It has been an exciting year for FMSA and I like to share the Top 10 FMSA activities and initiatives as following:

1. Family Medicine Specialist Technical Meeting

This meeting were conducted twice in 2011 where Family Health Division, MOH co-coordinating it – representative from all states majority are FMSA members attended this meeting. Special thanks to Dr Baizury Bashah, Head of Family Medicine Service, for her great work in putting together all the agenda!

2. 15^th Malaysian Family Medicine Specialists’ Conference

This conference was organized in collaboration with Negeri Sembilan State Health Department and  IMU in June 2011 in Hotel Royale Bintang Seremban. It was a great success where more than 450 participants attended the conference. This is also the main event which generates income for FMSA. Keep up the good work. This year I hope members will continue to support the coming 16^th FMSA Conference in Melaka

3. FMSA Membership Drive

We have strengthened the membership drive activities by making several road shows and keeping members alert in paying their membership fees. Let us all make our Treasurer’s job easier by ensuring payment early of the year. An association can only progress with full support from members. I like you all to also play your role in getting the juniors specialists to join FMSA

4. “Tools for Practice”

Thanks to the CME Team headed by Dr Nazrila who has provided several practical, evidence based CME activities. This initiative (some are in collaboration with the pharma industries) has gained recognition for its high quality and practical tips to improve practice.

5. Health Screening Guideline and Chronic Disease Management Module

FMSA collaborate with Academy Family Physician and MOH who has arranged several meetings in the preparation of the Primary Care Health Screening Guideline. Thanks to Assoc Prof Dr Tong Seng Fah and his team for the wonderful work so far. Hopefully once this guideline completed; this initiative will gain national recognition for its high quality, unbiased and practical tips to improve practice.

FMSA also has the opportunity to take part in the Chronic Disease Management Training Module. Thanks to Assoc Prof Anis who heads the project.  We hope to develop and deliver important educational initiatives around the new complex care plan. The research arm will continue this year in several health clinics in Selangor. Please give your fullest support in ensuring the success of the program

6. National Health Care Reform- 1CARE

Several members have been involved in the preparation of the 1CARE Blueprint. Currently I am the Chairperson for the Primary Health Care Benefit Package for 1CARE. I would like to thank all members who have taken time and lend their expertise in all the meetings and workshops. Let’s hope the journey to this coming health care reform will be smooth and primary care physicians’ will not be neglected.

7. Guidebook for FMS

This book consists of topics pertaining to FMS fraternity and is currently under editors’ review. The aim of this project is to provide FMS, especially the juniors, with input not just to be clinicians but other aspects as well.

8. Community Project

This is to promote FMSA among the community and other organizations, apart from implementing health activities advocated by the Ministry of Health.  A total of RM 10,000 per year is allocated to be given to 2 states (RM 5000 per state). The first project was held at Kedah on 20/1/11 together with ‘Persatuan Diabetes Malaysia’ (PDM) and the second project were held in Wilayah Persekutuan.

9. Getting the Director General of Health’s ear?

A meeting was held with the DG of Health and several issues were discussed among others were area of interest training and scholarship, FMS ‘Halatuju’ paper, organization chart in health clinic, KPIs, and constraint in primary care resources i.e budget and human resource etc .

10. FMSA Secretariat Room

FMSA has been renting a room in MMA Building for secretariat use while in process obtaining own property this year.

Looking ahead…

An organization is only as strong as its members and I hope this year FMSA true strength will be continuously demonstrated through the activity and passion of its members. I hope to get support from all members and the also the hard working team at the FMSA office!

Wishing you all the best in 2012!

Dr Mastura Ismail

President, FMSA

Management of Chronic Kidney Disease

Charlie Tomson, DM, FRCP; Pippa Bailey, MRCP, DTM&H

Management of chronic kidney disease (CKD) requires a systematic approach that includes all components of the chronic disease model. Some causes of CKD require specific additional management directed at the underlying cause.

Principles of Chronic Disease Management

Chronic kidney disease (CKD) is a prime example of a chronic disease requiring life-long management, involving the patient, the primary care team and specialists. Most people with CKD also have other long-term conditions (hypertension, cardiovascular disease, diabetes mellitus, atherosclerosis). Current disease-based clinical services (eg, nephrology clinics, hypertension clinics, diabetes clinics, heart failure clinics) seldom provide optimal care, with poor communication occurring between these ‘silos’ of care, and between hospital-based clinics, the primary care team, and the patient.

This lack of integration is harmful and can contribute to patients’ loss of control and to conflicting messages on what drug treatment the patient should be taking. The system is also wasteful, with much duplication of effort, tests, and wasted travel time. Research on systematic attempts to achieve improvement in the delivery of care for patients with chronic diseases has resulted in development of a framework, the ‘chronic care model’. Improvement is more likely if each component of the organization of care (self-management; decision support; delivery system design; clinical information systems) is addressed, and unlikely if, for instance, improvement efforts are confined to a hospital-based clinic.^1,2 Many of the components of the model, including national guidelines on identification, management and referral, are already in place for CKD.³

Early CKD is largely asymptomatic, so a balance has to be struck between ‘labelling’ patients as having ‘chronic kidney disease’ and ensuring that patients who are at increased risk of cardiovascular disease or progressive loss of kidney function are identified and offered the options of treatment that will reduce these risks.

Read the rest of this entry »

By Laura Stewart, PhD, RD, RNutr

Childhood obesity is widely acknowledged as having become a global epidemic.1,2 The prevalence of childhood obesity in the UK dramatically increased over a short period of time in the early 1990s.3,4 The importance of childhood obesity has gained national significance with the publication of expert reports5 and evidence-based guidelines.6,7 Doctors in primary, secondary and tertiary care are now more likely to see obese children and adolescents in their everyday practice.
DEFINITION

As in adult obesity, any definition of childhood overweight and obesity needs to be able to define not only body fatness but also the clinical relevance of this body fat. Body mass index (BMI) is generally agreed to be the most appropriate proxy measure for defining and diagnosing childhood obesity and overweight.6–8 In childhood, because body fat and muscle mass alter with age and differ between the sexes, BMI is meaningful only when it is plotted correctly on age- and sex-specific BMI centile charts (UK 1990). All health professionals should use the UK 1990 BMI centile charts for diagnosis and monitoring of treatment of childhood obesity.6,7 The UK BMI centile charts are available from Harlow Printing Ltd, South Shields, England.

Although there remains some disagreement on the precise cut-off points to use for defining overweight and obesity on BMI charts, both the SIGN 115 (2010) and NICE 43 (2006) guidelines agreed on cut-off points in the UK of ? 91st centile as overweight and ? 98th centile as obese,6,7 with SIGN 115 defining ? 99.6th centile as severe obesity.7 These cut-off points have been shown to be relevant to excess body fat and associated ill-health consequences.

Full article

WORLD DIABETES DAY
November 14, 2011

The number of Malaysians with diabetes continues to increase every year. In 2006, estimated to be about 1.5 million adult Malaysians living with diabetes. Unfortunately, the early results of National Health and Morbidity Survey ( NHMS) 2011 to be published in December 2011 showed that the number has now reached more than 3 million people in Malaysia, only in a period of 5 years. What is more worrying, and my own Ministry of Health is the number of Malaysians who have a blood sugar high, but have yet to be examined by a doctor, which is about 2 million individual adults. This indicates that there are still many Malaysians who have yet to do health screening on a regular and periodic.
Read the rest of this entry »

U.S. Food and Drug Administration prescribing guidelines for metformin contraindicate its use in men and women with serum creatinine concentrations ?1.5 and ?1.4 mg/dL (?132 and ?123 µmol/L), respectively. In a patient tolerating and controlled with this medication, should it automatically be discontinued as the creatinine rises beyond these cut points over time? Stopping metformin often results in poorly controlled glycemia and/or the need for other agents with their own adverse-effect profiles. Moreover, is the now widespread use of estimated glomerular filtration rate (eGFR) in lieu of serum creatinine levels creating even more confusion, especially in those with abnormalities in one but not the other indirect measure of renal function?

CONCLUSIONS AND RECOMMENDATIONS

CH Lim, B Baizury, on behalf of Development Group Clinical Practice Guidelines Management of Major Depressive Disorder

A. Introduction

Major depressive disorder (MDD) is a significant mental health problem that disrupts a person’s mood and affects his psychosocial and occupational functioning. It is often under-recognised and 30-50% of MDD cases in primary care and medical settings are not detected. Suicide occurs in up to 15% of hospitalised patients with severe MDD.

B. Screening

The routine use of screening instruments to identify depression is not recommended. However, the following two initial questions may be used to screen for depression:

1. “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
2. “During the past month, have you often been bothered by having little interest or pleasure in doing things?”

If the answer is “Yes” to one or both questions, assess the patient for depression.

For this Two-Question Case-Finding Instrument, the reported sensitivity is 96% and specificity 57%, at a prevalence rate of 18%. Clinicians are encouraged to screen for at least these two core symptoms of depression, especially in high risk groups e.g. those with physical health problems causing disability, a past history of depression, a family history of depression and those with other mental health problems such as substance abuse or dementia.

C. Diagnosis

The diagnosis of MDD is made using internationally accepted diagnostic criteria i.e. either the 10th Revision of the International Classification of Diseases (refer Table 1) or the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders IV.

More reading

But for How Long?

News Author: Nick Mulcahy
CME Author: Charles P. Vega, MD

CME Released: 08/29/2011; Valid for credit through 08/29/2012

Clinical Context

Anal cancer is approximately 35 times less common than cervical cancer among unscreened women, according to an editorial by Harper and Vierthaler that accompanies the current study. Nonetheless, anal cancer is still twice as common among women compared with men. Most anal cancers are related to human papillomavirus (HPV) infection, particularly with types 16 and 18, and risk factors for anal cancer include a history of cervical neoplasia. Men who have sex with men have a higher risk for anal cancer compared with men who have sex with women, and the presence of HIV infection also particularly increases the risk for anal cancer.

The HPV vaccine may help to prevent anal cancer. The current study by Kreimer and colleagues examines how the vaccine affects the risk for anal HPV infection.

Study Synopsis and Perspective

The bivalent HPV vaccine (Cervarix, GlaxoSmithKline), which is indicated for the prevention of cervical diseases caused by infection with HPV-16 and HPV-18, also provides “strong protection” against anal infection with these HPV types in young women, according to authors of new trial conducted in Costa Rica.

The study is the first to show that an HPV vaccine can prevent anal HPV infection in females.

However, the protection was not as effective at the anus as it was in the cervix, which was used as a comparator. The women, who were vaccinated at ages 18 to 25 years, were tested 4 years later for anal and cervical HPV-16 and HPV-18 infections to assess the vaccine’s efficacy.

In a cohort of 4210 women, vaccine efficacy at the anus against prevalent HPV-16/18 infection was 62% compared with 76.4% in the cervix (P = .031 for interaction by anatomical site).

The efficacy was higher in a subset of women in the study who received their vaccination before exposure to HPV.

In this restricted cohort of 1989 women, vaccine efficacy against anal HPV-16/18 infection was 83.6%, which was “similar” to vaccine efficacy of 87.9% in the cervix.

HPV causes most anal cancer, which is a “rare” disease, point out the study authors, led by Amiee Kreimer, MD of the National Cancer Institute in Bethesda, Maryland. An estimated 75% to 80% of HPV-associated cancers are caused by HPV-16 or HPV-18.

The study’s findings are welcome news for women, suggest 2 experts who penned an editorial that accompanies the study online in The Lancet Oncology.

“Women have twice the incidence of anal cancer as men…and are predisposed to anal HPV infection if they already have cervical neoplasia, irrespective of anal intercourse,” write Diane Harper, MD, and Stephen Vierthaler, MD, of University of Missouri–Kansas City School of Medicine.

However, the findings beg the question of how HPV vaccination should be used. “The public health benefit of prophylactic HPV vaccines for anal cancer is an open question,” say the pair.

According to the editorialists, the natural history of the infection is different in distinct populations. HPV infections are both more common and virulent in men who have sex with men and in immunosuppressed men. For these reasons, vaccinating men who have sex with men for the prevention of anal cancer is good public health policy, they argue. Another study of the quadrivalent vaccine Gardasil has shown evidence of efficacy against anal HPV infection in men who have sex with men.

However, the cost-effectiveness of vaccination for men and women “pivot on the duration of vaccine efficacy,” say the editorialists.

“Without duration of efficacy of at least 15 years, cancers will not be prevented for women or men who have sex with men, only postponed,” write Dr. Harper and Dr. Vierthaler.

The study authors also acknowledge the wild card of duration.

“HPV vaccines have great potential for prevention of a large proportion of HPV-associated cancers at the anus and other anatomical sites…assuming adequate duration of protection,” write the study authors.

In the new study, the median follow-up from vaccination was 4.1 years.

As a result, more study is needed, say the study authors. “Further, showing that the protection lasts beyond the 4 years assessed in this study will be important to ensure women are protected during the ages of higher exposure.”

Read the rest of this entry »

By Eliza Barclay

Hydration is something we’re inclined to worry about in the summertime, when we sweat more and can be at risk of heat exhaustion if we don’t get enough fluids. And while most doctors say water is the ideal fluid for rehydrating, coconut water, the latest faddish recovery drink, is being heavily marketed as “more hydrating” than H20.

Some companies allege that doctors even prefer coconut water to other solutions when treating dehydration. Coconut water is “identical to human blood plasma,” says YoungCoconuts.com, and “can be safely injected directly into the bloodstream,” according to BodyEcology.

That claim arose because coconut water was reportedly given intravenously to people during World War II when regular IV saline solution was in short supply. And one tiny study – of just one person – noted that it had been used successfully on a man in an emergency situation in the Solomon Islands when nothing else was available.

But would you really want a coconut IV if you got seriously dehydrated? Shots called up some doctors to get their take on whether they’d give coconut water to patients – either intravenously or by mouth.

First, we spoke to Mark Graber, professor of clinical emergency medicine at the University of Iowa Carver College of Medicine. Graber says that coconut water really isn’t much like blood plasma, and if a patient came into his ER dehydrated, he wouldn’t reach for it.

“It’s not an optimal IV solution for rehydration because it doesn’t have enough sodium content to stay in the bloodstream,” says Graber. “And it could cause elevated calcium and potassium, which could be dangerous.”

As a sport drink, Graber says coconut water is fine. But the data on all other clinical uses is weak and scant, he says.

But while coconut water isn’t a safe alternative for an IV, some doctors are recommending it to patients as an oral rehydration therapy. Robynne Chutkan, a gastroenterologist and an assistant professor of medicine at Georgetown University Hospital, grew up in Jamaica and says she’s been drinking the water from young, green coconuts as long as she can remember.

When coconut water finally hit the U.S. market, Chutkan was thrilled to discover it tasted pretty close to the real thing. Eventually she began to suggest it to her patients, many of whom have had their colons removed and struggle to stay hydrated.(The main function of the colon is to absorb water.) People with conditions like colitis from Crohn’s disease and gastroenteritis can lose a lot of water in diarrhea, too, Chutkan said.

“Diarrhea is the main obstacle to hydration [for these patients], but I am not a fan of Gatorade to treat it,” Chutkan says. “It’s very synthetic stuff and has citric acid, sodium benzoate and sugar, which could worsen diarrhea. Coconut water is great because it’s already diluted and it’s natural.”

Coconut water also has electrolytes, which Chutkan says give it a small advantage over water. “But it’s not magical. In our society, we’re always looking for the magical thing, and I see a little of that in [the marketing of] coconut water,” Chutkan says.

And even if it’s more natural than the other stuff on the market, the nutritional claims on the label may not always be accurate. A recent study by the independent health product reviewer Consumerlab.com found that two of the most popular brands, Vita Coco and ONE Coconut Water, contained less sodium and magnesium than advertised. Only Zico Natural contained the amount of sodium listed on its label — 160 milligrams. [Copyright 2011 National Public Radio]