Friday, 13 April 2012

MEC Talk - April 2012

Thursday (8.30 - 9.30 am) 
Seminar Room 
Kedah Medical Centre. 

Saturday, 12 November 2011

Complications After Prostate Biopsies Are Rising

Complications After Prostate Biopsies Are Rising

A recent upsurge in infectious complications is worrisome.
The rate of complications following prostate biopsy is relevant to the balance of benefits and harms from prostate cancer screening. Johns Hopkins urologists determined 30-day hospitalization rates after prostate biopsy in a random national sample of 17,000 Medicare participants who underwent biopsy procedures between 1991 and 2007.
The 30-day hospitalization rate of 6.9% was significantly higher than the 2.9% rate among 135,000 randomly selected controls of similar age (for controls, a 30-day period was selected randomly). Exclusion of men with diagnosed prostate cancer — who might have been hospitalized for cancer treatment after positive biopsies — yielded a similarly elevated relative risk for hospitalization. Men in the biopsy group were at significantly higher risk than controls for hospitalizations with diagnostic codes for urinary or prostatic infection (0.4% vs. 0.2%) and for noninfectious complications such as hematuria or urinary retention (0.30% vs. 0.04%). The rate of hospitalizations for infectious complications rose significantly over time: It was consistently lower than 0.5% before the year 2000, but, more recently, it's been between 0.5% and 1.0%.
Comment: The authors conclude that "there is a nontrivial risk of serious complications after prostate biopsy." These figures underestimate the total complication rates, given that some patients are treated in outpatient or emergency department settings. The authors also express concern that quinolone resistance might account for the temporal trend of increasing infection rates. Interestingly, a recent Canadian study also documented that the incidence of post-biopsy hospitalization for infection increased strikingly between 1996 and 2005 (J Urol 2010; 183:963).
— Allan S. Brett, MD
Published in Journal Watch General Medicine November 10, 2011
Loeb S et al. Complications after prostate biopsy: Data from SEER-Medicare. J Urol 2011 Nov; 186:1830. (

Wednesday, 9 November 2011

Primary Care Updates : 12.11.2011 : Holiday Villa (5.30 pm - 8.15 pm)

3 Consultants From KMC 

Dato' Dr Ismail Yaacob
Dr Mohd Riduan Abdullah 
Dr Ismayatim Ahmad 

Saturday, 29 October 2011

nnual Screening Chest X-Rays Don't Lead to Increased Survival in Lung Cancer

Annual Screening Chest X-Rays Don't Lead to Increased Survival in Lung Cancer
Lung cancer mortality is not reduced among people who undergo annual screening with chest x-rays, according to a report in JAMA.
Some 155,000 people aged 55 through 74 were randomized either to annual screening with chest radiographs or to usual care for 4 years. After a median follow-up of 12 years, lung cancer mortality in the two groups was roughly the same: 14.0 per 10,000 person-years in the x-ray group and 14.2 among controls.
An editorialist says that the results are valuable for putting to rest the question of whether lung cancer screening with chest radiographs is effective.

Saturday, 13 August 2011

Clinic-Based BP Measurement Is Inaccurate for Diagnosing Hypertension

Compared with ambulatory blood pressure measurements, those obtained in the clinic or at home are far less accurate.

Most clinicians rely on clinic- or home-based measurement of blood pressure (BP) for diagnosing hypertension. However, whether such measurements are accurate is unclear. In this systematic review and meta-analysis of 20 studies that involved 5700 patients, U.K. investigators determined how accurately clinic- and home-based BP measurements diagnosed hypertension; daytime ambulatory BP measurements were the reference standard.

The studies varied in the number of BP measurements obtained for ambulatory (24–111), clinic (2–18), and home (18–56) monitoring. Compared with a mean daytime ambulatory BP of >135/85 mm Hg for diagnosing hypertension (the reference standard), a mean clinic BP of >140/90 had a sensitivity of 75% and a specificity of 75%, and a mean home BP of >135/85 had a sensitivity of 86% and a specificity of 62%. How often these differences affected clinical accuracy depended on the prevalence of hypertension: If prevalence was 10% (e.g., in people 40), only one in four diagnoses of hypertension based on clinic BP measurements would be correct, whereas, if prevalence was 50% (e.g., in people 65), then three in four diagnoses of hypertension would be correct.

Comment: These results have important implications: Many people with diagnosed hypertension are not really hypertensive, especially if the diagnoses were based on clinic BP measurements (i.e., white-coat hypertension). The study investigators suggest using clinic- or home-based BP measurements to screen for hypertension, followed by ambulatory BP measurement to diagnose hypertension so that unnecessary antihypertensive treatment can be avoided. Notably, Medicare reimburses for 24-hour ambulatory BP measurements only in patients with white-coat hypertension (ICD-9 code 796.2).

— Paul S. Mueller, MD, MPH, FACP

Published in Journal Watch General Medicine August 11, 2011


Hodgkinson J et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: Systematic review. BMJ 2011 Jun 24; 342:d3621. (

Original article (Subscription may be required)

Medline abstract (Free)

Thursday, 14 July 2011

Intensified Early Treatment of Subclinical Diabetes: No Benefit at 5 Years

Summary and Comment

Intensified Early Treatment of Subclinical Diabetes: No Benefit at 5 Years

Longer follow-up might reveal benefit.
Clinicians often diagnose type 2 diabetes by screening asymptomatic patients, but how intensively patients should be managed at this early stage of disease is unclear.
Researchers in the U.K., Denmark, and the Netherlands randomized 343 primary care practices to provide either routine care or intensive multifactorial treatment to 3057 patients with early diabetes that was diagnosed through routine screening. Physicians and nurses in the intensive intervention received education on targets, algorithms, and lifestyle advice for managing hyperglycemia, blood pressure, and lipids; in some areas, patients also met periodically with diabetes nurses.
After a mean follow-up of 5.3 years, mean declines in levels of glycosylated hemoglobin (HbA1c), total and LDL cholesterol, and blood pressure were slightly but significantly greater in patients in the intensive treatment practices than in those receiving routine care. The incidence of the primary composite endpoint (cardiovascular death, nonfatal myocardial infarction or stroke, or revascularization), each of its components, and all-cause death was lower in the intensive treatment group. However, none of these differences in clinical outcomes reached significance (hazard ratio for composite endpoint, 0.83; P=0.12).
Comment: Although this trial had the virtue of a pragmatic setting, it took place against the background of improving evidence- and guideline-driven general diabetes care, which might have lessened the relative effect of the intensive intervention. The cumulative incidence curves for the primary endpoint began to diverge after 4 years; longer follow-up might reveal an important clinical benefit.
— Bruce Soloway, MD
Published in Journal Watch General Medicine July 12, 2011

Griffin SJ et al. Effect of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with type 2 diabetes detected by screening (ADDITION-Europe): A cluster-randomised trial. Lancet 2011 Jul 9; 378:156. (

Preiss D and Sattar N. The case for diabetes screening: ADDITION-Europe. Lancet 2011 Jul 9; 378:106. (

Friday, 24 June 2011

Diabetes mellitus, fasting glucose, and risk of cause-specific death.

Emerging Risk Factors CollaborationSeshasai SRKaptoge SThompson ADi Angelantonio EGao PSarwar NWhincup PHMukamal KJGillum RFHolme INjølstad IFletcher ANilsson PLewington SCollins RGudnason VThompson SGSattar NSelvin EHu FBDanesh J.

Erratum in

  • N Engl J Med. 2011 Mar 31;364(13):1281.



The extent to which diabetes mellitus or hyperglycemia is related to risk of death from cancer or other nonvascular conditions is uncertain.


We calculated hazard ratios for cause-specific death, according to baseline diabetes status or fasting glucose level, from individual-participant data on 123,205 deaths among 820,900 people in 97 prospective studies.


After adjustment for age, sex, smoking status, and body-mass index, hazard ratios among persons with diabetes as compared with persons without diabetes were as follows: 1.80 (95% confidence interval [CI], 1.71 to 1.90) for death from any cause, 1.25 (95% CI, 1.19 to 1.31) for death from cancer, 2.32 (95% CI, 2.11 to 2.56) for death from vascular causes, and 1.73 (95% CI, 1.62 to 1.85) for death from other causes. Diabetes (vs. no diabetes) was moderately associated with death from cancers of the liver, pancreas, ovary, colorectum, lung, bladder, and breast. Aside from cancer and vascular disease, diabetes (vs. no diabetes) was also associated with death from renal disease, liver disease, pneumonia and other infectious diseases, mental disorders, nonhepatic digestive diseases, external causes, intentional self-harm, nervous-system disorders, and chronic obstructive pulmonary disease. Hazard ratios were appreciably reduced after further adjustment for glycemia measures, but not after adjustment for systolic blood pressure, lipid levels, inflammation or renal markers. Fasting glucose levels exceeding 100 mg per deciliter (5.6 mmol per liter), but not levels of 70 to 100 mg per deciliter (3.9 to 5.6 mmol per liter), were associated with death. A 50-year-old with diabetes died, on average, 6 years earlier than a counterpart without diabetes, with about 40% of the difference in survival attributable to excess nonvascular deaths.


In addition to vascular disease, diabetes is associated with substantial premature death from several cancers, infectious diseases, external causes, intentional self-harm, and degenerative disorders, independent of several major risk factors. (Funded by the British Heart Foundation and others.).
[PubMed - indexed for MEDLINE]

Wednesday, 6 April 2011

KMC - Blood Donation Campaign : 21.4.2011

Thicker arteries in men who take antidepressants

NEW ORLEANS: Men who take antidepressants are more likely to have thickening of the arteries and higher heart and stroke risks than those who do not, said a study of middle-aged male twins on Saturday.

The difference translates to about a four-year age gap, making the twin taking the pills physically older than the twin who does not, said the study presented at a major cardiology conference in New Orleans.

The study is the first to examine the link between vascular disease and antidepressant use, and looked at 513 twins from the Vietnam Era Twin Registry, the authors said. The average age of the subjects was 55.

Researchers found that the inner lining of the carotid artery, which supplies oxygen to the brain, was five percent thicker in men who took antidepressants compared to their twin brothers who did not.

“There is a clear association between increased intima-media thickness (IMT) and taking an antidepressant, and this trend is even stronger when we look at people who are on these medications and are more depressed,” said Amit Shah, a cardiology fellow at Emory University in Atlanta, Georgia.

The study said antidepressant use was associated with a 37 micron increase in carotid IMT, or about five percent.

Previous research has suggested each additional year of life is linked to a 10 micron increase in IMT, and each 10 micron jump is linked to a 1.8 increased risk of heart attack or stroke.

Antidepressants raise the level of chemical messengers like norepinephrine and serotonin, which may have the negative effect of restricting blood vessels, though more research is needed to determine exactly why the difference was observed, the study’s main author said.

“Because we didn’t see an association between the depression itself and a thickening of the carotid artery, it strengthens the argument that it is more likely the antidepressants than the actual depression that could be behind the association,” said Shah. -- AFP

Read more:

Thicker arteries in men who take antidepressants

Friday, 11 March 2011

Olmesartan Delays Microalbuminuria in Diabetes, But With Risks

Olmesartan, an angiotensin-receptor blocker, delays the development of microalbuminuria in patients with type 2 diabetes and well-controlled blood pressure, but its use is associated with an increased risk of death from cardiovascular events, according to a New England Journal of Medicine study.

The ROADMAP trial, sponsored by the drug's manufacturer, randomized some 4500 diabetic patients with normoalbuminuria to daily olmesartan or placebo. In addition, participants' blood pressures were treated to maintain values under 130/80 mm Hg.

After a median 3-year follow-up, the olmesartan group showed a significant advantage over placebo in delaying time to onset of microalbuminuria (the primary outcome). However, fatal cardiovascular events were more common with olmesartan.

An editorialist writes that the finding of delayed microalbuminuria was not unanticipated.

And given the increased cardiovascular mortality found with olmesartan, she asks why wouldn't other renin-angiotensin blocking drugs be prescribed if they are not associated with fatal complications?

Comment: (Or would others also cause similar fatal complications?)

NEJM article (Free abstract)

NEJM editorial (Subscription required)

Wednesday, 12 January 2011

Public Health Talk @ Kedah Medical Centre - 24.1.2011

Tajuk Ceramah
Pembedahan Laproskopik (Key Hole Surgery) 

Dr Manisekar (Pakar Bedah Umum - Pelawat)

9.30 pagi - 11.00 pagi (24.1.2011)  

Semua dijemput hadir
Makanan ringan disediakan

Tuesday, 28 September 2010

Outcomes After Cardiopulmonary Resuscitation in Intensive Care Units

Critically ill patients, especially those requiring hemodynamic support, are unlikely to survive cardiopulmonary arrests.

Using national registry data from >400 intensive care units (ICUs), researchers examined outcomes of 49,656 adults (median age, 69) who suffered first cardiopulmonary arrests (CPAs) while in the ICU between 2000 and 2008. Overall rate of survival to hospital discharge was 15.9%.

Wednesday, 18 August 2010

Kuliah Ramadan By KMC Consultants.

KEDAH.FM – 97.5
Kuliah Ramadhan -  Radio Malaysia Kedah (RTM)

Dr Wan Mohd Rushidi Wan Mahmud  
 19hb Ogos 2010 (Thursday)

Dr Abdul Razif Abd Razak 
 5hb September 2010 (Sunday)

 Radio Kedah FM  :  1.45 pm  – 2.30 pm
Location : Surau Insaniah, KUIN.

 Yayasan Islam  Negeri Kedah

Dato’ Dr Ismail Bin Yaacob 
   25hb Ogos 2010 (Wednesday)
12.45 pm -1.45 pm

Dr Sharifah Khatijah Syed Hassan Barakbah 
 26hb Ogos 2010 (Thursday)
  12.45 pm -1.45 pm

Sunday, 1 August 2010

Public Lecture : 'Kanser Prostat' by Mr Murali - 9.8.2010

 Monday : 9.8.2010 - 9.30 - - Level 8, Kedah Medical Centre.

Saturday, 31 July 2010

Calcium Supplements Reportedly Raise Risk for Myocardial Infarction

Patients on calcium supplements show a modest increase in risk for myocardial infarction, according to a BMJ meta-analysis.
Investigators gathered data on some 12,000 participants in randomized controlled trials using calcium supplements without vitamin D. Subjects on calcium showed a roughly 30% increase in risk for MI and nonsignificant increases for stroke, death, and the composite outcome of MI, stroke, or sudden death.

Monday, 19 July 2010

Public Lecture : 'Gangguan Jiwa Wanita' : 18.07.2010 (Dr Wan)

Program: Sayangi Diri Sayangi Keluarga (Majalah Wanita)
Holiday Villa, Alor Setar, Kedah.

Wednesday, 30 June 2010

Early Dialysis Not Necessarily Better in Chronic Kidney Disease

In patients with chronic kidney disease, outcomes are similar regardless of the planned timing of dialysis, according to a New England Journal of Medicine study.

Researchers in Australia and New Zealand randomized some 830 adults with progressive, end-stage renal disease to early initiation of dialysis (when estimated glomerular filtration rate reached 10-14 ml/minute) or late initiation (eGFR, 5-7 ml/minute). Ultimately, dialysis began an average of 5.5 months earlier in the early-start group. About three-fourths of "late-start" patients actually began dialysis when eGFR was above 7 ml/minute, owing to symptoms such as uremia.

Wednesday, 23 June 2010

Public Talk - 'Bijak Berfikir Cerah Masa Depan' - Dr Wan

This was part of a one day program organized by MEC Kedah Medical Centre with the cooperation from Kedah's National Population and Family Development Board Malaysia (LPPKN) and SMK Tengku Laksamana Parents Teacher Association on June 22nd, 2010.

SMK Tengku Laksamana, Jalan Kuala Kedah, Alor Setar, Kedah

Sunday, 30 May 2010

Case : Dysphasia – Dysuria – Disaster

Mr W, a 70-year-old retired shoe mender, went to his GP surgery because he was experiencing difficulty passing urine. He had previously suffered a stroke leaving him with marked speech difficulty, so verbal communication was not easy. His main complaints were of dysuria, bouts of urinary incontinence and a split urinary stream. His symptoms had come on gradually and worsened over the course of a year.

Friday, 23 April 2010

Accuracy of X-Rays for Detecting Hip and Pelvis Fractures : Both false-positives and false-negatives are not uncommon.

X-ray imaging of the hip and pelvis can miss acute fractures. In a retrospective study to determine the accuracy of radiography, Duke University researchers identified 92 consecutive patients (mean age, 71) who received hip or pelvis x-rays in the emergency department and then underwent hip or pelvis magnetic resonance imaging (MRI) within 1 day. Falls and motor vehicle trauma were the usual indications for radiography. Key findings were as follows:

Tuesday, 23 March 2010

Risk Factors for Chronic Pain after Hysterectomy: A Nationwide Questionnaire and Database Study

Brandsborg, Birgitte M.D.; Nikolajsen, Lone M.D., Ph.D.; Hansen, Charlotte T. M.D.; Kehlet, Henrik M.D., Ph.D.; Jensen, Troels S. M.D., Ph.D.


Background: Women scheduled to undergo hysterectomy for benign indications frequently have preoperative pelvic pain, but it is largely unknown why pain in some cases persists or even develops after surgery. This nationwide questionnaire and database study describes pain and identifies risk factors for chronic postsurgical pain 1 yr after hysterectomy for benign indications.

Toxicity, Benzodiazepine: Treatment & Medication
eMedicine Specialties > Emergency Medicine > Toxicology

Updated: Jan 28, 2010



Benzodiazepines (BZDs) are sedative-hypnotic agents that were first introduced in 1960. BZDs commonly are used for a variety of situations that include seizure control, anxiety, alcohol withdrawal, insomnia, control of drug-associated agitation, as muscle relaxants, and as preanesthetic agents. They also are combined frequently with other medications for procedural sedation.

Because of their widespread use, these drugs have propensity for abuse. In addition, benzodiazepines frequently are used in overdose, either alone or in association with other substances.

High-Dose Simvastatin May Increase Risk for Muscle Injury, FDA Warns

Patients who are taking the highest approved dose of the cholesterol-lowering drug simvastatin (Zocor) may face increased risk for muscle injury compared with those taking lower doses or "possibly" other statins, the FDA warned on Friday.

Sunday, 28 February 2010

Metformin and Vitamin B12 Deficiency

Evidence suggests that metformin lowers vitamin B12 levels in patients with diabetes.
Observational studies have suggested that metformin causes vitamin B12 deficiency in some patients; researchers have proposed several possible mechanisms whereby metformin might interfere with B12 absorption. Understanding this interaction is important, because B12 deficiency could exacerbate neuropathic symptoms in patients with diabetes.
In this prospective case-control study, Canadian investigators identified 122 type 2 diabetic patients with peripheral neuropathy: Half had taken metformin for at least 6 months, and half had never received metformin. Otherwise, clinical characteristics of the groups were similar.

Tuesday, 16 February 2010

Thursday, 28 January 2010

Cardiovascular Benefit of Glycemic Control Is Limited to Those with Low Comorbidity

Does an HbA1c level of 7% remain an appropriate goal?

The effect of glycemic control on preventing adverse cardiovascular events has been difficult to demonstrate, possibly because such effects are limited to particular patient subgroups.

To determine whether achieving glycosylated hemoglobin (HbA1c) targets of 7% versus 6.5% had differential effects by comorbidity, industry-sponsored researchers studied 2613 Italian patients with type 2 diabetes who received care from general practitioners or in diabetes clinics. Comorbidity was measured by questionnaire and was dichotomized at a level that was associated with excess mortality. Comorbidities included heart disease, lung disease, arthritis, genitourinary disease, vision loss, adverse gastrointestinal conditions, and foot disease.

More Evidence Against Too-Intensive Glucose Control in Type 2 Diabetes

The most intensive glucose control is associated with increased risk for death, according to a retrospective cohort study published online in the Lancet.

Using a U.K. general practice database, researchers identified two diabetic cohorts together comprising some 48,000 patients whose treatments had been intensified. One cohort started treatment with oral glucose-lowering monotherapy and switched to a combination therapy using a sulfonylurea plus metformin. The other cohort switched from oral agents alone to insulin with or without oral agents.