Medical Education @ Kedah Medical Centre (KMC)

Primary Care Updates : 12.11.2011 : Holiday Villa, Alor Setar, Kedah

2011-11-13T11:08:00.000+08:00

Complications After Prostate Biopsies Are Rising

2011-11-12T11:10:00.000+08:00

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

Citation(s):

Loeb S et al. Complications after prostate biopsy: Data from SEER-Medicare. J Urol 2011 Nov; 186:1830. (http://dx.doi.org/10.1016/j.juro.2011.06.057)

Medline abstract (Free)

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

2011-11-09T16:15:00.000+08:00

3 Consultants From KMC

Dato' Dr Ismail Yaacob

Dr Mohd Riduan Abdullah

Dr Ismayatim Ahmad

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

2011-10-29T11:12:00.001+08:00

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.

JAMA article (Free)

JAMA editorial (Free)

Journal Watch General Medicine coverage of CT vs. x-ray screening (Free)

Media Report : Forum Kesihatan Mental Kedah Medical Centre - Sinar Harian Utara (12.10.2011 : U1) dan anyang Siang Pau (12.10.2011)

2011-10-12T15:42:00.001+08:00

Clinic-Based BP Measurement Is Inaccurate for Diagnosing Hypertension

2011-08-13T12:00:00.000+08:00

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

Citation(s):

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. (http://dx.doi.org/10.1136/bmj.d3621)

Original article (Subscription may be required)

Medline abstract (Free)

Kuliah Ramadan (Kedah FM) : 11.8.2011 : Dr Wan Rushidi ; 16.8.2011 : Dr Abd Rahim

2011-07-25T11:39:00.001+08:00

MEC Lecture : Pneumococcal Disease - Dr Abdul Razif (21.07.2011)

2011-07-19T15:53:00.000+08:00

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

2011-07-14T15:35:00.001+08:00

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 (HbA_1c), 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

Citation(s):

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. (http://dx.doi.org/10.1016/S0140-6736(11)60698-3)

Medline abstract (Free)

Preiss D and Sattar N. The case for diabetes screening: ADDITION-Europe. Lancet 2011 Jul 9; 378:106. (http://dx.doi.org/10.1016/S0140-6736(11)60819-2)

Medline abstract (Free)

MEC Kedah Medical Centre Committee Meeting : 10.7.2011

2011-07-04T15:10:00.002+08:00

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

2011-06-24T15:38:00.001+08:00

Emerging Risk Factors Collaboration, Seshasai SR, Kaptoge S, Thompson A, Di Angelantonio E, Gao P, Sarwar N, Whincup PH, Mukamal KJ, Gillum RF, Holme I, Njølstad I, Fletcher A, Nilsson P, Lewington S, Collins R, Gudnason V, Thompson SG, Sattar N, Selvin E, Hu FB, Danesh J.

Erratum in

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

Abstract

BACKGROUND:

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

METHODS:

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.

RESULTS:

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.

CONCLUSIONS:

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.).

PMID:: 21366474; [PubMed - indexed for MEDLINE]

No Tobacco Day KMC - in the Media (SINAR Harian 04.06.2011)

2011-06-05T09:51:00.001+08:00

No Tobacco Day in KMC - 31.05.2011

2011-06-01T09:47:00.000+08:00

MEC Lecture Series 2011 : Handling Violent Patients (Part 2) : 24.04.2011

2011-04-25T09:57:00.001+08:00

MEC Talk : 21.04.2011 - Backache by Dr Sarwan Singh

2011-04-12T15:51:00.002+08:00

KMC - Blood Donation Campaign : 21.4.2011

2011-04-06T16:58:00.000+08:00

Thicker arteries in men who take antidepressants

2011-04-06T16:56:00.002+08:00

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 http://www.nst.com.my/nst/articles/Thickerarteriesinmenwhotakeantidepressants/Article/#ixzz0k0AbjTCc

MEC Talk : Organ Donation by Dr Syed Faisal (24.3.2011)

2011-03-15T15:39:00.002+08:00

Olmesartan Delays Microalbuminuria in Diabetes, But With Risks

2011-03-11T16:05:00.000+08:00

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)

KMC @ Kempen Keselamatan Jalan Raya & Pameran Bandar Selamat 27.01.2011

2011-01-28T12:11:00.001+08:00

Public Health Talk @ SMK Darul Aman : Dr Wan - Stres (27.01.2011)

2011-01-28T10:42:00.000+08:00

Public Health Talk @ KMC : Dr Manisekar - Key Hole Surgery (24.01.2011)

2011-01-25T10:40:00.000+08:00

Public Health Talk @ Kedah Medical Centre - 24.1.2011

2011-01-12T15:07:00.001+08:00

Tajuk Ceramah

Pembedahan Laproskopik (Key Hole Surgery)

Penceramah

Dr Manisekar (Pakar Bedah Umum - Pelawat)

Tarikh/Masa

9.30 pagi - 11.00 pagi (24.1.2011)

Semua dijemput hadir

Makanan ringan disediakan

Public Talk : Love Your Heart - KMC : Dato' Dr Amin Sani (12.10.10)

2010-10-13T15:58:00.003+08:00

PET- CT Talk in Star City

2010-10-13T15:48:00.000+08:00

Health Lifestyle Campaign : KMC (7 - 12 /10/2010)

2010-10-13T11:38:00.002+08:00

Public Talk : Health Lifestyle : Dr Ismayatim (KMC : 11.10.10)

2010-10-11T16:12:00.000+08:00

Colouring Contest - Mental Health Day - KMC - 10.10.10

2010-10-10T15:45:00.000+08:00

Public Talk : Stress & Mental Illness (Dr Wan - KMC : 7.10.10)

2010-10-08T09:55:00.000+08:00

Aidil Fitri Celebrations For Staff of Kedah Medical Centre (5.10.10)

2010-10-06T09:59:00.001+08:00

Aidil Fitri Celebrations Kedah Medical Centre 5.10.10

2010-10-05T16:46:00.003+08:00

Outcomes After Cardiopulmonary Resuscitation in Intensive Care Units

2010-09-28T15:08:00.001+08:00

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%.

Patients who received pressors before CPA were about half as likely to survive to discharge (9.3% vs. 21.2%) or to be discharged home from the hospital (3.9% vs. 8.5%) as were patients who did not require pressors before CPA. The best outcomes were among patients with CPA owing to ventricular tachycardia or ventricular fibrillation who did not require pressors prior to CPA (40.7% survived to discharge; 17.1% were discharged home with good neurological function). Patients who were least likely to survive suffered CPAs caused by pulseless electrical activity or asystole that occurred while they were receiving pressor therapy (5.9% survived to discharge; 1.7% were discharged home with good neurological function). CPAs that occurred at night or on weekends, patient age 65, patient race other than white, and patient requirement for mechanical ventilation also were associated independently with lower survival.

Comment: Among ICU patients who experience CPAs, about 1 in 6 survives to discharge. In patients who require pressors before CPA occurs, the survival rate falls to 1 in 11, with only 1 in 25 discharged home.

Physicians should use this information to help guide families of critically ill patients as they weigh risks and benefits of CPR.

— Matthew Hoffman, MD, and Neil H. Winawer, MD, SFHM

Dr. Hoffman is a Fellow in Pulmonary and Critical Care Medicine at Emory University School of Medicine in Atlanta, Georgia.

Published in Journal Watch Hospital Medicine September 27, 2010

Citation(s):

Tian J et al. Outcomes of critically ill patients who received cardiopulmonary resuscitation. Am J Respir Crit Care Med 2010 Aug 15; 182:501. (http://dx.doi.org/10.1164/rccm.200910-1639OC)

Original article (Subscription may be required)

Medline abstract (Free)

Dato' Dr. Ismail Yaacob

Medical Director/Consultant Physician
Kedah Medical Centre

Kuliah Ramadan by Dato' Dr Ismail - Pusat Dakwah Alor Setar (25.08.2010)

2010-08-23T12:40:00.000+08:00

Kuliah Ramadan By KMC Consultants.

2010-08-18T11:50:00.000+08:00

KEDAH.FM – 97.5

Kuliah Ramadhan - Radio Malaysia Kedah (RTM)

Dr Wan Mohd Rushidi Wan Mahmud

“REMAJA”

19hb Ogos 2010 (Thursday)

Dr Abdul Razif Abd Razak

“FARDHU KIFAYAH”

5hb September 2010 (Sunday)

Radio Kedah FM : 1.45 pm – 2.30 pm

Location : Surau Insaniah, KUIN.

PUSAT DAKWAH ISLAM, ALOR SETAR

Yayasan Islam Negeri Kedah

Dato’ Dr Ismail Bin Yaacob

“PUASA DARI SUDUT PERUBATAN”

25hb Ogos 2010 (Wednesday)

12.45 pm -1.45 pm

Dr Sharifah Khatijah Syed Hassan Barakbah

KEUPAYAAN PUASA KANAK-KANAK”

26hb Ogos 2010 (Thursday)

12.45 pm -1.45 pm

KMC Accreditation Journey : Final Day & Closing Ceremony (5.8.2010)

2010-08-05T20:20:00.002+08:00

KMC's Accreditation Journey Continues...Day 2 (4.8.2010)

2010-08-04T15:00:00.001+08:00

Accreditation in KMC - 3-5/8/2010 : The Journey Begins...(Opening Ceremony & Day 1 - 3/8/2010)

2010-08-03T12:25:00.001+08:00

MEC Presentation - KMC Accreditation 3/8/2010 - 5/8/2010

2010-08-02T21:28:00.002+08:00

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

2010-08-01T00:24:00.000+08:00

Monday : 9.8.2010 - 9.30 - 11.am - Level 8, Kedah Medical Centre.

Calcium Supplements Reportedly Raise Risk for Myocardial Infarction

2010-07-31T23:13:00.000+08:00

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.

The authors propose that one mechanism for the effect could be the danger of increased vessel calcification.
They estimate that although treating 1000 people for 5 years would prevent 26 fractures, it would also lead to 14 MIs, 10 strokes, and 13 deaths.

An editorial concludes: "Patients with osteoporosis should generally not be treated with calcium supplements, either alone or combined with vitamin D, unless they are also receiving an effective treatment for osteoporosis."

BMJ article (Free)

BMJ editorial (Free)

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

Public Lecture : LPPKN - 'Berat Sama Dipikul Ringan Sama Dijinjing - 28.07.2010 (Dr Wan)

2010-07-29T11:59:00.000+08:00

MEC Talk : 22.7.2010 - Management of a Patient With Fits : Dr Sharifah

2010-07-20T15:11:00.000+08:00

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

2010-07-19T12:04:00.001+08:00

Program: Sayangi Diri Sayangi Keluarga (Majalah Wanita)

Holiday Villa, Alor Setar, Kedah.

KMC GPs Night 2010 (15.7.2010)

2010-07-16T00:42:00.000+08:00

Early Dialysis Not Necessarily Better in Chronic Kidney Disease

2010-06-30T23:29:00.001+08:00

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.

During a median 3.5 years' follow-up, mortality was similar in the two groups (about 35%). In addition, there were no differences in cardiovascular outcomes, infections, or dialysis complications.

The authors say their findings show that "with careful clinical management, dialysis may be delayed until either the GFR drops below 7.0 ml per minute or more traditional clinical indicators for the initiation of dialysis are present."

NEJM article (Free)

NEJM editorial (Free)

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

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

2010-06-23T23:43:00.000+08:00

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.

Location

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

MEC Special Lecture : Analysis of Culture & Sensitivity: Specimens from KMC 2001 & 2009 - 2.6.2010 (Dr Sarwan)

2010-06-03T12:12:00.001+08:00

Case : Dysphasia – Dysuria – Disaster

2010-05-30T23:34:00.002+08:00

http://www.medicalprotection.org/uk/casebook-september-2009/case-reports/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.

He saw four different doctors at the practice over a period of three months. He was treated with antibiotics for a presumed urinary tract infection on four occasions. This was on the basis of urine dipstick tests which were positive for nitrites, leucocytes, blood and protein. No definitive infecting organism was ever cultured from MSU samples.

On one occasion he mentioned that the tip of his penis had been sore, and this led one of the doctors to make a non-urgent referral to a urology clinic. At no point during his attendance with this problem is there any record of a physical examination.

About four months after his last attendance at the surgery, Mr W attended the urology clinic. Examination of the penis showed an ulcerated, erythematous mass close to the external urethral meatus which was causing partial obstruction and division of the urinary stream.

Biopsy of the lesion showed it to be an invasive, moderately differentiated keratinising squamous carcinoma. Mr W underwent partial penectomy. However, metastatic spread had already occurred and he died two years after his initial diagnosis.

Mr W’s wife sued the doctors at his GP practice, alleging negligence in their handling of his case, leading to a delay in diagnosis which contributed to Mr W’s death.

Expert opinion

The main failing in this case was considered to be the omission of examination of Mr W’s external genitalia, given that he had a persistent split urinary stream and at one point complained of penile soreness. Blindly continuing to treat for urinary tract infection without any confirmatory evidence was felt to be poor practice. The claim was settled for a moderate sum.

Learning points

When obtaining a detailed history is made difficult by communication issues, detailed physical examination and appropriate investigation is the best route to a correct diagnosis.

Treating a man of this age with such symptoms it would be prudent to examine the patient’s prostate.

Patients may be reluctant to mention that they have problems “down below” so have a low threshold for directly asking about penile lesions and examining the external genitalia, where there are distal urinary tract symptoms. It may be that the use of slang or euphemisms may aid communication.

Any complaint of itching, burning sensation, soreness or bleeding affecting the glans or prepuce should prompt consideration of the diagnosis of carcinoma of the penis, requiring examination of the external genitalia and inguinal lymph fields.

It is important to carry out investigation before referral and make use of available outpatient investigations.

Differential diagnosis of penile lesions is fraught with difficulty. Where there is any doubt, you should refer the patient to a urologist or dermatologist for an opinion and consideration of biopsy.

Any lesion of the penis that is potentially compatible with penile carcinoma should be referred urgently to a urologist.

Female practitioners should offer to have a male colleague examine the area if embarrassment is a bar to this.

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

MEC Special Lecture: Radiotherapy in Cancer Treatment

2010-05-24T15:44:00.003+08:00

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

2010-04-23T23:38:00.000+08:00

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:
In 13 patients with normal x-rays, MRI revealed 6 fractures of the hip and 17 fractures of the pelvis.

In 11 of 26 patients whose x-rays suggested fractures, MRI showed no fractures.

In 7 of the 15 patients whose MRIs confirmed fractures found on x-rays, MRI also identified second fractures that x-ray imaging missed.

Comment: Although the manner in which these cases were selected precludes a precise estimate of sensitivity and specificity of conventional x-rays for detecting acute hip and pelvis fractures, the study results suggest that both false-positives and false-negatives are not uncommon. However, these findings do not mean that MRI is necessary in all cases; x-rays should be followed by MRI only when a chance exists that MRI will change management.

— Allan S. Brett, MD

Published in Journal Watch General Medicine April 22, 2010

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

World Health Day & Public Talk in KMC - 7.4.2010

2010-04-06T15:35:00.001+08:00

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

2010-03-23T22:10:00.004+08:00

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.

Abstract

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.

Methods: A pain questionnaire was mailed to 1,299 women 1 yr after hysterectomy. The response rate was 90.3%, and the presence of persistent pain was correlated to indication for surgery, surgical procedure, type of anesthesia, and other perioperative data.

Results: Pain was reported by 31.9% 1 yr after hysterectomy (chronic pain), and 13.7% had pain more than 2 days a week. Pain was not present before surgery in 14.9% of women with chronic postsurgical pain. Risk factors for chronic pain were preoperative pelvic pain (odds ratio [OR], 3.25; 95% confidence interval [CI], 2.40-4.41), previous cesarean delivery (OR, 1.54; CI, 1.06-2.26), pain as the main indication for surgery (OR, 2.98; CI, 1.54-5.77), and pain problems elsewhere (OR, 3.19; CI, 2.29-4.44). Vaginal hysterectomy versus total abdominal hysterectomy was not significantly associated with a lower risk of chronic pain (OR, 0.70; CI, 0.46-1.06). Importantly, spinal versus general anesthesia was associated with less chronic pain (OR, 0.42; CI, 0.21-0.85).

Conclusions: Thirty-two percent had chronic pain after hysterectomy, and risk factors were comparable to those seen in other operations. Interestingly, spinal anesthesia was associated with a lower frequency of chronic pain, justifying prospective study of spinal anesthesia for patients with a high risk for development of chronic postsurgical pain.

© 2007 American Society of Anesthesiologists, Inc.

For full text - please visit this website

http://journals.lww.com/anesthesiology/Fulltext/2007/05000/Risk_Factors_for_Chronic_Pain_after_Hysterectomy_.19.aspx

Toxicity, Benzodiazepine: Treatment & Medication

2010-03-23T16:51:00.004+08:00

http://emedicine.medscape.com/article/813255-treatment
eMedicine Specialties > Emergency Medicine > Toxicology

Updated: Jan 28, 2010

Introduction

Background

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.

Pathophysiology
Gamma-aminobutyric acid (GABA) is the major inhibitory neurotransmitter in the CNS. Benzodiazepines (BZD) exert their action by potentiating the activity of GABA. They bind to a specific receptor on the GABA A receptor complex, which facilitates the binding of GABA to its specific receptor site. BZD binding causes increased frequency of opening of the chloride channel complexed with the GABA A receptor. Chloride channel opening results in membrane hyperpolarization, which inhibits cellular excitation.

Enhanced GABA neurotransmission results in sedation, striated muscle relaxation, anxiolysis, and anticonvulsant effects. Stimulation of peripheral nervous system (PNS) GABA receptors may cause decreased cardiac contractility and vasodilation. These changes could have the potential to alter tissue perfusion.

The rate of BZD onset of action is determined by its ability to cross the blood-brain barrier. The relatively lipophilic BZDs usually produce a faster onset of effect than the relatively water-soluble BZDs. BZD effects can be potentiated when ethanol is present as coingestant. Peak blood concentrations of most agents occur within 1-3 hours. After a single dose, the lipophilic agents can have a shorter duration of action (shorter CNS effect) than water-soluble agents because rapid redistribution from the CNS to peripheral sites (eg, adipose tissue); thus, lorazepam (water soluble) has a longer CNS duration of action than diazepam (lipophilic). However, diazepam metabolizes to active intermediates with prolonged half-life extending its therapeutic effects.

BZDs are metabolized predominantly in the liver by oxidation and/or conjugation. Most BZDs are broken down into pharmacologically active metabolites, which may have longer half-lives than the parent compounds.

Frequency
United States
In 2008, a total of 78,443 benzodiazepine single-substance exposures were reported to US poison control centers, of which 332 (0.004%) resulted in major toxicity and 8 (0.0001%) resulted in death.[1 ]

International
In the 1980s, an overall rate of 5.9 fatalities per million prescriptions for BZDs occurred in Great Britain, while exposure to temazepam and flurazepam was associated with the most toxic effects.[2 ]

Mortality/Morbidity
Benzodiazepines (BZDs) generally are thought to be safe and death is rare.

Mortality and morbidity from a pure oral BZD overdose is rare; it usually occurs in conjunction with concomitant alcohol ingestion or use of other sedative-hypnotics.
Intravenous administration or overdose of ultrashort-acting BZDs (eg, triazolam [Halcion]) is more likely to result in apnea and death. Elderly individuals and very young persons are more susceptible to the CNS depressant effects of BZDs than people in other age groups.
Intravenous administration is associated with greater degrees of hypotension than other routes of administration and occasional cardiac and respiratory arrest.

Age
The most reported BZD use is in persons older than 19 years.

Clinical
History
History should include the time, dose, and intent of the overdose. Determine if co-ingestants are present and the duration of benzodiazepine (BZD) use.

Dizziness
Confusion
Drowsiness
Blurred vision
Unresponsiveness
Anxiety
Agitation

Physical
Focus the physical examination on the patient's vital signs, cardiorespiratory and neurologic function. "Classic" isolated BZD overdose presents as coma with normal vital signs.

Nystagmus
Hallucinations
Slurred speech
Ataxia
Coma
Hypotonia
Weakness
Altered mental status, impairment of cognition
Amnesia
Paradoxical agitation
Respiratory depression
Hypotension

Differential Diagnoses
Alcohol and Substance Abuse Evaluation
Toxicity, Antidepressant

Encephalitis
Toxicity, Antihistamine

Hypernatremia
Toxicity, Barbiturate

Hypoglycemia
Toxicity, Carbamazepine

Hyponatremia
Toxicity, Carbon Monoxide

Pediatrics, Hypoglycemia
Toxicity, Clonidine

Pediatrics, Meningitis and Encephalitis
Toxicity, Ethylene Glycol

Stroke, Hemorrhagic
Toxicity, Neuroleptic Agents

Stroke, Ischemic
Toxicity, Sedative-Hypnotics

Subarachnoid Hemorrhage
Toxicity, Valproate

Subdural Hematoma

Toxicity, Alcohols

Workup
Laboratory Studies
Qualitative screening of urine or blood may be performed but rarely influences treatment decisions and has no impact on immediate clinical care.
Immunoassay screening techniques are performed most commonly and typically detect benzodiazepines (BZDs) that are metabolized to desmethyldiazepam or oxazepam; thus, a negative screening result does not rule out the presence of a BZD agent. Overall, the laboratory detection of BZDs depends upon the screening method used.
Obtain an arterial blood gas (ABG) if respiratory depression is present.
Following an intentional overdose, measure serum electrolytes, glucose, BUN, creatine clearance, ETOH, and acetaminophen concentration.
Obtain a pregnancy test in women of childbearing age.
Imaging Studies
Obtain a chest x-ray if respiratory compromise is present.
Evaluate for aspiration.
Evaluate for acute respiratory distress syndrome (ARDS).
Other Tests
Obtain an electrocardiogram (ECG) to evaluate for co-ingestants, particularly cyclic antidepressants.
Treatment
Prehospital Care
Cardiac monitoring
Supplemental oxygen and airway support
Intravenous access
Rapid glucose determination (finger stick) and administration of D50 if necessary
Naloxone can be administered at a very low dose (0.05 mg with gradual increase in dose if needed), if the diagnosis is unclear and an opiate co-ingestion is suspected (eg, evidence of severe respiratory depression).
CAVEAT: Administration of 0.4 mg of naloxone will reverse respiratory depression in most opioid overdoses; however, it will also result in severe withdrawal symptoms (nausea, vomiting) in opioid-dependent individuals. This can be detrimental in patients who are still unable to protect their airway due to BZD effect (sedation) and can suffer from aspiration of gastric contents.
Emergency Department Care
Continue supportive care and monitoring (eg, cardiac monitoring, IV, oximetry, vital signs).

Decontamination
Ipecac syrup is contraindicated for prehospital or hospital use because of the risk for CNS depression and subsequent aspiration with emesis.
Gastric lavage is not recommended but may be considered if the presence of a lethal co-ingestant is suspected and the patient presents within 1 hour of ingestion.
Single-dose activated charcoal is recommended for GI decontamination in patients with protected airway who present within 4 hours of ingestion. It is important to remember that isolated oral BZD overdose is relatively benign exposure (eg, prolonged sedation), and aspiration of activated charcoal can significantly worsen clinical outcome, sometimes resulting even in death.
Respiratory depression may be treated with assisted ventilation.
Flumazenil
Flumazenil is a competitive BZD receptor antagonist and should be used cautiously because it has potential to precipitate BZD withdrawal in chronic users, resulting in seizures.
Flumazenil administration is contraindicated in mixed overdoses (eg, TCAs) because BZD reversal can precipitate seizures and cardiac arrhythmias.
Ideal indication for flumazenil use is isolated BZD overdose in BZD-naive patients, particularly if overdose is iatrogenic in nature (eg, during conscious sedation on BZD-naive patient).
The American Psychiatric Association and the National Institute of Clinical Excellence have treatment and diagnostic guidelines available for cases of substance abuse and self-harm.[3,4 ]

Consultations
Toxicologist or a poison control center
Intensive care specialist
Psychiatrist, if suicide attempt
Medication
GI decontaminant
Empirically used to minimize systemic absorption of the toxin.

Activated charcoal (Liqui-Char)
Most useful if administered within 1-2 h of ingestion. Repeat doses may be used, especially with ingestion of sustained release agents. Limited outcome studies exist, especially when administration is more than 1 h of ingestion.
Administration of charcoal by itself (in aqueous solution), as opposed to coadministration with a cathartic is becoming the current practice standard. Studies have not shown benefit from cathartics, and, while most drugs and toxins are absorbed within 30-90 min, laxatives take hours to work. Dangerous fluid and electrolyte shifts have occurred when cathartics are used in small children.
When the ingested dose is known, charcoal may be administered at 10 times ingested dose of agent over 1 or 2 doses.

Dosing
Adult
1 g/kg PO/NG (typically 50-75 g); cathartic optional but not routinely recommended; repeat dose of 0.5 g/kg PO/NG if desired; do not use cathartic with repeat doses

Pediatric
Administer as in adults (typically 12.5-25 g); avoid cathartic in children <2 y

Interactions
May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix with sherbet, milk, or ice cream (decreases absorptive properties)

Contraindications
Documented hypersensitivity; poisoning or overdose of mineral acids and alkalies; unprotected airway with absent gag reflex

Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions
Protect airway before administration in patients with absent gag reflex or a depressed level of consciousness; when considering repeat dosing, monitor for active bowel sounds to minimize risk of charcoal ileus; not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administering activated charcoal; after emesis with ipecac, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black

Antagonist
Flumazenil is a selective competitive antagonist of the GABA receptor and the only available specific antidote for BZDs; it will reverse effects of BZDs but must be used with caution. If BZDs are being used to treat a potentially life-threatening condition (eg, seizure disorder), antagonists may exacerbate the underlying disorder.

Additionally, co-ingestion commonly occurs with agents that lower the seizure threshold (eg, cyclic antidepressants) and reversal may result in seizure or status epilepticus; therefore, antagonists are not recommended for use by prehospital personnel or for indiscriminate use before a complete evaluation.

In overdose situations, flumazenil may be used for patients with pure BZD overdose who are verbally unresponsive and have no history of long-term BZD use or seizure disorder. Perform an ECG should be performed before use to confirm the absence of cardiac conduction disturbances (which would suggest the presence of cyclic antidepressants). Use as a diagnostic and therapeutic agent for unsubstantiated drug-associated coma is controversial. A positive response to small titratable doses may obviate the need for endotracheal (ET) intubation and the search for other causes of coma.

Flumazenil (Romazicon)
DOC to reverse effects of BZDs in an overdose by selectively antagonizing GABA/BZD receptor complex.
If overdosed patient has not responded after 5 min of 5 mg cumulative dose, cause of sedation is not likely to be BZDs.

Dosing
Adult
0.1-0.2 mg IV q1min to a total dose of 1 mg at one time or 3 mg in 1 h; infusion rates of 0.1 mg/min decrease disconcerting rapid arousal

Pediatric
0.002-0.02 mg/kg IV q1min

Interactions
Caution with mixed drug overdose; toxic effects due to other drugs taken in overdose (eg, cyclic antidepressants) may occur with reversal of BZD effects

Contraindications
Documented hypersensitivity; serious cyclic-antidepressant overdosage; patients using BZDs to control a potentially life-threatening condition (eg, intracranial pressure, status epilepticus); chronic BZD use

Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions
Patients on BZDs for prolonged periods may experience seizures; monitor for resedation and unmasking of seizures

Follow-up
Further Inpatient Care
Admit patients with hemodynamic instability, coma, or respiratory depression to the ICU.
Watch for signs of withdrawal in patients who have been taking benzodiazepines (BZDs) chronically before overdose.
Further Outpatient Care
Patients may be discharged if they remain asymptomatic at least 6 hours post ingestion. Those with mild toxicity may be observed in the emergency department until they recover. Patients with intentional overdoses have to be evaluated by a psychiatrist.
Transfer
Transfer patients who may require more advanced care than is available in either the ED or inpatient setting.
Complications
Aspiration pneumonia
Rhabdomyolysis
Fatality (rare)
Patient Education
For excellent patient education resources, visit eMedicine's Poisoning - First Aid and Emergency Center, Mental Health and Behavior Center, and Substance Abuse Center. Also, see eMedicine's patient education articles Benzodiazepine Abuse, Drug Overdose, Activated Charcoal, and Poison Proofing Your Home.
Miscellaneous
Medicolegal Pitfalls
Unmasking an underlying disorder, specifically seizures, with indiscriminate use of flumazenil
Administration of full dose of naloxone (0.4 mg or more) and precipitation of opioid withdrawal in patients with mixed overdose resulting in aspiration of gastric content
Administration of charcoal in patients with unprotected airway
Failure to anticipate withdrawal in a patient with chronic benzodiazepine (BZD) use
Failure to consider the possibility of co-ingestant use or secondary causes of treatable altered mental status (eg, hypoglycemia, meningitis)
References
Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila). Dec 2009;47(10):911-1084. [Medline]. [Full Text].

Serfaty M, Masterton G. Fatal poisonings attributed to benzodiazepines in Britain during the 1980s. Br J Psychiatry. Sep 1993;163:386-93. [Medline].

[Guideline] Kleber HD, Weiss RD, Anton RF, et al. Treatment of patients with substance use disorders, second edition. American Psychiatric Association. Am J Psychiatry. Aug 2006;163(8 Suppl):5-82. [Medline]. [Full Text].

[Guideline] National Collaborating Centre for Mental Health. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. London (UK): National Institute for Clinical Excellence (NICE). 2004;199. [Full Text].

Bosse GM. Benzodiazepines. In: Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw-Hill; 1996:759-61.

Buckley NA, Dawson AH, Whyte IM, O'Connell DL. Relative toxicity of benzodiazepines in overdose. BMJ. Jan 28 1995;310(6974):219-21. [Medline].

Cairns C. Benzodiazepine overdose and withdrawal. In: Emergency Medicine: Concepts and Clinical Practice. 3rd ed. Mosby-Year Book; 1992:2684-9.

Drummer OH, Syrjanen ML, Cordner SM. Deaths involving the benzodiazepine flunitrazepam. Am J Forensic Med Pathol. Sep 1993;14(3):238-43. [Medline].

Hoffman RS, Wipfler MG, Maddaloni MA, Weisman RS. Has the New York State triplicate benzodiazepine prescription regulation influenced sedative-hypnotic overdoses?. N Y State J Med. Oct 1991;91(10):436-9. [Medline].

Longmire AW, Seger DL. Topics in clinical pharmacology: flumazenil, a benzodiazepine antagonist. Am J Med Sci. Jul 1993;306(1):49-52. [Medline].

Mullins ME. First-degree atrioventricular block in alprazolam overdose reversed by flumazenil. J Pharm Pharmacol. Mar 1999;51(3):367-70. [Medline].

Verghese J, Merino J. Temazepam overdose associated with bullous eruptions. Acad Emerg Med. Oct 1999;6(10):1071. [Medline].

Keywords
BZD toxicity, sedative-hypnotic toxicity, benzodiazepine toxicity, benzodiazepine treatment, flumazenil, benzodiazepine exposure, BZD exposure, seizure control, anxiety, alcohol withdrawal, alprazolam, flunitrazepam, chlordiazepoxide, diazepam, triazolam, temazepam, flurazepam, bromazepam, clorazepate, oxazepam, nitrazepam, alprazolam, lormetazepam, lorazepam, benzodiazepine overdose

Contributor Information and Disclosures
Author
Robin Mantooth, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Norman Regional Health System; Adjunct Clinical Assistant Professor, Family Medicine, Oklahoma State University; Consulting Staff, Department of Emergency Medicine, Integris Southwest Medical Center; Consulting Staff, Department of Emergency Medicine, Oklahoma University Medical Center; Consulting Staff, Department of Emergency Medicine, Integris Canadian Valley Health Center; Consulting Staff, Department of Emergency Medicine, Saint Anthony Hospital; Consulting Staff, Department of Emergency Medicine, Commanche County Medical Center; Consulting Staff, Department of Emergency Medicine, Claremore Medical Center
Robin Mantooth, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Medical Editor
David C Lee, MD, Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School
David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor
John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor
Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor
John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor
Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

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

2010-03-23T16:27:00.003+08:00

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.

Reviewing preliminary data from one clinical trial, the agency found that muscle injury, including rhabdomyolysis, was more common among patients on the 80-mg dose of simvastatin versus a 20-mg dose (0.9% vs. 0.02%).
As part of an ongoing safety review of the drug, the FDA is also examining data from other clinical trials, observational studies, and adverse event reports.

FDA MedWatch alert (Free)
FDA safety communication (Free)
Zocor prescribing information (Free PDF)
--
Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

Public Lecture : Stress Management : Dr Wan (TM Office Alor Setar) - 22.3.2010

2010-03-22T16:49:00.004+08:00

Metformin and Vitamin B12 Deficiency

2010-02-28T09:47:00.001+08:00

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.

Median serum B12 level was significantly lower in the metformin group than in the no-metformin group (231 vs. 486 pmol/L). Metformin recipients also had significantly higher levels of homocysteine and methylmalonic acid (markers of B12 deficiency) and significantly worse scores on standardized clinical assessments of severity of neuropathy. In multivariate analyses controlled for age, duration of diabetes, and glycosylated hemoglobin (HbA1c) level, metformin therapy was associated independently with worse neuropathic symptoms.
Comment: This study strengthens the case for an effect of metformin therapy on vitamin B12 levels. The analysis also suggests that this interaction worsens neuropathy, but confounding by unknown factors could be responsible for this observation. In one randomized placebo-controlled trial, metformin lowered B12 levels (J Intern Med 2003; 254:455); now, we need a trial to determine whether B12 supplementation is beneficial for diabetic patients who take metformin.
— Allan S. Brett, MD
Published in Journal Watch General Medicine February 25, 2010
Citation(s):
Wile DJ and Toth C. Association of metformin, elevated homocysteine, and methylmalonic acid levels and clinically worsened diabetic peripheral neuropathy. Diabetes Care 2010 Jan; 33:156.
Original article (Subscription may be required)
Medline abstract (Free)

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

MEC Talk : MRI

2010-02-17T10:01:00.000+08:00

KMC Consultant In the Media : Dr Kamaruzzaman Ali

2010-02-16T16:35:00.001+08:00

New Straits Times (14.02.2010 : V5)

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

2010-01-28T15:56:00.001+08:00

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.

Among patients who had HbA1c levels of <6.5%, 5-year incidence of adverse cardiovascular events was lower for those with low comorbidity (hazard ratio, 0.6) than for those with high comorbidity (HR, 0.9) in analyses adjusted for age and sex. For an HbA1c target level of 7%, the same finding was noted (i.e., lower incidence of adverse cardiovascular events only among those with low comorbidity).
Comment: When individual randomized trials have been analyzed in systematic reviews, intensive control (HbA1c <7% but not <6.5%) modestly lowered incidence of adverse cardiovascular events (mainly nonfatal myocardial infarction) at a cost of excess severe hypoglycemia.

Results of this observational study suggest that cardiovascular benefits might accrue only to those without substantial comorbidity. An editorialist concludes that 7% remains an appropriate goal to prevent adverse microvascular, neurological, and, possibly, cardiovascular events. However, for many patients with substantial comorbidity, the overall benefits of even a 7% goal might not exceed the burdens or harms associated with trying to achieve that goal.

— Richard Saitz, MD, MPH, FACP, FASAM
Published in Journal Watch General Medicine January 26, 2010
Citation(s):
Greenfield S et al. Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes: A cohort study. Ann Intern Med 2009 Dec 15; 151:854.
Original article (Subscription may be required)
Medline abstract (Free)
Nathan DM. The role of glycemia management in the prevention of cardiovascular disease — Starting over? Ann Intern Med 2009 Dec 15; 151:888.
Original article (Subscription may be required)
Medline abstract (Free)

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

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

2010-01-28T15:47:00.001+08:00

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.

During the 5 years after changing therapy, the investigators noted a U-shaped curve in both cohorts with respect to all-cause mortality and levels of glycated hemoglobin — patients in the lowest decile of glycated hemoglobin (median HbA1c, 6.4%) and the highest (10.6%) had significantly higher mortality rates than those in the reference decile (7.5%).

Lancet article (Free abstract; full text requires subscription)
Lancet comment (Subscription required)

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

TNB Safety Day 21.01.2010

2010-01-24T10:51:00.004+08:00

Public Talk : Dr Syed Faisal (30.01.2010)

2010-01-22T11:44:00.000+08:00

Should Physicians Be 'Punished' For Not Washing Their Hands?

2010-01-22T10:54:00.002+08:00

(original article - Medscape : http://boards.medscape.com/forums?128@659.WQ45aiaDlWk@.29f8f873!comment=1

by Leslie Kane, Other, 10:10AM Jan 14, 2010

Hospitals and healthcare organizations have made it a major goal to get physicians (and other health workers) to wash their hands more frequently, in order to prevent cross-contamination. While there are pockets of success, most efforts have been as useful as warning teenagers to put down the cell phone while driving.

Despite conveniently-placed sinks, admonishing signs, and rewards such as free movie tickets for best compliance, doctors still wash their hands as little as one-third to one-half times as often as they should, said Atul Gawande, MD, surgeon at Brigham Women's Hospital in Boston, in a New Yorker magazine article.

To promote hand washing, most health organizations use educational tactics, but the campaigns aren't working. Some executives say nothing will change unless non-compliance brings penalties. So the tactics are escalating.

Several tactics are being tested, sometimes together.

Interestingly, they hinge on different views of human nature. The positive approaches (education, rewards) assume that doctors will do what's right if they learn why it's important; the avoidance approach (penalties, fines) assume that people won't change a comfortable behavior (especially one that crops up all day long) unless they're trying to avoid a Skinnerian shock of electricity; the neutral approach (system) bypasses motivation and instead seeks to change the environment so that hand washing is unthinkingly routine.

In escalating order of punitiveness, here are some of the current options being used, and I'm sure there are many others.

1) More education and motivation, such as reminders, announcements, signage. This does help improve the situation, but in most cases it doesn't seem to get the compliance percentages where they need to be.

2) Rewards and incentives. Give unit heads performance goals and bonuses to improve the hand washing rate in their units. This is the time-tested (and typically effective) route to compliance among most corporations. Or, offer rewards to individuals who show improvement.

3) Systemic approaches, such as checklists and technology. Unfortunately, checklists aren't quite appropriate for an activity performed dozens (or many more) times each day, often on the run. Several systemic changes have been implemented to promote hand washing, with mixed success.

4) Harness peer pressure. Martin Kane, MD, from Altamonte Springs, FL (full disclosure = my brother) suggested using an automatic sink faucet that emits a tone or a light goes on when washing commences and stays on for the recommended hand washing time. If a doctor leaves the sink before the light or tone stops, it would be obvious to passersby, and peer pressure would promote more extensive hand washing.

5) Enlist staff members as whistleblowers. Some hospitals already ask the infection control staff to report doctors who don't wash when appropriate. Another suggestion is to have a phone number for anonymous tipsters to use. The notion of snitching in pursuit of the greater good has evoked anger from some people.

6) Caught on camera! Robert Wachter, MD, professor and associate chairman at the University of California San Francisco Medical Center, and a leader in patient safety and healthcare quality, once suggested the use of video monitoring, and the idea has gained momentum. Arrowsight Medical, Mt. Kisco, NY, a company that does video monitoring and feedback for various industries, ran a pilot program in a Georgia surgical center and saw hand washing increase from 30 percent to 90 percent.

Still, in our new YouTube culture where almost any video could end up on the web, this idea makes folks shudder.

7) Penalize the offenders. Let's say the non-hand-washers can be identified and they make only cursory efforts to wash more frequently. What's an appropriate penalty?

In some hospitals and health organizations, repeat culprits are called in for a chat with the head of the medical staff or the hospital CEO. (Some doctors are undaunted, others say it's like being called to the principal's office and they're not happy about it).

As far as actual penalties, if hospital officials feel a doctor is truly endangering patients, they want to take some action. Still, the situation is so widespread, might there be too many fish caught in the net? Also, I can't see a hospital - at least one that competes for doctors' services - creating such bad will with its physicians.

Not all doctors are convinced that the focus on hand washing is necessary. One physician recently told me that this is just another annoying thing that doctors are being pummeled for, and the link between hand washing and most nosocomial infections is not as strong as many would have us believe.

--
Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

Interesting Article : Combined Antiplatelet and Anticoagulant Drugs Raise Bleeding Risk

2010-01-13T21:14:00.001+08:00

Summary and Comment

Combined Antiplatelet and Anticoagulant Drugs Raise Bleeding Risk

Use of dual or triple therapy requires caution.

Aspirin and clopidogrel are recommended for patients after acute myocardial infarction (AMI), and many AMI patients also have indications for a vitamin K antagonist. But combining these drugs can elevate risk for bleeding, which in turn can lead to morbidity and mortality.

To assess the safety of combinations of antiplatelet and anticoagulant drugs, Danish researchers used national registries to identify 40,000 adults who filled prescriptions within 90 days after first AMIs for one or more of three drugs: aspirin, clopidogrel, and a vitamin K antagonist.

During a mean follow-up of about 16 months, 1852 patients were hospitalized for nonfatal bleeding, and 115 fatal bleeding events occurred. With aspirin monotherapy as a reference, the adjusted relative risks for fatal and nonfatal bleeding were 1.23 for a vitamin K antagonist alone (the only nonsignificant difference), 1.33 for clopidogrel alone, 1.47 for aspirin plus clopidogrel, 1.84 for aspirin plus a vitamin K antagonist, 3.52 for clopidogrel plus a vitamin K antagonist, and 4.05 for all three (all significant differences). The adjusted number needed to harm for triple therapy was 12.5. Of patients who experienced nonfatal bleeding events, 38% had recurrent AMIs or died during follow-up compared with 18% of patients who didn't experience bleeding events.

Comment: This study was retrospective, but its size makes it credible. These findings strongly suggest that decisions to prescribe dual and triple combinations of antithrombotic medications should reflect careful, individualized risk-benefit evaluations that are based (whenever possible) on published evidence.

— Bruce Soloway, MD

Published in Journal Watch General Medicine January 12, 2010

Citation(s):

Sørensen R et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: A retrospective analysis of nationwide registry data. Lancet 2009 Dec 12; 374:1967.

Medline abstract (Free)

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

KMC Consultant In the Media : Dr Wan (11.01.2010)

2010-01-12T21:16:00.001+08:00

Utusan Malaysia (Page:12) : Forum

Berita Harian - (Page 28) : Surat & E-mel

Interesting Article : Recommendations for Prescribing NSAIDs

2010-01-07T15:29:00.001+08:00

December 28, 2009 — A review article published in the December 15 issue of the American Family Physician offers recommendations for prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) in the primary care setting.

"...NSAIDs are commonly used to treat inflammation, pain, and fever by decreasing prostaglandin synthesis through blockage of the cyclooxygenase (COX) enzyme," write Amanda Risser, MD, MPH, from Oregon Health and Science University in Portland, and colleagues. "The two major isoforms of COX (COX-1 and COX-2) are inhibited by nonselective NSAIDs. COX-2 is also inhibited by selective NSAIDs. All nonselective NSAIDs inhibit platelet aggregation through inhibition of COX-1 and the thromboxane A2 (TXA2) pathway."

Although NSAIDs are in widespread use, there are accompanying risks, including significant upper gastrointestinal (GI) tract bleeding (particularly in older persons), risks in those receiving anticoagulant therapy, and risks in patients with a history of upper GI tract bleeding associated with NSAID use.

Dyspepsia, abdominal pain, GI discomfort, and GI bleeding may be reduced by combining the NSAID with a proton pump inhibitor (PPI) or histamine H2 blocker.

Despite the cardioprotective qualities of aspirin, other NSAIDs may have adverse cardiac effects, including worsening of congestive heart failure, increase in blood pressure, myocardial infarction, and ischemia. The risk for myocardial infarction is increased with COX-2 inhibitors, although celecoxib, which is the only COX-2 inhibitor still available in the United States, is somewhat safer regarding cardiovascular effects.
NSAIDs should not be used in patients with cirrhotic liver diseases because such patients are at greater risk of bleeding and for kidney failure. However, NSAIDs rarely cause hepatic damage, and any hepatic effects are usually reversible. NSAIDs with more potential for hepatic problems include sulindac and diclofenac.
Caution is advised when NSAIDs are prescribed in the setting of anticoagulant therapy, platelet dysfunction, or immediately before surgery.

Central nervous system adverse effects of NSAIDs may include aseptic meningitis, psychosis, and tinnitus. NSAIDs may also trigger or exacerbate asthma.

In patients with asthma, especially those with nasal polyps or recurrent sinusitis, NSAIDs and aspirin should be avoided.
During the last 6 to 8 weeks of pregnancy, NSAIDs should be avoided to prevent prolonged gestation from inhibition of prostaglandin synthesis, premature closure of the ductus arteriosus, and antiplatelet activity causing maternal and fetal complications.

However, most NSAIDs are likely safe in pregnancy.

In breast-feeding women, ibuprofen, indomethacin, and naproxen can be safely used. Parents should be educated regarding correct NSAID dosing and storage in childproof containers to prevent accidental NSAID overdose in children.

Key Recommendations

Specific key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

Physicians should consider prescribing PPIs, double-dose histamine H2 blockers, or misoprostol with NSAIDs for persons who must take NSAIDs, although they have had an NSAID-associated ulcer. Celecoxib may also be used alone in these patients, but this drug should be avoided in patients at increased risk for myocardial infarction. Women who might become pregnant should not take misoprostol (level of evidence, C). Two systematic reviews describe the use of NSAIDs in this setting for the prevention of endoscopic ulcers.

For prevention of acute renal failure, NSAIDs should be avoided whenever possible in patients with preexisting kidney disease, congestive heart failure, or cirrhosis (level of evidence, C, based on a literature review and a summary of consensus guidelines).

For patients at risk for renal failure, and in those taking angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, physicians should consider monitoring serum creatinine levels after prescribing treatment with NSAIDs (level of evidence, C, based on a summary of consensus guidelines).
In patients taking anticoagulants, NSAIDs and aspirin should be avoided if possible. An increase in international normalized ratio (INR) should be expected if concurrent use of NSAIDs and anticoagulants is required. These patients should have appropriate INR monitoring, dosage adjustments of warfarin, and GI prophylaxis (level of evidence, C, based on a systematic review).
In breast-feeding women, ibuprofen, indomethacin, and naproxen can be safely used (level of evidence, C, based on a consensus guideline).

Editorial: Increased Cardiovascular Concerns

In an accompanying editorial, Gunnar H. Gislason, MD, PhD, from Copenhagen University Hospital Gentofte in Copenhagen, Denmark, describes increased concerns regarding the cardiovascular safety profile of NSAIDs, which have come to light during the last decade. Although these concerns were first recognized for COX-2 inhibitors, increased cardiovascular risk associated with nonselective NSAIDs has recently been identified.

Because there will always be groups of patients with pain conditions who must take NSAIDs, there is a need to focus on the balance between risk and benefit before NSAID therapy is started.
"This is especially important in persons with established cardiovascular disease in whom alternative pain treatment with lower cardiac risk (e.g., acetaminophen, weak opiates) should always be the first choice,
" Dr. Gislason writes. "In persons needing NSAID treatment, NSAIDs with the highest COX-1 selectivity (e.g., naproxen, ibuprofen, aspirin) should be preferred and used in the lowest dosages and for the shortest durations possible. For stronger analgesic effect, a combination with other types of analgesics should be considered."

As supplements to analgesic therapy, Dr. Gislason also recommends considering nonpharmacologic treatment, such as physiotherapy and physical exercise.
"Epidemiologic studies have demonstrated extensive use of prescription NSAIDs in the general population, as well as in persons with established cardiac disease," Dr. Gislason concludes.

"Also, in many countries, NSAIDs are sold without a prescription, expert advice, limits on their use, or information on potential adverse effects. This indicates the need for reevaluation of current treatment strategies regarding NSAID use and the misconception that NSAIDs are harmless for everyone."
The review authors and editorialist have disclosed no relevant financial relationships.
Am Fam Physician. 2009;80:1371-1378. Abstract
Clinical Context

NSAIDs are commonly used to treat inflammation, pain, and fever by blockage of the COX enzyme, and there is limited evidence to support differences in effectiveness for pain treatment when comparing NSAIDs.

The likelihood of adverse effects increases with duration of use and dose.

However, the adverse effect profile of the different NSAIDs may differ. For example, aspirin is used for primary prevention of coronary and cardiovascular conditions such as stroke because of its antiplatelet effects, whereas COX-2 inhibitors have little antiplatelet effect.
This is a review of the adverse effects of NSAIDs and precautions needed to minimize risk when NSAIDs are prescribed. Adverse effects occur mainly in the GI, cardiovascular, hepatic, renal, hematologic, nervous, and respiratory systems.

Study Highlights

Taking drug holidays or using intermittent dosing may be strategies to reduce the risks associated with NSAID use.

Dyspepsia and GI discomfort occur in 10% to 20% of persons taking NSAIDs, but dyspeptic symptoms do not correlate well with clinically significant ulcers.
GI adverse effects are increased with age and comorbidity.
The 1-year risk of serious GI bleeding from long-term NSAID use ranges from 1 in 2100 adults younger than 45 years to 1 in 110 older than 75 years.

Risk for death for the 2 groups ranges from 1 in 12,353 to 1 in 647 adults, respectively.
Concomitant anticoagulant use increases the risk by 5 to 6 times.
In those with a history of bleeding ulcers, the risk is 5% in 6 months, even with the use of COX-2 inhibitors or nonselective NSAIDs with a PPI.
Eradication of Helicobacter pylori only minimally decreases the rate of peptic ulcer in persons taking NSAIDs.

Taking misoprostol with an NSAID reduces ulcer-related complications but is contraindicated in pregnancy (category X) and has undesirable GI effects.
Use of PPIs or double-dose antihistamines with NSAIDs decreases the rate of endoscopically diagnosed ulcers.

Although low-dose aspirin has been shown to reduce the risk for coronary artery and cerebrovascular disease, other NSAIDs are associated with an increased risk for worsening congestive heart failure, increased blood pressure, and adverse cardiovascular events.

Blood pressure increases by 5 mm Hg, whereas use of nonselective NSAIDs and some COX-2 inhibitors also increases blood pressure.

COX-2 inhibitors have been implicated in the risk for myocardial infarction, although celecoxib may be safer than the others.

COX-2 inhibitors should be avoided in persons at risk for cardiovascular events, who should consider a nonselective NSAID with misoprostol or a PPI for GI protection instead.
Sulindac and diclofenac are associated with a higher rate of hepatic dysfunction than other NSAIDs, but clinically significant events are rare.

Idiosyncratic liver toxicity may occur in those with hepatitis C or underlying liver impairment.
NSAIDs should be avoided in persons with preexisting renal disease, congestive heart failure, or cirrhosis to prevent renal failure.

It is unclear whether monitoring renal function in those with renal risk who are taking NSAIDs reduces morbidity or mortality rates.
In high-risk persons with recent myocardial infarction or stent placement, aspirin should be continued before and after surgery.

In those with bleeding risk, aspirin and other NSAIDs may be withheld before surgery for 5 elimination half-lives (eg, 7 - 10 days before surgery for aspirin and 2 days for ibuprofen).
Aspirin should be avoided in those for whom benefits do not outweigh risks.
In persons taking anticoagulants, INR monitoring is required when using NSAIDs, and GI prophylaxis should be prescribed.

Central nervous system effects are rare and occur mainly in elderly persons, including tinnitus, cognitive changes, confusion, and depression.
Indomethacin has been associated with psychosis, whereas aseptic meningitis has been seen with lupus in those taking ibuprofen or naproxen.
Bronchoconstriction has been associated with NSAID use, especially in those with underlying respiratory disease such as asthma.

NSAIDs are not teratogenic in humans, and the American Academy of Pediatrics considers ibuprofen, indomethacin, and naproxen safe in breast-feeding women.
NSAID use close to term in pregnant women is associated with prolonged labor or gestation, blood loss and anemia, and increased risk of neonatal bleeding.

Low-dose aspirin is considered safe during pregnancy and lactation.
Clinical Implications
The risk of GI bleeding with NSAID use is increased with age, duration of use, comorbidities, anticoagulant use, and a history of bleeding ulcers.
Other systemic adverse effects associated with NSAID use include those affecting the cardiovascular, hepatic, renal, hematologic, nervous, hematologic, and respiratory systems.

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

Interesting Article : Smoking Cessation Associated with Short-Term Increase in Diabetes Risk

2010-01-07T12:54:00.001+08:00

Adults who quit smoking face increased risk for type 2 diabetes during the first several years after quitting, according to an Annals of Internal Medicine study.
Researchers followed nearly 11,000 middle-aged adults for roughly 9 years, during which about 12% developed diabetes. Compared with adults who never smoked, those who continued smoking during follow-up had a roughly 30% elevated risk for diabetes, while those who quit smoking by year 3 had almost a 75% increase in risk. The elevated risk among these new quitters seemed to be mediated by adverse metabolic changes, including weight gain and systemic inflammation.

The authors write: "Of course, smoking cessation has many beneficial health effects that outweigh this short-term risk.

Nonetheless, physicians should be aware of this elevated risk and should consider countermeasures [e.g., lifestyle counseling, aggressive weight management], especially for heavy smokers."

Source : Annals of Internal Medicine article (Free abstract; full text requires subscription)

Dato' Dr. Ismail Yaacob
Medical Director/Consultant Physician
Kedah Medical Centre

MEC Talk - January 2010 : Dr Chua May Wah

2010-01-05T09:39:00.000+08:00

Speaker

Dr Chua May Wah (Consultant Paediatrician)

Topic
Premature Babies

Date

Thursday : 14 January 2010 (8.30 am - 9.30 am)

Location

Seminar Room, Level 8, Kedah Medical Centre

MEC KMC List of Activities for 2009

2010-01-02T10:04:00.000+08:00

The list of activities conducted by the Medical Education Committee for the Year 2009 can be accessed at these addresses :

MEC KMC - MEC Activities in KMC 2009
MEC KMC - Public Talk 2009

We would like to take this opportunity to thank all the consultants and members of the staff in KMC for their contributions and hard work. Hopefully we will be able to improve on our performance further this year.

Thank you.

MEC KMC (2009-2010)

Public Talk - Dr Wan : Stress & Mental Health

2009-10-11T14:36:00.001+08:00

Public Talk by Dr Wan Rushidi on Stress & Mental Health 10.10.2009 in conjuction with the World Mental Health Day 2009.

Special Lecture on H1N1

2009-09-11T14:43:00.001+08:00

Special Lecture H1N1 given by the Ministry of Health - 10.09.2009

Kuliah Ramadan by KMC Consultants at Kedah FM

2009-08-28T06:49:00.000+08:00

Kedah FM : 1.45 -2.30 pm - Live from Surau Insaniah

24/08/2009 - Dr Abdul Razif Abdul Razak (Lentur Buluh)
27/08/2009 - Dr Zuraini Abdul Hamid (Korban Ibu)
07/09/2009 - Dr Wan Mohd Rushdi Wan Mahmud (Tenang Hati)
10/09/2009 - Dr Riduan Soh Kam Lung (Ana Muslim)

Happy Listening

MEC Talk : September 2009

2009-08-27T09:51:00.000+08:00

The Things I have Never Learnt In Medical School

Dr. Ho Kok Chuan (Consultant General Surgeon)

Thursday 03.09.2009 - 8.30 - 9.30 am

8th Floor, Seminar Room, Kedah Medical Centre,
All are invited.Thank you.

MEC Lecture : Dr Chew (13.8.2009)

2009-08-14T00:03:00.000+08:00

Public Lecture : Stress & Mental Health - SMK Tun Syarifah Rodziah 12.08.2009 (Dr Wan)

2009-08-13T00:10:00.000+08:00

Medical Lecture : How To Quit Smoking

2009-08-05T16:16:00.000+08:00

This lecture was given by Dr Edward Nathan, a guest speaker from Penang Adventist Hospital. A very informative lecture indeed.

Public Lectures : TNB Safety Day - Dr Ismayatim / Dr Muhammad / Dr Wan (27.7.2009)

2009-07-28T00:07:00.000+08:00

CPR Course for TNB Staffs

2009-07-24T14:49:00.000+08:00

Special CPR Course arranged for the staffs from Tenaga Nasional Berhad -

Kedah Medical Centre 23.7.2009

MEC Talk July 2009

2009-07-15T10:13:00.000+08:00

Infertility

by
Dr. Kamaruzzaman Ali (Consultant Obstetrician & Gynaecologist)

Thursday 16.07.2009 8.30 - 9.30 am

All are invited.
Thank you.

Public Lecture : Drug Addiction - SK Seberang Nyonya (Dr Wan) - 11.7.2009

2009-07-12T00:16:00.000+08:00

Medical Health Talk - Obesity by Dr Mani Sekar - 20.06.2009

2009-06-21T10:02:00.000+08:00

WHO Website on Influenza A (H1N1)

2009-05-17T16:35:00.000+08:00

Please go to the address below on the latest update :

http://www.who.int/csr/disease/swineflu/en/

H1N1 Influenza (Swine Flu)

2009-05-14T10:58:00.000+08:00

Article on H1N1 Influenza (Swine Flu) in Medscape
and the Medscape's H1N1 influenza algorithm adaptation

Medical Director in the Media : SINAR (13.5.2009 : U4)

2009-05-13T10:51:00.000+08:00

Public Education Service : Talk by Dr Wan Rushidi (23.05.2009)

2009-05-12T10:22:00.000+08:00

Public Talk by Dr Wan Mohd Rushidi Wan Mahmud

(Consultant Neuro-Behaviour Medicine)

Topic

Stress Management

Location

Seminar Room KMC - 8th Floor
Date

Sabtu, 23 May 2009
Time
8.30 am – 11.00 am

Please call Puan Nor Ashikin / Puan Siti Mahani / Encik Fathuddin Riyadz / Puan Norlia for reservation ---> 04-737 3308 / 3307 / 3304

MEC Talk - May 2009

2009-05-07T16:38:00.000+08:00

Mood Disorder

Dr Wan Mohd Rushidi Bin Haji Wan Mahmud (Consultant Neuro-Behaviour Medicine)

(Thursday : 14.05.2009 - 8.30 - 9.30 am)

All are invited.

Thank you.

Special Talk : Retardation of Renal Failure by Dr Syed Faisal Taha (28.4.2009)

2009-04-28T13:13:00.000+08:00

KMC Consultant in the Media (SINAR - 24.4.2009 : U6)

2009-04-24T16:36:00.000+08:00

Special Talk : Retardation of Kidney Failure - 28.4.2009

2009-04-24T10:31:00.000+08:00

Retardation of Kidney Failure

by
Dr Syed Faisal Taha (Visiting Consultant Nephrologist)
(28.4.2009 - 8.00 - 9.00 am)
All are invited.
Thank you.

MEC Talk - April 2009

2009-04-20T10:17:00.000+08:00

Allergic Rhinitis
by
Dr Mahfudz Zakaria (Consultant ENT Surgeon)
(Thursday : 21.04.2009 - 8.30 - 9.30 am)
All are invited.
Thank you.

KMC Consultant in the Media (SINAR - 13.4.2009 : U6)

2009-04-13T16:33:00.000+08:00

KMC Consultant in the Media : SINAR 2.4.2009 - U6

2009-04-04T22:49:00.000+08:00

KMC Consultant in the Media : SINAR 30.3.2009 - U6

2009-03-30T20:30:00.000+08:00

Public Educational Service : Basic CPR Course (30.3.2009) in Kampung Telok Layang

2009-03-30T20:22:00.000+08:00

Today KMC Medical Education Committee has organized a public educational service - CPR Course in TABIKA Kampung Telok Layang, Jalan Kuala Kedah.

A group of 20 mothers from around the nearby village was invited to attend the course. They were indeed very thankful to KMC for organizing such an event.

MEC Talk - March 2009

2009-03-23T10:07:00.000+08:00

MEC Talk for March 2009
Arthroscopic Surgery by Dr Jasminder Singh (Consultant Orthopaedic Surgeon)
(Thursday : 26.03.2009 - 8.30 - 9.30 am)
All are invited.
Thank you.

Pictures From The Latest MEC Talk by Dr. Zamri

2009-02-23T22:51:00.000+08:00

Article on Stress & Strokes (STAR : 8/2/09 - SF12)

2009-02-11T16:13:00.000+08:00

Lecture on Pain Management

2009-02-07T16:28:00.000+08:00

MEC Talk for February 2009

Pain Management by Dr Zamri Jamingan (Consultant Anaesthetist)

(Thursday : 12/02/09 - 8.30 - 9.30 am)

All are invited.

Thank you.

Chikungunya Fever

2009-01-14T16:06:00.000+08:00

Our first MEC Talk for the year 2009 will be as follows :

Topic - Chikungunya Fever
Consultant - Dr Ismayatim Ahmad (Consultant Physician)
Date - Thursday : 22/01/09 (8.30 - 9.30 am)
Place - 8th Floor - Seminar Room

Thank you

http://www.cdc.gov/ncidod/dvbid/Chikungunya/CH_FactSheet.html

http://en.wikipedia.org/wiki/Chikungunya

Welcome to KMC Medical Education Blog

2009-01-13T15:29:00.000+08:00

Dear all,

As this is our first post, I would like to take the opportunity to thank and welcome all of you to our new blog. This is one of our new initiatives aimed at providing medical education to both the health care professionals (particularly general practitioner) and to the general community.
We have with us about 28 full time consultants and 4 visiting consultants, all of whom are forever willing help in any way they can.

Thank you