Friday, November 28, 2003
Well, DrGoat has come online. Not much happening here, except a steadily growing impatience to get on a plane and fly home. Surprisingly enough, the runup to the event comprises of endless all-night 10 hour shifts, giving testimony to the sheer skill and compassion of the NHS rota managers - not.
Trawling through my desktop I discovered a series of letters left for me to discover, which saddened me and filled me with remorse. But the fact remains - we can't unmake the past. And now I know too much. Every day in life is a chance to be taken, or lost. Cumulatively, too many battles lost cost the war.
There are many things that I still miss - I am human after all. But sitting here, utterly alone, typing this - I am at peace, and free from the ugly noise that used to cloud my eyes and ears.
And you were wrong - being christ-like doesn't involve power. Jesus came as a lamb to the slaughter and advocated turning the other cheek. If He had arrived wielding brute power and might, He would have arrived as an avenging titan and slain his adversaries, literally. And grown old surrounded by the spoils of victory - not died on a cross, alone and forsaken on Calvary.
Trawling through my desktop I discovered a series of letters left for me to discover, which saddened me and filled me with remorse. But the fact remains - we can't unmake the past. And now I know too much. Every day in life is a chance to be taken, or lost. Cumulatively, too many battles lost cost the war.
There are many things that I still miss - I am human after all. But sitting here, utterly alone, typing this - I am at peace, and free from the ugly noise that used to cloud my eyes and ears.
And you were wrong - being christ-like doesn't involve power. Jesus came as a lamb to the slaughter and advocated turning the other cheek. If He had arrived wielding brute power and might, He would have arrived as an avenging titan and slain his adversaries, literally. And grown old surrounded by the spoils of victory - not died on a cross, alone and forsaken on Calvary.
Wednesday, November 19, 2003
MTV...
is a strange thing. Watching MTV in the mess. I must confess that I never really used to watch MTV much. In Singapore there was just no point, and in the UK MTV's all sleek sexy raunchy stripped-down women gyrating in miniscule outfits; it has its own appeal I guess. But its also a little repetitive.
Sitting down today in the mess filling in two police statements I couldn't help but notice two of them.
The first had Rachel Stevens in it, surprisingly enough, gyrating manically in a miniscule outfit.
Rachel Stevens is one of the few celebrities that does it for me. She has the look that my body, if not my conscious mind craves for. The girl is hot, and according to latest papparrazzi gossip, single and available. Ooh la la, etcetc. Rachel Stevens is a looker, a walking promise of athletic sex hanging from assorted nasty instruments from the ceiling, on long, lean legs. But closing my eyes, all I heard was noise.
The second had Dido in it, singing, as she does, fully clothed, striding slowly between scenes. Closing my eyes, the music washed over me, a hauntingly familiar melody coupled with troubled lyrics and the husky warmth of her voice painting a picture of sadness, flooding between, around, and into my senses. Opening them only enhanced it - she holds the camera, and audience bound with level gazes and a slightly furrowed brow, only to cast off into the distance with some melancholy and disinterest.
And oddly enough, Dido appeals to me more than Rachel Stevens does. Slightly sad, very much a thinker, slightly philosophical. No overt sex appeal, not quite the same calibre looks and figure; but singing, for the singing. One of the few MTV girls who keeps her clothes on, and overpowers the watcher - because MTV is meant to be watched, and not (just) listened to - with slow, steady gazes and the strength of her voice.
I could imagine a night with someone like Rachel Stevens.
But I could imagine a lifetime with someone like Dido.
What does that say I wonder?
is a strange thing. Watching MTV in the mess. I must confess that I never really used to watch MTV much. In Singapore there was just no point, and in the UK MTV's all sleek sexy raunchy stripped-down women gyrating in miniscule outfits; it has its own appeal I guess. But its also a little repetitive.
Sitting down today in the mess filling in two police statements I couldn't help but notice two of them.
The first had Rachel Stevens in it, surprisingly enough, gyrating manically in a miniscule outfit.
Rachel Stevens is one of the few celebrities that does it for me. She has the look that my body, if not my conscious mind craves for. The girl is hot, and according to latest papparrazzi gossip, single and available. Ooh la la, etcetc. Rachel Stevens is a looker, a walking promise of athletic sex hanging from assorted nasty instruments from the ceiling, on long, lean legs. But closing my eyes, all I heard was noise.
The second had Dido in it, singing, as she does, fully clothed, striding slowly between scenes. Closing my eyes, the music washed over me, a hauntingly familiar melody coupled with troubled lyrics and the husky warmth of her voice painting a picture of sadness, flooding between, around, and into my senses. Opening them only enhanced it - she holds the camera, and audience bound with level gazes and a slightly furrowed brow, only to cast off into the distance with some melancholy and disinterest.
And oddly enough, Dido appeals to me more than Rachel Stevens does. Slightly sad, very much a thinker, slightly philosophical. No overt sex appeal, not quite the same calibre looks and figure; but singing, for the singing. One of the few MTV girls who keeps her clothes on, and overpowers the watcher - because MTV is meant to be watched, and not (just) listened to - with slow, steady gazes and the strength of her voice.
I could imagine a night with someone like Rachel Stevens.
But I could imagine a lifetime with someone like Dido.
What does that say I wonder?
Saturday, November 15, 2003
Surreal.
A 3 year old girl had ODd on kiddie paracetamol by accident. I walked in holding the casualty card in my hand, and stopped dead. His mum was Your doppleganger. She even sounded like you, down to the accent.
It was so, so strange, looking into her eyes. That same smile. The body language. Such a beautiful, and happy mother. Doesnt help that I'm ill and lightheaded enough as it is. The double whammy has made something disconnect.
Is that how it will be, someday? Me meeting You, with Your kid. Happy families.
I suppose so. If I ever meet You again.
So be it.
A 3 year old girl had ODd on kiddie paracetamol by accident. I walked in holding the casualty card in my hand, and stopped dead. His mum was Your doppleganger. She even sounded like you, down to the accent.
It was so, so strange, looking into her eyes. That same smile. The body language. Such a beautiful, and happy mother. Doesnt help that I'm ill and lightheaded enough as it is. The double whammy has made something disconnect.
Is that how it will be, someday? Me meeting You, with Your kid. Happy families.
I suppose so. If I ever meet You again.
So be it.
Wednesday, November 12, 2003
In response to Mr Alan Ho's article in the Commentary pages of the Straits Times, I have posted the following reply to the forum pages.
I fully expect this article to be discarded with a polite reply without publication, and am therefore posting it on my blog for public viewing.
*******
In response to Andy Ho's article claiming that thrombolysis is routine clinical practise for acute stroke, I would like to direct the public's attention to the following editorials and studies which fail to correlate the findings of the NINDs trial, which the ST reporter employs as the lynchpin with which to substantiate his arguments.
Thrombolysis for acute ischaemic stroke (Cochrane Review), Wardlaw JM, del Zoppo G, Yamaguchi T, Berge E , The Cochrane Library, Issue 4, 2003.
This meta-analysis of eighteen trials including 5727 patients did not support the widespread use of thrombolytic therapy in routine clinical practice at present moment, but suggested that further trials are needed to identify which patients are most likely to benefit from treatment and the environment in which it may best be given.
Anticoagulants for acute ischaemic stroke (Cochrane Review), Gubitz G, Counsell C, Sandercock P, Signorini D, The Cochrane Library, Issue 4, 2003.
This meta-analysis of twenty-one trials including 23,427 patients concluded that "Immediate anticoagulant therapy in patients with acute ischaemic stroke is not associated with net short- or long-term benefit. The data from this review do not support the routine use of any type of anticoagulant in acute ischaemic stroke."
Jerome R Hoffman, MA, MD, Professor of Medicine and Emergency Medicine at the School of Medicine UCLA writes in his article published in the MJA 2003; 179 (7): 333-334 that "Although advocates of the use of tissue plasminogen activator (tPA) in acute ischaemic stroke suggest that this “is one of the most important advances in stroke medicine” a recent Cochrane meta-analysis also supports “clinicians who choose . . . not to use the treatment at all” and all three major emergency medicine associations in North America have declined to endorse it as “standard of care”. Additionally, "the overall impact of tPA in acute ischaemic stroke is at most marginal, which makes it difficult to understand why “so much has been made of so little", and "There is a paucity of positive evidence; all but one small randomised controlled trial failed to find benefit in the primary outcome, or found substantial harm. Even in the NINDS trial, the benefit was primarily in patients treated less than 90 minutes after symptom onset (almost no such patients exist in actual community practice)". He then states that "Many of us believe that thrombolytic therapy in stroke remains far from proven, so that its use should be restricted to further randomised controlled trials... I f tPA use becomes more widespread, a very small number of patients may receive great personal benefit, while a very few others may be subjected to great personal harm. However, the broader implications of this debate are substantial. Modern health policy traditionally rests on the “precautionary principle”, which requires that no new practice be widely introduced until it is shown to be safe"
The Canadian Association of Emergency Physicians believes that "based on the available evidence, widespread use of thrombolytic therapy for acute stroke remains controversial and problematic." (Thrombolytic Therapy for Acute Ischemic Stroke, The CAEP Committee on Thrombolytic Therapy for Acute Ischemic Stroke)
In addition, they write that "Six grade-one multi-centre randomized controlled trials (RCTs) of thrombolytics for acute stroke demonstrated lack of benefit or worse outcomes with treatment. To date, the NINDS trial is the only published RCT (randomised controlled trial ) of intravenous thrombolytic therapy that has been positive... exuberance over the potential development of more effective stoke treatments has raised public expectations, causing anxiety, disappointment and confusion when treatments are not available, not indicated or not effective. Caution is warranted in public pronouncements of the value of thrombolytic therapy for stroke. Such pronouncements should detail the fact that this intervention is not appropriate for the majority of strokes... It is the position of the Canadian Association of Emergency Physicians that thrombolytic therapy for acute stroke should be restricted to use in the context of formal research protocols, or in closely monitored programs, until there is further evidence that the benefits of this therapy clearly outweigh the risks." They then argue that "Prior to NINDS, trials of thrombolytics for acute stroke provided very negative results....In an attempt to replicate the NINDS results, ECASS-II applied the same eligibility criteria and used the same 0.9 mg/kg t-PA dose, but enrolled patients within 6 hours of symptom onset. In this study, t-PA did not significantly increase the rate of favorable 90-day outcomes (40.3% vs. 36.6%, p=0.277), and was associated with a higher incidence of parenchymal hemorrhage (11.8% vs. 3.1%), symptomatic intracranial hemorrhage (8.8% vs. 3.4%), and early death due to intracranial hemorrhage (11 vs. 2 cases). Of note, there was no significant differences in 30- or 90-day mortality. An ECASS-II subgroup analysis showed a trend towards improved neurological outcomes in patients with <3 hours of symptoms, but the numbers were small and statistically insignificant. ECASS-II therefore failed to reproduce the positive results of NINDS... it is likely that the benefit seen with t-PA in the NINDS trial is applicable to only 2-3% of patients who present with acute stroke syndromes." Most damnably, "The problem of limited early diagnostic accuracy i ndicates the need to proceed with caution. Rushed decisions to administer t-PA within the 3-hour window will mean that a subset of patients will be exposed to a substantial risk of hemorrhage without any potential to benefit" The writers then quote Katzan et al (Cleveland) who wrote that "In-hospital mortality was higher among t-PA recipients than matched patients not treated with t-PA (15.7% vs. 7.2%; p<.01). Mortality was also higher in t-PA recipients than in the general population of stroke patients not receiving t-PA (15.7% vs. 5.1%; p< .001)" and conclude that "These demonstrate that eligible patients are rare and that protocol violations are common when this thrombolysis is provided outside of controlled research settings.The Cleveland experience suggests that stroke thrombolysis may be more dangerous and patient outcomes worse in community settings than they were in the NINDS stroke trial"
I invite Andy Ho to explain in the face of existing international evidence that routine thrombolysis for stroke remains controversial across the world why the UK health authorities (eg the National Institute for Clinical Excellence) should take "steps to make sure stroke patients get their scans and tPA within the first three hours".
In addition, I would like to ask if patients in Singapore routinely receive thrombolysis for ischaemic cerebrovascular accidents, and tPA for all myocardial infarctions as Andy Ho suggests in his article.
If this is indeed the case I must voice my grave concerns for the safety and well-being of patients within the Singapore Healthcare System, because according to conventional medical wisdom such measures would expose patients to unnecessary risks (including haemorrhagic stroke, lifelong disability and death) unbalanced by proposed benefits of early coronary reperfusion.
The mainstay of thrombolytic agents in the UK is streptokinase, which carries approximately half the risk of intracranial haemorrhage compared to tPA and its newer variants alteplase, retiplase and tenecteplase. The latter are employed in the UK in specific subgroups of patients (young males with anterior MIs) deemed at lower risk of cerebral haemorrhage.
This is also in line with current US guidelines for thrombolysis for Acute Myocardial Infarction published in 1999 by the American Heart Association, which state that "the cost-benefit ratio (of accelerated alteplase and reteplase with intravenous heparin) is greatest in patients presenting early after onset of chest pain or symptoms and in those with a large area of injury (eg. anterior infarction) and at low risk of ICH." "
I would also like to take this opportunity to wish Mr and Mrs Lee Kuan Yew good health in their time of need, and I sincerely hope Mrs Lee achieves as speedy and complete a recovery as is possible. God bless.
Dr (name)
MBBS (UK)
***********
Not mentioned in the article I submitted (for obvious reasons):
the local (Singaporean) guidelines updated in 2003 for stroke management published by the Singaporean Ministry of Health with regards to imaging, and tPA are as follows :
"All patients with acute stroke should undergo brain scanning (CT or MRI) as soon as possible*, preferably within 24 hours" (and not 3 hours as Andy Ho appears to claim)
Additionally, in the immediate management of stroke,
"The routine use of drugs to limit neural damage, including the administration of corticosteroids, neuroprotectants, plasma volume expanders, barbiturates and streptokinase, (which is a form of thrombolysis) is of no proven benefit and should be discouraged."
also,
"Patients receiving anticoagulants or recent thrombolytic therapy or those with bleeding diathesis require urgent correction of coagulation defects. Thrombolytics, anti-platelet therapy and anticoagulants should be discouraged".
tPA is indeed mentioned in the Ministry of Health guidelines as follows :
"A randomised study of intravenous r-TPA in cerebral infarction demonstrated significant improvement in functional outcome in selected patients treated in specialist units within 3 hours of the onset of stroke, as did an intra-arterial trial of prourokinase within 6 hours of stroke onset. The use of streptokinase is contraindicated in view of its lack of beneficial effect on mortality and morbidity. The management of patients with acute ischaemic stroke using thrombolytic therapy carries the risk of catastrophic intracerebral haemorrhage; there is difficulty in predicting who might benefit or be at most risk of haemorrhage. Thrombolysis should not yet be regarded as routine therapy."
It appears that when Andy Ho writes "What should be relevant to the British public is whether their health authorities are taking steps to make sure stroke patients get their scans and tPA within the first three hours", he omits to mention that stroke patients in Singapore are not getting their scans and tPA within the first three hours either, because the Singaporean Ministry of Health, having reviewed study data from around the world does not feel they are warranted either.
In addition, he also omits to mention that in the fierce and ongoing debate regarding thrombolysis for ischaemic stroke, conventional medical wisdom is not in favour for routine thrombolysis, and he has, in effect written an authoritatively-worded, but factually-challenged article that lays clear his stark medical ignorance and journalistic unprofessionalism, for all the world to see.
One wonders if all stroke patients in Singapore are now going to begin demanding immediate thrombolysis from the moment they step through the casualty doors. Worse still, one wonders what will happen if the doctors in Singapore, in dischord with their own guidelines, begin offering this service, thanks to pseudo-political pressure applied by an irresponsible press.
It is time that the Singaporean public awakens, and realises that the Press in Singapore, in its overwhelming drive to sycophantically pander to the incumbent People's Action Party, is not above misrepresenting "facts and realities" as half-truths. What you see in the news is not really what is really happening, around the world. Or, worse still, that the press is writing authoritatively, and ignorantly about things they know little about, and representing their personal opinions as undeniable truths.
Singapore, it seems, has become the Matrix. And if information be power, then the Singaporean public are firmly under the thumbscrews of a deceitful and politically controlled (by the PAP, although whether intentionally or not is debatable) press.
I personally believe that the PAP is not applying much pressure to the Straits Times. I feel that in fact, the ST is bending over backwards to do what it Thinks the PAP wants it to do - that it is trying to second guess the PAP and write the stuff that will get it the most pats on the back.
And therein lies the reason for the publication of this completely imprudent article, in the one major english language newspaper of the entire country.
It is also time that the Press in Singapore realises that anybody can write. Anybody can string the words together. What distinguishes a journalist from a layperson is not his ease or proficiency with the language - but his sense of responsibility, and professionalism.
With these, you are a reporter, bringing the news, and the truth to the people, and doing something worthwhile with your life.
Without these - you are nobody, jotting down your mundane personal opinions to an imaginary public audience - you might as well quit your day job and start a blog.
I fully expect this article to be discarded with a polite reply without publication, and am therefore posting it on my blog for public viewing.
*******
In response to Andy Ho's article claiming that thrombolysis is routine clinical practise for acute stroke, I would like to direct the public's attention to the following editorials and studies which fail to correlate the findings of the NINDs trial, which the ST reporter employs as the lynchpin with which to substantiate his arguments.
Thrombolysis for acute ischaemic stroke (Cochrane Review), Wardlaw JM, del Zoppo G, Yamaguchi T, Berge E , The Cochrane Library, Issue 4, 2003.
This meta-analysis of eighteen trials including 5727 patients did not support the widespread use of thrombolytic therapy in routine clinical practice at present moment, but suggested that further trials are needed to identify which patients are most likely to benefit from treatment and the environment in which it may best be given.
Anticoagulants for acute ischaemic stroke (Cochrane Review), Gubitz G, Counsell C, Sandercock P, Signorini D, The Cochrane Library, Issue 4, 2003.
This meta-analysis of twenty-one trials including 23,427 patients concluded that "Immediate anticoagulant therapy in patients with acute ischaemic stroke is not associated with net short- or long-term benefit. The data from this review do not support the routine use of any type of anticoagulant in acute ischaemic stroke."
Jerome R Hoffman, MA, MD, Professor of Medicine and Emergency Medicine at the School of Medicine UCLA writes in his article published in the MJA 2003; 179 (7): 333-334 that "Although advocates of the use of tissue plasminogen activator (tPA) in acute ischaemic stroke suggest that this “is one of the most important advances in stroke medicine” a recent Cochrane meta-analysis also supports “clinicians who choose . . . not to use the treatment at all” and all three major emergency medicine associations in North America have declined to endorse it as “standard of care”. Additionally, "the overall impact of tPA in acute ischaemic stroke is at most marginal, which makes it difficult to understand why “so much has been made of so little", and "There is a paucity of positive evidence; all but one small randomised controlled trial failed to find benefit in the primary outcome, or found substantial harm. Even in the NINDS trial, the benefit was primarily in patients treated less than 90 minutes after symptom onset (almost no such patients exist in actual community practice)". He then states that "Many of us believe that thrombolytic therapy in stroke remains far from proven, so that its use should be restricted to further randomised controlled trials... I f tPA use becomes more widespread, a very small number of patients may receive great personal benefit, while a very few others may be subjected to great personal harm. However, the broader implications of this debate are substantial. Modern health policy traditionally rests on the “precautionary principle”, which requires that no new practice be widely introduced until it is shown to be safe"
The Canadian Association of Emergency Physicians believes that "based on the available evidence, widespread use of thrombolytic therapy for acute stroke remains controversial and problematic." (Thrombolytic Therapy for Acute Ischemic Stroke, The CAEP Committee on Thrombolytic Therapy for Acute Ischemic Stroke)
In addition, they write that "Six grade-one multi-centre randomized controlled trials (RCTs) of thrombolytics for acute stroke demonstrated lack of benefit or worse outcomes with treatment. To date, the NINDS trial is the only published RCT (randomised controlled trial ) of intravenous thrombolytic therapy that has been positive... exuberance over the potential development of more effective stoke treatments has raised public expectations, causing anxiety, disappointment and confusion when treatments are not available, not indicated or not effective. Caution is warranted in public pronouncements of the value of thrombolytic therapy for stroke. Such pronouncements should detail the fact that this intervention is not appropriate for the majority of strokes... It is the position of the Canadian Association of Emergency Physicians that thrombolytic therapy for acute stroke should be restricted to use in the context of formal research protocols, or in closely monitored programs, until there is further evidence that the benefits of this therapy clearly outweigh the risks." They then argue that "Prior to NINDS, trials of thrombolytics for acute stroke provided very negative results....In an attempt to replicate the NINDS results, ECASS-II applied the same eligibility criteria and used the same 0.9 mg/kg t-PA dose, but enrolled patients within 6 hours of symptom onset. In this study, t-PA did not significantly increase the rate of favorable 90-day outcomes (40.3% vs. 36.6%, p=0.277), and was associated with a higher incidence of parenchymal hemorrhage (11.8% vs. 3.1%), symptomatic intracranial hemorrhage (8.8% vs. 3.4%), and early death due to intracranial hemorrhage (11 vs. 2 cases). Of note, there was no significant differences in 30- or 90-day mortality. An ECASS-II subgroup analysis showed a trend towards improved neurological outcomes in patients with <3 hours of symptoms, but the numbers were small and statistically insignificant. ECASS-II therefore failed to reproduce the positive results of NINDS... it is likely that the benefit seen with t-PA in the NINDS trial is applicable to only 2-3% of patients who present with acute stroke syndromes." Most damnably, "The problem of limited early diagnostic accuracy i ndicates the need to proceed with caution. Rushed decisions to administer t-PA within the 3-hour window will mean that a subset of patients will be exposed to a substantial risk of hemorrhage without any potential to benefit" The writers then quote Katzan et al (Cleveland) who wrote that "In-hospital mortality was higher among t-PA recipients than matched patients not treated with t-PA (15.7% vs. 7.2%; p<.01). Mortality was also higher in t-PA recipients than in the general population of stroke patients not receiving t-PA (15.7% vs. 5.1%; p< .001)" and conclude that "These demonstrate that eligible patients are rare and that protocol violations are common when this thrombolysis is provided outside of controlled research settings.The Cleveland experience suggests that stroke thrombolysis may be more dangerous and patient outcomes worse in community settings than they were in the NINDS stroke trial"
I invite Andy Ho to explain in the face of existing international evidence that routine thrombolysis for stroke remains controversial across the world why the UK health authorities (eg the National Institute for Clinical Excellence) should take "steps to make sure stroke patients get their scans and tPA within the first three hours".
In addition, I would like to ask if patients in Singapore routinely receive thrombolysis for ischaemic cerebrovascular accidents, and tPA for all myocardial infarctions as Andy Ho suggests in his article.
If this is indeed the case I must voice my grave concerns for the safety and well-being of patients within the Singapore Healthcare System, because according to conventional medical wisdom such measures would expose patients to unnecessary risks (including haemorrhagic stroke, lifelong disability and death) unbalanced by proposed benefits of early coronary reperfusion.
The mainstay of thrombolytic agents in the UK is streptokinase, which carries approximately half the risk of intracranial haemorrhage compared to tPA and its newer variants alteplase, retiplase and tenecteplase. The latter are employed in the UK in specific subgroups of patients (young males with anterior MIs) deemed at lower risk of cerebral haemorrhage.
This is also in line with current US guidelines for thrombolysis for Acute Myocardial Infarction published in 1999 by the American Heart Association, which state that "the cost-benefit ratio (of accelerated alteplase and reteplase with intravenous heparin) is greatest in patients presenting early after onset of chest pain or symptoms and in those with a large area of injury (eg. anterior infarction) and at low risk of ICH." "
I would also like to take this opportunity to wish Mr and Mrs Lee Kuan Yew good health in their time of need, and I sincerely hope Mrs Lee achieves as speedy and complete a recovery as is possible. God bless.
Dr (name)
MBBS (UK)
***********
Not mentioned in the article I submitted (for obvious reasons):
the local (Singaporean) guidelines updated in 2003 for stroke management published by the Singaporean Ministry of Health with regards to imaging, and tPA are as follows :
"All patients with acute stroke should undergo brain scanning (CT or MRI) as soon as possible*, preferably within 24 hours" (and not 3 hours as Andy Ho appears to claim)
Additionally, in the immediate management of stroke,
"The routine use of drugs to limit neural damage, including the administration of corticosteroids, neuroprotectants, plasma volume expanders, barbiturates and streptokinase, (which is a form of thrombolysis) is of no proven benefit and should be discouraged."
also,
"Patients receiving anticoagulants or recent thrombolytic therapy or those with bleeding diathesis require urgent correction of coagulation defects. Thrombolytics, anti-platelet therapy and anticoagulants should be discouraged".
tPA is indeed mentioned in the Ministry of Health guidelines as follows :
"A randomised study of intravenous r-TPA in cerebral infarction demonstrated significant improvement in functional outcome in selected patients treated in specialist units within 3 hours of the onset of stroke, as did an intra-arterial trial of prourokinase within 6 hours of stroke onset. The use of streptokinase is contraindicated in view of its lack of beneficial effect on mortality and morbidity. The management of patients with acute ischaemic stroke using thrombolytic therapy carries the risk of catastrophic intracerebral haemorrhage; there is difficulty in predicting who might benefit or be at most risk of haemorrhage. Thrombolysis should not yet be regarded as routine therapy."
It appears that when Andy Ho writes "What should be relevant to the British public is whether their health authorities are taking steps to make sure stroke patients get their scans and tPA within the first three hours", he omits to mention that stroke patients in Singapore are not getting their scans and tPA within the first three hours either, because the Singaporean Ministry of Health, having reviewed study data from around the world does not feel they are warranted either.
In addition, he also omits to mention that in the fierce and ongoing debate regarding thrombolysis for ischaemic stroke, conventional medical wisdom is not in favour for routine thrombolysis, and he has, in effect written an authoritatively-worded, but factually-challenged article that lays clear his stark medical ignorance and journalistic unprofessionalism, for all the world to see.
One wonders if all stroke patients in Singapore are now going to begin demanding immediate thrombolysis from the moment they step through the casualty doors. Worse still, one wonders what will happen if the doctors in Singapore, in dischord with their own guidelines, begin offering this service, thanks to pseudo-political pressure applied by an irresponsible press.
It is time that the Singaporean public awakens, and realises that the Press in Singapore, in its overwhelming drive to sycophantically pander to the incumbent People's Action Party, is not above misrepresenting "facts and realities" as half-truths. What you see in the news is not really what is really happening, around the world. Or, worse still, that the press is writing authoritatively, and ignorantly about things they know little about, and representing their personal opinions as undeniable truths.
Singapore, it seems, has become the Matrix. And if information be power, then the Singaporean public are firmly under the thumbscrews of a deceitful and politically controlled (by the PAP, although whether intentionally or not is debatable) press.
I personally believe that the PAP is not applying much pressure to the Straits Times. I feel that in fact, the ST is bending over backwards to do what it Thinks the PAP wants it to do - that it is trying to second guess the PAP and write the stuff that will get it the most pats on the back.
And therein lies the reason for the publication of this completely imprudent article, in the one major english language newspaper of the entire country.
It is also time that the Press in Singapore realises that anybody can write. Anybody can string the words together. What distinguishes a journalist from a layperson is not his ease or proficiency with the language - but his sense of responsibility, and professionalism.
With these, you are a reporter, bringing the news, and the truth to the people, and doing something worthwhile with your life.
Without these - you are nobody, jotting down your mundane personal opinions to an imaginary public audience - you might as well quit your day job and start a blog.
The following is an article that was posted in the Straits Times Forum. The background of the case is as follows : Lee Kuan Yew, the Senior Minister for Singapore, and ex Prime Minister, was on holiday in the United Kingdom with his wife when the latter had the misfortune to suffer a stroke.
All accounts make it out to be an ischaemic stroke, and the article that follows appears to corroborate this.
She was brought to the Royal London Hospital, where apparently SM Lee was "horrified" that she would not be seen ahead of three cardiac patients, and had to wait in a queue to be seen.
Subsequently, when she had been assessed by the on-call doctors, Mr Lee Kuan Yew was informed at 2 am that she would be admitted, and a CT scan performed at 8am the same morning. Outraged at the delay, Mr Lee's aides then proceeded to telephone 10 Downing Street, to attempt to "pull strings" and bring forwards her CT scan.
Her CT scan was then performed at 3.30 am, confirming an ischaemic stroke (Mr Lee said in a press release that the clot could be seen on the scan. It is probably more likely that he meant that the area of infarction could be seen on the scan) An official press release from Mr Lee went on to state that 10 Downing Street had assisted in obtaining the prompt CT, making it appear that the hospital in question had been ordered to do so. It later transpired that Downing Street had not, in fact intervened to pull strings, which it felt would have been "utterly inappropriate", and the on call doctors had apparently made special provisions to bring in a radiology consultant and organise the CT scan. SM Lee subsequently released an apology to 10 Downing Street, for essentially jumping to conclusions that his requests had been aceded to by the British government.
After 72 hours of treatment at the Royal London, Singapore then sensationalistically, and against medical advice, airlifted Mrs Lee home in a 747, with 2 ITU nurses, a consultant rheumatologist, and a constulant neurologist as an escort party, and, according to the Straits Times (the only main english-language newspaper in Singapore), a "drip", making this a "mobile ITU". No mention was made about ventilatory support equipment or provisions for artificial airways in this news article.
subsequently, in the aftermath of the event, a Straits Times reporter has taken it upon himself to carry implied accusations of negligence and incompetence on the part of the NHS still further, with the following article.
***********
From the Straits Times Commentary
"Why an early brain scan makes sense
By Andy Ho
WHEN Mrs Lee Kuan Yew suffered a stroke in London recently, she was taken to the Royal London Hospital at 12.30am. A brain scan was done at 3.30am, although it had supposedly been scheduled for 8am.
Four days later, accompanied by doctors and nurses, Mrs Lee flew home safely on a Singapore Airlines flight outfitted for the purpose.
Since then, there has been unhappy muttering on the ground about how high officials and members of their family enjoy special treatment. A doctor gave voice to some of these arguments in a posting on the Internet, albeit anonymously.
The imprimatur of his precise medical knowledge makes his arguments hard for the lay public to brush off.
But these guidelines need to be changed - not so that SM Lee may be proven correct, retroactively, but simply because research has now determined that the best time to treat a stroke is within the first three hours.
SM Lee probably did not look at the MOH guidelines but, more likely, would have got in touch with his daughter, Dr Lee Wei Ling, a noted neurologist, who would have apprised him of the golden three hour rule.[/b]
Since the early 1990s, American doctors have been advised to ward patients as quickly as possible if a stroke is suspected.
There are two varieties of strokes. Haemorrhagic strokes occur when a blood vessel within the brain bursts, pouring into the substance of the brain or spaces around brain cells.
Locally, however, 70 per cent of strokes are of the ischaemic variety. These are caused by clots that block blood flow to the brain, thus depriving it of oxygen.
For the ischemic stroke, a very important treatment option is thrombolysis - injecting an enzyme to dissolve the clot.
Here's the reason for the Golden Three Hour Rule: US studies show that damage in the zone surrounding the central area of a stroke is potentially reversible. If thrombolysis is started within three hours, the afflicted area of the brain can be limited.
A brain scan needs to be done within that time window to see if it is an ischaemic, not haemorrhagic, stroke, and thus amenable to thrombolytic therapy.
The drug used to dissolve clots is called tissue plasminogen activator (tPA). A National Institutes of Neurologic Disorders and Stroke trial in the US reported in 1995 that half of patients so treated achieved essentially full recovery.
[b]In Singapore, early scanning and thrombolysis therapy aren't practised widely enough simply because most stroke patients come in too late, 12 to 48 hours later.
In August last year, London clinicians at three medical schools reported in the British Medical Journal that their study of 400 female and 339 male stroke cases showed that UK hospitals should adopt the Golden Three Hour Rule already embraced in Western Europe and North America.
In the end, it wouldn't be right to say that Mrs Lee was granted special treatment: she simply received what everyone with a stroke - rich or poor, powerful or lowly - deserves.
Diplomatic niceties aside, the point isn't whether 10 Downing Street should or shouldn't intervene on behalf of visiting dignitaries. What should be relevant to the British public is whether their health authorities are taking steps to make sure stroke patients get their scans and tPA within the first three hours.
While they are at it, they should also ask their authorities if patients with acute heart attacks are being given tPA within the first six hours, a maxim in the US since the early 1990s.
They wouldn't be asking too much, either. Surely a teaching hospital in London - a First World city - should be able to simultaneously handle both strokes and heart attacks within their critical time periods. If not, should Britain still call itself 'Great'?"
All accounts make it out to be an ischaemic stroke, and the article that follows appears to corroborate this.
She was brought to the Royal London Hospital, where apparently SM Lee was "horrified" that she would not be seen ahead of three cardiac patients, and had to wait in a queue to be seen.
Subsequently, when she had been assessed by the on-call doctors, Mr Lee Kuan Yew was informed at 2 am that she would be admitted, and a CT scan performed at 8am the same morning. Outraged at the delay, Mr Lee's aides then proceeded to telephone 10 Downing Street, to attempt to "pull strings" and bring forwards her CT scan.
Her CT scan was then performed at 3.30 am, confirming an ischaemic stroke (Mr Lee said in a press release that the clot could be seen on the scan. It is probably more likely that he meant that the area of infarction could be seen on the scan) An official press release from Mr Lee went on to state that 10 Downing Street had assisted in obtaining the prompt CT, making it appear that the hospital in question had been ordered to do so. It later transpired that Downing Street had not, in fact intervened to pull strings, which it felt would have been "utterly inappropriate", and the on call doctors had apparently made special provisions to bring in a radiology consultant and organise the CT scan. SM Lee subsequently released an apology to 10 Downing Street, for essentially jumping to conclusions that his requests had been aceded to by the British government.
After 72 hours of treatment at the Royal London, Singapore then sensationalistically, and against medical advice, airlifted Mrs Lee home in a 747, with 2 ITU nurses, a consultant rheumatologist, and a constulant neurologist as an escort party, and, according to the Straits Times (the only main english-language newspaper in Singapore), a "drip", making this a "mobile ITU". No mention was made about ventilatory support equipment or provisions for artificial airways in this news article.
subsequently, in the aftermath of the event, a Straits Times reporter has taken it upon himself to carry implied accusations of negligence and incompetence on the part of the NHS still further, with the following article.
***********
From the Straits Times Commentary
"Why an early brain scan makes sense
By Andy Ho
WHEN Mrs Lee Kuan Yew suffered a stroke in London recently, she was taken to the Royal London Hospital at 12.30am. A brain scan was done at 3.30am, although it had supposedly been scheduled for 8am.
Four days later, accompanied by doctors and nurses, Mrs Lee flew home safely on a Singapore Airlines flight outfitted for the purpose.
Since then, there has been unhappy muttering on the ground about how high officials and members of their family enjoy special treatment. A doctor gave voice to some of these arguments in a posting on the Internet, albeit anonymously.
The imprimatur of his precise medical knowledge makes his arguments hard for the lay public to brush off.
But these guidelines need to be changed - not so that SM Lee may be proven correct, retroactively, but simply because research has now determined that the best time to treat a stroke is within the first three hours.
SM Lee probably did not look at the MOH guidelines but, more likely, would have got in touch with his daughter, Dr Lee Wei Ling, a noted neurologist, who would have apprised him of the golden three hour rule.[/b]
Since the early 1990s, American doctors have been advised to ward patients as quickly as possible if a stroke is suspected.
There are two varieties of strokes. Haemorrhagic strokes occur when a blood vessel within the brain bursts, pouring into the substance of the brain or spaces around brain cells.
Locally, however, 70 per cent of strokes are of the ischaemic variety. These are caused by clots that block blood flow to the brain, thus depriving it of oxygen.
For the ischemic stroke, a very important treatment option is thrombolysis - injecting an enzyme to dissolve the clot.
Here's the reason for the Golden Three Hour Rule: US studies show that damage in the zone surrounding the central area of a stroke is potentially reversible. If thrombolysis is started within three hours, the afflicted area of the brain can be limited.
A brain scan needs to be done within that time window to see if it is an ischaemic, not haemorrhagic, stroke, and thus amenable to thrombolytic therapy.
The drug used to dissolve clots is called tissue plasminogen activator (tPA). A National Institutes of Neurologic Disorders and Stroke trial in the US reported in 1995 that half of patients so treated achieved essentially full recovery.
[b]In Singapore, early scanning and thrombolysis therapy aren't practised widely enough simply because most stroke patients come in too late, 12 to 48 hours later.
In August last year, London clinicians at three medical schools reported in the British Medical Journal that their study of 400 female and 339 male stroke cases showed that UK hospitals should adopt the Golden Three Hour Rule already embraced in Western Europe and North America.
In the end, it wouldn't be right to say that Mrs Lee was granted special treatment: she simply received what everyone with a stroke - rich or poor, powerful or lowly - deserves.
Diplomatic niceties aside, the point isn't whether 10 Downing Street should or shouldn't intervene on behalf of visiting dignitaries. What should be relevant to the British public is whether their health authorities are taking steps to make sure stroke patients get their scans and tPA within the first three hours.
While they are at it, they should also ask their authorities if patients with acute heart attacks are being given tPA within the first six hours, a maxim in the US since the early 1990s.
They wouldn't be asking too much, either. Surely a teaching hospital in London - a First World city - should be able to simultaneously handle both strokes and heart attacks within their critical time periods. If not, should Britain still call itself 'Great'?"
