SORTING OUT CHEST PAINS IN ASIA PACIFIC ; ASPECT

The March 23rd issue of Lancet, carried a simple piece of work by the group from New Zealand on the evaluation of chest pains in the emergency department, in the Asian Pacific region. The study is called ASPECT - Asia Pacific Evaluation of Chest Pain Trial.
Sorting out chest pains in the ER ( emergency room ), can be quite a challenge. If you are too strict in your criteria, you may either discharge too many home ( and run the risk of deaths and AMIs at home ) with the attendant risk of patient complaints and law suits, or if you are too lax, you end up admitting too many chest pains and clog up all your hospital beds.
The group of workers from Christchurch, New Zealand, led by Dr Martin Than actually involved cases from 14 ER across the Asian Pacific regions, including hospitals in Hong Kong, Taiwan, Indonesia, Singapore, and Australia. This gives us the Asian flavour. They studied 3582 patients, age 18 and above who presented with chest pains of more then 5 mins duration. They categorised them into TIMI risk scores from 0-7, their ECG on presentation ( see if there are any ischemic changes ), and the stat Trop T, CK and Myoglobin, and 2 hours later. The primary endpoint was cardiac events at 30 days. They found that using these simple criteria, they could achieve a sensitivity of 99.3% ( they were not insensitive ), and they had a negative predictive value of 99.1%. that if the protocol predicts that the patient does not have cardiac chest pains, they were right 99.1% of the time. That is good, especially since the protocol cost is fairly cheap. In the USA, you may have to use the MSCT to exclude cardiac disease with chest pains, in those in the low and intermediate risk group.
I usually use a combination of what they do. In patients with chest pains, I think the history is very important and the associated cardiac risk ( TIMI risk score) factors. A good history of anginal type chest pains, and the presence of 1 or 2 cardiac risk factors, will make me very wary of sending that patient home. A good look at the ECG for ischemic changes, and a Trop T at point of care. Usually, this allows me to make up my mind whether to admit or not. I suppose the saying is true. If at the of all this, you are still unable to discriminate between cardiac or non cardiac pains ( and this can happen, especially in females with diabetes ), then admitting may be the better patient care option. Better to be over cautious then to risk a death at home.

A FAMOUS CARDIAC DEATH. THE LATE ELIZABETH TAYLOR

There are many of us who are charmed by Liz Taylor's beauty, not least, Richard Burton. She is a good actress, and obviously beautiful. Maybe you too, are one of her fan.
However, in 2004, she was diagnosed with heart failure ( the garden variety ), with a severe regurgitant mitral valve. In 2009, she underwent a percutaneous procedure, to implant a mitraclip device sub-mitral valve, to tighten the elongated and flail chordae tendinae, to reduce her MR. This was done percutaneously, without open heart surgery. She took the procedure well, and survived for another 15 months. She passed away, a few days ago.
The mitraclip device is another attempt by interventionist, to repair the mitral valve without the need for open heart surgery. Developed by Dr Ted Feldman, working with Evalve. Evalve is now bought over by Abbott Vascular ( the maker of the Xience V stent ). After their initial successes, Abbott Vascular has embarked on the REALISM registry and also the EVEREST 2 trial to test the clinical use of the Mitraclip against standard open heart surgery mitral valve repair in 37 sites. The 1 year results was presented by Dr Feldman at ACC 2010, and the 2 year results of EVEREST 2 is scheduled to be presented at ACC 2011, soon. I believe that Liz Taylor is a part of the trial. The 1 year results presented last Spring at ACC showed that the mitraclip performed as well as open heart surgical mitral repair, in terms of symptom relieve and LV function improvement and survival. It is widely believed, in our circles, that the results at 2 years will be just as good, except for Liz Taylor, I presume. I am sure that by now, the Americans will have expunge her mitral valve to study the pathology associate with the mitraclip, 15 months after implantation. This is required by the trial design. The earlier postmortem studies seemed to show that the lip just induces sub-mitral valve fibrosis and so some degree of shortening and tightening of the sub-mitral valvular apparatus. The pathologist seem to suggest that there is no mitral stenosis.
Well, I can only surmise that if EVEREST 2 is correct, the cardiac surgeons have one less surgery to perform, although I must say that the MitraClip cannot be cheap. It will surely be at Liz Taylor's price. God rest her soul.

OrbusNeich sues cardiologist over Genous stent data

I was reading through the internet news today. I came across this very upsetting piece of news at Heart.Org. I am very upset that a stent company is prepared to sue a clinician for reporting an unfavourable report on their stent, following a clinical trial. Orbus Niche is the company that manufactures the GENOUS stent, and the clinician being sued is one Dr Pavel Cerrinka of Masaryk Hospital, Czech Rep..
The clinical trial involved is called GENIUS - STEMI. It was a trial under Dr Pavel, which studied the use of the Genous stent in patients with STEMI. There were 100 patients enrolled and 50 received the Genous stent and 50, just cobalt chromium bare metal stents. The 30 days outcome was essentially the same. Dual anti-platelet therapy was used for 30 days. At 6 months there were 2x more MACE in the Genous group then the bare metal group. There were more TLRs and there were 3 stent thrombosis in the Genous arm. It is obvious that in this study, the Genous stent was not as good as the bare metal cobalt chromium stent.
With this news, Orbus Niche ( the maker of Genous ) was unhappy, and they decided to ask the trialist for an explanantion, and when the explanation was not to their liking, they sued the hospital and the principal investigator ( Dr Pavel ).
This is ridiculous. We are doing clinical trial to find out evidence of good effects and adverse effects. We cannot guarantee results. Otherwise, only positive results to the company will be reported, and negative results will be hidden. We will never know, which one is bad. I hope that this is a one off, bad manners in Orbus Niche company. Unable to come to terms that they have a stent which is not what they think it is. I must say that looking at the graphics and theorectical basis, the Genous stent, with the concept of EPC ( Endothelial Progenitor cell ) capture, is a very attracting concept. I never used it because, I was very concerned ( and I told Orbus Niche top guns too ), that when you switch on the capture you also turn on many other reactions that are not easy to predict. Along the pathway, the EPC capture, interacting with the monoclonal anti-bodies on the stent, turns on a whole series of reaction, some through the C34 ligand, and all hell can break loose. Having just returned from CIT 2011, Beijing, I asked my overseas colleagues ( corridor talk, which are usually acurrate ), their view of the Genous stent. They just told me simply, don't touch it. I am sure that Orbus Niche is not happy with that. But if that is the truth, the people to gain are the patients, and I am sure that Orbus Niche is here for the patients, or are they?
As far as I know, so far so bad for Orbus Niche. Their TRIA-1 study also showed poor results. As I always say, Genous is the only stent that performed poorer than Taxus in a control trial ( TRIAS-1 ). All other DES beat Taxus, or is non-inferior to Taxus.
Orbus Niche is not the only company doing this. earlier in 2007, NMT medical ( the maker of the LA appendage closure device for treatment of migraine ), sued Dr Peter Wilmshurst of the Royal Shrewsbury Hospital, UK, for comments he made about the device used in the MIST ( Migraine Intervention with STARFlex Technology ) trial.
I hope that these are not attempts by the " big boys" to muzzled the medical community. It is certainly a bad trend. When viewed with the fact that many interventionists are being sued in the USA, it makes one wonder whether there are too many lawyers in the US with nothing much to do, and doctors are easy meat.
In life we do have to accept our failures when it happens, go back to the drawing board, work out what is wrong, and get it right. Bashing doctors, is not going to help.

CIT 2011 - IN PARTNERSHIP WITH TCT. 16th-19th March 2011

I spend the major portion of last week in Beijing, attending CIT ( China Interventional Therapeutics ) 2011. Obviously my Beijing colleagues are very closely tied to the Americans ( TCT ). The meeting, which started on 16th March 2011, was held in the solemn shadow of the Japanese triple disaster ( 9.0 Earthquake, Mega Tsunami, nuclear disaster-level 5 disaster ). Everyone felt so sad for the Japanese, and of course many of the Japanese faculty did not turn up ( understandably so. Nonetheless, there were probably 2,000 ( my eyeballing ) attendees, mainly local interventionist and paramedics.
The course content was the usual bifurcations, CTOs, left main stems, IVUS, FFR, and a wide display of locally produced drug-eluting stents, and as usual, they do do their evaluations, with long term follow-up and the Americans are always very cynical of their excellent 2 year results.
I must say that China is doing alot of interventions, almost 250,000 last year with an estimate of 300,000 this year. They now have all the fancy toys, which we can only dream of. Fu Wai, where I was helping to start in 1993, is now doing 2,000 interventions a year and growing. There is a whole team of second and maybe third generation interventionist coming on. I observation that I made when I was chairing and moderating, was that the skills ( the hands ) are good. The decision making, is sometimes suspect. It only reflects that there is much work done, but the thought processes still have to catch up. All in all, it was a good meeting.
I did pick up a few tips and tricks. For example, you can use to FFR to interrogate and derive individual FFR for each lesion in tandem. It is false and inaccurate. There is more and more usage of the OCT machine ( the more expensive IVUS ). There is promise in the bio-degradable scaffolding ( the ABSORB stent ). The Chinese like the DKK-Crush, while we much prefer the Cullotte. I shared that which ever technique that you wish to use, in a bifurcation ( the accepted are Provisional T-stent, Cullottee, and the Crush ), learn it well, do it many, many well, and it will give you the best result. Trying what is fashionable, once in a while, may not be good for you patient. I was quite impressed ( and I told him so ) by Dr SJ Park ( of ASAN MC, Seoul ), work which showed that you could correlate lesion stenosis with FFR. That fact will prove useful. In the area of CTO, we are still lacking. Otherwise, we are OK, just that we lack hardware and also a co-ordinated way to keep our results, so that we know whether we are OK or not. It is a bit of a cowboy country now. Each man / women for himself / herself.
Because there was no MAS flight to come back on Saturday evening ( when the meeting ended ), I had to stay till Sunday, to catch the sunday evening flight back, so I got to go to Beijing city. I took the subway. Boy, for 2 yuan, you can go anywhere. I was staying near the Olympic Stadium. Going to Tian An Men was 14 stops on the subway, all for 2 yuan. A taxi would have cost me around 45 yuan, and I would have been stuck in traffic. Believe me, the subway is also crowded on Sundays, especially at about 10-11 am onwards. I do not know about later, as I was back in Hotel by 12 noon. I am sure that it will be crowed. The trains were on time, and the signages were good ( in Mandarin and English ).
Food prices have gone up. One of my little past time, was to walk around the locality, and eat at the local shop, where locals eat. When I first when to help in 1993, you could get a decent bowl of noodles ( la mein ), for 6-8 yuan ( no ambience dingy food shop ). Last year, it was around 15-18 yuan, and this year, it was 20+ yuan. The taxi fares advertised, was 1.20 yuan per kilometer. Now it is 2.00 per kilometer. Yes, there is inflation.
Well, it was a bit cold in Beijing, but not so bad. We were more concerned about the radiation fall out from Fukushima / Japan. There was no panic in Beijing. The Intercontinental Hotel, Beichen Beijing, is a very comfortable hotel, and near a subway line ( the Olympic Green station ).

THE RETURN OF AN OLD PROBLEM. ARBs AND AMIs?

I think the whole of the cardiology community is divided on this issue. Does ARB increase the incidence of AMIs? I remember, in the early 2000, there was a lot of debate about the earlier ARBs and AMIs and then On-Target came out , and showed that there was no increase risk. That was left that way.
Now, last summer, the early results of ROADMAP ( Randomised Olmesartan and Diabetes Microalbuminuria Prevention ). This trial involving 4447 patients with diabetes and at least one coronary risk factor, was randomised to placebo, or olmesartan at 40 mg daily, and followed up for 3.2 years. The early results released last summer, showed that Olmesartan did delay the onset of microalbuminuria, in this subset of patients, but it also showed an increase incidence of cardiac events. This prompted the FDA to ask for more information. Well, 9 months later, the ROADMAP has appeared in print in NEJM, March 10th issue, and the FDA has still not issued any statement, making one wondering what is happening. The ROADMAP, actually showed that there was a 23% delay in the onset of microalbuminuria. But this is severly offset by 15 cardiovascular events in the treatment arm, compared to 3 CVS events in the placebo arm. This is worrying.
There was also an earlier study, a smaller one to, studying the use of olmesartan to prevent microalbuminuria. That study of about 500 patients also showed a slight increase in cardiac events, while reducing the incidence of microalbuminuria.
Now, we are really confused? Does ARBs have an increase in cardiac risk? Is it the effective of BP to low normal levels ( the J curve effect ), that is causing the problem? Or are ARBs atherogenic, and also triggering events?
I do use alot of ARBs and so I am also a little concern. I searched the literature and consulted ( via email ) opinions from experts. They are also divided. Looks like we need more data, or a clinical trial looking specifically at this problem. It is an important issue to resolve, because ARB is otherwise a good drug.
I suppose, if we follow ROADMAP long enough, we may also get a better idea.

GREAT CALAMITY IN JAPAN THIS WEEKEND

I must take this opportunity to express my utter shock and sympathies with the people of Japan. I do not know how to express in words, what I saw on BBC TV. Looks like there is no defense against a tsunami. Houses, cars, trucks, ships, trains and buildings are like toys, in the face of the tsunami.
My condolences to all the people of Japan, for the lives lost.
I do have a few colleaques in Japan, mainly in the south and central Japan ( I did spend some time in Kita-kyushu ). I hope that they and their love ones are all well and safe.
I feel so sad. What a tragedy.
May God have mercy on Japan, in this their hour of need.

We are so fortunate in Malaysia. Thank God.

COFFEE ; THE NEW FEMALE NUTRICEUTICAL

Coffee is probably one of the most common imbibe beverage of all times. I must drink about 2-3 cuppa a day. It is nice to drink. I started when I was small, and have continued since. I need a cuppa to start the day. I hope that it does me some good too.
I just picked up an article from the journal Stroke, by the group from Karolinska Institute, Sweden. Dr Susanna Larssen et al, was studying 30,670 females as part of the Swedish Mammography Study. This study started in 1997, and the subjects were followed for an average of 10.4 years. All the subjects have no history of cardiovascular disease. They all filled in a nutrition questionaire, which include their coffee drinking habits. After follow up for 10 years, there were 1,680 strokes in the group, of which 80-90% were cerebral infarction ans the rest were cerebral hemorrhages. The stroke reduction rate noted was 22-25%. That is not bad. The researchers found that as long as you drink some coffee daily, there was a reduction in the incidence of stroke, after adjusting for confounding factors. It did not quite matter how many cups you drink, as long as it was not more then 5 cups a day. The protection did not get incrementally better, the more you drink.
Please note that this is an observational study, and by no means conclusive. But the simple truth is that if I drink 1-2 cuppa a day, I maybe protected, that speaks for itself.
The why of the observation is not so easy to answer. Much more work needs to be done. Is it the anti-inflammatory effect of the phenolic compounds in coffee, or the so called anti-oxidant effects of coffee, or the increase insulin sensitivity, noted with coffee, no one really knows at the moment, and this surely invites more study.
So, if you like a cuppa, please go on, especially if you are female. I am sure that it works for males too. I am not so sure about de-cafes?

MORE BAD NEWS FOR INTERVENTIONIST. UNNECESSARY STENTS

The March 3 edition of the Pittsburh Tribune carried a report that two interventionist in Pennsylvania has resigned their position as they were found to have implanted "unnecessary" stents in 141 patients in 2010. These comes after reports of unnecessary stenting by two interventionist in Maryland last year and another such case in Texas. Looks like interventionist are being held to account for the stents that they put down.
This raises the very important issue of medical audit. Can doctors ( in this case interventionist ) in practice do whatever they wish to " help" the patient or must he answer to another body, the community at large? How then do the community at large determine what is necessary treatment and what is unnecessary treatment?
This issues become more and more important as medicine is being viewed ( sadly ) as a business and doctors as businessmen. We are all in this for the money. Make as much money as you can!! This has gone against the very ethos of our long established profession, of always doing good and never doing harm ( it can be said in so many ways ), or as some will say, always putting the patient first.
How do we determine that these few interventionist being haul up ( I think there are more waiting to be hauled up ), have implanted unnecessary stents. Yes, I know that there are guidelines, written by societies. But, each patient is different, and a standard guideline cannot apply strictly to one and all. Whats even worse in Malaysia ( looking at our own community ), is that we do not do any original research, so we apt the west. Our guidelines are literally copy and paste from the west. Can you imagine, we just take it that Malaysian CADs are the same as American / European CADs, and Asian hypertensives and the same as American / European hypertensives, and we copy and paste their guidelines, sometimes even their value levels. How can that be, their size is different, their height is different, their diets are, how they live is different, but we follow their value. That is why so many of us, have NO faith in the Malaysian guidelines. I remember, one of the first guideline meetings ( this was in the 80s when guidelines were a fad ), I was invited to help write the Malaysian guidelines on dyslipidemia. I asked them the same. Of course, I was the dissenting voice ( as always ). I was never invited again, despite my seniority and significant contribution.
In the issue of stenting, the guidelines are even more controversial. Symptoms or no symptoms, FFR or IVUS or non? These increase use of devices to document, increases cost, and many interventional centers in Malaysia do not even have them. Triple vessel disease, left main stem stenting ( those less then syntax score 33, and those above syntax score 33 ), the Euroscore, the competency of the interventionist? These are all very complex issues. How then to decide "necessary" from "unnecessary" stents.
The other point that I observe from this story reported in the Pittsburg Tribune, is that the lay public in US is following what the medical community is doing. Interventional cardiology is a high profile discipline. Not to mention that there are many cardiac surgeons eying ( can I say, with a bit of disdain ) what we are doing. The public is watching and asking us to account.
If this trend continues, hospitals and medical centers will be asked to form committees to vet what we are doing. This is good, if it can be done fairly and justly. There is no perfect committee. Everyone have their axe to grind, with someone else, and so a good thing can become a witch-hunt for personal gain. I understand that the first two cases ( the ones in Maryland and the complaint in Texas ), may be personality motivated. There is an axe to grind, with the interventionists involved.
Anyway, interventionists ( doctors ) beware. The public is looking and may be asking you to account for what you do. Be a good doctor, and not a successful businessman. I think that principle should stand us in good state.
Interventionist, be warned.

MENOPAUSE AND YOUR HEART: THE SIGNIFICANCE OF HOT FLUSHES

The saying is true, that pre-menopausal females are protected from CAD, and when they reach menopause, the oestrogen/progestrogen balance is reversed, and they will then run the same risk of CAD as an adult male above 40years.
There is a recent paper that seem to focus the risk a bit more. Dr Emily Szmuilowicz at el, writing in the journal, Menopause, Feb 19th 2011 issue, described a study that they carried out under the " Women's Health Initiative Observational Study. It is an observational study. They observed 60,025 post menopausal women, and found that those women who experienced hot flushes early, early in their menopause, seemed to have a lower incidence of CAD then those who do not. Interestingly, those who experience hot flushes, late ( average 14 years ) after menopause, seem to have an increase risk of CAD. Mechanistically, that would be difficult to explain. Hot flushes are due to vasomotor response, meaning that it is healthy vaso-dilatation, which must mean a healthy circulation. So females who have health vasomotor reaction, early in their menopasue have a healthy circulation, though they are in menopause, but why does the same vasomotor response mean an increase CAD risk, later in menopause? Is it the same vasomotor response? That is where we do not know.
I though that it was interesting. We need to understand females with CAD better, as they are often slightly different in their presentation and also their outcome. Their vessels are smaller and often are more reactive.
I suppose we should still bank on the traditional risk factors to understand causation of CAD, until we can know the cause ( if any )? Cigarette smoking, hypertension, diabetes, dyslipidemia, obesity, lack of exercise, family history and risk factors like that are still more important then hot flushes, interesting though this may be. Perhaps one day , we will have a good explanation for the hot flushes. Until then it remains an interesting observation by the workers from North-Western University, Chicago.

POST DES ACCELERATED ATHEROSCLEROSIS. A POSSIBLE EXPLANATION FOR LATE STENT THROMBOSIS

One of the phenomena that we interventionist have yet to understand well is the issue of late stent thrombosis, especially with drug eluting stents. Why do stents, implanted 3-4 years ago, suddenly thrombose and cause an AMI? This is seen in bare metal stents as well, but much less. You see, we have always thought that after you implant a stent, there will be healing, fibrosis or in our language, neo-intimal hyperplasia, which gave us the problem of restenosis, which we did not want. So, the workers in Brazil and Netherlands, worked on drug coated stents to stop neo-intimal hyperplasia, and stop stent re-stenosis. They were successful and so we see the advent of drug coated stents. In Barcelona 2006, we learned to our horror, that with DES ( Drug Eluting Stents ), we no longer have the problem of restenosis, but we exchanged that for a problem of stent thrombosis, especially late stent thrombosis, and we were trying to answer why? We thought that it was the polymer, and so many second and third generation DES are now polymerless. We thought that it was the premature discontinuation of Clopidogrel. This is certainly true. But how long do we need to keep the clopidogrel? Now we may have another part of the answer to this puzzle.
While doing my reading this week, I came across this interesting paper by Dr Renu Vermani's group at CV Path, Maryland. The paper is entitled "The pathology of neoatherosclerosis in human coronary implants". In the J Am Coll Cardiol March 2 online edition. The lead author here is Dr G Nakazawa, who works with Dr Vermani. We all recognise Dr Vermani for her seminal work on stent thrombosis, way back in the mid 2000, acting as our conscience to see what we are doing wrong, in our endeavor to improve patient care. All that we see clinically, is not what they see, post mortem, and you cannot argue against post-mortem findings. When properly done, they are final.
Anyway, Dr Nakazawa and colleagues, studied 299 consecutive autopsies, of patients who have died post stenting, DES and bare metal. They went through 400 lesions. These were all patients who had their stents implanted, months or years earlier. They found that in those who had DES implanted, with the stent healing comes re-atherosclerosis or the authors call it neo-atherosclerosis. This is twice more likely with DES than with bare metal stents. I like re-atherosclerosis because, we thought that with stenting, we have exchanged atherosclerotic lesion with scar tissue formation and re-endothelisation ( the atherosclerotic plaque was digested away by the macrophages following stenting. With DES, plenty of re-endothelialisation and with bare metal stent, plenty of neo-intimal hypertplasia. Now we know that that is not true. Following stenting, after scar tissue, we again get re-atherosclerosis. With DES, this re-atherosclerosis seem to come earlier ( almost by a factor of 3 ), and it appears to be more aggressive, with thinner fibro-atheroma caps, and more prone to plaque rupture. With bare metal stents, there is thicker fibro-atheroma caps and less prone to rupture. They also noted that with bare metal stents, the re-atherosclerosis takes longer to form ( delayed by almost 3 years ) and with DES, it takes faster to form. Basically, the old disease comes back, and with DES, it comes back with a vengeance. The bad news is, that DES is good, and also is a temporary solution. Bare metal stents, may need a re-do, but is a longer ( at least from the re-atherosclerosis point ) temporary solution, but shorter from the re-stenosis point.
However, the good news is ( as I see it ), there is another chance for us, besides intensive anti-platelet therapy, to also institute, intensive statins, and other plaque cooling agents to lessen inflammation. Of course all these go along with intensive life style modifications, etc., etc., etc..
I also wonder what impact this new findings will have on the new ABSORB stent, or the bio-absorbable stents that are now in development. Will bio-absorbable stents also run the risk of re-atherosclerosis after the stent have melted away? Then we are back to square one again.
How amazing, PCI, like CABG is only a temporalising solution. It is not a cure, just a temporary relief, for us to get our lives back on track again. To give us a second chance, so to speak. Intensive medical therapy is still the main stay of treatment for coronary artery disease.

MALAYSIAN HEALTHCARE ISSUES HIGHLIGHTED IN MASS MEDIA : COMMENTS

These few days, the minister and DG have been rather busy making press statements and declaring open healthcare facilities. I think there is more to come as we head towards GE 13. Lets examine what they have said, and see if they make sense.

1. Yesterday, the YB, minister of Health announced that MOH have had discussion with the Association of Private Hospitals of Malaysia ( APHM ), to ask them to declare their private hospitals fees in their website.
A quick check yesterday and today showed that his statement has not been adhered to. It is possible that their fees schedule is hidden in some remote corner of their website, but it certainly is not easily accessible. This is something that we have fought for and hope that it will come about. A fees schedule for private hospital charges. The reason is simple. If you feel it important to have a doctors fees schedule ( doctors fees is roughly 15% of overall bill ), then it only make sense to also have a fees schedule for the 85% portion. Otherwise controlling the 15% makes no sense when the 85% is not controlled. Lets give it sometime. Obviously, this declaration of fees in their private hospital website is the first step, towards fees regulation in the private sector. This will come about, not because of us ( in case we get swollen headed ), but because the government is working towards a social health insurance scheme, for which reason, they must know how much each cost. Whatever their reason, if you wish to control doctors professional fees, it is only fair that the private hospital portion also be controlled. Our advice have always been that there should be no fees structure. It should be free market, as in Singapore, and promote healthy competition. Whatever insurance coverage should always be capped. The insurance pay so much ( declared before hand ), and the patient pay the rest. If you choose to go to a budget hospital, the extra portion will be small. If you go to a luxury private hospital ( for face-cy ), then you have to folk out more. That seems fair to us for all.

2. Yesterday too, the DG announced that they are looking for regulations towards " stem cell " research and therapy.
This is way overdue. I have heard of cardiologist, injecting bone marrow aspirates into coronary arteries post infarct angioplasty, charging patients and telling them that it will help heart muscle grow. There is a fool born every minute. And some people believe them. Actually, that idea is copied from a clinical trial being carried out overseas ( REPAIR-AMI trial ), and the 5 years follow-up results looks encouraging. Our Malaysian boys have simplified it, and hope for the best. What many do not realise is that stem cell therapy can cause harm. In the area of the heart and myocardium, patients have died in the early experiments, when the stem cells initiated wrong cells to grow, at the targetted sites. We had examples of bone cartilage growing in the heart muscle, causing the heart to stop. Doctors must always remember, first do no harm. The DG is correct. It is about time. This new and exciting field is promising, but can be severely miss-used. Then there is also the ethical issue of donors and recipients. I know of a group that is going around, harvesting fat tissue ( adipose tissue ), from their liposuction ( a procedure to suck away fat from the tummy ), selling the fat tissue to a third party, who treats it chemically and then use it as stem cells into joints to grow cartilages. There is some research being done, that shows that adipose fat cells can when triggered correctly, form targetted tissues at targetted sites. But it now begs the question, what is the law of selling ones tissue ( organ donation ) to another ( organ recipient )? I know that that is not allowed, under MMC code of conduct. But what about adipose tissue for stem cells?? So the DG is correct, this issue must be studied and proper regulations drawn up, to protect the medical fraternity and also the patient.

3. The YB minister announced today that the Medical Devices Act is coming and companies are asked to register their medical device with the MOH.
This Act has been in the pipeline for a long time. When we first started angioplasty, I remember, I just literally took in the rotablator, and later the stent, for use in my patients, after being trained in them. It is proper that these devices, which can potentially harm, be registered ( which is a form of licencing ). Just the other day, I saw a patient who was treated in another medical center, and he had received a " optimiser " stent. In my many years of interventional cardiological practice, I have no knowledge of the "optimiser" stent. I can onlky concclude that it is a generic stent produced by some small company, with little research and documentation. It is obviously not FDA approved. I suppose it comes cheap. What I would like to say, is that, it may cause harm. Is it a safe stent?. Stents are permanent implants that once sited in, cannot be removed ( short of cardiac surgery ), and so safety both short and long term, is very important. The government must act, to make sure that patients are protected. First cause no harm.
Besides stents, there are many machines and devices out there that can cause harm and are being used without proper documentation. We always wait for something to go wrong, and for patient to sue. That is too late. The damage has already been done to that victim, and to many others who are unaware.

All in all, looks like GE is coming and politicians are working very hard, making announcements and handing out goodies. I can only encourage all eligible to register as voters and to vote, when the time comes, FOR THE GOOD OF OUR NATION, Malaysia.