DEATH AT THE STANDARD CHARTERED KL MARATHON

I was told that a young Mr Lim, collapsed while participating at the KL marathon yesterday afternoon.
My condolences to Mr Lim's family for his untimely death. I only hope that it will serve as a reminder to participants and organisers that these things can happen and that we should take due precaution. I do not think that anyone should blame StanChart for what happened, but some may blame them for having not been more prepared for what happened ( if what is written in the press is true ).
What happened? Well, it is well known that marathon running has a health risk and should not be taken on casually without preparation, on an adhoc basis. Death in marathon running is often quoted at 1:50,000 or 1: 60,000. It happens. More so when the participants are casual, ill prepared marathon runners who take part without any preparation.
The problem in the young is usually undected cardiac disease. The off-quoted phrase " Oh you should take part. You look so fit and healthy ", is no guarantee that you are healthy. From what the fellow runners observed and I quote "Earlier, software engineer Toh Yit Ming, 26, said he was running his final lap on the 10km run when he saw a participant, whom he only knew as “Lim”, sitting on the roadside in front of City Hall before collapsing.
“He was having a seizure. A few runners tried to put him in a recovery position,” he said in a telephone interview, adding that he had told Lim to relax and breathe deeply as he was short of breath and clenching his teeth. Unquote. This description sounded very much like an episode of ventricular tachycardia or fibrillation ( or a terminal rhythm ). At that time, Mr Lim's heart had stoipped and beating chaotically. The most common cause of this happening is pre-existing heart disease like a cardiomyopathy, usually of the hypertrophic variety. It simply means that the heart muscle is unusually thick and that the heart muscle cannot receive enough blood supply because of the unusually thick muscle ( demand outstrips supply ), resulting in inadequate blood flow, and fatality. Of course this disease is not common. There is a small possibility that he could have occlut coronary artery disease, and had a heart attack while running. The USA experience seem to point to the fact that sudden cardiac seizures in trained athlete, is usually due to heart muscle disease. I understand that a post-morten had been carried out and so we will know the exact diagnosis.
What can be done? As usual, we would encourage all participants to have a checkup, before they embark on something like marathon running. It would be better if those who wish to take part in a marathon, train and built up their stamina. Train and try it out first, before this heavy duty activity is taken on. Regular exercise should be a pre-requisit for participation. Join a club. Join a gym.. Prepare and train. If you have heart disease or a family history of collapses or heart disease, be certified fit before taking part.
As for the organisers, be prepared. If you have declared that there will be help provided every 4 kilometers, then lets do it. A well established bank, branded on reliability, honesty and security, we expect better performance ( again, I am not accusing but relying on press accounts ). We expect better from StanChart.
Of course, the ambulance service in this country, needs much improvement. Most of the ambulance service in the Klang Valley is 3rd party, private owned. The HKL and UMMC services are inadequate for the city's needs. Sometimes they are also being misused. Maybe, this would also lead to a wake up call to the city healthcare providers to improve. What I am afraid of is adhoc upgrading, wasting money and resources and not improving services.
All Mr Lim needed at that time was an electric shock to the heart as he was having the seizure. That would have revived the heart, even without CPR. However, there were no defib. machines around and so the good doctor and fellow participants carried out CPR ( A big thank you to them ). This time they failed, but their attempts and civic consciouness should be appreciated. Nexttime they may succeed.
Again, my condolences to Mr Lim's family and loved ones.
It serves as a lesson for us all.

OVER THE WEEKEND. BALI WITH BBRAUN AND DRUG ELUTING BALLOON

Over the last weekend, B Braun assembled a small group of interventional cardiologist from the ASEAN region in Bali to discuss issues pertaining to their drug eluting balloon.
Bali is nice and thriving. The service is still very good. Things are a little pricey. We were meeting at the " Discovery Kartika Hotel " at the Kuta beach area, where you have almost everything right in front of the hotel, besides a heavily traffic congested road. It was a focus meeting and good in its own way.
Well, it looks like B Braun is making a renewed effort to promote the drug eluting balloon in the treatment of CAD, making it an alternative to drug eluting stents. They are promoting it like drug eluting stents without the metal jacket and polymer. However, many of us felt that much more working needs to be done, before its role in interventional cardiology can be fully appreciated and established.
I also got to meet up with many of my old friends in the ASEAN region and lament that we are growing old and must pass the touch to the young and eager.
That is life and its cycle.

STROKE IS PREVENTABLE

Since strokes did not benefit from coffee or tea drinking, to help our stroke prevention program. I have taken this study from the just concluded World Congress of Cardiology, at Beijing. This study led by Dr Martin O'Donnell of McMaster U, Ontario, Canada, called the INTERSTROKE study is also published online in the 18th June edition of Lancet. It mirrors the INTERHEART study conducted by Dr Salim Yusuff of McMaster U, not so long ago.
The following are the risk factors for stokes and correcting these risk factors will reduce your chances of stroke. For example, if you control your hypertension, you reduce the possibility of stroke by a factor of 3.

These 10 stroke risk factors account for 90% of all strokes. We are beginning to formulate a language of stroke risk factors ( SRF ) just as we did with coronary risk factors.

INTERSTROKE: Population-attributable risk for common risk factors

1. Hypertension
2. Smoking
3.Waist-to-hip ratio (tertile 2 vs tertile 1)
4.Dietary risk score (tertile 2 vs tertile 1)
5.Regular physical activity
6.Diabetes
7.Alcohol intake
8.Cardiac causes
9.Ratio of apolipoprotein B to A1 (tertile 2 vs tertile 1)
10.Psychological factors
Stress
Depression

Stroke is a very devastating disease probably worse ( to my mind ) than a heart attack, because, in many instance, witha severe devastating stroke, you cant live and your cant die. You become a burden to yourself and your loved ones.
So please, please reduce all your know stroke risk factors.

COFFEE AND TEA ARE GOOD FOR THE HEART

I have posted once before the anti-inflammatory effects of coffee, for coffee drinkers. The latest online edition on " Arteriosclerosis, Thrombosis and Vascular Biology " carried an article by the researchers at University Medical Center, Utrecht, Netherlands on the benefits of tea and coffee drinking. They surveyed 37,415 participants and asked them to detailed out their coffee and tea drinking habits, and recorded their rate of heart disease, cardiac mortality and stroke rates after 13 years. They found a linear correlation for tea drinkers. That the more tea you drink, the more benefit, in terms of heart disease prevention and also cardiac mortality. However for coffee drinkers. There was no improvement in cardiac mortality. Also, the beneficial effects for coffee drinkers seemed to be a U-shape effect, meaning that 2-4 cups of coffee is beneficial but more that 4 cups may not be beneficial and maybe potentially harmful. Neither of the beverage, had any effects on strokes. It must be noted that in this survey, there seemed to be very few cardiac deaths and strokes. Too few too make a meaningful conclusion. It is also important to note that in Netherlands, they drink mainly filtered coffee and also black tea. Whether or not having milk in the beverage will have the same benefit, is not so clear. At the end of the day, flavanoids in tea is probably the reason for the benefit and the anti-inflammatory effects of coffee is the other help.
It must however be noted that this is very much an observational, questionaire survey study with all the shortcomings of these kinds of study. Nonetheless, it does give us an idea, especially when seen together other studies in other communities with the same findings.
Of course they are cheaper to conduct.

EMERGING STRATEGIES FOR THE MANAGEMENT OF CV RISK FACTORS IN HYPERTENSION

Last weekend, I flew out to Hanoi on Friday to speak on the above topic at a Sanofi Aventis organised workshop for GPs in the ASEAN region. The "Hot Topics" were on Hypertension, Atrial Fibrillation and Diabetes. It was a Saturday, Sunday seminar, but I returned on Saturday evening.
I wish to always acknowledge Sanofi Aventis, who have been supporting CME ( continual medical education ) strongly, be it Nationally, Regionally or internationally. Of course, it is also promoting their product, in this case, I am sure that it has to do with Irbesartan for hypertension. Nonetheless, they have ben very supportive and their effort should be acknowledged. I always wonder what will happen when pharmas stop supporting CMEs and doctors have to pay to attend CMEs. I am sure they will, i) Not attend unless mandated by law, ii) pass the cost on to the patient, iii) try and armtwist the pharmas who are supplying them the drugs, to sponsor.

Anyway, my brief was " Emerging Strategies in the Management of CV risk factors in Hypertension. I have never learn how to post my teaching slides in the blog, so I will just give a gist of what I said.
1. I stress that as a country and a community, it is best to prevent hypertension. If we can prevent hypertension (currently standing at about 40% in Malaysia), we would automatically reduce CV risk. There is much work done in preventing hypertension. The better know strategies are losing weight,( cut down obesity), taking a no added salt diet, indulge in a regular exercise program ( even moderate exercise will help ), and the lesser known strategies namely sleep well ( 6-8 hours of good sleep is very important to maintain good CV health ), and also the taking of drugs ( some drugs have been shown to prevent hypertension when taken for a short duration of 2 years ). We do not prefer the last appraoch as it obvious cost money and also exposes the patient to side effects. We would very much encourage the initial 4 startegies, of losing weight, eat less salt, exercise regularly and also sleep well.
2. Of course, should you have hypertension already, it is important to have a cardiac assesment done to make sure that you do not have LVH ( left Ventricular Hypertrophy ) as LVH is an important CV risk factors associated with a higher risk of heart attacks and strokes. Certain drugs like Irbesartan have been know to regress LVH and improve the CV outcomes. The other important issue is to see if there are proteins ( even just traces ) in the urine. Micro-albuminuria is another important CV risk factor for heart attacks and strokes in ptients with hypertension. And of course, there is enough clinical evidence to say that ARBs like Irbesartan can reduce micro-albuminuria, and improve the CV outcomes.
3. I also encourage the audience to control hypertension well, and to treat the whole patient for all the other CV risk factors of the aptient, like diabetes, cigarette smoking and also to lower their cholesterol.
All in all, it was a good meeting. The question time was full of questions and also the informal interaction was good.

Unfortunately, I had other appointments in KL that I had to attend to, so that I did not get to see much of Hanoi, except the airport, the roads to and fro and also the Hanoi Hilton. I would have to visit Hanoi again. I am told that it is a nice place.

HEART NEWS OVER THE WEEKEND

Over the weekend, I was participating in a small, select ASEAN cardiac meeting organised by Sanofi Aventis, in Hanoi. The topic was on Hypertension, and my task was to speak on " Emerging strategies for the management of CV risk factors in Hypertension ". With Sanofi Aventis, it means the use of ARB ( angiotensin receptor blocking agent ), irbesartan in hypertension. Initiall, I thought that I will do a blog on that and talk about ARBs and hypertension.
However, yesterday, I picked up a Medscape article on the importance of cutting down sugary drinks and its effect in BP reduction, and also another article that just appeared in the BBC news health section, on the possible relationship between ARBs and cancers.
I thought that I will blog on this as the news is more important.

Drink less sugary drink to reduce BP
Dr Liwei Chan and colleagues at the Lousiana State University Health Center, published a small 810 adults with hypertension study which showed that if we were to drink 1.3 servings less of a sugary drink per day, we would drop our blood pressure significantly. This was part of the findings from the PREMIER study, funded by the National Heart, Lung and Blood institute, and published in the May24, online edition of Circulation. They felt that the mild BP reduction in patients with pre-hypertension and mild hypertension, was due to taking less caffiene and other stimulants which maybe present in the sugary drink. Of course the fact that your weight may come down also helps.

ARBs and cancers
The next article of public interest was highlighted in BBC news, health section. They highlighted an article, published in the latest Lancet Oncology, of a review of publicly available records of all cancers and cancer deaths, on about 93,000 patients and related them to se how many were also using ARBs for various reasons. The study was led by Dr Iile Sipahi, of the University Hospital Medical Center in Cleveland, Ohio. They found a correlation. They conclded that for every 105 patients on ARBs, there were one case on cancer diagnosed. This is alarming. Basically, in their review of 93,000 cancer patients, there was an incence of 7.2 taking ARBs and 6.0, not taking ARBs. And this was statistically significant. Interesting.
For alongtime, since a 2003 study, we have always been very concern about the effects of ARBs in new vessel formation ( neo-vascularisation ) and also on apoptosis. New blood vessels promote cancer growth. Apoptosis is programmed cell death, and there are currently some theories, that if cells do not die at the program time, there will be over abundance of cells and so cancers. Interesting.
However, I must quickly warn that althought this paper gives food for thought, it is by no means confirmatory. It obviously requires more study. PLEASE DO NOT TAKE IT AS PROVEN. For those of you on ARBs ( which are very good drugs ), please do not stop them without your doctor's advice. Consult your doctors first.
I will post on the Hanoi meeting later.

PAIN-KILLERS ( NSAIDs ) AND THE HEART

If you will remember, about 5-6 years ago, we were all concerned that VIOXX, a new pain-killer then, maybe causing more heart attacks. Just a brief overview. There are many types of pain-killers in the market. However, for common pains, especially arthritic pain, many of us use voltaren, or ibuprofen, or naproxen. These drugs belong to a group of drugs called the NSAID ( non-steriodal anti-inflammatory drugs ), as opposed to steriods which is also a powerful pain killer but with many side effects. NSAID however suffered from a propensity to cause gastric upset and bleeding. Researchers then found a new group of drugs called the COX2 inhibitors, which were anti-inflammatory ( reduce inflammation and pain ), but does not upset the gastric. They thought that they have found a blockbuster. As it turns out in 2004, the use of VIOXX ( the first COX2 inhibitor to hit the market ), was associated with an increase incidence of heart attacks. It was quickly withdrawn, amissed much "hooha" and many court cases are still pending.
Even as we were concerntrating on COX2 and the heart, we seemed to have forgottent to investigate the older version, NSAID and the heart. Is NSAID safe?
Well, the June 8th issue of Circulation, Cardiovascular Outcomes carried an article by Dr Emil Loldrup of Denmark. He and his colleagues in Denmark, did a search on 1 million Danes, who had used any NSAID, and related these to deaths from cardiac causes, including heart attacks. They found that the use of all NSAIDs were associated with an increase incidence of heart attacks. The worse being diclofenac ( found in Malaysia in 2 common brands namely voltaren and also cataflam ). The safest being Naproxen. Diclofenac was as dangerous as VIOXX.
Before we all panic, we must remember that this is an observational study, and the data collected is not very reliable. It depends on how deaths have been reported. The fact that someone has a prescription for diclofenac does not always mean that they took them.
It however gives us a rough guide that we should use diclofenac with some caution, especially if you have a high CV risk profile.
I have always advised my patients that we should only use drugs when they are clearly indicated, not as smarties whenever we feel like it. With reference to NSAID pain-killers, if you have a high CV risk profile, use them with a small daily does of aspirin.
As usual, remember, drugs and any therapy must always do more good then harm. If you are not sure, ask your favourate GP. That money is not worth saving.

MOH REPLY TO GROUSES ON PRIVATE HOSPITAL FEES.

I picked up this MOH reply to the article on " Monitoring Private Hospital fees.

Healthcare: Send grouses to ministry
2010/06/10DR NOORAINI BABA, Director Medical Practice Division Ministry of Health letters@nst.com.my
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THE Ministry of Health would like to refer to two letters published in the New Straits Times -- "Where do I take this complaint?" and "Medical insurance: Monitor private hospitals" dated May 27 and June 2 respectively.
The existing dichotomous public and private healthcare system allows the people to choose their preferred healthcare provider based on their eligibility and ability to pay for the services. Currently, the public continues to enjoy heavily subsidised healthcare from public healthcare facilities even though the premiums for medical insurance are said to have been on the increase.
However, the ministry realises the importance of equity and accessibility to good healthcare and this is one of the reasons to closely monitor and regulate both public and private healthcare facilities and services.
The Private Healthcare Facilities and Services Act 1998 (Act 586) and its regulations regulate and control the professional fees imposed on any patient for services rendered by medical practitioners by virtue of the Seventh Schedule (for private clinics) and Thirteenth Schedule (for private hospitals and other healthcare facilities). Hospital charges, on the other hand, are not regulated at the moment in view of the complexity, including the wide variation and choices available to the public within the private healthcare delivery system.
It is unethical to subject patients or insurance companies to unnecessary or unindicated articles, including tests and drugs, and medical practitioners and private hospitals should be held responsible for the additional and inappropriate healthcare costs. All medical practitioners should uphold the professional ethics of the medical profession in managing their patients and adhere to the Code of Professional Conduct issued by the Malaysian Medical Council under the Medical Act 1971 (Act 50).The writer may not be aware that a mechanism to complain against private hospitals is available under Act 586 and in place at all private hospitals.
Any grievance against private hospitals can be submitted to the relevant hospitals where a reply should be provided by the hospitals within 10 working days. For unresolved grievances, complaints can then be submitted to the ministry. Last year, 55 disputes pertaining to the reasonableness of fees, including those from the public and insurance companies, had been received by the ministry. On the other hand, any complaint against unethical practice or misconduct by medical practitioners can be dealt with under Act 50. In addition, the ministry is working closely with various stakeholders to ensure that the professional fees are adhered to.

For enquiries or complaints, email ckaps@moh.gov.my or call the ministry at 03-8883 1302 or 03-8890 6086 or write to the following address: The DirectorMedical Practice DivisionMinistry of HealthLevel 3, Block E1, Complex E,Federal Government Administrative Centre62590 Putrajaya.

IN APPRECIATION.

Following the "FPMPAM Weekend Seminar in Cardiology for GPs 2010 ", I received this email, that I would like to share with all of you. The writer appreciates the effort of all who helped to run the course I am sure, including the faculty, secretariat, and all the sponsors.

" I am writting this email to convey my great thanks to you.I got your email address from MSD rep. I am one of the participants who attended your ECG Workshop 9.5.2010 during Weekend Seminar in Cardiology for GPs in Ipoh. Just to share my story with you... 21.5.2010 4.10pm 55 y/o Malay gentleman walked in my clinic alone by motorbike.He looked unwell to me - cold clamy sweats but fully alert and concious. He said he has chest discomfort.I straight away did ECG for him. My record shows that he came once in 2008 for polyuria. RBS was 22mmol/l. I gave him Glucovance 500/5mg bd X 20's with TCA 1 week but he never came back. He admit that he did not continue the tablet after finished them. ECG: SR 83/min. Marked ST elevation 2,3, aVF, V2-V6.RBS=20.7 mmol/lBP: 137/72mmHg Called ambulance 4.20pm hot line (GHI) informing about he problem.While waiting, I gave him: T. disprin 300mg stat, T. plavix 300mg statOxygen vis mask 5 litre/minIV branula 18G on right hand. Ambulance arrived 4.30pm but later found out that their oxygen tank is empty.I lend them my tank. 10 days later, his wife came to visit me (and to settle the bill). She told me that her husband was in CCU for few days and later discharged with TCA in GH Penang (?for angio) Many thanks to you again for updating me during the course.Because of that I managed to give good services to my clients. Have a nice day".
Regards: XXXXX

Every now and then, someone appreciates.
It makes all the pains worthwhile

PHYSICAL FITNESS AND HYPERTENSION

I have always held the view that hypertension is better prevented then cured ( which is not possible ). As a community health prevention program we, could do more good then all the pills that we push out. Losing weight, eating less salt, avoiding diabetes, avoiding stress, sleeping better, and also being physically active.
The June 1st online edition of Hypertension, carried a report by Dr Mercedes Carnethon et all from Chicago, on physical activity, fitness and hypertension. Study 4,618 subjects aged 18-30years ( young people ) , over 20 years, he found that those who were physically active and fit, had a third lower incidence of hypertension. They did define physical activity by treadmill exercise and also physical activity reports weekly. Their study is called CARDIA ( Coronary Artery Risk Development in young Adults study ).
Healthcare cost is rising. If only the government would put in place some good preventive programs, that would save many from suffering from these chronic lifestyle diseases and save alot of suffering and deaths. That would be money well spend.
Just for closing, know that cardiologist would like to suggest physical exercise, eg brisk walking that all of us can do, about 3 times a week, and about 5 kilometers. A total of 15 kilometers a week. As I tell many of my less scientific patients, just exercise three times a week until you break out in sweat each time. Do not push yourself too hard if the bosy is tired. Never over do it.
A nice pair of walking shoes and a safe walk area or park really helps.

HOW CAN WE REGULATE MALAYSIAN PRIVATE HOSPITAL BILLS?

Thanks saudara MBI. I do not know how to reply to you, except through this blog. I hope you dont mind me sharing openly, your comments.
I am very interested in your way of trying to monitor and regulate private hospital bills. You may have a point here. Please teach me more. What constitute " fixed cost " and what constitute " variable cost". Can I assume that fixed cost is capital cost like land, electricity, etc? and variable cost is like for the treatment of that particular treatment? Where does HR cost ( a significant portion ) factor into? I will certainly discuss your approach at our next meeting on fees and see if it is workable. The last meeting scheduled for 4th June, the " Association of Private Hospital Malaysia " representative said that he cannot make it, so the meeting was postponed.
I was thinking more in-line with trying to suggest that we monitor and collect bills, to see the trends, and then try and cap the " mark-up". I have learn that mark-ups are so arbitrary, that it is like a free licence to increase profit margin.
You may wish to know that when I did the first angioplasty in private practice, the cost of angioplasty was about RM7K. I pitch it that way because coronary bypass surgery at that time was about RM15K. (This was back in 1998 ). This was because of the risk of re-stenosis with angioplasty. so basically 2 angioplasty for the cost of one bypass. When the stents came ( 1992 ), and these were bare metal stents, angioplasty + stents cost about RM 10K. The bare metal stents cost RM 3,500 each. At that time, the private hospital ( citing uncertainty that the venture will take off-this was in 1992 ), refuse to buy the stents, so I had to physically buy each stent for each patient, and carry them in. Johnson & Johnson ( the maker of the first stent ) was very kind to me, sold me the stents at cost, also gave me some stents to go to China to show them how to do it. When the drug coated stents came to us in 2002, although we implanted the first again, we lost oversight of the market. By 2002, angioplasty was very established and many, many interventionist were implanting them, using various mix of stents ( some FDA approved, and many not ). You may wish to know that FDA approved drug-coated stents, on the average, should cost about RM 5,500 to RM 7,500 ( before hospital mark-up ). Currently. an angioplasty with one drug coated stent ( FDA approved ), should be about RM 20K ( RM 12K for the cost of angioplasty, basic, and RM 7,500 for the cost of one drug coated stent ), before the mark-up. ( I assume that the procedure was straight-forward and uncomplicated ). The rest of the money collected is pure profit. Plain and simple. I would like all of you to know this, as we have observe the whole scene as it developed from 1998.
Dear MBI, if you wish to discuss further, please email me, then we can discuss privately.

HOW CAN WE REGULATE MALAYSIAN PRIVATE HOSPITAL BILLS?

I would like to seek your help in giving me some suggestions as to -
1. Can we regulate private hospital bills?
2. How can we regulate private hospital bills?

The ministry of Health say that they are keen to look into this. They would like very much to contain private healthcare cost. They notice that cost has escalated tremendously.

A meeting is coming and I have been asked to make reasonable suggestions.

Please help by giving me some suggestions. Please use the comments section to do so. I will read and collate.

Thank you.

REGULATING MALAYSIAN PRIVATE HOSPITAL BILLS, IS IT POSSIBLE?

This piece was written in response to a newsreader's comments that came out in the letters to the editor in NST on 2nd June 2010. It was send to the editor of NST today for his attention.

Dear Sir,

The Federation of Private Medical Practitioners’ Associations, Malaysia (FPMPAM) support the call by TSK calling on the government to monitor private hospitals (NST on-line 2.6.2010)

What TSK has written must be considered seriously. It is an important issue that needs to be addressed urgently. Nowadays, private hospital bills reaching RM100K is not a rarity anymore. FPMPAM find this trend extremely alarming.Th e public is of the perception that high hospital bills is a result of hefty doctors’ fees. This is not true. It should be noted that the average doctor’s professional fees forms about 10-15% of the overall private hospital bill.

The provisions of the Private Healthcare Facilities and Services Act 1998 and Regulations 2006, has NO provisions to regulate hospital bills. It regulates only the professional fees for doctors. Any doctor who cheats or overcharges should be reported the Ministry of Health for action. There are specific provisions in law and the Code of Professional Conduct of the Malaysian Medical Council that can deal with this.

However, as there is NO prescribed schedule for private hospital fees, private hospitals are free to charge as they see fit. Ultimately, they answer only to their shareholders.

The FPMPAM have made regular representation to the Ministry of Health on this matter. The usual response is that it is not possible to control hospital fees, as there were different classes of hospitals providing different class of services i.e. 3-star to 6-star hospitals.. The situation in some hospitals have reached to a point where doctors themselves find it hard to advise patient on the cost of hospitalization. Often, the hospital bills end up way above what was originally estimated and the doctor is accused of over-charging.

Now that most of the major private hospital chains are owned and operated by GLCs, we wonder whether the MOH will loose the political will to take appropriate action.
We urge the patients and the public to speak out against this disturbing trend. We call upon elected leaders and members of public office should take heed and institute appropriate measures to protect the patients and the public.