Monthly Archives: June, 2009

What Killed Michael Jackson?

Now that the initial autopsy had ruled out trauma and assault as possible causes, toxicology testing will need to be carried out to determine the existence and levels of foreign substances (read drugs) in the singer’s bloodstream. Not surprisingly, this is going to take “6-4 weeks”, according to the Coroner’s Office; as , even in the best centres, such an analysis is a laborious process.


Photo taken by "Entertainment Tonight" shows Jackson leaving his residence in ambulance. Note the Umbo bag attached to the endotracheal tube, indicating he was being manually assisted to breathe. The pair of hands on the chest means chest compression was taking place, part of the cardiopulmonary resuscitation (CPR) process.

According to various media reports, the singer had “cardiac arrest” at home and that his personal physician (a cardiologist) was in attendance at that point in time. You can hear the actual recording of the 911 call here.

Several news reports have said that Michael Jackson had been addicted to OxyContin for several years, among other drugs. This is collaborated by his children’s nanny who testified she had to perform stomach washouts several times to remove a cocktail of drugs, as reported by the Times of London. OxyContin is a effective pain-reliever but is a member of the narcotic class of analgesics, meaning it is in the same category as morphine and therefore habit-forming and can lead to addiction.

The other big problem with this class of drugs is that it is associated with several side-effects, notably its ability to suppress breathing. Hence, it is not used in patients who have breathing diseases like asthma and sleep apnoea.

Notoriously, OxyContin which is given as tablets, cannot be combined with other narcotic pain-killers, tranquillizers, sedatives and even alcohol as this potentiates the side-effects (all of them are depressants on the brain) and can cause confusion, breathing difficulties, coma and death.

In Michael’s case, this takes on added significance, as it has been reported that an hour before he collapsed, he had been given a shot of another narcotic pain-killer Demerol (aka Meperidine aka Pethidine). Eye-witnesses reported that they noticed his breathing was becoming shallower and shallower, which is consistent with respiratory depression( suppression of the brain’s breathing efforts) due to additive effects of the two narcotic drugs. The toxicology tests will bear out this possibility eventually but two questions remain:

1. Wasn’t the attending doctor aware that MJ had been on other narcotic pain-killers?

2. There is an effective antidote, Naloxone, which if given by injection immediately, can reverse the side-effects of the overdose. Was this given?


Australian actor Heath Ledger died in Dec 2008 of an overdose of 6 different prescription drugs

If the final autopsy results confirm drug interaction and overdose as the cause of death, MJ will join a long line of celebrities including Jimi Hendrix, Elvis Presley and most recently, Heath Ledger. In the latter’s case, the autopsy revealed that he had taken 6 different drugs: OxyContin, hydrocodone, diazepam (Valium), temazepam (Normison, for sleep), alprezolam (Xanax,for anti-anxiety) and doxylamine (available over-the-counter as Somnil for aiding sleep).

The message to take home obviously is that every medication has side-effects, and its use must be balanced by the benefits vs harmful effects.

Update (25 Aug 2009): see “MJ’s Death Explained

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Obama’s Oration to Doctors..and Some Boos Are Heard


President Obama at the AMA Meeting, Chicago

“We have to tackle the model that has taken the pursuit of medicine from a profession — a calling — to a business. You didn’t enter this profession to become bean counters and paper pushers. You entered this profession to be healers. And that’s what our health care system should let you be.”

-President Barack Obama, addressing doctors at the Annual Meeting of the American Medical Association,15th June 2009

By all accounts, many, including myself, will agree with the President on this. How often have we seen administrative paperwork eat into time that would be better spent looking after patients? And the preoccupation amongst some doctors in private practice to improve the financial bottom-line at all costs, sometimes at the expense of the patients’ well-being?

Somewhere in the middle of the President’s oration, however, boos erupted when he told doctors that he wouldn’t try to help them win their top priority – limits on jury damages in medical malpractice cases. What else could the President say? If he said otherwise, you can bet lawyers, trade unions and consumer groups would stand up in protest!

This is the problem with healthcare anywhere in the world – every stakeholder in the healthcare debate will have their own unique  list of priorities. For instance, private insurance companies do not want competition from a government-funded single-payor financial scheme. Drug companies want to charge to the hilt to maximise profits. Hospitals want no more cuts from Medicare or any payor system. Employers want to minimise employee coverage and benefits. And the public of course demand universal access whatever the cost.

Healthcare GDP of countries

With Healthcare Exceeding 16% of GDP presently, Its Reform is the Top Priority For the Obama Administration

No leader, President Obama included, can give all of them what they want. In fact, leaders over the decades have been grappling on a tightrope as to how much to give to keep as many as possible happy, without alienating others.

Its not often that a President receives boos (from doctors at that!), but he has to be prepared for more as he tackles sensitive and dicey issues like healthcare..

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New Drugs In The News – Searching For the Truth

In the last week alone, the media featured  reports about 2 new ways for treating prostate cancer, the most common cancer for men in the UK. One of them added more concrete evidence with regards to the already many health benefits from drinking green tea – that the polyphenols in the tea can prevent prostate cancer progressing (see here).

new drugs

New Drugs -It Costs Up To USD 200 million To Develop One and the Pitfalls are Plenty

The other remedy, about using a new drug, ipilimumab, may have raised many present cancer sufferers’ hopes, but the truth is that this new treatment is only in Phase 1 trial stage (there are 4 stages to go through before a drug is released for general public use). This means at the earliest, this drug will only be available in 2012; and this too,  assuming it passes all the 4 Phases. Another new drug for prostate cancer which first made headlines in 2008,  abiraterone, is now in Phase 3 and will be general use only in 2011. So, these ‘premature’ announcements in the lay press at best give an insight of probable cures to come, but are of little use to present-day sufferers.

In the best scenario, a new drug will appear after a few years and it will be costly(you bet!); and in the worse-case scenario, it will be consigned to the waste-basket due to the presence of terrible side-effects which hitherto had not yet been detected.

So why does the media appear to overplay new drug discoveries?

Put it simply, such items are big news..and news sells! Not forgetting, of course, the commercial benefits the company producing the drugs receive, or the publicity it attracts to the researchers concerned!

new drugs2

Here are  some tips on how to evaluate news items that you may come across..

  • It is a fact that competition is intense among medical journals, research bodies and medical journals to attract media attention. Media themselves compete with each other to come out with the latest. Try to read the same news from several sources. Obviously, if the item is reported in just one obscure source, it should carry less weight.
  • Look for key-words like suggestive or may (as opposed to will) as this does not always indicate a cause and effect meaning. Many people make hard-core assumptions based on such words.
  • It is the nature of scientific studies that, for a given topic, several would say one thing and a few would say the complete opposite. It is for the trained professional and their peer-groups to make an informed decision to advise consumers. Bear in mind that space is a premium with the mass media and such reports usually omit vital details which will affect accuracy.
  • Separate the wheat from the chaff..make sure the website you’re looking at is a reliable one!
  • Personally, I feel reports originating from researchers and pharma companies should not appear in the mass media without vetting by an appropriate professional body so as to convey the proper perspective to the audience at large. So if a news report originates from a known professional body, that should carry a lot of weight; as opposed to a solitary item in a health magazine.

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H1N1 Swine Flu – Pandemic, Panic & Profits

Last week’s announcement by WHO that the current H1N1 flu is now a pandemic is bound to cause some amount of panic or near-panic state among members of the public, especially those who associate pandemics with massive numbers falling ill and dying. Such was the case in the 1918 flu outbreak where 20 million died.


The 1918 Flu Pandemic - scene in hospital,Fort Riley,Kansas (pix from National Museum of Health and Medicine, Armed Forces Institute of Pathology)

But there’s been less than 150 people dead from the current flu pandemic! That’s much much less than the 36,000 Americans that die yearly from seasonal flu epidemics…so why the fuss?

Well, the number of deaths doesn’t matter – it’s the transmission in the human population that’s the key. Also, part of the confusion was also from WHO itself in terms of their definition of what constitutes a pandemic. For years, the organization’s Web site defined an influenza pandemic as causing “enormous numbers of deaths and illness.” This is their recently revised version:


So then, the number of deaths don’t really matter, as long as there is widespread human-to-human transmission across borders. One thing for sure – all good (and bad) things will come to pass and the post-pandemic stage will signal the end of the pandemic.

As I’ve mentioned before, where there are threats, there are opportunities..and the swine flu has not been spared. Several marketeers (call them innovative, if you will) have come up with several products that are purported to protect against the H1N1 virus. These include:

–A shampoo that claimed to protect against the H1N1 flu virus;
–A dietary supplement that claimed to protect infants and young children from contracting the H1N1 flu virus;
–A “new” supplement that claimed to cure H1N1 flu infection within four to eight hours.


The magnitude of these false claims has reached proportions that has caused the US FDA to issue a news release on June 15 2009 warning against fraudulent adverts that claim to diagnose, prevent, mitigate, treat or cure the 2009 H1N1 flu virus. See the full list here.

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Chinese Restaurant Syndrome

When the melamine debacle erupted last year and attracted the world’s attention to food safety issues globally, it seems rather unfair that another food safety issue should be attributed to the Chinese..

However, the Chinese Restaurant syndrome , which was first described in 1968 and referred to a collection of symptoms occuring after eating Chinese food is certainly not confined to this cuisine.

Chinese Restaurant

Unfairly Taking The Blame..Chinese Restaurants like this one in Manassas, Virginia, USA (photo courtesy of ZA Yusoff)

The symptoms – headache, throbbing of the head, dizziness, lightheadedness, sweating, a feeling of facial pressure, tightness of the jaw, burning or tingling sensations over parts of the body, chest pain, and back pain – can sometimes be mistaken for a pending heart attack. The cause is attributed to a form of food allergy to monosodium glutamate (MSG aka Ajinomoto, Vetsin, and Accent) and occurs only to some individuals.

I wrote above that it was unfair to blame Chinese food because while many people believe that MSG is the cause of these symptoms, a statistical association has not been demonstrated despite numerous research studies.  In fact, MSG is found in so many foods from so many cuisines that it raises one’s eyebrows : Maggi sauce, Marmite, Parmesan cheese, Knorr bouillon cubes, flavored potato chips, Kikkoman sauce, Worcestershire sauce, most barbeque sauces, to name a few!

Chinese Restaurant2

The Mother of All...100% pure MSG

So is MSG safe? The US Food & Drugs Administration (FDA) has classified it as safe as early as 1959. Most countries, including the European Union and the USA merely specify that there must be adequate labelling if MSG is added. In fact, most people recover from mild cases of Chinese restaurant syndrome without treatment and with no lasting problems. The only exception are those who develop severe allergy reactions, which can be life-threatening – watch out for

  • Chest pain
  • Heart palpitations
  • Shortness of breath
  • Swelling of the throat

In such cases, nothing less than a fast trip to the Emergency Department is mandated!

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Red Wine – Pros & Cons

Alcohol provokes the desire, but takes away the performance.’ shakespeare

(Shakespeare (1564-1616), Macbeth; Act II, Scene 3)

Even the Bard knew the ill-effects of too much alcohol..but really, when is it enough and when is it excessive?

Unless you’re the Malaysian Tree Shrew, the world’s heaviest drinker (featured in my earlier post here), how do you know whether you’re drinking too much? Get pen and paper ready and take this quick quiz here, courtesy of MSN.

red wine

White,Rose or Red? Choose Red for Resveratrol

The benefits of red wine on health are quite well-known, thanks largely to the French Paradox: – the low incidence of heart diseases among  the French despite ingesting foods high in saturated fats; this attributable to taking regular red wine.

So what is it in red (but not white) wine that confers the beneficial effects? This is attributable to the high content of polyphenols which originate from the skins, seeds, and vine stems of red grapes. This anti-oxidant comes in two main forms: flavonoids and nonflavonoids, the latter being the one well-known for resveratrol, the substance known to be the found in the skin of the red grape (or for that matter, any of the colored berries, like raspberry,cranberry,blueberry,etc).

One of most well-documented benefits of red wine is the heart protective effect. Moderate consumption of red wine on a regular basis may be a preventative against coronary heart disease, as well as increasing the levels of the good HDL-cholesterol. It is believed the polyphenols as anti-oxidants also prevent plaque formation and clogging of the arteries in the heart, besides having an anti-clotting effect that causes ‘thinning’ of the blood.

And what’s moderate consumption? 2 glasses (1 glass=5 oz=150 cc) for men and 1 glass for women daily.

And what about the bad? Apart from migraine and dehydration (the thirst the morning after), the alcohol in the wine interacts with a lot of medications – special warning to those taking tranquillizers and sedatives because alcohol is a downer which adds on to the effects of these pills to cause, in extreme cases, inability to breathe, coma and death. Impairment of attention and skills, including delayed reaction times is a well-known danger for drivers, a fact well-known in causing serious accidents on the road.

And there’s of course temporary amnesia if you’ve drunk too much!.. as in UB40’s Red Red Wine (watch it here!):

Red, red wine
Goes to my head
Makes me forget that I
Still need you so

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Losing Sleep Over Coffee

Some patients asked recently whether coffee was good for one’s health. Part of the recent upsurge in interest in the health benefits of this beverage has been the shift in marketing strategy by coffee-makers locally in promoting it as a rich source of anti-oxidants.


Plain Black Coffee - rich in antioxidants and with zero calories

Yes, coffee is a rich source of anti-oxidants, like chlorogenic acid and melanoidins, the latter being the most important component of roasted coffee. Some of the other beneficial effect of drinking coffee include:

  1. Reducing the incidence of Parkinson’s Disease and Alzheimer’s. Read “A Cup of Coffee a Day will Keep Alzheimer’s Away”.
  2. Protecting against diabetes. Moderate consumption  may lower the risk of type 2 diabetes in younger and middle aged women.
  3. Preventing liver disease and the formation of liver and kidney stones.
  4. The beneficial effects of caffeine in coffee on alertness, attentiveness, and wakefulness.

And the bad news? Among other things:

  1. Unfiltered coffee (as in Turkish coffee and kahawa) raises blood cholesterol. Filtered coffee, as in instant coffee, does not do so as diterpenes, responsible for raising cholesterol, are removed by filtration.
  2. Coffee consumption is also associated with an increase of plasma homocysteine, a risk factor for coronary heart disease.
  3. Caffeine in coffee can increase the risk of elevated blood pressure and hardening of the arteries, as well as palpitations.
  4. 4 cups or more will hasten osteoporosis, especially in those with low calcium intake in the diet.
  5. Coffee increases heartburn, aka gastro-eosophageal reflux disease (GERD).

What about heart disease? The verdict’s not in just yet..on one hand, diterpenes cause a rise in cholesterol and homocysteine but this seems balanced by the beneficial anti-oxidant properties.

I ought to clarify here that we are talking about coffee, just coffee. The pendulum swings the other way when we consume coffee with additives like milk and sugar. The latte at the local Starbucks will add on quite a substantial amount of fats, sugars and calories (260 to be precise, see here). Compare that to the ZERO calories of plain black coffee!


Gotten into a heated discussion recently about coffee preventing a proper sleep? Some people find that the mild stimulation of caffeine consumed even hours before bed time delays sleep, while others can consume a cup which will knock them out in no time! This paradox has never been fully explained even in medical circles..

Smoking… Where There’s A Threat, There’s Opportunity

As more and more countries join on the bandwagon to plaster graphic pics on cigarette packets in an attempt to reduce the numbers of smokers, some are questioning whether such measures are indeed successful. Well, there’s no need to go further..take a look at these figures from the United States’ CDC:


Its taken the Americans 40 years to reduce by half the number of smokers..and this in spite of the introduction of one of the nation’s strictest bans on smoking in public places by the state producing the most tobacco in the US –  North Carolina.


Tobacco companies exert their presence on Kimi Raikonen & John Todd at the Bahrein F1 Grand Prix,2007


Another Innovative Product - No Smoke But Still With Nicotine!

Some blame the slow reduction in the number of smokers to tobacco companies’ subtle strategies in fighting for their cause – sports sponsorship,adverts targeting teens and the like – but the real cause in the US is that Federal Agencies and public health advocates cannot regulate tobacco use, just like it can for drugs and breakfast cereals.

But this will not be for long..the US Senate will debate over the next few weeks giving the Food and Drug Administration (FDA) authority to regulate tobacco products. Some points include:

• The FDA needs to approve claims of “reduced harm” by the industry, which is already introducing a new generation of supposedly less dangerous products.

• Ingredients in tobacco products need to be revealed to the government — a big improvement over the current situation, where the public is in the dark.

• The FDA will mandate larger warning labels, curtail marketing to children, and ban the use of labels such as “light” and “mild.”

Tobacco companies, which have mastered the art of marketing deception into a fine art, will probably snigger a bit as they know the FDA is already overloaded with work ,and such new regulations aren’t going to lessen the burden. However, word has it that the extra costs needed to regulate smoking will be passed back to the tobacco industry!

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