CABG LAST LONGER THAN DES - ANTAGONIST

I spend Sunday morning at the Gurney Hotel, Penang, to speak at the Penang GP Cardiology Seminar. They had me take part in a debate with Dr Hafiz Law ( cardiac Surgeon ) on the topic " CABG last longer than DES ". He was the protagonist and I was the antagonist. Again, I am unable to download the slides. It does contain much laymen information.
Of course, interventionist are more matured now, and more realistic. I do agree that CABG is a more matured procedure and definitely have a longer history. However DES continues to evolve with newer and better DES, from 1st generation to 2nd, 3rd generation DES and in the near future, the disappearing stent ( bioabsorbable DES ). Of course SYNTAX trial has taught us that in CAD with low Syntax score ( 22 and below ) and high Euroscore, PCI is advantageous. In patients with medium or high scores and also high Euroscores, CABG is better, and when in doubt, a heart team consult is good for the patient, especially with severe 3 vessel CAD or left main stem CAD.
It is important to note that DES / PCI is a much lesser procedure when it is technically possible. The trade off is a high rate of re-intervention for restenosis. CABG does have graft attrition, which may come on in 5-10 years. So Trials like Syntax, at 4 years, does not do justice to PCI / DES as there is enough time for DES restenosis, but not enough time for graft failure. Also, Taxus is not the best competitor to CABG. Xience V would have been a m ore appropriate competitor with CABG. In fact, if you take Spirit 4 three years MACCE curve and superimpose on Syntax 4 years, Xience V came out just as good.
The heart-lung machine is a great stress for CAD patients and the "pump head" syndrome is a real problem.

This is my concluding slide :

CABG AND PCI, WHEN DONE BY EXPERTS, ARE BOTH GOOD MEANS OF MYOCARDIAL REVASCULARISATION. WHICH IS BETTER? IT DEPENDS ON THE PATIENT'S SYNTAX SCORE AND EUROSCORE. DECISION SHOULD BE ON A PATIENT TO PATIENT BASIS, AND NOT ON p- values AND HAZARD RATIOS.

That is how I spend 27th Nov 2011.

MALAYSIAN HEALTHCARE REFORMS.

I spend Sunday in Penang. I spoke at the Public forum on Healthcare, organised by the CAP, Private Medical Practitioners Society, Penang, Heath Action Initiative. I spoke on " Malaysia Healthcare Reforms, Is there a need? I tried to upload my slides, which had much statistics and data to this blog, without success ( do not know how to ).
Anyway, it was a very successful forum. The room was full, but then is was a small room ( room 1 of YMCA Penang ). I estimated about 70-80 in the room.
The organisers managed to get Dr Nordin of MOH to come and brief us on the planned Healthcare Reforms. The meeting was opened by the Deputy Chief Minister of Penang. Various people spoke, inlcuding a PAS politician ( forgot his name ), Dr Michael Jeyakumar ( PSM ), the CAP representative ( Dr Jayabalan ), Dr Abdul Hamid, and Prof Chan Chee Kong, and me.
After the various speeches, the forum was opened to questions and as expected, Dr Nordin ( MOH ) was bombarded with questions and comments ( some not so flattering ). Tan Sri Devaraj was the chairman for the discussion. Everything was civil. Nothing got out of hand.
The consensus seems to be that we do not reform, just improve the present system, correct her shortcomings with some injection of cash.
We all agreed that we basically have a good system ( no one disagreed ), with some shortcomings. Increasing the Malaysian Healthcare budget from the current ( 4.8% of GDP ), to the WHO recommended level of 8-9% of GDP, should solve most of out shortcomings.

This is my concluding slide

1.HC must be and can be improved. It is basically a good, proven system.

●

2.HC cost will rise, just as quality and quantity of life will rise, and population will rise.

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3.We must use the HC dollar more efficiently. Cut out leakages. Efficiency measured by health outcomes, Not KRAs.

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4.We, the FPMPAM believe that increasing the HC expenditure to the WHO recommended level ( THE 8-9% GDP ) is the way to go. Increasing taxes ( direct or indirect ), and parking RM 35B in a HC fund, is NOT the way to go.

SALT CONTROVERSY : HOW MUCH SALT SHOULD WE TAKE? IS THERE A SALT J-CURVE??

A long time ago, sometime in 2009, I wrote about the desired salt intake to prevent hypertension and stroke. At that time, the body of evidence seemed to be that taking less salt is good for us. The data was mainly driven by the British school of thought and my friend Dr Graham McGregor in UK. Since then, much work has been done, with some studies finding no correlation between salt intake and CV events, and some showing that too little salt intake is associated with increase CV events.
Well, Dr Martin O'Donnell of McMaster U, Hamiltoon, and colleague has published a paper in the 23rd Nov issue of the Journal of the American Medical Association, addressing this issue and adding more fire to the controversy.
They took a look into two large hypertension trials done earlier, the On-Target Trial and the Transcend trial, a total of 29,000 patients, on 56 months of follow-up. They looked into the Urinary Sodium excretion as a marker of sodium intake, meaning the higher the sodium intake the higher the Urinary Sodium, and vice versa. This has been established. They then correlated the Urinary sodium excretion levels with CV events. They found increase CV evenets in those with too high Urinary sodium ( >7gms/day ), and too low Urinary Sodium ( < 3 gms / day ).

Outcome	<2 g/d	2-2.99 g/d	6-6.99 g/d	7-8 g/d	>8 g/d
All CV events	1.21 (1.03-1.43)	1.16 (1.04-1.28)	1.09 (0.99-1.20)	1.15 (1.00-1.32)	1.49 (1.28-1.75
CV death	1.37 (1.09-1.73)	1.19 (1.02-1.39)	1.11 (0.96-1.29)	1.53 (1.26-1.86)	1.66 (1.31-2.10)
Stroke	1.06 (0.76-1.46)	1.05 (0.86-1.28)	0.95 (0.79-1.15)	1.06 (0.81-1.40)	1.48 (1.09-2.01)

This now lends us in more confusion. If their data is correct, one of the ways is to say that that is a J-curve in CV events with sodium intake. Neither too high, nor too low is good.
Obviously there are difficulties with this paper. The data was largely observational from trials not meant to study this. The long part of the J-curve, most of us will easily agree, as it can be easily demonstrated. The low sodium intake end ( short end of the J-curve) is more difficult to explain. Were these patients too sick, to take in salt? Did they have more complications from their hypertension, causing them not to be able to take in food / salt?
Anyway, in science, sometimes it is good to be controversial. It makes us think, and not swallow everything hook line and sinker.
How much salt then should I take? Well, if you believe them McMaster boys, then, not more then 7gms / day, and not less then 3 gms/day. Know that for every gram of salt you take in, you also pass out in the urine, the equivalent amount ( generally speaking, 7 gms sodium/day ingestion will give rise to 7gms sodium/day, urinary excretion ).
I suppose if you look at it philosophically, in life, everything must be in moderation. Extremes are bad for us.

MORE NEWS ON STEM CELLS AND THE HEART

The word "stem cells" mean different things to different people. For some, it is a panacea of cures for all ailments, from spinal cord injury, to burn repairs, to joint cartilage repairs, to cardiac muscle repairs. It is sometimes very difficult to separate the facts from the myths. I also have that difficulty, as I hear many surgeons around me using stem cells for various kinds of surgery and the commercialisation of cord blood storage for stem cells. I have been searching for the clinical trial data? I must say that they are few to find.
Anyway, at the just concluded AHA annual Scientific meeting at Orlando, Florida, a few papers were presented on cardiac stem cell therapy. I was particularly impressed by the paper from the University of Louisville, Kentucky. Dr Robert Bolli and colleagues, studied 16 patients with placebo control. They harvested cardiac muscle tissue from their ischemic cardiomyopathy patients ( the non ischemic portions ), process the harvested cardiac muscles, culture it to derive their adult cardiac stem cells, and at an average of 16 weeks or jusy over 3 months, infuse 1 million of these process autologous cardiac stem cells into the targetted coronary artery. A follow up MRI LV function assessment showed that the LV function have improved from a mean of 30.2% to 38.5%, and the infarct size have decreased. This is indeed good news. This is a phase 1 trial, meaning that it was primarily to test safety of the trial. However, the improvement is staggering and wonderful. There is no mention of sudden cardiac death. This gives hope to many out there whose LV function is 30%, following a severe myocardial infarction.
At the same meeting, the investigators of REPAIR-AMI ( this study was written up earlier, years ago ), also reported their 5 year follow-up. The results continue to show sustained improvement. Just to recap that in this study, Dr David Leistner and colleagues were using intracoronary autologous bone marrow infusions.
There was a third study presented at the same meeting, the LATE-TIME study, on intracoronary autologous bone marrow infusion. This study was neutral, showing no benefit.
Looks like much work is being done in this area of cardiac stem cells for myocardial repair following myocardial damage, following an acute myocardial infarction. The embryonic work is minimal in USA, but the adult stem cells research in going on, with some optimism.
There is hope out there for patients with Ischemic Cardiomyopathy, where in many cases. cardiac transplantation remains the only viable alternative.

CORONARY RISK FACTORS AND DEATH FROM FIRST HEART ATTACK.

The 16th Nov 2011 issue of the Journal of the American Heart Association carried a very interesting article. Dr John Canto and colleagues from the Watson Clinic, Lakeland Florida, took a look at the National Registry of Heart Attacks, from 1994-2006. They found about 500,000 patients who had suffered their first heart attack. They were looking into correlating coronary risk factors and heart attacks, and also heart attack survivors. Now 500,000 is a very large number and will surely give much information.
First they found that 85.6% of the heart attack patients had one or more major coronary risk factors. Only 14.4% had no coronary risk factors. The most common coronary risk factor was hypertension ( 52.3% ). Smoke ( 35.3% Lipids ( 28% ), Family History, defined as one relative <60years with a heart attack ( 28% ) and T2DM ( 22.4% ).
What is even more interesting is that those patients with more coronary risk factors do better following their first heart attack. Those with no or less coronary risk factors do worse.

Risk factors, n	In-hospital mortality, % of patients
0	14.9
1	10.9
2	7.9
3	5.3
4	4.2
5	3.6

Dr Canto and colleagues also found that compared to patients with all 5 coronary risk factors, those with no coronary risk factors have a 54% chance of dying from their first MI after adjusting for all the other confounding factors. This is also interesting.
How does one explain these findings? Is it that those with more risk factors are already under medical treatment and supervision, more likely to be on aspirin and also statins? or more likely to have collaterals, or chronic stenosis which induces ischemic pre-conditioning? and so promotes better survival? Obviously, much more work needs to be done in this area.
Don't get me wrong, I am not asking that we should all go out and abuse ourselves to increase our lipids and get hypertension and diabetes. I am just highlighting an interesting clinical observation. Remember, this is a registry and so not confirmatory and gospel truth. It just helps us to understand things a bit better.
Yes, sometimes coronary risk factors cannot be avoided, as in hypertension and family history, but those that can be avoided, we must avoid. Obviously, no CAD also means no heart attacks, and that is the better strategy and message.
Well, this is yet another medical paradox. More coronary risk factors, improves survival following a first heart attack.

SATURN AND THE WHOLE ISSUE OF PLAQUE REGRESSION

At the just concluded AHA annual scientific meeting at Orlando, Florida, one of thelate breaking trial was SATURN, or Study of coronary atheroma by intravascular ultrasound: Effect of rosuvastatin and atorvastatin. Led by Dr Stephen Nicholls of Cleveland clinic, they began to enrol patients in 2008. A total of 1385 patients were enrolled. They all had established coronary artery disease and were scheduled for coronary angiogram, when IVUS was also carried out, at day 0 and day 104 weeks. This was a double blind trial comparing rosuvastatin 40 mg and atorvastatin 80 mg. The primary endpoint was PAV ( plaque atheroma volume on IVUS ) regression. They also had secondary endpoints of LDL-C lowering and HDL-C elevation.
It was obvious after 104 weeks, that both statin at that dose regress plaques, similarly to about 1% ( not alot ). Rosuvastatin lowered LDL-C significantly better and increase HDL-C significantly better.
I am sure that the lipid lowering chararcteristics, we all know, what after JUPITER. What we were all surprised was the PAV regression, remembering that after REVERSAL ( the high dose atorvastatin 80mg trial with IVUS ), the plaques did not regress significantly, and also after JUPITER trial with Rosuvastatin, where the carotid intima did not regress significantly. It looks like SATURN is out of keeping with REVERSAL and JUPITER. It may be too good to be true. Anyway, PAV like carotid intima plaque regression are surrogate endpoints, which some of us find hard to correlate. We would rather prefer hard endpoints like death, or at least MACCE. Of course this will take too long and too costly to collect.
So, like many trials before it, SATURN tells me that Rosuvastatin and Atorvastatin lowers LDL-C and HDL-C well, at a dose that I would never use. What I did not see was the side effects. Not to forget that there are many trials that showed that at those doses or superdoses, I will get more muscle aches, pains, and even myo-necrosis, and of course liver dysfunction.
The Americans keep pushing their superdoses, maybe that is why their economy is in shambles. Perfection may be the enemy of good here.

AHA. ANNUAL SCIENTIFIC MEETING, ORLANDO. AIM-HIGH RESULTS

Even as this year's AHA annual scientific meeting at Orlando, draw to a close, one of the most controversial trials presented must be the AIM-HIGH ( Atherosclerosis Intervention in Metabolic Syndrome with low LDL-C / high TG and Impact on Global Health Outcomes ) trial. This trial, led by Dr William Boden ( of COURAGE fame ), of 3,414 patients comparing the use of Niacin Vs placebo in patients with established CAD low HDL-C and high TG. These patients all also had simvastatin + ezetimide to keep their LDL-C low. This trial was prematurely terminated in May of this year by the FDA, before the unblinding because the data safety committee found no benefit in the treatment arm and a small increase in ischemic strokes in the treatment arm.
Well, at the AHA on 15th Nov., the full trial results were presented and also simultaneously published in the New England Journal of Medicine, online.

End points	Niacin (%)	Placebo (%)	HR (95% CI)	p
Primary end point	16.4	16.2	1.02 (0.87-1.21)	0.80
CHD death/ nonfatal MI/ ischemic stroke/ high-risk ACS	9.3	10.0	1.08 (0.87-1.34)	0.49
CHD death/ nonfatal MI/ ischemic stroke	8.1	9.1	1.13 (0.90-1.42)	0.30

There were also 27 ischemic strokes in the niacin arm and 15 in the placebo arm.
The increase in HDL-C in the niacin arm was minimal. Whether this was bacause niacin is not a good raiser of HCL-C or that the placebo arm's HDL-C was high due to the effect of simvastatin, was not discussed in the presentation.
The controversies was because some ( the pro-niacin camp), feels that the trial's conclusion that niacin does not much good and may do some harm was unfair, as the trial was underpowered from the beginning, and that adding simvastatin and a low dose of niacin, in the placebo arm ( to produce a mild flushing ) may have mask some of niacin's benefit. On the other hand, the trialist felt that they have done a good job, this is a negative trial, and the results should be accepted. Of course, the middle roaders will say that, for the moment, we should agree to disagree and await the completion of the THRIVE trial, a bigger trial to answer basically the same question.
For the moment, I will not ( I have not been ), use niacin to raise HDL-C in this group of patients.
At least this trial gave this years AHA some excitement.

ANOTHER UNREASONABLE GUIDELINE. CHOLESTEROL SCREENING FOR CHILDREN AGE 9 years

The American Heart Association Annual Scientific meeting is currently on-going in Orlando, Florida. At this meeting, "the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents", appointed by the National Health, Lung, and Blood Institute (NHLBI) and endorsed by the American Academy of Pediatrics (AAP) is recommending that all children undergo routine lipid screening regardless of their backgroud, or family history. Those age 9-11 years, a test for non fasting lipids, and a follow-up at age 18-21 years with a full lipid profile. They also recommends screening for diabetes in those overweight and with family history. This second recommendation is more reasonable.
I think that the first recommendation is ridiculous. Where is the evidence that such screening will help?. The level of evidence here is level B, not conclusive by any means. There is no data that should they be high, they will suffer a heart attack in the next 5-10 years. Where is the evidence? What do you do, if the child's cholesterol level is raised? Give them a statin at age 10 years? Isn't that ridiculous? Only the pharmas will be happy. More sales. The poor adolescent will lose their childhood, doing the "I can't do these, I cant do that, I cant eat this, and I cant eat that" recommendation, and on flimsy evidence.
No wonder the cost of healthcare is so high that it is impacting their budget deficit, and making America bankrupt.
Looks like the first day of AHA is full of anti-thrombins and more hematology than cardiology.
More from the AHA later.

PARLIAMENTARY SELECT COMMITTEE ON ELECTORAL REFORMS, 12th Nov 2011

I led a group of 7 doctors to attend the hearing.

Committee room 2 where the hearing was held, was a small room. Half the room was filled with Government servants from all the related branches. The committee sat at the right end of the room, chaired by YB Maximus Ongkilli. I could recognise YB Radzi, YB Kamalathan, YB Wee Choo keong, YB Anthony Loke, YB Hatta and YB Fong Chan Onn. There was one that I could not recognise. The press ( about 6-7 ) were on one side, and the gallery ( public ) were only given about 10-12 seats at the other end from the committee. It was quite crowded. There was a big screen to show the committee. and microphones for those speaking.

Looks like Ambiga took a long time in the morning ( 2 hours I am told, with some controversy about whether she was speaking on behalf of "illegal" BERSIH 2.0 or as an individual ). We met them outside, and chatted with them for awhile.
After lunch, the hearing started with the PAS team, who came with thick files and records detailing election frauds, and details of election mismanagement. They were followed by Bar Council, Lim, who dealt with legal issues, especially indelible ink. Then DAPSY spoke, and then us.

We came on at about 4.15pm. They told us earlier that only 2 of us could speak. So I nominated myself and Dr Ng Kwee Boon. Three of us sat at the table representing ( Dr Steve Wong, Dr KB Ng and me ).
I spoke for 3 mins acknowledging that we have no data, except patient and general complaints of election unfairness, emphasising that we want free and fair elections so that the best men can win and that frauds will be weeded out. We do not wish a country led by not the best men.Dr KB Ng spoke for 2-3 mins on the reforms that we wish to see, including indelible ink, longer campaign periods, and equal access to the mass media. I think the gallery and committee appreciated that a group of doctors were concerned enough to come out to voice their unhappiness. We were complimented. We handed our memorandum with 6 signatures to the committee secretarial staff earlier, who say that they will receive on behalf of the committee. I hope they get it.

Basically, I think we achieved what we set out to do. I was quite glad that although we are not a recognised group, they allowed us airtime. We were not well prepared, but we spoke from our hearts and I think they appreciated that, as we are doctors.

Memorandum to the Parliamentary Select Committee on Electoral reforms

Preamble

We are a group of concerned doctors, all citizens of this beloved country of ours, who have since independence observed the gradual deterioration of the election process which is vital to sustain the democratic parliamentary political system we believe in and subscribe to. We feel the election process at present is severely flawed.

We thank you for giving us the opportunity to appear before you to submit our suggestions to reform and improve the present electoral system. We believe that these reforms, if implemented, will be good for the nation and the people.

A reform of the electoral process will require the full co-operation of the concerned public institutions/individuals vital for a free and fair election.

1. A totally neutral election commission that will act fairly and justly.

2. An independent judiciary willing to settle electoral disputes fairly should they arise.

3. A Police force that acts impartially to uphold the law equally when political parties on both sides of the political divide apply for permits to hold meetings to explain to the citizens their policies, and to take action on all individuals who break the law irregardless of political affiliation.

4. A mass media that allows equal opportunity for all political parties taking part in election campaigning, to have equal access to the television, radio and newspapers to explain their policies to the public.

5. Political parties and politicians who must refrain from “dirty” politics that slander, raise sensitive racial and religious issues, and use money to buy for votes.

The Reforms

1. Campaigning period should be at least 21 days. This will enable individuals and smaller parties with limited campaign machinery to have a reasonable chance to reach their constituents. Too short a period of campaigning will favour the big parties with their strong finances, and therefore will give them an unfair advantage. Of course the period campaigning cannot be too long. 21 days seems fair, given that many rural areas are difficult to get to.

2. Cleansing of the electoral roll. Electoral roll must be closely vetted so that only Malaysian citizens are eligible to vote. All phantom voters, dead voters must be expunged from the electoral rolls. Postal votes must be closely monitored so that the same postal voters does not vote twice or three times.

3. Use of indelible ink. This is to ensure that each voter gets to vote only once. It is simple, cheap and effective.

4. Automatic registration of citizens above 21 into electoral roll to enable all citizens above 21 to participate in choosing their representatives in parliament.

5. Postal voting to be made available to all eligible Malaysian citizens living, working and studying abroad.

Conclusion

We hope that our plea will get your full attention, and we hope that these electoral reforms will bring about a freer and fairer elections, in time for General Elections 13, due soon.

PARLIAMENTARY SELECT COMMITTEE ON ELECTORAL REFORMS, PUBLIC HEARING 11-12th ovember 2011

I shall be leading a small group of doctors to attend the Parliamentary Select Committee of Electoral Reforms, on the afternoon of the 2th Nov.2011.
If given time and opportunity, I shall make a short presentation:

FREE AND FAIR ELECTIONS

GUIDING PRINCIPLE :

The election commission must want a free and fair election. Where the heart is right, the actions will be right too. The public is watching and they know when the heart is not right.

Make the elections free and fair. May the best man win.

1. Voters list ( A fairer Election Commission ).

- Only those eligible to vote, be registered and can vote. Clean the voter registry.

- Try your best to eradicate phantom votes.

- Close watch on Postal votes – limited to very essential services, like Arm Forces on duty with pre-announced certified list.

- Illegals being given ICs

2. The campaign :-

- Ample time to campaign- 14 days

- Ample opportunity to campaign- non-partisan mass media

- non-partisan Police - permits for rallies.

- No dirty politics in campaigning. Maintain decorum and fairplay.

3. Balloting

- Use of system to make sure one man one vote – use of indelible ink.

- Voting agents must be non-partisan and clean. Not deface voting paper

- No vote buying. Any report should be thoroughly investigated, if serious and true, re-vote again to maintain fairness of system, and culprit punished including prosecution and jail.

- Allow international observers, to ensure transparency.

- Collection of ballot boxes, must be transparent. No boxes missing or extra boxes appear late.

4. Vote counting

- Transparent. In front of public

- No sudden light failure.

- International observers.

- Any suspicions of foul-play, re-election following thorough transparent investigation involving all parties.

5. Post election disputes

- Royal election commission inquiry – Joint body involving politicians from ruling party and opposition, appointed by the King after consulting all parties.

- Public hearing, transparent and fair

- Inquiries decision is final, Re-election or no re-election.

Conclusion

Implement reforms as soon as possible, in time for GE 13

A FREE AND FAIR ELECTION IS GOOD FOR ALL AND GOOD FOR MALAYSIA

After the short presentation, we shall hand over a simple memorandum to the committee.

Memorandum to the Parliamentary Select Committee on Electoral reforms

Preamble

We are a group of concerned doctors, all citizens of this beloved country of ours, who have since independence observed the gradual deterioration of the election process which is vital to sustain the democratic parliamentary political system we believe in and subscribe to. We feel the election process at present is severely flawed.

We thank you for giving us the opportunity to appear before you to submit our suggestions to reform and improve the present electoral system. We believe that these reforms, if implemented, will be good for the nation and the people .

A reform of the electoral process will require the full co-operation of the concerned public institutions/individuals vital for a free and fair election.

1. A totally neutral election commission that will act fairly and justly.

2. An independent judiciary willing to settle electoral disputes fairly should they arise.

3. A Police force that acts impartially to uphold the law equally when political parties on both sides of the political divide apply for permits to hold meetings to explain to the citizens their policies, and to take action on all individuals who break the law irregardless of political affiliation.

4. A mass media that allows equal opportunity for all political parties taking part in election campaigning, to have equal access to the television, radio and newspapers to explain their policies to the public.

5. Political parties and politicians who must refrain from “dirty” politics that slander, raise sensitive racial and religious issues, and use money to buy for votes.

The Reforms

1. Campaigning period should be at least 14 days. This will enable individuals and smaller parties with limited campaign machinery to have a reasonable chance to reach their constituents. Too short a period of campaigning will favour the big parties with their strong finances, and therefore will give them an unfair advantage. Of course the period campaigning cannot be too long. 14 days seems fair, given that many rural areas are difficult to get to.

2. Cleansing of the electoral roll. Electoral roll must be closely vetted so that only Malaysian citizens are eligible to vote. All phantom voters, dead voters must be expunged from the electoral rolls. Postal votes must be closely monitored so that the same postal voters does not vote twice or three times.

3. Use of indelible ink. This is to ensure that each voter gets to vote only once. It is simple, cheap and effective.

4. Automatic registration of citizens above 21 into electoral roll to enable all citizens above 21 to participate in choosing their representatives in parliament.

5. Postal voting to be made available to all eligible Malaysian citizens living , working and studying abroad.

Conclusion

We hope that our plea will get your full attention, and we hope that these electoral reforms will bring about a freer and fairer elections, in time for General Elections 13, due soon.

What do you call a large group of people from all walks of life, gathering near Parliament House and walking to the car-park, or parking their cars by the road side, and walking to Parliament house. If it is Saturday, wear yellow. Could this be a spontaneous BERSIH 3.0?

I do hope that many of you Malaysians will walk with us and also attend the public hearing of the committee, whether on the 11th or 12th November 2011.

NEWS FROM TCT. SAN FRANCISCO

I have been searching the internet for the last 3 days to see what is happening at TCT 2011, San Francisco. The truth maybe that nothing is happening. Is that true, or is there a cyber-blackout by the organisers. ( I doubt it ). TCT ends tomorrow, I think, and to date, looks like the most interesting news posted out was a paper by Dr Paul Williams of Manchester Heart Center on 10 cases of longitudinal stent compression, in 9,411 stents implanted by them. An incidence of 0.11%. What he means is that, when stents ( and in this era, mainly DES ) were implanted, some of them can be pushed inwards, and so the distal stent segment telescope into the mid portion of the stent.
If you remember, I reported on 3 cases published by the Irish, earlier, and they were all ( in my opinion ), due to procedural factors like guiding catheter abating on the stents. In Dr Williams presentation, he cited ( unfortunately ), the stent make, trying to make an issue that these cases of longitudinal stent compression were due to faulty stent design. Of his 10 cases, 7 were Promus Element, 1 each of Taxus, Endeavour and Biomatrix. I have not seen the details of each of the 10 cases, so I do not know if bad technique was to blame. Dr Williams message seemed to be that the Promus Element is poorly designed to with stand longitudinal stent compression. There is some truth in that. But, this slightly poor stent design ( from the longitudinal stent weakness point of view ), is off set by its greater deliver-ability, and also very good radial strength. It must also be remembered that the Promus element stent is more radio-opague and so any compression may be easier to see. What I fear most in these kind of paper ( if you think that there is an ulterior motive ), is that stent wars ( companies marketing their stents, have taken to attacking stent designs of competitors ), are getting more heated and more personal. I would have liked companies to tell us how good their stent is, and not how bad their competitor stents are.
When I was at ICF 2011, Kuching in early October, I was spoken to at some length about this issue, with bench testing data, etc.. I told them that in my opinion, the 3 cases from Ireland, were due to technical factors and no stent can withstand the guiding catheter directly abating the stent. That was the prodrome to this TCT presentation.
Anyway, like most of the commentaries after the Williams' paper, I feel that stenting techniques have to do with some of these longitudinal stent weakness issues, and operators must be more vigilant when implanting stents, and not do it carelessly, as some stents are so deliverable now. It is worth noting that the strongest stent, from the longitudinal stent strength point of view, is the now withdrawn Cypher stent. And we all know how much tougher it was to get that down. The tougher it is to get that stent down, the more care I take in choosing the stent, and in delivering the stent, and so there is less stent longitudinal compression issues.
We will keep watching this scene, but I must say that there is actually nothing much to watch for. All we need, I think, is for operators to be more careful, especially for those who choose to use the Promus Element stent, when they are implanting that stent. The rest of us, who do not use that stent, should also exercise equal care and caution, when implanting the Endeavour or Xience V because the message must be that longitudinal stent compression is avoidable, if we are meticulous in our technique, and not be rushing for tee off or a dinner meeting in 30 mins.
The other message must be, what is happening at TCT 2011 San Francisco. Is this major interventional meeting talking about gossip issues? Has the worldwide financial downturn cause it to be less glamorous?
Well, I do not know. I am just thinking aloud.