Pulmonary vein isolation beats AV node ablation for drug-refractory AF in HF patients

Pulmonary vein isolation beats AV node ablation for drug-refractory AF in HF patients

23 October 2008

MedWire News: Pulmonary vein isolation is superior to atrioventricular (AV) node ablation with biventricular pacing for the treatment of drug-refractory atrial fibrillation (AF) in patients with heart failure (HF), conclude researchers. continuing story..

Unfortunately, one requires a surgical procedure whereas the other is mainly a percutaneous procedure. Would it be cost effective? How about the surgical risks involved in patients who may not be hemodynamically stable to start of with? The jury is out there.

More on pulmonary vein isolation
Cleveland Clinic
Mayo Clinic

End of the road for Rimonabant?

From medscape,

Drug Maker Agrees to Suspend Rimonabant Marketing in Europe

from Heartwire — a professional news service of WebMD

Shelley Wood

October 23, 2008 (Zurich, Switzerland) — Rimonbant's rough ride may be nearly over: today, the European Medicines Agency (EMEA) announced that it has recommended suspension of the weight-loss drug, marketed as Acomplia in Europe [1]. According to an EMEA committee, the benefits of the drug "no longer outweigh its risks."

Its manufacturer, Sanofi-Aventis, has responded, agreeing to what it is calling a "temporary suspension" of the drug [2]. cont here

Related article on Medicine Malaysia,

Monday, September 10, 2007
Rimonabant : Weight Loss wonder?

Rimonabant is a CB1 cannabinoid receptor antagonist, some say the next generation anti obesity drug. Observations that heroin causes an increase in appetite led to the discovery of the role that the endocannabinoid system played appetite control and subsequent weight problems.

It first came into prominence in 2004 and recent trials have churned out data proving long term safety and superior efficacy in terms of weight loss, improved cholesterol profile, reduced abdominal circumference and even benefits for Type II diabetics.

Patients in the RIO-Europe trial who were on 20 mg of Rimonabant achieved 15-20 pounds weight loss, 7.5 cm waist reduction, 30% increase in HDL and 9% reduction in triglycerides. RIO-North America displayed similar results.

Indeed a promising addition to the armamentarium in our fight against the flab.

A case of too good to be true?

HYVET: Hypertension in the very elderly trial

HYVET showed that indapamide SR* ±perindopril treatment significantly reduced total mortality by 21% (P=0.019) and stroke mortality by 39% (P=0.046).


Furthermore, in patients receiving indapamide SR there were also relative risk reductions of 30% in stroke (P=0.055), of 64% in heart failure (P<0.001) and 34% in all cardiovascular events (P<0.001).

This means that one death would be avoided for every 40 patients treated with indapamide SR ±perindopril therapy for 2 years.

www.hyvet.com

Doubts on the benefits of aspirin

Aspirin Does Not Prevent Heart Attacks in High-Risk Patients

DUNDEE, United Kingdom -- October 17, 2008 -- Taking regular aspirin and antioxidant supplements does not prevent heart attacks in high-risk groups with diabetes and asymptomatic arterial disease, according to a study published today in the online issue of the BMJ.

Although there is considerable evidence showing no protective benefit of aspirin in high-risk patients without heart disease, guidelines are inconsistent and aspirin is commonly prescribed for the primary prevention of heart disease in patients with diabetes and with peripheral arterial disease.

Jill Belch, University of Dundee, Dundee, United Kingdom, and colleagues investigated whether aspirin and antioxidants given together or separately can reduce heart attacks and death in patients with diabetes and arterial disease.

The study included 1,276 patients aged over 40 years with diabetes and evidence of artery disease. Patients were randomised to receive either aspirin or placebo, an antioxidant or placebo, aspirin and antioxidant, or double placebo. Patients were followed over 8 years.

Overall, the researchers found no benefit from either aspirin or antioxidant treatment in the prevention of heart attacks or death. Patients in the aspirin groups had 116 primary events compared with 117 in the placebo group. No significant difference in events was seen between the antioxidant group and the placebo group.

The authors concluded by voicing their concern at the widespread prescribing of aspirin despite the lack of evidence to support its use in the primary prevention of heart attacks and death in people with diabetes and in view of its possible side effects.

In an accompanying editorial, William Hiatt, Colorado Prevention Center, Denver, Colorado, said: "These findings show that unlike statins and drugs for reducing hypertension, which have a benefit in all risk groups including those with and without heart disease, only patients with a history of clinical or symptomatic heart disease or stroke disease benefit from taking aspirin."

SOURCE: University of Dundee

However, the latest American Diabetes Association recommendations continue to advocate aspirin.

Antiplatelet Agents
● Use aspirin therapy (75–162 mg/day)as a secondary prevention strategy in diabetic individuals with a history of CVD. (A)
● Use aspirin therapy (75–162 mg/day)as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk, including those who are 40 years of age or who have additional risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (A)

Download the ADA 2008 recommendations on the treatment of diabetes. here.

Autoantibody Test Cost-Effective in Arthritis Diagnosis??

Autoantibody Test Cost-Effective in Arthritis Diagnosis

NEW YORK (Reuters Health) Oct 17 - Testing for autoantibodies against cyclic citrullinated peptide (aCCP) appears to be an economically feasible approach to early diagnosis of rheumatoid arthritis, and may even allow cost savings, German researchers report . more..

Anti CCP can diagnose rheumatoid arthritis even before clinical symptoms become apparent due to its high specificity for the disease. Similarly, IgM rheumatoid factor has occupied this role for decades before the discovery of anti CCP.

However, the controversy for a developing nation is whether anti CCP should be routinely implemented in our healthcare system. Is it as cost effective as believed.

Anti CCP is not without its drawbacks. There are incidences of false positives.

Positive anti-cyclic citrullinated proteins and rheumatoid factor during active lung tuberculosis.
Elkayam O; Segal R; Lidgi M; Caspi D
Ann Rheum Dis. 2006 Aug;65(8):1110-2. Epub 2005 Dec 16.

OBJECTIVES: To determine the prevalence of anti-cyclic citrullinated proteins (anti-CCP) and IgM rheumatoid factor (RF) in sera of patients with TB compared with healthy controls. PATIENTS AND METHODS: 47 consecutive patients with recently diagnosed active pulmonary TB and 39 healthy controls were studied. Data were collected by questionnaire on clinical features of the disease, duration of symptoms, fever, cough, arthralgia, myalgia, sicca symptoms. Serum samples were collected from patients before starting treatment for TB and frozen at -20 degrees C. Anti-CCP and IgM RF were evaluated by ELISA. RESULTS: The mean (SD) duration of TB related symptoms was 4.4 (1.7) months, 73% had fever, 94% a cough. Rheumatic symptoms were relatively rare: arthralgia (4%), myalgias (4%), eye and mouth dryness (2% and 9%, respectively). Mean (SD) levels of anti-CCP were significantly increased in patients with TB compared with controls: 44.9 (51) IU v 20 (7.3) IU (p = 0.002). Serum levels >40 U were found in 15/47 (32%) patients compared with 1/39 (2.6%) controls (p = 0.002). Mean (SD) serum levels of IgM RF were significantly increased in patients with TB: 17.8 (19) v 4.3 (5) (p<0.0001). IgM RF was positive (>6 IU) in 29/47 (62%) patients v 1/39 (2.6%) controls (p<0.0001). CONCLUSIONS: A significant proportion of patients with active TB have an increased titre of anti-CCP and IgM RF.

AD Department of Rheumatology, Tel Aviv Medical Centre, 6 Weizman Street, Tel Aviv 64239, Israel. oribe14@netvision.net.il

This study shows high false positives in active tuberculosis, a disease which is rather prevalent in Malaysia. Even other connective tissue diseases can give rise to a positive anti CCP.

My opinion is that the current role of anti CCP is to support a diagnosis of rheumatoid arthritis in cases where the diagnosis is difficult and uncertain. Combining both IgM RF and anti CCP improves the specificity of diagnosing the disease.

The consensus remains that rheumatoid arthritis should be diagnosed as early as possible and as aggressive as possible. Prognostication of disease with RF and anti CCP can lend credence to a more aggressive approach involving costly biologic agents.

In Malaysia, it can only be done at selective centers as many hospitals remain unmoved by this test. This test remains unavailable at UMMC. However, most private laboratories do offer this blood test.

Macrovascular benefits from long-term UKPDS

Long term studies from the UKPDS now show macrovascular benefits on top of previously proven microvascular protection. The morale of the study is to treat early as aggressively as possible without much untoward hypoglycemic symptoms.

Microbial flora on restaurant beverage lemon slices.

The next time you order a drink, you may get more than you bargained for.

Conclusion

Although lemons have known antimicrobial properties, the results of our study indicate that a wide variety of microorganisms may survive on the flesh and the rind of a sliced lemon. Restaurant patrons should be aware that lemon slices added to beverages may include potentially pathogenic microbes. Further investigations could determine the source of these microorganisms, establish the actual threat (if any) posed by their presence on the rim of a beverage, and develop possible means for preventing the contamination of the lemons. It could also be worthwhile to study contamination on other beverage garnishes, such as olives, limes, celery, and cherries, and to investigate whether alcoholic beverages have an effect not seen with water and soda.

Reference
Loving, Anne LaGrange; Perz, John. "Microbial flora on restaurant beverage lemon slices" The Free Library 01 December 2007.

Warfarin Warning: Shortfalls in Anticoagulation for AF Up Risks of ICH and Embolic Stroke

If the Americans are having problems maintaining INR targets with warfarin, I shudder to think what our data would be. (thesis project anyone??) Only 19% were in therapeutic range all the time according to this american study.

Walker AM, Bennett D. Epidemiology and outcomes in patients with atrial fibrillation in the United States. Heart Rhythm. 2008;5:1365-1372. doi:10.1016/j.hrthm.2008.07.014.

Litigation : A trend?

Housewife sues hospital, govt for RM5mil
By EMBUN MAJID

ALOR STAR: A housewife is suing the Government and the Sultan Abdul Halim Hospital for more than RM5mil in damages for alleged negligence that resulted in her suffering chronic kidney failure.

K. Hemalatha, 31, from Taman Sutera, Sungai Petani filed a suit at the Alor Star High Court Registrar Office on Monday.

In the suit, Hemalatha has named the Sultan Abdul Halim Hospital director and the Malaysian Government as the first and second defendants respectively.

She is seeking RM55,557.30 in special compensation, RM5mil in general damages and exemplary compensations, and other relief and cost deemed fit by the court.

In the suit, Hemalatha claimed that she suffered from chronic kidney failure due to the negligence committed by doctors who attended to her when she delivered her fourth child via the Caesarean section on July 11, 2007.

She claimed that the doctors had failed to conduct the necessary tests and diagnose her condition before the surgery.

She also claimed that the doctors had failed to make abdominal and renal evaluation to identify the correct stage of her renal failure before the surgery was performed.

Hemalatha further claimed that her stomach became bloated and she had difficulty in breathing the following day (July 12) after the Caesarean section was done.

She was told by a doctor who examined her that she had internal bleeding.

Hemalatha claimed that she was operated on for the second time on the same day and an ultrasound performed on her later showed that both her kidneys had shrunk.

She claimed that she then underwent an ultrasound at a hospital in Penang on Aug 28, 2007 and was told that both her kidneys have failed to function and she has to undergo dialysis treatment for the rest of her life. She is now under medication.

Much information has been left out in this article and it would be unwise to comment on the rationale for this suit.

However, I find that the press should not highlight litigations when it has yet to be brought forward to the courts. This move deflates confidence in the healthcare system and does little justice to those who have been working hard to maintain a good quality of healthcare. It passes unfair judgements to those involved.

My recommendation to the press is that they should thoroughly research the facts before putting it on paper. Many litigations are done without proper grounds. Highlighting each and every one of them will certainly tarnish the image of healthcare in Malaysia. They should have an independant panel of doctors to decide the factual basis of such allegations.

As of now, the only reason for such a press report is to sensationalise a topic that often times tickles the sensitivities of many, making them a good read.

Adalimumab Effective in Patients With Total Spinal Ankylosis

Those of us who treats ankylosing spondylitis will realise how difficult it is to treat this inevitably progressive disease. This study suggests improvement in patients with spinal ankylosis given an anti TNF alpha, adalimumab.

One major obstacle in Malaysia remains the cost. Many would argue that ultimately the disease is not cured but only offers symptomatic relief. Would one spend your life savings for some relief of pain? i think not.

Medical Rituals

Malaysia, once again, famous for all the wrong reasons. However, it is an important part of humanity and has been in existence in all shapes and forms for centuries. There are no rules here, anything goes. It is like creating games for children where the only limitation is one's imagination. So the question is, why do reasonably educated individuals fall for such a scam?

Vulnerability and desperation. When the 'sane' world offers little explanation to a problem, alternative views become a suitable substitute. From health to financial matters, the solutions from alternative sources are sometimes infinite. It's amazing that people will believe almost anything, no matter how ridiculous it may seem. From bizzare rituals to downright ludicrous concoctions, a cure is somehow always around the corner.

The placebo effect do assist alternative solutions to florish. Sure, there will be someone who will feel better and swear by its effectiveness. Clinical trials are almost never performed but those flocking to them could almost result in a stampede.

I remember how at one time a family sweared that a 'doctor' did perform a special surgical techniques that could remove water from the body for congestive cardiac failure, which was sutureless. He came with surgical plasters on his body. The family claimed to have seen blood oozing out and the 'surgeon' plucking things from the body. On removal of the plaster, only a superficial scratch that masqueraded as a surgical scar. It took some convincing talk before the family admitted that it was just a scam. They paid a few thousand ringgit for that.

Now that the Ministry of Health is allowing traditional medical practices to be set up in a hospital, i wonder if this will lend legitimacy to dubious claims or drugs. What regulations are in place and is evidence-based care important for this branch? Or are we perfecting the art of shooting ourselves in the foot!

Virtual Colonoscopy

A video presentation giving an opinion of virtual colonoscopy. I don't think the Gastroenterologists will be out of a job anytime soon. :-)

Ministry of Health short on funds

I find this report recently in a local daily as perplexing. Slashing the budget of healthcare pushing the Minister of Health into a begging mode is ridiculous. When a hospital does not have a proper and well equipped emergency room, there should be an urgent need to rectify the situation.

Instead, there is a budget cut. Such development funds are vital to ensure that Malaysia stays at a satisfactory level of healthcare provision. As the current situation stands, there is already a lack of monetary backing in research and development, a field so vital if we are to become a developed nation in the near future. Sadly, the infrastructure itself is lagging behind in acceptable standards and certainly not to mention the human capital.

The public expects a high standard of healthcare but the mismatch in funding is glaringly evident. I suggest a budget cut in military spending which remains a huge priority, be made. Acquiring submarines in this neck of the woods is foolish as it is geographically inappropriate and certainly adds little to the line of defence.

Healthcare budgets worldwide is forever expanding. A more prudent spending and planning is essential, a well known fact even to any non-economists.

Selamat Hari Raya Aidilfitri

Wishing all Selamat Hari Raya. Have a great enjoyable time.