As this academic year comes to an end, we are proud to present you the 49th MRT’s last issue of Elixir.
In this issue, read all about past events that have been organized by the various committees of NUSPS. We bring you plenty of coverage on:
- Late 2009’s YEP and Xperience Pharmacy Camp
- Patient Counselling Event and Brown Bagging
- The newly initiated Sports Carnivals
- and our very own Health Bazaar, held in conjunction with World Tuberculosis Day

Since final exams are looming ahead, we’re sure most of you must be feeling the stress.?In this issue, we meet up with two of our professors who are NUS Pharmacy alumni for some golden advice on how to survive the course, as well as some anecdotes of what life as a student was like for them. We’ve also included some tips of how to destress–will you take our quiz to check your stress levels?

So do take a short break from your studying and look through Elixir to unwind. This time round, we have taken much effort to print Elixir out in a glossy new MAGAZINE FORMAT for keeping in the PS room! So if you’re in school by any chance, do drop by to take a look.

Don’t forget, all work and no play makes one a dull person!

Click on the image to access the download link of the newsletter!

Happy reading, and we wish you all the best in your end-of-year exams!

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With much love,
Belinda & the 49th Media Resource Team
NUS Pharmaceutical Society

(Study not just hard, but smart. Plan your time well, stick to your goals, and be as efficient as you can!
Don’t end up like studying at the rate of the construction of the Kent Ridge MRT station)

Savvy Singaporeans are self-medicating. There are many people who prefer to self-medicate for common and small ailments rather than consult a doctor as buying medications straight from a pharmacy is cheaper than consulting a doctor. Moreover, many feel that doctors generally provide the same kinds of medicine for common cold and cough. Hence, there is no need to pay extra money to see a doctor when those medicines are readily available at the pharmacy. However, people are not able to buy more drugs which used to be prescription-only drugs, over the counter. As quoted from Ms Quek Zhi Yuan, a pharmacist at the National University Hospital, “down-regulation is strictly regulated by the Health Sciences Authority”.

Self-medication may be part of a trend as people are more educated and drugs are more accessible. However, doctors warn of possible risks in doing so. Medical professions noted that there are pros and cons to people taking matters into their own hands. Although responsible self-medication helps to move patients towards greater independence in making decisions about management of minor conditions and symptoms, misdiagnosis and taking wrong medication can cause possible dangers. Sometimes, patient take the right medication, but at the wrong dosage and timing. They may also mix medications in dangerous combinations unknowingly.

For example, mixing paracetamol with muscle relaxants, which already has paracetamol, can cause the risk of overdose. Cardiac patients who are on blood thinners should be careful about taking aspirin or anti-inflammatory drugs, as it can increase the risk of bleeding. One should also take caution when mixing medicine, especially when taking western medicine together with complementary medicine as it may cause potentially dangerous side effects. In addition, self-medication might also mask a more serious illness by treating the symptoms but not the underlying cause. Very often, persistent symptoms may be a signal for something more serious, which may go undetected when people self-medicate.

They can prevent this by asking reliable healthcare professions, such as pharmacist or doctor about the drugs they are consuming. This is to confirm that self-medication is suitable for the particular condition, and helps to ensure that they have adequate knowledge regarding the drug’s dosing and administration.

In this aspect, pharmacists can play an important role. They are a link between patients and their doctors. They help patients to understand the role of medications in treating their conditions, and ensure that the patients are having effective treatment plans. Pharmacy Practice in Singapore has evolved from being drug-oriented to patient-oriented. Equipped with their immense drug knowledge, many pharmacists are reaching out to the communities and taking up the role to counsel patients on their drug treatment. For people who would like to self-medicate but are unsure of what type of medications to take, consulting a pharmacist is very convenient, as pharmacists are found in at retail pharmacies which are highly accessible. Some pharmacies even have webcam services to talk to a pharmacist from another outlet if the pharmacist is not available in a particular outlet. In this way, pharmacies are providing a more effective way to serve patients.

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Review by Tan Yu Quan (Year 1)

Article Source: The Sunday Times, Tuesday, Mar 02, 2010.
(An online copy of the article can be found here)

Picture Credits:
Neel’s Corner
Unity Pharmacy

The newly opened Skin Pharmacy at City Square mall in Kitchener Road has been brought to attention due to its provision of products that are specially formulated to cater to individual customers? needs. What makes this pharmacy stand out from other existing pharmacies is that the pharmacists do not only dispense medication but are also involved in the blending and concoction of skin and hair care products specially tailored for individual customers.

The pharmacists are able to create an individualized formula for customers, from pharmacy stocks containing mostly ingredients that are not commercially available; including amino acids, essential oils and whitening agents. This formula is devised in accordance to individual customer?s skin type and needs, before mixing the product on the spot. Fragrance and colour can then be included to improve the presentation and appeal of the product. There are also machines available to perform skin analysis of the customers. In my opinion, these machines will definitely be of benefit especially to customers who are not fully aware of their skin types and conditions. Therefore these skin analyses can help to ascertain individual skin conditions; aiding in the identification of effective treatment methods to deal with existing skin problems.

The Skin Pharmacy is managed by a local husband-and-wife team who are both Australian-trained pharmacists and is believed to the first boutique pharmacy in Singapore. Besides offering custom-made products and its own skin and hair care line, it also functions as a regular pharmacy containing medicines for treatment of dermatological ailments such as fungal growth and hair loss.

Their main focus on establishing a boutique pharmacy was mainly driven by their knowledge that compounding work in a retail setting is not so common in Singapore, especially with technological advancements resulting in pharmacists taking on more patient-centered roles of solely recommending or dispensing medication instead of blending and making products. This is especially evident in retail pharmacies such as Guardian and Watsons; whereby pharmacists are mostly involved in dispensing over-the-counter medications.

Prices start from about $30 for a 230g tub of moisturizing cream which then ranges for customized products depending on the nature and amount of ingredients required by the customers. Service charges are also included as the pharmacists will provide professional advice on the compatibility and stability of the ingredients to ensure the best welfare of the customers.

Personally, I find that these personalized services are quite worthwhile especially since the effectiveness of skin-care or hair-care products may vary among individuals depending on their skin types. Therefore, by seeking professional pharmacist opinions, customers can feel more reassured rather than simply purchasing off-the-counter medications and products which may contain ingredients that may evoke allergic reactions among certain individuals.

Review by Chong Hui Ping (Year 1)

Happy holidays everyone!
The 49th Media Resource Team

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Article on the Bayer HIV Tainted Drug Scandal

For centuries, clear and simple principles shaped the relationship between physicians and their patients: work for the good of the patient; do no harm; keep the patient’s medical information confidential. The medical profession’s respect for patient privacy is rooted in the foundation of medical practice, as evidenced by provisions included in the earliest versions of the Hippocratic Oath.

These principles can be seen between a physician-patient relationship, but what happens in the relationship between a pharmaceutical company and her patients? Should these companies be bound by their respective code of ethics?

Pharmaceutical company Bayer sold large amounts of blood-clotting medicine for hemophiliacs in Asia and Latin America in the 1980s. However, the medicine sold carried a high risk of transmitting AIDS.

Hemophiliacs are people who are unable to stop bleeding or prevent bleeds from starting. The medicine, called Factor VIII concentrate, basically provides the crucial ingredient for clotting which hemophiliacs lack.

However, in the early years, the medicine used pools of plasma from 10,000 or more donors. Since there was still no screening test for AIDS, it carried a high risk of passing along the disease; even a tiny number of HIV-positive donors would contaminate an entire pool of plasma.

In response, Cutter Biological (division of Bayer) introduced a safer medicine in 1984 and sold it in the West. Yet for more than a year, the old medicine was sold overseas – an attempt to avoid being struck with large stocks of a product that was increasingly unmarketable in the West.

There were other reasons as to why the old medicine was still marketed: the company (Cutter) had several fixed-price contracts and believed the old version would be cheaper to produce. Later, when the whole incident was revealed, Cutter claimed that some patients believe that the older version worked better than the newer one.

Nearly 20 years later, the precise human toll of these marketing decisions is difficult, if not impossible, to document.

But in Hong Kong and Taiwan alone, more than 100 hemophiliacs contracted HIV after using Cutter’s old medicine, records and interviews show. Many have since died. Cutter also continued to sell the older product after February 1984 in Malaysia, Singapore, Indonesia, Japan and Argentina, records show.

Recently, a group of HIV-hemophiliac patients from Taiwan are appealing a US court ruling barring them from suing pharmaceutical giant Bayer. The group’s first appeal was in 2003.

Dr Sidney Wolfe, who as director of the Public Citizen Health Research Group has been investigating industry practices for 30 years, said “these are the most incriminating internal pharmaceutical industry documents I have ever seen.”

This incident have led many to wonder about pharmaceutical companies and their aims:
- Are they out to heal us or just out to earn money?
- Should we place our full trust in the medications we take? Are they any safeguards we should take and how?

Although this incident questions the goals of pharmaceutical companies, there are companies which strives to help others in need. Take Merck for example. Being one of the first to develop the HIV medication, they are now ’selling’ their HIV medication at a very low cost to needy patients in Africa, where HIV infection rates are high.

As we have learnt in Pharmacy Practice I, resolving the goals of a commercial business and professional ethics of pharmacy is of utmost importance. As some of you are already aware, “Commerce with Conscience” is the direction some companies have taken. The most famous example would be The Body Shop, were founder Mrs Anita Roddick reconciled profits with her ideals of returning what she have gained to the society. The Merck example above is a prime example of a pharmaceutical giant providing social change.

Perhaps it is time for health-care related industries to change their goals.

Review by Chua Jia Ni  (Year 1)

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Not Yesterday’s Pharmacist Any More

By Joyce Lee, Pharm.D., BCPS
NUS Assistant Professor, Department of Pharmacy
Primary Care Clinical Pharmacist, NHG Polyclinics/Pharmacy

A few months ago, I saw Mrs. Tan for her uncontrolled diabetes. She was referred to my clinic by her doctor. When I reviewed her medical history and lab results, it showed that her condition had been long-standing with hint of complication. Mrs. Tan had been using five insulin injections religiously every day for years, yet she could not keep her blood sugar under control. She was losing faith in the medical treatment.

After spending some time talking with her and performing a few simple physical assessments, I recommended that her insulin therapy to be converted from five injections to two injections. Mrs. Tan looked at me in amazement and asked, “Are you sure?” A few months later, I was happy to congratulate Mrs. Tan for achieving a dramatic improvement in her blood sugar control, something which she once thought impossible. Although she thanked me for helping her, I really should be the one to thank her for making my job as a clinical pharmacist so rewarding.

Dr Joyce Lee seeing a patient.

The role of pharmacists is rapidly changing from the traditional pill dispenser to an integral member of a patient?s healthcare team. Although the evolvement has started decades ago mainly in the United States, the change is only beginning to happen in Asia with Singapore among the Asian pioneers.

Two years ago, I came from the US to join the NUS ‘pharmily’ and National Healthcare Group Polyclinics/Pharmacy with a dream to help advance the pharmacy profession and to set up clinical pharmacist services in Singapore. During my site visit for the job, I was impressed by the contributions of Singaporean pharmacists in the hospital settings. More improvement, however, was still needed in the primary care setting.

HDL-C Clinical Pharmacists. From left: Ms. Lim Mui Eng, Ms. Anna Liew, Ms. Evonne Lee, Ms. Ng Sock Mui, myself (Dr. Joyce Lee), and Ms. Esther Bek. Not in the picture: Ms. Ong Soo Im.

In October 2007, I piloted the first pharmacist-managed multi-disease clinic, also known as the?hypertension, diabetes and lipids clinic (HDL-C) in Singapore. The clinic targets the top chronic diseases in the country. It aims to work collaboratively with doctors, nurses, and other allied healthcare professionals as a team in the primary care setting to manage uncontrolled chronic conditions and to minimize complications and unnecessary hospital admissions. HDL-C was first piloted in Bukit Batok Polyclinic and the service has since expanded to Clementi and Choa Chu Kang polyclinics. I am grateful to the doctors at NHG Polyclinics, especially Dr. Sabrina Wong, Dr. Elaine Tan and Dr. Keith Tsou for supporting an idea that is new to Singapore and for giving me the guidance and resources to train primary care pharmacists and provide the HDL-C service.

This is still the beginning. Whether in the hospital setting or the primary care setting, the role of pharmacists continues to evolve. I believe Singapore will remain the trend setter in this field in Asia not only because Singapore has supportive public health managers but also because of its bright students, and high quality faculty at the NUS Department of Pharmacy who are uniquely qualified to educate pharmacists of the future. To prepare for the coming changes in pharmacy practice, the Department of Pharmacy at NUS has modernized its pharmacy curriculum, and the first post-graduate Doctor of Pharmacy (Pharm.D.) class was launched this year in order to cultivate pharmacists with a high level of clinical skills.

Mrs. Tan’s story is only one of many success stories that take place every day in Singapore due to the changing role of today’s pharmacists. With more pharmacists stepping out from their traditional place behind the pharmacy counter and applying their knowledge and skills to direct patient care, Singaporeans can look forward to a new important improvement in their healthcare service.

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If you’re interested, you may also read the articles by our other 2 faculty members from here:
By Adjunct Assoc Prof Chan Cheng Leng and
By Adjunct Assoc Prof Lam Pin Woon.

Credits to The Ministry of Health blog for the articles.

Feel free to discuss your own opinions about the posts!

There has been much buzz on the newspapers recently about doctors who have been negligent in their prescriptions. Although stiff penalties have been imposed by the Health Ministry, there are still a good number of doctors who fall into the web of greed. These unethical acts pose threats not only to the reputation of the doctors, but also to the lives of their patients.

In the past five years, 23 doctors have been hauled before the Singapore Medical Council (SMC) and penalized for dispensing sleeping pills indiscriminately. Subutex drugs, meant for curbing heroin abuse, were also freely dispensed to patients?however the drugs ended up being abused.

Several people such as Madam Halimah Yacob (Jurong GRC) and Salma Khalik (Straits Times Health Correspondent) have suggested the separation of prescription from sale. Pharmacists, trained to check doctors? prescription, would help maintain patient safety by ensuring that the appropriate drugs are dispensed to the patients.

It has been agreed that it would be highly inconvenient for patients to go down to a pharmacy after consulting a doctor to get their medication, compared to the one-stop service patients are exposed to locally. However, this may not be applicable to drugs such as sleeping pills or obesity drugs. These drugs are not needed urgently by patients, but still can be easily abused if doctors are lax in prescribing them.
The Straits Time report also suggests that there could be an identifying of pharmacy-only drugs or the registering of patients who are prescribed such drugs, to prevent doctor-hopping.

The current dispensing system has been kept by the Health Ministry in order to ensure the convenience of patients. However, Health Minister Khaw Boon Wan has suggested that doctors provide patients with a clearly written prescription, and then leave the patient to decide where to obtain his medication.

Another good way of preventing greed by doctors while keeping the current system of practice would be to enforce transparency in bills from private clinics that itemize the costs of consultation, tests and drugs.

Review by: Selina Lim & Belinda Tan (Year 1)

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What do you think? Discuss your views here.
Time to apply what we have learnt in PR1103!

Melamine Scare

(Got milk?)

Many have heard about the recent commotion about melamine contamination in food products such as Cadbury Choclairs and White Rabbit Creamy Candy. Many more are indignant about the Machiavellian machinations of the unscrupulous middleman who added melamine to infant milk just to raise its protein level. But what is this melamine fuss all about?

Melamine is an organic base and contains 66% nitrogen by mass. It is used commercially to make melamine resin, a thermosetting plastic, and melamine foam, a cleaning product. It is also used to produce melamine polysulfonate, a super plasticizer for making high resistance concrete.

Unfortunately, melamine can be added to food products to increase the apparent protein content. The food tests performed by the various health agencies worldwide usually involve the Kjeldahl Method or Dumas Method which can only detect total nitrogen levels and not actual protein levels. This loophole is then exploited by knavish businessmen of the milk purchasing centers, the middleman between the dairy farmers and factories, who blatantly added melamine to the food products.

Melamine by itself at low doses is generally within acceptable limits of the human body. In fact, it is found naturally at low levels in food. However, when present at high concentrations together with cyanuric acid, it forms the insoluble melamine cyanurate, that crystallize in the kidneys forming kidney stones, ultimately resulting in kidney failure. It can also result in reproductive damage and bladder problems, leading to bladder cancer.

The damage so far is disturbing; More than 13,000 babies have fallen ill with 4 deaths in the People’s Republic of China. Numerous food products have been recalled or taken off the shelves worldwide. The Chinese dairy farmers are not spared either: many are feeling the pinch due to sudden drop in demand.

However, in Singapore, the Agri-Food and Veterinary Authority (AVA) assured local consumers not to worry unduly as the milk and its related products are safe for consumption. AVA has also suspended the sale and import of milk and its related products since 19 September 2008. (Source: http://www.ava.gov.sg/). The products imported from China that AVA has detected melamine and has since removed are found below.

• Cadbury Choclairs – Blueberry Flavour;
• Cadbury Choclairs - Coffee Flavour
• Panda Dairy Whole Milk Powder (industrial pack).
• Yi Li Choice Dairy Fruit Bar Yogurt Flavoured Ice Confection
• Dutch Lady Strawberry Flavoured Milk
• White Rabbit Creamy Candy
• Dutch Lady Banana Flavoured Milk
• Dutch Lady Honeydew Flavoured Milk
• Silang – House of Steamed Potato – Potato Cracker
• ??? Puffed Rice Rolls – Butter Corn Flavour;
• ??? Puffed Rice Rolls – Cheese Flavour
• New Sshmallows Mallow Dippers – Strawberry Flavour
• Silang – House of Steamed Potato – Potato & Tomato Cracker

(Source: http://www.ava.gov.sg/)

In Beijing, the official Xinhua news agency reported that severe punishments will be meted out for the culprits of this predicament, as well as for quality control officials who failed to do their jobs. It implemented public shaming of the culprits as one of the punishments. In addition, new regulations on dairy controls have been issued by the State Council in China. (Source: The Straits Times 11 September 2008)

The melamine scare is perhaps the quintessential example of human greed trampling upon ethics. The actions of the middleman in order to make a tidy profit are tantamount to adding poison to food. A thunderous furore has erupted because melamine has also been added to infant milk products which have caused many infants to have fallen ill. The problem is that we do not know whether the tainted milk has been used in other products not yet tested. Perhaps it is time that we take a good long look at our food and not take what we put into our mouths for granted.

Written by: Goh Wei Jiang

Information correct as of 15 October 2008

Plastic Blood (May 2007 article)

Summary of article + Review (by Marcus Heng, Year1)

Researchers in Sheffield University have created artificial blood by synthesizing plastic with an iron-containing porphyrin ring core, capable of transporting oxygen like how blood does. This structure is remarkably similar to haemoglobin itself. The advantage of this blood is that there is no antigen specificity, meaning anyone can use it in times of emergency. Being artificial, it does not have to be chilled, is light to carry, can be manufactured sterile and lasts a great deal longer than real blood.

Previous attempts at artificial blood include hemoglobin-based oxygen carriers (HBOCs) and perflourocarbons (PFCs).

Many people involved in accidents die because of massive loss of blood before a suitable blood supply is found. The problems associated with utilizing current blood supplies lie in identifying the victim’s blood type, finding a suitable match from blood reserves, making sure the blood has not expired, defrosting the blood and so on. This poses a huge delay for a patient on the verge of death, especially when special storage of donated blood makes it only possible to transfuse larger quantities at a hospital itself. Plastic blood does not have these limitations.

Being synthetically-made from polyethylene glycol (PEG-a water-soluble monomer already used in medical applications) and porphyrin, plastic blood’s shelf life may even allow it to be kept in powder form in your regular first aid kits, ready to be mixed with pure water to form blood when the need arises. Moreover, there is no risk of catching blood-borne diseases like HIV & Hepatitis from plastic blood.

This alternative blood source also poses as a life line to ailing blood supplies as fewer people heed the call to donate blood. However, this may yet pose another problem as people start to adopt the mentality of “With synthetic blood, we need not donate blood anymore”. This is not true.

HemAssist, the first Haemoglobin-Based Oxygen Carrier (HBOC) tested on humans, was discontinued after patients who received the transfusion died more often than those who received donated blood.

In reality, research has yet to discover what long-term side-effects plastic blood may inflict on a user when used in high quantities. If improperly metabolized, severe kidney and liver damage may result. Moreover, the idea of putting plastics in your blood probably would sounds alien to most laymen. I guess to most people, blood remains as a very complex part of the body. To perfectly create a man-made substance that duplicates the real thing is extremely difficult, not to mention risky. In addition, to those in the medical field, making a new drug or homologue is more than utilizing its therapeutic effect. It is thus necessary to investigate other pertinent factors like its elimination after use, its toxicity & its perfusion.

Concerns have also surfaced about misuse of artificial blood, especially in the area of sports. Sportsmen normally have a relatively higher blood oxygen capacity than average, which gives them an advantage in endurance events. This can be achieved by the legal way of long-term training or by a shortcut known as doping. While there are no cases of doping artificial blood, it still remains a possibility in the near future. A possibility which would threaten the very nature of sports itself.

For now, it will probably be best to stick with the real thing.

Acknowledgements
http://www.mondovista.com/plasticblood.html

http://health.howstuffworks.com/artificial-blood1.htm

The Context

Means Testing is a scheme introduced by the Ministry of Health (MOH), its purpose being to appropriately allocate limited healthcare resources in Singapore. Means testing will be based on salaries declared in tax or CPF returns [for salaried workers] and housing type [for the retirees, children and unemployed]. 

Why the need for Means Testing?

Patients going to the hospitals routinely ask for the senior consultants in the mistaken belief that their chances of recovery is guaranteed; however, they fail to recognise that the minor ailments that they are suffering from can be treated just as effectively by the other [albeit less, junior] doctors.  This has resulted in long queue-lines for all patients and MOH is looking towards improving this aspect of patient care.

Economists normally have 2 solutions for this phenomenon – either raise the price until supply equals demand, or let the queue mechanism sort itself out. Those who can afford to pay but cannot afford to wait will naturally leave the queue.

However, to apply this principle, ceteris paribus, to healthcare might result in some unpleasantness. Means Testing is the proposed solution: by allowing people who can afford to take up the better-class wards, we’ll be able to free up the remaining wards. This would also mean that we will be able treat more people, thus freeing up queue-lines. At least, this is the ideal case scenario.

Public views

The main concern from the public is whether healthcare costs incurred will increase under such a scheme. The reason is obvious – people are now expected to be warded according to their income or housing type. The concern is that people suffering from chronic diseases will be incurring large hospital bills, too much for them to handle. Retirees have also voiced their fears in that they may not be able to afford the bills since they no longer receive any remuneration and yet, hospital bills will be pegged to their housing type. 

Clarifications

In response to public concerns, Health Minister, Mr. Khaw Boon Wan, says that in the short term, the ‘majority of Singaporeans should continue to receive the same level of subsidies as they do today and will not be affected’. To keep the scheme fair, Minister Khaw feels that Means testing must fulfill these five criteria:

1.       Patients have autonomy over choice of ward.

2.       All C and B2 class patients will receive subsidies that are pegged to their income – that is, the higher –income patients will receive less subsidies.

3.       Assessment of the patient’s ability to pay must be kept simple and convenient [automated].

4.       Means testing should be flexible in implementation; patients will always be given special considerations in light of their circumstances.

5.       No patient will be denied treatment because he cannot afford it. 

The Means Testing seems like a fair and pragmatic solution to the already thinly spread healthcare resources. But what are your views? Comment at the Pharmacy Forum .

Other comments

Check out this link for more views on the matter:  http://www.todayonline.com/articles/230962.asp

DISCLAIMER: This post expresses the views of the author alone and is in no way representative of the views of NUS Pharmaceutical Society.

There you go.

For the avid blog readers amongst you, if you haven’t heard of this well-known pharmacist blogger, do take a visit to The Angry Pharmacist. The owner and author is a register pharmacist practising in the United States.

True to the blog’s slogan “Rants from the most trusted profession”, the Angry Pharmacist provides you an insight on the working life of a pharmacist. Although most of the articles lean towards the negative side, they do portray the problems faced by a working pharmacist. This is, after all, the Internet and you should be well-advised to take things with a pinch of salt, especially when the entries are full of angst. After a stressful day, it is a good way to release some steam by blogging about the various problems.

There are funny anecdotes and references to some real problems encountered by the author. All in all, the blog is a good read if you are looking for something to entertain yourself. For those of you who have yet to go on any attachment, it would give you a glimpse of what working life is like. I’m sure those who have been on attachments could very well relate to the various topics covered there.

One last note, as the Angry Pharmacist is based in USA, certain issues may not be of concern to us.

Got an idea for an article? Want to contribute an article? Have a suggestion for a topic to be discussed? Drop us a message here!

If you are a member of NUSPS, register on the main site and forum to contribute articles or interact with your fellow Pharmacy undergraduates.