CKD Road Shows to Be Rolled out Across Malaysia

1-31 January 2013

www.medicaltribune.com CKD road shows to be rolled out across Malaysia

FORUM CONFERENCE

Preparing healthcare OSA linked to glucose personnel to deal with dysmetabolism injury rehabilitation

3 1-31 January 2013 CKD road shows to be rolled out across Malaysia

Malvinderjit Kaur Dhillon

series of road shows to highlight the importance of practice points among AGPs in the early identification and management of renal anemia in chronic kidney disease (CKD) will be launched nation- wide over the course of 6 months. The road shows, an initiative of the Malay- GPs and primary care physicians can learn about renal anemia at the road sian Medical Association (MMA), come hot shows. on the heels of the recently launched guide- condition to highlight, Manalan said a large line booklet entitled Renal Anemia in CKD – number of patients with CKD are not aware Practice Points for GPs. that they suffer from the condition as early “The book launch was attended by more stage kidney disease tends to be asymptom- than 130 doctors, largely from Selangor and atic and patients often present with the com- Wilayah Persekutuan as the event was held plications associated with late-stage CKD. in Petaling Jaya. Keeping that in mind, the He added that patients with diabetic kid- MMA developed these road shows to provide ney disease, which is a leading cause for the opportunity for doctors in the remaining CKD, tend to see their GPs first for treatment states who were unable to attend the book of their symptoms without being aware that launch to benefit from this initiative,” said Dr. they have CKD. Thus, it is very important that S.R. Manalan, president of the MMA. GPs are able to identify and screen patients Manalan said the target groups for the road early for CKD and anemia before the condi- shows are GPs and primary care physicians. tion progresses and patients suffer complica- The road shows will stress the importance of tions that can be prevented. practice points in managing renal anemia in Manalan said the practice points will also CKD. assist GPs in co-managing renal anemia in In urging private practitioners to attend the CKD with nephrologists. The practice points road shows, he said the crucial difference be- act as a backbone for GPs to carry out their tween the practice points and clinical practice role in monitoring the treatment of anemia guidelines is that the latter were developed by and helping support the limited number of the Malaysian Society of Nephrology and ca- nephrologists in the country. ter specifically to nephrologists. The practice The road shows will kick off in Perak in points, on the other hand, provide an elemen- January, followed by several other states in- tal understanding for both GPs and primary cluding Kelantan and Pahang. Doctors who care physicians, and are a guide to managing are interested in attending the road shows CKD patients with renal anemia. should look out for announcements to be Responding to a question posed by Medical made by MMA’s state branches and invitation Tribune on why the MMA chose this particular letters sent by the association. 4 1-31 January 2013 Forum Preparing healthcare personnel to deal with injury rehabilitation

Excerpted from Medical Development Divison director, Dato’ Dr. Azmi Shapie’s speech at the 11th Asian Spinal Cord Network (ASCoN) Conference 2012, incorporating the 4th Annual Scientific Meeting of Rehabilitation Medicine Services and the 1st Meeting of the Malaysian Association of Rehabilitation Physicians.

pinal cord injury (SCI) is a debilitating event. Through thousands of years of Shuman history, SCI was considered a fatal medical condition associated with tet- raplegia. As far back as 2,500 B.C., this type of injury was considered an ‘ailment not to be treated.’ People were helpless at that time. During World War I, 90 percent of patients with SCI died within a year, with only 1 percent surviving more than 20 years. The lack available in our country. of knowledge and experience in managing In Malaysia, injury is one of the major patients with SCI during that era ended up causes of hospital admissions in public hos- with patients facing various complications pitals. The National Health and Morbidity and fatal consequences – pressure ulcers, re- Survey (NHMS III) 2006 revealed that the spiratory failure and renal problems. overall prevalence of disability in Malaysia However, a number of factors, principal- was about 6.3 per 1,000 population, and this ly the discovery of modern antibiotics and included disability as a consequence of SCI. the establishment of comprehensive, well- The figure gives an indication that, gen- coordinated multidisciplinary spinal injury erally, there was a two-fold increase in the units, have allowed countless individuals prevalence of adults with physical disabili- with SCI today the opportunity to survive ties over the previous 10 years, with the their injury and to lead happy, productive majority of them within the productive age lives. groups. The sadder news is that 59.1 percent The World Report on Disability 2011, pro- of this population had never participated in duced jointly by the WHO and the World or had access to any rehabilitation program. Bank, suggested that more than a billion The increase in road traffic accidents con- people in the world experienced some form tributes significantly to the volume of pa- of disability, of which 200 million faced con- tients with injuries – SCI, in particular. Road siderable difficulty functioning and continu- accidents are an added workload to the day- ing with meaningful activities of daily liv- to-day activities of the rehabilitative frater- ing. It is unfortunate that such data are not nity. Additionally, the rise in sporting activi- 5 1-31 January 2013 Forum ties and the involvement of our athletes in Basic rehabilitative facilities are available in very competitive and challenging activities almost all public hospitals, together with the often exposes them to injuries, and they necessary staffing of physiotherapists, occu- should be supported with competent sport pational therapists and support personnel – and rehabilitative services. In this aspect, we all of whom are there to assist patients. are fortunate as the MOH is very committed Currently, there are 15 public hospitals to continuously looking into ways we can being equipped with resident rehabilitative improve the delivery of healthcare services physicians. This will strengthen the rehabili- to the Malaysian people. tative services provided by those hospitals to We now have 138 public hospitals and patients. To ensure seamless services, some medical institutions providing a wide range aspects of rehabilitative services are also be- of specialized and subspecialized services. ing expanded into the community through At the same time, primary healthcare ser- our health clinics, which very much involves vices are being provided by more than 3,000 the provision of primary care. health centers throughout the country, not To address the needs of the nation, more to mention more than 200 private hospitals doctors have been given the opportunity to complementing the services provided by be trained as specialists. The intake for the public hospitals. Masters program was increased from 450 per The accessibility of medical care and reha- year to 600 per year in 2008, and was further bilitative services has improved with time. increased to 800 per year in 2011. 6 1-31 January 2013 Medical Briefs Elderly nutrition screening lacking in Singapore

lderly Singaporeans would benefit from nutritional screen- Eing during doctor visits, but over half of doctors who took part in the Access to Nutrition Information Survey, spon- sored by Abbott, said they were not equipped to conduct such screening. Of 200 doctors polled for the survey, 63 percent said they did not have time to assess elderly patients about their nutrition habits, although nearly 80 percent said nutrition was important for preventing disease and promoting good health. “As people age, the body requires more protein, vita- min D, calcium and other important nutrients for overall health,” said Dr. Tan Thai Lian, vice president of Singapore’s Society for Geriatric Medicine. “Older adults tend to eat less food as they age… and their bodies process many nutrients less efficiently.” Dr. Carol Tan, a consultant in geriatric medicine at Raffles Hospital, noted that many elderly Singaporeans are at risk of poor nutrition – 47.1 percent among adults who live in a nursing home or in a 1-2 bedroom government-subsidized flat.

Public health meeting draws 400 participants

lose to 400 local and international public health experts, health care workers and re- Csearchers convened for the 1st Singapore International Public Health Conference held recently in Singapore. The 2-day conference tackled current public health issues including the burden of diabetes, infectious diseases and aging populations. One of the highlights of the event was the launch of the Demographic Epidemiologi- cal Model of Singapore (DEMOS), a simulation model that forecasts the impact of public health interventions on future burden of diseases. Using DEMOS, it was predicted that by 2050, one in two adults will develop type 2 diabetes. The meeting was jointly organized by the National University of Singapore Saw Swee Hock School of Public Health and the Chapter of Public Health and Occupational Physi- cians, Academy of Medicine, Singapore. This year’s theme was Translating Public Health Research into Practice. pg03 EP Plus Refreshing Vibrant_Journal.pdf 1 9/19/12 5:13 PM

s ar e y

MTSEPT1-12/001 8 1-31 January 2013 Malaysia Focus Meningococcal vaccine with broader coverage is preferable

Saras Ramiya

eningococcal disease may be caused by serogroups that vary Mwith region and over time, thus, a single vaccine against as many serogroups as possible is one of the most effective preventive methods, says a senior consultant micro- biologist. “The majority of meningococcal disease cases worldwide are caused by five main serogroups – A, B, C, Y and W-135. Given the Vaccination is essential in preventing invasive meningococcal disease. disease’s unpredictability as to the dominant group cause, which varies widely by country The initial symptoms of meningococcal and region and can change over time, WHO disease can be non-specific and flu-like, mak- has indicated that one of the most effective ing it difficult for healthcare professionals ways to prevent meningococcal disease is to to diagnose early. [www.mayoclinic.com/ choose a single vaccine that offers protection health/meningitis/DS00118] Classic symp- against as many bacteria groups as possible,” toms such as neck stiffness and petechial rash said Professor Datin Dr. Che Ilina Che Isahak, do not appear until relatively late in the ill- Faculty of Medicine and Health Sciences, ness – 13 to 22 hours after the first symptoms Universiti Sains Islam Malaysia. appear. [Lancet 2006;367(9508):397-403] Meningococcal disease is a sudden, life- As invasive meningococcal disease can threatening illness that manifests as bacte- progress very rapidly, high levels of circulat- rial meningitis and sepsis. Each year, approxi- ing antibodies are critical for early protec- mately 500,000 cases occur around the world, tion. Typically, immune response takes up causing about 50,000 deaths. [www.mayo- to 5 days to develop, so there is often insuf- clinic.com/health/meningitis/DS00118 Ac- ficient time to mount a protective immune cessed on 31 December 2012] Even when the response once the disease has started, hence disease is diagnosed early and adequate treat- both pre-exposure circulating antibodies and ment is started, 5 to 10 percent of patients die, immune memory are important components typically within 24 to 48 hours after the onset of the body’s immune response. [Pediatrics of symptoms. Bacterial meningitis may result 2009;124(6):1633-41, US Department of Health in brain damage, hearing loss or learning dis- and Human Services, Centers for Disease Control ability in 10 percent to 20 percent of survivors. and Prevention, Advisory Committee on Immu- [www.who.int/mediacentre/factsheets/fs141/ nization Practices (ACIP). Summary Report, 27- en/ Accessed on 31 December 2012] 28 February 2008. Available at: www.cdc.gov/ 9 1-31 January 2013 Malaysia Focus vaccines/acip/meetings/meeting-info.html Menveo, a conjugate vaccine, was initially Accessed on 31 Dec 2012] approved for people aged 11 years and over. An estimated 28,000 Malaysians travel to Novartis Corporation (Malaysia) Sdn Bhd Saudi Arabia for the Hajj annually. In addi- has now announced an extended age indication, over 80,000 Malaysians perform the tion, so it is suitable for children 2 years and Umrah throughout the year. These travelers above. Only one dose is required at the time are especially at risk, because the pilgrimages of vaccination for both young children and place them in extremely crowded conditions adults. for extended periods of time, and bacteria can Besides having received recognition from easily spread from person to person. [www. the global Muslim fraternity, with halal cer- cdc.gov/meningococcal/about/index.html, tifications from Majelis Ulama Indonesia www.who.int/mediacentre/factsheets/fs141/ (MUI) and Islamic Services of America (ISA), en/] During the Hajj period alone, more than 2 Menveo has been shown to be effective for 3 million pilgrims from all over the world visit years after vaccination. [Gill, CJet al. The Per- Mecca. [Int J Antimicrob Agents 2003;21(2):96- sistence of Immune Responses and Boosting 101] in Adolescents Three Years After Administra- Extensive outbreaks of meningococcal tion of Menveo or Menactra to Healthy Ado- disease among pilgrims have prompted the lescents. Presented at the 2011 joint meeting Saudi Arabian health authorities to intro- of the Pediatric Academic Societies and Asian duce mandatory vaccination. Since 2010, all Society for Pediatric Research in Denver, Col- pilgrims must receive the quadrivalent me- orado, on April 30-May 3, 2011] ningococcal vaccine (Menveo®) that protects Menveo was introduced in Malaysia in against serogroups A, C, Y and W-135. [WHO December 2010. As of February 2012, it Weekly epidemiological record www.who. has been approved for use in more than 50 int/wer/2010/wer8543.pdf Accessed on 31 countries for active immunization to prevent December 2012, Special groups of travelers invasive meningococcal disease caused by www.who.int/ith/ITH2010chapter9.pdf Ac- Neisseria meningitidis serogroups A, C, W-135 cessed on 31 December 2012] and Y.

Wanted: New breast cancer screening awareness program

Saras Ramiya novative breast cancer screening awareness program in Malaysia. hilips and the National Cancer Society The participant with the best suggestion PMalaysia (NCSM) are calling upon local in the Best Breast Cancer Screening and Aware- NGOs, government hospitals and/or institu- ness Competition, which will be based on the tions to submit proposals for a new and in- number of touch points and possible impact 10 1-31 January 2013 Malaysia Focus of the program, will be awarded RM40,000 in toms. It is time to call on every individual to funding to execute the program. Experts from take breast cancer screening seriously. Thus, Philips, NCSM and long-time breast cancer Philips and NCSM are committed to deliver- awareness supporter, Theresa Manavalan, are ing the message through the Best Breast Can- judges of the competition. The winning pro- cer Screening and Awareness Competition,” he gram will be closely monitored by Philips and added. the NCSM. According to the National Cancer Registry “Cancer does not discriminate. It is also Report in 2007, breast cancer was the most not just a health issue. It impacts individuals, common cancer in women and accounted for families and communities on a social, eco- 32.1 percent of all female cancer cases. Out of nomic and human rights platform. It is, there- about 3,200 cases diagnosed in 2007, the in- fore, only fitting that cancer is fought not only cidence was 29 in 100,000 women. Chinese from the health front, but also by the com- women had the highest incidence, followed munity,” said Dr. Saunthari Somasundaram, by Indians and Malays. [www.radiologyma- NCSM president and medical director. laysia.org/Archive/NCR/NCR2007.pdf Ac- “This initiative gives the community the cessed on 2 January] opportunity to join the fight and make a dif- In spite of breast cancer being the most ference. It allows breast cancer awareness and common cancer among women, awareness of control issues to be raised from the common screening and early detection is still low. In ground, but from different perspectives,” she a community-based MOH survey of 59,903 added. women aged above 20, only 34 percent con- “Breast cancer is a serious health threat ducted breast self-examination (BSE), while across the world. At the same time, there 31 percent underwent clinical breast exami- are many organizations and hospitals that nation (CBE). are tirelessly educating communities about Mammography was only conducted in 3.8 breast cancer prevention and early detection. percent of women aged 50 years and above. As a company devoted to health and wellbe- [Narimah A. Breast examination. In: Report ing, we are committed to assisting these bod- of the 2nd National Health and Morbidity Survey ies in every way we can – be it in terms of Conference. Kuala Lumpur: Public Health In- domain expertise or resources. We are happy stitute, Ministry of Health; 1997:141-8.] to be associated with NCSM, which has been Another survey of a group of educated extremely aggressive in breast cancer aware- Malaysian women in Penang found a lack of ness in the country in the past,” said Naeem knowledge about risk factors, signs and symp- Shahab Khan, chief executive officer and toms of breast cancer. Out of 384, only 117 and chairman of Philips Group of Companies Ma- 120 women were aware of the recommended laysia. BSE and CBE guidelines, respectively. The “There is also a need to understand the study highlighted the need for an intensive importance of prevention through lifestyle breast cancer awareness campaign to stress modifications. Women, especially, should be the importance of early detection and report- educated to help fight cancer even at the ear- ing of breast cancer. [Med Princ Pract 2010;19 liest stage by detecting breast cancer symp- (1):61-7]

12 1-31 January 2013 Malaysia Focus Experts discuss white paper on incorporating IT into healthcare

Pank Jit Sin

white paper detailing New Zealand’s role in developing and expanding in- A formation technology (IT) in South- east Asia was previewed during the Health- care Information and Management Systems Society (HIMSS) AsiaPac 2012 conference. Malcolm Pollock, author of the white paper and director of the New Zealand Nation- al Institute for Health Innovation, said New Zealand is “focused on developing healthcare technology that tackles challenges that come with aging populations and rising healthcare Going forward information technology will play an important role in costs.” Technologies that focus on the two is- streamlining healthcare in Asia. sues are particularly apt in the Asia-Pacific setting as we are home to 335 million people lems are specific to the Malaysian and over 60 years and the number continues to Southeast Asian region? steadily rise. It is predicted that 900 million Azrin Zubir: Malaysia, like many other people will rise from poverty into the mid- parts of Asia, is characterized by a rapidly dle classes in developing Asian countries by growing, aging population. This means more 2020. [HIMSS media release] people with increasingly complex conditions In this respect, said Pollock, New Zealand will require medical attention. At the same is well-positioned to help Asia tackle its in- time, Malaysians are living increasingly ur- creasing demand for healthcare and higher ban and sedentary lifestyles – the 2003 Ma- expectations for quality and availability. laysian Adult Nutrition Survey highlighted Medical Tribune interviewed Dr. Azrin Zu- that Malaysians spend 74 percent of their day bir, chief executive officer (CEO) of Meridian performing sedentary activities like sitting or Project Management Sdn Bhd (MPMSB), and lying down. These lifestyle factors, coupled managing director of Advanced Informatics with an aging population, have led to a rising and Management Centre (AIMAC) Sdn Bhd; prevalence of non-communicable diseases, and a representative from Cortell Health, a such as diabetes. In Malaysia, the prevalence New Zealand company specializing in busi- of diabetes was 6.3 percent in 1985 and 14.9 ness intelligent systems, to get their views on percent in 2006 – that’s a 250 percent increase IT incorporation in the region. in 20 years, adding significantly to Malaysia’s healthcare burden. Q: In your opinion, what healthcare prob- Fast-growing demand for healthcare, cou- 13 1-31 January 2013 Malaysia Focus pled with rising medical costs, is putting in- but they will also have to develop novel ap- creasing pressure on medical resources. This proaches and products for new markets and means hospitals in Malaysia, like many other disease types. New Zealand, facing many of countries in Southeast Asia, are looking for the same issues, has focused on developing innovative, cost-efficient solutions that give innovative solutions for a number of years. more time back to medical professionals The country is well placed to offer new per- and ensure continuity of stable, high-quality spectives drawn from innovative approaches patient care. Many New Zealand health IT to healthcare challenges within tight budget- companies are exporting solutions that ad- ary constraints. dress these critical issues across Asia – there The per capita cost of healthcare in Malay- is plenty of room for collaboration between sia is US$620, but governments across South- New Zealand and Asia on health IT solutions. east Asia intend to invest more to improve the effectiveness of their healthcare systems, Q: While smaller countries such as Singa- particularly by utilizing health IT systems. pore and Brunei may be able to adopt wide- New Zealand’s use of health IT is amongst the spread use of electronic medical record sys- highest in the world – 99 percent of pharma- tems (EMRS), how is the pickup rate for cies are computerized, and New Zealand has EMRS in countries such as Malaysia, Thai- used electronic medical systems for over 20 land and Indonesia? years. There is significant scope for Malaysia Azrin Rubir: There are more hospitals and Southeast Asia to work with cutting-edge adopting EMRS and hospital information New Zealand health IT companies to address systems now in comparison to 10 years ago, the healthcare issues their sector faces. however, the focus of the implementation is centered on automation of business process. Q: What role can New Zealand play in the Nevertheless, we are seeing a health IT evo- transfer of technology to Asian countries? lution towards supporting quality and clini- Cortell Health: New Zealand health IT so- cal outcome. When the escalation of cost be- lutions are already helping medical profes- came a major concern, along with consumer sionals across the region address their clinical demand, more hospitals in Malaysia started issues. New Zealand faces similar healthcare to adopt EMRS. challenges to Malaysia and many other parts of Southeast Asia, with healthcare costs spi- Q: Could you highlight some pertinent raling upward every year, exceeding GDP points raised by the white paper? growth. This will eventually make healthcare Azrin Zubir: The New Zealand Informa- “unaffordable.” tion Technology for Healthcare Systems As a country, we are focused on develop- white paper highlights that developing so- ing and refining healthcare technology and lutions to meet the increasing and rapidly information management systems for our evolving demands of healthcare is one of own healthcare sector, and we have long been Southeast Asia’s key challenges. Not only will exporting these around the world – including Southeast Asian countries have to increase to Southeast Asia. Cortell Health is already the scale of service provision or production, working with partners in Malaysia, Thailand 14 1-31 January 2013 Malaysia Focus and Qatar. Our focus is on providing hospi- formance. With our technology focused on tal performance management using financial helping to develop this area, we can help Ma- and clinical information as well as activity- laysian medical providers ensure they fully based costing to measure true profitability understand the dynamics around patient ser- and performance of all aspects of a hospital. vice and they’re giving patients the best qual- This includes cost and profitability of cases ity and most cost-effective care possible. and patients, service lines, departments and doctors, and identifying areas where the hos- Q: What sort of solutions would be recom- pital can improve performance to lower cost mended for a country such as Malaysia, to serve patients. It also assists to formulate which is positioning itself to be a travel prices for procedures and diagnosis-related healthcare destination? groups (DRGs). Cortell Health: Malaysia has embarked on In 2011, a Malaysian health IT delegation an ambitious health information and com- visited a reference site in Bangkok Hospital to munications technology (ICT) framework, understand more about how our systems can especially in the public sector. The upgrade help streamline the quality and cost of medi- will affect the full spectrum of Malaysia’s cal care. This highlighted to the delegation healthcare system, from clinical and opera- how hospitals in Thailand are using the solu- tional to consumer. A seamless, professional tions to not only compete for medical tour- and cost-effective experience during hospital ists, but also lower costs for local patients. visits will improve Malaysia’s healthcare ser- Earlier this year, we signed a memo- vices, as well as the country’s standing as a randum of understanding with Meridian travel healthcare destination. Health, which will implement the use of our As mentioned earlier, case management systems across the country and we are cur- is in its early stages in Malaysia. Our focus rently working alongside one of the coun- on providing hospital performance manage- try’s leading heart hospitals. This hospital is ment using financial and clinical informa- working towards being a leading health IT tion as well as activity-based costing allows organization and looking to using advanced healthcare providers to understand more methodologies to improve the cost of care for about their performance and cost of care. patients. We are currently in the scoping and Understanding more about these pressure testing phases with this healthcare provider. points helps hospitals drive cost and pro- Proactive case management and funding ductivity efficiencies, as well deliver a higher in Malaysia is in its early stages. Increas- quality of care. This is a key enabler for medi- ingly, hospital reimbursements will be based cal tourism. on cases and will require an in-depth under- Typically, medical tourism to the region standing of patient and case costs. Case re- will be large, foreign-owned insurance com- imbursement rewards good performers and panies or foreign governments looking to de- may penalize poor performers. It will be vi- liver the most cost-effective care for a large tal for hospitals to understand when they do number of patients. Hospitals not only need not follow ‘best-practice’ and their case costs to be able to provide a competitive rate, they are out of line or what causes outliers in per- also need to be able to understand whether they have the capacity across labs, wards and tals with a deeper understanding of their own operating theatres to treat a large group of cost of care, while at the same helping to im- patients from end-to-end. prove the quality of care, will help the country The medical tourism market is highly com- cement its position in this market. petitive and Malaysia is among one of the Our systems not only allow hospitals to region’s more favorable destinations. It can understand if they have the capacity to pro- perform some of the more common opera- vide quality care to large groups of medical tions – heart bypasses, knee replacements and tourists, it also enables them to understand at cosmetic surgery – at about half the price of what price point they can still be profitable, countries like Singapore. while ensuring they are providing the best Adopting systems which provide hospi- possible care.

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PUBMED 16 1-15 October 2012 Conference Coverage

8th International Symposium on Respiratory Diseases and American Thoracic Society in China Forum, 8-11 November, Shanghai, China – Chuah Su Ping reports Omega-3 fatty acids come up short in afib

Elvira Manzano

hort-term supplementation with omega-3 Sfatty acids prior to cardiac surgery appears to have no benefits in terms of preventing- ar rhythmias, according to new research. In the largest trial of fish oil in surgery ever conducted (OPERA*), administration of ome- Two trials failed to show that fish oil prevented arrhythmias. ga-3 polyunsaturated fatty acids (n3-PUFAs) rhythmic actions. 2 to 5 days prior to surgery and until hospital The findings were backed by another trial discharge did not reduce the risk of postop- (FORWARD**) presented at the same meeting erative atrial fibrillation (AF). There was no which showed that 1 g/day of fish oil did not difference in the incidence of postoperative prevent recurrences in patients with previous AF of >30-second duration – the primary end- AF (HR 1.28, P=0.17). [Circ Cardiovasc Qual Out- point – between the treatment and placebo comes 2012; DOI:CIROUTCOMES.112.966168). groups (30 percent vs. 30.7 percent, respec- “Every time we’ve had a trial with omega- tively; P=0.74). 3s, we’ve come up short,” said Dr. Peter Wil- Results were similar for a number of sec- son, from the Emory University in Atlanta, ondary endpoints – postoperative AF that Georgia, US. “It’s very discouraging for the was sustained, symptomatic or treated, ma- omega story.” jor adverse cardiovascular events, 30-day Amiodarone and b-blockers have been test- and 1-year mortality and bleeding – among ed for postoperative AF, but these drugs only different patient subgroups. [JAMA 2012; partly reduced the risk. The effects of cardiac DOI:10.1001/jama.2012.28733] surgery on atrial remodelling may be too im- “Omega-3 fatty acids may not be powerful mense to be countered by most drugs, includ- enough to be effective in preventing arrhyth- ing n-3PUFAs, said OPERA lead author Dr. mias,” said study author Dr. Roberto Marchi- Dariush Mozaffarian, from the Brigham and oli, from Consorzio Mario Negri Sud, Santa Women’s Hospital in Boston, Massachusetts, Maria Imbaro, Italy. US. “Postoperative AF remains an intractable OPERA involved 1,516 patients scheduled and enigmatic complication of surgery. More for cardiac surgery in 28 centers in the US, Ita- investigations are needed to allow novel tar- ly and Argentina randomized to a periopera- geted preventive and therapeutic interven- tive loading dose of placebo or n-3 PUFAs 8 to tions,” he concluded. 10g, followed by 2 g/day postoperatively until hospital discharge. While previous small tri- *OPERA: Omega-3 Fatty Acids for Prevention of als of perioperative fish oil on postoperative Postoperative AF AF showed mixed effects, OPERA provides **FORWARD: Fish Oil Research with Omega-3 no evidence that n-3 PUFAs have anti-ar- for Atrial Fibrillation Recurrence Delay MTSEPT1-12/001 18 1-15 October 2012 Conference Coverage

8th International Symposium on Respiratory Diseases and American Thoracic Society in China Forum, 8-11 November, Shanghai, China – Chuah Su Ping reports OSA linked to glucose dysmetabolism

ccumulating evidence suggests that obstructive sleep apnea (OSA) is as- Asociated with glucose dysmetabolism, says an expert. “While the link … remains controversial, it is clear that both conditions are related to obesity,” said Professor Mary Ip of the Uni- versity of Hong Kong. “OSA may also have a causal role on increasing insulin resistance, glucose tolerance and type 2 diabetes mellitus [T2DM].” “There have been many studies examining the relationship between insulin resistance and OSA, but few studies on the role of B-cell dysfunction in OSA,” noted Ip. One such study by Punjabi NM et al showed that severe OSA is associated with impaired B-cell dysfunction. [Am J Respir Crit Care Med 2009;179:235-240] “This reduces the compensatory insulin secretion, leading to the development of glucose intolerance or diabetes,” said Ip. In the Sleep Heart Health Study, Seicean S et al found that OSA may be independently CPAP has been shown to improve insulin sensitivity in non-diabetic patients. associated with various states of glucose metabolism including impaired fasting glucose, [increased] waist circumference,” said Ip. impaired glucose tolerance and occult diabe- [Respir Med 2006;100:980-987] tes. [Diabetes Care 2008;31:1001-1007] More recent studies in Japan and China have also shown that patients with severe OSA The use of CPAP to improve had a higher prevalence of hypertension, dys- lipidemia, glucose intolerance and metabolic insulin sensitivity in OSA patients abnormalities. [Respirology 2010;15:1122-1126, remains to be validated Sleep Breath 2012;16:571-578] Continuous positive airway pressure “Similarly, a study in Hong Kong showed (CPAP) treatment for OSA has been shown that OSA was independently associated to improve insulin sensitivity in non-diabetic with metabolic syndrome, hypertension and patients with BMI less than 30 kg/m2. [Am J 19 1-15 October 2012 Conference Coverage

Respir Crit Care Med 2004;169:152-62] However, patients. “The use of CPAP to improve insu- the effects of CPAP treatment in patients with lin sensitivity in OSA patients remains to be T2DM remains controversial, Ip said. validated.” “Many studies have been carried out to ex- While convincing data demonstrate a link amine the effect of CPAP treatment of OSA in between OSA and B-cell dysfunction, insulin patients with T2DM, however, most did not resistance, metabolic syndrome and increas- report any significant difference on glycemic ing HbA1c levels, little is known about the control [post-treatment],” she said. Compli- long-term outcomes of OSA treatment for ance to CPAP may also play an important T2DM, which Ip said would be a key area for role in improving insulin resistance in OSA future research.

21 1-15 October 2012 Conference Coverage

8th International Symposium on Respiratory Diseases and American Thoracic Society in China Forum, 8-11 November, Shanghai, China – Chuah Su Ping reports Interview with the Presidents

The 8th International Society for Respiratory Disorders (ISRD) annual meeting marked the inaugural joint scientific session between the ISRD and the American Thoracic Society (ATS). Medical Tribune spoke to the leadership of both organizations - Professor Chunxue Bai, president of the 8th ISRD and ATS in China Forum, and Dr. Monica Kraft, president of the ATS - to Professor Dr. Monica Kraft Chunxue Bai gain their views on key topics in respiratory diseases.

MT: How will the updated Global Initia- the doctor’s office. In some cases, this data tive for COPD (GOLD) guidelines affect may enable doctors to make a preliminary current clinical practice? diagnosis. Doctors are also able to feedback Kraft: The main difference is the criteria for directly to patients via the internet upon diagnoses [of COPD]. They’re quite different receiving the results. This technology will from previous versions and we are current- allow data to be monitored and recorded ly in an adjustment period trying to better while the patient is asleep at home, which is understand how to best apply these guide- very useful in the diagnosis and treatment lines in practice. The definitions of different of sleep apnea. severities of COPD have also changed. Kraft: I think telemedicine is still an evolving field, and I am still skeptical as to how MT: How has respiratory clinical practice it will be applied to clinical practice in the today evolved to improve quality of care long term. This is an area we still need to for patients, in particular the use of tele- explore in greater detail. medicine? Bai: This year we will be introducing del- MT: What do you think are the implica- egates to what I like to refer to as the “Med- tions of the results from two early-phase ical Internet of Things”, which is basically clinical trials [NEJM 2012;366:2443-54, a combination of electronic medicine plus NEJM 2012;366:2455-65] presented at the mobile health, or telemedicine. This has 2012 ASCO meeting which provide further already started being implemented for pa- evidence on the role of the immune system tients being treated for sleep apnea [in Chi- in treating patients with NSCLC? na] and enables a doctor in a clinic or hospi- Bai: I do believe the immune system plays tal to monitor a patient who is at home. The an important role in lung cancer treatment. idea is for patients to take home a portable In China, there is ongoing research looking monitor and the data will be sent directly to into the development of a vaccine for [non- 22 1-15 October 2012 Conference Coverage small-cell lung cancer (NSCLC)]. However, of gene expression which are associated at the end of the day, early diagnosis of lung with response to specific chemo-therapeutic cancer is key to extending patient survival. agents, as this can help us ensure patients Kraft: Lung cancer remains a very challeng- are receiving the right combination of medi- ing area, but I think we’ve made some prog- cation. In other words we are getting closer ress in recent years. It’s exciting that we have to the goal of personalized therapy in lung discovered specific biomarkers and patterns cancer.

Towards targeted COPD treatment

hronic obstructive pulmonary disease acerbators in year 3, whereas, approximately C(COPD) treatment should be individual- 70 percent of patients who had no exacerba- ized based on each patient’s clinical pheno- tions in years 1 and 2 had no exacerbations type, says an expert. in year 3. Thus, they concluded that the sin- “To do so, we would need to move away gle best predictor of exacerbations, across all from the traditional assessment of COPD and GOLD stages, was a history of exacerbations. its treatment,” said Professor Paul W. Jones, [N Engl J Med 2010;363:1128-38] professor of respiratory medicine and head of “In this year’s GOLD [2012] update, we the division of clinical science at St. George’s, also recognize that hospitalization is a very University of London, UK. important risk factor. If a patient has had “One of the key updates to the Global Ini- one or more hospitalizations in a year, that tiative for COPD (GOLD) guidelines last year automatically places them in a high-risk was when we categorized the treatment aims category,” said Jones. [for COPD] into two groups – symptomatic In 1997, Jones and Bosh published a study benefit and risk reduction, said Jones, who is in which they observed that the patients‘ es- a member of the GOLD Science Committee. timate of treatment efficacy correlated with Symptomatic benefit includes relief of changes in the St. George’s Respiratory Ques- symptoms, improvement in exercise toler- tionnaire (SGRQ) score. ance and health status whereas risk reduction “If the patients judged their treatment includes prevention of exacerbations and dis- as ‘ineffective’, that correlated with a worse ease progression, and reduction in mortality. SGRQ score. However, if they judged their “This was a big step forward as we explicitly treatment as ‘effective‘ or ‘very effective’, the started to recognize that the manifestations of improvement in SGRQ score was either at COPD differ between individual patients.” the threshold of clinical significance or bet- In the Evaluation of COPD Longitudinally ter,” said Jones. [Am J Respir Crit Care Med to Identify Predictive Surrogate Endpoints 1997;155:1283-1289] (ECLIPSE) study, Hurst JR et al observed, over “These findings are significant as they tell a 3-year period, that 71 percent of frequent ex- us that the patients’ personal feedback should acerbators in years 1 and 2 were frequent ex- also be taken into consideration.” 23 1-15 October 2012 Conference Coverage

Highlighting a recent study by Mahler DA long-acting beta agonist and long-acting mus- et al, Jones noted that when indacaterol was carinic antagonist.” [Thorax 2012;67:781-788] added to tiotropium, there was a significantly “In treating COPD, one of the key things greater change in symptoms compared with to remember is to treat, to improve the pa- patients on tiotropium alone. “These results tient’s symptoms and reduce exacerbations,” are in line with the COPD guideline recom- Jones said. Physicians can then custom- mendations to combine bronchodilators with ize treatment based on the patient’s clinical different mechanism of actions, in this case a phenotype.

NIPPV for treating COPD exacerbations

on-invasive positive pressure venti- tients who require more than 50 percent oxy- Nlation (NIPPV) is currently the pre- gen; with significant hypotension induced eminent established application in acute by conventional ventilator therapy; with respiratory failure of chronic obstructive fractured skull base, facial fractures and in- pulmonary disease (COPD) exacerbations, creased intracranial pressure; and with re- but experts say skilled application is critical spiratory arrest. for patient breathing. Marraro cautioned that NIPPV should “The rationale for selecting NIPPV is to be discontinued if there is no improvement first of all reduce the patient’s breathing in gas exchange or dyspnea, or if there is a workload,” said Dr. Giuseppe A. Marraro, need for endotracheal intubation to man- director of the Anesthesia and Intensive Care age secretions or protect the airway. “Stop Department at the A.O. Fatebenefratelli and NIPPV immediately if the patient exhibits Ophthalmiatric Hospital in Milan, Italy, and coordinative problems, reduced conscious- this procedure can improve gas exchange, ness and increasing levels of carbon diox- reduce endotracheal intubation, reduce in- ide coupled with decreasing pH levels,” he fection rate and increase patient survival. stressed. [Lancet 2009;374:250] Patients with COPD who have exacerba- “These are all key factors which will tions of respiratory failure can benefit sig- eventually determine treatment success in nificantly from ventilator assistance. patients with COPD exacerbations.” “NIPPV has been shown to reduce the se- But he noted that patient collaboration verity of breathlessness within the first four and the skill of hospital staff can play a ma- hours of treatment, decrease the length of jor role in how effective NIPPV will be. hospital stay and reduce the rates of mortal- “Compared with conventional ventila- ity and intubation,” said Marraro. He noted tion, NIPPV confers a higher risk of mask that the advantages of NIPPV include the dislodgment and there is a need for higher avoidance of intubation, which is typically ventilator pressure,” said Marraro. He high- necessary for 16-35 percent of acute COPD lighted that NIPPV is contraindicated in pa- exacerbations and carries its own complica- 24 1-15 October 2012 Conference Coverage tions. it, and ingest orally. The facial mask on the “NIPPV preserves the patient’s ability to other hand, may be more useful for dyspneic cough, speak and swallow. It can also be patients who are usually mouth breathers,” used away from the ICU, thereby potentially said Marraro. “NIPPV can be applied in reducing costs.” appropriate non-ICU settings but it is impor- With NIPPV, physicians have the choice tant to take into consideration the patient’s of selecting either a nasal or facial mask for personal feedback as well as the need for their patients. “The advantages of the nasal fully trained and experienced hospital staff mask are that it is less claustrophobic and al- and appropriate equipment, monitoring and lows the patient to speak, expectorate, vom- support.”

www.MIMS.com

Smart Rx. Every Time.

26 1-15 October 2012 Conference Coverage

43rd Union World Conference on Lung Health, 13-17 November, Kuala Lumpur, Malaysia – Radha Chitale reports New TB therapies offer hope

wo promising new agents under de- take process required to get new therapies to velopment for treating multiple drug- where they are really needed. Tresistant tuberculosis (MDR-TB) can’t “Getting [drugs] approved in the US where be deployed fast enough, experts say. we only have 130 cases of MDR-TB a year is The US Food and Drug Administration really not going to be the place where these (FDA) Anti-Infective Drugs Advisory Com- drugs are going to make the biggest differ- mittee has approved a request for accelerated ence,” said Mr. Mark Harrington, executive approval of drug-maker Janssen’s investiga- director of the HIV/AIDS policy think tank tional agent bedaquiline for MDR-TB. Treatment Action Group. Interim results of a randomized controlled “Countries that have weak regulatory phase II trial showed that the addition of be- systems are going to need a lot of political daquiline to a five-drug background regimen will and community demand to drive accep- (standard second-line drugs) for 24 weeks im- tance... On the ground you’re going to need proved the rate of sputum culture conversion regulators, implementers and activists to (shift from positive to negativeMycobacterium work together to speed up not only the de- tuberculosis growth) in MDR-TB patients in a mand for the approved drugs but protocol shorter time compared with the background review for experiments.” regimen plus placebo (79 percent vs 58 per- Where normal treatment for drug-resis- cent, respectively). The effects of bedaquiline tant TB requires a barrage of drugs for up to were durable out to a follow-up assessment 2 years or more, novel drug regimens could at 72 weeks. shorten treatment courses and improve out- Meanwhile, Otsuka Pharmaceuticals comes. Group has filed for approval of another new But the time required for approval and TB agent – delamanid – with the European implementation of a novel regimen against Medicines Agency (EMA). MDR-TB, one that would likely include beda- Delamanid has demonstrated increased quiline and delamanid together, may prompt sputum culture conversion at 2 months rapid implementation without regulatory go- among patients with MDR-TB compared ahead. with placebo (45.4 percent vs 29.6 percent, “I think the issue is what to do until we respectively), plus background therapy for have better definitive evidence of a shorter both groups, in a randomized controlled tri- regimen,” said Dr. Mary Edginton of the al. [N Engl J Med 2012;366:2151-2160] University of the Witwatersrand School of Despite the possibility of approval of these Public Health in Johannesburg, South Africa. new agents in the US and Europe, some are “There doesn’t seem to me to be any reason frustrated by the prospect of the lengthy up- not to use the short course regimens, under 27 1-15 October 2012 Conference Coverage research conditions, with informed consent Of about 9 million cases of TB globally, of patients, and monitored and reported.” about 630,000 are resistant to treatment, and “We’re going to need to pick up the pace,” 440,000 people with MDR-TB die each year said Dr. Kenneth Castro, director of the Divi- according to the WHO Global Tuberculosis sion of TB Elimination at the US Centers for Report 2012. Disease Control and Prevention. “The times of waiting for the best possible evidence to formulate some early or preliminary recom- Note: FDA approved bedaquiline on 31 December mendations are gone.” 2012.

Intense antibiotic therapy may benefit TB meningitis patients

n intensified antibiotic treatment -regi Amen could improve outcomes in patients with tubercular (TB) meningitis, according to an Indonesian study. “We feel that our results challenge the current treatment model,” said lead researcher Dr. Rovina Ruslami, of Padjadjaran Univer- sity in Bandung, West Java, Indonesia. No optimal regimen for TB meningitis ex- ists. However, as the pathophysiology of TB meningitis differs from pulmonary tuberculosis, Ruslami and colleagues have suggested High-dose IV and oral antibiotics were better than standard therapy in an that a higher drug dose may garner better Indonesian study. treatment outcomes. In their open-label, phase II trial, 60 pa- niazid and pyrazinamide, which penetrate tients were randomized to receive a standard well into the cerebrospinal fluid (CSF), and dose (450 mg orally) or high dose (600 mg in- adjunctive corticosteroids. travenously) of rifampicin, after which they High-dose rifampicin tripled plasma and were divided again into groups to receive CSF concentrations compared with those seen none, 400 mg, or 800 mg of oral moxifloxacin with the standard dose (p<0.0001 for both). for 2 weeks, after which patients continued Patients given 800 mg moxifloxacin had with standard tuberculosis treatment. twice the plasma concentration of patients Most patients were young (median age 28 given 400 mg moxifloxacin and a 60 percent years) and with advanced disease. increase in CSF concentration (p<0.0001, Throughout the trial, patients received iso- p=0.006, respectively). 28 1-15 October 2012 Conference Coverage

“The higher exposure to rifampicin in our However, the rate of adverse events was no study suggests a combination of a higher more than that of standard therapy, Ruslami dose, intravenous administration, and non- said, and the mortality was lower in the high- linear pharmacokinetics of this antibiotic,” dose rifampicin group – 34 percent vs 65 per- the researchers said. cent in the standard therapy group. Moxifloxa- Ruslami noted that TB meningitis is rare cin did not appear to affect mortality. but can be severe and has high mortality; over “Rifampicin is still an appealing drug for 50 percent of patients die even when they tuberculosis, especially in developing coun- complete treatment. tries since it is cheap, accessible, well toler- In the current study, half of the patients ated, and physicians are aware of it,” Ruslami died within 6 months, many within the first said, adding that defining the optimum regi- month, mostly due to respiratory failure and men from such drugs could help control TB neurological deterioration. meningitis in areas of need.

Rapid TB test performs well onsite

aboratory diagnosis of tuberculosis (TB) Limproved by 50 percent when a novel rapid DNA test was added to standard sputum smear microscopy. When used alone, the Xpert® MTB/RIF rapid DNA test improved diagnosis by 41 percent compared with microscopy, according to data presented by the international group Medicines Sans Frontieres (MSF). Culture is the current gold standard for definitive TB diagnosis, but results can take up to 6 weeks. However, the Xpert® test can return results within 2 hours. The rapid assay can also distinguish bacteria resistant to rifampicin, a first-line TB drug,

as well as non-tubercular mycobacteria. WHO Photo credit: “For drug-sensitive TB, based on Xpert®, people can be put on treatment,” said Dr. Mar- A new rapid TB diagnostic test has been rolled out in various locations tina Casenghi, research advisor with MSF’s around the world. Campaign for Access to Essential Medicines. start patients on an optimized regimen and “For drug-resistant TB... in high multiple then send them for a full drug sensitivity test- drug-resistant TB (MDR-TB) settings, you can ing to tailor the regimen.” 29 1-15 October 2012 Conference Coverage

MDR-TB diagnosis in low-burden settings reported results in children. The total num- still necessitates a confirmatory culture for ri- ber of samples was 36,540. fampicin resistance, she noted. “When we added expert to microscopy we The Xpert® test is a semi-automated DNA had a relative gain of 50 percent in detection assay in a closed system. A technician pre- of TB,” said presenter Dr. Elisa Ardizzoni of pares a sputum sample with reagents in a car- the Mycobacteriology Unit of the Institute of tridge and loads it into the machine, which is Tropical Medicine in Antwerp, Belgium. about the size of a microwave. The machine The data included a relatively large number costs US$17,000 and each cartridge costs of inconclusive results from Xpert®, almost 7 US$10. percent among the whole data set. Howev- The process limits contamination and re- er, these decreased over the 18-month data turns fewer false-positive results as well as gathering period as technicians became more minimizing the skill set required to do diag- skilled and new cartridges became available. nostic testing. Although the benefits of the Xpert® test do The Xpert® was rolled out in 25 locations not exclude the need for better point of care around the world, including one site each in tests in peripheral, resource-poor settings, Vietnam and Myanmar. Some sites were in Casenghi said it is a step in the right direc- high burden MDR-TB locations, some used tion to have a simple, fast test that returns Xpert® together with sputum culture or mi- good results in TB endemic countries with- croscopy, some used Xpert® alone and some out requiring extensive infrastructure. 30 1-31 January 2013 Regional Preventing cancer by weight control?

Naomi Rodrig

ver 1,500 cancer cases could be prevented every year in Hong Kong if all Olocal residents kept their body weight within a ‘healthy’ range, according to a recent report from the Continuous Update Project (CUP) of the World Cancer Research Fund (WCRF). The CUP, commissioned by the WCRF in 2006 and conducted by a team of scientists at Imperial College, London, UK, is an ongoing review of published scientific evidence on the link between body weight, diet and physical activity and the incidence of various cancer types. According to recent demographic data, nearly 40 percent of Hong Kong’s population are overweight or obese (BMI of 23 and 25 kg/ m2, respectively). “A significant number of cancer cases could be prevented by people maintaining a healthy body weight,” said CUP Chair Professor Alan and uterus,” added Jackson. “The CUP report Jackson, from the University of Southamp- on breast cancer was released in 2009 and ton, UK. “The CUP report published this year colorectal cancer in 2011 and 2012.” looks specifically at pancreatic cancer, which By extrapolation, it was calculated that 18 is the sixth most common cause of cancer percent of the 9,700 cases of overweight-relat- death in Hong Kong, with very low survival ed cancers in Hong Kong could be prevented rates. Fewer than one in five patients survive annually. the first year after diagnosis, but we have Elaborating on the link between body fat found that 15 percent of new cases could be and carcinogenesis, Jackson said, “Fat cells re- avoided each year by keeping a healthy body lease cytokines that cause inflammation and weight.” may encourage the growth and proliferation The researchers calculated that 75 out of of cancer cells. Excess body fat also leads to about 500 annual cases of pancreatic cancer increased levels of insulin and related hor- could be prevented by maintaining a BMI be- mones that encourage faster cell growth and tween 18.5 and 23 kg/m2. division, promoting tumor development. In “Apart from pancreatic cancer, there is evi- addition, fat is also an important source of dence that body weight affects a person’s risk estrogen, and can promote estrogen-sensitive for breast, kidney and colorectal cancers, as cancers such as breast cancer and endometrial well as cancers of the esophagus, gall bladder cancer.” MT JOURNAL OGSS.pdf 1 1/7/13 11:24 AM

The Changing Panorama Of Women’s Health: Navigating New Frontiers

22-24 August 2013 Visit www.Sicog2013.com for more details soon! 32 1-31 January 2013 Regional Ophthalmology training center opens at CUHK

Naomi Rodrig

he Advanced Ophthalmic Training and Education Center (AOTEC) was inau- Tgurated at the Chinese University of Hong Kong (CUHK) last month, designated to serve as a regional hub and center of ex- cellence for advanced education and international exchange in ophthalmology and visual sciences. Located in the Hong Kong Eye Hospital, the AOTEC is equipped with state-of-the- art facilities to provide training for under- vides simulation technology for special surgi- graduate and graduate students, as well cal environments that are not available through as professional training for ophthalmol- traditional wet laboratory training, so that stu- ogy residents and advanced education for dents and doctors can master the complex eye specialists. anatomy and learn about eye diseases through AOTEC provides one-stop training using virtual practice. mostly noninvasive technologies for ophthal- Advance teleconferencing technologies are mic investigation and diagnosis, including available in the telemedicine center, allowing optical coherence tomography, high-resolu- doctors and students to participate in joint tion photography and multi-focal electroreti- educational programs and exchanges with nography. major international eye institutions. These fa- “The AOTEC allows researchers to use cilities will also be used for discussions and cutting-edge virtual-reality technologies consultations on ophthalmic cases with over- to study the diagnosis and treatment of seas experts. common eye diseases,” remarked Dr. Chi- The center is funded by a donation from Tim Hung, cluster chief executive of Kow- the Lee Wing Kit family, with support loon Central Cluster, at the inauguration from the University Grants Committee, the ceremony. Food and Health Bureau and the Hospital The AOTEC’s visual reality laboratory pro- Authority.

READ JPOG ANYTIME, ANYWHERE. Download the digital edition today at www.jpog.com 33 1-31 January 2013 Regional Age-related eye symptoms commonly ignored

Christina Lau

arly symptoms of age-related macular de- Egeneration (AMD) are commonly ignored by the elderly, according to a recent survey. The College of Ophthalmologists of Hong Kong and the Hong Kong Ophthalmologi- cal Society interviewed 156 AMD patients in September 2012 to investigate patients’ awareness of the condition and their atti- tudes towards treatment. Results, released on the occasion of the AMD Awareness Day on 4 November 2012, showed that 62.2 percent of AMD patients had never heard of the condition before they received the diagnosis. Nearly 35 percent of patients did not seek ma and 41 percent had distorted vision. As a immediate medical attention when symp- result, 83.9 percent of patients had impaired toms first appeared, as they believed that the quality of life. symptoms would improve without treatment “Although there is as yet no cure for (35.3 percent) or were a normal process of ag- AMD, 67.4 percent of patients in the survey ing (29.4 percent). Nearly 76 percent of those reported improvement or stabilization of vi- patients sought medical attention, only when sion after treatment with intravitreal injec- they noticed a progressive deterioration in tions and/or photodynamic therapy,” said Dr. their vision. Yin-Fung Yuen, who chaired the organizing At presentation, 80.1 percent of patients committee of the AMD Awareness Day last had blurred vision, 44.2 percent had scoto- year. 34 1-31 January 2013 Regional Cross-border cooperation on food safety

Naomi Rodrig Ko said at the meeting. Health inspection and quarantine issues, ealth, agriculture and quality-control animals, plants, and foods of animal and plant experts, and officials from Guang- H origin, and food safety and control were among dong, Hong Kong, Macau, Shenzhen and the topics discussed at the meeting. Zhuhai, gathered in Hong Kong last month Ko noted that, with support from the State for the Health, Animal & Plant Quarantine General Administration of Quality Supervi- & Food Safety Control Meeting. sion, Inspection & Quarantine, the govern- “Since more than 90 percent of Hong Kong’s ment has formulated the Pesticide Residues in food supply is imported, the government at- Food Regulation. “It will be implemented in taches great importance to collaborating with August 2014, enhancing control over pesticide other jurisdictions on food-safety matters,” residues in food,” he said. Secretary for Food & Health Dr. Wing-Man

36 1-31 January 2013 Regional NHCS develops human heart cell model to aid early ARVC diagnosis

Rajesh Kumar

esearchers at the National Heart Centre Singapore (NHCS) have suc- Rcessfully created a human heart cell model of arrhythmogenic right ventricular cardiomyopathy (ARVC), an inherited heart muscle disorder that can cause arrhythmias and sudden cardiac death. The model was developed using patient- specific induced pluripotent stem cell (iPSC) technology, which converted skin samples from a 30-year-old ARVC patient into heart The NHCS research team demonstrating the use of the model to study the muscle cells in a Petri dish. [Eur Heart Jour mechanism of ARVC and drug response. 2012; DOI: 10.1093/eurheartj/ehs226] The key characteristics of the disease such and drug therapy, on such diseases as they do as abnormal “fatty changes” and altered dis- not have to be tested on patients in the first tribution of desmosomal proteins (involved instance.” in cell-cell connections) were reproduced in ARVC may be under-diagnosed as it can those heart cells even outside of the patient’s be difficult to detect in people with mild or body, the researchers found. no symptoms. The development of the hu- This novel cellular model for studying the man heart cell model is, therefore, being con- disease could help improve understanding sidered a crucial step towards early detection on how these mutations lead to arrhythmias and treatment. and clinical manifestations of ARVC, said the “Although a rare condition, [ARVC] is researchers. more commonly detected in younger indi- “For the first time, we have created a ‘crys- viduals, in their 20s and 30s, particularly in tal ball’ of the disease outside the body, to males, and is more lethal in this age group,” look into the patient’s detailed genetic make- said principal investigator Dr. Reginald Liew, up and its relationship to the manifestation deputy director of the NHCS research and de- of disease,” said Associate Professor Philip velopment unit, NHCS. Wong, Director of NHCS research and devel- The research team has also been success- opment unit. ful in using the iPSC technology to replicate “There would be significant opportunities other inherited heart rhythm diseases such now to safely study the effects of environ- as long QT syndrome (LQTS) and Brugada mental factors and treatments, including gene Syndrome. These diseases are caused by mu- 37 1-31 January 2013 Regional tations in genes coding for proteins that con- stratify patients with risk of cardiac arrhyth- trol the electrical activity of the heart which mias,” said Wong. can lead to ventricular arrhythmias, blackouts “Such models will allow us to measure risk and sudden cardiac death. in individuals safely and tailor individual pre- “The next stage is for us to use this ARVC ventive programs and treatments to patients in model to understand more about the disease a more precise manner, ie, the practice of ‘strat- and to specifically use such models to risk ified and personalized‘ medicine,” he added.

Spontaneity makes way for satisfaction in sex

Rajesh Kumar The findings showed that 59 per cent of Sin- gaporeans planned for half or more of their hen it comes to sex, Singaporeans sexual encounters, with more men (66 per- Wwould much rather sacrifice spontane- cent) doing the advance planning than wom- ity to ensure a satisfying experience for self en (49 percent). Out of the 77 percent who and partner by planning the event in advance planned at least one of their past four sexual on most occasions, according to the results of encounters, 33 percent typically planned less a survey conducted by Eli Lilly. than 30 minutes in advance. “It’s funny that people are prepared to sacrifice spontaneity and are willing to plan It’s funny that people are for intercourse to avoid disappointment, although planning is counter to a great sex,” prepared to sacrifice spontaneity said Professor Peter Lim, consultant urologist and are willing to plan for at Gleneagles Hospital. While it is sometimes necessary for couples intercourse to avoid to plan in advance due to lifestyle or medical disappointment, although reasons, Lim said there will often be a trade- off with the excitement and romance ofa planning is counter to a great sex spontaneous experience. His views were buttressed by the survey results showing 64 per cent of the respon- Researchers recently polled 150 Singapor- dents agreed that sex was about spontaneity eans between the ages of 31 and 51 years, half for the romance and that planned sex of them men, in an attempt to understand took away the fun. Despite this, 41 per- their perceptions of planning their sexual ac- cent of Singaporean respondents would tivity in advance, considering “more than half rather sacrifice on the romance and fun of Singaporean men suffer from some degree by planning in order to improve their of ED [erectile dysfunction].” [Singapore Med J experience and avoid personal dissatisfaction 2003;44:20-26] or disappointing their partners. 38 1-31 January 2013 Regional New quick test for TB launched

Elvira Manzano

ingapore’s battle against tuberculosis (TB) has been bolstered by the launch Sof a new diagnostic chip (VereMTB™, Veredus Laboratories) which can quickly and simultaneously detect TB and other Mycobac- terium variants resistant to therapy. Unlike traditional methods of diagnosis which can take up to 8 weeks, the new chip The new VereMTBTM diagnostic chip undergoing trials in China. takes only 3 hours to identify TB. “Faster diagnosis is important, both for sionals need to fill the chip’s channels with the drug-susceptible and drug-resistant patients, patient’s sputum or cultured samples which for appropriate treatment to start,” said Asso- are then amplified through a process called ciate Professor Thomas Dick, of the National polymerase chain reaction (PCR). It then pass- University of Singapore’s microbiology de- es through micro-assay based detection where partment. “Otherwise, patients will be walk- the DNA sample is matched against TB DNA, ing around infecting others.” its mutation and non-TB cousins. Even when the diagnosis is made, treatment The chip has been tested in patients’ samples for TB can be difficult. Standard treatment in Russia, Bulgaria and Albania. It is currently takes from 6 to 9 months and up to 20 months in use in Uganda while the Chinese Centre for for multi-drug resistant (MDR) TB. Disease Control and Prevention in Beijing is “MDR-TB is difficult to cure as it does not undergoing clinical trials with the chip. In Sin- respond to standard anti-TB drugs isoniazid or gapore, the VereMTBTM chip is only used for rifampicin,” Dick said. Delays in second-line research purposes. However, it will be offered treatment make it more difficult to treat. to private and public hospitals for less than The new test addresses this problem as it de- US$100 each. tects not just isoniazid or rifampicin resistance “Diagnosis is a key element if we are to con- but nine non-TB Mycobacterium infections tain TB globally,” said Dick. “The chip is defi- that mimic TB symptoms, said Dr. Rosemary nitely a contribution to improved diagnostics.” Tan, chief executive officer of Veredus Labora- TB is the second leading cause of death tories, a Singapore-based subsidiary of semi- worldwide from infectious disease after HIV/ conductor giant STMicroelectronics. “It thus AIDS. The WHO said about one-third of the allows the clinician to administer the treatment world’s population is infected with the disease specific to the mutant strain, saving cost and and nearly 2 million people needlessly die time wasted on a hit-and-miss method of treat- from it each year. About 3.7 per cent of new ment.” cases and 20 per cent of previously treated To carry out a diagnosis, health care profes- cases have MDR-TB. 39 1-31 January 2013 Regional DOH releases advisory on stem-cell therapies

Dr. Yves Saint James Aquino

he Philippines Department of Health recently released a public advisory T on the use of stem cell therapies in response to a proliferation of supposed centers using the therapy for medical and aesthetic purposes. The DOH advised the public to be cautious in seeking the therapy despite heavy promo- tion in the media. The department stated that there is a worldwide increasing demand for the use of stem cells as therapy in oncology, end-stage organ diseases and regenerative medicine. Howev- er, the technology is young and not yet part of standard care. The therapy is still considered as investigative procedure for ‘compassionate include acting director of Food and Drug Ad- use.’ This means that most therapeutic uses of ministration Kenneth Hartigan-Go, Philip- stem cells are still under clinical evaluation. pine Council for Health Research and Devel- According to the US National Institutes of opment director Jaime Montoya, along with Health, pluripotent stem cells offer the pos- scientists from the University of the Philip- sibility of a renewable source of replacement pines-National Institutes of Health and Uni- cells to cure diseases and conditions that in- versity of the Philippines Marine Science. clude Parkinson’s disease, amyotrophic lat- According to the DOH, the regulatory eral sclerosis, spinal cord injury, burns, heart framework will cover the sources of raw ma- diseases, diabetes and arthritis. terials, good laboratory practices, assessment The department explained that stem cell of scientists involved in the technology, mon- research may employ either the autologous itoring of marketing and advertisements, and or allogenic method, and the various steps accreditation and regulation of centers. in the preparation necessitate a regulatory Regulatory processes will start once the le- framework to protect Filipino patients. gal and technical specifications have been re- Health secretary Dr. Enrique Ona has con- viewed by both the DOH and the task force. vened a task force to create recommendation At present, the public is strongly advised on how to apply stem cell therapy, ensuring to avoid therapies that use stem cells from quality, efficacy and safety documentation of embryoes, aborted fetuses, genetically altered this intervention. Members of the task force and animal fresh cells. 40 1-31 January 2013 Regional Filipino Sign Language module for health workers launched

Dr. James Salisi

ublic health workers in the Philippines P National Capital Region will soon be able to communicate with their deaf patients with the launch of the first Filipino Sign Language (FSL) module. The Center for Health Development Na- tional Capital Region director Dr. Eduardo Ja- nairo said the module will be used by health workers in understanding and communicating with patients with hearing disabilities. “Health workers will be educated and trained on the proper gestures and body movements illustrated in the module for them to be able to communicate properly with people worker, thereby minimizing the risk of errors who use sign language,” Janairo said. and inaccuracy in communication. The module introduces health worker to the “With this manual as a guide, we can ad- basic signs of communicating with deaf pa- dress the health inequities in our health care tients, like the alphabet, numbers, greetings, system and ensure persons with disabilities time, days, months, common questions asked (PWDs)the administration of accurate health in the emergency room, and using simple ges- care treatment. It is with optimism that this tures to talk with hearing-impaired patients. FSL module will pave the way for the adaption “We need to introduce FSL in our health of FSL as a second medium of communication care system and strengthen its use for the for the use of our Filipino Deaf community,” benefit of people who have difficulty hearing Janairo said. or speaking. Health workers will also benefit The FSL module was developed with the co- from using this module as it will enrich their operation and support of the Philippine Deaf knowledge, skills and awareness on the needs Resource Center, University of the Philippines- of people using FSL as their communication,” Philippine General Hospital, CAP College for Janairo explained. the Deaf, De La Salle University-College of The FSL module is designed to address the Saint Benilde and the Department of Educa- need to effectively communicate with deaf pa- tion-National Capital Region. tients. Proficiency in FSL enables health work- The number of Filipinos with hearing ers to give clear instructions about the services disabilities was pegged at 120,000 in the that they render to their hearing- and speech- 2000 Census on Persons with Disability. In impaired patients. 2004, 571 were registered with the National It also allows patients to disclose critical in- Region Registry on PWD with speech and formation about their condition to the health hearing impairment. 41 1-31 January 2013 Regional Operating room required for Level 1 hospitals

Dr. Nicolo Cabrera classified Level 1, 137 had no functioning operating rooms. Through the DOH he Department of Health (DOH) signed Health Facilities Enhancement Program, T the administrative order (AO) 2012-0012 PhP 2.3 billion has been earmarked for last July 18, 2012, requiring hospitals to have upgrading these district hospitals next an operating room to be classified as Level year to meet the current classification 1, conforming with Republic Act No. 4226 or scheme. the Hospital Licensure Act, that mandated all hospitals provide surgical and ancillary Data from March 2012 services. ‘‘ indicate that out of Under previous guidelines of the DOH, health facilities with functioning operating 283 district hospitals rooms were classified Level 2. Under the previously classified new AO, former Level 1 hospitals without Level 1, 137 had operating rooms will now be recognized as primary care facilities. A Level 2 hospital no functioning should possess Level 1 capacity with operating rooms departments for providing specialist care in medicine, surgery, pediatrics and obstetrics- gynecology. A Level 3 hospital should Health secretary Dr. Enrique Ona observed possess Level 2 capacity with a residency or that patients requiring surgical care who seek teaching program. health consult at some district hospitals often Apart from functional capacity (ie, Levels need to be referred to regional or provincial 1, 2 and 3), the AO also classifies hospitals hospitals. Efforts to upgrade district health in the Philippines based on ownership (ie, facilities will eliminate this referral and government or private) and scope of services ensure basic surgical problems would be (ie, general or specialized). Under the managed at the district level once properly previous classification scheme, 733 hospitals equipped. were owned by the government and 1,088 “With the new classification of hospitals were privately owned. Previously, 372 and other health facilities, we are ensuring government and 399 private hospitals were that all our hospitals have the minimum considered Level 1. capacity to render emergency surgical care, Data from March 2012 indicate that such as cesarean sections and appendecto- out of 283 district hospitals previously mies,” Ona said. 42 1-31 January 2013 International CABG more effective than PCI in older CAD patients

Rajesh Kumar

n patients with multivessel coronary artery disease, coronary artery bypass graft I(CABG) surgery was more effective in an older cohort, while percutaneous coronary intervention (PCI) was favored in a relatively younger one in a large analysis. Researchers pooled individual data from 7,812 patients who were randomized in 10 Researchers analyzed pooled data from 10 clinical trials involving patients who had undergone CABG or PCI. clinical trials of CABG or PCI to assess whether patient age modifies the comparative effective- Dr. Kenneth Ng Kwan Chung, cardiologist ness of those interventions. [J Am Coll Cardiol at Novena Heart Centre in Singapore, said in- 2012; 60:2150-2157] creasing age is known to be a risk factor for They analyzed age as a continuous vari- mortality and complications resulting from able in the primary analysis and divided it into CABG. three groups of ≤56.2 years, 56.3 to 65.1 years “Therefore in patients who are elderly, we and ≥65.2 years for descriptive purposes. The sometimes attempt to perform PCI on the ste- outcomes assessed were death, myocardial notic lesions rather than send them for surgery. infarction and repeat revascularization over However, this study points out that the older complete follow-up and angina at 1 year. Old- patients actually benefit more from CABG er patients were more likely to have hyperten- than PCI. It could be that older patients have sion, diabetes, and 3-vessel disease compared more diffuse disease than younger patients.” with younger patients (p=0.001 for trend). Ng said the findings are relevant for Asians as Over a median follow-up of 5.9 years, the we have a higher proportion of patients who are effect of CABG versus PCI on mortality- var diabetic, compared with Caucasians, and have ied according to age (interaction p=0.01), with a rapidly aging population in which ischemic adjusted CABG/PCI hazard ratios and 95 per- heart disease is the biggest cause of morbidity. cent confidence intervals of 1.23 (95% CI 0.95 to “The take home message for us is to explain 1.59) in the youngest group; 0.89 (95% CI 0.73 to the patients aged >59 years that CABG could to 1.10) in the middle group; and 0.79 (95% CI be a better option than PCI if they have triple 0.67 to 0.94) in the oldest group. vessel disease and diabetes. This is because The CABG/PCI hazard ratio was less than 1 of a 21 percent lower risk of cardiovascular for patients ≥59 years. A similar interaction of mortality in the >65 years age group in the age with treatment was present for the compos- study,” he said. ite outcome of death or myocardial infarction. “Also, there was no difference in compli- In contrast, patient age did not alter the com- cations between the PCI and CABG groups parative effectiveness of CABG and PCI on the in terms of death from the procedure and outcomes of repeat revascularization or angina. stroke.” 43 1-31 January 2013 International Blood protein resistin reduces statin effect in obese

Rajesh Kumar

anadian researchers have identified a Cprotein called resistin, secreted by fat tissue, as the cause of elevated low-density lipoprotein (LDL) in obese people. Their research, presented at the Canadian Cardiovascular Congress recently held in Toronto, Ontario, Canada, has shown that High resistin levels may attenuate the LDL cholesterol-lowering effects resistin increases the production of LDL in of statins. human liver cells and also degrades LDL receptors in the liver. As a result, the liver is less thereby increase the effectiveness of statins. able to clear LDL from the body. Dr. Goh Ping Ping, medical director of the Resistin also reduces the efficacy of statins, Singapore Heart Foundation, termed the re- so much so that a staggering 40 percent of pa- search findings as “progressive medical evi- tients taking statins cannot lower their blood dence” saying they reinforce the importance LDL, said senior author Dr. Shirya Rashid, of treating cholesterol levels to goal in order assistant professor in the department of med- to reduce cardiovascular risk. icine at McMaster University in Hamilton, “[But] this can be challenging in some Ontario, Canada. high-risk patients whose target cholesterol “The bigger implication of our results level has to be very low. Hence, we wel- is that high blood resistin levels may be come new developments in medical thera- the cause of the inability of statins to lower py to help patients reach their target levels patients’ LDL cholesterol,” said Rashid, add- safely,” said Goh. “As physicians, we need ing that the discovery could lead to revolu- to also continuously motivate patients tionary new therapeutic drugs, especially to exercise and adhere to a heart healthy those that target and inhibit resistin and diet.” 44 1-31 January 2013 International Bleeding rates with warfarin much higher in reality?

Elvira Manzano

he rates of major bleeding with warfarin use in atrial fibrillation (AF) may be Thigher than reported in clinical trials and are often fatal, new research suggests. A population-based study conducted in Canada involving 125,195 patients who started warfarin therapy after a diagnosis of AF showed an overall rate of hemorrhage of 3.8 Real-life bleeding rates associated with warfarin may be much higher than percent per person-year over a study period those reported in clinical trials. of 13 years. The risk of major hemorrhage (defined as a visit to an emergency department This prompted Gomes and colleagues or admission to hospital) was highest during to study the medical records of AF patients the first 30 days of treatment (11.8 percent (aged 66 years or older) who started warfarin per person-year). [CMAJ 2012;doi:10.1503/ therapy between April 1997 and March 2008. cmaj.121218] The cumulative incidence of hemorrhage The results were important as they re- was 4.1 percent at 1 year and 8.7 percent at flect the bleeding rates with warfarin in the 5 years. In total, 1,963 patients (18.1 percent) real world, said lead study author Assistant died in the hospital or a week after discharge. Professor Tara Gomes, of the University of Although the rate of intracranial hemorrhage Toronto in Ontario. “These rates are consid- was low in the study, it was associated with erably higher than the rates of 1 to 3 percent a high mortality rate (42 percent). As expect- per person-year reported in randomized con- ed, bleeding rates were higher in those with trolled trials of warfarin therapy.” a CHADS2 score of 4 or higher (16.7 percent The difference, she said, may be due to the per person-year) and in patients older than 75 strict inclusion criteria and close monitoring years (4.6 percent per person-year). of patients in clinical trials and the average “Our study provides timely estimates of age of participants in their study being older. warfarin-related adverse events that may be Warfarin helps prevent stroke and blood useful to clinicians, patients and policymak- clots in AF patients. However, it has a narrow ers as new options for treatment become therapeutic window (international normalized available,” Gomes said. ratio [INR] 3-4) and requires regular monitor- Doctors should know the potential for ing to minimize the risk of hemorrhage. bleeding in patients when starting them on Currently, there are no large trials offer- warfarin. However, the decision to shift to ing real-world, population based-estimates of new oral anticoagulants could not be made bleeding rates among patients on warfarin. on the basis of these data alone, she said. 45 1-31 January 2013 International Barrett’s esophagus linked to type 2 diabetes

Alexandra Kirsten

retrospective study has shown that patients with type 2 diabetes have A twice the risk of Barrett’s esophagus, a condition where the esophageal lin- ing becomes abnormal, whether or not other risk factors such as smoking or obesity were present. The findings were presented during the

American College of Gastroenterology’s 77th Patients with Barrett’s esophagus were also more likely to have smoked or Annual Scientific Meeting, held recently in consumed alcohol, and had a higher mean BMI than controls. Las Vegas, Nevada, US. [Abstract 49] To determine whether there is an asso- “Interestingly, we found that among the ciation between type 2 diabetes and Barrett’s study cohort, if you had diabetes there was esophagus, Dr. Prasad Iyer, associate profes- a twofold increase in your risk for Barrett’s sor of gastroenterology and hepatology at the esophagus,” Iyer said. “When we stratified Mayo Clinic College of Medicine in Roches- the results by gender, the association of type ter, Minnesota, US, and his fellow researchers 2 diabetes with Barrett’s esophagus was stron- conducted a population-based, case-control ger in males compared to females, which may study. reflect the different fat distributions in men They identified 14,245 patients with- Bar and women.” rett’s esophagus and 70,361 control subjects There is some evidence that central obe- who were matched for age, sex, enrolment sity is a risk factor for Barrett’s esophagus date, duration of follow-up, and practice re- and esophageal cancer through mechanical gion using the United Kingdom’s General or metabolic mechanisms, such as hyperin- Practice Research Database, a primary care sulinemia. The researchers suggested fat in database that includes over 8 million patients. the abdomen could be a reflux-independent The data showed that patients with Bar- mechanism leading to Barrett’s esophagus rett’s esophagus were more likely to have which is known to be a precursor of esopha- smoked and consumed alcohol, had a higher geal adenocarcinoma. body mass index, and a higher prevalence of ”If we find the precursor early enough, we type 2 diabetes than control subjects. could put these patients under surveillance Multivariate analysis showed a 49 per- or treat the precursor and reduce the risk,” cent increased risk for Barrett’s esophagus in Iyer said. He added that further prospective patients with type 2 diabetes. The link was studies are needed to better understand the stronger in men (OR, 2.03; 95% CI, 1.01 - 4.04) link between Barrett’s esophagus and type 2 than in women (OR, 1.37; 95% CI, 0.63 - 2.97). diabetes. 46 1-31 January 2013 International Elderly face higher hip fracture risk after starting BP drugs

Rajesh Kumar for ACE inhibitors (IRR, 1.53, 95% CI, 1.12 to 2.10) and β-blockers (IRR, 1.58, 95% CI, 1.01 lderly hypertensive patients may be at to 2.48). higher risk of hip fractures in the first Dr. Kenneth Ng Kwan Chung, cardiolo- E45 days after starting antihypertensive gist at Novena Heart Centre in Singapore, drug therapy, according to research. said physicians know that ACE inhibitors can Canadian researchers linked a cohort of cause first dose hypotension, especially in pa- 301,591 newly treated hypertensive rest home tients who are already on diuretics. But it is not residents (mean age, 81 years) to the records clear why β-blockers were also implicated in of 1,463 hip fractures between 1 April 2000 to the study. 31 March 2009. They analyzed the risk dur- “Elderly patients are more likely to have ing the first 45 days following therapy initia- sick sinus syndrome and β-blockers may tion, with equal control periods before and cause severe bradycardia and then fainting after that and a total of 450-day observation and falls [leading to fracture],” explained Ng. period. [Arch Intern Med 2012; doi:10.1001/2013. Asian patients are usually frailer and jamainternmed.469] smaller sized than their Western counter- The outcome was the first occurrence of a parts, which might make the effect of anti- proximal femoral fracture during the risk pe- hypertensive medications more marked in riod. The researchers found a 43 percent in- them, he said, adding that physicians should creased risk of having a hip fracture during the start with the lowest possible dose of one risk period compared with the control periods medication and first check for postural hy- (incidence rate ratio [IRR], 1.43; 95% confi- potension, particularly when starting ACE dence interval [CI], 1.19 to 1.72). inhibitors and β-blockers in elderly patients. Initiating antihypertensive drugs such as “Check the heart rate before starting thiazide diuretics, angiotensin II converting β-blockers…and educate the patient to get enzyme (ACE) inhibitors, angiotensin II re- up slowly out of the bed or chair. Wait for ceptor blockers (ARBs) or calcium channel any giddiness or instability to subside before blockers in the elderly is already associated taking the next few steps to walking. Ask a with an immediate increased risk of falls. The family member to watch over them when study sought to find out the immediate risk of they get up in the middle of the night,” said hip fracture. Ng. Adjusting for age and use of other medica- Patients could also monitor their blood tions implicated in falls, such as psychotropic pressure at home and send the readings to drugs, did not change the risk. The relation- their family doctor, who can then advise them ship was generally consistent for all classes of on the dose reduction or discontinuation of antihypertensive drugs (IRRs, 1.30 to 1.58), al- the medication if the blood pressure goes too though it reached statistical significance only low, he concluded. 47 1-31 January 2013 International Digoxin linked to raised mortality risk in patients with AF

Rajesh Kumar alternatives to digoxin as a first-line, such as β-blockers or calcium channel blockers, said hysicians should reassess the role of di- co-researcher Dr. Samy Claude Elayi, associ- goxin in the management of atrial fibril- ate professor of medicine at the Gill Heart In- Plation (AF) in patients with or without stitute, University of Kentucky in Lexington, heart failure (HF), experts warned following Kentucky, US. And if digoxin is used, use a study findings that link the drug to “a signifi- low dose with careful clinical follow-up, eval- cant increase in mortality” in such patients. uate potential drug interactions when start- Digoxin is widely used around the world ing new medications, and monitor plasma for the treatment of AF and HF. It is extracted digoxin levels, added Elayi. from the foxglove plant (digitalis) and helps “Patients should be aware of potential tox- the heart beat stronger and have a more regu- icity and see their physicians immediately in lar rhythm. However, it has a narrow thera- specific clinical situations, for instance if they peutic index beyond which it can be danger- experience palpitations or syncope, as those ous. may precede arrhythmic death,” he cau- Researchers analyzed data from 4,060 AF tioned. patients who had enrolled in the landmark AF- Until now, there have been limited data FIRM* trial to determine the relationship be- on the use of digoxin in AF patients as it has tween digoxin and deaths in this group. [Eur scarcely been studied in these patients. The Heart J 2012; doi:10.1093/eurheartj/ehs348] main prospective randomized controlled tri- Digoxin was associated with a 41 percent als involving the drug were performed in pa- increase in all-cause mortality (estimated haz- tients with HF and sinus rhythm, excluding ard ratio [EHR], 1.41, 95% confidence interval those with AF, said the researchers. (CI), 1.19 to 1.67, p<0.001], 35 percent increase The mechanism by which the drug increas- in cardiovascular mortality (EHR, 1.35, 95% es deaths among patients is unclear. Mortality CI, 1.06 to 1.71, p=0.016), and 61 percent in- from classic cardiovascular causes, whether crease in arrhythmic mortality (EHR, 1.61, due to arrhythmia or not, can partly but not 95% CI, 1.12 to 2.30, p=0.009). The all-cause entirely explain it. This suggests there must mortality was increased in patients with or be some additional mechanism that remains without HF (EHR, 1.37, 95% CI, 1.05 to 1.79, to be identified, they added. p=0.019 and EHR 1.41, 95% CI 1.09 to 1.84, “There is a need for further studies of the p=0.010, respectively). drug’s use, particularly in systolic HF and AF – The higher mortality remained even after patients that would, in theory, benefit the most controlling for other medications and risk fac- from digoxin,” concluded Elayi. tors, and regardless of gender. In view of these findings, we should try *AFFIRM: Atrial Fibrillation Follow-up Investigation of Rhythm to control a patient’s heart rate by using Management 48 1-31 January 2013 International Carb-heavy diet may lead to Alzheimer’s disease

Radha Chitale

carbohydrate-heavy diet nearly qua- druples the risk of cognitive decline, Awhich precedes neurological disorders, including Alzheimer’s disease, according to new research on macronutrient intake. In a population-based prospective cohort study of 1,233 adults whose median age was 79.5 years, dietary carbohydrates were correlated with the risk of developing mild cogni- The risk of MCI and dementia decreased tive impairment (MCI), dementia and other 42 percent in people with high total fat in- cognitive disorders over a median follow up take (>35 percent, P=0.03 for trend) and by period of 3.7 years while higher intakes of 21 percent in those with the highest protein protein and fat were somewhat protective. [J intake (>20 percent, P=0.03). Alzheimers Dis 2012;32:329-339] A total macronutrient comparison showed Subjects underwent cognitive testing that people who consumed the most carbo- at baseline and every 15 months to assess hydrates were 3.6 times more likely to suffer memory, executive function, language and MCI. visuospatial skills. Diagnostic tools included “A dietary pattern with relatively high the Clinical Dementia Rating scale and a full caloric intake from carbohydrates and low neurological examination. caloric intake from fat and proteins may in- Researchers also evaluated subjects’ diet, crease the risk of MCI or dementia in elderly including total daily caloric and macronutri- persons,” the researchers said. ent intake over the past 12 months. Diet analysis showed that people with In the 937-person study cohort who were high carbohydrate intake were consuming diagnosed as being cognitively normal at the most sugars and fruits (high in sugar) baseline, 200 developed incident MCI or de- without also eating more vegetables. These mentia over the follow-up period. people also had the lowest protein and fat After adjusting for demographic and life- intakes. style cofounders, including body mass index, Although appropriate amounts of carbo- type 2 diabetes, smoking, depressive symp- hydrates are necessary for brain function, the toms, and exercise, the risk of cognitive im- researchers suggested that habitual high glu- pairment increased in people with the high- cose consumption can disrupt glucose and est carbohydrate intake (>58 percent, P=0.004 insulin metabolism. High insulin levels may for trend). be detrimental to cognitive function and hy- 49 1-31 January 2013 International perglycemia, and diabetes may contribute to causal or alternately may be a marker for oxidative stress and increased formation of preclinical disease and risk of cognitive im- molecules associated with cognitive decline. pairment or dementia in elderly persons,” Fats and proteins are important for main- the researchers said. taining neurons, and thus neuronal activity, Prior studies have linked high sugar intake which could account for their protective ef- to Alzheimer’s disease, vascular dementia and fect on cognitive function and why insuffi- poor cognitive processing speed, reduced cal- cient intake could explain an increased risk orie intake to reduced cognitive impairment of MCI. and good glucose regulation to high cognitive “The dietary patterns observed may be performance. 50 1-31 January 2013 International Once weekly exercise enough to reduce GERD risk in obese

Rajesh Kumar pared with low physical activity (adjusted hazard ratio [HR] 0.41). Among the 2,146 bese individuals can reduce their normal-weight participants, a decreased risk risk of developing gastroesophageal of GERD was seen with higher physical ac- Oreflux disease (GERD) by exercis- tivity (HR 0.59), but the benefit was negated ing even if only once-a-week, according to a after adjusting for potential cofounders such Swedish study. as sleeping problems and high comorbidity. However, no such benefit from occasional A similar trend was seen in 1,859 overweight physical activity was seen in patients with nor- participants. mal body mass index (BMI). [World J Gastroen- The study’s limitations include an inherent terol 2012;28:3710-3714] uncertainty about the accuracy of self-report- Researchers randomly selected 4,910 peo- ed data and lack of validation of the assess- ple aged between 40 and 79 years from the ment of frequency of physical activity, BMI Swedish registry of the total population for and possible previous surgical interventions a cross-sectional survey. Data on their physi- for GERD, said the study authors. cal activity, GERD, BMI and the covariates Because it is a cross-sectional study, it is age, gender, comorbidity, education, sleep- not possible to know if the participants with ing problems, and tobacco smoking were ob- a self-detected association between reflux and tained using validated questionnaires. physical exercise may have changed their GERD was self-reported and defined behavior, resulting in reverse causality, they as heartburn or regurgitation at least once said. weekly, and the presence of at least moderate The current findings confirm the previous problems from such symptoms. Frequency of population-based studies assessing an asso- physical activity was categorized into high ciation between physical activity and GERD (several times/week), intermediate (approxi- within the general population. mately once weekly) and low (1-3 times a “However, none of the previous studies month or less). stratified analyses for BMI categories; mean- Analyses were stratified for participants ing that the decreased risk of GERD limited to with normal weight (BMI < 25 kg/m2), over- obese individuals is a first time observation,” weight (BMI 25 to ≤ 30 kg/m2) and obese (BMI said authors Dr. Therese Djärv and colleagues > 30 kg/m2). Obese participants were on aver- at the department of molecular medicine and age slightly older, had fewer years of educa- surgery, Karolinska Institutet in Stockholm, tion, more comorbidity, slightly more sleeping Sweden. problems, lower frequency of physical activity, Should the present results be confirmed in and higher occurrence of GERD. future research, the findings from this study In 680 obese individuals, intermediate fre- might be important for the prevention and quency of physical activity was associated treatment of GERD and its complications, with a decreased occurrence of GERD com- they concluded. Join the largest operator of Medical Centres in Australia. General Practice Opportunities in Australia are available

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Supporting Better Medicine www.ipn.com.au 52 1-31 January 2013 In Practice Managing COPD in primary care

Professor Neil Barnes Dr. Ong Kian Chung London Chest Hospital, President, Singapore COPD Association London, UK Mt Elizabeth Medical Centre, Singapore

Introduction creased neutrophils in sputum. Chronic obstructive pulmonary disease (COPD) is a chronic disease involving air- Diagnosis ways inflammation that affects about 5 per- Diagnosis of COPD is a two-step process. cent of the older population. The first is making a clinical diagnosis. A While cigarette smoking is the biggest GP should suspect COPD if a smoker or ex- risk factor, long-term exposure to indoor smoker complains of dyspnea, cough, fre- air pollution caused by burning of biomass quent chest infections and chronic sputum fuels, occupational dust and chemicals and production. But first, rule out other diseases underdeveloped lungs are among other con- including asthma, tuberculosis, congestive tributing factors. heart failure, obliterative bronchiolitis and Until recently, it was thought that only diffuse panbronchiolitis using differential 15 to 20 percent of cigarette smokers would diagnosis. eventually develop COPD at some stage in The second part of the diagnosis is equally their lives. It is now known that about half as important but happens rather patchily. It of smokers will develop this debilitating dis- consists of the need to confirm clinical diag- ease. By 2020, COPD will be the third lead- nosis by performing spirometry lung func- ing cause of death worldwide (after isch- tion test (LFT). It is a fairly simple procedure emic heart disease and stroke) and the sixth and doesn’t cost much. Still, many GPs don’t leading cause of disability. use it. That’s akin to managing someone In many countries, COPD exacerbations with hypertension without measuring their are now either the most common or second blood pressure. most common reason for hospitalization In spirometry, more than 80 percent of the with an identifiable medical condition. The values of forced expiratory volume in one situation is likely to get worse due to an ag- second (FEV1), as predicted on the basis of ing population. That puts general practice an individual patient’s age, sex and ethnicity, in an even more important position to diag- will classify them as having a mild COPD, nose the patients before their lung function whereas 30 to 50 percent of predicted FAV1 deteriorates irreversibly. indicates severe disease. A FEV1 of less than COPD is characterized by increased CD8+ 30 percent of the predicted value suggests a T cells and macrophages in biopsies, and in- very severe COPD. 53 1-31 January 2013 In Practice

While confirming the COPD diagnosis, the level of lung function also tells you some- thing about their likelihood of problems in the future. The worse their lung function, the more likely they are to run into other health problems in the future.

Practice guidelines The revised “Global initiative for chronic Obstructive Lung Disease (GOLD)” guidelines define two separate aims in COPD The two main aims of COPD management should be to reduce a patient’s management: symptom reduction and risk symptoms and their risk of disease progression. reduction. The COPD Assessment Test (CAT) is an persistent airflow limitation. Patients with a 8-point unidimensional measure of health sta- history of 2 or more exacerbations per year tus impairment. The score ranges from 0 to or very severe airflow limitation belong to 40. A score of more than 10 indicates a “more the high risk groups C or D. symptomatic” patient who should be placed into B or D groups of the assessment chart. Treatment The 0-4 point modified British Medical Treatment strategy for COPD is similar to Research Council (mMRC) dyspnea scale ischemic heart disease as it uses a range of also helps understand the level of breath- different drug and non-drug therapies such lessness (see Figure). as smoking cessation, lifestyle changes, flu The assessment of risk can either be done vaccination to help prevent chest infections, using the FEV1/FVC (forced vital capacity) pulmonary rehabilitation, and drug therapy. ratio with spirometry, using 1-4 GOLD clas- The latter includes short and long acting β2- sification of airflow limitation or it canbe agonists (SABA/LABA) and muscarinic an- based on the number of exacerbations the tagonists (SAMA/LAMA), inhaled cortico- patient has had during the past year. Post steroids (ICS), phosphodiesterase-4 (PDE-4) bronchodilator FEV1/FVC of <0.70 confirms inhibitors and long-acting anticholinergics such as tiotropium that are commonly recom- Figure: Assessment of COPD mended in varying combinations, depending on the disease severity. 4 2 or Patients with COPD are at high risk of de- (C) (D) more 3 veloping other comorbidities such as cardiovascular disease, osteoporosis, depression and

Risk 2 Risk anxiety, skeletal muscle dysfunction, metabolic Less (A) (B) than 2 (Exacerbation history) syndrome and lung cancer that can have a sig- 1 nificant impact on their prognosis. Depending

(Gold Classification of Airflow Limitation) (Gold Classification of mMRC 0-1 mMRC ≥2 CAT <10 CAT ≥10 on their clinical condition, the GOLD guidelines Symptoms (mMRC or CAT score) recommend that an appropriate fluid balance 54 1-31 January 2013 In Practice with special attention to administration of di- Compliance uretics, anticoagulants, and treatment of comor- Compliance with drug or non-drug ther- bidities and nutritional deficiencies should be apies can be a challenge. A good doctor- considered. patient relationship can, however, help im- COPD exacerbations deteriorate quality prove compliance. If patients feel that the of life, reduce lung function that becomes ir- doctor has listened to them and that the reversible in many patients, lead to avoidable treatment addresses their needs, they are hospitalizations and death. Although frequent more likely to stick to the drug and non- exacerbations amount to two or more breath- drug treatment regimen. A simple drug ing attacks in a year, each patient needs tobe regimen also helps. If patients are required judged individually. If someone ends up in a to take multiple medications at different hospital just once with a really bad exacerba- times of the day, they have more chances to tion, that should be taken as a red flag from the slip up. risk reduction point of view. One of the problems with COPD patients Emphasis on risk reduction is, in fact, the is that they begin to exercise less because most important change over the previous they easily get short of breath. And because GOLD guidelines. Just as in the management they exercise less, they end up develop- of ischemic heart disease you want to stop your ing other health problems. That’s why it is patients having angina and chest pain, but also important to recommend physical activity want to stop them from having a myocardial at an early stage of COPD. The more they infarct. That concept is familiar to most general keep themselves active, the better it will be practitioners because it is how they approach not just for their COPD symptoms, but also the treatment of other chronic diseases. for other associated chronic diseases.

The aims of COPD management Reduce symptoms: Relieve symptoms, improve exercise tolerance, improve health status Reduce risk: Prevent disease progression, prevent and treat exacerbations, reduce mortality

Online Resources: GOLD guidelines www.goldcopd.org Improving the Differential Diagnosis of Chronic Obstructive Pulmonary Disease in Primary Care www.goo.gl/ZraLr American Lung Association www.lung.org/lung-disease/copd/ 55 1-31 January 2013 In Practice Sacroiliac joint dysfunction

roiliac joint is a true diarthrodial joint, with the concave sacral surface covered with thick Dr. Eugene Wong hyaline cartilage and the convex iliac surface Consultant Orthopedic & Spine Surgeon Adjunct Assistant Professor covered with fibrocartilage. Perdana University Graduate School of The sacroiliac joint may fail because of Medicine Serdang, Selangor congenital malformation, increased stress due to lumbar fusion surgery, direct trauma or overuse. Other causes of sacroiliac joint acroiliac joint dysfunction is a term pain include infection, limb length discrep- used to describe pain in or around the ancy, scoliosis, rheumatoid arthritis, gout, Sjoint that is presumed to be due to ma- psoriasis and osteoarthritis. Multiple preg- lalignment or abnormal movement of the nancies may increase the risk of arthritis in sacroiliac joint. the joint later in life. Sometimes, the cause The sacroiliac joint as a painful entity was of the pain is unknown even after extensive first described in 1905 by Goldthwait and investigations. Osgood. [Boston Med Surg J 1905;152:593- Pathology in the sacroiliac joint causes re- 601] The belief that the sacroiliac joint can ferred pain to a wide area. (Figure 1) Clinical be a source of low back pain has waxed and tests can be grouped into pain provocative waned throughout the 20th century. The lack tests, palpation tests and motion demand of awareness of the joint as a pain genera- tests. Pain provocative tests include Patrick’s tor has contributed to diagnostic uncertainty test (77 percent sensitivity, 100 percent speci- and resulted in few available treatment op- ficity) and the thigh thrust test (80 percent tions to address resultant pain. sensitivity, 100 percent specificity). [J Spinal Up to 25 percent of patients presenting Disord 1998;11:341-5] to a spine clinic for low back pain have sig- Palpation tests include the midline sacral nificant contribution from the hip or sacroil- thrust test (89 percent sensitivity, 14 percent iac joints. [Anesth Analg 2005;101(5):1440-53] specificity) [Spine 1996;21:2594-602] Motion The sacroiliac joint is a contributing factor in demands tests consist of sitting tolerance (78 failed back surgery syndrome in 29 to 40 per- percent sensitivity, 58 percent specificity). cent of cases. Clinical examination cannot definitely con- The sacroiliac joints are weight-bear- firm that the sacroiliac joint is the source of ing joints located between the hips and the pain. spine, and they are susceptible to wear and Clinical findings include pain in there tear. There is sliding movement of a few mil- gion of the sacroiliac joint. Stressing the sac- limeters, tilt and rotation of 3°. The function roiliac joint reproduces the patient’s pain of the sacroiliac joints is to allow torsional or and injection of local anesthetic into the joint twisting movements when we move our legs. completely relieves the pain. The primary Without the sacroiliac joints and the pubic reason for sacroiliac joint injections is to de- symphysis (at the front of the pelvis), which termine whether or not the sacroiliac joint is allow these small movements, the pelvis the cause of the pain. It is useful in provid- would be at higher risk of fracture. The sac- ing immediate pain relief for some period 56 1-31 January 2013 In Practice of time. The gold standard for diagnosis is regular state through controlled distraction. intraarticular injection of the sacroiliac joint, This process is called ‘ligamentotaxis.’ which relieves the pain. Bone is then added to ensure solid and per- Imaging can be done using plain radio- manent immobilization of the joint after the graphs, computed tomography (CT) scans healing phase is complete. Patients can walk and magnetic resonance imaging (MRI) with crutches and activity is limited to par- scans. The joint is difficult to profile well tial weight bearing on the affected side for on radiographic views and, therefore, ra- the first 6 weeks. diographic findings of sacroiliitis are often Patients do not suffer stiffness in the tradi- equivocal. CT images can usually show the tional sense or increased stress in the untreated findings of sacroiliitis and osteoarthritis ear- sacroiliac joint. Bilateral fusion is unusual and lier than radiographs. MRI can reliably de- usually occurs in cases of increased stress from tect inflammation and structural changes in fused lumbar discs (especially multilevel) or a sacroiliac joints in patients with early inflam- congenital anomaly. The results of the surgery matory back pain. are encouraging. Experience shows that it pro- The first line of treatment often includes vides a reliable method of stabilizing the joint pain and anti-inflammatory medication to and treating sacroiliac pain. reduce the swelling that is usually contribut- The sacroiliac joint is a neglected cause of ing to the pain. An initial short period of rest low back pain. The pain referral zones are will help decrease inflammation and relieve wide. The gold standard test for diagnosis of muscle spasm. Some patients benefit from intraarticular sacroiliac pain is an intraartic- wearing a sacroiliac belt. Rehabilitation ex- ular injection of a local anesthetic. Radiofre- ercises may be performed. quency neurotomy can be used to ablate the These include hamstring stretch, quad- sensory pain fibers. Fusion is a last option riceps stretch, hip adductor stretch, knee to in managing pain arising from the sacroiliac chest stretch and gluteal sets. Radiofrequen- joint. cy ablation can be done to ablate pain fibers to the sacroiliac joint. This destroys any sen- Table 1: Sacroiliac joint pathologies. sation coming from the joint and its effect • Intraarticular sources: spondyloarthropa- can last for up to 2 years. thies, osteoarthritis, infection, metabolic. Fusion may be done in cases of severe • Extraarticular sources: ligamentous pain not responding to non-operative man- sprain, sacroiliac joint fractures, insuffi- agement. Several methods of fusion have ciency fractures, ligamentous, tendinious been used including anterior, transgluteal, and fascial attachment. through the iliac bone or a posterior ap- • Sacroiliac joint dysfunction: postpartum, proach. limb length discrepancy, repetitive minor The posterior approach from near the mid- trauma. line has been shown to need a very small in- • Infection: hematogenous. cision, but at the same time offering a better • Spondyloarthropathies: ankylosing spon- anatomic approach and good visualization of dylitis, Reiter’s. the sacroiliac joint. In this new procedure, an • Degenerative arthritis implant is inserted via a small incision (3 cm) • Post-traumatic arthritis: insufficiency using special instruments that approximate factures, major trauma. the ligaments of the pelvic girdle back to their • Previous spinal surgery: lumbar fusion. 57 1-31 January 2013 In Practice

• Metabolic and endocrine disorders: crys- • Aberrant gait tal induced joint disorders, hyperparathy- • Hip joint disorders roidism. • Primary tumors: chondrosarcoma, giant Table 3: Diagnostic criteria for idiopathic cell tumors. intraarticular sacroiliac joint pain. • Mets to pelvis • No neurologic deficits • Idiopathic • No laboratory, imaging or clinical evidence of medical causes of sacroiliac joint pain. Table 2: Differential diagnosis of sacroiliac • Maximal pain below L5 joint pain. • No evidence of lumbar pain generators • Spinal disorders (if indicated, maximally secured with • Non-spinal disorders: negative zygapophyseal joint blocks and • Gastrointestinal discography). • Genitourinary • At least 75 percent relief with controlled, • Pubic symphysis motion fluoroscopically guided, contrast-enhanced • Myofascial imbalances intraarticular sacroiliac joint injections.

Figure 4. Sacroiliac joint injection Figure 1. SI joint pain referral areas

Figure 5. Radiofrequency Figure 6. Distraction interference arthrodesis of neurotomy of lateral branch the SI ioint Figure 2. SI joint arthritis of S1 and S2 dorsal rami

Figure 3. Sacroilitis Figure 7. Postop CT scan of SI joint fusion 58 Industry Update

Hypoglycemia in T2DM negatively impacts outcomes and QoL

ypoglycemia remains one of the major sodes of depression and a lower quality of life. problems affecting people with type 2 Patients with hypoglycemic symptoms were Hdiabetes and negatively impacts their more likely to experience depression and felt quality of life, say two experts in diabetology. more pain and discomfort in their daily lives. Dr. Chan Siew Pheng, a consultant endo- [Diabetes Res Clin Pract 2012;96(2):141-8] In crinologist, said while hypoglycemia is a com- preventing hypoglycemia, Chan said incretin- mon condition facing many type 2 diabetic based treatments (such as sitagliptin [Janu- patients, there are two severe and potentially via®, MSD]) offer the advantage of not causing life-threatening types: in the first, the person hypoglycemia . has a blood glucose level below 2.8 mmol/L, requires assistance of any kind, and recovers More benefits emerging with incretin- after consumption of carbohydrates: in the based therapies second, the person requires medical assistance Dr. Edward S. Horton, a professor of medi- in the hospital setting. [BMJ 2010;340:b4909] cine at Harvard Medical School, was also pres- The risk of severe hypoglycemia increases ent to discuss developments in incretin-based as the diabetes treatment is intensified, as treatments. Incretins, which include both di- shown by three landmark glucose control trials peptidyl peptidase-4 (DPP-4) inhibitors and – ACCORD1, ADVANCE2 and VADT3. Chan said glucagon-like peptide-1 (GLP-1) agonists, the trials arrived at consistent findings – that do not cause hypoglycemia because of their severe hypoglycemia is linked to an increased mechanisms of action. This trait of incretins is risk of cardiovascular events. [New Engl J Med very important, said Horton, because major di- 2010;363:1410-8, N Engl J Med 2008;358:2545- abetes treatment guidelines all advocate that 59, N Engl J Med 2009; 360:129-39] “According each individual patient achieve a “blood glu- to the ADVANCE study, those who experienced cose level that is as close to normal as possible hypoglycemic events are 3.5 times more likely without significant hypoglycemia.” than those without hypoglycemic events to The incretin effect refers to the elicited re- suffer from a major macrovascular event. In sponse of increased insulin secretion after fact, all-cause mortality was increased in all food consumption. It also encompasses the in- cases [of those who experienced severe hy- hibition of glucagon secretion from alpha cells. poglycemia].” The three landmark studies con- Both of these effects are achieved in a glucose- cluded that while glucose control is important, dependent manner. “At high concentrations, hypoglycemia should be avoided. incretins also delay gastric emptying and also In the RECAP-DM Asia study, which she col- affect the central nervous system to suppress laborated in, it was also shown that patients appetite and create a sense of satiety,” said who experienced hypoglycemia had more epi- Horton. With regards to sitagliptin, he said the 59 Industry Update

drug also causes fewer side effects than met- livered and very well tolerated compared with formin and sulphonylurea whilst achieving GLP-1 agonists, which are associated with similar glucose control with monotherapy. nausea and vomiting. Additionally, current Horton said there is now evidence to sug- GLP-1 agonist formulations are only available gest that keeping GLP-1 levels high (through as injectables, while DPP-4 inhibitors are oral- the use of incretins) could be therapeutic in ly delivered. cardiovascular patients as GLP-1 receptors can Horton noted that although all DPP-4 inhib- be found in the vascular endothelium, vascu- itors work in the same way, they are metabo- lar smooth muscle and cardiac muscles. [Br J lized differently. Hence, the patients’ renal and Pharmacol 2009;157(8):1340-51] Furthermore, liver status have to be considered when choos- incretins have been shown to be neuropro- ing a suitable DPP-4 inhibitor. tective, although this has only been demon- 1. ACCORD : Action to Control Cardiovascular Risk in Diabetes strated in animal models. [Biochem Soc Trans 2. ADVANCE : Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation 2011;39(4):891-7] 3. VADT : Veterans Affairs Diabetes Trial 4. RECAP-DM : Real-Life Effectiveness and Care Patterns of Diabetes management in Horton said DPP-4 inhibitors are orally de- Asia-Pacific

61 1-31 January 2013 Calendar

MALAYSIA EVENTS

January May

Medication Error Conference 2013 National Regulatory Conference 2013 22/1 to 23/1; Kuala Lumpur 7/5 to 9/5; Kuala Lumpur Info : Pei Wan www.bpfk.gov.my Tel : (03) 6211 7009 /9008 /9002 Fax : (03) 6211 9003 Email : [email protected] June www.aep.com.my

8th Asean Conference On Primary Health Care 7/6 to 9/6; Ipoh February Info : Secretariat Tel : (05) 242 6549 Email : [email protected] Malaysian Society of Hypertension 10th Annual Scientific www.pmps.org.my Meeting 1/2 to 3/2; Kuala Lumpur 4th National Diabetes Conference Info : Secretariat Tel : (03) 7948 1888 14/6 to 15/6; Kuala Lumpur Fax : (03) 7948 1818 Info : Ms. Parameas Email : [email protected] Tel : (03) 7957 4062 /4063 [email protected] Fax : (03) 7960 4514 Email : [email protected] www.diabetes.org.my

April 6th National Conference for Clinical Research 18/6 to 23/6; Kuching 9th Asian Society for Paediatric Research Info : Amy Yu Bee Ling 18/4 to 21/4; Kuching Tel : (03) 4043 3809 / : (016) 263 2818 Info : Ms. YM Kong Fax : (03) 4043 3808 Tel : (03) 4023 4700 Email : [email protected] (03) 4023 5700 www.acrpm.com.my Fax : (03) 4023 8100 Email : [email protected] th www.aspr2013.org 12 Asean and Oceanic Society of Regional Anaesthesia & Pain Medicine Congress WOOMB International Conference 19/6 to 22/6; Kuching 26/4 to 28/4; Kuching Info : Secretariat Info : Dr. Chan Lek-Lim Tel : (03) 4023 4700 (03) 4025 4700 Tel : (013) 810 7004 (03) 4025 3700 (082) 423 226 Fax : (03) 4023 8100 Fax : (082) 578 682 Email : [email protected] Email : [email protected] www.aosra2013.org [email protected] [email protected] www.thebillingsovulationmethod.org 62 1-31 January 2013 Calendar

10th Liver Update September 20/6 to 23/6, Kuala Lumpur Info : Secretariat th Tel : (03) 7842 6101 9 Combined Pediatric & Spine Congress Fax : (03) 7842 6107 1/9 to 4/9; Kuching www.liver.org.my Info : Ms. Marianne Yee Tel : (65) 6410 9698 Fax : (65) 6372 1793 Email: [email protected] July www.apoa-home.org

International Conference on Cognitive Science 1/7 to 4/7; Kuching Info : Ms. Oon Yin Be October Tel : (012) 881 6681 Email: [email protected] World Conference on Chemical and Laboratory Safety in www.fcshd.unimas.my Science and Industry 3/10 to 5/10; Kuching Asia Pacific Rim International Counseling Conference Info : Scott Campbell 6/7 to 8/7; Kuching Tel : (082) 230 597 Fax : (082) 230 609 Info : Ms. Alvis Ng Email: scampbell@researchand Te : (03) 7982 4424 intelligence.com Fax : (03) 7980 3841 www.labsafetyinstitute.org Email: [email protected] www.asiapacificrimcounselling.com

August 2014 June 9th Combined Congress of the Spine and Paediatric Sections (APOA) Asia Pacific Regional Conference of the World 29/8 to 31/8; Kuching Organization of Family Doctors (WONCA) - TBC Info : Secretariat 1/6 to 4/6; Kuching Tel : (03) 402304700 http://wonca-asiapacific.org (03) 4025 4700 (03) 4025 4700 Fax : (03) 03) 4023 8100 Email: [email protected] www.apoa2013.org

READ JPOG ANYTIME, ANYWHERE. Download the digital edition today at www.jpog.com 63 1-31 January 2013 Calendar

INTERNATIONAL EVENTS

February June

Asia Pacific Society of Cardiology (APSC 2013) Congress World Congress of Nephrology 2013 21/2 to 24/2; Pattaya, Thailand 31/5 to 4/6; Hong Kong Info :Secretariat Info :Secretariat Email :[email protected] Email :[email protected] www2.kenes.com/apsc2013/Pages/Home.aspx http://www.wcn2013.org/

23rd Conference of the Asian Pacific Association for the March Study of the Liver 6/6 to 9/6; Singapore 62nd American College of Cardiology (ACC) Annual Info :Secretariat Scientific Session Email :[email protected] www.apaslconference.org 9/3 to 11/3; San Francisco, US Info :Secretariat Email :[email protected] 2013 Annual Meeting of http://accscientificsession.cardiosource.org/ACC.aspx American Society of Clinical Oncology (ASCO) 31/5 to 4/6; Chicago, US Info :Secretariat April http://chicago2013.asco.org/

European Congress on Osteoporosis and Osteoarthritis (ECCE013-IOF) 17/4 to 20/4; Rome, Italy Info :Secretariat Email :[email protected] http://www.ecceo13-iof.org/ Publisher : Ben Yeo Korea : Choe Eun Young Tel: (822) 3019 9350 Managing Editor : Greg Town Email: [email protected]

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Hepatology Tan Sri Dato’ Seri Dr. Mohd Ismail Merican

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Radiology Prof. Dr. John George FRCR (UK) University Malaya Medical Centre

Orthopedic & Dr. Eugene Wong Spine Surgery iHEAL Medical Centre