COFFEE IS ANTI-INFLAMMATORY. ?PREVENTS DIABETES

I have always been on the look out for latest articles on lifestyles and the heart. At the weekend seminar over the weekend ( a rather successful weekend seminar, if I may add ), I heard a comment made that drinking coffee may be good for the heart. When I had time, I went to do a bit of reading, and found a recent report that appeared in the American J of Nutrition ( report carried in " theheart.org " ) that there was a small study done by Dr Kerstin Kempf ( Dusseldorf, Germany ), of 47 habitual coffee drinkers who were 65yrs or younger, with no evidence of diabetes or heart disease. They were told to stop drinking coffee for 1 month, to washout. After 1 month, they had their inflammatory markers assessed and for the next month, they were allowed 4 cups of coffee a day and the following month, 8 cups of coffee a day. At the end of 2 months, their inflammatory markers were assessed again. Dr Kempf found that after two months of coffee, the levels of IL-18 ( interleukin 18 ) and adiponectin, were significantly lower. There were no change in the hs-CRP and interleukin 6. This was interesting as only some of the markers were affected. I think adiponectin is important, because that factor is often associated with anti-obesity and lessen CAD risk.
In fact there were earlier studies that seem to suggest that coffee drinking may be associated with less incidence of type2 diabetes. The relationship with CAD risk is still not that strong.
I suppose on this basis, we cannot avocate the habitual drinking of coffee as a form of CAD / diabetes protection ( quite unlike the evidence for red wine and fish oils). The studies were too small anyway. However, if you like coffee, you may know that besides your love for coffee, coffee may help you to prevent diabetes and also may protect your heart.

ASPIRIN IN THE PRIMARY PREVENTION OF HEART ATTACKS - UPDATE

In the 90's it was seemed well established that aspitrin had an important role in the prevention of heart attacks. The results of numerous anti-platelet trialist collaborations seemed to established that. In fact, we were all wondering whether we should all take a bit of aspirin? That went on for 10 years. Then in 2009, the " Aspirin Treatment Trialist Collaboration " group reviewed 6 mega-aspirin trials, including the US physician health study, the Women's Health study, the British Doctors study, the Thrombosis Prevention study, the Primary Prevention Project and also the HOT study, and found that the small benefit in the use of aspirin was far aoutweight by the significant side effects with aspirin. The ATTC was a meta-analysis of the mega-trials. That was 2009. Before I forget, they also reviewed the data for secondary prevention and found that aspirin was very useful in the secondary prevention. The event reduction was much more ( then primary prevention ), so that the small number of side effects was acceptable.
At the just concluded ACC Annual Scientific Meeting at Atlanta, Georgia, Dr Jay Das and group re-reviewed the ATTC data, plus another three aspirin trials ( the JPAD, POPADAD, AAA ) and also concluded basically, that althought there was some small benefit with aspirin, there was a significant level of side effects. They concluded that there was no role for aspirin in the primary prevention of heart attacks.
What has changed between the 90's and now for this turn around?
Thinking hard over it, it looks like the cohort of subjects studied in the 90's and new millenium ( the cohort studied by the trials used by the ATTC group ), are also taking statins and beta-blockers, resulting in more protection against heart attacks. Therefore the effects of aspirin was muted, when compared to the cohort of the 70's and 80's which form the cohort of the earlier Anti-platelet Trialist Collaborations of the 80's. This again showing that with clinical trials, the meieu and target is ever-changing and results have to be viewed with in the context of the trials.
Be that as it may, in the year 2010, it does looks like aspirin helps little, in the primary prevention of heart attacks, and does do harm, in terms of bleeging and gastric toxicity. Therefore there is no role for aspirin in the primary prevention of heart attacks. However, there is a very definite role for aspirin in the secondary pevention of heart attacks.
I wonder if 10 years from now, I will have to revise this position again.

FDA BOX WARNING ON CLOPIDOGREL, IS IMPROPER AND UN-WISE

Over the weekend, I was asked for my opinion on the latest FDA warning issued last week, asking Sanofi-A, the makers of clopidogrel ( Plavix ) to add a box warning " outlining the availability of genetic tests to identify patients who ineffectively convert clopidogrel to its active form". While I can see their reason for so doing, I cannot understand why they did it at this juncture ( I smell a BIG rat ). While it is true that some patients with genetic defiency of the cytochrome CYP 2C19, may not metabolise the drug well ( clopidogrel is a pro-drug ), and therefore may suffer inadequate anti-platelet efficacy, the black label at this point in time only creates confusion. The genetic testing is a research lab test and is not commercially available at the moment, there are no clinical trials carried out to see what to do with this sub-set of patients and what are the choices for the care-giver and patient. You have highlighted a problem, true. BUT what is the solution. Now we have many patients, having read the FDA announcement and read the STAR and NST, become very confused. What shall they do. At the moment, I just ask them to ignore and not to discontinue the clopidogrel.
If I am very naugthy ( and I have no data ), is the FDA in cahoots with Eli Lily to try and promote prasugrel ( Eli Lily )?
See there are also cheats in FDA / USA.

DANGERS OF HIGH DOSE STATINS

On Friday, the FDA made an announcement, through their newsletter, entitled MedWatch, that high dose zocor may be associated with a risk of rhabdomyolysis. They re-analysed the results of the " Study of the Effectiveness of Additional Reduction in Choelesterol and Homocystineine ( SEARCH ) study" and also other data in their files. So this is retrospective. They compared 6031 patients on 80mg simvastatin to 6033 patients on 20mg simvastatin and found that those on 80mg ( high dose ) had a higher incidence of myopathy and rhabdomyolysis ( about 60x higher ) than those on 20mg. Granted that the overall numbers were small ( 63 cases Vs 2 cases ). Rhabdomyolysis can lead on toward acute renal failure and death.
When I read this, it raises three issues to me.
One pushing LDL-cholesterol super-low has a price. The risk of myopathy / rhabdomyolysis, compared to a marginal gain of lesser MACE. Secondly, high dose statins ( I dont think that this problem is confined to simvastatin. There were reports of myolysis and death in the earlier studies of rosuvastatin 40mg too ). Thirdly, and which probably the most important, being a responsible enforcement agency, the FDA regularly analyses their reports of adverse events, so that it does mean once approved, always good. Overtime, many new thinks can be learned and in the issue of drugs, it is adverse reactions.
Well with superstatins, and high dose statins, beware.

MORE EVIDENCE ON FAILURE OF RADIAL ARTERY GRAFTS FOR CABG

CABG is a very matured operation now, in patients with CAD who needed re-vascularisation. One of the biggest problem with CABG is graft attrition, or failure / re-blockage of graft months or years after the surgery. There are alot of data showing that the saphenous vein graft is a poor conduit ( except perhaps in the hands of the late Dr Victor Chiang ). The left internal mammary graft is excellent, and should be used whenever possible. The radial artery, free pedicle graft, is an enigma, as data seem weak and conflicting. There are some cardiac surgeons who prefer the radial artery graft, thinking that since it is an arterial conduit, it should last better then the saphenous vein graft, maybe just a little inferior to the left internal mammary graft. I remember discussing with some cardiac surgeons, that the radial artery graft is a poor conduit because it is a free arterial pedicle graft. It cannot behave in anyway the same as the left internal mammary graft. Alas, they keep on doing it.
Well, the just concluded American College of Cardiology annual scientific meeting in Atlanta had a paper on this.
The study is called the CSP 474 study, led by Dr Steve Goldman, comparing the use of the radial artery graft with saphenous vein grafts in the treatment of CAD across 11 VA hospitals, involving 733 patients. 366 patients in the radial artery graft arm, and 367 patients in the saphenous vein arm. At one year followup, angiography was done to see graft patency. Angiographic followup was 73% ( not bad for a VA hospital ). Well it showed basically that the radial artery graft was no better then the venous graft ( as expected ). In each arm, at 1 year, graft attrition was 11%. The worse candidates was in the venous graft arm, who had the veins harvested using a videoscope, for off-pump bypass. ( Cardiac surgeons doing off-pump try to save time and minimising trauma, by using a videoscope to harvest veins, or even radial artery, as conduit for bypass. The technique is so rough and traumatic ( I saw a videoscopic presentation of it ) that it is not surprising that at the end of the harvesting, the veins is all but smah up and the endothelial integrity is all gone, that they very quickly close off.
Anyway, looks like the latest information would suggest that the radial artery is a poor conduit. Perhaps the cardiac surgeon would leave them alone, as they are very useful for the interventionist to do their transradial interventions.

NAVIGATOR IS FINALLY HERE. ITS A "NO"

Last weekend saw the start of the American College of Cardiology annual scientific meeting. As usual, many clinical trial results will be presentated. One in particular interest me as I have been waiting for the rsults for the last 5 years. This is the NAVIGATOR trial. Navigator stands for "Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research". Sponsored by the large Pharma " Novartis " I was briefed on this trial in the early 2004 ( I think ) when the trials was recruiting. Many sales representatives came by to tell me about the new wonder drug of " Starlix" for the treatment of my patients with diabetes, and how it will reduce cardiovascular events. Starlix is a secretogogue, and I told Novartis that I felt that it was too weak to do any good. I was not keen to use it until I had more data. Anyway, with much prompting, I said that I will hold final judgement until the trial results are out. Well, this trial of 9,306 patients, enrolled from 40 countries with followup for 5 years, had their results presented on Sunday at the ACC. It compared the use of valsartan, the blockbuster drug from Novartis for the treatment of hypertension and heart failure, with placebo, on one arm of the trial and compared starlix against placebo, on the other arm of the trial. The cohort were males who either had impaired glucose tolerance, CV risk factors or if they were younger ( >50years ), established CAD. The end point was to see if the use of Stalix or Valsartan will reduce the incidence of diabetes in people with impair glucose tolerance or if we could reduce CV events in patients with impaired glucose tolerance and also cardiovascular disease or risk factor of CV diseae. Basically, the answer came out as a big " NO ". Neither drug, used in this way reduce the major adverse cardiac events and the use of valsartan, marginally rreduced the incidence of diabetes ( by 14% ).
This was very much in line with the result os DREAM where the use of ramipril and rosiglitazone was not associated with a reduce incidence of diabetes.
Well, looks like NAVIGATOR will spll the end of Starlix ( which at the moment is almost dead ). The other issue is that Novartis, strong as they are, have used up alot of funds for this negative trial. I hope that they can re-coup.
More of the ACC trial results as we go down the week.

POLLUTION AND THE HEART

I read something rather interesting recently. Firstly I knew that there was a society called Cardiovascular Disease Epidermiology but I never knew that there was a society for Prevention, nutrition, physical activity and metabolism ( PNAM ). These two societies held their conjoint annual scientific meeting at San Francisco recently. Amonst the many papers presented were two that caught my attention. Dr Asghar Fakhri n coleagues at the Beth Israel Deaconess Medical Center, Boston, presented a paper on the effects of air pollution ( measured as the distance between a highway or main road, on heart disease. Studying a cohort of 187 subjects and using coronary arteriography ( I do not know how they justify it to the insurance company ), they found that the nearer ( <100m>25% stenosis ( not the suaul criteria). I suppose they were trying to pick out very early disease.
The second paper in the same vein was presented by Dr Joel Schwatz of Harvard Medical School, Boston, who presented the findings of his study of Normative Aging ( whatever that means ). He studied 939 subjects and found that pollution was associated with an increase incidence of Hypertension, ECG abnormalities ( including ST-T changes ) and also an increase incidence of atrial fibrillation.
Well I must advice caution in accepting the results. The conclusion is much too simplistic and obviously, more work needs to be done. Suffice to say that both papers come from very distinquished medical schools and so cannot be taken likely. There is probably an effect of " pollution and stress" in people who commute and use the highway alot. Whether it is pollution per se, or just the stress of commuting and travelling long distances, is not so well defined. Sometimes staying near your place of work is also stressful.
well, here you are. Early rsults seem to indicate ( vaguely ) that pollution maybe associated with heart disease.

CELECOXIB AND ROSUVASTATIN INTERACTION

The March 9th issue of the Journal of the American College of cardiology carried a small but interesting, hypothesis generating paper on the interaction of celecoxib ( a COX2-inhibitor for pain relief ) and rosuvastatin ( a new-kid on the block statin ). Dr Andrew Liuni and group studied 20 volunteers and gave them rosuvastatin and studied their " ischemic threshold " through the flow mediated response in the forearm, after a 40 mg dose of rosuvastatin, and then studied them after a few days of celecoxib. They found that with rosuvastatin alone, there was an increase in ischemic threshold which was blunted by the subsequent use of celecoxib.
This is indeed very interesting.
In cardiology and ischemic heart disease, there is this concept of " ischemic preconditioning " meaning that if you have heart artery blockages causing ischemia ( lack of block supply ), frequent small dosease of ischemia allows you to tolerate more ischemia, so that should a "big" ischemia happen, you are better to tolerate it with more limited consequences. This concept is well proven from the seminal work of pass cardiac researches like James Willerson and company. This paper by Dr Liuni is very interesting in that it showed that statins can help ischemic pre-conditioning, and more, that celecoxib can blunt it.
It is a small study and does not really prove it, but it is hypothesis generating, allowing us to understand disease concepts better. It may be that ischemic pre-conditioning is a platelet mediated phenomenon and that the COX2 receptors maybe involved in some way and that blocking the COX2 receptors, maybe abolishing the response.
Whatever it may, it does look like there is some significant interaction between statins and COX2 - inhibitors and they should be used together with some caution. We do not wish for our patients to get heart attacks through our wrong use of medications.

THE CURRENT MALAYSIAN HEALTHCARE SYSTEM : STRENGTHS AND WEAKNESSES.

This piece was submitted to the Star Helath editor, for publication this weekend. I hope that it will come to print. As usual, I also published in the blog. It is my attempt to let the public become more aware of the healthcare system, and begin to participate in improving it. Do not forget, that a general election is due soon ( the signs are there ) and your vote goes a long way to influencing healthcare reforms.

OUR CURRENT MALAYSIAN HEALTHCARE SYSTEM – STRENGTHS AND WEAKNESSES


Introduction

The Malaysian Healthcare system, is ever improving. Once upon a time, we had to refer many of our patients overseas for bypass graft surgery, valve replacements, angiograms, cranial surgery, spinal surgery and even second opinions for some medical conditions. Nowadays we can do all of the above here, and even more, including minimally invasive surgery ( of all types ), liver transplantation, cardiac transplantation, robotic surgery and many other sophisticated treatment modalities some of which even I may not be aware of. Yes, some still choose to go overseas for treatment, but that is their personal choice. They have the money, they have the means, it is their health, so it is their choice. But, the Malaysian Healthcare system, though not perfect, have come along way, since 1957.

THE WEAKNESSES.

In a consumer survey conducted in 2008, patient satisfaction level decreased from 94.4% in 2004 to 89% in 2008. The rate of patient expectations being met was 38.5% in 2008. On the one hand, 89% of patients satisfied with MOH hospitals is not bad. On the other hand 38.5% expectation being met level is too low.

Undoubtedly, there are problems with our healthcare system, primary of which is :

1. The long waiting list.
Whenever I chat with friends at social functions about what ails the public healthcare system in Malaysia, the most frequent comment is the long waiting list. They are all very unhappy with waiting. Only once did I find someone ( retired government servant ) who was full of praise for the public hospital, in particular the Selayang Hospital. The majority are very unhappy with the waiting to get an appointment to see the consultant, the waiting at the outpatient department on the day of the appointment, the waiting list for elective surgery and in some instances, “ urgent “ surgery. Sometimes scheduled surgery are cancelled for very many reasons ranging from “ consultants not being available “ to no ICU ( intensive care unit ) bed or OT ( operation theatre ) time. Sometimes the reason is as flimsy as blood test results or ECG ( electrocardiograph ) not being available for review. There have also been instances of surgery being cancelled because senior consultants were called away “ on government duties “ at short notice and the juniors dare not proceed. Some waiting list issues are just due to poor human resource organization. The pilot project in some public hospitals to allow doctors in government service some private practice rights also did not seem to help much in the “ brain drain “ problem. Perhaps a re-think is necessary.

I will classify this weakness as an organizational, human resource and management problem, nothing that an increase in healthcare budget, a large dose of morale booster and working closer with the private sector doctors, cannot solve. If the Ministry of Health ( MOH ) is agreeable, many private doctors would be more then happy to devote one or two days a week, to help shorten the medical and surgical waiting list. I remember when the private doctors offered to help years ago, in the 90s, it was rejected as some in the MOH administration. In the atmosphere of the 90’s, the private sector was seen as a rival and threat to MOH. Now that we are in the 21st Century, perhaps it is time to breakdown the artificial wall dividing the public and private sector and let us all work together for the betterment of healthcare in Malaysia. An increase in healthcare budget, maybe to 6% of GDP, will certainly go along way to helping the waiting list issue.

2. Trained, competent doctors, nurses and paramedicals

I have often been told that besides waiting, the other biggest weakness with the public hospitals is the level of competence of the doctors, nurses and paramedicals. Patients wait for their turn to be seen by a medical officer or house-officer who do not even care to take a proper history or do a proper medical examination. In a minute or so, they are “shooed “ out of the consult room with a prescription. Medical officers, probably because of inadequate exposure, cannot set IV drips, set central venous lines or perform arterial cannulation safely.
In an earlier article, I have alluded to the fact that we are mass producing doctors, as medical education is a business and also politically appealing. With mass production, there are inadequate supervision of junior doctors leading to poorly trained house officers and. medical officers. In 2009, there are 3,139 fresh medical graduates going for housemen training. In 2008, there are 409 specialist in MOH hospitals, so each specialist will have to train 8 house officers, plus his own work and responsibilities.
Similarly with nurses and para medics. They are also being mass produced and mainly class room exposed. They learned whatever they can through books, charts and computer simulation in the classroom. They have minimal exposure to actual bedside patient care in their training. For very many reasons, the senior ones seek their fortunes elsewhere, leaving the junior ones to help the junior ones.

As I see it, this quality problem is strictly an administrative problem, maybe with some political over-tone. By the stroke of the pen, we can cut down the number of medical schools in the country ( there are 22 at the moment, for a population of 27million ). That will allow more to have better supervision and training by their seniors. What it means is that we go for quality and not quantity. Healthcare has to do with sickness, live and death. We should not compromise here. I can only plea, on behalf of the patients that healthcare should not be taken as a political game. Doctors must all be adequate trained to meet the level of responsibility that they are entrusted with. A half-baked doctor will harm patients.
Similarly, nurses must also be adequately trained. To begin with, nursing enrollment must have a higher entry criteria, if possible graduates only. Of course, the pay must be commensurate with a graduates pay. Each nursing school must have a hospital attached for their nurses to train, and the nursing board will have to be strengthened.

3. Overemphasis on curative care

I suppose, being a developing country, going towards 2020, we are still looking after our bodies only when it falls sick and malfunctions. The cliché is stale “ Prevention is better then cure “. But it is true. If only all of us will look after ourselves, there will be so much less sufferings and so much less expenditure. We abuse our body. We eat too much, especially carbohydrates and fats. The food advertisement is so appealing. We promote food as a form of tourist attraction. “ Bah Kut Teh “, “Teh Tarik “, “ Nasi Lemak “ . We refuse to exercise. We take the lift up 1 floor, or even worse, down 1 floor. We do not go for regular checkups until something is wrong with the body, or until we collapse. I am sure you all know what I mean.
The MOH should put more emphasis on preventive care. For starters, all males above 40yrs and all females above 50years should go and see his favourate GP for a full medical checkup. For the younger females, they should go for their annual pap smear and breast examinations. Even if these check ups have to be funded by SOCSO, so be it. It is still cost savings in the long run. All adults who do not fall sick or claim on medical bills should be given a tax rebate. It pays to stay healthy. All who do not claim on their health insurance, should get an insurance “ no claim bonus “ not unlike the motor car insurance “ NCB “. The “ Tak Nak “ campaign to stop smoking, must be more seriously enforced. One day, while in a no smoking air-con restaurant, a patron was smoking. I went to alert the restaurant owner. He could not care less. He thought that I was weird. The “ eat less sugar” and “ eat less salt” campaign must be instituted. Those who lose weight should be rewarded. Everytime a dengue endemic area becomes dengue free, that area should be rewarded with incentives and recognized with a plaque or something. Companies who harbour dengue larvae should be severely punished as an example, even if they are government institutions or government linked companies. In all these, education is important. We must educate our public on what is good health and how to maintain good health.

4. Lack of control of charges in private hospitals.

The most popular complaint of anyone getting treatment in a private hospital, is COST. As the country gets more affluent, more and more private hospitals are set up. Some private hospitals are set up as no frills hospitals where the trimmings of luxury are few and it is basically catering to the lower social economic group, to give affordable private healthcare. Lets call this group the 3 star hospitals. Then there are those who boast of their marble flooring and overhanging chandeliers and golden door knobs. They compete with each other, to be more luxurious than the next. These “ boutique “ hospitals or 6-7star hospitals, charge a lot for their services and their mark-ups can be 100-200 percent on some items. We have nothing against “ boutique hospitals “, but it would be very unfair to include the cost of care there into the healthcare budget as private healthcare expenditure. Afterall, healthcare is for making people well to return back to society, not to let them be pampered with luxury at our expense. There is no end to cost of luxuries and pampering all done to boost the bottomline.
One easy way cut the cost of private healthcare is to regulate the cost of treatment in private hospitals. Just as you can regulate doctors’ fees ( although you should not ), you should also regulate cost of staying in hospital to get well. It is possible to detail how much a CT scan should cost?, how much an endoscopy should cost? How much an angiogram should cost? How much a normal delivery should cost? How much a “ lap chole” should cost? It is possible. Then the health expenditure for the private sector will reflect cost of care, not cost of luxury and profit margin
I have always wondered whether it was possible for the government to gather a price list for cost of care ( unsubsidized by the government ) to let the public know the true cost of medical treatment. Another way, I suppose is to give tax incentives to 3-4 star hospitals who give affordable healthcare without the frills to encourage more of them. Let the hospital with the frills pay more taxes, and let them attract the tourist who come for treatment. Let them compete and earn foreign exchange, while our locals have good and relatively affordable healthcare. That will save healthcare dollar.
Recently, it was mentioned to me that some private medical centers are charging “ admin fees “ as a form of kick-back from doctors. The implication would be that doctors who give “ admin fees or kick-backs” to the administration would get more patients, so that in some way, against the spirit of good medical practice, medical care is being decided by kickbacks. This is bad.
I belief if there is a political will, the cost of healthcare in private hospitals can be easily controlled. Afterall, it does not escape notice that almost all the private hospitals in the country belong to government linked companies ( GLC ). A stroke of the pen, is all that is required.

5. Lack of control of high tech medical equipment.
At a simple count, there are 15-20 CT scan machines in the Klang Valley, a population of about 3 million people. The owners of the machines ( usually doctors with a business partner, or medical centers, openly advertise their machines to the innocent public even offering discount packages. Some of these packages are even tied up with credit card companies so that the patient does not have to pay any cash upfront ( so slick ). CT scans are done left, right and center for any trivial excuse. Firstly the scans are costly. Secondly they are potentially hazardous ( the radiation from a CT scan of heart arteries may be the equivalent of 500 chest X-rays ). Thirdly, they may not be as accurate as what it is touted to be. Scans are not cheap. They can cost a few thousand dollars each. Depending on the indication, it may not help in the care of the patient. They may just add to the cost of healthcare. Again, the proliferation of these machines can easily be controlled by the authorities, if the wish to control healthcare cost. Maybe the authorities should also consider that doctors who refer patients for scans should have no financial interest in the scan companies, to avoid a conflict of interest situation.

There are many more weaknesses to write about, but these are the main ones. However, the situation is not all bad. There are strengths too.

THE STRENGTHS

1. Equitable access to healthcare for all.

As I have said previously, one of the greatest strengths in our present healthcare system, which I tell all my overseas consultants is the fact that all who come to Malaysia, can be guaranteed access to healthcare should the need arise. There is no need to wait for insurance approval before treatment, no need to fill in numerous forms and phone calls. Yes, there maybe a bit of waiting, especially during peak periods, but you will be attended to. Very few countries can boast of this.
Should you need tertiary care, arrangements will be made for you. Yes, there maybe some waiting, but you will be attended to. All the way to specialist consultants and sophisticated surgery, including liver transplantation and cardiac transplantation. All for minimal fee or no fee.
Of course, in the private, waiting period is minimal and medical care is prompt, all for a fee.

2. No interference to medical practice.

The other strength that I can see is that medical consultants can do his best for the patient without being controlled by third party payers. The doctor sees the patient, orders ( and it gets done ) the relevant investigations, and with the proper diagnosis, carry out the proper therapy. In some other country where there is social health insurance, that is not possible. Every test needs clearance from the third party payer and every treatment, needs approval, sometimes, the approval is by nurses who advises insurance companies. I was once told by a neuro-surgeon that he wanted to remove a brain tumour which was deeply seated in the cranial vault. He filled in the insurance form, and proposed a two prong approach to removed the tumour safely. The insurance manager ( a nurse ) rang him the day before the surgery and asked why he was doing it through two incisions? Was he trying to earn more by doing two incisions? That’s the problem with third party payers. They often try and interfere with medical decisions. We will write more on this in the future segments.

In our current system, the doctor does what is best for the patient. The policing is by the Malaysian Medical Council. Yes, there are some doctors who also abuse the system of trust. But these are fewer and can be controlled.

3. Patient can consult whoever they trust to make them well and buy medication from whoever they trust.

We are really blessed that the present system allows a patient to choose whichever doctor of his/her choice. Trust is very important in medical therapy. That trust should not be simply broken. We each have our family doctor for primary care, our family pediatrician, our family surgeon etc.. They have been with the family for decades and so there is a certain bond and trust.
Also, the doctor may or may not chose to dispense. There are some doctors who prescribe but do not dispense ( you buy your medicine from the pharmacy ). Some doctors prescribe and also dispense. There are pros and con for each. Some patients, because of their trust with the doctors would rather buy the medications from the doctor, and have the doctor explain to them the effects and side effects. Because of their longstanding relationship and trust, they would more likely take their medication and get well. In some healthcare system, you have to buy the medication from a pharmacy away from your comfort zone and rely on some stranger to explain things to you. Sometimes the pharmacy may not have the right stock of drugs and pharmacies have been known to substitute ( generic substitution ) the prescribe drug with what they think is the generic equivalent. I must say that that is not good. It may be wiser to allow patients to exercise the choice of who they wish to dispense the medications to them
This is another strong point of our present system.

4. Cost effective use of healthcare funds.

As I had illustrated in the earlier article, for 3.6% of GPD and 7% of total government expenditure, we have actually used our healthcare dollar very wisely, so far. The health outcome data that we were able to achieve speaks of a good health standard in the country.

Population of Malaysia 27,728,700
Average Annual Population growth rate 2.0%
Infant Mortality Rate 6.3% per 1,000 live births
Maternal Mortality Rate 0.3% per 1,000 live births
Perinatal Mortality Rate 7.3% per 1,000 live births
Live expectancy at birth
Males 71.70 years
Females 76.46 years

Conclusion

As with all public programs, there are always differing points of view, shortcomings and strengths. By discussion and brain-storming, we hope to develop a better system. Most of the shortcomings as outline can be easily corrected with some administrative adjustments and also some increase in healthcare budget. I suspect that with a complete transformation of the present system, the cost incurred would be so much more.
With the next article, we shall review healthcare by health insurance companies.

EARLY DETECTION OF DIABETES, THE CV DISEASE

Diabetes is a dreaded disease amongst us, because of its chronicity, and eventual CV outcomes that affects lives. In fact there are many of us who believe that diabetes should be a cardiovascular disease, as high blood sugar per se does not kill, but only through its CVS effects of eye complications, strokes, heart attacks, renal failure and peripheral vascular disease. There fore, we are very keen to pick up diabetes in their earliest possible stage and work hard to prevent it. The many diabetic society have developed for us guidelines for early diagnosis of pre-diabetes. But getting the message through has proven to be very challenging and an anti-diabetes lifestyle si almost taken as synonymous ( by some ) to be anti-life enjoyment lifestyle. However, we must keep pushing the message, as it will do the patient and also the country well, especially in this age of preventive medicine, and healthcare cost containment.

In line with this, the March 4th issue of the New England Journal of Medicine, carried an interesting report of the 14 year follo-up of a community survey of non-diabetics with no CVS, called the " Atherosclerosis Risk in Communities " study or the ARIC study. Dr Elizabeth Selvin and colleagues from the John Hopkins School of Public Health, published their 14 ear followup on 14,348 patients who were followed up for 14yrs after the secone community visit way back in 1990-1992. They found that the Glycated Hemoglobin A-1c was a useful predictor of the coming onset of diabetes and also CV risk. Patients who had a HbA-1c of >5.5% at the second visit back in 1992, after 14 years of follow-up, were much more likely to have future diabetes, CV mortality, strokes. The HbA 1c was a much better predictor then fasting glucose level. The American Diabetic Association takes a HbA 1c level of 5.7-6.5% as an indication of pre-diabetes, and any level of HbA 1c of >6.5% to be indicative of the presence of diabetes.

Therefore, in the issue of the dreaded diabetes, we now have a reliable marker of

EATING FATS AND STROKES IN WOMEN

An interesting paper was presented at the just concluded American Stroke Association International Conference on Stroke 2010, by Dr Sirin Yaemsiri ( sounds Thai ) from the University of North Carolina, Chapel Hill. She did a food survey on 87,230 post menopausal female subjects, paying attention to the amount of fats they consume each day. These females were age 50-79yrs and they were followed up for about 8 years. In the 8 years, there were 1,049 cases of ischemic strokes.
She was able to correlate the cases of inchemic strokes to the fat intake per day. Those who took 7 gms or more of trans fats per day had a 30% increase incidence of ischemic strokes. Those who ingested 86grams or more of total fats per day had a 40% increase in stroke.
The trend is obvious, more fats means more likely hope of stroke in 8 years. Although this paper is on post-menopausal females, I am sure that it reflects males as well. It is well known that females, pre-menopause had a low incidence of strokes, but they catch up quickly after menopause. It is also important to note that this study is about ischemic strokes and not hemorrhagic strokes, which seem to corre-late better with hypertension.
I have always been very worried about strokes, even more so than heart attacks as stroke can really incapacitate you, until you lose all your freedom and become totally dependant on others, making you a liability. That is why, many of us fear strokes, more then we fear death.
If eating less fats can reduce my chance of a stroke, in my later years, by 40%, then I must do it. Else all my retirement plans would have been in vain.
I am sure many of you feel the same way too.