FAPA 2010: Community Pharmacy Visit

Find out more about the community pharmacy in Taiwan HERE!

Some Facts about Eye Drops

On 28th November 2010, I attended the CPD Pharmacists' Workshop on Ophthalmology at the Saujana Hotel with several friends. This workshop is a breath of fresh air indeed-while the lunch is sponsored by Allergan, the workshop is not heavily laden with product talks; not only that, the invited speakers comprise consultant ophthalmologist and experienced pharmacists, sharing practical points on various topics:red eyes, dry eye, glaucoma and nutritional supplments for age-related macular disease.

Some learning points from the workshop that I would like to share with you all:
When instilling eye drops, 1 drop is sufficient as the ideal volume of a drop that the eye can hold, especially the conjunctiva cul de sac is 10-15uL and the typical volume of an eye drop is 40uL.

Sequence of instillation (if more than one type of topical drugs are to be used):
1) solution 2) suspension 3) Suspension/Gel

For contact lens wearer, instill the eye drop first, then wait for 15 minutes before putting on the contact lens.

Tear film is a barrier to effective drug delivery. Tear film penetration can be increased by manually blocking the nasolacrimal duct and tilting the head backwards. Occlusion of the nasolacrimal ducta after instillation of eye drop, minimises systemic absorption.Examples of systemic side effects: Gutt chloramphenicol may cause aplastic anaemia, Gutt timolol may cause acute exacerbation of bronchial asthma.


Once an eye drop passes the tear film, it penetrates the cornea which is the major site of absorption for topical drugs.

1 drop of eye drop: only 50% reach the site of action.

The iris acts as a reservoir for drugs instilled into the eye. Prostaglandin analogues used for glaucoma may change colour of iris as they stay in the iris.

Hydrophilic drugs do not enter the retina easily. They are prevented by tight junctions complexes at the retinal pigment epithelium, hence retinal toxicity is seen in certain drugs. E.g. Gutt. chloramphenicol may cause optic nerve toxicity.

Caution must be taken when recommending/prescribing steroid eye drops as they have contraindications and adverse effects. Adverse effects include: elevation of intraocular presure and possibly glaucoma with nerve damage, cataract formation, delayed wound healing, worsening corneal ulcers especially if bacterial or fungal.

One of the points to consider when recommending eye drop to patient-the types of preservatives used.

Mechanism-Based Therapies for Heart Failure and Cardiac Arrhythmias

Mechanism-Based Therapies for Heart Failure and Cardiac Arrhythmias

TOPICS COVERED IN MECHANISM-BASED THERAPIES FOR HEART FAILURE AND CARDIAC ARRHYTHMIAS

Introduction to excitation-contraction coupling - History of the field of EC coupling - Introduction to the ryanodine receptor/calcium release channel (RyR2) - Mechanisms that regulate the RyR2 channel during stress - Defective regulation of RyR2 in heart failure - Evidence that diastolic sarcoplasmic reticulum (SR) calcium leak causes heart failure and arrhythmias in vivo - Novel therapeutic approaches to treating heart failure and preventing sudden cardiac death by fixing the leak in RyR2 channels

How to cite this talk:
Marks, A. (2007), "Mechanism-Based Therapies for Heart Failure and Cardiac Arrhythmias", in Simpson, A. (ed.),Calcium Signaling: Regulation, Mechanisms, Effectors, Role in Disease and Recent Advances, The Biomedical & Life Sciences Collection, Henry Stewart Talks Ltd, London (online at http://hstalks.com/bio)

Effects of poor and short sleep on glucose metabolism and obesity risk

"The importance of sleep to hormones and glucose metabolism was first documented more than four decades ago. since then, sleep curtailment has become an endemic behavior in modern society. in addition, the prevalence of sleep disorders, particularly obstructive sleep apnea (OsA), has increased. OsA is very common in endocrine and metabolic disorders, but often remains undiagnosed. A review (Spiegel, K. et al. Nat. Rev. Endocrinol. 5, 253–261 (2009); doi:10.1038/nrendo.2009.23) summarizes the laboratory and epidemiologic evidence that suggests how sleep loss, either behavioral or disease-related, and poor quality of sleep might promote the development of obesity and diabetes mellitus, and exacerbate existing endocrine conditions. Treatment of sleep disorders has the potential to improve glucose metabolism and energy balance. screening for habitual sleep patterns and OsA might be critically important for patients with endocrine and metabolic disorders."

*If you need the full article, pls noticify us by posting your valid email address along. Thank you and enjoy reading.

GREACE STUDY

Safety and effi cacy of long-term statin treatment for cardiovascular events in patients with coronary heart disease and abnormal liver tests in the Greek Atorvastatin and Coronary Heart Disease Evaluation (GREACE) Study: a post-hoc analysis

Background
Long-term statin treatment reduces the frequency of cardiovascular events, but safety and efficacy in patients with abnormal liver tests is unclear. We assessed whether statin therapy is safe and effective for these patients through post-hoc analysis of the Greek Atorvastatin and Coronary Heart Disease Evaluation (GREACE) study population.

Methods
GREACE was a prospective, intention-to-treat study that randomly assigned by a computer-generated randomisation list 1600 patients with coronary heart disease (aged <75>2·6 mmol/L and triglycerides <4·5>Findings
Of 437 patients with moderately abnormal liver tests at baseline, which were possibly associated with non-alcoholic fatty liver disease, 227 who were treated with a statin (mainly atorvastatin 24 mg per day) had substantial improvement in liver tests (p<0·0001) p="0·0074)">Interpretation
Statin treatment is safe and can improve liver tests and reduce cardiovascular morbidity in patients with mild-to-moderately abnormal liver tests that are potentially attributable to non-alcoholic fatty liver disease

*If you need the full article, pls noticify us by posting your valid email address along. Thank you and enjoy reading.

Cardio classics revisited – focus on the role of candesartan

Author: Maria Leonarda De Rosa
Published Date November 2010 , Volume 2010:6 Pages 1047 - 1063 DOI 10.2147/VHRM.S9433

Maria Leonarda De Rosa
University of Naples Federico II, Department of Cardiology, Naples, Italy

Abstract: Angiotensin II receptor blockers (ARBs) are antihypertensive agents with considerable evidence of efficacy and safety for the reduction of cardiovascular (CV) disease risk in numerous patient populations across the CV continuum. There are several agents within this class, all of which have contributed to various degrees, to this evidence base. The evidence with ARBs continues to accumulate, with ongoing trials investigating their role in additional patient populations, potentially expanding their efficacy across a broad spectrum of CV disease states. Cardiovascular disease (CVD) is a leading cause of death around the world, accounting for approximately 29.2% of total global deaths. Of all the deaths attributed to CVD, approximately 43% are due to ischemic heart disease, 33% to cerebrovascular disease, and 23% to hypertensive and other heart conditions. CVD has been represented as a "CV continuum". This continuum concept can be used to describe CVD in general or in specific vascular beds (eg, coronary artery disease or cerebrovascular disease). This review article will discuss the results of the landmark ARB candesartan clinical trials published over the past decade. The evidence presented spans the entire CV continuum, including the effects of ARBs in at-risk patients, stroke, myocardial infarction (MI), and heart failure (HF), as well as a brief discussion of ongoing trials.

Keywords: candesartan, cardiovascular disease, angiotensin II receptor blockers

(Reference : http://www.dovepress.com/articles.php?article_id=5718)

FAPA 2010: A Snapshot

The delegates from Malaysian Pharmaceutical Society-Young Pharmacist Chapter (MPS-YPC) [being part of the bigger MPS delegation] attended the 23rd Federations of Asian Pharmaceutical Associations (FAPA) Congress at Taipei, Taiwan on 4th November-8th November 2010! Check out their experience HERE!

Vancomycin Update - Extracted from DiPiro

DiPiro Joseph T, "Updated Guidelines for Vancomycin Dosing" (Update). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 7e: http://www.accesspharmacy.com.ezp.imu.edu.my/updatesContent.aspx?aid=4000077.

Vancomycin has been in continuous use since the 1950’s, primarily for treatment of methicillin-resistant staphylococcal infections. However, dosing recommendations continue to be refined. The Infectious Diseases Society of America along with the American Society of Health-System Pharmacists and the Society of Infectious Diseases Pharmacists published updated, evidence-based guidelines for vancomycin dosing with Staphylococcus aureus infections.¹ The purpose of optimal dosing is to maximize the therapeutic benefits while minimizing risks of toxicity.

Factors that influence vancomycin dosing include patient weight and renal function, as well as the susceptibility of the infecting organism and the severity of the infection. The primary pharmacodynamic measure of vancomycin efficacy is the area under the serum concentration–time curve divided by the minimal inhibitory concentration (MIC).

The guidelines recommend that vancomycin dosing should be based on serum trough levels obtained just before the fourth dose when steady-state concentrations have been reached. Subsequent doses should be determined by vancomycin levels and changes in renal function.

The recommended trough serum levels are 15-20 mg/L for complicated S. aureus infections (such as bacteremia, endocarditis, osteomyelitis, meningitis, and hospital-acquired pneumonia) and at least 10 mg/L for less serious infections. Measurement of peak levels is not recommended. Trough levels less than 10 mg/L can result in development of vancomycin intermediately-susceptible S. aureus strains (VISA). The authors stated that there are limited data suggesting a direct causal relationship between toxicity and specific serum vancomycin concentrations.

Vancomycin is typically dosed at 15-20 mg/kg based on actual body weight (including for obese patients). For seriously ill patients a loading dose of 25-30 mg/kg can be given based on actual body weight. Subsequent doses are based on serum trough levels. Doses of 15-20 mg/kg (based on actual body weight) given every 8-12 hours are required in most patients with normal renal function, when the MIC is less than or equal to 1 mg/L. When the individual dose exceeds 1 g the infusion period should be extended to 1.5-2 hours.

Monitoring of serum trough vancomycin concentrations to reduce nephrotoxicity is recommended for patients receiving aggressive doses to achieve sustained trough levels of 15-20 mg/L and for patients at risk of nephrotoxicity (such as patients receiving concurrent treatment with nephrotoxins), as well as patients with unstable renal function and those receiving prolonged courses of therapy.

Frequent serum concentration monitoring for patients receiving short-course therapy (less than 5 days) or lower-intensity dosing (to achieve trough concentrations less than 15 mg/L) is not recommended. Once-weekly measurement of serum trough concentrations is recommended in patients receiving sustained dosing to achieve trough levels of 15-20 mg/L. Monitoring of trough levels to reduce ototoxicity is not recommended.

Readers are referred to the original article for more in-depth presentation of vancomycin serum concentration level monitoring.

Reference

1. Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Vancomycin therapeutic guidelines: A summary of consensus recommendations from the Infectious Diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis. 2009;49:325-7. [PMID: 19569969]

What Pharmacists Do: A Day at Desa Temuan

What got all the staff from a district health office (comprising pharmacists, doctors, dentists, nurses, medical assistants, health officers, administrators and drivers) up at 8 a.m. on a Saturday (30/10/10)? It was the Kem Kesihatan Kampung Orang Asli at Desa Temuan. This is part of the government's health promotion effort, offering the orang asli free medical and dental check-ups, educating them on medicines as well as raising awareness about tuberculosis and smoking.

Left: The Bukit Lanjan Community Centre.
Right: Dewan Seri Temuan.













It rained in the morning so it took a while before the crowd started to throng in.

The pharmacy station.

Busy packing goodie bags, some lucky ones received vitamins for their children.

Left: Simple items such as paracetamol, chlopheniramine, bisacodyl, calamine lotion etc.
Right: Prescription

Dispensing medicine to patient.

We went around pinning badges 'Kenali Ubat Anda. Tanya Ahli Farmasi Anda' on the kids. The kids were really happy to get the badge, they went on to bring their friends and asked us for it.

As we did pinned the badge on them, the 'promotion' of the role of pharmacist went like: 'Ubat ini comel kan? Jadi bila sakit, mesti ambil ubat ya.'

[To the older kids] 'ah kak siapa?' 'Doktor' 'Bukan, ah kak ahli farmasi'
(Nevermind that it may not stick into them yet, at least they know that someone other than the doctor is part of the healthcare team. By the way, I think it doesn't help in our effort to enhance the role recognition of pharmacists among the public when the word 'pharmacist' is not exactly easy to remember-for those not-so-educated ones and for kids to pick up.)

We also took the opportunity to speak to some people (targetting the right audience) about how to spot a genuine product (MAL number, hologram & meditag), proper storage of medicine and its importance as well as the products purported to cure certain chronic diseases which can't be advertised.

The pharmacy team.

Left: Awaiting their turns for medical check-up (blood pressure, immunisation among children, body mass index, any other chief complaints by patients)
Right: Phlegm-taking station (for Mantoux test)












Left: The crowd got larger after 10 a.m., so much so that we stayed till 2 p.m. (beyond the scheduled time)
Right: Lucky draws

Traditional performance by the Temuan girls.

In my opinion, the health promotion could have been better carried out if we were allocated a session to give a talk. Topics can be on 'Kenali Ubat Anda', but we do it in a more interactive way, bringing samples of counterfeit products, getting audience to check the genuine products with the Meditag (it was hard achieve the same outcome at the pharmacy counter though we had goodie bags as the patients came staggeredly and we couldn't hold their attention long enough). We can utilise the goodie bags more effectively (we had initially planned to do so but when we saw only a handful of people earlier on, we decided to give something to whoever who came to our pharmacy station) by giving them to those who ask questions about what we have presented.

Prior to the campaign, the authority could also have urged the people to bring their medicines from home so we can do a medicine cabinet clean-up for them. However, a colleague told me that when the health inspector did a pre-campaign survey, it seemed that the orang asli wasn't that interested in the whole campaign. Indeed, it is a long way towards raising their awareness about health and medicines. Perhaps the government can look into home medication review for these people as well.


Nevertheless, it was a fruitful morning and we shall strive to be better in upcoming activities!


Disclaimer: This is an opinion piece and therefore subjective by nature. The opinions expressed here are the opinions of the individual author and are not necessarily the views of the particular district health office.

Latest update on WHO's Antiretroviral Therapy for Children and Infants

Hi frens,

Check out the link if you are interested to know the latest update on antiretroviral therapy for children and infants.

http://www.who.int/hiv/pub/paediatric/infants2010/en/

(P/S: Thanks Ka Keat for sharing this out~)

Mai

Scenario in a Klinik Kesihatan

I have a patient discharged from a hospital to our clinic, and he is on life-long tiotropium bromide Handihaler (Spiriva) and Symbicort Turbohaler for chronic pulmonary obstructive disease (COPD). As these medicines are not in the formulary our pejabat kesihatan daerah (district health office), the hospital is to supply us with those medicines.


When I called up the hospital, I was told that my clinic has to find an alternative since the hospital in low on budget and will no longer supply those medicines to my patient. So this prompted my mini search (or rather, refreshing of) COPD guidelines.Tiotropium bromide (List A*) [Spiriva] is a long-acting anticholinergics (duration: 24 hours) used for the long term maintanance treatment of bronchospasm and dyspnoea associated with COPD. It is usually added to standard therapy (e.g. inhaled steroids, theophylline) and the dose is 18mcg od.

Symbicort Turbohaler (List A) contains budesonide (a glucocorticosteroid) 160mcg and formoterol (long-acting beta2-agonist, duration: 12+ hours) 4.5 mcg; the dose is 1-2puff bd,max 4puff bd.

My clinic only has MDI salbutamol, MDI budesonide and MDI Berodual. MDI Berodual contains ipratropium bromide (a short-acting anticholinergics; duration: 6-8 hours) 20 mcg/dose and fenoterol hydrobromide (short-acting beta2-agonist); duration: 4-6 hours)50 mcg/dose.

According to the GOLD guidelines, an inhaled glucococorticosteroid combined with a long-acting beta2 bronchodilator is more effective than individual components in reducing exacerbations and improving lung function and health status.

Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators.

GOLD guidelines: Therapy at each stage of COPD

Guidelines according to NICE

Since my patient is on a long-acting bronchodilator and inhaled steroids, his stage of COPD must have necessitated the use of these medicines, and that the short-acting bronchodilator and short-acting anticholinergics in my clinic are not sufficient for his condition. These are conveyed to the hospital and arrangement is made for them to supply us with those medicines currently, after which my budget-strained clinic has to exchange similar-valued medicines with tiotropium and Symbicort Turbohaler from the hospital for my patient's life-long supply of medicines. I believe that patient's care should not be compromised even when he is under follow-up in a clinic !

Can We Cure HIV? Update from Harvard Medical School

Research update on HIV

http://www.medscape.com/viewarticle/729212?src=mp&spon=30&uac=103666FX

SGLT2 Inhibition: A New Kidney-based Strategy to Reduce Hyperglycemia

New and emerging type 2 diabetes therapies with novel MOAs that reduce hyperglycemia while preserving insulin secretion, preventing hypoglycemia and controlling body weight. Explore renal glucose reabsorption via selective inhibition of the sodium-glucose transporter-2.

Please go through below link to understand more.

Center for HealthCare Education

http://www.medpagetoday.com/webcast/CHCE01/?mptts=20101005081329

Lessons from HPAIR Part II

In his seminar on Asia's Entrepreneurship Ecosystem, the interesting point brought up by Dr. Tan Wee Liang (Associate Professor of Entrepreneurship and Law at Singapore Management University) that got me thinking was 'the entrepreneurship question'. Entrepreneurship focuses on creativity, intervention and innovations in all walks of life and enterprises. It does not necessarily mean that you need to start an enterprise to be called an entrepreneur. People who work within companies and show entrepreneurial spirit is no less an entrepreneur.

Dr. Tan Wee Liang

The net outcomes of entrepreneurship are value creation and wealth creation. Wealth is not the same as profits-if you have helped somebody and and you feel great about that (you do not charge anything), that is wealth creation. Indeed, I am sure the pharmacists in Hospital Kuching who 'innovated' a spacer device from the normal saline drip bottle for patients who can't afford the Aerochamber, didn't mind walking to-and-for to the ward to get the right measurement of patient's mouth, trimming the mouth of the bottle etc. in order to ensure a tight fit for patients.
[Note for the unitiated: patients with asthma or chronic obstructive pulmonary disease who are on metered dose inhalers may require Aerochamber to ensure efficient delivery of drug since they (especially the elderly) have problem with coordination-pressing the canister and inhaler the drug at the same time]

Some of us may have big dreams we wish to pursue, like starting a pharmaceutical company eventually or being a pharmaceutical scientist in drug discovery and delivery. The pharmaceutical industry has a rich history of entrepreneurship. As shared with us HPAIR delegates in the seminar on Sustainable Entrepreneurship-A Case Study from the Pharmaceutical Industry by Dr. James Garner (Vice President & General Manager, Takeda Clinical Research Singapore), it dates back to the time of Sir Alexander fleming in deriving penicillin and the eventual implementation of large-scale production of penicillin by Howard Florey and Ernst Chain.

Dr. James Garner

In drug development, only 1 in 500 compounds (which have potential to become drug) make it to phase III of the clinical trial; and only 3 in 10 new drugs ever return their cost of development! Due to changing disease pattern and pandemic outbreak, there is urgent call for consistent delivery of transforming innovation in the pharmaceutical industry.

For us fledgling pharmacists who are in the compulsory service, before we get to be master of our own destiny (be it in clinical, retail pharmacy, sales and marketing, regulatory affairs or drug design etc), let us embrace the innovative spirit in our effort to enhance patient care. I have seen simple gestures by the pharmacists that go a long way towards improving patients' compliance and understanding in their treatment, such as the meticulously compiled pictures (together with captions in Malay, English and Chinese) of food/supplements that patients should not consume while on warfarin; to effort which improves the service of the pharmacy department, such as developing a software for the calculation of total parenteral nutrition. Always think 'What else can I do for this patient?'

So my dear fellow pharmacists, let's be a facilitator of change in your workplace!

Lessons from HPAIR Part I

The Harvard Project for the International & Asia Relations (HPAIR) Asia Conference 2010 was co-organised by Harvard University and Singapore Management University and was held on 20th -24th August in Singapore.



So what got a pharmacist interested in attending a business conference? While I graduated with a pharmacy degree, I have always sought out opportunity to further develop my interest outside my discipline. In fact, the pharmaceutical industry is a global business itself. The launching of a new drug requires extensive market research, SWOT analysis, targetting, position and differentiating the drug from that of the competitor's as well as a good marketing plan. Given the sheer size of a pharmaceutical company, it is no surprise that the management and organisational challenges are manifold.

There were several plenaries for selected delegates to choose from during our application, spanning from political,economic, and business to social and cultural. I was given my first choice: Business Strategy and Management. In the afternoon, there were seminars on various topics from which we had the freedom to select (before the capped number of people was filled and you had to go for your second choice, third choice etc.!!) On field trips day, we visited ExxonMobil and 3M Singapore PTE Limited.

I was truly enriched with the inspiring and interesting pearls of wisdom from the business leaders! It is impossible for me to put down in words but here are some snippets of their sharings.

Business Panel: Session I-Leadership
Distinguished speakers:
Mr. Gerald Chan, Country Head & CEO of UBS, Singapore
Mr. Eikoh Harada, CEO of McDonald's Japan
Mr. Tsun-yah Hsieh, founder & chairman of Linhait-Group

From Left: Ms SuiLin yap (moderator), Mr Gerald Chan, Mr Eikoh Harada, Mr Tsun-yah Hsieh

-The challenges to Mr Gerald:
'How do I motivate and galvanise the engagement of people?'
'How do I build up a management team that is able to capitalise on managerial skills of some people and gelling it with the entrepreneur spirit of some people?'

-The root of crisis is uncertainty. Because of uncertainty, the management learnt in school is not useful; it depends on one's quality (judgement, creativity, courage), not skills or knowledge in coping with crisis.

-Most colleges teach you knowledge, a bit of skills, but none on quality.

-There is a universal qualities of a leader; every progressive company put in time and effort to pinpoint what kind of quality they are looking for (not looking at which schools you graduated from). These qualities (to Mr Hsieh) are:

1. Operating skills
-make things happen
-e.g. set up 100 stores in China

2. Business Development
-You may have the best business plan, but do you know how to launch it?
-Do you know how to make a deal?
-How good is your network?
-Do you know how to originate?

3. Organisational Reform
-Large corporations have one universal characteristic-they have been around for centuries hence a lot of 'cobwebs' (complexities)
-In order to move forward, need leadership talent to 'simplify' process
-Leadership is about moving out of comfort zone and do things that people otherwise won't do


-It is always beneficial to have some perspective in the global market you will be operating in, but it is not critical. The criticality of your success lies in your personality.

-Mr Harada on leadership: leadership is about how to manage myself so that the team can be optimised?

-In order to be a global player, understand your own culture first. Think local before global.

-Has the economic crisis ended? We have relatively little control over those things; a better question to ask will be, 'What do you do now, so that when the cycle picks up, you are 2-3 steps ahead of your competitors?' It is important for one to build the innate ability to look around, to know what is around the corner [well, this reminds me of the lessons learnt in 'Who moved my cheese?]

-The constant compression of time and space brings about challenges (e.g. epidemic-spread from one country to another) and opportunities (e.g. ability to make the world your market place)

-The top management are looking for people who are comfortable with making decisions with less than perfect information.

-Sometimes, you need to slow down. When you are so activity-driven, can you really see the opportunity?

-Important asset to a company: someone who is adaptable to change and instinctively looking for a change



Business Panel: Session II-Global Strategy
Distinguished speakers:
Mr Emirsyah Satar, CEO of Garuda Indonesia
Mr Richard Pond, Global Candy Category Director, Kraft Foods
Ms Christina Ventura-Steinemann, Regional Retail Director, Prada
Mr SD Shibulal, co-founder of Infosys Technologies Limited

From left: Ms Suilin Yap (moderator), Mr Pond, Mr Satar, Mr Shibulal, Ms Ventura-Steinemann

Mr Satar
-We are in the travel service sector, not transport business

-Consumer's choice of airline is based on safety and value-for-money (not the cheapest airfare)

-Fuel: around 40% of operating cost; 20% of fuel price increase can be passed on to customers, the company has to find ways to reduce cost (for the other 20%), e.g. through utilisation of aircraft and create network to optimise utilisation (Garuda worked with local government to increase operating hours for airports-used to close at 6 p.m.)

-Airline is a long-term business; e.g. an aircraft ordered now will only be delivered in 12-18 months, hence need to think of where the cycle of business is then

-Don't see low cost carriers as a threat but complimentary to Garuda as they open up market: 60% of Indonesia are connected by air or sea, Garuda's job is to get people who have flown once with low cost carriers to fly with Garuda

-Good is not good when better is expected; you should never be satisfied as people expect more of what you have achieved


Mr Pond
-Kraft Food operates on skilled centres of excellence complimented by local sites (have small R & D groups within business e.g. flavour development in local group but big scale product development is kept similar is all countries)

-Food market that will be doing well is one that adds nutritional value or tackles nutritional issue (Kraft to reduce sodium content in one of its products)

-Global trends that will change the way you do business: Health & wellness, sustainability

-Take risks, you will learn from your mistakes


Ms Ventura-Steinemann
-China is top 2 buyer in the luxury product market; will be top 1 in 2014

-The average age of consumers in China is 20 years younger than that in USA

-Can target customers well as system can tell how many, what type/colour of the product that the customers have bought

-Need to ensure customers have different experience in stores (in the business of 'delivering dreams')

-4Ps:
Have a purpose in whatever you do
Passion makes the difference
Positive: right working attitude with the team
Persistence: be dedicated, your team will follow


Mr Shibulal
-In Indian schools, students are trained to be individual performers; in company, need to convert them to be team-based performers

-His company adopts a collaboration index to measure collaborative rate of a team through a 360 degrees feedback (everyone rates you, rewards will be given) to send a constant message across that teamwork is important and will be rewarded

-Need to customise product to local market; cites an exmaple of shampoo sale in India-shampoos in bottles didn't sell as people could not afford them, hence shampoos in sachets were marketed


Business Plenary: Session III-Creative Capitalism
Distinguished speakers:
Ms Karin Finkelston, Director of East Asia & Pacific of the World Bank's International Finance Corporation
Mr Kawahar Kanjilal, Global Head of Ovi Life Tools
Mr Sunny Verghese, Group MD & CEO of Olam
Mr Jack Sim, founder of World Toilet Organisation

From left: Ms Suilin Yap (moderator), Ms Finkelston, Mr Kanjilal, Mr Jack Sim, Mr Verghese

-Ovi Life Tools tagline: inform, involve, empower

-If you want to create something of value, it has to be something of daily use: agriculture, healthcare, education

-Charity doesn't help because when it stops, everything stops; need to solve problem via business model [Mr. Jack on the founding of World Toilet Organisation]

-The 'keyword' is OP: Other People: Use other people's money! Use other people's network!

-What blocks you are your ego and the government (addicted to status quo)

Antihypertensives in Renally Impaired Patients

Beta-blockers
Patients with renal disease respond well to beta-blockers. The choice of drug would be a cardioselective, hepatically excreted drug like metoprolol. However, atenolol, which is renally excreted, can eb given safely if introduced at low doses.


ACE inhibitors
ACE inhibitors are often useful since hypertension can be caused by activation of the renin-angiotensin system. However, renal function should be closely monintored in pre-dialysis pateitns when these drugs are introduced as they are contraindicated in patients with renal artery stenosis.

Do note that in conditions of decreased renal perfusion, the desirable effects will be efferent arteriolar vasocontriction to increase intraglomerular hydrostatic pressure and maintain ultrafiltrate production. Another effect will be afferent arteriolar vasodilatation to improve blood flow to the glomerulus. ACE inhibitors are efferent arteriolar vasodilators, hence they can increase the rate of decline of renal function. However, this can be used to advantage in patients with diabetes, where a reduction in hyperfiltration can delay the progression of diabetic nephropathy.

ACE inhibitors are renally excreted (ramipril is also partially hepatically excreted) and the half-life of these drugs is increased in renally impaired patients, hence they should be used with caution. Also, they can cause an increase in potassium levels.


Angiotensin II Receptor Blockers (ARBs)
ARBs can be beneficial in patients with chronic kidney disease since they block the effects of angiotensin II (a vasoconstrictor), causing vasodilation. As with ACEi, renal function should be closely monitored. They can also be useful when used in combination with an ACEi.


Calcium Channels Blockers (CCBs)
CCBs can be used safely in patients with chronic renal failure. However, one of the side effects of this group, especially of nifedipine, is ankle swelling and unresponsive to diuretics, which can be mistaken for fluid overland.

Ankle swelling is less of a problem with longer-acting agents, such as amlodipine.


Vasodilators
These include doxazocin, prazosin, hydralazine and minoxidil, all of which are hepatically metabolised. They are usually added when other drugs are ineffective. Minoxidil is best given with a beta-blocker and a diuretic, since it can cause tachycardia and fluid retention.


Summary
If BP > 130/80 mmHg: (proceed to next step if BP still not at goal)

1. Start ACEi or ARB
Check serum creatinine & potassium in 1 week; if SrCr or K increases by > 30%, discontinue
agent.

2. Add diuretics
CrCL > or = 30 mL/min: thiazide diuretic
Cr CL <>calcium channel blocker
May consider adding low-dose beta blocker instead of CCB if patient has angina, heart failure
or arrhythmia necessitating their use.

4. Baseline pulse > or = 84: low-dose beta blocker OR alpha/beta blocker (if not already in use)
Baseline pulse < style="color: rgb(51, 51, 255);">subgroup of CCB (e.g. a dihydropyridine if a
non-dihydropyridine is in use)
Note: the use of beta blcoker and a non-dihydropyridine CCB should be avoided in the
elderly and those with conduction abnormalities.

5. Add long-acting alpha blocker, central alpha agonist, OR vasodilator.
Note: Central alpha agonists (i.e. clonidine) should not be used with beta blockers due to the
high likelihood of severe bradycardia.


References:
1. Wells BG, Dipiro JT, Schwinghammer TL and Hamilton CW. Pharmacotherapy handbook. USA: The McGraw-Hills Company; 2006.

2. Morlidge C. Managing chronic renal disease. The Pharmaceutical Journal 2001; 266: 655-657.