CALCIUM SUPPLEMENTS AND YOUR HEART

In my many years in private practice, almost all my old dears that I see are on calcium pills, either prescribed by their GPs for osteoporosis and " foong supp" or taken on the advise of a friend or a friend of a friend. It is true that bone density scans are now commonly done in many urban centers and osteoporosis is very common in post-menopausal women. So calcium supplements are almost routinely prescribed. There are also milk formulations with added calcium, and many other food products with added calcium, supposedly for the post-menopausal.
Well, in the latest issue of BMJ ( British Medical Journal ), Dr Ian Reid and colleagues from the University of Auckland, New zealand, have published their meta-analysis of 11 studies, of 12,000 pateints with at least 4 years followup. They were trying to find out if there is any correlation between calcium supplements and heart disease and strokes. All the studies had one group on calcium and the other on placebo ( not on calcium ). They found that after 4 years of followup, there was a 30% increase incidence of heart attacks in the group taking calcium supplements. Now that is alarming. It is important to note that this is a meta-analysis, and not a randomised, controlled trial.
They did further analysis, and found that for every 1,000 patients on calcium pills, followed for 5 years, there will be 14 more heart attacks, 10 more strokes ( not in the same patients of course ) and 13 more deaths. There were also 26 less fractures, and 37 more adverse reactions. Interesting.
One must always remember that meta-analysis is taking studies which have populations that you would like to study, match them together using your sophisticated computer software, and make them answer questions, for which they were not meant to answer in the original clinical trial. It is very much an after-thought clinical study, with all their inherent shortcomings. The conclusion must not be taken for fact. At best, the conclusions give us an idea of what may be true and generate a hypothesis for us to study further. A meta-analysis is not fact, but should lead to further studies to find out the truth.
Anyway, for whatever good, it would appear that calcium pills are not so harmless and may be related to a higher incidence of heart attacks and strokes.
I for one ( and I am not the only one ), am stump as to how to explain these findings. To the best of my knowledge, I am not aware of calcium being a part of the atherosclerosis process. I also did not know that calcium is a trigger for CVS events. Along the way, the accumulation of calcium ( if the patient's vitamin D levels are good ), in the blood stream could either initiate the artherosclerosis process or act as a trigger for acute CVS events. I know that calcium can trigger arrhythmias.
Anyway, the take home message must be that we should only take pills if they are clinically indicated and not just for fun sake. Even health supplements may not be so innocent afterall. It is no good that in trying to prevent 26 fractures, to cause, 13 deaths, 14 heart attacks and 10 strokes, when using calcium supplements.
There is an alternative to fight post-menopausal osteoporosis, and that is called exercise, fresh air and sunshine. This will also avoid hypertension, obesity and even diabetes.

TICAGRELOR. FDA APPROVED

Yesterday, the FDA approved the use of ticagrelor, in the management of STEMI and also unstable angina and NSTEMI. I suspect that the decision was made because of the obvious benefit sen with the use of ticagrelor, in the PLATO trial, that was announced in ESC 2009 in Barcelona, and also simultanoeusly published in New England Journal of Medicine then.
That means that there are now 3 ADP receptor blocking agents for us to use in the management of STEMI and NSTEMI. More competition and also allowing us to individualise therapy, should the need arises. Also, hopefully, competition will bring down price, as it should in a free market economy.
Ticagrelor is another platelet ADP receptor blocker, like clopidogrel and prasugrel. But thats where the similarity ends. Firstly, it is not a pro-drug, thereby avoiding the problem that we now see with clopidogrel ( the problem of hypo-responsiveness because of the 2C19 allelee ) and other potential d-drug interaction. Secondly, it does not stick so strongly in the ADP receptor, allowing a more rapid onset of action and also some reversibility in its action. That has obvious advantage in that patients with unstable angina with undetermined anatomy, can undergo PCI loaded with ticagrelor. In the event that the anatomy is unsuitable for PCI, the patient can savely undergo CABG without too much worry of excessive bleeding or excessive blood transfusion. At least that's the theory. I say "that is the theory" because in PLATO, there was an excessive amount of bleeding ( when compared to clopidogrel ), especially hemorrahgic strokes ( and that is worrying ), that has yet to find a suitable explanation. I think we saw a bit of that with prasugrel against clopidogrel too. Looks like clopidogrel causes bleeding but much less then the other two. Rapidly reversible effect of of ticagrelor also has a downside. Should unstable patients on patients on ticagrelor following DES inplantation forget 1 or 2 doses of ticagrelor, the stent could thrombose or the lesion could become unstable again.
Yes, there are also side effects that were noted, including dyspnea. The dyspnea is difficult to explain, but AstraZeneca ( the manufacturers ) say that the dyspnea is usually mild and also reversible on stopping the drug.
Of course, the other issue is cost. I do not thing that new medical advances come cheaply. I am sure that Astra Zeneca knows that too and will plan their marketing strategy accordingly.
All in all, there is now a third ( I expect it to come to Malaysia soon ), ADP receptor blocker, anti-platelet agent. There are now 5 anti-platelet agents.
Not surprisingly since, CAD is so common and deadly, and anti-platelet therapy is so essential in the management.
Welcome aboard Ticagrelor ( AstraZeneca ).

NATIONAL HEALTH FINANCING MECHANISM: MALAYSIAN HEALTHCARE TRANSFORMATION UNDER 10th MALAYSIA PLAN

On saturday, the STAR newspaper wrote a feature article on the National Healthcare Financing mechanism, the Malaysian Healthcare transformation under the 10th Malaysia plan. Well one thing is for sure, I do not think that there will be any transformation in the next 5 years. The minister did say that there are four essential steps ( in his opinion ). By the time the 4th step is in plave, I rather suspect that this present minister will be gone and so will many of us. In the immediate future, I expect that there will be some improvement in public hospital services and rise in fees in private hospitals.
Anyway, I was rather disappointed in the research done by the Star investigative team. It is tru, that at the moment, whatever the Minister of Health had announce was vague, but I felt that the Star team could have done a better job looking into the proposed plans, because, those details are known to many in the industry as the ministry of Helath had systematically called meetings with many of the stakeholders to brief them, including ourselves. Dr David Quek ( President of MMA ), was at the meetings and ( unless he had forgotten ) know many more details. Interviewing fresh young specialist in the healthcare industry serves only to get personal opinions, but not help the bigger picture of what is coming ahead for the nation. Many of us from the profesional societies have dealt with these issues an know the many pros and cons.
It also seem to be the opinion of the writer of the articles that the present system is so very poor that transforming it is the only way out. Nothing can be further from the truth. As we have said over and over again, the present system is basically good and needs to be primed with a greater injection of funds ( increase healthcare expenditure from the present 4% of GDP to 8% GDP ) or from the present 7% of total national budget 2009 to 14% of national budget 2010. No need new taxes ( that is what this new scheme requires ), just make better use of what you have now. Cut down the leakages.
There seemed to be a thinking that we can have equal standards of healthcare for everyone. Nothing is further from the truth. Whatever you do, and wherever you go, the rich who can afford it will get better care, and the poor, lesser care Sad to say, that is the fact of the matter. BUT we must strive that all will have equitable care. All Malaysian must have access to good basic healthcare.
The article on saturday began by giving examples of patients in desperate financial needs, trying to get public sympathy and donations for treatment of some rather complicated condidtions. Well, I sat through some meetings on the previous, proposed national health finaancing mechanism ( there were many previously ), when we had to work out ( should there be national health insurance ) which conditions should be covered. There is no blank cheque to cover and pay for all medical conditions. We had to categorise payments for conditions which must be covered ( MUST HAVE ), conditions where payment may be necessary ( SHOULD HAVE ) and conditions where payments which may not be covered ( NICE TO HAVE ). So not all medical conditions will be covered. That is health insurance, they teach me. If insurance were to cover ALL conditions, a few complicated cases can blow the whole budget.
Undoubtedly, with all health insurance, there have to be rationing, and the decision can be very emotive. Those deprived will make those who deprive them of cover, look like butchers. The fact of the matter is, there is a fixed amount of money to take care of the naton's health. If you have RM 1 million, would you rather use it to treat 10 complex cases ( who may or may not recover ), or treat 1,000 cases and restore them to good health so that they can be productice to society?
Would you use your money, to prolong life for another 9 months, someone suffering from cancer ( who have a high chance of recurrence ), or use it to treat curable childhood diseases?
Yes, rationing sounds so bad, but those are the facts of life.
10th Malaysia plan healthcare re-structuring and transforamation, well we have written about it in February when we were briefed, lets see, what happens.

PHCFS REGULATIONS AMENDMENT COMMITTEE MEETING, 22nd July 2010

Well after 4 years of the regulations being launched in 2006 by YB Dato Dr Chua Soi Lek, we are still haggling over the amendments to the regulations. I think that it is fair to say that the regulations were so poorly drafted. The Act itself, comes in three parts, viz, those governing the private clinics ( small book ), those governing the dental clinics ( small book ), and those governing healthcare facilities and private hospitals ( big book ).
Hopefully, after yesterday's meeting ( we spend the whole afternoon haggling ), we have finished amending the small book, except the professional fees schedule. The fees schedule is causing so much headache, from all the stakeholders, that it is always in dispute. This will allow the rest of the amendments to pass through and have the Minister sign in. Then the regulations can be fairer and better for the doctors and patients.
In fact, we have asked MOH to consider, de-linking the fees schedule from the rest of the regulations. In fact, I made a proposal that we should scrap the fees schedule. Of course MOH said that is not possible. I proposed that we scrap it ( fees schedule or schedule 13 ), because, no doctor seem to agree with it, and so the more adventurous amongst us will think of ways and means to overcome it " legally ", making policing extremely difficult and tedious. By capping fees, we are not actually a free market. Anyway, how come professional fees are being capped ( 15% of overall fees ) when hospital fees are not ( 85% of overall fees ). Seems like severe discrimination.
For my friend out there who was advising me, yesterday when I raised the issue about capping hospital fees, the Chairperson ( she had two meetings ago raised the issue of looking into the possibility of having a hospital fees schedule ), now says that it is not possible. I must say that I am not surprised. Many things can happen in three months, to change some people's mind.
What to do? Now they are talking about transforming the whole system.
Malaysia boleh.

ANTI-PLATELET AGENTS, UPDATES

As I was looking over the medical literature and also after the weekend with Astra-Zeneca, I realised that the push in anti-platelet therapy is towards better monitoring, of anti-platelet activity and also the coming of new agents. The issue of bed-side identification of who is a responder and who is a hypo-responder, by genetic testing, seemed to have waned. Maybe it is not practical.
To begin with, lets establish that anti-platelet agents are basically blood thinners for the arterial system, where blood clots form primarily from rupture or tear ( loss of the integrity of the endothelium ). This is not the same as blood clots in the venous system or cardiac chambers, where blood clots form from blood clooting factors or stasis. This latter require warfarin or warfarin like drugs.
Since 2006, interventionist in particular have been struggling with this issue of stent thrombosis., be it subacute or late. It would appear that the acute stent thrombosis that we see, so occasionally now, is invariably due to technical factors at implantation. And the very late stent thrombosis and maybe also some of the reasons for late stent thrombosis, could be due to the polymers and reactions to the polymers of the DES ( drug-eluting stents ).
So far, it appears that the issues of subacute and late stent thrombosis maybe related to the lack of anti-platelet activity of the anti-platelet agents used. That gave rise to the efforts to find out which patient do not respond well to anti-platelet agents, primarily clopidogrel. We rely so heavily on clopidogrel. This search resulted in the findings that some of us carry a gene which make us hyporesponders to clopidogrel, the CYP 2C19 gene. There were attempts to produce some rapid kit to identify these people. Looks like that effort did not quite catch on, at the moment. Some of us just take the easy way out. If we should suspect clopidogrel hyporesponders, we just double the dose of clopidogrel. That is not my purpose on this blog.
I wanted to highlight that looks like much effort is being undertaken to produce a bedside kit to assess the efficacy of clopidogrel by the bedside. Back in 2006, when I enquired about this bedside kits, they were cumbersome to use, and not so easy to standardise, resulting in many inaccuracies. However, many recent publications seem to suggest that there are simpler and better kits out nowadays, to see the degree of platelet aggregation follwoing a dose of clopidogrel. A recent paper by Dr Dirk sibbing of Munich Germany, in the Journal of the American College of Cardiology, July 20th suggest that this is feasible and gave an accurate assessment of anti-platelet activity, allowing us to identify the hyporesponders ( platelet aggregate count of 468 or more, just before PCI ) or the hyper-responders ( aggregate count of <188 ). Of course, should the count be too high, it means more clots and thrombosis, and if the counts are too low, it means a higher risk of bleeding. I also heard this point being made over the weekend by Dr Gilles Montalescot.
Of course, so as to give our patients a choice, new drugs are also being developed where hopefully, we do not have this problem of non-responders to a drug. I think this is a wishy dream. The new drug being talked about more and more is ticagrelor, a new fast acting, non-prodrug, with good anti-platelet activity which is reversible to stopping of the drug. How ideal? But always remember, that fast on, fast off also has its problems, principal of which is loss of drug activity should you forget one or two doses.
Of course, the bottomline is that with medical progress and better therapy, the cost goes up. So what is new?

ASIA PACIFIC CV SUMMIT 2010

I spend part of Saturday and Sunday attending the Asia Pacific CV summit at the Hilton KL, at the invitation of Astra Zeneca. I was quite amazed that a pharma meeting could have such a grand title. It looks like AZ is trying very hard to re-invent Rosuvastatin, their number 1 product. They did bring down here quite an array of overseas faculty. No really big names. There was also a satellite symposium session from the American College of Cardiology featuring Dr Paul Ridker and Dr Antonio deMaria, speaking from the USA.
AZ does have quite a few good CV drugs which can help our patients. Of course the most popular and best selling, I think is Rosuvastatin ( Crestor ) for LDL-C lowering, anti-inflammatory and as we heard at the weekend, also a fairly effective HDL-C raiser. The data presented seemed to suggest that Crestor >20mg daily is safe. That is not quite my understanding. It is nice to know that if you care to use crestor >20mg, you may get to raise your HDL-C by 15%. Then again, there seemed to be some difference in protection between endogenous HDL-C and drug stimulated HDL-C. We learned this hard lesson from the " Torcetoprib fiasco ', the hard way.
Certainly, the data on rosuvastatin lowering hs-CRP is very firm. I must say that lowering hs-CRP is protective, except that I do have some difficulty finding a reliable hs-CRP laboratory. They seem so variable, depending on when and which lab measures them. In fact, looking at world-wide literature, accurate hs-CRP measurement seemed to be a " Paul Ridker Boston phenomena ". Many of us cannot get the same consistency and reliability.
I was very surprise at the lack of discussion on Candesartan, another important AZ product for BP control and CV risk modification. I wonder whether the organisers felt that they should avoid the on-going ARB - cancer controversies. CHARM was only mentioned in passing.
I wen there partly to hear Dr Gilles Montalescot discuss the new anti-platelet agent, ticagrelor, which I thought AZ was trying to launch. There was passing mention made on Ticagrelor, but I thought that Dr Montalescot was very fair, in mentioning more of the current problem with Clorpidogrel and also Prasugrel. In the limited time given to him, he dealt with the topic quite well. A good overall perspective.
Looks like there will be another meeting on Ticagrelor, which looks promising, given the data from PLATO. A reversible ADP receptor blocker can be useful, although it does have some downside. One day we should discuss PLATO here.
All in all, a good effort by AZ, but I fear that it may have cost them a bomb, flying so many speakers and delegates from all over Asia Pacific here.

REMOVAL OF SUGAR SUBSIDY. A GOOD THING

Last night, the Prime Minister announced the removal of many subsidies, including the removal of the sugar subsidy.
We have always advocated a reduced sugar diet, in an attempt to reduce the many dangerous chronic lifestyle diseases that so burden the healthcare delivery system. Obesity, diabetes mellitus, hypertension, strokes, heart attacks, and some even claim cancers, can be reduced, if we consume less sugar. In this matter of reducing sugar subsidy, so that Malaysians hopefully will consume less sugar, we must support the Prime Minister. Even he must lose weight. In 2009, Datuk Shahrir Abdul Samad announced that Malaysia is the 8th largest consumer of sugar in Asia. 7 out of every 10 Malaysian adult suffer from some form of adult lifestyle disease. We have the 4th highest incidence of diabetes in Asia, and the numbers are growing. In 2007 there were estimated 800,000 diabetics in Malaysia, and in 2010, that number has climbed to 1.3 million. According to the National Health and Morbidity Study, the prevalence of diabetes in 1986 is 6.3%, 1996 8.3% and in 2006 14.9%. As we all know, diabetes, hypertension and obesity are cousins. They travel together and they cause heart disease, strokes and kidney diseas. There are 6 strokes occuring in the country, every hour.
We take in 26 teaspoonful of sugar every day ( how did we do that? ). No, none of us take in naked white sugar, but we consume carbonated drinks ( 7-10 teaspoonful of sugar ), teh tarik ( 10-12 teaspoonful of sugar ), packet fruit juices ( 7-10 teaspoonful of sugar ). My standard challenge to my patients to convince them is to ask them to spill some coca cola on to the table and touch in with their fingers to feel the amount of sugar in the sticky drink.
I believe that I have made my point.
It is equally important, if not more important to know that physiological speaking, we do not need any of these sugars. we are drinking just for fun. We can live happily and healthily without any of these added sugars. It just all go to making us more fat and diabetic and hypertensive.
I sure hope that we will all be more healthy and richer, if we take in less sugar. Richer, not just from saving 25cents per kilo of sugar, but richer in terms of less chronic lifestyle diseases and saving of medical bills, which can come to alot.
In this, we fully support the Prime Minister.

HEALTHCARE FOR FREE. NST 11th July 2010

I read in New Straits Times, 11th July 2010, an announcement by the Minister of Health that Malaysia is looking towards a socialised healthcare system. You may remember that in Feb 2010, I had written about a seminar that I was invited to attend, organised by the Ministry of Health. A seminar for the trasnsformation and restructuring of the Malaysian Healthcare system.
Well, Dato Liow has just made the announcement to the public. According to him, there will be increase taxation through the employer ( almost like EPF ), so that those who earn more, pay more into the fund, and those who earn less pay less. He calls it a contribution by those 18years and above who is working. He has also announce the setting up of the National Health Financing Authority, to administer the funds. He declared that the restructuring will come in 4 phases, namely, i) strengthening the healthcare system like governance and standards of care. ii) to grant more autonomy to primary healthcare providers in areas like human resource and management, iii) to integrate all public and private clinics so that they are all linked under a common network so that people can access either one, iv) introduction of the national health insurance under the national health financing scheme.
The justification for all these is that healthcare cost is too high, RM 13.5B in 2009. I have always reasoned at all the healthcare seminars, that for a public expenditure of RM 13.5B ( which is about 4% of GDP ), the healthcare outcomes are very good, making us one of the more cost effective healthcare systems in the world. It is tu that healthcare cost is rising, because medical science has improved and patients are living longer and better.
It is true that most of the specialist are in the private sector that looks after the minority of patients. This may not be entirely by design. It may be by default, because of the push to leave public service. It is always made out to seem like everyone leave public service for greener pastures ( more money ). But that is not entirely true. The push to leave public service is also significant.
Whatever it is, look like the Minister is testing the waters. Increasing taxes and increasing EPF contribution is not going to go down well with the rakyat, especially when we are being asked to tigthen our belts, with removal of subsidy and whatnot. I suspect that this will become a " hot topic " in the coming GE 13. I am sure that the government of the day knows that the opposition will make an issue of this given that our " wastage " and " leakages" is more then our healthcare expenditure. Would stopping, or reducing the leakages not be a better choice than increasing EPF contribution for all workers 18 years and above, especially in times of economic slowdown and removal of subsidies?

MORE ON ALBUMINURIA AND HYPERTENSION THERAPY AND CV RISK.

It would appear that this decade could see an greater medical emphasis on diabetes and hypertension, and in particular, indentifying risk markers, in an attempt to target our therapy. The recently concluded European Society of Hypertension, European Meeting on Hypertension 2010 featured another paper presented by Dr Roland Schmeiger of the University of Elngen, Germany, on a subgroup analysis on " On-Target ". On-Target is a very large ( 27,000 patients ) clinical trial carried out by Boerhinger-Ingelheim to compare the BP lowering effects of Telmisartan ( an ARB ) against Ramipril ( an ACE-I ), and Telmisartan + Ramipril comination. As we now know ( the results were annonced last year ), Telmisartan was not inferior to Ramipril and Ramipril + Telmisartan did not confer any additional benefit and does carry an incease incidence of adverse reactions.
Well, Dr Schmeiger and colleagues looked into those patients with hypertension who also had albuminuria. There were about 23,000 in total. They found that albuminuria was an important CV risk marker. When albuminuria increase over 32 months, the CV risk increase and mortality increase by almost 50% should albuminuria increase by 2 folds during follow-up. Fortunately, when albuminuria reduce by half, the CV risk and all cause mortality also reduced by half.
This analysis clearly shows that monitoring of albuminuria, in patients whilst on treatment with an ACE-I or ARB is important as it is an important risk marker. Less albuminuria means less longterm problem and more albuminuria means more longterm problem Surfice to say that monitoring albuminuria is relatively cheap and should be done at least 6 monthly.
However, I think that more work needs to be done. The data on prolong ACE-I and ARB therapy ( greater then 3 years ) on albuminuria and micro-albuminuria, is still lagging. Will these effects last greater then 3 years? Do we have enough data?
The other very interesting point which I am beginning to understand is the role of statins? Does statin therapy, enhance and prolong the good effects of ACE-I and ARB, on albuminuria? There is some evidence to say so.
Looks like all these work is paving the way for combo pills of the future.
However, I still maintain that the best answer to chronic cardiovascular disease is prevention through aggressive life style modification. If only the Ministy of Health will limit the amount of sugar and salt in our food. That will surely go a long way, at no great cost, except perhaps the cost of self discipline.

THERAPY FOR ALBUMINURIA AND PROTEINURIA. WHERE ARE WE NOW?

Recently, there have been an increase interest, generally of diabetes, and also more specifically on albuminuria and proteinuria. There is also the entity called micro-albuminuria. This is partly because of the undisputed fact that albuminuria is a risk marker for cardiovascular disease in diabetics. If you have diabetes melitus and albuminuria, your chance of having cardiac and cerebral events are higher.
Recently, 3 clinical studies have been either presented, which seemed to throw some light into this problem and also what can be done. In the subsequent write up, albuminuria is used as a term to also include micro-albuminuria and also gross proteinuria.
Firstly, at the ESH European Meeting on Hypertension 2010, Dr Cesar Cerezo, presented a paper that showed that chronic ACE-I / ARB therapy dose not seem to help albuminuria. This group in Madrid, spain, studied 1433 patients on ACE-I / ARB for the management of hypertension and albuminuria. All th patients had been on ACE-I / ARB for a least 2 years. The were continued on ACE-I / ARB and monitored for an addition 3 years. The group found that while therapy did improve blood pressure control and also lowered albuminuria, the efect did not seem to last after two years. After two years, although the BP control became better, the albuminin excretion seem to rise. This is puzzling. Of course we are all concern, because albuminuria is a risk marker for CVS events. Does this also mean that CV risk also rises with ACE-I / ARB therapy, after two years of therapy.
The second presentation involved the use of statins in patients with and without diabetes, called the PLANET I and PLANET II study. These two papers were presented at the European Renal Association-European Dialysis + Transplantation Association Congress. It was presented by Dr Dick Zeeuw of Groningen, Netherlands. PLANET I was a study of diabetic patients with albuminuria and PLANET II were patients with albuminuria but not diabetic. The study compared high dose atorvastatin with high and medium dose rosuvastatin, and their effects on these two groups of patients. Both therapy were given for a period of 52 weeks after an initial run-in period of 8 weeks. The researchers found that whilest atorvastatin lowered albiminuria in diabetics, it did not improve renal function. Rosuvastatin, on the other hand did neither. There was no improvement in albuminuria and also some deterioration in renal function. It is obvious then that we should not use rosuvastatin in patients with albuminuria as it may worsen renal function. It would appear that the control of albuminuria by statins, is not a class effect and rosuvastatin is not kidney friendly. The studies were however small, 325 patients in PLANET I and 220 patients in PLANET II.
Looks like much work still needs to be done in the area of albuminuria, hypertension and diabetes. For the moment, these are the facts.

DEFENSIVE MEDICINE AND THE RISING COST OF HEALTHCARE

I have always grappled with the issue of rising healthcare cost and what to do about it. Whenever we go to the ministry of Health for our meetings, we are constantly reminded the private doctors are expensive and private hospitals are expensive, and the cost keeps rising. One survey in the " Personal Money " July issue, rates healthcare cost inflation at about 27% yearly. It is no longer cheap to fall sick. Yesterday morning, the DG of Health, held a dialog with doctors about reviewing the professional fees. Doctors are asking for a rise in fees.
The June 28th issue of the Archives of Internal Medicine, carried a survey by Dr Tara Bishop and colleagues from the Mount Sinai School of Medicine, New York City ( good USA hospital ). Dr Bishop and colleagues surveyed the practice patterns of 2,416 physicians in New York to see how many are practising defensive medicine. Guess what - 91% are. Their reason, fear of litigation. It is fair to say that this survey was carried out to pressure the government to limit medical suits and awards, as the fear of litigation, is driving doctors to be ultra cautious, and to carry out more test and do more ( sometimes maybe unnecessary ) procedures, so as to " play safe ". When medical legal suits award rises, the medical indemnity for doctors also rises. This year, I paid RM 4,600 for my medical indemnity. I understand that my O&G colleagues are paying about RM 40,ooo for medical indemnity. PriceWaterHouse Coopers, in 2008 estimated that 10% of healthcare cost is contributed by defensive medicine.
When medical indemnity goes up, doctors practice in a very insecure envirinment. So they become defensive and do all that they can, to avoid missing any thing ( as if that is possible ) and so avoid law suits.
One of my patients, who is PR in USA, but Malaysian citizen told me the other day, that in USA, the lawyers will come to you, when they hear that you are unhappy with your medical treatment to encourage you to complain and sue. If they win the case for you, the awards is shared. If they lose, no charge.
How do you practice medicine in that environment. Physicians are not the worse hit. It is the O&G, orthopedics, neuro-surgeons, or mainly the interventionist.
We are seeing more and more legal suits being filed against doctors, in Malaysia. Not a healthy trend. The notion that when something go wrong with a patient, it must be the fault of the doctor, may not be correct. Yes, an agrieved patient must have the right to complain, and the medical authorities must hear the complain and look into it ( if possible with independent local experts assisting ). A reasonable explanation must be given. Lets avoid law suits and unreasonable awards, as in the USA. Maybe, we can, in a small way ( 10% ), reduce medical cost.

IS TESTOSTERONE SAFE?

Recently, I have heard of many men who are conscious of their age. It appears that more and more men are going for their botox injections to take away the wrinkles. Some are even trying out testosterone injections and cream. I am quite sure that testosterone will enhance libido, but is there a downside?
The June 30th online issue of the New England Journal of Medicine carried an article by Dr Shehzad Baseria of Boston on the " Testosterone in Older Men with mobility limitations " trial. This study involved about 209 elderly males, average age 74yrs. They were randomised and given transdermal gel patches. one group received placebo and the treatment arm consist of transdermal gel patches containing 100mg of testosterone. They applied the patches daily for 6 months. The trial was terminated prematurely by the data monitoring and safety committee, because of an increase in heart attacks and other CVS events, including hypertension, arrhythmias, and there was one CV death. There were 23 events in the treatment arm ( 106 pts ) and 5 events in the 103 patients in the placebo arm.
Granted that the numbers of patients are small, but I think it still gives us an idea that testosterone is not exactly harmless, even transdermal.
Oh, I nearly forgot. The patients who received testosterone transdermal, were obviously more mobile and active after the testosterone patches, so it did achieve its primary objective.