Friday, March 4, 2011

Klinik Wan & Keluarga: Fillers for eye area

Klinik Wan & Keluarga: Fillers for eye area

Fillers for eye area

It's been a while since I've posted a medical blog.My cosmetic,medical, and personal postings are all entwined in this blog that it's almost impossible to separate them anymore. Anyway, patients who reads my blog and visits me tends to be more comfortable as they realized I am like them with humanly problems and stresses.
This posting is one cosmetic. Here I would like to highlight the usage of fillers and accompanied with pre and post procedural photos.
First patient is 45 years old. Bothered with the sunken eye  and decrease is mass over the tear trough area, she decided to get it corrected. 
45 degree angle profile
Frontal profile of pre injection. Sunken look is best assessed from the side, means lateral profile. Treating the eye is the most challenging part for facial augmentation by filers. Inexperience doctors may accidentally inject too superficially or too much would end up resulting a "puffed" look, basically an eye bag due to the loose elasticity of the skin that is unable to support the filler injected, hence gave way.
In this patient I injected  deep with the needle of the syringe touching the skull.
Initial result may not be the permanent as there would be bruises. I encouraged the patient to continually massage the injected area to spread out the bolus of filler.
...10 minutes later.....
Patient 2
25  year old woman came for second opinion as she was told to have eye bag and the only solution is surgery. She came to me for second opinion.
If you look carefully, she doesn't have an eye bag. It's just an illusion created by the narrow emptiness between her lower palpebral fissure and the tear trough hence  casting a shadow creating a eye bag like tired look.
I injected tiny amount to fill up the gap especially on the right eye(patient's right eye)
I would normally under treat the eye area, then prescribe some eye cream for the fine lines as her skin appeared dry.
The filler of my choice in this case in Juvederm ultra.
As Restylane which was the pioneer in non animal source hyaluronic acid(NASHA), I guess I would have to use Juvederm from now onwards.

Thursday, November 11, 2010

Test for allergies is now available in Klinik Wan & Keluarga

For those who suffers from allergies without knowing to what can be a burdensome and frustrating.
Ever wish you could find out about what you are  allergic against? Well the solution to your problem is new available at Klinik Wan dan Keluarga.
For adults, we have package called Malaysian Allergy Panel.
In this package approximately 5-8ml of blood would be required and tested against possible irritants such as
  1. egg yolks
  2. egg white
  3. cow's milk
  4. wheat
  5. peanuts
  6. soya beans
  7. squid
  8. crab
  9. ikan bilis
  10. chicken
  11. shrirmp
  12. dog dander
  13. cat dander
  14. cockroach
  15. pteronyssinus
  16. derm
  17. Farine
  18. blomia tropicalis
This package comes with a price tag of RM700.
Other package would be "Domestic Allergic Panel." which cost RM230. The test includes allergies towards:-
  1. House dust(Greer) 
  2. derm
  3. pteronyssinus
  4. farine
  5. blomia tropicalis
  6. cockroach
The third package is the Seafood allergy panel  thatcostRM260
  1. ikan bilis
  2. squid
  3. crab
  4. clam 
  5. shrimp
Last but not least, the Pediatric allergic panel.
  1. egg yolk
  2. eggwhite
  3. cow'smilk
  4. wheat
  5. peanut
  6. soya beans
  7. ikan bilis

Saturday, October 9, 2010

Revised price for Thin Prep Pap Smear

While getting ready to work yesterday, i thought to myself what else can be done reach out to more people concerning Cervical Cancer awareness.
Recently I found out Tzu Chi Buddhist group foundation jabs their followers with Cervarix at RM130+. Wow!
There are only two way one could get such a good price. Someone must have purchased it in a large lot with the best bonus.Unfortunately, it's only for Tzu Chi members.
I am not running a charity clinic,yet I want to give something back to the society as I felt compelled to do so.
The price for Cervarix will remain at RM165 per dose.
Unless of course GSK is willing to further bring down the price. Then I will definitely reduce the price further.
Then it struck me, perhaps there are two other things which I can still try to do(irrespective of the result, more importantly is the attempt) to enable people of the lower income group to get themselves protected.
Out of the available methods of Pap Smear today, Thin Prep Pap Smear still be a choice for a more thorough and accurate sampling, hence accurate result.
I took some time and thought of several possibilities:-
1. to lower the price for Thin Prep Pap Smear from RM90 to RM60, and each test were done using sterile gloves and disposable speculum.
Normal price of Thin Prep Pap Smear will be reduced from RM90 to RM60.
Sample are collected using the prepacked sterile brush for Thin Prep Pap Smear.
For hygienic purposes, only once only disposable speculum are used.
Hence, the whole package will cost RM60 instead of RM90, which has just begun yesterday.
My sincere plea to all readers to inquire more knowledge on Cervical Cancer, as it is the one of two cancers that we are given a choice whether to be willfully protected, rather than leaving to chances. It would be a crying shame when this revolutionary vaccine that is available in the market, yet there are few hundreds of new cases and at 2 deaths everyday due to Cervical Cancer in Malaysia.
Ladies and gentlemen, is has never and will ever be a stigma to get yourselves or your daughter or wife examined.

As a matter of fact, it is probably be one of the most important decision you've made in your life.
To demonstrate to you how rampant Cervical Cancer is in Malaysia, recently I've conducted a Cervical Cancer Prevention week, where I performed Thin Prep Pap Smear only on 4 individuals, out of which one of the four's test result came back as such.
...and when I proceeded with HPV DNA test where the samples are sent to Australia to identify presence of HPV virus and it's subtype.... it reads,
HPV subtype 16,18,31,33,45 are ranked top five that causes Cervical Cancer.
I sincerely ask the public please take care of your health.Please make use of the available "tools" today to detect and prevent this deadly disease before it fully develops.
This reaffirms my belief that one shouldn't have the attitude where disease as such won't happened to them.
It happened to my aunt, it happened to my mother in law. Do you think if ever given a choice, would they want it???
2.Income base/age base
Based upon the income of an individual, where patient would require to bring their pay slip. Monthly income below a certain amount would be charged much lower than RM165. This will be implemented soon, but yet to ascertain the cut off income point and the price offered.
3.Organize outreach program
90-95% of individuals who have heard of cervical cancer vaccine are urbanite, yet those who stepped forward for the vaccine is rather discouraging and insignificant. Perhaps to organize a talk in the rural area would be a good idea. It has never been tried for this vaccine, which doesn't mean it won't be receptive.
Ladies,please approach your doctor and ask regarding Cervical Cancer.With the availability of this vaccine, there is no one else to blame if one day your doctor informs that you've got cervical cancer.

Eh? Excuse me?

Cervarical Cancer symposium

Its a good day

Today was the day of the presentation for the Cervical Cancer prevention weekend.

Though the crowd wasn't large, nevertheless, it was worthwhile as it has the personal touch.
In a way, its good to have a small crowd as the interaction would be more personal. I started off the presentation by telling the crowd not to consider this as a talk, but rather a talk, and they are allowed to stop and question me at any time. 

I forgot to shave that particular morning, as I just completed the slides for the presentation at 6.30am, which gave me hardly 3 hours to sleep before the presentation. I tried not making this presentation too "medically orientated", hence making it more public orientated. No graphs, no dates, no charts in my presentation which is typical of any medical forum which bores not only the general public, but to me as well..
I didn't have time to practice my presentation, so everything that i presented was spontaneous.
When you are telling your genuine experience, as to why I developed the desire to educate the public, I told them my personal account with with cancer, it sounds genuine, because it is!

One of the featured slide was this, a true photo of my aunt while receiving her drips during her last visit to my clinic before being admitted to the hospital for the very last time. The computer screen was the true file on her during her visit on 16th June 2009, the time when she came with jaundice.
I guess what captured the audiences attention was the true life account that I've experienced, hence making the presentation more heartfelt and genuine.
For a while, while describing the last few hours of my aunt's ordeal, i started to stammer a little, as I felt a little emotional while recollecting those memories that will always stay at the back of my mind. I've emphasized that I sincerely do not want anyone else to experience the same ordeal as my aunt and uncle did. There in fact, isn't a reason to as Cervarix offers women the choice, the option to decide whether or not you want to be protected, rather than merely leading a healthy lifestyle, and hope you would be have cancer.

The most appealing part was I got to know there are people out there who are aware of such vaccine, and willing to step forward to get themselves protected from this deadly disease.
Perhaps, getting oneself vaccinated with this revolutionary vaccine would probably be one of the most important decision you've made in your life.

No one else can decide on the course of our lives. The discovery of a vaccine that protects us from Cervical Cancer has got to be one of the most highlighted and monumental significance in the history of medicine and mankind.

I ended the presentation is a short poem.

At the end of the day, with the amount of specimens  collected by Thin Prep Pap Smear is the most rewarding result that I hoped for, though I don't earn anything at the end.
I am already looking forward for the next campaign.

Preventing Premature Death

This write up on the particular product is based upon the author's own initiative, and not being influence in any way or given any remuneration in any form or manner by the manufacturer of the product. The views given are based upon medical journals conducted and information written here are from medical articles found by the author's effort and had not being helped in any way by the manufacturer.
Mankind and disease has come a long way and through out the course of history, humans had faced multiple diseases which were pandemic and had claimed millions of lives. Some of these deadly disease were so wide spread and claimed a biblical amount of lives worldwide that some faith believe it was the wrath of God. These deadly disease includes The Black Death, poliomyelitis,malaria,smallpox,cholera,Ebola,Bubonic plaque,The Spanish Flu, Influenza, and AIDS. History is marked with significant achievements that is forever immortalized as highlights in the course of science and medicine with discovery of vaccines that protects and prevents, and medicine to cure and control some of these deadly diseases that inflicts mankind. While most of the diseases I've mentioned can be prevented, while some has totally been eradicated, unfortunately there are those that its treatment or prevention are yet to be discovered. I believe it's just a matter of time before it's discovery. A promising fact is the nature of these diseases is known, and while medicine for cure and prevention is yet to be found, its methods of prevention is known.
At present the three most feared diseases with no known cure if influenza, AIDS, and cancer. 
While there are antiviral drugs and vaccines that were developed for previous influenza attacks, yet new mutated strains emerges from time to time. The latest being H1N1, and not too long ago SARS. While HAART(highly active antiretroviral treatment) regime prolongs and increases the quality of life, it's not curative. The quest for its vaccine is currently under research with it's recently published human trial on HIV type B and E, conducted in Thailand indicated 26% drop in infection rate. A promising number, yet far from being deemed an effective one.
Advancement in the field of medicine has come a long way with its progress forges on in steps.It's progress occasionally occurs by leaps and bounds with discoveries of vaccines and medicine that cures. One of the most significant moments as such by the turn of the century is the discovery of vaccine for cancer. 
(there are currently 2 brands available in the market for Cervical Cancer Vaccine, Gardasil by MSD, and Cervarix by GSK)
Perhaps(in my opinion) the fact that mortality rate and statistics presented in figures, percentages,and charts in medical conventions or symposium to highlight the impact of the disease on us fails to convey to doctors that cancer is a disease that affect the patient as well as the family members psychologically, financially, and emotionally,and not just merely numbers and figures. 

 From time to time, pharmaceutical company organizes symposiums and medical conventions for the purpose of sharing new data on latest studies conducted, it's efficacy, latest figures in mortality for a given year. 
Most presentation are on facts and figures, presented in the form of charts and graphs. These symposiums automatically becomes "logistically" orientated, instead of "patient" orientated.  
Personally(As this is purely a personal blog, contents of this write up is based on facts and figures presented are from the pharmaceutical company as well as independent health organizations. However opinion deducted is entirely based on the author's own personal opinion)  I feel these presentations ought to be more patient orientated. Instead of showing slides with charts and graphs, which I doubt interests majority of doctors present, they should perhaps consider showing this instead:-
Why can't medical conventions highlight upon the humanity side of the patient? Very often doctors forget the essence of medicine, their role in society, the impact they have on the patient and their family members, that certain decision which was made with much cavalier actually at times determines the outcome of patient's life. 
(Again, I would like to remind fellow readers that this post is written based on my personal point of view,ideas, and opinion. It may not be applicable for general public whether sharing the same profession or not. THIS IS A PERSONAL BLOG)
Perhaps one wouldn't understand why am i being so excessive in this matter. I wouldn't view it as being excessive. I think it's my deep rooted passion on this revolutionary discovery . Come on! This is cancer we're talking about. The disease that kills more than half a million woman worldwide out of which more than 270,000 is from Asia. A disease that potentially occurs on every woman irrespective of race, social status, religion, and age. Its a disease that reportedly affect approximately 4700 woman annually.  
Don't the public realize the impact this discovery has? It's advancement in medicine by leaps and bounds, it's a milestone in human history. My previous post, I mentioned that it's significance is in par with the landing of the first man on moon. I would like to rephrase that. It's more important than the landing of the first man on moon. Did Neil Armstrong "one step of man, giant step for mankind" save any live?? NO!!
I remember back in early 2006, when the first cervical cancer vaccine, Gardasil was launched. Not many doctors(mostly GPs) was keen on promoting this product for several factors. First, the doctors themselves aren't well versed to provide counselling to potential recipients, being the first of its kind- the price was most of the time unaffordable by middle class income group, even those who can afford it had to think twice as it cost  between RM1600-RM2400 for complete vaccination, and last but not least, it's difficult to even begin introducing the vaccine to patients as they perceived that the doctor have the impression that they lead a sexual promiscuous life. 
Personally,I felt the pharmaceutical company who manufactured this product which IS revolutionary that marked man's first step in the effort to have control over cancer, a disease that one shudders and dreaded upon being diagnosed to have and totally change the perspective of one's view towards life, shouldn't have put such an unaffordable price tag.
There's nothing wrong being financially orientated. Hey, which stake holders wouldn't want that? I wasn't forming any opinion in my head when Viagra was launched in 1998. No one dies as a result of erectile dysfunction. They can charge a few hundred dollars a tablet for all I care, but when it comes to life saving drugs, I felt there is a moral obligation one needs to consider. Cancer accounts for 14% of causes of death worldwide. Cardiovascular disease ranked 1st in the cause of death for many years, but it is primarily a disease that stems
from the lifestyle, which is within one's ability to control. Right from the beginning I felt it's morally wrong to commercialize such product, making it into a drug of exclusivity.
A significantly huge percentage of people cannot afford this vaccine, even if they genuinely longed for it. But it's a fact of life. Only the rich and financially capable group enjoys better health care. Why is that so?  Just because one is poor, does it mean they aren't as humane as the upper class people? This is absolutely ridiculous!
There are many opportunity to earn a good financial return, but to my opinion, by simply hike up the price since there is no competitor is a simple act of exploitation. 
I was most delighted when another well respected pharmaceutical giant came out with their own vaccine,Cervarix.
Right in the early phase after the launch of Cervarix, the manufacturer announced their intention to lower the cost price, with the intention of making this vaccine affordable to the masses.Cheers to this company! This company is known to produce superior quality medical products. Another product from this company that I endorse in the midst of H1N1 pandemic would be Relenza. This product is far superior than the alternative Tamiflu. Why?
Why not you google or read on Tamiflu's side effect in Wikipedia? You wouldn't even want it even if it's being given free to you!
the fact that the company decides to lower the cost price shows that being a pharmaceutical company where their products contributes to health care, they uphold their integrity and nobility, when their version of cancer vaccine is far superior than the previous in so many expects, could have easily raise the price a higher, but they chose not to. 

 Immediately, I knew without doubt this product would definitely be my choice. Right from it's pricing, awareness campaign, continuous support provided towards doctors, the multiple symposiums to keep health care workers up to date with the latest data on the product, their efficacy,degree, and duration of immunity,etc... are by far more superior to the many folds i might add!

Good patient information pamphlet.
Excellent support to doctors.
Regular symposium organized for latest updates.
its superior quality acknowledged and approved by renown leaders in Gynaeoncology...

Regular updates by the medical representatives that supports the doctors....
 Though being advertised as a bivalent vaccine, it gives protection against the 5 most high risk cancer causing subtypes of Human Papilloma Virus.(HPV).. while the previous provides immunity to only 2 subtypes.

It's unique formulation in making this vaccine that is by integrating aluminium hydroxide that acts as an adjuvant to boost up and maintain body's immunity for at least 20 years... I say again, AT LEAST 20 YEARS! The use of aluminium hydroxide is the first of its kind in Malaysia. The only other vaccine that uses the similar adjuvant is vaccine for Hepatitis B in Europe that is designed for immunocompromised patients.
Now tell me which among the two would you chose?

Why am I being so passionate about this matter? Why am I so concerned about this issue? 
Perhaps my direct encounter with family members of patients who had succumbed to cervical cancer, despite Pap Smear reported negative/normal. I felt their sense of frustration as to how is it possible when they undergo annual Pap Smear religiously. The question kept on lingering in the mind of family members as to why and how it  happened so suddenly?
How was it possible when the report came back normal? When there's no history of cancer within the family? It was apparently clear to me the distress and psychological trauma they had gone through seeing their helpless sister,wife,daughter, or wife dying. They just simply couldn't accept the fact. That they must be some mistake. There was no and will never be a closure for them.
At the same time, maybe perhaps due to the fact that I had experienced first hand how it felt like to have your own family member being diagnosed to have cancer and the traumatic one sided battle that dampens your spirit, leaving behind psychological and mental scars seeing your love ones dying as time passes by. The repeated hospitalization, the regrets that you have not lived a fulfilling life with them, and now being too late.
My aunt recently passed away from pancreatic tumour. I diagnosed her with possible pancreatic tumour when she came to me with post hepatic jaundice. 
I remember praying hard that I made the wrong diagnosis. Sadly, it was confirmed to be carcinoma of head and body of pancreas after CT Scan of abdomen being done in Selayang Hospital. 
It was heart wrenching to see my aunt getting emaciated each time she sees me from time to time. I stood by her deathbed during those final hours of her life. I see how the pre mature passing of her has affected my uncle whom I was with just last week and told me he has difficulties sleeping at night. No matter how hard he tries to hide his feelings, its rather obvious that he's traumatized by her passing. My cousin told me he would suddenly break into tears. No medication, sleeping aid, anti depressant, or anti anxiety can relieve the pain he is experiencing. 
I do not wish anyone else whether I know or don't to experience the same thing as any cancer patient and their family members endured. 
Right from the beginning, my inner consciousness tells me it's the right thing to do to make this vaccine affordable to all walks of life. 
It doesn't matter if I do not profit from this vaccine. What else is more satisfying and gratifying than knowing that you are living in an era that witnessed the discovery of a vaccine against a disease that previously deemed incurable and certain death for those who were diagnosed to have? Not only am I privileged enough to be living in this era, but to be given the opportunity to contribute to create awareness among the community on the importance of prevention of this killer disease. It's history in the making, and being part of it is certainly an opportunity not to be missed. 
When I announced that I am charging RM165 per dose, i received mixed reactions almost immediately.
I was sort of frustrated as despite the lowered price, not many people are interested to even inquire about it! 
Perhaps maybe the community do not realize how rampant the incidence of cervical cancer is. Maybe perhaps they weren't aware as they weren't informed by their doctors? Maybe it's the common attitude that ignorance is bliss and the delusional belief that it would not happen to them. Having such thoughts is akin to playing Russian Roulette! No kidding! It's like holding a revolver to your head hoping each time you pull the trigger, it would be an empty chamber. 
I have written numerous post in my blog, repeatedly emphasizing the importance of vaccination. It doesn't matter if I had to post repeatedly, as long as I am able to reach out to the public, I knew I had contributed to decreasing cervical cancer morbidity and mortality, even by an insignificant amount. 
The challenge of creating awareness among the public and to educate them became personal to me. Don't ask me why. Soon I begin to realized why am I not able to reach out to public. 
First of all, significant number of those who are considering the vaccination thought they would need to perform a Pap Smear prior to vaccination. -- NO YOU DON'T HAVE TO!!
Second factor being, they feel obliged to be followed up by me since they got vaccinated here!--NO YOU DON'T HAVE TO!
I insist that they can continue to be follow up with their regular doctors and not at all need to feel obliged to be follow up by me. However I always insist that they should ask for a Thin Prep pap Smear instead of conventional Pap Smear as it is significantly more accurate in detecting adenocarcinoma. 

Reason being conventional Pap Smear is not reliable in detecting adenocarcinoma as the sampling method is faulty. Thin Prep Pap Smear is an improvised version of Pap Smear. 

Notice the ectocervix and the endocervix? Adenocarcinoma is tumour that mostly arises from the inner part of the cervix, the endocervix, where conventional Pap Smear is unable to get a good sample. 

Wooden spatula used in conventional Pap Smear that fails to get a good sample from the endocervix and while smearing the sample onto the slides, only 20% of the collected samples are deposited, while the other 80% is left on the spatula.
The answer to the false negative from conventional Pap Smear.

The brush used in Thin Prep Pap Smear is designed for a more effective sample collection. I know what is in your mind now.THE ANSWER IS NO, ITS NOT ANY MORE PAINFUL THAN CONVENTIONAL PAP SMEAR.

So,please next time insist on Thin Prep Pap Smear. The fact is, not many doctors especially general practitioners are aware of the availability of such test. 
According to head of Cytology and Histology Department, Gribbles Lab(Malaysia), out of the samples they received, only 30% are Thin Prep Pap smear, out of which only 20% out of those Thin Prep Pap Smear samples are from General practitioner.
Its an alarming fact that indicates the depth on knowledge general practitioners have on Cervical Cancer and it's screening. 

What is more alarming is the fact that 8% of the doctors who attended a symposium on Cervical Cancer held at Le Meridien Hotel recently were strongly against vaccination of girls age between 10-15 years old! Aiikk!! that is the best time to vaccinate, before their first intercourse.
Determined to be more pro active, I thought perhaps woman who were contemplating the vaccination but holding back at the fact that it's being done by a male doctor, hence shy away.  

I've made a new poster announcing that our clinic provides free counselling, and if you feel hesitant on seeing me, you could always check out the URL written in blue. 
I've also prepared a notice informing passerby to snap a picture with their handphone  in case they can't remember the UR

Another reason for the low reception was the fact that the price I offered was so low that some actually question whether do I use the "real product"! No. That's a sensible, reasonable doubt to have considering my unreasonably low price! You SHOULD HAVE DOUBTS! 

One way to ensure you are receiving the genuine product is to insist on the doctor to open the box containing the prefilled syringe right in front of you.

Inside the box, the prefilled syringe comes along with 2 needles.Please take notice of the colour or the needle. One Blue and One Orange. Both the needles and the syringe is sealed with another layer of plastic. Make sure the doctor peel out the plastic IN FRONT OF YOU!

Don't feel awkward in insisting to inspect the syringe and its content. The vaccine is not entirely clear and transparent. It's a has a little murky look. 
The moment you decide to get the vaccination, you have already taken a huge step in preventing cervical cancer. Now that you are sitting in the consultation room, made sure that the doctor opened the box, peel the plastic, connect the needle, and had inspected the colour of the vaccine, you are 95% sure that it is the genuine stuff. But to be 100% sure, well, I know its silly but out of so many times you've received vaccination which was administered through intramuscular injection, I would assure you that you had received the original stuff when you notice this vaccination is OUCH!! more painful compared to others, due to its formulation, aluminium hydroxide. 

This is as far as I can think of in my effort to reach out to the public to create awareness  in the importance of getting vaccinated.