Strenghten Our Fratenity
FMSA President’s speech during the 14th FMSA Scientific Meeting - Gala Night
Assalamulaikum and Salam Sejahtera
I am honored and humbled by being elected as the 5th president of the Family Medicine Specialist Association. I consider myself as a lucky person in the Malaysia right now and I pledge to do my best to make our wonderful profession and all of you proud! Thank you also to all the previous FMSA Chairpersons and exco members who have contributed significantly to this association. I hope they will continue do so…
Dengue: Tips for QUICK 5-MINUTE CONSULTATION
With the amount of client attending Klinik Kesihatan forever increasing, pose a challenge for the PPPs and MOs NOT to MISS serious disorder with early constitutional symptoms and signs. ‘ Fever Lane ’ (managed by JT/JM/PPK from the MCH clinic) at the frontline help to identify documented fever for prompt consultation by either the PPPs or MOs (or sometimes FMS for that matter). Reason why the need is there way past heightened vigilance for Influenza A(H1N1).
Tips for QUICK 5-MINUTE CONSULTATION;
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Acute febrile illness + generalized (maculopapular) rash |
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DENGUE FEVER |
MEASLES |
RUBELLA |
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+ one of the following; 1. Headache or; 2. Retro-orbital pain or; 3. Myalgia or; 4. Arthralgia or; 5. Haemorrhagic manifestations (petechiae, spontaneous bleeding gums etc.) or; 6. FBC/CBC = Leukopenia |
+ one of the 3Cs; 1. Coryza (runny nose) or; 2. Cough (non-productive) or; 3. Conjunctivitis |
+ palpable & tender occipital and/or cervical lymph nodes. |
PROMPT notification has been emphasised to our PPPs and MOs for ALL of the above (through phone, followed by the form). DENGUE FEVER for immediate control measure while the latter two for timely investigation. This has been the practice in the Klinik Kesihatan.
ISKANDAR
Dr. Iskandar Firzada Osman
MD (USM), MMed (Family Medicine) (USM),
MAFPM (Mal.), FRACGP (Australia), FAFPM (Mal.),
Fellow in Adolescent Health (Melbourne)
Family Medicine Specialist / Primary Care Physician
Aspirin Recommended as Preventive for Cardiovascular Events in Diabetics
Low-dose aspirin (75 to 162 mg/day) is a “reasonable” choice for adults with diabetes who have a 10-year risk forcardiovascular disease above 10% and are not at increased risk for bleeding, according to a statement from theAmerican Diabetes Association, the American Heart Association, and the American College of Cardiology.
The statement, published in Circulation, is based on meta-analysis of nine trials examining the effects of aspirin to prevent cardiovascular disease events in patients with diabetes. It also recommends the following:
- Adults with diabetes who are at increased risk for cardiovascular disease (e.g., men over 50 or women over 60 with an additional CVD risk factor) should receive aspirin for primary prevention.
- Patients at intermediate risk for cardiovascular disease (e.g., younger patients with at least one risk factor, older patients with no risk factors, or patients with a 10-year risk of 5% to 10%) may consider taking daily aspirin.
Circulation article (Free PDF)
Erectile dysfunction often precedes heart attacks: Cardiologist
KUALA LUMPUR: Seven out of 10 men admitted to the University of Malaya Medical Centre (UMMC) for heart attack suffered erectile dysfunction (ED) earlier, a cardiologist at the hospital said.
Dr Ramesh Singh Veeriah said that a study conducted last year involving 111 sexually active men and admitted to the UMMC for heart attack demonstrated that 75.7% of them had experienced ED.
“The ED was traced in the six months prior to their admission,” he said in a statement here Sunday.
The data, he said was contained in his paper presented at the World Congress of Cardiology (WCC) Scientific Sessions in Beijing, China Friday.
He said a total of 219 men were admitted for heart attack to UMMC’s coronary care unit from April 2008 to February last year and out of these, 192 were screened and only 111 who were sexually active within the last six months were recruited for the assessment of ED.
Dr Ramesh said ED and Coronary Artery Disease (CAD) shared many common risk factors and were closely related.
“Arteriosclerosis, the root cause of CAD and ED, is a generalised inflammatory disorder that progresses at a similar rate throughout the vasculature of the body.
“Therefore, it is thought that ED should precede CAD since the penile arteries are considerably smaller than the coronary arteries,” he added - Bernama
Toothbrushing Less Than Twice a Day Linked to Increased CV Risk
May 28, 2010 (London, United Kingdom) — Individuals who do not brush their teeth twice a day have an increased risk of heart disease, a new study shows [1].
The study was published online May 27, 2010 in BMJ; corresponding author is Prof Richard Watt (University College London, UK).
The researchers note that while it has been established that inflammation in the body (including mouth and gums) plays an important role in the buildup of atherosclerosis, this is the first study to investigate whether the number of times individuals brush their teeth has any bearing on the risk of developing heart disease.
They analyzed data from more than 11 000 adults who took part in the Scottish Health Survey, in which individuals were asked about lifestyle behaviors such as smoking, physical activity, and oral health routines. Questions asked included how often they visited the dentist and how often they brushed their teeth (twice a day, once a day, or less than once a day). Information was also collated on medical history and family history of heart disease and blood pressure. Blood samples were taken from a subgroup of participants and tested for CRP and fibrinogen levels. The data gathered from the interviews were linked to hospital admissions and deaths.
Results showed generally good oral hygiene practices, with 62% of participants saying they visited the dentist every six months and 71% reporting that they brushed their teeth twice a day. After adjustment for established risk factors, it was found that participants who reported less frequent toothbrushing had an increased risk of heart disease compared with people who brushed their teeth twice a day. Participants who had poor oral hygiene also had increased levels of CRP and fibrinogen.
Hazard Ratio for Cardiovascular Events (Fatal and Nonfatal) Relative to How Often Teeth Are Brushed Each Day
| Frequency of toothbrushing | HR* (95% CI) |
| Twice a day | 1.0 |
| Once a day | 1.3 (1.0–1.5) |
| Less than once a day | 1.7 (1.3–2.3) |
| p for trend | 0.001 |
*Adjusted for age, sex, socioeconomic group, smoking, physical activity, visits to dentist, body-mass index, family history of cardiovascular disease, hypertension, and diabetes
The researchers say: “To the best of our knowledge, this is the first study to show an association between a single-item self-reported measure of toothbrushing and incident cardiovascular disease in a large representative sample of adults without overt cardiovascular disease.”
They add: “Our study suggests a possible role of poor oral hygiene in the risk of cardiovascular disease via systemic inflammation. Raised inflammatory and homoeostatic responses as well as lipid metabolism disturbance caused by periodontal infection might be possible pathways underlying the observed association between periodontal disease and the increased risk for cardiovascular disease.”
But they note that further studies are needed to confirm whether the observed association between oral health behavior and cardiovascular disease is in fact causal or merely a risk marker.
References
- de Oliveira C, Watt R, and Hamer M. Toothbrushing, inflammation, and risk of cardiovascular disease: Results from Scottish Health Survey. BMJ 2010; DOI:10.1136/bmj.c2451. Available at: http://www.bmj.com.
ACOG Recommends Pap Tests for Cervical Cancer Screening Begin Later, With Lower Frequency
Washington, DC — November 20, 2009 — Women should have their first cervical cancer screening at age 21 and can be rescreened less frequently than previously recommended, according to newly revised evidence-based guidelines issued today by The American College of Obstetricians and Gynecologists (ACOG) and published in the December issue of Obstetrics & Gynecology. Most women younger than 30 years should undergo cervical screening once every 2 years instead of annually, and those age 30 years and older can be rescreened once every 3 years.
North American Menopause Society’s 2010 Position Statement on Postmenopausal Hormone Use
The North American Menopause Society (NAMS) has updated its 2008 recommendations (JW Womens Health Jul 31 2008) for use of postmenopausal hormone therapy (HT) based on new evidence and collaboration with other professional societies. As before, the statement addresses only prescription HT products available in the U.S. and Canada. The guidelines newly acknowledge accumulating evidence that various estrogen and progestogen products, routes of administration, and timing of therapy confer differing benefit-risk profiles.
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What measure from a lipid panel is the best predictor of cardiovascular risk?
Evidence-Based Answer:
The ratio of total cholesterol (TC) to high-density lipoprotein cholesterol (HDL-C) is the best predictor of total cardiovascular risk in the currently offered standard lipid panel. (SOR A, based on multiple prospective cohort studies.) The apoB/apoA-I ratio was shown to be superior in predicting risk of fatal myocardial infarction (MI) in 1 population, but the clinical importance of this finding is unclear.
A 2007 prospective cohort study of 3,322 middle-aged white participants compared different lipid measures for cardiovascular heart disease (CHD) prediction over 15 years. The incidence of the first CHD event was measured and risk ratios were calculated for various lipid markers. Adjusting for nonlipid risk factors, the ratio apoB/apoA predicted CHD with a hazard ratio (HR) per standard deviation increment of 1.39 (95% confidence interval [CI], 1.23–1.58) in men and 1.40 (95% CI, 1.16–1.67) in women. The incremental HR for TC/HDL-C was 1.39 (95% CI, 1.22–1.58) in men and 1.39 (95% CI, 1.17–1.66) in women. For the ratio of LDL-C/HDL-C, the incremental HR was 1.35 (95% CI, 1.18–1.54) in men and 1.36 (95% CI, 1.14–1.63) in women. The authors concluded that the data do not support apoB or apoA-I measurements in clinical practice when total cholesterol and HDL-C are available.1
In 2005, a 10-year prospective cohort study compared the clinical utility of total cholesterol, LDL-C, HDL-C, non-HDL-C, and apolipoproteins A-I and B100 among 15,632 healthy US women aged 45 years or older for the occurrence of future cardiovascular events. The HRs for future cardiovascular events were 1.62 (95% CI, 1.17–2.25) for LDL-C, 1.75 (95% CI, 1.30–2.38) for apoA-I, 2.08 (95% CI, 1.45–2.97) for total cholesterol, 2.32 (95% CI, 1.64–3.33) for HDL-C, 2.50 (95% CI, 1.68–3.72) for apoB, and 2.51 (95% CI, 1.69–3.72) for non-HDL-C. The HRs for the lipid ratios were 3.01 (95% CI, 2.01–4.50) for apoB/apoA-I, 3.18 (95% CI, 2.12–4.75) for LDL-C/HDL-C, 3.56 (95% CI, 2.31–5.47) for apoB/HDL-C, and 3.81 (95% CI, 2.47–5.86) for TC/HDL-C.2
Another recent prospective study of 1,414 men and 1,436 women aged 35 to 64 years without a prior coronary event investigated whether apolipoproteins are independent risk factors for incident coronary events and whether they are superior to the usual lipoprotein measurements in the assessment of CHD. The incidence of fatal and nonfatal MI and sudden cardiac death over a period of 13 years was examined. In both sexes, the predictive ability of the apoB/apoA-I ratio for incident coronary events was virtually identical to that of the TC/HDL-C ratio.3
In 2004, a large prospective cohort study (AMORIS) followed more than 100,000 Swedish men and women older than 40 years for 8 years, to determine whether the apoB/apoA ratio was superior to other cholesterol ratios in predicting risk of fatal MI. The apoB/apoA ratio was significantly better at identifying fatal MI (incremental HR 1.4 per standard deviation; 95% CI, 1.36–1.49 in men and 1.27–1.47 in women) than TC/HDL (incremental HR 1.1; 95% CI 1.10–1.15 in men and 1.11–1.17 in women) and LDL/HDL (incremental HR 1.1; 95% CI, 1.09–1.13 in men and 1.11–1.17 in women). The authors concluded that the apoB/apoA-I ratio is the single best predictor of fatal MI in both men and women.4
HelpDesk Answer From EBP,
Sarah George, DO Karen Lin, MD Beatrix Roemheld-Hamm, MD, PhD
UMDNJ-Robert Wood Johnson FMR New Brunswick, NJ
1. Ingelsson E, Schaefer EJ, Contois JH, et al. Clinical utility of different lipid measures for prediction of coronary heart disease in men and women. JAMA. 2007; 298(7):776–785. [LOE 1b]
2. Ridker PM, Rifai N, Cook NR, Bradwin G, Buring JE. Non-HDL cholesterol, apolipoproteins A-I and B100, standard lipid measures, lipid ratios, and CRP as risk factors for cardiovascular disease in women. JAMA. 2005; 294(3):326–333. [LOE 1b]
3. Meisinger C, Loewel H, Mraz W, Koenig W. Prognostic value of apolipoprotein B and A-I in the prediction of myocardial infarction in middle-aged men and women: results from the MONICA/KORA Augsburg cohort study. Eur Heart J. 2005; 26(3):271–278. [LOE 1b]
4. Walldius G, Jungner I, Aastveit AH, Holme I, Furberg CD, Sniderman AD. The apoB/apoA-I ratio is better than the cholesterol ratios to estimate the balance between plasma proatherogenic and antiatherogenic lipoproteins and to predict coronary risk. Clin Chem Lab Med. 2004; 42(12):1355–1363. [LOE 1b]
Teens and Body Art- Into the Mainstream
From Medscape Nurses
Posted: 02/05/2007
Adolescent Development: Things Change
The one constant about adolescents is that nothing is constant — and that has been developmentally consistent throughout the generations. One of the most visible signs of changing cultural norms for today’s adolescents has been the movement of body art into the mainstream. Once considered a mark of a rebel or outcast, tattoos and numerous body piercings have become very common, almost a rite of passage for teenagers.
How should beta-blockers be prescribed for patients with congestive heart failure?
Evidence-Based Answer:
Beta-blockers should be prescribed at low initial doses and gradually titrated every 2 weeks to research-validated targets or the maximally tolerated dose. Two-thirds of patients will not achieve target doses. (SOR A, based on multiple randomized controlled trials [RCTs].) If worsening of heart failure symptoms occur during titration, the doses of diuretics (SOR B, based on multiple RCTs) or other concomitant medications (SOR C, based on expert opinion) should be adjusted.
Sustained-release metoprolol and immediate-release carvedilol both have a US Food and Drug Administration (FDA) indication for use in heart failure, based on high-quality RCTs.1–4 Bisoprolol has strong supporting evidence for its use and is recommended per guidelines, but has an FDA indication only for hypertension.1,2,5
Two trials used an every 2-week beta-blocker titration schedule (TABLE).3,4 The Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) and the Carvedilol Prospective Randomized Cumulative Survival Study (COPERNICUS) were both large, double-blind, randomized, placebo-controlled heart failure survival studies.3,4 Only 64% and 65.1% of patients, respectively, tolerated titration to target dose.
The Cardiac Insufficiency Bisoprolol Study (CIBIS) III was a large, randomized, open-label, blinded end point evaluation trial.5 CIBIS III evaluated beta-blockers as initial therapy in comparison with angiotensin-converting enzyme inhibitors. A 6-step titration was used. Only 65% of patients tolerated titration to target dose.
The above trials used diuretic adjustment as needed to facilitate beta-blocker titration, but failed to characterize the actual changes in diuretic frequency and/or dose during titration.3–5 Expert opinion suggests increasing diuretic dosing for patients with symptoms of fluid retention or worsening of heart failure.2 The American College of Cardiology/American Heart Association and the Heart Failure Society of America suggest extending beta-blocker titration and making vasoactive medication dose adjustments for patients with bradycardia and hypotension.1,2
HelpDesk Answer From EBP,
Inna Velychko, MD Stephen Thomas, PharmD
Flower Hospital Family Medicine Residency, Sylvania, OH
1. Hunt SA; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure).J Am Coll Cardiol. 2005; 46(6):e1–e82. [LOE 5]
2. Heart Failure Society of America. Executive summary: HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Card Fail.. 2006; 12(1):10–38. [LOE 5]
3. Hjalmarson A, Goldstein S, Fagerberg B, et al. Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group. JAMA. 2000; 283(10):1295–1302. [LOE 1b]
4. Packer M, Coats AJ, Fowler MB, et al; for the Carvedilol Prospective Randomized Cumulative Survival Study Group. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med. 2001; 344(22):1651–1658. [LOE 1b]
5. Willenheimer R, van Veldhuisen DJ, Silke B, et al; for the CIBIS III Investigators. Effect on survival and hospitalization of initiating treatment for chronic heart failure with bisoprolol followed by enalapril, as compared with the opposite sequence: results of the randomized Cardiac Insufficiency Bisoprolol Study (CIBIS) III. Circulation. 2005; 112(16):2426–2435. [LOE 1b]