Medical Tribune September 2012 HK

September 2012

Experts debate China’s healthcare reforms

Experts call for action on viral hepatitis

Healthcare in China: Finding the right balance

FORUM

Carbohydrate sources key in CHD mortality

CONFERENCE

HONG KONG FOCUS

NEWS

Involving patients reduces unnecessary antibiotic Rx

1,500 Academic Speakers340 Sessions70 Special TopicsDate: 11-14 October 2012

Venue: China National Convention Center (CNCC), Beijing, China

Congress Language:

English and Mandarin

Organized by:

Organizing Committee of Asia Pacific Heart Congress (APHC)Organizing Committee of Great Wall International Congress of Cardiology (GWICC)

Congress Secretariat for Overseas Delegates:

Secretariat Office of GWICC & APHC (Shanghai Office)Tel: 86-21-6157 3888 ext. 3861/3862/3864/3865Fax: 86-21-6157 3899Email: [email protected]

Please visit www.heartcongress.org for further details

10,000delegates already

confirmed!

1,500 Academic Speakers340 Sessions70 Special TopicsDate: 11-14 October 2012

Venue: China National Convention Center (CNCC), Beijing, China

Congress Language:

English and Mandarin

Organized by:

Organizing Committee of Asia Pacific Heart Congress (APHC)Organizing Committee of Great Wall International Congress of Cardiology (GWICC)

Congress Secretariat for Overseas Delegates:

Secretariat Office of GWICC & APHC (Shanghai Office)Tel: 86-21-6157 3888 ext. 3861/3862/3864/3865Fax: 86-21-6157 3899Email: [email protected]

Please visit www.heartcongress.org for further details

10,000delegates already

confirmed!

3 September 2012

Elvira Manzano

The inaugural Healthcare in China sum-mit held in Beijing recently served as a platform for experts to debate China’s

major health challenges, identify key issues that could derail implementation of its recent reforms, and formulate strategies to meet new targets.

The forum brought together top govern-ment officials, policy makers, academics and experts within the country and from around the world.

Mr. Lei Haichao, deputy director-general of the Beijing Health Bureau, said that al-though China has made significant headway towards system improvement (eg, the estab-lishment of a nationwide health insurance system, a primary drug list and a central-ized drug procurement system), some issues remain to be addressed including resource allocation. He said more than 85 percent of China’s health budget was spent on diagno-sis and treatment, with very little allocated for disease prevention.

Our services are still treatment-focused and the burden of healthcare on patients is still very heavy, especially on rural residents, he added.

In recent years, the government has ap-proved several health laws and initiated more projects that are set to benefit public hospitals. However, more investments have to be poured into insurance and equipment, Lei said.

China’s healthcare system funding is a balance between public and private. No country has a purely public or purely private health system, and no country can provide solely public funding, said Lei. Like any country, China is trying to find a balance between the two forms.

At the panel discussions convened dur-ing the conference, experts provided sug-gestions on how best to allocate resources, progress public hospital reforms, augment services and raise standards of care. Specific recommendations included removing physi-cians’ financial incentives to overprescribe drugs and tests, controlling investments and medical costs and refocusing efforts towards stemming the tide of chronic diseases which are responsible for a very high proportion (80 percent) of deaths in China.

Experts debate China’s healthcare reforms

China has implemented major reforms to its healthcare system in recent years, but resource allocation remains a major issue.

4 September 2012 Forum

Elvira Manzano

Over that past 3 years, China has made commendable progress with respect to its healthcare reforms. Since 2009,

the Chinese government has allocated more than RMB 1.5 trillion to improve the country’s healthcare system, with significant progress made in coverage of medical insurance and the establishment of a primary drug list and centralized drug procurement system.

There remain deeply entrenched issues, however, particularly with the way in which resources are allocated. Our services are still very much treatment focused, with more than 85 percent of medical resources spent on diagnosis and treatment. Relatively little is spent on the prevention of diseases. Further-more, the burden of healthcare on patients is

still very heavy, especially on rural residents. Overall however, the Chinese government

has been quite successful in implementing

Healthcare in China: Finding the right balanceBased on an excerpt from a keynote address by Mr. Lei Haichao, deputy director-general, Beijing Health Bureau, during the Healthcare in China 2012 Economist Conference held recently in Beijing, China.

its recent healthcare reforms, playing a lead-ing role in planning and showing high levels of commitment to building a better system. The government has already pushed through more than 10 new laws, as well as initiated many pilot projects. The results from these have been good and now they need to roll out to 10,000 public hospitals.

Further areas that the government can do to improve Chinas’ healthcare system include the following:• Invest more in insurance and equipment.• Guarantee quality of service in all health-care centers.• Provide better service when it comes to

China is looking to find the right balance between public and private

funding of its healthcare system.

With ongoing reforms,

we will see more financial

resources allocated to

hospitals, but personally

I don’t think it is enough yet

‘‘

5 September 2012 Forumpublic disclosure, so everyone knows the state of the market. • Better educate the general public in the prevention of diseases.

While it is important for the government to maintain its role as the main provider of pri-mary healthcare services, the private sector should also be involved in non-primary ser-vices. Indeed, the healthcare system needs to work closely together with the medical insur-ance system in order to help those with higher demands and who can afford more expensive and individualized services.

The situation for hospitals throughout Chi-na has been that day-to-day hospital charges have not been financed by the government. In fact, hospital staff salaries have usually been covered by patients’ treatment fees. Hospitals have therefore faced the ongoing challenges

of how to pay their staff and cover their daily costs.

With ongoing reforms, we will see more financial resources allocated to hospitals, but personally I don’t think it is enough yet.

In the near future we will also see more government money and training going into generalist doctors and local facilities, with GPs and family doctors given more oppor-tunities to train. In addition, in some places, people who go to local hospitals will be given more money back as an incentive to go to pri-mary healthcare centers.

We need to find the right balance between private and public.

No country has a purely public or purely private system and no country can provide solely public funding. Like every country, China is trying to find its balance.

6 September 2012 Hong Kong Focus

Naomi Rodrig

Marking the World Hepatitis Day on 28 July 2012, experts and ac-tivists are calling on Hong Kong

and other Asian countries to tackle viral hepatitis, which is endemic to the region.

It is estimated that 500 million pep worldwide are living with chronic hepati-tis B or C infection, resulting in about 1 mil-lion deaths each year attributed to hepati-tis-related complications such as cirrhosis, liver failure and hepatocellular carcinoma (HCC). Asia Pacific accounts for 75 percent of the global hepatitis B burden. In Hong Kong, the estimated prevalence of chronic hepatitis B is >8 percent, or 1 in 12 people.

“Despite its huge impact on health in Asia Pacific, hepatitis remains a group of viral diseases that are largely unknown, undiagnosed and untreated,” said Charles Gore, President of the World Hepatitis Al-liance, during a visit to Hong Kong. “Gov-ernments and public health bodies need to do more to boost awareness and help more people to seek and access diagnosis and treatment.”

“Despite an effective infant vaccination program introduced in the past 2 decades, the prevalence of hepatitis B in Hong Kong and China is still high due to the large popu-lation of adult HBV [hepatitis B virus] carri-ers,” remarked Professor George Lau, Chair Professor in Clinical Hepatology and Co- director of the Institute of Translational Hepatology, Beijing 302 Hospital.

According to Lau, who is a founding trustee of the Cheng Si-Yuan (China Inter-

national) Hepatitis Research Foundation, many local people are not aware of being HBV carriers. “By the time they experi-ence any symptoms it may be too late, as they may have already progressed to liver cirrhosis or even HCC. About 1,500 Hong Kong people die of HCC every year,” he said. “Therefore, it is each person’s respon-sibility to get tested to ascertain their hepa-titis B status. People who are positive for HBsAg [hepatitis B surface antigen] should be followed up regularly and receive ap-propriate antiviral treatment as necessary.”

Blood testing for HBsAg is simple and cheap, costing just HK$10. Moreover, vari-ous organizations are promoting and sub-sidizing testing in the community. “For example, the Cheng Si-Yuan Hepatitis Foundation has covered free testing for thousands of local people through charita-ble donations. To celebrate this year’s World Hepatitis Day, we have opened a new clinic in Western New Territories, which aims to

Experts call for action on viral hepatitis

A simple blood test can detect HBsAg

7 September 2012 Hong Kong Focusimprove access to diagnosis and treatment for local people, mostly immigrants from mainland China,” noted Lau.

ASIAHEP Hong Kong – a nonprofit or-ganization committed to raising public awareness of hepatitis B – is also urging people to get tested, providing free HB-sAg tests. “The knowledge and awareness of hepatitis B among Hong Kong residents has improved over the past decade. How-ever, one out of five chronic patients who fail to receive timely treatment will die of

liver cancer, cirrhosis or other related com-plications. Through appropriate treatment, we are hopeful that disease progression and complications will decline,” remarked ASIAHEP Hong Kong Chairperson, Dr. Nancy Leung.

The organization has also launched a free iPhone app called ‘myLiver’, which provides essential information about hepa-titis B and enables patients to monitor their HBV DNA and alanine aminotransferase levels.

Christina Lau

More than half of patients with cardio-vascular disease (CVD) in Hong Kong

experience a recurrent MI within 5 years, a survey has revealed.

The local patient group Care For Your Heart interviewed 263 adult CVD pa-tients between November 2011 and Janu-ary 2012 to investigate their disease history and opinions on drug treatment. Results showed that 71.7 percent had suffered from CVD for more than 5 years.

“More than 30 percent of the respondents had experienced at least one acute MI. Al-most 60 percent had a recurrent MI within 5 years, and 40 percent even experienced recurrence within 3 years,” said Professor Cheuk-Man Yu of the Department of Medi-cine and Therapeutics, Chinese University of Hong Kong, at a press conference.

Notably, 65 percent of the respondents experienced their first acute MI before the age of 60 years. In daily life, 63.4 percent of

the respondents were afraid of doing vig-orous exercise because of CVD, while 46.3 and 39.3 percent feared being irritated or traveling out of town, respectively.

“Acute reduction of blood flow to the heart may lead to sudden death,” said Yu. “Although no statistics on acute coro-nary syndrome [ACS] are available in Hong Kong, about 6,100 individuals were hospitalized and died from acute MI in 2009–2010. The hospitalization rate was 30 percent.” [www.ha.org.hk/upload/publica-tion_15/321.pdf]

“As shown in the survey, CVD patients wanted medications that better reduce re-currence [20.5 percent] with fewer side ef-fects [21.5 percent] than their current drugs,” he continued. “For those with ACS, who need sustained dual antiplatelet therapy to reduce recurrence and mortality, new-gen-eration antiplatelet drugs such as ticagrelor may offer a better option than conventional medications, as shown in the PLATO trial [Study of Platelet Inhibition and Patient

Recurrent MI common in local CVD patients

8 September 2012 Hong Kong FocusOutcomes].” [N Engl J Med 2009;361:1045-1057]

In the landmark trial, ticagrelor in com-bination with aspirin significantly reduced the risks of CV mortality, MI and stroke vs clopidogrel plus aspirin. “Ticagrelor is the first antiplatelet drug that significantly re-duces overall mortality in ACS patients,”

pointed out Yu, who was principal inves-tigator of the trial in Hong Kong. “Based on the results, European and US guidelines now recommend ticagrelor as first-line therapy for ACS patients. We suggest that Hong Kong follow these guidelines, and list the drug in the Hospital Authority’s formulary.”

Christina Lau

Researchers of the School of Life Scienc-es, Chinese University of Hong Kong

(CUHK) have identified pathogenic path-ways contributing to the development of spinocerebellar ataxia (SCA), opening up new research directions for this incurable genetic disorder.

SCAs are a group of genetic diseases that lead to progressive deterioration of the cerebellum. Patients gradually lose fine mo-tor functions and have difficulty maintaining balance or coordinating daily movements. With no known cure at present, treatment focuses on delaying deterioration and maximizing patients’ self-care ability through rehabilitation.

“We showed that mutant RNAs carrying an expanded CAG repeat [expanded CAG RNAs] induce apoptosis by activating the nucleolar stress pathway in both patients and transgenic animal disease models,” said Professor Edwin Chan, who led the study.

Researchers identify pathogenic pathways of spinocerebellar ataxia

[Proc Natl Acd Sci USA 2012, e-pub 30 July]“From a mechanistic point of view, ex-

panded CAG RNAs prevent a protein called nucleolin from binding with chromatin in the nucleolus, a special region in the nucle-us responsible for producing ribosomes,” he continued. “This phenomenon, described as ‘nucleolar stress’, eventually triggers apop-tosis in the cerebellum and leads to the de-velopment of SCAs.”

According to the researchers, the finding not only allows biomedical scientists and clinicians to better understand SCAs, but also opens up a novel angle for research on possible treatments that work at the RNA level.

“Our study is made possible with the support of CUHK’s Biochemistry Program, the Hong Kong Spinocerebel-lar Ataxia Association, and the Research Grants Council of Hong Kong,” said Chan.

9 September 2012 Hong Kong FocusTreating brain vessel malformations without a cutChristina Lau

Researchers at the Chinese University of Hong Kong have reported success with linear accelerator radiosurgery

in treatment of cerebral arteriovenous mal-formation (AVM), providing patients with a safe, effective and non-invasive option.

“Cerebral AVM is a cluster of abnormal connecting vessels between cerebral arteries and veins, with a morbidity and mortality rate of 40 percent. It represents the leading cause of stroke in young individuals aged 10-40 years,” said Dr. Deyond Siu of the Department of Imaging and Interventional Radiology. “The goal of treatment is there-fore to reduce the risk of fatal or debilitating hemorrhagic stroke.”

“Microsurgical resection is the mainstay of treatment for cerebral AVM, as it im-mediately eliminates the risk of hemor-

rhage with an obliteration rate of at least 90 percent,” said Professor George Wong of the Department of Surgery. “However, depend-ing on the location and size of AVM and pa-tient-related factors, microsurgery may be too risky in some cases.”

“In cases where AVMs are large or locat-ed in critical areas of the brain, for example, radiosurgery may be a preferred treatment option,” said Dr. Michael Kam of the Depart-ment of Clinical Oncology. “The radiation beams are believed to act on endothelial cells lining the AVM. These cells tend to multiply after radiosurgery and produce clots, leading to diminished blood flow through the tangle

of vessels. Eventually, the AVM becomes a harmless scar.”

However, Wong noted that the efficacy of linear accelerator radiosurgery was not well assessed in the literature. “We have treated more than 100 cerebral AVM pa-tients with this technique since 1998. In a recently-published report of 70 consecutive patients followed up for at least 2 years, the success rate, or rate of successful AVM obliteration without complications, was 86 percent,” he reported. “Seven percent of patients developed complications, includ-ing radionecrosis [3 percent], symptomatic edema [6 percent] and re-bleeding [6 per-cent].” [J Clin Neurosci 2012, e-pub 9 Jul]

The median age of patients in the series was 31 years, and the mean AVM volume was 7 cc. The mean radiation dosage was 20 Gy.

“The typical hospital stay for radiosur-gery is only 3 days, significantly shorter than that required for microsurgery and embolization,” said Kam. “The major limi-tation is that post-treatment obliteration of AVM takes 2-3 years. During that period, there is a risk of bleeding, and we monitor patients with MRI every 6 months.”

“We are now assessing the efficacy of new techniques, such as frameless stereo-tactic radiosurgery or delivery of radiation dose in fractions, for giant or brainstem ce-rebral AVMs,” added Wong. “Preliminary results are promising.”


Antiviral treatment cuts HCC recurrenceNaomi Rodrig

A meta-analysis conducted by research-ers from the Center of Liver Health, Chinese University of Hong Kong

(CUHK) suggests that antiviral treatment after surgical resection of hepatocellular carcinoma (HCC) is associated with a significant reduction of HCC recurrence compared with untreat-ed controls. [Aliment Pharmacol Ther 2011;33: 1104-1112]

According to Professor Henry Chan, the Center’s Director, although surgical resection can be applied to small HCC tumors (ie, <5 cm in diameter), about 70 percent of patients experience HCC recurrence within 5 years of surgery.

“In Hong Kong, over 80 percent of HCC is caused by hepatitis B virus (HBV) infection. High HBV replication, as reflected by high HBV DNA levels, is one of the key factors leading to the development of HCC,” he said.

“Previous research suggests that among patients who undergo surgical resection for HCC, those who have higher HBV DNA level tend to have a higher risk of recurrence. “Al-though many studies were conducted in the past few years to evaluate whether antiviral therapy can prevent HCC recurrence, sample sizes were usually small and failed to provide accurate data,” he noted.

Chan and colleagues analyzed nine studies from the literature reporting HCC recurrence in chronic hepatitis B patients who underwent surgical resection. The studies, which were conducted in Hong Kong, mainland China and Japan, included a total of 551 patients, of whom 204 received antiviral treatment and 347 were untreated controls.

“Our analysis revealed that antiviral treat-ment was associated with over 40 percent risk reduction for HCC recurrence as compared with the untreated controls,” reported Dr. Grace Wong, Associate Professor at CUHK’s Department of Medicine and Therapeutics. “Furthermore, antiviral treatment reduced the risk of liver failure by 85 percent and the risk of death due to HCC by 70 percent.”

A retrospective analysis by investigators from the University of Hong Kong, which was not included in CUHK’s meta-analysis, also demonstrated that antiviral treatment post HCC resection significantly prolonged dis-ease-free survival and overall survival (OS). The 1-, 3-, and 5-year OS rates in the treatment group were 88.1, 79.1 and 71.2 percent, respec-tively; in the control group, 76.5, 47.5 and 43.5 percent, respectively (p<0.005 for all periods). Subgroup analysis showed that the survival benefit of antiviral treatment was greatest in patients with stage I or II tumors without ma-jor vascular invasion. [Arch Surg 2011;146:675-681]

According to Wong, no specific antiviral agent is recommended for HCC patients to prevent recurrence. “In general, we will choose entecavir or tenofovir, which are recommend-ed for other chronic hepatitis B patients who require treatment,” she told Medical Tribune.

Based on the evidence from this meta-anal-

11 September 2012 Hong Kong Focusysis, CUHK physicians are representing Hong Kong in drawing up the chronic hepatitis B management consensus guideline of the Asian Pacific Association for the Study of the Liver [APASL].

“The latest APASL guideline recom-mends antiviral therapy for all HCC patients who have an HBV DNA level high-er than 2,000 IU/mL after surgical resection,” advised Wong.

High prevalence of overweight-related NAFLD in Hong KongNaomi Rodrig

“The Liver Health Census Study” conducted by the University of Hong Kong (HKU), Hong Kong

Liver Foundation and Hong Kong Red Cross Blood Transfusion Service, suggests that over 40 percent of healthy people in Hong Kong have nonalcoholic fatty liver disease (NAFLD), predisposing them to liver complications that may lead to hepatocellular carcinoma.

“The high prevalence of NAFLD in Hong Kong may lead to a high rate of cirrhosis and its complications in the near future, resulting in a heavy burden to the local healthcare sys-tem. So, it’s important to raise public aware-ness of NAFLD for better disease control and prevention,” noted Kam-Kee Yu, Chairman of the Hong Kong Liver Foundation.

The joint study, conducted between August 2010 and March 2012, recruited 2,493 subjects, including blood donors and healthy volun-teers from the general population. All sub-jects screened negative for hepatitis B and C infection, and reported no significant alcohol intake.

In addition to blood pressure, weight, height, and waist and hip circumference mea-surements, subjects completed a detailed

questionnaire and underwent ultrasound scan and Fibroscan of the liver, as well as blood testing for liver enzymes, fasting glucose and cholesterol levels.

“We found that 1,054 participants, or 42 percent, had NAFLD, including 18 percent with mild disease, 19 percent with moderate disease and 5 percent with severe NAFLD,” reported Dr. James Fung, Honorary Clinical Assistant Professor at the Department of Med-icine, HKU. “NAFLD prevalence increased with age and was slightly more prevalent in men than in women.”

The investigators found a strong associa-tion between higher waist circumference and

12 September 2012 Hong Kong Focusthe severity of steatosis, in both males and fe-males. Eighty-five percent of subjects in the highest waist circumference group – defined as >89 cm for men and >79 cm for women – had some degree of NAFLD.

“The study result is both surprising and alarming,” remarked lead investigator Prof. Man-Fung Yuen of HKU. “Local people are advised to be more alert to their liver health. It can be achieved by having a simple assess-ment of your waist circumference.”

Based on the study data, the researchers recommend new optimal cut-off values for waist circumference. “The current waist cir-cumference cut-off recommended by the De-partment of Health (DH) is 90 cm for men and 80 cm for women. We suggest the optimal cut-off should be lowered to 84 and 74 cm, respec-tively, to prevent NAFLD and progression to

NASH [non-alcoholic steatohepatitis] and cir-rhosis,” said Yuen.

According to local data, over 40 percent of men and 36 percent of women in Hong Kong are overweight (body mass index [BMI] >25) or obese (BMI >30). Additional risk factors linked to increasing severity of steatosis in the study included increased glucose and choles-terol levels and higher blood pressure, which are also associated with overweight and un-healthy lifestyle.

“With the societal and lifestyle changes, the current standard suggested by the DH may be too loose, and the new waist targets should be implemented to reduce the chance of develop-ing NAFLD by adopting lifestyle changes,” argued Dr. Cheuk-Kwong Lee, Consultant of the Hong Kong Red Cross Blood Transfusion Service.

A move towards popularizing Chinese medicine

Naomi Rodrig

A new initiative to enhance traditional Chinese medicine (TCM) services in

Hong Kong has been announced recently by the newly elected Chief Executive, Chun-Ying Leung.

“Dr. Wing-Man Ko, Secretary for Food and Health will chair the newly estab-lished preparatory task force on a Chinese Medicine Development Committee, to pro-vide better medical services,” said Leung. “The 11-member task force will advise the government on the committee’s terms of reference and composition, as well as future

priorities and strategic direction.” According to Ko, task force members will

comprise representatives of TCM practitio-ners, TCM industry and schools of Chinese medicine from the University of Hong Kong (HKU), Chinese University of Hong Kong (CUHK) and Hong Kong Baptist University (HKBU).

“Hopefully we can come up with a feasible and realistic plan,” remarked Kit Wong, who is Chairman of the Chinese Medicine Practitio-ners Board under the Chinese Medicine Coun-cil of Hong Kong. The Council is a statutory

13 September 2012 Hong Kong Focusbody established under the Chinese Medicine Ordinance. It is responsible for implementing regulatory measures for Chinese medicine, so as to protect public health and consumers’ rights and to ensure the professional standard of Chinese medicine practice and the trade of Chinese medicines.

Leung argued that the TCM industry should be more widely recognized in Hong Kong as millions of local people are al-ready seeking TCM treatments at the Chi-nese medicine clinics of the Hospital Au-thority as well as in the private TCM sector. “The regulatory background for Chinese medicine is in place,” he noted.

Following the introduction of accreditation and registration procedures for TCM practitio-ners in the past few years, nearly 6,400 of them are currently fully registered in Hong Kong, while another 68 have limited registration. Furthermore, about 80 practitioners graduate each year from the three local TCM schools at HKU, CUHK and HKBU.

The three universities, which are conduct-ing research and clinical trials to provide evi-dence-based data on TCM products, are plan-ning to establish a Chinese medicine hospital and are currently raising funds for the joint project. In addition, the Kwong Wah Hospital has announced plans to launch an inpatient service combining Chinese and Western medi-cine. At least 50 beds will be allocated for this service when the hospital’s two-phase redevel-opment project is completed in 2022.

Although the plans for expanding Chi-nese medicine services have been welcome by some, the local Western medical sector remains somewhat doubtful about the move. “As long as it is scientific and evidence-based medicine, it’s fine, but I think Dr. Ko is trying to promote another profession. It’s a totally different dis-

cipline,” said Dr. Hung-Hing Tse, President of the Hong Kong Medical Association.

This and other similar concerns have prompted Ko to issue a statement that the development of TCM will not affect the West-ern medicine services in Hong Kong. “On the contrary, the development of Chinese medi-cine hopefully may help alleviate some pres-sure on our public hospital system on West-ern medical side, in particular primary care and rehabilitation services,” he said. “Chinese medicine may be useful for patients recover-ing from stroke and cancer after receiving Western medical treatment or surgery, and also for people suffering from arthritis.”

According to Ko, now is the right time to ex-pand and promote TCM services. “There is a legal framework for registration of TCM prac-titioners and products, while research on Chi-nese medicine at local universities and public hospitals continues to expand,” he said.

14 September 2012 Hong Kong FocusCase Study

Aripiprazole augmentation in Tourette’s syndrome with comorbid OCDDr. Jimmy Yuet-Sun DongSpecialist in PsychiatryPrivate Practice

Introduction

Comorbid conditions, such as obses-sive-compulsive disorder (OCD) and attention-deficit hyperactivity disor-

der (ADHD), are present in many patients with Tourette’s syndrome (TS). These comor-bidities often cause more functional impair-ment than the tics characteristic of TS; hence, addressing these conditions is a treatment priority.

Presentation and historyA 22-year-old Hong Kong Chinese male,

diagnosed with TS and concomitant OCD at the age of 11 years, was referred to our clinic. His primary compulsive behaviors consisted of an unremitting urge to bite his own tongue, resulting in multiple abrasions and lacera-tions; and a compulsion to pick on the scabs that formed over the abrasions. Other com-pulsions included an urge to throw objects, swallow small items and remove his trousers in public.

The patient’s constant compulsions se-verely impeded his activities of daily living. He consulted a number of psychiatrists who prescribed various medications, including se-lective serotonin reuptake inhibitors (SSRIs), and typical and atypical antipsychotics, given as monotherapy or in varying combinations. There was neither significant improvement

nor remission of OCD symptoms during this long treatment period.

On presentation, the patient exhibited spasmodic, jerking arm movements, and was constantly spitting into a towel. Examina-tion of the tongue revealed a 4 cm long abra-sion. His treatment consisted of escitalopram 30 mg daily, risperidone 3 mg daily, and flu-pentixol/melitracen (0.5 mg/10 mg) three times daily. The patient reported extreme anxiety and depression over his compulsions and admitted to instances of suicidal ideation. At this time, he had also stopped his studies.

We modified the regimen to fluvoxamine maleate 300 mg daily, escitalopram 15 mg daily, and flupentixol/melitracen (0.5 mg/10 mg) four times daily, discontinuing risperi-done. However, only a minor improvement of OCD symptoms was observed. Sever-al weeks later paliperidone, titrated up to 9 mg/day, was added, resulting in partial con-trol of some compulsions and a marked de-crease in jerking movements. Concurrently, the patient received cognitive behavioral ther-apy (CBT) to deal with his compulsions. The two-pronged pharmacological/behavioral ap-proach was maintained for approximately 2 years.

Augmentation treatmentLast year, noting emerging evidence from

case reports and clinical trials, we decided to commence augmentation therapy with ar-ipiprazole, starting at 5 mg and increasing to 10 mg daily within 2 weeks. After 2 weeks of

15 September 2012 Hong Kong Focustreatment, the patient reported a 50 percent decrease in the frequency of his compulsions and significantly less anxiety about his obses-sive-compulsive behavior. In particular, the compulsions to bite his tongue and remove his trousers in public ceased; while he occa-sionally thought about swallowing random small items, he was able to control himself from acting on this urge. There was also a no-table decrease in the frequency and severity of his jerking movements.

The patient has been maintained on a regi-men of paliperidone, escitalopram, flupentix-ol/melitracen and aripiprazole, and is on reg-ular follow-up every 2 months. With his OCD symptoms under control, he has resumed at-tending class and is considering higher edu-cation.

DiscussionTS is an inherited neuropsychiatric disor-

der with childhood onset, characterized by multiple motor tics and at least one vocal tic. Worldwide, TS prevalence has been estimated at 4-5 cases per 10,000 individuals.1 In a sur-vey of 9,742 Chinese children aged 7-16 years, the prevalence of TS was 43 per 10,000.2

Comorbid conditions such as OCD and ADHD may affect up to 50 percent of TS patients.3 Current management of OCD is with CBT plus pharmacotherapy with either SSRIs or clomipramine. However, 40 to 60 percent of OCD patients either fail to respond or experience significant residual symptoms.4 In recent years, studies have as-sessed the efficacy of various antipsychotics in augmenting the anti-OCD effects of SSRIs. Agents that have demonstrated clinical ben-efit include risperidone,5-8 olanzapine,9-11 ami-sulpride,12 and quetiapine.13,14

Aripiprazole is an atypical antipsychotic

with partial agonist activity at the serotonin 5HT1A receptor and the dopamine D2 recep-tor, and antagonist activity at the 5HT2A

recep-tor.15,16 It has demonstrated clinical efficacy in the treatment of obsessive-compulsive symp-toms in adult patients with bipolar disorder17 and schizophrenia,18 and children with tic dis-orders.19

Our patient noted a marked decrease in compulsion frequency and an increased abil-ity to resist them upon starting aripiprazole treatment.

It is hypothesized that aripiprazole’s aug-mentation of the anti-OCD effect of SSRIs is mainly through modulation of serotonin transmission.20 Increased dopaminergic ac-tivity, postulated to play a central role in the pathophysiology of TS,21 has also been hy-pothesized to play a role in the pathophysiol-ogy of OCD.22 That aripiprazole augmentation resulted in both amelioration of the patient’s motor tics and relief of OCD symptoms lends credence to these theories, and is possibly at-tributable to aripiprazole’s partial agonist ac-tivity at dopamine D2 receptors.20

The efficacy of aripiprazole monotherapy or as add-on to SSRI-based therapy in re-fractory OCD was demonstrated in several clinical trials.20,23 Most recently, two case se-ries from Japan demonstrated significant im-provements in OCD patients with inadequate response to SSRI monotherapy treated with aripiprazole augmentation.24,25

Aripiprazole augmentation was generally well tolerated; the most common side effects were akathisia, nausea/vomiting, hyperkine-sias, tremors, and asthenia. Known side ef-fects of atypical antipsychotics include clini-cally significant weight gain, dysglycemia, extrapyramidal symptoms, and development of the metabolic syndrome.26 Notably, our

16 September 2012 Hong Kong Focuspatient did not experience any side effects with aripiprazole augmentation. Neverthe-less, more clinical trials are needed to fur-ther elucidate the safety and tolerability of aripiprazole augmentation in this setting.

In summary, this report adds to the emerg-ing evidence on the benefits of aripiprazole augmentation in intractable OCD.

References:

1. Nervenarzt 2002;73:805-819. 2. Zhongua Liu Xing Bing Xue

Za Zhi 2004;25:131-133. 3. Curr Opin Neurol 2011;24:119-125.

4. J Clin Psychiatry 2002;63(Suppl 6):20-29. 5. J Clin Psychiatry

1996;57:303-306. 6. Int Clin Psychopharmacol 2000;15:297-

301. 7. Arch Gen Psychiatry 2000;57:794-801. 8. J Clin Psychi-

atry 1995;56:423-429. 9. J Clin Psychiatry 2000;61:514-517. 10.

Psychiatry Res 2000;96:91-98. 11. Can J Psychiatry 2001;46:356-

358. 12. Human Psychopharmacol 2003;18:463-467. 13. Int Clin

Psychopharmacol 2002;17:37-40. 14. Int Clin Psychopharmacol

2002;17:115-119. 15. CNS Drugs 2004;18:251-267. 16. Eur J

Psychopharmacol 2002;441:137-140. 17. Gen Hosp Psychiatry

2010;32:556-558. 18. J Clin Psychiatry 2008;69:1856-1859. 19.

J Child and Adolescent Psychopharmacol 2009;19:441-447.

20. Clin Pract Epidemiol Ment Health 2011;7:107-111. 21. Am J

Psychiatry 2002;159:1329-1336. 22. Lancet 2002;360:397-405.

23. J Clin Psychiatry 2005;66:49-51. 24. World J Biol Psychiatry

2012;13:14-21. 25. Int J Psychiatry Clin Pract 2011;15:263-269.

26. J Clin Psychiatry 2004;65(Suppl 7):4-18.

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HK to adopt more stringent guideline for CMLChristina Lau

Patients with chronic myeloid leukemia (CML) should be monitored for early molecular response to treatment so

that slow responders can be switched to other drugs promptly as needed, according to new local guidelines.

The guidelines, announced recently at the Hematology Protocol Summit in Hong Kong, recommend that CML patients be assessed for BCR-ABL1 transcript levels at 3 months of first-line imatinib treatment. “If BCR-ABL1 does not fall to ≤10 percent of pretreatment level at 3 months, a switch to second-gener-ation TKIs [tyrosine kinase inhibitors] can be considered,” said Professor Yuk-Lam Kwong of the Division of Hematology, Medical On-cology and Bone Marrow Transplantation, University of Hong Kong.

This recommendation is more aggres-sive than current European or US guide-lines, which recommend that major molecu-lar response (MMR), or a drop of BCR-ABL1 transcript levels to 0.1 percent of pretreat-ment values, be achieved by 18 months of treatment.

“Recent studies suggest that early molecu-lar response at 3 months is predictive of long-term prognosis,” said Kwong.

In an analysis of the German CML Study IV, for example, patients receiving first-line imatinib treatment who achieved BCR-ABLIS (BCR-ABL transcript levels on the Internation-al Scale) ≤10 percent at 3 months had signifi-

cantly longer progression-free survival (PFS) and overall survival (OS) at 4.7-year follow up. [Hanfstein B, et al. ASH 2011, abstract 783] Similarly, patients treated with dasatinib who achieved early molecular response at 3 months had a significantly higher probability of even-tually achieving cytogenetic response (CCyR) than those without early molecular response. [Marin D, et al. ASH 2011, abstract 785]

“At 8 years, the probability of OS is 93.3 percent for imatinib-treated patients who achieved early molecular response at 3 months, vs 54 percent for those who did not,” said Kwong. [J Clin Oncol 2012;30:232-238]

“A nilotinib subsidy program is now open for application for patients at local public hospitals who develop resistance or fail to achieve early molecular response to ima-tinib at 3 months,” he continued. “Full sub-sidy will be given to five eligible patients to receive nilotinib therapy for 3 months, to help them achieve disease control as early as possible.”

Blast crisis of CML


Christina Lau

As social changes and Western culture exert an influence on the perception of

medical professionalism in Hong Kong, doc-tors may be expected to go beyond well-rec-ognized attributes to be seen as professional, a recent study revealed.

Researchers of the Medical Ethics Unit, University of Hong Kong interviewed 39 in-dividuals at the Queen Mary Hospital to ex-plore perceptions of medical professionalism – a subject widely discussed in Western litera-ture – in the local context. The interviewees included six medical faculty preceptors, six hospital residents, four medical interns, eight nurses, eight outpatients, and seven medical students. [Hong Kong Med J 2012;18:318-324]

The results suggest that medical profes-sionalism in Hong Kong is shaped by both Western medical ethics and traditional Chi-nese values.

In general, attributes recognized in Western bioethics – such as medical knowledge and skills, excellence, acting for patients’ best in-terest, holistic care, altruism and communica-tion skills – were widely agreed as attributes of a professional doctor. However, the inter-viewees also expected a professional doctor to be accountable to the public and have good conduct.

According to the authors, these expec-tations suggest that the image of a profes-sional doctor is similar to that of the morally ideal person in Confucianism. “Reference to Chinese culture and Chinese sayings of-ten appear in the subjects’ testimonies. This indicates that traditional Chinese thought is embedded, to a significant extent, in our subjects’ views of medical professionalism,” they wrote.

While good communication with col-leagues was emphasized, the nurse subjects were particularly critical about the commu-nication skills of younger doctors. “Friction between nurses and doctors (particularly younger doctors)… can be explained by the rapid development of nursing degree and master programs in Hong Kong. University education cultivates nursing students to see themselves as professionals with autonomy and critical thinking,” suggested the authors. “Therefore, doctors should accept that their ‘distance’ from nurses is getting less.”

Good emotional control when facing pa-tients was also seen as essential. As young-er patients brought up in Western educa-tion systems see themselves as more than equal to their doctors, they may be well prepared for visits and ask challenging questions, which could annoy doctors, the authors noted.

The changing face of medical professionalism


Naomi Rodrig

A recent survey among local adults showed that nearly half of the respon-dents consider their oral health as

‘poor’ or ‘fair’, which affects their personal and professional quality of life.

The survey, commissioned by Philips and conducted by the Social Science Research Cen-ter of the University of Hong Kong (HKU), in-cluded 532 local adults.

Nearly 50 percent of the subjects said they do not undergo annual dental check-ups de-spite suffering from tooth decay, gum prob-lems and bad breath. About one third said that dental care was ‘inconvenient’ and 25 percent were not aware of the need for regu-lar oral health checks.

“There is serious neglect among the lo-cal public. Regular dental visits are very im-portant as prevention is always cheaper than cure,” commented Professor Colman Mc-Grath of HKU’s Faculty of Dentistry. “Oral

health concerns the whole person, not just the mouth.”

A quarter of the respondents reported bad breath, while 10 percent said that the pain and discomfort due to poor oral health negatively impacts their work and career. Furthermore, these problems also affected their mood and confidence. Nearly 15 percent reported a nega-tive impact on their social and romantic inter-actions and the way they smile and laugh.

Survey shows poor oral health in HK


Naomi Rodrig

Following a recent incident of nitrous oxide (N2O) poisoning at the O&G

Department, Prince of Wales Hospital (PWH), the Hospital Authority (HA) is-sued an occupational safety alert on the hazards of exposure to high concentrations of N2O.

Also known as ‘laughing gas’, N2O is of-ten used for pain relief in labor wards. The evidence about the health effects of prolonged occupational N2O exposure among healthcare workers is limited.

With the labor ward staff at PWH reporting fatigue and headache at work, independent laboratory testing revealed that their level of N2O exposure exceeded the occupational ex-posure limit of 50 ppm as stipulated by the Labor Department (42 of 48 samples). The level of overexposure ranged from minor to 12 times the limit.

An initial HA review of all its labor wards showed no N2O overexposure in other hospitals.

In the safety alert, all staff members are re-minded to ensure proper fitting of N2O breath-ing masks and tubing to prevent gas leakage to the ward environment. Steps are also being taken to check the functioning of ventilation system in the relevant wards.

“The HA will continue to closely follow up the incident and will establish an Expert Group shortly to look into the incident for recommen-dations on further arrangements and appro-priate measures,” a HA spokesman said.

Warning on N2O use


Expanded flu reportingWey-Feng Ong

Statutory reporting is now required in Hong Kong for variant influenza A (H3N2), as detailed in a circular from

the Centre for Health Protection (CHP).In view of the increasing number of infec-

tions with this flu variant reported recently in the United States, the Hong Kong Govern-ment included variant influenza A (H3N2) in the list of scheduled infectious diseases in the Prevention and Control of Disease Ordinance on 17 August 2012.

According to the CHP spokesperson, the legislative amendment is intended to “pre-pare in advance for the possible importa-tions of this infection into Hong Kong and their consequences.” The inclusion of vari-ant influenza A (H3N2) will allow provisions of the Ordinance, such as medical surveil-lance, quarantine and isolation to be applied as and when necessary, and “will make Hong Kong better prepared against the dis-ease by facilitating earlier disease detection and implementation of appropriate public health measures if they are called for, de-pending on public health risk assessment,” he added.

The circular contains the reporting criteria for variant influenza A (H3N2). Medical prac-titioners encountering any patient who fulfils the clinical and epidemiological criteria are required to notify the Director of Health and collect relevant respiratory specimens. The

samples will be tested at the Public Health Laboratory Services Branch of CHP.

“The CHP has a sensitive laboratory sur-veillance system for the influenza virus,” the spokesperson remarked. “We will con-tinue to closely monitor the global and local influenza activity as well as genetic chang-es of the circulating influenza viruses in Hong Kong.”

Apart from the United States, variant influenza A (H3N2) was not reported in other parts of the world. A total of 12 cas-es were reported in 2011. However, the number of infections increased to 166 this year; 153 cases were reported in July and early August.

Thus far, no deaths were reported due to variant influenza A (H3N2). Most cases present with signs and symptoms of influ-enza and are generally mild and self limit-ing. Antivirals such as oseltamivir and zana-mivir are expected to be effective in treating variant influenza (H3N2).


Hong Kong Events

HK College of Community Medicine ASM 2012 – “Occupational Health for All: From Prevention to Rehabilitation”15/9Tel: (852) 2871 8844 / 2871 8745Fax: (852) 2580 7071E-mail: [email protected] / [email protected]/index.php

Hong Kong Pain Society ASM 2012 – New Light on Pain15/9Tel: (852) 2559 9973 Fax: (852) 2547 9528E-mail: [email protected]

Update on Osteoporosis ManagementOsteoporosis Center, Queen Mary Hospital; Research Centre of Heart, Brain, Hormone and Healthy Aging, HKU16/9Tel: (852) 2255 3577Fax: (852) 2255 4176E-mail: [email protected]/download/2012%20UOM%20flyer.pdf

Conjoint Scientific Congress 2012College of Surgeons of Hong Kong; Royal College of Surgeons of Edinburgh22/9-23/9Tel: (852) 2871 8825Fax: (852) 2518 3200E-mail: [email protected]/csc2012/index.html

Advances on Diagnostic and Therapeutic Colonoscopy 2012Departments of Medicine and Surgery, HKU28/9-29/9Info: Gladys ChuTel: (852) 2255 3348Fax: (852) 2816 2863E-mail: [email protected]/enteroscopy.htm

Transcatheter Renal Denervation (TREND) 2012 Asia-Pacific cme4u GmbH Congresses, Meetings and Education 29/9Tel: (49) 69 25 61 28 55Fax: (49) 69 25 62 86 58E-mail: [email protected] / [email protected]

14th Diabetes and Cardiovascular Risk Factors – East Meets West Symposium1/10-2/10Info: UBM Medica Pacific LimitedTel: (852) 2155 8557 / 3153 4374Fax: (852) 2559 6910E-mail: [email protected]

HK College of Community Medicine Annual Scientific Meeting 2012 – Occupational Health for All: From Prevention to Rehabilitation15/9Tel: (852) 2871 8844 / 2871 8745Fax: (852) 2580 7071E-mail: [email protected] / [email protected]/index.php

Hong Kong Pain Society Annual Scientific Meeting 2012 – New Light on Pain15/9Tel: (852) 2559 9973Fax: (852) 2547 9528E-mail: [email protected]

Annual Scientific Meeting 2012 Hong Kong Society of Pediatric Respirology7/10Info: UBM Medica Pacific LimitedTel: (852) 2155 8557 / 3153 4374Fax: (852) 2559 6910E-mail: [email protected]

Hong Kong Events


Hong Kong Events

Annual Scientific Meeting 2012

Hong Kong Society of Pediatric Respirology

7/10

Info: UBM Medica Pacific Limited

Tel: (852) 2155 8557 / 3153 4374

Fax: (852) 2559 6910

E-mail: [email protected]

www.hkspr.org

2012 Hong Kong International Wrist Arthroscopy

Workshop and Seminar, Pre-Congress event of

APFSSH 2012 Congress

Hong Kong Society for Surgery of the Hand

7/10-9/10

Info: Candy Chan

Tel: (852) 2647 7432


www.olc-cuhk.org

CUHK-OLC Surgeon Education Program – The 18th

Spine Workshop

Orthopaedic Learning Centre, CUHK

13/10-14/10

Info: Mandy Tse

Tel: (852) 2532 1653

Fax: (852) 2647 7432


www.olc-cuhk.org

CUHK SLEEP 2012 Conference and Workshop

Department of Psychiatry and Paediatrics, CUHK

17/10-21/10

Info: Mandy Yu

Tel: (852) 2636 7593

Fax: (852) 2635 8950


www.pae.cuhk.edu.hk/SLEEP2012/index.htm

20th Annual Scientific Meeting

Hong Kong College of Radiologists

27/10-28/10

Tel: (852) 2871 8788

Fax: (852) 2554 0739


www.hkcr.org

23rd Video Urology World Congress 2012

Hong Kong Urological Association

8/11-11/11

Tel: (852) 2632 2644

Fax: (852) 2632 4708


www.videourology2012.com/default.asp


Trajenta® (linagliptin)The new-generation DPP-4* inhibitor for the treatment of type 2 diabetes mellitus1

• Indication: Adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus, as monotherapy or as combination therapy with metformin or a sulphonylurea plus metformin2

Linagliptin 5mg is the only one-dose, once-daily DPP-4 inhibitor approved.2 No dose adjustment is required regardless of declining renal function or hepatic impairment.2

For type 2 diabetes patients, Trajenta® (5mg, once daily) demonstrated:

• Meaningful efficacy: Up to 1.2% HbA1c reduction in poorly controlled type 2 diabetes patients3

• Sustained efficacy over 104 weeks, comparable with sulphonylurea4

• Reliable efficacy: Significant improvement in HbA1c of up to -0.77% regardless of age or time since diagnosis5

• Favorable safety and tolerability profile6

• One dose fits all patients

*DPP-4: dipeptidyl peptidase-4

References:1. Curr Med Res Opinion 2009;25:1963-1972 2. Trajenta® Prescribing Information 3. Diabet Med 2011;28:1352-1361 4. Lancet 2012;380:475-483 5. Patel S, et al. European Association for the Study of Diabetes Annual Meeting 2011, Poster 832. 6. Diabetes Obes Metab 2012;14:470-478.

26 September 2012 News

Malvinderjit Kaur Dhillon

A synthetic protein, EP67, has been found very effective in kick-starting the innate immune system and help

fight influenza within just 2 hours of being ad-ministered, a recent animal study has shown.

Prior to this study, EP67 had been mainly used as an adjuvant for vaccines, something added to the vaccine to help activate the im-mune response.

“The flu virus is very sneaky and actively keeps the immune system from detecting it for a few days until you are getting symp-toms,” said Dr. Joy Phillips, lead author of the study at the University of Nebraska Medical Center, US. Phillips, alongside with her colleague Dr. Sam Sanderson, decided to investigate the potential of EP67 to work on its own.

“Our research showed that by introducing EP67 into the body within 24 hours of expo-sure to the flu virus caused the immune sys-tem to react almost immediately to the threat, well before your body normally would,” she said. [PLoS ONE 2012 doi:10.1371/journal.pone.0040303]

According to Phillips, EP67 functions the same, regardless of the influenza strain, as it works on the immune system itself and not on the virus. This is in contrast with the in-fluenza vaccine, which has to perfectly match the currently circulating strain.

In this study, testing was done primar-ily in mice by infecting them with influenza virus. Researchers found that mice given a dose of EP67 within 24 hours of infection did not get sick or were not as sick as those that

Synthetic protein may keep flu at bay

were not treated with EP67. In mice, being infected with influenza

translates to weight loss, which is how the level of illness was measured. Typically, mice lose approximately 20 percent of their weight when they are infected with influen-za. However, mice treated with EP67 were found to only lose an average of 6 percent.

More importantly, the mice that were treated a day after being infected with a le-thal dose of influenza did not die, Phillips said.

“When you find out you’ve been exposed to the flu, the only treatments available now target the virus directly but they are not reli-able and often the virus develops a resistance against them,” Phillips said. “EP67 could potentially be a therapeutic that someone would take when they know they’ve been exposed that would help the body fight off the virus before you get sick.”

Philips added that while the study fo-cused on influenza, EP67 could potentially work on other respiratory diseases and fun-gal infections, and could have huge potential for emergency therapeutics.

She also said it could be used in the event of a new strain of disease, before the actual pathogen has been identified, much like the SARS outbreak or the 2009 H1N1 influenza pandemic.

Future research plans include examining the effect EP67 has in the presence of a num-ber of other pathogens, and to investigate how EP67 functions within different cells in the body.


COPD patients benefit from antibiotic prophylaxis Alexandra Kirsten

Patients suffering from chronic obstruc-tive pulmonary disease (COPD) may benefit from a regular intake of antibiot-

ics to prevent acute exacerbations, according to new research.

A meta-analysis of two clinical trials involv-ing 1,251 patients with COPD showed that pa-tients taking a daily regimen of azithromycin for 1 year had a significantly reduced frequency of COPD exacerbations compared with those receiving placebo. [N Engl J Med 2012;367:340-7]

While there was no significant difference be-tween groups in terms of overall mortality, the study did show that azithromycin intake also prolonged time to first acute exacerbation and significantly improved patients’ quality of life.

“This approach has the potential to eliminate one-third of the severe exacerbations each year among patients with COPD,” said lead author Dr. Richard Wenzel, Virginia Commonwealth University, Richmond, Virginia, US, and col-leagues.

“A patient who continues to have frequent acute exacerbations despite guidelines-based treatment is a potential candidate for prophy-

lactic use of azithromycin.” Nevertheless, they cautioned, a patient

should have had at least two episodes of acute exacerbation in the previous year to be consid-ered for such therapy, both to provide a base-line against which to assess clinical response and to limit overuse of azithromycin.

This protocol may not be suitable for every patient, said Wenzel. Some may suffer adverse consequences with year-long use of azithromy-cin, such as hearing loss, antibiotic resistance and heart rhythm disturbances.

According to the WHO, approximately 64 million people suffer from COPD, the fourth leading cause of death worldwide.

Acute exacerbations of COPD contribute markedly to the condition’s morbidity and mortality. On average, patients experience one to two exacerbations annually, and the rate generally increases as the disease progresses. Every episode is potentially life-threaten-ing and can lead to additional lung function decline.

A meta-analysis has shown that a daily course of azithromycin for a year significantly cut rate of COPD exacerbations.

This approach has

the potential to eliminate

one-third of the severe

exacerbations each year

among patients

with COPD

‘‘


Involving patients reduces unnecessary antibiotic Rx Rajesh Kumar

A shared decision-making program for GPs led to greater patient involvement in the

treatment process and fewer prescriptions for antibiotics to treat acute respiratory infections, a Canadian study has shown.

The reduction in antibiotic prescriptions did not have a negative effect on patient out-comes 2 weeks after the GP consultation, said the researchers. [CMAJ 2012; DOI:10.1503/cmaj.120568]

They randomized nine family practice teaching units in six regions of Quebec, Canada into two study arms: DECISION+2 and con-trol. GPs in the DECISION+2 practices were offered a 2-hour online tutorial followed by a 2-hour interactive seminar about shared deci-sion-making, while those in the control group were asked to provide usual care. The primary outcome was the proportion of patients who decided to use antibiotics immediately after the consultation.

Outcomes among 181 patients who consult-ed 77 GPs in five family practice teaching units in the DECISION+2 group were then compared with 178 patients who consulted 72 GPs in four family practice teaching units in the control

group. The proportion of patients who decided to use antibiotics after consultation was 52.2 percent in the control group and 27.2 percent in the DECISION+2 group (absolute difference 25.0 percent, adjusted relative risk 0.48, 95% CI 0.34–0.68).

DECISION+2 was associated with patients taking a more active role in decision-making (P≤0.001) and patient outcomes 2 weeks after consultation were similar in both groups.

Few interventions have proven effective in reducing the overuse of antibiotics for acute re-spiratory infections. But the authors suggested that physician training in a shared decision-making process, with greater patient involve-ment, can make a huge difference.

Unnecessary antibiotic prescriptions may be reduced when patients are more involved in the decision-making process.


Single dose of iron improves quality of life in iron-deficient womenMalvinderjit Kaur Dhillon

Women with iron deficiency but are not anemic no longer have to suffer from fatigue and impaired

quality of life as a study shows one dose of ferric carboxymaltose (FCM) replenishes iron stores and reduces fatigue symptoms.

“Iron deficiency is very prevalent in up to a third of young western women. It is well doc-umented that iron deficiency leads to fatigue. Fatigue leads to impairment of cognitive function, quality of life and physical perfor-mance,” said Dr. Michael Hedenus, of Sunds-vall Hospital, Sweden, at the 17th Congress of the European Hematology Association. [Arch Intern Med 1993;153:2759-65, J Gen Intern Med 1992;7:276-86, Blood 2011;118:3222-7, Haemato-logica 2012;97(1):193]

“Almost 300 young women who were fa-tigued and non-anemic were recruited from four European countries and were blindly randomized to receive either 1 g of FCM or 250 mL of saline. The patients had to be fa-tigued according to the instrumental Piper Fatigue Scale (PFS) [score ≤5]. Several exclu-sion criteria included patients were not al-lowed to suffer from major depression or any other active diseases,” said Hedenus.

Percentage of patients with improved PFS total score (≥ 1 point reduction) was measured at 7, 28 and 56 days after treatment and it was found that the fatigue score improved sig-nificantly more often in FCM-treated patients compared to the placebo group (65.3 percent

versus 52.7 percent, P=0.03). Twice as many women in the FCM group also achieved a 50 percent reduction in their fatigue (33 percent versus 18 percent, P≤0.01). [Abstract P0405]

Hedenus also noted that a difference in the median fatigue score was observed in just 7 days after treatment initiation.

In addition to the total fatigue score, all sub-scores as well as mental quality of life and self-rated computerized visual analog scale (VAS) scores of alertness, contentment and calmness improved in the FCM-treated women.

Almost all women in the FCM-treated group successfully replenished their iron stores and the entire group had hemoglobin levels ≥ 12 g/dL on day 56.

“A single dose of FCM rapidly reduces fatigue within a week and was found in this study to be well tolerated.

Our message is to assess iron status in non-anemic women with fatigue and consid-er them for treatment of iron deficiency,” he concluded.

A single dose of iron may also reduce fatigue in iron-deficient women.

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GTC ad (E)_Medical Tribune_2012_406hx290w.pdf 1 18/06/2012 3:42 PM


Shift work increases CV risk Elvira Manzano

People working overnight shifts or any odd-shifts outside of regular 9am to 5pm working hours are at increased

risk of heart attack and stroke, a meta-analy-sis has found.

The analysis showed that shift workers were 23 percent more likely to experience a heart attack, 24 percent more likely to have coronary events, and 5 percent more likely to have a stroke compared with people work-ing day shifts. The risks remained consistent despite adjustment for factors such as study quality, socioeconomic status and unhealthy behaviors, including smoking. Interest-ingly, shift work was not associated with in-creased rates of death from any cause. [BMJ 2012;345:e4800]

“Our findings suggest that people who do shift work should be vigilant about risk fac-tor modification,” said lead study author Dr. Daniel G. Hackam, assistant professor at the Department of Epidemiology and Biostatis-tics at University of Western Ontario in Lon-don, Ontario, Canada. “Shift workers should be educated about cardiovascular symptoms to forestall the earliest clinical manifestation of the disease.”

Hackam and colleagues reviewed 34 pre-vious studies linking shift work to vascular events or mortality. Shift work was defined as night shifts, rotating or split shifts, on-call or casual shifts or any non-daytime schedules. The analysis involved over 2 million work-ers. Overall, there were 17,359 incidents of

coronary events, 6,598 heart attacks and 1,854 strokes. One in 14 heart attacks and 1 in 40 strokes were directly related to shift work.

The increased risk for heart attack and stroke may be related to disruption in the body’s circadian rhythm and impairment in sleep quality, said the authors. “Even a single overnight shift is enough to increase blood pressure and impair variability of heart rate.”

Those who worked night shifts had the highest risk for coronary events at 41 percent. Shift workers were also more likely to smoke, eat unhealthy foods and have no time to exer-cise. “They should be aware of the health risks that go with their work patterns. They should go to their doctors and have their blood pres-sure, cholesterol, waist circumference and blood glucose routinely checked,” Hackam said. He also recommends that employers in-stitute health screening programs in the work place, give employees time to sleep and ratio-nalize shift scheduling systems.

“Modification and rationalization of shift schedules may yield dividends in terms of healthier and more productive workers.”

The study is the largest synthesis of shift work and vascular risk reported thus far. De-spite several limitations of the study, includ-ing heterogeneity in the outcome of coronary events, “we have identified an epidemiologi-cal association between shift work and vas-cular events… which may have implications for public policy and occupational medicine,” the authors concluded.

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Abbott Ensure_Medical Tribune Sept Issue.pdf 1 06/08/2012 6:59 PM


Weight training lowers type 2 diabetes risk in men

Men who engaged in both aerobic and weight training for more than 150 minutes per week had the greatest reduction in T2D risk.

Alexandra Kirsten

Men who do regular weight training may be able to reduce their risk of type 2 diabetes (T2D), according

to the findings of a new study by researchers based in the US and Denmark.

“Until now, previous studies have reported that aerobic exercise is of major importance for type 2 diabetes prevention,” said lead au-thor Mr. Anders Grøntved, visiting research-er in the department of nutrition at Harvard School of Public Health, Boston, Massachu-setts, US. This is the first trial to examine the role of weight training in the prevention of T2D.

In their study, data from a prospective co-hort study involving 32,002 men enrolled into the Health Professionals Follow-up Study conducted in the US from 1990 to 2008 were analyzed. Participants recorded how much time they spent each week on weight train-ing and aerobic exercise (including jogging, running, cycling and swimming) on ques-tionnaires they filled out every 2 years. Dur-ing 18 years of follow-up, 2,278 new cases of T2D were documented. [Arch Intern Med 2012; DOI:10.1001/archinternmed.2012.3138]

What the researchers found was a dose-response relationship between an increasing amount of time spent on weight training and lower risk of T2D (P=0.001 for the trend).

To examine the association of weight train-ing with the risk of T2D and to assess the in-fluence of combining weight training with

aerobic exercise, the men were categorized according to how much weight training they did per week: up to 59 minutes, between 60 and 149 minutes, and 150 minutes or more.

Depending on the training amount, they reduced their T2D risk by 12 percent, 25 per-cent and 34 percent, respectively, compared with no weight training. Men who engaged in aerobic exercise and weight training for at least 150 minutes per week had the greatest risk reduction of 59 percent.

“This study provides clear evidence that weight training has beneficial effects on dia-betes risk over and above aerobic exercise, which are likely to be mediated through in-creased muscle mass and improved insulin sensitivity,” the researchers stated.

The authors added however that further research is needed to confirm the results of the study as well as to analyze whether the findings can be generalized to women. Fur-thermore, the effect of duration, type and in-tensity of weight training on T2D risk should be examined in greater detail.


Testosterone therapy linked to weight loss in menRajesh Kumar

Long-term testosterone therapy may reduce weight, waist circumference and body mass index (BMI) in hypo-

gonadal men who are overweight or obese, according to research presented at the Endo 2012 conference held recently in Houston, Texas, US.

The open-label, prospective registry study included 255 men (mean age 60.6 years) with testosterone levels between 1.7 and 3.5 ng/mL who were given parenteral testosterone undecanoate 1,000 mg every 12 weeks for up to 5 years.

Their mean body weight significantly de-creased from 106.22 kg at baseline to 90.07 kg after 5 years (P≤0.0001). Mean waist cir-cumference also significantly declined from 107.24 cm at baseline to 98.46 cm after 5 years (P≤0.0001), while mean BMI declined from 33.93 to 29.17 (P≤0.0001).

The benefit was progressive over the fol-low-up period, said the researchers. Mean weight loss after 1 year was 4.12 percent, after 2 years 7.47 percent, after 3 years 9.01 percent, after 4 years, 11.26 percent and af-ter 5 years 13.21 percent. At baseline, 96 percent of men had a waist circumference of ≥94 cm. This proportion decreased to 71 percent after 5 years.

“It is clear that long-term testosterone treatment in hypogonadal men makes them lose weight,” said study author Professor Farid Saad of the Gulf Medical University, Ajman, UAE and head of Global Medical Affairs (Andrology) at Bayer Pharma.

Adverse events and adverse drug reac-tions (ADRs) occurred in 12 percent and 6 percent of patients, respectively. The most

common ADRs were increase in hematocrit, increase in prostate specific antigen (PSA), and injection site pain (all <1 percent). No case of prostate cancer was observed.

Another study has confirmed similar benefits of testosterone therapy. The IPASS* study spanning 23 countries in Europe, Asia, Latin America, and Australia, ana-lyzed 1,438 (mean age 49.2 years) hypogo-nadal men who were overweight and were given a total of 6,333 injections of long-act-ing-intramuscular testosterone undecano-ate over 9 to 12 months. [J Sex Med 2012; DOI: 10.1111/j.17436109.2012.02853.x]

While their scores of mental and psy-chosexual functions (libido, vigor, overall mood, and ability to concentrate) improved markedly, mean waist circumference de-creased from 100 cm to 96 cm. Blood pres-sure and lipid parameters were also favor-ably altered in a significant manner, said the researchers.

After four injection intervals, the per-centage of patients with ‘low’ or ‘very low’ levels of sexual desire/libido decreased from 64 percent at baseline to 10 percent; moderate, severe, or extremely severe erec-tile dysfunction decreased from 67 percent to 19 percent. At the last observation, 89 percent of patients were ‘satisfied’ or ‘very satisfied’ with therapy.

“Keeping testosterone levels normal has clear health benefits for the male, other than sexual,” concluded Professor Peter Lim, urologist at the Gleneagles Medical Centre and head of the Society for Men’s Health Singapore.

*IPASS: International, multicenter, Post-Authorization Surveillance

Study on long-acting-intramuscular testosterone undecanoate


Calcium supplements linked to MI, kidney stonesYen Yen Yip

The safety of calcium supplements has come under further scrutiny as recent reports suggest they may be

linked with higher risks of myocardial in-farction (MI) and kidney stones.

“Calcium supplements have been widely embraced by doctors and the public on the grounds that they are a natural and therefore safe way of preventing osteoporotic fractures,” wrote Professor Ian Reid and Dr. Mark Bol-land from the Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand, in an editorial in a recent issue of Heart journal. [Heart 2012;98:895-896]

The editorial accompanied a study linking calcium supplements to an increased risk of heart attacks. [Heart 2012;98:920-925] The Eu-ropean Prospective Investigation into Cancer and Nutrition (EPIC) study, led by research-ers based in Heidelberg, Germany, assessed calcium intake through the diet and supple-ments of close to 24,000 subjects for about 11 years.

The results showed that subjects who took calcium supplements regularly were 86 per-cent more likely to have a heart attack than those who did not take any supplements. “Calcium supplements, which might raise MI risk, should be taken with caution,” conclud-ed lead author Dr. Kuanrong Li from the Divi-sion of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany, and colleagues.

The study also evaluated subjects whose calcium intake came from dietary sources.

Those who took a moderate amount of calcium through their diet (820 mg per day), instead of supplementation, were about 30 percent less likely to suffer a heart attack com-pared with those who took less dietary calci-um (513 mg per day). Interestingly, those who included more than 1,100 mg of calcium in their daily diet did not observe a lowered risk of heart attack.

In contrast to past research, the EPIC study did not show an association between higher calcium intake and reduced CV and stroke risk, or overall CV mortality.

The safety of calcium supplements has come into question, said Reid and Bolland.

“It is now becoming clear that taking this micronutrient in one or two daily [doses] is not natural, in that it does not reproduce the same metabolic effects as calcium in food.

“We should return to seeing calcium as an important component of a balanced diet, and not as a low cost panacea to the universal problem of postmenopausal bone loss.”

In a separate study, high doses of calcium

Calcium supplementation appears less safe when compared with normal dietary intake of calcium.

36 September 2012 Newsand vitamin D supplements were shown to cause higher rates of hypercalciuria and hy-percalcemia in 163 postmenopausal women with vitamin D insufficiency.

The study, presented at the 2012 Annual Meeting of The Endocrine Society in Hous-ton, US, randomized the women to vitamin D doses ranging from 400 IU to 4,800 IU per day, and calcium from 1,200 mg to 1,400 mg daily, over a year. Blood and urinary calcium levels were measured at baseline and every 3 months during the year-long study period.

The investigators found that about one in three subjects (33 percent) experienced hy-

percalciuria, defined as urinary calcium lev-els greater than 300 mg in a 24-hour urine calcium test. Hypercalcemia was also identi-fied in about one in 10 subjects (10 percent).

Given that both events are known to con-tribute to the risk of kidney stones, lead study investigator Professor Christopher Gallagher, director of the Bone Metabolism Unit at Creighton University Medical Cen-ter, Nebraska, US, has suggested that clini-cians should monitor the blood and urine calcium levels of patients who take calci-um and vitamin D supplements on a long- term basis.

Vitamin E may help reduce liver cancer risk Radha Chitale

Large amounts of dietary or supple-mentary vitamin E may help reduce the risk of liver cancer in women, ac-

cording to a large prospective, population-based study of Chinese adults.

“We found a clear, inverse dose-response relation between... vitamin E intake and liver cancer risk, an association that was indepen-dent of supplement use and that appeared to be slightly stronger among participants who reported no liver disease or family his-tory of liver cancer,” said researchers from Vanderbilt Epidemiology Center in Nash-ville, Tennessee, US, and the Shanghai Can-cer Institute in Shanghai, China.

Previous epidemiological studies have proved inconclusive about the effects of vi-tamin E on various cancers but there is evi-dence that vitamin E improves liver function in people with viral hepatitis. Case con-trolled studies of dietary vitamin E are few.

The study included 132,837 people from the Shanghai Women’s Health Study (1997-2000) and the Shanghai Men’s Health Study (2002-2006). [J Natl Cancer Inst 2012 Jul 17 Epub ahead of print]

Participants were interviewed about their

Supplemental vitamin E intake was inversely correlated with liver cancer risk in adult Chinese women.

37 September 2012 Newsdietary habits and vitamin supplement con-sumption and evaluated using food fre-quency questionnaires, plus follow-up in-terviews.

Not including the first 2 follow-up years, the analysis showed that 118 women and 149 men developed liver cancer an average 10.9 and 5.5 years, respectively.

People who consumed greater amounts of dietary vitamin E had a lower risk of de-veloping liver cancer compared with those who consumed less vitamin E (P Trend = 0.01). Supplemental vitamin E was similar-ly inversely associated with a lower risk of liver cancer.

The results were consistent for both men and women with and without self-reported liver disease or a family history of liver can-cer but were only statistically significant for women.

Liver cancer is the third most common cause of cancer deaths worldwide and has a poor survival rate – about 15 percent over 5 years. The majority of liver cancer cases occur in developing countries and over half occur in China.

Other studies have suggested that vita-min E is an antioxidant that prevents DNA damage, enhances DNA repair, prevents lipid peroxidation, inhibits carcinogens and boosts the immune system.

A high concentration of dietary vitamins and minerals may reduce inflammation and prevent infection, both of which can con-tribute to liver cancer, particularly in the presence of chronic hepatitis B or C virus, but this is so far unstudied. Hepatitis B is a known risk factor for liver cancer.

Contrary to vitamin E, the study showed that vitamin C supplements and multivita-mins were associated with a higher risk of liver cancer in adults with self-reported liver disease or family history of liver cancer, and highest in male smokers. However, dietary vitamin C and other vitamins were unrelat-ed to the risk of liver cancer.

The researchers noted this result may be due to reverse causation as people with a history of cancer are more likely to take vi-tamin supplements, but that further studies on the effect of vitamin supplements on liver cancer are warranted.

READ JPOG ANYTIME, ANYWHERE. Download the digital edition today at www.jpog.com


Elvira Manzano

Supplementation with vitamin B12 may help increase the effectiveness of antivi-

ral treatment administered to patients with chronic hepatitis C virus (HCV) infection.

This was the key finding of an open-label pilot study conducted in Italy.

Patients treated with vitamin B12 plus stan-dard therapy (pegylated interferon-alfa and ribavirin) had better sustained viral response (SVR) rates – undetectable serum HCV RNA 6 months after treatment – than those treated with standard therapy alone (72 percent vs. 38 percent, P=0.001). SVR rates were also sig-nificantly higher in genotype 1 carriers and patients with high viral loads at baseline (41 percent and 38 percent, respectively). [Gut 2012; Epub ahead of print]

“Overall, adding vitamin B12 to standard therapy strengthened the rate of SVR by 34 percent,” said study author Professor Gerar-do Nardone, from the Department of Clinical and Experimental Medicine, Gastroenterol-ogy Unit, University of Naples, Naples, Italy.

SVR is an indicator of long-term remis-sion and currently the best marker of success-ful therapy for HCV infection. While there is some support for detection of viral response 3 months after treatment, the 6-month post-therapy identification time-point remains the gold standard for treatment success.

Vitamin B12 has been shown to inhibit HCV replication in vitro. In the study by Nar-done and colleagues, adding vitamin B12 to standard treatment further increased viral response. A total of 94 patients with chronic, untreated HCV infection were randomized to standard therapy with or without vitamin

B12 5,000µg monthly for 6 to 12 months.After one month, response did not differ

between the two groups. However, patients on vitamin B12 had significantly greater re-sponses at all other time points, particularly 6 months after completion of treatment.

Six patients receiving standard care and five receiving vitamin B12 plus standard therapy discontinued treatment because of adverse events. Multivariate analysis demon-strated that only vitamin B12 supplementa-tion (overall response [OR]=6.9; P=0.002) and genotype 2 or 3 (OR=9; P=0.001) were inde-pendently associated with SVR.

HCV genotypes 2 and 3 are easier to treat than genotype 1. Patients with genotypes 2 and 3 may have to be treated for 6 months, with higher response rates of 70 to 80 percent in most studies, whereas genotype 1 carriers have to be treated for up to 12 months, with only 40 to 50 percent response rates.

The addition of vitamin B12 to current stan-dard therapy offers a safe and inexpensive option for difficult-to-treat patients and those with high baseline viral load, Nardone said. “This strategy would be useful in countries where, owing to limited economic means, the new generation antiviral therapies cannot be given in routine practice.”

Commenting on the study, Associate Prof. Tan Chee Kiat, senior consultant, Department of Gastroenterology and Hepatology, Singa-pore General Hospital said the study, being small and preliminary, has to be validated by other studies.

“We will need the result to be validated by other independent studies as the study is just a pilot study and was open-label rather than double-blind.”

Vitamin B12 may boost Hep C treatment response


No effect of maternal antibodies on Hep A vaccination in infants Alexandra Kirsten

Vaccination against the hepatitis A virus (HAV) in children 2 years of age and

younger remains effective for at least 10 years and is not affected by maternal anti-HAV an-tibody transfer. These were the results of a recently published study by epidemiologists from the Centers for Disease Control and Pre-vention in Atlanta, Georgia, US.

“Persistence of seropositivity conferred by hepatitis A vaccine administered to children under 2 years of age is unknown and passive-ly transferred maternal antibodies to hepa-titis A virus may lower the infant’s immune response to the vaccine”, the researchers ex-plained. The trial is the first to examine the ef-fectiveness of a two-dose inactivated hepatitis A vaccine in children younger than 2 years of age over a 10-year period.

Study author Dr. Umid Sharapov and col-leagues enrolled 197 infants and young chil-dren who were healthy at 6 months of age. The children were divided into three groups to receive a two-dose hepatitis A vaccine: group 1-infants 6 to 12 months; group 2-tod-dlers between 12 and 18 months; and group 3-toddlers 15 to 21 months of age. Each group was randomized by maternal anti-HAV sta-tus. HAV antibody levels were measured at 1 and 6 months, and additional follow-up took place at 3, 5, 7 and 10 years after the second dose of the vaccine.

At 1 month after the second dose of the vac-cine, children in all groups showed signs of seroprotection (>10 mIU/mL) from the Hepa-titis A virus.

After 10 years of follow-up, most children retained anti-HAV protection. In the first

group, 7 percent and 11 percent of children born to anti-HAV–negative and anti-HAV–positive mothers, did not retain HAV protec-tion from vaccination, respectively. Overall, 4 percent of group 3 children born to anti-HAV negative mothers lost HAV protection. [Hepa-tology 2012; DOI: 10.1002/hep.25687]

“Our study demonstrates that seropositiv-ity to hepatitis A persists for at least ten years after primary vaccination with two-dose in-activated HAV vaccine when administered to children at ages 12 months and older, re-gardless of their mothers’ anti-HAV status,” concluded Sharapov.

Additionally he pointed out that a future booster dose may be necessary to maintain protection against HAV. The study group will continue to follow-up participants into their teens to monitor benefits of the initial immunization.

A study in the US showed persistence of seropositivity for at least 10 years after hep A vaccination of infants less than 2.

Chinese Alliance Against Lung Cancer (CAALC)

English Sessions Highlights：

Mechanical VentilationSleep ApneaUpdate Biomarkers and Therapeutic Strategies inAirway DiseasesState-of-the-art Ventilation StrategyHighlight on COPD ManagementALI Forum - Mechanism and New Drug TargetPlenary Session - Message from ATSInfection and ImmunityALI Forum - Mechanism and New Drug TargetTranslational Respiratory Medicine

Please visit www.isrd.org for further details

Nearly 100 Academic Speakers,15 Sessions and 6 Special Topics

ISRD 2012The very first joint scientific sessions

with the American Thoracic Society

41 September 2012 Conference Coverage

Recreational runners may strain heart too ASEAN Federation of Cardiology Congress, 13-15 July, Singapore

Rajesh Kumar

H igh levels of endurance exercise in recreational runners may result in transient but significant ventricu-

lar stunning, release of cardiac biomarkers and acute kidney injury, according to a Sin-gapore study.

Previous studies involving elite long dis-tance runners have linked high-level endur-ance exercise with elevated cardiac biomark-ers, right ventricular dysfunction as well as a decrease in glomerular filtration rate. How-ever, it has been suggested that such findings may not apply to the majority of recreational runners participating in moderate endurance events.

In the present pilot study, the researchers recruited 10 healthy subjects (mean age 36.5 years) to complete a 21km treadmill run.

Before and after the run, echocardiograms and peripheral blood samples were taken from the participants to confirm the hypoth-esis that changes in cardiac biomarkers may reflect RV dysfunction after moderate endur-ance activity.

Highly sensitive troponin T (hsTnT), N-terminal pro brain natriuretic peptide (NT-ProBNP) and the novel renal biomarker neutrophil gelatinase-associated lipocalin (NGAL) were analysed prior to, within 1 hour of run completion, and 24 hours after the run.

The hsTnT in five out of 10 subjects ranged from 15 to 33 pg/mL within 1 hour post-exer-cise, which was above the 99th percentile (14 pg/mL) of the upper reference limit. These

A pilot study conducted in Singapore showed that recreational runners can strain their hearts or damage their kidneys while performing heavy amounts of endurance exercise.

fell below the cut-off in all but one subject at 24 hours. NTProBNP levels were below the established cut-off value for detection of heart failure. There was no direct correlation between changes in strain and hsTnT or NT-ProBNP.

While the findings support the concept of cardio-renal coupling in endurance exercise, the researchers acknowledge that the num-ber of subjects in this study is small, and vali-dation with a larger study is required.

“Whether these individuals are more prone to chronic myocardial and/or kidney injury is unknown. The findings warrant fur-ther investigation in larger populations of rec-reational runners and the general population should not be unnecessarily alarmed at this point,” said study researcher Dr. Yeo Tee Joo of the cardiac department at National Univer-sity Heart Centre, Singapore.

Yeo said that physicians should reassure any of their patients who are recreational runners that the benefits of regular exercise far outweigh any potential risks.

42 September 2012 Conference CoverageIn a healthy person with no history of car-

diovascular disease, he said some key points they need to be reminded of, are:• Always keep well hydrated.• Slow down or stop if there are any unusual symptoms including: chest pain/uneasiness, giddiness and/or palpitations. • Avoid strenuous activity when unwell (eg,

during fever or flu).• Engage in exercise in a progressive manner.

“[The latter] is in particular for ‘weekend warriors’ who lead a sedentary lifestyle and feel compelled to over-strain once or twice a week rather than exercise regularly at a manageable intensity, more frequently,” said Yeo.

Rajesh Kumar

Physicians are being reminded to take routine blood pressure (BP) measurements from

both arms of their patients following research that showed a difference of just 10 mmHg in in-ter-arm systolic BP is closely linked to peripheral artery disease, especially in non-obese and non-hypertensive patients.

“We as physicians neglect to evaluate BP from both arms. It’s a simple procedure which can reveal so much information on other vascular diseases and correlation with surrogate marker such as ankle brachial index (ABI),” said author Dr. Erwin Mulia of the department of cardiol-ogy and vascular medicine, faculty of medicine at Universitas Indonesia, Jakarta, Indonesia.

The cross-sectional study evaluated 80 pa-tients who followed elective coronary angiog-raphy from March to May 2011. The mean dif-ference in inter-arm systolic BP was 34.6 mmHg and mean ABI was 1.3 (0.7-1.8). A difference of 10 mmHg in systolic BP was found in 85 percent of subjects.

The correlation between inter-arm BP dif-ference and ABI in coronary artery disease pa-tients was 0.337 (P=0.001). In non-overweight/ obese and non-hypertensive patients, the cor-relation was 0.450 (P=0.001) and 0.501 (P=0.043), respectively.

“Some also say that [inter-arm difference in systolic BP] has correlation with severity of coronary stenosis, though my previous re-search didn’t show its correlation with Gen-sini score,” said Mulia.

In primary care services or in rural areas where availability of diagnostic tools is limit-ed, Mulia said such a simple procedure could prevent delays in the diagnosis of vascular diseases.

He pointed out that the textbook of cardio-vascular medicine Braunwald’s Heart Disease recommends blood pressure measurement on both arms, while earlier research had linked a difference of just 15 mm Hg or more in in-ter-arm SBP to the risk of vascular disease or death.

An earlier meta-analysis concluded that “a difference in systolic BP of 10 mm Hg or more…between arms might help to identify patients who need further vascular assess-ment [while] a difference of 15 mmHg or more could be a useful indicator of risk of vascular disease and death.” [Lancet 2012; 379:905-914]

Therefore, a patient with an inter-arm sytstolic BP difference of 10 mmHg would benefit from further investigation for vascular disease and ought to be targeted with aggres-sive management of their cardiovascular risk factors, said Mulia.

Measure BP on both arms

43 September 2012 Conference Coverage

Study of CV risk factors in Singapore Chinese

ASEAN Federation of Cardiology Congress, 13-15 July, Singapore

Rajesh Kumar

Diet and lifestyle factors have a strong impact on the risk of cardiovascular disease (CVD) mortality in the Sin-

gapore Chinese population, according to a study.

The researchers used prospective data from 53,469 male and female participants of the Singapore Chinese Health Study (SCHS) who were 45 to 74 years old at the time of enrolment during 1993-1998. [Cir-culation 2011; DOI:10.1161/CIRCULA-TIONAHA.111.048843]

The diet and lifestyle factors were assessed using validated questionnaires, while CVD mortality until the end of 2009 was identified through the Singapore Registry of Births and Deaths.

A combination of protective lifestyle factors were found to be associated with a decreased risk of mortality from coronary heart disease and cerebrovascular disease in both men and women. These included: 1) at least 2 hours of regular physical activity per week; 2) between 6 and 8 hours of usual sleep everyday; 3) light to moderate alcohol intake of no more than 2 drinks per day; 4) never smoking; 5) healthy relative BMI; and 6) a diet rich in fruits, veg-etables and soy.

Each lifestyle factor was independently associated with CVD mortality. When com-bined, there was a strong, monotonic decrease in age- and sex-standardized CVD mortality rates with an increasing number of protective lifestyle factors.

Relative to participants with no protec-tive lifestyle factors, the hazard ratios of CVD mortality for 1, 2, 3, 4, and 5 to 6 protective lifestyle factors were 0.60 (95% CI, 0.45– 0.84), 0.50 (95% CI, 0.38–0.67), 0.40 (95% CI, 0.30–0.53), 0.32 (95% CI, 0.24–0.43), and 0.24 (95% CI, 0.17– 0.34), respectively, among those without a history of diabetes, CVD, or cancer (P for trend >0.0001).

“This study utilized data from our local population and provided convincing evi-dence that diet and lifestyle factors such as smoking, obesity, physical activity and sleep, impact our risk of CVD mortality,” said co-au-thor Dr. Koh Woon-Puay, associate professor at the Saw Swee Hock School of Public Health at the National University of Singapore.

Singapore is often referred to as the coun-try that progressed from third world to first world in one generation. With this rapid eco-nomic development has come a rapid change in lifestyle and diet which have had a direct bearing on CVD mortality, said the research-ers.

While some earlier studies have looked at how various combinations of lifestyle factors and diet impact on risk of CVD, most of these studies have been conducted in western pop-ulations in US and Europe, said Koh.

The SCHS, being the largest cohort study in Singapore, is the first to look at the combi-nation of lifestyle factors and diet on the risk of CVD mortality in both men and women in an Asian population, she said.

When asked what physicians could make of the findings that seem intuitive, Koh said

44 September 2012 Conference Coveragepatients listen and adhere to the advice of their primary health physicians for health-related matters.

“Being at the frontline of public health education, physicians play a pivotal role in

health promotion and disease prevention. We hope that they can refer to the findings of these local studies to educate their patients to adhere to a healthy lifestyle and diet in order to reduce their CVD risk.”

Carbohydrate sources key in CHD mortality

Rajesh Kumar

The food sources of carbohydrate are more important than the overall quan-tity of carbohydrate intake with respect

to risk of coronary heart disease (CHD) mor-tality in the Singapore Chinese community, an observation study suggests.

Researchers sought to find out the impact of high-carbohydrate diets, as commonly con-sumed by Asian populations, on the risk of CHD and evaluated carbohydrate intake and its major food sources in relation to it.

They used prospective data from 53,469 male and female participants of the earlier Singapore Chinese Health Study (SCHS) who were 45 to 74 years at the time of their recruit-ment from 1993 to 1998. Their usual dietary intakes were assessed using a validated food frequency questionnaire, while CHD mortali-ty until the end of 2011 was identified through the Singapore Registry of Births and Deaths.

Total carbohydrate intake was not substan-tially associated with CHD risk. Major sources of carbohydrate were rice (40.7 percent), fruit (10.5 percent), and noodles (8.5 percent). Fruit consumption was associated with a lower risk of CHD, whereas noodle consumption was associated with a higher risk of CHD.

These associations were not explained by CHD risk factors or other dietary compo-nents. High rice consumption was associated

with a higher risk of CHD in women, but this was explained by the lower fruit and vegeta-ble consumption.

“We know that the quality and source of dietary fat is highly relevant for risk of CHD. Similarly, evidence is emerging that the qual-ity and source of carbohydrates is important for the development of heart disease,” said researcher Dr. Rob van Dam, associate pro-fessor at the Saw Swee Hock School of Pub-lic Health and Deptartment of Medicine at National University of Singapore.

“In our study of Singapore Chinese, the percentage of energy from carbohydrates was not linked to a higher or lower risk of heart disease. However, persons with higher con-sumption of fruits, a major source of carbo-hydrates and fiber, had a lower risk of heart disease.”

Consumption of fruits, even those rich in carbohydrates, had protective effects.

45 September 2012 In Pract ice

Nerves can be a pressing problem

A Singaporean patient who had un-dergone a kidney transplant com-plained of unsteadiness in 2009 and

developed a tendency to fall.The kidney specialist was concerned

enough to admit him for an MRI scan of the spine to see if there was anything com-pressing the nerves of his spinal column, which could cause such symptoms.

The scan revealed significant compres-sion of the nerves in the neck. We all know that the spinal column houses, protects and nourishes our nerves. Control of all our major body systems and organs is via our nervous systems, which are akin to electri-cal wires branching out from a central grid.

The nerves in the neck belong to the up-per motor nerves, which are more critical. Injury or damage to these nerves will result in greater damage and consequences than lower motor nerves.

There was little chance that this patient’s compressed nerves would get better by themselves. I advised him to undergo spi-nal surgery to free the compressed nerves and, at the same time, undergo a fusion of the affected level of the spine.

Fusion as the first surgical optionFusion involves linking the affected seg-

ments, or vertebrae, of the spine, by stimu-lating bone growth between the segments and by attaching them with rods, screws

Adjunct Associate Professor Hee Hwan TakM.B.B.S. (Singapore), F.R.C.S. (Glasgow)

and plates. This stops further movement between the segments and prevents them from compressing the nerves.

The patient was not keen and said that some form of transplant surgery might be made available to him should his nerves deteriorate further. I told him that nerve and stem-cell transplant was still in the ani-mal experiment stage and the only option at the time was to release the nerves from further compression before his condition worsened.

By making more room for the nerves in such cases, we hope that there will be more blood supply bringing nutrients to the nerves. The eventual result may be gradual recovery of the function of the nerves.

When patients see a spine specialist re-garding a spine problem, their main con-cerns usually are: whether their condition is serious, whether they will be paralysed and whether surgery is needed now or in the future.

Ruling out the “red flags”Our medical undergraduates have been

taught to rule out “red-flags” or serious spi-nal conditions, which may be life- or limb-threatening. Examples of such red-flag con-ditions include cancer, infections, unstable fractures of the spine and compression of the upper motor nerves.

These symptoms include weakness of the arms or legs, fever, urinary incontinence and loss of appetite or weight. Fortunately, most complaints of neck and back pain are due to muscular strain, poor posture and wear and tear of the spine.

The vertebrae in the spine are cushioned and separated by spongy intervertebral discs, which are each made of a fibrous

46 September 2012 In Pract ice

About the Author: Adjunct Associate Professor Hee Hwan Tak, a specialist in spinal disorders and deformities, is the medical director of the Centre for Spine and Scoliosis Surgery, Singapore Medical Group, and a lecturer at Singapore’s National University of Singapore Yong Loo Lin School of Medicine.

outer shell containing a gel-like material. When the spine degenerates, the shells of the intervertebral discs can weaken and tear.

When this happens, the inner mate-rial bulges out and compresses the spinal nerves. Chemicals called prostaglandins are also released from the discs. These can result in intermittent attacks of pain, punc-tuated with good symptom-free days.

When the nerves within the spinal col-umn are pinched, the pain may radiate or spread to the extremities. The patient may complain of numbness, tingling or weak-ness of the affected extremities.

The good thing is that most of these symptoms are resolved in most patients, usually after two to three months of simple treatment measures such as anti-inflamma-tory medication, back or neck exercises and lifestyle modification.

As they feel better, patients often ask if the extent of their nerve compression has been reduced.

A patient gets better not because the de-gree of nerve compression has lessened but because the chemical irritation of the nerves has become less acute.

Anti-inflammatory medication inhibits the effects of the chemicals that leak from the damaged intervertebral discs.

However, about 10 to 15 per cent of pa-tients do not feel significantly better after two to three months. It usually means that their nerves are unable to cope with the compression around them. This is when the possibility of surgery is discussed.

In general, the aim of all types of spinal

surgery is the same, regardless of the condi-tion of the spine – decompression or freeing of the nerves. Sometimes, the segment of the spine may be potentially unstable or pain-ful and may need to be stabilized to some degree.

Treatment options aboundAbout 10 to 20 years ago, fusion of the

segment was the only option. Nowadays, we have the luxury of more treatment methods at our disposal.

These include disc replacement, which means replacing the damaged interverte-bral disc with an artificial one made of met-al and plastic; and dynamic stabilization, which involves implanting a metal device to reinforce the damaged part of the spine.

Determining whether to stabilize or not and the type of stabilization to be used is often a joint decision by the spine specialist and the patient. We take into account the age, lifestyle, job demands and expecta-tions of the patient in the decision-making process.

Progress has been made in the treatment that he wanted, although it remains experi-mental. In October 2010, the world’s first clinical trial using human embryonic stem cells to treat spinal cord injuries began. The aim is to convert stem cells into cells simi-lar to our nerve cells.

Only time will tell if this method will improve the outcome for patients. Scien-tific research may not always produce the results that we want. But there is no going back in our quest for improvement in the treatment of spinal conditions.

47 September 2012 Atr ia l F ibr i l la t ion

Elvira Manzano

Anti-arrhythmic agents may improve survival in older patients with atrial fibrillation (AF) compared with rate

control drugs, a large population-based study has found.

In the study, which involved 26,130 pa-tients aged ≥66 years who had a primary or secondary hospitalization for AF, mortality rates were steadily lower in those receiving rhythm control therapy (24 percent) after 5 years (ratio [HR] 0.89; 95% CI 0.81 to 0.96) vs. rate control drugs. At 8 years, the HR for pa-tients on rhythm control drugs further went down to 0.77 (95% CI 0.62 to 0.95). [Arch Intern Med 2012;172:997-1004]

“With increasing follow-up time, mortal-ity among patients treated with rhythm con-trolled drugs gradually decreased relative to those treated with rate control drugs, reach-ing a 23 percent reduction after 8 years,” said study author Dr. Louise Pilote, from McGill University and the Royal Victoria Hospital in Montreal, Quebec, Canada. “Rhythm con-trol therapy seems to be superior in the long-term.”

Patients were followed for a mean of 3.1 years and for a maximum of 9 years. While there was a small increase in mortality associ-ated with rhythm control therapy in the first 6 months of treatment (HR 1.07), a survival benefit was seen in the same group of patients over time.

“The risk reduction associated with rhythm control was more pronounced in patients who maintained initial treatment over longer peri-ods of time, suggesting that the use of rhythm control therapy may be beneficial for AF pa-tients in whom antiarrhythmic drugs are ef-

fective and well-tolerated,” Pilote said. “Before we decide on giving rate control

therapy to a patient, we should see if [the pa-tient] can be on the current rhythm control therapies and if he can tolerate it. [We should] make an added effort in those who are good candidates for rhythm control.”

However, experts cautioned that given the limitations of such population-based studies, the findings should not change the current approach to managing AF.

In an accompanying editorial, Dr. Thom-as A. Dewland and Dr. Gregory M. Marcus, from the University of California, San Fran-cisco, US, said the choice of a rhythm control vs. a rate control strategy for AF is particu-larly prone to confounding by indication, as rhythm control is preferentially offered to younger patients with fewer medical co-mor-bidities.

“Although the findings are provocative, they are insufficient to recommend a univer-sal rhythm control strategy for all patients with AF,” they said.

However, they also noted that “no clinical trial has definitively shown that maintenance of sinus rhythm is inferior to rate control, and expert consensus recommends a rhythm con-trol strategy for individuals with arrhythmia-attributable symptoms.”

Shorter duration studies previously con-ducted such as the RACE (Rate Control Ver-sus Electrical Cardioversion) and the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trials provided evi-dence that the rate control strategy was pre-ferred for older patients without AF-related symptoms. Dewland and Marcus said the current study challenges the wisdom of this approach.

Anti-arrhythmics offer superior survival rates for older AF patients


Targeted cardiac ablation highly effective in treating AF Radha Chitale

Targeted cardiac ablation was twice as suc-cessful at treating atrial fibrillation (AF)

as standard catheter ablation, according to the results of the CONFIRM* trial.

The trial is the first to demonstrate that AF is sustained by small areas of abnormal elec-trical activity – electrical rotors and focal im-pulses – that can be targeted for ablation to achieve long-lasting AF improvement.

“Human AF rotors and focal impulses were fewer in number, longer lived, and more conserved in this study than suggested,” said researchers from the University of California at Los Angeles, University of California at San Diego and Indiana University in the US.

The prevalent hypothesis is that AF per-sists due to “meandering electrical waves,” which cardiologists treat by catheter ablation around the pulmonary veins. However, AF can return in a third or more treated patients, even after multiple procedures.

“That alters our conceptual framework for human AF, and enabled FIRM [focal impulse and rotor modulation] ablation to be practical and effective.”

The trial included 107 patients with AF who received standard catheter ablation (N=71) or FIRM-guided ablation followed by standard ablation (N=36). [J Am Coll Cardiol 2012 Jul 13. Epub ahead of print]

FIRM-guided patients were ablated based on a personalized computational map that showed precisely where to destroy the source tissue. Each of the FIRM intervention patients had about two sources of localized rotors or focal impulses.

AF terminated or slowed in 86 percent of

FIRM-guided patients compared with 20 per-cent of FIRM-blinded patients (P<0.001).

FIRM ablation at the source stopped AF in a median 2.5 minutes.

After 2 years (median 273 days) after one procedure, 82.4 percent of FIRM-guided pa-tients were AF-free compared to 44.9 percent of FIRM-blinded patients (P<0.001) based on implanted electrocardiograph monitoring.

Both FIRM-guided and standard catheter ablation procedures took similar amounts of time and adverse events were similar be-tween groups.

The researchers reported that FIRM abla-tion at target points stopped AF in a median time of 2.5 minutes, indicating the mechanis-tic role of rotors and focal sources in sustain-ing AF.

“Patients in whom FIRM ablation slowed rather than terminated AF had sources that could not be eliminated, for safety consider-ations or protocol imposed time limits… and may have had residual sources in unmapped regions,” the researchers said.

AF is the most common form of arrhyth-mia in the world and significantly increases the risk of stroke as well as being associated with cardiac issues. One-year success for ab-lation therapy without pharmacotherapy is up to 60 percent with one procedure and up to 70 percent for three or more.

“FIRM-guided therapy presents an oppor-tunity to improve ablation outcomes while avoiding more extensive strategies that may result in serious sequelae,” the researchers said.

*CONFIRM: Conventional Ablation for Atrial Fibrillation With or

Without Focal Impulse and Rotor Modulation


Rajesh Kumar

Physicians should be reassured that safe-ty indicators in place for anticoagulation

therapy in patients with atrial fibrillation (AF) are working well, a large European study suggests.

For patients on warfarin, the Internation-al Normalized Ratio (INR) should typically be between 2.0 and 3.0 (in healthy people, it is about 1.0). However there have been no large scale studies to establish the danger INR level in patients with AF.

The prospective European Action on Anti-coagulation (EAA) study has now confirmed INR >5.0 as the safety indicator, which is consistent to that currently outlined by the UK National Health Service improvement document. [J Clin Pathol 2012;65:452-456]

The EAA study researchers monitored the INR of 5,839 patients using their blood tests, which were independently assessed. Any clinical events, such as bleeding or thrombo-sis, were also monitored and matched to the patient’s INR reading.

At least 13 percent who had at least one INR >5.0 had a bleeding or thrombotic event. The incidence was significantly higher than for the 6.2 percent of patients who had a clinical event but did not develop an INR >5.0 (95% CI 1.41 to 2.04; P≤0.001).

Of patients starting oral anticoagulation who had a bleeding episode (minor, major or fatal), 9.5 percent had at least one INR >5.0. This was significantly higher than the 4.6 percent in patients who did not develop INR >5.0 (95% CI 1.32 to 2.04; P≤0.001). In the first 2 months of treatment, bleeding oc-curred in 11.0 percent of patients who had

at least one INR >5.0. This was significantly higher than the bleeding rate of 5.0 percent in patients who did not develop an INR >5.0 (P≤0.001).

“This study demonstrates through sig-nificant patient results that the ‘safety in-dicators’ (as listed in the UK document) are correct. This is a really important finding for the hundreds of thousands of patients who suffer from AF and for the medical staff who treat them,” said EAA project leader Profes-sor Leon Poller of the EAA central facility at the faculty of life sciences, University of Manchester, Manchester, UK

Warfarin is a commonly used anticoagu-lant all over the world and all countries have their own safety protocols around its use. But the findings on the UK protocols should influence practice. Medical professionals ev-erywhere, including Asia, should be aware of them and apply them to make the treatment of AF safer, said Poller.

Anticoagulant safety protocols working well in Europe

Safety indicators used in the UK for anticoagulant therapy with warfarin have been correct, according to a study.

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51 September 2012 Calendar

SeptemberMedical Fair Asia —9th International Exhibition on Hospital, Diagnostic, Pharmaceutical, Medical and Rehabilitation Equipment Supplies 12/9/2012 to 14/9/2012 Location: Singapore Info: Messe Düsseldorf AsiaTel: (65) 6332 9626Email: [email protected] Website: www.medicalfair-asia.com

Hospital Management Asia 201213/9/2012 to 14/9/2012Location: Hanoi, VietnamInfo: Ms. Sheila PepitoTel: (632) 846 8339Email: [email protected]: hospitalmanagementasia.com

London College of Clinical Hypnosis (LCCH-Asia) Certificate in Clinical Hypnosis22/9/2012 to 23/9/2012 Location: University of Malaya, Kuala Lumpur, MalaysiaInfo: LCCH SecretariatTel: (60) 3-7960 6439 / 7960 6449Email: [email protected]: www.hypnosis-malaysia.com

October48th Annual Meeting of the European Association for the Study of Diabetes1/10/2012 to 5/10/2012Location: Berlin, GermanyInfo: EASD SecretariatEmail: [email protected] Website: www.easd2012.com

15th Biennial Meeting of the European Society for Immunodeficiencies (ESID 2012)3/10/2012 to 6/10/2012Location: Florence, ItalyTel: (41) 22 908 0488Fax: (41) 22 732 2850Email: [email protected]: www.kenes.com/esid

8th World Stroke Congress 10/10/2012 to 13/10/2012 Location: Brasilia, Brazil Info: World Stroke Organization Tel: (41) 22 908 0488Email: [email protected] Website: www1.kenes.com/wsc

23rd Great Wall International Congress of Cardiology (GW-ICC) – Asia Pacific Heart Congress (APHC) 201211/10/2012 to 14/10/2012Location: Beijing, ChinaInfo: Secretariat Office of GW-ICC & APHC (Shanghai Of-fice)Tel: (86) 21-6157 3888 Extn: 3861/62/64/65Fax: (86) 21-6157 3899Email: [email protected]: www.heartcongress.org

42nd Annual Meeting of the International Continence Society 15/10/2012 to 19/10/2012Location: Beijing, ChinaTel: (41) 22 908 0488Fax: (41) 22 906 9140Email: [email protected]: www.kenes.com/ics

8th Asian-Pacific Society of Atherosclerosis and Vascular Diseases Meeting 20/10/2012 to 22/10/2012 Location: Phuket, Thailand Info: Asian-Pacific Society of Atherosclerosis and Vascular DiseasesTel: (66) 2940 2483 Email: [email protected]: www.apsavd2012.com

Upcoming

2012 Scientific Sessions of the American Heart Association 3/11/2012 to 7/11/2012 Location: Los Angeles, California, US Info: American Heart Association Tel: (1) 214 570 5935 Email: [email protected] Website: www.scientificsessions.org

52 September 2012 Calendar

8th International Symposium on Respiratory Diseases & ATS in China Forum 20129/11/2012 to 11/11/2012Location: Shanghai, ChinaInfo: UBM Medica Shanghai Ltd.Tel: (86) 21-6157 3888 Extn: 3861/62/64/65Fax: (86) 21-6157 3899Email: [email protected]: www.isrd.org

63rd Annual Meeting of the American Association for the Study of Liver Diseases9/11/2012 to 13/11/2012 Location: Boston, Massachusetts, US Info: American Association for the Study of Liver Diseases Tel: (1) 703 299 9766 Website: www.aasld.org

National Diagnostic Imaging Symposium 2/12/2012 to 6/12/2012Location: Orlando, Florida, USInfo: World Class CME Tel: (980) 819 5095Email: [email protected]: www.cvent.com/events/national-diag-nostic-imaging-symposium-2012/event-summary-d9ca77152935404ebf0404a0898e13e9.aspx

Asian Pacific Digestive Week 20125/12/2012 to 8/12/2012Location: Bangkok, ThailandTel: (66) 2 748 7881 ext. 111Fax: (66) 2 748 7880E-mail: [email protected]: www.apdw2012.org

World Allergy Organization International Scientific Conference (WISC 2012)6/12/2012 to 9/12/2012Location: Hyderabad, IndiaInfo: World Allergy OrganizationTel: (1) 414 276 1791 Fax: (1) 414 276 3349E-mail: [email protected]: www.worldallergy.org

53 September 2012 Humor

“I’ve been Dr. Lamont’s patient for over 12 years and I’ve never seen his face!”

“Glad you could make it!”

“What’s halitosis?”

“Lucy, I think we should get a divorce!”

“Go ahead and take those , I’m curious to see what they will do to you!”

“Do you know what gets me? You put on a white coat and right away everyone thinks

you are a doctor!”

“Do you have to go on and on about how gross the whole

thing is?”

“It was just a joke!”

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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 check-ing 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 there-from. 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.

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