NEW YORK (Reuters Health) Jul 18 - In a study that flies in the face of common sense, sicker patients fared worse under the care of seasoned doctors than when younger doctors looked after them.
According to findings published online July 11th in the American Journal of Medicine, patients whose doctors had practiced for at least 20 years stayed longer in the hospital and were more likely to die compared to those whose doctors were licensed in the past five years.
The results highlight "issues that we have as a medical profession in keeping up to date" with the latest medical knowledge, said Dr. Niteesh Choudhry of Harvard Medical School, who was not involved in the new study. It is "a quality of care problem that has been recognized for five to 10 years," he told Reuters Health.
Dr. William Southern and colleagues looked at records of more than 6,500 patients who'd been hospitalized between 2002 and 2004 on the general medical service at New York City's Montefiore Medical Center in the Bronx.
The patients were first seen by a resident who randomly assigned them to one of the hospital's six medical teams. Each team has a medical student, residents, and an attending physician.
Over the course of the study, there were 59 different attending physicians. The researchers stratified them according to how long they'd been practicing: five years or less, six to 10 years, 11 to 20 years, or more than 20 years.
Because the researchers thought doctors might behave differently with their own long-time patients, they confined the study to cases in which patient and doctor had never met before.
In comparing the most and least experienced doctors, researchers saw the most-experienced group had more patients die in the hospital.
At first glance, compared to patients with the newest doctors, those with the most experienced physicians had more than a 70% increase in their odds of dying in the hospital and a 50% increase in their odds of dying within 30 days.
However, when the researchers took into account how sick the patients were, they found that only the more complex patients were at higher risk in the hands of the more experienced doctors.
Dr. Southern's group also found that while the doctor's experience played a role in patients' length of stay, the doctor's in-patient volume also mattered.
When the volume was low, doctors kept patients in the hospital for roughly the same average time no matter how many years of experience they had. But when they did have a lot of patients to see in the hospital, those with more than 20 years of experience kept patients there about half a day longer than their peers who'd been practicing for less than five years.
Previous research has found similar results across a variety of physician specialties. Earlier studies have also shown that physicians with more time in practice are less likely to adhere to practice guidelines.
"It's not quite as simple to say that as you get further away from training, your quality gets worse," cautioned Dr. Choudhry.
The problem, he said, is not with the capability of the more experienced doctors, but rather, their familiarity with more current guidelines and practices. The results suggest the need to rethink the way doctors are continually educated in the years after completing their certification, he added.
The authors suggest that physicians with more than 20 years in practice be required to recertify periodically. Most of the older doctors in the current study are presently exempt from having to take recertification tests, they say.
Most doctors do participate in continuing medical education programs. But much of it is passive, consisting mostly of attending lectures and reading journal articles. Dr. Choudhry thinks it would be better to develop educational programs that would actively engage the more experienced physicians.
Dr. Steven Weinberger, executive vice president and CEO of the American College of Physicians, cautioned that it is premature to make drastic changes based on the results of the study, which only looked at small numbers of attending physicians. He also came up with several alternative explanations for the findings.
For instance, the fact that patients were in a teaching hospital might have contributed to the different rates of death, since more experienced doctors might give the residents more autonomy. And the varying lengths of stay could reflect a cultural difference in today's younger physicians, who are taught to focus on reducing hospital stays.
But despite his concerns about the study, Dr. Weinberger agreed, "It is important for physicians to stay as current as possible."
Tuesday, July 26, 2011
Tuesday, May 31, 2011
Fluid Resuscitation in Acute Illness — Time to Reappraise the Basics- NEW ENGLAND JOURNAL OF MEDICINE
Editorial
Fluid Resuscitation in Acute Illness — Time to Reappraise the Basics
John A. Myburgh, M.B., B.Ch., Ph.D.
May 26, 2011 (10.1056/NEJMe1105490)
Article
References
Fluid resuscitation is a fundamental intervention in the treatment of critically ill patients. However, there is little conclusive evidence to guide clinicians about the best type of resuscitation fluid; the appropriate timing, volume, and rate of fluid administration; and the optimal way to adequately monitor the efficacy and safety of fluid resuscitation in various clinical conditions.1
Although the complications associated with excessive volume of resuscitation fluid — such as pulmonary and interstitial edema — are well recognized, an emerging body of evidence suggests that the type of resuscitation fluid may adversely affect the outcomes in specific clinical conditions; for example, albumin is associated with increased mortality in patients with traumatic brain injury,2 and high-molecular-weight preparations of hydroxyethyl starch are associated with acute kidney injury in patients with severe sepsis.3
Conversely, improved outcomes associated with the use of albumin for resuscitation have been shown in children with severe malaria4 and in a subgroup of adults with severe sepsis in the Saline versus Albumin Fluid Evaluation study (SAFE; Current Controlled Trials number, ISRCTN76588266).5,6 However, these reports were not sufficiently conclusive to justify the adoption of strong clinical recommendations.
The results of the Fluid Expansion as Supportive Therapy (FEAST) trial,7 reported in this issue of the Journal, are an important contribution to the literature. This remarkable, pragmatic, randomized, controlled trial, conducted in six hospitals in Kenya, Tanzania, and Uganda, assessed the effects of bolus-fluid resuscitation with albumin or saline as compared with no bolus fluid in children with febrile medical illness and impaired perfusion. Children with severe hypotension, or decompensated shock, received boluses of either albumin or saline for resuscitation. The trial centers had no access to intensive care units, and the trial included a comprehensive education program aimed at optimizing early case recognition and by training in emergency pediatric life support. The primary outcome was 48-hour mortality — a relevant patient-centered outcome in regions in which the high prevalence of severe sepsis in children, often due to malaria, is associated with high early mortality.8
The trial was powered to determine a plausible absolute risk reduction in 48-hour mortality (as derived from power calculations described in the Methods section in the article) of 5 percentage points and was conducted with high standards of internal validity — excellent randomization procedures, a high rate of adherence to the protocol, concealment of the treatment assignments, a minimal loss to follow-up, the use of the intention-to-treat principle for the analyses, and performance of analyses according to prespecified subgroups. The sample size was appropriately increased from 2800 patients to 3600 patients after an interim analysis showed that the rate of death was lower than predicted in the intervention groups. However, the trial was stopped after the recruitment of 3141 patients when bolus-fluid resuscitation with albumin or saline was shown to increase the absolute risk of death at 48 hours by 3.3 percentage points and the risk of death, neurologic sequelae, or both at 4 weeks by 4 percentage points. No difference in mortality was observed in patients with decompensated shock, although these patients were few in number and had significantly higher mortality. The excess mortality associated with bolus-fluid resuscitation was consistent across all prespecified subgroups, which included subgroups according to age, lactate level, base deficit, presence or absence of severe anemia, and status with respect to coma and malaria.
These results will have an immediate effect on the way children presenting with febrile illness due to medical causes and with associated hypotension are treated in resource-poor settings. In conjunction with a program of education and training, discontinuation of the practice of bolus-fluid resuscitation in patients with febrile illness due to medical causes and impaired perfusion or compensated shock must be recommended. Given that 2 million children die from this condition each year in sub-Saharan Africa, the potential impact is enormous. Extrapolating these results to children with other hypotensive conditions, such as severe dehydration from gastroenteritis and malnutrition, burns, and surgery, is not justified on the basis of these data; further research would be required.
The results of the FEAST trial, as with those of other trials that generated results contrary to clinical opinion and practice,9,10 make it imperative that we reappraise the fundamentals. Early identification of shock, basic life support, and early antimicrobial therapy remain at the forefront of the clinical care of young patients with severe infection and shock. It is highly probable that education, training, and participation in a high-quality, randomized, controlled trial itself had a substantive positive effect on the overall rate of death, although these factors were not directly assessed in this trial. However, the entrenched practice of fluid-bolus resuscitation in patients with compensated shock remains highly questionable.
We can only speculate about the mechanisms by which bolus-fluid resuscitation had adverse biologic effects in these patients. Potential mechanisms may include the interruption of genetically determined catecholamine-mediated host defense responses by the rapid increase in plasma volume, which might result in a reperfusion injury. Similarly, transient hypervolemia or hyperosmolality might exacerbate capillary leak in patients who are susceptible to intracranial hypertension2 or pulmonary edema, with fatal consequences.
How should clinicians who work under circumstances different from those in this trial — that is, in high-income countries with access to intensive care units — or clinicians who care for adult patients interpret the results of this important trial? It seems clear that the results of this trial indicate that bolus-fluid resuscitation with either crystalloids or colloids in patients with compensated shock who do not have a clinical fluid deficit must be practiced with much greater caution than is now the case and with increased vigilance.
Fluid resuscitation is such a fundamental intervention in acute medicine that these results indicate that further high-quality research is urgently required to define appropriate practice for fluid resuscitation, including a study of the timing and rates of fluid administration and ways to monitor its effects. Similarly, a careful assessment of the safety, efficacy, and cost-effectiveness of various resuscitation fluids is mandatory before their incorporation into clinical practice.
The courage and dedication of the FEAST investigators and attending clinicians must be acknowledged, not only because of the quality of the research they conducted in this vitally important area of acute medicine, but also because they conducted a landmark trial in such challenging economic conditions in sub-Saharan Africa.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMe1105490) was published on May 26, 2011, at NEJM.org.
Source Information
From the George Institute for Global Health and University of New South Wales, Sydney.
Fluid Resuscitation in Acute Illness — Time to Reappraise the Basics
John A. Myburgh, M.B., B.Ch., Ph.D.
May 26, 2011 (10.1056/NEJMe1105490)
Article
References
Fluid resuscitation is a fundamental intervention in the treatment of critically ill patients. However, there is little conclusive evidence to guide clinicians about the best type of resuscitation fluid; the appropriate timing, volume, and rate of fluid administration; and the optimal way to adequately monitor the efficacy and safety of fluid resuscitation in various clinical conditions.1
Although the complications associated with excessive volume of resuscitation fluid — such as pulmonary and interstitial edema — are well recognized, an emerging body of evidence suggests that the type of resuscitation fluid may adversely affect the outcomes in specific clinical conditions; for example, albumin is associated with increased mortality in patients with traumatic brain injury,2 and high-molecular-weight preparations of hydroxyethyl starch are associated with acute kidney injury in patients with severe sepsis.3
Conversely, improved outcomes associated with the use of albumin for resuscitation have been shown in children with severe malaria4 and in a subgroup of adults with severe sepsis in the Saline versus Albumin Fluid Evaluation study (SAFE; Current Controlled Trials number, ISRCTN76588266).5,6 However, these reports were not sufficiently conclusive to justify the adoption of strong clinical recommendations.
The results of the Fluid Expansion as Supportive Therapy (FEAST) trial,7 reported in this issue of the Journal, are an important contribution to the literature. This remarkable, pragmatic, randomized, controlled trial, conducted in six hospitals in Kenya, Tanzania, and Uganda, assessed the effects of bolus-fluid resuscitation with albumin or saline as compared with no bolus fluid in children with febrile medical illness and impaired perfusion. Children with severe hypotension, or decompensated shock, received boluses of either albumin or saline for resuscitation. The trial centers had no access to intensive care units, and the trial included a comprehensive education program aimed at optimizing early case recognition and by training in emergency pediatric life support. The primary outcome was 48-hour mortality — a relevant patient-centered outcome in regions in which the high prevalence of severe sepsis in children, often due to malaria, is associated with high early mortality.8
The trial was powered to determine a plausible absolute risk reduction in 48-hour mortality (as derived from power calculations described in the Methods section in the article) of 5 percentage points and was conducted with high standards of internal validity — excellent randomization procedures, a high rate of adherence to the protocol, concealment of the treatment assignments, a minimal loss to follow-up, the use of the intention-to-treat principle for the analyses, and performance of analyses according to prespecified subgroups. The sample size was appropriately increased from 2800 patients to 3600 patients after an interim analysis showed that the rate of death was lower than predicted in the intervention groups. However, the trial was stopped after the recruitment of 3141 patients when bolus-fluid resuscitation with albumin or saline was shown to increase the absolute risk of death at 48 hours by 3.3 percentage points and the risk of death, neurologic sequelae, or both at 4 weeks by 4 percentage points. No difference in mortality was observed in patients with decompensated shock, although these patients were few in number and had significantly higher mortality. The excess mortality associated with bolus-fluid resuscitation was consistent across all prespecified subgroups, which included subgroups according to age, lactate level, base deficit, presence or absence of severe anemia, and status with respect to coma and malaria.
These results will have an immediate effect on the way children presenting with febrile illness due to medical causes and with associated hypotension are treated in resource-poor settings. In conjunction with a program of education and training, discontinuation of the practice of bolus-fluid resuscitation in patients with febrile illness due to medical causes and impaired perfusion or compensated shock must be recommended. Given that 2 million children die from this condition each year in sub-Saharan Africa, the potential impact is enormous. Extrapolating these results to children with other hypotensive conditions, such as severe dehydration from gastroenteritis and malnutrition, burns, and surgery, is not justified on the basis of these data; further research would be required.
The results of the FEAST trial, as with those of other trials that generated results contrary to clinical opinion and practice,9,10 make it imperative that we reappraise the fundamentals. Early identification of shock, basic life support, and early antimicrobial therapy remain at the forefront of the clinical care of young patients with severe infection and shock. It is highly probable that education, training, and participation in a high-quality, randomized, controlled trial itself had a substantive positive effect on the overall rate of death, although these factors were not directly assessed in this trial. However, the entrenched practice of fluid-bolus resuscitation in patients with compensated shock remains highly questionable.
We can only speculate about the mechanisms by which bolus-fluid resuscitation had adverse biologic effects in these patients. Potential mechanisms may include the interruption of genetically determined catecholamine-mediated host defense responses by the rapid increase in plasma volume, which might result in a reperfusion injury. Similarly, transient hypervolemia or hyperosmolality might exacerbate capillary leak in patients who are susceptible to intracranial hypertension2 or pulmonary edema, with fatal consequences.
How should clinicians who work under circumstances different from those in this trial — that is, in high-income countries with access to intensive care units — or clinicians who care for adult patients interpret the results of this important trial? It seems clear that the results of this trial indicate that bolus-fluid resuscitation with either crystalloids or colloids in patients with compensated shock who do not have a clinical fluid deficit must be practiced with much greater caution than is now the case and with increased vigilance.
Fluid resuscitation is such a fundamental intervention in acute medicine that these results indicate that further high-quality research is urgently required to define appropriate practice for fluid resuscitation, including a study of the timing and rates of fluid administration and ways to monitor its effects. Similarly, a careful assessment of the safety, efficacy, and cost-effectiveness of various resuscitation fluids is mandatory before their incorporation into clinical practice.
The courage and dedication of the FEAST investigators and attending clinicians must be acknowledged, not only because of the quality of the research they conducted in this vitally important area of acute medicine, but also because they conducted a landmark trial in such challenging economic conditions in sub-Saharan Africa.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMe1105490) was published on May 26, 2011, at NEJM.org.
Source Information
From the George Institute for Global Health and University of New South Wales, Sydney.
Sunday, May 29, 2011
Dr Chow Yok Wai - MD, MRCP(UK), AM(Mal)
1. Education
Basic Medical Qualification
University Attended: University of Science Malaysia
Degree Obtained: Doctor of Medicine (MD)
Date Awarded: 25th July 1999
MRCP (Member of the Royal College of Physicians)
Date Awarded: 22nd July 2003
2. Working Experience and Present Appointment
July 1999-October 2000
• Commenced internship training in Sultanah Aminah Hospital Johor Bahru
(HSAJB), Malaysia
• Underwent 18 months training in General Medicine, General Surgery
(Including Plastic Surgery, Urology, Neurosurgery and Paediatric Surgery),
Obstetrics and Gynaecology, Orthopaedics and General Paediatrics.
November 2000-March 2001
• Joined the Department of Medicine HSAJB as a medical officer
• Commenced subspeciality rotation in Nephrology
April 2001-October 2001
• Haematology rotation
November 2001-March 2002
• Neurology rotation
April 2002-November 2002
• Infectious Disease and Intensive Medicine rotation
December 2002-July 2003
• Cardiology, Respiratory Medicine, Gastroenterology and Endocrinology
rotation
July 2003-December 2004
• Granted membership to the Royal College of Physicians of United Kingdom
• Assigned to a 35 bedded general medical ward as general physician in Sultanah Aminah Hospital Johor Bahru, Malaysia upon completion of MRCP
January 2005-June 2006
• Commencement of Nephrology Subspeciality Training
(Nephrology Followship Programme) in HSAJB
July 2006-December 2007
• Completion of Nephrology Subspeciality Training in Kuala Lumpur
Hospital, Malaysia
January 2008- February 2010
• Attached to the Nephrology Unit, Department of Medicine, HSAJB as Consultant Nephrologist and Physician.
February 2010 – to date
• Consultant Nephrologist and Physician,
Hospital Pantai Ayer Keroh
75450, Melaka
3. Registration as a Medical Practitioner
5th July 2000
• Full registration with the Malaysian Medical Council
12th November 2008
• Full registration with the General Medical Council of United Kingdom
4. Official Gazettement by the Government of Malaysia (Ministry of Health)
22nd January 2005
• Gazetted as a Internal Medicine specialist
1st January 2008
• Gazetted as a Nephrologist
5. Professional Activities
2003
Clinical attachment in the New Royal Infirmary of Edinburgh, Scotland
Department of Nephrology
Position: Visiting Registrar
Supervisor: Dr Robin Winnie
Consultant Nephrologist
New Royal Infirmary of Edinburgh
Edinburgh
2008
Attended the Malaysian Nephrology Board Examination on 9th May 2008
Conducted by the Nephrology Board Malaysia
(Malaysian Society of Nephrology, Ministry of Health Malaysia, Academy of
Medicine, Malaysia)
Obtained the highest marks in the 2008 cohort
2008-2009
Awarded a full scholarship by the Public Services Department of Malaysia to
pursue a one year advance nephrology training in the field of vasculitis in Addenbrooke’s Hospital Cambridge University Hospitals NHS Foundation Trust
Position: Honorary Clinical Research Fellow
Supervisor: 1) Dr David Jayne
Director of Lupus and Vasculitis,
Addenbrooke’s Hospital
Cambridge University Hospitals NHS Foundation Trust
2) Professor Kenneth Smith
Cambridge Institute of Medical Research,
University of Cambridge,
United Kingdom.
2008- 2010
Coordinator for National Glomerulonephritis Registry, National Renal Registry
(Johor Bahru)
6. Professional Bodies
National
Member of the Malaysian Medical Association
Member of the Malaysian Society of Nephrology
Member of the Postgraduate Renal Society, Malaysia
International
Member of the Royal College of Physicians of Edinburgh
Member of the International Society of Nephrology
Member of the IgA International Network
7. Research Activities
Publications:-
Acute renal failure in the same hospital 10 years apart; A comparison of two prospective studies in Sultanah Aminah Hospital, Johor Bahru
Medical Journal of Malaysia Vol 62 No1 March 2007
Lactic acidosis in HIV patients receiving highly active antiretroviral therapy- the Johor Bahru experience
Medical Journal of Malaysia Vol 62 No 1 March 2007
Quality improvement in Department of Nephrology, Kuala Lumpur Hospital- an audit on clinical performance indicators
Journal of Quality Improvement Vol 10 No 2 2007
Rituximab in Behcet’s Disease
Submitted to Annals of Rheumatic Diseases for publication (May 2009)
Participation in clinical studies:-
National
HDP study- Hospitalisation rate among Dialysis Patients study (2007)
International
GIANT study- Greatest International Antibiotic Trial study (2006)
A randomized double blind placebo controlled multicenter study to evaluate the efficacy and safety of two doses of Ocrelizumab in patients with WHO or ISN Class III or IV nephritis due to systemic lupus erythematosus (2008)
A phase III multicentre, double blind, double dummy, randomized flexible dose comparative study of MCI-196 versus Simvastatin for the treatment of dyslipidaemia in subjects with chronic kidney disease on dialysis (2009)
Evaluation of chronic kidney disease patterns through the global information database (GRID) (2009)
Biologic therapies in neuro-behcet’s disease, an international collaborative case-series- neurobehcet study group, International Society of Behcet’s Disease (2009)
CHiC-TRIAD (Cambridge Hinxton Centre for Translational Research In Autoimmune Disease) (2008-2009)
MY-CYC (A randomised clinical trial of mycophenolate mofetil versus cyclophosphamide for remission induction in ANCA associated vasculitis) (2008-2009)
Abstracts:-
National
OUTCOME OF A COMMUNITY BASED HEALTH SCREENING PROGRAMME DURING THE PUBLIC AWARENESS CAMPAIGN ON KIDNEY CARE IN JOHOR BAHRU, MALAYSIA
Oral Presentation- 22nd MSN Annual Seminar in Nephrology
Prevention of Chronic Kidney Disease
MYCOPHENOLATE MOFETIL IN RELAPSING LUPUS NEPHRITIS
23rd Malaysian Society of Nephrology Annual Seminar
Johor Bahru, Malaysia
11-13th April 2007
MYCOPHENOLATE MOFETIL IN MEMBRANOUS NEPHROPATHY
23rd Malaysian Society of Nephrology Annual Seminar
Johor Bahru, Malaysia
11-13th April 2007
International
ACUTE RENAL FAILURE IN THE SAME HOSPITAL 10 YEARS APART;
A COMPARISON OF TWO PROSPECTIVE STUDIES IN SULTANAH AMINAH
HOSPITAL, JOHOR BAHRU, MALAYSIA
Poster Presentation- 3rd World Congress of Nephrology
Post Congress Satellite Symposium
Acute Renal Failure: From Bench to Bedside
1st -3rd July 2005
LACTIC ACIDOSIS IN HIV PATIENTS RECEIVING HIGHLY ACTIVE ANTIRETROVIRAL THERAPY- THE JOHOR BAHRU EXPERIENCE
Oral Presentation
14th IUSTI Asia Pacific International Conference- 27th to 30th July, 2006
ADULT POLYCYSTIC KIDNEY DISEASE IN PATIENTS ON DIALYSIS IN MALAYSIA
11th Asian Pacific Congress of Nephrology 2008
ELDERLY PATIENTS INITIATING DIALYSIS IN MALAYSIA
11th Asian Pacific Congress of Nephrology 2008
MALIGNANCY POST RENAL TRANSPLANTATION: A 25 YEAR EXPERIENCE
11th Asian Pacific Congress of Nephrology 2008
LATE ACUTE ANTIBODY MEDIATED REJECTION ASSOCIATED WITH CALCINEURIN INHIBITOR MINIMISATION
11th Asian Pacific Congress of Nephrology 2008
CASTLEMAN’S DISEASE OF THE KIDNEY IN PATIENT WITH SLE
11th Asian Pacific Congress of Nephrology 2008
CLINICAL BENEFITS OF ICODEXTRIN: A SINGLE CENTRE EXPERIENCE
11th Asian Pacific Congress of Nephrology 2008
‘SUDOKU’ INCREASES COGNITIVE FUNCTION IN HAEMODIALYSIS PATIENTS- A PROSPECTIVE PILOT STUDY (Awarded Best Abstract)
11th Asian Pacific Congress of Nephrology 2008
SHORT TERM INFECTIOUS COMPLICATIONS POST RENAL TRANSPLANT
11th Asian Pacific Congress of Nephrology 2008
Basic Medical Qualification
University Attended: University of Science Malaysia
Degree Obtained: Doctor of Medicine (MD)
Date Awarded: 25th July 1999
MRCP (Member of the Royal College of Physicians)
Date Awarded: 22nd July 2003
2. Working Experience and Present Appointment
July 1999-October 2000
• Commenced internship training in Sultanah Aminah Hospital Johor Bahru
(HSAJB), Malaysia
• Underwent 18 months training in General Medicine, General Surgery
(Including Plastic Surgery, Urology, Neurosurgery and Paediatric Surgery),
Obstetrics and Gynaecology, Orthopaedics and General Paediatrics.
November 2000-March 2001
• Joined the Department of Medicine HSAJB as a medical officer
• Commenced subspeciality rotation in Nephrology
April 2001-October 2001
• Haematology rotation
November 2001-March 2002
• Neurology rotation
April 2002-November 2002
• Infectious Disease and Intensive Medicine rotation
December 2002-July 2003
• Cardiology, Respiratory Medicine, Gastroenterology and Endocrinology
rotation
July 2003-December 2004
• Granted membership to the Royal College of Physicians of United Kingdom
• Assigned to a 35 bedded general medical ward as general physician in Sultanah Aminah Hospital Johor Bahru, Malaysia upon completion of MRCP
January 2005-June 2006
• Commencement of Nephrology Subspeciality Training
(Nephrology Followship Programme) in HSAJB
July 2006-December 2007
• Completion of Nephrology Subspeciality Training in Kuala Lumpur
Hospital, Malaysia
January 2008- February 2010
• Attached to the Nephrology Unit, Department of Medicine, HSAJB as Consultant Nephrologist and Physician.
February 2010 – to date
• Consultant Nephrologist and Physician,
Hospital Pantai Ayer Keroh
75450, Melaka
3. Registration as a Medical Practitioner
5th July 2000
• Full registration with the Malaysian Medical Council
12th November 2008
• Full registration with the General Medical Council of United Kingdom
4. Official Gazettement by the Government of Malaysia (Ministry of Health)
22nd January 2005
• Gazetted as a Internal Medicine specialist
1st January 2008
• Gazetted as a Nephrologist
5. Professional Activities
2003
Clinical attachment in the New Royal Infirmary of Edinburgh, Scotland
Department of Nephrology
Position: Visiting Registrar
Supervisor: Dr Robin Winnie
Consultant Nephrologist
New Royal Infirmary of Edinburgh
Edinburgh
2008
Attended the Malaysian Nephrology Board Examination on 9th May 2008
Conducted by the Nephrology Board Malaysia
(Malaysian Society of Nephrology, Ministry of Health Malaysia, Academy of
Medicine, Malaysia)
Obtained the highest marks in the 2008 cohort
2008-2009
Awarded a full scholarship by the Public Services Department of Malaysia to
pursue a one year advance nephrology training in the field of vasculitis in Addenbrooke’s Hospital Cambridge University Hospitals NHS Foundation Trust
Position: Honorary Clinical Research Fellow
Supervisor: 1) Dr David Jayne
Director of Lupus and Vasculitis,
Addenbrooke’s Hospital
Cambridge University Hospitals NHS Foundation Trust
2) Professor Kenneth Smith
Cambridge Institute of Medical Research,
University of Cambridge,
United Kingdom.
2008- 2010
Coordinator for National Glomerulonephritis Registry, National Renal Registry
(Johor Bahru)
6. Professional Bodies
National
Member of the Malaysian Medical Association
Member of the Malaysian Society of Nephrology
Member of the Postgraduate Renal Society, Malaysia
International
Member of the Royal College of Physicians of Edinburgh
Member of the International Society of Nephrology
Member of the IgA International Network
7. Research Activities
Publications:-
Acute renal failure in the same hospital 10 years apart; A comparison of two prospective studies in Sultanah Aminah Hospital, Johor Bahru
Medical Journal of Malaysia Vol 62 No1 March 2007
Lactic acidosis in HIV patients receiving highly active antiretroviral therapy- the Johor Bahru experience
Medical Journal of Malaysia Vol 62 No 1 March 2007
Quality improvement in Department of Nephrology, Kuala Lumpur Hospital- an audit on clinical performance indicators
Journal of Quality Improvement Vol 10 No 2 2007
Rituximab in Behcet’s Disease
Submitted to Annals of Rheumatic Diseases for publication (May 2009)
Participation in clinical studies:-
National
HDP study- Hospitalisation rate among Dialysis Patients study (2007)
International
GIANT study- Greatest International Antibiotic Trial study (2006)
A randomized double blind placebo controlled multicenter study to evaluate the efficacy and safety of two doses of Ocrelizumab in patients with WHO or ISN Class III or IV nephritis due to systemic lupus erythematosus (2008)
A phase III multicentre, double blind, double dummy, randomized flexible dose comparative study of MCI-196 versus Simvastatin for the treatment of dyslipidaemia in subjects with chronic kidney disease on dialysis (2009)
Evaluation of chronic kidney disease patterns through the global information database (GRID) (2009)
Biologic therapies in neuro-behcet’s disease, an international collaborative case-series- neurobehcet study group, International Society of Behcet’s Disease (2009)
CHiC-TRIAD (Cambridge Hinxton Centre for Translational Research In Autoimmune Disease) (2008-2009)
MY-CYC (A randomised clinical trial of mycophenolate mofetil versus cyclophosphamide for remission induction in ANCA associated vasculitis) (2008-2009)
Abstracts:-
National
OUTCOME OF A COMMUNITY BASED HEALTH SCREENING PROGRAMME DURING THE PUBLIC AWARENESS CAMPAIGN ON KIDNEY CARE IN JOHOR BAHRU, MALAYSIA
Oral Presentation- 22nd MSN Annual Seminar in Nephrology
Prevention of Chronic Kidney Disease
MYCOPHENOLATE MOFETIL IN RELAPSING LUPUS NEPHRITIS
23rd Malaysian Society of Nephrology Annual Seminar
Johor Bahru, Malaysia
11-13th April 2007
MYCOPHENOLATE MOFETIL IN MEMBRANOUS NEPHROPATHY
23rd Malaysian Society of Nephrology Annual Seminar
Johor Bahru, Malaysia
11-13th April 2007
International
ACUTE RENAL FAILURE IN THE SAME HOSPITAL 10 YEARS APART;
A COMPARISON OF TWO PROSPECTIVE STUDIES IN SULTANAH AMINAH
HOSPITAL, JOHOR BAHRU, MALAYSIA
Poster Presentation- 3rd World Congress of Nephrology
Post Congress Satellite Symposium
Acute Renal Failure: From Bench to Bedside
1st -3rd July 2005
LACTIC ACIDOSIS IN HIV PATIENTS RECEIVING HIGHLY ACTIVE ANTIRETROVIRAL THERAPY- THE JOHOR BAHRU EXPERIENCE
Oral Presentation
14th IUSTI Asia Pacific International Conference- 27th to 30th July, 2006
ADULT POLYCYSTIC KIDNEY DISEASE IN PATIENTS ON DIALYSIS IN MALAYSIA
11th Asian Pacific Congress of Nephrology 2008
ELDERLY PATIENTS INITIATING DIALYSIS IN MALAYSIA
11th Asian Pacific Congress of Nephrology 2008
MALIGNANCY POST RENAL TRANSPLANTATION: A 25 YEAR EXPERIENCE
11th Asian Pacific Congress of Nephrology 2008
LATE ACUTE ANTIBODY MEDIATED REJECTION ASSOCIATED WITH CALCINEURIN INHIBITOR MINIMISATION
11th Asian Pacific Congress of Nephrology 2008
CASTLEMAN’S DISEASE OF THE KIDNEY IN PATIENT WITH SLE
11th Asian Pacific Congress of Nephrology 2008
CLINICAL BENEFITS OF ICODEXTRIN: A SINGLE CENTRE EXPERIENCE
11th Asian Pacific Congress of Nephrology 2008
‘SUDOKU’ INCREASES COGNITIVE FUNCTION IN HAEMODIALYSIS PATIENTS- A PROSPECTIVE PILOT STUDY (Awarded Best Abstract)
11th Asian Pacific Congress of Nephrology 2008
SHORT TERM INFECTIOUS COMPLICATIONS POST RENAL TRANSPLANT
11th Asian Pacific Congress of Nephrology 2008
Sunday, April 3, 2011
Friday, March 4, 2011
Wednesday, March 2, 2011
Monday, February 28, 2011
Friday, February 18, 2011
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