To
all Manipalites in and around Malaysia

Hi guys,

How are things since the beginning of 2013? I hope you love the new look and design of the HOWZIT Newsletter. Sincerely, to tell you the truth, I have received quite a good amount of recommendations and comments for future improvement. Anyway, the Editorial team will progressively improve HOWZIT so that it will be more readable, enjoyable and on top of it, a great tool for your career development. As before, we like to welcome your generous comments and will be delighted if you could contribute articles to share with the rest of us. Thank you in advance.

 Since the last newsletter, and subsequently after further Executive Committee Meetings, our task was to increase the number of Alumni members, so also to get our existing members to be active in the Alumni. We have plenty of Manipalities who are spread out all over Malaysia, but many have not joined the bandwagon as yet or have not been participating in our activities. With this, we have decided to put in the Membership Application Form into this issue so that the present members can get their Manipal peers in their area to join the Alumni. Photocopies of the form are acceptable and can be post-mail, fax or e-mail to the given address.

To those existing Alumni members, the database that we have are outdated and time forgotten. Therefore, we are requesting that you spend about 5 minutes to send to us your new contact numbers, mailing addresses and e-mails so that we could send to you the latest activities of the Alumni regularly.

Anyway, let us see what the Committee has done so far. Just before the end of the year of 2012, we had the last CPD Lecture Series on the 8th December at Eastin Hotel, Petaling Jaya on Medical Concepts of Opioid Dependence and How Not To Miss Mood Disorders, by none other than our prominent speakers, Dr. Philip George and Dr. Prem Kumar.

Then, after the New Year Celebration, we were fortunately invited by the people from BMW Auto Bavaria in Sungai Besi to try out some of the Beemers and put our foot down on the pedal of their test-drive cars. Following that on 16th February, we had our first CPD Lecture Series of 2013 in Melaka Manipal Medical College. Our top Breast Surgeon, Dr. Patricia Gomez and Dr. Josephine Subramaniam, Interventional Radiologist was there to entertain the crowd with their topics Breast Lumps – When to Worry and Spectrum of Imaging in Diabetes. The number of attendees was good which also included MMMC faculty members and medical students. We also had Community Health Camps as part of our charitable work, which you could read it in this issue. The Organizing Committee for the 1st Global Manipal Alumni Health Sciences Convention are also steaming up into full mode in preparing to host this auspicious event for all the Manipalites from around the planet.

Alright, to sum up all in this issue, do join us this coming May 4th for the 27th Convention, 28th AGM and ‘Masquerade’ Dance & Dinner. Well, if you think you miss the ‘Luau’ Hawaiian Party in Penang, please be appropriately dressed for this night event then. And last but not least, after this ‘crazy’ night, hope you guys can still think rationally and cast your vote for a better Malaysia in GE13.

Kudos and bye for now.

Dr. Eugene Tan

President’s Message

A year has passed since I took over with this young committee. I must commend my committee for the excellent job that they are doing despite their hectic schedules of family demands and work overload.

It has been a challenging year especially when we have had predecessors who have done sterling work to lift MAAM to the heights that we are at today. I am glad to say that we have more than survived.

Let me give you a quick run through what is in the pipeline and what has transpired.

2014 is going to be a landmark year for MAAM as we play host to the prestigious 1st Global Health Sciences Convention from 7th to 9th August at the Royal Chulan, Kuala Lumpur. A two day multi disciplinary event followed by a day of games and social activities to rekindle our traditional camaraderie Manipal style. Mark your calender for this not to be missed event.

In 2012, we rocked the Pearl of the Orient again – Bayview Beach Hotel, Penang was the epicenter of the event. Our Vice President cum Organizing Chairman, Dr Sivaroshan, led the way with his constant companion – the iPhone, delivering on his word as Organizing Chairman to host an unforgettable event. We were honoured to have the Chief Minister, Mr. Lim Guan Eng, as our chief guest, who left a daunting impression on many on that wonderful evening. I will not be doing justice if I overlooked the informal night. We had a moonlit night on the beach minus the rain – our first after 7 years. A Hawaiian theme complete with flower girls, fire dancers and a great rock band that got the squirrels rocking too, made the night truly one that is still talked about.

In an effort to persevere in the field of Continuing Medical Education (CME) our 1st CPD lecture series was a 2 day event during our Convention in Penang. The first afternoon was in Orthopaedics, Diabetes and Hypertension. The high point of the day was the tussle for the iPad and other prizes which were given to the few fortunate people. The next morning, we had a session on Renal Anaemia after which Dr Kewaljit took the role of auctioneer with two golf sets.

The next CME session was in Petaling Jaya which was centered on Psychiatry and to keep things exciting, we had an offshore investment consultant who gave us tips on how to make our money work harder for us

A Scientific Committee 2014 meeting was held in MelakaManipal Medical College after which we adjourned to a CPD session on Breast Lumps and Interventional Radiography. There was a good mix of students and faculty members from the MMMC who attended which saw lively Q & A sessions. Watch out for our next CME session will be on the 4th of May 2013 at Saujana Hotel; Subang Airport road.

In an attempt to give back to the underprivileged, I would say that we can do so much more if we had more support from our members. MAAM has to transcend the norm and do great things as collectively we are a force to be reckoned with.

• Our Community Project at Sungei Buloh needs to be revived with your support.
• In Penang, Dr Sham Kumar was up against the wall but off late he seems to have sighted some light at the end of the tunnel. I wish him luck and let us hope something positive comes out of his efforts.
• A survey was done in Sungei Siput in an attempt to identify how we could contribute to the poor in that region. Five MAAM members have come forward and donated money to sponsor a teacher for a year to help in home schooling children of single mothers.

In this area we are hoping to get a mandate from the floor to help upkeep two teachers for a year, which is a mere Twelve Thousand Ringgit. Do I hear an aye?

For all the tech-savvy folks, we have something exciting for you. MIMS mobile is an iPhone ‘App’ which is being discounted for MAAM members at a great prize of only RM50 per year. This application is an interactive MIMS-on-the-go. It is downloaded on to your iPhone to be used anywhere without wifi connection. For those who are interested please get in touch with the secretariat and Josephine will be happy to assist you.

We are always looking for great offers and deals to improve member benefits. Information about all this is posted on the web. Make the MAAM web page your morning fix by visiting us frequently. There are some great offers from companies dealing in property, cars, and beverages to name a few. We are in the midst of negotiating with insurance companies and banks to offer some good deals for our members. All this information can only be found on our website. The web page has been upgraded so please log on for information of events and promotions and give us your feedback. Do not forget – log on to: www.manipal.org.my

We have a lot more to do and I urge you to get involved and play a part in shaping the future of MAAM. I firmly believe we have the opportunity to make MAAM truly great, a comradeship with a purpose. Step up and be a part of something great.

Till we meet on the 4th of May… keep well.

Dr Nirmal Singh
President 2012 – 2014

“It matters not how a man dies, but how he lives.” – Samuel Johnson

I have known Rasi since 1981.We first bumped into each other at the famous Malligas in Udupi. We have been good friends ever since.I remember him riding around Manipal . He used to have a tuft of hair back then. Not surprisingly half of it fell whilst I was his roommate.

We were meant to be near each other I think. When I first got posted to Taiping as a houseman he ended up there .Then some years later I moved to KL only to find that his practice was less than 2 km from mine in Puchong. Many a afternoon was spent having a cup of tea at the mamak shop nearby whilst we waited for our respective practices to pick up. His trademark sarcasm never failed to amuse me.

You have been a wonderful husband, a loving father, a dutiful son, a caring bother and uncle and most of all a great friend. Someone once said, “A friend is a gift you give yourself”. I must say I certainly got myself a gem. Weakness, if you had any, seemed overshadowed by your gentle and loyal heart. Not intrusive but always there in times of need.

So many memories running in my mind as if it were only yesterday, all the things we spoke and argued about… I can’t go on. Rasi my dearest friend, my heart aches and I fear I will start to cry. I can almost see you with your cynical smile from above saying ; “Getting all soft and mushy eh…’? I am giving you this chance to write about me, so cut the crap and don’t screw it up Naysa. “

I and all of us who hold you near and dear will miss you so much buddy.Your family meant the world to you.Please be comforted that I will always be there as Uncle Dr. Naysa for little Subhan.

As I put down my pen with a heavy heart the words of Thomas Campbell reverberates in my mind “To live in the hearts we leave behind is not to die.” ~ … And so you will always be alive in our hearts Rasi.

Your friend of 32 years,

Naysa
Dr. Naysadurai

Meeting the new Director General of Health

I had the chance to meet up with Datuk Dr Noor Hisham bin Abdullah twice in dialogue sessions since he assumed his office as the Director General of Health. – by Dr Koh Kar Chai

He spoke on a lot of issues, but top on his mind is the improvement of our present healthcare system. For that to be able to take place smoothly, he stressed on the importance of unity. Our DG mentioned about the fragmentation among the doctors of Malaysia which is not good for the medical fraternity as it will dilute the voice of us doctors. We need a single umbrella body which will lend strength to the whole medical fraternity.

His view on leadership really got me thinking about what is really happening with some of the medical associations out there. He said that a leadership which thinks about what is best for the association or the medical fraternity as a whole will empower us doctors unlike the present moment where we see the leadership of certain medical associations with an agenda of their own, which will tend to lead us nowhere. A leader is not there to rule but to govern. The key then, is good governance. There is a need for common goals, without which it would not be possible to move forward in healthcare. It is not about the leader as such, but about what the leader can do to improve the present situation. Our DG is of the opinion that being an effective leader is not about giving excellent speeches, but about having a good outcome and performance. True indeed, but there really is much to learn about being a leader.

He further stated, “ We all have our differences which should be respected, but our commonalities must come together as one ”.

He enumerated the three things that is being looked at in the healthcare of this country. First is quality which is of utmost importance. Second is accessibility of healthcare to all and third is equity of care.

Our DG mentioned that there is a need to improve our healthcare system based on our own experience and history. We need not adopt the healthcare system of another country as it may not be relevant to us. But we do need to have a system which have a maximum impact at a minimum cost.

What is the one care system? He insisted that it is not about healthcare financing which many people are harping on. Right now in this country we have the two care system, private and public, and it doesn’t bode well for our country. There is a need for us to bridge these two systems. Rightly said, but how many of us doctors out there agree on this?

Datuk Dr Noor Hisham stated that presently, the rich in Malaysia are making use of both the private and public systems. They utilise the public system for the more complex cases which need highly specialised management which may not be available in the private sector. The poor have got no choice but to rely only on public healthcare facilities. As the public system continue to improve, there will be increased utilisation of it’s resources leading to more congestion at public healthcare facilities. This will also lead to a dilution of the resources available to the public system. I can personally vouch that it is true that there are some who are economically stable and yet prefer to avail of public healthcare services. However, it is not only due to the improved services being offered but also because treatment is available almost free.

There are five stages in the transformation of healthcare in this country. Our DG is of the opinion that we may need only ten years to reach stage five as we are able to learn from the mistakes of other countries. With this, we may be able to accelerate the rate of transformation of healthcare in Malaysia. There is a need for all to understand the five stages that are involved here. It is not so complex if we were to look at the chart with an open mind.

He further added that right now, there is a move to improve the public system by strengthening it’s services and working on quality issues. Decongestion of public hospitals remain a priority and processes are being developed to decongest the public health facilities by literally keeping patients out of the hospitals. Patients are not kept longer than is necessary. Certain facilities and services are being taken out of the hospitals. Clinical services should be offered outside the hospital and not within. Day care services are deemed crucial to reduce the load on in-hospital services. Home care is also something that is being worked on. Early discharge back to primary care level will reduce the load on the specialists.

Our DG further opined that specialists should not be wasting their expertise on primary care cases. They should be earning based on their expertise and not on primary care level consultation. Giving in to market forces will mean the demise of all GPs as patients will only demand for specialist care for the most trivial of cases. The healthcare system will then collapse due to the increasing cost of medical care, something which we should steer clear of. I will reserve my comments here, as being a GP myself, I would greatly welcome a system which benefits primary care doctors.

More were discussed with the DG that will fill many more pages here. But suffice it to say that our new DG is a person who understands what it will take to transform the healthcare of this nation of ours. In his own words, he is going to break down the walls of resistance to change, brick by brick, starting first within the Ministry of Health itself.

Understandably, there will be some of our members who will beg to differ from the opinion of our new DG. According to Datuk Dr Noor Hisham, you may visit his face book where you can engage him in a discussion on issues that matter.

PRESS RELEASE!!

Functional cure for HIV infection seen in a two year old child! This is what the world has been waiting for!

But hold your horses here. What is so special about a functional cure seen in this two year old child? We should instead be upset that a child has been born with HIV infection present when every other country in the world worth it’s salt is having programmes to prevent mother to child transmission of this dreaded virus.

If this can happen in an advanced nation, then think about Malaysia. Are we missing many cases of HIV infection in pregnant mothers? Are we creating a population of HIV babies in this country?

We do have In Malaysia, a programme for the Prevention of Mother To Child Transmission which is carried out in public health institutions, including at primary care level. Awareness is also created among the private healthcare providers to ensure their participation in this programme.

This requires a three fold strategy which are

1. Prevention of HIV infection among prospective parents.
2. Avoidance of unwanted pregnancies among HIV positive women.
3. Prevention of HIVtransmission from HIVpositive mothers to their infants during pregnancy, labour, delivery and breast feeding.

The crux to note here would be an effective screening for HIV infection during the antenatal period. This will ensure that mothers who are screened positive for HIV infection will be started on anti retroviral therapy during pregnancy, safer delivery practices will be carried out as well as counselling and support given on infant feeding methods.

All these will lead to a drastic reduction in the transmission of HIV from mothers to their children. This is the message that needs to be carried across to everyone instead of the euphoria created by the first ‘functional cure’ of HIV infection in a two year old child.

TOWARDS ZERO TRANSMISSION OF HIV FROM MOTHER TO CHILD.

by Dr Koh Kar Chai

Sg. Siput walkabout with YB Dr Michael Jeyakumar

It was dawn on Sunday 16th. morning when Dr. Jeyaretnam (Ipoh member) and me sat down for breakfast at a restaurant near Dr. Manalan’s clinic at Tasek, Ipoh. We were joined shortly by YB Dr. Michael Jeyakumar ( Member of Parliment, Sg. Siput) and his son, Rovin. We then waited for Dr.Nirmal (President of MAAM), to join us. We then left for Sg.Siput and gathered at YB’s service centre with the other volunteers. Dr. Bala Kumaran of Klinik Tweedie, Sg. Siput had graciously sent 2 nurses as volunteers to help us out.

The agenda was to determine the socioeconomic status, health status, average household income, the basic needs of everyday living, any umbrella protection offered by SOCSO,EPF, disabilities etc.

During the briefing, we were allocated to 5 teams comprising of 3-5 volunteers each.

Subject of survey : Taman Lintang ,Sg.Siput, a low cost housing area with around 200-300 houses.

We started the survey at 9am and finished at 12.30 pm. We managed to do a survey of 100 houses.

We then met back at YB’s office, compiled all the data, and took copies for cross references. Breakfast and light refreshments were provided by YB.

Besides that we were also informed that YB’s group of volunteers have started shelters for single mothers , with and without children. At present they are running 5 homes with support from the church, Sai Baba’s group and other volunteer organisations. It costs around RM5,000 a month to maintain all the above homes.(inclusive of rental, food, tuition for children of single mums, utilities etc).

After saying our goodbyes, we adjourned to Chemor town, where we were treated to a sumptuous lunch at the famous Samy’s restaurant by Dr.Bala Kumaran.

From there on, we dropped Dr.Jeyaretnam at Ipoh before driving back to KL ( both Nirmal and me in separate cars)

by Dr Mohanadas

Imaging in DIABETES

Statistics from the Ministry of Health Malaysia in 2011 show that in people over 18 years of age, there is a 20.8% prevalence of diabetes, with an upward projection in the years to come. It is a systemic disease and the major complications are retinopathy, peripheral vascular disease, heart disease, neurovascular disease, infection and renal impairment/failure. The underlying cause of all this is damage to small blood vessels from a high glucose level.

Imaging is useful in screening diabetics, and particularly important in the assessment and treatment of its complications.

Renal impairment

A baseline ultrasound of the kidneys would tell us if there is cortical thinning from chronic renal disease, and allows us to exclude renal calculi and obstruction. In patients who have acute renal failure, image guided dialysis catheter insertion is performed so the patient can dialyze for the 6 weeks required while a forearm fistula matures.

Doppler ultrasound can be used to look for vein stenosis in long term fistulas and angiographic balloon dilatation of the fistula if there is a stenosis.

Ischaemic Heart Disease

CT coronary calcium scores inform us of the risk of coronary stenosis by measuring the amount of calcified plaque in the vessels.

CT angiograms are performed to look for vessel narrowing and ejection fraction in patients who are at high risk or have atypical chest pain.

MRI can be used to look at cardiac function, with structural assessment and myocardial perfusion. Segments of at risk ischaemic muscle or infarcted myocardium are visualized.

Neurovascular disease

Plaque in the extracranial carotid arteries can be directly visualized with a Doppler ultrasound. It informs us if the plaque is new or old and can assess if there is ulceration of the plaque, the usual cause of embolism or acute stroke.

CT and MRI are exquisite at looking for strokes and intracranial arterial stenosis. Intracranial stenosis is a more common cause of strokes in Asians; therefore ultrasound assessment of the extracranial arteries alone is insufficient.

In patients with acute stroke, treatment with thrombolytics can be done if the patient comes to the hospital early.

Intravenous thrombolysis is performed within the first 4.5 hours, intraarterial thrombolysis within the first 6 hours in the anterior circulation, and first 8 hours in the posterior circulation. Much of the decision making on treatment hinges on imaging, as haemorrhage needs to be excluded, and assessment of the size of the stroke and viable brain with perfusion CT or MR. New clot retrievers are now available to angiographically extract the clot from the arteries if there is a large clot burden or if there is a contraindication to thrombolysing agents.

Peripheral vascular disease

Diabetics suffer from a combination of peripheral neuropathy and arteriopathy

The neuropathy is a result of damage to the vasa vasorum of the nerves and can result in a Charcot joint. This, together with the arteriopathy can also pre-dispose to infection. Imaging is excellent at directly assessing the blood supply to the lower limbs, the degree of damage in the joint and the extent of infection involved.

The arteriopathy can also be treated with balloon angioplasty and stents.

The aim of treatment is to prevent amputation and allow non-healing ulcers to heal. The angiosome concept is now propogated, in which revascularization must be performed within the target arterial territory, often into the plantar arch.

Infection

Diabetics are at greater risk for certain kinds of infection and have greater complications with the usual infections. Soft tissue infections like necrotizing fasciitis, emphysematous pyelonephritis, emphysematous cholecystitis, empyemas and pulmonary mucormycosis are but a few. MRI demonstrates soft tissue well, and infections that produce air are well seen on CT. The humble chest x-ray is still extremely useful in chest infections.

In summary, diabetes is a systemic disease which affects most of our organs due to damage to small vessels. Imaging is utilized in the pro-active management by performing screening for high risk patients. It is also useful to assess the degree of complications and guides us to treat the patient in the best manner possible.

Lastly, interventional radiological management of the diabetic foot, stroke and dialysis fistulas promotes quality of life for patients with chronic disease.

Breast Lumps – When to Worry!

Let’s face facts, every single one of us knows someone who has breast cancer!

Breast cancer is after all the commonest female cancer in Malaysia and the second commonest cancer throughout the world; lung cancer being the first. However, unlike lung cancer, breast cancer is NOT a ‘death sentence’ if it is diagnosed early and treated adequately.

In actual fact, in most developed countries, the incidences as well as deaths from breast cancers have been declining due to the excellent and varied methods of treatment available in the present time. Early breast cancer is beginning to be treated like a ‘chronic disease’ i.e. diabetes or hypertension, where there is also no “cure” available, but prolonged control of the disease is possible, and with good quality of life.

As much as we would like to believe that breast cancer is a disease of the elderly woman, we are in fact seeing younger women being diagnosed with breast cancer; women in their 30’s and 40’s and even those as young as 20 are getting breast cancer. This is especially so for Asian women. It is also a well known fact that 1% of breast cancer patients are men.

The commonest symptom of breast cancer is a painless lump in the breast or axilla. Unfortunately because there is usually no pain, women are often lulled into complacency and do nothing about this lump until it is sometimes too late. In the Western countries where the incidence is very high (1 in 8 or 9 women get breast cancer), there are government run screening programs, but in Malaysia this is not available, and the onus is upon women aged 40 years and above to come forward for screening mammograms.

However, not all breast lumps are cancers! The commonest cause of a lump in the breast is usually a benign water cyst or a fibroadenoma; but ALL breast lumps must be investigated and usually by ‘Triple Assessment’; clinical examination, imaging (either a mammogram and or ultrasound) and a needle biopsy.

A mammogram involves an x-ray of the breasts. The radiation dose is very minimal, and is the ‘gold standard’ for detecting early breast cancers; sometimes even before a lump can be felt, or even a pre-cancer (ductal carcinoma in situ) which shows up as microcalcifications and is curable. Digital mammography is fast overtaking analogue mammography as the images are better, clearer and the need for repeat views is minimised. The radiation dose is also less with digital mammograms.

The ultrasound is an adjunct tool to supplement mammography findings and especially in dense breasts, and in women under the age of 40 years. The ultrasound can very quickly define lumps, ascertain if they are water filled, solid or complex, and define the vascularity or elasticity of a lump as well as assist in accurate guided biopsies

MRI (Magnetic Resonance Imaging) is not usually used as a screening tool, but has its advantages in detecting new malignancies after surgery and radiation, and in screening very high risk families. Enhancement curves should be done to diagnose cancers.

The BIRADS (Breast Imaging-Reporting and Data System) is an excellent tool to standardise reporting on Breast Imaging, started for mammography and now used for ultrasound and MRI reporting as well.

 By Dr. Patricia A. Gomez
Consultant Breast Surgeon