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April 2012 www.medicaltribune.com Bone screening recommended for heart failure patients     HONG KONG FOCUS
April 2012 www.medicaltribune.com Bone screening recommended for heart failure patients     HONG KONG FOCUS
April 2012 www.medicaltribune.com Bone screening recommended for heart failure patients     HONG KONG FOCUS
April 2012 www.medicaltribune.com Bone screening recommended for heart failure patients     HONG KONG FOCUS
April 2012 www.medicaltribune.com Bone screening recommended for heart failure patients     HONG KONG FOCUS

April 2012

April 2012 www.medicaltribune.com Bone screening recommended for heart failure patients     HONG KONG FOCUS

www.medicaltribune.com

Bone screening recommended for heart failure patients

Bone screening recommended for heart failure patients     HONG KONG FOCUS FORUM ESRD patients
 
   
 
   

HONG KONG FOCUS

FORUM

ESRD patients shifting towards home dialysis Diagnostics for the developing world

ESRD patients shifting towards home dialysis

ESRD patients shifting towards home dialysis Diagnostics for the developing world

Diagnostics for the developing world

 
   
 
   

CONFERENCE

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Psoriasis studies show link with stress Overeating doubles risk of memory loss

Psoriasis studies show link with stress

Psoriasis studies show link with stress Overeating doubles risk of memory loss

Overeating doubles risk of memory loss

 
   
 
   

ACUTE CORONARY SYNDROME

of memory loss     ACUTE CORONARY SYNDROME Cangrelor BRIDGE to cardiac surgery for at-risk patients

Cangrelor BRIDGE to cardiac surgery for at-risk patients

IN PRACTICE

ACUTE CORONARY SYNDROME Cangrelor BRIDGE to cardiac surgery for at-risk patients IN PRACTICE Management of endometriosis

Management of endometriosis

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3 April 2012

April 2012

Bone screening recommended for heart failure patients

Rajesh Kumar

recommended for heart failure patients Rajesh Kumar A large survey of more than 45,000 adults showed

A large survey of more than 45,000 adults showed that heart failure was associated with a 30 percent raised risk of major bone fractures.

association (HR 1.33, 95% CI 1.11-1.60) nor did further adjustment for total hip BMD (HR 1.28, 95%CI 1.06-1.53). Osteoporosisandheartfailure are common, chronic and costly conditions that share com- mon etiologic factors such as older age, post- menopausal status and diabetes. Previous studies have suggested that heart failure may predispose a patient to fractures not only because it increases incidence of falling, but because both heart failure itself and its medi- cal treatments can lead to loss of bone mass. “Understanding the mechanism between heart failure and osteoporosis might lead to new treatments for both conditions… Heart failure should be treated as a stronger risk fac- tor for fracture, just as the classic risk factors such as prior fracture and family history.” Part of screening for osteoporosis should involve looking at chest X-rays of patients with heart failure, said Majumdar. “Heart failure patients get a lot of X-rays and they often incidentally show many frac- tures of the spine that would automatically provide an indication of severe osteoporosis

and need for treatment.”

indication of severe osteoporosis and need for treatment.” R esearchers are recommending that patients with heart

R esearchers are recommending that patients with heart failure be aggres-

sively screened for osteoporosis and bone fractures. In their study, which analyzed data from 45,509 adult subjects undergoing bone min- eral density (BMD) testing over a 10-year period, the presence of heart failure was associated with a 30 percent increase in major fractures independent of traditional risk fac- tors and BMD. “Our study demonstrates for the first time that heart failure and thinning of bones go hand in hand,” said lead author Dr. Sumit Majumdar of the University of Alberta in Edmonton, Canada. The findings are relevant for Asians, partic- ularly for Chinese and Japanese populations in which rates of osteoporosis and fracture are higher than those seen in other ethnic groups, said the researchers. Of those included in the analysis, 1,841 (4 percent) had recent-onset heart failure. Subjects with heart failure were significantly older (74 vs 66 years), had more previous frac- tures (21 percent vs 13 percent), and lower total hip BMD than those without heart failure (T-score -1.3 vs -0.9). [JCEM 2012; 11:3055-R2] Over an initial 5-year observation period, 2,703 fractures were reported. Overall, 10

percent of heart failure subjects had major fractures compared with 5 percent of those without (unadjusted hazard ratio [HR] 2.45, 95% CI 2.11-2.85). Adjustment for osteopo- rosis risk factors, comorbidities, and medi- cations weakened but did not eliminate this

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5 April 2012 Forum

April 2012

Forum

Diagnostics for the developing world

Based on a lecture by Professor Jon Cooper, chair of bioengineering at the University of Glasgow in Scotland, UK, organized by the British High Commission in Singapore recently under the auspices of the UK-Singapore Partners-in-Science program.

D eveloping world diagnostics is an excit- ing new area. There is obviously the

humanitarian aspect of it in terms of doing better for the world. But it also has some very challenging engineering aspects. In low income countries, 40 percent of people die before the age of 14, whereas in high income ones, 70 percent will sur- vive beyond the age of 70. Most prevent- able deaths in poor countries occur due to five major diseases: tuberculosis, malaria, pneumonia, rotavirus and HIV. These diseases are responsible for 7.5 million worldwide deaths annually. At the University of Glasgow, we are working on the development of quick and cheap diagnostic tests, not only for the major diseases such as malaria and tuberculosis, but also for many of the so called neglected diseases – lymphatic fil- ariasis, trachoma, leishmaniasis, bilhar- zias (schistosomiasis), sleeping sickness, river blindness, Chagas disease, leprosy and hookworm disease – that massively impact the lives of millions. Several global health organizations, along with the UK and US governments, the Bill and Melinda Gates Foundation, and some pharmaceutical companies, recently pledged to combat 10 such neglected trop-

ical diseases over the next decade. They aim to eliminate these diseases through a dramatic increase in drugs and treatment programs in the affected countries. I think low cost diagnostic technologies will also

I think low cost diagnostic technologies will also play a key role in this initiative. Technologies

play a key role in this initiative. Technologies that are currently avail- able in the developing world tend to be fairly simple. Malaria tests, for example, typically involve a blood smear, a stain, and a microscope to look for the plasmo- dium within the red blood cell. To diag- nose sleeping sickness, the demands for detection are acute because of a very low level of parasitemia (perhaps less than one parasite per 100 million blood cells). The diagnostic test needs to be able to detect it, and that’s quite demanding. Currently, countries in East and Sub- Sarharan Africa (where sleeping sickness is a problem) have a basic chromatographic exchange column that is used to selectively concentrate the parasites before they are observed under a microscope. That might sound like a very successful technique and it

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6 April 2012 Forum

April 2012

Forum

works pretty well. But the columns are made locally and their availability is sporadic. The technological challenges for devel- oping diagnostics for sleeping sickness are also manifold. The tests need to have a sen- sitivity of at least 1 to 100 million or should have the capacity to detect a very small number of parasites against a very large background. They should be able to be delivered in places where power and infra- structure is non-existent and they should be very inexpensive. The tests should also work under severe ambient conditions, should be easy to use, and be able to han- dle blood, urine or saliva samples. The requirement is not just to detect the infection. Due to growing problem of drug resistance, the tests need to be able to see if the bacteria or parasite will respond to commonly used drugs, so we know which drug to give to patients to treat them suc- cessfully. These latter assays require the testing of DNA using a nucleic acid test. Several new technologies are already under development involving the use of mobile phones as microscopes and ultra low-cost amenable paper microfluidics- based tests. At the University of Glasgow, we are also interested in the use of mobile phones in diagnostics. In Africa, there are half a billion mobile phones – from the latest 3G ones to those that are 10 to 15 years old with basic functions. All of them have a bat- tery. We see them more as a source of rechargeable power supply for very low powered diagnostic tests. For diagnostic tests for malaria, sleeping sickness and tuberculosis, we are looking at the use of acoustics and dielectrophoresis for sepa- ration and sensing.

Surface acoustic wave technology is common in mobile phones. In diagnostics, when you put fluid in the path of those acoustic waves, the interface between the chip, the air and the liquids creates the con- ditions necessary to separate the sample into its different components for diagnosis. For malaria, we take a blood sample, per- form a lysis and use PCR amplification and detect the DNA. In 15 minutes, we can run 30 PCR cycles which provides clear signals at 0.07 percent of parasitemia (equivalent of 10 parasites in a finger prick of blood). There is possibility of using this test either for testing for drug resistant malaria (an emerging problem in northern Thailand) or for multiplexed analysis for malaria, tuber- culosis and pneumonia on the same chip. It can also check whether the parasite is resistant to drugs. In dielectrophoresis, particles includ- ing cells become polarized within electric fields and we are looking at how we can induce these electric fields optically using a very low power technique. That essen- tially works on the basic principle that manipulation of electric charges gives rise to a force. The cells move within the elec- tric field based on the magnitude of the force being exerted and result in blood moving in one direction and trypano- somes in another. We then use a simple algorithm to detect the enriched parasites in the sample. The challenge for us is testing and delivering these assays at a low cost. Demonstrating that we can now imple- ment technologically advanced assays into very low cost formats, such as those being developed in paper based Lab-on-a-chip is perhaps the most significant engineering

challenge we face.

such as those being developed in paper based Lab-on-a-chip is perhaps the most significant engineering challenge
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8 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

Aspirin safe for hemorrhagic stroke patients

Naomi Rodrig

A spirin use in Chinese patients who had a previous intracranial hemor-

rhage (ICH) does not increase the risk of recurrent ICH, a University of Hong Kong (HKU) study found. [Thromb Haemost

2012;107:241-247]

“Aspirin is often considered unsafe because of the associated bleeding risk, particularly for patients who have had a previous ICH,” said lead study author, Dr. David Siu of the Department of Medicine. “This presents a treat- ment dilemma because many patients with previous ICH are also at risk of cardiovascular disease [CVD] and still require aspirin for CVD prevention.” The observational retrospective study, conducted from May 1996 to February 2010, included 440 consecutive patients who presented with a first spontaneous ICH and survived the first month. Patients with ICH secondary to trauma, arterio- venous malformation, aneurysm, tumor, hemorrhagic transformation or ischemic stroke were not included in the study. Patients’ clinical characteristics, anti- platelet therapy after ICH, and outcomes of subsequent events (recurrent ICH, ischemic stroke, acute coronary syn- drome or death) were obtained from hos-

pital records. Of the 440 patients, 56 patients (12.7 percent) were prescribed aspirin. After an average follow-up of 5 years, 47 patients (10.7 percent) had recurrent ICH. “Patients prescribed aspirin did not have a higher risk of recurrent ICH

compared with those not prescribed aspi- rin (22.7 patient-aspirin years vs 22.4 per 1,000 patient-aspirin years; p=0.70),” the authors wrote. A multivariate analysis of the data fur- ther identified age >60 years and hyper- tension as independent predictors for recurrent ICH (hazard ratio=2.0 for both). A subgroup analysis of 127 patients with standard indications for aspirin use (atrial fibrillation, coronary artery disease and/or ischemic stroke) found that ICH recurrence rate among the 56 patients who were actually prescribed aspirin was similar to that for patients who did not receive aspirin (2.3 vs 2.2 percent per year). “In fact, the protective effect of aspirin was confirmed, as there was an overall 50 percent reduction in stroke and heart attack in the aspirin group compared with the non-aspirin group,” noted Dr. Jenny Pu of the Department of Surgery. “Our results reveal that aspirin is not a risk factor for developing recurrent ICH. Aspirin is protective against ischemic events and clinicians should consider pre- scribing it to Chinese patients with stand- ard indications despite a history of ICH,” advised Siu. Approximately 20,000 people in Hong Kong experience stroke every year. The high rate of hemorrhagic stroke among Chinese as compared with Caucasian pop- ulations (35 vs 15 percent of all strokes) further underscores the importance of the study results, indicating that aspirin can be used safely to protect ICH patients

from further CVD events.

of the study results, indicating that aspirin can be used safely to protect ICH patients from
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9 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

Transforming history of APL in HK

Christina Lau

H ong Kong patients with acute pro- myelocytic leukemia (APL) no longer

die of the disease as introduction of oral arsenic trioxide therapy in 1999 has pro- vided an effective strategy for salvage and prevention of relapses and substantially improved overall survival (OS). “Oral arsenic trioxide has been used for relapsed APL in Hong Kong since 1999. It has completely replaced IV arse- nic, and bone marrow transplantation is now reserved for refractory cases only,” said Dr. Wing-Yan Au of the Division of Hematology, Medical Oncology & Bone Marrow Transplantation of the Queen Mary Hospital (QMH), who won the best abstract award in the leukemia category at the 3rd International Hematologic Malignancies Conference held recently in Hong Kong. Oral arsenic trioxide was a stand- ard leukemia therapy worldwide in the 1940s, and was used at QMH until the 1950s. “The drug was then forgotten in the chemotherapy era. In the 1970s, clini- cians in mainland China started using IV arsenic trioxide. This was followed by use in New York in the 1990s, and subsequent FDA approval for treatment of relapsed APL,” said Au.

In Hong Kong, researchers at the QMH and the University of Hong Kong devel- oped an oral formulation of arsenic tri- oxide that has comparable bioavailability to the IV formulation. Use of the oral therapy has led to a significant decrease in 5-year relapse rate and a substantial

improvement in 5-year OS. “An epidemiological survey of all APL patients in Hong Kong in 1991–2001 showed that 5-year relapse rate has decreased from 54 percent to 16 per- cent,” said Au. “With blood support and

strategies to prevent or salvage relapses, 5-year OS has jumped from 44 percent to

80 percent.”

The survey included a total of 408 patients (complete remission [CR], n=318; induction death, n=88; lost cases, n=2) in four 5-year cohorts. Relapse was lower with oral arsenic trioxide than with all-trans-retinoic acid (ATRA) mainte- nance (17 vs 38 percent). Risk factors for relapse were age, high white cell count, and male gender.

“With maintenance and salvage ATRA since 1993 and oral arsenic trioxide since 1999, 5-year OS of APL patients in first CR [CR1] has increased significantly from

67 percent to 96 percent,” said Au. “The

prognosis is excellent” “In fact, no APL-related deaths have been reported in Hong Kong since 2006 in patients who achieved CR1,” he stressed. “Oral arsenic trioxide has changed the natural history of APL in Hong Kong.” APL patients treated with oral arsenic trioxide in Hong Kong cover a broad age range, from 6 to 86 years. No patients stopped the therapy due to side effects, which include headache, dyspep- sia, reversible liver function derange- ment and herpes zoster reactivation. “There is no QT prolongation, which is common with IV arsenic trioxide,”

said Au.

ment and herpes zoster reactivation. “There is no QT prolongation, which is common with IV arsenic
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10 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

ESRD patients shifting towards home dialysis

Naomi Rodrig

M ore patients with end- stage renal disease

Naomi Rodrig M ore patients with end- stage renal disease Patient training is crucial monitoring of

Patient training is crucial

monitoring of dialysis equipment and supplies, placing the needle in the vascu- lar access, keeping records of treatments, monitoring blood pressure and pulse, and cleaning the equipment and the room. Oftentimes, family members and carers also attend the course, so they are able to help the patient as needed. Home dialysis technology was first intro- duced to local public hospitals in 2006, ena- bling patients to perform dialysis at home every other night. NHHD patient training has now been extended to four public hospi- tals (Queen Mary Hospital, Queen Elizabeth Hospital, Princess Margaret Hospital and Alice Ho Nethersole Hospital), serving eligible patients from all HA’s renal units. To further promote the application of home dialysis for ESRD patients, the HKJCCT also supported 19 dialysis nurses who attended overseas workshops on

patient training and support.

attended overseas workshops on patient training and support. (ESRD) in Hong Kong are opt - ing

(ESRD) in Hong Kong are opt- ing for home dialysis with support from the Hospital Authority (HA) and charita- ble donations. Recently, 25 patients have completed a training course on home renal replacement therapy, aiming to improve their qual- ity of life and lead a normal lifestyle. The HA’s home dialysis

program has been operat- ing since 2009, supported by a HK$ 24.2 million donation from the Hong Kong Jockey Club Charitable Trust (HKJCCT) over 3 years. The funds were allocated to purchase 100 sets each of automated peritoneal dialysis (APD) machines and nocturnal home hemodialysis (NHHD) machines. “The donation from the HKJCCT helps relievethefinancialburdenofrenalpatients in performing self-help home dialysis treatment in a safe environment. Patients who join the program will not only gain better clinical outcome but also improve their quality of life,” said HA Chairman, Mr.

Anthony Wu, who officiated at the course graduation ceremony. At present, there are around 90 renal failure patients on APD or NHHD partici- pating in the program. Patient training, which takes sev- eral weeks, involves preparation and

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12 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

Epidemic warning: Fast HIV spread in China’s general population

Naomi Rodrig

Henan provinces through contaminated blood donations and IV drug use. “Unprotected sexual contact is the major mode of HIV-1 transmission among general populations,” remarked lead study inves- tigator, Dr. Zhiwei Chen, Director of HKU’s AIDS Institute. Another important finding was the evo- lution of circulating HIV-1 strains, which showed a trend towards increasing genetic diversity. Between the two study periods, the HIV-1 strains expanded from the dominant circulating subtype CRF 01 _AE, to include mul- tiple non-CRF 01 _AE strains (>21.0 percent), unique recombinant forms (8.1 percent) and some minor drug-resistant variants. “Our findings have implications on stra- tegic prevention programs among general populations. Since the epidemic remains largely hidden, the increased prevalence posts a new challenge in the fight against HIV/AIDS,” said Chen. He suggested that the data are criti- cal for Fujian to build a comprehensive HIV prevention program. Moreover, HIV-1 surveillance and prevention of infection should be immediately enhanced in low- prevalence regions as well. “We must improve surveillance and prevention by building up a transparent data collection and sharing system as well as a reliable method to evaluate the effi- cacy of our preventive measures,” added Chen. “The control and elimination of sexual transmission of HIV-1 among the general population may help prevent a larger epidemic in China and a growing

pandemic worldwide.”

A n epidemiological study from the University of Hong Kong (HKU) pub-

lished recently in the Journal of Acquired Immune Deficiency Syndromes demon- strated a rising prevalence of HIV-1 infec- tions among the general population in China’s Fujian province, coupled with an increasing genetic diversity of HIV-1 strains. The data have prompted the investigators to call for enhanced surveillance to pre- vent a looming epidemic. [JAIDS 2012; DOI:

10.1097/QAI.obo13e31824f19f5]

In the province-wide study, 915,830 and 2,152,658 specimens were collected in 2006-2007 and 2008-2009, respectively, and tested for HIV infections by serologic and genetic analysis. The overall prevalence rate increased significantly in the second sampling period, from 0.064 to 0.074 percent (p=0.003). The percentage of homosexual transmissions rose from 1.9 percent in 2006-2007 to 5.3 percent in 2008-2009. A high frequency of HIV-1 transmissions was related to unpro- tected heterosexual transmissions but not IV drug use. In general, the prevalence rate had significantly increased in 2008-2009 among general populations such as voluntary blood donors, recipients of blood transfusion, pregnant women and people undergoing

pre-operative screening (all, p <0.001). The data are alarming since Fujian is considered a low-prevalence region. Among nearly 800,000 people who live with HIV-1 in China, the majority of infec- tions occurred in Yunnan, Guangxi and

Among nearly 800,000 people who live with HIV-1 in China, the majority of infec - tions
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13 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

Full disclosure or censorship?

Naomi Rodrig

T he proverbial ‘publish or perish’ mantra of academia has assumed

a new meaning with a public debate

raging over two controversial papers describing highly pathogenic strains of

the H5N1 flu virus that are transmissible between mammals. In two separate studies, research- ers from the Erasmus Medical Center

in Rotterdam, The Netherlands and the

University of Wisconsin, Madison, USA created forms of the virus that can spread

between ferrets through airborne trans- mission. The papers – providing experi- mental details that might allow others to replicate the method and produce reassortant pathogenic H5N1 virus for humans – were slated to be published in Science and Nature, respectively.

slated to be published in Science and Nature, respectively. strains will not easily infect and spread

strains will not easily infect and spread between humans, object to any cen- soring and want their papers published in full,” commented Professor Kwok- Yung Yuen, Chair of the Department of Microbiology, University of Hong Kong

of the Department of Microbiology, University of Hong Kong Nature is by far the most efficient

Nature is by far the most efficient ‘bioterrorist’ of all

However, the US National Science Advisory Board for Biosecurity (NSABB) recommended that the experimental details should be redacted because of concerns they could be used in a bio- terror attack – in other words, ‘publish and perish’. The NSABB also argued that full publication would encourage more research on those pathogenic strains, risking accidental release. The scientific community is divided. “The studies cannot prove whether such mutants will or will not behave similarly in the human population. The scientists, who take the stand that those H5N1

(HKU). “Whereas the more cautious camp would like to omit the findings that may encourage bioterrorists to create a similar virus with deadly potential. Both camps have good reasons to support their claims.” After weeks of deliberations, a WHO meeting convened in late February decided that the papers should be pub- lished in full. “Concern over hypothetical ‘dual use’ must be tempered with the realization that H5N1 viruses are continuing to mutate and evolve in nature,” said virol- ogy expert Professor Malik Peiris of the

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14 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

School of Public Health, HKU, who was one of the participants at the WHO meeting supporting the decision. “And experience has taught us that nature is by far the most efficient ‘bioterrorist’ of all.” “A major unanswered question is how animal influenza viruses become adapted for efficient human-to-human transmission. It has major practical applications for assessing their pan- demic potential. This is the question these two research groups have inves- tigated. They identified mechanisms by which avian H5N1 may acquire transmis- sibility in humans, using the ferret as an animal model,” he told Medical Tribune. “This information needs to be built upon through further research by the

global scientific community. An increas- ing amount of animal influenza virus surveillance data permits such informa- tion to be applied in risk-assessment algorithms. This research also clearly indicates that H5N1 does indeed have pandemic potential and is one of the more virulent pandemic candidates.” Nevertheless, the debate is still far from over, and the moratorium on pub- lication has been extended. “The WHO did not specify when the papers should be published,” noted Yuen. In the mean- time, the organization is consider- ing how to handle the mutant viruses while it comes up with strict biosafety, security and oversight provisions for

further research.

security and oversight provisions for further research. The Complete Solution Innovations in workflow tools for
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15 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

Studies reveal impact of sleep on cognition in elderly

Christina Lau

reports in the literature, older adults in our study have less daytime sleepiness than their young counterparts.” In another study, Lau and colleagues found that OSA in middle-aged and older adults is associated with deficits in process- ing speed, attention and memory compared with healthy controls. “Some cognitive deficits in OSA patients are reversible after CPAP [continuous posi- tive airway pressure] treatment,” said Lau. “In those with moderate to severe OSA treated with CPAP, basic working memory functions were comparable to controls, but functions requiring the central executive still showed a significant reduction despite treatment.” [J Int Neuropsychol Soc 2010;16:1077-1088] “Severe OSA, if untreated, is associated with increased cardiovascular [CV] events. OSA is also an independent risk factor for stroke and mortality,” said Professor Mary Ip of HKU’s Division of Respiratory & Critical Care Medicine. [Lancet 2005;365:1046- 1053; N Engl J Med 2005;353:2034-2041; Sleep 2008;31:1079-1085] According to Ip, it is important to treat OSA early as excess mortality in OSA is observed only in those younger than 50 years. [Eur Respir J 2005;25:514-520] “The decision of whether to treat elderly OSA patients or not depends on symptoms, comorbidites and the degree of respiratory disturbance,” she sug- gested. “In elderly OSA patients, there are more hypopneas and central apneas, less oxy- gen desaturation with events, and less symp- toms and sequelae associated with sleep apnea. The association between OSA and

obesity is also less strong in this population.”

S leep disturbances may have a signifi- cant impact on the aging process as

studies have shown that they are associ- ated with increased morbidity and mortal- ity as well as impaired cognitive functioning in middle-aged and older adults, accord- ing to speakers at the 7th International Symposium on Healthy Aging. “Sleep disturbances in older adults include reduction in slow-wave sleep and rapid eye movement sleep, increase in awaken- ings, changes in sleep architecture and cir- cadian sleep-wake pattern, as well as sleep disorders such as insomnia and obstructive sleep apnea [OSA],” said Dr. Esther Lau of the Department of Psychology, University of Hong Kong (HKU). “These disturbances con- tribute to the lack of quality sleep, and are associated with impaired cognitive function- ing in the middle-aged and the elderly.” In an ongoing study, Lau and colleagues found that older adults (mean age, 76.51 years) have significantly poorer quality of sleep than their young counterparts (mean age, 23.3 years) as measured by sleep effi- ciency (ratio of time asleep to time spent in bed), sleep duration and sleep latency (time taken to fall asleep). “We found a correlation between sleep and cognitive functioning in older adults. For example, increased sleep latency is associated with slower speed of process- ing. Morning circadian preference is associ- ated with better basic attention compared with preference for afternoon or evening activity,” she reported. “Interestingly, unlike

basic attention compared with preference for afternoon or evening activity,” she reported. “Interestingly, unlike
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16 April 2012 Hong Kong Focus International Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong

April 2012

Hong Kong Focus

International Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong Kong – Naomi Rodrig reports

Remote device monitoring improves patient outcomes

I ncreasing use of cardiovascular implant- able electronic devices (CIED) with remote-monitoring function has improved treatment outcomes, enabling early detection of decompensation and prompt intervention and reducing the burden on patients and healthcare systems alike. “The pacemaker population is continu- ously expanding, with nearly half a mil- lion users reported in Europe in 2009. As subclinical atrial fibrillation [AF] and other complications are common in device users and are associated with increased risk of stroke and cardiac events, constant monitoring is indicated,” said Professor Johannes Holzmeister of the University Hospital Zurich, Switzerland. Today’s CIED, including pacemak- ers, implantable cardioverter defibrilla- tors (ICD) and cardiac resynchronization devices (CRD), can be monitored globally. “The device transmits data through a sat- ellite to a processing center, which then sends the report to the monitoring center/ physician via the Internet, fax or SMS. Transmission time from reported event to alert is less than 5 minutes,” he pointed out. “Although the external appliance is somewhat bulky to carry, most patients – especially those who travel a lot – feel safer being constantly monitored.” Remote monitoring involves automatic data acquisition with unscheduled trans- missionsofanyprespecifiedalertsrelatedto

devicefailure(eg,lowbatteryorleadimped-

ances out of range) and to clinical events

- ances out of range) and to clinical events (eg, ischemia, arrhythmia or hemodynamic instability).
- ances out of range) and to clinical events (eg, ischemia, arrhythmia or hemodynamic instability).
- ances out of range) and to clinical events (eg, ischemia, arrhythmia or hemodynamic instability).

(eg, ischemia, arrhythmia or hemodynamic instability). “This allows beneficial pre- emptive interventions that impact on dis- ease management,” remarked Professor David Hayes from the Mayo Clinic in Rochester, USA. For example, remote monitoring has been shown to reduce stroke risk in congestive heart failure [J Cardiovasc Electrophysiol 2009;20:1244-1251], as well as shorten the time from onset of events to clinical decisions in response to arrhyth- mias. [J Am Col Cardiol 2011;57:1181-1189] According to Hayes, remote monitor- ing of CIED is widely accepted in the USA, with more than 800,000 patients currently using such systems. “Remote monitoring provides time- lier and nearly identical information on CIED performance and patient status compared with traditional in-clinic fol- low-up. Randomized controlled trials dem- onstrated that it reduces the need for clinic visits,” stressed Holzmeister. The TRUST trial demonstrated a 45

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17 April 2012 Hong Kong Focus International Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong

April 2012

Hong Kong Focus

International Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong Kong – Naomi Rodrig reports

percent reduction in in-office follow-ups with home monitoring vs conventional care, with an equal event rate. [Circulation 2010;122:325-332] Even higher reduc- tions in clinic visits were reported in the COMPAS and REFORM trials (55 and 63 percent, respectively). [Doi: 10.1093/eur- heartj/ehr419; Computers Cardiol 2006;

33:241-244]

“The savings per patient-year resulting from reduction in clinic visits were esti- mated at 61 percent for hospital costs,

63 percent for transportation costs and 41 percent for physician time,” he added. [Computers Cardiol 2006; 33:241-244] “However, despite the growing posi- tive evidence, remote monitoring of CIED still lacks adequate reimbursement,” said Holzmeister. Additional reasons for the slow implementation may be related to patient preference for face-to-face con- sultations and reluctance of private prac- titioners whose income might be affected,

he speculated.

- titioners whose income might be affected, he speculated. The Essential Medical Reference The Complete Solution
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18 April 2012 Hong Kong Focus International Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong

April 2012

Hong Kong Focus

International Congress of Cardiology (ICC) 2012, 24-26 February 2012, Hong Kong – Naomi Rodrig reports

Role of echocardiography in heart failure

E chocardiography is an easily available technology with a major role in the

diagnosis and management of heart fail- ure (HF), according to Professor Jing-Ping Sun of the Emory University School of Medicine, Atlanta, USA. “When HF is clinically suspected, echo- cardiography is the single most important technique, essential in the diagnosis and identification of underlying etiology of HF,” she said. “In about half of the patients even- tually confirmed to have HF, it demonstrates a major structural and/or functional abnor- mality, such as systolic HF, severe valvular heart disease, congenital heart disease or cardiomyopathies.” In the remaining 50 percent of patients who have HF with preserved ejection frac- tion (EF), the abnormalities may be subtle on two-dimentional echocardiography. “To ascertain the underlying etiology of HF, additional investigations are required, such as myocardial or tissue Doppler imag- ing,” Sun suggested. “Tissue Doppler imag- ing of the septal mitral annulus is helpful in differentiating pseudo-normal from true normal mitral flow velocities, and differen- tiating constrictive pericarditis from myo- cardial diseases.” According to Sun, it is also important

to consider right HF, pulmonary pro- cess and non-cardiopulmonary process if diastolic function evaluation shows relatively normal filling pressure at rest. Another important condition to con- sider is exercise-induced increased fill- ing pressure that may have led to the patient’s symptoms of shortness of

may have led to the patient’s symptoms of shortness of breath. “Therefore, we need to assess

breath. “Therefore, we need to assess fill- ing pressure at rest and with exercise,” she suggested. New developments in echocardiogra- phy now allow objective quantification of regional and global myocardial function. Regional deformation (strain, rotation and twist) and deformation rate (strain-rate) can be calculated non-invasively in both ventricles.

Echocardiographyisalsohelpfulinselect-

ing the optimal therapy for HF patients. “For example, it can help identify patients who require cardiac resynchronization therapy according to established criteria, and adjust the optimal atrioventricular delay time,” said Sun. Furthermore, echocardiography is use- ful for monitoring treatment response and predicting patient prognosis, as well as an

evaluation tool in HF trials.

use- ful for monitoring treatment response and predicting patient prognosis, as well as an evaluation tool
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20 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

Peer counseling helps young smokers quit

Hong Kong Focus Peer counseling helps young smokers quit Christina Lau P eer counseling is effective

Christina Lau

P eer counseling is effective in young smokers with depressive symptoms

who find it harder to kick the habit, accord- ing to a study by the University of Hong

Kong (HKU). Depressive symptoms affect 47 percent of smokers who received service at HKU’s Youth Quitline between March 2006 and May 2011. “Youth smokers with depressive symptoms had a higher level of nicotine dependence,” said Professor Sophia Chan of the School of Nursing, who reported the findings at the opening ceremony of the Youth Quitline Center. Despite similar levels of intention to quit, youth smokers with depressive symp- toms perceived higher difficulty and lower confidence in kicking the habit than those without depressive symptoms. At 6-month follow-up, the quit rate was 10.6 percent for those with notable depressive symp- toms, vs 32.3 percent for those without

depressive symptoms. It also took longer for those with nota- ble depressive symptoms to initiate a quit attempt (average, 15 days post telephone counseling). While 45 percent of youth smokers had made a quit attempt after tel- ephone counseling, those with depressive symptoms were more prone to relapse as only 18 percent were able to abstain from smoking for at least 7 days (vs 35 percent for those without depressive symptoms). “Peer counseling provided by trained students of similar age reduced the num- ber of youth smokers with depressive symptoms by 7.2 percent after 6 months,” said Chan. Supported by funding from the Tobacco Control Office of the Department of Health, the new Youth Quitline Center now pro- vides more intensive telephone counseling for callers. “A web-based interactive cessa- tion service will be launched by the end of 2012 in collaboration with Quit Victoria in

Australia,” Chan added.

cessa - tion service will be launched by the end of 2012 in collaboration with Quit
21
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21 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

What medical information do doctors seek?

Hong Kong Focus What medical information do doctors seek? Naomi Rodrig A recent survey conducted by

Naomi Rodrig

A recent survey conducted by MIMS.com indicated that Asian doctors prefer

authoritative, expert-authored/reviewed clinical information over less formal sources such as peer discussion groups. [Medical

Information & Professional Networking HCP Survey, Jan 2012] The survey included over 1,700 phy- sicians and healthcare professionals from several Asian countries. Among the respondents, 34 percent ranked drug information as their top area of professional interest, followed by CME (Continuing Medical Education, 30 per- cent) and diagnostic/patient information (25 percent). Only 11 percent of respond- ents ranked peer-to-peer interaction as

their top priority. The majority of doctors consider highly credible information from clinical guide- lines and expert communications (ie, con- ferences, symposia and peer-reviewed journals) as the preferred source of medi- cal updates. In the area of drug information, 63 per- cent cited high interest in expert over- views, best practice sharing, and clinical experience in drug usage. Peer discussions and workshops on drug usage and patient outcomes ranked second at 35 percent, while only 19 percent were interested in learning about off-label drug indications. MIMS and MIMS.com are part of a com- prehensive drug information system from UBM Medica, a healthcare media company

and publisher of Medical Tribune.

a com- prehensive drug information system from UBM Medica, a healthcare media company and publisher of
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23 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

Hong Kong Events

Left Atrial Appendage Closure Workshop Hong Kong 2012 Division of Cardiology and Institute of Vascular Medicine, CUHK

26/5-27/5

Info: Ms. Chang Tel: (852) 2255 4257

www.hku.hk/ortho/forum2012

27/4-28/4

Tel: (852) 2647 6639 Fax: (852) 2144 5343 E-mail: cardiacsec@cuhk.edu.hk www.icc-hongkong.com/laa/

Advanced Laparoscopic Urology Workshop Department of Surgery; Pamela Youde Nethersole Eastern Hospital; Hong Kong Urological Association

20th Annual Scientific Congress Hong Kong College of Cardiology

4/5-6/5

28/5

Tel: (852) 2595 6362 Fax: (852) 2505 7101 E-mail: pyneh_mastc@ha.org.hk www.ha.org.hk/mastc

Advances in Medicine 2012 Department of Medicine & Therapeutics, CUHK

Info: Ms. Lynn Lam / Ms. Queenie Wong Tel: (852) 2911 7902 / 2911 7923 Fax: (852) 2893 0804 / 2838 7114 E-mail: lynn.lam@mci-group.com / queenie.wong@mci-group.com www.hkcchk.com/scientificcongress.php

2/6-3/6

Hospital Authority Convention 2012

Info: Ms. Priscilla Chu / Ms. Flora Lo Tel: (852) 2632 3593 / 2632 3307 Fax: (852) 2637 3852 E-mail: priscillachu@cuhk.edu.hk / floralo@cuhk.edu.hk

www.mect.cuhk.edu.hk/AIM2012/index.

7/5-8/5

Info: Ms. Cynthia Kong Tel: (852) 2300 6557 Fax: (852) 2890 7726 E-mail: hac@ha.org.hk

www.ha.org.hk/haconvention/hac2012

htm

17th Hong Kong Medical Forum Department of Medicine, HKU; Queen Mary Hospital

Hong Kong Primary Care Conference Hong Kong College of Family Physicians

2/6-3/6

12/5-13/5

Info: Ms. Crystal Yung / Ms. Priscilla Li Tel: (852) 2861 0220 Fax: (852) 2866 0981 E-mail: hkpcc@hkcfp.org.hk www.hkcfp.org.hk/

Tel: (852) 2255 4607 Fax: (852) 2855 1143 www.hku.hk/medicine/hkmf

9th Hong Kong International Orthopedic Forum – Orthopedics and Pain Department of Orthopedics & Traumatology, HKU

24
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24 April 2012 Hong Kong Focus

April 2012

Hong Kong Focus

Hong Kong Events

International Digestive Disease (IDD) Forum Institute of Digestive Disease, CUHK

12th Asian Conference on Clinical Pharmacy School of Pharmacy, CUHK

9/6-10/6

7/7-9/7

Info: Swire Travel Tel: (852) 3151 8900 Fax: (852) 2590 0099 E-mail: iddf2012@swiretravel.com www.iddforum.com

Info: UBM Medica Pacific Limited Tel: (852) 2155 8557 / 3153 4374 Fax: (852) 2559 6910 E-mail: info@accp2012.org

www.accp2012.org

Annual Scientific Meeting 2012 Hong Kong Society of Dermatology and Venereology

2012 Conference of Asia Oceania Research Organization on Genital Infection and Neoplasia (AOGIN 2012) Department of Obstetrics and Gynecology, HKU

13/7-15/7

10/6

Info: UBM Medica Pacific Limited Tel: (852) 2155 8557 / 2116 4348 Fax: (852) 2559 6910 E-mail: meeting.hk@ubm.com

2nd IDKD Intensive Course in Hong Kong – Diseases of the Abdomen and Pelvis

16/6-19/6

Info: PC Tour and Travel Tel: (852) 2734 3315 Fax: (852) 2367 3375 E-mail: conference@pctourshk.com

www.ogshk.org/2011/AOGIN_2012.pdf

Annual Scientific Meeting Hong Kong Institute of Musculoskeletal Medicine

21/7-22/7

Info: Swire Travel Limited Tel: 852 (0) 315 188 19 Fax: 852 (0) 315 463 24 E-mail: idkd-hk2012@swiretravel.com www.idkd.org

Info: UBM Medica Pacific Limited Tel: (852) 2155 8557 / 3153 4374 Fax: (852) 2559 6910 E-mail: meeting.hk@ubm.com www.hkimm.hk

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26
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26 April 2012 News

April 2012

News

Contaminated TCM products cause liver damage

Radha Chitale

C ontaminants in traditional Chinese medicines (TCM) can cause seri-

ous, sometimes fatal, liver failure, according to research presented at the 22nd Conference of the Asian Pacific Association for the Study of the Liver (APASL) held in Taipei recently. A recent survey of 26 patients admit- ted to National University Hospital (NUH) Singapore with acute liver fail- ure found that 11 (42.3 percent) of the cases were associated with the use of TCM products. Four of these patients died. “Drug-induced liver injury has a differ- ent etiology and severity profile in Asia compared with the West and TCMs were the most commonly implicated drugs in our series,” said lead researcher Dr. Lim Seng Gee, chief of gastroenterology at NUH. Lim added that the results were unique to Asia, where TCMs are widely available, and that data on herbal med- icines are under-reported or poorly reported in general. Previous evaluations of TCM medica- tions which may have been ingested by patients admitted to NUH with drug- induced liver injury liver showed that up to 30 percent were adulterated with pharmacologic agents such as corticos- teroids, beberine, metformin, phenylb- utazone, paracetamol and amidopyrine. Lim pointed out that a natural herb is not necessarily safe or effective, and that while it may not be classified as a ‘drug’ it can still have a pharmacologic

classified as a ‘drug’ it can still have a pharmacologic Some TCM products are contaminated with

Some TCM products are contaminated with pharmacologic ingredients which can cause liver toxicity.

effect that can be toxic. In order to reduce the risk of [liver injury], we should discuss [TCM] use in individual patients, recommend non- use or safe use of reputable products to reduce dose escalation, caution against drug-drug interactions, and monitor patients with hepatitis,” he said. “The risk of herbal hepatotoxicity and adverse events of herbs seems to outweigh the

benefits.”

he said. “The risk of herbal hepatotoxicity and adverse events of herbs seems to outweigh the
27
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27 April 2012 News

April 2012

News

Spinal cord monitoring imperative during surgery

Susie Sell

Spinal cord monitoring imperative during surgery Susie Sell Surgery can place a patient’s spinal cord at

Surgery can place a patient’s spinal cord at risk of serious complications including post- operative paralysis and paraparesis.

surgeries where the spinal cord is at risk,” said lead author Dr. Marc Nuwer, medical director of the University of California, Los Angeles and a fellow of the AAN. “Monitoring can help prevent damage by identifying problems early enough to allow for interventions. If intraoperative monitor- ing raises warnings, surgeons and anesthe- siologists can modify the surgery to reduce the risk of these complications,” he said. The expert panel said anesthesiologists and surgeons can intervene in a variety of ways when IOM raises warnings, includ- ing adjusting retractors, reimplanting or unclamping arteries or minimizing the remaining portion of the surgery. Surgeons also have the opportunity to check a wake- up test in some patients, it said. The panel said the literature review sup- ports the performance of spinal cord moni- toring under the supervision of a clinical neurophysiologist experienced with IOM. The studies do not support IOM conducted by technicians alone or by an automated device, it added. “The best way to treat paralysis is to pre-

vent it in the first place,” said Nuwer.

is to pre - vent it in the first place,” said Nuwer. T he spinal cord

T he spinal cord should be monitored dur- ing surgery to prevent post-operative-

onset paralysis and loss of muscle function, an updated guideline by the American Academy of Neurology (AAN) recommends. The guideline said there is strong evi- dence to show intraoperative monitoring (IOM) of the spinal cord during spinal sur- gery or certain chest surgeries can alert sur- geons and anesthesiologists of problems before damage occurs. A panel of experts at the AAN reviewed 12 research papers to determine whether IOM with somatosensory and transcranial electrical motor evoked potentials (EPs) can predict paralysis related to the surgery. [Neurology 2012; 78: 585-589] They found the studies were consistent in showing all paraparesis, paraplegia, and quadriplegia events occurred in patients with EP change. In one set of studies, 16-40 percent of IOM patients with EP changes developed post-operative-onset paraparesis, paraple- gia or quadriplegia, but no adverse out- come events occurred in patients without an EP change. The AAN guideline, which was developed with the American Clinical Neurophysiology Society, recommends surgeons and other

members of the operating team should be alerted to the increased risk of severe adverse neurologic outcomes in patients with important IOM changes. “Paraparesis, paraplegia and quadriple- gia are potential serious complications of

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April 2012

News

Smartphone technology being looked at for treating substance abuse, PTSD

Susie Sell

S martphones could be used to help treat patients with a history of substance

abuse and post-traumatic stress disorder (PTSD), according to a US-based study. Researchers at the University of Massachusetts Medical School, Worcester, Massachusetts, US, are developing a wrist- band that can identify and transmit drug cravings to a smartphone, which responds with tailored interventions aimed to pre- vent drug use. [J Medical Toxicology 2012 DOI: 10.1007/s13181-011-0200-4] The wristband could be used to make interventions for substance abusers more effective outside the clinical environment, the researchers said. The wristband measures physiological indicators of stress, such as body motion, skin temperature, electrical activity of the skin and heart rate.

electrical activity of the skin and heart rate. need, the researchers said. The technology was tested

need, the researchers said. The technology was tested on a focus group of seven male war veterans, aged between 27 and 55 years old, who were undergoing residential treatment for sub- stance abuse and PTSD. The group highlighted a number of potential limitations of the technology in its current form. It said the wristband

‘‘

The technology could be the next big thing for treatment across Asia

This information is wirelessly trans- mitted to a smartphone, where software applications process the data. If the soft- ware detects an increase in stress level, it asks the user to input information about their perceived level of stress, drug crav- ings and current activities. The goal is to use this data to create an algorithm that can predict real-time drug cravings and use a smartphone to deliver personalized, multi-media drug prevention interventions at the moment of greatest

was acceptable for research purposes but wearing it outside of a residential drug treatment center might attract unwanted attention. “The heightened visibility created a potential for stigmatization,” the research- ers said. The focus group said a more robust and less stigmatizing version would be necessary before the device could be worn in public, suggesting the develop- ment of a band that has the appearance

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30 April 2012 News

April 2012

News

of a wristwatch or a band that is worn on the ankle. Adjunct Associate Professor Munidasa Winslow from the department of psy- chological medicine at the National University of Singapore Yong Loo Lin School of Medicine said the technology could be “the next big thing” for treat- ment across Asia. “I think this could happen very fast as we are quick adopters of new technologies and methods for treatment,” he said. “The advantages are pretty good as most peo- ple keep the smartphone or 3G technology with them most of the time, unlike therapy

sessions. And the cyber program can pick up things faster and more remotely than a human can.” But Winslow stressed the technology should not substitute traditional treatment approaches. ”I think it would be best if tagged onto the more established forms of therapy which have already been tried and tested, such as 12-step therapies, individual and group counseling for substance abuse and eye movement desensitization and repro- cessing (EMDR), and other cognitive ther- apies for post-traumatic stress disorder,”

he said.

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31 April 2012 News

April 2012

News

Experts discuss pneumococcal disease burden in Asia

Radha Chitale

discuss pneumococcal disease burden in Asia Radha Chitale Children are not the only ones at risk

Children are not the only ones at risk of pneumococcal disease – the disease is also common among adults.

to the results of a prospective surveillance study presented at the Annual Meeting of

the Infectious Diseases Society of America in

2011.

High-level resistance to antibiotics also

decreased during the trial period, 2010 to

2011.

Dagan noted that children are not the only segment of the population at risk for complications of pneumococcal disease. Pneumococcal pneumonia is common among adults and it can be community acquired, leading to significant morbidity and mortality, particularly in Asia. [Clin Infect Dis 2000;31:347-382; Int J Antimicrob Agents

2011;38:108-117]

“With the rise in aging population in most Asian countries, [pneumococcal disease in

adults] is becoming a growing concern… it can have devastating effects at the societal and family level and that’s why it’s critical for healthcare professionals to work with par- ents and government authorities on advanc- ing the means to better protect them from

the disease,” Dagan said.

to better protect them from the disease,” Dagan said. I nfectious disease experts highlighted the need

I nfectious disease experts highlighted the need for increased awareness of pneumococcal disease and the effec- tive vaccines available against them dur- ing the 2012 Asia Pneumococcal Disease Conference, held recently in Hong Kong. In particular, the latest pneumococcal con- jugate vaccine, effective against 13 pneumo- coccal bacteria serotypes (PCV13), includes protection against serotype 19A infections, an emerging serotype that experts say is the underlying factor in the rise of pneumococ- cal infections in children under age 5 and is associated with antibiotic resistance. Pneumococcal disease is responsible for up to 1 million deaths among young children under age 5 around the world, according to the World Health Organization. About one- quarter of these infections are due to sero- type 19A, and are increasing in prevalence. [Diagn Microbiol Infect Dis 2008;61:256-263; Emerg Infect Dis 2008;14:275-281] “It is indeed very sad and frustrating to see that so many young children and fami- lies are suffering from pneumococcal dis- ease especially when it can be prevented,” said Professor Ron Dagan, director of the Pediatric Infectious Disease Unit at the Department of Pediatrics at Soroka University in Beer-Sheva, Israel. PCV13, which became available in Asia in 2010 and protects against six more serotypes than its predecessor, PCV7, decreased inva- sive pneumococcal disease by 36 percent fol- lowing its introduction among children in the US compared to the 3 years prior, according

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32 April 2012 News

April 2012

News

Strength of intestinal barrier key in cancer prevention

Susie Sell

of intestinal barrier key in cancer prevention Susie Sell Jefferson University in Philadelphia, Pennsylvania, US. A

Jefferson University in Philadelphia, Pennsylvania, US. A weakened intestinal barrier has been linked to diseases such as asthma, diabe- tes and food allergies. Waldman’s team had previously identified GC-C as a tumor suppressor and biomarker that reveals occult metastases in lymph nodes. But this latest study provides fresh evidence that GC-C plays a role in intestinal barrier integrity, the researchers said. Waldman said the study sets the founda- tion for future research into the role of GC-C in preventing and treating inflammatory bowel disease and cancer. A new drug containing GC-C is set to be released, but its intended prescribed purpose is to treat constipation. “We’ve shown that when you pull away GC-C in animals you disrupt the intestinal bar- rier, putting them at risk for getting inflam- matory bowel disease and cancer. And when you treat them with hormones that activate GC-C it helps strengthen the integrity of the intestinal barrier,” Waldman said. “If you want to prevent inflammation or cancer in humans then we need to start think- ing about feeding people hormones that acti-

vate GC-C to tighten up the barrier.”

hormones that acti - vate GC-C to tighten up the barrier.” A strong intestinal barrier could

A strong intestinal barrier could help prevent cancers forming in the rest of

the body and inflammatory bowel disease, preclinical research suggests. A study in mice has shown that the hor- mone receptor guanylyl cyclase C (GC-C) plays a key role in strengthening the intes- tinal barrier. [PLos ONE 2012. DOI:10.1371/

journal.pone.0031686]

Mice deficient in GC-C and mice with activated GC-C were administered dextran sulfate sodium (DSS) in drinking water for 7 days to disrupt the epithelial barrier and induce colitis. Severity of colitis was ana- lyzed by body weight and survival rate. The results showed that GC-C-deficient mice had DSS-induced colitis with a 3-fold greater severity compared with GC-C- activated mice. DSS colitis was also associated with >80 percent mortality in GC-C-deficient mice, as compared with GC-C-activated mice, which exhibited 100 percent survival. The researchers found the weakened intestinal barrier caused tumors in the liv- ers, lungs and lymph nodes in 50 percent of GC-C-deficient mice, but in only 10 per- cent of GC-C-activated mice. “If the intestinal barrier breaks down it becomes a portal for stuff in the outside

world to leak into the inside world. When these worlds collide it can cause diseases like inflammation and cancer,” said lead researcher Dr. Scott Waldman, chairman of the Department of Pharmacology and Experimental Therapeutics at Thomas

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34 April 2012 News

April 2012

News

Overeating doubles risk of memory loss

Elvira Manzano

O vereating appears to be associated with an increased risk of mild cognitive

impairment (MCI) in the elderly, according to a leading neurologist. Dr. Yonas E. Geda, from the Mayo

Clinic, Scottsdale, Arizona, US, was refer- ring to the results of her own study which found that people who consumed more than 2,142.5 kilocalories a day had nearly twice the risk of developing memory loss compared with those who ate fewer than 1,526 kilocalories a day.

“We observed a dose-response pattern

which simply means that the higher the

amount of calories consumed each day, the higher the risk of MCI,” said Geda, a member of the American Academy of Neurology (AAN).

MCI is an intermediate stage between

the expected cognitive decline of normal aging and the more pronounced decline of dementia. People with MCI are at an increased risk of later developing demen- tia, including Alzheimer’s disease, and may experience problems with memory, language, thinking and judgment that are greater than typical age-related changes. In this case-controlled study, Geda and colleagues surveyed a random sample of 1,233 people aged 70 to 89 participat-

ing in a population-based cohort study in Olmstead County, Minnesota, US, about their daily caloric consumption. Volunteers – 1,070 without demen- tia and 163 with MCI – were divided into three groups based on their daily caloric intake. The first group consumed between

their daily caloric intake. The first group consumed between People who consumed over 2,142.5 kilocalories/ day

People who consumed over 2,142.5 kilocalories/ day had almost twice the risk of developing memory loss than those who ate less than 1,526 kilocalories/day.

600 and 1,526 calories and was used as a reference group. The second group con- sumed between 1,526 and 2,143 calories, while the third group consumed between 2,142.5 and 6,000 calories. Compared with the first group, the sec- ond group had a higher risk of MCI, but the results did not reach any statistical signifi- cance (odds ratio [OR] 1.05, 95% CI 0.63 to 1.77). Interestingly, the third group had the greatest risk of developing MCI (OR 2.41, 95% CI 1.51 to 3.86). The results did not change even after adjusting for other factors that could affect risk of memory loss such as history of stroke, diabetes and education. “Cutting calories and eating foods that make up a healthy diet may be a simpler way to prevent memory loss as we age,” Geda concluded. The full study results are expected to be presented at the annual meeting of the AAN being held in New Orleans, Louisiana,

US, in April.

results are expected to be presented at the annual meeting of the AAN being held in
35
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35 April 2012 News

April 2012

News

Rapid memory loss linked to fatal stroke

Elvira Manzano

A sharp decline in memory is associated with worse stroke outcomes, accord-

ing to a recent US study. “We are most surprised that people who died after strokes had sharp mem- ory declines [in the] years before stroke onset,” said Ms. Qunyi Wang, lead author of the study and a graduate student at the Harvard University School of Public Health in Boston, Massachusetts, US.

The 10-year study involved more than 11,800 individuals aged 50 and older with no history of stroke at baseline. To assess declining memory function, they under- went word-recall tests every 2 years. For those whose memory loss was too severe to use the word lists, researchers interviewed spouses or other caregivers. [International Stroke Conference 2012; Abstract 31] During the study period, 1,800 suffered strokes and 364 died before their next memory test. While memory declined rap-

‘‘

We are most surprised that people who died after strokes had sharp memory declines [in the] years before stroke onset

Dr. M. Maria Glymour, co-author of the study from the same institution, said those who died from stroke may have worse underlying disease prior to stroke, “which suggests that early disease is accumulating and that something is happening to these people before they are diagnosed with clinical stroke.” Commenting on the study, Associate Professor N.V. Ramani, a senior consultant in the division of neurology at National University Hospital, Singapore, said: “It’s an interesting study showing that those with lower memory function had a higher stroke risk and those who had higher rates of memory decline had higher post- stroke mortality.” While he described the results as “intriguing,” he said these will not impact directly on clinical practice. “What we need are effective treatments that reduce stroke and stroke-mortality among those with lower memory function.”

idly each year for stroke survivors prior to stroke onset, it dropped even faster for those who did not survive the stroke. By comparison, memory decline for individu- als who did not have a stroke occurs at a much slower pace. On average, the memory scores of peo- ple who did not have a stroke dropped 0.078 points a year. Those who had a stroke but survived scored 0.137 points lower each year, while those who died from the event dropped 0.205 points a year. Contrary to what the findings suggest, severe memory loss is not a strong pre- dictor of future fatal stroke, said Ramani, a known stroke leader. “Those with severe memory loss tend to succumb to complications of a bedbound state. Stroke may cause cognitive impairment without memory loss. Cognitive impair- ment after stroke is a well-known and important clinical entity for which we

need better treatments.”

Cognitive impair- ment after stroke is a well-known and important clinical entity for which we need

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: Uniquely Targeted Action in Pre
:
Uniquely Targeted Action in Pre
DIRECT FACT : Uniquely Targeted Action in Pre : Uniquely Targeted Action in Preventing Clots 6

: Uniquely Targeted Action in Preventing Clots

6 t t t t No dietary restrictions 5 Abbreviated SmPC Xarelto 10 mg film-coated
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No dietary restrictions 5
Abbreviated SmPC
Xarelto 10 mg film-coated tablets.
Composition: Active ingredient: 10 mg rivaroxaban. Indication: Prevention of venous thromboembolism (VTE) in adult
patients undergoing elective hip or knee replacement surgery. Contraindications: Hypersensitivity to the active
substance or to any of the excipients; clinically significant active bleeding; hepatic disease associated with coagulopathy
and clinically relevant bleeding risk, pregnancy and lactation. Warnings and Precautions: Treatment with rivaroxaban is
not recommended in patients: - concomitantly treated systemically with strong concurrent CYP3A4- and P-gp-inhibitors,
ie, azole-antimycotics (such as ketoconazole, itraconazole, voriconazole and posaconazole) or HIV protease inhibitors
(eg, ritonavir), - with severe renal impairment (creatinine clearance <15 ml/min), and due to lack of data: - below 18
years of age, - undergoing hip fracture surgery. The following sub-groups of patients are at increased risk of bleeding
and are to be carefully monitored for signs of bleeding complications after initiation of treatment: patients with severe
renal impairment (creatinine clearance 15 - 29 ml/min), patients with moderate renal impairment (creatinine clearance
30 - 49 ml/min) Undesirable effects: Common: increased GGT, increase in transaminases (incl. increased ALT, AST),
anaemia (incl. respective laboratory parameter), nausea, post-procedural haemorrhage (incl. post-operative anaemia,
and wound haemorrhage). Uncommon: increase in: lipase, amylase, blood bilirubin, LDH, alkaline phosphatase,
tachycardia, thrombocythaemia (incl. platelet count increased), syncope (incl. loss of consciousness), dizziness, headache,
constipation, diarrhoea, abdominal and gastrointestinal pain (incl. upper abdominal pain, stomach discomfort),
dyspepsia (incl. epigastric discomfort), dry mouth, vomiting, renal impairment (incl. blood creatinine increased, blood
urea increased), pruritus (incl. rare cases of generalised pruritus), rash, urticaria (incl. rare cases of generalised urticaria),
contusion, pain in extremity, wound secretion, haemorrhage (incl. haematoma and rare cases of muscle haemorrhage),
gastrointestinal tract haemorrhage (incl. gingival bleeding, rectal haemorrhage, haememesis), haematuria (incl. blood
urine present), genital tract haemorrhage (incl. menorrhagia), hypotension (incl. blood pressure decreased, procedural
hypotension), nose bleed, localised oedema, peripheral oedema, feeling unwell (incl. fatigue, asthenia), fever.
oedema, feeling unwell (incl. fatigue, asthenia), fever. Bayer HealthCare Limited Nos. 801-808, 8/F Shui On Centre,

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Xarelto ® possess the criteria of ideal anticoagulant

Convenience of one 10-mg tablet, once daily 1

No dose adjustments with regard to age, gender, body weight, or ethnicity 1,2,3,4

No requirement for routine coagulation monitoring 1

References: 1. Xarelto ® prescribing note (BHC Hong Kong) 2. Kakkar AK, Brenner B, Dahl OE, et al. Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial. Lancet. 2008;372:29-37. 3. Kubitza D, Becka M, Zuehlsdorf M, Mueck W. Body weight has limited influence on safety, tolerability, pharmacokinetics, or pharmacodynamics of rivaroxaban (BAY 59-7939) in healthy subjects. J Clin Pharmacol. 2007;47:218-226. 4. Kubitza D, Becka M, Mueck W, Zuehlsdorf M. The effect of age, gender and weight on the safety and pharmacology of rivaroxaban (BAY 59-7939) - a novel, oral, direct factor Xa inhibitor. Poster presented at: the Annual Congressof the European Federation of National Associations of Orthopaedics and Traumatology; May 11-15, 2007. Florence, Italy. J Bone Joint Surg [Br]. In press. 5. Kubitza D, Becka M, Zuehlsdorf M, Mueck W. Effect of food, an antacid, and the H2 antagonist ranitidine on the absorption of BAY 59-7939 (rivaroxaban), an oral, direct Factor Xa inhibitor, in healthy subjects. J Clin Pharmacol. 2006;46:549-558 6. WeitzJl et al.Chest 2004; 126:265-86s

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April 2012

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20th Regional Conference of Dermatology, 20-23 February, Manila, Philippines

Re-emerging skin infections present major challenge

Dr. Yves St. James Aquino

Destura. For atypical mycobacterium infections, which can present as abscesses, ulcera- tions or lymphangitis, emergence may be a result of immunosuppression and increase in leisure activities that involve skin-to-skin contact, according to Destura. Atypical myco- bacteria are becoming more virulent espe- cially for skin and soft tissue infections. The medications against atypical myco- bacteria may include a combination of rifampicin, quinolones, doxycycline and/or erythromycin. There is still no standard dura- tion of treatment, but most of the time it’s 6 to 8 weeks, said Destura. Known commonly to cause chickenpox in children and herpes zoster mainly in adults, VSV may manifest as painful vesicular erup- tions with erythematous base in one to three dermatomal lines, facial weakness, post-her- petic neuralgia, among others. Besides immunosuppresion and an aging population, another potential contributor to the increase in incidence of VSV is the emer- gence of new manifestations associated with the disease. Destura added that recently, reactivated zoster presents with predomi- nance of cutaneous pain without associated rash, in addition to neurologic manifesta- tions, such as myelitis, meningoradiculitis, encephalomyelitis and ventriculitis. “The clinical dermatologist remains an important player in the detection of these agents. And as the world gets smaller and smaller, the practice of medicine needs to become more connective and collaborative,”

concluded Destura.

E pstein-Barr virus (EBV), varicella zoster virus (VZV) and atypical mycobacterium

are part of a growing list of re-emerging skin infections caused by organisms that have been relatively controlled in the past, but which have recently been reactivated due to changes in the environment, the organism or the host. “We have been encroaching so much upon our environment because our popula- tion is growing, and we try to cut more trees, and we get exposed to weird insects that har- bor weird organisms. And later we develop diseases,” said Dr. Raul Destura, infec- tious disease specialist and director of the National Institute of Molecular Biology and Biotechnology under the National Institutes of Health-University of the Philippines, Manila, Philippines. Destura explained that these factors can contribute to either increased host suscepti- bility or increased disease transmission. The re-emergence of EBV, a human herpes virus that infects human mucosal epithelial cells and B lymphocytes, has been attributed to the increasing trend of immunosuppres- sion in patients, such as those with cancer or autoimmune diseases, said Destura. Reducing immunosuppressive therapy is considered as part of treatment, as seen in

reported series of cases involving patients with methotrexate-associated EBV. “In this particular series, just removing methotrex- ate or discontinuing it actually resolved EBV- associated cutaneous lesions,” explained

just removing methotrex - ate or discontinuing it actually resolved EBV- associated cutaneous lesions,” explained
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April 2012

Conference Coverage

20th Regional Conference of Dermatology, 20-23 February, Manila, Philippines

Psoriasis studies show link with stress

Dr. Yves St. James Aquino

S tudies show that social aggressors and emotional stress can worsen symptoms

of psoriasis, providing further evidence for the existence of a brain-skin axis, said Dr. Christopher Griffiths, foundation pro- fessor of dermatology in the University of Manchester, Manchester, UK. Griffiths and other members of the Dermatological Sciences Research Group within the School of Translational Medicine in Manchester are studying the two-direc- tional relationship between psychological stress and skin disease. To understand the mechanism behind the psychosocial disability in psoriasis, one of the first studies performed by the group involved an “automatic vigilance test”. This psycholog- ical test was done by asking subjects to view a computer screen that showed words in different colors. The subjects were asked to identify the color and not to read the word. The researchers then measured the time it took for the subjects to identify the color after the word was shown. The more rele- vant the word is to that subject, the longer it takes for that subject to say the color. Condition-relevant words such as “embarrassed,” “ridicule” and “itchy” were used, as well as neutral ones like “table” and “tree.” Results show that subjects with

psoriasis take much longer than normal volunteers when the words are relevant to their condition, while there is no signifi- cant difference in neutral words. “What that means is that people with psoriasis are scanning their local

environment looking for cues about them having the disease. They misinterpret nor- mal, everyday events as the fact they’ve got psoriasis,” explained Griffiths. Another study demonstrated how worry makes patients with psoriasis less likely to respond to psoralen + ultraviolet A (PUVA) therapy. Griffith’s team assessed the sever- ity of psoriasis, psychological distress, alcohol consumption, skin type in 112 patients be fore starting PUVA therapy. The group used the Penn State Worry Questionnaire to discrimi- nate people who were low-worry (65 percent) and those who were high-worry (35 percent). The researchers found that high-level worriers took 1.8 times longer to respond to PUVA compared with the low-level wor- riers. “And even if they did respond, it took them more treatments to respond. So high-worry or high-anxiety has a negative effect on response,” said Griffiths. In order to promote a more holistic approach to psoriasis treatment, Griffiths and his colleagues investigated how cognitive behavioral therapy (CBT) may help alleviate symptoms. The CBT involved group therapy, teaching about psoriasis, stress reduction, and behavioral techniques to manage mis- interpretation of other people’s reactions. Using the Psoriasis Area and Severity Index (PASI), they compared patients who received regular treatments and CBT with patients who were receiving regular treatments alone. After 6 weeks, those who had behavioral therapy had a significantly improved PASI; and after 6 months, the same group had even better improvement in dealing with

emotional stress, said Griffiths.

PASI; and after 6 months, the same group had even better improvement in dealing with emotional
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April 2012

Conference Coverage

20th Regional Conference of Dermatology, 20-23 February, Manila, Philippines

Personal Perspectives

Personal Perspectives ‘‘ I think it’s important for dermatologists to share their information brewing, or what’s

‘‘ I think it’s important for dermatologists to share their

information

brewing, or what’s becoming more and more innovative in Asia.

Dr. Anthony Paul Bewley Dermatologist, Barts and The London NHS Trust Whipps Cross University Hospital NHS Trust, London, UK

It’s important for us to be familiar with what’s

UK It’s important for us to be familiar with what’s ‘‘ One of the interesting topics
UK It’s important for us to be familiar with what’s ‘‘ One of the interesting topics

‘‘ One of the interesting topics I think is STD [sexually transmitted diseases], because in my country there are so many cases. The information is something I can take home.

Dr. Dewi Martini Dermatologist, Fatmawati Hospital, Jakarta, Indonesia

‘‘ We share similar dermatologic diseases, but because of our

different locations and cultures, our approaches may be different. It’s important that we get together once in a while

and share what we know about skin diseases

ideas here in this convention and hopefully it does improve

patient care.

Dr. Belen Dofitas Dermatologist, University of the Philippines-Philippine General Hospital, St. Luke’s Medical Center Manila, Philippines

There are many

Luke’s Medical Center Manila, Philippines There are many ‘‘ A lot of the topics are informative.

‘‘ A lot of the topics are informative. Basically, the lectures were diseases that we commonly see in the out-patient department. Some are rare and worthy as case reports but are still very must-know.

Dr. Joahnna Villena Resident-in-training University of the Philippines-Philippine General Hospital, Manila, Philippines

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22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

APASL Hep B guidelines – Tenofovir added as first-line option

Hep B guidelines – Tenofovir added as first-line option Elvira Manzano N ew guidelines released by

Elvira Manzano

N ew guidelines released by the Asia Pacific Association for the Study of

the Liver (APASL) now also recommend tenofovir disoproxil fumarate (TDF), a nucleos(t)ide analogue (NUC), as a first- line treatment option for patients with chronic hepatitis B. TDF joins entecavir (ETV) and peginter- feron (peg-IFN) as a recommended first- line choice in treatment-naive patients with this disease. Lamivudine (LAM), tel- vibudine (LdT) or adefovir (ADV) can be used as second-line agents based on level B evidence, said Professor Yun-Fan Liaw, chairman of the guidelines review panel and head of the Liver Research Unit, Chang Gung University and Memorial Hospital in Taipei, Taiwan.

“TDF or ETV is the preferred NUC. TDF or ETV is also the treatment of choice for patients with impending or obvious hepatic decompensation,” he added. “Interferon- based therapy is contraindicated in this setting because of the risk of IFN-induced hepatitis flares and serious infection.” LAM has fallen out as a first-line therapy for hepatic decompensation due to high rate of resistance associated with its long- term use. By contrast, TDF and ETV are associated with the lowest rate of resist- ance in treatment-naive patients. The full version of the new guidelines is expected to be published in Hepatology International, the official journal of APASL. First-time recommendations include anti-viral therapy in patients with hepato- cellular carcinoma, use of biologic agents (rituximab, etanercept, etc) alone or in

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combination with corticosteroid containing regimens in HBsAg-negative patients, and prevention of mother-newborn transmis- sion. “LdT or TDF is preferred in pregnant women needing treatment,” Liaw said. Active anti-retroviral therapy (ART) containing TDF plus emtricitabine(FTC)/ LAM is preferred for HBV patients co- infected with HIV. ADV or peg-INF can be considered if CD4 count is >500 and ART is not warranted. Patients with advanced fibrosis or cir- rhosis and those with ALT of ≥ twice the upper limit normal (ULN) and an HBV-DNA of ≥20,000 IU/mL [if HBeAg positive] or 2,000 IU/mL [if HBeAg-negative] should be considered for treatment. Patients with hepatic decompensation need immedi- ate treatment. “Otherwise, 3 to 6 months observation is reasonable,” said Liaw. The new guidelines also suggest

monitoring of alanine aminotransferase (ALT) and HBV markers (HBeAg, HBV-DNA) for a minimum of 3 months during therapy; monthly for 3 months, and every quarter thereafter for 1 year, after therapy. In IFN therapy, monitoring of blood cell count and adverse effects is mandatory. The World Health Organization esti- mates that 600,000 people die every year from hepatitis B infection. The chal- lenge for clinicians is to identify patients at risk, offer treatment and avoid resist- ance to prevent cirrhosis, liver failure and liver cancer. Given the complex nature of hepatitis B and the coming of new effective treat- ments, choosing the right agent can be challenging. Liaw said the new guidelines will guide clinicians on how to best use these drugs to suppress the virus and mini-

mize adverse outcomes.

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April 2012

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22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

Evidence for managing chronic Hep B

Guideline recommendations and supporting data for the long-term management of chronic hepatitis B (CHB) were reviewed and discussed by an international panel of experts during a Bristol-Myers Squibb-sponsored symposium held in conjunction with the Asian Pacific Association for the Study of the Liver (APASL) conference. Pank Jit Sin reports.

Importance of guidelines In opening the symposium, panel chair Professor Jia-Horng Kao, distinguished pro- fessor of medicine at the National Taiwan University, Taipei, laid out the current guidelines and reiterated the importance of evidence-based clinical practice guide- lines, which are “systematically devel- oped statements to assist practitioner and patient decisions about appropriate healthcare for specific circumstances.” He pointed out that such guidelines serve to achieve the goal of improving quality of life and survival of CHB patients through pre- vention of disease progression to cirrhosis, end-stage liver disease, hepatocarcinoma and death. In order to prevent disease progression, said Kao, hepatitis B virus (HBV) replica- tion should be suppressed in a sustained manner and one of the ways to do this is through antiviral therapy. However, the emergence of antiviral resistance compro- mises the efficacy of therapy.

Rationale for first-line antiviral monotherapy Professor Ji-Dong Jia, hepatologist and director, Liver Research Centre, Beijing Friendship Hospital, Beijing, China, then discussed the rationale for first-line mono- therapy recommendations and reviewed combination therapy data. He said that

the pillars of successful therapy included, amongst others, potent and durable viral suppression. Unfortunately, in using nucleos(t)ide analogs, drug resistance becomes a major concern due to the long-term duration of therapy. In general, first-line therapy should be either entecavir (ETV) or tenofovir (TDF) and second-line therapy should be telbivu- dine (LdT), adefovir (ADV) and lamivudine (LVD). Five-year HBV DNA suppression data by ETV and TDF showed that the number of patients with extremely low HBV DNA rises to 94 and 99 percent, respectively. [Hepatology 2010;51:422-30, 62nd Annual Meeting of the American Association for the Study of Liver Diseases (AASLD); November 4-8, 2011; San Fransisco, US. Poster 1375] With regard to combination therapy involving two direct antiviral agents, Jia said there was no evidence pointing to better viral suppression compared with a single agent. The safety and efficacy of mono- therapy was affirmed by the Randomized, Observational Study of Entecavir to Assess Long-term outcomes Associated with Nucleos(t)ide Monotherapy for Patients with Chronic HBV Infection (REALM) study. REALM was carried out in China and established that ETV monotherapy was efficacious and safe in a heterogeneous setting. [21st APASL 2011; February 17-20;

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22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

Bangkok, Thailand. Poster PP05-146]

Evidence from long-term trials and real- world clinical practice Panel members then presented long-term trial results and real-world clinical practice setting supporting data of the use of ETV in CHB patients in Asia and Europe. Professor Ching-Lung Lai, chair of Medicine and Hepatology and chief, Division of Gastroenterology and Hepatology, Department of Medicine, Hong Kong University, emphasized the importance of potent viral suppression and its role in improving long-term patient health. On doing so, he revisited the ETV- 022/027 studies which had a large num- ber of Asian participants. Patients in the trials were given either ETV or LVD with the primary endpoint of seeking histologic improvements in either arm. At the end of 48 weeks, 78 percent of patients in the ETV group and 54 per- cent in the LVD group had HBV DNA lev- els <300 copies/mL. There were alanine transaminase (ALT) normalizations in 68 percent of patients and no resistance was reported in any Asian patient. [61st AASLD 2010; October 29-November 2; Boston, US. Poster 485] He noted that there was no emergence of resistance through year 5 and this finding is supported by real-world clinical practice data. Next, Professor Harry J. A. Janssen, professor of hepatology, Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands, presented on the viability of long-term CHB management in the real-world setting with reference to data from Europe. Based on results garnered from the

Efficacy and safety of ETV in clinical prac- tice in treatment-naive Caucasian chronic hepatitis B patients (ORIENTE) study, it could be seen that virologic responses increased over time in both the HBeAg(+) and HBeAg(-) patients, with more then 90 percent achieving undetectable HBV DNA. ORIENTE also showed that HBeAg and HBsAg seroconversion rates increased over time in HBeAg(+) patients. At the same time, no safety issues were noted and none of the patients had to stop or reduce their doses due to adverse events. [61st AASLD 2010; Poster 409] The European network of excellence for Vigilance against Viral Resistance (VIRGIL) Surveillance Study Group, noted that most patients with partial virologic response at week 48 achieved (full) virologic response with continuing ETV therapy and this prob- ability was not influenced by the severity of liver disease. Finally, VIRGIL also discovered that viro- logic response to ETV was associated with lower probability of disease progression for cirrhotic patients. [62nd AASLD 2011; Oral presentation 240] The efficacy of monotherapy in treatment of HBV is ech- oed by findings of real-world study of TDF where most nucleos(t)ide-naïve patients achieved undetectable HBV DNA by PCR assay and achieved normalized ALT levels at month-30. [62nd AASLD 2011; Poster

1433]

With all the available data from Europe, it was evident that long-term ETV or TDF monotherapy was well-tolerated in that cohort of patients. Additionally, the major- ity of ETV patients achieved a virologic response irrespective of response at week 48. Also, virologic response to ETV was

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22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

associated with a lower probability of dis- ease progression, and it was not influenced by severity of liver disease.

Minimizing the risk of resistance The last speaker on the panel, Professor Stephen Locarnini, head of Research and Molecular Development, Victorian Infectious Diseases Reference Laboratory, Australia, touched on the avoidance of resistance. “The risk of resistance can be mini- mized by choosing antivirals that result

in rapid, profound and durable viral sup- pression and have a high genetic barrier to resistance,” said Locarnini. However, he noted that none of the traits would work if patients do not take their medicine. While current nucleos(t)ide analogs are generally well-tolerated, he concluded by saying that doctors should be watchful, as individual long-term safety profiles vary, and that renal monitoring is indicated with nucleotide therapy. [AASLD Practice guide- lines. Chronic Hepatitis B: Update 2009;

Accessed February 2012]

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April 2012

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22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

Protease inhibitors improve outlook in Hep C

Rajesh Kumar

N ovel direct acting antiviral agents (DAAs) currently under development

promise to address a huge unmet need in the treatment of chronic hepatitis C. Protease inhibitors, the first generation of DAAs, offer much promise to hepati- tis C genotype 1 (HCV-1) patients who respond poorly to the existing standard of care (SOC) comprising peginterferon/ ribavirin combination therapy, according to Professor Ed Gane, hepatologist and deputy director of the New Zealand Liver Transplant Unit in Auckland, New Zealand. Looking at the impact of HCV genotype on sustained virologic response (SVR), Gane said peginterferon and ribavirin for 48 weeks has been shown to be associated with a SVR rate of 82 percent in patients with HCV genotypes 2 and 3 compared with only 42 percent in those with HCV-1. [Lancet 2001;358:958-965]. About 25 protease inhibitors are cur- rently in clinical development, with eight in phase III. Two such agents, telaprevir and boceprevir, were approved last year in Europe and the US for use in combination with the current SOC for the treatment of chronic HCV-1 in both treatment-naïve and experienced patients. In the Phase III studies of boceprevir and telaprevir, their addition to peginter- feron and ribavirin increased efficacy and shortened the duration of therapy in patients with HCV-1. As a result, the triple therapy is likely to become the new SOC, said Gane. However,

therapy is likely to become the new SOC, said Gane. However, Protease inhibitors are novel direct

Protease inhibitors are novel direct acting antiviral agents that may help Hep C genotype 1 patients in particular.

it will not be suitable for patients with non-HCV-1 infection, or who are intoler- ant of or have contraindications to inter- feron, he said. Over half of the total global burden of hepatitis C is in the Asia Pacific region. Although latest data suggests the preva- lence has stabilized and is actually fall- ing, Gane said an ageing cohort and low rate of eradication due to poor treatment uptake means the proportion of those with advanced disease is steadily rising. “The proportion of people who have cirrhosis is estimated to double over the

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next 20 years. That will lead to an increase in related complications,” he said. The Asia Pacific region has a marked variation of HCV genotypes: while HCV-1 dominates in north Asia, southern Asia has genotype 6 and accounts for a third of all the patients with this genotype while HCV-3 has become the predominant infection in the Indian sub-continent and in Australasia. Asians with HCV-1, however, respond better to the existing SOC than other races. The CHARIOT study involving 896 patients, including 116 Asians, showed dramatic difference in SVR rates in the two races. Treatment-naïve Asians with HCV-1 had a better chance of responding to the 48-week treatment with a 360 µg induction dose of peginterferon for the first 12 weeks, followed by a standard 180 µg dose for 36 weeks in combination with ribavirin 1000-1200 µg/day, said Gane. Four similar studies have confirmed better response among Asians with HCV-1,

apparently due to favorable patient IL28B CC genotype in Asian populations (70-90 percent) compared with Caucasians (30- 40 percent). But patients who failed to adhere to at least 80 percent of the prescribed therapy, irrespective of their genotype, had cure rates that were 80 to 90 percent lower than those who stuck with the regimen. The biggest issue in treatment of cirrhotic patients, however, is getting them to take the full dose therapy because their dose often needs to be reduced due to serious side effects, said Gane. The combination of multiple DAAs, which target different steps of HCV rep- lication, should provide interferon-free treatment regimen. Both ongoing and planned studies will now determine which combination (protease, nonnucleo- side polymerase, nucleoside polymerase, NS5A or cyclophyllin B inhibitors) and what duration of therapy will be required

to optimize care, he added.

of therapy will be required to optimize care, he added. Clinical Calculators At Your Fingertips MIMS
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April 2012

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22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

Hepatic infusion chemo gains popularity in Asia

Christina Lau

H epatic arterial infusion chemotherapy (HAIC) using an implanted port sys-

tem has emerged as a treatment option for unresectable hepatocellular carcinoma (HCC) in Japan and Korea, with centers reporting good clinical outcomes. “HAIC involves intermittent bolus infu- sion of chemotherapy at an interval of 1 to 3 months. The most commonly used regimens in Japan are low-dose 5-FU plus cisplatin, or intra-arterial 5-FU infusion combined with systemic interferon [IFN] therapy,” said Professor Masatoshi Kudo of the Kinki University in Osaka, Japan. According to Kudo, HAIC requires a lower drug dose than systemic chemother- apy, and is associated with less side effects, as well as better response and survival. “The procedure is performed under angio- graphic guidance and is feasible at outpa- tient clinics. However, it requires expertise and great care, and is time consuming.” Although not recommended as a stand- ard of care by the American Association for the Study of Liver Diseases (AASLD) [Hepatology 2011;53:1020-1022], HAIC is widely accepted in Japan. The procedure is recommended by the Japan Society of Hepatology for treatment of multiple (≥4) tumors or tumors with vascular invasion in

patients with Child-Pugh class A or B dis- ease, and for patients refractory to tran- sarterial chemoembolization. [Hepatol Res 2010;40:667-685; Dig Dis 2011;29:339-364] “Good results have been reported with HAIC in a number of Japanese studies. In

a nationwide survey by the Liver Cancer

Study Group of Japan, for example, a high response rate of 45.9 percent was achieved in patients treated by HAIC with 5-FU/cis- platin or 5-FU/IFN during 2002 and 2003,” said Kudo. “This is a significant jump from 14.5 percent in 1996-1997.” “In a study of 52 patients treated by HAIC with low-dose 5-FU/cisplatin, median over- all survival [OS] was 15.9 months. Those who achieved complete or partial response survived for a median of 40.7 months,” he reported. With HAIC using 5-FU/IFN, 5-year OS was 23.9 percent in complete or partial responders treated at the Kinki University between 1998 and 2007, said Kudo. “In some patients, complete response was maintained for more than 5 years.” In another Japanese study, HAIC with 5-FU/IFN was associated with complete and partial response rates of 10 and 24

percent, respectively. Among complete responders, survival rates at 1 and 2 years were 91 and 61 percent, respectively. Corresponding survival rates for partial responders were 52 and 16 percent. [Obi S,

et al. International Liver Cancer Association

2010 Annual Conference; abstract O-034] “IFN-alfa and IFN-beta induce tran- scription of the tumor suppressor p53.

IFN-alfa/beta signaling boosts p35 response to stress signals, and p53 gene induction by IFN-alpha/beta contributes to tumor suppression,” explained Kudo. [Nature 2003;424:516-523] “Suppression

of tumor growth can therefore be achieved

by adding 5-FU to IFN therapy.”

[ Nature 2003;424:516-523] “Suppression of tumor growth can therefore be achieved by adding 5-FU to IFN
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Benefits of sorafenib confirmed in Asian HCC patients

Naomi Rodrig

C linical trials and real-life practice have validated the efficacy and safety of

sorafenib in Asian patients with advanced (unresectable or metastatic) hepatocellular carcinoma (HCC), according to speakers at a Bayer-sponsored satellite symposium. “The Asia-Pacific Liver Cancer Study demonstrated that sorafenib significantly improved overall survival [OS] and progres- sion-free survival [PFS], and prolonged the time to progression [TTP],” reported lead investigator, Professor Ann-Lii Cheng of the National Taiwan University Hospital, Taipei, Taiwan. [Lancet Oncol 2009;10:25-34] The study, which enrolled 271 patients from China, South Korea and Taiwan, corrob- orated the results of the pivotal Sorafenib HCC Assessment Randomized Protocol (SHARP) trial, which led to the approval of sorafenib for HCC. [N Engl J Med 2008;359:378-390] In both trials, the addition of sorafenib pro- longed median OS by about 2.5 months vs placebo. The most common treatment-asso- ciated adverse events were hand-foot skin reaction, diarrhea and fatigue. According to Cheng, sorafenib was effica- cious across geographic regions, irrespective of baseline patient characteristics. “Subgroup analyses of the Asia-Pacific trial showed that sorafenib consistently improved both median

OS and median TTP. The efficacy was not affected by clinicopathologic features such as patient age, performance status, prior treat- ment, macrovascular invasion, extrahepatic metastases or disease etiology – whether it’s

hepatitis B- or hepatitis C-related,” he said. [Eur J Cancer 2012, e-pub Jan 10] Cheng added that sorafenib has been used

in HCC patients with cirrhosis (Child-Pugh class

A and B). While the pharmacokinetic profile

was similar, patients with Child-Pugh B sta- tus experienced more liver-specific adverse events and mostly had poorer outcomes. “Real-life experience from GIDEON (Global Investigation of therapeutic Decisions in unresectable HCC and Of its treatment with sorafeNib) also suggests that median OS with sorafenib is similar across geographic regions,” pointed out Professor Masatoshi Kudo of Kinki University, Osaka, Japan. “To date, some 3,300 patients have been enrolled from 39 countries across five regions, includ- ing the US, Europe, Latin America, Asia- Pacific, and Japan.” A number of predictive biomarkers have been evaluated to select patients who may benefit from sorafenib treatment. “For example, there is an indication that high bFGF [basic fibroblast growth factor] levels and low IGF-2 [insulin-like growth factor-2] levels in plasma may predict a greater posi- tive effect of sorafenib,” said Cheng. [Llovet JM, et al. AASLD 2008; abstract 149] Another study showed that early reduc- tion in alfa-fetoprotein (α-FP) levels predicts the efficacy of anti-angiogenic agents such as sorafenib, bevacizumab or thalidomide.

“To improve efficacy, combinations of sorafenib with other treatments, includ- ing chemotherapy or TACE [transarterial chemoembolization], are being explored,”

he noted.

other treatments, includ - ing chemotherapy or TACE [transarterial chemoembolization], are being explored,” he noted.
51
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51 April 2012 Conference Coverage

April 2012

Conference Coverage

22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

Molecular profiling may improve HCC management

Christina Lau

M olecular classification of hepato- cellular carcinoma (HCC) is getting

closer to clinical implementation as much work has been done to identify and validate relevant markers in recent years, accord- ing to an expert from the Massachusetts Institute of Technology in Cambridge, Massachusetts, USA. “HCC is a highly heterogeneous dis-

ease, with each tumor harboring distinct molecular aberrations irrespective of his- tological similarity,” said Dr. Yujin Hoshida, who took part in development of the first consensus classification framework for HCC based on gene expression profiles.

Hoshidaandcolleaguesperformedameta-

analysis of gene expression profiles in data sets from eight independent patient cohorts across the world. The analysis included 603 patients, representing the major etiologies of HCC in Western and Eastern countries. [Cancer Res 2009;69:7385-7392; Semin Liver Dis 2010;30:35-51] The researchers observed three robust HCC subclasses (S1, S2, S3) based on RNA expression, with each subclass correlating with clinical parameters such as tumor size, extent of cellular differentiation, and serum alfa-fetoprotein levels. “S1 and S2 represent aggressive HCC

tumors. S1 reflects aberrant activation of

theWNTsignalingpathway,whileS2ischar-

acterized by proliferation as well as MYC and AKT activation,” explained Hoshida. “S3 is less aggressive and is associated

Hoshida. “S3 is less aggressive and is associated with hepatocyte differentiation.” The classification may

with hepatocyte differentiation.” The classification may enhance the understanding of disease mechanism and promote biomarker discovery. “Exploratory profiling of tumor samples will be needed for these purposes,” he said. In other studies, researchers have found that molecular features of HCC tumors are more likely to be associated with early rather than late recurrence. “Recurrence within 2 yearsaftertreatmentofprimaryHCCisrelated to dissemination of primary tumor cells,” said Hoshida. “In contrast, de novo mechanisms are involved in late recurrence occurring after 2 years.” [J Hepatol 2003;38:200-207; Semin Liver Dis 2010;30:35-51] “Survival is determined by a combina- tion of early and late recurrence,” he said. “Recently, we’ve developed a composite prognostic model for HCC recurrence based on gene expression patterns in the tumor and adjacent tissues. The gene signatures we identified predict early and overall HCC recur- rence, and complement findings from clinical and pathology analyses.” [Gastroenterology

2011;140:1501-1512.e2]

recur - rence, and complement findings from clinical and pathology analyses.” [ Gastroenterology 2011;140:1501-1512.e2]
52
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52 April 2012 Conference Coverage

April 2012

Conference Coverage

22nd Conference of the Asian Pacific Association for the Study of the Liver, 16-19 February, Taipei

Tailored supportive cancer care will improve efficacy, reach

Radha Chitale

patients, nurses and palliative care physi- cians, showed that 21 percent of screened patients experienced nausea, which per- sisted for 7 weeks, on average. The most common contributing factors patients gave for nausea were food, odors, stress and anxiety, and movement. Physicians cited gastrointestinal obstruction, hypercalce- mia, gastrointestinal cancer and constipation as the most common contributing factors. Following thorough patient assessments, a guideline approach to supportive cancer care via specific protocols may prove better than general care with, for example, halop- eridol, an antipsychotic sometimes used to treat nausea. An ongoing study by Yates and colleagues, which has recruited about 70 patients so far, has been assigning them to receive haloperidol as a control or to receive spe- cific therapies based on their symptoms — metoclopramide for gastric statis or ileus, for example, or haloperidol plus dexameth- asone for mechanical obstruction. The researchers plan to recruit about 300 patients to the study. “We are getting more sophisticated in how we understand what patient support- ive care needs are,” said Yates, and under- standing that the problem is multifaceted, needing a team approach, she added. “We’re probably going to be allocating out supportive care services much more effectively than what we had, and perhaps reaching people who may in the past not have accessed the services or had inappro-

priate services.”

T ailoring supportive cancer care to individual patients can make it more

effective and more attractive to patients, according to an Australian study involving patients with cancer-related nausea. The study, by Professor Patsy Yates of Queensland University of Technology in Brisbane, Australia, found that a mechanistic approach to supportive care would be more desirable than a broad spectrum approach. “Supportive care is a fairly new discipline,” Yates said. “There is a need to redesign our services so that we get the right services to the right people at the right time… Part of that is having good targeted and tailored sorts of approaches to our delivery of supportive care.” Cancer patients have a greater need for supportive services during general activi- ties. These include eating and dressing, taking walks, or pursuing hobbies, for gas- trointestinal symptoms such as nausea and constipation, and for fatigue, pain, fear, anx- iety and depression. Yates noted that the psychosocial effects of cancer also need to be addressed as part of support services. Rather than “off-the-shelf” programs, Yates said clinicians should begin by under- standing patient experiences and the underlying mechanisms of their symp-

toms, develop strategies to address those symptoms, and translate those into service improvements to be put in place in clinics. The nausea study, which included a sur- vey of the related literature, interviews with

to be put in place in clinics. The nausea study, which included a sur- vey of
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54
54 April 2012 Acute Coronary Syndrome

April 2012

Acute Coronary Syndrome

Cangrelor BRIDGE to cardiac surgery for at-risk patients

Cangrelor BRIDGE to cardiac surgery for at-risk patients Radha Chitale A dministering the investigational plate -

Radha Chitale

A dministering the investigational plate- let inhibitor cangrelor in patients who

discontinued thienopyridine in prepara- tion for open heart surgery helped main- tain low platelet reactivity levels, new research showed. Ninety-eight percent of patients given cangrelor maintained low platelet reac- tivity levels compared with 19 percent of patients given placebo, without increas- ing the risk of major bleeding (P<0.001). [JAMA 2012;307:265-274] The researchers said cangrelor would be a feasible “bridging” strategy for patients waiting for cardiac surgery after discontin- uing potent dual antiplatelet therapy.

Standard therapy for patients at risk for recurrent antithrombotic events, such as those with acute coronary syndrome (ACS) or implanted stents, is aspirin plus an oral platelet receptor inhibitor, a regimen asso- ciated with bleeding complications. The bleeding risk increases significantly in these patients during surgery, par- ticularly coronary artery bypass grafting (CABG), so dual therapy must be halted about 1 week prior to a procedure so that platelet function can return to normal. However, studies have shown that the risk of thrombotic events in the interval between discontinuing therapy and sur- gery increases, and this can potentially lead to myocardial infarction and death. An estimated 5 percent of patients need

55
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55 April 2012 Acute Coronary Syndrome

April 2012

Acute Coronary Syndrome

surgery within a year of stent implanta- tion or ACS diagnosis. Prospective studies estimate that up to 12.5 percent of such patients will have complications in the waiting period that could delay surgery or prompt alternative intervention or treat- ment, resulting in a less desirable outcome. “A strategy to maintain adequate plate- let inhibition until the time of surgery, while avoiding the complications of both coronary thrombosis and surgical bleeding, is cur- rently lacking,” the researchers said. The study randomized 210 patients with ACS or a stent in need of CABG surgery to receive of cangrelor or placebo for at least 48 hours (maximum 7 days) after discon- tinuing thienopyridine therapy. Cangrelor was discontinued between 1 and 6 hours prior to surgery. Over 30 days of follow-up, CABG sur- gery-related bleeding occurred in 11.8 percent of cangrelor-treated patients compared with 10.4 percent of placebo patients (P=0.763).

There were no differences in major bleeds prior to surgery between the treatment groups, although there was a slight numerical increase in minor bleeds with cangrelor. Cangrelor may be more advantageous as a bridging strategy compared with drugs like heparin and glycoprotein inhibitors, which similarly provide consistent, rapid plate- let inhibition, because of its rapid onset of action — 1 hour as opposed to 3-4 hours. “Ultimately, cangrelor may represent a more natural bridging strategy because it selectively targets the P2Y12 receptor,” the researchers said. Cangrelor is not yet commercially avail- able but it has been well studied in large scale trials of patients with coronary artery disease. “Intravenous cangrelor is a feasible man- agement strategy, providing prolonged platelet P2Y12 inhibition in patients who must wait for cardiac surgery after thieno-

pyridine discontinuation.”

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56 April 2012 In Practice

April 2012

In Practice

Management of endometriosis: An approach for GPs

Dr. Beh Suan Tiong Consultant Obstetrician & Gynecologist Beh’s Clinic for Women Thomson Medical Centre

Dr. Beh Suan Tiong

Consultant Obstetrician & Gynecologist Beh’s Clinic for Women Thomson Medical Centre Singapore

A common progressive disorder Endometriosis – abnormal growth of endometrium outside the uterus – is a common, progressive disorder affecting women of reproductive age. The most common organs involved are the ovaries, the fallopian tubes and the pelvic region. Rarely, endometrial tissues or implants may be found in such remote areas as the lung, or the brain. The disease tends to progress under the repetitive stimulation of cyclical hor- monal changes. Displaced endometrial tissues thicken, break down and bleed with each menstrual cycle as it would in the uterus. As the body cannot eliminate

not all of them develops endometriosis. The factors that might cause the tissues to grow in some women but not in others however need further studies. Alteration in the immune system and coelomic meta- plasia – transformation of one cell to the other – may also contribute to the implan- tation of endometrial tissues, but all of these theories remain to be proven.

Clinical features of endometriosis Endometriosis should be considered in women from after menarche to before menopause, who present with pelvic pain that worsens during menses. Pain sever- ity is however not associated with surgical

‘‘

Up to 30 percent of infertile women who seek treatment are diagnosed with endometriosis

them, the tissues adhere to the surround- ing organs causing intense inflammatory response, internal adhesions, and forma- tion of ovarian cysts.

Pathogenesis The exact cause of endometriosis is unknown but the most widely accepted theory involves retrograde menstruation – the reflux of menstrual blood. Most women experience retrograde menstruation, but

diagnosis or how the disease has spread (stage I = minimal; stage II= mild, stage III= moderate, stage IV= severe). Some women with moderate endometriosis may have intense pain while others with advanced endometriosis may have no pain at all. Another common symptom is dyspare- unia – painful sex, especially during deep penetration. Endometriosis can also cause fatigue, diarrhea, constipation, dysmenor- rhea, menorrhagia or menometrorrhagia.

57
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57 April 2012 In Practice

April 2012

In Practice

57 April 2012 In Practice A laparoscopic surgical photo of bilateral ovarian endometriotic cysts. Ultrasound image

A laparoscopic surgical photo of bilateral ovarian endometriotic cysts.

surgical photo of bilateral ovarian endometriotic cysts. Ultrasound image of an endometriotic ovarian cyst. Women may

Ultrasound image of an endometriotic ovarian cyst.

Women may present with “cyclical” hema- turia and dysuria if endometriosis has spread to the bladder. Rarely, chest pain and hemoptysis may occur if endometrial implants have proliferated to the lung; even headache and seizures if they have reached the brain. Infertility is another presenting com- plaint. Up to 30 percent of infertile women who seek treatment are diagnosed with endometriosis in the course of the diag- nostic work-up for infertility. The mecha- nisms of how endometriosis interfere with fertility are not clearly understood, but

include anatomical disruption of normal reproductive organs, ovarian dysfunction, toxic effects on the oocytes, sperms and embryos. As endometriosis is an estrogen- dependent condition, symptoms tend to improve or disappear during pregnancy and after menopause.

Diagnosis A detailed history taking, especially on the relation of the symptoms to men- ses is important. The presence of a pelvic mass or a lump during palpation justifies an ultrasound to rule out ovarian cysts. The posterior fornix of the vagina should be assessed to check for thickening of the uterosacral ligaments. One biomarker that may be performed is CA-125, an elevated value of which may provide a supportive diagnosis. However, this test should not be performed during menses, when the level would be high, as it gives rise to false positive results. Definite diagnosis is confirmed by sur- gery, usually by laparoscopy.

Clinical guidelines GPs may refer to UK’s Royal College of Obstetricians and Gynecologists guide- line on the management of chronic pel- vic pain. However, practice standards may be slightly different for Asians and Caucasians. In the guideline, women with cyclical pain should be offered a therapeu- tic trial using the combined oral contra- ceptive pill or a gonadotrophin-releasing hormone (GNRH) agonist for a period of 3 to 6 months before having a diagnostic laparoscopy. The levonorgestrel-releasing intrauterine system could also be consid- ered when appropriate.

58
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58 April 2012 In Practice

April 2012

In Practice

When to refer

A study by an international patient support

group has shown that it takes an average of 9 years before a patient with endome- triosis gets a definitive diagnosis. The true chronic aspect and full scope of endome- triosis may not always be apparent. Thus, it is important to take a detailed history on the duration of pain, infertil- ity and dyspareunia. If the patient is mis- erable, disturbed, and symptoms do not

and voice changes. Oral contraceptive pills may also be used to prevent the endometrial implants from becoming active and to reduce the men- strual pain associated with endometriosis. These medical therapies are not advised in patients seeking conception because the drugs interfere with ovulation. Cystectomy and ablative surgery may ease symptoms and increase the chance of pregnancy if infertility is a problem.

‘‘

One biomarker that may be performed is CA-125, an elevated value of which may provide a supportive diagnosis

improve despite medication, and CA 125 is positive, refer. Infertile women should be

seen by an obstetrician-gynecologist early.

It is also best to refer when in doubt.

Management NSAIDs can be used in conjunction with other therapy, to relieve pain. Treatment in women who do not wish to become pregnant include hormonal therapy. Three hormonal stages should be achieved -- lower estrogen with GnRH agonist, increase progesterone level with one of the progestins , and increase androgen with danazol or gestrinone. GnRH agonist decreases follicle-stim- ulating hormone (FSH) and luteinizing hormone (LH), resulting in hypoestrogen- ism. Progestin counteracts estrogen and inhibits the growth of the endometrium. Many options are available, from the usual norethisterone to the more specific Visanne, and the choice depends on the tolerability of the patients to the various potential side effects. Danazol is a syn- thetic androgen that inhibits the growth of endometriosis but may cause hirsutism

Definitive surgery, which includes hyster- ectomy and oophorectomy, may be an option for women with intractable pain and who no longer desire pregnancy.

Conclusion There is no cure for endometriosis. The goal is to provide pain relief, restrict pro- gression of the process and restore or preserve fertility in patients within the

reproductive years.

fertility in patients within the reproductive years. Online Resources: The Royal College of Obstetricians and

Online Resources:

The Royal College of Obstetricians and Gynecologists www.rcog.org.uk/

Patient.co.uk

www.patient.co.uk/health/

Endometriosis.htm

The Endometriosis Association www.endometriosisassn.org/

The Endometriosis Network www.endometriosisnetwork.ca/

www.eastmeetswest.org.hk 14 t h Hong Kong Diabetes and Cardiovascular Risk Factors – East Meets West

www.eastmeetswest.org.hk

14 th Hong Kong Diabetes and Cardiovascular Risk Factors –

East Meets West Symposium

1 – 2 October 2012 • Hong Kong Convention and Exhibition Centre

October 2012 • Hong Kong Convention and Exhibition Centre A forum for healthcare professionals to work

A forum for healthcare professionals to work towards the common goal of prevention and management of diabetes. Take the opportunity to learn more about recent advances in diabetes care, obesity and management of atherosclerotic diseases.

Enquiry:

UBM Medica Pacific Limited Tel: (852) 2155 8557 or 2116 4348

Fax: (852) 2559 6910

E-mail: info@eastmeetswest.org.hk Website: www.eastmeetswest.org.hk

Organizers:

Website: www.eastmeetswest.org.hk Organizers: Hong Kong Foundation for Research and Development in

Hong Kong Foundation for Research and Development in Diabetes

Hong Kong Association for the Study of Obesity

Hong Kong Atherosclerosis Society
Hong Kong
Atherosclerosis Society

UBM Medica Pacific Limited

Hong Kong Institute of Diabetes and Obesity The Chinese University of Hong Kong

60
60
60 April 2012 Calendar

April 2012

Calendar

April

10th Conference of European Academy of Occupational Health Psychology 11/4/2012 to 13/4/2012 Venue: Zurich, Switzerland Info: European Academy of Occupational Health Psychology Contact: Aditya Jain Email: conference@eaohp.org Website: eaohp.org/conference.aspx

Drug Hypersensitivity Meeting 5 (DHM5

2012)

11/4/2012 to 14/4/2012 Location: Munich, Germany Info: European Academy of Allergy and clinical immunology Tel: (49) 89 54 82 34 62 Fax: (49) 89 54 82 34 43 E-mail: info@eaaci-dhm2012.com Website: eaaci-dhm2012.com/

HIV Immunologies and Preventive Technologies Conference 12/4/2012 to 13/4/2012 Location: London, United Kingdom Contact: Dr. Abubakar Yaro, Africa Health Research Organization Tel: (44) 79 3984-8586 Email: info@afrihero.org Website: www.eventsbot.com/events/

eb892234147

4th Spring Meeting of the International Society for Dermatologic Surgery (ISDS) 12/4/2012 to 15/4/2012 Location: The Leela Kempinski, Gurgaon, India

Tel: (49) 6151 9518 89 2 Fax: (49) 6151 9518 89 3 E-mail: info@isdsworld.com Website: www.isdsworld.com

27th Asia Pacific Academy of Ophthalmology Congress 13/4/2012 to 16/4/2012 Location: Busan, South Korea Contact: Secretariat Email: regi@apaobusan2012.com Website: www.apaobusan2012.com/

6th Biennial Congress of the International Society of Affective Disorders 18/4/2012 to 20/4/2012 Location: London, UK Contact: The Royal College of Physicians C/o Kenes UK Tel: (44) 20 7383 8030 Fax: (44) 20 7383 8040 Web: www.isadconference.com E-mail: isad@kenes.com

World Congress of Cardiology Scientific Sessions 18/4/2012 to 21/4/2012 Location: Dubai, UAE Info: World Congress of Cardiology Email: congress@worldheart.org Website: www.world-heart-federation. org

24th European Congress of Ultrasound in Medicine and Biology 22/4/2012 to 24/4/2012 Location: Madrid, Spain Tel: (34) 913 61 2600 Fax: (34) 913 55 9208

61
61
61 April 2012 Calendar

April 2012

Calendar

Email: info@euroson2012.com Website: www.euroson2012.com

III NWAC World Anesthesia Convention (NWAC 2012) 24/4/2012 to 28/4/2012 Location: Istanbul, Turkey Tel: (41) 22 908 0488 Fax: (41) 22 906 9140 Email: nwac@kenes.com Website: www.nwac.org

Upcoming

5th European Clinam Conference for Clinical Nanomedicine 7/5/2012 to 9/5/2012 Location: Basel, Switzerland Contact: Clinam, European Foundation for Clinical Nanomedicine Tel: (11) 41 61 695 9395 Fax: (11) 41 61 695 9390 Email: clinam@clinam.org Website: www.clinam.org

American Thoracic Society International Conference 2012 (ATS 2012) 18/5/2012 to 23/5/2012 Location: San Francisco, California, US Tel: (1) 212 315 8652 Email: conference@thoracic.org Website: www.thoracic.org/go/ international-conference

19th WONCA Asia Pacific Regional Conference 24/5/2012 to 27/5/2012 Location: Jeju, Korea

Tel: (82) 2 566 6031 Email: admin@woncaap2012.0rg Website: www.woncaap2012.org

2012 American Society of Clinical Oncology Annual Meeting 1/6/2012 to 5/6/2012 Location: Chicago, Illinois, US Tel: (571) 483 1300 Email: membermail@asco.org Website: chicago2012.asco.org

10th Royal College of Obstetricians and Gynecologists International Scientific Congress 5/6/2012 to 8/6/2012 Location: Kuching, Malaysia Tel: (603) 6201 1858 Email: info@rcog2012.com Website: www.rcog2012.com

17th World Congress on Heart Disease

2012

27/7/2012 to 30/7/2012 Location: Toronto, Ontario, Canada Info: International Academy of Cardiology Tel: (1) 310 657 8777 Fax : (1) 310 659 4781 Website: www.cardiologyonline.com E-Mail: Klimedco@ucla.edu

15th Biennial Meeting of the European Society for Immunodeficiencies (ESID

2012)

3/10/2012 to 6/10/2012 Location: Florence, Italy Tel: (41) 22 908 0488 Fax: (41) 22 906 9150 Email: esid@kenes.com Website: www.kenes.com/esid

63
63
63 April 2012 Humor

April 2012

Humor

“Well, exercising may not make you live longer, but you certainly will die healthier!”
“Well, exercising may not make you live longer,
but you certainly will die healthier!”
“Ok Doc, I’m awesomely impressed. Can you tell me now what should be done about
“Ok Doc, I’m awesomely impressed. Can you tell me
now what should be done about my cholesterol?”
“Good news honey. Dr. Carboni said that with proper medical care, you will live another
“Good news honey. Dr. Carboni said that with proper
medical care, you will live another ten minutes!”
“Did you wash your hands?”
“Did you wash your hands?”
“You have a very serious illness Mrs. Lucas. So far that’s all we know!”
“You have a very serious illness
Mrs. Lucas. So far that’s all we know!”
“The tests are back. You are a Sagittarius!”
“The tests are back.
You are a Sagittarius!”

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A specialty publication from UBM Medica An essential newspaper for the practice of oncology in Asia
A specialty publication from UBM Medica An essential newspaper for the practice of oncology in Asia
A specialty publication from UBM Medica An essential newspaper for the practice of oncology in Asia
A specialty publication from UBM Medica An essential newspaper for the practice of oncology in Asia

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Medical Tribune is published 12 times a year (23 times in Malaysia) by UBM Medica, a division of United Business Media. Medical Tribune is on controlled circulation publication to medical practitioners in Asia. It is also available on subscription to members of allied professions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter published herein has been prepared by professional editorial staff. Views expressed are not necessarily those of UBM Medica. Although great effort has been made in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. The information contained within should not be relied upon solely for final treatment decisions. © 2012 UBM Medica. All rights reserved. No part of this publication may be reproduced in any language, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the written consent of the copyright owner. Permission to reprint must be obtained from the publisher. Advertisements are subject to editorial acceptance and have no influence on editorial content or presentation. UBM Medica does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature. Philippine edition: Entered as second- class mail at the Makati Central Post Office under Permit No. PS-326-01 NCR, dated 9 Feb 2001. Printed by Fortune Printing International Ltd, 3rd Floor, Chung On Industrial Bldg, 28 Lee Chung Street, Chai Wan, Hong Kong. ISSN 1608-5086

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PRINT • ONLINE • DIGITAL EDITION Read Medical Tribune anytime, anywhere www.medicaltribune.com
PRINT • ONLINE • DIGITAL EDITION Read Medical Tribune anytime, anywhere www.medicaltribune.com
PRINT • ONLINE • DIGITAL EDITION Read Medical Tribune anytime, anywhere www.medicaltribune.com

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