Medical Tribune September 2012 HK

September 2012
Experts debate Chinas healthcare reforms
FORUM Healthcare in China: Finding the right balance
HONG KONG FOCUS Experts call for action on viral hepatitis
CONFERENCE Carbohydrate sources key in CHD mortality
NEWS Involving patients reduces unnecessary antibiotic Rx
1,500 Academic Speakers 1,500 Academic Speakers 340 Sessions 340 Sessions 70 Special Topics 70 Special Topics
Date: Date: Venue: Venue:
Congress Language:
English and Mandarin Congress Language: English and Mandarin
11-14 October 2012 11-14 October 2012 China National Convention Center (CNCC), China National Beijing, China Convention Center (CNCC), Beijing, China
Organized by:
Organizing Committee of Asia Pacific Heart Congress (APHC) Organized by: Organizing Wall International Congress Organizing Committee Committee of of Great Asia Pacific Heart Congress (APHC)of Cardiology (GWICC) Organizing Committee of Great Wall International Congress of Cardiology (GWICC)
Congress Secretariat for Overseas Delegates:
Secretariat Office of GWICC & APHC (Shanghai Office) Congress Secretariat for Overseas Delegates: Tel: 86-21-6157 3888 ext. 3861/3862/3864/3865 Secretariat Office of GWICC & APHC (Shanghai Office) Fax: 86-21-6157 3899 Tel: 86-21-6157 3888 ext. 3861/3862/3864/3865 Email: secretariat@heartcongress.org Fax: 86-21-6157 3899 Email: secretariat@heartcongress.org Please visit www.heartcongress.org for further details
delegates already 10,000 confirmed! delegates already confirmed!
10,000
September 2012
Experts debate Chinas healthcare reforms

Elvira Manzano
he inaugural Healthcare in China summit held in Beijing recently served as a platform for experts to debate Chinas 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 government 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 although China has made significant headway towards system improvement (eg, the establishment of a nationwide health insurance system, a primary drug list and a centralized drug procurement system), some issues remain to be addressed including resource allocation. He said more than 85 percent of Chinas health budget was spent on diagnosis 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 approved 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 has implemented major reforms to its healthcare system in recent years, but resource allocation remains a major issue.
Chinas 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 during the conference, experts provided suggestions on how best to allocate resources, progress public hospital reforms, augment services and raise standards of care. Specific recommendations included removing physicians 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.
September 2012
Forum
Healthcare in China: Finding the right balance

Based 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.
Elvira Manzano
ver 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 countrys 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. Furthermore, the burden of healthcare on patients is
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 dont think it is enough yet still very heavy, especially on rural residents. Overall however, the Chinese government has been quite successful in implementing
its recent healthcare reforms, playing a leading 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 healthcare centers. Provide better service when it comes to
September 2012
Forum
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 dont 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 opportunities 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 primary 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.
public 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 primary healthcare services, the private sector should also be involved in non-primary services. Indeed, the healthcare system needs to work closely together with the medical insurance system in order to help those with higher demands and who can afford more expensive and individualized services. The situation for hospitals throughout China 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
September 2012
Hong Kong Focus
Experts call for action on viral hepatitis

Naomi Rodrig
arking 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 hepatitis B or C infection, resulting in about 1 million deaths each year attributed to hepatitis-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 Alliance, 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 population of adult HBV [hepatitis B virus] carriers, remarked Professor George Lau, Chair Professor in Clinical Hepatology and Codirector of the Institute of Translational Hepatology, Beijing 302 Hospital. According to Lau, who is a founding trustee of the Cheng Si-Yuan (China Inter-
A simple blood test can detect HBsAg
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 persons responsibility 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 subsidizing testing in the community. For example, the Cheng Si-Yuan Hepatitis Foundation has covered free testing for thousands of local people through charitable donations. To celebrate this years World Hepatitis Day, we have opened a new clinic in Western New Territories, which aims to
September 2012
Hong Kong Focus

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.
improve access to diagnosis and treatment for local people, mostly immigrants from mainland China, noted Lau. ASIAHEP Hong Kong a nonprofit organization 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
Recurrent MI common in local CVD patients

Christina Lau
ore than half of patients with cardiovascular 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. Almost 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 Medicine 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 20092010. 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 recurrence [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
September 2012
Hong Kong Focus

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 Authoritys formulary.
Outcomes]. [N Engl J Med 2009;361:10451057] 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,
Researchers identify pathogenic pathways of spinocerebellar ataxia

Christina Lau
esearchers of the School of Life Sciences, Chinese University of Hong Kong (CUHK) have identified pathogenic pathways 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 motor 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.
[Proc Natl Acd Sci USA 2012, e-pub 30 July] From a mechanistic point of view, expanded CAG RNAs prevent a protein called nucleolin from binding with chromatin in the nucleolus, a special region in the nucleus responsible for producing ribosomes, he continued. This phenomenon, described as nucleolar stress, eventually triggers apoptosis in the cerebellum and leads to the development 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 CUHKs Biochemistry Program, the Hong Kong Spinocerebellar Ataxia Association, and the Research Grants Council of Hong Kong, said Chan.
September 2012
Hong Kong Focus
Treating brain vessel malformations without a cut

Christina Lau
esearchers at the Chinese University of Hong Kong have reported success with linear accelerator radiosurgery in treatment of cerebral arteriovenous malformation (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 therefore to reduce the risk of fatal or debilitating hemorrhagic stroke. Microsurgical resection is the mainstay of treatment for cerebral AVM, as it immediately eliminates the risk of hemorrhage with an obliteration rate of at least 90 percent, said Professor George Wong of the Department of Surgery. However, depending on the location and size of AVM and patient-related factors, microsurgery may be too risky in some cases. In cases where AVMs are large or located in critical areas of the brain, for example, radiosurgery may be a preferred treatment option, said Dr. Michael Kam of the Department 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 patients 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, including radionecrosis [3 percent], symptomatic edema [6 percent] and re-bleeding [6 percent]. [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 radiosurgery is only 3 days, significantly shorter than that required for microsurgery and embolization, said Kam. The major limitation 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 stereotactic radiosurgery or delivery of radiation dose in fractions, for giant or brainstem cerebral AVMs, added Wong. Preliminary results are promising.
10 September 2012 Hong Kong Focus
Antiviral treatment cuts HCC recurrence

Naomi Rodrig
meta-analysis conducted by researchers 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 untreated controls. [Aliment Pharmacol Ther 2011;33: 1104-1112] According to Professor Henry Chan, the Centers 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. Although 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 treatment was associated with over 40 percent risk reduction for HCC recurrence as compared with the untreated controls, reported Dr. Grace Wong, Associate Professor at CUHKs 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 CUHKs meta-analysis, also demonstrated that antiviral treatment post HCC resection significantly prolonged disease-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, respectively; 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 major vascular invasion. [Arch Surg 2011;146:675681] 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 recommended for other chronic hepatitis B patients who require treatment, she told Medical Tribune. Based on the evidence from this meta-anal-

ysis, 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 recommends antiviral therapy for all HCC patients who have an HBV DNA level higher than 2,000 IU/mL after surgical resection, advised Wong.
High prevalence of overweight-related NAFLD in Hong Kong

Naomi Rodrig
he 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 system. So, its important to raise public awareness 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 volunteers from the general population. All subjects 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 measurements, 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 Medicine, HKU. NAFLD prevalence increased with age and was slightly more prevalent in men than in women. The investigators found a strong association between higher waist circumference and

the severity of steatosis, in both males and females. 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 assessment of your waist circumference. Based on the study data, the researchers recommend new optimal cut-off values for waist circumference. The current waist circumference cut-off recommended by the Department of Health (DH) is 90 cm for men and 80 cm for women. We suggest the optimal cutoff should be lowered to 84 and 74 cm, respectively, to prevent NAFLD and progression to NASH [non-alcoholic steatohepatitis] and cirrhosis, 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 cholesterol levels and higher blood pressure, which are also associated with overweight and unhealthy 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 developing 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
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 established preparatory task force on a Chinese Medicine Development Committee, to provide better medical services, said Leung. The 11-member task force will advise the government on the committees terms of reference and composition, as well as future
priorities and strategic direction. According to Ko, task force members will comprise representatives of TCM practitioners, 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 Practitioners Board under the Chinese Medicine Council of Hong Kong. The Council is a statutory

body 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 already seeking TCM treatments at the Chinese medicine clinics of the Hospital Authority 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 practitioners 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 conducting research and clinical trials to provide evidence-based data on TCM products, are planning 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 medicine. At least 50 beds will be allocated for this service when the hospitals two-phase redevelopment project is completed in 2022. Although the plans for expanding Chinese 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, its fine, but I think Dr. Ko is trying to promote another profession. Its 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 Western medicine services in Hong Kong. On the contrary, the development of Chinese medicine hopefully may help alleviate some pressure on our public hospital system on Western medical side, in particular primary care and rehabilitation services, he said. Chinese medicine may be useful for patients recovering 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 expand and promote TCM services. There is a legal framework for registration of TCM practitioners and products, while research on Chinese medicine at local universities and public hospitals continues to expand, he said.

Case Study
Aripiprazole augmentation in Tourettes syndrome with comorbid OCD

Dr. Jimmy Yuet-Sun Dong Specialist in Psychiatry Private Practice Introduction omorbid conditions, such as obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD), are present in many patients with Tourettes syndrome (TS). These comorbidities often cause more functional impairment than the tics characteristic of TS; hence, addressing these conditions is a treatment priority. Presentation and history A 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 lacerations; and a compulsion to pick on the scabs that formed over the abrasions. Other compulsions included an urge to throw objects, swallow small items and remove his trousers in public. The patients constant compulsions severely impeded his activities of daily living. He consulted a number of psychiatrists who prescribed various medications, including selective 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. Examination of the tongue revealed a 4 cm long abrasion. His treatment consisted of escitalopram 30 mg daily, risperidone 3 mg daily, and flupentixol/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 risperidone. However, only a minor improvement of OCD symptoms was observed. Several weeks later paliperidone, titrated up to 9 mg/day, was added, resulting in partial control of some compulsions and a marked decrease in jerking movements. Concurrently, the patient received cognitive behavioral therapy (CBT) to deal with his compulsions. The two-pronged pharmacological/behavioral approach was maintained for approximately 2 years. Augmentation treatment Last year, noting emerging evidence from case reports and clinical trials, we decided to commence augmentation therapy with aripiprazole, starting at 5 mg and increasing to 10 mg daily within 2 weeks. After 2 weeks of

treatment, the patient reported a 50 percent decrease in the frequency of his compulsions and significantly less anxiety about his obsessive-compulsive behavior. In particular, the compulsions to bite his tongue and remove his trousers in public ceased; while he occasionally thought about swallowing random small items, he was able to control himself from acting on this urge. There was also a notable decrease in the frequency and severity of his jerking movements. The patient has been maintained on a regimen of paliperidone, escitalopram, flupentixol/melitracen and aripiprazole, and is on regular follow-up every 2 months. With his OCD symptoms under control, he has resumed attending class and is considering higher education. Discussion TS is an inherited neuropsychiatric disorder 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 survey 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 assessed the efficacy of various antipsychotics in augmenting the anti-OCD effects of SSRIs. Agents that have demonstrated clinical benefit include risperidone,5-8 olanzapine,9-11 amisulpride,12 and quetiapine.13,14 Aripiprazole is an atypical antipsychotic with partial agonist activity at the serotonin 5HT1A receptor and the dopamine D2 receptor, and antagonist activity at the 5HT2A receptor.15,16 It has demonstrated clinical efficacy in the treatment of obsessive-compulsive symptoms in adult patients with bipolar disorder17 and schizophrenia,18 and children with tic disorders.19 Our patient noted a marked decrease in compulsion frequency and an increased ability to resist them upon starting aripiprazole treatment. It is hypothesized that aripiprazoles augmentation of the anti-OCD effect of SSRIs is mainly through modulation of serotonin transmission.20 Increased dopaminergic activity, postulated to play a central role in the pathophysiology of TS,21 has also been hypothesized to play a role in the pathophysiology of OCD.22 That aripiprazole augmentation resulted in both amelioration of the patients motor tics and relief of OCD symptoms lends credence to these theories, and is possibly attributable to aripiprazoles partial agonist activity at dopamine D2 receptors.20 The efficacy of aripiprazole monotherapy or as add-on to SSRI-based therapy in refractory OCD was demonstrated in several clinical trials.20,23 Most recently, two case series from Japan demonstrated significant improvements 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, hyperkinesias, tremors, and asthenia. Known side effects of atypical antipsychotics include clinically significant weight gain, dysglycemia, extrapyramidal symptoms, and development of the metabolic syndrome.26 Notably, our

patient did not experience any side effects with aripiprazole augmentation. Nevertheless, more clinical trials are needed to further elucidate the safety and tolerability of aripiprazole augmentation in this setting. In summary, this report adds to the emerging 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;15:297301. 7. Arch Gen Psychiatry 2000;57:794-801. 8. J Clin Psychiatry 1995;56:423-429. 9. J Clin Psychiatry 2000;61:514-517. 10. Psychiatry Res 2000;96:91-98. 11. Can J Psychiatry 2001;46:356358. 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 CML

Christina Lau
atients 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-generation TKIs [tyrosine kinase inhibitors] can be considered, said Professor Yuk-Lam Kwong of the Division of Hematology, Medical Oncology and Bone Marrow Transplantation, University of Hong Kong. This recommendation is more aggressive than current European or US guidelines, which recommend that major molecular response (MMR), or a drop of BCR-ABL1 transcript levels to 0.1 percent of pretreatment values, be achieved by 18 months of treatment. Recent studies suggest that early molecular response at 3 months is predictive of longterm 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 International Scale) 10 percent at 3 months had signifi-
Blast crisis of CML
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 eventually 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 imatinib at 3 months, he continued. Full subsidy will be given to five eligible patients to receive nilotinib therapy for 3 months, to help them achieve disease control as early as possible.
The changing face of medical professionalism
Christina Lau
s social changes and Western culture exert an influence on the perception of medical professionalism in Hong Kong, doctors may be expected to go beyond well-recognized attributes to be seen as professional, a recent study revealed. Researchers of the Medical Ethics Unit, University of Hong Kong interviewed 39 individuals at the Queen Mary Hospital to explore perceptions of medical professionalism a subject widely discussed in Western literature 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 professionalism in Hong Kong is shaped by both Western medical ethics and traditional Chinese values. In general, attributes recognized in Western bioethics such as medical knowledge and skills, excellence, acting for patients best interest, holistic care, altruism and communication skills were widely agreed as attributes of a professional doctor. However, the interviewees also expected a professional doctor to be accountable to the public and have good conduct.
According to the authors, these expectations suggest that the image of a professional doctor is similar to that of the morally ideal person in Confucianism. Reference to Chinese culture and Chinese sayings often 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 colleagues was emphasized, the nurse subjects were particularly critical about the communication 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 patients was also seen as essential. As younger patients brought up in Western education 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.
Survey shows poor oral health in HK

Naomi Rodrig
recent survey among local adults showed that nearly half of the respondents 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 Center of the University of Hong Kong (HKU), included 532 local adults. Nearly 50 percent of the subjects said they do not undergo annual dental check-ups despite suffering from tooth decay, gum problems and bad breath. About one third said that dental care was inconvenient and 25 percent were not aware of the need for regular oral health checks. There is serious neglect among the local public. Regular dental visits are very important as prevention is always cheaper than cure, commented Professor Colman McGrath of HKUs 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 negative impact on their social and romantic interactions and the way they smile and laugh.
Warning on N2O use

Naomi Rodrig
ollowing a recent incident of nitrous oxide (N2O) poisoning at the O&G Department, Prince of Wales Hospital (PWH), the Hospital Authority (HA) issued an occupational safety alert on the hazards of exposure to high concentrations of N2O. Also known as laughing gas, N2O is often 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 exposure 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 reminded to ensure proper fitting of N2O breathing 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 recommendations on further arrangements and appropriate measures, a HA spokesman said.
Expanded flu reporting

Wey-Feng Ong
tatutory 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 infections with this flu variant reported recently in the United States, the Hong Kong Government 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 prepare in advance for the possible importations of this infection into Hong Kong and their consequences. The inclusion of variant influenza A (H3N2) will allow provisions of the Ordinance, such as medical surveillance, quarantine and isolation to be applied as and when necessary, and will make Hong Kong better prepared against the disease by facilitating earlier disease detection and implementation of appropriate public health measures if they are called for, depending on public health risk assessment, he added. The circular contains the reporting criteria for variant influenza A (H3N2). Medical practitioners 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 surveillance system for the influenza virus, the spokesperson remarked. We will continue to closely monitor the global and local influenza activity as well as genetic changes 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 cases 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 influenza and are generally mild and self limiting. Antivirals such as oseltamivir and zanamivir 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 15/9 Tel: (852) 2871 8844 / 2871 8745 Fax: (852) 2580 7071 E-mail: yandy_hkccm@hkam.org.hk / hkccm@hkam.org. hk www.hkccm.org.hk/index.php Hong Kong Pain Society ASM 2012 New Light on Pain 15/9 Tel: (852) 2559 9973 Fax: (852) 2547 9528 E-mail: hkps.asm@icc.com.hk www.hkpainsociety.org Update on Osteoporosis Management Osteoporosis Center, Queen Mary Hospital; Research Centre of Heart, Brain, Hormone and Healthy Aging, HKU 16/9 Tel: (852) 2255 3577 Fax: (852) 2255 4176 E-mail: osteoctr@hku.hk www.medic.hku.hk/download/2012%20UOM%20flyer. pdf Conjoint Scientific Congress 2012 College of Surgeons of Hong Kong; Royal College of Surgeons of Edinburgh 22/9-23/9 Tel: (852) 2871 8825 Fax: (852) 2518 3200 E-mail: csc@cshk.org www.cshk.org/csc2012/index.html Advances on Diagnostic and Therapeutic Colonoscopy 2012 Departments of Medicine and Surgery, HKU 28/9-29/9 Info: Gladys Chu Tel: (852) 2255 3348 Fax: (852) 2816 2863 E-mail: gchu@hku.hk www.medic.hku.hk/enteroscopy.htm Transcatheter Renal Denervation (TREND) 2012 Asia-Pacific cme4u GmbH Congresses, Meetings and Education 29/9 Tel: (49) 69 25 61 28 55 Fax: (49) 69 25 62 86 58 E-mail: info@cme4u.org / trend@cvcfrankfurt.de www.csi-trend.org 14th Diabetes and Cardiovascular Risk Factors East Meets West Symposium 1/10-2/10 Info: UBM Medica Pacific Limited Tel: (852) 2155 8557 / 3153 4374 Fax: (852) 2559 6910 E-mail: info@eastmeetswest.org.hk www.eastmeetswest.org.hk HK College of Community Medicine Annual Scientific Meeting 2012 Occupational Health for All: From Prevention to Rehabilitation 15/9
Tel: (852) 2871 8844 / 2871 8745 Fax: (852) 2580 7071 E-mail: yandy_hkccm@hkam.org.hk / hkccm@hkam.org.hk www.hkccm.org.hk/index.php
Hong Kong Pain Society Annual Scientific Meeting 2012 New Light on Pain 15/9
Tel: (852) 2559 9973 Fax: (852) 2547 9528 E-mail: hkps.asm@icc.com.hk www.hkpainsociety.org
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: meeting.hk@ubm.com www.hkspr.org

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: meeting.hk@ubm.com 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 E-mail: olc@ort.cuhk.edu.hk 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 E-mail: olc@ort.cuhk.edu.hk www.olc-cuhk.org 23rd Video Urology World Congress 2012 Hong Kong Urological Association 8/11-11/11 Tel: (852) 2632 2644 Fax: (852) 2632 4708 E-mail: info@videourology2012.com www.videourology2012.com/default.asp 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 E-mail: mandyyu@cuhk.edu.hk 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 E-mail: enquiries@hkcr.org www.hkcr.org
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, asmonotherapy 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
Synthetic protein may keep flu at bay

Malvinderjit Kaur Dhillon
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 administered, 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 immune response. The flu virus is very sneaky and actively keeps the immune system from detecting it for a few days until you are getting symptoms, 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 exposure to the flu virus caused the immune system 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 influenza vaccine, which has to perfectly match the currently circulating strain. In this study, testing was done primarily 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
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 influenza. 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 lethal dose of influenza did not die, Phillips said. When you find out youve been exposed to the flu, the only treatments available now target the virus directly but they are not reliable and often the virus develops a resistance against them, Phillips said. EP67 could potentially be a therapeutic that someone would take when they know theyve been exposed that would help the body fight off the virus before you get sick. Philips added that while the study focused on influenza, EP67 could potentially work on other respiratory diseases and fungal 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 number of other pathogens, and to investigate how EP67 functions within different cells in the body.
COPD patients benefit from antibiotic prophylaxis

Alexandra Kirsten
atients suffering from chronic obstructive pulmonary disease (COPD) may benefit from a regular intake of antibiotics to prevent acute exacerbations, according to new research. A meta-analysis of two clinical trials involving 1,251 patients with COPD showed that patients 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;367:3407] While there was no significant difference between 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. the potential to eliminate one-third of the severe exacerbations each year among patients with COPD 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 colleagues. A patient who continues to have frequent acute exacerbations despite guidelines-based treatment is a potential candidate for prophy-
A meta-analysis has shown that a daily course of azithromycin for a year significantly cut rate of COPD exacerbations.
This approach has
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 considered for such therapy, both to provide a baseline 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 azithromycin, 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 conditions 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-threatening and can lead to additional lung function decline.
Involving patients reduces unnecessary antibiotic Rx

Rajesh Kumar
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 outcomes 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 control. GPs in the DECISION+2 practices were offered a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-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 consulted 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
Unnecessary antibiotic prescriptions may be reduced when patients are more involved in the decision-making process.
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 0.340.68). DECISION+2 was associated with patients taking a more active role in decision-making (P0.001) 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 respiratory infections. But the authors suggested that physician training in a shared decisionmaking process, with greater patient involvement, can make a huge difference.
Single dose of iron improves quality of life in iron-deficient women

Malvinderjit Kaur Dhillon
omen 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 documented that iron deficiency leads to fatigue. Fatigue leads to impairment of cognitive function, quality of life and physical performance, said Dr. Michael Hedenus, of Sundsvall 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, Haematologica 2012;97(1):193] Almost 300 young women who were fatigued 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 fatigued according to the instrumental Piper Fatigue Scale (PFS) [score 5]. Several exclusion criteria included patients were not allowed 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 significantly more often in FCM-treated patients compared to the placebo group (65.3 percent
A single dose of iron may also reduce fatigue in iron-deficient women.
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, P0.01). [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 consider them for treatment of iron deficiency, he concluded.
Shift work increases CV risk

Elvira Manzano
eople 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-analysis 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 working day shifts. The risks remained consistent despite adjustment for factors such as study quality, socioeconomic status and unhealthy behaviors, including smoking. Interestingly, shift work was not associated with increased rates of death from any cause. [BMJ 2012;345:e4800] Our findings suggest that people who do shift work should be vigilant about risk factor modification, said lead study author Dr. Daniel G. Hackam, assistant professor at the Department of Epidemiology and Biostatistics at University of Western Ontario in London, Ontario, Canada. Shift workers should be educated about cardiovascular symptoms to forestall the earliest clinical manifestation of the disease. Hackam and colleagues reviewed 34 previous 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 workers. 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 bodys 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 exercise. They should be aware of the health risks that go with their work patterns. They should go to their doctors and have their blood pressure, cholesterol, waist circumference and blood glucose routinely checked, Hackam said. He also recommends that employers institute health screening programs in the work place, give employees time to sleep and rationalize 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. Despite several limitations of the study, including heterogeneity in the outcome of coronary events, we have identified an epidemiological association between shift work and vascular events which may have implications for public policy and occupational medicine, the authors concluded.
Weight training lowers type 2 diabetes risk in men

Alexandra Kirsten
en 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 author Mr. Anders Grntved, visiting researcher in the department of nutrition at Harvard School of Public Health, Boston, Massachusetts, 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 cohort 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 training and aerobic exercise (including jogging, running, cycling and swimming) on questionnaires they filled out every 2 years. During 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 doseresponse 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 training with the risk of T2D and to assess the influence of combining weight training with
Men who engaged in both aerobic and weight training for more than 150 minutes per week had the greatest reduction in T2D risk.
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 percent 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 diabetes risk over and above aerobic exercise, which are likely to be mediated through increased 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. Furthermore, the effect of duration, type and intensity of weight training on T2D risk should be examined in greater detail.
Testosterone therapy linked to weight loss in men

Rajesh Kumar
ong-term testosterone therapy may reduce weight, waist circumference and body mass index (BMI) in hypogonadal 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 decreased from 106.22 kg at baseline to 90.07 kg after 5 years (P0.0001). Mean waist circumference also significantly declined from 107.24 cm at baseline to 98.46 cm after 5 years (P0.0001), while mean BMI declined from 33.93 to 29.17 (P0.0001). The benefit was progressive over the follow-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 after 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 reactions (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, analyzed 1,438 (mean age 49.2 years) hypogonadal men who were overweight and were given a total of 6,333 injections of long-acting-intramuscular testosterone undecanoate over 9 to 12 months. [J Sex Med 2012; DOI: 10.1111/j.17436109.2012.02853.x] While their scores of mental and psychosexual functions (libido, vigor, overall mood, and ability to concentrate) improved markedly, mean waist circumference decreased from 100 cm to 96 cm. Blood pressure and lipid parameters were also favorably altered in a significant manner, said the researchers. After four injection intervals, the percentage 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 erectile 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 Mens Health Singapore.
*IPASS: International, multicenter, Post-Authorization Surveillance Study on long-acting-intramuscular testosterone undecanoate
Calcium supplements linked to MI, kidney stones

Yen Yen Yip
he safety of calcium supplements has come under further scrutiny as recent reports suggest they may be linked with higher risks of myocardial infarction (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 Bolland 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 European Prospective Investigation into Cancer and Nutrition (EPIC) study, led by researchers based in Heidelberg, Germany, assessed calcium intake through the diet and supplements of close to 24,000 subjects for about 11 years. The results showed that subjects who took calcium supplements regularly were 86 percent 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, concluded lead author Dr. Kuanrong Li from the Division of Cancer Epidemiology, German Cancer Research Center, Heidelberg, Germany, and colleagues. The study also evaluated subjects whose calcium intake came from dietary sources.
Calcium supplementation appears less safe when compared with normal dietary intake of calcium.
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 compared with those who took less dietary calcium (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

and vitamin D supplements were shown to cause higher rates of hypercalciuria and hypercalcemia in 163 postmenopausal women with vitamin D insufficiency. The study, presented at the 2012 Annual Meeting of The Endocrine Society in Houston, 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 hypercalciuria, defined as urinary calcium levels greater than 300 mg in a 24-hour urine calcium test. Hypercalcemia was also identified in about one in 10 subjects (10 percent). Given that both events are known to contribute to the risk of kidney stones, lead study investigator Professor Christopher Gallagher, director of the Bone Metabolism Unit at Creighton University Medical Center, Nebraska, US, has suggested that clinicians should monitor the blood and urine calcium levels of patients who take calcium and vitamin D supplements on a longterm basis.
Vitamin E may help reduce liver cancer risk

Radha Chitale
arge amounts of dietary or supplementary vitamin E may help reduce the risk of liver cancer in women, according to a large prospective, populationbased study of Chinese adults. We found a clear, inverse dose-response relation between... vitamin E intake and liver cancer risk, an association that was independent of supplement use and that appeared to be slightly stronger among participants who reported no liver disease or family history of liver cancer, said researchers from Vanderbilt Epidemiology Center in Nashville, Tennessee, US, and the Shanghai Cancer Institute in Shanghai, China. Previous epidemiological studies have proved inconclusive about the effects of vitamin E on various cancers but there is evidence that vitamin E improves liver function in people with viral hepatitis. Case controlled studies of dietary vitamin E are few.
Supplemental vitamin E intake was inversely correlated with liver cancer risk in adult Chinese women.
The study included 132,837 people from the Shanghai Womens Health Study (19972000) and the Shanghai Mens Health Study (2002-2006). [J Natl Cancer Inst 2012 Jul 17 Epub ahead of print] Participants were interviewed about their

dietary habits and vitamin supplement consumption and evaluated using food frequency questionnaires, plus follow-up interviews. 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 developing liver cancer compared with those who consumed less vitamin E (P Trend = 0.01). Supplemental vitamin E was similarly 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 cancer 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 vitamin 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 contribute 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 multivitamins 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 unrelated 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 vitamin supplements, but that further studies on the effect of vitamin supplements on liver cancer are warranted.
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Vitamin B12 may boost Hep C treatment response

Elvira Manzano
upplementation with vitamin B12 may help increase the effectiveness of antiviral 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 standard 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 significantly 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 Gerardo Nardone, from the Department of Clinical and Experimental Medicine, Gastroenterology Unit, University of Naples, Naples, Italy. SVR is an indicator of long-term remission and currently the best marker of successful therapy for HCV infection. While there is some support for detection of viral response 3 months after treatment, the 6-month posttherapy 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 Nardone 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 5,000g 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 responses 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 demonstrated that only vitamin B12 supplementation (overall response [OR]=6.9; P=0.002) and genotype 2 or 3 (OR=9; P=0.001) were independently 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 standard 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, Singapore 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.
No effect of maternal antibodies on Hep A vaccination in infants

Alexandra Kirsten
accination 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 antibody transfer. These were the results of a recently published study by epidemiologists from the Centers for Disease Control and Prevention in Atlanta, Georgia, US. Persistence of seropositivity conferred by hepatitis A vaccine administered to children under 2 years of age is unknown and passively transferred maternal antibodies to hepatitis A virus may lower the infants immune response to the vaccine, the researchers explained. The trial is the first to examine the effectiveness 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 colleagues enrolled 197 infants and young children 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-toddlers between 12 and 18 months; and group 3-toddlers 15 to 21 months of age. Each group was randomized by maternal anti-HAV status. 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 vaccine, children in all groups showed signs of seroprotection (>10 mIU/mL) from the Hepatitis A virus. After 10 years of follow-up, most children retained anti-HAV protection. In the first
A study in the US showed persistence of seropositivity for at least 10 years after hep A vaccination of infants less than 2.
group, 7 percent and 11 percent of children born to anti-HAVnegative and anti-HAV positive mothers, did not retain HAV protection from vaccination, respectively. Overall, 4 percent of group 3 children born to anti-HAV negative mothers lost HAV protection. [Hepatology 2012; DOI: 10.1002/hep.25687] Our study demonstrates that seropositivity to hepatitis A persists for at least ten years after primary vaccination with two-dose inactivated HAV vaccine when administered to children at ages 12 months and older, regardless 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.
Please visit www.isrd.org for further details
Chinese Alliance Against Lung Cancer (CAALC)
Nearly 100 Academic Speakers, 15 Sessions and 6 Special Topics

English Sessions Highlights
Mechanical Ventilation Sleep Apnea Update Biomarkers and Therapeutic Strategies in Airway Diseases State-of-the-art Ventilation Strategy Highlight on COPD Management ALI Forum - Mechanism and New Drug Target Plenary Session - Message from ATS Infection and Immunity ALI Forum - Mechanism and New Drug Target Translational Respiratory Medicine
ISRD 2012
The very first joint scientific sessions with the American Thoracic Society
41 September 2012 Conference Coverage

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

Rajesh Kumar
igh levels of endurance exercise in recreational runners may result in transient but significant ventricular stunning, release of cardiac biomarkers and acute kidney injury, according to a Singapore study. Previous studies involving elite long distance runners have linked high-level endurance exercise with elevated cardiac biomarkers, right ventricular dysfunction as well as a decrease in glomerular filtration rate. However, 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 hypothesis that changes in cardiac biomarkers may reflect RV dysfunction after moderate endurance activity. Highly sensitive troponin T (hsTnT), Nterminal pro brain natriuretic peptide (NTProBNP) 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-exercise, 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 NTProBNP. While the findings support the concept of cardio-renal coupling in endurance exercise, the researchers acknowledge that the number of subjects in this study is small, and validation with a larger study is required. Whether these individuals are more prone to chronic myocardial and/or kidney injury is unknown. The findings warrant further investigation in larger populations of recreational 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 University 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.

In a healthy person with no history of cardiovascular 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.
Measure BP on both arms

Rajesh Kumar
hysicians 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 inter-arm systolic BP is closely linked to peripheral artery disease, especially in non-obese and nonhypertensive patients. We as physicians neglect to evaluate BP from both arms. Its 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 cardiology and vascular medicine, faculty of medicine at Universitas Indonesia, Jakarta, Indonesia. The cross-sectional study evaluated 80 patients who followed elective coronary angiography from March to May 2011. The mean difference 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 difference and ABI in coronary artery disease patients was 0.337 (P=0.001). In non-overweight/ obese and non-hypertensive patients, the correlation 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 research didnt show its correlation with Gensini score, said Mulia. In primary care services or in rural areas where availability of diagnostic tools is limited, Mulia said such a simple procedure could prevent delays in the diagnosis of vascular diseases. He pointed out that the textbook of cardiovascular medicine Braunwalds Heart Disease recommends blood pressure measurement on both arms, while earlier research had linked a difference of just 15 mm Hg or more in inter-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 morebetween arms might help to identify patients who need further vascular assessment [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 aggressive management of their cardiovascular risk factors, said Mulia.

ASEAN Federation of Cardiology Congress, 13-15 July, Singapore
Study of CV risk factors in Singapore Chinese

Rajesh Kumar
iet and lifestyle factors have a strong impact on the risk of cardiovascular disease (CVD) mortality in the Singapore 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. [Circulation 2011; DOI:10.1161/CIRCULATIONAHA.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, vegetables and soy. Each lifestyle factor was independently associated with CVD mortality. When combined, 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 protective 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, 0.380.67), 0.40 (95% CI, 0.30 0.53), 0.32 (95% CI, 0.240.43), 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 evidence that diet and lifestyle factors such as smoking, obesity, physical activity and sleep, impact our risk of CVD mortality, said co-author 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 country that progressed from third world to first world in one generation. With this rapid economic development has come a rapid change in lifestyle and diet which have had a direct bearing on CVD mortality, said the researchers. 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 populations in US and Europe, said Koh. The SCHS, being the largest cohort study in Singapore, is the first to look at the combination 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

patients listen and adhere to the advice of their primary health physicians for healthrelated 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
he food sources of carbohydrate are more important than the overall quantity of carbohydrate intake with respect to risk of coronary heart disease (CHD) mortality in the Singapore Chinese community, an observation study suggests. Researchers sought to find out the impact of high-carbohydrate diets, as commonly consumed 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 recruitment from 1993 to 1998. Their usual dietary intakes were assessed using a validated food frequency questionnaire, while CHD mortality until the end of 2011 was identified through the Singapore Registry of Births and Deaths. Total carbohydrate intake was not substantially 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 components. High rice consumption was associated
Consumption of fruits, even those rich in carbohydrates, had protective effects.
with a higher risk of CHD in women, but this was explained by the lower fruit and vegetable consumption. We know that the quality and source of dietary fat is highly relevant for risk of CHD. Similarly, evidence is emerging that the quality and source of carbohydrates is important for the development of heart disease, said researcher Dr. Rob van Dam, associate professor at the Saw Swee Hock School of Public 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 consumption of fruits, a major source of carbohydrates and fiber, had a lower risk of heart disease.
45 September 2012 In Practice
Nerves can be a pressing problem

Adjunct Associate Professor Hee Hwan Tak
M.B.B.S. (Singapore), F.R.C.S. (Glasgow)
Singaporean patient who had undergone a kidney transplant complained 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 compressing the nerves of his spinal column, which could cause such symptoms. The scan revealed significant compression 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 electrical wires branching out from a central grid. The nerves in the neck belong to the upper 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 patients compressed nerves would get better by themselves. I advised him to undergo spinal 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 option Fusion involves linking the affected segments, or vertebrae, of the spine, by stimulating bone growth between the segments and by attaching them with rods, screws
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 animal 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 regarding a spine problem, their main concerns 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 spinal conditions, which may be life- or limbthreatening. Examples of such red-flag conditions 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 Practice

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 material bulges out and compresses the spinal nerves. Chemicals called prostaglandins are also released from the discs. These can result in intermittent attacks of pain, punctuated with good symptom-free days. When the nerves within the spinal column are pinched, the pain may radiate or spread to the extremities. The patient may complain of numbness, tingling or weakness 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-inflammatory 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 degree 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 patients 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 condition of the spine decompression or freeing of the nerves. Sometimes, the segment of the spine may be potentially unstable or painful and may need to be stabilized to some degree. Treatment options abound About 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 intervertebral disc with an artificial one made of metal 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 expectations of the patient in the decision-making process. Progress has been made in the treatment that he wanted, although it remains experimental. In October 2010, the worlds first clinical trial using human embryonic stem cells to treat spinal cord injuries began. The aim is to convert stem cells into cells similar to our nerve cells. Only time will tell if this method will improve the outcome for patients. Scientific 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.
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 Singapores National University of Singapore Yong Loo Lin School of Medicine.
47 September 2012 Atrial Fibrillation
Anti-arrhythmics offer superior survival rates for older AF patients

Elvira Manzano
nti-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 patients 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 patients 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, mortality among patients treated with rhythm controlled drugs gradually decreased relative to those treated with rate control drugs, reaching 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 control therapy seems to be superior in the longterm. 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 associated 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 periods of time, suggesting that the use of rhythm control therapy may be beneficial for AF patients 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 patient] 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. Thomas A. Dewland and Dr. Gregory M. Marcus, from the University of California, San Francisco, US, said the choice of a rhythm control vs. a rate control strategy for AF is particularly prone to confounding by indication, as rhythm control is preferentially offered to younger patients with fewer medical co-morbidities. Although the findings are provocative, they are insufficient to recommend a universal 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 control strategy for individuals with arrhythmiaattributable symptoms. Shorter duration studies previously conducted such as the RACE (Rate Control Versus Electrical Cardioversion) and the AFFIRM (Atrial Fibrillation Follow-up Investigation of Rhythm Management) trials provided evidence that the rate control strategy was preferred for older patients without AF-related symptoms. Dewland and Marcus said the current study challenges the wisdom of this approach.
Targeted cardiac ablation highly effective in treating AF

Radha Chitale
argeted cardiac ablation was twice as successful 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 electrical activity electrical rotors and focal impulses 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 persists 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 percent 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 patients 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 between groups. The researchers reported that FIRM ablation at target points stopped AF in a median time of 2.5 minutes, indicating the mechanistic role of rotors and focal sources in sustaining AF. Patients in whom FIRM ablation slowed rather than terminated AF had sources that could not be eliminated, for safety considerations or protocol imposed time limits and may have had residual sources in unmapped regions, the researchers said. AF is the most common form of arrhythmia in the world and significantly increases the risk of stroke as well as being associated with cardiac issues. One-year success for ablation 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 opportunity 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
Anticoagulant safety protocols working well in Europe

Rajesh Kumar
hysicians should be reassured that safety 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 International 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 Anticoagulation (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 thrombosis, were also monitored and matched to the patients 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; P0.001). 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; P0.001). In the first 2 months of treatment, bleeding occurred in 11.0 percent of patients who had
Safety indicators used in the UK for anticoagulant therapy with warfarin have been correct, according to a study.
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 (P0.001). This study demonstrates through significant patient results that the safety indicators (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 Professor Leon Poller of the EAA central facility at the faculty of life sciences, University of Manchester, Manchester, UK Warfarin is a commonly used anticoagulant 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 everywhere, including Asia, should be aware of them and apply them to make the treatment of AF safer, said Poller.
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51 September 2012 Calendar

September
Medical 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 Dsseldorf Asia Tel: (65) 6332 9626 Email: shirley@mda.com.sg Website: www.medicalfair-asia.com
8th World Stroke Congress

10/10/2012 to 13/10/2012 Location: Brasilia, Brazil Info: World Stroke Organization Tel: (41) 22 908 0488 Email: stroke@kenes.com Website: www1.kenes.com/wsc
23rd Great Wall International Congress of Cardiology (GW-ICC) Asia Pacific Heart Congress (APHC) 2012
11/10/2012 to 14/10/2012 Location: Beijing, China Info: Secretariat Office of GW-ICC & APHC (Shanghai Office) Tel: (86) 21-6157 3888 Extn: 3861/62/64/65 Fax: (86) 21-6157 3899 Email: secretariat@heartcongress.org Website: www.heartcongress.org
Hospital Management Asia 2012

13/9/2012 to 14/9/2012 Location: Hanoi, Vietnam Info: Ms. Sheila Pepito Tel: (632) 846 8339 Email: sheilapepito@exedraevents.com Website: hospitalmanagementasia.com
London College of Clinical Hypnosis (LCCH-Asia) Certificate in Clinical Hypnosis

22/9/2012 to 23/9/2012 Location: University of Malaya, Kuala Lumpur, Malaysia Info: LCCH Secretariat Tel: (60) 3-7960 6439 / 7960 6449 Email: info@hypnosis-malaysia.com Website: www.hypnosis-malaysia.com
42nd Annual Meeting of the International Continence Society

15/10/2012 to 19/10/2012 Location: Beijing, China Tel: (41) 22 908 0488 Fax: (41) 22 906 9140 Email: ics@kenes.com Website: www.kenes.com/ics
October
48th Annual Meeting of the European Association for the Study of Diabetes
1/10/2012 to 5/10/2012 Location: Berlin, Germany Info: EASD Secretariat Email: secretariat@easd.org Website: www.easd2012.com
th Asian-Pacific Society of Atherosclerosis and 8 Vascular Diseases Meeting

20/10/2012 to 22/10/2012 Location: Phuket, Thailand Info: Asian-Pacific Society of Atherosclerosis and Vascular Diseases Tel: (66) 2940 2483 Email: apsavd@lawson-marsh.com Website: www.apsavd2012.com
Upcoming
012 Scientific Sessions of the American Heart 2 Association
3/11/2012 to 7/11/2012 Location: Los Angeles, California, US Info: American Heart Association Tel: (1) 214 570 5935 Email: sessionsadmin@heart.org Website: www.scientificsessions.org
15th Biennial Meeting of the European Society for Immunodeficiencies (ESID 2012)
3/10/2012 to 6/10/2012 Location: Florence, Italy Tel: (41) 22 908 0488 Fax: (41) 22 732 2850 Email: esid@kenes.com Website: www.kenes.com/esid
52 September 2012 Calendar

8th International Symposium on Respiratory Diseases & ATS in China Forum 2012
9/11/2012 to 11/11/2012 Location: Shanghai, China Info: UBM Medica Shanghai Ltd. Tel: (86) 21-6157 3888 Extn: 3861/62/64/65 Fax: (86) 21-6157 3899 Email: secretariat@isrd.org Website: www.isrd.org
3rd Annual Meeting of the American Association 6 for the Study of Liver Diseases
9/11/2012 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 6/12/2012 Location: Orlando, Florida, US Info: World Class CME Tel: (980) 819 5095 Email: office@worldclaswscme.com Website: www.cvent.com/events/national-diagnostic-imaging-symposium-2012/event-summaryd9ca77152935404ebf0404a0898e13e9.aspx
Asian Pacific Digestive Week 2012

5/12/2012 to 8/12/2012 Location: Bangkok, Thailand Tel: (66) 2 748 7881 ext. 111 Fax: (66) 2 748 7880 E-mail: secretariat@apdw2012.org Website: www.apdw2012.org
World Allergy Organization International Scientific Conference (WISC 2012)

6/12/2012 to 9/12/2012 Location: Hyderabad, India Info: World Allergy Organization Tel: (1) 414 276 1791 Fax: (1) 414 276 3349 E-mail: WISC@worldallergy.org Website: www.worldallergy.org
53 September 2012 Humor
Ive been Dr. Lamonts patient for over 12 years and Ive never seen his face!
Lucy, I think we should Go ahead and take those , Im curious get a divorce! to see what they will do to you!
Whats halitosis?
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!
Glad you could make it!
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