Today went for the CASE's talk on medicine

The talk was interesting - it kept going on generic drugs and patent drugs, but I feel that it really missed out on services pertaining to issuance of medication. I can give you all the best drugs in the world, but if lousy advice was dispensed, what is the use? It may even kill you.

Generics - drugs that have expired patents - so they can be copied and sold e.g. Dhamol (paracetamol / acetominophen)
Patent drugs - aka original innovator, innovator, proprietary, brand drugs e.g. Panadol (paracetamol / acetominophen)

So far I hope the general public have learnt the following about generic and patent drugs:
- Generic drugs and patent drugs are very similar : I quote Miss Fatimah, "... both will take you to your destination..." Patent drugs may be likened to Mercedes Benz and generics likened to Hyundai - Mercedes may look nicer
- Patent drugs go through a lot of human testing and the cost of bringing it from day one to the market is a lot higher.
- Generics just required to show bioequivalence: meaning that it works physiologically the same as the patent drug, active ingredients are the same, etc.
- Generics are usually a lot cheaper
- Patent drugs are usually more costly but there's no choice when generics are not available
- If generic substitution was done properly, the cost savings can be tremendous.
- Expiry dates between generics and branded drugs are similar. The pharmacist will not be that unethical to sell close to expiry drugs.

Others
- Pharmacists can help check for potential drug interactions
- HSA's responsible for mainly registered drugs
- MOH is in charge of spot checking doctors (practice issue)
- Singapore-treated patients pay only about 10% of the healthcare cost in terms of drugs - compared with 11 - 14 % in USA and UK and as high as 30% in the Philippines and Vietnam
- Please bring ALL YOUR MEDICATIONS that you are taking when youre admitted or going for your regular appointment: this aids in Drug Recon(solidation), the pharmacist will calculate what you need and in any case if changes in drug therapy, pack your drugs to be stopped or continued and add on drugs that your current amount may not fulfill.
- SMA provides a Medik Awas card service for those with known drug allergies.
- The expiry date of drugs is usually a date when the drug degrade to 90% potency (e.g. 10mg -> 9mg)

However, these were not mentioned (to simplify things):
- Studies on humans are done large scale on patent drugs only
- Some pharmacists and doctors prefer to use patent drugs for certain more critical diseases.
- Some hospitals may use innovator drugs to treat patients at low cost: if they make it to formulary or if the tender given is a very good deal.
- The % cost of healthcare in the form of drugs is so low because diagnostics cost a lot more - perhaps a subsidy for diagnostics now?
- Carry along your entire prescription listing on admission: it helps in immediate ER treatment.

I poised a question to Dr Tan, spokesperson for SMA about sharing responsibilities in patient care between doctors and pharmacists in a community setting:

"So far, we have heard about generic drugs and brand drugs - products mainly. I would like to seek the opinion or perhaps the stand of SMA on the concept of sharing the responsibilities of patient care in a community setting?

For example, certain drugs with an increased potential for abuse and special instructions and storage requirements to pass through a second checkpoint -i.e. asking a patient to bring a doctor's precription to a pharmacy instead of being packed and given by a clinic assistant.

Let me elaborate in 2 scenarios
- in the recent hoo-ha about Dormicum and Subutex, perhaps the issues evolved could be better managed if 2 checkpoints were implemented: 1st is the doctor's assessment, 2nd is through the pharmacist. In such a way, only patients with a real need for such medication will go through the appropriate steps to get their medication.

- Drugs with special storage conditions such as Angised sublingual (check price in CASE here). During my pharmacy training, I was quite appalled when patients come in with Angised in plastic containers dispensed by clinics, saying that the medication is no longer effective for their chest pains and they had to take more potent drugs which may cost higher and more side effects (I had to coax some patients to tell me about their previous medications - some were prescribed Herbesser, chew before swallowing).

I think it would be best to make full use of a pharmacist knowledge to benefit consumers even though it may use some initial opportunity cost.

So would it be better if for the consumer if certain drugs can only be given through a pharmacist with a doctor's prescription if we want to give the patient the best care possible?"

His answer basically covered with the following points [ if there's any discepancies, pls post comments hor - didn't copy answer, only stand there jittery and red as I saw some one with a passive annoyed look liaoz]
- Singapore, Malaysia and other parts of the region, doctors are allowed to dispense compared with UK and USA.
- So far the system works, patients have immediate access to their medication
- As for such issues, complaints can be lodge with the SMA (or SMC - can't really decipher)
- SMA feels that the clinics that are dispensing medications are good and do not have any issues
- There's no need for 2 checkpoints
- and here comes the standard answer - "Here is not the forum to discuss such issues" (3rd time I heard this liaoz =.=)

Perhaps I was too jittery about what I was going to say (some people reach an age where they become so concious about what they are about to say that they did not dare to say it anymore - skin thinning liaoz), or my timing was off again, or doctors were trained to counter such discussion or I was too chong hey. But I hope to drive home the point about our place in the healthcare sector.

I'm not interested in what market share but more interested in patient care.

Frontline community pharmacies can do a lot given the chance, but we will have to take first baby steps by convincing the public about our usefulness.

Take on the responsibilities before you can be given the rights. (Something I always say to people who discuss with me dispensing issues - even to doctors and medical students) - It's like gardening- why want a plant when you can't even nurture it?

I hope I didn't miss out any pointers or write anything wrong in this post - correct me via a comment plox

Wah!!! Long time never watch already sooo nice

It was a long time since I watched Ah! My Goddess! The season 2 is soooo good.

Beautiful goddess and devils chanting spells in chorals, very nice spell castings and soooo ka'waii HOW TO RESIST?!

A good section to watch for the uninitiated:

Previous OSSEA meeting pix

Oops, started to Flock my pictures this evening only. Forgot a nong nong time liaoz.

Tah bao stuff for live demo on Paphiopedilum culture and repotting.

I think I threw 4 Paphiopedilum liemianum seedlings into lucky draw, one NBS P. liemianum and P. primulinum were repotted and thrown into lucky draw as well.

My Dendrobium canaliculiatums

I do not think it is a common item as my prez (commentator) didn't know much to say. But I must reiterate that I should be tried in every sunny skyrise.

In the centre of table for live demo


Doc LL's Eria (can't remember species name, but see next bulletin for update)

Gotten during the Singapore Orchid Show from Purificacion Orchids when they popped by here. Speaking of them, my jade-coloured Eulophia spectabilis a currently sprouting @@

Paphiopedilum lowii

Not easy for the flatlanders, some plants may not even survive here

Bulbophyllum sp.

One of those B. fascinator complex thingy, not my cup of tea - crisps up in skyrise easily

Dendrobium sulawesii (Arghhhh can't remember the most current name...)


At the money burning area:

Cute cute mini Phalaenopsis spp.


P. parishii

Some of my friends killed them before so they called it P. perishii.

P. gibbosa

So cute. Dang1 shoulda bought a flask during SOS

P. wilsonii (I think)


Jewel orchids


Pendulous Cymbidium hybrid

I like pendulous Cymbidiums but they are either tooo big or too cool-growing sianz0.5

Interesting Oncidiinae complex hybrid

Striking colours

Raspberry scented Dendrobium anosum


Parvisepalum complex Paphiopedilum hybrid


Paphiopedilum wenhanense syn. P. conco-bellatulum

Easy to grow. Easy to buy - now in the hands of a lawyer....

South American relative to Paphiopedilums, Phragmipedium pearcei.

Needs wet feet, preferably distilled water. Tempted to buy one but then hor, put where? Under my bed? All my P. godefroyae bbs all growing steadily. Anyway I still prefer flask - lidat get hardier plants and won't end up having the same plant as everyone else on this island =.=

Knuckling - a "new" method for applying nasal spray

Today had a rogue customer-cum-boh chap about father scenario in a community setting. Not easy when the patient is absent and you end up counselling the third party to reply message to the patient @@.

Made a few blunders here and there,
- Realised I was leaning against the table
- Was looking down at the patient - he sat, I stood
- Didn't realised I mentioned "expectorant" when I wanted to pass him a normal cough linctus
- Should have intro the range of Duro-tuss products available
- Forgot to give frequency of use and ended with the word "often"
- Never explained in depth about certain instructions and their importance.
- No need to shake Afrin spray but I still ask to shake (because of consistency)
- My big handwriting and gaps left behind in the earlier questions rendered me insufficient space to write - only 1 sheet given *sianz 0.5* discrimination against people with big handwriting bleah
- and most idiotic of all - DUNNO HOW TO SIMULATE PHARMACIST AND DOCTOR COMMUNICATION ... should have asked doctor direct about patient when son boh hiu right? *tock on th head*

With regards to nasal sprays, there are several techniques of use out there.
Most common method is the use of a finger to press down on nostril and inhale through the other. But then hor, if you suffered from rhinitis, I confirm you will super jiak lat if you do that.

During congestion of your nose, your nasal conchae would have become swollen and tender. Adding pressure to that area may because pain and may trigger a bout of sneezing = more pain!

Some may use the pointed cap of the spray to jam up the nostril but I find that a bit yucky - especially if you forgot to clean the cap later. Ast least skin will secrete their own anti-microbial substances

My tester heard my technique for the first time. When I was counselling he was thinking "Oh realllllyyyyy"-because I never explained the background behind the technique (tell son for what, his father suffering but he boh chap) - whether he eventually accepted it or not is another issue.

1. Wash hands
2. Stand by nasal spray
3. Shake nasal spray
4. Using your non-spraying hand, fold your index finger towards palm and insert the knuckle into the other nostril that is not being sprayed into.
5. The knuckle should fit snuggly into the nostril and the skin folds help to form a tighter seal as compared to you pressing on your tender nasal conchae or using a rigid spray cap.
6. Start inhaling through your nose and spray a dose.
7. Breathing in deeply through nose as possible.
8. Repeat with the other nostril if needed.
9. Some people would pinch the nose after spraying to suck in another time (to try to get some stuff into the sinual cavity)
10. If using a steroidal spray, you may want to gargle mouth after use.

Should we conduct a multicentre RCT on techniques of spraying stuff into stuffed noses?

Reminder to self

A lot of hypertensive patients walik into a community pharmacy not to be treated for their hypertension but to get treatment for other ailments. A pharmacist must have good knowledge on the patient's current situation, the disease and the appropriate drug therapy for the ailment the OTC is meant for.
- there is a need for us to have a thorough knowledge on OTCs
- there is a need for us to understand the seriousness of the chronic ailment

Do not just stay there and yak away at the patient. Take note of non-verbal cues nd get the patient more involved and get them interested in the pharmacotherapy.

The more difficult cases usually involve a third party helping the patient get the meds when the patient is MIA...
- try to get the third party to repeat whatever advice given so that they can relay it better
- where possible, use PILs
- try to convince the third party about the methods of administration and therapy so they can convey it better

Show empathy
- allow the patient to connect with you
- make the patient more involved in the drug therapy
- show/demonstrate techniques of use before being asked (take initiative)

Be specific
- some patients do not know how to decide
- in terms of frequency of use, make sure one specify the time and frequency, do not use words like "often", "regularly". Try to give something more specific, e.g. TDS, every 2 hrs etc. If not some patients will be CONSTANTLY using the drug.

Try to convince the patient and be true to your principles of "Doing no harm, then do something good"
- If patient insists that they wanted a drug even though you have already told them the implications, just give it to them with a warning, or if it is really serious, REFUSE TO DISPENSE. Depending on individual opinion, I think it would be better to lose a customer (in retail) than to lose a life.

Consumers FIGHT FOR YOUR RIGHTS!!!! "Know Your Medicine, Understand Your Options"

PSS is working together with Consumer Association of Singapore (CASE) to educate the public & highlight the points about:

- what are the differences between innovator drugs vs. generic drugs,
- transparency in medical bill & public’s awareness towards itemized bill from private GP,
- the consumers’ freedom to shop for best deal for their medications & rights to request for a prescription,
- greater understanding about the common chronic diseases now being treated at community.
There will be a public forum to address these issues. PSS Vice-President, Ms Fatimah MK, will be speaking at the forum together with representative from Singapore Medical Association and Health Sciences Authority. The forum will end with a discussion forum of where SAPI will also join in the panel.

We urge all members to come and attend this forum, bringing along your family members and friends. There is no charge for the forum. For more information, please visit the link below or CASE website.

Date: 31 Mar 2007, Saturday
Time: 9 am to 12.30 pm (participants to be seated by 8.45 am)
Venue: NTUC Centre, 1 Marina Boulevard, NTUC Auditorium Level 7, Singapore 018989

http://www.pss.org.sg/main/content/view/483/2/

To the elusive ALG, wrt Keiki grow

With regards to the plant hormone wanted, the nearest source now is in Australia.

The name of the product is known as Keikigrow (Keiki = "baby" in Hawai'ian).

There used to be a company in SG that used to stock this product but the sales sucked, so the company folded - what to do, most people here ai pi ai qi. So, no one wants to pay intermediate price, in the end have to fork out $$$ for shipping.

Most of this plant hormones are stabilised in lanolin (sheep wool) as it is a fat that absorbs water well and holds the active constituent there.

Today went out to makan Dimsum buffet

Went out with my pharmacy classmates to celebrate KX and SH's BD during our (or rather my) 4 hrs long lunch break - in between DFD3 and IP.

FE, SL, AL and me actually was thinking of going off to pepper lunch when be bumped into J and JC on the bus. They told us about the lunch, and my group actually had to flip a coin to determine the fate of the afternoon as we felt like we were gatecrashing without the BD gift.

Eventually the coin toss decided dimsum buffet it was. We went to Riverview Restaurant (but no river to see one) at Excelsior-Peninsular Hotel @ SGD$10.50 +++ per person for lunch.

Volume of the food was good but quality-wise, it was palatable for that kind of low low price. I'm a fan of guo tie and xiao long bao, but I must say theirs CMI. Even the vinegar used seemed watered down. One classmate attempted to order some 18 pieces of har gao which never came. The orders may have been mixed up.

The good stuff:
-Porridge
-Sweet and sour pork
-Pepper beef
-Deep fried shrimp dumplings
-Guiling gao (some people may not like the taste of Danggui and it's on the bitter side - limited to 1 bowl per person Sianz0.5)
-Cha shao bao
-Cha shao sou
-Har gao

Farnie thing was the guys at my table like Guiling gao more than the girls! I'm not for vanity but I like the herby taste.

Once again HAPPY BD to KX and SH (long time lab partner)

Message to Doc DL - Cattleya seedling culture and mounts

PS, As I feel obligated to share cultivation techniques (sans my "secret recipes), I would rather answer questions pertaining to culture,etc on the blog. If it involves ultra-sensitive drug-disease-related question then it's altogether a different matter.

Pertaining to where to get orchid culture materials in Singapore, you may want to get it froma garden centre specialising in orchids such as Woon Leng Orchids (click on link on RHS of blog for address and contacts)

For Cattleya alliance, the mount of choice in Singapore is tree-fern slab aka fernroot slab.Saw into appropriate pieces to accomodate a couple more new growths, fix up the hook, tie your plant on and you are ready to go.

I find growing orchids a bit like providing pharmaceutical care. It is individualised to the plant type,your home/growing environment, the direction and exposure of growing area (to estimate thru' solar solstice), your habits and the time you can spare. So a little more detail would be appreciated.

With regards to place to grow, Cattleya alliances in general like good air flow with good relative humidity - however there are some species which prefer wetter conditions as they are found hanging over rivers such as Cattleya violacea, which are found above rivers. Interesting story about cattleya violacea - in the past, young men froma village had to find the blue version in order to get a bride and the black version heralds DOoms Day!

Remember that Cattleyas in general are heavy feeders - do not hang them over white tiles or any expensive floorings or wall unless you want massive algae growth from fertiliser run off !

For seedlings, slowly increase exposure to sunlight - go from 60% to 90%. If you live in a skyrise with a overhanging shelter (e.g. balcony), move from 2 feet in doors, to 1 feet then to as close as possible to to window - do it with sucessive pseudobulb formation. This is to acclimatise the plant slowly to develop roots and leaves appropriate to that solar exposure.

Growing epiphytic orchid seedlings Part II

Continuation of Part I and you'll need to know how to create mounts.

Here, the victim is Phalaenopsis pallens.


Arrange between 3-6 seedlings onto the mount. Just to see how they fit. make sure there is enough space for them to grow. When they have grown big enough, the mount can be broken into individual plants and mounted or potted up onto bigger mounts or pots respectively.


Wrap the seedling with sphagnum moss. This helps in 2 ways - stops the seedlings from becoming dehydrated too soon and to prevent the strings used to tie the seedlings from cutting into the roots and stem - akin to a bandage.


Tie the seedling. Some people may used old panty hoses, BBQ twine, crochet threads, telephone wires, etc. I personally prefer straw string - flexible and slightly expandable to accommodate growth. But then dun be over zealous and start mummifying the plant - some strings are water proofed and stops the moss from wetting, also it restricts the growth of the plant.



Tie up all the seedlings


Remember to label!!!

A lesson in pharmaceutics

It cracked Sianz0.5.



Tried to fiddle around with my neem emulsion recipe to increase the preservative content. But it changed from a stable emulsion to one that needs shaking before use.

After shaking


But then the consistency is much thinner.

Neem oil is only effective as prophylaxis but never as acute treatment. Effective against red spider mites and other insects with an appetite centre in the brain. It kills by causing the insect to stop eating. Ineffective against catepillars - they lack the appetite centre.

When an infestation strikes, use a systemic pesticide such as an OP. Wear protective gear when applying such potent nerve poisons.

SBG's NOG and EvoG

Last Saturday supposed to do guiding but the staff there a bit MCC (miscommunication because the regular staff went holiday - when you have chewren that time, you'll lead a restrictive fulfilling life), so went to walk walk and become trigger happy shutterbug (with shaky hands)

Went to National Orchid Gardens and saw my first cicada close up

Dunno who trampled on it.

Burst seedpods of Cymbidium finlaysonianum

I wonder if anyone is collecting to sell on Ebay? "Rare!!!: 10 Cymbidium finalysonianum seeds for sale"

The raspberry scented deciduous Dendrobium anosum (I personally prefer to refer to it as D. superbum as "anosum" means "no smell" =.=)



Forgot the name liaoz. Must check up. Related to Cattleyas. Big plant but tiny flower


An orchid which I would like to refer to as the Dutch lady orchid due to the resemblance of the top 3 petals to that of a Dutch Lady's (refer to bottle milk for picture) hat. Dendrobium uniflorum


Dendrobium wulanense Slightly fragrant


A hybrid of Caulathron bicornatum


A hybrid of Laelia crispus or Laelia lobata with miniaturising parentage


A Cattleya mossiae hybrid


Tan Hoon Siang Misthouse
Misting in operation

The misthouse houses mainly temporary displays

Yuen-Peng McNeice Bromeliad House
Misters in operation


The Cool House
Don't ask about the cooling bill - very very high!!! When misters are in operation, remember to keep your electronic gadgets and cameras - the mist is sooo dense that you get drenched. It is sooo thick that you can't see 2 feet in front of you - opportune time for people to pilfer plants - very sad indeed.


Paphiopedilum rothschildianum

For some reason, there are plants ex-situ than in-situ due to habitatb destruction
*Please promote ex-situ conservation if you can't do anything about habitat destruction*

Paphiopedilum victoria-mariae


Paphiopedilum lowii



Dendrobium macrophyllum


Dendrobium rhodisticum (may be sic)


Masdevallia tovarensis


Stellis sp.

Some species of this genus can take the heat of SIngapore and flower regularly

A grasshopper on Simpoh air (Sim-poh ai-air <--- some people mispronunce it as "simple air") en route to the Evolution Gardens from NOG


Ensete flowering and fruiting




Boxfruit



Start of EvoGardens. You'll ferns after fern trees after mosses after cycads after stones blah blah blah (showing bias to flowering plants)