Tuberculosis (TB) is still a danger!

A recent paper in the New England Journal of Medicine once again highlights the fact that we tend to ignore certain older disease states that we have archived before their demise. TB is one of these. In developed countries it rarely gets a mention, except in immune-compromised patients. In Third World countries TB is still an issue.

The World Health Organisation (WHO) in 2014 places mortality at 1.5 million, with a total of 9.6 million infected individuals(http://www.who.int/mediacentre/factsheets/fs104/en/).

The study carried out in the article emphasises that intensified therapy does not improve intervention outcomes and that mortality is still significant. In a global context, more emphasis must be placed on eradicating basic and long-standing communicable disease, prior to simply discovering new ways in which to market and monetise pharmaceutical care!


The paper, "Intensified Antituberculosis Therapy in Adults with Tuberculous Meningitis",
can be found @http://www.nejm.org/doi/full/10.1056/NEJMoa1507062.

Exercise and fasting are good for the brain!

Watch this TED talk. Stimulating concept and topical for various reasons.

The official Youtube attribution is below:

"Mark Mattson is the current Chief of the Laboratory of Neurosciences at the National Institute on Aging. He is also a professor of Neuroscience at The Johns Hopkins University. Mattson is one of the foremost researchers in the area of cellular and molecular mechanisms underlying neurodegenerative disorders such as Alzheimer's Disease, Parkinson's Disease, and amyotrophic lateral sclerosis."

I'm back!!

After a two year hiatus, I have finally decided to continue updating this blog. Watch this space!

The only way forward!

Now that all is said and done, a new administration is in place.

It is up to all of us involved in the provision and administration of healthcare in the Maltese Islands to form a united front and co-operate in an effort to ameliorate  a system that albiet of a very high standard, can be made to perform even better.

We are one nation and one people and our moral responsibility is to all Maltese, regardless of political belief, colour or creed.

Multiple chronic conditions increase the cost of care

At the risk of stating the obvious this what a recent post on the Healthcare Economist blog discusses. It draws from data forming part of a report by Robert Wood Johnson which tackles the problem of caring for patients suffering from chronic conditions. 

Highlighted in this report are the facts that the percentage of individuals in the United States diagnosed with multiple chronic disease is increasing rapidly, 28% of the population suffer from two or more chronic conditions and that two-thirds of Medicare expenditure are for individuals with five or more chronic states.

The chart above evidences the fact that multiple diagnoses of chronic disease account for the lion's share of expenditure. This view is reinforced by the second chart below where one can note that the per capita spend rises exponentially as the number of comorbidities increases.

 

 

It would be interesting and also valuable to the administration of our healthcare system if we could get hold of data for the local population and derive a detailed analysis. If the data had to mirror that in the United States it would be both worrying and enlightening and it would allow us to develop strategies to minimise or avoid an impending healthcare crisis.

The original post by Jason Shafrin can be found here: http://healthcare-economist.com/2013/02/07/multiple-chronic-conditions/

Back to basics to move forward!

Back to basics to move forward!

The world is changing at a speed none of us could have imagined in our undergraduate years. I typed out my undergrad project on a so-called computer with an 8086 processor chip; these days a scientific calculator packs more punch and occupies much less space. This example is just one of countless ways in which the educational and professional aspects of the pharmacy profession have evolved, in the most part for the better.

There is one area where we have ostensibly taken a step backwards and this is in the manner in which we approach our face to face meetings with our patients. One of the reasons for this is the lack of personal communication skills which are fundamental to productive human interaction.

The main drivers in this lack of drive for human connection can be summarized as such:

I) Social media such as Facebook, Twitter and others have reduced a large percentage of our person to person interventions to electronic means, e-mail included. This decrease in direct communication has engendered a confidence gap and also a lcl of warmth and understanding in professional exchanges.

II) The majority of undergraduates, and also to a certain extent of pharmacy graduates, have no clear idea of why they have chosen their appointed profession. In some instances it is a case of following in the footsteps of a parent or close relative and taking over a long-held family business. In others it is a case of taking the easiest route to a good quality degree as a health professional. However, how many of these individuals can actually profess that they always wanted to become a pharmacist?

Thus what is missing in the majority of cases is the vocation to work as a health professional, to listen, emphasize and sympathize with patients and provide moral comfort as well as physical relief to the condition at hand. The mind and body are inextricably linked and no one medical professional can hope to heal the latter without paying great attention to the needs of the former.

III) Educational institutions are failing to recognize this gap between better informed students or graduates and better world-ready and personable ones. Focused and specific training in personal communication is missing in the curricula of most health professions. At least, with respect to our local pharmacy course, a six month work placement in the fifth year Master stage goes someway to addressing this point since Bachelor of Science graduates can observe licensed pharmacists in their daily patient interactions. The only drawback to this is that the educational and professional gain to be made depends on the randomness of a students placement, and thus uniformity of education is not guaranteed.

The take-home message of this short piece is that educational priority within the health professions, with the inclusion of the local pharmacy profession, should not only be on academic prowess but also on the development of graduates with a capacity for the basic human skills of communication and empathy.

John

The National Audit Office Report 2011 - The healthcare perspective

The latest version of the NAO report out last week highlights deficiencies across the board with the government sector, as is the remit of the individuals trusted with its collation and publication. What is of concern to those of us with a vested interest in the health sector and the formulation of health policy and its actuation, are certain grave and fundamental shortcomings within this same sector. The aim of this short note is not to dwell in depth on each point but to emphasize the importance and relevance of the basic facts elucidated by this report.

The NAO report 2011 review of the Ministry for Health and the Elderly can be easily subdivided into the following criticisms:

I) The lack of control on employee attendance and the brazen refusal of doctors' and dentists' unions to accept such a basic tenet of employment. 

II) The fact that tendering procedures for medicines and surgical materials and also non-surgical equipment are routinely circumvented by direct orders, and the limits and approvals required for the latter are disregarded at will.

III) The storage of medicines and surgical materials is not centralized and one of the depots does not provide satisfactory storage conditions under the regulations laid out by the MA. This suggests that sub-standard medicinal and supplies are being passed onto the local treatment chain.

IV) The discrepancy in stocks held was said to be less than Eur 2,000 on a total figure of over Eur 18 million. This range of accuracy is not credible to the trained observer, as it implies no human error in stock transfers and no inventory pilferage. For some reason this did not seem odd to the auditors.

The implications of the NAO report are many and will be discussed in detail in a future note. What these brief points do immediately emphasize is that the Maltese healthcare system is not suffering from a lack of funding, but rather from a very inefficient utilization of the funds available to it. With points of failure at every main cost sector: wages, stocks and purchasing and stock control are all major weaknesses. This implies that major gains are to be had by simply getting the basics done right. Deeper analysis is required to quantify the magnitude of the savings to be had, but the report leaves no doubt that the material impact on the level of local health outcomes would be dramatic, given the gross wastage of resources identified.

John

Its not about the bike

The title of this post was also the title of Lance Armstrong's autobiographical narrative of his fight against almost certain death from testicular cancer and his subsequent return to professional cycling and to the pinnacle of his chosen sport. Recent events have borne Armstrong out to be a liar and a cheat of the highest calibre, however our revulsion at his cowardly acts must be restricted to his sporting achievements. 

The Livestrong Foundation, set up by himself, has raised close to $500 million and provided hope and solace to countless individuals who have battled cancer. As much as all observers and involved persons alike would prefer to black out all reference to Armstrong and damn him to the darkest abyss, such instincts must be curbed for the greater good. Livestrong must be allowed and supported in its good work, and one hopes that Armstrong will have the good grace to disassociate himself from the foundation and allow it to create its own legacy, free from his own tainted and deeply flawed journey.

Another year begins!

A quick word to wish good luck to all pharmacy students on the start of the new academic year, especially to the new entrants!

Lets hope we all get settled pretty quickly and manage to juggle the twin feats of having a good time and getting some productive learning time under our belts.

See you!

John

Why education and business must mix for the greater good

Business interests and the aims of tertiary education are not initially similar or even remotely , related at an initial and cursory first glance. However, upon further evaluation one will come to the conclusion that the two are mutually connected and the possibilities for gain for both parties can lead to a situation where cooperation is the only way forward in the near future.

The current situation in the Maltese Islands is such that various university departments suffer from a chronic lack of funding due the limited resources available and the fact that the University of Malta has little sources of income, save for tuition fees charges to overseas(non-EU) students and certain evening and part-time courses.

Without going into the politics of it all, we are currently punching above our weight, taking into consideration the small pool of students and lecturers at hand, and the quality of graduands has improved greatly.

The next step must involve external funding, on a level to that similar in the United States. Various industry and business leaders often complain of a chronic shortage of quality and specialised graduands. One manner in which this might be solved could be by having  companies sponsor courses in fields where we have little or no current expertise, and then allow  these same companies to offer job opportunities to the students prior to the course completion, even have the students undergo work placements at these companies as part of the course curriculum. Alternatively, companies might be allowed to sponsor a chair in a particular area, and be given the opportunity to promote themselves to students in a regulated environment.

Opponents to this might state that education must never be subservient to financial interests and pressures, and they may be right. However, such an arrangement, or a derivative of the above idea, might be the only way in which our minute country can continue to punch above its weight in the field of tertiary education.

--

John Vella B.Pharm. (Hons.) M.Sc.(Pharmacoeconomics)

8, Islets Promenade, Bugibba, SPB2502, Malta

+356-21571649, +356-27571649, +356-99497510

http://www.stsimonpharmacy.com

Breaking News! Statins are safe again!

Up to recently, a majority of studies had  shown no obvious gain  in administering statins to patients who had not experienced a previous cardiac event or were at an elevated risk of cardiac pathology.  These studies had not been widely publicised by the pharmaceutical industry for obvious reasons. 

A preview of the results of a meta-analysis of 27 large studies (175,000 subjects in total) to be published in the Lancet in late 2013 suggests otherwise. According to authors quoted from the University of Oxford, anyone over the age of 50 would benefit from statin therapy. The authors insist that the extra cost of therapy would be outweighed by the savings made by a reduction in cardiac events and subsequent hospitalisation and rehabilitation costs.

The link to the full article is here: http://www.bbc.co.uk/news/health-18091708

Why I refuse to lie down and shut up!

Why I refuse to lie down and shut up!

It is easy enough to go along with the rest of the world and accept what is the present state of affairs as the norm. This is all well and good if one's conscience is at peace and the majority of society is well served. In this case, however, both the former and the latter are not satisfied.

I argue that the formulators of public policy are not being given the right amount of information and professional direction to enable decisions to be taken in their best interest. I argue that public health would be better served if those taking macro health decisions placed the well-being of Maltese citizens ahead of personal, political or corporate gain. I argue that the time has come to take a stand and put forward the case for wholesale reform of the manner in which we apply ourselves to healthcare and its delivery.

I will not rest my case.


John

Does money or patient welfare drive our profession?

An extremely well-written and thought provoking book is The Truth About The Drug Companies: How They Deceive Us And What To Do About It, by Marcia Angell. Dr. Angell is a former editor of the New England Jounrnal of Medicine and a respected authority in the field of medical and pharmaceutical matters. Her book tackles what she has termed the takeover of the pharmaceutical field by 'big pharma'

Dr. Angell opines that the massive profits generated by the leading pharmaceutical companies are no longer morally justified and sustainable. She argues that truly innovative and socially profitable drugs are now few and far between, and that the current system of patent protection and profit taking is being manipulated by pharmaceutical companies, to the detriment of the general public. Her arguments are well reasoned and backed up by fact and lead one to give a certain credence to her thesis.

In this light, an introspective view at the manner in which we conduct our profession is warranted. Do we, as Dr. Angell so well describes in her writing, take every word and advertised fact proposed by drug companies as being incontrovertibly right? Do we question research we are quoted and probe the efficacy of newer and more costly medicinal products? Do we consider the financial implications that pharmaceuticals have on the daily well-being of our patients? Are we placing our own motives for profit, financial or otherwise, before those of the public we are obliged to treat impartially?

The above questions are not easily answered, and as in most situations in life, the pragmatic response is a grey line somewhere down the moral middle. Considering them and applying the consequent thoughts to our daily professional practice can only lead to better application and patient benefit. The above mentioned book is also worth a read as it portrays the pharmaceutical industry in a manner few have had the courage to.

Watch what you drink!!

The study below, from the American cardiac journal Circulation, raises some very troubling points. In short, the study concludes, to a high level of significance, that one sugary soft-drink a day increases the risk of CHD (Coronary Heart Disease) by 20%!

The implications of such a discovery are far reaching. If the findings are substantiated and replicated in further studies, then steps should be taken to have health warnings on the products in question and also to initiate public awareness campaigns. There might also be the possibility of introducing a tax on the raw material for sugar containing drinks, as apart from this new link to CHD they are also directly connected to the increase in the incidence of diabetes mellitus, both locally and also world-wide.

These statements may be considered idealistic in view of the financial clout and lobbying power wielded by the soft-drinks industry, however this must not deter us from pursuing the best course of action required for optimum public health. As with the tobacco industry in the past, no interest is too potent to surpass that of society as a whole.

From Heartwire

A Soda a Day Raises CHD Risk by 20%

Lisa Nainggolan

March 12, 2012 (Boston, Massachusetts) — Sugary drinks are associated with an increased risk of coronary heart disease (CHD) as well as some adverse changes in lipids, inflammatory factors, and leptin, according to a new analysis of men participating in the Health Professionals Follow-up Study, reported by Dr Lawrence de Koning (Children's Hospital Boston, MA) and colleagues online March 12, 2012 in Circulation [1].
"Even a moderate amount of sugary beverage consumption — we are talking about one can of soda every day — is associated with a significant 20% increased risk of heart disease even after adjusting for a wide range of cardiovascular risk factors," senior author Dr Frank B Hu (Harvard School of Public Health, Boston, MA) told heartwire . "The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda, not only in the US but also increasing very rapidly in developing countries."

 

The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda.

The researchers did not find an increased risk of CHD with artificially sweetened beverages in this analysis, however. "Diet soda has been shown to be associated with weight gain and metabolic diseases in previous studies, even though this hasn't been substantiated in our study," says Hu. "The problem with diet soda is its high-intensity sweet taste, which may condition people's taste. It's still an open question whether diet soda is an optimal alternative to regular soda; we need more data on this. "
Hu says water is the best thing to drink, or coffee or tea. Fruit juice is "not a very good alternative, because of the high amount of sugar," he adds, although if diluted with water, "it's much better than a can of soda," he notes.
And Hu says although the current results apply only to men, prior data from his group in women in the Nurses' Health Study [from 2009] were comparable, "which really boosts the credibility of the findings."

Inflammation could be a pathway for impact of soda upon CHD risk
Hu and colleagues explain that while much research has shown a link between the consumption of sugar-sweetened beverages and type 2 diabetes, few studies have looked at the association of these drinks with CHD.
Hence, they analyzed the associations of cumulatively averaged sugar-sweetened (eg, sodas) and artificially sweetened (eg, diet sodas) beverage intake with incident fatal and nonfatal CHD (MI) in 42 883 men in the Health Professionals Follow-up study. Beginning in 1986 and every two years until December 2008, participants answered questionnaires about diet and other health habits. A blood sample was provided midway through the study.
There were 3683 CHD cases over 22 years of follow-up. Those in the top quartile of sugar-sweetened-beverage intake had a 20% higher relative risk of CHD than those in the bottom quartile (RR 1.20; p for trend < 0.001) after adjustment for age, smoking, physical activity, alcohol, multivitamins, family history, diet quality, energy intake, body-mass index, preenrollment weight change, and dieting.
Adjustment for self-reported high cholesterol, high triglycerides, high blood pressure, and diagnosed type 2 diabetes only slightly attenuated these associations, which suggests that drinking soda "may impact on CHD risk above and beyond traditional risk factors," say the researchers.
Consumption of artificially sweetened drinks was not significantly associated with CHD (multivariate RR 1.02; p for trend=0.28).
Intake of sugar-sweetened drinks, but not artificially sweetened ones, was also significantly associated with increased triglycerides and several circulating inflammatory factors — including C-reactive protein, interleukin 6 (IL-6), and tumor-necrosis-factor receptor 1 (TNFr1) — as well as decreased HDL cholesterol, lipoprotein (a) (Lp[a]), and leptin (p < 0.02).
"Inflammation is a key factor in the pathogenesis of cardiovascular disease and cardiometabolic disease and could represent an additional pathway by which sugar-sweetened beverages influence risk," say Hu et al.

Cutting consumption of soda is one of easiest behaviors to change
Hu says that one of the major constituents of soda, high-fructose corn syrup, is subsidized in the US, making such drinks "ridiculously cheap" and helping explain why consumption is so high, particularly in lower socioeconomic groups.

 

Doctors should be advising people with heart disease or at risk to cut back on sugary beverages; it's almost a no-brainer.

"Doctors should set an example for their patients first," he stresses. "Then, for people who already have heart disease or who are at high risk, physicians should be advising them to cut back on sugary beverages; it's almost a no-brainer, like recommending that they stop smoking and do more exercise. The consumption of sugary beverages is a relatively easy behavior to change."
And although this particular study included mostly white subjects and there are few data on the risk of cardiovascular disease associated with the consumption of soda in people of other ethnicities, there are data on its effect on type 2 diabetes in these groups, he says.
"It has been shown for minority groups — such as African Americans and Asians — that they are more susceptible to the detrimental effects" of sugary drinks on diabetes incidence, he notes.
The authors report no conflicts of interest.

Statins in the dock

The FDA has updated statin labelling and literature to include prior screening for hepatic function. Also included in the release is the information that statins are implicated in a higher incidence( 8-13%) of diabetes in patients on them, especially with higher doses. Also highlighted is the connection, though tenous, between statin therapy and cognitive disorders.

The full article is here http://www.medscape.org/viewarticle/759588?src=cmemp.

--

John Vella B.Pharm. (Hons.) M.Sc.(Pharmacoeconomics)

8, Islets Promenade, Bugibba, SPB2502, Malta

+356-21571649, +356-27571649, +356-99497510

http://www.stsimonpharmacy.com

Well done to all!

The Pharmacy Symposium 2012 has been a run away success. The quality of the work on offer is a credit to students and department staff alike, taking into account the limited resources avaiable. All involved deserve a slap on the back and congratulations for a job well done. John

Owen Farrugia

Owen's passing is a loss for all of us within local pharmaceutical circles, and also to all those he touched throughout his brief but worthy life. My thoughts are with his family at this hardest of times.

May he be with us in spirit, always.

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The benefit of a healthy lifestyle and pharmaceutical consumption

We have become accustomed to turning to our very well-stocked medicine chests or if that fails us, to our friendly pharmacist for immediate  relief to all our ailments. This tendency has led us to be symptomatic  in our treatment of disease, rather than attempting to get to the root of the problem. 

It is unfortunate that this attitude has crept into  the manner in which health professionals approach most medical  problems presented by patients. The quick fix consists of а prescription, or in the case of a pharmacist a recommendation for а particular drug or referral to a certain physician. This has led to an  increase in the demand for medical services and pharmaceutical  products, with a concomitant increase in the financial pressures on  the payer, whether the cost is state-financed or paid out-of-pocket.

It is quite likely that a percentage of patients being treated with  lipid-lowering pharmaceutical therapies and anti-hypertensive  medication, would achieve the same or improved treatment outcomes, without treatment(or at least at a lower dose and variety), if induced  to adopt lifestyle changes that are conducive to better health. In  other words, if the patients on the above mentioned drugs are  overweight, smoke and possibly consume amounts of alcohol that аре above the recommended limits, then there is room for improvement. Persuading these people, indeed the whole of the Maltese population  that lifestyle and positive health outcomes are inexorably linked, would be beneficial to all of society as a whole.

In fact, not only would patients be better off if they required less  or no medication, they would also reap the benefits of an improved  well-being and healthy outlook. Society at large would gain, and the  state would also see a reduction in the increase in pharmaceutical  expenditure that is threatening to derail the whole public healthcare  system.

The subject requires a much deeper and considered discussion, but one  cannot discount and ignore the positive effects of combining health  promotion and prevention together with treatment. It is unfortunate  that, especially locally, we are dedicating most of our efforts and  funding towards the latter, and ignoring the long-term benefits that  the former could provide.

Professional morals and education

It is all so easy for members of the health professions to forget the true reason for their daily work routine. All health professionals are inexorably linked to the principles of patient primacy and the over-riding moral authority derived from the Hippocratic oath and related philosophies. Unfortunately financial matters and other conflicts have come to exert ever increasing pressures on practitioners in various fields. This has lead to a situation where the health of the patient is no longer the primary concern, but takes second place to career advancement, profiteering or a combination of both.

It is imperative that institutions of higher education place great emphasis on the creation of graduate professionals, that are not only of a high academic standard, but also of strong moral fibre. Such a task is no mean feat, as persuading students who are just about to attempt to establish a foothold in the societal rat-race, that principles are worth more than financial reward, is a tall order.

The first step in achieving the above is to have educators that practice and hold themselves to the same standards that students aspire to. As is often the case, remuneration within the academic world does enable universities to hold on to,or attract the best talent available. In certain cases it might make sense to utilise a system of visiting lecturers from various specialities, or create a pool of volunteers from leading professionals who would dedicate a certain amount of time to mentoring.

Attaining a high level of moral standards and ethical practice within the pharmacy profession will enable the possibility of self-regulation with respect to a multitude of issues that need to be approached. This in turn will create the opportunity to negotiate with other stakeholders and indeed patients themselves, from the vantage point of moral high ground.

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End of year thoughts!

End of year thoughts!

Firstly I would like to wish a Happy New Year to all health professionals, their families and patients. I would also like to pass on my regards to my colleagues and team members at UDKA Company Limited; I consider myself lucky to have such a competent and pleasant set if people with whom to work. I would also like to include the University of Malta Third Year students, who have provided me with much inspiration in our weekly lectures and also all members of the Pharmacy Department.

God willing, we will all strive to ensure a satisfying and goal-driven 2012.

John

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