This live webinar was recorded on the 11th July 2021.
This event was organized by The Association of Private Practitioners Sabah (APPS) for the benefit of medical practitioners and the general public regarding current issues of COVID-19 as we battle into the second year of this pandemic.
Various issues of the COVID-19 pandemic are being discussed including new variants of COVID-19 and vaccinating children and adolescents. Get first hand, accurate and reliable information from Dr Timothy William from this webinar.
You can click the time stamp below to go directly to the specific issue of interest:
0:03 Introducing the speaker, Dr Timothy William, Infectious Disease Physician, Gleneagles Hospital Kota Kinabalu 1:21 Various types of coronaviruses 2:28 How does COVID-19 transmit? 3:28 Can airborne transmission occur? 6:42 How about contact transmission of COVID-19? 7:54 How does COVID-19 cause disease? 9:41 How long is the incubation period? 11:42 Spectrum of disease severity 13:08 Case studies 15:48 Time course of illness and 'Happy Hypoxia' 18:10 Asymptomatic Infection 18:40 Progression of disease and risk factors 21:22 Diagnosis 21:48 Interpreting diagnostic tests for COVID-19 23:28 Investigations 24:49 Management 25:04 Prognosis 25:21 Therapeutic management of hospitalized adults with COVID-19 based on disease severity 27:30 Vaccine update 28:50 Risk of side effects from COVID-19 vaccines 32:25 Should we give mRNA vaccines to children/Adolescents? 34:32 Benefits and risks after 2nd dose of COVID-19 vaccination 35:46 New variants of COVID-19 40:35 Mixing vaccines 42:24 Safety of vaccines in pregnancy and breast feeding mothers 43:29 Q&A Can Ivermectin be used as an anti-viral drug? 45:13 Q&A Can a person develop covid infection after vaccination? 45:45 Q&A Is there a role for anti-fungals in preventing mucomycosis? 46:24 Q&A If the patient dies after vaccination, when will it be considered as the direct cause of death? 48:18 Q&A Any studies done to investigate levels of antibodies after vaccination or if booster doses are necessary? 48:54 Q&A What is the maximum interval between dose 1 and dose 2? 49:35 Q&A Should people buy pulse oxymeter to check their oxygen saturation at home? 49:49 Q&A Any prohibitions in taking alcohol after vaccination?
In KK, 91% of cases are not linked to any known clusters, events or history of traveling. People are screened because they only have symptoms. Some of these patients did not even have fever as a symptom. Therefore the temperature check is not going to help much in identifying who to suspect. It means there are many people without symptoms who are potentially infectious still moving around and there is no way we can trace the source of the spreader. This means the more people you meet, the higher the chances of you coming in contact with one of those asymptomatic spreaders. You may even be a spreader without realizing it. THIS IS WORRYING the medical team in Sabah. THIS IS A PRE-MEGA SURGE TREND. We may be heading for 1000 new cases per day by the end of October 2020!
As of now the ICU beds in QEH 1 are already full according to colleagues working there.
If we refer to our national statistics, in order to "flatten the curve", our new cases number from 7-11 October should be below 500 case per day and downward trend. However if you isolate the figures for Sabah in the following graph it reveals a disturbing fact.
As of 11th October 2020, Sabah had a 76% jump to a new high from to 488 cases per day! Our Sabah healthcare system is truly being "tested" as Tan Sri DG puts it. Berita Harian today (12/10/2020) carries the title, "Perang COVID-19 di Sabah sedang mencapai tempoh kritikal" says it all.
How is COVID-19 infection confirmed?
1.Positive RT-PCR (Reverse Transcriptase Polymerase Chain Reaction)- Nasopharyngeal Swab test
2.2 positive RTK-Ag (Rapid Test Kit- Antigen) 14 days apart- Nasopharyngeal Swab test
IF Positive for COVID-19 will I be admitted to the HOSPITAL, sent to QUARANTINE CENTER or given HOME QUARANTINE?
Not all COVID-19 positive patients need to be admitted. In view of the very likely possibility that wards and quarantine centers in KK are full, home quarantine can be done if these requirements at home are fulfilled:
Have separate bedroom and bathroom that is not shared with other family members.
Have access to food and other necessities.
Has access to face masks, gloves and disinfectant at home.
Able to seek medical care if necessary and return with own private transport.
Able to follow instructions for home surveillance.
No family members at home who are considered high risk e.g. elderly, young children, having chronic diseases.
DO NOT go for RTK-Ab (Rapid Test Kit-Antibody as a confirmatory test or screening method because if it is positive, it does not reflect the current presence or infectious status of the virus. It merely indicates past exposure to COVID-19. If it is negative, it does not mean that the person is not exposed to the virus. It is possible that the antibody to COVID-19 has not developed at the time the test was done and the antibody could develop later and result in a positive result. Therefore, DO NOT DO RTK-Ab test on your own to avoid such diagnostic confusion.
If you feel unwell (FEVER, COUGH, SORETHROAT, SHORTNESS OF BREATH) and worries about the possibility of getting COVID-19, please do not go for COVID-19 testing immediately. The first thing you should do is to put on a mask, use hand sanitizers or wash your hands before and after you touch anything. Most importantly STAY AT HOME! Do not go anywhere, not even to the clinic yet. Give your doctor a call. Let the doctor talk to you to find out more about your symptoms. If you could video call your doctor even better. Let your doctor decide if the symptoms and history presented are consistent with COVID-19 or not. It could be other diseases e.g. heart attack, lung infection, dengue or other medical conditions that should be managed differently instead of going to the lab to request for a COVID-19 test.
After assessing you remotely, if the doctor thinks that you are not so ill to warrant a visit to the hospital or clinic, he might just prescribe you with some medicine to control the symptoms first. Please keep in touch with your doctor to update your condition. If it is just common cold or mild upper respiratory tract infection, you would feel better or at least your symptoms would not worsen. However, if you feel your symptoms worsen especially SHORTNESS OF BREATH, then your doctor may advise you to go to the hospital straight away for further testing to rule out COVID-19.
The reason I would prefer patients to home quarantine themselves if they are qualified is because I assume they could rest and be better cared for at home. Bear in mind that if you are not able to physically isolate yourself from other family members, then please consider going to the quarantine center.
The spread of COVID-19 can only be stopped if everyone minimizes their movement and contact with other people. Doing RT-PCR or RTK-Ag alone will not help. STAYING AT HOME WILL HELP to break the chain of infection. This is especially true for asymptomatic spreaders. Everyone must have this mindset that they could potentially be positive therefore they must avoid spreading the virus to other people. Everyone must also assume everybody they meet could potentially be positive therefore do their best to avoid being infected. All these could be easily achieved with faithful adherence to wearing mask, using hand sanitizer and social distancing or just STAYING AT HOME!
Our politicians currently have a lot at stake i.e. power struggle, economic recession, political instability. They will always take the middle path or the path with the least resistance to maximize the number of people they will please. The health policy makers and technocrats are also not independent of their political masters. They are not supposed to issue any public statement that would jeopardize the peace and cause society to panic.
For us common people, OUR PRIORITY IS TO KEEP OURSELVES AND OUR LOVED ONES SAFE. That is all that matters for the time being. So do what is right. #kitajagakita
Heart attack remains the leading cause of death in Malaysia for the 14th year.
Ischaemic heart diseases, which occur when arteries of the heart cannot deliver enough oxygen-rich blood to the heart, continued to be the main cause of death in Malaysia last year with a total of 18,267 deaths or 15.6% of total deaths from various causes, the latest Statistics on Causes of Death in Malaysia released by the Department of Statistics Malaysia (DOSM) revealed.
It was the principal cause of death for males in Malaysia with 12,510 deaths (17.8%) while for females, the principal cause of death was pneumonia with 6,033 deaths (12.8%), it said.
Last year, 172,031 total deaths from various causes were recorded, an increase of 2.3% compared to 168,168 in 2017, it said.
“On average, 50 persons in Malaysia die of ischaemic heart diseases every day,” DOSM said in the statistics released yesterday.
According to the National Heart, Lung and Blood Institute in the United States, the most common type of ischaemic heart diseases is coronary heart disease (also known as coronary artery disease).
It is caused by the build-up of plaque inside the coronary arteries. The build-up can partially or totally block blood flow in the large arteries of the heart. The condition may be caused by disease or injury which affects how the arteries work in the heart.
Coronary microvascular disease is another type of ischaemic heart diseases which occurs when the heart’s tiny arteries do not function normally. Risk factors include smoking, high blood pressure, high cholesterol, diabetes, being physically inactive, overweight or obese, and family history. DOSM said ischaemic heart diseases were the principal cause of death in 90 administrative districts in Malaysia and the highest percentage was recorded in Petaling, Selangor (16.3%).
Urban areas recorded 12,101 cases, double that in rural areas (6,166 cases), it said.
Pneumonia was the principal cause of death in 48 administrative districts with the highest percentage recorded in Kota Setar, Kedah (17.8%). The number of deaths due to ischaemic heart diseases in Malaysia in 2010 was 9,371 and the figures increased gradually through the years. The jump increased more prominently from 2016 to 2017 (13.9%) and from 2017 to 2018 (15.6%).
After ischaemic heart diseases, the second main cause of death last year was pneumonia (11.8%), followed by cerebrovascular diseases (7.8%), transport accidents (3.7%) and chronic lower respiratory diseases (2.6%). On the main causes of death by age group, 4.8% of those aged 0 to 14 died of pneumonia and 20.4% of those aged 15 to 40 died in transport accidents. The main cause of death among those above age 40 was ischaemic heart diseases: ages 41 to 59 (19.2%) and ages 60 and above (16.6%).
What is EECP®️? It stands for Enhanced External Counter Pulsation.
What is the difference between EECP®️ and ECP? The technology of reversing heart ischemia without surgery by enhancing coronary collateral flow using external pneumatic lower limbs cuffs synchronized to the diastolic phase of cardiac cycle is generally known as ECP (External Cardiac Pulsation). EECP®️ is a registered trademark of a certain ECP machine marketed by the Vasomedical, Inc. In terms of form and functions, both are basically the same and the term EECP®️ and ECP are often used interchangeably.
How does ECP reverse heart ischemia? This technology of pumping blood into the coronary arteries when the heart is in the relaxed phase has been developed since 1953 by the Kantrowitz brothers from Harvard University. They invented the IABP (Intra Aortic Balloon Pump) which has been refined over the years and still being used today to treat cardiogenic shock. This procedure is highly invasive and only highly skilled Interventional Cardiologists are qualified to perform this procedure. However, due to IABP's effectiveness in improving the heart coronary blood flow, this concept of 'diastolic augmentation' has been modified from 'internal-IABP' to 'external-ECP' by Dr.Sarnoff and Dr. Birtwell to enable more people both healthy and sick, to have access to this technology to improve blood circulations to the heart, brain, kidneys and liver effectively. The milking of of blood from the lower-limbs in a sequential manner from calf to thigh to buttocks are able to increase blood flow to the heart as much as 20-40%. EECP®️/ECP is able to increase blood flow to the heart and vital organs without any surgery, painlessly and without needles. ECP does so by compressing the lower limbs and buttocks using pneumatic cuffs effectively.
Does it mean any massage machine that compresses the legs is able to achieve the same effectiveness as EECP? No. Diastolic augmentation is only effective when the counter pulsation machine is able to generate a peak diastolic arterial waveform that is 1.5 to 2 times higher than the peak systolic arterial waveform. Thus the timing accuracy and the effective pressure transmission of the ECP machine are two vital features that make ECP therapeutic compared to an ordinary calf massage machine.
Why is it that I have never heard of ECP treatment before? ECP is a disruptive innovation that could change the course of heart disease progression if the intervention is timely. The more ECP is proven to be effective in reducing the number of heart attacks, the less cases of heart bypass and angioplasty may be possible in the near future. If the medical facility you visit considers this scenario as a conflict of interest, you will most probably not hear of ECP being promoted. However, heart centers offering holistic heart treatment would have the ECP incorporated in their heart rehabilitation module. To date ECP is available in more than 40 countries in the world. Now ECP is also available in Kota Kinabalu @ DamaiMedic Oasis Medi-Hub. You can call +6016-4117100 for more info about EECP/ECP therapy.
Who will benefit from ECP therapy? Those who have:
Chest pain (stable angina)
Known heart blockages
Stenting and bypass surgery done previously
Poor energy and easy fatigability
High risk factor for diabetes, hypertension, hypercholesterolemia.
Sedentary lifestyle (no exercise)
Need for general well-being
If you have any of these conditions below, ECP is not advisable:
Pregnant
Arrhythmias
Aortic Aneurysm
Blood Pressure more than 180/110mmHg
Pacemaker/ Defibrillator
Pulmonary Hypertension
Acute Decompensated Heart Failure
Haemorrhagic Stroke
Venous Thrombosis in Lower Limbs
On Warfarin with INR >3.0
Bleeding Disorders
What is the mechanism of ECP? Well, let the Dr Wong Teck Wee, the Interventional Cardiologist explain:
What are the evidences to prove ECP therapy really works? The European Society of Cardiology (ESC) has given the recommendation of Class IIa with Level of Evidence B in their clinical guideline for patients with Refractory Angina Pectoris.
Major EECP studies like IEPR2, MUST-EECP and PEECH Trial provide convincing evidences on the role of EECP in cardiovascular care.
Do you know that higher breast density is associated with higher risk of developing breast cancer? The article below seems to support the evidence (click here for the full article).
This article suggests that it is not good enough to do mammogram at 40 years old and older to detect breast cancer. Breast density percent which can be calculated from mammogram are convincingly suggesting the link between denser breast with higher risk of developing breast cancer. Sounds like we have another useful modifiable risk factor which can help us in our quest of preventing breast cancer that attacks 1 in 16 women in Malaysia.
But we have a problem. We don't routinely do mammogram for women below 40 years old. This is due to 2 reasons; 1) Women less than 40 years old have denser breast which may mask any abnormal breast growth thus negatively affecting the mammogram's sensitivity to detect cancer. 2) If this rule is not strictly adhered to, we will be having lots of women in their teens and 20's doing mammogram for screening purpose and subjecting their developing breasts to potentially harmful X-ray radiations. Young women may risk developing breast cancer when they are older if their breasts are exposed to ionizing radiation like mammogram when their breast are immature and still developing.
But all hope is not lost. A rather convincing estimation of breast density can be achieved with ultrasonography of the breasts. Ultrasound breast does not emit ionizing radiation, thus it is safe to do (even repeatedly) on young or developing breasts.
Alternatively, in my clinical practice, a low-tech and simple manual breast examination would reliably distinguish a lumpy breast from a normal (non-lumpy) breast tissue. Establishing an abnormal breast growth (ie Cancer) among lumpy breast tissues is more challenging. In other words, a lumpy breast detected by manual breast examination is more likely to be a dense breast. Alternatively, a non-lumpy breast tissue detected by manual breast examination is more likely to be not dense.
So what can we do when we know our breast is dense? The current medical establishment approach to breast care is rather fatalistic in my personal opinion. They are focusing on detecting abnormalities (breast cancer) early rather than prevent its occurrence altogether. It is equivalent to saying that we are expecting a robber to come to our house (because of certain risk factors) and our only strategy is to anticipate the robber's arrival as early as possible so that we can catch the robber successfully. Nothing wrong with that idea. But personally, I would rather establish a local security force and stop any unregistered stranger from entering the gated neighborhood. I don't know about you but my family feels less traumatized if I can stop the robber from even entering my neighborhood altogether.
Risk factors for developing breast cancer are well-established namely:
Older age (the older she gets, the higher her risk)
Age of menarche (the earlier her first menses, the higher her risk)
Nulliparous (never given birth before, the higher her risk)
Late child birth (the later she delays having a baby, the higher her risk)
Not breast feeding (higher risk compared to moms who breastfeed)
Use of oral contraceptive (the earlier and longer duration of OCPs use, the higher her risk)
Positive family history of breast cancers in 1st degree relatives (15% chance higher risk)
Frequency of previous benign breast growth (the more growth, the higher her risk)
Genetics (BRCA1 & BRACA2); if she has this gene, the higher her risk. Remember Angelina Jolie removing both her breasts for this?)
I am not sure if you have noticed that most of the risk factors above are beyond your control. You don't get to choose your parents, do you? And it is not like you can stop aging or delay menarche or when you will meet your Mr Right and procreate.
Therefore, detecting a dense breast by virtue of self-breast examination or ultrasonographic examination at the doctor's office seemed to be a more practical and acceptable solution.
So what causes dense breast? When we say dense breast, we are actually referring to the 'water' component of the breast rather than the fat tissues. In mammogram, the milk glands, blood vessels and lymphatics complex which constitutes the 'water' component of the breast appears white and so is differentiated from the fat tissues that appears darker. The percentage density is thus calculated. Breast density can be influenced by hormones such as estrogen and human growth hormones. Apart from stimulatory effects, these hormones cause water retention. Any obstruction in the lymphatic, mammary ducts and venous return can compromise the breast fluid circulation. Therefore, non-pharmaceutical methods of improving breast lymphatics and blood circulations includes:
Massage and suction devices: providing direct positive and negative pressures, assisting in the flow of fluids in the intra-vascular, intra-compartmental, and trans-cellular compartments of the breast.
Direct Tactile Vibrations at 120Hz: reducing blood vessels resistance by unclogging capillaries and preventing stasis of the lymphatics at the extracellular spaces.
Far-Infra Red (3-12 um): stimulatory effects on cells and tissues, promoting healing.
Negative ions: restoring the negative charge/cations on cell surfaces and the cellular milieu for optimal cell functioning and intra-cellular communication/signalling.
Devices which support breast care are available in the market. Nevertheless, it cannot be over-emphasized that a good diet, regular exercise, normal sleep wake cycle, loving relationships and inner peace are all essential components in a holistic model of breast care.
