and the like.
But if you think of it, dengue can also make money for the decision makers. I have reasoned and concluded that dengue is still deadly in Malaysia, because there is no one taking charge of this problem. The deaths are quietly disposed off and no one make a fuss. Our own research institute ( the old IMR used to be instrumental in helping eradicate malaria ) use to be very good, until the Mahathir years came, and priorities change. You see, since dengue is a developing country problem, the USA CDC has no priority program to research dengue. We are not Africa, which has attracted alot of US dollars to do research in malaria and HIV. So we have to research for our selves. So far, our great local innovators have not risen to the challenge. Many have been sent overseas to study the issues, but all have come to not. Mosquito ( the aedes mosquito ) larvae thrives in pools of water, which are abundant all over Malaysia, varying from housing estates, developed and being developed, government department compounds, including drains in Putrajaya, private compounds, etc. Every now and then, there is a campaign ( usually so that "orang besar" can have some publicity ), and then all is forgotten. Sporadically spray here and there and then when the show is over, life goes back to normal. With the raining weather, puddles of water form, virtually overnight.
When I was in medical school, we were taught that Malaysia had a very good strategy to eradicate Malaria, another mosquito borne disease. I remember that we had very distinguished physicians, like Dr Sandosham, who with the help of the British administration ( those were the days before and just after independence, was able to eradicate malaria and also tuberculosis. They set targets and met the targets. We had a strong social and preventive medicine department, to study the issues of eradication of the mosquitoes. I am convinced that to eradicate dengue, we must attack the mosquito larva. I am sure that MOH agrees, but I cannot understand why they still have not done it? 1,000 deaths a year do not seem important enough? Why?
I can only conclude after 30 years, that there is no political will. When a death occurs, we feel bad for awhile, then we forget. Why? Maybe I should think of how money can be made. Perhaps then some ears will perk up and some will take on the deadly killer.

I WILL LIKE TO WISH ONE AND ALL
HAPPY NEW YEAR 2010.