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JULY 2013 I ISSUE 6

THE UNDER-DIAGNOSED MODYWhat to keep in mind when making a diagnosis

GM CROPSTaking a closer look at the issue

CONTINUING PROFESSIONAL DEVELOPMENTThe Malaysian experience

OUR FIRST ANNUAL ORTHOPAEDIC SEMINAR!A report on what took place

DETAILS ON

UPCOMING

INFOMED

SEMINARS

ON PG52.INFOMED

exclusive interviewDATO’ DR.

JACOB THOMASPresident of the Association of Private Hospitals of Malaysia,

on quality of care and medical tourism in Malaysia

PUBLISHER/MANAGING DIRECTOR

Mohan Manthiry

EDITORIAL ADVISORY BOARD

Tan Sri Datuk Dr. Ridzwan Bakar Consultant Cardiologist and Hospital Management Consultant

Dato’ Dr. Jacob Thomas President APHM and President of the Asian Hospital Federation

Dr. Ahmad Razid Salleh Director of Medical Practice Division, Ministry of Health Malaysia

Dato’ (Mr.) V. Pathmanathan Consultant Hand and Micro Surgeon

Dr. Eugene Wong Consultant Spine and Orthopaedic Surgeon

Dr. Premitha Damodaran Consultant Obstetrician and Gynaecologist

Ir. Zamane Abdul Rahman Director Medical Device Bureau, Ministry of Health Malaysia

Dr. Ng Soo Chin Consultant Hematologist

Dr. Cecilia Wong Consultant Obstetrician and Gynaecologist

Dr. Mehdi Khaled Healthcare Strategy Consultant, Austria

Dr. Eashwary Consultant Rheumatologist

Dr. Mohd. Azrin Zubir Consultant Healthcare Informatics

EDITOR-IN-CHIEF

Dr. Karam Singh

ASSOCIATE EDITOR-IN-CHIEF

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CONTENTSJULY 2013

ON THE COVER14 CARE QUALITY, MEDICAL

TOURISM, AND PRESERVING WHAT’S WORKING IN MALAYSIA: THE VIEW FROM PRIVATE HEALTHCARE

In this exclusive interview, Dato’ Dr. Jacob Thomas, President of The Association of Private Hospitals in Malaysia, discusses quality of care and medical tourism in the context of the current public-private partnership in Malaysia healthcare.

26 INFOMED FIRST ANNUAL ORTHOPAEDIC UPDATE SEMINAR

Our inaugural orthopaedic update seminar! Here’s what took place. Plus, abstract of some of the topics presented.

38 CONTINUING PROFESSIONAL DEVELOPMENT (CPD)

The Malaysian experience.

46 GM CROPS: A CASE AGAINST SCIENTIFIC TERRORISM

There’s more to the issue of genetically modified crops.

48 THE UNDER-DIAGNOSED MODY The importance of proper diagnosis.

52 INFOMED ORTHO-NEURO-SPINE ANNUAL SPINE SYMPOSIUM 2014

Don’t miss your chance to be part of this symposium.

53 INFOMED 2ND ANNUAL ORTHOPAEDIC UPDATE SEMINAR 2014

Sign up now for our second orthopaedic update seminar.

IN THIS ISSUE20 MEDICAL TOURISM AND HEALTH

SYSTEMS IN THE PHILIPPINES An interview with Cesar V. Purisima,

the Secretary of Finance, Department of Finance of The Philippines.

21 SINGLE INCISION LAPAROSCOPIC SURGERY IN GYNAECOLOGY

Details on the surgery technique.

32 THE MEDICAL TOURIST (OR VISITING FOREIGN PATIENT) IN MALAYSIA

The ethical and legal considerations that come into play.

34 21ST APHM INTERNATIONAL HEALTHCARE CONFERENCE & EXHIBITION REPORT

A look at what happened at this event.

42 TREATING NECK PAIN What needs to be done.

54 HEALTHCARE AND CUSTOMS Our continuation article.

56 COMMON-SENSE EATING ADVICE Expert tips on healthy eating.

60 CERVICAL DISC REPLACEMENT, A STEP BEYOND CERVICAL FUSION

An update on the procedure.

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61 MOLECULAR HUB LINKS OBESITY AND HEART DISEASE TO HEART BLOOD PRESSURE

Better hypertension treatments for at-risk patients.

66 TAKING CHARGE OF YOUR OWN HEALTH

A consequence of obamacare?

70 HOW TO FIND OUT YOUR GENETIC RISK FACTORS LIKE ANGELINA JOLIE DID

The details on genetic testing.

74 NEW FATHER RECEIVED DONOR

KIDNEY... FROM HIS FATHER A true-life success.

76 SOUTH EAST ASIA’S FIRST EXCELLENCE CENTRE FOR SLEEP DISORDERS

Philips and University Malaya Specialist Centre’s Asean Sleep Research & Competence Centre (ASRCC)

EVERY ISSUE8 EDITOR’S NOTE

10 HEALTHCARE HIGHLIGHTS FROM AROUND THE GLOBE

The latest healthcare news that matter.

68 BE A CONTRIBUTOR! Share your stories with InfoMed.

Plus, how you can advertise.

78 LAST LOOK: YOUR INTERSTITIAL SMILE

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DR. KARAM SINGHEDITOR IN CHIEF

I nfoMed’s first orthopaedic update seminar held on 8 June 2013 was a successful event. We received good feedbacks and reviews. The 150 participants were exposed to the latest

information on drugs and treatment protocols available in orthopaedics. The coverage of topics was quite extensive for the medical practitioners. It ranged from updates on the current trends and treatments available in the management of joint pain, osteoporosis, osteoarthritis, wound healing, pain management and physiotherapy in orthopaedics.

We also had some international speakers and participants. Twenty papers were presented in the seminar. More on the seminar are detailed in this issue as well as the plan for the next year’s event. As a magazine themed to assist in the development of the healthcare industry for quality and evidence based medicine, we shall continue to organise similar events. We hope to build on the success of our first seminar and bring forth more interesting and current content of interest for the benefit of the medical fraternity.

In the same series, InfoMed shall be organising a Spine Symposium on 23 March 2014. This symposium is an annual one-day event emphasising up-to-date trends in diagnostic and therapeutic strategies for patients suffering from spinal disorders. This course is designed to be interactive with talks given by leaders in the spine community. All lectures are followed by case discussions aimed at highlighting key issues in breakthrough treatments.

The importance of managing non-communicable diseases is going to be a standard feature in InfoMed. Thus starting from this issue, we shall publish case studies of specific conditions for the benefit of the care givers. We believe this would give opportunity for the medical professionals to exchange expertise and treatment plans for the benefit of the patients.

For this issue, we were privileged to interview Dato’ Dr. Jacob Thomas, President of the Association of Private Hospitals Malaysia (APHM), President of the Asian Hospital Federation and Group Medical Advisor of Sime Darby Healthcare. We discussed various issues and developments in the healthcare industry, and in particular on healthcare travel. Dato’ Dr. Jacob, being

EDITOR’S NOTE

GET IN TOUCH WITH INFOMED! Have something to share with us? Write in at enquiry@infomed.com.my.

an accomplished expert in the healthcare delivery system particularly in the Malaysian environment, shares his thoughts on the progress and future of the industry for the benefit of our readers. I trust you will find his feedback very useful.

InfoMed was also invited to interview the Honourable Mr. Cesar V. Purisima, the Secretary of Finance, Department of Finance, Philippines, during the recent Healthcare in Asia 2013 Conference held in Kuala Lumpur. We got to get a firsthand view of the growing medical tourism industry and its impact in this region.

Another area of interest that is taking shape is in the administration and management sector of the healthcare industry. InfoMed is in the forefront to be a medium to enhance the knowledge and understanding of our healthcare professionals and is starting a series of workshops in partnership with KPMG on taxation. The objective is to assist our medical practitioners understand and adhere to the tax regulations. The workshop shall address fundamental issues and latest guidelines by the Malaysian tax authorities. The first workshop in the series, titled “Upholding the Responsibility as a Taxpayer in the Medical Profession”, will be held on 8 September 2013.

Adding another milestone to our progress, in this issue we are introducing a smart mobile technology called “Augmented Reality” or AR for our advertisers and readers to enjoy our articles with more animated content and visuals. As a prelude, we have our CEO Mr. Mohan Manthiry to say a few words on InfoMed. Please experience AR on page 5.

We wish to thank you for the support and hope that you will continue to benefit from the articles we publish. More importantly, we welcome your contribution and feedback.

With only the standard 12‐lead ECG hookup, physicians are able to obtain ECG information from all regions of the heart, including:  

  ‐   Standard 12‐lead ECG   ‐   Right Ventricular leads: V3R, V4R, V5R   ‐   Posterior leads: V7, V8, V9  

Presented by Nihon Kohden, this newest technology bypasses the usual limitations of the standard 12‐lead  Electrocardiogram.  This  saves  time,  effort  and  improves  patient  management.  This improves  time  taken  to  manage  patients  with  hidden  posterior  or  right  ventricular  myocardial ischemia  and would  help  in  fast‐paced  environments  like  the Accident &  Emergency Departments and the CICUs. 

(i) Standard 12‐lead ECG and additional 6 synthesized ECG waveforms / data 

(ii) Meets IEC 60601‐2‐51  International Standard for Electrocardiographs  

(iii) Incorporated analysis & interpretation program (ECAPS) for both 12‐leads & 18‐leads ECG to aid physicians in patient management. 

Nihon Kohden’s Electrocardiograph: ECG‑2550 model 

ECG‐2550 Electrocardiograph Detailed analysis display, with interpretation  and graphical ST changes for easy data visualization. 

Synthesized 18‑lead Electrocardiogram 

No. 9, Jalan PJS 11/18, Bandar Sunway

46100 Petaling Jaya, Selangor, Malaysia

Tel : 603-5638 0015 / 603-5637 9054 / 603-5637 9204

Fax : 603-5638 0100

Email: sales@lifetronic.com website: www.lifetronic.com

Nihon Kohden Malaysia Authorized Distributor:-

V3R 

V4R 

V5R 

V7 

V8 

V9 

  V9        V8              V7                  V5R                        V4R                             V3R 

< 0  0 –    0.2 

0.2 –    0.5 

0.5 –    0.7 

0.7 –    0.8 

0.8 –    0.9 

0.9 –    1.0 

50 

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30 

20 

10 

 0 

Electrode Placement 

Correlation Coefficient 

No. of Cases 

Accuracy  of  the  synthesized  18‐leads ECG  has been  studied,  and  the  graph above  shows  the  calculated  correlation  coefficients  of  P‐wave  to  T‐wave between Synthesized ECG waveforms and actual ECG waveforms. Reference: “Clinical  Significance  of  Synthesized  Posterior  Right‐Sided  Chest  Lead Electrocardiograms  in  Patients  with  Acute  Chest  Pain,  2011”  by  by  Takao Katoh,  Akira  Ueno,  Keiji  Tanaka,  Jiro  Suto  and  Daming  Wei,  a  study collaboration with Nihon Kohden Co Ltd, Tokyo, Nipon Medical  School,  and the University of Aizu. 

10 / JULY 201310 /

CUTTING DOWN ANTIBIOTICS MISUSEA recent study published in the Journal of the American Medical Informatics Association shows that using an electronic health record’s clinical decision support (CDS) system can “substantially” affect the prescribing patterns of antibiotics by primary care practices.

The researchers found that using a CDS system had a significant impact on the prescribing rate of antibiotics. The rate of prescribing broad spectrum antibiotics for adults treated by the practices using the CDS declined 16.6 per cent compared to an increase of 1.1 per cent in the control practices. The decline was even greater for practices treating pediatric patients; those using CDS saw a decline of 19.7 per cent versus the control practices, which experienced an increase of 0.9 per cent.

Other studies have found that overprescribing of antibiotics and prescribing of them when not clinically indicated is of limited benefit and can carry risks. It’s also costly and a waste of resources. Unfortunately, patients often clamour for a prescription simply because they are unaware that the drug doesn’t help cure many respiratory infections, according to National Institutes of Health, USA research.

JULY 2013 / 11

The popular antibiotic azithromycin (Zithromax and Zmax, Pfizer) poses the risk for a potentially fatal irregular heart rhythm, which therefore warrants careful screening of patients for this drug, the US Food and Drug Administration (FDA) announced. The macrolide-class antibiotic can cause abnormal changes in the electrical activity of the heart that may prolong the QT interval and trigger a rare, associated arrhythmia called torsades de pointes.

The FDA stated that patients at risk for this azithromycin-induced arrhythmia include those who already have a prolonged QT interval, low blood levels of potassium or magnesium, and an abnormally slow heart rate, or who take drugs to treat arrhythmias. Elderly patients and patients with cardiac disease also may be more susceptible to the arrhythmogenic effects of the antibiotic. The agency advised clinicians

AZITHROMYCIN POSES FATAL CARDIAC RISK, FDA WARNS

to put the cardiac risk for azithromycin in an “appropriate context,” because other antibiotics in the macrolide class as well as nonmacrolides such as fluoroquinolones can prolong the heart’s QT interval.

The FDA safety announcement about azithromycin follows a review of a study conducted by Pfizer on the antibiotic’s effect on cardiac electrical activity and another study published in the New England Journal of Medicine in May 2012. The study reported that patients receiving a five-day course of azithromycin had a small, increased risk for sudden cardiac death compared with those who received amoxicillin or no antibiotics. The FDA said at the time that it would review these findings.

The agency has updated the label of azithromycin to warn of the risk for QT interval prolongation and torsades de pointes.

The first-ever hysteroscopic permanent birth control procedure was performed in Malaysia, by Professor

Bernard Chern, Head of the Obstetrics and Gynaecology Department at Singapore’s KK Women’s and Children’s Hospital.

The procedure, known as Essure, is surgery-free and does not require cutting or anaesthesia. It is done on an outpatient basis and can be performed in a regular clinical setting, requiring no operating theatre.

During the under 10-minute procedure, the patient’s fallopian tubes were accessed via her natural channels (vaginal cavity and uterus) and micro inserts were placed to block her tubes and prevent pregnancy. She was fully awake during the procedure and able to walk out of the

hospital immediately after placement.With over 600,000 cases performed worldwide, the procedure is

becoming the standard of care internationally. It is over 99 per cent effective in preventing pregnancy, and it is safer and more reliable

than tubal ligation. Tubal ligation involves having tubes clipped through cuts in the abdomen while under general anaesthesia.

The Essure device is manufactured by an American company, Conceptus, and distributed locally by RainTree

Medical, a medical device supplier.

MALAYSIA’S FIRST!EVER PERMANENT BIRTH CONTROL

PROCEDURE PERFORMED WITHOUT CUTTING OR ANAESTHESIA

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Neil has echoed the warning of the UK Chief Medical Officer, Professor Sally Davies, who spoke out of the dangers posed by growing resistance to antibiotics by infectious diseases in her annual report recently, describing it as a “ticking time bomb.”

Neil met with UK infection control company ICNet, a local business based in Stroud, to discuss the growing healthcare risks of antibiotic resistant infections. Dame Sally Davies, the UK’s most senior medical adviser, has said that we could face an “apocalyptic antibiotic scenario” if action is not taken on this issue. Antibiotic resistant infections can result in common illnesses becoming life threatening if the resistance to treatment is not promptly identified in hospitals when drugs are prescribed.

At the meeting with ICNet, Neil was shown a demonstration of their clinical alert software system ABX Alert. This is a real-time clinical support system, which connects information on patient’s infections and treatments allowing medical professionals to quickly identify risks and enable early intervention to prescribe the most effective drugs.

Neil, who is Secretary of the All Party Health Group at Westminster said, “There is now a growing

awareness of the risk of drug resistant infections and the need to identify the risk of potential infection at the earliest opportunity. The work of ICNet and other companies in developing software to assist medical professionals in “early alerts” to these risks is clearly important in reducing drug expenditure; patient stays in hospital and costs, and most importantly, ensuring patient safety. Significant benefits have been felt by the users of such technology, and this is outlined in a recent report commissioned by the Department of Health. The use of technology to help the NHS move towards greater efficiency and support the delivery of high-quality care has been repeatedly stressed by the Secretary of State for Health in recent statements. “As the local MP, I hope to bring the importance of this work to the attention of a wider audience of healthcare professionals and policy makers at Westminster. Pharmaceutical companies need to also be encouraged to develop new drugs, as a new class of antibiotics has not been developed since the 1980s.”

The Department of Health will publish the UK Antimicrobial Resistance Strategy setting out how it will meet the challenge that the Chief Medical Officer has outlined.

TRANSFORMING HEALTH WITH MOBILE TECHNOLOGYEvery year, 270,000 women die in childbirth and over three million babies do not survive their first month of life. Thankfully, this number is falling – though not fast enough – and one of the reasons is because of improved access to basic health information and services, all thanks to the mobile phone. After all, more than a billion women in low- and middle-income countries have access to a mobile phone.

Johnson & Johnson and one of its companies, BabyCenter, are two of the founding partners of the Mobile Alliance for Maternal Action (MAMA), which also includes the United States Agency for International Development (USAID), the United Nations Foundation, and the mHealth Alliance. The work of MAMA leverages the power of a mobile phone to deliver timely health messages to new and expectant mothers, especially in places where access to health information is limited. By entering an estimated due date or birth date, pregnant girls or women receive text and voice messages timed to their stage of pregnancy or the age of the baby. Globally, MAMA offers free adaptable messages that have been downloaded to more than 100 organisations across 40 countries, tailoring them to meet the needs of women in their communities.

mothers2mothers contributed to the development of specialised messages to meet the unique needs of HIV positive pregnant women. Messages on when to take antiretroviral medicines, how to breastfeed, and how to navigate challenging cultural that may keep women from accessing care for themselves and their babies are sent via the mobile phone.

At the mHealth summit in Washington, D.C., December 2012, thousands of people representing the private sector, NGOs, governments, and multi-lateral organisations convened to learn how to expand on the dynamic progress that has been made in delivering health information through mobile phones. The conversations were hopeful, creative and inspiring – every new connection and new partnership bring new possibilities to empower women and save lives.

Extracted from gatesfoundation.org

UK MP NEIL CARMICHAEL WARNS OF INFECTION CONTROL “TICKING TIME BOMB”

JULY 2013 / 13

ICNet UK, the leading global software provider with about 1,000 hospitals now using its case management and surveillance software, has announced a new partnership with Salux of Porto Alegre, Brazil, which serves to strengthen their vision to deliver a safer hospital environment in Brazil.

The problem and costs of Healthcare Acquired Infections (HAI) in Brazil have created headlines in the Brazilian Press with reports that Hospital Conceição in Porto Alegre has significant problems with HAI so this agreement has come at just the right time to bring expert UK software to Brazil to help with case management, surveillance, and improvement in antimicrobial stewardship in Brazil.

HAI has long since been known to be a serious issue to both the healthcare environment and its patients. The CDC estimates that 1 in 20 hospitalised patients will receive a HAI, of which the implications can be far reaching. Evidence

indicates historically that the majority of patients with a HAI will have an extended length of stay, for as long as a week. The U.S. Department of Health has declared that HAIs are the most common complication of hospital care, and are one of the top 10 leading causes of death in the United States. The cost of the economy runs into billions of dollars, not only direct costs to the healthcare facility, but also societal costs. The quality of life for a person with an HAI can be severely impacted. HAIs add USD28 to USD33 billion in excess U.S. healthcare costs annually.

Michael Houghton, Global Chairman of ICNet says, “The partnership of Salux is a significant step forward for providing hospitals with a safer environment in which patients can be treated. Of every 100 hospitalised patients at any given time, seven in developed and 10 in developing countries will acquire at least one health care-associated

infection.” He continues, “The focus Salux is delivering in Brazil shows a great contribution to deliver high quality products and services to their market, of which in turn will help combat these deadly infections.”

According to Fabricio Colvero Alvini, CEO of Salux, “several studies have indicated that efficient, proactive, and efficient HAI system in any healthcare facility can save lives, time and money significantly helping to reduce the infections rates in hospitals and support medical teams working towards better results. It is vital for Salux to partner with ICNet, the most innovative vendor in the industry, to stimulate a safer hospital environment. Salux is committed to helping healthcare providers and consumers improve efficiency and quality care. “Our partnership with ICNet is another milestone of our journey to effectively lead the patient safety software revolution in the Brazil,” he said.

UK MINISTER RT HON KENNETH CLARKE WITNESSES STRATEGIC PARTNERSHIP AGREEMENT BETWEEN SALUX DO BRASIL AND ICNET UK TO BRING NEW FOCUS TO PATIENT SAFETY WITH HAI REDUCTION IN THE BRAZIL

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According to one analysis, 65 per cent of the population attends public sector facilities, which are served by just 45 per cent of all registered doctors and 25 to 30 per cent of specialists. !e report, by the Centre for Public Policy Studies, called it “just one consequence of the so-called ‘brain drain’ from the public to the private sector.”

JULY 2013 / 15

M alaysia’s unique model of subsidised care in public hospitals and fee-for-service care in private hospitals “have developed into a model for the rest of

the world,” Dr. Jacob said. Rather than finding tension in a dual system, the

government views private hospitals as a partner and also as the growth sector of Malaysia healthcare, having expanded from approximately 50 facilities in the 1980s to about 220 today.

The government buys services from the private sector that are not available in the public sector. “We have doctors in the public sector who come and practise in the private sector part time, and we also have experienced senior consultants from the private sector who provide their services in some public hospitals,” Dr. Jacob said.

And the government is an advocate for the private sector as the provider of care for patients who come from abroad, he said.

CARE QUALITY, MEDICAL TOURISM, AND PRESERVING WHAT’S WORKING IN MALAYSIA:

In the April issue of InfoMed, we wrote about the role infection prevention and control plays in hospitals achieving international accreditation – a key to success in medical tourism. This article expands on that theme. Based on an interview with Dato’ Dr. Jacob Thomas, President of The Association of Private Hospitals of Malaysia, it discusses quality of care and medical tourism in the context of the current public-private partnership in Malaysia healthcare and a possible shift to a universal healthcare system in the coming years. BY TODD SLOANE

Dato’ Dr. Jacob Thomas is the president of the Association of Private Hospitals of Malaysia, which represents 112 private facilities, and is recognised as the voice of private healthcare in Malaysia. A medical doctor, Dr. Jacob has vast experience in hospital management, having served in various capacities at the Sime Darby Medical Centre, a leading tertiary care facility in Subang Jaya, Selangor. He was its Executive Director from 1998 to 2006. He is currently the Group Medical Advisor of Sime Darby Healthcare, in addition to serving on the board of directors of the hospital. Dr. Jacob serves as a Councilor of the Malaysian Society for Quality in Health, an accredited member of The International Society for Quality in Health Care. He is a member of the Malaysia Healthcare Travel Council. He is also the current President of the Asian Hospital Federation.

THE VIEW FROM PRIVATE HEALTHCARE

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ADVANTAGES IN ATTRACTING FOREIGN PATIENTS“Malaysia was quite late to medical tourism. Singapore and Thailand have been in it for quite a long time, but Malaysia has come in with a bang in the last five years,” he said. The nation’s competitive advantages are being able to deliver quality care in good healthcare settings at much lower cost than in neighbouring countries.

“Malaysia is a multinational, multicultural, multireligious centre,” Dr. Jacob said. “English is widely spoken here, Chinese is widely spoken, as well as other languages. Everybody is welcome to our country, which is a melting pot of customs, races and religions. We provide an affordable, friendly destination for healthcare.”

Critical to its success in medical travel is being able to prove it has clean facilities and low infection rates, Dr. Jacob said. Patients who come here don’t ask for data, but want to the comfort of knowing that a hospital has given hospital-acquired infections some thought and enough measures are being taken so that the hospital stay is safe.

Patients coming from abroad often ask whether the blood being transfused here has been adequately screened. They are informed that blood here is safe, and that the government insists that all donor blood is screened for HIV, hepatitis B, and other selected infections.

MANY PREVENTION PROCESSES IN PLACEThe newer pathogens, many resistant to frontline antibiotics, have led to a surge in hospital-acquired infections globally, which is now a big focus of Malaysian healthcare, Dr. Jacob said. “We have used every avenue to communicate to the public that hospitals are dangerous places and not to visit unless necessary,” he said.

Staff are encouraged to take all precautions to ensure that they are not carriers of infection. If a nurse has been in contact with someone with MRSA, for example, it is mandatory that she be screened with nasal swabs for possible acquired infections.

Hand hygiene is vigorously encouraged in all hospitals, with disinfectant dispensers everywhere. A national programme seeks to educate the public on the importance of clean hands.

All hospitals today have active infection control committees headed by doctors. These became even more prominent during the SARS and H1N1 outbreaks, when the government and private hospitals worked together to contain them.

Screening at admission is critical, Dr. Jacob said. Patients transferred from other facilities are treated as potentially infected until proven otherwise. Most hospitals today have isolation rooms for patients testing positive for contagious diseases.

Terminal cleaning is done on any room after a patient who had an infection is discharged. The room is sealed off and floors, ceilings, windows and filters are all cleaned. Swabs are taken to ensure that all of the room is negative for infection before it is released for further use.

The government does not mandate reporting of routine infections, but when outbreaks such as H1N1 or SARS occur, hospitals must provide daily reports of new cases or suspected outbreaks, and screen patients in makeshift facilities before patients even enter the main hospital to avoid contagion. MRSA is also considered a disease to be reported, along with dengue fever, malaria and TB.

SURVEILLANCE SOFTWARE ON THE HORIZONAdopting automated infection surveillance software is not on most hospitals’ radar at this point, Dr. Jacob says, but it ought to be. “I only learned about it quite recently when I met with (a team from ICNet). What is important is to develop an awareness of surveillance and documentation of infections, then you can look at getting some system in place.”

Hospital Selayang in Kuala Lumpur is the only hospital that has adopted ICNet’s electronic infection surveillance software, which monitors an array of clinical data streams to immediately alert hospital staff of potential infections.

“I am sure many private hospitals will get into

All hospitals today have active infection control committees headed by doctors. !ese became even more prominent during the SARS and H1N1 outbreaks, when the government and private hospitals worked together to contain them.

JULY 2013 / 17

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automated infection surveillance as they look for assistance in the data and in managing infections,” he said. “This is a very useful tool, especially in the context of what the Malaysian Society for Quality and Joint Commission International says about the steps you need to take to be proactive in controlling infections.”

Although there is no way for the government to fund the adoption of surveillance technology in private hospitals, the government could give incentives to private sector in the form of tax rebates for showing Malaysia is a safe destination – just as it gives tax incentives for hospitals achieving international accreditation, he said.

1CARE AND THE FUTUREThe government’s role in private healthcare is an issue very much on the minds of government leaders, who in 2009 proposed a reform package for the health sector entitled 1Care for 1Malaysia, now known simply as 1Care. The perception of a large disparity in resources between public and private sector facilities fueled this effort. According to one analysis, 65 per cent of the population attends public sector facilities, which are served by just 45 per cent of all registered doctors

be considered very carefully in light of some other realities, Dr. Jacob said.

For example, today some of the public hospitals are better equipped and staffed than some private hospitals because of the way in which they developed. Some surgeries they perform are not done in some private hospitals or in some parts of the country at all. And some public hospital patients are referred to private hospitals for similar reasons.

“So the Ministry of Health and the government of Malaysia are saying we need to bridge this gap in who can go to a private hospital versus a public one,” he said. The government is looking at one system of healthcare so that anyone can go to any hospital; that anyone can access the same care without having to pay extra, while those who can afford to can get a better room of their own choice.

Although he agrees that healthcare should be

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For example, today some of the public hospitals are better equipped and sta!ed than some private hospitals because of the way in which they developed. Some surgeries they perform are not done in some private hospitals or in some parts of the country at all.

and 25 to 30 per cent of specialists. The report, by the Centre for Public Policy Studies, called it “just one consequence of the so-called ‘brain drain’ from the public to the private sector.”

Dr. Jacob said that although no one in Malaysia goes without needed treatment based on ability to pay – in stark contrast with many countries around the world – he agrees there are some issues of disparities in access. “If you have elective procedures such as hip replacement or non-emergent cardiac surgery, waiting times are long,” he said. “Outpatient departments are overcrowded and might not have all the medications you need on hand. If the drugs are expensive, you may have to purchase them from the pharmacy at your own cost. Right now premiums for private insurance for the elderly are exorbitantly high.”

However, any move to a single national healthcare system must be about improving the system, and must

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affordable and available to all, turning it into reality must avoid fixing what isn’t broken as well as solving any inequities in access.

“What the medical community is saying is, ‘please learn from the mistakes made elsewhere and implement good practices which work well, whether it is a British NHS model or the U.S. model,’” Dr. Jacob said.

HEALTH MINISTER SEES CONTINUED TIES TO HEALTH PROFESSIONALSFollowing the nation’s 13th general election in May, Prime Minister Datuk Seri Najib Tun Razak named as the new health minister Datuk Seri Dr. Subramaniam, a dermatologist who had been Minister of Human Resources. “We are happy that our new health minister is a medical doctor, so he is able to understand these important issues,” Dr. Jacob said.

Indeed, in his first public statements upon

being designated as Health Minister, Datuk Seri Dr. Subramaniam cited his 26-year medical background. He said he would focus early detection and prevention of diseases to save lives and avoid more serious health problems, while reducing government expenditures on public health. He also said he would continue the ministry’s close relationship with health professional groups to achieve his goals.

Datuk Seri Dr. Subramaniam noted that the World Health Organisation had recognised Malaysia as among the countries that provided the best health services to their people.

As Dr. Jacob concluded, “Listening to doctors from different parts of the world, I think we are very fortunate in Malaysia in that we are safer than many other countries. However we must improve upon the current system that we have, making it more accessible and always safe for everyone.”

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M edical tourism has become very popular recently. In fact, it has ascended to become a global phenomenon as demand for better and more affordable

healthcare increases. In many parts of the world, the demographic transformation caused by the ageing population and the increased medical care for the elderly has fuelled demand for improved and auxiliary healthcare services. The epidemiological change such as the escalating incidence of chronic diseases among younger people also adds to the increased need for such health services.

The increasing cost of health services and long waiting time for certain medical procedures in the local medical facilities may be the triggering factor for patients to seek medical treatments overseas. This used to be the privilege of the elites in society but it is not so anymore. Many developing countries are providing cheaper alternatives for the same health services and that has led to the development of a new sector in the tourism industry known as medical tourism.

ON THE RISEIn ASEAN, medical tourists have increased tremendously, and countries like Singapore, Malaysia and Thailand have capitalised upon this new needs. The Philippines, Indonesia and Vietnam are also

jumping onto this bandwagon by upgrading their hospitals and medical facilities. With their countries as popular tourist destinations, these governments have leveraged upon medical tourism by providing comparative international quality in healthcare augmented by competitive prices.

Singapore has specialised in attracting patients who need high-end medical treatments such as joint replacements, liver transplants, cardiovascular, and neurological surgery. Recently, some of the private hospitals there also provide stem cell therapy. Thailand is famous for its low-cost cosmetic surgery and sex change operations. Malaysian hospitals offer affordable cardiovascular and cosmetic surgery.

During the recent Healthcare in Asia 2013 Conference held on 21 March 2013 in Kuala Lumpur, InfoMed interviewed one of the conference speakers, Cesar V. Purisima, the Secretary of Finance, Department of Finance of the Philippines, about the growing medical tourism industry and its impact in this region.

Purisima pointed out that the cost of health services is indeed rising worldwide. Patients in developed countries are definitely looking for cheaper medical services that can provide similar or better levels of medical treatments and healthcare. He says that this creates a good opportunity for countries such as the Philippines to attract medical tourists from all

The rising healthcare cost has encouraged leaders around the world to seek out medical tourism as a way out. The Philippines is not lagging behind in this, says Cesar V. Purisima, the Secretary of Finance, Department of Finance of the Philippines. BY GRACE KANG-ONG

MEDICAL TOURISM AND HEALTH SYSTEMS IN THE PHILIPPINES

JULY 2013 / 21

“Singapore can continue to be the leading edge in technology. Malaysia can be the expert in the Islamic market. !ailand can be in the aesthetic market. !e important point is we co-invest and we support each other.” CESAR V. PURISIMA, THE SECRETARY OF FINANCE, DEPARTMENT OF FINANCE OF THE PHILIPPINES

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over the world. That is the reason why the Philippines is working with the United States to get portability for Medicare insurance. Once this is approved, medical procedures done for an American in the Philippines can be reimbursed by Medicare that is based in United States. This should be the primary source of financing for the healthcare services provided to most of the medical tourists. To secure this source of funds, he insisted that all medical facilities have to meet the required accreditation internationally.

Purisima said that their initial target for medical tourism in the Philippines is the three to four million Filipinos living in the United States. He believed that many will prefer medical treatments done in the Philippines both because of costs and culture.

The Japanese population is ageing fast and the cost of healthcare in Japan has also escalated. The Secretary was of the opinion that the upgraded Filipino medical facilities will be a good alternative for these elderly patients. He revealed that the Philippines is trying to attract the Tokushukai Medical Corporation to

invest in the Philippines. As this is the largest hospital chain in Japan, its highly professional presence in the Philippines will add to the confidence of the Japanese medical tourists and patients from other nations around the world to seek treatments in the Philippines.

The Secretary stated that at this juncture, First Pacific Company Limited, an affiliate of The Salim Group, the giant Indonesian conglomerate, is now running eight to nine private hospitals in the Philippines through its Filipino company, Metro Pacific Investments. He believed that the more investments from the private sector into the medical field, the better the quality of the medical services will become. Moreover, the private sector is very good at promoting what they have invested in and thus medical tourism will get additional boosts.

Unlike Japan and other countries, according to

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Purisima, the Philippines is blessed with a younger population. He believed that this is the appropriate time for his country to activate these young people to build and upgrade healthcare facilities so as to cater to the influx of medical tourists.

WORKING HAND IN HANDHe was certain that the medical tourism market is big enough to be shared by all ASEAN nations. Different countries will provide different medical expertise, and they can all share resources. Unlike Singapore, Thailand and Malaysia, the Philippines is looking more to attract medical tourists to use its non-emergency medical services. He said, “Right now, we have medical tourism in the area of eye care and dermatology.” He trusts that in the near future, the Filipino medical services will consider more advanced medical procedures such as stem cell therapy.

Concerning the possible collaboration among ASEAN countries in this area, the Secretary believes that every country can play a role. He added, “The more advanced ones – Thailand, Malaysia and Singapore – will naturally be the leaders in medical tourism. Other countries will slowly catch up.”

Purisima elaborated that the most important aspect of this industry is the general reputation of ASEAN. Once this group of countries develops a reputation as a viable and affordable healthcare hub, they will all attract medical tourists from around the world. He understands that the vision of the founders of ASEAN is for all its member countries to work together as each of them alone is not big enough to achieve much individually. Therefore by sharing healthcare and other skills with each other, they can complement each other in this emerging industry.

The Secretary put forward that, “Singapore can continue to be the leading edge in technology. Malaysia can be the expert in the Islamic market. Thailand can be in the aesthetic market. The important point is we co-invest and we support each other.

“Ultimately, our competition should not be from within. There are many others trying to compete in this sector, like Latin America and Middle East. The advantage we have is that we have the people, high-skilled workers,” he said. Moreover, the Philippines is

the largest supplier of medical personnel in this part of the world. With medical tourism, many medical personnel will not need to find jobs in other faraway countries but remain in gainful employments within the Philippines and ASEAN countries.

Health systems in countries that attract medical tourism are broken down into a two-tier healthcare provision – private medical services that cater primarily to patients who can afford the substantial medical bills, and public services for the rest of the local citizens who have financial constraint. With medical tourism as a lucrative business, the profit is able to help fund and improve the public healthcare facilities and services. Thus, this becomes a win-win situation.

At this moment, the healthcare financing system for the general public in the Philippines is through a government-owned insurance company, PhilHealth. According to Purisima, based on record, 86 per cent of the population are covered by this scheme. He added, “We are trying to make sure that knowledge about this is universal and so we have to improve the way by which these services are made available. We have to also expand the insurance coverage from just primary to catastrophic services especially for the poor.”

Purisima is thankful that the population in his country does not suffer much from ageing diseases such as high blood pressure, stroke, diabetes and cancer. He noticed that infectious diseases among the younger people are more rampant. He advocated that health education is given to the people in the barangays, which are the smallest units of the population. The government will build better healthcare facilities in the barangays and provide the people with easy access to healthcare workers. By doing all these, he hopes to see young people adopting a healthier lifestyle.

In conclusion, Purisima has great hope for the medical tourism industry. He trusts that when all the nations in ASEAN work together, they will be able to capture a major portion of the world’s market in medical tourism. He encouraged all countries to work closely for the health of their own people and also for medical tourism. By exchanging ideas and sharing experience, the whole region will definitely become a viable healthcare and medical hub.

By exchanging ideas and sharing experience, the whole region will de!nitely become a viable healthcare and medical hub.

CONFERENCE PROGRAM Sub‐themes  

⇝ Governance in Transformation of Healthcare  ⇝ Ethics in Clinical Practice ⇝ Academic Medicine / Health Sciences : Educating for the Future ⇝ Safety and Quality; Inculcating Patient Safety Culture ⇝ Multidisciplinary Care; Team Work for Seamless Care ⇝ 3rd Global Patient Safety Challenge: Tackling Antimicrobial Resistance  ⇝ Patient Centred Care: Patients First ⇝ The Art and Science of Medicine: Expert Care for All 

www.kpjconference.com 

Deadline for registration        : 20 October 2013 Deadline for Paper and Poster submission  : 15 September 2013 Notification of Paper and Poster acceptance: 30 September 2013 

Important dates

Alice Thornton Bell,  Advisory Board Company, USA✔  

Professor Siaw‐Teng Liaw, University of New South Wales ✔ International Speaker from Planetree, USA ✔

Among Plenary Speakers

KPJ Healtcare  Conference & Exhibition 2013 is a healthcare conference which covers many aspects of care including Clinical Governance, Good Medical Practice and Ethics, Patient Centered Care, Clinical 

Informatics, Safety and Quality, Healthcare Education and Advances in Clinical Practice. 

November 6th - 8th 

“ Transforming Healthcare ­ Reaching New Heights ”

ONE WORLD HOTEL

~ International Speaker from Thailand ~ Speaker from Ministry of Health, Malaysia  

Among Invited Speakers

2nd announcement

WHO SHOULD ATTEND?  

Doctors, Nurses, Clinical Support Services, Public Health Practitioners, Medical Professional from various disciplines, Administrators, Managements, Medical 

students etc. 

Need further details? Contact us ‐  

Organizing Committee of KPJ Healthcare Conference & Exhibition 2013 Address : KPJ Healthcare Berhad 

Level 12, Menara 238, No 238, Jalan Tun Razak,  50400, Kuala Lumpur. 

Tel   : +603 2681 6222 Fax  : +603 2681 0190 Email  : conference@kpjhealth.com.my 

 

KPJ Healthcare Berhad is proud to bring you our annual KPJ  Healthcare  Conference  &  Exhibition  at  One  World Hotel, First Avenue, Bandar Utama, Petaling Jaya from 6th to 8th November 2013.  

An  exciting  and  stimulating  program  with  outstanding plenary  speakers  and  symposium  session  has  been prepared  to  explore  the  themes  which  covers  many aspects of care encompasses in improving patient safety, measuring  quality  and  smoothing  transitions  across healthcare settings.  

Free viewing of 40 exhibition booths from renowed exhibitors showcasing their latest products in healthcare technologies.  

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Submit your abstracts for free paper and poster presentations. 

 

Contact : Pn Hana Tel   : 03 2681 6222 ext 1415 Email  : conference@kpjhealth.com.my 

Call for PAPER and POSTER PRESENTATION 

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INFOMED FIRST ANNUAL ORTHOPAEDIC UPDATE SEMINAR

T he Orthopaedic Update Seminar 2013 was held on 8th June at Seri Pacific Hotel. There was a good response from the participants of the event and industry

leaders. There were a total of 17 speakers who came from different musculoskeletal disciplines such as orthopaedic surgery, pain management, physiotherapy, podiatry, and hand surgery. It was a fully packed

one-day programme aimed at addressing various musculoskeletal issues. Abstracts of the topics covered are detailed in the following pages. Next year’s symposium is being planned and many new topics will be included. An interactive style discussion would also be a feature to encourage participation from fellow doctors. Keep a look out for the flyer on next year’s event in this issue of InfoMed.

JULY 2013 / 27

Abstract of some of the topics presented

DATO’ (MR.) V. PATHMANATHAN MBBS (Mal), FRACS, Fellowship in Hand & Microsurgery (USA)

COMMON HAND PROBLEMS Carpal Tunnel Syndrome is compression of the median nerve at the wrist presenting with pain numbness and tingling in the thumb, index and middle. With early treatment, there is a better chance of conservative treatment working. Modification of activity and wrist splints work in two-thirds of patients in early stages. Carpal Tunnel Release is indicated if symptoms are troublesome after four to six weeks of conservative treatment.Trigger Finger is treated with steroid injection and limited to three injection to avoid tendon rupture. Release of the A1 pulley is done if steroid injection does not work.Ganglion Cysts is the most common hand swelling. If the cyst is large, surgery maybe indicated.De Quervain’s Tenosynovitis presents with pain and tenderness over the radial styloid. Early treatment with splint and steroid injection works in more than 95 per cent.Most Common Hand Infection A paronychia is an infection of the nail fold. A felon is a pulp space infection presenting initially with throbbing pain and requires early I & D and antibiotics. If not treated early, destruction of the soft tissues and bone can occur.

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DR. EUGENE WONGMBBS, MS Ortho (Mal), DipSurgAnat(Melb), AM(Mal), Fellowship in Spine Surgery & Orthopaedic Trauma

THE ROLE OF ACTIVATED VITAMIN D IN NEUROMUSCULAR FUNCTION AND OSTEOPOROSISVitamin D deficiency is a silent pandemic with 60 per cent of the older population in the world not having a satisfactory vitamin D status. Recent epidemiological data document the high prevalence of vitamin D inadequacy among elderly patients and especially among patients with osteoporosis. Factors such as low sunlight exposure, age-related decreases in cutaneous synthesis, and diets low in vitamin D contribute to the high prevalence of vitamin D inadequacy. Asia has the second highest vitamin D inadequacy levels with a prevalence of 71 per cent.

Vitamin D has important musculoskeletal functions such as decreasing bone resorption, increasing bone quality, and reducing the incidence of falls. Controversial evidence suggests it may help prevent type 1 diabetes mellitus, hypertension, and many common cancers. Vitamin D inadequacy may represent an under-recognised source of nociception and impaired neuromuscular functioning among patients with chronic pain.

Testing of vitamin D levels is justified in patients with musculoskeletal pain, low back pain, muscle weakness, and loss of balance. Low levels of serum 25(OH)D are common amongst women with osteoporosis. Abnormal motor performance, increased body sway, and quadriceps weakness have been reported in patients with a 25OHD < 20-30 nmol/L. Vitamin D deficiency is an independent predictor of falls in older women in residential care. Levels

of 25-OH vitamin D should be maintained at > 32 ng per mL (80 nmol per L) to maximise bone health. 2000 to 3000 IUs of Vitamin D is needed for maintenance in patients with adequate vitamin D levels.

Despite evidence of its profound importance, vitamin D inadequacy is not widely recognised as a problem by physicians and patients. There is a need for greater awareness among researchers, clinicians, and patients of the high prevalence of vitamin D inadequacy and more aggressive screening for vitamin D inadequacy with a serum 25(OH) D determination, particularly among high-risk populations such as elderly patients and patients with osteoporosis.

The Burden and Importance of Musculoskeletal DisordersMusculoskeletal conditions are commonly associated with pain and impaired physical function. There is a spectrum of conditions ranging from acute onset and short duration such as sprains and ligament injuries to lifelong disorders, including osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. The prevalence of these conditions increases markedly with age, and is affected by lifestyle factors, such as obesity and lack of physical activity. The increasing number of elderly people and the changes in lifestyle throughout the world mean that the burden on people and society will increase dramatically.

Musculoskeletal complaints are a major cause of absence because of sickness, and are second only to respiratory disorders as a cause of short-term sickness absence. They also are common reasons for people claiming disability pensions. In spite of their widespread prevalence, musculoskeletal conditions are not among the top 10 health conditions funded by research. This is primarily due to the low mortality from musculoskeletal conditions in comparison with other health conditions. However, the morbidity cost of musculoskeletal conditions is tremendous because musculoskeletal conditions restrict activities of daily living, cause the loss of work days, and are the source of lifelong pain.

The impact of musculoskeletal disorders on individuals and society is expected to increase dramatically. Many of these conditions are more prevalent or have a greater impact in older patients, and the predicted ageing of the world’s population, predominantly in less-developed countries, will markedly increase the number of people affected by these conditions. In addition, changes in lifestyle factors, such as increased obesity and lack of physical activity with the urbanisation and motorisation of the developing world, will further increase the burden. In spite of musculoskeletal conditions being common, disabling, and costly, they remain under recognised, underappreciated, and under resourced.

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DR. IVAN RANDAL RANATUNGA MBBS (Mal), MS Ortho (Mal)

PAIN RELIEVE IN OSTEOARTHRITIS Management of osteoarthritis (OA) with NSAIDs has developed and evolved over the years, with newer drugs and combination of treatments with the intention to improve patient care and quality of life. This session helps participants to gain insights into recent discoveries in OA treatment, and what the future holds.

DR. OZLAN IZMA MUHAMED KAMIL MD (UKM), MS Ortho (UKM)

MANAGING PAIN WHEN NSAIDS/ COXIBS IS NOT AN OPTIONPain has always been managed by the severity or degree of pain that the patient is experiencing but is this right thing to do? Will it be more appropriate if the

DR. FERNANDO CORTIZO BSc, BSc (Hon), PhD

CURCUMIN – EVIDENCE IN OSTEOATHRITISCurcumin (diferuloylmethane) is the yellow pigment isolated from the

TAN WOO TECK B. Sc, Physical Therapy (Taiwan)

BRACING FOR KNEE OSTEOARTHRITISIn a musculoskeletal pain research conducted in University Malaya Medical Centre on 2,700 persons, 64.8 per cent reported suffering from knee pain and more than half of those examined presented with clinical evidence of knee osteoarthritis (OA). Knee OA is one of the most common forms of OA in Malaysians. Those whom present mild symptoms that is too early for a total knee replacement surgery or have co-morbidities such as diabetes, heart complications that disallows surgery, the Unloader One is an option for them to regain their mobility and relief their pain.

The Ossur® Unloader One knee brace is designed as a lightweight low-profile brace that provides excellent suspension and pain relief. The brace uses a clinically proven 3-Points leverage system with Dynamic Force Straps to reduce pressure on the affected part of the knee.

Those suffering from unicompartmental knee conditions will be able to benefit from this offloading brace as it is a safe, simple, and non-surgical treatment option that reduces the user’s dependency on pain medication, improve their knee function to delay, or postpone surgery. Tan has developed a two-year standard treatment protocol for the Unloader One to ensure that follow-ups were done to make adjustments to the brace if necessary. Preliminary results from the Steadman and Hopkins Research Foundation show that after a six-months period of using an unloader brace, users had reported decreased pain and improved knee function leading to an increased quality of life.

The Unloader One is the most researched unloader brace is the world with over 20 studies performed worldwide and with millions spent on its 2009 research alone. With the use of the Unloader One and doing knee exercises, mobility is improved hence assisting the user to achieve a healthy weight. They may then resume their active lifestyle and continue with their sporting activities.

pain is treated or managed by the physiology or the type of pain that the patient is experiencing? This lecture include the introduction and definition of pain, and how is pain being classified. It will highlights options and restriction of the pharmacological approach in pain management. Dr. Ozlan also shares some cases of musculoskeletal pain that he managed and managing, and hopes to use these case studies to share his experiences in pain management.

rhizomes of Curcuma Longa. It is widely researched as an anti-infammatory nutraceutical with cancer risk reduction properties. Interleukin 1β (IL-1β) and tumuor necrosis factor α (TNF-α) are key cytokines that drive the production of inflammatory mediators and matrix-degrading enzymes in osteoarthritis (OA).

This paper will show the molecular and cellular evidence of curcumin in down regulating not only the pro-inflammatory cytokines but the preservation of articular structure without side effects. The available data from published in-vitro and in-vivo studies suggest that curcumin may be beneficial complementary treatment for OA in humans. However, there are pharmacological challenges to resolve the low solubility and poor bioavailability of curcumin to improve its therapeutic outcome.

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DR. K. RAVEENDRANMBBS (UM), MS ORTHO (UM)

UNVEILING THE EVOLUTION OF NSAIDS IN PAIN MANAGEMENTNonselective Nonsteroidal anti-inflammatory drugs (NSAIDs) are a heterogenous group of compounds characterised by different degrees of analgesic, anti-inflammatory and antipyrectic activity. Some Nonselective NSAIDs have been used for years to treat mild to moderate pain and constitute the first step in the WHO analgesic ladder. Dexketoprofen trometamol is the water-soluble salt of the S-isomer of the racemic non-steroidal anti-inflammatory (NSAID) drug ketoprofen. S-isomers rotate polarised light to the right while R isomers rotate it to the left. Dexketoprofen acts by inhibition of cyclooxygenase, thus diminishing prostaglandin synthesis. It has been shown that

the stereo-isomer of ketoprofen is about 3,000 times more potent than the R-isomer at doing this. Additionally in-vitro studies have shown greater COX-1 inhibition with this S-isomer of ketoprofen, compared with other racemic NSAIDs.

Formulation is important, especially the use of the trometamol salt for rapid absorption. In healthy volunteers, absorption of dexketoprofen from dexketoprofen trometamol capsules was similar to ketoprofen, while the extent of absorption of dexketoprofen free acid was significantly lower than that for ketoprofen.

DR. RAJESH SINGHMBBS Hons (NSW), MS Ortho (Distinction, UM)

SORTING OUT YOUR UPPER LIMB PATIENTS: THE GOOD, THE BAD AND THE UGLYThe primary care physician has to be able to screen through problems quickly to see if:It is fully something that he or she can safely handle;If it partly something they can safely handle but will eventually need to be referred and what the time frame for that referral is;If it is something that they cannot handle and to learn from that.This talk focuses on a systems approach that encompasses common upper limb musculoskeletal conditions seen in general practice, and highlight some of the pitfalls that Dr. Rajesh Singh has come to see and deal with.

DR. MAYA NAGARATNAMMBBS (Imperial, Lon), FRCA, FFPMRCA (UK)

UPDATES ON PAIN MANAGEMENTCurrent thinking, new concepts, and cutting edge therapy in chronic pain diseases. Chronic pain as a disease is fast gaining wider recognition and this year is the global year for Pain: the unseen disease. This talk looks at some of the newer and current thinking behind scientific explanations and potential therapeutic interventions for chronic pain patients.

Dexketoprofen trometamol showed the most rapid absorption rate, with highest maximum plasma concentration and shortest time to maximum values, while ketoprofen had an intermediate absorption rate, and dexketoprofen free acid the slowest absorption rate. After repeated-dose administration of dexketoprofen trometamol, the pharmacokinetic parameters were similar to those obtained after single doses, indicating that no drug accumulation occurred. Food slowed absorption of dexketoprofen, even from the trometamol salt.

The main concern related to NSAID use in clinical practice is gastro-intestinal safety. The safety concern is not only related to the pharmacodynamic and pharmacokinetic properties of the compounds itself, but also the way it is used in clinical practice. The safety profile of oral dexketoprofen trometamol for treatment of acute mild to moderate pain of different causes in actual conditions of use in the primary care setting was assessed. A prospective cohort study was designed to evaluate the tolerability of dexketoprofen compared with other commonly prescribed analgesics. A total of 7,337 patients (median age [IQR] = 46 [33-61] years) were included in the study comparing dexketoprofen (n = 5,429), diclofenac (n = 485), ibuprofen (n = 479), paracetamol (n = 459), metamizole (n = 207), aceclofenac (n = 103), naproxen (n = 74), piroxicam (n = 69) and dexibuprofen (n = 32). Metamizole-paracetamol and dexketoprofen showed the lowest prevalence of AEs (2.7 per cent and 3.6 per cent, respectively), while aceclofenac-diclofenac showed the highest prevalence (8.2 per cent) (P < 0.0001). These results confirm the safety of oral treatment with dexketoprofen in patients with acute pain of various etiologies observed in previous studies and support the use of dexketoprofen as a first-line drug for the approved therapeutic indications.

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DR. LEE JOON KIONGMBBS (MAL), FRCS (Edin), MS ORTHO (MAL), AM (MAL)

DISEASE MODIFICATION IN OSTEOARTHRITISTraditionally, osteoarthritis (OA) has been considered as a disease involving wear and tear of the articular cartilage lining of joint leading on to damage to the joint surface. However, with the various biochemical and inflammatory factors being identified in the synovial fluid and synovial lining, it is now understood that OA is a disease resulting from damage from the combination of all these factors. These lead on to damage the articular cartilage lining, meniscus as well as the underlying subchondral bone. Treatment of osteoarthritis does not involve replenishing or regenerating the cartilage lining with glucosamine and chondroitin alone, but it involves modulating the biochemical, inflammatory as well as the immunologic factors involved in the disease process with various disease modulating agents. This will further minimise the erosion of the cartilage lining and subchondral bone damage. Annual Injectables for OsteoporosisPoor compliance and adherence to long-term treatment of osteoporosis remain the main reason for treatment failure in the management of osteoporosis. Studies have shown that less than half of patients on oral medication adhere to the treatment prescribed after one year. Bisphosphonates, one of commonest agent for the treatment of established osteoporosis, act by reducing the action of osteoclast mediated bone resorption. The available weekly and monthly preparation of bisphosphonates did not improve the compliance and adherence significantly. The yearly single infusion of zoledronic acid reduced bone turnover markers, increased bone mineral density, and reduced fracture risks for vertebral fracture, hip and other types of fracture. The simple yearly dosing regimen ensures yearly compliance and adherence to the treatment of osteoporosis. It’s well tolerated with very good safety profile.

Topical Regimen in Management of PainVarious anti-inflammatory medicines and analgesics have been used in combination to achieve effective pain relief for acute or chronic painful conditions in clinical practice. The common types of pain include the inflammatory, mechanical, neuropathic, post surgical pain as well as cancer pain. It is well known that the use of the traditional non-steroidal anti-inflammatory drugs (NSAIDs) and COXIBs may induce gastric irritation, renal impairment, cardiovascular as well as cerebrovascular events. The basic principle is that oral anti-inflammatory medicines should be prescribed with the lowest dose and shortest period possible. Analgesics, opioids or non-opioids are often used to complement the anti-inflammatory medicines in order to achieve better pain control and yet to reduce the dose and duration of each medicine used. Topical or transdermal anti-inflammatory medicines and analgesics are commonly used to relieve pain together with oral medications with the same purpose to reduce the dose and duration of oral medications used. Transdermal lidocaine is used to relieve neuropathic pain and other musculoskeletal pain in order to reduce the use of oral medications. Transdermal buprenorphine is also commonly used for cancer pain and patients with other chronic pain conditions.

KARTHIK MOHAN

LOW LEVEL LASER THERAPY FOR WOUND HEALING AND PAIN RELIEFLow Level LASER Therapy ( LLLT) has evolved as a very effective modality for treatment of chronic non healing wounds. Also this modality is extensively used in physiotherapy for pain management and inflammation conditions. LLLT causes Bio Stimulation of the cells. Thus biological processes such as proliferation, migration, adhesion are stimulated by LLLT. Selecting the right wavelength, power and dosage is essential to yield good results.

ALISON DEACONB.Sc (Hons), MChS, HPC

BACK PAIN, ORTHOPAEDICS AND PODIATRYThe link between orthopaedics and podiatry is discussed as Alison Deacon leads you into the fascinating world of podiatry. Biomechanics, the study of the function and form of the lower limbs, gait and examination of calluses/corns/ulcers to diagnose the cause of injuries/development of deformities are examined. The history of biomechanics, Galen, Dr. Root’s classification system, foot function and biomechanical interventions aim to provide you with the optimum foot diagnosing tool to enable a swift referral to a podiatrist which could save money, limbs and lives.

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I n the face of a rapidly growing medical tourism component of Malaysian healthcare, it is perhaps timely to consider some of the unique issues that medical tourists may face as patients who

access health services in various parts of the country. In this article, I shall briefly raise several ethical and legal concerns from the perspective of patients’ rights and expectations, bearing in mind that these issues are not unique to persons coming to Malaysia, but are in fact common to cross-border patients globally.

I will first argue for a change in the nomenclature applied to such patients, re-framing them as individuals with similar needs and basic rights of local citizens who seek health services. Next, I will outline several characteristics of these persons, arguing that they form a demographic with unique susceptibilities, which are potentially compounded by complications of treatment. Finally, I will pose constructive questions related to the development of policy aimed at protection of persons visiting Malaysia for medical care.

The unfortunate term “medical tourist” has the propensity to label individuals seeking medical treatment overseas in terms of their ability to generate much valued revenue, not unlike the manner in which host countries view ordinary sightseeing tourists. By calling them medical tourists, it is not difficult to forget that they are in fact patients with illnesses, disabilities, disfigurements and pain, who are unable to obtain or afford timely or appropriate medical help in their home countries.

As one can imagine, to leave the comforts and supports of home

The ethical and legal considerations. BY DR. RICHARD VEERAPEN, PH.D. CANDIDATE (LAW AND SOCIETY), FACULTY OF LAW, UNIVERSITY OF VICTORIA, BRITISH COLUMBIA, CANADA.

THE MEDICAL TOURIST (OR VISITING FOREIGN PATIENT) IN MALAYSIA

Although many requirements have largely been addressed by Malaysian private hospitals, such as a high standard of comfort, food, hygiene and clinical quality, a degree of cultural disorientation may still be expected.

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to seek medical services abroad implies that the person and his family or close others may face some degree of hardship. This should remain an important consideration in the host system. In order to remind healthcare practitioners that such individuals are indeed much more than mere sources of revenue, it may be a useful starting point to refer to them more empathically, for example as Visiting Foreign Patients (VFPs), instead of using the travel industry’s misleading descriptive medical tourist.

Besides the disconnection from their regular supports in the form of family and friends, VFPs are expected to navigate the cultural and environmental differences in the host country. Although many requirements have largely been addressed by Malaysian private hospitals, such as a high standard of comfort, food, hygiene and clinical quality, a degree of cultural disorientation may still be expected. Despite the availability of translators, communication and interactions in a wider sense can be challenging.

Many of the interactions between the patient and healthcare workers take place outside of formal processes such as admissions procedures or guided orientation to the facility, or consent-taking. Not having a support network can be limiting for the VFP, since accompanying persons such as spouses or parents may not necessarily be the type of personal supports (such as fellow members of a religious group or close friends) upon whom the patient ordinarily depends on.

Being able to impact the local reputation of individual healthcare providers and institutions is a form of social power, and can influence the manner in which the interactions between patients and caregivers play out. VFPs, being by and large unconnected locally, have this disadvantage compared to local persons, even though on the longer term, through word of mouth in their home countries or through social media, they are free to disseminate reports about their experiences.

The downsides of being a VFP become most pronounced in the event of serious treatment

complications. For example, should the patient require one or more re-operations or unexpected multidisciplinary intensive care, the factor of cost overrun in a private hospital becomes a major issue. Unlike the situation with Malaysians, for logistical reasons, it is very difficult for foreign nationals to be referred to government institutions for ongoing care of complications. Added to this is the uncertainty about legal redress mechanisms in the event of medical malpractice, particularly if the patient has already returned to his or her home country. As can be imagined, filing an action in a Malaysian court from overseas against a Malaysian medical practitioner or institution for alleged malpractice is a formidable undertaking.

On returning to their home countries, VFPs may also face stigmatisation by local doctors who sometimes view them as persons who either did not trust local practitioners, or regard them as privileged persons who jumped the queue in a publically funded system. This is particularly so if the specialised procedure they underwent happens to be a new form of treatment not yet approved by healthcare licensing authorities or one that is actually illegal in their home country. Often the lack of direct communication of clinical information between medical providers in the home and host countries fractures the continuum of care and presents yet another risk to the patient.

Given the above list of disadvantages of being a VFP, a question arises whether extraordinary measures should be made by Malaysian healthcare institutions and individual practitioners in order to offer these patients a comprehensive safety net. For example, should a special form of insurance arrangement be made mandatory, to offer VFPs as well as healthcare institutions financial protection in the event of cost overrun arising from unforeseen treatment outcomes? Should all medical institutions involved in medical tourism be required to develop a holistic VFP Safety Plan that meets approval by the Ministry of Health via the Malaysian Healthcare Travel Council (MHTC)? This seems appropriate for a healthcare system that already has several ethical and legal rules in place to protect persons who have special risks or needs. I submit that robust regulatory as well as practical measures to protect the interests of VFPs, have the potential to place Malaysian healthcare in a better light than many countries that are currently competing for the medical tourism dollar.

RECOMMENDED READING

Cohen, I. G. (2010). “Medical Tourism: The View From Ten Thousand Feet.” Hastings Center Report, 40(2), 11-12.

Crooks, V., Kingsbury, P., Snyder, J., & Johnston, R. (2010). “What Is Known About The Patient’s Experience Of Medical Tourism? A Scoping Review.” BMC Health

Services Research, 10(1), 266.

Johnston, R., Crooks, V. A., Snyder, J., & Kingsbury, P. (2010). “What Is Known About The Effects Of Medical Tourism In Destination And Departure Countries? A

Scoping Review.” International Journal for Equity in Health, 9(1), 24.

Musa, G., Thirumoorthi, T., & Doshi, D. (2012). “Travel Behaviour Among Inbound Medical Tourists In Kuala Lumpur.” Current Issues in Tourism, 15(6), 525-543.

Snyder, J., Crooks, V, Johnston, R., & Kingsbury, P. (2012). “Beyond Sun, Sand, And Stitches:

Assigning Responsibility For The Harms Of Medical Tourism.” Bioethics.

JULY 2013 / 35

On returning to their home countries, VFPs may also face stigmatisation by local doctors who sometimes view them as persons who either did not trust local practitioners, or regard them as privileged persons who jumped the queue in a publically funded system.

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T he 21st APHM International Healthcare Conference & Exhibition was held from 2 to 4 July 2013 at the Sunway Pyramid Convention Centre. The theme for this year

was “Technology – An Enabler To Better Healthcare”. The Association for Private Hospitals in Malaysia (APHM) was founded in 1972 to solely represent the private hospitals in Malaysia and has 113 members. APHM is an active member of the Asian Hospital Federation.

This year’s conference received more than 550 delegates from 17 different countries and had the largest number of exhibitors so far, which is 135 exhibitors. The Honourable Minister of Health Malaysia YB Datuk Seri Dr. S. Subramaniam officiated the event. In his opening address, the Minister, who is a trained and experienced medical specialist, showed his comfort and expertise in the industry by addressing some of the key areas in the healthcare industry that need to develop and change. Specifically he spoke on

the need to look at outcome measurement and quality in healthcare’s delivery system. One of the measures he mentioned is that the government is beginning to look at not only accreditation of all government hospitals but also the upgrading.

He also spoke on various current issues and trends in the healthcare industry and requested the private healthcare sector to play a key role in the development of the industry. In this respect, the government wishes to engage the private sector on a more meaningful public-private partnership. The Minister also mentioned that the Government of Malaysia is keen to implement the universal healthcare coverage and shall come out with our own model soon.

Dato’ Dr. Jacob Thomas, the President of APHM, who gave the welcome speech at the opening, also stressed on the need to enhance the public-private partnership, specifically in the delivery of services. He wants more active partnerships with government hospitals in areas where there is a need to exchange

APHM INTERNATIONAL HEALTHCARE CONFERENCE & EXHIBITION REPORT

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expertise and specialist services. As the Malaysian healthcare industry is set to grow exponentially with the increasing medical tourists and local demand, such partnership is necessary for the overall development of the industry. He indicated that from 2010 to 2012 the number of healthcare travellers to Malaysia has increased from 392,956 to 671,727, which is an increase of 278,771 healthcare travellers in a span of two years or a 70.9 per cent increase from 2010 to 2012. The revenue from healthcare travellers for 2010 was RM378 million and for 2012 was RM592 million. This is a double digit growth of 56.6 per cent.

Dato’ Dr. Jacob hopes that the government will continue to support this growth trend and also continue with the current tax incentives and allowances for hospitals involved in healthcare tourism. The special investment tax allowances (ITA) for hospitals involved in health tourism includes:

ITA for hospitals catering for foreign patients

Building new hospitals (more beds) Refurbishment of facilities New services and International Patient desk Replacement and upgrading of medical equipment International hospital accreditation

The conference was well attended by both local and foreign delegates who had the opportunity to learn and exchange knowledge on the developments in healthcare technology from eminent speakers, industry practioners and experts. The topics for the conference ranged from electronic medical records, patient safety, infection control and surveillance, workflow improvements, to cool apps and cool technologies for healthcare.

InfoMed will be carrying an interview with the APHM President in our next issue, October 2013, on the success of the conference and exhibition this year and what is in store for next year’s event.

Keep a look out for the flyer for next year’s event in InfoMed.

JULY 2013 / 37

MSQH welcomes abstracts for poster presentations from healthcare facilities and students in Medical, Nursing and Allied Sciences in any of the areas listed below:

1. Patient Focus Care2. Governance, Leadership and Direction3. Education in Safety and Quality4. Measuring Service Performance and KPI5. Quality and Safety in Healthcare6. Promoting Patients & Family Rights

Selected posters will be on display for the period of the conference and also presented at scheduled poster networking sessions. At these sessions, each with moderator, presenter will briefly outline their poster and delegates will have opportunitiy to explore question with them.

For abstract guidelines, please visit MSQH website at www.msqh.com.my/conference

CLOSING DATE : 31st July 2013

For further details, please contact :

Secretariat Malaysian Society for Quality in Health

B.6-1, Level 6, Menara Wisma Sejarah,

230 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia

Tel : +603 2681 2232 Fax : +603 2681 3199

Email : msqh@msqh.com.my

In Collaboration with

Claimable

under HRDF

Scheme

CPD

Claimable

Submit your abstract for posters

CONFERENCEEXHIBITION 2013

MSQH & Ministry of Health, Malaysia

NGAGING PATIENTS IN THE DELIVERY OF CARE :

POSTERS

EThe Everly Hotel, Putrajaya

SPONSORSHIP OPPORTUNITIESInvitation to sponsor to an audience of key decision makers. Kindly contact the MSQH Secretariat for sponsorship opportunity to suit your budget and marketing objectives.

Please visit MSQH website at www.msqh.com.my/conference for more details

PRE CONFERENCE ANNOUNCEMENT

Supported by

Standard Shell Scheme design(3m x 3m) – RM 7,000.00 per boothInclusive of :• Rear and dividing walls of 2500mm high using white coated aluminum

system space• Two 36W fluorescent light & one 13 amp power point• One information desk, 2 units folding chairs & one wastepaper basket• Fascia to include Exhibitor name on colored sticker• Carpet for booth area

(Fees includes lunch, tea breaks, conference materials and certificate of attendance)

MSQH Members RM 850 per person RM 750 per personNon Members RM 1000 per person RM 900 per personStudents RM 650 per person RM 600 per personASQua / ISQua Members USD 400 per person USD 350 per personForeign Participants USD 500 per person USD 450 per person

5th SEPTEMBER 2013The Everly Hotel, Putrajaya

(*Root Cause Analysis)

*

0900 - 1230

MSQH Members RM 300 per person RM 275 per personNon Members RM 400 per person RM 350 per personStudents RM 200 per person RM 175 per personASQua / ISQua Members USD 150 per person USD 125 per personForeign Participants USD 200 per person USD 175 per person

MSQH Members RM 1000 per personNon Members RM 1250 per personStudents RM 750 per personASQua / ISQua Members USD 500 per personForeign Participants USD 600 per person

PATIENTS FOR PATIENT SAFETY

5th - 6th SEPTEMBER 2013The Everly Hotel, PutrajayaBy invitation only Conducted by WHO, Geneva

For registration and exhibition inquiries & contacts:

POST CONFERENCE

OVERVIEW OF 2 DAYS EVENT

POST CONFERENCE

CONFERENCE FEE

WORKSHOP FEE

PACKAGE FEECONFERENCE + POST CONFERENCE

WORKSHOP

RegistrationWelcome AddressKeynote Address by Director General of Health, Malaysia (tbc)Official Opening of ConferenceMinister of Health, Malaysia (tbc)Tea BreakExhibition ViewingPlenary 1

“Getting to Zero: Eliminating Preventable Serious Safety Events”Ms. Ronni P. Solomon J.D.Executive Vice President & General Counsel, ECRIPlenary 2

“WHO Patients for Patient Safety Movement”Ms. Nittita Prasopa PlaizierWHO Programme Manager, Patients for Patient SafetyLunchExhibition ViewingConcurent Session 1Plenary 3

“Malaysian Patient Safety Goals”Dr. Nor’aishah Abu BakarPublic Health PhysicianActing Deputy Director Quality in Medical Care Section, MOH“Short Film” - Patients for Patient SafetyTea & End

Tuesday, 3rd September 2013

073009000920

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14001530

16301700

Wednesday, 4th September 2013

RegistrationPlenary 4

(tbc)Tan Sri Lee Lam Thye (tbc)Chairman National Institute of Occupational Safety and Health (NIOSH)Plenary 5

“Engaging Patients to Enhance Patient Safety”Patient Safety Champion - WHOTea BreakConcurent Session 2LunchExhibition ViewingConcurent Session 3Plenary 6

“Road Map: Malaysian Patient Safety Movement”Assoc. Prof. Dr. M.A Kadar MarikarChief Executive Officer, MSQHForum: Patient Safety - In action”Moderator: Ms. Ronni P. Solomon J.D.Executive Vice President & General Counsel, ECRITea & Close of Conference

07300830

0930

103011001230

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Disclaimer **MSQH reserves the right to alter the programme schedule and details without prior notification.

Facilitator: Ms. Ronni P. Solomon J.D.

Ms Nasihah Nurul Ain nasihah@msqh.com.myMs Hidayat Fathi hidayat@msqh.com.my

Phone: 03 2681 2232 | Fax: 03 2681 3199www.msqh.com.my/conference

Early Bird PriceBefore 1st Aug 2013

Early Bird PriceBefore 1st Aug 2013

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C ontinuing Professional Development (CPD) is a process of systematic learning that allows health professionals to update and enhance their skills, and address their

career educational aspirations, while continuing to meet the needs of the population they served1.

Implementation of the Continuing CPD programme for medical doctors in Malaysia started since the 1990s by the Malaysian Medical Council (MMC) through the Continuing Medical Education (CME) activities2. The goals were to encourage participation in academic and professional activities with the

purpose of updating and upgrading the knowledge and skills of medical practitioners, to enable the practitioners to self-assess their professional knowledge and skill from time to time. In addition, it is also to enhance the professional standards for the best quality of patient cares in line with rapid evolving technologies and demands3.

The CPD programme provides guided planning and proof of documented evidence that the practitioner had to take part in professional development activities to keep up to date with latest advancement in medical field3 and learn about new development. In this way, the Ministry of Health (MOH) can ensure all doctors are able to

Read on to find out what it involves. By Dr. Hj. Rohaizat b. Hj. Yon (MD, MHP, PhD), Senior Deputy Director, Medical Professional Development Branch, Medical Development Division, Ministry of Health Malaysia; Dr. Sabariah Jaafar (MBBS, MSc, (OH & Safety)); Dr. Mohd. Fikri B. Ujang (MD, MScCommHlth (OH)); and Dr. Nurul Ainie Anwar (MD MPH), Medical Development Division, Ministry of Health Malaysia.

With proper monitoring and established mechanism for evaluation, the myCPD system will continue to play a signi!cant role in MOH for multiple purposes as the myCPD system is now established and is capable to meet the demands in the developing world of medicine.

CONTINUING PROFESIONAL DEVELOPMENT (CPD): THE MALAYSIAN EXPERIENCE

JULY 2013 / 41

keep abreast with recent updates in the medical field such as new technologies and medicine.

Malaysian Medical Association (MMA) has initiated the MMC-CME Grading System and is responsible for accrediting CME since 1994. MMA has continued to give excellent support for CPD programmes by accrediting providers, collecting credit points from participating medical practitioners and submitting to MMC for issuance of the CME Certificate, but largely for members of the MMA3.

CPD SYSTEM OF THE MINISTRY OF HEALTH The Ministry of Health (MOH) has developed a structured electronic CPD system in 2007, which is known as myCPD system for monitoring and recording of health professionals’ training. It is capable of extending its functions to include health professionals in non-MOH sectors (private sectors, universities, armed forces and other ministries). Initially, three healthcare schemes professionals used myCPD involving medical doctors, dentists and pharmacists. Gradually it was expanded to involve other healthcare

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N schemes and professionals in MOH such as nurses and other allied health professionals. As of May 2013, more than 144,000 registered users are using myCPD system.

The MOH-CPD system (ie myCPD system) was initially developed incorporating the modified MMC Grading system defining two main areas or category of activities namely as follows:

A. The core categories (Category A1 to A11) The core categories essentially involved all

events participated by the medical practitioner, from attendance to presentation of papers at congresses, scientific meetings, workshops, forums, courses and lectures. It also includes publications in journals (indexed, non-indexed), chapters in book, attendance at grand ward rounds, self-study, distance learning and on-line self-appraisal, obtaining postgraduate degrees and diplomas, and involvement in academic committees. Core activities are already available nationwide as well as through self-study programmes, so medical staffs will have no difficulty accessing programme to score credit points in the various categories.

B. The Non-Core Activities (Category B1 and B2) include membership in editorial boards, and other supporting activities related to personal development, self-improvement, leadership, management, IT and even involvement in arts, music, languages, teamwork, etc. These add value to the extra-curricular attributes of the practitioner and help to elevate the level of quality of care to the patients.

CPD points claimed for these categories will need documented evidence and verification. By this system, MOH staffs will be able to send in their CPD Grading System credit points directly to the Secretariat in Ministry of Health and their supervisor to view their progress.

THE ORGANISATION OF MOH’S CPD SYSTEMThere are several committees appointed for the implementation of MOH mycPD system. The Director-General of Health chairs the National CPD committee and the members are representatives from different profession and schemes made up the decision for referred policy in CPD. The secretariat is now based at the Medical Development Division in Ministry of Health. The CPD Grading System has been formulated by the National CPD Committee of the Ministry of Health in consultation with the Malaysian Medical Association, the Academy of Medicine Malaysia, Academy of Family Physicians, and other related government and private professional groups including universities.

There are other committees established at various Divisions of MOH, states, hospitals and health clinics in managing the myCPD system.

AUDIT FOR VERIFICATION OF CPD CREDIT POINTSTo maintain CPD as a credible system, auditing for verification of CPD points is essential to see whether the points claimed was in the correct category, and had proof for verification. As it is an honest system, proof or verification of attendance need to be reviewed thoroughly.

ACCREDITATION OF CME PROVIDERAccreditation of providers will be monitored by respective council for their own profession. For example, the Malaysian Nurses Association (MNA) will do the accreditation, monitoring on development of CPD activities for public and private nurses.

THE USAGE OF MOH’S CPD SYSTEM There are multiple purposes or usage of the CPD system. Amongst the usage are as follows:

A. CPD Points for Competency Assessment PTK The MOH CPD system was initially linked to

competency assessment or popularly known as PTK (Penilaian Tahap Kecekapan/Competency Level Assessment) in the Ministry of Health as endorsed by Public Service Department (JPA) in 2007. Passing the PTK was one of the requirements for promotion. PTK was applicable specifically to all medical workers employed or working in government healthcare facilities and services. Now CPD has made it more convenient for the doctors, as their hectic working hours makes it difficult for them to attend PTK assessment, which might delay their promotion to higher grades.

Although PTK had been abolished since 2011, the CPD system will still be used and modified accordingly for future competency system which may be introduced by the Public Service Department/Jabatan Perkhidmatan Awam (JPA).

B. CPD for APC Compulsory CPD points requirements for renewal

of Annual Practising Certificate (APC) will be made compulsory following the passing of the amended Medical Act (1971) (2012). The regulations are yet to be formulated by Malaysian Medical Council. All fully registered medical practitioners in Malaysia, whether Malaysian or foreign doctors on contract, will have to comply with the CPD requirements to renew their APC. This is in line with the amendment of Medical Act 1971 (2012).

C. CPD for NSR As for the clinical specialists, currently the Academy

of Medicine Malaysia (AMM) is developing a system that need them to register with the National Specialist Register (NSR) to be recognised as

JULY 2013 / 43

REFERENCES

1. WHO. 2006. Regional Strategy On Human Resource For Health 2006-2015. Regional Office

For The Western Pacific. New Zealand.

2. Malaysian Medical Council. 2007. Continuing Professional Development (CPD) :

Frequently Asked Questions. www.mmc.gov.my/v1/index.php?option=com_content&task=view&id=

10&Itemid=25

3. A. Hamid. 2007. Continuing Professional Development (CPD). Ministry of Health. Putrajaya.

4. Academy Of Medicine Malaysia. 2102. Introduction To Academy Of Medicine. www.acadmed.org.my

5. National Specialist Register. 2012. www.nsr.org.my

specialists. This is also in line with the amendment of Medical Act 1971 (2012).

The AMM is a professional organisation embracing all specialities to assure the maintenance of a high standard of professional and ethical practice4. The MOH, MMC and the AMM have worked together to establish the National Specialist Register (NSR).

The NSR will ensure that doctors designated as specialists are appropriately trained and fully competent to practise the expected higher level of care in the chosen specialty. With the NSR in place, doctors will be able to identify fellow specialists in the relevant specialties to whom they can refer either for a second opinion or for further management. Importantly, the NSR protects the public and will help them identify the relevant specialist doctors to whom they may wish to be referred or may wish to consult. The National Specialist Register is in fact an exercise in self-regulation by the medical profession, striving to maintain and safeguard the high standards of specialist practice in the country, having the interest and safety of the public at heart5.

Specialist Registration in the NSR is for credentialing of a specialist who has attained specialty knowledge and skill in a recognised specialty and applies to all specialist practitioners in the country (public, private and others). Obtaining minimum credit points requirements in their respected fields involving core and non-core

categories for certain period of years will be used for maintenance of their registration with NSR5.

D. CPD for Seven Days Training Requirements CPD points as per requirement of the government

have been accepted to be used as equivalent to seven days training requirements for medical professionals who work with MOH. Due to their hectic working hours and job restrictions, chances for them to be away from their workplace for CPD activities are limited. Thus the minimum requirement is 40 CPD credit points to be attained annually by MOH healthcare professionals.

CPD plays an important role in enhancing the professionalism of MOH healthcare personnels. With proper monitoring and established mechanism for evaluation, the myCPD system will continue to play a significant role in MOH for multiple purposes as the myCPD system is now established and is capable to meet the demands of the developing world of medicine.

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TREATING NECK PAIN

Dr. Eugene Wong, Consultant Spine & Orthopaedic Surgeon, A/Prof Perdana University Graduate School of

Medicine, Pantai Hospital Kuala Lumpur, on what needs to be done.

JULY 2013 / 45

N eck pain is a ubiquitous and recurring symptom. The prevalence of neck pain is 15 per cent in men and 23 per cent in women (Gummesson, 2006). Seventy

per cent of individuals report experiencing neck pain at some point in their life (Bovim, 1994). This is the second commonest cause of chronic disability following low back pain (Wright, 1999).

Most people with neck pain do not experience a complete resolution of symptoms. Despite the favourable natural history of acute neck pain, a proportion of patients will develop chronic neck pain. Between 50 to 85 per cent of those who experience neck pain initially will report neck pain recurrence one to five years later.

Non-modifiable risk factors for neck pain include age, gender and genetics. There is no evidence that common degenerative changes in the cervical spine are a risk factor for neck pain. Modifiable risk factors for neck pain include smoking and physical activity. Poor health, prior pain episodes, and psychological factors have a negative effect on prognosis.

WHAT CAUSES NECK PAINThe various causes of neck pain can be divided into two main groups (Table 1). Cervical spondylosis is a common cause of neck pain, and it refers to age-related degenerative changes within the cervical spine. These changes are a natural consequence of ageing and are asymptomatic in most of the population. It can be present as one of three symptom complexes or a combination of either. Axial neck pain denotes pain along the spinal column and its related paraspinal musculature. Cervical radiculopathy refers to pain radiating into the arm, which may be accompanied by sensory or motor changes in a radicular distribution. Cervical spondylotic myelopathy is the development of long tract signs.

Cervical radiculopathy can be a significant cause of neck pain and disability. The reported annual incidence is 83.2 out of 100,000 persons and reported prevalence is 3.5 out of 1,000 persons. Patients presenting with cervical radiculopathy most frequently complain of neck pain, paresthesia, and radicular pain. While sensory symptoms typically present along a dermatome, pain is often myotomal. It is crucial to note other conditions that can present as radiculopathy (Table 2).

DETERMINING THE BEST TREATMENTDecision analysis is a method to identify the best treatment based on the outcomes of a specific treatment and patients’ preferences for these outcomes. From the standpoint of health policy, and when the objective is to maximise life expectancy and quality adjusted life expectancy, there is no single treatment among NSAID, exercise, and manual

therapies that is clearly better for neck pain (Spine 2008 Feb 15;33(4 Suppl):S184-91). Thus, a physician’s decision about the best treatment should be based on the patient’s informed treatment preferences and attitudes towards risk. Some clinical recommendations for managing cervical radiculopathy are given on Table 3.

There is support for short-term symptomatic improvement of cervical radicular symptoms with epidural or selective root injections with corticosteroids. It is not clear that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to non-operative measures; however, relatively substantial pain and impairment relief after surgical treatment seem to be reliably achieved.

Anterior cervical discectomy and fusion is a surgical procedure performed to remove a herniated or degenerative disc. A cervical foraminotomy is performed from the back of the neck to remove a small portion of bone and joint overlying the spinal nerve as well as any soft tissue that may also be causing compression. In some cases, a disc prolapsed is also removed. A disc replacement is done in some patients to maintain motion in the neck. Multiple level compressions can be tackled by a posterior laminoplasty technique. Endoscopic cervical discectomy is a less invasive surgical technique where a 0.4cm tube is inserted into the disc and the soft disc herniation removed.

The best treatment, in general, for patients with axial symptoms consists of non-surgical interventions. Surgical decompression and stabilisation should be

NON-TRAUMATIC

Myofascial – muscle spasm, inflammation, sprain, and strain syndrome

Degeneration or inflammation of the cervical disc

Degeneration or inflammation of the cervical joint or facet instability

Tumour of the cervical spine

Infection of disc space or spine (osteomyelitis)

Poor postural control

Meningitis

Fibromyalgia

TRAUMATIC

Fracture

Whiplash/injury

Muscle strain

TABLE 1: ETIOLOGY OF NECK PAIN

Peripheral entrapment syndromes Rotator cuff or shoulder pathology Herpes zoster Brachial plexitis Epidural abscess Thoracic outlet syndrome Intraspinal or extraspinal tumours Cardiac ischemia Sympathetic mediated pain syndrome

TABLE 2: DIFFERENTIAL DIAGNOSES OF CERVICAL RADICULOPATHY

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ACUTE RADICULAR PAIN

A short period (one week) of immobilisation in a cervical collar may relieve radicular pain.

Home cervical traction units may provide temporary relief of radicular pain.

Exercises and manipulation should focus on stretching and strengthening after the acute pain has subsided.

Selective nerve root blocks may relieve radicular pain.

CHRONIC RADICULAR PAIN

Antidepressants (tricyclic antidepressants) and tramadol may alleviate chronic radicular pain.

TABLE 3: CLINICAL RECOMMENDATIONS FOR TREATING CERVICAL RADICULOPATHY

considered in patients who continue to have symptoms despite appropriate treatment. Surgical treatment for neck pain alone, without radicular symptoms or clear serious pathology, is not supported by current evidence. Patients with clinically evident myelopathy may be candidates for operative intervention. An algorithm depending on the type of presentation is a helpful guide (Diagram 1).

The Task Force on Neck Pain suggests that a shift in current thinking about neck pain is needed (Diagram 2). Rather than neck pain being considered a sign of a disease or injury that needs to be diagnosed and treated, it is viewed as a common occurrence in life where self-management should be encouraged. It has suggested a grading and management system for neck pain (Table 4).

Preventive efforts are best directed at reducing injuries and dealing effectively with neck pain to avoid the development of disabling neck pain. Neck pain is multifactorial in etiology and has differing impact on affected persons. There is the need to address cognitive and behavioural factors involved in the maintenance of neck pain and encourage active pain coping skills and self-management of pain.

GRADE 1 NECK PAIN GRADE 2 NECK PAIN GRADE 3 NECK PAIN GRADE 4 NECK PAIN

No symptoms or signs of major pathology.

Little interference with daily activities.

No further investigation.

Reassurance that significant underlying pathology is unlikely.

Self-care (remain active, simple analgesics, avoid immobilisation).

Occasionally conservative therapy options.

No symptoms or signs of major pathology but interference with daily activities.

No further investigation.

Reassurance that significant underlying pathology is unlikely.

Assess for environmental or personal factors that may be contributing to the clinical presentation.

Consider conservative therapy options.

Neck pain with neurological signs or symptoms (radiculopathy).

Does not require immediate referral or investigation unless major neurological deficit exists.

Manage symptomatically (there is little evidence for or against specific therapies).

Close monitoring to detect any progression of neurology.

Referral and investigation if progression of neurological deficits, intractable pain persists despite four to six weeks of conservative treatment.

Neck pain with symptoms or signs of major structural pathology.

Referral or investigation dependent on the suspected underlying pathology.

TABLE 4: TREATMENT GUIDELINES ACCORDING TO THE TASK FORCE ON NECK PAIN

Diagram 1: Algorithm in Managing Neck Pain

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Diagram 2: Neck Pain Task Force Conceptual Model of Neck Pain

Decision analysis is a method to identify the best treatment based on the outcomes of a speci!c treatment and patients’ preferences for these outcomes.

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A ct of terror to create fear, motivated by religious, political and ideological goals, is called terrorism.

And this is exactly what environmental NGOs are doing. When Michael Moore, one of the founders of Greenpeace realised that waging a war against a potential technology is against humanity, he defected from Greenpeace while still having environmental issues close to his heart. Another Greenpeace dropout is Mark Lynas who recently made a public

apology at a conference in University of Oxford for his anti-biotech movements in 1990s.

The technology that irks environmentalists is genetic engineering or genetic modification, especially so if it is employed in the field of agriculture. Never mind that thousands of recombinant drugs are made from genetically modified microbes.

TAKING A CLOSER LOOKIf we scrutinise all the plants that produce our foods today, none of them are free from genetic modification.

GM CROPS: A CASE AGAINST SCIENTIFIC TERRORISMDr. Mahaletchumy Arujanan, Executive Director, Malaysian Biotechnology Information Centre, shares her thoughts.

Little do we know that all plants have undergone gene evolution either naturally or guided by man. Teosinte, the origin of corn, looks nothing like corn. So are the wild plants where wheat, broccoli, tomato and carrot originated. Hundreds of years of selection and cross breeding have resulted in the food crops and plants that are cultivated today for commercial purposes.

Imagine how genes have been reshuffled, deleted, added and silenced to produce these new varieties. Yet, there are no issues or public outcry about them as they are perceived to be natural.

On the other hand, modern biotechnology that involves inserting specific genes into plants with tremendous level of precision causes aversion, in spite of hundreds of tests and a stringent regulatory regime.

The most common GM crops globally are corn, soybean and cotton, and others include sugarbeet, alfalfa, papaya, squash, poplar, tomato, and sweet pepper. To date, 17.3 million farmers are growing GM crops in 28 countries on over 170.3 million hectares of land.

Most GM crops in the market are inserted with a gene from Bacillus Thuringiensis, a common soil bacterium that has been used or is still being used as a

Dr Mahaletchumy

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biological control by organic farmers – the gene codes for a protein that is toxic towards very specific insects but on the other hand is harmless to non-target species including human beings.

The major traits of GM crops are insect-resistance and herbicide-tolerance, while others in the pipeline are tolerant to drought, salinity and frost, which is deemed extremely important in the light of climate change.

Here is a look at the various aspects of GM crops. SAFETY: The safety of GM crops is established through compositional analyses to verify any changes in nutritional and anti-nutritional composition, biochemical characterisation to analyse any new proteins in terms of its digestibility, toxicity, and allergic activities. Feeding trials are conducted to detect unexpected changes on bioefficacy and bioavailability. Grain compositional analysis is carried out on proximates, minerals, amino acids, fatty acids, fibre, vitamins, and secondary metabolites. Field trials are also conducted to ensure the crops do not cause any environmental or ecological damage.

In fact, GM crops are the most tested food in human history and the regulatory cost takes up the bulk of GM-seed research.

ECONOMIC IMPACT: There have been substantial net economic benefits at the farm level amounting to USD10.8 billion in 2009 and USD64.7 billion for the 14 year period from 1996 to 2009. Of the total farm income benefit, 57 per cent (USD36.6 billion) has been due to yield gains, with the balance arising from reductions in the cost of production. Two thirds of the yield gain is derived from adoption of insect resistant crops and the balance from herbicide tolerant crops.

ENVIRONMENTAL IMPACT: Biotech crops have contributed to significantly reducing the release of greenhouse gas emissions from agricultural practices. In 2009, this was equivalent to removing 17.7 billion kilogrammes of carbon dioxide from the atmosphere or equal to removing 7.8 million cars from the road for

one year. This is achieved through the reduction in the use of caustic agrochemicals. As crops are imbedded with genes that produce natural insecticidal compound, it is akin to vaccination that requires no external spray of chemicals.

Biotech crops have reduced pesticide spraying (1996-2009) by 393 million kilogrammes (-8.7 per cent) and as a result decreased the environmental impact associated with herbicide and insecticide use on the area planted to biotech crops by 17.1 per cent.

If GM technology had not been available to the (14 million) farmers using the technology in 2009, maintaining global production levels at the 2009 levels would have required additional plantings of 3.8 million ha of soybeans, 5.6 million ha of corn, 2.6 million ha of cotton, and 0.3 million ha of canola. This total area requirement is equivalent to about seven per cent of the arable land in the United States, or 24 per cent of the arable land in Brazil, thus making GM technology a land-saving technology that conserves biodiversity.

While GM crops in the market contribute towards poverty alleviation, increased yield, and reduction of environmental footprints, what is in the pipeline has more direct benefits to consumers. Rice rich in vitamin A, cassava enriched with minerals and vitamins, oils with healthier lipid profile are some of the crops in the waiting for commercialisation. The Golden Rice that is rich in pro-vitamin A would benefit millions of hardcore poor who suffer from irreversible blindness but it has not stopped critics from halting its commercialisation.

To date, not a single health hazard has been reported due to GM crops and billions have consumed it over a period of 17 years. This could serve as the biggest feeding trial involving all sectors of global population. The E.coli outbreak in the Europe in 2011 originated from an organic farm yet it was swept under the carpet and dozens die in the United States every year after consuming organic produce but this is never made a big issue. Just imagine one single health hazard from GM foods and there will be a global moratorium. The double-standard in evaluating GM foods has to stop, and assumptions should be based on scientific data.

Rising population, environmental degradation, depletion of resources, and climate instability are contributing towards food insecurity. GM technology could serve as an effective tool to address these challenges if employed in combination with existing conventional techniques and proper agronomic practices should scientific terrorism rest in peace and science is allowed to prevail.

The evolution of carrot through selection and cross breeding.

Teosinte: The ancestor of modern corn.

“Farming looks mighty easy when your plough is a pencil and you are a thousand miles from the corn field.”– Dwight D Eisenhower (34th President of the United States of America)

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with MODY. It is an autosomal dominant inheritance with age of onset before 25 years. MODY should be suspected in cases whereby there is mild diabetes on presentation without significant ketosis, family history in at least two generations in an autosomal dominant fashion, absence of pancreatic autoantibodies, low insulin requirement to maintain normoglycaemia, marked sensitivity to sulphonylurea and no significant obesity. There are six common variants of MODY. MODY 1 involves mutation in hepatic nuclear factor 4A and results in progressive decline in insulin production. The treatment of choice is either sulphonylurea or insulin. MODY 2 involves mutation in glucose sensing receptor of beta cell, glucokinase. This leads to higher set point for fasting blood glucose with persistently raised blood glucose of 5.5-8 mmol/L. The beta cell’s ability to respond to glucose load is preserved; hence there is only a small rise in blood glucose on oral glucose tolerance test (less than 3-4.6 mmol/L at two hours). Mild fasting hyperglycaemia is present from birth and remains stable throughout life. No treatment is generally required and interventions rarely have an impact on the HbA1C level. Of utmost importance, treatment is indicated in pregnancy if the foetus does not have the gene mutation as it can sense the higher than normal levels of blood glucose in the mother.

MODY 3, the most common form of monogenic diabetes, involves mutation in hepatic nuclear factor 1A, transcription factor involved in insulin synthesis. Hyperglycaemia is progressive with decline in insulin secretion. One way to differentiate it from MODY 2 is the large rise in blood glucose level with the oral glucose tolerance test (more than 5 mmol/L). Sulphonylureas are the treatment of choice, in small doses due to marked sensitivity, and insulin may be required in 30 per cent of patients. MODY 4 and 5 are less common and involve mutations in beta cell nucleus transcription factors.

WHICH PATIENTS WITH TYPE 1 DIABETES SHOULD BE REFERRED FOR GENETIC TESTING?MODY should be considered in patients with evidence of continuous endogenous insulin secretion three to five years after diagnosis of presumed type 1 diabetes. Other factors to consider are persistent C peptide production after three years of diagnosis, low insulin

M ODY or monogenic beta cell dysfunction is a rare but important variant of diabetes in terms of implications on management. An example of a case is a

24-year-old female from Jakarta, who was diagnosed with diabetes at the age of 15 when she presented with symptoms of lethargy and sleepiness. She was commenced on oral hypoglycaemic agent, which she was on for few years. She did not present with any symptoms of hyperglycaemia. Subsequently, she moved to Australia at the age of 19 and was seen by the endocrinologist in Perth who thereafter ceased her tablets due to recurrent hypoglycaemia attacks. On examination, her BMI was 26 and she had no features of insulin resistance. On further family history, her mother was diagnosed with diabetes subsequent to her diagnosis but is currently not being treated. Her maternal grandmother had diabetes with complications of dialysis dependent renal failure. She has two siblings who tested negative for diabetes at this stage. There was no history of deafness in the family. On investigations, her HbA1C was seven per cent, C peptide 0.45ng/mL, GAD antibodies <0.1 unit, IA 2 antibodies <0.2 unit, and insulin of 15 units/mL. Her oral glucose tolerance test revealed a fasting blood glucose of 5.8 mmol/L, and two-hour blood glucose of 14.5 mmol/L. Based on the results and clinical history, she was suspected to have a variant form of MODY, mostly likely MODY 3, as explained below.

WHAT IS MODY?MODY is a monogenic disorder characterised by beta cell dysfunction from single gene mutation either transcription factors in beta cell nucleus or glucose sensing receptor on beta cell membrane. There are up to 10 different genes that have been implicated

THE UNDER-DIAGNOSED MODY

Monogenic diabetes is increasingly more common now and should be kept at the back of our minds when diagnosing young adults with diabetes, as it has genetic implications and impacts on management options.

BY DR. SHALINI SANDRA MOHAN, WESTERN AUSTRALIA

JULY 2013 / 51

requirement and no tendency to ketoacidosis when insulin is omitted.

WHICH PATIENTS WITH TYPE 2 DIABETES SHOULD BE REFERRED FOR GENETIC TESTING?Patients who are diagnosed with diabetes at a young age of less than 45 years with no features of insulin resistance (central obesity, acanthosis nigricans or dyslipidaemia) should be considered for genetic testing. Patients who are also markedly sensitive to sulphonylureas with recurrent hypoglycaemias should be considered for MODY 1 or 3 variant.

Looking back at the case of the 24-year-old girl,

she had multiple features, which were highly suggestive of MODY, such as young age of diagnosis, autosomal dominant penetrance, negative antibodies and no features of insulin resistance. She was also markedly sensitive to oral hypoglycaemic agent. In terms of her OGTT, her fasting glucose of 5.8 mmol/L makes it unlikely to be MODY 2 due to higher set point and the increase of blood glucose of greater than 5 mmol/L at two hours suggests MODY 3.

Monogenic diabetes is increasingly more common now and should be kept at the back of our minds when diagnosing young adults with diabetes, as it has genetic implications and impacts on management options.

The seminar fee and place for the one full-day programme shall be notified in our next issue in October 2013.

You can register your interest to participate by sending us your details. The seminar secretariat shall contact you once the date and place is finalised.

Name: ................................................

.........................................................

Email: ................................................

Telephone: ..........................................

INFOMED (MALAYSIA) SDN BHDUnit A-3-3 (Block A, Arena Mentari), No. 1, Jalan PJS 8/15, Dataran Mentari, 46150 Petaling Jaya, Selangor. Tel/Fax: +603-5611 3114 Email: seminar@infomed.com.my

INFOMED OrthoNeuroSpine Annual Spine Symposium 2014

Proposed Date: 23 March 2014

Enhance regional collaboration through case presentations, didactic multidisciplinary lectures, and hands-on learning from experts in spine and pain care.

Target AudienceAcupuncturists, chiropractors, dieticians, neurosurgeons, nurses, occupational therapists, orthopaedic surgeons, physical therapists, pharmacists, physicians, psychologists and other healthcare professionals who would like to build or update their knowledge in the care of patients with spinal disease.

Topics Flag Identification in Spine Disorders Chronic Low-Back Pain Understanding Spinal Pain Biologics in Spine Surgery Cervical Myelopathy Surgery VS Intense Rehabilitation for Spinal Degenerative Conditions

Cost-Effect Analysis in the Treatment of Low-Back Pain

Pain Generator in Low-Back Pain Patients Imaging of the Painful Degenerative Disc Disease Patient

Overview The OrthoNeuroSpine Spine Symposium is an annual one-day event emphasising up-to-date trends in diagnostic and therapeutic strategies for patients suffering from spinal disorders. This course is designed to be interactive with talks given by leaders in the spine community. All lectures are followed by case discussions aimed at highlighting key issues in breakthrough treatments.

ObjectivesUpon completion of this symposium, participants should be able to: Evaluate and treat spinal pain in a cost effective and reliable manner.

Identify appropriate indications for surgery of the painful, degenerated spine.

Discuss pain management strategies for patients with spine-related pain.

Identify spinal instability related to spinal tumours and formulate surgical treatment plans to deal with neurological deficits and pain in spine oncology patients based on recently published guidelines.

Describe the importance of outcomes data for spine and pain care.

Explore how to integrate a variety of evidence-based assessment and treatment methods.

The Ageing Spine Injections for Spinal Pain Bracing for Spinal Disorders Neuropathic & Nociceptive Pain Management Vertebral Insufficency Fractures Physical Therapy- Management of Patients with Back and Leg Pain of Spinal Origin

Scoliosis 101: Diagnosis & Management

INFOMED 2nd Annual Orthopaedic Update Seminar 2014

TOPICS FOR THE SEMINAR

INFOMED (MALAYSIA) SDN BHDUnit A-3-3 (Block A, Arena Mentari), No. 1, Jalan PJS 8/15, Dataran Mentari, 46150 Petaling Jaya, Selangor. Tel/Fax: +603-5611 3114 Email: seminar@infomed.com.my

Annual Infusion Treatments for Osteoporosis

Autologous Adipose Derived Stem Cells

What is the Role of Glucosamine in Osteoarthritis?

Transdermal Pain Control

Synergism in Pain Management

Local Pain Management

Bracing for Osteoarthritis

Neuromuscular and Bone Health

Treatment of Neuropathic Conditions

Shockwave for Musculoskeletal Conditions

Foot Orthotics

DVT Prophylaxis in Orthopaedics

Antiosteoporotic and Osteoarthritic Agents

Viscosupplementation for Osteoarthritis

Disease Modification for Rheumatoid Conditions

What’s New in the Management of Osteoporosis?

The 2nd Annual Orthopaedic Symposium 2014 is an annual one-day event emphasising up-to-date trends in diagnostic and therapeutic strategies for patients suffering from musculoskeletal disorders. This course is designed to be interactive with talks given by leaders in the musculoskeletal, orthopaedic and pain management community.

All lectures are followed by case discussions aimed at highlighting key issues in breakthrough treatments.

The seminar fee, date and place for the one full0day programme shall be notified in our next issue in October 2013. You can register your interest to participate by sending us your details. The seminar secretariat shall contact you once the date and place is finalised.

Name:

Email: Telephone:

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HEALTHCARE AND CUSTOMSCustoms duties and taxes on healthcare products. BY TIRUCHELVAM VALLIPURAM

JULY 2013 / 55

It is advisable to any person who is currently manufacturing or intents to manufacture healthcare products to visit the nearest o!ce of Royal Malaysian Customs to get further information on the requirements of the custom laws and the facilities available to them. "is short visit might be able to save you a lot of unnecessary expenditure and heartache in the future, and also keep you on the right side of the law.

I n the previous issue, we looked at Chapter 30 of The Malaysian Customs Duties Order, which covered pharmaceutical products. However there are other chapters that deal with chemicals that

are used in the manufacturing of drugs. This will be of interest to pharmaceutical manufacturing concerns. These chapters include Chapter 29 for organic chemicals and Chapter 28 for inorganic chemicals. Some of these chemicals attract import duty and sales tax. Later in this article, I will give some insight as to the procedures by which one can claim customs’ tax exemption on these raw materials.

One particular item of interest to the healthcare industry is the empty capsules that are often used in the manufacture of pills. There is a difference between capsules that are vegetable based and capsules that non-vegetable based. The vegetable-based capsules falls under a code that attracts import duty of 5 per cent and sales tax of 10 per cent whereas non-vegetable based capsules do not attract any customs duty or tax.

As persons involved in the healthcare industry, you may want to know that medical, surgical, dental, or veterinary furniture (e.g. hospital beds and dentist chairs) do not attract any tax or duties. Instruments and appliances used in medical, surgical, dental or veterinary also do not attract any duties or taxes. The same also applies to mechano-therapy appliances, breathing appliances, orthopedic, and appliances apparatus based on the use of X-rays or of alpha, beta or gamma radiations. Optical instruments and corrective lens are also not taxable.

Some may question why not all items related to healthcare is exempted from taxes. Well, HS codes sometimes group together the products that are used in healthcare and products that are used in other fields. Some products can be used in both the healthcare and non-healthcare industries. Since they are grouped together, it becomes difficult to isolate the items used in healthcare.

When a person imports any items and is not satisfied with the decision of the customs’ officer with regards to the classification of the item, he or she can appeal within a stipulated time for a reclassification. In fact, a person who intents to import any product can apply to the Royal Malaysian Customs Department for a advance ruling. This way, the person can be sure of the HS code and therefore the duties and taxes involved even before the item is imported. This would be useful for pricing purposes.

It must be noted that any manufacturer of healthcare products that are subject to sales tax must apply and obtain a Sales Tax license. This must be done before commencing the manufacturing operations. With a Sales Tax license, the manufacturer will be eligible to claim sales tax exemption on all sales taxable raw materials (including packing materials) used in the manufacture of the finished product. However, the manufacturer

must collect sales tax from their customers and remit the taxes collected to the Royal Malaysian Customs Department within a stipulated time. As a person licensed under the Sales Tax Act, he is subject to the sales tax laws and regulations. It must be mentioned here that it is an offence for a person to manufacture sales taxable products without a valid Sales Tax license. The relevant laws and regulations for this are the Sales Tax Act 1972 and the Sales Tax Regulations 1972.

Any manufacturer of pharmaceutical products falling under Chapter 30 (which is not subject to sales tax) can also buy taxable raw materials (including packing material) free of sales tax. This is on condition the raw materials are used in the manufacture of the pharmaceutical product. The manufacturer needs to visit the nearest office of the Royal Malaysian Customs Department and apply for exemption using the relevant forms called CJP2. With this approval, he can buy locally or import the raw materials free of sales tax.

If the manufacturer exports his products, he is also eligible to claim drawback on the import duty and sales tax paid on the imported raw material used (if any). This is also subject to some conditions including that he must state his intention to claim drawback at the time of export.

These exemptions are useful although many raw materials are not taxable. However these exemptions can be used for purchasing taxable items like carton boxes, plastic packaging materials, and similar items.

It is advisable to any person who is currently manufacturing or intents to manufacture healthcare products to visit the nearest office of Royal Malaysian Customs to get further information on the requirements of the custom laws and the facilities available to them. This short visit might be able to save you a lot of unnecessary expenditure and heartache in the future, and also keep you on the right side of the law.

This is the end of the series of articles touching on the customs taxation with regards to the healthcare industry. In the next issue, we will look at GST (Goods and Service Tax) and try to understand the taxation system with special regards to how it possibly can affect the healthcare industry.

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COMMON-SENSEEATING ADVICE

WHOLE GRAIN EATERS DO EVERYTHING ELSE RIGHTThose who eat more whole grain foods each day also eat more fruits and vegetables, exercise more, and don’t smoke. Is it whole grain foods or is it the healthy lifestyle or the combination of both that makes this group more disease free? We don’t know but we do know that it works.

HEALTHY LIFESTYLE LOWERS BLOOD PRESSUREHigh blood pressure contributes annually to over seven million deaths worldwide. To avoid from becoming a statistics, here’s what you should do.

Drink less than two ounces of alcohol a week. Exercise at least three times a week. Eat vegetables daily. Maintain a normal weight.

By following these four healthy habits, you can reduce your high blood pressure by almost 70 per cent!

MAKE FAMILY MEALS BETTEROnly 23 per cent of all family meals include a vegetable. If vegetables are a hard sell, try raw carrots, celery, or cherry tomatoes. Or swap in fruit like watermelon, apple slices, or fresh grapes.

POPEYE WAS RIGHTCooked spinach has more iron than raw spinach. Raw spinach contains oxalic acid, which prevents some of the minerals in spinach from being completely absorbed by the body. Cooking prevents this, making more iron available. One cup of raw spinach has 0.8 milligrams of iron; one cup cooked has 6.5 milligrams.

Jo-Ann Heslin, MA, RD, CDN and food and nutrition columnist, shares her tips for healthy eating.

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ADVERTORIAL

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cosmetic issues. In addition to hair thinning and hair loss, these tricky little parasites can cause skin ageing, large pores, redness, facial discolouration, acne, wrinkles, itching and general discomfort.

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Most individuals with thin-looking hair have hair mites living in their hair and on their skin. Many people don’t like the idea of parasites living on their body, and some get really bent out of shape just thinking about it. The adult Demodex mites usually are 1/2 to 2/3 of human hair, around 0.3mm in length. They have semi-transparent elongated bodies with eight short segmented legs.

A Demodex hair mite feeds on oils, hormones and fluids around the follicle.

These itty-bitty bugs can initiate a variety of problems. When something causes the mites to reproduce at a higher rate, they can break out of the hair follicle. In some cases, the interaction with Demodex mites causes skin to actually slough off.

While mites may cause certain problems, it is also possible specific skin conditions become a breeding ground for Demodex mites. If you have high levels of hormones, you’re going to have high levels of Demodex mite reproduction because these invertebrate insects obtain their steroids from the host.

Demodex hair mites are invisible to the eye unless aided by a microscope. Three to five days are required for egg laying and hatching, followed by one week for the larvae to develop into adults. Their total life span is around one to three months. They are transferred from host to host by contact, particularly in hair and face.

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Demodex mitesnew breakthrough therapy with the unique Demodex hair mites technology to eliminate parasites and germs, therefore reducing infections on the scalp and continue with a maintenance treatment to stop hair mites from growing. Demodex hair mites are not easy to eliminate but Ungex uses a combination of products to help your scalp, hair and skin return to full health.

The Ungex products will determine if there are Demodex hair mites present. The Ungex system is helping customers around the world to get rid of Demodex hair mites once and for all. This treatment is safe for all hair types.

Ungex hair mites treatment is an all-new concept targeted at eliminating the Demodex hair mites and provides support for hair strands, roots and scalp. Respected readers or clients can find more information about hair mites and the treatment via website at www.ungex.com or the Facebook page at www.facebook.com/hairmites.

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PESTICIDES AND PRODUCEThe benefits of eating fruits and vegetables are well established – reducing high blood pressure, stroke, heart disease, some cancers, and digestive problems. These benefits far outweigh any very, very small risk of exposure to pesticides.

A TIP TO LOWER CHOLESTEROLOlive oil can help lower cholesterol in recipes. For each whole egg, simply substitute one egg white and one teaspoon olive oil. You eliminate all the cholesterol in the egg and add heart healthy monounsaturated fat from the olive oil.

MILK IS A NUTRITION BARGAIN FOR KIDS For children ages 2 to 18, milk is the number one food source for nine essential nutrients – calcium, potassium, phosphorus, protein, and vitamins A, D, B12, riboflavin and niacin.

BREAKFAST MAKES KIDS SMARTEREating breakfast after a full night of fasting not only feeds a child’s belly but it feeds their brain too, promoting brain development and learning. Interacting

with parents during breakfast promotes vocabulary and may increase IQ.

CHOOSE FATS WISELYHere’s our guide. Follow this and you’ll be on your way to good health.

Saturated Fats: Eat less of this type of fat. Keep portions small.

Polyunsaturated Fats: Use these fats to replace some saturated fat.

Monounsaturated Fats: Eat more of these fats. Trans Fats: Eat as little as possible of these fats.

SORT OUT SUGAR ON LABELSOn the nutrition facts panel, you will see a value for Total Carbohydrate and right beneath it a value for Sugars. Sugar is part of the Total Carbohydrate value. If a food has 30 grams of carb and 28 grams of sugar, it is high in sugar.

CHEW ON THISEating fibre-rich foods is smarter than popping fibre supplements. Fibre-rich foods are also rich in antioxidants, vitamins and minerals. Supplements are not.

A REASON NEVER TO BINGEBinge drinking causes insulin resistance, which puts you at greater risk for type 2 diabetes and makes blood sugar harder to control. Binge drinking equals five or more drinks for men or four or more drinks for women within two hours.

UNHEALTHY EATING MAKES A BAD MOOD WORSEIn a study of women without eating disorders, researchers found that the women’s moods got darker after they made unhealthy eating choices. This is an important finding since most of the information we have on eating and mood is based on adults with eating disorders. This study focused on normal women leading normal lives who did not have negative feelings about food before they ate.

Jo-Ann Heslin, MA, RD, CDN, is a registered dietitian and the author of the nutrition counter series for Pocket Books with sales of more than 8.5 million books.

Reprinted with permission from HealthNewsDigest.com

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the adjacent vertebra and a decrease in the mobility of the cervical spine, hence the development of cervical disc replacement prosthesis.

CERVICAL DISC PROLAPSEThe goal of the development of cervical prosthesis is to restore the physiological height of the disc, cervical lordosis and the physiological mobility. The requirement of this cervical prothesis is that the implant is of reliable and durable design, is simple and safe in the process of implantation that result in minimal wear and attrition preferably without the need to replace a new one in one’s lifetime to maintain the same mobility.

Several made of cervical disc prothesis has been used since 2002. These include the Bryan and Prestige by Medtronic, Prodisc C by Synthes and PCM by Cervitech, Mobi-C by LDR Medical, and Baguera by Spinart. The made, mobility, advantages and disadvantages of each of these prosthesis are discussed.

Recent results indicated that patients who underwent proper cervical replacement adhering to the strict indications of the technique showed excellent results with satisfaction in 97 per cent of patients, cervical pain relief for more than 80 per cent, radicular pain relief for 75 per cent, and the ease of walking for 80 per cent. More than 80 per cent were working at one year compared to 38 per cent reoperatively. Analgesic usage decreased from 80 per cent to 23 per cent. Radiological study did not show any subluxation, device migration or subsidence. In one series, out of 218 cases only four cases had heterotopic calcifications and one fusion at tw years. The range of movement was more than five per cent in 84 per cent of the cases.

CERVICAL DISC REPLACEMENTThe advantages versus disadvantages of cervical disc replacement and cervical fusion should be discussed and compared by the doctor with the patient. The doctor managing the case should carefully consider the wish of the patient versus other factors including the surgeon’s personal wish and skill, and the social and financial condition of the patient.

A recent hybrid solution concept has been developed combining disc replacement arthoplasty and cervical fusion with cage in many cases, especially in considering the fact that many a time cervical spondylosis and disc prolapse involve multiple levels.

T he ageing process results in a decrease in the water content of the nucleous pulposus of the cervical disc, which causes a reduced overall deformation, smaller elastic zone,

and lower threshold for failure. It causes an even distribution of the forces to the end plate and may lead to the narrowing of the intervertebral forament, facet loading, and even compression fracture of the cervical spine. The effect of cervical spine with degeneration is that of overall decreased in cervical mobility, usually only sparing the rotation on neck flexion. The resulting pathology includes disc prolapse, cervical spondylosis, spinal stenosis, posterior longitudinal calcification, subluxation, and compression fractures.

Cervical disc prolapse and spondylosis without severe stenosis is usually present with neck pain, radiculopathy, and myelopathy. The classical surgical treatment includes discetomy with or without fusion using bone graft, plating or cage,and sometimes foraminotomy. Usually, discetomy and fusion result in good relief in the symptoms and allow stability. The main concerns are that of accelerated degeneration on

CERVICAL DISC REPLACEMENT, A STEP BEYOND CERVICAL FUSIONDr. Chee-Pin CHEE, MD, FRCS (Ed), FRCS (Glasg), FAMM Senior Consultant Neurosurgeon.

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1. Cervical Disc Prolapse. C4/5 and C5/6 cervical disc prolapse with spinal cord changes in MRI.

2. Cervical Disc Replacement Intraoperative picture showing arthoplasty implant Mobi-C in place.

3. Extension six months after arthroplasty.

4. Flexion six months after arthroplast.

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O besity, heart disease, and high blood pressure (hypertension) are all related but understanding the molecular pathways that underlie cause and effect is complicated.

A new University of Iowa (UI) study identifies a protein within certain brain cells as a communications hub for controlling blood pressure, and suggests that abnormal activation of this protein may be a mechanism that links cardiovascular disease and obesity to elevated blood pressure.

“Cardiovascular diseases are the leading cause of death worldwide, and hypertension is a major cardiovascular risk factor,” says Kamal Rahmouni, UI associate professor of pharmacology and internal medicine, and senior study author. “Our study identifies the protein called mTORC1 in the hypothalamus as a key player in the control of blood pressure. Targeting mTORC1 pathways may, therefore, be a promising strategy for the management of cardiovascular risk factors.”

The hypothalamus is a small region of the brain that is responsible for maintaining normal function for numerous bodily processes, including blood pressure, body temperature, and glucose levels. Signaling of mTORC1 protein in the hypothalamus has previously been shown to affect food intake and body weight.

The new study, which was published 2nd April in the journal Cell Metabolism, shows that the mTORC1 protein is activated by small molecules and hormones that are associated with obesity and cardiovascular disease, and this activation leads to dramatic increases in blood pressure.

MOLECULAR HUB LINKS OBESITY AND HEART DISEASE TO HIGH BLOOD PRESSURE

Leucine is an amino acid that we get from food, which is known to activate mTORC1. The UI researchers showed that activating mTORC1 in rat brains with leucine increased activity in the nerves that connect the brain to the kidney, an important organ in blood pressure control. The increased nerve activity was accompanied by a rise in blood pressure. Conversely, blocking this mTORC1 activation significantly blunted leucine’s blood pressure-raising effect.

This finding may have direct clinical relevance as elevated levels of leucine have been correlated with an increased risk of high blood pressure in patients with cardiovascular disease. “Our new study suggests a mechanism by which leucine in the bloodstream might increase blood pressure,” Rahmouni says.

Previous work has also suggested that mTORC1 is a signaling hub for leptin, a hormone produced by fat cells, which has been implicated in obesity-related hypertension.

Rahmouni and his colleagues showed that leptin activates mTORC1 in a specific part of the hypothalamus causing increased nerve activity and a rise in blood pressure. These effects are blocked by inhibiting activation of mTORC1.

“Our study shows that when this protein is either activated or inhibited in a very specific manner, it can cause dramatic changes in blood pressure,” Rahmouni says. “Given the importance of this protein for the control of blood pressure, any abnormality in its activity might explain the hypertension associated with certain conditions like obesity and cardiovascular disease.”

Rahmouni and his team hope that uncovering the details of the pathways linking mTORC1 activation and high blood pressure might lead to better treatments for high blood pressure in patients with cardiovascular disease and obesity.

The research was funded by the National Institutes of Health (HL084207 and HL014388), the American Diabetes Association, and the Fraternal Order of Eagles Diabetes Research Center at the UI. In addition to Rahmouni, the UI team included Shannon Harlan, Deng-Fu Guo, Donald Morgan, and Caroline Fernandes-Santos.

Source: University of Iowa Health Care

Targeting pathway may lead to better hypertension treatments for at-risk patients. BY JENNIFER BROWN

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Details on the surgery technique. By Dr. Sevellaraja Supermaniam, MBBS (Mal) FRCOG (UK) FICS (USA) Master of Reproductive Medicine (Sydney), Consultant Obstetrician and Gynaecologist, and Subspecialist in Reproductive Medicine (NSR) Mahkota Medical Centre, Melaka, Malaysia.

SINGLE INCISION LAPAROSCOPIC SURGERY IN GYNAECOLOGY

WHAT IS THE SINGLE INCISION LAPAROSCOPIC SURGERY?Traditional laparoscopy requires three to four incisions ranging from 5mm to 10mm to perform the surgery. Single incision laparoscopic surgery is performed using a single incision of 20 to 25mm in the umbilicus to perform the surgery.

HOW IS IT PERFORMED? There are several ways of performing the single incision laparoscopic surgery. One method is to use commercially available devices such as the SILS port, Gel Port and Triport. In this technique, a single incision measuring 2cm to 2.5cm is made in the umbilicus. The incision is extended into the abdominal cavity

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surgery also benefit single incision laparoscopic surgery. This includes:

Less postoperative pain. Quicker return of bowel function. Quicker return to solid food. Quicker return to daily activities. Reduced chance of scar formation in the abdomen. Reduced infection rate. Reduced bleeding during surgery. Shorter hospital stay. Video magnification offers the surgeon a better view of diseased organs and its surrounding vessels.

The added benefit of the single incision laparoscopic surgery is that there will be only one scar and it is hidden in the umbilicus. Due to a single incision, the postoperative pain is also believed to be lesser than the traditional laparoscopic surgery.

WHAT ARE THE DISADVANTAGES?It is technically more demanding for the surgeon to perform this surgery. There is crowding of instruments in the umbilicus, and there will be limitations in the movement of instruments (triangulation).

WHO ARE CONSIDERED SUITABLE CANDIDATES FOR THE SINGLE INCISION LAPAROSCOPIC SURGERY? Single incision laparoscopic surgery in gynaecology is usually performed for uncomplicated cases such as:

Diagnostic laparoscopy and dye test. Laparoscopic tubal ligation. Laparoscopic salpingoophrectomy for ovarian cysts. Laparoscopic cystectomy for ovarian cysts. Laparoscopic salpingectomy for ectopic pregnancy. Total laparoscopic hysterectomy. Laparoscopic myomectomy.

by cutting the rectus sheath and the peritoneum, and the device is then fixed in place. Carbon dioxide insufflation is done. Trocars measuring 5mm to 10mm is placed into the port to introduce a laparoscope and instruments to perform the surgery.

The second method is performed by not using any special device but using only trocars that are generally used during traditional laparoscopic surgery. After making the skin incision measuring 2.5cm, the skin is detached from the rectus sheath and a space with a distance of about 1.5cm is created all around the incision to release the skin from the rectus sheath. An instrument called a Verres needle is used to pass carbon dioxide into the abdominal cavity. The aim is to separate the abdominal wall from the abdominal organs. A trocar with a rubber band attached to it is inserted into the abdomen in middle of the incision. A laparoscope attached to a camera is passed into the abdomen, and video images captured by the video camera are displayed on a video monitor. A powerful light source is channeled into the abdominal cavity for illumination purpose. Another two 5mm trocars are placed lateral to the first trocar on either side to allow passage of instruments such as laparoscopic scissors and graspers to perform the surgery.

At the end of the surgery, all the instruments are removed, and the carbon dioxide is released. The umbilicus is then reconstructed.

WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF THESE TWO DIFFERENT TECHNIQUES? The advantage of using commercially available devices is that devices are designed to fit into the abdominal incision tightly so as to prevent leakage of carbon dioxide. It is also easy to change trocars from 5mm to 10mm trocars during the surgery. However, these devices are expensive and not reusable. The distances between the trocars are also small, making surgery especially suturing difficult.

The advantage of using just the trocars is that this technique is cheaper because no extra device is necessary. The trocars can also be placed quite far apart, so there is more space, making dissection and suturing easier. However, the disadvantage is that, if the incisions made in the rectus sheathe is large, leakage of carbon dioxide may cause surgery to be difficult. It is also more difficult to change trocars that are already placed in the abdomen.

WHAT ABOUT THE ADVANTAGES OF SINGLE INCISION LAPAROSCOPIC SURGERY? The many advantages of traditional laparoscopic

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Workshop Series ObjectiveAs a medical practitioner in Malaysia, it is the responsibility of each individual to understand and adhere to the tax regulations. Since there is a lack of awareness of the recent tax developments, we fail to understand the basic requirements of tax compliance and eventually end up paying penalties.

In this workshop series, we will address the fundamental issues and latest guidelines set up by the Malaysian tax authority. This will ensure that with efficient tax planning, taxpayer can optimise the potential tax savings.

Who Should Attend?The workshop is specifically designed for medical practitioners having their own practice or planning to have one.

Proposed Tax Workshop Series Understanding tax audit requirements set by

the Malaysian tax authority. Upholding the responsibility as a taxpayer in

the medical profession. The implication of withholding tax on medical

industry. Are medical practitioners entitled to

entertainment claims? On GST – getting ready

TAX WORKSHOP SERIES FOR MEDICAL PRACTITIONERS

TIME FOR A TAX HEALTH

CHECK!

SPEAKER PROFILESoh Lian Seng, Executive Director KPMG

Soh has more than 19 years of experience in tax compliance and advisory particularly in tax audits and investigations. He has represented companies from various industries, which include public-listed companies and multinational corporations in tax audit and in investigation assignments. He has been involved in assisting companies in complying with its tax obligations as well as proactively identifying tax related opportunities with the view to creating value and bringing competitive advantage to them.

He also conducts workshops and seminars on corporate tax and tax risk management. Soh is regularly invited by professional bodies to speak on tax risk management as well as tax audits and investigations.

He is a member of CTIM, MAICSA, the Institute of Internal Auditors Malaysia and is a licensed tax agent. He is currently a member of the CTIM’s Tax Audit and Investigation Working Group.

KPMG in Malaysia provides audit, tax and advisory services. Established in 1928, it is not only one of the oldest firms in the country but also the oldest KPMG firm in the Asia Pacific region. With over 1,800 staff positioned in 10 offices nationwide, we work closely with our clients to mitigate risks and grasp opportunities. Our business in Malaysia has established industry groups which enable the delivery of targeted, industry-specific experience and methodologies.

This focus on industry and country-specific knowledge helps us deliver exceptional people with an intimate knowledge of our clients’ specific business issues, as well as an overriding commitment towards service excellence. A single management structure for all our Malaysia offices allows efficient and rapid allocation of experienced professionals wherever the client is located in the country.

InfoMed magazine brings a comprehensive up-to-date coverage of articles on innovative medical therapies, disease awareness and discoveries, and management topics to give the medical organisations and professionals a broad overview on improving their services to their patients. It is published with the objective to assist and participate in the development of the Malaysian healthcare industry and healthcare delivery system. There is good mix of international articles as well as local ones. The theme of the magazine is “Embracing Global Healthcare Challenges”.

The quarterly magazine is published in both print and online and distributed free to the medical community in Malaysia and subscribers globally.

Topic for Workshop Series 1:Upholding the responsibility as a taxpayer in the medical profession.

Participants shall benefit from: Tax expert’s review on the latest changes

in the local tax regimes and discuss service enhancement ideas.

Comprehensive coverage of all taxation issues. In-depth understanding of Malaysian tax laws/

rules. Case studies and hands-on experience. Gain expertise on maximising your tax efficiency

and minimise tax administration costs.

Fee and PaymentParticipation fee is RM450 per person. Fee is inclusive of seminar materials, breakfast, morning tea break, and lunch. Please fill up the registration form with payment to confirm your seat before 25 August 2013.

WORKSHOP DETAILS Date: Sunday, 8 September 2013Time: 9am to 12:30pmPlace: Seri Pacific Hotel, Kuala Lumpur

Jointly Organised by and

JULY 2013 / 65

InfoMed (Malaysia) Sdn Bhd Unit A-3-3 (Block A, Arena Mentari), No. 1, Jalan PJS 8/15, Dataran Mentari, 46150 Petaling Jaya, Selangor, Malaysia.

Tel/Fax: +603-56113114 Email: seminar@infomed.com.my; infomedmagazine@gmail.com Website: www.infomed.com.my

Tax Workshop Series for Medical Practitioners

8 September 2013 Seri Pacific Hotel, Kuala Lumpur

To participate in the above workshop, please fill out the form** below and return it to InfoMed (Malaysia) Sdn Bhd

Participant’s Name: ……………………………………………………………………………………………………………

Employer: ……………………………………………………………………………………………………………

Address: ……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

Telephone: ………………………………………………… Fax:…………………………………………………

E-mail: ……………………………………………………………………………………………………………

**For online registration, please visit www.infomed.com.my

I hereby enclose the payment of RM450 (Four Hundred and Fifty Ringgit only) being the full payment for my participation in the workshop.

Cheque No ……………………………………… Bank Draft No …………………………………………… Payment should be made to: Infomed (Malaysia) Sdn Bhd

Signature: …………………………………………………… Date: ………………………………………………………

Name: ……………………………………………………………………………..……………………………………………

PARTICIPANTS REGISTRATION FORM

FOR OFFICIAL USE ONLY

We accept the above application to participate in the 2013 Infomed Tax Workshop for Medical Practitioners – Series 1

Date: Authorized Signature:

Name: Date Application Received:

DEADLINE FOR SUBMISSION: 25 AUGUST 2013

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F rom back in the day, and persisting to the present, is the notion that care of our health is necessarily something to be contracted out to experts. Moreover, it was quite common,

at least through the mid-1960s, for patients to have almost no understanding of their conditions, simply following their doctor’s orders without question. While it has always been a good (and natural) idea to take charge of your own health, 2014 and the advent of full implementation of the Patient Protection and Affordable Care Act (Obamacare) will make it essential.

TAKING CHARGE OF YOUR OWN HEALTH

An unintended consequence of

Obamacare? Michael D. Shaw, Executive Vice

President of Interscan Corporation, writes.

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Reprinted with permission from healthnewsdigest.com

As will become painfully clear in less than nine months, our relatively benign and simple system of HMOs, PPOs, Medicare, and Medicaid – with all of the flaws – will soon be our “Good Old Days.”

For starters, insurance premiums are expected to rise – most likely by quite a bit. Twenty to 100 per cent increase figures are being mentioned by many authorities. Last December at Aetna’s investor conference, CEO Mark Bertolini spoke of premium rate shock. “We’ve done all the math, we’ve shared it with all the regulators, we’ve shared it with all the people in Washington that need to see it, and I think it’s a big concern.”

The Society of Actuaries released a report recently entitled “Cost of the Future Newly Insured under the Affordable Care Act,” and there were some interesting findings. Non-group enrollment was expected to increase under ACA for a number of reasons, not the least of which is that some employers will stop offering the coverage. Indeed, the SOA predicts that three years in (by 2017), the individual non-group market will grow 115 per cent, from 11.9 million to 25.6 million lives; 80 per cent of that enrollment will be in the Exchanges.

As such, the percentage of uninsured nationally will decrease from 16.6 to around 6.7 per cent, compared to pre-ACA projections. The bad news is that the non-group cost per member per month will increase 32 per cent under ACA, compared to pre-ACA projections. Factors in play here include the addition of higher-risk patients, and thus higher morbidity rates, along with a mandated increase in certain benefits.

Likewise, this influx of new patients, set against a backdrop of the current – and ever-increasing – shortage of physicians might make it difficult for patients to take advantage of their newfound health care benefits in a timely manner. De facto rationing, although it will probably never be called that, could become the order of the day.

In the wake of rapidly increasing costs and decreasing availability, we could finally see a paradigm shift from the current disease care model to a true healthcare model. Superficially, a disease care emphasis would seem to be a direct result of the allopathic philosophy – but such analysis ignores the real 500-pound gorilla. The reimbursement scheme itself is primarily at fault. Simply put, there is very little money in health, and lots of it in disease.

Note that the longstanding focus on disease and acute care has influenced the very philosophy and ethics of the medical profession. One example of this is the controversy surrounding the so-called G-Shot, an injection of hyaluronic acid into the G-Spot, to produce enhanced sensation.

As an elective procedure, it would not be covered under insurance, but then provides a rare “cash on the barrelhead” opportunity for the physician. Since the shot is not really treating a disease, it is frowned upon

by some doctors, who also point to the risks inherent in such an injection. In addition, not all of the procedures are successful, and there are those who doubt that the G-Spot even exists. Never mind that the effects are only temporary, and another shot is required a few months later.

However, a great deal of accepted mainstream medicine is far from proven scientifically, and may not be terribly effective, either. Undeniably, there is also an undercurrent against the patients who are trying to improve themselves – sexually, no less. Or, does self-improvement only include weight loss and smoking cessation?

One way people are taking charge of their own health is through relevant smartphone and tablet apps. But, in that overcrowded space, how can you best find them? Bala Velmurugan, Founder and CEO of Airomo Inc., recently told me about Appcurl, which lets you “Discover the apps that matter,” as they put it.

In the wake of rapidly increasing costs and decreasing availability, we could !nally see a paradigm shi" from the current disease care model to a true health care model.

The challenge, for both patients and practitioners, is that there are tens of thousands of applications, for which there is not enough manpower to distinguish between those that are popular (and effective) and those that are not. Appcurl solves that problem by providing users with the equivalent of a search engine for iOS and Android devices.

Appcurl brings the power of search – and news about mobile trends – to a worldwide audience. This technology levels the playing field among developers, allowing otherwise obscure (but powerful) applications to find a new group of users, within the medical field and elsewhere.

Sounds like a fine tool to help you take charge of your own health.

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I nfoMed provides current updates and issues on healthcare for the medical fraternity. It is a forum for healthcare providers, stakeholders, organisations, product manufacturers and

distributors to reach out and share useful information on the various facets of healthcare.

We are interested in original articles on the dynamic healthcare industry, both clinical and non-clinical issues that reflect your expertise and experience. We want to hear from you! Why not contribute to the healthcare community to further enhance its development with the objective of bringing benefits to the consumers of healthcare at large? Send us technical or clinical articles, case studies, product write-ups and personal experiences in the delivery of healthcare. Or if you have an event or product launch, share it with InfoMed!

Articles should not exceed 1,500 words and must be sent to InfoMed in soft copy MS Word format. We welcome images to go with the article as well! Images must be of high resolution files and in JPG format.

The final decision regarding the selection and publication of the articles rests solely with Infomed (Malaysia) Sdn Bhd. Authors whose articles are published will automatically receive a free subscription of InfoMed.

Send your contribution together with the Contributor’s Checklist and Contributor’s Declaration Forms, available on the InfoMed website at www.infomed.com.my.

We look forward to hearing from you!

Have something you would like to share? Contribute to InfoMed and let your voice be heard!

Write For

MOHAN MANTHIRYPublisher/Managing Director

InfoMed (Malaysia) Sdn. Bhd.

JULY 2012 / 69

InfoMed takes you straight to the healthcare professionals in Malaysia and globally through a network of print and

electronic media that includes: 10,000 complimentary copies of print copies delivered to GP clinics, private hospitals, public hospitals, healthcare

organisations and institutions in Malaysia. Online e-magazine made available to healthcare

professionals by free subscription through our website that reaches out to the global healthcare community.

For advertising enquiries, please contact: INFOMED (MALAYSIA) SDN BHD (949750-W)

Unit A-3-3 (Block A)No. 1, Jalan PJS 8/15, Dataran Mentari46150 Petaling Jaya, Selangor, Malaysia

Tel/Fax: +603-5611 3114 Mobile: +6019-3353600

e-mail: enquiry@infomed.com.my Website: www.infomed.com.my

Send your request for advertising using the Advertisement Booking Form, available on the InfoMed website.

INFOMED!ADVERTISE WITH

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W hen Angelina Jolie told the world about her double mastectomy, she expressed a wish for all women with a family history of breast cancer: “It is my hope

that they, too, will be able to get gene tested, and that if they have a high risk they, too, will know that they have strong options.”

You may think that such a test is something only movie stars can afford, but almost everyone can afford one, according to Dr. Stephen Shrewsbury, author of Defy Your DNA: How the New Gene Patch Personalized Medicines Will Help You Overcome Your Greatest Health Challenges (www.defyyourdnabook.com).

Shrewsbury said that 23andME will perform a gene test for USD$99. “They send you a simple spit

HOW TO FIND OUT YOUR

GENETIC RISK FACTORS LIKE

ANGELINA JOLIE DID

Genetic testing is surprisingly easy and affordable,

according to author of new gene patch medicine book.

Reprinted with permission from healthnewsdigest.com

In his book, Shrewsbury says that there are already medicines being developed so that surgery like mastectomies will be replaced by pills or nasal sprays. “!ese personalised medicines will eventually override the genetic defects that cause breast cancer. When they’re "nally approved, women won’t have to have invasive surgery in order to remain healthy.”

test that will test for more than 200 traits, including breast cancer,” he said. The Mountain View, California company’s spit tests let you know your risk for a wide variety of diseases, from breast and prostate cancer to heart disease and Alzheimer’s. Companies like Genetics Testing Laboratory of Las Cruces, New Mexico have a breast cancer test for USD$285 that is administered by your physician.

“In some cases,” said Shrewsbury, “these tests can put your mind at ease. In others, especially in terms of Alzheimer’s, diabetes and heart disease, it will encourage you to be more diligent in making changes to lower your risks.”

Jolie’s mother died at 56 after a 10-year long battle with cancer. Jolie had her mastectomy done in part for her children’s peace of mind and as a preventive measure. Her children may never have to have surgery if they inherit the gene.

In his book, Shrewsbury says that there are already medicines being developed so that surgery like mastectomies will be replaced by pills or nasal sprays. “These personalised medicines will eventually override the genetic defects that cause breast cancer. When they’re finally approved, women won’t have to have invasive surgery in order to remain healthy,” he said.

Shrewsbury is a physician whose 33-year career has taken him from the intimate world of family practice to Chief Medical Officer at a leading biotech firm on the cutting edge of global drug development and therapeutics. Since 2009, he has served on the Oligonucleotide Safety Working Group (OSWG), an international working group devoted to the safe development of gene patch medicines.

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E xactly two weeks ago, Leonard Burke, 32, of Richmond Hills, Queens, received the gift of life from his father, Ronald, in the form of a second transplanted kidney. During a press

conference held at the North Shore University Hospital Transplant Center to showcase the Burke family’s courage and compassion, Leonard described his five-year battle with kidney disease.

It was back in 2008 that Leonard learned that his kidneys were failing due to hypertension. After undergoing two difficult years of dialysis, Leonard was shocked to learn that tests had revealed his wife, Rhonda, was, indeed, a perfect match. The pair is, as he described it, “a match made in heaven.”

The kidney transplant took place on 29 March 2010. The successful transplant was especially meaningful for the young couple because they were very eager to begin a family. With his health restored, Leonard and Rhonda became the proud parents of Isabel on 20 November 2011, just a few days before Thanksgiving. Isabel, now a healthy 18-month-old

toddler, was the centre of attention as she sat in her mother’s lap during the press event.

But the family got the shocking news a few months ago that the transplanted kidney was failing and he would need another. Ernesto Molmenti, MD, surgical director of the healthcare system’s transplant centre, performed both transplants and called Leonard’s subsequent medical journey truly unique.

“This time, it was his father, Ronald, who stepped in and after all the tests were completed, agreed to donate a kidney to his son,” Dr. Molmenti said. “We have never heard of a man receiving a kidney first from his wife, then from his father. What a testimony to the close bonds shared by this family. This father gave his son the most precious gift of all. It’s a beautiful story.”

The transplant took place on 3rd June, and after a three-day stay at North Shore University Hospital in Manhasset, Leonard and his father returned to the family home they share in Queens, just in time to celebrate a very special Father’s Day.

For his part, Ronald Burke said that his entire family is looking forward to spending Father’s Day at home celebrating their good health and fortune. “I think I did what any loving father would have done,” said the elder Burke. “To see my son so healthy, with his beautiful family, is the best gift I could ever ask for. We are a very lucky family,” he said.

NEW FATHER RECEIVED DONOR KIDNEY... FROM HIS FATHERThis is one family that really knows how to celebrate Father’s Day.

Reprinted with permission from healthnewsdigest.com

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ADVERTORIAL

M alaysia’s high quality doctors, reputable health institutions, and affordable rates compared with

the neighbouring countries and the region are attracting international medical tourists to seek treatment here. Malaysia received more than 583,000 patients from abroad last year, a tenfold increase over the last decade.

In tandem with the expansion of our healthcare industry and increasing demand of health management and support services nationwide, Seri Pacific Hotel Kuala Lumpur prides itself with services rendered with passion as an active player in medical tourism. It is cooperating with established hospitals and medical centres in providing healthcare packages.

The package of four days-three nights is from RM1,743.35, which includes accommodation in a deluxe room, daily buffet breakfast, return airport transfers, transfer to the hospital, and a halfday tour. Guests have the option to extend their stay at a special rate of RM290.00++ only per night inclusive of breakfast.

Malaysia’s healthcare industry is undergoing a transformation and revolution process. There are many developments that are taking place that will further drive our healthcare industry to the next level. The good

support from the government and the seemless support from the service providers coupled with the advancement of medicine, the facilities, good infrastructure, and reasonable costs are enabling more international patients to seek treatment in Malaysia for their healthcare needs.

Seri Pacific Hotel Kuala Lumpur is an independent five-star property that is the only hotel strategically connected to the Putra World Trade Centre in Malaysia’s capital city. With a capacity of 560 rooms, elegantly decorated suites, 14 meeting rooms including a pillarless Pacific Ballroom, the property is suitable for both business and leisure. It is the preferred venue to many national and international conferences including those related to the healthcare industry.

“Since a few years ago, Seri Pacific Hotel Kuala Lumpur has been the venue for meetings and conferences for health and medical related organisations. This includes events organised by pharmaceutical companies, wellness, health and beauty products, universities, Malaysia Medical Association, and the Ministry of Health. This has provided us with a good profile to attract more medical tourism or healthcare tourists to stay with us,” said Mr. Mohammad Halim Merican, General Manager of Seri Pacific Hotel Kuala Lumpur.

Seri Pacific Hotel Kuala LumpurComfort and convenience for your healthcare.

ABOUT SERI PACIFIC HOTEL KUALA LUMPURSeri Pacific Hotel Kuala Lumpur is a five-star property, which is wholly owned and managed by Seri Pacific Hotel Corporation Sdn Bhd and in partnership with the Great Hotels of World and ENRICH.

For more details on our meeting and conference packages, please contact our Sales Department at 03- 4049 4428 /4417/4422 (Ruby/Liz/ Fauziah).

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En Zakariya MusaDirector of Sales & MarketingEmail: zakariya@seripacific.comTel: 603-4042 5555 ext 4405 Mobile: 6019-611 3031Web: www.seripacifichotel.com Fax: 603-4041 7236/4043 8717

Ms Teh Maizila Mohd NazriMarketing Communications ExecutiveEmail: tehmaizila @seripacific.comTel: 603-4042 5555 ext. 4314 Mobile: 6012-3167353

Ms Nur Jihan HalimMarketing Communications ExecutiveEmail: nurjihan@seripacific.comTel: 603-4042 5555 ext. 4403 Mobile: 6017-3771204

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SOUTH EAST ASIA’S FIRST EXCELLENCE CENTRE FOR SLEEP DISORDERSPhilips and University Malaya Specialist Centre open South East Asia’s first excellence centre for sleep disorders – known as the ASEAN Sleep Research & Competence Centre (ASRCC) – to overcome challenges faced by the region in early diagnosis and management of sleep disorders.

R oyal Philips Electronics and University Malaya Specialist Centre (UMSC) introduce South East Asia’s first excellence centre for sleep disorders in Malaysia, the ASEAN

Sleep Research & Competence Centre (ASRCC). It is housed at UMSC and opens its door in July 2013. The ASRCC will focus on driving awareness and early diagnosis of sleep disorders through clinical research, training, and a full spectrum of sleep medicine services.

“We often forget to acknowledge the role of a good night’s sleep and its effect on our health. Research has shown that the quality and amount of sleep we have can affect our health, safety and productivity. The most common of sleep disorders, Obstructive Sleep Apnoea (OSA), is also closely linked to other diseases. For example, moderate-to-severe OSA patients have a three-fold increase in the risk of hypertension and a two-fold increase in the risk of heart failure. As such, sleep disorders are a clear concern across different fields of medicine. I believe the ASEAN Sleep Research & Competence Centre will help hospitals across the region to provide new levels of understanding and

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REFERENCE

2012, Database of drivers’ offences, Malaysia. New Straits Times. 27 Feb [Online]

2 Epidemiology of Obstructive Sleep Apnoea, 1 May 2002, American Journal of Respiratory and Critical Care Medicine

will offer corporate packages for sleep disorder screening and check-up services.

“As a global leader in healthcare, Philips constantly seeks to find meaningful solutions and partnerships to improve the health and wellbeing of people. The ASEAN Sleep Research & Competence Centre is a great example of a partnership that will improve the lives of patients with sleep disorders. As a result, we believe that this will help to relieve the healthcare costs on economies,” said Naeem Shahab

Khan, Managing Director of Philips Malaysia. “We are delighted to welcome the ASEAN Sleep

Research & Competence Centre, the first of its kind in Asia. It’s heartening to see the fruition of our efforts to promote Kuala Lumpur as a regional hub for business, innovation and talent; in this case, a centre of excellence. Our city has much to offer – plenty of business opportunities for global MNCs as demonstrated by this partnership between Philips with UMSC, a growing economy, and a pro-business government. I am confident that this centre will act as a catalyst to attract more like-minded centres and its contributions would be invaluable, offering Malaysians high-value jobs and specialised training opportunities, which is in line with our Economic Transformation Programme,” said Zainal Amanshah, Chief Executive Officer of InvestKL.

SLEEP DISORDERS IN THE REGIONSleep is the most under-diagnosed and least talked pillar of a healthy lifestyle. The estimated prevalence of Sleep Disordered Breathing (SDB) is 24 per cent among men and 9 per cent among women between the ages of 30 and 60.

Increasing obesity in Asia especially in Malaysia, Philippines, and Singapore is driving higher prevalence of OSA, which is the most common disorder that is associated with SDB. 15.1 per cent of Malaysia’s adult population, or 2.5 million adults, are classified as obese.

Even though OSA was clinically recognised over 30 years ago, awareness of this condition outside the field of sleep medicine has been slow to develop.

In Asia, the prevalence of OSA among middle-aged men is 4.1 to 7.5 per cent and, 2.1 to 3.2 per cent among middle-aged women. Besides obesity, facial bone structure is also a major contributor of OSA among Asians.

competencies in the diagnosis and management of sleep disorders,” said Professor Dato’ Dr Amin Bin Jalaludin, Chief Executive Officer, University Malaya Specialist Centre.

According to a recent survey by Malaysian Institute of Road Safety Research on 289 bus drivers, 44.3 per cent were found to have sleep disorders. Road accidents are one of the significant impacts from OSA. Other sleep disorders such as insomnia, parasomnia, and narcolepsy also interfere with normal physical, mental, and emotional functioning causing people to become less productive at work, irritable, depressed, and sleepy behind the wheel while driving.

FOR BETTER SLEEPThe ASRCC opens its doors for screening and management of OSA for public vehicle drivers and works with the government for drivers to undergo compulsory OSA screening. The ASRCC will focus on all areas of sleep disorders, including OSA, insomnia, and narcolepsy.

Known also to be first of its kind in Asia and with the aim of improving the state of health and wellbeing in the region, the ASRCC constitutes of four sub-sections: Training Academy, Clinical Research Centre, Tele-Medicine Centre, and Corporate Services Centre. Here’s a look at each sub-section.Training Academy: Sleep medicine training by the ASRCC will be recognised by hospitals worldwide, as it will be conducted by a global faculty and based on the global standards by the American Society of Sleep Medicine. The training sub-section of the ASRCC aims to increase the number of trained sleep specialists in the region. Clinical Research Centre: The ASRCC will be involved in clinical research to improve the understanding sleep disorders from an Asian perspective. Patient-oriented product and application research will also be conducted through this sub-section. Tele-Medicine Centre: Asia needs more trained specialists and facilities for sleep disorders, as this field of medicine that is still developing. To overcome this, a tele-medicine centre will be set up to help meet the needs of more patients across far-flung areas. The hub will provide sleep consultation across ASEAN through a centralised hub for sleep reports scoring, analysis, and patient management. Corporate Services Centre: To raise awareness of sleep disorders and its link to employee productivity, the corporate services sub-section of the ASRCC

Other sleep disorders such as insomnia, parasomnia, and narcolepsy also interfere with normal physical, mental and emotional functioning causing people to become less productive at work, irritable, depressed, and sleepy behind the wheel while driving.

78 / JULY 2012

Your beautiful filaments eclipsed the windows of love and descended into shyness

I lifted your veil,gently,by holding up your chin;and my eyes fell like a wave upon a shy full-moon.

Your interstitial smile that teases your coynesspierces my heart with a thousand rippling dreams.

The setting sun douses its flaming tresses in the wetness of the horizon.

The heat of my love lights up your body;and my urgent lipstattoo your gardenwith kisses.

The river of your lips;the soft moss of your skin;the buttons of pleasure beneath the triangle of your necklinemake me a wanton worshipperin your holy land.

The moon glows upon your thighs;your filaments dance!I gravitate towards you,and we swim together to the rhythm of the waves.

By Manian Raju

your interstitialsmile

www.abexmedical .com.my

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