december 2014

Audiovisual aids
an effective learning tool
for new parents

forum
Funding for
smoking cessation
campaigns
disclosures matter

drug
profile
Inhaled fluticasone
furoate /
vilanterol for the
management of
stable COPD

FEATURE
Emerging trends
in preeclampsia

conference
coverage
Making a case
for adiponectin in
diabetes and its
complications

De c e mb e r 2 01 4

Audiovisual aids an effective

learning tool for new parents
Lianne Cowie

The

intervention

consisted of a video

nteractions with caregivers during the first few

addressing four spe-

years of life are crucial for the psychosocial

cific activities related

development of children, and programs aimed

to early child develop-

at promoting parent-child interactions can be an

ment: reading aloud to

important tool for modifying parental knowledge

the baby, early expo-

regarding effective care practices.

sure to music, and pro-

A recent study showed that early exposure to

motion of early social-

an audiovisual aid (when the infant was 1 month

ization for the parents

of age) altered parental knowledge regarding

and their children. The

such practices, whereas exposure at a later

video was delivered

point (age 7 months) altered parental attitudes.

via a home visit by a

[BMC Paediatrics 2014;14:222]

psychologist. Ninety-nine families (52 in the ear-

A recent study supports

the use of audiovisual
programs for new parents.

Our results support the idea that audiovisual

ly and 47 in the late group) completed the study.

materials, if properly designed and adminis-

Parents in the early intervention group more

tered, can be an effective complementary tool

frequently reported modification of their knowl-

in programs aimed at supporting parents, par-

edge relating to the importance of early reading

ticularly when dealing with their first baby, said

aloud and infant socialization. Parents in the late

the study authors, led by Dr. Anna Roia, Institute

intervention group more frequently reported the

for Maternal and Child Health, IRCCs Ospedale

acquisition of positive attitudes towards early

Infantile Burlo Garofolo, Trieste, Italy. They also

reading aloud, early exposure to music, and pa-

provide useful insight about the different ben-

rental socialization.

efits of using such visual aids at different times

during the first year of the baby.

[T]he importance of an appropriate setting

of administration, ideally through a home visit as

The researchers contacted a convenience

in our study, cannot be overlooked, concluded

sample of 127 families living in the area imme-

the authors. This aspect may be even more

diately after birth while the mother and infant

important when dealing with population groups

were still in the maternity ward. Of the families

which, due to specific cultural or social reasons,

who agreed to participate, 53 were randomly as-

are more difficult to reach out to and yet are

signed to the early intervention group and 52 to

those that would yield the greatest benefit from

the late intervention group.

such interventions.

De c e mb e r 2 01 4

New guideline for preventing kidney

stone recurrence
Elvira Manzano

The guideline is based on published studies

on kidney stones from January 1948 through

new guideline from the American College

March 2014. The clinical outcomes evaluated

of Physicians (ACP) recommends increas-

for the guideline were symptomatic stone recur-

ing fluid intake for patients who have had kidney

rence, pain, urinary tract obstruction with acute

stones, and pharmacotherapy if increased fluid

renal impairment, infection, procedure-related ill-

alone is inadequate, to prevent stone recurrence.

ness, emergency department visits, hospitaliza-

Increased fluid intake spread throughout the

tions, quality of life, and end-stage renal disease.

day can decrease the stone recurrence by at

Intake of fluids was one of the dietary interven-

least half with virtually no side effects, said Dr.

tions evaluated.

David A. Fleming, ACP president.

In one study, patients with calcium stones

The goal for increasing fluid intake is to im-

who increased their fluid intake to achieve >2L

prove urine output to a minimum of 2L a day. For

of urine per day had less composite stone re-

patients who fail to reduce stone formation de-

currence within 5 years compared with the

spite this approach, monotherapy with a thiazide

control group (12.1 versus 27 percent). [J Urol

diuretic, citrate, or allopurinol may be considered.

1996;155:839-843] Another study showed that

[Ann Intern Med 2014;161:659-667]

increased fluid intake resulted in a non-statisti-

The evidence for both recommendations was

classified as low to moderate quality.
Kidney stones (nephrolithiasis) form when
crystals or substances that are normally pres-

cally significant decrease in stone recurrence

compared with no treatment (8 vs 56 percent)
within 2 to 3 years of follow-up. [Urol Res
2006;34:184-189]

ent in the urine become highly concentrated,

The authors, however, cautioned that drink-

said guideline author Dr. Amir Qaseem from

ing extra fluids may not work for some patients

the University Health System of Pennsylvania in

with kidney stones. It is also contraindicated in

Philadelphia, Pennsylvania, US. In most cases,

heart failure patients. With regard to pharma-

the stones consist of calcium oxalate and/or cal-

cologic treatments, combination therapy with

cium phosphate, or other substances such as

a thiazide diuretic, citrate or allopurinol was no

uric acid, struvite, and rarely, cystine. The lifetime

more beneficial than any of these agents taken

prevalence of kidney stones is 13 percent in men

alone. Some of the adverse effects associated

and 7 percent in women. Five-year recurrence

with these drugs included fatigue, gastrointesti-

rate can reach up to 50 percent, if left untreated.

nal problems, headache and anemia.

De c e mb e r 2 01 4

FORUM

Funding for smoking cessation

campaigns disclosures matter
An increasing awareness of the harms of tobacco smoking has coincided with the growth of
a new industry smoking cessation campaigns worldwide. With a high proportion of the
worlds tobacco smokers, the Asia Pacific region is not an exception. A question of ethics now
arises with regards to smoking cessation campaigns, which are being increasingly funded
by pharmaceutical companies, in particular those with interests in nicotine replacement
therapies (NRTs).
Chuah Su Ping

key challenge faced by anti-smoking bodies is that there is a lack of funds for their

campaigns. There is still a lack of awareness of

the risk factors associated with tobacco smoking, and smoking in general is often viewed as
an issue of personal behavior, which is inaccurate, said Dr. Carolyn Dresler, associate director for Medical and Health Sciences in the Office
of Science at the US FDA Center for Tobacco

Dresler noted that she was a former medical

Products Office. Its not just a behavioral prob-

director of research and development for NRT

lem were dealing with; its a chemical addiction

products at a leading pharmaceutical company.

nicotine addiction which is a serious disease.

With regards to the relationship between

Market forces at play

the pharmaceutical industry and smoking ces-

It is true that both smoking as well as smok-

sation, to me it depends a little on the duplicity

ing cessation are driven by market forces, said

of the industries involved, said Dresler. In my

Dresler, highlighting a recent case in which a US

opinion, the tobacco industry are convicted liars,

District Court in Washington D.C., ruled against

but we cannot ignore that the pharmaceutical in-

the US FDA in favor of cigarette makers Loril-

dustry has had similar issues. However, the mis-

lard Inc and Reynolds American Inc, who had

sion of pharmaceutical companies is ostensibly

sued the FDA in 2011, alleging conflicts of inter-

for good, whereas the product produced by the

est and bias by several members of the panel

tobacco industry, when used as indicated, kills.

tasked with advising the FDA on tobacco-relat-

D e c e m b e r 2 01 4

FORUM

ed issues. Their lawsuit specifically alleged that

at Kulliyyah of Pharmacy at the International Is-

some committee members had conflicts of in-

lamic University Malaysia. However, given the

terest as they were paid expert witnesses, and

limitations, sometimes we do have to consider

possessed financial ties to pharmaceutical com-

accepting funding from pharmaceutical compa-

panies that manufactured smoking-cessation

nies to facilitate certain events. In such cases,

products.

the funding company should not become in-

In his ruling, which took place in July 2014,

US District Judge Richard Leon said the FDA

volved in the planning of the advocacy program

it should be completely independent.

had erred in determining that the members did

The worst thing to do, he stressed, would

not have conflicts of interest and therefore, the

be to accept funding from the tobacco indus-

agencys appointment of those members was

try, for whatever purpose. Dr. Zarihah Zain of

arbitrary and capricious, and tainted both the

the Disease Control Disease, Ministry of Health

panel and its work. The FDA was ordered to

Malaysia, agrees. According to Article 5.3 of

reconstitute the tobacco panel and the use of

the Framework Convention on Tobacco Control

its 2011 report on menthol cigarettes has been

(FCTC), parties to the Convention should not

barred. [Available at https://ecf.dcd.uscourts.

partner with tobacco corporations to promote

gov/cgi-bin/show_public_doc?2011cv0440-82.

public health, nor accept the tobacco indus-

Accessed on 13 December 2014]

trys so-called corporate social responsibility

It is difficult to separate conflict of interests

and biases from something like smoking cessa-

schemes, which are really just marketing by another name, she said.

tion, especially when theres funding involved,

The Article 5.3 Guidelines also outlined trans-

Dresler admitted. This is because, as I men-

parency measures including, Disclosure of cur-

tioned, there is already very little funding being

rent or previous work with tobacco industry by

allocated for smoking cessation campaigns,

applicants for government positions related to

said Dresler. When you put it up against some-

health policy, and of plans to work for tobacco

thing as large as the tobacco industry, with their

industry by former public health officials. Also,

large resources, and their ability to influence

disclosure of tobacco industry activities, includ-

government and political decisions, its an uphill

ing: production, manufacture, market share,

battle.

revenues, marketing, expenditures, philanthropy with penalties for providing false or mis-

Is there an ideal source of funding?

leading information. [Available at www.fctc.org/

If you have sources of funding from non-

media-and-publications/media-releases-blog-

pharmaceutical organizations, such as non-gov-

list-view-of-all-313/industry-interference/718-ar-

ernmental organizations or the health ministry,

ticle-53-framework-convention-on-tobacco-con-

that would be best, said Associate Professor Dr.

trol-tobacco-industry-interference. Accessed on

Mohamad Haniki Nik Mohamed, Deputy Dean

14 December 2014.]

De c e mb e r 2 01 4

N E WS

Discussing preferences critical

during end-of-life care
Radha Chitale

However, it was clear that halting discussion

there was not necessary. Patient satisfaction

nd-of-life care discussions are tricky and

scores were directly proportional to how much

necessary, but a new survey reveals these

physicians were willing to discuss end-of-life

conversations are not happening, based on

care. Patient satisfaction improved as they cov-

what patients and their families say their end-

ered more topics and as the number of times

of-life goals are versus what they are advised by

they had such discussions increased.

experts. [CMAJ 2014. doi:10.1503/cmaj.140673]

The Canada-based survey included 233 el-

Our findings could be used to identify impor-

der adults in hospital who had serious illnesses

tant opportunities to improve end-of-life com-

and 205 of their family members.

munication and decision-making in the hospital

The researchers found that end-of-life care

setting, said lead researchers Dr. John You, as-

discussions occurred in less than one-third of

sociate professor of Medicine and Clinical Epi-

cases, sometimes as little as 1.4 percent of the

demiology and Biostatistics at McMaster Univer-

time. This appeared to support national data

sity in Hamilton, Ontario, Canada.

showing that rates of cardiopulmonary resus-

The current literature regarding end-of-life

citation (CPR), dying in-hospital, and intensive

care discussions suggests 11 topics that are

care unit deaths are rising among elderly pa-

considered most important by doctors, with

tients with serious disease, despite the fact that

little to no input from patients or families, the re-

80 percent of these patients prefer a less ag-

searchers noted.

gressive and more comfort-oriented end-of-life

However, when the researchers surveyed real

patients (mean age 81) and families about which
topics they felt were most important, opinions

care plan that does not include CPR, the researchers said.
Other topics of discussion on the 11-item list

converged to identify the following five areas:

that patients did not identify in their top five in-

- preferences of care in event of life threatening

cluded facilitating access to legal documents to

illness
- patient values (what is important when considering healthcare decisions)

record patient wishes and providing information

about the outcomes, risks, benefits of comfort
care. [Med J Aust 2007;186:S77,S79,S83-108;

- prognosis of illness

Advance Care Planning. Concise Guidance

- fears or concerns

to Good Practice Series, No 12. London (UK),

-a
 dditional questions regarding care

2009]

D e c e m b e r 2 01 4

N E WS

Mental disorders may cause cardiac

symptoms
and depression, idiopathic pain with a poten-

Radha Chitale

tially psychological root, hypochondriac ten-

epression, anxiety and other psychological

dencies, and quality of life in relation to physical

disorders are known to influence cardiac

and mental health before and 6-8 months after

activity and can result in cardiac symptoms even

when tests show patients to be free of heart dis-

undergoing an invasive coronary angiography.

The test revealed that 8.7 percent of patients
reported severe cardiac symptoms prior to

ease.
Despite this high importance, in patients
with non-cardiac chest pain, mental disorders

coronary angiography and 28 percent reported

moderate symptoms.

are often diagnosed too late, because cardiologists without psychosomatic experience lack
uncomplicated diagnostic tools to detect them
accurately, said researchers from University
Hospital Dresden in Germany, who surveyed
disease-free patients about their mental state in

A
 bout 20 percent of people who
suffer from cardiac symptoms ...
do not have heart disease 

order to determine the extent of the correlation.

About 20 percent of people who suffer from
cardiac symptoms such as chest pain or short-

However, even after CAD exclusion following

ness of breath do not have heart disease but

angiography, 70 percent of patients reported

they are just as likely to use healthcare resourc-

persistent symptoms.

es and can have lower quality of life. Early identification could alleviate this problem.
The trial included 235 patients with at least
one cardiac symptom chest pain (55.3 per-

Compared to a population of healthy adults,

general anxiety was higher by 37 percent
(p<0.001) among women in the study population and by 22 percent (p=0.003) among men.

cent), dyspnea (35.4 percent), or palpitations

Somatoform disorder was 120 percent

(39.4 percent) who were assessed for and

(p<0.001) more common among study par-

did not have coronary artery disease (CAD).

ticipants after coronary angiography and hypo-

[Open

Heart

2014;1:e000093.doi:10.1136/

openhrt-2014-000093]

chondria was 68 percent (p<0.001) more common, both compared to healthy controls.

These patients were given a questionnaire

These figures were reflected in lower physical

that tested for general and heart-related anxiety

and psychological quality of life scores reported

De c e mb e r 2 01 4

N E WS

by study participants compared to the normal

or procedural solutions, and to improve their

population.

quality of life.

The researchers noted they were unable to

Without training, cardiologists are more likely

determine cause and effect between psycho-

to overlook psychosomatic symptoms, but the

pathological symptoms and cardiac symptoms

researchers suggested the 120-minute ques-

or vice versa. They also lacked information

tionnaire that takes 15 minutes to evaluate by a

about gastrointestinal disorders, skeletal condi-

nurse was a practicable solution for inpatients

tions or other non-cardiac causes of chest pain.

and outpatients.

However, the study did suggest patients with

These [standardized questionnaires] may

non-cardiac chest pain should be offered psy-

prevent repeated utilization of the healthcare sys-

chological or psychiatric support early in order

tem and this could help to reduce costs for these

to begin psychosomatic therapy, which may

patients due to initiation of an early psychoso-

prevent patients from seeking pharmaceutical

matic therapy, the researchers said.

De c e mb e r 2 01 4

N E WS

10

Neuroticism, long-term stress

linked to higher risk of Alzheimers
in women
Elvira Manzano

omen who worry a lot and cope poorly

said lead researcher Dr. Lena Johansson from

the Sahlgrenska Academy at Gothenburg University in Molndal, Sweden.

with stress may be at an increased risk of

Using the Eysenck Personality Inventory

developing Alzheimers disease (AD) later in life,

scale, women were assessed of their dominant

research suggests.

personality traits (ie, extraversion vs introversion

A study of 800 women in Sweden followed

and neuroticism vs stability). Dementia was di-

for 38 years showed that women with the high-

agnosed according to DSM-III-R criteria, based

est scores on neuroticism scale and had expe-

on information culled from neuropsychiatric ex-

rienced long-term distress in midlife were twice

aminations, hospital records, and registry data.

as likely to develop AD than those with the

During the study period, 153 women who had

lowest scores. [Neurology 2014; pii:10.1212/

neurotic tendencies at midlife had developed

WNL.0000000000000907;E-pub ahead of print]

some types of dementia, 104 of which had AD.

Neuroticism is the enduring tendency to be

Advancing age, family history, and genetics

in a negative emotional state. People with neu-

are known risk factors for AD and other demen-

rotic personality may perceive daily run-of-the-

tia-related disorders. This is the first study to

mill situations as alarming or depressing. They

show a link between personality and AD, said

suffer from negativity, feelings of guilt, anxiety,

Johansson. However, the finding does not sug-

envy and anger more frequently and more se-

gest that neuroticism alone could increase the

verely than other people and have difficulty

risk of AD.

managing stress, although they are in touch

with reality.
We have shown in this study that midlife
neuroticism is associated with increased risk of

Personality could determine behavior, lifestyle and how we react to stress. Ultimately, all
these may significantly affect the risk of developing AD.

AD, and that distress mediates this association.

She said future studies should exam-

Clearly, there was a clear statistical correlation in

ine whether this group of women will re-

those who had been exposed to a long period

spond well to interventions. It remains to be

of stress, said Johansson. It is the stress itself

seen whether neuroticism could be modi-

that is harmful. A person with a neurotic tenden-

fied by medical treatment or through lifestyle

cy is more sensitive to stress than other people,

changes.

De c e mb e r 2 01 4

RES E A RCH REV I E WS

11

Reducing knee load with lateral wedge insoles does not

alleviate knee OA pain

educing external knee adduction moment

(EKAM), a surrogate measure of medial

joint loading, by wearing lateral wedge insoles

does not reduce knee pain in patients with
knee osteoarthritis, according to a multinational group of researchers.
In their study, 70 patients (mean age 60.3
years) with radiographically confirmed painful medial knee osteoarthritis underwent a gait
analysis whilst walking in a control shoe, a
typical lateral wedge insole, and a supported
wedge insole.
The researchers compared changes in
EKAM and knee pain scores, and found that

enced consistent major reductions in EKAM

significant reductions in pain were only ob-

did not report a consistent reduction in knee

served when patients were using the medial

pain.

supported lateral wedge insole (-6.29 percent vs control). However, there was no differ-

Jones R et al. The relationship between reductions

ence in pain reduction between patients who

in knee loading and immediate pain response whilst

experienced a decrease in EKAM and those

wearing lateral wedged insoles in knee osteoarthritis. J

who did not. Moreover, patients who experi-

Orthop Res 2014;32:1147-1154.

D e c e m b e r 2 01 4

RES E A RCH REV I E WS

12

Clinical effects of deiodinase polymorphisms studied

odothyronine deiodinases are key regulators

of thyroid hormone metabolism and since

thyroid hormones are functionally active in numerous tissues, deiodinase polymorphisms

have the potential to affect multiple clinical
endpoints.
In a recent systematic review, researchers
evaluated the relationship between iodothyronine deiodinase polymorphisms and a variety
of parameters. Eligible studies were identified
by searching the Pubmed, EMBASE, Web of
Science, Cochrane Library, CINAHL, Academic
Search Premier, and Science Direct databases
for articles published up to 13 August 2013.

osteoarthritis. However, the researchers noted

The researchers found that deiodinase type

that the clinical implications of these associa-

1 (D1) polymorphisms showed a moderate-to-

tions are far from clear and may vary among

strong relationship with thyroid hormone pa-

different populations. They commented that

rameters, insulin-like growth factor 1 produc-

further research is required to determine the

tion, and risk for depression. D2 variants were

exact role of deiodinase polymorphisms and

correlated with thyroid hormone levels, insulin

their potential as therapeutic targets.

resistance, bipolar mood disorder, psychological well-being, mental retardation, hyperten-

Verloop H et al. Genetic variation in deiodinases: a sys-

sion, and risk for osteoarthritis, and one D3

tematic review of potential clinical effects in humans. Eur

polymorphism was associated with a risk for

J Endocrinol 2014;171:R123-R125.

De c e mb e r 2 01 4

d r u g p r ofi l e

13

Inhaled fluticasone furoate /

vilanterol for the management
of stable COPD
COPD is a leading cause of mortality worldwide and deaths from COPD are expected to
keep rising over the coming decade. In Asia, the burden of COPD is currently higher than in
the West. This article profiles a novel once-daily combined inhaled corticosteroid/long-acting
beta 2-agonist formulation fluticasone furoate / vilanterol and its use in the management
of COPD.

Naomi Adam, MSc (Med), Category 1 Accredited

Education Provider (Royal Australian College
of General Practitioners)
Introduction
Chronic

obstructive

pulmonary

disease

(COPD) is a term used to describe chronic

lung diseases that limit airflow, and includes
the conditions previously known as chronic
bronchitis and emphysema. Symptoms include
breathlessness, chronic cough and sputum
production.
The main risk factors for the development of

of death worldwide and total deaths from COPD

COPD include cigarette smoking, air pollution

are projected to increase by more than 30 per-

(both outdoor and indoor) and occupational

cent in the next 10 years.

hazards such as vapours, fumes and irritants.

In Asian countries COPD burden is higher

In high-income countries, smoking is the pre-

than in their Western counterparts, with more

dominant cause whereas in low-income coun-

deaths, years spent living with disability, and

tries indoor air pollution associated with the

years of life lost. This can be attributed to high

use of fuels for cooking and heating produces

tobacco smoking rates, poor quality of outdoor

most COPD burden. [WHO Fact Sheet No 315.

air and the use of biomass fuels indoors. [Int J

Chronic obstructive pulmonary disease]

Tuberc Lung Dis 2008;12:713-717]

COPD is now the fifth-most common cause

The diagnosis of COPD in symptomatic pa-

De c e mb e r 2 01 4

d r u g p r ofi l e

14

tients is made on the basis of spirometry, which

in stable COPD patients. Over time, there have

measures the presence and severity of airflow

been progressive improvements in available

obstruction: COPD is characterised by airflow

LABA and ICS therapies, allowing the develop-

obstruction that is not fully reversible on the

ment of treatment delivered in once-daily, sin-

administration of bronchodilators. [Ann Intern

gle device format. [Int J COPD 2014;9:249-256]

Med 2011;155:179-191]
Fluticasone furoate / vilanterol

I n high-income countries, smoking

Mode of action
Fluticasone furoate is a corticosteroid with

is the predominant cause whereas

anti-inflammatory activity. It is highly potent,

in low-income countries indoor air

binding more strongly to the glucocorticoid re-

pollution associated with the use

ceptor than other commonly used ICS, includ-

of fuels for cooking and heating

produces most COPD burden

ing fluticasone propionate, mometasone furoate, budesonide and ciclesonide. Fluticasone

furoate also has the largest cellular accumulation and slowest rate of efflux among these ICS,

The priorities in management of COPD in-

leading to prolonged efficacy and the potential

clude smoking cessation and using effective

for once-daily dosing. [Am J Physiol Lung Cell

inhaled therapy. In patients with stable disease

Mol Physiol 2007;293:L660L667]

who remain breathless or experience exacer-

Vilanterol is a long-acting beta2-adrenergic

bations despite use of short-acting bronchodi-

agonist (LABA) that stimulates intracellular ad-

lator reliever therapy, guidelines recommend

enyl cyclase to increase levels of cyclic-3,5-

the use of maintenance therapy. Those with a

adenosine monophosphate (cAMP). Increased

forced expiratory volume (FEV) 50 percent of

cAMP levels lead to relaxation of bronchial

predicted should be given either a long-acting

smooth muscle and inhibition of release of

beta-2 agonist (LABA) or long-acting musca-

mediators of hypersensitivity. [Breo Ellipta Pre-

rinic antagonist (LAMA). When FEV falls below

scribing Information]

half that predicted, patients should be given

either a LABA with an inhaled corticosteroid

Clinical efficacy

(ICS) in a combined inhaler or a LAMA. [NICE.

Two clinical trials of 1 year in duration have

Management of chronic obstructive pulmonary

demonstrated the effectiveness of fluticasone

disease in adults in primary and secondary

furoate / vilanterol compared with vilanterol

care. June 2010]

alone. The studies enrolled patients aged 40

The combination of ICS and LABA in a single

years and over, with a history of COPD and

device is well tolerated and results in improved

smoking (10 pack-years) and history of one or

FEV, quality of life and respiratory symptoms

more moderate-to-severe exacerbations in the

De c e mb e r 2 01 4

d r u g p r ofi l e

15

previous year (approximately 1,300 patients in

fects (occurring in 5 to 10 percent of patients)

each study). Subjects were randomized to ei-

include nasopharyngitis, upper respiratory tract

ther 25 g vilanterol alone or 25 g vilanterol

infection, headache, dysphonia and oropha-

combined with either 50 g, 100 g or 200 g

ryngeal candidiasis. In the long-term clinical tri-

fluticasone furoate once daily. Combination

als of fluticasone furoate / vilanterol, fractures

therapy provided a significant reduction in the

and pneumonia were more common with the

primary endpoint of annual rate of moderate-

combination therapy. Although the overall rate

to-severe COPD exacerbations. [Lancet Respir

of pneumonia was low, there were eight deaths

Med 2013;1:210-223]

due to pneumonia in the fluticasone furoate /

vilanterol group and none with monotherapy.

F
 luticasone furoate combined
with vilanterol is the first oncedaily ICS/LABA combination to
be available

As with other inhaled LABAs, vilanterol is associated with clinically significant cardiovascular effects such as increased heart rate, blood
pressure and QT interval prolongation. It should
therefore be used with caution in patients with
arrhythmias, acute coronary syndromes or

Two other trials have examined the effect of

heart failure. In healthy subjects however, the

fluticasone furoate / vilanterol on lung function

safety of single and repeat doses has been

compared with placebo and each component

demonstrated, with no deleterious effects upon

alone. Both of these were 24 weeks in duration

ECG measurement, QT interval or blood glu-

and enrolled patients with stable moderate-to-

cose or potassium. [Int J COPD 2014;9:249-56]

severe COPD. Acute (04 hours post-dose) and

trough (2324 hours post-dose) effects on lung

Dose and administration

function were assessed. All active treatments

Fluticasone furoate combined with vilanterol

improved FEV, and confirmed that fluticasone fu-

is the first once-daily ICS/LABA combination to

roate / vilanterol results in significant, sustained

be available (marketed under the trade names

bronchodilation. [Respir Med 2013;107:550-

Relvar and Breo). It is available in a new dry

559, Respir Med 2013;107:560-569]

powder inhaler delivery device (Ellipta) which

is designed for simplified usage. The dose for

Adverse effects

maintenance therapy of COPD is one inhala-

The treatment of patients with stable COPD

tion daily, which delivers 100 g of fluticasone

with fluticasone furoate / vilanterol in combina-

furoate and 25 g of vilanterol. [Breo Ellipta

tion is usually well tolerated. Common side ef-

Prescribing Information]

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D e c e m b e r 2 01 4

F E ATU RE

17

Emerging trends in preeclampsia

Preeclampsia is unpredictable. The cause of disease, aggressiveness, and speed of escalation varies from patient to
patient.

Professor Holger Stepan

Director of Obstetrics
University Hospital Leipzig
Leipzig, Germany

symptoms of preeclampsia go away following

birth or more specifically, removal of the placenta the condition leaves mothers with longterm health risks.
The incidence rate of preeclampsia in devel-

oped nations is between 2 to 5 percent, higher

reeclampsia is a hypertensive complica-

in developing countries. While the overall inci-

tion of pregnancy, characterized by high

dence of preeclampsia is not high, the conse-

blood pressure as well as possible kidney

quences are severe. In Europe, for example,

damage. Typically, preeclampsia occurs after

the incidence of preeclampsia is about 3 per-

20 weeks of pregnancy and, if untreated, can

cent, but 25 percent of perinatal mortality is

pose significant threats to the mother and the

caused by preeclampsia.

baby, especially if birth is premature. While the

Importantly, preeclampsia is unpredictable.

De c e mb e r 2 01 4

F E ATU RE

18

The cause of disease, aggressiveness, and

(PIGF), an angiogenic factor from the VEGF

speed of escalation varies from patient to pa-

family (a large group of proteins responsible for

tient. For example, a pregnant woman in week

blood vessel growth). Soluble fms-like tyrosine

24 could be feeling fine but wakes up one

kinase-1 (sFlt-1) is an antagonist to PIGF, bind-

morning with some abdominal pain and if there

ing to it and inhibiting cell growth.

are complications, her situation can shift to very

severe within a day.

In a normal pregnancy, these two proteins

are in balance ensuring the health of mother
and baby. Karumanchi showed that pregnant

Predicting preeclampsia

women with preeclampsia have too much sFlt-

The many other symptoms of preeclampsia

1 circulating in their blood, and too little PIGF.

can be equally non-specific: excess protein in

This fundamentally changed the view of pre-

the urine, headaches, blurred vision, nausea,

eclampsia and confirmed it as a state of imbal-

low platelet levels, shortness of breath, swell-

ance between angiogenic and anti-angiogenic

ing.

factors.

Other cases of preeclampsia may be less

In addition to blood pressure monitoring or

severe. The problem is that a doctor with nor-

proteinurea measures, blood tests for these

mal measures to assess pregnancy cannot dif-

biomarkers have the potential to identify wom-

ferentiate between normal, moderate, and high

en at high risk of preeclampsia earlier in the

danger. Those at risk include very young preg-

pregnancy, before the onset of the disease.

nant women (teenaged) or mature mothers

These types of biomarker tests are also

(over 40 years), twin pregnancies, overweight

helpful for differential diagnosis. Typically, one

women, women with kidney disease, and preg-

out of five women presenting with preeclamptic

nant women with poor placental perfusion.

symptoms will go on to develop preeclampsia.

Early diagnosis is challenging, and in the

If you can tell four of those women that they

past doctors were only able to identify pre-

will not develop preeclampsia, the benefit is tre-

eclampsia as it occurred. However, the last de-

mendous.

cade has seen the discovery of novel biomarkers that show promise both for early detection,

The emerging importance of a

risk stratification and management.

biomarker ratio

A significant breakthrough in understand-

A number of studies have shown that the ra-

ing preeclampsia came about in 2002, when

tio of sFlt-1 to PlGF is more useful than either

Dr. Ananth Karumanchi, a kidney specialist at

measure alone. The ratio has proven highly

Harvard University in Boston, Massachusetts,

useful in helping clinicians identify which preg-

US, observed the role of two proteins prior to

nant women are at highest risk and need to be

the onset of preeclampsia. During pregnancy,

referred for timely interventions.

the placenta releases placental growth factor

A European study of women with differing hy-

D e c e m b e r 2 01 4

F E ATU RE

19

pertension-related conditions and normal con-

to monitor maternal and fetal heart rate, well

trols (n=630) has shown that the sFlt-1/PIGF

being, ultrasound, and so on to pinpoint the

ratio could be used to differentiate the various

correct time for delivery too early and there

types of hypertensive diseases in pregnancy.

is risk for the baby, too late and there can be

The value was also found to correlate with the

complications for both mother and baby.

time span from diagnosis until delivery; women

These placental proteins driving preeclamp-

with the highest ratios had the shortest time

sia are future targets for therapies but for now,

interval from diagnosis until delivery with the

tracking their concentration can help indicate

most aggressive disease course while women

when a woman can safely deliver.

with the lower ratios had a longer time interval

and less aggressive disease.
At the moment, the only cure for preeclamp-

New therapeutic approaches

for preeclampsia

sia is removing the placenta. Simply lowering

Given the new understanding of preeclamp-

blood pressure with antihypertensive medica-

sia as a state of angiogenic imbalance, treat-

tions will not stop preeclampsia because it is

ments aimed at interfering with the effects of

driven by placental proteins. The disease seems

sFlt-1 to restore the balance have shown initial

to originate from the placenta, if the placenta is

promise.

not removed during delivery, preeclampsia will

Extracorporeal removal of sFlt-1 from the

continue. And it is impossible to remove the pla-

blood of a pregnant woman has shown favor-

centa without delivering the baby.

able initial results. The future is in determining

A specialized center with pediatricians expe-

whether the technique prolongs pregnancy

rienced in premature babies is critical for pre-

and improves maternal and fetal outcomes in a

eclamptic women. The goal of management is

larger patient population.

D e c e m b e r 2 01 4

F E ATU RE

20

Informed consent

Patients should be educated prior to entry into clinical trials so they may give informed consent.

Dr. Eugene Wong

Consultant Orthopedic and Spine

Surgeon
Adjunct Assistant Professor
Perdana University Graduate School of
Medicine
Serdang, Selangor

Patients beliefs, culture, occupation or other

factors have a bearing on the information they
need in order to reach a decision. Touching a
person without consent constitutes battery and
putting a person in fear of being touched without consent is an assault.

Informed consent differs from implied con-

nformed consent is defined as approval or

sent. Consent is implied for gathering informa-

permission given by the patient based on

tion by history taking and performing neces-

knowledge of the procedure or treatment to be

sary examinations. Subsequent treatment plans

performed. The information includes the risks

need to be discussed with the patient and in-

and benefits, as well as alternatives to the pro-

formed consent taken.

posed treatment.

There are two types of consent. The first is

D e c e m b e r 2 01 4

F E ATU RE

21

the expressed consent, either oral or written,

the contrary. Only an autonomous person can

given by the patient to undergo a specific pro-

give informed consent. If the patient is incom-

cedure or treatment. Implied consent is inferred

petent, proxy consent is allowed, but no more

from circumstances. It is rarely documented and

than minimal risk to the patients is allowed. The

is relied upon for care or treatment that is rou-

reasonable person and best interest judgment

tine and does not involve significant risks to the

standards need to be applied. A risk, even if it

patient. The doctor performing the procedure

is a mere possibility, should be regarded as sig-

or administering the treatment in question is re-

nificant if its occurrence can cause serious con-

sponsible for engaging the patient in the con-

sequences.

sent process.

Adequate decision-making capacity is the

Competence requires patients ability to un-

ability to understand, evaluate and communicate.

derstand the consequences of their decision and

As a rule, consent should not be obtained from

the need of freedom from coercion. It requires

a sedated or anesthetized patient for an elective

the ability to understand the proposed treatment

procedure. Emergency treatment without con-

and make an informed decision. Competence is

usually assumed unless there are indications to
Table 1: Requirements for informed consent.

Table 3: Justification for informed consent.

Respects autonomy

Competence

Respects the right to control what happens to ones

body

Adequate Disclosure

Respects the right to control access to the self

Adequate Understanding / Comprehension

Promotes greater social goods

Voluntary Decision

Promotes trust between doctor and patient

Consent

Reduces liability and malpractice claims

Table 2: Features of adequate disclosure.

Nature of the procedure (diagnostic or therapeutic)
Probable complications
Risks involved, especially if they are severe and
likely to occur v
Expected benefits of the procedure

Can be justified at least on utilitarian, deontological,

and rights grounds, also on virtue ethics grounds.

Table 4: Obstacles to informed consent.

Difference in the knowledge base of the doctor and
patient
Patients are compromised by illness, anxiety, etc
Language of probabilities is unfamiliar to lay-persons

Alternatives to the procedure, along with their risks

and benefits

Takes too much time

Probable outcomes

Some patients just dont want to know

Table 5: Informed consent for treatment.

Risks/Benefits
Alternatives
Second opinion
Competence of doctor, team, institution
Nature of procedure
Life after recuperation, bodily and psychological
changes
Cost
Who is involved in the treatment?
Patients role in procedure, recovery
Conflicts of interest

sent may be undertaken if the patient is in immediate need of treatment. The patient is unable
to provide consent because of physical or mental
impairment or because the patient is a minor. Implied consent is required in cases of emergency
treatment, where it is presumed that the patient
would have consented to treatment if it is necessary to save his life or from serious harm.

De c e mb e r 2 01 4

F E ATU RE

22

Table 6: Informed consent Research on human subjects.

Consent
Intentional, the result of deliberation
Free, without coercion
Authentic, from ones own values and desires
Conditions for informed consent
Information about:
Nature of the research
Therapeutic or non-therapeutic
Risks
Benefits
Whos doing it competence of investigators
What will be done to the subject
Privacy and confidentiality of information
Right to withdraw without penalty
Provisions for adverse circumstances
Competence/decision-making capacity
Informed consent presupposes competence
Competence is determined in relation to the task
at hand
Legal competence/moral competence
Conditions for competence:
- some degree of self-knowledge and selfawareness
- able to process information
- able to comprehend information
- able to restate information in ones own terms
- able to act from stable set of values
- free from acute anxiety, acute depression and
denial

Research involving clinical trials of drugs or

treatments and research into the causes of, or

that the results are not predictable.

possible treatment for, a particular condition, is

Giving treatment without consent is a failure to

important in increasing doctors ability to provide

respect the patients autonomy and violates an

effective care for present and future patients.

individuals right of self-determination. The con-

The benefits of the research may, however, be

sent form is for patients to acknowledge that the

uncertain and may not be experienced by the

nature and purpose of treatment has been fully

person participating in the research. It is particu-

explained, understood and consented to. Poor

larly important that you ensure that the research

handling of informed consent can lead to com-

is not contrary to the individuals interests, the

plaints, medico-legal litigation and discipline for

participants understand that it is research and

negligence.

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24

2014 IASLC Asia Pacific Lung Cancer Conference, November 6-8,

Kuala Lumpur, Malaysia

Asia Pacific Lung Cancer

Conference targets tobacco,
overlooks air pollution
Chuah Su Ping

at the FDA Center for Tobacco Products Office,

US. If a smoker does not quit, then they have

here was a strong emphasis on the role

a 50 percent chance of dying from a tobacco-

of tobacco smoking in the development

related disease.

of lung cancer at this years Asia Pacific Lung

In the Resolution presented at the close of

Cancer Conference (APLCC) in Kuala Lumpur,

the conference, the first statement highlights

Malaysia. However, discussion regarding anoth-

that Tobacco is a key risk factor for lung can-

er key risk factor outdoor air pollution was

cer claiming about 1.6 million lives globally ev-

strangely absent from the agenda.

ery year. The Resolution notes that complete

The ASEAN region has 10 percent of the

implementation of the WHO Framework Con-

worlds smokers, with Indonesia making up 51

vention on Tobacco Control (WHO FCTC) is

percent of the distribution in the region, followed

the most effective way forward for prevention

by the Philippines with 13.6 percent and Viet-

of lung cancer, and the APLCC supports full

nam with 12 percent, said Dr. Tara Singh Bam,

implementation of the WHO FCTC especially in

who represents the International Union Against

all countries that are party to this treaty. Addi-

Tuberculosis and Lung Disease (The Union) in

tionally, the Resolution noted, Tobacco prod-

Indonesia. He noted that here are approximately

ucts should be explicitly excluded from future

127 million adult smokers in the ASEAN alone.

international, regional and bilateral trade and

Smoking is the leading preventable cause

investment agreements.

of death in the developed world and quickly becoming so in developing countries. Currently,

Air pollution a leading environmental cause

there are between 5 and 6 million deaths year-

of cancer deaths (WHO, 2013)

ly in the world, and this figure is expected to

In October 2013, the specialized cancer

climb to 10 million by around 2025, said Dr.

agency of the WHO, the International Agency

Carolyn Dresler, associate director for Medical

for Research on Cancer (IARC), announced that

and Health Sciences in the Office of Science

it had classified outdoor air pollution as carci-

D e c e m b e r 2 01 4

CO N F ERE N CE COV ERAGE

25

nogenic to humans (Group 1). This conclusion

be ignored as a major cause of mortality, says

was reached by leading experts convened by

the WHO. In 2012 alone, 3.7 million deaths

the IARC Monographs Programme who, after

globally were attributable to AAP, with about 88

thorough review of the latest scientific literature,

percent of these deaths occurring in low- and

concluded that there is sufficient evidence

middle-income countries, which represent 82

that exposure to outdoor air pollution causes

percent of the world population. [Available at

lung cancer. [Press release no. 221, 17 October

www.who.int/phe/health_topics/outdoorair/da-

2013, WHO]

tabases/AAP_BoD_results_March2014.pdf. Ac-

Ambient air pollution (AAP) should also not

cessed on 12 December 2014]

De c e mb e r 2 01 4

CO N F ERE N CE COV ERAGE

26

Diabetes Asia 2014 Conference, October 16-19, Kuala Lumpur, Malaysia

Making a case for adiponectin

in diabetes and its complications
Adiponectin is a protein synthesized and secreted predominantly by adipocytes into the
peripheral blood. Low circulating adiponectin concentrations are associated with a variety of
metabolic diseases and cancers, with recent studies demonstrating the potential of the protein
as various clinical biomarkers and therapeutic targets. Professor Karen Siu Ling Lam from the
University of Hong Kong shared some insights into the latest development in this area.

Kathlin Ambrose

ypoadiponectenemia in obese individuals

plays a pathogenic role in the develop-

ment of type 2 diabetes mellitus (T2DM) as well

as its complications, which include coronary artery disease, ischemic stroke and nephropathy.
Hence, the potential clinical applications of adiponectin as a biomarker for predicting the development of T2DM and its cardiovascular complications, plus the development of therapeutic

188] In addition, Lam and her colleagues study

targets, have been suggested based on cumu-

of non-diabetics in the Hong Kong Cardiovas-

lative data from multiple studies. These studies

cular Risk Factor Prevalence Study (CRISPS)

were described extensively by Professor Karen

cohort showed that the combined use of serum

Siu Ling Lam of the Li Ka Shing Faculty of Medi-

adiponectin and tumor necrosis factor-alpha

cine, University of Hong Kong.

receptor 2 (TNF- R2) as biomarkers provid-

In a meta-analysis of 13 prospective studies,

which included almost 15,000 subjects, high ad-

ed added-value over traditional risk factors for

T2DM prediction. [PloS one 2012;7:e36868]

iponectin levels were observed to confer a lower

The association between adiponectin and

risk of T2DM relative risk of 0.72 per 1-log g/

insulin sensitivity has also been analyzed at

mL increment in adiponectin levels. This inverse

the genetic level, where evidence of a causal

association was consistently observed across all

relationship was found in a study of Swedish

populations, said Lam. [JAMA 2009; 302:179-

men. [Diabetes 2013; 62:1338-1344] This cor-

De c e mb e r 2 01 4

CO N F ERE N CE COV ERAGE

27

responds to an earlier study in the CRISPS

adiponectin participates in the development of

cohort and a subsequent meta-analysis includ-

carotid atherosclerosis. However, this was not

ing two European studies, which concluded

the case in ischemic stroke patients, although

that the ADIPOQ single nucleotide polymor-

serum adiponectin was indeed lower compared

phism (SNP) T45G (rs2241766) independently

to controls. A meta-analysis of eight prospec-

predicted persistent hyperglycemia at 5 years

tive studies showed that in the long term, serum

and the development of T2DM. [Diabetologia

adiponectin levels did not predict incidence, but

2006;49:1806-1815]

instead was found to be a good predictor of the

5-year survival rate following the first episode of

T
 he myriad of studies described
show clear potential for the

ischemic stroke. [Stroke 2014;45:10-17; Stroke

2005;36:1915-1919]
In almost all populations studied, there was

manipulation of adiponectin

a clear indication that a high level of adiponectin

in diseased states to create

is protective against incident myocardial infarc-

therapeutic remedies 

tion (MI), even after correcting for cholesterol

levels. This produced up to a 40 percent MI risk

The link between adiponectin and T2DM is

reduction in the Healthcare Professionals Fol-

taken further with associations found between

low-up Study, said Lam. In obese individuals

the protein and T2DM complications. A study

who did not undergo bariatric surgery, a follow-

of a large Caucasian cohort showed that a vari-

up of 10 years found that a protective effect for

ant of the ADIPOQ gene, adipo4 (rs266729),

the development of T2DM and MI was conferred

which results in low adiponectin levels, is as-

by adiponectin. This was confirmed by a 16-year

sociated with increased carotid intima-media

longitudinal study in the CRISPS cohort in which

thickness (CIMT), a marker of atherosclerosis

the ADIPOQ gene +276G>T (rs1501299) SNP

and a stroke risk factor, suggesting a causal

when present even in the heterozygous state,

role of adiponectin in carotid atherosclerosis.

was associated with an increased risk of coro-

[Stroke 2011;42:1510-1514] This relationship

nary heart disease in men even after correcting

was also observed in a multi-ethnic population

for confounding risk factors, she added.

and was even more marked in those with T2DM.

In diabetic nephropathy, serum adiponectin

[Stroke 2012;43:1123-1125] Hui et al confirmed

is inversely related to albumin excretion rates

this relationship in a prospective study in the

in individuals with normal albuminuria. How-

CRISPS cohort, whereby low serum adiponec-

ever, once the state of microalbuminuria or al-

tin independently predicted progression of ca-

buminuria is reached, the direction of the rela-

rotid atherosclerosis identified via CIMT incre-

tionship is changed, with a positive correlation

ments over the years. [Metab Syndr Relat Disord

observed between serum adiponectin and uri-

2014 Epub ahead of print] All these suggest that

nary albumin concentration (UAC). An inverse

D e c e m b e r 2 01 4

CO N F ERE N CE COV ERAGE

28

relationship is also observed between serum

cell-based studies. In humans, low adiponectin

adiponectin levels and glomerular filtration rate

levels found in diabetes-related cancer patients

(GFR). However, patients with end-stage renal

have been found to have a decreased ability to

failure have serum adiponectin levels as high

limit proliferation and metastasis. [Endocr Relat

as controls, potentially as a result of a second-

Cancer

ary phenomenon. [Kidney Int 2013;83:487-494;

2010;33:1674-1685]

2009;16:1103-1123;

Diabetes

Care

Nephrol Dial Transplant 2014;doi:10.1093/ndt/

The myriad of studies described show clear

gfu249] These indicate that levels of serum adi-

potential for the manipulation of adiponectin in

ponectin differ according to phases of nephrop-

diseased states to create therapeutic remedies.

athy. In a prospective study of a small cohort

Current anti-diabetic and cardiovascular drugs

with relatively well preserved kidney function

such as agonists of peroxisome proliferator-

followed up to 20 months, a low serum adipo-

activated receptor (PPAR) and statins are as-

nectin level was able to predict progression of

sociated with increased plasma adiponectin in

albuminuria, suggesting that in this selected

humans. The recently discovered fibroblast

population, adiponectin is indeed protective

growth factor 21 (FGF21), a metabolic regula-

against renal failure, said Lam.

tor, is the most potent adiponectin stimulator to

Fatty liver disease is another complication fre-

date, said Lam. Many pharmaceutical com-

quently seen among T2DM patients. An inverse

panies are now developing FGF21 mimetics

relationship is seen between serum adiponec-

or analogues to improve the activity as well as

tin and serum alanine aminotransferase (ALT),

the circulating half-life of FGF21. All these are in

suggesting a protective effect conferred by the

various stages of clinical trials, one of which has

protein. The increase in serum adiponectin lev-

already been used in a phase II clinical trial in

els also correlates to improvements in hepatic

humans, she added.

incidences. [J Clin Invest 2003;112:91-100]

Lam also briefly spoke of the importance

It is now commonly known that T2DM in-

of lifestyle measures in improving adiponectin

creases the risk for the development of certain

levels, stating that a low-energy Mediterranean

types of cancers. These include cancer of the

diet, combined with increased physical activ-

pancreas, liver, colorectum, bladder and repro-

ity, has shown to increase adiponectin levels by

ductive tract. Adiponectin, working through vari-

30 percent over 2 years in individuals who suc-

ous signaling mechanisms, has been shown to

ceeded in losing weight. [JAMA 2003; 289:1799-

decrease cell proliferation in many animal- and

1804]

De c e mb e r 2 01 4

CO N F ERE N CE COV ERAGE

29

Diabetes Asia 2014 Conference, October 16-19, Kuala Lumpur, Malaysia

Possible future indications

for metformin
Dr. Joslyn Ngu

bination with sulfonylurea were associated with

improved mortality rates in patients with diabetes

etformin is commonly used to treat type 2

and HF compared with sulfonylurea monothera-

diabetes mellitus (T2DM), but it may have

py alone. [Diabetes Care 2005;28:2345-2351]

other benefits, says a prominent specialist.

Another study alluding to metformins cardio-

In recent years, metformin has been suggest-

protective benefit utilized information from the

ed to have beneficial effects in type 1 diabetes

Diabetes Audit and Research in Tayside Scot-

mellitus (T1DM), heart failure (HF) and cancer,

land (DARTS) database. The study included

said Professor Andrew Morris, vice principal,

diabetic patients who had a history of conges-

data science, School of Molecular, Genetic and

tive heart failure (CHF) and were prescribed oral

Population Health Sciences, University of Edin-

antidiabetic agents, but not insulin. The findings

burgh, UK.

concluded that metformin may lower the risk of

A systemic review of 197 clinical trials showed

death in patients with CHF and DM when used

that prescribing metformin on top of insulin ther-

as monotherapy or in combination with sulfonyl-

apy to patients with T1DM reduces insulin-dose

urea. [Am J Cardio 2010;106:1006-1010]

requirement. Metformin was also linked to reduc-

There is also the link between metformin and

tions in HbA1c, weight and total cholesterol. Still,

cancer to be explored further. Metformin activates

it is not conclusive whether these benefits last

AMP-activated protein kinase (AMPK) in hepato-

more than a year and if there is any additional car-

cytes, which leads to reduced hepatic glucose

dioprotective benefit. [Diabetologia 2010;53:809-

production and increased glucose utilization. An-

820]

drew said there is new insight into the function

Currently, there are 24 clinical trials investigat-

of AMPK. As LKB1 is an upstream regulator of

ing the effects of metformin on HF, said Morris.

AMPK and a known tumor suppressor, metformin

Examples of older studies that have demonstrat-

may be able to lower cell turnover and protein

ed the cardioprotective benefit of metformin are,

synthesis. [J Biol 2003;2:28] He said that based

for one, a Canadian study that ran from 1991 to

on data from clinicaltrials.gov, there are currently

1996. The study analyzed the data of patients re-

214 studies on metformin and cancer patients.

ceiving oral anti-diabetic therapies from the Sas-

As Morris said, We are only at the beginning.

katchewan Health database. The researchers

As the understanding of how metformin works

found that metformin monotherapy or in com-

improves, so will the quality of treatment.

D e c e m b e r 2 01 4

december

upcoming

20th World Congress on

Controversies in Obstetrics,
Gynaecology and Infertility (COGI)
4/12/2014 to 7/12/2014
Location: Paris, France
Info: COGI Secretariat
Tel: (972) 73 706 6950
Fax: (972) 3 725 6266
Email: cogi@congressmed.com
Website: www.congressmed.com/cogi

International Conference on
Infectious and Tropical Diseases
16/1/2015 to 18/1/2015
Phnom Penh, Cambodia
Info: Govt. Gandhi Memorial Science
College
Email: geo_stv_goss@hotmail.com
Website: http://10times.com/ictid

12th Asian Congress of Urology

(ACU)
5/12/2014 to 9/12/2014
Location: Kish Island, Iran
Info: Secretariat
Tel: (971) 4 4218996
Fax: (971) 4 4218838
Email: Plus@InfoPlusEvents.com
Website: http://12thacu2014.org
56th American Society of
Hematology Annual Meeting and
Exposition (ASH)
6/12/2014 to 9/12/2014
Location: San Francisco, US
Info: ASH Registration Center
Tel: (1) 888-273-5704 - US and
Canada
Tel: (1) 703-449-6418 - International
Fax: (1) 703-563-2715
Email: ashregistration@jspargo.com
Website: www.hematology.org
37th San Antonio Breast Cancer
Symposium (SABCS)
9/12/2014 to 13/12/2014
Location: San Antonio, Texas, US
Info: SABCS Registration
Tel: (1) 210-450-1550
Fax: (1) 210-450-1560
Email: sabcs@uthscsa.edu
Website: www.sabcs.org

9th Asia Pacific Conference on

Clinical Nutrition (APCCN)
26/1/2015 to 29/1/2015
Location: Kuala Lumpur, Malaysia
Info: Congress Secretariat
Tel: (603) 2162 0566
Fax: (603) 2161 6560
Email: apccn2015@console.com.my
Website: www.apccn2015.org.my
14th World Congress on Public
Health
11/2/2015 to 15/2/2015
Kolkata, India
Phone: (91) 124 463 6713
Email: info@14wcph.org
Website: www.14wcph.org
24th Conference of the Asian
Pacific Association for the Study of
the Liver (APASL)
12/3/2015 to 15/3/2015
Location: Istanbul, Turkey
Info: APASL Secretariat
Tel: (90) 312 440 50 11
Fax: (90) 312 441 45 63
Email: info@apasl2015.org
Website: www.apasl2015.org
World Congress of Nephrology
(WCN) 2015
13/3/2015 to 17/3/2015
Location: Cape Town, South
Africa
Info: International Society of
Nephrology
Tel: (32) 2 808 71 81
Fax: (32) 2 808 4454
Email: registration@wcn2015.org
Website: www.wcn2015.org

C A LEN DA R

30

64th Annual Scientific Session of

the American College of Cardiology
(ACC)
14/3/2015 to 16/3/2015
Location: San Diego, California, US
Info: ACC Registration and Housing
Center
Tel: (1) 703 449 6418
Email: accregistration@jspargo.com
Website: http://accscientificsession.
cardiosource.org/ACC.aspx
6th Association of Southeast Asian
Pain Societies (ASEAPS) Congress
15/3/2015 to 17/3/2015
Location: Manila, Philippines
Info: ASEAPS Secretariat
Tel: (65) 6292 0732
Fax: (65) 6292 4721
Email: info@aseaps2015.org
Website: www.aseaps2015.org
16th World Congress on Human
Reproduction
18/3/2015 to 21/3/2015
Location: Berlin, Germany
Info: Biomedical Technologies srl
Tel: (39) 070340293
Fax: (39) 070307727
Email: hr2015reg@btcongress.com
Website: www.humanrep2015.com
4th Global Congress for Consensus
in Pediatrics and Child Health (CIP)
19/3/2015 to 22/3/2015
Location: Marrakech, Morocco
Info: Paragon Group
Tel: (41) 22 5330948
Fax: (41) 22 5802953
Email: Regisration@cipediatrics.org
Website: http://2015.cipediatrics.org/
marrakesh/
World Congress on Osteoporosis,
Osteoarthritis and Musculoskeletal
Diseases (WCO-IOF)
26/3/2015 to 29/3/2015
Location: Milan, Italy
Info: Yolande Piette Communication
Tel: (32) 0 4 254 1225
Fax: (32) 0 4 254 1290
Email: info@piettecommunication.
com
Website: www.wco-iof-esceo.org

Shall we begin?

De c e mb e r 2 01 4

I dont think doctors are ready for,

what you call, post impressionism X-rays!

When did you discover that

you were accident prone?

Its about time you showed up!

I had a great evening and I

would love to ask you in, but I
heard you doctors dont make
house calls!

hu m o r

What do you mean

you feel dehydrated?

Forget about organic food.

At your age, you need all the
preservatives you can get!

31

Find out what these experts have to say about how to improve
patient care for osteoporosis and sarcopenia in Asia through
awareness building and the use of new therapies

Professor
Peter Ebeling

Professor
Serge Ferrari

Dr Edith Lau

Professor Bess
Dawson-Hughes

Widespread vitamin D
deficiency and low calcium
levels in Asians

Selective estrogen
receptor modulators
(SERMs), a new class of
therapy for post-menopausal
woman with osteoporosis

Treatment plans for

post-menopausal women
with osteoporosis

How aging contributes to

sarcopenia and impaired
muscle function in the
elderly

How low levels of awareness

in the public and in
healthcare professionals
affect osteoporosis care in
Asia
Benefits of fracture
registries and fracture liaison
registries (FLS) in Asia

MIMS Video Series features

interviews with leading experts

For A 5-minute Update

Go to www.mims.asia/video_series

SCAN TO WATCH VIDEO

Brought to you by MIMS

Publisher

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